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THE ABDOMINAL WALL: STRUCTURE & FUNCTION OF WOUND HEALING

THE ABDOMINAL WALL: STRUCTURE & FUNCTION OF WOUND HEALING

Sarah Jamieson / News, Reflections, Thoughts, Tips / / 0 Comment

Incision and closure of the abdominal wall is one of the most frequently performed; yet least discussed, of surgical procedures. Another often over looked topic is; understanding the rehabilitation process and post surgical care. Placing the power in the clients hands and arming them with the knowledge to self manage the healing process can significantly reduce movement dysfunction caused by scar tissue or change in posture habits and inactivity; as well as, a basic understanding of the timeline for wound healing and wound health.

The structural integrity of the anterior abdominal wall depends upon the rectus abdominis muscles, the muscles of the flank, and the conjoined tendons of the flank muscles that combine to form the rectus sheath. These terms, the anatomy and function were introduced in length in my last article. The rectus abdominis muscle is found on either side of the midline with the pyramidalis muscle lying superficial to the rectus muscle just above the pubis.

Factoring in connective tissue; we mentioned the rectus sheath also forms and intertwines with the superfiscial front line and the deep front lines of the fascia matrix. However, two notable structures are often overlooked when discussing abdominal wall surgery and post surgical care. They are the pyramidalis and the transversalis fasica.

 

abdominal wall 1

The Pyramidalis:

One important muscular structure that is often not discussed in re training/ re patterning post-surgical rehabilitation is the pyramidalis.

The pyramidalis muscles arise from the pubic bones and insert into the linea alba in an area several centimeters above the symphysis pubis. Normally, the precise function of the pyramidalis muscle is unclear and considered to be of no value in the human structure. That is until abdominal incisions are made along the linea alba and near the umbilicus. The function this muscle acts to contact the linea alba, as well as stabilize the pelvis.

Therefore, if scar tissue or adhesion builds up, as it naturally will due to cutting through the abdominal wall and connective tissue, the innervation and nerve response could be diminished. In many patients, I have worked with I have seen Si joint dysfunction and low back pain that was not present prior to surgery. Something to consider in rehabilitation.

Transversalis Fascia 

Deep to the muscular layers, and superficial to the peritoneum, lies a layer of fibrous tissue called the transversalis fascia, which lines the abdominal cavity. It is visible during abdominal incisions as the layer just underneath the rectus abdominis muscles.

It’s importance lies in the nature of it’s structure. The transversalis fascia in its entirety is second in importance perhaps only to the peritoneum as an encasing membrane of the abdominal contents. It acts to reinforce and stabilize the spine, as well as regulate intra abdominal pressure. Where function demands, it thickens and develops its strong elastic fibers to a protective perfection. When there are multiple incisions necessary for surgery, like a laparoscopic appendectomy this wall is perforated and comprised for several weeks to months. Tissue strength is a integral concern and factor in corrective rehabilitation; as well as wound healing.

WOUND HEALING:

Understanding the fundamental processes that are responsible for these functions is necessary to best create and close an abdominal incision and limit the risk of inflection, as well as to understand the complex process of healing post surgery.

Inflection is the first major risk; or failure of the healing process to synthesize adequate quantities of collagen to restore abdominal wall strength.

Psychoneuroimmunology (PNI):  (Pyschological + Neurological + Immunology)

The wound-healing process is a balance between the amount of damage done to the tissue during an operation, and the ability of the body to decontaminate and repair its function.

With any incision, there is exposure of blood and platelets to connective tissue; which ultimately begins the inflammatory response that will sterilize and heal the wound. Psychoneuroimmunology (PNI) plays a critical role in both healing and immune function at the biological and biochemical levels. PNI is the study of the interaction between psychological processes,  the nervous and immune systems of the human body.  Recent work in psychoneuroimmunology (PNI) has demonstrated that stress delays wound healing; which is directly related to the pre and post surgical anxiety and nervousness a patient will ultimately feel.

Greater fear or distress prior to surgery is associated with a slower and more complicated postoperative recovery because anxiety presumably interferes with recuperation through both behavioral and physiological mechanisms. Seems logical enough.

Listening to mindful music for an hour every day can reduce chronic pain by up to 21% and depression by up to 25%, but I will leave that stat for another article.

Our body’s nature inflammatory response

During the initial phases of this process, the small vessels in the region of the injury become permeable to both molecular and cellular mediators of the inflammatory response. First, healing is under the direction of the inflammatory response, as this is essential to eliminating bacteria; as well as immunology. Every person has a unique biological and biochemical healing process; which should be taken into account.

