BASIC SCIENCE

Anatomy of the pancreas The body of the pancreas passes to the left, inclining slightly
upwards to become continuous with the tail. As it passes from

and spleen right to left, the body of the pancreas arches across in front of the
aorta and vertebral column, approximately in the transpyloric
plane at the level of the first lumbar vertebra.
Peter J Bazira
Vishy Mahadevan
Learning point

The pancreas crosses the midline at the transpyloric plane

Abstract
The pancreas is a large, retroperitoneal organ situated immediately
behind the posterior wall of the lesser sac, in the floor of the supracolic
compartment of the abdominal cavity. Although principally an exocrine The deep location of the pancreas and the presence of various
gland, the pancreas also performs crucially important endocrine func- anteriorly situated viscera render the pancreas inaccessible to
tions. Its deep location and its close topographical relationship to physical examination. The pancreas has a dual function. Besides
several vital structures make pancreatic surgery both challenging being an important accessory exocrine digestive gland, the
and hazardous. A sound appreciation of the topographical, vascular pancreas possesses an important endocrine component made up
and ductal anatomy of the pancreas is fundamental to the successful of the million or so islets of Langerhans that are distributed
surgical management of pancreatic cancers, congenital malformations throughout the substance of the pancreas.
of the pancreas and various surgical complications of acute pancrea-
titis. The spleen is the largest lymphoid organ in the body. It is situated Learning point
deep in the left hypochondrium, wedged between the gastric fundus,
left hemidiaphragm and left kidney. Trauma, lymphoid neoplasia, The pancreas is both an exocrine and an endocrine gland
gastric cancers, portal hypertension and idiopathic thrombocytopenia
may necessitate splenectomy. A sound knowledge of the surgical and
functional anatomy of the spleen is essential if splenectomy is to be
Topographical relations of the pancreas
performed safely and effectively.
The head of the pancreas is the broadest part of the pancreas and
Keywords Islets of Langerhans; lesser sac; pancreatic ducts; portal lies snugly within the C-curve of the duodenum. Superomedially,
vein; splenic artery and vein; splenic hilum the head is continuous with the neck of the pancreas, which in
turn is continuous with the body. Projecting inferomedially from
the head is the uncinate process. The latter insinuates itself
The pancreas behind the superior mesenteric vessels as the latter descend
obliquely behind the body and neck of the pancreas into the
The pancreas is an elongated, soft, flat, lobulated and yellowish mesenteric root (Figure 1). The structures related to the anterior
gland that lies on the posterior abdominal wall, more-or-less aspect of the pancreas are as follows.
transversely. It is a retroperitoneal structure and possesses a The root of the transverse mesocolon has a continuous
thin capsule. For descriptive purposes the pancreas is divided attachment to the ventral surface of the head and neck of the
into a head, neck, body and tail. The head and tail mark the right pancreas and along the anterior surface of the body of the
and left extremities of the gland, respectively (Figure 1). The pancreas adjacent to its lower border. Superior to the line of
head and neck of the pancreas lie slightly to the right of the attachment of the transverse mesocolon, the lesser sac is an
midline while the tail is to the left of the midline. immediate anterior relation of the pancreas. The lesser sac lies
between the pancreas and the posterior surface of the
stomach.
Learning point

The pancreas is retroperitoneal and has a head (with an uncinate Learning point
process), neck, body and tail
The immediate anterior relations of the pancreas are the root of the
transverse mesocolon and the lesser sac

The posterior relations of the pancreas (Figure 1), moving from

Peter J Bazira MBChB MSc EdD SFHEA is Professor of Clinical Anatomy right to left, are as follows.
and Medical Education and Director of the Centre for Anatomical and The head of the pancreas overlies the inferior vena cava,
Human Sciences at Hull York Medical School, Hull, UK. Conflicts of
which at this level receives the right and left renal veins.
interest: none.
Immediately behind the head of the pancreas is the lower end of
Vishy Mahadevan MBBS PhD FRCS (Ed & Eng) is Emeritus Professor of the common bile duct before the latter tunnels into the head of
Anatomy at the Royal College of Surgeons, London, UK. Conflicts of the pancreas to join the main pancreatic duct. The neck of the
interest: none.

