Anatomy abdomen kasr al ainy

ANATOMY OF THE DIGESTIVE SYSTEM AND RENAL SYSTEM For Second Year Medical Students y Stall Members Department of Anatomy and Embryology Faculty of Medicine Cairo University Staff Members Ehab Abdel-Aziz Hassan Heidar Helana Labib Hafiz Waly Soheir El-Sharouny Saber Shona Mohamed Bakry Emad Naquib Nabila Yousef Abdel-Halim Mohamed Emad Sherif Galal Fayza Abdel-Raouf Abdel-Wakeel Essawy Safwat Wadie Al-Moatasem Bellah Al-Sherif Maha Ashmawy Amina Borhamy Hoda Alaasar Mohamed Wahdan Medhat Morsi Sherif Zaki Naglaa Ali Ayman Abou El-Enein Abeer Oueida Inas Ahmed Hanan Nabeh Mogeda Mahdy Magdy Fouad Walaa Mohamed Sayed Shereen Abdelfattah Tarek Abdelgaiil Ahmed Al-Zainy Doaa Mahmoud Hosam Yehya Sherif Fahmy Tamer Shawky Rasha Abd El Khalek Bahaa Khaled Waleed Abd El Galil Eid Nassar Ahmed Hamed CONTENTS Chapter 1: ANTERIGR ABDOMINAL WAGE yc cisscsmicsaveranieyeiarateauaenueninosaacmntasnemenpeaiwes SUPGMTiCfal FASC: cemaswiziwnenencsmamanimnieanencaminne conn. External Abdominal oblique MUSCIG Internal Abdominal oblique muscle TRANSVEPSUS ADCOMINIS MUSCIE ..........c.ccccccceceeseceecseseesecssvecessecrecesteusereeeeees ......000000..00 ooo ook eeeccee ence oo. cccccceseseesecesserereceeeuerseuseseaseeneuees Rectus ADCOMINIS MUSCIE o......ccccccesccsessenseeeecsssscscsnvesesssenensetsensntenens Pyrainiclals MUMBO: scscciincacisaavconiscuies elaeaniannananenaanneydinmE RECTUG SNGAREN iscsi ae Veins of the Anterior Abdominal Wall .o..0...0.. 0.00.00 Lymphatics of the Anterior Abdominal wall ceeceecenecee eee .....0....0.....ccccceeseeseee sees Nerves of the Anterior Anterior Abdominal Wall Inguinal Peaament: ca aia ..........ccceeeceeeers sun noeee eee errr | itn aie ibeannieanaenes Inguinal Canal 600 Chapter 2: MALE EXTERNAL GENITAL ORGANS ooo... cccecceecececesseceeeeeanesssenss TRSES © amenuncsiecne ee eo Epididymis and vas d@fErens SOGIMGGC CORE Scrotum o..........cccccccccsecseeceeseceescseecessceseseecesecsees sassaainnaene niin iene a Chapter 3: ABDOMINAL CAVITY Regions of the Abdomen and their Contents .............c.ccccecseseesenerens Chapter 4: PERITONEUM Peritorvnal Covet siccncencineeelan eae ea ae aaa | ccna esi Greater Sac Of PerrttOM@uin leai alc sancesacdd necanestecerscuxecoen eee sieenmeeineaence ........c.cccesescccsccccesscscsersnsnseneeencesersusaneueenses Lesser Sac of Peritoneum EPIPIGIC FOPArTiGM — .......ececccsesecseeeccesesecnenseceeneceesecseetsneesateesenersustenseaeass Peritone@al Folds Greater QMeONtum ooo... ccc ce cee ccc ceeceeeecececeecneceeceeceuececcsreesenseeenseceeanecaees ooo... eee cccccccccccsceecceceecuscececceueuseeesueceneasecuavecaeuwe ee | Lesser Omentum #4 Subphrenic Spaces #6 Paracolic Gutters #8 78 80 Umbilical Folels Peritoneal Recesses Chapter 5: go STOMACH Chapter 6: 99 SMALL INTESTINE Duedenum wdc Ra eee eta a ures a Mobile Part of the Small Intestine .occceeeeeesen LARGE INTESTINE 99 107 111 14 Caecum 116 Comparison between the Jejunum and Ileum ee eereae Vermiform Appendix Ascending Colon 119 123 126 128 Colic Flexures Transverse Colon Descending Colon Pelvic (Sigmoid) Colon 130 132 136 138 139 Arterial Supply and lymphatic Drainage of the Colon Nerve Supply of the Colon Rectum and anal camal 0.0... ceceeccccccccccccecceceeveccusausesceuceueuseesesveccecceeceseevne Chapter 7: VESSELS OR THESE Coeliac Trunk easine el ge ss a ata 159 159 Left Gastric Artery Splenic Artery 161 162 Hepatic Artery 164 166 172 175 176 Superior Mesenteric Artery Inferior Mesenteric Artery Portal Circulation Portal Vein Splenic Vein ous Superior Mesenteric Vein Partosystemic Anastomoses 178 180 182 Chapter 8: SPERss sicis ad ie SUH LS SSSH A Nana beaeeenesdlesarsnneaensumanorsanaanersmanrannsuaypautsnaernsniinenyy PeneeeuG DECES 9 saauicaee Lent eee ean 185 189 Chapter 9: LIVER, BILIARY EE STS TEM AND SPLEEN essiscassucasiesenev cess veravaricanwaceascnuiwetvnnies sac saesrepenereancianrinnmeennenimemeaningat ae uenereneupzereannnddentenseace aoe aateNNaRnarnRaManaes Extrahepatic Biliary SYSterm oo... cccececcesecesceseceeseceeceeceenensueessseeccssseesevareereeneee SHIT: osatencteeperencennneecnenenneesanermenesnnssestnerasnrenmreanauptnagernenen suaesegentnegneteacepsusannpenced 192 192 206 213 Chapter 10: KIDNEY, SUPRARENAL GLAND AND URETER ooooo.....ccccccccecccsasecseseseceeereesaeeseeees BIGGS wasnssccicenani ea amend ene aEnna RA OAR aaa: OVENS GFIME RRIEY: x .cscseccsconnavacn copmuaruaennaasennai STR RENW RRS SUprarenal GAM oo... cccseesecseeesecseseceeceuerseseracseceeceacecsecateneeestensescssesseaeceasess UIE escennrsernsennesannesgeeeunserenssicwsanreineeusasimrannssarnunelends crasstaupsuaieiaaetveereaniepaneesnareasi Chapter 219 219 225 230 233 236 11: POSTERIOR ABDOMINAL WAL scssenncceuncereieacinnia wisn eeu te PUNGRMOALOEES sceeesncsezssevenuieoateacneeanrennmier aaa TE POSTCGIGE TAS occa cncecanaceuervennshemnananeel ARERR ENNA Aa teN ea eed amacaes 240 240 245 oon. ccceccececcececaecseeeeeseceusesucesscessesssseccsssveusareasnenaascunsueeesecees 245 COMMON Tia Ary oe. ccc cceeeccecceesceeeesseceeeeteneeceeceecsccececsseeveseceecetusnentinesees PREC SN ANGE PUY: eee Sey aidi vapsen uennaecanvnae reas casueeseoneeunnpetenanerevenessevencanenunes Eferor Vene-Cave: acanwaiecarnancn RSS ERE Nanciasa Anastombpses between LV.ccand SVG. ssiinsowneeenncinidiwwn Lymph Modes-of Tie ABAGINER: scccomecnsccsnnmmuaemueeee eect eka 247 249 251 253 254 255 256 256 262 265 266 266 267 268 268 270 2/1 Ovarian APTOFS CEE IVTE csnsencqsxnnenseynsiereeninieaennodinn ian csmelendiiadsinieasinns lai Gwiecleusen aoeemaremeauetaarekncadys Muscles of the Posterior Abdominal Wall oo... cece cesessceecesenseeerceeceees DIGGIN oe eeeeeceteeeneecesee sees seeeuenee suse ssuuuuesasueeueucnaussussssssssssceusecessusenaveanesenees Psoas Mapor Mischa sccccicescscccieeiiiiiiesiacncorsenececeoennsctenraneecensneresercnnersuearaneneseed Quadratus LUMDONUT: MUSClE: sche ae aha as PSGRS RIGOR MSIE gsc ace ssies azeu es erie ee eee pre ecg re Nerves of the Posterior Abdominal Wall o.0.....0.0..0.0ceccececccceceesececeeceeresneeeneesecseres Lumbar PIGKUS ...ccccc cscs cccsecessesssesseceseececenscersuesessssssecasescnsaecesasesssteecnsnseeeseaseessees Lutribar Part of Sympathetic Chal -syeaccacycisgngenssieeee ei abbadideesaeceneceeeenncs AUTBOETAICPIGRUBES” ss cinasatenannin inane MSR RN cee Chapter 12: Embryology of GIT , Kidnay , Ureter and Testes 274 Anterior Abdominal Wall ET CHAPTER 1 ILOs: By the end of the lectures, the student should be able to: * Qutline the layers of fhe abdominal wail. « Describe the characters of the abdominal fascia. : Explain cases of rupiure bulbar urethra in male. * Describe the origin, insertion, direction of fibers, nerve supply and action of the muscles of the anterior abdarninal wail. * Describe figameni, the structures related to the abdominal superficial and deep inguinal muscles rings, as inguinal conjoint fendon, cremasienc muscle and fascia transversalis and recognize their clinical applications. « List the coverings and constituents of the spermatic cord. * Describe the formation and contents of the rectus sheaih. * Describe the arteries, veins, nerves and lymphatics of the anterfor contents of the abdominal wall. * Describe the site, direction, ends, boundanes and inguinal canal. * Recognize the weak areas of the inguinal canal and the mechanisms which compensate this weakness. * Define hernias and describe their types, causes and structure. Anterior Abdaminal Walt fete ee ANTERIOR ABDOMINAL WALL - It is bounded by the costal margin superiorly and the inguinal ligaments and iliac crests inferiorly. - It is formed of: Boa oe Ge le LP Skin. Superticial fascia. Muscles. Fascia transversalis. Extraperitoneal fat. Parietal peritoneum. i No deep fascia in the anterolateral wall of the trunk (thorax and abdomen). Wine Skin of the Abdomen - The skin of the abdomen is thin and capable of stretching to accommodate for obesity, pregnancy, ascites and distension of hollow organs. - The abdominal skin shows a normal scar in the anterior abdominal wall. The Umbilicus: - tis a depressed scar in the skin of the anterior abdominal wall and in the linea alba, resulted by separation of the umbilical cord stump after birth. - It lies a little below the midpoint of the linea alba. - Itis found in the median plane, at the level of the disc between 3™ and 4" lumbar vertebrae in young adults, but it is lower in infants and its level changes with age and condition of tone of the abdominal muscles. Ue em Anterior Abdominal! Wall ees: 0S Skin External oblique aponeurosis Superiicial Internal oblique muscle fascia Transversus abdominis msucle Fascia transversalis Extraperitoneal fat Parietal peritoneum Conjoint tendon Spermatic cord Inguinal ligament _s Sh | Femoral ring and septum (oe Superior ramus of pubis a Femoral canal and sheath Mf é eee Cribriform fascia Pectineus muscle Layers of the anterior abdominal wall (Longitudinal section at the level of the femoral sheath) | Anterior Abdominal Wallies superficial Fascia - The superficial fascia of the anterior abdominal wall above the level of the umbilicus is formed of a single layer containing variable amounts of fat. - Below the umbilicus the superficial fascia is divided into: 1. Superficial fatty layer (Camper's fascia). 2. Deep membranous The Camper's fascia layer (Scarpa's fascia). is continuous inferiorly, over the inguinal ligament, with the corresponding fascia of the thigh. * In the male, this layer loses its fat and continues over the penis and at the scrotum it loses its fat content which is replaced by non-striated muscle fibers called Dartos muscle (which is supplied by the genitofemoral nerve). * In the female, this fascia preserves its fat content and is continuous in the labia majora. The Scarpa’s fascia is a membranous layer which is loosely connected by areolar tissue to the external abdominal oblique aponeurosis. * Inthe midline it is adherent to the linea alba and the symphysis pubis. * It is thickened and prolonged on the dorsum of the penis to form the fundiform ligament. ° It extends cavernosa to form and the fascia of penis corpus spongiosum and which surrounds separates the beth corpora superficial and deep dorsal veins of the penis. » It descends into the scrotum and perineum forming Colle's fascia which is attached to the posterior border of the perineal membrane forming the superficial perineal pouch which contains bulbar urethra. * Laterally the Searpa's fascia lata about fascia a finger's descends breadth into the thigh to fuse with the below the inguinal ligament horizontal line starting from the pubic tubercle and running laterally). (at a Anterior Abdominal F dppiiva Anatomy: 7. Rupture of the bulbar urethra in the male may be Wali at. followed tae * by extravasation of the urine in the superficial perineal pouch to reach the scrotum, and penis. 2. The urine is collected into the lower part of the abdomen (between Searpa's fascia and the muscles) and it may nse up to the level of fhe umbilicus. 3. Urine doesn't reach the lower limbs because the Scarpa’s fascia is 7 attached to the deep fascia of the thigh. External oblique yl Linea alba aponeurosis Deep membranous layer (Scarpa's fascia) Superticdal Inguinal ring Pubic tubercle Pubic Inguinal ligament _ . Fascia lata arch Saphenous Spermatic card opening Pubic arch Colle's fascia — ~ Great saphenous vein Posterior margin of perineal Membrane Extension and attachment of Scarpa’s fascia a Anterior Abdominal WE Linea alba Scarpa's fascia Camper's fascia Skin — —. Spermatic card Pubis Deep perineal pouch Suberficial perineal pouch Dartos Colle's fascia Fiosinetm muscle Scratum Scarpa's fascia Skin Fundiform ligament of the penis symphysis pubis Penis scrotum spongy urethra Extension and attachment of Scarpa’s fascia (Sagittal section) Anterior Abdominal Wall EFI The muscles of the anterior abdominal wall are arranged in two a. Anterolateral group: formed of three muscles on each external, internal abdominal obliques and the transversus b. Anterior group: formed of two muscles on each side groups: side. These are abdominis. of the median plane. These are rectus abdominis and pyramidalis muscles. Common intercostal nerve supply: and subcostal All these muscles are supplied by lower five (T12) nerves. Internal oblique and transversus abdominis have additional nerve supply from 1° lumbar nerve. Common action: * Increase intra-abdominal pressure, thus help in delivery, defecation, micturition, cough and vomiting. * Protect abdominal viscera and keep them in position. * The oblique muscles bend the trunk laterally while rectus abdominis flex the trunk mainly from the supine position. e External oblique of one side and can do lateral rotation of the trunk. internal oblique of the opposite side Origin: By eight fleshy digitations from the outer surfaces and lower borders of the lower eight ribs, interdigitating with the serratus anterior and latissimus dorsi muscles. Insertion: 1. By fleshy fibers into the anterior 1/2 of the outer lip of the iliac crest. 2. By aponeurosis into the xiphoid process, linea alba, symphysis pubis and pubic crest. Its lower free border is folded upon itself forming the inguinal ligament, which is attached anterior superior iliac spine laterally. to the pubic tubercle medially and Anterior Abdominal Wale Important features: 1. Its fibers run downwards, forwards and medially. 2. It has thee free borders: * Upper horizontal. * Lower free border forming the inguinal ligament. * Posierior vertical free border forming the anterior boundary of the inferior lumbar triangle. 3- The superficial inguinal ring is an opening in the aponeurosis of this muscle. 4- The aponeurosis is prolonged at the external inguinal ring to form the external spermatic fascia. 5- Below a line between anterior superior iliac spine and umbilicus, the muscle becomes aponeurotic., Serratus anterior muscle MM External abdominal Lurribar triangle ae aah eS jae? Muscle + moe ie Latissmuss aa “y sot msucle mae ee F oblique ; 2 ar be ae Inguinal ligament ‘y Quter lip of iliac “crest Superficial inguinal ring External oblique muscle Anterior Abdominal Wall (EP Femoral branch of genito-femoral N. Lateral cutaneous WN. of Inguinal ligament the thigh ae llio-psoas muscle ia 3 a Femoral N. - ~ A) Femoral a. - fF. Spermatic cord Femoral V. et Femoral ring ies Ob Suge ricer lbcpue Apormeuns.s Sere Inequuinel iy ere Co Reflected part of inguinal ligament External Anterior { Pectineal ligament Lcaunar ligament eS external lsqancreennt Femoral actery Lacunar and weim Inguinal ligament of oblaque ligament Pubic tuberchs Anterior Abdominal Wall es) Internal Abdominal Oblique Origin: 1. Thoracolumbar fascia. 2. Anterior 2/3 of the intermediate lip of the iliac crest. 3. Lateral 2/3 of the upper concave surface of the inguinal ligament. Insertion: 1. By fleshy fibers into the lower borders of the lower three ribs. 2. By aponeurosis into 7", 8" and 9" costal cartilages, xiphoid process, linea alba, symphysis pubis, pubic crest and pectineal line. Important features: 1. The fibers run upwards, forwards and medially 2. The lower fibers of this muscle has a triple relation to the spermatic cord: > First anterior to the cord forming the lateral 1/2 of the anterior wall of inguinal canal. ° Arch above the cord forming the roof of inguinal canal. * Finally, the conjoint tendon lies behind the cord farming the medial 1/2 of the posterior wall of inguinal canal. 3. The aponeurosis of this muscle splits at the lateral border of the rectus abdominis into anterior and posterior laminae which extend anterior and posterior to the rectus abdominis muscle to reach the linea alba. 4. The conjoint tendon: (falx inguinalis) * « Itis a sickle-shaped tendon formed of internal abdominal oblique and transversus abdominis aponeuroses. Its base is attached to the pubic crest and pectineal line of the superior pubic ramus. {tis found in front of the rectus abdominis and behind the spermatic cord or the round ligament of the uterus forming the medial 1/2 of the posterior wall of the inguinal canal. * The conjoint tendon is supplied by the ilio-inguinal nerve. 5. Cremasteric muscle: * Origin: From the middle of upper concave surface of inguinal ligament as an extension of the origin of the internal oblique. * Insertion: After forming U-shaped loops around the spermatic cord and testis, it is inserted into the pubic tubercle. * Nerve supply: Genital branch of the genitofemoral nerve (cremasteric nerve). eee ce ae Anterior Abdorina! VT * Action: It supports the weight of the testis and elevates during ejaculation or increased intra-abdominal pressure. * Cremasteric reflex: Stroking the medial the testis side of the thigh results in contraction of cremasteric muscle and elevation of the testis. Thoraco-lumbar fascia Posterior lamina : fF Rectus muscle Anterior lamina Inguinal ligament Lower arched fibres Internal oblique muscle Internal oblique muscle and aponeurosis Inguinal Lower arched — ligament Pubic tubercle —.Spermatic cord Tests Cremasteric muscle fibres Anterior Abdominal Wall (Ey Transversus Abdominis Origin: 1. Thoracolumbar fascia. 2. Anterior 2/3 of the inner lip of iliac crest. 3. Lateral 1/3 of the upper concave surface of the inguinal ligament. 4. Inner surface of the lower six costal cartilages interdigitating with the costal slips of origin of the diaphragm. Insertion: 1. By an aponeurosis into the xiphoid process, linea alba and symphysis pubis. 2. The lowermost fibers run downwards and medially to join the conjoint tendon to be inserted inte the pubic crest and pectineal line. important features: 1. The fibers run transversely (except its lower fibers). 2. It is lined by transversalis fascia. 3. The transversus aponeurosis splits horizontally at the level of the arcuate line. Its upper part extends behind the rectus abdominis sharing in the formation of the posterior wall of rectus sheath, while its lower part extends anterior to the rectus to unite with the internal oblique aponeurasis and both form the conjoint tendon. Rectus Abdominis © Origin: . lt arises from the pubic crest and front of the symphysis pubis. — Insertion: lt is inserted along a horizontal line into: 1. The outer surfaces of the 5", 6" and 7" costal cartilages. 2. |he outer surface of the xiphoid process Important features: 1.lt is a lang muscle which is found on each side of the middle line of the anterior abdominal wall. Anterior Abdominal Wait 2.\ts lateral border is convex and indicated on the skin groove called the linea semilunaris. 3. ltis enclosed in a fibrous sheath called the rectus sheath. by a Pe eee alae shallow 4. |tis divided into segments by three or four tendinous intersections (white collagenous fibrous tissue) which indicate that the muscle is formed by fusion of a number of myctomes. These tendinous intersections are found: * One at a level with the xiphoid process. * * One midway between the xiphoid process and the umbilicus. Qne at the level of fhe umbilicus. * The 4" (if present) is below the umbilicus. These tendinous intersections are seen on the anterior surface and adherent only to the anterior wall of the rectus sheath. only It is a small muscle found in front of the lower part of the rectus abdominis muscle and it may be absent. Origin: Pubic crest. Insertion: Lower part of linea alba. Nerve supply: subcostal nerve, Action: lt stretches the linea alba. Slips. of origin of transversus i muscle Thoracolumbar fascia cheer ——— Inguinal ligament—— Fascia transversalis Transversus abdominis muscle inferior epigastric a: Deep inguinal ring fe Femoral sheath Femoral a. Femoral¥Y. Spermatic cord Femoral candl Testis Deep inguinal ring and femoral sheath Anterior Abdomine! Vi Upper end tins erlion} Tendin cus iInters ections Lmbilicus Lines alba Pyramidalis TES) Lower end erigin Rectus abdominis muscle muscle a) Rectus My muscle Ie ; ~~ Fos Ss free (ohne border Inguinal ligament. , is ata naLLode ony qo [ELL cy Slips of origin of external oblique Anterior Abdominal Wall a Definition: * lt is an aponeurotic sheath enveloping the rectus abdominis and pyramidalis muscles with their associated nerves and vessels. * It is formed by the aponeuroses of the three muscles of the anterolateral abdominal wall. Features: 1. Anterior wall: - |t forms a complete covering for the rectus abcominis. ‘lt is firmly abdominis. attached to the tendinous intersections of the rectus ‘It is thin above and increases in thickness downwards. 2. Posterior wall: * It is deficient above the costal margin. “It is also deficient below a level midway between the umbilicus and symphysis pubis. * lts lower border forms a curved margin called the arcuate line. Formation: 1. Above the costal margin: " The anterior wall is formed by the external oblique aponeurosis. * The posterior wall is deficient. The rectus muscle rests directly on the 5", 6" and 7" costal cartilages. 2.Between the costal margin and a level midway between the umbilicus and symphysis pubis: * The anterior wall is formed of the external oblique aponeurosis and the anterior lamina of the internal abdominal oblique aponeurosis. * The posterior wall is formed by both the posterior lamina of the internal abdominal oblique and the transversus abdominis aponeuroses. ee Anterior Abdominal Wall (7 Serralus anterior Sth costal cartilaga Anterior layer af rectus sheath Anterior layer of rectus sheath Rectus abdominis External oblique External oblique Lateral culanedus nerves Tandinows intersection Antertar culane@ous nerves Anterior superior iliac sping Aponeurasts af external oblique Superticial clreumllex iliat ariery and vein uperticial fascia, membranous layer Superficial epigastric artery and vein External pudendal artery and vein Great saphenous vein ntercrural fibers ch) ‘A. Sania ae = Rectus : 7 j i 4 eae ; sheath ee j F liginguinal nerve Spermatic cord Anterior Abdominal Wall Rae 3. Below the level midway between the umbilicus and symphysis pubis: (i.e. below the arcuate line) ¢ The anterior wall is formed by the aponeuroses of the three muscles (external abdominal oblique, internal abdominal oblique and the transversus abdominis). « The internal abdominal oblique and transversus abdominis aponeuroses unite at the lower part of this wall to form the conjoint tendon. * The posterior wall is deficient and the rectus muscle is directly related to the fascia transversalis. Contents of the rectus sheath: a. Two muscles: Rectus abdominis and pyramidalis. b. Two vessels: Superior epigastric and inferior epigastric vessels. They farm anastomosis at the level of the umbilicus. They lie between the rectus muscle and the posterior wall of its sheath. c. Lower five intercostal and subcostal nerves and vessels. d. Connective tissue, lymphatics (passing from breast to umbilicus) and sympathetic fibers. “ ( Applied anatomy: \ 7. /n paramedian abdominal laterally fo avoid injury of ifs 2. Malignant cells may spread in the rectus sheath leading incision, the rectus muscle is retracted nerve supply. from cancer breast through the lymphatics to malignant nodules in fhe umbilicus. J Rectus Abdominis Coastal Cartilare | Ext. oblique = Transversus aibdeminis tnt. fa oblique Ext. w— 8 =Level I —_ Level 2 a oblique Fascia transverslis Arcuate linc Level 3 tansyersalis 3 aponeuroses Fascia Above the costal margin: External oblique aponeurosis___ Ractus muscle Costal cartilages Below the costal margin: Exiemeal oblique aponeurosis Internal oblique aponeurosis a. Transversusaponaurosig Fascia transversalis ——__ Below a level 1/7 way between umbilicus and symphysis pubis Fascia ransversalis Rectus sheath wails Intemal mammary (thoracic) a. Posterior wall of rectus sheath f- SLUperior epigastric a. Anastamosis—__ Umbilicus — 4 Inferior epigastric a.—— . ° Musculo-phrenic a. Subcostal . — n. ; |lio-hypogastric _— llio-inguinal n. Pyramidalis "i eae | VA wimg a Deep circumflex iliaca, = External iliac a. Femoral Rectus sheath contents a. n. | Anterior Abdominal Wall Tq Fascia Transversalis Definition: It is the fascial lining of the anterior abdominal wall between the abdominal muscles and the parietal peritoneum. Extensions: 1. Superiorly It is continuous with the diaphragmatic fascia. 2. Inferiorly: « At the inner lip of the iliac crest and lateral to external iliac vessels, it is continuous with the fascia iliaca. * At the external iliac vessels, it descends below the inguinal ligament in front of these vessels forming the anterior wall of the femoral sheath. « Medial to the external iliac vessels, it is continuous downwards with the pelvic fascia. 3. Posteriorly: It is continuous with the renal fascia. 4. Anteriorly: It is continuous with the fascia transversalis of the opposite side. The Deep Inguinal Ring The fascia transversalis contains the deep inguinal ring, 1/2 an inch above the midinguinal point, where it extends over the spermatic cord down to the scrotum forming the internal spermatic fascia. Fascia transyersals Diaphragmatic ih Pelvic fascia Ing uifal | ligarent | Fascia Femorar _vesselS Fascia iliaca Laterally ' Fascia iliaca Pubic bone transversalis In between Medially Sagittal section Fascia transversalis _- Renal fascia Kidney Transverse Diaphragm section Diaphragmatic Fascias Diaphragm Diaphragmatic fascia Fascia transversalis Internal Np Tramsversus RAaiNE SanteeTy ant. wall of femoral sheath abdomines Waseia Fasei ‘hee : we ot ransversalis Femural H nerve Post wall of femoral sleath Hiacus —— Felyic Fascia Fascia transversalis Anterior Abdominal Wail EER” Arteries of the Ante rior Abdominal Wall Above the umbilicus: 1. Branches of the internal thoracic artery: a. Superior epigastric artery: It descends behind the 7" costal cartilage to enter the upper part of the rectus sheath to descend down behind the rectus abdominis muscle to the level of the umbilicus where it anastomoses with the inferior epigastric artery. b, Musculophrenic artery: It enters the upper lateral part of the anterior abdominal wall and runs downwards and laterally along the costal margin. 2. Posterior intercostal arteries from the 7" to the 11" and the subcostal artery (branches of the descending thoracic aorta): They descend downwards and medially through the neurovascular plane between the internal oblique and the transversus abdominis to enter the rectus sheath and extend behind the rectus abdominis from lateral to medial. Below the umbilicus: 1. Superficial branches of the femoral artery: a. Superficial epigastric artery. b. Superficial circumflex iliac artery. 2. Branches of the external iliac artery: a. Inferior epigastric artery: * Origin: li arises ligament. * from the external iliac artery just behind the inguinal Course: - lt passes upwards and medially, medial to the deep inguinal ring. - It pierces the fascia transversals and passes in front of the arcuate line to enter the rectus sheath behind the rectus abdominis. = Termination: It terminates at the level of the umbilicus by anastomosing with the superior epigastric artery. Internal thoracic a. Superior epigastric a. Musculo-phrenic a. Posterior wall of - Lower 5 posterior rectus sheath f intercostals arteries ~ Subcostal a. Lumbar ON arteries Ascending branch Y Deep circumflex iliac a. i ”y External iliac a. Arterial supply of anterior and lateral abdominal walls Linea semilunaris ; ; Fascia transversalis Posterior wall of rectus sheath [ Inferior epigastric a. Arcuate line—_____ Cremasteric branch Pubic branch of _ inferior epigastric a. Deep inguinal ring -Externaliliac a. Lacunar ligament-—— CH * Pectineal ligament Obturator Pubic branch Anterior abdominal a. of obturator a. wall seen from (from behind) inside the abdomen | Anferior Abdominal Wat! ee * Branches: 1. Cremasteric artery: It enters the deep inguinal ring and passes as one of the contents of the spermatic cord to supply the cremasteric muscle. It ends by anastomosing with the testicular artery. 2. Pubic branch: - lf descends behind the lacunar ligament and superior pubic ramus to anastomose with the pubic branch of the obturator artery. - In 30% of cases, the obturator artery abnormal obturator artery which epigastric artery. is absent and replaced by is a large pubic branch of inferior { appited Anatomy: » 7. fhe inferior epigastric artery is an important landmark during hemia operation. ff is medial to the neck of the sac of oblique inguinal hernia but lateral to that of direct inguinal hernia. 2. fhe abnormal obturator artery passes just behind the free sharp border of the facunar ligament and it fs Hable for injury during operation for femoral hernia. cll b) Deep circumflex iliac artery: * Origin: It arises from the external iliac artery just behind the inguinal ligament. *« Course: - It pierces the fascia transversalis and passes upwards and laterally ae -2 behind the inguinal ligament to reach the anterior superior iliac spine. - [tt runs on the inner lip of iliac crest where it pierces the transversus abdominis and runs in the neurovascular plane. * Branches: . Muscular branches to the muscles of the anterior abdominal wall. . Anastomotic branches sharing in the anastomosis around the anterior superior iliac spine. Ascending branch arises at the anterior superior iliac spine and ascends to anastomose with the lumbar and musculophrenic arteries. Anterior Abdominal Wal! A. Samer: Above the level of the umbilicus: 1. Superior epigastric vein: runs in the rectus sheath deep to the rectus muscle vein). fo end in the internal thoracic vein (a tributary of innominate 2. Lateral thoracic vein: runs in the superficial fascia on the lateral side of the abdomen and thorax to end in the axillary vein. B. Below the level of the umbilicus: 1. Inferior epigastric vein: runs in the rectus sheath deep to the rectus muscle to end in the external iliac vein. 2. Superficial epigastric and superficial circumflex iliac velms: run in the superficial fascia of the lower part of the abdomen long saphenous vein (tributary of femoral vein). to end in the Venous anastomosis in the anterior abdominal wall: 1. Anastomosis between the superior and inferior epigastric veins in the rectus sheath. It connects the superior and inferior venae cavae. 2. Anastomosis between the lateral thoracic and superficial epigastric veins. This anastomosis forms the thoraco-epigastric vein which connects the superior and inferior venae cavae. 3. Anastomosis between systemic veins of the anterior abcominal wall (tributaries of superior and inferior venae cavae) and para-umbilical veins (tributaries of portal vein). Applied Anatomy: Opening of the portosystemic anastomosis in portal hypertension results in formation of caput medusae. Oey Lat. thoracic v. (of axillary) Sup. epigastric v. (of int. Sup. hemiazygos v. peop . mammary v.) azygos ¥. Inf. hemiazygos v _ Inf. epigastric v. (of ext. iliac v.) superficial epigastric v. (of long saphenus) Anastomosis between 8.V.C. and LV.C. Veins Arteries Cutaneous arleras accompanying —_ anterior cutaneous branches of the nerves Axillary V. Cutaneous arteries Lateral thoracic y. Jus lke wes ccompanying lateral cutaneous branches of the nerves pe pathear whey canis eid Supenicial epigastric v. rs Superficial epigastric a. Supercial circumflex iliac a. Great Femoral a. Saphenous y Femoral ¥. Esimal Superficial external pudendal . genitalia Cutaneous blood supply of anterior and lateral abdominal wall Anterior Abdominal Wall (EFI Lymphatic Drainage of the Anterior Abdominal Superficial lymphatics: (follow veins) 1. Above the umbilicus: drain into the pectoral 2. group Wal of axillary lymph nodes. Below the umbilicus: drain into the superticial inguinal lymph nodes, Deep lymphatics: (follow arteries) 1. Above the umbilicus: drain into the parasternal lymph nodes (along internal thoracic artery). 2. Below the umbilicus: drain into the external iliac lymph nodes. 3. The deep surface of the umbilicus is drained by lymphatics around the ligamentum teres, in the falciform ligament, which drain in the lymph nodes in the porta hepatis. ¥ Pectoral group of axillary ————»oal9 lymph nodes Umbilicus Inguinal ligament Superticial —_— inguinal lymph nodes Cutaneous lymph drainage of anterior abdominal wall | | Anterior Abdominal Wall Eee Nerves of the Anterior Abdominal Wall Motor supply: 1. The lower five intercostal and subcostal nerves: - They supply the three anterolateral muscles of the abdominal wall. * They pass through the neurovascular plane of the abdominal wall (between the internal oblique and the transversus abdominis}, then enter the rectus sheath (by piercing the deep lamina of the internal oblique aponeurosis) to run between the rectus abdominis and the posterior wall of rectus sheath. * They pierce the rectus abdominis after supplying it and pierce the anterior wall of rectus sheath to end by becoming the anterior cutaneous nerves lateral to the linea alba. 2, lliohypogastric and ilioinguinal nerves: (branches of the anterior primary ramus of L,} * They pierce the psoas lateral muscle, border; then behind major muscle to emerge fram under cover of its descend the kidney laterally with the on the quadratus iliohypogastric lying lumborum at a slightly higher level than the ilio-inguinal nerve. * Above muscle the iliac crest and run both forwards nerves in the pierce the transversus neurovascular plane abdominis between the internal oblique and the transversus muscles (supplying both) until they reach the level of anterior superior iliac spine; nerve pierces the internal oblique and then extends the iliohypogastric between it and the external oblique aponeurasis * The ilichypogastric nerve pierces the aponeurosis of the external oblique about 2-3 cm above the superficial above the symphysis pubis. inguinal ring to supply the skin ee, Anterior Abdomi WiLL na! SSS Posternor 1 ramus hy Thoraco-|umbar fascia Latissi ris dorsi Aenea fl] LU eo hieurcvemeonsion plane PUG fh fil Thoracic spinal N. j i Ht, uD 4 Lateral Psoas minar | cute neous | branch Quadratus Ey he ere oblique Antenor 1 ramus lum borum Rectus sheath Rh aig tel f Rectus muscle brilenrteal cotolieg use Trae versus muscle Linea alba Antenor cutaneo.is— branch Subcostal nerve (transverse section) Qusadratus humborumd muscle Transversus abdomimis muscle ff Lateral cut. br [| | Ps I ra it A Pinas anlage ryrsade Hicinguinal n, i a Hh, Internal oblique muscle —— ——llishypogastric n. b. Ext. oblique muselS Smuperttcial imeuinal ring Seretum BYAHLIS | — of lab lliohypogastric and ilio-inguinal nerves Anterior Abdominal Wat * [3G TI Qn the other hand, the ilio-inguinal nerve pierces the arched fibers of the internal oblique to reach the inguinal canal and extends below the spermatic cord to emerge through the superficial inguinal ring. It supplies the skin of the external genitalia and upper part of medial side of the thigh. It also supplies the conjoint tendon. Applied anatomy: Injury of iio-inguinal nerve during appendicectomy leads to weakness of conjoint tendon which predisposes to Girect inguinal hernia. sensory supply: 1. Lateral cutaneous branches of the lower five intercostal and subcostal nerves. 2. Anterior cutaneous branches of the lower five intercostal and subcostal nerves. 3. Lateral cutaneous branch of the iliahypogastric nerve. 