Surgical incisions are the division of tissue to expose the desired operative field. It is therefore important to be familiar with the composition and organization of the tissue. Underneath skin, subcutaneous adipose tissue and Scarpa’s fascia, the abdominal wall consists of muscles arranged in layers and their aponeuroses. The external and internal oblique muscles are usually fairly well developed whereas the underlying transversus abdominis muscle can be less prominent. The aponeuroses of all three of those abdominal wall muscles fuse to the rectus sheath towards the center of the abdomen extending from the sternum to the symphysis pubis as shown in Figure 1. The rectus sheath consists of an anterior and posterior layer engulfing the rectus muscles above the arcuate line (approximately the midpoint between umbilicus and symphysis pubis) whereas below this line, the sheath is located solely anterior to the rectus muscles. Underneath the posterior rectus sheath above the arcuate line and directly posterior to the rectus muscle below that line, the transversalis fascia is located, which can be of variable thickness. Preperitoneal adipose tissue and the parietal peritoneum are the remaining tissue layers before entering the abdominal cavity.
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