Abdomen [ 155 - 222 ]

ANTERIOR ABDOMINAL WALL

The anterior abdominal wall is formed of the following layers (from superficial
to deep).
1. Skin
2. Superficial fascia (the deep fascia is denied)
3. Muscles
4. Transversalis fascia
5. Extraperitoneal tissue
6. Peritoneum (parietal layer)

SUPERFICIAL FASCIA
It is formed of 2 layers
a. Outer layer : fatty
b. Inner layer : membranous (Scarpa’s fascia)
The membranous layer is well-differentiated in the lower part of the
anterior abdominal wall. It descends to the upper part of the thigh to
fuse with the fascia lata along a horizontal line extending laterally
from the pubic tubercle.

MUSCLES OF THE ANTERIOR ABDOMINAL WALL

These muscles are 5 :
1. External oblique
2. Internal oblique
3. Transversus abdominis
4. Rectus abdominis
5. Pyramidalis
EXTERNAL OBLIQUE:
Origin:
 From the outer surface and lower border of the lower 8 ribs.
 Its slips interdigitate with 2 muscles :
a. Serratus anterior : at the middle 4 ribs
b. Latissimus dorsi : at the lower 4 ribs
N.B.: in contrast to the internal oblique and transverses
abdominis, the external oblique has no origin from the
lumbar fascia.
Insertion:
 Its fibres pass obliquely downwards, forwards and medially to end in
an aponeurosis (expanded tendon): No fleshy fibres extend below a
line passing from the anterior superior iliac spine to the umbilicus.
 It is inserted as follows:
a. Medial part of the aponeurosis:
is attached to the linea alba
N.B.: The alba is the median fibrous partition extending from the
xiphoid process to the symphysis pubis.
b. Lower part of the aponeurosis:
Is folded backwards and upwards upon itself to form the inguinal
ligament which extends from the pubic tubercle to the anterior
superior iliac spine.

155
 Abdomen [ 155 - 222 ]

c. Most posterior fibres (fleshy):

Descend vertically to be inserted into the anterior 1/2 of the outer
lip of iliac crest. This part forms the anterior boundary of the
lumbar triangle (bounded by the external oblique, latissimus dorsi
and iliac crest).
INTERNAL OBLIQUE:
Origin: from :
 Lateral 2/3 of the concave upper surface of the inguinal ligament.
 Anterior 2/3 of the intermediate area of the iliac crest (extends
backwards more than the external oblique, so forms the floor of the
lumbar triangle).
 Lumbar fascia.
Insertion:
 Its passes pass obliquely upwards, forwards and medially to end in
an aponeurosis.
 The muscle is inserted as follows:
a. Above: into the lower 6 ribs
b. Below: into the pubic crest and pectineal line (pecten pubis)
through the conjoint tendon.
N.B.: The conjoint tendon is formed by fusion of the lower parts of
the aponeurosis of both the internal oblique and
transverses abdominis.
c. In between : into the linea alba, by aponeurosis. The aponeurosis
passes medially till the lateral border of rectus abdominis muscle
where it splits into 2 lamellae (anterior and posterior) which
enclose the muscle and share in formation of the rectus sheath.
Relations of the muscle to the spermatic cord:
The muscle has a triple relation to the cord :
1. It is 1st anterior to the cord
2. Then arches above it
3. Then descends behind it
N.B.: As the spermatic cord passes through the inguinal canal, the
arched fibres of the internal oblique muscle give off the cremaster
muscle which joins the cord down into the scrotum. It is supplied
by the genital branch of the genito-femoral nerve.
TRANSVERSUS ABDOMINIS
It lies deeper to the internal oblique muscle
Origin: from :
 Lateral 1/3 of the concave upper surface of the inguinal ligament
(shorter than the internal oblique which extends along the lateral 2/3).
 Anterior 2/3 of the inner lip of the iliac crest (same as the internal
oblique).
 Deep surface of he lower 6 ribs (interdigitating with the origin of
diaphragm).
 Lumbar fascia.
Insertion:
It fibres pass horizontally to end in an aponeurosis, by which the muscle
is attached as follows:
 The lower part of the aponeurosis fuses with that of the internal
oblique to form the conjoint tendon.
 The rest of the aponeurosis passes medially to reach the linea alba.

156
 Abdomen [ 155 - 222 ]
 The concave fleshy lower border arches above the deep inguinal ring
here the constituents of the spermatic cord pass.
RECTUS ABDOMINIS:
 It is a long muscle lying one on each side of the linea alba and is
enclosed within the rectus sheath (rectus = straight).
 Its lateral border is marked on the skin by a groove called the linea
semilunaris that crosses the tip of 9th costal cartilage.
Origin:
From the pubic crest and anterior pubic ligament (its origin is narrower
than its insertion).
Insertion:
Into the 5th, 6th and 7th costal cartilages along a horizontal line.
Tendinous intersections:
 The muscle shows 3 transverse tendinous intersections that indicate
its segmental origin from several myotomes.
 These intersections are fused to the anterior wall of the rectus sheath
but not to its posterior wall.
 They are found at the following levels:
1. One at the umbilicus
2. One at the xiphoid process
3. One midway between the above 2 levels

NERVE SUPPLY OF THE ANTERIOR ABDOMINAL MUSCLES:

They are supplied by the lower 6 thoracic and 1st lumbar nerves

ACTION OF THE ANTERIOR ABDOMINAL MUSCLES:

 They assist in raising the intra-abdominal pressure so help in
defaecation, parturition, cough, expiration, vomiting, etc.
 By their contraction, they protect the abdominal viscera from external
violence and by their tone they keep these viscera in position.
 The rectus abdominis can flex the trunk, while the obliques can bend it
laterally (the trasnversus has no action on the vertebral column).
RECTUS SHEATH
It is a sheath formed by the 3 aponeuroses of the external oblique, internal
oblique and transverses abdominis, the anterior wall is complete while the
posterior wall is incomplete below, and above.
To understand the walls of the sheath, one has to know the following:
1. Upper part of rectus abdominis:
Lies directly on the costal cartilages below a horizontal line passing
through the 5th, 6th and 7th cartilages. This part of the muscle has no
aponeurotic layers behind but only the chest wall (the posterior wall is
deficient above).
2. Aponeurosis of internal oblique:
Splits at the lateral margin of the rectus abdominis into anterior and
posterior lamellae that enclose the muscle.
3. Posterior wall of the sheath:
Ends below at a point midway between the umbilicus and symphysis
pubis where both the anterior and posterior walls come to lie anterior to
the lower part of the rectus abdominis muscle. So, the posterior wall is
also deficient below.

157
 Abdomen [ 155 - 222 ]
WALLS OF THE RECTUS SHEATH:
1. ABOVE THE COSTAL MARGIN:
 Anterior wall : by the external oblique aponeurosis only.
 Posterior wall : by the costal cartilages up to a horizontal line
extending along the 5th, 6th, and 7th cartilages.
2. FROM COSTAL MARGIN TO MIDWAY BETWEEN THE UMBILICUS AND
SYMPHYSIS PUBIS:
 Anterior wall: by
 External oblique aponeurosis
 Anterior lamella of the internal oblique aponeurosis.
 Posterior wall : by
 Aponeurosis of the transverses abdominis.
 Posterior lamella of the internal oblique aponeurosis.
The posterior wall ends midway between the umbilicus and symphysis
pubis in a concave lower border called the arcuate line.
3. BELOW THE LEVEL OF ARCUATE LINE:
 Anterior wall :
Is formed by the 3 aponeuroses of the external oblique, internal
oblique and transverses abdominis.
 Posterior wall:
No aponeurosis, but only formed by the transversalis fascia which
lines the deep surface of the trasnversus abdominis (it is thickened
here for compensation).
CONTENTS OF THE RECTUS SHEATH:
1. Rectus abdominis msucle
it is the main content .
2. Pyramidalis muscle:
It is a small muscle that arises from the front of the pubis and is inserted
into the linea alba (supplied by the sub-costal nerve) lies in front of the
lower most part of the rectus muscle.
3. Superior epigastric artery :
It is one of the 2 terminal branches of the internal thoracic artery that
enters the upper part of the sheath, behind the rectus abdominis.
4. Inferior epigastric artery :
It is a branch of the external iliac artery that ascends upwards across
the arcuate line and anastomoses with the superior epigastric. This is a
link between the external iliac and subclavian arteries.
5. Lower 6 thoracic nerves:
They pierce the posterior wall of the sheath, the rectus muscle and the
anterior wall of the sheath to appear in the superficial fascia as the
anterior cutaneous nerves just lateral to the linea alba.

NERVE SUPPLY OF SKIN OF ANTERIOR ABDOMINAL WALL

 The abdominal skin is supplied by the lower 6 thoracic and 1st
lumbar nerves.
 Distribution:
a. Skin at subcostal angle : by the 7th thoracic nerve.
b. Skin of the region of umbilicus : by the 10th thoracic nerve.
c. Skin above symphysis pubis : by ilio-hypogastric (L.1).
d. Skin of external genitalia : by ilio-inguinal nerve (L.1)
Course:
1. Each of the lower 6 thoracic nerves runs forwards between the
transversus abdominis and the internal oblique muscles:
158
 Abdomen [ 155 - 222 ]
a. The 7th and 8th nerves pass upwards and medially.
b. The 9th nerve passes horizontally.
c. The 10th, 11th and 12th nerves pass downwards and
medially.
2. Each nerve enters the rectus sheath through its posterior wall
then passes through the rectus abdominis. It leaves the sheath as
the anterior cutaneous nerve.
3. The ilio-hypogastric and ilio-inguinal nerves (L.1) do not enter the
rectus sheath:
a. The ilio-hypogastric nerve:
Pierces the aponeurosis of external oblique muscle 3 cm
above the superficial inguinal ring.
b. The ilio-inguinal nerve:
Enters the inguinal canal and leaves it through the superficial
inguinal ring. It supplies the skin of the scrotum in the male
(or the labium majus in the female) and skin of the upper part
of the medial side of thigh.

ARTERIES OF THE ANTERIOR ABDOMINAL WALL

1. From the internal thoracic artery (of subclavian)
 Superior epigastric artery
 Musculophrenic artery
2. From the external iliac artery:
 Inferior epigastric artery
 Deep circumflex iliac artery
3. From the femoral artery :
 Superficial epigastric artery
 Superficial circumflex iliac artery
 Superficial external pudendal artery
4. From the descending aorta:
 Lower posterior intercostal arteries (10th, 11th)
 Subcostal artery (12th)
 All 4 lumbar arteries.
N.B.: The intercostal and lumbar arteries pass in the neurovascular
plane of the anterior abdominal wall which lies between the
transversus abdominis and internal oblique muscles.
INFERIOR EPIGASTRIC ARTERY :
COURSE AND RELATIONS:
 It arises from the external iliac artery just behind the inguinal ligament.
 It passes upwards and medially medial to the deep inguinal ring, in the
extraperitoneal tissue deep to the transversalis fascia.
 It then pierces the transversalis fascia and ascends between it and the
rectus abdominis muscle inside the rectus sheath where it crosses the
arcuate line.
 It continues upwards between the posterior wall of the rectus sheath
and the rectus abdominis where it anastomoses with the superior
epigastric artery at about the level of the umbilicus.
BRANCHES:
1. Cremasteric artery :
Enters the deep inguinal ring to supply the cremaster muscle.

159
 Abdomen [ 155 - 222 ]
2. Pubic branch:
Descends behind the lacunar ligament and the superior ramus of the
pubis to anastomose with the pubic branch of the obturator artery.
N.B.: In absence of the obturator artery, this anastomosis enlarges to
form the abonormal obturator artery (in 30% of cases). It
descends behind the lacunar ligament and may be injured in
operations on femoral hernia.
DEEP CIRCUMFLEX ILIAC ARTERY :
COURSE AND RELATIONS:
 It arises from the external iliac artery immediately above the inguinal
ligament and runs laterally and upwards behind the inguinal ligament
to the anterior superior iliac spine.
 It continues along the inner lip of the iliac crest where it pierces the
trasnversus abdominis and continues its course between it and the
internal oblique.
BRANCHES:
1. Ascending branch:
It is a big branch that arises at the anterior superior iliac spine and
ascends between the trasnversus abdominis and internal oblique. It
anastomoses with the lumbar arteries and musculophrenic artery.
2. Muscular branches:
To the transversus abdominis and internal oblique muscles. They
anastomose with the ilio-lumbar and superior gluteal arteries (from
internal iliac) around the anterior superior iliac spine.

VEINS OF THE ANTERIOR ABDOMINAL WALL

1. Below the level of umbilicus:
This area is drained by the veins which accompany the superficial
inguinal arteries and end in the great saphenous vein, these are:
 Superficial circumflex iliac
 Superficial epigastric
 Superficial external pudendal
2. Above the level of umbilicus:
This area is drained by the lateral thoracic vein that ends in the axillary
vein. This vein anastomoses with the superficial epigastric vein to form
together the thoraco-epigastric vein.
3. At the level of umbilicus:
There are 3 anastomoses :
a. Between the lateral thoracic vein and superficial epigastric vein on
each side (this is a link between the superior and inferior venae
cavae).
b. Between the para-umbilical veins (tributaries of the portal vein) and
systemic veins (this represents a link between the portal and
systemic circulations).
c. Between the superior epigastric vein and inferior epigastric vein in
the rectus sheath (this is a link between S.V.C. and I.V.C.).

FASCLA TRANSVERSALIS
It lines the transversus abdominis muscle and it is separated from the parietal
peritoneum by extra-peritoneal tissue.
Extensions:
1. Above: is continuous with the diaphragmatic fascia (covering the
diaphragm)
160
 Abdomen [ 155 - 222 ]
2 At the iliac crest: is continuous with the fascia iliaca (covering the
iliacus muscle).
3 At the inguinal ligament:
a. Lateral to the external iliac vessels: it blends with the fascia
iliaca.
b. Medial to the external iliac vessels : it blends with pelvic fascia at
the pectineal line.
c. At the external iliac vessels : it descends in front of these vessels
forming the anterior layer of the femoral sheath.
N.B The deep inguinal ring is an opening in the transversalis
fascia where it is evaginated by the contents of the
spermatic cord.

INGUINAL LIGAMENT
(Poupart`s Ligament)
 It is the lower border of the external obligue aponeurosis which is
thickened and folded backwards upon itself.
 It has a groove upper surface (towards the abdomen) from which fibres
of the internal obligue and transversus abdominis take origin.
 Its lower surface is convex (towards the thigh) and is attached to the
fascia lata of the thigh.
ATTACHMENTS:
 Laterally : to the anterior superior iliac spine.
 Medially: to the pubic tubercle.
PARTS OF THE INGUINAL LIGAMENT :
1. Lacunar ligament :
 It is triangular in shape and is attached to the medial part of the
pectineal line (pecten pubis).
 It has 2 surfaces (upper and lower) and 3 borders:
a. Posterior border : attached to the pectineal line.
b. Anterior border : continuous with the inguinal ligament.
c. Lateral border (base) : free and concave and formed the
medial boundary of the femoral ruing.
 Its apex is attached to the pubic tubercle.
2. Reflected part of inguinal ligament :
It is an expansion which arises from the site of attachment of the lacunar
ligament, and passes medially behind the spermatic cord to reach the
linea alba.
N.B. :
Pectineal ligament i.e. the (cooper’s ligament) :
It is a strong band extending laterally from the base of the lacunar
ligament along the pectineal line.
RELATIONS OF THE INGUINAL LIGAMENT:
I. Between its convex lower surface and the hip bone :
1. Femoral sheath and its contents (femoral canal, femoral artery and
femoral vein)
2. Femoral nerve.
3. Lateral cutaneous nerve of the thigh.
4. Iliopsoas muscle.
II. Its grooved upper surface :
1. Gives Origin to the internal oblique and transversus abdominis.

161
 Abdomen [ 155 - 222 ]
2. Forms the floor of the inguinal canal which transmits the spermatic
cord ( in the male ) or the round ligament of uterus (in the female).
III. Deep relations : (towards the abdomen)
1. Inferior epigastric artery : passes upwards and medially behind It.
2. deep circumflex iliac artery : passes laterally behind it.
IV. Superficial relations :
1. Superficial external pudendal vessels.
2. Superficial epigastric vessels.
3. Superficial circumflex iliac vessels.

INGUINAL CANAL
it is a passage about 4 cm long that extends medially and downwards from the
deep inguinal ring to the superficial inguinal ring (oblique direction ).
BOUNDARIES :
1. Anterior wall : formed by :
 External oblique muscle along its whole length.
 Internal oblique muscle : in its lateral 1/3.
2. Posterior wall : ( from behind forwards) by :
 Transversalis fascia : along its whole length.
 Conjoint tendon : in its medial 2/3.
 Reflected part of inguinal ligament in its medial 1/4
N.B. : Its lateral 1/3 is formed only by transversalis fascia (thin).
3. Floor:
It is formed by the concave upper surface of the inguinal ligament and
its lacunar part.
4. Roof:
Formed by the lower arched fleshy fibres of both the internal oblique
and transversus abdominis which arch over the spermatic cord (they
cross over the cord to reach the posterior wall of the canal and form the
conjoint tendon).
SUPERFICIAL INGUINAL RING :
 It is a triangular opening in the aponeurosis of the external oblique
muscle, just above the pubic crest.
 It lies above and medial to the femoral canal.
 Its base (1½ cm) corresponds to the pubic crest and its sides are called
the crura of the ring.
 Its long axis is directed upwards and laterally, and its crura meet at the
apex which is 21/2 cm from the base.
 You can feel the crura by invaginating the skin of the scrotum by the
little finger upwards and laterally.
 From its circumference a tubular sheath called external spermatic fascia
extends around the spermatic cord.
 The ring transmits:
1. Spermatic cord ( in the male) or round ligament ( in the female).
2. Ilio–inguinal nerve.
DEEP INGUINAL RING :
 It is an opening in the transversalis fascia midway between the anterior
superior iliac spine and the symphysis pubis (mid inguinal point). It lies
1/2 cm above the inguinal ligament.
 It is oval in shape with its long axis vertical.
 It is related medially to the inferior epigastric artery.

