Anatomy II block 3 notes

Abdomen (Inguinal Hernia)

 Inguinal canal
Formed in relation to descent of testis during fetal development
Oblique passage 4cm long inferomedially thru inferior part of anterolateral ab wall
Contains spermatic cord in male & round ligament of uterus in female & genital branch of genitofemoral
nerve
2 openings of inguinal canal:
1. Deep (internal) inguinal ring  lies in transverse fascia lateral to inferior epigastric artery & at
midpoint of inguinal ligament
2. Superficial (external) inguinal ring  triangular opening in the aponeurosis of external oblique
muscle lying lateral to pubic tubercle in which the spermatic cord or round ligament exit from the
canal
- Ilioinguinal nerve exits here (anesthesia)

 Development of Inguinal Canal

Testis develop in extraperitoneal CT in superior lumbar region of posterior ab wall
Male gubernaculum is a fibrous ligament cord connecting primordial testis to anterolateral abdominal
wall & connects bottom of testes to scrotum
o It pulls testis down as it migrates and is homologous to ovarian ligament & round ligament of uterus
Processus vaginalis is a peritoneal diverticulum that traverse the developing inguinal canal carrying
muscular & fascial layers of anterolateral abdominal wall before it as it enters primordial scrotum
o Extension of the peritoneum to scrotum  which obliterates  only a part of it is present around
testes which is called  tunica vaginalis (remnant of parietal peritoneum)
o Congenital Inguinal Hernia (Indirect):
- If processus vaginalis still present  intestine content reach scrotum by passing thru deep
inguinal ring, inguinal canal, and thru superficial inguinal ring
o Hydrocoele  abdominal fluid can reach tunica vaginalis due to persistent processus vaginalis &
causes scrotal swelling
- Associated with indirect inguinal hernia
- Transillumination  detect hydrocele by bright light applying to scrotal enlargement in the
dark  red glow indicates excess serous fluid
o Hematocoele  peritoneal blood can also reach tunica vaginalis (ex: rupture of branches of
testicular artery by trauma to testis)
o Torsion of spermatic cord  twisting of testes  causes twisting of spermaticord  veins,
arteries, vas deferens affected  necrosis

Testis Descendant:
o 2nd mo  starts to descend
o 7th mo  reaches deep inguinal ring
o 8th mo  inside inguinal canal
o 9th mo  reaches scrotum
o Layers of anterior ab wall: Skin  superficial fascia  camper (fatty)  scarpa (fibrous)  EO 
IO  tranversus abdominis  transversalis fascia  extraperitoneal fat  parietal peritoneum
1. 7th mo: testes present in extraperitoneal layer (between transversalis fascia & parietal peritoneum)
2. Testes pokes transversalis fascia  gets a layer of transversalis fascia with it called Internal
spermatic fascia  creating opening in transversalis fascia called deep inguinal ring
3. Then it passes thru transversus abdominus (no layer taken)
4. Pass thru internal oblique  gets its second layer from internal oblique called  cremasteric layer
 5. Reaches external oblique  gets its third layer  external spermatic fascia  creating opening
called  superficial inguinal ring
6. After 8 mo, testis exit superficial inguinal ring and enters scrotum

 Lifeline in male: Spermaticord  contains testicular arteries, veins, lymphs

o Spermatic cord begins at deep inguinal ring lateral to inferior epigastric vessels, pass thru inguinal
canal, exits superficial inguinal ring and ends in scrotum at posterior border of the testis
o Constituents:
1. Testicular artery  arise from abdominal aorta
2. Cremasteric artery  arise from inferior epigastric artery
3. Pampiniform venous plexus (testicular vein)  drains into IVC
4. Lymphs
- Cancer of testes  lymphatics of posterior ab wall (lumbar group of lymph nodes)
- Cancer of scrotum  superficial inguinal ring
5. Vas deferens (ductus deferens)  arise from inferior vesical artery
6. Genital branch of genitofemoral nerve
- Cremasteric reflex: afferent (femoral), efferent (genital branch)
7. Testicular PNS & SNS nerve fibers
8. Vestige of processus vaginalis  incompletely remnant of peritoneum
 Boundaries of Inguinal Canal
 Superior wall (roof): internal oblique, transversus abdominis
 Inferior wall (floor): inguinal ligament
 Anterior wall: superficial inguinal ring (aponeurosis of external oblique)
 Posterior wall: deep inguinal ring (transversalis fascia)

 Inguinal Hernia
 Protrusion or passage of peritoneal sac with or without ab contents
 Indirect Inguinal Hernia  thru deep inguinal ring
o Most common & congenital
o Processus vaginalis remains open or patent
o Bulging is lateral to inferior epigastric hernia
o Ab content from deep to superficial inguinal ring then into scrotum
o More common on R side
 Direct Inguinal Hernia  through posterior wall of inguinal canal
o Rarely descends to the scrotum
o Protrudes forward (rarely through) superficial inguinal ring
o Acquired (due to weakened ab musculature) & developed after birth
o Bulging is medial to inferior epigastric vessels in the inguinal triangle (Hesselbach’s triangle)
 Inguinal Triangle (Hesselbach’s Triangle)
1. Laterally  inferior epigastric artery
2. Medially  rectus abdominus
3. Inferiorly  inguinal ligament
  Inguinal hernia examination
o Reduction method: ask pt to cough  intestine comes into scrotum  push intestine back into place
 place palm in deep inguinal ring & apply pressure  ask pt to cough again if intestine won’t
come back out into scrotum (because of pressure applied over deep inguinal ring) indirect hernia
- If content comes back thru scrotum  direct hernia  reduction only maintained by pressure
over external ring
o Other test: insert finger & feel pulse d fsd
- Pulse on lateral aspect (inferior epigastric vessel) direct
- Pulse on medial aspect  indirect
o Percussion  may be resonant if gas-filled bowel
o Auscultation  may have audible bowel sounds

 Different Types of Hernia

1. Inguinal hernia  above inguinal ligament
2. Femoral hernia  below inguinal ligament thru femoral triangle (in upper medial thigh)
3. Epigastric  protrudes thru linea alba  occurs in midline of upper abdomen between rib cage &
umbilicus & composed of fat but rarely abdominal organs
4. Umbilical
- Failure of closure of umbilical ring
- Common in premature infants
- Acquired in adults with cirrhosis, obesity, ascites, malnutrition
5. Spigelian (semilunar)
 - Spontaneous lateral ventral hernia below umbilicus and lateral to rectus muscle
- Located 0-6 cm above anterior superior iliac spine (spigelian belt of spagel)
- More common in male with median age of 50 years
- More common R side
6. Incisional
- More common in females
- Incomplete surgical wound healing due to poor suturing technique
-
7. Differential diagnosis (not hernia): psoas abscess  tuberculosis of lumbar vertebrae goes all the way
down to the psoas major

