THE ABDOMINAL CAVITY AND

ABDOMINAL VISCERA

• The abdominal cavity proper contains

abdominal viscera (organs)
• two groups with respect to their relation to
the peritoneum.
 Intra-Peritoneal Organs
• Organs almost completely enclosed by
peritoneum.
• the Stomach, Liver, Gall Bladder, Transverse
Colon, Jejunum, Ileum, and Cecum (very start
of ascending colon).
 Retro-Peritoneal Organs
• are organs that are located mostly or
completely behind the posterior parietal
peritoneum.
• Duodenum, Ascending Colon (only 25-50%
covered), Descending Colon (only 25-50%
covered), Pancreas and Kidneys.
INTRODUCTION ABDOMINAL ORGANS
ACCORDING TO THE GUTS

Embryological GIT were developed from primitive

gut (has 3 region)
 Fore gut
 Mid gut
 Hind gut
 FOREGUT
• STRUCTURES: GIT up to major duodenal papilla of 2nd part of
duodenum, Gall Bladder and Pancreas.
• ARTERIAL SUPPLY: Branches of the Celiac Trunk.
• LYMPHATIC SUPPLY: Branches of the Celiac Nodes.
• REFERRED PAIN: Occurs in the Epigastric Region.
• VENOUS RETURN: The portal vein.
• INNERVATION:
Parasympathetic:- From Vagus nerve (C10). It is perivascular and
Sympathetic:- Greater Thoracic Splanchnic Nerves (T6-T10).
 MIDGUT
• STRUCTURES: terminal region of 2nd part , Third and fourth parts of duodenum,
Jejunum, Ilium, cecum, Ascending Colon and First 2/3 of Transverse Colon.

• ARTERIAL SUPPLY:- Branches of the Superior Mesenteric Artery;

• LYMPHATIC SUPPLY: Branches of the Superior Mesenteric Nodes.

• REFERRED PAIN: Occurs in the Umbilical Region.

• VENOUS RETURN: The Superior Mesenteric Vein.

• INNERVATION:
Parasympathetic: From Vagus nerve (C10). It is perivascular
Sympathetic: From the Lesser Thoracic Splanchnic (T9-T11)
 HINDGUT
• STRUCTURES: Distal 1/3 of Transverse Colon, Descending Colon, Sigmoid
Colon, Rectum and Upper portion of anal canal.

• ARTERIAL VASCULAR SUPPLY; Branches of the Inferior Mesenteric Artery

• VENOUS RETURN:- The Inferior Mesenteric Vein.
• LYMPHATIC SUPPLY: Branches of the Inferior Mesenteric Nodes.
Exception: The upper and lower rectum goes to the Right and Left Common
Iliac nodes, which then drains straight to the Lumbar Chain Nodes, and then
to Thoracic Duct.

• REFERRED PAIN:- Occurs in the Hypogastric (Suprapubic) region.

