The abdomen Ⅲ liyingchd@163.com - PowerPoint Presentation

Slide1

The abdomen Ⅲ

liyingchd@163.com

Department of anatomy and neurobiology

O:65985626

Slide2

Slide3

Hepato

-gastric ligament

Hepato

-duodenal ligament

Gastro-phrenic ligamentGastro-splenic ligamentGastro-colic ligament

Greater

omentum & Lesser omentum

Slide4

The

omental

bursa communicates with the greater sac only through the (

epiploic

) omental foramen.Omental (epiploic)foramen

The boundary:Anteriorly --- the hepatoduodenal

ligament, Posteriorly---IVC & the right crus of diaphragmSuperiorly--- liverInferiorly --- 1st part of the duodenum

Slide5

Digestive system

Digestive tube

Mouth

Pharynx

Esophagus

Stomach

Small intestine

Large intestine

Duodenum

Jejunum

Ileum

Cecum

，

Vermiform appendix

,

Colon

,

rectum

,

Anal canal

Slide6

Digestive glands

Major salivary glands

Liver

PancreasFunction: Ingestion - selective intake of food.Digestion – mechanical and chemical breakdown of food into a form the body can use. Absorption – uptake of nutrients into blood and lymph.Compaction – absorption of water and consolidation of wastes into fecal mass.

Defecation – the elimination of the fecal mass.

Slide7

7

（

position and division

3

constrictions of the esophagus:

narrows

position distance from middle inscior first beginning

15cm

second in front of left branchus 25cm

third esophageal hiatus 40cm

three parts:

Cervical parts

：

5cm;

Thoracic parts: 18-20 cm;

Abdominal

parts : only

1-2cm

.

:

Esophagus

Slide8

Ⅱ. Three constrictions

beginning, lies at level of C6, the narrowest part

crossed by left main bronchus, 25cm from incisors, lies at level of intervertebral disc between T4 and T5.

passes through the esophageal hiatus of diaphragm, 40cm from incisors, at level of T10

Carcinoma of esophagus

Slide9

stomach

Shape:

Location:

digestion

gastric juice---chymePeristalsisEnzymatic digestionPH: 2

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Peristaltic movement

ring-like movements

of esophagus - contracting then relaxing to move food downward.

Z-line: at the junction

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11

Cardia

Lesser curvature

Greater curvature

fundus

body

Pyloric canal

Two curvature

Lesser curvature

Greater curvature

Two wall

Anterior wall

Posterior wall

Cardial notch

angula

notch

Pyloric antrum

4 parts

:

cardia

fundus

body

pyloric part—

Pyloric canal

and Pyloric antrum

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Relations of the stomach

Anteriorly

:

Live (right part) Diaphragm (left upper part) Anterior abdominal wall (left lower part) Posteriorly－separated by peritoneum of lesser sac from the following (“stomach-bed”) Pancreas Left suprarenal glandLeft kidneySpleen Transverse colon and transverse mesocolon

Slide14

Abdominal Aorta and branches

Slide15

Left gastric a.

Common

hepatic a.

Splenic a.

Gastroduodenal a.

Proper hepatic a.

Right gastric a.

Left branch

Right branch

Cystic a.

Short gastric a.

Left gastroepiploic a.

Right gastroepiploic a.

Superior pancreaticoduodenal a.

Splenic branches

Celiac trunk

Slide16

Arteries of stomach

Left

and

right gastric arteries

Arise from celiac trunk and proper hepatic artery, respectively. These two vessels run in lesser omentum along lesser curvature , and anastomose end-to-end.

Slide17

Arteries of stomach

Right

and

left

gastro-omental arteries Arise from the gastroduodenal and splenic artery. These two vessels pass into the greater omentum, run parallel to the greater curvature, and anastomose end-to-end.

Slide18

Arteries of stomach

Short gastric arteries

Branches of splenic artery

through the gastrosplenic ligamentSupply the fundus of stomach. Posterior gastric artery (72%) Arise from the splenic artery through the gastrophrenic ligament and supply the posterior wall of fundus of stomach.

Slide19

Venous drainage of stomach

Right

and

left gastric veins

empty directly into hepatic portal vein.Left gastroepiploic and short gastric veins drain into hepatic portal vein via the splenic vein.Right gastroepiploic vein drain into superior mesenteric vein.