 Abdominal Surgical Incision

 Longitudinal Incisions
1. Median or midline  cut thru linea alba superior & inferior to umbilicus
2. Paramedian  lateral, left or right to median plane in the sagittal plane & may extend from costal
margin to pubic hairline
 Oblique & Transverse Incisions
1. Gridiron (muscle-splitting)  appendectomy
2. Suprapubic (bikini)  at pubic hairline for Cesarean section & removal of tubal pregnancy
3. Subcostal  gallbladder & biliary ducts on R side, spleen on L side

 Scrotum
 Cutaneous sac consisting of 2 layers:
1. Skin
2. Dartos fascia  fat free fascial layer containing smooth muscle fibers responsible for rugose
(wrinkle) & regulation of temp
 Artery supply of scrotum
1. Posterior scrotal branches of perineal artery (branch of internal pudendal artery)
 2. Anterior scrotal branches of deep external pudendal artery (branch of femoral artery)
 Nerve supply of scrotum
1. Anterior scrotal nerve: which is a branch of Ilioinguinal nerve (L1) supplying anterior surface
2. Posterior scrotal nerve: which is a branch of perineal branch of the pudendal nerve (S2-S4)
 Anesthetizing scrotum
o Anterior 1/3rd of scrotum  L1 of ilioinguinal nerve
o Posterior 2/3rd of scrotum  S3 of pudendal nerve
o Spinal anesthetic agent is injected more superiorly to anesthetize the anterior surface of scrotum than
is necessary to anesthetize posterior surface

 Testes
 Outermost layer is covered by tunica albuginea which lies beneath the visceral layer of tunica vaginalis
 Epididymis
o Efferent ductules of testis transport newly developed sperms to epididymis from rete testis
o Epididymis consists of: head, body, and tail

 Blood supply of testis

o Testicular arteries  arise from anterolateral aspect of abdominal aorta just inferior to renal
arteries
o Venous drainage
- All veins (8 to 12 veins) from testes form venous plexus called pampiniform venous plexus 
which then converge superiorly to form R & L testicular vein
- R testicular vein  enters IVC (R adrenal vein also joins IVC, whereas L adrenal vein joins L
renal vein)
- L testicular vein  enters L renal vein (hence L testis is lower)
 Lymphatic Drainage
o Lymph drainage follows testicular artery & vein to the R & L lumbar (caval/aortic) & preaortic
lymph nodes
 Varicocele
 o Vine-like pampiniform plexus of veins may become dilated (varicose) & tortuous producing
varicocele which is visible only when standing or straining
o More common on L side  due to longer pathway of L testicular vein
o Palpating feels like a bag of worms
o Result from defective valves in testicular vein, renal vein problems leading to distension of
pampiniform veins

 Cancer of testis & scrotum

 Cancer of Testis  Metastasize initially to retroperitoneal lumbar lymph nodes
 Cancer of Scrotum  Metastasizes to superficial inguinal lymph nodes
 Cremasteric Reflex
 Testing L1 & L2
 Lightly stroking superior & medial part of thigh in downward direction
 Normal response  contraction of cremaster muscle pulling up the scrotum & testis
 Upper & lower motor neuron disorders can cause an absence of cremasteric reflex


Fetal Abdomen
 Internal surface of anterolateral abdominal wall
 5 umbilical peritoneal folds: 2 on each side and 1 in the median plane pass toward the umbilicus
1. Median umbilical fold  from apex of urinary bladder to umbilicus
- Apex of urinary bladder to umbilicus
- Remnant of urachus
- If patent  dripping of urine from umbilicus
2. Two Medial umbilical
- Formed by obliterated umbilical arteries
- Lateral to median umbilical fold
3. Two Lateral umbilical
- Patent and are folds above inferior epigastric artery
- Lateral to medial umbilical fold

 Umbilical cord
 Umb cord is surrounded by fetal membrane amnion and contains wharton’s jelly
 Wharton’s jelly contains:
o Remnant of vitellointestinal duct
o Allantois
o Single umbilical vein  12 o’clock position
o 2 umbilical arteries  4 & 8 o’clock position
 Umbilical vessel catheterization: fluid or blood can be injected into the vein or arteries

Peritoneum

 Peritoneum
 Peritoneum is a serous membrane that lines the walls of ab cavity & most of the viscera
 Parietal peritoneum  lines abdominal & pelvic walls & inferior surface of diaphragm
o Innervated by somatic nerves (T6-T12, L1)  sensitive to pain
- Phrenic nerve
- Lower intercostal nerve
- Subcostal
- Iliohypogastric
 - Ilioinguinal
o Served by the same blood & lymphatics as in the region of the wall it lines
 Visceral peritoneum  covers viscera
o Innervated by visceral nerve  autonomic (PNS & SNS)  insensitive to pain
 Peritoneal cavity  space between parietal & visceral

 Intraperitoneal organs  completely covered by peritoneum

o Esophagus
o Stomach
o First 1 inch of first part of duodenum
o Jejunum
o Ileum
o Appendix
o Cecum
o Transverse colon
o Sigmoid colon
o Liver
o Spleen
 Retroperitoneal organs  covered by peritoneum usually on just one surface
o Rest of duodenum
o Ascending colon
o Descending colon
o Rectum
o Kidney
o Ureter
o Pancreas
 Forgut: esophagus  stomach  first & half of second part of duodenum (opening of ampula where bile &
pancreatic duct open)
 Ventral Mesentery (only present in foregut)  attached to anterior abdominal wall
o Lesser omentum  connects lesser curvature of stomach & proximal part of duodenum to liver and
contains all these ligaments:
- Hepatogastric ligament  attach liver to stomach
- Hepatoduodenal ligament  attach liver to duodenum
o Falciform ligament  liver to anterior ab wall
 Dorsal Mesentery  attached to posterior abdominal wall
o Mesoesophagus
o Mesogastrium
o Gastrophrenic  stomach to diaphragm
o Gastroplenic  stomach to spleen
o Splenirenal (leinorenal)  spleen to kidney
o Greater omentum (gastrocolic ligament)
- Lesser sac  space between 2 layers of greater omentum that turns back and attached to
transverse colon
o Phrenicocolic ligament  diaphragm to transverse colon (spleen is just above this ligament so
enlarged spleen is seen towards the umbilicus due to position of the ligament)
 Midgut: second half of second part, 3rd, 4th part of duodenum  jejunum  ileum  secum  ascending
colon  R 2/3rd of transverse colon
 Dorsal Mesentery
 o Mesentery (root of mesentery)  dorsal mesentery of jejunum & ileum (small intestine mesentery is
referred to simply as the mesentery)
o Cecum  Only intraperitoneal organ that does NOT have a mesentery
o Mesoappendix
o Trasnversemesocolon  divides abdominal cavity into supracolic & infracolic compartment
1. Supracolic compartment: contains stomach, liver, spleen
2. Infracolic compartment: contains small intestine, ascending & descending colon

