Regional anatomy of abdomen

1. Regional anatomy of abdomen 山东大学医学院 解剖教研室 李振华

2. Relations of abdominal viscera • First layer－live, gallbladder, stomach • Second layer－duodenum, pancreas, spleen • Third layer－suprarenal gland, kidney, ureter, inferior vena cava, abdominal aorta, nerves and lymphatics

3. Relations of the stomach • Anteriorly: • Live (right part) • Diaphragm (left upper part) • Anterior abdominal wall (left lower part) • Posteriorly－separated by peritoneum of lesser sac from the following (“stomach-bed”) • Pancreas • Left suprarenal gland • Left kidney • Spleen • Transverse colon and transverse mesocolon

4. Arteries of stomach • Left and right gastric arteries • Arise from celiac trunk and proper hepatic artery, respectively. • These two vessels run in lesser omentum along lesser curvature , and anastomose end-to-end.

5. Arteries of stomach • Right and leftgastroepiploic arteries • Arise from the gastroduodenal and splenic artery, respectively. • These two vessels pass into the greater omentum, run parallel to the greater curvature, and anastomose end-to-end.

6. Arteries of stomach • Short gastric arteries • Branches of splenic artery • Course through the gastrosplenic ligament • Supply the fundus of stomach. • Posterior gastric artery (72%) • Arise from the splenic artery • Course through the gastrophrenic ligament and supply the posterior wall of fundus of stomach.

7. Venous drainage of stomach • Right and left gastric veins empty directly into hepatic portal vein. • Left gastroepiploic and short gastric veins drain into hepatic portal vein via the splenic vein. • Right gastroepiploic vein drain into superior mesenteric vein.

8. Lymph drainage of stomach • Right and left gastric ln. lie along the same vessels and finally to the celiac ln. • Right and left gastroomental ln. lie along the same vessels, the former drain into subpyloric ln., the latter drain into splenic ln. • Suprapyloric and subpyloric ln. receive lymphatics from pyloric part and finally to the celiac ln. • Splenic ln. receive lymphatics from fundus and left third of stomach, and finally to the celiac ln.

9. Nerve supply of stomach • Parasympathetic innervation • The anterior vagal trunk divides into anterior gastric and hepatic branches • The posterior vagal trunk divides into posterior gastric and celiac branches • The anterior and posterior gastric branches descend on the anterior and posterior surfaces of the stomach as a rule about 1 to 2 cm from the lesser curvature and parallel to it in the lesser omentum as far as the pyloric antrum to fan out into branches called “crow’s foot” to supply the pyloric part • Sympathetic innervation • Mainly from celiac ganglia • Afferent and efferent fibers derives from thoracic segments (T5 －L1)

10. Relations of duodenum Relations of superior part • Anteriorly • Quadrate lobe of live • Gallbladder • Posteriorly • Common bile duct • Gastroduodenal a. • Hepatic portal v. • Inferior vena cava • Superioely • Omental foramen • Inferiorly • Head of pancreas

11. Relations of duodenum Relations of descending part • Anteriorly • Live • Transverse colon and transverse mesocolon • Loops of small intestine • Posteriorly • Right renal hilum and ureter • Right renal vessels • Medially • Head of pancreas • Common bile duct and pancreatic duct • Laterally • Right colic flexure

12. Relations of duodenum Relations of horizontal part • Superiorly • Head of pancreas • Inferiorly • Loops of small intestine • Anteriorly • Radix of mesentery • Superior mesenteric a. and v. • Posteriorly • Right ureter • Inferior vena cava • Abdominal aorta

13. Relations of duodenum Relations of ascending part • Right — Head of pancreas and abdominal aorta • Left — left kidney and ureter

14. Blood supply of duodenum • Arteries • Superior pancreaticoduodenal a. • Inferior pancreaticoduodenal a. • Veins－follow arteries, draining directly into superior mesenteric and hepatic portal veins

15. Relations of liver • Diaphragmatic surface－separated by diaphragm from the following • Right costodiaphramatic recess and lung • Cardiac base • Visceral surface • Left lobe is related to the stomach and abdominal part of esophagus • Right lobe is related to the right colic flexure anterioly, gallbladder and superior duodenal flexure medially, right kidney, superarenal gland posteriorly

16. Divisions and relations of common bile duct Divisions • Supraduodenal segment 十二指肠上段 • Retroduodenal segment 十二指肠后段 • Pancreatic segment 胰腺段 • Intraduodenal segment 十二指肠壁段

17. Relations of common bile duct Supraduodenal segment • Descends along the right margin of hepatoduodenal lig. • To the right of proper hepatic a. • Anterior to hepatic portal v. Retroduodenal segment • Behind the superior part of duodenum • Anterior to the vena cava • To the right of the hepatic portal v.

