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The Abdomen and Pelvis 3 1/11/2022 Surgical Societyior Anatomy Series Presented By Mohamad Abou -Eid Learning Objectives 1 mins Structure of Overview of retroperitoneal structures 5 mins the session Spleen 10 mins Pancreas 10 mins Ascending & Descending Colon 10 mins Kidneys and Ureters 10 mins Adrenal Glands 10 mins Imaging 10 mins Summary, Tips and Practice Questions 1 mins Surgical Society Junior Anatomy Series Learning Objectives Pancreas: Describe the anatomy of pancreas and its relations to other abdominal organs. Spleen: Describe the anatomy of spleen and its relations to other abdominal organs and the thoracic wall. Demonstrate physical examination of the spleen. Kidneys & ureters and adrenal glands: Describe the anatomy of the kidneys, ureters and adrenal glands including their relations. Demonstrate palpation of the kidneys. Discuss the clinical significance of ureteric anatomy in relation to retention of urinary stones. Innervation ofabdomino-pelvic and perineal viscera: Describe the distribution and function of the autonomic innervation of the viscera. Abdominal, pelvic and perineal vasculature: Describe the origins, courses and major branches of the abdominal aorta and the inferior vena cava and what they supply or drain. Demonstrate palpation of the abdominal aortic artery pulse. Lymph drainage of abdomen, pelvis and perineum: escribe their lymph drainage to the inguinal, iliac and para-aortic nodes in relation spread of infection and malignant disease. Diagnostic imaging of the abdomen, pelvis and perineum: Interpret standard diagnostic images, e.g. CT, MRI, X-ray and ultrasound of the abdomen, and recognise common abnormalities. Surgical SocietyJunior Anatomy Series 4 6 5 SAD PUCKER 1 8 2 9 3 7 Surgical Society Anatomy SeriesSecondary retroperitoneal Surgical Societyr Anatomy Series Structure of the spleen • Intraperitoneal • Has 2 ligaments – lienorenal and gastrosplenic • Hilum contains splenic artery and vein (+ lym• Within lienorenal ligament • Has diaphragmatic, colic, renal and gastric surfaces • Processes red cells and is a source of B lymphocytes • Vulnerable to rupture leading to haemorrhage in paracolic gutter Surgical Societyunior Anatomy SeriesRelation of the spleen 1 2 4 5 3 Surgical Societynior Anatomy Series KEY POINT The splenic artery is above the splenic vein. They run posteriorly Blood supply of the splee along the superior surface of the pancreas. The vein is usually hidden by the pancreas – it joins IMA & SMA to make portal vein Surgical Society Junior Anatomy SeriesQUIZ • Which artery supplies the area no. 9? • Short gastric arteries • What are they a branch of? • Splenic artery Surgical Societyior Anatomy SeriesQUIZ • What is no. 2? • Hepatic artery proper • Name 1 function of 8? • Processes erythrocytes • Source of B lymphocytes Surgical Societyior Anatomy SeriesQUIZ • What is no. 4? • Spleen • Which ribs protect the spleen? • 9, 10 and 11 Surgical Societyior Anatomy Series KEY POINT The uncinate process is hidden Structure of the pancreas behind the SMA/V • Sits around L1 • Uncinate process (normally hidden) • Head (C shaped) • Neck and body • Tail (intraperitoneal) • Relation to: • Medially/Laterally à Duodenum and spleen • Posteriorly à Posterior abdominal wall contents (including SMA origin) • Anteriorly à Stomach (lesser sac) • Inferiorly à Duodenojejunal flexure, jejunum inferiorly and left colic flexure • MPD and CBD open into 2 nd part of duodenum Surgical Societyunior Anatomy SeriesBlood supply of the pancreas Surgical Societyr Anatomy Series QUIZ • What structure is hidden by no. 20? • Uncinate process • Which part of the pancreas is sup• Inferioro. 