THE ABDOMEN

Surface Landmark

• Umbilicus – level of IVD of L3-L4

• Subcostal plane – L3
• Transtubercular – Body of L5
Abdominal Regions
• NINE REGIONS
• Central:
• Epigastric
• Umbilical
• Hypogastric/Pubic
• Lateral:
• R/L Hypochondriac
• R/L Lumbar
• R/L Inguinal
Muscles
• 4 paired
• 3 flat
• 1 strap like

• Strengthens abdominal wall

• Decrease risk of protrusion of
viscera
EXTERNAL OBLIQUE
• Most superficial
• Free inferior margin=inguinal ligament
• Interdigitate w/ serratus anterior and
latissimus dorsi
• Obliquely downward and medially
• Form aponeurosis

INTERNAL OBLIQUE
• Deep to external oblique
• Upward and medial
• Aponeurotic fibers of int oblique and
transversus abdominis=conjoint tendon
TRANSVERSUS ABDOMINIS
• Innermost
• Flat
• Ends in aponeurosis
• Contribute to conjoint tendon
RECTUS ABDOMINIS
• On either side of linea alba
• Segmented = tendinous intersections
• Lateral border convex=linea semilunaris
PYRAMIDALIS
• Not always present
• Tenses linea alba
RECTUS SHEATH
• formed by the aponeuroses of
the transverse abdominal and
the internal and external oblique
muscles
ARCUATE LINE
• Cresenteric border on the posterior wall
• Midway between umbilicus and pubic crest
CONTENTS OF RECTUS
SHEATH
• Rectus Abdominis
• Pyramidalis
• Superior Epigastric vessel
• Inferior Epigastric vessels
• Lower 5 intercoastal and subcoastal
vessels and nerves
BLOOD SUPPLY:
• Superior Epigastric –from internal thoracic
• Inferior Epigastric-from external iliac
• Deep circumflex Iliac –from external iliac
VENOUS DRAINAGE:
• Superior Epigastric-to internal thoracic
• Inferior Epigastric-to external iliac
• Deep circumflex iliac-to external iliac
NERVE SUPPLY:
• Ventral Rami of the Lower six Thoracic nerves and First Lumbar
nerve
 INGUINAL TRIANGLE AND CANAL
INGUINAL TRIANGLE
• Hesselbach’s
• Boundaries:
vSuperior and lateral - Inferior
Epigastric artery
vInferior and lateral – Inguinal
ligament/Poupart’s lig.
vMedial – Rectus Abdominis
INGUINAL CANAL
• Boundaries
• Anterior- External Oblique muscle
• Posterior-Transversalis fascia and
conjoint tendon
• Superior- Internal Oblique and
Transverse Abdominis
• Inferior- Inguinal Ligament
• Males-Spermatic cord
• Females-round ligament
• Common Structure-Ilioinguinal nerve
Guide Question
After surgical repair of a hernia,the patient experiences
numbness in the skin on the anterior aspect of the scrotum. What
nerve may have been lesioned during the herniorrhaphy?

A. Femoral
B. Obturator
C. Iliolinguinal
D. Ilihypogastric
E. Pudendal
SPERMATIC CORD
STRUCTURES WITHIN:
1. Vas Deferens
2. Testicular artery
3. Testicular veins(pampiniform
plexus)
4. Testicular lymph vessels
5. Autonomic nerves
6. Processus vaginalis
7. Cremasteric artery
8. Artery of vas deferens
9. Genital branch of genitofemoral
nerve
Spermatic cord mnemonics
• Spermatic cord contents "3 arteries, 3 nerves, 3 other things“
• 3 arteries: testicular, artery of ductus deferens, cremasteric.
• 3 nerves: genital branch of the genitofemoral, cremasteric, autonomics
• 3 other things: ductus deferens, pampiniform plexus, lymphatics
CLINICAL CORRELATE
ABNORMAL CYSTS IN THE SPERMATIC CORD
• Hydrocele- accumulation of serous fluid
• Hematocele- accumulation of blood; results from rupture of testicular
blood vessels after trauma
• Spermatocele-cyst containing sperm that develops in the epididymis
• Varicocele-results from dilatations of tributaries of testicular vein
GUIDE QUESTION
Which of the ff is TRUE regarding Indirect Inguinal hernia?
A. Acquired type
B. Never enters the scrotum
C. Common in elderly individuals
D. Passes lateral to inferior epigastric vessels
CLINICAL CORRELATE
INGUINAL HERNIAS
INDIRECT DIRECT

