Transcript Document

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
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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
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