Retroperitonium

Yosef Tadesse
Outline
• Introduction
• Urinary System
– Kidneys
– Urinary bladder
– Ureters
• Neurovasculature
– Abdominal aorta
– Inferior Vena Cava
– Lymphatics
– Lumbar plexus
• Posterior abdominal wall
Introduction
• Retroperitonium is a region behind the
peritoneal cavity on posterior abdominal wall
• Viscera
– Urinary organs: kidneys and ureters
– Endocrine organ: suprarenal gland
• Blood vessels: aorta and inferior vena cava
• Nerves: lumbar plexus and ANS
• Lymphatics
The Urinary System
 Functions of the Urinary System
• Filtration of the blood
– Occurs in the glomerulus of the kidney nephron
– Contributes to homeostasis by removing toxins or
waste
• Reabsorption of vital nutrients, ions and water
– Occurs in most parts of the kidney nephron
– Contributes to homeostasis by conserving important
materials
• Secretion of excess materials
– Assists filtration in removing material from the blood
– Contributes to homeostasis by preventing a build-up of
certain materials in the body such as drugs, waste,
etc.
• Activation of Vitamin D
– Vitamin D made in the skin is converted to Vitamin D3 by
the kidney
– Active Vitamin D (D3) assists homeostasis by increasing
calcium absorption from the digestive tract
• Release of Erythropoietin by the kidney
– Erythropoietin stimulates new RBC production
• Release of Renin by the kidney
– Renin stimulates the formation of a powerful
vasoconstrictor called Angiotensin II
• Release of Prostaglandins
– Prostaglandins dilate kidney blood vessels
– Dilated blood vessels contribute to homeostasis by
maintaining blood flow in the kidneys
• Secretion of H+ and reabsorption of HCO3-
– Eliminates excess hydrogen ions and conserves buffer
material such as bicarbonate
– Contributes to homeostasis by controlling acid/base
conditions in body fluids
Organs of Urinary System

• Kidneys
• Urinary
bladder
• Ureters
• Urethra
Kidneys
Location
• Each kidney lies in paravertebral grooves on
posterior abdominal wall retroperitoneally
• The kidneys extend from the level of the T12
to L3
• They receive some protection from ribs
 Position

• The kidneys are retroperitoneal, or behind the

peritoneum
 Kidney: Location

• The right lies

somewhat lower
than left as it is
positioned under
liver
 Relations
• Posterior:
– Muscles: diaphragm, psoas major, quadratus lumborum
and the origin of the transversus abdominis from
medial to lateral
– Nerves: subcostal, iliohypogastric and ilioinguinal
nerves
• Anterior:
– Right kidney
• Superior pole: liver, suprarenal gland
• Hilum: duodenum
• Inferior pole: part of small intestine, right colic
flexure
– Left kidney
• Suprarenal gland, stomach, spleen, pancreas,
jejunum, descending colon
External Anatomy

• The adult kidney weighs about 150 g

• Size: 12 cm long, 6 cm wide, 3 cm thick
• Color: reddish-brown
• Shape: bean-shaped
• The lateral surface of each kidney is convex,
while the medial is concave
External Anatomy

• Atop each kidney is an adrenal gland

• Medial surface has a vertical cleft called the
renal hilus that leads into the space within the
kidney called the renal sinus
• Ureters, renal blood vessels, lymphatics, and
nerves enter the kidney at the hilus
• These structures occupy the renal sinus
 Supportive tissue
• Kidneys are supported by three layers of supportive
tissue
• Renal capsule
– outer membrane that encloses, supports and protects
the kidney
– adheres directly to the kidney surface and isolates it
from surrounding region
• Adipose capsule
– Immediately outside the renal capsule, there is an
accumulation of extraperitoneal fat-the perinephric
fat (perirenal fat), which completely surrounds the
kidney
– attaches the kidney to the posterior body wall and
cushions it against trauma
• Renal fascia
– Enclosing the perinephric fat is a membranous
condensation of the extraperitoneal fascia (the
renal fascia)
– The suprarenal glands are also enclosed in this
fascial compartment, usually separated from the
kidneys by a thin septum
– dense fibrous connective tissue which surrounds
the kidney and anchors these organs to the
surrounding structures
• In addition to perinephric fat and the renal fascia, a
final layer of paranephric fat (pararenal fat)
completes the fat and fascias associated with the
kidney. This fat accumulates posterior and
posterolateral to each kidney.
 Internal Anatomy

