ABDOMEN BY DR. SAMEH DOSS (Ph.D) PROFESSOR OF ANATOMY FACULTY OF MEDICINE, CAIRO UNIVERSITY All Rights Reserved GSI Slay EU Ady 2015 / 1662 1S.B.N.: 978 — 977 — 90 - 2544 -5 Correspondence 01229129090I AMY. ABDOUNNAL WALL a ee | Siructules itis formed of the following layers from outside inwards, | W skin @superficial fascia ()abdominal muscles | (fascia transversalis (S)extraperitoneal falty issue | (6) parietal layer of peritoneum. ens : * itis thin & presents 3 u(pubic hairsy in females the hair is limited to the(pubie region.) in moles. a strip of hairs extends up to the | © the umbilicus: lies in the cantre of the ant- abdominal wall. (The Umbilicus SEES ot ¥ Definition: it is,a depressed wrinkled scar formed by the 56 ion of the stamp of the umbili i ‘separation of timp of the umbilical cord after birth. ¥ Position : it lies in the linea alba in the ant-middle bine at Lhe level of the dise between the Gd 4aBJunbar vertebrae. *N ply sits supplied bfTioy da impo w the level of the umbilicus is called the Water shed line oF the ‘body? that markséthe direction of the-venous & lymphatic olainage ef the ant- abdominal walle Above the level of the umbilicusithe lymph and venous blood pass upwards while below this level they pass dbumwards..» @) the umbilicus is one of the sites of porto-caval anastomosis Cp.81 ). tt (3) anastomosis between sup.s/inf- epigastric arteries occurs at : the level of the umbilicus - S W the post. surface of the umbilicus is the meeting point of 4 peritoneal ligaments: (9 lgamentum tees of liver (obliterated umbilical v-of the embtye)-—— af (median umbilical lig- obliterated uracus of the embryo). et mei unbelief») Ly 5 (5) the umbilicus is the site of attachment of the umbilical cord during Foetal life - | \ A- Skin of abdominal wall(BXFascia_of ant. abdominal wall 2 (1) There is no deep fascia in the GE-abdominal wall. 2) The Superficial fascia differentiates particularly below the umbilicus, into 2 layers: (A)Superficial Fatty layeP Camper's fascia) which is continuous with the superficial iE fascia of the adyoining parts of the body. (B\Deep membranous layer) (Scarpa’s fascia) « x itis well defined below the umbilicus forming a €ontinuous sheet- (lateral to each pubic tubercles ik is attached to the fascia lata of thigh a finger breadth below the inguinal lig (aymedial to pubic tubercle «itis attached lothe pubic arch s tubercle. @)in the median plane it gives a€ubular) likeCenelepSarourd the iia seta) SS Cutaneous nerve supply of ant. abdominal Wal} he skin of the@nterolateral) abdominal wall is supplied segmental by the lat-Sant-Cutaneous branches of the lowers inter DI te subcostal n.¢Tia))ilohypogastric &ikninguinal nerves (Li) @) follows ? (3 nerves (Fred supply the skin eietally§\” fiom the lvl ofthe Xpheil process te tHewmblius. \/~ far by Tosupplies the segment of skin at thdlevel] Thee 8 ©) 3 nerves (Tit 212 &Li) supply the skin “Sagmienitally From the level of the umbilicus to inguinal region)the indscles of the anterdlateral abdominal wall are classified into 2 groups ¢ | ‘Pluscles of the anterolateral abdominal wall | | Wexternal abdominal oblique m. @ internal abdominal oblique mi | @) transversus abdominis m. ink- abd. oblique transversus abd. Goal | emi agra ow organization) the 3 muscles layer of the 3 muscles | layer of the 3muscles Origin | has one site of origin: | has 2 sites of origin: | has 3 sites of origin: ! ¥ ‘ Costal : from the ribs. | (lumbar Fm lunber fascial (0) Costal origin. ilioinguinal sFrom itiac | (2) lumbar origin. PETE CEE crest & inguinal fig - I 8) tlio inguinal origin. e Direction | the 3 muscles have 3oifferent directions (to strengthen the ant-abd- wall). of flores [Fibres aré directed mainly | fibres oo “Fibres are clirected mainly | dormers frtords gmedisly upwards, forwards medially | transversely Ferwards. | the 3 muscles develop 2 broad aponeuroses towards the median plane. These aponearoses help in formation of « sheath for the rectus abdominis m. | then become inserted mainly in the linea alba which is afibrous band in the. i | ant-middleline extending from the xighoid process te the symphysis pubis: ne ree nnn4 External abdominal oblique m: x Origins (costal) : from the outer siirfaces of the lower sibs by 8 fleshy digitations NB: the upper 4 digitations interdligitate with serratus ant-m-while the lower» =» v lak-dorsi Direction of Fibres: most of the fibes. = sun downwards, forwards &medially except: \ aI (@) the upper most Fibres 2 run horizontally Forwards. (b) + lowermost » ° + sun vertically downwards : \ ¥ Insertion: Wby to xiphoid provess, linea alba, pubic crest , pubic Lubercle 8.ant-sup.ilac spine - MeB: the lower border of the oponeutosis extending between the A.S-I-S & pubic tubercle has no bony attachment but is folded backwerds upwards upon itself toform the Inguinal ligament (by Fleshy Fibres «into the ant Y of the outer lip of iliac crest- \ #N: -Supply ‘lower 6 thoracicnerves- + Forticular features: oblique aponeurosis lying gust above &lat-lo pubie crest it is described in detail with the inguinal canal (see page (7 (a) an upper horizontal Free border _——— tb) a posterior vertical Free border. yf / forming the ant- boundary of the lumbar triangle Ag Sesion dors which is bounded posteriorly by latissimus dorsi} muscle x inferiorly by the iliac crest « (c)lower Free border forming the Inguinal ligament-The Inguinal ( Pouparts)figament 5 Definition: isthe thickened lower border of the ext- abd-oblique aponeurosis which is folded backwards supwards upon itself. rAttachments : gf A Inguinal -its ha 44 gives origin to transversus alm ine iece NEEM Fue! “ered en its grooved med-Ie forms the Flor of the inguinal conal. Wer Surface (Convex &dlirected downwards towards the thigh) : it gives attachment to the Faseia lata of the thigh: superficial relations » Rebios: Ne (A)- inside the inguinal canal + Soemat oes A yiterior}y : the ant, wall of the cancl - ~ posteriorly: the post.wall of the canal. ~Superiorly + the roof of the canal - anteriorly : skint fasciad superficial external pudendal a. . ~ posteriorly tendon of aclductor longus + deep ext- puelerdal aCoverings of the spermstic Corel: the spermatic cord h 3 coverings arranged from outside inwards as follows : Wexternal spermatic fasaia (2)Eremasteria muscle & fin (internal spermatic fascia ) Interne! Spermatic fascia : {the innermost Coot) + “itis derived Flom the fascia transversalis&is prolonged over | the spermatic cord at the deep inguinal ring - » Gremasteric muscle & fascia: (thie middle coat) : | derived from the internal abd oblique mais prolonged over the { | cord as it passes below the lower arching fibres of internal abliquen \éxtemal Spermatic fascia : (the outermost coat) + derived from the external oblique aponeurosis Xis prolonged ‘ _ over the cord at the superficial ingusirual ring. 3 | constituents of the spermatic cond: | >) the vas deferens. @pampiniform plexus of veins. es) ~“@) lymphatic vessels. > ti)lesticular a. (br. from the abd-aorta)- =e) artery of vas Chr. from the ink vesical a). 7 (3) Cremasteric a. ( br from the inf epigastric a). _-» (0) Sympathetic nerve Fibres (O3NEFVES 212 Cremusteric n- (genital br ofgenitofomeraln.). ~~*@) ilio inguinal n. (orVestique of the processus vaginalis: ee wane cen Cleat - ibis 0 Abus band representing the obliterated pacessus © a. vaginalis of the embtye ( an embrycine oict kreversing the i | inguinal canal & connecting the peritoneal Cavity above with the scrotal cavity Called! | tunica vaginalis below).~Comment on the Constituents of the Spermatic Cord 24 deep ing-ring - (i) The Vas deferens: et ONG m; » begins: inthe scrotum as a continuation to the tai] \ ; of the epididymis - x ends + in the pelvis by Joining the duct of the seminal vesicle tb» form the eyaculatory duct which opens inlo the prestatic urethra. ¥ Chametersray iis 45 cm- long. (ayitis firm Cord-dike structure having = athick muscular wall & a narrow lumen, »Course arelations: (A) Inthe scrotum: it ascends behind the testis along” : a the med: Side of the epididymis - ®)In| the Inguinal Canal it enters the superficial inguinal ring ,runs among the Constituents of the spermatic Cord (post-in position) then (7) it leaves the spermatic cord at the deepinguiral ring &hooks around the inf-epigastric a. = ~ (c) Inthe pelvis: see pelvis: k (8 (2) Pampiniform plexus of veins — Je \oem ~ itis a plexus formed by several veins that drain the testis 8 c ( epididymis (it forms the main bulk of the spermatic cord). ~ at the deep inguinal ring, the veins of the plexus unite to form the testicular vein. ~ the Rt-testicular y. ends in the inf-vena cava (at acute angle). ~ the Lt » » 4 » Le-renal vein Cat right angle) NB: abnormal dilation ¥ tortuosity of the veins of the plexus is called Yaricecele. Ibis more Common on the Lt-side- i> (3) Lymphatic vessels : ~ they drain the testis &epielidymis.- ~ they accompany the testicular vessels fo the abdomen. ~ they end in the paru-aortic lymph nodes alongside the abdominal aorta - NB = the lnohaties of the scrotum & penis drain inte theTesticular a. : = arises From the abd-aorta opposite \-3- » ~descends on the post-abd-wall ,enters the deep ing. ring Aurunsin the spermatic cord down to the testis. ~it supplies the testis &anastomoses with the cremasteric at) A the artery of the vas - (5) artery of the Vas deferens: = arises from the inf vesical a- (br. of int-iliac a.) inside the pelvis. ~ it accompanies the vas deferens jn the spermatic cord. | - it supplies the vas & the.epididymis- inet ‘ate a: AN og fas — 5) Cremasteric a-: | arises from the inf-epigastrie a. kaccompanies the spermatic aard supplying its Coverings- I () Cremasteric 1-* (genital br. of genitofemoral n-): it supplies the cremasteric m. then taverses the inguinal canal to supply the skin of the ant.¥% of the scrotum. (8) Sympathetic fibres: arise from the renal \ the aortic plexuses & surround the testicular a. toreach the testis - (9) lia inguinal nerve + ~ arises From the lumbar plexus (From L1)- ~ enters the inguinal Canal by piercing its posb- wall- ~ emerges From the superficial ring to supply the skin of the external genttalia- , U0 Vestigue of the processus Vaginalis : see page 23 Neiln ‘5 replaced by ¥ lige | which is derived from the gubernaculum of the foetus-It ends below ky getting attached to the superficial fascia of the labiuirr mapus: As it passes through : the inguinal canal it acquires coverings corresponding to those of the spermatic \ cord but they ae thin &adherent lo its wall. | | renalIE The Scrotum + Definition: it is a cutaneous bag Contairiing the 2 testes, & toe epididymes % the lower parts of the spermatic cords of both shen pt sides. JE corresponds to the labia mayora of females: enn ) + Features : externally, itis divided into Rt- &LE- portions >: by amedian raphé which is continued to te undersurface of | thes penis. DB: the Lt-portion usually hangs lower than the Rt. pertion, Layers of the Scrotum: the scrotal wall is formed of the following layers (From outside inwards) : () Skin brown in colour, thin &rigose (2) dartos muscle:replaces the fatty layer of s-Fascias itis a thin layer of involuntary m-fibres adherent to the skin -[¢ sends an inward seplant itrthe middle line dividing the scrotal Cavity inte 2 compartments for the 2testes. It is supplied by sympathetic fibres &is fesponsible for the rugosity of the overlying skin- (3) Membranous layer of superficial fascia (Colles kascia) () External spermatic fascia. ) cremasteric muscle & Fasc’ (8 internal spermatic Fascia: (7) parietal layer of the tunica Vaginalis-——— *Nerve Supply of the Scrotum: (a the ant-¥3is supplied by L1 through the ilioinguinal 1-8. the genital br: of genitofemoral n- b) the post-2/3 is supplied by $3 through the post. scrotal branches of the perineal n. & the perineal bf of the post-culanecus 11. of the thigh Blood Supply: (y Superficial &deep external pudenda’ arteries ( frots femora a.) + bi @) post-scrotal branches of internal pudendal a. (0. of internal iliac a.)+ @) Cremasteric a-: from inf -sicastric & i Lymphatic drainage: into the superficial inguinal lymph nodes.