Download 가로막, 간, 쓸개

2016-01-10
가로막, 간, 쓸개
(Diaphragm, Liver, Gall bladder)
가 로 막 (Diaphragm)
 가장자리 : 근육, 가운데: 널힘줄 로 구성
 둥근 천장모양의 구조물
 가로막 근육의 세부분
 복장부분(Sternal part)
 갈비부분(Costal part): 왼/오른 지붕
닿는곳
(대정맥공 : caval foramen)
 허리부분(Lumbar part)
 가로막다리
이는곳
이는곳
 오른다리(right crus) : 위 3개의 허리뼈몸통(body of lumbar vertebrae)에서 일어남.
 왼다리(left crus) : 위 2개의 허리뼈몸통오름쪽에서 일어남.
** 식도가 지나가는 식도구멍은 중간선의 왼쪽에 위치하지만
식도구멍은 오른다리가 형성한다 (70%)
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2016-01-10
허리갈비삼각
가로막
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 활꼴인대(Arcuate ligaments) :
 큰허리근(psoas major)과 허리네모근(quadratus lumborum)을 덮고 있는 근
막이 두꺼워져 형성
 안쪽활꼴인대 :
• 허리뼈몸통과 가로돌기 사이 인대
• 큰허리근과 교감신경줄기가 지나감
 가쪽활꼴인대 :
• 가로돌기와 12번째 갈비뼈 사이 인대
• 허리네모근이 지나감
 정중활꼴인대 :
• 양쪽다리(crura) 사이 인대
• 대동맥구멍의 앞과 옆둘레 만듬
 복장갈비삼각(Sternocostal triangles) :
 갈비뼈 부분과 복장뼈부분 사이에 생기는 삼각형의 틈새
 허리갈비삼각(Lumbocostal triangle) :
 가로막근육의 시작부분 중에서 갈비뼈부분과 허리뼈부분 사이에 틈이 생긴 것
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선청성가로막탈장 (Congenital diaphragmatic hernia,CDH)
: lumbocostal trigone
•
•
•
간이 오른쪽에 있기 때문에 왼쪽에서 주로 탈장
신생아 2200명당 1명꼴
허파가 형성되지 않을 가능성이 높으며
(폐형성부전증, pulmonary hypoplasia)으로 사망률이 높다
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Thoracic diaphragm
- The diaphragm is a dome-shaped, musculotendinous partition separating the thoracic and
abdominal cavities. Its mainly convex superior surface faces the thoracic cavity, and its
concave inferior surface faces the abdominal cavity. The diaphragm, the chief muscle of
inspiration, descends during inspiration; however, only its central part moves because its
periphery, as the fixed origin of the muscle, attaches to the inferior margin of the thoracic
cage and the superior lumbar vertebrae.
- The muscular part of the diaphragm is situated peripherally with fibers that converge radially
on the trifoliate central aponeurotic part - the central tendon. The central tendon has no
bony attachments and is incompletely divided into three leaves, resembling a wide cloverleaf.
- The crura of the diaphragm are musculotendinous bundles that arise form the anterior
surfaces of the bodies of the superior three lumbar vertebrae, the anterior longitudinal
ligament, and the IV discs.
- The entire motor supply to the diaphragm is from the phrenic nerves, each of which is
distributed to half of the diaphragm and arises from the ventral rami of C3 through C5
segments of the spinal cord. The phrenic nerves also supply sensory fibers (pain and
proprioception) to most of the diaphragm.
가로막
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ㅍ
위자국
(Gastric impression)
ㅍ
날문자국
(pyloric area
오른시상틈새
왼쪽시상틈새
(간원인대틈새)
(정맥관인대틈새)
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2016-01-10
시계방향
오른간, 왼간  간세동의 일차가지에 따라
안쪽, 가쪽구역  오른간문틈새, 왼간문틈새  오른, 왼간정맥에 따라  2차가지
앞, 뒤구역  3차가지
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+
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Inf view
** 간엽절제술(hepatic lobectomy):
Hepatic a.과, hepatic duct(간관), portal v(문맥)이 일차가지를 낸 후 서로 연결되지 않기 때문
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Portal vein and Portal-Systemic anastomoses
- The portal vein is the main channel of the portal venous system. It collects poorly oxygenated
but nutrient-rich blood from the abdominal part of the GI tract, including gallbladder, pancreas,
and spleen, and carries it to the liver. There it branches to end in expanded capillaries - the
venous sinusoids of the liver.
