Vascular anatomy of the abdominal wall (𝘃𝗮𝘀𝗰𝘂𝗹𝗮𝗿 𝘇𝗼𝗻𝗲𝘀 𝗼𝗳 𝗮𝗯𝗱𝗼𝗺𝗶𝗻𝗮𝗹 𝘄𝗮𝗹𝗹):
Vascular anatomy of the abdominal wall is divided into three zones based on the origin of the blood supply (Fig. 11.5).
𝗭𝗼𝗻𝗲 1 is the central upper abdomen. Superiorly it receives blood supply from the descending superior epigastric artery, a branch of the internal mammary artery. Inferiorly it is supplied by the ascending inferior epigastric artery, a branch of the external iliac artery. As the superior and inferior epigastric arteries run posterior to the rectus abdominis muscle, they supply musculocutaneous perforating vessels (the so-called periumbilical perforator vessels) to the overlying tissues. The superior and inferior epigastric arteries converge in the supraumbilical region.
𝗭𝗼𝗻𝗲 2 encompasses the suprapubic area below the arcuate line. The area is supplied medially by the superficial and deep branches of the inferior epigastric artery. Laterally, blood supply comes from the superficial circumflex iliac artery as a branch of the external iliac.
𝗭𝗼𝗻𝗲 3 is the area superior the arcuate line and lateral to the linea semilunaris. It is perfused inferiorly by the deep circumflex iliac artery and superiorly by the mus-
culophrenic artery as a lateral branch of the internal mammary artery.
When evaluating a patient who requires ventral herniorrhaphy, the blood supply to each zone should be considered as it may be comprised by prior surgical incisions (such as a panniculectomy or paramedian incision) or prior surgical procedure (such as epigastric ligation or abdominal aortic aneurysm repair) (Fig. 11.6).
𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝗶𝗺𝗼𝗽𝗿𝘁𝗮𝗻𝗰𝗲:
𝗭𝗼𝗻𝗲𝘀 1 and 3: Kocher and Chevron incisions generally divide the right and potentially left superior epigastric artery and must be considered in patients who have had open cholecystectomy, liver resection, or liver transplantation. In addition, patients who have had the internal mammary artery harvested for coronary bypass grafting, mediastinal dissection, or mediastinal chest tubes can disrupt the internal mammary, superior epigastric artery, or musculophrenic blood supply to Zones 1 and 3.
𝗭𝗼𝗻𝗲 2: blood supply is at risk with prior paramedian, Mcburney, Rockey-Davis, and Pfannenstiel incisions.
Additionally the periumbilical region is a watershed area with tenuous blood supply in patients with large umbilical hernias and previous midline scars. Failure to excise compromised skin or scar can lead to wound breakdown and surgical site infections.