 Hindgut: L 1/3rd transverse colon  descending colon  sigmoid  rectum

 Dorsal mesentery
o Transversemesocolon
o Sigmoidmesocolon

 Peritoneal Ligaments
 Liver connected to:
o Anterior ab wall by falciform ligament
o Stomach by hepatogastric ligament
o Duodenum by hepatoduodenal ligament
 Stomach connected to:
o Inferior surface of diaphragm by gastrophrenic ligament
o Spleen by gastrosplenic ligament
o Transverse colon by gastrocolic ligament (apron-like part of greater omentum)
 Greater & Lesser sac
 Greater sac
o Main & larger part of peritoneal cavity with fluid expanding from diaphragm to pelvis & perineum
o Surgical incision thru anterolateral ab wall enters the greater sac
 Lesser sac (also has 3 names)
o Omental bursa  lies posterior to stomach & lesser omentum
o Superior recess of lesser sac  where lesser sac extends to diaphragm
o Inferior recess of lesser sac  where lesser sac extends to end of greater omentum extension
 Epiploic foramen (foramen of winslow or omental foramen)
o Opening from greater sac to lesser sac
o Loated by running finger along gallbladder to free edge of lesser omentum
o Has 4 boundaries:
1. Anterior
- Hepatodudenal ligament
- Portal triad: portal vein, hepatic artery, bile duct
2. Posterior
- IVC
- Right crus of diaphragm
3. Superior - Liver
4. Inferior – first part of duodenum
 Clinical Correlates of Abdomen
 Paracentesis of Abdomen
o To withdraw excess collections of peritoneal fluid as in ascites secondary to cirrhosis of liver or
portal vein obstruction (portal HTN)
o Needle or catheter inserted thru anterior ab wall under local anesthetic
o Underlying coils of intestine are not damaged because they are mobile and are pushed away by the
cannula
o Needle can be inserted in midline which passes thru linea alba or inserted into lateral aspect of skin
(which goes thru all 8 layers)
 Peritoneal dialysis
o Send NS into ab cavity on one line  and the other line taking out waste product
o Can be used to remove waste product such as urea in renal failure

Esophagus & Stomach

 Esophagus
 Muscular tube (25 cm or 10 in long) with average diameter of 2cm that conveys food from pharynx to
stomach
 Has 3 constrictions:
1. Cervical  pharyngoesophageal junction
2. Thoracic  broncho-aortic
3. Diaphragmatic constriction
 Abdominal Oesophagus
o Measures 1.25 cm in length
o Esophagogastric junction: T11, Zline
 o Above Z line  squamous epithelium
o Below Z line  simple columnar epithelium
o Phrenicoesophageal ligament  circular layer of smooth muscle at terminal end of esophagus that
causes tonic contraction of the sphincter to prevent stomach content from regurgitating into
esophagus
o Hiatal or esophageal hernia  can be caused by a weakened phrenicoesophageal ligament or
increased ab pressure.
1. Paraesophageal hiatal hernia  cardia remains in normal position, but pouch of peritoneum
containing part of fundus extends thru esophageal hiatus
- Herniation of only fundus of stomach
2. Sliding hiatal hernia  ab part of esophagus (the cardia) and parts of fundus of stomach slide
superiorly thru esophageal hiatus into the thorax
- Herination of most part of stomach
 Barrett’s esophagus  normal squamous epithelium lining esophagus is replaced by metaplastic
columnar epithelium
 Nerves of abdominal esophagus
o R & L vagus nerve divide into branches that form esophageal plexus around inferior esophagus
o Anterior & posterior gastric branches of plexus accompany esophagus thru esophageal hiatus for
distribution to anterior & posterior aspects of stomach
o Rotation of stomach 90 degree clockwise:
- Posterior stomach  L side
- R vagus  posterior  becomes posterior vagus nerve
- L vagus  anterior  becomes anterior vagus nerve
- Anterior & posterior vagal trunk join to form esophageal plexus (innervates esophagus, stomach,
intestine)
- Paristalisis  vagus nerve
- Postganglionic neuron:
1. Aurebach plexus (myenteric plexus)  between circular & longitudinal muscle
2. Meissner’s plexus (submucosal plexus)  continuation of aurebach plexus located between
muscular externa & muscularis interna
 Achalasia of cardia (esophagogastric junction)  associated with degeneration of PNS plexus
(Auerbach’s plexus)
 Esophageal Varices  lower third of oesophagus is anastomosed by L gastric vein & azygos vein 
obstruction of portal vein leading to L gastric vein dilation
o Portal: L gastric vein  portal vein
o Caval: azygous vein  SVC
 Caput Medusae
o Portal: paraumbilical
o Caval: superior epigastric vein
 Hemorrhoids
o Portal: superior rectal vein
o Caval: inferior & middle rectal vein

