2.3 Peritoneal cavity 2.4 Liver and gallbladder 2.5 Stomach and spleen Abdomen 2 Albert van Schoor...

2.3 Peritoneal cavity2.4 Liver and gallbladder2.5 Stomach and spleen

Abdomen 2

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

• 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

2.3.1 Peritoneum

Mesentry of jejenum and ileumTransverse mesoclolonSigmoid mesocolonMeso-appendix

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

2.3.1 Peritoneum

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

• 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


Supracolic

Infracolic

Right Left



• Name and identify the peritoneal folds• Name and identify the peritoneal fossae• Name and identify the paracolic gutters

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


Folds

Superior to the umbilicus• Falciform ligament• Round ligament of the

liver (obliterated foetal umbilical vein)


Fossae / Recess

• Duodenal recess

• Caecal recesses:– Superior ileocaecal– Inferior ileocaecal– Retrocaecal

• Intersigmoid recess

• Omental bursa


Fossae / Recess• Duodenal recess• Duodenojejunal

flexure• Formed by

superior and inferior duodenal folds

• Superior and inferior duodenal recesses

• Paraduodenal recess


Fossae / Recess• Caecal recesses:

– Superior ileocaecal– Inferior ileocaecal– Retrocaecal

• Formed by:– Caecal fold– Ileocaecal fold– Vascular fold


Fossae / Recess• Intersigmoid

recess• Meso-sigmoid

attached to posterior abdominal wall in relation where the left ureter crosses the left common iliac artery


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)



• Identify the following: – Gastrosplenic ligament, – Splenorenal ligament, – Transverse and sigmoid mesocolon, – Ileocoecal fold, – Meso-appendix and – The mesenterium of the small intestine


• 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

Omental bursa (left subhepatic space)

• Superior recess• Inferior recess• Splenic recess


Omental bursaSuperior recess

• Anterior:– Lesser omentum– Caudate process

of liver

• Posterior:– Diaphragm

• Right:– IVC

• Left: – Oesophagus


Omental bursaInferior recess

• Anterior:– Stomach– Anterior 2 layers

of greater omentum

• Posterior:– Pancreas,

transverse colon and mesocolon, poster 2 layers of greater omentum


Omental bursaSplenic recess

• Anterior:– Gastrosplenic

ligament

• Posterior:– Splenorenal

ligament

• Left: – Hilum of the

spleen


Omental foramen

• Connects greater sac (peritoneal cavity) and lesser sac (omental bursa)


Omental foramen

• Anterior:• Free border of

lesser omentum:– Common bile

duct (right)– Proper hepatic

artery (left)– Hepatic portal

vein (posterior)


Omental foramen

• Posterior:– Inferior vena cava


Omental foramen

• Superior:– Caudate lobe of

liver


Omental foramen

• Inferior:– 1st part of

duodenum– Common hepatic

artery



• Name and identify the subphrenic spaces

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


• Right and left subphrenic spaces (separated by the falciform ligament)


• Right subhepatic space (Morison’s pouch)


• Extraperitoneal subphrenic space



• 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


• Review the surface anatomy of the liver and gallbladder

• Indicate where a liver biopsy should be done

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


Gallbladder

• Inferior to 9th costal cartilage on right

• Lateral to semilunar line (lateral border of rectus abdominis)

• Approx. hands breadth from midline


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

Diaphragmatic surface

Visceral surface

2.4.2 Structure

Left Right

2.4.2 Structure

ColonKidneyDuodenumStomach

2.4.2 Structure

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

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

2.4.2 Structure

ERCPEndoscopic 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

• Left & right hepatic arteries

• Well-oxygenated blood

• Hepatic portal vein• Poorly oxygenated

blood, nutrient-rich blood from GI tract

2.4.3 Blood supply

2.5 Stomach and spleen


2.5.2 Structure




• Review the surface anatomy of the stomach and spleen in relation to the anterior abdominal wall

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 above-

mentioned plane


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

Pyloric zone

Gastric and fundic zones

Cariac zone

Fundus

Body

Cardio-oesophageal orifice

Pylorus

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

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

Posterior Anterior

2.5.2 Structure


• Identify and briefly discuss the arterial supply and venous drainage of the stomach and spleen

• Schematically illustrate the coeliac trunk and it's branches

• 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

Coeliac trunk2.5.3 Blood & nerve supply, Lymph drainage

• Splenic artery– Left Gastro-

omental artery– Short gastric

artery

Coeliac trunk2.5.3 Blood & nerve supply, Lymph drainage

Coeliac trunk

• Left gastric artery

2.5.3 Blood & nerve supply, 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

• 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


• Left vagus nerve (X) – Ant. vagal trunk

• Branches:– Oesophageal branches– Gastric branches– Hepatic branches to

hepatic portal vein– Pyloric branches


• Right vagus nerve (X) – Post. vagal trunk

• Branches:– Oesophageal branches– Gastric branches– Coeliac branches to

coeliac plexus– Pyloric branches



• 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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2.3 Peritoneal cavity 2.4 Liver and gallbladder 2.5 Stomach and spleen Abdomen 2 Albert van Schoor...

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