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 BASIC SCIENCE

Figure 1 Topographical relations of the pancreas

pancreas lies immediately in front of the commencement of the As implied in their names, the pancreaticoduodenal arcades also
portal vein which is formed by the union of the splenic and su- supply the adjacent duodenum. Ligation or interruption of the
perior mesenteric veins (Figure 1). The body of the pancreas, arcades will result in significant devascularization of the duo-
immediately medial to the neck, overlies the abdominal aorta denum. The body and tail of the pancreas are supplied by mul-
and the origin of the superior mesenteric artery. Further to the tiple branches of the splenic artery. The latter is a major terminal
left the body overlies the left crus of the diaphragm, the left renal branch of the coeliac trunk. It runs tortuously and to the left,
hilum and left suprarenal gland (Figure 1). The splenic vein runs along the upper border of the body and tail of the pancreas
immediately posterior to the length of the body of the pancreas (Figure 2) before entering the splenorenal ligament to reach the
and receives the inferior mesenteric vein 2e3 cm before joining splenic hilum. The splenic artery gives off multiple branches
the superior mesenteric vein (see Figure 3). Just lateral to the left which enter the dorsal surface of the pancreas (Figure 2).
renal hilum the tail of the pancreas extends into the lienorenal Venous drainage of the pancreas is to the portal system
ligament. (Figure 3). The portal vein is formed immediately behind the neck
of the pancreas by the confluence of the splenic vein and superior
mesenteric vein (Figure 3). The splenic vein, unlike the splenic
Learning point artery, pursues a straight course. Commencing in the vicinity of the
splenic hilum, the splenic vein adheres to the posterior surface of
The immediate posterior relations of the pancreas are the inferior the tail and body of the pancreas. Often it is contained, at least for
vena cava, renal veins, common bile duct, hepatic portal vein, splenic part of its length, in a fibrous tunnel that is partially embedded in the
vein, superior mesenteric artery and vein, abdominal aorta, left dia- pancreas. The splenic vein receives five to twelve tributaries from
phragmatic crus, left renal hilum and left suprarenal gland. the tail and body of the pancreas, besides receiving the inferior
mesenteric vein (Figure 3). The head and neck of the pancreas drain
into the superior and inferior pancreaticoduodenal veins. The su-
Arterial supply, venous drainage and lymphatic perior veins drain partly into the right gastroepiploic vein and partly
drainage of the pancreas into the portal vein directly. The inferior pancreaticoduodenal
The head and neck of the pancreas are supplied by two pan- veins drain into the superior mesenteric vein. Thus, regardless of
creaticoduodenal arterial arcades; one anterior and one poste- the route, the entire venous drainage of the pancreas reaches the
rior (Figure 2). Each arcade is fed by the superior and inferior portal vein eventually.
pancreaticoduodenal arteries. The arcades lie between the
convex periphery of the pancreatic head and the concave inner Learning point
margin of the duodenum. The superior pancreaticoduodenal
arteries are branches of the gastroduodenal artery, which in Venous blood from the pancreas drains along the splenic vein to the
turn is a branch of the common hepatic artery. The inferior portal system
pancreaticoduodenal arteries are the earliest branches of the
superior mesenteric artery. The pancreaticoduodenal arcades Lymphatic vessels draining the pancreas accompany the
thus represent anastomoses between the coeliac and superior pancreatic arteries. The body and tail of the pancreas drain into
mesenteric arteries. the retropancreatic nodes. The upper half of the head and neck
drain into the coeliac lymph nodes while the lower half of the
head drains into the superior mesenteric nodes.
Learning point
Learning point
The head and neck of the pancreas and adjacent duodenum are
supplied by branches of both the coeliac and superior mesenteric Lymph from the head and neck of the pancreas drain alongside their
arteries. However, the body and tail of the pancreas are only supplied blood supply to coeliac and superior mesenteric nodes, while that
by branches of the splenic artery (coeliac). from the body and tail drain into retropancreatic nodes.

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 BASIC SCIENCE

Figure 2 Arterial supply of pancreas

Ductal system of the pancreas (Figure 4) papilla about 2 cm proximal to the opening of the major duct
The main duct of the gland, the duct of Wirsung, runs the length (Figure 4).
of the gland and usually joins with the termination of the com-
mon bile duct to form the ampulla of Vater that opens into the Learning point
posteromedial aspect of the mucosa of the second part of the
duodenum at the major duodenal papilla. The accessory The accessory pancreatic duct (of Santorini) opens at the minor
pancreatic duct, the duct of Santorini, passes from the upper part duodenal papilla proximal to the opening of the main pancreatic duct
of the head and opens into the duodenal mucosa at the minor (of Wirsung) at the major duodenal papilla.

