Transcript Posterior abdominal wall

In the name of God
Posterior abdominal wall 2
Dr. Zahiri
Dr. Maria Zahiri
VASCULAR SUPPLY AND LYMPHATIC
DRAINGE
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ABDOMINAL AORTA
Anterior:
• Coeliac trunk and its branches.
• coeliac plexus and the lesser sac lie between it and the left
lobe of the liver and lesser omentum.
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Superior mesenteric artery
left renal vein, the body of the pancreas
the splenic vein
the gonadal arteries, and the third part of the duodenum
small intestinal mesentery.
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Posterior relations of Aorta
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thoracolumbar intervertebral discs
upper four lumbar vertebrae
Lumbar arteries
third and fourth (and sometimes second) left lumbar
veins
• the left psoas major.
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Right relations of Aorta
• cisterna chyli and thoracic duct
• azygos vein
• right crus of the diaphragm, which overlaps and
separates it from the inferior vena cava and right coeliac
ganglion.
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Left relations of Aorta
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left crus of the diaphragm
left coeliac ganglion
duodenojejunal flexure
left sympathetic trunk
the fourth part of the duodenum
inferior mesenteric vessels.
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Branches of Aorta
• Anterior group
• Lateral group
• Dorsal group
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Anterior group:
Coeliac trunk
• is the first anterior branch
• at the level ofT12/Ll
Superior mesenteric artery
• 1 cm below the coeliac trunk
• at the level of the Ll-L2
Inferior mesenteric artery
• 3 or 4 cm above the aortic bifurcation
• at the level of L3
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Lateral group:
• Suprarenal arteries
• The renal arteries
• The gonadal arteries
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Dorsal group:
• Inferior phrenic arteries
• Lumbar arteries
• Median sacral artery
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INFERIOR VENA CAVA
Relations of the abdominal part of the inferior
vena cava:
Anteriorly:
• right common iliac artery
• root of the mesentery
• right gonadal artery
• head of the pancreas
• first part of the duodenum
• common bile duct
• portal vein
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posterior :
• The lower three lumbar vertebral bodies
• their intervertebral discs
• the anterior longitudinal ligament
• right psoas major
• sympathetic trunk
• right crus of the diaphragm
• the medial part of the right suprarenal gland
• the right coeliac ganglion
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Right & Left relations of IVC
Right :
• The right ureter
• the second part of the duodenum
• medial border of the right kidney
• the right lobe of the liver
left :
• The aorta
• the right crus of the diaphragm
• the caudate lobe of the liver
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Lumbar veins
Ascending lumbar vein
Gonadal veins
Renal veins
Suprarenal vein
Inferior phrenic veins
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Lumbar veins
Four pairs of lumbar veins collect blood by dorsal
tributaries from the lumbar muscles and skin.
anastomose with:
• lumbar origin of the azygos
and hemiazygos veins
• branches of the inferior
and superior epigastric veins.
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Ascending lumbar vein
The ascending lumbar vein connects the common iliac,
iliolumbar and lumbar veins.
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Gonadal veins
Only the right gonadal vein
joins the IVC directly.
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Renal veins
The left is three times longer
than the right in length
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Suprarenal vein
The right suprarenal vein drains directly into the inferior
vena cava
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Inferior phrenic veins
• run on the inferior surface of the central tendon of the
diaphragm.
• drain into the posterolateral aspect of the IVC
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LYMPHATIC DRAINAGE
posterior abdominal wall:
The small upper left and upper right
nodes
lateral aortic
The larger lower left and lower right portions
lateral and retro aortic lymph nodes
Or the left and right superficial inguinal nodes.
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abdominal viscera:
through the cisterna chyli and the thoracic duct
The lymph nodes of the retroperitoneum lie around the
abdominal aorta and form pre-aortic, lateral aortic
and retro-aortic groups.
Collectively, they are referred to as the para-aortic
lymph nodes
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Cisterna chyli and abdominal lymph
trunks
The abdominal origin of the thoracic duct:
• lies to the right of the midline
• at the level of the lower border of the T12
• receives all the lymph delivered by the four main
abdominal lymph trunks
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The lumbar lymph trunks are formed by vessels
draining from the lateral aortic nodes. Thus, either
directly or after traversing intermediary groups, they
carry lymph from:
the lower limbs, the full thickness of the pelvic, perineal
and infra-umbilical abdominal walls, the deep tissues of
most of the supra-umbilical abdominal walls, most of the
pelvic viscera, gonads, kidneys and suprarenal glands.
