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THE ABDOMINAL WALL
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Abdominal wall
The abdomen is a roughly cylindrical chamber extending from
the inferior margin of the thorax to the superior margin of the
pelvis and the lower limb
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The nine regions of abdominal wall
b. Epigastric region
d. Umbilical region
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• In the clinical practice the abdomen is divided in to four
quadrants by two perpendicular lines bisecting at the
umbilicus.
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At the ends of these lines following four important regions of the
abdominal wall also known.
a. Epigastrium
b. Rt & lt flanks
c. Pubis
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The abdominal wall consists of different layers of
tissues
Subcutaneous tissue
Extraperitoneal tissue
Peritoneum
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Superficial Fascia
• superficial layer(Camper's fascia):
In men, continues over the penis and, after losing its fat and fusing
with the deeper layer of superficial fascia, continues into the scrotum
where it forms a specialized fascial layer containing smooth muscle
fibers (the dartos fascia)
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Neurovascular structures of of the anterior abdominal wall
Arteries
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• Veins - share similar name with the arteries, in addition to
which there are unaccompanied paraumbilical vein and
thoracoepigastric veins.
• Lymphatic drainage
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Anterolateral Abdominal wall muscles
There are five muscles :
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1. External oblique muscle
5. pyramidalis 20
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Muscle Origin Insertion Innervation Function
External oblique Muscular slips from Lateral lip of iliac Anterior rami of lower Compress abdominal
the outer surfaces of crest; aponeurosis six thoracic spinal contents; both
the lower eight ribs ending in midline nerves (T7 to T12) muscles flex trunk;
(ribs V to XII) raphe (linea alba) each muscle bends
trunk to same side,
turning anterior part of
abdomen to opposite
side
Internal oblique Thoracolumbar fascia; Inferior border of the Anterior rami of lower Compress abdominal
iliac crest between lower three or four six thoracic spinal contents; both
origins of external and ribs; aponeurosis nerves (T7 to T12) muscles flex trunk;
transversus; lateral ending in linea alba; and L1 each muscle bends
two-thirds of inguinal pubic crest and trunk and turns
ligament pectineal line anterior part of
abdomen to same
side
Transversus Thoracolumbar fascia; Aponeurosis ending in Anterior rami of lower Compress abdominal
abdominis medial lip of iliac crest; linea alba; pubic crest six thoracic spinal contents
lateral one-third of and pectineal line nerves (T7 to T12)
inguinal ligament; and L1
costal cartilages lower
six ribs (ribs VII to XII)
Rectus abdominis Pubic crest, pubic Costal cartilages of Anterior rami of lower Compress abdominal
tubercle, and pubic ribs V to VII; xiphoid seven thoracic spinal contents; flex vertebral
symphysis process nerves (T7 to T12) column; tense
abdominal wall
Pyramidalis Front of pubis and Into linea alba Anterior ramus of T12 Tenses the linea alba
pubic symphysis 22
• The fibres of internal oblique and external oblique
muscles take different orientations above the ASIS,
but below that they run parallel to each other.
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• The 1st tendinous intersection lies at the level of the 8th rib,
the 3rd at the level of the umbilicus
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Contents of the rectus sheath:
2. Pyramidalis muscle
6. Lymphatic vessels
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Deep fascia of the abdominal wall
• Superficial, intermediate, and deep layers of investing
fascia cover the external aspects of the three muscle
layers
The internal aspect of the abdominal wall is lined with
endoabdominal (Transversalis)fascia
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Umbilicus
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• Before the time of birth, because the ring is open, some
segments of the intestine protrude through it, this is
called physiological umbilical hernia
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Internal Surface of Anterolateral
Abdominal Wall
• The infraumbilical part of this surface exhibits five
peritoneal folds
The median umbilical fold extends from the apex of the
urinary bladder to the umbilicus and covers the median
umbilical ligament, a fibrous remnant of the urachus
Two medial umbilical folds, lateral to the median
umbilical fold, cover the medial umbilical ligaments,
formed by occluded parts of the umbilical arteries
• Two lateral umbilical folds, lateral to the medial umbilical
folds, cover the inferior epigastric vessels and therefore
bleed if cut 35
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Inguinal canal
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• Contents of the inguinal canal:
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Spermatic cord
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Contents of the spermatic cord
1. Ductus deferens
3. Testicular artery
8. Lymphatic vessels
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Inguinal hernia
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A. Direct inguinal hernia
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- Bulging occurs medial to inferior epigastric vessels in the
inguinal triangle bounded by:
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B. Indirect inguinal hernia
- enters the inguinal canal through the deep inguinal ring that lies in
the lateral inguinal fossa and leaves the canal through the
superficial inguinal ring to extend to the scrotum or labia majora
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Other hernias of the abdominal wall
• Epigastric hernia
• Umbilical hernia
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- if it occurs in infants and small children it is the herniation of
the peritoneum and some abdominal contents through the
umbilicus due to the weakness of the umbilical scar.