-The testis 8 sreamaric coKo" Definition: it she male primary sex orgarrtt isa mixed gland proclucing eee secretions ( the sperms): endocrine secretions (testasterone hormene) » Site: itis located in the scrotum where the temperature ~~ js Jess than 37%(which is essential for spermatogenesis Fach testis lies in one scrotal Gompartmed suspended hy the spermatic cord. “ Shape ssize: ibis ovalin shape (compressed from side toside) “WS : ibis 1f"lona . road tiem before backward 83/5 Di Fag ee thick (Fram side to side)» + External feattres: it has 2poles upper slower), 2borders (ant-x post)&zsurfaces (med-Afat)- — the 2poles are convex. & smooth. The upper pole provides attachment tothe spermatic coral- « the ant-border is smooth, Convex covered with tunica vaginalis. ~ the post- border is straight Sreiated lo the epididymis \laterally)x the vas deferens (medially) . ~ the 2 sutfaces are Covered by tunica vaginolis .The post. port of the lat-surface is separated from the eplaidymis by agrove called sinus of epididymis. + Coverings of the testis | 3 special Coats 23 Coals fiom the abd-wall_| 3 cutancous§ subcutancous Coats] | [Wtunica albuginea (Fibrous éapsle}4) internal spermatic fascia |r) memb-layer of superficial Fascia | visceral layer of tunica vaginalis \6) cremasteric musclexfascia (8) dartos muscle parietal » yy on lo external spermaticfascia | |g) Skin The Epididymis the testis has 9 Coverings as follows (from inside outveanels: | [Eis a comma shaped body attached lo the posterolateral aspect «! the testis. | + Structure: itis formed of highly coiled single tube (6meters long) tightly puckered in Fibrous tissue. | + parts» | Whead : the expanded upper end whichis cormected to the upper pole of the testis by efferent. ductules- | body: is the central portion made up of the single coiled tube- | abl } vthe Le-border is Formed by | ay the leFt margin of the greater omentum ° (2) He meeting of the gastrosplenic &lienorenal ligaments at the hilum of spleen Development of the lesser sac tit develops as a pouich (diverticulum which evaginates from the greater sac behind & beyond the stomach as avesult of its rotation. Opening into lesser Sac (epiploic forarnen) Ww) | Definition: it is a vertical slit like passage which . communicates the greater sac & the lesser sac | Sitezit lies behind the RE- Free margin of lesser omentum at the level of Tiz vertebra. + Size : about: 3.em-long (admits 2 Fingers). so Boundaries: enggAntertorly : the Rt-Free margin of | leseremenlutn endaning: W portal vein (2) hepatic a. (3) Common bile duct- \posteriorly + peritoneum covering the inf venta cava. | superiorly: the Caudate process of the caudate labe of the liver. inferiorly : peritoneum covering the Ist inch of duodenum, portal vshepatica- free margin of lesser omemturt “4¢" Clinical importance: (a loop of smalf intestine may herniate through the epiploic F. (internal hernia). (2) haemorrhage from the liver Can be contrefled by putting the index Finger in the epiploic F. & Compressing the hepatic a- Cin the Free margin of the lesser omentum) by the ttumb-Peritoneal Folds 34 ¥ Definition: they are double layers of peritoneum connecting different abd- organs or connecting an organ le the abdominal wall. a ¥ Function: (y they attach organs teeach other er to the abdominal wall - ° 2)» allow Free mobility lo certain abdominal organs » I ©)» act as media for the passage of vessels,nerves & lymphatics to the : suspended organs ¥S ¥ Classification: peritoneal folds are arbitrarily classified into 3 kypes : 7 T-omenta : are peritoneal folds connectingthe Stomach to other organs-They include: fi lesser omentum : between the stomach 8, the liver (page 62 )- @greater omentum: 9» » 9» & transverse colon (page 35)+ (3)gast1o splenic omentum (or lig-): between the stsmach & spleen (see below )- ~! ( IE-Mesenteries: peritoneal folds connecting the mobile Parts of the intestine tothe 7 pest- abdominal wall They include: () the mesentery of the smallintestine (, (page 48 ) (2) transverse mesocolon (p.35) 8) sigmoid mesocolon (p.s4y Gomesoappendix(p5| )- IE- Ligaments: include the rest of the peritoneal folds which connect abd. organs a together or tothe abdominal wall - Lienorenal ligament attachments: it extends between: Ohilum of spleert (2)Front of Lt. ktdney. * Contents : 1 splenic vessels aan 7 ©) Eail of the pancreas. ()extiaperitoneal fatty tissue. autonomic n-fibres@)lympaticsaLNs : ¥Embryolegically: itis a part of dorsal mesogastriim. | Gastrosplenic ig-lomentum)__ i + Attachments: it stretches between: upper part of ‘greater curvature of stomach, (@ the hilum of the'spleen. i ¥Gonlents : ()) short gasric vessels @Lt-gastro-epiploic vessels . ' ) Lymph vessels & lymph-riodes (pancreatico splenic L-Ns)- 4 ) autonomic n- fibres (6) extraperitoneal Fatty tissue + +Embryologically: itis a part of the dorsal mesogastrivm.Greater Omentum 35 uti is a peritoneal fold connecting the stomach to He tr-tolon- iit descends as an apton from the greater curvature. & | of the Stomach te cover the Intestine (separating lt rom the ant-abdominal wall)- mSbructure : itis made up of 4 layers (zant-2pest} | The u layers are usually fused. fegether formiyga thin | Fenestrated membrane containing Variable anounts.of fat. \¥ | +Altachments : /)e | ~theant-Z layers are attached above to the greaker curvature of stomach & the 4st inch of duadenum. They descend for a varlable distance then fold back upon themselves becoming post-2 layers. = thepost-2 layers: ascend infront of the sriall intestine ta reach the transverse colon where pas) they become adherent fo the Font of the tr:colon &tr-mesocolon toreach the ank-border of the D- | bedy of pancreas- s | «Contents: WRE-8, LE-gastroepiploic vessels @)RE-gastroepiploic LNs x lymph vessels t | | @lautonomic nerve Fibres Wextraperitoneal fatty tissue - | i | 2 f | ' } ‘long the greater curvature of stomach . +Functions : ‘Wheat insulator Covering the intestine (2)reservior of Fat @ defensive function : it contains fixed macrophages which canbe mobilized asfree macrophyes: It also moves towards inflamed abd. organs to surround them & prevent the speadet inflammation (policeman of abdomen). Transverse Mesocolon +itis abroad peritoneal fold enclosing the transverse colon Gnits Free margin) &, suspending it to the upper part of ich. He post-abol-wall- ¥ Attachments : its teot is attached to the front of the head. , Athe ant-border of the body of pancreas. ¥ Contents : (t) transverse colon (in the Free margin). @ middle colic vessels & their branches (8) lymphatics & L-Ns- Udautonemic n-fibres —_(5)extraperitoneal fatly Lissue- SSSferitoneal recesses 36 & Definition : these are small pockeks or pouches of peritoneal cavity enclaseal hy small Inconstant: peritoreal lolds- x gites : they commonly occur at the transitional zones between the absorbed & unabsorbed parts of the mesentery Ue yunctional zones between the fixed & mobile parts of the intestine): They are mainly found inrelation t the duodenum, Caecum & sigmoid Color. : Characters they are best observed in the newlyborn 8 frequently become i obliterated in the aduts- i Clinical importance : ~Wwhen they persist in the adult, they become possible sites of internal hernia. i tite peritoneal folds overlying these recesses may be related toblood Vessels Chable b ingury during sutgtcal operations) - Pg ¥ Classification : fetradiod eg) : A) Duodenal recesses: there are recesses related le the tyth part of the cluoclenurm : (ysupduodenal recess : ~ itunder! the sup-dlucdenal fold aes on the Lt:side of upper end of kth part of duedenui (ut levelofl2)- ~it is z cm-deep &its orifice looks downwards. - — its overlying fold is related to the inf. mesenteric vein. N (yin duodenal : — jtunderfies the inf-duodenal fold on the Lt: side of lowerend of ith part of ued. (at evel a itis 3 om- deep &its orifice looks upwards: yh — its overlying fold is not related to vessels. (@ parudluodenal recess: ~-iunderlies the paraduodenal fold onthe Le-side of the wlle 4th part ofduodenum. ~ its orifice looks to the right- fas t = its overlying Fold is related to: nin of Clic artery. a (i) Retroduodenal recess: “ik underlies the 4th & and parts of the duodenum - ibis the largest of all duodenal recesses (8-tocm deep) ies: infront of the abd.aorta. = its orifice looks te the left W &(8) Caecal recesses: there are 3 recesses related to the ileocaecal junction: 37 vaseator fold [Sunliveacaec = lies undlecover of the vasealay fold oF Caecum which extends from the lowermost part of the mesentery of small intestine to the Front of taccum;. ~ the orifice of the recess looks downwards x tothe lt ~ the overlying vascular fold Contains ant-caecal a: (Inferior ileocaecal recess : ies undercover of the bloodless fold of Teves ae from the terminal end of ileum to the front of Caecum ~ the orifice of the recess looks cena s | fothe Lt. (3) Rettocaecal recess : ~ lies behind the Caecum & may extend upwards behind the ascending color. erie ~ this recess lodges the appendix iit 74 of Cases- ~ the orifice of the recess looks downwards + rg 7 q (cyIntersigmoid recess : ig br! Common iliac artery + lets Umbilical Folds [savers ~ lies behind the apex of the V-shaped sigmoid mesocglen Couh Lee - we where the LE-ureler crosses the end of Lt: - AS ~ its orifice looks downwards - | NB: the lesser sac may be regarded as the largest peritoneal recess- at Mey include 5 peritoneal folds {ying on the imer surface of the ant abd. wall & Cowerge towards the umbilicus as follows : Median umbilical Fold’ lies in the middle line behind hinea alba tis raised by the median umbilical lig. (obliterated urachus) which extends from the apex of the urinary bladder to the umbilicus 2) Medial umbilical folds (Rt.& LE) : lying on each side of midline they are raised by the lat-umbitical ligaments (obitented unbiied aa} . which extend from the side of the pelvis to the umbilicus i D>vaiyy (a) Lateral umbilical folds (RE-sLL.) lying lot. to the med folds via Each Fold is raised ky an inf. epigastric a- AStomach anicninieneean Ik is the widest & most distensible part of the G-I-T- it lies obliquely in the left hypochondrim, epigastric “ a.umbilical regions- » Shope: rT wo J-shaped Coommonest shape) tits fong axis is vertical____,\ () Sheer (8 hom (less common) + its long axis ts horizontal NB: the shape of the stomach depends on: (a the degree of its distension: the emply stomach is mare vertical than distended stoma h the body builé + ibis more horizontal in short obese indtvidaals- (©) the phase. of respiration: ibis mote vertical with inspiration (d the posibion of the body : it is more vertical in the standing position distensible organs inean Copaciky is 2 liters in aclult w 2 orifices : cardiac’ lorie: External features: the stomach has Kw 2 borders : lesser ater curve (©) 2 surfaces ¢ anterosuperior &posteroint d) 3 parts’ ¢ fundus body & pyloric po + Sike= 4 Size: the stomach is avery (A) orifices of the. stomach: () Cardiac orifi e or end (the more fixed end) = sites in the upper part of the epigastrium at the Sunction with the sesophagus -It lies behind the L-7th costal esrtilage one inch From the medians ant-abdominal wall- plone & inches deep to th a#relations -anteriorly : Lt-lobe of the liveré ant- gastric. 1 posteriorly: diaphragm 6, post-gastsic a Sphincter it has no tue anatomical sphincter: “The ‘gastro-cesophages! junction closes by a physiological sphincter which on: cn the acute angle ab which the cesophagus Joins the stomach (@ the sphincteric action of the fibres of theRt-crus of diaphragm --. which enelrele the lower end of the oesophagus cathe thick mucesd folds at the lower end of the oesophagus: poloricend transpylorie plandG, \} [acts as a mucosal valve which closes the lumen of the lower end of sesh ae Contraction of the circular muscle fibres in the lower end of the cesephagus | prevents the. regurgitation of the gastric Contents. p Pyloric orifice orend (the less fixed end): | Sites it lies in the transpyloric plane (LU Y% an inch to the | Re-of the median pa ee the junction with the duodenum. | Its position is indicated by: hw creulor groove (pyloric Dicer ell | @ plepyloric v- of Mayo (seen only in the living mach, connecting the Kt-gaskric. V. with the Rt-gastrepiploic v- thickness of the pyloric sphincter. anteriorly : quadrate lobe of liver — posteriorly : neck of pancreas- tit has a true anatomical sphincter (thickening of the circular muscle layer)- ue’ (I) Lesser curvature (Rt-Concave border): JE keri é part. ~ its lowermost part presents a.notch (angular notch) AS so fast (2) Greater Curvature (Lt. Convex border): (|_| =Abits beginning it presents anotch Ccardiac notch) at its junction with the lower end of the oesophagus Its uppermost part constitutes the Fundus. | ~Relations: wit gives atvachment to 3 ligaments (From above downwards): (a) gastrophrenic li tending From the Fundus to the diaphragm. & gastrosplenic lig: exteriding from the upper part of the greater curvature t the hilum of the spleen. © greater omentum: extends from the ower part of the greater curvature- @ikis elated to the RE-8 Lt. gaskreepiploic vessels & the gastroepiploic LNs. which lie parallel to the greater curvature between the 2 layers of the greater omentum.» Parts of the stomach; line. Joining the cardiac orifice to the: greater curvalane GyBodly : extends Frein the level of the Cardiac: notch la axriwaginary line between the angular notch to a. corresponding bulge on the grealer curvalure - pyloric portion : distal lo the imaginary line g Consishs of © "@ PATeFE antrum: the dilated part below the body. & 9 Canal : the distal narrow 'of the stomach . ©)» sphincler :ihe distal end of the stomach. + Surfaces of the stomach : ‘inch WAnterosuy Completely covered by the peritoneum of Ue greater sac bree (@) postervinferior y+ Covered by the periloner of the lesser sac except asiall area (of th close tothe cardinc orifice (bare area of the. slomact) which is not E of th covered by peritoneum Xs reliled lo the Lt-crus of the diaplyagn. a Relations of the Stomach 1-The Fundus: is related to the diaphragms which separates it from the pericardium Sheart a-The Antero-superior surface (ant-relations): ~———__ | ©) diaphragm : related to the upper &L.L-area of ant. surfice_——= separating it From the Lé- pleura 8, lung. 4 tb) Lt-costal margin ; © LE: lobe of liver: related fe a narrow area adjoining | the. lesser curvature - gp @) Ant- abd. wall: related fo the lower 8,Rk- part of theank-surface~ ‘ @ LE. crus of diaphragy Ife sidd (3) LE Suprarenal land LL: kidney ————— (5) Splenic artery ——— transverse.) (6) body of pancreas — Struchwes) (7) Eransverse mesocelon ——~ (3) Lransverse Colon NB? the stomach is separated from A ed the previous structures by the lesser sac-Q» The Pyloric end: i ch’ telated anteriorly to — lobe of the liver. 