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The intestinal lymph trunks receive vessels draining
from coeliac nodes and, via these nodes, the superior and
inferior mesenteric nodes, which are collectively the
pre-aortic nodes.
Either directly or via intermediary groups, they drain the
entire abdominal gastrointestinal tract down to
the anus.
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Pre-aortic group
lie around the origins of the anterior (visceral) arteries and
receive lymph from the gastrointestinal tract and its
accessory structures (liver, spleen and pancreas) from
the abdominal oesophagus to the level of the anus.
They are divisible into coeliac, superior mesenteric and
inferior mesenteric groups, being near the origins of
these arteries.
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Coeliac nodes
• The coeliac nodes lie anterior to the abdominal aorta
around the origin of the coeliac artery.
• receive lymph draining from the regional lymph nodes
around the branches of the coeliac artery (left gastric,
hepatic and pancreaticosplenic nodes).
• They also receive lymph from the lower pre-aortic
groups (the superior mesenteric and inferior
mesenteric).
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Gastric Nodes
• There are a great number of gastric lymph node groups.
They drain the stomach, upper duodenum, abdominal
oesophagus and the greater omentum.
• They drain to the coeliac group.
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Hepatic Nodes
• They vary in number and site
• but almost occur at the junction of the cystic and
common hepatic ducts (the cystic node), and in the
anterior border of the epiploic foramen.
• Hepatic nodes drain the majority of the liver, gallbladder
and bile ducts, but also receive drainage from some parts
of the stomach, duodenum and pancreas.
• They drain to the coeliac nodes
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Pancreaticosplenic Nodes
The pancreaticosplenic nodes drain the spleen, pancreas
and part of the stomach.
Their afferents join the coeliac nodes.
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Superior mesenteric and inferior
mesenteric nodes
• lie anterior to the aorta near the origins of their
respective arteries.
• They collect from outlying groups, including the
mesenteric, ileocolic, …
• drain into the coeliac nodes.
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lateral aortic group
The lateral aortic nodes lie on either side of the abdominal
aorta anterior to the medial margins of psoas major,
diaphragmatic crura and sympathetic trunks.
On the right, some nodes lie lateral and anterior to the
inferior vena cava near the end of the right renal vein.
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lateral aortic group
The lateral aortic nodes drain the viscera and other
structures supplied by the lateral and dorsal aortic
branches.
The upper lateral groups receive the lymph drainage
directly from the suprarenal glands, kidneys, ureters,
gonads, uterine tubes and upper uterus. They also
receive lymph directly from the deeper tissues of the
posterior abdominal wall.
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Lymphatics from the pelvis, most of the pelvic viscera, the
perineum and the anterolateral abdominal wall pass first
to regional nodes largely related to the iliac arteries and
their branches.
These include the common iliac, external iliac, internal
iliac and circumflex iliac nodes, in addition to the
inferior epigastric and sacral nodes.
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Lymph from the lower limbs passes through the pelvic
lymph nodes via the iliac groups.
The lateral aortic group drains into the two lumbar lymph
trunks, one on each side, which terminate in the
confluence of lymph trunks.
A few vessels may pass to the pre-aortic and retro-aortic
nodes and others cross the midline to flow into the
contralateral nodes, forming a loose plexus.
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Retro-aortic group
The retro-aortic group is the smallest of all the para-aortic
lymph nodes.
They have no particular areas of drainage, although they
may receive some lymph directly from the paraspinal
posterior abdominal wall.
They effectively provide peripheral nodes of the lateral
aortic groups and interconnect between surrounding
groups.
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• INNERVATION
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PNS:
Somatic fiber
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PNS:
Visceral fibers
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ANS: Autonom nervous tissue
Intermediolateral columns
(IMLs)
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Prevertebral plexus
• Celiac plexus
• Abdominal aortic plexus
• Superior hypogastric plexus
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Prevertebral ganglion
• Celiac
• SMG
• IMG
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Prevertebral & paravertebral plexus
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Lumbar plexus
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Iliohypogastric nerve
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originates from the L1 ventral ramus
lateral border of psoas major
in front of quadratus lumborum.
lateral cutaneous branches (iliac crest)
Ant. cutaneous branches (ASIS)
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Motor –
transversus abdominis and internal oblique, including the
conjoint tendon.
