Abdomen

Dr Solomie Ayalew,M.D.
Wolkite University

05/06/2024 1
 Introduction
• The abdomen is the part of the trunk between the
thorax and the pelvis.
• It has musculotendinous walls, except posteriorly,
where the wall includes the lumbar vertebrae and
intervertebral (IV) discs.
• The abdominal wall encloses the abdominal cavity,
containing the peritoneal cavity and housing most
of the organs (viscera) of the digestive system and
part of the urogenital system.

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 Abdominal Cavity
• The abdominal cavity is the space bounded by the
abdominal walls, diaphragm, and pelvis. The abdominal
cavity is:
• Enclosed anterolaterally by the dynamic musculo-
aponeurotic abdominal walls.
• Separated superiorly from the thoracic cavity by the
diaphragm.
• Undercover of the thoracic cage superiorly extending to
the 4th intercostal space.
• Continuous inferiorly with the pelvic cavity.
• Lined with peritoneum, a serous membrane.
• The location of most of the digestive organs, the spleen,
the kidneys, and the ureters for most of their course.
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• The abdomen is divided into 9 parts for the sake of
description.
– right hypo-chondriac,
– right lateral (lumbar),
– right inguinal (groin),
– epigastric, umbilical,
– pubic (hypogastric),
– left hypochondriac,
– left lateral (lumbar), and
– left inguinal (groin).
• The nine regions are delineated by four planes

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• Two horizontal:
• Subcostal plane, passing through the inferior
border of the 10th costal cartilage on each side.
• Transtubercular plane, passing through the
iliac tubercles and the body of the L5 vertebra.
• Two vertical:
• Midclavicular planes, passing from the
midpoints of clavicles to the midinguinal points,
the midpoints of lines joining the anterior
superior iliac spines and the superior edge of
the pubic symphysis.
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• More often than not clinicians divide the
abdomen into 4 parts.
• These are the right and left upper quadrants
and the right and left lower quadrants.
• The planes used to divide the abdomen into 4
parts is the median plane and the
transumblical plane(plane passing through the
umblicus and the iv discs of the L3 and L4)

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 Anterolateral Abdominal Wall
• Although the abdominal wall is continuous, it is
subdivided for descriptive purposes into the
anterior wall, right and left lateral walls (flanks),
and posterior wall. The boundary between the
anterior and the lateral walls is indefinite.
Consequently, the combined term anterolateral
abdominal wall, extending from the thoracic cage
to the pelvis, is often used.
• The anterolateral abdominal wall is bounded
superiorly by the cartilages of the 7th-10th ribs and
the xiphoid process of the sternum and inferiorly
by the inguinal ligament and pelvic bones.
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• The wall consists of
– skin,
– subcutaneous tissue (superficial fascia),
– muscles and their aponeuroses,
– deep fascia,
– extraperitoneal fat, and
– parietal peritoneum .
The skin attaches loosely to the subcutaneous
tissue except at the umbilicus, where it adheres
firmly.
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• The fascial layers from superficial to deep
include the subcutaneous tissue (superficial
fascia), which lies deep to the skin and
contains a variable amount of fat.
• Inferior to the umbilicus, the subcutaneous
tissue is composed of two layers: a superficial
fatty layer (Camper fascia) and a deep
membranous layer (Scarpa fascia).

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Muscles of the anterolateral abdominal wall

• There are 5 bilaterally paired muscles making

part of the anterolateral abdominal wall.
There are 3 flat and 2 vertical muscles.
1. External oblique- is the most superficial of
the all. Its fibers run infermedially and
interdigitate with fibers of serrratus anterior.
Its most inferior part thickens to form the
inguinal ligament(ASIS to pubic tubercle).

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• 2. internal oblique- the intermediate muscle
• 3. transverse abdominal- the deepest of the flat
muscles. Almost all its fibers run in a horizontal
fashion.
All three of the flat muscles attach to a midline
thicken aponeurosis called the rectus sheath.
The rectus sheath spans from the midclavicular
line to the midline.
The fibers of the rectus sheath interweave to
form a thickened structure called the linea
alba.
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• 4. rectus abdominis- this is a long, broad strap
like flat muscle that is encased in the rectus
sheath.
• It is located in the midline. The contractile
(fleshy) fibers of the rectus do not run the
length of the muscle; rather they run between
three or more tendinous intersections , which
are typically located at the level of the xiphoid
process, umbilicus, and a level halfway between
these points.
• Each intersection is firmly attached to the
anterior layer of the rectus sheath.
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• 5. Pyramidalis, a small triangular muscle
(absent in about 20% of people), lies in the
rectus sheath anterior to the inferior part of
the rectus abdominis.
• It ends in the linea alba and tenses it.

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 Functions of the muscles of the
anterolateral…
• Form an expandable wall that support the
anterolateral abdominal wall.
• Protect the abdominal viscera from injury.
• Help maintain or increase intra-abdominal pressure
which helps push the relaxed diaphragm during
expiration, in coughing, burping or yelling. When
the diaphragm contracts during inspiration, the
anterolateral abdominal wall expands as the
muscles relax to make room for the viscera that are
pushed inferiorly.
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• Help generate the force to bring about
defecation, micturation, vomiting and
parturition( child birth).
• Produce lateral and anterior flexion of the
trunk, torsional (rotatory) movements of the
trunk and help maintain posture.

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 NVS of the anterolateral…
• Nerves that supply the skin and muscle of are
– Throacoabdominal nerves which are the distal anterior
parts of the anterior rami of the inferior six thoracic spinal
nerves T7-T11. they supply the skin and the muscles. Spinal
nerves T7-T9 supply the skin superior to the umbilicus; T10
innervates the skin around the umbilicus.
– Subcostal nerve: large anterior ramus of spinal nerve T12.
– Ilioinguinal and iliohypogastric terminal branches of the
anterior ramus of spinal nerve L1.
– Spinal nerve T11, plus the cutaneous branches of the
subcostal (T12), iliohypogastric, and ilioinguinal (L1)
nerves: supply the skin inferior to the umbilicus.

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 Vessels of Anterolateral Abdominal Wall

• The blood vessels of the anterolateral abdominal wall are

the:
• Superior epigastric vessels and branches of the
musculophrenic vessels from the internal thoracic vessels.
• Inferior epigastric and deep circumflex iliac vessels from the
external iliac vessels.
• Superficial circumflex iliac and superficial epigastric vessels
from the femoral artery and great saphenous vein.
• Posterior intercostal vessels in the 11th intercostal space
and anterior branches of subcostal vessels.

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 Surface anatomy..

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• The umbilicus is where the umbilical cord entered into the fetus and is the
reference point for the transumbilical plane . It indicates the level of the T10
dermatome and is typically at the level of the IV disc between the L3 and L4
vertebrae; however, its position varies with the amount of fat in the
subcutaneous tissue.
• The linea alba is a subcutaneous fibrous band extending from the xiphoid
process to the pubic symphysis that is demarcated by a midline vertical skin
groove as far inferiorly as the umbilicus. The pubic symphysis can be felt in the
median plane at the inferior end of the linea alba.
• The bony iliac crest at the level of the L4 vertebra can be easily palpated as it
extends posteriorly from the anterior superior iliac spine.
• In an individual with good muscle definition, curved skin grooves, the
semilunar lines (L. linae semilunares) demarcate the lateral borders of the
rectus abdominis and rectus sheath. The semilunar lines extend from the
inferior costal margin near the 9th costal cartilages to the pubic tubercles.
Three transverse skin grooves overlie the tendinous intersections of the rectus
abdominis .
• The site of the inguinal ligament is indicated by a skin crease, the inguinal
groove, just inferior and parallel to the ligament, marking the division between
the anterolateral abdominal wall and the thigh.
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 Internal surface of the anterolateral..
• The internal surface of the anterolateral
abdominal wall is covered with transversalis
fascia, a variable amount of extraperitoneal
fat, and parietal peritoneum.
• The infraumbilical part of this surface of the
wall exhibits several peritoneal folds, some of
which contain remnants of vessels that carried
blood to and from the fetus.

