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Abdomen 2 2.3 Peritoneal cavity 2.4 Liver and gallbladder 2.5 Stomach and spleen Albert van Schoor GNK 288 (SA4 Anatomy dissection) 2.3 Peritoneal cavity and Disposition of abdominal organs 2.3.1 Peritoneum 2.3.2 Organs and relations 2.3.3 Peritoneal specialisation 2.3.4 Radiographic anatomy 2.3.1 Peritoneum • Define the terms: – Peritoneum, – Omentum and – Mesentery • Identify the parietal and visceral peritoneum • Identify and briefly discuss the attachments of the greater and lesser omentum 2.3.1 Peritoneum • Serous membrane that lines the abdominopelvic cavity and invests the viscera • Parietal peritoneum • Visceral peritoneum • Intraperitoneal organs – Stomach, spleen • Retroperitoneal organs – Kidneys, ascending & descending colon 2.3.1 Peritoneum Mesentry of jejenum and ileum Transverse mesoclolon Sigmoid mesocolon Meso-appendix 2.3.1 Peritoneum Lesser Omentum Greater Omentum 2.3.1 Peritoneum Innervation • Central aspect, diaphragmatic peritoneum – Phrenic nerve (C3-5) (referred pain) • Peripheral aspect, diaphragmatic peritoneum – Inter- and subcostal nerves (T7-T12) • Parietal peritoneum – T7-T12 and L1 (pain at precise point of stimulation) • Visceral peritoneum – Insensitive to mechanical stimulation 2.3.2 Organs and relations • Explain the functional anatomy of the mesentery, it’s position, vascular, lymphatic and neural contents • Explain how the abdomen is divided into a supracolic and infracolic compartment • Identify and briefly discuss the attachments of the mesentery of the small intestine to divide the infracolic compartment in two regions 2.3.2 Organs & relations • Mesentry: – double layer of peritoneum – serves as continuation of visceral and parietal peritoneum – provides a means for neurovascular communication between organ and body wall 2.3.2 Organs & relations Transverse Mesoclolon Mesentry of jejenum and ileum Sigmoid mesocolon 2.3.2 Organs & relations Supracolic Infracolic Right Left 2.3.3 Peritoneal specialisation • Name and identify the peritoneal folds • Name and identify the peritoneal fossae • Name and identify the paracolic gutters 2.3.3 Peritoneal specialisation Folds Inferior to the umbilicus • Reflection of peritoneum • Raised from abdominal wall by underlying structure • Median umbilical fold – urachus • Medial umbilical fold – obliterated umbilical artery • Lateral umbilical fold – inferior epigastric vessels 2.3.3 Peritoneal specialisation Folds Superior to the umbilicus • Falciform ligament • Round ligament of the liver (obliterated foetal umbilical vein) 2.3.3 Peritoneal specialisation Fossae / Recess • Duodenal recess • Caecal recesses: – Superior ileocaecal – Inferior ileocaecal – Retrocaecal • Intersigmoid recess • Omental bursa 2.3.3 Peritoneal specialisation • • • • • Fossae / Recess Duodenal recess Duodenojejunal flexure Formed by superior and inferior duodenal folds Superior and inferior duodenal recesses Paraduodenal recess 2.3.3 Peritoneal specialisation Fossae / Recess • Caecal recesses: – Superior ileocaecal – Inferior ileocaecal – Retrocaecal • Formed by: – Caecal fold – Ileocaecal fold – Vascular fold 2.3.3 Peritoneal specialisation Fossae / Recess • Caecal recesses: – Superior ileocaecal – Inferior ileocaecal – Retrocaecal • Formed by: – Caecal fold – Ileocaecal fold – Vascular fold 2.3.3 Peritoneal specialisation Fossae / Recess • Intersigmoid recess • Meso-sigmoid attached to posterior abdominal wall in relation where the left ureter crosses the left common iliac artery 2.3.3 Peritoneal specialisation • • • • Gutters Right paracolic gutter Left paracolic gutter Right, between mesentry of jejenum and ileum and ascending colon (no exit) Left, between mesentry of jejenum and ileum and descending colon (exit inferior) 2.3.3 Peritoneal specialisation • Identify the following: – Gastrosplenic ligament, – Splenorenal ligament, – Transverse and sigmoid mesocolon, – Ileocoecal fold, – Meso-appendix and – The mesenterium of the small intestine 2.3.3 Peritoneal specialisation • Identify and describe the omental bursa (lesser