ABDOMEN - Improving care in ED



ABDOMEN

Foregut: from mouth to duodenum (at entrance of bileduct)

Midgut: ( 2/3 across transverse colon

Hindgut: ( to end

Regions

Vertical lines: midclavicular to midinguinal

Transverse lines: subcostal plane (inf border of 10th costal cartilage); transtubercular plane (iliac tubercles @ level of L5)

Anterolateral abdo wall bounded by cartilages of 7-10th ribs and xiphoid process, inguinal ligament and pelvic girdle (iliac crests, pubic crests, pubic symphysis)

Ant Abdominal Wall

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Arcuate line: point where all flat ab muscles pass ant to rectus abdominus, half way between umbilicus and pubic bone

Nerves:

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Veins:

1) Superior epigastric and branches of musculophrenic vessels

2) Inferior epigastric and deep circumflex iliac vessels ( drain to great saphenous, or superiorly to lat thoracic, intercostal, and in thoracic veins

3) Superficial circumflex iliac and superficial epigastric vessels

4) Post intercostals and subcostal vessels

Arteries:

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Post Abdominal Wall

Parietal peritoneum / Endoabdominal fascia / psoas or thoracolumbar or quadratus lumborum fascia / muscle

Psoas major: long, thick, fusiform; from transverse processes of L and bodies of T12-L5 ( passes deep to inguinal lig to lesser trochanter; innervated by lumbar plexus L2-4

Iliacus: large, triangular; sup 2/3 iliac fossa, ant SI lig ( crosses SI jt to join tendon of psoas; innervated by femoral nerve

Quadratus lumborum: med ½ inf 12 rib and lumbar transverse process ( runs beside lumbar transverse processes ( iliolumbar lig and iliac crest

Subcostal nerve: ant rami T12 ( post to lat arcuate lig ( run on ant surface quadratus lumborum ( through transversus abdominis and in oblique

Lumbar spinal: L1-5 ( post rami ( supply muscles and skin of back

Ant rami ( skin and muscles of lower trunk and limb

Inguinal Region

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Inguinal ligament: extends from ASIS to pubic tubercle – formed by aponeurosis of ex oblique.

Lacunar ligament: most medial; formed when some fibres pass posteriorly onto pectineal line of pubis

Pectineal ligament: the very lateral fibres of lacunar ligament as they run along pecten pubis.

Reflected inguinal ligament: superior fibres cross linea alba and blend with contralateral ex oblique aponeurosis

Conjoint tendon: infmed fibres of in oblique merge with transversus abdominis

Inguinal canal: oblique passage 4cm long; lies parallel to inguinal ligament.

Boundaries: post = transversalis fascia ( transversalis fascia ( conjoint tendon

ant = ex oblique and in oblique (for lat 1/3)

roof = transversalis fascia ( in oblique ( ex oblique

floor = iliopubic tract ( inguinal ligament ( lacunar ligament

Opening at either side:

a) Deep inguinal ring: entrance to inguinal canal; sup to inguinal ligament, lat to inf epigastric artery, 2-4cm suplat to pubic tubercle; where transversalis fascia evaginated; ilioinguinal nerve DOES NOT pass through this

b) Superficial inguinal ring: exit; split in ex oblique aponeurosis suplat to pubic tubercle (med and lat crus)

Inguinal hernias:

a) Indirect: protrude through inguinal ring; results of failed closure of deep inguinal ring; lateral to inferior epigastric vessels; is within spermatic cord; more common

b) Direct: enters through weak Hesselbach’s triangle (bounded by RA medially, inguinal ligament inferiorly, inf epigastric vessels suplat) in post wall; medial to inferior epigastric vessels; less common; lies outside inner 1-2 fascial coverings of spermatic cord

Contents:

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R testicular vein enters IVC, L testicular vein enters L renal vein

Internal spermatic fascia = tunica vaginalis communis

Artery: testicular artery come from ab aorta inf to renal arteries ( pass retroperitoneally obliquely over ureters and ex iliac arteries ( through deep inguinal ring into inguinal canal through sup ring

Scrotum

Layers: heavily pigmented skin; dartos fascia (responsible for rugae, continuous with Scarpa fascia and Colles fascia); then ex spermatic, cremaster, in spermatic… then testis

Divided by septum which is seen externally as scrotal raphae

Blood supply: int pudendal ( sup perineal (post scrotal branches)

Femoral ( sup and deep ext pudendal (ant scrotal branches)

Inf epigastric ( cremasteric

Nerve supply: ant lat – genital branch of genitofemoral nerve (L1-2)

Ant – Ilioinguinal nerve ( ant scrotal nerves

Post – pudendal nerve (S2-4) ( posterior scrotal nerves

Inf – post femoral cutaneous (S2-3) ( perineal branches

Testis

L testis hangs more inferiorly than R

Layers: Tunica vaginalis (parietal and visceral)

Tunica albuginea (tough fibrous inner) ( forms mediastinum of testis and septae which form

Lobules

Tunica vasculosa

Parts: seminiferous tubules (sperm produced) ( straight tubules ( rete testis pass up and backwards ( efferent ductules in head superiorly perforating tunica albuginea ( body of epididymis heading inferiorly ( epididymal duct in tail postinferiorly ( ductus deferens heads upwards

Epididymis lies on postlat border; sinus of epididymis lies between testis and pouch

Appendix of testis lies on upper extremity just below head of epididymis; appendix of epididymis lies on head of epididymis

Blood supply: testicular arteries – from antlat ab aorta, descend retroperitoneally INFRONT of ureters and ex iliacs ( enters inguinal canal at DEEP ring

Venous drainage: veins from Pampiniform plexus ant to ductus deferens ( R testicular vein to IVC, L testicular vein to L renal

