APOSTLE JOHN'S SMART ANATOMY PREVIEW

ABDOMEN
EXTERNAL OBLIGUE
 Arise by 8 digitations.
 Lower 4 slips interdigitate with costal fibres of latissimus dorsi.
 Upper 4 interdigitate with digitations of serratus anterior.
 Has wide insertion most of which is aponeurotic.
 Superficial layers of aponeurotic insertion runs obliquely upwards.
 Those of deep layer are at right angle downwards.
 Posterior border of the muscle is free, forms anterior border of lumbar triangle.
 Lower border forms inguinal ligament between pubic tubercle and ASIS.
 From medial end of inguinal ligament, triangular lacunar ligament entends horizontally to pectineal line on pubis.
INTERNAL OBLIGUE
 Arises from whole length of lumbar fascia, anterior 2/3 of Iliac crest and front of lateral 2/3 of inguinal ligament.
 It's aponeurosis fuse with transversus aponeurosis to form conjoint tendon.
 Has free lower border which arches over spermatic cord
TRANSVERSUS ABDOMINIS
 Lower fibres of aponeurosis curve with those of internal obligue as conjoint tendon.
RECTUS ABDOMINIS AND PYRAMIDALIS
Rectus abdominis
 Medial head is from front of pubic symphysis.
 Lateral head from upper border of pubic crest.
 Inserted to front of 5-7th costal cartilages.
Pyramidalis
 Arises from pubis and symphysis between rectus abdominis and it's sheath.
 Linea alba is attached to xiphoid process above and pubic symphysis below.
RECTUS SHEATH
 External oblique aponeurosis forms anterior layer.
 Transversus abdominis aponeurosis forms posterior layer.
 Aponeurosis of Internal and External obligue and Transversus abdominis are bilamina.
Contents
 Rectus and pyramidalis, lower six thoracic nerves, Lower six intercostal vessels, superior and inferior epigastric
arteries.
Intercostal nerves
 Pass to abdominal wall between Internal Oblique and Transversus Abdominis.
 Pierce posterior layer of Internal Oblique to enter rectus sheath.
 In Rectus sheath T7 nerve runs upwards, T8 runs transversely and others obliguely downwards.
Superior epigastric Artery
 Supplies rectus muscle.
INGUINAL CANAL
 Transmits spermatic cord and ilioinguinal nerve in male
 Transmits round ligament of uterus and ilioinguinal nerve in female
 Anterior wall formed by External obligue aponeurosis.
 Lateral wall by internal obligue.
 Floor is lower edge of inguinal ligament.
 Medially is lacunar ligament.
 Roof is lower edge of Internal obligue and Transversus muscle.
 Posterior wall is conjoint tendon and transversalis fascia

16
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Integrity of Inguinal canal depends on anterior and posterior wall.

 Conjoint tendon lies posterior to superficial inguinal ring.
Deep inguinal ring
 Is an opening is transversalis fascia
Structures deep to posterior wall
 Inferior epigastric Artery crosses posterior wall medially.
 Laterally Ductus deferens and round ligament of uterus in female enter canal by hooking around interfoveolar
ligament.
 At deep ring, inferior epigastric Artery gives off cremaster branch.
 Inguinal triangle is bounded laterally by Internal epigastric artery, medially by lateral border of rectus muscle, below
by inguinal ligament.
 Indirect hernia passes lateral to artery (through deep ring).
 Direct hernia passes medial to artery (through inguinal triangle).
 Direct hernia emerges through superficial ring and lies above and medial to pubic tubercle.
 Neck of femoral hernia is below and lateral to pubic tubercle.
SPERMATIC CORD
 Internal spermatic fascia is derived from Transversalis fascia at deep ring.
 Cremaster muscle and fascia are the second layer.
 In 3rd layer, external spermatic fascia is acquired from external obligue aponeurosis.
Contents
 Ductus deferens.
 Arteries - testicular (largest), artery to ductus and cremaster artery.
 Veins - pampiniform plexus.
 Lymphatic and nerves (genital branch of genitofemoral nerve)
 Processus vaginalis.
TESTIS
 Epididymis is attached to posterolateral surface.
 Vas deferens arise from lower pole of epididymis and runs up medial to it.
 Testis, epididymis and turnica vaginalis lie in scrotum.
 Right and left sides are separated by median scrotal raphe.
 Appendix testis is attached to its upper pole within turnica vaginalis.
Blood supply
 Testicular artery gives branch to epididymis.
 There's anastomosis between testicular, cremaster and ductal arteries in region of epididymis.
 Pampiniform plexus surrounds testicular artery.
 Pampiniform plexus separates into four veins in inguinal canal.
 The leftt vein joins renal vein at right angle.
 Right vein drains directly into IVC at acute angle.
 Testicular veins usually have valves.
 Variocele occurs more on leftt side than the right.
Lymph drainage
 Lymphatics run with testicular artery to para-aortic nodes lying at L2 level just above umbilicus (origin of testicular
artery).
 Does not drain to inguinal nodes.
 Overlying scrotal skin drains to inguinal nodes.
Nerve supply
 Celiac plexus and lesser splanchnic nerve
EPIDIDYMIS

17
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Attached behind testis.