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• There are 5 umbilical peritonial folds.
• A median umbilical fold which covers the
median umbilical ligament that attaches the
apex of the urinary bladder to the
umbilicus( the urachus in fetal life.)
• Two medial umbilical folds which cover the
medial umbilical ligaments that are the
occluded umbilical vessels.
• Two lateral umbilical folds that cover the lateral
umbilical ligaments which contain the inferior
epigastric vessels.
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• The depressions lateral to the umbilical folds are peritoneal
fossae, each of which is a potential site for a hernia.
• Supravesical fossae between the median and the medial
umbilical folds, formed as the peritoneum reflects from the
anterior abdominal wall onto the bladder.
• Medial inguinal fossae between the medial and the lateral
umbilical folds, areas also commonly called inguinal
triangles (Hesselbach triangles). These are potential sites
for direct inguinal hernias.
• Lateral inguinal fossae, lateral to the lateral umbilical folds,
include the deep inguinal rings and are potential sites for
the most common type of hernia in the lower abdominal
wall, the indirect inguinal hernia.
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 Inguinal Area
• The area extends between the anterior superior iliac
spine and the pubic tubercle. Anatomically, it is a
region where structures exit and enter the abdominal
cavity and is, therefore, clinically important because
these are potential sites of herniation.
• Inguinal hernias occur in both sexes, but most (about
86%) occur in males because of the passage of the
spermatic cord through the inguinal canal.
• The migration of the testes from the abdomen into the
perineum accounts for many of the structural features
of the region.
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• The inguinal ligament, the inferior most part of the
external oblique aponeurosis extend from the
anterior superior iliac spine to the pubic tubercle.
• Most of the fibers of the inguinal ligament insert
into the pubic tubercle, but some fibers:
• Attach to the superior pubic ramus lateral to the
pubic tubercle as the lacunar ligament and then
continue to run along the pectin pubis as the
pectineal ligament (of Cooper).

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• The iliopubic tract is a fibrous band that is a
thickened inferior part of transversalis fascia that
runs parallel and posterior (deep) to the inguinal
ligament.
• It is seen in place of the inguinal ligament when the
inguinal region is viewed from its internal (posterior)
aspect, as through an endoscope .
• The iliopubic tract reinforces the posterior wall and
floor of the inguinal canal as it bridges the structures
(hip flexors and much of the neurovascular supply of
the lower limb) traversing the subinguinal space.
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 Inguinal Canal
• The inguinal canal is formed in relation to the
descent of the gonad (testes or ovary) during fetal
development.
• The inguinal canal in adults is an approximately 4-
cm-long, inferomedially directed oblique passage
(between the superficial and the deep inguinal rings)
that runs through the inferior part of the anterior
abdominal wall.
• The inguinal canal lies parallel and just superior to
the medial half of the inguinal ligament.
• The canal contains the spermatic cord in males and
round ligament in females, blood and lymphatic
vessels and illioinguinal nerves in both sexes.
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• The canal has two openings-
• deep(internal) inguinal ring-internal entrance to
the inguinal canal) is an evagination of the
transversalis fascia superior to the middle of the
inguinal ligament and lateral to the inferior
epigastric vessels
• superficial(external) inguinal ring (exit from the
inguinal canal) is a slit-like opening between the
diagonal fibers of the aponeurosis of the external
oblique, superolateral to the pubic tubercle.

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• The inguinal canal has two walls (anterior and posterior), a roof,
and a floor.
• Anterior wall: formed by external oblique aponeurosis
throughout the length of the canal;
• Posterior wall: formed by transversalis fascia; the posterior wall
of the medial part of the canal is reinforced by merging of the
pubic attachments of the internal oblique and transverse
abdominal aponeuroses into a common tendon the inguinal falx
(conjoint tendon).
• Roof: formed laterally by transversalis fascia, centrally by the
musculoaponeurotic arches of internal oblique and transverse
abdominal muscles, and medially by the medial crus of the
external oblique aponeurosis.
• Floor: formed laterally by the iliopubic tract, centrally by the
superior
05/06/2024 surface of the inguinal ligament, and medially by the38
 Spermatic Cord

• The spermatic cord contains structures

running to and from the testis and suspends
the testis in the scrotum.
• The spermatic cord begins at the deep
inguinal ring lateral to the inferior epigastric
vessels, passes through the inguinal canal,
exits at the superficial inguinal ring, and ends
in the scrotum at the posterior border of the
testis.
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• The fascial coverings are
– internal spermatic fascia- transverse fascia
– Cremasteric fascia- derived from the superficial
and deep surface of the internal oblique .
– external spermatic fascia-derived from the
external oblique aponeurosis and its investing
fascia.

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• The spermatic cord contains
1. ductus deference-a muscular tube that conveys sperms from the
epididymis to the ejaculatory duct. It courses through the substance of the
prostate to open into the prostatic part of the urethra.

2. artery to the ductus deference

3. testicular artery- arising from the aorta (vertebral
level L2) and supplying the testis and epididymis.
4. cremasteric artery
5. pampiniform venous plexus
6. sympathetic nerve fibers
7. genital branch of the genitofemoral nerve
8. lymphatic vessels
9. vestige of the processes vaginalis
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 Clinical
• Hernia –is a protrusion of a loop or a knuckle of
organ or tissue through an abnormal opening.
Inguinal hernia
• There are two types of inguinal hernia,
direct and indirect inguinal hernias, the
boundary between them being the lateral
umbilical fold containing the inferior
epigastric vessels
• Inguinal hernia is more common in males
(90% of all the cases)
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A. Direct inguinal hernia
- It is less common than the indirect (15 - 25% of the cases) and is
usually acquired.
- It penetrates the abdominal wall medial to the lateral umbilical fold
through the medial inguinal fossa to enter the inguinal canal.
-Such hernia usually occurs in older age groups when the abdominal
musculature and the conjoint tendon become atrophied.
- Direct inguinal hernia enters the inguinal canal and protrudes
through the superficial inguinal ring only if it is particularly
large
- Bulging occurs medial to inferior epigastric vessels in the
inguinal triangle bounded by:

 Laterally: Inferior epigastric vessels

 Medially: Rectus abdominus muscle
 Inferiorly: Inguinal ligament
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B. Indirect inguinal hernia
- is more common than the direct constituting 75 -
85% of all the cases.

