Anatomyofthe Annexesofthe Digestive Tract

Anatomy of the Annexes
of the
Digestive Tract
Monograph Series
978-93-86337-37-5
Bartos Dana Monica

Bartos Adrian
Anatomy of the Annexes of the Digestive Tract Anatomy of the Annexes of the Digestive Tract
Preface
Anatomy of the Annexes of the Digestive Tract is a second This approach not only provides students with a re-
book from a series of books designed for students, resi- source to guide them through the requisite steps of the
dents and teachers. anatomy class, but also serves for independent study
and review.
Anatomy is difficult to teach, and students can often be
overwhelmed by its massive amount of material. Because it is an e-book with free access a lot of persons
can benefit from it.
The aim of this textbook is to make students and residents
focus on important and essential anatomical aspects, to Scientific acknowledgement by (alphabetically
facilitate the learning of human anatomy. order):
The textbook was written with several goals in mind: ac- Achimaș-Cadariu Patriciu Andrei MD, PhD, Associate
cessible format, customization, a concise description of Professor, Oncological General Surgery and Gynaecol-
anatomical structures and the need to satisfy students’ ogy Surgery Department, “Iuliu Hatieganu” University
demands in regard with anatomy. of Medicine and Pharmacy Cluj-Napoca
The textbook has an easy to follow design, chapters are Opincariu Iulian MD, PhD, Associate Professor, Chief
written in the same manner, following the same pattern; of the Anatomy and Embryology Department, “Iuliu
this way the rider can easily find what is looking for. Each Hatieganu” University of Medicine and Pharmacy Cluj-
chapter has the same subchapters, structured the same Napoca
way.
Szabo Bianca MD, PhD, Associate Professor, Anatomy
Teachers can customize the textbook, adapting it to the and Embryology Department, “Iuliu Hatieganu” Univer-
approach that works best with their students. They can sity of Medicine and Pharmacy Cluj-Napoca
add clinical details, talk about pathologies by helping
themselves with the intraoperative pictures that can be
found in the book.
www.avidscience.com www.avidscience.com
Contents Chapter 5
EXCRETORY SYSTEM OF THE LIVER
Chapter 1 (HEPATIC DUCT, GALLBLADDER, CYSTIC DUCT,
SUBLINGUAL GLAND COMMON BILE DUCT)
Authors: Bartoș Adrian, Breazu Caius, Bartoș Dana Authors: Bartoș Dana, Pop Miana, Blidaru Dana,
Corresponding author and Coordinator of the chap- Bartoș Adrian
ter: Bartoș Dana Corresponding author and Coordinator of the
chapter: Bartoș Adrian
Chapter 2
SUBMANDIBULAR GLAND Chapter 6
Authors: Bartoș Dana, Blidaru Dana, Bartoș Adrian LIVER
Corresponding author and Coordinator of the Authors: Bartoș Adrian, Pop Miana, Breazu Caius,
chapter: Bartoș Adrian Bartoș Dana
Corresponding author and Coordinator of the
Chapter 3 chapter: Bartoș Dana
PAROTID GLAND
Authors: Bartoș Adrian, Breazu Caius, Bartoș Dana Chapter 7
Corresponding author and Coordinator of the PANCREAS
chapter: Bartoș Dana Authors: Bartoș Dana, Ciucă Irina, Iancu Ioana,
Bartoș Adrian
Chapter 4 Corresponding author and Coordinator of the
GALLBLADDER, BILIARY VESICLE OR CHOLECYST chapter: Bartoș Adrian
Authors: Bartoș Dana, Pop Miana, Stoian Raluca,
Bartoș Adrian Chapter 8
Corresponding author and Coordinator of the PERITONEUM
chapter: Bartoș Adrian Authors: Bartoș Adrian, Stoian Raluca, Iancu
Ioana, Bartoș Dana
Corresponding author and Coordinator of the
chapter: Bartoș Dana
www.avidscience.com www.avidscience.com
Chapter 1
Sublingual Gland Position in Human Body
Over the Mylohyoid muscle
Bartoș Adrian1, Breazu Caius2, Bartoș Dana1,3*
1
Superior to the oral diaphragm
Regional Institute of Gastroenterology and Hepatology
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania In the sublingual fossa
2
Anesthesiology and Intensive Care Department, UMF The sublingual fossa
“Iuliu Hațieganu”, Romania
3
Anatomy and Embryology Department, UMF “Iuliu ᴏ Walls
Hațieganu”, Romania ■ Medial wall
*
Corresponding Author: Bartoș Dana, Anatomy and Em- • Genioglossus muscle
briology Department, UMF “Iuliu Hațieganu”, Cluj-Napoca, • Hyoglossus muscle
Romania; Regional Institute of Gastroenterology and
Hepatology ‘’Prof Dr. Octavian Fodor’’, Surgery Depart- ■ Lateral wall
ment, Cluj-Napoca, România, Tel: 0040758020399; Fax: • Mandibular bone (sublingual
0040264334734; Email: bartosdanamonica@gmail.com groove)
■ Superior wall
First Published June 15, 2017
• Sublingual oral mucosa
■ Inferior wall
Copyright: © 2017 Bartoș Adrian, Breazu Caius and Bartoș
Dana. • Mylohyoid muscle
This article is distributed under the terms of the Creative Organ Type
Commons Attribution 4.0 International License Part of the digestive system
(http://creativecommons.org/licenses/by/4.0/), which per-
Parenchymatous organ (gland)
mits unrestricted use, distribution, and reproduction in any
medium, provided you give appropriate credit to the original Exocrine secretion
author(s) and the source.
2 www.avidscience.com www.avidscience.com 3
Shape and General Features ■ More accessory canals also called Rivi-
nus’s accessory canals which open indi-
Paired organ vidually along the sublingual fold
Ovoid, almond-shaped
Lobulated on the external surface
Grey in color
Composed of
ᴏ One main gland and about 20 accessory lob-
ules
ᴏ Two surfaces: internal and external
ᴏ Two margins: superior and inferior
ᴏ Two extremities: anterior and posterior
ᴏ One major duct: Bartholin and more acces-
sory ducts: Rivinus’s ducts
Weights about 4 grams
Specific Features
Its secrets saliva, secretion type: muco-serous
Saliva drainage
ᴏ Sublingual gland has
■ A major salivary duct called also Bar- Figure 1: Sublingual and submandibular glands drainage inside the
tholin canal, which together with the floor of the mouth.
Warthons duct of the submandibular
gland open sublingually through the
sublingual (submandibular) caruncle
Relationships
External surface
ᴏ Medial part of the mandibular bone
Medial surface
ᴏ Genioglossus muscle
ᴏ Hioglossus muscle
ᴏ Lingual nerve
ᴏ Deep lobe of the submandibular gland togeth- Figure 2: Sublingual gland relationships.
er with the Warthons duct
Vascularisation
ᴏ Sublingual vessels
Arterial supply
Inferior margin
ᴏ Lingual artery
ᴏ Mylohyoid muscle
ᴏ Sublingual artery
Superior margin
Venous supply
ᴏ Sublingual mucosa forming the sublingual
ᴏ Drain in the deep lingual vein
fold
Lymphatic drainage
Anterior extremity
ᴏ Submandibular nodes
ᴏ Reaches the mental spine
Posterior extremity Innervation
ᴏ Reaches submandibular gland Sympathetic
ᴏ Plexus around vessels
Parasympathetic
ᴏ Lingual nerve
Acknowledgment
Bartoș Dana is the coordinator of this chapter.
References
1. Papilian V. Salivary glands in Human Anatomy.
ALL. 12th edn. 2010; 2.
2. Papilian V. The sublingual gland in Elementary
Treaty of topographic and descriptive anatomy
(medico-surgical applications). Dacia Traiana.
4th edn. 1946; 2.
3. Gray H. The mouth in Anatomy of the Human
Body. 20th edn. Philadelphia: Lea & Febiger. 1918;
Bartleby.com. 2000.
Chapter 2
Position in Human Body
Submandibular Gland
Is located under the floor of the mouth in a space
1,2 1
Bartoș Dana , Blidaru Dana , Bartoș Adrian 2* formed by the mandible and the superficial cervi-
cal fascia, called the submandibular fossa
1
Anatomy and Embryology Department, UMF “Iuliu The submandibular fossa
Hațieganu”, Romania
2
Regional Institute of Gastroenterology and Hepatology ᴏ Walls
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania ■ Lateral wall
*
• Mandibular bone
Corresponding Author: Bartoș Adrian, Regional Institute
of Gastroenterology and Hepatology ‘’Prof Dr. Octavian ■ Medial wall
Fodor’’, Surgery Department, Cluj-Napoca, Romania, Tel: • Mylohyoid muscles
0040744495933; Fax: 0040264334734; Email: bartos.adi@
• Anterior belly of digastric muscle
gmail.com
• Hyoglossus muscle
Copyright: © 2017 Bartoș Dana, Blidaru Dana and Bartoș

Adrian.
This article is distributed under the terms of the Creative

Commons Attribution 4.0 International License
medium, provided you give appropriate credit to the original
Figure 1: Medial wall of the submandibular fossa. Inferior view.
■ Inferior wall ᴏ Tail

• Skin ᴏ The gland wraps around the posterior border
of mylohyoid muscle
The gland has two parts a deep one which pro-
trudes in the sublingual fossa and a superficial one ᴏ One duct, Wharton
Is partially enclosed in the deep cervical fascia Weights about 7 grams
The mylohyoid muscle separates the submandibu- Specific Features
lar fossa from the sublingual fossa
Its secrets saliva, secretion type: sero-mucous
Organ Type Saliva drainage
Part of the digestive system ᴏ Warthon’s duct leaves the gland on its medial
Parenchymatous organ (gland) surface, it has a triple relationship with the
lingual nerve (first the nerve is located super-
Exocrine secretion ficial, then inferior and in the end deep to the
Shape and General Features duct)
Paired organ
Irregular, hook like shape
Composed of
ᴏ Body
■ Prismatic in shape
■ Three surfaces: external (bony surface),
internal (muscular surface) and inferior
(skin surface)
■ Two extremities: anterior and posterior Figure 2: The relationship of the Warthon’s duct with the lingual
nerve.
Relations
ᴏ Goes along the deep part of the gland to enter Superficial segment
the sublingual fossa
ᴏ The lateral surface of superficial part
ᴏ Along the medial surface of the sublingual
gland ■ At the level of submandibular fossa
ᴏ Opens at the level of the floor of the mouth ■ In relation with the mandible
on the midline under the tongue through the ■ Facial artery
sublingual caruncle
■ Submental vessels
■ Lymph nodes
■ Posterior with the medial pterygoid
muscle
Figure 4: Relationships of the superficial and deep part of subman-

dibular gland. Coronal section.
Figure 3: Salivary drainage.
ᴏ The medial surface of superficial part

