Anatomy of Abdomen- GI tract

Adonye Banigo & Abigail Vooght, Oct 2010

Plan- Lecture 1

Abdo Wall

Surface markings Regions Layers Inguinal canal & hernias Incisions Whistlestop tour of GI tract Viscera + peritoneum + embryology Peritoneal cavity

Abdo cavity

Plan- Lecture 2

Key features of each organ The GI adnexae- liver, gallbladder, pancreas, spleen Not including the bony pelvis, genitourinary system, or histology of the gut

The Abdominal Wall

Role of Abdo Wall

Moving the trunk Depressing the ribs Compressing the abdomen Supporting and protecting organs

Surface Markings

Linea Alba Tendinous intersections (3) Linea semilunaris

Landmarks

Xiphisternum T9

Costal Margin Umbilicus L3/4

Iliac crest

9 regions
Midclavicular line

9 regions
Midclavicular line

Transpyloric plane (L1) Transtubercular plane (L4/5)

9 regions

Epigastric Umbilical

Suprapubic

9 regions

Hypochondrium Lumbar Iliac Fossae

Layers of Abdo Wall- Laterally

Skin Superficial fascia Campers (soft & spongy fat!) Scarpas (membranous) External Oblique (Aponeurosis) Internal Oblique Transversus Abdominis Transversalis Fascia Extraperitoneal fat Peritoneum

Layers of Abdo Wall- Medially

Skin Superficial fascia

Campers (soft & spongy fat!) Scarpas (membranous)

Rectus Abdominis and Rectus Sheath Transversalis Fascia Extraperitoneal fat Peritoneum

Abdo wall- Layers Medially

Costal Margin

Arcuate line (of Douglas)

Inguinal canal

Passage for spermatic cord // round ligament 4cm long Deep (internal) ring to superficial (external) ring Boundaries:

Anteriorly- E-O aponeurosis + I-O lateral 1/3 Posteriorly- transversalis fascia + conjoint tendon medially Above- arching fibres of internal oblique + transversalis Below- inguinal ligament (infolded gutter of E-O)

1) External oblique aponeurosis, 2) Internal oblique muscle, 3) Transversus abdominis muscle, 4) Endo abdominal fascia, 5) Internal inguinal ring, 6) Iliopubic tract, 7) Inguinal ligament, 8) Pubic symphisis, 9) Spermatic cord, 10) Interparietal connective tissue (cremasteric fascia), 11) cremasteric muscle, 12) Aponeurotic layer of posterior inguinal wall, 13) Fascial layer of posterior inguinal wall

Inguinal Canal- conceptual- from above

Anterior
Internal Oblique Extenal Oblique Aponeurosis Tubercle

ASIS

Pubic Transversalis fascia Conjoint Tendon

Posterior

Deep and Superficial Rings

Deep Ring:

Transversalis fascia evagination into canal as internal spermatic fascia inch above midpoint of inguinal ligament Transmits spermatic cord or round ligament

Superficial Ring:

V-shaped defect in E-O aponeurosis Transmits spermatic cord + ilioinguinal nerve

Spermatic Cord: 3 coverings,6 constituents

Coverings

External spermatic Fascia (from E-O apo) Cremastic muscle + fascia (?I-O, TA) Internal spermatic Fascia (transversalis fascia)
Ductus Deferens Arteries: Testicular artery, artery to ductus Veins: Pampiniform plexus Lymphatics Nerves: Genital br of genitofemoral n + sympathetic twigs Processus Vaginalis

Constituents

Indirect Inguinal Hernia

Generally congenital Lax deep ring Repair by excising hernia sac and mesh to reinforce ring

Direct Inguinal Hernia

Generally weakness in EO aponeurosis Repair by reinforcing external ring, suturing mesh to conjoint tendon

PRINCIPLES OF INCISIONS

Adequate exposure of the organ Follow cleavage lines in skin (Langers lines) Avoid neurovascular structures Consider direction of muscles fibres and location of aponeuroses

Abdo wall nerve supply

7 8

9
10 11 12-s/c L1-i/h L1-i/i

Abdo Wall Arterial Supply

Principles of Abdominal Incisions

Adequate exposure of the organ Follow cleavage lines in skin (Langers lines) Avoid neurovascular structures Consider direction of muscle fibres and location of aponeurosis

Abdominal Incisions- access vs healing

Midline
Paramedian Subcostal (Kochers)
Muscle split Gridiron Pfannenstiel

The Abdominal Cavity

Viscera + peritoneum

Peritoneal Cavity

Viscera
Paired
Unpaired

Urinary- kidneys, ureters Endocrine- adrenal glands

Digestive- GI tract, liver & biliary tract, pancreas Haemopoietic- Spleen Develop on post. Abdo Develop on a mesentery wall (1 retroperitoneal) (which some lose to become 2 retroperitoneal) Arterial supply from corresponding side of aorta Arterial supply from front of aorta Nerve supply bilateral, true to level of origin Nerve supply bilateral Referred pain to Referred pain to midline corresponding side

Intro: the Peritoneum

Serous membrane (latin =thin skin) 2 layers- visceral + parietal Parietal

Lines interior of body wall Nerve & vascular supply from body wall (somatic) Covers viscera (!) Visceral supply

Visceral

Mesenteries

Double layer of serous membrane (peritoneum), suspends all intraperitoneal viscera Intermediary structure between parietal and visceral peritoneum Function Provide mobile attachment for viscus Contains supply lines (sandwiched between 3 layers) All unpaired viscera develop on a mesentery

Whistlestop tour of gut

Stomach

Duodenum

Jejenum

Ileum

Caecum

Large Bowel

Rectum & Anus

Embryology of gut- 6/40

Posterior abdo wall
Mesentery (ventral)

Foregut
Midgut
Mesentery (dorsal)

Hindgut

Foregut

Oropharynx to D2 (precisely opening of bile duct) Includes

Outgrowths: biliary tract Glands: liver & pancreas Spleen

Artery: Coeliac Nerve supply: T6- T9 spinal segments Rotation (on vertical axis of gut)- 90 left

Spleen from posterior (dorsal mesogastrium)

Rotation of foregut
liver

Mesentery (ventral)

Mesentery (dorsal)

Spleen

Foregut Midgut

Hindgut

Foregut rotation 2

Greater sac

Lesser sac

Midgut

D2 to mid-transverse colon Artery: SMA Nerve supply: spinal segments T9, T10 Rotation: On axis of SMA 270 anticlockwise 6- 10/40 gestation Via physiological hernia Retroperitoneal: duodenum, ascending colon

Midgut rotation 6-10/40

Rotation occurs around the axis of the SMA on a single mesentery, the mesentery

Hindgut

Mid-transverse colon- upper anal canal Artery: IMA Nerve supply: T11 -S4 Mesenteries:

transverse mesocolon (shared with midgut) sigmoid mesocolon

Rotation: swings to left vertical axis of dorsal mesentery Retroperitoneal: L colon (line of Toldt), rectum

Peritoneal Attachments
Bare area of liver Lesser sac Epiploic foramen Greater sac

Abdominal Viscera

Next time!

Any Questions?