TH E ABD O MEN
T ABLE OF C ONTENTS
Surface Anatomy ...................................................................................................... 3
Fascial Layers ............................................................................................................ 4
Muscles of the Anterior Abdominal Wall ............................................................ 5
Rectus Sheath ........................................................................................................... 6
Transversalis Fascia ................................................................................................. 6
Nerves of the Anterior Abdominal Wall.............................................................. 7
Lymphatic Drainage ................................................................................................ 7
Arterial Supply .......................................................................................................... 7
Venous Drainage...................................................................................................... 7
Principal Muscles ..................................................................................................... 8
Fascial Coverings ..................................................................................................... 9
Innervation of Posterior Abdominal Wall ......................................................... 10
Lumbar Plexus........................................................................................................ 11
Inguinal Canal ......................................................................................................... 13
Spermatic Cord Constituents ............................................................................... 14
Spermatic Cord Coverings.................................................................................... 15
The Scrotum ........................................................................................................... 16
Testes and Their Ducts ......................................................................................... 17
Anatomy & Relations ............................................................................................ 20
Venous Drainage.................................................................................................... 20
Arterial Supply ........................................................................................................ 21
Innervation .............................................................................................................. 21
Lymphatic Drainage .............................................................................................. 21
Functional and Clinical POints ............................................................................ 21
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anatomy & Relations ............................................................................................. 22
Pancreatic Ducts .................................................................................................... 24
Arterial Supply ........................................................................................................ 25
Venous Drainage .................................................................................................... 25
Innervation .............................................................................................................. 25
Lymphatic Drainage .............................................................................................. 25
General Anatomy ................................................................................................... 26
Arterial Supply ........................................................................................................ 28
Venous Drainage .................................................................................................... 29
Innervation of the Stomach ................................................................................. 29
Lymphatic Drainage .............................................................................................. 30
The Duodenum ...................................................................................................... 31
Arterial Supply to the Duodenum ....................................................................... 33
Innervation of the Duodenum............................................................................. 33
Venous Drainage from the Duodenum ............................................................. 33
Lymphatic Drainage of the Duodenum ............................................................. 33
The Jejunum and Ileum ........................................................................................ 34
Arterial Supply to the Jejunum and Ileum ......................................................... 35
Venous Drainage from the Jejunum and Ileum ................................................ 35
Innervation of the Jejunum and Ileum ............................................................... 35
Lymphatic Drainage of the Jejunum and Ileum................................................ 36
Surface Anatomy .................................................................................................... 37
Surfaces of the Liver .............................................................................................. 38
Lobes of the Liver.................................................................................................. 39
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Peritoneal Relations of the Liver ......................................................................... 40
Arterial Supply to the Liver .................................................................................. 41
Venous Drainage from the Liver ........................................................................ 41
Inntervation of the Liver ...................................................................................... 41
Lymphatic Drainage of the Liver ........................................................................ 41
position, Form and Size ........................................................................................ 43
Surface Anatomy .................................................................................................... 43
Renal Fascia & Fat ................................................................................................. 44
Relations of the Kidneys ....................................................................................... 44
General Anatomy of Ureter ................................................................................. 45
Relations of the Ureters ........................................................................................ 45
Arterial Supply to the Kidneys and Ureters ....................................................... 46
Venous Drainage from the Kidneys and Ureters ............................................. 46
Lymphatic Drainage of the Kidneys and Ureters ............................................. 46
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Innervation of the Kidneys and Ureters............................................................. 46
General Anatomy ................................................................................................... 47
Arterial Supply to the Adrenal Glands ............................................................... 48
Venous Drainage from the Adrenal Glands ...................................................... 48
Lymphatic Drainage of the Adrenal Glands...................................................... 48
Innervation of the Adrenal Glands ..................................................................... 48
Relations of the Abdominal Aorta ...................................................................... 49
Branches of Abdominal Aorta ............................................................................. 50
General Anatomy ................................................................................................... 52
Relations .................................................................................................................. 52
Tributaries of the Inferior Vena Cava ................................................................ 53
Portal Vein .............................................................................................................. 54
Main Portal-Caval Anastomoses.......................................................................... 55
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 A NTERIOR A BDOMINAL WALL

S U R FA C E A NA TOM Y

 The umbilicus is the most obvious feature of the abdomen, and is the ANATOMICAL PLANES
site of attachment of the umbilical cord.
 In physically fit people, it lies at the level between L3 and L4.  Subcostal Plane (SCP) – a horizontal plane that joins the inferior points of
 Linea Alba – a line joining the Xiphoid Process to the Pubic Symphysis. the Costal Margins. (Often the inferior margin of the 10th CC)
 A midline fibrous white line that divides the anterior abdominal wall  Lies at the level of the upper part of the body of L3.
into two halves.  Transtubercular Plane (TTP) – horizontally passes through the Iliac
 Linea Semilunaris – a curved line, convex laterally, that extends from the Tubercles on the Iliac Crests, usually at the level of the body of L5.
9th Costal Cartilage (CC) to the Pubic Tubercle.  Sagittal Planes – essentially the mid-clavicular planes running from the
 Indicates the lateral border of the Rectus Abdominis Muscle mid-point of the Clavicle, inferiorly to the Mid-Inguinal Point.
 The muscle lies to each side of the midline, and is crosses  (Mid-Inguinal Point = midway between the ASIS and the Pubic
transversely by three tendonous intersections. Symphysis)
 The Inguinal groove marks the site of the Inguinal Ligament.  These planes divide the anterior abdominal wall into 9 areas:
 The Pubic Symphysis is located at the inferior end of the Linea Alba.  Right Hypochondrium
 The Pubic Crests may be felt along 2.5 cm lateral to the Symphysis,  Epigastrium
and they terminate at the Pubic Tubercle.  Left Hypochondrium
 The Iliac Crests run from the Anterior Superior Iliac Spines (ASIS) to the  Right Lateral (Lumbar)
Posterior Superior Iliac Spines.  Umbilical region
 Epigastric Fossa – a small depression in the anterior abdominal wall, just  Left Lateral (Lumbar)
inferior to the Xiphoid Process.  Right Inguinal
 More visible in the supine position, since the abdominal viscera  Hypogastrium
spread out, to allow the anterior abdominal wall to be drawn  Left Inguinal
posteriorly in this region.  Alternatively, the Anterior Abdominal Wall may be divided into 4
Quadrants, centred around the Umbilicus.

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 Transpyloric Plane – horizontal plane lying at the level of the inferior
FA S C I A L L AY E R S
border of L1 Vertebrae.
 Passes through the Pylorus
 Also passes through the anterior parts of: SUPERFICIAL FASCIA
 9th CC
 Duodeno-jejunal Junction  Over most of the abdomen, it consists of a single layer of fascial tissue
 Neck of the Pancreas containing variable amounts of fat.
 Hila of the Kidneys.  In the region above the Inguinal Ligament, it may be divided into two
layers:
 Transumbilical Plane – horizontal plane lying at the level of the
Intervertebral Disc between L3 & L4, and passing through the  Fatty Superficial Layer (Camper’s Fascia) – contains a variable amount of
Umbilicus. fat.
 Merges with superficial fascia of the thigh.
 Membranous Deep Layer (Scarpa’s Fascia) – contains fibrous tissue, and
very little fat.
 Continuous with the deep Fascia Lata of the thigh.
 Continuous with the superficial fascia of the Perineum (investing
the scrotum, penis and labia majora).
 Continuous with the deep fascia of the rest of the abdomen.
 Lying between these two layers of Superficial Fascia in the supra-
inguinal region is the superficial neurovascular plane.

DEEP FASCIA

 Very thin.
 Strong layer that lies on top of all the superficial muscles, and is not
easily separated from them.

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 M U S C L E S OF T H E A N T E R I O R A B D OM I N A L W A L L

NAME. ORIGIN. INSERTION INNERVATION ACTION

1. Linea Alba Inferior 6 Intercostal Nerves +
External surfaces of 5th to 12
External Oblique 2. Pubic Tubercle Subcostal Nerve 1. Compress and support
ribs
3. Anterior half of Iliac Crest abdominal viscera
1. Inferior borders of 10th to 2. Flex trunk
1. Thoracolumbar Fascia
12th ribs 3. Rotate Trunk
Internal Oblique 2. Anterior 2/3 Iliac Crest
2. Linea Alba (c/l = EO, i/l = IO)
3. Lateral ½ Inguinal Ligament
3. Pubis (via Conjoint Tendon)
1. Ventral Rami of Inferior 6
1. Internal surfaces of 7th to
1. Linea Alba (with Intercostal Nerves
12th Costal Cartilages
aponeurosis of IO) 2. 1st Lumbar Nerve
Transversus 2. Thoracolumbar Fascia Compresses and supports
2. Pubic Crest
Abdominis 3. Iliac Crest abdominal viscera
3. Pecten Pubis (via Conjoint
4. Lateral 1/3 of Inguinal
Tendon)
Ligament
1. Flexes trunk
1. Pubic Symphysis 1. Xiphoid Process Ventral Rami of Inferior 6
Rectus Abdominis 2. Compresses Abdominal
2. Pubic Crest 2. 5th – 7th Costal Cartilages Intercostal Nerves
Viscera
An insignificant abdominal muscle present in 80% of people. Located anterior to the inferior part of Rectus Abdominis, with its action
Pyramidalis
being to tense the Linea Alba.

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 RECTUS SHEATH T R A N S V E R S A L I S FA S C I A

 A strong, incomplete fibrous compartment, containing the Rectus  Partially transparent layer of investing fascia that lines most of the
Abdominis. internal aspect of the Abdominal Wall.
 Formed by the fusion of separated aponeuroses of the 3 flat abdominal  Posteriorly fuses with the anterior lamina of the Thoracolumbar Fascia.
muscles.  Covers the deep surface of Transversus Abdominis muscle, and its
 The Internal Oblique Aponeurosis splits at the lateral margin of Rectus aponeurosis.
Abdominis.  It is continuous from side to side, over the midline, deep to the Linea
 One layer passes anterior to Rectus Abdominis, and joins the Alba.
aponeurosis of External Oblique, to form the anterior wall of the  It is named, corresponding to what it covers:
Rectus Sheath.  Diaphragmatic Fascia
 The posterior layer of Internal Oblique’s aponeurosis joins the  Iliac Fascia (overlying Iliacus muscle)
aponeurosis of Transversus Abdominis, to form the posterior wall of  Psoas Fascia
the Rectus Sheath.  Pelvic Fascia
 The two walls of the Rectus Sheath interlace in the median plane to form  Extends into the thigh to form the Femoral Sheath.
a tendonous raphé = Linea Alba.  Passes through the Inguinal Canal to form the Internal Spermatic Fascia.
 The Linea Alba separates the two Recti Abdominis, and the Umbilicus  The Extraperitoneal Fat separates the Transversalis Fascia from the
lies just below its mid-point. underlying Peritoneum.
 Superior to the costal margin, the posterior wall of the Rectus Sheath is
deficient  the Rectus Abdominis lies directly on the thoracic wall.
 Mid-way between the umbilicus and the pubic crest, lies the crescentic
Arcuate Line = the inferior limit of the posterior wall of the Rectus
Sheath.
 Below this the aponeurosis of all three flat muscles pass anterior to
the Rectus Muscle to form the anterior wall of the Rectus Sheath.
 Therefore, the Rectus muscle will lie directly on the posterior
abdominal wall below the Arcuate Line.
 Within the Rectus Sheath lie:
 The Superior + Inferior Epigastric Vessels
 The terminal parts of the inferior 5 Intercostal Nerves
 The terminal part of the Subcostal Nerve.