4. Cutaneous branches of the ilio-inguinal nerve. They supply the skin of the scrotum and the upper part of medial side of the thigh. The lower five intercastal and subcostal nerves and the branches of L; supply successive and almost horizontal bands of the skin of the anterior abdominal wall. « Skin at the subcostal angle is supplied by 7" thoracic nerve (T?). Three nerves (T; »,3) supply the region above the umbilicus. Skin at the level of the umbilicus is supplied by 10" thoracic nerve (Tia). Three nerves (T+), 42,L1) supply the region below the umbilicus. Skin above the symphysis pubis is supplied by the iliohypogastric nerve (L;). Anterior view 9 ae i ~~ rs}. papers 7s, t i Supra-clavicular nerves 03,4 Pp a, “a Dermatomes 2 : . Intercosto-brachial N. eo Lateral cutaneous branches + Tels a Tal>t~ ——— Anterior cutaneous branch Sy Re eA _—Lateral cutaneous branch of Inguinal—__ : Ti] 24s ligament Sih] Superficial subcostal N. (T12) Se cp \ ** Lateral cutaneous branch of iliohypogastric N. Anterior cutaneous branch | inguinal ring of iliohypogastric N. Femoral branch of genito-femoral N. Anterior cutaneous branch of ilio-inguinal N. Lateral View Slips of origin of extemal oblique muscle Lateral cutaneous Lateral view as cs pe branch of iliohypogastric N am Lateral cutaneaus et branch of subcostal N. om ee eee os oe Lateral cutaneous branches Gluteal region Cutaneous nerves of anterior and lateral abdominal walls Anterior Abdominal Watt es The Groin (Inguinal Region) Definition: “It is the junctional area between the anterior abdominal wall and the thigh. ‘It is an area of weakness in the abdominal wall as the processus vaginalis (peritoneal process) passed, during intra-uterine life, through the layers of the lower part of the anterior abdominal wall forming an intermuscular canal called the inguinal canal. The Inguinal Ligament. _ (Poupart's Ligament) _ Definition: "It fs the rolled in free lower border of the external oblique aponeurosis. ‘It is curved with a convexity downwards due to its attachment to the fascia lata of the thigh. Attachments: * Laterally: to the anterior superiar iliac spine. > Medially: to the pubic tubercle. Extensions (parts): 1. Lacunar ligament (Pectineal part or Gimbernat's ligament): ° > It is a triangular backward extension from the medial part of the inguinal ligament, [ts apex is attached at the pubic tubercle. * * Its posterior border is attached to the medial part of the pectineal line. Its anterior border is attached to the inguinal ligament. * Its base (lateral free border) is directed laterally forming the medial sharp crescentic border of the femoral ring. 2. Pectineal ligament (Cooper's ligament): * It is the lateral extension of the postericr border of the lacunar ligament * on the pectineal line of the superior pubic ramus. Itliés posterior to the femoral ring. Reflected part of inguinal ligament: * lt is an extension 3. upwards and medially from the lateral crus of the sUperticial inguinal ring to the lower part of the linea alba. Anterior Abdominal Vall — * It lies behind the spermatic cord, in front of the conjoint tendon and the rectus sheath. * |tforms the medial 1/4 of the posterior wall of inguinal canal, Site: It lies below the fold of the groin. Surfaces: a. Upper concave surface: * Its lateral 2/3 gives origin to internal abdominal oblique muscle. > lis lateral 1/3 gives origin to transversus abdominis muscle. * |lts medial 1/2 forms the floor of inguinal canal. b. Lower convex surface: gives attachment to the fascia lata of the thigh. Relations: a. Superficial relations: * Skin and superticial fascia. * The ligament is crossed circumflex iliac vessels. by superficial epigastric and superficial b. Deep relations: * * « Femoral sheath Femoral nerve, cutaneous nerve Psoas major and (enclosing femoral vessels and femoral canal). femoral branch of genitofemoral nerve and of the thigh. iliacus muscles. Medial crus Reflected part inguinal ligament lateral Intercrural fibers “4 < -, Uy z YZ ff Superticial inguinal ring ids Inguinal ligament Lateral crus =e Spermatic cord Reflected part of the inguinal ligament Anterior Abdominal ‘The Wail pc Pg Inguinal Canal Definition: It is an oblique passage through the lower part of the muscles of the anterior abdominal wall. Site: It is found above the medial half of the inguinal ligament. Direction: It extends downwards, forwards and medially between the superticial (external) and deep (internal) inguinal rings. Length: It is four cm long. Beginning: At the deep (internal) inguinal ring: * [tis an oval opening in the fascia transversalis. « lt is found 1/2 an inch above the mid-inguinal point immediately lateral to the inferior epigastric artery. * From the margins of this opening extends the internal spermatic fascia. + Itis wider in males. « It allows the passage of the spermatic cord in male or round ligament of uterus in females. End: At the superficial (external) inguinal ring: * It is a triangular opening in the external oblique aponeurosis. « [tis found above and medial to the pubic tubercle. * It has medial crus and lateral crus. « The meédial crus is attached to the symphysis pubis. - The lateral crus is attached to the pubic tubercle. « The base of the opening is found at the pubic crest while its apex is directed upwards and laterally at the meeting of the two crura. » The two crura are bound together by intercrural fibers above the apex of the opening. * The external spermatic fascia extends from the crura of the opening. « lt allows the passage of the spermatic cord in the male or the round ligament in the female and the ilic-inguinal nerve in both sexes. ia Anterior Abdominal Wall ¢ The ring is wider in the male than the spermatic cord. in the female, Me due to the passage seo of Boundaries of the inguinal canal: 1. Anterior wall: * Along its whole length: it is formed by external abdominal oblique aponeurosis. * Along its lateral half: it is reinforced by the origin of the lower fleshy fibers of the internal abdominal oblique muscle. 2, Posterior wall: = Along its whole length: it is formed of fascia transversalis. ° |ts medial halfis reinforced by the conjoint tendon. * |Its medial 1/4: is reinforced by the reflected part of the inguinal ligament in front of the conjoint tendon. N.B.: The lateral 1/2 of the posterior wall of inguinal canal is weak because it is formed of fascia transversalis only. 3. Roof: lt is formed by the arching lower fleshy fibers of the internal abdominal oblique and transversus abdominis muscles. 4, Floor: « It is formed by the upper concave surface of the inguinal ligament along its whole length. * It is reinforced by the lacunar ligament medially. Contents: 1. Spermatic cord and its coverings (internal spermatic cremasteric muscle and fascia) in the male or round fascia and the ligament of the uterus in the female. 2. The ilio-inguinal nerve passes below the spermatic cord in the canal and accompanies it through the superficial inguinal ring in both sexes. eee Anterior Abdominal Mall Applied anatomy: a. inguinal canal is a weak area due to: 1. Presence of an area below the arching fibers of internal oblique and transversus abdominis in which the anterior abdominal wall is formed of external oblique aponeurosis only and the posterior wail is formed by fascia transversatis only. 2. The spermatic cord passes between the layers of the abdominal wait. 3, Presence of internal inguinal & external inguinal rings. &. This weakness is normally compensated by the following mechanisms: 1. Shutter mechanism: During standing, coughing or straining, contraction of lower fibers of internal abdominal oblique decreases its concavity (they become more straight) teading fo closure of the inguinal canal around the spermatic cord. 2. Valvular mechanism: The inguinal canai is oblique thus the internal and external rings are not opposite each other. 3. Increased intra-abdominal pressure forces the posterior wall of the canal against the anterior wall to close the external ning. 4. The superficial ring is compensated by strong part of posierior wall which is reinforced by the conjoint tendon and reflected part of inguinal ligament. 5. The deep ring is compensated by strong part of anterior wall which is reinforced by the fleshy lower fibers of internal oblique. 6, The intercrural fibers prevent separation of the two crura of external inguinal ring. /. Cremasteric mechanism: Contraction of cremasteric muscle during increased intra-abdominal pressure leads to pull of the festis upwards in attempt to close extemat inguinal ring. Pee Anterior Abdominal Wall SERRE Ext. Abdominal oblique Superficial inguinal ring Fascia ss irda Cord Inguinal transversalis 7 Lig. Canjoint tenden Testis Reflected part Int. Abdominal Oblique Arching fibres Conjoint Tendon tater pei Hlioinguinal n. Lig Deep inguimal ring, Edy *Medial Inf. epigastric a. FasciaT. Transversus Deep inguinal rin i “Sy a, gee Abdominis C. Tendon Reflected Lig. Spermatic cord Fascia transversalis Inguinal Lig. Spermatic cord Inguinal canal st : fae blique (BSL: Anterior Abdominal Wall ee “Inguinal (Hasselbach's) Triangle = Boundaries: 1. Medially: The lateral border of the rectus abdominis muscle. 2. Laterally: The inferior epigastric vessels and its peritoneal fold (lateral umbilical fold}. C3 . Inferiorly: The inguinal ligament. 4, Floor: Formed by the parietal peritoneum, extraperitoneal tissue and fascia transversalis with the conjoint tendon and the reflected part of the inguinal ligament at its medial part. Subdivision: The triangle is divided by the lateral umbilical ligament (obliterated umbilical artery} into lateral and medial parts. Applied anatomy: Weakness of abdominal walt in inguinal hemia. this triangle predisposes Posterior wall of rectus sheath Arcuate line to direct Inferior epigastric a. _ Fascia transversalis Superficial inguinal ring — Deep inguinal ring Ingul nal igament —- External iliac A. Femoral Medial 1/2 Lacunar ligament Femoral vein ring Lateral umbilical ligament Inguinal (Hasselbach’s) triangle Anterior abdominal wall as seen from behind (from inner aspect) Anterior Abdominal Wall ro = eS ies. Hernia Definition: Protrusion of abdominal content through a weak point in the abdominal wall. Types of abdominal hernia: 1. External hernia: appears on the surface e.g. Inguinal, femoral, umbilical, incisional ... etc. 2. Internal hernia: does not appear on the surface e.g. diaphragmatic hernia. Etiology: 1. Congenital patency of 2. Weakness or injury of 3. Increased sac e.g. congenital oblique inguinal hernia due to persistent processus vaginalis. of the abdominal wall due to obesity, pregnancy, weak scar nerve supply to the muscles during operation. intra-abdominal pressure: a. Chronic straining: ¢.g. cough, constipation, deliveries ... etc. b. Abdominal swelling: e.g. repeated pregnancies, hepatosplenomegaly and ascites. Structure: Any hernia consists of: 1. Detect: through which the sac bulges out e.g. internal inguinal ring. 2. Sac: It is a peritoneal pouch protruding through the defect and containing the protruded organ. It consists of fundus, body and neck. 3. Content: any of the mobile abdominal viscera (mainly intestine and omentum). 4. Coverings: Consist of layers of abdominal wall. | | | Sac Neck Body Fundus LMU OGS.19 gf Contents ae Lm E nd fo fo = Structure of the hernia | Anterior Abdominal Wall ae Inguinal Hernia A hernia which traverses the inguinal canal; it may be one of the following: Indirect (oblique) inguinal Direct inguinal hernia hernia lt is a hernia which enters the inguinal canal indirectly through the deep inguinal ring It is a hernia which enters the inguinal canal directly through its posterior wall It is lass cornmon at operation) lt is the commonest hernia Stretched deep ring, lateral inferior epigastric artery Descent Forwards, Definition | Incidence Defect (seen downwards to and Hasselbach’s triangle, medial to inferior epigastric artery Directly forwards medially Reduction External i test ‘Internal Upwards, laterally and backwards Directly backwards Inguinal or inquinoscrotal Only inguinal Hemia will ring | Hernia dose not descend descend above inguinal ligament ring Impulse on the tip of the finger test | Impulse on the posterior aspect of the finger Complications Common Coverings a. In inguinal region: «= 8kin * Rare (wide neck) (narrow neck} * Extraperitoneal tissue * Transversallis fascia Superficial fascia External oblique aponeurosis Coverings of the cord in this region (cremasteric muscle and fascia and fascia) internal spermatic Skin * Won fatty superficial fascia containing Dartos muscle Coverings of the cord in this region =(external spermatic fascia, cremasteric muscle and fascia) and intemal spermatic medial External oblique aponeurosis Skin * (in Spermatic cord Superticial fascia b. In scrotum: fascia * Canjoint tendon type only} Anterior Abdominal A pit indicating site of processus vaginalis Deep inguinal ring . Peritoneum T. abdeminis Internal oblique Wall Inferior epigastric a. Lateral umbilical ligament ~~ External oblique ~ ascia transversalis aponeurosis Superficial inguinal ring External spermatic fascia Testis Cremasteric muscle and fascia Internal spermatic fascia Normal inguinal canal Deep inguinal ring (neck of sac) jf Inferior epigastric a. — = oe at Persistant processuss vaginalis Widened superficial inguinal ring Oblique inguinal hernia Anterior Abdominal Wail Be Neck of hemial Inferior epigastric a. sac | Lateral umbilical ligament | Posterior wall of inguinal “ — —— Conjoint tendon \ Superficial inguinal ring Lateral direct hernia Inferior epigastric a. Lateral umbilical ligament Neck of hermial sac Medial direct hernia canal ee Anterior Abdominal Vail Femoral Hernia In this type of hernia, the protrusion of viscus occurs through the femoral ring. Differences between inguinal and femoral hernia: inguinal hernia * Femoral hernia More in male (wide inguinal * canal} More in female (wide femoral ring) * Above the inguinal ligament * Below the inguinal ligament - Above and medial to pubic tubercle « Below and lateral to pubic tubercle ¢ * It descends downwards, forwards |t descends forwards, downwards and medially then upward « Reduction is upwards, laterally and backwards * Reduction is downwards, backwards and upwards * Hernia does not appear in internal ring test (in case of * Hernia appears below the inguinal ligament in internal ring oblique type) test _ Umbilical Hernia it is classified into three types: 1. Congenital umbilical hernia: * Normally, the midgut herniates into the umbilical cord during foetal life. * This is called physiological umbilical hernia of the fetus. * Persistence hernia. of this hernia after birth is called congenital umbilical Anterior Abdominal Walt "qa 2. Infantile umbilical hernia: ® It is due to weak umbilical scar (due to infection} and increase intraabdominal pressure (e.g. straining or cough). * A hernial sac passes through and eversion of umbilical scar. * Spontaneous years. a defect in the umbilicus with stretch closure of the defect usually occurs at the age of three 3. Adult para-umbilical hernia: « Itis the commonest hernia at the region of the umbilicus. * |t usually occurs in fatty multiparous females. * [i pass through a defect in the linea alba just above the umbilicus. Other Abdominal Hernias 1.Incisional hernia: A hernial sac passes operation. It is the second common hernia. 2.Sliding hernia: A viscus (caecum, through bladder or a scar ovary) of previous slides extra- peritoneally beside the sac through a wide hernial defect. 3. Lumbar Hernia: may be: a) Inferior lumbar hernia: The commonest, passes through the inferior lumbar triangle of Petit which is bounded by: - Anterior: the posterior free border of the external abdominal oblique. * Posterior: the anterior border of the latissimus dorsi muscle. * Base: the part of the iliac crest between the origin of latissimus dorsi and the insertion of the external abdominal oblique. *Apex: the meeting of the external abdominal oblique and latissimus dorsi. « Floor: internal oblique muscle. b) Superior lumbar hernia: passes through the superior lumbar triangle which is bounded by 12" rib, lateral border of sacrospinalis and posterior border of internal oblique. 4. Obturator hernia: Passes through the obturator canal, more common in Women. Anterior Abdominal Vell SEQ: Explain: ruptured bulbar urethra causes accumulation 1. abdomen and not the thigh. 2. Explain: Presence of umbilical nodules in cancer breast. 3. Describe the anterior wall of direct inguinal hernia. of urine 4. Describe the attachments and parts of the inguinal ligament. 5. Mention weak’? the weak points in the inguinal canal and explain McQ: Choose the correct answer: a. b. The superficial ring lies in the internal oblique aponeurosis. The internal ring lies in fascia transversalis. c. The inguinal ligament forms the roof of the inguinal canal. d. The ilio-inguinal nerve runs through the deep inguinal ring. why ORS in the they are Maie External Genital Organs = gg (| CHAPTER 2 / tos: ) By the end of the lectures, the student should be able to: \ * Describe the external features of the testis and epididymis. * * List the coverings of fhe testis and the scrotum. Define the blood supply, nerve supply and lymphatic drainage of the scrotum and testis. * Explain cases of hydrocele and varicocele on anatomical basis. * * Describe the beginning, course and fermination of the vas deferens. List the coverings and constituents of the spermatic cord. y MALE EXTERNAL GENITAL ORGANS Male external genital scrotum and penis. organs consist of testis, epididymis, spermatic cord, The Testis It is the primary male sex organ. It is a mixed endocrine and exocrine gland. Its endocrine secretion is testosterone while its exocrine secretion is the sperms. Site: * The two septum, posterior * The level testes are found in the scrotum, one on each side of the median suspended by the spermatic cords which are attached to their aspects. of the left testis is slightly lower than that of the right one. Shape, size and weight: " The testis is oval in shape; it is compressed from side to side. * It is 5 cm long, 2.5 cm thickness and its anteroposterior diameter is 2.5 cm (i.e. 2X 1X1 inch). * The weight of the testis is 10-15 gm. Wale External Genital Organs eG isle External features: it has Two borders: 1. Anterior border: convex, smooth and covered with the tunica vaginalis (Serous sac). 2. Posterior border: straight and partially covered with the tunica vaginalis. It is related to: a. Epididymis laterally. It is partially separated fram the testis by the sinus of the epididymis. b. Vas deferens medially. Two surfaces: medial and lateral. Coverings of the testis: I. Three special direct coverings: 1. Tunica vaginalis: it is the outer covering of the testis. ® It represents the persistent lower part of the processus vaginalis. * The testis is invaginated into it from behind, so it has: - Two layers: a. Visceral layer: covers the testis except its posterior border. b. Parietal layer: lines the scrotum. - Cavity: contains capillary film of serous fluid between the visceral and parietal layers. - Sinus of the epididymis: is a lateral recess found between the testis and the epididymis. ° The upper end of the tunica vaginalis is connected to the peritoneum by a fibrous band called the vestigue of processus (obliterated proximal part of processus vaginalis). vaginalis CA pplied Anatomy: s 7. Accumulation of clean serous fluid in the tunica vaginalis is called hydrocele while accumulation of blood or lymph inside it is called haematocele or chylocele respectively. 2. Ne. Failure of obliteration of processus vaginalis oblique inguinal hemia or congenital hydrocele. results in congenital gf Male External Genital organs| i gS 2. Tunica albuginea: * It is a dense white fibrous tissue layer that covers the testis completely. * It is found deep to the visceral layer of the tunica vaginalis. > |ts posterior part is thickened forming the mediastinum of the testis which sends septa inside the testis dividing it into 200-300 lobules. 3. Tunica vasculosa: testicular lobules. It is the innermost vascular coat lining the il. Three coverings of the spermatic cord which extend downwards to surround the testis. These are the internal spermatic fascia, cremasteric muscle and fascia and external spermatic fascia. Ill. Three cutaneous and subcutaneous 1. Skin. 2. Dartos muscle. layers of the scrotum: 3. Membraneous layer of superficial fascia. Umbfical [nfer| HE WPeriloneam Subperiteneal fat Fascia trangversalia Tramsyvoraus dntemel Gibigue Extercal Obtgae epkeoeivic folds act, Uhilterated tanabitical ort, 1 — on. a ayoueorosla Subcutaneous fet Sian -# —t a Constituents ofthe cord --—-—¢ a 57 ¥ & Sérotunris Colles’ fascia Taartoz: magelef —- Skin. ——— zi F™" ;.— Layers of the abdominal wall and scrotum Urearkwa (Wate External Genifal Organs ae). Arterial supply: * The testis is supplied by the testicular artery which is a branch from the abdominal aorta at the level of the upper border of 3 jJumbar vertebra. * It descends in front of the ureter and psoas major muscle. « As it reaches the deep inguinal ring, it descends one of the constituents of the spermatic cord. down to the testis as Venous drainage: The testis is drained by the pampiniform plexus of veins, which collects its blood into 4-8 veins at the superficial ring. These veins unite into two venae commitantes at the deep ring. These two veins unife to form one festicular vein which drains obliquely into the inferior vena cava on the right side, and at right angle into the left renal vein on the left side. F nestion Anatomy: - Varicocele NX is a condition oy in which the veins of the pampiniform plexus become dilated, elongated and tortucus. - lf is more common on the left side because: » The leit testicufar vein is longer than the right one. * The left testicular vein enters the loft renal vein at right angle. * The left testicular vein is compressed by the heavy pelvic colon. # Lymph drainage: By lymphatics that run along the testicular vessels to the para-aortic groups of lymph nodes. Nerve supply: The testis is supplied by sympathetic nerves which arise from the 10" thoracic segment of the spinal cord and reach it along its arterial supply. Male External Genital Organs Ee Vasa Efferentia They are 15-20 tubules arising from the rete testis. Each dilatation that fuse together to form the head of epididymis. ends by a conical Epididymis shape, * position and size: It is a comma-shaped border of the testis. * It is about five cm duct that found at the lateral aspect of the posterior in length and formed of a highly coiled single tube packed in a fibrous tissue coat. When uncoiled it measures about 6 meters in length. Parts: * Head: tis the expanded the testis. It is formed upper end which is found above the upper pole of by the fusion of the expanded parts of the vasa efferentia. * Body: It is the central part which lies posterolateral to the testis, separated trom it laterally by the sinus of epididymis. * Tail: Itis the lower pointed end of the epididymes. pole of the testis. It continues as the vas deferens. It is related to the lower Blood supply: * Arterial supply: testicular artery and artery of the vas. * * Venous drainage: papmpiniform plexus of veins. Lymphatic drainage: para-aortic lymph nodes. Vas Deferens * Itis the duct which carries the sperms from the epididymis to the ejaculatory duct. * |tis cordike with narrow lumen and thick muscular wall. * It extends from the tail of the epididymis, on the medial aspect of the * posterior border of the testis, into the spermatic cord till the deep inguinal ring. It crosses the side wall of the pelvis and extends medially crossing the ureter to reach the back of the urinary bladder where it is ampulated to form the ampulla of the vas. Maie External Genital Organs Ry * Arterial supply: artery of the vas which is a branch from the inferior vesical artery. head of epididymis vas deferens body of __ | epididymis } tail of epididymis. Vasa efferentia Epididymis and vas deferens inferior Ductus or deferens Vas epigastrie tipoe FTA EL a Prostate Bulkbeourethral qtand Unrethirn Ductus deferens Epidiaymis Male external genital organs Co Tis Male External Genital Organs Pees. Definition: It is a cord-like structure which extends from the lower pole of the testis ta the deep inguinal ring containing structures to or from the testis. Contents: Three arteries: 1. Testicular artery (branch of abdominal aorta). 2. Artery of the vas deferens (branch of the inferior vesical artery). 3. Cremasteric artery (branch of the inferior epigastric artery). Three nerves: 1. Cremasteric nerve (genital branch of genitofemoral nerve, L1). 2. llio-inguinal nerve (L1). However, it is covered by external spermatic fascia only. 3. Sympathetic plexus (Tj) segment). Three structures: 1. Vas deferens. 2,Pampiniform plexus of veins. 3, Lymphatics which drain the testis. Vestigue of the processus vaginalis. Coverings of the spermatic cord: 1. Internal spermatic fascia which is derived from the fascia transversalis at the deep inguinal ring. It is the inner layer. 2.Cremasteric fascia and muscle which arise from the internal oblique muscle and form the middle layer. 4, External spermatic fascia which starts at the superficial inguinal ring as an extension from the external oblique aponeurosis. It is the outer layer. P ine In Female: mh * There is no spermatic cord. It is replaced by the round ligament of the uterus, This ligament is derived from the gubernaculum of the foetus, and ends below by getting attached to the superficial fascia of the labium majus, * As it passes in the inguinal canal, the round ligament of the uterus géts coverings corresponding to those of the spermatic cord, but these S coverings are thin and adherent to it. , Wale External Genital Organs The Scrotum Definition: It is a skin and subcutaneous bag containing the testes, epididymes the lower part of the spermatic cords of both sides. and It corresponds to the labia majora of the female. External Features: It is divided externally into right and left halves by a median raphe at its middle. lt is divided internally by a median septum formed by the dartos muscle and the fascia between the two sides of the scrotum. The left side of the scrotum hangs lower than the right. The skin muscle. of the scrotum is corrugated due to the presence of Dartos 4am & & hk Layers of the scrotum: from outside inwards 1. Skin. . Dartes muscle. . Membranous layer of the superficial fascia. . External spermatic fascia. . Cremasteric muscle and fascia. . Internal spermatic fascia. . Parietal layer of tunica vaginalis. Arterial supply: * a Superficial external pudendal artery: a branch of the femoral artery. Deep external pudendal artery: a branch of the femoral artery. ¢ Scrotal arteries: from the internal pudendal artery. * Cremasteric artery: from the inferior epigastric artery. Nerve supply: Sensory: 1.Anterior 1/3 is supplied by L- (ilio-inguinal and genital branch of genitofemoral nerve). 2.Posterior 2/3 is supplied by Ss through two scrotal branches of the pudendal nerve and the perineal branch of the posterior cutaneous nerve of the thigh. Male External Genital Organs |BA Motor: Sympathetic supply to the dartos muscle which reaches the muscle through the cremasteric nerve (branch of the genitofemoral nerve). Lymphatic drainage: Superticial inguinal lymph nodes. Peta iguirtal ing esticular ¥. and 4 Testicular Vv. and A f intemal suermatic fascia, Cremasier muscia eno fascda Bian Extemal spermatic fae tne 1 =f . Intemal spermatic fascia Cremaster muscle and fascia Ex:amal! spermatic fasc a Paneta layer Visceral layer of — Tun vaginalis Spermatic cord Vas deferens Enpidicymis Skin of scrotum Dartos muscle Deep membranous layer of supermcial fascia __ Extemal spormatic fascia Cremasier fascia muscle and intemal spermatic fascia Up 29 ™ Pariatal layer (Be Visceral layer_J vaginalis section of scrotum showing its wall and layers Wale External Genital Organs coe Formative Assessment SEQ: . Describe the layers of the scrotum (from inside outwards). The testis is outside the body. What is the lymph drainage Exolain. Explain why varicocele is more common on the left side? MCG: Regarding the testis, choose the correct answer: The b . The Gh The d _ The a. testis is supplied by the gonadal artery. uncoiled epididymis is one meter in length. scrotum is drained by the para-aortic lymph nodes. right testis is drained by the right renal vein. of testis? Abdominal Cavity oo CHAPTER 3 (10s: be By the end of the tecture, the student should be able to: * Outline the planes and regions of the abdominal cavity. : Define their clinical application. ABDOMINAL CAVITY - The abdomen is the part of the trunk below the thorax. The abdominal wall surrounds a large abdominal cavity. - The abdominal cavity is divided into two parts: 1. Cavity of the abdomen proper which is bounded superiorly by the diaphragm and inferiorly by the level of the inlet of the lesser pelvis. 2. Cavity of the true (lesser) pelvis below the inlet of lesser pelvis. - The shape and size of the abdomen vary with the degree of distension of the abdominal organs, phases of respiration, tone of abdominal and position of the body. muscles Planes of the abdomen: 1. Transpyloric plane: * It is a horizontal plane passes midway between the suprasteral notch and symphysis pubis or roughly midway between xiphisternal junction and umbilicus or a hand's breadth below xiphisternal junction. » It also lies opposite 1“ lumbar vertebra posteriorly and tips of 9" costal eo ees of * cartilages anteriorly. It passes through the following structures: 1. The pylorus. Beginning of the duodenum. Fundus of the gall bladder. Upper border of the neck and body of pancreas. Origin of the superior mesenteric artery. Hilum of the kidney. Epiploic foramen. * Structures at the tip of 9" costal cartilage: 1. 2. Upper end of linea semilunaris. Lower end of spinal cord. 3. Body of L1 vertebra. ?. Subcostal plane: « |tis a horizontal plane passes at the lower border of the costal margin anteriorly and the 3™ lumbar vertebra posteriorly. « It passes through the 3™ part of the duodenum and the origin of inferior mesenteric artery. 3. Intertubercular plane: « A horizontal plane extending between the tubercles of the iliac crests (5 cm behind the anterior superior iliac spine). * It crosses the upper border of 5" lumbar vertebra posteriorly. « It passes through the beginning of inferior vena cava and through the junction between the caecum and ascending colon. 4. Right and left lateral planes: Each of these planes crosses the midclavicular point and midinguinal point (a point midway between the anterior superior spine and the symphysis pubis) on each side. Abdominal the iliac regions: * The abdomen proper is divided, for descriptive purpose into nine regions by: 1. Two horizontal planes: the subcostal and intertubercular planes. 2. Two vertical planes: the right and left lateral vertical planes. * The nine regions are: 1. Right hypochondrium. 2. Epigastrium. 3. Left hypochondrium. 4. 5. 6. 7. Right lumbar. Umbilical. Left lumbar. Right iliac. 8. Hypogastrium (suprapubic). 9. Left iliac. * The abdomen is also divided into four quadrants by two planes: 1. A horizontal transumbilical plane at the level of the disc between and fourth lumbar vertebra. 2. A vertical median plane. «The abdomen is subdivided by these two planes into four quadrants (right and left upper quadrants & right and left lower quadrants). third Regions of the abdomen and their contents: Region Epigastric Viscera The Part The The Part greater part (or all) of the left lobe of the liver of the right lob of the liver gall bladder two orifices of the stomach (cardiac and pyloric} of the stomach The first and second parts of the duodenum The duodeno-jejunal flexure The pancreas The upper (inner) end of the spleen The suprarenal glands and parts of the kidneys Right hypochondrium |The greater part of the right lobe of the liver The right (hepatic) flexure of the colon Part of the right kidney Part of the stomach Lett | hypochendrium The greater part of the spleen, and the tail of the pancreas The left (splenic) flexure of the colon Part of the left kidney Sometimes a small part of the left lobe of the liver The greater part of the transverse colon The third part of the duodenum and some coils of the jejunum and Umbilical ‘ileum Parts of the greater omentum and the mesentery Part of both kidneys, (sometimes) only the right kidney can reach | | the umbilical region | Right lumbar Left lumbar ___Rightiliac Left iliac |The ascending colon, part of the kidney, sometimes part of the | ileum The descending colon, sometimes part of the jejunum, | left kidney The caecum and the appendix, the end of the ileum |The sigmoid colon, coils of the jejunum and ileum part of the Abdominal Cavity Plane of superior thoracie aperture Bodyof Stee Thoracic vertebrae Therache diaphragm Pearirvevom Parts of the abdominal Subcoatel plane cavity Midclavicular planes Interlubercutar plane Planes and regions of the Abdomen Abdominal Cavity Assessme Formative eo nt < SEQ: Mention the structures present in the right iliac region. Moa: One of the following structures is transpyloric plane: a. Neck of the gall bladder. b. The origin of inferior mesenteric artery. c. The cardiac orifice of the stomach. d. The lower end of the spinal cord. present at the level of the ee ae Pertoncum atin CHAPTER 4 ‘m ~ By the end of this subject the student should be able to- " Define the layers and arrangement of the peritoneum. * QOutline the compartments of the peritoneal cavily (greater and lesser sac) and define their subdivisions. * Describe the posilion and boundanes of the fesser sac and epiploic foramen. « Describe the peritoneal recesses and peritoneal folds (site, attachments anc contents). : Explain some clinical cases related to the peritoneal folds (vascular and avascular folds), peritoneal recesses (internal hernia) and collection of pus in the subphrenic spaces (sites and direction of spread). Definitions: * Peritoneum is a smooth shiny serous membrane abdominal and pelvic cavities, and covers the abdominal for variable degrees. It is a closed sac in male which lines the and pelvic organs but pierced by Fallopian tubes in female. * Peritoneal sac is a large serous sac formed by the peritoneal membrane and containing a peritoneal cavity. * Peritoneal cavity is the cavity of the peritoneal sac which is empty except for a thin film of serous fluid. Peritonoun eGR Formation: |. During intrauterine life, the peritoneal sac develops from mesoderm as a closed sac which lines the abdominal cavity. 2. The abdominal organs develop and grow on the posterior abdominal wall outside the peritoneal sac. 3. The abdominal organs bulge forwards to invaginate the peritoneal sac. 4. As a result of this invagination the peritoneum becomes differentiated into: a. Visceral layer: * It covers the abdominal organs. «It is supplied by autonomic nerves and insensitive to pain but sensitive for stretch. b. Parietal layer: » |t lines the wall of the abdomen. » lt is separated from the abdominal wall by extraperitoneal tissue. - It is supplied by somatic nerves. It is very sensitive and its irritation leads to pain, tenderness and rigidity. c. Peritoneal cavity: between the visceral and parietal layers. o. The degree of invagination of the abdominal organs varies, as follows: a. Some organs leave the posterior abdominal wall completely and become suspended by a fold of peritoneum called: > Mesentery (in case of the intestine). * Omentum (in case of the stomach). * Ligament (as in the spleen and liver). b. Some other organs may bulge into the peritoneal cavity to a limited extent, and peritoneum, they ¢.g. descending colon. are covered kidneys, on their front and pancreas, sides ascending only colon with and Peritoneum (Say Degrees of invagination of viscera into the peritoneal cavity N.B.: Alf abdominal organs whether suspended by mesentery or not lie outside the peritoneal cavity which remains as empty cavity except for a thin film of peritoneal fluid. Sex Difference: The peritoneal cavity is a closed sac in the male, but receives the openings of the uterine tubes in the female, the outside through these tubes. and accordingly it communicates with Functions of the peritoneum: 1. It provides a smooth surface for the viscera to move freely. 2. 3. It secretes the peritoneal fluid which contains antibodies (prevent infection). Its mesothelial cells can transform into fibroblasts which allow rapid healing of abdominal wounds. 4. The greater omentum tends to surround the slruciures (in case of infection) and thus can localize the spread of infection (policeman of the abdomen). 5. Storage of fat (e.g. in the greater omentum). Peritoneal Cavity The peritoneal cavity consists of two sacs: 1. Greater sac: forms most of the peritoneal cavity. 2. Lesser sac: is a small pouch which lies behind the stomach and opens into the greater sac through an opening called sac (epiploic foramen or foramen of Winslow). opening into the lesser Peritonoum AUNTY Greater Sac of Peritoneum * The greater sac fills the whole abdominal cavity as well as the pelvic cavity. * An incision made through the anterior abdominal wall will open the greater sac. * Itis subdivided into two compartments by a transverse partition formed by the greater omentum, + the transverse colon and its mesocolon. These two compartments are: 1. Supracolic compartment: present infront of and above colon, greater omentum and transverse mesocolon. the transverse 2. Infracolic compartment: - It lies behind and below the transverse colon, greater omentum transverse mesoccolon. - Itis divided by the mesentery of the small intestine into: and a. Upper right region. b. Lower left region which communicates freely with the pelvic cavity. c. The ascending and descending colons bulge into this compartment leaving two paracolic gutters alongside each of them. Lesser Sac of Peritoneum (Omental Bursa) Position: * |t is a part of peritoneal cavity which lies behind the stomach and lesser omentum. * It is separated from the greater sac except at the opening into the lesser sac (epiploic foramen or foramen of Winslow} where the two sacs communicate together. = It has the following thee extensions: 1. It extends upwards behind the caudate lobe of the liver forming the superior recess. 2. lt extends downwards between and the ascending posterior forming the inferior recess. the descending two layers of the anterior two layers greater omentum 3. It extends to the left as far as the spleen forming the splenic recess. portoncun eT Liver is retracted & cut BRL A en rie ’ es f a ce hanes as absieegaglacs posterior abdominal wall ed Ge inn as cae ee ct = i mate \N . AIL i ih fh] Na Lesser sac ER refi an AN | ry \ Stomach Lienorenal ligament Se =— —_ = ys . \ N Pancreas Transverse oie mesocolon * Transverse colon \ Post. 2 layers of greater omentum iN Lower free border The lesser sac of peritoneum ‘i Gastrosplenic ligament greater omentum Splenic artery —S<y | Spleen Left border of yT : Splenic recess rs | Peritoneum PS Development: It develops as a pouch which extends from the greater sac behind the stomach as a result of its rotation. Boundaries: OF he Seo Ne The lesser sac has two walls and four borders, as follows: Anterior wall: from above downwards Peritoneum on the caudate lobe of the liver. Lesser omentum. Peritoneum on the posterior surface of the stomach. Gastrosplenic ligament. Descending anterior two layers of the greater omentum. Posterior wall: from above downwards. 1. Peritoneal covering of the stomach bed. 2. Transverse mesocolon and transverse colon. 3. Ascending posterior two layers of the greater omentum. Left border: from above downwards. 