Congenital type Acquired type

Children and Young Adults Elderly

Neck of Hernial sac is narrow; Lateral to inferior Neck of hernial sac is wide; Medial to inferior
epigastric vessels epigastric vessels

Enters the scrotum Never enters the scrotum

More common

MUST KNOW
LATERAL- INDIRECT
MEDIAL-DIRECT
GUIDE QUESTION

Cremaster muscle is derived from what layer of the adominal wall?

A. Internal Oblique
B. Transversus abdominis
C. External Oblique
D. Transversalis fascia
ABDOMINAL WALL
LAYERS Of ABDOMINAL WALL
1. Skin vDERIVATIVES
Skin Skin
2. Superficial Fascia-campers
Superficial fascia Dartos muscle
scarpas
Ext. Oblique External spermatic fascia
3. Deep fascia
Int. Oblique Cremaster muscle
4. Muscles
Transversus Abdominis NONE
5. Transversalis fascia
Transversalis fascia Internal spermatic fascia
6. Extraperitoneal fat Extraperitoneal fat NONE
7. Parietal peritoneum Peritoneum Tunica Vaginalis
• CREMASTERIC REFLEX
• Utilizes sensory and motor fibers in the ventral ramus of the L1 spinal nerve
• Stroking the skin f the superior and medial thigh stimulates sensory fibers of
the Ilioinguinal nerve
• Motor fibers from the genital branch of the genitofemoral cause the
cremaster muscle to contract, elevating the testis
PERITONEUM

• Glistening transparent serous membrane

• Consist of 2 continuous layers
• Parietal Peritoneum-lining the internal surface of the
abdomino-pelvic wall
• Visceral Peritoneum-investing organs/ viscera
• Peritoneum and Viscera muscle are located in the
abdominopelvic cavity
PARIETAL VISCERAL

Sensitive to pressure, pain, heat and cold; pain is Insensitive to touch, heat, cold and stimulated
generally localized primarily by stretching: pain is poorly localized

Served by the same blood and lymphatic vasculature Served by the same blood and lymphatic vasculature
and same somatic nerve supply as the region of the and same visceral nerve supply as the organs it covers
wall it lines
GUIDE QUESTIONS
If an abdominal infection spread retroperitoneally, which of the
following structures would most likely be affected?
A. Stomach
B. Transverse colon
C. Descending colon
D. Spleen
PERITONEAL ORGANS
1. Esophagus
2. Stomach
3. 1st duodenum
4. Jejunum/Ileum
5. Cecum and Appendix
6. Transverse/ Sigmoid colon
7. Superior rectum
8. spleen
RETROPERITONEAL ORGANS
PRIMARY- not GIT SECONDARY- GIT
Kidney Duodenum (2nd -4th)
Ureter Pancreas
Urinary bladder Ascending /Descending colon
Uterus Middle rectum
Fallopian tube
Aorta
IVC
Suprarenal glds
EXTRAPERITONEAL ORGAN
• No peritoneal covering at all
• Inferior rectum

TAKE NOTE:

Sup. Rectum--- Peritoneal

Middle Rectum---Retroperitoneal
Inf. Rectum----Extraperitoneal
PERITONEAL CAVITY
• Potential space between the parietal and visceral layers of
peritoneum
• Contains a thin layer of peritoneal fluid that keeps the surfaces
moist;
Lubricates enabling the viscera to move each other without friction
• NO ORGANS in the peritoneal cavity
• Peritoneal cavity is within the abdominal cavity and continues into
the pelvic cavity
• COMPLETELY CLOSED in males
• In Females-there is communication pathway to the esterior of the
body through the Uterine cavity and Vagina
SUBDIVISIONS OF PERITONEAL CAVITY
1. GREATER SAC- mainand larger part of the
peritoneal cavity; extends from diaphragm to
the pelvis
2. LESSER SAC/OMENTAL BURSA- smaller
part;lies posterior to the stomach and lesser
omentum. Permits free movement of the
stomach on adjacent structures. Has two
recesses: superior recess and inferior recess
• BOUNDARIES OF FARAMEN OF WINSLOW
• A: Hepatoduodenal ligament
Portal vein, Hepatic artery, Bile duct
• P:IVC
• S: Caudate lobe of liver
• I: Superior part of Duodenum
PERITONEAL REFLECTIONS
• Extensions of the visceral peritoneum

