Abdomen: Kidney, Suprarenal Glands, Posterior Abdominal Wall Flashcards
Kidneys
- Produce urine
Ureters
- Convey urine to bladder
Suprarenal glands
- Endocrine system
Kidneys, ureters, and suprarenal glands are all
- Retroperitoneal
Left kidney position/relationship
- T11-L3
- Hilum at transpyloric plane (L1)
Right kidney position/relationship
- T11-L3
- About 5-6cm lower than the left (b/c of liver)
- Fingers width from iliac crest
Renal fascia and surrounding connective tissue function
- Helps maintain kidney position
Renal fascia and surrounding connective tissue contains
- Kidney capsule
- Perinephric fat (perirenal fat capsule)
- Renal fascia
- Paranephric fat
Perinephric fat (perirenal fat capsule)
- Surrounds kidney and suprarenal gland
- Extends into renal sinus
Renal fascia encloses
- Perirenal fat
- Kidneys
- Suprarenal gland
Kidney location
- Position changes with respiration and posture
- Lateral to vertebral column
Superior to kidneys
- Suprarenal glands
Posterior to kidneys
- Diaphragm and ribs 11 & 12 (superior aspect)
- Separates from pleura
Anterior to right kidney
- Right colic flexure
- Liver
- 2nd part of duodenum
Anterior to left kidney
- Tail of the pancreas
- Left colic flexure
- Stomach
- Spleen
Borders/margins of kidneys
- Lateral: convex
- Medial: concave; hilum
Poles of kidneys
- Superior: suprarenal gland located here
- Inferior:
Renal sinus
- Space within the kidney
- Filled with vessels, nerves, fat, renal pelvis and calices
Renal hilum
- Entrance/exit of the renal sinus
Renal hilum contains
- Renal sinus
- Renal vein (anterior)
- Renal artery (middle)
- Ureter (posterior)
- Nerve plexus
Urine flow
- Collecting duct in renal pyramid excreted at renal papilla
- Minor calyx
- Major calyx
- Renal pelvis (basin)
- Ureter
Sites of constriction and urteric calculi obstruction
- Ureteropelvic jxn
- Crossing of external iliac vessels & pelvic brim
- Bladder wall
Ureter
- Connect renal pelvis to bladder
- Descend on the psoas muscle
- Crosses common (or external) iliac arteries
Renal Arteries
- Arise from AA at the level of L1/2
- Right is longer than left
- Branch into 5 segmental arteries
Each renal artery branch (5 segmental arteries) supplies
- Independent renal segment
Kidney blood flow
- Renal artery
- Segmental arteries
- Interlobar arteries
- Arcuate arteries
- Interlobular arteries
Renal veins
- Left is longer than right
- Left has additional tributaries
- Left passes between aorta and SMA
Left renal veins additional tributaries
- Left suprarenal
- Left gonadal
- Left inferior phrenic
Passage of left renal vein between aorta and SMA
- Site of compression
- Renal vein entrapment
- “Nutcracker syndrome”
Suprarenal glands are between
- Superior pole of kidney and diaphragm
Suprarenal glands are separated from kidney by
- Septum of renal fascia
Right suprarenal gland
- Pyramid-shaped
Left suprarenal gland
- Crescent-shaped
- More medially oriented on kidney
Suprarenal gland consists of 2 parts
- Cortex
- Medulla
Cortex of suprarenal gland
- Androgens and corticosteroids
Medulla of suprarenal gland
- Catecholamines (primarily epinephrine)
- Innervated by sympathetic presynaptic neurons
Arterial supply of suprarenal glands
- Superior suprarenal (multiple branches from inferior phrenic)
- Middle suprarenal (from AA)
- Inferior suprarenal (from renal)
Venous drainage of suprarenal glands
- Right suprarenal drains into the IVC
- Left suprarenal drains into the left renal vein
Innervation of suprarenal glands
- Presynaptic sympathetics from T10-L1 directly innervate medulla
Posterior abdominal wall contains
- 5 Lumbar vertebrae & IVD
- Intervertebral disc
- Ilium
- Muscles
- Lumbar plexus
- Aorta & IVC
- Aortic plexus
