Gastrointestinal

Skeleton of the Abdomen

The skeleton of the abdomen is represented in the adjacent figure. Starting

from the from we have:
xiphoid process X
costal cartilages (ribs 7-10)
tips of ribs 11 and 12
vertebrae L1-L5
iliac crests IC
tubercle of the crest TC
anterior superior iliac spine ASIS
anterior inferior iliac spine AIIS
inguinal ligament IL
pubic tubercle PT
pubic crest PC
pubic symphysis PS
the separation of the abdomen from the pelvis, the pelvic brim PB
The inguinal ligament extends
from the anterior superior iliac
spine ASIS to the pubic
tubercle PT and is used as one
of the lower borders of the
abdomen. This ligament is
really a turned under edge of
the aponeurosis of the external
abdominal oblique muscle. We
will mention it again when we
cover the inguinal region of
the abdomen.
The thoracic diaphragm
separates the abdominal cavity
from the thoracic cavity.
 Abdominal Wall
Surface Anatomy of the Abdomen
• Before getting into the nitty gritty of the
abdomen, keep in mind that you want to be able
to use your knowledge to project the anatomy
onto the surface of the abdomen. You will want
to be able to visualize the relative positions of
abdominal organs as they lie within the
abdomen. Clinicians might use several different
ways of subdividing the surface of the anterior
abdominal wall but I will only present two of
them here. By subdividing the surface into
regions, one person can tell another person
exactly where to look for possible problems.
The easiest is to separate
the surface into 4
quadrants:
upper left quadrant ULQ
lower left quadrant LLQ
upper right quadrant URQ
lower right quadrant LRQ
These quadrants are
developed by dropping a
vertical line down the
middle of the sternum
MSP and a horizontal line
across and through the
umbilicus TUP
The second way of dividing the
abdominal surface is into 9 regions:
left hypochondriac LH
left lumbar LL
left iliac LI
epigastric E
umbilical U
hypogastric H
right hypochondriac RH
right lumbar RL
right iliac RI
These regions are formed by two
vertical planes and two horizontal
planes. The two vertical planes are
the lateral lines LLL and RLL. These
lines are dropped from a point half
way between the jugular notch and
the acromion process.
The two horizontal planes are the
transpyloric plane TPP and the
transtubercular plane TTP. The
tubercles are the tubercles of the
iliac crests.
As a student of anatomy, it is sometimes fun to
pretend that you are going to be a surgeon and
are, at this point, considering entering the
abdominal cavity to remove or reconstruct
something in the abdominal cavity. It would
helpful if you knew what makes up the wall of
the abdomen so that you would be able to
judge how deep you have gone with each knife
cut. This brings us to the discussion of the
abdominal wall.
When considering the abdominal wall, you will
need to know where, specifically it is that you
want to enter.
 Layers of the Abdominal Wall
• The layers of the abdominal
wall vary, depending on where
it is you are looking. For
instance, it is somewhat
different along the lateral
sides of the abdomen than it
is at the anterior side. It is
also somewhat different at its
lower regions.
Lets start out along the lateral
side of the abdomen:
• skin
• superficial fascia
• deep fascia
• muscle
• subserous fascia
• peritoneum
At the lateral side of the abdomen (1) there is a dotted line passing
through the abdominal wall. Note the layers a surgeons knife, a
criminal knife or a anatomy student's knife must pass through to get
to the peritoneal cavity:
1.skin
2.superficial fascia (this may be as thin as or less than a half inch or
as thick as 6 inches or more)
3.deep fascia (all skeletal muscle is surrounded within its own deep
fascia). The deep fascia of the abdominal wall is different than that
found around muscles of the extremities, however. It is of the loose
connective tissue variety. It is necessary in the abdominal wall
because it offers more flexibility for a variety of functions of the
abdomen. At certain points, this fascia may become aponeurotic and
serve as attachments for the muscle to bone or to each other, as is
the case at the linea alba.
4.subserous fascia also known at extraperitoneal fascia (a layer of
loose connective tissue that serves as a glue to hold the peritoneum
to the deep fascia of the abdominal wall or to the outer lining of the
GI tract. It may receive different names depending on its location
(i.e. transversalis fascia when it is deep to that muscle, psoas fascia
when it is next to that muscles, iliac fascia, etc.)
5.peritoneum (a thin one cell thick membrane that lines the
abdominal cavity and in certain places reflects inward to form a
double layer of peritoneum) Double layers of peritoneum are called
mesenteries, omenta, falciform ligaments, lienorenal ligament, etc.)
At the anterior
wall of the
abdomen, in the
midline there is
no muscle so a
knife would only
go through the:
1.skin
2.superficial
fascia
3.deep fascia (in
this case a
thickened area of
deep fascia called
the linea alba)
4.subserous
fascia
5.peritoneum
If we look at the wall
inferior to the level of
the belly button
(umbilicus), you will
see that the superficial
fascia has become
divided into to parts:
a superficial fatty part
that is continuous with
the same layer over
the rest of the body
(Camper's fascia)
a deep membranous
layer that is
continuous down into
the perineum to
surround the penis and
to form a layer of the
scrotum. (Scarpa's
fascia)
As you examine the abdomen in thin subjects, you
may be able to see the superficial veins that drain the
abdominal wall. These veins drain into one of two
major veins:
subclavian (not shown)
femoral (F)
and also into a minor, but important vein, the
paraumbilical vein PU. The paraumbilical vein drains
into the portal vein and then through the liver. This is
an important clinical connection.
The lower abdominal wall is drained by way of the
superficial epigastric SE and superficial circumflex
iliac SCI veins into the femoral vein.
The upper abdominal wall is drained by way of the
thoracoepigastric TE and lateral thoracic LT veins
into the subclavian.
Muscles of the Abdominal Wall
• It is now time to consider the muscles that
make up the anterior and anterolateral
abdominal wall. There are 4 pairs of
muscles to consider. We will remove
layers carefully to see the deeper levels.
As we go deeper through the layers, you
should be aware of the cutaneous veins
and nerves that travel in the layers.
The most superficial layer of anterolateral muscles are the:
external abdominal obliques EAO
Notice on the right side of the specimen that the lower part of the
superficial fascia has been left behind so that you might see its two
layers, the fatty layer (Camper's fascia) CF and the membranous
layer (Scarpa's fascia) SF. Running through the fatty layer are the
superficial veins, the superficial epigastric SE, the paraumbilical
veins radiating out from the umbilicus and the thoracoepigastric vein
TE.
The cutaneous nerves to the abdomen are mainly continuations of
the lower intercostal nerves (T7 - T12). An important level to
remember is that the umbilical region is supplied by the 10th
intercostal nerve. The lowermost part of the abdominal wall is
supplied by a branch of L1, the iliohypogastric IH nerve. Its other
branch is the ilioinguinal II nerve.
You should also identify the linea alba LA. This white line is where
the aponeuroses of the external abdominal oblique, internal
abdominal oblique, and transverse abdominis muscles converge at
the midsagittal part of the abdominal wall.
In the image, the left external abdominal oblique has been
cut away at the white dotted line and removed in order to
show the internal abdominal oblique IAO. You can also see
lower cut edge of the external abdominal oblique at the
inguinal ligament IL
The anterior wall of the rectus sheath RS has also been
removed on the right side in order to see the underlying
right rectus abdominis RA muscle. Note that the rectus
abdominis muscle is subdivided into small sections by so
called tendinous inscriptions TI. This arrangement is what
forms the wash-board abs in well-exercised people.
We will discuss the formation of the rectus sheath in a
moment.
You may also see a small muscle overlying the inferior end
of the rectus abdominis muscle, the pyramidalis muscle PY.
This small muscles tenses the lower part of the linea alba.
In this specimen, the rectus abdominis muscle,
internal abdominal oblique and anterior rectus
sheath have been removed. You can identify the
posterior rectus sheath and its lower free margin,
the arcuate line AL. What you see below this line is
the transversalis fascia and running in the fascia is
the inferior epigastric artery IEA, a branch of the
external iliac artery. This artery enters the rectus
sheath posterior to the rectus abdominis muscle
and supplies the anterior abdominal wall. Extending
from the top, is a branch of the internal thoracic (or
mammary) artery, the superior epigastric artery.
Also note that the cutaneous nerves are found to
lie between the internal abdominal oblique and the
transversus abdominis muscles.
 Makeup of the Rectus Sheath at
Different Levels
• The rectus sheath consists of two lamina, the
anterior sheath and the posterior sheath. The
sheath is made up of the aponeuroses of the
three anterolateral abdominal muscles (external
abdominal oblique, internal abdominal oblique
and the transversus abdominis) as they
converge at the linea alba. The makeup of the
anterior and posterior sheaths vary depending
on the level of the abdominal wall you examine.
The three levels that we will examine are:
above the costal margins
there is only an anterior sheath made up of the aponeurotic
fibers of the external abdominal oblique EAO
between the costal margin and the arcuate line
anterior sheath is made up of a combination of the
aponeurosis of the external abdominal oblique EAO and the
internal abdominal oblique IAO.
posterior sheath is made up of a combination of the
aponeuroses of the internal abdominal oblique IAO and the
transversus abdominis muscles TA. Notice that the
aponeurosis of the internal abdominal oblique splits around
the two sides of the rectus abdominis muscle.
below the arcuate line
the anterior sheath is made up of the aponeuroses of all three
abdominal muscles EAO, IAO, and TA.
there is no posterior sheath below the arcuate line. The
transversalis fascia makes up the posterior aspect of the
rectus abdominis muscle.
 Inguinal Region, Spermatic Cord
and Testis
• Start examining the inguinal region by identifying the
external oblique aponeurosis which forms the anterior
boundary to the canal. In the first image, identify the
external abdominal oblique muscle EAO and its
aponeurosis. Notice that the lower margin of the external
oblique forms the inguinal ligament IL. There is a
weakness in the aponeurosis of the external oblique
called the superficial inguinal ring SIR and is shown as a
white dotted line. The superficial ring has a medial crus
(or superior)MC and a lateral crus (or inferior)LC.
Passing through the superficial ring are the spermatic
cord SC and the ilioinguinal nerve IIN which is a branch
of L1 nerve.
In the second image, the
external oblique has been
removed and you see the
internal abdominal oblique
IAO. Notice the cut margin
of the external oblique at
the inguinal ligament IL.
Note that some of the
fibers of the internal
oblique continue down and
around the spermatic cord
to become the
creamasteric layer of the
spermatic cord. These
muscle fibers perform an
important reflex called the
cremasteric reflex, a test
performed in most routine
physical exams in males.
In the third image, the internal oblique has
been removed and you see the transversus
abdominis muscle TA. If you look just
below the lower fibers of the tranversus
abdominis you will see the spermatic cord
SC as it passes through the deep inguinal
ring DIR. Identify the ilioinguinal nerve as it
runs deep to the inguinal ligament. Notice
that it does not enter the inguinal canal
along with the spermatic cord. The deep
inguinal ring is nothing more than a
thickening of the transversalis fascia at the
point where the structures that make up the
spermatic cord converge.
 Cremasteric reflex.

