Abdomen 1 - Speaker Deck

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Abdomen

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Antero-lateral Abdominal Wall

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Median groove that correspond to linea alba Umbilicus (in midline a little below its midpoint – L3/4) Costal margin Inguinal ligament Dr. Sherif Fahmy

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Layers 1- Skin (thin and elastic) and umbilicus. 2- Superficial fascia. Above umbilicus: one layer containing variable amount of fat. Below umbilicus: is composed of 2 layers: ➢ Superficial fatty (Camper’s fascia). ➢ Deep membranous (Scarpa’s fascia) 3- Muscles. 4- Fascia transversalis. 5- Extraperitoneal fat. 6- Parietal peritoneum.

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Skin Superficial fascia Rectus sheath External oblique abdominis m. Internal oblique abdominis m. Transversus abdominis m. Rectus abdominis Linea alba Umbilicus Fascia transversalis Extra-peritoneal fat Parietal peritoneum Dr. Sherif Fahmy

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Superficial Fascia (Page 4) Above umbilicus: Formed of one layer that contains variable amount of fat. Below umbilicus: composed of two layers: 1-Superficial fatty (Camper’s fascia): That is continuous below with corresponding layer in the thigh. It replaced by Dartos muscle in the scrotum. 2-Deep membranous (Scarpa’s fascia): which ➢Forms fundiform ligament of penis. ➢Separates between superficial and deep dorsal veins of penis. ➢ Formes Coll’s fascia in the scrotum. ➢Continuous with corresponding layer in the thigh, fused with fascia lata one inch below inguinal ligament.

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Fundiform ligament Membranous fascia Superficial dorsal vein of penbis Deep dorsal vein of penis Dr. Sherif Fahmy

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Inguinal ligament Line of fusion between membranous layer of superficial fascia and fascia lata

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Applied Anatomy of superficial fascia •Rupture of bulbar urethra leads to escape of urine in superficial perineal pouch. •Urine will be accumulated deep to Scarpa’s fascia In the lower part of anterior abdominal wall. •Urine will be prevented to reach front of thigh due to fusion between Scarpa’s fascia with fascia lata.

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Anterolateral Abdominal Muscles (Page 7)

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Orientation

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External oblique abdominis m. Internal oblique abdominis m. Transversus abdominis m. Aponeurosis Rectus sheath Rectus abdominis m Linea alba Dr. Sherif Fahmy

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Inguinal canal Dr. Sherif Fahmy

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ASIS Pubic tubercle Pectineal line Pubic crest

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Muscles of Antero-lateral Abdominal Wall ➢External abdominal oblique m. ➢Internal abdominal oblique m. ➢Transversus abdominis m. ➢Rectus abdominis m. ➢Pyramidalis m. (if present)

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External abdominal oblique Internal abdominal oblique Transversus abdominis Rectus abdomins

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External Abdominal Oblique Muscle

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Outer surfaces of lower 8 ribs Anterior ½ of iliac crest Inguinal ligament Linea alba

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External oblique abdominis m. Latissimus dorsi muscle Serratus Anterior muscle

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Superficial inguinal ring Spermatic cord Inguinal ligament Anterior 2/3 of iliac crest Linea alba

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External oblique abdominis m. Latissimus dorsi muscle Iliac crest Lumbar triangle with internal oblique in its floor Lumbar Triangle

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Internal Abdominal Oblique Muscle

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Internal abdominal oblique

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Lateral 2/3 of Inguinal ligament Anterior 2/3 of iliac crest Lumbar fascia Lower border of lower 6 ribs Linea alba Conjoint tendon

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Specific Features of Internal Abdominal Oblique Muscle ➢Lower fibers of the muscle form triple relation with spermatic cord. ➢Aponeurosis of the muscle splits into anterior and posterior lamina around rectus abdominis muscle (from costal margin till midway between umbilicus and symphysis pubis). ➢Conjoint tendon (Falx inguinalis). ➢Cremastric muscle.

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Triple relation & Conjoint tendon Lower fibers of internal oblique abdominis m. Conjoint tendon

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Cremastric Muscle

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Cremastric muscle

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Nerve supply Genital branch of genito-femoral nerve. Action of cremasteric muscle ➢It supports and elevates testis (during ejaculation, increased intraabdominal pressure and in cold weather) ➢Cremasteric reflex .

