2.3 Peritoneal cavity 2.4 Liver and gallbladder 2.5 Stomach and spleen Abdomen 2 2.3 Peritoneal cavity 2.4 Liver and gallbladder 2.5 Stomach and spleen Albert van Schoor GNK 288 (SA4 Anatomy dissection)

2.3 Peritoneal cavity and Disposition of abdominal organs 2.3.1 Peritoneum 2.3.2 Organs and relations 2.3.3 Peritoneal specialisation 2.3.4 Radiographic anatomy

2.3.1 Peritoneum Define the terms: Omentum and Mesentery Identify the parietal and visceral peritoneum Identify and briefly discuss the attachments of the greater and lesser omentum

Intraperitoneal organs Retroperitoneal organs 2.3.1 Peritoneum Serous membrane that lines the abdominopelvic cavity and invests the viscera Parietal peritoneum Visceral peritoneum Intraperitoneal organs Stomach, spleen Retroperitoneal organs Kidneys, ascending & descending colon

Mesentry of jejenum and ileum Transverse mesoclolon Sigmoid mesocolon 2.3.1 Peritoneum Mesentry of jejenum and ileum Transverse mesoclolon Sigmoid mesocolon Meso-appendix

2.3.1 Peritoneum Lesser Omentum Greater Omentum

Central aspect, diaphragmatic peritoneum Innervation Central aspect, diaphragmatic peritoneum Phrenic nerve (C3-5) (referred pain) Peripheral aspect, diaphragmatic peritoneum Inter- and subcostal nerves (T7-T12) Parietal peritoneum T7-T12 and L1 (pain at precise point of stimulation) Visceral peritoneum Insensitive to mechanical stimulation

2.3.2 Organs and relations Explain the functional anatomy of the mesentery, it’s position, vascular, lymphatic and neural contents Explain how the abdomen is divided into a supracolic and infracolic compartment Identify and briefly discuss the attachments of the mesentery of the small intestine to divide the infracolic compartment in two regions

Mesentry: double layer of peritoneum 2.3.2 Organs & relations Mesentry: double layer of peritoneum serves as continuation of visceral and parietal peritoneum provides a means for neurovascular communication between organ and body wall

Transverse Mesoclolon 2.3.2 Organs & relations Transverse Mesoclolon Mesentry of jejenum and ileum Sigmoid mesocolon

2.3.2 Organs & relations Supracolic Infracolic Right Left

2.3.3 Peritoneal specialisation Name and identify the peritoneal folds Name and identify the peritoneal fossae Name and identify the paracolic gutters

Inferior to the umbilicus 2.3.3 Peritoneal specialisation Folds Inferior to the umbilicus Reflection of peritoneum Raised from abdominal wall by underlying structure Median umbilical fold – urachus Medial umbilical fold – obliterated umbilical artery Lateral umbilical fold – inferior epigastric vessels

Superior to the umbilicus 2.3.3 Peritoneal specialisation Folds Superior to the umbilicus Falciform ligament Round ligament of the liver (obliterated foetal umbilical vein)

Fossae / Recess Duodenal recess Caecal recesses: Intersigmoid recess 2.3.3 Peritoneal specialisation Fossae / Recess Duodenal recess Caecal recesses: Superior ileocaecal Inferior ileocaecal Retrocaecal Intersigmoid recess Omental bursa

Duodenojejunal flexure Formed by superior and inferior duodenal folds 2.3.3 Peritoneal specialisation Fossae / Recess Duodenal recess Duodenojejunal flexure Formed by superior and inferior duodenal folds Superior and inferior duodenal recesses Paraduodenal recess

Fossae / Recess Caecal recesses: Formed by: Superior ileocaecal 2.3.3 Peritoneal specialisation Fossae / Recess Caecal recesses: Superior ileocaecal Inferior ileocaecal Retrocaecal Formed by: Caecal fold Ileocaecal fold Vascular fold

Fossae / Recess Caecal recesses: Formed by: Superior ileocaecal 2.3.3 Peritoneal specialisation Fossae / Recess Caecal recesses: Superior ileocaecal Inferior ileocaecal Retrocaecal Formed by: Caecal fold Ileocaecal fold Vascular fold

2.3.3 Peritoneal specialisation Fossae / Recess Intersigmoid recess Meso-sigmoid attached to posterior abdominal wall in relation where the left ureter crosses the left common iliac artery

Right paracolic gutter Left paracolic gutter 2.3.3 Peritoneal specialisation Gutters Right paracolic gutter Left paracolic gutter Right, between mesentry of jejenum and ileum and ascending colon (no exit) Left, between mesentry of jejenum and ileum and descending colon (exit inferior)

2.3.3 Peritoneal specialisation Identify the following: Gastrosplenic ligament, Splenorenal ligament, Transverse and sigmoid mesocolon, Ileocoecal fold, Meso-appendix and The mesenterium of the small intestine