A reflex is a reaction to some kind of stimulus (stroke,

pin prick, etc.). A stimulus is picked up by sensory
(afferent) nerves and carried to the spinal cord
(central nervous system) where it forms a synapse
with motor (efferent) neurons that pass out to a
muscle to perform an action.
In the case of the cremasteric reflex, the afferent limb
of the reflex is by way of the genitofemoral nerve and
the efferent limb is by way genitofemoral fibers to the
cremasteric muscle. The result is that by stroking the
skin on the medial side of the thigh next to the
scrotum, the scrotum is pulled up on that side. The
spinal cord segments involved are L1 - L2.
Three layers of the spermatic cord are picked up from
three layers of the abdominal wall: 1)internal spermatic
fascia, 2)cremaster muscle and fascia, and 3)external
spermatic fascia.
As the structures within the spermatic cord pass through
the transversalis fascia they pick up one of the layers of
the spermatic cord, the internal spermatic fascia. As it
continues through the canal, it picks up the cremasteric
layer of muscle and fascia from the internal oblique
muscle and finally, when it passes through the
superficial ring, it picks up an external spermatic fascia
layer, derived from the aponeurosis of the external
oblique. Surgeons utilize their knowledge of these layers
in the repair of inguinal hernias.
Notice the conjoined tendon (or falx inguinalis) X
superior to and behind the spermatic cord SC.
As a final exercise, you should learn the walls of the inguinal canal.
anterior wall
laterally - muscles fibers of the external oblique
medially - aponeurosis of the external oblique
most medially there is not wall but instead there is a deficiency
called the superficial inguinal ring.
superior -- arching fibers of the internal oblique and sometimes
transverse abdominis. These fibers start anterior and lateral, pass
over the spermatic cord and the medially forms part of the posterior
wall of the canal.
posterior -- lateral the posterior wall is deficient at the deep inguinal
ring. Medially the posterior wall is made up of the fused aponeuroses
of the internal oblique and transverse abdominis, called the
conjoined tendon X.
inferior (or floor) -- inguinal ligament. Medially, some of the fibers of
the inguinal ligament curve under the spermatic cord and fasten into
the pectineal line of the pubis, this is the lacunar ligament which
forms part of the floor of the inguinal canal.
Once you know where the inguinal region is and what makes up its
boundaries and contents, you might want to know what inguinal
hernias are. A hernia is a protrusion of part of the intestinal tract,
greater omentum or just fat through a weakened part of the
abdominal wall. In our case, we are talking about a weakness in the
inguinal region of the abdominal wall. There are two weakened parts
of the lower abdominal wall in the inguinal region: 1)at the deep
inguinal ring and 2)at the conjoined tendon. There are two types of
inguinal hernias: 1)indirect and 2)direct.
When a hernia occurs at the deep inguinal ring, it is called an
indirect inguinal hernia. This type of hernia will carry all the same
layers as the spermatic cord and if foreceful enough will end
showing through the superficial inguinal ring. This type of hernia is
definitively diagnosed at surgery by being lateral to the inferior
epigastric artery.
When a hernia occurs at the conjoined tendon, it is called a direct
inguinal hernia. If the force and weakness is great enough, the
herniated material will also appear through the superficial ring, but it
will not carry all of the layers that the spermatic cord has. At surgery
it is definitively diagnosed as direct by being medial to the inferior
epigastric artery.
After the spermatic cord traverses the
inguinal canal, it leads into the scrotum
and to the testes. In order to free the
testes and its coverings from the
scrotum, the remains of the embryonic
gubernaculum testis has to be cut. At this
point the testes can be withdrawn from
the scrotum. What you see is the outer
side of a closed sac called the tunica
vaginalis. This must be cut in order to
view the parts of the testis.
Once the tunica has been
opened, identify the:
parietal layer of the
tunica vaginalis ptv
visceral layer of the
tunical vaginalis vtv
head of the epididymus h
body of the epididymus b
tail of the epididymus t
sinus of epididymis s
appendix epididymis ae
testis
ductus (vas) deferens dd
The anterior border of
the testis is to your right.
Hydrocele is a condition
in which fluid collects in
the space c of the tunica
vaginalis
 Spermatic Cord
• If you examine a cross
sectional area of the spermatic
cord, you will see the following
layers:
• external spermatic fascia
• cremasteric muscle and fascia
• genitofemoral nerve gfn
• internal spermatic fascia
• ductus deferens dd
• lymph vessels lv
• pampiniform plexus of veins
ppv. These veins will become
the testicular vein.
• testicular artery
The anterior surface of the
spermatic cord is toward the top.
During physical examination, the
ductus deferens can be felt as a
rope-like cord. Surgeons who
perform vasectomies can roll the
spermatic cord over the pubic
bone so that they know exactly
where make their incisions.
 Peritoneum and Peritoneal
Reflections
• The best way to try to visualize the
peritoneum and its reflections is to
examine sagittal and cross sections
through the abdomen. After looking at
images of these sections, students who
have a cadaver available can then follow
the road map that I will be giving as a way
to classify various organs in the abdominal
cavity before actually displaying them.
First, we will take a
look at a sagittal
section through the
abdomen just to the
right of the midline
of the body. The
parietal peritoneum
is colored bright
blue and the
visceral peritoneum
is colored magenta.
After cutting through the abdominal wall, if you put your hand under
the wall, you will be touching parietal peritoneum. If you start by
putting your finger as high as possible 1, then run it along the inner
aspect of the abdominal wall 2 until you reflect onto the superior
surface of the urinary bladder 3, then over the uterus in the female 4,
then down into the pouch of Douglas 5, again in the female, up along
the anterior surface of the rectum onto the posterior abdominal wall
6 until you reach the root of the mesentery of the small intestine.
From here you follow the mesentery of the small intestine 7 going
around its coils until you reach the other side of the mesentery back
down to the posterior abdominal wall where you will cross over the
horizontal part of the duodenum 8. Your finger will then travel along
the inferior aspect of the gastrocolic ligament 9, down the posterior
surface of the greater omentum (go) to its lower border and back up
along its anterior surface 11. Your finger then passes over the
anterior surface of the stomach 12, along the anterior lamina of the
lesser omentum 13. At this time you probably couldn't continue the
trip because you would have to enter the epiploic foramen (ef) to
enter the lesser peritoneal cavity (lpc) where visceral peritoneum
lines this space anteriorly and parietal peritoneum posteriorly.
Second, we will take
a look at a couple of
cross sections taken
through the
abdomen: 1)one
through the level of
the liver, stomach
and spleen and
2)another through a
lower level. These
levels are shown at
A and B on the
sagittal section
above.
Again, start at 1 and follow around the peritoneal
cavity. Once on the back of the abdomen, 2 you will
reflect onto the anterior surface of the right kidney,
pass through the epiploic foramen, along the
posterior wall of the lesser peritoneal cavity, 3 then
up along the renal lienal ligament 4 onto the
posterior surface of the stomach 5. Your finger will
continue through the epiploic foramen again to turn
around the free margin of the lesser omentum 6,
then over the anterior surface of the stomach again
7. Continue to follow around the greater curvature of
the stomach 8 until you reflect again along the
gastrolienal ligament 9. Your finger will now pass
around the spleen, onto the left kidney to the
parietal peritoneum and back to the falciform
ligament fl.
In the second cross section, start
out anteriorly in the abdomen 1.
Trace around to the posterior
abdominal wall until you reach
the lateral paracolic gutter 2, over
the anterior surface of the
ascending colon ac, down into
the medial paracolic gutter 3then
onto the large vesselsvessels
posterior abdomen. Over the
front of the vessels, your finger
will travel along the right part of
the mesentery of the small
intestine 4. You then travel
around the coils of the small
intestine until you reach the
posterior abdominal wall again 5.
Continue along the left side, over
the descending colon dc and
finally, up to the anterior part of
the abdominal wall.
In the above discussion, you followed the peritoneal
lining of the abdominal cavity in two different
directions and classified organs and specialities of
the periperitoneum along the way. The peritoneal
cavity is a closed cavity made up of a thin, one-cell-
thick serous membrane. The word serous denotes
that this membrane can produce fluid;slidinghe
intestinal tract is highly moveable within the
abdominal cavity, there is a need to have some
lubrication between the sliding surfaces and this is
produced by the peritoneum. On the other hand
infections and other pathologies might result in an
overproduction of fluid, which is not what one would
like. There are certain pathological conditions that
produce extra fluid in the peritoneal cavity and this
results in what is called ascites.
The peritoneum has the following properties:
1.it becomes double in certain areas. This double layer of
peritoneum is given different names: mesentery, ligament,
fold, or omentum.
2.as already mentioned, it lines the abdominal cavity
3.it almost completely surrounds some parts of the intestinal
tract. These parts are called intraperitoneal structures.
4.it only covers the anterior part of some structures. These
structures are called retroperitoneal. Retroperitoneal
structures include: urinary system, ascending colon,
descending colon, horizontal part of duodenum, pancreas
(except for its tail).
5.it produces a covering around some of the intestines. The
covering is called its serous coat.
6.peritoneal folds are usually caused by underlying blood
vessels, ducts or embryonic remnants.
 General Inspection of the
Abdominal Cavity and its Contents
• This image shows the peritoneum following the
removal of the abdominal wall. When the
abdominal wall aw is removed, what you have
remaining is the transversalis fascia covering
the peritoneum. It is thicker and fatty in some
areas and it contains some of the blood vessels
supplying the anterior abdominal wall (i.e., the
inferior epigastric artery iea in this case).
After the peritoneum is opened, identify the
major organs as they lie within the abdominal
cavity.
In this dissection, the lower part of the
peritoneum has been reflected downward in
order to display the peritoneal folds in this
region:
lateral peritoneal fold lpf produced by the
inferior epigastric artery.
medial peritoneal fold mpf produced by the the
embryonic umbilical arteries
median peritoneal fold mepf produced by the
closed embryonic urachus which arose from the
apex of the urinary bladder in the embryo.
You will frequently
read that the
peritoneal folds are
called ligaments. In
this case, only the
folds formed by left-
over embryonic
structures are named
ligaments. The
embryonic urachus is
the median umbilical
ligament and the
embryonic umbilical
arteries are the lateral
umbilical ligament.
Structures that should be identified at this stage are:
.liver in the upper right quadrant of the cavity. It is
separated into right rlli and left llli lobes by the
falciform ligament fl.
.the tip of the gall bladder gb hanging down under the
margin of the liver
.stomach st in the upper left quadrant
.a small edge of the spleen sp in the upper left
quadrant
.greater omentum go covering most of the abdominal
structures
.small intestines (ileum) il in the lower right quadrant
.sometimes the transverse colon tc can be seen
through a thin portion of the greater omentum.
The free margin of the falciform ligament fl contains
the remnant of the embryonic umbilical vein, now
called the ligamentum teres (round ligament) lt of the
liver. The paraumbilical veins run along either side of
the ligament and empty into the portal vein, a
clinically important connection discussed later.
At this point, you might want to take a tour of the
abdominal cavity by following the peritoneum around
and identifying structures as you go. Take a look at
this page and follow the instructions. It would be nice
if this could be done at the cadaver, but not everyone
has that opportunity so you have to imagine what is
going on.
 When the greater
omentum is pulled up
and to the right side,
you can see more of
the small intestine si.
Most of this small
intestine is jejunum.
The transverse colon
tc is attached to the
under side of the
greater omentum and
can also be seen.
By pulling the small
intestine from the left
side of the abdomen up
and to the right, you can
see the structures under
it. The descending colon
dc, a piece of the
sigmoid colon sc and the