Figure 3 Venous drainage of pancreas

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 BASIC SCIENCE

Microscopic structure
The pancreas is a finely lobulated gland contained within a Learning point
delicate fibrous capsule. The lobules are composed of acini of
serous secretory cells. The acini comprise the exocrine part of the The pancreatic islets of Langerhans are responsible for the produc-
pancreas and discharge their secretions via ductules into the tion of pro-insulin, glucagon, and somatostatin
principal ducts. Between the acini lie the islets of Langerhans.
The islets are discrete aggregations of different secretory cell Development of the pancreas
types, distinguishable by histochemical staining. The alpha cells The pancreas is formed by two endodermal buds which arise
of the islets secrete glucagon; the beta cells secrete pro-insulin (a from the duodenum: a large dorsal bud and a relatively small
congener of insulin). A third cell type, the delta cell, secretes ventral bud that is closely related to the developing bile duct. The
somatostatin. subsequent rotation of the duodenum to the right results in the

Figure 4 Development of the pancreas

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 BASIC SCIENCE

ventral bud migrating posteriorly and coming to lie inferior and

posterior to the dorsal bud. This is followed by fusion of the duct
systems and parenchyma of the two buds. The ventral bud gives
rise to the uncinate process and lower part of the head of
pancreas. The dorsal bud gives rise to the remainder of the gland.
The entire ventral pancreatic duct and the distal part of the dorsal
pancreatic duct give rise to the main pancreatic duct (of Wir-
sung), which empties into the duodenum through a shared
opening with the common bile duct. The proximal part of the
dorsal duct of the pancreas forms the accessory duct of Santorini.

Learning point

The pancreas develops from a dorsal and ventral bud. The ventral
bud rotates developmentally to form the uncinate process and infe-
rior head while the rest of the gland is derived from the larger dorsal
bud.

Figure 5 Visceral surface of spleen

The spleen (Figures 1 and 5)
The spleen is the largest lymphoid organ in the body and lies The posterior pole of the spleen lies in, or close to, the left par-
deep in the left upper quadrant of the abdominal cavity. The avertebral gutter. The anterior pole of the spleen normally does
healthy spleen, in life, is a soft, friable organ that is dark purple not extend anterior to the mid-axillary line. Consequently the
in colour and has a smooth surface. This contrasts strikingly with spleen is not palpable in the normal subject. Indeed, the spleen
its appearance and texture in the embalmed cadaver, in whom must be three to four times larger than its normal size before its
the spleen is a firm, rigid and relatively pale structure. The spleen anterior pole is palpable just inferior to the left costal margin.
is variable in size, shape and weight. Its length, width and
thickness are approximately 12, 7 and 3 cm, respectively. Its
weight, on average, is 150 g. Learning point
The spleen possesses a thin capsule, outside which it is
enveloped almost completely in visceral peritoneum, and has a The normal spleen lies deep to the rib cage and is not normally
moderate degree of mobility. The spleen is in the shape of an palpable. A palpable spleen is several times larger than normal.
irregular, somewhat elongated wedge and may be pictured as
having a convex lateral surface facing the left hemidiaphragm,
and a reciprocally concave medial surface that is related to the
gastric fundus, tail of the pancreas and the anterior surface of the Topographical relations of the spleen
left kidney (Figure 5). Posterolaterally, the spleen is related to the inferior surface of the
left hemdiaphragm being separated from the latter by the upper,
Learning point left limit of the peritoneal cavity. The left hemidiaphragm in-
tervenes between the spleen on the one side and the pleura, base
The spleen is a peritoneal organ whose visceral surface is related to
of left lung and the 9th, 10th and 11th left ribs, on the other. It is
the gastric fundus, tail of pancreas, and left kidney.
easy to imagine a stab injury of the posterolateral aspect of the
left lower chest resulting in a pneumothorax, a lacerated lung
and a torn spleen.
The medial surface is, therefore, also termed the visceral surface.
The posterior pole of the spleen lies in or just lateral to the left
The lateral and medial surfaces of the spleen are demarcated
paravertebral gutter, level with the first lumbar vertebra. The
from each other by superior and inferior borders. The anterior
anterior pole of the spleen lies immediately supero-lateral to the
and posterior extremities of the spleen are termed the anterior
splenic flexure of the colon (see Figure 1) and just above the
and posterior poles, respectively. The long axis of the spleen
phrenicocolic ligament. The latter is a short double-layered
corresponds approximately to the line of the left 10th rib, and the
peritoneal fold that extends laterally and upwards from the
location of the spleen may be indicated on the surface over the
splenic flexure to become continuous with the peritoneum on the
posterolateral aspects of the left 9th, 10th and 11th ribs.
inferior surface of the left hemidiaphragm.
The relations of the medial surface of the spleen are best
Learning point appreciated by reviewing briefly the embryological development
of the spleen. The spleen is a mesodermal structure formed
The spleen lies deep to the posterolateral aspects of the left 9th, originally in the left leaf of the dorsal mesogastrium (the dorsal
10th, and 11th ribs mesentery of the stomach). Further growth of the embryonic

