Small intestine Colon & Anorectum

Embryological DEVELOPMENT The large intestine :

• The first precursor of the small intestine is the embryonic gut tube : • Extends
E from the ileocecal valve to the anus
anus. Anorectum
• It is divided anatomically & functionally into : colon
colon, rectum, and anal canal. The rectum is approximately 12 to 15 cm in length. Three dis>nct
- Formed from the endoderm
th
• The wall of the colon & rectum comprise 5 distinct layers
layers: submucosal folds, the valves of Houston,, extend into the rectal lumen.
- Time : during 4 week of gestation
gestation.
mucosa, submucosa,
submucosa, inner circular muscle, outer longitudinal muscle, serosa. Posteriorly, the presacral fascia separates the rectum from the presacral
• The gut tube is divided into : (
venous plexus and the pelvic nerves. At S4, the rectosacral fascia (Waldeyer's
- In the colon: Outer longitudinal muscle is separated into three teniae coli, fascia)) extends forward and downward and attaches to the fascia propria at
1- Foregut : blood supply: Celiac
eliac & Superior mesenteric artery which converge proximally at the appendix & distally at the the anorectal junction. Anteriorly, Denonvilliers' fascia separates the rectum
- Duodenum rectum, where outer longitudinal muscle layer is circumferential. from the prostate and seminal vesicles in men and from the vagina in
- In the distal rectum: inner smooth muscle layer coalesces to form the women. The lateral ligaments support the lower rectum. The surgical anal
2- Midgut: uperior mesenteric artery.
Superior
"internal anal sphincter" . canal measures 2 to 4 cm in length and generally is longer in men than in
- Rest of small intestine. women. It begins at the anorectal junction and terminates at the anal verge.
- Intraperitoneal colon & Proximal 1/3 of the rectum : are covered by serosa;
- Ascending colon The dentate or pectinate line marks the transition point between columnar
Mid & Lower 1/3 of rectum : lack serosa.
- Proximal transverse colon rectal mucosa and squamous anoderm. The 1 to 2 cm of mucosa just
• During the 6th week of gestation : Colon proximal to the dentate line shares histologic characteristics of columnar,
cuboidal, and squamous epithelium and is referred to as the anal transition
midgut herniates out of the abdominal cavity, and then rotates 270° • Beginning: It begins at the junction of the terminal ileum & cecum zone.. The dentate line is surrounded by longitudinal mucosal folds, known as
counterclockwise around the superior mesenteric artery to return to • Extension: Extends 3 to 5 = to the rectum. the columns of Morgagni,
Morgag , into which the anal crypts empty. These crypts are
its final position inside the abdominal cavity during the 9th week.
Cecum
ecum : the source of cryptoglandular abscesses (Fig. 29-3).
29
3- Hindgut : Inferior mesenteric artery. • The widest diameter por>on of the colon (normally 7.5 to 8.5 cm)
• The
T thinnest muscular wall. In the distal rectum, the inner smooth muscle is thickened and comprises
- Distal transverse colon,
As a result, the cecum is most vulnerable to : perforation and the internal anal sphincter that is surrounded by the subcutaneous,
subcutaneous
- Descending colon, least vulnerable to : obstruction. superficial,, and deep external sphincter. The deep external anal sphincter is
- Rectum
Ascending colon : an extension of the puborectalis muscle. The puborectalis,, iliococcygeus, and
- Proximal anus pubococcygeusmuscles form the levator ani muscle of the pelvic floor (Fig.
• The ascending colon usually is fixed to the retroperitoneum.
29-4).
- During the 6th week of gestation: Hepatic flexure :
the distal-most
most end of the hindgut ( the cloaca ), is divided by the • The hepatic flexure marks the transition to the transverse colon.
urorectal septum into : Transverse colon :
a- Urogenital
rogenital sinus
• The intraperitoneal transverse colon is relatively mobile,
b- Rectum.
ectum.
• but is tethered by :
• Distal anus : 1- Gastrocolic ligament and
- It's derived from ectoderm 2- Colonic mesentery.
- Receives
eceives its blood supply from : Internal pudendal artery. 3- Greater
reater omentum is attached to the anterior/superior edge
- The dentate line divides : These attachments explain the characteristic triangular appearance of the
Endodermal hindgut from Ectodermal distal anal canal. transverse colon observed during colonoscopy.
The splenic flexure :
Gut tube initially communicates with the yolk sac;
• It marks the transition from the transverse colon to the descending colon.
he communication between these two structures narrows by the 6th week
The
• The attachments between the splenic flexure & spleen (lienocolic ligament)
to form " vitelline duct " .
can be short & dense, making mobilization of this flexure during colectomy challenging.
The yolk sac & vitelline duct usually undergo obliteration by the end of
gestation Incomplete obliteration of the vitelline duct results in the
Desending colon :
• The descending colon is relatively fixed to the retroperitoneum.
spectrum of defects associated with Meckel's diverticula.
Sigmoid colon :
GROSS ANATOMY • It's the narrowest part of the large intestine most vulnerable to obstruction.
• The small intestine is a tubular structure that extends from : • It's extremely mobile.
Pylorus to Cecum. - Although the sigmoid colon usually is located in the left lower quadrant,
• Length : 4 to 6 m . redundancy & mobility can result in a portion of the sigmoid colon residing
• The small intestine consists of three segments lying in series: in the right lower quadrant.
1- Duodenum, - This mobility explains:
- the most proximal segment, 1- Why volvulus is most common in the sigmoid colon
- lies in the retroperitoneum immediately adjacent to the head & 2- Whyy diseases affecting the sigmoid colon, such as diverticulitis, may
inferior border of the body of the pancreas. occasionally present as right-sided
sided abdominal pain.
- The duodenum is demarcated from : • Rectosigmoid
R junction : ANORECTAL VASCULAR SUPPLY
• the stomach by the pylorus and - is found at about the level of the sacral promontory and is The superior rectal artery arises from the terminal branch of the inferior