4 - oy posteriorly f the neck of pancreas & lesser sac - Peritoneal relations of the Stomach : | He stomach is Completely Covered by peritoneum except a small triangular area on the post-surface Close to the Cardiac orifice (bare atea)which is related ta the leFé crus of the chaphragm. 7 igaments of the stomach: ) esser omentum : attached to the lesser curvature of the stomach + the First 1 hSmater omentum : attached lo the Rt. 2/3 of the greaker curvature. of the stomach+ the 18 inch | of the duodenum (see p.35 For details) . > Gastro splenic. lig. or omentum :atbached ls the upper Gastro phrenic lig. :extends upwards from the Findus of ) If oes J the stomach to the ander surface of diaphragm - LL i Blood Supply )) Arterial Supply: derived From the Coeliac. irunk aits branches? gy | arises from the hepatic a- Bike runs along the lower part of lesser curvature 8, anastomoses jLt-gastracpiploic a-: ises From the splenic a- &.suns along the upper part: of the greater curvalure- gastro-epiploic a- ; ia From the gastroduodenal a. (br-of hepatica) i _ ‘along the RE. part of greater curvature s-anastomases with the Lt. gastreepiploica- )) Short gastric arteries: arise from splenic a-&, pass to the Fundus of the stomach. the Le-gasiric a-B-Verious drainage: into portal v.xits eribularies? wht gastr fein into portal ¥.__—_——~-| ic Vv A? Z ORE-gostric v- @LE-gastroepiploic) tin 7 y i 4)shiork gastric vv- } drain inte splenic v- i anys i, ORE gastro epiploic v.: drain inlo Sup. mesenteric ¥. ge c- Lymphatic drainage : ee Lyme (areas) of the Stomach: an imaginary line along the longitudinal oxi, ran of the stomach divides it. intto a -Rt- 2/3 + superiok gasLticares 0 -Lt. 3. ewhielis Tattler subdivided into! @) upper Yo: gastro splenic oreo. Y jor gastric area: ing LNs are. orranged in chains long Ue greater Besser curvatures invelation to the. major’ Buinclade the following groups- Comp! ; +-Sup.gastric Lilts which include: I Sup-gastric area. coeliac L-Ns- | ca paracardiac group axoul exdinc once _ [Coeliac LNs.-Few pass to the hepatic LNs: lus LE-gastric group along Lt gastric.a- suprapyloricqroup above pyloris a» Nerve supply of stomach : autonomic Fibres : (A) Sympathetic fibres ( arise From spinal cord segments From T6 to Tio)? ~ Course : pass wilh greater lanchnic n.—z-relay in Coeliac ganglion»; | fibres reach the a vie gastric Rgustioepipe srleries eee | —Funckion 4) vasomotor @) motor to pyloric sphincter but. inhibitory fo therest oF stomach imusculaure. (a)chieF pathway for pain sensation From stomach. (B)Parasympathelic Fibres (arise from both Vagi): ~ Course :()ant-gastric N- (continuation of LL-Vaqus) supplies the ant. surface of the. stomach down lo the pylorus @ post- gastric n-Ccontinuation of RE. vagus) ” » post. surface of the stomach except the pylorus & gives branches to the Coeliac. plexus. psnolor bo the gastric wall (A)secrelory fo, gastric uice-Small intestine PoSitiosy in the infracolic. compartment. of the qrealer sac _ occupying the Central & lower parts of the abdomen lations : it is Surrounded by the curve of Use large intestine AXcovered anteriorly by greater omentum & the ank- abdominal wall. ynming: at the pyloroducdenal yuncLior. yejunum : Follows the duodenum-Ibis 8 feet.long &forms the proximal 2/5 of the sinalliv'estine. B)Tleum : next te the jerunum-Ib is 12 feet long &lorms : the distal 3/5 of small inestine -Ikends by Joining the Caecum at the ileocaecal valve .—— yee at NB: both jepunum &ileurn have amesentety attaching them to the post-abd-wall - Fis the shortest,widest Xniost Fixed part of the small intestine- ite: in the epigastric xumbilical regions, above.the level of the umbilicus: [~~ Jkis applied to the post-obd-wall against. the upper 3 lunbar vertebra. Shape: C-shaped loop surrounding the head of pancreas Besis:at the pyloricend of the stomach "to the RE-of the median plowe nds» » duodenogeyunal Flexure 1’ tothe Mt-» » » igth xparts : it is 10“long is divided into y. parts : la) JS Gupertor) part: 2% long &lies opposite the 15 L-vertebra- and (descending) » : 3° » acextends jm 14 ls L-3 vertebme- 3nd Chorizontal) » : If» &lies atthe level of 3 vertebra iy uth (ascending) » : 1 » Scascends from Uie level of L3 fo L2 | ir] peritoneal relations: the. jum 15 mostly retroperitoneal and Sixed to the post- ual except the Flewing 2mabile parts’ ean aohne Lo) the proximal 1“ihich is suspended by pesterior relations: med. border of Lt-psads mayor m.— (2) Lt- renal vessels (3) LE- sympathetic chain ——___ dy Lt-gonadal vessels ge A Termination : it ends by curving forwards to form the ee dulodeno-eyunal Flexure on the Le-side of La lysi suspensory muscle of duedenuyn (Lig-of Fitz) itis afibromuscular band which suspends theduodeneyejuntal Flesure- wit arises From the Rt-crus of diaphragm close to the cesophagas ' wit descends behind the pancreas tobe attached tothe post- Coase turk < Dvasone Aesure aspect of the duodencyesunal Flexute & the 30d sth parts ofuod: Ca wit contains striated &smooth muscle fibres galso elastic fibres iF Arterial supply of duodenum : Bi both arteries unin the curved groor = G) sup. pancreatico duodenal a. (br-of. ‘gastroduodenal a.) : @inf » » —-» Abrof sup-mesenteric ) betucen te ded dof panes (3)Branches From hepatic, Rt-gastric, Rt.gastepiploic & supraduedenal arteries. ¥ Venous drainage : into splenic, sup-mesenteric & portal veins. + Lymphatic dbainage: inte pyloric , sup-mesenteric &chepatic: mph nodes: Nerve Si ly s sympathetic nerves from Tg &Tie and the parasymp. nerves From vagi | pass through the ceeliac plexus Byaccompany the arteries tothe duodenum.we not ran sanojef foove| eas the JeJUnum & eum a7 marmerou's circular fold of mucasa Sees . —~ Feweirculat folds of mucosa ith ito peyer’s patches a Peyer's patch inthe >. simple compl eX arterial ereades | dawalle | asrrow lumen + about 8 feet long ie aboul Z feat long: lvsite:tends tole more jn the umbilical region | » Lerls tolie more inthe fypegastrium- b+ Lumen > wider than ileum. #narrower thon yesunum- beWall: thicker having bricker muscasa (ducts x thin wall ( having thinner mucasa and “active absorption) &, thicker musculosa (due & | musculosa) becouse digestion &absorption | active peristalsis). ave. less active in the ileum than yezunum ytircular folds of | the tutes are mere numero. | ¥ the mucosa Contains few circular folds. ‘e Payers patches (aggregation of lymphoid ‘may Peyer$ patches in the submucosa along fallicles in the shibmucosa): are absent the ontimesenteric border of jlewrt- the. -Jefunal arteries anastomese together % the {es form 3 or & oreven & forming one or 2 arches (simple arterialarcades)| "ches in the mesentery of Meum Complicated inthe mesentery of the yerunu- arterial arcades). gi ¥ the “yepunal mesentery contains less fat » the mesentery of ileum Contains dense allowing light lo pass in the spaces between fot which masks the arteries (wo windows). | arteries (windows of mesentery). +Aboperation, the serunal walt & felt as » At operation the ileal wall is felt as single d layersMesentery of the Small intestine 48+C " duoclenoyepunal flexure #* Definition: itis a peritoneal Fold enclosing the See part of the smal} ae (geguru ileus) & connecting it to the post. abdorminal wal | +ghape » fan-shaped fold having broad free border s narrow attached border, ithe fee berdersis 6 meters 2ofectdlong encloses Hre yesuvnum ileum. a (Rook of mesentery): 6" long 8 g/away fromm the free border ibis attached lo the post-abdominal wall extending from thedduodeneyeyunal fle rH onthe Lt. side of 2) to the fleocaecal unction (above the RE- sacroiliac joint y. pe _ its attachment follow a curved Course withits Concavity directed tothe Rt-side-| the mek Crosses 6 structures on the post-abd- wal) (2,parts of duodenun)@ | a. large vessels & Ziuiscles) ¢ pé | ty the 4th part of duodenum. the ard pare of ducdenum. @) the abdeminal aorta - de) the inferior vena Cava (LV-C)- * Oy) the Respsoas muyor m.wvith strackures on ite Rt-useter, Re-gonadal vessels &-RE ” genitefemoral 1.) li Fe aie, SEContents of the mesentery: 49 re ) superior mesenteric a-&its branches ~~ = cit runs downwards & to the RE-in the wot of mesentery arches (arcades) g | Rts side of the sup.mesenteric artery. ~ receives tributaries Corresponding to the branches of the sup.mesenteric a ~ itends by joining the Splenic veint (oformportaly. tly (a) simall lymph nodes near the intestine in the frre border- (by medium-sized L-N fn the middle of the mesentery © large L-Ns sie along the sup. mesenteric vessels these nodes are Connected by lymph vessels called lacteals (carry white milk-like lymph loaded with absorbed fart caffed chyle from the simall intestine). tine der (6) Extraperitoneal fatty Lissue- ish Tleocaecal Valve ley, Hels the valve which guards the opening of the lew into the Caecum. ¥ site & surface anatomy : it lies in RE-iliac Fossa at the point of |) | Junction between the Rt-lat-vertical plane & the itertubercular plane. eet ¥ Structure: it has 2 lips (upper glower)&,2 Frenula (Rt-8LE)= ‘ _— horizontal <es at the ileo colic sunction « 3 Concave Slonger, lying at the ileo coecal yunction- the RE-&LE-Frenula are formed by fusion of the lips at the ends of the apearture + Functlon :itregulates the passage of ileal Contents into the Caecum %, prevents reflux From ‘caecum te ileum. ep.) + Mechanism: it closes actively by symp. stimulation & passively by distension of the Caecum.acculations — rewire — i q ) I, » Beginning: it begins at the ileccaecal valve iy the Kt-illac fossa- ri Termination + at the anal orifice + | 2 Length 2 5 feet (t-smeters) long: 3 ¥ por£S ¢ 4) Caecum s appendix (2) ascending colon (3)Rt colic hepatic) Flesure) Z (4) bransverse colon (5) Le-colic (splenic) Flexure (6) descending colon. (7) pelvic ¢sigmoid) colon (8) Rectum Sanal canal. \ Differences between the lates small intestine: ae the targe intestine is charecterized by the following 3 features = | w) Appendices epiploicae: are small peritoneal sacs Filled with fat scattered over I 7 the surface of large intestine (except appendix, caecum & rectum) « i (2) Taenia Coli : the longitudinal muscle fibres of the large intestine are grouped into, y longitudinal bands starting at the base of the appentdix-They ate arranged as ¥ one ant: & 2 post-bands int both ascending adescending colon In the transverse colon they are 2ant-Bone post In the appendix srectum they are absent ; (@Sacculations (haustrations)* the length of the taenia coliis shorter than the |. the true length of the large intestine causing puckering of its wall- E : NB: the previous 3 characters ore. absent in the small intestine - :Caecum ; 51 + Site: in the RE -iliac fossa above the lat-/2 of the inguinal ligoment: j 2 @ triangular areain the Rt-iliac fossa bounded by: Wy intertubercular plane. rabove 7 Cp lat-Ya of the inguinal lig. > below (@Rt-lateral vertical plane; medially wprShape a size : « blind pouch 3*long (closed below xopen above). Communications: () above : itis Continuous-with ascending colon. : @ medially : » communicates with terminal part oF ileum via ileocaecal valve- : Gppesteromedially the appendix opensinleit about below » Peritoneal Covering :itis usually completely Covered with peritoneum (thus itis a mobile organ)- his related fo 3 peritoneal recesses (see page 37)- Relations (y anb- abdominal wall ——_—| & T-Anterior| ly | el | % Cap p ae — ibis accompanied by’ apperdicular V-whic f drains into Supmesenteric ¥- oe Wy Lymphatic drainage: copper (9 in Hemsaped LID See ee perio in dtailioolic LANs alongside ileacalic. ortepy es ps din ine ica x Nerve Su; Wy Sympathetic : from Tio segment via. the sup-mesenteric plexus. | wee nee < asympalheic + Front the Vagus 11+ Applied anatomy : (inflammation of appendix (appendicitis) is Common because: itis the narrowest part of the qu achas a blind end Uhus liable to obstruction « G)its submucosa is rich in lymphoid Lissue (Uus lable to infection). @) necrosis rupture ofthe. inflosed appendix is common becouse it has asingle artery (appendicular a.) which anay become thrombosed by the inflammation. F (p pain of the inflamed appendix is referred fo tre umbilicus because both are supplied by Tos (4) the 3 taenia. Col of the Caecum converge towards the. bose of epperdix (o. lardmark for identification of the appendix al surgical operations)+Ascending colon Site: inthe RE- lumbar region (extending from the ___ ileacaecal valve. to the. Rt- Colic Flexure). ie + about 64(15 cm) long: Taenia Coli: one anterior & 2 posterior. Peritoneum : Govers the Front &,sides only and, forming : the Rt -medial % Ré- lateral paracolic, guiters (see p.31) * Relations pe ~ Anteriorly laterally: &) anterior abdominal wall — (@ RE. border of greater omentum 3) coils of ileum — U-Medially : coils of ileum: Bt Posteriorly sit les the following structures (From above downwards);/ Rt | (lower lateral part of Rt. kidney —— Ken @)origin of transversus abdominis muscle (@)quadratus lumborum muscle Brelated nerves < lliohypogastric Sitioinguinal ‘PIS’ Fal aif Jo Wiliac crest iliolumbar ligament — Wy @iliacus muscle- ) @lateral cutaneoun n-of thigh —————-E 9 i being Convex downwards reaching the umbilical region. Begins tin the RE. hypochondrium, following the Rt-colic Flexure: ( inds:» » Lt. hypochondriumt by becoming the LE- colic Flexure ( cin 18-20 inches long. ation Qetig. Coli: 2anterior Xone posterior. itoneum : it is Completely covered with peritoneum except the Rt.2? where ibis adherent: lo the 2nd part of duodenum schead of pancreas It has a transverse mesocoln (see p.3 5).Relations of transverse colon i L-Antero-superiorly : (From right to eft): i © Right. lobe of liver-— @ gall bladder: (9 greater curvature of stomach @) greater omentum——— IE posteriorly :« From right to tefl): I (second part. of duodenum I (head of pancreas (3) duodenoyeyunal Flexure 8coils of yeyuniumm g-Inferiorly 7 coils of small intestine—>- f ¥Arterial Supply: middle colic a- 8 ascending br-of upper left colic a i Iz: ee eS _ in the JE-hypochondrium in cont with lat-end of spleen. ties ata higher level (L1) ymore dist From middle line 8. more deep. asharp flexure forming acute ang attached lo the diaphragm via phe colic thg- below the Rt-lobe of liver- ties at alower level (12), more clos to middle line wmore superficial.4 5S Right colic (hepatic) Flexure_| Left: Colic (Splenic) Flexare Wantero-superiorly :right lobe | (0) antero-superiorly : spleen 2/ of liver (colic impression)- tail of pancreas - 2) poslero-inferiorly -right Kidney | (2) pastero-inferiorly: left: kidney Adio 1 LE Kidete. japhregn lo) medially : 204 part of duodenum (3) medially RL-Colic a- Site: in the LE- lumbar xLt- iliac regions, descending from the .