Diaphragm

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Peritoneal Cavity

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|Structure |From |To |Contains |

|OMENTA |

|Greater omentum |Greater curvature of stomach and prox duodenum |Ant transverse colon |NB. Composed of 4 layers of |

| | | |peritoneum |

|Lesser omentum |Lesser curvature of stomach and prox duodenum |Liver |Lies post to L lobe of liver, |

| | | |attached to liver in fissure for |

| | | |ligamentum venosum, attached to porta|

| | | |hepatis |

|MESENTERIES |

|Mesentery proper |Small intestine |Post abdominal wall |Sup mesenteric art |

|Transverse mesocolon |Transverse colon, continuation of greater omentum |Post abdominal wall |Middle colic art |

|Sigmoid mesocolon |Sigmoid colon |Pelvic wall |Sigmoid arts |

|Mesoappendix |Mesentery of ileum |Appendix |Appendicular art |

|LIGAMENTS |

|Gastrosplenic |Stomach, from greater omentum, L part |Spleen |Short gastric art, L gastro-omental |

| | | |art |

|Gastrophrenic |Stomach, from greater omentum, sup part |Diaphragm | |

|Gastrocolic |Stomach, from greater omentum, apron part |Transverse colon | |

|Splenorenal |Spleen |Kidney |Splenic art, tail of pancreas |

|Hepatogastric |Lesser curvature of stomach – makes lesser omentum |Liver | |

|Hepatoduodenal |1st 2.5cm duodenum - makes lesser omentum |Liver |Hepatic art, hepatic portal vein, |

| | | |bile duct (portal triad) |

|Falciform |Ant Liver, ligamentum teres is obliterated remnant of L|Diaphragm, ant abdo wall |Round ligament of liver, |

| |umbilical vein and lies in free edge (upper border) of | |paraumbilical veins |

| |falciform ligament extending to umbilicus | | |

|Round |Liver |Umbilicus | |

|Coronary |R lobe Liver, over sup aspect, split into sup an inf |Thoracic diaphragm | |

| |layers; on either side of bare area of liver | | |

|Ligamentum venosum |Liver |Liver | |

|Phrenicocolic |L colic flexure |Thoracic diaphragm | |

|L+R triangular |R formed by fused parts of coronary ligament | | |

| |L formed by falciform ligament | | |

|Broad |Uterus |Lat pelvic wall |Mesovarium, mesosalpinx, mesometrium |

|Ovarian |Uterus |Inguinal canal | |

|Suspensory |Ovary |Pelvic wall |Ovarian art |

|Hepatorenal |Postinf R lobe liver |R kidney | |

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Peritoneal fold: reflection of peritoneum with sharp border; infraumbilically there are 5 peritoneal folds (2 on each side and 1 in median plane)

1) 1 Median umbilical – covers median umbilical ligament (remnant of urachus), extends from urinary bladder to umbilicus

a. SPLIT BY SUPRAVESICAL FOSSAE

2) 2 Medial umbilical – lateral; cover medial umbilical ligaments formed by obliterated umbilical arteries, extends from in iliac arteries to umbilicus

a. SPLIT BY MEDIAL INGUINAL FOSSAE

3) 2 Lat umbilical – lat to medial; cover inf epigastric arteries; extend from deep inguinal ring to each side of arcuate line

a. LAT INGUINAL FOSSA LAT TO LAT UMBILICAL FOLD

Peritoneal pouch:

1) Rectouterine – separates rectum from uterus in women

2) Rectovesical – separates rectum from bladder in men

3) Vesicouterine – separates bladder from uterus in women

Factoid: in women peritoneum is not a closed sac, uterine tubes open into it

aAlimentary Tract

Blood supply: from aorta ( celiac trunk, sup and inf mesenteric

Venous drainage: portal vein (from union of sup mesenteric and Splenic veins)

Oesophagus

25cm; passes through oesophageal hiatus in R crus of diaphragm at T10, attached here by phrenicoesophageal ligament; ends at cardinal orifice of stomach L of T11; diaphragm forms inferior physiological sphincter

Blood supply: L gastric artery (from celiac trunk), L inf phrenic artery

Venous drainage: submucosal veins ( L gastric vein ( portal venous system

( oesophageal veins ( systemic venous system

Nerve supply: oesophageal nerve plexus from vagal trunks and thoracic sympathetic trunks (from greater splanchnic nerves and periarterial plexuses)

3 constrictions

1) Cervical: at pharyngoesophageal junction caused by cricopharyngeus muscle

2) Thoracic: where crossed by arch or aorta and L main bronchus

3) Diaphragmatic: where passed through oesophageal hiatus of diaphragm

Stomach

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Ligaments: Hepatogastric ligament attaches to lesser curvature, contains L+R gastric arteries

Gastrosplenal ligament attaches to greater curvature

Gastrophrenic ligament attaches to post stomach

Nerve supply: ParaS: ant (L) vagal trunk ( ant gastric branches – lies on ant surface of oesophagus,

runs on lesser curvature; controls pyloric sphincter

post (R) vagal trunks ( celiac branch ( post gastric branch– lies on post

surface of oesophagus, runs on lesser curvature

Sym: greater splanchnic nerve ( celiac plexus

Blood supply: Celiac trunk ( L gastric

Celiac trunk ( Hepatic artery ( R gastric

Celiac trunk ( Splenic artery ( L gastroepiploic and short and posterior gastric

Celiac trunk ( hepatic artery ( Gastroduodenal ( R gastroepiploic

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Transpyloric plane: halfway between jugular notch and upper border of symphysis pubis; cuts through pylorus, tips of 9th costal cartilages, lower border L1, fundus of GB, neck of pancreas, origin of SMA and portal vein (ie splenic vein joining SMV), root of transverse mesocolon, DJ junction, D2, termination of spinal cord, spleen. R hilum kidney is just above, L hilum kidney is just below.