■ From anterior to posterior and from su-
perficial to deep: anterior belly of digas-
tric muscle, mylohyoid muscle, hyoglo-
ssus muscle and stylohyoid muscle
■ Facial artery
■ Hypoglossus nerve
Figure 6: Relationships of the medial surface of the superficial part of

submandibular gland.
ᴏ Inferior surface of superficial part

■ Skin
■ Superficial cervical fascia
Figure 5: The medial surface relationships of the superficial part. ■ Platysma muscle
■ Facial vein
■ Cervical branch of the facial nerve
Deep segment
ᴏ Extended from the posterior border of the
mylohyoid muscle till the posterior part of the
sublingual gland
References
ᴏ Inferolateral: mylohyoid muscle
1. Papilian V. Salivary glands in Human Anatomy. ALL.
ᴏ Medial: hyoglossus and styloglossus muscles 12th edn. 2010; 2.
ᴏ Superior: lingual nerve 2. Papilian V. The submandibular gland in Elementary
ᴏ Inferior: hypoglossal nerve and deep lingual Treaty of topographic and descriptive anatomy (med-
vein ico-surgical applications). Dacia Traiana. 4th edn.
1946; 2.
Vascularisation 3. Gray H. The mouth in Anatomy of the Human Body.
Arterial supply 20th ed. Philadelphia: Lea & Febiger. 1918; Bartleby.
ᴏ Facial artery com. 2000.
ᴏ Submental artery
Venous supply
ᴏ Drain in the facial vein
Lymphatic drainage
ᴏ Submandibular lymph nodes which drain in
to the lateral deep cervical nodes
Innervation
Parasympathetic
ᴏ Lingual nerve
Sympathetic
ᴏ Nerve plexus located around the vessels
Acknowledgment
Bartoș Adrian is the coordinator of this chapter.
Chapter 3
Parotid Gland Position in Human Body
Anterior and inferior to the external acoustic me-
Bartoș Adrian1, Breazu Caius2 and Bartoș Dana1,3*
atus
1
Regional Institute of Gastroenterology and Hepatology Superficial, posterior and deep to the ramus of the
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania mandible
2
Anesthesiology and Intensive Care Department, UMF
Anterior covers the posterior part of masseter
“Iuliu Hațieganu”, Romania
3
muscle
Anatomy and Embryology Department, UMF “Iuliu
Hațieganu”, Romania Extends superior till the zygomatic arch
* Posterior covers the anterior part of the sterno-
Corresponding Author: Bartoș Dana, Anatomy and Em-
cleidomastoidian muscle
briology Department, UMF “Iuliu Hațieganu”, Cluj-Napoca,
Romania; Regional Institute of Gastroenterology and Organ Type
Hepatology ‘’Prof Dr. Octavian Fodor’’, Surgery Depart-
ment, Cluj-Napoca, România, Tel: 0040758020399; Fax: Has an accessory gland attached on the Stensen
0040264334734; Email: bartosdanamonica@gmail.com duct
Part of the digestive system
Parenchymatous organ (gland)
Copyright: © 2017 Bartoș Adrian, Breazu Caius and Bartoș
Exocrine secretion
Dana.
Shape and General Features
Commons Attribution 4.0 International License Paired organ
(http://creativecommons.org/licenses/by/4.0/), which per- Irregular, prismatic shape
medium, provided you give appropriate credit to the original
Composed of
■ Parotid lymph nodes
ᴏ Three surfaces: anterior, postero-medial and
ᴏ Postero-medial
external (lateral)
■ Postero-lateral: Mastoid process
ᴏ Apex located inside the carotid triangle
■ Postero-medial: Posterior belly of the
ᴏ One internal margin
digastric muscle
ᴏ One duct, Stensen
■ Postero-lateral: Anterior part of sterno-
Weights about 30 grams cleidomastoidian muscle
Specific Features ■ Medial:
Its secrets saliva, secretion type: serous • Styloid process with styloglossus,
stylopharyngeal and stylohyoid
Saliva drainage muscles
ᴏ Stensen duct leaves the parotid gland anteri- • Stylopharyngeal aponeurosis di-
orly, goes over the lateral surface of the mas- vides the area between the parotid
seter muscle, under the zygomatic arch, punc- gland and pharynx into the pre-
tures the buccinator muscle to open inside the stylian (anterior parapharyngeal
superior vestibule of the mouth at the level of space) and retrostylian (posterior
the second superior molar parapharyngeal space or carotid
space) space
Relationships
• Carotid sheet
Extrinsic
ᴏ Anterior
ᴏ Lateral
■ Posterior margin of the ramus of man-
■ Skin
dible
■ Platysma muscle enclosed inside the su-
■ Lateral aspect of the temporomandibu-
perficial cervical fascia
lar joint
■ Facial branches of the great auricular
■ Posteroinferior part of masseter muscle
nerve
■ Branches of the facial nerve: zygomatic, ral superficial artery near the inferior border
buccal of the ear
ᴏ Medial border: Pharynx ᴏ The retromandibular vein formed inside the

parotid gland through the junction of the su-
ᴏ Inferior: posterior belly of digastric perficial temporal vein and maxillary vein
ᴏ Lymphatic nodes
ᴏ The facial nerve which leaves the skull through
the stylomastoid foramen, entering imme-
diately in the parotid gland and dividing the
gland into a superficial and a deep part
ᴏ The auriculotemporal nerve
Figure 1: Position of the parotid gland into the mandibulo-vertebro-

pharyngeal space.
Intrinsic
ᴏ The external carotid artery going through
the gland, gives up the posterior auricular ar-
tery branch and then divides in it’s terminal Figure 2: Parotid gland relationship.
branches the maxillary artery and the tempo-
Vascularisation Acknowledgment
Arterial supply Bartoș Dana is the coordinator of this chapter.
ᴏ Branches form the external carotid artery
References
■ Posterior auricular artery
1. Papilian V. Salivary glands in Human Anatomy.
■ Anterior auricular artery ALL. 12th edn. 2010; 2.
■ Transverse facial artery 2. Papilian V. The parotid gland in Elementary Trea-
Venous supply ty of topographic and descriptive anatomy (med-
ico-surgical applications). Dacia Traiana. 4th edn.
ᴏ Small capillaries form larger branches which
1946; 2.
drain into the retromandibular vein
3. Gray H. The mouth in Anatomy of the Human
Lymphatic drainage
Body. 20th edn. Philadelphia: Lea & Febiger. 1918;
ᴏ From the deep parotid lymphatic nodes into Bartleby.com. 2000.
the deep, lateral and superficial cervical nodes
Innervation
Parasympathetic
ᴏ Auriculotemporal nerve through the otic gan-
glion (secretory)
Sympathetic
ᴏ Fibers that come from the external carotid
plexus and travel along the vessels for vaso-
motricity
Sensitive innervation
ᴏ Auriculotemporal nerve
ᴏ Greater auricular nerve
Chapter 4
Gallbladder, Biliary Vesicle or Cholecyst Position in Human Body
On the visceral surface of the liver, in a fossa ex-
Bartoș Dana1,2, Pop Miana1, Stoian Raluca1, Bartoș
tending from the right side of the portal vein to
Adrian2*
the anterior border of the liver
1
Anatomy and Embryology Department, UMF “Iuliu Between segments IVB and V of the liver
2
Regional Institute of Gastroenterology and Hepatology In the supramesocolic region
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania It’s projection on the anterior abdominal wall is in
*
the right quadrant of the abdomen, in the angle
Corresponding Author: Bartoș Adrian, Regional Institute formed by the rectus abdominal muscle and the
of Gastroenterology and Hepatology ‘’Prof Dr. Octavian costal margin
Fodor’’, Surgery Department, Cluj-Napoca, Romania, Tel:
0040744495933; Fax: 0040264334734; Email: bartos.adi@ Organ Type
gmail.com
Part of the extrahepatic biliary tract
First Published June 15, 2017 Reservoir for the bile
Occasionally can present a thin serous layer con-
Copyright: © 2017 Bartoș Dana, Pop Miana, Stoian Raluca,
necting with the liver (mesentery) – wandering
Bartoș Adrian.
gallbladder
This article is distributed under the terms of the Creative Shape and General Features
(http://creativecommons.org/licenses/by/4.0/), which per- Unpaired organ, pear shaped
mits unrestricted use, distribution, and reproduction in any 7-10 cm in length, weights approximate 30-35
medium, provided you give appropriate credit to the original grams, capacity of 30-50 ml
Divided in 3 parts: fundus, body and neck
2 surfaces: superior (hepatic) surface and inferior
(peritoneal, visceral) surface
Division with the liver, through connective tissue

and vessels)
3 parts: fundus, body and neck
■ Inferior surface (covered by peritoneum
ᴏ Fundus which reflects and continues with liver
■ Caudal part of gallbladder, bag shaped, peritoneum)
high mobility ■ Directed supero-posterior and to the
■ Covered completely by peritoneum left
■ Directed infero-anterior and to the right ᴏ Neck
■ Corresponds with the cystic notch on ■ Infundibulum – narrowed area between
the anterior border of the liver the body and the neck
■ S – shaped
■ Located inside the free border (right
side) of the hepato-duodenal ligament
■ Continues with the cystic duct
■ At the junction with the cystic duct –
Hartmann’s pouch (dilated infundibu-
lum)
External Features
Relationships
Figure 1: Position of the gallbladder (intraoperative aspects). ᴏ Fundus
ᴏ Body ■ Anterior
■ The largest part of the gallbladder • Anterior abdominal wall, projects

