ABDOMINAL WALL — the skin and musculoaponeurotic education limiting an abdominal cavity in front behind and from sides.
the Muscular basis back and front and side departments of B. of page consists of two symmetric muscular rudiments (myotomes) which develop and kpered grow and, merging on the centerline, form an abdominal cavity. In the course of embryonic development intestinal loops will stand kpered out of limits of level of myotomes (fiziol, an eventeration), but in the course of merge of myotomes on the centerline gradually enter an abdominal cavity.
B. page is limited from above to costal arches, below — pubic bones, inguinal sheaves (lig. inguinale) and crests of ileal bones, behind — side surfaces of a backbone.
Front B. is divided page into three departments: upper — epigastriß area, a nadchrevya (epigastrium), average — mezogastralny area, a chrevya (mesogastrium) and lower — hypogastric area, a hypogastrium (hypogastrium) (fig. 1).
In an upper part of epigastric area the xiphoidal shoot (processus xiphoideus) will stand individually various length, below the end to-rogo there is small retraction called by an epigastric pole (fossa epigastrica); from below this area is limited from mezogastralny to the cross line connecting cartilages of the X edges. The Mezogastralny area is delimited from hypogastric area by the line connecting upper front ileal awns (spinae iliacae ant. sup.). The hypogastric area from below is limited to a femoral arch, edges corresponds to the direction of an inguinal sheaf (lig. inguinale), and upper part of a pubic symphysis (symphysis pubica). Each of three departments of front B. of page is subdivided into three areas by two parasternal lines continued from top to bottom to outside departments of a pubic symphysis. The epigastriß area is subdivided into the right and left subcostal areas (regiones hypochondriacae) symmetrized under costal arches and actually epigastriß area, the cut is in an upper part an epigastric pole. The Mezogastralny area is subdivided into symmetric side areas of a stomach (regiones laterales) and the central department — umbilical area (regio umbilicalis), hypogastric area — into symmetric inguinal areas (regiones inguinales) and pubic area (regio pubica) — in the center, (fig. 1).
In inguinal area is located pakhovy channel (see) and pakhovy interval; the last is limited by bottom edges of internal slanting and cross muscles of a stomach (mm. obliquus internus abdominis et transversus abdominis), from the inside — the outer edge of a direct muscle of a stomach (m. rectus abdominis), from below — an inguinal sheaf (lig. inguinale) — see. Inguinal area .
Through the pakhovy channel at men there passes the seed cord (funiculus spermaticus), and women have a round uterine sheaf (lig. teres uteri).
All front B. is innervated by page at the expense of 6 couples of last intercostal nerves (from VII to XII) and at the expense of iliohypogastric and ilioinguinal nerves (nn. iliohypogastricus et ilioinguinalis), epigastriß area — from VII, VIII, IX chest segments, mezogastralny area — from IX, X, XI, hypogastric area — from XI, XII; besides, there pass podvzdoshnopodchrevny and ilioinguinal nerves. The front and side department of B. of page has the following layers:
2. The hypodermic fatty tissue together with superficial circulatory and limf, vessels and the superficial fascia (fascia superficialis) located in its thickness, edges in a lower part of front B. of page has two leaves — superficial, passing to a hip, and deep, attached in the area of an inguinal sheaf.
3. Own fascia covering outside oblique muscles of a stomach (mm. obliqui externi abdominis).
4. Outside oblique muscles of a stomach; muscle fibers have the direction from above outside down and medially; the muscle begins on a side surface of a thorax 8 teeth from the lower edges, back bunches are attached to an outside lip of a crest of an ileal bone (labium externum cristae iliacae), and other fibers pass into wide tendinous stretching.