Duodenum

C-shaped, around head of pancreas; from pylorus to duodenojejunal junction; all but 1st part are retroperitoneal; 25cm long; fixed

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Lymph: ant lymphatic vessels ( pancreaticoduodenal nodes (situated along sup and inf PD arts) (

pyloric nodes

post lymphatic vessels ( pass post to head of pancreas ( sup mesenteric lymph nodes

Jejunum and Ileum

Jejunum in LUQ, ileum in RLQ; jejunum is 2/5, ileum 3/5; jejunum red, wide and thick walled, large valvulae conniventes (present in lower duodenum maximally), large villi, less lymph nodules, sparse arcade; ilium pink narrow and thin walled, few circular folds, multiple Peyer’s patches, multiple arcades

Mesentery: attaches jejunum and ileum to post ab wall (root at L side of body at L2 to R SI J); from duodenojejunal junction at L2 to ileocolic junction at R SI joint; passes duodenum, ab aorta, IVC, R ureters, R psoas major, R testicular and ovarian vessels

Blood supply: SMA – branches form arterial arcades ( vasa recta (straight arteries)

Venous drainage: SMV – lies ant and to R of SMA

Lymph: pass to 4 groups of nodes: juxta-intestinal (near intestinal wall), mesenteric (along arterial arcades), and superior central (along prox SMA), ileocolic

Nerve: perivascular nerve plexus surrounds SMA and branches

Sym: T8-10; sympathetic trunk and thoracic abdominopelvic splanchnic nerves ( sup mesenteric

plexus ( synapse on celiac and sup mesenteric ganglia

ParaS: post vagal trunks ( synapse on myenteric and submucosal plexuses

Cecum and Appendix

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Colon

1.5m long; Can distinguish LI from SI by: omental appendices (not found in appendix, cecum or rectum), teniae coli (3 thickened bands of smooth muscle (mesocolic, omental and free; not found in appendix or rectum; converge at vermiform appendix), haustra, greater caliber, sacculated.

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Descending colon – retroperitoneal; 30cm

Post is L subcostal gonadal and ex iliac vessels; iliohypogastric, Ilioinguinal, lat femoral cutaneous and genitofemoral nerve

Sigmoid colon

Has long mesentery and therefore mobile; 15-45cm; crosses common iliac artery bifurcation, ureters and SI jt

Blood supply: IMA ( L colic and sigmoid artery

Venous drainage: IMV

Lymph: epicolic and Paracolic nodes ( intermediate colic nodes on L colic artery ( inf mesenteric nodes

Nerve: from ab aortic plexus via periarterial plexuses

Sym: from lumbar part of sympathetic trunk ( lumbar splanchnic nerves, sup mesenteric plexus

and periarterial plexuses

ParaS: pelvic splanchnic nerves ( inf hypogastric nerve

Rectum

Retro and subperitoneal; commences at S3

Spleen

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Pancreas

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Retroperitoneal in transpyloric plane; posterior to stomach, SMA and SMV, lesser sac, transverse mesocolon (attached to ant margin); inf to splenic artery; ant to L crus of diaphragm, psoas, R renal vein, L kidney, IMV, splenic and portal vein, aorta

Ampulla of Vater: Wirsung duct opens into D2 at major duodenal papilla. Accessory pancreatic duct (Santorini) opens into duodenum at minor duodenal papilla

Blood supply: celiac artery ( hepatic ( Gastroduodenal ( sup pancreaticoduodenal arteries ( head

SMA ( inf pancreaticoduodenal ( head

Splenic artery provides branches ( body and tail

Venous drainage: pancreaticoduodenal ( splenic vein ( portal vein

Lymph: pancreaticosplenic and pyloric nodes ( hepatic nodes ( sup mesenteric or celiac nodes

Nerve: vagus and abdominopelvic splanchnic, passing from celiac and sup mesenteric plexuses

Liver

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Gallbladder

Bile duct: runs between folds of lesser omentum

Blood supply: cystic artery (prox), R hepatic artery (middle), post sup pancreaticoduodenal artery and Gastroduodenal artery (distal)

Venous drainage: post sup pancreaticoduodenal vein ( portal vein

Lymph: cystic nodes near neck of GB, node of omental foramen and heptiac nodes ( celiac

Gallbladder:

Lies on visceral surface of liver @ junction of R + L parts; ant to duodenum

Fundus – lies at levels of 9th costal cartilage in MCL

Blood supply: Celiac ( hepatic ( R hepatic ( cystic artery (arises in angle where cystic and hepatic ducts meet, note that arteries lie post to ducts)

Venous drainage: cystic vein ( portal vein or drain directly into liver

Lymph: hepatic nodes and cystic ( celiac

Nerve: ParaS: vagus

Sym: celiac

Visceral afferent: celiac

Somatic afferent: R phrenic

Kidneys

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Suprarenal: R gland pyramidal in shape, more apical, makes contact with IVC and liver; L gland crescenteric, lies medially over kidney; veins and lymph leaves at hilum

Lymph: Renal and suprarenal vessels ( R+L lumbar

Middle ureters ( common iliac

Lower ureters ( common, ex and in iliac nodes

Nerve: Renal, ab aortic and sup hypogastric nerve plexuses

Factoids: Has a short dilated region just prox to ex urethral meatus

Is horizontal in cross-section when empty

Bulbous part is part of spongy urethra

Arteries

Ab Aorta:

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Coeliac Trunk:

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Superior Mesenteric Artery:

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Supplies: from 2nd part duodenum ( splenic flexure;

Relations: arises at L1; 1cm below celiac trunk; passes under neck of pancreas and splenic vein; anterior to L renal vein, 3rd part of duodenum and uncinate process of pancreas; to L of SMV; descends between layers of mesentery to RIF; passes infront of IVC, R ureter and psoas major

