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Abdominal Wall e708af38-508f-4404-b7c5-6b8c7d75804f
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Ultrasound 385d1c6c-f4ac-463a-80b7-dfe4876e5da2 28 06/30/21 Abdominal Wall Ultrasound, Anatomy, Abdomen, Abdominal Wall Abdominal Wall | STATdx Abdominal Wall ANATOMY true
Ultrasound
Anatomy
Abdomen
Abdominal Wall

title: "Abdominal Wall" docid: "e708af38-508f-4404-b7c5-6b8c7d75804f" authors:

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  • "Ultrasound"
  • "Anatomy"
  • "Abdomen"
  • "Abdominal Wall"

TERMINOLOGY

  • Definitions

    • Abdomen is region between diaphragm and pelvis

GROSS ANATOMY

  • Anatomic Boundaries

    • Anterior abdominal wall bounded superiorly by xiphoid process and costal cartilages of 7th-10th ribs
    • Anterior wall bounded inferiorly by iliac crest, iliac spine, inguinal ligament, and pubis
    • Inguinal ligament is inferior edge of external oblique muscle aponeurosis

  • Muscles of Anterior Abdominal Wall

    • Consists of 3 flat muscles (external oblique, internal oblique, and transversus abdominis), and 1 strap-like muscle (rectus abdominis)
    • Combination of muscles and aponeuroses (sheet-like tendons) acts as corset to confine and protect abdominal viscera
    • Linea alba is fibrous raphe stretching from xiphoid to pubis - Forms central anterior attachment for abdominal wall muscles - Formed by interlacing fibers of aponeuroses of oblique and transversus abdominis muscles - Rectus sheath is also formed by these aponeuroses, as they surround rectus muscle
    • Linea semilunaris is vertical fibrous band at lateral edge of rectus sheath bilaterally - Aponeuroses of internal and transversus abdominis join in linea semilunaris before forming rectus sheath
    • External oblique muscle - Largest and most superficial of 3 flat abdominal muscles - Origin: External surfaces of ribs 5-12 - Insertion: Linea alba, iliac crest, pubis via broad aponeurosis
    • Internal oblique muscle - Middle of 3 flat abdominal muscles - Runs at right angles to external oblique - Origin: Posterior layer of thoracolumbar fascia, iliac crest, and inguinal ligament - Insertion: Ribs 10-12 posteriorly, linea alba via broad aponeurosis, pubis
    • Transversus abdominis (transversalis) muscle - Innermost of 3 flat abdominal muscles - Origin: Lowest 6 costal cartilages, thoracolumbar fascia, iliac crest, inguinal ligament - Insertion: Linea alba via broad aponeurosis, pubis
    • Rectus abdominis muscle - Origin: Pubic symphysis and pubic crest - Insertion: Xiphoid process and costal cartilages 5-7 - Rectus sheath: Strong fibrous compartment that envelops each rectus muscle - Contains superior and inferior epigastric vessels
    • Actions of anterior abdominal wall muscles - Support and protect abdominal viscera - Flex and twist trunk, maintain posture - Increase intraabdominal pressure for defecation, micturition, and childbirth - Stabilize pelvis during walking, sitting up
    • Transversalis fascia - Lies deep to abdominal wall muscles and lines entire abdominal wall - Separated from parietal peritoneum by layer of extraperitoneal fat

  • Muscles of Posterior Abdominal Wall

    • Consist of psoas (major and minor), iliacus, and quadratus lumborum
    • Psoas: Long thick, fusiform muscle lying lateral to vertebral column - Origin: Transverse processes and bodies of vertebrae T12-L5 - Insertion: Lesser trochanter of femur (passing behind inguinal ligament) - Action: Flexes thigh at hip joint; bends vertebral column laterally
    • Iliacus: Large triangular sheet of muscle lying along lateral side of psoas - Origin: Superior part of iliac fossa - Insertion: Lesser trochanter of femur (after joining with psoas tendon) - Action: "Iliopsoas muscle" flexes thigh
    • Quadratus lumborum: Thick sheet of muscle lying adjacent to transverse processes of lumbar vertebrae - Invested by lumbodorsal fascia - Origin: Iliac crest and transverse processes of lumbar vertebrae - Insertion: 12th rib - Actions: Stabilizes position of thorax and pelvis during respiration, walking, bends trunk laterally

