The Retroperitoneum, Urinary System and Posterior Abdominal Wall

Question 1

[10-minute video]: Abdominal Aorta and Inferior Vena Cava with Dr. Adel Bondok

Answer 1

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Question 2

[12-minute video]: Muscles of the Posterior Abdominal Wall with Dr. Adel Bondok

Answer 2

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Question 3

[16-minute video]: The Kidney with Dr. Adel Bondok

Answer 3

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Question 4

[10-minute video]: The Anatomy of the Ureter with Dr. Adel Bondok

Answer 4

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Question 5

[3-minute video]: Thoracolumbar fascia

Answer 5

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Question 6

[4-minute video]: Mesenteric Arteries

Answer 6

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Question 7

Click on Answer for diagrams on lymphatics of the abdomen.

Answer 7

[Diagram 1] [Diagram 2] [Diagram 3]

Question 8

List the paired and single branches of the abdominal aorta.

Answer 8

(a) Paired branches:
☛ Inferior phrenic arteries (at level of upper border of L1) [superior phrenic arteries arise in the thorax]
☛ Middle suprarenal arteries (at the level of lower border of L1)
☛ Renal arteries (at level of L1-L2 intervertebral disk)
☛ Gonadal arteries (opposite L2)
☛ 4 lumbar arteries [the 5th arises from the median sacral artery]
☛ Common iliac arteries [terminal branches]

(b) Single branches:
☛ Celiac artery [upper border of L1]
☛ Superior mesenteric artery [opposite L1]
☛ Inferior mesenteric artery [opposite L3]
☛ Median sacral artery [opposite L4]

[Diagram]

Question 9

At what level does the abdominal aorta terminate?

Answer 9

L4

Question 10

Outline the origin and termination of the inferior vena cava.

Answer 10

origin: It is formed by the union of the two common iliac veins at the level of the intertubercular plane [L5].
termination: opposite T8 by piercing the central tendon to end in the right atrium

Question 11

List 7 tributaries of the the inferior vena cava.

Answer 11

☛ common iliac veins
☛ 3rd and 4th lumbar veins [the first and second unite to form the ascending lumbar vein. The ascending lumbar veins unite with the corresponding subcostal veins to form the azygos vein on the right and hemiazygos vein on the left.]
☛ right gonadal vein [the left gonadal vein terminates in the left renal vein]
☛ 2 renal veins
☛ right suprarenal vein [the left suprarenal vein terminates in the left renal vein]
☛ inferior phrenic veins
☛ 2 hepatic veins

Further notes:
➤ The superior mesenteric vein drains into the hepatic portal vein.
➤ The inferior mesenteric vein drains into the splenic vein.
➤ While there are multiple arteries that supply the adrenal glands, the venous drainage is usually through one primary vein on each side.

Question 12

Where does the middle sacral vein terminate?

Answer 12

It terminates in the left common iliac vein.

Question 13

State the anterior relations of the right kidney.

Answer 13

☛ right suprarenal gland
☛ right lobe of the liver
☛ second part of the duodenum
☛ hepatic flexure
☛ jejunum
[Diagram]

Note that the liver and jejunum are separated from the kidney by peritoneum.

Question 14

State the anterior relations of the left kidney.

Answer 14

☛ left suprarenal gland
☛ stomach
☛ spleen
☛ pancreas and splenic vessels
☛ left colic flexure
☛ jejunum
[Diagram]

Out of these, stomach, spleen, and jejunum are separated from the kidney by peritoneum.

Question 15

State the posterior relations of the right and left kidneys. [4 muscles, 3 nerves, ribs]

Answer 15

Four muscles: diaphragm, quadratus lumborum, psoas major, transversus abdominis
Three nerves: subcostal (T12), iliohypogastric (L1) and ilioinguinal (L2)
Ribs: The right kidney is related to the 12th rib whereas the left kidney is related to the 11th and 12th ribs. [The diaphragm intervenes between the ribs.]
[Diagram] [Diagram 2]

Question 16

From within outwards, list the four coverings of the kidney.

Answer 16

(a) Fibrous capsule (true capsule)
(b) Perirenal (perinephric) fat
(c) Renal fascia (false capsule)
(d) Pararenal (paranephric) fat

Question 17

Discuss the macroscopic structure of the kidney as seen in the longitudinal section.

Answer 17

The naked eye examination of the kidney proper presents an outer cortex and an inner medulla.
The cortex is located just below the renal capsule and extends between the renal pyramids (vide infra) as renal columns (columns of Bertini). The cortex appears pale yellow with granular texture. The medulla is composed of 5–11 dark conical masses called renal pyramids (pyramids of Malpighi). The apices of renal pyramids form nipple-like projections—the renal papillae which invaginate the minor calyces.
[Diagram] [Diagram 2]

Question 18

State the contents of the renal sinus.