5. Internal oblique muscles of a stomach (mm. obliqui interni abdominis), covered with own fascia; muscle fibers have the direction from below outside up and medially, i.e. is perpendicular to muscle fibers of the previous muscle. The muscle begins behind from a thoracolumbar fascia (fascia thoracolumbalis), the intermediate line of an ileal crest (linea intermedia cristae iliacae) and from lateral two thirds of an inguinal sheaf. Back bunches, ascending up, XII, XI and X edges are attached to bottom edge. Other fibers go slantwise and cross, and lower partially in the descending direction and are a part of the muscle lifting a small egg (m. cremaster). The border of transition of muscle bundles to an aponeurosis goes on slightly convex knaruzha of the line beginning above at a cartilage of the X edge and suitable below a pubic hillock (tuberculum pubicum).
6. Cross muscles of a stomach (mm. transversi abdominis), covered with own fascia, begin from an inner surface of 6 lower edges, alternating with teeth of a diaphragm, from a deep leaf of a thoracolumbar fascia, from an internal lip of an ileal crest and outside two thirds of an inguinal sheaf. Fibers of a muscle go cross, kpered and medially, passing into a wide aponeurosis. 7. Cross fascia (fascia transversalis). 8. Pristenochny peritoneum (peritoneum parietale).
Considerable part of front B. of page is formed by direct muscles of a stomach (mm. recti abdominis), which go in lengthwise direction, beginning from a front surface V, VI and VII costal cartilages and a xiphoidal shoot of a breast, from each side of a muscle are symmetrized, converging from top to bottom, and are attached to pubic bones between a symphysis and a pubic hillock from each party. Yarns extend to the front party of a pubic symphysis, supporting the last, and cross with the same bunches of other party. Under a front wall of a vagina of a direct muscle over a symphysis the small steam room of triangular shape a pyramidal muscle (m. pyramidalis) is located. She begins from an upper part of a symphysis and is attached to the white line of a stomach (linea alba), to-ruyu and pulls at the reduction. Tendinous stretchings of an internal oblique muscle of a stomach in upper two thirds about the outer edges of direct muscles are divided from each party into two tendinous plates which go for formation of front and back walls of a vagina of direct muscles of a stomach (fig. 2) and proceed on both sides to the white line of a stomach. Tendinous stretching of an internal oblique muscle of a stomach entirely passes in the lower third of front B. of page from each party of a kpereda from direct muscles, taking part in formation of a lower part of the white line of a stomach. The cross muscle of a stomach (m. transversus abdominis) passes from each party into the tendinous stretchings on the convex semi-lunar line of a knaruzha — linea semilunaris (Spigelii). Tendinous stretchings of these muscles in upper two thirds of front B. of page entirely go for formation of back walls of vaginas of direct muscles and the white line of a stomach, and in the lower third — for formation of front walls of vaginas of direct muscles of a stomach and the white line. In the lower third of front B. of page direct muscles have no back wall of a tendinous vagina. Direct muscles of a stomach have on three, and sometimes more tendinous crossing points (intersectiones tendineae) which go in the horizontal direction, dividing segments of direct muscles of a stomach (fig. 3). The upper crossing point is located at the level of VIII of a costal cartilage, average — between this edge and a navel, and lower — at the level of a navel. If the fourth meets, poorly developed, a crossing point, then it lies lower than the level of a navel. Within these tendinous crossing points front walls of a vagina of direct muscles densely grow to them throughout. Interlacings of tendinous fibers of aponeuroses of wide muscles of a stomach form the white line of a stomach extending from a xiphoidal shoot of a breast to a pubic symphysis (see. White line of a stomach). From a lower part of the white line and from a superficial fascia there is a sheaf suspending a penis or a clitoris (lig. suspensorium penis s. clitoridis).
Deeper layers on the centerline above a navel are the cross fascia of a stomach, then preperitoneal cellulose and a peritoneum. Direct muscles of a stomach are attached to an anterosuperior surface of a pubic symphysis. The Myshechnoaponevrotichesky complex forming a front abdominal wall is functionally uniform education called by a prelum abdominale which plays an important role in breath, regulation of intra belly pressure, maintenance of a normal statics of a body. The cross fascia (fascia transversalis) is attached to a posterosuperior surface of a pubic symphysis. Between these two layers over a symphysis the fatty tissue is located, from a middle part the cut between inner edges of direct muscles goes a strip of cellulose up. The Pristenochny peritoneum in this department from front B. passes page to verkhnezadny department of a bladder, limiting deeper pozadilobkovy space (spatium retropubicum) filled with a fatty tissue and limited in front to a cross fascia, and from below here — a bladder. On a back surface of a lower part of front B. of page there is a number of peritoneal folds (fig. 4).