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Transversus Abdominis Muscle

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Transversus abdominis

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Lateral 1/3 of inguinal lig. Anterior 2/3 of iliac crest Lumbar fascia Inner surfaces of lower 6 ribs and costal cartilages Linea alba Conjoint tendon

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Specific Features of Transversus Abdominis Muscle ➢Most of its fibers runs transversely except lowermost that join the arching fibers and conjoint tendon). ➢It is lined with fascia transversalis. ➢Its aponeurosis lies behind rectus muscle from costal margin till midway between umbilicus and symphysis pubis, below which the aponeurosis splits to lie infront the muscle.

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Relations of the 3 Aponeuroses to Rectus Abdominis Muscle

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External abd. oblique m. Internal oblique Transversus abdominis Rectus abdominis m. Between costal margin and midway between umbilicus and symphysis pubis. Below midway between umbilicus and symphysis pubis.

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Rectus Abdominis & Pyramidalis Muscles

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Rectus abdominis Pyramidalis Linea semilunaris

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Lateral head Medial head Pyramidalis m. Tendinous intersections 5th, 6th & 7th ribs

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Action of antero-lateral abdominal muscles: ➢Increase intra-abdominal pressure during cough, micturition,…..etc ➢Protect abdominal viscera against external trauma. ➢Keep organs in their position. ➢Oblique muscles bend the trunk laterally. ➢Rectus muscles bend the trunk foreword. ➢External oblique of one side and internal oblique of the opposite side rotate the trunk. Nerve supply: ➢Lower 6 thoracic nerves. ➢L1 gives additional nerve supply to internal oblique and transversus abdominis. ➢Subcostal to pyramidalis muscle.

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Relations of Aponeuroses of 3 Lateral Muscles to Rectus abdominis Muscle (Rectus Sheath)

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Rectus Sheath (Page 16)

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Aponeurosis of external oblique abdominis External oblique aponeurosis and Anterior lamina of aponeurosis of internal oblique 3 aponeuroses Anterior wall Costal margin Midway between umbilicus and symphysis pubis

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Rectus abdominis m. Fascia transversalis Posterior lamina of internal oblique aponeurosis & aponeurosis of transversus abdominis Arcuate line (linea semicircularis) 5th, 6th & 7th costal cartilages Posterior wall

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A B C Anterior wall Posterior wall A B C Aponeurosis of external abdominal oblique m. -Aponeurosis of external abdominal oblique. -Anterior lamina of internal abdominal oblique m. 3 aponeuroses of lateral abdominal muscles. Conjoint tendon 5th, 6th and 7th costal cartilages. Aponeurosis of transversus abdominis m. Posterior lamina of internal abdominal oblique m. Fascia transversalis.

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Posterior wall of middle part of rectus sheath Fascia transversalis Arcuate line

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Contents of Rectus Sheath

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Rectus abdominis m. Pyramidalis m Superior epigastric artery Inferior epigastric artery Lower 6 thoracic nerves

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Applied anatomy: ➢Paramedian abdominal incision rectus abdominis muscle should be reflected laterally to avoid injury of nerves supplying it. ➢Malignant nodule in the umbilicus may be formed secondary to spread of cancer breast through lymphatics in the rectus sheath.

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Fascia Transversalis(Page 20) It Is the fascial lining of transversus abdominis. Extensions: It is continuous with: Above: diaphragmatic fascia. Posterior: Renal fascia. Medially: fascia of other side. Below: ➢At inner lip of iliac crest. ➢Lateral to ext. iliac vessels: is continuous with fascia iliaca. ➢Infront ext. iliac vessels, it forms anterior wall of femoral sheath. ➢Medial to external iliac vessels, it is continuous with pelvic fascia. Deep inguinal ring: It is present in fascia transversalis ½ an inch above mid-inguinal point.

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Nerves of Anterior Abdominal Wall (Page 28)

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A- Lower 5 intercostal nerves (thoraco-abdominal,T7 –T12). B- Subcostal nerve (T12). C- Ilio- hypogastric and ilio- inguinal nerves (L1).

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Nerves of Anterior abdominal Wall Thoraco-abdominal nerves (T7-T11) Subcostal n. Ilio-hypogastric n. Ilio-inguinal n.