£.Colic Flexue above to the LE-border oF pelvic brinr below where it ends by becoming the sigmoid (pelvicitolon [Size 1o-127long (about double the length of ascenching colon — but having anarrower lumen). briloneum : Covers the front &sides only (like ascending colon) & Forming the . Lé-medial & Lé-lateral paracolic gutters (see p.3))- Relations fAnteriorly & laterally :u) anterior abdominal wall “— Q@)LE-border of greater omentun (2) Coils of small intestine. IMedial relations: coils of small intestine- tit descends on the Following structures tunsversus lominis m- | @ Lat. cutaneous n-ef thigh (b)femoral n- le) Lt-Psoas mayor muscle (@ ht-gonadal vessels tat-cut-n. pbs Bsoas mayor muscle o LE Senifeteral it pad a y structures infront of it << (cy pbexternal iliac a-— ;N-B:0 the ant-relations of the descending colon are. like. these of the ascersding Colah, Ov post » vp » DDD Dp BB BD »e but more extensive above &below- ’ #Arterial Supply :upper & lower left colic arteries: pelvic (sigmoid) colon Site: in the Lt.iliac fossa a,inthe pelvic cavity: : S-shaped - ¥Size : about 16 inches long- Begins :infront of external iliac. a- atthe left’ border of pelvic brim 2’above the inguinal lig. ¥ a5 a continuation of the descending Colon- wgnds opposite the 3rd sacral piece by bea~wing the recta. ¥* Relations * E-Superiorly & to tre right: JL-Posteriorly : | ji ¢ w sacrum wstructures infront oF if 4 (piriformis ssacral plexus _ _ (2 Lb.urecer (3) L- internal iliac vessels| TE onthe left side {2 oils of ile differs accord! 1g fo the sex + (uterus inthe Female—\ in both male &female. & el ud -t TS NE ¥ Blood Supply: Lower left colic (sigmoid) arteries- # Peritoneal covering: the pelvic colon is Completely covered by peritoneum iz lof &has a mesentery Called pelvic mesocolon Connecting it to the posterior abdominal wall (see page $7).| Colon bo the upper part of the post. wall of the pelvis- Shope s inverted ¥-shaped. having 2 limbs: (ay lat. limb (ascending). ©) med. limb (descending). Attachments: @)lab-Timb: attached to the med.side of Lt- ext.iliac along line starting 2%above the inguinal tig. & ascending upwards to the point of bifurcation of the Lt. Common iliac a- _ (hymed-limb: attached to the Front of sacrum till the 34d sacral piece- © the apex of the Inverted V-is attached infront: of the LE. ureter. Contents of the pelvic mesocolon: W sigmoid (pelvic) colon in the Free margin. @) sigmoid (lower Lt-tolic) a-in the med. links. (3) suprectal vessels in the med- limb. G) sympathetic Fibres (around the arteries). f Wextmperitoneal Fatty tissue. Blood Supply of the Colon 1) The Caecum, ascending cal colon & | RL-2/3 of transverse Colon: are supplied ly the Sup mesenteric a. through is Heocaic,RL-colc S middle colic branches (see page 80): Venous dainage bytorespending veins. bain ng into Sup. mesent (pe i E15 formed hy anastomosis of ileacolic, Ré-Colicssmiddle tolic, upper Lt-Colic. S sigmoid aa. | Straight branches Called Vasa tecla arise From the te marginal ato supply the colott. F Lymphatic drainage of the Colon: the bmmphatics of le colon pass ough groups ont He wall of the Colon (2) pai along inner border of colon. Ns along the Hunks of the preaortic 1:Ns)-{_Liver_] # Site: in the upper part of the abdominal Cavity nag, the Rt-hypockondrium,epigastrium aextending to the lefE hypochondrium « ¥Size ‘itis the largest organin the body It is Yoo of body weight of the adull: (about 1-5 kg)- ¥Surface anatomy ; eur Aapyxopru-qy B Ba eroumppi sn Z @ | The Upper border : represented ky a line soining the following points: ta point on the tL-5th intercostal space ab the Lt-lat-vertical plane. I @apoint at the xiphistermal junckion . | (Sa point on the RE-5th rib on the Re- lat-vertical plane. t 0 a point on the Rt-7ih rib in the midayillary line- The lower border: is marked by joining the following points : W point on the Lt-5th intercostal space in the. Li-lak-vertical plane- | @ point on the Lt-Costal margin ab the tip of the Lt BL castal carkiluge- @point ak Yye transpyloric plane in the middle line - : & points 1c below costal mesyin in the Rt-lat-vertical gRb mid axilaty lise t She right border :sepresented by a line slighlly cones tothe right soning 2 points :| i ()apoint on the RE- 7th rib at the midaxillary line - e@Yapoint on the RE Wi rib» » ons Iight. BD ape sit is wedge-shaped wilh its bose directed to the ri Posts Surface faces :it has 5 surfaces: RE-lat-surface (buse):quadrilaleral-Liy,7%, 4 SUP» Surfacc.c, s Why 7X qm OY @superior surface :oblong fy an eeae wees @anterior surface + briangular. 8B" pee surly O)inkerior surface: irregular Sa h (5)Posterior surface : irregular. %, ens L-Coudate fohe:is the part on the posb-surface lying is between :(@ groove for the I-V.C : bo the right } (Fissure fer ligarnentaim venosum: tothe left. ZN (Oporta hepatis : below. /, the caudale lobe hus 2. processes : (a) papillary process (b) rocess Connecting it with the rest of the RE-lobe forming the post: hp of the porta heputis separates the portal vein From the IV.C-Tt also forms the upper boundary ofepiploic F- | 1-quadrate lobe is the part on the inf-surface lying between: i (a fossa. for gall bladder : to the right - (b) fissure for higamentuny teres : Lo the left © porta hepatis :above - | & hf voreck the liver :below- | NB: both caudate x quadrate lobe. belong morphologically to Une. Rl-lobe but structurally Urey are. parts of | the left lobe. (see. page. 60B-Surgical (Structural) lobes: «on the basis of intrahepatic distribution of hepatic ct, portal Yew, biliary ducts, the liver is divided into 2 nearly equal lobes (RE-3, Lt) by an antero-posterior plane. <<. Passing through the.gall bladder fossa & glove for Fey-c- ~ the surpical RE-lobe is Further divided into -—{ @ Ant-segment- each of which is subelivides! &) post-seginent J into sup. x inf-subsegments~ ~ the surgical Lb-lobe is also divided into 2:| (a) fat-segment hich j A ; : med segment Set ihe spoiled VR: babe Relations of the liver E- Superior Surface: is related to the diaphragin separating it From ; (y bases of both lungs & pleurae (oneither side) 2) pericardium aheart in the middle): I-Right: lateral Surface: isrelated lo the diaphragm separating it from: Uy base of the right jung 7 (2) Costo-diaphragmatic recess of Rt-pleura @) ribs of the RE-side (From 7 be Wm TL-Anterior Surface : gives attachment to falcilorsn liq. is related to? w) diaphragm, separating this suriace From Rt- Costo- @ the costal margins (3) the anterior abdominal wall (in the middle part: between the 2.costal margins) japhragmalic recess of pleut :features of post-surlace of liver groove for oesophagus Fissure for F lig. venosum [Y papillary process Posterior Surface : presents the following features (om Lt: tat): (y oesophageal groove : on the post-aspect of Lt: fobe close lo Fissure For ligamentum venosuin &is related to the abdorninal part of oesophagus. fissure for ligamentum Veriosum: lodges. the lig venosum (obliterated ductus venosus of the Foelus) &qives attachment lo the lesser omentum. (Coudale lobe trelated to the upper recess of the lesser sac 8 the: diaphragm separting it. from the descending thoracic aorta- | (grove for the LV-G tit lodges the upper part of the LV-C IL Show's 2-3 openings for the hepatic veins in its upper part N-B occasionally, the groove is bridged over by part of liver tissue, called pons hepatis, transforming it into a tunnel. (6) the bare area: itis « triangular area devoid of peritoneal Covering &is directly related to the diaphragin x.RE-suprarcnal g land. WO Ibis bounded by: (ay the groove for -V.C~~ - ~~ => + ~~~ tablets forming ts base. y ; (bythe upper layer of coronary lig --~-- above - | ©» lower» » 9 y---~cbelows pl (dythe apex. sis Formed by the meeting of the layers of the coronary lig-on the RE-side lo form the righ triangular lig- seFissure For lig-teres 62 CC v-Inferior (visceral) Surface of the liver : _ itis directed downwards, to the Lt & Slightly backwards. Itincludes : Inf. Surface of the 1t- lobe is related to : Ff this surface (gastric impression). (Stomach :related to the greater part ol @lesser omentum :relaled to an elevation Called tuber omentale between the gastric impression & the Fissure for ligamesLun teres. N.B:< tuber omental of liver is related lo the arit-surface_of lesser omentum. 2» » pancreas» » » » pos » 7 # SHE Iv.) - (8) Fissure for ligamentum teres: lodges the lig. teres (obliterated Mumba (CGuadrate lobe : es tothe RE-of Fissure for lig-teres dis related to: (@lesser omentum. __. : posterosuperiorly- dy» pyloroduodenal gunction—: int the middle - @lransverse colon ___: anlero-inferiorly - (p) Gall badder fossa: isrelated to the anlerosuperior surface of gall bladder (Plithesurtace of Rt-lobe,to the RE- side of gall bladder fossais related to + (upper portion of 21d part of duodenuin: lat-to theneck of gall bladder. @RE-Colic Flexure.:in Hie-ants park of the inf-surface,Clhse fo the inf-border of liver front of Ri-Kidney behind the duodenal 8 colic impressions -oO Porta hepatis Chilum of the liver):— ¥Sile:ibis a deep transverse slit 2”long on the post-part of inf-surface of liver. _ ¥Boundaries: | Wposteriorly : caudate process of Caudate lobe. | wanteriorly :quadrate lobe of hiver- 7ZP | @to the LE: : post-end of Fissure for ligamentunh teres | @b the Rt: : post-end of the gall bladder fossa’ t ¥Contents (structures passing through it) + © portal v-& ils 2 branches (REX LL)? posteriorly | hepatic a-gits 2branchescs » »):anlerior &lo the Lt | @ythe 2 hepatic ducts uniting to form the Common hepatic duct - P anterior & bo the RE- EW) hepatic plexus of autonomic nerves raround the hepatic a-tils branches - L (s)lymphatic vessels & 2-3 hepatic L-Ns & amount of Fal: Peritoneal Covering a.connections of the liver |» The liver is completely covered with peritoneum except the following bare areas”: (the bare area. onthe post-surface (2) fossa for gall bladder. @gioveforIVln» » » UW bottom of the porta hepatis- (5) bottom of fissure for lig- venosum - @boltomof fissure for ligamentum teres _ Fhe liver gives attachment to 5 peritoneal folds as follows: | L-Falciform ligament : phrag | *Shape :ibis a sickle- shaped Fold of peritoneum connecting the pap dhaphragm tant abd. wall. IL sepresents the ant-part of lie vents mesogastrium of the embryo- | Borders yattachments. it has 3 margins: | lgpvex margin: attached to the under surfae of dinphiager) | Rimer surface of ‘ant-abd. wall (alittle to the Rt of middle fa Free margin endesing lig. tores Fe —umbiews fine) down to the umbilicus. by) Concave margin: is attached to the upper sant-surkaces : _ of liver down lo ils inferior boraer. cjFree margin rextends From the umbilicis to the ant-end inf. border of the liver: of Fissure for ligeteres at the.N.8: higamentum teres + is Layers of the falciform lige : (a) Ri-layer: continuous with the peritoneum of Rk of liver including the upper layer of the Coronary lig: ft © L-layer : Continuous with the peritoneum of LE. ff lobe of liver including the ant-layer of Lt-A.lig- wpratthe free margin of the Falciforsn hig-Use two layers are conbinucus with eaclrother,enclosing fhe round lig-of the liver Cigamentwn beres} ti i ; Contents of faleiform lig < Right triariqular ligament, :-— : : the Reend of the bare area of liver to Ibis a peritoneal fold extending from : the under surface of the diaphragm Ibis formed by he meeting of the 2 layers | of the. Coronary ligament:- 2 obliterated Vascular ligaments are attached fo the liver: tum teres: obliterated LE-umbilical vein (See p.64 for its attachments): is Fo Ligament(2) Ligamentum venosumn: represents the obliterated ductus venosus of the embryo 6 St extends from the Lt-branch of portal y. lo the I-V-C lies in the Fissure for lig vertosum x Fixation of the liver: stability of the liver in ils positiondepends on: we () the attachment of the hepatic veins emerging from the liver to the fined TV-C- a peritoneal ligaments attaching the liver to the diaphragm & abdominal walls- f @) the positive intre-abdominal pressure &-the pressure of the surrounding organs. : Nerve Supply of the liver: the liver receives nerve supply