• the jejunum by the ligament of Treitz - described as the point at which the three teniae coli coalesce to form the mesenteric artery and supplies the upper rectum. The middle rectal artery
2- Jejunum, outer longitudinal smooth muscle layer of the rectum. arises from the internal iliac; the presence and size of these arteries are
3- Ileum.
COLON VASCULAR SUPPLY highly variable. The inferior rectal artery arises from the internal pudendal
- The jejunum and ileum lie within the peritoneal cavity and are
artery, which is a branch of the internal iliac artery. A rich network of
tethered to the retroperitoneum by a broad
broad-based mesentery. Superior
uperior mesenteric artery,
artery branches into
into: collaterals connects the terminal arterioles of each of these arteries, thus
- No distinct anatomic landmark demarcates the jejunum from the 1 Ileocolic artery (absent in up to 20% of people) , which supplies :
1- making the rectum relatively resistant to ischemia (Fig. 29--5).
ileum :
a- Terminal ileum
• The
he proximal 40% of the jejunoileal segment defined as the
b- Proximal ascending colon,
jejunum and
2 Right colic artery, which supplies : Ascending
2- scending colon,
• The
he distal 60% as the ileum.
- The ileum is demarcated from the cecum by ileocecal valve. 3 middle colic artery, which supplies: Transverse
3- ransverse colon.
Inferior mesenteric artery, branches into:
• The small intestine contains mucosal folds known as plicae circulares or 1 Left colic artery, which supplies : Descending
1- escending colon,
valvulae conniventes .
2 Several sigmoidal branches, which supply
2- supply: Sigmoid colon,
• Features on gross inspection that are more characteristic of the proximal
than distal small intestine : 3 Superior rectal artery, which supplies: Proximal
3- roximal rectum.
1- Valvulae conniventes. are more prominent in the proximal intestine The terminal branches of each artery form anastomoses with the terminal
2- Other features evident on gross inspection that are more branches of the adjacent
adjacent artery and communicate via :
3- Larger circumference, marginal artery of Drummond
Drummond.
4- Thicker wall,
5- Less fatty mesentery,
6- Longer vasa recta .
• Gross examination of the small intestinal mucosa also reveals ag aggregates of
lymphoid follicles (Peyer's patches) located in the ileum, are the most
prominent . The venous drainage of the rectum parallels the arterial supply. The superior
rectal vein drains into the portal system via the inferior mesenteric vein. The
middle rectal vein drains into the internal iliac vein. The inferior rectal vein
drains into the internal pudendal vein, and subsequently into the internal
iliac vein. A submucosal plexus deep to the columns of Morgagni forms the
hemorrhoidal plexus and drains into all three veins.
ANORECTAL LYMPHATIC DRAINAGE
Lymphatic
hatic drainage of the rectum parallels the vascular supply. Lymphatic
channels in the upper and middle rectum drain superiorly into the inferior
mesenteric lymph nodes. Lymphatic channels in the lower rectum drain both
Venous Drainage : superiorly into the inferior mesenteric
mesenteric lymph nodes and laterally into the
Gross features of jejunum contrasted with those of ileum. • The
The veins of the colon parallel their corresponding arteries & bear same name.
Relative to the ileum, the jejunum has a larger diameter, thicker wall, more internal iliac lymph nodes.
prominent plicae circulares, a less fatty mesentery, and longer vasa recta. Except for the inferior mesenteric vein : The anal canal has a more complex pattern of lymphatic drainage. Proximal
- The inferior mesenteric vein ascends in the retroperitoneal plane over to the dentate line, lymph drains into both the inferior mesenteric lymph
Blood supply : psoas muscle & continues posterior to pancreas to join the splenic vein. nodes and the internal iliac lymph nodes. Distal to the dentate line, lymph
- During a colectomy, this vein often is mobilized independently and primarily drains into the inguinal lymph nodes, but also can drain into the
Arterial : ligated at the inferior edge of the pancreas. inferior mesenteric lymph nodes and internal iliac lymph nodes.
• Most of the duodenum derives its arterial blood from branches of both : COLON LYMPHATIC DRAINAGE ANORECTAL NERVE SUPPLY
1- Celiac
• The lymphatic drainage of the colon originates in a networ
network of lymphatics in Both sympathetic and parasympathetic nerves innervate the anorectum.
a
2- Superior mesenteric arteries.
the muscularis mucosa. Sympathe>c nerve fibers are derived from L1–L3 L1 L3 and join the preaor>c
• istal duodenum, jejunum, and ileum ,from :
Distal
• Lymphatic vessels and lymph nodes follow the regional arteries. plexus. The preaortic nerve fibers then extend below the aorta to form the
1- Superior mesenteric artery.
• Lymph nodes are found:
found hypogastric plexus,
plexus, which subsequently joins the parasympathetic fibers to
Venous drainage : 1- On the bowel wall (epicolic LNs), form the pelvic plexus. Parasympathetic
Parasympathetic nerve fibers are known as the nervi
• Via the Superior mesenteric vein. 2- Along inner margin of bowel adjacent
djacent to the arterial arcades
arcades(paracolic LNs), erigentes and originate from S2–S4.
S2 S4. These fibers join the sympathe>c fibers
3- Around the named mesenteric vessels (Intermediate
ntermediate LNs), to form the pelvic plexus. Sympathetic and parasympathetic fibers then
Lymphatic drainage : 4- At the origin of the superior & inferior mesenteric arteries (M
(Main LNs).
• Lymph drainage occurs through lymphatic vessels coursing parallel to supply the anorectum and adjacent urogenital organs. The internal anal
corresponding arteries. • The sentinel lymph nodes are the first one to four lymph nodes to drain a specific segment sphincter is innervated by sympathetic and parasympathetic nerve fibers;
• This lymph drains through mesenteric lymph nodes to cisterna chyli, of the colon, and are thought to be the first
first site of metastasis in colon cancer. both types of fibers inhibit sphincter contraction. The external anal sphincter