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Course of Nerves of Anterolateral Abdominal Wall

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Ext abdominal oblique m. Internal abdominal oblique m. Transversus abdominis Thoracoabdominal n. Lateral cutaneous n Rectus Abdominis Anterior cutaneous n Course of Thoraco-abdominal nerves T7 – 11)

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Subcostal n. Psoas major m. Ilio-hypogastric n. Ilio- inguinal n. Quadratus lumborum m Transversus abdominis Lateral cutaneous n. of thigh Femoral n. Course of subcostal, iliohypogastric & ilioinguinal nerves

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Ilio- hypogastric n. Ilio-inguinal n.

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External abdominal oblique. Internal abdominal oblique Ilio-hypogastric n Ilio-inguinal n Anterior superior iliac spine

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Lateral cutaneous branches of T7 – T11 Transversus abdominis Subcostal nerve Ilio-hypogastric nerve Ilio-inguinal nerve Anterior superior iliac spine Internal oblique muscle Ilio-hypogastric nerve Ilio-inguinal nerve T7 T8 T9 T10 T11

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Cutaneous nerves Thoraco-abdominal nerves (T7-T11) Subcostal n. Ilio-hypogastric n. Ilio-inguinal n. Dr. Sherif Fahmy

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Motor supply ➢Lower 5 intercostal and subcostal nerves supply rectus abdominis, external abdominal oblique, internal abdominal oblique and transversus abdominis muscles. ➢Subcostal nerve supplies pyramidalis m. ➢Ilio- hypogastric and ilio-inguinal nerves gives additional nerve supply to lower parts of internal abdominal oblique and transversus abdominis muscles.

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Sensory Supply (Cutaneous Branches) ➢Lateral cutaneous branches of lower 5 intercostal, subcostal and ilio-hypogastric nerves. ➢Anterior cutaneous branches of lower 5 intercostal, subcostal and ilio-hypogastric nerves. ➢Ilio- inguinal supplies the skin of external genitalia and upper medial side of thigh.

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Applied Anatomy ➢Injury of ilio-inguinal nerve during appendicectomy leads weakness of conjoint tendon which predispose to direct inguinal hernia.

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Vascular Supply (Page 22)

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A- Arteries of Anterior Abdominal Wall

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Arteries of Anterior Abdominal Wall Above umbilicus: Superior epigastric and musculophrenic arteries (Terminal branches of internal thoracic artery). Below umbilicus: Superficial: Superficial epigastric artery and superficial circumflex iliac artery (Two of the superficial inguinal arteries from femoral artery). Deep: Inferior epigastric and deep circumflex iliac (branches of external iliac artery)

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Superior epigastric artery Musculo-phrenic artery Inferior epigastric artery Ascending branch of deep circumflex iliac artery Lower posterior intercostal, subcostal and lumbar arteries Superficial epigastric artery Superficial circumflex iliac Internal thoracic artery

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Course & Branches of Inferior Epigastric Artery

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Superior epigastric artery Inferior epigastric artery External iliac artery Fascia transversalis Deep inguinal ring Umbilicus

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External iliac artery Inferior epigastric artery Deep inguinal ring Fascia transversalis Arcuate line Umbilicus Pubic branch Dr. Sherif Fahmy

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External iliac artery Deep circumflex iliac artery Inferior epigastric artery Cremastric artery Pubic branch Lacunar part of inguinal ligament Obturator artery Pubic branch of obturator artery ASIS Branches of Inferior Epigastric Artery

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Applied Anatomy of Inf. Epigastric Artery 1- Inguinal hernia: In oblique inguinal hernia: Impaction of intestine lateral to the artery. In direct inguinal hernia: Impaction of intestine is medial to the artery. 2- Abnormal obturator artery

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Veins of the Anterior Abdominal Wall

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Lateral thoracic vein Superficial epigastric vein Internal thoracic vein Musculophrenic vein Superior epigastric vein Inferior epigastric vein Superficial circumflex iliac Superficial veins Deep veins

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Venous Anastomosis in the Anterior Abdominal Wall Anastomosis between SVC & IVC ➢Thoraco-epigastric vein. ➢Anastomosis between superior & inferior epigastric veins. Porto-systemic anastomosis: Around umbilicus, there is an anastomosis between systemic veins (epigastric) and portal vein (through paraumbilical veins). N.B. In case of portal hypertension, opening of porto-systemic anastomosis leading to formation of caput medusa.