20? Surgical Societyior Anatomy Series QUIZ • What does no.12 drain into? • Second part of duodenum • Name 1 structure that runs behind the pancreas? • Splenic artery • Splenic vein • Hepatic portal vein • IVC • Aorta • Coeliac trunk • SMA Surgical Societynior Anatomy Series QUIZ • At which spinal level does no. 25 ari• T12-L1 • What is no. 26? • Splenic artery Surgical Societyior Anatomy Series Ascending and descending 3, 6, 9 rule à SB, LB, Caecum max normal diameter in cms Haustra are a result of the taenia coli Ascending colon: • Supplied by ileocolic and right colic artery of SMA (?Marginal artery) • SMA arises 1 cm below CT which arises at T12-L1 Descending Colon: • Supplied by the ascending & descending branch of the left colic artery which arises sharply from the IMA • IMA arises at L3 (above where the aorta bi4cates) Surgical Societyior Anatomy Series KEY POINT SMV lies in front of artery… joins splenic vein behind pancreatic head Portal circulation (briefly) Portal vein is posteriopart of duodenum • Follows the arterial pathway • Working backwards: •IMV drains the distal colon into the splenic vein •SMV drains rest of the colon and SB, joining with the splenic artery •Splenic veins drains majority of foregut • Splenic and SMV join together to form the hepatic portal vein that enters the hepatic hilum (portal triad) • Liver has dual supply • 25% arterial – keeping it healthy • 75% venous (HPV) – detoxifying and regulating nutrients Surgical SocietyJunior Anatomy SeriesLymph nodes • Retroperitoneal lymph nodes •Pre-aorticlymph nodes • CT, SM, IM •Para aorticlymph nodes • Bilateral structures (including gonads) • Drain intoisterna chyli • Iliac lymph nodes • Inguinal lymph nodes Surgical Societyunior Anatomy SeriesInnervation •Coeliac ,uperior mesenteric and inferior mesenteric plexuses • Pre-ganglionic fibres from splanchnic nerves (sympathetic) and vagus nerve + pelvic splanchnic nerves (parasympathetic) • Post-ganglionic fibres to smooth muscle and glands of GIT (i.e. via peri - arterial nerves to the organs of GIT) • Visceral sensory (afferent) fibres of viscera follow the efferent fibres • Visceral peritoneum refers the pain to one of 3 areas (via the plexuses) • Parietal peritoneum localises the pain to the exact area as it has spinal afferent nerves Surgical Societyunior Anatomy Series QUIZ • What does structure 7 join with? • Splenic vein • …what do they form together? • Hepatic portal vein Surgical Societyior Anatomy Series QUIZ • Where do the postganglionic arise from? innervate structure 11 • Coeliac plexus Surgical Societyior Anatomy Series QUIZ • What is structure no. 9? • Jejunum • What are structures no. 10? • Jejunal arteries and veins Surgical Societyior Anatomy Series QUIZ • What is structure no. 29? • Cisterna chyli • Where does structure no. 23 drain into? • Left subclavian vein Surgical Societyior Anatomy Series Structure of the kidneys • Renal Capsule – fibrous capsule • Perinephric fat – fat around kidney • Renal Fascia – membranous fascia which encloses the kidneys and adrenal glands and fuses with the transversalis fascia laterally and the diaphragmatic fascia superiorly • Paranephric fat – posterolateral to kidneys (forms the posterior paranephric space) Surgical SocietyJunior Anatomy Series Structure of the kidneys • Renal Cortex à Renal Medulla à Renal Papilla à Minor calyx à Major calyx 3 Renal pelvis à Ureter 1 •Renal sinusis an area containing : 4 • Renal pelvis 5 • Renal calyces 6 • Blood vessels • Nerves 4 • Fat 2 Surgical Societynior Anatomy SeriesRelations of the kidneys Surgical Societyor Anatomy Series Structure of the Ureters • Travel from the abdomen to the pelvis • Renal pelvis à Bladder • Lie in front of thesoas major •Gonadal vessels pass in front of them • At pelvic brim, ureters passes in front of common iliac (as it bifurcates • In the male,vas deferens crosses in front of ureter in pelvis • Ureter passes into bladder wall obliquely, entering ureteric ostium • 3 main ureteric constrictions i.e., sites where a urinary calculus (stone) can get stuck and cause problems Surgical Societyunior Anatomy Series Structure of the adrenal glands • Triangular shaped, located ve the kidneys(hence suprarenal) but not related to them • Pale outer layer for corticosteroid production –x • Dark inner layer for catecholamine production – medulla • Veryvascula, receiving many arteries but only 1 central vein • Receive large number ofre-ganglionic fiberthat synapse with adrenalin secretoryhromaffin cells (modified post-ganglionic sympathetic