A. MESENTERY
• 2 layered
• Supports hollow viscous to body wall
• Provides a means for neurovascular
communication between the organ and the
body wall; viscera with mesentery are
mobile
. LIGAMENTS
• 2 layered
• Connects viscera to each other or to the
body wall
C.OMENTUM
• Connects stomach with other viscera
GREATER OMENTUM LESSER OMENTUM
• 4 layered • 2 layered
• Greater curvature of stomach • Connects lesser curve of the stomach , duodenum
• “Abdominal policemen” and proximal part of duodenum to the liver
• Greater omentum extends superiorly , laterally to • Hepatoduodenal ligament
the left and inferiorly from the greater curvature • Hepatogastric ligament
of the stomach and proximal part of duodenum
• Has 3 parts:
1. Gastrophrenic
2. Gastrosplenic
3. Gastrocolic
• HEPATODUODENAL LIGAMENT
CONDUCTS THE PORTAL TRIAD:
1. Portal vein lying posterior
2. Common bile duct lying anterior and to the
right
3. Hepatic artery anterior and to the left
CLINICAL CORRELATE
INFLAMMATION OF THE PARIETAL PERITONEUM
• Caused by an enlarged gastrointestinal structure or by escape of fluid
results in sharp, localized pain over the affected area
• May exhibit Rebound tenderness (pain that is elicited after the pressure of
palpation over the affected area is removed)and guarding (reflex spasms of
abdominal muscles in response to palpation)
PERITONITIS
• Inflammation and infection of the peritoneum and commonly occurs due
to ruptured appendix, a penetrating abdominal wound , a perforated ulcer
or poor sterile technique during surgery
 • Treated by rinsing the peritoneal cavity with large amounts of sterile saline
and administering antibiotics
ASCITES AND PARACENTESIS
• Accumulation of fluid in the peritoneal cavity due to peritonitis from
congestion of the venous drainage of the abdomen
• Surgical puncture of the peritoneal cavity for aspiration or drainage of fluid is
called PARACENTESIS
GUIDE QUESTION
Which of the following statements in reference to the abdominal
aorta is NOT anatomically TRUE?
A. It bifurcates into 2 common iliac arteries at the level L4
B. It has the three unpaired anterior branches
C. It enters the abdomen at the level of 12th thoracic vertebra
D. It courses on the right side of the IVC
ABDOMINAL AORTA
I. ANTERIOR III. LATERAL PAIRED
UNPAIRED ABDOMINAL
VISCERAL a) Inferior Phrenic
a) Celiac b) Lumbar
b) Superior
Mesenteric
c) Inferior IV. TERMINAL
Mesenteric
BRANCHES
II. LATERAL PAIRED a) Common iliac
VISCERAL b) Median Sacral
a) Suprarenal
b) Renal
c) Gonadal
CELIAC ARTERY (T12) SUP. MESENTERIC ARTERY (L1) INF. MESENTERIC ARTERY (L3)
• left gastric Inferior pancreaticoduodenal Left Colic
• Splenic – Left gastroepiploic
short gastric
• Hepatic - Right gastric
R/L Hepatic
Gastroduodenal-Right
gastroepiploic
-Sup.
Pancreaticoduodenal

