3. Anatomy (Abdomen Continuation) Flashcards
layers of abdominal wall
skin superficial fascia (camper, scarpa) Deep fascia muscles transversalis fascia extraperitoneal fat parietal perotineum
dartos fascia is a derivative of
superficial fascia
external spermatic fascia is a derivative of
external oblique
cremaster muscle is a derivative of
internal oblique muscle
internal spermatic fascia is a derivative of
transversalis fascia
tunica vaginalis is a derivative of
peritoneum
potential space between the parietal and visceral layers of the peritoneum
peritoneal cavity
peritoneal cavity is within this cavities
abdominal and pelvic
how does peritoneal cavity in males and women differ?
completely closed in males
in females- pathway through Uterine tubes , Uterine cavity and vagina
Subdivisions of peritoneal cavity
Greater sac
Lesser sac / Omental bursa
this subdivision of the peritoneal cavity lies posterior to the stomach and lesser omentum
lesser sac/ omental bursa
two recesses of lesser sac
superior recess
and inferior recess
is the passage of communication between the general cavity and omental bursa
epiploic foramen/ foramen of Winslow
boundaries of the foramen of winslow
A: hepatoduodenal ligament, portal vein, hepatic artery, bile duct
P: IVC
S: caudate lobe of the liver
I: superior part of the duodenum
extensions of the Visceral peritoneum
Peritoneal reflections
Peritoneal reflections (3)
mesentery
ligaments
omentum - greater and lesser
Peritoneal reflection that supports hollow viscus to the body wall
provides neurovascular communication
allows mobility of vicera
mesentery
connects viscera to each other or to the body wall
ligaments
connects the stomach with other viscera
omentum
peritoneal reflection composed of 4 layers
greater omentum
abdominal policement
greater omentum
omentum found in the greater curvature of the stomach
greater omentum
greater omentum will cover these organs
greater curvature of the stromach and proximal part of the duodenum
3 parts of the greater omentum
gastrophrenic
gastrosplenic
gastrocolic
connects lesser curvature of the stomach, duodenum and proximal part of the duodenum to the liver
lesser omentum
2 ligaments of lesser omentum
hepatoduodenal ligament
hepatoagastric ligament
this ligament contains the portal triad
hepatoduodenal ligament
portal triad consists of
Posterior: portal vein
Anterior and to the right: common bile duct
Anterior and to the left: hepatic artery
inflammation of the parietal peritoneum may exhibit
rebound tenderness
guarding
sharp localized pain
accumulation of fluid in the peritoneal cavity due to peritonitis from congestion of venous drainage of the abdomen
ascites
sx management ascites
paracentesis
sites of paracentesis
2 cm below the umbilicus through the LINEA ALBA
2-4 CM superomedial to ASIS
2 recommended areas for abdominal wall entry of paracentesis
- 2 cm below the umbilicus in the midline (through the linea alba)
- 3-5 cm superior and medial to the ASIS on either side
Paracentesis
from superficial to deep
midline
Midline •Skin •Superficial fascia •deep fascia •linea alba •transversalis fascia •extraperitoneal fat •parietal peritoneum
Paracentesis
from superficial to deep layers
lateral to inferior epigastric artery , above the deep circumflex artery
- Skin
- Superficial fascia
- deep fascia
- ext oblique
- internal oblique
- transversalis fascia
- extraperitoneal fat
- parietal peritoneum
primitive gut (endoderm) divisible into
foregut - celiac trunk
midgut -sup. mesenteric artery
hindgut - inf. mesenteric artery
Abdominal aorta branches
I. Anterior unpaired visceral
a. celiac
b. superior mesenteric
c. inferior mesenteric
II.lateral paired visceral
a. supraprenal
b. renal
c. gonadal
III. lateral paired abdominal
a. inferior phrenic
b. lumbar
IV. terminal
a. common iliac
b. median sacral
foregut
gut tube proper
pharynx
esophagus
stomach
proximal duodenum
midgut
gut tube proper
proximal duodenum to right half of transverse colon
hindgut
gut tube proper
left half of transverse colon to anus
derivatives of foregut
thyroid parathyroid tympanic cavity trachea bronchi lungs liver gallbladder pancreas
Duodenum
primitive gut
second part
•proximal - foregut
•distal - midgut