- enters the inguinal canal through the deep inguinal

ring that lies in the lateral inguinal fossa and leaves
the canal through the superficial inguinal ring to
extend to the scrotum or labia majora

- the indirect inguinal hernia can be congenital or

acquired

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 Other hernias of the abdominal wall
• Epigastric hernia
- small protrusion of extraperitoneal fat through a defect in the
linea alba above the umbilicus.
• Umbilical hernia
- protrusion of the mid gut through the umbilicus, occurs in
infants.when it occurs in infants and small children it is the
herniation of the peritoneum and some abdominal contents
through the umbilicus due to the weakness of the umbilical
scar.
• Femoral hernia
- protrusion through the femoral ring found behind the medial
part of the inguinal ligament. this is more common in females
b/c of the wide pelvis that females have.
Incisional hernia
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is a hernia that protrudes through an operative incision. 45
 Scrotum
• The scrotum is a cutaneous sac that contains
the testes. It has two layers-heavily pigmented
skin and closely related dartos fascia.
• Smooth muscle fibers- dartos muscle in the
dartos fascia help in wrinkling the skin during
the cold so the surface area will decrease there
by reducing heat loss.
• Scrotal veins accompany the arteries. The
lymphatic vessels drain into the superficial
inguinal lymph nodes.
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 Testes
• The ovoid testes are suspended in the scrotum by
the spermatic cords. The testes produce sperms
(spermatozoa) and hormones, principally
testosterone.
• The surface of each testis is covered by the visceral
layer of the tunica vaginalis, except where the testis
attaches to the epididymis and spermatic cord.
• The tunica vaginalis is a closed peritoneal sac
surrounding the testis.

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• Descent of Gonads-The fetal testes descend
from the dorsal abdominal wall in the superior
lumbar region to the deep inguinal rings
during the 9th-12th fetal weeks. This
movement probably results from growth of
the vertebral column and pelvis.

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 Clinical …
• Hydrocele -the presence of excess fluid in a
persistent processus vaginalis is a hydrocele of the
testis.
• Certain pathological conditions such as injury and/or
inflammation of the epididymis may also produce a
hydrocele of the spermatic cord.
• A hematocele of the testis is a collection of blood in
the cavity of the tunica vaginalis .
• Vasectomy-the ductus deferens is ligated bilaterally
when sterilizing a man.
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• Varicocele-the pampiniform plexus of veins may
become varicose (dilated) and tortuous. These
varicose vessels often result from defective
valves in the testicular vein. The palpable
enlargement, which feels like a bundle of worms,
usually drains and thus seems to disappear when
the person lies down.
• Testicular artery arises from the abdominal
aorta(L2) just below the renal artery and go
retroperitoneally passing the ureter and
traversing the inguinal canal to join the spermatic
cord and supply the testes.
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• The testicular veins emerging from the testis and
epididymis form the pampiniform venous plexus,
consisting of anastomosing veins lying anterior to
the ductus deferens and surrounding the
testicular artery in the spermatic cord.
• The pampiniform plexus is part of the
thermoregulatory system of the testis, helping to
keep this gland at a constant temperature.
• The left testicular vein originates as the veins of
the pampiniform plexus coalesce; it empties into
the left renal vein. The right testicular vein has a
similar origin and course but enters the inferior
vena cava (IVC).
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 Peritoneum and peritoneal cavity
• The peritoneum is a glistening transparent
serous membrane that consist of two layers.
-Visceral layer- then envelops the abdominal organs.
-Parietal layer- that lines the internal surface of the
abdominopelvic wall.
The peritoneum and the abdominal viscera
are found in the abdominal cavity.

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 Terms
• Intraperitoneal organ- an organ that is covered
by a visceral peritoneum like the stomach or the
spleen.
• Extra peritoneal, retroperitoneal or sub
peritoneal-are outside the peritoneal cavity,
external or posterior to the parietal peritoneum
and are only partially covered with peritoneum
(usually on one surface).

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• An omentum is a double-layered extension of
peritoneum passing from the stomach and
proximal part of the duodenum to adjacent
organs.
• A mesentery is a double layer of peritoneum that
occurs as a result of the invagination of the
peritoneum by an organ and constitutes a
continuity of the visceral and parietal
peritoneum (e.g., mesentery of small intestine
and transverse mesocolon).

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• Mesenteries provide a means for neurovascular
communication between the organ and the body
wall and thus have a core of connective tissue
containing blood and lymphatic vessels, nerves, fat,
and lymph nodes. Viscera with a mesentery are
mobile; the degree of mobility depends on the
length of the mesentery.
• A peritoneal ligament consists of a double layer of
peritoneum that connects an organ with another
organ or to the abdominal wall.

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• The peritoneal cavity( b/n the visceral and parietal)
contain no organs. It contains a thin layer of fluid
that serves as a lubricant enabling the viscera to
move over each other without friction.
• In addition, the fluid contains leukocytes and
antibodies that resist infection.
• The peritoneal cavity is completely closed in males;
however, there is a communication pathway in
females to the exterior of the body through the
uterine tubes, uterine cavity, and vagina.
• This communication constitutes a potential
pathway of infection from the exterior.
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• The parietal peritoneum has it blood and nerve
supply from the region of the wall it lines.
• It is sensitive to pressure, pain, heat and cold.
And pain from the parietal peritoneum is well
localized.
• The visceral peritoneum gets it blood and nerve
supply from the organ it covers.
• It is not sensitive to pain, heat, cold or laceration
but is to stretching and chemical irritation.

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• Pain coming from the visceral peritoneum is
not well localized and follows the embryologic
origin of the various organs( epigastric- forgut,
midgut- umblical and pubic- hindgut).

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• Peritonitis-when bacterial contamination occurs or
when the gut is traumatically penetrated or
ruptured as the result of infection and
inflammation, gas, fecal matter, and bacteria enter
the peritoneal cavity. The result is infection and
inflammation of the peritoneum, called peritonitis.
• Ascites -under certain pathological conditions such
as peritonitis and metastatic cancers the peritoneal
cavity may be distended with abnormal fluid.
• Surgical puncture of the peritoneal cavity for the
aspiration or drainage of fluid is called paracentesis.
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 Omentum
• The greater omentum extends superiorly, laterally to the
left, and inferiorly from the greater curvature of the stomach
. Has three parts:
• The gastrophrenic ligament between the greater curvature
of the stomach and the diaphragm.
• The gastrosplenic ligament between the greater curvature
of the stomach and the spleen.
• The gastrocolic ligament is the largest part, descending
anteriorly and inferiorly beyond the transverse colon and
then ascending again posteriorly, fusing with the visceral
peritoneum of the transverse colon and the superior layer of
its mesentery. The descending and ascending portions of the
gastrocolic
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part of the greater omentum usually fuse 62
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 Functions
• 1. it is used to store fat- fat apron.
• 2. It protects the peritoneal cavity against
infection b/c of the presence of macrophages
(collections of this forms Milky spots)
• 3. it limits the spread of infection by confining
it to a certain area- so called policeman of the
abdomen.

