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Subcostal plane

The subcostal plane is a horizontal (transverse) anatomical plane in the human body that passes through the lowest points of the 10th costal cartilages on both sides of the abdomen, lying just inferior to the costal margin and corresponding to the level of the third lumbar vertebra (L3).^[1]^[2] This plane serves as a key surface landmark in abdominal anatomy, intersecting with vertical lines such as the midclavicular lines to divide the abdomen into nine regions: the upper three (epigastric, right and left hypochondriac) above the subcostal plane, and the lower six below it.^[3]^[4] In clinical and radiological contexts, the subcostal plane is essential for localizing intra-abdominal structures and pathologies on imaging studies, such as CT or MRI scans.^[4] It marks the approximate level of the origin of the inferior mesenteric artery from the abdominal aorta, as well as the third (horizontal) part of the duodenum.^[4]^[5] The plane's position relative to the rib cage—specifically the 10th costal cartilage—makes it a reliable external reference for surgical planning, physical examination, and anatomical education, distinguishing it from superior planes like the transpyloric plane (at L1) or inferior ones like the intertubercular plane (at L5).^[2]^[5] Variations in body habitus may slightly alter its vertebral alignment, but it consistently bisects the L3 vertebral body in standard anatomy.^[4]

Anatomy

Definition and Position

The subcostal plane is defined as a transverse, or horizontal, plane that passes through the inferior margins of the 10th costal cartilages on both sides of the body.^[2]^[4]^[3] This plane forms an imaginary horizontal line across the anterior abdominal wall, positioned just inferior to the costal margin, which marks the lower boundary of the rib cage.^[2]^[4] In standard anatomical orientation, it lies perpendicular to the median plane, providing a key reference for subdividing the trunk.^[3]^[6] In adults, the subcostal plane is typically located at the level of the third lumbar vertebra (L3) posteriorly, aligning the anterior surface anatomy with deeper skeletal structures.^[2]^[4]^[1] This positioning situates it superior to the pelvic brim and inferior to the diaphragm, effectively separating the upper abdominal region from the lower thoracic structures above and the pelvic region below.^[7]^[6] The plane's transverse nature ensures it intersects the body uniformly from side to side, facilitating consistent anatomical descriptions across individuals.^[3]^[5]

Anatomical Landmarks and Variations

The subcostal plane is defined by a transverse line connecting the lowest points of the 10th costal cartilages bilaterally, marking the inferior boundary of the thoracic cage on the anterior abdominal surface.^[4]^[3] This landmark provides a palpable and reproducible reference for dividing the abdomen, primarily based on the costal margins rather than pelvic structures.^[5] In standard anatomical descriptions, the subcostal plane corresponds to the level of the third lumbar vertebra (L3).^[4]^[8] However, in vivo assessments using computed tomography (CT) scans of 108 supine adults (aged 18–97 years, mean 60 years; 59% female) scanned at end-tidal inspiration reveal that it aligns with the second lumbar vertebra (L2) in 58% of cases (30% upper L2, 28% lower L2), with the remainder ranging from the T12/L1 intervertebral disc to the upper border of L3.^[9] The study excluded patients with kyphosis, scoliosis, abnormal lordosis, space-occupying lesions, or visceromegaly. These findings highlight discrepancies between cadaveric and living body references, potentially due to respiratory phase (end-tidal inspiration) and postural effects during imaging.^[9] Anatomical variations in the subcostal plane's position arise from factors such as body habitus, including obesity, which can alter the apparent level through increased soft tissue depth, and posture, which influences the projection of costal landmarks.^[8] Age and sex differences show no significant impact in controlled CT studies of adults aged 18–97 years (59% female), but broader population variability underscores the need for individualized assessment in clinical contexts.^[9]