Slide20

Lymph drainage of stomach

Accompany the A. along the 2 curvatures

Right

and

left gastric LNRight and left gastroomental LN drain into pancreaticosplenic ,pyloric LN, pancreaticoduodenal LN finally to the celiac LN. lymphatic metastasis

Slide21

Nerve supply of stomach

Parasympathetic innervation

The left vagus N→The

anterior vagal trunk → anterior gastric hepatic branchesThe right vagus N → The posterior vagal trunk → posterior gastric celiac branches

“crow’s foot” → supply the pyloric part

Sympathetic innervationMainly from celiac plexusAfferent and efferent fibers derives from thoracic segments (T5 －L1)

Slide22

Celiac ganglion and plexus

Superior mesenteric ganglion and plexus

Lie anterior to vertebral column and near the arteries

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Slide24

gastrectomy

1.BillrothⅠ 1881

1.Billroth Ⅰ Ⅰ ：1885Laparoyomy :Laparoscopy :Paracentesis:

Slide25

Question 2

1. What are the four parts, five ligaments and arterial supply of the stomach?

2. What’s the bed of stomach?

3. The

lesser omentum is divided into __________ and _______________ ligaments.4. The __________ foramen connects the omental bursa with the peritonial cavity( the great sac).5. The __________ recess (pouch of morison) is the lowest point of the peritoneal cavity in a supine patient.

Slide26

If you do not learn to think when you are young,you may never learn.

---

Thomas  Edison

Slide27

The liver

Wedge-

shaped,largest

single organ ,1,500g,

Function :1.The largest metabolic organ ,nutrients absorbed from the digestive tract are initially conveyed to the liver by the portal vein;2.The largest gland ,secrete bile---yellowish ,brown fluid aids in the emulsification of fat;3.The pirimary site for detoxification;4.The large lymph-producing organ,5.produce RBC prenatally .

Slide28

Liver

★

Position

Most lies in the right hypochondrium and epigastric regionless part extends into the left hypochondrium

Slide29

Liver

★

Surface projection

Upper border

the right midclavicular line --- 5th rib process Lower borderthe right lobe extends just beneath the costal margin, median line ,lower border crosses a point about 3~5cm below the xiphoid In children, larger, extends below the costal arch within in 2cm

Slide30

Liver

Diaphragmatic

surface

Convex and smoothDivided into right and left lobes by falciform lig.superiorlycoronary lig. of

liverBare area

：Posteriorly

Slide31

Visceral surface of liver

left lobe right lobe caudate lobe quadrate lobe

31

Right lobe

Quadrate lobe

Caudate lobe

left lobe

Slide32

Liver

★

Visceral surface

Covered with peritoneum,H-shaped fissures and groovesAnterior (inferior) border –thin and sharpNotch for gallbladder Notch for ligamentum teres

hepatis (round ligament of liver)

Slide33

Liver

1.Left

sagittal

fissure

Anteriorlyfissure for round ligament(remnant of umbilical V )Posteriorly fissure for ligamentum venosum (remnant of

Ductus

venosus)2.Right sagittal fissure Anteriorlyfossa for gallbladder Posteriorly

Sulcus for IVC (inferior vena cava

Slide34

Liver

★

transverse fissure --

Porta hepatis 5 cm long, transversely across the under surface of the liver, ContentsRight and left hepatic ductsLeft and right branches of proper hepatic artery Left and right branches of hepatic portal veinNerves and lymphatic vessels

These structures are surrounded by connective tissue

and called “hepatic pedicle”

Slide35

Blood supply of liver:

1.proper hepatic artery( ← hepatic

A←celiac

trunk)

2.hepatic portal veinA dual supply,the venous supply for75%(dominant) ,The arterial supply account for 25%(lesser) vessels of liver(4)

Slide36

Hepatic

portal vein

General features

the union of superior mesenteric vein SMV and splenic vein passing through the lesser

omentum to the

porta hepatis, divides into right and left branches Has no

valves in hepatic portal system Drains blood from GI

tract from the lower end of oesophagus to the upper end of anal canal, pancreas, gall bladder, bile ducts and spleen

Slide37

2.Hepatic portal vein

Tributaries of hepatic portal v.

1. Superior mesenteric v.

SMV

2. Inferior mesenteric v. IMV 3. Splenic v. 4. Left gastric v. 5. Right gastric v. 6. Cystic v.

7. Paraumbilical

v.