Between a bladder and a navel the median umbilical fold (plica umbilicalis mediana) is located. Here the pristenochny peritoneum is raised by a zarashchenny uric channel (urachus). Very seldom both children, and at adults can have it partially (closer to a bladder) nezarashchenny (see. Mochevoy Canal ). Knaruzhi from the specified fold located symmetric medial umbilical folds (plicae umbilicales mediales) — folds of a peritoneum over the obliterated symmetrically located umbilical arteries (aa. umbilicales). Two last folds form a supravesical triangle (trigonum supra vesicale), the median fold is height of this triangle. Knaruzhi from medial umbilical folds, from an inguinal sheaf to a navel a peritoneum on both sides is raised in the form of folds over the lower epigastriß arteries and veins (aa. et vv. epigastricae inferiores) — lateral umbilical folds (plicae umbilicales laterales). At the basis of a supravesical triangle near medial umbilical folds is located on symmetric deepening of a peritoneum — a supravesical pole (fossa supravesicalis). At the bases of each lateral umbilical fold deepening of a peritoneum — a femoral pole (fossa femoralis), and knutr from it a medial inguinal pole (fossa inguinalis medialis) is located. Over the middle of an inguinal sheaf there is a deepening of a peritoneum — a lateral inguinal pole (fossa inguinalis lateralis) corresponding to an internal opening of the inguinal channel (anulus inguinalis abdominalis) where components of a seed cord enter from the different parties.
Front B. page is supplied with blood from systems longwise of the located superficial and deep arteries going with the corresponding veins and from system of lumbar and intercostal arteries. In a hypodermic fatty tissue of front B. of page there are from below up superficial epigastriß arteries (aa. epigastricae superficiales) with the corresponding veins. Both arteries, and veins have a plentiful anastomosis in the form of networks. Behind from direct muscles of a stomach the lower and upper epigastriß arteries and veins are located (aa. et vv. epigastricae inferiores et superiores). Back n side departments of B. of page are supplied with blood from lumbar and intercostal arteries. Superficial and deep limf, B.'s vessels of page in the lower half go to inguinal limf, nodes.
Side B. page is formed outside and internal slanting and cross by muscles of a stomach and the page to back is a transitional part from front B. From within to a sidewall of a stomach prilezhat covered with a peritoneum from three parties the ascending colon on the right and the descending colon at the left. At the getting wounds of side departments of a stomach damage of these departments of a large intestine is the most probable.
Back B. of page corresponds to lumbar area. Above it is limited to the XII edge, from the inside — a backbone, from below — a crest of an ileal bone. Behind handles and cross shoots of lumbar vertebrae the powerful muscle straightening a trunk, unbending and rotating a backbone (m. erector spinae) lies. Muscles of actually lumbar area are located with Knaruzhi. Deeper than skin, hypodermic cellulose and a superficial fascia the part of the broadest muscle of a back (m. latissimus dorsi) corresponding to this area beginning from acanthas of all lumbar vertebrae, six lower edges, a back half of a crest of an ileal bone and from a back leaf of a thoracolumbar fascia (fascia thoracolumbalis) covering the muscle straightening a trunk is located. The broadest muscle of a back is covered with own fascia. More deeply the internal oblique muscle of a stomach and the lower back gear muscle lie. The last begins from a superficial leaf of a thoracolumbar fascia in the area XI and XII of chest, I and II lumbar vertebrae, being attached to four lower edges, the initial department of a cross muscle of a stomach covered with a leaf of a cross fascia, and, at last, a square muscle of a waist (m. quadratus lumborum) lies even more deeply. It begins a part from the XII edge, a part from cross shoots III, IV and V lumbar vertebrae. Muscle fibers are attached to an iliolumbar sheaf (lig. iliolumbale) and comb of an ileal bone. Deeper than this muscle covered with own fascia the adipose capsule of a kidney (capsula adiposa renis) lies. Within back B. the page located individually variously expressed lumbar triangle (Pti) which is limited by the lower outer edge of the broadest muscle of a back, edge of an outside oblique muscle of a stomach and a crest of an ileal bone. A bottom of this triangle are the internal oblique muscle of a stomach and a thoracolumbar fascia. Above the lumbar quadrangle described by P.F. Lesgaft and Grinfelt is located (J. Page of Grynfelt). From below it is formed by edge of an internal oblique muscle of a stomach, from the inside the muscle straightening a trunk and a square muscle of a waist (t. quadratus lumborum), from above — a back lower gear muscle and the XII edge.
