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بسم هللا الرحمن الرحيم 1 Abdomen Part 4 2 Greater Omentum and Abdominal Vicsera 3 Greater Omentum and Abdominal Vicsera, Greater Omentum Raised 4 Mesenteric Relations of Intestines Transverse Colon Elevated 5 Mesenteric Relations of Intestines Small Intestine Removed 6 The Root of Mesentery • The short root of small intestinal mesentery is continuous with parietal peritoneum on posterior abdominal wall along a line that extends downward to right from left side of 2nd lumbar vertebra to region of right sacroiliac joint • It permits exit and entrance of arterial, venous and lymphatic vessels, and nerves to intestine 7 Function of Peritoneum • 1- Movements (gliding) of viscera on each other • 2- Peritoneal fluid contains leukocytes secreted from peritoneum • 3- Peritoneal fluid is not static and moves continuously toward subphrenic space quickly absorbed into lymphatic capillaries of diaphragmatic peritoneum • 4- Vessels and nerve supply to viscera • 5- Fat storage (large amount) • 6-Providing extensive surface for absorption and secretion (peritoneal dialysis) 8 Mesenteric Relations of Intestines Sigmoid Colon Reflected 9 Mesenteric Relations of Intestines Stomach Reflected 10 Suspensory Muscle of Duodenum (Ligament of Treitz, Dirived from Right Diphragmatic Crus) 11 12 13 14 15 16 17 18 19 Relations of Epiploic foramen • Anterior: free border of lesser omentum & its components • Posterior: IVC • Superior: Caudate process of liver • Inferior: 1st part of duodenum 20 21 Question 1 • How do you define peritoneal pouches? 22 Mesenteric Relations of Intestines Sigmoid Colon Reflected 23 Question 2 • What is the function of peritoneal membrane? 24 25 Stomach Variation in position and contour 26 Stomach Variation in position and contour • Hypertonic • Position & body • Orthotonic shape of stomach • Hypotonic depend: • Atonic • Habitus (Body build) • Its fullness • Its muscle tone • Status of surrounding viscera 27 Surface Anatomy of stomach • Upper and left part of abdomen: • Epigastric area • Umblical area • Left hypochondriac area 28 29 Cardia & Pylorus • Cardia lies: Behind 7th C.C. 2.5 cm left of midline at the level of T11 • Pylorus lies 2.5 cm right of midline at the level of L1 • Between these two points the stomach is fixed and position & body shape of stomach depends to: …… 30 Stomach Parts • Cardiac orifice • Cardiac incisure • Fundus • Body • Angular incisure • Pyloric antrum • Pyloric canal • Pyloric orifice 31 32 33 34 35 36 37 38 39 40 Gastric Cells + Fundus and Body: • 1- Chief or peptic cells, digestive enzymes • 2- Parietal or oxyntic cells, Acid and intrinsic factor • 3- Mucus cells, mucus • 4- Neuroendocrine cells, somatostatin & histamine • 5- Somastotine is secreted by D cells which inhibits gastrin • 6- Histamine role is like gastrin + Pylorus: Gastrin, is released by G cells under influence of mechanical stimuli and increases gastric motility and secretions of chief & oxyntic cells + Cardia: Mucus and lyzozym is secreted from cell in this region 41 Relations Anterior surface: • Left ribs & costal margin • Left lobe of liver • Left dome of diaphragm separates stomach from left lung and heart • Anterior abdominal wall 42 43 Relations Posterior surface: Inside lesser sac: • Pancreas • Spleen • Splenic vessels • Left kidney • Left Suprarenal gland • Transverse mesocolon 44 Blood Supply • 1- Left gastric artery • 2- Right gastric artery • 3- Right gastroepiploic artery • 4- Left gastroepiploic artery • 5- Short gastric arteries 45 46 Venous Drainage • 1- Left gastric vein & • 2- Right gastric vein Portal vein • 3- Left gastroepiploic vein & 4- Short gastric veins Splenic vein 5- Right gastroepiploic vein Superior mesentric vein 47 Venous Drainage 48 Lymphatic drainage of stomach • Area I = Superior 1/3 • Area II = Inferior 1/3 • Area III = Left superior 1/3 49 50 Lymphatic drainage of stomach • Area I: along left and right gastric artery to aortic nodes • Area II: along right gastroepiploic artery to subpyloric nodes • Area III: along short gastric and splenic artery to suprapancreatic nodes 51 52 Lymphatic Drainage of stomach • All lymph reach celiac nodes • In rare case of stomach carcinoma there might be a supracalvicular lymphadenopathy (Virschow ganglion) 53 Innervation • 1- Sympathetic fibers from celiac plexus (T6 –T10) • 2- Sympathetic fiber are vasomotor and motor to pyloric sphincter, but inhibitory for rest of stomach • 3- Sympathetic fibers contains also pain fibers • 4- Parasympathetic fibers from L & R vagal trunks: • Anterior, gives rise branches to stomach and a branch to liver a branch of which goes to pyloric region • Posterior, gives rise to branches to stomach and a branch to celiac ganglion • Parasympathetic fibers are motor and secretomotor to stomach but inhitbitory to pyloric sphincter 54 Anterior & posterior vagal trunks 55 Myenteric & Sub mucosal Plexus 56 57 58 59 60 61 62 63 Applied Anatomy • Gastric pain is felt in epigastrium and T6 - T10 are its responsible dermatoms • Pain is produced by spasm or by overdistention 64 65 66 Duodenum • Duodenum means twelve • Ancient anatomists suggested: 12 finger breadth, about 25 cm • Including 4 parts: • 1st part, superior, cap, or bulb, 5cm • 2nd or descending part, 8 cm • 3rd or horizontal part, 8cm • 4th or short ascending part, 5cm 67 68 69 Duodenum, continued • Duodenal Cap: • Its medial half: • Superiorly: • free edge of lesser omentum is attached • Inferiorly: • greater omentum and transverse mesocolon is attached • So, this part is a bit mobile 70 Duodenum, continued • Duodenal Cap: • Anteriorly : • Liver & gall bladder overlap this part • Posteriorly : • Gastroduodenal artery, portal vein and bile duct cross it vertically (partially embedded in the head of pancreas) 71 72 Duodenum, continued • 2nd part: • Descends along right side of verte. L1,2,3 • Anterior: • Liver, transverse mesocolon, transverse colon and coils of jejunum • Posterior: hilum of right kidney, right ureter • Lateral: ascending colon, right colic flexture right lobe of liver • Medial: common bile duct embedded in the head of pancreas, joins with main pancreatic duct 73 74 .
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