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ANATOMI SHAKAVELS

WEEK 1
UPPER GIT
1. Discuss among the group boundaries and parts of the
Upper G I T
 Upper GIT dari mulut sampai duodenum
sebelum ligament of Treitz.
(Mulut -> Faring -> Esofagus -> Lambung (
Fundus -> Corpus -> Pylorus) -> Duodenum
sebelum ligament of treitz).
2. Identify at the cadaver parts of the G I T
3. Discuss among the group the normal constrictions of
oesophagus.
 Terbagi menjadi 3 :
 Cervical Constriction  at cricoid cartilage
(angustia cricoidea; pharyngo-oesophageal
constriction). Located at the upper oesophageal sphincter and 6 th cervical
vertebra.
 Thoracic Constriction  at the Aorta (angustia aortica; aorto bronchial
constriction). Crated by the direct proximility of aortic arc from the left and
dorsal side (4th thoracic vertebra).
 Diaphragmatic Constriction (angustia diaphragmatica). Lies in the hiatus
oesophagus (10th thoracic vertebra).
STOMACH ( GASTER )
1. Identify at the specimen parts of the stomach (gaster):

1.1. Cardial orifice ( ostium cardiacum )


 Di bagian pars cardiac, not guarded by any anatomic sphincter only lower
circular smooth muscle fiber of oesophagus serves as physiologic sphincter
 Lower oesophageal sphincter (LES).
What part of the Upper GIT enter cardial orfice ?
 Oesophagus
1.2. Cardial notch ( incisura cardialis )
 Nama lainnya angle of his, lengkungan didekat LES.
1.3. Fundus of stomach ( fundus gastricus )

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 Bagian di atas corpus, setelah pars cardiac


1.4. Body of stomach ( corpus gastricum )
 Diantara fundus dan pylorus, sebelum antrum.
1.5. Angular incisure ( incisura angularis )
 Marks the beginning of pars pylorica.
1.6. Pyloric part of gaster ( pars pylorica gastricus )
1.6.1. Intermediate notch ( sulcus intermedius )
 Membatasi antrum pyloricum dengan canalis pyloricus.
1.6.2. Pyloric antrum ( antrum pyloricum )
 Bagian pertama pylorus setelah corpus. Memiliki gerakan peristaltic yang
paling besar di lambung untuk pencampuran.
1.6.3. Pyloric canal ( canalis pyloricus )
 Bagian kedua pylorus setelah antrum. Setelah bagian ini terdapat sphincter
sebelum chymus masuk ke duodenum yaitu pyloric sphincter.
1.7. Anterior wall of the stomach ( paries anterior gastricus )
1.8. Posterior wall of the stomach ( paries posterior gastricus )
1.9. Greater curvature of the stomach ( curvatura major )
 Lekukan pada corpus lebih besar dan cembung.
1.10. Lesser curvature of the stomach ( curvatura minor )
 Lekukan pada corpus lebih kecil dan cekung.
1.11 Discuss among the group Magenstrasse Waldeyeri  Disebut juga canalis
gastricus.
1.11.1. Its location
 Sepanjang curvature minor.
1.11.2. Its clinical application
 Mengalirkan cairan, untuk radiologi. Tempat paling sering terjadi ulkus.
1.12 Pyloric orifice ( ostium pyloricum )
 Lubang untuk mengalirkan chymus dari lambung ke duodenum.
2. Discuss among the group vascularization of the stomach. Try to identify it at the
Specimen

Arteries of the stomach:


 Lesser Curvature :
- A. gastrica sinistra ( direct branch of
the Truncus Coeliacus)
- A. gastrica dextra ( derived from A.
hepatica propria)
 Greater Curvature :
- A. gastroomentalis sinistra ( derived
from A. splenica)
- A. gastroomentalis dextra ( derived
from the A. gastroduodenalis of the A.
hepatica communis)
 Fundus : Aa. gastricae breves (derived
from the A. splenica)
 Posterior side : A. gastrica posterior
(derived from the A. splenica)

Veins of the stomach :