Slide38

Portal-

Caval

venous

anastomoses

1. Site at the esophagus left gastric vein → esophageal venous plexus → esophageal vein → hemiazygos

vein → superior vena cava

Esophageal varices,---bleeding 2. At rectum splenic vein → inferior mesenteric vein →

superior rectal vein → rectal venous plexus → inferior

rectal and anal veins → internal iliac vein → inferior vena cava

Hemorroid ---Hemorrage

Portal hypertension

Slide39

Portal-

Caval

venous

anastomoses

3. At paraumbilical venous rete paraumbilical vein→periumbilical venous rete→thoracoepigastric

and superior epigastric vein →intercostal

vein--- superior vena cavaCaput medusa4.retroperitoneal anastomosis the retroperitoneal branches of the colic veins pancreaticoduodenal veins -----the lumbar veins,, twigs of colic veins (portal) anastomosing

with systemic retroperitoneal veins Intestinal bleeding

pancreaticoduodenal veins

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3

Intrahepatic

bile duct

Slide43

4

hepatic veins

Slide44

Liver

The segments of the liver

The

segments of the liver, bases upon the principal divisions of the proper hepatic artery and accompanying hepatic ducts and hepatic portal vein－Glisson system.The hepatic vein do

not follow the same pattern : their main tributaries tend to run rather

intersegmental of the three ducts .

Slide45

Couinaud

segments 8 by controversial

Slide46

Peritoneal Relations of the Liver

The falciform ligament attaches the liver to the anterior abdominal wall

Coronary ligaments attach the liver to the diaphragm

Slide47

Peritoneal relations of the liver

-Bare area

-

Subphrenic

recessSubhepatic space

Slide48

Ligaments of liver

Falciform

ligament of liver

from anterior abdominal wall (umbilicus) to liverFree border containsround ligament of liverCoronary ligament Left and right triangular ligaments －formed by left and right extremity of coronary ligament

Ligaments

Slide49

Hepatorenal

recess

－

lies between the right lobe of liver, right kidney, and right colic flexure, and is

the lowest parts of the peritoneal cavity in supine positionMorrison ‘s pouch

Slide50

Hepatorenal

recess

Paracolic

gutters are formed by the ascending and descending colons

Slide51

Transplantation of liver

1

2

3

Cirrhosis (or cancer )of liver

Slide52

Relations of liver

Diaphragmatic surface

－

separated by diaphragm from the following Right costodiaphramatic recess and lungCardiac baseVisceral surfaceLeft lobe is related to the stomach and abdominal part of esophagus Right lobe is related to the right colic flexure anterioly, gallbladder and superior duodenal flexure medially, right kidney, superarenal gland posteriorly

Slide53

★

Biliary

duct and gallbladder

★ Consists of Gallbladder, Left and right hepatic ducts Common hepatic duct Common bile duct

Slide54

★

Gallbladder

★

Position Lies in fossa for gallbladder on visceral surface of liver★ Four parts1. Fundus of gallbladder protrude below the inferior margin of the liver, behind the point where the lateral margin of the right rectus

abdominis meets the costal arch(Murphy ’ point).2.Body

of gallbladder 3.Neck of gallbladder 4. Cystic duct Function: stores and concentrates bile

Slide55

★

Biliary duct system

Left

and right hepatic ducts unite outside of liver to form common hepatic duct common hepatic duct Cystic duct joins common hepatic duct to form common bile duct

Slide56

★

Biliary duct system

Hepatopancreatic

ampulla (Vater) Common bile duct and pancreatic duct run obliquely through the wall of the descending part of duodenum ,unite to form the hepatopancreatic ampulla --- rounded by sphincter of

hepatopancreatic ampulla

(Oddi), has sphincteric for regulating flow, opens at the major duodenal papilla

Obstruction of the biliary system results in the clinic condition of jaundice (yellow skin) .

Slide57

Cystohepatic

triangle

Calot’s

TriangleBoundariesCommon hepatic duct on the left Cystic duct on the rightLiver superiorlyContent: cystic artery

Slide58

Divisions and relations of common bile duct

Divisions

Supraduodenal

segment Retroduodenal segment Pancreatic segment Intraduodenal segment

Slide59

Bile is secreted by the liver cells

Common hepatic duct

When fat enters small intestine, gallbladder contracts, sphincter of hepatopancreatic ampulla relax

Common bile duct

Major duodenal papilla

Biliary ductuli

Right and left hepatic ducts

Cystic duct

Gallbladder (store, concentrate)

Duodenal cavity

★

Bile circulation

Main Pancreatic duct

the

hepatopancreatic

ampulla

Slide60

Magnetic resonance

cholangiopancreatogram

.

