External anatomy the surface markings

The abdominal wall, bounded by the lower margin of the thorax above, and by the pubes, the iliac crests and the inguinal ligaments below, is easily recognized in the upright man. Vertically down the centre of the abdomen the depression of

Prominent Umbilicus
Figure 14.4. Topographical anatomy of the abdomen shows the distinctly different male and female characteristics.

the linea alba is obvious and is usually more apparent above the umbilicus. The umbilicus lies at the junction of the upper three-fifths and lower two-fifths of the linea alba. In the healthy young adult the rectus muscle is prominent on either side of the linea alba. The rectus muscle is particularly prominent inferolaterally to the umbilicus: this infra-umbilical rectus mound is of surgical importance. With ageing and obesity, the lower abdomen sags but the infra-umbilical rectus mound remains obvious and visible to the subject, even into old age.

The outer margin of each rectus is indicated by a convex vertically directed furrow, the semilunar line (linea semilunaris), which is most distinct in the upper abdomen where it commences at the tip of the ninth costal cartilage. At first it descends almost vertically, but inferior to the umbilicus it gently curves medially to terminate at the pubic tubercle. It is along this line that the internal oblique aponeurosis bands and splits to enclose the rectus muscle in the upper two-thirds of the abdomen. The broad furrow of the inferior semilunar line is also described as the Spigelian fascia and is the site of herniation. In the lower abdomen the configuration varies, a wider pelvis and greater pubic prominence being important female characteristics (Fig. 14.4).

The surgeon must be aware of the elastic and connective tissue lines in the skin (Langer's lines) if optimum healing is to be obtained. Incisions made at right angles to Langer's lines gape and tend to splay out when they heal. The longitudinal contraction of the healing wound, particularly when the wound crosses a skin delve or body crease, can make healing very unsightly with contracture and for these reasons vertical incisions over the groin should be avoided. However, rapid abdominal access requires adequate vertical incisions and they continue to remain in everyday general surgical and gynaecological practice particularly in emergency surgery.

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