THE ABDOMEN

Surface Anatomy, Vessels, Muscles, and Peritoneum

TOKUNBO O.S
Anatomy Department, Uniosun
 a rt
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Introduction Up
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The trunk of the body is divided by the

diaphragm into an upper part, called the
thorax, and a lower part called the
abdomen.

Low
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Bony Landmarks Around the Abdomen
• Iliac crest
• Anterior superior iliac
spine (ASIS)
• Pubic crest
• Inguinal ligament
• Costal margin
• Xiphoid process
Surface Anatomy
• Anterior abdominal wall extends from
costal margin to inferior boundaries:
• Iliac crest
• Anterior superior iliac spine
• Inguinal ligament
• Pubic crest
• Superior boundary
• Diaphragm
• Central landmark
• Umbilicus
• Linea alba (white line)
• Tendinous line
• Extends from xiphoid process to pubic
symphysis
The Abdominal Wall
The anterior abdominal wall comprises of:
 Skin
 Superficial fascia
 Abdominal muscles (and their respective
aponeuroses)
 Transversalis fascia
 Extraperitoneal fat, and
 Parietal peritoneum
Fascia
 There is no deep fascia in the trunk
 Superficial fascia comprises of two layers:
 Superficial fatty layer (Camper’s fascia) –
continuous with the superficial fat over the rest
of the body
 Deep fibrous or membranous layer (Scarpa’s
fascia) – fades above and laterally; continuous
with the fascia lata of the thigh just below the
inguinal ligament.

 Called Colles’ fascia in the perineum.

Rectus Sheath

 The rectus sheath encloses the rectus muscles.

 It contains also the superior and inferior epigastric vessels
and anterior rami of the lower six thoracic nerves.
 The sheath is made up from the aponeuroses of the muscles
of the anterior abdominal wall.
 The linea alba represents the fusion of the aponeuroses in
the midline.
 Rectus Sheath
• Above the costal margin: only the external
oblique aponeurosis is present and forms the
anterior sheath.

• Above the pubic symphysis: about halfway

between the umbilicus and pubic symphysis
the layers passing behind the rectus muscle
gradually fade out and from this point all
aponeuroses pass anterior to the rectus
muscle, leaving only the transversalis fascia.

linea semilunaris???
Arteries of the AW

 These include the superior and inferior epigastric arteries

(branches of the internal thoracic and external iliac arteries,
respectively), and the deep circumflex iliac artery (a branch of
the external iliac artery) anteriorly.

 The two lower intercostal and four lumbar arteries supply the
wall posterolaterally.
Veins of the AW

 The abdominal wall is a site of porto-systemic anastomosis.