 Has large head at upper end and pointed tail at lower end.
 Head is connected to upper end by vasa efferentia and tail to lower end by loose connective tissue.
 The body is separated from testes by sinus of epididymis.
VAS DEFERENS
 Direct continuation of canal of epididymis.
 Passes up medially.
 Blood supply by br from testicular artery.
 Nerve by celiac ganglion.
ABDOMEN
 Stomach is fixed at its 2 ends but suspended by mesentery elsewhere.
 Duodenum is plastered to posterior abdominal wall.
 Whole length of small intestine swings freely its mesentery.
 Ascending and descending colons are adherent to posterior abdominal wall.
 Transverse colon is mobile in its mesentery between colic flexures.
 Sigmoid colon swings freely on a mesentery.
 Suprarenals, kidneys and ureters, aorta, IVC lie behind peritoneum.
Transpyloric plane
 Transpyloric plane (TP) insects body between jugular notch and pubic symphysis, mid way between xiphisternum and
umbilicus which cuts costal margin at tip of 9th costal cartilage.
 TP plane passes through lower border of L1 vertebra where spinal cord ends at conus medullaris.
 TP plane passes through pylorus, along head nech and body of pancreas, above attachment of transverse mesocolon.
 Supracolic compartment lies above TP plane while infracolic compartment lie below it.
 Superior mesenteric artery, splenic vein joins superior mesenteric vein to form portal vein at level of TP plane.
 Hilum of kidney lies at this plane. The rightt just below and leftt just above.
PERITONEUM
 Covers anterior and posterior abdominal walls.
 Consist of single layer is flattened cells.
 Double fold supporting small intestine is the mesentery.
Peritoneal folds of anterior abdominal wall
 Raised into 6 folds, 1 above and 5 below umbilicus.
 Falciform ligament connects liver to supraumbilical part of anterior abdominal wall and inferior surface of diaphragm.
 Below umbilicus, central fold is median umbilical fold containing medial umbilical ligament.
 Lateral to median umbilical fold is medial umbilical fold containing medial umbilical ligament.
 Farther laterally is lateral umbilical fold containing inferior epigastric artery and does not reach as far as umbilicus.
LESSER PERITONEAL SAC
 Opens into greater sac through epiloic foramen.
 Anterior wall of lesser sac is formed by posterior layer of lesser omentum.
 Posterior wall is anterior of 2 posterior layers of greater omentum.
 Cavity of lesser sac does not extend much below Transverse colon because of fusion of its layers.
GREATER OMENTUM
 Forms four layers which fuse with each other below Transverse colon.
 It envelops spleen except for the hilum of spleen.
 Splenic vessels lie in splenorenal ligament.
 Short gastric and left gastroepiploic vessels run in gastrosplenic ligament.
EPIPLOIC FORAMEN
 Upper boundary is caudate process of liver.
 Lower boundary is 1st part of duodenum.

18
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Posterior boundary is IVC.

 Anterior boundary is right free margin if lesser omentum.
PERITONEAL COMPARTMENT
 Transverse colon and mesocolon are adherent to posterior surface of greater omentum.
 Lateral limb of sigmoid mesocolon passes along pelvic brim to inguinal ligament while medial limb slopes down to
hollow sacrum reaching S3 (commencement of rectum).
Nerve supply
 Diaphragmatic Pleura - phrenic (C4 mainly)
 Rest of parietal peritoneum is by intercostal and lumbar nerves.
 Obturator nerve is the chief source in pelvis.
RETROPERITONEAL SPACE
 Include aorta, IVC, Cisterna chyli, lymph nodes and vessels, nerves, kidneys, ureters, pancreas, ascending and
descending colons, most of duodenum and suprarenal glands.
CELIAC TRUNK
 Is artery of foregut
 Arise between crura of diaphragm, below median arcuate ligament at level of T12 body.
 Celiac ganglia lie one of each side
 Divides into 3 branches at upper border of pancreas behind peritoneum.
Left gastric Artery
 Runs across left crus towards esophageal opening.
 Runs to right in lesser omentum along lesser curvature to supply stomach.
Splenic artery
 Runs across left crus and left psoas to hilum of left kidney.
 It is main supply to the pancreas.
 May give of posterior gastric Artery from its mid part to stomach.
Common hepatic artery
 Passes over upper border of pancreas.
 Gives off right gastric and gastroduodenal arteries.
Left gastric Artery
 Leaves common hepatic, runs to left along lesser curvature, anatomose with left gastric Artery.
Gastroduodenal artery
 Passes behind 1st part of duodenum.
 Divides into 2 at lower border of duodenum.
Rightt gastroepiploic artery
 Passes between 1st part of duodenum and pancreas, entrance of bile duct marks junction of foregut and midgut and
is the meeting point of Coeliac and superior mesenteric arteries.
SUPERIOR MESENTERIC ARTERY (SMA)
 Supplies from entrance of bile duct to splenic fissure of colon.
 Arise a centimeter below coeliac trunk at level of lower border of L1.
 Behind splenic vein and body of pancreas.
 Superior mesenteric vein on its right side.
 Lies anterior to left renal vein.
Inferior pancreaticoduodenal artery
 1st branch of superior mesenteric artery from the posterior surface.
 May come off the first jejunal branch.
Jejunal and illegal branches
 Arise from left of main trunk.
 Pass down between 2 layers of mesentery.
Ileocolic artery

19
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Arise from right side of SMA.

 Descends to right iliac fossa.
Right colic artery
 From right side of SMA in common with ileocolic artery.
Middle colic artery
 From right side, emerges at lower border of neck of pancreas.
 Lies to right of midline.
 Right branch anastomoses with ascending branch of right colic artery
VENOUS DRAINAGE OF MIDGUT
 Each branch of SMA is accompanied by a vein.
Superior mesenteric vein (SMV)
 SMV lies to right of SMA.
 Crosses 3rd part of duodenum and uncinate process of pancreas.
 Joins splenic vein behind neck of pancreas to form portal vein.
INFERIOR MESENTERIC ARTERY (IMA)
 Arise from front of aorta, behind inferior border of 3rd part of duodenum, opp L3, at level of umbilicus, 3 or 4cm
above aortic bifurcation
Left colic artery
 Ascending branch crosses left psoas, gonadal vessels, ureter, genitofemoral nerve and quadratus lumborum
 Crossed anteriorly by inferior mesenteric vein.
VENOUS DRAINAGE OF HINDGUT
Inferior mesenteric vein (IMV)
 Runs to left of IMA
 Lies on psoas muscle in front of gonadal vessels, ureters, genitofemoral nerve.
 Pass behind lower border of body of pancreas, in front of renal vein and joins splenic vein
LYMPHATIC DRAINAGE OF GUT
 Coeliac group - Cisterna chyli
 First filtering is by lymphoid follicles, not numerous in esophagus, more in stomach, becomes peyer's patches in lower
ileum, aggregated in appendix as in a tonsil.
 First groups lies in peritoneum adjacent margin of Small Intestine.
 Second group - along main blood vessels of supply
 Third group - preaortic nodes at origin of celiac, SMA and IMA.
 large intestine has additional epiploic nodes.
ESOPHAGUS
 1 or 2cm in length.
 Grooves posterior surface of leftt lobe of liver.
 Posterior wall is shorter than anterior wall.
 Left Inferior phrenic nerve lies behind esophagus.
STOMACH
 Relatively fixed at both ends.
 Gastro-esophageal junction (cardia) is the most fixed part, lies 2.5cm to left of midline at T10 level.
 Gastro-duodenal junction (pylorus) is a little to right of midline at L1 level when empty.
 Pyloric canal lies at head and neck of pancreas.
 Stomach bed consist of left crus and dome of diaphragm, splenic artery, body of pancreas, Transverse mesocolon,
upper part of left kidney, left suprarenal gland, spleen and left colic flexure.
 To right of lesser curvature in the midline lie Aorta and Celia trunk, celiac plexus and ganglia, coeliac lymph nodes.
Blood supply
 Gastric arteries may be double.
 Fundus and upper leftt part receive about 6 short gastric arteries.