below the 9th right costal cartilage
■ Superior surface (in intimate contact
■ Posterior
• The proximal segment of the
transverse colon
ᴏ Body
■ Superior surface
• Liver (gallbladder fossa)
■ Inferior surface
• Transverse colon
• Proximal part (supramesocolic Figure 2: Gallbladder relationships.
segment) of the descending seg-
ment of the duodenum (D2) ᴏ The Calot’s triangle
• In rare cases, with the superior ■ Borders
segment of the duodenum (D1) • Medial
and the pyloric region of the
stomach ✓ Common hepatic duct
ᴏ Neck • Inferior
■ Superior and medial ✓ Cystic duct
• Portal vein (right branch) • Superior
■ Inferior ✓ Visceral surface of the liver
• Superior segment of duodenum ■ Content
(D1) • Cystic artery
• Mascagni lymph node
■ At the level of the neck forms the spiral

valves of Heister
■ Rokitansky – Aschoff sinuses – hernia-
tion of the epithelial cells in the fibro-
muscular layer
■ Yellowish-brown color
Vascularization
Arterial supply
Figure 3: Calot’s triangle (intraoperative aspects).
ᴏ Cystic artery
Internal Configuration ■ Most commonly it has its origin from
the right hepatic artery
3 layers
■ Other less common origins: common
ᴏ External serous layer or left hepatic artery, gastro-duodenal
■ Covers the fundus entirely artery
■ Continues with peritoneum ■ Gives up recurrent cystic artery (when
■ Contains blood vessels and lymphatics the blood supply reaches the fundus of
the gallbladder)
ᴏ Fibromuscular layer
■ Inside the Calot’s triangle it divides into
■ Dense fibrous tissue
• Anterior and posterior branches
■ Smooth muscular tissue (with irregu- for the gallbladder
lar disposal: longitudinal, oblique and
transverse) • Small arteries for the cystic duct
ᴏ Internal mucous layer ■ Not a terminal artery
■ A single layer of columnar cells and the ᴏ Liver parenchyma arteries reach inside the
lamina propria below gallbladder bed
■ 2 routes
• To the right side of the hepatoduo-
denal ligament (pericholedochal,
pancreaticoduodenal, aortocaval)
• To the left side of the ligament
(pericholedochal, hepatic artery,
celiac, para-aortic)
Innervation
Sympathetic
Figure 4: Arterial supply gallbladder.
ᴏ From T7-9 – through celiac plexus
Venous supply Parasympathetic
ᴏ Cystic vein – drains into the portal vein ᴏ From the right vagus nerve – through hepatic
branch
ᴏ Cholecistohepatic veins from fundus and body
drain directly in the parenchyma of the quad- Sensory innervation
rate lobe of the liver (intrahepatic branches of ᴏ Right phrenic nerve
the portal vein, segments IV and V)
Lymphatic drainage Acknowledgment
ᴏ Lymphatic vessels from the serosa and mu- Bartoș Adrian is the coordinator of this chapter.
cosa drain in References
■ Cystic lymph node of Lund (Mascagni) 1. Papilian V. Gallbladder in Human Anatomy. ALL.
---> node of the hiatus ---> posterior 12th edn. 2010; 2.
pancreatico-duodenal lymph node 2. Papilian V. Gallbladder in Elementary Treaty of topo-
graphic and descriptive anatomy (medico-surgical
applications). Dacia Traiana. 4th edn. 1946; 2.
3. Gray H. Gallbladder and biliary tree in Anatomy.

The Anatomical Basis of Clinical Practice. 41th edn.
Amsterdam: Elsevier. 2016.
4. Skandalakis JE, Colburn GL, Weidman TA, Foster Jr
RS, Kingsworth AN, et al. Extrahepatic biliary tract
and gallbladder in Skandalakis’ Surgical Anatomy:
The Embryologic and Anatomic Basis of Modern
Surgery. Greece: Paschalidis Medical Publications.
2004; 2.
Chapter 5
Excretory System of the Liver Under the liver, in the supramesocolic region
(Hepatic Duct, Gallbladder, Cystic Duct, Descends along the right border of the lesser
omentum
Common Bile Duct)
Together with the portal vein and the hepatic ar-
Bartoș Dana1,2, Pop Miana2, Blidaru Dana2 and Bartoș tery forms the hepatic pedicle
Adrian1*
Projection on the anterior abdominal wall:
1
ᴏ Superior – a line between anterior extremities
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania
2 of the 9th ribs
Hațieganu”, Romania ᴏ Inferior – a horizontal line that passes be-
*
tween S3-S4
Corresponding Author: Bartoș Adrian, Regional Institute
of Gastroenterology and Hepatology ‘’Prof Dr. Octavian ᴏ Medial – lateral margin of the right abdomi-
Fodor’’, Surgery Department, Cluj-Napoca, Romania, Tel: nal muscle
gmail.com Organ Type
Tube-like structure
First Published June 15, 2017 Unpaired
Copyright: © 2017 Bartoș Dana, Pop Miana, Blidaru Dana
and Bartoș Adrian. Shape and General Features
Right and left hepatic ducts
Commons Attribution 4.0 International License ᴏ Continue intrahepatic bile ducts, outside the
(http://creativecommons.org/licenses/by/4.0/), which per- liver
mits unrestricted use, distribution, and reproduction in any ᴏ In the hepatoduodenal ligament
medium, provided you give appropriate credit to the origi-
nal author(s) and the source. ᴏ 3-4 mm in diameter, approximate 1cm length
ᴏ In Porta Hepatis (hilum of liver) - join to form

the common hepatic duct Division
Hepatic duct Depending on their relationship to the liver, ex-
trahepatic bile ducts can be divided in:
ᴏ Formed by the junction of left hepatic duct
(from the left lobe of the liver) and right he- ᴏ Proximal or perihilar bile ducts
patic duct (from the right lobe of the liver) ■ Hepatic ducts join to form the common
ᴏ 2-8mm in diameter, 1-5cm length hepatic duct
Cystic duct ■ Cystic duct joins the common hepatic
duct
ᴏ Drains bile from the gallbladder into the com-
mon bile duct ᴏ Distal extrahepatic bile duct
ᴏ Length approximate 2-4 cm ■ The common bile duct
ᴏ Usually drains into the common bile duct into ■ Between the junction of the cystic duct
a sharp angle and the ampulla of Vater
Common bile duct
ᴏ Formed by the junction of Hepatic duct with
the cystic duct (gallbladder duct)
ᴏ Length approximate 7.5cm
ᴏ Diameter 6-7mm, 2-9cm in length
ᴏ Descends along the first portion of the duo-
denum
ᴏ Crosses the head of the pancreas
ᴏ Ends on the right side of the pancreatic duct
ᴏ Opens in the second part of the duodenum
together with the pancreatic duct, forming the
ampulla of Vater (hepatopancreatic ampulla) Figure 1: Division of the biliary tree.
✓ Left branches of the hepatic

Depending on its relationship to the duodenum, artery
the common bile duct can be divided in the fol-
lowing segments: • Inferior– Posterior
ᴏ Supraduodenal ✓ Portal vein bifurcation (ante-

rior face)
ᴏ Retroduodenal
ᴏ Hepatic duct
ᴏ Infraduodenal/retropancreatic
■ Posterior
ᴏ Intraduodenal/intramural
• The origin of the right branch of
ᴏ Boyden sphincter – smooth muscle sphincter the portal vein
proximal to the hepatopancreatic ampulla
• The right branch of the hepatic
External Features artery
Relationships ᴏ Cystic duct
ᴏ Left and right hepatic ducts ■ Located posterior and medial to the
neck of the gallbladder
■ Right hepatic duct
■ Joins the common bile duct on its lateral
• Posterior
right side
✓ Right branches of the portal
ᴏ Common bile duct
vein
■ Anterior – the superior portion of the
✓ Right branches of the hepatic
duodenum
artery
■ Posterior – the portal vein; joins the left
■ Left hepatic duct
part of the portal vein in the middle part
• Anterior of the hepatic pedicle
✓ Left branches of the portal ■ Medial – hepatic artery
vein
✓ Duodenum (superior portion)

✓ Gastroduodenal artery (or
medial)
• Posterior
✓ Treitz’s fascia
✓ Omental foramen (Winslow
hiatus)
✓ Portal vein
• Medial
✓ Hepatic artery
Figure 2: Relationship of the common bile duct inside the Porta He-
patis. ✓ Superior posteropacreati-
coduodenal artery
■ Supraduodenal segment ■ Retropancreatic or infraduodenal seg-
• Anterior – hepatoduodenal ligament
ment • Anterior
• Posterior ✓ Head of the pancreas
✓ Omental foramen (Winslow • Posterior
hiatus)
✓ Treitz’s fascia
✓ Portal vein
✓ Inferior vena cava
• Medial
✓ Right renal vein
✓ Portal vein
✓ Pancreaticoduodenal arterial
■ Retroduodenal segment arcades
• Anterior
Vascularisation
■ Intraduodenal or intramural segment
Arterial supply
• Medial border second part of the
duodenum ᴏ Branches from the celiac trunk
ᴏ Right and left hepatic ducts, hilar region
■ Cystic artery
■ Right and left hepatic artery
■ Hilar plexus
ᴏ Hepatic duct
■ Cystic artery
■ Right hepatic artery
ᴏ Hepatic duct and supraduodenal segment of
common bile duct
Figure 3: Biliary tree relationship. ■ Anastomoses between ascending and
descending arterial branches
Internal Configuration ■ 3 o’clock (left) and 9 o’clock (right) ar-

teries sideways from duct
External fibrous layer
■ Marginal arteries sideways from duct
ᴏ Fibrous tissue
• Ascending arteries – from:
ᴏ Muscular circular fibers
✓ Superior posteropacreati-
Internal mucous layer coduodenal artery
ᴏ Columnar epithelium ✓ Supraduodenal artery
ᴏ Mucous glands ✓ Gastroduodenal artery
• Descending branches – from: Venous supply
✓ Right hepatic artery ᴏ Two plexuses
✓ Cystic artery ■ Epicholedochal venous plexus
ᴏ Supraduodenal segment of common bile duct ■ Paracholedochal venous plexus
■ Poor vascularisation ᴏ Common bile duct
ᴏ Supraduodenal and retroduodenal segments ■ Postero-superior pancreaticoduodenal