 The lateral thoracic, lumbar and superficial epigastric tributaries of

the systemic circulation anastomose around the umbilicus with the
para-umbilical veins which accompany the ligamentum teres and
drain into the portal circulation.
Muscles
• Function:
• Help contain abdominal organs
• Move trunk
• Forced breathing
• Increase intra-abdominal pressure
• Abdominal wall
• Anterior (4)
• Innervated by intercostal nerves
• Continuous with layers of intercostal
muscles
• Fibers of layers run in different directions
for strength
• Ends in aponeurosis which contains
rectus abdominis muscle
• Posterior (3)
Anterior Abdominal Wall Muscles
 Rectus Abdominis
• Origin
• Pubic crest, symphysis
• Insertion
• Xiphoid process, costal cartilages of ribs 5-7
• Function
• Flex, rotate trunk, fix and depress ribs, stabilize pelvis,
compress abdomen
• Internal oblique
• Origin
• Lumbar fascia, iliac crest, inguinal ligament
• Insertion
• Linea alba, pubic crest, last 3-4 ribs, costal margin
• Function
• Same for external obliques
Anterior Abdominal Wall
• External oblique
• Origin
• Lower 8 ribs
• Insertion
• Aponeurosis to linea alba, pubic and iliac crest
• Function
• Flex trunk, compress abdominal wall (together), Rotate trunk
(separate sides)
• Transversus abdominis
• Origin
• Inguinal ligament, lumbar fascia, cartilage of last 6 ribs, iliac crest
• Insertion
• Linea alba, pubic crest
• Function
• Compress abdominal contents
Posterior Abdominal Wall
• Iliopsoas
• Psoas major
• Origin
• Lumbar vertebrae, T12
• Insertion
• Lesser trochanter of femur via iliopsoas tendon
• Function
• Thigh flexion, trunk flexion, lateral flexion
• Innervation
• Ventral rami L1-L3
• Iliacus
• Origin
• Iliac fossa, ala of sacrum
• Insertion
• Lesser trochanter of femur via iliopsoas tendon
• Function
• Thigh flexion, trunk flexion
• Innervation
• Femoral nerve (L2 and L3)
• Psoas minor – variable (40-60% do not have)
Posterior Abdominal Wall
• Quadratus lumborum
• Origin
• Iliac crest and lumbar fascia
• Insertion
• Transverse process of upper lumbar vertebrae,
lower margin of rib 12
• Function
• Flex vertebral column, maintains upright
posture, assists in inspiration
• Innervation:
• T12 and upper lumbar spinal nerves (ventral
rami)
Inguinal Canal
 The canal is
approximately 4 cm long
 allows the passage of
the spermatic cord
(round ligament in the
female) through the
lower abdominal wall.
 The canal passes
obliquely from the deep
inguinal ring in a medial
direction to the
superficial inguinal ring.
 Inguinal Canal
 The deep ring: is an opening in
the transversalis fascia. It lies
halfway between the anterior
superior iliac spine and the
pubic tubercle. The inferior
epigastric vessels pass medial
to the deep ring.
 The superficial ring: is not a
ring but a triangular-shaped
defect in the external oblique
aponeurosis lying above and
medial to the pubic tubercle.
 Walls of the Inguinal Canal
 Anterior: external oblique covers
the length of the canal anteriorly.
It is reinforced in its lateral third
by internal oblique.
 Superior: internal oblique arches
posteriorly to form the roof of the
canal.
 Posterior: transversalis fascia
forms the lateral part of the
posterior wall. The conjoint
tendon (the combined common
insertion of the internal oblique
and transversus into the pectineal
line) forms the medial part of the
posterior wall.
 Inferior: the inguinal ligament.
 Contents of the Inguinal Canal

 Spermatic cord in males

 Round ligament in the
female
 Ilioinguinal nerve (L1)
 The Spermatic Cord

External spermatic fascia:

from the external oblique
aponeurosis.

• Cremasteric fascia and

muscle: from the internal
oblique aponeurosis.

• Internal spermatic fascia:

from the transversalis fascia.
The Spermatic Cord

The contents of the

spermatic cord include the:

• Ductus (vas) deferens (or

round ligament).
• Testicular artery
• Pampiniform plexus of
veins
• Lymphatics
• Autonomic nerves.
The Abdominal Aorta
 Continuation of the thoracic aorta
 Descends in the retroperitoneum
 Bifurcates into left and right common
iliac arteries to the left of the midline at
the level of L4
Relations
 Posteriorly - vertebral bodies and IV
discs
 Anteriorly – anterior branches, coeliac
plexus, lesser sac, body of the pancreas,
3rd part of the duodenum, and parietal
peritoneum
 Right – IVC
 Left – duodenojeunal jxn & inf.
Mesenteric vein
The Coeliac Trunk

 Arises from the aorta at

T12/L1
 Divides into 3 terminal
branches after a brief
course;
Left gastric artery
Splenic artery
Hepatic artery
 Superior Mesenteric Artery
Course
 Arises from the abdominal aorta at the level of L1.
 From above downwards, it passes over the left
renal vein behind the neck of the pancreas, over
the uncinate process and anterior to the third part
of the duodenum. It then passes obliquely
downwards and towards the right iliac fossa
between the layers of the mesentery of the small
intestine where it divides into its terminal
branches.
Branches
 Inferior pancreaticoduodenal artery
 Ileocolic artery
 Jejunal and Ileal branches
 Right colic artery
 Middle colic artery
Renal, Gonadal, & Inf. Mesenteric
 Veins of the Abdomen
Inferior Vena Cava
Course
 Formed by the union of the common iliac veins in front
of the body of L5.
 It ascends in the retroperitoneum on the right side of
the abdominal aorta.
 Along its course, from below upwards, it forms the
posterior wall of the epiploic foramen of Winslow and is
embedded in the bare area of the liver in front of the
right suprarenal gland.
 Passes through the caval opening in the diaphragm at
the level of T8 and drains into the right atrium.
Portal Venous Systems

In the circulatory system of animals,

a portal venous system occurs when
a capillary bed pools into another capillary
bed through veins, without first going
through the heart. Both capillary beds and
the blood vessels that connect them are
considered part of the portal venous
system.
 Veins of the Abdomen

Portal Vein
The portal vein is formed behind the neck of the pancreas by the
union of the superior mesenteric and splenic veins. It passes
behind the first part of the duodenum in front of the inferior
vena cava and enters the free border of the lesser omentum.