- Lymph nodes
Muscles of the posterior abdominal wall
- Psoas major and minor
- Quadratus lumborum
- Iliacus
- Diaphragm
- Transverse abdominis
Psoas Major superior attachment
- TP of lumbar vertebrae
- Bodies & discs T12-L5
Psoas Major inferior attachment
- Lesser trochanter of femur
- Descends over pelvic brim
- Posterior to inguinal ligament
Psoas Major innervation
- Ventral rami L1-3
Psoas Minor superior attachment
- T12,L1 bodies/IVD
Psoas Minor inferior attachment
- Pectineal line
- iliopubic eminence
Iliacus superior attachment
- iliac fossa
- Ala of sacrum
- Anterior sacroiliac ligaments
Iliacus inferior attachment
- Psoas major tendon/lesser trochanter
Iliacus innervation
- Femoral (L2-4)
Iliopsoas muscle
- Combination of iliacus and psoas major
Iliopsoas muscle function
- Trunk and thigh flexion
- Stabilize hip
Quadratus Lumborum superior attachment
- 12th rib
- TPs of Lumbar vertebrae
Quadratus Lumborum inferior attachment
- iliolumbar ligament
- iliac crest
Quadratus Lumborum innervation
- Ventral rami T12-L4
Quadratus Lumborum function
- Fixes 12th rib (inspiration)
- Stabilizes trunk
- Extends and lateral flex vertebral column
Nerves of the posterior abdominal wall
- Subcostal nerve (ventral rami T12)
- Abdominal sympathetic trunk
Abdominal sympathetic trunk
- 4 paravertebral ganglia
- Passes deep to medial arcuate ligament
Lumbar plexus (L1-4)
- Oriented around psoas major
Branches of the lumbar plexus (L1-4)
- Ilioinguinal (L1)
- Iliohypogastric (L1)
- Genitofemoral (L1,2)
- Lateral femoral cutaneous (L2,3)
- Femoral (L2-4)
- Obturator (L2-4)
- Accessory obturator (L3,4)
- Lumbosacral trunk (L4,5)
Genitofemoral (L1,2) nerve
- Genital and femoral branches
Lateral femoral cutaneous (L2,3) nerve
- Enters thigh deep to inguinal ligament
Femoral (L2-4) nerve
- Largest branch of lumbar plexus
- Enters thigh deep to inguinal ligament
Obturator (L2-4) nerve
- Supplies adductor thigh muscles
Accessory obturator (L3,4) nerve
- Not always present
Lumbosacral trunk (L4,5)
- Contributes to sacral plexus
Direct branches of the abdominal aorta
- Aortic hiatus (T12) to bifurcation into common iliac arteries (~L4)
- Common iliacs arteries divide (~ L5/S1)
Common iliacs arteries divide (~ L5/S1) into
- Internal iliac: pelvis
- External iliac: lower limb
- Ureters pass anterior to the bifurcation of the CIA
- Slightly left of midline
Paired (parietal and visceral)
- Inferior phrenic
- Lumbar: 4 on each side
- Middle suprarenal
- Renal
- Gonadal
Unpaired (parietal and visceral)
- Median sacral
- Celiac trunk
- Superior mesenteric
- Inferior mesenteric
Inferior vena cava
- Formed by junction of common iliac veins (L5)
- Ascends to the right of midline
- Passes through diaphragm (T8)
- Drains into right atrium
Junction of common iliac veins (L5) is located
- Posterior to right common iliac artery
Portal vein does not drain directly into the inferior vena cava
- Portal vein > liver > hepatic veins > IVC
Differences left vs right tributaries of IVC
- Left gonadal > left renal
- Left suprarenal > left renal
- Left inferior phrenic > left renal
The right gonadal, suprarenal, inferior phrenic drain into the
- Inferior vena cava
Major tributaries of the inferior vena cava
- L/R hepatic
- L/R renal
- L/R common iliac
- L/R internal/external iliac
- L/R femoral
- R suprarenal
- R gonadal
Lumbar lymph nodes (lateral aortic) receive drainage from
- Gonads
- Kidneys
- Suprarenal glands
- Posterior abdominal wall
Pre-aortic lymph nodes (celiac, superior and inferior mesenteric) receive drainage from
- GI tract
Cisterna chyli and anterior aspect of L1,2 bodies receive drainage from
- Lumbar lymph nodes (lateral aortic)
- Pre-aortic lymph nodes (celiac, superior and inferior mesenteric)
