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Abdomen, pelvis and perineum 2 Surgical Society | Junior anatomy series Lecture 2 27/10/2022 Presented by Alessandro Troiani Learning objectives – 5 minutes Structure of Peritoneum and associated structures – 15 session minutes Oesophagus and Stomac– 12 minutes The Small Intestine – 10 minutes Break – 5 minutes The Large Intest– 10 minutes The Hepatobiliary sy– 15 minutes Summary, Questions and Tips! – 10 minutes Surgical Societynior Anatomy Series Learning objectives PP2 Session Intended Learning Objectives: Stomach: Describe the anatomy of the stomach, its key relations to other abdominal organs; gastro- oesophageal junction and hiatal hernias. Small and large intestineDescribe the anatomy and sub-divisions of the small and large intestines and their key relations. Recall the anatomical variations in the position of the appendix. Peritoneum and mesenteries: Describe the anatomy of parietal and visceral peritoneum; the greater and lesser sacs; mesenteries and peritoneal ‘ligaments’ and the retro-peritoneum and its contents. Explain the role of the innervation of visceral peritoneum in referred pain. Liver, gall bladder and portal venous systemDescribe the anatomy of the liver, gall bladder, biliary tree and the clinical presentation of gallstones. Outline the portal venous circulation and the sites of porto-systemic anastomoses. Demonstrate palpation and percussion of the liver. Abdominal vasculature: Describe the origins, courses and major branches of the abdominal aorta and the inferior vena cava, particularly the blood supply and drainage of the stomach, small intestine, large intestine, liver and gall bladder.. Innervation of abdominal viscera:Describe the distribution and function of the autonomic innervation of the stomach, small intestine, large intestine, liver and gall bladder. small intestine, large intestine, liver and gall bladder.be their lymph drainage of the stomach, Surgical Society| Junior Anatomy Series Peritoneum Surgical Society Anatomy Series Peritoneum - Serous membrane lining abdominal cavity walls and organs - Contains blood supply and innervation for abdominal viscera - Two continuous layers: o Parietal o Visceral Surgical Societynior Anatomy SeriesPeritoneal formations 1 Omental membranes: Peritoneal cavity: - Small space between the viscera - Contains peritoneal fluid (lubrication), immune role - ‘divided’ in: o Omental bursa o Supracolic o Infracolic Surgical Societynior Anatomy SeriesPeritoneal formations 2 Mesenteries: • Double layer of folded peritoneum around organs. • Anchors them to wall and contains neurovasculature. • All have one named accordingly, they can be KEY POINT • Non fused with parietal peritoneum • Fused with parietal peritoneum The mesentery of the jejeno- ileum is commonly known simply as ‘esentery’. Surgical Societyior Anatomy Series Peritoneal ligaments Gastrophrenic Falciform Hepatogastric Epiploic foramen Gastrosplenic Hapatoduodenal Gastrocolic Surgical Societyior Anatomy SeriesOrgans and REVISION TIP peritoneum 3 types of organs classified by relation to To remember RETROPERITONEAL organs peritoneum: useSAD PUCKER - Intraperitoneal organs S Supradrenal glands - Retroperitoneal organs: A Abdominal aorta D Duodenum o primarily o secondarily P Pancreas - Sub-peritoneal organs U Ureters C Colon K Kidneys E Esophagus R Rectum Surgical Societyior Anatomy Series Oesophagus and Stomach Surgical Societyor Anatomy SeriesOesophagus 1 - 25cm fibromuscular tube, from pharynx to stomach, collapsed unless food in it - Begins at C6, crosses diaphragm at T10, enters stomach at cardiac orifice (T11) - Actual junction slightly above, (z-line) sudden change in mucosa (squamous to columnar) REVISION TIP To remember th onstrictions of the oesophagususe ABCD: A Arch of Aorta B Left Bronchus C Cricoid cartilage D Diaphragm Surgical Societyior Anatomy SeriesOesophagus 2 - Arterial supply: o Thoracic: inferior thyroid artery o Adbominal: left gastric artery - Venous