• INNERVATION:-
Parasympathetic: From Pelvic Splanchnic Nerves (S2-S4) and
Sympathetic: From the Upper Lumbar Splanchnic (L1-L2)
 NVB OF ABDOMINAL CAVITY
• From DESCENDING ABDOMINAL AORTA
• three unpaired (single visceral) branches
from its anterior aspect to the fore gut, mid
gut and hind gut.
• Celiac Trunk (an artery)
• Superior Mesenteric Artery
• Inferior Mesenteric Artery
 passes through esophageal hiatus
 1 inch long
 inter to cardia of the stomach
 Esophagogastric junction ( Z line) lies to the left of the
T11 vertebra on the horizontal plane that passes
through the tip of the xiphoid process
 The esophagus is attached to the margins of the
esophageal hiatus in the diaphragm by the
phrenicoesophageal ligament.
 Neurovascular structures
aa
 Esophageal branch of left gastric artery
 left inferior phrenic artery
Vv
 submucosal veins of this part of the esophagus is
both to the portal venous system through the left
gastric vein and into the systemic venous system
through esophageal veins entering the azygos vein.
Lym:- to celiac lymph nodes.
Nerve : esophageal nerve plexus.
 Esophageal Varices
• Because the submucosal veins
• In portal hypertension (an
abnormally increased blood
pressure in the portal venous
system), blood is unable to pass
through the liver via the portal
vein.
• This causing a reversal of flow
in the esophageal tributary.
• The large volume of blood
causes the submucosal veins to
enlarge markedly, forming
esophageal varices.
• J-shaped muscular organ
• Found epigastric, umbilical and left
hypochondriac regions.
• Function as food blender and reservoir
• chief function is enzymatic digestion.
• The gastric juice gradually converts a mass of
food into a semiliquid mixture, chyme
 Cont…
• Empty stomach is not more wider than large intestine.
• But it can expand considerably, accommodate 2-3 liter
in adult and up to 30ml in infants.
it has two curvatures
• greater curvature: Long and convexgreater
omentum.
• lesser curvature : shorter and concave lesser
omentum.
in the two third distance along lesser curvature there is
sharp indentation that indicates junction of body part
with pylorus is called angular inciser or notch
Parts stomach
Cont…
 Cardia
 Fundus
 body
 pylorus
Initial dilated part is p.
antrum
Narrow part is p.canal
Thicked circular smooth
muscle is p.
sphincter.
• mucous membrane of the stomach is thick
and vascular
• it is thrown into folds: gastric fold or rugae
• flatten out when the stomach is distended
• increase the surface area of the mucous
membrane without increase in space
occupied.
• Gastric canal is furrow which is made by
mucosal fold around lesser curvature.
Relation of stomach
 Left and right
gastric arteries
 Right and left
gastroepiploic
arteries
 Short gastric
arteries(4-5)
 Posterior gastric
artery
 veins
• Veins into the portal vein, either directly or indirectly via the splenic or
superior mesenteric vein (SMV)
 gastric lymphatic vessels
• It drain lymph from
its anterior and
posterior surfaces.
• toward its node
around curvatures
along with arteries.
• The efferent vessels
from these nodes
accompany the
large arteries to the
celiac lymph nodes.
 Hiatal Hernia
• protrusion of a part of
the stomach into the
mediastinum through
the esophageal hiatus
two main types
• paraesophageal hiatal
hernia
• sliding hiatal hernia.
 Gastric Ulcers and Vagotomy
• Gastric ulcers are open lesions
of the mucosa of the stomach
• often have high gastric acid
secretion
• Most ulcers are associated with
Helicobacter pylori (H. pylori)
infection.
• secretion of acid by parietal
cells is controlled by the vagus
nerves.
• So vagotomy is performed in
some people with chronic or
recurring ulcers
 Visceral Referred Pain
• Organic pain is poorly localized
• It radiates to the dermatome level
Example: stomach is supplied by pain afferents that reach the T7
and T8 which pass through dorsal root ganglia with
dermatome level around epigastric region, so brain interprets
the pain as it come from skin around this region.
o 1st , shortest, widest and the most fixed part.
o Pylorus to the duodenojejunal flexure
o C-shaped part of the intestine
o Curves around the head of pancreas
o Almost entirely retroperitoneal except the
initial portion 1st part (ampula or duodenal
cap)
1st , superior part (5cm)
 Proximal part is intraperitonial
2nd , descending part (7-10cm)
 bile and main pancreatic ducts enter through major duodenal papilla
via hepatopancreatic ampulla
3rd , horizontal part (6-8cm)
 crossed by the superior mesenteric vessels and the root of the
mesentery anteriorly
 Cross over the 3rd lumbar vertebra
4th , ascending part (5cm)
 attached with diaphragm by suspensory ligament of the duodenum
(ligament of Treitz).
 Bend anteriorly to form duodenojejunal flexure
WWW.SMSO.NET
Relation of duodenum
• Is from foregut
and mid gut.
– Superior
pancreaticoduodenal
artery from gastro
duodenal artery
– Inferior
pancreaticoduodenal
artery from superior
mesenteric artery
Veins drainage
- follow arteries,
- To portal vein directly
or indirectly through
superior mesenteric
and splenic veins
 Paraduodenal Hernias
• There are two or three
inconstant folds and
fossae (recesses) around
the duodenojejunal
junction
• fold and fossa are large
and lie to the left of the
ascending part of the
duodenum.
• If a loop of intestine
enters this fossa, it may
strangulate.
• 2nd part of the small intestine is jejunum, begins
at the duodenojejunal flexure where it resume
to intraperitoneal course.
• 3rd part of the small intestine, the ileum, ends at
the ileocecal junction
• Both derived from endoderm of mid gut so
supplied with superior mesenteric artery.
• No sharp junction can be observed grossly
between the jejunum and the ileum.
• Then what is good to demarcate ?
Feature Jejunum Ileum

