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2 the Anatomy and Physiology of the Stomach 111 2 3 2 4 5 6 The Anatomy and Physiology of 7 8 the Stomach 9 1011 Ian R. Daniels and William H. Allum 1 2 3 4 5 6 7 8 9 2011 of absorption. Gastric motility is controlled by 1 Aims both neural and hormonal signals. Nervous 2 control originates from the enteric nervous sys- 3 To detail the anatomy and physiology of the tem as well as the parasympathetic (predomi- 4 stomach. nantly vagus nerve) and sympathetic systems. 5 A number of hormones have been shown to 6 influence gastric motility – for example, both 7 Introduction gastrin and cholecystokinin act to relax the 8 proximal stomach and enhance contractions 9 The stomach is the most dilated part of the in the distal stomach. Other functions of the 3011 digestive tube, having a capacity of 1000–1500 stomach include the secretion of intrinsic factor 1 ml in the adult. It is situated between the end necessary for the absorption of vitamin B12 2 of the oesophagus and the duodenum – the (Figure 2.1). 3 beginning of the small intestine. It lies in the 4 epigastric, umbilical, and left hypochondrial 5 regions of the abdomen, and occupies a recess Anatomy 6 bounded by the upper abdominal viscera, the 7 anterior abdominal wall and the diaphragm. It Embryology 8 has two openings and is described as having two 9 borders, although in reality the external surface Towards the end of the fourth week of embry- 4011 is continuous. The relationship of the stomach onic development, the stomach begins to differ- 1 to the surrounding viscera is altered by the entiate from the primitive foregut – a midline 2 amount of the stomach contents, the stage that tube, separated from the developing peri- 3 the digestive process has reached, the degree of cardium by the septum transversum and dor- 4 development of the gastric musculature, and the sally to the aorta. Initially a fusiform dilation 5 condition of the adjacent intestines. However, forms, beyond which the midgut opens into the 6 borders are assigned by the attachment of the yolk sac. The foregut, owing to the presence of 7 peritoneum via the greater and lesser omentum, the pleuroperitoneal canals on either side, is 8 thus dividing the stomach into an anterior and connected to the dorsal wall by a mesentery 9 posterior surface. that is continuous with the dorsal mesentery of 5011 The principal function of the stomach is the mid- and hindguts. Thus a primitive mesen- 1 to mix the food with acid, mucus and pepsin tery extends from the septum transversum to 2 and then release the resulting chyme, at a con- the developing cloaca. The liver and ventral 311 trolled rate into the duodenum for the process pancreas (uncinate process) develop from the 17 18 2 · UPPER GASTROINTESTINAL SURGERY Oesophagus ventral aspect of the foregut and grow into the 1111 Fundus septum transversum, thus forming a ventral 2 mesentery – the ventral mesogastrium. As the 3 Cardia embryonic period continues the growth of the 4 two “borders” becomes notably altered and 5 the curvature of the stomach becomes apparent 6 Lesser curvature Body (Figure 2.2). The distal end rotates ventrally and 7 (Parietal cells: with the increased growth of the dorsal border 8 HCL Intrinsic factor the concavity of the lesser curvature becomes 9 apparent. With further increasing growth of 1011 Duodenum Chief cells: Pepsinogen) the entire gut and the return of the gut to the 1 abdominal cavity the stomach becomes rotated 2 Greater along its cranial-caudal plane so that the 3 curvature “stomach sac” rotates and the original right 4 Antrum surface becomes dorsal and the left ventral. The 5 Pylorus (gastrin) position of the dorsal and ventral mesogastrium 6 is affected by the rotation (Figure 2.3). 7 Figure 2.1. The regions and functions of the stomach. (With As the dorsal mesogastrium becomes in- 8 permission from Review of Medical Physiology, WF Ganong, creased in length, it folds upon itself forming the 9 13th edition, Lange Medical Press, 1987.) lesser omentum. This lies transverse rather than 2011 1 2 Longitudinal 3 rotation axiis 4 5 6 Lesser 7 curvature 8 Stomach 9 3011 1 Greater 2 Duodenum curvature 3 ab c 4 Figure 2.2. a–c The rotation of the stomach along its longitudinal axis. 5 6 7 Cardia 8 Oesophagus 9 4011 1 Lesser 2 curvature 3 Anteroposterior axix 4 5 6 7 Greater 8 Greater curvature 9 abPylorus curvature 5011 1 Figure 2.3. The rotation of the stomach along its anteroposterior axis. (With permission from Langman’s Medical Embryology, 5th 2 edition, Williams & Wilkins, Baltimore, 1985.) 311 18 19 THE ANATOMY AND PHYSIOLOGY OF THE STOMACH 111 anteroposterior and leads to the formation of incomplete duplications may be defined as 2 the lesser sac. This lies between the stomach and spherical or tubular enteric formations which lie 3 posterior abdominal wall, bounded laterally on in contiguity with the normal alimentary tract 4 the left by the dorsal mesogastrium, anteriorly and which share with it a common blood supply, 5 by the stomach and laterally on the right by the and usually a common muscle coat. These cyst- 6 developing liver. The foramen of Winslow is the like structures, or duplication cysts, usually do 7 only opening into the space and formed by not communicate with the normal lumen. They 8 the free border of the lesser omentum, between may have a mucosal lining and may be pedun- 9 the stomach and liver (Figure 2.4). culated. A duplication cyst of the stomach 1011 With the rotation of the stomach, the duo- is a communicating or non-communicating 1 denum is carried to the right. Initially the cyst lined by gastric, intestinal or pancreatic 2 duodenum is fixed by a thick