 Lesser curvature :
- V. gastrica sinistra

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- V. gastrica dextra
Drainage into the V. portae hepatis
 Greater curvature :
- V. gastroomentalis sinistra (to V. splenica)
- V. gastroomentalis dextra ( to V. mesenterica superior)
 Fundus : Vv. Gastricae breves ( to V. splenica)
 Posterior side : V. gastrica posterior (to V. splenica)

2. Discuss among the group innervation of the stomach.


 Preganglionic parasympathetic fibers (Rr. gastrici) reach the stomach as :
Trunci vagales anterior and posterior.
Along the oesophagus and course along the lesser curvature.
- Trunci vagales anterior  left N. vagus
- Trunci vagales posterior  right N. vagus
Pars pylorica  innervated by Rr. hepatici of Trunci vagales
Parasympathetic innervations  stimulate production of gastric acid,
promote gastric peristalsis.

 Preganglionic sympathetic fibers traverse the diaphragm on both sides 


Nn. Splanchnici major and minor.
Synapsed to the postganglionic sympathetic neurons  in ganglia
coeliaca located at the origin of Truncus coeliaca, reach the stomach as
periarterial nerve plexus.
Sympathetic innervations  reducing gastric acid, reducing peristalsis,
reducing perfusion.

DUODENUM

1. Discuss among the group characteristics of duodenum


- Terdapat 4 pars : superior  descending  horizontalis (inferior) 
ascending.
- “C” shaped

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- Terdapat caput pancreatica

2. Identify at the specimen :


2.1. Parts of the duodenum
2.1.1. Superior part of the duodenum ( pars superior duodeni )
 Lebih pendek dan lebar, lumen  ampulla (bulbus) duodeni.
2.1.2. Superior duodenal flexure ( flexura duodeni superior )
 Peralihan superior ke descenden.
2.1.3. Descending part of the duodenum ( pars descendens duodeni )
 Bagian ke arah bawah, lebih panjang dan sempit.
2.1.4. Inferior duodenal flexure ( flexura duodeni inferior )
 Peralihan descend ke horizontal
2.1.5. Inferior / horizontal / transverse part of the duodenum ( pars inferior /
pars horizontalis duodeni )
2.2. Sphincter pyloric muscle ( M. sphincter pyloricum )
 Diantara lambung dan duodenum. Mengatur masuknya chymus
dari lambung ke duodenum dan mencegah terjadinya regurgitasi
dengan cara otot – otot sphincter akan berkontraksi untuk
menutup sphincternya.
2.3. Major duodenal papilla ( papilla duodeni major Vateri )
What is the name of the duct that end at major duodenal papilla ?
 Jalur keluar dimana jalur tersebut berasal dari gabungan ductus
pancreaticus wirsungi dan ductus choledocus. Kalau dipotong
kayak kabel. Terdapat di bagian pars descendens dari
duodenum.

 Vaskularisasi : dibagi 2 :

- Proximal to the major duodenal papilla : gastroduodenal artery brach


of the coeliac trunk.
- Distal to the major duodenal papilla : inferior pancreaticoduodenal
artery branch of superior mesenteric artery.

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WEEK 2
LOWER GIT + ACCESSORIES
After finished laboratory practice Students are able to identify :
1. Components of Lower Gastrointestinal tract ( G I T ):
1.1. Location of each components
1.2. Parts of each components.
1.3. Boundaries of each components
2. Vascularization of Lower G I T
3. Innervation of lower G I T
4. Accessory digestive organs : location , vascularization and innervation

ATTENTION FOR STUDENTS :

To achieve the learning objectives Students at Dissection Room must do the


following procedures :
4. Identify at the cadaver location of the lower GIT by using quadrant of four and region
of nine methods.

 9 region :

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 4 Quadrant :

5. Discuss among the group characteristics of the small intestine ( intestinum tenue ).
Identify it at the specimen.
- Plicae Circulares Kerckringi  pada duodenum sangat rapat dan
tinggi (sehingga absorpsi duodenum paling kuat)
- VIli interstinales  di duodenum paling banyak ( sehingga absoorpsi
duodenum paling kuat )
- Noduli limpatici
6. Discuss among the group what is the difference in external appearance
between.duodenum and jejunum/ileum.
7. Discuss among the group the differences between jejunum and ileum.
Identify as much as possible those differences at the specimen.