  • Paraspinal Muscles

    • a.k.a. erector spinae muscles - Invested by lumbodorsal fascia
    • Composed of 3 columns: Iliocostalis: Lateral; longissimus: Intermediate; spinalis: Medial
    • Origins: Sacrum, ilium, and spines of lumbar and 11th-12th thoracic vertebrae
    • Insertions: Ribs and vertebrae with additional muscle slips joining columns at successively higher levels
    • Action: Extends vertebral column

ANATOMY IMAGING ISSUES

  • Imaging Recommendations

    • Higher frequency (5-18 MHz) linear transducer for anterior abdominal wall and paraspinal muscles
    • 3-5 MHz for posterior abdominal wall muscles
    • Supine position for examination of anterior and lateral abdominal wall - Image during Valsalva maneuver and in standing position to increase abdominal pressure and elicit hernias - Prone position for ultrasound of paraspinal muscles
    • Compare with contralateral side to check for symmetry

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References

Selected References

  1. Draghi F et al: Abdominal wall sonography: a pictorial review. J Ultrasound. 23(3):265-78, 2020

Images

Anterior Abdominal Wall

Graphic shows the aponeuroses of the internal and external oblique and transverse abdominal muscles are 2 layered and interweave with each other, covering the rectus muscle and constituting the rectus sheath and linea alba. About midway between the umbilicus and symphysis, at the arcuate line, the posterior rectus sheath ends (arcuate line), and the transversalis fascia is the only structure between the rectus muscle and parietal peritoneum. Graphic shows the aponeuroses of the internal and external oblique and transverse abdominal muscles are 2 layered and interweave with each other, covering the rectus muscle and constituting the rectus sheath and linea alba. About midway between the umbilicus and symphysis, at the arcuate line, the posterior rectus sheath ends (arcuate line), and the transversalis fascia is the only structure between the rectus muscle and parietal peritoneum.

Graphic shows the aponeuroses of the internal and external oblique and transverse abdominal muscles are 2 layered and interweave with each other, covering the rectus muscle and constituting the rectus sheath and linea alba. About midway between the umbilicus and symphysis, at the arcuate line, the posterior rectus sheath ends (arcuate line), and the transversalis fascia is the only structure between the rectus muscle and parietal peritoneum. Graphic shows the aponeuroses of the internal and external oblique and transverse abdominal muscles are 2 layered and interweave with each other, covering the rectus muscle and constituting the rectus sheath and linea alba. About midway between the umbilicus and symphysis, at the arcuate line, the posterior rectus sheath ends (arcuate line), and the transversalis fascia is the only structure between the rectus muscle and parietal peritoneum.

Graphic shows the lumbar vertebrae are covered and attached by the anterior longitudinal ligament, and the diaphragmatic crura are closely attached to it, as are the origins of the psoas muscles, which also arise from the transverse processes. The iliacus muscle arises from the iliac fossa of the pelvis and inserts into the tendon of the psoas major, constituting the iliopsoas muscle, which inserts onto the lesser trochanter. Quadratus lumborum arises from the iliac crest and inserts onto the 12th rib and transverse processes of the lumbar vertebrae. Diaphragmatic and transversus abdominis fibers interlace. Psoas and quadratus lumborum pass behind the diaphragm under medial and lateral arcuate ligaments. Graphic shows the lumbar vertebrae are covered and attached by the anterior longitudinal ligament, and the diaphragmatic crura are closely attached to it, as are the origins of the psoas muscles, which also arise from the transverse processes. The iliacus muscle arises from the iliac fossa of the pelvis and inserts into the tendon of the psoas major, constituting the iliopsoas muscle, which inserts onto the lesser trochanter. Quadratus lumborum arises from the iliac crest and inserts onto the 12th rib and transverse processes of the lumbar vertebrae. Diaphragmatic and transversus abdominis fibers interlace. Psoas and quadratus lumborum pass behind the diaphragm under medial and lateral arcuate ligaments.