Branches: Inferior pancreaticoduodenal – opposite inf duodenum, courses between head of pancreas

and duodenum; to head of pancreas and distal duodenum

Intestinal (12-15) – to ileum and jejunum; form arches

Ileocolic – to cecum and appendix; divides into inf and post branch; inf anastomosis with

SMA and gives off cecal, appendicular and ileal branches; sup anastomoses with R colic

R colic – to ascending colon; R internal spermatic vessel, R ureters and psoas major;

divides into descending branch (anastomose with ileocolic) and ascending

branch (anastomose with middle colic)

Middle colic – to transverse colon; arises just below pancreas

Branches anastomose to form marginal artery along inner border of colon

Renal Arteries:

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Suprarenal arteries also split into sup and middle suprarenals; arise opposite SMA

Internal Spermatic Artery

Arise below renals, pass behind peritoneum, on psoas; R is infront of IVC and behind middle colic and ileocolic and terminal ileum; L is behind L colid and sigmoid arteries; each is INFRONT of ureters and ex iliac artery ( pass through deep ring

Inferior Mesenteric Artery:

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Comes from ab aorta ½ way between origin of renal arteries and bifurcation, 3-4cm above bifurcation, at L3, behind inf border of D3, @ level of umbilicus; passes ant then to L of aorta, crosses ant to L common iliac

Supplies: splenic flexure ( upper rectum

Branches: L colic – supplies descending colon; runs to L behind peritoneum infront of psoas major, divides

into ascending (crosses infront of L kidney to anastomose with middle colic) and

descending (anastomose with sigmoid)

Sigmoid (2-3) – run to L behind peritoneum, infront of psoas, ureter and in spermatic vessels

Sup rectal – terminal branch; name changes as passes over pelvic brim; main source of blood

supply to rectum

Veins

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Portal vein: formed by union of splenic vein and SMV ant to IVC and post to head of pancreas (@ level of L1) ( divides into L + R branches before enters liver at porta hepatis ( runs within hepatoduodenal ligament ( become hepatic sinusoids ( enter hepatic veins which drain into IVC.

Receives L gastric: runs in lesser curvature; drains stomach

Receives oesophageal: drains oesophagus

R gastric: runs in lesser curvature; drains stomach

Cystic: drains GB

Portal-systemic anastomosis occur at inferior oesophagus, anal canal, paraumbilical area, in bare area of liver.

Splenic ( joins SMV ( portal: drains stomach, pancreas, LI, duodenum and spleen; is beneath splenic artery, is straight

Receives short gastric: fundus and L greater curvature; run in Gastrosplenic ligament

L gastroepiploic: drains stomach

Inferior and superior pancreaticoduodenal: drains pancreas and stomach

SMV ( joins splenic ( portal: drains stomach, pancreas, appendix, duodenum, jejunum, ileum and transverse colon

Receives R gastroepiploic: runs between 2 layers of greater omentum; drains stomach

Iinferior pancreaticoduodenal

Ileocolic: drains cecum, appendix and ascending colon

Ileal

Middle colic: drains transverse colon

R colic: drains ascending colon

IMV ( drains into splenic vein: drains large intestine, sigmoid colon, rectum

Receives L colic vein: drains descending colon

Sigmoid

Superior rectal vein

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Nerves

Sympathetic innervation

Abdominopelvic splanchnic nerves arise from ant rami and are presynaptic:

T5-9 ( greater splanchnic nerve ( celiac ganglion ( liver, gallbladder, pancreas

T10-11 ( lesser splanchnic nerve ( sup mesenteric ganglia ( suprarenal, kidney, gonad

T12 ( least splanchnic nerve ( aorticorenal ganglia ( suprarenal, kidney, gonad

L1-3 ( lumbar splanchnic nerve ( intermesenteric, inf mesenteric, sup hypogastic ganglia ( large

and small bowel

Once synapsed in ganglia, pass via periarterial plexuses to organ

Visceral afferent (pain) accompany sympathetic fibres ( through post root to spinal sensory ganglia

Segments:

T6-8 Spleen T6-L2 Suprarenals

T6-9 Stomach T10 – L1 Kidneys

Pancreas L2 Lower descending colon

T8-12 Small intestine S2 Sigmoid colon

T8 Cecum and ascending colon S4 Rectum

T10 Transverse colon

T12 Descending colon

Parasympathetic:

Travel with visceral afferent (pain) fibres

1) Ant (L) and post (R) vagal trunks – pass through oesophageal hiatus on ant and post aspects; synapse at plexuses; supply foregut and midgut

2) Pelvic splanchnic nerve - arise from ant rami of S2-4; travel to inferior hypogastric plexus beside rectum; regulate emptying of urinary bladder and rectum, and erection (not ejaculation); supply hindgut and pelvis

Abdominal autonomic plexuses: networks of sym and paraS fibres surrounding aorta and major branches

1) Celiac plexus: R+L celiac ganglia unite. ParaS from post vagal trunk; sym from greater and lesser splanchnic nerves

2) Sup mesenteric plexus: contains branch from celiac plexus and from lesser and least splanchnic nerves

3) Inf mesenteric plexus: receives root from intermesenteric plexus and lumbar ganglia

4) Intermesenteric plexus: between sup and inf; gives risde to renal, gonadal and ureteric plexuses

5) Sup hypogastric plexus: receives root from intermesenteric and inf mesenteric plexuses; supplies ureteric and testicular plexuses

6) Inf hypogastric plexus: attached to sup by hypogastric nerves

Lumbar Plexus:

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Factoid: genitofemoral nerve runs on ant border of psoas major

Distinguishing Features

IN DUODENUM:

S-cells: secrete secretin in duodenum in crypts of Lieberkuhn

I-cells: secrete cholecystokinin in duodenum ( release of enzymes and bile from pancreas and gallbladder