drainage: o Thoracic: azygous vein o Adbominal: left gastric vein Click to add text - Neural plexus: vagus + cervical and thoracic trunk branches KEY POINT The different venous drainage of thoracic and abdominal oesophagus form one of This Photo by Unknown Author is licensed under CC BY two porto-systemic anastomosis. Surgical Societyunior Anatomy SeriesStomach 1 - Very variable in size and position - Divided in 4 parts o Cardia o Fundus o Body o Pyloric - Transpyloric plane: L1 - Greater and lesser curvature - Internally, mucosal differences between different parts, more rugae towards pylorus Surgical Societynior Anatomy SeriesREVISION TIP Abdominal vasculature Use the mnemonic below to learn the branches of the abdominal aorta Hepatic Right gastric Canned Coealic trunk Hepatic propria Left Soup, Superior mesenteric gastric Really Renal Good Gonadal Gastroduoden Splenic In Inferior Mesentealc Cans Common iliac Superior pancreaticoduodenal Left gastro- omental Right gastro- omental Not shown: short gastric arteries Inferior pancreaticoduodenal Surgical Societynior Anatomy SeriesStomach 2 - Lymph nodes along curvatures (named after arteries) and splenic artery - Innervation from vagal trunk and coeliac plexus (T6-T9) - Arterial supply along the curvatures: o Lesser: left and right gastric o Greater: left and right gastro- omental Surgical Societynior Anatomy Series Small intestine Surgical Societyr Anatomy SeriesDuodenum - C shaped around head of pancreas, 4 parts: o Superior o Descending o Inferior o Ascending - Major and minor papilla in descending - Ends at duodeno-jejunal flexure, suspended This Photo by Unknown Author is licensed under CC BY-ND by ligament of Treitz. KEY POINT - Superior duodenal and inferior duodenal arteries The change in arterial supply from - Venous drain in portal coeliac trunk branches to SMA occurs around major papilla, where the - Vagal trunk and coeliac plexus,-T10 arterioles anastomose. Surgical Societyunior Anatomy SeriesJejeno-ileum 1 - No clear separation but some differences, in total around 7 metres (1/3 jejenum) - Mesentery contains vessels, Root of mesentery anchors it the posterior abdominal wall, starts at L of L2 to R sacroiliac joint Jejenum Ileum • Redder • Vice-versa • More folds (plicae circulares • Thicker • LUQ • More vascularised Surgical Societyunior Anatomy SeriesJejeno-ileum 2 - SMA supplies it, arteries structured in arches (arterial arcades) with straight vessels (vasa recta) branching off - SMV drains to splenic then portal vein - Specialised lymphatics: lacteals to absorb fat - SMA plexus (peri arterial), formed by: o Postsynaptic neurons from SMA and coeliac ganglia o Presynaptic neurons from vagal trunk Surgical SocietyJunior Anatomy Series PRACTICE QUESTIONS PRACTICE QUESTIONS 1. Which one is NOT a role 3. Which among these is of the peritoneum? primarily retroperitoneal? • Contain viscera • Stomach • Kidneys • Carry neurovasculature • Lubricate • Ascending colon • Absorb nutrients • Liver • Sigmoid colon • Immune role 2. The omental bursa is 4. Which one is not a constriction found behind the…? of the oesophagus? • Kidneys • Right bronchus • Pancreas • Left bronchus • Small intestine • Cricoid cartilage • Transverse colon • Arch of aorta • Lesser omentum • Diaphragmatic hiatus Surgical Societynior Anatomy Series PRACTICE QUESTIONS PRACTICE QUESTIONS 1. Which one is NOT a role 3. Which among these is of the peritoneum? primarily retroperitoneal? • Contain viscera • Stomach • Kidneys • Carry neurovasculature • Lubricate • Ascending colon • Absorb nutrients • Liver • Sigmoid colon • Immune role 2. The omental bursa is 4. Which one is not a found behind the…? constriction of the oesophagus? • Kidneys • Right bronchus • Pancreas • Left bronchus • Small intestine • Cricoid cartilage • Transverse colon • Arch of aorta • Lesser omentum • Diaphragmatic hiatus Surgical Societynior Anatomy Series PRACTICE QUESTIONS PRACTICE QUESTIONS 5. Which section of the stomach is 7. In which section of the associated with