 Stomach
 Spans epigastric, umbilical, hypochondrum regions
 1500 mL storage capacity
 Anteriorly: ab wall, L costal margin, diaphragm & L lobe of liver
 Posteriorly: lesser sac separating stomach from pancreas, transverse mesocolon, L kidney, L suprarenal,
spleen, splenic artery
 Superiorly: L dome of diaphragm
  Has 2 openings: cardiac & pyloric orifices
 Stomach regions:
1. Cardia
2. Fundus
3. Body
4. Pyloric: pyloric antrum & pyloric canal (terminal part of stomach connecting duodenum)
 Contains stomach folds called rugae which is present most in pyloric part along greater curvature
 3 layers of stomach:
1. Innermost  oblique
2. Middle  circular  forms pyloric sphincter & anal sphincter
3. Outer  longituidinal
 Congenital hypertrophic pyloric stenosis  thickening of smooth muscle in pylorus affecting 1/150
male infant, 1/750 female infant
 Blood supply of stomach
 Cilic trunk  arise from anterior ab aorta at L1 to supply foregut and gives 3 branches:
1. L gastric artery  supplies lesser curvature of stomach
2. Splenic artery  posterior of stomach  supplies spleen
a. Short gastric artery  fundus of stomach
b. L gastroepiplogic artery (L gastroomental artery)  greater curvature
3. Common hepatic artery
a. R gastric artery  lesser curvature of stomach
b. Gastroduodenal artery  passes posterior to first part of duodenum & has 3 branches:
i. Supraduodenal artery  superior aspect of 1st part of duodenum
ii. R gastroepiploic artery  anastomose with L gastroepiploic to supply greater curvature
iii. Superior pancreaticoduodenal artery  upper part of pancreas & superior duodenum (lower
parts supplied by superior mesenteric artery which supplies midgut)
c. Hepatic artery  supply liver
i. R hepatic artery (has 1 branch)
- Cystic artery  supplies gallbladder
ii. L hepatic artery
  Venous drainage is to portal system
o Venous drainage of stomach & duodendum is into portal vein thru splenic or superior mesenteric
vein
o Splenic vein receives inferior mesenteric vein & unites with superior mesenteric vein to form portal
vein
o R & L gastric veins  drains into portal vein
o Short gastric vein & L gastroomental vein  drains into splenic vein
o R gastroomental vein  drains into superior mesenteric vein

 Nerve supply of stomach

 Anterior & posterior vagal trunks arise from oesophageal plexus & enters abdomen thru oesophageal
hiatus
 PNS:
 L vagus  anterior vagal trunk
1. Hepatic branch  supply liver
2. Anterior nerve of Latarjet  anterior surface of stomach (all the 4 layers & secret HCl of parietal
cells)
 R vagus  posterior vagal trunk (supplies majority of foregut)
1. Celiac branch  forms ganglion near celiac trunk (L1) called celiac ganglion
o Celiac ganglion continues as superior mesenteric ganglion (where post vagal trunk terminates)
 winds around superior mesenteric arteries  supplies midgut
2. Posterior nerve of Latarjet  posterior stomach & supply parietal cells to secret HCl (most ulcers
are from posterior aspect)
o Contains both celiac ganglion & superior mesenteric ganglion???
 Vagus nerve innervates foregut & midgut
 Pelvic splanchnic nerve (S2-S4) & inferior mesenteric artery supply hindgut
 o Pelvic splanchnic nerve forms ganglion called inferior mesenteric ganglion
 Ganglion only formed by PNS
 Plexus contains both PNS & SNS

 SNS: thoracolumbar (T1-L2)

 Sympathetic nerve supply to stomach: T5-T9 of spinal cord passes thru celiac plexus thru greater
splanchnic nerve
o Spleen:
- PNS  posterior vagus
- SNS  greater splanchnic  pain sensation  pain felt above umbilicus (umb is at T10)
o Pain in foregut (greater splanchnic) & midgut (lesser splanchnic) carried by SNS
o Pain in hindgut is carried by PNS (pelvic splanchnic S2-S4)
o Appendix (midgut)  pain in umbillicus (T10)
 Celiac plexus formed by  splanchnic nerve & branches from vagus nerve
 T1: superior, middle, inferior cervical ganglion  nerve supply to heart
o MI: T1  brachial plexus (C5-T1)  pain in L arm
 T10-T11: lesser splanchnic nerve  joins posterior vagus  forms superior mesenteric plexus
 T12: least splanchnic
 L1-L2: Lumbosplanchnic

 Peptic Ulcer
 Lesser curvature  erosion of L & R gastric artery
 Posterior surface of stomach  splenic artery
 Fundus  short gastric artery
 Posterior wall of 1st part of duodenum  gastroduodenal artery
 Vagotomy is performed to reduce production on acid in chronic or recurring ulcers

 Lymph nodes
1. Gastric LN
2. Pancreatiocsplenic LN
3. Pancreatioduodenal LN
4. Celiac LN

 Gastrectomy
 Antrectomy (Billroth I)  remove part of pyloric antrum & attach duodenum to rest of stomach
 Gastrojejunostomy (Billroth II)  attach stomach to jejunum (2nd part of duodenum where bile duct
opens into is still intact)
  Total gastrectomy  esophagus directly to jejunum

Small Intestine

 Small Intestine
 6-7 m long
 Duodenum curves around head of pancreas & is 10 in (25cm) long

 Duodenum
1. Superior (1st part)
o Anterior:
- Gallbladder  immediately anterior to 1st part of duodenum
- Peritoneum (1st 1 inch or 2.5 cm)
- Liver (quadrate lobe)
o Posterior:
- Bile duct
- Gastroduodenal artery
- IVC
- Portal vein
2. Descending (2nd part)
o Anterior
- Transverse colon
- Transverse mesocolon
- Small intestine coils
o Posterior (HUR-P)
- Hilum of R kidney
- R ureter
- Renal vessels
- Psoas major
3. Horizontal (3rd part)
o Anterior
- Superior mesenteric artery & vein
- Small intestine coil
o Posterior (iPAU 3)
- IVC
- R psoas major
- Aorta
- R ureter
4. Ascending (4th part) – don’t need to know

 Blood supply of duodenum

o Superior pancreaticoduodenal artery (branch of gastroduodenal)
o Inferior pancreaticoduodenal artery (branch of superior mesenteric artery)

 Paraduodenal Hernias
o There are 2 or 3 inconstant folds & fossae (recesses) around duodenojejunal junction
o Paraduodenal fold & fossa are large & lie to the L of the ascending part of the duodenum  if a loop of
intestine enters this fossa, it may strangulate

 Jejunum
 Begins at duodenojejunal flexure where alimentary tract resumes an intraperitoneal course
  Constituting 2/5th of intraperitoneal section of small intestine
 Most of the jejunum lies in the L upper quadrant of the infracolic compartment
 Ileum
 3/5th of intraperitoneal section of the small intestine
 Lies in R lower quadrant

 The Root (Origin) of the mesentery (small intestine)

 Fan-shaped fold of peritoneum that attaches the jejunum & ileum to posterior abdominal wall
 15 cm long is obliquely, inferiorly, and to the R
 Extends from duodenojejunal junction on the L side of vertebra L2 to ileocolic junction and R sacroiliac
joint
 Between 2 layers of mesentery contains: superior mesenteric vessels, lymph nodes, fat, and autonomic
nerves

 Differences between Jejunum & Ileum

 Jejunum vasa recta & arcades
o Blood supply to jejunum & ileum  branch of superior mesenteric artery
o Superior mesenteric artery forms archlike structures  arcades
o Vasa recta  long blood vessels supplying jejunum
o Fewer arcades in jejunum than ileum