162
 Abdomen [ 155 - 222 ]
 It transmits the constituents of the spermatic cord (not its coverings) in
the male or the round ligament of uterus in the female.
 It gives from its circumference a tubular sheath around the spermatic
cord called the internal spermatic fascia.
APPLIED ANATOMY:
 The presence of the inguinal canal between the muscles weakens the
lower part of the abdominal wall which predisposes to the occurrence of
inguinal hernia.
 However, there are compensatory mechanisms to prevent hernia
formation
1. The canal has an oblique direction, so its deep and superficial
openings are not opposite each other and any increase in intra-
abdominal pressure approximates the posterior wall of the canal to
its anterior wall.
2. The weak part of one wall is compensated by the strong part of the
other wall :
The conjoint tendon is behind the superficial ring, while the thick
fleshy part of the internal oblique faces the deep ring.

HERNIA
It is the protrusion of an abdominal (viscus most commonly a part of intestine
or greater omentum) through a weak point in the abdominal wall (some organs
as the kidneys or pancreas never herniates).
Types of herniae:
1. Inguinal hernia : in the inguinal region.
2. Femoral hernia : through the femoral canal.
3. Umbilical hernia : related to the umbilicus
Parts of the hernia :
As the herniated part passes to the exterior, it takes in front of it an envelop
of parietal peritoneum called sac of the hernia. This sac has the following
parts.
1. Neck: the proximal constricted part
2. Fundus: the distal end
3. Coverings: all layers separating the fundus from the skin.
4. Contents: the protruding viscus inside the sac.
I. INGUINAL HERNIA
 It is the hernia which passes through a part or the whole of the
inguinal canal.
 It is described either as indirect (oblique) if it traverses the canal
through the deep inguinal ring, or direct if it traverses the canal
through any point of the posterior wall of the inguinal canal (not
through the deep ring)
A. INDIRECT [OBLIQUE] INGUINAL HERNIA:
 The hernial sac protrudes through the deep inguinal ring,
[having the inferior epigastric artery medial to it] and enters the
inguinal canal taking all the coverings of the spermatic cord as
its coverings [the sac will pass inside the cord in front of the
vas deferens).
 As it passes along the canal it receives the following coverings
one after the other according to the degree of its protrusion:
1. Internal spermatic fascia : from the fascia transversalis [at
the deep ring].

163
 Abdomen [ 155 - 222 ]
2. Cremaster muscle and fascia : from the internal oblique (in
the canal).
3. External spermatic fascia : from the external oblique (at the
superficial ring).
4. Skin and fascia ( in the scrotum)
B. DIRECT INGUINAL HERNIA :
 This hernia makes its way through the posterior wall of the
inguinal canal medial o the inferior epigastric artery.
 It may protrude through the lateral 1/3 of the posterior wall
(formed by transversalis fascia) or through its medial 2/3
(formed by conjoint tendon).
 If it protrudes through the lateral 1/3 of the posterior wall : It is
called lateral direct and will be covered by :
1. Extraperitoneal tissue
2. Transversalis fascia.
3. As it passes along the canal it gets more coverings
(cremaster muscle and fascia, external spermatic fascia,
skin and fascia).
N.B.: These coverings are similar to those of the indirect
hernia except that it is not covered by the internal
spermatic fascia. The sac lies between the innermost
layer and middle layer of the spermatic cord
coverings (the sac of indirect hernia is inside the
innermost layer).
 If it protrudes through the medial part (2/3) of the posterior wall
It is called medial direct and will be covered by :
1. Extraperitoneal tissue
2. Transversalis fascia
3. Conjoint tendon
4. External spermatic fascia. (If it succeeds to bulge through
the superficial ring).
N.B.: Its coverings don’t include:
1. Internal spermatic fascia
2. Cremaster muscle and fascia (but instead, it is
covered by the conjoint tendon).
Differences between direct and indirect inguinal herniae:
1. Direct hernia is less frequent than indirect hernia
2. Direct hernia is common in old age as the conjoint tendon becomes
weaker and so yields under pressure.
3. The conjoint tendon usually prevents descent of direct hernia into
the scrotum but indirect hernia easily descends.
4. The inferior epigastric artery is medial to the neck of the sac of
indirect hernia but lateral to that of the direct one (important).
5. They differ in some of their coverings (see above)
II FEMORAL HERNIA
 Pathway:
It passes downwards through the femoral canal then forwards
through the saphenous opening to become subcutaneous. It then
runs upwards and laterally along the inguinal ligaments.
 Coverings:
 Femoral septum (extraperitoneal tissue).
 Anterior wall of femoral canal (part of the femoral sheath).
 Cribriform fascia (covering the saphenous opening)
164
 Abdomen [ 155 - 222 ]
 Skin and fascia.
 In reducing the femoral hernia:
The surgeon has to push it downwards and medially along the
inguinal ligament then backwards through the saphenous opening
and finally upwards through the femoral canal.
Differences between femoral and inguinal herniae:
1. The femoral hernia is more common in females (wide pelvis and
accordingly wide femoral canal).
2. The inguinal hernia is more common in males (the inguinal canal is
wider to accommodate the thicker spermatic cord).
3. The inguinal ligament intervenes between the 2 herniae : the inguinal
hernia above it while the femoral hernia below it.
4. The pubic tubercle serves to differentiate between them : the neck of
the inguinal hernia is above and medial to the tubercle, while the
neck of the femoral hernia is below and lateral to it.
III. UMBILICAL HERNIA
It is a hernia that occurs through the linea alba. It may be classified as
follows:
A. Congenital umbilical hernia:
It is due to persistence of the loop of midgut which has herniated
in the umbilicus of the foetus (a normal temporary finding in the
foetus which disappears by the 3rd month of intrauterine life).
B. Infantile umbilical hernia:
It is due to increased intra-abdominal pressure during the 1st 3
years after birth leading to bulging of the scar of the umbilicus
(usually contains extra-peritoneal tissue).
C. Acquired umbilical hernia:
It occurs through the linea alba just above or just below the
umbilicus (para-umbilical hernia). It usually occurs in adult obese
females.

MALE EXTERNAL GENITAL ORGANS

TESTIS
 It is the primary sex organ
 It is oval in shape having 2 borders (anterior and posterior), 2 ends
(upper and lower) and 2 surfaces (lateral and medial).
 It lies in the scrotum and measures on the average 5 cm in length and
2½ cm from side to side.
 Its posterior border is related to 2 structures:
a. Epididymis : laterally
b. Vas deferens : medially.
 Coverings of the testis : (statring from inside)
 Visceral and parietal layers of the tunica vaginalis.
 The 3 coats of the spermatic cord : surround the testis as well as
the cord (internal spermatic fascia, cremaster muscle and fascia
and external spermatic fascia). Contraction of the cremaster
muscle draws the testis upwards (cremaster reflex).
 To know a testis right or left:
1. The epididymis lies on the posterior border of the testis.
2. The sinus of the epididymis opens on the lateral surface.

165
 Abdomen [ 155 - 222 ]
3. The head of epididymis lies on the upper end of the testis while
the vas deferens is continuous with the tail of the epididymis at
the lower end of the testis.
 Descent of the testis :
 In early embryonic life, the testis develops high up in the posterior
abdominal wall.
 Before its descent a tube of peritoneum called processus
vaginalis descends through the inguinal canal to reach the
scrotum. This is followed by descent of the testis which reaches
the scrotum just before birth.
 The testis reaches the following sites at specific times:
1. Iliac fossa : by the 3rd month of intra-uterine life
2. Deep inguinal ring : by the 7th month of intra-uterine life.
3. Enters the scrotum : by the 9th month (full term).
 Before descent, the testis takes its blood supply and its lymph
vessels from high up in the abdomen:
1. The testicular artery : arises from the abdominal aorta.
2. The testicular veins : end on the left renal vein (left side) or
inferior vena cava (left side).
3. The lymphatics : drain into the aortic lymph nodes.
 Fate of processus vaginalis :
1. The testis invaginates the terminal blind end of the processus
vaginalis from its posterior aspect. The part of the processus which
surrounds the testis is called the tunica vaginalis.
The tunica vaginalis has a visceral layer fused with the surface of the
testis and a parietal layer adherent to the wall of the scrotum and a
cavity in between. If this cavity is filled with serous fluid a hydrocele
is produced.
2. The part of the processus vaginalis between the deep inguinal ring
and the tudnica vaginalis becomes obliterated to form a fibrous
strand called the vestige of processus vaginalis. Its persistence as a
patent tube will lead to congenital inguinal hernia or congenital
hydrocele.

EPIDIDYMIS
 It is a highly coiled tube that lies on the lateral part of the posterior
border of the testis.
 It has an enlarged head attached to the upper end of the testis, a body,
and a narrow tail attached to the lower end of the testis. The tail is
continuous with the vas deferens.
 A space lined by the tunica vaginalis exists between the body of the
epididymis and the back of the testis. It is named sinus of the
epididymis and opens laterally.

SCROTUM
 The scrotum contains the 2 testes and the lower parts of the spermatic
cords.
 Its wall is formed of skin and the dartos muscle. The dartos muscle is
an involuntary muscle which is closely adherent to the skin.
 There is a septum inside its cavity which is thus divided into 2
compartments (one for each testis).

166
 Abdomen [ 155 - 222 ]
 Its arterial supply comes from :
1. External pudendal arteries (superficial and deep) : from the
femoral artery.
2. Internal pudendal artery : from the internal iliac artery.
3. Cremasteric artery : from the inferior epigastric artery.
 It nerves are : (L. 1 and S. 3):
1. Ilio-inguinal nerve (L. 1)
2. Scrotal branches of the perineal nerve (S. 3)
3. Perineal branch of posterior cutaneous nerve of thigh (S.3).
(Note the combination of 1st lumbar and 3rd sacral nerve roots).

SPERMATIC CORD
 The spermatic cord lies in both the inguinal canal and in the scrotum. It
extends from the lower end of the testis to the deep inguinal ring where
its constituents enter the pelvis as separate structures.
 The constituents of the cord are surrounded by 3 coverings.
CONSTITUENTS OF THE CORD:
1. Vas deferens (ductus deferens):
It has a thick muscular wall and can be distinguished from the other
constituents by being firm and cord-like. It ascends on the medial side
of the epididymis (posterior to the testis) then through the spermatic
cord till the deep inguinal ring. At the deep ring it curves lateral to the
inferior epigastric artery.
2. Artery of the vas deferens:
Arises from the inferior vesical artery at the base of the bladder and
enters the deep inguinal ring along with the vas.
3. Vestige of th e rocessus vaginalis:
It is a fibrous strand which remains after obliteration of the connection
between the tunica vaginalis and the peritoneal cavity.
4. Vessels and nerves of the testis:
a. Testicular artery : arises from the abdominal aorta opposite the
2nd lumbar vertebra (represents the original site of development
of the testis).
b. Sympathetic firbes : surrounding the testicular artery (testicular
plexus).
c. Pampiniform plexus of veins : several veins emerge from the
posterior border of the testis and join each other to form the
pampiniform plexus. This plexus ends at the deep inguinal ring
by forming the testicular vein (pampiniform = like coiled threads).
The testicular vein on the right side ends in the inferior vena cava,
while that on the let side ends in the left renal vein.
N.B.:
The left colon is usually filled with hard faecal matter, so by
pressure on the left testicular vein it may lead to varicosities in
the pampiniform plexus on the left side, a condition known as
varicocele (common on the left than on the right).
d. Lymph vessels : drain the testis into the aortic lymph nodes
(lymph drainage of the penis and scrotum is into the superficial
inguinal lymph nodes).
COVERINGS (COATS) OF THE CORD:
1. Internal spermatic fascia :
Derived from the fascia transversalis at the deep inguinal ring and forms
the innermost coat of the cord.
167
 Abdomen [ 155 - 222 ]
2. Cremaster muscle and fascia:
The cremaster muscle is derived from the internal oblique muscle and
forms the middle coat. It runs on the sides of the cord in the form of 2
bands (medial and lateral).
The cremaster is inserted into the pubic tubercle as well as in the wall of
the cord. It is supplied by the genital branch of genito-femoral nerve.
3. External spermatic fascia :
Derived from the margins of the superficial inguinal ring and forms the
external coat.
N.B.:
The female has the round ligament of uterus, passing through the
inguinal canal which is not wide as in the male. This round ligament
does not correspond to any of the constituents of the spermatic cord
but it is a part of the gubernaculum of the foetus.

PENIS
Described with the perineum.

ABDOMINAL CAVITY
PLANES AND REGIONS OF THE ABDOMEN
The cavity of the abdomen consists of :
1. Cavity of the abdomen proper.
2. Pelvic cavity
PLANES :
The cavity of the abdomen proper is divided for convenience of
description into region by horizontal and vertical planes:
1. Subcostal Plane :
It is a transverse plane that passes through the lower border of
the costal margin. It is at the level of the 10th rib and the 3rd
lumbar vertebra.
2. Transtubercular plane :
It is a transverse plane at the level of the tubercle of iliac crest; it
cuts the 5th lumbar vertebra. At this plane there are :
a. Junction of the ascending colon with the caecum.
b. Beginning of the inferior vena cava.
3. Right and left lateral planes
They are represented by 2 vertical lines extend upwards from the
midinguinal points (one on each side).
REGIONS :
The transverse and vertical planes divide the cavity of the abdomen
proper into the following 9 regions:
1. Above the subcostal plane :
 Right hypochondrium (on right side).
 Left hypochondrium (on left side)
 Epigastrium ( in the middle).
2. Between the subcostal and transtubercular planes :
 Right lumbar region ( on right side)
 Left lumbar region ( on left side ).
 Umbilical region ( in the middle)
3. Below the transtubercular plane :
 Right iliac region ( on right side ).
 Left iliac region ( on left side).
168
 Abdomen [ 155 - 222 ]
 Hypogastrium or pubic region ( in the middle).

OTHER IMPORTANT PLANES AND THEIR RELATIONS :

1. Transpyloric plane ( L.I )
 It passes midway between the symphysis pubis and upper margin of
the manubrium sterni opposite the 1st lumbar vertebra.
 At this level there are 4 following :
a. Fundus of gall bladder ( at the junction of this plane with the
linea seminularis which corresponds to the lateral border of
rectus abdominis).
b. Pylorus of the stomach
c. Hilus of the kidney
d. Origin of the superior mesenteric artery.
2. Plane of the 2nd lumbar vertebra:
At this level there are:
a. End of the spinal cord (at the disc between L.1 and L.2).
b. Beginning of the thoracic duct
c. Beginning of the azygos vein
d. Origin of the renal artery
3. Plane of the 4th lumbar vertebra:
 It passes through the highest points of the iliac crests (supracristal
plane).
 It is a usual landmark for lumbar puncture.
 It corresponds to the lower end of abdominal aorta.

PERITONEUM
GENERAL COSNIDERATIONS
The peritoneum is a serous sac that lines the abdominal cavity. The cavity of
the peritoneal sac is called the peritoneal cavity which is empty except of a
thin film of serous fluid.
If the quantity of fluid increases than normal, the condition is called ascites.
 Development:
1. During development the abdominal viscera and organs bulge from the
posterior abdominal wall and invaginate the peritoneal sac which, as a
result, acquires 2 layers (visceral and parietal).
a. The layer of peritoneum covering the organ (viscus) is named
visceral layer.
b. The layer of peritoneum which remains lining the walls of the
abdomen (parieties) is termed parietal layer.
2. The degree of invagination by the abdominal organs varies:
a. Some organs leave the posterior abdominal wall completely and
become suspended inside the peritoneal cavity by a fold of
peritoneum called mesentery (e.g. intestine) or omentum (e.g.
stomach) or ligament (e.g. spleen which has gastro-splenic and
lieno-renal ligaments).
b. Some other organs, only bulge in the peritoneal cavity to a limited
extent and are covered by peritoneum on the front and sides only,
with no mesentery (e.g. ascending and descending colon, kidneys
and pancreas).
 Remember that :
1. All the abdominal organs, without (exception are extraperitoneal, i.e.
develop and lie outside the peritoneal cavity which is an empty cavity.
169
 Abdomen [ 155 - 222 ]
2. The peritoneal cavity is a closed sac in the male while in the female the
uterine tubes open into it, so, the peritoneal sac is continuous with the
exterior through the uterine tubes (possible source of infection).
 Divisions of peritoneal cavity:
The peritoneal cavity consists of 2 sacs
a. Greater sac
b. Lesser sac (omental bursa)
Both sacs are continuous with each other through an opening termed
the opening to the lesser sac (epiploic foramen).

GREATER SAC
The greater sac fills the whole abdominal cavity and is divided into 2
compartments by a partition formed by :
1. The stomach : together with the lesser omentum (attached to its lesser
curvature) and the greater omentum (attached to its greater curvature).
2. The transverse colon and its mesocolon.
 The 2 compartments are :
1. Antero-superior compartment : in front of the partition.
2. Postero-inferior compartment : behind the partition.
 Each of these compartments is divided further into right and left parts as
follows:
a. The antero-superior compartment : is divided by the falciform
ligament of the liver.
b. The postero-inferior compartment is divided by the mesentery of the
small intestine.
 Constituents of the partition between the 2 compartments :
Starting from the stomach : it is covered on both of its anterior and
posterior surfaces by layers of peritoneum which meet each other at its
lesser and greater curvatures to form the following :
1. At the lesser curvature :
The 2 layers of peritoneum enclosing the stomach form the lesser
omentum which extends upwards towards the liver. These 2 layers split
at the porta hepatis to become continuous with the peritoneum covering
the liver.
2. At the greater curvature :
The peritoneum enclosing the stomach forms 3 folds :
a. Gastro-phrenic ligament :
Extends upwards from the fundus of the stomach to the under
surface of diaphragm.
b. Gastro-splenic ligament:
Extends to the left as 2 layers to enclose the spleen.
c. Greater omentum :
 Descends from the greater curvature of the stomach as 2
layers for a variable distance where these 2 layers return
upwards and ascend posterior to the descending 2 layers,
(therefore it becomes formed of 4 layers of 2 descending and
2 ascending).
 The 2 posterior (ascending) layers, on their way to the
posterior abdominal wall, enclose the transverse colon and
then continue upwards as the transverse mesocolon which
gets attached to the anterior border of pancreas.