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Lymph Drainage Anterior axillary lymph nodes Superficial inguinal lymph nodes

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Lymph Drainage of Abdominal Wall

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Superficial lymph drainage Deep lymph drainage Anterior axillary lymph nodes Parasternal lymph nodes Superficial inguinal lymph nodes External iliac lymph nodes Hepatic lymph nodes

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Lymph Drainage of Abdominal Wall Superficial: Above umbilicus: to anterior axillary nodes. Below umbilicus: To superficial inguinal nodes. Deep: Above umbilicus: to parasternal nodes. Below umbilicus: to external iliac nodes. From area of umbilicus: to hepatic nodes.

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The Groin (Inguinal Region)

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ASIS Pubic tubercle Pectineal line Pubic crest

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Groin (inguinal region)

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Inguinal (Poupart’s) Ligament (Page 32)

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Inguinal ligament External abdominal oblique ASIS Pubic tubercle

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Pubic tubercle A.S.I.S Pectineal lig Lacunar part Reflected part Inguinal ligament Femoral ring

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Muscles that take origin from upper concave surface of inguinal ligament

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Relations of the Inguinal Ligament Superficial: -Skin and superficial fascia. -Superficial epigastric and superficial circumflex iliac vessels. Deep: -Iliacus, psoas major and pectineus muscles. -Femoral vessels, femoral nerve, lateral cutaneous n. of thigh and femoral sheath.

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Inguinal Canal (page 34)

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Development of Inguinal Canal

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Fascia transversalis Transversus abdominis Internal oblique m. Cremastric m & f External oblique aponeurosis Ext. spermatic fascia Int. spermatic fascia Deep inguinal ring Superficial inguinal ring

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Inguinal Canal Defin.-It is an oblique passage through the lower medial part of anterior abdominal wall. -Site: above medial ½ of inguinal ligament. -length: 4 cm -It has: - 2 openings: 1- Deep inguinal ring (in fascia transversalis). 2- Superficial inguinal ring (in ext. oblique aponeurosis). - 4 walls: -Anterior, posterior, floor and roof.

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Anterior Wall 1- External abdominal oblique aponeurosis (whole length). 2- Lower fibers of internal abdominal (lateral part). So, lateral part of anterior wall is more thick.

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Floor -Medial ½ of upper surface of concave Inguinal ligament. -Lacunar part of inguinal ligament (medial part of the floor).

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Roof - Arching fibers of internal abdominal oblique and transversus abdominis muscles.

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Arching fibers of internal oblique and transversus abdominis

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Posterior Wall -Fascia transversalis (whole length). -Conjoint tendon in the medial ½ of the wall. -Reflected part of inguinal ligament in the medial ¼ of the wall. -So, the posterior wall is thicker at its medial part.

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Fascia transversalis Conjoint tendon Reflected part of linguinal ligament

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Rings of Inguinal Canal Superficial Deep Site Above and medial to pubic tubercle in the aponeurosis of ext oblique m. ½ inch above midinguinal point in the fascia transversalis Triangular Oval Shape Spermatic fascia External spermatic fascia Internal spermatic fascia Crura Lateral & medial No crura - Spermatic cord. - Ilio-inguinal nerve. - Contents of spermatic cord. Supporting factors - Approximation of posterior inguinal wall. - Cremastric reflex. Approximation of anterior inguinal wall. Structures passing

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Contents of Inguinal Canal Males: 1-Spermatic cord. 2-Ilio-inguinal nerve. Females: 1-Round ligament. 2-Ilio-inguinal nerve.

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Weakness of the region of Inguinal Canal -Below arching fibers of internal oblique and transversus abdominis, abdominal wall is formed of aponeurosis of ext. abdominal oblique and fascia transversalis. -Presence of spermatic cord in the canal. -Presence of rings.

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Mechanism of Inguinal Canal Shutter: Closure of the canal by approximation of walls to each other by contraction of walls. Valvular: Support of each ring by the opposite wall. Narrowing of superficial ring: By upward and lateral pulling of external oblique aponeurosis. Intercrural fibers: Prevent widening of superficial ring. Cremastric reflex: Contraction of cremastric muscle leads to upward pulling of testis supporting superficial ring.

