The abdomen liyingchd163 com Department of anatomy and

The abdomen Ⅲ liyingchd@163. com Department of anatomy and neurobiology O: 65985626

Go over peritoneum and esophagus Stomach & duodenum : parts, position , arteries , ligaments , Liver and biliary ducts

Greater omentum & Lesser omentum Hepato-gastric ligament Hepato -duodenal ligament Gastro-phrenic ligament Gastro-splenic ligament Gastro-colic ligament

Omental (epiploic)foramen The omental bursa communicates with the greater sac only through the (epiploic) omental foramen. The boundary: Anteriorly --- the hepatoduodenal ligament, Posteriorly---IVC & the right crus of diaphragm Superiorly--- liver Inferiorly --- 1 st part of the duodenum

Digestive system Digestive tube Mouth Pharynx Esophagus Stomach Small Duodenum intestine Jejunum Ileum Large intestine Cecum ， Vermiform appendix , Colon , rectum, Anal canal

Digestive glands • Major salivary glands • Liver • Pancreas Function: Ingestion - selective intake of food. Digestion – mechanical and chemical breakdown of food into a form the body can use. Absorption – uptake of nutrients into blood and lymph. Compaction – absorption of water and consolidation of wastes into fecal mass. Defecation – the elimination of the fecal mass.

Esophagus （position and division three parts: Cervical parts： 5 cm; Thoracic parts: 18 -20 cm; Abdominal parts : only 1 -2 cm. 3 constrictions of the esophagus: : narrows position distance from middle inscior first beginning second in front of left branchus third esophageal hiatus 15 cm 25 cm 40 cm 7

Ⅱ. Three constrictions ß ß ß beginning, lies at level of C 6, the narrowest part crossed by left main bronchus, 25 cm from incisors, lies at level of intervertebral disc between T 4 and T 5. passes through the esophageal hiatus of diaphragm, 40 cm from incisors, at level of T 10 Carcinoma of esophagus

stomach Shape: Location: digestion gastric juice---chyme Peristalsis Enzymatic digestion PH: 2

Peristaltic movement ring-like movements of esophagus - contracting then relaxing to move food downward. Z-line: at the junction

Two wall Anterior wall Cardial notch Posterior wall Two curvature Lesser curvature Greater curvature 4 parts: cardia fundus Cardia Pyloric canal Lesser curvature angula notch body pyloric part— Pyloric canal and Pyloric antrum Greater curvature 11 Pyloric antrum

Relations of the stomach ß ß Anteriorly: Þ Live (right part) Þ Diaphragm (left upper part) Þ Anterior abdominal wall (left lower part) Posteriorly－separated by peritoneum of lesser sac from the following (“stomachbed”) Þ Pancreas Þ Left suprarenal gland Þ Left kidney Þ Spleen Þ Transverse colon and transverse mesocolon

Abdominal Aorta and branches

Celiac trunk Left branch Right branch Cystic a. Common hepatic a. Left gastric a. Short gastric a. Splenic a. Right gastric a. Proper hepatic a. Gastroduodenal a. Splenic branches Left gastroepiploic a. Right gastroepiploic a. Superior pancreaticoduodenal a.

Arteries of stomach ß Left and right gastric arteries Þ Þ Arise from celiac trunk and proper hepatic artery, respectively. These two vessels run in lesser omentum along lesser curvature , and anastomose end-to-end.

Arteries of stomach ß Right and left gastroomental arteries Þ Þ Arise from the gastroduodenal and splenic artery. These two vessels pass into the greater omentum, run parallel to the greater curvature, and anastomose end-to-end.

Arteries of stomach ß Short gastric arteries Þ Þ Þ ß Branches of splenic artery through the gastrosplenic ligament Supply the fundus of stomach. Posterior gastric artery (72%) Þ Þ Arise from the splenic artery through the gastrophrenic ligament and supply the posterior wall of fundus of stomach.

Venous drainage of stomach ß ß ß Right and left gastric veins empty directly into hepatic portal vein. Left gastroepiploic and short gastric veins drain into hepatic portal vein via the splenic vein. Right gastroepiploic vein drain into superior mesenteric vein.