170
 Abdomen [ 155 - 222 ]
LESSER SAC (OMENTAL BURSA)
POSITION
It is the peritoneal space which :
1. Lies behind the stomach and lesser omentum.
2. Extends upwards behind the caudate lobe of the liver (hepatic recess).
3. Descends downwards in the greater omentum (between the anterior 2
layers and posterior 2 layers).
4. Extends to the left to reach the spleen (splenic recess).
5. Communicates with the greater sac : the lesser sac is shut off from the
greater sac except at the upper part of its right border where both sacs
are continuous through the opening to lesser sac (epiploic foramen)
BOUNDARIES OF THE LESSER SAC:
A. Anterior wall : (from above downwards) by:
1. Caudate lobe of the liver
2. Lesser omentum
3. Back of the stomach
4. Gastro-splenic ligament
5. Anterior 2 layers of the greater omentum
B. Posterior wall : (from below upwards) by:
1. Posterior 2 layers of the greater omentum
2. Transverse colon.
3. Transverse mesocolon
4. Peritoneum covering the stomach bed
C. Left border by:
1. Left border of the greater omentum
2. Gastro-splenic and lieno-renal ligaments.
D. Right border:
1. Right border of the greater omentum.
2. Right free border of the lesser omentum (behind which lies the
epiploic foramen).
E. Upper boundary :
1. It is formed by the reflection of peritoneum on the diaphragm
from the anterior wall to the posterior wall of the sac.
2. It extends from the fissure for ligamentum venosum (on the
right) to the lower end of the oesophagus (on the left).
F. Lower boundary:
It is the turn up of the descending anterior 2 layers of the greater
omentum to ascend as its posterior 2 layers (i.e. lower margin of
the greater omentum).
OPENING TO LESSER SAC: (epiploic foramen)
It is the opening of communication between the greater and lesser sacs.
Identification:
To identify the epiploic foramen, pull the stomach away from the liver to
stretch the lesser omentum then pass the finger downwards along the
gall bladder and its duct to reach the free border of the lesser omentum.
Push the finger behind this border towards the left side, it will enter the
opening to lesser sac.
BOUNDARIES OF THE EPIPLOIC FORAMEN
 Anteriorly :
Is related to the 3 contents in the free border of lesser omentum :
1. Portal vein
2. Hepatic artery surrounded by sympathetic fibres
3. Bile duct (to the right of the hepatic artery)
171
 Abdomen [ 155 - 222 ]
The portal vein is posterior to both the bile duct and hepatic
artery.
 Posteriorly by:
The inferior vena cava (covered by the peritoneum of the posterior
abdominal wall).
N.B.: A finger placed in the epiploic foramen will be in direct
relation to 2 veins : the inferior vena cava posteriorly, and
the portal vein anteriorly.
 Superiorly by:
caudate process of the liver.
 Inferiorly by:
1. 1st inch of the duodenum
2. The portal vein as it curves forwards from the behind the
duodenum to enter the free border of lesser omentum.

PERITONEAL FOLDS
1. GREATER OMENTUM:
 It is a large fold of peritoneum that descends over the
intestine and separates it from the anterior abdominal wall.
 It is of great value in localizing infections in the peritoneum
and preventing its spread and thus called “Policeman of the
abdomen.”
 It consists of 4 layers of which 2 are anterior and 2 are
posterior, with the lower extension of the lesser sac in
between.
ATTACHMENTS:
 It is attached to the greater curvature of the stomach.
 Its anterior 2 layers descend for a variable distance then
return upwards as its posterior 2 layers.
 The posterior 2 layers enclose the transverse colon.
CONTENTS:
1. Left and right gastro-epiploic arteries : run close and
parallel to the greater curvature of the stomach, between
the anterior 2 layers. They form an anastomotic channel
that supplies both the stomach and the greater omentum.
2. Lymph nodes and vessels : along the gastro-epiploic
vessels.
2. LESSER OMENTUM:
It is a fold of 2 layers of peritoneum extending between the
stomach and the liver.
ATTACHNENTS :
 Below and to the left :
To the lesser curvature of the stomach and 1st inch of the
duodenum.
 Above :
To the lips of the porta hepatis and the fissure for ligamentum
venosum. It extends on the lower surface of the diaphragm
between the end of the fissure for ligamentum venosum and
the lower end of oesophagus.
 On the right :
It has a free border.

172
 Abdomen [ 155 - 222 ]
CONTENTS :
1. Right and left gastric vessels : run along the lesser
curvature where they anastomose together.
2. At the free border of the omentum there are :
 Portal vein (posterior).
 Hepatic artery (anterior and to the left).
 Bile duct (anterior and to the right).
 Sympathetic and parasympathetic fibres (around
the artery).
3. Lymph nodes and vessels.
RELATIONS :
 Anteriorly : liver.
 Posteriorly : cavity of the lesser sac separating the
omentum from the stomach bed.
3. FALCIFORM LIGAMENT :
DEVELOPMENT :
The falciform ligament and the lesser omentum developing in the
foetus from a single fold called the ventral mesogastrium
extending from the ventral border of the stomach to the anterior
abdominal wall.
The liver develops between the 2 layers of the ventral
mesogastrium and divides it into 2 parts :
a. Lesser omentum : between the liver and the stomach.
b. Falciform ligament : between the liver and anterior
abdominal wall.
N.B. The dorsal mesogastrium (dorsal to the stomach )
will similarly form 2 parts : the gastro-splenic and
lieno–renal ligaments (by development of the spleen).
ATTACHMENTS :
The falciform ligament is a sickle-shaped fold of peritoneum
extending from the anterior abdominal wall (in the midline) to the
fissure on the anterior and upper surfaces of the liver between the
right and left lobes of the liver ( to the right of the median plane)
Therefore, the ligament is placed obliquely so as to have anterior
and posterior surfaces.
BORDERS :
 Apex : reaches the back of the umbilicus.
 Base : is attached to the fissure between the right and left
lobes of the liver (on its anterior and upper surfaces.
 Lower border: concave where its 2 layers are continuous
together and enclose the ligamentum teres of the liver
(fibrosed left umbilical vein of the foetus) together with the
para-umbilical veins around the ligamentum teres.
 Upper border : is convex and attached to the anterior
abdominal wall and under surface of the diaphragm.
4. UMBILICAL FOLDS:
 These are 5 folds related to the lower part of the anterior
abdominal wall:
a. Median umbilical fold : contains the obliterated urachus
and extends from the apex of the bladder to the
umbilicus.

173
 Abdomen [ 155 - 222 ]
b. 2 medial umbilical folds ; (one each side) each contains
the obliterated umbilical artery. They extend to the
umbilicus.
c. 2 lateral umbilical folds : (one on each side) each
contains the inferior epigastric artery on its way to enter
the rectus sheath.
 Between these umbilical folds there are 2 inguinal fossae
(medial and lateral)
a. Medial inguinal fossa : between the lateral and medial
umbilical folds.
b. Lateral inguinal fossa : lateral to the lateral umbilical fold
and overlies the deep inguinal ring.

PERITONEAL RECESSES
These peritoneal recesses are of surgical importance as they may be sites
for internal hernia. It is necessary to remember whether the entrance of the
recess is related to a blood vessel or not, because this has surgical
importance.
1. DUODENAL RECESSES:
There are 4 duodenal recesses:
a. Superior duodenal recess:
It is present to the left side of the upper end of the 4th part of
duodenum behind the superior duodenal fold. The edge of this fold
is closely related to the inferior mesenteric vein. The opening of the
recess looks downwards.
b. Inferior duodenal recess:
It is present to the left side of the lower end of the 4th part of
duodenum behind the inferior duodenal fold (non-vascular). Its
orifice looks upwards.
c. Paraduodenal recess:
It lies to the left of the 4th part of duodenum behind the paraduodenal
fold. This fold contains the inferior mesenteric vein and the
ascending branch of the superior left colic artery.
d. Retroduodenal recess:
It is the largest of all duodenal recesses and lies behind the 3rd and
4th parts of duodenum in front of the aorta.
2. CAECAL RECESSES:
There are 3 caecal recesses:
a. Superior ileocaecal recess:
Formed by a fold of peritoneum extending from the lower part of the
mesentery of the small intestine to the caecum (called the vascular
fold of the caecum). It is open downwards and to the left.
b. Inferior ileocaecal recess:
Formed by the ileocaecal fold extending from the end of the ileum to
the caecum and the mesentery of the appendix.
c. Retrocaecal recess:
Lies behind the caecum and may contain the appendix
3. RECESS OF THE PELVIC MESOCOLON:
It lies at the meeting of the 2 limbs of the pelvic mesocolon. The
apex of the recess lies in front of the left ureter where it crosses the
end of the common iliac artery.

174
 Abdomen [ 155 - 222 ]
STOMACH AND INTESTINE
STOMACH
POSITION:
 It lies in the upper left part of the abdominal cavity (in epigastric,
umbilical and left hypochondriac regions).
SHAPE
 The various forms of the stomach are best shown by X-ray examination
in the living after taking a radio-opaque material by mouth (barium
meal).
 The most common form is the J-shaped outline. The stomach descends
vertically to a level below the umbilicus then turns upwards and to the
right to join the duodenum.
 A less common form is the steer-horn type where the stomach has a
more transverse position.
PARTS OF THE STOMACH:
1. Cardiac end:
It is the end where the oesophagus joins the stomach. The cardiac notch
separates the oesophagus from the greater curvature.
2. Fundus:
It is the part bulging above a horizontal line extending from the cardiac
end to the greater curvature.
3. Body:
It is the part limited below by a horizontal line extending from the
angular notch on the lesser curvature to the greater curvature.
4. Pyloric portion:
It is the part below the line drawn from the angular notch to the greater
curvature. It consists of the following parts:
a. Pyloric antrum: is the dilated left part of the pyloric portion
(antrum = chamber).
b. Pyloric canal: is the narrow canal to the right side of the pyloric
antrum.
c. Pylorus (pyloric sphincter): corresponds to the pyloric orifice and
lies 1 inch to the right of the median plane.
N.B.:
1. The cardiac end is fixed while the pyloric end is mobile.
2. The pyloric orifice is demarcated by the prepyloric vein
which runs vertically in front o the pylorus and connects
the right gastric vein with the gastro-epiploic vein.
RELATIONS OF THE STOMACH:
The stomach has : 2 ends, 2 borders and 2 surfaces.
ENDS:
1. Cardiac end: related to:
 Anteriorly : liver
 Posteriorly : diaphragm
2. Pyloric end : related to :
 Anteriorly : quadrate lobe of the liver
 Posteriorly : Lesser sac
Neck of pancreas
BORDERS:
1. Greater curvature:
 The right and left gastro-epiploic vessels pass along it.

175
 Abdomen [ 155 - 222 ]
 It gives attachment to the following ligaments : (from above
downwards).
a. Gastro-phrenic ligament
b. Gastro-splenic ligament
c. Greater omentum
2. Lesser curvature:
 The right and left gastric vessels pass along it.
 The lesser omentum is attached to it.
SURFACES:
1. Anteriorly surface : related to :
 Liver
 Diaphragm
 Anterior abdominal wall
2. Posterior wall:
 It is related to the stomach bed but separated from it by the lesser
sac.
 The stomach bed comprises the following :
1. Pancreas (passing transversely across the posterior abdominal
wall).
2. Splenic artery (at the upper border of the pancreas)
3. Left kidney (related to the tail of pancreas).
4. Left suprarenal gland (related to the left kidney)
5. Spleen (related to the left kidney)
6. Transverse mesocolon (along the anterior border of pancreas).
7. Diaphragm (behind all these structures).
PERITONEAL RELATIONS OF THE STOMACH:
1. The stomach is covered in front and behind by peritoneum.
2. There is a small triangular area on the posterior surface near the
cardiac end which is bare (devoid of peritoneum).
3. The stomach gives attachments to the following peritoneal folds:
a. Greater omentum
b. Gastro-phrenic ligament
c. Gastro-splenic ligament
d. Lesser omentum
SURFACE ANATOMY
 Cardiac end:
Lies 1 inch to the left of the median plane at the 7th costal cartilage
(10th T.V).
 Pylorus:
Lies 1 inch to the right of the median plane on the transpyloric plane
opposite the 1st L.V
 Fundus:
Lies at a point at the 5th intercostal space in the mid-clavicular line (a
little below the left nipple).
ARTERIAL SUPPLY
 The stomach is supplied from the 3 branches of the celiac artery (left
gastric, hepatic and splenic):
1. Left gastric artery : to the lesser curvature
2. Right gastric artery : to the lesser curvature
3. Left gastro-epiploic artery : to the greater curvature
4. Right gastro-epiploic artery : to the greater curvature
5. Short gastric arteries : to the fundus

176
 Abdomen [ 155 - 222 ]
 The pyloric portion is supplied from the hepatic artery, while the rest
of the stomach is supplied from both the left gastric artery (to its
right part) and splenic artery (to its left part)
 Anastomosis in the gastric wall:
1. Gastric and oesophageal arteries have free anastomosis
2. On the other hand, anastomosis between the gastric and
duodenal arteries is scanty (the pyloro-duodenal junction is
described as bloodless-line).
3. The anastomosis between the gastric and oesophageal
veins at the cardiac end is one of the sites of porto-
systemic anastomosis.
NERVE SUPPLY:
1. Anterior vagal trunk (anterior gastric nerve):
Runs on the anterior surface of stomach and represents the left vagus
nerve (due to rotation of the stomach to the right).
2. Posterior vagal trunk (posterior gastric nerve):
Runs on the posterior surface of stomach and represents the right
vagus nerve.
3. Sympathetic fibres:
From the coeliac plexus
LYMPH DRAINAGE:
The stomach is drained into the following lymph nodes
1. Left gastric nodes : along the left gastric vessels.
2. Right gastro-epiploic nodes : along the right gastro-epiploic vessels.
3. Pyloric nodes : behind the duodenum at the angle between its 1st and
2nd parts (along the gastroduodenal artery).
4. Pancreatico-splenic nodes : along the splenic artery.
5. Hepatic nodes : along the stem of the hepatic artery
N.B.: All these lymph nodes drain into the coeliac group of lymph nodes
(around the celiac artery).

SMALL INTESTINE
The small intestine is divided into 3 parts:
1. Duodenum : is the 1st part and is fixed to the posterior abdominal wall
for the greater part of its length (retroperitoneal).
2. Jejunum: follows the duodenum and forms 2/5 of the free coiled part of
the small intestine which is 20 feet long.
3. Ileum: ends by joining the colon at the ileo-caecal junction and forms
the distal 3/5 of the coiled part of the small intestine.
N.B.: Both the jejunum and ileum have a mesentery which attaches them
to the posterior abdominal wall.

DUODENUM
 It is C-shaped tube, 10 inches long, and is curved around the head of
pancreas.
 Except for its 1st inch which is free off the posterior abdominal wall, the
rest of the duodenum is retroperitoneal and accordingly it is fixed in
place.
 It is described to be formed of 4 parts : upper, descending, horizontal
and ascending.
I. UPPER (FIRST) PART : (2 inches)
It runs to the right and backwards. Its 1st inch (free part) differs from the
2nd inch (fixed part) in its relations.
177
 Abdomen [ 155 - 222 ]
A. FREE PART : related to
 Anteriorly :
 quadrate lobe of the liver
 Posteriorly :
 the lesser sac which separates it from the neck of the
pancreas.
 Above :
 gives attachment to the lesser omentum
 Below:
 gives attachment to the greater omentum.
N.B.:
The free part is termed the duodenal cap in X-ray films after taking
barium meal.
B. FIXED PART : related to :
 Anteriorly:
 Quadrate lobe of the liver.
 Neck of the gall-bladder
 Posteriorly:
 Bile duct
 Gastroduodenal artery (branch from hepatic artery)
 Portal vein
 Inferior vena cava (most posterior)
N.B.: These are the structures running in front and behind
the epiploic foramen as they are traced downwards
behind the 1st part of the duodenum.
 Above :
 epiploic foramen
 Below :
 neck of pancreas
II. DESCENDING (SECOND) PART: (3 inches)
Descends vertically from the level of the 1st lumbar vertebra till the
3rd lumbar vertebra.
It is related to the following:
 Anteriorly :
 Right lobe of the liver.
 Transverse colon (in direct contact with the duodenum with no
peritoneum intervening).
 Loops of jejunum
 Posteriorly:
 Hilus of right kidney with the renal vessels separating the
duodenum from the psoas major muscle.
 Laterally:
 Right colic flexure
 Medially:
 Head of pancreas
 Pancreatico-duodenal vessels.
N.B.: The bile duct opens into the postero-medial surface of the
2nd part at its middle.
III. HORIZONTAL (THIRD) PART : (4 inches)
Passes nearly horizontal at the level of the 3rd lumbar vertebra. It is
related to the following:
 Anteriorly:
 Root of the mesentery
178
 Abdomen [ 155 - 222 ]
 Superior mesenteric vessels in the root of the mesentery.
 Transverse mesocolon.
 Posteriorly:
 Aorta but is separated by the inferior mesenteric artery.
 Inferior vena cava but is separated by the right gonadal artery
(testicular or ovarian).
 Right psoas major muscle but is separated by the right ureter.
N.B.: It is related to 3 structures, with 3 other structures
intervening.
 Above:
 Head of pancreas
IV. ASCENDING (FOUTH) PART: (1 inch)
It is the shortest part and curves upwards along the left side of the
head of pancreas and aorta to join the jejunum at the level of 2nd
lumbar vertebra by forming the duodeno-jejunal flexure.
It is related to the following:
 Anteriorly:
 Loops of jejunum
 Posteriorly:
 Left sympathetic trunk
 Left gonadal artery (testicular or ovarian).
 On the right:
 Head of pancreas
 Aorta
DUODENAL PAPILLAE:
 The bile duct and the main pancreatic duct enter the wall of the
duodenum together where they unite to form a dilatation called
the hepato-pancreatic ampulla (of Vater). The 2 ducts may open
separately.
 This ampulla opens on the summit of a papilla called the major
duodenal papilla. It lies at the posteromedial surface of the
middle of the 2nd part of duodenum and is guarded by the
sphincter of Oddi.
 About 1 inch proximal (above) to the major duodenal papilla, the
accessory pancreatic duct opens on the summit of the minor
duodenal papilla.
ARTERIAL SUPPLY:
1. Right gastric artery
2. Right gastro-epiploic artery
3. Supraduodenal artery
4. Superior pancreatico-duodenal artery
5. Inferior pancreatico-duodenal artery.
N.B.:
These branches arise from the hepatic artery (of the coeliac)
except the inferior pancreatico-dueodenal which comes from the
superior mesenteric artery.
LYMPH DRAINAGE: TO:
1. Hepatic lymph nodes
2. Superior mesenteric lymph nodes

179
 Abdomen [ 155 - 222 ]

SURFACE ANATOMY OF THE DUODENUM:

1. First part:
From a point on the transpyloric plane (1st L.V.) 1 inch to the right of the
median plane, draw a line 2 inches long towards the right side.
2. Second part:
From the right end of the previous line, draw downwards a vertical line 3
inches long.
3. Third part:
From the end of the 2nd part, draw a horizontal line to the left side 4
inches long (at the level of the 3rd lumbar vertebra).
4. Fourth part:
From the end of the 3rd part, draw upwards a line 1 inch long. Its end
lies 1 inch to the left of the median plane (opposite 2nd L.V).
N.B.: Note that the duodenum begins 1 inch to the right of the median
plane and ends also 1 inch to the left of the median plane.