upper part of the rectum
rec. You can also see
the root of the mesentery
of the small intestine
dotted line.
 Summary of Ligaments attached to
the Umbilicus
• The falciform ligament is a double fold of peritoneum which
extends from the umbilicus to the antero-superior surface of the
liver. In its free edge, you will see that it contains a cord-like
structure which passes to the inferior border of the liver. This is
the round ligament of the liver, which is formed by the remains of
the left umbilical vein of the fetus. Running adjacent to the
ligament are small veins the connect the paraumbilical veins
around the umbilicus to the portal vein.
On the deep surface of the lower abdominal wall, note that there
are three cord-like structures seen through the peritoneum and
extending upwards towards the umbilicus. These are the median
umbilical ligament (or median umbilical fold), and the lateral
umbilical ligaments (or medial umbilical folds). The median
umbilical ligament extends from the tip of the bladder to the
umbilicus and is the remains of the fetal urachus. The lateral
umbilical ligaments arise from the pelvis as a continuation of the
internal iliac artery and extend to the umbilicus. These are the
obliterated parts of the fetal umbilical arteries that carried blood
from the fetus back to the placenta of the mother.
 Reflections of the Peritoneum
• On the adjacent sagittal section of the body, you can
identify the following parts of the peritoneum and its
reflections. The parietal peritoneum is colored greenish
blue and the visceral peritoneum is dark purple. Just
imagine that you have a cadaver available. Insert your
fingers between the diaphragm d and the top of the liver
and push until you are stopped by a reflection of the
peritoneum from the diaphragm onto the diaphragmatic
surface of the liver. This reflection forms the superior
limb of the coronary ligament cl. If you could push your
fingers up behind the liver, you would encounter another
reflection, this would be the inferior part of the coronary
ligament. The two superior parts come forward and unite
to become continuous with the falciform ligament.
If you continue to move your fingers along the
diaphragmatic surface of the liver to its lower border and
then onto the visceral surface of the organ, your fingers will
be directed towards the lesser curvature of the stomach.
This layer is the lesser omentum lo and extends from the
visceral surface of the liver (specifically the porta hepatis
region of the liver) to the lesser curvature of the stomach
and then over the anterior surface of the stomach. The
lesser omentum has a free margin near the gall bladder and
behind this margin is the epiploic foramen ef which
connects the greater peritoneal sac to the lesser peritoneal
sac ls which is also known as the omental bursa.
If you place your fingers within the epiploic foramen and
grasp the free margin of the lesser omentum, you will feel
several structures: bile duct, hepatic artery and portal vein.
We will talk about these later. If you place your fingers
superiorly, you will feel the caudate lobe of the liver. If you
feel posterior, you will feel the inferior vena cava and if you
feel inferiorly, you will touch the first part of the duodenum.
You should constantly look
at enough cross sections
so that you feel comfortable
with them. Remember that
your left is the cross
section's right since you
are looking upwards
towards the body. In this
image, you can identify
some of the peritoneal
ligaments that you couldn't
see on the sagittal section
above. Identify the:
.falciform ligament FL
.lienorenal ligament LR
.gastrolienal ligament GL
.lesser omentum LO
Also, identify the epiploic
foramen EF and the
relationships of the lesser
sac LS (or omental bursa).
Here is a summary of the all of the various names used to describe
different parts of the peritoneal reflections:
1. coronary ligament
.superior border
.inferior border
.right triangular ligament - from liver to right kidney
.left triangular ligament
2. falciform ligament - from anterior abdominal wall to liver
ligamentum teres - in free margin of the falciform ligament
paraumbilical veins
3. lesser omentum - extends from liver to lesser curvature of stomach
and first part of duodenum
.hepatogastric part - from liver to lesser curvature of stomach
.hepatoduodenal part - free margin of lesser omentum from liver to
first .part of duodenum
.portal vein
.bile duct
.proper hepatic artery
4. greater omentum
.gastrocolic part - from greater curvature of stomach to point
where transverse colon attaches to the back side of the greater
omentum
.gastrosplenic part - from greater curvature of stomach to
spleen
.gastrophrenic part - from the fundus of the stomach to the
diaphragm
5. transverse mesocolon - from transverse colon to posterior
abdominal wall
6. mesentery of the small intestinee - from jejunum and ileum to
the root of the mesentery on the posterior wall of the abdominal
cavity. The root extends obliquely across the posterior
abdominal wall from the beginning of the jejunum to the end of
the ileum at the cecum.
7. lienalrenal ligament - double layer of peritoneum extending
from the spleen to the anterior surface of the left kidney
8. sigmoid mesocolon - from sigmoid colon to posterior
abdominal wall over the psoas muscle
9. mesoappendix - from base of appendix to its apex
The Oesophagus
-is a narrow muscular tube, forming the food
passage between the pharynx and stomach.
-It extends from the lower part of the neck to
the upper part of the abdomen.
-The oesophagus is 25cm(10inches) long.
-The tube is flatened anteroposteriorly, and
the lumen is kept collapsed;it dialtes only
during the passage of food bolus.
-The pharyngooesophageal junction is the
narrowest part of the alimentary canal
except for the vermiform appendix.
. The oesophagus begins in the neck at
the lower border of the cricoid cartilage
where is is continuation with the lower
end of the pharynx.
-It descends in front of the vertebral
column through the superior and posterior
part of the mediastinum,and pierces the
diaphragm at the level of vertebra T1o.
-It ends by opening into the
stomach( cardiac end) at the level of
vertebraeT11.
CURVATURES
In general, the oesophagus is vertical,but shows
slight curvatures in two sides-both in left side.
-one is at the root of the neck and the other near the
lower end.
Constrictions
Normally, the oesophagus shows 4 constriction at
the following levels
1.At its beginning ( 6 inches from the incisor teeth)
2.Where it is crossed by the aortic arch(9 inches
from the incisor teeth)
3.Where it is crossed by the left bronchus(11inches
from the incisor teeth)
4.Where it pierces the diaphragm(15 inches from the
incisor teeth)
Relations of the thoracic part of the
oesophagus
A.Anterior:a. trachea b.right pulmonary
artery c. left bronchus d. pericardium with
left atrium e.diaphragm
B.Posteriorly:a.vertebral column b.right
posterior intercostal arteries,c. thoracic
duct, d.. azygos vein with the terminal
parts of the hemiazygos vein. E. thoracic
aorta ,f. right pleural recess ,g.diaphragm.
C.To the right:a. right lung and pleura,b.azygos
vein, c. the right vagus
D.To the left:a. thoracic duct,b. left subclavian
artery.c.aortic arch ,d. left lung and left pleura ,e.
left recurrent laryngeal nerve,all in the superior
mediatinum.
In posterior medistinum it os related to1.the
descending thoracic aorta ,2.the left lung and
pleura.
Abdominal part of oesophagus
-- is only about half an inch long.
--Enters the abdomen through the oesophageal
opening of the diaphragm situated at the level of
vertebraeT10,slightly situated at the left of the
median plane.
The opening also transmits the anterior and posterior
gastric nerves, oesophageal branches of the left
gastric artery artery and accompanying veins.
-The oesophagus runs downward and to the left in
front of the crus of the diaphragm and of the left
inferior phrenic artery.Anteriorly, it lies in agroove on
the posterior surface of the left lobe of the liver, and
ends by openieng into the cardiac end of the
stomach at the level of T11, about an inch to the left
median plane.Its right border is continous with the
lesser curvature of the stomach, but the left border is
seperated from the fundus of the stomach by the
cardiac notch. Peritoneum covers the oesophagus
only anteriorly and on the left side.
 Blood supply
1.The cervical part ( including the
segment up to the arch of aorta) is
supplied by the inferior thyroid arteries.
2. The thoracic part is supplied by the
oesophageal branches of the aorta.
3. The abdominal part is supplied by the
oesophageal branches of the left gastric
artery.
 Venous drainage
-Upper part of oesophagus—
brachiocephalic veins.
.Middle part of oesophagus—azygos
vein
.Lower part of oesophagus—left gastric
vein.
Lymphatic Drainage
. Cervical part----deep cervical nodes.
.Thoracic part---posterior mediastinal
nodes.
.Abdominal part—left gastric nodes.
 Nerve supply of the oesophagus.
A. Parasympathetic nerves---upper half of
the oesophagus—recurrent laryngeal nerve.
--lower half of the oesophagus plexus
formed mainly by the two
vagi.parasympathetic nerves are sensory,
motor, and secretomotor to the oesophagus.
B.Sympathetic nerves---upper half of the
oesophagus ---middle cervical ganglion
Lower half of the oesophagus—directly
upper thoracic ganglia.They are vasomotor.
 Applied Anatomy
1.oesophageal varices.
2.The normal constrictions should be kept
in mind during oesophagoscopy.
3.Achalasia
4.Tracheo-oesophageal fistula
5.Mediastinal syndrome--- dysphagia
6.Lower end is the commonest site of
oesophageal carcinoma.
 Dr. ARUN KUMAR GUPTA
MBBS, MD(2ND Year)
Department of Respiratory Medicine,
MCZU.
 The Stomach
• In the living and in the upright posture, the
stomach is usually J-shaped. The lowest
part of the body can even extend into the
greater pelvis. The pylorus lies at the level
of the lower border of of the body of the L1
vertebra.
• When partially distended—piriform inshape.
• Obese person---horizontal – steerhorn
stomach
 Size
• The stomach is a very distensible organ.
It is about 10 inch long , and the mean
capacity is 30ml at birth,1000ml at
puberty at and 1500ml—2000ml or more
in adults.
The parts of the stomach that you should
identify are:
• connection to the esophagus E
• cardiac notch CN
• fundus F
• body B
• angular notch AN
• pyloric antrum Py
• area of pyloric sphincter PS
• 1st part of the duodenum D
• lesser curvature LC
• greater curvature GC
 Inside Structures of the Stomach
• When the stomach is
opened, you can identify
these structures:
• esophagus coming into
the stomach
• cardiac notch
• fundus
• body
• gastric folds or rugae
• angular notch
• pylorus of stomach
• pyloric sphincter
• first part of the
duodenum
 Relations of stomach
A.Peritoneal relations
.The stomach is lined by peritoneum on both its surface.At
the lesser curvature the layers of peritoneum lining the
anterior and posterior surfaces meet and become
continous with the lesser omentum.
.Along the greater part of the greater curvature the two
layers meet to form the greater omentum.Near the cardiac
end of the greater curvature the two layers meet to form
the gastrosplenic ligament.
.Near the cardiac end of the peritoneum on the posterior
surface is reflected on to the diaphragm as the
gatrophrenic ligament.
.Cranial to this ligament a small part of the posterior
surface of the stomach is in direct contact with the
diaphragm. This is the bare area of the stomach.
 B.Visceral relations
.The anterior surface of the stomach is
related to the liver, diaphragm and the
anterior abdominal wall.
.The diaphragm seperates the stomach from
the left pleura,the pericardium,and 6th to 9th
ribs.
.The costal cartilages are seperated from the
stomach by the transversus abdominis.
.The posterior surface of the stomach is
related to the structures forming bed ,all of
which are seperated from the stomach by the
cavity of the lesser sac.
 Arteries of the Stomach
• The arteries that supply the stomach are
branches of the celiac trunk or artery. This
is the first unpaired branch of the abdominal
aorta, arising just after the aorta passes
behind the diaphragm.
The branches of the celiac artery are three:
• left gastric
• splenic
• common hepatic
The branches to the stomach arise from the above:
celiac C
left gastric LG - supplies the lesser curvature of the
stomach and lower esophagus
esophageal E
splenic S which gives rise to:
short gastric SG - supplies area of the fundus
left gastroepiploic LGE - supplies the left part of
greater curvature of the stomach
common hepatic CH
gastroduodenal GD
right gastric RG - supplies right side of lesser
curvature of the stomach
right gastroepiploic RGE - supplies the right part
of the greater curvature of the stomach
 Venous Drainage of the Stomach
• The stomach drains either directly or indirectly into the
portal vein as follows:
• short gastric veins SGfrom the fundus to the splenic vein
S
• left gastroepiploic LGE along greater curvature to
superior mesenteric vein SM
• right gastroepiploic RGE from the right end of greater
curvature to superior mesenteric vein SM
• left gastric vein LG from the lesser curvature of the
stomach to the portal vein PV
• right gastric vein RG from the lesser curvature of the
stomach to the portal vein PV
 Lymphatic Drainage

