Sie sind auf Seite 1von 112

Index

TEMPORAL AND INFRATEMPORAL FOSSAE


1
The temporal and infratemporal fossae are interconnected spaces on the
lateral side of the head. Their boundaries are formed by bone and soft tissues.
The temporal fossa is superior to the infratemporal fossa, above the zygomatic arch,
and communicates with the infratemporal fossa below through the gap between the
zygomatic arch and the more medial surface of the skull.
The infratemporal fossa is a wedge-shaped space deep to the masseter
muscle and the underlying ramus of the mandible.
Contents: 2 Muscles: Medial and lateral pterygoids, 2 Nerves: Mandibular and
horda tympani, 2 Vessels: Maxillary artery and !terygoid plexus of veins and 1
ganglion: "tic ganglion.
"f the four muscles of mastication #masseter, temporalis, medial pterygoid,
and lateral pterygoid$ that move the lower %aw at the temporomandibular %oint, one
#masseter$ is lateral to the infratemporal fossa, two #medial and lateral pterygoid$ are
in the infratemporal fossa, and one fills the temporal fossa #temporalis$.
Bony boundaries of the infrate!ora" fossa

2

Anatoi#a" features of andib"e

Mus#"es of asti#ation
There are four muscles of mastication&
'- Temporalis
(- Masseter
)- Medial pterygoid
*- +ateral pterygoid
Te!ora"is us#"e:
Ori$in: ,loor of temporal fossa and deep surface of temporal fascia, inferior temporal
line.
Insertion: oronoid process and anterior border of ramus of mandible.
Ner%e su!!"y: -eep temporal nerves #from the anterior division of mandibular
nerve$.
A#tion: .levation #anterior fibers$ and retraction #posterior fibers$ of the mandible.
Masseter us#"e:
Ori$in: +ower border and inner surface of the zygomatic arch.
Insertion: +ateral aspect of the ramus of the mandible.
Ner%e su!!"y: anterior division of the mandibular nerve.
A#tion: .levation and protraction of the mandible.
3
Latera" !tery$oid us#"e:
Ori$in:
/pper head& from the infratemporal surface of the greater wing of sphenoid bone.
+ower head& from the lateral surface of the lateral pterygoid plate.
Insertion: anterior aspect of the neck of the mandible and the articular disc of the
temporo-mandibular %oint.
Ner%e su!!"y: anterior division of the mandibular nerve.
A#tion: pulls the head of mandible forward during opening of the mouth #helps in
depression of mandible$, protracts the mandible and side to side moves it #chewing$.
Masseter& te!ora"is& edia" and "atera" !tery$oid us#"es
Media" !tery$oid us#"e:
Ori$in:
0uperificial head& from the maxillary tuberosity.
-eep head& from the medial surface of the lateral pterygoid plate.
Insertion: medial surface of the ramus of the mandible above the angle and below
mylohyoid groove.
Ner%e su!!"y: Main trunk of the mandibular nerve.
A#tion: helps in elevation of mandible, protraction of the mandible and side to side
movement.
.xternal surface Medial surface
Atta#hent of us#"es of asti#ation to the andib"e
Mandibu"ar ner%e
4
Course:
1 It enters the Infra-temporal fossa through the foramen ovale.
1 It has a large sensory root and a smaller motor root.
1 In foramen ovale, both roots %oin each other to form the trunk of the nerve
which is very short and rapidly divides below the foramen into anterior and
posterior division.
I' Bran#hes of the trun(:
'. 2erve to medial pterygoid muscle which also supplies tensor palate and tensor
tympani muscles.
(. Meningeal branch to meninges of middle cranial fossa.
II- Bran#hes of Anterior di%ision &
#3ll its branches are motor EXCEPT the bu##a" Ner%e$
'$ Mus#u"ar bran#hes& to masseter, lateral pterygoid and temporalis.
($ Bu##a" ner%e& It supplied the skin covering buccinators muscle. Then, it
pierces buccinators to supply the mucous membrane of the mouth in the inner
surface of buccinators.
III' Bran#hes of Posterior di%ision:
#3ll branches are sensory EXCEPT the mylohyoid nerve$
)* Inferior a"%eo"ar ner%e:
It innervates the lower teeth. The inferior alveolar nerve and its accompanying
vessels enter the mandibular foramen on the medial surface of the ramus of
mandible and travel anteriorly through the bone in the mandibular canal. 4efore it
enters the mandibular canal it gives motor ner%e to y"ohyoid us#"e #which
pierces sphenomandibular ligament$ and anterior be""y of di$astri# muscle.
3d%acent to the first premolar tooth, the inferior alveolar nerve divides into incisive
and mental branches&
The in#isi%e bran#h innervates the related teeth and gum.
The enta" ner%e exits the mandible through the mental foramen and
innervates the chin and lower lip.
(. Lin$ua" ner%e: It originates in the infratemporal fossa and passes anteriorly
into the floor of the oral cavity and continues forward on the medial surface of
the mandible ad%acent to the last molar tooth at the posterior end of mylohyoid
line #dangerous position$. The lingual nerve then continues anteromedially
across the floor of the oral cavity and ascends into the tongue on the lateral
surface of the hyoglossus muscle.
+' Auri#u"o'te!ora" ner%e: It arises by two roots which encircle the middle
meningeal artery. It supplies the scalp over the temporal region.
5
Mandibu"ar ner%e Bran#hes of !osterior di%ision of
and its bran#hes andibu"ar ner%e
Distribution of andibu"ar ner%e
Oti# $an$"ion:
It is a parasympasytic ganglion in the infratemporal fossa below foramen ovale
medial to the main trunk of mandibular nerve.
Roots:
'. Sensory root: from mandibular nerve.
(. Sy!atheti# root: from plexus around middle meningeal artery.
). Parasy!atheti# root: lesser superficial petrosal nerve #from $"osso!haryn$ea" nerve.
"nly the parasympathetic root relays in ganglion$.
Bran#hes:
'. !arasymathetic postganglionic branches to parotid gland.
(. 0ensory branches to parotid gland.
). 0ympathetic branches to blood vessels of parotid gland.
6
- The ganglion is also traversed by the nerve to medial pterygoid which passes
through the ganglion without relay to supply tensor palati and tensor tympani.
Position& roots and bran#hes of the oti# $an$"ion
Ma,i""ary artery
Origin:
The maxillary artery originates from external carotid artery within the
substance of the parotid gland
Course:
The course of the artery is divided into ) parts according to its relation with
the lateral pterygoid muscle
)' ,irst !art& Medial to the neck of the mandible.
-' 0econd part& "n the lateral surface of the lateral pterygoid muscle.
+' Third part& !asses between the two heads of the lateral pterygoid to reach the
pterygopalatine fossa.
Branches:
'- Bran#hes of )
st
!art It gives the middle meningeal and inferior alveolar
arteries and a number of smaller branches #deep auricular, anterior tympanic,
and accessory meningeal$.
(- Bran#hes of -
nd
!art It gives origin to deep temporal, masseteric, buccal, and
pterygoid branches for medial and lateral pterygoid muscles, which course
with branches of the mandibular nerve.
7
)- Bran#hes of the +
rd
!art #in the pterygopalatine fossa$& It gives posterior
superior alveolar, infra-orbital, greater palatine, pharyngeal, and
sphenopalatine arteries, and the artery of the pterygoid canal. the infraorbital
artery gives a. "rbital branches to the orbit. b. 3nterior superior alveolar
artery. c. Terminal branches in face #palpebral, nasal, and labial branches$.
Co""e#ti%e"y, these branches supply much of the nasal cavity, the roof of the
oral cavity, upper teeth, sinuses, oropharynx, and floor of the orbit.
Ma,i""ary artery .#ourse and bran#hes/
Ptery$oid P"e,us of 0eins
Site& It is a network of veins lying around and within the lateral pterygoid
muscle.
Tributaries:
'. 5eins corresponding to the branches of the maxillary artery.
(. Inferior ophthalmic vein through the inferior orbital fissure.
). -eep facial vein.
Draina$e:
The pterygoid plexus drains into the maxillary vein which unites with the
superficial temporal vein to form the retromandibular vein.
Fun#tion: It acts as a peripheral heart to aid venous return by the pumping
action of the lateral pterygoid.
Conne#tions:
It communicates with&
'. 3nterior facial vein through the deep facial vein.
(. avernous sinus via emissary veins passing through foramen ovale,
foramen spinosum and emissary sphenoid foramen.
). Inferior ophthalmic vein via a communicating vein passing through the
inferior ophthalmic fissure.
8
The Ptery$oid P"e,us of 0eins
The Mouth Ca%ity
Di%isions:
The mouth cavity is divided into ( main parts&
)' 5estibule of the mouth.
-' Mouth cavity proper.
)' 0estibu"e of outh:
It is a slit like space bound externally by the lips and cheeks, internally by
gums and teeth. The vestibule opens into outside through the oral fissure. 6hen the
%aws are closed, the vestibule is connected to the mouth cavity proper through an
interval behind the last molar teeth on each side.
-' Mouth #a%ity !ro!er
It is bounded by:
)' Anterior and "atera""y: the gums and teeth.
-' Posterior"y: it communicates with the pharynx through the isthmus of fauces.
This isthmus is bounded by the palato-glossal arch on each side.
+' Roof: is formed by the hard and soft palate.
1' F"oor: is formed by the anterior (7) of the tongue.
3 median fold of mucosa connects the under surface of the tongue to the floor of
the mouth8 this is called the frenulum linguae. The floor presents a small ridge on
each side of the frenulum. This ridge is called the sublingual fold. +ateral to the
frenulum there are the lingual vein and lateral to it are the fimbriated folds #one on
each side$.
9
0estibu"e of the outh
Mus#"es of the f"oor of the outh
)' Di$astri# us#"e:
Origin and insertion:
This muscle has a posterior belly, an intermediate tendon, and an anterior belly.
The !osterior be""y arises from the mastoid notch and ends in the intermediate
tendon. The intermediate tendon is held in position by a loop of deep fascia, which
binds the tendon down to the %unction of the body and greater cornu of the hyoid
bone.
The anterior be""y is attached to the digastric fossa near the median plane.
Nerve supply: The !osterior be""y is supplied by the facial nerve and the anterior
be""y by the nerve to the mylohyoid #mandibular nerve$.
ction: It depresses the mandible or elevates the hyoid bone.
Di$astri#& y"ohyoid and sty"ohyoid us#"es
-' Sty"ohyoid us#"e:
Origin: It takes origin from the styloid process.
!nsertion: It is inserted into the hyoid bone.
Nerve supply: ,acial nerve.
ction: .levates the hyoid bone.
+' My"ohyoid us#"e:
10
Origin: It arises from the whole length of the mylohyoid line of mandible.
!nsertion: The posterior fibers are inserted into the body of the hyoid bone8 the
anterior fibers are inserted into a fibrous raphe in the mid line.
Nerve supply: It is supplied by mylohyoid branch of the inferior alveolar nerve.
ction: - 6hen the mandible is fixed, they elevate the floor of the mouth and hyoid
bone during the first stage of swallowing.
-6hen the hyoid bone is fixed, it assists in the depression of the mandible and the
opening the mouth.
My"ohyoid us#"e 2eniohyoid us#"e
1' 2eniohyoid us#"e:
Origin: It takes origin from the inferior genial tubercle of the mandible.
!nsertion: It is inserted into the anterior surface of the body of the hyoid bone.
Nerve supply: . ' component of the hypoglossal nerve.
ction: .levates the hyoid bone or depresses the mandible.
Sa"i%ary $"ands
The paired parotid glands, together with the paired submandibular and
sublingual glands and the numerous small glands scattered throughout the mouth
cavity, constitute the salivary glands.
Latera" side of the head sho3in$ the sa"i%ary $"ands
The Parotid 2"and
11
The parotid gland is the largest of the salivary glands.
3 small part of the facial process may be separated from
the main gland and is called the a##essory !art of the
$"and*
Sha!e and "obes and surfa#es of the $"and:
The parotid gland is wedge-shaped, with its base above
and its apex behind the angle of the mandible.
It has three surfaces&
'- 0uperficial surface.
(- 3ntromedial surface.
)- !osteromedial surface.
Boundaries:
- /pwards& 9ygomatic arch.
- -ownwards& 3ngle of the mandible #%ust below it$.
- 3nterior& Masseter #overlies its posterior part$.
- !osterior& 0ternomastoid #overlies its upper part$.
Ca!su"es of the $"and:
The parotid gland is surrounded by a connective-tissue
capsule. In addition, the gland is enclosed in a dense fibrous capsule derived from the
investing layer of deep cervical fascia.
Parotid du#t:
The parotid duct emerges from the anterior border of the gland and passes forward
over the lateral surface of the masseter muscle. 3t the anterior border of the muscle it
turns sharply medially and pierces the buccal pad of fat and buccinator muscle. It then
opens into the vestibule of the mouth opposite the upper second molar tooth.
Surfa#e anatoy of the !arotid du#t:
- It corresponds to the middle third of a line extending between two points&
'. 3 point midway between the red margin of the upper lip and ala of the nose.
(. 3 point at the lower end of the tragus of the ear.
Position of the !arotid $"and and !arotid du#t
12
Stru#tures 3ithin the !arotid $"and after its reo%a"
Stru#tures 3ithin the !arotid $"and:
)' Fa#ia" ner%e&
- The facial nerve enters the gland through the postero-medial surface. Then, it breaks
to form a plexus #pes anserinus$ inside the parotid gland.
- The plexus gives a group of terminal branches which leave the gland through&
a. /pper end& Temporal branches. b. 3nterior border& 9ygomatic, buccal, and,
mandibular branches.c. +ower end& ervical branch.
-' Retroandibu"ar %ein The superficial temporal vein enters the parotid gland
through the upper end. The maxillary vein enters the gland through the antero-medial
surface. The two veins form the retromandibular vein inside the gland.
- The retro-mandibular vein leaves the gland through the lower end as anterior and
posterior branches.
+' E,terna" #arotid artery - The external carotid artery enters the gland through the
postero-medial surface. It divides inside the gland into the maxillary and superficial
temporal arteries. The superficial temporal artery leaves the gland through the upper
end. The maxillary artery leaves the gland through the antero-medial surface.
1' Auri#u"ote!ora" ner%e - it enters the gland through the antero-medial surface
and leaves it through the upper pole.
4* Parotid $rou! of "y!h nodes are also located within the gland.
B"ood su!!"y:
The external carotid artery and the terminal branches within the gland, namely,
superficial temporal and maxillary arteries, supply the gland. The veins drain into
retromandibular vein.
Ly!h draina$e:
The lymph vessels drain into parotid lymph nodes and the deep cervical lymph
nodes.
Ner%e su!!"y:
13
Parasy!atheti# secretomotor fibers from the inferior salivary nucleus of the ninth
cranial nerve supply the parotid gland. The nerve fibers pass to the otic ganglion via
the lesser petrosal nerve. !ostganglionic parasympathetic fibers reach the parotid
gland via auriculotemporal nerve.
!ostganglionic sy!atheti# fibers reach the gland as a plexus of nerves around the
external carotid artery.
Sensory:
,or the capsule---------:reat auricular nerve.
,or parenchyma-------3uriculo-temporal nerve.
Re"ations of the !arotid $"and:
Trans%erse se#tion in the !arotid re$ion
' The su!erfi#ia" ."atera"/ re"ations are skin, superficial fascia containing platysma,
parotid lymph nodes and great auricular nerve.
' The !osteroedia" re"ations are mastoid process, sternocleidomastoid, posterior
belly of the digastric, styloid process and its attached muscles, carotid sheath with
internal carotid artery, internal %ugular vein and vagus nerve, glossopharyngeal,