• Femoral hernia
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• Paraumbilical hernia
• Interstitial hernia
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• Spigelian hernia
• Incisional hernia
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ABDOMINAL CAVITY
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The Abdominal cavity
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4. Endocrine glands (suprarenal, ovaries)
5. Autonomic plexuses
1. Peritoneal cavity
2. Retroperitoneal space
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Peritoneum
• The peritoneum is a smooth glistening, serous membrane
that lines the abdominal wall and covers the outer
surfaces of some abdominal organs.
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1. Some organs are called intraperitoneal organs e.g. liver,
stomach, spleen, superior part of the duodenum, jejunum,
ileum transverse colon and sigmoid colon
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2. Some organs like the kidneys, ureters, abdominal aorta,
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3. Other organs originally develop with in the peritoneum
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Clinical significance of the peritoneum
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• This excessive accumulation of fluid in the peritoneal
cavity is known as Ascites.
• Ascitic fluid can be removed by puncturing (taping) the
anterior abdominal wall (abdominal paracentesis)
– This is done above the emptied bladder, half way
between the pubic symphysis and the umbilicus or
– lateral to the epigastric vessels at a point lying
between the upper 2/3 and the lower 1/3 of a line
joining the left ASIS
• This point lies at the lateral border of the rectus abdominis
muscle
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Innervations of the peritoneum
• Parietal peritoneum
1. Supplied by sensory & vasomotor nerves of the adjacent
body wall
2.The subdiaphragmatic part is innervated by the phrenic
nerve
3. Sensitive to oain and touch
Visceral peritoneum
1. Sensitive to distension and chemical irritation
2. Insensetive to touch, laceration or pain
3. innervated by autonomic visceral nerves of associated organs 66
Peritoneal folds
• These folds bind the organs together and to the wall of the
abdominal cavity and contain blood vessels and nerves
that supply the respective organs.
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• These peritoneal reflections between the organs or between the
body wall and the organs are termed as ligaments.
E.g. 1. Hepatogastric ligament
2. Hepatoduodenal ligament
They form the lesser omentum that suspends the
stomach and duodenum from the liver)
3. Gastrocolic lig.
4. Gastrolienal (Gastrosplenic) lig.
5. Lienorenal (splenorenal) lig.
6. Gastrophrenic lig.
7. Falciform ligament
8. Umbilical folds or ligaments
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• A broad reflection of peritoneum that attaches the stomach to the
neighbouring organs is called Omentum and is divided in to two
parts.
• The stomach is a muscular bag forming the widest & most dilated
part of the alimentary canal.
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• Size - it is a very distensible organ with a maximum length
of about 25 cm and a maximum breadth of about 14 cms.
~ 30 ml at birth
~ 1 L at puberty
~ 2 L or more in adults.
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PARTS OF THE STOMACH
A. stomach has four part:
1. Cardia - adjacent to the esophagogastric junction found at the level
of T10-11
2. Fundus - above the entrance of the oesophagus and usually
contains 50 ml of swallowed air.