• All of the lymphatic vessels drain into

nodes scattered along the arteries and
named accordingly. The final group of
nodes that receive lymph from the
stomach is the preaortic (celiac) nodes
located around the celiac trunk as it
arises from the abdominal aorta.
 Nerve supply of stomach
• The stomach is supplied by both the
parasympathetic and sympatethic parts of the
autonomic nervous system.
• parasympathetic
– preganglionic from right (posterior vagal trunk) and
left (anterior vagal trunk) vagus nerves.
– postganglionic neurons are very short and lie within
the wall of the stomach.
• sympathetic
– preganglionic fibers mainly from the thoracic
splanchnic nerves.
– postganglionic arise in the ganglia of the celiac plexus
The direction of lymph flow
and the position of the major
lymph nodes are essential in
understanding the possible
spread of malignancy from
the stomach.
 Functions
1.The stomach acts primarly as a reservoir of
food.
2.By its peritaltic movements it softens and mixes
the food with the gastric juice.
3.The gastric glands produce the gastric juice
which contains enzymes that play an important
role in digestion of food.
4.The gastric glands also produce HCL which
destroys many organisms present in food and
drink.
5. The lining cells of the stomach produce
abundant mucous which protects the gastric
mucosa against the corrosive action of HCL.
6.Some substances are absorbed in the stomach.
 Applied Anatomy

1.Gastric pain is felt in the epigastrium becz.