of common bile duct vein
■ Retroportal artery Lymphatic drainage
• Originates in celiac trunk or su- ᴏ Lymphatic vessels ---> cystic lymph node --->
perior mesenteric artery hepatic lymph nodes
• Posterior to the portal vein ᴏ Hepatic lymph nodes
ᴏ Retropancreatic segment of common bile duct ■ Hepatic group – hepatic artery
■ Arteries from superior posteropacreati- ■ Infrapyloric group – 4 or 5, gastro-duo-

coduodenal artery denal artery
■ Retroportal artery Innervation

ᴏ Common bile duct Sympathetic
■ Common hepatic artery ᴏ From T7-9 – through celiac plexus
■ Gastro-duodenal artery Parasympathetic
■ Right gastric artery ᴏ From the right vagus nerve – through hepatic
■ Posterior superior pancreatico-duode- branch
nal arteries Sensory innervation
ᴏ Right phrenic nerve
Acknowledgment
Bartoș Adrian is the coordinator of this chapter.
References
1. Papilian V. Biliary tract in Human Anatomy. ALL.
12th edn. 2010; 2.
2. Papilian V. Biliary tract in Elementary Treaty
of topographic and descriptive anatomy (med-
ico-surgical applications). Dacia Traiana. 4th
edn.1946; 2.
3. Gray H. Gallbladder and biliary tree in Anatomy.
The Anatomical Basis of Clinical Practice. 41th
edn. Amsterdam: Elsevier. 2016.
4. Skandalakis JE, Colburn GL, Weidman TA, Fos-
ter Jr RS, Kingsworth AN, et al. Extrahepatic bil-
iary tract and gallbladder in Skandalakis’ Surgical
Anatomy: The Embryologic and Anatomic Basis
of Modern Surgery. Greece: Paschalidis Medical
Publications. 2004; 2.
Chapter 6
Liver Position in Human Body
In the supramesocolic peritoneal cavity
Bartoș Adrian1, Pop Miana2, Breazu Caius3 and Bartoș
Dana1,2* In both the right hypochondriac and epigastric re-
gion of the abdomen
1
Covered by the right costal arch, excepting 3-4 cm
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania
2 below the xiphoid process
Hațieganu”, Romania In the right side (3/4 of the liver), and left side of
3
Anesthesiology and Intensive Care Department, UMF the abdomen (only 1/4 of the liver)
“Iuliu Hațieganu”, Romania Projection on the anterior abdominal wall:
*
Corresponding Author: Bartoș Dana, Anatomy and Em- ᴏ Superior: a horizontal line that passes through
briology Department, UMF “Iuliu Hațieganu”, Cluj-Napoca, the 5th rib
Romania; Regional Institute of Gastroenterology and ᴏ Inferior: a horizontal line that passes through
Hepatology ‘’Prof Dr. Octavian Fodor’’, Surgery Depart- the 12th thoracic vertebra
ment, Cluj-Napoca, România, Tel: 0040758020399; Fax:
0040264334734; Email: bartosdanamonica@gmail.com ᴏ Lateral: a vertical line, tangent to the lateral
part of the thoracic wall
First Published June 15, 2017 ᴏ Medial: a vertical line 5-6 cm to the left from
Copyright: © 2017 Bartoș Adrian, Pop Miana, Breazu Caius the median line
and Bartoș Dana
Organ Type
This article is distributed under the terms of the Creative The largest gland in the body
Commons Attribution 4.0 International License Important metabolic function
mits unrestricted use, distribution, and reproduction in any Exocrine secretion – the bile - important role in
medium, provided you give appropriate credit to the original digestion

Unpaired organ, triangular pyramid shape
28 cm in length, weights approximate 2000-2100
grams
1/40 of the total body weight
Structured as follow: three surfaces, two margins
Three surfaces: superior, inferior and posterior
ᴏ A sharp margin (anterior) divides the supe-
rior surface from the inferior surface
ᴏ The superior surface (diaphragmatic surface)
■ Convex form
■ Covered by peritoneum (except from a
triangular area in contact with the dia- Figure 1: Diaphragmatic surface. Anatomic division of the liver into
phragm – bare area) lobes.
■ Is attached to the diaphragm ᴏ The inferior surface (visceral surface)
■ In contact with anterior abdominal ■ Is divided into four regions by five fos-
wall by the falciform ligament and the sae, forming the “H” of the liver
ligamentum teres (obliterated umbilical
vein) ■ Quadrate and caudate lobes are posi-
tioned in between the H legs
■ The falciform ligament divides the liv-
er into two parts, the right and the left ■ The left limb of the H (left sagittal sul-
lobes (by anatomical point of view) cus)
• Marks the division into right and
left lobes
• Anteriorly - the fossa of the um- • Contains the hepatic ducts,

bilical vein (obliterated) branches of the portal vein and
proper hepatic artery
✓ Continues with the round lig-
ament
• Posteriorly - Arantius venous lig-
ament (obliterated ductus veno-
sum)
✓ Continues to the left hepatic
vein
■ The right limb of the H (right sagittal
sulcus)
• Larger
• Anteriorly - the fossa of the gall- Figure 2: Diaphragmatic surface of the liver.
bladder
ᴏ The posterior surface
• Posteriorly - the fossa for the infe-
rior vena cava ■ Bare area of the liver (area nuda), is not
covered by peritoneum
■ The transvers limb (fissure)
Ligaments of the liver
• Connects the two limbs of the H
ᴏ Fix the liver in position in the human body
• Formed by the Porta Hepatis (hi-
lum of the liver) ᴏ Coronary ligament
• Divides the liver tissue between ■ Diaphragmatic peritoneal duplication

the two limbs of the H in quad- ■ All around the bare area
rate lobe (anterior) and caudate
■ Can be examined if the liver in pulled
lobe (posterior)
down and detached from the diaphragm
■ 2 layers with areolar tissue in between

■ Continues with the triangular ligaments
(left and right)
ᴏ Left triangular ligament
ᴏ Right triangular ligament
ᴏ Falciform ligament
■ From the diaphragmatic surface of the
liver to the anterior abdominal wall
■ From the middle of the coronary liga- Figure 3: Ligaments of the liver.
ment
■ Peritoneal duplication Boundries
■ Contains round ligament (left umbilical Proximal (superior)
vein obliterated) ᴏ Diaphragm
■ Divides the liver into two parts, the Distal (inferior)
right and the left lobes
ᴏ From right to left
ᴏ Round ligament
■ Superior border of hepatic flexure
■ Superior border of right side of trans-
vers colon
■ Anterior surface of D2
■ Anterior surface of stomach
Right anatomical lobe is formed by: segments 4,

Right 5, 6, 7, 8
ᴏ Right lateral abdominal wall with ribs and in-
tercostal spaces
Left
ᴏ Spleen
Figure 5: Anatomical segmentation of the liver (done by visible ana-

tomical land marks) (intraoperative aspects).
On the diaphragmatic surface - along the falci-

form ligament
ᴏ The right lobe
Figure 4: Borders of the liver.
■ Much larger than the left lobe
Division ■ Occupies the right hypochondriac re-
2 lobes: the right and left gion
On the visceral surface - along the left sagittal sul- ■ Quadrilateral form
cus (left-hand limb of the H) ■ Its left part is separated in 2 smaller
Anatomical division into lobes is done by use of lobes on the visceral surface
falciform ligament • The quadrate lobe:
Left anatomical lobe is formed by: segments 1, 2, 3 ✓ Bounded antero-inferior by
the anterior margin
✓ Bounded postero-superior by
Porta Hepatis
✓ Bounded on the right by the
fossa of the gallbladder
✓ Bounded on the left by the
fossa for the umbilical vein
✓ Its antero-posterior diameter
is greater than its transverse
one
• The caudate lobe: Figure 6: Anatomic lobes of the visceral surface of the liver.
✓ Bounded antero-inferior by
Porta Hepatis Surgical division into lobes is done by the division
of the portal vein inside Porta Hepatis
✓ Supero-posterior it corre-
sponds to the 10th and 11th Segmentation is very important for surgical resec-
thoracic vertebrae tion
✓ Bounded on the right by the Left surgical lobe is formed by: segments 1, 2, 3, 4
fossa of the inferior vena cava Right surgical lobe is formed by: segments 5, 6,
✓ Bounded on the left by the 7, 8
fossa for the ductus venosus The segmentation of the liver
ᴏ The left lobe ᴏ 2 lobes (right and left), each lobe being divid-
■ Smaller and more flattened than the ed into 4 segments => 8 segments in total
right lobe ᴏ Made by the branches of the portal vein, fol-
■ Situated in the epigastric region lowed by:
■ The inferior surface presents gastric im- ■ Branches of the hepatic artery
pression and omental tuberosity ■ Bile ducts
ᴏ Portal branches for segment 1can come from • Medio-inferior segment or 4b

both right and left portal branches segment
ᴏ Right portal vein is divided in 2 branches => • Latero-superior segment or 2nd

