Abdomen 3

Abdomen 3

This presentation covers the 3rd quarter of Anatomy of the Abdomen

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Dr.Sherif Fahmy

August 13, 2019
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Transcript

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    Lobes of the liver: A- Anatomical: - Left lobe. -

    Right lobe. -Caudate lobe. -Quadrate lobe. By attachments of falciform ligament, fissure of ligamentum teres and fissure of ligamentum venosum.
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    Posterior Surface 1- Back of left lobe. 2- Fissure of

    ligamentum venosum. 3- Cudate lobe. 4- Fossa for inferior vena cava. 5- Back of right lobe.
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    Groove for esophagus Fissure for lig. venosum Caudate lobe I.V.C.

    Upper layer of coronary lig. RT triangular lig. Lower layer of triangular lig. Gall bladder Quadrate lobe Fissure for lig. teres Omental tuberosity Gastric area Bare area Porta hepatis Papillary process Caudate process Inferior surface of RT lobe
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    Esophagus Stomach Lesser omentum Pyloro-duodenal junction Area for transverse colon

    Gall bladder 2nd part of duodenum Rt. Colic flexure Rt. kidney Rt. Suprarenal gland Dr. Sherif Fahmy
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    Areas not covered with peritoneum: 1- Bare area of the

    liver. 2- Fossae for gall bladder & for IVC. 3- Porta hepatis. Peritoneal folds related to liver: 1- Falciform ligament. 2- Coronary ligament. 3- Triangular ligaments. 4- Lesser omentum (Page 82)
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    Fissures of the Liver (Page 185) 1- Porta hepatis. 2-

    Fissure of ligamentum venosum. 3- Fissure of ligamentum teres.
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    Ligaments of the Liver: (Page 186) A- Obliterated vascular ligaments:

    1- Ligamentum teres. 2- Ligamentum venosum. B- Peritoneal ligaments: 1- Coronary ligament. 2- Right & left triangualr ligaments. 3- Lesser omentum. 4- Falciform ligament.
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    5th intercostal space Xiphisternal junction Rt. 5th rib Rt. 7th

    rib 1 cm below the costal margin Rt 9th costal cartilage Transpyloric plane Left 8th costal cartilage
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    Lymphatic Drainage:(Page 197) A- Lymph vessels: Superficial & Deep. B-

    Lymph nodes: 1- Lateral diaphragmatic nodes. 2- Paracardial nodes. 3- Parasternal nodes. 4- Hepatic nodes. 5- Coeliac nodes.
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    Factors supporting liver in position:(Page 198) 1- Hepatic veins. 2-

    Intra-abdominal pressure. 3- Tone of anterior abdominal muscles. 4- Peritoneal folds and ligaments.
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    Main pancreatic duct Infra-duodenal common bile duct Ampulla of Vater

    Sphincter of Oddi in the major duodenal papilla Common hepatic duct Cystic duct Left hepatic duct Right hepatic duct Supraduodenal bile duct Retro-duodenal duct
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    Neck of gall bladder 2nd inch of 1st part of

    duodenum Cystic artery Hepatic artery Body of Gall bladder 2nd part of duodenum
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    Neck of gall bladder Cystic duct 2nd inch of 1st

    part of duodenum Cystic artery Common hepatic duct Common bile duct Hepatic artery Gall bladder Calot’s triangle
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    Applied anatomy: Cholecystitis: pain in right hypochondrium and radiate to:

    ➢The tip of right shoulder because it receives sensory fibers from right phrenic (C3,4,5) while the right shoulder receives sensory fibers from lateral supraclavicular nerve (C3,4). ➢At the back below scapula because pain is transmitted through greater splanchnic nerve (T5 – 9). Stone in Hartman’s pouch: Can obstruct neck of the gall bladder or common hepatic duct leading to obstructive jaundice. Rare gall bladder gangrene: because it has arterial supply.
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    Portal Circulation It is the venous drainage of stomach, spleen,

    pancreas and intestine. Portal vein Systemic veins Portal vein and tributaries. IVC & SVC and tributaries No valves May contain valves. Starts by tributaries and ends by divisions Starts by tributaries and ends by larger vein. Has 2 sets of capillaries One set of capillaries Blood contains absorbed food. Blood contains waste products. Blood is incompletely deoxygenated blood. Blood is completely deoxygenated blood. Blood pressure is higher. Blood pressure is lower.
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    Splenic vein Superior mesenteric vein Beginning of portal vein Ends

    in porta hepatis Neck of pancreas (cut) Portal vein (3 inches X 12 mms)
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    First part of duodenum Hepatic artery Bile duct Neck of

    pancreas Lesser omentum Anterior relations
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    Jejunal veins Ileal veins Ileocolic vein Right colic vein Middle

    colic vein Pancreatico-duodenal veins Right gastro-epiploic vein Superior mesenteric vein
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    T12 L3 Site -It lies on the posterior abdominal wall

    from T12 to L3. -Left kidney reaches 11th rib while right kidney reaches 11th intercostal space.
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    Transpyloric plane (L1) Midline 2 inches 2 inches -Hilum is

    2 inches away from midline at transpyloric plane -Upper end is 2 inches above hilum and 1 inch from midline. -Lower end is 2 inches below hilum and 3 inches from midline. -Long axis is directed downwards and laterally. Size: 4 X 2 X1 inches
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    Hilum External features: - Its shape is bean shape. -

    It has: -Two ends (upper & lower). -Two surfaces (anterior & posterior). -Two borders (lateral & medial). - Hilum -is concave and present in the middle of the medial border. -It contains renal vein, renal artery and pelvis of ureter ( from anterior to posterior) -Sinus is the space that lies inner to the hilum and deficient of renal tissue but contains segmental branches of renal artery and pelvis of ureter. -Transpyloric (L1) plane passes through upper part of right hilum and lower part of left hilum. - It is lined with fibrous capsule and perinephric fat.
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    Diaphragm Medial arcuate lig. Lateral arcuate lig. Psoas major m.

    Quadratus lumborum m. Transversus abdominis m. Subcostal vessels & nerve Ilio-hypogastric n. Ilio-inguinal n. Posterior Relations
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    Anterior relations of left kidney Body of pancreas Splenic artery

    Left suprarenal gland Descending colon Ascending branch of superior left colic artery Coils of jejunum Area for spleen Area for stomach & lesser sac
  42. 109.

    Anterior relations of right kidney Right supra- renal gland 2nd

    part of duodenum Right colic flexure Ascending colon Ascending branch of right colic artery Coils of jejunum Area for Rt lobe of liver
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    Stability of Kidney: 1- Its position in paravertebral gutter. 2-

    Coverings of the kidney. 3- Intra-abdominal pressure. 4- Apposition of surrounding organs. Applied Anatomy ➢ Renal pain is a result of stretch of renal capsule or spasm of smooth muscle of renal pelvis of the ureter. ➢ Renal pain is transmitted along sympathetic supply (T10 – T12), so pain is felt in the flanks and down to lower abdominal wall.
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    Applied Anatomy - Stone ureter is usually impacted at site

    of constrictions. - Ureteric pain from loin to groin (due to sympathetic supply comes from T11 – L2 Nerves). - Identification of stone ureter in X-ray.
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    Abdominal Aorta Splenic vein Left renal vein Head of pancreas

    (cut) Superior mesenteric a. 3rd part of duodenum Inferior vena cava
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    Coeliac artery Superior mesenteric artery Inferior mesenteric artery Common iliac

    artery Renal artery Middle suprarenal artery Inferior phrenic Gonadal artery Ventral single arteries Side paired branches
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    Sympathetic chains Body of L5 Sympathetic fibers from aortic plexus

    to superior hypogastric plexus Posterior Relations Anterior relations Inferior mesenteric artery crosses infront left common iliac artery
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    Lumbosacral junction Deep to inguinal ligament at mid- inguinal point

    Femoral artery Course of Ext. Iliac Artery External iliac artery
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    External iliac artery Deep circumflex iliac artery Inferior epigastric artery

    Cremastric artery Pubic branch Obturator artery Pubic branch of obturator artery ASIS Branches of Inferior Epigastric Artery
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    External iliac a. Inferior epigastric a. Fascia transversalis Cremastric a.