JEJUNUM AND ILEUM

A. The jejunum and ileum (6 metres long) are suspended from the posterior
abdominal wall by a mesentery.
B. The jejunum joins the duodenum at a bend known as the duodeno-jejunal
flexure while the ileum joins the beginning of the ascending colon at the
ileo-caecal (ileo-colic) junction.
C. About 2-3 feet proximal to (above) the ileo-caecal junction a small pouch (2
inches long) may be present (in 2% of persons) called Meckel’s
diverticulum which represents a remnant of the vitello-intestinal duct of the
foetus.
DIFFERENCES BETWEEN JEJUNUM AND ILEUM:
1. The mesentery :
The mesentery of the jejunum contains less fat and if one looks at the
mesentery against light the vessels are clearly seen with the spaces in
between are translucent and called windows. In the ileum the fat is greater
in amount and hides the vessels, so no windows can be seen.
2. Arterial arcades:
The arteries in the mesentery break up into branches which unite together,
then new branches arise and unite again and so on forming a series of
arcades.
3. Villi:
The wall of the jejunum is thicker due to larger and more numerous villi,
while in the ileum the villi are shorter and less numerous.
4. Circular folds:
There are numerous circular folds in the mucosa of the jejunum more than
in the ileum.
5. Peyer’s patches:
In the wall of the ileum there are aggregations of lymphoid tissue called
Peyer’s patches, but in the jejunum no Peyer’s patches are present.
MESENTERY OF THE SMALL INTESTINE:
 It is a fold of 2 layers of peritoneum having 2 borders (free and
attached) ileum.
 Attached border : (6 inches long) is attached to posterior abdominal
wall and forms the root of mesentery. It extends obliquely from the

180
 Abdomen [ 155 - 222 ]
duodeno-jejunal flexure downwards and to the right where it ends at
the ileo-caecal junction.
 The depth of the mesentery between the 2 borders is about 6 inches
in its middle part but diminishes towards its ends.
 Relations of the root of mesentery:
The root crosses the following structures (from left to right)
1. Inferior vena cava
2. Right psoas major
3. Right ureter
4. Right testicular or ovarian vessels
 Contents of the mesentery:
1. Jejunum and ileum : in the free border of the mesentery.
2. Superior mesenteric vessels : in the root of the mesentery.
3. Jejunal and ileal branches : they pass towards the intestine
parallel to each other with anastomotic connections in between
forming arterial arcades. From the terminal arcades, vasa
recta pass as straight vessels to the gut (arcades = in arches ;
recta = straight).
4. Sympathetic fibres : around the arteries
5. Mesenteric lymph nodes : they are arranged in 3 rows:
 Small-sized nodes : near the free border.
 Medium-sized nodes : midway between the borders of
the mesentery.
 Large-sized nodes : at the root (attached border).
N.B.:
The lymph vessels from the small intestine are called
lacteals and end in these mesenteric nodes. The final
efferents form the intestinal lymph trunk which ends in the
cisterna chyli.
6. Fatty areolar tissue : the deposition of fat increases towards
the ileum.

LARGE INTESTINE
 It is the distal part of the gastro-intestinal tract (1½ metres) whose
diameter is greater than that of the small intestine. It consists of the
caecum, appendix, colon, rectum and anal canal.
 The large intestine differs from the small intestine in having the
following 3 main features :
1. Taeniae coli : these are 3 longitudinal muscular bands in the wall
of the colon (one anterior and 2 posterior, but are reversed in the
transverse colon where they are one posterior and 2 anterior).
2. Sacculations (haustrations) : the wall is sacculated because the
taeniae coli are shorter than the length of the colon.
3. Appendices epiploicae : these are folds of peritoneum filled with
fat. They are scattered over the surface of the colon (not present
on the caecum, appendix or rectum).

CAECUM
 It is the beginning of the large intestine and lies in the right iliac fossa
immediately above the lateral 1/2 of the inguinal ligament.
 The vermiform appendix opens into its postero-medial aspect about 1-2
cm below the ileo-caecal opening.

181
 Abdomen [ 155 - 222 ]
 It is covered by peritoneum nearly completely and is mobile. (It can
herniate down into the inguinal canal).
 The 3 taeniae coli converge on the base of the appendix where they form
its longitudinal muscle layer.
 The anterior taenia coli of the caecum is taken as a guide to reach the
appendix.
RELATIONS:
 Anteriorly:
 Anterior abdominal wall.
 Posteriorly:
It rests on the iliacus and psoas major with 3 nerves intervening :
 Lateral cutaneous nerve of thigh
 Genito-femoral nerve
 Femoral nerve
SURFACE ANATOMY:
A. The caecum:
Lies in a triangular area bounded by :
1. Right inguinal ligament
2. Transtubercular plane : (at 5th L.V.) passes through the junction
of the caecum with the ascending colon.
3. Right lateral plane : (a vertical plane from the midinguinal point
upwards).
B. The opening of the appendix into the caecum : (base of appendix)
Is marked on the surface at the McBurney’s point. This point is at the
junction of the lateral 1/3 and middle 1/3 of a line drawn from the anterior
superior iliac spine to the umbilicus. McBurney’s point is an important
point in diagnosing appendicitis.

VERMIFORM APPENDIX
 It is a narrow worm-like part of the large intestine which varies in length
(average 10 cm). It opens into the postero-medial aspect of the caecum
1/2 cm below the ileo-caecal opening.
 To reach the appendix:
Follow the anterior taenia coli on the wall of the ascending colon down
towards the caecum. The 3 taeniae coli meet each other at the base of
the appendix to form a continuous coat.
 The appendix has a mesentery (meso-appendix) :
It is a triangular fold of peritoneum which, extends along the whole
length of the appendix. The appendicular artery runs in its free margin.
 The appendicular artery :
a. It is a branch of the ileo-colic artery that descends behind the end
of the ileum to enter the free margin of the meso-appendix.
b. It anastomoses with the posterior caecal artery at the base of the
appendix.
c. Near its termination the artery lies directly on the wall of the
appendix and may be thrombosed in appendicitis leading to
gangrene.
 The submucosa of the appendix is rich in lymphoid tissue.
POSITIONS OF THE APPENDIX:
1. Retrocaecal or retrocolic: (65%)
Behind the caecum (retrocaecal) and if long enough it reaches up
behind the ascending colon (retrocolic).

182
 Abdomen [ 155 - 222 ]
2. Pelvic: (30%)
It hangs over the pelvic brim where it may be related to the uterine tube
and ovary.
3. Subcaecal : (3%)
Just below the caecum.
4. Pre-ileal or post-ileal : (2%)
In front of the termination of the ileum (pre-ileal) where it directly comes
in contact with the anterior abdominal wall, or behind the ileum (post-
ileal).
SURFACE ANATOMY:
McBurney’s point

THE COLON
It is formed of 4 parts : ascending, transverse, descending and sigmoid
(pelvic).

ASCENDING COLON
It begins as a continuation of the caecum and ascends in the right lumbar
region to end just below the liver by forming the right colic flexure which is the
arched junction between the ascending and transverse colon (flexure = bend).
It is 15 cm long.
RELATIONS:
 Anteriorly :
 Anterior abdominal wall
 Greater omentum
 coils of small intestine (ileum)
 Posteriorly : (from below upwards)
 Iliacus
 Quadratus lumborum
 Lower part of right kidney
The Quadratus lumborum is separated from the colon by the
following:
o Ilio-hypogastric and ilio-inguinal nerves
o Lateral cutaneous nerve of thigh
o 4th lumbar artery (the other 3 lumbar arteries run behind the
Quadratus lumborum).
 Medially:
 Small intestine
 Laterally:
 Abdominal wall
PERITONEAL RELATIONS:
 The ascending colon is covered by peritoneum on its front and sides
only (not on its posterior aspect).
 On each side of the colon, there is a groove (gutter) along which fluid
collected in the upper part of the abdomen passes downwards.
 The groove on the medial side of the ascending colon is shut off from
the pelvic cavity by the root of mesentery of the small intestine and so
fluid passing along it cannot reach the pelvis.
N.B.: In contrast the 2 gutters alongside the descending colon are
continuous with the pelvic cavity.

183
 Abdomen [ 155 - 222 ]

ARTERIAL SUPPLY:
The ascending colon is supplied by the superior mesenteric artery
through:
1. Ileocolic artery
2. Right colic artery
ILEOCAECAL JUNCTION:
 The ileum opens into the postero-medial aspect of the caecum at its
junction with the ascending colon.
 The opening is provided with a valve which regulates the passage of
ileal contents into the colon. It is provided with a sphincter.

TRANSVERSE COLON
 It begins in front of the 2nd part of duodenum as a continuation of the
right colic flexure. It is 50 cm long.
 Its position varies but usually it runs transversely a little below the
umbilicus.
 It ends at the lateral margin of the left kidney where it becomes
continuous with the left colic flexure.
 The left colic flexure has the following features:
 It is more acute than the right flexure and lies at a higher level.
 It is attached to the diaphragm by a fold of peritoneum called
phrenico-colic ligament which supports the spleen.
 It is related to 2 structures:
o Lateral end of the spleen
o Front of the left kidney
PERITONEAL RELATIONS:
The transverse colon is suspended from the posterior abdominal wall by
the transverse mesocolon except for its 1st 2 inches where it lies
directly on the duodenum without peritoneal covering on its posterior
wall.
Transverse mesocolon:
 It is formed by the posterior 2 layers of the greater omentum.
 It is attached to the anterior border of the pancreas, while its free border
encloses the transverse colon.
 It contains:
 Transverse colon
 Middle colic artery surrounded by sympathetic nerves
 Lymph nodes and vessels
RELATIONS OF TRANSVERSE COLON:
 Anterior relations:
 Right lobe of liver
 Greater omentum
 Posterior relations : (from right to left)
 2nd part of duodenum
 Head of pancreas
 Duodeno-jejunal flexure
 Coils of small intestine.
ARTERIAL SUPPLY:
The transverse colon is supplied by the superior and inferior mesenteric
arteries through:
1. Middle colic artery

184
 Abdomen [ 155 - 222 ]
2. Right colic artery
3. Superior left colic artery

DESCENDING COLON
 It extends from the left colic flexure (close to lateral end of the spleen) to
the brim of the pelvis where it becomes continuous with the sigmoid
colon. It is 25 cm long.
 It is covered by peritoneum only on its front and sides (as the ascending
colon) and has a gutter one each side both of which lead down to the
pelvic cavity.
RELATIONS:
 Anteriorly:
 Loops of small intestine (jejunum)
 Anterior abdominal wall (direct contact with its lower part)
 Posteriorly: (from above downwards)
 Lower part of left kidney
 Quadratus lumborum
 Iliacus and psoas major muscles
The muscles are separated from the colon by:
o Ilio-hypogastric and ilio-inguinal nerves
o Lateral cutaneous nerve of thigh
o 4th lumbar artery
o Femoral nerve
o Genito-femoral nerve
o Left testicular (or ovarian) vessels
o External iliac artery
(Relations from 1 to 3 as in the ascending colon while from 4 to 7
are due to its crossing over the iliacus and psoas major).
 Medially:
 Small intestine
 Laterally:
 Abdominal wall
ARTERIAL SUPPLY:
The descending colon is supplied by the inferior mesenteric artery through:
1. Superior left colic artery
2. Inferior left colic (sigmoid) arteries

SIGMOID (PELVIC) COLON

 It begins at the left side of the (inlet of lesser pelvis brim) and ends at
the middle piece of the sacrum where the rectum begins (it is a pelvic
structure).
 It is S-shaped and is suspended by the pelvic mesocolon. It is 40 cm
long.
RELATIONS :
 Laterally :
It is related to the left pelvic wall, with the following structures in
between:
 External iliac vessels
 Obturator nerve
 The ovary (in the female)
 The vas deferens (in the male)

185
 Abdomen [ 155 - 222 ]
 Posteriorly:
 Internal iliac vessels
 Ureter
 Sacral plexus
 Piriformis muscle
 Inferiorly:
 Urinary bladder
 Uterus (in the female)
PELVIC (SIGMOID) MESOCOLON:
It has 2 limbs (lateral and medial) which meet each other forming an
inverted V-shaped with its apex related to the left ureter where it crosses
the end of the common iliac artery.
1. Lateral (left) limb :
Runs backwards from the inguinal ligament, along the external iliac
artery, to the end of the common iliac artery.
2. Medial (right) limb:
Passes downwards and backwards across the front of the sacrum to
end opposite the 3rd sacral piece (where the rectum starts).
Contents of sigmoid mesocolon:
1. Sigmoid colon (in its free border)
2. Superior rectal artery : in the medial limb
3. Inferior left colic branches (sigmoid branches) : in the lateral limb.
ARTERIAL SUPPLY:
The sigmoid colon is supplied by the inferior left colic (sigmoid) branches of
the inferior mesenteric artery.
N.B.:
The transverse colon and sigmoid colon are the only parts of the colon
provided with mesenteries.The transverse colon has 2 folds (the
transverse mesocolon above and the greater omentum below), while the
sigmoid colon has only one (sigmoid mesocolon).

VESSELS OF THE GUT

The gut is divided embryologically into 3 parts :
1. Foregut : ends at the middle of the 2nd part of duodenum and is
supplied by the coeliac artery (includes the stomach and upper 1/2 of
duodenum).
2. Midgut : ends at the junction of the left and middle thirds of the
transverse colon, and is supplied by the superior mesenteric artery
(includes lower 1/2 of duodenum, jejunum, ileum, ascending colon
right 2/3 of transverse colon).
3. Hindgut : is the terminal part of the gut and is supplied by the inferior
mesenteric artery (includes left 1/3 of transverse colon, descending
colon, sigmoid colon, rectum and upper 1/2 of anal canal ).

COELIAC TRUNK
COURSE AND BRANCHES :
 It is a very short artery that arises from the from of the aorta just below
the aortic opening of diaphragm (at the level of 12th thoracic or upper
border of 1st lumbar vertebra).
 It lies behind the lesser omentum from which it is separated by the
lesser sac, and passes forwards just above the pancreas to give off its 3
branches :

186
 Abdomen [ 155 - 222 ]
1. Left gastric artery.
2. splenic artery,
3. Hepatic artery.

I. LEFT GASTRIC ARTERY:

 It passes upwards and to the left on the surface of diaphragm
behind the cavity of lesser sac to reach the cardiac end of the
stomach.
 It then descends along the lesser curvature of the stomach
between the 2 layers of the lesser omentum to anastomose with
the right gastric artery.
Branches:
1. Oesophageal branches :
To the abdominal part of oesophagus
2. Gastric branches :
To the stomach
Left gastric vein :
 Accompanies its artery, then continues along the hepatic
artery to end in the portal vein.
 It communicates with the oesophageal veins which are
systemic (draining into the azygos vein) at the lower end of
oesophagus.
Therefore, the lower end of the oesophagus is a site of
anastomosis between portal and systemic circulations.
II. SPLENIC ARTERY :
 It is the widest branch of the coeliac trunk.
 It has a wavy course along the upper border of pancreas behind
the stomach but is separated from it by the cavity of the lesser
sac.
 It enters the lieno-renal ligament to reach the hilus of the spleen
where it gives off the splenic branches to supply the spleen.
N.B. : Other wavy arteries are the facial, lingual and uterine
Branches :
1. Pancreatic branches :
To the pancreas
2. Short gastric arteries :
5-6 branches that arise from the terminal part of the splenic
artery or from its splenic branches. They pass to the fundus of
the stomach through the gastro-splenic ligament.
3. Left gastro-epiploic artery :
Arises from the terminal part of the splenic artery or one of its
splenic branches . It reaches the greater curvature of the stomach
through the gastro-splenic ligament. It passes along the greater
curvature in the greater omentum to anastomose with the right
gastro-epiploic artery ( from hepatic artery).
4. Terminal branches
Enter the hilus of the spleen and run in its trabeculae . Each of
these branches supplies a splenic segment ( end-arteries).
III. HEPATIC ARTERY :
 Runs to the right to reach the 1st part of duodenum where it
enters the tree border of lesser omentum superficial to the portal
vein and to the left of the bile duct.

187
 Abdomen [ 155 - 222 ]
1. It passes to the porta hepatis where it divides into 2 terminal
branches.
2. It is not accompanied by a vein
N.B. The part from its origin to the point where it gives off its
gastro-duodenal artery is called common hepatic artery,
while, its continuation thereafter till liver is called hepatic
artery proper.
Branches :
1. Gastro-doudenal artery :
 It is the 1st branch to arise from the hepatic artery as it
reaches the duodenum (not accompanied by a vein).
 It descends behind the 2nd inch of the 1st part of the
duodenum, in front of the portal vein.
 It then leaves the portal vein to lie in a groove on the front of
the neck of pancreas (the portal vein is behind the neck of the
pancreas).
 It ends by dividing into :
a. Superior pancreatico-duodenal artery :
It runs In the groove between the duodenum and the
pancreas to anastomose with the inferior pancreatico-
duodenal artery branch of the superior mesenteric
artery.
b. Right gastro-epiploic artery :
Runs along the lower border of the 1st part of duodenum
and greater curvature of the stomach to anastomose
with the left gastro-epiploic branch of the splenic artery.
N.B : The right gastro-epiploic vein ends in the superior
mesenteric vein.
2. Right gastric artery :
 Arises from the hepatic as it enters the lesser omentum.
 It runs to the left on the upper border of the duodenum to
reach the lesser curvature of the stomach.
 Its vein ends in the portal vein.
3. supra-duodenal artery :
 May arise from the hepatic artery while it lies in the lesser
omentum.
 It supplies the junctional area between the 1st and 2nd parts of
the duodenum (the area commonly affected by peptic ulcer).
4. Right and left terminal branches :
 Arise at the porta hepatis and enter the right and left lobes of
the liver.
5. cystic artery :
 Arises from the right terminal branch and passes along the
cystic duct to the gall-bladder.
 Its vein ends in the right branch of portal vein.