The vein then ascends towards the porta hepatis in the anterior
margin of the epiploic foramen (of Winslow) in the lesser
omentum. At the porta hepatis it divides into right and left
branches. The veins that correspond to the branches of the
coeliac and superior mesenteric arteries drain into the portal
vein or one of its tributaries
Porto-Systemic Anastomoses
The sites of porto-systemic anastomosis include:

 The lower oesophagus: formed by tributaries of the left gastric (portal) and
oesophageal veins (systemic via the azygos and hemiazygos veins).
 The anal canal: formed by the superior rectal (portal) and middle and inferior
rectal veins (systemic).
 The bare area of the liver: formed by the small veins of the portal system and
the phrenic veins (systemic).
 The periumbilical region: formed by small paraumbilical veins which drain
into the left portal vein and the superficial veins of the anterior abdominal
wall (systemic).
 Clinical Correlates – Caput Medusae
 Appearance of distended
and engorged superficial
epigastric veins, which are
seen radiating from
the umbilicus across the
abdomen.

 The name caput
medusae (Latin for "head of
Medusa") originates from
the apparent similarity
to Medusa's head, which
had venomous snakes in
place of hair.
Lymphatic Drainage
 Skin of the anterolateral abdominal wall above the level of the
umbilicus drains to the anterior axillary lymph nodes.

 Efferent lymph from the skin below the umbilicus drains to the
superficial inguinal nodes.
Lymphatic Drainage
The lymph nodes and trunks
Two main lymph node groups
They are closely related to the aorta vis: the pre-aortic and para-aortic groups.

• The pre-aortic nodes are arranged around the three ventral branches of the aorta and
consequently receive lymph from the territories that are supplied by these branches. This includes
most of the gastrointestinal tract, liver, gall-bladder, spleen and pancreas. The efferent vessels from
the pre-aortic nodes coalesce to form a variable number of intestinal
trunks which deliver the lymph to the cisterna chyli.

• The para-aortic nodes are arranged around the lateral branches of the aorta and drain lymph
from their corresponding territories, i.e. the kidneys, adrenals, gonads, and abdominal wall as well
as the common iliac nodes. The efferent vessels from the para-aortic nodes coalesce to form a
variable number of lumbar trunks which deliver the lymph to the cisterna chyli.
Lymphatic Drainage
Cisterna chyli
 It is a lymphatic sac that lies anterior to the
bodies of the 1st and 2nd lumbar vertebrae.
 It is formed by the confluence of the intestinal
trunks, the lumbar trunks and lymphatics from
the lower thoracic wall.
 It serves as a receptacle for lymph from the
abdomen and lower limbs which is then relayed
to the thorax by the thoracic duct.
Abdominal Quadrants & Regions
• 9 regions
• 4 quadrants
• Draw “line” through navel
• Right upper quadrant
• Left upper quadrant
• Left lower quadrant
• Right lower quadrant
Abdominopelvic Cavity
• Ventral body cavity
• Thoracic
• Abdominopelvic
• Abdominopelvic
• Abdominal
• Liver
• Stomach
• Kidneys
• Pelvic cavity
• Bladder
• Some reproductive organs
• Rectum
Abdominal cavity
The space bounded by:
• Anterolateral abdominal wall
• Posterior abdominal wall
• Diaphragm
• Pelvic walls and pelvic floor.
Subdivided into:
• True abdominal cavity (from diaphragm to linea terminalis)
• Pelvic cavity (below linea terminalis).
 Peritoneum and Peritoneal Compartment

Peritoneum is a continuous serous membrane, composed of two layers:

• Parietal peritoneum, lines abdominal and pelvic wall
• Visceral peritoneum, lines abdominal and pelvic organs.
Peritoneal compartment is part of the abdominal cavity enclosed within the parietal
peritoneum. Contains organs covered with peritoneum and peritoneal structures.
Outside the parietal peritoneum is the extraperitoneal compartment of the abdominal
cavity.
Peritoneal cavity
Peritoneal cavity (PC) - the space between the two peritoneal layers, is a potential
space, into which the organs are tightly packed against each other.
•PC contains thin layer of fluid, which lubricates the peritoneal surfaces and allows
movement of the organs without friction.
•PC is closed in males, but communicates with the external environment in
females through the uterine tubes, uterus and vagina.
•Peritoneum, peritoneal cavity and all the organs are situated in the abdominal
cavity.
 Abdominal Oesophagus
 The esophagus is a muscular tube (approximately 25 cm
long) with an average diameter of 2 cm that conveys food
from the pharynx to the stomach.
 As seen during fluoroscopy (x-ray, using a fluoroscope)
after a barium swallow, the esophagus normally
has three constrictions where adjacent structures produce
impressions:
 Cervical constriction (15cm from incisor teeth)
 Thoracic (broncho-aortic) constriction (22.5cm from
incisor)
 Diaphragmatic constriction (40cm for incisor teeth)
 Blood supply of the abdominal part of
the esophagus is from the left gastric artery, a branch of the
celiac trunk, and the left inferior phrenic artery.

The venous drainage from the submucosal veins of this part
of the esophagus is both to the portal venous system through
the left gastric vein and into the systemic venous
system through esophageal veins entering the azygos vein.

The lymphatic drainage of the abdominal part of the
esophagus is into the left gastric lymph nodes;
efferent lymphatic vessels from these nodes drain mainly to
celiac lymph nodes.

The esophagus is innervated by the esophageal plexus,
formed by the vagal trunks (becoming anterior and posterior gastric
branches), and the thoracic sympathetic trunks
via the greater (abdominopelvic) splanchnic nerves and periarterial plexuses
around the left gastric and inferior phrenic arteries.
 Stomach

Blood supply
The arterial supply to the stomach is exclusively from branches of the coeliac axis. Venous drainage is
to the portal system
Nerve Supply
The anterior and posterior vagal trunks descend along the lesser curve as the anterior and posterior
nerves of Latarjet from which terminal branches arise to supply the stomach.
The vagi provide a motor and secretory supply to the stomach.
 The Duodenum
 First part of the small intestine.
 It is approximately 25 cm long and
curves around the head of the
pancreas.
 Its primary function is in the absorption
of digested products.
 Despite its relatively short length the
surface area is greatly enhanced by the
mucosa being thrown into folds bearing
villi which are visible only at a
microscopic level.
Peptic Ulcer Disease
 Most peptic ulcers occur in the stomach and proximal duodenum. They
arise as a result of an imbalance between acid secretion and mucosal
defenses.

Etiological factor - Helicobacter pylori infection (eradication of this organism,

as well as the attenuation of acid secretion, form the cornerstones of medical
treatment.)
 In a minority of cases the symptoms are not controlled by medical
treatment alone and surgery is required.
Jejunum & Ileum

 Excluding the duodenum, the proximal two-fifths of the small intestine comprises jejunum whereas the
remaining distal three-fifths comprises ileum. Loops of jejunum tend to occupy the umbilical region
whereas the ileum occupies the lower abdomen and pelvis.
 The mucosa of the small intestine is thrown into circular folds – the valvulae conniventes. These are
more prominent in the jejunum than in the ileum.
 The diameter of the jejunum tends to be greater than that of the ileum.
 The mesentery to the jejunum tends to be thicker than that for the ileum.
Lower GIT
Lower GIT
The Caecum and Colon
 In adults, the large bowel measures
approximately 1.5 m.
 The caecum, ascending, transverse,
descending and sigmoid colon have
similar characteristic features. These
are that they possess:
• Appendices epiploicae
• Teniae coli
• Sacculations
The Appendix
The appendix has the following characteristic features:
• It has a small mesentery which descends behind the terminal ileum.
The only blood supply to the appendix, the appendicular artery (a branch
of the ileocolic), courses within its mesentery.
• The appendix has a lumen which is relatively wide in infants and
gradually narrows throughout life, often becoming obliterated in the
elderly.
• The teniae coli of the caecum lead to the base of the appendix.
• The bloodless fold of Treves (ileocaecal fold) is the name given to a
small peritoneal reflection passing from the anterior terminal ileum to
the appendix. Despite its name it is not an avascular structure!
 The Rectum
• The rectum measures 10–15 cm in length. It
commences in front of the 3rd sacral vertebra as a
continuation of the sigmoid colon and follows the
curve of the sacrum anteriorly. It turns backwards
abruptly in front of the coccyx to become the anal
canal.