From the hepatic plexus Containing (5) WSympathetic fibres : derived from the Coeliac plexus - ‘ @)parasympathetic Fibres: From the ant: post. vagal trunks - bw NB: the hepatic plexus runs around lhe hepatic artery Some. nerve fibres also reach the. liver via its various peritoneal ligament s- | 4+ Blood supply of the liver : cotal 386 fe ~ itis 707. from portal V-2only 30% From hepatica. [fj = blood of both vessels is mixed in the liver sinusoids —>¢ B15 wthe blood is collected From each hepatic lobule by a central Vi ~the central Veins unite to form 2-3 hepatic Veins which open into the I-V.C- st Testis ad br-of portal v- brief hepatica: ¥ Lymphatic drainage: superficial lymphatics :run on the surface 7 7 ee beneath the peritoneum: ~ the liver has 2 sets of lymphatics“) deep lymphatics: ran in the par ynchyma. “lymphatics of boll ses pass through the follwing routes: “9 Herat ee: C bff ediaatinal LNs dy Lymphatics of the past-part-of the liver: — mast of them follow the IVC upwards toend it mediastinal L-Ns inthe thorax 6) some lymphatics pass lo phrenic LNs then P/N porta to the Coeliac group of LNs | yy hepalis (ay Lymphatics of bre ant-Binf- aspect of the liver: pass fo 2-1 LNs in the porta hepatis then Follow hepatic artéfy toend in coeliac LNs (few lymphatics From post-surface of Le-lobe end in left gastric L-Ns~ Wr» » central part of ant-surface ran along falciform tig-->- parasternal or” » pass along ligamentust teres to communicate with lymphatics around untilEXTRA-HEPATIC BILIARY PASSAGES 67 cExcrelory apparatus of Uhe liver) From Lt lobe of liver. = A » Relobe of liver A 8 ieee Comirion hepatic duct : — feimed by the union of RE-LL-hepatic duct s- gall bladder x its Cystic duct (5) Common bile duct, -— - Formed by the union of common hepatic acystic ducts. gends by yoining the pancreatic duct to form ampulla of Vater : L ubich opens iato Uke posteromedial aspect of 2nd part of duodenum: *¢ -panereatic duct: € hape: pear-shaped- i tgall blader fossa on the inf. surface of Rt. lobe of liver-attached fait by loose. CT & ky small veins passing from gall bladder to the liver)- My Size: 7-10 cm-long &3cm-broad (at its widest part) xabout 30-50 a in Capacity. rele ti consists of fundus, bodyaneck- (A) fundus zis the expanded loverend which projects beyond the inf. border of theliver. - Relations = anteriorly: ant-abdominal wall below tip of 9¢4 castal Cartilage q posteriorly: Lransverse Colon. (©)Bodly: in contack with G-B- fossa of liver is Coverd by peritoneum inferiorly. Relations = anterosuperiorly : liver. Relations ter -polon a st partof ducdenum. Neck itis the narrow upperend of 6-B which is Continuous with the cystic duct- wits posteromed-wall is dilated lo form Hartmann ‘pouch. liver ,with cystic artery inbetween end of {st part: of duodenum ~ Relations «common hepatic duct— (orGystic duct : (duct of te gall bladder): >-——— ar wikis $-shaped duct about: 14“long , Continuous with the neck of gall bladder. 8 ~itrans downward, backwards &to the left: Cnaking 5-shaped bend with theneck) ~itends by joining the Common hepatic duct: al an acute angle ts form Ue common bile duct below the Rt-end of the porta.hepatis- mits mucous membrane projects into the lumen forming a.spiral ridge. called “spiral Valve. of Heister?> ——__—_———— sArterial Supply of gall bladder : Cystic arlery: —— ————= arises from Rt-br.of hepatic a- & passes in the A of ( Callots. (between cystic ducts Rll-D-, ¢-H40 ainF surface of liver). iy a Vents cleminage cystic wins: open cliecty Into liver 8 x erve Su ly: ‘s0lso in Hie RE-branch of portal vein- Se = sensory + Rt-phrenic n= C3,4,5 (pail referred lo Rtshouldey io! apices yup. Rt- vagus ¢ pain vis vagus is elevred lo stoniach) REP cu E T7-9 by greater splanchnic (pain via symp.is: referred lo ink-atigle of scapula). mp. ylymphatic drainage into cystic hepatic L-Ns- sSurface anatomy of the fundus oF gall bladder :it corresponds to: (ya point at the tp of the Rt- gli costal cartilnge- athe unctional point: of the Rt-costal margin with the transpyloric plane— » linea senilunaris—] >" gy » cen eww (the fat-edge of the RL-reckus abdominis muscle)- Peritoneal Covering of gall bladder: Gy the fundus: is completely Covered with peritoneur tothe body its postero-inferior surface Bsides are Covered wile its anterosuperior surface is bar (aytheneck:» # ” ope kh om aw e ® : -Hepatic ducts : ~ Aright wa left hepalic duct draia the bile from the RE-B-Ld- lobes of Ihe liver ~ they emerge. from porta. Iepatis,lying infront. of the branches of the hepatic a& the portal ¥- athe 2ducks unite in the RE-parbof the porta hepatis te form the Common hepatic duck Common hepatic duck: ~ibis a short duct (about, 17/ong) fornied by the union of Lhe Rb-&LLhepatic ducts: ~ it descends infront of Ute portal V- &cott the Re-side of the hepatic artery ~itends by yoining lhe Cystic duct. ab acute aingle to form Ure Common bile ductformation: itis formed below the porta hepalis by Lhe union of the Cystic &y Common hepatic ducts - ‘ . sLength Xparls:ib is about F’long aisdivided into3 parks, ae ae : x Course & relations: infns-dtodenal- : |-Anteriorly liver. | 4-|Supraduodenall a TBTD portal v-xepipoic 4p ~on the Rt-side: hepatic artery. : i =ant-: 13f-part of duoden | 2-| Retroduodenall I Vopost-tportal V.xtven P fot the. Ri-side :gaslroduodenal a- /~ant-t head of pancreas (it may be compressed by cancer head-—» obstructive soundice)- ~post 1 1-V-C- passes ina groove on the post. surface of thehead of payicseds oF event embedded inl sc Ee [=] tninor duodenal ¥ Termination of C-B-D: ee the Lerminal part of the C-B-D unites with the main CBD Pancreatic duct to form the ampulla of Vater which opens at the summit: of the mayor duodenal papilla at the middle of the posteromedial aspeet:of 2nd part | __ of duodenum (surrounded by the sphincter of odd:)- NB: (9 the C-8-D may open separately in the lumen of the duodenum. the intra-mural part of the C-B.D, before enter'ing the ampulla, is surtounded by the sphincter of Boyden ; ; j part : by Cystic a-or RE-hey 7 x Arterial Supply of the C-B>Ds<—, ears ; oe or Rt-bepaicas srhigcer perestc duct Sphincter of Oddispleen Nalure: Lymphatic organ Comected lo Use vascularsystem- ¥SiLetit lies obliquely inthe post: part of Lt-hypochondrin wedged between the furdusof stomach atte diaphragm. ¥Surface anatomy ~ it lies opposite the ribs 9,10%11 withits long axis 2 parallel tthe 1th rib-mekinganangl of "wil he hari. ~ its post-(med-Jend lies 14, inches From the toth thoracic spine- = its ant. ClatJend reaches the I.t-midaxillary line Ne: normall y, Ure spleen isnot palpable.as it does not: extend below costal margin 3 Size & weight : (easy fo remember by the odd numbers 1,315.79 &11) ? The avarage spleen is YL thick 3broad ,5”long ,7 ounces (zoogm)in weights gis related to the 9-M{ribs- (iter perme Shoped features itis sh ned as cupped hand,having:4 2borders : upper & lower : taped as cupped ard rang fac chophagnaticn vse | (Medial (post-Jend : is rounded-It is directed upwards, backwards aanedially lying Winches From the median plane - (pLateral (ant) end sis expanded (resembles a border)-Ikis directed downwards ° |. forwards, reaching the Lt- midaxillary line -evests on plurenicocolic lg, (3) @)lipper border +s sharp snotched near its ant-end xterininates laterally byan | angle. N-p:notching oF the upper border is an indication of foetal lobulation « Lower border: is thick, rounded %Sinooth (presenting ro nioLches) « (5) Diaphragmatic surface:'s Gonvex,smooth & related to the diaphragi- (Visceral Surface: concave irregular Belated to abdominal viscenx-I presents the hilum &impressions for the related viscera. * [Relations of the Spleen (A) The Diaphragmtic surface: is related lothediaphragin which separates the spleen From: (0 lower part of the Lt- pleura (costodiaphraginalic recess): or» » ? y LE- lung (3) post-parts of the olf, lott ait ribs qy cat Sect atheir intercostal muscles «caw ‘ oly F ()-Relations of the Visceral Surface : 's a large concave area belween the hilun adhe upper border. This related la the post-wall-of the fundus of stomach. F @). Renal impressiosi:asuall shallow impression between the hilumt’y the lower border: Ibis related lothe Front: of the left kidney. NB : Ue gastric xxrenal impressions ave separated by axaised margin Gntermediate border), ¥(3)Pancreatic impression : a small impression belosy the Jalerol end of the hilum: LC This wlated lo the Lai of Uie pancreas [a Colicimpression :a Flat area close to the lat-end of the splees- F Ikis related lo the LL-Colic flexure. Xits lower part: isrelabed to the. plrenico-colic ligament + Jum of the spleen: >—____— | -Iis a longitudinal slit onthe visceral surface between the gastric \ Colic impressions - | 0) Gastric impression oplerminal branches of splenic ortery— ‘@bsibutaries of the. splenic vein 7 ‘()aulonomic nerves & lyinphatics - tgives attachment to 2 ligaments: Lienorenal lig « See igeoumeop enc ‘Peritoneal relations of the spleen: the spleen is Completely covered with peritoneumof thegreater sac excepl the pancreatic impression + hilum forms the left lateral extrimity of the lesser sac (belween the gustrosplessic 2, lieno-renal ligament). 4 tase+Peritoneal ligaments of the spleen: () Lienorenal ligament : ¥ Attachments: it extends bebween: | ay lower part of Use hilum of spleen: | (bythe Front of the upper Ya of LL-ki xContents :ursplenic vessels {peer @) tail of pancreas (3) lymphatics & pancreaLicosplenic LNs- Qi) extraperitoneal fatly Lissue. » (saulonomic nerve libres ® Gastrosplenic ligasnent : : ibextends between: @ upper part of the hilum of the spleen. upper J of the greater curvature. of the stomach. wContents:a short gastric vessels. (2»Lb-gastro-epiploic vessels» g) autonomic nerve Fibres - (i) extraperiloneal fatty Lissue- (©) lymph vessels & pancrealico-splenic LNs i % Stability of the Spleen: depends on: : : ihe iniraabdominal pressure (2) position of the surrourtding organs Gate ligaments: gastrosplenic lig. tb) lienorenal lig . (© phrenian-Colic lig. which extends below tie spleen, between the Lt-colic Flexure athe diaphragm. ¥ Arterial Supply: Splemc artery: arises asthe lanyest branch tke Coeliac trunk. ~ikrunsatortuous Course along the. upper border of tie body of pancreas. wit enters the lienorenal lig-Lo reach Lhe hiluin of the spleen toond by dividing into 5-6 branches _ Venous drainage: Splenic vein: : Taries al the hilum of the spleen then enters the lienorenal ligament ~ ~itruns a Straight Course behind the pancreas - it ends by Joining Hie superior mesenteric V-to form the portal V- len has No lytuphatics but few lymphatics | ehymphiatic drainage: red bulb of the spl : arise from the Capsule ‘trabeculae sedrain into the pancreaticosplenic LNs (along splenic a-)- a#Nerve Supply: Sympathetic Vasometor fibres From the Coeliac plexus. 7 | How be place the leer in the correct anatomical position ?: Ahold the splen in your lft hard witht convex (digphragmaticysuace applied to the palin Ure rounded post-end towards the wrist lhe broad ant-end bowards the tips of Fingers tthe notched upper border applied tothe thurnb- put your hana behind the L-nidaxilaryfine,with anrangle oF 1 degrees with the horizontal»pancreas 73 ae Type: a mixed gland (exocrine &endocrine)- ¥Site xshape: itis an elongated retroperitoneal gland lying transversely across the post-abdominel wall extending Srom the concavity of theduodemita onthe right to the hilum of the spleeo on the left. TL ies mainly in the lower part of epigastric RLL-hypochondrial regions, sparts a relations: itis formed of head, eck body & tail : E-The head: (B)posterior relations :yunction belwween splenic | sup-mesenteric veins to form the. portal vein. n-6 :Cancer head of pancreas affects the structres related to head a ‘tanteck of pancreas leading to: wwidening of the duodenal Concavity (appears in X-ray): compression of the Common bile duct ——> obstructive yaundice- @ poy pyloroduodenal, [junction ——>-Pyloric obstruction- Woo» » » inferior yena Cava———>- cede of lower | limbs- 6 » » » portal veirt —————> ascitis (Fluid in ue peritonea! Cavity)-IIE Body of pancreas: 74 - extends fo the LE.2 slightly upwards crossing the median plane opposite Lt. db is triangular in cross section having 3 borders w 3 surfaces: Superior border: ~ has an upward prosection Just below the Coeliac trunk; called the omental tuberosity of the pancreas the rest of the superior border js related to lhe splenic (Inferior border: — ° is related fo superior mesenteric vessels at its RE: end —>\ (Anterior border : gives attachment lo transversé niesocolon (i) Anterior surface. is bourtded by the superior d.anterior borders: "= itis Covered by the peritoneum of post- wall of lesser sac: \ -4 eins ! pean ——~(pLt-renal veinn——> ©) (5) LE- psoas major ] 2 truss ony ens of diaphragm (Le. Kidney: : (2.glands<— LE -Supra renal gland4 W- Jai] of pancreas: Eig the narrow left end of the gland which lies inthe lienorenal lig. ther with the splenic vessels ————~ ; ~itis related to the visceral surface of the spleen.just below ) the lateral end of its hilum 7 5 “Ducts of 8 inn pancreatic duc Ducts of the. jancreas. ——~ accessory pancreatic duck Main pancreatic duct (of Wirsung): eel ~begins in the tai] &.passes lo theright towns | PM the head traversing the whole length of Ure: -gland. emerges From the fread &unites with Uke common bile dact inside the wall of Ue 2nd part of duodenum forming adilatation called ampulla