Peritoneal converinos: l.Ascending & descending colons are covered on the front and sides by peritoneum, not from behind (retro-peritoneal- no mesentery). N.B: A mesentery for the ascending colon & descending colon might be abnormally present & this may lead to volvulus of the caecum & rnfussusception. -;]-.Transverse colon has a transverse mesocolon (mobile segment), which is

 

Sitg: Left hypochondrium, epigastrium and umbilical regions.

J-shaped (vertical): COMMONEST.

Steer-horn (horizontal): less common.

The stomach has 2 orifices, 2 borders & 2 surfaces:

A- Cardiac oriflce:

o At the junction of the esophagus.

o At the level of T10, l inch to the left of

the midline.

o At 45 cm from incisors

endoscopy.

B- Pvloric orifice:

o At the junction with the duodenum.

Plloio Shiffir

lBtqrEl

o At the level of L1,yz inch to the right of the midline.

o ldentified at operation by: {F

1. Pre-pyloric vein of Mayo between Rt. gastric and Rt.

2. Annular groove.

3. Feeling its thickness.

gastro-epiploic

{F

vetns.

ABDOMEN I

Borders:

Lesser curvature & greater curvature (4 times long as the lesser curvature).

Sufaces:

A-Anterior: related to the liver, diaphragm, & ant abdominalwall

B- Posterior: (The Stomach neA)f

1- Lt. crus of diaphragm.

2- Lt. suprarenal gland,

3- Lt. kidney.

4- Spleen (separated by greater sac).

5- Splenic artery.

6- Body of pancreas.

7- Transverse mesocolon.

8- Transverse colon.

N.B. atl are separated from the stomach by lesser sac

separated by greater sac.

spleen which is

lordonrt*xftgt lpf.fi brrfrrrTn

lrtelilErH,

Foltrlorvaen|

Slro.tgtdt

artt{illt

PrrilEsac lF.ttr

{3}llfficrrlil g.fiofful

rfiIy

Fooftrgutloilary

except {r

Prloni

olsr/

o|[rnnr

r ABDOMEN

Parts of the Stomach:

0rprlsnum

A muauue*

1 . Fundus: above the level of cardiac notch.

2. Bodv: between the fundus & the pyloric portion.

3. Pvtoric portion:

o Distal to imaginary line between incisura angularis to corresponding

bulge in the greater curvature.

o lt consists of 3 parts:

i- Pyloric antrum ) proximal dilated part.

ti- Pyloric canal ) distal narrow part.

i-i-Pyloric sphincter ) at the end of the stomach.

peritoneal covering: {* lgrrsnrnlum

Hspateduodernl lgamed Hepalograstrb rgnrtent

ligarr€nl

Lrfrcdh{*phnhf llmrm

Highlrolh flsfarcl

Transrrrgc mlon *

Tho laffi gr'trll OrilffiIn 16 oilffr ta€d

ar a rynmlm for lhs geglrpslh Fgfirnstl,

tld it artual$ alto incllds tEe gnltlpsphnk

and gmlrtphrrtic lfiemst*, .[ ot rrtrtch

lsru acorthuou*8tttdmfil }} lhr

grenlerc$rrlalllre sl th+ Hloftiqfi"

Assan(lng

B Anrlrbr v{rw

&did nnfth

- completelv covered with peritoneum

ABDOMEN I

Liqaments attached to it:

o Lesser omentum attached to the lesser curvature.

o Liqaments attached to qreater curuature ) Greater omentum, includinq:

1. Gastro-phrenic.

2. Gastro-splenic.

3. Gastro-colic (the name greater omentum is commonly used for this):

- ls a 4-layered serous structure.

- Acts as a plug in acute abdominal inflammation (Policeman of the

abdomen)

- lt occasionally has congenital openings.

- lt is mainly supplied by gastro-epiploic artery.

- Lies anterior to the transverse colon.

Supplied by branches of celiac trunk (foregut)

Celiac trunk

Esophagea,u.

Unon

Left

gastric aa.

gastric a.

Hepatic

artery proper

Gastroduodenal a.

Supraduodenal

Splenic

a.

Left gastroomentala.

Right gastro-omental a.

Superior pancreaticoduodenal a,

Along the lesser curvature

i. Rt. gastric (from hepatic artery).

ii. Lt. gastric (from celiac trunk).

Along the Greater Curvature

i. Rt. gastro-epiploic (from gastro-duodenal artery).

ii. Lt. gastro-epiploic (from splenic artery).

aTo the Fundus

tr Short gastric arteries (from splenic artery passing through gastrosplenic ligament).

Surgical Importance:

ln subtotal gastrectomy, the land mark is the upper border of descending branch of lt.

gastric a. & the last short gastric a.

Arterial Supplv:

{F

I ABDOMEN

(Poftal + anastomosis with esophageat veins)

Rt. & Lt. gastric veins ) portal vein.

Rt. gastro-epiploic vein ) superior mesenteric vein.

Lt. gastro-epiploic vein & short gastric veins ) splenic vein.