Slide61

Pancreas

Function

The pancreas is both an exocrine and an endocrine gland

The exocrine portion of the gland produces a secretion that contains enzymes that are capable of hydrolyzing proteins, fats, and carbohydratesThe endocrine portion of the gland, the pancreatic islet, produces the hormones insulin and glucagons that play a key role in carbohydrate metabolism

Slide62

★

Pancreas

Shape

A soft yellowish lobulated gland★ PositionLies in epigastric and left hypochondriac regions, behind the peritoneum on the posterior abdominal wall, roughly at the level of of L1~L2

Slide63

★

Pancreas

★

Four parts

Head--Lies within the C-shaped curvature of duodenum.Uncinate process A projection to the left from the lower part of the head behind the superior mesenteric vessels.Neck--narrow part, overlies the superior mesenteric vessels and beginning of the portal veinBody--triangular in cross section, passes upward

ang to the left across the midlineTail

--extends to the hilum of spleen in the splenorenal ligament

Slide64

Pancreas

Pancreatic duct

Main Pancreatic

duct

Begins at tail and throughout gland Joins common bile duct before entering descending part of duodenum at major duodenal papillaAccessory pancreatic ductWhen present, drains head of pancreas separatelyOpens 2cm above main duct at lesser duodenal papilla

Slide65

Blood supply of pancreas

Arteries

1.Mainly from

splenic

A 2.Superior pancreaticoduodenal a.(from gastroduodenal A)Inferior pancreaticoduodenal a.(from SMA)Veins－ draining into superior mesenteric and splenic veins –potal vein.

Slide66

CT scan of pancreas

.

Slide67

Vessels of pancreas

1,

2,

Slide68

The Small

Intestine

About 5-7m long,

Divided into

Duodenum Jejunum Ilium Duodenum

Jejunum

IliumThe major part of digestion occurs , extends from the pylorus to the ileocecal junction .permanent circular folds and

villi

Slide69

duodenum

Features:

25cm

long,the

widest and fixed part of small intestine.Pursue a C-shaped course around the head of pancreas.Has 4 parts

Slide70

Duodenum

Four parts

Superior part 1st 5cm,L1 vertebraeSuperior duodednal flexure Descending part 2nd 7~10cm, L2~3

Inferior

part 3rd 6~8cm,L3 to the left Ascending part 4th duodenojejunal flexure

Ligament of tretz

Slide71

Suspensory

muscle of

duodenum

(ligament of Treitz), is composed of a skeletal muscle from diaphragm, and a fibromuscular band of smooth muscle from the duodenum. a surgical landmark, descends from the right crus of diaphragm to duodenal termination.

Slide72

duodenum

superior part

Anteriorly

Quadrate lobe of liveGallbladderDuodenal cap (radiography )2cm,intraperitoneal,mobileSite of duodenal ulcer

Slide73

duodenum

Medially

Head of pancreas

Common bile duct and pancreatic duct

Laterally Right colic flexure1.Major duodenal papilla(opening)Hepatopancreatic

ampulla

(Vater ampulla)---united of the bile and pancreatic ducts2.Minor duodenal papilla

Relations of descending part

Slide74

duodenum

Relations of horizontal part

Anteriorly

Root of mesentery

Superior mesenteric a. and v.

ascending part

Right — Head of pancreas and abdominal aortaLeft — left kidney and ureter

Slide75

Blood supply of duodenum

Arteries

Superior

pancreaticoduodenal

a.Inferior pancreaticoduodenal a.Veins－follow arteries, draining directly into superior mesenteric and hepatic portal veins Lymph drainadge follow the arteries to celiac LNNerve innervation: superior mensenteric plexus

celiac plex

Slide76

Jejunum

and

ilium

76The jejunum and ileum lies free in the abdomen. They are attached to the posterior abdominal wall by the mesentery

.Intraperitoneum

Slide77

Jejunum and

ileum

jejunum

is shorter , emptier, more vascular (redder in vivo), more thickly walled .

Slide78

78

Jejunum

and

ileum

CharacteristicJejunum

Ileum

Position

Upper 2/5

Lower 3/5

caliber

2~4cm

2~3cm

Wall

Thicker and heavy

Thin and light

Circular folds

Large, tall and large

villi

low

，

sparse, less abundant

villi

Vascularity

Greater

Less

Colour

Deeper red

Paler

vasas

recta

Arcades

Fat in

mensentery

Long

A few large loops

less

Short

Many short loops

more

Slide79

Mesentery

The

mensentery

-suspends the small intestine from the posterior abdominal wall-Broad and a fan-shaped;vasculature vessels are between the two layers of peritoneum. Root of mesentery 15 cm long

Directly obliquely run from left side of L2 to right sacroiliac joint

Slide80

Superior

mesenteric a.

