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Posterior Abdominal Wall MOB TCD Posterior Abdominal Wall Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

Posterior Abdominal Wall Muscles MOB TCD Diaphragm Psoas major Psoas minor Quadratus lumborum Transversus abdominus Iliacus

Psoas Major MOB TCD Origin Intervertebral discs, adjoining bodies of T12-L5 vertebrae Medial half, anterior aspect of five lumbar transverse processes Fibrous arches on the sides of the bodies of the four upper four lumbar vertebrae, over four lumbar arteries Inserted into the lesser trochanter of femur Nerve L2,3

Psoas Minor Minor Origin T12 – L1 Insertion Arcuate line MOB TCD Minor Origin T12 – L1 Insertion Arcuate line Iliopubic eminence

Psoas Major Muscle and Fascia MOB TCD The psoas is covered by fascia which is attached medially to the lumbar vertebrae To the fibrous arches Medially along the brim of the pelvis to the arcuate and pectineal lines. Laterally, the fascia is attached to the transverse processes of the lumbar vertebrae. Medial arcuate ligament is a thickening of fascia over the psoas

Psoas Psoas flexes hip when acting from above MOB TCD Psoas flexes hip when acting from above Lumbar plexus is formed inside the substance of psoas A strain of the psoas muscle may be the cause of chronic groin pain You must take care not to mistake it for an adductor strain

Psoas Psoas bursa, between psoas and capsule of hip joint MOB TCD Psoas bursa, between psoas and capsule of hip joint May communicate with the synovial membrane of the joint Psoas abscess will present in the groin

Iliopsoas Iliacus Origin: iliac fossa and iliac crest MOB TCD Iliacus Origin: iliac fossa and iliac crest Inserted into the lateral aspect of the psoas and into the femur below the lesser trochanter; nerve L2,3 Iliopsoas is an active postural or stabilising muscle of the hip which helps to prevent hyperextension of the hip while standing Acting from above, the iliopsoas flexes the hip and may be either a medial or a lateral rotator Acting from below, psoas flexes spine

Iliopsoas MOB TCD In walking, the iliopsoas is used to start swinging the leg forwards On level ground the leg moves forwards like a pendulum to complete the swing Stronger contraction of the iliopsoas is required when running or walking up a hill When climbing stairs, the iliopsoas lifts the leg and places the foot on the stair above

Iliopsoas MOB TCD When preparing to stand from sitting, the iliopsoas pulls the trunk forwards as the femur is fixed The trunk leans forwards and, before standing upright, the centre of gravity of the trunk moves over the feet In sitting up from lying, the iliopsoas pulls on the pelvis and the lower vertebrae in order to pull the trunk up Tyldesley and Grieve, 1989

Iliopsoas MOB TCD Running with the legs lifted high, helps to develop the iliopsoas The iliopsoas is also used in the downbeat of freestyle swimming The iliopsoas is the main muscle involved in straight leg sit-ups These, however, should never be done as they put stress on the lumbar vertebrae and do nothing for the abdominal muscles

Quadratus Lumborum Transverse process L5 Iliolumbar ligament MOB TCD Transverse process L5 Iliolumbar ligament Adjoining part iliac crest Attached to lateral, half of anterior of L1-4 Inserted lower border 12th rib

Quadratus Lumborum Anterior compartment lumbar fascia MOB TCD Anterior compartment lumbar fascia Lateral arcuate ligament Nerve T12, L1-4 Lateral flexion Stabilises 12th rib

Abdominal Aorta Continuation descending aorta T12 median arcuate Ends MOB TCD Continuation descending aorta T12 median arcuate Ends Lower L4 to left midline Common iliacs

Abdominal Aorta Anterior branches Unpaired branches Lateral paired MOB TCD Anterior branches Unpaired branches Lateral paired Postero-lateral paired One posterior unpaired Median sacral

Anterior Branches Abdominal Aorta MOB TCD Coeliac T12 Superior mesenteric L1 Inferior mesenteric L3

Coeliac Trunk Left gastric branches: oesophageal gastric MOB TCD Left gastric branches: oesophageal gastric Common hepatic gives origin: right gastric, gastro duodenal, cystic, right and left hepatic arteries Splenic gives off: pancreatic, left gastro-epiploic, short gastric branches, spleenic branches

Coeliac MOB TCD

Superior Mesenteric Branches Jejunum Ileal MOB TCD Branches Jejunum Ileal Inferior pancreatico-duodenal Ileocolic Right colic Mid colic

Anterior Branches Abdominal Aorta MOB TCD

Paired Branches Lateral Phrenic Middle suprarenal Renal Gonadal MOB TCD Lateral Phrenic Middle suprarenal Renal Gonadal Posterolateral Four Lumbar arteries

Inferior Vena Cava Formed at L5 Right of midline MOB TCD Formed at L5 Right of midline Union of the common iliac veins Passes upwards to the right of the aorta Pierces the right horn of the central tendon Attached to the margins of the central tendon Ends in the postero inferior angle of right atrium