After this initial phase, the polymorphonuclear neutrophils (PMNNs) and wandering tissue macrophages begin their work of digesting damaged tissue, killing bacteria, and synthesizing the chemotactic factors that direct wound repair. These cells lay the groundwork for the later appearance of the fibroblast that will reestablish wound strength.

The next critical factor in proper healing is the amount of necrotic tissue created. Actual repair must begin from healthy tissue. Healing must then begin from the uninjured tissue behind the area of damage.

Collagen & Tissue Strength

The re-establishment of abdominal wall strength depends upon the synthesis of new connective tissue. This is accomplished by fibroblasts and requires, not only the protein precursors for collagen synthesis, but also occurs most rapidly in a normally oxygenated environment where the enzymes and cofactors needed for collagen synthesis are present.

Collagen, the primary structural protein of the body, is synthesized by the fibroblast. It begins to appear in the wound on the second day, as an amorphous gel devoid of strength. Maximum collagen synthesis occurs around the fifth day. It depends especially upon the presence of oxygen, vitamin C, and amino acid precursors.

Maximum strength development does not occur for several months and depends upon the interconnection of the collagen subunits. Approximately 80% of original strength is reached in about 6 weeks; therefore it is recommended that light activity building up to moderate activity are only encouraged after 6 weeks and as long as there is no pain or discomfort.

It is important to recognize that perfusion of the wound is the most important factor in wound healing. Integrity of the microvasculature and flow is responsible for the oxygenation needed for cellular metabolism. Damage to tissue that impairs the delivery of oxygen to the wound increases the number of wound infections and the likelihood of herniation or infection. Which could complicate and impair movement quality in the future.

CONCLUSION:

Empower the patient is first and foremost. Education each client on the complex healing process and concerns moving forward with post surgical care is crucial to not only the healing process but self management on behalf of the client. Understanding tissue strength and the body’s healing process from the inside out is of equal importance when re entering sport, play and or professionals that require manual labor.

Sources:

  • Milloy FJ, Anson BJ, McAfee DK: The rectus abdominus muscle and the epigastric arteries. Surg Gynecol Obstet 110: 293, 1960
  • Cruse PJE, Ford R: The epidemiology of wound infection: A 10-year prospective study of 62,939 wounds. Surg Clin North Am 60: 27, 1980
  • Cherney LS: A modified transverse incision for low abdominal operations. Surg Gynecol Obstet 72: 92, 1941
  • Surgical anatomy of the transversus abdominis and transversalis fascia. Ann Surg. Jan 1971; 173(1): 1–5.

 

 

Getting to the “CORE” of the Abdominal Wall Post Surgery

Getting to the “CORE” of the Abdominal Wall Post Surgery

Sarah Jamieson / News, Reflections, Tips / / 0 Comment

lap

 

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:Abdominal-Muscles-Rectus-Abdominis

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).

mm-superficial-front-line

The layers of the abdominal wall consist of (external to internal):

  1. Skin
  2. Superficial fascia (or subcutaneous tissue)
  3. Muscles and associated fascia
  4. 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.

Laparoscopic Surgery:

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.

Conclusion:

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.

Sources:

Anatomy Trains

University of Michigan Medical School – Clinical Case, Abdominal Wall

Instant anatomy – Anatomy lecture made easy – Anterior abdominal wall

Getting to the “Core” of POSTURE: What’s in your “TRUNK”?

Getting to the “Core” of POSTURE: What’s in your “TRUNK”?

Sarah Jamieson / Reflections, Styles, Thoughts, Tips / , , / 0 Comment

The root of many common limitations and injuries in yoga (sore backs, shoulders, hips, etc) often come from a lack of awareness and ability to properly engage trunk muscles and the stabilizing muscles associated with breath; which regulate intra abdominal pressure thereby leaving the joints and spine unsupported and vulnerable. You will notice that in this first sentence I have used the word “trunk” instead of core. The word core, in the fitness industry usually sends both professionals and fitness go’ers in the direction of understanding to merely include the abdominals groups (inner and outer unit etc); whereas, the word trunk brings to mind not only the core group of abdominals and pelvic stabilization muscles, but the postural muscles of the spine, serratus group associated with breath and muscle that connect the shoulders to the hips, and fascial lines. As well as, from a strength and conditioning standpoint, your trunk is your powerhouse, it’s the epicenter of  reactionary movement and control.

The various syndromes we have looked at have targeted either the shoulder girdle or the pelvic girdle, as separate syndromes so that we could portray the articulation and understanding of each classified group of breakdowns. In this article we integrate the two by showcasing the postural integration of the trunk and associated movement patterns.