2.3.3 Peritoneal specialisation Identify and describe the omental bursa (lesser sac) in respect of its relations, borders and entrance - the omental foramen Identify the structures forming the borders of the omental foramen Name and identify the subphrenic spaces

(left subhepatic space) 2.3.3 Peritoneal specialisation Omental bursa (left subhepatic space) Superior recess Inferior recess Splenic recess

Omental bursa Superior recess Anterior: Posterior: Right: Left: 2.3.3 Peritoneal specialisation Omental bursa Superior recess Anterior: Lesser omentum Caudate process of liver Posterior: Diaphragm Right: IVC Left: Oesophagus

Omental bursa Inferior recess Anterior: Posterior: Stomach 2.3.3 Peritoneal specialisation Omental bursa Inferior recess Anterior: Stomach Anterior 2 layers of greater omentum Posterior: Pancreas, transverse colon and mesocolon, poster 2 layers of greater omentum

Omental bursa Splenic recess Anterior: Posterior: Left: 2.3.3 Peritoneal specialisation Omental bursa Splenic recess Anterior: Gastrosplenic ligament Posterior: Splenorenal ligament Left: Hilum of the spleen

2.3.3 Peritoneal specialisation Omental foramen Connects greater sac (peritoneal cavity) and lesser sac (omental bursa)

Free border of lesser omentum: 2.3.3 Peritoneal specialisation Omental foramen Anterior: Free border of lesser omentum: Common bile duct (right) Proper hepatic artery (left) Hepatic portal vein (posterior)

Omental foramen Posterior: Inferior vena cava 2.3.3 Peritoneal specialisation Omental foramen Posterior: Inferior vena cava

Omental foramen Superior: Caudate lobe of liver 2.3.3 Peritoneal specialisation Omental foramen Superior: Caudate lobe of liver

Omental foramen Inferior: 1st part of duodenum Common hepatic artery 2.3.3 Peritoneal specialisation Omental foramen Inferior: 1st part of duodenum Common hepatic artery

2.3.3 Peritoneal specialisation Name and identify the subphrenic spaces

Right and left subphrenic spaces (separated by the falciform ligament) 2.3.3 Peritoneal specialisation Spaces Right and left subphrenic spaces (separated by the falciform ligament) Right subhepatic space (Morison’s pouch) Left subhepatic space (omental bursa) Extraperitoneal subphrenic space

Right and left subphrenic spaces (separated by the falciform ligament) 2.3.3 Peritoneal specialisation Right and left subphrenic spaces (separated by the falciform ligament)

Right subhepatic space (Morison’s pouch) 2.3.3 Peritoneal specialisation Right subhepatic space (Morison’s pouch)

Extraperitoneal subphrenic space 2.3.3 Peritoneal specialisation Extraperitoneal subphrenic space

2.3.4 Radiographic anatomy Identify the following structures on a plain erect abdominal X-ray: ASIS, lumbar vertebrae, SI-joint, large intestine, diaphragm, stomach with air in fundus of stomach, liver, psoas line www.up.ac.za/academic/medicine/anatomy/current/sa4/week01e.html#radio

2.4 Liver and gallbladder 2.4.1 Surface anatomy 2.4.2 Structure 2.4.3 Blood supply, nerve supply and lymph drainage

2.4.1 Surface anatomy Review the surface anatomy of the liver and gallbladder Indicate where a liver biopsy should be done

Right, midaxillary line: 2.4.1 Surface anatomy Liver Right, midaxillary line: 7th rib almost to right iliac crest Right, midclavicular plane: 5th rib cartilage to 9th costal cartilage Left, midclavicular plane: 2.5cm short 5th intercostal space and left nipple

Inferior to 9th costal cartilage on right 2.4.1 Surface anatomy Gallbladder Inferior to 9th costal cartilage on right Lateral to semilunar line (lateral border of rectus abdominis) Approx. hands breadth from midline

2.4.1 Surface anatomy

2.4.2 Structure Name and identify the borders and surfaces of the liver Name and identify the lobes, segments, fissures with their contents Identify the subhepatic and subphrenic spaces, and their possible implication in the spread of infection

Diaphragmatic surface 2.4.2 Structure Diaphragmatic surface Visceral surface

2.4.2 Structure Left Right

2.4.2 Structure Colon Kidney Duodenum Stomach

2.4.2 Structure Name and identify the following: Triangular ligaments, Coronary ligaments, Falciform ligament, Lesser omentum, Round ligament of the liver and Ligamentum venosum

2.4.2 Structure Identify, schematically illustrate and discuss the extrahepatic bile ducts as follows: Origin, Course, Outlet and Relations to the pancreas head and duodenum Name and identify the extrahepatic bile ducts on radiographs

Right and left hepatic ducts 2.4.2 Structure Right and left hepatic ducts Common hepatic duct Cystic duct (Common) bile duct Main pancreatic duct of Wirsung Ampulla of Vater with the sphincter of Oddi