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Jejunum Ileum
Less complex and less arterial More complex and more arterial
arcades arcades
Longer Vasa Recta Shorter Vasa Recta
More plicae circulares, thicker, more Less plicae circulares, thinner, less
highly folded folder
No fat in mesentery (sebenarnya ada Fat present in mesentery
, tapi tidak sampai tepi)

8. Identify at the caecum anatomical structures at the location where terminal ileum
( pars terminalis ilei ) ended. Look for :

5.1. Ileocecal valve ( valvula ileocaecalis )


 Yang memisahkan antara caecum dan ileum terminalis (ileocecal
junction).
5.2. Ileal orifice ( ostium ileale )
 Tempat masuknya makanan dari ileum ke caecum, melewati
valve.

5.3. Frenulum of ileal orifice ( frenulum ostii ilealis )


 Perpanjangan dari ileocecal valve (bibir bawah dan atas)
5.4. Superior / ileocolic lip ( labrum ileocolicum / superius )
 Bibir atas dekat colon
5.5. Ileocaecal / inferior lip ( labrum ileocaecale / inferius )
 Bibir bawah dekat caecum

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LARGE INTESTINE / COLON ( INTESTINUM CRASSUM / COLON )

1. Discuss among the group composition of large intestine.


 Caecum  Appendix  Colon Ascenden  Flexura Coli Dextra
 Colon Transversum  Flexura Coli Sinistra  Colon
Descenden  Sigmoid  Rectum 
2. Discuss among the group characteristics of the large intestine.
- Taenae Coli : Berakar dari appendix. 3 bands of smooth muscle  di
junctura sigmoid rectalis jadi 1. Panjangnya tidak sesuai dengan colon
sehingga tertekuk (kontraksi)  membentuk haustra.
- Plicae Semilunares
- Haustra : bulges caused by contraction of taeniae coli (seperti
kantong).
- Epiploica Appendages (Omental Appendices) : small pouches of the
peritoneum filled with fat and situated along the colon.
- Vermiform Appendix
- Larger Diameter
Look for those characteristics at the specimen.
3. What is the clinical application of taeniae coli ( taeniae coli )?
 Contract for gastrocolic reflex.
 Untuk cari lokasi appendix untuk appendostomy.
4. Discuss among the group which of the taeniae coli that has clinical application. Why ?
 Libera : karena bebas dan menghadap ventral.
 Jika mesocolica tidak karena tertutup mesenterika.
 Omentalis tidak karena tertutup oleh omentum majus.
5. Identify anatomical structures that ended at caecum. Look for :
5.1. Terminal ileum ( pars terminalis ilei )
5.2. Vermiform appendix ( appendix vermiformis )
 Anterior  pre-ileal
 Splenic  post-ileal
 Pelvic  Descending position
 Sub-caecal
 Post-caecal
 Ectopic position
5.3. Discuss among the group variety of the position of vermiform appendix
according to Wakeley. Which one is the most usual position ?

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 Most : Post - Caecal


5.4. Orifice of vermiform appendix ( ostium appendicis vermiformis )
5.5. Discuss among the group how to determine the position / location of vermiform
appendix. Make the projections of the location at the cadaver:
5.5.1. Line of Lanz
 Garis yang menghubungkan sias dextra sampai sias sinistra.
5.5.2. Point of Lanz
 1/3 sias dextra atau 2/3 sias sinistra. Menandakan ileocecal junction.
5.5.3. Line of Monro – Richter
 Menghubungkan sias dextra sampai umbilicus.
5.5.4. Point of McBurney
 1/3 lateral dari line dari Monro – Richter. Menandakan orifice dari appendix.
Titik sakit dari appendicitis.
9. Study the colic flexures ( flexurae colicae ). Look for ( if the specimen are not
available, use your anatomy atlas ) :
6.1. Right colic flexure ( hepatic flexure, flexura coli dextra , flexura coli hepatica )
 Dari colon ascendens ke colon transversum.
6.2. Left colic flexure ( splenic flexure , flexura coli sinistra , flexura coli splenica )
 Dari colon transversum ke colon descendens.
6.3. Why did those flexures were also named:hepatic and splenic flexures ?
 Right  Adjacent to liver.
 Left  Adjacent to spleen.
10. Where do transverse colon ( colon transversum ) ended ?
 Flexura coli splenica
11. What is the name of the continuation of transverse colon ?
 Colon Descendens
12. What is the name of the continuation of descending colon ( colon descendens ) ?
 Colon Sigmoideum

