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Anatomy of the abdomen > The retroperitoneum > Flashcards

The retroperitoneum Flashcards

1
Q

List the primary retro-peritoneal structures

A 
Abdominal aorta and its branches
Inferior vena cava and its tributaries
Kidneys & ureters
Adrenal glands
Nerves (lumbar plexus & sympathetic trunk
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2
Q

What is meant by primary retroperitoneal structures

A

These structures developed outside the parietal peritoneum. They never had a mesentery.

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3
Q

List the secondary retroperitoneal structures and explain why they are secondary

A

Duodenum (except the first part) *
Pancreas (tail is INTRAperitoneal) *
Colon (ascending and descending only)*

  • These organs originally had a mesentery, then became secondarily retroperitoneal when the mesentery fused with the body wall
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4
Q

Are any retroperitoneal structures found on the anterior abdominal wall

A

No- they are found on the posterior abdominal wall

Therefore we access the body posteriorly to perform biopsies of these organs

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5
Q

What is the first superimposed structure

A

the duodenum

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6
Q

Describe the first part of the duodenum

A

Superior
Extends from pyloric orifice to neck of gallbladder
Just to the right of L1
Passes anteriorly to bile duct, gastroduodenal artery, portal vein and IVC
5cm long

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7
Q

Why is the first part of the duodenum important clinically

A

Referred to as the ampulla or duodenal cap

Most duodenal ulcers occur in this part of the duodenum

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8
Q

Describe the second part of the duodenum

A

Right of midline extends from neck of gall bladder to the lower border of L3
Anterior surface is crossed by the transverse colon
Posterior to it is the right kidney
Medially is the head of the pancreas
This part contains the major duodenal papilla- entrance for bile and pancreatic ducts
Also contains minor duodenal papilla- entrance for accessory pancreatic duct
7-10cm

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9
Q

Where is the junction between the foregut and midgut found

A

Just below the major duodenal papilla

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10
Q

Describe the 3rd part of the duodenum

A

The inferior part- crosses the IVC, the aorta and vertebral column
It is crossed anteriorly by the superior mesenteric artery and vein
6-8cm

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11
Q

Describe the 4th part of the duodenum

A

Ascending
Passes upward on or to the left of the aorta to approximately the upper border of L2 and terminates at the duodenojejunal flexure
5cm

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12
Q

Describe the superimposed structures

A

Duodenum, pancreas and spleen are superimposed on the ‘background’ structures. All are retroperitoneal except the spleen and the tail of the pancreas.

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13
Q

What type of organ is the pancreas

A

Exocrine and endocrine gland

It is therefore a secretory organ

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14
Q

Describe the relations of the pancreas

A

It extends across from the posterior abdominal wall from the duodenum, on the right, to the spleen on the left
Lies mostly posterior to the stomach

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15
Q

Describe the head of the pancreas

A

Lies within C-shaped concavity of the duodenum

anterior to IVC

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16
Q

Describe the uncinate process

A

Projects from the lower part of the head
Passes posterior to the superior mesenteric vessels
But passes anterior to the IVC

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17
Q

Describe the neck of the pancreas

A

Anterior to the superior mesenteric vessels and IVC

Posterior to the neck is where the superior mesenteric vein and splenic vein join to form the portal vein

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18
Q

Describe the body of the pancreas

A

Elongate and extends from neck to tail

extends to the left side across the aorta to left kidney

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19
Q

Describe the tail of the pancreas

A

Passes between layers of the splenorenal ligament

kidney to spleen in dorsal foregut mesentery (lieno-renal or spleno-renal ligament)

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20
Q

Describe the pancreatic duct

A

Begins at tail
After entering the head it moves inferiorly and in the lower part of the head it joins the bile duct
This joining forms the hepatopancreatic ampulla (Ampulla of Vater), which enters the descending part of the duodenum at the major duodenal papilla
Surrounding the ampulla of vater is the sphincter of oddi- a collection of smooth muscle

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21
Q

Describe the accessory pancreatic duct

A

Empties into the duodenum just above the major duodenal papilla in the minor duodenal papilla
Presence of two ducts reflects the embryological origin of the pancreas