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 BASIC SCIENCE

splenic mass is directed leftward causing the dorsal mesogas- It is now well-known and acknowledged that the spleen is
trium to be stretched to the left side. This results in the formation made up of well-delineated segments determined by the
of two double layered peritoneal folds. One is the gastrosplenic segmental arrangement of the splenic artery branches. Upper and
(gastrolienal) ligament that connects the visceral aspect of the lower polar segments of the spleen are fairly constant. In addition
spleen to the greater curvature of the stomach, while the other the spleen possesses a variable number (two to four) of ‘central
fold the splenorenal (lienorenal) ligament runs from the splenic segments’. These segmental branches of the splenic artery were
hilum towards the anterior surface of the left kidney. These so- not previously thought to be significant. However, now that the
called ligaments convey blood vessel and lymphatics. advantages of splenic conservation have been established
Part of the medial surface of the spleen between these two beyond doubt, there is increasing recognition that ligation of
folds forms the left lateral extremity of the lesser sac segmental branches allows segmental splenectomies to be per-
(Figure 5). formed safely.
The venous drainage of the spleen displays as much vari-
ability as the arterial arrangement. A variable number of venous
Learning point
tributaries (three to six) emerge from the splenic hilum and unite
within the splenorenal ligament to form the trunk of the splenic
Two peritoneal ligaments (gastrosplenic and splenorenal) connect
vein.
the visceral surface of the spleen to the stomach and tail of pancreas
The course and termination of the splenic vein have already
respectively.
been reviewed earlier in this article. The lymphatic drainage of
the spleen is to lymph nodes in the splenic hilum and to the
retropancreatic nodes and thence to the preaortic coeliac lymph
The medial surface of the spleen features the splenic hilum which nodes.
is a cleft through which vessels enter or leave the spleen. The Accessory spleens (also known as splenunculi, supernumary
peritoneum which envelops the splenic capsule, surrounds the spleens or splenules) are fairly common. Based on observations
hilum and from the hilar margin it extends posteromedially to the in the dissection room and abdominal CT scans of patients, it has
left kidney as the splenorenal ligament (Figure 5). The medial been estimated that accessory spleens are present in 20e30% of
surface of the spleen, anterior to the hilum, is related to the individuals. They appear as grape-sized nodules, and are located
splenic flexure of the colon. Anterosuperior to the hilum, the most commonly near the splenic hilum or more proximally
medial surface is related to the upper part of the greater curva- alongside the splenic vessels. Occasionally, they may be found in
ture and fundus of the stomach. Posteroinferior to the hilum, the the greater omentum, small bowel mesentery or even on the
medial surface of the spleen is related to the anterolateral surface surface of the ovary or testis. They are, of course, of little
of the left kidney (Figures 1 and 5). consequence in splenic trauma. However, if unnoticed or left
behind following splenectomy for conditions such as thrombo-
Blood supply of the spleen
cytopenic purpura or autoimmune haemolytic anaemia, the
The spleen derives its arterial supply solely from the splenic ar-
retained splenunculi may result in persistence of the original
tery. The latter, as already seen, runs along the upper border of
symptoms for which the splenectomy was undertaken. A
the body and tail of the pancreas and enters the splenorenal
ligament accompanied by the splenic vein and often by the
pancreatic tail. Either at the splenic hilum or more proximally FURTHER READING
within the splenorenal ligament, the splenic artery bifurcates into Ellis H, Mahadevan V. Clinical anatomy. 13th edn. Wiley Blackwell,
inferior and superior divisions. Just before entering the splenic 2013; 110e3.
hilum, either the main trunk of the splenic artery or one or other Moore K, Persaud T, Torchia M. The developing human. 9th edn.
of the terminal divisions of the splenic artery gives rise to the Philadelphia: Elsevier, 2013.
short gastric arteries and the left gastroepiploic artery. These Moore KL, Dalley AF, Agur Wolters AMR. Clinically oriented anatomy.
arteries, accompanied by veins, reach the greater curvature of the 7th edn. Kluwer/Lippincott Williams & Wilkins, 2014; 263e8.
stomach by running within the gastrosplenic ligament. The short Moses K. Atlas of clinical gross anatomy. 2nd edn. Philadelphia:
gastric arteries travel proximally to the gastric fundus, while the Elsevier/Saunders, 2013.
left gastroepiploic artery travels distally, along the greater cur- Sinnatamby CS. Last’s anatomy: regional and applied. 12th edn.
vature, to meet the right gastroepiploic artery. Churchill Livingstone Elsevier, 2011; 267e72.

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