Lymph drainage of stomach ß Accompany the A. along the 2 curvatures Right and left gastric LN ß Right and left gastroomental LN drain into ß pancreaticosplenic , ß pyloric LN, pancreaticoduodenal LN finally to the celiac LN. lymphatic metastasis ß

Nerve supply of stomach ß Parasympathetic innervation The left vagus N→The anterior vagal trunk → anterior gastric hepatic branches Þ Þ Þ ß The right vagus N → The posterior vagal trunk → posterior gastric celiac branches “crow’s foot” → supply the pyloric part Sympathetic innervation Þ Þ Mainly from celiac plexus Afferent and efferent fibers derives from thoracic segments (T 5 －L 1)

l Lie anterior to vertebral column and near the arteries ß ß ß Celiac ganglion and plexus Superior mesenteric ganglion and plexus

gastrectomy 1. BillrothⅠ 1881 1. Billroth Ⅰ Ⅰ ： 1885 Laparoyomy : Laparoscopy : Paracentesis:

Question 2 1. What are the four parts, five ligaments and arterial supply of the stomach? 2. What’s the bed of stomach? 3. The lesser omentum is divided into _____ and ________ ligaments. 4. The _____ foramen connects the omental bursa with the peritonial cavity( the great sac). 5. The _____ recess (pouch of morison) is the lowest point of the peritoneal cavity in a supine patient.

If you do not learn to think when you are young, you may never learn. ---Thomas Edison

The liver Wedge-shaped, largest single organ , 1, 500 g, Function : 1. The largest metabolic organ , nutrients absorbed from the digestive tract are initially conveyed to the liver by the portal vein; 2. The largest gland , secrete bile---yellowish , brown fluid aids in the emulsification of fat; 3. The pirimary site for detoxification; 4. The large lymph-producing organ, 5. produce RBC prenatally.

Liver ß ★ Position Þ Þ Most lies in the right hypochondrium and epigastric region less part extends into the left hypochondrium

Liver ★ Surface projection Upper border the right midclavicular line -- 5 th rib process Lower border the right lobe extends just beneath the costal margin, median line , lower border crosses a point about 3~5 cm below the xiphoid In children, larger, extends below the costal arch within in 2 cm

Liver ß Diaphragmatic surface Þ Þ Convex and smooth Divided into right and left lobes by falciform lig. superiorly Þ coronary lig. of liver Þ Bare area ：Posteriorly

Visceral surface of liver left lobe right lobe caudate lobe quadrate lobe Caudate lobe left lobe Quadrate lobe 31 Right lobe

Liver ß ★ Visceral surface Covered with peritoneum, H-shaped fissures and grooves ß Anterior (inferior) border –thin and sharp Þ Þ Notch for gallbladder Notch for ligamentum teres hepatis (round ligament of liver)

Liver 1. Left sagittal fissure Anteriorly fissure for round ligament (remnant of umbilical V ) Posteriorly fissure for ligamentum venosum (remnant of Ductus venosus) 2. Right sagittal fissure Anteriorly � fossa for gallbladder Posteriorly � Sulcus for IVC (inferior vena cava

Liver ★ transverse fissure --Porta hepatis 5 cm long, transversely across the under surface of the liver, Þ Contents � Right and left hepatic ducts � Left and right branches of proper hepatic artery � Left and right branches of hepatic portal vein � Nerves and lymphatic vessels Þ These structures are surrounded by connective tissue and called “hepatic pedicle”

vessels of liver(4) Blood supply of liver: 1. proper hepatic artery( ← hepatic A←celiac trunk) 2. hepatic portal vein A dual supply, the venous supply for 75%(dominant) , The arterial supply account for 25%(lesser) ß

Hepatic portal vein General features ß the union of superior mesenteric vein SMV and splenic vein ß passing through the lesser omentum to the porta hepatis, divides into right and left branches ß Has no valves in hepatic portal system ß Drains blood from GI tract from the lower end of oesophagus to the upper end of anal canal, pancreas, gall bladder, bile ducts and spleen

2. Hepatic portal vein Tributaries of hepatic portal v. 1. Superior mesenteric v. SMV 2. Inferior mesenteric v. IMV 3. Splenic v. 4. Left gastric v. 5. Right gastric v. 6. Cystic v. 7. Paraumbilical v.