 Jejunum vasa recta & arcades

 Superior mesenteric artery
 Comes off aorta just inferior to celiac trunk
 Origin is hidden behind pancreas
 Comes off between head of pancreas and uncinate process of pancreas & passes over 3rd part of
duodenum to enter root of mesentery
 Branches of superior mesenteric artery
1. Inferior pancreaticoduodenal artery  supplies duodenum & pancreas
2. Jejunal artery  jejunum
3. Ileal artery  ileum
4. Ileocolic artery  ileum & cecum  2 branches:
a. Anterior cecal artery
b. Posterior cecal artery  1 branch:
i. Appendicular artery
5. R colic artery  ascending colon
6. Middle colic artery  R 2/3rd transverse colon (L 1/3rd supplied by inferior mesenteric artery)
 Superior mesenteric nerve plexus (supplies midgut)
 PNS: Posterior vagal trunk  supplies jejunum & ileum
 SNS: Lesser splanchnic nerve (T10-T11)  pain sensation
 Mesenteric lymph nodes
 Mesenteric lymph node
 Superior central lymph node: located along proximal part of superior mesenteric artery

Large Intestine

 Characteristics of large intestine

 Three taeniae coli
 o 3 longitudinal bands of smooth muscle that start at cecum & ends at rectum
o Help to locate appendix  base of appendix is the start of taeniae coli
 Omental appendices  adipose tissue attaching to taeniae coli
 Haustra  sacculations of the wall of the colon between taeniae
 Large caliber  internal diameter

 Cecum
 Ileocecal valve  opening of ileum into cecum
 7.5 cm in length & breadth
 Has NO mesentery
 Appendix
 Contains lymphoid tissue
 Located posteromedial (retrocecal) aspect of cecum inferior to ileocecal junction
 Contains short triangular mesentery called mesoappendix
 Blood supply:
o Appendicular artery (branch of posterior cecal which is branch of ileocolic artery)
o Venous blood drains into superior mesenteric
 Nerve supply:
o Visceral pain at T10 (umbilicus)  since superior mesenteric plexus (formed by posterior vagus of
PNS & lesser splanchnic T10-T11 of SNS)
o Ascending colon has nerve supply from T11
 McBurney’s point
o Base of appendix located here
o 1/3rd from oblique line (spinoumbilical line) at ASIS to umbilicus
o Pain in first 24 hrs  umbilicus
o Pain after 24 hrs  Mcburney’s point  rebound tenderness
 Appendectomy  gridiron incision or transverse
 Colon
 Ascending colon
o R iliac fossa to liver
o Hepatic flexure (R colic flexure)
o Retroperitoneal
  Transverse colon
o 45 cm long
o Hepatic flexure to splenic flexure (L colic flexure)
o transversemesocolon – movile part of colon
 Descending colon
o Splenic flexure to L iliac fossa (sigmoid colon)
o Retroperitoneal
o Diverticulosis common
 Sigmoid colon
o Sigmoidmesocolon is inverted V shape
o Diverticulosis  MOST common here
- Diverticula: external evaginations or outpocketing of mucosa of colon developing along intestine
- Diverticula may devlop anywhere in large intestine but more common in sigmoid colon

 Inferior mesenteric artery (at level of L3, celiac trunk at level of L1)
 L colic  L 1/3rd transverse colon & descending colon (R colic supplies ascending colon)
 Sigmoid  sigmoid colon & descending colon
 Superior rectal

 Nerve Supply
 Superior mesenteric plexus  supplies cecum & appendix
 Inferior mesenteric plexus  hindgut
o PNS  pelvic splanchnic (S2-S4)
o SNS  lumbarsplanchnic (L1, L2)
o Pain sensation: pelvic splanchnic (whereas pain sensation for foregut & midgut is by SNS)

 Surgical procedure
 Ileostomy
o Ileum is attached to anterior abdominal wall
o Causes: Marfan’s sundrome, UC, Crohn’s, cancer of colon
o Requires more intake of fluid & electrolyes
o Waste matter will be like diarrhea (since no fluid reabsorbed)
o Ileostomy on the R side
 Colostomy
o More common than ileostomy
o Colostomy on the L side
o Fecal matter can’t be controlled as soon as it’s formed goes directly into pouch
o Sections of colon is removed

Liver & Gallbladder

 Liver
 Weighs 1500g
 Located: R hypochondrium, epigastrium, L hypochondrium
 Rises to 5th intercostal space
 4 Surfaces
1. Anterior
a. Falciform ligament  completely covers liver & continues to L & R as triangular
o L triangular ligament
 o R triangular ligament
b. Coronary ligament  attaches liver to diaphragm
2. Posterior
3. Diaphragmatic
4. Visceral  near visceral organs (stomach, duodenum, gallbladder, kidney & pancreas)
a. Ligamentum teres or round ligament
b. Ligamentum venosum (remnant of ductus venosus which shunted blood from umbilical vein to
IVC, short-circuiting liver)
 Inferior border of liver  below R costal margin can feel when liver enlarged
 Gallbladder is right below inferior border
 Bare area: between triangular ligament (where no ligament attached) in the posterior diaphragmatic
surface (where liver is in direct contact with diaphragm)
 4 Lobes
1. R lobe
a. Caudate lobe
b. Quadrate lobe
2. L lobe
 8 Segments of liver
 Porta hepatis  entrance into the liver on the R lobe (present between caudate & quadrate lobe)
 Portal vein (R & L)
 Hepatic duct (R & L)
 Hepatic artery (R & L)
 Lymphs
 Nerves
 Portal Triad: bile duct, hepatic artery, portal vein all enclosed by lesser omentum
 Location from anterior to posterior:
1. R & L hepatic duct  joins to form bile duct
2. Hepatic artery (branch of celiac trunk)  carries oxygenated blood to liver
3. Portal vein  posterior to hepatic artery
 Blood supply
o Portal vein  carries 80% blood to liver, carries nutrients from intestinal absorption &
deoxygenated blood
o Hepatic artery  carries 20% blood to liver, oxygenated blood
 Venous drainage
o Blood from all 8 liver segments carried by hepatic veins  drains into IVC
o Hepatic artery & portal artery blood flows thru sinusoids  reaches central vein  hepatic vein 
IVC
 Biliary ducts
 R hepatic duct & L hepatic duct  joins to form common hepatic duct  joins cystic duct (arise from
gallbladder) to form bile duct
 Bile duct location:
1. 1st part  lies in front margin of portal vein & on the R of hepatic artery
2. 2nd part  lies behind first part of duodenum to the R of gastroduodenal artery
3. 3rd part  posterior surface of head of pancreas, here it comes into contact with main pancreatic duct
 Bile duct
o Bile duct Pass posterior to 1st part of duodenum where it joins pancreatic duct  forms
hepatopancreatic duct (ampulla of vata)  opens into medial of 2nd part of duodenum (opening is
called major duodenal papillae)
o Foregut ends near major duodenal papillae
 Pancreatic duct (has 2 ducts):
 1. Main pancreatic  joins bile duct to form  hepatopancreatic duct
2. Accessory pancreatic duct doesn’t join anything  opens into 2nd part of duodenum  opening is
called minor duodenal papillae
 Sphincter of Odi  all 3 sphincter joined is called sphincter of odi
1. Present around hepatopancreatic duct (sphincter of papillae)
2. Present around pancreatic duct (pancreatic sphincter)
3. Present around bile duct (sphincter of choledochus)

