Abdomen 4 - Speaker Deck

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Spleen

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Site, Size

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Spleen Diaphragm Stomach

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Spleen Stomach Diaphragm 9th rib 10th rib 11th rib

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Surface Anatomy

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1.5 inch Mid-axillary line

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Peritoneal Covering

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Spleen

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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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Features of Spleen It has: 1- Two Ends: Anterior & Posterior. 2- Two Borders: Upper & Lower. 3- Two Surfaces: Diaphragmatic & Visceral.

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Posterior (medial) end Anterior (lateral) end Upper border Lower border

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Surfaces of the Spleen Visceral Surface Diaphragmatic Surface Hilum

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Relations A- Diaphragmatic surface. B- Visceral surface.

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Spleen Diaphragm 9th rib 10th rib 11th rib Diaphragmatic relations

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Hilum of Spleen Left colic flexure Tail of pancreas Stomach Visceral Relations Left kidney

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Gastric impression Renal impression for left kidney Colic impression for left colic flexure Impression of tail of pancreas

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Blood Supply

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Splenic artery Celiac trunk 4-5 Terminal branches

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Splenic vein Superior mesenteric vein Portal vein

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Lymph Drainage ➢Red bulbs of spleen has no lymphatics. ➢Few lymphatics from the capsule and trabeculae are drained to pancreatico- splenic nodes.

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Pancreatico-splenic lymph nodes Coeliac lymph nodes

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Factors supporting spleen in position 1- Peritoneal ligaments. 2- Intra-abdominal pressure. 3- Contact with surrounding organs.

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Functions of Spleen 1- Store of blood and iron. 2- Destruction of old red blood cells. 3- Formation of red blood cells during intra-uterine life till the 5th month of intrauterine life.

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Applied Anatomy 1- Common causes of splenic enlargement? 2- Spleen can be felt below costal margin after being enlarged 3 times its normal size. 3- Spleen enlarge downwards and to the right due to presence of phrenico-colic ligament.

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Pancreas

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Site of Pancreas 2nd part of duodenum Spleen

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Parts of Pancreas Head Uncinate process Neck Body Tail Dr. Sherif Fahmy

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Peritoneal Coverings

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Relations to peritoneum Transverse colon Transverse mesocolon

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Relations of Pancreas

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1- Relations of Head

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Transverse colon Superior mesenteric vessels Dr. Sherif Fahmy

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IVC Common bile duct Right renal vein Deep surface of pancraes

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Head of panceas Duodenum Superior pancreatico- duodenal vessels Inferior pancreatico- duodenal vessels

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2-Relations of Neck of Pancreas

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Pyloro-duodenal junction

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Portal vein Splenic vein Superior mesenteric vein Neck of pancreas (cut)

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3- Relations of the Body The body of pancreas is triangular in cross section. It has 3 surfaces & 3 borders: Surfaces: - Anterior. - Posterior. - Inferior. Borders: - Anterior. - Upper. - Lower

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Posterior surface Inferior surface Upper border Anterior border Inferior border

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Omental tuberosity Transverse mesocolon Celiac trunk Celiac lymph nodes Splenic artery Pancreatico-splenic lymph nodes Duodeno-jujenal flexure Coils of jujenum Left colic flexure

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Abdominal aorta Superior mesenteric artery Splenic vein Left renal vein Left crus of diaphragm Left sympathetic chain Left psoas major muscle Left kidney Left suprarenal gland

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4- Relations of the Tail

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Lieno-renal lig. Tail of pancreas Splenic vessels

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Pancreatic Duct

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Main pancreatic duct Common bile duct Ampulla of Vater Sphincter of Oddi in the major duodenal papilla Accessory pancreatic duct Minor duodenal papilla

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Blood Supply of Pancreas

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Celiac trunk Splenic artery Gastro-duodenal a. Superior mesenteric artery Inferior pancreatico- duodenal artery Superior pancreatico- duodenal artery

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Splenic vein Superior & inferior pancreatico- duodenal veins Superior mesenteric vein Portal vein

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Lymph Drainage

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Pancreatico-splenic lymph nodes Celiac lymph nodes Superior mesenteric lymph nodes

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Applied Anatomy Cancer head: may lead to obstruction of: 1- Common bile duct: leads to jaundice. 2- Inferior vena cava: Edema in lower limb. 3- Portal vein: Portal hypertension. 4- Pyloric end: leads to pyloric stenosis. 5- Duodenum: Duodenal obstruction. Pancreatic pain: Felt in epigastric region, referred to back. Relieved by leaning forward. Duodenal ulcer: May be complicated by erosion of pancreas.

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Arteries of the Gut

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Abdominal aorta Coeliac artery (upper border of L1) Superior mesenteric artery (lower border of L1) Inferior mesenteric artery (L3)

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1- Coeliac Trunk (Page 139)

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Level & Relations of Coeliac Trunk

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Lesser omentum & lesser sac Coeliac trunk (at lower border of T12 or upper border of L1) Median arcuate ligament Anterior Relations Superior Relations

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Crura of diaphragm Coeliac ganglia Coeliac trunk Lateral Relations

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Coeliac ganglia Omental tuberosity of pancreas Lateral & Inferior Relations

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Branches of Coeliac Trunk 1- Celiac trunk. 2- Splenic artery. 3- Hepatic artery.