Portal- Caval venous anastomoses 1. Site at the esophagus left gastric vein → esophageal venous plexus → esophageal vein → hemiazygos vein → superior vena cava Esophageal varices, ---bleeding 2. At rectum splenic vein → inferior mesenteric vein → superior rectal vein → rectal venous plexus → inferior rectal and anal veins → internal iliac vein → inferior vena cava Hemorroid ---Hemorrage Portal hypertension ß

Portal- Caval venous anastomoses 3. At paraumbilical venous rete paraumbilical vein→periumbilical venous rete→ thoracoepigastric and superior epigastric vein →intercostal vein--- superior vena cava Caput medusa 4. retroperitoneal anastomosis the retroperitoneal branches of the colic veins pancreaticoduodenal veins -----the lumbar veins, , twigs of colic veins (portal) anastomosing with systemic retroperitoneal veins Intestinal bleeding pancreaticoduodenal veins

3 Intrahepatic bile duct

Ø 4 hepatic veins

Liver ß The segments of the liver Þ Þ The segments of the liver, bases upon the principal divisions of the proper hepatic artery and accompanying hepatic ducts and hepatic portal vein－Glisson system. The hepatic vein do not follow the same pattern : their main tributaries tend to run rather intersegmental of the three ducts.

ß Couinaud segments 8 by controversial

Peritoneal Relations of the Liver The falciform ligament attaches the liver to the anterior abdominal wall Coronary ligaments attach the liver to the diaphragm

Peritoneal relations of the liver -Bare area -Subphrenic recess Subhepatic space

Ligaments of liver ß Falciform ligament of liver Þ from anterior abdominal wall (umbilicus) to liver Þ Free border contains round ligament of liver Þ Þ Coronary ligament Left and right triangular ligaments －formed by left and right extremity of coronary ligament

ß ß ß Hepatorenal recess －lies between the right lobe of liver, right kidney, and right colic flexure, and is the lowest parts of the peritoneal cavity in supine position Morrison ‘s pouch

Hepatorenal recess Paracolic gutters are formed by the ascending and descending colons

Transplantation of liver 1 2 Cirrhosis (or cancer )of liver 3

Relations of liver ß Diaphragmatic surface －separated by diaphragm from the following Þ Right costodiaphramatic recess and lung Þ Cardiac base ß Visceral surface Þ Þ Left lobe is related to the stomach and abdominal part of esophagus Right lobe is related to the right colic flexure anterioly, gallbladder and superior duodenal flexure medially, right kidney, superarenal gland posteriorly

★ Biliary duct and gallbladder ß ★ Consists of Þ Þ Gallbladder, Left and right hepatic ducts Common hepatic duct Common bile duct

★ Gallbladder ß ß ★ Position Þ Lies in fossa for gallbladder on visceral surface of liver ★ Four parts 1. Fundus of gallbladder protrude below the inferior margin of the liver, behind the point where the lateral margin of the right rectus abdominis meets the costal arch(Murphy ’ point). ß 2. Body of gallbladder 3. Neck of gallbladder 4. Cystic duct Function: stores and concentrates bile

★ Biliary duct system ß ß ß Left and right hepatic ducts unite outside of liver to form common hepatic duct Cystic duct joins common hepatic duct to form common bile duct

★ Biliary duct system ß Hepatopancreatic ampulla (Vater) Þ Common bile duct and pancreatic duct run obliquely through the wall of the descending part of duodenum , unite to form the hepatopancreatic ampulla --- rounded by sphincter of hepatopancreatic ampulla (Oddi), has sphincteric for regulating flow, opens at the major duodenal papilla Obstruction of the biliary system results in the clinic condition of jaundice (yellow skin).

Cystohepatic triangle Calot’s Triangle ß Boundaries Þ Þ Þ ß Common hepatic duct on the left Cystic duct on the right Liver superiorly Content: cystic artery

Divisions and relations of common bile duct Divisions ß ß Supraduodenal segment Retroduodenal segment Pancreatic segment Intraduodenal segment

★ Bile circulation Bile is secreted by the liver cells Common hepatic duct Biliary ductuli Cystic duct Right and left hepatic ducts Gallbladder (store, concentrate) When fat enters small intestine, gallbladder contracts, sphincter of hepatopancreatic ampulla relax Common bile duct Main Pancreatic duct the hepatopancreatic ampulla Major duodenal papilla Duodenal cavity

Magnetic resonance cholangiopancreatogram.