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Inguinal Triangle (Hasselbach’s) (page 38)

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Hasselbach’s triangle Inferior epigastric vessels Lateral margin of rectus abdominis m. Deep inguinal ring Medial ½ of inguinal ligament Lateral umbilical ligament (obliterated umbilical ligament Floor of the triangle = posterior wall of inguinal canal

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Inguinal Triangle (Hasselbach’s) -It is a triangular area on the inner aspect of anterior abdominal wall above the medial ½ of inguinal ligament. -Posterior wall of inguinal canal is represented by the lower part of the triangle.

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Hernia (Page 39)

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It is the abnormal site of movable abdominal content (intestine or omentum). Types of hernia: External (protrusion through weak abdominal wall): Inguinal (direct & indirect),femoral hernia, umbilical hernia and other abdominal hernia. Internal (protrusion through weak part of abdominal cavity) : 1- Diaphragmatic hernia. 2- Hernia in lesser sac of peritoneum.

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Etiology (causes): 1- Congenital hernia sac: persistence of patent processus vaginalis. 2- Weakness of the abdominal wall due to: obesity, pregnancy, weak scar or injury of a muscular nerve. 3- Increased intra-abdominal pressure: Due to chronic straining or abdominal swelling.

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Structure (parts) of a hernia: 1- Defect: through which the hernia passes. e.g. deep inguinal ring, femoral ring. 2- Hernial sac: formed of parietal peritoneum (neck, body and fundus). 3- Contents: any part of mobile abdominal contents e.g. intestine and omentum. 4- Coverings: from layers of abdominal wall.

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Direct Inguinal Hernia Indirect (oblique) Inguinal Hernia Inferior epigastric vessels Deep inguinal ring Inferior epigastric vessels Medial Lateral Lateral Medial Types of inguinal hernia

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Inguinal Hernia Indirect (oblique) Direct Definition Incidence Defect (inner aspect of abdominal wall) Descent Reduction Types (site) Coverings It is the hernia that passes through deep inguinal ring. It is the hernia that pushes the posterior wall of inguinal canal It is the commonest type mainly in young age Less common, mainly in old age. Deep inguinal ring (lateral to inferior epigastric vessels) Hasselbach’s triangle (medial to inferior epigastric vessels) Forewords, downwards and medially. Forewards Upwards, laterally and backwards. Backwards Inguinal or inguino-scrotal Only inguinal In inguinal canal: Extraperitoneal fatty tissue, internal spermatic fascia, cremastric muscle and fascia, external oblique aponeurosis, superficial fascia and skin. In scrotum: coverings of spermatic cord Colle's fascia, dartos m., and Skin. In inguinal canal: Extraperitoneal fatty tissue, Fascia transversalis, conjoint tendon (medial type), internal spermatic fascia, cremasteric muscle and fascia, external oblique aponeurosis, superficial fascia and skin.

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Femoral hernia

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Inguinal Hernia Femoral Hernia More common in males (wide inguinal canal) More common in female (wide femoral ring) Above the inguinal ligament Below inguinal ligament. Above and medial to pubic tubercle Below and lateral to pubic tubercle. Descends forewords, downwards and medially. Descends downwards, forewords and upwards Reduction is upwards, laterally and backwards Reduction is downwards, backwards then upwards. Dr. Sherif Fahmy

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Umbilical Hernia ➢Congenital umbilical hernia: Failure of return of physiological hernia. ➢Infantile hernia: Occurs at the umbilicus in first year of life, due to weak scar tissue and continuous straining. ➢Adult para-umbilical: Defect of linea alba above umbilicus, usually in fatty multiparous females.

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Other Abdominal Hernia 1- Incisional hernia. 2- Sliding hernia. 3- Lumbar hernia: Inferior and superior. 4- Obturator hernia.

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Male External Genital Organs (Page 46)

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Male External Genital Organs 1- Scrotum 2- Epididymis 3- Vas deferens 4- Testis

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Scrotum (Page 53)

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Scrotum (from external to internal) - Skin - Dartos muscle. - Colle’s fascia Spermatic cord Median septum Median raphe External spermatic fascia Cremasteric m.& fascia Internal spermatic fascia Testis

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Definition: Skin bag extended from lower median region of anterior abdominal wall that contains testis, epididymis and lower part of spermatic cord. Features: - External median raphe and internal incomplete septum. - Left side is lower. - Corrugated skin. Layers of scrotum - Skin, Dartos muscle and Colle’s fascia. Coverings of spermatic cord. Parietal layer of tunica vaginalis. Arterial supply - Superficial and deep external pudendal - Posterior scrotal (br. From int. pudendal) Lymph drainage: Superficial inguinal nodes Nerve supply Ilio-inguinal (ant. 1/3) Posterior scrotal (from pudendal nerve) and posterior cut. N. of thigh (post.2/3).