1. Meeting of gastrosplenic and lienorenal ligaments at the hilum of the spleen. é. Left free margin of the greater omentum. Right border: from above downwards 1. Reflection of peritoneum at the right margin of the caudate lobe of the liver to the posterior abdominal wall. 2. Opening inte the lesser sac. 3. Right free margin of the greater omentum. Upper border: - tis formed by reflection of the peritoneum from the anterior wall to the posterior wall of the lesser sac. * It extends transversely from the fissure for ligamentum venosum right) to the lower end of the oesophagus (on the left). Lower border: It corresponds to the free lower margin of the greater omentum. (on the Peritoneum Definition: The epiploic foramen is the orifice through which the lesser sac communicates with the greater sac. Position It lies directly behind the free right border of the lesser omentum at the level of T12 vertebra. Boundaries: Anteriorly: structures in the free border of the lesser omentum which are: (PAB) 1. Portal vein (most posterior). 2, Hepatic artery (anterior to the vein and to the left of the duct). 3. Bile duct (anterior to the vein and to the right of the hepatic artery). Posteriorly: Inferior vena cava (a finger in the forarnen has the portal vein in front of it and the inferior vena cava behind it). superiorly: Caudate process of the caudate lobe of the liver. Inferiorly: 1. The 1* inch of the duodenum. 2. Part of the portal vein where it curves forwards from behind the duodenum to enter the free border of the lesser omentum. O asssaieu Anatomy: 1. ) Liver haemorrhage can be controlled by compressing the portal vein and hepatic artery in the free border of the lesser omentum by a finger a 2. Exploration pe inserted in the epiploic foramen. omentum can be done by a finger inserted in the epiptoic foramen. Coils of small intestine may pass through epiptoic foramen leading to of common internal hernia. bile duct in the free border of the /esser ) Lpper recess Epiplioc foramen OMENTAT. BURSA pe eite recess Lower recess Upper recess Lesser omentum Lower recess Greater omentum “Transverse mesocolon Extensions of the lesser sac Perioncum SS Lesser Liver omentum | Stomach Epiplioc foramen Duodenum- Gall bladder Caudate process Portal Duodenum vein Boundaries of the epiploic foramen rae Pariionsum Peritoneal Folds Definition: These are double layers of peritoneum connecting different abdominal organs together or connecting an organ to the abdominal wall. Function: 1. They atiech organs to each other or to the abdominal wall. 2. They allow free mobility to certain abdominal organs. 3. They act as passages of vessels, nerves and lymphatics to the suspended organs. Classification: Peritoneal folds are classified into three types: I. Omenta: are peritoneal folds connecting the stemach te other organs. They include: 1. Lesser omentum (gastro hepatic ligament): between the stomach and the liver. 2. Greater omentum (gastrocolic ligament): between the stomach and transverse colon. 3. Gasirosplenic omentum (or ligament): between the stomach and spleen. ll. Mesenteries: Peritoneal folds connecting the mobile parts of the intestine to the posterior abdominal wall. They include: 1. The mesentery of the small intestine (mesentery proper). 2. Transverse mesocolon. 3. Sigmoid mesocolon. 4. Mesoappendix. Ill. Ligaments: include the rest of the peritoneal folds which abdominal organs together or to the abdominal wall. They include: 1. Gastrophrenic ligament between connect the greater curvature of the stomach md and diaphragm. 2. Falciform ligament between umbilicus, anterior abdominal wall, diaphragm and the anterior & superior surfaces of the liver. . Coronary ligament between right lobe of the liver and diaphragm. 4. Rt. triangular ligament between right lobe of the liver and diaphragm. Peritoncum a 5. Lt. triangular ligament between 6. Lienorenal (splenorenal) left lobe of the liver and diaphragm. ligament between the front of left kidney and hilum of the spleen. It contains tail of pancreas and splenic vessels. ¢. Phrenicocolic ligament between the diaphragm and left colic flexure. &. Broad ligament of the uterus between the uterus and lateral wall of the pelvis. Definition: The greater omentum stomach is a large fold of peritoneum which descends from the superficial to the intestine separating it from the anterior abdominal wall. Structure: lt consisis of four layers: two are anterior descending and two are posterior ascending with the inferior recess of the lesser sac in between. Function: 1. It localizes infection in the peritoneum and prevents its spreading. Hence, it is called "Policeman of the abdomen". 2. Storage of fat. Attachments: * * . The greater omentum is a downward extension of the peritoneal covering of the anterior and posterior surfaces of the stomach. The anterior two layers of the greater omentum are attached to the right 2/3 of the greater curvature of the stomach and to the lower border of the 1™ inch of the 1™ part of the duodenum. = They descend for a variable distance, then fold upwards and backwards to form the posterior two layers. Accordingly, the greater omentum has a free lower border. * Its posterior two layers ascend to reach the transverse colon where they split to surround the transverse colon and continue as the transverse mesocolon to reach the anterior border separate as follows: of the pancreas where they Pertoneum — ISHN) - The superior layer ascends to form the posterior wall of the lesser sac. - The inferior layer descends downwards over the posterior abdominal wall of the infracolic compartment. Contents: 7. Right and left gastro-epiploic arteries: run between the anterior two layers close and parallel to the greater curvature of the stomach. These vessels anastomose together and supply both the stomach and oA a greater omentum. 4. Lymph nodes and vessels: lie along the gastro-epiploic vessels. Autonomic nerve fibers. Extraperitoneal fat. Gastro-phrenic ligament Spleen Lesser omentum WN - ray ee ae d ri j Gastro-splenic ligament Dusdenum Transverse Greater omentum colon Peritoneal folds related to the stomach the Perifaneum SUPERIOR —_ —— —_ Liver Superior recess of omental bursa Omental (epiploic) foramen Lesser omentum ANTERIOR Pancreas POSTERIOR Omental bursa (lesser sac) Transverse mesocolon Transverse colon inferior recess of omental bursa bit (obliterated) Greater omentum INFERIOR Sagittal section in the peritoneal cavity LesserOmentum _ (Gastrohepatic Ligament) - [tis a fold of peritoneum extending between the stomach and the liver. - ltrepresents the posterior part of the ventral mesogastrium. - tis formed of two layers (anterior and posterior). Attachments: 1. Above and to the right: * To the margins cf porta hepatis. « To fissure for ligamentum venosum. « To the lower surface of the diaphragm between the end of fissure for ligamentum venosum and the oesophagus. 2. Below and to the left: To the lesser curvature of stomach and first inch of the duedenum. 3. On the right side: Anterior and posterior layers are continuous forming the free border of the lesser omentum which forms the anterior boundary of the epiploic foramen. Gontents: 1. Right and left gastric vessels: run along stomach. 2. Inthe free border of lesser omentum: the lesser curvature of the * Portal vein (posterior). * Hepatic artery (anterior and to the left). « Common bile duct (anterior and to the right). 3. Between the two layers: + Lymph vessels and lymph nodes. * Sympathetic and parasympathetic fibres. « Extraperitoneal fatty tissue. Relations: : Anterior: tuber omental on the inferior surface of left lobe of liver. * Posterior: omentale the cavity of the of the body of the lesser sac separates pancreas, plexus, ganglia and lymph nodes. coeliac it from the tuber trunk and coeliac Perifoneum PORTA FISSURE FOR LIG. VENOSUM LESSER OMENTUM PYLORUS BILE Attachments DUCT of the lesser omentum (Lesser omentum) , Stomach _ Gastrosplenic ligament Portal | Hepatic artery triad + Bile duct Portal ven (right kidney) | (Acrta) “tt Kidney) (inferior vena cava) Lesser sac and lesser omentum (transverse section) Peritoneum GR - Subphrenic Spaces eI Definition: They are potential spaces lying between the diaphragm and transverse colon. They may be sites of collection of pus forming a subphrenic abscess. Classification: The liver and its peritoneal folds divide the supracolic compartment into three subphrenic spaces on each side of the falciform ligament, two intraperitoneal and one extraperitoneal as follows: 1. Right anterior intraperitoneal space: * * * It lies between the right lobe of the liver and the diaphragm on the right side of the falciform ligament. It is closed posteriorly by the upper layer of coronary ligament and the anterior layer of right triangular ligament. It can be infected from gall bladder, diseases. 2. Right posterior intraperitoneal renal pouch): * space: liver, stomach (Morison's or pouch duodenum or hepato- Boundaries: - Anteriorly, inferior surface of the right lobe of the liver. - Posteriorly, anterior surface of the right kidney. - Superiorly, lower layer of the coronary ligament. - Inferiorly, it opens into the general peritoneal cavity. = Importance: . - It is the commonest site for subphrenic abscess because it is the most dependent area in the peritoneal cavity during lying down. - It can be infected from gall bladder, duodenum, colon or kidney. Left anterior intraperitoneal space: 3. * subhepatic appendix, Boundaries: lies between the left lobe of the liver and the diaphragm on the left side of falciform ligament, anterior abdominal wall and anterosuperior surface of the stomach. * * [tis closed posteriorly by the anterior layer of left triangular ligament. It is infected after splenectomy, gastrectomy or anterior gastric perforation. 4. Left posterior subpherenic space: * tis the upper part of the lesser sac. * tis infected from stomach, pancreas, liver or splenic diseases. Peritoneum 9. Right extraperitoneal subphrenic space: * Boundaries: between the bare area of the liver and the diaphragm, bounded by the upper and lower layers of the coronary ligament. * Itcan be infected from kidney, liver or pleural diseases. 6. Left extraperitoneal subphrenic space: * it les around the left suprarenal kidney. = gland and the upper pole of the left It may be infected fram kidney, pleura or colon diseases. N.B.: The right and the left extraperitoneal spaces are not connected to the general pentoneal cavity. Diaphragm Coronary lig. Rt. extraperitoneal ; subpbrenic space | Bare area Coronary or Hepatorenal lig. tbphrenic space Hepatorenal pouch (Right posterior subphrenic space) Pelvic brim Saymplhivsis pubis pe Hepato-renal pouch Recto-vesical pouch (Recto-utevine} Dependent areas in the peritoneal cavity Peritoneun — ABISR Paracolic Gutters Definition: These are longitudinal grooves lying along the sides of the ascending and descending colons. Classification: paracolic gutters include: 1. Right lateral paracolic gutter: - {tlies lateral to the ascending colon. - {tis the only gutter which is open above. « |t communicates with the right anterior and posterior subphrenic spaces above and with the pelvic cavity below. 2. Right medial paracolic gutter: = Itlies medial to the ascending colon. * tis closed both above and below, * It lies between the root of mesentery, the ascending colon transverse mesocolon. 3. Left lateral paracolic gutter: - {tlies lateral to the descending colon. - Itis closed above by the phrenicocolic ligament and opens the pelvic cavity. and the below into . 4, Left medial paracolic gutter: * ltlies medial to the descending colon. * {tis closed above by left colic flexure but open below into the pelvic cavily. Applied anatomy: Paracolic gutters may transmit pus between ihe different parts of peritoneal cavity in peritonitis. Umbilical Folds There are five peritoneal folds which lie on the internal surface of the anterior abdominal wall below the umbilicus, as follows: 1. Median umbilical fold: * It extends from the apex of the bladder to the umbilicus. - It contains the median umbilical ligament (obliterated urachus). Pertoncon Ss 2. Medial umbilical folds: « These are two folds, one on each side. ¢ They extend from the borders of the bladder fundus to the umbilicus. ¢ Each fold contains the lateral umbilical ligament (obliterated umbilical artery). 3. Lateral umbilical folds: « These are two folds, one on each side, lateral to the medial folds. - Each feld contains the inferior epigastric artery. Posterior “a Lateral inguinal fossa, > External SG iliac = ’ ia ea oa) * A fe : External *. : Po wallof rectus ‘Ae “nn ae ae 92 Inferior epigastric vessels ~Deep circumflex vessels ay: iliac —M ed dal om bilical fold iliac vein ~~-~. Median wm bilical fold —Ductes deferens Umbilical folds and related fossae | Peritoneun SGT! Peritoneal Recesses Definition: These are pouches of peritoneal cavity bounded by peritoneal folds. Sites: * Peritoneal recesses are mainly found in relation with the duodenum, caecum and sigmoid colon. > They are frequently found in the fetus and the newborn child and usually obliterated in the adults. Applied anatomy: Peritoneal recesses are of surgical importance because they may be sites of infernal hernia. Classification: A. Duadenal recesses: There are four recesses related to the terminal part of the duodenum: 1. Superior duodenal recess: » ft is present on the left side of the upper end of the 4" part of the duodenum, * The opening behind a superior duodenal fold. of this recess looks downwards, and is related to the inferior mesenteric vein which runs in the edge of the superior duodenal Told. 2. Inferior duodenal recess: » It is present on the left side of the lower end of the 4" part of the duodenum, behind an inferior duodenal fold. * The opening of this recess looks upwards and is not related to vessels. Peritonour is 3. Paraduodenal * recess: It lies a little to the left of the whole 4" part of the duodenum, behind a paraduodenal fold. « Its opening looks to the right with the inferior mesenteric vein present in the overlying fold. 4. Retroduodenal recess: * {tlies pehind the 3° and 4" parts of the duodenum, in front of the aorta. * ts opening is directed downwards and to the left. Inferior mesenteric rem | duodenal fold : JEWUNU A duodenal recess | / aE Inferior duodenal recess <o—, * Duodenal folds and 7 Inferior duodenal fold Left colic artery recesses | B. Caecal recesses: There are three recesses related to the ileocaecal junction: 1. Superior ileocaecal recess: » If lies under cover of a fold of peritoneum called the vascular fold of the caecum which lodges the anterior caecal artery. * This fold extends from the lowermost part of the mesentery of the smail intestine to the front of the caecum. * 2. The opening of this recess looks downwards and to the left. Inferior ileocaecal recess: * It lies under cover of the ileocaecal fold (bloodless fold of Treves) which extends from the end of the ileum to the front of the caecum. * 3. The opening of the recess looks also downwards and to the left. Retrocaecal recess: ° It lies behind the * caecum and may extend upwards behind ascending colon. It contains the appendix in 75% of cases. Its opening looks downwards. Descending colon Vascular fold of caecum ae Superior ileocaecal recess mh sg Heocaccal fol a ce ‘ Caecal fold Caen Retrocaecal Vermiform Ape i Ppenets recess Caecal folds and recess ® recess : the Peritoncum SS C. Intersigmoid Recess: * « It is found behind the apex of the V-shaped sigmoid mesocolon, where the left ureter crosses over the end of the left common iliac artery. Its opening looks downwards. Inferior mesenteric artery Medial limb ——; Intersigmoid recess Sigmoid mesocolon and intersigmoid recess Peritoncum nani ‘Formative Assessment SEQ: 1. Describe the boundaries of the lesser sac and its clinical importance. 2. Describe the boundaries of the epiploic foramen and its clinical importance. 4. Recite the boundaries of Morison’s pouch and explain its clinical importance. 5. Mention the peritoneal recesses related to vascular folds. McQ: Chose the correct answer: The paracolic gutter connected to the subphrenic spaces a. b. c. d. The The The The right lateral gutter. right left gutter. left lateral gutter. left medial gutter. is: atomach CHAPTER 5 ln Os: \ By the end of the feciure, fhe student should be able to- * Describe the gross anatamy of the stomach (position, shape, parts, peritoneal covenng, relations, blood supply, nerve supply and lymphatic drainage). Outline the surface projection of the stomach. Recognize some related clinical problems (e.g. peptic ulcers and spread of « e cancer). The stomach is the most dilatable part of the digestive tube. between the esophagus and the beginning of the small intestine. It is found Position: lt lies in the epigastric, umbilical and left hypochondrial regions of the abdomen. Shape: - The shape of the stomach is modified according to the position of the body and its shape. - It takes the horizontal shape (steer horn stomach) in the supine position and in short stout persons. It takes the vertical shape (J-shape stomach) in the standing position - and in tall slender persons. The stomach has: » Two ends: cardiac and pyloric ends. « Two surfaces: anterosuperior and postero-inferior surfaces. « Two borders: right (lesser curvature) and left (greater curvature), Size: The capacity of the stomach reaches about 1500 ml in the adult. stone Desophague SCRE Cardiac notch ™., Cardiac orlfee. Lasser curvature Inctsure angularis “ Prloric orifice i Greg ter ae a \ Shape of the stomach Position of the stomach Ends of the stomach: Pyloricend Cardiac end _ 1. It is found at the junction of the stomach with the oesophagus . It is found at the junction of the stomach with the duodenum 2. It is ane inch to the left of the median plane at . It is found “% an inch to the level of the left 7" costal cartilage (11" thoracic vertebra), 10 cm from the the right of the median plane at the level of the anterior abdominal wall and 40 cm from the incisor teeth transpyloric 3. It is controlled by a physiological formed by: ® The valve-like action of the acute plane = (first lumbar vertebra) sphincter It is controlled by an anatomical sphincter formed by thickening of gastro-oesophageal angle Pinch-like action of the right crus af the circular muscle fibers of the stamach. It is the diaphragm termed The mucosal rosette of the upper end of sphincter the stomach forming a plug to the lower end of the oesophagus The abdominal part of the esophagus is subjected to high positive intra-abdarninal pressure circular muscle fibres of the fundus of the stomach encircle the lower end of the oesophagus. During gastric contraction, these fibres prevent gastro-oesophageal reflux the pyloric Stomach Curvatures (borders) of the stomach: Greater curvature Lesser curvature 1. It is the stomach right border of the 1. Itis the left border of the stomach. itis 4-5 times longer than the lesser curvature 2. lt shows a notch at its right 1/3 called the incisura angularis (angular notch) which marks the junction of the body with the 2. It shows a notch with the oesophagus called incisura cardia (cardiac notch) pyloric part of the stomach 3. It gives attachment to the lesser omentum | 3. It gives attachment to the gastrophrenic ligament, gastrosplenic ligament and greater omentum of the peritoneum 4. The right and lett gastric vessels 4. The short gastric, left run along it gastro-epiploic and right gastro-epiploic vessels run along it Parts of the stomach: 1. Fundus: « It is the part found above a horizontal artificial line running to the left from the cardiac end to the greater curvature. « Itis Usually empty of food in the erect position and contains gastric air. 2. Body: It is the part between the above mentioned horizontal line and a perpendicular 3. line drawn from curvature of the stomach. Pyloric part: is the part to the the incisura angularis right of the body. to the greater It is subdivided into three regions: « Pyloric antrum: is a dilatation just to the right of the body. « Pyloric canal: is a narrow part to the right of the antrum, length. » Pyloric sphincter: it is 2-3 cm in It is a narrow thickened end to the right of the pyloric canal. It can be identified during the operation by: a. Thickening of its muscle wail. b. Presence of prepyloric vein of Mayo crossing over it to connect the right gastro-epiploic vein on the greater curvature to the right gastric vein on the lesser curvature. Stomach (ENISHI Peritoneal covering: - The stomach is completely covered by peritoneum except a small bare area found at the posterior surface of the fundus. It is related directly to the diaphragm. - Peritoneal ligaments of the stomach: These are folds of the peritoneum attaching the stomach to the surrounding organs: 1. Lesser omentum (Gastrohepatic ligament): It extends from the lesser curvature of the stomach, and the first inch of the duodenum to the hilum of the liver and the fissure for ligament venosum, at the posterior surface of the liver. 2. Gastrophrenic ligament: It extends from the fundus (around the bare area) to the diaphragm. 3. Gastrosplenic ligament: It extends from the upper left part of the greater curvature of the stomach to the hilum of the spleen. 4. Greater omentum (gastrocolic ligament): It extends from the lower 2/3 of the greater curvature of the stomach and the lower border of the first inch of the duodenum to the transverse colon. Relations of the stomach: « Anterior relations: The greater sac of peritoneum separating the stomach from: 1. The inferior surface of the liver (left lobe and quadrate lobe) which is related to the area adjoining to the lesser curvature. 2. The diaphragm is related to the upper left part of the stomach. 3. The anterior abdominal wall is related to the lower part of the stomach. « Posterior relations (stomach bea): (Four organs and four related structures) 1. Anterior surface of body of pancreas and the splenic artery above it. 2. Anterior surface of left kidney and left suprarenal gland above it. 3. Visceral surface of spleen and the left crus of the diaphragm above it. 4, Transverse colon and the transverse mesocolon above it. NB: Alf the above mentioned structures stomach by ihe lesser sac of peritoneum separated from it by the greater sac. are separated except the spleen from the which ts Stomach Lesser omentum Gastrophrenic Hepatogastric ——., ligament 4 Hepatoduodenal ligament Duodenum — Milky spots (dense patches of macrophages) Peritoneal ligaments of the stomach Cardial orifice of stomach Pytoric, : ; é ee Amterior View, Internal ™ eo a Gastric folds ' Surface Shape, parts and mucous membrane of the stomach | Sroma ESSN Structure of the stomach: » « The musculature of the stomach is formed of three layers of smooth muscle fibers. The superficial layer is arranged longitudinally, the middle one is arranged circularly and the inner layer is arranged obliquely. e The superficial oesophaqus. « The Mucous and middie membrane layers of the are continuous stomach shows with two those types of the of folds (rugae); longitudinal folds near the lesser curvature and Irregular folds elsewhere. Fericardium & heart, — Costal margin -.. Left labe of liver ra “ Stomach Li. lobe of liver ~~ Stomach Relations of the stomach the liver Anterior relations of the stomach Upper Lt. part: lies Area adjoining curvature: the lesser is related to Lt. lobe of liver. Lower part: is related to the anterior abdominal wall below the subcostal angle: under the left costal margin & is related to Lt. cupola of diaphragm. a Relations of the anterior surface of the stomach to Stomach Ty Left cupola of the a diaphragm Left inferior - Phrenicartery Decussatin g fibres of the right crus Left suprarenal aland — Spleen e. yee Nes 33 Splenic artery ‘a -\ “) Origin of mesentery Body of pancreas Left kidney Duodenoj ejunal flexure Posterior relations of the stomach (stomach bed) Outer layer Middle layer (longitudinals feircular} Inner layer (oO DTGUe) Musculature of the stomach Sto SR IB Lymphatic Drainage: + Afferent lymphatics communicate freely in the stomach wall. «Lymphatics fram the anterior and posterior surfaces of the stomach pass towards its curvatures where lymph nodes are located along the arteries supplying the stomach and have the same names. « The stomach drains to the following lymph nodes: a. Para-oesophageal lymph nodes: which lie around the cardia and lower end of the oesophagus. b. Splenic lymph nodes which lie in the gastrosplenic ligament and hilum of the spleen. Efferent lymphatics from splenic and left gastro-epiploic lymph nodes pass to the pancreatico-splenic lymph nodes along the splenic artery and upper border of the pancreas. c. The left and right gastro-epipleic lymph nodes which lie on the left and right gastro-epiploic arteries respectively between the anterior two layers of the greater omentum. d. The left and right gastric lymph nodes which lie along the left and right gastric vessels respectively between the two layers of the lesser amentum. é. Right gastric, suprapyloric end of the right lymph gastro-epiploic, nodes. stomach and subpyloric, The latter nodes beginning of retropyloic and are related to the pyloric the duodenum along gastroduodenal artery. f. From the previously mentioned groups, lymphatics converge more proximally to end mainly in the coeliac lymph nodes. Some lymphatics also pass to the superior mesenteric lymph nodes. (Coeliac group of Preaortic lymph nodes) (Final poal) Right Paracardiac group Pyloric group gastric Li. gastric qroup. a a qroup Subpyleric group Right gastro-epiploic group Lymph Drainage of the Stomach Stomach Applied anatomy: e From coeliac lymph nodes, malignant cells can spread to cysierna chyli— thoracic duct — retrograde spread to left supraclavicular lymph nodes (Virchow’s glands). From coeliac lymph nodes, retrograde spread of malignant cells in the lymphatics around the hepatic artery feads to enlargement of lymph « nodes in the porta hepatis. « Retrograde spread of malignant cells from lymph nodes in the porta hepatis may lead fo liver metastases or spread in the lymphatics in the falciform ligament around the ligamentum teres — malignant nodule in i the umbilicus called Sister Joseph nodule. Arterial supply: Along the lesser curvature: 1. Right gastric artery: eltis a branch from the hepatic artery. «lt extends from right to left on the lower part of the lesser curvature to anastomose with the left gastric artery. 2. Left gastric artery: elt is the largest artery to the stomach. «lt is a branch from the coeliac trunk. «lt ascends on the diaphragm towards the oesophagus. «lt then arches forwards to run along the upper part of the lesser curvature of the stomach to anastomose with the right gastric artery. «lt gives ascending oesophageal branches. ALB: Both right and left gastric arteries run between the two layers of lesser omentum and give gastric branches adjacent fo fhe fesser curvature. to both surfaces of the stomach Siomach NGAI” 3. Right gastro-epiploic artery: «lt is a branch from the gastro-duodenal artery. sit runs to the left between the anterior two layers omentum. elt anastomoses with the left gastro-epipolic artery. elt sends branches to the first part of the duodenum, of the greater the lower part of the stomach and the greater omentum. 4. Left gastro-epiploic artery: ¢ itis a branch from the splenic artery. sli runs from left to right through the gastrosplenic ligament and the anterior two layers of the greater omentum along the greater curvature. - lt supplies both surfaces of the stomach and sends branches to the greater omentum. ». Short gastric arteries: « They are branches from the splenic artery. « They pass through the gastrosplenic ligament to the fundus of the stomach. . Venous drainage: - The venous drainage of the stomach accompanies its arterial supply. e The short gastric veins and the left gastro-epiploic veins drain into the splenic vein. » The right and left gastric veins drain into the portal vein. « The right gastro-epiploic vein drains into the superior mesenteric vein. { Applied Anatomy: s The feft gastric and short gastric veins receive oesophageal draining the, abdominal part of the oesophagus (portal). These anastomose with oesophageal veins (tributaries of azygos draining the thoracic part of the oesophagus hypertension, opening of this portosystemic Me gastric and oesophageal varices. (systemic). anastomosis veins veins vein) in portal results in J Coeliac trunk ised Lert Bastro- epiploic Lr ph neces associated wilh Stomach He jl phoic Arterial supply of the stomach Right gastricVv. Lett gastric V. Oesophageal V. phort gastric veins Right gastroepiplaic v. Superior - Prepyloric V_ of Mayo mesenteric V. Venous drainage of the stomach HH - aes Stomach RGGI Nerve supply of the stomach: 1. Parasympathetic supply: « lt reaches which the stomach enter the via the anterior and abdomen through the posterior vagus oesophageal nerves hiatus of the diaphragm in close relation to the oesophagus. « Each nerve trunk gives off gastric branches before continuing parallel to ihe lesser curvature as the nerve of Latarjet that ends in the pylorus. « The nerve of Latarjet is motor to the pyloric antrum and canal while it relaxes the pyloric sphincter i.e. responsible for gastric evacuation. « The anterior vagus gives hepatic branch to the liver and gall bladder while the posterior vagus gives coeliac branch to the coeliac plexus; it shares in the innervation of the gut till the right 2/3 of the transverse colon. « The main trunks as well as the nerves of Latarjet provide the stomach with preganglionic fibers that relay in ganglia within the stomach wall. « The vagi contribute to acid secretion and to gastric motility. Applied Anatomy: Vagotomy may be indicated in cases of peptic utcer to diminish gastric acid secretion. 2. Sympathetic supply: « Preganglicnic branches from the greater splanchnic nerves to the coeliac ganglion. « Postganglionic fibers reach the stomach along its arteries. « Afferent fibers that carry visceral pain sensation appear to be carried with sympathetic nerves. fram the stomach Stomach GUEST Posterior vagal nerve Coeliac branch Hepatic branch Gastric the body Nerve of Latarjet . Parasympathetic supply to the stomach branches to Stomach Sn _ Formative Assessment SEQ: 1. Recite the peritoneal ligaments related to the stomach and describe one of them in detail. 2. Describe the blood vessels related to the greater curvature of the stomach. 3. How can you identify the pyloric sphincter? 4. Explain: oesophageal and gastric varices in case of portal hypertension. MCG: Chose the correct answer about the stomach: a. The cardiac orifice lies in the subcostal plane. b. The pyloric orifice has a physiological sphincter. c. In gastroscopy, the cardiac orifice is 11 cm from the incisors. d. The pyloric sphincter lies in the transpyloric plane. The Intestine CHAPTER 6 JLOs: By the end of these lectures, the student should be able to: « Describe the gross peritoneal covering, anatomy of the small intestine relations, blood supply, (position, nerve supply shape, parts, and lymphatic drainage). Qutline the surface projection of the duodenum. « e Recognize some related clinical problems (e.g. peptic ulcers and spread of } cancer). , THE SMALL INTESTINE -It is the part of the digestive system between the stomach and large intestine. - According to its peritoneal covering, it is divided into a fixed part which is the duodenum and a mobile part including the jejunum and ileum. The Duodenum Site: lt is the proximal part of the small intestine, present partly in the epigastric and partly in the umbilical regions. Length: It is 10 inches long. Shape: It is C-shaped, with its concavity to the left. Parts: |t is divided into four parts: 1. The first part: * It is two inches long. It extends horizontally to the right from the pyloric end of the stomach an inch to the right side of the midline vertebra (transpyloric plane). at the level of the 1/2 1° lumbar Theintestine 4. YOO The second part: « lt is three inches long. * It extends vertically downwards from the right end of the first part to end at the level of the 3 lumbar vertebra. 3. The third part: * [tis four inches long. ° It extends horizontally from the lower end of the 2" part to the left at the level of the 3" lumbar vertebra. 4. The fourth part: * [tis one inch long. : It extends vertically upwards from the left end of the 3” part to join the jejunum at the duedenojejunal flexure, one midline, at the level of 2" lumbar vertebra. inch to the left of the NBL: The duodenum begins at the level of L; vertebra, ends at the level of Lz vertebra and its lowest part (i.e. 3” part) lies at the level of Ls vertebra. Peritoneal covering: » The duodenum abdominal . is a wall except retroperitoneal structure its 1“ inch which completely by peritoneum. * The peritoneum covers the duodenum fixed to the posterior is mobile and is covered anteriorly and along its periphery only. Relations: 1. First part: a. First inch (duodenal cap): (the only mobile part). > Anteriorly: quadrate lobe of the liver, but separated greater sac. from it by the * Posteriorly: neck of the pancreas, but separated from it by the lesser sac, * Superiorly: it gives attachment to the free border of the omentum (containing common bile duct, hepatic artery and lesser portal vein) with the epiploic foramen behind it. * Inferiorly: it gives attachment to the greater omentum of pancreas behind it. with the head b. Second inch: Anteriorly: 1. Neck of the gall bladder; lies at the junction between the 4% 2™ parts of the duodenum. 2. Quadrate lobe of liver; separated from it by the greater sac. Posteriorly: 1. Gastroduodenal artery. 2, Gammon bile duct; to the right of the artery. 3. Portal vein; behind the artery and the duct. 4, Inferior vena cava; posterior to portal vein. Inferiorly: head of the pancreas. Right lateral plane Transpyloric plane “4 or, Duodenum Intertubercular plane Position of the duodenum ana The incest Sa Lesser omentum Creater omentum Peritoneal attachments of 1° inch of the duodenum 2. Second part: Anteriorly: | 1. Upper part is related to the inferior surface of the right lobe of the liver, but itis separated from it by the greater sac, 2. Middle part is crossed by the transverse colon. 3. Lower part is related to coils of jejunum. Posteriorly: 1. Hilum of the right kidney and the structures in it (renal vein, renal artery and pelvis of the ureter). 2. Right psoas major muscle. Medially: 1. Head of the pancreas. 2. Ampula of Vater opens in the middle of the posteromedial aspect of the 2" part of the duodenum. 3. Superior and inferior pancreatico-duodenal arteries in the groove between the 2" part of the duodenum and head of the pancreas. Laterally: 1. Right lobe of the liver. 2. Ascending colon. 3. Right colic flexure. The intestine 3. aS Third part: Anteriorly: 1. Root of the mesentery of the small intestine containing the superior mesenteric vessels. 2. Coils of jejunum. Posteriorly: 1. Right psoas major muscle separated from it by the right ureter. 2. Inferior vena cava separated from it by the right gonadal artery. 3. Abdominal aorta separated from it by the inferior mesenteric artery. Superiorly: head of the pancreas and its uncinate process. inferiorly: coils of jejunum. 4. Fourth part: Anteriorly: Coils of jejunum. Posteriorly: 1. Left sympathetic chain. 2. Left gonadal artery. Medially: 1. Uncinate process of the head of the pancreas. 2. Abdominal aorta. Laterally: 1. Coils of jejunum. 2. Hilum of the left kidney. Ist. part (2 inches) pyloro-ducdenal _—" junction peerless ae” 2nd, part (3 inches) 3rd. part (4 inches) Parts of the doudenum The Intestine rey Neck of G. B. foramen of Winslow C.b.D. Quadrate lobe Anterior Posterior Relations of the 1* part of the duodenum Rt. colic flexure isi tit a thi bid eg Posterior small intestine Anterior Relations of the 2" part of the duodenum The intestine is, 7 loops of Root of mesentry Rt. psoas inbestine Inferior Theserleric . Anterior Rt. gonadal a. - : Rt. ureter ae Posterior Relations of the 3 part of the duodenum hilum of Lt. kidney Li. psoas Lt. gonadal a. Root of mesentry ' Lt. sympathetic chain Relations of the 4™ part of the duodenum The intestine SOG Suspensory ligament of the duodenum (ligament of Treitz): - It is a fibromuscular band that suspends and fixes the duodenojejunal flexure. " It arises from the right crus of the diaphragm just to the right side of the oesophagus. * It descends behind the pancreas to gain attachment into the posterior surface of the duodenojejunal flexure, 3" and 4" parts of the duodenum. - It fixes the terminal part of the ducdenum. Arterial supply: - 1“ inch of the first part is supplied by the supraduodenal artery (a branch of the gastroduodenal or hepatic artery) with additional supply from right gastric and right gastro-epiploic arteries. « 2™ inch of the first part and the upper half of the second part (the foregut part of the duodenum) are supplied by the superiar pancreatico-duodenal artery (a branch of the gastroduodenal artery). = The remaining parts of the ducdenum (the midgut part of the duodenum) are supplied by the inferior pancreatico-duodenal artery (a branch of the superior mesenteric artery). Venous drainage: It accompanies the arterial supply to drain into the portal circulation (splenic, superior mesenteric and portal veins). Lymphatic drainage: Pyloric, superior mesenteric and hepatic lymph nodes. ( ‘ Applied Anatomy: 1. The end of the duodenum (ie. duodenojejunal function) is marked at operation by the fligament of Treitz. 