Inferior Vena Cava Tributaries are the common iliac arteries MOB TCD Tributaries are the common iliac arteries Third and fourth lumbar veins Right gonadal vein Right and left renal veins Right suprarenal vein Median sacral Hepatic veins

Anterior to Inferior Vena Cava MOB TCD Root of mesentery Superior mesenteric vessels and branches Right ureter Right gonadal vessels Third part of the duodenum Head of the pancreas and the common bile duct Opening lesser sac Liver

Inferior Vena Cava MOB TCD Posteriorly lies on the bodies of the lumbar vertebra and the right sympathetic trunk Psoas muscles

Inferior Vena Cava MOB TCD

Inferior Vena Cava MOB TCD Forms the posterior boundary of the opening into the lesser sac Then lies posterior to the liver

Kidneys MOB TCD

Kidneys Retroperitoneal Convex lateral border MOB TCD posterior anterior Retroperitoneal Convex lateral border Concave medial hilum on medial aspect Upper and lower poles Anterior and posterior surfaces

Perinephric fat Adipose tissue perinephric fat Renal fascia MOB TCD Adipose tissue perinephric fat Renal fascia Fuses at lateral border Medially fuses with fascia on vessels Fuses above suprarenals Separated by septum Inferiorly open Surrounded by paranephric fat

Kidneys MOB TCD The upper poles are wider than the lower poles and lie nearer the midline The right extends to the lower border of the 11th interspace The left reaches the 11th rib

Kidneys The lower poles are narrower The anterior surface is convex MOB TCD The lower poles are narrower The anterior surface is convex The posterior surface is flat The hilum contains The renal vein, artery and ureter From before backwards From above downwards

Anterior Relations of Kidneys MOB TCD

Right Kidney Anteriorly the hepatic flexure of the large intestine MOB TCD Anteriorly the hepatic flexure of the large intestine The second part of the duodenum The entrance of the common bile duct Superiorly the triangular right suprarenal gland The liver (hepato-renal pouch) The coils intestine

Left Kidney Left suprarenal gland medial border MOB TCD Left suprarenal gland medial border The spleen lateral upper margin The lesser sac from stomach Crossing the hilum The body of the pancreas with the splenic vein posterior to the body The splenic artery along its upper border Left hepatic flexure Coils intestine

Posterior Relations MOB TCD Diaphragm which separates it from the 12th rib and the pleura From medial to laterally psoas muscle Quadratus lumborum and the transversus muscle The subcostal vessels and nerve Ilio hypogastric and Ilioinguinal nerves

Kidneys and Pleura MOB TCD Fracture of 11th rib on left may damage spleen and pleura Left kidney is higher than right Related to more of the pleura Right is pushed down by liver

Posterior Relations of Kidneys MOB TCD

Renal Artery and Vein MOB TCD

Kidneys MOB TCD

Nephron Nephron Glomerulus Proximal convoluted tubules Loop of Henle MOB TCD Nephron Glomerulus Proximal convoluted tubules Loop of Henle Distal convoluted tubule Collecting ducts

Kidney Open at the apex of pyramid into the renal papillae MOB TCD Open at the apex of pyramid into the renal papillae 9-10 minor calyces 2-3 major calyces Pelvis of ureter Ureter starts at the lower pole of the kidney

Blood Supply Blood supply is by the renal artery MOB TCD Blood supply is by the renal artery Three branches enter the hilum Two in front and one behind the renal pelvis Posterior branch One to the upper pole and lower pole One posterior Two segments anteriorly

Intrarenal arteries MOB TCD

Blood Vessels MOB TCD

Nerve Innervation MOB TCD

Embryology MOB TCD Cortex Intermediate mass mesoderm of sacral segments which ascends adult position changes its blood supply Diverticulum of lower end of mesonephric duct Ureters and calyces collecting tubules

Right Suprarenal Gland MOB TCD Triangular Cortex essential to life Medulla sympathetic Inferior vena cava Right crus of diaphragm pleura Bare area of liver Three arteries branches from phrenic, aorta, renal One short vein at hilum enters IVC

Left Suprarenal Gland Semilunar Medial margin of upper pole MOB TCD Semilunar Medial margin of upper pole Lesser sac from stomach Tail of pancreas Left crus of diaphragm Three arteries branches from phrenic, aorta, renal One vein at hilum enters left renal vein

Spleen Convex diaphragmatic surface Concave visceral MOB TCD Convex diaphragmatic surface Concave visceral Completely covered with peritoneum except at hilum where find tail of pancreas and spleenic vessels in lieno renal ligament Lies between 9-11th ribs Along long axis of 10th

Spleen Normally anterior border just above costal margin MOB TCD Normally anterior border just above costal margin Enlarges downwards and to right Visceral related to left kidney, stomach, flexure of left colon and tail pancreas Rupture of kidney irritates pleura under surface left dome of diaphragm; pain referred to left shoulder

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