Transverse grayscale ultrasound of the abdominal wall at the midline shows the bilateral rectus abdominis muscles approximated by the linea alba. A portion of the left lobe of the liver and bowel is seen within the peritoneum. Transverse grayscale ultrasound of the abdominal wall at the midline shows the bilateral rectus abdominis muscles approximated by the linea alba. A portion of the left lobe of the liver and bowel is seen within the peritoneum.

Also in the transverse plane, color Doppler is applied to show the right inferior epigastric artery and vein deep to the rectus abdominis muscle. These are important to identify in order to avoid when performing procedures and are landmarks that are used to determine hernia type when present. Also in the transverse plane, color Doppler is applied to show the right inferior epigastric artery and vein deep to the rectus abdominis muscle. These are important to identify in order to avoid when performing procedures and are landmarks that are used to determine hernia type when present.

Longitudinal image with color Doppler flow in the same location shows the right inferior epigastric artery and its perforating branches into the rectus abdominis muscle. These are of relevance when this muscle is harvested for a possible flap used for reconstruction. Longitudinal image with color Doppler flow in the same location shows the right inferior epigastric artery and its perforating branches into the rectus abdominis muscle. These are of relevance when this muscle is harvested for a possible flap used for reconstruction.

Anterolateral Abdominal Wall

Longitudinal extended FOV grayscale image shows the relationship between the rectus abdominis and the oblique muscles. Longitudinal extended FOV grayscale image shows the relationship between the rectus abdominis and the oblique muscles.

High-resolution transverse grayscale ultrasound at the right anterolateral abdominal wall shows the relationship of the lateral abdominal wall muscles in better detail. Note the oblique and transversus abdominis muscles taper medially as they become aponeuroses. High-resolution transverse grayscale ultrasound at the right anterolateral abdominal wall shows the relationship of the lateral abdominal wall muscles in better detail. Note the oblique and transversus abdominis muscles taper medially as they become aponeuroses.

Correlative, axial CECT illustrates the muscles of the abdominal wall. The rectus abdominis muscle in the anterior abdominal wall, and the oblique and transversus abdominis muscles in the anterolateral abdominal wall and their aponeuroses are shown. Correlative, axial CECT illustrates the muscles of the abdominal wall. The rectus abdominis muscle in the anterior abdominal wall, and the oblique and transversus abdominis muscles in the anterolateral abdominal wall and their aponeuroses are shown.

Posterior Abdominal Wall

Longitudinal grayscale ultrasound at the level of the lower pole of the right kidney shows the psoas and oblique muscles. Longitudinal grayscale ultrasound at the level of the lower pole of the right kidney shows the psoas and oblique muscles.

Transverse grayscale ultrasound of right midabdomen using the kidney as an acoustic window is shown. The kidney is anterior and lateral to the psoas and anterior to the quadratus lumborum. The psoas runs along the paravertebral region in its entire abdominal course. The quadratus lumborum originates from the iliolumbar ligament and iliac crest to insert into the last rib and lumbar transverse processes. It is easily identified as the muscle on which the kidney rests. Transverse grayscale ultrasound of right midabdomen using the kidney as an acoustic window is shown. The kidney is anterior and lateral to the psoas and anterior to the quadratus lumborum. The psoas runs along the paravertebral region in its entire abdominal course. The quadratus lumborum originates from the iliolumbar ligament and iliac crest to insert into the last rib and lumbar transverse processes. It is easily identified as the muscle on which the kidney rests.

Transverse grayscale ultrasound of the right upper abdomen more inferiorly shows the relationship of the posterior abdominal wall muscles are maintained. Transverse grayscale ultrasound of the right upper abdomen more inferiorly shows the relationship of the posterior abdominal wall muscles are maintained.

