1. Dr. Ahmed Fathalla Ibrahim

2. LUMBAR PLEXUS

3.  FORMATION:  FORMATION: formed by anterior (ventral) rami of L1,2,3 + part of L4  SITE:  SITE: in the substance of psoas major  DISTRIBUTION:  Gives muscular branches to psoas major & quadratus lumborum from roots  Gives 6 branches

4. BRANCHES OF LUMBAR PLEXUS  Four branches lateral to psoas major:  Iliohypogastric nerve (L1)  Ilioinguinal nerve (L1)  Lateral cutaneous nerve of thigh (L2,3)  Femoral nerve (L2,3,4)  One branch anterior to psoas major:  Genitofemoral nerve (L1,2)  One branch medial to psoas major:  Obturator nerve (L2,3,4)

5. BRANCHES OF LUMBAR PLEXUS  Iliohypogastric: superficial to QL supplies  Iliohypogastric: superficial to QL, passes through anterior abdominal wall, supplies TA, IO & EO + skin of lower part of anterior abdominal wall  Ilioinguinal: superficial to QL, supplies  Ilioinguinal: superficial to QL, passes through inguinal canal, supplies TA, IO & EO + skin of external genitalia  Lateral cutaneous nerve of thigh: superficial to iliacussupplies  Lateral cutaneous nerve of thigh: superficial to iliacus, deep to inguinal ligament, supplies skin of lateral surface of thigh

6. BRANCHES OF LUMBAR PLEXUS  Femoral nerve: between psoas major & iliacussupplies supplies  Femoral nerve: between psoas major & iliacus, supplies iliacus (in abdomen), deep to inguinal ligament, supplies muscles of anterior compartment of thigh  Genitofemoral nerve:  Genitofemoral nerve: divides into: 1.Genital branch: supplies 1.Genital branch: enters spermatic cord, supplies cremaster muscle 2.Femoral branch: supplies 2.Femoral branch: supplies skin of upper part of front of thigh

7. BRANCHES OF LUMBAR PLEXUS  Obturator nerve: anterior to sacroiliac joint (behind common iliac vessels) supplies through obturator canalsupplies  Obturator nerve: anterior to sacroiliac joint (behind common iliac vessels), supplies pelvic peritoneum, passes through obturator canal, supplies muscles of medial compartment of thigh

8. SYMPATHETIC TRUNK & AORTIC PLEXUSES

9. ABDOMINAL PART OF SYMPATHETIC TRUNK  BEGINNING: behind medial arcuate ligament  BEGINNING: continuation of thoracic part after passing behind medial arcuate ligament  TERMINATION: behind common iliac vessels  TERMINATION: continues in the pelvis by passing behind common iliac vessels  COURSE: along medial border of posas major  COURSE: runs along medial border of posas major 1)Left: 1)Left: to left side of abdominal aorta 2)Right: 2)Right: behind IVC

10. ABDOMINAL PART OF SYMPATHETIC TRUNK  NUMBER OF GANGLIA:  NUMBER OF GANGLIA: 4  BRANCHES: 1.White rami communicantes to L1 & L2 1.White rami communicantes (preganglionic & visceral afferent sensory nerve fibers): join upper 2 ganglia to L1 & L2 2.Gray rami communicantes to corresponding lumbar nerve 2.Gray rami communicantes (postganglionic nerve fibers) to blood vessels & sweat glands): join each ganglion to corresponding lumbar nerve join aortic plexuses share in formation of superior hypogastric plexus 3.Fibers join aortic plexuses & share in formation of superior hypogastric plexus

11. AORTIC PLEXUSES  AORTIC PLEXUS:  AORTIC PLEXUS: around abdominal aorta  CELIAC PLEXUS: 2 ganglia  CELIAC PLEXUS: formed of 2 ganglia connected by fibers around celiac artery  RENAL PLEXUS:  RENAL PLEXUS: around renal artery  SUPERIOR MESENTRIC PLEXUS:  SUPERIOR MESENTRIC PLEXUS: around superior mesenteric artery  INFERIOR MESENTERIC PLEXUS:  INFERIOR MESENTERIC PLEXUS: around inferior mesenteric artery

12. AORTIC PLEXUSES  FORMATION:  FORMATION: each plexus is formed of: 1.Preganglionic sympathetic fibers 1.Preganglionic sympathetic fibers from greater & lesser splanchnic nerves that usually relay in celiac ganglia 2.Postganglionic sympathetic fibers 2.Postganglionic sympathetic fibers from celiac ganglia & sympathetic trunks 3.Preganglionic parasympathetic fibers 3.Preganglionic parasympathetic fibers from vagus or pelvic splanchnic nerves ( in case of inferior mesenteric plexus) 4.Visceral afferent fibers N.B.: Sympathetic fibers from plexuses & sympathetic trunks form superior hypogastric plexus below bifurcation of abdominal aorta

13. LYMPH NODES

14. PREAORTIC LYMPH NODES  CELIAC L.N.:  CELIAC L.N.: around celiac trunk Afferents:Afferents: from foregut  SUPERIOR MESENTERIC L.N.:  SUPERIOR MESENTERIC L.N.: around superior mesenteric artery Afferents:Afferents: from midgut  INFERIOR MESENTERIC L.N.:  INFERIOR MESENTERIC L.N.: around inferior mesenteric artery Afferents:Afferents: from hindgut  EEFERENTS FORM THE INTESTINAL LYMPH TRUNK

15. LATERAL AORTIC LYMPH NODES paraaorticlumbarAlso called: “paraaortic or lumbar L.N.” AFFERENTS:AFFERENTS: from kidneys, gonads, uterine tubes, fundus of uterus, anterior abdominal wall (deep lymphatics), common iliac L.N. EFFERENTS: RIGHT & LEFT LUMBAR LYMPH TRUNKSEFFERENTS: form RIGHT & LEFT LUMBAR LYMPH TRUNKS

16. CYSTERNA CHYLI & THORACIC DUCT  CYSTERNA CHYLI: (opposite L1 & L2), on the right side of abdominal aorta  An elongated lymph sac (opposite L1 & L2), on the right side of abdominal aorta  Afferents: 1)Intestinal lymph trunk 2)Right & left lumbar lymph trunks 3)Lymphatics from thorax  THORACIC DUCT:  Upward continuation of cysterna chyli  Ascends to thorax through aortic opening