DAY 21 AM

LECTURE: Intro to Pelvis LIVING ANATOMY of

the abdominal wall, abdominal organs, vasculature, spinal nerves

and dermatomes
. OBJECTIVES Describe the topographical areas of the anterior abdominal wall and the horizontal and vertical lines defining them. There are two schemes, one using quadrants and the other defining nine regions (Grays p268-69, 388-89). Identify bony landmarks and body planes on the skeleton and your living anatomy partner Identify the transpyloric, subcostal, supracristal and transtubercular planes at correct vertebral levels ! Draw surface projections of the a. Diaphragm b. Liver and gall bladder c. Stomach d. Small intestine e. Large intestine f. Pancreas g. Spleen Describe the layers and muscular composition of the anterior abdominal wall Understand the continuity between the layers of the walls of the abdomen, thorax, pelvis and perineum Be able to recognize viscera of the abdominopelvic cavity in X-rays

BONY LANDMARKS (Grays p385 & 408 fig. 5.4)

Use the skeleton to identify the th th ! 9 and 10 costal cartilages ! highest point of the iliac crest ! iliac tubercle (. 424, fig 5.21) ! anterior superior iliac spine ! pubic tubercle ! pubic symphysis Locate these bony landmarks on your partner. Note: You do not palpate your partners pubic symphysis in this course.

VERTEBRAL LEVELS
Locate, lightly draw, and label the lines representing these horizontal planes and the vertebral levels on

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your partner (Grays pp 385-386, fig 4.165) ! The transpyloric plane is located one hands breadth below the xiphisternal junction and this th plane intersects the 9 costal cartilage and L1. The transpyloric plane is also located halfway between the suprasternal (jugular) notch and the pubic crest. ! ! ! The subcostal plane intersects the lower border of the costal cartilage of rib 10 and L3. The supracristal plane passes through the highest point on the iliac crests and L4. The transtubercular (intertubercular) plane intersects the tubercles of the iliac bone and L5.

Lightly draw the bodies of T12 and lumbar vertebrae 1 through 5 on the anterior abdominal wall of your partner using the horizontal planes you constructed and Figure 4.163, page 385 of Grays to guide you. Draw the vertebral bodies the correct size by referring to the skeleton. DIAPHRAGM (Grays pp 253, fig 4.8; 351; and 383, fig 4.166) The diaphragm is a double-domed, musculotendinous partition separating the thoracic and abdominal cavities. The muscle fibers of the diaphragm arise from the sternum anteriorly, the inferior costal margin laterally and the bodies of T12-L2 posteriorly. The muscle fibers insert into a central tendon. The two domed diaphragm is shallow anteriorly and deep posteriorly and shaped as an inverted J in a sagittal section. Anteriorly the surface projections of the domes reach rib 6 on the right and rib 5 on the left. During forced expiration, the diaphragm raises 5 to 8 cm and the right dome can reach the level of the fourth intercostal space. After finding the 5 and 6 ribs on your partner, draw the domes of the diaphragm to indicate the superior extent of the abdominal cavity as projected anteriorly. LIVER (Grays p388, fig 4.166) The wedge-shaped liver is located in the uppermost portion of the abdominal cavity immediately beneath the diaphragm. The wide surface of this liver-wedge faces laterally and represents the lateral surface of the right lobe of this four-lobed organ. The tapered medial portion extends to 4 cm lateral to the left midclavicular line. The right half of the liver is covered by the ribs and the right lobe of a normal liver does not extend below and can not be palpated inferior to the costal margin. You can draw a highly simplified outline of the liver beginning with its superior border which lies beneath the diaphragm. Begin your drawing at the level of the xiphisternal junction at a point 4 cm lateral to the left midclavicular line. Extend a horizontal line from this point to the right midaxillary line. You should realize the diaphragmatic surface of the liver actually adheres to the diaphragm and follows its contours. Construct the right border of the liver by drawing a line from the point on the midaxillary line straight downward to rib 10 and the costal margin Draw a diagonal line drawn from this point to the starting point to represent the inferior border of the liver You can locate the position of the gall bladder at the intersection of the right midclavicular line and the costal margin STOMACH (Grays p388 fig 4.166)
th th