The stomach is supplied from segmentsT6
toT10 of the spinal cord,which alos supply
the upper part of the abdominal wall.Pain is
produced either by spasm of muscle, or by
overdistension.
2.The interior of the stomach can be
visualized by taking a skiagram after giving a
barium meal.It can also be examined directly
with the use of a gastroscope,which can be
passed into the stomach through the mouth.
 Duodenum
• The duodenum, into which the stomach
opens, is about 25 cm long, C-shaped and
begins at the pyloric sphincter. It is almost
entirely retroperitoneal and is the most
fixed part of the small intestine.
The duodenum is described as having four
parts:
1. Part one, superior part (SD)
2. Part two, descending part (DD)
3. Part three, horizontal part (HD)
4. part four, ascending part (AD)
The fourth part of the duodenum terminates
at the duodenojejunal flexure DJF with the
jejunum.
The ligament of Treitz is a musculofibrous
band that extends from the upper aspect of
the ascending part of the duodenum to the
right crus of the diaphragm and tissue around
the celiac artery.
As you can see, the head of the pancreas sits in the C-
shaped duodenum, so as long as we are here, we may
as well point out the structures here:
.head of the pancreas PH
.uncinate process of the head of the pancreas PUP
.neck of the pancreas PN where the superior
mesenteric artery and vein pass behind the pancreas
.body of the pancreas PB
.tail of the pancreas PT. This part is within peritoneum
and abuts the spleen
The other structures in the area are the:
.inferior vena cava IVC
.portal vein PV
.aorta aorta
.celiac trunk C
.kidneys
 Part one, superior part (SD)
A. Peritoneal Relations
1.The proximal 1 inch is movable. It is attached to
the lesser omentum above,and to the gretaer
omentum below.
2. The distal 1 inch is fixed. It is retroperitoneal. It
is covered with peritoneum only on its anterior
aspect.
B.Visceral relations:
1.Anteriorly: quadrate lobe of liver,and gall
bladder.
2.posteriorly:gastroduodenal artery, bile duct and
portal vein.
3.Superiorly: epiploic foramen.
4.inferiorly: head of
and the neck of the pancreas.
 Part two, descending part (DD)
.this is about three inches long.
.It begins at the superior duodenal flexure, passes downwards to reach the
lower border of the third lumbar vertebra,where is curves towards the left( at
the inferior duodenal flexure) to become continuous with the third part.its
relations are as follows:
A.Peritoneal relations
.It is retroperitoneal and fixed, its anterior surface is covered with
peritoneum, except near the middle,where it is directly related to the colon.
B.Visceral relations:
1.Anteriorly:(a)right lobe the liver; (b) transverse colon;© root of the
transverse mesocolon; (d) small intestine.
2. Posteriorly:(a) anterior surface of the right kidney near the medial border;
(b) right renal vessels; © right edge of the inferior vena cava;(d) right psoas
major.
3.Medially: (a) head of the pancreas;and (b) the bile duct.
4.Laterally: right colic flexure.
The interior of the second part of the duodenum shows the following special
features.
1. The major duodenal papilla is an elevation present posteromedially,8 to 10
cm distal to the pylorus. The hapatopancreatic ampulla opens at the
summit of the papilla.
2.the minor duodenalpapilla is present 6 to 8 cm distal to the pylorus,and
presents the opening of the accessory pancreaticduct.
 Third part of the duodenum
This part is about four inches long.
-it begins at the inferior duodenal flexure,on the right side of the lower
border of the third lumber vertebra.
- it passes alomost horizontally and slightly upwards in front of the
inferior vena cava,and ends by joining the fourth part infront of the
abdominal aorta.
-Its relations are as follows:
A.Peritoneal relations
.It is retroperitoneal and fixed .its anterior surface is covered with
peritoneum,except in the median plane,where it is crossed by the
superior mesenteric vessels and by the root of the mesentery.
B.Visceral relations
1.Anteriorly: (a) superior mesenteric vessels;and (b) root of
mesentery.
2.posteriorly:(a) right ureter,(b) right psoas major,© right testicular or
ovarian vessles; (d) inferior vena cava (e) abdominal aorta with origin
of inferior mesenteric artery.
3. Superiorly: head of the pancreas with uncinate process.
4. Inferiorly: coils of jejunum
 Fourth part of the duodenum
This part is one inch long .
It runs upwards on or immediately to the cleft of the aorta,up to the
upper border of the second lumbar vertebra,where it turns frowards
to become continuous with the jejunum at the duodenojejunal
flexure.its relation are as follows:
A.Peritoneal relations
It is mostly retroperitoneal, and covered with peritoneum only by
anteriorly.The terminal part is suspended by the uppermost part of
the mesentery,and is mobile.
B.visceral relations
1.Anteriorly: (a) transverse colon;(b)transverse mesocolon; © lesser
sac; and (d) stomach
2. Posteriorly:(a) left sympathetic chain. (b) left psoas major;© left
renal veeels(d) left testicular vessels(e) inferior mesenteric vein.
3. To the right: Attachment of the upper part of the root of the
mesentery.
4.to the left:(a) left kidneys; and (b) left ureter
5.superiorly:Body of pancreas.
Suspensory muscle of duodenum ( ligament of treitz)

This is afibromuscular band which suspends and supports

the duodeno-jejunal flexure.

It arises from the right crus of the diaphragm, close to the

right side of the oesophagus, passes downwards behind
the pancreas,and is attached to the posterior surface of the
duodenojejunal flexure and the third parts of the
duodenum.

.It is made up of:(a) striped muscle fibres in its upper part;

(b) elastic fibres in its middle part;and © plain muscle fibres
in its lower part.
.Normally its contraction increases the angle of the
duodeno-jejunal flexure. Sometimes it is attached only to
the flexure,and then its contraction may narrow the angle of
the flexure, causing partial obstruction of the gut.
Blood Supply of the Duodenum
• superior pancreaticoduodenal
• anterior and posterior branches
• inferior pancreaticoduodenal
• anterior and posterior branches

Most duodenal ulcers occur within 5 cm of

the pylorus and most frequently on the
anterior wall.
 Venous Drainage

.The veins of the duodenum drain into the splenic,

superior mesenteric and portal veins.

Lymphatic drainage
.Most of the lymph vessles from the duodenum end in
the pancreaticoduodenal nodes present along the
inside of the curve of the duodenum.From here the
lymph passes partly to the hepatic nodes,and through
them to the coeliac npdes;and partly to the superior
mesenteric nodes.
.Some vessels drain into the hepatic nodes directly.
.All the lymph reaching the hepatic nodes drains into
the coeliac nodes.
 Nerve supply
.Sympathetic nerves from
the spinal segments T9 TO
10, and parasympathetic
nerves from the vagus, pass
through the coeliac plexus
and reach the duodenum
along its arteries.
 Applied anatomy
1. In skiagrams taken after giving a barium meal, the first
part of the duodenum is seen as a triangular shadow called
the duodenal cap.
2.The first part of the duodenum is one of the commonest
sites for peptic ulcer, possibly becz. Of direct exposure of
this part to the acidic contents reaching it from the
stomach.
3.Duodenal diverticula are fairly frequent.They are seen
along its concave border, generally at points where arteries
enter the duodenal wall.
4.Congenital stenosis and obstruction of the second part
of the duodenum may occur at the site of the opening of
the bile duct.Other causes of obstruction are(I) an annular
pancreas;(ii)Pressure by the superior mesenteric artery; or
(iii)contraction of the suspensory muscle of the duodenum.
 The duodenum, jejunum and ileum make up the small intestine. We have already discussed the duodenum.

Jejunum and Ileum

• The jejunum and ileum is slung from the posterior
abdominal wall by the mesentery of the small intestines
and, therefore, is extremely mobile. The mesentery of the
small intestine arises from the root of the mesentery
which extends from the duodenojejunal flexure to the
ileocecal junction.

• The jejunum is about 2.5m (8ft) long and passes

imperceptibly into the ileum, which is about 4m (12ft) long.
this part of the small intestine occupies a central position
in the abdominal cavity, below the liver and the stomach,
and behind the transverse mesocolon, the transverse
colon and the greater omentum. The lowest coils of the
intestine lie in the pelvic cavity. The purple dotted line in
the lower image is an arbitrary line that can be used to
separate the jejunum which is to the upward left of the line
and the ileum which is to the downward and right of the
line.
 Blood Supply to Ileum and
Jejunum
• The ileum and jejunum are supplied by the superior
mesenteric artery and its intestinal branches.

The branches are rather special in that small arcades

are formed and from the arcades, the straight vessels,
vasa recta arise and supply the intestine. These straight
vessels are end arteries and if they should be occluded,
the part of the intestine supplied by them will die.

One way to tell the ileum from the jejunum, other than by
general location, is that there are more layers of arcades
before the vasa recta are given off, in the ileum.
 Lymphatic drainage
.Lymph from lacteals drain into
plexuses in the wall of the gut.From
there it passese into lymphatic vessels
in the mesentery and along the superior
mesentery artery
.Drains into nodes present infront of the
aorta at the origin of the superior
mesenteric artery.
 Large Intestine
• The large intestine extends from the ileocecal
junction to the anus and is about 1.5m long. On the
surface, you can identify bands of longitudinal
muscle fibers called taeniae coli, each about 5mm
wide. There are three bands and they start at the
base of the appendix and extend from the cecum to
the rectum. Along the sides of the taeniae, you will
find tags of peritoneum filled with fat, called epiploic
appendages (or appendices epiploicae). The
sacculations, called haustra, are characteristic
features of the large intestine, and distinguish it from
the rest of the intestinal tract.
The large intestine
consists of the
following parts:
1. cecum
2. ascending colon
3. transverse colon
4. descending colon
5. sigmoid colon
6. rectum Not seen
in diagram.
7. anal canal Not
seen in diagram.
8. anus Not seen in
diagram.
There are two flexures associated
with the colon:
1. right colic flexure or hepatic
flexure
2. left colic flexure or splenic
flexure
 Caecum
a large blind sac forming the commencement of
the large intestine.
-it is situated in the right iliac fossa, above the
lateral half of the inguinal ligament.
-it communicates superiorly with the ascending
colon,medially at the level of the caecocolic
junction with the ileum,and posteromedially with
the appendix.
- it is 6cm long and 7.5 cm broad.
-it is one of those organs of the body that have
greater width than the length.(another example
is the prostate.)
 Relations
A.Anterior- coils of the intestine and
anterior abdominal wall
B.posterior- right psoas and iliacus,
genitofemoral,femoral and lateral
cutaneous nerve of the thigh( all of the
right side)
vessels: testicular or ovarian, and often
the external iliac( of the right side),and
the appendix in the retrocaecal recess.
 Types
.the caecum and appendix develop from the caecal bud arising
from the postarterial segment of the midgut loop.
The proximal part of the bud dilates to from the caecum.
.the distal part remains narrow to form the apex of the caecum.
However,due to rapid growth of the lateral wall of the caecum,
attachment of the appendix shifts medially.
Developmental arrest in the shift of the appendix forms the
basis of the types of caeca.
1.conical type(13%),where the appendix arises from the apex of
the caecum.
2.intermediate type(9%) where the right and left caecal pouches
are equal in size,and the appendix arises from a depression
between them.
3.ampullary type(78%),where the right caecal pouch is much
larger than the left,and the appendix arises from the medial
side.
 Vessels and nerves