Diseases and damages of an abdominal wall
B. the village takes part in the act of breath; range of its movement sharply decreases or even disappears at acute inflammatory processes of abdominal organs, at peritonitises (see). At its palpation in such cases symptoms of irritation of a peritoneum are defined. Front B.'s asymmetry of page matters at diagnosis of various diseases of abdominal organs; in combination with the peristaltics seen approximately it is a symptom of impassability of intestines (see. Bringing down a symptom ). In the conditions of pathology at blockade of the lower hollow or portal vein venous roundabout blood circulation, in addition to lumbar veins and veins of cardial department of a stomach, goes also through superficial and deep venous network B. of page. Expanded veins of front B. of page are visible through skin in a navel (caput Medusae).
At incomplete merge of myotomes by the time of the birth of a fruit abdominal organs on a considerable extent are covered only with a peritoneum, a cross fascia and skin. Through these layers in side departments of B. of page the condensed concave inner edges of underdeveloped muscles (embryonal eventration of intestines) are probed. Development of myotomes can continue also after the birth, in this case with growth of the child inborn eventration can decrease considerably. At smaller degree of an underdevelopment of myotomes forms inborn diastases of direct muscles of a stomach, and at localization of an underdevelopment in a navel inborn umbilical hernia — rather frequent pathology. The underdevelopment of the white line of a stomach and muscles in a lower part of front B. of page can be combined with ectopia of a bladder (see). Small inborn diastases of direct muscles meets often, with growth of the child it usually decreases.
On the mechanism of development omphaloceles of an umbilical cord are close to inborn eventration.
At this malformation in umbilical area there is an underdevelopment of all layers of an abdominal wall owing to what abdominal organs are covered only with a thin translucent amniotic cover. This pathology demands the emergency surgical treatment in the first days of the post-natal period since drying or a rupture of an amniotic cover often conducts to eventration and development of peritonitis. The incomplete obliteration of a vitelline and intestinal channel is the reason of the inborn intestinal fistulas which are localized in a navel, and less often than B.'s cysts of page.
Front B. of page is the most frequent area of development of hernias of a stomach (see. Hernias ), which anatomic premises of development quite often are these or those defects of development or options of an anatomic structure of B. of page. In rare instances hernias can develop also in anatomically weak points of back B. of page, according to Pti's triangle and Lesgaft's quadrangle — Grinfelta.
In a zone of a navel there can also be fistulas or cysts connected with disturbance of process of involution of an uric channel. They usually are located in the lower semi-circle of a skin navel and an umbilical ring. At full not fusion of this channel there is uric fistula in a navel. Fistulas and cysts of an urakhus can be located in any site on the white line throughout all hypogastric area.
Damages of an abdominal wall share on closed (without disturbance of an integrity of integuments) and opened (with their disturbance). The closed B.'s damages by page usually result from a stupid injury of a stomach and are quite often combined with * injury of abdominal organs (see. Stomach , damages). The closed B.'s damages by page can be followed by bruises, gaps and other more rough damages of musculoaponeurotic educations and B.'s vessels of page. At a hypodermic rupture of muscles of B. of page full or partial discrepancy of the ends of the injured muscle on site of a gap takes place. The closed B.'s damages by page, as a rule, are followed by formation of a hematoma. Chipped and cut wounds, bullet wounds, burns, foreign bodys of B. of page
=== Inflammatory and other diseases of an abdominal wall === belong to open damages of B. of page Inflammatory diseases of B. of page can be acute or chronic. That and others can initially arise as independent inflammatory defeat of fabrics B. of page or for the second time, as a result of transition of inflammatory changes to B. of page from one of abdominal organs or a metastaticheska at sepsis.