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N E RV E S O F T H E A N T E R I O R A B D O M I NA L W A L L
 Mainly supplied by the Ventral 1 Rami of the inferior 6 Intercostal
Nerves (T7-T11), and the Subcostal Nerve (T12).
 The inferior part of the anterior abdominal wall is supplied by 2 branches
of the Ventral 1 Ramus of L1.
 The Iliohypogastric Nerve supplies the skin over the Inguinal Region
 The Ilioinguinal Nerve runs antero-inferiorly, just superior to the
Iliac Crest, until it reaches the Superficial Inguinal Ring.
 Here it emerges to supply the supero-medial aspect of the thigh.
 The Neurovascular plane lies between the Internal Oblique and
Transversus Abdominis muscles.
 The main trunks of the intercostal nerves run antero-medially in this
plane, and are accompanied by:
 Inferior Intercostal Arteries
 Subcostal arteries
 Lumbar arteries.
 Anterior Cutaneous branches of the trunks will pierce the Rectus Sheath,
a little away from the midline.
 T7-T9  skin above umbilicus.
 T10  skin around the umbilicus.
 T11-L1  skin below umbilicus.
LY M P H A T I C D R A I NA G E
 General drainage of the anterior abdominal wall to the Lumbar Lymph
Nodes, and to the External Iliac Lymph Nodes.
 Anterolateral wall, superior to umbilicus Axillary Lymph Nodes.
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 Anterolateral wall, inferior to umbilicus  Superficial Inguinal Lymph
Nodes.
A RT E R I A L S U P P LY
 Inferior Epigastric Artery – branch of the External Iliac artery.
 Runs superiorly in the Transversalis Fascia, to reach the Arcuate
Line.
 Here it enters the Rectus Sheath.
 Deep Circumflex Iliac Arteries – branches of the External Iliac artery.
 Runs along the deep aspect of the anterior abdominal wall within the
neurovascular plane, parallel to the Inguinal Ligament, and along the
Iliac Crest.
 Superior Epigastric Artery – terminal branch of the Internal Thoracic
artery.
 Enters the Rectus Sheath superiorly, just below the 7th CC.
 Minor arteries arise from anterior and collateral branches of Posterior
Intercostal Arteries in the 10th and 11th Intercostal Spaces, as well as from
anterior branches of the Subcostal Artery.
 These will anastomose with each other, as well as with the 3 main
arteries above.
V E N OU S D R A I NA G E
 Superficial Epigastric Vein and the Lateral Thoracic Vein anastomose,
thus uniting all the venous tributaries of the upper and lower halves of
the body.
 3 Superficial Inguinal Veins drain to the Great Saphenous Vein of the
Lower Limb.
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 P OSTERIOR A BDOMINAL WALL

P R I N C I PA L M U S C L E S

NAME. ORIGIN. INSERTION INNERVATION ACTION

1. If fixed superiorly, it flexes
the thigh (with Iliacus)
2. Flexes the vertebral column
1. Transverse Processes of
laterally
Lumbar Vertebrae (L1-L4) Strong tendon to the Lesser Lumbar Plexus via ventral
Psoas Major 3. Stabilises the trunk when
2. Sides of bodies of T12-L5, Trochanter of the Femur branches of L2, L3 & L4
sitting
and their intervening discs
4. If fixed inferiorly, it flexes
the trunk (in association
with its partner and Iliacus)
1. Aids Psoas Major in flexing
Psoas Minor
Sides of T12 and L1, and their Iliopubic Eminence on the the thigh
(50-60%, often Ventral 1 Ramus of L1
intervening disc Pelvic Brim 2. Aids flexion of lumbar
unilateral)
region of vertebral column.
1. Superior 2/3 Iliac Fossa
1. Flexes thigh (with Psoas
2. Ala of Sacrum Strong tendon to the Lesser
Iliacus Femoral Nerve (L2-L4) Major)
3. Anterior Sacroiliac Trochanter of the Femur
2. Stabilises hip joint
Ligaments
1. Extends vertebral column
1. Iliolumbar Ligament (from 2. Laterally flexes vertebral
1. Medial ½ of Inferior border
conical transverse process of L5, column
Quadratus of 12th Rib
horizontally and laterally to the Ventral branches of T12-L4. 3. Fixed 12th rib during
Lumborum 2. Tips of Lumbar Transverse
posterior part of the Iliac Crest) inspiration
Processes (L1-L4)
2. Internal Lip of Iliac Crest 4. Depresses 12th rib in forced
inspiration.

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 FA S C I A L C OV E R I N G S

ILIAC FASCIA THORACOLUMBAR FASCIA

 Iliac Fascia is thin superiorly, but thickens as is approaches the Inguinal
Ligament.
 Continuous with the Transversalis Fascia, and also with the Fascia of
the Thigh (inferiorly).
 As the Transversalis Fascia passes into the thigh, over the Inguinal
Ligament, it is here that it is continuous with the Iliac Fascia.
 The Psoas Fascia covers the Psoas Major muscle.
 Attached medially to the anterior surfaces of the transverse processes
of the Lumbar Vertebrae and the Pelvic Brim.
 It ends superiorly, in an abrupt & thickened fashion, over Psoas
Major’s anterior aspect to form the Medial Arcuate Ligament (of the
Diaphragm).
 It is fused laterally with the Anterior layer of Thoracolumbar Fascia.
 It is continuous with the Iliac Fascia, below the Iliac Crest.
 Blends with the fascia overlying Quadratus Lumborum.
QUADRATUS LUMBORUM FASCIA
 A dense membranous layer.
 Continuous, laterally, with the anterior layer of Thoracolumbar Fascia.
 Attached to :
 Anterior surfaces of Transverse Processes of Lumbar Vertebrae.
 Middle part of the Iliac Crest.
 Lateral ½ of the 12th Rib.
 Transversalis Fascia.
 It ends abruptly, in a thickened fashion over the anterior aspect of
Quadratus Lumborum  Lateral Arcuate Ligament.
 Inferiorly attached to the Iliolumbar Ligament.
 An extensive sheet of fascia, which covers the deep muscles of the back.
Two of its three layer will split and enclose Quadratus Lumborum to
form the Quadratus Lumborum Fascia.
 Its lumbar part extends from the 12th rib to the Iliac Crest.
 It is attached laterally to the Internal Oblique and Transversus
Abdominis muscle bellies.
 Splits into 3 layers:
 The anterior layer attaches to the Anterior surfaces of Transverse
Processes of Lumbar Vertebrae.
 Lies anterior to Quadratus Lumborum.
 The middle layer is attached to the Tips of the Transverse Processes
of Lumbar Vertebrae.
 Lies deep to Quadratus Lumborum.
 The posterior layer is dense, and attaches to the Spinous Processes
of the Lumbar and Sacral Vertebrae.
 Also attaches to the Sacrospinous Ligament.
 It passes over the Sacrospinalis (Erector Spinae) Muscle.
 Extends from the posterior aspect of the sacrum, all the way
up to the base of the skull.
 It extends the Vertebral Column.
 Innervated by the 1 Dorsal Ramus of each Spinal Nerve,
before they give a cutaneous supply to a hand’s breadth of
skin to each side of the posterior midline.

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 I N N E RVA T I ON O F P OS T E R I OR A B D OM I N A L WA L L

 Innervation consists of somatic nerves of the Lumbar Plexus, and Visceral/Splanchnic nerves of the Autonomic Nervous System.
 The five lumbar nerves leave the vertebral canal, through their intervertebral foramina of exit, below each corresponding vertebra.
 They then divide into 1 Ventral and Dorsal Rami, containing motor and sensory fibres.
 The dorsal rami pass posteriorly to supply the muscle and skin of the back.
 The ventral rami pierce Psoas Major, and are attached to the Sympathetic Trunk, by Rami Communicantes.
 They then supply Psoas Major, Iliacus, and Quadratus Lumborum.
 The 1 Ventral Rami of L1-L3, as well as the superior branch of the 1 Ventral Ramus of L4, form the Lumbar Plexus, within the substance of Psoas Major.
 The inferior branch of the 1 Ventral Ramus of L4, and the whole 1 Ramus of L5, will form the Lumbosacral Trunk.
 This descends into the pelvis, to join the Sacral Plexus.

 The Subcostal Nerve is the 1 Ventral Ramus of T12.

 It sends a branch to the 1 Ventral Ramus of L1.
 It passes behind the Lateral Arcuate Ligament, running infero-anteriorly across the anterior aspect of Quadratus Lumborum.
 It then pierces Transversus Abdominis, to run within the neurovascular plane of the anterior abdominal wall.
 It supplies the anterior abdominal wall, between the Umbilicus and the Pubic Symphysis.
 It sends a Lateral Cutaneous Branch, from the mid-axillary line.
 This turns inferiorly, and passes down the Iliac Crest.
 It supplies the upper thigh, in the region of the lateral part of the Inguinal Ligament.

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 L U M BA R P L E X U S

ILIOHYPOGASTRIC NERVE

 Derived from L1, often from a common stem with the Ilioinguinal Nerve.
 Emerges from the lateral border of Psoas Major muscle.
 Enters the Abdomen posterior to the Medial Arcuate Ligament.
 Passes infero-laterally over the anterior aspect of Quadratus Lumborum.
 On reaching the lateral edge of Quadratus Lumborum, it continues infero-laterally on the Thoracolumbar Fascia, beneath Transversus Abdominis.
 Pierces Transversus Abdominis to run infero-medially around the body wall, within the neurovascular plane between Transversus Abdominis and Internal
Oblique.
 Pierces Internal Oblique, 2-cm medial to the Anterior Superior Iliac Spine (ASIS).
 Continues to run between Internal and External Obliques.
 Pierces External Oblique, 3-cm superior to the Superficial Inguinal Ring.
 Therefore it never contacts the Rectus Sheath or Rectus Abdominis.
 This anterior cutaneous branch innervates the Hypogastric region.
 Sends a lateral branch to the skin of the Gluteal region.
 May supply the External Oblique muscle in the lowest part of the anterior abdominal wall.

ILIOINGUINAL NERVE

 Derived from L1, often from a common stem with the Iliohypogastric Nerve, otherwise it follows a similar course inferior to the Iliohypogastric Nerve.
 Emerges from the lateral border of Psoas Major muscle, at a lower level than the Iliohypogastric Nerve.
 Enters the Abdomen posterior to the Medial Arcuate Ligament.
 Passes infero-laterally over the anterior aspect of Quadratus Lumborum.
 On reaching the lateral edge of Quadratus Lumborum, it continues infero-laterally on the Thoracolumbar Fascia, beneath Transversus Abdominis.
 Pierces Transversus Abdominis to run infero-medially around the body wall, within the neurovascular plane between Transversus Abdominis and Internal
Oblique.
 Pierces Internal Oblique, infero-medial to the Anterior Superior Iliac Spine (ASIS).
 Continues to run between Internal and External Obliques, heading towards the Superficial Inguinal Ring.
 Emerges through the Superficial Inguinal Ring, onto the lowest part of the Anterior Abdominal Wall.
 Therefore it never contacts the Rectus Sheath or Rectus Abdominis.

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  This anterior cutaneous branch innervates
 The skin over the Inguinal Ring
 The proximal ½ inch of the Penis, and upper ½ inch of Scrotum or Labium Major.
 The medial aspect of the Thigh, just below the Inguinal Ligament.
 The Ilioinguinal Nerve gives of no Lateral Cutaneous Branches.
 Instead it is regarded as the Collateral Branch of the Iliohypogastric Nerve.
 May supply the External Oblique muscle in the lowest part of the anterior abdominal wall.

GENITOFEMORAL NERVE

 Arises from the Ventral 1 Rami of L1 and L2.

 Emerges from the anterior aspect of Psoas Major, at a level lower than both Iliohypogastric and Ilioinguinal nerves.
 Runs vertically down within the Psoas (Iliac) Fascia.
 Pierces the Fascial Envelope, and in the region of the Inguinal Ligament, it divides into its 2 branches.

Femoral Nerve

 Passes down posterior to the Inguinal Ligament, and enters the Lateral Compartment of the Femoral Sheath (along with the Femoral Artery).
 Works its way anteriorly, to pierce the Femoral Sheath and Fascia Lata.
 It then innervates a large area of skin, inferior to the central 1/3 of the Inguinal Ligament.
 Upper part = L1 fibres.
 Lower part – L2 fibres.
 Femoral Nerve also supplies Iliacus muscle, and sometimes parts of the Psoas muscle.
 It is chiefly the Nerve of the Extensor Muscles of the Knee.

OBTURATOR NERVE

 The Nerve of the Adductor Muscles of the Thigh.

LATERAL FEMORAL CUTANEOUS NERVE

 Innervates the skin on the antero-lateral surface of the Thigh.

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 I NGUINAL R EGION

I N G U I N A L C A NA L

 An oblique passage (4 cm long), through the inferior part of the anterior abdominal wall.
 It runs infero-medially, superior and parallel to the medial ½ of the Inguinal Ligament.
 Anterior wall = aponeurosis of External Oblique. Reinforced laterally by the fibres of Internal Oblique and Transversus Abdominis.
 Posterior wall = formed throughout by Transversalis Fascia, but reinforced medially by the Conjoint Tendon.
 Floor = superior surface of the Inguinal Ligament, and the Lacunar Ligament.
 Roof = arching fibres of Internal Oblique and Transversus Abdominis
 Contractions of External Oblique will approximate the anterior wall of the canal to the posterior wall.
 This prevents herniation, and is reinforced posteriorly by the Internal Oblique and Rectus Abdominis muscles.
 Contractions of Internal Oblique and Transversus Abdominis cause the roof of the canal to descend, and prevent herniation.
 Particularly when standing, coughing or straining.

SUPERFICIAL INGUINAL RING

 A triangular aperture in the aponeurosis of External Oblique.

 Its base is the Pubic Crest.
 Its two sides are the Medial & Lateral Crura.
 Lateral Crus is formed by the part of the External Oblique Aponeurosis that attached to the Pubic Tubercle via the Inguinal Ligament.
 Medial Crus is formed by the part of External Oblique Aponeurosis that diverges and attaches to the Pubic Crest.
 Inter-crural fibres arch super-medially across the Superficial Inguinal Ring, and prevent Crura from spreading apart.
 The Superficial Inguinal Ring is palpable supero-lateral to the Pubic Tubercle.

DEEP INGUINAL RING

 Located just lateral to the Inferior Epigastric Artery, and 1.3 cm superior to the Mid-Inguinal Point.
 An opening of a finger-like diverticulum of Transversalis Fascia, formed pre-natally by the evagination of Processus Vaginalis through the Transversalis Fascia.
 Its margins are ill defined.

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 S P E R M A T I C C OR D C O N S T I T U E N T S

 A cord that suspends the Testis, and contains structures that pass either to or away from it.
 It begins at the Deep Inguinal Ring, and ends at the posterior border of the Testis.
 Therefore it passes through the Inguinal Canal, emerges at the Superficial Inguinal Ring, and descends into the Scrotum.