1. Location Upper & left part , Lower & right part

proximal 2/5th Distal 3/5th

2. Walls Thicker & more Thinner & less

vascular Vascular

3. Lumen Wider & often empty Narrower & often

loaded

4. Mesentry - fat less abundant - fat more abundant

- arterial arcades 1-2 - arterial arcades 3-6
vasa recta longer & vasa recta shorter
& numerous
fewer
5.circular mucosal larger & more smaller & sparse
folds closely set

6.villi Large, thick ( leaf like) Shorter , thinner

& more abundant ( finger like) & less
abundant

7. Peyer’s patches absent Present

8. solitary fewer numerous

lymphatic follicles
IdentifyJ&I
 Arterial supply
• superior mesentric artery(15-18 branches)
vv.(superior mesenteric vein )
Lymphatic drainage
 lymphatic vessels in the
intestinal villi is lacteals
which drain to lymph in wall
of intestine
 lacteals drain in turn into
lymphatic vessels between
the layers of the mesentery
 Juxta-intestinal lymph
nodes: located close to the
intestinal wall.
 Mesenteric lymph
nodes: scattered among the
arterial arcades.
 Superior central nodes:
located along the proximal
part of the SMA
 Nerve supply
superior
mesenteric
nerve plexus
• sympathetic -
T8- T10
segments
• parasympathetic
- posterior vagal
trunks
 Caliber: diameter is much larger
 absence of villi
 widely dispersed mucosal folds( semilunar)
 more lymphatic tissues
 Is cul-de-sac
 below the opening of the
ileum into the colon
(ileoceal orofice)
 lies in the right iliac fossa
 bound to the lateral
abdominal wall by one or
more cecal folds of
peritonium.
 Interperitonial but has no
mesentry.
 The valve prevent reflux
from the cecum into the
ileum
Cont..
• A diverticulum of
cecum, about 2cm
below the ileocecal
opening
• short triangular
mesentery, the
mesoappendix
• 6-10cm long
• contains masses of
lymphoid tissue
• Normal ( most incident)
 Retrocecal = 64 %
 Pelvic = 32%
• Abnormal ( least
incident)
 Subceacal = 2%
 Preileal= 1%
 Postileal= 0.5%
AA.
 ileocolic artery, the terminal branch of the SMA for ceacum
 appendicular artery, branch of ileocolic artery for appendix
LL.
 Drains to lymph nodes in the mesoappendix and ileocolic lymph
node then into superior mesenteric lymph node.
N.
 Sympathetic(lower thoracic part of the spinal cord) and
 parasympathetic nerves (vagus)
 Afferent nerve fibers from the appendix accompany the
sympathetic nerves to the T10 segment of the spinal cord
 Appendicitis
• Acute inflammation of the appendix is a
common cause of an acute abdomen
• occludes the lumen and swell
• vague pain in the periumbilical region
• Later, severe pain in the right lower quadrant
Appendectomy- surgical removal of appendix
Ascending colon Descending colon
• Cecum to hepatic • Splenic flexure to
flexure sigmoid
• Runs upward , on right • Runs downward, on
• Retroperitoneal left
• mid gut • Retroperitoneal
• Supplied by right colic • Hind gut
aa. and right branch of • Supplied by left colic
middle colic aa. aa.
Transverse colon
• Hepatic flexure to splenic
flexure
• Runs almost horizontally
• Intraperitoneal
(transverse mesocolon)
• Mid gut (proximal 2/3)
and Hind gut( distal 1/3)
sigmoid ( pelvic ) colon
• Descending colon to
rectum
• S-shaped course
• Intraperitoneal
(sigmoid mesocolon)
 Rectum and Anal Canal
• Fixed terminal part of
the large intestine
• continuous from the
sigmoid colon at the
level of S3 vertebra.
• rectum is continuous
inferiorly with the anal
canal
• Gets its blood supply
from inferior
mesenteric artery.
  Colic marginal artery

 Collateral circulation, if one is ligated.