In the field of B. of page acute nonspecific inflammatory diseases rather often meet: furuncles, an anthrax, abscesses, are more rare than phlegmon, an erysipelatous inflammation. Diagnosis and treatment but have them features in comparison with the corresponding disease of other localization (see. Abscess , Furuncle , Anthrax , Ugly face , Phlegmon ). Phlegmons and the front B.'s abscesses of page which are localized in direct muscles of a stomach are usually delimited by tendinous crossing points, the outer edge of a vagina of these muscles and the white line. However at distribution of pus to a back surface of the direct muscles which do not have additional fixing to a back wall of their vagina, purulent [[ | flow ZATYoKI ]] (see) can widely extend under front B.'s muscles of page. Deep phlegmons of B. of page can be complicated by break of pus in an abdominal cavity and development of peritonitis. B.'s phlegmons of page demand early broad opening.
Inflammations of a navel rather quite often occur among other acute primary inflammatory diseases of B. of page (see. Omphalitis ). They arise at newborns owing to infection of an umbilical cord, at children and adults owing to having combed, pollution or an intertrigo, in the presence of umbilical hernia, at eczema of area of a navel. An omphalitis of newborns — a dangerous disease owing to a possibility of its complication peritonitis, a pylephlebitis and umbilical sepsis. At adults the omphalitis should be differentiated with primary and secondary malignant tumors.
The most frequent acute inflammatory diseases of B. of page are purulent complications of operational wounds (see. Wounds , wounds, Purulent infection ). Acute inflammatory process can extend for the second time to B. of page at some diseases of abdominal organs, hl. obr. at their late recognition and in the absence of timely treatment (an acute appendicitis, the restrained hernias, tumors of a large intestine).
Hron, inflammatory diseases of B. of page can be nonspecific and specific. Nonspecific hron, inflammatory diseases of B. of page most often meet in a look is long the existing inflammatory infiltrates. More often they are formed in the field of hems after various operative measures, the page, napr, after the postponed typhoid is more rare in the unimpaired B. At the heart of postoperative hron, infiltrates infection of a suture material with formation of small abscesses in deep layers of B. of page quite often lies. In these cases antibacterial and physiotherapeutic treatment usually does not yield a positive take. More bystry and absolute recovery can achieve by broad opening of infiltrate with removal of a ligature and excision of the changed fabrics. Depending on extent of inflammatory changes of fabrics the wound can be sewn up tightly, closed through a nek-swarm time by imposing of secondary seams or a tamponirovan.
Hron, specific inflammatory diseases of B. of page are presented to hl. obr. tuberculosis and an actinomycosis and usually are secondary defeats at primary disease of abdominal organs.
B.'s tuberculosis of page meets seldom, generally in the form of secondary tubercular abscesses (natechnik). They can be localized in the field of the inguinal channel, extending from I and II lumbar vertebrae at a tubercular spondylitis along iliohypogastric and ilioinguinal nerves here. Along intercostal nerves congestive abscesses can extend from bodies of chest vertebrae and to other departments of front B. of page. Congestive tubercular abscesses can be localized also in the thickness of back B. by page, in the field of Pti's triangle and Lesgaft's quadrangle — Grinfelta. B.'s actinomycosis of page usually arises for the second time owing to distribution of pathological process of intestines. The disease proceeds with formation of the abscessing infiltrate and development of the fistulas having all signs characteristic of this disease (see. Actinomycosis ).
Parasitic diseases of B. of page. (Echinococcosis, cysticercosis) meet seldom.
