Abdominal wall 山东大学医学院 解剖教研室 李振华

Anterior wall Layers ( from superficial to deep) Skin Superficial fascia Anterolateral muscles Transversalis fascia 腹横筋膜 Extraperitoneal fascia 腹膜下筋膜 Parietal peritoneum 壁腹膜

Superficial fascia－divisions below umbilicus Superficial fatty layer (Camper’s) Membranous layer (Scarpa’s)

Muscles of abdomen Anterolateral group Obliquus externus absominis 腹外斜肌 Oblequus enternus abdominis腹内斜肌 Transversus abdominis腹横肌 Rectus abdominis 腹直肌

Posterior group Quadiatus lumborum 腰方肌 Psoas major 腰大肌

Obliquus externus absominis 腹外斜肌 General direction of fibers: downward, forward and medially (run down and inward) Structures Inguinal ligament 腹股沟韧带 Lacunar ligament 腔隙韧带 Superficial inguinal ring 腹股沟浅环 －triangular-shaped defect in aponeurosis of obliquus externus abdominis above pubic tubercle

Obliquus internus abdominis 腹内斜肌 Deep to obliquus externus abdominis General direction of fibres: upwards, forwards and medially

Transversels abdominis 腹横肌 Deep to obliquus internus

Inguinal falx 腹股沟镰: arch over spermatic cord, inserted with transverses abdominis fiber into medial part of pecten of pubis Cremaster 提睾肌: around the spermatic cord and testis

Rectus abdominis 腹直肌 Position: lie on to either of midline Origin: pubic crest and symphysis Insertion: xiphoid and 5th-7th costal cartilages Has 3-4 tendinous intersections 腱划 linea semiluaris 半月线

Similar functions for above four pairs of muscles Support and compress the abdominal viscera Increase intra-abdominal pressure, aid in expulsive efforts-vomiting, coughing, sneezing, defecation, urination and childbirth. Depress ribs, assist in (the act of force(4)expiration. Flex, lateral flex, and rotate vertebral column

Sheath of rectus abdominis 腹直肌鞘 Ant layer－formed by fusion of aponeurosis of obliquus externus abdominis and anterior leaf of aponeurosis of obliquus internus abdominis Post layer Formed by fusion of posterion leaf of aponeurosis of obliquus internus abdominis and aponeurosis of transverses abdominis Absent in about 4-5cm below the umbilicus, where aponeuroses of all three muscles form anterior layer the lower free border named arcuate line Below this line rectus abdominis in contact with transverse fascia

Linea alba 白线 －tendinous raphe between right and left recti from xiphoid to pubic symphysis.

Inguinal region 腹股沟区 Boundaries Inguinal ligament Lateral margin of rectus abdominis A horizontal line stretching from anterior iliac spine to laeral margin of rectus abdominis

Descent of testes Seven-week embryo showing the testis before its descent from the dorsal abdominal wall

Fetus at 28 week the testis passing through the inguinal canal

Newborn

Inguinal canal 腹股沟管 Position: oblique passage, 4cm long, located 1.5cm above medial half of inguinal lig.

Boundaries Ant wall Aponeurosis of obliquus externus abdominis Obliquus internus abdominis (lateral third of wall)

Post wall Transverse fascia Inguinal flax medially Roof－arched lower fibers of obliquus internus and transversua abdominis Floor－inguinal lig．

Two openings Superficial inguinal ring 腹股沟浅环 Deep inguinal ring 腹股沟深环 －defect in transverse fascia 1.5cm above midpoint of inguinal ligament

Structures passing through the inguinal canal Spermatic cord 精索 and ilioinguinal nerve髂腹股沟神经 in males Round ligament of uterus 子宫圆韧带and ilioinguinal nerve髂腹股沟神经 in females

Inguinal Triangle (of Hesselbach) 腹股沟三角 Boundaries Inguinal ligament inferiorly Lateral border of rectus abdominis medially Inferior epigastric artery laterally

Indirect inguinal heinia and direcet inguinal heinia

Superficial vessels and cutaneous nerves Arteries Superficial epigastric a. Superficial iliac circumflex a. Veins Thoracoepigastric v. Superficial epigastric v. Cutaneous nerves Anterior and lateral cutaneous n. of lower six thoracic Iliohypogastric n. (first lumb nerves)

Deep vessels and nerves Arteres Superior and inferior epigastric arteris Lower posterior intercostal a. Subcostal a. Four lumbar a.