20
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 The right gastroepiploic artery (GEA) is closer to greater curvature than the leftt GEA.
 Prepyloric vein drain into rightt gastric vein.
Lymphatic drainage
 From upper leftt quadrant - gastroepiploic nodes.
 From rest of greatet curvature - nodes along right gastroepiploic vessels.
 Pyloric part - hepatic nodes.
Nerve supply
 Anterior vagal trunk lies in contact with anterior esophageal wall nearer its right margin
 Anterior vagal trunk is usually double or triple.
 Posterior vagal trunk lies in loose connective tissue (CT) a little behind and to right and not in contact with posterior
surface of esophagus.
DUODENUM
 Lies in front and to right of IVC and aorta.
 First 2.5cm is between peritoneum of lesser and greater omenta.
 Makes C-shape round head of pancreas, opposite body of L2.
 1st part lies at level of L1.
 2nd part lies on right side of L2.
 3rd part crosses in front of L3.
 4th part on left of L2.
1st part
 Forms lower most boundary of opening into lesser sac.
 Lies in front of gastro-duodenal artery, bile duct and portal vein behind which lies IVC.
 Gallbladder is ant to duodenal cap.
 Posterior surface is bare of peritoneum
2nd part
 Curves downwards over hilum of right kidney.
 Its upper half lies in supracolic compartment to left of hepatorenal pouch.
 Lower half lies in right infracolic compartment medial to Inferior pole of rightt kidney.
 Lies alongside head of pancreas at level of L2 vertebra.

3rd part
 Curves from right paravertebral gutter over slope of right Psoas.
 Lies on commencement of Inferior mesenteric artery as its inferior border crosses aorta.
 Its upper border hugs lower border of pancreas.
 Lies in both right and left infracolic compartments.
 Its anterior surface is in contact with coils of jejunum.
4th part
 Ascends to left of aorta
 Lies on left of psoas and left lumbar sympathetic trunk.
 Reaches lower border of body of pancreas.
 Duodenojejunal flexure is fixed to leftt Psoas.
 Mouth of four paraduodenal recesses or fossae face towards each other.
JEJUNUM AND ILEUM
 Jejunum is wider-bored and thicker-walled than ileum.
 Thick wall of jejunum feels double.
 Thin wall of ileum feels single.
 Both lie in free margin of the mesentery.
 Jejunum consists of 2/5 of the length.

21
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Ileum is 3/5 of total length.

 Occlusion of straight arteries make lead to infarction of part supplied.
 Occlusion of arcade vessels is usually without effect.
 Ileal arteries have larger arcades - 3 to 5.
 Vagus gives parasympathetic supply which arguments peristalsis.
 Sympathetic supply is from lat horn of T9-10 spinal segments.
CAECUM
 Usually completely covered by peritoneum.
 Lateral wall ougrows medial wall in adults.
 Appendix lies on its posteromedial wall in adults.
 Lies in peritoneal floor of right iliac fossa over iliacus.
 Lower end lies at pelvic brim.
 Posterior caecal artery is larger than anterior.
APPENDIX
 Opens at posteromedial wall of caecum 2cm below ileocaecal valve (McBurney's point).
 McBurney's point lies 1/3 way up the obligue line joining right ASIS to umbilicus.
 Most common position is retrocaecal, followed by pelvic.
 Retroileal site is most common in absence of disease.
 Appendicular artery is an end artery with no corresponding veins.
COLON
 Transverse and sigmoid are suspended in mesenteries.
 Ascending and descending colon are plastered to posterior abdominal wall so that their post walls are devoid of
peritoneum.
Ascending colon
 Lies on iliac fascia and ant layer of lumbar fascia.
 Is sacculated due to three taeniae being too short for the bowel.
Transverse colon
 Hangs free on Transverse mesocolon which hangs between inferior poles of right and leftt kidneys.
 Splenic flexure lies at higher level than hepatic flexure.
 Due to rotation, anterior taenia of ascending and descending colons lie posteriorly while other two lie anteriorly
above and below.
 Appendices epiploicae are larger and more numerous than on ascending colon.
Descending colon
 Extends from splenic flexure to pelvic brim.
 Plastered to posterior abdominal wall by peritoneum.
 Mesentery is present in about 20% of adults
 Splenic flexure lies on lateral surface of leftt kidney below. and in contact with tail of pancreas and the spleen.
 Phrenicocolic ligament attaches splenic flexure to diaphragm at 10th and 11th rib level.
 Lies on lumbar fascia and iliac fascia.
 Ends in pelvic brim 5cm above inguinal ligament
 Taeniae coli lie one anterior and two posterior.
 Appendices epiploicae are numerous.
Sigmoid colon
 Extends from descending colon at pelvic brim to commencement of rectum in front of 3rd piece of Sacrum.
 Completely invested in peritoneum and hangs free on a mesentery (Sigmoid mesocolon).
 Taeniae coli wider than elsewhere.
 Possesses well developed appendices epiploicae.

22
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 There's anastomosis between portal and systemic venous drainage where ascending and descending colons are in
contact with post abdominal wall.
 Lymph channels follow arteries.
 Sympathetic supply - T10-12.