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• The lesser omentum (hepatogastric and
hepatoduodenal ligaments) connects the lesser
curvature of the stomach and the proximal part of the
duodenum to the liver.
• The hepatogastric and hepatoduodenal ligaments are
continuous parts of the lesser omentum and are
separated only for descriptive convenience.
• The stomach is connected to the liver by the
hepatogastric ligament, the membranous portion of the
lesser omentum.
• The hepatoduodenal ligament, the thickened free edge
of the lesser omentum, conducts the portal triad:
portal
05/06/2024 vein, hepatic artery, and bile duct. 65
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 Subdivisions of the abdominal cavity
• The peritoneal cavity is divided into a greater sac and an omental
bursa(lesser sac).
• The greater sac is the main and larger part of the peritoneal cavity.
A surgical incision through the anterolateral abdominal wall enters
the greater sac.
• The omental bursa (lesser sac) is the smaller part of the peritoneal
cavity that lies posterior to the stomach, lesser omentum, and
adjacent structures. The omental bursa permits free movement of
the stomach on adjacent structures because the anterior and
posterior walls of the omental bursa slide smoothly over each other.
The omental bursa has two recesses :
– A superior recess, which is limited superiorly by the diaphragm and the
posterior layers of the coronary ligament of the liver.
– An inferior recess between the superior part of the layers of the greater
omentum.
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 Abdominal Viscera
• The abdominal viscera include the terminal part of the
esophagus, stomach, small intestine, large intestine, liver,
pancreas, spleen, gall bladder, kidneys and suprerenal glands.
• The mouth, pharynx, esophagus, stomach and intestines make
up the alimentary tract where food is ingested, digested and
absorbed.
• The arterial supply for the abdominal part of the alimentary tract,
liver, gall bladder, pancreas and spleen come from the abdominal
aorta. The 3 major branches of the abd aorta are the celiac
trunk, the superior and inferior mesenteric arteries.
• The portal vein, formed by the union of the superior mesenteric
and splenic veins.
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 Esophagus
• Is a muscular tube which is app 25cm with an average
diameter of 2cm. It transports ingested food from the
mouth to the stomach.
• The upper third muscular wall contains straited
muscle while the lower third has smooth muscle and
the middle had a combination of both.
• The esophagus goes through the right crus of the
diaphragm through the esophageal hiatus.
• It forms a physiological sphincter at the point it where
joins the cardia of the stomach- inferior esophageal
sphincter which prevents reflux of stomach contents.
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 Stomach
• The stomach acts as a food blender and reservoir;
its chief function is enzymatic digestion. The gastric
juice gradually converts a mass of food into a
semiliquid mixture, chyme (G. juice), which passes
into the duodenum.
• The shape of the stomach is dynamic (changing in
shape as it functions) and highly variable from
person to person.
• The stomach has four parts and two curvatures.

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• The cardia is the part surrounding the cardial orifice, the
trumpet-shaped opening of the esophagus into the
stomach.
• The fundus is the dilated superior part of the stomach that
is related to the left dome of the diaphragm and is limited
inferiorly by the horizontal plane of the cardial orifice. The
fundus may be dilated by gas, fluid, food, or any
combination of these.
• The body, the major part of the stomach, lies between the
fundus and the pyloric antrum.
• The pyloric part of the stomach is the funnel-shaped
region; its wide part, the pyloric antrum, leads into the
pyloric canal, its narrow part. The pylorus, the distal
sphincteric region, is a thickening of the circular layer of
smooth
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 Relations of the stomach
• The stomach is completely covered by the peritoneum except
where the blood vessels run along its curvature.
• Anteriorly, the stomach is related to the
– diaphragm,
– the left lobe of the liver, and
– the anterior abdominal wall.
• Posteriorly, the stomach is related to the
– omental bursa and pancreas;
The stomach bed on which the stomach rests when a person is in the
supine position is formed by the structures forming the posterior wall
of the omental bursa. From superior to inferior, the stomach bed is
formed by the left dome of the diaphragm, spleen, left kidney and
suprarenal gland, splenic artery, pancreas, transverse mesocolon, and
colon.
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 Vasculature of the stomach
• The stomach has a rich blood supply. The arteries
travel and anastomose along the lesser and
greater curvatures.
• The right and left gastric arteries run along the
lesser curvature while the right and left gastro-
omental arteries run along the greater curvature.
The fundus and upper body of stomach receive
blood from the short and posterior gastric
arteries branches of the splenic artery.
• The veins are parallel and corresponding to the
arteries. The right and left gastric veins drain
directly to the portal vein.
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 Interior of the Stomach

• When contracted, the gastric mucosa is thrown

into longitudinal gastric folds, or gastric rugae.
These are most marked toward the pyloric part
and along the greater curvature.
• A gastric canal (furrow) forms temporarily during
swallowing between the longitudinal gastric folds
along the lesser curvature.
• Saliva and small quantities of masticated food and
other fluids pass through the gastric canal to the
pyloric canal when the stomach is mostly empty.
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 Small Intestine
• Is made up of the duodenum, jejunum and the ileum.
It starts from the pylorus of the stomach and ends at
the cecum, the first part of the large intestine.
• The major part of digestion and absorption occurs in
the small intestine
• In the small intestine the food is broken down in to its
molecular components by the secretion of the
intestine, pancreas and liver enzymes and then
absorbed through the intestinal mucous membrane
into the blood or lymphatic capillaries
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 Duodenum
• the duodenum is the first part of the small intestine which
is also the shortest(25cm), widest and most fixed. It spans
from the pylorus to the duodenojejunal jxn. It has 4 parts.
• First part(superior)- short (approximately 5 cm), mostly
horizontal, and lies anterolateral to the body of L1
vertebra.
• Second part(descending)- longer (7-10 cm) and runs
inferiorly along the right sides of the L2 and L3 vertebrae,
curving around the head of the pancreas; initially it lies to
the right and parallel to the IVC. The bile duct and main
pancreatic ducts via the hepatopancreatic ampulla enter
its posteromedial wall.

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• Third (horizontal) part: 6-8 cm long and crosses
anterior to the IVC and aorta and posterior to the
superior mesenteric artery (SMA) and SMV at the
level of the L3 vertebra.
• Fourth (ascending) part: short (approximately 5 cm)
and begins at the left of the L3 vertebra and rises
superiorly as far as the superior border of the L2
vertebra, 2-3 cm to the left of the midline. It passes
on the left side of the aorta to reach the inferior
border of the body of the pancreas. Here it curves
anteriorly to join the jejunum at the duodenojejunal
junction.
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• The blood supply to the duodenum comes from two
sources. This is because the duodenum is derived
embryologically from the forgut( supplied by the celiac
trunk) and the midgut( supplied by the sup mesentric art).
• The first and second part are supplied by the
gastroduodenal artery and its branch the sup
pancreaticoduodenal art.
• The third and fourth parts are supplied by SMA and its
branch the inf pancreaticoduodenal art.
• Duodenal veins, follow the arteries and drain into the portal
vein (; some veins drain directly and others indirectly
through
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the superior mesenteric and splenic veins. 82
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 Duodenal (Peptic) Ulcers
• Most inflammatory erosions of the duodenal wall,
duodenal ulcers, are in the posterior wall of the superior
part of the duodenum within 3 cm of the pylorus.
• Occasionally, an ulcer perforates the duodenal wall,
permitting its contents to enter the peritoneal cavity and
produce peritonitis.
• Because the superior part of the duodenum closely relates
to the liver and gallbladder, either of them may adhere to
and be ulcerated by a duodenal ulcer.
• Erosion of the gastroduodenal artery, a posterior relation
of the superior part of the duodenum, by a duodenal ulcer
results in severe hemorrhage into the peritoneal cavity.
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 Jejunum and ileum
• The jejunum is the next part of the small intestine
and starts at the duodenojejunal jxn. The ileum
follows and ends at the ileocecal jxn.
• In a cadaver the combined length of the two is 6-
7m long, about 2/5 of it is the jejunum and the
rest is the ileum.
• Although no clear line of demarcation between
the jejunum and ileum exists, they have
distinctive characteristics for most of their lengths

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Characterstics Jejunum ileum
color Deeper red Paler pink
caliber 2-4cm 2-3cm
wall Thick and heavy Thin and light

vascularity Greater Lesser

vasarecta long short
archades Few large loops Many short loop
Fat in mesentry less more
Payers patches
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few many 86
05/06/2024 87
• The jejunum and ileum have:
• Arterial supply from the SMA. The SMA runs
between the layers of the mesentery and sends
many branches to the jejunum and ileum. The
arteries unite to form loops or arterial arcades that
give rise to straight arteries-the vasa recta .
• Venous drainage from the SMV . The SMV lies
anterior and to the right of the SMA in the root of
the mesentery. The SMV ends posterior to the neck
of the pancreas, where it unites with the splenic
vein to form the portal vein.