• The kidney has

three distinct
regions
– Cortex
– Medulla
– Pelvis
Internal Anatomy: Cortex

• The outer layer of the kidney

• Light in color and has a granular appearance
• Contains most of the nephron; main site for
filtration, reabsorption and secretion
 Internal Anatomy: renal medulla
• Deep to the cortex; inner core of the kidney
• Darker tissue which exhibits cone shaped tissue masses
called medullary or renal pyramids
• Contains the pyramids, columns, papillae, and parts of the
nephron
• Used for salt, water and urea absorption
• Renal pyramid
– Each renal pyramid has a base which is convex, and an
apex which tapers toward its papilla
– Triangular units in the medulla that house the loops
of Henle and collecting ducts of the nephron
– The pyramids appear striped because they are formed
almost entirely of roughly parallel bundles of urine
collecting tubules
• Renal Papilla
– The tip of the renal pyramid that releases
urine into a calyx
• Inward extensions of cortical tissue called
renal columns separate the pyramids
• Each medullary pyramid is surrounded by a
capsule of cortical tissue to form a lobe
 Internal Anatomy: renal pelvis
• Within the renal sinus is the renal pelvis
• This flat, funnel shaped tube is continuous with the
ureter leaving the hilus
• Branching extensions of the renal pelvis form 2-3 major
calyces, each of which sub-divides to form several minor
calyces
• Calyx
– A collecting sac surrounding the renal papilla
– transports urine from the papilla to the renal pelvis
• Renal pelvis collects urine from all of the calyces
• Urine flows through the renal pelvis into the ureter,
which transports it to the bladder
• The walls of the calyces, pelvis, and ureter contain
smooth muscle which contract to move urine
Blood Supply
• Kidneys possess an extensive blood supply
– Under normal resting conditions, the renal arteries
deliver approximately one-fourth of the total systemic
cardiac output (1200 ml) to the kidneys each minute
Renal artery
• A single large renal artery, a lateral branch of the
abdominal aorta, supplies each kidney
– arise just inferior to the origin of the superior
mesenteric artery between vertebrae L1 and L2
– The left renal artery usually arises a little higher than
the right, and the right renal artery is longer and
passes posterior to the inferior vena cava
• Accessory renal arteries are common
– They originate from the lateral aspect of the abdominal
aorta, either above or below the primary renal arteries,
enter the hilum with the primary arteries or pass
directly into the kidney at some other level, and are
commonly called extrahilar arteries.
Segmental arteries
• Each renal artery divides close to the hilum into five
segmental arteries that are end arteries (i.e., they do
not anastomose significantly with other segmental
arteries, so that the area supplied by each segmental
artery is an independent, surgically resectable unit or
renal segment)
• Segmental arteries are distributed to the renal
segments:
–The superior (apical) segment is supplied by the superior
(apical) segmental artery; the anterosuperior and
anteroinferior segments are supplied by the anterosuperior
segmental and anteroinferior segmental arteries; and the
inferior segment is supplied by the inferior segmental
artery. These arteries originate from the anterior branch of
the renal artery.
–The posterior segmental artery, which originates from a
continuation of the posterior branch of the renal artery,
supplies the posterior segment of the kidney.
• The segmental arteries branches into
lobar and then interlobar arteries, which
pass through the renal columns toward
the cortex
• Interlobar arteries then form arcuate
arteries
• Arcuate arteries branch into the cortex
and lead to interlobular arteries which
distribute the blood evenly throughout
the cortex to the afferent arterioles
which serve the nephrons
• Blood flow leaving the nephrons returns
by veins of the corresponding names
Renal veins
• Several renal veins drain each kidney and
unite in a variable fashion to form the right
and left renal veins
• The right and left renal veins lie anterior to
the right and left renal arteries
• The longer left renal vein receives the left
suprarenal vein, the left gonadal (testicular or
ovarian) vein, and a communication with the
ascending lumbar vein
• Importantly, the longer left renal vein
crosses the midline anterior to the abdominal
aorta and posterior to the superior
mesenteric artery and can be compressed by
an aneurysm in either of these two vessels
• Each renal vein drains into the IVC
Lymphatic drainage and Innervation of kidneys

