Kidneys and Retroperitoneum Practice Quiz
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A 57-year-old male complains of intense chest pain, but tests
rule out any cardiac pathology. It was determined that the patient
suffers from an esophageal (hiatal) hernia in which the stomach
herniates through an enlarged esophageal hiatus. Muscle fibers
from which of the following parts of the diaphragm would border
directly on this hernia?
Sympathetic fibers in the greater splanchnic nerve arise from
neuron cell bodies found in the:
After successfully performing two adrenalectomies (removal of the IVC and drain into it. In the case of the suprarenal glands, you
the adrenal gland), the surgical resident was disappointed to learn can see that the IVC is laying over the right suprarenal gland and
that he would be merely assisting at the next one. The chief
of surgery told him: "I'm doing this one, since the one on the
right side may be a little too difficult for you." The difficulty he draining into the renal vein.) As far as the other structures in the
envisioned stems from the fact that the right suprarenal gland is question go... The aorta lies fairly evenly between the suprarenal
partly overlain anteriorly by the:
During preparations to remove the left kidney from a 28-year-old
female patient, the surgeon asked an observing medical student
where best to ligate the renal vein. Upon hearing the reply: "as
close to the inferior vena cava as possible, leaving just enough
stump to ensure tight closure," the surgeon's eyebrow shot up.
"Do you mean to say you're willing to compromise the venous
drainage of the other structures that drain into the renal vein?" By
this he meant these structures:
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Right crus
-------------
The right crus is the part of the diaphragm that takes origin from
L1-L3. It splits to enclose the esophagus. So, in the case of
an esophageal hernia, the herniating stomach would be entirely
surrounded by the fibers of the right crus. The left crus is the part
of diaphragm that takes origin from L1 and L2. It is smaller and
shorter than the right crus, and it intermingles with the right crus
around the aortic hiatus. It does not contribute to the esophageal
hiatus. The central tendon is the tendon in the middle of the
diaphragm where all the fibers of the diaphragm attach. It provides
an opening for the inferior vena cava. Finally, sternal and costal
fibers refer to muscle fibers in the diaphragm that take origin from
the xyphoid process or the ribcage. This could not refer to the right
crus, since it originates on the lumbar vertebrae.
Spinal cord
---------------
The sympathetic fibers in the greater thoracic splanchnic nerve
are preganglionic sympathetic fibers that have left the sympathetic
chain and are going to synapse in abdominal ganglia. These
preganglionic sympathetic fibers originate in the lateral horn of
the spinal cord grey matter. The celiac ganglia and the superior
mesenteric ganglia are the two ganglia where the fibers from the
greater thoracic splanchnic nerve can go to synapse. Finally, re-
member that these fibers did not originate in the chain ganglia--the
fibers from there are the postganglionic sympathetic fibers.
Inferior vena cava
-----------------
Remember that the inferior vena cava is a little off center, on the
right side of the abdomen. This means that structures on the right
might be closely associated with this vessel, while structures on
the left will need to have longer venous channels to connect with
is very far from the left gland. (This means that the right gland is
draining directly into the inferior vena cava, while the left gland is
glands--it is not overlying either gland. The left hepatic vein, which
drains blood from the liver to the inferior vena cava, is superior to
the kidneys and not really involved with this area. The right crus of
the diaphram is a set of fibers that splits to make the esophageal
hiatus, and the right renal artery is a branch off the aorta to the
kidney which enters the kidney below the level of the suprarenal
gland.
Diaphragm, ovary, and suprarenal gland
NOT pancreas
---------------
Since the inferior vena cava is on the right side of the abdomen,
structures on the left will need to have longer venous channels
to connect to the IVC and drain into it. Consequently, some of
the paired retroperitoneal structures that drain directly into the
IVC on the right side cannot do that on the left. Instead, they
must drain into the renal vein, which crosses over the aorta and
under the superior mesenteric artery to connect to the inferior
vena cava. The left inferior phrenic vein, left suprarenal vein, and
left ovarian/testicular vein all drain into the left renal vein (although
their analogs on the right side drain directly into the IVC). If the
left renal vein was ligated as it crosses the aorta, blood from the
left diaphragm, ovary, and suprarenal gland would have to drain
posteriorly - into the left second lumbar vein, which connects to
the posterior aspect of the left renal vein. The pancreas drains
 Kidneys and Retroperitoneum Practice Quiz
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The celiac plexus of nerves may contain fibers derived from which ganglia. This plexus also contains vagal fibers. Even though the
sources?