of Valer // IS a which opens on the sumunit of the mayor duodenal papilla. aa Vier duct (2) Accessory pal icrealic duct (of Santorini): wall of 2nd part of duodenum -jtisa small duck which drains the uncinate process & te lower part of the head. ~it runs upwards infront of the main pancreatic duct to open separately into the and part of duodenum at the minor dusdenal popilla oe itch above the mayor duodenal papilta- sfrequently, Ure main accessory ducts Communicate in thehead of pancreas: xArterial Supply of pancreas: «pancreatic branches of splenic a- (br of coeliac brunk) = supply tlie body. @)sup-pancreatico- duodenal a. (br of "gastroduodenal a.) supply the upper part of the head - gif pancreatico-duodenal a-(br-of supmesenteric a): supply the lower part of Uxehead: a | Np: the pancreas is supplied by Vie a-oF foregut: (Coeliac) the a ¥Venous drainage: (veins of the body: drain into tie splenic vein. veins of the he ‘dl edrain into portal vein directly i “#kymphatic drainage: the lymphatics follow ihe arteries 8drain into? 7 the pancreatico splenic L-Ns (around splenic.a.) aycocliac LNs (around Coeliac trunk) (3) sup-mesenteric LNs Calong sup-inesenteric a-)-Arterial supply of the gut a 6 7 ipper ak di xOrigin: i 7 From the Front of abdominal \* rorta opposite the upper border of LA vertebra, yust below the aortic opening of the diaphragm. xCourse: itis a short trank an inch long which passes forwards infront of the aorta, above the pancreas &soon divides into 3berminal branches :\u-gastric, hepatic & splenic arteries + *Relations : & Coeliac ganglion & coeliac plenus oF autonomic nerves: d Coeliac group of L-Ns (around it) - : ~ottench side < gy gr, crus of diaphragm & caudaLe process of liver (onthe Rt-side)- | Whe» » » 8, Cardiac end of the stomach Con the LL-side) § -Anteriorly: Cavity of the lesser sac ofperitoneum, separating it from the lesser omentum ~Superiorly: median arcuate Kigament of the diapluagm- -Inferiorly : omental tuberosity of the pancreas xBranches: 1- Left gastric artery: (the smallest: branch): ; ~ it passes upwards % to the Le-on the Lt-crus of the diaphragun ( behind the lesser | sac) to reach the lower end of the cesophaqus- ~ ther it curves downwards & to the right along the lesser curvature of the stomach (between the 2 layers of the lesser omentum). ~ itends by anastomosing with the Rt-gastric a. about the middle of the lesser curvatut ~ Branches :0) oesophageal brs. to the. lower end of the oesophagus. @ gastric branches : fo both surfaces of the stomach-Gastro- duodenal a, ~ | MO S | 2- Spleriic artery (the largest branch): ~ it runs, in a tortuous Course, lo the left along the upper border of the pancreas & infront of the Lt-Kidney &,LE.suprarenal gland to enter the lieno-rental ligament» ~ along its course it lies behind the stomach but separated fromit by the cavity of thelesser sac ~it ends Close to the spleen by dividing into 5-6 Lermuinal brs-which ertter the hilum x Branches: () pancreatic brs.: to the body & tail of pancreas The largest of themis called the. “orteria. pancreatica magna) (see page 75)- short gastric arteries : 5-7 small brs. which arise From the terminal part of the. splenic a- Senter te gastrosplenic lig. to supply the Fundus of stomach. @)Lt-gastro-epiploic a-: arises near the hilum of the spleen then enters the gastrosplenic Hig. to seach the stomach where trans downwards along the upper oF the greater curvature (between the ant-2 layers of greater omentur)- ‘It supplies both surfaces of the stomch+ the greater omentuim sends by anastomosing with the Kt-gastro-epiploic a- Terminal Splenic branches: 5-6 end arteries which enter the hilurn of the spleen. N84 - Causes of tortuosity of the splenic artery : @ to accomodate for enlargement of the spleent&its movement. during respiration. (byto sow the- circulation allowing blood fo pass in the branches supplying the pancreas. 2-Other tortuous arteries inthe body: ; Facial a- (lingual a C)int-Carotid a- (ch post-inf- cerebellar a- eyuterine a-RE-BLb terminal bes. lesser omentunt of hepatic a- i KD) 78) (3) Hepatic artery + (intermediatein size between the splenic a:L4-gastric arteries). + Course &.selations: it passes forwards & tothe right on the Rt-crus of the diaphragin &cbehind the lesser sac- it reaches the upper border of the 15k part of duodenum : ~it curves upwards & ascends in the right Free margin of thelesser omentum (infront of the epiploic foramen) having the portal Vibehind il:& the common bile duct on its Rt-side~ ~it reaches the porta hepatis where itends by dividing into RE-BLE-terminal branches: ¥Branches: () Gastro-duodenal a-: “-descends behind the 1st part of duodenum Cinfront of portal v.xmedial lo G-bile duct). aitends ky dividing into @right gastro-epiploic a-:runs ls the Le- between the 2 layers of greater omenturn, along the greater cul re of stomach (supplying both surfaces the greater omentun)s ends by anastomosing with the Lt gastro-epiploic a (sup. pancreatico-cuedena! a+ descends belween the head of pancreas &,the dusdettum (supplying both of them), ten ends by anastomosing with the inf,pancreakicoduodend! a (anastomosis between artery of foregut Barter of. tntilgut, - : “(D Right gastric a-: passes tothe LE- along the lesser curvature of stomach (between the. layers ofthe lesser omentum), Supplying both surfaces o Ihe stomach-Itends ky | anastomosing with the Lé.gastric a- : (3)Supraduodenal a- : a small inconstant a. supplying upper part of the 1st part of daodenum. | @ReE- terminal hepatic branch : enters the Rt lobe of the liver. ()lt-terminal hepatic branch :enters the Mrlobe. of the liver’ . (@cystic artery: arises From the RE-Lerminal br. It passes to the RE. behind the. common hepatic acystic ducks to reach the gall bladderUI- superior mesenteric artery 79 x Ibis the artery of midgut: (lower 4 of duodenum, Jesunum, ileum , Caecum, ascending colon & right 2/3 of transverse Colon). y Ori gin : From the front of the abdominal aorta. opposite. the lower border of L4 vertebra ;Acm below the origin of the Coeliac trunk. *Courseaselations: - AL its origin it lies behind the body of pancreas between »> 2veins: splenic vein Cabove it) 8.1.t-rertal vein (belowit)- ff ~It descends First infronl of ca) left renal vein buncinate process of pancreas:, 3:0 part of duodenum. /&7 - then it enters the root of mesentery kruns downwards [<7 & to the RE-, crossing Une following stuctures i succession: w abdominal aorta @)1.V-C- (3)RE«psoas mayor m- pancreas (cut) root of »Branches : area of midgut supplied inf. pancreatico- | lower 4 of duodenum+ part of] 1 duodenal a. | the head of pancreas. Jeyunal and | jeyunum ileum (except its finn Foal branches I terminal part). MS «ay. | cerminal part of ileum, Coecum,| Tleo-colic a prone lner sof asd cl - | pe-colic a. | upper 2/3 oF ascending colon tr] Re-colic: a +Kt-colic flexure 5-(Middle colic a- proximal (right) 2/3 of transverse colon for details of the branches see page B0-( Ink.pancreaticoduodenal a-: ~orise's From sup.mesenteric a- as itcrosses the uncinate process of the pancreas - ~ ascends between the head of pancreas &duode nur (supplying both) ,ends by anastomosing with sup. pancreaticodued-a. @)yequnal 3. ileal branches: ~ are 12-15 branches which arise From the Convex side of sup. mesenteric a> fi ~ they pass through the mesentery, dividing into branches which anastemose witheach other Forming a series of arterial arches (arcades) ~—— the terminal ones give straight end arteries Vasa recta which supply the jeyanurt & ileum (excepts teriminal part’) (@lleacolic artery: arises From the RE-side of supmesenteric a-alittle below the originof right colic artery. ~it runs downwards &to the KE- on the post-abdorinal wall giving the following branches: «pileal branches to: theterminal part of iJeurrt-sanastomose with the. termination of sup-mesenteric a}. (b)qnt-caecal br: to the Front of Caecum: Srey Colon wpest. » x» » back» 9- & SAN Wappendicular a: passing behind the terminal part oF ileum Breaching the appendix Hirough its mesentery « (eyascending br: ta lower 's oF ascending colon, anastomosing with the descending branch of the right colic a. Right colic artery: ~ arises From the RE-side of sup-mesent-a alittle below the middle colic a. =runs to the Kt- behind the parietal peritoneum \ = crossing the RE. psoas, RE-ureter & Rkeganadala ~ it divides into 2 brs ascending adesceneling which supply the upper 245 of ascending colt 7 xanastomese with the ascending br. of Rt.colica’ & the Rt-br-oF middle colic a - Middle Colic artery: ~ orises just below the pancreas - ‘x -itent ‘e megacolon where it dividesinto: @ ee with the ascending br. of Re.Colic a- both branches supply the dhit-bre oy yop 9 Whkebolic & RE-2/3 of kransverse colonI- inferior mesenteric artery 81 +ltis the artery of hindgut ( Le. 4% of tr.colon descending colon, sigmotd colon &rectum)- | ¥Origin : From the Front of abd- aorta oppasite 13- WAL. origin it lies behind 3rd partsof duodenum which separates it from the superior mesenteric a. Witdescends,with a slight curve convex tothe leFE, behind the peritoneum of the post- abdorninal wall | (3) then it enters the pelvis by crossing the Lt-common iliac a. where it ends by becoming the superior rectal artery. N\ ‘Relations: —_w ard part of the duodenum | A) Anterior ly <— gy peritoneum of the post -abd.wall- ‘3)Coils of small intestine (9) abdominal aorta Gn its upper part)- @ Lt-sympathetic chain. LE- psoas mayor muscle- Ui) LE- common iliac artery- (superior mesenteric v-(inits lowerpart) | on Lb-si na Le-ureter ate gonadal a. Lt genitofemoral n. (on RE side > ower part of abdominal aorta. ¥Branches: Ut: poas maser m- FSuperior Lé-colic a-: ZL he ureter ~passes(o the Lt- behind peritoneum of post-abd. wall crossing —— (Lt-gonadal a- ~Tt divides into 2. brs.:1a) ascending br: ascends to anastomose with Lt-brof middle colie a- (b descending br.: anastomoses with the uppermost sigmoid artery. ~it supplies : Lt of transverse colon & the upper part of the descending colon. ~ + ~ it leads fo awide space inside the kidney Called renal sinus. |. ~it gives passage to the Following structures arranged From before backwards : (Renal Vein : most anteriorly. Vv @Renal Artery sin the middle eee ()Pelvis of the ureter: most posteriorly. P- | *How to identify the RE-Kidney from the Lt-kidney: | 1-the med.border is identified by the hilam (2) the pelvis is the most post- structure (marking postsuia). 3-the ureter projects downwards marking the lower pole -Now put the kidney in the anatomical position. anterior —~Jeiunal area Colic area T-Anterior relations: the ant-relations of the 2 kidney are different (out comparabld: Ant-relations of the lut-kidney Ant-relations of the RE. kidney P Lt-suprarenal gland : along upper end 3pper (oRE-suprarenal gland: along the ant-soed- aspect of the upper pole tg) 2nd part of duedenum:: along the hilum & \(2)Stomach related lo triangular areain the area adjoining ié- upper part of the ant-surface~ (3) R-lobe of the liver :related to the area Spleen :related tothe upper 243 oF the lak - between the suprarenal duodenal Xcolic arens part of the anterior surface __ (WARE-colic lexure :infront of the lat-part oF (descending Colon: infront of lower Ys of lak: the lower Ys of the ant-surface.| * part of the antesurface- (5) Cols of seyunusn infront: of thelower med.part- | Soils of fequnum:infront of the lower med,part Gy Receading br. of RE-calica-‘infion-of loner end] (9 Ascending oF Li-coic infront of lower end (7) lat-part of body of (with splenic a- al saa Meh fad Dinko of middle j part of the med:iliohypogastric 1 iko-inguinal n. \\ i iy muscles ¥ The posterior relations of the kidneys are similar Biinelude Gy ty neurovascular structures A- (D-PAT): : ( Diophrogmn (athe med slat-orcuate: ligs.): behind the upper part of the kidney- ~The diaphragm separates the Kidney From the Costo-diaphragmatic recess of pleara Acthe ribs 11 & 12 (on the LE-side) or the tath rib (on the RE-side)- NB:iF the vertebro costal A of the diaphragms wide (fleshy Fibres of daphragmareabsent) the kidney will be directly related to the pleura (Commoner on the Lt-side)- (2) Psoas major (and minor ifpresent): behind the medial border hilum of the kidney ()Quadratus lumborum int: behind intermediate Vertical part of post-surface + Strip close tothelat border of the kidney (i) Transversus abdominisim-: behind avertical nna vessels. B-[Thebneurovasculor Structures ]:inchide gt subcostal nerve: They intervene between the kidney 8 the- blihypogastric nerve. quadratus Jumborum & transversus abdominis. #)tlioinguinal nerve- ¥ Peritoneal relations (covering) oF the kidneys: Right Kidney Left kidney The ant--surface is covered. <| ij the ant-surface is Covered by by pentoneum only in “a y jroo peritoneum only in the aes the areas related to: a hate ay the livers : Gs @)Stomach qagmall intestine- N67 ABER small intestine irface are devoid of peritoneal covering #The other areas of the ant-su, ‘Hays 1) Fibrous copsule » Capsules (coverings) of tne kidney: 3 F: apne te ) Fibrous Capsule: is the inmer true capsule that fascial capsule, invests the kidney extends lo the renal sinus-Normally ===> ~ itis not adherent ive ib carr be stripped off easily - (2)Fatty Capsule ( peri-renal Fat): surrounds the kidney :suprarenal gland -Rapid depletion of this Fat leads te ptosis (drop) of the kidney (+25 4.5). (3)Fascial Capsule (Zukercandle fascia): ~ lis derived From the Fascia