Brunner’s glands: tubular submucosal glands in duodenum; produce alkaline secretion to protect duodenum from chime and active intestinal enzymes

IN ILEUM:

Paneth cells: defense against microbes in ileum; secrete alpha-defensins known as cryptdin, lysozyme and phospholipase A2

Peyer’s patches: secondary lymphoid organs, found in lower ileum

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Fascia:

1) Camper fascia (superficial, fatty)

2) Scarpa fascia (deep, membranous) – extends to perineum to be Colles fascia, and to thigh as fascia lata

3) Investing fascia – cover muscles, attached to them

4) Endoabdominal fascia – deep to muscles, named depending on muscles overlying (eg. transversalis fascia). Parietal peritoneum underlies this layer

Muscles: all have long sheet-like aponeurosis ( form rectus sheath which encloses rectus abdominis and pyramidalis ( form linea alba in midline

Bladder is between peritoneum and transversalis fascia

IN SPERMATIC CORD:

Vas deferens

Artery to vas – from inf vesicular artery

Testicular artery (from aorta)

Testicular vein (from IVC/L renal)

Cremasteric artery and vein (from inf epigastric)

Pampiniform venous plexus (lie ant to vas)

Sympathetic nerve fibres

Genital branch of genitofemoral nerve (motor to cremaster, sensory to scrotal skin)

Lymphatics

Vestige of processus vaginalis

IN CANAL BUT NOT SPERMATIC CORD:

Cremasteric fascia

Cremaster muscle – innervated by genital branch of genitofemoral nerve

Ilioinguinal nerve

Parietal: pain is well localized

Visceral: stimulated by stretching or chemical irritation; pain is poorly localized

Peritoneal cavity: potential space between parietal and visceral layers

Omental bursa (lesser sac): large diverticulum of peritoneum. It communicates with greater sac through epiploic foramen situated post to hepatoduodenal ligament, ant to IVC and R crus of diaphragm, below liver, above D1.

Compartments: Transverse mesocolon splits abdo into supracolic compartment (stomach, liver, spleen) and infracolic compartment (SI, colon). Infracolic compartment divided into L and R infracolic spaces by mesentery proper. Paracolic gutters allow communication between supra and infracolic compartments.

Mesentery: double layer of peritoneum by invagination of peritoneum by an organ, so there can be neurovascular communication between organ and body wall

Bare area: allows passage of neuroV structures

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Cardia: surrounds cardial orifice; at T10 to L of midline

Fundus: limited inferiorly by horizontal plane of cardial orifice; sup part reaches 5th IC space

Pyloric antrum leading to pyloric canal (at upper L1 to R of midline) to sphincter – contains more rugae

Angular incisure is notch in lesser curvature

Lies to L of midline

Greater curvature goes up to 6th costal cartilage

Anterior: abdo wall, L costal margin, diaphragm, L lobe liver

Posterior: lesser sac, pancreas, transverse mesocolon and colon, L kidney, spleen

Superior: L dome of diaphragm; L and quadrate lobes of liver

Covered by lesser omentum; on R is R celiac ganglion and caudate process of liver; on L is L celiac ganglion and cardia of stomach, below is pancreas

1- Splenic – runs above sup pancreas, above splenic vein, post to omental bursa, ant to upper pole of L kidney ( transverse Splenorenal ligament to hilum of spleen; supplies pancreas via pancreatic branches, spleen and greater curvature of stomach; is tortuous

a) L gastroepiploic – passes along greater curvature in greater omentum; supplies greater curvature

b) Short gastric – passes to fundus between layers of

Gastrosplenic ligament; supplies fundus; anastomose with L

gastric and L gastroepiploic

c) Posterior gastric – along post wall of lesser omental sac to Gastrophrenic ligament; supplies post wall and fundus

2- L gastric – ascends to oesophageal hiatus post to omental bursa ( along lesser curvature to anastomose with R gastric; supplies distal oesophagus and lesser curvature of stomach

a) Oesophageal and cardia branch

3- Hepatic – passes to upper sup duodenum ( crosses portal vein anteriorly and ascends between layers of lesser omentum ( bifurcates into R + L hepatic arteries at porta hepatis; supplies liver, gallbladder, biliary ducts (lie on R), stomach, duodenum, pancreas, liver

a) R gastric – arises above pylorus ( runs along lesser curvature; supplies lesser curvature

b) Gastroduoedenal – descends between sup duodenum and neck of pancreas ( supplies pylorus ( divides at lower border of duodenum; supplies stomach, pancreas, D1, bile duct

i. R gastroepiploic – passes along greater curvature of stomach between layers of greater omentum

ii. Sup pancreaticoduodenal – divides into ant and post branches on either side of pancreatic head; supplies prox duodenum and head of pancreas; anastomosis with inf branch from SMA

R hepatic gives off cystic artery

Venous drainage:

R and L gastric veins ( portal vein

Short gastric and L gastroepiploic ( Splenic vein

R gastroepiploic ( SMV

Lymph: accompany arteries;

Sup 2/3 ( R+L gastric, short gastric and L gastro-omental vessels ( gastric or pancreaticosplenic nodes

R side ( R gastro-omental ( pyloric node

L side ( short gastric and splenic ( pancreaticoduodenal node

Part One:

5cm; at level of L1

Passes R, up, back to neck of gallbladder

Ant: quadrate lobe of liver and GB; sup: epiploic foramen; post: gastroduodenal artery, common bile duct and portal vein

1st half has a mesentery (the ampulla, v mobile) and is attached to hepatoduodenal ligament and greater omentum

Part Two:

8cm; from L1-3

From neck of gallbladder down to upper L4

To L: IVC, common bile duct and head of pancreas; post: R kidney, renal vessels, IVC and psoas; ant: GB, duodenal impression on R lobe liver, SI and hepatic flexure of colon

peritoneum on ant surface forms transverse mesocolon

has hepatopancreatic ampulla at major duodenal papilla (posteromedial)