• Lymph vessels follow renal veins and drain into

lumbar lymph nodes

• Nerve supply is from renal plexus (lesser and

lower splanchnic nerves)
 Ureters
• Thick walled muscular duct with narrow lumina
• Carry urine from kidneys to urinary bladder
• It measures 25cm
• Each leaves the renal pelvis, descends behind the
peritoneum to the base of the bladder, turns and then
runs obliquely through the medial bladder wall
• Abdominal part
– Runs down anterior to the psoas major,
retroperitoneally
– Right ureter lies closely related to inferior vena
cava, lumbar lymph nodes and sympathetic trunk
– Inferiorly, testicular or ovarian vessels cross over
the ureter
– Crosses pelvic brim and external iliac artery just
beyond bifurcation of common iliac arteries
• Pelvic part
– Course posteroinferiorly on lateral wall of
pelvis anterior to internal iliac arteries
– At base of urinary bladder curve medially
superior to levator ani
– In the male ductus deferens lies between
ureter and peritoneum
– In the female uterine artery crosses
superiorly at lateral portion of fornix of
vagina
– Enters posterosuperior angle of bladder,
passes obliquely through bladder wall, opening
has no anatomical valve
• The ureters are protected from a backflow of
urine because any increase within the bladder
compresses and closes the ends of the ureters
• The ureters play an active role in transporting
urine
• Distension of the ureters by incoming urine
stimulates the muscularis layer to contract,
which propels the urine into the bladder
• The strength and frequency of peristaltic waves
are adjusted to the rate of urine formation
 Obstruction of ureter
• Obstruction results from ureteric calculus
(kidney stones)
• Ureters dilate if obstructed
– Excessive distension causes severe pain –
ureteric colic, results from hyperperistalsis
in ureter
• Causes complete or intermittent obstruction
of urinary flow
• Occur any where along ureter, but often in the
3 narrow regions
– at the junction with the pelvis of the kidney
– where it crosses the brim of the pelvic bone
– as it enters the bladder
• Arterial supply: It is well supplied by the
renal artery, aorta, gonadal arteries and
various pelvic vessels.
• Venous drainage: Testicular/ovarian veins
• Lymphatic drainage: aortic, common iliac,
external iliac and internal iliac lymph nodes
• Innervation: renal, testicular/ovarian,
inferior hypogastric plexus
Suprarenal glands
• Pair of ductless glands on the upper poles of each kidneys
• Right suprarenal
– Triangular, partly covered with peritoneum
– Relations
• Posteriorly – diaphragm
• Postero-inferiorly – right kidney
• Anteriorly – liver and inferior vena cava
• Medial border- celiac ganglion
• Left suprarenal
– Semilunar, partly covered with peritoneum of the lesser sac
– Relations
• Posteriorly – diaphragm
• Anteriorly – stomach ( forms stomach bed) separated by
lesser sac
• Postero-inferiorly - left kidney
• Medial border- celiac ganglion
Neurovasculature
• Arterial supply
Superior suprarenal arteries - from phrenic
artery
Middle suprarenal arteries - from abdominal
aorta
Inferior suprarenal arteries - from renal
artery
• Veins – single vein from each
Left – drains into left renal vein
Right- directly into IVC
• Nerve supply
Sympathetic preganglionic from splanchnic
nerves, reach through celiac & renal plexuses
General structures
• Thick CT capsule
– bringing arteries to serve radial capillaries draining
down towards the venules and central vein of the
medulla
– Arterioles also penetrate the cortex to serve a
medullary capillary bed
• Cortex
– Polyhedral glandular cells, in cords usually two cells
wide, run roughly radially, along with sinusoidal
capillaries
• Medulla
– thin strip of basophilic cells
• Embryologically and functionally distinct
– Mesodermal cells of coelomic mesothelium
differentiate into cortex
– Neural crest form the medulla
Neurovasculature
 Abdominal aorta
Location
• Continuation of thoracic aorta
• Lies in the midline against vertebral bodies
• It enters the abdomen through aortic hiatus at T12 and
L1 level
• Ends at L4, left of the midline by dividing into the 2
common iliac arteries
• The main continuation of the aorta is the median or middle
sacral artery
Relations
• Superior: diaphragm
• Anterior: celiac trunk and plexus, pancreas, left renal vein, duodenum,
mesentry
• Posterior: bodies of L1-L4 vertebrae, cisterna chili
• Lateral: inferior vena cava (right), left celiac ganglion, sympathetic
trunk
Abdominal aorta: Branches
• Subdivided into groups of 4:
– 3 unpaired visceral
– paired visceral
– paired parietal
– unpaired parietal
• Inferior phrenic: T12
• Celiac trunk: T12
• SMA: L1
• Renal: L1
• Gonadals: L2
• IMA: L3
• Bifurcation: L4
 Unpaired visceral branches
• Ventral branches; arise from anterior surface
– arteries to the fore-, mid- and hindgut respectively
• celiac trunk
• superior mesenteric
• inferior mesenteric
• Celiac trunk
– Foregut - esophagus to second part of duodenum
• Superior mesenteric
– Midgut - second part of duodenum to distal 1/3
transverse colon
• Inferior mesenteric
– Hindgut - distal 1/3 transverse colon to upper 2/3
of rectum
Paired visceral branches
• Arise from sides; lateral branches
• Supply suprarenal glands, kidneys and gonads
• Renal arteries
– Arise just below the superior mesenteric artery
– The right renal artery passes posterior to the inferior
vena cava
– They also send branches to the suprarenal glands and
the renal pelvis
– Pass to hilum of kidney between ureter and renal vein
• Gonadal (ovarian or testicular) arteries
– Arise from the aorta just below the renal arteries
– Descend lying anterior to the surface of the psoas to
reach the ovary or pass into the inguinal canal to go to
the scrotum
• Middle suprarenal arteries
– Arise near the origin of SMA
Paired parietal branches
• Arise from posterolateral surface
• Are branches to the body wall
• The inferior phrenic arteries
– Gives branch to the suprarenal gland and
ramify on the inferior surface of the
diaphragm
• The 4 lumbar arteries
– gives a posterior branch going through the
back and giving a spinal branch
– The anterior branch runs in the anterior
abdominal wall between the transversus and
the internal oblique muscle
Unpaired parietal branch
• Arise from posterior surface
• The median (middle) sacral artery
– in the midline, anterior to the sacrum
– from bifurcation of aorta
 Inferior Vena Cava