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• Specialized lymphatic vessels, called lacteals, in
the intestinal villi that absorb fat and drain into the
lymphatic plexuses in the walls of the jejunum and
ileum.
• The lymphatic plexuses drain into lymphatic
vessels between the layers of the mesentery and
then sequentially through three groups of lymph
nodes: juxta-intestinal lymph nodes (close to the
intestinal wall), mesenteric lymph nodes (scattered
among the arterial arcades), and superior central
nodes (along the proximal part of the SMA).
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• In general, sympathetic stimulation reduces motility
of the intestine, and secretion and acts as a
vasoconstrictor, reducing or stopping digestion and
making blood (and energy) available for fleeing or
fighting.
• The parasympathetic fibers derive from the
posterior vagal trunk. The presynaptic
parasympathetic fibers synapse with postsynaptic
parasympathetic neurons in the myenteric and
submucous plexuses in the intestinal wall.

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 Large Intestine
• The large intestine consists of the cecum, colon
(ascending, transverse, descending, and sigmoid),
rectum, and anal canal. The large intestine can be
distinguished from the small intestine by:
• Teniae coli: three thickened bands of longitudinal
muscle fibers.
• Haustra: sacculations or pouches of the colon
between the teniae.
• Omental appendices: small, fatty appendices
(projections) of colon.
• Caliber: the internal diameter is much larger.
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 Cecum and appendix
• The cecum, the first part of the large intestine that
is continuous with the ascending colon, is a blind
intestinal pouch in the right lower quadrant where
it lies in the iliac fossa inferior to the junction of the
terminal ileum and cecum.
• The ileum enters the cecum obliquely and partly
invaginates into it, forming folds superior and
inferior to the ileal orifice . These folds form the
ileocecal valve.

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• The cecum is supplied by the ileocolic artery,
the terminal branch of the SMA. The appendix
is supplied by the appendicular artery, a
branch of the ileocolic artery.
• A tributary of the SMV, the ileocolic vein,
drains blood from the cecum and appendix.
• The lymphatic vessels from the cecum and
appendix pass to lymph nodes in the
mesoappendix and to the ileocolic lymph
nodes that lie along the ileocolic artery

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• The vermiform (L. worm-like) appendix, a blind
intestinal diverticulum, extends from the
posteromedial aspect of the cecum inferior to the
ileocecal junction.
• The appendix varies in length and has a short
triangular mesentery, the mesoappendix, which
derives from the posterior side of the mesentery of
the terminal ileum.
• The appendix is supplied by the appendicular
artery, a branch of the ileocolic artery. A tributary
of the SMV, the ileocolic vein, drains blood from the
cecum and appendix.
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• Acute inflammation of the appendix is a common
cause of an acute abdomen (severe abdominal pain
arising suddenly).
• Digital pressure over the McBurney point registers the
maximum abdominal tenderness.
• The pain of appendicitis usually commences as a vague
pain in the periumbilical region because afferent pain
fibers enter the spinal cord at the T10 level.
• Later, severe pain in the right lower quadrant results
from irritation of the parietal peritoneum lining the
posterior abdominal wall.
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 Meckels diverticulum

• An ileal diverticulum (of Meckel) is a congenital

anomaly that occurs in 1-2% of people.
• A remnant of the proximal part of the embryonic yolk
stalk, the diverticulum usually appears as a finger-like
pouch (3-6 cm long).
• It is always on the antimesenteric border of the
ileum.
• An ileal diverticulum may become inflamed and
produce pain mimicking the pain produced by
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 Colon
• The colon is made of 4 parts- ascending, transverse,
descending, sigmoid
• The ascending colon passes superiorly on the right
side of the abdominal cavity from the cecum to the
right lobe of the liver, where it turns to the left as the
right colic flexure (hepatic flexure).
• It lies retroperitoneally.
• The arterial supply to the ascending colon and right
colic flexure is from branches of the SMA,the ileocolic
and right colic arteries.
• Tributaries of the SMV, the ileocolic and right colic
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• The transverse colon, the largest and most mobile
part of the large intestine, crosses the abdomen
from the right colic flexure to the left colic flexure.
• The left colic flexure (splenic flexure)usually more
superior, more acute, and less mobile than the
right colic flexure,lies anterior to the inferior part
of the left kidney and attaches to the diaphragm
through the phrenicocolic ligament.
• The mesentery of the transverse colon, the
transverse mesocolon, loops down, often inferior
to the level of the iliac crests, and is adherent to
the posterior wall of the omental bursa.
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• The arterial supply of the transverse colon is
mainly from the middle colic artery, a branch of
the SMA; however, it may also be supplied to
variable degrees by the right and left colic
arteries via anastomoses. Venous drainage of
the transverse colon is through the SMV.
• The descending colon passes retroperitoneally
from the left colic flexure into the left iliac
fossa, where it is continuous with the sigmoid
colon.
• As it descends, the colon passes anterior to the
lateral border of the left kidney.
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• The sigmoid colon, characterized by its S-shaped
loop of variable length, links the descending colon
and the rectum.
• The termination of the teniae coli indicates the
rectosigmoid junction.
• The sigmoid colon usually has a long mesentery
(sigmoid mesocolon) and, therefore, has
considerable freedom of movement, especially its
middle part.
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• The arterial supply of the descending and
sigmoid colon is from the left colic and sigmoid
arteries, branches of the IMA. The left colic and
sigmoid arteries pass to the left where they
divide into ascending and descending branches.
• The IMV returns blood from the descending and
sigmoid colon, flowing usually into the splenic
vein and then the portal vein on its way to the
liver.

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 Functions of the colon
• Formation, transportion and evacuation of faeces.
• Absorption of water, salt and glucose (but not protein, fat or
Ca++)
• Secretion of mucus that lubricates the intestinal mass and
neutralises acids which are produced by the bacteria in the
large intestine
• Formation of vitamins belonging to the B-group and vitamin k
by the flora.
• Decomposition of carbohydrate and protein remnants of
digestion which is responsible for the foul smelling of the
faeces
• Excretion of some heavy metals and phosphates
• Reduction of biliary products and other toxic substances
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 Spleen
• The spleen lies superficially in the left upper
abdominal quadrant between the 9th and
11th ribs.
• The spleen is seldom palpable through the
anterolateral abdominal wall unless it is
enlarged.