Describe the suprarenal glands.
The nerve that innervates the cells of the suprarenal medulla
consists of fibers of the:
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into the portal venous system and would not be affected by this
ligation.
Posterior vagal trunk, lumbar splanchnic nerves, greater thoracic
splanchnic nerve
NOT lesser thoracic splanchnic nerve
--------------
The celiac plexus of nerves contains fibers from the greater
thoracic splanchnic nerves, which are synapsing in the celiac
vagus does not synapse in the celiac ganglia, it passes through
the ganglia and contributes to the celiac plexus. This allows the
vagal fibers to travel on arteries to reach their eventual targets.
The lesser thoracic splanchnic nerves are not part of the celiac
ganglia--these nerves synapse in the aorticorenal ganglia and
contribute to the renal plexus. The first lumbar splanchnic nerve
may occasionally contribute to the celiac plexus.
Cells that secrete epinephrine and norepinephrine are innervated
by preganglionic fibers
-----------
The suprarenal medulla is directly innervated by preganglionic
sympathetic fibers from the greater thoracic splanchnic nerve.
These preganglionic fibers synapse on the cells of the adren-
al medulla, causing the cells in the adrenal medulla to release
norepinephrine and/or epinephrine. The preganglionic fibers can
synapse on these cells of the adrenal medulla because they are
modified nervous tissue. The epinephrine and norepinepherine
enters the blood stream to cause a systemic response. The su-
perior suprarenal arteries branch from the inferior phrenic, the
middle suprarenal artery is a direct branch of the abdominal aorta,
and the inferior suprarenal arteries are branches of the renal
artery. Although the vein from the right gland drains into the inferior
vena cava, the vein from the left suprarenal gland drains into the
left renal vein. Finally, the pararenal space is the space outside the
renal fascia, covered with the pararenal fat. The suprarenal gland
is covered by the renal fascia, so it's in the perirenal space, not in
the pararenal space.
Greater thoracic splanchnic nerve
-----------------
The suprarenal medulla is directly innervated by preganglionic
sympathetic fibers from the greater thoracic nerve. These fibers
synapse on the cells in the adrenal medulla, causing a systemic
sympathetic response. Other preganglionic fibers from the greater
thoracic nerve synapse in the celiac ganglion; the postganglionic
fibers from this ganglion distribute along branches of the celiac
trunk. The preganglionic fibers from the lesser thoracic splanch-
nic nerve synapse in the aorticorenal ganglion--postganglionic
processes from this ganglion supply vascular smooth muscle of
branches of the renal artery and suprarenal arteries. The pregan-
glionic fibers of the least thoracic splanchnic nerve synapse in the
renal plexus.
The anterior vagal trunk has a gastric and hepatic branch, supply-
ing parasympathetic fibers to the stomach and liver. The posterior
vagal trunk supplies some parasympathetic fibers to the stomach,
but it also sends a celiac branch to the celiac plexus. The fibers
from the posterior vagal trunk which pass to the celiac plexus
eventually distribute to the organs of the abdomen, all the way to
the last third of transverse colon.
Vertebrocostal trigone - lateral arcuate ligament
Esophageal hiatus - right crus
Medial arcuate ligament - psoas muscle
Vena caval foramen - right phrenic nerve
 Kidneys and Retroperitoneum Practice Quiz
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----------------
The aortic hiatus is not in the central tendon of the diaphragm--the
caval opening, for the inferior vena cava, is found in the central
tendon of the diaphragm. The aortic hiatus is formed by the medi-
an arcuate ligament, which unites the two crura of the diaphragm.
The vertebrocostal trigone is an area of the diaphragm superior
to the lateral arcuate ligament. Here, the diaphragmatic muscle
Regarding the diaphragm, what is paired? is deficient and the trigone is closed primarily by the inferior and
superior fascia of the diaphragm. It is a significant area for hernias.