then through the thoracic duct, ultimately into the left subclavian vein. COLON NERVE SUPPLY and puborectalis muscles are innervated by the inferior rectal branch of the
The colon is innervated by both : parallel the course of the arteries. internal pudendal
pud nerve.. The levator ani receives innervation from both the
internal pudendal nerve and direct branches of S3 to S5. Sensory innerva>on
Nerve supply : 1-
1 Sympathetic (inhibitory)
to the anal canal is provided by the inferior rectal branch of the pudendal
- Sympathe>c nerves arise from T6–T12
T12 & L1–L3.
• Parasympathetic Vagus . Althoug the rectum is relatively insensate, thee anal ca
nerve.. Although canal below the
• sympathetic Splanchnic nerves. 2-
2 Parasympathetic (stimulatory) nerves,
erves, dentate
te line is sensate.
- to the right & transverse colon is from the vagus nerve;
- to the left colon is from sacral nerves SS2–S4 to form "nervi erigente"
 Gall Bladder Bile ducts
Shape: pear-shaped sac, The extrahepatic bile ducts consist of : Anomalies
Size: about 7 to 10 cm long
Capacity: average of 30 to 50 mL. 1- Right & left hepatic ducts The classic description of the extrahepatic biliary tree and its
When obstructed, the gallbladder can distend mark
markedly and • Left
eft hepatic duct is longer than the right arteries applies only in about one third of pa>ents.4 The gallbladder
contain up to 300 mL. • The two ducts join to form a "Common hepatic duct
duct" , close to their may have abnormal positions, be intrahepatic, be rudimentary,
Site: It's located in a fossa on the inferior surface of the liver. emergence from the liver. have anomalous forms, or be duplicated.
duplicated. Isolated congenital
A line from this fossa to the inferior vena cava divides the liver into absence of the gallbladder is very rare, with a reported incidence of
right and left liver lobes. 2- Common hepatic duct
0.03%. Before the diagnosis is made, the presence of an
• Length: 1 to 4 cm in length
Division: The gallbladder is divided into four anatomic areas: intrahepatic bladder or anomalous position must be ruled out.
• Diameter : about 4 mm.
1- Fundus : Duplication of the gallbladder with two separate
se
• It lies in front of the portal vein and to the right of the hepatic artery.
- The fundus is the rounded, blind end cavities and two separate cystic ducts has an incidence of about one
• Common
ommon hepatic duct is joined at an acute angle by the cystic duct to
- Extends
xtends 1 to 2 cm beyond the liver's margin. in every 4000 persons. This occurs in two major varie>es: the more
- It contains most of the smooth muscles of tthe organ form Common Bile Duct (CBD).
common form in which each gallbladder has its own cystic duct that
2- Corpus (body) 3- Cystic duct empties independently into the same or different
different parts of the
- It's the main storage area • Length: It's quite variable. extrahepatic biliary tree, and as two cystic ducts that merge before
- Contains
ontains most of the elastic tissue. - It may short or absent and have a high union with the hepatic duct, or they enter the common bile duct.
- The body extends from the fundus & tapers into the neck. - Long and run parallel, behind, or spiral to the main hepatic duct before Duplication is only clinically important when some pathologic
3- Infundibulum (Hartmann's pouch) joining it processes affect one or both organs. A left-sided
left sided gallbladder with a
4- Neck. cystic duct emptying into the left hepatic duct or the common bile
• The segment of the cystic duct adjacent to the gallbladder neck
- Funnel-shaped
shaped area tha
that connects with : the cystic duct duct and a retrodisplacement of the gallbladder are
- The neck usually follows a gentle curve, the convexity of bears a variable number of mucosal folds called :
both extremely rare. A partial or totally intrahepatic gallbladder is
which may be enlarged
larged to form the infundibulum. spiral valves of Heister
Heister.
associated with an increased incidence of cholelithiasis.
- The neck lies in the deepest part of the gallbladder fossa & 4- Common
C bile duct. Small ducts (of Luschka) may drain directly from the liver into the
extends into free portion of the hepatoduodenal ligament nd
• Common bile duct enters the 2 portion of the duodenum through body of the gallbladder. If present, but not recognized at the time of
a muscular structure, the sphincter of Oddi.3 a cholecystectomy, a bile leak with the accumulation of bile
• Length: 7 to 11 cm in length (biloma) may occur in the abdomen. An accessory right hepatic duct
• Diameter: 4 to 6 mm. occursrs in about 5% of cases. Varia>ons of how the common bile
• Parts : duct enters the duodenum are described
1- Upper third (supraduodenal portion) : in Bile Ducts above.
asses downward in the free edge of the hepatoduodenal
- Passes Anomalies of the hepatic artery and the cystic artery are quite
ligament, to the right of the hepatic artery & common, occurring in as many as 50% of cases.5 In about 5% of
anterior to the portal vein. cases, there
there are two right hepatic arteries, one from the common
2- Middleiddle third (retroduodenal portion) : hepatic artery and the other from the superior mesenteric artery. In
urves behind the first portion of the duodenum and
- Curves about 20% of pa>ents, the right hepa>c artery comes off the
- diverges laterally from the portal vein and the hepatic arteries. superior mesenteric artery. The right hepatic artery may course
anteriorr to the common duct. The right hepatic artery may be
3- Lower third (pancreatic portion) : vulnerable during surgical procedures, in particular when it runs
- Curves behind the head off the pancreas in a groove, or parallel to the cystic duct or in the mesentery of the gallbladder.
nd
and enters : medial aspect of 2 part of the duodenum. The cystic artery
There, the pancreatic duct frequently joins it. arises from the right hepa>c artery in about 90% of cases, but may
- The common bile duct runs obliquely downward within the arise from the left hepatic, common hepatic, gastroduodenal, or
wall of the duodenum for 1 to 2 cm before opening on a superior mesenteric arteries (Fig. 32-4).
32
papilla of mucous membrane (ampulla of Vater), about 10 cm
distal to the pylorus.