SUPERIOR MESENTERIC ARTERY

COURSE:
 It rises from the front of abdominal aorta behind the pancreas at the
lower border of the 1st lumbar vertebra (only 1 cm below the coeliac
artery).

188
 Abdomen [ 155 - 222 ]
 It descends in front of the uncinate process of pancreas, then in front
of the 3rd part of duodenum to enter the root of the mesentery of
small intestine.
 In the mesentery it runs downwards and to the right where it ends at
the ileo caecal junction.
 It supplies the part of the gut extending from the middle of 2nd part
of duodenum to the junction of the left and middle thirds of
transverse colon.
RELATIONS:
1. At its origin:
It lies behind the body of pancreas in between 2 veins:
a. Splenic vein : above
b. Left renal vein : below
2. Before it enters the mesentery:
It crosses:
a. Uncinate process of pancreas
b. 3rd part of duodenum
N.B. The superior mesenteric vein is on its right side.
3. In the root of the mesentery
It crosses the following structures (from left to right):
a. Inferior vena cava
b. Right psoas major
c. Right ureter
d. Right testicular or ovarian vessels.
BRANCHES
1. Inferior pancreatico-duodenal artery:
 Ascends between the head of pancreas and duodenum to
anastomsoe with the superior pancreatico-duodenal branch of the
coeliac artery.
2. Middle colic artery:
 Enters the transverse mesocolon where it divides into right and
left branches to supply the right 2/3 of transverse colon.
 Its right branch anastomoses with the ascending branch of the
right colic artery, while its left branch anastomoses with the
superior left colic branch of the inferior mesenteric artery.
3. Right colic artery:
 Passes downwards and to the right towards the ascending colon
where it divides into ascending and descending branches to
supply the ascending colon and right colic flexure.
 Its ascending branch anastomoses with the right branch of the
middle colic artery, while its descending branch anastomoses
with the ascending branch of the ileocolic artery.
4. Ileocolic artery:
Descends downwards and to the right towards the terminal part of the
ileum. It gives off.
a. Ascending branch : supplies the lower part of the ascending
colon and anastomoses with the right colic artery.
b. Anterior and posterior caecal arteries : to the front and back of the
caecum.
c. Appendicular artery : passes behind the terminal part of the ileum
to enter the meso-appendix where it supplies the appendix.
d. Ileal branches : to the terminal part of the ileum.

189
 Abdomen [ 155 - 222 ]
5. Jejunal and ileal branches:
a. About 12 or more branches that arise from the convexity (left side)
of the superior mesenteric artery.
b. They enter the mesentery of small intestine where they divide
repeatedly to form arterial arcades which anastomose with each
other and give off the vasa recta to the wall of jejunum and ileum
(vasa recta = straight arteries).

INFERIOR MESENTERIC ARTERY

COURSE:
 It arises from the front of aorta opposite the level of the 3rd lumbar
vertebra, behind the 3rd part of duodenum.
 It passes downward and to the left on the posterior abdominal wall.
 It crosses the middle of the left common iliac artery where it
becomes the superior rectal artery which descends to the back of the
rectum.
 It supplies the part extending from the left 1/’3 of transverse colon
down to the rectum.
RELATIONS:
 Deep relations:
As it passes downwards and to the left, it crosses:
 Aorta
 Left psoas major
 Left sympathetic trunk
 On its left side:
 Inferior mesenteric vein
 Left ureter
(These are vertical structure which run parallel to the artery).
 Superficial relations:
 3rd part of duodenum (embraced between the superior mesenteric
artery in front and the inferior mesenteric artery behind).
 Peritoneum of the posterior abdominal wall below the duodenum (so
it is more accessible).
BRANCHES:
1. Superior left colic artery:
Passes to the left and divides into:
a. Ascending branch: to the left colic flexure and anastomoses with
the left branch of the middle colic artery.
b. Descending branch : anastomoses with the ascending branch of
the inferior left colic artery.
2. Inferior left colic (sigmoid) arteries:
They supply the descending colon and sigmoid colon. They
anastomose above with the descending branch of superior left colic
artery and below with branches of the superior rectal artery.
N.B.:
It is said that, the anastomosis between the sigmoid branches and
superior rectal artery is a poor anastomosis while that between
the superior left colic and the sigmoid is good.
So it is better in operations on the sigmoid colon to ligate the
inferior mesenteric artery between the origins of the superior left
colic and the sigmoid branches (good anastomosis) rather than to
ligate it below the origin of the sigmoid branches.

190
 Abdomen [ 155 - 222 ]
3. Superior rectal artery:
It is the continuation of the inferior mesenteric at the middle of the left
common iliac artery. It descends in the right limb of the pelvic
mesocolon to the back of the rectum.
It anastomoses with the inferior rectal artery in the submucosa of the
anal canal.
N.B. The branches of the inferior mesenteric artery are now named left
colic (for the superior left colic) and sigmoid (for the inferior left
colic).
Inferior mesenteric vein:
 It begins in front of the left common iliac artery between the inferior
mesenteric medially and the left ureter laterally it is the continuation
upward of the superior rectal vein which drains the rectum.
 It ascends in front of the left psoas major and behind the peritoneum to
end in the splenic vein deep to the pancreas.
 It has a vertical course to the right of the left ureter and does not
accompany its artery (in contrast to the superior mesenteric vein which
accompanies its artery).
ANASTOMOSES BETWEEN ARTERIES OF THE GUT:
1. Anastomosis between the coeliac and superior mesenteric arteries:
Through the superior and inferior pancreatico-duodenal arteries.
2. Anastomosis between the superior and inferior mesenteric arteries:
Through the middle colic and superior left colic arteries.
3. Anastomosis between the colic arteries:
Through the marginal artery which is a long chain of anastomosis close
to the inner side of the ascending, transverse and descending colon.
The ileocolic, right colic, middle colic, left colic and sigmoid arteries all
share in formation of the marginal artery.

SPLEEN, PANCREAS, LIVER

SPLEEN
It lies in the left hypochondrium where it is connected to the stomach by the
gastro-splenic ligament and to the left kidney by the lieno-renal ligament (lien
= spleen).
SURFACE ANATOMY :
 It corresponds to an area opposite the 9th, 10th, and 11th left ribs with
its long axis parallel to the 10th rib.
 Its anterior (lateral) end does not extend beyond the mid-axillary line.
 Its posterior (medial) end is about 11/2 inches from the 10th thoracic
spine.
SHAPE AND RELATIONS :
It has 2 surfaces, 2 borders and 2 ends:
1. Diaphragmatic surface:
Convex and is related to the diaphragm which separates it from the lung
and pleura.
2. Visceral surface:
Presents the following impressions:
a. Gastric impression: (for the stomach) large concave area that lies
above the hilus of the spleen.
b. Renal impression: (for the left kidney) below the hilus and is
separated from the gastric impression by a prominent ridge.

191
 Abdomen [ 155 - 222 ]
c. Colic impression: (for the left colic flexure) close to the anterior
(lateral) end of the spleen.
d. Pancreatic impression: (for the tail of pancreas) a small area
below the lateral end of the hilus.
3. Upper border:
Sharp and shows notches near the anterior (lateral) end.
4. Lower border:
Rounded and thicker than the upper border.
5. Posterior (media) end:
Narrower than the anterior (lateral) end.
6. Anterior (lateral) end.
More expanded and takes the shape of a border more than an end. It is
supported by the phrenico-colic ligament which stretches below it
(between the diaphragm and left colic flexure).
PERITONEAL RELATIONS :
 The spleen is covered completely by peritoneum which is adherent to its
capsule.
 Developmentally, the spleen divides the dorsal mesogastrium into 2
parts:
1. A part between the spleen and stomach: gastro-splenic ligament.
2. A part between the spleen and left kidney : lieno-renal ligament.
 Gastro-splenic ligament: contains:
a. Short gastric arteries : from the splenic artery and pass
to the fudnus of stomach.
b. Left gastro-epiploic artery : from the splenic artery and
passes to the greater curvature of stomach.
 Lieno-renal ligament: contains:
a. Splenic vessels
b. Tail of pancreas
VESSELS OF SPLEEN :
1. Splenic artery:
Arises from the coeliac trunk. Its terminal branches which enter the
hilus of the spleen are end-arteries, i.e. they do not anastomose with
each other and if one branch is occluded it will lead to ischaemia and
necrosis of the related splenic segment.
2. Splenic vein:
Joins the superior mesenteric vein to form the portal vein at the neck of
pancreas (portal circulation).

PANCREAS
It lies in contact with the upper part of the posterior abdominal wall extending
transversely from the duodenum to the spleen. It is composed of head, neck,
body and tail.
I. HEAD:
It occupies the concavity of the duodenum and has a hook-like process
called uncinate process which projects behind the superior mesenteric
vessels (unciante = hook-like).
RELATIONS OF THE HEAD :
 Anteriorly:
 Transverse colon
 Coils of jejunum
 Superior mesenteric vessels (anterior to the uncinate process).
192
 Abdomen [ 155 - 222 ]
 Posteriorly:
 Right crus of diaphragm
 Inferior vena cava and the ends of the 2 renal veins.
 Bile duct (passes in a groove on its posterior surface or
embedded in its substance).]
 Laterally:
 Superior and inferior pancreatico-duodenal vessels.
 2nd part of duodenum
 Above and below:
 Duodenum
II. NECK:
 It is the junctional area between the head and body of pancreas (a
vague definition).
 The boundary between the head and neck of the pancreas is marked
by:
a. The groove for the gastroduodenal artery (anteriorly).
b. Beginning of the portal vein (posteriorly).
RELATIONS OF THE NECK :
a. Anteriorly:
Pylorus and 1st inch of duodenum (with the lesser sac intervening).
b. Posteriorly:
Terminal part of superior mesenteric vein and beginning of the portal
vein.
III. BODY:
 It extends to the left and slightly upwards crossing over the lumbar
vertebrae.
 It has 3 surfaces (anterior, inferior and posterior) separated by 3
borders (upper, anterior and posterior).
1. ANTERIOR SURFACE:
 Is bounded by the upper and anterior borders.
 A part of the upper border bulges above the pyloric canal in the
median plane and is called omental tuberosity (tuber omentale). It
comes in relation to the lesser omentum.
 The omental tuberosity lies behind the lesser sac and lesser
omentum with the coeliac artery projecting forward just above it.
 Relations of the anterior surface:
a. Splenic artery : has a wavy course along the upper border.
b. Transverse mesocolon : is attached to the anterior border.
c. Stomach: the pancreas : forms a part of the stomach bed.
2. INFERIOR SURFACE:
 Is bounded by the anterior and posterior borders.
 Relations of the inferior surface:
a. Duodeno-jejunal flexure (just to the left of the midline).
b. Loops of jejunum.
3. POSTERIOR SURFACE:
 Is bounded by the upper and posterior borders.
 Relations of posterior surface:
1. Aorta (and origin of superior mesenteric artery).
2. Left crus of diaphragm.
3. Left psoas major muscle
4. Left kidney.
(The above 4 vertical structures are from right to left).
193
 Abdomen [ 155 - 222 ]
5. Splenic vessels : (the vein lies lower than its artery).
6. Left renal vessels: (lie below the splenic vein).
(The last 2 structures run horizontally).
IV. TAIL:
 It is the left end of pancreas.
 It lies in the lieno-renal ligament together with the splenic vessels.
 It is related to an area on the visceral surface of the spleen just
below the lateral part of its hilus.
PANCREATIC DUCTS :
1. main pancreatic duct :
 it passes through the whole length of pancreas from left to
right nearer to the posterior than to the anterior surface.
 At the neck, it curves downwards through the head of
pancreas.
 As it leaves the pancreas, it lies on the left side of the bile duct.
Both ducts pierce the posteromedial surface of the 2nd part of
the duodenum at about its middle. They unite together in a
dilation called the hepatopancreatic ampulla which opens into
the duodenum on an elevation termed the major duodenal
papilla. This papilla is surrounded by the sphincter of oddi.
 The bile and pancreatic ducts may open separately into the
duodenum.
2. Accessory pancreatic duct :
 It is a shorter duct that arises in the lower part of the head of
pancreas and runs upward to the right in front of the main duct
where a communication occurs between the 2 ducts [the 2
ducts cross each other ].
 It opens into the duodenum on the minor duodenal papilla
about 1 inch above [proximal] to the opening of the main duct.
ARTERIAL SUPPLY OF THE PANCREAS :
1. pancreatic branches [of splenic artery].
2. superior pancreatico-duodenal artery [of hepatic artery].
3. inferior pancreatico-duodenal artery [of superior mesenteric artery].

LIVER
It lies in the right hypochondrium, epigastrium and extends to the left
hypochondrium.
LOBES OF THE LIVER
 The liver consists of a larger right lobe and a smaller left lobe which are
separated from each other by:
1. Attachment of falciform ligament : on the anterior and superior
surfaces.
2. Fissure for ligamentum teres : on the inferior surface.
3. Fissure for ligamentum venosum: on the posterior surface.
 The right lobe shows 2 small lobes (as subdivisions):
1. Quadrate lobe : (on the inferior surface) between the gall
bladder and fissure for ligamentum teres.
2. Caudate lobe : (on the posterior surface) between the inferior
vena cava and the fissure for ligamentum venosum.
N.B.: The porta hepatis lies transversely between the
quadrate and caudate lobes.

194
 Abdomen [ 155 - 222 ]
SURFACES OF THE LIVER
The liver is wedge-shaped having 5 surfaces:
1. Inferior (visceral) surface
2. Posterior surface
3. Upper surface
4. Anterior surface
5. Right lateral surface (base of the wedge)
INFERIOR (VISCERAL) SURFACE : shows:
 Fissure for the ligamentum teres:
Separates the right and left lobes (the ligamentum teres of the liver
represents the obliterated left umbilical vein).
 The part belonging to the left lobe shows:
a. Gastric impression : for the stomach
b. Omental tuberosity (tuber omentale) : an elevation on the right
side of the gastric impression, close to the left end of porta
hepatis and is related to the lesser omentum.
 The part belonging to the right lobe shows:
A. Quadrate lobe : (to the left of gall bladder) is related to 3
structures:
1. Lesser omentum: close to porta hepatis
2. Pylorus and 1st part of duodenum : at its middle part.
3. Transverse colon : close to the inferior border of the liver.
B. Fossa for gall bladder : lodges the gall bladder.
C. To the right of gall bladder:
1. Duodenal impression : for 2nd part of duodenum (an area
just to the right of the neck of gall bladder).
2. Colic impression : a concave area for right colic flexure
extending to the inferior margin of the liver.
3. Renal and suprarenal impressions : for the upper part of the
right kidney and right suprarenal gland. Both lie posterior
to the colic impression, and the suprarenal lies close to the
groove for inferior vena cava (in the bare area).
PORTA HEPATIS (HILUS OF LIVER):
It is a transverse fissure situated near the posterior aspect of the inferior
surface.
Boundaries of porta hepatis:
 Anteriorly : quadrate lobe
 Posteriorly : caudate lobe and its caudate process
Contents of porta hepatis:
1. Portal vein (right and left branches) : most posterior
2. Hepatic artery (2 terminal branches) : intermediate position.
3. Hepatic (bile) ducts : most anterior
4. A lymph node and lymph vessels.
POSTERIOR SURFACE:
It is a narrow triangular surface which is broad in its right part but narrows
(as a border) in its left part. It shows the following features :
1. Groove for inferior vena cava:
It lodges the inferior vena cava (vertical groove). A mass of liver
sometimes bridges over the groove and is called pons hepatis. At
the upper part of the groove, the 2 hepatic veins are seen.
2. Bare area of the liver:
 It is triangular with its apex directed to the right and its base to
the left coinciding with the groove for I.V.C.
195
 Abdomen [ 155 - 222 ]
 It upper border gives attachment to the upper layer of coronary
ligament, while its lower border gives attachment to the lower
layer of the ligament. The 2 layers of the coronary ligament
meet at the apex of the bare area (to the right) to form the right
triangular ligament.
 The bare area is related to 2 structures:
 Diaphragm
 Right suprarenal gland
3. Caudate lobe:
 It lies between the groove for I.V.C and fissure for ligamentum
venosum, and is bounded inferiorly by the porta hepatis
(caudate = with tail).
 It has 2 projections:
1. Caudate process:
Connects the caudate lobe with the right lobe and
forms the posterior lip of porta hepatis. It forms the
upper boundary of the epiploic foramen and
separates the I.V.C from the portal vein.
2. Papillary process:
Projects at the lower part of the caudate lobe close to
the porta hepatis.
4. Fissure for ligamentum venosum:
Lies between the caudate lobe and left lobe and lodges he
ligamentum venosum (obliterated ductus venosus which connects
the left branch of portal vein with the I.V.C in the foetus)
Note that the ligamentum teres and ligamentum venosum are attached
to the left branch of portal vein.
UPPER SURFACE:
Related to the diaphragm which separates the liver from :
1. Heart and pericardium : in the median plane
2. Lung and pleura : on each side
ANTERIOR SURFACE:
Related to :
1. Diaphragm : separates the liver from the pleurae and lungs (on both
sides).
2. Anterior abdominal wall (the liver extends a hand-breadth below the
xiphi-sternal junction).
RIGHT SURFACE:
Related to the diaphragm which separates it from the right pleura and
lung (take care of these relations in taking a biopsy from the liver).
PERITONEAL RELATIONS
 Right lobe:
The peritoneum covers its inferior, anterior and upper surfaces, but
leaves a bare area on the posterior surface devoid of peritoneum which
comes in direct contact with the diaphragm. The peritoneum is reflected
onto the diaphragm forming the upper and lower layers of the coronary
ligament and bordering the bare area. At the right end of the bare area
the 2 layers of the coronary ligament meet each other to form the right
triangular ligament.
 Left lobe:
It is covered completely by peritoneum except posteriorly where the
peritoneum is reflected onto the diaphragm to form the left triangular
ligament.
196
 Abdomen [ 155 - 222 ]
 Bare areas of the liver : (no peritoneal covering)
1. The main bare area lies on the posterior surface of the right lobe
between the 2 layers of the coronary ligament. It is triangular in
shape with its base situated at the groove for the I.V.C.
2. The fossa for gall bladder (is bare)
3. The groove for I.V.C. (is bare).
4. The porta hepatis is not covered by peritoneum (but the
peritoneum is only attached to its lips).
 Peritoneal folds attached to the liver:
1. Coronary ligament : to diaphragm (on right lobe)
2. Right triangular ligament : to diaphragm (on right lobe).
3. Left triangular ligament : to diaphragm (on left lobe)
4. Falciform ligament : to diaphragm and anterior abdominal wall
(between the 2 lobes).
5. Lesser omentum : to stomach and 1st inch of duodenum.
FACTORS RESPONSIBLE FOR FIXATION OF THE LIVER:
1. The peritoneal folds attaching the liver to the diaphragm and anterior
abdominal wall.
2. The hepatic veins connecting the liver to the I.V.C.
3. Intra-abdominal pressure and tone of the anterior abdominal wall.
SURFACE ANATOMY OF THE LIVER
1. Upper border:
from a joint on the left 5th rib in the mid-clavicular line (3.5 inches from
the median plane close to the apex of the heart) draw a line towards the
right passing by the xiphi-sternal joint.
It crosses right 5th rib in the mid-clavicular line, then the 7th rib in the
mind-axillary line. The line slightly concave upwards in the median plane
2. Right border
From the right end of the previous line, draw a line downwards till a
point an 1/2 inch below the costal margin in the mid-axillary plane.
3. Inferior border:
from the last point (1/2 inch below the right costal margin), draw a line
towards the left and upwards to meet the point at the left 5th rib in the
mid-clavicular plane.
This border lies about a hand-breadth below the xipht-sternal junction.
N.B.: These 3 lines makes the borders of the anterior surface of the
liver which appears triangular.