Middle colic sigmoid

Right colic Superior Rectal
Ileo-colic
Jejunal-Ileal
RULE:
PRIMITIVE GUT divisible into:
FOREGUT-supplied by Celiac trunk
MIDGUT-Sup. Mesenteric artery
HINDGUT-Inf. Mesenteric artery
CLINICAL CORRELATE
AORTIC ANEURYSM
• Common site -just proximal to the bifurcation of the aorta at the level of L4 vertebra
• Patients have a pulsating mass at the midline
CELIAC ARTERY OCCLUSION AND EROSION
• If occluded- collateral circulation may develop in the head of the pancreas by way of
anastomoses between the pancreaticoduodenalbranches of SMA and
gastroduodenal
• 3 branches of celiac circulation may be eroded
1. Splenic may be eroded by contents of penetrating ulcer of post. wall of stomach
2. Left gastric-lesser curvature of stomach
3. Gastroduodenal-posterior wall of the 1st part of duodenum
• May have pain referred in the shoulder
INFERIOR VENA CAVA
• Ant. Visceral: R/L hepatic
• Lateral Visceral: R suprarenal
R/L renal
R gonadal
• Lateral Abdominal: Inferior
phrenic
Lumbar
• Veins of origin: R/L common iliac
median sacral
PORTAL VEIN
• Formed by union of (behind the neck of
pancreas)
a. Superior Mesenteric Vein
b. Splenic Vein
• Tributaries:
1. Left gastric vein
2. Right gastric vein
3. Cystic veins
4. Posterior superior pancreaticoduodenal
vein
PORTAL VENOUS SYSTEM
• TRIBUTARIES:
• Superior mesenteric
• Splenic
• Inferior mesenteric
• Left gastric
• Paraumbilical
PORTAL-CAVAL ANASTOMOSES
• Normal route-portal vein liver hepatic vein IVC
PORTAL-CAVAL ANASTOMOSES

• If bocked:
• Esophageal branch of L gastric= esophageal of azygos

• Superior rectal- middle and inferior rectal

• Paraumbilical –superficial veins of ant. Abdominal wall
• Colic vein-retroperitoneal veins
• Liver cirrhosis- causes portal HPN which can produce esophageal varices, caput medusae
and internal hemorroids
• REMEMBER

R/L hepatic IVC

veins
R gonadal and R IVC
suprarenal
L gonadal and L L renal
suprarenal
R gastroepiploic SMV
L gastroepiploic Splenic vein
R colic SMV
L colic IMV
STOMACH
• 1.5 liter capacity
• Acts as food blender and reservoir
• Enzymatic digestion
• Divided into 4 parts:
1. Cardia –near the gastroesophageal
junction
2. Fundus –dilated superior part
3. Body –major part, lies between
fundus and pyloric antrum
4. Pylorus – distal part; divisible into
pyloric antrum ( wide part) and
pyloric canal (narrow part)
• Curvatures:
• Lesser curvature- forms the shorter concave border of the
stomach; angular incisure /notch is the sharp indentation
approximates the junction of the body and pyloric part of the
stomach
• Greater Curvature- forms the longer convex border of the stomach
• SURFACE ANATOMY OF STOMACH
• Cardiac orifice-lies posterior to the 6th left costal cartilage 2-4 cm
from the median plane at the level of T10 or T 11 vertebra
• Fundus - lies posterior to the 5th left rib in the midclavicular plane
• Greater curvature-passes inferiorly to the left as far as the 10th left
costal cartilage
• Pyloric antrum- lies at the level of 9th costal cartilage or at the level of the L1
vertebra ; pyloric orifice is approximately 1.25 cm left of the midline
• Pyloric canal – lies at the right side; location varies from the L2 to the L4
vertebra
BLOOD AND NERVE SUPPLIES
• ARTERIAL BLOOD SUPPLY OF STOMACH
• R and L gastric arteries- lesser curvature
• R and L gastroepiploic arteries-greater curvature
• Short gastric- fundus
• VENOUS DRAINAGE OF STOMACH
• R and L gastric vein to portal vein
• L gastroepiploic and Short veins to splenic vein to portal vein
• R gastroepiploic vein to superior mesenteric vein to portal
• NERVE SUPPLY OF THE STOMACH
• Parasympathetic nerve supply is from the ant. Vagal trunk from the L vagus
nerve and post. vagal trunk from R vagus nerve which enter the abdomen
through esophageal hiatus
• Sympathetic nerve supply is from T6 to T9 segments of the spinal cord
CELIAC ARTERY (T12) SUP. MESENTERIC ARTERY (L1) INF. MESENTERIC ARTERY (L3)
• left gastric Inferior pancreaticoduodenal Left Colic
• Splenic – Left gastroepiploic
short gastric
• Hepatic - Right gastric
R/L Hepatic
Gastroduodenal-Right
gastroepiploic
-Sup.
Pancreaticoduodenal