Nerves Iliohypogastric n. 髂腹下神经 Ilioinguinal n. 髂腹股沟神经 Arises from lubar plexus Passes forward in the interval between obliquus internus and tranversus abdominis Pieces obliquus internus abdominis 2.5 cm medial to anterior superior iliac spine Pieces aponeurosis of obliquus externus abdominisabout 2.5 cm above superficial inguinal ring Ilioinguinal n. 髂腹股沟神经 Runs parallel with iliohypogastric n. at a lower level Enters inguinal canal and emerges through superficial inguinal ring Genitofemoral n. 生殖股神经

Layer ? Median or midline incision Subcostal incision Muscle-splitting incision Left paramedian incision Transverse incision Suprapubic incision

Abdomen 2 山东大学医学院 解剖教研室 李振华

Abdominal aorta 腹主动脉 Continuation of thoracic aorta at aortic hiatus of diaphragm in front of T12 Terminates at lower border of L4 vertebra by dividing into right and left common iliac arteries

Parietal branches Inferior phrenic a. 膈下动脉(one pair) Lumbar a. 腰动脉(four pairs of arteries that supply the posterior abdominal wall) Median sacral a. 骶正中动脉

Visceral branches Paired branches Middle suprarenal artery 肾上腺中动脉 Testicular (ovarian) artery 睾丸（卵巢）动脉

Unpaired branches Celiac trunk 腹腔干 －a short thick vessel that arises from the front of aorta, at the level of T12 Superior mesenteric a. 肠系膜上动脉－arises from the front of aorta, at the level of L2 Inferior mesenteric a. 肠系膜下动脉 －arises from the front of aorta, at level of L3

Celiac trunk Left gastric a. Left branch Right branch Short gastric a. Common hepatic a. Cystic a. Splenic a. Right gastric a. Splemic branches Proper hepatic a. Gastroduodenal a. Left gastrioeploic a. Superior pancreaticoduodenal a. Right gastroepiploic a.

Celiac trunk

Superior mesenteric a. Superior Middle colic a. Mesenteric v. Inf. pancresticodudenal a. Superior mesenteric a. Right colic a. Jejunal and ileal a. Ileocolic a. Appendicular a.

Inferior mesenteric a. Inferior mesenteric v. Left colic a. Sigmoid a. Superior rectal a.

Colic marginal artery

Relations of abdominal aorta Anteriorly (from above downward) Pancreas Ascending part of duodenum Radix of mesentery Posteriorly Upper four lumber vertebrae On its right Inferior vena cava On its left Left sympathetic trunk

Veins of abdomen and pelvis Internal iliac vein 髂内静脉 Parietal tributaries: accompany with arteries Visceral tributaries →superior rectal vein→inferior mesenteric v. ①Rectal venous plexus →inferior rectal vein→internal iliac v. 直肠静脉丛 →anal vein→internal pudendal v. ②Vesical venous plexus 膀胱静脉丛→vesical v. ③Uterine venous plexus 子宫静脉丛→uterine v.

External iliac vein 髂外静脉– accompany the artery Common iliac vein 髂总静脉– formed by union of internal and external iliac veins in front of sacroiliac joint, end upon L4~L5 by uniting each other to form inferior vena cava

Inferior vena cava 下腔静脉 Formed by union of two common iliac veins anterior to and just to the right of L4~L5 Ascends on the right side of aorta, pierces vena cava foramen of diaphragm opposite the T8 and drains into the right atrium Conveys blood from the whole body below the diaphragm to the right atrium

Chief tributaries Parietal Visceral Paired inferior phrenic v. 膈下静脉 paired lumbar v. 腰静脉 (four) Visceral Right and left renal veins 左、右肾静脉 Right suprarenal vein 右肾上腺静脉 (left drain into left renal vein) Right testicular or ovarian v右睾丸（卵巢）静脉. (left drain into left renal vein) Hepatic veins 肝静脉: right, left and intermediate

Relations of inferior vena cava Anteriorly (cranially to caudally) Liver Head of pancreas Horizontal part of duodenum Right testicular (or ovarian) a. Radix of mesentery Posteriorly Right crus of diaphragm Upper four lumber vertebrae Left sympathetic trunk Parietal branches of abdominal aorta On its right Psoas major Right kidney Right suprarenal gland On its left Abdominal aorta

Hepatic portal vein 肝门静脉 General features Formed behind the neck of pancreas by the union of superior mesenteric vein and splenic vein Ascends upwards and to the right, posterior to the first part of duodenum and then enters the lesser omentum to the porta hepatis, where it divides into right and left branches There are no functioning valves in hepatic portal system Drains blood from gastrointestinal tract from the lower end of oesophagus to the upper end of anal canal, pancreas, gall bladder, bile ducts and spleen

Variation and anomalies of hepatic portal vein

Tributaries of hepatic portal vein 1. Superior mesenteric v. 肠系膜上静脉 2. Inferior mesenteric v. 肠系膜下静脉 3. Splenic v. 脾静脉 4. Left gastric v. 胃左静脉 5. Right gastric v.胃右静脉 6. Cystic v. 胆囊静脉 7. Paraumbilical v. 附脐静脉