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1- Left Gastric Artery

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Coeliac trunk Left gastric artery Esophageal branch

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2- Splenic Artery

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Coeliac trunk Splenic artery Pancreatic branches Arteria pancreatica magna

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Coeliac trunk Splenic artery 5 terminal splenic branches (end arteries) Short gastric arteries Left gastro-epiploic artery Posterior gastric 50 %

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3- Hepatic Artery

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Coeliac trunk Common hepatic artery Right gastric artery Gastroduodenal artery Supraduodenal artery (50 %) Right gastro-epiploic a. Superior pancreatico- duodenal artery Hepatic artery proper

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Coeliac trunk Hepatic artery Hepatic artery proper Cystic artery Left & right divisions of hepatic artery proper

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Superior Mesenteric Artery (Page 146)

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Course & Relations

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Superior mesenteric a. Superior mesenteric vein 3rd part of duodenum Body of pancreas

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Splenic vein Left renal vein Head of pancreas (cut) Superior mesenteric a. 3rd part of duodenum Inferior vena cava

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Branches of Superior Mesentric Artery 1- Inferior pancreatico-duodenal. 2- Jujenal & ileal 3- Middle colic. 4- Right colic. 5- Ileocolic.

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Superior mesenteric a. Inferior pancreatico- duodenal a.

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Middle colic Right colic Ileocolic Superior mesenteric artery Jejunal arteries Ileal arteries

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Inferior Mesenteric Artery (Page 152)

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Abdominal aorta Common iliac artery Coeliac artery Superior mesenteric artery Inferior mesenteric artery

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Inferior mesenteric a. Superior rectal a.

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Branches of inferior mesenteric artery: 1- Superior left colic. 2- Inferior left colic (sigmoidal). 3- Superior rectal artery.

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Marginal Artery

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Perineum (Page 104- pelvis book)

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Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Ischio-rectal Fossa (Page 112)

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Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Internal Pudendal Artery & Pudendal Nerve (Page 115)

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Dr. Sherif Fahmy

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Deep Perineal Pouch (Page 124)

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Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Superficial Perneal Pouch (Page 127)

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Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Female superficial pouch Dr. Sherif Fahmy

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MUSCLES OF POSTERIOR ABDOMINAL WALL

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Diaphragm (Page 233)

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Attachments of Diaphragm

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Origin of Diaphragm

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Xiphoid process Lower 6 ribs & costal cartilages Right crus of diaphragm Left crus of diaphragm Median arcuate ligament Medial arcuate ligament Lateral arcuate ligament Psoas major muscle Quadratus lumborum Central (trifoliate) tendon

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Insertion of Diaphragm & Defects in the Diaphragm

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Sternal origin Costal origin Vertebral origin Anterior defect (foramen of Morgagni) Posterior defect (foramen of Bockdalek – vertebrocostal triangle) Central tendon Median part (folium) of central tendon Lateral parts (folia) of central tendon

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Pericardium Pleura Peritoneal canal Pleuro-peritoneal membrane Pleuro-pericardial membrane Reason of formation of vertebro-costal defect

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Major Openings of Diaphragm

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Vena caval opening (1 inch to the right of midline at T8) IVC Right phrenic nerve Esophageal opening (1 inch to the left of midline at T10) Esophagus Anterior & posterior vagal trunks Aortic opening of diaphragm (midline at T12) Aorta Thoracic duct

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Minor openings of diaphragm ➢Superior epigastric and musculophrenic arteries. ➢Lower 5 intercostal nerves and subcostal nerve. ➢Subcostal vessels. ➢Inferior hemiazygos vein. ➢Splanchnic nerves and sympathetic chain.

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Arterial supply of diaphragm ➢Superior phrenic artery from descending aorta. ➢Inferior phrenic artery from abdominal aorta. ➢Musculophrenic artery. ➢Lower posterior intercostal arteries. ➢Pericardiacophrenic artery.

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Applied anatomy Diaphragmatic hernia: A- Hiatus hernia: through esophageal opening. B- Hernia of Bockdalk: between vertebral and costal origin of diaphragm. C- Hernia of Morgagni: between sternal and costal origin of diaphragm.

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Psoas Major Muscle (Page 239)

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T12 Lumbar vertebrae & intervertebral discs Transverse processes of lumbar vertebrae

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Iliac fossa of hip bone Lesser trochanter Ala of sacrum Inguinal lig.

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Psoas Major Muscle

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Psoas major m. T12 Lumbar vertebrae Ilio-psoas tendon to lesser trochanter & 1 inch below Inguinal lig.

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Lumbar arteries

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Relations of Psoas Major Muscle ➢Anterior. ➢Posterior. ➢Lateral. ➢Medial.

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Anterior Relations

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Right kidney 2nd part of duodenum 3rd part of duodenum Ureter Gonadal artery Genito-femoral nerve 4th part of duodenum

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Descending colon Root of mesentery of small intestine & superior mesenteric vessels

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Lateral & Posterior Relations

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Quadratus lumborum Ilio-hypogastric nerve Ilio-inguinal nerve Iliacus muscle Lateral cutaneous nerve of thigh Femoral nerve Quadratus lumborum muscle Iliac crest Iliacus muscle Lumbar plexus and transverse processes of lumbar vertebrae Posterior Relations Lateral Relations

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Medial Relations

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Inferior vena cava Abdominal aorta Common iliac arteries

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Diaphragm Transversus abdominis Quadratus lumborum Iliacus Psoas major Psoas minor

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Relations of Psoas Major in the Femoral Triangle

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Femoral nerve Psoas major Iliacus m. Femoral vessels inside femoral sheath Inguinal ligament Pectineus m.