3. Body - between the fundus and the
pyloric part
4. Pylorus - between the body and1st part of the duodenum
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B. There are two curvatures of the stomach
1. Greater - convex
2. Lesser - concave
1. Posterior
2. Anterior
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D. The stomach has also two openings:
1.Cardiac opening
- the cardiac orifice lies about 3 cms to the left of and below
the xiphoid process .
- is fixed
2. Pyloric opening
- the pyloric part of the stomach is movable.
- surrounded by the pyloric sphincter, the circular fibres of
which may be congenitally thickened, a condition known
as infantile (congenital) hypertrophic pyloric stenosis
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• infantile (congenital) hypertrophic pyloric stenosis
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Relations of the stomach
Peritoneal relation
• lined on both sides i.e both anteriorly & posteriorly by
peritoneum.
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Structure of the stomach
• Like all parts of the GIT, the wall of the stomach consists
of 4 layers: mucosa, submucosa, muscularis and serosa.
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• There are parallel longitudinal folds of the mucosa along
the lesser curvature extending from the region of the
oesophagogastric junction in the direction of the pylorus.
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Blood vessels of the stomach
A. Arteries
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• Those along its great curvature are:
Right gastroepiploic artery (from gastroduodenal artery)
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B. Veins of the stomach
Right & left gastric vein - directly drains into the portal
vein
Prepyloric vein - drains into the right gastric vein
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• Veins along the greater curvature:
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• Portal vein also form anastomosis with veins of the
neighbouring organs connecting the portal vein to the
systemic circulation, which is important for
portosystemic circulation during portal hypertension
E.g.
• The regional lymph nodes lie along the arteries and are named
accordingly.
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• The proximal part of the stomach drains in to the short
gastric, splenic and left gastroepiploic lymph nodes.
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Innervations of the stomach
• Sympathetic innervation – from sympatheric trunk
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Function
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PARTS & LENGTH
• It is divided in to 3 segments:
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• The small intestine measures about 2.5 cm in diameter and
about 6.35m (5-8m) in length.
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Duodenum
• The shortest, widest & most fixed part of the small intestine.
• Has a shape like the letter “C“ the concavity of which encloses the
head of the pancreas.
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• Lies above the umbilicus at the level of L1- L3 vertebra.
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• The bile duct and the main pancreatic duct usually open
together in to the greater duodenal papilla (about 8 -10cms
from the pylorus)
• In most of the cases the bile and pancreatic ducts unite and form
a short hepatopancreatic ampulla (ampulla of Vater), which
opens into the duodenum at the greater duodenal papilla being
controlled by the hepatopancreatic sphincter (sphincter of Odi)
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• In case the accessory pancreatic duct (duct of Santorini)
persists, it opens into the duodenum at the lesser (minor)
duodenal papilla which is found on the anteromedial aspect of
the second part of the duodenum about 2 cm above the greater
papilla.
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Blood vessels of the duodenum
A. Arteries
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Jejunum and Ileum
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Mesentry
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Blood vessels of the jejunum & ileum
3. Lymphatic
- the lymph from the jejunum and ileum flows into the
lymphatic vessels accompanying the blood vessels and is
drained into the superior mesenteric lymph nodes.
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Structure of the small intestine
• The luminal surface of the small intestine is composed of a
series of parallel folds that run in a circular manner
• These folds are known as plicae circulares or valves of
Kerckring or semilunar folds.
• Unlike the rugae of the stomach the folds cannot be flattened
by distension.
• Such folds are absent in the upper part of the duodenum and
most part of the ileum.
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• The large intestine has a length of 1.2 -1.5m.
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Structure of the large intestine
• Except for the rectum and anal canal the mucosa of the large
intestine is characterised by goblet cells, glands and
absorptive cells.
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2. Teniae coli - three band like thickenings of the outer
longitudinal layer of the muscularis externa (about 1cm
in width).
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3. Haustrations (Sacculations)
- the teniae are shorter than the intestine itself and lead
directly to the root of the appendix.
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Large Intestine - Unique Features
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• Abnormal out-pocketings of the wall sometimes appear
between the teniae in the form of diverticula.
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Caecum
• Is the beginning part of the large intestine that joins the ileum.
