Getting to the “CORE” of the Abdominal Wall Post Surgery
The abdominal wall encloses the abdominal cavity, which holds the bulk of the gastrointestinal viscera. A topic I have grown quite font of over the last couple of weeks, post appendectomy.
It’s structure and function can be broken down into these key areas:
- Forms a firm, flexible wall which keeps the abdominal viscera in the abdominal cavity
- Protects the abdominal viscera from injury
- Maintains the anatomical position of abdominal viscera against gravity
- Assists in forceful expiration by pushing the abdominal viscera upwards
- Involved in any action (coughing, vomiting) that increases intra-abdominal pressure
Its structure is complex, yet in most cases we think of the abdomen as merely the “six pack.” When it comes to rehabilitation of abdominal injuries like an appendectomy we should consider this two fold: (1) The Rectus Sheath and (2) The Abdominal Sheath and the Superficial and Deep Front Lines.
The rectus sheath is formed by the aponeuroses of the three flat muscles, and encloses the rectus abdominus and pyramidalis muscles. It has an anterior and posterior wall for most of its length:
- The anterior wall is formed by the aponeuroses of the external oblique, and of half of the internal oblique.
- The posterior wall is formed by the aponeuroses of half the internal oblique and of the transversus abdominus.
But what about the front line connective tissue? Should that not be included when discussing the complexity of the abdominal cavity and strength of the front line connective tissue? Yes!
The Abdominal Sheath & The Superficial and Deep Front Lines:
If we include the superficial front line to the integral working of “the abdominal sheath,” we can see that the entire structure starts at the feet, then travels up the front of the body and all the way to the neck and skull. The Superficial Front Line acts to contract the front of the bod.
The Deep Front Line makes up our myofascial “axial core.” This means that out of all the myofascial meridians, it is the deepest and has the function of maintaining our core alignment and core stability.
The orientation of fibers in the muscles of the left and right abdominal wall; give it strength and flexibility of movement in many directions. By contrast, the fibers of the rectus sheath are oriented for flexing the trunk.
The anterior wall is reinforced by the tough rectus sheath and one muscle. Since the sheath is composed of aponeuroses anchored at the midline, the lateral muscles oppose one another to make the trunk of the body rigid when they contract (for structural support or to increase intra-abdominal pressure).
One other notable fact is that the anterior rectus sheath is complete, but the posterior sheath is deficient (absent) below the arcuate line (linea alba).
The layers of the abdominal wall consist of (external to internal):
- Superficial fascia (or subcutaneous tissue)
- Muscles and associated fascia
- Parietal peritoneum
“The Core” of An Appendectomy:
What is the appendix?
The appendix produces a bacteria destroying protein called immunoglobulins which help fight infection in the body. Its function, however, is not essential; however there is some evidence to suggest it play a role in maintaining a healthy gut. People who have had appendectomies do not have an increased risk toward infection. Other organs in the body take over this function once the appendix has been removed.
In most laparoscopic appendectomies, surgeons operate through 3 small incisions (each ¼ to ½ inch) while watching an enlarged image of the patient’s internal organs on a television monitor. In some cases, one of the small openings may be lengthened to 2 or 3 inches to complete the procedure. The notable factor here, is one of those incisions (for me) is directly above my belly button.
How can the incisions affect the function of the superficial fascia?
The superficial fascia consists of fatty connective tissue. The composition of this layer depends on its location:
- Above the umbilicus: A single sheet of connective tissue. This continuous with the superficial fascia in other regions of the body.
- Below the umbilicus: It is divided into two layers; the fatty superficial layer (Camper’s fascia) and the membranous deep layer (Scarpa’s fascia). Superficial vessels and nerves run between these two layers of fascia.
The umbilicus is the most visible structure of the abdominal wall, and is the scar of the site of attachment of the umbilical cord. It is usually midway between the xiphoid process and the pubis symphysis.
The linea alba is poorly vascularised, so blood loss is minimal, and major nerves are avoided. All can be used in any procedure that requires access to the abdominal cavity. This is a common site for incision because it can leave minimal scar tissue.
Understanding the nature and complexity of the human structure can aid in supporting your rehabilitation program. Fiber composition, the body natural inflammatory response, and the body’s ability to compensation post op is equally important to reduce the impact of surgery, as well as reduce the risk of tissue restrictions and movement dysfunction.
When there are alterations made to our structure, even the smallest of cuts changes the way our body moves, adapts and responds. Our viscera is the gateway to our nervous system and when recovering from surgery we must take this into account and begin to rebuild from the inside out.
Regarding rehabilitation, understanding that the tissue around the incision is only 60% repaired for the first 4 weeks after surgery means you should take care when re entering your sport or hitting the gym. Hernia’s are the biggest consideration when returning back to work or sport after an appendectomy. Make sure to consult with your surgeon or GP prior to engaging in physical activity post surgery. Use this as a time to nurture and honor other priorities in your life so that when you do get back to your sport, you are 100% and ready to pick up where you left off.
Next week, we will look at rehabilitation and corrective movement to reduce the risk of movement dysfunction in post operative patients appendectomy.
University of Michigan Medical School – Clinical Case, Abdominal Wall
Instant anatomy – Anatomy lecture made easy – Anterior abdominal wall