Portal-systemic anastomoses 1. At the lower end of the oesophagus Hepatic portal vein → left gastric vein → esophageal venous plexus → esophageal vein → azygos vein → superiorvena cava 2. At rectal venous plexus Hepatic portal vein → splenic vein → inferior mesenteric vein → superior rectal vein → rectal venous plexus → inferior rectal and anal veins → internal iliac vein → inferior vena cava 3. At periumbilical venous plexus Hepatic portal vein→paraumbilical vein→periumbilical venous plexus→ thoracoepigastric and superior epigastric vein → superiorvena cava superficial epigastric and inferior epigastric veins → inferior vena cava

4. Portal-retroperitoneal anastomosis Between the retroperitoneal branches of the colic veins and the lumbar veins, pancreaticoduodenal veins with the renal veins and the subcapsular veins of the liver with the phrenic veins twigs of colic veins (portal) anastomosing with systemic retroperitoneal veins

The lymphatic drainage of abdomen Lymphatic drainage of abdominal wall To axillary lymph node from region above umbilicus To superficial inguinal lymph node from region below umbilicus To lumbar lymph node from post wall of abdomen

Lymphatic drainage of abdominal viscera Lumbar lymph nodes 腰淋巴结 Lie on posterior abdominal wall, along the abdominal aorta and inferior vena cava Receive lymph from kidneys, suprarenal glands, testes, ovarirs, fundus of uterus, ovary, and common iliac nodes Right and left lumbar trunks formed by efferent vessel Paired viscera－drain to the lumbar lymph nodes

Celiac lymph nodes 腹腔淋巴结 －situated around the celiac trunk Superior mesenteric lymph node 肠系膜上淋巴结 －situated around superior mesenteric a. Inferior mesenteric lymph node 肠系膜下淋巴结 －situated around inferior mesenteric a. Intestinal trunk 腹腔干 －formed by efferent vessel of celiac, superior and inferior lymph nodes

Thoracic duct 胸导管 Begins in front of L1 as a dilated sac, the cisterna chyli, which formed by joining of left and right lumbar trunks and intestinal trunk Enter thoracic cavity by passing through the aortic hiatus of the diaphragm and ascends along on the front of the vertebral column, between thoracic aorta and azygos vein Travels upward, veering to the left at the level of T5 At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angle Just before termination, it receives the left jugular, subclavian and bronchomediastinal trunks Drains lymph from lower limbs, pelvic cavity, abdominal cavity, left side of thorax, and left side of the head, neck and left upper limb

Spleen 脾 Location: lies in the left hypochondriac region (between stomach and diaphragm) deep to the 9th to 11th rib, its long axis corresponds roughly to the 10th rib Shape－reddish in colour

Two surfaces Diaphragmatic: smooth, convex Visceral: concave, hilum of spleen Two extremities Anterior－wider Posterior－rounder Two border Superior－has 2-3 splenic notch 脾切迹, which serve as a landmark on palpation when it is enlarge; normally it is not palpable Inferior－rounder Functions: the spleen is considered to be important in: Formation of lymphocytes and monocyte Phagocytosis of bacteria, inert particles and white blood cells and platelets Destroying effete or abnormal red blood cells Making antibodies

Ralationships of spleen Diaphragmatic surface－diaphragm Visceral surface Anteriorly－fundus of stomach Posteriorly－left suprarenal gland and kidney Inferiorly－tail of pancreas and left colic flexure

Nervers of abdomen Lumbar plexus 腰丛 Formation: formed by anterior rami of L1-L3, a part of anterior rami of T12and L4 Position: lies within substance of psoas major

Branches Lateral femoral cutaneous 股外侧皮神经 Femoral n. 股神经 Iliohypogastric n. 髂腹下神经Supplies lower part of anterior abdominal wall Ilioinguinal n. 髂腹股沟神经Passes through inguinal canal to supply skin of the groin and scrotum Lateral femoral cutaneous 股外侧皮神经 Femoral n. 股神经 Obturator n. 闭孔神经 Genitofemoral n. 生殖股神经

Lumbar sympathetic trunk 腰交感干 Made up of paired chains with four to five lumbar ganglia anterolateral to vertebral column Enters abdomen via the diaphragm and as a continuation of he thoracic part Passes inferiorly behind common iliac vessels and terminations by joining to form unpaired ganglion impar, anterior to sacrum

Abdomen 3 山东大学医学院 解剖教研室 李振华

Relationships of abdominal viscera First layer－live, gallbladder, stomach Second layer－duodenum, pancreas, spleen Third layer－suprarenal gland, kidney, ureter, inferior vena cava, abdominal aorta, nerves and lymphatics

Relationships of the stomach Anterior: Live (right part) Diaphragm (left upper part) Anterior abdominal wall (left lower part) Posterior－separated by peritonum of lesser sac from the following (“stumach-bed”) Pancreas Left suprarenal gland Left kidney Spleen Transverse colon and transvers mesoclon

Arteries of stomach Left and right gastric arteries arise from celiac trunk and proper hepatic artery, repectively. These two vessels run in lesser omentum along lesser curvature , and anastomose end-to-end.