sac) in respect of its relations, borders and entrance - the omental foramen • Identify the structures forming the borders of the omental foramen • Name and identify the subphrenic spaces 2.3.3 Peritoneal specialisation Omental bursa (left subhepatic space) • Superior recess • Inferior recess • Splenic recess 2.3.3 Peritoneal specialisation Omental bursa Superior recess • Anterior: – Lesser omentum – Caudate process of liver • Posterior: – Diaphragm • Right: – IVC • Left: – Oesophagus 2.3.3 Peritoneal specialisation Omental bursa Inferior recess • Anterior: – Stomach – Anterior 2 layers of greater omentum • Posterior: – Pancreas, transverse colon and mesocolon, poster 2 layers of greater omentum 2.3.3 Peritoneal specialisation Omental bursa Splenic recess • Anterior: – Gastrosplenic ligament • Posterior: – Splenorenal ligament • Left: – Hilum of the spleen 2.3.3 Peritoneal specialisation Omental foramen • Connects greater sac (peritoneal cavity) and lesser sac (omental bursa) 2.3.3 Peritoneal specialisation Omental foramen • Anterior: • Free border of lesser omentum: – Common bile duct (right) – Proper hepatic artery (left) – Hepatic portal vein (posterior) 2.3.3 Peritoneal specialisation Omental foramen • Posterior: – Inferior vena cava 2.3.3 Peritoneal specialisation Omental foramen • Superior: – Caudate lobe of liver 2.3.3 Peritoneal specialisation Omental foramen • Inferior: – 1st part of duodenum – Common hepatic artery 2.3.3 Peritoneal specialisation • Name and identify the subphrenic spaces 2.3.3 Peritoneal specialisation Spaces • Right and left subphrenic spaces (separated by the falciform ligament) • Right subhepatic space (Morison’s pouch) • Left subhepatic space (omental bursa) • Extraperitoneal subphrenic space 2.3.3 Peritoneal specialisation • Right and left subphrenic spaces (separated by the falciform ligament) 2.3.3 Peritoneal specialisation • Right subhepatic space (Morison’s pouch) 2.3.3 Peritoneal specialisation • Extraperitoneal subphrenic space 2.3.4 Radiographic anatomy • Identify the following structures on a plain erect abdominal X-ray: – – – – – – – – ASIS, lumbar vertebrae, SI-joint, large intestine, diaphragm, stomach with air in fundus of stomach, liver, psoas line www.up.ac.za/academic/medicine/anatomy/current/sa4/week01e.html#radio 2.4 Liver and gallbladder 2.4.1 Surface anatomy 2.4.2 Structure 2.4.3 Blood supply, nerve supply and lymph drainage 2.4.1 Surface anatomy • Review the surface anatomy of the liver and gallbladder • Indicate where a liver biopsy should be done 2.4.1 Surface anatomy Liver • Right, midaxillary line: – 7th rib almost to right iliac crest • Right, midclavicular plane: – 5th rib cartilage to 9th costal cartilage • Left, midclavicular plane: – 2.5cm short 5th intercostal space and left nipple 2.4.1 Surface anatomy Gallbladder • Inferior to 9th costal cartilage on right • Lateral to semilunar line (lateral border of rectus abdominis) • Approx. hands breadth from midline 2.4.1 Surface anatomy 2.4.2 Structure • Name and identify the borders and surfaces of the liver • Name and identify the lobes, segments, fissures with their contents Identify the subhepatic and subphrenic spaces, and their possible implication in the spread of infection 2.4.2 Structure Diaphragmatic surface Visceral surface 2.4.2 Structure Left Right 2.4.2 Structure Colon Kidney Duodenum Stomach 2.4.2 Structure • Name and identify the following: – Triangular ligaments, – Coronary ligaments, – Falciform ligament, – Lesser omentum, – Round ligament of the liver and – Ligamentum venosum 2.4.2 Structure • Identify, schematically illustrate and discuss the extrahepatic bile ducts as follows: – Origin, – Course, – Outlet and – Relations to the pancreas head and duodenum • Name and identify the extrahepatic bile ducts on radiographs 2.4.2 Structure Right and left hepatic ducts Common hepatic duct Cystic duct (Common) bile duct Main pancreatic duct of Wirsung Ampulla of Vater with the sphincter of Oddi ERCP Endoscopic retrograde cholangiopancreatography 2.4.2 Structure 2.4.3 Blood supply • Discuss and identify the