2. XL, fhe duodenum is the commonest site for peptic ulcer. af The intestine mn Common Minor Accessory pancreatic duct bile duct duodenal papilla Major duodenal papilla Main pancreatic duct Opening of common bile duct and pancreatic ducts Parts: Itis formed of the jejunum and the ileum. Beginning and end: lt starts at the duodenojejunal flexure and ends at the ileocaecal junction. Length: Itis about six meters (20 feet) in length. Arrangement: li is arranged in series of loops or coils which are completely covered peritoneum and found in the free border of the mesentery of small intestine. by The jejunum: * It forms the proximal 2/5 of the mobile part of small intestine. It is about eight feet (2.4 meters) in length. « Its junction with the duodenum forms a bend termed the duodenojejunal flexure. « This flexure is fixed in position by a fibromuscular band called the suspensory ligament of duodenum (ligament of Treitz). The ileum: + |t forms the distal 3/5 of the small intestine. It measures about 12 feet (3.6 meters) in length. * It ends at the ileocaecal junction at the meeting of the right lateral vertical plane with the intertubercular plane. The mesentery of the small intestine: « it is a fan-shaped fold of peritoneum, extending from the covering the small intestine to the posterior abdominal wall. peritoneum «lt has two borders: a. Free border: and ileum. b. Attached It is six meters long and contains the coils of the jejunum border (root of mesentery): It is six inches long, extending obliquely downwards and to the right fram the duodenojejunal flexure to the ileocaecal junction, and crosses over the following structures fram above downwards: 1. The third part of the duodenum. 2. The abdominal aorta. 3. The inferior vena cava. 4. The right psoas major muscle. 5. The right genitofemoral nerve. 6. The right gonadal artery. ?. The right ureter. « The central part of the mesentery is the longest part, which is about 20 cm when measured from its root to its intestinal border. - Contents of the mesentery: 1. Loops of small intestine in the free border of the mesentery. 2. Superior mesenteric vessels run in the root of the mesentery and their ileal and jejunal branches run in between the two layers of the a. mesentery. 3. Sympathetic and parasympathetic plexuses. . Extraperitoneal connective tissue and fat. 5. Lymph vessels called lacteals because they carry lymph which is milky in appearance and called “chyle”. Mesenteric lymph nodes; 100-150 lymph nodes arranged in three rows: 6. - §mall-sized nodes: near the intestine in the free border. - Medium-sized nodes: midway between the free and borders. - Large-sized nodes: along the superior mesenteric vessels. Parts of the small intestine and its mesentery attached ; - Superior mesenteric A. —nes, : wc Superior mesenteric V. =, ae in the root of the Mesente a Small intestine =4(Jejunum & ileum) mesentery Large-sized lymph nodes .c” in the root of the = mesentery Extra-peritoneal fat z= nodes Medium-sized lymph nodes Arterial-—% arcades (1-2) Peyer’: Transverse Jejunum section Comparison between jejunum and ilium the The intestine NNN omparison between the Jejun andum Ilium The comparison between jejunum mobile than the ileum. This hypermobility keeps the jejunum always is more empty of food. the jejunum Elongation and ileum is based on the fact that the of jejunal mucous papillae and its wider lumen increase the rate of absorption through its wall. Jejunum . lleum Proximal 2/5 of the small intestine | Distal 3/5 of the small intestine and and usually empty usually contains food 2. Tends to lie in the umbilical region ; 3. Wide lumen, thick wall, thick a Narrow lumen, thin wall, thin mucosa, mucosa, thick musculosa (due to | thin musculosa (due to less active active peristalsis & absorption) peristalsis & absorption) 4. Numerous oS. Papillae are longer & less circular mucosal folds | Few circular mucosal folds Papillae are shorter & more NUMEeErOouUs NW TTE Prous . More vascularity Less vascularity . Bright red (redder) 8. Tends to lie in the hypogastrium & Rt. lliac fossa | Pale red No Peyer's patches : Many Peyer's patches along the antimesenteric 9. 10. At operation, felt as double layer Jejunal arteries arterial arcades form simple | At operation, felt as one layer | lleal (1 or 2) in the | arterial mesentery border arteries arcades form (3 complicated or 4) in mesentery 11. Small amount of fat in mesentery | Large amount of fat in mesentery 12. Vessels appear clear in the Vessels are not clear in the mesentery (presence of windows) | mesentery (no windows) . Poor in lymph vessels and nodes | Rich in lymph vessels and nodes the Arterial supply: lt is supplied by the jejunal and ileal branches of the superior mesenteric artery. Venous drainage: The venous drainage follows the arterial supply. mesenteric vein (portal circulation). Lymphatic drainage: Mesenteric lymph nodes. It ends into the superior Formative Assessment MCaQ: 1. The ligament of Treitz is the landmark of the: a. lleocaecal junction. b. Pyloroduodenal junction. c. Gastro-esophageal junction. d. Duodenogjejunal junction. 2. The caudal part of the duodenum a. Hepatic artery. b. Splenic artery. c. Superior mesenteric artery. is supplied by the: d. Inferior mesenteric artery. 3. The 3 part of the duodenum is related posteriorly to the: a. Superior mesenteric artery. b. Inferior mesenteric artery. c, 2™ |umbar vertebra. d. 1° lumbar vertebra. 4, The 2" part of the duodenum is related anteriorly to the: a. Transverse mesocolon. b. Transverse colon. c. Coils of ileum. d. Left lobe of the liver. lit Gig - By the end of these fectures the student should be able to: * Describe the gross anatomy of the large intestine (position, shape, parts, peritoneal covering, relations, blood supply, nerve supply and lymphatic drainage}. » Outline fhe surface projection of the different parts of the large intestine. THE LARGE INTESTINE Itis about 150-180 cm (5 feet) in length. lt is the ascending distal part colon, of GIT transverse and colon, is formed of the descending caecum, colon, pelvic appendix, (sigmoid) colon, rectum and anal canal. The large intestine differs from the small intestine in three features: 1. The taéniae coli: * These are three bands of the longitudinal muscle layer of the colon. » They * terminal part of the sigmoid colon to be continuous with the longitudinal muscle layer of the rectum. The length of the taeniae coli is one foot shorter than the length of start at the base of the vermiform appendix and end in the the large intestine. In the ascending and descending colons, the taeniae coli are anterior, poasteramedial and posterolateral. In the transverse colon they are one posterior and two anterior (one superior and one inferior in positions). 2. Sacculations (or haustrations): > The wall of the colon bulges outwards in between the taeniae coli to form pouches called sacculations. * These sacculations are formed because the taeniae coli are shorter than the length of the colon. * They are absent in the appendix, rectum and anal canal. 3. Appendices epiploicae: * They are small peritoneal projections filled with fat on the surface of the large intestine. * They are absent in the appendix, caecum, rectum and anal canal. The Inestioe ES Sacculations Taenia Appendices epipliocae Features of the large intestine coll : The Intestine Pie Definition: It is the most proximal part of the large intestine. Length: lt measures 5-7 cm in length. Site: ' * Itlies in the right iliac fossa above the lateral 1/2 of right inguinal ligament. * tis closed inferiorly and continuous above with the ascending colon. Peritoneal covering: * Itis nearly completely covered by peritoneum but has no mesentery. * A wide retrocaecal peritoneal recess is present behind it, and may €xtend up to the lower part of the ascending colon (retrocolic recess). Caecal orifices: 1. lleocaecal orifice: opens into the posteromedial aspect of the upper end of the caecum. It is guarded by the ileocaecal valve. 2. Vermiform appendix: opens into the posteromedial aspect caecum, one inch below and lateral to the ileocaecal valve. 3. Colic orifice: the caecum is continuous ascending colon. Relations: Anteriorly: 1. Anterior abdominal wail. 2. Small intestine. 3. Greater omentum, Posteriorly: a. Three muscles: 1. lliacus. 2. Psoas major. 3. Psoas minor. b. Three nerves: 1. Fernoral nerve. 2. Genitofemoral nerve. 3, Lateral cutaneous nerve of the thigh. at its upper end of the with the The Ascending colon Tew Vermiform appendix Taenia coli Position of the caecum Right psoas major Lat. cutaneous N. of the thigh Femoral N. Intestine Extermal thac A_ Posterior relations of the caecum rns neste c. Three vessels: 1. External iliac artery. 2. Right gonadal artery. 3. Right gonadal vein. Arterial supply: It is supplied by anterior and posterior caecal arteries which are branches from the ileccolic artery (a branch of the superior mesenteric artery). Venous Veins drainage: of the caecum drain into the superior mesenteric vein (portal circulation). surface anatomy: The caecum lies within a triangular area bounded by: 1. Lateral 1/2 of right inguinal ligament. 2. Right midclavicular line. 3. Intertubercular plane. The ileocaecal valve: * The jleum nosteromedial enters obliquely through wall of the caecum a _ horizontal slit to form two folds (an into upper the and a lower) that constitute the ileocaecal valve. The two folds meet medially and laterally in two ridges, the frenula of the valve. * Reflux of caecal contents into the ileum is prevented by contraction of the circular muscle of the ileum and by tightening of the frenula which draws the lips of the valve together closing the orifice. Ascenling column Taenin coli — __ Anterior caecal artery __- lleocaecal orifice Heoceccai valve _ (superior lip) Frenolum of deocecesl valve —— —_ Terminal [leocaceal valve — ileum {inferior lip) ___— Mesa ppendix — Caccum _ —_ : Orifice of vormiform appendix — Appendicolar artery Fes ‘: Vermiform appendix lleocaecal valve Shape, site and wall: « |tis a worm-like process in the right iliac fossa. - Its base is attached to the posteromedial aspect of the caecum, one inch below and lateral to the ileocaecal valve. - At its base, its longitudinal muscle coat is continuous with the three taeniae of the caecum and colon. « The wall of the appendix is very rich in lymphoid tissue, so it is called the “tonsil of the abdomen”. Length: lt is the narrowest part of the large intestine and varies in length from 2-20 cm. Peritoneal covering: lt is completely covered by peritoneum and has a mesoappendix which is continuous with the mesentery of the ileum. The mesoappendix: * Itis a triangular fold of peritoneum that covers the vermiform appendix. « it has a base attached to the back of the lower end of the mesentery of small intestine, close to the ileocaecal junction. * It has right and left free borders. Contents: 1. Vermiform appendix in the right free border, 2. Appendicular vessels in the left free border. 3. Sympathetic and parasympathetic fibers. 4. Lymph vessels and lymph nodes. Position: it could be found in the following positions: 1. Retrocaecal position (75%): the appendix lies freely coiled up in the retrocaecal recess (commonest position). 2. Pelvic position (20%): the appendix hangs down over the pelvic brim into the pelvis where it may be related to the right uterine tube and ovary in the female. 3. Subcaecal position (3%): the appendix lies horizontally just below the caecum. 4. Preileal or postileal position (2%): the appendix passes either in front or behind the terminal ileum. 9. Other rare positions: as subhepatic (where the appendix lies under the liver in congenital short ascending colon), or retrocolic position in which the appendix lies deep to the ascending colon. Tleocolic artery Colic branch lical branch Superior mesenterte artery Posterior caecal artery Appendicular artery Anterlor caceal artery Vascular fold of earcum Superior ileocaecal recess: Bloodless fold of caecum (fitof frevex) Terminal part of ileum Inferior ileocaecal recess Mesoappenilix Appendicular artery External iliae vessels (retroperitones|) Retrocaecal recess Caecal folds Right paracolic gutter Appendicular artery Taenia coli Taenia coli Posterior caccal artery Caecal folds Retrocaecal recess Asceoling branch lhooclic artery Teenin coll Heal hraeele Anmterler wind paccterbor raced] prterics Super lor (hecagesl recess. Wosculag fohl af caecum Heum liferlor |leecnecul recess Hlomiiess fol of coee iim Mesnappe nal y Apprulicaler artery Vermifern mppomdia Mesoappendix | Positions of the appendix Surface anatomy: The base of the appendix is represented by “McBurney’s point” which lies at the junction of the lateral 1/3 with the medial 2/3 of a line drawn from the umbilicus to the right anterior superior iliac spine. Blood supply: * The only arterial supply is the appendicular artery which is a branch from the posterior caecal descends artery or from termination of the ileocolic artery. behind terminal part of ileum to run in the mesoappendix. It It is an end artery that does not anastomose with the adjacent arteries. * The venous drainage is appendicular vein which ends in the ileocolic vein (tributary of superior mesenteric vein). * Both the artery and vein run in the left free border of the mesoappendix. Nerve supply: Parasympathetic: from vagus nerve Sympathetic: from the superior mesenteric plexus. The afferent (sensory) fibers that carry visceral pain from the appendix pass through the sympathetic fibers that enter the 10" thoracic spinal segment, which also supplies the skin around the umbilicus. f apetes Anatomy: . 7. Pain of appendicitis is felt in the right iliac fossa and may be referred to the umbilicus (visceral pain of the appendix is conveyed to the 10" thoracic spinal segment, which gives rise to the 10" intercostal nerve that supplies the skin around the umbilicus). 2. Acute appendicitis is the commonest cause for acute abdomen. 3. Af operation, the appendix is identified by the three taeniae coli which meet at its base. Position: * It begins at the ileocaecal junction as an upward continuation of the Caecum. « lt ends at the right colic flexure anterior to the lower part of the right kidney and just below the right lobe of the liver. Length: lt is about eight inches (12-20 cm) in length. Peritoneal covering: « |tis covered by peritoneum along its anterior surface and on its sides. * Paracolic gutters are found along its lateral and medial sides. Cp pplied Anatomy: Fiuid colfection in the 7 upper part of fhe abdomen can pass downwards along these gutters (e.g. in perforated peptic ulcer). NX P Relations: Anteriorly: 1. Anterior abdominal wall. 2, Coils of small intestine (mainly ileum). 3. Greater omentum. Posteriorly: ‘3 Right iliacus muscle. ee Right transversus abdominis muscle. a: Right iliac crest. The previous structures are separated from the ascending colon by Right quadratus lumborum muscle. three nerves: a. lliohypogastric nerve. b. Wlio-inguinal nerve. ¢. 6. Lateral cutaneous nerve of the thigh. Lower part of the right kidney. Medially: coils of small intestine (mainly ileum). Arterial supply: 1. lleocolic branch of the superior mesenteric artery. 2, Right colic branch of the superior mesenteric artery. Venous drainage: It follows the arterial supply {i.e. ileocolic and superior mesenteric vein (portal circulation). right colic veins) to the Posterior relations of the caecum and ascending colon The gan mecoe | ore Shape Peritoneum ree (Golie Rlamites Right colic (hepatic) flexure | Position Infestine Left colic (splenic) flexure In the right hypochendrium In the left hypochondrium Under cover of the right lobe At the anterior (lateral) end | of liver which push it downwards of the spleen It lies at a lower level lt lies at a higher level Right angle. Acute angle. Covered with peritoneum except posteriorly Covered with peritoneum except posteriorly It is attached to the diaphragm by a peritoneal fold called phrenicocolic ligament Relations Above, in front and laterally: right lobe of liver Posteriorly: lower part of Above: spleen and tail of pancreas Posteriorly: diaphragm the right kidney Medially: 2" part duodenum and small intestine Arterial supply Ascending branch right colic artery of the coils of of the Medially: left kidney and |} coils of small intestine Ascending branch of upper left colic artery the The Right lobe of liver Right colic flexure Intestine Spleen Transverse colon Left colic flexure Spleen Diaphragm Left colic Left kidney flexure Right colic flexure Left kidney 2™ part of duodenum Descending colon Ascending colon Transverse colon and colic flexures The Transverse Colon Position: * It starts from the right colic flexure at the right lumbar region and descends dawn to the umbilical region. * It ends at the left colic flexure in the left hypochondrial region. Length: : It is about 18-20 inches long. Peritoneal covering: It is completely covered “transverse mesocolon”. by peritoneum and has a mesentery called the Transverse mesocolon: - It is a fold of peritoneum formed of two layers. It is found ascending posterior two layers of the greater omentum. behind the + Ithas two borders: 1. Free border containing the transverse colon (the first two inches of the transverse colon are bare of peritoneum and lie directly on the 2™ part of the duodenum). - 2. Altached border (root) is attached to the posterior abdominal wall along the following structures from right to left: a) Anterior surface of the head of pancreas. oh 1. Transverse colon in the free border (except its first two inches). aap * b) Anterior border of the body of pancreas. Contents: Ascending branch of the superior left colic artery... Branches of the middle colic artery: run from behind forwards. Lymph vessels and lymph nodes. Sympathetic plexuses. Extraperitoneal fatty tissue. Attachment of root of Attachment of root of transverse mesocolon to trunsyerse mesocolon to the anterior border of body of panercas head of pancreas Attachment of the root of the transverse Relations: Anteriorly: 1. Inferior surface of the right lobe of the liver. 2. Body and fundus of the gall bladder. 3. Greater 4. Greater Posteriorly: 1. Second 2. Head of omentum. curvature of the stomach. part of the duodenum. the pancreas. 3. Duodenojejunal flexure and coils of jejunum. 4. Left kidney. mesocolon Arterial supply: 1. Right 1/3 is supplied by the ascending branch of right colic artery (branch from superior mesenteric artery). 2. Middle 1/3 is supplied by the middle colic artery (branch from the superior mesenteric artery). 3. Left 1/3 is supplied by the ascending branch of superior left colic artery (branch trom the inferior mesenteric artery). Venous drainage: It follows the arterial supply to drain into the superior and inferior mesenteric veins (portal circulation). The Descending Colon Position: * - itlies in the left hypochondrium, left lumbar and lett iliac regions. [t extends down from the left colic flexure to the pelvic brim becomes continuous with the pelvic colon. where Length: Itis about 9-12 inches long. Peritoneal covering: * » Itis covered by peritoneum anteriorly and on both sides. Peritoneal paracolic gutters are found along its medial and which reach down to the pelvic cavity. lateral sides, Relations: Anteriorly: (like those of ascending colon) 1. Anterior abdominal wall. 2. Loops of small intestine. 3. Greater omentum. Posteriorly: (like those of ascending downwards) 1. Left kidney. colon but extend more 2. Left quadratus lumborum muscle. 3. Left transversus abdominis muscle. 4. Left iliac crest. 5. Left iliacus, left psoas major and psoas minor muscles. upwards and it The Intestine 6. Nerves and vessels: « Left Subcostal nerve and vessels. « « « Left iliohypogastric nerve. Left ilio-inguinal nerve. Left lateral cutaneous nerve of the thigh. « Left femoral nerve. « « Left gonadal vessels. Left genitofemoral nerve. - Left external iliac artery. Arterial supply: By the superior and of the inferior mesenteric inferior left colic branches artery. Venous drainage: By superior and inferior left colic veins which drain into the inferior mesenteric vein (portal circulation). Left kidney aft subcostal nerve Left quadratus lumberum nouscle Left pooas = maior a bs 3g f a Left iliac crest Left Left iliacus miner sche Left gonadal vessels j 7 Left lateral cutaneous —" nerve of the thigh nerve Posterior relations of the descending colon The Intestine Position: ° It begins in the left iliac fossa, at the left border of the pelvic brim, as a continuation of the descending colon. * It ends in the pelvic cavity opposite the 3° sacral piece, by becoming continuous with the rectum. Shape and Length: * Itis S-shaped. * Itis 15-25 inches long. Peritoneal covering: * ’ It is completely covered by peritoneum. It has a triangular shaped mesentery, called “pelvic sigmoid} mesocolon’. Pelvic mesocolon: - Itis a peritoneal fold formed of two layers attaching the pelvic colon to the * Upper part of the posterior wall of the pelvis. It has an attached border or root formed of two limbs: Lateral limb: attached to the medial side of left external iliac vessels along a line starting two inches above the inguinal ligament and ascending upwards to the point of bifurcation of the left common iliac artery. Medial limb: descends from the apex till the 3 sacral piece. It is attached to the front of the sacrum. The apex crosses in front of the left ureter at the bifurcation of left common iliac artery. wh An intersigmoid recess is found deep to the apex of the mesocolon. Contents: 1. Sigmoid (pelvic) colon in the free border. Sigmoid vessels in the lateral limb. Superior rectal vessels in the medial limb. Autonomic fibers. Extraperitoneal fatty tissue, lymph vessels and lymph nodes. ak * The intestine SS => as gen aease da colic artery - A Superior lett Inferior left Sigmoid colon Let psoas major muscle colic arterics Genitofemoral nerve Left gonadal vessels Left uret elt ureter Sigmoid colon Sacral plexus External iliac vessels Left piriformis muscle Relations and arterial supply of the sigmoid colon Relations: Laterally: Lateral wall of the pelvis separated from the sigmoid colon by the vein (portal followings: 1. Left external iliac vessels. 2. Obturator nerve and vessels. 3. Left ovary (in female) or left vas deferens (in male). Above and medially: Coils of ileum. Posteriorly: |. Left internal iliac vessels. 2. Left ureter. 3. Sacral plexus. 4. Left piriformis muscle. Below: 1. Urinary bladder in both sexes. 2. Uterus in female. Arterial supply: Sigmoid branches of the left colic artery. Venous drainage: sigmoid veins which drain into the inferior mesenteric circulation). lnte rior Mics bey be wi eae oe linah ~ ‘ A Nedial Innb _s Wes essen ich 1) Signe wl Colon i A it i I \ t i uk Sigmo idl et , ral Late kk :, | Seema f ' 7ir |!: " | Inter- siz il recess. Sigmoid mesocolon and intersigmoid recess The Iniesitine Descending colon Sacrum Baginning af sigmoid colon Pelvic brim Sigmoid colon Rectum Lnal canal sigmoid (pelvic) colon in a side view of the pelvis Inf. mesenteric A. Lt. C. 1. AL t. psoas major Sud, rectalA. Lt. ureter Ant. surface of the sacrum Ascending the root Inguinal ligament Inverted V-shaped root of the pelvic mesocolon The Infestine Arterial supply of the colon is derived from: a. Branches from superior mesenteric artery (to the part of the colon which is derived from the midgut): 1. lleocolic artery. 2. Right colic artery. 3. Middle colic artery. Branches from inferior mesenteric artery (to the part of the colon b. which is derived from the hindgut): 1. Superior left colic artery. 2. Inferior left colic arteries (sigmoid arteries). The marginal artery of Drummond connects all the mentioned arteries as it lies in the concavity of the colon. . * Itis an important collateral channel between the superior and inferior mesenteric arteries. = It gives straight branches (vasa recta) which pass directly to the colon, a a ; a Applied Anatomy: The marginal artery has a great surgical importance as it can maintain the viability of a long segment of the colon after division of a major colic branch. This allows colon bypass operation to be feasible. Lymph vessels from the colon follow the following lymph node groups, in sequence: 1. Epicolic nodes: on the bowel wall. arterial supply to drain / into the 2. Paracolic nodes: between the marginal artery and the bowel. 3. Intermediate nodes: on the main vessels along the colic arteries. 4. Central nodes: alongside the superior and inferior mesenteric vessels. Transverse colon Superior Upper left colic artery # mesenteric artery Bue?” feilicddle colic artery Right colic ue i) artery Ascending Descending colon a colon Lower left colic artery Gas ge fi Neocolic artery Sigmeial colon Interior mesenteric artery The marginal artery of the colon * Parasympathetic nerve supply: The caecum, ascending colon and right 2/3 of transverse colon receive their parasympathetic supply from the vagus nerve, while the distal colon and the rectum are supplied by the “nervi erigentes” (pelvic splanchnic nerves) which originate from S2, 3 and 4. The parasympathetic system is motor to the bowel wall and inhibitory to the sphincters. - Sympathetic nerve supply: It is distributed to the blood vessels of the large intestine through the greater and lesser splanchnic nerves. Pelvis site: in the posterior part of the pelvis It begins at the level of the 3 sacral vertebra as a continuation of the pelvic colon. It ends one inch below the tip of coccyx where it bends backwards forming the anal canal. Shape: It is five inches long. 1. It follows the sacrococcygeal concavity forming the sacral flexure of the rectum. 2. At its lower end it bends backwards forming the anal canal. This posterior 3. bend is termed the perineal flexure of the rectum. lt has three lateral flexures: the upper and lower are concave to the left and the middle is concave to the right. 4, The lower part of the rectum is dilated and called ampuila of the rectum. The rectum differs from the sigmoid (pelvic) colon in that: * No mesentery. * No appendices epiploicae. * No taeniae colli. * No sacculations. Peritoneal covering: “Upper 1/3: is covered on its front and sides. “Middle 1/3: is covered only anteriorly. “Lower 1/3: is not covered with the peritoneum (bare) because the Peritoneum is reflected forwards to: A. the upper part of the posterior wall of the urinary bladder (in male) forming the rectovesical pouch (7.5 cm from the anus). B. The back of the upper 1/3 of the posterior wall of the vagina {in female) forming the rectouterine pouch (Douglas pouch) 5.5 cm from the anus. Pelvis Relations of the Rectum: {A} Anterior Relations: are different in male and female. * In male: 1. The upper 2/3 of the rectum: is covered by peritoneum and is related to coils of pelvic colon and ileum which occupy the rectovesical pouch and separates the rectum from the urinary bladder. 2. The lower 1/3 of the rectum: is devoid of peritoneum and is related to the back of the base of the urinary bladder separated from it by: * The two seminal vesicles and the termination of the two vas deferences. * Upper part of posterior surface of the prostate and rectovesical fascia. “In female: 1. The upper 2/3: is covered by peritoneum and is related to coils of pelvic colon and ileum which occupy the Douglas pouch and separates the rectum from the uterus and upper 1/3 of the vagina. 2. The lower 1/3: is devoid pf peritoneum and is related to the middle 1/3 of the posterior wall of the vagina. (B)Posterior Relations (bed of rectum): The same in male and female o Bones and ligaments: e Lower 3 sacral vertebrae + Concyx * Anococcygeal ligament. a (Muscles: « §=Piriformis e Coccygeus e Levator ani muscle Pelvis col of eum sigmoid colon % bladder 3S SF puboprostatic ligaments . Late cecal cxf ihourn bladder Female ih} ~ Sjaculatory duct 5 a Vessels: * Median sacral artery o » Lateral sacral arteries + Superior rectal artery. Werves: « The sacral sympathetic chains + Ganglion impar * Sacral plexus. iC) Lateral refations: on each side Upper 1/3: e Para-rectal fossa which contains coils of the ileum and pelvic colon. Lower 2/3: e Levator ani and coccygeus. e = Inferior hypogastric plexus. Mucosa of the rectum: it shows ?. Longitudinal folds: which appear only when the rectum is empty. 2. Three transverse distension. Each folds: They are permanent, semilunar and marked on fold lies on the concave side of one of the three lateral flexures of the rectum. The superior fold is at the beginning of the rectum and commonly project from the left side. The middie | fold : is the largest and most constant and ampulla and projects mainly from the right wall. The flower fold: is variable and projects from the feft side. lies above the rectal Pelvis Median sacral vessels Superior rectal vessels Sympathetis trunk Lateral sacral vessels Pirlformls Ganglion impar Anococcygea Ischial sping a 'a \ & ligament or hg Levator anl i Cocecygeus Rectum Ferineal body work lumber sy npathetic trunk aortic ploxus superior hypogastric pleaus commen pintormia muscle ’ t : / i, obturator nemo Aight and lett Inferior hypogastric plaxus \ Pd eden sacial 0 Pelvic syrnipallvetic trunk ariary Posterior relations of the rectum iliac artery Pelvis Midelle rectal volves Inferior recta! valve ‘Lerwentigy* emi enmusele a“ Intornes! hamoarehaieal ——. nd aphinebar = Rectal column plexus _——— Recto} sinus interree| ates apteinctee gland Soper! — sphincter Inferior hypogastric Pigkus Doap axial 1 Subsulangous axiernic Splineheer ’ Lateral relation of the rectum and transverse rectal folds Blood supply: A. Arterial Suppiy: f. Superior rectal artery: It is the continuation of the inferior mesenteric common artery in front of the left iliac artery. It descends in the medial limb of the root of the pelvic behind mesocolon. It divides into right and left branches which descend the rectum membrane and pierce and rectum of the muscular the the coat upper % supply and anal of the mucous the canal. They anastomose with the ascending branches of the inferior rectal arteries. 2. Middle rectal arteries: arise from the anterior division of the internal iliac artery. The right and left arteries run medially to supply the muscle layer of the mid and lower rectum. They form poor anastomoses with the superior and inferior rectal arteries. 3. Inferior rectal arteries: arise from the internal pudendal artery. They supply the lower half of the anal canal and the anal ascending which submucosa in the branches sphincters and give anastomoses with the terminal branches of the superior rectal artery. B. Venous Drainage: correspond to the arteries. 1. Superior rectal vein: which continues as the’ inferior mesenteric vein which ends in the splenic vein (portal circulation) © 2. Middle rectal vein: ends in internal iliac vein (systemic circulation). 3.Inferior rectal vein: ends in the internal pudendal vein (systemic circulation). Lymphatic drainage: Upper part of the rectum: inferior mesenteric rectal artery. lymph drains nodes. into the pararectal lymph nodes and The lymph vessels accompany the the superior Peis superar rectal upper fell transverse fold of rectum wiery f ' i anal columns «: ] y “as tailA | Wie A lower left transverse told of rectum puborectalis . external anal sphincter inferior rectal artery Arterial supply of the rectum GER * superior rectal v. {IM - pertal) internal iliac v. (systemic) * middle rectal v. (internal Mac) Internal rectal (hemorrhoical) * inferior rectal v plaxus finternal pudendal to Internal ills) Extemal rectal (hemorrhoidal) plexus Venous drainage of the rectum and anal canal To inferior mesenteric nodes with superior rectal arteng To internal iliac nodes with middle rectal artery To internal iliac nodes with pudendal arteny TO Sipe hd ficial tiyguinal nodes Lymphatic drainage of the rectum and anal canal Pevis EARNS: The fower part of fhe rectum: drains into the internal iliac lymph nodes. The lymph vessels accompany the middle rectal artery. Nerve supply: 1- Parasympathetic fibres: from pelvic splanchnic nerve (82,3,4}. 2- Sympathetic fibres: from L1,2 via inferior mesenteric plexus. Per-rectal examination: with the right index finger introduced anal canal the following structures can be felt: e « e In male The external anal sphincter. The bulb of the penis. The prostate. « e The two seminal vesicles. The two vas deferentia. '@ through the In female The external anal sphincter. The cervix. The back of vagina. *« e e The base of the urinary bladder. Clinical notes: e The anteroposterior flexures of the rectum, as it follows the curvature of the e sacrum and coccyx and the three lateral flexures remembered when one is passing the patient unnecessary discomfort. a siqmoidoscope Proctoscope: an is introduction of internally , must be to avoid causing illuminated tubular instrument through the anus enables the physician greater part of the rectal mucosa under vision. to examine the ANAL CANAT Beqinning and direction: It begins one inch below and in front of the tip of coccyx as a continuation of rectum. It passes downwards and backwards. Its length is about 4 cm. End: it ends at the anus in the perineum. Povis — Ssymphysi § pubis ea Inferior pubic Urogenital triangle ligament Ischial tuberosity . TIp of coccyx" WAN Anal tae triangle TANS Sacrotuberous ligament Boundaries and divisions of the perineum Re. Relations: Anteriorly: ° in mate: perineal body, membranous urethra, bulb of penis « in femafe: perineal body and lower 1/3 of vagina Posteriorly: anococcygeal body separating it from the tip of coccyx. Laterally: ischiorectal fossa. Lining of anal canal: f. Voper part (15 mm): « Endodermal in origin (from cloaca), lined by mucous membrane. e It shows Worgagni, a number of longitudinal the columns ridges are connected called anal columns of together at their lower ends by the anal valves of Ball. e The line at the level of the anal valves is termed the pectinate fine (it is the site of the anal membrane of the fetus). e The anal sinuses: are small recesses above the anal valves. The ducts of the anal glands present in the submucosa open into the anal sinuses. 2. Lower part (25mm): It is 2 parts: ectodermal in origin from proctodeum a- The transitional zone of (Pectin) (15 mim): e It extends from the pectineal line above to the white line of Hilton below. lt is transitional in structure between the mucous membrane above and true skin below. e It is lined by non keratinized stratified squamous sweat glands (false skin). b- Lower cutaneous part (70 mm), it is lined by true skin. epithelium with no Pelvis Anterior and posterior relations of anal canal in male Anterior and posterior relations in female of anal canal N.B.: the upper part being endodermal is supplied by autonomic nerves and it is not sensitive to pain. The lower part being ectodermal is supplied by somatic nerves and is sensitive to pain. Anal sphincters: (1) Internal anal sphincter: e Itis formed by the thickened inner circular muscle layer. e« li surrounds the upper 3/4 of anal canal. « It is formed of involuntary smooth muscle fibers and is supplied by autonomic nerve fibers. (2) External anal sphincter: e Itlies outside the internal anal sphincter. * |t surrounds the whole length of the anal canal and is formed of voluntary striated muscle fibers. « it has three parts: A} Subcutaneous part: it surrounds the lower 1/4 of anal canal and anal orifice. B)Superficial part: part which has it is superior to the subcutaneous a Sony attachment. behind to the perineal body in front. It extends from part. It is the only the tip of the coccyx . ©} Deep part: it is the strongest part. It is superior to the and surrounds puborectalis upper part part of the canal. of levator ani. Both — superficial part Its deep fibers are reinforced by the parts blend with the internal anal sphincter and form a strong anorectal ring. The external anal sphincter is supplied by somatic nerves from the inferior rectal nerve which is a branch from the pudendal nerve and perineal branch of 4" sacral nerve. Pelvis ischial Obturator tuberosity internus 5 Pudendal canal Ischiorectal fossa External anal sphincter Lateral relations of anal canal External anal sphincter Longitudinal muscie " FUN CUTANAOUS * superficial Internal anal sphincter + deap Anal sphincters of anal canal Peis Arterial supply of anal canal: 1- Upper cloacal part: is supplied by the superior rectal artery which is the continuation of the inferior mesenteric artery 2- Lower proctodeal part: is supplied by the inferior recta! artery which is a branch Venous from the internal pudendal artery. drainage of the anal canal: 1- Superior rectal veii: it ends in the inferior mesenteric vein (portal). It (systemic). It drains the cloacal part of the anal canal. 