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AAD abdomen worksheet

Regional Anatomy (University of Birmingham)

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SurgSoc’s Annual Anatomy Away Day 2022

Anatomical Region: Abdomen
Key Learning Objectives
• Identify the important landmarks defining the boundaries of the abdominal
cavity
• Describe the descriptive regions and quadrants of the abdomen and identify
the organs and viscera underlying these regions
• Recall the muscular layers of the anterolateral abdominal wall
• Describe the structure of the peritoneum, mesentery and omentum.
• Understand the gross anatomy and neurovascular supply of oesophagus, stomach, intestines, liver,
gallbladder, biliary tree and pancreas

Abdominal Anatomy
Abdominal Cavity
• Superiorly bounded by the inferior thoracic aperture and the diaphragm
• Inferiorly bounded at the pelvic inlet (continuous with pelvic cavity)
• Antero-posteriorly bounded by the abdominal wall

Surface Anatomy
1. Four quadrants: intersection of two planes
a. Horizontal trans-umbilical plane
b. Vertical median plane
2. Nine regions: intersection of two horizontal and two vertical planes
a. Subcostal plane (Horizontal at level L3)
b. Intertubercular plane (Horizontal at level L5 and iliac crest)
c. Two midclavicular planes (Vertical from mid-clavicle to anterior-superior iliac spine)

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Regions of the Digestive Tract

1. Foregut
• Distal oesophagus à proximal part of
duodenum
• Includes liver, pancreas and gallbladder
• Arterial supply: Coeliac Trunk
• Venous drainage: Portal and splenic vein
• Innervation:
o Sympathetic: Greater splanchnic nerve
and coeliac plexus
o Parasympathetic: Vagus nerve
o Referred pain to epigastric region

2. Midgut
• Distal part of duodenum à proximal 2/3 of
transverse colon
• Arterial supply: Superior mesenteric artery
• Venous drainage: Superior mesenteric vein
• Innervation:
o Sympathetic: Lesser splanchnic nerve
o Parasympathetic: Vagus nerve
o Referred pain to umbilical region

3. Hindgut
• Distal 1/3 of transverse colon à
rectum
• Arterial supply: Inferior
mesenteric artery
• Venous drainage: Inferior
mesenteric vein
• Innervation:
o Sympathetic: Least
splanchnic nerve and
inferior mesenteric plexus
o Parasympathetic: Pelvic
splanchnic nerves (S2-S4)
o Referred pain to pubic
region

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Abdominal Viscera
Peritoneum
A continuous thin membrane lining the walls of the abdominal cavity and
viscera
• Parietal:
o Lines the innermost lining of the abdominal wall
o Somatic innervation – localised pain
• Visceral:
o Covers the abdominal viscera
o Autonomic innervation – poorly localised pain

• Intraperitoneal organs (A): Suspended in the peritoneal cavity

• Retroperitoneal organs (B): Suspended outside the peritoneal cavity

Peritoneal Cavity
• Potential space between parietal and
visceral peritoneum divided into greater
sac and lesser sac (omental bursa)
• Cavity is closed in men and open in women
• Greater sac:
o Most of the space in peritoneal
cavity
o Diaphragm à pelvic cavity
• Lesser sac (omental bursa):
o Smaller space posterior to stomach
and liver
o Continuous with greater sac via
omental/epiploic foramen

Omenta
• Folded layers of visceral peritoneum
• Greater omentum:
o Four layers of peritoneum
o Greater curvature of stomach à
transverse colon
• Lesser omentum:
o Two layers of peritoneum
o Lesser curvature of stomach/1st part of
duodenum à inferior surface of liver
o Contains hepatogastric and
hepatoduodenal ligament

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Mesenteries
• Peritoneal folds that attach viscera to the posterior abdominal wall
• A channel for vessels, nerves and lymphatics to travel from wall to
viscera
• Mesentery: Connects jejunum and ileum to posterior wall
• Transverse mesocolon: Connects transverse colon to posterior wall
• Sigmoid mesocolon: Connects sigmoid colon to posterior wall

• Intraperitoneal organs suspended my mesentery (stomach, liver,

spleen
• Retroperitoneal organs not suspended (adrenals, aorta, duodenum,
pancreas, ureters, ascending/descending colon, kidneys, oesophagus
and rectum)

Anterolateral Abdominal Wall

Layers:
1. Skin
2. Superficial fascia
a. Camper’s fascia (fatty)
b. Scarpa’s fascia (thin)
3. 3 flat muscles + 2 vertical muscles
4. Transversalis fascia
5. Extraperitoneal fascia
6. Peritoneum

Rectus Sheath

• Aponeurotic tendinous sheath enclosing vertical muscles

• Tendinous sheath arising form the 3 flat muscles
• Arcuate line: Midway between umbilicus and pubic symphysis
• A: Above arcuate line

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o Complete enclosure of rectus abdominis