Transverse colon
primitive gut
Upper 2/3 - right side : midgut
lower 1/3 - left side : hindgut
Anal canal
primitive gut
upper part : hindgut
lower part - proctoderm : ectoderm
celiac artery is at this level
T12
superior mesenteric artery
is at this level
L1
celiac artery branches
A. left gastric
•gastric branches
•esophageal branches
B. Splenic •left gastroepiploic •short gastric •branches to the spleen •branches to the body and tail of pancreas
C. Hepatic •Proper hepatic artery –left branch of proper hepatic artery –right gastric artery –right branch of proper hepatic artery •Gastroduodenal –right gastroepiploic –sup. pancreaticoduodenal
Superior mesenteric artery branches
- inferior pancreaticoduodenal
- middle colic
- right colic
- ileo-colic
- jejunal-ileal
inferior mesenteric artery level
L3
inferior mesenteric artery
branches
left colic
sigmoid
superior rectal
aortic aneurysm
common site
just proximal to the bifurcation of the aorta at the level of L4 vertebra
(+) pulsating mass at the midline
aortic aneurysm
celiac artery occlusion
pain is referred to
pain referred in the shoulder
if celiac artery is occluded
this may develop
collateral circulation may develop at the head of pancrease
by way of anastomoses between pancreaticoduodenal branches of SMA and gastroduodenal
celiac artery occlusion
what 3 branches maybe eroded
- splenic - penetrating ulcer of posterior wall of stomach
- left gastric - lesser curvature of tomach
- gastroduodenal - posterior wall of the first part of duodenum
inferior vena cava branches
A. anterior visceral –right/ left hepatic B. Lateral visceral –right suprarenal –R/L renal –R gonadal
C. lateral abdominal
–Inferior phrenic
–lumbar
D. veins of origin
–R/L common iliac
–median sacral
portal vein is formed by the union of ____ behind the neck of pancreas
superior mesenteric vein
splenic vein
The vessel is formed by the union of the common iliac veins at the L5 vertebral level.
inferior vena cava
IVC
It ascends superiorly, and leaves the abdomen by piercing the central tendon of the diaphragm at
T8 level (the caval hiatus)
They drain the lower limbs and gluteal region.
common iliac veins
drain the posterior abdominal wall.
lumbar veins
drain the kidneys, left adrenal gland and left testis/ovary.
renal veins
drain the diaphragm.
inferior phrenic veins
There are no tributaries from the spleen, pancreas, gallbladder or the abdominal part of the GI tract – as these structures are first drained into the
portal venous system
It is the point of convergence for the venous drainage of the spleen, pancreas, gallbladder and the abdominal part of the gastrointestinal tract.
portal vein
portal vein is found at level
L2
posterior to neck of pancreas
portal vein receives additional tributaries from
Right and left gastric veins – drain the stomach.
Cystic veins – drains the gallbladder.
Para-umbilical veins – drain the skin of the umbilical region.
Tributaries to the splenic vein include:
Short gastric veins – drain the fundus of the stomach.
Left gastro-omental vein – drains the greater curvature of the stomach.
Pancreatic veins – drain the pancreas.
Inferior mesenteric vein – drains the colon.
drains blood from the rectum, sigmoid colon, descending colon and splenic flexure. It begins as the superior rectal vein and ascends, receiving tributaries from the sigmoid veins and the left colic veins. As it ascends further it passes posteriorly to the body of the pancreas and typically joins the splenic vein.
inferior mesenteric vein
drains blood from the small intestine, cecum, ascending colon and transverse colon.
SMA
SMA
begins in the _____
as a convergence of the veins draining the terminal ileum, cecum and appendix. It ascends within the mesentery of the small intestine, and then travels posteriorly to the neck of the pancreas to join the splenic vein.
right iliac fossa
tributaries of MSA
Right gastro-omental vein – drains the greater curvature of the stomach.
Anterior and posterior inferior pancreaticoduodenal veins – drain the pancreas and duodenum.
Jejunal vein – drain the jejunum.
Ileal vein – drain the ileum.
Ileocolic vein – drains the ileum, colon and cecum.
Right colic vein – drains the ascending colon.
