Anatomy, Anterolateral Abdominal Wall Veins


Article Author:
Abel Joseph


Article Editor:
Hrishikesh Samant


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Jasleen Jhajj
Cliff Caudill
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Phillip Hynes
Tehmina Warsi


Updated:
12/6/2018 4:04:00 PM

Introduction

The anterolateral abdominal wall includes the front and side walls of the abdomen.

The venous drainage of the superficial anterolateral abdominal wall involves an elaborate subcutaneous venous plexus. This plexus drains superiorly and medially to the internal thoracic vein. It drains superiorly and laterally to the lateral thoracic vein. Further, the plexus drains inferiorly to the superficial epigastric vein and the inferior epigastric vein which are tributaries of the femoral vein and external iliac vein, respectively.

A layer of connective tissue lining the abdominal cavity namely the extraperitoneal fascia lies deep to the transversalis fascia and contains varying amounts of fat. The vasculature extending into mesenteries is located in this extraperitoneal fascia which is abundant on the posterior abdominal wall, especially around the kidneys, and continues over organs covered by peritoneal reflections.

Structure and Function

The veins of the anterolateral wall carry deoxygenated blood into the systemic venous circulation and back to the lungs for oxygenation. The superficial abdominal veins dilate and provide a collateral circulation when the portal vein, superior vena cava, or the inferior vena cava get obstructed. The obstruction causing dilated, distended, and tortuous veins often resembles the venomous serpents on the head of the Greek god “Medusa” giving rise to the term “Caput Medusae.”[1][2][3]

Embryology

Veins of the systemic circulation are derived from the vitelline veins, and a portion of the inferior vena cava (IVC) along with the portal venous system is derived from the cardinal veins of the abdominal wall, which drains into systemic veins.

Blood Supply and Lymphatics

The veins of the anterolateral abdominal wall accompany the arteries supplying the anterior abdominal wall.[4][5][6]

Veins

Superficial Venous Drainage

The venous drainage of the anterior abdominal skin around the midline is by branches of the superior and inferior epigastric veins. The skin of the flanks is drained by branches of the intercostal, lumbar, and deep circumflex iliac veins. Also, the skin in the inguinal region is drained by the superficial epigastric, the superficial circumflex iliac, and the superficial external pudendal veins, tributaries of the femoral vein.

  1. The anterior cutaneous veins carrying deoxygenated blood from the superficial abdominal wall are tributaries of the superior and inferior epigastric veins and accompany the anterior cutaneous nerves.
  2. The lateral cutaneous veins are tributaries of the lower intercostal veins and accompany the lateral cutaneous nerves.
  3. These superficial inguinal veins drain into the femoral vein and drain the skin of the lower part of the abdomen. The superficial epigastric vein runs upward and medially and drains the skin up to the umbilicus. The superficial external pudendal veins run medially passes in front of the spermatic cord and drain the skin of the external genitalia, and the adjoining part of the lower abdominal wall. Laterally, the superficial circumflex iliac vein runs just below the inguinal ligament and receives blood from the skin of the abdomen and thigh.

Deep Venous Drainage

The anterior abdominal wall is drained by:

  1. Two large veins from above: the superior epigastric (medial) and musculophrenic (lateral)
  2. Two large veins from below, the inferior epigastric and the deep circumflex iliac
  3. Small tributaries of the intercostal, subcostal and lumbar veins, which accompany the corresponding arteries

The superior epigastric vein and Musculophrenic vein are the 2 terminal tributaries of the internal thoracic vein inferior epigastric vein. The anterior intercostal veins carry deoxygenated blood from the diaphragm, the anterior abdominal wall and the seventh, eighth and ninth intercostal spaces and continues upward and laterally along the deep surface of the diaphragm as far as the tenth intercostal space part of the abdominal wall

The inferior epigastric vein drains into the external iliac vein near its lower end just above the inguinal ligament. It runs upward and medially in the extraperitoneal connective tissue, passes just medial to the deep inguinal ring, pierces the fascia transversalis at the lateral border of the rectus abdominis and enters the rectus sheath by passing in front of the arcuate line. Within the sheath, it drains the rectus muscle and ends by joining with the superior epigastric vein.