$hori gsstric yein

Fo(tsl

Prapylurir

Lalt gart*orneolal vein

FaruqtimduedErst

vsins

Arrlerkrr virrr

Flbhlgs*lm.onlifital rdn

lnkermr*efialc ycln

Sup€risr nrecsnt€rk

Right 1/3

LN on the lesser curve LN in gastrosplenic ligament

Celiac LNs

The lvmoh vessels are in the stomach itself

&-

LYMPH DRAIN OF THE STOMACH

AB DOM EN

tltsclrt lcuhr

ADdomhal psrt d eophague

Pyfmrl

DuodgflIm- -

Site in chest

Branches in abdomen

Continues as

End by

orllics of ammach

anrueluro{sbmadr

crltvaltrlof stumrdt

AsofltdlnS mbn--- -

Trarufr.tertnrhr piang /

Nerve Suoolv:

A- Sympathetic: from celiac plexus (Greater Splanchnic Nerve).

B- Parasympathetic (secretomotor):

Pylodcantrum

Trgngreree mbn

Left

Hepatic

Ant. nerve of Laterjet

Crow's foot

Right

Celiac

Post. nerve of Laterjet

No crow's foot

Anterior

vagal trunk

Hepatic

branch

Anterior nelve

(of L-ateriet)

Crows'foot

lilrrlor vlru

I ABDOMEN

*

I

t

is the shortest, widest & most fixed portion of the small intestine.

It is usually the breadth of 12 fingers.

It forms a c - shaped curve around the head of the pancreas.

- Duodenum has no mesentery (it is the fixed portion of small intestine

retroperitoneal) except for the 1't part.

- lt lies anterior to the structures of posterior abdominal wall.

)

Aryfieupr6r€nal gififll

Hrlr Frorlato filcl

Sr4€rir mqsefilsrt

veln and arlery

Duodollum

L€f, UDIEI

voh

A. trtortor ytm lnl$|ff m63ailhdc afisry

PartS Of The DuOdenUm: ft is subdivided into 4 pafts

1st Part: (2inches tong)

- lt is 2 inches long & begins at the level of the L1 vertebra.

- lt is the only mobile part of the duodenum (specially the 1't inch).

- lt is covered anteriorly by peritoneum of greater sac.

- lt is covered posteriorly by peritoneum of the lesser sac.

Relations:

.f,t#*"=5f:?ti:33"J {r

o Posteriorlv: Gastro-duodenal artery, CBD, portal vein & IVC (from anterior to

posterior).

. @fly.: quadrate lobe of liver & neck of GB.

I-{ P{rtsoldlEdon0m

I ucnet pocodl I lSod I

C lxct lotpelE.rs

0 Soc, t

rril J

ABDOMENI

2nd Part:

- lt is 3 inches long desceA.ling vertically from L1 to L3.

- The bile duct opens in its postero-medial aspect.

- The bile duct usually unites with the main pancreatic duct to form the ampulla of

.Vater & opens at the major duodenal papilla.

a

a

The accessory pancreatic duct opens separate]y at the minor duodenal

papilla 1 inch dncive the major duodehal papilla. {F

Relations:

Anterior: the liver & the transverse colon.

Posterior: the Rt. kidney & Rt. psoas major.

Pflorus *l

SEnaDh

Rightsdil

flenfle

Ilsnuerse

00hn

Ascsndhs

001ffr

3rd Part: {[

- lt is 4 inches in'length at the level of L3 vertebra.

- lt is covered by peritoneum anteriorly & inferiorly.

Relations:

oAnterior: superior mesenteric vessels at root of mesentry.

Al.B; Superior mesenteric vein lies on the right side of superior

mesenteric aftery

.-terrol: the aorta, IVC, origin of the inferior mesenteric artery, Rt. ureter and

psoas major.

.Superiot: head of pancreas

.lnferior: small intestine

UodnaE praca{g

$qp.alor fiE#nt{rls vcn

B"eericr rtr€e€nbEa rd€rf

JABDOMEN

4th Part:

- lt is 1 inch long.

- lt is covered by peritoneum anteriorly & to the Lt.

.r- - lt ends at the D-J flexure which is supported by Iigament of Treitz from the Rt.

* crus of the diaohraom.

Posterior relations:

- ,.4, border of Lt. psoits major muscle.

- Lt. renal vessels.

- Lt. sympathetic chain.

- Lt. gonadal vessels.

Anterolatera I relations:

- Coils ofjejunum.

Medial relations (and to the Rt.):

- Uncinate process of the pancreas.

- Abdominal aorta.

- Vertebral column.

2 parts, probably neither attached to crura

1. Slip of striated muscle from diaphragm at esophageal opening, ending in

connective tissue of celiac prtery.

2. Fibro-muscular (non-striated) band from region of cetiac a. to D-J, 3'd and 4th parts

of the duodenum.

Bleeding above this ligament ) hematemesis + melena, while below this ligament )

melena & if massive, bleeding per rectum occurs.

Bleeding per rectum & not melena occurs if bleeding is from the beginning of the

hindgut.

The small gut is suspended by its mesentery which extends from the left side of the 2nd

Iumbar vertebra to the Rt. iliac fossa crossing the 3'd part of the duodenum, aorta, lVC,

Rt. ureter.