transversalis which divides at the @) ant-layer : passes infront of the kidney & fuses withthe CT infront of aortaX,E-V-C- (by post-layer : passes behind the kidney & Fuses with the vertebral column. Neg superiorly, the Llayers Fuse above the suprarenal gland but below the 2 layers remain separate. #Skability of the kidney the kidney is Fixed in position by + (ijies position inthe depth of the paravertebral gutter pits Coverings of fatty & fascial Capsules. (its vascular pedicle i-e the renal vessels Connecting the Kidney lo the mayor vessels (aotteetvc)- Gy the positive intra-abdominal pressure Causing apposition of neighbouring viscera tothe kidney ¥, ial Supply of the ki : Renal artery :arises from the aorta at the level of L2: (aythe Lt-renal a.is short & passes behind the Lt-renal V- (ithe RE renal a: is long passes behind LV.CaRt-renal V. Each renal artery divides into 5 segmental brs. (end arteries) which supply 5 pyramidal segments of the kidney apical supper, lower; middle, posterior Segments) which are considered independent units @Accessory renal artery (present in 30/only of individuals) : itarises From the aorta, runs parallel to the renal artery, and enters the kidney either at the hilum or at one of the 2 poles of the kidney (usually the lower pole). ¥ Venous drainage : renal vein emerges from each kidney toopen intothe I-V-C : (a RE-renal v. zis short & passes infront of the RE-renal artery- : (ht-renal ¥-+ is long & passes infront: of the abd-aorta % the LE-renal artery 3 Lymphatic drainage = into the paraaortic LNs atthe levelof origin oF renal arteries (12) #Ner + the renal plexus of nerves around renal a- (derived From the coeliac plexus) vung it contain: Sympathetic vasomotor Fibres arising From Tio->L1 rb cues lied anatomy: kidney swellings are Felt in the renal angle (the angle between thetath vib & the lab-border of sacrospinalis in- Incisions for kidt rations shouldbe performed one inc below the renal ange to avetd ingury Ste key petal plea eerieURETERS] 91 ¥Shape &Size :eachueteris a thick-walled relroperiloncal muscular tube 25-30 Cm long & 6 1m indiameter- x Beginning: infront of tr process of 1 by Funnel shaped dilatation called pelvis of the ureter which is relat posteriorly to psoas mayor muscle xis related anteriorly to renal vessels 82nd [part of duodenurn (right ureter) & body of pancreas (LE-ureter) ¥Termination :by opening tothe posterosuperier angle ofthe urinary bladder ey te 7 abdominal part: tits upper! (on post-abd.wal])- xLourse :is divided into 3 parts —Bpen ‘ls lo ley (ona vallo pelvis). intramural part: ‘last 2cm inside bladder wall) - A. Abdominal Part: ener! SNOTLYTHY YOLYGINY SNOLLVTAY YOTAALSOd po Re ureter ee ureter) COS re nara eee elaine eesti eee reer &) Rt- Colic a- (b) Upper Le tolica- mateo © iliocolic a- lower» v w (3 slictures related Lo Mesentery} (2) sigmoid Mesocolon & coils itsroot , sup. mesenteric vessels.& | of sigmoid Colon - coils of ifewn Inf. vena Cava (1-V-c) Inf. mesenteric vein (LM.B.Pelvic Part; Course arelations: 92 wy itenters the pelvis by crossing infront. of the bifurcation of C-iliac a-Copposite sacto-iliac int). @itruas dowawards & backwards along Ure lower border of internal iliac a- ¢rossing ext-iliac vess.,obLuralor 1. avess-scovered medially by peritoncom, (a) opposite the ischial spine, the ureter curves anleromedially to open into the postero-sup. ongle of urinary bladder-Here it passes on the side of vagina in the female &is crossed by the vas deferens in the wtole- C. Intramural Part: +The weter Joins the posterosuperior angle of urinary bladder aeruns avery oblique course. lirough its wall for 2cm before opening This arrangement provides a Valve-like mechanism preventing regurgitation of urine From bladder lo lhe ureter #(onstrictions of the ureler| x Blood Supply of ureter theureter shows ly ormal Constrictions: ~each ureter receives a.rich segmental Wat the pelvi-ureteric junction supply from all arteries along its course : (2) at the pelvic brim A : Abdominal aorta: entilac @opposite the ischial spine us : Renal artery the intramural inside bladder} Testicular or ovarian a- a i. I :Inf-vesicala-(br-of int-iliac a-). C Common iliac artery: ¥ Surface anatomy of the ureter: (Anterior Surface markings of ureter | Posterior Surface markings oF ureter represented by aline drawn downwards | draw a vertical line on the back extending medially between 2 points: between 2poinks : “ \()a point on the Eranspyloric. Wapoint 2%from median plane| | plane 2“From median plane. at thelevel of Li spine. | ~ a point at pubic tubercle- @apoink ak the post-sup- iliac spine. xxNerve supply of the ureter: (@) sympathetic Fibres From Tn->Ls spinal segments ) y inFunction- @) parasympathetic From 2nd, 3A 3 uth sacral» i ern at sas thick muscular bube with longitudinal ‘vessels along its wall - Vit shows peristalsis agives urine on aspiration. )Ureteric poin Cinrenal colic)is referred to the skin of ant-abd-wall supplied by Tio to Lt spinal nesves-Pain startsin the loin &extends to Ue groin external genitalia - Applied anatomy: wit. the ureter is identified at operation by {,Vessels of posterior abdominal wall 93 ABDOMINAL AORTA Beginning: at the aortic opening of the diaphragm — (at-the level of lower border of Ti2)asacontinuation of the descending thoracic aorta- Course zit descends downwards (with slight inclination tothe Lt infront: of the upper 4, lumbar vertebrae (behind peritone! Termination : at: the lower border of |-4 vertebra, slightly to the Le-oF median plane by dividing into 2.comion iliac age Relations A- Anterior! y :From above downwards, it-is related lo: (Coeliac trunk & its branches, Coeliac &aortic plexuses separating the abd. aorta from post-wall of lesser sac - (2)Body of pancrens &.3 structures behind it : tay splenic V- ) LE-renal v. (origin of sup.mesent-a (2 ri @)3rd part of duodenum & origin of ‘inferior mesenteric artery gl part upper part of root of mesentery aits contents a (Superior mesenteric vessels)- KX ils of (parietal peritoneum separating it from coils of sos A etc small intestine.- B-Posteriorly :itis related to: W the bodies of the upper lumbar vertebrae x intervertebral discs @) the anterior longitudinal ligament (3) the 3rd % hth lumbar veins as they Cross behind the aorta to open into the I-Y-C-Right side relations of the aorta | Left side relations of the aorta 94 Finthe uré (above 12) iis related fo 3 W)Cisterna chy Sthoracie duct | E HA Lt. crus of diaphragin @lower part: of azygos vein. @ Lt Coeliac ganglion |)right coeliac ganglion —— \ @)Rt-crus of the diaphragm —\& U Separating the aorta from LV.C- tbody of pancreas \ () Te-inthe lower parb (lyelow 12): (| itis directly related to the 'V.c he S 6) 44h part of duodenum. (3) Lt-sympathetic chain ¥ Surface anatomy of aorta ris marked by 2 Vertical lines 2¢m apartextendingbebween: (i) 4 point in the median plane one inch above the transpyloric plane + @apoint Ye inch below and to the left of the umbilicus (level of 14 vertebra): ¥ Branches of abdominal aorta v | ‘iromthelront te obd-corta uip.Mmesenteric a. lower border of Lt FPS Behera tie arana L2 L3 Tuf. mesenteric a- Rt-8Lt-gorradal arteries (fem the Front of abd-aorta) | “3 (rom anterolateral aspect of aorta Median sacral a. is YY REL common iliac aa L4 From the back of abd-corta ey SN seas a fama brevet lower (itis the continuation of the PRR, winiines Ad In addition to the previous branches, the aorta gives 4 poits of lumbar arteries- Each pair arises from the back of the aorta oppasite ‘ach vert Body From/sto Ly.Details of the branches of the aorta 4- Coeliac trunk: see p.76. (2)Sup-mesent-a(p.79) 3-Inferior mesent-a- (page 81)- 4-Median Sacral artery : = ~ Arises From the back of aorta just above its bifurcation ~descends infront of Ly &5 & behind Lt-commoniliac v- enters the pelvis infront of sacral promontary te descend infront: of the middle line of sacrum xbehind the reckun- ~itends ina swelling Called glomus coccygeum infront of coccyx. ~ Branches: the 5h pair of lumbar arteries. @% Lwigs to the Sacral canal. @) twigs to the rectum. NB: ibis accompanied ky median sacral v. which ends in L&-cormmeniliac vein- | each artery ramifies on the under surface of 5-Inferior phrenic arteries: Rt-RLL. — - Origin : From the side of aorta opposite upper border of L1. — Course : they run upwards, forwards Materally on the Corresponding crus of diaphragm : + the Kk-a- passes behind the I-V.C- + the Lt. a-passes behind the oesophagus the diaphragm sgives Superior suprarenal a. 6-Middle Suprarenal arteries:RERLE. \\ ~ origin : each artery arises From the side of aorta opposite lower border of LI ~ Course: each artery passes laterally onthe corresponding crus of diaphragm (the Rt-a- passes behind the IN-C)-&end by supplying the suprarenal gland, 7Renal arteries : Rt-wit- + Origin : From the side of abd. aorta opposite 1.2 ~Course :éach artery runs laterally infront of the corresponding crus of diaphragm & psoas major m- to reach the hilum of the kidney ylying infront of the pelvis of the ureter. ¥the Rt-renal a-is longer &.passes behind I-V.C, Rt-renal v. &shead of pancreas. U -is shorter & passes behind the Lt-renal v & the body of pancreas Branches: w inferior suprarenal artery : to the suprarenal gland. @)terntinal (lobar) branches (5) to supply the 5 vascularsegments of the! Kidney. @Guureteric brs. to the upper end of the ureter.sup-nieseuteric artery —| 3rd part. of duodenum Rt-gonadal artery. middle Colic. artery. (8) Gonadal arteries: & They are testicular or ovarian aa-which arise from gonadal artery 96 ower part of descending colon the post-abd.wall towards the pelvic rien. it crosses obliquely infront of : 0) LL symp-chain (2) LE- psoas mayor cylL-ureter &) Lt-genitofemoral n- (G)LL- external iliac artery - #1 Course | ney descend downwards slaterally on it crosses obliquely infront: of : #| Posterior lwry.c @)RE- psoas major muscle yelations GRE: ureter (i) RE-genitofemoral n Re-external iliac a w 35d part of duodenum. | Anterior ic Rileocolit i : RE. Colic Bileocolic artes relatior 2) lic Rileocolic arteries lu) terminal part of lew ¥ Termination: both testicular & ova rook of mesenttery containing sup.mtes-vesseb 4th part of duodenum @lé-colic Bsigmoid arteries (inferior mesenteric vein. Uy) terminal part of descending colon rian a-have the same. Course down to the pelvic inlet then: inal ring &% passes Urough the inguinal canal among the -Tes! reaches the deep ing constituents of the sper matic cord lo reach the testis (see page 25)- ~Ovarlan_a.: turns medially crossing the ext-iiac vessels toenter the suspensory lig-oF the the ovary toreach the broad lig then reaches the ovary via the mesovarium (see pelvis): g- Lumbar arteries : ~ they are ly pairs of arteries which arise ~ they rup laterally backwards deep to the sympathetic trunks ~ then they run behind psoas major & (except the ith lumbar a-uhich passes infront ofthe @muscles of post-abd.wall %,lat-abd- wall cb spir VB: Fhe 5th pai r arteries ari 10- Common iliac arteries from the: round the bodies ofthe upper ly lambar — athe tendinous arches of psoas mayor. quadratus lunborum muscles 5 From the median sacral a~ back of abd-aorta Irqtus) to supph nat via valde:INFERIOR VENA CAVA (LV.C.) ¥Course sitascends infront of the vertebral column (to the Rt- ¥ Beginning: infront of the body of 1.5 vertebra, shghtly lothe { side of abd. aorta) &cleaves the abdomen ky piercing the central tendon of the diaphragin opposite T8,2ne RE-of median plane by the union of the RE-RLL- Common iliac veins Elly j i inch to the Rt-of median plane. y ¥Termination: in the Urorax by piercing the Fibrous pericardium} ; * Relations EAnteriorly :< trom below upwards): @) Rook of mesentery asup.mesent -vessels- a @)Kt-gonadal vessels - YW (B) Ab the duodenum : tis related to: R ( oy 3rd part of duodenum (separated fom { ) Free margin of ner omentum & its contents TV.c by the Rt.goradal a-)- @head of pancreas with common bile duct embedded in its post-surface.~ @)1st part of duodenum (separated From I-V.c by common bile duct, gastroduodenal a-2.portal V- (the epiploic foramen (separating the I-V.C from the Free margin of lesser omentum & its contents : portal v-, hepatic 4-8, common bile duct). 