Sensory - The iliohypogastric nerve supplies sensory
fibres to transversus abdominis, internal oblique and
external oblique, and innervates the posterolateral
gluteal and suprapubic skin.
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Ilioinguinal nerve
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originates from the L1 ventral ramus
It is smaller than the iliohypogastric nerve
the lateral border of psoas major
just inferior to the iliohypogastric nerve
Ilioinguinal nerve emerges with the cord
• skin of the thigh and the skin over the root of the penis
and upper part of the scrotum in males, or the skin
covering the mons pubis and the adjoining labium majus
in females.
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Ilioinguinal nerve
Motor –
transversus abdominis and internal oblique.
Sensory
to transversus abdominis and internal oblique
medial skin of the thigh and the skin over the root of the
penis and upper part of the scrotum in males or the skin
covering the mons pubis and the adjoining labium majus
in females.
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Genitofemoral nerve
• originates from the L1 and L2 ventral rami.
• It is formed within the substance of psoas major
• It descends beneath the peritoneum on psoas major
Crosses obliquely behind the ureter and divides above
the inguinal ligament into genital and femoral branches.
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Genitofemoral nerve often divides close to its origin; its
branches then emerge separately from psoas major.
The genital branch crosses the lower part of the
external iliac artery, enters the inguinal canal by the
deep ring and supplies cremaster and the skin of the
scrotum in males.
In females, it accompanies the round ligament and ends in
the skin of the mons pubis and labium majus.
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The femoral branch descends lateral to the
external iliac artery
and sends a few filaments round it.
It then crosses the deep circumflex iliac artery
passes behind the inguinal ligament and enters the
femoral sheath lateral to the femoral artery.
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Motor –
cremaster via the genital branch.
Cutaneous –
the skin of the scrotum in males or mons pubis and
labium majus in females via the genital branch,
and the anteromedial skin of the thigh via the
femoral branch.
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Femoral nerve
descends through psoas major
It passes between psoas major and iliacus and runs
posterior to the inguinal ligament into the thigh.
It gives off branches, which supply iliacus and pectineus
and sensory fibers to the femoral artery
Posterior to the inguinal ligament, it lies lateral to the
femoral artery and is separated from it by a part of psoas
major.
Lateral femoral cutaneous nerve of the thigh
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The lateral femoral cutaneous nerve of the thigh emerges
from the lateral border of psoas major and crosses
iliacus obliquely towards the anterior superior iliac
spine.
It supplies sensory fibers to the parietal peritoneum in the
iliac fossa.
The right nerve passes posterolateral to the caecum,
separated from it by the iliac fascia and peritoneum. The
left nerve passes behind the lower part of the descending
colon. Both pass behind or through the inguinal ligament
c.l cm medial to the anterior superior iliac spine and
anterior to, or through, sartorius into the thigh.
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Obturator nerve
The obturator nerve descends within the substance of
psoas major to emerge from its medial border at the level
of the pelvic brim.
It passes posterior to the common iliac vessels and lateral
to the internal iliac vessels. It then descends on the
lateral wall of the pelvis attached to the fascia over
obturator intern us. Here it lies anterosuperior to the
obturator vessels before running into the obturator
foramen to enter the thigh. It gives no branches in the
abdomen or pelvis.
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Accessory obturator nerve
When present, the accessory obturator nerve emerges
from the medial border of psoas major and runs along
this border over the posterior surface of the superior
pubic ramus posterior to pectineus. It gives off branches
here to supply pectineus and the hip joint, and it may
join with the main obturator nerve.
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LUMBOSACRAL PLEXUS
The lumbosacral plexus provides the nerve supply to the
pelvis and lower limb, in addition to part of the
autonomic supply to the pelvic viscera. It gives origin to
the sciatic, inferior gluteal, superior gluteal and
pudendal nerves, in addition to the nerves to quadratus
femoris, obturator intemus and the posterior cutaneous
nerve of the thigh.
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