ACCESSORY DIGESTIVE ORGANS ( ORGANAE DIGESTIVAE ACCESSORIAE )


3. Discuss among the group Accessory digestive organs. Make the projection at the
cadaver of :
1.1. Its components
 Tongue, salivary gland, pancreas, liver, and gallbladder.
1.2. Its location
 Salivary Gland : Sublingual, Submandibular, Parotid Gland.
 Liver : Right hypochondriac and epigastric atau right upper quadrant
extending to left upper quadrant.
 Pancreas : Most lie posteriorly to the stomach. Extend across the posterior
abdominal wall from the duodenum, on the right, to the spleen, on the left.
 Gallbladder : Lying on the visceral surface of the right lobe of the liver in the
diaphragma, in the area of ribs 9-10, left upper quadrant or left
hypochondriac.
 Spleen : Lies against fossa between the right and quadrate lobes.
1.3. Their excretory ducts
 Hepar : Ductus Hepaticus Communis dimana merupakan gabungan dari
Right and Left Hepatic Duct.
 Gallbladder : Ductus Cysticus, dimana nantinya akan bergabung dengan
Ductus Hepaticus Communis menjadi Ductus Choledocus Billiaris.
 Pancreas :

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- Ductus Pancreaticus (Wirsungi). Bergabung dengan Ductus


Choledocus Billiaris menjadi Ampulla Vater yang nantinya keluar di
pars descendens of duodenum dalam bentuk Papilla Duodeni Major.
- Ductus Pancreaticus Accesorius (Santorini) : Keluar di pars
descendens of duodenum dalam bentuk Papilla Duodeni Minor.

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4. Identify:parts of the liver ( hepar ) at the specimen. Look for :

2.1. Diaphragmatic surface of liver ( facies diaphragmatica hepatis )


 Smooth and Domed lied against the inferior surface of diaphragm. Termasuk
anterior, superior dan posterior surface.
2.2. Visceral surface of liver ( facies visceralis hepatis )
 Inferior direction.
2.3. Superior surface of liver ( facies superior hepatis )
2.4. Anterior part of liver ( pars anterior hepatis )
2.5. Inferior border of liver ( margo inferior hepatis )
2.6. Coronary ligament of liver ( ligamentum coronaria hepatis )
Untuk menghubungkan liver ke diafragma. Terdapat anterior dan posterior.

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2.7. Right triangular ligament of liver ( lig. triangulare dextra )


Untuk attach di diafragma di ujung kanan dari lig. Coronarium.
2.8. Left triangular ligament of liver ( lig. triangulare sinistra )
Untuk attach di diafragma di ujung kiri dari lig. Coronarium.
2.9. Falciform ligament of liver ( lig. falciforme hepatis )
Untuk attach ke anterior wall of abdomen. Di tengah – tengah lobus kanan
dan kiri.
2.10. Bare area of liver ( area nuda hepatis ). Discuss among the group why that part was
named bare area.
Daerah yang menempel pada diafragma yang tidak dilapisi oleh peritoneum.
2.11. Round ligament of the liver ( ligamentum teres hepatis )
Sisa embryonal dari pegantung vena umbilicales. Lanjutan dari lig. Falciforme.
What is the name of its embryologic origin and function ?
Origin : V. umbilicales untuk menyalurkan darah kaya O2 dari ibu ke fetal circulation.
2.12. Inferior vena cava ( V. cava inferior )
DI tengah – tengah lobus hepar setelah portal vein.
2.13. Discuss among the group the lobes of the liver. Look for :
2.13.1. Right lobe of liver ( lobus hepatis dexter )
Lebih besar ukurannya.
2.13.2. Quadrate lobe of liver ( lobus quadratus hepatis )
Dari anterior part dari visceral surface of the liver and bounded on the left by the
fissure for lif terres and on the right by the fossa for the gallbladder.
2.13.3. Caudate lobe of liver ( lobus caudatus hepatis )
Vissible posterior part of the visceral surface of the liver. Bounded on left by the
fissure of lig. Venosum and the right by the groove of IVC.
2.13.4. Left lobe of liver ( lobus hepatis sinister )
Lebih kecil ukurannya.
2.14. Discuss among the group what is the pattern of facies visceralis hepatis.
Identify it and the anatomical structures located there. Look for :
2.14.1. Left lobe of liver
2.14.2. Gastric impression ( impressio gastrica )
Di lobus kiri bagian visceral di daerah sebelah tengah atas.
2.14.3. Fissure for ligamentum venosum ( sulcus ligamenti venosi )
Perbatasan antara left lobe dengan caudatus lobe.
2.14.4. Ligamentum venosum ( lig. venosum ) Arantii.
What is the name of its embryologic origin and its function ?
Dari ductus venosus fungsinya untuk bypass liver di fetal circulation.
2.14.5. Groove for vena cava ( sulcus venae cavae )
2.14.6. Fossa for gallbladder ( fossa vesicae biliaris , fossa vesicae felleae )

