大體老師 無語良師

大體解剖學實驗 HUMAN DISSECTION POSTERIOR ABDOMINAL VISCERA & WALL 盧家鋒 助理教授 臺北醫學大學醫學系 解剖學暨細胞生物學科 臺北醫學大學醫學院 轉譯影像研究中心

http://www.ym.edu.tw/~cflu REFERENCES

• Dissector‘s guide • [1] Dissection Guide for Gray's Human Anatomy, 2ed, 2006 • [2] Grant’s Dissector, 15ed, 2012 • Photographic Dissector • [3] Gray's Clinical Photographic Dissector of the Human Body, 2013 • Human Atlas • [4] Gray's Atlas of Anatomy, 2ed, 2014 • [5] Grant's Atlas of Anatomy 13ed, 2012 • [6] Color Atlas of Anatomy: A Photographic Study of the Human Body, 7ed, 2011 • [7] Atlas of Human Anatomy, 6ed, 2014 http://www.ym.edu.tw/~cflu 2 (2/3)

• Posterior Abdominal Viscera • Posterior Abdominal Wall • Diaphragm

http://www.ym.edu.tw/~cflu 3 POSTERIOR ABDOMINAL VISCERA/ PRIMARY RETROPERITONEAL ORGANS 後腹壁內臟

http://www.ym.edu.tw/~cflu 4 DISSECTION

• Use your fingers to tear through the renal fascia and separate the kidney from the perirenal fat. • Identify suprarenal glands.

腎周脂肪 腎筋膜 腎旁脂肪 http://www.ym.edu.tw/~cflu 5 腰方肌 腰大肌 RENAL Ref. [5], p. 324 LEFT  RIGHT

• Identify the left renal vein. Use a probe to trace the left renal vein from the left kidney across the midline to the inferior vena cava. • Observe that it lies anterior to both renal Abdominal and the aorta.

http://www.ym.edu.tw/~cflu Ref. [6], p. 323 RENAL VEIN LEFT VS. RIGHT

• Identify and clean the tributaries of the left renal vein: 2. 1. Left testicular (or ovarian) vein 2. Left suprarenal vein 1. • Clean the relatively short right renal 3. vein. Note that it has no tributaries. 3. Right testicular (or ovarian) vein directly returns to IVC. http://www.ym.edu.tw/~cflu Ref. [5], p. 167 7 RENAL ARTERIES

• Use scissors to cut the renal close to the inferior vena cava and reflect it (black dashed line). Superior • Identify the renal , which lies mesenteric posterior to the renal vein. Follow the artery to the hilum of the kidney. • Accessory renal arteries are common.

http://www.ym.edu.tw/~cflu RENAL ARTERIES

• Identify branches of the renal artery 1. 1. 2. include: 2. 1. Inferior suprarenal artery –to the suprarenal gland 2. Ureteric branch –to the ureter

http://www.ym.edu.tw/~cflu Ref. [5], p. 169 RENAL & URETER • Using the renal artery as a hinge, turn the left kidney toward the right.

腎盂

http://www.ym.edu.tw/~cflu 10 Ref. [5], p. 170 RELATIONSHIPS OF KIDNEY • The suprarenal gland is superior to the kidney. • Through the peritoneum, the right kidney is in contact with the right colic flexure, the visceral surface of the , and the second part of the duodenum. • Through the peritoneum, the left kidney is in contact with the tail of the pancreas, the left colic flexure, the , and the spleen. • The hilum of the kidney faces anteromedially and the lateral border faces posterolaterally. http://www.ym.edu.tw/~cflu 11 KIDNEY DISSECTION Ref. [5], p. 170 Renal papilla 小腎盞 • Divide the left kidney into anterior Minor calyx Major calyx and posterior halves by splitting it 大腎盞 longitudinally along its lateral border. Renal pelvis Renal sinus • Open the two halves of the kidney Renal cortex like a book using the renal pelvis as the hinge. Renal medulla: Renal column • Identify the labeled structures. Renal pyramid

Renal papilla  minor calyx  major calyx  renal pelvis  ureter http://www.ym.edu.tw/~cflu 12 4 3 (SG) 4 SUPRARENAL GLANDS 3 SG SG • The suprarenal (adrenal) glands are 2 2 fragile and may be easily torn! 1 • Identify arteries: 1 1. Inferior suprarenal artery –arises from the renal artery. 2. Middle suprarenal artery –arises from the aorta near the celiac trunk. 3. Superior suprarenal arteries –arise from the 4. inferior phrenic artery. http://www.ym.edu.tw/~cflu Ref. [5], p. 169 SUPRARENAL GLANDS & SYMPATHETIC NERVES

http://www.ym.edu.tw/~cflu 14 Ref. [5], p. 185 T12 • Observe that the abdominal aorta has three types of branches: • Unpaired visceral arteries –to the gastrointestinal tract (celiac trunk, superior (behind mesenteric artery, inferior mesenteric artery). Psoas major m.) • Paired visceral arteries –to the three paired abdominal organs (middle suprarenal arteries, renal arteries, testicular or ovarian arteries). L4 • Paired somatic arteries –to the abdominal wall (, inferior phrenic arteries).

