1. Cover slide

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

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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. 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

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

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

18. 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

19. Coeliac
MOB TCD

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

21. Anterior Branches Abdominal Aorta
MOB TCD

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

23. 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

24. 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

25. 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

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

27. Inferior Vena Cava
MOB TCD

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

29. Kidneys
MOB TCD

30. 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

31. 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

32. 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

33. 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

34. Anterior Relations of Kidneys
MOB TCD

35. 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

36. 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

37. 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

38. 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

39. Posterior Relations of Kidneys
MOB TCD

40. Renal Artery and Vein
MOB TCD

41. Kidneys
MOB TCD

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

43. 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

44. 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

45. Intrarenal arteries
MOB TCD

46. Blood Vessels
MOB TCD

47. Nerve Innervation
MOB TCD

48. 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

49. 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

50. 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

51. 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

52. 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

53. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved
Copyright slide