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22
Q

Describe the embryogenesis of the pancreas

A

Derived from buds growing into dorsal and ventral foregut mesenteries

At the foregut/midgut junction the septum transversum generates 2 pancreatic buds (dorsal and ventral endoderm) which will fuse to form the pancreas. The dorsal bud arises first and generates most of the pancreas. The ventral bud arises beside the bile duct and forms only part of the head and uncinate process of the pancreas.
Dorsal swings to the ventral

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23
Q

Describe the arterial supply to the pancreas

A

Branches from common hepatic artery
Branches from splenic artery
Branches from superior mesenteric artery

24
Q

Discuss the significance of these relations to pancreatitis and pancreatic cancer

A

Pancreas is in close proximity to many important epigastric structures: duodenum, stomach, spleen, left kidney, adrenal gland
Cancer or trauma to the pancreas can damage these structures
Cancers can spread locally, invading the portal vein and superior mesenteric vessels and may extend into the porta hepatis
Lymph node spread is common
Can cause obstructive jaundice

25
Describe the duct system for bile
Connects gallbladder to the descending part of the duodenum Coalescence of ducts begins in the liver parenchyma and continues until the right and left hepatic ducts are formed These combine to form the common hepatic duct Descends until it is joined by cystic duct from gallbladder- completing the formation of the bile duct Descends posteriorly to the superior part of duodenum before joining the pancreatic duct.
26
Describe the relations of the duct system
Common hepatic duct runs near the liver, with the hepatic artery proper and portal vein in the free margin of the lesser omentum Bile duct is to the right of the hepatic artery proper and usually to the right of and anterior to the portal vein omental foramen is posterior
27
Describe the clinical significance of gall stones
Gallstones occur in 10-20% of adults Risk factors include age, obesity and being female 80% are cholesterol stones and 20% are pigment (bilirubin calcium salts) stones. Gallstones can block the flow of bile from the gallbladder to the duodenum and cause inflammation (cholecystitis) or block the hepatopancreatic ampulla and impede pancreatic excretion from the pancreas The pain of acute cholecystitis may be felt in the right upper abdominal quadrant, radiating laterally just beneath the right breast to the back just below the inferior angle of the right scapula
28
Describe the histology of the endocrine pancreas
The islets of Langerhans are clumps of secretory cells (up to around 3000) supported by reticulin fibres, and containing numerous fenestrated capillaries. There is a delicate capsule around each islet. They are paler than the surrounding exocrine cells, as they have less rER. These islets do not have an acinar organisation. Highly vascularised
29
Describe the histology of the acinus of the pancreas
Intensely eosinophilic Have basal nuclei and produce digestive enzymes Centroacinar cells- paler cytoplasm and protrude into the ducts
30
Describe the difference between interlobular and intralobular ducts
shorter intercalated ducts- branching- initial part of excretory system- lined by a low simple cuboidal epithelium longer intralobular ducts- lined by simple cuboidal epithelium- consisting of more plump cells larger interlobular ducts- lined by cuboidal epithelium- invested by deep fibrous connective tissue- drain directly to main pancreatic ducts
31
Which part of the kidney is palpable
the lower pole- upper pole is behind the ribs
32
Describe the gross structure of the kidney
At the gross level, the interior of the kidney is divided into an outer cortical layer and an inner medullary layer At its apex each medullary pyramid has a real papilla in which the collecting ducts of the nephron deliver urine to minor and major calicies. Several major calicies coalesce to form the real pelvis, which exits the kidney at its hilum and forms the ureter. The ureter conveys urine to the urinary bladder
33
Describe the hilum of the kidney
Present in medial margin of each kidney Deep vertical slit through which renal vessels, lymphatics and nerves enter and leave the substance of the kindey, Internally, the hilum is continuous with the renal sinus Perinephric fat continues into the hilum and sinus and surrounds all structures Lies in transpyloric plane (L1)
34
Describe the anterior relations of the right kidney
Small part of superior pole- suprarenal gland Large part of rest of upper part- liver (separated by layer of peritoneum) Medially- descending part of duodenum Inferolaterally- right colic flexure Inferomedially- segment of intraperitoneal S.I
35
Describe the anterior relations of the left kidney