• Returns blood from lower limbs, abdominal wall and
abdominopelvic viscera
• Begins in front of the body of L5 by union of common
iliac veins
• Ascends, on right psoas muscle right to aorta, to the
diaphragm
• Pierce the central tendon at T8 forming vena caval
foramen
• Relations
– posterior: bodies of L3-L5, right psoas major muscle, right
sympathetic trunk, right renal artery, right suprarenal
gland
– anterior: superior mesenteric vessels, head of pancreas,
duodenum
– lateral: aorta (left), right ureter and kidney (right)
Tributaries
• Ventral tributary: right testicular or ovarian
vein
• Lateral tributaries: renal and right suprarenal
and hepatic veins
• Correspond to the named arteries except
on the left where the suprarenal and
gonadal veins open into the left renal vein
• Tributaries from the body wall: the inferior
phrenic and lumbar veins
• the median sacral opens into the left
common iliac vein
67
Lymphatics
• Lymphatic drainage from all structures and regions
of the body below the diaphragm converges on
collections of lymph nodes and vessels associated
with the major vessels of the posterior abdominal
region
• Lymph from the lower limb and perineum passes
upward to the collection of nodes and vessels
associated with the external iliac artery and vein
• It continues its upward journey to lymph nodes and
vessels around the common iliac artery and vein
• At this point, it is joined by lymph from the pelvic
cavity that has passed through nodes and vessels
associated with the internal iliac artery and vein.
• Approaching the aortic bifurcation, the collections
of lymphatics associated with the two common iliac
arteries and veins merge, and multiple groups of
lymphatic vessels and nodes associated with the
abdominal aorta and inferior vena cava pass
superiorly
• These collections may be subdivided into pre-aortic
nodes, which are anterior to the abdominal aorta,
and right and left lateral aortic or lumbar nodes,
which are positioned on either side of the abdominal
aorta
• As these collections of lymphatics pass through
the posterior abdominal region, they continue to
collect lymph from a variety of structures
• The lateral aortic or lumbar lymph nodes receive
lymphatics from the body wall, the kidneys, the
suprarenal glands, and the testes or ovaries
• The pre-aortic nodes are organized around the
three anterior branches of the abdominal aorta
that supply the abdominal part of the
gastrointestinal tract, as well as the spleen,
pancreas, gallbladder, and liver
• They are divided into celiac, superior mesenteric,
and inferior mesenteric nodes, and receive lymph
from the organs supplied by the similarly named
arteries
• Finally, the lateral aortic or lumbar nodes
form the right and left lumbar trunks,
while the pre-aortic nodes form the
intestinal trunk
• These trunks come together and form a
confluence that, at times, appears as a
saccular dilation (the cisterna chyli)
• This confluence of lymph trunks is
posterior to the right side of the abdominal
aorta and anterior to the bodies of
vertebrae LI and LII
• It marks the beginning of the thoracic duct
Lumbar plexus
• Lies in the psoas major
• Formed by the anterior primary rami of L1, 2, 3,
and 4
• The sacral plexus is from L4, 5, S1, 2, 3 and 4
• L4 is also called the nervus furcalis or
lumbosacral trunk because it splits itself
between the lumbar and sacral plexuses
• The sacral and lumbar plexuses overlap
substantially
• Since many of the fibers of the lumbar plexus
contribute to the sacral plexus via the
lumbosacral trunk, the two plexuses are often
referred to as the lumbosacral plexus
Branches
• Its proximal branches innervate parts of the
abdominal wall and iliopsoas
• Major branches of the plexus descend to
innervate the medial and anterior thigh
• Branches
– Iliohypogastric nerve
– Ilioinguinal nerve
– Genitofemoral nerve
– Lateral cutaneous nerve of the thigh
– Femoral nerve
– Obturator nerve
 Branches
• Iliohypogastric nerve
– Supply skin of inguinal region
• Ilioinguinal
– This runs between the layers of the anterior
abdominal wall
– emerges from the superficial inguinal ring
– supplies the skin on the medial side of the
thigh and the scrotum or labium majus
• Genitofemoral nerve
– emerges from the anterior surface of the
psoas major
– runs down deep to the psoas fascia
– supplies cremaster muscle via its genital branch
and a small area under the inguinal ligament by
its femoral branch
• Lateral cutaneous nerve of the thigh
– emerges from the lateral border of the psoas
– sweeps around the iliac fossa and leaves the abdomen
by passing under the inguinal ligament
• Femoral nerve
– large and emerges from the lateral border of psoas
– may give branches to psoas and iliacus
– It lies outside of the fascia covering psoas and iliacus
• Obturator nerve
– emerges from the medial border of the psoas near
the brim of the pelvis
– lying posterior to the common iliac vessels
– It then travels anteriorly and inferiorly, anterior to
obturator internus and leaves the pelvis by passing
through the superior part of the obturator foramen
The autonomic nervous system in the abdomen
• The paravertebral chain of ganglia
– found along the anterior border of the psoas
– White rami from the first 2 lumbar nerves pass to
the ganglia and all ganglia have gray fibers passing
back to the lumbar nerves
• Celiac ganglia and plexuses
– lie around the celiac and mesenteric arteries
– Plexuses are joined by the 3 splanchnic nerves, branches of the
vagus nerves (parasympathetic) and branches from the
sympathetic trunk
– Postganglionic sympathetic fibers from plexuses travel with all
the major arteries, along with preganglionic parasympathetic
fibers to innervate viscera
• Plexuses around the aorta continue downward and
anterior to the aortic bifurcation forms the superior
hypogastric plexus
– This divides into the right and left inferior hypogastric plexuses
joined by the parasympathetic pelvic splanchnic nerves (S2,3,4)
The posterior abdominal wall
Introduction
• The posterior abdominal wall consists
• Bones
– lumbar vertebrae
– sacrum
– ilium
• Muscles
– Psoas
– quadratus lumborum
– transversus abdominis muscle
– posterior part of the diaphragm and its crura
• The parietal peritoneum covers the posterior
abdominal wall along with the retroperitoneal
organs
– duodenum and the kidneys lying on the vertebrae
and muscles
Bones
Muscles