• Is the largest lymphatic organ in the body.
• is a soft, ovoid, easily injured vascular & dark purple
organ
• lies against the diaphragm at the level between the
9th -11th rib
• On left hypochondriac region
• receives the protection of the lower thoracic cage.
• Can be Enlarged by about 10 times( splenomegally)
• Completely surrounded by peritoneum except at
hilum
 gastrosplenic (gastrolienal) ligament
 phrenicosplenic (phrenicolienal) ligament.
 splenorenal (lienorenal) ligament
- extends up to hilum and contain vascular
structures.
 Phrenicocolic ligament
• It has two surface and three borders or margins
• Notch characterizes the superior margin
• fibrous capsule covers spleen extending from it
is trabecule; carry blood vessels to and from
splenic pulp(parenchyma)
Internal part includes
• Red pulp
• White pulp
 Functions of the spleen

Filtration:- filters blood

Defence:-production of lymphocytes.
Storage: red blood corpuscles.
Cytopoiesis: 4th month, hemopoietic organ.
 Nvb, s
• aa: splenic artery and
branches(5); 2 of them
supply 84% and 3 supply
the rest leaving avascular
region in between
Therefore subtotal splenctomy
• vv: splenic vein-portal
vein
• Lln: pancraticosplenic
nodes celiac nodes
• Nn: from celiac nerve
plexus
 lies retroperitoneally in Umbilical, Epigastric,
and left hypochondriac regions.
 transversely across the posterior abdominal
wall
 posterior to the stomach
 between the duodenum on the right and the
spleen on the left
• Head
– lies within the curve of the duodenum
– uncinate process is a prolongation of the head.
– superior mesenteric vessels crosses this process
in front.
• neck
– A constricted portion to the left of the head
• Body
– The part between neck and tail.
 Cont..
Tail of pancreeas
– Runs in spleniorenal
ligament to reach hilum of
spleen
– Accompanies with splenic
vessels
– is relatively mobile
• main pancreatic duct
( duct of Wirsung)
• accessory pancreatic
duct ( Santorini` duct)
• Both have sphincter of
there own
• Mostly unit to form
hepatopancratic ducts
aa.
• Superior Pancreaticoduodenal Arteries (Anterior and Posterior):
branch of Gastroduodenal Artery, common hepatic from the Celiac
Trunk.
 supplies head
• Pancreatic branches come off the Splenic Artery, from the Celiac
Trunk.
 Supplies body and tail.
• inferior pancreaticoduodenal arteries (anterior and posterior)
 Head and uncinate process
Vv :- Mostly to splenic vein  portal vein
Lln :-SM and celiac lymph nodes  thoracic duct
Nn :- Sympathetic : abdominopelvic splanchnic nerves
parasympathetic: vagus nerves
– secretomotor, but pancreatic secretion is primarily mediated by
hormone secretin and cholecystokinin(CCK).
Cont..
Diabetes mellitus:
• Due to degeneration of the islets of
Langerhans
Pancreatitis
• serious inflammatory condition of the
exocrine pancreas (acinar parts)
Cancer of the head of the pancreas is many time
a fatal pathology because if tumors are
present in the head, bile flow will be
obstructed resulting in jaundice.
Liver (Hepar)
 Liver
• largest visceral organ and the largest gland in the body.
• weights about 1.5 kg
• wedge-shaped, redish brown in colour due to its
extreme vascularity.
• Location: entire right hypochondrium, most of
epigastrium and part of left hypochondrium.
 Function of the liver
• synthesis of bile salts, fatty acids and plasma proteins- like
globulins (e.g. immunoglobulines), albumins, clotting factors ,
complement component, heparin anticoagulants.
• Detoxification and inactivation of toxic substances.
• Storage of iron, glycogen and triglycerides.
• Formation of blood in foetus .
• Metabolism of CHO and proteins. Many of the metabolic
functions depend on the portal blood drained from the
alimentary canal.
Liver cells have a very high regeneration capacity. One third of
the liver is sufficient to maintain normal function but total
removal of the liver is fatal.
 Surfaces
• The superior or anterior-superior or diaphragmatic surface
which is related to the domes of the diaphragm.
• The inferior or posterio-inferior or visceral surface which is
related to the adjacent viscera and is irregular in shape.
• This surface are separated by superior and inferior border