Right and left gastroepiploic arteries arise from the gastroduodenal and splenic artery, repectively. These two vessels pass into the greater omentum, run parallel to the greater curvature, and anastomose end-to-end. Short gastric arteries, branches of splenic artery, course through the gastrosplenic ligament and supply the fundus of stomach. Posterior gastric artery (72%) arise from the splenic artery, course through the gastrophrenic ligament and supply the posterior wall of fundus of stomach.

Venous drainage 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 join either superior mesenteric vein.

Lymphatics of stomach Right and left gastric ln. lie along the same vessels and finally to the celiac ln. Right and left gastroomental ln. lie along the same vessels, the former drain into subpyloric ln., the latter drain into splinic ln. Supra- and subpyloric ln. receive lymphatics from pyloric part and finally to the celiac ln. Splenic ln. receive lymphatics from fundus and left third of stomach, and finally to the celiac ln.

Nerve supply Parasympathetic innervation by anterior (left) and posterior (right) vagal trunks The anterior trunk divides into anterior gastric and hepatic branches The posterior trunk divides into posterior gastric and celiac branches The anterior and posterior gastric branches descend on the anterior and posterior surfaces of the stomach as a rule about 1 to 2 cm from the lesser curvature and parallel to it in the lesser omentum as far as thr pyloric antrum to fan out into branches called “crow’s foot” to supply the pyloric part Sympathetic innervation Mainly from celiac ganglia Affent and effent fibers derives from thoracic segments (T5 －L1

The duodenum Relationships of superior part Anteriorly Posteriorly Quadrate lobe of live Gallbladder Posteriorly Commom bile duct Gastroduodenal a. Hepatic portal v. Inferior vena cava Superioely Omental foramen Inferiorly Head of pancreas

Relationships of descending part Anteriorly Live Transverse colon and mesocolon Loops of small intestine Posteriorly Right renal hilum and ureter Right renal vessels Medially Head of pancreas Common bile duct and pancreatic duct Laterally Right colic flexure

Relationships of horizontal part Superiorly Head of pancreas Inferiorly Loops of small intestine Anteriorly Radix of mesentery Superior mesenteric a. and v. Posteriorly Right ureter Inferior vena cava Abdominal aorta

Relationships of ascending part Right Left Head of pancreas and abdominal aorta Left Left kidney and ureter

Relationships of liver Diaphragmatic surface－separated by diaphragm from the following Right costodiaphramatic recess and lung Cardiac base Visceral surface Left lobe is related to the stomach and abdominal part of esophagus Right lobe is related to the right colic flexure anteroly, gallbladder and superior duodenal flexure medially, right kidney, superarenal gland posteriorly

Blood supply Arteries Superior pancreaticoduodenal a. Inferior pancreaticoduodenal a. Veins－follow arteries, draining directly into superior mesenteric and hepatic portal veins

Divisions and 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 duodenum Anterior to the vena cava To the right of the hepatic portal v.

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

Divisions and relations of pancreas Head of pancreas Located in C-shapes curvature of doudenum Anteriorly Transverse mesocolon Posteriorly Inferior vena cava Right renal vessels Common bile duct Neck of pancreas Anteriorly－pylorus Posteriorly－commencement pf hepatic portal v. (formed by union of splenic and superior mesenteric veins

Body of pancreas Anteriorly Posteriorly Superiorly Separated from stomach by omental bursa Posteriorly Abdominal aorta Left suprarenal gland Left kidney Left renal vessels Spleen vein Superiorly Celiac trunk Celiac plexus Splenic a.

Tail of pancreeas Runs in spleicorenal ligament to reach hilum of spleen Accompanies with splenic vessels

Relationships of spleen Diaphragmatic surface－diaphragm Visceral surface Anteriorly－fundus of stomach Posteriorly－left suprarenal gland and kidney Inferiorly－tail of pancreas and left colic flexure

Celiac trunk Left gastric a. Left branch Right branch Short gastric a. Common hepatic a. Cystic a. Splenic a. Right gastric a. Splemic branches Proper hepatic a. Gastroduodenal a. Left gastrioeploic a. Superior pancreaticoduodenal a. Right gastroepiploic a.

Superior mesenteric a. Superior Middle colic a. Mesenteric v. Inf. pancresticodudenal a. Superior mesenteric a. Right colic a. Jejunal and ileal a. Ileocolic a. Appendicular a.

Inferior mesenteric a. Inferior mesenteric v. Left colic a. Sigmoid a. Superior rectal a.