VAS DEFERENS VEINS

 The large duct of the Testis, a continuation of the Epididymus.
 It lies in the posterior part of the Spermatic Cord.
 Its thick smooth muscle wall is easily palpable.
ARTERIES
 Testicular Artery – arises from the anterior aspect of the abdominal aorta,
at the level of L2.
 Main vessel supplying the Testis and Epididymus.
 Artery of the Vas Deferens – arises from the Inferior Vesicular Artery, and
accompanies the Vas Deferens.
 Anastomoses with the Testicular Artery near the Testis.
 Cremasteric Artery – arises from the Inferior Epigastric artery.
 Supplies the Cremaster muscle and the coverings of the Spermatic
Cord.
 Accompanies the Spermatic Cord.
 Also anastomoses with the Testicular Artery near the Testis.
LYMPH VESSELS
 Up to 12 veins leave the posterior surface of the Testis, and anastomose
to form the Pampiniform Plexus.
 Surrounds the Vas Deferens and the arteries of the Spermatic Cord.
 It is located in the Internal Spermatic Fascia.
 Drains into the Testicular Vein.
 An important heat exchange system.
NERVES
 Sympathetic fibres lie on the arteries, while both sympathetic and
parasympathetic fibres lie on the Vas Deferens
 Alter the lumen size of the arteries and the Vas Deferens.
 Also transmit excruciating visceral pain and nausea, if these
structures are damaged.
 They also innervate the Dartos muscle within the Superficial fascia
of the Scrotum, which wrinkles the scrotum skin.
 The Genital branch of the Genitofemoral Nerve also passes into the
Spermatic Cord.
 It innervates the Cremaster Muscle fibres.

 The lymph vessels drain the testes.

 They immediately pass superiorly within the Spermatic Cord.
 Empty into Lumbar and Pre-aortic Lymph Nodes, situated between the Common Iliac and Renal Veins.

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 S P E R M A T I C C OR D C OV E R I N G S

INTERNAL SPERMATIC FASCIA

 Derived from Transversalis Fascia, as the Processus Vaginalis evaginated out of it.
 It was carried forward with the Processus Vaginalis, and became the filmy, innermost layer covering the spermatic cord.

CREMASTERIC FASCIA & CREMASTER MUSCLE

 After evaginating through the Transversalis Fascia, the Processus Vaginalis then evaginated under the edge of Internal Oblique.
 Thus fascia and muscle fibres were acquired and pushed forward with the Processus Vaginalis.
 These became the middle covering of the Spermatic Cord, the Cremasteric Fascia – containing a loop of Cremaster Muscle.
 Cremaster Muscle – continuous with Internal Oblique.
 Reflexively draws the Testis superiorly, as part of a thermoregulatory reflex.
 Originates from Internal Oblique.
 Passes through the Inguinal Canal, and descends into the perineum.
 Loops under the Testis, and then passes superiorly along the same course.
 Inserts onto the Pubic Tubercle.
 Innervation = Genital branch of the Genitofemoral Nerve.
 Cremasteric reflex is caused by stroking an area of skin on the inner thigh, innervated by the Ilioinguinal Nerve.

EXTERNAL SPERMATIC FASCIA

 The Processus Vaginalis then evaginates through the External Oblique aponeurosis, forming the Superficial Inguinal Ring.
 From the point of the Superficial Inguinal Ring onwards, it pushed forward some of the External Oblique aponeurosis.
 This became the External Spermatic Fascia.
 A thin outermost covering of the Spermatic Cord, attached superiorly to the Crura of the Superficial Inguinal Ring.

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 T H E S C ROT U M

 Develops embryologically from 2 cutaneous outpouchings of the anterior INNERVATION

abdominal wall = Labioscrotal Swellings.
 Normally fuse to from a pendulous cutaneous pouch, at the Scrotal
Raphé.
 Only later will the Testes and Spermatic Cord descend into it.
 Scrotum consists of skin and superficial fascia.
 The skin is dark coloured and wrinkled.
 Superficial Fascia is devoid of fat, but contains a thin sheet of
smooth muscle = Dartos Muscle.
 This fascia is continuous anteriorly with the membranous deep
layer of superficial fascia of the anterior abdominal wall.
 The Dartos Muscle fibres are attached to the skin.
 Contraction causes further wrinkling, as part of a thermoregulatory
reflex.
ARTERIAL & VENOUS SUPPLY
 Anterior surface = Genital branch of the Genitofemoral Nerve + Scrotal
branches of the Ilioinguinal Nerve.
 Posterior surface = Perineal branch of the Pudendal Nerve.
 Inferior surface = Perineal branches of the Posterior Femoral Cutaneous
Nerve.
 Lateral surface = Genital branch of the Genitofemoral Nerve.
 Also innervates the Cremaster muscle.
LYMPH VESSELS
 The lymph vessels draining the scrotum ascend in the superficial fascia of
the scrotum.
 They empty into the Medial Members of the Horizontal Group of
Superficial Inguinal Lymph Nodes.

 The skin of the scrotum and dartos muscle are supplied by

 The Perineal Branch of the Internal Pudendal Artery.
 External Pudendal branches of the Femoral Artery.
 And the Cremasteric Artery (a branch of the Inferior Epigastric
Artery.

 Scrotal Veins accompany the scrotal arteries.

 The External Pudendal Veins drain into the Great Saphenous Vein.

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 TESTES AND THEIR DUCTS
 The main male reproductive organs, responsible for spermatogenesis and
the production of male androgens.
 Paired, ovoid glands – almond shape with an upper pointing antero-
superiorly, and a lower pole pointing postero-inferiorly.
 Suspended in the scrotum by the spermatic cords.
 The Visceral Layer of the Tunica Vaginalis covers the surface of each
Testis entirely, except posteriorly, where it is attached to the Epididymus
and Spermatic Cord.
 The Tunica Vaginalis is the unobliterated remnant of the Processus
Vaginalis, which was derived from the Peritoneal Sac, and thus has 2
layers.
 The parietal layer is separated from the visceral layer by a very small
amount of serous fluid.
 Excess fluid results in a Testicular Hydrocoele.
 External to the parietal layer of the Tunica Vaginalis, lie the three
coverings of the Spermatic Cord.
 Internal to the visceral layer of the Tunica Vaginalis, lies the Tunica
Albuginea – the connective tissue coat of the Testis.
 From the internal aspect of the Tunica Albuginea arise many fibrous
septa.
 These divide up the Testis into numerous lobules.
 The fibrous septa coalesce posteriorly to form an area of fibrous
tissue = Mediastinum Testis.
 Within each lobule, there are up to 3 convoluted Seminiferous Tubules –
the site of spermatogenesis.
 These straighten out posteriorly, as they enter the Mediastinum
Testis, forming the Straight Seminiferous Tubule.
 Within the Mediastinum Testis, they anastomose to form a plexus of
tubules = Rete Testis.
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 15-20 Efferent Ductules leave the upper part of the posterior border
of the Testis, connecting the Rete Testis to the Head of the
Epididymus.
EPIDIDYMUS
 Comma-shaped structures, applied to the superior and postero-lateral
surfaces of each Testis.
 Its Head is the superior expanded part.
 Composed of the Lobules of the Epididymus, which are the coiled
ends of the Efferent Ductules of the Testis (held together by a
minimum amount of connective tissue.
 The Body consists of the highly convoluted Canal of the Epididymus,
where sperm are stored to undergo their final stages of maturation.
 This Canal forms as the Lobules of the Epididymus coalesce.
 The Tail of the Epididymus forms as the Canal loses its coiling, and
straightens out.
 The lumen narrows, as its wall increases in musculature.
 It is continuous with the beginning of the Vas Deferens.
VAS DEFERENS
 Extends upwards, to leave the Testis and Epididymus, lying within the
Internal Spermatic Fascia.
 Passes through the Superficial Inguinal Ring, and enters the Inguinal
Canal.
 On exiting the Deep Inguinal Ring, it loses its fascia covering, and enters
the Abdominal Cavity.
 It opens into the male Prostatic Urethra.
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 T HE P ERITONEUM AND P ERITONEAL C AVITY

MESENTERY GREATER OMENTUM

 A double layer of peritoneum.  Double layered sheet of peritoneum.

 Encloses an organ, and connects it to the posterior abdominal wall.  Contains a variable amount of fat and extra-peritoneal tissue, depending
 Have a core of loose connective tissue; containing fat cells and lymph on the fitness of the individual.
nodes, as well as nerves & blood vessels running to the viscus it encloses.  Hangs down from the Greater Curvature of the Stomach, and connects
 All invaginated organs have mesenteries, named according to the organ to the diaphragm (superiorly), and to the spleen (to the left).
(e.g. mesogastrium or mesocolon).  Inferiorly, it extends down as far as the pelvis, before looping back
 Retroperitoneal structures have no need of a mesentery. on itself. It then passes superiorly to attach to the Transverse
Mesocolon.
LESSER OMENTUM  This loop normally fuses with itself in the foetal period  the Greater
Omentum is composed of 4 layers of peritoneum.
 Double layered sheet of peritoneum.  Also fuses with the Transverse Mesocolon.
 Connects the lesser curvature of the stomach and the proximal part of  This fusion obliterates the Inferior Recess of the Lesser Sac, which
the duodenum, to the Liver. commonly inserts itself between the loop of the Greater Omentum.
 Hepatogastric Ligament  It is divided into three main parts (or ligaments – may contain blood
 Hepatoduodenal Ligament. vessels or remnants of blood vessels)
 Lies posterior to the left lobe of the Liver.  e.g. the Falciform Ligament contains
 Attaches to the liver at: the Ligamentum Teres (a remnant of
 The Fissure for the Ligamentum Vernosum (remnant of the foetal the foetal Umbilical Vein).
ductus vernosus).  Gastrocolic Ligament (apron-like)
 The Porta Hepatis.  Gastrosplenic Ligament (left part)
 Its right free margin contains:  Gastrophrenic Ligament (superior part).
 The Portal Vein (posteriorly)  The Greater Omentum, along with the Transverse Colon and Transverse
 The Hepatic Artery Proper (anteriorly) Mesocolon, forms a shelf that divides the peritoneal cavity into
 The Bile Duct (anteriorly) supracolic and infracolic compartments.