Role in Abdominal Subdivision

Division into Regions

The subcostal plane serves as the superior horizontal demarcation in the standard nine-region scheme for abdominal compartmentalization, intersecting with the transtubercular plane inferiorly and two vertical midclavicular lines to delineate three horizontal tiers of regions.^[10] This configuration separates the uppermost tier—comprising the right and left hypochondriac regions laterally and the epigastric region centrally—from the middle tier of right and left lumbar regions and the umbilical region.^[3] The lowermost tier, including the right and left inguinal regions and the hypogastric region, lies below the transtubercular plane, with the subcostal plane thus indirectly bounding the superior aspects of the middle and lower regions.^[4] In the four-quadrant abdominal division, which employs a transverse plane at the level of the umbilicus and a vertical median plane, the subcostal plane lies within the upper quadrants (right upper and left upper), above the horizontal divider to help contextualize the extent of the upper abdominal cavity.^[10] While the four-quadrant system primarily uses the umbilical plane for horizontal separation, the subcostal plane provides an additional reference for distinguishing upper abdominal contents from those in the lower quadrants (right lower and left lower).^[3] Regions superior to the subcostal plane, such as the hypochondriac and epigastric areas, encompass structures including the liver, gallbladder, stomach, pancreas, and spleen.^[10] In contrast, areas inferior to this plane, including the lumbar, umbilical, inguinal, and hypogastric regions, contain elements like the small intestine, ascending and descending colon, bladder, and sigmoid colon.^[3] Occasionally, the transpyloric plane may substitute for the subcostal plane as the superior horizontal boundary in variations of these divisions.^[4]

Relation to Other Planes

The subcostal plane, positioned at the level of the third lumbar vertebra (L3), lies inferior to the transpyloric plane, which is located at the first lumbar vertebra (L1).^[6]^[4] This relative positioning distinguishes the subcostal plane's role in surface marking the lower costal margins from the transpyloric plane's deeper anatomical significance, such as aligning with the pylorus of the stomach, the origin of the superior mesenteric artery, and the neck of the pancreas.^[6]^[11] In contrast, the subcostal plane is superior to the intertubercular (or transtubercular) plane, which passes through the tubercles of the iliac crests at the upper border of the fifth lumbar vertebra (L5).^[6]^[4] These two planes, separated by approximately 10 cm in the average adult, serve as the superior and inferior horizontal boundaries, respectively, in the standard subdivision of the abdomen into nine regions when intersected by paired vertical midclavicular lines.^[6]^[11] This orthogonal grid formed by the subcostal and intertubercular planes with sagittal (midclavicular) and coronal (parasagittal) vertical lines enables precise localization of abdominal structures across the hypochondriac, lumbar, and iliac regions.^[4]^[11]

Clinical Applications

Surgical and Procedural Use

The subcostal plane serves as a critical surgical landmark for upper abdominal procedures, guiding incisions that provide access to the liver, gallbladder, and biliary tree while minimizing disruption to the costal margin and associated neurovascular structures. In open surgery, the Kocher incision, a right subcostal approach, is positioned approximately 2-3 cm inferior and parallel to the right costal margin, extending from the midline to the mid-axillary line; this placement allows muscle splitting in the aponeurotic plane of the transversus abdominis, reducing the risk of intercostal nerve injury that could occur if the incision encroaches on the inferior rib border.^[12]^[13]^[14] This incision is particularly employed in cholecystectomy and hepato-biliary surgeries, where the plane's position superior to the intestines and inferior to the liver facilitates direct exposure without excessive retraction; for instance, it enables safe mobilization of the gallbladder while preserving diaphragmatic attachments. In laparoscopic contexts, subcostal ports are routinely placed along this plane—typically two 5-mm trocars in the right upper quadrant—for procedures like cholecystectomy, allowing optimal triangulation and instrument maneuvering in the upper abdominal cavity.^[15]^[16]^[17] Historically, the subcostal approach gained prominence in the late 19th century through the work of Swiss surgeon Emil Theodor Kocher (1841-1917), who refined it for standardized biliary access amid early advancements in abdominal surgery, contributing to reduced postoperative morbidity compared to midline incisions. Misidentification of the plane, often due to anatomical variations in costal cartilage or obesity, can lead to complications such as intercostal nerve entrapment causing chronic pain, wound infections, or incisional hernias.^[18]^[19]^[20]