 Gallbladder
 3 parts
1. Fundus  present below liver & anterior to 1st part of duodenum
2. Body
3. Neck
- Infundibulum of gallbladder near neck  forms Hartman’s pouch
 Gallbladder continues as cystic duct
 7-10 cm
 Stores 50 mL of bile
 Blood supply  cystic artery (branch of R hepatic artery)
 Venous drainage  cystic vein drains directly into portal vein
 Nerve supply  celiac plexus  contraction of gallbladder in response to CCK
 Gallstones
1. Seen in Hartman’s pouch
2. Seen in ampulla of vata  leads to posthepatic jaundice
o Chronic gallstones  lead to fistula (2 openings)  stone can directly go into duodenum  stone
finally reaches ilealcecal junction  called gallstone ileus
 Cholecystitis
o Inflammation of gallbladder
o Referred pain: R shoulder (supraclavicular region supplied by supraclavicular nerve C3, C4)  due
to phrenic nerve
 o When gallbladder enlarged, it touches diaphragm (which is innervated by phrenic nerve C3-C5)
o Examination with Murphy’s sign
- Feel R costal margin at MCL  Ask pt to first inhale  diaphragm goes down  touches
gallbladder  pt will have severe pain on R side
- If pt has pain on both side it’s not cholecystitis

 Portal Vein Obstruction Treatment
 Splenorenal shunt
o Attach splenic vein to L renal vein  IVC (to divert blood flow from portal vein into IVC)

Spleen & Pancreas

 Spleen
 Largest single mass of lymphoid tissue in body
 L hypochondriac region just anterior to ribs 9 to 11
 Dimension:
o Thick  1 inch
o Wide  3 inches
o Long  5 inches
o Weight  7 ounces (200g) (1 ounce = 28.35 grams)
 Spleenomegaly: increasing in length > 5 inches
 2 surfaces
1. Diaphragmatic surface
2. Anterior (visceral) surface
 2 borders
1. Anterior border
- Anterior border is notched
- Notch is due to: development of spleen is from several mesodermal structure, they all join
together to form the spleen creating the notch
2. Posterior border  smooth, no notch
 Impressions (hilum present between the 2 impression)
1. Gastric impression  above hilum of spleen is stomach
2. Renal impression  below hilum of spleen
  Ligaments
1. Gastrosplenic ligament (greater curvature of stomach to spleen)
- Short gastric artery
2. Splenorenal ligament (between spleen & kidney)
- Splenic arteries
- Splenic veins
- Tail of pancreas
 Blood supply
1. Splenic artery
2. Splenic vein
 Nerve supply  celiac plexus (posterior vagus PNS, greater splanchnic nerve SNS)
 Palpation  spleen always enlarge inferomedially towards umbilicus due to phrenicocolic ligament
between diaphragm and colon

 Pancreas
 Endocrine & exocrine
 Epigastric region (near umbilical & tail of pancreas extends to hilum of spleen)
 Pancreas is present around transpyloric plane (L1)
 Parts:
1. Head
2. Neck
3. Body
4. Tail
5. Uncinate
 Ventral & dorsal pancreatic buds forms the pancreas
 Annular pancreas  pancreas obstruct & completely duodenum
 Pancreas is retroperitoneal organ
 Posterior Relations (from R to L side)
1. Bile duct  posterior to head of pancreas
2. Portal vein (splenic & superior mesenteric vein forms portal vein)  posterior to neck
- Superior mesenteric vein present anterior to 3rd part of duodenum
- Splenic vein present posterior to body & tail of pancreas
3. IVC  posterior to the portal vein
4. Abdominal aorta
 Pancreatic ducts
1. Main pancreatic duct
- Main pancreatic duct joins bile duct  forms hepatic duct  opens into 2nd part of duodenum
called major duodenal papillae
2. Accessory pancreatic duct
- Opens into 2nd part of duodenum  minor duodenal papillae
 Pancreas located posteromedially
 3 Sphincters
1. Sphincter of oddi  smooth muscle present around hepatopancreatic duct
2. Pancreatic sphincter  around pancreatic duct
3. Around bile duct
 Blood supply
o Superior mesenteric artery  inferior pancreaticoduodenal artery
o Celiac trunk  superior pancreaticoduodenal artery

 Nerve supply
o Celiac plexus
o Superior mesenteric plexus
  Pancreatic cancer
o Cancer of head of pancreas  bile duct obstruction  jaundice
o Cancer of neck  portal vein obstruction  portal HTN
o Cancer of body & tail  splenic vein

Posterior Abdominal Wall

 Structures of Posterior AB Wall

 All retroperitoneal organs (all structures beneath parietal peritoneum)
 Kidney
 Ureter
 Testes
 Ovaries
 IVC
 Ab aorta
 L1 to L5 nerves (lumbar plexus)
 Muscles of post ab wall:
1. Psoas major
2. Psoas minor
3. quadratus lumborum
4. iliacus

