I ABDOMEN Syrface anatomy: e Mark 3 points: 1. At the lower border of the cricoid cartilage in the midline. 2. At the sternal angle in the midline.
Surqical lmportance: lumbar hernia
* S*irrl lrportrnrr, Testicular nerves develop from T1 o-T12,so testicular
pain may be felt around the umbilicus.
o Wolffian ducts become epididymis & vas deferens.
o Gubernaculum joins the testis (at junction of vas & epididymis) with the
.- At the 6th month of the intrauterine life, they lie at the internal inguinal rings
(common site for undescended testis).
- At 7th month they go through the inguinal canal.
At 8th month they lie at the external inguinal rings or at the neck of scrotum.
They descend to scrotum iust before birth.
Invagination of peritoneum going with the testis is called the processus
vaginalis, which is obliterated soon after birth at 2 points (at the internal ring &
just above the testis). Later on, it becomes obliterated forming a fibrous cord
Temperature in the scrotum is lower than the body by 2.5' (i.e. 35').
Maternal chorionic gonadotrophin and fetal testosterone stimulate growth of
the testes and their migration through the inguinal canal.
Testis is an ovoid structure 4 - 5 cm in rength & 2.s - 3.5 cm in width.
It is oval in shape, fqving & 2
2 borders (anterior & posterior), 2 ends (upper & lower) surfaces (ta'terat a m6Oial).
RelatiOnS: tts posterior border is retated to:
lntBrnalobllque TrEnerrerae abdomlnd
Extemslspamatc fascia Teettsularveesds
5. Cremasteric muscle & fascia
7. Tunica vaginalis (parietal & visceral layers).
8. Tunica albuginea (fibrous capsule).
. The testis is covered by thick fibrous layer (tunica albuqinea), which is
thickened posteriorly to form the mediastinum testis. lt sends septa that divide
the testis into 400 spaces, each contains 2-4 semineferous tubules which are
. The semineferous tubules open into rete testis in the mediastinum testis.
. The rete testis forms the vasa efferentia (15-20).
. The semineferous tubules are surrounded by vascular connective tissue
contains Levdiq cells that secrete testosterone.
N.B: When ta the cannula traverses:
1- Testicular artery from the Aorta.
2- Artery to vas (from inferior vesical artery). lt
may be efficient to maintain the testicular
viability when the testicular artery is divided,
however, testicular atrophy might occur (2%).
1-Testicular veins are formed from the
pampiniform plexus of veins which are the
most bulky constituents of the cord.
o lt is formed of about 20 veins.
. They reduce in number upwards till
reaching about 4 in the inguinal canal
then one vein retroperitoneally.
Rt. testicular vein ) directly to lVC.
Lt. testicular vein ) left renal vein.
2-Cremasteric veins anastomose freely with
the testicular veins. They form mainly the
anterior compartment of the cord & end in
3-Vein of vas ends in the internal iliac vein.
- Testis ) Para-aortic LNs (at the level of L1).
- The scrotum )inguinal LNs (medial group of
Seminoma may infiltrate the inguinal LNs in
1. Genital branch of Genitofemoral n.
Genital brEndr of gmitroitrffial
- External spermatic fascia ) from
- Cremasteric muscles ) from internal
oblique & transversus abdominis,
- lnternal spermatic fascia ) from
lnternal spermatic fascia, cremasteric muscle & external spermatic fascia.
o Anterior abdominal wall is divided into quadrants by
midline plane and transverse plane (through umbilicus):
upper right (UR), upper left (UL), lower right (LR) and
o Another method for dividinq it into 9 regions:
2. Right Iateral (lumbar) region.
3. Left lateral (lumbar) region.
5. Right hypochondrial region (chondral is the Latin for ribs).
7. Pubic (or hypogastric) region.
Duodeno-jejunal junction (D-J flexure).
Origin of superior mesenteric artery.
The peritoneum is the serous membrane that forms the lining of abdominal cavity.
. The outer layer, the parietal peritoneum, is attached to the abdominal wall.
. The inner layer, the visceral peritoneum, is wrapped arounii-I66li-[EliEJ'irgans
that are located inside the intra-peritoneal cavity.