VESSELS AND LYMPH DRAINAGE

Vessels of the liver:
1. Hepatic artery: gives a terminal branch to each of the right and left
lobes.
2. Hepatic veins: a vein from each lobe to end in the I.V.C.
3. Portal vein: gives off a division for each of the right and left lobes.
Note that inside the liver there are both portal blood and systemic
blood.
Lymph drainage of the liver:
Lymphatic vessels (superficial and deep) from the liver pass along the
following routes.
1. Through portal hepatis: to hepatic nodes in the lesser omentum
then finally to coeliac nodes.
2. Through the back of the liver: to diaphragmatic nodes around the
upper most part of I.V.C (in the chest).
197
 Abdomen [ 155 - 222 ]
3. Along the inferior phrenic artery: to coeliac nodes (around coeliac
artery).

GALL BLADDER
It lies in a fossa on the inferior surface of the liver with only its superficial
surface covered by peritoneum. It has a fundus, body and neck with the funds
forming its lowermost part.
FUNDUS :
Protrudes a little beyond the inferior border of the liver and is related to
the anterior abdominal wall opposite the of 9th right costal cartilage
BODY:
Its upper surface is adherent to its fossa on the inferior surface of the
liver, while its lower surface is covered by peritoneum.
The body is related to:
1. Transverse colon
2. The junction between the 1st and 2nd parts of duodenum
NECK :
It is the narrowest part, and is related to the 1st part of duodenum
CYSTIC DUCT :
It arises from the neck of gall bladder and joins the common hepatic
duct to form the bile duct. It is S-shaped and measures about 4 cm in
length.
SURFACE ANATOMY OF THE GALL BLADDER
The fundus lies in the transpyloric plane (1st L.V.) where it meets the
right vertical plane. This point corresponds to the tip of the right 9th
costal cartilage (at the point where the linea semilunaris crosses the
right costal margin).
VESSELS :
1. Cystic artery : from the right terminal branch of the hepatic artery.
2. Cystic vein : ends in the portal vein (many veins leave the bladder
directly to the liver).
LYMPH DRAINAGE :
Its lymphatics pass to the lymph nodes in the lesser omentum.
NERVES :
1. Sympathetic fibres from the coeliac plexus (along the hepatic artery).
2. Some filaments of the right phrenic nerve (C. 3, 4, 5) join the hepatic
plexus to the liver and gall bladder. So, irritation of these phrenic
filaments may produce referred pain at the top of the right shoulder
(its skin is supplied by C. 4).
BILIARY DUCTS
 The bile is secreted by the liver cells and passes in fine canaliculi inside
the liver. It is then collected into the right and left hepatic ducts (from
each lobe of liver).
 hese 2 ducts leave the porta hepatis anterior to the hepatic artery, and
join each other to form the common hepatic duct.
 The cystic duct of the gall bladder joins the common hepatic duct to
form the bile duct.
THE BILE DUCT :
1. It passes downwards in the free edge of lesser omentum superficial to
the portal vein and to the right of the hepatic artery.

198
 Abdomen [ 155 - 222 ]
2. It then runs behind the 1st part of duodenum on the right side of the
gastroduodenal artery.
3. After leaving the duodenum, it runs in a groove on the posterior surface
of the head of pancreas in front of the I.V.C.
[Note its relations to vessels in the above course].
4. It runs by the side of the main pancreatic duct to enter together the
posteromedial surface of the duodenum at about the middle of its 2nd
part.
5. The 2 ducts open together into a single dilatation called the hepato-
pancreatic ampulla on the top of the major duodenal papilla (but they
may open separately).
6. The circular muscle fibres around the hepato-pancreatic ampulla are
thickened to form the sphincter of Oddi.
N.B.:
The gall bladder and its duct as well as the bile duct can be
demonstrated radiologically (cholecystogram) after using special
staining dyes. Such dyes are excreted by the liver into the bile.

KIDNEYS
POSITION AND SHAPE :
 The kidney lies opposite the 12th thoracic and upper 3 lumbar vertebrae.
 The left kidney is slightly higher than the right kidney (because the liver
is on the right side). The left kidney reaches up to the 11th rib, while the
right kidney reaches only to the 11th space.
 Each kidney is about 4 inches long, 2 inches wide and 1 inch thick. It
has 2 borders (medial and lateral), 2 surfaces (anterior and Posterior)
and 2 ends (upper and lower).
 The hilus of the kidney leads to a cavity inside the kidney named the
renal sinus. The renal sinus is lined by an extension from the fibrous
capsule of the kidney and lodges the pelvis of the ureter and the renal
vessels.
TO KNOW THE KIDNEY RIGHT OR LEFT :
1. Lateral border : convex
2. Medial border : concave and contains the hilus (hilum) which transmits 3
structures :
 Renal vein : Anteriorly
 Pelvis of the ureter : Posteriorly
 Renal artery : In between
3. Anterior surface : identified by the renal vein.
4. Posterior surface : identified by the pelvis of ureter
5. Lower end : the ureter is directed downwards towards the lower end.
COVERINGS OF THE KIDNEY :
The kidney is surrounded by several coverings of fat and fascia arranged as
follows:
1. Fibrous capsule of the kidney:
It closely invests the kidney and continues to line the renal sinus.
Normally, it is easily detached from the surface of the kidney.
2. Renal fat:
Covers the fibrous capsule of the kidney
3. Renal fascia:
Surrounds both the kidney (with it renal fat) and the suprarenal gland. It
has anterior and posterior layers that fuse together at the upper and
199
 Abdomen [ 155 - 222 ]
lateral aspects of the kidney, but remain separate at the medial and
lower aspects.
4. Pararenal fat:
A mass of fat outside the renal fascia.
FACTORS KEEPING THE KIDNEY IN ITS PLACE :
1. The renal vessels (fixed to the aorta and I.V.C)
2. Its coverings of fat and fascia.
3. The intra-abdominal pressure and neighboring viscera.
RELATIONS OF THE KIDNEY :
I. ANTERIOR RELATIONS OF RIGHT KDINEY:
1. Suprarenal gland : at the upper medial part (above the hilus).
2. 2nd part of duodenum : on the hilus.
3. Right lobe of liver : related to the upper lateral part (lateral to the
duodenum).
4. Right colic flexure : related to the lower lateral part (below the
area for the liver).
5. Loops of jejunum : related to the lower medial part.
6. Ascending branch of right colic artery : ascends on its lower end
(to reach the right flexure).
7. Peritoneal coverings:
 The anterior surface is covered by peritoneum only in the
areas related to the liver and jejunal loops.
 he other viscera are in direct contact with the surface of the
kidney without peritoneum in between (suprarenal
duodenum, colic flexure).
II. ANTERIOR RELATIONS OF LEFT KIDNEY:
1. Suprarenal gland : at the upper medial part (above the hilus).
2. Body of pancreas and splenic vessels related to the middle of the
surface (extending from medial to lateral).-
3. Spleen : at the upper lateral part.
4. Stomach : related to a triangular area in the upper part between
the pancreas, spleen and suprarenal gland.
5. Descending colon : close to the lower part of the lateral border
(below the spleen).
6. Loops of jejunum : related to the lower medial part.
7. Ascending branch of superior left colic artery : ascends on the
lower end (to reach the left flexure).
8. Peritoneal coverings:
The areas related to the spleen, stomach and jejunum are covered
by peritoneum, while the other areas, are in direct contact with the
related viscera without peritoneum intervening (suprarenal,
pancreas and descending colon).
III. POSTERIOR RELATIONS OF BOTH KIDNEYS:
The relations of the anterior surface differ between the right and left
kidneys, while the relations of the posterior surface of both kidneys are
similar.
The kidney lies directly on 4 muscles of the posterior abdominal wall
with 4
structures intervening :
A. The 4 muscles:
1. Diaphragm : at the upper part of the posterior surface. It
separates the kidney from the pleura (costo-diaphragmatic
recess).
200
 Abdomen [ 155 - 222 ]
2. Psoas major : related to a vertical part close to the medial
border of the kidney.
3. Quadratus lumborum : related to an intermediate vertical part
lateral to the psoas major.
4. Transversus abdominis : related to a vertical area close to
the lateral border of the kidney.
B. The 4 intervening structures : (from above downwards)
1. Subcostal vessels
2. Subcostal nerve
3. Ilio-hypogastric nerve
4. Ilio-inguinal nerve.
SURFACE ANATOMY :
A. SURFACE ANATOMY OF ANTERIOR SURFACE:
(projected to the anterior abdominal wall).
1. Hilus:
Its centre is in the transpyloric plane (L.1) 2 inches from the
median plane.
2. Upper end:
Corresponds to a point 1 inch from the median plane. It is higher
on the left (11th rib) than on the right (11th space).
3. Lower end:
Corresponds to a point in the subcostal plane (L.3) 3 inches from
the median plane (it is about 2 inches above the iliac crest).
N.B. The distance between the 2 ends is 4 inches.
B. SURFACE ANATOMY OF POSTERIOR SURFACE:
1. Draw 2 horizontal lines : one at the 11th thoracic spine and the
other at the 3rd lumbar spine.
2. Then, draw 2 vertical lines, to cross the 2 horizontal lines : One at
1 inch from the median plane, while the other is at 3 inches from
the median plane.
3. The kidney lies in the rectangle formed by these 4 lines which is
called Morris parallelogram. The hilus is opposite the 2nd lumbar
spine.
VESSELS OF THE KIDNEY :
At the hilus:
The renal artery gives off about 5 branches that lie in front of the
pelvis of the ureter.
In the renal sinus:
The renal branches divide into lobar arteries one for each renal
papilla. The lobar arteries also divide into interlobar arteries which
run in between the pyramids. The interlobar arteries are end arteries.
These arteries are accompanied by veins which end in the renal vein.
N.B.: If accessory renal arteries are present they arise directly from the aorta
and do not enter the hilus but pierce the upper or lower end of the
kidney.
NERVES OF THE KIDNEY :
 The kidney is supplied by branches from the renal plexus
(autonomic). The nerves of the kidney are derived from 10th, 11th,
and 12th thoracic segments of the spinal cord.
 They communicate with the testicular plexus of nerves so referred
pain from the kidney may be felt in the testis.

201
 Abdomen [ 155 - 222 ]
SUPRARENAL GLANDS
RIGHT SUPRARENAL GLAND :
1. Triangular in outline
2. Does not reach the hilus of the kidney
3. Its hilus is directed upwards
4. Its vein ends in the I.V.C.
LEFT SUPRARENAL GLAND :
1. Semilunar in shape
2. Reaches down to the hilus of the kidney
3. Its hilus is directed downwards.
4. Its vein ends in the left renal vein.
ARTERIES :
1. Superior suprarenal artery : from the inferior phrenic artery.
2. Middle suprarenal artery : from the aorta
3. Inferior suprarenal artery : from the renal artery.
(Therefore, it has a rich blood supply)
VEINS :
Although the gland is supplied by 3 arteries it is drained by only one vein
which comes out through its hilus:
1. Right suprarenal vein : ends in I.V.C.
2. Left suprarenal vein : ends in the left renal vein.

URETER
It is 10 inches (25cm) long, with 1/2 of its length in the abdomen proper and the
other 1/2 in the pelvis.
COURSE :
A. IN THE ABDOMEN PROPER:
1. Pelvis of the ureter:
 The ureter begins inside the sinus of the kidney as a dilated
part called the pelvis of ureter.
 The pelvis of ureter is formed by union of 2 or 3 major
calyces into which open several minor calyces (10-12) each
of which surrounds a renal papilla (the renal papillae
represent the apices of the renal pyramids).
2. Ureter proper:
 The renal pelvis runs downwards along the medial border of
the kidney to become the ureter proper at the lower end of
the kidney.
 The ureter descends with an inclination medially on the
posterior abdominal wall behind the peritoneum opposite the
tips of the lumbar transverse processes.
 It crosses the end of the common iliac artery to enter the
pelvis.
B. IN THE PELVIS:
1. On the side of pelvis:
It passes downwards along the lower border of the internal iliac
artery till the ischial spine (attachment of pelvic floor), where it
changes its direction to run on the floor of the pelvis.
In the female it forms the posterior boundary of the ovarian fossa.

202
 Abdomen [ 155 - 222 ]
2. On the floor of pelvis:
It runs forwards and medially to reach the postero-superior angle of
the urinary bladder.
3. In the wall of the bladder
It passes obliquely in the wall of the bladder for 1 inch before it
opens at the side of the trigone (intramural part).
RELATIONS :
The relations of the ureter (including its pelvis) differ between both sides as
well as between both sexes.
A. IN THE ABDOMEN PROPER:
 Inside the renal sinus : the renal pelvis is surrounded by renal fat and
has the renal vessels in front of it.
 Outside the renal sinus : the relations on the right side differ from those
on the left side.
1. RELATIONS OF RIGHT URETER
Posteriorly:
 Psoas major muscle
 Genito-femoral nerve
 End of common iliac
Anteriorly : (from above downwards)
 2nd part of duodenum and renal vessels (in front
of renal pelvis).
 Right colic vessels
 Gonadal (testicular or ovarian) vessels
 Ileocolic vessels
 Root of the mesentery containing terminal part
of ileum.
Note the duodenum above, ileum below, and
vessels in between.
Medially :
 Inferior vena cava
2. RELATIONS OF LEFT URETER:
Posteriorly : (as the right)
 Psoas major muscle
 Genito-femoral nerve
 End of common iliac artery
Anteriorly : (from above downwards)
 Renal vessels
 Superior left colic vessels
 Gonadal vessels
 Pelvic colon and its mesocolon.
Note that the left renal pelvis is more exposed
than the right renal pelvis.
Medially :
 Inferior mesenteric vein
N.B.:
Note that a vein runs vertically medial to the ureter on both
sides: I.V.C on the right and inferior mesenteric vein on the
left.

203
 Abdomen [ 155 - 222 ]

B. IN THE PELVIS:
1. On the side or pelvis:
Medially:
 Peritoneum only
Laterally
 External iliac vessels
 Obturator nerve and vessels
2. On the floor of pelvis:
 In the male:
At the back of the bladder, it lies between 2 structures : the
ductus deferens (above it) and the seminal vesicle (below
it).
 In the female:
It passes in the root of the broad ligament, 1 inch lateral to
the cervix of uterus. At this site, the uterine artery crosses
in front of the ureter.
The ureter (commonly the left) passes in front of the upper
part of the vagina before it enters the bladder.
N.B.:
Note the important relations of the ureter in the female : to
the ovarian fossa, to the uterine artery, to the cervix and to
the upper part of the vagina.
CONSTRICTIONS OF THE URETER :
There are 3 sites of constriction:
1. At the junction between the pelvis of the ureter and the ureter proper
(pelvi-ureteric junction).
2. Where it crosses the end of the common iliac artery [at the pelvic
brim].
3. Intramural part : the part inside the wall of the bladder.
N.B.: At these sites the renal stones are liable to become impacted.
POSITION OF THE URETER IN X-RAY FILM :
a. The ureter is seen at the following landmarks:
1. Opposite the tips of transverse processes of all lumbar
vertebrae.
2. At the sacro-iliac joint
3. At the ischial spine
b. The lumen of the ureter is demonstrated radiologically by injection of
radio-opaque material in the blood or by injection of sodium iodide
directly into the ureter by a catheter. The X-ray is then called
descending or ascending psylogram respectively.
ARTERIAL SUPPLY OF THE URETER :
Its arteries come from :
1. Renal artery
2. Abdominal aorta
3. Gonadal arteries
4. Internal and common iliac arteries
5. Inferior vesical artery.
This arrangement is explained by the ascent of the kidney during
development and taking blood supply at all levels.

204
 Abdomen [ 155 - 222 ]
NERVE SUPPLY OF THE URETER :
 The nerves supplying the upper (autonomic) are derived from the last 3
thoracic (10, 11, 12) and 1st lumbar segments of spinal cord (pain
passes along sympathetic fibres).
 In renal colic the pain is felt at the following sites:
1. At the loin: its skin is supplied by 10th thoracic segment.
2. May radiate to the groin : supplied by 12th thoracic and 1st lumbar
segments
3. May radiate to the testis: through communication with the
testicular plexus.
4. May lead to contraction of the cremaster muscle (elevation of
testis) : due to irritation of the genito-femoral nerve which
supplies the cremaster muscle.