    Pubic branch Obturator a. Pubic branch Course & beanches of Inferior epigastric artery Inner Aspect of Anterior Abdominal wall
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    Rt common iliac artery Superior mesenteric vessels in the root

    of mesentery 3rd part of duodenum &right gonadal vs Head of pancreas & common bile duct 1st part of duodenum Portal vein
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    Rt. Renal artery Rt. Crus of diaphragm Middle suprarenal art.

    Rt, suprarenal gland Inferior phrenic artery Lower 3 lumbar vertebrae Rt. Psoas major muscle
  80. 212.

    Anastomosis Between Superior & Inferior Vena Cava (Page 230) A-

    At posterior abdominal wall: 1- Azygos vein. 2- Inferior hemiazygos vein. 3- Vertebral venous plexuses. B- At anterior abdominal wall: 1- Superior & inferior epigastric veins. 2- Thoraco-epigastric vein.
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    Inferior mesenteric nodes Inferior mesenteric nodes Ext. iliac nodes Int.

    iliac nodes Common iliac nodes Para-aortic nodes Lumbar lymph trunk Intestinal lymph trunk Coeliac nodes Cisterna chyli
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    Dr. Sherif Fahmy Psoas major m. Lumbar plexus Roots of

    lumbar plexus: Anterior primary rami of upper 4 lumbar nerves
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    L1 L2 L3 L4 Ilio-hypogastric n. Ilio-inguinal n. Genito-femoral n.

    Lateral cutaneous nerve of thigh Femoral n. Accessory obturator n. Obturator n. Lumbo-sacral trunk L5 Dr. Sherif Fahmy Posterior (dorsal division) Anterior (ventral division)
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    Ilio-hypogastric n. Ilio-inguinal n. Lateral cutaneous nerve of thigh Femoral

    n. Genito-femoral n. Obturator n. Lumbo- sacral trunk Psoas major m. Iliacus Dr. Sherif Fahmy
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    Branches of Lumbar Sympathetic Chain Rami communicants: 1- White ramus

    communicant: from upper 2 ganglia. 2- Grey ramus communicants: from 4 ganglia. Splanchnic: 1- Upper 2 ganglia gives splanchnic branches to aortic plexus. 2- Lower 2 ganglia gives splanchnic branches to superior hypogastric plexus. Vascular: to abdominal aorta.
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    Coeliac Aortic (Inter- mesenteric) Superior hypogastric Inferior hypogastric Site Sympathetic

    part Parasympathetic part Branches -Around coeliac trunk. - Infront abdominal aorta between origin of 2 mesenteric arteries -Below bifurcation of aorta infront L5 vertebra. - In pelvic cavity on both sides of rectum and urinary bladder -Greater and lesser splanchnic nerves relay in coeliac and aortico renal ganglia. -Postganglionic fibers join the coeliac plexus -From coeliac plexus. -Splanchnic nerves from L1 & L2 sympathetic ganglia. -From aortic plexus. -From splanchnic nerves of L3 & L4 ganglia. -From superior hypogastric plexus. -From splanchnic nerves S1 & S2 Vagus nerve Pelvic splanchnic nerve (S2,3,4) -Plexuses around branches of coeliac trunk. -Plexus around superior mesenteric artery. -Plexus around renal artery. -To aortic plexus. -Plexus around inferior mesenteric artery. -Gonadal plexus. -Iliac arteries plexus. -To superior hypogastric plexuses. -Gonadal plexus. -Iliac arteries plexus. -To inferior hypogastric plexuses. -Pelvic viscera plexuses (rectum, urinary bladder. Prostate and utero- vaginal.