2- Inferior rectal vein: it ends in the internal pudendal vein drains the proctodeal part. The 2 veins communicate with each other (porfosysfemic anastomosis). Clinical » notes: Piles (Haemorrhoids): itis of 2 types: 1- External piles: are varicosities (dilatation) of the tributaries of the inferior rectal vein as they run laterally from the anal margin. They are covered by skin, 2- Internal piles: are varicosities of the tributaries of the superior rectal vein (internal rectal venous plexus} and are covered by mucous membrane. it occurs mainly in the veins of the 3 anal columns situated at the 3,7,11 o'clock positions. e Anal which valves may be torn by hard faeces is very painful because producing an anal fissure it involves the lower sensitive dermal part of the anal canal. « Anal glands may be infected producing an abscess. « Peri-anal abscesses ischiorectal abscesses. may be: submucosal, subcuateneous or Pelvis Inferior mesenteric artery Middle Sacral artery Interna! iliac artery Superior rectal artery Middle rectal artery Loews an mu tor seche inferior rectal artery inf. vena cava Inf. mesesteric Mickle Common Sap. oectal v rectal v. itiac w. w. Ext. iliac w Int. fia w. Lewalor ani brat. puncieceatal w. lant, recited wv. Amel verge Blood supply of anal canal it. Pelvis Internal iliac—_@a vein Rectum Ya Middle rectal vein Internal. oudendal vein Internal i t hemorrhoid Inferior rectal vei External rectal plexus | Ee low plexus a Internal rectal- Piles (Haemorrhoids) Inbutery Of sa peror rectal vein External anal sphincter Pelvis Sites of internal piles Submucous abscess Ischlorectal abscess e Peri-anal abscesses Subcutaneous abscess N.B.: P.R. examination lt is done by introducing the finger through the anal orifice to palpate the different structures related to the rectum and anal canal. Posteriorly: anorectal body and coccyx. (In both sexes) On either side: ischiorectal fossa and ischial spines. (In both sexes) Anteriorly: ¢ e In male: prostate and seminal vesicle. In female: vagina, posterior fornix of vagina, cervix of the uterus, perineal body and ovaries. ENT ore,| —_ << ry Ft SOLER sane McQ: 1. The commonest position of the appendix is: a. Subcaecal position. b. Pelvic position. c. Retrocaecal position. d. Pre-ileal position. 2. The medial limb of the sigmoid mesocolon contains: a. Superior left colic artery. b. Inferior left colic artery. c. Superior rectal artery. d. Inferior rectal artery. 3. The following part of the gut is supplied by branches inferior mesenteric artery: a. Ascending colon. b. Right 2/3 of transverse colon. c. Left 1/3 of transverse colon. d. Vermiform appendix. 4, An a. b. c. d. inconstant posterior relation of the caecum Is: Right iliacus muscle. Right psoas major muscle. Right psoas minor muscle. Right femoral nerve. from the Vessels of the Gut CHAPTER f 1S, 7 iLOs: \ >» « By the end of these lectures, the student should be able to: Describe the origin, course, relations and branches of the coeliac trunk, superior and inferior mesenteric arteries. Describe the formation, course, relations and tributaries of the portal vein. Qutline the sites of portosystemic anastomosis. » Explain » oesophageal varices, piles and caput medusae. identify the vessels of gut on cadavers and angiographs. « lt is a wide abdominal fhe clinical short aorta, conditions trunk, opposite one the cm related long, upper to which the portal arises border of the hypertension as Py, from the 1“ lumbar front of the vertebra, just below the aortic opening of the diaphragm. Course: It runs forwards, immediately above the omental tuberasity of the pancreas. Relations: Anteriorly: the lesser sac, which separates it from the lesser omentum. Laterally: 1. Coeliac ganglia and coeliac plexus of nerves. 2. Coeliac lymph nodes. 3. Crura of the diaphragm. superiorly: median arcuate ligament of the diaphragm. inferiorly: omental tuberosity of the pancreas. Termination: It ends by dividing into three branches: |. Left gastric artery: to the stomach and abdominal part of the oesophagus. 2. Hepatic artery: to the liver, stomach, duodenum and upper part of the head of the pancreas. 3. Splenic artery: to the spleen, stomach and remaining parts of the pancreas. Li. pasiric Median srcuaie arkery diaphragm ligament of diaphragin \ COELIAC Li. Crus of Lt. suprarenal gland 4 Splenic TRUNK i i i} fs pes 2 pF = I Coeliac . sanclion AN i ‘le R/ Coeliac plexus is - Body of pancreas Pancreatic branches 7 : ‘ Lt. sympathetic Aorta Coeliac trunk Lt. psoas mayor Vessels of the Gut WEES si Course and relations: . lt passes upwards and to the left behind the cavity of the lesser sac to reach the cardiac end of the stomach. - Then it descends along the lesser curvature of the stomach between the two layers of the lesser omentum. -It ends by anastomosing with the right gastric artery (from the hepatic artery). Branches: | 1. Oesophageal branches: to the abdominal and lower thoracic parts of the oesophagus. It ascends to the thorax through the oesophageal opening of the diaphragm. . 2. Gastric branches: to the upper part of the lesser curvature and adjoining part of the stomach (excluding the plyoric region). Median arcuate ligament of the diaphragm Oesophageal branch of left gastric artery Short vastric Cocliae trunk yessels Lett gastric artery Spleen a eianiominns: Splenic artery Castroducdecnal artery Right gastric artery Richt gastro-epiploic artery Coeliac trunk and its branches | Vessels of the Gut he Course and relations: - Itis the largest branch of the coeliac trunk. - It is characterized by having a wavy (tortuous) course. - ltruns to the left along the upper border of the pancreas. - It crosses in front of the left crus of the diaphragm, left suprarenal gland and left kidney, and then enters the lienorenal ligament to reach the spleen. - Along its course, it runs posterior to the stomach (in the stomach separated from it by the cavity of the lesser sac. - Near the hilum of the spleen, it divides into terminal splenic branches. bed), Branches: 1. Pancreatic branches: . The largest of these branches is called arteria pancreatica magna. » They supply the body and tail of the pancreas. 2. Short gastric arteries: - These are about five branches which arise from the terminal part of the splenic artery. . They pass in the gastrosplenic ligament to supply stamach. 3. Left gastro-epiploic artery: . It arises from the terminal part of the splenic artery. the fundus of the - lt runs downwards and to the right between the anterior two layers of the greater omentum along the greater curvature of the stomach. - It supplies the stomach and greater omentum, and ends by anastomosing with the right gastro-epiploic artery. 4. Posterior gastric artery: . - tis present in 50% of people, and arises from the intermediate part of the splenic artery. «lt ascends behind the lesser sac up to the fundus, and then descends on the posterior wall of the stomach. 5. Terminal splenic branches: These are about five segmental end arteries that enter the hilum of the spleen. Applied anatomy: . The spleen is segmentaily supplied by the branches of the splenic artery. « Partial splenectomy operation is carried out according to this fact. Vassels of fhe Gui ys N.B.: The splenic artery fs tortuous to: 1. Protect the friable spleen from forceful blood flow. ?. Allow movement and volumetric changes of the spleen. Falcifonn ligament Lesser omentum (gastrohepatic ligament) DS Greater sac Stomach ® , Gastrosplenic ligament Sheri gastric vessels Spleen Splenic recess of lesser sac Leinorenal ligament Splenic ariery Coeliac rani Aorta Left kidney Transverse section in the peritoneal cavity at the level of the upper abdomen Sa eee Vessels of the Gut ie Hepatic Artery Course and relations: * It runs forwards and to the right to reach the superior border of 1° part of the duodenum. This part is called “common hepatic artery”. ‘The artery then ascends in the free border of the lesser omentum where it lies in front of the portal vein and to the left of the common bile duct. This part is called “proper hepatic artery”. * lt ends at the porta hepatis by dividing into right and left terminal branches. Branches: 1. Right gastric artery: ‘It arises from the hepatic artery just above the superior part of the duodenum, and runs to the left along the lesser curvature of the stomach between the two layers of the lesser omentum. ‘It ends by anastomosing with the left gastric artery. “It supplies the pyloric region and 1* part of the duadenum. 2. Gastroduodenal artery: *lt is a short wide branch, which arises from the hepatic artery just above the duodenum. «It descends behind the middle of the 1° part of the duodenum, where it is related to: - Anteriorly: 2"° inch of 1" part of the duodenum. - Posteriorly: portal vein. - On its right side: common bile duct. *Itis not accompanied by a vein. ‘It ends by dividing into two branches: a. Superior pancreatico-duodenal artery: descends in the groove between the duodenum and head of the pancreas to anastomose with the inferior pancreatico-duodenal artery (branch of superior mesenteric artery). b. Right gastro-epiploic artery: runs to the left between the two layers of the greater omentum along the lower part of the greater curvature of the stomach, to anastomose with the left gastro-epiploic artery. 3. Supraduodenal artery: an inconstant branch that arises from the hepatic artery or one of its branches, and supplies the proximal inch of the 1™ part of the duodenum. Vessels of the Gut [7 4. Right and left terminal branches: > They pass through the “porta hepatis” to supply the right and left lobes of the liver. * The cystic artery arises from ihe right terminal branch, and passes behind the common hepatic duct to reach the Calot's triangle and the gall bladder. Right terminal branch Common of hepatic artery hepatic artery Calot’s triangle Cystic artery Right lobe of the liver —___Right gastric artery (Cystic duct Common bile duct Gastroduodenal urtery The hepatic artery and its branches Vessels of the Gut Beginning: It arises from the front of the abdominal aorta opposite the lower border of the 1" lumbar vertebra (about 1 cm below the coeliac trunk). Course and relations: * At its 1. 2. its origin, the artery lies behind the body of the pancreas, just to the left of neck, vetween two veins: Splenic vein: crosses above the origin of the artery. Left renal vein: crosses below the origin of the artery. « Then, it descends in front of the uncinaie process of the pancreas, then in front of the 3™ part of the duodenum to enter the root of the mesentery of the small intestine. « In the mesentery, it runs downwards and to the right, with the superior mesenteric vein on its right side, crossing over the following structures: 1. Abdominal aorta. 2. Inferior vena cava. 3. 4, 5. 5. Right Right Right Right psoas major. ureter. gonadal vessels. genitofemoral nerve. Termination: It ends at the ileocaecal junction by anastamosing with its ileo-colic branch. AL8.: Throughout its course, the artery is surrounded by the superior mesenieric plexus of nerves. Vessels of the Gut Common hepatic artery Righi and left inferior phresic arteries — Left gastric re Right gastric artery oeliae tran Splenic artery and vein Supraduaodenal artery Gastroduodenal artery Short gastric arteries Posterior braach of superior Dorsal pancrentic pPancreationd sodenal artery artery Inferiorrae pancreatic Right gastroepiploic artery Superior oie artery and vein Anterior branch of superior pancreaticoduodenal artery Left gastrocpiploic (Conineon partiont Inferior panereatico- Posteriar duodenal artery (Anterior a ue Anastomosis between c i: Right colic = artery * og aE : ae ei a fe ‘ a _ a grea |e inferior panereatico‘ artery =. 4 duodenal artery and ISNNNNIN ‘+ , Pr, 3 9 7 wa : ait “=S ! ; Ileoealic artery Colic branch Ieal branch Superior mesenteric artery Anterior caecal artery Posterior caecal artery Appendicular artery Jejunal and ileal arteries Arterial areades Vasa recta Coeliac trunk and superior mesenteric artery faut) Vessels of the Gut Body of panereas ( fi Superior mesenteric 4 TeRoRESs _| : Superior YC Fs mescuteric artery 3" part of duodenum Superior mesenteric vessels before they enter the root of mesentery L¥.C. 3” rd part of | Duodenum Ri. psoas major— {i ; : Aorta af pamereas ™ Uneinate process of head of pancreas e\* Intcrior mesenteric V, Rt. eonadal Ao# Ri. Ureter— Right genitofemoral nerve Inferior mesenteric A. * Superior mesenteric V, Relations of the superior mesenteric artery Vessels of the Cu lS Branches: 1. Inferior pancreatico-duodenal artery: - itis the 1* branch to arise as the artery crosses the uncinate process. « It runs to the right and upwards pancreas and the duodenum. in the groove between the head of the * it ends by anastomosing with the superior pancreatico-duodenal artery (a branch of the hepatic artery). - It supplies the lower 1/2 of the duodenum, pancreas and its uncinate process. Gastroduodenal artery - . i Superior pancreatico- duodenal artery Site of major duodenal papilla Inferior pancreaticoduodenal artery —Pr'#,f af, AGE? if bg ‘Head a8 a 4 * ‘ pancreas, 4a 1/2 of the head of * re Fair a : a le .., lower a a a Superior mesenteric . artery Uncinate process | | 3"" part of the dudgdenum Anastomosis between superior and inferior pancreatico-ducdenal arteries 2. Jejunal and ileal branches: « These are 12-15 branches which arise from the convex left side of the superior mesenteric artery. + They run between the two layers of the mesentery of the small intestine where they divide repeatedly to form series of arches called “arterial arcades” which give straight end arteries called “vasa recta”. * The jejunal branches are longer and less numerous and their arcades are fewer than the ileal branches. 3. Middle colic artery: - It arises just below the pancreas and runs downwards and forwards in the transverse mesocolon, where it divides into right and left branches. = lts right branch anastomoses with the ascending branch of the right colic artery. * lts left branch anastomoses with the ascending branch of the superior left colic artery. * It supplies the right 2/3 of the transverse colon. | 4. Right colic artery: * It arises from the concave right side of the superior mesenteric artery at its middie. * It runs to the right retroperitonealy towards the ascending colon crossing in front - Right - Right - Right of the following structures: gonadal vessels. ureter. psoas major. > Close to the colon, it ends by dividing into ascending and descending branches which supply the upper 2/3 of the ascending colon and the right colic flexure: - The ascending branch anastomoses with the right branch of middle colic artery. -The descending branch anastomoses with the ascending branch of ileocolic artery. 5. lleocolic artery: * It arises from the lower mesenteric artery. part of the concave right side of the superior *Itruns downwards and to the right retroperitonealy towards the right iliac fossa. * It divides into two branches: - Ascending branch: which anastomoses with the right colic artery. «Descending branch: which runs towards the ileocaecal junction where it anastomoses with the termination of the superior mesenteric artery, and gives off the following branches: a. Ascending branch: to the lower 1/3 of the ascending colon. b. Anterior and posterior caecal of the caecum respectively. branches: to the front and back c. Appendicular artery: descends behind the termination of the ileum to enter the meso-appendix and supplies the appendix. d. Neal branch: to the terminal part of the ileum. Vessels of the Gut haarginal artery of Drummond \ <ein is ena, \ Superior left colic artery AC b N | Tris artery i Inferior left colic ~My: <a mh ‘ad| (gas Tleocolie artery Inferior mesenteric XE 1 D> ¥ Right colic artery artery Beaten, artery Superior mesenteric ¢ ' ‘ Middle colic Feet arteries Superior rectal artery Branches of the superior and inferior mesenteric arteries Vessels of the Gut ee Course: ‘It arises from the front of the aorta opposite the 3” lumbar vertebra, behind the 3™ part of the duodenum, about three cm above the end of the aorta. * It passes downwards abdominal wall. and to the left retroperitonealy, on the posterior * It lies at first in front of the aorta then comes on its left side. ° It crosses in front of the left common iliac artery just medial to the left ureter, and here it continues “superior rectal artery”, downwards ‘into the sigmoid mesocolon as the Relations: superficial relations: 2 1, The 3" part of the duodenum (in front of the origin ofthe artery), 2. Peritoneum of the abdominal wall. Deep relations: = 1. Lower part of the abdominal aorta. 2. Left psoas major muscle. — 3. Left sympathetic trunk. 4. Left common iliac artery. On its left side: 1. Inferior mesenteric vein in contact with and lateral to the lower part of the artery, but higher up the two vessels are apart from each other. 2. Left ureter just lateral to the inferior mesenteric vein. On its right side: lowermost part of the aorta. Branches: 1. Superior left colic artery: ’ It passes upwards and to the left towards the descending colon, crossing in front of the following structures: a. Left psoas major. b. Left ureter. c. Left testicular (or ovarian) vessels. * Near the descending colon, it divides into ascending and descending branches: a. The ascending branch anastomoses with the left branch of the middle colic artery. Vessels of the Gut mare. b. The descending branch anastomoses with the highest sigmoid artery. « It supplies the left 1/3 of the transverse colon, left colic flexure and upper part of the descending colon. 2. Inferior left colic arteries (sigmoid arteries): « These are 2-3 branches which run downwards and to the left in the lateral limb of the sigmoid mesocolon to reach the sigmoid colon. * They anastomose above with the superior left colic artery and below with the superior rectal artery. - They supply the sigmoid colon and lower part of the descending colon. 3. Superior rectal artery: * It is the downward continuation of the inferior mesenteric artery in front of the left common iliac artery. « lt descends in the medial limb of the sigmoid mesocolon as far as the 3™ sacral vertebra then descends along the posterior surface of the rectum where it divides into two branches that pierce the wall of the rectum. *- In the submucosa of the rectum and upper 1/2 of the anal canal, the superior rectal artery anastomoses with the middle and inferior rectal arteries. « |t supplies the rectum and upper 1/2 of the anal canal. Superior left colic artery Branches eae Superior rectal P| Inferior mesenteric artery =o gy o* artery “SSE SS — interior left colic Aa \ ee arteries (Sigmoid arteries) of inferior mesenteric artery Vessels of fhe Gut - Right gastric Left gastric artery artery Verdc Coeliac trunk Common hepatic artery Proper hepatic aulery Splenic Gastroduodenal artery artery Left gastra- Superior epiploic artery mesentenic artery Middle colic Right gastro- artery epiploic artery Right colic Inferior artery mesenteric artery Superior left colic artery * llin-colic artery Inferior left colic arteries Superior rectal artery Arteries of the gastro-intestinal tract alee em Vessels of the Gut Portal Circulation Partal circulation means a circulation that begins and ends by capillaries (i.e. arterial blood which leaves the heart has to pass through two networks of capillaries before it returns to the heart) as follows: a. The 1* network lies in the submucosa of the alimentary canal. b. The 2™ network forms sinusoidal capillary network between the columns of the liver cells. The portal circulation carries venous blood from four sites: 1. Digestive tract (from the lower end of the oesophagus to the upper 1/2 of the anal canal). 2. Spleen. 3. Pancreas. 4, Gall bladder. Blood passes through the portal vein to the liver where metabolism occurs. Portal blood circulates in the liver sinusoids, and then passes to the central veins which are collected in the hepatic veins which terminate in the I.V.C. Differences between the portal and systemic veins Portal vein « Formed Systemic vein ° Formed by the L.V.C. & S.V.C. and by the portal vein and its tributaries their tributaries * Has no valves ¢ May contain valves ¢ Starts by tributaries and ends | - Starts by tributaries and ends in. by * Has two sets of capillaries large vein * Has only one set of capillaries * The blood inside contains absorbed > The blood inside contains products | branches digested food (glucose, acids ... etc.) - Contains incompletely deoxygenated blood » The pressure inside is higher of metabolism argans amino from the different | - Contains completely deoxygenated blood « The pressure inside is lower | Vessels of fhe Gut ao The Portal Vein Beginning: lt begins behind the neck of the pancreas by the union of splenic and superior mesenteric veins. Course: It ascends behind the 1* part of the duodenum to enter the free margin of the lesser omentum behind the hepatic artery and the common bile duct. Termination: . it ends in the porta hepatis where it divides into right and left branches. Size: lt is about three inches long and up to 12 mm in diameter. N.B.: The portal vein has NO valves, so it allows passage of blood in the two directions. Relations: (from below upwards) 1. Before it reaches the lesser omentum: * Anteriorly: 1" part of the duodenum, separated from it by: a. Common bile duct (anterior and ta the right). b. Gastroduodenal artery (anterior and to the left). * Posteriorly: inferior vena cava. 2. In the lesser omentum: * Anteriorly: a. Common bile duct (anterior and to the right). b. Proper hepatic artery (anterior and to the left). - Posteriorly: inferior vena cava, separated from it by the epiploic foramen. 3. In the porta hepatis: « Anteriorly: hepatic artery. *Posteriorly: caudate process of the separates it from the inferior vena cava. Tributaries of the portal vein: 1. Two veins at its beginning: a. Splenic vein. b. Superior mesenteric vein. caudate lobe of the liver, which Vessels of the Gut ct, Soares 2. Two veins at its termination: a. Paraumbilical veins drain the skin around the umbilicus and accompany the ligamentum teres in the falciform ligament to end in the left branch of the portal vein. b. Cystic Vein drains the gall bladder and ends in the right branch of the portal vein. 3. Two veins join the main trunk: a. Right gastric vein. b. Left gastric vein. Left gastric : vein Portal yein Splenic vein Right gastric vein Inferior mesenteric vein Superior mesenteric vein Inferior ¥EHA Cava Portal vein: formation and tributaries a Vessels of the Gut Beginning: It begins at the hilum of the spleen by union of five or six splenic tributaries. Course: It leaves the spleen and passes through the lienorenal ligament (between the spleen & the left kidney), then continues to the right behind the body of the pancreas and in front of the following structures: 1. Left kidney and its hilum. 2. Left sympathetic trunk. 3. Left crus of diaphragm. 4. Abdominal aorta (but separated from it by the superior mesenteric artery). Termination: It ends behind the neck of the pancreas by joining the superior mesenteric vein to form the portal vein. N.B.: The splenic vein is not tortuous (unlike the splenic artery). Tributaries: 1. Splenic tributaries: 5-6 tributaries from the spleen. 2, short gastric veins: from the fundus of the stomach. 3. Left gastro-epiploic vein: from the greater curvature of the stomach. 4. Pancreatic veins: from the body of the pancreas. ». Inferior mesenteric vein: * It is the most important tributary of splenic vein. « It is the continuation of the superior rectal vein (at the middle of the left common iliac vein). * |t receives the superior and inferior left colic veins. Vessels of the Gut (a Lt. crus of diaphragm = Lt. Supra- Abdominal Swortel gland — renal Lt. kidney Spleen ANLErior end of hilum or spleen Aye t Splenic Lt. renal Tail of V._—*. pancreas V. Body of pancreas Superior mesenteric A. LA. syrnpathetic chain Lt. psoas major Relations of the splenic vein Vessels of the Gut 6 Beginning: It begins at the lower end of the root of the mesentery by union of the tributaries of the midgut veins. Course: ’ It ascends in the root of the mesentery of the smail intestine, along the nght side of the superior mesenteric artery. * Then it ascends anterior to the 3" part of the duodenum and the uncinate process of the pancreas. Termination: It ends behind the neck of pancreas by joining the splenic vein te form the portal vein. Tributaries: 1. fleocolic vein: from the ileum and ascending colon. 2. Right colic vein: from the ascending colon. 3. Middle colic vein: from the transverse colon. 4. Jejunal and ileal veins: from the small intestine. 5. Pancreatico-duodenal vein: from the duodenum and head of pancreas. 6. Right gastro-epiploic vein: from the right part of the greater curvature of the stomach. Pancreaticoduodenal veln Middle colic vein ¢ Right gastroepiploic vein v. Right colic vein Jejunal and ilial veins lliocolle vein Tributaries of superior mesenteric vein Vessels of fhe Gut pct gee Portosystemic Anastom joses 0 sees tee ee each lt is the tlh BeRRMAOEIE ie between the portal and systemic ied circulations Se mh which occurs at many sites. a. Anastomosis at the lower end of the oesophagus: Contributing veins: 1, Oesophageal tributaries of the left gastric vein (portal). 2. Oesophageal tributaries of the azygos vein (systemic). Applied anatomy: in portal hypertension, opening of this anastomosis feads ta cesophageal varices, which may rupture and fead to haematemesis and melena. b. Anastomosis at the lower end of the rectum and upper end of the anal canal: Contributing veins: 1. Superior rectal vein (portal). 2. Middle and inferior rectal veins (systemic). Applied anatomy: fn portal hypertension, opening of this anastomosis leads to formation of piles and bleeding per rectum. c. Anastomosis around the umbilicus: Contributing veins: 1. Paraumbilical veins (partal). 2. Superior and inferior epigastric veins (systemic). Applied anatomy: In portal hypertension, opening of this anastomosis leads to dilatation of the veins around the umbilicus in a radial pattern, a condition called “Caput Medusae”. d, Other sites of anastomosis: 1. Bare area of the liver: between the capillaries inside the liver (portal) and the phrenic veins of the diaphragm (systemic). 4. Posterior abdominal wall: between the colic veins (portal) and the lumbar veins (systemic). ee Vessels of the Gut cee Lower end of oesophagus Paraumbilical veins Superticial epigastric veins @) Lett gastric vein Skin around the umbilicus Superior rectal vein Lower end of Internal iliac vein Middle rectal vein A ay ily, , he, pr ee rectum and upper part of anal canal Inferior rectal vein Major sites of portosystemic anastomoses ire 0 Vessels of fhe Gut ao Explain: 1. Obstruction of the appendicular artery by thrombosis in cases of appendicitis may result in gangrene of the appendix with subsequent fatal peritonitis. 2. Perforaiionof a peptic ulcer in the posterior wall of the stomach accompanied by severe intra-abdominal hemorrhage and shock. may be 3. Pain of appendicitis may be referred to the region of umbilicus before it finally localizes at the region of the right iliac fossa. NCQ: , 1. The celiac trunk arises from the aorta at the level of: a. Upper border of Li vertebra. b. Lower border of L1 vertebra. c. Lower border of L2 vertebra. d. Upper border of L3 vertebra. 2. The largest branch of the coeliac trunk is: a. Left gastric artery. b. Right gastric artery. c. Splenic artery. d. Hepatic artery. 3. Fundus of the stomach is supplied by branches derived from: a. Left gastric artery. b. Right gastric artery. c. Splenic artery. d. Hepatic artery. 4. One of the following branches of the superior does not run within a mesentery: a. Appendicular artery. b. Middle colic artery. c. Right colic artery. d. Jejunal arteries. mesenteric artery Pencrees ETS CHAPTER 8 a iLOs: By the end of this subject the student should be able to: . Describe the position, parts, peritoneal covering, relations, supply of the pancreas. ducts and blood . Outline the surface projection of the pancreas. . Explain related clinical conditions on anaiomical basis (e.g. spread of cancer head of pancreas, pancreatic pain, erosion of pancreas by peptic tlcer). ltis a mixed gland: - [he endocrine part secretes insulin, glucagon and gastrin. - The exocrine part secretes pancreatic juice containing digestive enzymes. Position: - It lies in the epigastrium and left hypachondrium. - lt is a retroperitoneal lobulated gland, lying obliquely across the upper part of posterior abdominal wall, extending from the 2™ part of duodenum to the hilum of the spleen. Parts and relations: a. Head: It lies within the concavity of the duodenum, with the “uncinate process” projecting to the left from its lower part. Anterior: .In front of the head proper: transverse colon and loops of small intestine. . In front of uncinate process: superior mesenteric vessels. Posterior: . Behind the head proper: common bile duct and interior vena cava. . Behind the uncinate process: abdominal aorta. Superior, right and inferior: the head is surrounded by the duodenum. roneroas 6 b. Neck: It is the constricted part between the head and the body. . Anterior: pyloroduodenal junction, being separated from it by the cavity of the lesser sac. . Posterior: union of splenic and superior mesenteric veins to form the portal vein. * Relations of head of pancreas * 1* part of the di uodenum “ Neck of pancreas 2" part of the duodenum Py ty Nera — Transverse colon Supenor mesenteric A. Uncinate process of head of pancreas Fa situs * part * Anterior relations Cammarn af ae part of the duodenum the duodenum Bile duct. | oe —~ : Renal veins Uncinate process Abdominal aorta IWOG. Right kidney * Posterior relations * Relations of neck of pancreas * Portal * Anterior relation ¥. Splenic VV. * Posterior relation Poncress iN c. Body: Ii is prismatic in shape (triangular in borders and three surfaces: Anterior surface: is related to the stomach, cut being section), having separated three from it by the cavity of the lesser sac. Inferior surface: is related to: ‘1. Duodenojejunal flexure. 2. Loops of jejunum. 3. Left colic flexure. Posterior surface: is related to: 1. Left renal vein and splenic vein. 2. Abdominal aorta and origin of superior mesenteric artery. 3. Left crus of the diaphragm and left psoas major muscle. 4. Left kidney and left suprarenal gland. 5. Left sympathetic chain. Superior border: related to the coeliac trunk, celiac ganglia and artery, a NBL: splenic The superior border shows an upward projection at its beginning in the median plane called “omental tuberosity”, which ) projects upwards above the level of the pylorus. ft is related to 2 structures: 1. Coeliac trunk: above. 2. Lesser omentum: in front, with the lesser sac in between (hence called omental tuberosity). y - Anterior border: gives attachment to the transverse mesocolon. « Inferior border: related to loops of jejunum. cd. Tail: It is the left end of the pancreas, which lies in contact with the hilum of the spleen and runs in the lienorenal ligament in front of the left kidney. Splomic A. eeel!: re Transverse mesocolon Relations of the body of the pancreas Pancreas SST Lt. crus of diaphragm 14. Suprarenal sland Abdontinal | Lt. kidney Hots Anterior ond of hilum of SPCC eee Splenic ¥. 0 -—-® Lt. renalV. Tail of Va pancress er | ;4eeeea liad aah worn LF I | al i } \ Body of pancreas h 14. sympathetic chain Li. psoas major Relations of the posterior surface of the body of the pancreas Pancreatic ducts: 1. The main pancreatic duct (duct of Wirsung): - It begins in the tail and passes to the right in the body. - In the head of the pancreas, the duct runs downwards and to the right to unite with the common bile duct, forming a dilatation called “ampulla of Vater”, which is surrounded by the “sphincter of Oddi” and opens on the summit of the major duodenal papilla in the posteromedial aspect of the 2" part of the duodenum. middle of the 2. The accessory pancreatic duct (duct of Santorini): «lt is a small short duct that begins in the lower part of the head of the pancreas and its uncinate process. «lt runs upwards and to the right in front of the main pancreatic duct and common bile duct to open in the 2™ part of the duodenum in the summit of the minor duodenal papilla, which present one cm above the major duodenal papilla. - The main and accessory pancreatic ducts communicate inside the head of the pancreas. Pancreas Common bile duct Minor duodenal Maio pancreatic duct ‘papilla Uncinate process of head of pancreas Major duodenal papilla Main pancreatic duct Accessory pancreatic duct Pancreatic ducts Arterial supply: 1. Head of the pancreas is supplied by: «Superior pancreaticoduodenal artery (a = branch from _ the gastroduodenal artery). «Inferior pancreaticoduodenal mesenteric artery). 2. Neck, body and tail of the artery (a pancreas branch are from supplied the by superior pancreatic branches of the splenic artery (a branch from the coeliac trunk). Venous drainage: 1. Pancreatic veins from the body the splenic vein. 2. Pancreatic veins from the and tail of the pancreas head superior mesenteric and portal veins. of the pancreas drain drain into into the Pancreas GUERIN Lymphatic drainage: 1. Pancreaticosplenic lymph nodes (around the splenic artery). 2. Coeliac lymph nodes (around the coeliac trunk). 3. Superior mesenteric lymph nodes (along superior mesenteric artery). Nerve supply: autonomic supply from the coeliac plexus. Apptied Anatomy: a. Cancer head of the pancreas may infiltrate the folowing structures: f. Common bile duct; leading to obstructive jaundice. 2, IVC; leading to oedema in the fower limb. 3. Portal vein; teading ta portal hypertension. 4. Pyloric part of the stomach; leading to pyloric stenosis. 5, Duodenum; leading to duodenal obstruction. 5b, Pancreatic pain due to pancreatic disease (cancer or inflammation), is felt in the epigastric region and radiate to the back, increases by lying down and relieved on leaning forwards. c. Peptic ulcer in the stomach or duodenum may be complicated by erosion of the pancreas. wl Panereas MCQ: 1. The uncinate process of the head of pancreas is supplied by the: a. Hepatic artery. b. c. d. 2. The a. b. c. Splenic artery. Superior mesenteric artery. Inferior mesenteric artery. head of the pancreas is related posteriorly to the: Superior mesenteric artery. Upper part of the common bile duct. Lower part of the common bile duct. d. Splenic vein. 3. The part of the pancreas related to the celiac trunk is the: a. Uncinate process. b. Neck. c. Tail. d. Omental tuberosity. 4. The tail of the pancreas lies within the: a. Gastrosplenic ligament. b, Gastrophrenic ligament. c. Lienorenal ligament. d. Ligament of Trietz. Liver, Biliary System and Spleen CHAPTER 9 fm, * * ' * * * 1925 —_ By the end of this subject the student should be able to: Identify the normal size, site and surface anatomy of the liver and to draw this surface anatomy on himself and ofher persons. Describe the shape of the fiver including its surfaces and lobes. Indicate the features of each surface and recognize their reiations to the peritoneum and to the other viscera. Describe the different peritoneal egaments attached fo ihe liver and their role io support the fiver in its position. Describe the details of the blood supply and tymphatic drainage of the liver. identify the base and clinical importance of the vascular segmentation of the he if Size: ~The liver is the largest gland in the body. It weighs from one to 2.5 Kg. Site: Right Ree hypochondrium, Brea. epigastrium and may Site of the liver extend slightly in the left Liver, Biliary System and Spleen Cy shape: » The liver is wedge-shaped, with the base of the wedge on the right side. * It has five surfaces: anterior, superior, right, posterior and inferior. The borders which separate these surfaces are rounded and ill-defined except the inferior border which is sharp. « The liver is divided anatomically into a large right lobe and lobe separated by: 1. Falciform ligament (on the anterior and superior surfaces). 2. Fissure for ligamentum teres (on the inferior surface). 3. Fissure for ligamentum venosum (on the posterior surface). ligament Fundus of gall bladder ligamentum VEDosh , Fissure for ligamentum . teres shape of the liver (postero-inferior view) a smaller left Liver, Biliary System and Spidgin oan = Surface anatomy of the liver: 1. Upper border: A concavo-convex line passing through: a. The 5'" intercostal space in left midclavicular line (very close to the apex of the heart and fundus of stomach}. b. Xiphisternal junction i.e. at the level of 7'" sternocostal junction. c. The §" rib in right midelavicular line. This point represents the highest point of the liver. d. The 7" rib in right midaxillary line. 4. Right border: Curved line to the right between two points: a. The 7"rib in right midaxillary line. b. One cm below the costal margin in the right midaxillary line. 3. Inferior border: Passes through five points: a. One cm below the costal margin in the right midaxillary line. b. The 9" costal cartilage in the midclavicular line. This point is called “Murphy's point" and represents the surface anatomy of the fundus of the gall bladder, c. The transpyloric plane in the midline (a hand's breadth below the xiphisternal junction or midway between xiphisternal junction and umbilicus). d. The tip of the left 8 costal cartilage. e. The 5" intercostal space in the left midclavicular line. mid-clavicular line RL. Lt. Ri. mid-axillary line Sthetiby Sth. space oo 7thrib, costal margin eS ena ae 1/2 inch below transphyloric plane Surface anatomy of the liver Liver, Biliary System and Sple Relations and features of the surfaces of the liver: 1. Relations of the anterior surface: « Most of the anterior surface of the liver is related to the diaphragm which separates it from the bases of the lungs and pleurae. However, a part of the anterior surface of the liver, about one hand's breadth below the xiphoid process, and another part about one finger’s breadth below the lowest point of the right costal margin are directly related to the anterior abdominal wall. * lt gives attachment to the base of the falciform ligament. 