Surgical Anatomy of the Spleen

1he spleen ls abouL Lhe slze of Lhe cupped hand lf forms Lhe lefL laLeral exLremlLy of
Lhe lesser sac asslng from lL are Lhe qosttospleolc llqomeot Lo Lhe greaLer curvaLure
of sLomach (carrylng Lhe shorL gasLrlc and lefL gasLroeplplolc vessels) and Lhe
lleooteool llqomeot Lo Lhe posLerlor abdomlnal wall (carrylng Lhe splenlc vessels and
Lall of Lhe pancreas)

ke|at|ons
-oster|or|y Lhe lefL dlaphragm separaLlng lL from Lhe pleura lefL lung and Lhe
9Lh 10Lh and 11Lh rlbs
-Anter|or|y Lhe sLomach
-Infer|or|y Lhe splenlc flexure of Lhe colon
-Med|a||y Lhe lefL kldney
1he Lall of Lhe pancreas abuLs agalnsL Lhe hllum of Lhe spleen Lhrough
whlch vessels and nerves enLer and leave Lhls organ

8|ood supp|y
1he splenlc arLery ls one of Lhe Lhree maln branches of Lhe coellac axls 1he splenlc
veln ls [olned by Lhe superlor mesenLerlc Lo form Lhe porLal veln (noLe LhaL Lhe
splenlc vessels also provlde Lhe prlnclpal blood supply of Lhe pancreas)

Structure
1he spleen represenLs Lhe largesL reLlculoendoLhellal accumulaLlon ln Lhe body lL
has a Lhln flbrous capsule Lo whlch Lhe perlLoneum adheres lnLlmaLely 1he flbrous
Llssue of Lhe capsule exLends lnLo Lhe spleen Lo form a serles of Lrabeculae beLween
whlch lles Lhe splenlc pulp


||n|ca| features
1ln performlng a splenecLomy Lhe close relaLlon of Lhe pancreaLlc Lall Lo Lhe hllum
and splenlc pedlcle musL be remembered lL ls easlly wounded
2noLe Lhe close proxlmlLy of Lhe lower rlbs lowesL parL of Lhe lefL lung and pleural
cavlLy lefL dlaphragm lefL kldney and Lhe spleen ln[urles Lo Lhe lefL upper abdomen
may damage any comblnaLlon of Lhese sLrucLures Slmllarly a sLab wound of Lhe
posLerlor lefL chesL may peneLraLe Lhe dlaphragm and Lear Lhe spleen 1he spleen
wlLh lLs Lhln Lense capsule ls Lhe commonesL lnLraabdomlnal vlscus Lo be rupLured
by blunL Lrauma
3Accessory spleens (one or more) may occur mosL commonly near Lhe hllum buL
also ln Lhe Lall of pancreas Lhe mesenLery of Lhe spleen Lhe omenLum small bowel
mesenLery ovary and even LesLls 1hey occur ln abouL one ln Len sub[ecLs and lf lefL
behlnd may resulL ln perslsLence of sympLoms followlng splenecLomy for congenlLal
acholurlc [aundlce or LhrombocyLopenlc purpura

Surgical Anatomy of the Kidneys

1he kldneys lle reLroperlLoneally on Lhe posLerlor abdomlnal wall Lhe rlghL kldney ls
03 ln (12 mm) lower Lhan Lhe lefL presumably because of lLs downward
dlsplacemenL by Lhe bulk of Lhe llver Lach measures approxlmaLely 43 ln (11 cm)
long 23 ln (6 cm) wlde and 13 ln (4 cm) Lhlck

ke|at|ons
-oster|or|y Lhe dlaphragm (separaLlng pleura) quadraLus lumborum psoas
Lransversus abdomlnls Lhe 12Lh rlb and Lhree nervesLhe subcosLal (112)
lllohypogasLrlc and lllolngulnal (L1)
-Anter|or|y Lhe rlghL kldney ls relaLed Lo Lhe llver Lhe 2nd parL of Lhe duodenum
(whlch may be opened accldenLally ln performlng a rlghL nephrecLomy) and Lhe
ascendlng colon ln fronL of Lhe lefL kldney lle Lhe sLomach Lhe pancreas and lLs
vessels Lhe spleen and Lhe descendlng colon
1he suprarenals slL on each slde as a cap on Lhe kldney's upper pole
1he medlal aspecL of Lhe kldney presenLs a deep verLlcal sllL Lhe llom whlch
LransmlLs from before backwards Lhe renal veln renal arLery pelvls of Lhe ureLer
and usually a subsldlary branch of Lhe renal arLery LymphaLlcs and nerves also
enLer Lhe hllum Lhe laLLer belng sympaLheLlc malnly vasomoLor flbres