VESSELS OF POSTERIOR ABDOMINAL WALL

ADBOMINAL AORTA
ORIGIN AND COURSE:
 It begins at the lower border of the body of 12th thoracic vertebra as a
continuation of the thoracic aorta.
 It ends at the lower border of 4th lumbar vertebra, where it bifurcates
into 2 common iliac arteries.
RELATIONS:
 Anteriorly: (from above downwards)
 Pancreas
 Splenic vein
 Left renal artery
[The origin of superior mesenteric artery is related above to the
splenic vein and below to the renal vein].
 3rd part of duodenum
 Root of mesentery with the superior mesenteric artery in it.
 Peritoneum of the posterior abdominal wall separating the aorta from
coils of small intestine.
 Posteriorly:
 Bodies of the upper lumbar vertebrae and intervening discs.
 Anterior longitudinal ligament
 3rd and 4th left lumbar veins which cross from left to right behind the
aorta to end in I.V.C.
 On the side of the aorta:
 Crus of diaphragm : on each side of its upper part.
 Sympathetic chain : on each side of its lower part
 I.V.C. : on the right side below 2nd lumbar vertebra.
 Vena azygos and thoracic duct : on the right side above 2nd lumbar
vertebra.
 4th part of duodenum : on the left side opposite the 2nd lumbar
vertebra.
N.B.: The veins are on the right side of the aorta.
BRANCHES:
The aorta has 2 groups of branches (single and paired).
I. SINGLE BRANCHES:
These are the 3 arteries of the gut (coeliac, superior mesenteric and
inferior mesenteric) which arise from the front of the aorta. This is in
205
 Abdomen [ 155 - 222 ]
addition to the median sacral artery which arises from the back of the
lower end of the aorta.
1. Coeliac artery:
Arises at the lower border of the 12th T.V., and is distributed to the
stomach, upper 1/2 of duodenum, liver and spleen.
2. Superior mesenteric artery:
Arises at the lower border of 1st L.V., and is distributed to the lower
1/2 of duodenum, jejunum, ileum and colon as far as the left 1/3 of the
transverse colon.
3. Inferior mesenteric artery:
Arises at the 3rd L.V., and is distributed to the left 1/3 of transverse
colon and the rest of the colon, rectum and upper 1/2 of anal canal.
4. Median sacral artery:
Arises from the back of the lower end of the aorta and descends in
front of the 5th L.V. and sacrum.
II. PAIRED BRANCHES : (one on each side)
1. Inferior phrenic arteries:
Are the highest and ramify on the under surface of the diaphragm,
one on each side. Each artery gives off the superior suprarenal
artery to the suprarenal gland.
2. Middle suprarenal arteries:
Arises just below the inferior phrenic and go to the right and left
suprarenal glands.
3. Renal arteries:
Arise at 2nd L.V. below the middle suprarenal artery. It is the
biggest branch of the paired group (except the terminals).
Each artery runs laterally in front of 2 muscles (crus of diaphragm
and psoas major) and behind veins (the left is behind its own
vein, while the right is behind its own vein and I.V.C).
4. Testicular or ovarian arteries:
Arise close to the renal arteries and descend for a long course on
the posterior abdominal wall to reach the testis in the male or the
ovary in the female.
5. Lumbar arteries:
These are 5 pairs of which the upper 4 rise from the aorta while
the 5th arises from the median sacral artery. They arise in series
with the posterior intercostal arteries and like them they enter the
anterior abdominal wall.
6. Common iliac arteries:
These are the terminal divisions of the aorta which arise at the
lower border of 4th L.V.

TESTICULAR ARTERY
Course:
 Arises from the anterolateral aspect of the aorta just below the renal
artery [opposite L. 2]
 It passes downwards and laterally on the posterior abdominal wall to
enter the inguinal canal through the deep inguinal ring.
Relations:
 On the right side:
 The artery crosses in front of:
o I.V.C.
o Psoas major
206
 Abdomen [ 155 - 222 ]
o Ureter
o Terminal part of external iliac artery
 It is crossed by:
o 3rd part of duodenum
o Vessels of ascending colon (right colic and ileocolic)
 On the left side:
 The artery crosses in front of:
o Psoas major
o Sympathetic trunk [on the right side the sympathetic trunk is
hidden by I.V.C].
o Ureter
o Terminal part of external iliac artery
 It is crossed by:
o 4th part of duodenum
o Inferior mesenteric vein
o Left colic vessels [superior and inferior]
o Terminal part of descending colon [this is an important relation as
it is usually filled with hard fecal matter and may press on the left
testicular vein leading to varicocele.

OVARIAN ARTERY
It corresponds to the testicular artery but does not enter the deep inguinal
ring. At the pelvic brim, the ovarian artery crosses the proximal part of external
iliac artery [1 inch below its origin] to enter the suspensory ligament of the
ovary. It then passes through the mesovarium to reach the ovary.

LUMBAR ARTERIES
 These are 5 pairs, of which the upper 4 pairs arise from the back of aorta
while the 5th one arises from the median sacral artery.
 Each artery passes on the side of the body of the corresponding lumbar
vertebra deep to the origin of psoas major to supply muscles of the
abdominal wall.
 The upper 3 arteries, continue behind the Quadratus lumborum whereas
the 4th runs in front of it.

COMMON ILIAC ARTERY

ORIGIN AND COURSE:
 It begins at the lower border of 4th lumbar vertebra as one of the 2
terminal branches of abdominal aorta.
 It is about 2 inches long and passes downwards and laterally on the
medial side of psoas major.
 It ends at the lower border of 5th lumbar vertebra by giving off the
external and internal iliac arteries.
RELATIONS OF RIGHT COMMON ILIAC:
 Anterior relations:
 Covered by peritoneum
 Its end is crossed by the ureter
 Posterior relations:
 Sympathetic trunk
 Beginning of I.V.C. [difference from the left]

207
 Abdomen [ 155 - 222 ]
RELATIONS OF LEFT COMMON ILIAC:
 Anterior relations:
 Covered by peritoneum
 Its end is crossed by the ureter
 Its middle is crossed by superior rectal vessels [difference from the
right]
 Posterior relations:
 Sympathetic trunk
BRANCHES:
It gives off only 2 terminal branches:
1. External iliac artery
2. Internal iliac artery [see the pelvis]

EXTERNAL ILIAC ARTERY

ORIGIN AND COURSE:
 It is larger [longer and wider] than the internal iliac artery.
 It passes downwards and laterally along the brim of pelvis on the medial
side of the psoas major.
 It leaves the pelvis from under cover of the inguinal ligament at the mid-
inguinal point where it becomes the femoral artery.
RELATIONS:
 External iliac vein : lies behind its upper part but median to its lower
part.
 Ureter: crosses the end of common iliac and beginning of external iliac
arteries.
 Vas [ductus] deferens : crosses its end [close to inguinal ligament].
[Note that 2 tubes cross its 2 ends]
 Testicular artery : crosses its lower part [in the male]
 Ovarian artery : crosses its upper part [in the female] [Note its relation to
gonadal arteries]
 On the right side: it is covered by the caecum [separated from it by
peritoneum].
 On the left side : it is covered by the terminal part of descending colon
[without intervening peritoneum].
[Note its relation to large intestine].
BRANCHES:
It has only 2 branches that arise just above the inguinal ligament.
1. Inferior epigastric artery:
Passes medially and upwards close to the medial margin of the deep
inguinal ring. It enters the rectus sheath where it anastomoses with the
superior epigastric artery.
2. Deep circumflex iliac artery:
Passes laterally behind the inguinal ligament then along the iliac crest .
SURFACE ANATOMY:
1. Surface anatomy of aorta:
From a point 1/2 inch above the transpyloric plane in the middle line, to
a point in the supracristal plane (4th L.V.) 1/2 inch to the left of the
middle.
2. Surface anatomy of iliac arteries:
From a point in the supracristal plane [4th L.V.] 1/2 inch to the left of the
midline draw a line to the mid-inguinal point. Its medial 1/3 is the
common iliac artery while its lateral 2/3 is the external iliac artery.

208
 Abdomen [ 155 - 222 ]
INFERIOR VENA CAVA
ORIGIN AND COURSE:
 It arises by union of the 2 common iliac veins at the level of 5th lumbar
vertebra slightly to the right of the median plane. The origin is behind
the right common iliac artery.
 It ascends on the posterior abdominal wall to the right of aorta till it
pierces the central tendon of diaphragm at the 8th thoracic vertebra 1
inch to the right of median plane.
 Immediately after piercing the diaphragm and pericardium, it enters the
lower and posterior part of right atrium [has a very short course in the
chest].
ANTERIOR RELATIONS: [from below upwards]
A. Below the duodenum : related to:
 Right common iliac artery
 Root of mesentery : with superior mesenteric vessels in it.
 Right gonadal vessels.
B. At the duodenum : related to :
 3rd part of duodenum
 Head of pancreas : with the bile duct on its deep surface.
 1st part of duodenum : separated from it by the portal vein, bile duct
and gastroduodenal artery.
C. Above the duodenum : related to:
 Epiploic foramen : separating it from the free margin of the lesser
and its contents.
 Posterior lip of porta hepatic separating from the structures in the
porta hepatis.
 Back of right lobe of liver
POSTERIOR RELATIONS:
A. Lower part of I.V.C. [below renal veins]
 Right sympathetic trunk [along the medial margin of psoas major].
The trunk runs lengthwise behind I.V.C.
 Bodies of lower lumbar vertebrae.
B. Upper part of I.V.C. [above renal veins]
 It lies on the diaphragm separated from it by the following [from
below upwards].
1. Right renal artery
2. Right middle suprarenal artery
3. Medial part of right suprarenal gland
4. Right inferior phrenic artery
[Note the many vessels behind the upper part of I.V.C., but no vessels behind
its lower part].
RELATIONS ON ITS LEFT SIDE : [from below upwards]
 Aorta [in most of the course]
 Caudate lobe of liver [in uppermost part]
RELATIONS ON ITS RIGHT SIDE: [from below upwards]
 Right ureter [some distance apart]
 Part of the right lobe of liver
TRIBUTARIES:
1. 2 common iliac veins
2. 3rd and 4th lumbar veins : on both sides [the 1st and 2nd lumbar
veins join the ascending lumbar vein].
3. Right gonadal vein : [the left vein joins left renal vein]
209
 Abdomen [ 155 - 222 ]
4. 2 renal veins : the left vein is longer than the right. The left renal vein
is joined by the left testicular or ovarian vein from below and by the
left suprarenal vein from above.
5. Right suprarenal vein : [the left joins the left renal vein].
6. 2 inferior phrenic veins : from the under surface of diaphragm.
7. 2 hepatic veins : are very short and join the I.V.C on the back of the
liver.
COMMON ILIAC VEIN:
 It starts opposite the sacro-iliac joint by union of the external and
internal iliac veins.
 The right and left veins end at the right side of the 5th lumbar vertebra
by uniting together to form I.V.C.
 The left vein is longer and more oblique. It lies medial to the left
common iliac artery but continues to the right behind the right common
iliac artery.
 Each common iliac vein receives the iliolumbar vein as the only
tributary.
EXTERNAL ILIAC VEIN:
 Begins at the inguinal ligament as a continuation of the femoral vein.
 It ascends on the brim of the pelvis medial to its artery [below] then
behind it [above].
 It receives the inferior epigastric and deep circumflex iliac veins.

ANASTOMOSES BETWEEN INFERIOR VENA CAVA AND SUPERIOR

VENA CAVA:
These anastomses take place in the posterior as well as in the anterior
abdominal walls:
A. IN POSTERIOR WALL OF ABDOMEN : through:
1. Azygos vein:
Arises from the back of the I.V.C at the level of the renal veins and runs
upwards to enter the chest through aortic opening of the diaphragm. It
joins the S.V.C.
2. Inferior (accessory) hemiazygos vein:
Arises from the back of left renal vein [but sometimes from union of the
ascending lumbar and subcostal veins]. In the chest, it joins the azygos
vein which ends in the S.V.C.
3. Vertebral venous plexuses:
These are external and internal plexuses which surround the vertebrae.
They are connected with the sacral, lumbar and intercostal veins, and
through these connections the I.V.C. anastomoses with the S.V.C.
B. IN ANTERIOR WALL OF ABDOMEN:
1. In superficial fascia:
An anastomotic vertical channel [thoraco-epigastric vein] exists
between the superficial epigastric vein [femoral] and the lateral thoracic
vein [axillary].
2. In rectus sheath:
Between the superior epigastric vein [to internal thoracic] and the
inferior epigastric vein [to external iliac].

210
 Abdomen [ 155 - 222 ]
PORTAL CIRCULATION
 The portal circulation carries venous blood from the stomach, small
intestine, large intestine, large intestine as well as from the spleen, gall
bladder and pancreas through the portal vein to the liver [called portal
because it leads eventually to the porta hepatis].
 The portal blood circulates in fine capillaries inside the liver and is
collected by the hepatic veins which end in the I.V.C..
N.B.:
The upper part of the gut [oesophagus] as well as its lower part
[anal canal and part of the rectum] are drained into the systemic
circulation.
PORTAL VEIN
ORIGIN AND COURSE:
 It is only 2 inches long and is characterized by the fact that it begins as a
vein [by tributaries] but ends as an artery [by giving branches].
 It begins behind the neck of pancreas by union of the splenic and
superior mesenteric veins.
 It ascends behind the 1st part of the duodenum to enter the free margin
of lesser omentum.
 It enters the porta hepatis where it divides into right and left divisions.
 It is devoid of valves
RELATIONS:
A. BEFORE IT REACHES LESSER OMENTUM : related to :
 Anteriorly:
 1st part of duodenum separated from it by:
o Bile duct [to the right]
o Gastroduodenal artery [to the left]
 Posteriorly:
 I.V.C.
B. IN LESSER OMENTUM: related to :
 Anteriorly :
 Bile duct [to the right]
 Hepatic artery [to the left]
 Posteriorly:
 I.V.C, but separated from it by the epiploic foramen.
C. IN PORTA HEPATIS : related to:
 Anteriorly:
 Right and left hepatic ducts
 Terminal divisions of hepatic artery
 Posteriorly:
 Posterior lip of porta hepatis which separates it from the
I.V.C.
N.B.
Note that is posterior relation all through is I.V.C, but is separated
from it by epiploic foramen and posterior lip of porta hepatis and
that in front of it are always 2 structures, viz., a bile duct and an
artery.
TRIBUTARIES:
1. SPLENIC VEIN:
 Emerges from the spleen and passes to the right behind the
pancreas.

211
 Abdomen [ 155 - 222 ]
 It runs in front of :
1. Left kidney
2. Left crus of diaphragm
3. Aorta
 It ends in front of the I.V.C. by joining the superior mesenteric vein.
 It has the following tributaries:
1. Splenic tributaries : from the spleen
2. Short gastric veins : from the fudnus of stomach
3. Left gastro-epiploic vein : from the greater curvature of
stomach.
4. Pancreatic veins : from the pancreas.
5. 5. Inferior mesenteric vein : the continuation of the superior
rectal vein. It joins the terminal part of the splenic vein.
2. SUPERIOR MESENTERIC VEIN:
 Ascends in the root of the mesentery of the small intestine on the
right side of its artery.
 It crosses the 3rd part of duodenum, then the uncinate process of
pancreas to end behind the neck of pancreas by joining the splenic
vein.
 It has the following tributaries:
1. Jejunal and ileal veins : from the small intestine
2. Ileocolic vein : from the ileum and ascending colon.
3. Right colic vein : from the ascending colon.
4. Middle colic vein : from the transverse colon
5. Right gastro-epiploic vein: from the right part of the greater
curvature of the stomach.
6. Pancreatico-duodenal vein: from the duodenum and head of
pancreas.
3. OTHER TRIBUTARIES OF PORTAL VEIN:
a. Left gastric vein: [anastomoses with the oesophageal veins].
b. Right gastric vein.
c. Para-umbilical veins : drain the skin around the umbilicus and
accompany the ligamentum teres of the liver in the falciform
ligament to end in the left branch of portal vein.
N.B.:
The portal vein is 2 inches long, formed by 2 veins [splenic
and superior mesenteric], ends by 2 branches [to right and
left lobes of the liver], receives 2 main tributaries [right and
left gastric veins] and 2 ligaments are attached to its left
branch [ligamentum teres and ligamentum venosum].

ANASTOMOSES BETWEENT THE PROTAL AND SYSTEMIC

CIRCULATIONS:
1. AT THE LOWER END OF OESOPHAGUS : between:
a. Oesophageal tributaries of the left gastric vein [portal]
b. Oesophageal tributaries of the azygos vein [systemic]
In portal hypertension this anastomosis enlarges to form
oesophageal varices [dilated and tortuous veins in the
submucosa of lower end of oesophagus]. Its rupture leads to
bleeding in the stomach [haematemesis].
2. AT THE LOWER END OF RECTUM : between:
a. Superior rectal vein [portal]

212
 Abdomen [ 155 - 222 ]
b. Inferior rectal veins (systemic)
If this anastomsis enlarges, the veins in the submucosa of the
anal canal become dilated and tortuous leading to the formation
of piles [haemorrhoids].
3. AROUND THE UMBILICUS : between
a. Para-umbilical veins [portal vein].
b. Vein of anterior abdominal wall [systemic].
These veins anastomose together around the umbilicus and may
lead to dilatation of the skin veins in a radial direction round the
umbilicus, a condition called caput medusae.
4. LESS EFFECTIVE SITES OF ANASTOMSIS:
 At the bare area of liver : between:
a. Capillaries within the liver [portal]
b. Phrenic veins on the under surface of the diaphragm
[systemic].
 On the posterior abdominal wall : between
a. Lumbar veins [systemic]
b. Colic veins [portal]. [Note that the ascending and
descending colon lie in direct contact with the posterior
abdominal wall].

NERVES OF POSTERIOR ABDOMINAL WALL

These nerves include the lumbar plexus, lumbar part of sympathetic chain and
autonomic plexuses.