Anterior branch and posterior branch segment
■ Each of the 2 branches of the right por- • Latero-inferior segment or 3rd

tal vein is divided into one superior and segment
one inferior branch corresponding to
the 4 segments of the right lobe:
• Antero-superior segment or 8th
segment
• Antero-inferior segment or 5th
segment
• Postero-superior segment or 7th
segment
• Postero-inferior segment or 6th
segment
ᴏ Left portal vein is divided in 2 branches =>
Lateral branch and medial branch
■ Each of the 2 branches of the left por-
tal vein is divided into one superior and Figure 7: Surgical segmentation of the liver (done by portal system).
one inferior branch corresponding to External Features
the 4 segments of the left lobe:
Relationships
• Medio-superior segment or 4a
segment ᴏ Inferior surface or visceral surface
■ The hilum of the liver
■ The right part of the inferior surface ■ Caudate lobe:

corresponding to the right lobe • Posterior from the lesser omen-
• 4 impressions: tum in the omental bursa
✓ Gallbladder impression • Posterior: left pillar of the dia-
✓ Colic impression- Hepatic phragm
flexure of the colon and trans- • Right: inferior vena cava
verse colon • Left: esophagus
✓ Duodenal impression – de- • Inferior: celiac trunk, celiac plex-
scending part of the duode- us, the superior margin of the
num pancreas, and the lesser curvature
✓ Renal impression - The right of the stomach
kidney ᴏ Superior surface or diaphragmatic surface
■ The left part of the inferior surface cor- ■ Covered by peritoneum, except a small
responding to the left lobe: part of its posterior portion which is ad-
• Gastric impression – The anterior hering closely to the diaphragm (area
side of the stomach nuda)
■ Quadrate lobe: ■ Via the diaphragm: the right lung and
• Anterior from the lesser omen- its pleura and the heart covered by the
tum in the greater peritoneal cav- pericardium
ity ᴏ Posterior surface of the liver
• Inferior - Superior part of the du- ■ Triangular impression of the vena cava
odenum – in the right
• Lateral - Right portion of the ■ Esophageal impression – in the left
transverse colon
• Coronary ligament of the liver

• Triangular ligaments of the liver
ᴏ Laennec capsule
■ Beneath the serous layer
■ Is the proper membrane that covers the
entire surface of the liver (including the
bare area) but also goes inside the he-
patic parenchyma to envelope the Glis-
sonean pedicles and suprahepatic veins
(like a glove)
ᴏ Fibrous capsule = Glisson capsule
Figure 8: Relationships of the liver. ■ Beneath the Laennec capsule
■ Covers only the hepatic pedicles
Internal Configuration
Enveloped by 3 layers: peritoneum (serous layer),
Laennec capsule and fibrous layer (Glisson cap-
sule)
ᴏ External serous coat = peritoneum
■ Starting from the inferior margin the
peritoneum covers the inferior surface
and much of the diaphragmatic surface
■ As it goes from the liver over the other
organs the peritoneum forms:
• Lesser omentum
• Falciform ligament of the liver
Figure 9: Liver capsules.
liver together with the portal vein and

ᴏ The lobules common bile duct through hepatic hi-
■ Chief mass of the hepatic substance lum
■ 1 lobule is formed by the liver tissue
surrounding 1 central vein
■ 3 lobules form a portal space
■ Microscopy
• Each lobule consists of a mass of
cells (hepatocytes) arranged in
irregular radiating columns be-
tween which are the sinusoids
• Between the columns of hepato-
cytes are the bile capillaries
• Inside a lobule there are all the es-
sentials of a secreting gland: blood
vessels, cells, and ducts
• Hepatocytes are polyhedral in
form, with one or two distinct nu-
clei
Vascularization Figure 10: Hepatic pedicle (intraoperative aspects).

Arterial supply
ᴏ Proper hepatic artery ■ Located inside the hepato-duodenal
ligament
■ From the celiac trunk, through the com-
mon hepatic artery • Anterior to the portal vein
■ The proper hepatic artery enters the • Left to the common bile duct
■ Is formed by the confluence of the su-

perior mesenteric vein and the trunk
formed by the splenic and inferior mes-
enteric vein
■ Provides about 2/3 to 3/4 of the blood
flow inside the liver (more than the he-
patic artery), 80%
■ It splits at the level of the hilum in right
and left portal veins
• Right portal vein branches out
into anterior and posterior divi-
sions
Figure 11: Relationships of proper hepatic artery inside the hepato-
duodenal ligament (intraoperative aspects). ✓ Antero-superior branch for
8th liver segment
■ Provides about 2/3 to 3/4 oxygen in the ✓ Antero-inferior branch for 5th
liver liver segment
■ Gives up two terminal branches: right ✓ Postero-superior branch for
and left hepatic arteries and two collat- 7th liver segment
eral branches: right epiploic and cystic
arteries ✓ Postero-inferior branch for
6th liver segment
■ Inside the liver the arterial hepatic
branches follow the portal veins path • Left portal vein branches out into
a lateral and medial division
Venous supply
✓ Longer than the right branch
ᴏ Portal vein
✓ Usually gives up a branch for
■ Originates posterior to the head of the caudate lobe
pancreas
✓ Medio-superior branch for 4a ■ They are solitary, and easy to distinguish

liver segment from the portal branches which are fol-
✓ Medio-inferior branch for 4b lowed by arterial braches and bile ducts
liver segment
✓ Latero-superior branch for
2nd liver segment
✓ Latero-inferior branch for 3rd
liver segment
■ Collects the blood from the small bow-
el, large bowel and the superior 1/3 of
the rectum
■ Left and right gastric vein, cystic vein
and pancreatico-duodenal veins drain
in portal vein
■ Normal pressure 3-5 mmHg
ᴏ The hepatic veins
Figure 12: Venous vascularization of the liver.
■ Drains the blood from the liver through
the intrahepatic veins and then through Lymphatic drainage
3 hepatic veins into the inferior vena ᴏ There are 2 types of lymphatic vessels: super-
cava ficial and deep
• Left hepatic vein – drains directly ■ Superficial vessels
into inferior vena cava or forms
a trunk with the middle hepatic • Retroperitoneal networks will
vein drain into internal thoracic nodes
• Right hepatic vein – drains direct- • From the interlobular spaces of

ly into inferior vena cava the surface of the liver, they go
under the peritoneum and are di- bile ducts) to drain the lymph
vided into 3 groups into the hepatic and celiac lymph
✓ A group that goes through nodes
the falciform ligament and
through the diaphragm to the
Innervation
parasternal lymph nodes From the vagus nerve (parasympathetic) and
from the celiac plexus (sympathetic)
✓ A group that goes through
the coronary ligament and The nervous fibers for the liver form the hepatic
through the diaphragm to the plexus
superior phrenic lymph nodes ᴏ The anterior hepatic plexus
✓ A group of lymph nodes who • Fibers from both celiac ganglions
drains the lymph of the vis- (mostly from the left one)
ceral surface of the liver to the
hepatic and inferior phrenic • Fibers from the right vagus nerve.
lymph nodes. ᴏ The posterior hepatic plexus
■ Deep vessels • Fibers from right celiac ganglion
• They are formed deeply into the (mostly from the left one)
liver parenchyma • Fibers from the right vagus nerve
• Some of them have an ascending Acknowledgment
direction, following the hepatic
veins and inferior vena cava to Bartoș Dana is the coordinator of this chapter.
drain the lymph to the superior
phrenic lymph nodes
• The others have a descending di-
rection, following the elements of
the portal pedicle (portal branch-
es, branches of the hepatic artery,
References
1. Papilian V. Liver in Human Anatomy. ALL. 12th
edn. 2010; 2.
2. Papilian V. Liver in Elementary Treaty of topo-
graphic and descriptive anatomy (medico-surgi-
cal applications). Dacia Traiana. 4th edn.1946; 2.
3. Gray H. Liver in Anatomy. The Anatomical Basis
of Clinical Practice. 41th edn. Amsterdam: Else-
vier. 2016.
4. Skandalakis JE, Colburn GL, Weidman TA, Foster
Jr RS, Kingsworth AN, et al. Liver in Skandalakis’
Surgical Anatomy: The Embryologic and Ana-
tomic Basis of Modern Surgery. Greece: Pascha-
lidis Medical Publications. 2004; 2.
Chapter 7
Pancreas Situated transversely on the posterior abdominal
wall crossing the vertebral spine at the level of
Bartoș Dana1,2, Ciucă Irina2, Iancu Ioana2 and T12/L1-L3
Bartoș Adrian2* Projects on the anterior abdominal wall at the lev-
el of the epigastrium & left hypochondrum
1
Hațieganu”, Romania The transvers mesocolon inserts on the anterior
2
Regional Institute of Gastroenterology and Hepatology surface of the pancreas positioning this way the
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania organ at the limit between the supra and infra-
mesocolon compartments
*
Corresponding Author: Bartoș Adrian, Regional Institute Posterior to the stomach and omental bursa (less-
of Gastroenterology and Hepatology ‘’Prof Dr. Octavian er sac)
Fodor’’, Surgery Department, Cluj-Napoca, Romania, Tel:
Organ Type
gmail.com Part of the digestive system
Partially extra peritoneal organ (retroperitoneal)
Parenchymal
Copyright: © 2017 Bartoș Dana, Ciucă Irina, Iancu Ioana Mixed secretion gland (endocrine and exocrine)
and Bartoș Adrian.
This article is distributed under the terms of the Creative Shape and General Features
Commons Attribution 4.0 International License Unpaired organ
Hockey stick shaped
medium, provided you give appropriate credit to the origi- Its length very a lot from 12.5 to almost 20 cen-
nal author(s) and the source. timeters in some cases
Has 3.8 centimeters in width