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The stomach is roughly J-shaped. Study Figure 4.61, page 299 of Grays to learn its several named parts. The length, width and size of the stomach are highly variable, but it is possible to estimate the position of the lesser curvature because the cardia and pyloric antrum are fixed at the proximal and distal ends of the stomach respectively. Lesser Curvature Mark the point where the abdominal esophagus joins the cardia of the stomach 3 cm to the left of the midline and 2 cm inferior to the costal margin. Mark the point where the pyloric canal joins the duodenum 3 cm to the right of the midline in the transpyloric plane (vertebral level L1). Connect the two points with a curved line to indicate the lesser curvature of the stomach (Grays p 299, fig 4.61). Fundus The fundus of the stomach lies beneath the right dome of the diaphragm. Its upper border can be located th posterior to the left 6 rib in the midclavicular line. DUODENUM (Grays pp 300, 301, fig 4.64 ,386 and fig 4.164) The duodenum is the first part of the small intestine. It is roughly C-shaped and has four parts. The1st or superior, the 2nd or descending, the 3rd or inferior and the 4th or ascending portions constitute the four parts of the duodenum. Draw the duodenum on your partner using Figures 4.64 and 4.164 and these instructions to guide you. (You should practice by making this drawing on a sheet of paper if you want to produce a nearly perfect projection of the duodenum on your partners abdomen). Using the bodies of the lumbar vertebrae as guides 1. Begin your drawing at the pylorus, 1 cm to the right of the midline in the transpyloric plane (vertebral level L1). 2. Draw the short, superior portion of the duodenum between the pylorus and a point at the upper border of the right side of the body of L1. This segment is 4 cm long. 3. Draw the second or descending portion between the upper border of the right side of the body of L1 and a point at the lower border of the right side of the body of L3. Refer to the textbook illustration to understand that this portion of the duodenum is curved rather than being straight (Grays p 301, fig 4.64). 4. Draw the third or inferior part between the lower border of right side of the body of L3 and the lower border of the left side of L3. This inferior part of the duodenum is 6-8 cm long and is curved inferiorly.

5. The fourth or ascending portion is 2-3 cm long. Draw it between the lower border of the left side of the body of L3 and the upper border of the left side of the body of L2. This point marks the position of the junction of the ascending portion of the duodenum with the jejunum named the duodenal jejunal junction. PANCREAS (Grays 320 fig 4.98; 300; 386, fig 4.164) The pancreas has a head, neck, body and tail. The flattened head fits into the C-shaped curve of the duodenum. The tail of the pancreas contacts the spleen.