accessory, hypoglossal, and facial nerves.
' The anteroedia" re"ations are the posterior border of the ramus of the mandible,
masseter and medial pterygoid muscle.
The Subandibu"ar 2"and
14
The submandibular gland is a large salivary gland which lies partly under
cover of the body of the mandible and is made up of a large superficial part and a
small deep part, which are continuous with each other around the posterior border of
mylohyoid muscle.
The su!erfi#ia" !art of the $"and lies in the digastric triangle. !osteriorly, it is
separated from the parotid gland by stylomandibular ligament.
Position of subandibu"ar $"and Ner%e su!!"y of subandibu"ar& sub"in$ua"
$"ands
Re"ations of the su!erfi#ia" !art of the $"and:
'Su!erfi#ia" .inferior/ surfa#e: 0kin, superficial fascia containing platysma, and
the investing layer of the deep cervical fascia, cervical branch of the facial nerve,
0ubmandibular lymph nodes and anterior facial vein.
'Media" surfa#e: it is related medially to mylohyoid muscle, mylohyoid nerve and
vessels, hyoglossus muscle, lingual and hypoglossal nerves.
'Latera" surfa#e: it lies in contact with the submandibular fossa on the medial
surface of the mandible, facial artery, and medial pterygoid.
The dee! !art of the $"and extends forward in the interval between mylohyoid
below and laterally and hyoglossus and styloglossus medially.
15
Position and re"ations of subandibu"ar $"and Dee! re"ations of the $"and
Re"ations of dee! !art of subandibu"ar $"and
Re"ations of the dee! !art of the $"and:
- It extends forwards between mylohyoid and hyoglossus muscles also8 it is related to
the lingual nerve above and to the hypoglossal nerve below.
Ca!su"es of the $"and:
The submandibular gland is surrounded by a connective-tissue capsule. In
addition, the gland is partly enclosed in a dense fibrous capsule derived from the
investing layer of deep cervical fascia.
Subandibu"ar du#t:
The submandibualr duct from the medial surface of the superficial part of the
gland. It emerges from the anterior end of the deep part of the gland. It passes forward
along the side of the tongue, beneath the mucous membrane of the floor of the mouth.
It is crossed laterally by the lingual nerve #triple relation$ and then lies between the
sublingual gland and genioglossus muscle. It opens into the mouth on the summit of a
small papilla, which is situated at the side of the frenulum of the tongue.
B"ood su!!"y:
16
It is supplied by branches of the facial and lingual arteries. The veins drain into the
facial and lingual veins.
Ly!h draina$e:
+ymph vessels drain into the submandibular and deep cervical lymph nodes.
Du#ts of sa"i%ary $"ands Arteria" su!!"y of subandibu"ar $"and
Ner%e su!!"y:
!arasympathetic secretomotor supply from the superior salivary nucleus of the
seventh cranial nerve #facial nerve$ via the chorda tympani nerve. !ostganglionic
parasympathetic fibers reach the gland either directly or along the duct.
!ostganglionic sympathetic fibers reach the gland as a plexus of nerves around the
facial and lingual arteries.
The Sub"in$ua" Sa"i%ary 2"and
17
Position of the sa"i%ary $"ands
The sublingual gland is the smallest of the three main salivary glands. It lies
beneath the mucous membrane of the floor of the mouth, close to the midline.
Re"ations:
Media""y: it is related to genioglossus muscle, lingual nerve, and submandibular duct.
Latera""y: it is related to sublingual fossa of the medial surface of the mandible.
Su!erior"y: it is related to mucous membrane of the floor of the mouth.
Inferior"y: the gland is supported by the mylohyoid muscle.
Sub"in$ua" du#ts: The sublingual ducts are eight to twenty in number. The ma%ority
open into the mouth on the summit of the sublingual fold.
B"ood su!!"y: The gland is supplied by branches of the facial and lingual arteries.
The veins drain into the facial and lingual veins.
Ly!h draina$e: +ymph vessels drain into the submandibular and the deep cervical
lymph nodes.
Ner%e su!!"y: 0imilar to submandibular
gland.
The !a"ate
The palate forms the roof of the mouth. It is divided into&
18
5ard !a"ate &
It is the bony anterior two thirds. It is composed of the palatine processes of
the maxillae and the horizontal plates of the palatine bones. It is bounded by the
alveolar arches and is continuous posteriorly with the soft palate. It forms the floor of
the nasal cavity. It is covered with mucous membrane with an inferior median raphe
and bilateral corrugations on both sides.
Ora" #a%ity sho3in$ !arts of the !a"ate Mus#"es of the !a"ate
Soft !a"ate: It extends from the posterior border of the hard palate. It is covered with
mucous membrane. It ends posteriorly with the uvula and is continuous on both sides
with the lateral wall of the pharynx.
Contents of the soft !a"ate:
!alatine aponeurosis.
Muscles.
2erves.
5essels.
+ymphoid
tissue.
Pa"atine a!oneurosis:
It is a fibrous sheet attached to the posterior border of the hard palate. It is the
expanded tendon of the tensor palati muscle. It splits to enclose the musculus uvula
muscle.
19
Mus#"es of the soft !a"ate:
)* Tensor !a"ati us#"e:
Ori$in: It takes origin from scaphoid fossa, greater wing of sphenoid, spine of the
sphenoid and outer surface of the auditory tube #cartilaginous part$.
Insertion: Its tendon hooks around the pterygoid hamulus to be inserted in the
palatine crest.
Ner%e su!!"y: Trunk of mandibular nerve.
A#tion: Tenses or tighten the soft palate.
-* Le%ator !a"ati us#"e:
Ori$in: ,rom ;uadrangular area on the inferior surface of the petrous part of temporal
bone and medial surface of the auditory tube #cartilaginous part$.
Insertion: It is inserted into the upper surface of palatine aponeurosis.
Ner%e su!!"y: ranial part of accessory nerve through the pharyngeal plexus.
A#tion: .levation of the soft palate.
+* Pa"ato$"ossus us#"e:
Ori$in: The under surface of palatine aponurosis.
Insertion: It is inserted into the lateral side of the tongue.
Ner%e su!!"y: ranial part of accessory nerve through the pharyngeal plexus.
A#tion: It depresses the palate, elevates the root of the tongue, and narrows the
oropharyngeal isthmus #between the mouth cavity and oropharynx$.
1* Pa"ato!haryn$eus us#"e:
Ori$in: !osterior border of the hard palate and palatine apponeurosis.
Insertion: The lamina of thyroid cartilage.
Ner%e su!!"y: ranial part of accessory nerve through the pharyngeal plexus.
A#tion: -epression of the palate and together with the soft palate it narrows the
nasopharyngeal isthmus during deglutition.
4* Mus#u"us u%u"ae:
Ori$in: ,rom posterior nasal spine.
Insertion: It is inserted into mucous membrane of the uvula.
Ner%e su!!"y: ranial part of accessory nerve through the pharyngeal plexus.
A#tion: <etract and elevate the uvula.
20
Media" side of the head sho3in$ us#"es of !a"ate
Ner%e su!!"y of the !a"ate:
A' Sensory ner%e su!!"y:
)* :reater palatine nerve. =ard palate
-* 2asopalatine nerve
+* +esser palatine nerve. 0oft palate
1* :lossopharyngeal nerve.
- Se#retootor fibres to the !a"atine $"ands:
The facial nerve through its greater petrosal nerve relays in the sphenopalatine
ganglion. !ostganglionic fibers reach the palatine glands through the lesser palatine
nerves.
- Taste sensation:
Taste fibers reach the inferior surface of the palate through the lesser palatine nerves.
B' Motor ner%e su!!"y:
3ll the muscles are supplied by the cranial part of accessory nerve except the tensor
palati muscle which is supplied by the mandibular nerve.
Arteria" su!!"y of the !a"ate:
)* :reater palatine artery #branch from the maxillary artery$.
-* 3scending palatine artery #branch from the facial artery$.
+* !alatine branch of ascending pharyngeal artery.
0enous draina$e of the !a"ate: Through pterygoid and pharyngeal plexuses of veins.
Ly!hati# draina$e of the !a"ate:
)* The hard palate drains into submandibular lymph nodes.
-* The soft palate drains into upper deep cervical and retropharyngeal lymph nodes.
21
The Ton$ue
It is a mass of striated muscles covered with mucous membrane.
Parts:
It is formed of & tip > dorsal and ventral surfaces > root.
The u#ous ebrane of the ton$ue:
The dorsal surface of the anterior two thirds #oral part$ is separated from the
posterior third #pharyngeal part$ by a 5 shaped sulcus, the sulcus terminalis. The apex
of the sulcus is marked by a small pit #the foramen caecum$.
The anterior surface is covered with papillae #filiform, fungiform and vallate$,
6hile the posterior surface is devoid of papillae and contains aggregations of
lymphoid tissue #lingual tonsil$.
The mucous membrane of the inferior surface of the tongue is smooth and
reflected to the floor of the mouth, and is connected to it by the frenulum.
"n both sides lie the lingual artery, lingual nerve, and deep lingual vein #from
medial to lateral$. +ateral to the lingual vein the mucous membrane forms a fringed
fold #plica fimbriata$.
Mus#"es of the ton$ue:
The muscles of the tongue are divided into two types&
)* Intrinsi# us#"es: They are confined to the tongue and not attached to bone. They
are supplied by the hypoglossal nerve. They change the shape of the tongue as
narrowing the tongue #by transverse muscle$, 0hortening #by longitudinal muscle$,
Thinning #by vertical muscle$.
Dorsu of the ton$ue sho3in$ its u#ous ebrane
22
Sa$itta" se#tion of the head sho3in$ E,trinsi# us#"es of ton$ue
intrinsi# us#"es of ton$ue
-* E,trinsi# us#"es:
They change the position of the tongue
)' Sty"o$"ossus us#"e:
Origin: 0tyloid process of the temporal bone.
!nsertion: The side of the tongue.
Nerve supply: =ypoglossal nerve.
ction: It draws the tongue upwards and backwards.
-' Pa"ato$"ossus us#"e:
It is described with the palate.
+' 2enio$"ossus us#"e:
It is a flat fan shaped muscle which lies close to its fellow of the opposite side.
Origin: 0uperior genial tubercle of the mandible.
!nsertion: The whole length of the tongue.
Nerve supply: =ypoglossal nerve.
ction: 6ith the opposite muscle it protrudes the tongue. They also depress the
median part of the tongue.
1' 5yo$"ossus us#"e:
It is a ;uadrilateral muscle.
Origin: It takes origin from the lateral part of the body and whole length of the
greater horn of hyoid bone.
!nsertion: It is inserted into the side of the tongue lateral to the hyoglossus muscle.
Nerve supply: =ypoglossal nerve.
ction: -epression of the tongue.
Ner%e su!!"y of the ton$ue:
23
)' Sensory ner%e su!!"y:
- 2enera" sensation:
It is through the lingual nerve to the anterior two thirds of the tongue. The posterior
third is supplied by the glossopharyngeal nerve.
- Taste sensation:
It is carried by the chorda tympani to the anterior two thirds, and by the
glossopharyngeal nerve to the posterior third. :eneral and taste sensations of the most
posterior part of the tongue are carried by superior laryngeal branch of vagus nerve.
-' Motor inner%ation:
3ll muscles of the tongue are supplied by hypoglossal nerve, except the palatoglossus
muscle which is supplied by cranial part of accessory nerve through the pharyngeal
plexus.
Ner%e su!!"y of ton$ue B"ood su!!"y of ton$ue
Arteria" su!!"y of the ton$ue:
)* +ingual artery.
-* Tonsillar branch of facial artery.
+* 3scending pharyngeal artery.
0enous draina$e of the ton$ue: +ingual vein which drains into the internal %ugular
vein.
Ly!hati# draina$e of the ton$ue:
'- The tip and frenulum of the tongue drain into submental lymph nodes.
(- The peripheral lymphatics from the anterior two thirds pass to the submandibular
lymph nodes. 0ome pass directly to the upper and lower deep cervical lymph
nodes.
)- The central lymphatics from the anterior two thirds drain mainly to the deep
cervical lymph nodes and few pass to the submandibular lymph nodes. They drain
to both sides.
*- +ymphatics from the posterior third of the tongue drain into deep cervical lymph
nodes of both sides.
The Pharyn,
24
It is a musculomembranous tube present posterior to the nose, mouth, and
larynx. It extends from the base of the skull to the sixth cervical vertebra, where it
%oins the oesophagus. The wall of the pharynx is composed of&
)* +ining mucous membrane.
-* The inner fibrous coat #pharyngobasilar fascia$ which is attached to the base of the
skull superiorly and blends with the wall of the oesophagus inferiorly.
+* The muscles of the pharynx.
1* The outer fibrous coat #buccopharyngeal fascia$.
Mus#"es of the !haryn,:
)' Su!erior #onstri#tor us#"e:
Ori$in: lower part of the posterior border of the medial pterygoid plate, pterygoid
hamulus, pterygomandibular raphe and posterior end of the mylohyoid line of the
mandible.
!nsertion: Into the pharyngeal tubercle and the median fibrous pharyngeal raph.
Nerve supply: !haryngeal plexus.
-' Midd"e #onstri#tor us#"e:
Origin: +ower part of the stylohyoid ligament and lesser and greater horns of the
hyoid bone.
!nsertion: Its fibres radiate medially to be inserted into the median fibrous pharyngeal
raphe.
Nerve supply: !haryngeal plexus.
+* Inferior #onstri#tor us#"e:
Origin: "bli;ue line of thyroid cartilage and the side of the cricoid cartilage.
!nsertion: It overlaps the lower surface of the middle constrictor muscle and is
inserted into the median pharyngeal raphe.
Nerve supply: !haryngeal plexus
Latera" side of the ne#( sho3in$ us#"es of !haryn,
ction o" constrictor #uscles:
25
- -uring the process of swallowing contraction of the upper fibres of the superior
constrictor will pull the pharyngeal wall forwards. This will aid the soft palate in
closure of the nasopharyngeal isthmus #between the nasopharynx and oropharynx$.
- The successive contractions of the superior, middle and inferior constrictor muscles
propel the bolus of food downwards to the oesophagus.
1* Sty"o!haryn$eus us#"e:
Origin: It takes origin from styloid process of the temporal bone.
!nsertion: It is inserted into the posterior border of thyroid cartilage.
Nerve supply: :lossopharyngeal nerve.
ction: .levation of the larynx and pharynx during swallowing.
4* Sa"!in$o!haryn$eus us#"e:
Origin: It takes origin from the inferior surface of the cartilaginous part of auditory
tube.
!nsertion: It blends with the palatopharyngeus muscle.
Nerve supply: !haryngeal plexus.
ction: It assists in elevation of the pharynx.
6* Pa"ato!haryn$eus us#"e:
It has been discussed with the palate.
The interior of the !haryn,:
The !haryn, is di%ided into three !arts:
)' Naso!haryn,
-' Oro!haryn,
+' Laryn$o!haryn,
)' Naso!haryn,:
- It extends from the base of the skull to the upper surface of the soft palate #at
level of . '$. It is discussed with the respiratory system.
-' Oro!haryn,:
- It extends from the lower surface of the soft palate to the upper border of the
26
epiglottis.
- It communicates anteriorly with the oral cavity by an opening called the
oropharyngeal
isthmus made by the palatoglossal arch on each side #each arch is made by
palatoglossus muscle covered by mucous membrane$.
- It also contains the palatopharyngeal arch #made by palatopharyngeus muscle
covered by mucous membrane$.
- 4etween the palatoglossal and palatopharyngeal arches there is the ?palatine
tonsil@.
Sa$ita" se#tion of the head sho3in$ the interior of oro'!haryn,
Pa"atine tonsi"s
They are two masses of lymphoid tissue in the lateral wall of the oropharynx.
They are covered with mucous membrane. Its medial surface pro%ects into the lumen
of the oropharynx. Its surface is pitted by numerous small openings which lead into
the tonsi""ar #ry!ts. The upper part of the medial surface has a deep intratonsi""ar
#"eft. It is covered on its lateral surface by a #a!su"e.