- The union of the common bile duct & the main pancreatic
Anterior aspect of the biliary anatomy. duct follows
ws one of three configurations :
a = right hepatic duct; b = left hepatic duct;
c = common hepatic duct; d = portal vein; a) In about 70% of, these ducts unite outside the duodenal
e = hepatic artery; f = gastroduodenal artery; wall and traverse the duodenal wall as a single duct.
g = left gastric artery; h = common bile duct;
i = fundus of the gallbladder; j = body of gallbladder; b) In about 20%, they join within the duodenal wall and
k = infundibulum; l = cystic duct; have a short or no common duct, but open through the
m = cystic artery; n = superior pancreaticoduodenal artery.
Note:
same opening into the duodenum.
• The situation of the hepatic bile duct confluence anterior to the right branch of the portal vein, c) In about 10%, they exit via separate openings into the
• The posterior course of the right hepatic artery behind common hepatic duct
duodenum.
Peritoneal covering:
1- Mostly, the
he same peritoneal lining that covers the liver covers : • The sphincter of Oddi :
- Fundus & - Thick coat of circular smooth
- Inferior
nferior surface of the gallbladder. muscle, surrounds the
common bile duct at the
2- Occasionally, gallbladder has a complete peritoneal covering, and is
ampulla of Vater
suspended in a mesentery off the inferior surface of the liver
- It controls the flow of bile,
3- Rarely, embedded deep inside the liver parenchyma ( intrahepatic GB ).
and pancreatic juice, into the
Lining : duodenum.
1- Epithelium :
• It's lined by a single, highly folded, tall columnar epithelium that contains
cholesterol & fat globules.
• The mucus secreted into the gallbladder originates in the tubuloalveolar glands:
found in the mucosa lining the infundibulum & neck of the GB, but are
absent from the body & fundus.
2- Lmina propria :
• The epithelial lining of the GB is supported by a lamina propria.
3- Muscle layer :
• The muscle layer has : 1- circular 2- longitudinal 3- oblique fibers .
4- Perimuscular subserosa :
• The perimuscular subserosa contains connective tissue, nerves, vessels,
lymphatics, and adipocytes.
5- Serosa :
• It is covered by the serosa except where the GB is embedded in liver.
N.B. The gallbladder differs histologically from the rest of the GI tract in that it
lacks a muscularis mucosa & submucosa
submucosa.
Vascular supply :
The cystic artery supplies GB,
It' usually a branch of the Right
ight hepa?c artery (>90% of the ?me). Variations in the arterial supply to the gallbladder.
Course : A. Cystic artery from right hepatic artery, about 80–
80
• It may vary, but itt nearly always is found within: hepatocystic triangle, 90%.
(triangle of Calot) , the area bound by :
B. Cystic artery from right hepatic artery (accessory or
1- Cys>c duct 2- common he hepa>c duct 3- Liver margin
replaced) from superior mesenteric artery, about 10%.
• When the cystic artery reaches the neck of the gallbladder
gallbladder, it divides into
anterior & posterior divisions. C. Two cystic arteries, one from the right hepatic, the
Venous return is carried either through
through: other from the common hepatic artery,
artery, rare.
- Small veins thatt enter directly into the liver, or D. Two cystic arteries, one from the right hepatic, the
- A large cystic vein that carries blood back to portal vein ( rarely ). other from the left hepatic artery, rare.
Lymphatic supply : E. The cystic artery branching from the right hepatic
\\
\ artery and running anterior to the common hepatic
• Gallbladder lymphatics drain into nodes at the neck of the
duct, rare.
gallbladder.
F. Two cystic arteries arising
arising from the right hepatic
Nerve supply : The nerves of the gallbladder arise from : artery, rare.
1- Vagus :
- The hepatic branch of the vagus nerve supplies cholinergic fibers to the :
a- gallbladder b-- bile ducts c- liver. Variations of the cystic duct anatomy.
- The vagal branches also have peptide
peptide-containing nerves containing agents A. Low junction between the cystic duct and common hepatic duct.
such as: substance P, somatostatin, enkephalins, & vasoactive intestinal polypeptide. B. Cystic duct adherent to the common hepatic duct.
C. High junction between the cystic and the common hepatic duct.
2- Sympathetic
ympathetic branches that pass through the celiac plexus. D. Cystic duct drains into right hepatic duct.
- The preganglionic sympathe>c level is TT8 and T9. E. Long cystic duct that joins common hepatic duct behind th
the duodenum.
- Impulses from gallbladder, bile ducts & liver pass by means of sympathetic F. Absence
Abse of cystic duct.
afferent fibers through the splanchnic
nchnic n
nerves & mediate pain of biliary colic. G. Cystic
Cys duct crosses posterior to common hepatic duct and joins it anteriorly.
H. Cystic
Cyst duct courses anterior to common hepatic duct and joins it posteriorly.
 Liver
• The liver is the largest organ in the body, weighing about: 1500 g . Additional functional anatomy was by Bismuth based on the distribution of the • The portal vein pressure in in normal physiology is low at 3 to 5 mmHg.
hepatic veins : • The portal vein is valveless, in the setting of portal hypertension, the
• It sits in the right upper abdominal cavity beneath the diaphragm and is
protected by the rib cage. The three hepatic veins run in corresponding scissura (fissures) and div
divide the pressure can be high (20 to 30 mmHg).
liver into four sectors : This results in decompression of the systemic circulation through
• It is reddish brown & is surrounded by a fibrous sheath : Glisson's capsule. 1-
1 Right scissura : The right hepatic vein runs along the right scissura and portocaval anastomoses, most commonly via coronary (left gastric)
separates right posterolateral sector from right anterolateral sector. vein, which produces esophageal & gastric varices.
rices.
• The liver is held in place by several ligaments (Fig. 31
31-1).
2-
2 Main scissura : contains the middle hepatic vein and separates
1- The round ligament : • Another branch of the main portal vein is :
right & left livers.
is the remnant of the obliterated umbilical vein and enters the left liver Superior pancreaticoduodenal vein
3-
3 Left scissura : contains the course of the left hepatic vein and separates
hilum at the front edge of the falciform ligament. (which comes off low in an anterior lateral position and is divided during
Left posterior & Lefteft anterior sectors.
2- The falciform ligament: pancreaticoduodenectomy).
separates the left lateral and left medial segments along the umbilical Hepatic Artery
fissure and anchors the liver to the anterior abdominal wall. The liver has a dual blood supply , consisting of : • Closer to the liver, the main portal vein typically gives off a short branch
3- Ligamentum venosum : 1- Hepatic artery delivers about 25% of the blood supply (posterior lateral) to the caudate process on the right side.
side
Deep in the plane between the caudate lobe & the left lateral segment is the 2- Portal vein delivers about 75% of the blood supply . It is important to identify this branch and ligate it during hilar dissection for
fibrous ligamentum venosum, which is the obliterated ductus venosus. anatomic right hemihepatectomy to avoid avulsion.
Celiac
eliac trunk , gives :
4- The left and right triangular ligaments :
1- Left gastric artery Hepatic Veins and Inferior Vena Cava
secure the two sides of the liver to the diaphragm.
2- Splenic artery There are three hepatic veins , that pass obliquely through the liver to
5- Coronary ligaments :
3- Common hepatic artery which divides into : drain the blood to the suprahepatic IVC then to the right atrium :
- They are extending
xtending from the triangula
triangular ligaments anteriorly on the liver
a- Gastroduodenal artery and 1- Right :
- The right coronary ligament also extends from the right undersurface of
b- Hepatic artery proper : - Drains
D segments V to VIII
the liver to the peritoneum overlying the right kidney, thereby anchoring
1- Typically , it gives Right gastric a. 2- Middle :
the liver to the right retroperitoneum.
6- Hepatoduodenal & Gastrohepatic ligaments
igaments (Fig. 31
31-2) : 2- It divides into Right & Left
eft hepatic arteries. - Drains
D segment IV , V , VIII
- Centrally and just to the left of the gallbladder fossa, the liver attaches via N.B. This "classic" or standard arterial anatomy is present in oonly approximately 75% of cases, 3- Left :
with the remaining 25% having variable anatomy. D
- Drains segments II , III
hepatoduodenal & gastrohepa>c ligaments (Fig. 31 31-2).
- The hepatoduodenal ligament is known as the porta hepatis and contains: - Left & middle hepatic veins form a common trunk in 95% of the >me
1- common bile duct 2- hepa>c artery 33- portal vein. before entering the IVC,
- From the right side and deep (dorsal) to the porta hepatis is the foramen - Right hepatic vein inserts separately (in an oblique orientation) into the IVC.
IVC
of Winslow (also known as epiploic foramen ) :
• This passage connects directly to the lesser sac & allows complete
The hepatic vein branches bisect the portal branches inside the liver
vascular inflow control to the liver when the hepatoduodenal parenchyma :
ligament is clamped using the Pringle maneuver. • Right hepatic vein runs between : right anterior & posterior portal veins;
• Middle
iddle hepatic vein passes between : right anterior & left portal vein;
• Left
eft hepatic vein crosses between
betwee : segment III & II branches of left portal vein.