LUMBAR PLEXUS
 It is formed in the substance of psoas major muscle by the ventral
primary rami of the upper 4 lumbar nerves.
 It gives off the following branches:
1. Ilio-inguinal and ilio-hypogastric nerves [L.1]
2. Genito-femoral nerve [L. 1, 2]
3. Lateral cutaneous nerve of the thigh [L. 2, 3]]
4. Femoral nerve [posterior divisions of L. 2, 3, 4]
5. Obturator nerve [anterior divisions of L. 2, 3, 4].
1. Ilio-hypogastric nerve:
 It emerges on the lateral border of psoas major as the highest
branch. It passes downwards and laterally on the quadratus
lumborum behind the kidney to pierce the transversus abdominis
just above the iliac crest.
 It runs between the transversus abdominis and internal oblique, then
pierces the internal and external obliques to supply the skin above
the inguinal ligament. It also supplies the lower part of the anterior
abdominal muscles [note the rectus].
2. Ilio-inguinal nerve:
 It lies below the ilio-hypogastric nerve and has the same course and
relations.
 However, it does not pierce the external oblique but enters the
inguinal canal and passes through the superficial inguinal ring.
 It supplies the skin of the upper part of medial side of thigh as well as
part of the skin of scrotum [or labium majus].

213
 Abdomen [ 155 - 222 ]
3. Lateral cutaneous nerve of thigh:
 It emerges from the lateral border of psoas major below the ilio-
inguinal nerve.
 It crosses the iliacus muscle in the pelvis where it enters the thigh
deep to the inguinal ligament just medial to the anterior superior iliac
spine.
4. Femoral nerve:
 It arises from the posterior divisions of the ventral rami of L. 2, 3, 4.
 It emerges at the lateral border of psoas major between it and the
iliacus muscle [it is the thickest branch].
 It supplies the iliacus and descends under cover of the inguinal
ligament lateral to the femoral sheath where it rapidly divides into
muscular and cutaneous branches.
5. Genito-femoral nerve:
 It descends on the anterior surface of psoas major where it crosses
obliquely behind the ureter.
 Lower down it divides into 2 branches:
a. Genital branch:
Enters the deep inguinal ring to supply the cremaster muscle.
b. Femoral branch:
Enters the femoral sheath, lateral to the femoral artery and
supplies the skin of upper part of the front of thigh.
6. Obturator nerve
 It arises from the anterior divisions of the ventral rami of L. 2, 3, 4 and
emerges on the medial side of psoas major.
 It passes on the lateral wall of pelvis accompanied by the obturator
vessels to enter the obturator canal.
 In the obturator canal it divides into anterior and posterior divisions.
N.B.: An accessory obturator nerve may be present [in 30%] and
passes on the medial side of psoas major to enter the thigh
above the superior ramus of pubic bone. It supplies the
pectineus muscle.
7. Lumbo-sacral trunk (L. 4, 5):
It is formed by the lower half of the 4th lumbar root [L. 4} together with
the whole 5th lumbar root. It descends on the medial side of psoas
major deep to the obturator nerve where it lies in contact with the ala of
sacrum.
N.B.:
The medial part of the anterior surface of the transverse process of 5th
lumbar vertebra is crossed by the descending part of L. 4 to join the
lumbo-sacral trunk. Its lateral part is crossed by the roots of the
obturator nerve.
Therefore deformity of this transverse process [5th L.V.] will affect these
nerves.

LUMBAR PART OF SYMPATHETIC CHAIN

COURSE AND RELATIONS:
 The sympathetic chain [trunk] enters the abdomen behind the medial
arcuate ligament, one each side.
 It passes downwards in the groove between the vertebral column and
the medial border of psoas major muscle.

214
 Abdomen [ 155 - 222 ]
 It enters the pelvis behind the common iliac vessels and descends just
medial to the anterior sacral foramina to end by uniting with the chain of
the opposite side in front of the coccyx to form the ganglion impar.
 The right chain lies behind the I.V.C., while the left chain is on the left
side of the aorta [therefore, the left chain is more exposed].
 Each chain has 4 lumbar ganglia.
BRANCHES:
1. Rami communicantes :
a. The 4 ganglia give off grey rami communicates [postganglionic to
all lumbar nerves].
b. The 1st and 2nd lumbar nerves send white rami communicates
[preganglionic] to the corresponding ganglia.
2. Lumbar splanchnic nerves:
a. These are 4 nerve, one from each ganglion.
b. They join the abdominal autonomic plexuses [coeliac, aortic and
hypogastric].
3. Vascular branches:
They surround the aorta and iliac arteries, and accompany them to the
viscera.

AUTONOMIC PLEXUSES
1. COELIAC PLEXUS:
 It is present around the celiac artery and is composed of 2 large
celiac ganglia, one on each side of the artery.
 It is formed by:
a. Sympathetic fibres : from the greater and lesser splanchnic
nerves coming from the thoracic sympathetic chain [of both
sides].
b. Parasympathetic fibres: from vagal branches
 It gives off secondary plexuses, which surround the branches of the
coeliac artery as well as the renal and superior mesenteric arteries.
2. AORTIC INTERMESENTERIC PLEXUS:
 It covers the aorta at the segment between the origins of the 2
mesenteric arteries.
 It is formed by:
1. Branches from the coeliac plexus
2. Branches from the lumbar sympathetic ganglia.
 It gives off secondary plexuses around the inferior mesenteric,
testicular and iliac arteries.
3. SUPERIOR HYPOGASTRIC PLEXUS:
 It lies just below the bifurcation of aorta in front of 5th L.V. and
promontory of sacrum.
 It is formed by:
1. Filaments descending on each side from the aortic plexus.
2. 3rd and 4th lumbar splanchnic nerves
 It divides into right and left divisions which descend into the pelvis to
join the inferior hypogastric [pelvic] plexuses that lie one on each
side of the rectum and urinary bladder.

215
 Abdomen [ 155 - 222 ]

MUSCLES OF POSTERIOR ABDOMINAL WALL

PSOAS MAJOR MUSCLE
Origin: from:
1. Front of the transverse processes of all lumbar vertebrae.
2. Contiguous sides of each 2 lumbar vertebrae and intervertebral
discs.
3. Tendinous arches on the sides of lumbar vertebrae and bridging
over the lumbar vessels.
Insertion:
The muscle descends along the brim of the pelvis medial to the
iliacus where both muscles join to form the iliopsoas muscle. It
passes deep to the inguinal ligament to gain insertion into the lesser
trochanter of femur.
Nerve supply:
By branches from the lumbar plexus.
Action:
1. It flexes the thigh, and rotates it medially.
2. Acting from below, it bends the trunk forwards.
3. In fracture neck of femur, the muscle produces lateral rotation of
the thigh.
PSOAS FASCIA:
 It covers the psoas major muscle [as an envelope] and is thickened
above to form the medial arcuate ligament. Pus deep to the psoas
fascia can descend to accumulate below the inguinal ligament.
Attachments:
Medially:
To the bodies of lumbar vertebrae and intervertebral discs.
Laterally:
Blends above with the fascia on the quadratus lumborum,
and below it fuses with the fascia on the iliacus to form the
fascia iliaca.
IMPORTANT RELATIONS OF PSOAS MAJOR:
A. In the abdomen and pelvis:
 Anterior relations:
 Kidney and renal vessels
 Ureter
 Gonadal vessels
 Genito-femoral nerve
 Psoas minor muscle [inconstant]
 Medial relations:
 Sympathetic chain [along its medial margin]
 External iliac vessels [at the brim of pelvis]
 Obturator nerve and lumbo-sacral trunk [descend along its medial
side].
 Lateral relations:
 2 msucles:
o Quadratus lumborum [above]
o Iliaccus [below]
 4 nerves
o Ilio-hypogastric nerve
o Ilio-inguinal nerve
o Lateral cutaneous nerve of thigh
216
 Abdomen [ 155 - 222 ]
o Femoral nerve
B. In the thigh :
 Anteriorly :
 Femoral artery (inside the femoral sheath).
 Posteriorly :
 Capsule of the hip joint from which it is separated by a bursa.
 Medially :
 Pectineus muscle.
 Laterally :
 Femoral nerve.
PSOAS MINOR :
Origin :
From the adjoining parts of the thoracic and 1st lumbar vertebrae
and the intervertebral disc in between (in 60% of subjects).
Insertion :
The muscle descends in front of psoas major to be inserted into
the ilio-pectineal eminence.
Nerve supply :
By the 1st lumbar nerve.
QUADRATUS LUMBORUM :
Origin : from
a. ilio-lumbar ligament.
b. medial part (5cm) of the inner lip of iliac crest.
Insertion : into
a. medial 1/2 of the last rib.
b. by tendinous slips into the tips of the transverse processes of the
upper 4 lumbar vertebrae.
Nerve supply :
By the subcostal nerve.
Action :
a. fixes the last rib so helps the diaphragm to contract more
effectively.
b. Bends the vertebral column towards its side (lateral flexion).
c. if both muscles act together, they extend the lumbar part of the
vertebral column (because of lumbar lordosis).
ILIACUS :
Origin :
From the iliac fossa.
Insertion :
Is inserted together with the psoas tendon into the lesser
trochanter of the femur.
Nerve supply :
From the femoral nerve while in the abdomen.
Action :
Acts with the psoas major as the main flexor of the thigh.
THORACO-LUMBAR FASCIA
 It is usually called lumbar fascia as it is more thickened and well
formed at the lumbar region. However, it extends high up to the
back of the neck and below to the sacrum.
 it binds the muscle of the back to the sides of the vertebral column
and is composed of 3 layers :

217
 Abdomen [ 155 - 222 ]
a. anterior layer :
covers the anterior surface of the quadratus lumborum. It is
thickened above to form the lateral arcuate ligament.
b. Middle layer:
Covers the posterior surface of quadratus lumborum and fuses
with the anterior layer at the lateral margin of this muscle.
Medially, it reaches the back of transverse processes of lumbar
vertebrae and separates the quadratus lumborum from the
sacrospinalis muscle.
c. Posterior layer:
Covers the back of sacrospinalis muscle. Medially, this layer
gains attachment to the spines of vertebrae while laterally it is
fused with the back of the middle layer of lumbar fascia.
N.B.: The lateral border of lumbar fascia is thickened and gives
origin to the internal oblique and transversus abdominis
muscles
DIAPHRAGM
ORIGIN:
It has a wide origin from the whole circumference of the inner
aspect of the thoracic outlet. This is divided into 3 regions:
1. Sternal origin:
By 2 slips from the back of xiphoid process.
2. Costal origin:
By slips from the deep surface of the lower 6 costal cartilages
interdigitating with the slips of transversus abdominis.
3. Vertebral origin:
By the 2 crura and from the arcuate ligaments. These are
described as follows:
A. Right and left crura:
a. Right crus:
Arises from sides of the upper 3 lumbar vertebrae. It
is larger than the left crus as it has to act against the
liver.
b. Left crus:
Arises from the sides of the upper 2 lumber
vertebrae.
B. Arcuate ligaments:
a. Lateral arcuate ligament : [one on each side]
Extends from the tip of the transverse process of 1st
lumbar vertebra to the last rib. It arches over the
quadratus lumborum muscle.
b. Medial arcuate ligament : [one on each side]
Extends from the crus of diaphragm to the tip of
transverse process of the 1st lumbar vertebra. It
arches over the psoas major muscle.
c. Median arcuate ligament: [only one in the median
plane]
Extends between the right and left crura. It arches
over the aorta.
N.B.: A triangular gap called the vertebro-costal triangle lies
between the origin from the last rib and the origin
from the lateral arcuate ligament. Here, the pleura

218
 Abdomen [ 155 - 222 ]
comes in contact with the posterior surface of the
kidney ( the kidney is retroperitoneal).
INSERTION:
It has no bony insertion, but all the fibres are inserted into
the central tendon of diaphragm. This tendon is semilunar
in shape having a median lobe and 2 lateral lobes.
RELATIONS:
Relations of its upper surface:
 On the right : right pleura and lung.
 On the left : left pleura and lung
 In the middle : heart and pericardium
Relations of its lower surface:
 On the right: Right lobe of liver
Right kidney and right suprarenal gland
 On the left : left lobe of liver
Fundus of stomach
Spleen
Left kidney and left suprarenal gland
OPENINGS IN THE DIAPHRAGM:
1. Aortic opening:
 In the median plane behind the median arcuate ligament at the
level of the 12th thoracic vertebra.
 It transmits:
a. Aorta : to the left
b. Azygos vein : to the right
c. Thoracic duct : between the aorta and azygos vein
2. Oesophageal opening:
 Lies within the right crus, at the level of 10th thoracic vertebra, 1 inch
to the left of median plane.
 It transmits:
a. Oesophagus
b. Anterior and posterior vagal trunks [applied to oesopahgus]
c. Oesophageal arteries and veins [from left gastric vessels].
3. Opening for inferior vena cava:
 Lies within the central tendon [fibrous] at the level of the 8th thoracic
vertebra, 1 inch to the right of median plane.
 When the diaphragm contracts in inspiration, the central tendon
stretches and so the opening of I.V.C. widens and helps venous
return.
 It transmits:
a. I.V.C.
b. Right phrenic nerve
c. Lymph vessels from the liver to lymph nodes in the thorax
OTHER STRUCTURES PASSING THROUGH [OR BEHIND] THE DIAPHRAGM:
 Musculo-phrenic artery : passes between the slips of origin of the
diaphragm from 7th and 8th costal cartilages.
 Superior epigastric artery : enters the rectus sheath between the
sternal and costal origins of diaphragm.
 Lower 5 intercostal nerves and vessels: pass between the digitations
arising from the costal cartilages.
 Subcostal nerve and vessels : pass behind the lateral arcuate
ligament.

219
 Abdomen [ 155 - 222 ]
 Hemiazygos vein : pierces the left crus to enter the chest.
 Sympathetic chain: runs behind the medial arcuate ligament.
 Greater and lesser splanchnic nerves : pierce the crus on each side.
NERVE SUPPLY OF DIAPHRAGM:
1. Phrenic nerves : [C. 3, 4, 5]
They ramify on the under surface of diaphragm. The phrenic nerve is the
motor nerve to the diaphragm. [Its cervical origin is an evidence that the
diaphragm has developed in the cervical region and migrated caudally].
2. Lower 6 thoracic nerves:
To the peripheral part of diaphragm [sensory]
ARTERIAL SUPPLY OF DIAPHRAGM
The arteries of diaphragm are:
1. Superior phrenic : from thoracic aorta
2. Lower intercostals : from thoracic aorta
3. Inferior phrenic : from abdominal aorta
4. Musculo-phrenic : from internal thoracic artery
5. Pericardiaco-phrenic : from internal thoracic artery
[All enter its upper surface except the inferior phrenic which enters its
lower surface].
ACTION OF DIAPHRAGM:
1. It is acting all the time during inspiration and expiration. [It is the chief
muscle of respiration].
2. By its descent, it increases the intra-abdominal pressure but decreases
the intra-thoracic pressure.
SUBPHRENIC SPACES
 These are 6 spaces between the liver and under surface of the
diaphragm : 3 spaces on the right side and 3 spaces on the left side of
the falciform ligament.
 They are of surgical importance as pus may collect in any of them
forming a subphrenic abscess.
A. Spaces to the right of falciform ligament:
1. One space is related to the bare area of the liver between the 2 layers
of coronary ligament [extraperitoneal].
2. One space anterior and another space posterior to the coronary
ligament [intraperitoneal]. The posterior space is closely related to
the right kidney [to the right of epiploic foramen].
B. Spaces to the left of falciform ligament:
1. An area around the upper pole of left kidney [extraperitoneal].
2. One space anterior and another space posterior to the left triangular
ligament [intraperitoneal]. The posterior space is actually the lesser
sac of peritoneum.

LYMPH NODES OF THE ABDOMEN AND PELVIS

The lymph nodes of the abdomen and pelvis are arranged into chains or
groups which lie along the course of the main arteries.

ABDOMINAL LYMPH NODES

1. Pre-aortic nodes:
 They are placed on the anterior surface of aorta.
 They receive afferents from the gastro-intestinal tract, spleen, liver
and pancreas [the gut in the foetus lies in front of the aorta].

220
 Abdomen [ 155 - 222 ]
 Their efferents unite to form the intestinal lymph trunk [single] which
ends in the cisterna chyli.
2. Lateral aortic nodes:
 They are placed as 2 chains, one on each side of the aorta.
 They receive afferents from bilateral structures:
a. Kidneys, ureters, gonads, uterine tubes and upper part of
uterus [direct drainage].
b. Common iliac lymph nodes in the pelvis
c. Deep layers of abdominal wall [its superficial layers drain into
the axillary and superficial inguinal nodes].
 Their efferents from the right and left lumbar trunks which end also in
the cisterna chili.
3. Lymph nodes around the vessels of the gut:
These nodes surround the origins of the 3 main arteries of the gut:
a. Coeliac nodes : around the coeliac artery
b. Superior mesenteric nodes : around the superior mesenteric
artery.
c. Inferior mesenteric nodes: around the inferior mesenteric artery.
These nodes drain mainly the stomach, intestine [small and large],
liver, gall bladder and pancreas.

PELVIC LYMPH NODES

1. External iliac nodes:
 Lie along the external iliac vessels
 Receive afferents mainly from
a. Inguinal lymph nodes
b. Some pelvic viscera [partial drainage] : prostate, cervix of
uterus, part of vagina, fundus of urinary bladder and
membranous urethra.
 Send efferents to the common iliac nodes
2. Internal iliac nodes:
 Lie along the internal iliac vessels
 Receive afferents from:
a. All pelvic viscera
b. Deep tissues of the buttock and perineum.
 Send efferents to the common iliac nodes
3. Common iliac nodes:
 Lie along the common iliac vessels
 Receive afferents from the external and internal iliac nodes
 Send efferents to the lateral aortic nodes
CISTERNA CHYLI
 It is a reservoir into which the lymph is collected from the lower limbs
and abdomen.
 It has 3 lymph trunks
1. One intestinal lymph trunk : draining the stomach, intestine as well
as the pancreas, liver and spleen [gut derivatives].
2. lumbar lymph trunks : draining the remaining contents of the
abdomen and pelvis in addition to the lower limbs [bilateral
structures].
 It is 2 inches long, and lies in front of the upper 2 lumbar vertebrae
behind the right crus of diaphragm [contraction of the diaphragm helps
to compress the cisterna chili].
221
 Abdomen [ 155 - 222 ]
 The thoracic duct arises from the upper end of cisterna chyli and passes
upwards to enter the chest through the aortic opening of diaphragm
between the aorta and azygos vein.

222