mesentery to epithelium, and usually located along the 3 the posterior abdominal wall. However, with greater curvature. Occasionally it may be situ- 4 this rotation the duodenum comes to lie on ated in the wall of the pyloric region; in such 5 the posterior abdominal wall and the primitive cases encroachment on the lumen may produce 6 mesentery disappears. This results in the gastric outlet obstruction, or an appearance 7 duodenum coming to lie retroperitoneally. Sim- resembling infantile hypertrophic pyloric steno- 8 ilarly the bilary ducts and pancreas come to lie sis. In non-communicating duplication cysts, 9 within the concavity of the duodenum, the bile accumulation of acid and pepsin may produce 2011 duct having passed behind its proximal part. a local inflammatory reaction, perforation, 1 Within the folds of the dorsal mesogastrium abscess formation and peritonitis. 2 the spleen develops and this remains intimately 3 attached to the stomach. Congenital Double Pylorus, Pyloric 4 Membrane, Web or Diaphragm 5 Congenital Abnormalities Congenital double pylorus is an extremely rare 6 Pyloric Atresia condition. A pyloric membrane is defined as a 7 thin, circumferential mucosal septum in the 8 Almost all cases of gastric atresia occur in the pyloric region, projecting intraluminally per- 9 pyloric region and may present as a membrane pendicular to the long axis of the “antrum”. It 3011 occluding the lumen, as a gap in continuity, or is composed of two layers of gastric mucosa, 1 as a fibrous cord intervening between patent with a central core of submucosa and muscu- 2 portions at the gastroduodenal junction. There laris mucosae. It is generally regarded as a con- 3 is a reported association with epidermolysis genital anomaly and is usually associated with 4 bullosa. Clinically the condition presents as symptoms and signs of gastric outlet obstruc- 5 upper abdominal distension and bile-free vom- tion. 6 iting in the newborn. Maternal hydramnios 7 occurs in approximately 50% of cases. Ectopic Pancreatic Tissue 8 Aberrant pancreatic nodules have been 9 Duplications reported in the upper gastrointestinal tract. 4011 True or complete duplication of the stomach is Although usually in the duodenum they have 1 exceedingly rare. More common (but also rare) been reported in the stomach near the pylorus. 2 3 4 Dorsal mesogastrium Omental bursa 5 6 7 Stomach 8 9 Ventral 5011 abmessogastrium c 1 2 Figure 2.4.a–c The effect of rotation on the ventral and dorsal mesogastrium (a, b) and the formation of the lesser sac (omental 311 bursa) (c). (With permission from Langman’s Medical Embryology, 5th edition, Williams & Wilkins, Baltimore, 1985.) 19 20 2 · UPPER GASTROINTESTINAL SURGERY Macroscopic Anatomy Greater Curvature (Curvatura 1111 Ventriculi Major) 2 The stomach has two openings, two curvatures, This is directed mainly forward, and is four to 3 two surfaces and two omenta. five times longer than the lesser curvature. It 4 starts from the incisura cardiaca and arches 5 Openings backward, upward, and to the left; the highest 6 7 Gastro-oesophageal Junction point of the convexity is on a level with the sixth left costal cartilage. It then descends downwards 8 The oesophagus communicates with the stom- and forwards, with a slight convexity to the 9 ach via the cardiac orifice, which is situated on left as low as the cartilage of the ninth rib, 1011 the left of the midline at the level of T10. before turning to the right, to end at the pylorus. 1 The intra-abdominal oesophagus (antrum car- Directly opposite the incisura angularis of 2 diacum) is short and conical. After passing the lesser curvature, the greater curvature pre- 3 through the diaphragm it curves sharply to the sents a dilatation, which is the left extremity of 4 left, and becomes continuous with the cardiac the pyloric part; this dilatation is limited on the 5 orifice of the stomach.
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  • The Peritoneum General Features • General Features • the Peritoneum Is a Thin Serous Membrane Consisting Of: • 1- Parietal Peritoneum －Lines the Ant
    The Peritoneum General features • General features • The peritoneum is a thin serous membrane Consisting of: • 1- Parietal peritoneum －lines the ant. Abdominal wall. • 2- Visceral peritoneum - covers the viscera - Peritoneum is continuous below with parietal peritoneum lining the pelvis. • 3- Peritoneal cavity - the potential space between the parietal and visceral layer of peritoneum - in male, is a closed sac - but in the female, there is a communication with the exterior through the uterine tubes, the uterus, and the vagina Peritoneum cavity divided into Greater sac Lesser sac Communication between them by the epiploic foramen Deep to lesser omentum Behind the stomach Between two layers of greater omentum Under the diaphragm and liver Deep to lesser opening (Epiploic opening) Walls： Superior－peritoneum which covers the caudate lobe of liver and diaphragm Anterior－lesser omentum, peritoneum of posterior wall of stomach, and anterior two layers of greater omentum Inferior－conjunctive area of anterior and posterior two layers of greater omentum Posterior－posterior two layers of greater omentum, transverse colon and transverse mesocolon, peritoneum covering posterior abdominal wall. Omental bursa……cont Left－ spleen, gastrosplenic ligament splenorenal ligament Right－omental foramen Deep to ant. Abdominal wall Below the diaphragm Above pelvic viscera Out to: Liver surround all the liver except bare area Stomach completely surrounded by peritoneum Transverscolon Greater omentum two layers of peritoneum from greater curvature
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