.the arterial supply of the caecum is

derived from the caecal branches of the
ileocolic artery.
.The veins drain into the superior
mesenteric vein.
.the nerve supply is same as that of the
midgut( sympathetic,T11to L1;
parasympathetic,vagus
 Ileocaecal valve
.The lower end of the ileum opens on the
posteromedial aspect of the caeco-colic junction.
The ileocaecal opening is guarded by the ileocaecal
valve.
Structure
The valve has two lips and two f renula.
(1)The upper lip is horizontal and lies at the ileocolic
junction.
(2) The lower lip is longer and concave,and lies at the
ileocaecal junction.
The two frenula are formed by the fusion of the lips
at the ends of the aperture.these are the left and right
frenula.the left end of the aperture is rounded;and
the right end narrow and pointed.
 Control and mechanism
1.The valve is actively closed by sympathetic
nerves,which causes tonic contraction of the
ileocaecal sphincter.
2. It is mechnically closed by distension of the
caecum.

Functions
1. It prevents reflux from caecum to ileum.
2. It regulates the passage of ileal contents into
the caecum,and prevents them from passing too
quickly.
 Ascending colon
.IT is about 5 inches long and extends from the caecum
to the inferior surface of the right lobe of the liver..
Here,it bends to the left to form the right colic
flexure.usually it is retroperiotoneal.
Anteriorly, it is related to the coils of small intestine, the
right edge of the greater omentum,and the anterior
abdominal wall.
Posteriorly,it is related to the iliacus, the iliolumbar
ligament,the quadratus lumborum,the transversus
abdominis,the diaphragm at the tip of the last rib; the
lateral cutaneous nerve,ilio-inguinal and ilio-hypogastric
nerves;the iliac branches of the iliolumbar vessels, the
fourth lumbar artery; and the right kidney.
 Right colic flexure(hepatic flexure)

.This flexure lies at the junction of the

ascending colon and transverse colon.
Here,the colon bends forwards,downwards
and to the left.
.The flexure lies on the lower part of the right
kidney.
.Anterosuperiorly,it is related to the colic
impresssion on the inferior surface of the
right lobe of the liver.
 Transverse colon

• .IT is about 20 inches long and extend across the

abdomen from the right colic flexure to the left colic
flexure .
.Actually it is not transverse,but hangs down as
aloop to avariable extent,sometimes reaching the
pelvis.
.It is suspended by the transverse mesocolon,and
has a wide range of mobility.
Anteriorly,it is related to the greater omentum and
to the anterior abdominal wall.Posteriorly,it is
related to the second part of the duodenum,the
head of the pancreas,and to coils of small intestine.
Left colic flexure(splenic flexure)
• .This flexure lies at the junction of the transverse
colon and the descending colon.here,the colon
bends downwards and backwards.
.the flexure lies on the lower part of the left
kidney and diaphragm,behind the stomach,and
below the anterior end of the spleen
.the flexure is attached to the 11th rib by a
horizontal fold if peritoneum,called the phrenico
colic ligament.
. The ligament supports the spleen and forms a
partial upper limit of the left paracolic gutter.
 Descending colon
• .It is about 10 inches long and extend from the left colic
flexure to the sigmoid colon.
.It runs vertically up to the iliac crest,and then inclines
medially on the iliacus and psoas major to reach the
pelvic brim,where its continous with the sigmoid colon.
The descending colon is narrower than the ascending
colon.usually,it is retroperitoneal.
.Anteriorly,it is related to the coils of small
intestine.Posteriorly,it is related to the transversus
abdominis,the quadratus lumborum,the iliacus and
psoas muscles;the ilio0hypogastrc,ilio-inguinal,lateral
cutaneous,femoral and genitofemoral nerves, iliac
branches of the ilio lumbar vessels,and the testicular
and external iliac vessels.
 Sigmoid colon( pelvic colon)

• .It is about 15 inches long,and extends from the

pelvic brim to the third piece of the sacrum,
where it becomes the rectum.
.IT Forms a sinous loop,and hangs down in the
pelvic over and uterus.
.Ocassionaly ,it is very short,and takes a
straight course.
.It is suspended by the sigmoid mesocolon and
is covered by the coils of small intestine.
 vermifomAppendix
• -worm like diverticulum arising from the posteromedial wall of
the caecum,about 2 cm below the ileocaecal orrifice.
Dimensions
Length-2-20cm( 1-9inch)
width- 9cm
.It is longer in children than in adults.
Diameter- 5mm
positions—clockwise position.
Appendicular Orrifice
1. It is situated on the posteromedial aspect of the caecum 2cm
below the ileocaecal orifice.
2. The appendicular orrifice is occasionally guraded by an
indistinct semilunar fold of mucous membrane,known as valve
of gerlach.
3. The orifice is marked on the surface by a point situated 2 cm
below the junction of the transtubercular and right lateral
planes.
 Peritoneal relations

• -suspended by a
small , trangular fold of a peritoneum –
mesoappendix or appendicular mesentery
Blood supply
.appendicular artery—lower division of ileocolic
artery.
Nerve supply—sympathetic nerves T9to T10
,Parasympathetic from vagus
lympahtic drainage
.directly into ileocolic nodes,,,,appendicular nodes.
Applied anatomy
.appendicitis
.MC Burneys point
 Arterial Supply of the Colon
• The colon is supplied by branches of the superior mesenteric and inferior
mesenteric arteries.
• Superior mesenteric artery
• ileocolic artery
– superior branch that joins the right colic
– cecal branch
– appendicular branch
– ileal branch
• right colic artery
– descending branch to join the superior branch of the ileocolic
– ascending branch that joins the right branch of the middle colic
• middle colic artery
– right branch
– left branch that joins with the ascending branch of the left colic artery
• Inferior mesenteric artery
• left colic
– ascending branch that joins the middle colic
– descending branch that joins the highest sigmoid branch
• sigmoid arteries (2-3)
– superior sigmoid branch join the left colic
– inferior sigmoid branch joins the superior rectal
• superior rectal artery - not shown in the image
 Venous Drainage of the
Gastrointestinal Tract
• The venous drainage of the gastrointestinal tract, from the lower
esophagus to the upper rectum is by way of the portal venous
system. This system also drains the spleen and pancreas.
The portal vein is usually described as being formed by the splenic
and superior mesenteric veins. The inferior mesenteric vein then
joins the splenic vein. However, there are variations to this pattern
and might exist. Two of these are that the inferior mesenteric vein
may join at the junction of the splenic with the superior mesenteric
or the inferior mesenteric veins may join the superior mesenteric
vein before it merges with the splenic. Identify the:
• superior rectal vein
• inferior mesenteric vein
• splenic vein
• superior mesenteric vein
• esophageal veins
• left gastric vein
• portal vein
The numbered stars represent the areas where the
portal venous system anastomoses with the caval
venous system and are clinically important in portal or
caval hypertension.
1. esophageal plexus - caval drainage into azygos
veins, portal drainage into the left gastric vein
2. rectal plexus - caval drainage into middle and inferior
rectal veins and then into the pudendal and internal
iliac veins back to inferior vena cava, portal drainage
into the superior rectal, the inferior mesenteric and the
splenic
3. paraumbilical veins - caval drainage downward to the
superficial inferior epigastri c vein to the femoral vein,
to the external iliac, to the inferior vena cava, upward to
the thoracoepigastric vein, the lateral thoracic vein,
subclavian vein, superior vena cava, portal drainage
through the paraumbilical vein to the portal vein.
 Clinical Consideration
• Portal obstruction. In cases of liver disease where the portal blood can
no longer pass through the liver, the blood will try to get back to the
heart any way it can and this usually involves the superior or inferior
venae cavae. One possible cause of liver disease is chronic
alcoholism. When the liver becomes impassable, it will pass
backwards through the portal vein into the left gastric, paraumbilical or
superior rectal. At each of these sites, the veins become enlarged and
will result in other clinical signs and symptoms.
In case of the esophageal plexus (*1), esophageal varices will develop
and massive hemorrhage may occur resulting in death.
In case of the rectal plexus (*2), hemorrhoids occur, resulting in pain
and bleeding.
In case of the paraumbilical veins (*3), visible signs of venous
enlargement and tortuosity occur on the abdomen and these are
referred to the caput medusae.
Caval blockage. In cases where tumors or other pathologies compress
the vena cava, the blood will utilize the above connections to return
blood to the heart but this time through the caval system.
 The rectum and Anal canal
• .The rectum is the distal part of the large gut.
.It is placed between the sigmoid colon above and the anal canal below.
.Distension of the rectum causes the desire to defaecate.
.The rectum in man is not straight as the name implies.infact it is curved in
an anteroposterior direction and also from side.
.The rectum is situtated in the posterior part of the lesser pelvis,infront of
the lower three pieces of tha sacrum and the coccyx.
IT begins as acontinuation of the sigmoid colon at the level of vertebra S3.
.The rectosigmoid junction is indicated by the lower end of the sigmoid
mesocolon.
The rectum ends by becoming contionous with the anal canal at the
anorectal junction.
.THE junction lies 2 to 3 cm in front of and a little below the tip of the
coccyx.
.The rectum is 12 cm(5inch) long.in the upper part it has the same
diameter(4cm) as that of the sigmoid colon,but in the lower part is dilated
to form the rectal ampulla.
 Course and direction