Re"ations of the !a"atine tonsi"s:
3nteriorly& !alatoglossal arch.
!osteriorly& !alatopharyngeal arch.
0uperiorly& 0oft palate.
Inferiorly& !osterior third of the tongue.
Medially& avity of the oropharynx.
+aterally #tonsillar bed$& 0uperior
constrictor muscle, paratonsillar vein
and tonsillar artery.
Arteria" su!!"y of the tonsi":
'- Tonsillar artery .fro fa#ia" artery/*
(- 3scending palatine artery #from facial artery$.
)- +ingual artery #from external carotid artery$.
*- 3scending pharyngeal artery #from external carotid artery$.
27
0enous draina$e: !aratonsillar vein
Ner%e su!!"y of the tonsi"s:
)*:lossopharyngeal nerve* -* +esser palatine nerve*
Ly!hati# draina$e of the tonsi": -eep cervical lymph nodes #mainly the %ugulo-
digastric nodes$.
+' Laryn$o!haryn,:
- It extends from the upper border of the
epiglottis to the level of the cricoid cartilage
#level of . A$ where it continues as the
oesophagus.
- Its upper part lies behind the inlet of the
larynx.
B !yriform fossa&
- It is a depression on each side of the
inlet of the larynx.
- It has the following boundaries&
a. Medial& 3ryepiglottic fold of the larynx.
b. +ateral& Thyrohyoid membrane above
and the lamina of the thyroid cartilage below.
- The nerve supply of the mucous membrane
of the pyriform fossa is the internal laryngeal
nerve.
28
Laryn$o!haryn,
2a!es of the !haryn,:
'. 3 gap between the upper border of the superior constrictor and the skull base
- This gap is occupied by the pharygobasilar fascia.
- It gives passage to levator palati, ascending palatine artery, and auditory tube.

(. 3 gap laterally between the superior and middle constrictors
- It gives passage to the following&
a. 0tylopharyngeus passing down to the pharynx.
b. :lossopharyngeal nerve passes forwards to the tongue.
). 3 gap laterally between the middle and
inferior constrictors
- This gap is closed by the thyrohyoid
membrane.
- The structures passing through this gap are&
a. Internal layryngeal nerve. b.
0uperior laryngeal artery.
*. 3 gap between the two parts of the inferior
constrictor
- It is a weak area at the back of the pharynx
called #CillianDs dehiscence$
E. 3 gap at the lower border of the inferior
constrictor
- It is pierced by&
a. Inferior laryngeal artery. b.
<ecurrent laryngeal nerve.
Ner%e su!!"y of the !haryn,:
29
It is supplied mainly by the pharyngeal plexus which is composed of&
'- The glossopharyngeal nerve.
(- The pharyngeal branch of the vagus nerve #carrying fibres of cranial accessory nerve$.
)- 4ranches of the superior cervical sympathetic ganglion.
Motor ner%e su!!"y:
Through the pharyngeal plexus #by cranial part of accessory nerve$ except the
stylopharyngeas muscle which is supplied by the glossopharyngeal nerve.
Sensory ner%e su!!"y:
- Mucous membrane of the nasopharynxis supplied by Maxillary nerve.
- Mucous membrane of the oropharynxis supplied by :lossopharyngealnerve.
- Mucous membrane of the laryngopharynx is supplied by internal laryngeal branch
of the vagus nerve.
Arteria" su!!"y of the !haryn,:
- 3scending pharyngeal artery.
- 3scending palatine artery.
- ,acial and lingual arteries.
0enous draina$e of the !haryn,:
!haryngeal plexus of veins which drains into the internal %ugular vein.
Ly!hati# draina$e of the !haryn,:
- -eep cervical lymph nodes. - <etropharyngeal lymph nodes.
- !aratracheal lymph nodes.
The Eso!ha$us
The esophagus is a long muscular tube about 'F inches long that extends through
the neck, thorax and abdomen. It begins as a lower continuation of the pharynx and
ends at the cardiac end of the stomach.
Parts:
'. Cervical part: It begins opposite the lower border of cricoid cartilage, at the
level of A
th
cervical vertebra. The cervical part of esophagus lies between the
trachea anteriorly and the vertebral column and prevertebral muscles
posteriorly. The recurrent laryngeal nerve lies in the groove between the
trachea and esophagus on each side.
(. Thoracic part: It is the longest and the main part of the esophagus. It lies in
the superior then posterior mediastina. It has a slightly sinuous course. In the
superior mediastinum, It lies between the trachea anterior and the vertebral
column and prevertebral muscles posterior. The le"t recurrent laryngeal nerve
lies in the groove between the trachea and esophagus on the left side. The
azygos vein is close to the right side of esophagus while the thoracic duct is
close to its left side. In the posterior mediastinum, the esophagus is surrounded
by esophageal plexus of nerves #derived from both vagi$.
30
3. $do#inal part: It is the shortest of all parts. It enters the abdomen through
an opening in the right crus of the diaphragm. 3fter a course of about '7( inch #'.(E
cm$, it enters the stomach on its right side.
- It is covered on its anterior and lateral surfaces by peritoneum !eft and ri"#t va"i
lie on its anterior and posterior surfaces$ respectively

Sites of eso!ha$ea" #onstri#tion:
3t the beginning8 pharyngeo-esophageal %unction.
3t the site where the left bronchus cross in front of it.
3s crossed by the arch of aorta.
3t its termination #at the gastro-esophageal %unction$.
B"ood su!!"y:
'. ervical part& Inferior thyroid artery and vein
(. Thoracic part& 4ronchial arteries and descending thoracic aorta. Its venous
drainage is by 3zygos and hemiazygos and hemiazygos veins.
). 3bdominal part& +eft gastric artery and +eft gastric vein.
The lower end of esophagus is a site of portosystemic anastomosis so
vulnerable to esophageal varices in case of portal hypertension as in 4ilharzial
hepatic fibrosis or liver cirrhosis.
The Abdoen
3bdomen is the part of the trunk that lies between thora, and !e"%is. It lies
between the thora#i# dia!hra$ and the !e"%i# bri.
Anterior Abdoina" 7a""
Abdoina" Re$ions:
The abdomen is divided into G regions by two pairs of planes&
5ertical !lanes& +eft and right lateral midclavicular planes
=orizontal !lanes&
a. 0ubcostal plane& It lies immediately
inferior to the costal margins and
passes posterior through the body of +)
vertebra.
b. Intertubercular plane& onnects the
tubercles of iliac crests and reaches the
upper part of the body of +E.
Abdoina" re$ions are:
31
'- <ight hypochondrium.
(- .pigastric region.
)- +eft hypochondrium.
*- <ight lumbar #flank$ region.
E- +eft lumbar #flank$ region.
A- /mbilical region.
H- <ight iliac fossa #groin$.
I- +eft iliac fossa #groin$.
G- =ypogastric region.


Deratoes of anterior abdoina" 3a""
- The dermatome is the skin area supplied by a single segment of the spinal cord.
- There are ?three@ anatomical landmarks #levels$ for the dermatomal supply of the
skin of the anterior abdominal wall, at the xiphoid process T. H, 3t the umbilicusT. 'F
and at the suprapubic region T. '( #above the symphysis pubis$
Deratoes of anterior abdoina" 3a""
Fas#ia of Anterior Abdoina" 7a"":
0uperficial ,ascia&
This superficial fascia consists of one layer that contains a variable amount of
fat.
The superficial fascia %ust above the inguinal ligament can be divided into t3o
"ayers&
'- Su!erfi#ia" fatty "ayer #amperJs fascia$ containing a variable amount of
fat.
(- Dee! ebranous "ayer #0carpaJs fascia$ containing fibrous tissue and
very little fat. The superficial vessels and nerves run between these two layers.
32