• The caudate lobe is unique because its venous drainage feeds directly into the IVC.
• In addition, the liver usually has a few small, short hepatic veins that directly enter
the IVC from the undersurface of the liver.

Hepatic
epatic arterial variants :
1- The right hepatic artery is replaced coming off
superior mesenteric artery (SMA) "18 to 22%"
When there is a replacement or accessory right
hepatic artery, it traverses posterior to the portal vein
Hepatic ligaments suspending the liver to the diaphragm and anterior abdominal wall. and then takes up a right lateral position before diving
into the liver parenchyma.
2- A replacement (or accessory) left hepatic artery
comes off of the left gastric artery "12 to 15%"
It runs obliquely in the gastrohepatic ligament
anterior to the caudate lobe before entering the hilar
plate at the base of the umbilical fissure.
3- Early
Early bifurcation of the left and right hepatic arteries,
as well as a completely replaced common hepatic
artery coming off the SMA "2%"

4- Completely replaced common

c hepatic artery from
SMA "1-
"1 2 % "

Important
mportant point is that the right hepatic artery passes Bile Duct and Hepatic Ducts
po
deep and posterior to the common bile duct about 88% Within Hepatoduodenal
epatoduodenal ligament :
of the time BUT crosses anterior to the common bile duct Common Bile Duct
D (CBD) lies anteriorly & to the right.
in approximately 12% of cases. • It gives the Cystic duct to the gallbladder
• It becomes Common hepatic duct before dividing into :
Rt. & Lt. Hepatic ducts.
- In general, Hepatic ducts follow arterial branching pattern inside the liver.
- Right hepatic duct :
The bifurcation of :
In situ liver hilar anatomy with hepatoduodenal and gastrohepatic ligaments. Foramen of Portal Vein • Right
ight anterior hepatic duct enters the liver above the hilar plate,
Winslow is depicted.
The portal vein is formed by the confluence of:
of • Right
ight posterior duct dives behind the right portal vein and can be
1- Splenic vein ( Inferior
nferior mesenteric vein drains into splenic vein ) found on the surface of the caudate process before entering the liver.
Segmental Anatomy 2- Superior mesenteric vein.
• The liver is grossly separated into the right and left lobes by the plane from the - Left
eft hepatic duct :
gallbladder fossa to the inferior vena cava (IVC), known as Cantlie's line. The main portal vein traverses the porta hepatis dividing into branches : Has
as a longer extrahepatic course before giving off segmental branches
• The right lobe typically accounts for 60 to 70% of the liver mass, with the le= 1- Right portal vein behind the left portal vein at the base of the umbilical fissure.
lobe (and caudate lobe) making up the remainder. - The division of right portal vein is usually higher in the hilum and
• The caudate lobe lies to the left and anterior of the IVC and contains three may be close to (or inside) the liver parenchyma at the hilar plate. Lymphatic Drainage
subsegments: the Spiegel lobe, the paracaval porportion, and caudate process. 2- Left portal vein. Lymph is produced within the liver and drains via :
• The falciform ligament does not separate the right and left lobes, but rather it
- The left portal vein typically branches from the main portal vein 1- Perisinusoidal
erisinusoidal space of Disse and
divides the left lateral segment from the left medial segment.
outside of the liver with a sharp bend to the left and consists of: 2- Periportal clefts of Mall
• The left lateral and left medial segments also are referred to as sections
transverse portion followed by a 90 90-degree turn at the base of
• Couinaud divided the liver into eight segments, numbering them in a clockwise to larger lymphatics that drain to the :
the umbilical fissure to become : umbilical portion then entering
direction beginning with : 1- Hilar
H cystic duct lymph node
ode (Calot's triangle node),
the liver parenchyma (Fig. 31-7).
- The caudate lobe as segment I. - The left portal vein then divides to give off : 2- Common
C bile duct,
- Segments II and III comprise the left lateral segment, • Segment III & II branches to the left lateral segment, 3- Hepatic
H artery,
- Segment IV is the le= medial segment (Fig. 31 31-3). • Segment
egment IV branches that supply the left medial segment. 4- Retropancreatic
R
• Thus, The left lobe is made up of the left lateral segment (Couinaud's - The left portal vein also provides the dominant inflow branch to the
segments II & III) and the left medial segment (segment IV). 5- Celiac
C lymph nodes.
caudate lobe (although branches can arise from the main and right portal veins also),
• Segment IV can be subdivided into segment IVB and segment IVA. usually close to the bend between transverse & umbilical portions. • This is particularly important for resection of hilar cholangiocarcinoma,
- Segment IVA is cephalad and just below the diaphragm, spanning which has a high incidence of lymph node metastases.
from segment VIII to the falciform ligament adjacent to segment II.
• The hepatic lymph also drains cephalad to the cardiophrenic lymph nodes
- Segment IVB is caudad and adjacent to the gallbladder fossa.
• Many anatomy textbooks also refer to segment IV as quadrate lobe. and the latter can be pathologically identified on a staging CT or MRI scan.
Quadrate lobe is an outdated term, and the preferred term is
segment IV or left medial segment. Neural Innervation and Lymphatic Drainage
- The right lobe is comprised of segments V, VI, VII, and VIII, with :
• Segments V and VIII making up the right anterior lobe, and Parasympathetic
arasympathetic innervation : Comes from :
• Segments VI and VII making up the right posterior lobe.
1- Left
L vagus, which gives Anterior hepatic branch.
2- Right
R vagus, which gives Posterior
osterior hepatic branch.