Middle colic vein – drains the transverse colon.
is a connection between the veins of the portal venous system, and the veins of the systemic venous system.
porto-systemic anastomosis
major sites of
porto-systemic anastomosis
Oesophageal – Between the oesophageal branch of the left gastric vein and the oesophageal tributaries to the azygous system.
Rectal – Between the superior rectal vein and the inferior rectal veins.
Retroperitoneal – Between the portal tributaries of the mesenteric veins and the retroperitoneal veins.
Paraumbilical – Between the portal veins of the liver and the veins of the anterior abdominal wall.
A portal venous pressure in excess of___ is defined as portal hypertension.
20mmHg
causes portal hpn
liver cirrhosis
porta-caval shunts may involve anastomosis of portal vein to
anterior wall fo IVC
behind the entrance into the lesser sac
s a treatment for portal hypertension. A connection is made between the portal vein, which supplies 75% of the liver’s blood, and the inferior vena cava, the vein that drains blood from the lower two-thirds of the body.
portacaval shunt (or portal caval shunt)
in porta caval shunts
what is anastomosed
portal vein- anterior wall of IVC
splenic vein - left fenal vein (if spleen is removed due to congestive enlargement)
R and L hepatic veins drains into
IVC
R gonadal and right suprarenal vein
drains into
IVC
L gonadal and L suprarenal
drains into
L renal
R gastroepiploic
drains into
SMV
L gastroepiploic
drains into
splenic vein
R colic
drains into
SMV
L colic
drains into
IMV
how long is the esophagus
10 inches/ 25 cm long
straight muscular tube that extends from the pharynx to stomach
esophagus
Esophagus -continuous above with the laryngeal part of the pharynx opposite this level
6th cervical vertebra
Esophagus
passes through the diaphragm at this level
T10
importance of esophageal constrictions
- common sites of carcinoma in the esophagus
- strictures develop
- diff to pass an esophagoscope
- sites where swallowed foreign bodies can lodge
esophageal constrictions
- Upper/Pharyngoesophageal - cricopharyngeus muscle
- Middle/thoracic - by aortic arch and left main bronchus
- Inferior/Diaphragmatic - esophageal hiatus
anatomic division of esophagus
- Cervical - 18 cm from incisors
- Thoracic - 18-23 cm
- Mid thoracic 24-32 cm
- Lower thoracic -32-40 cm
- Abdominal - 32-40 cm
esophagus
from lower end of pharynx (C6; lower border cricoid cartilage) extends to thoracic inlet (suprasternal notch)
cervical
esophagus
from thoracic inlet to tracheal bifurcation
thoracic
this nerve accompanies the esophagus through the diaphragm
vagus nerve
Arterial supply of the esophagus
Upper 1/3 : inferior thyroid artery (from subclavian artery)
Middle 1/3 : descending thoracic aorta
Lower 1/3 : left gastric artery from celiac trunk of abdominal aorta
venous drainage
of esophagus
Upper 1/3 : inferior thyroid vein
Middle 1/3 : azygous vei
Lower 1/3 : left gastric vein
lymph drainage of esophagus
Upper- deep cervical
Middle- mediastinal
Lower- celiac
- 56 year old experiences GERD
- sliding hiatal hernia
- what other structure might be compressed by hernia that courses through the same opening in the diaphragm
vagal trunks
substernal burning pain that is worse when lying down
incompetent LES
GERD
difficulty swallowing liquids and solids
failure of relaxation of inferior esophageal sphincter
achalasia
hernia at the esophageal hiatus
hiatal hernia
most common type of hiatal hernia. It occurs when the gastroesophageal junction, along with a portion of the stomach, migrates into the mediastinum through the esophageal hiatus
sliding type hiatal hernia
tx for esophageal hemorrhage from esophageal varices
gastric balloon anchors the tube against the esophageal gastric junction; occludes he varices by counter pressure
sengstaken- blakemore balloon insertion
ave distance between external orifices of the nose and stomach
17.2 inches
44 cm
stomach has this capacity
1.5 L
4 parts of the stomach
cardia
fundus
body
pylorus
dilated superior part of the stomach
fundus
pylorus is divisible into
pyloric andtrum
pyloric canal
a sharp indentation that approximates the junction of the body and pyloric part of the stomach
angular incisure / notch
cardiac orifice level
6th costal cartilage
2-4 cm from the median plane at T10 or T11
fundus position
5th, L rib
midclavicular plane
position
greater curvature
10th left costal cartilage
pyrloric antrum level
9th costal cartilage
L1 vertebra
pyloric orifice 1.25 cm left of midine
pyloric canal
position
right side
L2 to L4
- associated with projectile vomiting after feeding
* small palpable mass at the right costal margin
hypertrophic pyloric stenosis
muscularis external in the pyloric region hypertrophies - narrow pyloric lumen that obstructs the passage of food
hypertrophic pyloric stenosis
on which the stomach rests when a person is in supine position is formed by structures forming the posterior wall of the omental bursa
stomach bed
stomach bed
superior to inferior
left dome of diaphragm spleen left kidney suprarenal gland splenic artery pancreas transverse mesocolon colon
The pyloric sphincter demarcates the transpyloric plane at the level of
L1 `
surrounds the superior opening of the stomach at the T11 level.