Fas#ia of the Anterior Abdoina" 7a""
Mus#"es of anterior abdoina" 3a"":
Mus#"e Ori$in Insertion A#tion Inner%ation
.xternal
abdominal
obli;ue
.xternal surface of
lower I ribs.
Its fibers are
directed
downwards,
forwards and
medially.
4y an apponeurosis
into linea alba, pubic
crest K tubercle,
anterior superior iliac
spine K anterior half
of iliac crest.
,lexes and
laterally bends the
trunk
Intercostal nerves H-
'', subcostal,
iliohypogastric and
ilioinguinal nerves
Internal
abdominal
obli;ue
Thoracolumbar
fascia, anterior (7)
of the iliac crest,
lateral (7) of the
inguinal ligament.
Its fibers are
directed upwards,
forwards and
medially.
+ower ) or * ribs,
linea alba, pubic crest
and pectin. Its lower
fibers form an arch
called con%oint
tendon.
,lexes and
laterally bends the
trunk
Intercostal nerves H-
'', subcostal,
iliohypogastric and
ilioinguinal nerves
Transversus
abdominis
Inner surface of the
lower A ribs,
thoracolumbar
fascia, anterior (7)
of the inner lip of
iliac crest, lateral
'7) of inguinal
ligament.
+inea alba, pubic
crest and pectin. Its
lower fibers form an
arch together with the
lower fibers of
internal obli;ue
called con%oint
tendon.
,lexes and
laterally bends
trunk
Intercostal nerves H-
'', subcostal,
iliohypogastric and
ilioinguinal nerves
<ectus
abdominis
!ubic crest and
symphysis pubis.
Liphoid process, E
th
,
A
th
K H
th
costal
cartilages.
,lexes the trunk
and raises the
intra-abdominal
pressure.
intercostal nerves H-
'' and subcostal
nerve
!yramidalis !ubic crest, anterior
to rectus abdominis.
+inea alba. -raws the linea
alba inferiorly.
0ubcostal nerve
remasteric
muscle
+ower fibers of
internal obli;ue
muscle.
!ubic tubercle,
forms thin network of
muscle fascicles
elevates testis #not
well developed in
females$
genital branch of
the genitofemoral
nerve
33
around the spermatic
cord and testis #or
around the distal
portion of the round
ligament of the
uterus$
Notes:
The inguinal ligament is the infolded lower part of the external abdominal obli;ue
aponeurosis. The external spermatic fascia is the external abdominal obli;ue
muscleJs contribution to the coverings of the testis and spermatic cord.
'. <eflected ligament
(. +acunar ligament
- The lacunar ligament has the following boundaries& its apex #medial$ attached to
the pubic tubercle. its base #lateral - 0harp and free$ forms the medial boundary of
the femoral ring. its upper border attached to the medial part of the inguinal
ligament while its lower border attached to the medial part of the pectineal line.
). !ectineal ligament
- ,ew fibers extend from the lacunar ligament to be attached to the pectineal line.
The cremasteric muscle and fascia is the internal abdominal obli;ue muscleJs
contribution to the coverings of the testis and spermatic cord. remasteric reflex
may be elicited by stroking the medial thigh #where the femoral branch of the
genitofemoral n. distributes cutaneously$ #cremaster M a suspender$.
The con%oint tendon is formed of the lower arched fibers of both internal obli;ue
and transversus abdominis muscles.
- These arching fibers pass directly from origin to insertion #run for a short
distance$.
,unction&
- The contraction of the con%oint tendon tightens it and lowers the roof of the
inguinal canal #narrowing it$ #shutter mechanism$.
- This narrowing prevents passage of the intestine through the inguinal canal.
Transversalis fascia, the deep fascia that covers the inner surface of the
transversus abdominis, forms the internal spermatic fascia. The muscle is divided
into segments by tendinous intersections,it has an opening called deep inguinal
ring. - Its lower part shows an opening called the ?deep inguinal ring@ which is the
beginning of the inguinal canal.
!yramidalis m. is not always present.
34
Mus#"es of anterior abdoina" 3a""
Mus#"es of anterior abdoina" 3a""
Re#tus Sheath:
Definition:'
It is a fibrous envelope that surrounds rectus abdominis muscle formed by the
aponeurosis of the anterior abdominal wall muscles.
Foration:
'$ The internal obli;ue muscle splits for a greater part of its length into anterior
and posterior layers.
($ The anterior layer fuses with the aponeurosis of the external obli;ue to form
the anterior 3a"" of the re#tus sheath, while the posterior layer fuses with the
35
aponeurosis of the transversus abdominis to form the !osterior 3a"" of the
re#tus sheath*
7a""s of the re#tus sheath:'
The wall of the rectus sheath is subdivided into three !arts by t3o "ines which are&
'. +ine midway between the ubi"i#us and the
,i!hoid !ro#ess.
(. +ine midway between the ubi"i#us and the
sy!hysis !ubis*
#3$ /pper part&-
3nterior wall formed by& 3poneurosis of the
external obli;ue muscle.
!osterior wall formed by& The E
th
, A
th
and H
th
costal cartilage.
#4$ Middle part&-
3nterior wall formed by &
'. 3poneurosis of external obli;ue.
(. The anterior layer of the aponeurosis of internal
obli;ue
!osterior wall formed by &
'. !osterior wall of the aponeurosis of internal
obli;ue. Trans%erse se#tion of re#tus sheath
(. 3poneurosis of the transversus abdominis.
#$ +ower part&-
3nterior wall formed by &
'. 3poneurosis of external obli;ue.
(. 3poneurosis of internal obli;ue.
). 3poneurosis of the transversus abdominis.
!osterior wall formed by& ,ascia transversalis. The posterior wall ends here
forming an arched border called the ar#uate "ine.
36
Anterior and !osterior 3a""s of re#tus sheath
Contents of re#tus sheath
Content of the re#tus sheath:'
'. Two muscles '$ <ectus abdominis.
($ !yramidalis.
(. Two groups of vessels '$ 0uperior epigastric vessels
($ Inferior epigastric vessels.
). Two groups of nerves '$ +ower E intercostal nerves
($ 0ubcostal nerve.
I!ortant surfa#e ar(in$ of anterior abdoina" 3a""
B"ood Su!!"y of Anterior Abdoina" 7a"":
'. 0uperior epigastric artery #from the internal thoracic artery$.
- It pierces the posterior wall of the rectus sheath to anastomose with the inferior
37
epigastric artery.
(. Musculophrenic artery #from the internal thoracic artery$.
). +ower two posterior intercostal and subcostal arteries #from the descending
thoracic aorta$.
*. Inferior epigastric artery #from the external iliac artery$.
- It passes medial to the deep inguinal ring then it pierces fascia transversalis to
enter the rectus sheath in front of the arcuate line.
- It ends by anastomosing with the superior epigastric artery.
- It gives the following branches, pubic branch, cremasteric branch #supplies
cremaster muscle$ and muscular branches.
E. -eep circumflex iliac artery #from the external iliac artery$
- It gives the following branches, ascending branch, anastomotic branch and
muscular branches.
A. 0uperficial branches of the femoral artery which are superficial epigastric artery,
superficial circumflex iliac artery, and superficial external pudendal artery.
H. +umbar arteries #from the descending abdominal aorta$.
Arteries of anterior abdoina" 3a""
Ner%e Su!!"y of Anterior Abdoina" 7a""&
- The anterior abdominal wall muscles and the overlying skin are supplied by&
I. +ower five intercostal and subcostal nerves&
38
- They run in the costal groove #the subcostal nerve runs below the last rib$.
- Then, they pass between the costal origin of the diaphragm and transversus
abdominis muscle.
- More laterally, they pass between transversus abdominis and internal obli;ue
muscles.
- ,inally, they pierce the posterior wall of the rectus sheath, rectus abdominus, and
the anterior wall of the rectus sheath to terminate as the anterior cutaneous nerves.
II. Iliohypogastric and ilioinguinal nerves&
- 4oth nerves pierce psoas ma%or where they appear on its lateral border, then they
pass between the kidney and ;uadratus lumborum.
- Then, they pierce transversus abdominis and pass between it and internal obli;ue
where they supply both muscles #the ilioinguinal nerve pierces it close to the anterior
superior iliac spine which is the site of the appendicectomy$.
- ,inally, they pierce internal obli;ue and pass between it and external obli;ue where
they supply both muscles.
B The iliohypogastric nerve pierces the aponeurosis of external obli;ue two inches
above the medial part of the inguinal ligament to supply the overlying skin.
B The ilioinguinal nerve passes through the superficial inguinal ring to supply the
skin of the upper part of the medial side of the thigh and the skin of the anterior part
of the scrotum or labia ma%ora.
Inner%ations of anterior abdoina" 3a""
Ly!hati#s of anterior abdoina" 3a"":
Ly!hati#s in the re$ion abo%e the ubi"i#us are drained into the axillary
lymph nodes.
Ly!hati#s in the re$ion be"o3 the ubi"i#us are drained into the superficial
inguinal nodes.
39
The In$uina" #ana"
It is an obli;ue inter-muscular slit * cm long above the medial half of inguinal
ligament.
It begins at the deep inguinal ring and terminates at the superficial ring.
In$uina" rin$s:
Su!erfi#ia" in$uina" rin$:
It is a triangular opening in the aponeurosis of the external obli;ue muscle that
lies %ust lateral to the pubic tubercle.
Dee! in$uina" rin$:
It lies in the transversalis fascia, %ust lateral to the inferior epigastric vessels. It
is half an inch above the midpoint of inguinal ligament.
Boundaries:
3nterior wall& aponeurosis of the external obli;ue muscle along the whole
length of the canal and fleshy fibers of internal obli;ue muscle along the lateral
'7( of the canal.
!osterior wall& it is formed by transversalis fascia along the whole length of the
canal, con%oint tendon along medial '7( and reflected ligament along medial
'7*.
0uperior wall #roof$& arching fibers of the internal obli;ue and transverse
muscles.
Inferior wall #floor$& inguinal and lacunar ligaments.
ontents& it transmits the spermatic cord or the round ligament of the uterus
and the genital branch of the genitofemoral nerve, both of which also run
through the deep inguinal ring and the inguinal canal. 3n indirect inguinal
hernia #if present$ also passes through this canal.
In$uina" #ana"& #ontents and boundaries
In$uina" trian$"e:
40
Is bounded medially by the linea semilunaris #lateral edge of the rectus
abdominis$, laterally by the inferior epigastric vessels, and inferiorly by the
inguinal ligament. Is an area of potential weakness and hence is a common site
of a direct inguinal hernia.
5ernia:
It is a protrusion of the peritoneum or extra-peritoneal fat through an abnormal
opening in the abdominal wall.
- Inguinal hernia is a common type and it is further subdivided into&
a. Indirect inguinal hernia which is common in the younger age and the viscera
pass through the deep inguinal ring, then through the inguinal canal. The neck of
the hernia lies lateral to the inferior epigastric artery.
b. -irect inguinal hernia which is common in the older age and occurs in the
inguinal triangle. The neck of the hernia lies medial to the inferior epigastric
artery.
The Posterior abdoina" 3a""
The posterior abdominal region is the part posterior to the abdominal
gastrointestinal tract, as well as the spleen and pancreas. This area is bounded by
bones and muscles making up the posterior abdominal wall, contains numerous
structures, for example muscles forming the posterior abdominal wall, aorta and its
associated nerve plexuses, the inferior vena cava, sympathetic trunk, and lymphatics.
Boundaries:
Mid"ine& E lumbar vertebrae K their I5 discs.
41
On ea#h side: '(
th
<ib, upper part of the bony pelvis, psoas muscles, ;uadratus
lumborum muscles, and aponeurosis of origin of the transverses abdominis muscles.
The iliacus muscles lie in the upper part of the bony pelvis.
Su!erior"y: the diaphragm forms the boundary of the posterior abdominal region.
Mus#"es of Posterior Abdoina" 7a"":
Mus#"e Ori$in Insertion Inner%ation A#tions
Psoas Ma8or Transverse processes
of lumbar vertebra8
lateral surface of
bodies of T'(-+E and
intervening I5 discs.
4y a strong
tendon to
lesser
trochanter of
femur.
+umbar plexus
via anterior
rami of +'-(-)
nerves.
- ,lexion of the
thigh.
- +ateral flexion
of the trunk.
Psoas Minor
#May be absent$
+ateral surface of
bodies of T'(-+' and
intervening I5 discs.
!ectineal line
and ilio-
pectineal
eminence.
3nterior rami
of +'.
6eak flexion of
the trunk.
I"ia#us /pper two thirds of
iliac fossa, ala of
sacrum, anterior
sacroiliac and
iliolumbar ligaments.
+esser
trochanter of
femur and
shaft inferior
to it. #6ith
the tendon of
psoas ma%or
muscle$.
,emoral nerve
#+( - +*$.
,lexes thigh and
stabilizes hip
%oint, acts with
psoas ma%or.
9uadratus
"uboru
Iliolumbar ligament,
internal lip of iliac
crest and transverse
processes of +E.
Medial half of
inferior
border of '(
th

rib and tips of
lumbar
transverse
processes.
3nterior rami
of T'( and +'-
+* nerves
+aterally flexes
vertebral column
and fixes '(
th
rib
during
inspiration.
42
Mus#"es of !osterior abdoina" 3a""
The Abdoina" aorta
The abdominal aorta is the largest artery in the abdominal cavity.
It is a direct continuation of descending thoracic aorta. It is ') cm long.
It enters the abdomen opposite '(
th
thoracic vertebra through aortic opening of
the diaphragm. It ends by dividing into ( common iliac arteries opposite the
*th lumbar vertebra.
Anterior re"ations of aorta and inferior %ena #a%a

43
Anterior view
Re"ations of abdoina" aorta:
Anterior re"ations fro su!erior to inferior:
eliac ganglia and plexus.
4ody of the pancreas.
0plenic and left renal veins.
#)
rd
part$ part of the duodenum.
0uperior mesenteric vessels and root of mesentery.
Posterior re"ations:
+umbar vertebrae #'-*$ and intervertebral discs.
3nterior longitudinal ligament .
)
rd
and *
th
lumbar veins.
On the ri$ht:
3zygos vein.
isterna chyle and thoracic duct.
<ight crus of the diaphragm.
Inferior vena cava.
On the "eft:
+eft crus of the diaphragm.
-uodeno- %e%unal %unction.
*
th
part of the duodenum.
0ympathetic trunk.
0ome coils of the small intestine.
Inferior mesentric vessels.
Posterior& ri$ht and "eft re"ations of aorta and inferior %ena #a%a
44
Bran#hes of abdoina" aorta:
Bran#h 0ertebra" "e%e" Paired or sin$"e
inferior phrenic arteries +' #upper border$ !aired
coeliac trunk +' #upper border$ 0ingle
superior mesenteric artery +' #lower border$ 0ingle
middle suprarenal arteries +' #lower border$ !aired
renal arteries +( !aired
gonadal arteries +) !aired
four lumbar arteries +'-+* !aired
inferior mesenteric artery +) 0ingle
median sacral artery +*
0ingle
common iliac arteries +* !aired
N*B* 4ifurcation #union$ of the inferior vena cava is at +E #below that of the
bifurcation of the aorta$.
Bran#hes of aorta
Coon I"ia# Arteries:
1 The abdominal aorta divides, on the left side of the body of the fourth lumbar
vertebra, into the two common iliac arteries.
1 .ach artery ends in front of sacro- iliac %oint by dividing into external and
internal iliac arteries.
45
E,terna" i"ia# Arteries:
1 "ne of the two terminal branches of the common iliac artery.
1 .ach begins at the sacro-iliac %oint.
1 It leaves the abdomen by passing behind the mid-inguinal point where it
becomes the femoral artery.
1 4ranches& inferior epigastric artery and deep circumflex iliac artery.
46
Inferior %ena #a%a .I0C/
1 It is the largest vein in the body. It is formed by union of two common iliac veins
anterior to and %ust to the right of E
th
lumber vertebra.
1 It ascends on the right side of aorta, passes in the vena cava opening of diaphragm
opposite TI and drains into the right atrium.
1 It conveys blood from the whole body below the diaphragm to the right atrium.
Posterior re"ations:
+ower part& is related to vertebral column, anterior longitudinal ligament, right
sympathetic trunk.
/pper part& is related to right crus of the diaphragm, right renal artery, right middle
suprarenal artery, right suprarenal gland, right celiac ganglion and right phrenic
artery.
Anterior re"ations:
!osterior surface of the liver, '
st
part of the duodenum, head of the pancreas, )
rd
part of
the duodenum, right gonadal and common iliac arteries, peritoneum and coils of the
small intestine.
Tributaries of I*0*C:'
'. Two common iliac veins&
- they unite together forming
I.5..
(. Two pairs of lumbar veins&
- )
rd
, *
th
.
). Two renal veins #<t. K +t.$.
*. Two inferior phrenic veins.
E. Two hepatic veins.
A. <ight gonadal vein.
H. <ight suprarenal vein.