The esophageal hiatus is formed entirely by the fibers of the
right crus. The psoas major muscle passes behind the medial
arcuate ligament. Finally, the right phrenic nerve passes through
the central tendon of the diaphragm, near the vena caval foramen.
See Netter Plate 181 for a picture of all these structures and their
relationships.
Preganglionic fibers from the greater thoracic splanchnic nerve
------------
Preganglionic fibers from the greater thoracic splanchnic nerve
directly innervate the suprarenal medulla, causing a systemic
sympathetic response. Postganglionic sympathetic axons from
the celiac plexus distribute along branches of the celiac trunk to
The nerves that end on the secretory cells of the medulla of the
supply the vascular smooth muscle of those arteries. Pregan-
suprarenal glands are principally:
glionic fibers from the lesser thoracic splanchnic nerve travel to the
aorticorenal ganglia; postganglionic fibers from the aorticorenal
ganglia supply the vascular smooth muscle of the branches of
the renal arteries. The postgangionic fibers from the renal plexus
provide sympathetic innervation to smooth muscle to the blood
vessels supplying the kidney, renal pelvis and upper ureter.
Esophageal hiatus
-------------
Remember back to the thorax--the vagus joins the esophageal
plexus and covers the esophagus. The anterior and posterior
vagal trunks form from the esophageal plexus-- they pass into
The vagus nerve passes into the abdomen by passing through the abdomen through the esophageal hiatus, on the anterior and
the posterior surfaces of the esophagus. The aortic hiatus is deep
to the median arcuate ligament--it transmits the aorta and the
thoracic duct. The caval foramen is found in the central tendon of
the diaphragm; it transmits the inferior vena cava. Psoas major is
deep to the medial arcuate ligament, and quadratus lumborum is
deep to the lateral arcuate ligament.
Suprarenal medulla
---------------
The suprarenal medulla is directly innervated by preganglionic
sympathetic fibers from the greater thoracic splanchnic nerve.
With one exception, preganglionic sympathetic axons synapse
These preganglionic fibers synapse on the cells of the adren-
upon postganglionic sympathetic dendrites or cell bodies. The
al medulla, causing the cells in the adrenal medulla to release
exception to this general rule occurs within the:
norepinephrine and/or epinephrine. The preganglionic fibers can
synapse on these cells of the adrenal medulla because they are
modified nervous tissue. The epinephrine and norepinepherine
enters the blood stream to cause a systemic response.
Extraperitoneal connective tissue
--------------
Each kidney is embedded in two layers of fat, with a membrane
(the renal fascia), in between the layers. Inside the renal fascia,
and directly atop the kidney, is the perirenal fat. Outside the renal
The pararenal fat in the kidney bed is an elaboration of: fascia, you will find the pararenal fat, which is an elaboration
of extraperitoneal connective tissue. Although the kidney is not
peritonealized, the peritoneum from the posterior body wall lies
over the anterior surface of the pararenal fat. The kidney is not
a secondarily retroperitoneal organ--it began development in the
retroperitoneum. So, it does not have a fusion fascia.

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 Kidneys and Retroperitoneum Practice Quiz
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The cisterna chyli accompanies which structure as it passes
through the diaphragm?
Blood from an injured kidney will seep through the perirenal fat
until it contacts the internal surface of the renal (Gerota's) fascia.
Without perforating this fascia the blood could then continue to
pass in what direction?
A 19-year-old male suffers a tear to the psoas major muscle
during the course of a football game. A scar, which formed on the
medial part of the belly of the muscle, involved an adjacent nerve,
immediately medial to the muscle. The nerve is called the:
While recovering from an open abdominal hysterectomy (i.e.,
using a midline abdominal incision to gain entry to the pelvis), nerve is injured, the patient will experience some numbness on
a patient realizes that she has lost sensation to the skin of her her leg, and she will be unable to extend her knee. In this case,
anterior thigh and cannot extend her knee. Retractors holding the both the symptoms and the history of abdominal surgery point to
incision open and pressing against the posterior abdominal wall damage to the femoral nerve.
most likely caused injury to which nerve?
Aorta
------------
In 25-50% of cases, the inferior portion of the thoracic duct in-
cludes a dilated portion called the cisterna chyli. When present,
all of the lymph trunks draining the abdomen and lower limbs
dump into it, as well as the most inferior intercostal lymph trunks.