Part Three:

10cm; at level of L3

Passes L and forward to infront of aorta

Post: IVC, aorta and psoas major; ant: SMA and SMV, mesentery; sup: head of pancreas

Part Four:

2.5cm; ascends to L2

To L of aorta; Post to transverse colon, medial to L kidney and ureters, below body of pancreas

( duodenojejunal junction at level of L2, 2-3cm to L of midline

Supported by suspensory muscle of duodenum – from connective tissure around celiac artery to sup duodenoljejunal flexure

Blood supply:

Before bile duct: celiac trunk ( Gastroduodenal artery ( sup pancreaticoduodenal artery; R gastric

After bile duct : SMA ( inf pancreaticoduodenal artery

Venous drainage: Into portal vein via SMV and splenic vein

Nerve supply: celiac and sup mesenteric plexuses ( periartertial plexuses ( vagus, greater and lesser splanchnic

Ascending colon

Narrower than cecum; retroperitoneal; 15cm

Blood supply: SMA ( ileocolic, R colic and middle colic arteries

Venous drainage: ileocolic and R colic ( SMV

Lymph: epicolic and Paracolic nodes ( ileocolic and R colic nodes ( sup mesenteric nodes

Nerve: sup mesenteric plexus

Transverse colon

Splenic flexure attaches to diaphragm via phrenicolic ligament; mesentery is transverse mesocolon; 45cm

Blood supply: SMA ( middle colic, R colic artery; IMA ( L colic artery

Venous drainage: SMV

Lymph: middle colic nodes ( sup mesenteric nodes

Nerve: sup mesenteric plexus

Head: enveloped by duodenum; on R of sup mesenteric vessels; ant to IVC, R renal artery and vein, L renal vein; bile duct lies in groove on post aspect

Uncinate process: posterior to SMA

Neck: lies ant to sup mesenteric vessels; ant surface is adjacent to pylorus; SMV and splenic vein join post to neck

Body: to L of sup mesenteric vessels, over aorta, SMA, L suprarenal gland, L kidney, renal vessels and L2; post to omental bursa

Tail: ant to L kidney

Subphrenic recess = superior extension of peritoneal cavity; split into R + L recesses by falciform ligament

Subhepatic space – hepatorenal recess is postsup extension of subhepatic space. This communicates with R subphrenic recess

Lies from 7-11th ribs along midaxillary line

Surfaces:

Superior: attached to diaphragm and ant ab wall by falciform ligament (ligamentum teres (round ligament) in free margin, obliterated umbilical vein; divides liver into L+R lobes); middle lies behind xiphoid process

Inferior: L lobe has gastric impression; quadrate lobe in relation to pylorus, sup duodenum and transverse colon; R lobe has colic, renal and duodenal impressions

Posterior: has deep mould for vertebral column; has suprarenal impression

Posterior and Inferior (visceral): split into lobes by

R sagittal fissure: formed from GB to groove for IVC

SEPARATED BY CAUDATE AND QUADRATE LOBES

JOINED BY PORTA HEPATIS

` L sagittal fissure: separates R +L lobes; formed from fissure for ligamentum teres (round ligament) and fissure for ligamentum venosum

Bare area demarcated by upper (continuous with falciform ligament) and lower layers (continuous with lesser omentum) of coronary ligament which meets to form R triangular ligament. L part of coronary ligament forms L triangular ligament.

IVC fills groove in bare area on post aspect of liver.

Ligaments:

Falciform: attached to diaphragm and R RA ( notch on ant margin to post surface; free edge contains round ligament and paraumbilical veins

Coronary – upper layer from upper bare area to diaphragm; lower layer from lower bare area to R kidney (hepatorenal ligament)

Triangular (L+R): R formed by 2 layers of coronary ligament, passes from R bare area to diaphragm; L continuous with falciform ligament, from postsup L lobe to diaphragm

Hepatogastric – attaches from lesser curvature to L sagittal fissure

Hepatoduodenal – formed by lesser omentum

Lobes: R lobe split from L lobe by falciform ligament, L sagittal fossa and umbilical notch

Quadrate lobe: bounded by ant margin, porta, fossa for GB, fossa of umbilical vein

Caudate lobe: bounded by porta, fossa for IVC, fossa for ductus venosus

Porta hepatis enclosed within lesser omentum: contains portal vein (lies central and posterior); L+R hepatic artery (lies L and anterior); L+R hepatic ducts (lies R and anterior); lymphatics and lymph nodes; autonomic nerves

Blood supply: Portal vein - supplies blood to parenchyma

Celiac trunk ( common hepatic artery which gives off Gastroduodenal artery then becomes named hepatic artery proper ( bifurcates to supply R + L livers – supplies blood to non-parenchymal structures

Venous drainage: central veins ( collecting veins ( R, middle and L hepatic veins ( IVC

Lymphatics:

Superficial in fibrous capsule, deep in connective tissue

Deep formed in perisinusoidal spaces ( lymphatics in portal triads ( converge with superficial draining at porta hepatis ( hepatic nodes in lesser omentum ( celiac nodes ( chyle cistern

Superficial ( phrenic nodes at bare area ( posterior mediastinal nodes

Some go to L gastric and parasternal nodes

Nerve: from hepatic plexus; sym from celiac plexuses, paraS from L vagus; enter at porta hepatis

Arise between L1-2; below SMA; R is longer and lower than L; R passes posterior to IVC, R renal vein, head of pancreas and descending duodenum; L passes posterior to L renal vein, body of pancreas, splenic vein and IVC; each divide at hilum into 5 segmental arteries between renal vein and ureter: superior, anterosup, anteroinf, inferior, posterior segmental arteries as per segments; also give off inf suprarenals

Veins lies ANTERIOR to arteries. L vein longer, receives L suprarenal, gonadal and ascending lumbar veins. Passes ANTERIOR to aorta. Drain into IVC.