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Draw the head of the pancreas within the C-shaped boundary of the duodenum. The neck of the pancreas connects the head with the body which extends from the transpyloric plane and obliquely to the left for 10 cm. The tail projects 2cm above the transpyloric plane to the hilum of the spleen and just lateral to the midclavicular line. Lightly draw the pancreatic neck, body and tail on your partner. JEJUNUM AND ILEUM (Grays p388) The jejunum and ileum make up the final part of the small intestine. This final portion is fixed to the posterior abdominal wall for a few centimeters at both its proximal and distal ends. The rest of the tube is suspended from the posterior abdominal wall by an extensive fan-shaped mesentery commonly referred to as the mesentery. The site of the attachment of the mesentery to the posterior abdominal wall is named the root of the mesentery (Grays p 297, fig 4.58). 1. Relocate the point where the 4 or ascending part of the duodenum ends (the upper border of the left side of the body of L3 is the site of the duodenal jejunal junction). 2. Locate the position of the ileocecal junction by locating the approximate position of the appendix as follows. Palpate and mark the location of the anterior superior iliac spine on your partner. Draw a straight line between the anterior superior iliac spine and the umbilicus. Divide the line into thirds. The appendix is located approximately at the junction of the lateral and medial thirds of this line. Mark this point on your line. (The point indicating the approximate position of the underlying appendix was described by the American surgeon Charles McBurney in 1898 and is used by clinicians today.) 3. Draw an oblique line between the duodenal jejunal junction and the point marking the position of the root of the appendix. This last line represents the location of the root of the mesentery, the site where the mesentery of the small intestine attaches to the posterior abdominal wall.
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LARGE INTESTINE (Grays pp 296, fig 4.57; 300, fig 4.63 and 388, fig 4.166) 1. The cecum is located in the right flank where you can palpate it. The ascending colon ascends vertically from the cecum to vertebral level L1 where it contacts the right lobe of the liver. Draw the ascending colon. You can palpate the ascending colon of your partner. Will its contents be soft or firm normally? 2. At the liver the ascending colon makes a 90 degree turn to the left, called the right colic flexure, and travels transversely toward the left side of the abdominal cavity as the transverse colon. 3. The transverse colon is suspended from the posterior abdominal wall by its mesentery, the transverse mesocolon. It is found in various positions and need not be drawn (Grays p297, fig 4.58). You can lightly sketch in the location of the root of the transverse mesocolon between the right and left colic flexures. It crosses the second part of the duodenum, the head of the pancreas and the upper border of the body and tail of the pancreas (Grays p. 300, fig 4.63). 4. The transverse colon ends beneath the spleen at vertebral level T10 as the left colic flexure. Here the colon makes another right angle turn to descend vertically in the left flank and left iliac

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fossa as the descending colon. Draw the descending colon. 5. You can palpate the descending colon in the left flank of your partner. Will its contents be soft or firm normally? 6. The descending colon is continuous with the sigmoid colon in the left iliac fossa which continues into the pelvis. SPLEEN (Grays p388, fig 4.166) The spleen is oval shaped, 12 cm long and 7 cm wide. It lies in the posterior superior aspect of the left side of the abdominal cavity. It sits immediately anterior to ribs 9, 10 and 11 with its long axis oriented obliquely along rib 10. Locate ribs 9, 10 and 11 on the left posterior lateral aspect of the thorax of the skeleton and your partner. Then outline the position of the spleen on your partners thorax referring to Figures 4.166 on page 388 and 4.169 on page 390 in Grays. What kinds of trauma are most likely to damage the spleen? KIDNEY (Grays pp 357, fig 4.137; 320, fig 4.120, p390, fig 4.169) The kidneys are paired, bean-shaped organs lying adjacent to the vertebral column in the extraperitoneal connective tissue of the posterior abdominal wall. They are 5 cm wide and 10 cm long, their long axis being parallel to the vertebral column. These organs have anterior and posterior surfaces, superior and inferior poles, medial and lateral borders and a hilum. The renal hilum faces medially. The left kidney is higher in the posterior abdominal wall than the right. Its hilum is at vertebral level L1 and the hilum of the right kidney is at L2. Draw the transpyloric plane on your partners back and locate L1 and L2 vertebrae. Palpate and draw the th th 11 and 12 ribs on the back. Outline the position of the left and right kidneys using Figures 4.137, page 357 and 4.169, page 390 in Grays as your guide. The upper pole of the right kidney reaches the superior border of the 11 rib and its lower pole reaches the inferior border of the body of L2. The upper pole of the left kidney reaches the middle of the 10 intercostal space and its lower pole extends to the inferior border of the body of L3.
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ABDOMINAL AORTA (Grays p 387, fig 4.165) The aorta penetrates the diaphragm at T12 and descends to the left of the vertebral column to L4 where it bifurcates into the common iliac arteries. Locate vertebral levels T12 and L4 in the midline of the anterior body wall of your partner. Draw the aorta to the left of the midline between these levels and include its bifurcation into the common

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iliac arteries. Three unpaired branches arise from the anterior aspect of the abdominal aorta. Proceeding from superior to inferior they are the celiac, superior mesenteric and inferior mesenteric arteries. Indicate the position of the origin of these three arteries as follows: The celiac artery, or trunk, arises at T12 The superior mesenteric artery arises at L1 The inferior mesenteric artery arises at L3 INFERIOR VENA CAVA The inferior vena cava (IVC) leaves the abdomen at vertebral level T8 to the right of the midline through the diaphragmatic hiatus for the inferior vena cava.