• 1.In its course,the rectum runs first downwards and

backwards,then downwards,and finally downwards and
forwards.
2. The beginning and the end of the rectum lie in the
median plane,but it shows two types of curvatures in its
course.
A.Two anteroposterior curve(1) the sacral flexure of the
rectum follows the concavity of the sacrum and coccyx;
and (2) the perineal flexure of the rectum is the
backward bend at the anorectal junction.
B. Three lateral curves:(1) the upper lateral curve is
convex to the right;(2) the middle lateral curve is convex
to the left and is most prominent; and (3) the lower
lateral curve is convex to the right
 Relations
A.Peritoneal realtions
• (1) The upper one third of the rectum is covered
with the peritoneum in front and on the sides.
(2) the middle one third is covered only infront;
(3) the lower one third,which is dialted to form
the ampulla is devoid of peritoneum,and lies
below the rectovesical pouch in male and below
the rectouterine pouch in females.
. The distance between the anus and the floor of
the pouch is 7.5 cm in males but only 5.5 cm in
females.
 B.visceral relations
• a.Anteriorly in males:(1) the upper two thirds of the rectum are related
to the rectovesical pouch( with coils of intestine and sigmoid colon),(2)
the lower one third of the rectum is related base of the urinary
bladder,the terminal parts of the ureters,the seminal vesicles, the
deferent ducts and the prostate.
Anteriorly in females:(1) the upper two thirds of the rectum are related
to the rectouterine pouch( with coils of intestine and sigmoid colon).
The pouch seperates the rectum from the uterus,and form the upper
part of the vagina.(2) the lower one third of the rectum is related to the
lower part of the vagina.
B. Posteriorly- the relations are same in the male and female.they are
(1) lower 3 pieces of the sacrum,the coccyx and the anococcygeal
ligament.(2) piriformis,the coccygeus and the levator ani; (3) the
median sacral,the superior rectal and the lower lateral sacral vessels.
(4) the sympathetic chain with the ganglion impar;the anterior primary
rami of S3.4,5.col,and the pelvic splanchnic nerves; lymph nodes,
lymphatics and fat.
 Mucosal folds

• . The mucous membrane of an empty rectum shows two types of

folds, longitudinal and transverse.
A. THE longitudinal folds are transitory. They are present in the
lower part of an empty rectum,and are obliterated by diatension.
B. the transverse of horizontal folds( houston’s valves or plicae
trans versales) are permanent and most marked when the
rectum is distended.(1) the upper fold lies near the upper end of
the rectum,and projects from the right or the left wall.
Sometimes it may encircle and partially constrict the lumen.(2)
the middle fold ( largest and most constants) lies at the upper
end of the rectal ampulla,and projects from the anterior and
right walls.(3) the lowest fold( inconstant) lies 2.5 cm below the
middle fold,and projects from the left wall.(4) sometimes a fourth
fold may be present on the left wall 2.5 cm above the middle fold.
 Functional parts of the rectum
• According to some authorities, the rectum has two
functional parts. The upper part( related to the peritoneum)
develops from the hindgut and lies above the middle of fold of
the rectum. It acts as faecal reservoir which can freely
distended anteriorly. The lower part ( devoid of peritoneum)
develops from the cloca and lies below the middle fold. It is
empty in normal individuals,but may contain faeces in cases
of chronic constipation, or after death.being sensitive causes
the desire to defaecate.
However, according to other authorities the sigmoid colon
is the faecal reservoir and the whole of the rectum is empty in
normal individuals,being sensitive to distension,therefore,
causes the desire to dafaecate.
 ARTERIAL SUPPLY

• 1.Superior rectal artery---chief artery of the rectum,,continuation

of the inferior mesenteric artery.
2. Middle rectal artery– anterior division of the internal iliac artery
3. Median sacral artery.– arising from the back of the aorta.
Venous drainage
1. Superior rectal vein
2. Middle rectal vein—open into the internal iliac veins.
lymphatic drainage
1. Lymphatics from more than the upper half of the rectum pass
along the superior rectal vessels to the inferior mesenteric nodes
after passing through the pararectal and sigmoid nodes.
2. Lymphatics from the lower half of the rectum pass along the
middle rectal vessels to the internal iliac nodes.
 Nerve supply
• The rectum is supplied by both sympathetic(L1,2) and
parasympathetic(S2,3,4) nerves through the superior
rectal( inferior mesenteric) and inferior hypogastric
plexuses.
Sympathetic nerves are vasoconstrictor, inhibitory to the
rectal musculature and motor to the internal
sphincter.Parasympathetic nerves are motor to the
musculature of the rectum and inhibitory
sphincter.Sensations of distension of the rectum pass
through the parasympathetic nerves,while pain
sensations are carried by both the sympathetic and
parasympathetic.
 Supports of rectum
• 1. Pelvic floor
2. Fascia of walder– it attaches the lower part of the rectal
ampulla to the sacrum. It is formed by condensation of the
pelvic fascia behind the rectum.it encloses the superior
rectal vessels and lymphatics.
3. Lateral ligaments of the rectum– they are formed by
condensation of the pelvic fascia on the each side of the
rectum. They enclose the middle rectal vessels, and
branches of the pelvic plexuses,and attach the rectum to the
posterolateral walls of the lesser pelvis.
4. Rectovesical fascia( of denovilliers). It extends from the
rectum behind to the seminal vesicles and prostate in front.
5. The pelvic peritoneum and the related vascular pedicles
also help in keeping the rectum in position.
 Applied anatomy
• 1. Digital examination per rectum(PR)
In a normal person, the following structures can be palpated by a
finger passed per rectum
A. In males:
• (1) posterior surface of the prostate;
• (2) seminal vesicles; and vasa deferentia
B.In females:
• (1) perineal body;
• (2) cervix;and
• (3) occasionally the ovaries
C.In both sexes:
• (1) anorectal ring;
• (2) coccyx and sacrum;and
• (3) ischiorectal fosaae and ischial spines.
2. Proctoscopy and sigmoidoscopy.
3.Prolapse of recrum.
 ANAL CANAL
• The anal canal is the terminal part of the large intestine.
.It is situated below the level of the pelvic diaphragm.
It lies in the perineum ( anal triangle) in between the right and
left ischiorectal fossae.
.The anal canal is 3.8 cm long.it extends from the anorectal
junction to the anus.
.It is directed downwards and backwards.the anal canal is
surrounded by sphincters which keep the lumen closed in the
form of an anteroposterior.
.the anorectal junction is marked by the forward convexity of
the perineal flexure of the rectum and lies 2-3 cm infront of and
slightly below the tip of the coccyx.
.the anus is the surafce opening of the analcanal,situated about
4 cm below and infront of the tip of the coccyx in the cleft
between the buttocks.
.The surrounding skin is pigmented and thrown into radiating
folds,and contains a ring of large apocrine glands.
 Relations of the anal canal
• .Anteriorly.(a) in both sexes: perineal body.(b) in males:
membraneous urethra and bulb of the penis.© in
females: lower end of vagina.
B. Posteriorly.(1) Anococcygeal ligament; and (2) tip of
the coccyx.
C. Laterally. Ischiorectal fossa.
Interior of the anal canal
The interior of the anal canal shows many important
features and can be divided into three parts.;(A ） The
upper [art,about 15mm long;(B)the middle part,about
15mm long and ©the lower part 8 mm long.Each part is
lined by a characteristic epithelium and reacts diffferently
to various diseases of this region.
 Upper part ( mucous)
• This part is about 15mm long. It is lined by mucous
membrane,and if of ectodermal origin.the mucous
membrane shows 6 to 10 vertical folds: folds are
called the anal columns( of moragagni). The lower
ennds of the anal columns are united to each other
by short transverse folds of mucous membrane:
these are called the anal valves.Above each valve
there is depression( in mucosa) which is called anal
sinus. The anal valves together form atransverse
line that all round the anal canal. This is pectinate
line. Occasionally,the anal valves show epithelial
projections called anal papillae.
Middle part( transitional zone or pecten)
• .the next 15mm or so of the anal canal is alos
lined by mucous membrane,but anal columns
are not present here. The mucosa has a bliush
appearance of dense venous plexus that lies
between it and the muscle coat. The mucosa is
less mobile than in the uper part of the anal
canal. This region is referred to as the pecten or
transitional zone. The lower limit of the pecten
often has a whitish appearance because of
which it is referred to as the white line( of
hilton)
 Lower part( cutaneous)
• .IT is about 8 mm lomg and is lined by true
skin containing sweat and sebaceous glands.
The epithellium lining the upper 15 mm of the
canal is columnar; that lining the middle
part( pecten) is stratified squamous,but is
distinguished from the skin in that there are no
sebaceous or sweat glands,or hair, in relation
to it. The epithellium of the lowest part
resembles that of true skin in which sebaceous
and sweat glands are present.
 Musculature of the anal canal
• A.Anal sphincters
1. the internal anal sphincter is involuntary in nature. It is
formed by the thickend circular muscle coat of this part
of the gut.it surrrounds the upper three fourths(30mm) of
the anal canal extending from the upper end of the anal
canal to the white line of hilton.
2.The external anal sphincter is under voluntary control. It
is made up of striated muscle and is suppled by inferior
rectal nerve and the perineal branch of the fourth sacral
nerve.it surrounds the whole length of the anal canal and
has three parts,subcutaneous,superficial and deep. The
subcuatneous part lies below the the level of the internal
sphincter and surrounds the lower part of the anal canal.
.it is in the form of a flat band about 15mm
broad. It has no bony attachement.the
superficial part is elliptical in shape and arises
from the posterior surtace of the terminal
segment of the coccyx as the anococcygeal
ligament. The fibres surround the lower part of
the internal sphincter and are inserted into the
perineal body. The deep part surround the
upper part of the internal sphincter and is fused
with the puborectalis. It arises from the
anoccygeal ligamnet,and is inserted into the
perineal body where the fibres decussate and
become continous with those of the superficial
tranaverse perineal muscles.
 B.Conjoint longitudinal coat.
• It is formed by fusion of the puborectalis with the
longitudinal muscle coat of the rectum at the anorectal
junction. It lies between the external and internal
sphincters. When traced downwards it becomes fibroelastic
and at the level of the white line it breaks up into a number
of fibroelastic septa which spread fanwise, pierce the
subcuqatneous part of the external sphincter,and are
attached to the skin around the anus.The most lateral of
these septa forms the perianal fascia. The most medial
septum forms,the anal intermuscular septum,which is
attached to the white line. In addition, some strands pass
obliquely through the internal sphincter and end in the
submucosa below the anal canal valves.
 C.Anorectal ring