Pancreas ß Function Þ Þ Þ The pancreas is both an exocrine and an endocrine gland The exocrine portion of the gland produces a secretion that contains enzymes that are capable of hydrolyzing proteins, fats, and carbohydrates The endocrine portion of the gland, the pancreatic islet, produces the hormones insulin and glucagons that play a key role in carbohydrate metabolism

★ Pancreas ß Shape Þ ß A soft yellowish lobulated gland ★ Position Þ Þ Lies in epigastric and left hypochondriac regions, behind the peritoneum on the posterior abdominal wall, roughly at the level of of L 1~L 2

★ Pancreas ß ★ Four parts Þ Head--Lies within the C-shaped curvature of duodenum. � Uncinate process A projection to the left from the lower part of the head behind the superior mesenteric vessels. Þ Neck--narrow part, overlies the superior mesenteric vessels and beginning of the portal vein Þ Body--triangular in cross section, passes upward ang to the left across the midline Þ Tail--extends to the hilum of spleen in the splenorenal ligament

Pancreas ß Pancreatic duct Þ Main Pancreatic duct � Begins at tail and throughout gland � Joins common bile duct before entering descending part of duodenum at major duodenal papilla Þ Accessory pancreatic duct � When present, drains head of pancreas separately � Opens 2 cm above main duct at lesser duodenal papilla

Blood supply of pancreas ß Arteries 1. Mainly from splenic A 2. Superior pancreaticoduodenal a. (from gastroduodenal A) Þ Inferior pancreaticoduodenal a. (from SMA) ß Veins－ draining into superior mesenteric and splenic veins – potal vein.

CT scan of pancreas.

Vessels of pancreas 1, 2,

The Small Intestine ß ß About 5 -7 m long, Divided into Þ Þ Þ Duodenum Jejunum Ilium Duodenum Ilium 1. The major part of digestion occurs , extends from the pylorus to the ileocecal junction. 2. permanent circular folds and villi Jejunum

duodenum Features: 1. 25 cm long, the widest and fixed part of small intestine. 2. Pursue a C-shaped course around the head of pancreas. 3. Has 4 parts

Four parts Duodenum Superior part 1 st 5 cm, L 1 vertebrae Þ Superior duodednal flexure Descending part 2 nd 7~10 cm, L 2~3 Inferior part 3 rd 6~8 cm, L 3 to the left Ascending part 4 th Þ Þ duodenojejunal flexure Ligament of tretz

ß ß Suspensory muscle of duodenum (ligament of Treitz), is composed of a skeletal muscle from diaphragm, and a fibromuscular band of smooth muscle from the duodenum. a surgical landmark, descends from the right crus of diaphragm to duodenal termination.

duodenum superior part ß Anteriorly Þ Quadrate lobe of live Þ Gallbladder Duodenal cap (radiography ) 2 cm, intraperitoneal, mobile Site of duodenal ulcer

duodenum Relations of descending part ß ß Medially Þ Head of pancreas Þ Common bile duct and pancreatic duct Laterally Þ Right colic flexure 1. Major duodenal papilla(opening) Hepatopancreatic ampulla (Vater ampulla)--united of the bile and pancreatic ducts 2. Minor duodenal papilla

duodenum Relations of horizontal part ß Anteriorly Þ Root of mesentery Þ Superior mesenteric a. and v. ascending part Right — Head of pancreas and abdominal aorta Left — left kidney and ureter

Blood supply of duodenum ß Arteries Þ Þ ß Superior pancreaticoduodenal a. Inferior pancreaticoduodenal a. Veins－follow arteries, draining directly into superior mesenteric and hepatic portal veins ß Lymph drainadge follow the arteries to celiac LN ß Nerve innervation: superior mensenteric plexus celiac plex

Jejunum and ilium The jejunum and ileum lies free in the abdomen. They are attached to the posterior abdominal wall by the mesentery. Intraperitoneum 76

Jejunum and ileum jejunum is shorter , emptier, more vascular (redder in vivo), more thickly walled.

Jejunum and ileum Characteristic Jejunum Ileum Position Upper 2/5 Lower 3/5 caliber 2~4 cm 2~3 cm Wall Thicker and heavy Thin and light Circular folds Large, tall and large villi low，sparse, less abundant villi Vascularity Greater Less Colour Deeper red Paler vasas recta Arcades Fat in mensentery Long A few large loops less Short Many short loops more 78

Mesentery The mensentery - suspends the small intestine from the posterior abdominal wall -Broad and a fan-shaped; vasculature vessels are between the two layers of peritoneum. ß Root of mesentery Þ Þ 15 cm long Directly obliquely run from left side of L 2 to right sacroiliac joint