http://www.ym.edu.tw/~cflu Ref. [5], p. 179 15 INFERIOR VENA CAVA

• The inferior vena cava does receive venous drainage from the paired abdominal organs (renal vein, suprarenal vein, testicular or ovarian vein) either directly (right side) or indirectly (left side). • The inferior vena cava receives paired veins from the abdominal wall (, inferior phrenic veins).

http://www.ym.edu.tw/~cflu Ref. [5], p. 179 16 POSTERIOR ABDOMINAL WALL 後腹壁

http://www.ym.edu.tw/~cflu 17 Ref. [6], p. 323

REMOVE PARIETAL PERITONEUM • Remove any remaining parietal peritoneum from the

posterior abdominal wall. Abdominal aorta

ureter

Uterus Ref. [5], p. 166 18 Urinary Bladder MUSCLES 腹橫肌

• Identify…. 腰方肌 • • Quadratus lumborum muscle

• Transversus abdominis 髂肌 muscle iliacus muscle • Iliacus muscle 腰大肌

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• The psoas minor muscle is absent in approximately 40% of cases and may be present on only one side of the cadaver. • The psoas minor muscle has a long flat tendon that passes down the anterior surface of the psoas major muscle. • Its distal attachment is on the iliopubic eminence and arcuate line of the ilium.

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• The lumbar plexus (L1 to L4) is formed within the 髂下腹神經 psoas major muscle 髂腹股溝神經 大腿外側皮神經 • Its branches can be seen as they emerge from the 股神經 lateral border of this muscle. 腰薦神經 生殖股神經

http://www.ym.edu.tw/~cflu 21 Ref. [5], p. 177 DISSECTION GUIDE

• Dissect the lumbar plexus on the left side only. • Follow each nerve proximally into the psoas major muscle, removing the muscle piece by piece (一束一束肌纖維小心撕開找). • Use the peripheral relationships of the nerves (their region of distribution or a point of exit from the abdominal cavity) for positive identification.

http://www.ym.edu.tw/~cflu Ref. [5], p. 176 22 L1

GENITOFEMORAL NERVE L2

L3 • It is found on the anterior surface of the psoas major muscle. L4

• Genital branch – passes through L5 the deep inguinal ring and down the inguinal canal. • Femoral branch – passes under the Femoral branch inguinal ligament on the anterior (cut) surface of the external iliac artery. Genital branch http://www.ym.edu.tw/~cflu Ref. [5], p. 176 23 ILIOHYPOGASTRIC AND L1 ILIOINGUINAL NERVES Iliohypogastric L2 L3 Ilioinguinal • They descend steeply across the L4 anterior surface of the quadratus lumborum muscle. L5 • To positively identify the ilioinguinal nerve, follow it to the superficial inguinal ring.

http://www.ym.edu.tw/~cflu Ref. [5], p. 176 24 L1

FEMORAL NERVE L2

L3

• It lies on the lateral side of the L4 psoas major muscle in the groove between the psoas major and L5 iliacus muscles. • The femoral nerve passes deep to the inguinal ligament and provides motor and sensory branches to the anterior thigh. http://www.ym.edu.tw/~cflu Ref. [5], p. 176 25 LATERAL CUTANEOUS NERVE L1 OF THIGH L2 L3

• It passes deep to the inguinal L4 ligament near the anterior superior iliac spine. L5 • The lateral cutaneous nerve of the thigh supplies the skin on the lateral aspect of the thigh.

http://www.ym.edu.tw/~cflu Ref. [5], p. 176 26 Ref. [5], p. 180

http://www.ym.edu.tw/~cflu 27 DIAPHRAGM 橫膈膜

http://www.ym.edu.tw/~cflu 28 DIAPHRAGM Sternal origin/part Costal origin/part Central tendon Lumbar part, Lumbar part, • Identify Right crus Left crus • Central tendon –the aponeurotic center of the diaphragm (distal attachment of its muscle part). • Sternal part • Costal part • Lumbar part http://www.ym.edu.tw/~cflu Ref. [5], p. 178 29 Medial Median DIAPHRAGM arcuate arcuate ligament • Identify arcuate ligaments 弓狀韌帶 ligament • Lateral arcuate ligament – bridges the anterior surface of the quadratus lumborum muscle. • – bridges the anterior surface of the psoas major muscle. • – (unpaired) bridges the anterior surface of the aorta at the . http://www.ym.edu.tw/~cflu Ref. [5], p. 178 30 Psoas major muscles have been removed. DIAPHRAGM Vena caval foramen Aortic hiatus • Identify three large openings • Vena caval foramen – passes through the central tendon (vertebral level T8). • Esophageal hiatus – passes through the right crus (vertebral level T10). • Aortic hiatus – passes behind the diaphragm (vertebral level T12).

http://www.ym.edu.tw/~cflu Ref. [5], p. 178 31 SPLANCHNIC NERVE 內臟神經 Celiac ganglion • Identify the greater splanchnic nerve in the thorax and follow it Splanchnic nerves to the superior surface of the Greater (T5-T9) diaphragm. Lesser (T10-T11) Least (T12) • Note that the greater splanchnic nerve penetrates the crus to enter the abdominal cavity. • Identify the celiac ganglion.

http://www.ym.edu.tw/~cflu Ref. [5], p. 180 32 THE END [email protected] (TMU EXT. 3273)

http://www.ym.edu.tw/~cflu 33