LIVER
 1500g and recieves 1500mL of blood per minute
 Occupies most of right hypochondrium and epigastrium.
 Surface is convex.
 Sharp inferior border separates right and anterior surfaces from visceral surface.
 Most vessels enter and leave at porta hepatis on visceral surface.
 Hepatic vein emerges from posterior surface.
 Inferior border is botched by ligamentum teres.
 Porta hepatis lies centrally in the H shape pattern of structures.
 Right limb of the H - IVC and gallbladder.
 Left limb of the H - fissure for ligamentum venosus and ligamentum teres.
 Triangular bare area lies to right of IVC (forming its base).
 Caudate lobe lies behind right part of lesser omentum.
 Caudate process extends between porta hepatis and IVC.
Porta hepatis
 Enclose rightt and left hepatic ducts, right and left branches of hepatic artery and portal vein.
 Several lymph nodes and nerves of liver are present in the porta.
 Gallbladder lies on visceral surface.
 Cystic duct lies close to right end of porta hepatis.
 Its neck is highest and fundus lowest.
 Quadrate lobe lies between gallbladder and fissure for ligamentum teres.
 Bare area is in contact with diaphragm and right suprarenal gland.
 Esophagus makes shallow impression on posterior surface of liver.
 Hepatic veins are entirely intrahepatic.
 Visceral surface rests on stomach and hepatic flexure of colon.
Surface markings
 Upper margin of liver - level with xiphisternal joint.
 It reaches 5th intercostal space on the left 7-8cm from midline.
 Reaches 5th rib on the right 7-11cm from mid axillary line.
Lobes
 Larger right and smaller left lobes.
 Caudate lobe lies between IVC and fissure for ligamentum venosus.
 Quadrate lobe lies between gallbladder fossa and fissure for ligamentum teres.
 Subdivisions is not in accordance with arrangement of vascular and biliary channels.
Segments
 Caudate lobe is an autonomous segment having independent venous drainage into IVC.
 Segment V - inferior segment of right posterior sector.
 Segment VI - inferior segment of right anterior sector
 Segment VII - superior segment of right posterior sector.
 Segment VIII - superior segment of right anterior sector.
 Hepatic segments are arranged in anticlockwise direction.
 IVb segment coincides with quadrate lobe.
Blood supply

23
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Right branch of hepatic artery pass behind common hepatic duct.

 Left branch divide into medial and lateral sectoral branches.
 Common hepatic artery arises from mesenteric artery or aorta and runs behind portal vein.
 Right hepatic artery arises from SMA - 15%
 Left hepatic artery arises from left gastric Artery - 20%
 No communication between rightt and leftt halves of liver.
 Arteries in each half are end arteries.
 3 main hepatic veins drain into IVC.
 Large central vein runs between right and leftt halves and recieves from both.
 All the veins have no extrahepatic course, enter IVC just below central tendon of diaphragm.
 Separate vein from caudate lobe enter IVC.
 There's anastomosis between portal venous channel and azygos venous channel across bare area of liver.
 Hepatic branch of anterior vagal trunk reach porta hepatis via lesser omentum.
BILIARY TRACT
 Right and left hepatic ducts form common hepatic duct near right end of porta hepatis.
 Left hepatic duct may run along base of quadrate lobe prior to its emergence from liver.
 Cystic duct joins common hepatic duct at acute angle to form bile duct
GALLBLADDER
 50mL capacity.
 Lies on visceral surface of liver adjacent to quadrate lobe
 Fundus touches tip of 9th costal cartilage.
 Fundus lies on commencement of T colon to the left of hepatic flexure.
 The body is in contact with 1st part of duodenum.
 Neck lies at higher level than fundus in normal position.
 Cystic duct joins common hepatic duct in front of right hepatic artery and its cystic branch.
 Fundus and body are usually bound to under surface of liver.
 Small cystic vein passes from gallbladder to liver substance.
 Gallbladder occasionally hangs free in narrow mesentery from liver under surface.
 Gallbladder may rarely be embedded in liver.
 Gallbladder may very rarely be absent.
 Gallbladder may rarely be duplicated with single or double cystic ducts.
 Cystic artery may pass in front of cystic and bile ducts.
 Cystic veins do not accompany cystic arteries.
COMMON HEPATIC DUCT
 Right and leftt hepatic ducts form common hepatic duct near its right margin in Y-shaped manner.
 Cystic duct joins it after about 3cm.
 Right br of hepatic artery Pass behind common hepatic duct. May also run in front of it.
 Union of cystic and common hepatic duct is on right side of common hepatic duct.
 Rarely Cystic duct may be absent and gallbladder drains directly into common hepatic duct.
BILE DUCT
 Upper third lies in front of portal vein and to right of hepatic artery.
 Middle third runs behind 1st part of duodenum.
 IVC is behind the duct.
 Lower third slopes in groove between back of head of pancreas and 2nd part of duodenum and in front of renal vein.
 Joins pancreatic duct at 60° angle at hepatopancreatic ampulla of Oddi.
 Ampulla opens into posteromedial wall of 2nd part of duodenum at major duodenal papilla 10cm from pylorus.
 Receives small branches from cystic and rightt hepatic artery.
 Sympathetic fibres - T7-9.

24
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Some from gallbladder runs in right phrenic nerve (C3-C5).