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Testis (Page 46)

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Scrotum Site Spermatic cord Testis

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Shape, Size & Weight

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2 inches 1 inch Shape: oval Dimensions: 2 X 1 X 1 inch Level: left testis is lower. Weight: 10 – 15 gm

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External Features

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Testis Body of Epididymis Appendix of testis Appendix of epididymis Lateral aspect Posterior Anterior Sinus of epididymis Head of epididymis Tail of epididymis Anterior border Spermatic cord Lateral surface

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Internal Features

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Tunica vaginalis Tunica albuginea Vas deferens Fibrous septa Seminiferous tubules Rete testis Efferent ductules (vasa efferentia) Convoluted efferent ductules (lobules) inside head of epididymis Testicular artery Pampiniform plexus Body Tail of epididymis Beginning of vas deferens Vestigue of processus vaginalis Mediastinum testis Tunica vasculosa

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Coverings of Testis Direct coverings (from internal to external): - Tunica vasculosa. - Tunica albuginea. - Tunica vaginalis (visceral and parietal). Indirect coverings (from internal to external): - Internal spermatic fascia. - Cremastric muscle and fascia. - External spermatic fascia. Three cutaneous layers of scrotum (from internal to external): - Colle’s fascia. - Dartos muscle. -Skin

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Vascular supply of testis: Arterial: - Testicular artery from abdominal aorta. Venous: -Pampiniform plexus of veins which gives testicular vein which drain into IVC (on right side) and left renal vein (on left side). Lymph drainage: Para-aortic nodes.

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Applied Anatomy Varicocele Dilated veins forming pampiniform plexus. It is more common on the left side due to: ➢Longer left testicular vein. ➢Left vein joins the left renal vein at right angle. ➢Pressure of pelvic colon (which contains heavy stool).

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Epididymis & Vas Deferens

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Vas deferens Epididymis

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Vas deferens Rete testis Efferent ductules (vasa efferentia) Convoluted efferent ductules (lobules) inside head of epididymis Testicular artery Pampiniform plexus Body Tail of epididymis Beginning of vas deferens

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Epididymis It is comma-shaped highly coiled duct that is a part of male external genital organs. Site: On the posterior border of testis, lateral to vas deferens and separated from lateral surface of the testis by a sinus of epididymis. Length: 5 cm that contains highly coiled duct (6 meters when uncoiled). Parts: ➢Head is the broad upper end that overlies upper end of testis. ➢Body is the longest part that lies postero-lateral to the testis. ➢Tail is the lower narrow part that continues as vas deferens. Blood supply: ➢Arterial: testicular and artery of vas. ➢Venous: pampiniform plexus of veins. Lymph drainage: Para-aortic nodes. Functions: Complete maturation of sperms and transmits sperms to the vas deferens.

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Vas Deferens It is narrow lumen thick wall muscular duct that transmits sperms from epididymis to ejaculatory duct. Length: 45 cm Course: ➢It begins as a continuation of the tail of epididymis. ➢It passes upwards behind testis and medial to epididymis. ➢It ascends in the spermatic cord till it enters the abdominal cavity through the deep inguinal ring. ➢It descends on the lateral pelvic wall. ➢Then it descends on the back of urinary bladder where it is dilated to form ampulla of vas. ➢It ends by joining duct of seminal vesicle to form ejaculatory duct. Blood supply: ➢artery of vas from inferior vesical artery.

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Spermatic Cord (Page 52)

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Spermatic cord

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Definition: It is the ensheathed structures dragged by the testis after its descend to scrotum. Site: in the inguinal canal and scrotum. Extension: begins at deep inguinal ring and extends till the posterior border of testis Contents: -Arteries: Testicular, artery of vas and cremastric. -Nerves: Cremastric, sympathetic plexus (T10) & ilio-inguinal nerve (?). -Vas deferens, pampiniform plexus of veins, lymph vessels and vestigue of processus vaginalis.

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Coverings (sheath) of spermatic cord: 1- Internal spermatic fascia. 2- Cremastric muscle and fascia. 3- External spermatic fascia.