Diagnostic and Imaging Relevance

In physical examination of the abdomen, the subcostal plane serves as a key horizontal landmark for dividing the region into upper and lower portions, facilitating palpation to detect tenderness, organ enlargement, or masses that may indicate pathology such as peritonitis or hepatomegaly.^[21] For instance, tenderness above the subcostal plane can suggest upper abdominal issues like gastric or hepatic disorders, while findings below it may point to lower abdominal conditions, aiding in differential diagnoses such as distinguishing epigastric pain from appendicitis-related symptoms.^[22] Accurate identification of this plane is crucial for reliable localization during auscultation and percussion as well, as variations in its position due to body habitus can affect clinical interpretation.^[23] In medical imaging, the subcostal plane provides a standardized transverse reference for aligning and interpreting scans, particularly in ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) protocols to evaluate abdominal organ positions and pathologies.^[24] Ultrasound commonly employs a subcostal transducer position to visualize the liver in transverse views, allowing assessment of its size, texture, and lesions, while also capturing the upper pole of the right kidney adjacent to the liver for detecting hydronephrosis or tumors.^[25] CT and MRI slices at or near the subcostal level (typically corresponding to the L3 vertebral body) help delineate the inferior liver margin and superior renal poles, enabling precise localization of subcostal masses that may signal hepatic neoplasms or abscesses.^[23]^[26] The diagnostic significance of the subcostal plane extends to pathology localization, where deviations in organ positioning relative to this plane can indicate conditions like ectopic kidneys or diaphragmatic hernias, with imaging confirming whether the upper renal pole lies at or below the plane in cases of maldescent.^[27]

References

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plane | Taber's Medical Dictionary
subcostal plane. A horizontal plane passing through the lowest points of the 10th costal cartilages. It lies approx. at the level of the third lumbar vertebra.Missing: definition | Show results with:definition
[2]
Subcostal plane - e-Anatomy - IMAIOS
The subcostal plane refers to a horizontal (or transverse) plane which lies just below the level of the costal margin, ie, connecting the 10th costal ...
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Abdominal regions: Anatomy, landmarks and contents - Kenhub
The first horizontal plane is the subcostal plane which runs at the level of the lower edge of the 10th costal cartilage. The second horizontal plane is the ...
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Oct 28, 2021 · subcostal plane. corresponds to a line drawn joining the lower most bony point of the rib cage, usually 10th costal cartilage · transtubercular ...
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Feb 6, 2025 · Subcostal Plane - Typically aligned with the lowermost bony point of the rib cage, it contains the origin of the inferior mesenteric artery.
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Subcostal (upper horizontal) plane. Transversely courses inferior to the costal margin, through the level of the L3 vertebra. The L3 vertebra serves as an ...
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Jun 16, 2016 · A line through the most inferior point of the rib cage gives the position of the subcostal plane, which marks the level of the third lumbar ...
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plane, subcostal plane, and supracristal plane with their variations. Sternal ... age, sex, stature, obesity, and posture. The cardiac apex is located ...
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Surface Anatomy Horizontal lines can be drawn across the subcostal plane (the most inferior aspect of the anterior thoracic cage) and the intertubercular plane ...
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Surgical Access Incisions - StatPearls - NCBI Bookshelf - NIH
Oct 5, 2024 · The Kocher incision, a subcostal incision made inferior and parallel ... incision as needed, and largely avascular plane. Despite being ...
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Jun 3, 2024 · A Kocher incision is made parallel to the subcostal margin to access the underlying liver and biliary tree. It is commonly used for open ...
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A Kocher (subcostal) incision is commonly performed in the right upper quadrant for open cholecystectomy. The skin incision is placed approximately 3 cm below ...
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Abdominal Incisions - Lanz - Kocher - Midline - TeachMeSurgery
Apr 23, 2023 · A Kocher incision (no. ③) is a subcostal incision used to gain access for the gall bladder the biliary tree. The incision is made to run ...
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Mar 1, 2018 · Subcostal Trocar Approach Using Four 5-mm with Exclusive Removal (STAUFFER): An Efficient and Useful Technique for Laparoscopic Cholecystectomy.
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Sep 26, 2017 · The classic technique for minimal invasive laparoscopic cholecystectomy involves four ports: one umbilical port, two subcostal ports, and a single epigastric ...
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Emil Theodor Kocher • LITFL • Medical Eponym Library
Nov 3, 2020 · Kocher incision: subcostal incision performed on the right side ... Kocher Surgical Clamp – used to prevent blood loss during surgery (1882) ...
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Dec 1, 2012 · Among other surgical house- hold terms bearing his name is the Kocher incision, a right subcostal incision used for open biliary sur- gery ...
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Mar 21, 2023 · Oblique Incisions. A Kocher incision is defined as a subcostal incision performed 2 cm parallel to the costal border, either at the right or ...
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Aug 9, 2025 · The aim of this study was to reassess the accuracy of common anatomical planes in vivo using computed tomographic (CT) imaging.
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Sep 8, 2015 · The present study reports the case of a 34-year-old female who came to our attention due to a voluminous mass in the right subcostal region. The ...
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Jun 10, 2021 · Three-dimensional visualization technology can be used for the accurate evaluation of patients with complex abdominal defects before surgery.