Double-domed, muscular peripherally, converges on central tendon; attaches to inf margin of thoracic cage and sup lumbar vertebrae; R dome higher

Sup central tendon fuses with inf fibrous pericardium

Caval opening (T8-9): contains IVC, R phrenic nerve, lymphatic vessels; situated on R side and most superior;, through tendinous not muscular diaphragm

Aortic hiatus (T12): contains aorta, thoracic duct and azygous vein; formed by R+L crus united by median arcuate ligament

Oesophageal hiatus (T10): contains oesophagus, ant and post vagal trunks, oesophageal branches of L gastric, lymphatic vessels; formed by R crus

Crura: musculotendinous bundles that arise from ant bodies of L1-3 and IV discs; R crus is larger and longer than L

Medial arcuate ligament covers psoas major, lateral arcuate lig covers quadratus lumborum.

Blood supply: internal thoracic ( pericardiophrenic and musculophrenic arteries, thoracic and ab aorta ( sup and inf phrenic arteries

Venous drainage: PCP and MP ( IT vein; SP and IP ( IVC

Nerve: motor supply solely from phrenic nerves

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Formed by ant divisions; in post part of psoas major, infront of transverse processes of lumbar vertebrae

L1 divides into sup and post branches; L2-4 divide into ventral and dorsal divisions

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Femoral: emerge from lat border of psoas ( deep to inguinal lig

Obturator: emerge from med border psoas, into lesser pelvis, through obturator foramen, to med thigh

Lumbosacral trunk: over ala of sacrum ( descends into sacral plexus

IH and II: post to med arcuate lig, ant to quadratus lumborum, pass through ex and in obliques

Genitofemoral: pierces psoas onto ant surface but deep to fascia, divides lat to iliac arteries

Lat cut nerve of thigh: inflat on iliacus, deep to inguinal lig med to ASIS

13cm long

Course: begins at aortic hiatus in diaphragm at T12 ( divides into L+R common iliacs at L4 2-3cm inf to umbilicus ( common iliacs follow medial borders of psoas to pelvic brim ( divides into in and ex iliacs. Internal enters pelvis, external follows iliopsoas and gives off inferior epigastric and deep circumflex iliac.

Lies behind IVC superiorly, infront of IVC inferiorly

Relations:

Anterior: celiac plexus, lesser omentum and stomach, body of pancreas and splenic vein, L renal vein, duodenum, mesentery, coils of SI

Posterior: L lumbar veins, ant longitudinal ligament

Right: azygos vein, chyle cistern, thoracic duct, R crus of diaphragm, R celiac ganglion, IVC

Left: L crus of diaphragm, L celiac ganglion, duodenum

Branches:

Anterior midline / unpaired visceral ( alimentary tract

1) Celiac T12 2

2) SMA L1 3

3) IMA L3

Lateral / paired visceral ( urogenital and endocrine

1) Suprarenal L1 4

2) Renal L1 4

3) Gonadal L2 5

Posterolateral / paired parietal ( diaphragm + body wall

1) Subcostal L2

2) Inf phrenic T12 1

3) Lumbar L1-4

4) Median sacral (unpaired)

Ovoid, size of a fist; weight 150g; Fibrous capsule which form trabeculae internally splitting spleen into areolae which contain splenic pulp; Superior extremity at T11, lower extremity lies on splenic flexure; has notch on ant border

Ligaments: Gastrosplenic – contains short gastric and L gastroepiploic

Vessels

Splenorenal – contains splenic vessels

Phrenicocolic – supports lower end

Surface: diaphragmatic

visceral – gastric - stomach and pancreas contact

renal - narrower than gastric, renal and suprarenal

contact

Relations: Posterior: 9-11th ribs

Anterior: fundus of stomach – attached to greater curvature

by Gastrosplenic ligament

Inferior: splenic flexure – as it enlarges, glides infront of splenic flexure

Medial: L kidney – attached by Splenorenal ligament

Blood supply: splenic artery divides into 5 branches that enter hilum

Venous drainage: splenic vein ( joined by IMV ( unites with SMV behind pylorus to form portal vein

1) External oblique: from lat surfaces of last 8 ribs ( xiphisternum, linea alba, pubic symphysis, inguinal ligament, ant ½ iliac crest; become aponeurotic at MCL; inf margin forms inguinal ligament; interdigitates with serratus anterior (ribs 5-8) and latissmus dorsi (ribs 9-12); forms sup inguinal ring

a. Nerve: intercostal 7-11, subcostal, iliohypogastric and ilioinguinal

2) Internal oblique: from ant 2/3 iliac crest, lat 2/3 inguinal ligament, lumbar fascia, ileopectineal arch ( inf surfaces of ribs 10-12, costal margin, rectus sheath, linea alba; becomes aponeurotic at MCL; contributes to cremaster muscle

a. Nerve: intercostal 7-11, subcostal, iliohypogastric and II, 1st lumbar

3) NEUROVASCULAR PLANE RUNS HERE contains

4) Tranversalis abdominis: inner lower 6 costal cartilages, interdigitates with origin of diaphragm, costal margin, ant 2/3 iliac crest, lat ½ inguinal ligament ( rectus sheath and linea alba; fibres run horizontally; is post to rectus abdominus until arctuate line, then anterior

a. Nerve: IC 7-11, SC, IH and II, 1st lumbar

5) Rectus abdominis: pubic crest, tubercle and symphysis ( costal cartilages 5-7, sternum and diaphragm; fibres run vertically

a. Nerve: IC 7-11, SC

1) Internal thoracic artery

a. Musculophrenic (supplies ant ab wall sup to umbilicus); gives off ant intercostal arteries and med branches that anastomose with sup epigastric arteries

b. Superior epigastric – travels between RA and post rectal sheath; anastomosis with inf epigastric artery at umbilicus behind rectus muscle within sheath; supplies ant abdo wall and diaphragm