PORTAL VEIN
 It's SMV after receiving splendid vein behind neck of pancreas.
 Lies in front of IVC.
 Lies behind pancreas and 1st part of duodenum.
 Lies behind bile duct and hepatic artery.
 Valveless (and its tributaries).
 In portal hypertension, 80% of portal blood maybe shunted into collateral channels, only 20% reaches liver.
Sites of portal/systemic anastomosis
 Lower end of esophagus.
 Upper end of anal canal.
 Bare area of liver.
 Periumbilical region.
 Retroperitoneal areas.
PANCREAS
 Its surface is lobulated.
 Head is on right.
 Has short neck.
 Body crosses midline.
 Narrow tail is on left.
 Head and neck inclines towards paravertebral gutters.
 Neck and body curves curves over IVC and aorta in front of L1 vertebra.
 Neck lies on transpyloric plane.
 Transpyloric plane passes across head and body and below the tail.
Head
 Lies over IVC and right and left renal veins at L2 level.
 Posterior surface is indented by terminal part of bile duct.
 Anterior surface lies in both supracolic and infracolic compartments.
 Transverse colon is attached to ant surface.
Uncinate process of head
 Hook-shaped extension of head.
 Behind SMV and SMA.
 In front of aorta.
Neck
 Lies in front of commencement of portal vein.
 SMV is embraced btwn neck and uncinate process of head.
 Splenic vein runs behind left side of the neck to form portal vein.
 Transverse mesocolon is attached toward lower border of neck.
Body
 Slopes upwards across leftt renal vein and aorta, leftt crus of diaphragm, leftt psoas, lower part of leftt suprarenal
gland to hilum of left kidney.
 Superior border crosses aorta at origin of coeliac trunk.
 Splenic artery passes to left along upper border of body and tail.
 Inferior border alongside neck crosses origin of SMA.
 Splenic vein lies applied to posterior surface.
 IMV joins splenic vein behind body of pancreas in front of left renal vein.
 Transverse mesocolon is attached along anterior border.
 Lies behind lesser sac and forms part of stomach bed.

25
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

Tail
 Passes to left from anterior surface of left kidney.
 Accompanied by splenic artery, vein and lymphatic.
 Lies within 2 layers of splenorenal ligament.
 Reaches hilum of spleen.
Pancreatic duct
 Continuous tube from tail to head.
 Joined at 60° by bile duct at hepatopancreatic ampulla.
 Drains most of pancreas EXCEPT uncinate and lower part of head (which drain by accessory pancreatic duct (APD) of
Santorini).
 APD of Santorini opens into duodenum at minor duodenal papilla.
Blood supply
 Splenic artery supplies neck, body and tail.
 Head is supplied by Superior and Inferior pancreaticoduodenal arteries.
Nerve supply
 Parasympathetic - vagal trunk.
 Sympathetic vasoconstrictor impulse - T6-10 spinal nerves.
SPLEEN
 Lies deep to left 9th to 11th ribs.
 Lies to leftt margin of lesser sac below diaphragm.
 Hilum lies in angle between stomach and leftt kidney.
 Its long axis lies along line of 10th rib.
 Lower pole doesn't project further forward than midaxillary line.
 Hilum makes contact with tail of pancreas lying within splenorenal ligament.
 Spleen must double its normal size for ant surface to pass beyomd leftt costal margin.
 Behind hilum is concave renal surface.
 At lower pole is the small colic impression.
 May consist of 2 or 3 segments based on vascular arrangement.
Blood supply
 Spleenic artery passes between layers is splenorenal ligament.
 Spleenic artery has 2-3 main branches and 5 or more branches.
Nerve supply
 Coeliac plexus - sympathetic fibres only.
POSTERIOR ABDOMINAL WALL
 Midline forward projection is enhanced by IVC and aorta lying in front of vertebral bodies.
 Paravertebral gutters are floored by Psoas and quadratus lumborum and below iliac crest by iliacus.
 Kidney lies high up in paravertebral gutters.
 Lumbar vertebrae are separated by thick intervertebral disc
PSOAS MAJOR
 Lies in gutter between bodies and Transverse processes of lumbar vertebrae.
 Vertebral attachment - disc above 5 lumbars, adjoining parts of body and medial ends of all lumbar Transverse
processes.
 There's one continuous attachment from lower border of T12 to upper border of L5.
 Passes beneath inguinal ligament.
 Tendon is attached to lesser tronchanter of femur.
 Lumbar plexus is embedded within the muscle.
 Part of external vertebral venous plexus is behind it.
 Genitofemoral nerve emerge from front of Psoas muscle.

26
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Iliohypogastric, ilioinguinal, lateral femoral cutaneous and femoral nerves emerge from its lateral border.
 Obturator nerve and lumbosacral trunk from its medial border.
 4 lumbar arteries and veins run behind the muscle.
 Retains pus of Psoas abscess.
 Thickening in Psoas fascia curving from body of L1 or L2 to Transverse process of L1 is median arcuate ligament
(MAL).
 Part of Psoas above MAL is above diaphragm (in thorax).
 Sympathetic trunk passes beneath MAL from thorax to abdomen.
 Nerve supply - L1-L3 lumber nerves mainly L1.
 Action is lat flexion of vertebral column and assists in flexion of trunk.
PSOAS MINOR
 Present in 2 out of every individual.
 Lies on surface of Psoas muscle.
 Short belly arise from T12 and L1.
 Attached to iliopubic eminence.
 Supplied by L1 nerve.
 A weak flexor of lumbar spine.
QUADRATUS LUMBORUM
 Lies edge to edge with Psoas medially and Transversus abdominis laterally in Paravertebral gutter.
 Lies in anterior compartment of lumbar fascia.
 Arises from Transverse process of L5.
 Anterior surface is covered by ant layer of lumbar fascia.
 Represents innermost layer of the 3 muscular layers of the body wall.
 Nerve supply - T12, L1-L3 (L4) lumbar nerves.
 Action - prevents diaphragm from elevating 12th rib during inspiration.
ILIACUS
 Arise from upper 2/3 of iliac fossa, inner lip of iliac crest and anterior sacroiliac ligament.
 Insertion - Psoas tendon to lesser tronchanter.
 Covered by strong iliac fascia.
 Nerve supply - femoral nerve.
 Action - with Psoas on hip joint.
FASCIA OF POSTERIOR ABDOMINAL WALL
 3 fascial layers enclose 2 muscular compartments.
 Quadratus lumborum - anterior
 Erector spinae - posterior

Vessels of post abdominal wall

 Veins lie of right side of arteries.
ABDOMINAL AORTA
 Passes behind median arcuate ligament
 Passes between the crura of diaphragm on from of T12 body.
 Inclines slightly to left
 Left sympathetic trunk is as its left margin.
 Divided into common iliac arteries on body of L4.
 Crossed by splenic vein between origins of coeliac trunk and superior mesenteric artery.
 Between superior mesenteric and inferior mesenteric arteries lie left renal vein, uncinate process and 3rd part of
duodenum.