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SUPRACOLIC COMPARTMENT
 Subdivided into smaller parts by the Falciform Ligament.
 Contains:
 The Right and Left Anterior Subphrenic Recesses – located between
the inferior surface of the diaphragm and the superior surfaces of the
right and left lobes of the Liver.
 The Hepatorenal Recess – located between the inferior surface of
the right lobe of the Liver and the right Kidney.
INFRACOLIC COMPARTMENT
 Divided into right and left infracolic spaces by the Mesentery of the
Small Intestine.
 Owing to its obliquity, the right infracolic space lies at a superior
level to the left infracolic space.
 Contains:
 Right & Left, Medial & Lateral Paracolic Gutters – related to each
side of the Ascending and Descending Colon.
 Paravertebral Gutters – on each side of the Vertebral Column
 Each contains a kidney, a ureter, and part of the colon.
 The Right Lateral Paracolic Gutter is of particular clinical significance:
 Continuous superiorly with the Hepatorenal Recess, and beyond this
with the Superior Recess of the Lesser Sac.
 Continuous inferiorly with the Retrovesical Pouch (males), and the
Retrouterine Pouch (females).
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THE LESSER SAC OF PERITONEUM (OMENTAL BURSA)
 Located between the posterior aspect of the stomach and the posterior
abdominal wall.
 Lies posterior to the Lesser Omentum.
 The anterior and posterior walls of the Omental Bursa move freely on
each other  this allows considerable movement of the Stomach during
contraction and distension.
 The Omental Bursa can be considered the simple posterior extension of
the main peritoneal sac, if the stomach was considered to have
invaginated the peritoneal sac from the left.
 The Inferior Recess of Lesser Sac lies between the duplicated layers of
the Gastrocolic Ligament of the Greater Omentum.
 Only a potential space, since the Inferior Recess is usually obliterated
in adult life, owing to adhesion of the layers of the Gastrocolic
Ligament (i.e. the fusion of the loop of Greater Omentum).
 The Superior Recess is limited by the diaphragm, and the posterior layers
of the Coronary Ligament.
 The Epiploic (Omental) Foramen marks the point of communication of
the Aditus of the Omental Bursa with the Greater Sac of Peritoneum.
 It is located posterior to the right free edge of the Lesser Omentum,
and its associated 3 structures.
Boundaries of the Omental Foramen
 Anterior = Portal Vein, Hepatic Artery, and the Bile Duct (all lying in the
right free edge of the Lesser Omentum).
 Posterior = the Inferior Vena Cava, and the Right Crus of the
Diaphragm.
 Superior = the Caudate Lobe of the Liver.
 Inferior = the Superior Part of the Duodenum, the Portal Vein, Hepatic
Artery, & the Bile Duct.
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 T HE S PLEEN
A NA TO M Y & R E L A T I O N S
 A large, soft vascular lymphatic organ in the Left Hypochondrium – the
largest single mass of lymphoid tissue in the body.
 Located between the layers of Dorsal Mesogastrium that suspends the
stomach from the posterior abdominal wall.
 Lies posterior to the stomach, but anterior to the superior part of the
left kidney.
 Lies against the diaphragm laterally, behind which is the lower
border of the left lung, and associated visceral and parietal pleura.
 It is related therefore to the left costo-diaphragmatic recess.
 It lies deep to the 9th, 10th and 11th ribs, with the long axis of its external
(diaphragmatic surface) lying along the shaft of the 10th rib.
 The spleen is supported on all sides:
 Superiorly by the diaphragm.
 Laterally by the Phrenico-colic Ligament.
 Inferiorly by the Left Colic Flexure of the Transverse Colon.
 The spleen is usually about 12 cm long, and 7 cm wide.
 Its superior and anterior borders are sharp and often notched – an
indication of its lobulated embryological development.
 Its inferior and posterior borders are usually curved.
 The spleen seldom extends below the left costal margin, and so is
rarely palpable through the antero-lateral abdominal wall.
 It is palpable, though, in infancy, since it does extend below the
left costal margin.
 The anterior tip of the spleen will usually extend no further medially
than the mid-clavicular line.
 Connected to the Greater Curvature of the Stomach by the
Gastrosplenic Ligament.
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 Connected to the left kidney by the Lienorenal Ligament.
 The Gastrosplenic and Lienorenal Ligaments are connected to the Spleen
at its Hilum, on its medial (visceral) surface.
 This is where the branches of the Splenic Artery and Vein
enter/leave.
 On its internal surface, there are 4 impressions made by adjacent
abdominal viscera:
 Colon – colic impression lies anteriorly.
 Stomach – gastric impression lies above.
 Left Kidney – renal impression lies posteriorly = indirect relation
(presence of intervening peritoneum)
 Tail of Pancreas – at hilum of spleen = direct relation (no
intervening peritoneum).
 With the exception of at the Hilum, the Spleen is completely covered by
Greater Sac of Peritoneum.
 The capsule and trabeculae of the Spleen contain some smooth muscle
fibres, to enable it to expel blood out into the circulation.
V E N OU S D R A I NA G E
 Splenic Vein – forms by the union of several tributaries emerging from
the hilum of the spleen.
 Runs posterior to the superior border of the body and tail of the
Pancreas.
 The Inferior Mesenteric Vein usually joins it.
 The Splenic Vein terminates by uniting with the Superior Mesenteric
Vein, posterior to the neck of the Pancreas, to from the (Hepatic) Portal
Vein.
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 A RT E R I A L S U P P LY
 The Splenic Artery is the largest branch of the Coeliac Trunk.
 It runs posterior to the Omental Bursa (Lesser Sac),
 Along the superior border of the Pancreas.
 Anterior to the Left Kidney.
 Between the layers of the Lienorenal Ligament, it divides into 5 or more
branches, which enter the spleen at its hilum.
 These branches supply individual parts of the spleen, as end arteries
 There is no anastomosis between the branches within the spleen.
 Any obstruction in one of them will result in a regional splenic
infarction.
I N N E RVA T I ON
 The Nerves of the Spleen are usually derived from the Coeliac Plexus of
autonomic nerves, running along the external surface of the Coeliac
Trunk.
 They distribute mainly to the branches of the Splenic Artery, and are
vasomotor in function.
LY M P H A T I C D R A I NA G E
 Lymph from the spleen passes to the Pancreatico-splenic Lymph Nodes.
 These are related to the posterior surface and superior border of the
Pancreas.
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F U N C T I ON A L A N D C L I N I C A L P OI N T S
 The spleen filters the blood, removing foreign particles, and old &
damaged erythrocytes.
 Thus it has a profuse blood supply relative to its size.
 It is not essential for life though, and can be removed surgically, if it
becomes pathological
 It could become enlarged = Splenomagoly.
 It could start destroying normal erythrocytes.
 However, removal may result in immunological problems later in
life.
 10% of the population have Accessory Spleens.
 These are found principally in the Gastrosplenic Ligament.
 They are 1cm in diameter.
 If the Spleen is removed, an Accessory Spleen can enlarge to the
original spleen’s size, and take over its activity.
 The Spleen is friable (= brittle).
 It is easily ruptured, and so will need removal.
 E.g. from blunt trauma to the Left Hypochondrium.
 Rupture will result in profuse bleeding into the Peritoneal Cavity.
 This will result in a large build up of blood in the cavity, before
symptoms present themselves = The Lucid Interval.
 Prior to surgical removal, the Splenic Vessels are ties off.
 The tail of the Pancreas must not be tied or broken off.
 Otherwise, its exocrine enzymes and secretions will be released into
the peritoneal cavity.
 Peritonitis.
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 T HE PANCR EAS

A NA TO M Y & R E L A T I O N S

 An elongated soft, greyish digestive gland – 12 to 15 cm long. HEAD

 Located near the Transpyloric plane.
 Lies transversely across the posterior abdominal wall, behind the
stomach.
 Lies in the Epigastric, and Left Hypochondriac regions.
 Right side (head) lies across the bodies of L1 to L3, and is slightly
inferior to the Transpyloric plane.
 Left side (tail) lies slightly superior to the Transpyloric plane.
 The pancreas is located posterior to the Omental Bursa  forms a major
part of the stomach bed.
 Produced an exocrine secretion that enters the duodenum via the
pancreatic duct.
 Also produces an internal secretion that enters the blood and controls
blood glucose levels.
 Located within the curve of the duodenum.
 Rests posteriorly on the Inferior Vena Cava, the Right Renal Vessels, and
the Left Renal Vein.
 Has a superior prolongation to the left = Uncinate Process.
 Lies behind to the Superior Mesenteric Vessels, and rests posteriorly
against the abdominal aorta.
 The common bile duct, on its way to the duodenum, lies embedded in a
groove on the postero-superior surface of the head of the Pancreas.
NECK
 2 cm long, and continuous with the superior, left portion of the Head of
the Pancreas.
 Merges imperceptibly with the Body of the Pancreas.
 Grooved posteriorly by the Superior Mesenteric Vessels.
 Its anterior surface is covered with peritoneum, and is adjacent to the
Pylorus of the Stomach.
 Posterior to the Neck of the Pancreas, is the site of the origin of the
Portal Vein (from the union of the Splenic and Superior Mesenteric
Veins).

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BODY TAIL

 Extends to the left, and slightly superiorly, across the abdominal aorta  The narrow left end of the Pancreas.
and the upper lumbar vertebrae.  It is thick, but may be pointed or blunt.
 Extends posterior to the Omental Bursa (Lesser Sac).  Passes between the 2 layers of the Lienorenal Ligament, along with the
 Triangular in cross-section: Splenic Vessels.
 Anterior surface – covered in peritoneum, and forms part of the  Its terminal part is usually directly related with the Hilum of the Spleen.
stomach bed.
 Provides attachment for the Transverse Mesocolon.
 Posterior surface – devoid of peritoneum where it overlies the
abdominal aorta, superior mesenteric artery, left adrenal gland, and
left kidney (+ vessels).
 Inferior surface.
 The Body of the Pancreas is intimately associated with the Splenic Vein.
 Where it lies anterior to the abdominal aorta, it is between the origins
of the Coeliac Trunk and Superior Mesenteric Artery.
 The Omental Tuberosity arises from its superior border, and contacts the
Lesser Omentum.
 Located immediately inferior to the Coeliac Trunk.

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 PA N C R E A T I C D U C T S

MAIN PANCREATIC DUCT ACCESSORY PANCREATIC DUCT

 Begins in the tail of the Pancreas, and passes to the right, through the  The pancreas develops from 2 outgrowths = Dorsal & Ventral
substance of the gland. Pancreatic Buds.
 It picks up tributaries in a herringbone pattern.  These fuse to allow their individual ducts to communicate.
 Embedded superficially in the posterior surface of the Pancreas.  The proximal part of the Ventral Pancreatic Duct and the distal part of
 Becomes Y-shaped as it is joined by parts of the duct from the Head and the Dorsal Pancreatic Duct form the Main Pancreatic Duct.
Uncinate Process.  The proximal end of the Dorsal Pancreatic Duct frequently persists as
 Within the head, it turns inferiorly it becomes related to the Common the Accessory Pancreatic Duct.
Bile Duct.  It is usually connected to the Main Pancreatic Duct.
 It then obliquely pierces the postero-medial wall of the descending  In 9% of people, it is a completely separate duct that opens into the
(2nd) part of the Duodenum, at its mid-point. Minor Duodenal Papilla.
 The two ducts unite to form a short, dilated Hepatopancreatic
Ampulla (of Vater).
 This opens into the Duodenum at the Major Duodenal Papilla.
 2 sphincters control the release of bile and pancreatic juices into the
duodenum:
 Pancreatic Duct Sphincter – around the terminal part of the main
duct.
 (Hepatopancreatic) Sphincter of Oddi – around the hepatopancreatic
ampulla.

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 A RT E R I A L S U P P LY
 Splenic Artery – up to 10 small branches supply the Body and Tail of the
Pancreas.
 The Head of the Pancreas is supplied by the:
 Anterior & Posterior Superior Pancreaticoduodenal Arteries (from
the Gastroduodenal Artery).
 Anterior & Posterior Inferior Pancreaticoduodenal Arteries (from
the Superior Mesenteric Artery).
 All these Pancreaticoduodenal arteries will anastomose freely
with one and other.
 The groove between the anterior part of the Head of the Pancreas, and
the Duodenum, lodges the Anterior Pancreaticoduodenal Arcade.
 The groove between the posterior part of the Head of the Pancreas, and
the Duodenum, lodges the Posterior Pancreaticoduodenal Arcade.
V E N O U S D R A I NA G E
 The Pancreatic Veins drain to the Portal, Splenic and Superior
Mesenteric Veins.
 However, they mainly drain to the Splenic Vein.
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I N N E RVA T I ON
 Innervation is derived from the Vagus and Splanchnic Nerves.
 The Splanchnic Nerves alone carry pain fibres.
 Sympathetic and Parasympathetic Autonomic innervation arrives along
arteries, from the Coeliac and Superior Mesenteric Plexuses.
LY M P H A T I C D R A I NA G E
 Lymph vessels follow the blood vessels.
 Lymph passes to the Pancreatico-splenic Lymph Nodes, which lie along
the Splenic Artery on the superior border of the Pancreas.
 However, some lymph drains to Pyloric Lymph Nodes.
 Efferent lymph vessels from these nodes drain to:
 Coeliac Lymph Nodes.
 Hepatic Lymph Nodes.
 and Superior Mesenteric Lymph Nodes.
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 T HE S TOMACH

G E N E R A L A NA TOM Y

A greatly expanded portion of the digestive track PYLORUS

CARDIA
 A rather indefinite region around the Cardiac Orifice – receives the
opening of the abdominal oesophagus.
 Lies near the part of the diaphragm, on which the pericardial sac lies.
 The distal sphincteric region that guards the Pyloric Orifice.
 The middle layer of the muscularis externa is thickened, and there is extra
circular muscle to form the Pyloric Spinctor.
 Controls the rate of discharge of Chyme into the duodenum, by gastric
peristalsis.

FUNDUS SURFACE ANATOMY

 A rounded vault – lies superior and to the left of the cardiac orifice.  Usually located in the Left Upper Quadrant, occupying parts of the
 It is the most superior part of the stomach, and is related to the left Epigastric, Umbilical and Left Hypochondriac regions.
dome of the diaphragm.  Its size and shape varies greatly.
 It usually contains a bubble of gas – shows up on radiographs.  The Cardiac Orifice lies posterior to the 7th Left CC – 2-4 cm to the left
of the median plane, at the level of T10 or T11.
BODY  The superior tip of the Fundus lies posterior to the 5th Left Rib, in the
mid-clavicular line.
 The major portion of the stomach.  The Pylorus lies in the Trans-pyloric Plane.
 Lies between the fundus, and the pyloric antrum.  In the supine position, it varies from the level of L1 to L3.
 Together with the fundus, with which it is widely continuous, they form  In the erect position, it varies from the level of L2 to L4.
the most capacious area of the stomach.
 A normal stomach is not palpable, because of its flat, flabby walls.
 Contain longitudinal rugae.
 The Lesser Curvature is continuous with the right border of the
Oesophagus, and forms the smaller concave border of the stomach.
PYLORIC PART
 The Greater Curvature is continuous with the left border of the
 Consists of two parts: Oesophagus, at the Cardiac Notch, and forms the convex border of the
 Pyloric Antrum – wide portion stomach (up to 4 times longer).
 Pyloric Canal – narrow, and continuous with pylorus.

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 The Angular Notch separates the terminal part of the Lesser Curvature
from the Pyloric Part.

RELATIONS

 The stomach is entirely covered by Peritoneum.

 Except where blood vessels run along its greater and lesser
curvatures, as well as at a small bare area posterior to the Cardiac
Orifice.
 The two layers of Lesser Omentum connect the Lesser Curvature to the
Porta Hepatis.
 It two layers split to surround the stomach, converge to leave the
Greater Curvature as the Greater Omentum.
 The fundus of the stomach is in contact with the diaphragm, posterior to
the inferior left costal cartilages.
 The anterior surface of the stomach is in contact with
 The diaphragm, in the fundic region.
 The left lobe of the Liver.
 The anterior abdominal wall.
 The posterior surface of the stomach is in contact with the Stomach Bed.