• Psoas major
– arises from the transverse processes and sides of
the bodies and intervertebral discs of the 5 lumbar
vertebrae
– passes with iliacus (Iliacus arises from the inner
surface of ilium) under the inguinal ligament
– insert in to the lesser trochanter fusing with iliacus
(iliopsoas)
– innervated by L1, 2 and 3 inside the abdomen
– flexes the hip joint
– Because the muscle fills in the angle between the
transverse processes and the sides of the bodies of
the vertebrae, it covers the intervertebral foramina
– The lumbar plexus thus enters the psoas major and
its branches emerge from the surface of the muscle
Iliacus
• Origin - iliac
fossa
• Insertion -
lesser
trochanter of
femur
• Action - hip
flexion
Iliopsoas
• Iliacus and psoas muscle
• Covered by dense layer of fascia so that
muscles and lumbar plexus are behind
fascia and iliac vessels are in front of it
Psoas minor
• An occasional small
muscle belly with its
long tendon lying over
the psoas major
• Origin - transverse
processes and bodies
of T12 and L1
• Insertion - rim of
acetabulum
• Action - flexes lumbar
vertebrae
Quadratus lumborum
• Lies lateral to psoas, running between
the iliac crest and R12
• It is a side flexor of the trunk
• Innervated segmentally by the adjacent
lumbar nerves