Middle colic sigmoid

Right colic Superior Rectal
Ileo-colic
Jejunal-Ileal
Clinical correlates
qGASTRIC ULCERS- most often occur within the body of the stomach along the
lesser curvature above the incisura angularis
qCARCINOMAS OF THE STOMACH-most commonly found in the pylorus
qNASOGASTRIC INTUBATION
• To empty, decompress the stomach; obtain sample of gastric juice
• Patient is placed in semi upright or left lateral position
• From the nostril to cardiac orifice of stomach-17.2 inches/ 44cm

MUST KNOW
3 SITES OF ESOPHAGEAL NARROWING MAY OFFER RESISTANCE TI THE NGT:
1st part-7.2 inches /18 cm
2nd -11.2inches/28 cm
3rd -17.2 inches /44 cm
DUODENUM
• 1st and shortest part of the small intestine
• Widest and fixed part
• C-shaped, about 10 inches long (25 cm)
• Begins at the pylorus on the R side and ends at the
duodenojejunal junction on the L side( L2 vertebra)
• DIVISIONS:
• Sup ( 1st part) 5 cm and lies anterolateral to the body of L1
• Descending (2nd part)- 7-10cm and descends along the R sides of L1 through L3
• Horizontal (3rd)- 6-8 cm and crosses L3
• Ascending (4th)- 5 cm and begins at the L of L3 and rises superiorly as far as
superior border of L2
• BLOOD SUPPLY
• Upper part-superior pancreaticoduodenal from gastroduodenal
• Lower part-inferior pancreaticoduodenal from superior mesenteric
• VENOUS DRAINAGE
• Superior pancreaticoduodenal vein drains into portal vein
• Inferior pancreaticoduodenal joins the superior mesenteric
Clinical correlate

• DUODENAL ULCERS- most often occur on the anterior wall of the first
part of the duodenum followed by the posterior wall

• PERFORATION OF THE DUODENUM- occur most often with ulcers on

the anterior wall; less often with ulcers on the posterior wall ( may
erode the gastroduodenal artery causing severe hemorrhage and
perforate into the pancreas)
Gastric vs Duodenal ulcers
GASTRIC
25%
Male to female ratio=1:1
Increased risk with blood type A
Bleeding from left gastric artery
Burning epigastric pain soon after eating; pain
increases with food intake; relieved by antacids
DUODENAL
75%
Male to female ratio=2:1
Increased risk with blood type O
Bleeding from gastroduodenal artery
Burning epigastric pain 1-3 hrs after eating; pain
decreases with food intake ; relieved by antacids;
patient wakes at night because of pain
• DUODENAL COMPRESSION
• The superior mesenteric vessels may compress the horizontal part of the
duodenum; patients experience epigastric pain, nausea after meal and bilious
vomiting
• GIT BLEEDING
• Hematemesis- vomiting of blood, commonly results from bleeding into the
lumen of the esophagus, stomach or duodenum proximal proximalto the
ligament of Trietz; commonly caused by duodenal ulcer, gastric ulcer or
esophageal varices
• Hematochezia –blood in the stool, usually results from bleeding into lumen of
the jejunum, ileum, colon or rectum distal to the ligament of Trietz
JEJUNUM AND ILEUM
• Jejunum, begins at the duodeno-jejunal
flexure and ends at the ileocecal
junction
• 20 ft/6 meters long
• Jejunum lies in the LUQ;ileum lies in the
RLQ
• BLOOD SUPPLY
• Superior mesenteric artery from the
abdominal aorta at level L1, sending 15-18
branches which unite to form loops-
arterial arcades that gives rise to vasa recta
Jejunum vs Ileum
Characteristic Jejunum Ileum
Color Deeper red Paler pink
Caliber 2-4 cm 2-3 cm
Wall Thick and heavy Thin and light
Vascularity Greater Less
Vasa recta Long Short
Arcades Few, large Many
Fat Less more
Plicae circularis Large, tall Low, sparse- absent in distal
Lymphoid nodules Few Many
Clinical correlate
Intussuception
• Part of the small intestine invaginates into an adjacent distal segment
(intussucipiens)
• May be jejunoileal, ileoileal or most commonly , ileocecal
• More common in children; may be caused by hyperplasia of
lymphatic tissue in the wall of ileum
• Obstructed bowel, right sided colicky pain, abdominal distention and
hematochezia
PANCREAS
• Exocrine and Endocrine gland
• Pancreatic acinar-exocrine
• Islets of Langerhans-endocrine
• Elongated accessory digestive gland; lies
retroperitoneally and transversely across
the posterior abdominal wall
RELATIONS
• Ant-from R-L: transverse mesocolon, lesser
sac and stomach
• Post-from R-L: bile duct, portal and splenic
veins,IVC, aorta, SMA, left psoas, left
suprarenal, left kidney, spleen
PARTS:
• Head-expand parts; is embraced by the
C shaped curve of the Duodenum
• Neck-short and overlies the Superior
Mesenteric vessels
• Body- to the left of SMA and SMV
• Tail- closely related to the hilum of
spleen and left colic flexure
• Uncinate process- projection from the
inferior part of head; extends medialy
to the left post. to SMA
PANCREATIC DUCTS
Main pancreatic of pancreas
• Extends length of pancreas
• Joins duct to form the hepatopancreatic
ampulla
• Empties into duodenum
Accessory pancreatic duct
• Lies in head of pancreas
• Enters duodenum
BLOOD SUPPLY
• Superior pancreaticoduodenal artery
• Inferior pancreaticoduodenal
• Pancreatic arteries from splenic
VENOUS DRAINAGE
• Pancreatic veins which are tributaries of the Splenic
and Suprior Mesenteric; most of them empty into
the splenic vein
CELIAC ARTERY (T12) SUP. MESENTERIC ARTERY (L1) INF. MESENTERIC ARTERY (L3)
• left gastric Inferior pancreaticoduodenal Left Colic
• Splenic – Left gastroepiploic
short gastric
• Hepatic - Right gastric
R/L Hepatic
Gastroduodenal-Right
gastroepiploic
-Sup.
Pancreaticoduodenal