DISCUSSION SESSION
LAYERS of the ABDOMINAL WALL (Grays p270-279, Table 4.1) From the surface to the parietal peritoneum, the layers of the abdomen correspond to the layers in the thorax. Skin and the superficial fascia [fatty (Campers) and membranous (Scarpas) layers] are separated by a fascial plane from 3 muscle layers enclosed in deep fascia. Deep to the muscles are the endoabdominal (transversalis) fascia and fat and the parietal layer of peritoneum. The anterior abdominal wall muscles consist of the paired external oblique, internal oblique, transversus abdominus and rectus abdominus muscles. The first three muscles terminate medially in broad aponeuroses that form a dense fibrous sheath for the vertical rectus abdominis lying on each side of the midline. The external oblique originates from ribs 4 through 12. Its fibers run medially and inferiorly (hands in the pockets) ending in a broad aponeurosis. The aponeurosis contributes to the rectus sheath medially. Its

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inferior border extends between the ASIS and pubic tubercle inferiorly and is called the inguinal ligament. The fascia of the ext oblique continues into the scrotum as the external spermatic fascia.. The internal oblique originates along the lateral 2/3 of the inguinal ligament and the anterior 2/3 of the iliac crest. Its fibers run medially and superiorly, 90 degrees to the fibers of the external oblique. The internal oblique inserts on the lower margin of the rib cage and in a broad aponeurosis that contributes to the rectus sheath. Fibers from the internal oblique continue along the spermatic cord as the cremaster muscle (see figure above). The transversus abdominis forms the deepest layer of muscle. Its horizontal fibers originate on the inguinal ligament, the iliac crest and the thoraces-lumbar fascia. The transversus abdominis arches above the inguinal canal and does not contribute a covering to the spermatic cord. The aponeurosis forms a layer of the rectus sheath. The rectus sheath is formed by the fusion of the aponeuroses of the external, internal and transversus muscles (see horizontal section below). Above the arcuate line (located midway between the umbilicus and pubic symphysis), the aponeurosis of the external oblique is anterior and that of the transversus abdominis is posterior to the muscle. The aponeurosis of the internal oblique contributes equally to the anterior and posterior layers. Below the arcuate line, all aponeuroses are anterior and only the transversalis fascia and parietal peritoneum are posterior to the muscle. The rectus muscle is bounded laterally by the line of fusion of the aponeuroses, the linea semilunaris, and in the midline by the linea th th th alba. The superior end of the rectus abdominis attaches to the 5 , 6 and 7 costal cartilages and its inferior end attaches at the pubic crest. Three horizontal tendinous intersections are obvious in muscular individuals.

Innervation of the abdominal muscles is through the lower intercostal and the subcostal nerves. The abdominal wall is specialized to form the inguinal canal and the rectus sheath. In the male and female, the skin and superficial fascia of the abdominal wall continue into the perineum. In the male the fatty layer of superficial fascia in the scrotum is replaced by a dartos muscle composed of specialized smooth muscle. The spermatic cord and the round ligament of the uterus are surrounded by layers continuous with the layers of the abdominal wall. Regions of the Abdomen and Abdominal Referred Pain (Grays p389). Pain from abdominal organs is carried by sensory fibers of autonomic nerves and is not localized. In contrast, the source of the pain stimuli carried by somatic sensory nerves of the body wall can be accurately pinpointed. Referred pain from abdominal organs is not perceived at the source of the pain but is referred to another region. Four lines drawn on the anterior body wall generate regions that can be used to describe referred pain from abdominal organs:

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The two midclavicular lines intersecting the horizontal transpyloric and transtubercular (intertubercular) planes produce 9 regions. The epigastric region is where referred pain from the foregut presents. Referred pain from the midgut presents in the umbilical region, and hindgut pain refers to the pubic region.