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Abdominal Cavity

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Subcostal plane (L3) Intertubercular plane (L5) Midclavicular lines

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Dr. Sherif Fahmy

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Transpyloric plane (L1) Dr. Sherif Fahmy

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Orientation of Peritoneum

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Peritoneum (Page 61)

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PERITONEUM • The largest serous sac that lines abdominal wall and covers abdominal viscera. It has the following parts: 1- Visceral layer: covers abdominal viscera, supplied by autonomic nerves and sensitive to stretch only. 2- Parietal layer: lines abdominal wall, supplied by somatic nerves and it is very sensitive that when irritated leads to pain, tenderness and rigidity. 3- Peritoneal fold: when peritoneum is in contact other peritoneal layer to form either ligament, omentum or mesentery. 4- Peritoneal cavity: It separates visceral from parietal. It is potential space.

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Sex differences: Peritoneal sac is a closed in male but in females it is opened by uterine tubes. Functions of peritoneum: 1- provides smooth surfaces for viscera to avoid friction. 2- Protects against infection as peritoneal fluid contains antibodies. 3- Allows rapid healing of abdominal wounds. 4- Can localize the spread of infection (policeman of the abdomen). 5- Storage of fat.

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Parts of Peritoneal sac •It is divided into: 1- Greater sac: It is the part of peritoneal sac that fills most of abdominal cavity. 2- Lesser sac: It is the part of the peritoneal sac that is present behind stomach.

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Greater Sac

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Greater Sac It is divided by transverse colon & its mesentery into: Supracolic compartment. That is divided into right and left parts by falciform ligament. Infracolic compartment. That is divided into upper right and lower left sides by mesentery of small intestine.

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Dr. Sherif Fahmy Root of mesentery of small intestine

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Transverse colon Transverse mesocolon Mesentery of small intestine

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Lesser Sac (Omental Bursa)

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Orientation of site of lesser sac

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Lesser omentum Common bile duct Hepatic artery Portal vein Opening of lesser sac

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It is the peritoneal sac that lies behind the stomach and lesser omentum. It communicates with the greater sac through opening of lesser sac (epiploic foramen). It is composed of: ➢Main part behind stomach and lesser omentum. ➢Superior recess (extension): behind liver (caudate lobe). ➢Inferior recess (extension): inside the greater omentum. ➢Splenic recess (extension): at hilum of spleen.

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Lesser omentum Common bile duct Hepatic artery Portal vein Opening of lesser sac

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Dr. Sherif Fahmy Opening of lesser sac

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Boundaries of Lesser Sac

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Anterior & Posterior walls Upper & Lower Borders

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Left & Right Borders

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Recesses of Lesser Sac

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Applied Anatomy

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Lesser sac hernia

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How to stop bleeding from the liver

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Peritoneal Folds

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Peritoneal Folds 1- Ligaments. 2- Omenta (lesser & greater). 3- Mesentery (folds of small & large intestine).

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Peritoneal Ligaments

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Spleen is completely covered with peritoneum except hilum that gives attachment to: -Gastrosplenic lig. -Lienorenal lig. Gastrosplenic lig. Lienorenal lig.

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Omental Folds

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Mesenteries of Intestine

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Mesentery of transverse colon Mesentery of small intestine

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Subphrenic Spaces

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Paracolic Gutters

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Umbilical Folds

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Hasselbach’s triangle Inferior epigastric vessels Lateral margin of rectus abdominis m. Deep inguinal ring Medial ½ of inguinal ligament Obliterated umbilical ligament

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Peritoneal Recesses

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Duodenal Recesses

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A) Ilio-cecal Recesses

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B) Retrocecal Recess

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Intersegmoid Recess

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Anatomy of the Stomach

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Site, Shape & parts

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Shape & Size

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Dr. Sherif Fahmy In standing position: it is J- shaped In supine position and in short stature: it is steer horn Capacity of stomach: 30 ml at birth 1500 ml in adult

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Parts of Stomach

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Cardiac notch Angular notch Fundus Body Pyloric orifice Pyloric canal Pyloric antrum Pyloric part

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Cardiac orifice Esophagus Pyloric orifice Lesser curvature Greater curvature Duodenum

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Comparison between cardiac & pyloric ends

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Cardiac orifice -Between esophagus and stomach. -1 inch to the left at level of 7th costal cartilage (T11) 40 cm from incisors. -Controlled by physiological sphincter: -Acute angle. -Pinch-like action of right crus of diaphragm. -Mucosal rosette. -Effect of high intra-abdominal pressure on esophagus. -Circular muscle fibers around cardiac orifice.

