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Abdomen 4 2.7 Duodenum and pancreas 2.8 Kidneys, suprarenal glands and ureters 2.9 Posterior abdominal wall and diaphragm Albert van Schoor GNK 288 (SA4 Anatomy dissection) 2.7 Duodenum and pancreas 2.7.1 Surface anatomy 2.7.1 Structure 2.7.3 Blood supply, nerve supply and lymph drainage 2.7.1 Surface anatomy • Review the surface anatomy of the duodenum and pancreas • Name the vertebral heights of the various parts of the pancreas 2.7.1 Surface Anatomy 1st part • Approx. 5 cm long • Anterolateral of body of L1 • On the transpyloric line 2.7.1 Surface Anatomy 2nd part • Approx. 7-10 cm long • Descends along the right sides of L1-L3 2.7.1 Surface Anatomy 3rd part • Approx. 6-8 cm long • Horisontal • Crosses the body of L3 2.7.1 Surface Anatomy 4th part • Approx. 5cm cm long • Begins at the left of L3 • Rises superior as far as the superior border of L2 2.7.1 Surface Anatomy L1 L2 L3 L1 L2 T12 2.7.2 Structure • Identify and briefly describe the four parts of the duodenum and the structures opening into it 2.7.2 Structure 1st part • 1st 5cm from gastroduodenal junction • Anterior: – Liver – Gallbladder • Posterior: – Ant. Border of omental foramen (gastroduodenal artery) 2.7.2 Structure • • • • 2nd part 7-10cm long Vertical Curves around head of pancreas Anterior: – Transverse colon • Posterior: – Right kidney and ureter • Posteromedial: – Major and minor duodenal papillae 2.7.2 Structure 3rd part • Horisontal 6-8cm • Anterior: – Superior mesenteric artery – Mesentry of small intestines • Posterior: – IVC – Aorta – L3 • Superior: – Head of pancreas 2.7.2 Structure 4th part • Runs vertical for 2.5 - 5cm to duodenojejenal junction • Suspensory ligament of duodenum (Lig. of Treitz) extend from right crus of diaphragm • Suspends duedenojejenal junction 2.7.2 Structure • Identify and schematically illustrate the different parts (regions) and duct system of the pancreas • Identify and list the general and peritoneal relations of the four parts of the duodenum • Identify and briefly discuss the relations of the pancreas to the spleen, duodenum, stomach and transverse colon and peritoneum • Identify the root of the transverse colon 2.7.2 Structure Accessory pancreatic duct of Santorini Major pancreatic duct of Wirsung 2.7.2 Structure • Identify and briefly discuss the relations of the pancreas to the spleen, duodenum, stomach and transverse colon and peritoneum • Identify the root of the transverse colon 2.7.2 Structure • Superior: – Splenic artery – Common hepatic artery • Posterior: – IVC – Aorta – Sup. mesenteric vessels – Crurae of diaphragm – Coeliac plexus – Left kidney • Anterior: – Stomach – Transverse mesocolon – Omental bursa 2.7.3 Blood supply and lymph drainage • Identify, trace and list the arterial supply and venous drainage of the duodenum and pancreas • Give a broad overview of the major lymph node groups into which the upper abdominal organs drain 2.7.3 Blood & Lymph 2.7.3 Blood & Lymph • Veins follows the arteries • Drains into portal vein either directly or indirectly through: – Superior mesenteric vein – Splenic vein 2.8 Kidneys, suprarenal glands and ureters 2.8.1 Surface anatomy 2.8.2 Structure 2.8.3 Blood supply, nerve supply and lymph drainage 2.8.4 Radiographic anatomy 2.8.1 Surface anatomy • Review the surface anatomy of the kidneys • Identify the bony relations of the kidneys and ureters 2.8.1 Surface Anatomy • Left: L1 L2 – 5cm from median plane – Transpyloric line through hilum of kidney • Right – Transpyloric line through superior pole of kidney – Inferior pole 2.5cm from ileac crest 2.8.1 Surface Anatomy T11 T11 T12 Psoas Major Quadratus Lumborum Transverse Abdominis T12 2.8.2 Structure • Annotate a coronal section of the kidneys as follows: hilus, pelvis, calices, pyramids and columns • Identify and name the general and peritoneal relationships of both kidneys • Identify and name the abdominal course and relationships of both ureters in both sexes 2.8.2 Structure • Identify both suprarenal glands • Compare the relative position of the two kidneys and suprarenal glands • Distinguish the three parts of the ureter and list where a kidney stone might obstruct it 2.8.2 Structure 2.8.2 Structure • Approximately 25cm long • Urine moves by means of peristaltic movements • 3 Components: – Abdominal: adjacent to transverse processes of lumbar vertebrae L2-L5 – Pelvic: enters true pelvis, continues medial, over internal iliac artery, and anteromedial towards bladder – Intramural: short part between 2 layers of bladder wall. Serves as a mechanical valve to prevent reflux of urine 2.8.2 Structure • Potential constrictions: – Renal pelvis – Where ureter crosses the internal iliac artery – Between the 2 muscle layers of the bladder wall 2.8.3 