Axial correlative CECT below the kidneys shows the quadratus lumborum muscle is more laterally located, and the psoas muscle is directly anterior to the erector spinae muscle. Axial correlative CECT below the kidneys shows the quadratus lumborum muscle is more laterally located, and the psoas muscle is directly anterior to the erector spinae muscle.

Axial correlative CECT shows the psoas muscle has begun its dorsolateral course and is now anterior to the iliacus muscle. The iliacus muscle is easily identified as a flat muscle filling the iliac fossa, arising from the upper 2/3 of the iliac fossa, inner lip of the iliac crest, anterior sacroiliac and the iliolumbar ligaments, and base of the sacrum. Axial correlative CECT shows the psoas muscle has begun its dorsolateral course and is now anterior to the iliacus muscle. The iliacus muscle is easily identified as a flat muscle filling the iliac fossa, arising from the upper 2/3 of the iliac fossa, inner lip of the iliac crest, anterior sacroiliac and the iliolumbar ligaments, and base of the sacrum.

Axial correlative CECT shows the psoas and iliacus muscles have converged and are now indistinguishable from one another. The resultant iliopsoas muscle passes beneath the inguinal ligament and becomes tendinous as it inserts into the lesser trochanter of the femur. Axial correlative CECT shows the psoas and iliacus muscles have converged and are now indistinguishable from one another. The resultant iliopsoas muscle passes beneath the inguinal ligament and becomes tendinous as it inserts into the lesser trochanter of the femur.

Muscles of Back In Situ

Transverse extended FOV grayscale ultrasound of the back (with patient prone) shows the erector spinae muscles flanking the spinous process. They are invested by lumbodorsal fascia, which also invests the anteriorly located quadratus lumborum muscle. The kidneys are partially demonstrated. Transverse extended FOV grayscale ultrasound of the back (with patient prone) shows the erector spinae muscles flanking the spinous process. They are invested by lumbodorsal fascia, which also invests the anteriorly located quadratus lumborum muscle. The kidneys are partially demonstrated.

Transverse oblique grayscale ultrasound of the left erector spinae muscle (with patient prone) is shown. The 3 columns (iliocostalis, longissimus, and spinalis muscles, from lateral to medial) comprising the erector spinae are not clearly separated from one another on ultrasound. They are identified collectively as a thick, fleshy muscle lateral to the spinous process. Transverse oblique grayscale ultrasound of the left erector spinae muscle (with patient prone) is shown. The 3 columns (iliocostalis, longissimus, and spinalis muscles, from lateral to medial) comprising the erector spinae are not clearly separated from one another on ultrasound. They are identified collectively as a thick, fleshy muscle lateral to the spinous process.

Axial correlative CECT of the paraspinal muscles at the level of the kidneys shows that the erector spinae muscles originate from a broad and thick tendon, which originates from the sacrum and iliac crest, lumbar, and 11th and 12th thoracic spinous processes. Axial correlative CECT of the paraspinal muscles at the level of the kidneys shows that the erector spinae muscles originate from a broad and thick tendon, which originates from the sacrum and iliac crest, lumbar, and 11th and 12th thoracic spinous processes.

Posterior Abdominal Wall, CT Correlation

Coronal correlative CECT shows the paralumbar location of the psoas muscles and their medial location relative to the kidneys. The psoas muscles originate from the lumbar and 12th thoracic vertebral bodies and their transverse processes and run past the pelvic brim, where they course inferolaterally to be joined by the iliacus muscle. Coronal correlative CECT shows the paralumbar location of the psoas muscles and their medial location relative to the kidneys. The psoas muscles originate from the lumbar and 12th thoracic vertebral bodies and their transverse processes and run past the pelvic brim, where they course inferolaterally to be joined by the iliacus muscle.

Axial correlative CECT better illustrates the anatomic relationships of the kidney with the posterior abdominal wall muscles. The kidney is lateral to the psoas muscle and rests upon the quadratus lumborum muscle. The erector spinae muscles are immediately posterior to the quadratus lumborum, and the 2 muscles are invested by the lumbodorsal fascia. Axial correlative CECT better illustrates the anatomic relationships of the kidney with the posterior abdominal wall muscles. The kidney is lateral to the psoas muscle and rests upon the quadratus lumborum muscle. The erector spinae muscles are immediately posterior to the quadratus lumborum, and the 2 muscles are invested by the lumbodorsal fascia.