STOMACH BED

 Formed by the posterior wall of the Omental Bursa + retroperitoneal

structures lying between it and the posterior abdominal wall (e.g.
Pancreas and left Kidney).
 Superiorly, the stomach bed includes part of the Diaphragm, the Spleen,
and left Adrenal Gland.
 Inferiorly, the stomach bed includes the body & tail of the Pancreas, and
the Transverse Mesocolon.

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 A RT E R I A L S U P P LY

 The stomach has a rich blood supply from all three branches of the
Coeliac Trunk.
BRANCHES OF THE LEFT GASTRIC ARTERY
 A small branch of the Coeliac Trunk. Passes superiorly and to the left
across the posterior wall of the omental bursa.
 It thus lies in the floor of the omental bursa, posterior to the parietal
peritoneum, against the posterior abdominal wall.
 Passes from the posterior abdominal wall to the cardiac region of the
stomach.
 It then runs along the Lesser Curvature, within the two layers of Lesser
Omentum, up to the Pylorus.
 It supplies both surfaces of the stomach, by means of 5 or more
branches.
 It terminates by anastomosing with the Right Gastric Artery.
BRANCHES OF THE COMMON HEPATIC ARTERY
 The Common Hepatic Artery divides into the Hepatic Artery Proper,
and the Gastroduodenal Artery.
 The Hepatic Artery Proper gives off the Right Gastric Artery.
 The Gastroduodenal Artery gives of the Right Gastro-epiploic
Artery.
 The Right Gastric Artery also supplies the region of stomach around the
Lesser Curvature, as well as the Pyloric region.
 It terminates by anastomosing with the Left Gastric Artery.
 The Right Gastro-epiploic Artery runs along the inferior part of the Greater
Curvature, between layers of Greater Omentum.
 It runs to the left, supplying
 The right part of the stomach.
 The superior part of the duodenum.
 The Greater Omentum.
 It terminates by anastomosing with the Left Gastro-epiploic artery,
along the Greater Curvature of the Stomach.
BRANCHES OF THE SPLENIC ARTERY
 The Left Gastro-epiploic Artery, branches of the Splenic artery, and runs
between the layers of the Gastrosplenic Ligament, to the Greater
Curvature.
 It runs along the Greater Curvature, to the right, until it anastomoses
with the Left Gastro-epiploic Artery.
 It supplies the left part of the stomach, as well as Greater Omentum.
 Short Gastric Arteries – 4 or 5 branches of the Splenic artery.
 Run between layers of the Gastrosplenic Ligament, to the Fundus of
the Stomach.
 Here they anastomose with branches of the Left Gastric and Left
Gastro-epiploic arteries.

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 V E N O U S D R A I NA G E I N N E RVA T I ON O F T H E S TOM A C H

 The gastric veins follow the course and position of the gastric arteries,
and drain into the Portal Venous System.
 Left & Right Gastric Veins – drain directly into the Portal Vein.
 Right Gastro-epiploic Vein – drains into the Superior Mesenteric Vein.
 But may also drain into the Portal Vein or Splenic Vein.
 Left Gastro-epiploic Vein & Short Gastric Vein – drain into the Splenic Vein
or one of its tributaries.
 The Right Gastric vein and Right Gastro-epiploic vein are linked by the
Pre-pyloric Vein Of Mayo.
 Marks the position of the pylorus.
 Parasympathetic supply is from the branches of the Vagal Trunks
 Related to where the Left Gastric artery approaches the cardiac
region of the stomach.
 Anterior Vagal Trunk – derived from the Left Vagus Nerve.
 Enters the abdomen on the anterior surface of the oesophagus.
 Runs towards and along the Lesser Curvature.
 Gives of Hepatic and Duodenal branches, that leave the stomach in
the Hepato-duodenal Ligament.
 Also gives of Anterior Gastric Branches,
 Posterior Vagal Trunk – derived from the Right Vagus Nerve.
 Enters the abdomen on the posterior surface of the oesophagus.
 Runs towards and along the Lesser Curvature.
 Gives off a Coeliac Branch, to the Coeliac Plexus.
 Also gives off Posterior Gastric Branches.
 The Sympathetic Nerve supply is mainly from the Coeliac Plexus, via the
plexuses on the Gastric and Gastro-epiploic Arteries.
 Efferent sympathetic fibres to the stomach arise from Spinal Cord
segments T6-T9.

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 LY M P H A T I C D R A I NA G E

 Lymph vessels accompany the arteries along the Greater and Lesser
Curvatures of the Stomach, draining lymph from both its surfaces.

 4 main areas of lymphatic drainage:

 Largest = the Lesser Curvature + a large part of the Body:
 Drain to the Left Gastric Lymph Nodes (lie along the Left
Gastric Artery).
 2nd Largest = right part of the Greater Curvature + most of Pyloric
region:
 Drain to Right Gastro-epiploic Lymph Nodes  drain to
Pyloric Lymph Nodes (on anterior surface of the Head of the
Pancreas).
 3rd Area = left part of the Greater Curvature:
 Drain to Left Gastro-epiploic Lymph Nodes along the Left
Gastro-epiploic vessels.
 Alternatively drain to Pancreatico-Splenic Lymph Nodes, which
lie along the Splenic vessels.
 Smallest Area = Pyloric part of Lesser Curvature:
 Drain to Right Gastric Lymph Nodes (lie along the Right
Gastric Artery).

 Efferent vessels from the lymph nodes draining these 4 major areas of
the stomach, go to the Coeliac Lymph Nodes.
 These lie around the origin of the Coeliac Trunk.
 The lymph goes on to the Cisterna Chyli and the Thoracic Duct.

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 T HE S MALL I NTEST INE
T H E D U OD E N U M
SUPERIOR PART
 Lies antero-lateral to the body of L1.
 5 cm long.
 It is the most mobile part of the duodenum.
 Begins at the pylorus and passes to the right, posteriorly & slightly
superiorly.
 Goes towards the neck of the Gallbladder, and the Right Kidney.
 Hence passes almost at right angles to the pylorus of the stomach.
 The beginning / ampulla of the superior part of the duodenum = the
Duodenal Cap.
 The proximal ½ of the superior part of the duodenum has a mesentery
 mobile.
 The Greater Omentum and Hepato-duodenal Ligament attach here.
 Therefore this part moves with the stomach.
 The distal ½ of the superior part of the duodenum has no mesentery,
and is fixed to the posterior abdominal wall  immobile.
 Anterior relations = peritoneum, Gallbladder, and Quadrate Lobe of the
Liver.
 Posterior relations = Bile Duct, Gastroduodenal artery (+Hepatic Artery
Proper), Portal Vein, Inferior Vena Cava.
 Superior relations = neck of Gallbladder.
 Inferior relations = neck of the Pancreas.
C REATED BY M ICHAEL C HEERAN D AVID
DESCENDING PART
 Usually 7.5 cm long, with no mesentery.
 Descends retroperitoneally along the right sides of L1 to L3 vertebrae.
 Passes to the right, and parallel to the Inferior Vena Cava.
 The Bile Duct, and Main Pancreatic Duct enter the postero-medial wall
of the descending part of the duodenum, about 2/3 the way along its
descent.
 Enter the wall obliquely, as a united Hepato-pancreatic Ampulla.
 This opens on the Major Duodenal Papilla – located 8-10 cm distal
to the Pylorus.
 The opening of the Major Duodenal Papilla is guarded by the
Sphincter of the Hepato-pancreatic Ampulla – which can constrict it.
 Anterior relations = Transverse Colon, Transverse Mesocolon, as well as
some coils of Jejunum.
 Posterior relations = Hilum of the Right Kidney, Renal Vessels, Ureter,
and Psoas Major muscle.
 Medial relations = Head of the Pancreas, Superior Mesenteric Vessels,
Inferior Vena Cava.
 Lateral relations = Right Colic Flexure, and part of the Liver.
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HORIZONTAL PART
 10 cm long.
 Runs horizontally from right to left, across the L3 vertebrae.
 Passes anterior to the Inferior Vena Cava, Aorta, and Inferior
Mesenteric Vessels.
 Retroperitoneal, and adherent to the posterior abdominal wall.
 Anterior relations = superior mesenteric artery, and coils of Jejunum.
 Posterior relations = the right Psoas Major muscle, Inferior Vena Cava,
Abdominal Aorta, origin of Inferior Mesenteric Artery, lower pole of
Right Kidney, and Right Ureter.
 Superior relations = the head of the Pancreas, and superior mesenteric
vessels.
 Inferior relations = coils of Jejunum.
ASCENDING PART
 2.5 cm long.
 Ascends from the level of L3 to the L2 vertebrae.
 Ascends to the left side of the abdominal aorta, and anterior to the
left renal vessels.
 Here it meets the body of the pancreas.
 Terminates by turning abruptly anteriorly, to join the Jejunum at the
Duodeno-jejunal Junction.
 This distal end is covered with peritoneum, and is movable.
 The rest of the ascending part of the duodenum is retroperitoneal,
immobile and adherent to the posterior abdominal wall.
 A fibro-muscular band called the Suspensory Muscle of the Duodenum
(Ligament of Treitz) supports the Duodeno-Jejunal Flexure.
 The superior part of this band contains striated muscle.
 The intermediate part contains elastic fibres.
 The inferior part contains smooth muscle.
C REATED BY M ICHAEL C HEERAN D AVID
 Origin = superior surface of the ascending part of the duodenum +
Duodeno-Jejunal Flexure.
 2 Insertions = right crus of diaphragm (close to the oesophageal
opening) + connective tissue around the coeliac trunk.
 Action = supports the Duodeno-Jejunal Flexure, and widens its angle 
facilitates movement of intestinal contents.
 Anterior relations = beginning of root of The Mesentery, and coils of
Jejunum.
 Posterior relations = left Psoas Major muscle, left renal vessels, and left
margin of aorta.
 Medial relations = Head of Pancreas.
 Superior relations = Body of Pancreas.
PERITONEAL RECESSES
 Several peritoneal folds and recesses are related to the duodenum,
particularly near the Duodeno-jejunal Junction.
 This is where the small intestine changes from a retroperitoneal
position to an intra-peritoneal one.
 Most are inconstant.
 Superior Duodenal Recess
 Inferior Duodenal Recess – extends to the left from the distal part of
the duodenum.
 Retroduodenal Recess – between the superior and inferior duodenal
recesses.
 Para-duodenal Recess – posterior to the inferior mesenteric vein 
highly vascularised
 Need to know if cutting it, to relieve a strangulated paraduodenal
hernia
 Watch for the Inferior Mesenteric and Superior Left Colic
arteries.
 Duodenojejunal-Mesocolic Recess (Mesocolic Recess) – located just
superior to the duodeno-jejunal flexure.
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 A RT E R I A L S U P P LY TO T H E D U OD E N U M
 Supplied by the Coeliac Trunk (foregut), and the Superior Mesenteric
Artery (midgut).
 Superior Pancreatico-duodenal Artery – a branch of the Gastro-duodenal
artery (from the Common Hepatic artery, which arises from the Coeliac
Trunk)
 Supplies the proximal half of the duodenum.
 Inferior Pancreatico-duodenal Artery – a branch of the Superior Mesenteric
artery.
 Supplies the distal half of the duodenum.
 The Superior and Inferior Pancreatico-duodenal arteries anastomose with
each other, to form Anterior & Posterior Arterial Arcades.
 Lie in the angle between the Pancreas and the Duodenum.
 The superior part of the duodenum, may also receive an arterial supply
from
 The Supra-duodenal artery.
 The Right Gastric artery.
 The Right Gastro-epiploic artery.
 The Right Gastro-duodenal artery.
I N N E RVA T I O N O F T H E D U OD E N U M
 The duodenum is supplied by the Vagus and Sympathetic nerves, via the
plexuses on the Pancreatico-duodenal arteries.
C REATED BY M ICHAEL C HEERAN D AVID
V E N OU S D R A I NA G E F R OM T H E D U OD E N U M
 The veins follow the course of the arteries, and drain to the Portal
Venous System.
 Most duodenal veins drain to the Superior Mesenteric vein, but some
may enter the Portal Vein directly.
 There are numerous small veins on the anterior and posterior parts of
the Superior Part of the Duodenum.
 These drain to the Superior Pancreatico-duodenal Veins.
 One of these anterior veins = the Prepyloric Vein of Mayo.
 Ascends from the Right Gastro-epiploic Vein, anterior to the
Pylorus.
 Drains into the Right Gastric Vein.
 A useful guide to the Gastro-duodenal Junction, and the site of the
Pyloric Orifice.
LY M P H A T I C D R A I NA G E O F T H E D U OD E N U M
 The lymph vessels on the anterior and posterior surfaces of the
duodenum anastomose freely, within the wall of the duodenum.
 Anterior vessels follow the arteries, and drain:
 Superiorly to the Pancreatico-duodenal Lymph Nodes (along the
Splenic artery).
 And also to the Pyloric Lymph Nodes along the Gastroduodenal
artery.
 Efferent vessels pass to the Coeliac
Lymph Nodes
 Posterior vessels pass posterior to the head of the pancreas and drain
inferiorly into the Superior Mesenteric Lymph Nodes (located around the
origin of the Superior Mesenteric artery).
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 THE JEJUNUM AND ILEUM

 Jejunum begins at the Duodeno-jejunal Flexure. THE MESENTERY

 The Jejunum and Ileum are together 6-7 metres long – the Jejunum
constituting 2/5 of this, and the Ileum 3/5  The Jejunum and Ileum are suspended from the posterior abdominal wall
 Greatly coiled, and covered in varying extents by the Greater Omentum. by a large, fan-shape Mesentery.
 There is no clear line of demarcation between the Jejunum and the  Its root is 15 cm long, and directed obliquely.
Ileum, but their character changes gradually.  Passes from the left side of the L2 vertebra, to the right sacro-iliac
 The Jejunum is often empty. joint.
 It is thicker, more vascular, and redder than the Ileum, in living  In doing so, it crosses:
specimens.  The horizontal part of the Duodenum
 Most lies in the umbilical region of the Abdomen.  The Abdominal Aorta
 The Ileum occupies most of the Hypogastric (Pubic) and Right Inguinal  The Inferior Vena Cava
regions.  Right Psoas Major muscle
 It ascends over the right Psoas Major muscle, and Right Iliac vessels  Right Ureter
to enter the Caecum.  Right Testicular / Ovarian vessels.
 Plicae Circulares – circular folds of mucous membrane.  The proximal part of the Jejunum, and the terminal part of the Ileum,
 Large and well developed in the proximal part of the Jejunum. have shorter mesenteries  less mobile than the other parts.
 Small in the superior part of the Ileum.  Mesentery is pleated and fan-shaped. Its two layers of peritoneum
 Absent in the terminal part of the Ileum. contain:
 Jejunal and Ileal blood vessels
 Lymphatics
 Nerves
 Extra-peritoneal Fatty Tissue.
 The Jejunal mesentery contains less fatty tissue than the Ileal mesentery
 its arterial arcades are more visible (another differentiating
characteristic).

