Posterior abdominal wall 2

Dr. Zahiri

In the name of God

Dr. Maria Zahiri

VASCULAR SUPPLY AND LYMPHATICDRAINGE

Dr. Maria Zahiri

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.

• 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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Dr. Maria Zahiri

Posterior relations of Aorta• 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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Dr. Maria Zahiri

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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Dr. Maria Zahiri

Left relations of Aorta• 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 CAVARelations 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 IVCRight :• The right ureter• the second part of the duodenum• medial border of the right kidney • the right lobe of the liverleft :• 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 veinThe ascending lumbar vein connects the common

iliac, iliolumbar and lumbar veins.

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Gonadal veinsOnly 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 veinThe 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 DRAINAGEposterior abdominal wall: The small upper left and upper right

lateral aortic nodes

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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Dr. Maria Zahiri

Cisterna chyli and abdominal lymph trunksThe 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 grouplie 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 NodesThe 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 groupThe 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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Dr. Maria Zahiri

Dr. Maria Zahiri

PNS:Somatic fiber

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PNS: Visceral fibers

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Dr. Maria Zahiri

ANS: Autonom nervous tissue

Intermediolateral columns (IMLs)

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Dr. Maria Zahiri

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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

•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

• 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 nerveMotor – transversus abdominis and internal oblique.Sensory to transversus abdominis and internal obliquemedial 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

arterypasses 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.

Dr. Maria ZahiriLateral femoral cutaneous nerve of the thighThe 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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