One key component of movement incompetency and structural breakdowns is asymmetry. As we know the importance of identifying asymmetry and movement in competency is to avoid building stability over poor mobility. Movement incompetency may demonstrate altered motor control, a neurodevelopmental component, or regional interdependence.

When we exercise or increase mobility to an already dysfunctional joint, this creates greater dysfunction resulting in a poor outcome to treatment and possible further injury.

What’s in your trunk, and how do you screen for instability?

In the FMS screen (as mentioned previously) is a diagnostic tool for health professionals and coaches to use to screen 7 common movement patterns.  The Trunk Stability Push Up demonstrates pain, global muscle weakness, hyperextension of the lumbar spine, and “winging of the scapula”. Positive findings can indicate weak or inhibited core pelvic, and postural stabilizers including a lack of symmetrical trunk stability.

The first signs of most postural and muscular imbalance usually develop in the patient’s static pelvic positioning in tandasana (mountain pose), best while in the focus of the breath.

As in the LCS an anterior tilting of the pelvis suggests shortening of the hip flexors (iliopsoas, rectus femoris and tensor fascia lata) and/or the lumbar spinal extensors. The Posterior tilting of the pelvis suggests tightness of the hamstrings, and a lateral pelvic shifts suggests unilateral shortening of the hip adductors. Thus including weakness of the lateral pelvic stabilizers or leg length inequality; which could also be associated with lumbar motion segment pathology.

Secondarily, observing the general postural attitude, the quality of the lumbar spine lordosis and the symmetry of body landmarks and muscular contours we then can move upward and compare the quality of the spinal extensors, postural muscles in the lumbar and thoracolumbar region bilaterally. Still heading north to the shoulders and carriage of the head. Most often we have touched on rounded shoulders, and weakness in the posterior body, with concurrent tightness in the anterior body.

Predominance of the thoracolumbar musculature could suggest overactivation in gait, poor stabilization of the lumbar spine and is associated with a weak gluteus maximus, especially if you are teaching a room full of runners and cyclists in yoga.

One other focal point to compare is thoracic mobility through motion segmentation. The rib pull or arm stack variation (modified of the “T” rotation in Yoga) will indicate limitations on right and left sides, which then can lead into postural observation in the anterior body, take a peek at the abdominal wall, breathing pattern in a variation of abdominal breathing patterns standing, supine and prone. The role of the abdominal wall and what Tom Meyers calls the “Four Pillars” (for more information please revert back to my “breath for inspiration” article earlier this year) whose role in stabilization and protection of the spine is crucial.

How can we start to integrate better movement, stabilization and connection with our trunk, shoulder and hips?

Best place to start is to understand what it means to re-pattern and “clean up” asymmetries.

1. Muscle function is movement-pattern specific. Isolation does not necessarily improve integrated movement; which is why we “re-train” movement’s not specific muscle. In a stressful (i.e. survival or threatened) environment/situation, the body will always sacrifice movement quality for movement quantity. Our fascia is connected to our ANS which functions on fight or flight for protection of our body.

2. Remember that we must train the CNS (central nervous system): The brain many times, will create a mobility problem, because it’s the only option left. Movements require the communication of our CNS, the governing body which transfers impulses and motor recruitment to primitive memory banks!

3. Motor Control is key! The timing of the stabilizers with the mover muscles is the key to healthy movement quality.  Soft-core/Reactive Core (RC)/low-threshold strategy– this involves the deeper “stabilizer” muscles (aka “Inner Unit or 4 pillars) including TVA, respiratory diaphragm, pelvic diaphragm, pelvic floor, multifidus. Gray cook  calls this “tapping the breaks.”

Next, it’s easy to modify traditional Yoga postures in your class or session format. Keeping in mind you need to identify whether there is a mobility or stability breakdown in movement.

FMS integrated Yoga: Yin, Hatha & Vinyasa Focused:

  • Mobility: T-Spine Rob Pulls and Arm Stack Variations.
  • Mobility/Stability: Modified Vinyasa All fours to Plank to Downward Facing Dog with Arm Reach (Sun Salutation Series)
  • Mobility: Modified wide leg upward facing dog with transverse anterior opening sequence (Sun Salutation Series)
  • Stability: Bridge Single Leg Lock with Posterior/Pelvic Stability
  • Stability: Modified Side Plank Variations and Kneeling Side Angle to Gate Pose variations.
  • Stability: Quadruped Stability Ball Rock with Arm Raise

Next week we will dive further into posture,  structural joint integrity and once again re visit the power behind our breath. Namaste!

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