27
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Surface marking is 2.5cm above transpyloric plane in midline to a point 1 or 2cm below normally situated umbilicus
(level with highest points of iliac crest).
 Median sacral artery leaves aorta a little above its bifurcation and runs in midline over sacral promontory
 Median sacral artery anatomoses with lateral sacral arteries
 1st branch of abdominal aorta is Inferior phrenic arteries and may arise my a common stem.
Phrenic arteries
 Left phrenic artery passes behind esophagus
 Right phrenic artery passes behind inferior Vena Cava
 Phrenic arteries give of small suprarenal branches
Suprarenal
 Suprarenal arteries arise between inferior phrenic and renal branches.
 Right suprarenal artery passes behind inferior Vena Cava
 Left suprarenal artery passes behind posterior wall of lesser sac to reach suprarenal glands.
Renal arteries
 Renal arteries arise at right angles from aorta at L2 level.
 Left renal artery is shorter than right.
 Left crosses left crus and psoas and is behind renal vein (both covered by tail of pancreas and splenic vessels).
 Right crosses right crus and psoas behind inferior Vena Cava and right renal vein (they separate the artery from head
of pancreas bile duct and second part of duodenum).
 Each gives off small suprarenal and ureteric branches.
 1 or 2 accessory renal arteries frequently arise from aorta below the main artery.
Gonadal arteries
 Arise from near front of aorta below renal arteries but above origin of inferior mesenteric.
 Steep downwards over psoas and genitofemoral nerve.
 Right artery first crosses IVC, ureter and being crossed by colic vessels.
 Right artery is crossed by 3rd part of duodenum.
 The left artery is crossed by inferior mesenteric vein
 Testicular artery passes in spermatic cord to testis
 Ovarian artery enters suspensory ligament and pass to ovary and uterine tube
Subcostal arteries
 Arise from lowest part of thoracic aorta
 Enters abdomen beneath lateral arcuate ligament
 Runs between subcostal nerve and vein over quadratus lumborum behind kidney.
 Passes between internal oblique and tranversus (neurovascular plane).

Lumbar arteries
 Are 4 in number
 Arise opposite bodies of upper 4 vertebrae.
 They pass behind lumbar sympathetic trunk
 IVC overlies lower 2 and right crus the upper 2 on the right side.
 Left crus overlies uppermost left artery.
 Each gives posterior and spinal branches and pass laterally behind quadratus lumborum.
 4th passes into neurovascular plane in front of lower border of quadratus lumborum.
 There's no 5th lumbar artery
Iliolumbar artery
 Passes behind obturator nerve and psoas muscle.
Common iliac arteries

28
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Formed by aortic bifurcation on body of L4 to left of midline.

 Right artery is longer than the left.
 Ureter lies in front of bifurcation or beginning of external iliac.
 Left common iliac is crossed by inferior mesenteric (superior rectal) vessels.
 Sympathetic trunk passes behind the artery
 Each is crossed by sympathetic contribution to hypogastric plexus.
External iliac artery
 Passes beneath inguinal ligament to enter femoral sheath
 Its 2 branches are given off above the ligament.
 Deep circumflex iliac branch runs above inguinal ligament
 Bifurcation of common iliac arteries is 3cm from midline level with tubercle of iliac crest.
 Common iliac arteries correspond to 1/3 and external iliac arteries 2/3 of line from aortic bifurcation to midpoint
between ASIS and pubic symphysis.
INFERIOR VENA CAVA
 Has longer course than aorta in abdomen
 Begins opposite L5 vertebra behind right common iliac artery.
 Runs upwards on right of aorta.
 Grooves bare area of liver and pierce central tendon of diaphragm at T8 level
 Lies on bodies of lumbar vertebrae and right crus of diaphragm.
 Crosses right renal, suprarenal and inferior phrenic arteries.
 Partly overlaps right suprarenal gland and coeliac ganglion.
 Lies behind peritoneum of posterior abdominal wall in infracolic compartment
 Crossed by root of mesentery, right gonadal artery and 3rd part of duodenum.
 IVC and its tributaries have no valves EXCEPT gonadal (especially testicular) arteries.
 Surface marking is 2.5cm to right of midline from intertubercular plane to 6th costal cartilage.
 Highest tributary is hepatic vein.
Common iliac vein
 Formed in front of sacroiliac joint by union of internal and external iliac veins.
 Femoral vein enters abdomen on medial side of corresponding artery.
 The 2 common iliac veins continue upwards medial to corresponding arteries.
 They unite behind right common iliac artery.
 Left common iliac vein is longer than right.
 They join almost at right angle across body of L5
Lumbar veins
 Anastomose anteriorly with epigastric veins and posteriorly with vertebral veinous plexuses.
 The 3rd and 4th empty into Vena Cava.
 Those from left pass behind aorta and behind sympathetic trunk but occasionally 1 or more may be in front.
 1st and 2nd join the ascending lumbar vein.
 Each ascending lumbar vein joins subcostal vein to form azygos and hemiazygos veins before 3ntering thorax.
Gonadal veins
 Each is usually paired.
 The 2 comitamtes unite as they run up on Psoas.
 Enters Vena Cava below renal vein on the right.
 Right testicular vein may occasionally join the renal vein.
 Left gonadal vein invariably joins left renal vein at right angle.
 Testicular veins have valves at their termination.
 Valves may be present in the ovarian veins.
Renal veins

29
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Lie in front of renal arteries and behind pancreas.