ERCP Endoscopic retrograde cholangiopancreatography 2.4.2 Structure ERCP Endoscopic retrograde cholangiopancreatography

2.4.3 Blood supply Discuss and identify the arterial blood supply and venous drainage of the liver and gallbladder Take note of variations in the arterial blood supply of the liver and gallbladder

Left & right hepatic arteries Well-oxygenated blood 2.4.3 Blood supply Left & right hepatic arteries Well-oxygenated blood Hepatic portal vein Poorly oxygenated blood, nutrient-rich blood from GI tract

2.5 Stomach and spleen 2.5.1 Surface anatomy 2.5.2 Structure 2.5.3 Blood supply, nerve supply and lymph drainage 2.5.4 Radiographic anatomy

2.5.1 Surface anatomy Review the surface anatomy of the stomach and spleen in relation to the anterior abdominal wall

Stomach Cardiac part: Pylorus: Fundus: Body: 2.5.1 Surface anatomy Stomach Cardiac part: Deep to 7th costal cartilage, 2.5cm to the left of the midline Pylorus: On transpyloric plane, 2.5cm to the right of the midline Vertebral height L1 / L2 Fundus: Superior of a plane that extends horizontally from the cardia Body: Lies inferior of the above-mentioned plane

In relation to the 9th - 11th rib in the midaxillary line 2.5.1 Surface anatomy Spleen In relation to the 9th - 11th rib in the midaxillary line

2.5.2 Structure Name and identify the various regions, curvatures and surfaces of the stomach. Identify these also on radiographs Identify and briefly describe the general and peritoneal relations of the stomach

Cardio-oesophageal orifice 2.5.2 Structure Cariac zone Fundus Cardio-oesophageal orifice Pylorus Body Gastric and fundic zones Pyloric zone

Anterosuperior relations: 2.5.2 Structure Anterosuperior relations: Left lobe of liver Diaphragm Anterior abdominal wall Left costal margin

Postero-inferior relations: 2.5.2 Structure Postero-inferior relations: Omental bursa with Transverse colon and mesocolon Pancreas Spleen Coeliac artery Left kidney and suprarenal gland Coeliac plexus Coeliac ganglia Diaphragm

2.5.2 Structure Identify and briefly discuss the structure and surfaces of the spleen Identify and briefly discuss the relations of the spleen to: ribs, stomach, pancreas, kidney, transverse colon, suprarenal gland Identify the possible routes of surgical access to the lesser sac: omental foramen, directly through the lesser omentum, posterior

2.5.2 Structure

2.5.2 Structure Posterior Anterior

2.5.3 Blood supply, nerve supply and lymph drainage Identify and briefly discuss the arterial supply and venous drainage of the stomach and spleen Schematically illustrate the coeliac trunk and it's branches

Coeliac trunk Common hepatic artery Gastroduodenal artery 2.5.3 Blood & nerve supply, Lymph drainage Coeliac trunk Common hepatic artery Gastroduodenal artery Anterior superior pancreaticoduodenal artery Right gastro-omental artery Proper hepatic artery Right gastric artery Right hepatic artery Cystic artery Left hepatic artery

Splenic artery Coeliac trunk Left Gastro-omental artery 2.5.3 Blood & nerve supply, Lymph drainage Coeliac trunk Splenic artery Left Gastro-omental artery Short gastric artery

Left gastric artery Coeliac trunk 2.5.3 Blood & nerve supply, Lymph drainage Coeliac trunk Left gastric artery

2.5.3 Blood supply, nerve supply and lymph drainage Identify and briefly discuss the vagus nerve as follows: Abdominal entrance (anterior and posterior vagus trunks), Prominent plexuses and Branches and extent of abdominal supply Identify the intra-abdominal part of the oesophagus 

Enters abdomen at T10 together with oesophagus 2.5.3 Blood & nerve supply, Lymph drainage Vagus nerve (X) Enters abdomen at T10 together with oesophagus Parasympathetic supply to GI tract as far as the left colic flexure Contributions to Cardiac plexus Oesophageal plexus Aortic plexus Coeliac plexus Branches: Oesophageal Gastric Pancreatic Branches to gallbladder Branches to intestine as far as the left colic flexure

Left vagus nerve (X) – Ant. vagal trunk 2.5.3 Blood & nerve supply, Lymph drainage Left vagus nerve (X) – Ant. vagal trunk Branches: Oesophageal branches Gastric branches Hepatic branches to hepatic portal vein Pyloric branches

Right vagus nerve (X) – Post. vagal trunk 2.5.3 Blood & nerve supply, Lymph drainage Right vagus nerve (X) – Post. vagal trunk Branches: Oesophageal branches Gastric branches Coeliac branches to coeliac plexus Pyloric branches

2.5.4 Radiographic anatomy Identify the stomach and air in the fundus of the stomach on a plain erect abdominal X-ray Identify the stomach on a barium meal www.up.ac.za/academic/medicine/anatomy/current/sa4/week01e.html#radio