Segments
Head, uncinate process, neck (istmus) and the
Weighs approximately 80 grams
body are extraperitoneal, tail is intraperitoneal
Pale yellow colored
Head:
Very fragile
ᴏ Situated proximally (the right side of the or-
Soft, lobulated texture gan) framed by the duodenal loop
Segments: head, uncinated process, neck, body, ᴏ Flattened antero-posteriorly
tail
ᴏ Two surfaces: anterior, posterior
Boundries ᴏ One circumference
Right side Uncinate process:
ᴏ Head of the pancreas and uncinate process ᴏ Hook-shaped
placed inside the duodenal loop (superior D1,
ᴏ Progresses left and inferiorly from the pancre-
right D2, inferior D3)
atic head
Left side
ᴏ Pancreatic incisura: the limit between the
ᴏ Tail of the pancreas at the level of the splenic head and the uncinate process
hilum
ᴏ Variable in size and shape, sometimes absent
Superior
Neck (istmus):
ᴏ Virtual horizontal plane that passes through
ᴏ The bulk of the pancreas
the eight-costal cartilage
ᴏ Is the junction between the head and the body
Inferior
of the pancreas
ᴏ Virtual horizontal plane that passes at about 3
ᴏ Constitutes a narrowing on the vertical part of
cm. above the umbilicus
the parenchyma
ᴏ 1.5-2 centimeters in length
Body:
Anterior surface
ᴏ The bulk of the pancreas
ᴏ Covered by peritoneum
ᴏ Stretches to the left from the neck of the pan-
ᴏ Facing antero-superiorly
creas
ᴏ Progresses from right to left and infero-supe-
ᴏ The orientation is from inferior to superior,
riorly
from right towards left
ᴏ The root of the transverse mesocolon crosses
ᴏ Prismatic-shaped
it obliquely from right to left and infero-su-
ᴏ Three surfaces: anterior, posterior, inferior periorly
ᴏ Three margins: superior, anterior and inferior ᴏ The superior segment of the transverse me-
Tail: socolon is in relation with the omental bursa
and through it with the pancreas
ᴏ The most mobile part of the organ
ᴏ Continues to the left of the body of the pan-
creas
ᴏ Extends into the pancreatosplenic ligament
toward the hilum of the spleen
External Configuration
Proximal part
ᴏ Head of the pancreas framed by the duodenal
loop
Distal part
ᴏ Tail of the pancreas encased in the pancreato-
splenic ligament
Figure 1: Anterior surface of the pancreas (intraoperative aspects).
Inferior surface
Posterior surface
ᴏ Facing the inframesocolic compartment
ᴏ Same orientation as the anterior surface
Superior margin
ᴏ The fusion fascia of Treitz (no peritoneum)
ᴏ In relation with the portal vein (proximally)
ᴏ Has important relations with vessels and and the origin of the celiac trunk (the middle
nerves part)
ᴏ Has indentations made by the splenic artery Anterior margin
and vein
ᴏ Facing the inframesocolic compartment
Inferior margin
ᴏ In relation with the superior mesenteric vein
and artery
Internal Configuration
Parenchymatous organ
Intraparechymatous ducts that drain the exocrine
secretions
ᴏ Located in a plane anterior to the main vas-
cular plane
ᴏ There is commonly a main duct (Wirsung)
and a secondary/accessory duct (Santorini)
Figure 2: Posterior surface vascular relationships ᴏ Wirsung duct
(intraoperative aspects).
■ Crosses the spine at the level of the L1
vertebral body
■ Supero-inferior trajectory from the tail

towards the head
■ Travels on the medio-transverse plane
of the organ and slightly posterior to the
frontal plane
■ At the level of the head it does an ante-
ro-postero-inferior rotation to join the
main biliary duct
■ Has a variable number of superior and
inferior tributary ducts
■ Opens into the duodenum (D2) at the
level of Vater’s ampulla through the ma-
jor duodenal papilla merged or separate
from the main biliary duct
Figure 3: Pancreatic ducts.
ᴏ Santorini duct
Relationships
■ Located at the level of the head antero-
The pancreatic head
superiorly to the Wirsung duct
ᴏ Framed by the duodenal loop
■ Drains the pancreatic juice either di-
rectly into the duodenum through the ᴏ The superior part of its anterior surface is cov-
minor papilla or joins the Wirsung duct ered by the posterior peritoneum of the bursa
omentalis
ᴏ The inferior part of its anterior surface is in
relation with the transverse colon
ᴏ The posterior surface is in direct contact with
the retroduodenopancreatic fascia of Treitz
ᴏ Anterior to the inferior vena cava ᴏ Anterior to the spleno-mesenteric confluence
ᴏ Anterior to the right renal vessels ᴏ Anterior to the portal vein
ᴏ Located left to the hilum of the right kidney, ᴏ The inferior margin of the neck is in relation
ureter and gonadal vein to the inferior pancreatico-duodenal and right
gastro-epiploic vein
ᴏ Is surrounded (superiorly, to the right and in-
feriorly) by the anterior and posterior pancre-
atico-duodenal arcades which travel parallel
to the duodenal loop
ᴏ The third part of the common bile duct runs
through it (multiple anatomic variations)
The uncinate process
ᴏ Its anterior surface is in direct relation with
the superior mesenteric vessels
ᴏ Anterior to the aorta and inferior vena cava
ᴏ Inferior and anterior to the left renal vein
ᴏ Superior and slightly anterior of the third part
of the duodenum (D3)
ᴏ Its posterior surface is in direct contact with
the retroduodenopancreatic coalescence fas-
cia of Treitz
The pancreatic neck (istmus)
Figure 4: Posterior relationships of the neck of the pancreas
ᴏ Partially posterior to the pylorus (intraoperative aspects).
ᴏ Left and inferior to the gastro-duodenal artery
ᴏ Anterior to the superior mesenteric vessels
The pancreatic body The pancreatic tail
ᴏ Its anterior surface is covered by the posterior ᴏ Extends into the pancreatosplenic ligament,
peritoneum of bursa omentalis up to the hilum of the spleen along with the
splenic artery and the origin of the splenic
ᴏ Posterior to the stomach vein
ᴏ At the level of the inferior margin the perito-
neum that covers the anterior surface contin-
ues with the peritoneum that covers the infe-
rior surface
ᴏ These layers of peritoneum will cover anterior
the transvers mesocolon
ᴏ The middle colic artery emerges from under
the inferior margin and passes between the
two peritoneal layers of transvers mesocolon
to reach the transverse colon
ᴏ Anterior to the aorta
ᴏ Anterior to the origin of the superior mesen-
teric artery
ᴏ Its left extremity is in relation with:
Figure 5: Vascular relationships of the pancreas.
■ The left kidney and renal vessels
■ Left adrenal gland Vascularization
ᴏ The superior margin is in relation with the Arteries
tortuous trajectory of the splenic artery ᴏ Superior pancreatico-duodenal arteries
ᴏ The posterior surface is in relation to the ■ An anterior and a posterior artery
splenic vein that drains the pancreas through
■ Emerge from the gastroduodenal artery
small tributaries
through a common trunk or separately ᴏ Dorsal pancreatic artery

■ The posterior artery is initially situ- ■ Emerges from the splenic artery close to
ated between the pancreatic head and its origin
the main bile duct, but as it descends it ■ Branches into two right and one left ar-
passes to the right side of the bile duct tery (inferior pancreatic artery)
■ The anterior artery originates posterior • One of the right branches travels
to the first part of the duodenum (D1) laterally towards right to eventu-
and descends in between the pancreatic ally anastomose with the anterior
head circumference and duodenal loop arterial arch
■ They anastomose inferiorly with the • The other branch passes posteri-
inferior pancreatico-duodenal arteries orly to the superior mesenteric
forming two arches (anterior and poste- vein supplying the uncinate pro-
rior) that follow the duodenal loop cess and finally anastomosing
■ The arterial arches give out duodenal with the posterior arterial arch
arteries towards the right side and pan- ■ The left branch is known as the inferior
creatic arteries towards the left side pancreatic artery and progresses on the
ᴏ Inferior pancreatico-duodenal arteries inferior pancreatic margin towards the
■ An anterior and a posterior artery tail
■ Emerge from the superior mesenteric ᴏ Great pancreatic artery

artery either posterior to the pancreas ■ Emerges from the splenic artery at the
or at the level of its inferior margin junction of the right 2/3 with the left 1/3
■ Initial common trunk or separate of the pancreas
■ Progress superiorly and anastomose ■ Has a descending trajectory

with the superior pancreatico-duodenal ■ Midway towards the inferior margin it
arteries forming the arches mentioned splits into three branches (left, middle
before
and right) that will anastomose with the ᴏ The superior pancreatico-duodenal veins
inferior pancreatic artery ■ Drain into the gastroduodenal vein that
ᴏ The pancreatic tail artery will drains into the portal vein
■ Emerges from a terminal branch of the ᴏ The inferior pancreatico-duodenal veins
splenic artery ■ Drain into the superior mesenteric vein
■ Loops back to the tail of the pancreas ᴏ The anterior and posterior venous arches form
■ Progresses inferiorly to anastomose a collateral link between the superior mesen-
with the inferior pancreatic artery teric and portal vein
ᴏ The pancreatic veins
■ Drain blood from the body and tail into
the splenic vein
Figure 6: Arterial supply of the pancreas.
Veins
Figure 7: Pancreatic vascularisation (intraoperative aspects).
ᴏ The veins that drain the pancreas have the
same trajectory as the corresponding arteries
Lymphatic drainage Acknowledgment

ᴏ Lymph vessels originating in the interlobular Bartoș Adrian is the coordinator of this chapter.
septa converge to form the perilobular lym-
phatic network References
ᴏ Lymph is drained to the pancreatico-renal, 1. Papilian V. Pancreas in Human Anatomy. ALL.
superior mesenteric, pyloric (inconstant) and 12th edn. 2010; 2.
eventually to the celiac nodes
2. Papilian V. Pancreas in Elementary Treaty of top-
ᴏ Lymph is also drained through the hepatic ographic and descriptive anatomy (medico-surgi-
and left gastric nodes cal applications). Dacia Traiana. 4th edn.1946; 2.
Innervation 3. Gray H. Pancreas in Anatomy. The Anatomical
Basis of Clinical Practice. 41th edn. Amsterdam:
Rich autonomic nerve supply Elsevier. 2016.
Supplied by both sympathetic and parasympa- 4. Skandalakis J E, Colburn GL, Weidman TA, Fos-
thetic innervation through the periarterial plex- ter Jr RS, Kingsworth AN, et al. Liver in Skanda-
uses (splenic, hepatic, superior mesenteric) lakis’ Surgical Anatomy: The Embryologic and
Parasympathetic innervation Anatomic Basis of Modern Surgery. Greece: Pas-
ᴏ Vagal trunks chalidis Medical Publications. 2004; 2.
ᴏ Fibers have a secretory effect on the glands