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• The spleen, a mobile ovoid lymphatic organ,
• It is intraperitoneal organ except at hilum
• Diaphragmatic surface - convex
• Anterior and superior borders are sharp and
often notched,
• Posterior and inferior borders are rounded.
• The spleen contacts the posterior wall of the
stomach and is connected to its greater
curvature by the gastrosplenic ligament and to
the left kidney by the splenorenal ligament
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• The splenic artery, follows a tortuous course
• The splenic artery divides into five or more branches
that enter the hilum of the spleen
• Divides spleen into two to three vascular segments.
Tributaries of splenic vein:
• From the hilum
• IMV
The splenic vein + SMV = hepatic portal vein / posterior
to the neck of pancreas/
The splenic lymphatic vessels ---> pancreaticosplenic
lymph nodes
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 Pancreas
• The pancreas extends across the posterior
abdominal wall from the duodenum, on the right,
to the spleen, on the left.
• The root of the transverse mesocolon lies along its
anterior margin.
• The pancreas is (secondarily) retroperitoneal except
for a small part of its tail.
• It is a mixed gland- endocrine gland produces
insulin and glucagon from the islet of langerhan and
the exocrine gland- produce pancreatic juice from
the acinar cells.
• Secondarily retroperitoneal organs: pancreas,
duodenum, ascending colon, descending colon

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• Four parts: head, neck, body, and tail.
• The uncinate process, a projection from the inferior
part of the head, extends medially to the left,
posterior to the SMA and SMV.
• The posterior aspect of the neck of pancreas forms
grooves for superior mesenteric vessels.
• The main pancreatic duct merges with the bile duct.

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• The pancreatic and bile ducts unite to form a short,
dilated hepatopancreatic ampulla  major duodenal
papilla.
• The sphincter of the bile duct controls the flow of bile -
hepatopancreatic sphincter (sphincter of Oddi)
• The accessory pancreatic duct drains the uncinate
process and the inferior part of the head of the
pancreas minor duodenal papilla.
• The pancreatic arteries derive mainly from the
branches of the splenic artery except head of pancreas
• Most of the pancreatic veins are tributaries of the
splenic vein

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 Innervations
• The nerves of the pancreas are derived from the
vagus and abdominopelvic splanchnic nerves
passing through diaphragm.

• Sympathetic fibers are also distributed to pancreatic

acinar cells and islets.

• The parasympathetic fibers are secretomotor, but

pancreatic secretion is primarily mediated by
hormones, secretin and cholecystokinin.
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 Clinical
Splenic rupture
• This tends to occur when there is localized trauma to the left
upper quadrant.

Splenic enlargement
• The spleen is an organ of the reticuloendothelial system.
Diseases that affect the reticuloendothelial system (e.g.
leukemia, lymphoma, and certain infections) may produce
generalized lymphadenopathy and enlargement of the spleen
(splenomegaly).
Rupture of Pancreas
• Pancreatic injury can result rupture of the pancreas. Rupture of
the pancreas frequently tears its duct system, allowing
pancreatic juice to enter the parenchyma of the gland and to
invade adjacent tissues. Digestion of pancreatic and other
tissues
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by pancreatic juice is very painful. 120
 Liver
• The liver, the largest internal organ and largest gland in
the body, weighs about 1500 g.
• The diaphragm separates the liver from the pleura,
lungs, pericardium, and heart.
• With the exception of lipids, every substance absorbed
by the alimentary tract is received first by the liver.
• In addition to its many metabolic activities, the liver
stores glycogen and secretes bile.

Surfaces of the liver :

i) a diaphragmatic surface
ii) a visceral surface
• 05/06/2024 121
 Surface Anatomy

The liver lies mainly in the right upper quadrant where it is hidden and protected by the
thoracic cage and diaphragm. The normal liver lies deep to ribs 7-11 on the right side and
crosses the midline toward the left nipple.
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 Surfaces of the liver
1. The convex diaphragmatic surface (anterior, superior, and
some posterior) is smooth and dome-shaped where it is
related to the concavity of the inferior surface of the
diaphragm.

2. The relatively flat, concave visceral surface (posteroinferior)

. The visceral surface of the liver is covered with
peritoneum, except at the bed of the gallbladder and the
porta hepatis. The porta hepatis is a transverse fissure in
the middle visceral surface of the liver that gives passage
to the portal vein, hepatic artery, hepatic nerve plexus,
hepatic ducts, and lymphatic vessels.
• The two surfaces are separated anteriorly by the sharp
inferior border.
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• The visceral surface of the liver is related to the:
– Right side of the anterior aspect of the stomach-gastric and
pyloric areas.
– Superior part of the duodenum-duodenal area.
– Lesser omentum.
– Gallbladde fossa for gallbladder.
– Right colic flexure and right transverse colon—colic area.
– Right kidney and suprarenal gland—renal and suprarenal
areas.
• The lesser omentum, enclosing the portal triad (portal
vein, hepatic artery, and bile duct), passes from the
liver to the lesser curvature of the stomach and the
first 2 cm of the superior part of the duodenum

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 Lobes and segments of the liver
• Anatomically the liver is said to have 4 lobes- the
right, left, caudate and quadrate lobes.
• But functionally, in terms of blood supply and
glandular secretion it is divided into right and left
liver portal lobes.
• The anatomical right lobe is divided from the left by
the falciform ligament.
• On the visceral surface the right and left saggital
fissures and the porta hepatis demarcated the
caudate and quadrate lobes.
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 The diaphragmatic surface is covered with peritoneum, except posteriorly in the
bare area of the liver, where it lies in direct contact with the diaphragm
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• The right saggital fissure is formed by the
groove for the IVC and the fossa for the gall
bladder.
• The left saggital fissure is formed by the
fissure for the ligamentum venosus( fetal
ductal venosus) posteriorly and the round
ligament(ligamentum teres- obliterated
umbilical vein).

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• The division between right and left livers (parts or
portal lobes) is approximated by the sagittal plane
passing through the gallbladder fossa and the fossa
for the IVC on the visceral surface of the liver and
an imaginary line over the diaphragmatic surface
that runs from the fundus of the gallbladder to the
IVC.
• The left liver includes the anatomical caudate lobe
and most of the quadrate lobe. The right and left
livers are more equal in mass than the anatomical
lobes, but the right lobe is still somewhat larger.
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• Each portal lobe has its own blood supply from the
hepatic artery and portal vein and its own venous and
biliary drainage.
• The portal lobes of the liver are further subdivided into
eight segments .
• The segmentation is based on the principal branches of
the right and left hepatic arteries, portal veins, and
hepatic ducts.
• Each segment is supplied by a branch of the right or left
hepatic artery and portal vein and drained by a branch of
the right or left hepatic duct.
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 Vasculature of the liver
• The liver has two blood supply.
• 1, the hepatic artery-20-25%- is a branch of the
celiac truck from the abdominal aorta.
• 2, the portal vein-75-80% - brings nutrient rich
deoxygenated blood from the alimentary system.
• At or close to the porta hepatis, the hepatic
artery and portal vein terminate by dividing into
right and left branches, which supply the right
and left livers, respectively.
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• Within each lobe, the primary branches of the
portal vein and hepatic artery are consistent
enough to form vascular segments.
• Between the segments are the right,
intermediate (middle), and left hepatic veins,
which drain parts of adjacent segments.
• The hepatic veins open into the IVC just inferior
to the diaphragm. The attachment of these
veins to the IVC helps hold the liver in position.
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• The liver is a major lymph-producing organ
• The hepatic plexus of nerves accompanies the
branches of the hepatic artery and hepatic
portal vein to the liver.
• Sympathetic fibers from the celiac plexus.
• Parasympathetic fibers from the anterior and
posterior vagal trunks.