the diaphragm? duodenum the supply shifts • Cardia form coeliac to SMA? • Body • Descending • Fundus • Ascending • Pyloric antrum • Superior • Pylorus • Inferior 6. The greater curvature of 8. Which one of these the stomach is the origin of contains specialized which peritoneal formation? • Lesser omentum ly• Large intestine • Mesocolon • Small intestine • Mesentery • Duodenum • Hapatogastric ligament • Stomach • Greater omentum • Kidney Surgical Societynior Anatomy Series PRACTICE QUESTIONS PRACTICE QUESTIONS 5. Which section of the stomach is 7. In which section of the associated with the diaphragm? duodenum the supply shifts • Cardia form coeliac to SMA? • Body • Descending • Fundus • Ascending • Pyloric antrum • Superior • Pylorus • Inferior 6. The greater curvature of 8. Which one of these the stomach is the origin of contains specialized which peritoneal formation? • Lesser omentum ly• Large intestine • Mesocolon • Small intestine • Mesentery • Duodenum • Hapatogastric ligament • Stomach • Greater omentum • Kidney Surgical Societynior Anatomy Series Break – 5 minutes Surgical Societyr Anatomy Series Large intestine Surgical Societyr Anatomy SeriesLarge intestine - Function: - H20 reabsorption, foecal condensation and storage - Sections: coecum, appendix, colon, rectum, anal canal - Characteristics: o Large o Teniae coli: mesocolic, free, omental o Haustra o Omental appendices Surgical Societynior Anatomy SeriesCoecum and appendix - Blind pouch, contains ileocoecal junction and valve, close to inguinal canal - Can move freely, bound by peritoneal folds - Appendix: blind diverticulum, contains lymphoid tissue, has mesentery, variable postion - Supply: ileocolic artery (branch of SMA), branches in appendicular - Similar drainage and nerve supply to small intestine Surgical Societynior Anatomy SeriesColon 1 - Ascending: - from coecum to hepatic flexure (9 /10 rib) - Transverse: very mobile, - hepatic to splenic flexure (slightly higher), - around L3 but can change depending on height/bone structure - Descending: splenic to L iliac fossa - Mesentery of ascending and descending forms paracolic gutters - Sigmoid: s shaped, terminates at S3 at rectosigmoid junction, intra peritoneal Surgical Society | Junior Anatomy SeriesColon 2 - Supply: L, R and middle colic anastomose - Nerves forming the juxtacolic/marginal artery. o until splenic flexure, thoracic trunk to o R and middle à SMA. SM plexus and vagal trunk; o L and Sigmoidalà IMA. o After, lumbar trunk to splanchnic o 2/3 of transverse colon SMA, 1/3 IMA nerves and IM plexus Surgical Societynior Anatomy Series Hepatobiliary system Surgical Societynatomy SeriesLiver 1 - RUQ + LUQ (left lobe), fills R dome of diaphragm, slightly mobile - Convex and smooth anterior surface (diaphragmatic), one area is bare - Flat and irregular posterior surface, due to other organs’ impressions. - Posterior saggital fissures o Right: continuous with IVC and gall bladder impression; o Left: formed by ligamentum venosum and round ligament Surgical Societyunior Anatomy SeriesLigaments - Falciform - Round (non visible) - Coronary ligaments - Triangular ligaments, left and right (non visible) - Ligamentum teres - Ligamentum venosum (not visible) This Photo by Unknown Author is licensed under CC BY-SA-NC Surgical SocietyJunior Anatomy SeriesLiver 3 - Lobes o Anatomical: Left and Right, anatomically separated by falciform ligament, different branches of blood supply. o Accessory: caudate (part of left, as same supply) and quadrate (part of right), formed by saggital fissures and portal triade EXTRA MATERIAL o Functional divisions (8 segments, important surgically) given by portal The liver produces lymph , supply, caudate lobe is first segment which is secreted in intralobular ducts and drain to cisterna chyli. Surgical Societynior Anatomy SeriesThe portal vein The portal vein is forms at the union of the splenic vein and the superior mesenteric vein. The splenic vein receives the following contributions: - Left and right gastric