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2.14.7. Gallbladder ( vesica fellea ) (Terdapat di right lobe). Identify its part, Look for :

2.14.7.1. Fundus of gallbladder ( fundus vesicae biliaris , fundus vesicae


felleae ) : bagian bawah.
2.14.7.2. Neck of gallbladder ( collum vesicae biliaris , collum vesicae
felleae ) : bagian atas dekat dengan ductus cysticus.
2.14.7.3. Body of gallbladder ( corpus vesicae biliaris , corpus vesicae
felleae ) : bagian tengah.
2.14.7.4. Infundibulum of gallbladder ( infundibulum vesicae biliaris )
2.14.7.5. Spiral fold / valve ( plica / valvula spiralis Heisteri )
2.14.7.6. Bile duct ( ductus choledochus , ductus biliaris ).
What ducts form ductus chodelochus ?
- Cystic duct dan common hepatic duct.
2.14.7.7. Discuss among the group :
2.14.7.7.1. Where do bile duct ended?
Pars descendens duodenum.
2.14.7.7.2. What is the name of anatomical structures form by
bile duct and pancreatic duct ( ductus pancreaticus
Wirsungi ) before ended at the mucosa of
Duodenum? Ampulla of Vater
2.14.7.7.3. What is the name of the bulging at the mucosa of
Duodenum made by the above ( 2.14.7.7.2. )
anatomical structure ? Papilla Duodeni Major.
2.14.7.7.4. Look for the above mention anatomical structures
at the specimen.

2.14.8. Porta hepatis ( porta hepatis )


 Point of entry into the liver for hepatic arteries and portal vein and exit point for
hepatic duct.

2.14.9. Identify anatomical structures located at porta hepatis. Look for :


2.14.9.1. Common hepatic artery ( A. hepatica communis ). Where is the
origin of this artery? Celiac Trunk
2.14.9.2. Common hepatic duct ( ductus hepaticus communis )
2.14.9.3. Portal vein ( V. porta )
Discuss among the group what veins make portal vein.
- V. lienalis dan V. mesenterica superior

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2.14.9.4. What is the name of ligament that covers those three structures?
- Lig. Hepatoduodenale ( menutupi A. hepatica communis, V. porta, dan ductus
choledocus).
2.14.10. Omental tuberosity ( tuber omentale )
2.14.11. Colic impression ( impressio colica )
 Lobus sebelah kanan di daerah sebelah pojok kanan bawah. Dibagian
visceral.
2.14.12. Renal impression ( impressio renalis )
 Di lobus sebelah kanan di bagian tengah. Dibagian visceral.
3. Identify parts of the pancreas. Look for :

3.1. Head of pancreas ( caput pancreatis )


 Ke arah ductus.
3.2. Neck of pancreas ( collum pancreatis )
 Di antara head and body. Terdapat lekukan.
3.3. Body of pancreas ( corpus pancreatis )
 Sebelum tail.
3.4. Tail of pancreas ( cauda pancreatis )
3.5. Pancreatic duct ( ductus pancreaticus Wirsungi )
3.6. ( If available ) Accessory pancreatic duct ( ductus pancreaticus accessorius
Santorini )
 Keduanya berasal dari ductus pancreatic principalis.
3.7. Excretory ducts of pancreas form a fish bone appearance. What is the name
of that appearance ? Discuss it with your fellow students.
 Herring bone system / appearances (ductus pancreaticus dengan ductuli
pancreatici).