Sympathetic
ympathetic innervation : involves :
1- Greater
G thoracic splanchnic nerves
2- Celiac
C ganglia,
• although the function of these nerves is poorly understood.
• The denervated liver after hepatic transplantation seems to function
with normal capacity.

The portal vein drains the splanchnic blood from : N.B.

1- Stomach, A common source of referred pain to :
2- Pancreas, - Right shoulder
3- Spleen, - Scapula
4- Small intestine, - Right side or back
5- majority of the colon is the right phrenic
phr nerve, which is stimulated by tumors
ors that stretch
to the liver before returnin
returning to the systemic circulation. Glisson's capsule
capsu or by diaphragmatic irritation.
 Stomach
Shape: Asymmetrical, Pear-shaped.
shaped.
Parts :
1- Cardia :
- The part of the stomach attached to the esophagus is called the cardia.
- Just proximal to the cardia at the gastroesophageal (GE) junction is lower esophageal sphincter
(which is anatomically indistinct but physiologically demonstrable )
2- Fundus :
- The superior-most
most part of the stomach iiss the distensible floppy fundus
- Bounded superiorly: by diaphragm & laterally by spleen.
- The "angle of His" is where the fundus meets the left side of the GE junction.
- The
he inferior extent of the fundus is considered to be the horizontal plane of the GE junction, where the
body (corpus) of the stomach begins.
3- Body (corpus) :
- Bounded on the right by : the relatively straight lesser curvature
on the left by : the more curved greater curvature.
- At the angularis incisura,, the lesser curvature turns abruptly to the right, marking the anatomic
beginning of the Pyloric antrum (which comprises the distal 25 to 30% of the stomach ) Anatomic regions of the stomach
4- Pylorus :
- At the distal end, the pyloric sphincter connects the stomach to the proximal duodenum.
- The stomach is relatively fixed at these points, but the large midportion is quite mobile.
Relationships :
The organs that commonly abut the stomach are the liver, colon, spleen, pancreas, and occasionally the kidney
• Anteriorly : The left lateral segment of the liver usually covers a large part of the anterior stomach.
• Inferiorly : Stomach
tomach is attached to the transverse colon by the gastrocolic omentum.
• The lesser curvature is tethered to the liver by hepatogastric ligament,
also referred to as the lesser omentum or pars flaccida.
• Posteriorly : lesser omental bursa & pancreas.

Arterial
erial and Venous Blood Supply
The large majority of the gastric blood supply is from the Celiac Trunk via four named arteries (Fig. 26-3) :
Left & Right
ight gastric arteries form an anastomotic arcade along the lesser curvature,
curvature and
• Left gastric artery :
- Largest
argest artery to the stomach
stomach.
- Arises from the "Celiac
liac trunk
trunk" and divides into an ascending & descending branch
along lesser curvature.
- In 15%, the le: gastric artery supplies an aberrant vessel that travels in the gastrohepa;c
ligament (lesser omentum) to the left side of the liver Rarely, this is the only arterial blood
supply to this part of the liver, and ligation may lead to clinically significant hepatic ischemia.
• Right gastric artery :
- Arises from the "Hepatic
atic artery
artery", near the Pylorus & Hepatoduodenal ligament
epatoduodenal ligament, and runs
proximally along the distal stomach.

Left & Right gastroepiploic arteries form an arcade along the greater curvature.
curvature
• Right gastroepiploic artery :
- The secondd largest artery to the stomach.
- Arises from the "Gastroduodenal artery" , behind
stroduodenal artery ehind the first portion of the Duodenum. Anatomic relationships of the stomach

• Left
eft gastroepiploic artery:
- Arises from the "Splenic
lenic artery"

In the fundus along the proximal greater curvature

curvature, "short
short gastric arteries & veins" from splenic circulation.

The veins draining the stomach generally

enerally parallel the arteries :
• Left gastric & Right
ight gastric veins usually drain into Portal vein & occasionally the splenic vein.
• Right gastroepiploic vein drains into Superior mesenteric vein , near inferior border of pancreatic neck
• Left gastroepiploic vein drains into Splenic vein.
Important clinical implications.
1- Erosion of a peptic ulcer or gastric cancer into a large perigastric vessel may cause hemorrhage.
2- Because of the rich venous interconnections in the stomach, a distal splenorenal shunt,shunt which connects the
distal end of the divided splenic vein to the side of the left renal vein, can effectively decompress
esophagogastric varices in patients with portal hypertension.
Lymphatic Drainage
Generally speaking, the gastric lympha?cs parallel the blood vessels (Fig. 26-4).
26
• The cardia & medial half of the corpus usually drain to Nodes along 1- left gastric & 2- celiac axis.
• The lesser curvature side of the antrum usually drains to 1- Right gastric & 2- pyloric nodes,
• The greater curvature half of the distal stomach drains to nodes along Right
ight gastroepiploic chain.
• The greater curvature half of the proximal stomach drains to nodes along Left
L gastroepiploic or splenic hilum.
The nodes along both the greater & lesser curvature commonly drain into Celiac nodal basin.