Answer 18

(a) Greater part of the renal pelvis, major and minor calyces
(b) Renal vessels, lymphatics and nerves
(c) Fat

Question 19

renal arteries
(a) origin
(b) termination
(c) course/relations
(d) branches [before termination]

Answer 19

(a) origin: abdominal aorta at level of L1-L2 intervertebral disk
(b) termination: 5 segmental arteries
(c) course relations: ✓ runs behind the renal vein, ✓ runs in front of the renal pelvis, ✓ the right renal artery is longer because it crosses the midline
(d) branches: ✓ inferior suprarenal artery [the superior suprarenal artery is a branch of the inferior phrenic artery], ✓ ureteric branches, ✓ gonadal artery [in about 15% of people]
[Diagram]

Question 20

Discuss the arterial supply of the suprarenal gland.

Answer 20

(a) superior suprarenal artery from the inferior phrenic artery
(b) middle suprarenal artery from the abdominal aorta
(c) inferior suprarenal artery from the renal artery

Question 21

“According to Graves (1954), on the basis of distribution of major branches of the renal artery each kidney is anatomically divided into five vascular segments. Each segment has its own artery and between the segments there is no anastomosis.”
Name the five renal segments and explain how the renal artery terminates to supply them.

Answer 21

(a) Apical
(b) Upper
(c) Middle
(d) Lower
(e) Posterior

In the hilum/hilar area, the main renal artery divides into anterior and posterior divisions. The anterior division supplies the apical, upper, middle, and lower segments, while the posterior division supplies the posterior segment of the kidney

Question 22

Discuss the right and left renal veins.

Answer 22

The left renal vein is longer than the right renal vein.
The left renal vein crosses the abdominal aorta whereas the right renal vein does not.
Each renal vein terminates into the inferior vena cava.
The right renal vein has no tributaries. The left renal vein has two tributaries: the left suprarenal vein and the left gonadal vein.

Question 23

Identify the anomaly: [Image].

Answer 23

pelvic kidney

Question 24

Identify the anomaly and state its cause: [Image].

Answer 24

polycystic kidney: caused by failure of fusion of the secretory and excretory parts of the kidney

Question 25

Identify the anomaly: [Image].

Answer 25

horseshoe kidney [fusion of inferior poles of the two kidneys; inferior mesenteric artery prevents its ascent into the abdomen]
[Diagram]

Question 26

Identify the anomaly: [Image].

Answer 26

renal agenesis

Question 27

State the length and origin of the ureter.

Answer 27

Length: 10 inches [5 in the abdomen, 5 in the pelvis]
Origin: continuation of the renal pelvis

Question 28

Outline the course of the ureter.

Answer 28

Abdominal part:
☯︎ from the renal pelvis to the bifurcation of the common iliac artery

Pelvic part:
☯︎ from the bifurcation of the common iliac artery to the posterosuperior angle of the urinary bladder

[Diagram]

Question 29

List the anterior relations of the right ureter.

Answer 29

⚚ second part of the duodenum
⚚ right colic vessels
⚚ ileocolic vessels
⚚ right testicular or ovarian vessels
⚚ root of mesentery
⚚ terminal part of ileum
[Diagram]

Question 30

List the anterior relations of the left ureter.

Answer 30

⚚ left colic vessels
⚚ sigmoidal vessels
⚚ left testicular or ovarian vessels
⚚ sigmoid mesocolon
⚚ sigmoid colon
[Diagram]

Question 31

List the posterior relations of the right and left ureters.

Answer 31

⚚ psoas major muscle
⚚ bifurcation of the respective common iliac artery
[Diagram]

Question 32

List 7 arteries that supply the ureter.

Answer 32

✓ Renal
✓ Testicular or ovarian
✓ Direct branches from aorta
✓ Internal iliac
✓ Vesical (superior and inferior)
✓ Middle rectal
✓ Uterine

Question 33

State the constrictions of the ureter and state their clinical importance.

Answer 33

(1) Pelviureteric junction
(2) Bifurcation of the common iliac artery [alt: where it crosses the pelvic brim]
(3) Uretero-vesical junction
[Diagram]

These constrictions are common sites for arrest of kidney stones.

Question 34

State the lymphatic drainage of the ureters in the:
(a) upper part
(b) middle part
(c) lower part

Answer 34

(a) para-aortic lymph nodes
(b) common iliac lymph nodes
(c) internal iliac lymph nodes