• B: Below arcuate line
o Anterior enclosure of rectus abdominis

Abdominal Oesophagus
• Muscular tube from pharynx to stomach
• Distal 2cm located in abdominal cavity
• Emerges through the right crus of the diaphragm
via oesophageal hiatus at T10

• Arterial supply: Left gastric artery and left inferior phrenic artery
• Venous drainage: Azygos and hemiazygos veins
• Lymphatic drainage: Posterior mediastinal nodes and left gastric nodes
• Innervation:
o Striated muscle: Branchial efferents from Vagus
o Smooth muscle: Parasympathetic from Vagus
o Sensory: Visceral afferents from Vagus, sympathetic trunk and
splanchnic nerves
• Left and right vagus nerve converge to form anterior and posterior vagal
trunk which pass into the abdomen with the oesophagus

Stomach
• Divided into cardia, fundus, body, pyloric part
• Cardial notch where the oesophagus
• A greater curvature to which greater omentum is attached to
• A lesser curvature to which lesser omentum is attached to

• Arterial supply: R+L gastric artery, R+L gastro-omental artery

• Venous drainage: R+L gastric veins, R+L gastro-omental veins
• Innervation:
o Sympathetic: Greater splanchnic nerve (T6-T9)
o Parasympathetic: Vagus nerve

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Small Intestine
• Pyloric orifice à ileocecal fold

Duodenum
• Widest lumen, 20-25cm long and divided
into four parts
• Superior
o Pyloric orifice à neck of gallbladder
• Descending
o Neck of gallbladder à lower border
of L3
• Inferior
o Inferior duodenal flexure (L3)
o Longest section
• Ascending
o Travels from L3 to L2 and terminates
at duodenojejunal flexure
• Arterial supply: Branches of gastroduodenal artery and superior mesenteric artery
o Supra
• Venous drainage: Pre-pyloric vein and superior/inferior pancreaticoduodenal veins

Jejunum
• Makes up the proximal 2/5 of the rest of the small
intestine
• Located in LUQ
• Compared to ileum:
o Thicker intestinal wall
o Numerous plicae circulares
o Longer vasa recta
o Fewer arterial arcades

• Arterial supply: Superior mesenteric artery

• Venous drainage: Superior mesenteric vein and splenic vein
• Innervation:
o Sympathetic: Celiac and superior mesenteric plexus
o Parasympathetic: Vagus nerve

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Ileum
• Makes up distal 3/5 of the rest of the small intestine
• Ends at ileocecal junction
• Located in RLQ
• Compared to jejunum:
o Thinner intestinal wall
o Fewer plicae circulares
o Shorter vasa recta
o Numerous arterial arcades

• Arterial supply: Superior mesenteric artery

• Venous drainage: Superior mesenteric vein and
splenic vein
• Innervation:
o Sympathetic: Celiac and superior mesenteric plexus
o Parasympathetic: Vagus nerve

Large Intestine
• Ileocecal junction à anus
• Absorbs fluids and salts forming faeces
1. Caecum
2. Appendix
3. Colon
a. Ascending
b. Transverse
c. Descending
4. Sigmoid colon
5. Rectum
6. Anal canal

Caecum
• Inferior to ileocecal opening
• Located in RIF

Appendix
• Narrow, hollow, blind-ended tube
• Suspended by mesoappendix
• Contains aggregations of lymphoid tissue
• Location varies
• Arterial supply: Anterior/posterior caecal artery and
appendicular artery
• Venous drainage: Ileocolic vein à superior mesenteric
vein
• Innervation:
o Sympathetic: Superior mesenteric plexus
o Parasympathetic: Vagus nerve

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Colon
• Ascending à R colic flexure à Transverse à L colic flexure à Descending à Sigmoid
• Ascending and descending colon are secondarily retroperitoneal
• Transverse and sigmoid are intraperitoneal
• Sigmoid colon is an S shape from pelvic inlet to S3 vertebrae

Rectum and Anal canal

• Rectum
o Rectosigmoid junction à S3 vertebrae
o Retroperitoneal structure
o Sacral flexure and anorectal flexure
• Anal canal
o Continuation of large intestine inferior to
rectum
o Internal anal sphincter (involuntary control)
o External anal sphincter (voluntary control)

Arterial Supply
Superior Mesenteric Artery
• Ileocolic and right colic artery branches à Ascending colon
• Right and middle colic artery branches à First 2/3 of transverse
colon

Inferior Mesenteric Artery

• Left colic artery branch à Final 1/3 of transverse colon
• Left colic artery à Descending colon
• Sigmoid arteries à Sigmoid colon
• Superior rectal artery à Rectum (above dentate line)

Internal Iliac Artery

• Middle and inferior rectal artery branches à Rectum (Below
dentate line)