Axial correlative CECT at the level of the inferior pole of the right kidney is shown. The psoas muscle and quadratus lumborum muscles, seen in their midsections, are now thicker. Axial correlative CECT at the level of the inferior pole of the right kidney is shown. The psoas muscle and quadratus lumborum muscles, seen in their midsections, are now thicker.

Additional Images

Longitudinal color Doppler ultrasound shows a perforating branch of the deep inferior epigastric artery extending into the rectus muscle . These perforators are important for breast reconstruction with abdominal wall flaps. Longitudinal color Doppler ultrasound shows a perforating branch of the deep inferior epigastric artery extending into the rectus muscle . These perforators are important for breast reconstruction with abdominal wall flaps.

Graphic shows the paraspinal muscles and muscles of the back. The latissimus dorsi muscles are not included. The erector spinae have thick tendinous origins from the sacral and iliac crests and the lumbar and 11th-12th thoracic spinous processes. Superiorly, the muscle becomes fleshy, and in the upper lumbar region subdivides to become the iliocostalis, longissimus, and spinalis muscles (from lateral to medial), tapering as they insert into the vertebrae and ribs. The erector muscles flank the spinous processes and span the length of the posterior thorax and abdomen. They are responsible for extension of the vertebral column. Graphic shows the paraspinal muscles and muscles of the back. The latissimus dorsi muscles are not included. The erector spinae have thick tendinous origins from the sacral and iliac crests and the lumbar and 11th-12th thoracic spinous processes. Superiorly, the muscle becomes fleshy, and in the upper lumbar region subdivides to become the iliocostalis, longissimus, and spinalis muscles (from lateral to medial), tapering as they insert into the vertebrae and ribs. The erector muscles flank the spinous processes and span the length of the posterior thorax and abdomen. They are responsible for extension of the vertebral column.

Transverse grayscale ultrasound in the lower abdominal region shows the right psoas muscle, composed of the psoas minor which rests upon the psoas major. The 2 muscles cannot be separated clearly on ultrasound. Because of their depth, the paraspinal muscles cannot be demonstrated in detail. Transverse grayscale ultrasound in the lower abdominal region shows the right psoas muscle, composed of the psoas minor which rests upon the psoas major. The 2 muscles cannot be separated clearly on ultrasound. Because of their depth, the paraspinal muscles cannot be demonstrated in detail.

Transverse grayscale ultrasound of the right lower abdomen in the same case shows that the distal psoas muscle has diminished in size. It rests on the medial portion of the iliacus muscle; the latter is a flat muscle that fills the iliac fossa. Both continue inferiorly together. Transverse grayscale ultrasound of the right lower abdomen in the same case shows that the distal psoas muscle has diminished in size. It rests on the medial portion of the iliacus muscle; the latter is a flat muscle that fills the iliac fossa. Both continue inferiorly together.

Distally, the fibers from the iliacus muscle converge and insert into the lateral side of the psoas muscle to form the iliopsoas muscle. Common iliac vessels can be seen medially. Distally, the fibers from the iliacus muscle converge and insert into the lateral side of the psoas muscle to form the iliopsoas muscle. Common iliac vessels can be seen medially.

Axial T2 HASTE MR in a younger male patient shows more bulky abdominal wall musculature with little intermuscular fat. Axial T2 HASTE MR in a younger male patient shows more bulky abdominal wall musculature with little intermuscular fat.

Axial T2 HASTE MR in an older patient with muscle atrophy shows fat in between the individual muscles of the anterior and posterior abdominal wall. Axial T2 HASTE MR in an older patient with muscle atrophy shows fat in between the individual muscles of the anterior and posterior abdominal wall.

Axial T1 MR at a lower level shows the iliopsoas as 1 muscle bundle. Axial T1 MR at a lower level shows the iliopsoas as 1 muscle bundle.

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