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 A RT E R I A L S U P P LY TO T H E J E J U N U M A N D I L E U M V E N OU S D R A I NA G E F R OM T H E J E J U N U M A N D I L E U M

 Derived from the Superior Mesenteric Artery – 2nd of the unpaired  Superior Mesenteric Vein drains the Jejunum and Ileum – accompanies
branches of the abdominal aorta. the superior mesenteric artery.
 Usually arises at the level of L1 vertebra, about 1 cm inferior to the  Lying anterior and to its right, in the Mesentery.
Coeliac Trunk.  Crosses the horizontal part of the Duodenum, and Uncinate Process
 Origin lies posterior to the body of the Pancreas, and the Splenic of the Pancreas.
Vein.  Terminates posterior to the neck of the Pancreas, by uniting with the
 Descends across the left renal vein, the uncinate process of the Splenic vein, to form the Portal Vein.
Pancreas, and the horizontal part of the Duodenum.  The tributaries of the Superior Mesenteric Vein follow the same
 Enters the Mesentery. distribution as the arteries, and drain the same area.
 The Superior Mesenteric Artery descends obliquely in the root of the
Mesentery, to the right iliac fossa.
I N N E RVA T I ON O F T H E J E J U N U M A N D I L E U M
 Sends numerous branches to the intestines.
 Its Ileal branches anastomose with a branch of the Ileocolic Artery.
 15-18 Jejunal and Ileal branches arise from the left side of the Superior  Nerves of the Jejunum and Ileum are derived from the Vagus and
Mesenteric artery. Splanchnic nerves, through the Coeliac Ganglion, and nerve plexuses on
 Pass between the 2 layers of mesentery. the Superior Mesenteric Artery.
 Unite to form Arterial Arcades (loops).  Superior Mesenteric Nerve receives its parasympathetic fibres from the
 From these Vasa Recta arise – do not anastomose within the Coeliac division of the Posterior Vagal Trunk.
Mesentery.  Its sympathetic fibres come from the Superior Mesenteric Ganglion.
 The Vasa Recta pass from the arcades, to the Mesenteric border of the
Intestine.
 Pass more or less alternately to opposite sides.
 There are many anastomoses of blood vessels within the walls of the
Jejunum and Ileum.
 There is greater vascularity in the Jejunum. But the arterial arcades are
shorter and more complex in the Ileum.

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 LY M P H A T I C D R A I NA G E O F T H E J E J U N U M A N D I L E U M

 The Lymphatics in the intestinal villi = Lacteals.

 Drain into a plexus of lymph vessels in the walls of the Jejunum and
Ileum.
 Pass between the 2 layers of the Mesentery, to the Mesenteric Lymph
Nodes.
 Mesenteric Lymph Nodes – lie in 3 locations:
 Close to the wall of the Intestine.
 Amongst the Arterial Arcades.
 Along the proximal part of the Superior Mesenteric Artery.
 Efferent vessels from all the Mesenteric Lymph Nodes will drain into the
Superior Mesenteric Lymph Nodes.
 Lymph from the terminal part of the Ileum follows the Ileal branch of
the Ileocolic Artery, to the Ileocolic Lymph Nodes.

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 T HE L IVER

S U R FA C E A NA TOM Y

 A huge glandular organ, belonging to the GI system – also acts as a storehouse for glycogen, and secretes bile.
 It is the largest gland in the body – 2% of body weight in adults. (5% in infants)
 Its smooth surfaces are in contact with the diaphragm, and anterior abdominal wall.
 Attached by the Falciform Ligament, and the Coronary Ligaments.
 In life, it is a soft, reddish-brown organ, surrounded by a strong connective tissue capsule = Glisson’s Capsule.
 Receives venous blood returning from the GI-Tract, laden with the products of digestion.
 Liver Bile passes to the Gallbladder, via the Hepatic ducts and Cystic duct.
 There is it concentrated by absorption of water.
 When fat-containing chyme enters the duodenum, it stimulates the release of Cholecystokinin.
 This induces contraction of the Gallbladder.
 Forces concentrated Gallbladder Bile into the duodenum, along with the liver bile already in the bile duct.
 The Liver lies more inferiorly in the erect position, than in the supine position.
 It also moves inferiorly, during contraction of the Diaphragm.
 It conforms to the right dome of the diaphragm, but also crossed the median plane, to occupy some of the left dome.
 Its highest point is posterior to the right 5th Rib (just inferior to the nipple).
 The Liver lies in the right upper quadrant – occupies the entire Right Hypochondriac region, part of the Epigastric region, and extends into the Left
Hypogastric Region.
 Pyramidal in shape: the base to the right, and the apex to the left.
 The Liver is protected by the osteo-cartilaginous Thoracic Cage, but extends inferiorly as far as the Right Costal Margin.
 Therefore if the patient inspires deeply, then the liver will move inferiorly with the diaphragm, and hence be palpable.

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 S U R FA C E S O F T H E L I V E R

DIAPHRAGMATIC SURFACE

 Smooth and convex because it conforms to the inferior surface of the diaphragm.
 It is mainly separated from the inferior aspect of the diaphragm, by a region of peritoneum known as the Sub-Phrenic Recess.
 Bounding the tips of the Sub-phrenic and Hepato-renal recesses, are the 2 Coronary Ligaments.
 Between the reflections of the Coronary Ligaments, is the Bare Area of the Liver – forms much of the posterior part of the Liver.
 It is not separated from the Diaphragm by peritoneum.
 Instead there is just a layer of loose connective tissue.
 The Inferior Vena Cava occupies a fossa in the left part of the posterior Bare Area, just to the right of the median plane.

VISCERAL SURFACE

 Directed inferiorly, posteriorly and to the left.

 Separated from the extensive diaphragmatic surface by the Inferior border.
 Beneath the Visceral surface, lie the:
 Superior right portion of the anterior surface of the Stomach
 Superior (1st) part of the Duodenum
 Lesser Omentum
 Gallbladder
 Right Colic Flexure
 Many associated nerves and vessels.
 The visceral surface of the liver is completely covered in peritoneum, except at the Gallbladder, and the Porta Hepatis.
 Many irregularities on this surface.
 It has an H-shaped group of deep fissures and fossae – the crossbar of the “H” is the Porta Hepatis.
 Porta Hepatis – deep transverse fissure, 5 cm long.
 Contains the Portal Vein, Hepatic Artery Proper, Hepatic Ducts, Hepatic Nerve Plexus, and Lymphatic Vessels.
 The left sagittal limbs of the “H” = fissures for the Ligamentum Teres and Ligamentum Venosum.
 The right sagittal limbs of the “H” = fossae for the Gallbladder and Inferior Vena Cava.

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 L OB E S OF T H E L I V E R

RIGHT LOBE

 The functional right lobe is demarcated by:

 A plane passing through the fossae for the gallbladder and the inferior vena cava, on the Visceral Surface.
 An imaginary line that runs from the Fundus of the Gallbladder (anteriorly), across the Diaphragmatic Surface, to the inferior vena cava (posteriorly).

LEFT LOBE

 The functional left lobe includes the Caudate lobe, and most of the Quadrate lobe.
 It is separated from the Caudate and Quadrate lobes by:
 The fissure for the Ligamentum Teres, on the visceral surface.
 The fissure for the attachment of the Ligamentum Venosum, on the visceral surface.
 The attachment of the Ligamentum Teres on the diaphragmatic surface.

CAUDATE LOBE

 Lies between the Fissure for the Ligamentum Venosum (left), and the fossa for the Inferior Vena Cava (right).
 Bounded inferiorly by the Porta Hepatis.
 The Caudate Process extends from the right side of the Caudate lobe – separates the Inferior Vena Cava from the Portal Vein.
 Forms a bridge between the Caudate and the Right Lobe.
 The Superior Recess of the Omental Bursa (Lesser Sac) extends superiorly posterior to the Caudate Lobe.

QUADRATE LOBE

 Four sided.
 Lies between the fissure for the Ligamentum Teres (left), and the fossa for the Gallbladder (right).
 Bounded posteriorly by the Porta Hepatis.
 The inferior border of the Quadrate Lobe lies between the Notch for the Ligamentum Teres, and the Gallbladder.

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 P E R I TON E A L R E L A T I O N S OF T H E L I V E R

 The Falciform Ligament connects the anterior and superior surfaces of the Liver to the anterior abdominal wall.
 Enclosed in its posterior margin is the Ligamentum Teres.
 On the visceral surface, the layers of the posterior end of the Falciform Ligament reflect onto the Liver, along the line of the Fissure for the Ligamentum Teres.
 As far as the Porta Hepatis.
 At the superior end of the falciform ligament, its 2 layers separate, exposing a triangular area on the superior surface = Bare Area of Liver.
 Here the 2 peritoneal layers diverge laterally.
 They are reflected onto the diaphragm, to form Coronary Ligament.
 It has a right and left layer, that are spread apart, since the Liver is applied directly onto the liver in this region.
 As a result the 2 diverged peritoneal layers never have the opportunity to return to the midline.
 Thus the 2 layers of the Coronary Ligament are essentially two separate coronary ligaments that surround the bare area of the liver.
 .
 From the Porta Hepatis, the peritoneal reflections continue to the Stomach and Duodenum, as the Lesser Omentum.
 The Left Triangular Layer is continuous with this.
 The Lesser Omentum can be broken up into its two constituents:
 Between the Liver and the Stomach = Hepato-gastric Ligament.
 Between the Liver and the superior part of the duodenum = Hepato-duodenal Ligament.
 The Lesser Omentum encloses
 The Portal Vein
 The Bile Duct
 The Hepatic Artery Proper
 A few lymph nodes and vessels
 The Hepatic Nerve Plexus.

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 A RT E R I A L S U P P LY TO T H E L I V E R V E N OU S D R A I NA G E F R OM T H E L I V E R

 The liver has a double blood supply: from the Hepatic Artery Proper  The Hepatic Veins are formed by the union of the Central Veins in it
(30%), and from the Portal Vein (70%). lobules.
 Open into the Inferior Vena Cava, just inferior to the diaphragm.
HEPATIC ARTERY PROPER  The superior group – consist of right, left and middle veins, from the
Right, Left and Caudate Lobes.
 The Common Hepatic Artery arises from the Coeliac Trunk.  The inferior group – consist of 6-18 small veins from the Right Lobe,
 Passes anteriorly and to the right, in the posterior wall of the Omental and part of the Caudate Lobe.
Bursa (Lesser Sac).
 It runs inferior to the Epiploic Foramen, to reach the superior part of the
Duodenum. I N N T E RVA T I ON OF T H E L I V E R
 Here it gives off the Gastro-duodenal artery.
 It then passes between the layers of the Lesser Omentum, as the Hepatic  There is sympathetic and parasympathetic innervation.
Artery Proper.  Fibres reach the liver via the Hepatic Plexus – the largest derivative
 Ascends in the Lesser Omentum’s right free edge, anterior to the Portal of the Coeliac Plexus.
Vein, and to the left of the Bile Duct.  This plexus also receives filaments from the Left and Right
 On approaching the Porta Hepatis, it divides into Right and Left terminal Vagus, and the Right Phrenic nerves.
branches.  The Hepatic Nerve Plexus accompanies the Hepatic Artery Proper and
 Carries oxygenated blood to the Liver. the Portal Vein, and enters the Porta Hepatis.
PORTAL VEIN

 Formed posterior to the neck of the Pancreas, by the union of the

Splenic and Superior Mesenteric Veins.
 It also runs in the right free edge of the Lesser Omentum, anterior to the
Epiploic Foramen.
 At the right end of the Porta Hepatis, it terminates by dividing into right
and left branches, that each supply about half of the liver.