 Muscles of Post Ab Wall

 Psoas major
o Arise on lateral surface of T12, L1-L5 & inserts into lesser trochanter of femur
o Flexion of thigh
 Psoas minor
o Also arise from lumbar vertebrae & inserts into pectineal line of pelvic brim
o Weak flexion of lumbar vertebral column
 Quadratus lumborum
o Arise from iliac crest & inserts into 12th rib
 o Depression & stabilizing 12th rib, lateral bending of trunk
 Iliacus
o Arise from iliac fossa of hip bone & joins muscle of psoas major  iliopsoas tendon that inserts into
lesser tronchanter of femur
o Flexion of thigh
 Arteries
 Aorta branches becomes Ab aort at level of T12  ab aorta ends at L4 & divides into 2 branches of
common iliac artery & median sacral artery
 IVC (starts at T5 & ends at level of T8) present on R side of ab aorta
 Ab aorta has 3 planes
1. Anterior plane (unpaired)
a. Celiac trunk (at level of L1)
b. Superior mesenteric artery (L1)
c. Inferior mesenteric artery (L3)
2. 2 Lateral
a. Renal artery (L1)
b. Suprarenal artery (L1)
c. Testicular/Ovarian artery (L2)
3. 2 posterolateral
a. Subcostal artery  12th intercostal space
b. Inferior phrenic artery  inferior aspect of diaphragm (superior aspect of diaphragm supplied by
superior phrenic artery, a branch of aorta)
c. Lumbar artery (L1-L4)
 Adrenal gland arteries (arise from ab aorta)
1. Superior suprarenal artery  branch of inferior phrenic artery
2. Middle suprarenal artery  direct branch of aorta
3. Inferior suprarenal artery  arise from renal artery
 Ab aorta  2 common iliac artery & median sacral artery

 Veins (IVC)  same branches as ab aorta with 2 variations

 R testicular/ovarian vein  IVC
 L testicular/ovarian vein  drains into L renal vein
 R suprarenal vein (does not have middle & inferior like in artery) IVC
 L suprarenal vein  drains into L renal vein

 Lumbar Plexus (in relation to psoas major)???

 Anterior to psoas major  genitofemoral nerve (L1, L2)
 Medial to psoas major  Obturator nerve (L2-L4)
 Posterior to psoas major  the rest arise from posterior

 Lymphatic Drainage
 Entire lower limbs  Superficial & deep inguinal  external iliac LN
 Pelvis & Perineum (except ovaries & testes which drains into lumbar)  all drains into internal iliac LN
(ex: cancer of uterus will be internal iliac)
 External & Internal LN  drains into common iliac LN  lumbar group of LN (also drains gonads,
kidneys)  cisterna chyli (formed by 3 lymph nodes)
1. Celiac LN (around celiac trunk)  drains foregut
2. Superior mesenteric LN (around superior mesenteric artery)  drains midgut
3. Inferior mesenteric LN (around inferior mesenteric artery)  drains hidgut
  All 3 forms cistnera chyle  continues as thoracic duct  junction of L subclavian vein & L internal
jugular vein

Kidneys, Ureters, Suprarenal gland

 Kidneys
 Location
o At level of T12-L3
o Hilum of kidney pass thru transpyloric line (stomach, 1st part of duodenum, pancreas, celiac trunk,
superior mesenteric???)
o Size: 4 inch L, 2 inch breath, 1 inch thickness
 Coverings of kidney
o Fibrous capsule  surrounds kidney & closely applied to its outer surface
o Perinephric fat  outside fibrous capsule
o Renal fascia  outside perinephric fat
o Paranephric fat  outside renal fascia
o During fasting: adipose tissue disappear  hanging of kidney (decent downward)
 Relations of Kidney
o R Kidney
- Anterior: R suprarenal gland, liver, 2nd part of duodenum, small intestine
- Posterior: 12th rib (it’s a bit lower due to liver)
o L kidney
- Anterior: L supra renal gland, stomach, pancreas, jejunum
- Posterior: 11th & 12th rib
 Contains 2 surfaces, 2 borders, 2 poles
 Renal structure
o Anterior to Posterior: VAUA (renal vein  2 branches of renal artery  ureter  3rd branch of
renal artery)
o Differentiate between R & L kidney: Ureter position should be downward, if flipped VAUA is in the
same order but Ureter would be upward
  Blood supply???
o Renal artery (arise at level of L2)
- R renal artery is longer & passes posterior to IVC
o Renal vein
- L renal vein is longer (anterior to ab aorta & & below superior mesenteric artery which can
compress L renal vein)
- Receives terminations from L suprarenal vein & L gonadal vein
 Nerve supply
o Renal plexus (PNS & SNS)
o Renal plexus is supplied by fibers from least splanchnic nerves (abdominopelvic)

 Ureters
 Ureters is 25 cm long
 Emerges from hilum of kidney & runs downward behind the parietal peritoneum on the psoas muscle
 Enters pelvis by crossing bifurcation of common iliac artery in front of sacroiliac joint & turns forward
to enter lateral angle of bladder
 3 important constrictions (where stones can be present)
1. Ureter & renal pelvis junction  near hilum of kidney
2. Pelvic inlet (where ureter pass thru pelvic inlet)
3. Near wall of urinary bladder
o Vessical caliculi  stones present in bladder
o Ureteric caliculi  stones in ureter
 Blood supply (arteries & veins are the same)
o Upper part  renal artery
o Middle part  gonadal artery
 o Pelvis region  superior vesicle artery (branch of internal iliac artery)

 Suprarenal gland (Adrenal Gland)

 Adrenal medulla  neurocrest cells  which forms postganglion SNS so medulla produce
catecholamine
 Adrenal cortex  mesoderm
 Preganglionic neuron is very long and ends in medulla  medulla acts as postganglionic neuron
 Zones of cortex:
o Zona reticularis  androgens
o Zona fasiculata  glucocorticoids
o Zona glomerulosa  mineralocorticoids
 Blood supply
o Arteries
- Superior suprarenal artery (branch of inferior phrenic)
- Middle suprarenal artery (branch of ab aorta)
- Inferior suprarenal artery (branch of renal artery)
o R suprarenal vein (short)  drains into IVC
o L suprarenal (longer)  joined by inferior phrenic vein  empties into L renal vein
o Veins
1. R suprarenal vein (does not have middle & inferior like in artery) IVC
2. L suprarenal vein  drains into L renal vein
 Nerves
o Myelinated presynaptic sympathetic fibers derived from intermediolateral cell column (IML) or
lateral horn of gray matter of spinal cord segments T10-L1  traverse both paravertebral &
prevertebral ganglia without synapse  distributed to chromaffin cells in suprarenal medulla

 Kidney stones
 Pain present first present in flank (loin) region (posterior aspect) radiates downward to groin (loin to
groin pain)
 Nerve supply for kidney: least splanchnic nerve T12 subcostal (renal plexus)  pain at subcostal space
in loin and moves downward to L1
Pelvis & Perineum

 Different between pelvis & perineum

 All structures above pelvic diaphragm  pelvis
o Prostate
o Uterus, ovaries
 All structures below pelvic diaphragm  perineum
o External genitalia, corpus cavernosum, corpus spon???