. The potential space between these two layers is the peritoneal cavitv. lt is filled
with a small amount (about 50 ml) of serous fluid that elows the two layers to
There are two main regions of the peritoneum, connected by the epiploic foramen:
. The qreater sac (or general cavity of the abdomen).
. The lesser sac (or omental bursa) is divided into two "omenta":
o The lesser omentum (or gastro-hepatic) is attached to the lesser curvature of
o The qreater omentum (or gasfro-colic) hangs from the qreater curve of the
stomach and loops down in front of the intestines before curving back upwards
to attach to the transverse colon. ln effect it is draped in front of the intestines
like an apron and may serve as an insulating or protective layer.
The mesentery is the part of the peritoneum through which most abdominal organs
are attached to the abdominal wall and supplied with blood and lvmph vessels and
Pathological Spread of Fluids: The peritoneal recesses are of clinical importance with
the spread of pathological fluids like pus that may occur when an organ is injured or
diseased. The recesses determine the extent and direction of the spread of fluids that
rnay enter the peritoneal cavity.
These are peritoneal spaces lying below the diaphragm & may become sites for
collection of pus (subphrenic abscess).
They include the following spaces:
Between the Rt. lobe of liver & the diaphragm on the Rt. side of
2) Right posterior (Hepato-renal or Morrison pouch):
- Between posterior surface of Rt. Iobe of liver, anterior surface of Rt.
kidney and lower layer of coronary ligament of liver.
- lt is the most dependent part of peritoneal cavity in the supine
lF ffir"iH::.mmonest site or subphrenic abscess.
Between Lt. lobe of the liver, the diaphragm and the Lt. side of
4) Left Posterior (Lesser sac of Peritoneum):
Behind the stomach & lesser omentum.
1) & 2) Right & Left Perinephric Spaces:
Extra-peritoneal spaces around the kidneys
3) Space between bare area of the llver & diaphragm.
Pa ftS: it is a muscular tube (25 cm) with the following parts:
- Lies in front of pre-vertebral fascia slightly to the Lt.
- Starts at level of cricoid cartilage (C6).
o Anterior trachea, recurrent laryngeal nerve.
o Anterior: trachea, Lt. main bronchus,
pericardium, Lt. atrium & Rt. pulmonary artery.
o Left side.' arch of aorta, lung, pleura & Lt.
o Right side.' azygos vein, lung, pleura & Rt.
o lt pierces diaphragm 1 inch to the left of
midline opposite to body of T10 or 7th left
It ends at the gastro-esophagealjunction.
Peritoneal covering: only anteriorly.
It is closely related to both gastric nerves
(Anterior usually lies within its wall; posterior is
o 40 cm: opening in diaphragm.
These are the sites of foreign body impaction.
. Middle poftion: esophageal branches from the aorta.
. Lower Dart: esophageal branches of the left ga
These are small vessels which can easily be dissected
in trans-hiatal esophagectomy.
. Upper paft: to the brachio-cephalic veins.
. Middte paft: to the azygos veins on the Rt. & to the
. Lower part: to the left gastric vein then the porta!
Lower esophageal veins lie in the lamina propria )
o Cervical: recurrent laryngeal n.
o Abdominal: autonomic suplly.
o ln the neck: Deep cervical LNs.
o ln the chest: Mediastinal LNs.
Factors controlling Comoetence of the Cardial
1) Angle of Hiss: Acute ) valvular effect between left side of esophagus & fundus.
2) Lower part of esophagus (5 cm) is intra-abdominal ) closed on rise of abdominal
3) Rosette-shaped mucosal folds of lower end ) bulging in the lumen.
4) Pinch-cock effect of Rt. crus of diaphragm.
5) Phrenico-esophageal ligament: Keeping the intra-abdominal part in place.
6) Gontinuous release of acetyl choline ) lower end relaxes only on swallowing.
7) Pressure at lower 5 cm of esophagus is 8 - 25 mmHg while the lntra-gastric
pressure is 7 mmHg, thus, no reflux occurs.
1. At the lower border of the cricoid cartilage in the midline.
2. At the sternal angle in the midline.
Points of Surqical Importance:
o Endoscopically, the cardia is known by Z-line which is 1 - 4 cm from the
anatomical gastro-esophageal junction.
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