Middle colic sigmoid

Right colic Superior Rectal
Ileo-colic
Jejunal-Ileal
Clinical correlate
Pancreatic Cancer
• Cancer involving the pancreatic head accounts for most cases of
extrahepatic obstruction of the biliary system
• Compresses and obstructs the bile duct causing obstructive jaundice
resulting in the retention of the bile pigments, enlargement of GB and
jaundice
• Cancer of neck and body may cause portal or IVC obstruction
Clinical correlate
Whipple’s-Pancreaticoduodenectomy
• Surgical resection done in cases of pancreatic cancer
• Structures removed:
• Head of pancreas
• Duodenum
• CBD
• GB
• Distal part of stomach
Liver
SURFACE ANATOMY
• Lies mainly in the RUQ of the
abdomen; occupies most of the
R hypochondrium, the upper
epigastrium and extends into
the L hypochondrium
SURFACES
• Diaphragmatic- dome shaped;anterior, superior and posterior
parts, covered with visceral peritoneum except posteriorly in
the bare area
LIGAMENTS
• Falciform ligament
• Coronary ligament
• R/L triangular ligaments
• Ligamentum teres/ round ligament-remnant of umbilical vein;
between L lobe and quadrate lobe
• Ligamentum venosum- remnant of ductus venosus;between L
lobe and caudate lobe
EMBRYOLOGY
• Umbilical vein-ligamentum teres
• Umbilical artery-medial umbilical ligament
• Ductus venosus-ligamentum venosum
• Urachus –median umbilical ligament
• Foramen ovale- fossa ovalis
• Ductus arteriosus- ligamentum arteriosum
Porta Hepatis
Blood Supply

• Portal Vein – 70%

• Hepatic artery – 30%
• Hemorrhage from the liver can be
controlled by clamping the
HEPATODUODENAL LIGAMENT
(Pringles’s Manuever)
Gall Bladder
• Cytohepatic Triangle
• Superior- Liver
• Medial – CHD
• Lateral/Inferior – Cystic duct
• Blood supply
• Cystic artery
CELIAC ARTERY (T12) SUP. MESENTERIC ARTERY (L1) INF. MESENTERIC ARTERY (L3)
• left gastric Inferior pancreaticoduodenal Left Colic
• Splenic – Left gastroepiploic
short gastric
• Hepatic - Right gastric
R/L Hepatic
Gastroduodenal-Right
gastroepiploic
-Sup.
Pancreaticoduodenal

Middle colic sigmoid

Right colic Superior Rectal
Ileo-colic
Jejunal-Ileal
Large Intestines