Position& re"ations and tributaries of inferior %ena
#a%a

47
Inferior %ena #a%a and its tributaries
Ner%es of !osterior abdoina" 3a""
0everal important components of the nervous system are in the posterior
abdominal region. These include the sympathetic trunks and associated splanchnic
nerves, the plexus of nerves and ganglia associated with abdominal aorta, and lumber
plexus of nerves.
Sy!athati# Trun(:
1 Two long ganglionated nerve strand one on each side of the vertebral column.
1 It extends from the base of the skull to the coccyx.
1 It enters the abdomen deep to the medial arcuate ligament of the diaphragm.
1 It lies along the medial border of psoas ma%or. 3nteriorly on the right side, it lies
behind the I.5.. and on the left side, it lies along the left side of the aorta.
1 It passes inferiorly behind common iliac vessels.
1 Its termination is by %oining to form unpaired ganglion impar #anterior to sacrum$.
.ach trunk has four ganglia and receives a white ramus from each of the upper
two or three lumber nerves and sends grey rami to each of the five lumber nerves to
be distributed with nerves to somatic structures. ,our rami, the lumber splanchnic
nerves, run medially to the inter-mesentric and superior hypogastric plexuses to be
distributed with blood vessels to viscera.
48
Sy!athati# trun( and !re%ertebra" !"e,uses and $an$"ia
Lubar !"e,us:
,ormation& formed by anterior rami of +'-+), and upper part of +*.
!osition& lies within substance of psoas ma%or. Therefore, relative to the psoas
ma%or muscle the various branches emerge either&
3nterior N genitofemoral nerve8
Medial N obturator nerve and lumbosacral trunk
+ateral- iliohypogastric, ilioinguinal, femoral nerve and lateral cutaneous
nerve of the thigh.
The i"iohy!o$astri# ner%e
The iliohypogastric nerve is formed by fibers from +'. It supplies the skin over the
lateral gluteal region and the skin above the pubis.
The i"ioin$uina" ner%e
49
The ilioinguinal nerve is formed in common with the iliohypogastric nerve. It
passes through the superficial inguinal ring.
The $enitofeora" ner%e
The genitofemoral nerve is formed from +', ( and passes through the psoas to emerge
on its anterior surface. It runs downwards on the psoas and divides into genital and femoral
branches. The genital branch enters the inguinal canal through the deep inguinal ring to
supply the cremasteric muscle and a small area of overlying skin. The femoral branch
passes behind the inguinal ligament to enter the femoral sheath and supply the skin over the
femoral triangle.
Latera" #utaneous ner%e of the thi$h
The lateral cutaneous nerve of the thigh emerges at the lateral border of the psoas
muscle. It is formed from the posterior division of the +(,) anterior primary rami. It
supplies the skin on the lateral part of the thigh.
The feora" ner%e
The femoral nerve arises from posterior division of the +(,),* anterior primary rami.
The nerve lies between psoas and iliacus and enters the thigh behind the inguinal ligament.
The obturator ner%e
The nerve arises from anterior division of the +(,),* anterior primary rami. It emerges
medial to the psoas muscle and leaves the pelvis through the obturator foramen.
The "ubosa#ra" trun(
3 part of the anterior division of the +* primary ramus and the +E primary ramus form the
lumbosacral trunk. The trunk lies anterior to the ala of the sacrum to %oin the 0' anterior
primary ramus.
Mus#u"ar ner%es
The T'( and lumbar primary rami send short nerves into neighboring muscles8 the
;uadratus lumborum, and psoas.
Bran#hes of "ubar !"e,us
Thora#o'"ubar fas#ia:
50
This is strong fascia which covers the muscles of the back and trunk. It is also called
lumber fascia because it is well developed in the lumbar region, but it extends
upwards to the neck and downward to the sacrum.
It is formed of three layers in the lumbar region&
a. 3nterior layer& lies infront of ;uadratus lumbrum muscle and is attached to the
anterior surface of transverse processes of lumbar vertebrae.
b. Middle layer& it covers the posterior surface of ;uadratus lumbrum muscle and
is attached to the tip of transverse processes of lumbar vertebrae.
c. !osterior layer& It covers the deep muscles and is attached to lumbar spines.
Trans%erse se#tion of abdoen sho3in$ the thora#o"ubar fas#ia
The Peritoneu
51
!eritoneum is a thin serous membrane lines the walls of abdominal cavity that
cover much of the viscera.
- The !arieta" !eritoneu lines the walls of the abdominal cavity. It clothes the
anterior and posterior abdominal walls, the under surface of the diaphragm, and the
cavity of the pelvis. The %is#era" !eritoneu is the continuation of the parietal
peritoneum which leaves the posterior wall of the abdominal cavity to invest certain
viscera. 4etween the parietal and visceral layers of peritoneum is a potential space
#the peritoneal cavity$. 3bdominal viscera are either suspended in the peritoneal
cavity by folds of peritoneum #esenteries$ or are outside the peritoneal cavity.
"rgans suspended in the cavity are referred to as intraperitoneal8 organs outside the
peritoneal cavity, with only one surface or part of one surface covered by peritoneum,
are retroperitoneal. :reater sa# accounts for most of the space in the peritoneal
cavity, beginning superiorly at the diaphragm and continuing inferiorly into the pelvic
cavity-it is the part of the peritoneal cavity %ust behind the anterior abdominal wall.
+esser sa# is a smaller subdivision of the peritoneal cavity posterior to the stomach
and liver and is continuous with the greater sac through an opening, the e!i!"oi#
foraen of 7ins"o3*
Sa$itta" se#tion of the abdoen sho3in$ !eritonea" ref"e#tions on the
different %is#era
Peritonea" ref"e#tions in sa$itta" se#tion:
52
'To understand the extent of the greater sac, it is followed in a vertical direction.
,ollowing the peritoneum on the inner aspect of the anterior abdominal wall in an
upward direction, a sickle shaped fold of peritoneum connects the anterior abdominal
wall with the liver to the right of the median plane. "n the right side of the falciform
ligament, the peritoneum continues on the under surface of the diaphragm. Then, it is
reflected from the under surface of the diaphragm on to the superior surface of the
liver. This reflection is called the u!!er "ayer of #oronary "i$aent.
- The peritoneum passes from the upper surface of liver to its anterior surface, then to
its inferior surface. ,rom the posterior part of the inferior surface, the peritoneum is
reflected to the front of right kidney and suprarenal gland. This reflection is called the
"o3er "ayer of #oronary "i$aent* These two layers of coronary ligament bound the
bare area of the "i%er which has no peritoneal covering.
- ,ollowing the upper and lower layers of coronary ligament to the right shows that
they meet at the apex of bare area to form the ri$ht trian$u"ar "i$aent*
- ,rom the front of right kidney, the peritoneum passes to the front of the duodenum
and right colic flexure. Oust above the duodenum, the peritoneum passes medially in
front of inferior vena cava to form the posterior boundary of the e!i!"oi# foraen*
- If the stomach is reflected away from the liver, a peritoneum fold ."esser
oentu/ is found connecting the liver with the stomach which is formed by two
layers. The two layers of peritoneum separate to enclose the stomach. Then, they
come close together at the greater curvature of stomach to form a big peritoneal fold
.$reater oentu/. The two layers of greater omentum descend down and then recur
up to be attached to the anterior border of pancreas.
- The peritoneum of greater sac passes down from the anterior border of the pancreas
to form another peritoneal fold .trans%erse eso#o"on/ to enclose the transverse
colon.
- ,rom the anterior border of pancreas, the peritoneum passes down to cover the
inferior surface of body of pancreas, duodenum and structures found in the posterior
abdominal wall.
- !eritoneum covering the posterior abdominal wall makes a reflection along the
course of superior mesenteric artery to enclose the free part of small intestine
.esentery of sa"" intestine/*
- The peritoneum continues down to continue into the pelvis to form the pelvic
peritoneum.

53

Sa$itta" se#tion of the abdoen sho3in$ Trans%erse se#tion of the
atta#hent of fa"#ifor "i$aent* abdoen sho3in$ the
atta#hent of esentry*

Atta#hents of the $reater Anterior %ie3 of abdoina" #a%ity
and "esser oentu sho3in$ atta#hent of esentery
and trans%erse eso#o"on
54
Atta#hent of !eritoneu on the different surfa#es of the "i%er
Peritonea" ref"e#tions in hori:onta" se#tion:
- the peritoneum covers the inner aspect of the anterior abdominal wall and reflects in
a horizontal pattern to form gastrosplenic, lienorenal, lesser omentum, falciform
ligaments of the liver.
Lesser sa#:
This is a diverticulum from greater sac8 it extends down behind the stomach as far as
the transverse mesocolon and is bounded below the stomach by the greater omentum.
The opening of the lesser sac #e!i!"oi# foraen$ lies behind the free edge of the
lesser omentum.
Boundaries of the e!i!"oi# foraen:
Posterior: the inferior %ena #a%a lies immediately behind the posterior peritoneum.
Su!erior: the inferior surface of the liver, the #audate !ro#ess.
Inferior: the first !art of the duodenu.
Anterior: the free edge of the lesser omentum8 in which the !orta" %ein "ies behind& the #oon
bi"e du#t in front and the he!ati# artery in front on the "eft of the bi"e du#t*
Re"ations of the "esser sa#:
The lesser sac has t3o 3a""s& anterior and posterior, and four borders: upper,
lower, left and right.
Anterior 3a""& It is formed by&
55
The lesser omentum.
!eritoneum covering the posterior surface of the stomach K first part of
duodenum.
3nterior two layers of the greater omentum.
Posterior 3a"": Its lower part is formed by the posterior two layers of the greater
omentum, while its upper part is formed by peritoneum covering structures on the
posterior abdominal wall which include&
4ody of the pancreas.
/pper part of abdominal aorta.
eliac artery and its branches.
-iaphragm.
+eft kidney.
+eft suprarenal gland.
;!!er border: It is formed by reflection of peritoneum between liver and the
diaphragm.
Lo3er border: It is formed by the inferior margin of the greater omentum where the
anterior two layers become continuous with the posterior two layers.
Left border: formed by the gastrosplenic K lienorenal ligaments.
Ri$ht border the epiploic foramen #foramen of 6inslow$.
The Stoa#h
Site:
The stomach is situated in the left hypochondriac, epigastric and umbilical regions
of the abdomen. It is O-shaped organ and has t3o orifi#es, the cardiac and pyloric
orifices, t3o #ur%atures, the greater and lesser curvatures, and t3o surfa#es, an
anterior and a posterior surface.
Parts of the stoa#h:
'- Fundus: is dome-shaped and pro%ects upward and to the left of the cardiac
orifice. It is usually full of gas.
(- Body: extends form the fundus to a line extending from the incisura angularis
on the lesser curvature to the prepyloric bulge on the greater curvature.
)- !y"ori# !art: it is lower part of the stomach. It has three parts #pyloric antrum,
pyloric canal and pyloric sphincter$.
Cur%atures of the stoa#h:
)' Lesser #ur%ature: forms the right border of the stomach and extends from the
cardiac orifice to the pylorus. The lesser omentum extends from the lesser
curvature to the liver. It is related to the right and left gastric vessels.
-' 2reater #ur%ature: forms the left border of the stomach and extends from
the cardiac orifice to the pylorus. It gives attachment to gastrophrenic,
56
gastrosplenic and greater omentum from above downwards. It is related to
right and left gastroepiploic vessels.
Orifi#es of the stoa#h:
)' Cardia# orifi#e: is ) in#h to the left of the median plane at level of T*)<.
It is a physiological sphincter as it depends on the presence of mucosal folds,
positive intra-abdominal pressure and few fibers from the right crus of the
diaphragm which encircle it.
-' Py"ori# orifi#e: is )=- in#h to the right of the median plane at level of L*)
#transpyloric plane$.
' It is anatomical sphincter as it contains circular muscle fibers.
Re"ation of Anterior surfa#e:
'- =epatic area #liver$.
(- 3nterior abdominal wall.
)- -iaphragmatic area #-iaphragm$.
Re"ation of Posterior surfa#e .stoa#h bed/:
It is related posteriorly to lesser sac,
diaphragm, spleen, left suprarenal gland,
upper part of the left kidney, splenic
artery, pancreas, transverse mesocolon
and transverse colon.
Surfa#es of the stoa#h:
57
Stru#tures forin$ the stoa#h bed
B"ood su!!"y of the stoa#h:
)' Arteria" su!!"y to the stoa#h:
These are derived from the bran#hes of the #e"ia# trun(.
a. Left $astri# artery arises from the celiac artery.
b. Ri$ht $astri# artery arises from the hepatic artery.
c. Short $astri# arteries arise from the splenic artery.
d. Left $astroe!i!"oi# artery arises from the splenic artery.
e. Ri$ht $astroe!i!"oi# artery arises from the gastroduodenal branch of
the hepatic artery.
-' 0enous draina$e of the stoa#h:
The "eft and ri$ht $astri# %eins drain directly into the portal vein.
The short $astri# %eins and the "eft $astroe!i!"oi# %ein %oin the splenic vein
The ri$ht $astroe!i!"oi# %ein %oins the superior mesenteric vein.
Ly!h draina$e of stoa#h:
58
- The gastric lymph vessels drain ultimately into the celiac lymph nodes.
Ly!hati# draina$e of stoa#h
Ner%e su!!"y of the stoa#h:
'- Sy!atheti#: from celiac plexus around celiac trunk. It causes relaxation of
the wall and contraction of pyloric sphincter. It carries also pain sensation.
(- Parasy!atheti#: from anterior and posterior gastric nerves. It is secretory to
the glands of the stomach, inhibitory to the pyloric sphincter and motor to the
wall.
The Sa"" Intestine
The sa"" intestine& is a convoluted tube, about A meters long, extending from the
!y"orus to the i"eo'#e#a" %a"%e, situated centrally in the abdominal cavity and is
flanked laterally and superiorly by the large intestine.
Di%isions:
'. -uodenum (. Oe%unum ). Ileum
The Duodenu
59
' It is the shortest, widest and most fixed part of the small intestine.
Parts of the duodenu
Position and Sha!e:
,ixed to the posterior abdominal wall #retroperitoneal$, occupies the epigastric
and umbilical regions.
,ollows a C' shaped course around the head of the pancreas.
.xtends from the pylorus to the duodeno-%e%unal flexure.
Parts of the duodenu:
)* First !art:
' - inches long, its '
st
inch is mobile because it is covered by peritoneum
anteriorly and posteriorly.
' It be$ins at the pylorus, '7( an inch to the right of the median plane at the level of
L) #transpyloric plane$.
Re"ations:
Anterior"y& ;uadrate lobe of the liver and gallbladder.
Posterior"y& neck of the pancreas, portal vein, bile duct, and gastro-duodenal
artery.
Inferior"y& head of pancreas.
Su!erior"y: related to epiploic foramen.
-* Se#ond !art:
) inches long and descends vertically from the level of +' to the level of +). This part
is only covered by peritoneum anteriorly.
Re"ations:
Anterior: right lobe of the liver, gall bladder, transverse colon and coils of
%e%unum.
Posterior: hilum of the right kidney.
Latera": hepatic flexure of the large intestine.
Media": head of pancreas, bile duct and pancreatico Nduodenal arteries.
+* Third !art&
* inch long, lies horizontally opposite to the level of L+*
Re"ations&
60
Anterior: superior mesenteric vessels in the root of the mesentery of the small
intestine and coils of small intestine.
Posterior: it is related to the following structures from the right to the left side&
right ureter, right psoas ma%or, right. gonadal vessels, I5, aorta and inferior
mesenteric artery.
Su!erior& head of pancreas.
Inferior& coils of small intestine.
1* Fourth !art&
It is one inch long. It ascends from the level of the third to the level of the second
lumber vertebra one inch to the left of median plane at the dudeno-%e%unal flexure.
Re"ations:
Anterior: transverse colon and transverse mesocolon.
Re"ations of the duodenu
Posterior: left sympathetic chain, left psoas ma%or, left gonadal and left renal vessels.
Media": head of pancreas and aorta.
61
Latera": +t Cidney.
Re"ations of the duodenu
B"ood su!!"y of the duodenu:
Arteria" su!!"y of the duodenu:
'. 0upra-duodenal artery& from the hepatic artery proper #celiac trunk$.
(. 0uperior pancreatico-duodenal artery& from gastro-duodenal #celiac$.
). Inferior pancreatico-duodenal artery& from superior mesenteric artery.
Peritoneal recesses of the duodenum:
'. 0uperior duodenal recess.
(. Inferior duodenal recess.
). !araduodenal recess.
*. <etroduodenal recess.
>e8unu and i"eu
62
They form the mobile part of the small intestine, suspended from the posterior
abdominal wall by a mesentery.
Differen#es bet3een 8e8unu and i"eu&
>e8unu I"eu
'. Len$th The proximal (7E The distal )7E
(. Diaeter 6ide 2arrow
+*Arteria" ar#ades ,ew and simple 2umerous and complex
1* Mesentery ,ew fat ,presents 3indo3s Much fat, no 3indo3s
4* Mu#osa" Cir#u"ar
Fo"ds
. P"i#a Cir#u"aris/
2umerous ,ew
?*Peyer
&
s Pat#hes no Nuerous Peyer
@
s !at#hes
63
Mesentery of sa"" intestine
Mesentery of the sa"" intestine& is a fan- shaped peritoneal fold which has an
anterior free border and posterior attached border. The anterior border contains the
%e%unum and ileum and is A meter long. The posterior border is the root of mesentery
and is A inches long.
Borders:
)* Atta#hed border #root of mesentery$& It is Ainches, extends from duodeno-%e%unal
flexure to iliocecal %unction.
Stru#tures #rossed by the root of the esentery .6/:
64
'. )
rd
part of duodenum
(. 3bdominal aorta and right gonadal vessels.
). I5.
*. <ight psoas ma%or.
E. <ight ureter.
A. <ight genitor-femoral nerve.
Contents of the esentery:
'- 0uperior mesenteric artery.
(- 0uperior mesenteric vein.
)- oils of the small intestine
*- .xtraperitoneal tissue and fat.
E- 0ympathetic nerve fibers.
A- Mesenteric +2 #arranged in three groups& large, medium, and small$.

