Posterior abdominal wall

Posterior abdominal wall 2Dr. ZahiriIn the name of God1VASCULAR SUPPLY AND LYMPHATICDRAINGEDr. Maria Zahiri2ABDOMINAL 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 veinthe gonadal arteries, and the third part of the duodenumsmall intestinal mesentery.

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4Posterior relations of Aortathoracolumbar intervertebral discsupper four lumbar vertebrae Lumbar arteries third and fourth (and sometimes second) left lumbar veins the left psoas major.Dr. Maria Zahiri5

Dr. Maria Zahiri6Right relations of Aortacisterna chyli and thoracic ductazygos 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 Zahiri8Left relations of Aortaleft crus of the diaphragmleft coeliac ganglionduodenojejunal flexure left sympathetic trunk the fourth part of the duodenum inferior mesenteric vessels.

Dr. Maria Zahiri9Branches of AortaAnterior groupLateral groupDorsal groupDr. Maria Zahiri10Anterior group:Coeliac trunkis the first anterior branch at the level ofT12/Ll

Superior mesenteric artery1 cm below the coeliac trunkat the level of the Ll-L2

Inferior mesenteric artery3 or 4 cm above the aortic bifurcation at the level of L3

Dr. Maria Zahiri11Lateral group:Suprarenal arteriesThe renal arteriesThe gonadal arteries

Dr. Maria Zahiri12Dorsal group:Inferior phrenic arteriesLumbar arteriesMedian sacral artery

Dr. Maria Zahiri13INFERIOR VENA CAVARelations of the abdominal part of the inferior vena cava:Anteriorly:right common iliac artery root of the mesentery right gonadal arteryhead of the pancreas first part of the duodenumcommon bile duct portal vein

Dr. Maria Zahiri14posterior :The lower three lumbar vertebral bodiestheir 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

Dr. Maria Zahiri15Right & Left relations of IVCRight :The right ureterthe second part of the duodenummedial 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

Dr. Maria Zahiri16Lumbar veinsAscending lumbar veinGonadal veinsRenal veinsSuprarenal veinInferior phrenic veinsDr. Maria Zahiri17Lumbar 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 veinsbranches of the inferior and superior epigastric veins.

Dr. Maria Zahiri18Ascending lumbar veinThe ascending lumbar vein connects the common iliac, iliolumbar and lumbar veins.

Dr. Maria Zahiri19Gonadal veinsOnly the right gonadal vein joins the IVC directly.

Dr. Maria Zahiri20Renal veinsThe left is three times longer than the right in length

Dr. Maria Zahiri21Suprarenal veinThe right suprarenal vein drains directly into the inferior vena cava

Dr. Maria Zahiri22Inferior phrenic veinsrun on the inferior surface of the central tendon of the diaphragm.drain into the posterolateral aspect of the IVC

Dr. Maria Zahiri23LYMPHATIC 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 nodesOr the left and right superficial inguinal nodes.Dr. Maria Zahiri24abdominal 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 nodesDr. Maria Zahiri25

Dr. Maria Zahiri26Cisterna 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

Dr. Maria Zahiri27The 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. Dr. Maria Zahiri28The 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.

Dr. Maria Zahiri29Pre-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.

Dr. Maria Zahiri30Coeliac nodesThe 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).

Dr. Maria Zahiri31Gastric NodesThere 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.

Dr. Maria Zahiri32Hepatic NodesThey 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 nodesDr. Maria Zahiri33Pancreaticosplenic NodesThe pancreaticosplenic nodes drain the spleen, pancreas and part of the stomach. Their afferents join the coeliac nodes.

Dr. Maria Zahiri34Superior mesenteric and inferior mesenteric nodeslie 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.

Dr. Maria Zahiri35lateral aortic groupThe 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. Dr. Maria Zahiri36lateral aortic groupThe 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.

Dr. Maria Zahiri37Lymphatics 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. Dr. Maria Zahiri38Lymph 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.

Dr. Maria Zahiri39Retro-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.

Dr. Maria Zahiri40INNERVATIONDr. Maria Zahiri41

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Dr. Maria Zahiri43PNS:Somatic fiber

Dr. Maria Zahiri44PNS: Visceral fibers

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Dr. Maria Zahiri46ANS: Autonom nervous tissue

Intermediolateral columns (IMLs)Dr. Maria Zahiri47

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Dr. Maria Zahiri49Prevertebral plexusCeliac plexusAbdominal aortic plexusSuperior hypogastric plexus

Dr. Maria Zahiri50Prevertebral ganglionCeliacSMGIMGDr. Maria Zahiri51

Dr. Maria ZahiriPrevertebral & paravertebral plexus52Lumbar plexusDr. Maria Zahiri

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Dr. Maria Zahiri54Iliohypogastric nerveoriginates from the L1 ventral ramuslateral border of psoas majorin front of quadratus lumborum.lateral cutaneous branches (iliac crest)Ant. cutaneous branches (ASIS)

Dr. Maria Zahiri55Motor 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.Dr. Maria Zahiri56Ilioinguinal nerveoriginates from the L1 ventral ramus It is smaller than the iliohypogastric nervethe lateral border of psoas majorjust inferior to the iliohypogastric nerveIlioinguinal 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.

Dr. Maria Zahiri57Ilioinguinal 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.Dr. Maria Zahiri58Genitofemoral nerveoriginates 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.

Dr. Maria Zahiri59Genitofemoral 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.

Dr. Maria Zahiri60The femoral branch descends lateral to the external iliac arteryand 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. Dr. Maria Zahiri61Motor 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.Dr. Maria Zahiri62Femoral 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 Zahiri63Lateral 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.

Dr. Maria Zahiri64Obturator nerveThe 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.Dr. Maria Zahiri65Accessory obturator nerveWhen 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.Dr. Maria Zahiri66LUMBOSACRAL PLEXUSThe 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.Dr. Maria Zahiri67

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