A small part of the superior pole and its medial side- suprarenal gland Rest of superior pole is covered by intraperitoneal stomach and spleen Inferiorly- retroperitoneal pancreas Lateral lower half- left colic flexure and beginning of the descending colon Inferomedially- intraperitoneal jejunum
36
Summarise the visceral relations of the kidneys
``` Adrenal glands on both sides Liver on the right 2nd part of duodenum on the right Ascending colon on the right Descending colon and stomach on the left Spleen on the left Tail of pancreas on the left Coils of small bowel especially on the left ```
37
Describe the differences in location of the right and left kidney
Right kidney is usually slightly lower than the left Superior pole of the R kidney lies at the level of the 11th intercostal space and that of the L at the 11th rib Hilum lies at about the level of L1 (R & L) L1 is a large vertebrae- this is why they have their hilum at the same vertebral level Left kidney is slender and longer and more medial
38
Describe the locations of the kidneys
Extend from T12 to L3 Hilum is 5cm from midline Inferior pole is 3-4cm above iliac crest
39
Summarise the positions of the kidneys
Right often lower than left Upper poles closer to median plane than lower poles 12th ribs run diagonally across posterior surfaces of kidneys Ureters descend vertically, anterior to lumbar transverse processes Ureter narrows at 3 places: 1) ureteropelvic junction, 2) at pelvic brim (common iliac vessels cross) 3) Entrance of urinary bladder
40
Describe the posterior relations common to both kidneys
Superiorly is the diaphragm and inferior to this moving in a medial to lateral direction are the psoas major, quadratus lumborum and transversus abdominis muscles.
41
Describe the posterior relations of the right kidney
The superior pole of the right kidney is anterior to rib 12.
42
Describe the posterior relations of the left kidney
The superior pole of the left kidney is anterior to ribs 11 and 12
43
Describe the relations of the pleural sacs to the kidneys
The pleural sacs and specifically, the costo-diaphragmatic recesses therefore extend posterior to the kidneys Also passing posteriorly, are the subcostal vessels and nerves and the iliohypogastric and ilio-inguinal nerves
44
Summarise the posterior relations of the kidneys
Lie on the diaphragm, psoas, quadratus lumborum & transversus abdominis muscles Between kidneys and muscles cross the T12 (subcostal) and L1 (ilio-hypogastric and ilio-inguinal) nerves A posterior approach to the kidneys is used for open surgery and for renal biopsy
45
Describe the renal arteries
lateral branches of the abdominal aorta that supply each kidney; arise inferior of the SMA origin at L2/3, with the left renal artery shorter and higher
46
Describe the renal veins
are formed by multiple smaller veins, and run anterior to the arteries; left renal vein crosses anterior to aorta but posterior to the SMA, and can be compressed by aneurysms in either vessel
47
Describe the ureters
muscular tubes transporting urine from kidneys to the bladder; continuous with the renal pelvis - formed by the condensation of 2/3 major calices
48
Describe the uteropelvic junction
: narrowing of the renal pelvis where it becomes continuous with the ureter
49
Describe the course of the ureters
descend retroperitoneally on the medial aspect of Psoas major to the pelvic brim, where they cross the common iliac/proximal end of the external iliac artery to enter the pelvic cavity and enter the bladder (at the level of the ischial spine)
50
Describe the sites of constrictions of the ureters
Ureteropelvic junction Point of crossing the common iliac vessels at the pelvic brim Entrance to the bladder Urinary stones: will cause renal colic at these constrictions as painful stimulus as passes tight area
51
Descirbe the blood supply of the ureters
Vasculature: renal arteries, abdominal aorta and internal iliac arteries all branch to supply
52
Describe innervation of the ureters
renal, aortic and sup/inferior hypogastric plexuses all innervate (visceral efferents from both SNS and PSNS sources - visceral afferents return to T11-L2 leading to referred pain at their dermatomes - e.g. Posterolateral abdominal wall pain)
53
Describe the suprarenal glands
also enclosed within the renal fascia and separated by a thin septum, with the fused layer connecting with the transversalis fascia on the lateral abdominal wall
54
Where should you look for ureters on an X-ray
shadow at transverse lumbar processes stones sometimes radiolucent white- due to calcium
55
Describe kidney stones
AKA nephrolithiasis can form in kidney and enter the urinary collecting system where they may cause renal colic (loin to groin pain) and obstruct the flow of urine small variations in pH may cause the salts to precipitate Hematuria may be noticed need to exclude infection

Anatomy of the abdomen (13 decks)

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