and the acini
Sympathetic innervation
ᴏ Splanchnic nerves
ᴏ Fibers have a vasomotor effect
Sensitive fibers that pass through the laterover-
tebral sympathetic ganglia (6-11) enter the spine
through the thoracic spinal nerves
Chapter 8
Peritoneum Position in Human Body
Abdominopelvic cavity and the contained viscera
1 2 1
Bartoș Adrian , Stoian Raluca , Iancu Ioana , Bartoș
Dana1,2* Organ Type
1
Continuous, smooth serous membrane
‘’Prof Dr. Octavian Fodor’’, Surgery Department, Romania Covers the abdominopelvic walls and organs
In males, it forms a closed sac
2
In females, it is open at the lateral ends of the fal-
*
Corresponding Author: Bartoș Dana, Anatomy and Em- lopian (uterine) tubes
briology Department, UMF “Iuliu Hațieganu”, Cluj-Napoca,
Romania; Regional Institute of Gastroenterology and
Hepatology ‘’Prof Dr. Octavian Fodor’’, Surgery Depart- Mesentery
ment, Cluj-Napoca, România, Tel: 0040758020399; Fax: ᴏ Double layer of peritoneum that comes from
0040264334734; Email: bartosdanamonica@gmail.com the body walls and envelopes an organ
First Published June 15, 2017 ᴏ Connects an intraperitoneal organ to the body
wall
Copyright: © 2017 Bartoș Adrian, Stoian Raluca, Iancu ᴏ It has a core of connective tissue containing
Ioana, Bartoș Dana. blood and lymphatic vessels, nerves, lymph
nodes and fat
ᴏ e.g.: mesentery of the small intestine, trans-
verse and sigmoid mesocolon
mits unrestricted use, distribution, and reproduction in any Omentum
medium, provided you give appropriate credit to the original ᴏ Is a double or four-layered extension (fold) of
author(s) and the source. peritoneum that passes from the stomach and
the gastrohepatic ligament close to its

proximal part of the duodenum to adjacent gastric attachment
organs in the abdominal cavity
■ It is formed by: hepato-gastric ligament
ᴏ The greater omentum and hepato-duodenal ligament
■ Four-layered peritoneal fold that hangs Peritoneal ligaments
down like an apron from the greater
curvature of the stomach and the proxi- ᴏ Double layer of peritoneum that connects an
mal part of the duodenum organ with another organ or to the abdominal
wall
■ After descending, it folds back and at-
taches to the anterior surface of the ᴏ Falciform ligament (reflection of the peri-
transverse colon and its mesentery toneum on the round ligament of the liver):
liver - anterior abdominal wall
■ It is formed by: gastro-phrenic liga-
ment, gastro-splenic ligament, gastro- ᴏ Coronary ligament of the liver
colic ligament and epiploic apron ᴏ Left and right triangular ligament of the liver
ᴏ The lesser omentum ᴏ Hepatogastric ligament: liver - lesser curva-
■ Between the visceral surface of the liver, ture of the stomach
abdominal esophagus and the stomach, ᴏ Hepatoduodenal ligament: liver - duodenum
pylorus and first part of the duodenum (it contains the portal triad: portal vein, prop-
■ It also connects the stomach to a triad er hepatic artery and bile duct)
of structures that run between the duo- ᴏ Gastrophrenic ligament: stomach - inferior
denum and liver in the free edge of the surface of the diaphragm
lesser omentum formed by two layers
of peritoneum separated by a variable ᴏ Gastrosplenic ligament: stomach - spleen
amount of connective tissue and fat ᴏ Gastrocolic ligament: stomach - transverse
■ The right and left gastric vessels, branch- colon
es of the vagus nerves and lymph nodes ᴏ Broad ligament
are contained within the two layers of ᴏ Suspensory ligament of ovary
ᴏ Round ligament of uterus internal surface of the anterolateral ab-

dominal wall)
ᴏ Some authors recognize some other peritone-
al ligaments: hepatoesophageal, splenorenal, ■ Lateral umbilical folds: covers the infe-
colorenal; these structures are better said that rior epigastric arteries
they are adhesions (adherences, attachments Peritoneal recess or fossa
or simply ligaments) because by definition,
ᴏ Peritoneal depression that is formed by the
a peritoneal ligament involves the presence
reflections of the parietal peritoneum over
of two layers of peritoneum and it links two
intraperitoneal or secondary retroperitoneal
intraperitoneal organs or one intraperitoneal
viscera and becomes visceral peritoneum or
organ and the abdominal wall, the peritone-
space located between peritoneal folds
um being a continuous layer
Adhesion and continuity
Bare areas of intraperitoneal organs
ᴏ Parietal peritoneum is linked to the abdomi-
ᴏ The area that is not covered by peritoneum
nal and pelvic cavity walls by subperitoneal
■ To allow the entrance or exit of neuro- fascia (formed by areolar tissue)
vascular structures
ᴏ Subperitoneal fascia under the parietal perito-
■ ‘Bare area’ of the liver is located postero- neum is thicker at the level of posterior wall of
superior on the liver, in direct contact the abdomen (pararenal fat in retroperitoneal
with the right hemidiaphragm space) and between pelvic peritoneum and
Peritoneal fold pelvic diaphragm (tissue of pelvisubperito-
neal space)
ᴏ Reflection of peritoneum that is raised from
the body wall by underlying blood vessels, ᴏ Visceral peritoneum is firmly adherent to the
ducts and ligaments formed by: underlying viscera and often blends with con-
nective tissue in the wall of the organ
■ Median umbilical fold: covers the ura-
chus Visceral Positioning
■ Medial umbilical folds: covers the oblit- Intraperitoneal organs- covered by visceral peri-
erated fetal vessels (e.g., umbilical folds- toneum
• The root of the transverse me-

ᴏ Stomach, Duodenum (D1), Jejunum, Ileum, socolon passes obliquely from the
Appendix, Transvers Colon, Sigmoid Colon, anterior aspect of the second part
Spleen, Liver, Pancreas (tail) of the duodenum, over the head,
neck and body of the pancreas,
Extraperitoneal organs- between abdomen and superior to the duodenojejunal
pelvic walls and parietal peritoneum junction over the upper pole of
– Retroperitoneal: Kidneys, Adrenal glands, the left kidney to the splenic flex-
Pancreas (head, uncinated process, neck, ure
body) • It contains the middle colic vessels
– Secondary retroperitoneal: Duodenum and their branches, together with
(D2, D3, D4), Cecum, Ascending Colon, autonomic nerves from the aor-
Descending Colon tic plexus, lymphatic and lymph
nodes
– Preperitoneal: Urachus
– Infraperitoneal: Rectum
Divisions of Peritoneal Cavity

Peritoneal Abdominal Cavity
ᴏ Greater Abdominal Cavity
■ Transverse mesocolon
• The mesentery of the transverse
colon is a broad fold of visceral
peritoneum reflected anteriorly
from the posterior abdominal
wall
• Suspends the transverse colon in
the peritoneal cavity
Figure 1: Peritoneal cavity.
• The left limb of the attachment

■ Mesentery of the small intestine runs over the left psoas major and
• Fan like disposition that is formed along the external iliac vessels
from two layers of peritoneum • The right limb passes over the
(anterosuperior and posteroinfe- pelvic brim towards the midline
rior) separated by fatty connec- at the level of the third sacral ver-
tive tissue containing vessels and tebra
nerves
■ Recesses of the peritoneal cavity
• The root of the mesentery crosses
over the third part of the duode- • Lesser sac
num, abdominal aorta, inferior • Duodenal recesses
vena cava, right ureter and right
psoas major. ✓ Superior duodenal recess
■ Mesoappendix ✓ Inferior duodenal recess
• Mesentery of the appendix is a ✓ Paraduodenal recess

fatty, triangular fold of peritone- ✓ Retroduodenal recess
um that passes between the pos- ✓ Duodenojejunal recess
terior surface of the mesentery
of the terminal ileum close to the ■ Cecal recesses
ileocaecal junction and the vermi- ✓ Superior ileocecal recess
form appendix
✓ Inferior ileocecal recess
• Inside travel blood vessels, nerves,
✓ Retrocecal recess
lymph vessels and lymph nodes of
the vermiform appendix ■ Intersigmoid recess
■ Sigmoid mesocolon
• The root of the sigmoid colon
usually has a shallow, inverted V-
shaped attachment
■ Falciform ligament of the liver- perito-

neal reflection over the round ligament
■ Median umbilical ligament: urinary
bladder to the umbilicus (peritoneal re-
flection over urachus)
■ Medial umbilical ligaments: lateral sur-
face of urinary bladder to umbilicus
(peritoneal reflection over umbilical ar-
teries)
■ Lateral umbilical ligaments: lateral to
the medial umbilical ligaments (perito-
neal reflection over inferior epigastric
vessels)
■ These peritoneal ligaments separate
paired peritoneal fossas: supravesical
fossa, medial inguinal fossas, lateral in-
guinal fossas
Figure 2: Peritoneal recesses. ᴏ Supramezocolic compartment
■ It is an intraperitoneal region
ᴏ Previsceral space
■ Between the diaphragm and the trans-
■ Between parietal peritoneum of posteri- verse mesocolon
or surface of anterior abdominal cavity
wall and stomach, liver, greater omen- ■ Right supramesocolic space can be sub-
tum, bowels divided into the right subphrenic space,
right subhepatic space and the lesser sac
■ Round ligament of the liver: umbilicus-
liver
■ The left supramesocolic space can be ✓ Posterior: superior pole of the

divided into two subspaces: the left sub- right kidney and right adrenal
phrenic space and left perihepatic space gland
■ Organs: liver, stomach, first part of duo- • It is bounded

denum (D1), tail o the pancreas and the ✓ Superiorly: inferior layer of
spleen the coronary ligament
■ Right subphrenic space (recess) ✓ Laterally: right lateral abdom-
• Located between inal wall
✓ Superior: diaphragm ✓ Posteriorly: anterior surface of

the superior pole of the right
✓ Inferior: anterior, superior kidney and right adrenal gland
and right lateral surfaces of
the right lobe of the liver ✓ Inferomedially: hepatic flex-
ure, transverse mesocolon,
• It is bounded: second part of the duodenum
✓ Left side: falciform ligament and thr right circumference of
the head of the pancreas
✓ Postero-superior: the superior
layer of the coronary ligament ■ Left subphrenic space (recess)
and right triangular ligament • Located between
■ Right subhepatic space (recess) - hepa- ✓ Superior: diaphragm
torenal pouch of Morison
✓ Inferior right: anterior and su-
• Located between perior surfaces of the left lobe
✓ Anterior: inferior (visceral) of the liver
surface of the right lobe of the ✓ Inferior left: the anterosuperi-
liver or surface of the stomach and
the diaphragmatic surface of
the spleen
• It is bounded spaces (recesses or gutters)