Inf. pancreaticodudenal a.

Jejunal and ileal a.

Ileocolic a.

Appendicular a.

Right colic a.

Middle colic a.

Superior

Mesenteric v.

Slide81

81

large

intestine

Approximately 1.5m long,

Five parts: Cecum Vermiform appendix Colon Rectum

Anal Canal

formation, transport, and evacuation of feces . the absorption of water and the secretion of mucus

Slide82

Paracolic

gutters are formed by the ascending and descending colons

Slide83

83

Features of

：

1.

Teniae coli: 3 longitudinal smooth muscles

2. haustra

: sacculation 3. Omental appendices: small fatty projections

Teniae

coli

haustra

of colon

omental

appendices

Slide84

84

（一）

Cecum

first part of large intestine, Lies in right iliac

fossa.Free

and has no

mensentery--- mobile cecum The ileum enters the cecum

obliquely, and partly invaginates into it, forming the ileocecal valve

－consists of two folds.

ileocecal valve

Slide85

Appendix

85

a blind

diverticulummesoappendix

the

base of appendix ： Lies deep to a point that 1/3 of the way along the oblique line joining the right anterior superior iliac spine to

the umbilicus .(Mcburney’s point)

The base of the appendix lies at the point of convergence of three

teniae

coli

Slide86

86

（

二）

vermiform

appendix orifice

appendix

is a narrow blind tube, usually 6 ~ 8cm long. It opens into the

cecum

。

position:

very variable in position, frequently lies in the

retrocecal

recess

or extend into the lesser

pelvis.

Slide87

87

colon

1

、asccending colon2、transverse colon

3、descending colon 4、sigmoid colon right colic flexureleft colic flexure

Slide88

Inferior mesenteric a

.

Left colic a.

Sigmoid a.

Superior rectal a.

Inferior mesenteric v.

Slide89

Slide90

Hepatogastric

ligament

Hepatoduodenal

ligament

Slide91

Relations of common bile duct

Supraduodenal segment

Descends along the right margin of hepatoduodenal lig.

To the right of proper hepatic a.Anterior to hepatic portal v.Retroduodenal segment Behind the superior part of duodenumAnterior to the vena cavaTo the right of the hepatic portal v.

Slide92

Relations of common bile duct

Pancreatic segment

Lies in a groove between posterior surface of head of pancreas and duodenum

Intraduodenal segment

Enters the wall of descending part of duodenum obliquely where jions the pancreatic duct to form the hepatopancreatic ampulla Opens at the major duodenal papilla

Slide93

spleen

Diaphragmatic surface

Visceral surface

Anteriorly

－fundus of stomachPosteriorly－left suprarenal gland and kidneyInferiorly－tail of pancreas and left colic flexure

Slide94

Ligaments of spleen

Gastrosplenic

ligament

－

connects the fundus of stomach to hilum of spleen. the short gastric and left gastroepiploic vessels pass through it.Splenorenal ligament －extends between the hilum of spleen and left kidney.

The splenic vessels

tail of pancreasPhrenicosplenic ligament Splenocolic ligament

Slide95

★

You must identify follow structures

！

Liver

Falciform lig. of liverligamentum teres hepatic(round ligament )porta hepatisCoronary ligamentNothch for gallbladderGallbladderFundus of gallbladderBody of gallbladderNeck of gallbladder

Cystic ductRight and left hepatic ducts

Common hepatic ductCommon bile ductPancreasHeadUncinate processNeckBodyTailPeritoneumLessor omentum

Omental foramenGreater omentumMesenteryMesoappendix

Gastrosplenic ligamentrectovesical pouchRectouterine pouchVesicouterine pouch

Slide96

1.What is the extension of the root of the mesentery?

The mesentery extends about 15 cm downward and to the right from the

duodenojejunal

flexure to the

ileocolic junction . The intestinal border is many times longer (6 or 7 m.) than the root of the mesentery; hence the mesentery is pleated.2 Where are the junctions between the foregut and midgut and between the

midgut and hindgut?

The foregut-midgut and celiac-superior mesenteric junction is at the middle of the duodenum, superior to the major duodenal orifice. The midgut-hindgut and superior-inferior mesenteric junction is near the left end of the transverse colon.3. How is the liver maintained in position?

The liver is maintained in position by being (1) joined to the posterior abdominal wall by veins (hepatic and caval

) and ligaments (coronary and triangular), (2) supported inferiorly by viscera (e.g., the right kidney and colic flexure), and (3) suspended by ligaments (falciform and teres)