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4. Discuss among the group vascularization and innervation of the lower G I T.


 Vaskularisasi

- Jejunum : Jejunal artery branch of superior mesenteric artery.


- Ileum : ileocolic artery and ileal artery branch of superior mesenteric
artery.
- Cecum and Appendix :
 Anterior cecal artery branch of ileocolic artery branch of
superior mesenteric artery.
 Posterior cecal artery branch of ileocolic artery branch of
superior mesenteric artery.
 Appendicular artery branch of ileocolic artery branch of
superior mesenteric artery.
- Ascending Colon :
 Colic branch, anterior cecal artery and posterior cecal artery
branch of ileocolic artery branch of superior mesenteric artery.
 Right colic artery branch of superopr mesenteric artery branch
of anterior surface of abdominal aorta.
- Transverse Colon :
 Right and middle colic artery from superopr mesenteric artery.
 Left colic artery branch of inferior mesenteric artery.
- Descending Colon :
 Left colic artery branch of inferior mesenteric artery.
- Sigmoid Colon :
 Sigmoidal arteries branch of inferior mesenteric artery.
- Rectum and Anal :
 Superior rectal artery branch of inferior mesenteric artery.
 Middle rectal artery branch of internal iliac artery.

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 Inferior rectal artery branch of internal pudendal artery branch


of internal iliac artery.
 Innervasi
 Symphatetic & parasympathetic nerves generate plexus at
anterior side of aorta  plexus aorticus abdominalis.
 Small & large intestine  innervated by fibers derived from
the plexus around 3 major visceral branches of aorta (plexus
coeliacus, plexus mesenterica inferior & superior)
 Colon descendens  innervated by sacral division of
parasympathetic nervous system.
 Colon ascendens & transversum  innervated by plexus
mesentericus superior.
 Colon descendens  plexus mesentericus inferior (cranial/
sacral divisions of parasympathetic system).
 Anal rectal  Inferior hypogastric plexus, rectal nerve plexus,
inferior rectal nerve

Accessory GIT

 Vaskularisasi :
- Liver :
 Hepatic artery proper – supplies the liver with arterial blood.
Branch of coeliac trunk.
 Hepatic portal vein – supplies the liver with deoxygenated
blood, carrying nutrients absorbed from the small intestine.
The dominant blood supply to the liver parenchyma and allows
the liver to perform detoxification. Branch of Splenic vein +
Superior mesenteric vein.

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- Gallbladder :
 Cystic artery branch of hepatic artery proper branch of coeliac
trunk.

- Pancreas :

 Pancreatic branches of the splenic artery.


 Head of Pancrea supplied by superior and inferior
pancreaticoduodenal arteries branches of the gastroduodenal
and superior mesenteric arteries.
 Innervasi :
- Liver :
 By hepatic plexux which contains sympathetic (from the
coeliac plexus) and parasympathetic (from the vagus nerve)
nerve fibers. Enter the liver at the porta hepatis and follow the
course branches of the hepatic artery and portal vein.
 Glisson’s capsule (fibrous covering the liver) innervated by
branches of the lower intercostal nerves.

- Gallbladder :
 Receive parasympathetic, sympathetic and sensory
innervation. Sympathetic and sensory fibers from celiac plexus
and parasympathetic fibers from vagus nerve.

- Pancreas :
 The pancreas receives neural innervation from the vagus (cranial X). This
is part of the autonomic parasympathetic supply. The role of the vagus
is to stimulate secretion of the pancreatic digestive juices.
 Autonomic sympathetic nerves to the pancreas derive from the celiac
ganglionic plexus, the superior mesenteric plexus, and the hepatic
plexus. These plexuses lie outside the pancreas and send
postganglionic fibers into the pancreatic cells. These sympathetic
nerves inhibit the production of digestive enzymes.

GOODLUCK 

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