• The mucosa of the rectum is thrown into three

horizontal folds that project into the lumen - the
valves of Houston.
 The Rectum
• The rectum lacks haustrations. The teniae
coli fan out over the rectum to form anterior
and posterior bands.
• The rectum is slightly dilated at its lower end
- the ampulla, and is supported laterally by the
levator ani.
• Peritoneum covers the upper two-thirds of
the rectum anteriorly but only the upper third
laterally. In the female it is reflected forwards
onto the uterus forming the recto-uterine
pouch (pouch of Douglas). The rectum is
separated from anterior structures by a tough
fascial sheet - the rectovesical (Denonvilliers)
fascia.
 The Anal Canal
The canal is approximately 4 cm long and angled
postero-inferiorly. Developmentally the midpoint of
the anal canal is represented by the dentate line. This
is the site where the proctodeum (ectoderm) meets
endoderm.

 The epithelium of the upper half of the anal canal is columnar, while the lower
half of the anal canal is squamous. The mucosa of the upper canal is thrown into
vertical columns (of Morgagni). At the bases of the columns are valve-like folds
(valves of Ball). The level of the valves is termed the dentate line.
The Anal Canal
 The blood supply to the upper anal canal is from the superior rectal artery
(derived from the inferior mesenteric artery) whereas the lower anal
canal is supplied by the inferior rectal artery (derived from the internal
iliac artery).
 The upper anal canal is insensitive to pain as it is supplied by autonomic
nerves only. The lower anal canal is sensitive to pain as it is supplied by
somatic innervation (inferior rectal nerve).
 The lymphatics from the upper canal drain upwards along the superior
rectal vessels to the internal iliac nodes whereas lymph from the lower
anal canal drains to the inguinal nodes.
The Liver

 The liver predominantly occupies the right

hypochondrium but the left lobe extends to the
epigastrium.
 Its domed upper (diaphragmatic) surface is
related to the diaphragm and its lower border
follows the contour of the right costal margin.
Lobes and Divisions of the Liver
 Liver is the heaviest gland of the body
 Liver is composed of
 Hepatocytes – major functional cells of liver
 Wide variety of metabolic, secretory, and endocrine
functions – secrete bile (excretory product and digestive
secretion)
 Bile canaliculi – ducts between hepatocytes that
collect bile
 Exits livers as common hepatic duct, joins cystic duct
from gallbladder to form common bile duct
 Hepatic sinusoids – highly permeable blood
capillaries receiving oxygenated blood from
hepatic artery and deoxygenated nutrient-rich
blood from hepatic portal vein
Venous Circulation Through Liver
The Gall-Bladder
 Lies Adherent to the undersurface of the liver in the transpyloric plane at the
junction of the right and quadrate lobes.
 The duodenum and transverse colon are behind it.
 Reservoir for bile which it concentrates
 Contains approximately 50ml of bile
 Transports via cystic and then common bile ducts into duodenum
 Comprises a fundus, body and neck
 Blood supply via the cystic artery and small branches of the hepatic arteries
The Biliary Tree
 Common hepatic duct = r. hepatic duct + l. hepatic duct in the
porta hepatis
 Common bile duct = common hepatic duct + cystic duct

 Passes behind the 1st part of duodenum and in the groove

between the 2nd part of duodenum & head of pancreas.
 Ultimately opens at the papilla on the medial aspect of the 2nd
part of the duodenum.
 CBD usually joins with the main pancreatic duct (of Wirsung)
Clinical Correlates

 Hepatitis
 Cholelithiasis/Gallstones
 Cholecystitis
 Cholangitis
 Pancreatitis
The Pancreas