Cisterna chyli and anterior aspect of L1,2 bodies drain TO
- Left venous angle
Pre-aortic nodes (celiac, superior and inferior mesenteric) drain THROUGH
- Intestinal lymphatic trunks
Lumbar lymph nodes (lateral thoracic) drain THROUGH
- Lumbar lymphatic trunks
Cisterna chyli and anterior aspect of L1,2 bodies drain THROUGH
- Thoracic duct
Autonomic plexues
- Celiac plexus
- Superior mesenteric plexus
- Inferior mesenteric plexus
Celiac plexus
- Surrounds celiac trunk
- Celiac ganglion
Superior mesenteric plexus
- Surround origin of SMA
- Superior mesenteric ganglion
Inferior mesenteric plexus
- Surrounds IMA
- Inferior mesenteric ganglion
Autonomic plexuses contain
- Presynaptic and postsynaptic sympathetic nerve fibers
- Presynaptic parasympathetic nerve fibers
Diaphragm
- Double-domed musculotendinous structure
- Separates thoracic and abdominal cavities
- Function in the abdominal cavity
Components of the diaphragm
- Central tendon
- Muscular periphery
Diaphragm separates
- Thoracic and abdominal cavities
Diaphragm function in the abdominal cavity
- Increase intraabdominal pressure (Valsalva maneuver)
Diaphragm sphincter function
- Helps prevent esophageal reflux
- Right crus of the diaphragm forms esophageal hiatus
Parts of the diaphragm
- Sternal
- Costal
- Lumbar
Sternal part of diaphragm attaches to
- Xiphoid process
Costal part of diaphragm attaches to
- Inner surface of costal cartilage ribs 7-10
- Ribs 11 & 12
Lumbar part of diaphragm attaches to
- Medial and lateral arcuate ligaments
- L1-L3 vertebral bodies, IVD
Left crus of diaphragm attaches to
- L1,L2
Right crus of diaphragm attaches to
- L1-3
MediaN arcuate ligament of diaphragm attaches to
- Connects crura
MediaL arcuate ligament (medial lumbocostal arch) of diaphragm attaches to
- L1 (L2) vertebral body to L1 TP
Lateral arcuate ligament (lateral lumbocostal arch) of diaphragm attaches to
- L1 TP to tip of 12th rib
Diaphragmatic apertures
- Caval opening
- Esophageal hiatus
- Aortic hiatus
- Smaller openings
Caval opening is located
- T8 level, right of midline
Caval opening contains
- IVC (adherent to diaphragm)
- Right phrenic nerve
- Lymph vessels
Esophageal hiatus is located
- T10 level
- Formed by right crus of diaphragm
Esophageal hiatus contains
- Esophagus
- Anterior and posterior vagal trunks
- Esophageal branches of left gastric a. & v.
Aortic hiatus is located
- T12
- Formed by crura and median arcuate ligament
Aortic hiatus contains
- Aorta (passes posterior to diaphragm, not adherent)
- Thoracic duct
- Azygos and hemiazygos veins
Smaller openings transmit
- Greater and lesser splanchnic nerves
Smaller opening structures
- Sympathetic trunk
- Least splanchnic nerve
- Pass posterior to medial arcuate ligament
Sternocostal foramen transmit
- Superior epigastric vessels
- Lymph
Arterial bloody supply of diaphragm
- Pericardiophrenic
- Musculophrenic
- Inferior phrenic arteries
- Intercostal arteries
Motor nerve supply of diaphragm
- Left & right phrenic nerves (C3-5)
Central sensory supply of diaphragm
- Phrenic
Periphery nerve supply of diaphragm
- Lower intercostal nerves
- Subcostal nerves
Types of diaphragmatic hernias
- Congenital
- Acquired
- Hiatal
Congenital diaphragmatic hernia
- Embryological defect in diaphragm development
- Can cause pulmonary hypoplasia (high mortality rate)
Two types of congenital diaphragmatic hernias
- Bochdalek: posterolateral (left-sided is most common)
- Morgagni: anterior
Bochdalek congenital hernia
- Posterolateral
- Left-sided is most common
Morgagni congenital hernia
- Anterior
Acquired hernia
- Trauma (blunt or penetrating)
- More common on the left
Hiatal hernia
- Hernia through esophageal hiatus