The Lar$e Intestine
65
Len$th: is about '.E meters.
Parts:
aecum and appendix.
olons #ascending,transverse,descending and pelvic$
,lexures #right and left colic flexures$.
<ectum.
3nal anal.
The Main Differen#es bet3een Sa"" and Lar$e intestine:
Tenia Co"i: are the longitudinal outer muscle layer which is represented by )
bands. They are not found in the appendix and rectum.
Sa##u"ations: this due the length of tenia coli is shorter than the length of the
large intestine.
A!!endi#es E!i!"oi#ae: small sacs of peritoneum-covered fat hanging from
the surface of the colon.
Sa"" intestine
Tenia #o"i !resent 3bsent
Sa##u"ations !resent 3bsent
A!!endi#es e!i!"oi#ae !resent absent
Parts and #hara#teristi#s of "ar$e intestine
The Cae#u
It is a mobile blind sac at the beginning of the large intestine.
66
%acculations
Position: It occupies the right iliac fossa and is completely covered with peritoneum.
Re"ations:
Anterior"y& anterior abdominal wall, greater omentum, and coils of small
intestine.
Posterior"y& - Muscles& !soas ma%or and iliacus.
( 2erves& ,emoral and lateral cutaneous nerve of the thigh.
Posterior re"ations of #ae#u
Couni#ations of the #ae#u:
Terina" i"eu: opens into the posteromedial aspect of the caecum at
i"eo#e#a" orifi#e& guarded by i"eo#e#a" %a"%e*
A!!endi,& opens into the posteromedial aspect, inferior to the ileocecal
opening*
As#endin$ #o"on: continuous upwards with it.
Interior of #e#u to sho3 i"eo#e#a" %a"%e
Peritonea" re#esses re"ated to the #e#u:
)* Su!erior I"eo#e#a" Re#ess: behind the vascular fold of the cecum.
67
-* Inferior I"eo#e#a" Re#ess: behind the ileocecal fold.
+* Retro#e#a" Re#ess: behind the cecum.
Peritonea" re#esses re"ated to the #e#u
B"ood su!!"y of #ae#u:
Arteria" su!!"y: anterior and posterior #ae#a" arteries from i"eo#o"i# artery
which is a branch from superior mesenteric artery.
0enous draina$e: into superior mesenteric vein then into portal vein.
The 0erifor a!!endi,
It is a worm like tube, about 'F cm long, opens by its base into posteromedial
aspect of the caecum below the terminal ileum. It has a mesentery known as
mesoappendix which is a triangular peritoneal fold, containing the appendicular artery
in its free border.
Positions of the A!!endi,:
'. <etrocecal #AEP$ (. !elvic #)FP$
). 0ubcecal #)P$ *. !re or post- ileal #(P$
Different !ositions and arteria" su!!"y of a!!endi,
B"ood su!!"y of the a!!endi,:
Arteria" su!!"y& appendicular artery from
68
the posterior caecal artery from ileocolic artery.
0enous drain$e: into superior mesenteric vein.
Surfa#e anatoy of the Base of the a!!endi,
.M#Burney@s !oint/:
It is represented by a point at the %unction of
lateral
'
7
)
rd
and medial
(
7
)
rd
of a line connecting
anterior superior iliac spine and the umbilicus.
C"ini#a" note: inflammation of the appendix
#appendicitis$ causing ill-defined colicky pain, felt in the umbilical region whyQ
4ecause, the appendix is supplied with sympathetic fibers from 'F
th
thoracic spinal cord
segment, and the 'F
th
thoracic somatic nerve supplies the skin of umbilical region.
The As#endin$ #o"on
It begins as a continuation of the cecum and ends %ust below the "i%er& here it
continues with the transverse colon at the ri$ht #o"i# .hepatic/ f"e,ure* It is covered
by peritoneum anteriorly and on each side.
Position and !eritonea" #o%erin$ of as#endin$ #o"on
Re"ations:
Posterior re"ations&
iliolumbar ligament, transverses abdominis, ;uadratus lumborum and iliacus.
) nerves& iliohypogastric, ilioinguinal and lateral cutaneous of the thigh.
' viscera& right kidney.
Anterior re"ations: oils of small intestine and greater omentum.
69
Posterior re"ations of as#endin$ #o"on
B"ood su!!"y:
Arteria" su!!"y: ,rom superior mesenteric artery
'- Ileocolic artery (- <ight olic artery
0enous draina$e: Into the veins corresponding to the arterial supply.
The Trans%erse #o"on

It runs from the right colic #hepatic$ flexure across the abdomen to the "eft #o"i#
.s!"eni#/ f"e,ure. It is completely covered with peritoneum which forms transverse
mesocolon and it is freely mobile.
Re"ations:
Anterior re"ations: +iver, stomach and greater omentum.
Posterior re"ations: 0econd part duodenum, head of pancreas, %e%unum and left
kidney.
Posterior re"ations of the trans%erse #o"on
Trans%erse eso#o"on:
Transverse colon is suspended from the posterior abdominal wall by its trans%erse
eso#o"on which is attached to the anterior border of !an#reas*
70
Contents of trans%erse eso#o"on:
'. Transverse colon. (. Middle colic artery.
). .xtra-peritoneal fat. *. sympathetic nerves.
B"ood su!!"y:
Arteria" su!!"y:
'. <ight (7) by right and middle colic arteries of superior mesenteric artery.
(. +eft '7) by ascending branch of left colic artery from inferior mesenteric artery.
0enous draina$e: Into the veins corresponding to the arterial supply.
Arteria" su!!"y of #o"on
The Des#endin$ #o"on
It runs from the left colic #s!"eni#$ flexure and descends till the pelvic brim to
continue as si$oid#!e"%i#$ colon.
71
Peritonea" #o%erin$s: It is covered by peritoneum anteriorly and on each side.
N*B: left colic flexure is higher than the right flexure and attached to the diaphragm
by a peritoneal fold called !hreni#o'#o"i# "i$aent which prevents vertical descent
of the spleen into the left iliac fossa in case of splenomegaly.
The Pe"%i# .si$oid/ #o"on
It begins at the left side of the pelvic brim.
It ends at the )
rd
sacral piece where the rectum begins.
It describes 0-shaped course.
It is completely covered with peritoneum and suspended by the sigmoid
mesocolon.
Arteria" su!!"y of "ar$e intestine Inferior re"ations of !e"%i# #o"on
B"ood su!!"y:
Arteria" su!!"y: sigmoid branches of the inferior mesenteric artery.
0enous draina$e: It drains its venous blood into the veins corresponding to the
arterial supply.
72
Si$oid eso'#o"on: is a peritoneal fold which is attached to the posterior pelvic
wall by an inverted 0' shaped root*
0igmoid meso-colon has an apex and two limbs.
The apex of the meso-colon lies anterior to the left ureter and the point of
bifurcation of the left common iliac artery.
Medial limb& descends infront of the sacrum and ends opposite the )
rd
sacral
piece.
+ateral limb& extends along the left side of pelvic brim along the left external
iliac vessels.
Contents of the si$oid eso#o"on:
'. 0igmoid colon in the free border.
(. 0igmoid vessels in the lateral limb.
). 0uperior rectal vessels in the medial limb.
The Re#tu
Be$innin$:
Course:
Terination:
Be$ins at the +
rd
sa#ra" !ie#e as a continuation of the
sigmoid colon.
Fo""o3s the concavity of sacrumK coccyx #sa#ra" f"e,ure/*
Ends at the recto-anal %unction, about ) in#h in front and
be"o3 thetip of coccyx by bending posteriorly #!erinea"
f"e,ure/.
Its lower part is dilated and called a!u""a*
73
Peritonea" #o%erin$ ;!!er )=+
rd
front and sides are covered by peritoneum.
Midd"e )=+
rd
front is only
covered by peritoneum.
Lo3er )=+
rd
has No
peritoneal covering.
Latera" F"e,ures
A
Mu#osa" fo"ds
.valves$*
'. +ateral flexures&
a. /pper flexure& oncave to the left side.
b. Middle flexure& oncave to the right side.
c. +ower flexure& oncave to the left side.
(. 3ntero-posterior flexures&
a. 0acral flexure&
- It is concave forwards #following the concavity of the
sacrum$.
b. !erineal flexure&
- It is convex forwards and lies at the recto-anal %unction.
- The lower end of the rectum is dilated and called the
?ampulla of the rectum@.
Re"ations of the re#tu:
In a"es: In fea"es
74
Anterior - <ecto-vesical pouch containing coils of
ileum and sigmoid colon.
- 4ase of urinary bladder.
- 3mpulla of vas deference.
- 0eminal vesicles.
- !rostatic gland.
- Terminal part of ureter.
- <ecto-uterinepouch, coils of ileum and
sigmoid colon.
- !osterior wall of vagina.
Posterior Mus#"es :
' !iriformis
- +evator3ni
'occygeus
Bones :
' 0acrum
-occyx
0esse"s:
' 0uperior <ectal 3rtery
- Median0acral 3rtery
Ner%es:
' 0ympathetic Trunks
' +ower ) 0acral 2erves
- occygeal 2erves
As a"es
Latera""y -+evator3ni
- occygeus
-!ararectal ,ossa
As a"es
B"ood su!!"y of the re#tu&
Arteria" su!!"y 0enous draina$e
75
'* Su!erior re#ta" artery&
- It is the continuation of inferior
esenteri# artery*
- It supplies the rectum and upper half
of anal canal.
(. Midd"e re#ta" artery&
It arises from the anterior division of
internal iliac artery.
)* Inferior re#ta" artery&
It arises from internal pudendal artery.
)* Su!erior re#ta" %ein continues up
as inferior esenteri# %ein 3hi#h
drains into the s!"eni# %ein*
.Porta" #ir#u"ation/
-* Midd"e re#ta" %ein:
-rains into internal iliac vein.
.Systei# #ir#u"ation/
+* Inferior re#ta" %ein:
-rains into interna" !udenda" %ein*
.Systei# #ir#u"ation/
C"ini#a" note:
0uperior, middle, and inferior rectal
veins anastomose with each other in
submucosa of rectum and anal canal.
5eorrhoids .!i"es/: is the dilation
of the veins at the site of anastomosis*
Ly!h draina$e:
'- /pper half drains to para rectal +.2s which drain to inferior mesenteric +.2s.
(- +ower half drains to internal iliac lymph nodes.
The Ana" #ana"
Be$innin$: It be$ins one in#h below and anterior to the tip of the coccyx at the
recto-anal %unction*
Course: It runs down and backwards.
Terination: It ends at the anus.
Re"ations:
Latera""y: Ischioanal fossae.
Posterior"y: 3nococcygeal raphe between it and tip of coccyx.
Anterior"y: !erineal body between it and bulb of penis in males.
!erineal body between it and vagina in females.
76
&emorr#oids
'(iles)
In fea"e In a"e
Anterior and !osterior re"ations of ana" #ana" .sa$itta" se#tion/
Latera" re"ations of ana" #ana" .#orona" se#tio
B"ood su!!"y& ner%e su!!"y and "y!h draina$e of ana" #ana":
/pper part +ower part
4lood
supply
-It is supplied by superior rectal
artery.
- It is drained by superior rectal vein
.!orta" #ir#u"ation$.
-It is supplied by&
'- Middle rectal artery of internal iliac artery.
(- Inferior rectal artery of internal pudendal
artery.
-The corresponding veins drain into internal
iliac vein #systei# #ir#u"ation.$
2erve
supply
3bove pectinate line by autonomic
nerve fibers.
4elow pectinate line by inferior rectal nerve
.Sensiti%e to !ain Atou#h$.
+ymphatic
drainage
Abo%e pectinate line into interna"
i"ia# LNs.
Be"o3 the pectinate line into su!erfi#ia"
in$uina" LNs*
77
Ana" s!hin#ters:
Interna" ana" s!hin#ter:
'It is the thickened inner in%o"untary #ir#u"ar muscle layer of the anal canal.
-Surrounds the upper +=1
th
of the anal canal, extending from ano-rectal %unction till
the white line #=iltonDs line$.
Ner%e su!!"y: autonomic
E,terna" ana" s!hin#ter:
'Striated %o"untary us#"e fibers*
'Surrounds the 3ho"e "en$th of the anal canal outside the internal anal sphincter*
'Parts:
I/ Sub#utaneous Part&
-0urrounds the anus %ust under the perianal skin.
-3ttached to perineal body Kanococcygeal raphe.
II/ Su!erfi#ia" Part:
'0urrounds the lower part of the internal sphincter above the subcutaneous part.
- It takes origin from anococcygeal body and last piece of coccyx.
III/ Dee! !art:
' It encircles the upper part of anal canal and no bony attachments.
7a"" of ana" #ana" sho3in$ ana" s!hin#ters
Ana" trian$"e:
1 It is the posterior division of the perineum that is bounded by&
- Tip of coccyx #post.$
- 0acrotuberous ligament on each side.
78
- 3n imaginary line that connects the two ischialtuberosities #ant$.
Di%isions of the !erineu
Contents:
1 +ower part of anal canal in the middle.
1 Ischio-anal #Ischio-rectal$ fossa on each side.
The Is#hiore#ta" Fossa
79
1 It is the wedge shape fascial lined space that lies on each side of the anal
canal.
1 The fossa is filled with fatty tissue to give a space that can accommodate the
distended anal canal during defecation.
Boundaries:
1 Inferior boundary: skin of perineum on each side of the anus forming the base
of the wedge.
1 Su!erior boundary& linear origin of levatorani.
1 Anterior boundary& !osterior border of the perineal membrane and
superficial and deep transversusperinei muscles.
1 Posterior boundary: sacrotuberous ligament.
1 Media" boundary: 0loping. It
is formed by levatorani
muscle and external anal
sphincter
1 Latera" boundary& 5ertical.
It is formed by obturator
internus muscle, obturator
fascia and pudendal canal.
Contents of is#hiore#ta" fossa:
'- Ischiorectal bad of fat.
(- 2erves& Inferior rectal nerve, perineal branch of 0* and scrotal or labial nerve.
)- 5essels& Inferior rectal vessels, scrotal or labial vessels and transverse perineal
vessels.
Pudenda" #ana":
It is a tunnel formed by splitting of obturator fasciaon the lateral wall of ischio-
rectal fossa about one and half inches above the lower end of the ischium.The canal
connects the ischio-rectal fossa with the urogenital triangle.
The #ontents of the #ana":
'. Internal pudendal vessels.
(. !udendal nerve.
80
Contents and !osition of !udenda" #ana"
Arteria" su!!"y of the a"ientary #ana"
6hen the disposition of the peritoneum in the adult is clear, the course of the three
ventral branches of the aorta to the gut can be followed simply. They are distributed
subse;uently to the foregut, midgut, and foregut.
Arteria" su!!"y of the fore$ut
Coe"ia# trun(
- It is the artery of the foregut, and it divides into three branches which supply the
alimentary canal down to the opening of bile duct, and liver, spleen and pancreas.
- It arises from the front of the aorta opposite the upper part of the body of the first
lumbar vertebra. It is a short wide trunk.
- The semilunar sympathetic #coeliac$ ganglia lie on each side of the artery and send
nerves to the artery which are carried along all its branches.
Coe"ia# trun( and its bran#hes
81
- It appears at the upper border of the pancreas and divides immediately into its three
branches&
)' Left $astri# artery: It gives an oesophageal branch which runs up on the
oesophagus to supply the lower part of oesophagus. It then enters between the two
leaves of the lesser omentum and turns to the right along the lesser curvature. It breaks
into two parallel branches which anastomose with the two branches of the right gastric
artery.
Bran#hes of #e"ia# trun(
-' S!"eni# artery arises at the upper border of the pancreas and passes to the left. It is
very tortuous. It runs above the pancreas then it turns forward in the lieno-renal
ligament to the hilum of the spleen. =ere it breaks up into four or five short
branches that radiate as they sink into the splenic substance.
Bran#hes:
'. Pan#reati# branches& They are the main source of arterial supply to the
pancreas. 0everal branches supply that gland one large branch is named the
arteria !an#reati#a a$na.
(. Left $astro'e!i!"oi# artery& It passes to the greater curvature of the stomach
between the leaves of lesser omentum.
). Short $astri# arteries: They are short arteries that pass to the fundus of the
stomach.
+' 5e!ati# artery passes over the upper border of the pancreas, downwards and to
the right as far as the first part of the duodenum. It turns forward at the opening
into the lesser sac and curves upwards between the two layers of lesser omentum
82
at its free edge. =ere it meets the common bile duct and lies on its left side, both
in front of the portal vein.
Bran#hes:
'. Ri$ht $astri# artery leaves the hepatic artery as it turns into the lesser
omentum and anastomoses with the left gastric artery.
(. 2astro'duodena" artery passes down behind the first part of the duodenum,
to the left of the portal vein, and divides into two branches.
a* The ri$ht $astro'e!i!"oi# bran#h turns to the left to enter between the two
leaves of the greater omentum and runs on the greater curvature to anastomose
with the left gastro-epiploic artery
b* 0u!erior !an#reati#o'duodena" artery. It passes between the head of the
pancreas and the duodenum and anastomoses with inferior pancreatico-
duodenal branch of the superior mesenteric artery.
Arteria" su!!"y of the id$ut
The artery of the midgut is the su!erior esenteri#, which supplies the gut from
the entrance of the duct to a point %ust short of the splenic flexure of the colon.
Su!erior esenteri# artery
- It arises from the front of the aorta '7( inch below the celiac trunk at the level of the
lower border of the body of first lumbar vertebra.
- It is directed downwards behind the neck of the pancreas. 6ith the superior
mesenteric vein on its right side then it lies in the groove between the neck and the
uncinate process of the pancreas.
83
- The two vessels then pass over the third part of the duodenum and enter the upper
end of the mesentery of the small intestine. - They pass down to the right along the
root of the mesentery and end at the ileum ( feet proximal to the caecum.
Position and re"ations of su!erior esenteri# artery
Bran#hes :
'- Inferior !an#reati#o'duodena" artery: It supplies the duodenum below the
entrance of the bile duct. It runs in the curve between the duodenum and the head
of the pancreas and anastomoses with the superior pancreatico-duodenal artery.
(- >e8una" arteries: They arise from the left of the main trunk and pass forward
between the two layers of the mesentery. They %oin each other in a series of
anastomosing loops which form single arterial arcades in the upper part of the
%e%unum, double arcades down. ,rom the arcades straight arteries pass to the
mesenteric border of the %e%unum.
)- I"ea" arteries: They enter the mesentery and form a series of arterial arcades.
0traight vessels #vasa recta$ pass to the mesenteric border of the ileum. The arcades
of the terminal ileal branch anastomose with those of the terminal part of the main
trunk of the superior mesenteric artery.
*- I"eo'#o"i# artery: It arises from the right side of the superior mesenteric trunk low
down in the base of the mesentery. It runs to the ielo-colic %unction, where it gives
off&
a* I"ea" bran#h: It anastomoses with the terminal branch of the superior
mesenteric artery.
b* Co"i# bran#h: It runs up along the left side of the ascending colon to
anastomose with the right colic artery.
#* Anterior #oe#a" artery: It ramifies over the anterior surface of the caecum.
84
d* Posterior #oe#a" artery: It supplies the posterior wall of the caecum.
e* A!!endi#u"ar artery: It passes towards the tip of the appendix in the meso-
appendix.
E- Ri$ht #o"i# artery: It arises in the root of the mesentery from the right side of the
superior mesenteric artery. It runs to the right and divides near the left side of the
ascending colon into two branches.
a* The descending branch runs down to anastomose with the colic branch of the
ileo-colic artery. b* The ascending branch runs up to anastomose with a
branch of the middle colic artery.
A- Midd"e #o"i# artery passes forwards between the two leaves of the transverse
mesocolon and at the intestinal border of the transverse mesocolon it divides into
right and left branches which run along the transverse colon. The right branch
anastomoses with the ascending branch of the right colic artery. The left branch
anastomoses with a branch of the left coli artery.
Arteria" su!!"y of the hind$ut
The inferior esenteri# which supplies the whole extent of the hindgut.
Inferior esenteri# artery
- It arises from the front of the aorta at the inferior border of the third part of the
duodenum opposite the third lumber vertebra. - It runs obli;uely down to the pelvic
brim. "ver the pelvic brim it continues along the pelvic wall in the root of the pelvic
mesocolon as the su!erior re#ta" artery.
Bran#hes:
)' Left #o"i# artery& It passes up to the left towards the splenic flexure. It divides into
two branches. 3. The upper branch passes to splenic flexure. 4. The lower branch
passes transversely to the descending colon. .ach of the arteries divides into
ascending and descending branches which anastomose with the left branch of the
middle colic artery and with each other.
-' Si$oid arteries: They are three or four branches which pass forwards between
the layers of the pelvic mesoclon, in which they form anastomosing loops from which
vessels sink into the wall of the pelvic colon.
85
Arteria" su!!"y of id and hind $ut
The Porta" %enous syste
It is the system formed by the veins draining the :IT.
These veins collect into the portal vein which breaks into the liver sinusoids.
Porta" %ein:
Ori$in: It is formed by union of the superior mesenteric and splenic veins behind
the neck of pancreas and in front of I5.
CourseA re"ations: It ascends behind the '
st
part of duodenum and in front of
I5, then in the free border of the lesser omentum with the hepatic artery
#left$ and bile duct #right$ anterior to it.