neurons) of adrenal medulla Surgical Societynior Anatomy Series Kidney , ureter and adrenal glands vasculature •Kidney: • Arteries originate just below SMA • Right renal artery is lower & longer than the left • Due to the liver pushing down the right kidney and aorta being left of the midline • Right renal artery is behind the IVC • Both arteries sharply pass backwards to the kidneys •Suprarenal glands: • Superior suprarenal arteries from inferior phrenic • L/R middle suprarenal arteries directly from aorta • Inferior arteries from renal artery • Right adrenal vein drains directly into the IVC whilst left drains into the renal vein Surgical Societyunior Anatomy Series •Ureters are supplied by any passing arteriesAbdominal Aorta For you to look at in your own time – helped me complete the image of the arterial circulation Quick point about the gonadal arteries: • Start in the abdomen as that is their embryological origin before they descended • Clinically important due to spread of cancer in the blood/lymph supply Surgical Societyunior Anatomy Series QUIZ • What is structure no. 22? • Right kidney • What are structures no. 21? • Right ureter and kidney Surgical Societyior Anatomy Series QUIZ • Wh• Left renal veine no. 14 drain into? • What is structure no. 19? • Left ureter Surgical Societyior Anatomy Series QUIZ • Wh• Ureteropelvic junctioncalled? • What is likely to get stuck there? • Ureteric stone Surgical Societyior Anatomy Series QUIZ • What is the circled area called? • Renal sinus • Wh• Major papilla no. 5? • What is structure no. 6? • Renal papilla Surgical Societynior Anatomy Series QUIZ • Name 1 function of structure 5? • Corticosteroid synthesis (any of its subparts like MC, GC, sex hormones) • Catecholamine synthesis • What is structure no. 7? • Right renal vein Surgical Societynior Anatomy SeriesImaging Basics: • Black (Radiotransparent) = air • Grey (Radiolucent) = soft tissue • White (Radiopaque) = metal (e.g., bone (Calcium), blood (Iron), fresh = whiter) • Foreign bodies also look white • IV Contrast also looks white, injected into vein to highlight blood vessels and organs/tissues with good blood supply. Provides generally better image. CT vs X-ray: • CT scans are 3D images made up of a stack of 2D images (often frontal (coronal), transverse and sagittal) Surgical Societyunior Anatomy SeriesImaging Systemic approach for an abdominal X -ray (AXR): • Patient details + indication for scan • Image type (Plain abdominal radiograph, AP, Supine) • Image quality (rotation, inspiration, penetration, exposure) • Exposure (for AXR): should include from hernial orifices to diaphragm, from left to right abdominal walls (specific for AXR) BBC: • Bowel and other organs: small bowel, large bowel, lungs, liver, gallbladder, stomach, psoas muscles, kidneys, spleen and bladder. • Bones: ribs, lumbar vertebrae, sacrum, coccyx, pelvis and proximal femurs. • Calcification and artefact (e.g. renal stones, surgical clips) Surgical Societyunior Anatomy SeriesImaging (AXR) • Purple: Liver • Pink: Spleen • Green: Left 11th rib • Orange: Kidneys • Red: Psoas muscle • Brown: Spinous process of L1 • Light Blue: Pedicles of L3 • Black: Transverse processes of L3 • Yellow: ertebral body of L4 • Dark Blue: Urinary bladder • Dotted Green: Usual path of the ureter (not usually visible) • Dotted White: Left sacroiliac joint Surgical Societynior Anatomy SeriesImaging (CT scan) CT: https://radiopaedia.org/cases/how -to-read-a-ct-of-the-abdomen-and-pelvis J Surgical Societyor Anatomy SeriesSurgical Society | Junior Anatomy Series Mohamad Abou -Eid JAS LEADS Contact ma2219@ic.ac.uk Phase 1a: Sree Kanakala (sk1821) Phase 1b: Ananya Jain (aj620) CPA Lead: Mohamad Abou-Eid (ma2219) Please fill out the following feedback form in Feedback order to receive a copy of the slides on Medall, along with bonus SBAs to aid your revision! Form We hope you enjoyed this lecture! See yTuesday 8th November 2022 for our next lecture on Gastrointestinal and Genitourinary system. https://app.medall.org/training/feedbac k/anonymous?organisation=imperial- college-surgical- society&keyword=66eff0e517f4c204ff26 28bd