• On its diaphragmatic surface there is a peritoneum free

area called “bare area” or area nuda of the liver that has a
direct contact to the diaphragm. The bare area or area nuda
is triangular in outline
• This surface is attached to the diaphragm by coronary,
triangular and faliciform ligaments.
Cont….
 On visceral surface
• covered with peritoneum , except at the fossa for the
gallbladder and the porta hepatis
• includes H-shaped group of fissures and ligaments.
• The liver-H is formed:
Left limb – by the fissure of the ligamentum teres hepatis anteriorly and the
fissure of the ligamentum venosum posteriorly.
Right limb – by the fossa of the gall bladder anteriorly and fissure of the
inferior vena cava posteriorly.
Horizontal part
– by the porta hepatis ; is a deep, transverse fissure
- It lies between the caudate lobe above & the quadrate lobe below and in
front.
- The portal vein, hepatic artery & the hepatic plexus of nerves enter the
liver through the porta hepatis, while the right & left hepatic ducts & a
few lymphatics leave it.
Cont..
 Visceral surface
• Has many
surface
impression
from adjacent
structure.
 Lobes
• anatomically into a larger right lobe
and a smaller left lobes demarcated
by the facliform ligament on
diaphragmatic surface and left
sagital fissure on visceral surface.

• divided functionally on the basis of

arterial supply and hepatic drainage
into the right and left lobes by an
imaginary line going between the
inferior vena cava (superior part)
and the gall bladder (inferior part)
called as cantlie line

• Liver divided into four division and

further to eight surgically resectable
segment.
 The Left lobe
• is demarcated from the caudate and quadrate lobes(accessory lobe)
by the fissure for the round ligament of the liver and the fissure for the
ligamentum venosum on the visceral surface.

• The round ligament (ligamentum teres) is the obliterated remains of

the left umbilical vein, which carried well oxygenated blood from the
placenta to the fetus.
• The ligamentum venosum is the fibrous remnant of the fetal ductus
venosus that shunted blood from the umbilican vein toe ht IVC, short
circulating the liver.
 The left lobe (segment)
• is divided into medial and lateral segments.
• Left of which is subdivided into superior and inferior areas or
segments.

• Thus the segments of the left lobe include posterior (caudate lobe),left
medial segment (quadrate lobe), lateral superior segment and lateral
inferior segment.

• That is, caudate and quadrate lobes are anatomically considered as

part of right lobe but functionally as left lobe.
 The right lobe
• is divided into medial and lateral
segments
• each in turn is subdivided into
superior(post.) and inferior(ant.)
areas or segements.
• Thus the segments of the right
lobe include right posterior and
anterior medial segment & right
anterior and posterior lateral
segment.
 Liver lobules and bile flow
• Liver is traditionally described as hexagonal-shaped
liver lobules.
• Each lobule has a central vein at the center
• sinusoids (large capillaries) and plates of hepatocytes
radiate toward central vein from surrounding
interlobular portal triads
• hepatocytes secrete bile into the bile canaliculi,
which drain in opposite direction with blood flow
• Bile canaliculi  interlobular biliary ducts bile
ducts of the intrahepatic portal triad right and left
hepatic ducts common hepatic duct.
 Arterial supply to liver
Portal vein

• is a vein which drains the abdominal part of alimentary canal

except the lowest part of rectum and anal canal.
• It carries products of digestion of carbohydrates and proteins to
the liver and contains one –third of the total volume of blood
in the body.
• Accounts (70%-80%) of blood supply to liver
• It contains 40% more oxygenated blood than blood returning to
heart.
• It is formed behind the neck of the pancreas by union of splenic
and superior mesenteric veins.
hepatic artery (20% - 30%) supply non-parencymal part of liver
particularily intrahepatic bile ducts.
 Porto systemic anstomosis
• under normal conditions venous blood
transverses liver and drains into IVC by way of
hepatic veins,
• smaller communications occur between portal
and systemic systems forming portosystemic
anastomosis at some sites.
Site Portal tributary Systemic tributary

Lower third of Esophageal branches of Esophageal veins which

esophagus left Gastric vein Drain Middle third of it to
azygous

Half way down anal Superior rectal veins Middle and inferior rectal
canal veins

Bare area of liver Left branch of portal Superficial veins of anterior

vein Abdominal wall via
paraumblical veins
 Venous drainage
- The hepatic veins,
formed by the union
of the central veins of
the liver, open into
the IVC just inferior to
the diaphragm.
- right, intermediate
(middle), and left
hepatic veins, which
are intersegmental in
their distribution
- drains parts of adjacent
segments
 Lymph drainge

- superficial lymphatic under glisson capsule and deep

lymphatic along with the interlobular portal traids.