 Join Vena Cava at right angles at L2 level.
 Left RV is 3 times as longt as right RV (7.5cm compared to 2.5cm)
 Left RV crosses in front of aorta.
 Left RV recieves left suprarenal, left gonadal possibly left inferior phrenic veins.
 Right RV usually drains only its own kidney.
Suprarenal veins
 Left Suprarenal Vein runs downwards and medially to left RV.
 Right Suprarenal Vein passes horizontally to posterior of IVC behind bare area of liver.
Inferior phrenic veins
 Join Vena Cava below the liver.
 Left one may join left renal or suprarenal vein and may be double.
ABDOMINAL LYMPH NODES AND TRUNKS
 Preaortic nodes are situated around origin of coeliac, superior and inferior mesenteric arteries.
 Para-aortic nodes lie along aorta at origin of paired branches of aorta
 Common iliac nodes drain to para-aortic nodes.
Cisterna chyli
 Situated undercover of right crus in front of bodies of L1 and L2.
 Lies between aorta and azygos vein.
 Its upper end is continuous with thoracic duct.
NERVES
SOMATIC NERVES
 Emerge from intervertebral foramina an pass into substance of Psoas major
 Give segmental branches to supply Psoas and quadratus lumborum.
Lumbar plexus
 Is within the substance of Psoas.
 Most of the branches are for lower limb supply.
 T12 and L1 participate in supply of anterior abdominal wall.
 L2 to L4 give branches to posterior abdominal wall (Psoas and quadratus lumborum) and participate in formation of
nerves to flexor and extensor compartments of thigh.
 A part of L4 and all L5 pass down as lumbosacral trunk.
 Nerves for supply of anterior abdominal wall crosses anterior surface of quadratus lumborum (i.e. subcostal,
iliohypogastric and ilioinguinal nerves).
Subcostal nerve
 Pass behind lateral arcuate ligament.
 Lies below subcostal artery and vein
 Passes through transversus abdominis
 Ends by supplying lower part of rectus abdominis
 Lateral cutaneous branch pierces obligue muscles to supply skin of anterior part of buttock (between iliac crest and
greater tronchanter)
Iliohypogastric and ilioinguinal nerves
 Lie in front of quadratus lumborum at all levels
 Both arise from anterior ramus of L1.
 Ilioinguinal represents collateral branch of iliohypogastric.
 They emerge from lateral border of Psoas major
 They pierce anterior layer of lumbar fascia as they slope across quadratus lumborum behind kidney.
 They pass in front of transversus abdominis.
Iliohypogastric nerve

30
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Collateral branch pierce obligue muscles to supply skin of upper part of buttocks behind area supplied by subcostal.
 Pierce internal oblique above ASIS.
 Pierce external oblique 2.5cm above superficial inguinal ring.
 Ends by supplying suprabic skin.
Ilioinguinal nerve
 Enters inguinal canal and emerges through superficial inguinal ring.
 Pierces external spermatic fascia to become subcutaneous.
 Supplies anterior 1/3 of scrotum (mons pubis and labia majus), root of penis (clitoris) and upper and medial part of
groin.
 Gives motor branches to muscle fibres of internal oblique and transversus (inserted into conjoint tendon - important
maintaining integrity of inguinal canal).
Lateral femoral cutaneous nerve
 Formed by union of fibres from posterior divisions of anterior rami of L2 and L3.
 Emerge from lateral border of Psoas major.
 Passes on surface of iliacus muscle deep to iliac fascia, posterior to caecum on right and descending colon on left.
 Perforates inguinal ligament 1cm from ASIS.
 Supplies parietal peritoneum of iliac fossa.
Femoral nerve
 Formed in substance of Psoas major by union of posterior divisions of anterior rami of L2 to L4.
 Emerges from lateral border of Psoas in iliac fossa.
 Gives branches (L2 and L3) to iliacus.
 Passes beneath inguinal ligament on lateral side of femoral sheath.
Genitofemoral nerve
 Formed in substance of Psoas major by union of branches from L1and L2.
 Emerges from anterior surface of Psoas major and runs down on the muscle deep to psoas fascia.
 The left nerve is overlaid by ureter, gonadal vessels, ascending branches of left colic artery and inferior mesenteric
vein.
 Right nerve is overlaid by ureter, gonadal vessels, ileocolic artery and root of mesentery of small intestine.
 Perforates psoas fascia above inguinal ligament and divide into genital and femoral branches.
 Femoral branch is L1 and genital branch is L2.
 Genital branch supplies cremaster muscles, spermatic fascia, tunica vaginalis of rete testis, small area of skin of
scrotum and mons pubis and labia majus.
 Femoral branch passes down behind inguinal ligament with femoral artery, supply skin over upper part of femoral
triangle.
Obturator nerve.
 Emerge from medial border of Psoas with lumbosacral trunk to enter pelvis.
AUTONOMIC NERVES
 Coeliac plexus is wholly visceral and supplies abdominal organs including gonads.
 Ganglionated Lumbar trunk supplies somatic branches for lower abdominal wall and lower limbs. Its visceral branch
supply only pelvic organs.
 Parasympathetic supply is by vagus from above and pelvic splanchnic nerves from below (it's wholly visceral)
 Vagus branch to coeliac plexus and pelvic splanchnics join the inferior hypogastric plexus.
SYMPATHETIC NERVES
 Lumbar part of sympathetic trunk recieves preganglionic fibres from L1 and L2 nerves.
 Sympathetic trunk passes down across pelvic brim behind common iliac vessels to become sacral part of the trunk.
 Lumbar part enters abdomen by passing behind medial arcuate ligament on front of Psoas major and runs down on
medial margin of Psoas muscle.
 It lies in front of lumbar arteries and veins (segmental vessels).
 Some lumbar veins may pass in front of the trunk.