Radiology of the Abdomen:

In an X-ray, the soft tissue of the abdominal organs is difficult to see unless contrast medium is present. In this X-ray barium, highlights the stomach, duodenum and jejunum. IDENTIFY the bony points: ! ! ! T12 with a floating rib (R12) L1 behind the pylorus and superior part of the duodenum. L2, 3 parallel to the descending part of the duodenum where the inferior part crosses the midline to ascend and join the jejunum. L5 above the sacrum. (S) Superior crest (SC) of the ilium. The belt buckle and zipper (Walmart).

! ! !

IDENTIFY: ! The fundus of the stomach (F) at about T11 ! The pylorus (P) at L1 ! The superior duodenum (SD), L1 ! The descending duodenum (DD), L1-L3 ! The inferior duodenum, L3 ! The ascending duodenum (AD), L2 ! The small intestine (SI)

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Identify the bony points: ! T11 and floating rib (R11) ! T12 and floating rib ! L1,2,3,4 ! Crest of the ilium ! ASIS Contrast medium is in the large intestine. The haustra of the ascending (AC) and transverse colon (TC) are obvious (Grays p279-280). Observe the sigmoid shape (SC) of the sigmoid colon descending to the rectum. The right colic flexure is at the level of L1 and the left is higher at about T10.

BRANCHES OF THE ABDOMINAL AORTA: Locate the vertebral column. Identify L4, post superior iliac spine (PSIS) of the pelvis, and the sacrum... Identify the branches of the descending aorta: Celiac trunk (CT): common hepatic artery (CHA) & splenic artery (S); Renal arteries, left and right Superior mesenteric (SMA) Inferior mesenteric? Common iliacs (CI) The branches of the IM are difficult to identify as they descend into the pelvis.

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REVIEW ON YOUR PARTNER (if there is time): o o o o o o o o o o o The level of the diaphragm The stomach The duodenum The pancreas and gut arteries Root of the appendix Root of the mesentery and small bowel Large bowel The spleen The liver and gallbladder The kidneys Layers of the abdominal wall, rectus sheath, inguinal canal and scrotum:

A comment: One purpose of living anatomy to provide an opportunity to transfer knowledge of the cadaver and textbooks to the living body. A meaningful physical examination relies on an ability to describe anatomy to your patients or your colleagues clearly and quickly. This will be learned in detail in ICM. IMPORTANT DISCUSSION POINTS ABOUT THE ABDOMINAL ORGANS: ! The transpyloric plane is important because it marks the position of the pylorus of the stomach entering the superior part of the duodenum, the head and body of the pancreas, the renal arteries, veins and ureters as they enter the hilum of each kidney, and the superior mesenteric artery (SMA) branching from the descending aorta (Grays p262, Fig 4.16, 387). The subcostal plane intersects the lower edge of the costal margin (10 rib) at vertebral level L3 where the inferior mesenteric artery (IMA) and inferior, horizontal part of the duodenum is found(Grays p387). The supracristal plane passes through the highest point on the iliac crests corresponding to vertebral level L4 where the aorta bifurcates into the common iliac arteries (Grays p387). The transtubercular or intertubercular plane at vertebral level L5 intersects the tubercles of the iliac crest the level where the common iliac veins join to form the IVC (Grays p387).
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The transpyloric plane (L1) is the guide to the beginning, superior section of the duodenum and the connection with pylorus of the stomach. The pylorus is about 2 cm to the right of the midline on the transpyloric plane. the first superior part of the duodenum horizontally about 1" long with a slight angle up to T12. The 3 inferior part of the duodenum crosses L3 horizontally to reach the midline and turns up to become th the 4 ascending part for about 2 cm to the left of the median plane where the duodenum ends at the duodenojejunal junction. The junction is situated to the left of the body of L2, just below the transpyloric plane. The result is a C-shaped organ surrounding the head of the pancreas. The duodenum is retroperitoneal (behind the peritoneum of the posterior abdominal cavity). The neck of the pancreas lies behind the pylorus and the body extends slightly obliquely above the transpyloric plane for about 10 cm to the left. The tail of the pancreas contains the splenic vessels and projects to the hilum of the spleen about 2cm above the intersection of the transpyloric plane just lateral to the midclavicular line. The spleen lies along the axis of the tenth rib in the posterior abdominal cavitiy. between ribs 8 and 10 (Grays p390, fig 4.169).
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The diaphragm is a musculotendinous partition separating the abdomen and thorax. The muscular fibers attaching the diaphragm to the costal margin were derived from the embryonic body wall. The fusion of the septum transversum with the pleuroperitoneal folds separates the body cavity into the thoracic and abdominal cavities. These were derived from the embryonic somatic mesoderm. In the adult, the fibers of the diaphragm descend steeply along the vertebral column. The left crus of the diaphragm extends to vertebral body L2 and the right crus to L3. The result is a steep arch posteriorly. Contraction provides a strong force to expand the lungs inferiorly (Grays p159, fig 3.35; p249, fig 4.3&4; p383, fig 4.161). The height of the diaphragm varies during respiration (Grays p 135). The central tendon is at the level of the xiphisternal junction (6 costal cartilage) in the midline. During forced expiration, the diaphragm can move as much as 5 to 8 cms and the right dome of the diaphragm can rise to the level of the fourth intercostal space anteriorly. The left is a little lower. The steepness is the reason that the IVC, esophagus, and aorta penetrate the diaphragm at vertebral levels T8, T10 and T12 respectively (Grays p130, fig 3.8). On the right side, the diaphragm is directly superior to the liver, and the lower margin of the liver is protected by the right costal margin. The inferior boundary of the liver ascends diagonally just below the costal margin across the midline. The gall bladder is found at the intersection of the right midclavicular line and the costal margin (Grays p388, fig 4.166). Just below the liver at the level of costal cartilage 7 (vertebral level T10), the cardia of the stomach joins the esophagus after it penetrates the diaphragm. The pylorus of the stomach joins the duodenum, 2 cm to the right of the midline on the transpyloric plane and a curved line form the lesser curvature of the stomach. The greater curvature is variable and influenced by the type of body build. The stomach is more or less "J" shaped (Grays p388, fig 4.166). The root of the mesentery is represented by a straight line joining the duodenal-jejunal junction with the root of the appendix. The mesentery carries the jejunal and ileal branches (with autonomic innervation from the preaortic plexus) of the superior mesenteric vessels in the posterior body wall to the small intestine. The coils of the small intestine are suspended in the abdomen from this attachment and fill most of the peritoneal cavity. The small bowel ends when it attaches to the colon in the right iliac fossa at the ileocolic junction. The cecum is in the right iliac fossa, just lateral to McBurney's point (Grays p388, fig 4.166). The ascending colon ascends from the cecum parallel and lateral to the right midclavicular line from the transtubercular plane to a point halfway between the subcostal and transpyloric planes. At this point the right colic (hepatic) flexure is just beneath the liver. The position of the transverse colon is variable, but it can be represented by a line drawn from the right hepatic flexure to below the umbilicus and then returning upwards to the intersection of the transpyloric plane and the left midclavicular line where the splenic or left colic flexure is located. The left colic flexure makes an impression on the spleen and slightly higher than the hepatic flexure (on the right). From the splenic flexure, the descending colon descends just lateral to the left midclavicular line, into the iliac fossa as far as the inguinal ligament where the sigmoid colon begins (Grays p388, fig 4.166). The kidneys are two bean-shaped organs that maintain the bodys fluid and electrolyte balance. The right kidney usually a little lower than the left because of the liver. The transpyloric plane passes above the hilum of the right kidney and just below the hilum of the left kidney (Grays p386).
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