Middle colic a. Inf. pancreaticodudenal a. Right colic a. Ileocolic a. Appendicular a. Superior Mesenteric v. Superior mesenteric a. Jejunal and ileal a.

large intestine • Approximately 1. 5 m long, • Five parts: – Cecum – Vermiform appendix – Colon – Rectum – Anal Canal formation, transport, and evacuation of feces. the absorption of water and the secretion of mucus 81

Paracolic gutters are formed by the ascending and descending colons

Features of ： 1. Teniae coli: 3 longitudinal smooth muscles 2. haustra : sacculation 3. Omental appendices: small fatty projections haustra of colon Teniae coli omental appendices 83

（一）Cecum first part of large intestine, Lies in right iliac fossa. Free and has no mensentery--- mobile cecum n. The ileum enters the cecum obliquely, and partly invaginates into it, forming the ileocecal valve－consists of two folds. ileocec al valve 84

Appendix a blind diverticulum mesoappendix the base of appendix ： Lies deep to a point that 1/3 of the way along the oblique line joining the right anterior superior iliac spine to the umbilicus. (Mcburney’s point) n. The base of the appendix lies at the point of convergence of three teniae coli 85

（二）vermiform appendix is a narrow blind tube, usually 6 ~ 8 cm long. It opens into the cecum 。 position: very variable in position, frequently lies in the retrocecal recess or extend into the lesser pelvis. orifice appendix 86

colon 1、asccending colon 2、transverse colon 3、descending 4、sigmoid colon right colic flexure left colic flexure 87

Inferior mesenteric v. Inferior mesenteric a. Left colic a. Sigmoid a. Superior rectal a.

ß ß Hepatogastric ligament Hepatoduodenal ligament

Relations of common bile duct Supraduodenal segment ß ß ß Descends along the right margin of hepatoduodenal lig. To the right of proper hepatic a. Anterior to hepatic portal v. Retroduodenal segment ß ß ß Behind the superior part of duodenum Anterior to the vena cava To the right of the hepatic portal v.

Relations of common bile duct Pancreatic segment ß Lies in a groove between posterior surface of head of pancreas and duodenum Intraduodenal segment ß ß Enters the wall of descending part of duodenum obliquely where jions the pancreatic duct to form the hepatopancreatic ampulla Opens at the major duodenal papilla

spleen ß ß Diaphragmatic surface Visceral surface Þ Þ Þ Anteriorly－fundus of stomach Posteriorly－left suprarenal gland kidney Inferiorly－tail of pancreas and left colic flexure

Ligaments of spleen ß Gastrosplenic ligament －connects the fundus of stomach to hilum of spleen. the short gastric and left gastroepiploic vessels pass through it. n. Splenorenal ligament － extends between the hilum of spleen and left kidney. The splenic vessels tail of pancreas Phrenicosplenic ligament Splenocolic ligament

★You must identify follow structures！ Liver ß Falciform lig. of liver ß ligamentum teres hepatic(round ligament ) ß porta hepatis ß Coronary ligament ß Nothch for gallbladder Gallbladder ß Fundus of gallbladder ß Body of gallbladder ß Neck of gallbladder ß Cystic duct ß Right and left hepatic ducts ß Common hepatic duct ß Common bile duct Pancreas ß Head ß Uncinate process ß Neck ß Body ß Tail Peritoneum ß Lessor omentum ß Omental foramen ß Greater omentum ß Mesentery ß Mesoappendix ß Gastrosplenic ligament ß rectovesical pouch ß Rectouterine pouch ß Vesicouterine pouch

1. What is the extension of the root of the mesentery? 1. The mesentery extends about 15 cm downward and to the right from the duodenojejunal flexure to the ileocolic junction. The intestinal border is many times longer (6 or 7 m. ) than the root of the mesentery; hence the mesentery is pleated. 2 Where are the junctions between the foregut and midgut and between the midgut and hindgut? The foregut-midgut and celiac-superior mesenteric junction is at the middle of the duodenum, superior to the major duodenal orifice. The midgut-hindgut and superior-inferior mesenteric junction is near the left end of the transverse colon. 3. How is the liver maintained in position? The liver is maintained in position by being (1) joined to the posterior abdominal wall by veins (hepatic and caval) and ligaments (coronary and triangular), (2) supported inferiorly by viscera (e. g. , the right kidney and colic flexure), and (3) suspended by ligaments (falciform and teres)