ABDOMEN I

Esophags

0hpkagm

Mtsde wihin fE

sspenmry ligarent

plilre dudenum

0uodenolejwnl juulitrr

Abdfininsl aorb

Blood Supplv:

Supplied by branches of both celiac trunk & sup mesenteric a (foregut + midgut)

a- Superior pancreatico-duodenal aftery ) from the gastro-duodenal artery.

b- lnferior pancreatico-duodenal artery ) from superior mesenteric artery.

Both of them supply the head of pancreas & the duodenum.

c- Supra-duodenal aftery ) from hepatic artery.

Gas,bodudenal artery

lhpath artmy proper

Common hepratic ertery Grealer

Hncreatic ffeliac tank

Splenic artery

artery

$uperior

pancrmticol

dusdenal

artery

Dorsal

pancreatie

artery

Pancratieaduodenal

arteries:

Arterior

l-eft

gasUo-amenEl

artery

Superhr rn+scnterie artery

Herhr lnlerior pancreaticoduodenal artery

Points of Suroica! Imoortance:

1) Obstruction of 3'd part of the duodenum may be caused by:

o Pressure by superior rnesenteric artery"

o Contraction of the ligament of Trietz.

2) ln barium meal:

. Widening of C-curve of the duodenum ) cancer head of pancreas.

. lnverted figure J ---+ peri-ampullary carcinoma.

o Trifoliate deformity ---+ duodenal ulcer.

I ABDOMEN

. Root: 6 inches long and is attached to the posterior abdominal wall crossing 6

structures:

1) 4th part of duodenum 2) 3t part of duodenum 3) Aorta.

4) rvc 5) Rt. Psoas major muscle 6) Rt. ureter

. Blg4lgg5. lt extends from left side of L2 to Rt. sacroiliac joint.

. Q!Ig!I$,

1) Coils of jejunum & ileum.

3) Superior mesenteric vein.

Distal 3/5

Diameter Smaller diameter

E

-."*.

t,, .alr- ^x

\

{ A

=

#

x***

\.*,o**

a

2) Superior mesenteric artery.

4) Lymphatics & LNs.

Payer's

patches

Mesentery

More numerous

IT.l

;.al ta

--.".'O\--. #

More LNs

Large amount of mesenteric fats.

Has 2 or 3 arterial arcades.

Windows aren't apparent.

Thin & less vascular

Larger diameter

- Few lymphoid follicles.

- Small amount of mesenteric fats.

- Has 1 or 2 arterial arcades in the

mesentery.

A The mesent{' shbws w.lndows

-+r,lbserecta

-.-i*Arl6rial ff$edas

a

ABDOMEN I

i ns: at the end of the ileum, at the ileo-caecal valve.

EndS: at the anal canal (recto-analjunction).

. Caecum

. Appendix

. Ascending colon

. Hepatic flexure

. Transverse colon

. Splenic flexure

o Descending colon

. Pelvic colon

. Rectum

o Anal canal

L€ft OAie fiexur€

tlamlra of cohn

Related tcl anterior er"tu olF srri+eii

Supplied by left colic vessels of

inferior mesenteric vessels.

Supported by phrenico-colic ligament

Lies higher than right colic flexure.

Msl

mpffdica$

o Reiated to right lobe of liver.

Supplied by superior mesenteric

vessels.

Lies anterior to Rt. kidney.

I ABDOMEN

2.

Haustrations: due to the presence of taenia

coli which is shorter than the length of the

intestine (in ulcerative colitis, the large

intestine is fibrosed ) loss of haustrations).

Appendices epiploicae (more in the left).

. Transverse colon is the longest segment of the colon,

, Sigmoid colon makes an S-shaped course.

, By endoscopy, the promontory of the sacrum might be clinical landmark

between cancer rectum & sigmoid colon.

. By endoscopy, recto-sigmoid junction is 15 cm from the anal verge.

Peritoneal converinos:

l.Ascending & descending colons are covered on the front and sides by

peritoneum, not from behind (retro-peritoneal- no mesentery).

N.B: A mesentery for the ascending colon & descending colon might be abnormally

present & this may lead to volvulus of the caecum & rnfussusception.

-;]-.Transverse colon has a transverse mesocolon (mobile segment), which is

Storred of 2 layers attached to the anterior border of'the pancreaZ.

3. Sigmoid colon has a sigmoid mesocolon. This mesocolon:

. lt has 2 limbs, meeting each other to form inverted V-shaped mesentery.

. lts apex is directed upwards (lies near the division of left common iliac artery).

. The left ureter descends

behind the apex.

. Superior rectal vessels run

along the right limb.

ABDOMEN I

MIEU,T: SuPerior mesenteric artery

HINDGUT: lnferior mesenteric artery

1- Proximal Group: situated on the main blood vessels as superior mesenteric,

inferior mesenteiic, ilio-colic, right colic. "etc'

2- Intermediate Group: along the smaller branches (e'g' ascending & descending

branches of right colic).

3- Distul Group (epicolic & parucolic): near the gut wall.

Proximal group

lntermediate group

Distal group

a

a