When it is not present, these trunks simply empty into the thoracic
duct. So, the cisterna chyli is a portion of the thoracic duct, and
the thoracic duct passes through the diaphragm with the aorta at
the T12 level. The inferior vena cava passes through the central
tendon of the diaphragm at the T8 level. The esophagus and vagal
branches pass through the right crus of the diaphragm at the T10
level. The greater thoracic splanchnic nerves pass through the
fibers of the left and right crus.
Inferiorly towards the pelvis
----------------
The kidney is surrounded by a perirenal fatty capsule, the renal
(Gerota's) fascia and pararenal fat. The fat offers no resistance to
hemorrhage, but blood is contained in the renal fascia. This means
that blood would not flow toward the body wall, other kidney, or
toward the diaphragm. However, a kidney injury might involve part
of the urinary collecting system, and blood from such damage
would travel into the ureters and bladder.
Obturator
-------------
The obturator nerve runs along the medial border of the psoas
major muscle, eventually passing through the obturator canal to
innervate muscles of the medial thigh. So, it might be damaged
by an injury to the medial portion of psoas major. The femoral
nerve runs along the lateral border of psoas major, where psoas
major contacts iliacus. The genitofemoral nerve pierces through
psoas major at the level of L3 or L4. The iliohypogastric and
ilioinguinal nerves run under psoas major, emerging at the lateral
border of psoas major to run over quadratus lumborum. The way
to distinguish between these two nerves is to remember that the
iliohypogastric is superior to the ilioinguinal nerve.
Femoral nerve
----------------------
During open abdominal surgeries (i.e., hysterectomy), retractor
blades are used to keep the abdominal cavity open. The blade may
come to rest on the femoral nerve as it lies between the iliacus and
the lateral side of the psoas major muscle. So, the femoral nerve
can be easily injured or crushed during abdominal surgery. If this
The genitofemoral nerve pierces the psoas major muscle before
entering the pelvis. The iliohypogastric nerve and lateral femoral
cutaneous nerve emerge at the lateral border of psoas major and
then travel laterally. The obturator nerve is at the medial border of
psoas major. None of these other nerves are in the right position
to be injured by the retractor blades. For a picture of these nerves
of the lumbar plexus, see Netter Plate 464.
Psoas major
--------------
This patient has Pott's disease, which is tuberculosis of the spine.
Tuberculosis of the spine frequently occurs in untreated tuber-
culosis in young individuals, especially those on a poor diet. The
tubercle bacilli enter through the respiratory tract and pass from
lungs to systemic circulation. The bacilli tend to lodge in the bone
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 Kidneys and Retroperitoneum Practice Quiz
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marrow of the spine, including the lumbar vertebrae. An infection
in the lumbar vertebrae may pass to the psoas major muscle,
since psoas major takes origin from the lumbar vertebrae. This
infection can cause an abscess in psoas major, which will be
In the lumbar region, tuberculosis may spread from the vertebrae
contained by the fascial sheath of the muscle. The psoas major
into an adjacent muscle to produce an abscess. Pus from the ab-
muscle arises from the bodies of the lumbar vertebrae, passes
scess may travel within the fascial sheath surrounding the affected
under the inguinal ligament, and joins with the iliacus to insert
muscle. A patient presents with pus surfacing in the superomedial
on the lesser trochanter of the femur as the iliopsoas tendon.
part of the thigh. To which muscle did the tuberculosis most likely
Psoas major passes through the superomedial part of the thigh,
spread?
so an infection in this muscle matches with the location of the pus.
None of the other muscles are closely associated with the lumbar
vertebrae or found in the superomedial thigh, so they could not
have been ones infected.
Obturator nerve
------------
The obturator nerve lies along the medial border of the psoas
The nerves of the lumbar plexus are arranged around specific
major muscle. The femoral nerve lies along the lateral border of
muscles of the posterior abdominal wall. Which nerve lies imme-
the psoas major muscle, between psoas major and iliacus. The
diately medial to the psoas major muscle?
genitofemoral nerve pierces psoas major then lies on top of that
muscle. The ilioinguinal nerve emerges at the lateral border of
psoas major, then travels laterally.

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