31
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Left lumbar trunk lies beside left margin of aorta, with para-aortic nodes in front of it.
 Right lumbar trunk lies behind IVC.
Lumbar ganglia
 White rami communicate from first 2 lumbar nerves join the trunk and relay in lumbar and sacral ganglia.
 Grey rami communicate from lumbar ganglia accompany lumbar arteries.
 Vasoconstrictor fibre for femoral artery and its branches travel in femoral nerve.
 Lumbar splanchnic nerves arise from all lumbar ganglia.
 Those from the 1st and 2nd ganglia pass to plexuses in front of the aorta.
 Those from 3rdd and 4th ganglia pass respectively in front and behind common iliac arteries.
Superior hypogastric plexus
 Lies anterior to the aortic bifurcation and the left common iliac vein in front of L5 vertebra and sacral promontory.
 Lies behind the parietal peritoneum.
 It often lies a little to the left of midline.
Coeliac plexus
 Lies around origin of coeliac trunk above upper border of the pancreas.
Greater and lesser splanchnic nerves
 Pierce crura of diaphragm and enter coeliac ganglia.
 Coeliac ganglia lie in front of the crura, right one behind IVC and left behind splenic artery.
 Splanchnic nerves are almost preganglionic and many relay in coeliac ganglia.
 Least splanchnic relays in a smal renal ganglion behind renal artery.
 Renal plexus is behind renal artery.
 Testis and ovary are supplied sympathetic plexus that accompany gonadal artery.
 Preganglionic fibres from greater splanchnic nerve pass without relay to cells of Suprarenal medulla.
 Vasomotor supply to Suprarenal gland reaches postganglionic fibres which have relayed in coeliac ganglion.
PARASYMPATHETIC NERVE
 With relay they accompany postganglionic sympathetic fibres
Pelvic splanchnic nerves
 From cell bodies in lateral horn of sacral segment 2 to 3 or 4.
 They join inferior hypogastric plexus for distribution to pelvic viscera.
 Fibres passing to left of superior hypogastric plexus arise up out of pelvis. They supply the large intestine.
 Vagus is inhibitory to pyloric sphincter.
 Vagus is motor and secretomotor to guts and its glands down to transverse colon. Pelvic splanchnic takes over from
splenic flexure.
 Sensory fibres are present in vagus and pelvic splanchnics.
KIDNEYS
 Lie behind peritoneum largely undercover of costal margin.
 Only their lower poles can be palpated in normal individual.
 Each lies obliquely with its long axis parallel with lateral border of Psoas major.
 Measures 12x6x3cm
 Right kidney lies just below and the left above the transpyloric plane 5cm from the midline.
 The bulk of the right lobe of liver accounts for the lower position of the right kidney.
 Upper pole of the left kidney overlies the 11th rib.
 Upper pole of the left kidney overlies the 12th rib.
 Each kidney moves 2cm vertically during full inspiration.
 Pelvis emerges from hilum behind the vessels.
 Posterior relation of both kidneys are diaphragm and quadratus lumborum, overlapping medially on Psoas and
laterally on to transversus abdominis.
 Upper poles lie on fibres of diaphragm arising from lateral and medi arcuate ligaments.

32
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 A small triangular part of Costodiaphragmatic recess of the pleura is at risk in lumbar approach to the kidney.
 Subcostal vein, artery and nerve emerging beneath lateral arcuate ligament lie behind the kidney as do iliohypogastric
and ilioinguinal nerves.
 Hilum lies over Psoas and the convexity lies on the aponeurosis of origin of transversus abdominis.
 Suprarenal gland overlap a small part of anterior surface.
 Rest of upper halves of rest of each kidney lie in contact with peritoneum. On the right is peritoneum of hepatorenal
pouch and on left is peritoneum of lesser sac medially and greater sac laterally.
 Hilum is separated from peritoneum on right by 2nd part of duodenum and on left by body of pancreas and splenic
vessels.
 Lateral part of lower pole is separated from peritoneum by hepatic and splenic flexures.
 Medial part of the lower pole on each side lie in contact with peritoneum separating it from coils of jejunum.
 Between peritoneum and kidney are ascending branches of right sand left colic arteries.
 Renal fascia restrains extension of perinephric abscess.
 Fascial septum separates kidney and Suprarenal gland.
 At lateral renal border the anterior and posterior layers fuse.
 Renal fascia is attached to renal vessels at hilum.
 Renal fascia fades into into extraperitoneal tissue around ureter.
Renal pelvis
 Usually the most posterior of the 3 main structures in the hilum.
 Capacity of average pelvis is less than 5ml.
Blood supply and segments
 Renal arteries leave abdominal aorta at right angles and lie behind the pancreas and renal veins.
 Each kidney posses 5 segments based on blood supply.
 Posterior division of RA supplies posterior segment while anterior give branches that supply apical, upper, middle and
lower segments.
 There's no collateral circulation between the five segments.
 Abnormal renal arteries are not usually accompanied by veins.
Lymph drainage
 Lymphatics drain to para-aortic nodes at level of renal arteries origin (L2)

Nerve supply
 Sympathetic preganglionic cells lie in spinal cord from T12 to L1 segment.
 Afferent fibres including those subserving pain accompany sympathetic nerves.
 Some afferents may possibly run with vagal.
URETERS
 The ureter is 25cm long.
 Narrowest point is pelviureteric junction where it crosses pelvic brim.
 It passes down on Psoas major in front of genitofemoral nerve being crossed anteriorly by gonadal vessels.
 On right the upper part is behind 3rd part of duodenum while lower down it's crossed anteriorly by right colic and
ileocolic vessels and root of mesentery.
 On left it is lateral to inferior mesenteric vessels and is crossed anteriorly by left colic vessels, and at pelvic brim by
apex of sigmoid mesocolon.
 Leaves psoas muscle at bifurcation of common iliac artery over sacroiliac joint.
 It is a whitish nonpulsatile cord which shows peristaltic activity when gently pitched.
Surface marking
 Tip of 9th coastal cartilage to bifurcation of common iliac artery on anterior abdominal wall.
 It lies medial to the tips of transverse processes of the lumbar vertebrae.
Blood supply
 Upper part is supplied by ureteric branch of renal artery

33
 APOSTLE JOHN'S SMART ANATOMY PREVIEW

 Lower end is by branches from inferior and superior vesical and uterine arteries.
Lymph drainage
 Abdominal portion drain into para-aortic nodes.
 Pelvic portion drains into common iliac and internal iliac nodes.
Nerve supply
 Sympathetic fibres is from T10 to L1. They reach the cord via coeliac and hypogastric plexuses.
 Parasympathetic fibres are from pelvic splanchnic nerves.
 Pain fibres accompany sympathetic nerves same with kidney.
SUPRARENAL GLANDS
 They lie anterosuperior to upper part of each kidney.
Right Suprarenal gland
 Pyramidal in shape.
 Lies on diaphragm and encroaches on front of the right kidney.
 Anterior surface is overlapped medially by IVC.
 Rest of anterior surface is in contact above with bare area of liver.
Left Suprarenal gland
 Crescentic in shape.
 Drapes over medial border of left kidney above the hilum.
 It lies on left crus of diaphragm and overlaps the front of left kidney.
 Upper part of anterior surface is covered by peritoneum of posterior wall of lesser sac
 Lower part is in contact with body of pancreas and the splenic vessels.
Blood supply
 There's usually a single vein.
 The left vein is longer and enters left renal vein.

34