2. Relations of the superior surface: * It is related to the diaphragm which separates it from: a. Base of right lung and pleura. b. Pericardium and inferior surface of the heart. c. Small part of left lung and pleura. » It gives attachment to the upper part of the base of falciform ligament. 3. Relations of the right surface: « tis related to the diaphragm which separates it frorn: a. Right 7 to 11" ribs. b. The right lung and pleura. 4. Relations of the posterior surface: The posterior surface shows the following features from left to right: a. Oesophageal groove: * On the posterior aspect of the left lobe just to the left of the upper part of the fissure for ligamentum venosum. * |tis related to abdominal part of the oesophagus. b. Fissure for ligamentum venosum: - It lodges the ligamentum venosum which is the obliterated ductus venosus that connects the left branch of portal vein to the inferior vena cava during intra-uterine fetal life. After birth, the ductus venosus Is fibrosed and transformed into ligamentum venosum. « |ts margins give attachment to the lesser omentum. c. Caudate lobe: * Boundaries: On the left side: fissure for the ligamentum venosum. On the right side: groove for inferior vena cava. Below: porta hepatis. * Above: superior surface of the liver. It is related to the diaphragm which separates it from the descending thoracic aorta. It is separated from the diaphragm by the superior recess of lesser sac. Liver, Biliary System and Spleen » Inferiorly and to the left the caudate projection Known as papillary process. lobe shows a 196° rounded ° Inferiorly and to the right, it shows the caudate process which connects the caudate lobe with the rest of the right lobe and forms the Upper boundary of the epiploic foramen. d. Groove for inferior vena cava: » It is a deep * * vena Cava. tis devoid of peritoneal covering (bare area). ; The upper part of the groove is pierced by the right and left hepatic vertical groove which lodges the upper part of inferior veins. » Qccasionally, the groove is bridged over by part of liver tissue called pons hepatis transforming it into a tunnel. e. The bare area proper of the liver: * ‘(tis a triangular area on the back of the right lobe. peritoneal covering. * It is directly related suprarenal gland. * |tis bounded by: to the diaphragm and It is devoid upper part of of right - The groove for inferior vena cava: to the left forming its -base. - The upper layer of coronary ligament above. The lower layer of coronary ligament below. - The apex is formed by the meeting of the two layers of the coronary ligament on the right side to form the right triangular ligament. * Lymph vessels from the bare area, ascend through the vena caval opening of the diaphragm to end in the thoracic duct. Ocsophageal impression Bare area of the liver Caucdate lobe Inferior Vena Fissure for cHva litamentam YEDOSUMM Papillary a at. aia Brecess Relations of the posterior surface of the liver process Liver, Biliary System and Spleen 197 6. Relations of the interior surface: The Inferior (visceral) surface shows the following features from left to right: a. Gastric impression: ° lt lies on the inferior surface of the left lobe of the liver. * It is related to the fundus and body of the stomach. b. Tuber omentale: It is an elevation in the inferior surface of the left lobe related to the lesser omentum. It lies ligament venosum. between the gastric area and the fissure for N.6.: Tuber omentale of the liver is related to the anterior surface of the fesser omentum. Tuber omentale of the pancreas is related to the posterior surface of the lesser sac. c. Fissure for ligamentum teres (round ligament of the liver): lt represents the obliterated left umbilical vein which transmits the blood from the placenta via the umbilical cord to the left branch of the portal vein during intra-uterine fetal life. It passes from the umbilicus to the free border of the falciform ligament then to the floor of the fissure for ligamentum teres, on the inferior surface of the liver, to end in the left branch of the portal vein. d. Quadrate lobe: * Boundaries: On the right side: gall bladder. On the left side: fissure for ligament teres. Above: porta hepatis lies transversely separating from quadrate lobe. the caudate | lobe Below: inferior border of the liver, * Relations: lt is related to the transverse colon, pyloroduodenal junction, lesser omentum, from below upwards. e. Gall bladder fossa: It is related to the anterior surface of the gall bladder. f. Inferior surface of the right lobe to the right side of gall bladder is related to: "Second bladder. part of duodenum: just fo the right of the neck of gall | Liver, Bifiary System and Spleen 198 » Front of right kidney: large concavity to the right side of the duodenal impression and above the colic impression. * Right colic flexure: just to the right of the duodenum, close to the inferior border of the liver. * Lower part of right suprarenal gland: above the right kidney. g. Porta hepatis (hilum of the liver): - It is a transverse fissure presents between the posterior and inferior surfaces of the liver. ‘ * It lies between the quacrate lobe anteriorly and the caudate lobe and caudate process posteriorly. « lis margins give attachment to the lesser omentum. = Contents: 1. The right and left hepatic ducts most anteriorly and near the right end of the hilum. 2. The right and left branches of hepatic artery in the middle and near the left end of the hilum. 3. The right and left branches cf portal vein most posteriorly. 4. Hepatic nerve plexus runs along the hepatic artery. 5. Lymph neces, lymph vessels and extraperitoneal fat. Gastric impression Suprarenal impression Tuber omentale Fissure for ligamentum teres Quadrate lobe Relations of the inferior surface of the liver Rena! impression Duodenal Saath elie ‘ impression Liver, Bilary System and Spleen Peritoneal relation of the liver: » Bare areas of the liver: The liver is completely covered with peritoneum except the following areas: 1. Bare area proper related to the diaphragm, on the posterior surface of the right lobe. 2. Groove for inferior vena cava, on the posterior surface. 3. Fossa for gall bladder, on the inferior surface. - Peritoneal folds and ligaments related to the liver: |. Lesser omentum: (gastro-hepatic ligament) (see before) It is a fold of peritoneum extending between the stomach and the liver. It is attached to the liver to the margins of portahepatis and margins of the fissure for ligamentum ventral mesogastrium. venosum. It represents the posterior part of Lesser omentum The ll, Falciform ligament: » It is a sickle-shaped * fold lesser omentum of peritoneum extending from the anterior abdominal wall and diaphragm to the liver. It represents the anterior part of the ventral mesogastrium. * [tis obliquely placed and formed of two layers (anterior and posterior); the anterior layer is in contact with the anterior posterior layer is in contact with the liver. abdominal wall and the Liver, Biliary System and Spleen ° [t has two attached borders and a free border: - A concave border attached to the margins of the falciform ligament on the anterior and superiors surfaces of the liver. - An upper convex attached border attached to the undersurface of the diaphragm and anterior abdominal wall in the median plane. - A lower free border where the two layers are continuous together and enclose the ligamentum teres of the liver and the para-umbilical veins. This free border extends from the back of umbilicus to the fissure for ligamentum teres on the inferior surface of the liver. :- Contents: - Ligamentum teres and para-umbilical veins in its free border. - Lymph vessels draining the deep surface of the umbilicus. running along ligamentum teres to drain into lymph nedes in the porta hepatis. - Extraperitoneal fatty tissue between the two layers of the ligament. Falciform ligament Falciform ligament Il. Coronary ligament: * It consists of two layers (upper and lower) which enclose the bare area of the liver. * The Upper layer of coronary ligament is a reflection of the peritoneum from the diaphragm to the upper surface of the right lobe of the liver, while the lower layer of coronary ligament is a reflection of peritoneum from the inferior surface of the right lobe of the liver to the posterior abdominal wall. 200 Liver, Biliary System and Spleen « The two layers of the coronary ligament meet together at their right ends where they form the right triangular ligament. IV. Right triangular ligament: lt is a short triangular fold of peritoneum extending from the back of the right lobe of the liver, at the right end of the bare area, to the diaphragm. It is considered to be the right extension of the coronary ligament. V. Left triangular ligament: lt is a short triangular fold of peritoneum extending from the upper surface of the left lobe of the liver to the undersurface of the diaphragm. Upper layer of coronary ligament Left triangular ligament Lower layer of coronary ligament Coronary and triangular ligaments Blood supply of the liver: * Mainly portal vein (70%) and hepatic artery (30%). * Inside the liver, blood coming from the portal vein and hepatic artery are mixed in the sinusoids. * Blood is collected from each hepatic lobule in a central vein. ¢ The central veins are collected to form three hepatic veins (right, left and middie) which join the inferior vena cava. moe Liver, Bilary System and Spleen Blocd inflow and outflow to and from the hepatic lobule Vascular segments of the liver: The liver is divided into eight functionally independent segments. Each segment has its own vascular inflow, outflow and biliary drainage. In the center of each segment there is a branch of the portal vein, hepatic artery and bile duct. In the periphery of each segment there is a vascular outflow through the hepatic veins. The middle hepatic vein divides the liver into right and left lobes. The plane af the middle hepatic vein corresponds to a plane running from the inferior vena cava to the gall bladder fossa. The right hepatic vein divides the right lobe into anterior and posterior parts. The left hepatic vein divides the left lobe into medial and lateral parts. The left and right branches of the portal vein, with the accompanying branches of the hepatic artery, divide the liver into upper and lower segmenis. They branch superiorly and inferiorly to project into the center of each segment. The segments of the right lobe are supplied by branches of the right branches of the hepatic artery and portal vein, while those of the leit lobe are supplied by branches of the left branches of the hepatic artery and portal vein. The caudate lobe is the segment number segments runs in a clockwise direction. one, then numbering of the Liver, Biliary System and Spleen « » The caudate and quadrate lobes are functionally parts of left lobe of the liver because they are supplied by left branch of portal vein and hepatic artery. Because of this division into self-contained units, each segment can be resected without damaging those remaining. For the liver to remain viable, resections must proceed along the vessels that define the peripheries of these seqments. Right hepatic vein, Middle hepatic wein Left hepatic vein oe Umbilical weir Cronmant) Hepatic duct Inferior vena cava Hepatic artery Portal vein Gall bladder Bile duct Vascular segments of the liver Vascular segments of the liver (clockwise direction) 203 Liver, Biliary System and Spleen a4 Lymphatic Drainage of the liver: The liver is drained by: 1. Superticial lymph vessels run in the subserous areolar tissue. 2. Deep lymph vessels join to form: - Ascending trunks accompany the hepatic veins inferior vena caval opening of the diaphragm. and pass in the - Descending trunks emerge from the porta hepatis. The main iymph nodes draining the liver are: 1. Lateral diaphragmatic lymph nodes: around the end of inferior vena cava. 2. Paracardial lymph nodes: around the lower part of the oesophagus. 3. Hepatic lymph nodes: in the porta hepatis and free border of lesser omentum around the hepatic artery. 4. Coeliac lymph nodes: around the coeliac trunk, drain the hepatic lymph nodes. Few lymph vessels accompany the inferior phrenic artery also pass directly to coeliac lymph nodes. Factors supporting the liver in position: 1. The hepatic veins connecting it with the |.V.C. 2. intra-abdominal pressure and tone of the anterior abdominal wall. 3. Peritoneal folds and ligaments attaching the liverto the diaphragm and the anterior abdominal wall. l” appiien Anatomy: 7. fo stop bleeding from fiver tear, the free border of the fesser omentum is compressed by clamp for a period up to 20 minutes to occlude the hepatic artery and portal vein. 2. In the living adult, normal liver is soft and cannot be felt but its position can be determined by percussion. if the liver can be felt, this indicates pathology. 3. Physiological vascular segments of the fiver are essential to the performance of partial hepatectomy and partial liver transplantation. Ne, J Liver, Biliary System and Spleen ,. Formative Assessment Explain: 1. In normal conditions, the liver cannot be felt by palpation. 2. The caudate and quadrate lobes are functionally parts of left lobe of the liver. 3. The vascular segmentation of the liver is important in hepatic surgery. McQ: 1. Regarding the liver, one of the following statements is correct : a. The caudate lobe is the segment number eight. b. The liver weighs from one to 2.5 Kg. c. Fissure for ligamentum venosum lies on the inferior surface. d. Fissure for ligamentum teres lies on the posterior surface. 2. The liver is divided functionally into right and left lobes by: a. Middle hepatic vein. b. Portal vein. c. Right hepatic vein. d. Left hepatic vein. | Liver, Biliary System and Spleen 206 Extrahepatic Biliary System 1. Hepatic Ducts: * The right and left hepatic ducts emerge from the right and left lobes of the liver respectively, near the right end of the perta hepatis and anterior to the branches of hepatic artery and portal vein. » The two ducts unite to form the common hepatic duct which is 3-4 cm long and descends in the free border of the lesser omentum, on the right side of hepatic artery and in front of the portal vein. The common hepatic duct joins the cystic duct at an acute angle to form the common bile duct. * 2. Cystic duct: * itis an S-shaped duct, 3-4 cm long. * If arises from the neck of the gall bladder and ends by joining the common hepatic duct te form the common bile duct. The mucous membrane of the cystic duct and the neck of the gall bladder projects inte their lumina to form a spiral valve that keeps them patent, * 3. Common bile duct: * It is formed « porta hepatis. {tis 3-4 inches long and about six mm wide. * by union of common Itis divided into: a. Supraduodenal hepatic duct and cystic duct below the part: Passes in the free border of the lesser omentum, in front of the portal vein and on the right side of the hepatic artery, separated from the IVC behind by the epiploic foramen. b, Retroduodenal part: Lies behind the 2™ inch of the first part of the duodenum, with the gastroduodenal artery on its left side and portal vein behind separating them from the inferior vena cava. c. Infraduodenal part: Lies behind the head of the pancreas (may be embedded jn it) and in front of the inferior vena cava. d. Intraduodenal part: The terminal part of common bile duct unites with the main pancreatic duct to form the “ampulla of Vater” which opens at the major duodenal papilla in the middle of the posteromedial aspect of the 2° part of duadenum. It is surrounded by the “sphincter of Oddi”, Applied Anatomy: fhe common bite duct may be compressed leading to obstructive jaundice. in cancer head of pancreas — BS, Liver, Biliary System and Spleen Right and left hepatic ducts Proper hepatic artery Portal vein pyc Cystic artery Cystic duct Common bile duct Free border of lasser omentum Extrahepatic biliary system Common tale Main pancreatic duct duct Miner duodenal papilla saa Major Orlfice of Sphincter of duodenal ampulla of Vater Oddi papilla Intraduodenal part of common bile duct bile Liver, Biliary System and Spleen pe 4. Gall bladder: site: * |t lie¢s in the gall bladder fossa on the inferior surface of the right lobe of the liver, just to the right of the quadrate lobe. « Itis fixed to the liver by: 1. The visceral peritoneum of the inferior surface of the liver. 2. The loose connective tissue containing the cystic artery, 3. The small veins passing from the gall bladder to the liver. Ligamentum feres Quadrate lobe Gall bladder Site of the gall bladder shape: Pear-shaped. Size: 3-4 inches long, 3 cm wide, 30-50 ml capacity. Function: Concentration (10 times) and storage of bile. Parts and relations: a. Fundus: Protrudes below the inferior border of the liver. 1. Anterior: Anterior abdominal wall. 2. Posterior: Transverse colon. b, Body: 1. Superior: inferior surface of the liver (gall bladder bed), 2. Inferior: » Transverse colon. End of 1° part and beginning of 2™ part of the duodenum. a Liver, Biliary System and Splaan Po eta c. Neck: * Itis the uppermost and narrowest part. « It gives rise to the cystic duct. « lis right wall presents a dilatation called “Hartman's pouch”. = Relations: 1. Superior: cystic artery separating the neck from the liver. 2. Inferior: 2" inch of the 1* part of the duodenum. Arterial supply: 1. Cystic artery: it is a branch of the right hepatic artery, reaches the gall bladder by passing in the triangle of Calot between the cystic duct, common hepatic duct and inferior surface of the liver. 2. Many small arteries pass to the gall bladder from its bed in the liver. Right terminal branch of hepatic artery Common hepatic artery Calot’s triangle Right lobe of the liver Cystic duct Common bile duct Gastroduodenal artery Arterial supply of the gall bladder Venous drainage: Cystic veins: open directly into the hepatic veins or into the right branch of the portal vein. Liver, Bilary System and Spleen aes Lymphatic Drainage: « Lymph vessels from the superior surface communicate with lymph vessels in the liver. « Lymph vessels from the remaining parts of the gall bladder pass to cystic lymph node (at the junction of cystic duct and common hepatic duct) and hepatic lymph nodes (in the porta hepatis along the hepatic artery). Nerve supply: * Parasympathetic: Vagus nerve through the coeliac plexus. " Sympathetic: Greater splanchnic nerves (T5-9) through the coeliac plexus along the hepatic artery and its branches. NB. fibers from the right phrenic nerve through its communication with the hepatic plexus also reach the galt bladder through the hepatic plexus. Peritoneal covering: * The fundus is completely covered with peritoneum, as it projects below the inferior border of the liver. * The body and neck are only covered from their inferior surface. surface anatomy: The fundus of the gall bladder corresponds to the tip of right 9th costal cartilage where the transpyloric plane, right linea semilunaris or right lateral vertical plane crosses the right costal margin (Murphy's point). Right lateral vertical plane Ath rib Fundus of gall bladder Transpyloric plane Surface anatomy of the fundus of the gall bladder Liver, Biliary System and Spleen (, Applied Anatomy: ha * 1. In cholecystitis, pain is felt in the right hypochondrium and radiates to: ¢ The tip of right shoulder (C3 and C4 give both the phrenic and /ateral supraclavicular nerves). - At the back (below the scapula) (T5-9 spinal segments give greater splanchnic nerve and supply the skin below the scapula). the 2. Stone in the Hartman's pouch can cause obstruction of the neck of gaif bladder and common hepatic duct leading to obstructive jaundice. 3. The gall bladder has double arterial supply. This explains rarity of gangrene of the bladder in case of acute cholecystitis. NN # | | Liver, Siilary System and Splaan a Formative Assessment Explain: 1. The gall bladder is usually not so much affected by obstruction of the cystic artery. 2. The mucous membrane of the cystic duct and the neck of gall bladder form 4 spiral valve. 3. Pain of cohlecystitis usually radiates to the right shoulder, below the scapula and to the epigastric region. McQ: 1. The capacity of the gall bladder is: b. 10-20 cc. c. 30-50 cc. d. 50-60 cc. e. 5-10 ce. 2. Sympathetic supply of the a. Vagus nerve. b. Phrenic nerve. c. Greater splanchnic nerve. d. Lesser splanchnic nerve. gall bladder is derived from: to the back Liver, Biliary System and Spleen pie Tea On Os: By the end of this subject the student should be able to: * Identify the normal size, site, shape and surface anatomy of the spleen. * Indicate the features of each surfaced pentoneum and to the other viscera. and recognize their relations " to the * Describe the blood supply and lymphatic drainage of the spleen. Ne # Nature: «lt is the most important component in the lymphatic system. «In the living, itis highly vascular, soft and friable, site: In the left hypochondrium region. but its posterior end extends into the epigastric «It lies between the fundus of the stomach and the diaphragm. size and weight: One inch thick, three inches in breadth, five inches in length and seven ounces in weight. Shape: lt has two borders, two ends, two surfaces: 1. Superior border: it is sharp and is marked the lateral end. 2. by one or more notches near Inferior border: itis rounded and smooth. 3. Medial (posterior) end: it is tapering and is directed upwards, backwards and medially. 4, Lateral (anterior) end: and laterally. it is broad and is directed downwards forwards Liver, Biliary System and Spleen pe 5, Diaphragmatic surface: «It is smooth, convex and directed laterally. elt is related to the diaphragm which separates it from the lower part of left pleura, lung, 9", 10" and 11" ribs and intercostal muscles. 6. Visceral surface: -|tis directed medially towards the abdominal cavity. «lt presents the hilum and four impressions: - Gastric impression above the hilum, related to the fundus of the stomach. -Renal impression between the inferior border and hilum; related to the front of the left kidney. -Colic impression near the lateral end and related to the left colic flexure. - Pancreatic impression just below the lateral end of the hilum and related to the tail of pancreas. * The Hilum: - |t is an anteroposterior slit between gastric and renal impression. - It allows passage of the splenic vessels, lymphatics and nerves. Task postrie artery Anterior gasirke nerve : Linphragnr _—__ , E {viaepular Liga nmcut ] © Custodinphrogeatic OCs «-. Phrenicocolic ligament =— Lesser Left gastrogpipluic artery omentom Splenic artery and vein Pylorus of stomach Greater omentum Site of the spleen a Liver, Biliary System and Spleen Medial {posterior) end aaa. Upper border ra Hilum N etre Gastric impression Splenic A. and its terminal branches si Lateral (anterior) end Pancreatic impression ; Colic impression Visceral surface of the spleen Peritoneal relations: 1. The spleen is completely covered by peritoneum. 2. It is related to the left extremity of the lesser sac (splenic recess). 3. tis related to three peritoneal ligaments: a. Gastrosplenic ligament: - Attachment: It extends from the upper lip of the hilum of the spleen to the upper part of the greater curvature of the stomach. - Contents: 1. The short gastric and left gastroepiploic vessels passing from the splenic artery to the greater curvature of the stomach. 2. Lymphatics and pancreaticosplenic lymph nodes 3. Extrapentoneal fat and autonomic nerve fibers. 4. Accessory splenules in some cases. b. Lienorenal ligament: « Attachment: It extends from the lower lip of the hilum of the spleen to the front of the left kidney. + Contents: 1. Splenic vessels. 2. Tail of pancreas. 3. Lymphatics and pancreaticosplenic lymph nodes. 4. Extraperitoneal fat and autonomic nerve fibers. Liver, Bilary System and Spleen c. Phrenocolic ligament: *It extends from the left colic flexure to the inferior surface Pe of the diaphragm. «lt supports the spleen from below. Blood supply: ° Splenic artery: through its five terminal branches (end arteries). * Splenic vein: runs behind the body of pancreas and joins the mesenteric vein to form the portal vein. superior Lymphatic drainage: - Red bulb of the spleen has no lymphatics. -Few lymphatics arise from the capsule and trabeculae and pancreaticosplenic lymph nodes (along the splenic artery). drain into the Surface anatomy: : It lies opposite the 9", 10", 11" ribs, with its long axis parallel to 10" rib. «Its medial end lies 1.5 inch from midline posterior. + lts lateral end lies in the left midaxillary line. Medial (posterior) end. Lower border Surface anatomy of the spleen | bs Liver, Biliary System and Spleen Factors supporting the spleen in position: 1. Intra-abdominal pressure. ?. Position of the surrounding organs. 3. The peritoneal ligaments. Function of the spleen: 1. Reserve? of blood and iron. 2. Destruction of old red blood cells, foreign materials and toxins. 3. Formation of red blood cells during intra-uterine fetal life. Applied Anatomy: 1. In the living adult, normal spteen (or even enlargement less than 2-3 times) can not be felt but its position can be determined only by percussion. 2. if the spleen is enlarged 2-3 times, it can be felt as a swelting in the feft hypochandrium. 3. Splenic swelling is characterized by the presence of notch or notches on its superior border. 4. Splenic swelling usually enlarges towards the right iliac fossa due to the direction of the long axis of the spleen and the presence of phrenicocolic ligament. Tall due to splenic diseases is felt in the left hypochonrium. SS aaa Liver, Biliary System and Spleen ois Formative Assessment SEQ: 1- Describe the peritoneal ligaments related to the spleen. 2- Describe the relations of the visceral surface of the spleen. MCG: 1- A patient presented with an enlarged spleen, which medially towards the umbilicus. A vertical and expansion of the spleen was resisted by: is directed downward a. Tail of pancreas. b. Left colic flexure. c. Phrenicocolic ligament d. Stomach. Regarding surface anatomy of the spleen, answer: fF a. It lies opposite 10", 11" and 12" ribs. b. It lies opposite 9", 10" and 11" ribs. . It lies opposite 8", 9°" and 10" ribs. oO 2- . It lies opposite 9", 10", 11" and 12" ribs. choose the correct Kidney, Suprarenal Giand and Ureter CHAPTER hn « oy 10 ~\ &y the end of this lecture, the student should be able to: fdentify the normal size, site and surface anatomy of the kidney and to draw this surface anatomy on himself and other persons. e » Describe the shape of the kidney including its hilum. Indicate the features of each surface and recognize « peritoneum and to the other viscera. Describe the different coverings of the kidney and their rofe to support the « kidney in its position. Describe the detaifs of the blood their relations to the supply and lymphatic drainage of the kidney. Site: - It is a retroperitoneal organ lies on the posterior abdominal wall opposite the 12" thoracic and upper three lumbar vertebrae. * The right kidney is 1/2 inch lower than the left kidney. - The left kidney reaches up to the 11” rib while the right kidney reaches _ only to the 11" space. * The long axis of each kidney is directed upwards and medially i.e. the the upper poles of the two kidneys are nearer than the lower poles. Size: It is one inch thick, two inches wide and four inches long. ae Kidney, Suprarenal Gland and Ureier aa Site and size of the kidney The hilum of the kidney: : * Itis directed medially and lies at the level of L1 vertebra. It lies in the transpyloric plane two inches from the middle line. The transpyloric plane passes through the lower part of the left hilum and through the upper part of the right hilum. It contains the renal vein (anterior), renal artery (in the middle) and pelvis of the ureter (posterior), (Remember VAP). - Itlies in the middle of the medial border and it leads to space inside the kidney called the renal sinus which is lined by extension of the fibrous capsule of the kidney and lodges the renal vessels and the pelvis of the ureter. Shape: The kidney is bean-shaped and has: Two ends (upper and lower ends). Two borders (Lateral and medial borders). Two surfaces (anterior and posterior surfaces). Kidney, Suprarenal Gland and Ureter Cortex Medulla Renal pelvis Sinus of the right kidney Fibrous capsule Renal artery Renal vein Pelvis of the Hilum of the right kidney cs: an Kidney, Suprarenal Gland and Ureleh 0 99F Relations: a. + Posterior relations: The posterior relations of both kidneys are the same. Each kidney is related directly to ‘four muscles of the posterior abdominal wall with four neurovascular structures in between. : A four muscles are the following: . Diaphragm and its medial and lateral arcuate ligaments lies behind the upper" part of the kidney. It separates the kidney from the costodiaphragmatic-recess of the pleura and 11" and 12" ribs (on the left side) or 12" rib only (on the right side). Psoas major is related to a vertical area of the kidney. 3. Transversus abdominis is related to a lateral border of the kidney. 4. Quadratus lumborum is related to an belween the psoas major and transverses The four neurovascular structures intervening z * the latter two muscles are: 1. Subcostal vessels. 3. lliohypogastric nerve, close to the medial border vertical area close to the intermediate vertical area abcorminis. between the kidney and 2. Subcostal nerve. 4, llio-inguinal nerve. Left crus of diaphragm 40m Fi +1" Ss -12" rib = = = Ab: . AuUbcastal NM. and vessels ye: 7 * De \ = Na = * gastric N. = Hlid-Inguinal N. . Transversus \wadratus Posas'major “ Right Kidney * lurmborum “ Left Kidney * Posterior relations of the kidney muscle Kidney, Suprarenal Gland and Ureter Eleventh rib Tealfifi rib fs Soe Twelfth rit First un bar LiatvsSse [acess hiaphragmatiz area Qiaphragmiatic area Area for iransvertus lendar Area for transversus tendon Area for quadrats lumbarum Ares tor quadratues leimeborum Psoas anea Area for pooas Second lumbar {heiHISe process 7 : : Left aneler : Inferior vana raya Rignt ureter f Aarla Posterior relations of the kidney Right supra- Left supra-renal renal Char Area related to the stomach Area related to Spleen splenic vessels night lobe of liver Right colic flexure colon Descending colon Ascending branch of left colic A, Ascending Srenen tf right colic A. Loops of jejunurn : \ Rignt colic , * Left colic A, | Loops of jejunum * Right Kidney * " Left Kidney * Anterior relations of the kidneys Kidney, Suprarenal Gland and rele a. a gga Anterior relations: differ on both sides Left kidney Right kidney 1. Right su prarenal gland is related to the upper medial part of the anterior surface 1. Left suprarenal gland is related to the 2. Second part of duodenum is related 2. Stomach is related to the tri-angular part [| upper medial part, just above the hilum to area of the anterior surface close to ithe hilum of the | 3. Right lobe of the liver is related to a 3. Spleen is related to the upper lateral part of the anterior surface large area at the upper lateral part of the anterior surface 4. Right colic flexure is related to the lower lateral area, below the hepatic area anterior areas for the suprarenal gland surface, bounded pancreas, by spleen the andf 4, End of transverse colon and beginning of | descending colon are related to the anterior F | surface close to the lower part of the lateral border, just below the splenic area 3. Ascending branch of right colic 5. Ascending branch of superior left colic artery ascends in front of the lower end of the kidney to reach the right colic flexure. artery runs in front of the lower end of the 6. Loops of jejunum are related to the lower pole, medial to the colic area kidney to reach the colon Fs Loops of jejunum are related to the lower medial part of the anterior surface 7. Body of pancreas and splenic vessels | are related to quadrilateral area middle 1/3 of the anterior surface Peritoneal relations: at Peritoneal relations: * The anterior surface is covered by * The anterior surface is covered by peritoneum at the hepatic and peritoneum at the splenic, gastric and jejunal areas * jejunal areas The areas for the right suprarenal, | duodenum and right colic flexure are not covered by peritoneum, and these viscera lie in direct contact with the kidney « The areas for the suprarenal, pancreas and descending colon are not covered by peritoneum, and these viscera lie in direct contact with the kidney the Kidney, Suprarenal Gland and Ureter Coverings of the kidney: from within outwards 1. True fibrous capsules: « |t closely surrounds the kidney. « |t continues over the renal sinus. « It can be stripped off easily from the kidney. 2. Perirenal (Perinephric) fat: 3. li surrounds the capsule and prolongs into the renal sinus. Renal fascia (Zukercandle’s or perinephric fascia): 4. * * Itis derived from fascia transversalis. It consists of two layers (anterior and posterior). * Its two layers fuse above the kidney, enclosing the suprarenal gland, and at the lateral and medial borders of the kidney. « Its two layers remain separate inferiorly down to the iliac fassa. Pararenal fat: lt is a condensation of the retroperitoneal fat outside the renal fascia. uiprarenal gland FPerinephric fat Renal fascia Coverings of the kidney Kidney, Suprarena! Gland and Ureter Fascia trans ersalis B26 Diaphragmatic } * fascia Fascia Fansversalis ~Pelvic fascia Supra-renal sland Renal fasda Perinephric fat Pelvis of ureter Sinus of kidney True fibrous capsule Coverings of the kidney Surface Anatomy of the Kidney: * Surface anatomy as projected to the anterior abdominal wall: The upper end lies one inch, the hilum two inches and the lower end three inches from the median plane: 1. Hilum: lies in the transpyloric plane (L1). 2. Upper end: two inches above the hilum. 3. Lower end: two inches below the hilum in the subcostal plane opposite the third lumbar vertebra. "Surface anatomy as projected to the posterior abdominal wall: The kidney lies in a rectangle called Morris" parallelogram, drawn on the back as follows: Kidney, Suprarenal Gland anc Ureter ages! 1. Upper and lower horizontal lines: drawn opposite the 11" thoracic and 3" lumbar spines respectively. 2. 3. Medial and lateral vertical lines: drawn one inch and three inches from the median plane respectively. The hilum is two inches from the middle line at the level of first lumbar spine. Spinous Process Tat F —s at Let kicney [2 Tiz 4 e s f ¥ é sl: Ly \ i L 3° mA “ne . , i) ' G Lg Morris parallelogram Arterial Supply: 1. Renal artery: * lt arises from the side of the aorta opposite the upper border of the 2™ lumbar vertebra. * It runs laterally to reach the hilum of the kidney. * * 2. The left renal artery is shorter and lies behind its vein. The right artery is longer than the left, and passes behind the end of the left renal vein, inferior vena cava and right renal vein. Accessory renal artery: «lt may be found in 30% of cases. It arises from the aorta just above or just below the renal artery and runs laterally parallel to it. * It commonly enters the upper or lower poles of the kidney. | Kidney, Suprarenal Gland and Ureter ere. Venous Drainage: * Renal veins run horizontally in front of the renal arteries to open into the inferior vena cava. « The left vein is longer than the right one, and crosses anterior to the aorta just below the origin of the superior mesenteric artery. Lymphatic drainage: To the hilar lymph nodes around the renal artery then to para-aortic lymph nodes, Nerve supply: The kidney receives sympathetic and parasympathetic fibers from the renal plexus (around the renal artery) which is derived from the celiac plexus. F session anatomy: The sympathetic fibers carry pain sensation from the kidney to 70”, Le 17" and 12" thoracic segments of the spinal cord. so renal pain is felt along the distribution of these segments (mainlyT12). it is commonly felt in the flank and may radiate downward into the lower abdomen. Renal pain can result from streiching of the capsule of the kidney or spasm of the smooth muscfes in the renal pelvis. Stability of the kidney: The following factors keep the kidney in position: « lts position in paravertebral gutter. « |ts coverings. + Intra-abdominal pressure. + Appasition of neighboring viscera. Kidney, Suprarenal Gland and Ureter MCQ: The following structure lies in front of the left kidney: a. The splenic vessels. b. The neck of the pancreas. c. The liver. d. The right colic flexure. Why: 1. The right kidney is slightly lower than the left kidney? 2. During operations on the left kidney, the left pleura may be injured? Kidney, Suprarenal Gland and Ureter ae Suprarenal Gland fLOs: By the end of this tecture, the student should be able to identify the differences in size, shape, refations and blood supply of suprarenal Glands. Right Suprarenal Left Suprarenal . Triangular in shape 1. Semilunar in shape . Higher, lying on upper pole of kidney é. Lower, reaching hilum of kidney - Right suprarenal vein is short and drains into LV.C. 3. Left suprarenal vein is long and drains into the left renal vein . The hilum is directed upwards 4. The hilum is directed downwards o. Related posteriorly to the right crus of diaphragm 5. Related posteriorly to the left crus of the diaphragm . Related anteriorly to inferior vena cava and right lobe of liver (bare area) 6. Related anteriorly to stomach and lesser Sac . Peritoneal covering: /. Peritoneal covering: Covered inferiorly, bare superiorly Covered superiorly, bare inferiorly . Medial relation: each gland is related to coeliac ganglion. . Arterial Supply: superior suprarenal artery (from phrenic artery), middle suprarenal artery (from aorta) and inferior suprarenal artery (from renal artery). 