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 Hepatic Lobectomies and Segmentectomy

• When it was discovered that the right and left

hepatic arteries and ducts, as well as branches of
the right and left portal veins, do not communicate
significantly, it became possible to perform hepatic
lobectomies removal of the right or left (part of
the) liver with a minimal amount of bleeding.
• If a severe injury or tumor involves one segment or
adjacent segments, it may be possible to resect
(remove) only the affected segment(s):
segmentectomy.
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• Hepatic tissue may be obtained for diagnostic
purposes by liver biopsy. The needle puncture is
commonly made through the right 10th intercostal
space in the midaxillary line.
• Although less so than the spleen, the liver is
vulnerable to rupture because it is large, fixed in
position, and friable.
• Often the liver is torn by a fractured rib that
perforates the diaphragm. Because of the liver's
great vascularity and friability, liver lacerations often
cause considerable hemorrhage and right upper
quadrant pain.
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 Biliary Ducts and Gallbladder
• Bile is produced continuously in the liver and
stored in the gallbladder. In addition to storing
bile, the gallbladder concentrates it by
absorbing water and salts.
• When fat enters the duodenum, the
gallbladder sends concentrated bile through
the cystic and bile ducts to the duodenum.
• Bile emulsifies the fat so it can be absorbed in
the distal intestine.
05/06/2024 136
• The hepatocytes (liver cells) secrete bile into the
bile canaliculi formed between them . The canaliculi
drain into the small interlobular biliary ducts and
then into large collecting bile ducts of the
intrahepatic portal triad, which merge to form the
right and left hepatic ducts.
• The right and left hepatic ducts drain the right and
left livers (portal lobes), respectively.
• Shortly after leaving the porta hepatis, the right
and left hepatic ducts unite to form the common
hepatic duct, which is joined on the right side by the
cystic duct to form the bile duct
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05/06/2024 138
• On the left side of the descending part of the
duodenum, the bile duct comes into contact
with the main pancreatic duct.
• The two ducts run obliquely through the wall
of this part of the duodenum, where they
unite to form the hepatopancreatic ampulla
(ampulla of Vater).

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05/06/2024 140
• The arteries supplying the bile duct include the:
• Posterior superior pancreaticoduodenal artery and
gastroduodenal artery, supplying the retroduodenal
part of the duct.
• Cystic artery, supplying the proximal part of the
duct.
• Right hepatic artery, supplying the middle part of
the duct.
• The veins from the proximal part of the bile duct
and the hepatic ducts generally enter the liver
directly. The posterior superior pancreaticoduodenal
vein drains the distal part of the bile duct and
empties into the portal vein or one of its tributaries
05/06/2024 141
 Gall bladder
• The pear-shaped gallbladder (7-10 cm long) lies in the
gallbladder fossa on the visceral surface of the liver
• Peritoneum completely surrounds the fundus of the
gallbladder and binds its body and neck to the liver.
• The gallbladder has three parts:
1. The fundus, the wide end, usually located at the tip of the
right ninth costal cartilage in the midclavicular line.
2. The body contacts the visceral surface of the liver, the
transverse colon, and the superior part of the duodenum.
3. The neck is narrow, tapered, and directed toward the
porta hepatis. The neck makes an S-shaped bend and
joins the cystic duct.
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• Internally, mucosa of the neck spirals into a spiral fold
(spiral valve), which keeps the cystic duct open so that
bile can easily divert into the gallbladder when the
distal end of the bile duct is closed by the sphincter of
the bile duct and/or the hepatopancreatic sphincter, or
when bile passes to the duodenum as the gallbladder
contracts.
• The cystic duct (approximately 4 cm long) connects the
neck of the gallbladder to the common hepatic duct.
The cystic duct passes between the layers of the lesser
omentum, usually parallel to the common hepatic duct,
which it joins to form the bile duct.
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05/06/2024 144
• The cystic artery, which supplies the gallbladder and
cystic duct, commonly arises from the right hepatic
artery in the angle between the common hepatic
duct and the cystic duct .
• Variations in the origin and course of the cystic
artery are common.
• The cystic veins draining the biliary ducts and the
neck of the gallbladder may pass to the liver directly
or drain through the portal vein to the liver.
• The veins from the fundus and body pass directly
into the visceral surface of the liver and drain into
the hepatic sinusoids.
05/06/2024 145
• Gallstones are present in approximately 10% of of
people over the age of 40 and are more common in
women.
• They consist of a variety of components, but are
predominantly a mixture of cholesterol and bile
pigment. They may undergo calcification, which can
be demonstrated on plain radiographs.
• From time to time, gallstones impact in the region
of Hartmann's pouch, which is a bulbous region of
the neck of gallbladder that produce severe pain.
• If this persists, a cholecystectomy (removal of
gallbladder) may be necessary. Sometimes the
gallbladder may become inflamed (cholecystitis).
• If bile cannot leave the gallbladder because
impaction, it enters the blood and causes
obstructive jaundice
05/06/2024 146
 Hepatic Portal Vein and Portal-Systemic
Anastomoses
• The hepatic portal vein is the main channel of the portal
venous system.
• It collects nutrient-rich blood from the abdominal part of the
alimentary tract, and carries it to the liver. Within the liver, end
in the venous sinusoids of the liver.
• Portal-systemic anastomoses, locations:
i) Anastomoses between esophageal veins /between azygos
system and portal system/; when dilated these are esophageal
varices.
ii) Anastomoses between rectal veins/ the inferior and middle
veins and the superior rectal vein/; when abnormally dilated
these are hemorrhoids.
iii)Anastomoses between paraumbilical veins (portal) and small
epigastric
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veins of the anterior abdominal wall; when dilated 147
 Posterior abdominal wall
• The posterior abdominal region is posterior to the
abdominal part of the gastrointestinal tract, as well as
the spleen and pancreas.
• Posterior abdominal region, Contains:
--the abdominal aorta and its associated nerve plexuses,

--the inferior vena cava,

--the sympathetic trunks, and lymphatics.

-- the lumbar plexus of nerves

--the kidneys and suprarenal glands

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• The posterior abdominal wall is covered with a continuous
layer of endoabdominal fascia, which lies between the
parietal peritoneum and the muscles. The fascia lining the
posterior abdominal wall is continuous with the transversalis
fascia that lines the transverse abdominal muscle
• . It is customary to name the fascia according to the structure
it covers. The psoas fascia covering the psoas major (psoas
sheath) is attached medially to the lumbar vertebrae and
pelvic brim. The psoas fascia is thickened superiorly to form
the medial arcuate ligament and fuses laterally with the
quadratus lumborum and thoracolumbar fascia

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• Muscles of Posterior Abdominal Wall
• The main paired muscles in the posterior abdominal
wall are the:
• Psoas major, passing inferolaterally.
• Iliacus, lying along the lateral sides of the inferior
part of the psoas major; together the psoas and
iliacus form the iliopsoas.
• Quadratus lumborum, lying adjacent to the
transverse processes of the lumbar vertebrae and
lateral to the superior parts of the psoas major.
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 Psoas Abscess

