Lumbar region borders

● Superiorly - 12th rib

● Inferiorly - iliac crest
● Laterally - midaxillary
● Medially- spinous process

Layers
● Skin
● subcutaneous tissue
● Superficial fascia
● Fatty layer inferiorly
● Proper fascia
● Deep fascia that covers muscles

Medial and lateral muscles

Lateral - 3 layers
1st layer-
latissimus Dorsi
External oblique
2nd layer-
Serratus posterior inferior
Internal oblique
3rd layer-
Transverse abdominis
Medially (deeply)-
● Quadratus lumborum
● Psoas major
● Erector spinae

Medially these muscles are lined by intra abdominal

fascia/transverse fascia
Anterior to this- retroperitoneal space

Retroperitoneal space
Ant- parietal peritoneum of post abdominal wall
Post- intra abdominal/transverse fascia

Layers (all together- from Post to ant)

1. Intra abdominal fascia
2. Proper retroperitoneal fat
3. Posterior layer of renal fascia
4. Perirenal fat - continues as parauretic
5. Ant layer of renal fascia
6. Pericolic fat
7. Toldi's fascia/Retrocolic

3 layers of fat (from Post- anterior)

● Proper retroperitoneal fat - lies between intra abdominal
fascia (post) and posterior layer of renal fascia (anterior to it)
 ● Perirenal fat (enclosed by renal fascia), paruretic
● Pericolic fat - between anterior layer of renal fascia and
parietal peritoneum - TOLDI's fasci/Retrocolic fascia (behind
ascending colon)

Fascia
Retroperitoneal fascia
Retrocolic
Endoabdominal

Content - Organs, vessels and nerves

● Organs
● Kidneys ureters suprarenal glands pancreas posterior part of
ascending and descending colon descending ascending and
horizontal part of duodenum

Retroperitoneal space - plexus

● Plexus
● Aortic plexus
● Lumbar plexus
● Sympa trunk

Branches of lumbar plexus -

● ilioinguinal
● Femoral
● Iliohypogastric
● Genitofemoral which divides into genital and femoral
● Obturator nerve
 ● Lateral cutaneous nerve of thigh
● Lumbosacral trunk - portion of 4th lumbar nerve

Great vessels

Inf vena cava tributaries -

● Short hepatic vein
● Right gonadal vein (left gonadal vein enters left renal vein)
● Inferior phrenic vein and lumbar veins
● 2 renal veins

Abdominal aorta branches

3 divisions
1.For organs paired branches-
● Renal - right and left renal artery
● Middlesuprarenal
● Gonadal going to testis/ovary

2.For viscera unpaired

● Celiac trunk - T12/L1
● Superior mesenteric L2
● Inferior mesenteric L3

3.Branches going to body wall-

● Inferior phrenic arteries
● 4 pairs of lumbar segmental arteries
Terminal branches
● 2 Common iliac arteries
● Median sacral arteries

● Kidney -
either side of vertebral column
T11-12 - L2/3
● 2 surfaces- anterior and posterior
● 2 poles- Superior and Inferior
● 2 borders lateral convex and Medial concave
● Lies in perirenal fat (enclosed by retroperitoneal fascia)

Hilus-
vertical slit on the medial concave border (at L1)
CONSISTS OF-
Renal vein, 2 branches of renal arteries, renal pelvis and ureter, renal
artery 3rd branch
Perirenal fat encloses kidney
Perirenal fat enclosed by renal fascia

Layers of kidney -
● Closest- fibrous capsule - renal capsule - attached to contex

● Perinephric fat/perirenal fat - covering kidney+Suprarenal glands

● Renal fascia - extends medially and wraps the great vessels like
IVC
Syntopy of kidney
● Right kidney is lower than left kidney (cause of right lobe of liver)
● Anteriorly to left kidney - stomach, spleen and tail of pancreas

● Anterior to right kidney - right lobe of liver & descending part of

duodenum sits in front of it medially

● Hilus region of left kidney- pancreas

● Hilus region of right kidney- duodenum

● Anterior to Lower pole of left kidney - left colic flexure/splenic

flexure
● Anterior to Lower pole of right kidney- hepatic flexure/right colic
flexure

● Left Lower pole of kidney- covered with peritoneum

● On the right too- lesser area covered with peritoneum
● Small intestine lies in front of both

LIGAMENTS of Kidney - Hepatorenal, Duodenorenal,

Splenorenal (near tail of pancreas)

Pedicle of kidney - consists of vein, artery and ureter/renal pelvis,

sympathetic nerves and lymph vessels.

Suprarenal glands - located on medial side of Upper superior pole of

kidneys

Blood supply - branches of inferior phrenic and renal arteries from

suprarenal branches of the aorta.
Blood drains to the inferior vena cava on the right and to the left renal
vein on the left

Covered by anterior layer of renal fascia (covered by renal fascia) -

perirenal fascia (just tell it)

Ureter
Located in Post abdominal wall
Behind the peritoneum
3 constrictions
First- where renal pelvis joins ureter

Second - crosses pelvic brim ; genitofemoral nerve- compression of

the nerve shows irradiation of pain to external genitalia and femur in
nephrolithiasis if the stone stops before second constriction - clinical
importance

Third - pierces the bladder wall

Arteries - renal artery- Superiorly

Branches of common iliac
Vesical artery- Inferiorly

Pelvic outlet borders

● Post-coccyx
● Ant- pubic arch
● Lateral - ischial tuberosities

Pelvic inlet borders

 ● Post - sacral promontory
● Laterally - iliopectineal lines
● Anteriorly- pubic Symphysis

Parietal muscles that line wall of pelvic cavity -

● Piriformis
● Obturator internus
● Levator ani

Pelvic diaphragm is formed by 2 muscles -

● Levator ani and small coccygeus muscles

Pelvic Fascia
Divides into Parietal and Visceral-
Parietal covers walls of pelvis.
It forms arcus tendinous on boundary between superior half of
obturator internus muscle and levator ani.

The pelvic fascia is formed by 2 ligaments (puboprostatic and

pubovisceral ligaments) between the pubic Symphysis and urinary
bladder in female.

Parietal muscles of pelvic region- Obturator internus

Visceral pelvic fascia covers all the pelvic viscera.

Pelvic viscera borders -

Anteriorly - pubic bones
Posteriorly- sacrum & coccyx
Laterally- sagittal plates
Neurovacular bundles -
Plexus of pelvic region-
Sacral plexus
Lumbosacral trunk

MAIN ARTERY OF PELVIC REGION- INTERNAL ILIAC ARTERY

Nephrectomy operation-

The 2 accesses/incisions are-

● Lumbar subtotal approach by Fludoolov- (incision performed

on skin) STARTS at angle between 12th rib and lateral border of
Erector spinal muscle to downwardly to a curved line between
12th rib and iliac crest at the level of umbilicus and can be
extended forwards to the lateral border of the rectus muscle

● Bergmen-Israel - begin incision from bisector of angle of 12th

rib and lateral border of erector spinae muscle and is carried
downwards and forwards in a curved line between the 12th rib
and iliac crest.

It ends at the Ant wall- 4-5cm above ant sup iliac spine at
iliac crest

Difference Between Fludoolov and Bergman - READ THE LINES

IN BOLD