3 Kidney, Suprarenal Gland and Ureter Interior phrenic artery Superior suprarenal arteries Lett Right suprarenal gland Right suprarenal vein " sais suprarenal gland Middle suprarenal artery Left suprarenal vetn Inferior Suprarenal artery Left kidney Abdominal aorta Aight kidney Inferior vena cava Suprarenal glands Kidney, Suprarenal Gland and Ureter Ree? Explain: The hilum of the right suprarenal gland is directed upwards, while that of the left Suprarenal is directed downwards. MCQ: 1. Regarding the suprarenal glands, the following statement is correct: a. Veins from right and left suprarenal glands drain directly into I.V.C. b. Left suprarenal gland lies in the stomach bed. c. Right suprarenal gland is related to the pancreas. d. Each suprarenal gland lies along the lower pole of the kidney. 2. Regarding the suprarenal glands, one of the following statements is correct: ) a. The left gland is drained into the I.V.C, b. The left gland is related anteriorly to the head of the pancreas. c. Each gland receives four suprarenal arteries. d. The left gland reaches the hilum of the kidney. ae Kidney, Suprarenal Giand and Ureter SS The Ureter ILOs: \ By the end of this lecture, the student should be able to: * Identify the course and the relations of the abdominal parts of both ureters and their appearance during radiography. Draw the surface anatomy of the ureter both anteriorly and posteriorly * * Detect the sites of constrictions of the ureter and the importance constrictions as possible sites of stone impaction. * * Identify the blood supply of the ureter. fdentify the nerve supply of the ureter and the anatomical base of the refer of ‘ of these the ureteric pain. oe : Peer ee FEE, The ureter is a retroperitoneal tubular muscular structure. Beginning: * The ureter begins in the renal sinus by a funnel-shaped pelvis of ureter (renal pelvis) which is formed by fusion of 2-3 major calyces. > The pelvis of the ureter is partly inside the renal sinus and partly outside it. * The pelvis of the ureter descends along the medial border of the kidney to become continuous with the ureter proper at the pelvi-ureteric junction opposite the lower pole of the kidney at the level of the tip of transverse process of L» vertebra. End: At the Length: Itis 10 Course » The * superior lateral angle of trigone of urinary bladder. inches long and six mm in diameter. and relation of abdominal part of the ureter: upper half of the course of each ureter lies in the abdomen lower half lies in the pelvis. It descends vertically downwards abdominal wall opposite and slightly the tips of transverse medial on processes lumbar vertebrae (Lo-Ls). the while its posterior of lower four Relations of the renal pelvis: Right renal pelvis. Anterior Posterior | Left renal pelvis Renal vessels Second part of duodenum Body of pancreas Psoas major Kidney, Suprarena! Gland and Ureter 9 234 Relations of the abdominal part of the ureter: Right ureter Posterior Left ureter 1. Medial border of psoas major and psoas minor 2. Tips of transverse processes of L2-L5 vertebrae 3. Genitofemoral nerve crosses behind the ureter Anterior 7, Peritoneum of posterior abdominal wall. 2. 3™ part of duodenum | 3. Right colic, iliocolic and right gonadal arienes (3 arteries) 4. 2. Upper & lower left colic and left gonadal arteries (3 arteries) Root of mesentery, superior | 3. Sigmaid colon and apex of mesenteric vessels loops of small intestine and its mesocolon where it crosses in front of the bifurcation of common iliac artery Medial —=—| Inferior vena cava Inferior mesenteric vein surface anatomy: « « Anterior surface markings: It is represented by a line drawn from a point on the transpyloric plane two inches from the middle line to the pubic tubercle. Posterior surface markings: It is represented by a line on the back from a point two inches from the middle line at the level of L1 spine to the posterior superior iliac spine (indicated by dimple on the skin). Constrictions: 1. Pelvi-ureteric junction. 2. Where the ureter crosses the bifurcation of common iliac artery. 3. At ischeal spine. 4. Intramural part and ureteric orifice. Blood supply: Renal artery, aorta, gonadal artery, common and internal inferior vesical artery in male or uterine artery in female. iliac arteries, Nerve supply: It is supplied by nerves derived fram renal, aortic, superior and inferior hypogastric plexuses, which are derived from lower three thoracic, first lumbar and 2™ to 4" sacral segments. Kidney, Suprarenal Gland and Ureter Inf. Mesenteric vein 3° part of th duodenum Lt ureter Rt. colic 4, Rt. gonadal Upper ct colic.aA. 4 Lower Lt. colicA, Rt. urete Ileo- colic A Lt ponadal A. Superor mesenteric A, Bifurcation of common ac A. & beginning of ext, fiac A. Abdominal part of the Ureter Pelvis of ureter Pralyi‘ Tips oftmnsvere processes of: lim har vertehrar ureteric Junction Ureler Genitofernoral NM. Sacro- iliac joint / Psoas major lecheéal Spine Postero- sup. Angle of urinary bladder Posterior relations of the abdominal part of the ureter Kidney, Suprarenal Gland and Urefar” 3aig PELVIC PART OF URETER Course: It enters the pelvis at the bifurcation of the common on each side. Then border of the iliac artery it runs downwards and slightly backwards along the lower internal iliac artery. At the level of the ischial spine it curves forwards and medially (in female it runs below the root of the broad ligament} to enter the posterosuperior angle of the urinary bladder. It passes obliquely downwards upper and medially fer 2 cm in its wall (intramural part) to open in the lateral angle of trigone. This obliquity provides a valve like mechanism that prevents reflux of urine into the ureter when the bladder ts distended. Relations: Medially: it is covered by peritoneum. Laterally: as it descends it crosses the external iliac artery and vein, obturator nerve, obturator artery and vein from above downwards. in male : near the wall of the bladder the ureter is crossed by the vas deferens, here it crosses the.upper end of the seminal vesicle. in female: it passes closely lateral to the upper end of vagina below the root of the broad ligament , here it is crossed above by the uterine artery. Arterial supply: « « Inmale: inferior vesical artery In female: vaginal and uterine arteries. Nerve supply: Autonomic plexus derived from : ® The flower thoracic and first lumbar segments of the spinal cord (sympathetic): ® | The second to fourth sacral segments of the spinal cord { para-sympathetic). Kidney, Suprarenal Gland and Ureter Boe ie iu ureter Sommnon iliac vessels internal lac artery external iliac ariery inferior epigastric artery vas deferens blacecer ' ischial spine obturator internus prostate uterine artery ureter round Egament of uterus hevator ant inforior apigastric artery posterior fornix anterlor fornie bladder urethra Vag!)a Relation of the pelvic part of the ureter | Kidney, Suprarenal Gland and Ureter a8 Clinical note: In ureteric colic the pain is spinal segments referred to cutaneous areas innervated from which supply the groin and scrotum ureter. It shots down from the loin to the fin male) or labium majus fin female) and the proximal anterior aspect of the thigh. Inferior Ureter—** epigastric Vas deferens Obturator nerve and vessels A a HA Internal iliac artery Lateral relations of the pelvic part of ureter Kidney, Suprarenal Gland and Ureter Sac, (roped anatomy: ic” * Stone ureter usually migrates from the kidney and impacted in one of the normal anatomical constrictions. * Ureteric pain is radiated to cutaneous areas innervated from the same segmeris of the spinal cord that supply the ureter, mainly T;;, -— Lo. This pain commences in the loin and shoots downwards to the groin and scrotum or labia majora. This pain may extend to the upper part of the front of the thigh and along the area supplied by the genitofemoral nerve (Lj). * fn radiology, stone ureter is identified near the tips of fhe processes of lumbar vertebrae, — transverse opposite the sacroiliac joint or medial ia the ischial spine. ) Formative Assessment SAQ: Give an account on: 1. The sites of constriction of the ureter. 2. The surface anatomy of the ureter 3. Relations of the ureter in the abdomen. McQ 1.Regarding the ureter, one of the following statements is correct: a. It descends vertically along the tips of transverse processes of T2—-T5. b. It is crossed in the abdomen by the gonadal artery, c. The inferior mesenteric vein lies on the lateral side of the left ureter. d. Pain sensation from the ureter is carried by sympathetic fibers to T2-T5 spinal segments. : Explain: 1. The pain of ureteric colic is referred to groin and external genitalia. 2. The stone ureter is liable to be impacted course of the ureter. in many sites along the Posterior Abdominal Wall CHAPTER Mio 11 ILOs: By fhe end of this lecture, fhe student should be able to: « » Describe the beginning, end, course, relations and branches of the abdominal aorta. Describe the beginning, end, course, relations and tributaries of the inferior Vena Gave. » Outline the anastomoses between S.V.C. and LV.C. « Mame the abdominal lymph nodes and cofine their sites and drainage areas. - « Describe the formation, position and drainage areas of the cisterna chyli. Describe the origin, insertion, nerve supply, action, relations and openings of the diaphragm. « Describe fhe origin, insertion, nerve supply relations and action of the » psoas major, psoas minor, quadratus fumboarum and iliacus muscles. Outline the layers of the thoracolumbar fascia. Desenbe the formation and branches of the lumbar plexus, fumbar » Explain sympathetic chain and autonomic nerve plexuses in the abdomen. clinical cases of diaphragmatic hernias and psoas abscess on anatomical basis. POSTERIOR ABDOMINAL WALL The Abdominal Aorta Beginning: at the lower border of 12" thoracic vertebra, as a continuation of the descending thoracic aorta. End: at lower common border of 4" lumbar vertebra, where it bifurcates into two iliac arteries. Course: lt passes through the aortic opening of the diaphragm and descends in front of the bodies of the upper four lumbar vertebrae with slight inclination to the left. Posterior Abdominal Wall! <Q@a see) LV .C. opening of diaphragm Rt. phrenic A. Median arcuate lig. (Aortic opening of Rt. supra-renal gland thediaphragm) Rt. middle suprarenal A: Azygos V. Thoracic duct Cysterna chrli Rt. renal rah (AES chain A Ea = = A Rt. crus of diaphragm Rt. psoas major i o [ts Nt\ = Lt. psoas major N LV: Rt. Rt. common urete iliac V Lt. com mon ihac V Origin, course, end and relations of the aorta and |.V.C. surface anatomy: It is represented by a line drawn from a point in the median plane two cm above the transpyloric plane, to a point two cm below and to the left of the umbilicus. Relations: Anterior Relations: from above downwards 1. Body and uncinate process of the pancreas. 2. Splenic vein, above the superior mesenteric artery. 3. Left renal vein, below the superior mesenteric artery. 4. The 3" part of duodenum. 5. Root of mesentery of small intestine and superior mesenteric vessels. 6. Peritoneum of the posterior abdominal wall. 7. Gails of small intestine. Posterior Abciominal Wall Posterior Relations: 1. Bodies of the upper four lumbar vertebrae and the intervening Poe discs with the anterior longitudinal ligament. 2. The left 3 and 4" lumbar veins which cross behind the aorta to end in the inferior vena cava. On the sides: 1. Crus of diaphragm: on each side of its upper part. 2. Sympathetic chain: on each side of its lower part. 3. Azygos vein, cysterna chyli and beginning of thoracic duct: on the right side above the 2™ lumbar vertebra. 4. Inferior vena cava an the right side, below 2™ lumbar Vertebra. 5. The 4"" part of duodenum on the left side, opposite 2"7 lumbar vertebra. ALB.: The. aorta is surrounded by networks of aufonomic nerves, ganglia, lymph vessels and lymph nodes. Portal V. Huy LV Opening to: lesser sac Hepatic 4 Gastro-duod A. ji" — | * ij » iti =4\ | at hi Fi bei, Median arenate ipament | bite He i 7 Hi fi Bi bi eeu —Cochaec A, & its branches ve i, Splenic V. part of. duodenum Hody of pancrea Bile duct Li. renal V. a part of the Head of. daadenum d& dhe palieress duadeno-jejuzal : flexure 3°" part of _— duodenum Rt zonadal A. oe if, mesenteric A. a Coils of small reese Sup. hfesenteric Wessels in the root of mesentery of emall intertne Relations of the Aorta and I.V.C. ae Posterior Abdominal Branches: a. Paired branches: From above 4. Inferior phrenic arteries: «They arise at the beginning downwards of the abdominal aorta to ramify on the inferior surface of the diaphragm. « Each gives a superior suprarenal artery. 2 . Middle suprarenal arteries: They arise at 1° lumbar vertebra to supply the suprarenal glands. 3 . Renal arteries: (see before) They arise at 2" lumbar vertebra and pass in front of the crus of the diaphragm and psoas major muscle to reach the kidney. Each gives an inferior suprarenal artery. * On the left side, the artery passes behind its vein. *On the right side, the artery passes behind the left renal vein then the inferior vena cava and right renal vein. . Gonadal (testicular or ovarian) arteries: They arise from the anterolateral renal arteries. 9. Lumbar arteries: aspect of the aorta just below the - Four pairs, arise from the back of the aorta, while the 5" pair arises from the median - sacral artery. Each artery passes at the side of the corresponding lumbar vertebra deep to the origin of psoas major and continues between the internal oblique and transversus abdominis muscles to supply the muscles of the abdominal wall. 6. Common liliac arteries: «= The two terminal branches of the aorta. * They arise at the 4"" lumbar vertebra slightly to the left of the middle line. b. Single branches: From above downwards 1. Coeliac trunk: Arises opposite the lower border of 12" thoracic vertebra (T12) or upper border of 1* lumbar vertebra . 2. Superior mesenteric artery: Arises opposite the lower border of the 12" thoracic vertebra (T12) or upper border of 1° lumbar vertebra. 3. Inferior mesenteric artery: Arises opposite the 3 lumbar vertebra (L3). 4. Median sacral artery: Arises from the back of the lower end of the aorta at the level of 4" lumbar vertebra and descends to the pelvis. Posterior Abdominal Wall er Suprarenal a i, hE Fay phrenic a. Coeliac trunk Renal a. Sup. mesenteric a. Lumbar a a. Inf. mesenteric a. , Gonadal a. Commen iliac a. Median sacral a. =xternal iliac a. aN Internal iliac a. Femaral a. _ Sacra Sacral canal | Hid if fs = Median Le : he = : i arteries ay AN sacral A. _ Twigs to sacral canal Rectum \ Median _ sacral A. Syuuphysis pubis OCC Anal canal Glomus coccygeus Median sacral artery and lumbar arteries Ten Posterior Abdominal Wail eas Ssisigcat Testicular Arteries Origin and course: * Pair of arteries; arise from the anterolateral aspect of the aorta just below the renal artery (L2). - They pass downwards and laterally on the posterior abdominal wall, to enter the inguinal canal through the deep inguinal ring. Relations: a. | On the right side: - It passes in front of: 1. Inferior vena cava. 2. 3. Right psoas major muscle. Right ureter. 4. Right external iliac artery. - It passes behind: 1. 3” part of the duodenum. 2. Right colic and ileacolic vessels. 3. Root of mesentery and terminal ileum. b. On the left side: « |t passes in front of: 1. Left psoas major muscle. 2. Left sympathetic trunk. 3. Left ureter. 4. Left external iliac artery. - |t passes behina: 1. Third part of the duodenum. 2. Inferior mesenteric vein. 3. Superior and inferior left colic vessels. 4. Terminal part of the descending colon. - Gorrespond to the testicular arteries but do not enter the deep inguinal ring and inguinal canal, but pass to the pelvic cavity. - | At the pelvic brim, the ovarian artery crosses the external iliac artery to enter the pelvis and passes to the suspensory ligament of the ovary. Then it passes through the mesovarium to supply the ovary. Posteriar 3” x part of duodenum Sup. mesenteric A. ~ ; f %, Inf_ mesenteri ey. | re imeri colic A 3 if \\i / ‘ee HeocolicA | Abdominal Wall #_ Inferior mesenteric A. att i V “y if Terminal ileum End of descending colon Anterior relations of testicular artery LV. Aort i ‘i ‘ Lt. symp. chain Lt. ureter t. testicular A i Lit ELA. Rt. testicularA. Posterior relations of testicular artery 2467 Posterior Abdominal Wall Pe Beginning and course: « At the lower border of 4" |umbar vertebra (L4) as one of the two terminal branches of the aorta. « It is about two inches long and passes medial side of psoas major muscle. downwards and laterally on the End: At the lower border of the 5" lumbar vertebra by dividing into: external and internal iliac arteries. Relations: Right C. |. A. Left C. 1. A. — Anterior 1. Covered by peritoneum 2. Its end is crossed by right ureter and the sympathetic (presacral nerve) 1. Covered by peritoneum | 2. Its end is crossed by left ureter fibers) _ and the sympathetic (presacral nerve) fibers _ 3. Its middle is crossed by inferior mesenteric vessels | Posterior 1. Fifth lumbar vertebra 2. Right sympathetic trunk 3. Beginning of |. V. C. 1. Fifth lumbar vertebra 2. Left sympathetic trunk “More deeply: obturator nerve, lumbosacral trunk and iliolumbar artery Branches - of the common iliac artery: It gives two terminal branches opposite the lumbosacral disc in front of the sacro-iliac joint: 1. External iliac artery. 2. Internal iliac artery. > The former is directed to the lower limb, while the latter is directed to the pelvis. Posterior Abdominal walt il. qugsenlene A. RL. ureter Rt. Lt. ureter FA FE, TA Sup. reeral « Anterior relations = Eva: «48 RL. Sympathetic chain ___ AL psoas major Rt C.D A, Fil. olvturwtar Wy. ———— Fat, Tanobo- sacral unutik ® Posterior relations Kt lumbosacral trunk Relations of common iliac artery (C.1.A.) 24B Posterior Abdominal Wall Beginning: « It begins as one of the two terminal branches of the common iliac artery at the lower border of L5. + Itis larger, longer and wider than the internal iliac artery. « |i passes downwards and laterally along the pelvic brim on the medial side of psoas major muscle. End: lt ends by leaving the pelvis from under cover of the inguinal ligament at the midinguinal point (midpoint between anterior superior iliac spine and pubic symphysis) where it becomes femoral artery. Relations: - Structures crossing external iliac artery: 1. The ureter at its beginning. - 2. Gonadal vessels. 3. Genital branch of genitofemoral nerve. 4. Vas deferens at its end. External iliac vein: lies behind its upper part but medial to its lower part. - On the right side: it is covered by the caecum. It is separated from it by peritoneum. - On the left side: it is covered by the terminal part of the descending colon. Branches: lt gives only two branches which arise just above the inguinal ligament: 1. Inferior epigastric artery: It passes upwards medial to the deep inguinal ring. It enters the rectus sheath where it anastomoses with the superior epigastric artery. 2. Deep circumflex iliac artery: Passes laterally behind the inguinal ligament then ascends along the iliac crest (see before). Posterior Abdominal Wall Rt, psoas major KL. bestieular A. RL. external liae A. Genital branch of genitotemoral WN. Famoral %, " Fr left ers Rr, ext’ iliag ¥, ‘Terminal ileum lind of descending colon & the beginning of sigmoid colo Appendix Lt. BLA External Iliac Artery (E.1.A.} (250 Posterior Abdominal Wall Beginning and course: * |t is formed by the union of the two common iliac veins at the 5" lumbar vertebra (L5), behind the right common iliac artery. « [t ascends to the right of the aorta till it pierces the central tendon of the diaphragm opposite the 8" thoracic vertebra (T8), one inch to the right of the median plane. End: It ends by piercing the diaphragm, the pericardium and entering the lower posterior part of right atrium. Tributaries: ti Two common 2. The 3 and 4" lumbar veins on both sides (the 1° and 2™ lumbar veins 3. 4. 5. 6. join the ascending lumbar vein). Right gonadal vein (the left gonadal vein joins the left renal vein). Right and left renal veins. Right suprarenal vein (the left one joins the left renal vein). Right and left inferior phrenic veins from under surface of the diaphragm. 7. iliac veins. Right, left and middle hepatic I.V.C. in the back of the liver. Vena azygos. 8. veins which are very short and join the Relations: Anterior relations: From below upwards fe . Right gonadal artery (testicular or ovarian). on _ 3" part of the duodenum. & . Head of pancreas, with the common bile duct on its deep surface. —~J to Bo t. Right common iliac artery. . Parietal peritoneum of the posterior abdominal wall. . Root of mesentery, with superior mesenteric vessels. . Portal vein, common bile duct and gastroduodenal artery separating from the 1* part of the duodenum. . Epiploic foramen separating it from the free margin of lesser omentum containing portal vein, bile duct and hepatic artery. . Posterior surface of the right lobe of the liver. it Posterior Abdominal Wat Ri. lobe of liver Anterior relations of uppermost part of I.V.C. LV.C. opening of diaphragm Rt, & Lt, hepatic veins Lt. phrenic V. Rt. phrenic V.——pe=3 Middle hepatic ¥. Lt. suprarenal ¥. Ri. suprarenal ¥—— Rt. renal ¥. Rt, renal A. a7 Td & 4 mh ____ Vv, Rt Lumbar veins cara Rt. £ conadal ¥.—— a Lumbar veins Bi. cormmmon iliac ¥. (CLV) Lt. Lt. gonad a gonadal oN Lt. common iliac ¥. (CLV) *~Median sacral ¥- Tributaries of the 1.V.C. QB2 Posterior Abdominal Wall Ee. a Posterior relations: 1. Right sympathetic trunk. 2, Medial margin of the right psoas major muscle. 3. Bodies of the lower three lumbar vertebrae with the anterior longitudinal ligament. 1am oO . The 3 & 4" lumbar arteries. . Right renal artery. _ Right middie suprarenal artery and medial part of right suprarenal gland. . Right inferior phrenic artery. 8. Right coeliac ganglion. Relation to the right side: 1. Right ureter and medial border of right kidney. 2. The 2™ part of the duodenum. 3. Right lobe of the liver. Relation to the left side: 1. The aorta. 2. Right crus of the diaphragm. 3. Caudate lobe of the liver. Surface anatomy: a by Represented vertical line extending between a point at the intertubercular plane, one inch to the right of the midline and another point at the right 6" sternocostal junction. Se a are Se SS * At the posterior abdominal wall: > The azygos vein. - The inferior hemiazygos vein: lt arises from the back of left renal vein thorax to end in the superior vena cava. (or the IVC). It ascends in the Posterior Abdominal Wail a : The vertebral venous plexuses: There are vertebrae. two plexuses; They external are connected and internal which surround ‘the with the sacral, lumbar and intercostal veins. So, they connect the inferior and superior vena cavae through their tributaries, At the anterior abdominal wall: «In the Superficial fascia: There vein is anastomotic vertical channel (tributary of long saphenous between the superticial epigastric vein) and the lateral thoracic vein (tributary of axillary vein), forming thorace-epigastric vein. «In the rectus sheath: Between the superior epigastric vein which drains to the internal thoracic vein and the inferior epigastric vein which drains to the external iliac vein. Lymph Nodes of the Abdomen The lymph nodes of the abdomen and pelvis are arranged on chains or groups which lie along the course of the main arteries. Abdominal lymph nodes: Pre-aortic lymph nodes: (drain the organs supplied by single arteries) - They are placed anterior to the aorta around the single branches and forming coeliac, superior and inferior mesenteric groups. - They receive afferents from the spleen, liver, Pancreas and gastro- intestinal tract. - Their efferents unite to form the gastro-intestinal lymph trunk which ends in the Cisterna Chyli. Para-aortic lymph nodes: (drain the organs supplied by paired arteries) - They are placed on each side of the aorta. - They drain the following: 1. The deep layers of abdominal wall (the superficial layers drain into axillary and superficial inguinal lymph nodes). The accompany the deep and superficial blood vessels. lymph vessels Posterior Abdominal! Vall 2. The kidneys, ureters, gonads, uterine tubes and upper part of the - Their efferents form the right and left lumbar trunks which end in the uterus (direct drainage). 3. The common iliac lymph nodes in the pelvis. Cisterna Chyli. Retro-aortic lymph nodes: (drain the posterior abdominal wall and send the efferents to the para-aortic lymph nodes. Pelvic lymph nodes: The structures of the pelvis drain into the internal and external iliac lymph nodes and finally drain into the common - {tis a reservoir inte which the lymph iliac lymph nodes. is collected from the lower limb and abdomen. - {treceives three lymph trunks: * One gastrointestinal lymph trunk: Draining the stomach, intestine, pancreas and spleen. It also drains all parts of the liver except the upper part of the inferior surface from which lymphatics pass directly to lymph node of the thorax. *« Two lumbar abdomen lymph trunks: Draining the remaining contents of the (except the bare area of the right lobe of the liver), deep layers of abdominal wall and lower limbs. - tis two inches long and lies in front of the upper two lumbar vertebrae behind the right crus of the diaphragm, between the aorta and azygos vein. - The thoracic duct arises from its upper end. | Posterior Abdominal Wall 602. Musclesof the Posterior Abdominal Wall The Diaphragm Shape: -It ls a large dome-shaped fibromuscular partition, which separates the thoracic cavity from the abdominal cavity. - It is convex upwards. -Its right side {called right cupola) is higher than its left side (called left cupola) due to the underlying large right lobe of liver. Origin: - It has a wide origin from the whole circumference of the inner aspect of the thoracic outlet and the vertebral column. - Ittakes origin from three areas: * Sternal origin: From the back of xiphoid process by two fleshy slips. * Costal origin: From the deep surface of the lower six costal cartilages by fleshy slips interdigitating with the origin of the transversus abdominis muscle. * Vertebral origin: By two fleshy crura (right and left) and five arcuate ligaments (median, two medial and two lateral). 1. Crura of the diaphragm: ¢ The right crus: - It arises from the bodies of the upper three lumbar vertebrae. - tis larger than the left crus (as it has to contract against the liver). - Its fibers extend up to surround the lower end of the oesophagus forming a physiclogical sphincter around the cardiac end of the stomach. « The left crus: |t is smaller and arises from the bodies of the upper two lumbar vertebrae. Posterior Abdominal Wall eR 2. Arcuate ligaments: Median « arcuate ligament: It plane. One only, lies in the median extends between the right and left crura. It arches over the aorta. * Two medial arcuate ligaments: One on each side. It extends from the crus of the diaphragm to the tip of transverse process of 1° lumbar vertebra. It arches over the psoas major muscle. Two lateral arcuate ligaments: One on each side. It extends from « the tip of transverse process of 1* lumbar vertebra to the last rib. It arches over the upper part of quadratus lumborum muscle. Defects in the diaphragm: are There small defects between the different parts of origin of the diaphragm. They are filled with loose areolar tissue. 1. Foramen of Morgagni: Lies between the sternal and costal origins on the two sides. It transmits the superior epigastric vessels. It may be the site of anterior (parasternal) diaphragmatic hernia. 2. Foramen of Bockdalek: (Vertebrocostal triangle) It lies between the costal and vertebral origins. It may be the site of - | posterior diaphragmatic hernia. It is a triangular gap present mainly on the left side. - At this triangle, the pleura of costodiaphragmatic recess comes in contact with posterior surface of the kidney which is separated from it by areolar tissue. This triangle is the remnant of the pleuroperitoneal canal in the fetus. Insertion: > The diaphragm has no bony insertion, but all the fibers converge to be inserted into the central tendon of the diaphragm. > This tendon is a strong aponeurosis, semilunar in shape and formed of one median and two lateral folia (i.e. trifoliate). The the pericardium and heart. median lobe is related to | Posterior Abdominal Wall pee Nerve Supply: * Motor: right and left phrenic nerves (C3, 4 & 5) which arise in the cervical region and descend to ramify on the inferior surface of the diaphragm. N.B.: The phrenic nerve supplies the inferior (abdominal) surface due to folding of the embryo (phenomenon of folding). " Sensory: mainly to the peritoneum and the pleura related to the diaphragm. However, proprioceptive fibers fram the musculature are few. sensory supply includes: 1. Lower six thoracic spinal nerves, are sensory to the peripheral parts. 2. The phrenic nerves are sensory to the central part of the diaphragm. Action of the diaphragm: 1. It is the chief muscle of respiration, 2.lt is used to increase the intra-abdominal pressure in different circumstances as parturition, coughing, defecation and micturition. Relations: The superior surface: 1. The right cupola is related to the right pleura and lung. 2. The left cupola is related to the left pleura and lung. 3. The central tendon is related to base of the heart and pericardium. The inferior surface: |. On the right: « Right lobe of the liver. - Right kidney and right suprarenal gland. 2. On the left: « Left lobe of the liver. *Fundus of the stomach and spleen. * Left kidney and left suprarenal gland. Pasterior Abdominal Openings of the diaphragm: a. Major openings: Oesophageal Aortic Opening Site I Vv. C, er 1S Opening Opening °Ty2 vertebra °Tio vertebra. -In the middle line 1 | | « Ty vertebra inch to left of] middle line 1 inch to right | | *Behind median arcuate | «In the right crus of middle line | + In the central ligament tendon Structures | «Aorta to the left passing through ° Oesophagus ¢ LV.C. -Azygos vein to the right | » Two vagi | «Thoracic duct in Right phrenic |" Oesophageal between nerve branches of left | +* Lymphatics gastric vessels b. Minor openings and structures passing 1. Musculophrenic artery: between through them: the slips of origin of the diaphragm from 7" and 8" costal cartilages. . Superior epigastric artery: passes between sternal and costal origins. .Lower five intercostal nerves and vessels: between the costal digitations of the diaphragm. .Subcostal nerve, subcostal vessels and quadratus lumborum muscle: behind the lateral arcuate ligament. . Hemiazygos vein: pierces the left crus to enter the chest. . Sympathetic chain and psoas major muscle: behind the media! arcuate ligament. .Greater and Lesser splanchnic nerves: corresponding side. . Left phrenic nerve: pierces the left cupola. pierce the crus of the Posterior Abdominal Wall Ps i Starnal origin 7 Hy, : Gostal origin Forainen of Morgagni Fh Vena caval foramen =a ——Esophageal tials Madian arcuate ligaeteaat oe AOC tnabus Gap lor paaas itaj.00 Gramen of Bochklalek oe Lateral arcuate ligament Medial arcuate ligament ; | iH 4 ~ lunborum Lati crus —Frigglit crits The diaphragm (af Sternum Transpyloric plane ——_— 2} Major openings of the diaphragm a Posterior Abdominal Wall roy Arterial supply of the diaphragm: 1. Superior phrenic artery from thoracic aorta. 2. Lower intercostal arteries from thoracic aorta. 3. Inferior phrenic artery from abdominal aorta. 4. Musculophrenic artery from internal thoracic artery. 5. Pericardiophrenic artery from internal thoracic artery. ( Applied anatomy: Diaphragmatic hernia may be one of the following: 7. Hiatus hernia: stomach passes through the oesophageal opening. 2. Hernia of Bockdalek: between the costal & vertebral origins 3. Parasternal hernia of Morgagni: between the sternal & costal origins \ of the diaphragm. r. Caval foramen (transmitting inferior vena caval and right phrenic nerve at T3) yy Esophageal hiatus (transmitting esophagus / and vagal trunks at TL0) Aortic hiatus (transmitting Central tendon) Avcuate ligaments: | Median. | aorta and thoracic duct at TI) | Media] “~~. | ~~ Bi hteral | Quadratus - 4 lumborum muscle ; Psoasmajor | External abdominal | muscle ae Psoas minor muoscde** fT hl Tia cos muscle ransversus | abdominis muscle “Tila crest | | A | Anterior iliac spine - Inguinal Anterior longitudinal lipament Lacanar ligament + _ | eeof ice. |, IWopsoas tendon Lg ae ¥L Lesser trochanter, al - oblique muscle : ; Muscles of the posterior abdominal wall superior iganrent ee el Posterior Abdominal Wall mia. Origin: *The front and lower borders of the transverse processes of all lumbar vertebrae, « The adjacent sides of the lumbar bodies and intervertebral discs. «The tendinous arches bridging over the lumbar vessels. Insertion: The muscle descends along the brim of the pelvis medial to the iliacus where both of them join to form the iliopsoas tendon, it passes deep to the inguinal ligament to enter the thigh to be inserted into the lesser trochanter of the femur. Nerve supply: Branches from lumbar plexus (L2, 3, 4). Action: 1. The main flexor and medial rotator of the thigh. 2. Causes lateral bending of the trunk. 4. Both psoas muscles bend the trunk forward. 4. Lateral rotator of the thigh, only when the neck of the femur is fractured due to change of the axis of rotation. Relations: In the abdomen and pelvis: Anteriorly: «Medial arcuate ligament of the diaphragm. « Kidney and renal vessels. « Ureter. « Gonadal vessels. « Genitofemoral nerve. «Psoas minor "if present”. Posterior Abdominal! ° The 3™ part of duodenum on the right side and 4" part of duodenum on the left side. « End of ileum on the right side and descending colon on the left side. « Inguinal ligament. Posteriorly: « Transverse processes of the lumbar vertebrae. «Lumbar arteries. «Lumbar nerves which form the lumbar plexus are embedded in the posterior part of the muscle. « The medial edge of the quadratus lumborum. Medially: «Sympathetic chain, along its medial margin. * External iliac vessels. « Obturator nerve and «The aorta medial lumbosacral trunk. to the left psoas, while the inferior vena medial to the right psoas. Laterally: - The quadratus lumborum (lateral to its upper part). : The iliacus (lateral to its lower part). « lliohypogastric nerve. - llio-inguinal nerve. «Femoral nerve. « Lateral cutaneous nerve of the thigh. In the thigh: Anteriorly: Femoral artery inside the femoral sheath. Posteriorly: Capsule of the hip joint, separated from it by a bursa. Medially: Pectineus muscle. Laterally: Femoral nerve (between psoas & iliacus). cava is Posterior Abdominal Wall Inferior phrenic veins sili Right testicular OF Ovarian van Abdominal ~ gorta Right external iliac Left external iliac artery and vein artery and vem Right fem oral Left femoral artery and vein artery and vein Relations of psoas major muscle Posterior Abdominal Wall 265° Psoas Fascia: It covers the psoas major muscle and is thickened above to form the medial arcuate ligament. » It is attached medially to the bodies of lumbar vertebrae and intervertebral discs. « Laterally, it blends above with the fascia on lumborum, quadratus while below it is continuous with the fascia iliaca. - T.B. of the spine leads to collection of caseous material between the psoas major muscle and its fascia to form psoas cold abscess which present as abdominal swelling and another swelling in the upper part of the thigh with cross fluctuation in between. Origin: * |liolumbar ligament. ¢ Medial part of the inner lip of iliac crest. Insertion: « Medial 1/2 of the last rib. « By tendinous slips into the tips of transverse processes of the upper four lumbar vertebrae. Nerve supply: By the last thoracic and the upper four lumbar nerves (T12 &L1, 2, 3, 4). Action: 1. Fixes the last rib, so helps the diaphragm to contract during respiration. 2. Lateral flexion (bending) of the vertebral column. more effectively 3. If the two muscles act together, they extend the lumbar part of the vertebral column. | Posterior Abdominal! Vall 16602 Psoas Minor Muscle Origin: From adjoining parts of last thoracic and 1° lumbar vertebrae and intervertebral discs in between. Insertion: The muscle descends in front of the psoas major muscle to be inserted into the iliopectineal eminence. Nerve Supply: From the 1* lumbar nerve. Action: If it is present (60%), it will assist in the flexion of the trunk. lliacus Muscle Origin: From the iliac fossa of the hip bone and passes deep to the inguinal ligament to enter the thigh. Insertion: Lesser trochanter of the femur together with the psoas major muscle. Nerve Supply: Femoral nerve (main trunk), in the abdomen. Action: Flexion of the thigh with psoas major, Posterior Abdominal Wall ee - It extends high up to the back of the neck and below to the sacrum. - It binds the muscles of the back to the sides of the vertebral column. - Inthe lumbar region, it is well farmed and thickened and sometimes called lurmbar fascia and it is composed e Anterior layer: of three layers: It covers the anterior surface of quadratus lumborum muscle; it is thickened above as the lateral arcuate ligament. ¢« It covers the posterior surface of quadratus Middle layer: muscle, and muscle. Medially, fuses with the anterior layer at the it reaches the back lateral lumborum margin of the transverse lumbar vertebrae and separates the quadratus lumborum of this processes of muscle from the sacrospinalis muscle. Posterior layer: Covers the back of the sacrospinalis muscle. Medially, * this layer gains attachment to the spines of vertebrae, while laterally, it _ fuses with the back of the middle layer of the lumbar fascia. The lateral border of the lumbar fascia gives origin to the internal oblique - and transversus abdominis muscles. Psaas major muscle Psoas fascia Quadratus lumborum voy i i i o~ EF i Anterior longitudinal ligament Crus of diaphragm —— Anterior layer Middle layer ——— Postenar longitudinal ligament Posterior layer — Vhoraco-lumbar fascia Thoracolumbar fascia Faint ridge on the front Of transverse process rss Posterior Abdominal Wat [ZR uNNNNNN) The nerves of the posterior abdominal wall include: 1. Lumbar plexus. 