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Tighten or loosen quickly with a flip of the reversing lever. Surface Drive open end design - eliminates fastener rounding. The forceps is placed between under the anterior pubic ligament that spans over the symphyseal joint. The pyramidalis muscle P arises from the pubic crest and the anterior pubic ligament. The proximal adductor longus tendon white arrow interlaces with the deep portion of the anterior pubic ligament black arrows.

The anterior pubic ligament has transversely orientated fibres black arrows and extends into the inguinal ligament dashed line bilaterally. Pect pectineus muscle. Add adductor longus muscle. RA rectus abdominis muscle. Drawing demonstrating the pyramidalis—anterior pubic ligament—adductor longus complex comprising the pyramidalis muscle P , anterior pubic ligament arrow and adductor longus tendon arrow head and fibrocartilage FC.

The rectus abdominis RA is posterior to the pyramidalis muscle, and its musculotendinous junction cranial to the superior edge of the symphysis. With traumatic avulsion of the adductor longus, the fibrocartilage red dots of the adductor is avulsed in partial tears. Both the fibrocartilage red dots and anterior pubic ligament blue dots avulse in complete tears. The aponeurosis anterior to the pyramidalis muscle and rectus abdominis is comprised of two layers Fig. The superficial layer has oblique orientated fibres, the fibres of the deeper layer have a horizontal orientation and form the fascia anterior to the pyramidalis muscle, and both layers insert into the linea alba Fig.

The anterior pubic ligament is the medial anchor point for the part of the anterior abdominal aponeurosis medial to the external inguinal rings and pubic tubercles and fascia lata. The aponeurosis anterior to the pyramidalis muscle and the rectus abdominis comprises two layers. The superficial layer has oblique oriented fibres arrow right side , and the fibres of the deeper layer have a more horizontal orientation.

The window in the superficial fascia of the left abdominal external oblique muscle demonstrates the transverse orientation of the fibres of the deep layer arrowhead , anterior to the pyramidalis muscle P. A linea alba. S spermatic cord. Note the transversely oriented fibres.

These fibres interlace with the fibres from the rectus abdominis aponeurosis and the linea alba arrowhead. A cord-like linea alba. The deep portion of the anterior pubic ligament is composed of transversely orientated fibres extending medially from the ipsilateral pubic tubercle across the symphysis to the pubic tubercle on the contralateral side.

The ligament attaches to the pubic crest and crosses anteriorly to the symphyseal joint, connecting the pubic bones Fig. A triangular pyramidalis muscle of the inferior abdominal wall on each side of the linea alba was observed in all specimens. The muscle arises from the pubic crest medial to the pubic tubercles Fig. The muscle has no attachment to the anterior aspect of the pubic bone cranial to pubic crest.

The width of the base extends from the pubic tubercle to the symphyseal midline, and no interspace was encountered between the bases of the pyramidalis muscles. The muscle is separated from the rectus abdominis by a thin, but well-defined aponeurosis Fig. The measurements of the anterior surface of the pyramidalis muscle are listed in Table 1.

The pyramidalis muscle is sharply detached from the linea alba white arrows and folded distally. The internal tendons of the rectus abdominis run anterior to the symphyseal joint white line , and the external tendon inserts on the superior lateral edge of the pubis arrowheads.

There is a thin aponeurosis on the posterior side of the pyramidalis muscle P with transverse fibre orientation. This aponeurosis does not cover the pyramidalis muscle anterior to the pubic bone asterisk. Dashed line region of the anterior pubic ligament. The internal tendon of the rectus abdominis receives contributions from left and right sides giving the tendon a Y-shape arrow. The pyramidalis muscle inserts on the anterior pubic ligament, which spans the symphyseal joint and acts like a pulley through its position anterior to the internal tendon of the rectus abdominis muscle.

Measurement of the dimensions of the pyramidalis muscles: the range of measurements per specimen between brackets and average. The anterior tendon fibres interlace with the deep portion of the anterior pubic ligament Fig. The adductor longus fibrocartilage deep to the tendon originates from the anterior pubic body inferior to the pubic crest Figs.

It shows the anterior symphyseal and perisymphyseal area after resection of the pyramidalis muscle and the anterior pubic ligament. It demonstrates that the internal tendon of the rectus abdominis interlaces with the gracilis G and fascia lata arrow.

It shows the footprint of the external tendon of the rectus abdominis arrowheads and the footprint of the adductor longus fibrocartilage large arrow. The adductor longus Add tendon thin arrows and the fibrocartilage asterisk are detached. The rectus abdominis muscle arises from internal and external tendons, respectively Fig. The external tendon is broader and attaches to the cranial border of the pubis between the pubic tubercle and the symphysis.

The internal tendon is slender and interlaces with the contralateral internal tendon and descends below the deep portion of the pubic ligament [which seems to act similarly to a pulley Fig. Additionally, we observed that the musculotendinous junction of the rectus abdominis was proximal to the superior edge of the pubic bone in all specimens Fig.

The most important finding of the present study is introduction of a new anatomical concept, i. In addition, it was observed that the only abdominal muscle anterior to the pubic bone is the pyramidalis and not the rectus abdominis. To our knowledge, this study is the first to systematically examine the pyramidalis muscle and all its connections with the anterior pubic ligament, adductor longus enthesis and rectus abdominis muscle.

A significant advantage of the study is that all dissections were performed on fresh-frozen cadavers, thereby avoiding potential confounders associated with cadaveric embalming such as tissue adhesions and shrinkage [ 10 ]. The current study demonstrated, similarly to other authors [ 8 , 15 — 17 , 26 , 27 ], that the slender internal tendon of the rectus abdominis interlaces with that of the opposite side in the median line and runs only anterior to the symphyseal joint.

A point of disagreement is the insertion of the internal tendon: some authors [ 15 , 25 ] report it connects with the ligaments covering the symphysis pubis; our observations were that the internal tendon in males attaches to the fascia lata and gracilis and this is similar to findings of Schilders [ 27 ] and Schache [ 26 ].

The exact function of the internal tendon of rectus abdominis is unknown. The tendon runs under the deep portion of the anterior pubic ligament, which seems to act as a pulley system and prevents anterior displacement. The present study also demonstrates that the aponeurosis that comprises the superficial layer, covering the lower abdomen, pubis and adductor area, has distinctly different connections than the deeper musculotendinous layer.

Specifically, during our dissection we observed the aponeurosis of the external oblique and anterior rectus sheath to connect with the fascia lata over the adductor area via the anterior pubic ligament superficial portion. During the dissections, it was observed that there are two aponeurotic layers anterior to the pyramidalis muscles, identifiable as an obliqui and a transversalis aponeurosis, based on the observed orientation of each of the respective aponeurotic fibres.

Additionally, we observed a thin aponeurosis, posterior to pyramidalis muscle, which separated it from rectus abdominis. This aponeurosis contains fibres with a distinct, transverse orientation, suggesting this structure most likely represents transversalis aponeurosis.

Such transverse fibres can be readily observed during inguinal surgery. Most anatomical textbooks report that the aponeurosis anterior to pyramidalis and rectus abdominis comprises the obliqui and transversalis, but it is unclear as to whether or not the pyramidalis has a separate sheath [ 15 , 33 ]. Hancock [ 16 ] and Ellis [ 13 ] report that the pyramidalis has it own fascial sheath, and imply that the muscle can contract independently of the recti muscles.

It has generally been assumed that the pyramidalis muscle is not large enough to generate a significant force load. However, a large variety in length 2. Although it was not the aim of the study to report on anatomical variants, we found the pyramidalis was present bilaterally in all specimens examined.

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