Clinical significance of this rich lymphatic anastomosis :

1- Tumor
umor arising in the distal stomach may give rise to positive lymph nodes in the splenic hilum.
2- The rich intramural plexus of lymphatics and veins accounts for the fact that there can be microscopic evidence of
malignant cells in the gastric wall at a rese
resection
ction margin that is several centimeters away from palpable malignant tumor.
3- It also helps explain the not infrequent finding of positive lymph nodes which may be many centimeters away from the
primary tumor, with closer nodes that remain negative.

Innervation
Both the extrinsic & intrinsic innervation of the stomach play an important role in gastric
gastr secretory and motor function :

The vagus nerves

- Provide the extrinsic parasympathetic innervation to the stomach
- From the vagal nucleus in the floor of the fourth cerebral ventricle,
the vagus traverses the neck in the carotid sheath and enters the
Arterial blood supply to the stomach
mediastinum, where it gives off :
1- Recurrent laryngeal nerve and
2- Divides into several branches around the esophagus.
These branches come together again above the esophageal hiatus
and form left (anterior) & rightght ((posterior) vagal trunks
a- Anterior vagus :
- Near the GE junction the anterior vagus sends a branches to
the liver in
n the gastrohepatic ligament and continues along
the lesser curvature as the anterior nerve of Latarjet .
• The nerves of Latarjet send segmental branches to
body of the stomach before they terminate near the
angularis incisura as the "crow's foot," sending branches to the antropyloric region.
region

b- Posterior vagus :
- The posterior vagus sends branches to the celiac plexus and continues along the posterior lesser curvature.
- The branch that the posterior vagus sends to the posterior fundus is termed the criminal nerve of Grassi.
This branch typically arises above the esophageal hiatus and is easily missed during truncal or highly selective
vagotomy (HSV).
- Vagal fibers originating in brain synapse with neurons in Auerbach's myenteric plexus & Meissner's submucosal plexus. Lymph node stations draining the stomach
h according
accord to the Japanese Research Society for Gastric Cancer.
- Although clinicians are accustomed
tomed to thinking about the vagus nerves as important
portant efferent nerves (i.e., carrying
3- Sta?ons 3–6 are commonly removed
moved wwith D1 gastrectomy.
portant to consider the fact that fully 75% of the
s>muli to the viscera), it is important he axons contained in the vagal trunks are
4- Sta?ons 1, 2, and 7–12 are commonly
monly removed
r with D2 gastrectomy.
afferent (i.e., carrying stimulii from th
the viscera to the brain).
 Pancreas
Gross Anatomy Lymphatic Drainage :
• The pancreas is a retroperitoneal organ that lies in an oblique position, sloping • The lymphatic drainage from the pancreas is diffuse and widespread.
denum to
upward from: the C-loop of the duodenum splenic hilum . • This diffuse lymphatic drainage contributes to the fact that pancreatic
• Weight: 75 to 100 g and . cancer often presents with:
with
• Length: 15 to 20 cm long. 1- Positive lymph nodes and
Due to its deep retroperotineal location : 2- High
igh incidence of local recurrence after resection.
1- Patients with pancreatic cancer without bile duct obstruction usually present after
• Lymph nodes can be palpated along :
months of vague upper abdominal discomfort, or no antecedent symptoms at all.
2- Pain
ain associated with pancreatitis often is characterized as penetrating through to back.
osterior aspect of the head of the pancreas in pancreaticoduodenal
1- Posterior
groove, where the mesenteric vein passes under neck of pancreas.
REGIONS OF THE PANCREAS 2- Inferior border of the body
Surgeons typically describe the location of pathology within the pancreas in 3- Hepatic
epatic artery ascending into the porta hepatis,
Embryology of pancreas and duct variations.
relation to four regions: the head, neck, body, and tail. 4- Splenic
plenic artery & vein.
• The duct of Wirsung from the ventral bud connects
connects to the bile duct, while the duct of
1- Head of pancreas : Santorini from the larger dorsal bud connects to the duodenum.
• With gut rotation, the two ducts fuse in most cases such that the majority of the pancreas • The pancreatic lymphatics also communicate with lymph nodes in:
in
• The head of the pancreas is nestled in the C
C-loop of the duodenum .
drains through the duct of Wirsung to the major papilla. 1- Transverse
ransverse mesocolon and
• It lies posterior to the transverse mesocolon.
• The
The duct of Santorini can persist as a blind accessory duct or drain through the lesser 2- Mesentery
sentery of the proximal jejunum
• Just behind the head of the pancreas lie : papilla. In a minority of patients, the ducts remain separate, and the majority of the
- Vena cava, pancreas drains through the duct of Santorini, a condition referred to as pancreas divisum. Tumors in the body and tail of the pancreas often metastasize to these
- Right renal artery nodes and lymph nodes along the splenic vein and in the hilum of the
- Both Renal veins VASCULAR AND LYMPHATIC ANATOMY spleen.
• The Common Bile Duct (CBD) , runs in a deep groove on the posterior aspect 1- Blood supply :
of the pancreatic head until it passes through the pancreatic parenchyma to The blood supply to the pancreas comes from multiple branches from :
join : main pancreatic duct at the ampulla of Vater. 1- Celiac Trunk.
2- Superior mesenteric artery.
• Uncinate process & Head of the pancreas wrap around the right side of the
portal vein and end posteriorly near the space between :
Head of pancreas :
1- Common
C hepatic artery gives Gastroduodenal
astroduodenal artery before continuing
Superior mesenteric vein & Superior mesenteric artery.
toward the porta hepatis as the proper hepatic artery
artery.
• Venous branches draining the pancreatic head & uncinate process enter along the right 2- Gastroduodenal
G artery becomes Superior
uperior pancreaticoduodenal artery :
lateral and posterior sides of the portal vein.
• There are usually no anterior venous tributaries, and a plane can usually be developed • A the superior pancreaticoduodenal artery passes behind the 1st portion of
As
between the neck of the pancreas and the portal and superior mesenteric veins during the duodenum and branches into :
pancreatic
reatic resection, unless the tumor is invading the vein anteriorly. - Anterior superior pancreaticoduodenal artery
- posterior superior pancreaticoduodenal artery.
2- Neck of pancreas : • As the Superior mesenteric artery passes behind the neck of the pancreas, it
• The neck of the pancreas overlies the vertebral body of L1 & L2
gives Inferior pancreaticoduodenal artery at the inferior margin of the neck
blunt anteroposterior trauma can compress the neck of the pancreas against the spine,
causing parenchymal and, sometimes, ductal injury. of the pancreas which divides into :
• The neck divides the pancreas into approximately two equal halves. - Anterior inferior pancreaticoduodenal artery.
Relations : - Posterior inferior pancreaticoduodenal artery.
• over: the portal vein.
The neck of the pancreas lies directly over • Superior
S & Inferior
nferior pancreaticoduodenal arteries join together within the
• At the inferior border of the neck of the pancreas : parenchyma of the anterior and posterior sides of the head of the pancreas
Superior mesenteric vein joins Splenic vein and then continues toward a
along the medial aspect of the C loop of the duodenum to : form arcades that
the porta hepatis as the portal vein. give off numerous branches to the duodenum & head of the pancreas.
Therefore, it is impossible to resect the head of the pancreas Neuroanatomy :
• Inferior mesenteric vein often joins the splenic vein near its junction with portal V. The pancreas is innervated by :
• Sometimes joins the superior mesenteric vein; or
without devascularizing the duodenum, unless a rim of pancreas
containing the pancreaticoduodenal arcade is preserved. 1- Sympathetic
ympathetic nervous system
• Sometimes the three veins merge as a trifurcation to form the portal vein.
- Inhibits endocrine and exocrine secretion
Superior mesenteric artery lies parallel to & just to the left of the Body & Tail : 2- Parasympathetic
arasympathetic nervous systems
Superior mesenteric vein. 1- They are supplied by multiple branches of the splenic artery : - Stimulates
S endocrine and exocrine secretion
- Splenic artery arises from celiac trunk & travels along the posteriorsuperior
• Acinar cells responsible for exocrine secretion,
A
3- Body : border of the body and tail of the pancreas toward the spleen.
• I
Islet cells responsible for endocrine secretion,
• The body overlies the aorta at the origin of the Superior mesenteric artery. 2- Inferior
I pancreatic artery:
- Arises from : Superior mesenteric artery • I
Islet vasculature are innervated by both systems.
4- Tail : - Runs
uns to the left along the inferior border of the body and tail of the
pancreas, parallel to the splenic artery. The pancreas is also innervated by neurons that secrete amines and
• The tail lies anterior to the left kidney
- 3 vessels run perpendicular to the long axis of the pancreatic body and peptides, such as :
• It's nestled in the hilum of spleen near the splenic flexure of the left colon.
tail and connect the splenic artery and inferior pancreatic artery, from 1- Somatostatin,
Relations of body & tail : medial to lateral are : 2- vasoactive intestinal peptide (VIP),
• The body & tail of the pancreas lie just anterior to the splenic artery & vein. 1- Dorsal pancreatic artery 3- calcitonin gene-related
related peptide (CGRP),
- The Splenic Vein runs in a groove on the back of the pancreas and 2- Great
reat pancreatic artery 4- galanin.
It's fed by multiple fragile venous branches from pancreatic parenchyma. 3- Caudal
audal pancreatic arteries. The exact role of these neurons in pancreatic physiology is uncertain,
These branches must be ligated to perform a spleen
spleen-sparing distal pancreatectomy. These arteries form arcades within the body & tail of the pancreas. but they do appear to affect both exocrine and endocrine function.
- The Splenic Artery is tortuous , runs parallel and just superior to the vein
along the posterior superior edge of the body & tail of the pancreas. The The pancreas also has a rich supply of
of afferent sensory fibers,
fibers which
splenic artery often is tortuous. are responsible for the intense pain associated with :
• The anterior surface of the body of the pancreas is covered by peritoneum. 1- Advanced pancreatic cancer
• Once the gastrocolic omentum is divided the body & tail of the pancreas 2- Acute & chronic pancreatitis.
can be seen along the floor of the lesser sac, just posterior to the stomach
stomach. These somatic fibers travel superiorly to the celiac ganglia.
- Pancreatic pseudocysts commonly develop in this area , and Interruption of these somatic fibers can stop transmission of pain.
pain
- The
he posterior aspect of the stomach can form the anterior wall
of the pseudocyst, allowing drainage into the stomach.
• Transverse mesocolon :
- The base of the transverse mesocolon attaches to the inferior margin of
the body & tail of the pancreas.
- The transverse mesocolon often forms the inferior wall of pancreatic
pseudocysts
ysts or inflammatory processes, allowing surgical drainage
through the transverse mesocolon.

