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Abdominal Boundaries, Lymphatic Drainage and Peritoneal Arrangement WILL FINNAN Learning Outcomes ▪ Identify the following bony landmarks: xiphoid process, costal margin, iliac crest, anterior superior iliac spine, pubic symphysis, pubic tubercle and pubic crest ▪ Identify and describe the location of the 9 regions and 4 quadrants of the abdomen ▪ Describe the peritoneal cavity and the terms 'visceral peritoneum' and 'parietal peritoneum’ ▪ Describe and identify the arrangement of the visceral and parietal peritoneum ▪ Describe the term 'retroperitoneal' and describe which organs and structures are defined as being retroperitoneal ▪ Describe the lymphatic drainage of the abdominal cavity Bony Landmarks Xiphoid Process ▪ Small cartilaginous (usually ossified inferior projection of sternum ▪ Lies at the level of T10 vertebra XP Costal Margin ▪ Costal cartilages of ribs 7-10 Iliac Crest CM ▪ Superior margin of iliac bone ▪ Extends from ASIS to PSIS Pubic Symphysis PSIS ▪ Cartilaginous symphysis (fibrocartilage) ▪ Unites bodies of the pubic bones in the midplane IC ASIS Pubic Tubercle ▪ Rounded bony projection on lateral aspect of pubic crest ▪ Femoral hernias → inferior and lateral to pubic tubercle ▪ Inguinal hernias → superior and lateral to pubic tubercle PC Pubic Crest PT ▪ Superior ridge of body of pubic bone ▪ Medial to the pubic tubercle 4 Quadrants of the Abdomen - 1 horizontal and 1 vertical line passing through the umbilicus • Umbilicus located at level of intervertebral disc between L3-L4 vertebrae • Important to know what organs are located in each quadrant for palpation, percussion and auscultation during physical examination 9 Abdominal Regions ▪ More accurate way of describing location of abdominal viscera ▪ Regions are outlined by 4 planes: 2 Sagittal (Vertical) Planes- ▪ Midclavicular planes ▪ Mid point of clavicles → Mid-inguinal point 2 Transverse (Horizontal) Planes- ▪ Subcostal Plane (L3) th ▪ Passes through inferior border of 10 costal cartilage on each side ▪ Transtubercular Plane (L5) ▪ Passes through iliac tubercles on each side Abdominal Regions Clinical Correlations ▪ Pain in a particular region does not necessarily indicate pathology of the underlying organ → Referred Pain ▪ E.g., Epigastric Pain → Myocardial Infarction ▪ Remember underlying organs are found in pelvis as well as abdomen ▪ Hypogastric / Iliac Fossa → Gynecological / Urological Pathology Peritoneum and Peritoneal Cavity ▪ Continuous serous membrane that overlies the abdominal wall and lines the abdominal cavity ▪ Mesothelium (similar to the pericardium and pleura) ▪ 2 layers which are continuous with each other: Parietal Peritoneum ▪ Lines the walls of the abdominopelvic cavity Visceral Peritoneum ▪ Lines most of the abdominal organs Peritoneal Cavity: ▪ Fluid filled space between the 2 layers of peritoneum ▪ Contains peritoneal fluid Ø Reduces friction between walls / organs during peristalsis Ø Immune cells Peritoneum Clinical Correlations Parietal Peritoneum ▪ Like the overlying skin, is sensitive to pressure, pain and temperature ▪ Pain is generally well localised Visceral Peritoneum ▪ Insensitive to pressure and temperature, pain sensation by stretching or chemical irritation ▪ Pain is poorly localised- referred to central portion of dermatome of spinal nerves providing sensory innervation ▪ Foregut → Epigastric Region ▪ Midgut → Umbilical Region ▪ Hindgut → Suprapubic / Hypogastric Region Appendicitis: ▪ Pain initially due to stretching and irritation of visceral peritoneum from inflammation ▪ Referred to central portion of the dermatome → umbilical region ▪ As the infection progresses and inflammation worsens, the parietal peritoneum becomes irritated ▪ Pain migrates to a well localized pain felt in the region overlying the appendix → right iliac fossa Ø Migratory Pain Peritoneal Formations ▪ Various terms are used to describe the parts of the peritoneum that connect organs with other organs or to the abdominal wall Mesentery- double layer of peritoneum that suspends an organ in peritoneal cavity from the posterior abdominal wall Omentum- double layered extension extension of peritoneum that passes from stomach and proximal part of duodenum to other organs Ligament- double layer of peritoneum that connects an organ with another organ or to the anterior abdominal wall Omentum Greater Omentum • Double layer of peritoneum extending from the greater curvature of the stomach to various structures Lesser Omentum • Double layer of peritoneum extending from lesser curvature of stomach and first part of duodenum to the liver Hepatic Peritoneal Ligaments Hepatic Ligaments: Falciform Ligament Anterior surface of liver → Anterior abdominal wall Coronary Ligament Superior surface of liver → Diaphragm Left and Right Triangular Ligaments Superolateral surfaces of liver → Diaphragm Omental Ligaments Greater Omental Ligaments: Gastrocolic ligament Greater curvature of stomach → Transverse colon Gastrosplenic ligament Greater curvature of stomach → Spleen *Splenorenal Ligament* Spleen → Left kidney Gastrophrenic ligament Greater curvature of stomach → Inferior surface of diaphragm Lesser Omental Ligaments: Hepatogastric ligament Liver → Stomach Hepatoduodenal ligament Liver → Duodenum Peritoneal Ligaments Clinical Correlates • Portal Triad runs in the hepatoduodenal ligament • Hepatic Artery • Hepatic Portal Vein • Common Bile Duct • In case of a portal bleed during surgery, pressure can be applied by squeezing the hepatoduodenal ligament → Pringles Manoeuvre • Reduce blood flow to liver • Help to control bleeding • Hand is placed around free border of the hepatoduodenal ligament through the omental foramenUmbillical Folds 2 Lateral Umbilical Folds = underlying inferior epigastric vessels 2 Medial Umbilical Folds = underlying medial umbilical ligaments (remnants of foetal umbilical arteries) 1 Median Umbilical Fold = underlying median umbilical ligament (remnant of foetal urachus which drained urine from bladder to umbilicus) L Depressions or Fossae Created by Folds: S M • 2 supravesical fossae • 2 medial inguinal fossae • 2 lateral inguinal fossae Intraperitoneal vs Retroperitoneal Intraperitoneal: covered by visceral peritoneum and suspended by a mesentery / ligament Secondarily Retroperitoneal: initially intraperitoneal and then pushed against and fused with posterior abdominal wall during development Primarily Retroperitoneal: organs on posterior wall, covered by peritoneum only on anterior surfaceIntraperitoneal and Retroperitoneal Structures Intraperitoneal Retroperitoneal Stomach Aorta / IVC Spleen Oesophagus nd rd Liver + Gallbladder 2 + 3 parts of duodenum 1 part of duodenum Ascending + descending colon Small intestine Head + body of pancreas Tail of pancreas Kidneys Caecum Ureters Appendix Adrenal Glands Transverse and sigmoid colon Upper rectum Lymphatic Drainage • Peritoneal fluid contains leukocytes and antibodies • Lymphatic vessels scattered throughout the abdominal cavity • Particular concentration on the inferior surface of diaphragm • Constant movement helps to encourage lymphatic flowThanks for Listening Questions to wfinnan01@qub.ac.uk