Porta" %ein and its tributaries
Tributaries:
'- 0uperior mesenteric vein.
(- 0plenic vein #It receives the inferior mesenteric vein$.
86
)- <ight gastric vein.
*- +eft gastric vein.
E- !araumbilical vein #in the left branch$.
A- ystic vein #in the right branch$.
S!"eni# %ein:
Tributaries:
'. 0plenic veins
(. 0hort gastric veins
). +eft gastroepiploic vein
*. !ancreatic veins
E. Inferior mesenteric vein
Tributaries of su!erior esenteri# %ein:
'. <ight gastroepiploic v.
(. 0uperior and inferior pancreatico-duodenal veins
). Middle colic vein
*. <ight colic vein
E. Oe%unal and ileal veins
A. Ileocolic vein
Tributaries of inferior esenteri# %ein:
'. +eft colic vein
(. 0igmoid branches
Portosystei# anastoosis:
These are the sites where veins belong to the portal venous system anastomose
with veins belong to the systemic circulation.
They are important surgically because in case of liver cirrhosis, the pressure in
the portal vein and its tributaries increases. The anastomotic veins will be
enlarged, tortuous and engorged with blood and it will shift from the portal
veins to the systemic circulation.
Sites of !ortosystei# anastoosis:
87
Site Porta" %ein Systei# %ein Effe#t
'- 3t the lower end of
oesophagus
+eft gastric vein 3zygos vein
"esophageal varices
haematemesis
(- 3t the lower end of
anal canal
0uperior rectal vein Middle, inferior rectal veins
<ectal varices !iles
#haemorrhoids$ ----R
bleeding per rectum
)-3round umbilicus +eft br. of portal vein 5eins of ant. 3bdominal wall aput meduosa
*. 3nastomosis between the right colic vein #portal$ and the right renal vein
#systemic$.
#the same on the left side$
E. 3nastomosis between the bare area of the liver #portal$ and the phrenic veins
#systemic$.
A. 3nastomosis between the superior mesenteric vein #portal$ and the I5 #systemic$
through the vein of <itzius.
Sites of !ortosystei# anastoosis
88
Anatoy of the "i%er
Site: It lies under the diaphragm, in the right hypochondrium, epigastrium and left
hypochondrium.
Sha!e& It is wedge shaped. It has five surfaces& superior, inferior, anterior, posterior
and right surfaces.
A dia$ra sho3in$ surfa#es of the "i%er Position of the "i%er
Lobes of the "i%er .1/:
It is formed of right large and left small lobes by&
a. The attachment of fa"#ifor "i$aent on anterior and superior surfaces.
b. ,issure for "i$* %enosu on posterior surface.
c. ,issure for "i$* teres on visceral surface.
It also contains #audate and Buadrate lobes.
Re"ations of the "i%er:
The diaphragm and base of right lung and pleura are related to the superior,
anterior and right surfaces.
'- Anterior surfa#e is also related to ant. abdominal wall.
(- Su!erior surfa#e is also related to heart, pericardium.
)- Ri$ht surfa#e is also related to H
th
to ''
th
ribs.
89
Su!erior re"ations of the "i%er
*- Posterior surfa#e: It is formed of& bare area, groove for I5, caudate lobe #it has
two processes& the caudate process anteriorly to the right, and the papillary process
anteriorly to the left$, fissure for ligamentum venosum and oesophageal notch.
Bare area of "i%er: It is a triangular area related directly to the diaphragm #not
covered by peritoneum$, its base is formed by the groove for I5, its apex is formed
by right triangular ligament, its sides are the two layers of coronary ligament.
E- Inferior .0is#era"/ surfa#e& it shows the following features and impressions&
a. :astric impression, b. ,issure for ligamentum teres, c. Suadrate lobe, d. ,ossa for
gall bladder, e. -uodenal impression, f. <enal impression, g. 0upra renal impression
h. olic impression, and i. Tuber omental #elevated area in the left lobe overlying the
lesser omentum$.
Posterior and inferior surfa#es of "i%er
9uadrate "obe:
90
It is a rectangular part of the inferior surface of liver. It is bounded by&
- inferior border of liver #inf$.
- porta hepatis #post$
- gall bladder fossa #on the right$
- fissure for ligam. teres #on left side$
B It is related to& transverse colon #ant$, pylorusK
'st part of duodenum #middle$ and lesser
omentum #post$.
Caudate "obe:
It is related on the right side to groove for the
I5, "n the left side to fissure for the
ligamentum venosum superior to ligamentum
venosum as it curves to %oin the I5. and
inferior to porta hepatis.
The lower and right part of the caudate lobe
forms a pro%ection called the caudate
process which forms the superior boundary of
the epiploic foramen.
The lower and left part of the caudate lobe forms a pro%ection called the papillary
process.
- It is related posteriorly to lesser sac #it forms its anterior wall$ diaphragm
descending thoracic aorta and T. '(.
Porta he!atis:
It forms the hilum of the liver. 3nteriorly it is bounded by ;uadrate lobe and
posteriorly by caudate lobe and process.
0tructures passing through it&
a. =epatic ducts& anterior in position.
b. =epatic artery& intermediate in position.
c. !ortal vein& posterior in position.
d. +ymphatics.
It gives attachment to lesser omentum.
B"ood su!!"y of "i%er:
It receives blood from two sources&
'- =epatic arteries which divides into right and left branches.
(- !ortal vein which divides into right and left branches.
The venous drainage is by three hepatic veins which terminate in the inferior
vena cava #right, left, middle$.
91
Ly!hati# draina$e of "i%er:
The liver is drained by portal lymph nodes then into the coeliac lymph nodes
except bare area of the liver drains into subphrenic lymph nodes, or !osterior
mediastinal lymph nodes.

Different %ie3s of "i%er
Peritonea" #onne#tions:
'- ,alciform ligament. (- /pper layer of coronary ligament.
)- +ower layer of coronary ligament. *- <ight triangular ligament.
E- +eft triangular ligament. A- +esser omentum.
92
Ebryoni# reinants:
)' Li$aentu teres:
It connects the umblicus with the left branch of portal vein. It represents the
obliterated umbilical vein.
-' Li$aentu %enosu: It connects the left branch of portal vein with the I5. .
It represents the obliterated ductus venosus.
Areas of the "i%er not #o%ered by !eritoneu:
'- 4are area
(- :roove for I5
)- !orta hepatic
*- ,ossa of gall bladder
E- ,issures for ligamentum teres and for ligamentum venosum.
5e!ati# se$entation:
It depends on the vascular distribution to the liver #according to the venous
drainage by the hepatic veins$.
It is divided into right and left lobes by an imaginary line passing through I5
and fossa of gall bladder. This includes caudate, ;uadrate lobes as parts of left
lobe.

Surfa#e anatoy of "i%er:
'- Su!erior surfa#e& from the E
th
left
intercostal space in the midclavicular
line to the upper border of right E
th

costal cartilages in right lateral plane,
to the H
th
rib in mid axillary line.
(- Ri$ht border& from right H
th
-'F
th
ribs
#mid axillary line$.
)- Fundus of $a"" b"adder: tip of G
th

costal cartilage.
Surfa#e anatoy of "i%er
Bi"iary syste
93

It consists of& the gall bladder and the biliary ducts.
2a"" b"adder:
It is a pear-shaped sac situated on the inferior surface of the liver. It has three
parts8 fundus #at the tip of the right ninth costal cartilage$, body and neck. It is
supplied by the cystic artery #from right branch of hepatic artery$. Its venous
drainage goes to the cystic vein which drains to the right branch of portal vein.
Bi"iary du#ts:
)' 5e!ati# du#ts:
These are two ducts #right, left$, one from each lobe of the liver.
They lie in front of the two branches of portal veins and hepatic artery.
They unit in the right part of porta hepatis to form the common hepatic duct.
-' Coon he!ati# du#t:
It is one inch long. It descends in front of the portal vein and to the right of the
hepatic artery. It %oins the cystic duct to form the bile duct.
+' Cysti# du#t:
It is one and half inches long. It is 0- shaped. It %oins the common hepatic
duct at an acute angle to form the bile duct %ust below the porta hepatis.
1' Bi"e du#t:
It is ) inches long. It descends in the free margin of the lesser omentum
anterior to portal vein and on the right side of hepatic artery. Then, it descends
behind the '
st
part of duodenum.
Then, it %oins the pancreatic duct to form the ampulla of 5ater which opens in
the posterior wall of the (
nd
part of duodenum below its middle. The opening is
guarded by the sphincter of "ddi.

Bi"iary and !an#reati# du#ts
Anatoy of the Pan#reas
94
Position of !an#reas:
It is a combined exocrine K endocrine gland which lies transversely across the
posterior abdominal wall.
It extends from the concavity of the duodenum on the right side to the spleen
on the left side.