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 LY M P H A T I C D R A I NA G E O F T H E L I V E R

 Most of the Deep Lymph Vessels converge at the Porta Hepatis, and end in the Hepatic Lymph Nodes.
 These lie scattered along the hepatic vessels and ducts within the Lesser Omentum.
 Efferent Lymph from the Hepatic Lymph Nodes, drains to the Coeliac Lymph Nodes.
 These lie around the Coeliac Trunk, and the proximal parts of its branches.
 Alternatively, Deep Lymph Vessels may follow the Hepatic Veins, through the Vena Caval Foramen in the Diaphragm.
 They drain to the Middle Group of Phrenic Lymph Nodes  Parasternal Lymph Nodes.
 Most of the Superficial Lymph Vessels also drain to the Hepatic Lymph Nodes.
 Lymph from the Bare Area of the Liver, on the diaphragmatic surface, pass through the Sternocostal Hiatus and Vena Caval Foramen.
 They enter the Phrenic and Mediastinal Lymph Nodes.
 Drain to the Right Lymphatic and Thoracic Ducts.

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 T HE K IDNEYS AND U RETERS
P O S I T I O N, F O R M A N D S I Z E
 Each kidney lies in a mass of Peri-renal Fat, retroperitoneally on the
posterior abdominal wall.
 Lie alongside the vertebral column, against the Psoas Major muscles.
 The superior parts of the kidneys are protected by the thoracic cage, and
are tilted obliquely so that their superior poles are nearer the median
plane.
 Owing to the size of the right lobe of the liver, the Right Kidney lies at a
slightly lower level than the Left Kidney.
 Each kidney has a convex lateral border, and a concave medial border.
 Each kidney is 10 cm long, 5 cm wide, and 2.5 cm thick – the left kidney
being slightly longer than the right.
 Renal Hilum – lies in a cleft on the concave medial border.
 Site for entry of the Renal Vein (anterior), Renal Artery and Renal
Pelvis (posterior).
 Leads into the Renal Pelvis – 2.5 cm deep.
 Occupied by the Renal Pelvis, Renal Calices, Renal Vessels &
Nerves, and varying amounts of fat.
S U R FA C E A NA TOM Y
 The levels of the Kidney change with breathing and posture.
 Each Kidney moves 3 cm in a vertical direction beneath the diaphragm,
during deep breathing.
 Left Kidney – Hilum lies in the Trans-Pyloric Plane, about 5 cm to the
left of the midline.
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 Yet this plane cuts through the superior part of the Right Kidney
(lying more inferiorly).
 Right Kidney – its inferior pole lies a fingerbreadth superior to the Iliac
Crest.
 Its superior pole reaches the lower border of the 12th rib, and may
pass just superior to it.
 Each kidney is closely invested in a strong fibrous capsule – giving the
kidney a glistening appearance.
 The capsule strips easily from a normal kidney.
 It passes over the lips of the Hilum, to line the Renal Sinus, and
become continuous with the walls of the Calices.
 The capsule and the kidney are surrounded by Peri-renal Fat – sparse on
the anterior surface.
RENAL PELVIS
 Funnel shape, and continuous inferiorly with the Ureter.
 Surrounded by fat, vessels and nerves, within the Renal Sinus.
 The Renal Pelvis usually breaks up into 2 wide, cup-shaped Major
Calices.
 Each Major Calyx is subdivided into 7-14 Minor Calices.
 Within each Minor Calyx is a Renal Papilla = site where 12 Collecting
Tubules open obliquely into the minor calyx.
 Thus each Renal Papilla is at the apex of a Renal Pyramid.
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R E N A L FA S C I A & FA T
 Each kidney (invested in its strong fibrous capsule) is embedded in a
substantial mass of peri-renal fat, which constitutes a fatty renal capsule.
 This fatty renal capsule is sparse anteriorly.
 Fibro-areolar Renal Fascia then encloses the kidney, its accompanying
fibrous and fatty capsules, and the Adrenal Gland.
 Maintains the position of these two organs, and keeps them separate.
 Superiorly – the fascia is continuous with the fascia on the inferior
surface of the diaphragm.
 Medially:
 Anterior layers on the left and right, blend with each other,
anterior to the inferior vena cava and abdominal aorta.
 Posterior layers fuse medially with the fascia over Psoas Major
muscle.
 Inferiorly – the layers of fascia from the anterior and posterior
surfaces of the kidney, will loosely unite.
 The encasement of the kidney in fat, is important in anchoring it in
position.
 Para-renal Fat – extra-peritoneal fat, lying outside the Renal Fascia.
 Separates the Renal Fascia from the peritoneum of the posterior
abdominal wall.
RELATIONS OF THE KID NEYS
POSTERIOR RELATIONS
 Each kidney lies on muscle.
 The posterior surface of the superior pole is related to the diaphragm.
 Separates it from the Pleural Cavity and the 12th rib.
 Also related superiorly, to the Medial and Lateral Arcuate Ligaments.
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 More inferiorly, each kidney is related to:
 Quadratus Lumborum muscle.
 Psoas Major muscle, medially.
 Transversus Abdominis muscle, laterally.
 The Subcostal Nerve & Vessels, the Iliohypogastric & Ilioinguinal
Nerves, descend diagonally across the posterior surface of each kidney.
ANTERIOR RELATIONS OF RIGHT KIDNEY
 Anterior and medial aspects of the superior pole are covered by the right
Adrenal gland.
 Superior pole is related to the inferior surface of the Liver.
 The Hepato-renal Pouch (of Morrison) separates the rest of the right
kidney anteriorly from the Liver.
 More inferiorly, the Descending Part of the Duodenum, passes anteriorly
over the Hilum of the Right Kidney.
 The Right Colic Flexure lies anterior to its lateral border, and inferior
pole.
 These adrenal, duodenal and colic areas of the right Kidney are not
covered in peritoneum  Direct Relations.
 Part of the small intestine lies anteriorly across the inferior pole of the
right kidney, separated by peritoneum  Indirect Relation.
ANTERIOR RELATIONS OF LEFT KIDNEY
 The left kidney is related anteriorly to:
 The Stomach, Spleen, and Jejunum = indirect relations.
 The Adrenal Gland, Pancreas and Descending Colon = direct
relations.
 The Left Kidney (and the Pancreas and Spleen), is in the Stomach Bed.
 Both Kidneys - Covered by the posterior wall of the Omental Bursa
(Lesser Sac), and directly related to the Ascending branch of the Right
Colic Artery.
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 G E N E R A L A NA TO M Y O F U R E T E R RELATIONS OF THE URETERS

 Thick-walled, expandable muscular ducts, with narrow lumina. RIGHT URETER

 Each is continuous superiorly with the funnel-shaped Renal Pelvis.
 Emerges through the Hilum, and descends the medial margin of the
Kidney to the inferior pole – here begins the Ureter Proper.
 The abdominal part of each ureter is 12.5 cm long, and 5 mm wide.
 Adheres closely to the parietal peritoneum, lying retro-peritoneally.
 Descends vertically, anterior to Psoas Major Muscle.
 Right Ureter – as it descends, it is related to the Inferior Vena Cava,
Lumbar Lymph Nodes, and Sympathetic Trunk.
 Both ureters cross the pelvic brim, and the External Iliac Artery – just
beyond the bifurcation of the Common Iliac Artery.
 The pelvic parts of the ureters run postero-inferiorly on the lateral wall of
the pelvis.
 Run external to the parietal peritoneum, and anterior to the Internal
Iliac Arteries.
 Continue to a point about 1.5 cm superior to the Ischial Spines.
 Then curves antero-medially, above the Levator Ani muscle,
adhering closely to the peritoneum.
 Enters the postero-superior angle of the Bladder.
 Extra-renal part – covered anteriorly by the Descending Part of the
Duodenum, and renal vessels.
 Ureter Proper – emerges from inferior pole of Kidney, at the beginning
of the Horizontal Part of the Duodenum.
 Anterior relations = Right Colic and Right Testicular/Ovarian arteries.
 Ileocolic artery + Root of Mesentery (and associated vessels).
 Posterior relation = Genitofemoral Nerve.
 Medial relation = Inferior Vena Cava.
LEFT URETER
 Extra-renal Part – covered by Pancreas, and the Renal Vessels.
 Anterior relations = Left Colic and Left Testicular/Ovarian arteries.
 Sigmoid artery.
 Posterior relation = Genitofemoral Nerve.
 Medial relation = Inferior Mesenteric Vein.

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 A RT E R I A L S U P P LY TO T H E K I D N E Y S A N D U R E T E R S
 Renal Arteries – arise at right angles from the Abdominal Aorta, at the
level of the intervertebral disc between L1 and L2.
 Right Renal artery passes posterior to the Inferior Vena Cava.
 Each artery divides close to the Hilum of the Kidney, into 5
Segmental Arteries.
 Most pass anterior to the Renal Pelvis, but 1 or 2 may pass
posteriorly.
 Each Segmental Artery supplies a Renal Segment.
 Divides into Lobar arteries, that branch into Interlobar arteries.
 The arterial supply to the Ureters, is from branches of:
 Renal arteries.
 Testicular or Ovarian arteries.
 Abdominal Aorta.
 Common and Internal Iliac arteries.
 Superior / Inferior Vesical or Uterine arteries.
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V E N OU S D R A I NA G E F R OM T H E K I D N E Y S A N D U R E T E R S
 Several veins drain each Kidney, and unite to form the Renal Vein.
 The Renal veins lie anterior to the renal arteries.
 The Left Renal Vein passes anterior to the Aorta – just inferior to the
origin of the Superior Mesenteric artery.
 Each Renal Vein drains to the Inferior Vena Cava.
 Venous drainage from the Ureters, is into the Testicular or Ovarian
arteries.
LY M P H A T I C D R A I NA G E O F T H E K I D N E Y S A N D U R E T E R S
 Lymph vessels of the kidneys, follow the renal veins, and drain into the
Lumbar (Lateral Aortic) Lymph Nodes.
 Lymph from the superior portion of the Ureters, joins these vessels
or drain directly to these nodes.
 Lymph from the middle part of the Ureters, drains to the Common Iliac
Lymph Nodes.
 Lymph from the inferior part of the Ureters, drains to the Internal or
External Iliac Lymph Nodes.
I N N E RVA T I ON O F T H E K I D N E Y S A N D U R E T E R S
 Innervation derived from the Renal Plexus.
 Consist of sympathetic and parasympathetic fibres.
 The Renal Plexus is supplied by fibres of the Lesser and Lowest
Splanchnic Nerves.
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 A DRENAL G LANDS

RIGHT ADRENAL GLAND

G E N E R A L A NA TOM Y
 Paired glands, 3-5 cm long.
 Located on each side of the vertebral column, on the supero-medial
surface of each Kidney.
 Between the gland are the crura of the diaphragm, aorta, inferior vena
cava, and coeliac trunk & plexus.
 In vivo, they are yellowish-brown, owing to the presence of lipoid
substances.
 Each gland is enclosed in a tough connective tissue capsule, and then a
fatty capsule.
 This is enclosed along with the kidney in Renal Fascia.
 Only a little fatty connective tissue separated each adrenal gland from the
superior pole of each kidney – this provides an easy cleavage plane.
 The adrenal gland has two distinct regions: the outer cortex, and inner
medulla.
 Cortex – divided up into three main regions:
 Zona Glomerulosa – secretes mineralocorticoid hormones (e.g.
Aldosterone)
 Zona Fasiculata – secretes glucocorticoid hormones (e.g.
Cortisol)
 Zona Reticularis – secretes weak androgens.
 Medulla – derived from embryonic Neural Crest Cells; packed with
Chromaffin Cells that secrete adrenaline and noradrenaline.
 Pyramidal in shape, with its apex superiorly and its base embracing the
right kidney.
 Lies between the diaphragm (postero-medially), and the inferior vena
cava (antero-medially);
 The medial part of its anterior aspect is behind the inferior vena
cava.
 Superiorly related to the bare area of the liver.
 Its inferior end is covered over in peritoneum, which has been reflected
over it from the liver.
 Its Hilum lies on the anterior surface.
LEFT ADRENAL GLAND
 Semi-lunar in shape – extends further inferiorly along the left kidney’s
medial margin.
 Lies on the stomach bed, therefore located behind the posterior wall of
the Omental Bursa.
 Anterior relations = stomach and pancreas.
 Posterior relation = diaphragm.
 Its inferior part is not covered by peritoneum, where the Tail of the
Pancreas and the Splenic Artery cross it.
 Its Hilum also lies the anterior surface.