- The portal venous system communcates with the systemic venous system in the following
locations
- between the esophageal veins draining into either the azygos vein (systemic system) or the
left gastric vein (portal system) ► esophageal varix
- between the rectal veins, the inferior and middle draining into the IVC (systemic system), and
the superior rectal vein continuing as the IMV (portal system). The submucosal veins
involved are normally dilated (varicose in appearance), even in newborns; when the mucosa
containing them prolapses, they form hemorrhoids
- paraumbilical veins of the anterior abdominal wall (portal system) anastomosing with
superficial epigastric veins (systemic system); when dilated, these veins produce caput
medusae - varicose veins radiating from the umbilicus
- twigs of colic veins (portal system) anastomosing with retroperitoneal veins (systemic
system)
Left
Right
Gastric a. Gastric a.
Hepatic a.
Celiac
trunk
Aorta
Gastro
Duodenal a.
Common
Hepatic a.
Splenic a.
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Functional parts of the liver
- The liver has functionally independent right and left parts (portal lobes) that are
approximately equal in size. Each part has its own blood supply from the hepatic artery
and portal vein and its own venous and biliary drainage. On the visceral surface, the right
(part of the) liver is demarcated from the left (part of the) liver by the gallbladder fossa
inferiorly and the fossa for IVC superiorly. An imaginary line over the diaphragmatic
surface of the liver that runs from the fundus of the gallbladder to the IVC separates the
parts. Both the right and left parts of the liver have medial and lateral divisions; those of
the left liver are separated by the falciform ligament. In current terminology, the left liver
includes the caudate lobe and most of the quadrate lobe.
- The round ligament of the liver is the fibrous remnant of the umbilical vein that carried
well-oxygenated and nutrient-rich blood from the placenta to the fetus. The umbilical
vein remains patent in infants for a while. In individuals with portal hypertension
(abnormally increased blood pressure in the portal venous system), there may be
enlarged paraumbilical veins that course along the round ligament.
간
- The ligamentum venosum is the fibrous remnant of the fetal ductus venosus that shunted
blood from the umbilical vein to the IVC, short-circuiting the liver.
- The porta hepatis (hepatic portal) is a transverse fissure on the visceral surface of the liver
between the caudate and quadrate lobes, where the portal vein and hepatic artery enter the
liver and the hapatic ducts leave. The porta hepatis gives passage to the portal vein, hepatic
artery, hepatic nerve plexus, hepatic ducts, and lymphatic vessels.
- The portal vein, a short, wide vein, is formed by the superior mesenteric and splenic veins
posterior to the neck of the pancreas, ascends anterior to the IVC, and divides at the right
end
- The liver is a major lymph-producing organ: between one-quarter and one-half of the lymph
received by the thoracic duct comes from the liver.
- hepatic LNs → celiac LNs → cisterna chyli (a dilated sac at the inferior end of the thoracic
duct)
간
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Biliary ducts and gallbladder
- bile canaliculi → interlobular biliary ducts → large collecting bile ducts → right & left hepatic
ducts → common hepatic duct → common bile duct
- The common bile duct forms in the free edge of the lesser omentum by the union of the cystic
duct and the common hepatic duct. The bile duct descends posterior to the superior (first) part
of the duodenum and lies in a groove on the posterior surface of the head of the pancreas. On
the left side of the descending (second) part of the duodenum, the bile duct comes into contact
with the main pancreatic duct. These ducts run obliquely through the wall of this part of the
duodenum, where they unite to form the hepatopancreatic ampulla (ampulla of Vater) - the
dilation within the major duodenal papilla.
Gallbladder
- fundus
- body
- neck - spiral valve
간
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