18. Relations of common bile duct Pancreatic segment • Lies in a groove between posterior surface of head of pancreas and duodenum Intraduodenal segment • Enters the wall of descending part of duodenum obliquelywhere jions the pancreatic duct to form the hepatopancreatic ampulla • Opens at the major duodenal papilla

19. Cystohepatic triangle(Calot’s Triangle)胆囊三角 • Boundaries • Common hepatic duct on the left • Cystic duct on the right • Live superiorly • Content: cystic artery

20. The Pancreas 胰 Four parts • Head • Lies within the cancavity of the C-shaped curvatune of duodenum • Uncinate process－ a projection to the left from the lower part of the head behind the superior mesenteric vessels. • Neck－narrow part, overlies the superior mesenteric vessels and beginning of the portal vein • Body－triangular in cross section, passes upward and to the left across the midline • Tail－extends to the hilum of spleen in the splenorenal ligament

21. Relations of pancreas Head of pancreas • Located in C-shapes curvature of doudenum • Anteriorly • Transverse mesocolon • Posteriorly • Inferior vena cava • Right renal vessels • Common bile duct

22. Relations of pancreas Neck of pancreas • Anteriorly－pylorus • Posteriorly－beginning of hepatic portal v.

23. Relations of pancreas Body of pancreas • Anteriorly • Separated from stomach by omental bursa • Posteriorly • Abdominal aorta • Left suprarenal gland • Left kidney • Left renal vessels • Spleen vein • Superiorly • Celiac trunk • Celiac plexus • Splenic a.

24. Relations of pancreas Tail of pancreeas • Runs in splenorenal ligament to reach hilum of spleen • Accompanies with splenic vessels

25. Relations of spleen • Diaphragmatic surface－diaphragm • Visceral surface • Anteriorly－fundus of stomach • Posteriorly－left suprarenal gland and kidney • Inferiorly－tail of pancreas and left colic flexure

26. Retroperitoneal space 腹膜后隙 • Position－it lies between the parietal peritoneum and transvers fascia of the posterior abdominal wall, from diaphragm to promontory of sacrum, continuation with extraperitoneal fascia. • Contents • Kidney • Suprarenal gland • Ureter • Abdominal aorta • Inferior vena cava • Nerves and lymphatics • Loose connective tissue

27. Suprarenal gland 肾上腺 Shape and position • Right is pyramidal in shape, left one semilunar in shape, consisting of out cortex and inner medulla • Located retroperitoneally, superomedial to superior poles of each kidney, enclose with the kidney by the renal fascia Blood supply • Arteries • Superior suprarenal a. • Middle suprarenal a. • Inferior suprarenal a. • Venous drain • Right suprarenal v. drains into inferior vena cava • Left suprarenal v. joins left renal v.

28. Axial CT scan of the upper abdomen. • On soft-tissue windows, to demonstrate retroperitoneal anatomy. IVC, inferior vena cava.

29. Dissection Live Stomach Gallbladder Greater omentum

30. Dissection Omental foramen

31. Dissection Transverse colon Right mesenteric sinus Radix of mesentery Ascending colon Vermiform appendix

32. Dissection Transverses colon Left mesenteric sinus Radix of mesentery Descending colon Sigmoid colon

33. Left gastric a. Left branch Right branch Short gastric a. Common hepatic a. Cystic a. Splenic a. Right gastric a. Proper hepatic a. Gastroduodenal a. Splemic branches Left gastroepiploic a. Right gastroepiploic a. Superior pancreaticoduodenal a. Celiac trunk

34. Superior Mesenteric v. Middle colic a. Inf. pancreaticodudenal a. Superior mesenteric a. Right colic a. Jejunal and ileal a. Ileocolic a. Appendicular a.

35. Inferior mesenteric v. Inferior mesenteric a. Left colic a. Sigmoid a. Superior rectal a.

36. Stomach Lesser curvature Greater curvature angular incisure cardiac incisure Cardiac part Fundus of stomach Body of stomach Pyloric part Duodenum Superior part Descending part Major duodenal papilla Horizontal part Ascending part Large Intestine Colic bands Haustra of colon Epiploic appendices Cecum ileocecal valve Vermiform appendix Ascending colon Transverse colon Descending colon Sigmoid colon ★You must identify follow structures！

37. Liver Falciform lig. of liver ligamentum teres hepatic porta hepatic Notch for ligamentum teres hepatis Nothch for gallbladder Gallbladder Fundus of gallbladder Body of gallbladder Neck of gallbladder Cystic duct Right and left hepatic ducts Common hepatic duct Common bile duct Pancreas Head Uncinate process Neck Body Tail Peritoneum Lessor omentum Omental foramen Greater omentum Mesentery Mesoappendix Gastrosplenic ligament rectovesical pouch Rectouterine pouch Vesicouterine pouch ★You must identify follow structures！

38. Kidney Renal hilum Renal sinus Renal cortex Renal pyramid Renal papilla Minor renal calices Major renal calicle Renal pelvis Bladder Apex Fundus Body Neck Trigone of bladder Interureteric fold Ureters Peritoneum Lessor omentum Omental foramen Greater omentum Mesentery Mesoappendix Gastrosplenic ligament rectovesical pouch Rectouterine pouch Vesicouterine pouch Spleen Splenic notch ★You must identify follow structures！

39. Celiac trunk Left gastric artery Common hepatic artery Proper hepatic artery Right gastric artery Left and right branches Cystic artery Gastroduodenal artery Right gastroepiploic artery Splemic artery Short gastric arteries Left gastrioeploic artery Superior mesenteric artery Jejunal and ileal arteries Ileocolic artery Right colic artery Middle colic artery Inferior mesenteric artery Left colic artery Sigmoid arteries Superior rectal artery Renal artery Testicular (ovarian) artery Inferior vena cava Right and left renal veins Right suprarenal vein Hepatic portal vein Superior mesenteric vein Inferior mesenteric vein Splenic vein ★You must identify follow structures！