Tumors of an abdominal wall
Benign tumors of integuments of B. of page meet often: flat nevus pigmentosus, angiomas, lymphangiomas and angiofibromas. Malignant tumors of integuments of B. of page meet rather seldom. Most often it is an ozlokachestvlenny nevus pigmentosus. Benign tumors of deep fabrics B. of page can have various structure. Most often in hypodermic cellulose lipomas and fibrolipomas meet, and it is frequent also the neurofibromas, sometimes the desmoids arising from tendinous crossing points or aponeuroses and which are localized in the thickness of B.'s muscles of page. The frequent place of development of tumors is the navel. Here endometrioma meet as the tumors described above, and benign tumors of other structure, napr. In group of malignant tumors of a zone of a navel metastasises of cancer of abdominal organs most often meet (e.g., a stomach), but can take place and primary malignant tumors (cancer, sarcoma).
Belonging of a tumor to B. of page is defined by its palpation at intense B. by page. At the same time the tumors which are localized in an abdominal cavity are probed worse, and the majority of tumors of B. of page is defined more clearly.
Treatment of tumors of B. of page is carried out by the general principles of treatment of tumors.
Operations on an abdominal wall
Abdominal section for a laparotomy can be various on localization, a form and the size (see. Laparotomy ). The coal mine B. of page shall be low-traumatic, provide good access to body, give the chance without tension to sew edges of a wound or to create its sufficient gaping. The arrangement of a section has to be planned so that it was not the reason of formation of postoperative hernia. B.'s punctures of page are made for evacuation of ascitic liquid or a laparoscopy in typical places, is the most frequent on the centerline between a navel and a pubis or on the middle of distance between a navel and an anterosuperior awn of an ileal bone (see. Laparocentesis ).
Closing of defects of an abdominal wall (their plastics) is carried out in various ways. If there is no tension of fabrics, then closing of defect manages to be made simple layer-by-layer sewing together of edges or after mending of a peritoneum overlapping of area
of defect duplikatury the aponeurotic rags showered over it on both sides. At a tension of fabrics it is necessary to resort after sewing together of a peritoneum to plastic closing of defect with a free rag of a fascia, the rag of «cutis-subcutis», a piece of leather exempted from epidermis by coagulation, or a piece of leather on a leg without elimination of epidermis. The last offer is controversial. There are also ways of plastic closing of defect of an abdominal wall with alloplastichesky material.
Bibliography: Strong E. D. Diseases of a front abdominal wall after wound and a laparotomy, Kiev, 1956, bibliogr.; Zolotareva T. V. Surgical anatomy of a front sidewall of a stomach, in book: Hir. annate. a stomach, under the editorship of A. N. Maksimenkov, page 23, L., 1972, bibliogr.; Knorre A. G. A short sketch of embryology of the person with elements of comparative, experimental and pathological embryology, page 184, L., 1967; Kovanov B. Century and Anikina T. I. Surgical anatomy of fastion and kletchatochny spaces of the person, page 326, M., 1967, bibliogr.; Mordvinkina T. N. About desmoids of an abdominal wall, Klin, hir., No. 3, page 40, 1966; M y sh V. M. Sketches of surgical diagnosis, page 11, Novosibirsk, 1948; Napalkov P. N. Anatomy of front and side departments of an abdominal wall, Mnogotomn, the management on hir., under the editorship of B. V. Petrovsky, t. 7, page 9, L., 1960; Petten B. M. Embryology of the person, the lane with English, page 448, M., 1959; A. I. crayfish of an ichekharin of E. A. Malignant tumors of soft tissues of extremities and trunk. L., 1968, bibliogr.; Christopher F. Textbook of surgery, p. 471, Philadelphia — L., 1960; Goldhahn R. u. Jorns G. Lehrbuch der speziellen Chirurgie, S. 324, Lpz., 1962; Kuntzen H. Bauchwand, Bauch-fell und Zwerchfell, Lehrbuch d. Chir., hrsg. v. E. Gohrbandt u. E. Redwitz, Bd 1, S. 908, Jena, 1956.
P.N. Napalkov, B. V. Ognev.