✓ To the right by the falciform ■ Right paracolic gutter - lateral to the as-
ligament cending colon
✓ To the left by the lateral left ■ Left paracolic gutter - lateral to the de-
abdominal wall scending colon
■ Extraperitoneal subphrenic spaces ■ Intraperitoneal organs inside this com-
• They lie outside (posterior) the partment: small intestine, cecum, ap-
peritoneum and they are of clini- pendix, transvers colon, sigmoid colon
cal relevance because they may be ■ Right infracolic space
sites of pathologic fluid accumu- • Triangular space
lation
• Smaller than its left-sided coun-
• Right extraperitoneal space is terpart
bounded by the two layers of the
coronary ligament, the bare area • Located posterior and inferior to
of the liver and the inferior sur- the transverse colon and mesoco-
face of the right hemidiaphragm lon and to the right of the small
intestinal mesentery
• Left extraperitoneal space lies an-
terior to the left suprarenal gland ■ Left infracolic space
and superior pole of the left kid- • Larger than its right-sided coun-
ney terpart
ᴏ Inframesocolic compartment • It communicates freely with the
■ Inferior to the transverse mesocolon pelvis cavity
and transverse colon • Located posterior and inferior to
■ Is divided into two unequal spaces by the transverse colon and meso-
the root of the small intestine mesen- colon and to the left of the small
tery: right and left infracolic (enteral) intestinal mesentery
✓ Gastro-hepatic ligament
✓ Quadrate lobe of the liver
• Posterior
✓ Body of the pancreas
✓ Part of the inferior surface of
diaphragm
Figure 3: Attachments of peritoneum.
ᴏ Lesser Abdominal Cavity or Lesser Sac or Figure 4: Posterior wall Omental bursa.
Omental Bursa
• Superior
■ Main area of omental bursa
✓ Gastrophrenic ligament
• Anterior
• Inferior
✓ Posterior wall of stomach
✓ Transverse mesocolon
✓ Gastrocolic ligament
✓ The insertion of gastro-colic

ligament on the transvers co-
lon
• Right side
✓ Winslow (epiploic or omen-
tal) foramen
• Left side
✓ Spleen hilum
✓ Junction of gastrosplenic and
pancreatosplenic ligaments
■ Extensions of omental bursa Figure 5: Transvers section Omental bursa.
• Vestibule of omental bursa ■ Epiploic foramen (Winslow)

• Superior omental recess: between • Anterior: the free right lateral bor-
esophagus and inferior vena cava der of the lesser omentum (more
precise the hepato-duodenal seg-
• Splenic recess: between gastros-
ment) that contains portal vein,
plenic ligament and splenophren-
main bile duct and proper hepatic
ic attachment
artery
• Posterior: posterior parietal peri-
toneum that covers the inferior
vena cava
• Superior: caudate lobe of the liver
• Inferior: the superior border of
the duodenum (D1)
vesicles and on to the posterior surface

of the bladder, creating this way the rec-
tovesical pouch (Douglas)
■ The peritoneum covering the postero-
superior surface of the bladder forms a
paravesical fossas, limited on each side
by a ridge of peritoneum containing the
vas deferens
Figure 6: Winslow hiatus.
Peritoneal Pelvic Cavity

ᴏ Peritoneum of the male pelvis
■ The peritoneum of the left lower ab-
dominal wall is reflected from the distal
sigmoid colon and anterolateral surface
Figure 7: Midsagittal section male pelvis.
of the upper rectum to the side walls of
the true pelvis, where it forms the right
ᴏ Peritoneum of the female pelvis
and left pararectal fossae (recesses, gut-
ters) ■ The peritoneum that covers the ante-
rolateral surface of the superior rectum
■ The peritoneum is reflected anteriorly
descends approximately 4 cm. over the
from the anterior surface of the rectum
anterior surface of the rectum and then
over the superior poles of the seminal
ascends by reflecting itself anteriorly on
the posterior surface of the fornix of the Structure

vagina and uterus; forming the recto-
uterine pouch (of Douglas) Secreting mesothelium of mesodermal origin
■ The pararectal and paravesical fossae Conjunctive-vascular layer that contains collagen
are limited laterally by the peritoneum and elastic fibers, blood vessels, lymph vessels and
that covers the uterosacral and round lymph nodes, fat cells and lymphocytes
ligaments of the uterus Peritoneal cavity contains a small amount of peri-
■ Peritoneum is also reflected from the toneal fluid (up to 5 ml males and 25 ml females)
anterior and posterior uterine surfaces Microscopic mesothelium pores peritoneal sto-
to the lateral pelvic walls as the broad mata and sites of lymphoid aggregates (‘milky
ligaments of the uterus spots’) in the omentum contribute to peritoneal
fluid absorption
Blood Supply and Lymphatics

Arterial supply
Parietal peritoneum: abdominal and pelvic
walls vessels
Visceral peritoneum: splanchnic vessels
Venous supply
Parietal peritoneum: veins tributary to infe-
rior vena cava and superior vena cava
Figure 8: Midsagittal section female pelvis. Visceral peritoneum: veins tributary to por-
tal vein firstly and secondary to inferior
vena cava
Lymphatics
Parietal peritoneum lymph is absorbed

mainly at the level of the diaphragmatic
peritoneum and drained into mediastinal
lymph nodes, from this point the lymph is
drained into the thoracic duct and second-
ary into the right lymphatic duct
Visceral peritoneum lymph is drained into
visceral nodes and then into thoracic duct
and cisterna chili
Innervation
Parietal peritoneum - somatosensory innervation:
last 6 pairs of intercostal nerves, subcostal nerves,
lumbar plexus branches, phrenic nerves
Visceral peritoneum- vegetative innervation:
splanchnic sympathetic nerve fibers, parasympa-
thetic vagal and sacral fibers
Acknowledgment
Bartoș Dana is the coordinator of this chapter.
References
1. Papilian V. Peritoneum in Human Anatomy. ALL.
12th edn. 2010; 2.
2. Gray H. Peritoneum and peritoneal cavity in
Anatomy of the Human Body. 20th edn. Philadel-
phia: Lea & Febiger. 1918; Bartleby.com. 2000.

Anatomyofthe Annexesofthe Digestive Tract

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Anatomyofthe Annexesofthe Digestive Tract

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Anatomy of the Annexes

Bartos Dana Monica

Copyright: © 2017 Bartoș Dana, Blidaru Dana and Bartoș

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Figure 1: Medial wall of the submandibular fossa. Inferior view.

■ Inferior wall ᴏ Tail

Figure 4: Relationships of the superficial and deep part of subman-

ᴏ The medial surface of superficial part

Figure 6: Relationships of the medial surface of the superficial part of

ᴏ Inferior surface of superficial part

Specific Features ■ Medial:

ᴏ Medial border: Pharynx ᴏ The retromandibular vein formed inside the

Figure 1: Position of the parotid gland into the mandibulo-vertebro-

Division with the liver, through connective tissue

■ The largest part of the gallbladder • Anterior abdominal wall, projects

■ At the level of the neck forms the spiral

ᴏ Internal mucous layer ■ Not a terminal artery

3. Gray H. Gallbladder and biliary tree in Anatomy.

ᴏ In Porta Hepatis (hilum of liver) - join to form

✓ Left branches of the hepatic

ᴏ Supraduodenal ✓ Portal vein bifurcation (ante-

✓ Duodenum (superior portion)

Internal Configuration ■ 3 o’clock (left) and 9 o’clock (right) ar-

• Descending branches – from: Venous supply

✓ Right hepatic artery ᴏ Two plexuses

✓ Cystic artery ■ Epicholedochal venous plexus

ᴏ Supraduodenal segment of common bile duct ■ Paracholedochal venous plexus

■ Poor vascularisation ᴏ Common bile duct

ᴏ Supraduodenal and retroduodenal segments ■ Postero-superior pancreaticoduodenal

■ Retroportal artery Lymphatic drainage

• Posterior to the portal vein ᴏ Hepatic lymph nodes

ᴏ Retropancreatic segment of common bile duct ■ Hepatic group – hepatic artery

■ Arteries from superior posteropacreati- ■ Infrapyloric group – 4 or 5, gastro-duo-

■ Retroportal artery Innervation

Shape and General Features

• Anteriorly - the fossa of the um- • Contains the hepatic ducts,

• Divides the liver tissue between ■ Diaphragmatic peritoneal duplication

■ 2 layers with areolar tissue in between

Right anatomical lobe is formed by: segments 4,

Figure 5: Anatomical segmentation of the liver (done by visible ana-

On the diaphragmatic surface - along the falci-

ᴏ Portal branches for segment 1can come from • Medio-inferior segment or 4b

ᴏ Right portal vein is divided in 2 branches => • Latero-superior segment or 2nd

■ Each of the 2 branches of the right por- • Latero-inferior segment or 3rd

■ The right part of the inferior surface ■ Caudate lobe:

• Coronary ligament of the liver

liver together with the portal vein and

Vascularization Figure 10: Hepatic pedicle (intraoperative aspects).

■ Is formed by the confluence of the su-

✓ Medio-superior branch for 4a ■ They are solitary, and easy to distinguish

• Right hepatic vein – drains direct- • From the interlobular spaces of

Has 3.8 centimeters in width

■ Supero-inferior trajectory from the tail

ᴏ Anterior to the inferior vena cava ᴏ Anterior to the spleno-mesenteric confluence

ᴏ Anterior to the right renal vessels ᴏ Anterior to the portal vein

The pancreatic body The pancreatic tail

through a common trunk or separately ᴏ Dorsal pancreatic artery

■ Emerge from the superior mesenteric ᴏ Great pancreatic artery

■ Progress superiorly and anastomose ■ Has a descending trajectory

Figure 6: Arterial supply of the pancreas.

Lymphatic drainage Acknowledgment

ᴏ Fibers have a secretory effect on the glands

the gastrohepatic ligament close to its