veins - Left and right gastro-omental veins - The inferior mesenteric vein Surgical Societyunior Anatomy SeriesGall bladder - Bound by peritoneum to liver - Fundus, body and neck - Cystic artery from right hepatic - Cystic veins directly in liver - Coeliac plexus (contains sympathetic and afferent fibres) and vagus (responsible for contraction and relaxation of sphincters). Surgical SocietyJunior Anatomy SeriesBile pathway Porta hepatis - From canaliculi, bile is collected in interlobular ducts. - Interlobular ducts form right (A) and left (B) hepatic ducts. Common hepatic duct (C) Common bile duct (G) D: Gallbladder Ampulla of Vater E: Neck Cystic duct (F) (K) I: Accessory duct Main pancreatic duct (H) L: Major duodenal papilla Surgical Societynior Anatomy Series PRACTICE QUESTIONS PRACTICE QUESTIONS 1. Which one isNOT a 3. At which point of the colon characteristic of the colon? does the nerve spinal level • Large switch to lumbar? • Longitudinal muscle is • Hepatic flexure concentrated in bands • Splenic flexure • Absorbs water • 1/3 of Transverse colon • Is 7m long • Sigmoid colon 2. Which artery does not 4. Which TWO are supply the transverse colon? intraperitoneal parts of the • Marginal colon? • Middle colic • Coecum • Appendix • SMA • Ileocoecal • Sigmoid • IMA • Ascending colon • Descending colon Surgical Societynior Anatomy Series PRACTICE QUESTIONS PRACTICE QUESTIONS 5. Which of these does NOT 7. Which anatomical leave an impression on the landmark is associate with the liver? • Left kidney position of the gallbladder? • Xyphisternal joint • Right kidney • 10 Costal cartilage • Gallbladder th • 10 rib • Portal triad • 9 Costal cartilage • Duodenum th 6. Which of the ligaments • 9 rib 8. The common bile duct is anchors the right lobe of the formed by which TWO liver to the diaphragm? ducts? • Cardiac ligament • Main pancreatic duct • Falciform ligament • Right hepatic duct • Right triangular • Cystic duct • Ligamentum venosum • Common hepatic duct • Ligamentum teres • Left hepatic duct | Junior Anatomy Series Surgical Society PRACTICE QUESTIONS PRACTICE QUESTIONS 1. Which one isNOT a 3. At which point of the colon characteristic of the colon? does the nerve spinal level • Large switch to lumbar? • Hepatic flexure • Longitudinal muscle is concentrated in bands • Splenic flexure • Absorbs water • 1/3 of Transverse colon • Sigmoid colon • Is 7m long 2. Which artery does not 4. Which TWO are intraperitoneal supply the transverse colon? parts of the colon? • Marginal • Coecum • Middle colic • Appendix • SMA • Sigmoid • Ileocoecal • Ascending colon • IMA • Descending colon Surgical Societynior Anatomy Series PRACTICE QUESTIONS PRACTICE QUESTIONS 5. Which of these does NOT 7. Which anatomical leave an impression on the landmark is associate with the liver? • Left kidney position of the gallbladder? • Xyphisternal joint • Right kidney • 10 Costal cartilage • Gallbladder th • Portal triad • 10 rib • 9 Costal cartilage • Duodenum th • 9 rib 6. Which of the ligaments 8. The common bile duct is anchors the right lobe of the formed by which TWO liver to the diaphragm? ducts? • Main pancreatic duct • Cardiac ligament • Falciform ligament • Right hepatic duct • Cystic duct • Right triangular • Ligamentum venosum • Common hepatic duct • Ligamentum teres • Left hepatic duct | Junior Anatomy Series Surgical Society Any questions? Surgical Society Anatomy SeriesSurgical Society | Junior Anatomy Series ALESSANDRO TROIANI JAS LEADS Contact At2419@imperial.ac.uk Phase 1a: nya N n kalhal (821)9) Phase 1b: Anarya Jae Navarro (ap6618) CPA Lead: Mohae ArtAb(da1Eid (ma2219) Please fill out the feedback form below to Feedback receivea copy of the slides, as well as some additional SBAs to aid your revision! Form st We hope you enjoyed this lectureSee you on Tuesday 1 November 2022 for our next lecture oAbdomen, Pelvis and Perineum 3. https://app.medall.org/training/fee dback/anonymous?organisation=i mperial-college-surgical- society&keyword=1a66bd936903c 48cb1049d21
