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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