• An abscess resulting from tuberculosis in the lumbar

region tends to spread from the vertebrae into the
psoas sheath, where it produces a psoas abscess. As a
consequence, the psoas fascia thickens to form a
strong stocking-like tube.
• Pus from the psoas abscess passes inferiorly along the
psoas within this fascial tube over the pelvic brim and
deep to the inguinal ligament. The pus usually surfaces
in the superior part of the thigh. Pus can also reach the
psoas sheath by passing from the posterior
mediastinum when the thoracic vertebrae are
diseased.
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 Kidneys
• The kidneys lie retroperitoneally on the posterior
abdominal wall, one on each side of the vertebral
column, at the level of the T12-L3 vertebrae with
supine position.
• The right kidney lies at a slightly lower level than the
left kidney.
• The kidneys remove excess water, salts, and wastes of
protein metabolism (creatinin & urea) from the blood
while returning nutrients and chemicals to the blood.
• The kidneys convey the waste products from the blood
into the urine, which drains through the ureters to the
urinary bladder.
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• Perinephric fat (perirenal fat capsule) surrounds the
kidneys and suprarenal glands and is continuous with
the fat in the renal sinus.
• The kidneys, suprarenal glands, and perinephric fat
surrounding them are enclosed (except inferiorly) by a
membranous layer of renal fascia.
• The suprarenal glands are usually separated from the
kidneys by a thin septum.
• Inferomedially, the renal fascia is prolonged along the
ureters as periureteric fascia.
• External to the renal fascia is the paranephric fat
(pararenal fat body), the extraperitoneal fat of the
lumbar region that is most obvious posterior to the
kidney.
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• The kidneys lie on the posterior abdominal wall at
the level of the T12-L3 vertebrae.
• Each kidney has anterior and posterior surfaces,
medial and lateral margins, and superior and inferior
poles.
• Concave medial margin ( renal hilum) and convex
lateral margin.
• The kidney is a somewhat bean-shaped appearance.
• The hilum is the entrance of the renal sinus, which is
occupied mostly by fat in which the renal pelvis,
calices, vessels, and nerves are embedded.
• At the hilum, the renal vein is anterior, renal artery in
the middle and renal pelvis is posterior.
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 Right kidney

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 Relations of the kidney
• Superiorly, the kidneys are related to the diaphragm
and the 12th pair of ribs.
• More inferiorly, the posterior surface of the kidney is
related to the quadratus lumborum muscle.
• The subcostal nerve and vessels and the
iliohypogastric and ilio-inguinal nerves descend
diagonally across the posterior surfaces of the kidneys.
• The liver, duodenum, and ascending colon are anterior
to the right kidney.
• The left kidney is related to the stomach, spleen,
pancreas, jejunum, and descending colon.
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 Posterior view

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 Internal structures of the kidney
• In a coronal section the kidney has an outer renal
cortex and an inner renal medulla.
• The renal cortex is a continuous band of pale
tissue
• Extensions of the renal cortex (the renal columns)
project into the inner aspect of the kidney,
dividing the renal medulla into the renal pyramids
• The renal papilla of renal pyramids is surrounded
by a minor calyx, which represents the proximal
parts of the tube that will eventually form the
ureter.
• In the renal sinus, several minor calices unite to
form a major calyx, and two or three major calices
unite to form the renal pelvis, which is the funnel-
shaped superior end of the ureters.
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• Renal artery, supplies each kidney.
• The left renal artery usually arises a little higher than
the right, and the right renal artery is longer and
passes posterior to the inferior vena cava.
• As each renal artery approaches the renal hilum, it
divides into anterior and posterior branches, which
supply the renal parenchyma.
• Accessory renal arteries or extrahilar arteries are
common
• Multiple renal veins contribute to the formation of the
left and right renal veins, both of which are anterior to
the renal arteries
• Importantly, the longer left renal vein crosses the
midline anterior to the abdominal aorta and posterior
to the superior mesenteric artery and can be
compressed by an aneurysm in either of these two
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• Perinephric Abscess
• The attachments of the renal fascia determine the path
of extension of a perinephric abscess. For example, the
fascia at the renal hilum firmly attaches to the renal
vessels and ureter, usually preventing spread of pus to
the contralateral side. However, pus from an abscess (or
blood from an injured kidney) may force its way into the
pelvis between the loosely attached anterior and
posterior layers of the pelvic fascia.
• Renal Transplantation
• Renal transplantation is now an established operation
for the treatment of selected cases of chronic renal
failure.
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 Ureters
• The ureters are muscular tubes.
• The renal pelvis becomes continuous with the
ureter at the ureteropelvic junction.
• The ureters descend retroperitoneally on the
medial aspect of the psoas major muscle.
• At three points along their course the ureters are
constricted:
• i) At the ureteropelvic junction
• ii) Where the ureters cross the common iliac
vessels at the pelvic brim
• iii) Where the ureters enter the wall of the
bladder.
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 Clinical
• Urinary tract stones (calculi) occur more frequently
in men than in women, are most common in people
aged between 20 and 60 years, and are usually
associated with sedentary lifestyles.
• The stones are polycrystalline aggregates of
calcium, phosphate, oxalate, urate, and other
soluble salts within an organic matrix.
• The typical presentation is a patient with pain that
radiates from the infrascapular region (loin) into the
groin, and even into the scrotum or labia majora.
• Blood in the urine (hematuria) may also be noticed.
• The complications of urinary tract stones include
infection, urinary obstruction, and renal failure.
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 Suprarenal glands
• The suprarenal glands are endocrine glands
that are associated with the superior pole of
each kidney.
• They consist of an outer cortex and an inner
medulla.
• The suprarenal cortex secretes corticosteroids
and androgens, and the medulla secretes
epinephrine (adrenalin) and norepinephrine
(noradrenalin).

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• Anterior to the right suprarenal gland is part of
the right lobe of the liver and the inferior vena
cava,
• while anterior to the left suprarenal gland is
part of the stomach, pancreas, and, on
occasion, the spleen.
• The suprarenal glands are surrounded by the
perinephric fat and enclosed in the renal fascia,
though a thin septum separates each gland
from its associated kidney.
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 Vasculature
• The arterial supply to the suprarenal glands is
extensive and arises from three primary sources:
• From inferior phrenic arteries--superior suprarenal
arteries
• From abdominal aorta--middle suprarenal artery
• From the renal arteries--inferior suprarenal
arteries.
• The venous drainage is usually consists of a single
vein leaving the hilum of each gland.
• On the right side, the right suprarenal vein is short
and almost immediately enters the inferior vena
cava; while on the left side, the left suprarenal vein
passes inferiorly to enter the left renal vein.
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Summary of Innervation of Abdominal Viscera

• The autonomic nerves of the abdomen consist of

several different splanchnic nerves and one cranial
nerve (the vagus, CNX) which deliver presynaptic
sympathetic and parasympathetic fibers, respectively,
to the abdominal aortic plexus and its associated
sympathetic ganglia.
• The periarterial extensions of these plexuses deliver
postsynaptic sympathetic fibers and the continuation of
the parasympathetic fibers to the abdominal viscera,
where intrinsic parasympathetic ganglia are located

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• The sympathetic part of the autonomic nervous
system in the abdomen consists of:
• Abdominopelvic splanchnic nerves consisting of lower
thoracic splanchnic nerves (greater, lesser, and least)
from the thoracic part of the sympathetic trunks and
lumbar splanchnic nerves from the lumbar part of the
sympathetic trunks.
• Prevertebral sympathetic ganglia.
• Abdominal aortic plexus and its extensions, the
periarterial plexuses. The plexuses are mixed, shared
with the parasympathetic nervous system and visceral
afferent fibers.
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• The parasympathetic part of the autonomic nervous
system in the abdomen consists of the:
• Anterior and posterior vagal trunks.
• Pelvic splanchnic nerves.
• Abdominal (para-aortic) autonomic nerve plexuses
and their extensions, the periarterial plexuses; the
nerve plexuses are mixed—that is, are shared with
the sympathetic nervous system and visceral
afferent fibers.
• Intrinsic (enteric) parasympathetic ganglia.
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Reference books
Essential clinical anatomy- Moore 3rd edition
Atlas of human anatomy-anatomia Frank H.
Netter
Gray’s Anatomy

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