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Pyloric orifice -At the junction between stomach and duodenum. -It is present at the transpyloric plane, ½ an inch to the right from median plane. -It is controlled by anatomical sphincter (pyloric sphincter) which is formed of thickened circular muscle fibers. -It is marked on the surface by a groove and prepyloric vein of Mayo.

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Curvatures of the Stomach

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Lesser curvature Lesser omentum Angular notch Greater curvature Cardiac notch

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Structure of stomach wall

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Muscles of stomach wall are arranged as follow: -outer longitudinal. -Middle circular. -Inner oblique.

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Muscles of stomach wall are arranged as follow: -outer longitudinal. -Middle circular. -Inner oblique.

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Mucosal Folds (Rugae)

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Longitudinal folds Irregular folds

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Relations of Stomach

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A- Anterior Relations

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Diaphragm Left lobe of the liver

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B- Posterior Relations (lesser sac and stomach bed)

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Less sac

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Pancreas Left kidney Spleen Left crus of diaphragm Splenic artery

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Blood Supply

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Arterial Supply

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Coeliac artery Left gastric artery Splenic artery Short gastric arteries Left gastroepiploic Hepatic artery Right gastric a. Gastro- duodenal a. Right gastro-epiploic a.

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Venous Drainage

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Portal vein Left gastric vein Right gastric vein Short gastric vein Left gastroepiploic vein Right gastroepiploic vein Superior mesenteric vein Splenic vein

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Applied Anatomy: -Porto-systemic anastomosis is present at the lower end of esophagus. -It is drained by left gastric vein to portal and esophageal veins to azygos vein. -In case of portal hypertension, this anastomosis will be opened to form esophageal and gastric varices.

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Lymph Drainage

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paraesophageal nodes Splenic nodes Left gastric nodes Rt gastroepiploic nodes Subpyloric nodes Suprapyloric nodes Coeliac nodes Left gastroepiploic nodes Retropyloric nodes Right gastric nodes

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Applied anatomy: ➢Spread of malignant cells may occurs to thoracic duct then retrograde spread to left supra-clavicular nodes (Virchow’s glands). ➢Retrograde spread of malignant cells may reach hepatic nodes. ➢Retrograde spread may reach skin of umbilicus from hepatic nodes through ligamentum teres inside falciform ligament to form a malignant nodule in the umbilicus known as Sister Joseph nodule.

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Nerve Supply

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Anterior vagal trunk Nerve of Latarjet Evacuating the stomach Gastric branches increases acid formation Coeliac plexus Treatment of peptic ulcer -Vagotomy. -Selective vagotomy. Parasympathetic supply Sympathetic supply

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Peritoneal Covering of the Stomach

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Lesser Omentum (Gastro-hepatic ligament) It is a double layer of peritoneum. Relations: Superficial: left lobe of the liver. Deep: lesser sac. Attachments: Gastric: lesser curvature and 1st inch of duodenum. Hepatic: Hilum of the liver and fissure of ligamentum venosum. Contents: In right free margin: portal vein, hepatic artery and common bile duct. Along lesser curvature: Left gastric vs., right gastric vs. and lymph nodes. Extraperitoneal fat, lymph vessels and autonomic nerves

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Greater Omentum (Gastro-colic Ligament) It is a double layer of peritoneum. Relations: Superficial: anterior abdominal wall. Deep: small intestine and parts of large intestine. Attachments: Gastric: Lower 2/3 of the greater curvature and 1st inch of duodenum. Colic: to transverse colon or pancreatic to anterior border of body of pancreas. Contents: -In right free margin: portal vein, hepatic artery and common bile duct. -Along greater curvature: Left gastroepiploic vs., right gastroepipoic vs. and lymph nodes. -Extraperitoneal fat, lymph vessels and autonomic nerves

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Gastro-phrenic ligament: Double layer of peritoneum that extends from fundus to diaphragm. Gastro-splenic ligament: Double layer of peritoneum that extends from upper part of greater curvature to hilum of spleen. Contents: Short gastric vessels, left gastro-epiploic vessels, extraperitoneal fat, lymphatics and autonomic nerves.