 Pelvis
 Has 2 parts
o False pelvis (greater) above pelvis inlet (brim)  it is part of ab content
- Urinary bladder empty is pelvis, full it’s abdominal
o True pelvis (lesser) present between pelvis inlet & outlet  related to inferior parts of pelvic
bones, sacrum, and coccyx
- Above: opens into ab cavity
- Below: closed by pelvic diaphragm
 Pelvic girdle:
o Formed by 3 bones:
1. Sacrum  from fusion of 5 originally speparated sacral vertebrae
2. L & R hip bones  from fusion of ilium, ischium, pubis
o Pelvic inlet (brim)  heart shaped
o Pelvic outlet  diamond shaped

 Male & female inlet difference

 Diameters of pelvic inlet
1. Diameters Conjugates  insert finger into vagina posteriorly to touch sacrum & other finger can
feel pubis symphysis & measure distance between the finger  13 cm (< 13cm will have difficulty
delivery)
2. True Conjugates (obstetric conjugate)  distance between upper margin of pubic symphysis to
sacrum  we can’t measure it so we take diameters conjugate and subtract 1.5 cm  11.5 cm
 Gynecoid type of pelvic inlet most common in female
 Boundaries of pelvic wall
1. Anterior wall  pubis symphysis
2. Posterior wall  sacrum
3. Lateral wall  hip bone, obturator internus muscle
4. Floor  pelvic diaphragm
 Pic of obtrator internus
  Pelvic diaphragm has 4 muscles (innervated by pudendal nerve)
o Small gap in pelvic diaphragm: Exit of urethra  posteriorly vagina  posteriorly rectum
o All muscles meet between vagina & rectum  and the area is called perennial body
o Perennial body: during childbirth & head doesn’t come out  procedure called median episotomy
 cut vagina downward which will damage perennial body  prolapse of uterus & vagina, urinary
bladder due to all the muscles meeting up at that point
o Inferi latero epiostomy is preferred
o All muscles help in support, urination, defecation
1. Female: Sphincter vagina  around urethra & vagina
2. Male: Levator prostate
3. Puborectalis  forms sling around rectum & holds fecal material in rectum  only when it relaxes
that we get defecation
- Innervated by pudendal nerve (S2-S4) no control of defecation

4. Iliococcygeus  arise from ileum

5. Ischiococcygeus (coccygeus) arise from ischium

 Blood supply
 Internal Iliac artery (11 branches)
 o Common iliac artery divides at level of L4 into internal & external iliac artery
I. Anterior division (8 branches)
1. Umbilical artery  obliterates & becomes median umbilical ligament, proximal part is patent
and called superior vesical artery
2. Superior vesical artery  blood supply to urinary bladder
3. Inferior vesical artery  inferior aspect of urinary bladder (absent in female which is
compensated by vagina artery)
4. Vagina artery (absent in male)  blood supply to vagina & inferior aspect of female urinary
bladder
5. Uterine artery (absent in male) uterus
- Urine passes below uterine artery (water under the bridge)
6. Obturator artery  Medial compartment of thigh
7. Inferior gluteal artery  gluteus maximus
8. Middle rectal artery  rectum (superior rectal branch of inferior mesenteric artery & middle
rectal artery of internal iliac artery supplies rectum)
II. Posterior division (3 branches)
1. Iliolumbar artery
2. Lateral sacral artery  supplies sacral  anastomose anterior & posterior spinal artery
3. Superior gluteal artery  gluteus medius & minimus
 Veins  same pathway as arteries

 Nerve Supply
 Sacral plexus (L4-S4)
o Pudendal nerve (S2 – S4)
- Exits thru greater sciatic foramen & re-enters pelvic region thru lesser sciatic foramen near
ischial spine  where pudendal canal (alcock’s canal) occurs  then gives 3 branches:
1. Inferior rectal nerve  rectum
2. Dorsal nerve of penis (glands clitoris in female)
3. Perineal nerve  pelvic, diaphragm, skin around penis ???
- Pudendal canal contents:
1. Internal pudendal artery (branch of internal iliac artery)
a. Inferior rectal artery
b. Dorsal artery of penis (glands clitoris)
c. Perineal artery
2. Internal pudendal veins
3. Pudendal nerve
o Pudendal nerve block  insert finger into vagina & feel ischial spine  blocks pudendal nerve & its
branches

 Nerves of pelvic region

  Inferior mesenteric plexus:
1. SNS  lumbar nerve
2. PNS  Pelvic splanchnic (S2-S4)
 Superior hypogastric plexus (continuation of inferior mesenteric plexus)
1. SNS  lumbar
2. PNS  pelvic splanchnic
 Inferior hypogastric plexus (continuation of superior mesenteric plexus)
1. SNS  sacral splanchnic nerve
2. PNS  pelvic splanchnic nerve
 From inferior hypogastric plexus  wind around internal iliac artery  so need to know the
branches of iliac artery and the nerve is the same ????
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Pelvic 2

 Peritoneal covering
 Female: rectouterine pouch (pouch of douglas)  common place for ectopic pregnancy
o Needle accidentally inserted into pouch of douglass  peritonitis (ab inflammation)
o Uterovesical pouch  uterus to bladder  second female pouch
 Male: rectovesical pouch

 Blood supply to rectum

 Superior rectal artery (branch of inferior mesenteric artery)
 Middle rectal artery (branch of internal iliac artery)
 Inferior rectal artery (branch of internal pudendal artery which is a branch of iliac artery)
 Venous drainage:
1. Superior rectal vein  inferior mesenteric vein
2. Middle rectal vein  drains into internal iliac vein
3. Inferior rectal vein  drains into internal pudendal vein  iliac vein
 Venous Plexus:
1. Internal rectal venous plexus  internal hemorrhoids
2. External rectal venous plexus  external hemorrhoids
 External hemorrhoids covers the skin, internal only seen when pt is pushing
 External hemorrhoids  nerve supply from pudendal nerve  so more painful
 Internal hemorrhoids  autonomic nerve
 Internal hemorrhoids  above pectinate line
 External hemorrhoids  below pectinate line
 Below pectinate line: stratified squamous
 Above pectinate: simple columnar epithelium

 Pathology
 Hemorrhoids
 Prostate gland enlargement
 Perianal abscess
 Cancer
 Fistula in ano
  Mucous membrane in rectum
 Pudendal nerve: severe pain sensation
 Bleeding
 Inspection:
o

 Anal fissure