arterial blood supply and venous drainage of the liver and gallbladder • Take note of variations in the arterial blood supply of the liver and gallbladder 2.4.3 Blood supply • Left & right hepatic arteries • Well-oxygenated blood • Hepatic portal vein • Poorly oxygenated blood, nutrient-rich blood from GI tract 2.5 Stomach and spleen 2.5.1 Surface anatomy 2.5.2 Structure 2.5.3 Blood supply, nerve supply and lymph drainage 2.5.4 Radiographic anatomy 2.5.1 Surface anatomy • Review the surface anatomy of the stomach and spleen in relation to the anterior abdominal wall 2.5.1 Surface anatomy Stomach • Cardiac part: – Deep to 7th costal cartilage, 2.5cm to the left of the midline • Pylorus: – On transpyloric plane, 2.5cm to the right of the midline – Vertebral height L1 / L2 • Fundus: – Superior of a plane that extends horizontally from the cardia • Body: – Lies inferior of the abovementioned plane 2.5.1 Surface anatomy Spleen • In relation to the 9th - 11th rib in the midaxillary line 2.5.2 Structure • Name and identify the various regions, curvatures and surfaces of the stomach. Identify these also on radiographs • Identify and briefly describe the general and peritoneal relations of the stomach 2.5.2 Structure Cariac zone Fundus Cardio-oesophageal orifice Pylorus Body Gastric and fundic zones Pyloric zone 2.5.2 Structure • Anterosuperior relations: – Left lobe of liver – Diaphragm – Anterior abdominal wall – Left costal margin 2.5.2 Structure • Postero-inferior relations: – Omental bursa with – Transverse colon and mesocolon – Pancreas – Spleen – Coeliac artery – Left kidney and suprarenal gland – Coeliac plexus – Coeliac ganglia – Diaphragm 2.5.2 Structure • Identify and briefly discuss the structure and surfaces of the spleen • Identify and briefly discuss the relations of the spleen to: ribs, stomach, pancreas, kidney, transverse colon, suprarenal gland • Identify the possible routes of surgical access to the lesser sac: omental foramen, directly through the lesser omentum, posterior 2.5.2 Structure 2.5.2 Structure Posterior Anterior 2.5.3 Blood supply, nerve supply and lymph drainage • Identify and briefly discuss the arterial supply and venous drainage of the stomach and spleen • Schematically illustrate the coeliac trunk and it's branches 2.5.3 Blood & nerve supply, Lymph drainage Coeliac trunk • Common hepatic artery – Gastroduodenal artery • Anterior superior pancreaticoduodenal artery • Right gastro-omental artery – Proper hepatic artery • Right gastric artery • Right hepatic artery – Cystic artery • Left hepatic artery 2.5.3 Blood & nerve supply, Lymph drainage Coeliac trunk • Splenic artery – Left Gastroomental artery – Short gastric artery 2.5.3 Blood & nerve supply, Lymph drainage Coeliac trunk • Left gastric artery 2.5.3 Blood supply, nerve supply and lymph drainage • Identify and briefly discuss the vagus nerve as follows: – Abdominal entrance (anterior and posterior vagus trunks), – Prominent plexuses and – Branches and extent of abdominal supply • Identify the intra-abdominal part of the oesophagus 2.5.3 Blood & nerve supply, Lymph drainage • Vagus nerve (X) • Enters abdomen at T10 together with oesophagus • Parasympathetic supply to GI tract as far as the left colic flexure • Contributions to – – – – Cardiac plexus Oesophageal plexus Aortic plexus Coeliac plexus • Branches: – – – – – Oesophageal Gastric Pancreatic Branches to gallbladder Branches to intestine as far as the left colic flexure 2.5.3 Blood & nerve supply, Lymph drainage • Left vagus nerve (X) – Ant. vagal trunk • Branches: – Oesophageal branches – Gastric branches – Hepatic branches to hepatic portal vein – Pyloric branches 2.5.3 Blood & nerve supply, Lymph drainage • Right vagus nerve (X) – Post. vagal trunk • Branches: – Oesophageal branches – Gastric branches – Coeliac branches to coeliac plexus – Pyloric branches 2.5.4 Radiographic anatomy • Identify the stomach and air in the fundus of the stomach on a plain erect abdominal X-ray • Identify the stomach on a barium meal www.up.ac.za/academic/medicine/anatomy/current/sa4/week01e.html#radio