• .This is a muscular ring present at the

anorectal junction. It is formed by the
fusion of the puborectalis,deep external
sphincter and the internal sphincter.it is
easily felt by a finger in the anal
canal.Surgical division of this ring results
in rectal incontinence. The ring is less
marked anteriorly where the fibres of the
puborectalis are absent.
 D.Surgical spaces related to the anal
canal
• 1.The ischiorectal space lies on each side of the anal
canal.
2. the perineal space surrounds the anal canal below the
white line. It contains the subcutaneous external
sphincter rectal ,the external rectal venous plexus,and
the terminal branches of the inferior rectal vessels and
nerves.Pus in this space tends to spread to the anal
canal at the white line or to the surface of the perianal
skin rather than to the ischiorectal space.
3. The submucous space of the canal lies above the white
line between the mocous membrane and the internal
sphincter. It contains the internal rectal venous plexus
and lymphatics
 Liver
• The liver is the largest gland of the body. It
normally weighs about 1.5kg. The sharp inferior
border of the liver does not normally extend
below the right costal margin. If it does, it is
enlarged. In order to free the liver for study, you
must cut the falciform ligament, superior and
inferior parts of the coronary ligament, the right
and left triangular ligaments, the lesser omentum
and the structures in its free margin (common
bile duct, proper hepatic artery and portal vein)
and the hepatic veins at the point where they
empty into the inferior vena cava.
This is an anterior
view of the liver. You
should identify the:
•right lobe
•cut edge of the
falciform ligament
•left lobe
•diverging cut edges
of the superior part
of the coronary
ligament
•fundus of the gall
bladder
This an image of the visceral surface of the liver. Make sure you
can orient yourself properly. Check out to see where the fundus
of the gall bladder is located. Identify the following structures:
.right lobe
.fundus of the gall bladder
.cystic duct
.portal vein
.hepatic arteries
.common bile duct
.quadrate lobe
.ligamentum teres
.left lobe
.ligamentum venosum and its groove
.caudate lobe
.groove for the inferior vena cava and the cut hepatic veins within
it
.porta hepatis outline in yellow. The area where the arteries,
ducts and portal vein enter and leave the liver.
Finally we take a look at the superior aspect of the liver.
This part of the liver is separated from the heart by the
domes of the diaphragm. In this image, the anterior
(diaphragmatic) surface of the liver is upward and the
visceral surface is downward on the page. This aspect
allows you to identify the:
.right lobe
.cut edge of the falciform ligament
.the cut edges of the superior and inferior parts of the
coronary ligament
.the left triangular ligament
.the right triangular ligament
.bare area of the liver (where there is no peritoneum
covering the liver
.groove for the inferior vena cava and the hepatic einvs
.caudate lobe of the liver more or less wrapping around the
groove of the inferior vena cava
Separation of the four lobes
of the liver:
•right sagittal fossa - groove
for inferior vena cava and
gall bladder
•left sagittal fissure -
contains the ligamentum
venosum and round
ligament of liver
•transverse fissure (also
porta hepatis) - bile ducts,
portal vein, hepatic arteries

Relationship of the visceral

aspect of the liver to other
abdominal viscera.
 Biliary System
• The biliary system is made up of the ducts arising in the liver,
the gall bladder and its duct and the common bile duct. Starting
in the liver, the small biliary ducts converge to form the larger
right and left hepatic ducts. These, in turn, join to form the
common hepatic duct which joins with the cystic duct to form
the common bile duct. Remember, when we studied the
duodenum, that the common bile duct joins the major
pancreatic duct to empty into the ampulla which then empties
into the second part (descending part) of the duodenum.
The gall bladder receives bile from the liver by way of the
common hepatic duct into the cystic duct. The gall bladder
stores and concentrates its contents and also excretes its bile
back through the cystic duct to join the common hepatic duct to
become the common bile duct which then carries the bile into
the duodenum.
The location of the tip of the fundus can be approximated on the
surface of the abdomen at the point where the lateral edge of
the rectus abdominis crosses the cartilage of the 9th rib.
.Clinical Considerations
Cirrhosis of the liver is the result of atrophy of
the liver parenchyma and a hypertrophy of the
connective tissue. Over time, there will be
jaundice and portal hypertension.
.Jaundice is an accumulation of bile pigment in
the blood stream. This is frequently a result of
obstruction of the duct system.
.The liver is frequently a site for secondary
metastasis of cancer from almost any part of the
body because of its great vascularity.
 List of Items to Know
• Liver Celiac Trunk
• right lobe
• left lobe
• quadrate lobe .common hepatic artery
• caudate lobe
• falciform ligament .proper hepatic artery
– ligamentum teres of liver .left hepatic
• coronary ligament .right hepatic
– right triangular ligament
– left triangular ligament
.cystic artery
• porta hepatis
– common hepatic duct
– portal vein
– proper hepatic artery
• left hepatic
• right hepatic
– cystic
– gall bladder
• fundus
• cystic duct
– ligamentum venosum or
groove for the ligament
 Pancreas
• The pancreas has two functions:
• 1. digestive - produces digestive enzymes
• 2. hormonal - islets of Langerhans
produce insulin needed to control blood
sugar levels
Parts and relations
1. Head
.lies within the curve of the duodenum
.uncinate process is a prolongation of the head. The superior
mesenteric artery and vein crosses this process.
2. uncinate process
.the part of the head that wraps behind the superior mesenteric
artery and vein and comes to lie adjacent to the ascending part of
the duodenum.
3. Neck
.a constricted portion to the left of the head. It abuts the pylorus
above and the beginning of the portal vein behind.
4. Body
.anterior surface separated from the stomach by the omental
bursa
.posteriorly related to the aorta, splenic vein, left kidney and renal
vessels, left suprarenal, origin of superior mesenteric artery and
crura of diaphragm.
5. Tail
.extends into the lienorenal ligament and abuts the spleen.
Dorsal Aspect of the Pancreas and
its Ducts
• When the pancreas and duodenum are
flipped over and the pancreas dissected,
you will be able to identify the ducts of the
pancreatic system. In order to see the
complete system, you must open the
descending part of the duodenum.
Identify the following:
. major pancreatic duct of Wirsung
. accessory pancreatic duct of Santorini
. common bile duct
. major duodenal papilla
. minor duodenal papilla
Note that the major pancreatic duct merges with the
common bile duct to form a swelling in the duodenal
wall called the ampulla (of Vater). The muscular wall of
the ampulla may be thickened, forming the sphincter of
Oddi. This ampulla then empties into the descending
part of the duodenum at the major duodenal papilla.
There may not be an accessory pancreatic duct but if
there is, its opening is located a couple of centimeters
above the major papilla at the minor duodenal papilla.
 Blood Supply of Pancreas
• Arteries
• small branches from the splenic
• superior pancreaticoduodenal - from the
gastroduodenal
• inferior pancreaticoduodenal - from the superior
mesenteric
• Veins
• splenic vein to portal vein
• superior mesenteric vein which then becomes
the portal vein
Clinical Considerations

.hypertrophy of the head may cause portal or bile

duct obstruction
.degeneration of the islets of Langerhans leads to
diabetes mellitus
.pancreatitis is a serious inflammatory condition of
the exocrine pancreas
.cancer of the head of the pancreas is many time a
fatal pathology