The venous drainage from the lateral abdominal wall drains above mainly into the axillary vein via the lateral thoracic vein and below into the femoral vein via the superficial epigastric and the superficial circumflex iliac vein. The level of the umbilicus is a watershed. Venous blood and lymphatic fluid drain upward above the plane of the umbilicus and flows downward below this plane.

Surgical Considerations

Veins of the anterolateral wall can get dilated due to multiple causes. Obstruction to the superior vena cava or inferior vena cava (by a mass or thrombus) can present as dilated, tortuous veins over the abdomen. Urgent surgery may be required in such situations. Supra-umbilical median incisions through the linea alba have several advantages such as being bloodless as most vasculature courses lateral to the linea alba. Furthermore, these incisions are safe to muscles and nerves but tend to leave a postoperative weakness through which a ventral hernia may form.[7]

Clinical Significance

Among the sites at which tributaries of the portal vein anastomose with systemic veins (portocaval anastomoses), the umbilicus is one of the important sites. Cutaneous veins surrounding the umbilicus (tributaries of the superficial and inferior epigastric vein) anastomose with small tributaries of the portal vein called paraumbilical veins. Elevated pressures of the portal venous system cause these anastomoses to recanalize to create dilated veins radiating from the umbilicus called the caput medusae and can also result in esophageal and rectal varices. However, the blood flow in the dilated veins is normal and does not break the barrier of the watershed line.

Blockage of the hepatic portal vein or vascular channels in the liver can interfere with the pattern of venous return from abdominal parts of the gastrointestinal system. Vessels that interconnect the portal and caval systems can become greatly distended and tortuous, allowing blood in tributaries of the portal system to bypass the liver, enter the systemic caval system, and thereby return to the heart.

In a vena caval obstruction, the thoracoepigastric veins open up, connecting the great saphenous vein with the axillary vein. In a superior vena cava obstruction, the blood in the thoracoepigastric vein flows downwards, breaking the barrier of water-shed line. In an inferior vena cava obstruction, the blood flows upward, once again crossing the watershed line.


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Anatomy, Anterolateral Abdominal Wall Veins - Questions

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Which of the following vessels runs parallel to the round ligament of the liver?



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A 45-year-old male patient is diagnosed with portal hypertension from hepatitis C cirrhosis. Which of the following is the only benign portosystemic anastomosis, arising as a complication of increased portal venous pressure?



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A 24-year female presents to the clinic complaining of abdominal distension. She reports irregular menstrual cycles and breast tenderness. On abdominal examination, there is superficial abdominal venous engorgement below the umbilicus. On pelvic examination, there is a non-tender adnexal mass. Which of the following is likely responsible for the patient's venous dilation?



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A 44-year-old male presents to the clinic with a cough and hemoptysis. He noticed blood on the tissue following an episode of cough. He reports a 44-pack-year smoking history. On further questioning, he reports a 4 kg weight loss over the past two months. On examination, He appears emaciated, and there is superficial abdominal venous engorgement. Other system examinations are within normal limits. Chest x-ray reveals a superior mediastinal mass. Obstruction of which of the following structures is most likely responsible for the venous engorgement?



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A 60-year-old male is diagnosed with alcoholic cirrhosis. Which of the following is the embryological derivative of the veins causing his abdominal varicosity?



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Anatomy, Anterolateral Abdominal Wall Veins - References

References

Tucker WD,Burns B, Anatomy, Abdomen and Pelvis, Inferior Vena Cava null. 2018 Jan     [PubMed]
Tröbinger C,Wiedermann CJ, Bodybuilding-induced Mondor's disease of the chest wall. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2017 Jan     [PubMed]
Barber B,Horton A,Patel U, Anatomy of the Origin of the Gonadal Veins on CT. Journal of vascular and interventional radiology : JVIR. 2012 Feb     [PubMed]
Alvarez-Garrido H,Garrido-Ríos AA,Sanz-Muñoz C,Miranda-Romero A, Mondor's disease. Clinical and experimental dermatology. 2009 Oct     [PubMed]
Nagasaki S,Nishiguchi S,Branch J, Portal hypertension, oesophageal varices     [PubMed]
Giambelluca D,Caruana G,Cannella R,Picone D,Midiri M, The     [PubMed]
Bartolo M,Bartolo M,Amoroso A,Bonomo L, [Mondor's disease. Report of 22 cases]. Recenti progressi in medicina. 1993 Nov     [PubMed]

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