cardia
the rounded, often gas filled portion superior to and left of the cardia.
fundus
the large central portion inferior to the fundus of stomach
body
Pylorus – This area connects the stomach to the duodenum. It is divided into the
pyloric antrum, pyloric canal and pyloric sphincter
forms the long, convex, lateral border of the stomach
greater curvature
supply branches to the greater curvature.
The short gastric arteries and the right and left gastro-omental arteries
forms the shorter, concave, medial surface of the stomach
Lesser curvature
The most inferior part of the lesser curvature ____ , indicates the junction of the body and pyloric region.
angular notch
lesser curvature gives attachment to this ligament
hepatogastric ligament
lesser curvature
blood supply
left gastric artery and right gastric branch of the hepatic artery.
inferior oesophageal sphincter
level
T11
hangs down from the greater curvature of the stomach and folds back upon itself where it attaches to the transverse colon
greater omentum
It contains many lymph nodes and may adhere to inflamed areas , therefore playing a key role in gastrointestinal immunity and minimising the spread of intraperitoneal infections.
greater omentum
its main fx is to attach the stomach and duodenum to the liver.
lesser omentum
continuous with peritoneal layers of the stomach and duodenum, this smaller peritoneal fold arises at the lesser curvature and ascend to attach to the liver.
lesser omentum
the greater and lesser omenta divide the abdominal cavity into two:
the greater
lesser sac
a hole in lesser omentum
epiploic foramen
greater and lesser sacs communicate via the
epiploic foramen
The arterial supply to the stomach comes from the
celiac trunk
right and left gastric veins drain into the
hepatic portal vein
short gastric vein, left and right gastro-omental veins ultimately drain into the
superior mesenteric vein
stomach innervation
- Parasympathetic nerve supply arises from the anterior and posterior vagal trunks, derived from the vagus nerve.
- Sympathetic nerve supply arises from the T6-T9 spinal cord segments
Lymphatics stomach
drains into the gastric and gastro-omental lymph nodes found at the curvatures
–> celiac LN
There are three main causes of reflux disease:
Dysfunction of the lower oesophageal sphincter
Delayed gastric emptying
Hiatal hernia
occurs when a part of the stomach protrudes into the chest through the oesophageal hiatus in the diaphragm.
Hiatal hernia
The lower oesophageal sphincter slides superiorly. Reflux is a common complication, as the diaphragm is no longer reinforcing the sphincter.
sliding hiatal hernia
The lower oesophageal sphincter remains in place, but a part of the stomach herniates into the chest next to it. This type of hiatus hernia is more likely to require surgical correction to prevent strangulation of the herniated pouch.
rolling hiatal hernia
blood supply
stomach
- Right gastric – branch of the common hepatic artery, which arises from the coeliac trunk.
- Left gastric – arises directly from the coeliac trunk.
- Right gastro-omental – terminal branch of the gastroduodenal artery, which arises from the common hepatic artery.
- Left gastro-omental – branch of the splenic artery, which arises from the coeliac trunk.
gastric ulcers most often occur
lesser curvature, above the incisura angularis
carcinomas of the stomach most commonly found in
pylorus
nostril to cardiac orifice of stomach
17.2 inches / 44 cm
3 sites of esophageal narrowing may offer resistance to NGT
1st part : 18 cm
2nd: 28 cm
3rd : 44 cm