2) post- surface of RE- lobe of liver (related to the uppermost park of I-V-C)-{f- Posterior relations: A) the lo Uy bodies of the lower 3 lunbar vertebrae (2) RE. psoas mayor muscle @RE- sympathetic Chain (B) the upper part of .V-C is related to Rt-crus of diaphragm but separated From it ky (RE coeliac ganglion reaRSTET- RE Sympathetic chain tamed part of RE-suprorenal (gland (3) 3 arteries 110) RL- inf. phrenic. a+ dy Rtmiddle suprarenal a © Reerenal a. [-Right: side velations of I-v-C WRight lobe of liver-—F Cin the upper part). — (inthe upper part _, | etvem 2 : tamed. border of Rt-kidney\(Re-tebey YA ta Rt -crus of diaphragin (inthe smiddle part)- tin the middle part @ Right ureter 3) Abdominal aorta (int the lower part). (in the lower part) * Tributaries of I-V-C- 1) 2 Common iliac. veins = they uni together forming LV.C} i : wg ¢ ahd lumbar V- (RE. LE @ 2pairs of lumbar veins < lumber Ve (REX LL | (3) 2renal Veins (RE-&Lt)- —__— Rt-suprarenal vein 32 Right sided vein's mo» the Lip of Er. process of Lt with the last rib- INC parteInsertion of the diaphragm: ————--—-- the Fibres of the sternal y Costa &vertebral origin converge. to be inserted into a crescentic-shaped central tendon which is more anterior than posterior in position Nerve Supply: (A) Motor : phrenic nerves (RE-x1.t) are Uje. Sole siotor nerves ta the diaphragin ()Sensory: (y phrenic nerves are sensory to the central port. lower 6 thoracic nerves are sensory le Ure peripheral parts. ¥Arterial Supply: (phrenic branches of thoracic % abdominal aorla @ pericardiaco phrenic & musculo phrenic branches of internal mammary a- (slower 3 posterior intercostal arteries - ¥ Actions of the diaphragm: ty It is the main muscle of inspiration : on contraction itdescends leading to increase. in the veiticol diameter of the thorax thus air is sucked in- Q)iE increases the intra abdominal pressure to give additional power ta all expulsive actions €-g vomiting , micturition, defaecalion & labour Othe Re- crus of diaphragm has a sphincterie action onthe lower end of oesophagus (P.38)- Wit helps the venous relurn to the heart ky: @ increasing the intra-abdominal pressure @y decreasing the intrathoracic preesure (€)widening of the vena caval apening. : Mena taval opening & ¥Major foramina of the diaphragny Desopha slope hor (Voice OF America) A ie 3 Aortic opening Opening [Vena caval opening | desophageal opening | Aortic opening Vertebral level T8 Tho oe Vlo the Rt-of median | 1“to the Lt-of mediart | in the median plane,behind Position | plane,piercing the — | plane piercing the RE | the median arcuate lig. 5 central tendon of daph. F diaphragm to | of the diaphragm which Pee ph. | crus of diaphragm iaphragm 7 significance tobe always patent to | act as sphincter for the | protects the aorta From help venous return | lower end of oesophagus | contractions of the diaphragm. Ko Ute E-V-C- Woesophagus w Aorta SErUCtures |yRe-phrenic nerve- | @Ant-apost vagal trunks | 2) Hroracic duct a)lymphatics from the | Boesophageal br.of Lt |G) azygos vein- PassWAG |i Htencdislinal NS] qacttcadtery Up ymplabds fra the trax : aaeaea! to the. cisterna Chyli_¥Minor Foramina of the diaphragm & Structures passing through 102 Sup- epigastric a- : passes betwee sternal 8, costal origins ymusculophrenic 4-:passes between slips From Wis ethribs: @) the lower 5 intercostal nerves — pass between the slips of Gostal ortgin @)LE phuenicn- pierces the Lt-cupola of diaphragen {5} the greater 8 lesser - splanchnic nerves + pieie the corresponding cras of Uie diaphragm (6) Subcostal n-s.vessels pass behind let-arcuate big-—“\ psympathetic chain passes behind med.arcuate lig: B)intf-hemiazyges y. pierces the Lecrus Naam WeB:10 the Verlebro Costal Ais a triangular gop between the vertebral costal origins which is wider on the Lt-side - Abdéminal contents may herniate Uwough this gap inlo the thorax (Congenital diaphragmatic hernia of Bockdalek)- the. Sternocastal zis a small triangular gap between the sternal costal origins ‘IE may lead to herniation of an intestinal loop into thorax (congenital parasternal hernia ¥Relations of the diaphragm: (Ayupper surface : g)its central tendon: is related to the pericardium & heart: gate RE-cupola :is related lo Rt. pleura % base oF RE-lung Qithe Le-cupola:» » » LE- pleura & base of Lt- lang (8) Lower Surface: Rt lobe ofthe iver (wits BE: sideis related fo py. Kidney 8,kt-suprarenal gland a ed lobe of the liver : ay @ its He sideis related oe kidney z.Lt-suprarenal gland e Spleen stomach & spleen: . “¥Applied anatomy : uy Hiccough is tie result of spasmodic contraction of the diaphragen- (giirritation of the diaphragm Causes referred pain inthe shoulder because the phrenicn- sensory to diaplragin) ache supraclavicular nn. (sensory {athe shoulder) have Uhesame rob Vale (2) Byingury of one pe in lends to paradoxical diaphragmatic movements i-e the normal cupola descends down while the paralysed cupola moves up with cach inspiration (i acrired hiatus hernia: widening of the esophageal opexiig of diaphragm—s-herniatioyt EEE of ‘lonach into the age epee type of internal hernias)2-Psoas major muscle- —— i Tis along fusiformm lyingancither side of the lumbar vertebral Column along the side of the pelvic brim. | ¥Origin: (from the ant-surfaces of the Slumbar Lransvers processes <— @by 5 ships, each of which arises from the bodies of Ewo adjacent verlebrae & the disc inbetween (the highest slip arises From the 1204 thoracic vertebra): | @plrom the tendinous arches which bridge over the lumbar vessels on the sides of lumbar verlebme! a#Course: the lower part: of the muscle leaves the abdomen by passing behind the lat-part of the inguinal ligament: closely related ty the iliacus muscle. Insertion: = \ Together with lacus, it forms te ilopsons tendon ——~ ee which is inserted into ant-g med. aspects of lesser trochanter of femur —~ Nerve Supply: ventral rami of £ 1,2,3- Action: Fe acting From above: it is «.powerlil Hlexor of the thigh dalso rotates tt medially ‘acting from below sit produces Hexion of Ue pelvis over the thigh (e-g when rising from the recumbent position 3-one psoas: produces lateral Flexion of the vertebral column fowards its side WB:in frackure neck of femur, the muscle retales Ue thigh laterally Relations. ; E-Medially : it is related to (i) bodies of Jumbar vertebme a lumbar vessels @) sympathetic chain ————— Ser rereEee eee @)external iliac vessels (along the pelvic brim) (4) I-V-C overlapping the Rt- psoas major in. ) hort & parmaortic LNs: anteromedial to Lt- psoas, N (6 obturator 1. & lumbosacral trunk & iliolumbar a- in the lumbosacral A whichis a triangular gap between xa) med- border of psoas mayor (by body of L5 vertebra (c) the ala of sacrum.T- Latera Hy Calong its Jat-border): 2muscles hi nerves: 104 @) quadratus Jumborum muscle (inthe upper part)- gy iliacus muscle (in the lower part). @ iliohypogastric nerve dilioinguinal nerve (e) lateral cutaneous nerve of thie ©) femoral nerve as T-Anterolateral relations: medio arcuate big. of diaphragen @ psoos mirtor m- (iF present) @inferior vena. Cava y and part of duodenur {(5) RE- Kidney, renal vessels useler 5) RE- gonadal vessels agenitofemoraln (7) Sup-mesenteric a- Bits RE |_ colic Rileocolic branches (@)Lerminal ileum & coecuin- ) RE- inguinal ligament W- Posterior relations: (medial border of quadratus lumborum muscle: = (eylumbar arteries- aoe (gylumbar transverse processes: a ) lumbar plexiss (embedded in the post-partof the muscle so copsule of the hip yoink inthe thigh)- Psoas fascia (sheath) itis a fascial sheath enveloping Ure psoas mayor muscle throughout its whole length down toits insertion ~ Aboverit is thickened to form the medial arcuate lig- ~ medially ‘itis attached to the Jambar vertebrae~ laterally sit blends with the Fasciae covering quadratus lumborum & iliacas muscles 105 ¥Applied anatomy : Psoas abcess : pus arising from tuberculous abcess of lumbar spreads to the psoas sheath xtracks downwards within the sheath to reach the front ofthe thigh just: below the inguinal liganent» 3. Psoas_minor muscle ¥Itis along slender muscle lying infront of psoas mayor in 607. of people. From the sides of Ti2 & 1 vertebrae & the disc inbetween- by along flat tendon into the iliopubic eminence of hip bone Nerve supply: by branch from Li nerve- x Action : weak flexor of the trunk. _ 4-ILIACUS Asec lowerlimb) __ 5- _ Quadratus fumborum muscle. ¥Ikis a.qudrilateral muscle lying posterolateral lo psoas major 1m Origin : From iliolumbar lig. the adyoining Sci of inner lip oF hac crest- @ med Js of the lower border of the last rib: 2Nerve Supply : brs-from the nth thoracic x upper fy lumbar an. | Action: 0) lateral Flexor of the vertebral column. (muscle of inspiration zing Jost rib during the'contraction of the diaphragm - . #Relations: T-Anteriorly :itis covered by the ant-layer of thoracolumbar smnmmmaniee fascia & is related to: lateral part of psoas mayor muscle- @ the kidney. ) Colon (ascending on the RE-side x descending on the Lt) Witis crossed by the Followiig nerves : “ feopyesin | above downwards. (ilioinguinal n- IL-Posteriorly : itis covered bymiddle layer of thoracolumbar Fascia nmacanemniomninon is related fo Sacro spinalis muscle.\ Se—int-abd-oblique Thoracolumbar fascia Fi—tensveses a . : \ Se —latissimus dorsi LOG vaste Mayers of thorocobunbar Fecia # ILisa strong sheet of deep Fascia which covers senvelops most of the deep inusclesof the back 2 binds them to the vertebral column ] 4s Extent :itextends from the sacrum below to the neck above bub ibis well developed inthe lamber ron. w Layers * in the lumbar regionit differentiates into 3 layers: Wanterior layer : covers Use ant--surface of quadratus lumboruin m-3is attached ta the ant-aspect of the transverse processes of he lumbar vertebrae- layer + covers the post surface of quadrabus lumborumn (separating it From erector Spinue 1.) 3s attached lo the bips of Ue Lrans verse process oF lumbar vertebree. tg) posterior layer: covers the post-surface of erector spitiee (sacrospinalis) n-3js attached imedially to the spines of the lumbar vertebrae. NN.B: w the post-layer is the strongest one aextends upto the neck xdows lo the sacrum qyot the lat-border of quadratus lunaborum the. ant-2 middle layers Fuse together ‘Au this Fusion gives origin to 3mmuscles : a) bransversus abdominis & internal abd- oblique __ OQ latissionus dor 2 EUMBAR VERTEBRAE * Characteristics: (nthe body? lane in size, kidney.shaped &has no Costal facets () Hie verkebral foramen is, small m size tcbriangular in outlines @ the transverse process is Flat kelongated. - ‘W) the sup-articular Facets are Concave Adiected medially ©)» Inf» wy Conver & » laterally» Lert Ole spine is quadrilatera) s.proyects directly backwards. * nag: the slit lumbar verbebra differs From the rest its havittg id a. tick strong Lransverse process which is attached be the pedicle ( Siracares attached tothe bodies of verlebme| Structures attached to the Lranswase presses (yanit-g,post--longitudinal ligaments - tjpseus major kquadrakas lumboram muscles a) RE-a14-crus of the diaphragm - @plat-Symed-arcuate ligs-of the diaphragen @) psoas mayor aminor aniscles @)iliolunbar fig. (to L5 only) ) lumbar intervertebral discs - (lumbar fascia & sacrospinalis muscleNerves of posterior abdominal wall 1- Lumbar plexus ‘sittin £5) oan ne ag 7 Subcostal a. c = —lliohypegastrie m. -lioingvinel n. Genitofemorai a. dag fo Sal UBIG?E LOFFOULIOY Lot. bala, wo. ‘amo Za wal btn *SIEC sit ties inside the past-part of the substance of psoas major-m.initheabdomen formation : by the ant- I ransi of the upper f, lumbar nerves (Ly 2»35l)-Each of which Cexcept L1) divides into ant (ventral) % post- (dorsal )divisions | xBranches of the plexus : Large branches | Smali branches _Distribution of theroots of the plexus (i) Femoral n. | (3yiliohypogastric (L1) as _ Miohypogastsicn. From post-divisions |...) 800227 SMES— Hioinguinal n- oF eos tee ay ie stro of enitofemoraln- (s)genitofemoral (1.152, 211d rook of genitokemoral n- dbturator 1. (6) lat-cut-n-of thigh | +2 gives Ke wot “at cane igh From ant-divisions eee 188 reot of obturator. of 12,34 (post-divisions of L253 1st root of femoral n- He Toot of lab-cut-tt-of thigh. (7) Accessory obturator n- is fr requently 1.3 gives << and reot of Moen present and arises From the ventral divisions id root of Femtoral ri: 3BALy 23rd rook of obturator 1- Ly gies rd root: of femoral n. ipper rook of lumbosacral trunk, »EXit of the branches from the psoas major muscle : @ Se TE ata a pemerge From the medial border of pseas mayor @) lumbosacral trunk-Wpilichypogastric n- 108 Oilio inguinal nerve S emerge fi 2 E st la, ea 7 merge. from the lat border of psoas mayor (1) Femoral nerve (3) Genitofemoral nerve :emerges from the ant-Surlace of psoas mayor. _NeBifor details of the branches of the unbar plexus : See lower limb- 2 Lumbor part of the sympathelfe chain Begins aenters the abdomen : by passing behind the med. arcuate lig. of the dlaphraginé » Course g relations + : cet ‘ ~each symp-chain descends verbieally downwards on the side of lunbar vertebrae along the med: border of psoas major muscle ‘ = the Ré-chain: lies behind the L-V.c: =the LE chainlies on the Lt.side of the abd-aorta- + Each chain leaves the abdomen genters the pelvis by passing behind the common iliae vessels fo continue as the pelvic part of the symip.chain- ¥ Ganglia: each chain contains 4 ganglia » Brunches: (A) Rami comunicantes (lat. branches): ~ each ganglion of te 4 lumbar ganglia gives of 0 gfey ramus Communicans (postganghonic) to the corresponding lumbar nerve- = each of the Ist a, 2nd garighia receives a white ramus ' » Ib receives the following tributaries: \ trunk : drairting the lymph From the intestines Reerus h trunks : draining the lower linbs Sal the abdomen except the upper surface of the liver. alts upper end tapers forming the thoracic duct-Index of Contents Page ( Anterolateral abdominal wal] ——_——__—_——-I-I7 @) Inguinal canal xinguinal hernias 18-22 (3) Male external genital orgat's-———_—— 22-27 (0 Abdominal cavity 2 peritoneum ——______—_————28-37 (6) Stomach— 38-42 (6 Small intestine (cluodenum , Jejwnunyt ileum) ————-43- 49 (p Large intestine $$ 50-57 3) Liver- —______—___----—- 58-66 (Biliary system 67-9 -@) spleen—_________________70-72 an pancreas ____________B-75 (0) Blood supply of the 6-1-7 ——_____—76-8s (8) supra renal gland. Sees 86 ( The kidrieys 87-99 (9) «Urebers 8-2 6) Abdominal aorta __— 93-96 (a Inf-Vena cava 97-99 03) Diaphragm 100 ~ 102 (9 Muscles of the post. abd. Wall____—103-l06 (20)Nerves of the abdomen s.autonomic plexuses 407-110 (a) Abdominal lymph nodes———----————1l1avo wun ionazu z = de we og Atoure