Venous Drainage
Superior Mesenteric Vein
• Drains small bowel, cecum, ascending colon and
transverse colon
Inferior Mesenteric Vein
• Drains rectum above dentate line (superior rectal vein),
sigmoid colon, descending colon and splenic flexure
Inferior Vena Cava
• Drains rectum below dentate line (inferior rectal vein)

IMV à SMV and sigmoid colon à Portal vein à Liver à

Inferior Vena Cava

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Innervation
Sympathetic
• Pre-ganglionic neurone
• Paravertebral neurone
• Celiac, superior mesenteric, inferior mesenteric, inferior hypogastric ganglia
• Post-ganglionic neurone
• Abdominal viscera
Parasympathetic
• Vagus Nerve
• Pelvic splanchnic nerves (S2-S4)

Liver
• Intraperitoneal
• Located in the right hypochondrium and epigastric region
with extension into left hypochondrium

Surfaces
• Diaphragmatic surface (anterior, superior, posterior)
o Smooth, domed
o Lies against the inferior diaphragm
o Covered with visceral peritoneum (except posterior
aspect)
o Subphrenic recess separates diaphragmatic liver from diaphragm
• Visceral surface (inferior)
o Covered with visceral peritoneum (except gall bladder and porta hepatis)
o Porta hepatis is the entry point for hepatic arteries and portal vein
o Hepatorenal recess separates the visceral liver surface from right kidney and right adrenal
gland

Ligaments
• Connects liver to other structures on the abdomen
• Falciform ligament à Anterior Abdominal Wall
o Free edge contains ligamentum teres
• Hepatogastric ligament à Stomach
• Hepatoduodenal ligament à Duodenum
• Triangular ligaments à Diaphragm
• Coronary ligament à Diaphragm

Lobes
• Divided into right and left lobes anterosuperiorly by:
o Falciform ligament and the ligament teres
• Quadrate Lobe
o Anterior part of visceral surface
o Bound by ligamentum teres and gallbladder fossa
o Structurally appears from right lobe but functionally related to left
• Caudate Lobe
o Posterior part of visceral surface

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o Bound by ligamentum teres and IVC groove

o Functionally separate to right and left lobe

Neurovascular Supply
Arterial Supply
• Abdominal Aorta à Coeliac trunk à Common Hepatic artery à Hepatic artery proper à R/L
Hepatic Arteries (25%)
• Hepatic portal vein (75%, partially deoxygenated blood)
Venous Drainage
• Hepatic sinusoids à Hepatic vein à IVC
Lymphatic Drainage
• Anterior: Hepatic lymph nodes
• Posterior: Phrenic and posterior mediastinal lymph nodes
Innervation
• Hepatic plexus
• Sympathetic: Coeliac plexus
• Parasympathetic: Vagus Nerve

Gallbladder
• Intraperitoneal on visceral surface of the right love of the liver in a fossa between the right and
quadrate lobes
• Receives, concentrates and stores bile made from the liver

Structure
• Fundus
o Rounded end projecting from inferior liver border
• Visceral
o Located in gallbladder fossa
• Neck
o Mucosal folds forming spiral fold
o Hartmann’s pouch
• Arterial supply: Cystic artery from R Hepatic artery
• Venous drainage:
o Cystic vein à Portal vein
o Hepatic sinusoids
• Lymphatic drainage: Cystic lymph nodes

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Duct System
• Drains bile formed in liver into duodenum
• Liver à R/L hepatic duct à Common hepatic duct (joins with cystic duct) à Bile duct (joins with
pancreatic duct) à Hepatopancreatic ampulla à Descending part of duodenum (major duodenal
papilla)

Pancreas
• Extends across posterior abdominal wall within epigastric and left hypochondrium
• Retroperitoneal structure (except small part of tail)

Structure
• Head
o Lies within C-shaped part of duodenum
• Uncinate process
o Projects from lower head posterior to superior
mesenteric vessels
• Neck
o Anterior to superior mesenteric vessels
• Body
o Elongated area from neck to tail
• Tail
o Passes between layers of splenorenal ligament

Pancreatic Duct System

• Main pancreatic duct runs from tail à body à
head.
• Joins bile duct to form hepatopancreatic ampulla
before entering descending duodenum via major
duodenal papilla
• Sphincter of ampulla (Oddi) surrounds the ampulla
• Accessory pancreatic duct empties into duodenum
via minor duodenal papilla

• Arterial supply:
o Head and neck: Superior/inferior pancreaticoduodenal branches
o Body and tail: Dorsal and greater pancreatic artery from splenic artery
• Venous drainage:
o Head and neck: Pancreatic veins à SMV à Portal vein
o Body and tail: Pancreatic veins à Splenic vein à Portal vein
• Lymphatic drainage: Coeliac, superior mesenteric and splenic nodes

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Worksheet Exercises

2)

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3) Label the abdominal regions:

4) Label the abdominal muscles and related structures:

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5) Label as many structures as you can from this CT:

6) Label the following structures:

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