2. Lumbar part of sympathetic chain. 3. Autonomic plexuses. 4. Subcostal nerve. - It is formed in the substance of psoas major muscle from the ventral rami of the upper four lumbar nerves. - Itsupplies the psoas major and quadratus lumborum muscles. Branches of lumbar plexus: * iliohypogastric nerve (L,): It emerges on the lateral border of the psoas major, passes downwards and laterally on quadratus lumborum behind the kidney to pierce the transversus abdominis above the iliac crest. It then pierces the internal and external oblique muscles to supply the skin above the inguinal ligament and the lower part of the anterior abdominal about two inches above the medial part of the inguinal ligament. wall It gives lateral cutaneous branch to the skin of the gluteal region. ° [lio-inguinal nerve (L1): It lies below the iliohypogastric nerve and has the same course and relation; however it does not pierce the external oblique muscle, but enters the inguinal canal and passes through the superficial inguinal ring. The ilio-inguinal nerve supplies the lower lateral part of the anterior abdominal wall and the skin of the upper part of the medial side of the thigh as well as part of skin of scrotum in male or labium magus in female. * Lateral cutaneous nerve lateral border of psoas of the thigh (L2 & 3): It emerges from the major below the ilio-inguinal nerve. It crosses the iliacus muscle in the pelvis where it enters the thigh deep to the inguinal ligament just medial to the anterior superior iliac spine. Posterior Abdominal Wall « Femoral lateral nerve border (posterior of psoas division major in the apg ae of L2, 3 & 4): It emerges at the groove between it and iliacus the muscle. it supplies the iliacus in the abdomen and descends under cover of the inguinal ligament lateral to the femoral sheath in the femoral triangle, where it rapidly divides into muscular and cutaneous branches. « Genitofemoral psoas nerve major muscle (L1, where 2): It descends on it crosses obliquely the anterior behind surface of the ureter, lower down it divides into two branches: 1. Genital branch: enters the deep inguina! ring to supply the cremasteric muscle. 2. Femoral branch: enters the femoral sheath lateral to the femoral artery and supplies the skin of the upper part of the front of the thigh just below the inguinal ligament. « Obturator nerve (anterior divisions of the ventral rami of L2,3 & 4): Emerges on the medial side of psoas major at the pelvic brim. It descends on the lateral wall of the pelvis accompanied by the obturator vessels to enter into the obturator canal where it divides anterior and posterior divisions to supply the adductor muscles of the thigh. ALG.: Accessory obturator nerve (L3 & 4): may be present in 30% of people, passes on the medial side of psoas major then enters the thigh above the superior ramus of the pubic bone. It supplies the pectineus muscle and the hip joint. ¢ Lumbosacral with L5 root. trunk (L4 & 5): Formed It descends obturater nerve where on the medial by the lower half of L4 together side of psoas major deep it lies close to ala of the sacrum formation of the sacral plexus. to share to the in the Posterior Abdominal Wall 12" rib Ni Thuesversus Subeostal nm (12) = Tlic = hes : ipo uasiric nerve (14 Ific- ineninialn. Lat. Citaneous no. at thiol £9 7 Femoral n Gonito-¢il (2.3.4) femoral fl Solatic nerve Penviral Terve | } me: Oh uralar nerve (2, 3 44 Nerves of the posterior abdominal wall _ Lumbar Part of Sympatheti Chacin — - The sympathetic chain enters the abdomen behind the medial arcuate ligaments of the diaphragm, one on each side. It passes downwards in a groove between the vertebral column and the medial border of the psoas major muscle. Then it enters the pelvis behind the common iliac vessels. It descends medial to the anterior sacral foramina to end by uniting with the chain of the opposite side in front of coccyx to form the “ganglion impair". - The right chain lies behind the LV.C. while the left chain is on the left side of the aorta (therefore, the left chain is more exposed). Each chain has four lumbar ganglia. Branches: «Rami communicants: 1. The four ganglia give off postganglionic fibers to all lumbar nerves. Posterior Abdominal Wall 2.The 1° and 2”? lumbar nerves send preganglionic fibers ps Orel to the corresponding ganglia. «Lumbar splanchnic nerves: 1. There are four nerves, one from each ganglion. 2. They jain the abdominal autonomic plexuses (coeliac, aortic and hypogastric). « Vascular branches: Surround the aorta and iliac arteries. Coeliac plexus: «lt is present around the coeliac trunk and is composed of two large coeliac ganglia, one on each side of the coeliac artery, the lower part of the coeliac ganglion is partly detached anc is called aorticorenal ganglion. «It is formed by: 1. Sympathetic fibers: from the greater and lesser splanchnic nerves coming from the thoracic sympathetic chain. 2. Parasympathetic fibers: from the vagal branches. * The coeliac plexuses give off secondary plexus around the branches of the coeliac artery as well as the aorta, renal and superior mesenteric arteries. Aortic plexus: «lt covers the aorta between the origins of the two mesenteric arteries. It is formed by: 1. Branches from the coeliac plexus. 2. Branches from the lumbar sympathetic plexus. «It gives off secondary plexuses around the inferior mesenteric, testicular and iliac arteries. Superior hypogastric plexus (Presacral nerve): «It lies just below the bifurcation of the aorta in front of 5 lumbar vertebra and promontory of the sacrum. It is formed by: Posterior Abdominal Wail hace 1. Filaments descending on each side from the aortic plexus. 2. The 3" and 4" lumbar splanchnic nerves. - It divides into right and left divisions which descend into the pelvis to join the inferior hypogastric (pelvic) plexuses that lie one on each side of the rectum and the urinary bladder. Cellac ganglion Prewertebral plexus Superior mesenteric ganglion = Aorticorenal ganglion Celiac plexus Lumbar splanchnic nerves boric Sympathetic trunk and ganglion plexus Inferior mesenteric ganolion Superior hypogastric plexus Inferior hypogastric plexus Autonomic plexuses Posterior Abdominal wat SEQ: 1. 2. 3. 4. 5. Enumerate the single branches of the abdominal aorta. Mention the tributaries of the inferior vena cava. Describe the major openings of the diaphragm. Mention the lymph node groups of the abdomen. Describe the formation and branches of the autonomic plexuses of the abdomen. McQ: 4. The renal arteries arise from the aorta at the level of: a. First lumbar vertebra. b. Second lumbar vertebra. c. Third lumbar vertebra. d. Forth lumbar vertebra. 2. The following represents anastomosis lies in the anterior abdominal wall: between the SVC and IVC a. Azydgos vein. b. Inferior hemiazygos vein. c. The vertebral venous plexus. d. Anastomosis between the superior epigastric and inferior epigasiric veins. 3. The foramen of Bockdalek is: a. The aortic opening of the diaphragm. b. The defect lies between the costal and vertebral diaphragm. c. The defect lies between the costal and sternal diaphragm. d. The esophageal opening of the diaphragm. origins of the origins of the CHAPTER 12 ~\ ILOs By the end of the lectures, the student should be able to: Name the derivatives of the caudal part of the foregut. Describe the development of the esophagus. Determine the development of the stomach and its congenital and its congenital anomalies. Identify the development of the duodenum anomalies. Detect the development of pancreas, possible congenital anomalies. Identify the development liver & gallbladder and the of midgut and the possible congenital anomalies. 1- Esophagus ?- Stomach. 2- Proximal '/> of the duodenum. 3- Liver and gall bladder 4- Pancreas. Development of the esophagus It develops with the respiratory system. Its mucosa is derived from the endoderm of the foregut. The muscular mesoderm. coat is formed by the surrounding splanchnic a Inthe 5" week, the stomach appears as a fusiform dilatation. o Ithas: « Two surfaces: « Two ends: upper (cardiac) and lower (pyloric). e Two borders: a) right and Left (anterior and posterior). lt is connected to the ventral and dorsal body walls by the ventral & dorsal mesoqastria. a The shape and position of stomach « Differential growth: The posterior change due to: border grows faster than the anterior border: e © The posterior border becomes the greater curvature of the stomach. « The anterior border becomes the lesser curvature of the stomach. 90° clockwise rotation around its longitudinal axis resulting in: o The original left surface becomes the anterior surface while the original right surface becomes the posterior surface of the stomach. a Thé ofiginal' left & right vagi become anterior and posterior gastric nerves respectively. a * The dorsal mesogastrium will be pulled to the left forming the lesser sac. The stomach rotates around anterior-posterior axis so that. o The pyloric end moves to the right and upward o Thé cardiac end moves to the left and downward. i) Congenital anomalies of the stomach Congenital hypertrophic pyloric stenosis: there is extreme thickening of the circular smooth muscles of the pyloric sphincter, with consequent narrowing of the lumen of the pylorus. Longitudinal rotation axis Lesser curvature He C i | Greater curvature Cardia Lesser curvature Greater D Greater curvature Pylorus curvature E Dorsal aorta, mental bursa (losser sac} oe ‘omentum Splean — Trarsverse colom Ascending 2 cofon Deseanding eolon Small imbestir Pa CseD od Sigmiald aslon Dy Aiectum Duodenu rm Normal Anatomy r—— Stamach — Pylori stenosis Development of the duodenum The duodenum develops from both the foregut and the midgut: - The first and second part of duodenum up to the opening of common bile duct develop from foregut. - The second part of the duodenum below the opening of common bile duct along with third and fourth part develop from midgut. The developing duodenum forms a forward convex loop that is attached to a The hepatic bud is attached to the ventral wall of the duodenal loop 3 posterior abdominal wall by a mesentery called mesoduodenum. The position of duodenum - Clockwise Rotation changes due to: of the stomach 90° along longitudinal axis rotates the duodenal loop to the Right. - Differential growth of the duodenal walls, so the common bile duct will open into the postero-medial wall of duodenum. - Absorption of the mesoduodenum: = The duodenum » The wall, becomes duodenum and the and right retro-peritoneal except its 1° inch. head of the pancreas surface of the dorsal press against the dorsal body mesoduodenum fuses with the adjacent peritoneum. ." Both layers subsequently disappear, and the duodenum and head of the pancreas become fixed in a retroperitoneal position.During the 2"? month, the lumen of the duodenum is obliterated by proliferation of the cells in its lumen. However, the lumen is recanalized shortly after that. Congenital anomalies of the duodenum Stenosis or atresia of duodenum: duodenum due to incomplete recanalization of the . Bare area of liver, Lesser omentum i Celiac artery Dorsal mesoduodenum # interior mesenteric artery Dorsal mesocolon Umbilical artery Dorsal mesoduodenum Head of {fl pancreas | Pancreas and duodenum in Parietal peritaneu Buodenum Diksted dhuebenuin B retroperitoneal PH eitio a nl Eebited duodenum 4 “ -Somach ew Duedorvat atressin ~ . Dupdexmen tdoorased in sta) Development of the liver and gall bladder The liver primordium appears as an outgrowth from the lower end of the foregut. | The liver bud elongates and penetrates the inferior part of the septum transversum | where it divides into two parts: pars hepatica (cranially) & pars cystica (caudally). Pars Hepatica e It forms the common « Each hepatic duct branches into multiple cords of liver cells. e The hepatic cords will differentiate into: hepatic duct, which divides into right and left hepatic ducts. - Hepatocytes. - The epithelial lining of the intrahepatic part of the biliary system. * Hepatic sinusoids are derived from the two vitelline and the two umbilical veins, which are broken down by the developing hepatic cords. Pars Cystica * It forms a distal dilated part called the gall bladder and its proximal stem forms the cystic dust. e The original stem of the hepatic bud forms the common bile duct. septum transversum Septum transversum will be divided by growth of the liver into: i c Caudal region (ventral mesogastrium): will give falciform, coronary and triangular ligaments. o Central mesenchyme: gives rise to lasser omentum, _ & rise to hematopoietic cells, Kupffer cells, connective tissue cells of the liver. a | and a Cranial region: This will give rise to central tendon of diaphraqm. Size and weight of the liver e By 10" week, the liver is about 10% of the total body weight « At birth, the liver from only 5% of the total body weight. Congenital anomalies 1. Biliary atresia: intrahepatic or extrahepatic. 2. Accessory asymptomatic hepatic ducts & duplication of gall bladder: are common and Bare area OPliver Lasser armentun Borsal mesogastium Tracheobronchial diverticulum Vitalline dict Gallbladder Allartois A Cloacal membran - B Ligaments of liver Distended hepatic duct obliterated Gallbladder & Wy Duodenal Cystic duct aie duct, i Hepatic duct Duplication of gallbladder loop Anomalies of liver Bile duct Development of midgut The midgut begins caudal to the liver bud and extends to the junction of the right °/; and left '/, of the transverse colon in the adult lt relates to the secondary yolk sac by the vitelline duct & with the posterior wall bya mesentery. It elongates to form a U-shaped midline loop which has o Apex: relates to the yolk sac by the vitello-intestinal duct. o Cephalic limb: forms the distal part of duodenum, jejunum and most of the ileum. o Caudal | limb: forms small part of ileum, caecum, appendix, ascending colon and right */; of transverse colon. o Axis is formed by superior mesenteric artery. Physiological umbilical hernia: the intestinal loops leave the abdominal cavity and enter the umbilical cord about the 6"" week. Reduction of physiological umbilical hernia o The herniated intestinal loops nee to return to the abdominal cavity during the 10™ week of development: © oThe factors mesonephric responsible kidney, reduced for caduciion growth of the are: liver, regression and of expansion the of the abdominal cavity. o The loops return to the abdominal cavity in a special order: = The proximal part of jejunum is the first part to enter the abdomen and lies on left side. = The next returning loops gradually lie more to the right = The caecal swelling: o Itis the last to return to the abdomen; o Then it descends it lies below right lobe of liver. into right iliac fossa thus forming ihe right colic flexure and ascending colon. = Later, when the ascending and descending portions of the colon obtain their definitive positions, their mesenteries press against the peritoneum of the posterior abdominal wall i.e. the ascending and descending colons become retroperitoneal. «= Rotation of the intestinal loop = At the same time in which the intestinal loop is elongating, around an axis formed by the superior mesenteric artery. « The rotation takes place anticlockwise for 270°: - 90° during herniation - 180° during the return it rotates Midgut loop = Superior mesenteric anery Liver... Veritral mesentery. Gallbladder se }— Stomach Urmbylieal cord Dorsal aorta Omental bursa ; {laseer sac) i ’ 4 yy: nae omentum i ! Speen =| TRansvareea So4ori Ascending édion —~——] i <a } i | it ~~ ¥ : . . Mi f ot colon a " a | yy Cia D, A E Smal inteetine “—— sigmoid colon Rectum OSES Congenital anomalies of midgut 4- Anomalies of the mesenteries e Mobile caecum: persistence of a portion of the mesocolon. « Incomplete fusion of. the behind the ascending a, mesentery may give rise to retro-colic pockets colon. Body wall defect Omphalocele: due to failure of the bowelto return to the body cavity. Gastroschisis: It is a protrusion of abdéminal contents lateral to umbilicus. Umbilical hernia: the intestine returns to the abdomen during the 10" week and then herniated through imperfectly closed umbilicus. ae Atresia and stenosis of any part of the intestinal 4- subhepatic caecum 5- Abnormal A. and appendix: due to failure of descent of caecum. rotation of the midgut loop lf rotation and loop. occurs caecum abdominal for only 90° anticlockwise: Left sided colon: The colon will be the first parts to return & settle on the left side of the cavity. The later returning intestinal loops will become located to the right side. . Reversed rotation of the intestinal loop: the transverse colon passes behind duodenum. 6- Remnants of the vitelline duct: Normally the vitelline duct disappears The following anomalies may arise from duct remnants: Meckel’s diverticulum: is the persistence of the proximal part of the vitelline duct. If affects 2 % of the population, is typically 2 inches long, is 2 times more likely in males, and typically presents at the age of 2 years. Vitelline cyst: Both ends of the vitelline duct change to fibrous cords while its middle forms a large cyst. Vitelline fistula: the whole vitelline duct remains open connecting channel between the intestine and the umbilicus. forming a direct easiness chisis Superior mesenteric artery [Compressing transverse caton) * Left sided cofon Meckel's | saad i) Vitelline cyst diverticulum if \ i: Umbilicus~y | Vitelline ligament Remnanis af the vitelline duct as Development of hindgut It is the part found in the tail fold extending from left '/; of the transverse colon till cloacal membrane. It gives rise to the left ‘fg of transverse colon, descending colon, left colic flexure, sigmoid colon, rectum, and upper part of the anal canal. The part of hindgut caudal to the origin of allantois is called the cloaca. Cloacal membrane forms the ventral boundary of the cloaca. Development of rectum and upper part of anal canal A transverse ridge (urorectal septum) arises between allantois & hindgut. This septum grows caudally dividing the cloaca into: o An anterior part called the primitive urogenital sinus. o A posterior part called the recto-ana/ canal. lt also divides the cloacal membrane o A'tirogénital‘ membrane o An anal membrane (behind). into: {in front). Development of the lower part of the anal canal a The mesoderm around the anal membrane proliferates to from anal folds. co The anal membrane o The anal membrane then ruptures. lies at the bottom of the proctodeum or anal pit. 20, the anal canal is of double origin o The upper part is endodermal. © The lower part is ectodermal , Cloacal membrane | Aliantois Primitive urogenital sinus Urogenital membrane==. Perineum A Cloaca Urorectal Lnaly Beas ~_4 Anal septum B membrane G Hindgut Anorectal canal Development of hindsut @ Surrou masoderm anal membrane Ectodarm Anal membrane Proclodeum, Upper partof anal canal (ancocerm) Lower partof anal Proctodeum canal ectoderm) Anal membrane Development of the lower part of the anal canal Congenital anomalies of hindgut Congenital megacolon: (Hirschsprung disease): It is due to an absence of parasympathetic ganglia in the bowel wall. Rectourethral and rectovaginal fistulas: may be caused by abnormalities > ae [i formation of the cloaca and/or the urorectal septum. Rectoanal atresia: loss of a seqment of the rectum and anus. Imperforated anus occurs due to failure of the anal membrane to break down. in | 7 j imine { wk, a ives a” Ads Rectourethral fistula Peritoneal cavity | pa Symphysis- Scorotum te Rectoperineal fistula Rectum Rectoanal atresia Congenital anomalies of hindgut Development of the tongue | (1) Muscles of the tongue 1. Most of the tongue muscles are derived from the 2™, 3” and 4" occipital myotomes. 2. Some of the tongue muscles differentiated in situ. (IT) Mucous membrane Anterior 7/, arises from 3 swellings derived from the 1" pharyngeal arches a a One median swelling: tuberculum impar. Two lateral lingual swellings. Posterior ‘/3 develops from the hyobranchial eminence (copula): o The hyobranchial eminence: is formed by mesoderm of the second, third, and part of the fourth arch. s The tissue of the 3™ arch overgrows that of the 2 arch. « The posterior "fg fs separated from the anterior */s by the sulcus terminalis. =» At first the tongue gingival groove is fused with the floor of the pharyngeal appears on either side and frees the tongue gut. Later, linquo- from the floor of the mouth. Nerve supply of the tongue The composite character of the tongue is indicated by its innervation. Hypoglossal nerve (nerve of occipital myotomes). General sensation: lingual of mandibular (nerve of {* arch). 4I5 Taste sensation: Chorda tympani (pretrematic nerve of the 1° arch). General and taste sensation: Posterior | - Glossopharyngeal Y, nerve (nerve of the a arch). - Internal laryngeal of superior laryngeal nerve (nerve of the 4" arch). Congenital 1. Bifid tongue: a rare anomaly anomalies due to failure of fusion of the 2 lingual swellings. i 2. Microglossia: is abnormally small-sized tongue. 4. Macroglossia: is abnormally large-sized tongue. Tongue tie: due to failure of development of the linguo-gingival groove. The frenulum extends to the tip of the tongue preventing its protrusion. Lateral lingual swelling Tuberculum impar Tarminal erminal (1 x Fi f Foramen caecum Copula -+— (hypobranchial. if Epigtottal swelling Body of tongue LT f eaRB Tees sulcus sulcu ‘ee i ‘ ee swellings"): \ fe i? 5 Palatine tonsil / tongue : Epiglotts Tongue tie Macrnolassia | * Root of Laryngeal orifice —,. —=- Arytenoid i i. Mca Go T i 1- The midgut begins with and ends with a. b. 1/2 jejunum; 2/3 transverse colon 1/2 ileum; 2/3 sigmoid colon c. 1/2 jejunum; 2/3 rectum d. 1/2 duodenum; ; 2/3 transverse colon. The first stomach rotation causes the and the and vagal trunks, respectively. a. Left: Right; Superior; Inferior. b. Right: Left; Lateral; Medial c. Left; Right; Lateral; Medial d. Left; Right; Anterior; Posterior. vagus nerves to become Meckel's diverticulum is a congenital connection from the umbilicus via a vitelline ligament to the an of Duedenum mn 1 4 Which a. b. c. d. Jejunum lleum. Transverse colon of the following is NOT a part of the developing pancreas? Dorsal bud Ventral bud Ventral bile duct. Main pancreatic duct The following events in the development of the abdominal cavity are greatly affected by the rapid growth of the liver: a. Urorectal septum formation b. Dorsal mesentery morphogenesis c. Formation of inferior recess of lesser sac d. Herniation of midgut loop Development of the Kidney and Ureter eee A) IN DIFFERENT GONADS 1. Although the sex of the embryois determined at the time of fertilization, it is impossible to know whether the sex gland js an ovary or a testis until the 7") week. 2. Before this time the sex gland is called “the in different gonad”, 3. SOURCES: I, Intermediate mesoderm: (genital or gonadal ridge) “| The genital ridge lies on the medial side of the mesonephros. J It gives the stroma of the gland. if. Coelomic epithelium: It consists of mesothelial cells (which line the coelomic cavity). ‘| Mesothelial penetrate cells overlying the underlying the genital mesoderm ridge forming proliferate and the primitive sex cords of in different gonad. iff, Primordial germ cells: [| They are endecdermal cells which arise from the wall of yolk sac. | They proliferate and migrate along dorsal mesentery of hindgut to reach the genital ridge. [ They have inductive influence on the development of the gonad into ovary or testis. Develapment of the Kidney and Ureter | eee Abnormal urethral orifices. Mucosa of urinary bladder Ureteric opening —§ Genital i‘Mesonephros Primordial germ cells Development of the Kidney and Ureter eva f. The primitive sex cords continue to proliferate and penetrate deep into the medulla forming the testis (medullary) cords. 2. Towards the hilum of the gland, the cords break up forming the tubules of fhe rete testis. 3. Testis cords then lose their connection with the surface epithelium and become separated from the epithelium by tunica albuginea. 4. Testis cords become horse shoe-shaped (seminiferous tubules) and their extremities are continuous with the rete testis. 5, The seminiferous tubules: L Remain solid until puberty when they acquire a lumen. "| Their walls are composed. of 2 kinds of cell: A. Sertoli cells are derived from the surface epithelium of the gland. B. Spermatogonia are derived from primordial germ cells, 6. interstitial cells of Leydig: they are derived from the original mesenchyme of the gonadal ridge and lie between the testis cords. /, Finally, the rete testis becomes continuous with 15— 20 mesonephric tubules which become the efferent ductules of the testis. e Testis develops’in the posterior abdominal wall, but it has to descend to lie in the scrotum, * bcs ie The descent of the testis is guided by a fibrous cord called gubernaculums which extends from the lower pole of the testis till the floor of the scrotal ° pouch. Evagination gubernaculum, e of peritoneal sac (process vaginalis) By accompanies the Factors affecting the descent are © Outgrowth of the extra-abdominal portion of the gubernaculums drags the testis & produces intra-abdominal migration. O Increase in intra-abdominal pressure produces passage through the inguinal canal O Regression of the extra-abdominal portion of the gubernaculums completes movementof the testis into the scrotum. Development of the Kidney and Ureter o ti Tunica egenerating albuginea mesonephric tubule Rete testis——__| cords i “ testis cords __-4~Testis ' cords Excretory F : ‘Tunica 1 Horseshoe - shaped ( ‘aramesonepnric es H | | | ys mesonephric ie ai | - albuginea ‘y.—--—Paramesonephric tubules iaiatr ania (ductuli efferentas duct duct | Mesonephric duct (ductus deferens) B A | Testis (medullary) cords tails prgoseatin vaginalis Oy 7 ovary qubermarculun qubarmaculurn | | | | a \e | \OCe a @ | 1ernains ot round gonent 1 ialis Lune. vaginalis renaine: of ubamacuiurs round Hgorncnt oat neers Descend of the testis & ovary Development of the Kidney and Ureter 296 » Time sequence of the descent ie) 3" month -—-------- reaches the iliac fossa. O a MONEH ----------- traverses the inguinal canal } 0 9° month ----------- descends into the scrotum, | Fate of the processus vaginalis 1. Proximal part --------- obliterated (vestige processus vaginalis) 2. Distal part -------—--- forms the tunica vaginalis. A) ANOMALIES OF FORMATION: na esis: primordial germ cells. improper Kline formation due felter syndrome: to failure of migration (47, XXY): characterized by infertility & gynecomastia. Hermaphrodites a. True hermaphrodites: Both ovarian and testicular patients of are (intersex): tissues are combined and external genitalia predominantly female. b. Pseudo-hermaphrodites: gonads are of testis while external genitalia are of females. B) ANOMALIES OF DESCENT Cryptorchism (undescended testis): O One or both testes fail to descend. © The testis may bear rested at the abdomen or inguinal canal along its normal pathway. Ectopic tesiis: Q The gubernaculum may have accessory slips attached to abnormal sites e.g. Root of the penis, perineum or upper part of the medial side of thigh. C) ANOMALIES OF PROCESSUS VAGINALIS: Congenital hydrocele: persistence of the whole processus vaginalis narrow so the tunica vaginalis filled with peritoneal fluid. Congenital inguinal hernia: Persistence of the whole processus vaginalis wide and loop of intestine herniates into it. Development of the Kidney and Ureter Deep ring af Inguinal canal Diagrams Superficial ring of inguinal canal showing the Ectopic testis possible sites of eryptorchid and ectopic testes. A, Positions af cryptorchid testes, numbered in order of frequency. 8, Usual locations of Congenital hydrocele ectopic testes. I Peritoneal cavity Intestinal loop Obliterated portion __ Intestinal loop of processus vaginalls Guctus-deferane:-—— 3 Tunica vaginalis Unclosed vaginalis Gubernaculum Gubernaculum forimnorediun B of scrotal ligament) Congenital in guinal hernia Scrotum Development of the Kidney and Ureter ae in different stage O Mesenchymal cells originating in the region of the primitive streak migrate around the cloacal membrane to form a pair of cloacal folds. © Cranial fubercle, to the cloacal membrane the folds unite to form the genitaf OQ Caudally the folds are subdivided into: L Urethral folds (genital or urogenital folds) (anteriorly). L Anal folds (posteriorly). O Another pair of elevations (genital swellings) becomes visible on each side of the urethral folds. © The genital tubercle elongates to form the phallus. It pulls the urethral folds so that they form the lateral walls of the urethral groove. QO Fusion of the genita/ (urethra!) foids forms the ventral surface of the penis. © Fusion of the genital swellings forms the scrotum. Development of the Kidney and Urater Genital tubercle Genital tubercle —LUrethral folds Cloacal fold Cloacal membrane Anal fold Glans penis Glaas clitoridiz Urethral Urethral groove orifice Genital fold Farina ae Labial Scretal seoeliinngy sooellingr \P Alnor = Glare penis Glan clireridiz Urethral orifice ites used p t folds Fesribute Labiunr moajus Serotun fedian rave sins Development of external genitalia ee Genital swelling Development of the Kidney and Ureter 3000 O The excretory part of the urinary system develops from three overlapping kidney systems which are formed in a cranial to caudal sequence during intrauterine life. QO These systems are: the pronephros, mesonephros and metanephiras. O They develop from the intermediate mesoderm. M Site: cervical region. \| Structure 1-PRONEPHRIC TUBULES: 7-10 tubules are arranged one caudal to the other. Each tubule has ? ends OQ Mediaf end - It is connected with the coelomic cavity. - It has both internal & external glomeruli O Lateral end: opens in the pronephric duct. 2-PRONEPHRIC DUCT: Extends downwards to open into the cloaca. 1 FATE L! Pronephric tubules: degenerate completely. " Pronephric duct: persists and forms mesonephric duct for the developing mesonephros. | SITE: thoracic and upper lumbar regions. L. STRUCTURE. f- MESONEPHRIC TUBULES: _ 70-80 tubules are arranged one caudal to the other. _ Each tubule'is S-shaped and has 2 ends O Medial end: it is not connected to the coelomic cavity & has only O an internal glomerulus. Lateral end: opens into the mesonephric duct. Segmented intermediate mesodem (pronephiic system) SRS | Development of the Kidney and Ureter Vastigial pronephiic system Vitelline duct Unsegmented intermediate mesoderm Maac- nephric (mesonephiic system) Allantois excretory units Cloaca Mesonephric Mesonephric Ureteric bud Unsegmented mesoderm (metanaphric svstem) A dul a duct Pronephros & mesonephros Glomerulus » Somite - Internal % Dorsal aorla Nephrotame + — aap "| Ho , ryonic “Intraemblom tubule Exiernal a is ~ Endadearmn -Mesonephric Aorta YW, glomerulus : Excretory tubule p rluct hros Dorsal masentery ic . vat? M Gunital riche Masonephiric ricigé coe Pronephric tubules Mesonephric tubules Development of the Kidney and Ureter ie eee | 2- MESONEPHRIC DUCT (WOLLFIAN DUCT) Pies arias 1 | J It is the remaining part of the pronephric duct. . ltextends caudally to open into the cloaca. _ Fate tamale phric Vasa eHerentia arid head of epididymis. at TE DeeEhon __ | Paradidymis (mesonephric remnants). Paroophron Appendix of epididymis (mesonephric|Gardner's duct (lies -_|remnants). beside the vagina). - Body and tail of epididymis. _-Vas deferens, seminal vesicleand ejaculatory . |Ureteric bud and trigoneof urinary bladder. _ C) METANEPHROS (PERMANENT KID| NEY) a oe ae at ieee arises as a diverticulum from the lower end of the A- DEVELOPS FROM 2 SOURCES 1) Ureteric bud O The ureteric bud mesonephric duct. O It grows dorso-cranially penetrating the metanephric cap. © The stalk of ureteric bud becomes the ureter. O The expanded cranial end forms the renal pelvis. © Its cranial end undergoes repeated branching farming successive génerations of collecting tubules: O The first four generations (& resorption) form the majorcalyces. O The second four generations (resorption) form the minorcalyces. O The remaining generations form the collecting tubules. Development of the Kidney and Ureter . Seminal vosicts TE a } : Parageniball \ | LUtriculus Ee be & bests 5 protiakcus Teelis cores E Tuna: x albugines : Dwectue Appendix fpididymis ¥ delerens. Tutsier3——e Mesonephttic: uct Paramesonephric Quctuii clenentes Tubrrcin Derivatives ee Ureler Mhcsonephrac duct Trigorne Formation of the trigone Segmented intermediate mesodenm {pronephrc system) rc if Vestigial fie Vitalline duct Unsagmentad intermediate mesodenn : i Altantoisi . Wy eh i j F lmesonephiic system} Wasa. nephric excretory Units Cloaca Mesonaphric Mesonephric duct du Unsegmented masedann A s [metanephic system) Mesonephros Ureteric bud B & metanephros Development of the Kidney and Ureter ee (derived from the nephrogenic cord in the sacral region). O The metanephnic caps form the renal vesicles, which give rise to the metanephric tubules. © Capillaries «row into proximal end of the tubules and differentiate into glomeruli. O These tubules together with their glomeruli form nephrons. © The proximal end of each nephron forms Bowman's capsule while the distal end opens into a collecting tubule. © Continuous lengthening of the nephron results information of the proximal convoluted tubules, loop of Henleand distal convoluted tubules. O Changes in shape: At first the kidney is lobulated and then it becomes smooth. O Ascent of the kidney: initially, the kidney lies in the pelvic region. Later, it shifts upwards in the abdomen. O Medial rotation: initially the hilum of the kidney faces vemntrally. As the kidney ascends it rofates medially 90°. © Change in the blood supply: As it ascends it changes its blood supply: el - 1 - from common iliac artery. Finally frorn abdominal aorta. Development of the Kidney and Ureter 1- RENAL AGENESIS:; eee. unilateral or bilateral absence of kidney. 2- PELVIC KIDNEY: one kidney may fail fo ascend and remains in the pelvis. 3- HORSE-SHOE KIDNEY: |s due to fusion of the lower poles of the 2 kidneys across the miclline. 4- ACCESSORY RENAL ARTERIES: represent the persistence of embryonic vessels. 3- CONGENITAL POLYCYSTIC KIDNEY: _ It is numerous cysts form. lt may be inherited as autosomal recessive or autosomal dominant disorders. 6- Multicystic dysplastic kidney . Numerous ducts are surrounded by undifferentiated cells. _ Nephrons fail to develop, and the ureteric bud fails to branch, so that the collecting ducts never form. f- Wilms’ fumor is a cancer of the kidneys due to mutations in the WT1 gene. &- Bifid ureter: resulted from early splitting of the ureteric bud. 9- Ectopic Ureter: The ectopic ureler enters the vagina, urethra, or vestibule. wee Development of fhe Kidney and Ureter Frontal view Ascend, & rotation of kidney Kiglanephric issue on Vx. Atherial gland - 4 ng a ephron »-CILESTErE yay Sallecthng fubule Inferior vena cava Renal vesicle a = eer 3 capsule OT Distal cogs. lubyle ei | Glomerulus Distal convoluted tupule \ Glomendus : FE Callesting Bowman's capsule Proximal convoluted i ; Bowman & jubule capeule tubules Ascending and D E descanding.< ° limb ol F Hernla’s loop Development of nephron REFERENCES Anne, M.R.A. and Arthur, F.D. (2013): Grant's Atlas of Human Anatomy. Thirtieth Edition. Lippincott Williams & Wilkins. Drake, R.L.; Vogl, A.W. and Mitchell, A.W.M. (2004): Gray's Anatomy for Students. First Edition. Edinburgh: Churchill Livingstone, Elsevier. Drake, R.L.; Vogl, A.W. and Mitchell, A.W.M. (2015): Gray’s Anatomy for Students. Third Edition. Edinburgh: Churchill Livingstone, Elsevier. Gaballah, F. and Badawy, Z. (1988): Atlas of Anatomy. Netter, F.H. (2010): Netter’s Atlas of Human Anatomy. Fifth Edition. Paulsen, F. and Waschke, J. (2010): Sobotta: Atlas of Human Anatomy. Twenty-third Edition. Munchen: Elsevier. Schuenke, M.; Schulte, E.; Schumacher, U. and Cass, W. (2016): limb, Mosby, Thieme’s Atlas of Anatomy. Third Edition. Singh, V. (2011): Anatomy of the abdomen saunders, Churchill Livingstone, Elsevier. and lower Standring, 5S. (2008): Gray's Anatomy, The Anatomical Basis of Clinical Practice. Fortieth Edition. Elsevier. 10- www.radiologyassisstant.com: Liver segmentation. Maha Mobarak Print Tel: 01001480892 — 01003325874

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