- Superficial lymphatics from the anterior aspects of the

diaphragmatic and visceral surfaces and the deep lymphatic
vessels drains to celiac lymph nodes, which in turn drain into
the chyle cistern.

- superficial lymphatic from posterior aspects of

diaphragmatic and visceral surfaces drain to posterior
mediastinal lymph node.

- Few others to left gastric lymph node, parasternal and

anterior abdominal wall lymph node
 Cont..
Nerve supply
• hepatic nerve plexus, the largest derivative of
the celiac plexus.
 Clinical anatomy
Cirrhosis of the liver
• progressive destruction of hepatocytes (parenchymal
liver cells) and replacement of them by fat and
fibrous tissue
• Fibrous accumulation around duct system impede
circulation and bile flow.
• Over time, there will be jaundice and portal hypertension.
Jaundice is an accumulation of bile pigment in the blood
stream.
• This is frequently a result of obstruction of the duct
system.
• The liver is frequently a site for secondary metastasis of
cancer from almost any part of the body because of its
great vascularity
Hepatic Lobectomies and Segmentectomy
• right and left hepatic arteries, ducts and
branches of the right and left portal veins, do
not communicate.
• it became possible to perform hepatic
lobectomies and segmentectomies, removal
of part of the liver without excessive bleeding
• intersegmental hepatic veins serve as guides
to the planes between the hepatic divisions
Gall bladder and bile duct
 Biliary System
• series of ducts which drain bile from liver and gall bladder into
duodenum
• Includes six ducts:
1. Right hepatic duct
2. left hepatic duct
3. Common hepatic duct
4. Cystic duct
5. Common bile duct
6. Hepatopancreatic duct
- the last duct has smooth muscle sphincter that controls release of bile
from the duct.
- When this sphincter contracts, the bile return back to gall bladder for
storage and concentration
 Gall bladder
• pear-shaped bag
which stores and
concentrates bile
• lies in gall bladder
fossa or fossa
vesicae felleae
• covered inferiorly
and on its sides by
peritoneum.
• Separated from
liver by connective
tissue of fibrous
capsule.
 Size
• is about 8 - 12 cm long, 3cm wide
• volume of about 30 -50 ml.
Has three parts.
 Fundus: blind end covered by Peritoneum
 Body :- tightly fixed to the fossa of the gall bladder

 Neck: continues in to the cystic duct (4cm)

- bile flow into and out of the gall bladder
 Cont…
 Cystic duct - ( 3- 4 cm long) connects the neck
of the gallbladder to the common hepatic duct
- The mucosa of the neck spirals into the spiral
fold (spiral valve)
- This valve resistance sudden dumping of bile
to bladder during sudden close of sphincter
and increase in the abdominal pressure
- The fold also keeps duct open.
 Nvb’s
• cystic artery:-commonly from right hepatic artery
• cystic veins:- to portal vein(left portal vein) or
directly to liver.
drains neck and cystic duct.
fundus and body part drains to visceral surface
of the liver and drain into the hepatic sinusoids.
• Cytic nodes: to hepatic and cystic lymph nodes to celiac
nodes
• ANS: Sym. and visceral afferent: celiac plexus
Para. :- vagus nerve
SNS: right phrenic nerve (sensory).
 clinical
Gall stones or cholelithiasis
• concretions of cholesterol monohydrate,
calcium salts and phospholipids.
• common in females, and incidence increases
with age.
• common site for impaction of gallstones are
hepatopancreatic ampulla and infundibulum
of the gallbladder
 Infundibulum of the Gallbladder
• In diseased states of the gallbladder, a dilation
or pouch appears at the junction of the neck
of the gallbladder and the cystic duct. This
pouch is called the infundibulum of the
gallbladder (Hartmann pouch).
• Gallstones commonly collect in the
infundibulum.
• If a peptic duodenal ulcer ruptures, gallstones
may get entry to duodenum from the pouch.
Variations in the Cystic and Hepatic Ducts
The end
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