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 A RT E R I A L S U P P LY TO T H E A D R E N A L G L A N D S
 Glands have a profuse arterial supply from 3 sources:
 One or more Middle Supra-renal Arteries – direct lateral branches of
the abdominal aorta, at the level of L1.
 6-8 Superior Supra-renal Arteries – from the Inferior Phrenic artery.
 One or more Inferior Supra-renal Arteries – from the Renal artery.
V E N O U S D R A I NA G E F R O M T H E A D R E N A L G L A N D S
 Each gland is drained by a single large, (central), Supra-renal Vein.
 The Right Supra-renal vein drains to the inferior vena cava.
 The Left Supra-renal vein drains to the left renal vein.
 There are also many small veins that accompany the supra-renal arteries.
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LY M P H A T I C D R A I NA G E O F T H E A D R E N A L G L A N D S
 Lymph vessels arise from a plexus deep to the capsule, and one from in
the medulla.
 Drain to the Superior Lumbar (Lateral Aortic) Lymph Nodes.
I N N E RVA T I ON O F T H E A D R E NA L G L A N D S
 Rich nerve supply from the adjacent Coeliac Plexus, as well as from the
Greater Thoracic Splanchnic Nerves.
 These pre-ganglionic sympathetic fibres pass through the Hilum, and
synapse directly onto cells of the Adrenal Medulla.
 The Adrenal Cortex receives only a vasomotor nerve supply.
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 T HE A BDOMINAL A ORTA

The abdominal aorta is the continuation of the Descending Thoracic Aorta. It begins at the aortic hiatus of the diaphragm, at the level of the Intervertebral
Disc between T12 and L1. Terminates at the level of L4, by dividing into 2 Common Iliac Arteries.

R E L A T I O N S O F T H E A B D OM I N A L A OR TA

ANTERIOR RELATIONS RIGHT RELATIONS

 Coeliac Trunk (and is branches, and associated Coeliac Plexus)  Cisterna Chyli
 Omental Bursa (Lesser Sac of Peritoneum)  Thoracic Duct
 Pancreas  Right Crus of the Diaphragm
 Left Renal Vein  Inferior Vena Cava
 Ascending Part of Duodenum
 Root of the Mesentery LEFT RELATIONS
 Intermesenteric Plexus of nerves.
 Left Crus of Diaphragm
POSTERIOR RELATIONS  Left Coeliac Ganglion
 Duodeno-jejunal Flexure (at the level of L2)
 Bodies of L1 to L4 vertebrae (plus intervening intervertebral discs)  Sympathetic Trunk runs along its left side.
 Corresponding part of the Anterior Longitudinal Ligament.

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 B R A N C H E S O F A B D OM I NA L A OR TA

UNPAIRED VISCERAL BRANCHES
 These arise from the anterior surface of the Abdominal Aorta:
 Coeliac Trunk – at the level of T12.
 Superior Mesenteric Artery – at the level of L1.
 Inferior Mesenteric Artery – at the level of L3.
PAIRED VISCERAL BRANCHES
 These arise from the sides of the Abdominal Aorta:
Middle Supra-renal Arteries
 Arise at the level of L1 – one or more on each side.
 Arise close to the origin of the superior mesenteric artery.
 Run laterally on the Crura of the Diaphragm, to the Adrenal Glands.
Renal Arteries
 Also arise at the level of L1, just inferior to the origin of the superior
mesenteric artery.
 Occasionally there is an Accessory Renal Artery, particularly on the left.
Gonadal Arteries (Testicular or Ovarian)
 Arise at the level of L2.
 Long slender vessels, passing inferiorly onto Psoas Major muscle.
 The Right Gonadal artery passes in over the Inferior Vena Cava.
 Testicular Artery – passes through the Deep Inguinal Ring, entering into
the Inguinal Canal
 It leaves the canal at the Superficial Inguinal Canal, and becomes a
constituent of the Spermatic Cord.
 Ovarian Artery – follows a similar course through the abdomen.
 Crosses the proximal ends of the External Iliac Vessels, to enter the
True Osteo-ligamentous Pelvis.
 There supplies the Ovaries and Uterine Tubes.
PAIRED PARIETAL BRANCHES
 These vessels arise from the postero-lateral surfaces of the Abdominal
Aorta:
Inferior Phrenic Arteries
 Arise just inferior to the diaphragm.
 Pass supero-laterally over the crura of the diaphragm.
 Gives off several Superior Supra-renal Arteries.
 Then spreads out on the inferior surface of the Diaphragm.
4 pairs of Lumbar Arteries
 Each pair passes around the sides of the superior 4 Lumbar Vertebrae
(L1-L4).
 Pass postero-medial to the Sympathetic Trunks.
 On the right, run posterior to the Inferior Vena Cava.
 Each lumbar artery passes deep to a Fibrous Psoas Arch, to enter a Psoas
Canal.

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  They run backwards in the Psoas Canal, to reach the root of the UNPAIRED PARIETAL BRANCH
anterior surface of the Transverse Process.
 Here they divide into an anterior, posterior and radicular branch.  Median Sacral Artery – a tiny artery, that used to be the dorsal aorta in the
 Anterior Branches – superior 3 pairs pass deep to Quadratus Lumborum sacral region of the embryo.
muscle.  Arises from the dorsal surface of the Abdominal Aorta, just proximal
 The 4th pair of lumbar arteries may pass in front of Quadratus to its bifurcation.
Lumborum.  Descends in the midline, anterior to L4 and L5 vertebrae.
 Run around the abdominal wall, within the neuro-vascular plane  Gives off a 5th Lumbar Artery to each side. (Arteria Lumbalis Ima)
between Transversus Abdominis and Internal Oblique.  Similar distribution as other lumbar arteries.
 Anastomoses within the substance of Rectus Abdominis, with the
Inferior Epigastric Arteries.
 Supply the antero-lateral walls of the inferior ½ of the abdomen.
 Posterior Branches – pass posteriorly, lateral to the articular processes of
the vertebrae.
 Supply the Erector Spinae Muscles.
 Radicular Branches – may be given off from the posterior branches.
 Pass medially through the Intervertebral Foramen, into the vertebral
canal.
 Supply:
 Spinal Cord
 Cauda Equina
 Spinal Meninges
 Vertebrae.

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 I NFERIOR V ENA C AVA

 Right Inferior Phrenic Artery

G E N E R A L A NA TOM Y
 Right Crus of Diaphragm.
 Largest vein in the body.
ANTERIOR RELATIONS
 Returns blood from the lower limbs, most of the abdominal wall, and
abdomino-pelvic viscera.  The first anterior relation is the Right Common Iliac Artery.
 Blood from these viscera passes through the Portal System and liver,  Peritoneum.
before entering the Inferior Vena Cava, via the Hepatic Veins.  Superior Mesenteric Vessels in the root of the Mesentery.
 Begins anterior to L5, by the union of the Common Iliac Veins.  Then the Ileo-colic artery, the Right Colic artery, and the Right
 2.5 cm to the right of the midline, posterior to the proximal part of Testicular/Ovarian artery.
the Right Common Iliac artery.  Horizontal part of the Duodenum, and the Epiploic Foramen just above
 Inferior Vena Cava ascends on the right Psoas Major, to the right of the this.
midline and abdominal aorta.  The Head of the Pancreas, with the Portal Vein and Bile Duct
 Passes through the Vena Caval Foramen of the diaphragm at the level of intervening.
T8.  Finally, the Inferior Vena Cava is related anteriorly to a groove in the
 Pierces the fibrous pericardium, and enters the inferior part of the Right posterior surface of the Liver, between the Right and Caudate lobes.
Atrium of the Heart.
LEFT RELATIONS
RELATIONS
 Inferiorly, the Abdominal Aorta lies to the left of the Inferior Vena Cava.
 More superiorly, these two great vessels become separated by the Right
POSTERIOR RELATIONS Crus of the Diaphragm.
 Initially this is the Right Psoas Major muscle, then the vertebral bodies of RIGHT RELATIONS
L3 and L4.
 2 lower Lumbar Arteries on the right hand side.  Inferiorly, related on the right to the Right Ureter, the Right Kidney and
 More superiorly, the Inferior Vena Cava lies on the Diaphragm, passing the Right Adrenal Gland.
over:  Also related to the Descending Part of the Duodenum.
 Right Renal artery.
 Right Middle Supra-renal artery
 Medial part of the right Adrenal Gland.

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 T R I BU TA R I E S OF T H E I N F E R I O R V E NA C AVA

COMMON ILIAC VEINS RENAL VEINS

 The left vein passes upwards and to the right – lying medially to the  Drain into the Inferior Vena Cava at the level of L2.
corresponding artery.  They lie anterior to the corresponding arteries.
 Passes in front of L5.  Right Renal Vein – receives few tributaries.
 Passes in front of the Median Sacral Artery.  0.5 inches long.
 Whose vena commitantes unite to form a single Median Sacral  Left Renal Vein – receives tributaries draining the Left Adrenal Gland,
Vein, which drains into the Left Common Iliac vein. and Left Testis or Ovary.
 The right vein initially lies behind the corresponding artery  2 inches long.
 More inferiorly, it slowly takes up a medial position.
RIGHT SUPRA-RENAL VEIN
3RD & 4TH LUMBAR VEINS
 Short and drains into the posterior aspect of the Inferior Vena Cava.
 The lumbar veins consist of 4 or 5 segmental pairs.
 The dorsal branches drain the back, and communicate with vertebral INFERIOR PHRENIC VEINS
venous plexuses.
 They may drain into the Inferior Vena Cava, or the Common Iliac Vein.  Drain the abdominal surface of the Diaphragm.
 Generally united on each side by vertical Ascending Lumbar Veins.  The Left Inferior Phrenic Vein may alternatively drain into the Left
 These lie posterior to Psoas Major muscle. Supra-renal Vein.
 Pass into Thorax, by running posterior to the Medial Arcuate
AZYGOS VEIN
Ligaments.
 Right Ascending Lumbar vein joins the Right Subcostal vein   Connects the superior vena cava, and the inferior vena cava, either
Azygos Vein. directly or indirectly.
 Left Ascending Lumbar vein joins the Left Subcostal vein   Commonly arises from the posterior aspect of the Inferior Vena Cava, at
Hemiazygos Vein. the level of the Renal Veins.
 May also arise from the posterior aspect of the Left Renal Vein.  May also arise from the union of the Right Subcostal and Right
Ascending Lumbar Veins.
RIGHT TESTICULAR (OVARIAN) VEIN  Enters the thorax through the Aortic Hiatus, or the right Crus of the
Diaphragm.

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HEPATIC VEINS
 Short veins draining the Liver Sinusoids.
 Open into the Inferior Vena Cava, just as it enters the Vena Caval
Foramen of the Diaphragm.
 The Right Hepatic Vein sometimes passes through the foramen,
before opening into the Inferior Vena Cava.
 Described as upper and lower groups.
 Upper group – right, left and middle, draining the right, left and
caudate lobes of the liver.
 Lower group – 6-18 small veins draining the right and caudate lobes.
 A large Accessory Hepatic Vein draining the right lobe, has been
noted.
C REATED BY M ICHAEL C HEERAN D AVID
P OR TA L V E I N
 Collects blood from the abdominal part of the GI-Tract, the Gallbladder,
Pancreas and Spleen.
 The venous blood contains the products of digestion, and the
products of haemolysis.
 Carries it to the Liver.
 It branches to end in expanded capillaries = Sinusoids.
 From these, blood drains to Hepatic Veins, which run to the Inferior
Vena Cava.
 The Portal Vein drains the Superior Mesenteric, Inferior Mesenteric and
Splenic Veins.
 It is formed posterior to the neck of the Pancreas, by the union of
the Superior Mesenteric and Splenic veins.
 The inferior mesenteric vein drains into the splenic vein.
 May alternatively drain into the Superior Mesenteric or Portal
Vein.
 Ascends to the Liver, within the right free margin of the Lesser
Omentum.
 Lies posterior to the Hepatic Artery Proper and the Bile Duct.
 At the Porta Hepatis, the Portal Vein terminates by dividing into right
and left branches, which eventually empty into Hepatic Sinusoids.
 Portal-Caval Anastomoses provide collateral circulations to the Inferior
Vena Cava, if the portal circulation is obstructed (e.g. in Liver disease), or
in the case of Portal Hypertension.
 The sites of these Portal-Caval anastomoses may dilate and varicose.
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 M A I N P ORTA L - C AVA L A NA S T OM O S E S

GASTRO-OESOPHAGEAL REGION PARAUMBILICAL REGION

 Oesophageal tributaries of the Left Gastric Vein anastomose with the
Azygos Vein
 Via Oesophageal Veins passing through the oesophageal opening in
the diaphragm at the level of T10.
 Can lead to Oesophageal Varices, that are thin-walled and easily ruptured
 Haematemesis (fatal).
ANO-RECTAL REGION
 Superior Rectal Vein (a tributary of the Superior Mesenteric Vein leading
to the portal circulation), anastomoses with the Middle & Inferior Rectal
Veins (tributaries of the Internal Iliac vein, leading to the systemic
circulation).
 Varices will result in Piles or Haemorrhoids.
 These lie within the anal canal, and can fall out.
 Painful if thrombosed, or broken & infected.
 Para-umbilical Veins connect the left branch of the Portal Vein, to the
systemic subcutaneous veins of the anterior abdominal wall, which
radiate from the umbilicus.
 The para-umbilical veins travel to the anterior abdominal wall
through the Ligamentum Teres (inferior margin of the Falciform
Ligament).
 Varices result in swelling of the subcutaneous veins  Caput Medusae.
RETROPERITONEAL REGION
 Systemic veins may communicate with portal veins supplying
retroperitoneal viscera.
 Bare Area of Liver is applied directly onto the posterior abdominal
wall  potential for a portal-caval anastomosis, via Right Internal
Thoracic Vein.
 Ascending and Descending Colon – potential anastomoses.

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