2) Aorta

a. Post intercostal and subcostal arteries

3) Ex iliac artery

a. Deep circumflex iliac – anastomose with lumbar arteries; deep to lat ½ inguinal ligament between TA and IO

b. Inf epigastric ( arises from ex iliac just above inguinal ligament ( pierces tranversalis fascia ( ascends between RA and transversalis fascia ( then between RA and post rectus sheath; vas deferens/round ligament wind around lat + post aspects of artery; gives off cremasteric artery, pubic branch; anastomoses with sup epigastric, lower intercostal arteries and subcostal arteries

4) Femoral artery

a. Superficial circumflex

b. Superficial epigastric arteries – arises 1cm below inguinal ligament, passes through femoral sheath, turns up infront of ligament, ascends in sup fascia of ab wall; supplies ant ab wall sup to umbilicus; anastomosis with inf epigastric

Lymphatics: deep ant ab wall above umbilicus has lymphatic drainage to mediastinal nodes; deep ant ab wall below umbilicus has drainage to ex iliac and para-aortic nodes

1) Thoracoabdominal nerves (T7-11) – runs between 2nd + 3rd layers then form:

a. Ant (7-11) and lat (7-10) cutaneous branches which pierce at ant axillary or parasternal line

2) Iliohypogastric nerve (L1) – emerges from upper lat psoas major ( crosses quadratus lumborum ( perforates TA then divides into lat and ant cutaneous branches; lat pierces IO and EO above iliac crest to skin of gluteal region, ant continues on between IO and TA and pierces EO near inguinal ring

3) Ilioinguinal nerve (L1) – emerges from lat border of psoas major ( crosses quadratus lumborum and iliacus ( perforates TA near ant iliac crest ( pierces IO ( accompanies spermatic cord through sup inguinal ring (does NOT pass through deep ring, only travels in part of canal); communicates with IH; supplies inner thigh, ant scrotum, root of penis; can be damaged during inguinal hernia repair

4) Genitofemoral nerve (L1-2) – genital branch enters deep inguinal ring to innervate cremaster; femoral branch enters thigh on ant surface of femoral artery and pierces fascia lata ( inf med half inguinal lig sensation

5) Subcostal nerve (T12) – runs along inf border of 12th rib then between 2nd + 3rd layers of muscles ( ant and lat cutaneous branch

IVC: No valves (except gonadal); begins at L5 2.5cm to R of median plane, inf to bifurcation of aorta, post to prox R common iliac artery ( ascends on R of L3-5 on R psoas on R of aorta ( passes through caval opening of diaphragm at T8

Receives hepatic: drain liver

Renal: L longer than R because IVC on R

body;

L renal vein and R IVC receive L suprarenal, lumbar, gonadal

Testicular vein: have valves; emerge from back of testis ( form pampiniform plexus infront of ductus deferens ( unite to form 3-4 veins below superficial ring ( pass along inguinal canal ( form 2 veins which ascend on psoas lying on either side of in spermatic artery –> single vein drains.

Cecum: blind intestinal pouch below ileocaecal valve; ileocaecal valve is double fold of mucosa and circular muscle which acts as anti-reflux mechanism; situated above lat ½ inguinal ligament; rests on iliacus and psoas major; freely moves

Appendix: blind intestinal diverticulum, contains masses of lymphoid tissue, arises inf to ileocolic junction; has own mesentery (Mesoappendix) which carries appendicular artery; McBurney’s point is 1/3 distance from ASIS to umbilicus; most common position is retrocecal

Blood Supply: SMA ( ileocolic artery ( Appendicular artery

Venous drainage: ileocolic vein ( SMV

Lymph: ileocolic nodes ( sup mesenteric nodes

Nerve: from sup mesenteric plexus

Nerve: from celiac plexus

Lymph: drain to pancreaticosplenal glands beside splenic artery post to pancreas ( celiac group

Factoids: in contact with lesser sac; projects into greater sac

Retroperitoneal; surrounded by perinephric fat, which in turn is enclosed by renal fascia which is then surrounded by paranephric fat; lies at level of T12-L3; R kidney lies inf to L

R kidney: post to liver, D2, SI and R colic flexure; separated from liver by hepatorenal recess; on 12th rib

L kidney: post to stomach, spleen, pancreas, jejunum and L colic flexure; on 11/12th ribs

Posterior to kidneys is diaphragm, lumbocostal arches, psoas major, quadratus lumborum, tendon of TA, subcostal and upper lumbar arteries, thoracic, IH and II nerves.

At hilum, renal vein is anterior to artery, which is anterior to renal pelvis.

Renal pelvis: @ L1; renal pyramids in renal medulla ( minor calyces (separated by renal columns in cortex) ( major calyces ( renal pelvis ( ureters (retroperitoneal) ( pass on psoas muscles over pelvic brim at bifurcation of common iliac arteries ( in lateral wall of pelvis

Ureters: pass ant to psoas major passing over pelvic brim at bifurcation of common iliac arteries ( run along lat wall of pelvis to enter bladder; 25-30cm long; contain no valves; pass post to gonadal and renal vessels

R ureters: post to descending duodenum, R colic and ileocolic vessels, mesentery, terminal ileum, to R of IVC

L ureters: post to L colic vessels, sigmoid colon and mesentery

Are constricted in 3 places: junction of pelvices and ureters; where cross brim of pelvic inlet; during passage through wall of bladder

On X-ray they lie medial to tips of transverse processes, cross pelvic brim at SI jt

Blood supply; usually renal arteries; sometimes testicular, ovarian, common iliac and ab aorta.

Venous drainage: renal and gonadal

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