Blood supply, nerve supply and lymph drainage • Trace, identify and compare the course and relations of both renal arteries and veins • Identify, trace and name the arterial supply and venous drainage of both suprarenal glands 2.8.3 Blood & nerve supply, Lymph drainage 2.8.4 Radiographic anatomy • Identify the following on a urogram (or IVP): – – – – – – Kidneys ureters, bladder, major and minor calyces, pelvis of kidney, and relation of the ureters to the transverse processes of the lumbar vertebrae www.up.ac.za/academic/medicine/anatomy/current/sa4/week01e.html#radio 2.9 Posterior abdominal wall and diaphragm 2.9.1 Abdominal aorta 2.9.2 Abdominal inferior vena cava 2.9.3 Lymph drainage 2.9.4 Nerve structures 2.9.5 Fascia 2.9.6 Muscles 2.9.7 Diaphragm 2.9.8 Osteology 2.9.1 Abdominal aorta • Identify the course, relationships and branches of the abdominal aorta 2.9.1 Abdominal aorta • 3 unpaired to viscera (anterior) – Coeliac trunk – Sup. mesenteric – Inf. mesenteric • 3 paired to viscera (lateral) – Suprarenal – Renal – Gonadal • 5 paired (lateral) – Inferior phrenic – 4 pairs of lumbar • 2 paired terminal branches – Common iliac – Median sacral 2.9.2 Abdominal inferior vena cava • Briefly discuss and identify the course, relations and tributaries of the inferior vena cava • Identify the different drainage of the left and right gonadal veins 2.9.3 Lymph drainage • Give a broad overview of the lymph drainage of the abdomen 2.9.4 Nerve structures • Identify and briefly describe the sympathetic trunk and where possible the plexuses 2.9.4 Nerve structures • 2 parallel nerve cords • Extending on either side of the vertebral column from the base of the skull to the coccyx. • 2 sympathetic trunks come together anterior to the coccyx to form the ganglion impar. 2.9.4 Nerve structures • Identify and discuss the distribution and root values of the following nerves of the lumbar plexus: – – – – – – – Subcostal, iliohypogastric, ilioinguinal, lateral cutaneous nerve of the thigh, genitofemoral, femoral and obturator nerves • Give an overview of the autonomic nerve supply of the abdomen 2.9.4 Nerve structures Autonomic Sympathetic • Splanchnic nerves – Thoracic (Coeliac plexus) – Lumbar (Intermesenteric / aortic & superior hypogastric plexus) – Sacral (Inferior hypogastric plexus) – Pelvic* (Inferior hypogastric plexus) * Both sympathetic and parasympathetic Paraympathetic • Vagus nerve (X) ~ cranial outflow – Foregut & midgut • S2-S4 ~ abdominal outflow – Hindgut • Intermesenteric / aortic plexus • Superior & inferior mesenteric plexuses • Superior & inferior hypogastric plexuses 2.9.5 Fascia • Identify the layers of the thoracolumbar fascia • Identify the psoas and iliac fascia 2.9.6 Muscles • Identify and briefly discuss the major attachments, relationships to organs and nerves, as well as the nerve supply of the following muscles: – psoas major, – iliacus and – quadratus lumborum 2.9.6 Muscles Muscle Origin Insertion Psoas major Lateral surface of bodies and intervertebral discs of T12 and L1 to L5, transverse processes of the lumbar vertebrae Lesser trochanter of the femur Quadratus Lumborum Iliacus Transverse process of L5, iliolumbar ligament, and iliac crest Upper two-thirds of iliac fossa, anterior sacro-iliac and iliolumbar ligaments, and upper lateral surface of sacrum Innervation Anterior rami of L1 to L3 Transverse processes of L1-L4 and inferior border of rib 12 Anterior rami of T12 and L1 to L4 Lesser trochanter of femur Femoral nerve (L2 - L4) 2.9.7 Diaphragm • Review the surface anatomy of the diaphragm • Identify and name it's attachments, blood supply and nerve supply 2.9.7 Diaphragm 1a) Vertebral ~ crura • Right Crus – L1-L3 • Left Crus – L1-L2 2.9.7 Diaphragm 1b) Vertebral ~ fibrous arches • Median arcuate lig – aorta • Medial arcuate lig – Psoas major • Lateral arcuate lig – Quadratus lumborum 2.9.7 Diaphragm 2) Costal • Ribs 7-12 3) Sternal • 2 small attachments to xiphisternum 2.9.7 Diaphragm • Innervation – Motor supply ~ phrenic nerve • Blood supply ~ superior – Superior phrenic artery (thoracic aorta) – Musculophrenic and pericardiophrenic arteries(internal thoracic artery) • Blood supply ~ inferior – Inferior phrenic artery (abdominal aorta) 2.9.7 Diaphragm • List it's superior and inferior relations on the left and right • Identify and name the orifices of the diaphragm with their vertebral heights and contents and the structures penetrating the diaphragm separately 2.9.7 Diaphragm T8 T10 T12 2.9.7 Diaphragm • Identify and name the arcuate ligaments of the diaphragm and the structures related posterior to them • Identify and name the crura of the diaphragm in relation to the oesophageal hiatus 2.9.8 Osteology • Identify and briefly discuss the bony elements of the posterior abdominal wall