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10-30-09 Vascular Patterns 1.

Arterial Patterns General characteristic of the abdominal aorta: ● Origin: from the aortic hiatus between diaphragmatic crura at T12. ● ermination: birurcates at L4 into the two common iliac arteries ○ he common iliac arteries birfurcate into external iliac arteries and internal iliac arteries anterior to the sacroiliac joint. ○ he e!ternal iliac arter" becomes the femoral artery after crossing the inguinal ligament he abdominal aorta has ## branches$ ● Paired parietal branches ser%e abdominal walls ○ Inferior phrenic ○ Lumbar &' pairs( ○ Median sacral ● Paired %isceral branches ser%e three paired glands on the posterior abdominal walls: )idne"s* suprarenal glands ○ Suprarenal ○ Renal ○ onadal &o!arian or testicular( ● +npaired %isceral branches ser%e G, &foregut* midgut* and hindgut(* 3 unpaired glands* and the spleen ○ "eliac &ser%es foregut %iscera( ■ Splenic ● Short #astrics ● Left #astroepiploic ■ Left #astric ■ "ommon hepatic ● astroduodenal ○ Ri#ht #astroepiploic ● Proper hepatic ○ Ri#ht #astric ○ Superior mesenteric &SMA(: ser%es midgut %iscera ■ Middle colic arter$ supplies trans%erse colon ■ %ejunal branches ● ,ntestinal arcades ○ -traight arteries ■ -ubmucosal anastamoses between ad.acent straight arteries ■ Ileal branches ● ,ntestinal arcades ○ -traight arteries ■ -ubmucosal anastamoses between ad.acent straight arteries

Inferior mesenteric &IMA(: ser%es hindgut %iscera ■ Left colic that splits off into an ascending and descending branch ■ Si#moid arter$ ■ Superior rectal /nastomoses ■ Within the walls of the gut tube ■ Along the length of the gut tube ■ Pancreaticoduodenal arcades spanning between celiac arter" and -0/ ■ Mar#inal arter$ &of 'rummond( is formed as anastamoses between the -0/ and ,0/. ,t is a watershed area that is onl" 1marginall" ser%ed2 b" two arterial trun)s. ,t has not direct blood suppl"3 ,t is the most common site of Mesenteric Ischemia in the colon. ● -traight arteries ○ -ubmucosal anastamoses between ad.acent straight arteries

2. )enous patterns * hepatic portal s$stem Veins run along the posterior abdominal wall. 4rom inferior to superior$ ● +emoral becomes the e,ternal iliac after crossing the inguinal ligament ● Internal iliac and e!ternal iliac .oin to form the common iliac ● he two common iliacs .oin to form the inferior !ena ca!a &I)"( ● onadal &o!arian or testicular( ○ 5eft gonadal enters the left renal %ein ○ 6ight gonadal enters the ,V7 directl" 8epatic portal s"stem &b" definition* a portal s"stem9%essels that carr" %enous blood through a second capillar" networ) before it returns to the heart( ● Portal !ein is what goes ,: O the li%er* ascending along the free edge of the lesser omentum ○ 4ormed b" the .oining of the superior mesenteric !ein and the splenic !ein ○ Inferior mesenteric !ein .oins to the splenic %ein ● -epatic !eins are what comes O+ of the li%er and .oins with the ,V7 ● Sinusoids are what lie within the li%er 1between2 the portal %ein and hepatic %ein ● / few notes on portal h"pertension: obstruction of blood flow within the li%er &i.e. within the sinusoids* from cirrhosis( or near its entr" point &i.e. at the portal %ein* from a thrombus;embolus( causes an increased %enous pressure in the portal vein and its tributaries. 7onse<uences include$ ○ /scites &,0V and -0V don=t drain properl"( ○ -plenomegal" &splenic %ein doesn=t drain properl"( ○ Portocaval anastomoses &enlargement of collateral %enous pathwa"s between tributaries of the portal vein and the IVC(. he" include$ ● .sopha#eal %arices ● Rectal %arices ● Retroperitoneal %arices &as"mptomatic( ● Paraumbilical &caput medusae( %arices &abdominal wall e!hibits e!tremel" dilated %eins in the superficial fascia( ● 4acts: ● Varices de%elop in 90> of cirrhotic patients

?leeding occurs in 30> of those cases @0> die without surgical inter%ention -urgical inter%eintions ● Transju#ular intrahepatic portos$stemic shunt &TIPS(: placement of a stent within the li%er between portal branches and hepatic %ein tributaries( ○ A!amples of ,P- include a portocaval shunt or a splenorenal shunt* the latter being the more modern method ○ ,t is performed under ultrasound guidance that %isualiBes the ad%ancement of the needle from the hepatic %ein to the portal %ein
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/. Prenatal !s postnatal circulation 4i%e uni<ue features to fetal circulation ● 'uctus arteriosus ○ ?ecomes the li#amentum arteriosum ● +oramen o!ale ○ ?ecomes the fossa o!alis ● 'uctus !enosus ○ ?ecomes the li#amentum !enosum ● 0mbilical !ein ○ ?ecomes the li#amentum teres &a)a round li#ament of the li%er( ● 0mbilical arteries ○ ?ecomes the median umbilical li#ament 4. abdominal l$mphatic s$stem 4rom inferior to superior$ ● ,nguinal nodes ● A!ternal iliac nodes ● 7ommon iliac nodes ● 5umbar &aortic( nodes ● Ri#ht and left lumbar trun1s ● Intestinal trun1 ○ /ll l"mph from abdominal G, drains into here ● "$sterna chili: forms from the .oining of the right lumbar trun)* left lumbar trun)* and intestinal trun) ● Thoracic duct ● Chat do l"mphatics containD ○ "h$le: mil)" lipid-rich substance originating from the lacteals of the intestines &lacteals are specialiBed l"mphatic capillaries for absorbing fat3( ○ MALT &mucosal-associated l"mphoid tissue( ■ Solitar$ l$mphoid nodules ■ Pe$er2s patches &aggregated l"mphoid nodules(

-ide note: when "ou ha%e cancer at$ ● he cecumperform a right hemicolectomy ● /t the hepatic fle!ureperform an extended right hemicolectomy ● /t the splenic fle!ureperform a left colectomy ● /t the sigmoid colonperform a sigmoidectomy -ide note: l"mphatic drainage of the s)in;superficial fascia ● all abdominal G, tract l"mph drains through the intestinal trunk into the cisterna chili ● all G, %iscera drain through about #00 %isceral nodes located in mesenteries associated with each %iscusE all G, l"mph nodes are named after the %isceral arteries to which the" are related 7olon cancer can spread both hematologicall" as well as l"mphaticall". 7onse<uentl"* oncologic operation must ta)e into account both l"mphatic suppl" 8ow is drainage determinedD ● ransumbilical plane separates a!illar" from inguinal drainage ● L$mphoscinti#raph$ will show us %isuall"* on an F-ra"* what locations &a!illar" %ersus inguinal nodes( the cancer has metastasiBed to ● L$mpho3urin blue injection: )nown as the 1sentinel node2 techni<ue VA6G important point: l"mphatic drainage of the scrotum and testes are different3 ● -crotumdrains to inguinal external iliac common iliac and lumbar !aortic" nodes ● estesdrains O:5G to the lumbar !aortic" nodes