• It is one of those organs of the body that have greater width than
length
- the ileocaecal artery gives two branches that supply the caecum.
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Vermiform Appendix
• Is a small diverticulum of the caecum.
• Is about 9-10 cms long but its length can vary between 2-20
cms; and is about 0.5-1 cm wide.
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• It contains no sacculations, no appendices epiplocae and no teniae
coli.
• The appendix also gets additional arterial supply from the caecal
arteries.
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0.5%
1%
64%
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• The inflammation of the appendix is called appendicitis
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Ascending colon
• The ascending colon extends from the caecum in the right ileac fossa
to the right colic flexure or hepatic flexure and measures about 25
cms in length.
• It is secondarily retroperitoneal.
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Transverse colon
• The transverse colon extends from the right colic (hepatic)
flexure to the left colic (splenic) flexure measuring about 50 cms.
• Developmentally its right 2/3 is derived from the midgut and its
left 1/3 from hindgut.
• - its right 2/3 is supplied by the middle colic artery, which is from
superior mesenteric artery, while its left 1/3 is supplied by left
colic artery from inferior mesenteric artery
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Descending colon
• The descending colon, with a length of 25 cms, extends from the
left colic flexure to the pelvic brim where the sigmoid colon
begins.
• It is secondarily retroperitoneal
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Sigmoid (pelvic) colon
• The sigmoid colon extends from the left sacroiliac joint at the
pelvic brim to the level of the 3rd sacral vertebra in the pelvis,
where it becomes continuous with the rectum.
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• It has a mesosigmoid that has an inverted V-shaped and attaches
it to the posterior abdominal wall, pelvic brim and front part of
the sacrum.
• Blood supply
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Rectum
• The rectum is a retroperitoneal segment, which is covered by
peritoneum only anteriorly in its upper part.
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• Three sharp lateral flexures of the rectum (superior and
inferior on the left side, and intermediate on the right)
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Anal canal
• The anal canal extends from the pelvic diaphragm to the anus.
• It has a length of about 3cm, but its length from the pectinate line
to the anus is 1.5 cm.
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• The external longitudinal and internal circular layers of its
muscularis are continuations from the rectum, but the fibres
of the levator ani muscle join the longitudinal layer and
form a conjoined longitudinal muscle, which is a
combination of smooth and skeletal muscle fibres.
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• The external anal sphincter, a striated muscle that encircles
the lower part of the anal canal, consists of three parts:
1. subcutaneous part,
3. deep part.
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• The anal mucosa is divided into 3 zones.
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1. The columnar zone:
- The lower ends of the anal columns are joined together by small
crescent shape folds of the mucosa, the anal valve
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• The serrated edges of the anal valves form the so-called
pectinate (dentate) line.
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Pancreas
• The pancreas is a soft, tadpole-shaped gland
• It extends across the posterior abdominal wall from
the duodenum, on the right, to the spleen, on the
left.
• The pancreas is retroperitoneal and lies deep
to the greater curvature of stomach between
duodenum and spleen
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Pancreas
• mixed gland, both exocrine and endocrine
– Exocrine portion forms the bulk of the gland and secretes enzyme
rich fluid
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Blood supply and innervation
• Vessels
– Pancreatic arteries from splenic artery
– Pancreaticoduodenal arteries from superior
mesenteric artery
– Pancreatic veins drain to splenic and superior
mesenteric veins
• Nerves
– From vagus and abdominalpelvic splanchnic nerves
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Spleen
• In the adult, the spleen lies against the diaphragm, in
the area of rib T9-T11.