1he teool pelvls ls sub[ecL Lo conslderable anaLomlcal varlaLlons lL may lle
compleLely ouLslde Lhe subsLance of Lhe kldney (even Lo Lhe exLenL of havlng parL of
Lhe ma[or calyces exLrarenal) or may be almosL burled ln Lhe renal hllum All
gradaLlons exlsL beLween Lhese exLremes lf a calculus ls lodged ln Lhe pelvls of Lhe
ureLer lLs removal ls comparaLlvely slmple when Lhls ls exLrarenal and lL ls
correspondlngly dlfflculL when Lhe pelvls ls hldden wlLhln Lhe subsLance of Lhe
kldney
WlLhln Lhe kldney Lhe renal pelvls dlvldes lnLo Lwo or Lhree mojot colyces each of
whlch dlvldes lnLo a number of mloot colyces Lach of Lhese ln Lurn ls lndenLed by a
papllla of renal Llssue and lL ls here LhaL Lhe collecLlng Lubules of Lhe kldney
dlscharge urlne lnLo Lhe ureLer
1he kldneys lle ln an abundanL faLLy cushlon (petloeptlc fot) conLalned ln Lhe teool
fosclo Above Lhe renal fascla blends wlLh Lhe fascla over Lhe dlaphragm leavlng a
separaLe comparLmenL for Lhe suprarenal (whlch ls Lhus easlly separaLed and lefL
behlnd ln performlng a nephrecLomy)
Medlally Lhe fascla blends wlLh Lhe sheaLhs of Lhe aorLa and lnferlor vena cava
LaLerally lL ls conLlnuous wlLh Lhe Lransversalls fascla Cnly lnferlorly does lL remaln
relaLlvely open Lracklng around Lhe ureLer lnLo Lhe pelvls
1he kldney has ln facL Lhree capsules
1fasclal (renal fascla)
2faLLy (perlnephrlc faL)
3LrueLhe flbrous capsule whlch sLrlps readlly from Lhe normal kldney
surface buL adheres flrmly Lo an organ LhaL has been lnflamed



8|ood supp|y
1he teool ottety derlves dlrecLly from Lhe aorLa 1he teool velo dralns dlrecLly lnLo
Lhe lnferlor vena cava 1he left teool velo passes ln fronL of Lhe aorLa lmmedlaLely
below Lhe orlgln of Lhe superlor mesenLerlc arLery 1he tlqt teool ottety passes
behlnd Lhe lnferlor vena cava

ymph dra|nage
LymphaLlcs draln dlrecLly Lo Lhe paraaorLlc lymph nodes

||n|ca| features
18lood from a rupLured kldney or pus ln a perlnephrlc abscess flrsL dlsLend Lhe
renal fascla Lhen force Lhelr way wlLhln Lhe fasclal comparLmenL downwards lnLo
Lhe pelvls 1he mldllne aLLachmenL of Lhe renal fascla prevenLs exLravasaLlon Lo Lhe
opposlLe slde
2ln hypermoblllLy of Lhe kldney ('floaLlng kldney') Lhls organ can be moved up and
down ln lLs fasclal comparLmenL buL noL from slde Lo slde 1o a lesser degree lL ls ln
Lhls plane LhaL Lhe normal kldney moves durlng resplraLlon
3posote of te klJoey vlo te lolo An obllque lnclslon ls usually favoured
mldway beLween Lhe 12Lh rlb and Lhe lllac cresL exLendlng laLerally from Lhe laLeral
border of erecLor splnae LaLlsslmus dorsl and serraLus posLerlor lnferlor are dlvlded
and Lhe free posLerlor border of exLernal obllque ls ldenLlfled enabllng Lhls muscle
Lo be spllL along lLs flbres lnLernal obllque and Lransversus abdomlnls are Lhen
dlvlded reveallng perlLoneum anLerlorly whlch ls pushed forward 1he renal fasclal
capsule ls Lhen broughL clearly lnLo vlew and ls opened 1he subcosLal nerve and
vessels are usually encounLered ln Lhe upper parL of Lhe lnclslon and are preserved
lf more room ls requlred Lhe laLeral edge of quadraLus lumborum may be dlvlded
and also Lhe 12Lh rlb exclsed care belng Laken Lo push up buL noL Lo open Lhe
pleura whlch crosses Lhe medlal half of Lhe rlb