Position of !an#reas Parts of !an#reas
Parts of !an#reas:
It consists of head, neck, body and tail. The lower part of the head forms a pro%ection
called uncinate process.
Re"ations of !an#reas:
5ead of !an#reas:
It lies in the concavity of the duodenum.
It is related to the '
st
part of duodenum superiorly, (
nd
part on the right side
#separated from it by superior K inferior pancreatico- duodenal arteries$, and
)
rd
part inferiorly.
3nteriorly& it is related to transverse colon.
!osteriorly& it is related to I5, renal veins and common bile duct.
/ncinate process lies between abdominal aorta and superior mesenteric
vessels.

Different re"ations of !an#reas
Ne#( of !an#reas:
95
Anterior"y& it is related to gastro-duodenal %unction.
Posterior"y& it is related to the formation of portal vein from splenic and
superior mesenteric veins.
Body .trian$u"ar in #ross se#tion/:
It has three surfaces #anterior, posterior and inferior$ and three borders #anterior,
superior and inferior$.
Surfa#es:
'- Anterior surfa#e: <elated to stomach, separated from it by the lesser sac.
(- Inferior surfa#e: <elated to duodeno-%e%unal flexure, loops of ileum and end of
transverse colon #from right to left$.
+' Posterior surfa#e: It is related to posterior abdominal wall&
'- 3orta and origin of sup. mesenteric artery.
(- 0plenic and left renal vein.
)- +eft psoas ma%or.
*- +eft crus of diaphragm.
E- +eft kidney.
A- +eft supra renal gland.
H- +eft sympathetic chain.

Re"ations of !an#reas and its arteria" su!!"y
96
Borders:
)' Su!erior border: It is related to splenic artery.
-' Anterior border: It gives attachment to
transverse mesocolon and greater omentum.
+' Inferior border: It separates the inferior
from the posterior surfaces.
Tai" of !an#reas:
It is related to the visceral surface of
spleen near its hilum.
It reaches the hilum via the lieno-renal
ligament.
Corona" se#tion of the abdoen sho3in$ the !osition of !an#reas
Du#ts of !an#reas:
It has two ducts&
)' Main !an#reati# du#t:
It drains the upper part of the head, all the body and tail of pancreas.
It runs from the tail to the head, then it unites with common bile duct to form
ampulla of 5ater which opens in the (
nd
part of duodenum.
The ampulla of vater opens into the apex of a mucosal elevation in the second
part of the duodenum called the ma%or duodenal papilla.
-' A##essory !an#reati# du#t:
It drains the uncinate process and lower part of head.
It open in the (
nd
part of duodenum above the ampulla of 5ater.
Bi"e du#t and !an#reati# du#ts
B"ood su!!"y:
Arteria" su!!"y:
'- 0uperior, inferior pancreatico-duodenal arteries& to the head.
(- !ancreatic branches of splenic artery& to the rest of pancreas.
0enous draina$e: To splenic vein and portal vein.
Ly!hati# draina$e:
'. To the left of the neck& -rains into the pancreatico-splenic lymph nodes.
97
(. The upper part of the head& -rains into the coeliac lymph nodes.
). The lower part of the head& -rains into the superior mesenteric lymph nodes.
De%e"o!ent of the di$esti%e syste
Ori$in:
.ndoderm of gut #except mouth and lower half of anal canal which are ectodermal$
mucosa K its glands.
0planchnic secondary mesoderm smooth muscles and connective tissue.
It is formed from the incorporation of the dorsal part of yolk sac into the embryo due to
head, tail and lateral folds.
It extents from the oral membrane to the cloacal membrane.
De%e"o!ent of the !riiti%e $ut tube:
It extents from the oral membrane to
the cloacal membrane.
It is divided into&
'- foregut& from pharynx to the
middle of (
nd
part of duodenum.
(- midgut & from lower half of (
nd

part of duodenum to the %unction
between medial (7) K lateral '7)
of transverse colon.
)- hindgut& the remaining part of
large intestine.
Deri%ati%es of the $ut:
98
,oregut Midgut =indgut
- !harynx
- "esophagus
- 0tomach
- '
st
and half of (
nd

parts of duodenum
- +iver and gall bladder
- !ancreas
- <espiratory system
- =alf of (
nd
, )
rd
and *
th

parts of duodenum
- Ou%enum
- Ileum
- 3ppendix
- aecum
- 3scending colon
- <ight colic flexure
- <ight (7) of transverse
colon.
- +eft '7) of transverse colon.
- +eft colic flexure.
- -escending colon.
- 0egmoid colon.
- <ectum.
- /pper T of anal canal.
- !rimitive urogenital sinus
derivatives.
The foregut derivatives are supplied by coeliac trunk.
The midgut derivatives are supplied by superior mesenteric artery.
The hindgut derivatives are supplied by inferior mesenteric artery.
Arteria" su!!"y of the $ut
De%e"o!ent of the oeso!ha$us
"rigin&
.ndoderm of foregut mucosa K its glands.
99
0planchnic secondary mesoderm submucosa K musculosa.
Mesenchyme of branchial arches striated muscles of upper'7) of oesophagus.
-evelopment&
The oesophagus at first is short then elongates.
The trachea develops from its ventral border. They are comunicating
then a trachea-oesophageal septum develops between them.
.pithelium of oesophagus proliferates, obliterating the lumen then recanalization
occurs.
Con$enita" anoa"ies:
'. 0hort oesophagus& due to failure of elongation. It is associated with thoracic stomach.
(. Tracheo-oesophageal fistula& due to non separation between trachea and oesophagus
milk in lungs pneumonia and air in stomach respiratory distress.
). "esophageal atresia& due to failure of recanalization.
*. "esophageal stenosis& due to incomplete recanalization.
De%e"o!ent of stoa#h
"rigin&
.ndoderm of foregut mucosa K its glands.
100
0planchnic secondary mesoderm submucosa, musculosa and serosa.
-evelopment&
,usiform part of foregut&
'- Its dorsal border grows more greater curvature.
(- Its dorsal border grows less lesser curvature.
)- Most cranial part of dorsal border grows rapidly fundus.
De%e"o!ent and rotation of stoa#h
<otation of stomach GF
F
clockwise around its longitudinal axis +eft surface becomes
anterior K right surface becomes posterior. 0o left vagus becomes anterior gastric nerve
K right vagus becomes posterior gastric nerve. The stomach was first vertical by
development of liver its long axis will be obli;ue.

De%e"o!ent and rotation of stoa#h
101
Con$enita" anoa"ies:
'. Thoracic stomach& associated with short oesophagus.
2 ongenital pyloric stenosis& due to hypertrophy of the circular muscles in the pyloric
region pro%ectile vomiting of the infant after feeding.
). =ourglass stomach.
*. Transposition of stomach # may be associated with situs inversus$.
De%e"o!ent of Intestine
.xcept -uodenum and =indgut
"rigin& .ndoderm of midgut mucosa K glands.
0planchnic secondary mesoderm submucosa K musculosa and serosa
0tages of development&
'- !reherniation stage&
0traight midgut midgut loop cranial limb and caudal limb
ranial limb small intestine #%e%unum > upper part of ileum$.
audal limb large intestine #lower part of ileum > caecum > appendix
> ascending colon > right (7) transverse colon$.
(- =erniation stage&
auses&
'- 0mall abdominal cavity.
(- +arge liver and kidney.
)- .xtraembryonic coelom in primitive umbilical cord.
0ite&
.xtraembryonic coelom of umbilical cord.
<otation GF
F
anticlockwise cranial limb right limb K caudal limb
left limb.
5erniation and rotation of intestine
)- !ostherniation stage&
102
<eduction of small intestine first, large intestine second and caecum last.
<otation 'IF
F
3nticlockwise right limb left. left limb right
!roliferation recanalization of the endoderm of the intestine occurs.
Nora" rotation of intestine
Con$enita" anoa"ies:
'- ongenital umbilical hernia& It is due to presence of defect in the anterior
abdominal wall herniation of loop of the intestine.
(- .xomphalos& It is due to failure of a loop of intestine to return back to the abdominal
cavity loop of intestine coming from the base umbilicus covered by amnion.

103
AAB E,o!ha"os
)- MecklDs diverticulum&
It is due to persistace of small pouch of the yolk stalk.
B+ength & ( inches B -istance from caecum& ( feet
BIncedance& (P of people.
*- ongenital umbilical #fecal$ fistula due to persistence of all yolk sac.
E- <otation clockwise transposition.
A- Intestinal atresia& due to failure of recanalization of the intestine.
H- Intestinal stenosis& due incomplete recanalization.
104
I- -uplication of the intestine& duplication of segment of the intestine due
to abnormal recanalization.
De%e"o!ent of duodenu
"rigin&
.ndoderm of foregut mucosa of '
st
> T second part.
.ndoderm of foregut mucosa of T second > )
rd
> *
th
parts.
0planchnic (ry mesoderm submucosa K musculosa.
-evelopment&
It starts as a vertical tube formed of caudal part of foregut and cranial part of midgut.
/ne;ual growth of the walls K traction of Treitz ligament leads to&
'- shaped loop pro%ecting anteriorly.
(- 5entral opening of bile duct will be shifted posteromedial.
<otation of the duodenum to the right #clockwise$ leads to&
'- The ventral convex margin right.
(- The right surface posterior.
!roliferation of the endoderm occurs followed by recanalization.

Con$enita" anoa"ies:
'- -uodenal atresia& due to non canalization.
(- -uodenal stenosis& due to partial canalization.
)- ongenital intestinal obstruction& due to traction of Treitz ligament on the
duodeno%e%unal %unction.
*- -uplication of the duodenum& due to abnormal recanalization.
105
De%e"o!ent of re#tu and u!!er C of ana" #ana"
"rigin&
.ndoderm of hindgut mucosa K glands.
0planchnic secondary mesoderm submucosa K musculosa.
-evelopment&
The cloaca #dilated caudal part of hindgut$ is divided by cloacal septum # wedge- shaped
mesoderm between allantois and hindgut$ which grows towards the cloacal membrane
into&
'- 3 dorsal part #anorectal canal$.
(- 3 ventral part #primitive urogenital sinus$.
The cloacal membrane is also divided into anal and urogenital
membrane.
The anorectal canal gives the rectum and upper '7( of anal canal.
The rectum will be convoluted due to une;ual growth of its walls.
106
De%e"o!ent of "o3er ha"f of ana" #ana"
"rigin&
.ctoderm 0tratified columnar epithelium.
0planchnic secondary mesoderm submucosa, musculosa and anal
sphincters.
0o, its upper T is endodermal and its lower half is ectodermal.
-evelopment&
Mesenchyme around anal membrane proliferates producing elevations of the surface
ectoderm called anal hillocks.
The anal membrane is now located at the bottom of an ectodermal depression called
proctodium #primitive anal canal$ lower T of anal canal.
The anal membrane ruptures leaving remnants as anal valves and the two halves of anal
canal are continuous with each other.
Latera" %ie3 of the ana" #ana"
Con$enita" anoa"ies:
'- ,istulae formation& #<ectovaginal, rectouretheral, rectovesical, anouretheral and
anovaginal fistula$ due to incomplete development of cloacal septum.
(- <ectal atresia& due to either abnormal canalization or defect in blood supply causing
focal atresia.
)- Imperforate anus& due to failure of rupture of anal membrane . 3 layer of tissue
separates the anal canal from the exterior.
107
*- 3nal stenosis& due to dorsal deviation of the cloacal septum as it grows caudally
small anal canal.
E- 3nal agenesis& it terminates blindly. It associates with a fistula between rectum and
urinary bladder, urethra or vagina.
Con$enita" anoa"ies of ana" #ana"
De%e"o!ent of the "i%er
"rigin&
- .ndoderm of pars hepatica gives hepatocytes and epithelial lining of biliary tree.
- Mesoderm of septum transversum gives the blood forming or hematopoietic tissue
#Cupffer cells$ and connective tissues.
- 5itelline and umbilical veins give hepatic sinusoids.
108

De%e"o!ent of "i%er bud
-evelopment&
=epatic bud develops from the ventral border of duodenum #foregut$.
It divides into pars hepatica and pars cystica.
!ars hepatica divides into right and left branches which arrange in solid cords. These
cords invade septum transversum giving liver cells and epithelial lining of bile
canaliculi, hepatic ducts and common hepatic duct.
!ars cystica undergoes canalization and gives gall bladder and cystic
duct.
0eptum transversum gives capsule forms the stroma, liver capsule, the falciform
ligament, lesser omentum and the blood forming, or hematopoietic tissue #Cupffer
cells$ of the liver.
5itelline and umbilical veins inside septum transversum break down into hepatic
sinusoids.
Different #e""s of the "i%er and their ori$in
Con$enita" anoa"ies:
1- Increased lobulation of liver.
2- 3bsence of gall bladder and cystic duct& It is due to failure of development of pars
cystica.
109
3- -ouble gall bladder and cystic duct& It is due to development of two separate gall
bladders connected by a single cystic duct or by separate ducts.
4- 3tresia of common bile duct& It is due to failure of canalization of biliary passage and
associated with %aundice after birth.
5- 3tresia of gall bladder.
6- ongenital choledochal cyst& It is a dilated part of common bile duct due to weakness
of the wall of this part.
De%e"o!ent of the Pan#reas
The pancreas develops from dorsal and ventral pancreatic buds that arise from
the caudal part of the foregut at the site of the duodenum.
The dorsal pancreatic bud grows more rapidly than the ventral and soon
extends dorsally behind the duodenum into the dorsal mesentery.
The duodenum grows and rotates to the right #clockwise$ and carries the
ventral pancreatic bud to the dorsal mesentery where it fuses with the dorsal
bud during the seventh week.
The dorsal bud forms the body and tail of the pancreas.
5entral bud forms the uncinate process and most of the head of the pancreas.
110
De%e"o!ent and rotation of !an#reas
- The main pancreatic duct is formed by the union of distal part of the duct of the dorsal
bud with the duct of the ventral bud and the communication in between.
- The accessory pancreatic duct is formed from the proximal part of the duct of the
dorsal bud.
- .ach solid duct gives branches #ductules$ which gives solid cell masses #acini$ and
solid cell masses without connection to duct system #Islets of +angerhans$.
- The connective tissue of the gland develops from the splanchnic mesoderm.
- 4y the fifth month, insulin secretion begins.
De%e"o!ent of !an#reas
111
Con$enita" anoa"ies:
)' 3nnular pancreas&
The part of the ventral pancreatic bud rotates towards the left in front of
the duodenum.
=ence, the pancreatic tissue surrounds the
duodenum, it obstructs the duodenum.
(- 3ccessory or ectopic pancreatic tissue&
It lies fre;uently in the mucosa of the stomach
and MeckelDs diverticulum.
)- 3bsence of dorsal or ventral pancreas.
)- 0eparate ducts.

Annua" !an#reas
112