• Veins
– Venous drainage from the spleen flows via the splenic vein
• Lymphatic
– pass along the splenic vessels to the pancreaticosplenic
lymph nodes en route to the celiac nodes
• The nerves of the spleen, derived from the celiac plexus
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The Liver and Gallbladder
• The liver and gallbladder are accessory organs
associated with the small intestine
• Liver Functions
– Detoxification
– Synthesis of bile
– Synthesis of plasma proteins
– Metabolic activities
• The gallbladder is a storage site for bile
177
The Liver: gross anatomy
• The reddish, blood rich liver is the largest
gland in the body weighing about 1.5 kg
in the average adult
• Above the liver is the diaphragm, to its left is
the stomach and below is the transverse
colon and right colic flexure
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The Liver: gross anatomy
• Shaped like a wedge, it occupies most of the
right hypochondriac and epigastric regions
extending farther to the right of the body
midline than the left
• Located under the diaphragm, the liver lies almost
entirely within the rib cage
• The location of the liver within the rib cage offers this
organ some degree of protection
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The Liver: gross anatomy
• The liver has four lobes; right, left, caudate
and quadrate
• Falciform ligament separates the right and left
lobes anteriorly and suspends the liver from
the diaphragm and anterior abdominal wall
– Running along the free inferior edge of the
falciform ligament is the ligamentum teres,
a remnant of the fetal umbilical vein
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The Liver: gross anatomy
• Except for the superiormost liver area,
which is fused to the diaphragm, the
entire liver is enclosed by a serosa
(visceral peritoneum)
• The lesser omentum, anchors the liver to
the lesser curvature of the stomach
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The Liver: gross anatomy
• The bile duct, hepatic artery and portal
vein, enter the liver at the porta hepatis
• External surface is invested by thin
collagenous capsule=Glisson’s capsule
– Thick at hilum, surround vessels and ducts to
interior
– Fine meshwork of reticular fibers radiate from
this to support liver cells
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The Liver: Microscopic Anatomy
• Liver lobule
– Liver parenchymal cells (hepatocytes) are arranged into
lobules
• structural & functional units called liver lobules
– around one million liver lobules
– Each lobule is roughly hexagonal in shape
– Bounded by thin septa of collagenous tissue
– Angle of lobule are portal tracts (triad)
• Terminal braches of portal vein and hepatic artery and
bile duct
– Center of lobule is a centrolobular venule (central vein)
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The Liver: Microscopic Anatomy
• Liver parenchyma
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The Liver Lobule
• blood comes from the hepatic artery (20%) and
portal vein (80%)
– The hepatic artery supplies oxygen rich arterial blood
to the liver
– The hepatic vein carries blood laden with nutrients
from the digestive viscera
• A bile duct carry secreted bile toward the
common bile duct and ultimately to the
duodenum
• Inside the sinusoids are star shaped hepatic
macrophages, also called Kupffer cells
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Portal vein, hepatic artery,
hepatic veins and bile duct
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Liver regeneration
• Liver cells have extraordinary capacity for
regeneration
• Loss of hepatic tissue triggers cell division and
restore original mass
• Regenerated tissue is similar to the removed
but if there is repeated damage, regeneration
and production of connective tissue occurs
simultaneously which results in
disorganization of liver structure=cirrhosis
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The Gallbladder
• The gallbladder is a thin-walled, green
muscular sac
• Pear-shaped muscular sac
• Store and concentrate bile
• ~10cm long
• It snuggles in a shallow fossa on the
posteroinferior surface of the liver
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The Gallbladder
• Expels bile when acidic chyme enters the
duodenum or as a result of cholecystokinin
release
• When empty, its mucosa adopts the ridge like
folds or rugae
• Its muscular walls can contract to expel its
contents into the cystic duct which then flows
into the bile duct
• Like most of the liver it is covered by visceral
peritoneum
197
The Gallbladder
• When digestion is not occurring, the
hepatopancreatic sphincter is tightly closed
• Bile then backs up the cystic duct into the gallbladder
where it is stored until needed
198
Gall bladder: microscopic anatomy
• Mucosa
– In non distended state is thrown into many folds
– Lined by simple columnar epithelium
• Submucosa
– Loose, rich in elastic fibers, blood and lymph vessels
• Muscular layer
– Thin, fibers are disposed obliquely
– In neck region, epithelium invaginate and form mucous glands
• Serosa/adventitia
– Binds superior surface to liver (adventitia)
– Opposite surface is lined by serosa (peritoneum)
• Cystic duct
– Wall formed into twisted mucosa covered folds=spiral valve of
Heister
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Blood supply
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