2- Venous Drainage :
• Venous
V drainage of pancreas follows a pattern similar to that of arterial supply.
• Veins
V are usually superficial to arteries within the parenchyma of the pancreas.
• There is an anterior & posterior venous arcade within the head of pancreas.
- Superior
S veins drain directly into Portal vein just above the neck of pancreas.
- Posterior
P inferior arcade drains directly into Inferior mesenteric vein at the
inferior border of the neck of the pancreas.
- Anterior
A inferior pancreaticoduodenal vein joins Right gastroepiploic vein &
Middle
M colic vein to form a common venous trunk, which enters into the
Superior mesenteric vein.
• Venous return from body & tail of the pancreas drains into Splenic vein

PANCREATIC DUCT ANATOMY

The main pancreatic duct :
• Length: It's only 2 to 3 mm in diameter
• Course: Runs
uns midway between the super
superior & inferior borders of pancreas,
usually closer to the posterior than to the anterior surface.
• Pressure inside the pancreatic duct is: about twice that in CBD , which is
thought to prevent reflux of bile into the pancreatic duct.

Main pancreatic duct joins with Common

ommon bile duct and empties at the
ampulla of Vater or major papilla,, which is located on :
medial aspect of the second portion of the duodenum.
The muscle fibers around the ampulla form
form: "sphincter of Oddi",
Function: controls the flow of pancreatic & biliary secretions into duodenum.
Regulation: contraction & relaxation of the sphincter is regulated by
complex neural and hormonal factors.
• When the accessory pancreatic duct
uct or les
lesser duct drains into the duodenum,
a lesser papilla can be iden>fied approxim
approximately 2 cm proximal to the ampulla
of Vater.