DIGESTI 2

dr. agus budi utomo

Anterior wall
Layers ( from superficial to
deep)
 Skin

 Superficial fascia

 Anterolateral muscles

 Transversalis fascia

 Extraperitoneal fascia

 Parietal peritoneum
Superficial fascia－
divisions below
umbilicus
 Superficial fatty layer
(Camper’s)
 Membranous layer
(Scarpa’s)
Muscles of abdomen

Anterolateral group
 Obliquus externus
absominis
 Oblequus enternus
abdominis
 Transversus
abdominis
 Rectus abdominis
Posterior group
 Quadiatus lumborum

 Psoas major
Obliquus externus absominis

General direction of fibers:

downward, forward and
medially (run down and
inward)
Structures
 Inguinal ligament
 Lacunar ligament
 Superficial inguinal ring
－triangular-shaped defect
in aponeurosis of obliquus
externus abdominis above
pubic tubercle
Obliquus internus abdominis

 Deep to obliquus
externus abdominis
 General direction of
fibres: upwards,
forwards and medially
Transversels abdominis

 Deep to obliquus
internus
 Inguinal falx :
arch over spermatic
cord, inserted with
transverses abdominis
fiber into medial part of
pecten of pubis
 Cremaster :
around the spermatic
cord and testis
Rectus abdominis
 Position: lie on to either of
midline
 Origin: pubic crest and
symphysis
 Insertion: xiphoid and 5th-7th
costal cartilages
 Has 3-4 tendinous
intersections
 linea semilunaris
Similar functions for above four pairs of muscles

 Support and compress the abdominal viscera

 Increase intra-abdominal pressure, aid in expulsive
efforts-vomiting, coughing, sneezing, defecation,
urination and childbirth.
 Depress ribs, assist in (the act of force(4)expiration.
 Flex, lateral flex, and rotate vertebral column
Sheath of rectus abdominis
Ant layer－formed by fusion of
aponeurosis of obliquus externus
abdominis and anterior leaf of
aponeurosis of obliquus internus
abdominis
Post layer
 Formed by fusion of posterion leaf
of aponeurosis of obliquus
internus abdominis and
aponeurosis of transverses
abdominis
 Absent in about 4-5cm below the
umbilicus, where aponeuroses of
all three muscles form anterior
layer the lower free border named
arcuate line
 Below this line rectus abdominis in
contact with transverse fascia
Linea alba
－tendinous raphe between right and left recti from xiphoid to pubic symphysis.
Inguinal region

Boundaries
 Inguinal ligament

 Lateral margin of
rectus abdominis
 A horizontal line
stretching from
anterior iliac spine to
laeral margin of
rectus abdominis
Descent of testes

Seven-week embryo showing the

testis before its descent from the
dorsal abdominal wall
Fetus at 28 week the testis passing
through the inguinal canal
Newborn
Inguinal canal
Position: oblique passage, 4cm long, located 1.5cm
above medial half of inguinal lig.
Boundaries
 Ant wall
 Aponeurosis of
obliquus externus
abdominis
 Obliquus internus
abdominis (lateral
third of wall)
 Post wall
 Transverse fascia
 Inguinal flax medially
 Roof－arched lower
fibers of obliquus
internus and
transversua abdominis
 Floor－inguinal lig．
 Two openings
 Superficial inguinal ring
 Deep inguinal ring －defect in
transverse fascia 1.5cm above
midpoint of inguinal ligament
 Structures passing through the inguinal canal
 Spermatic cord and ilioinguinal nerve in males
 Round ligament of uterus and ilioinguinal nerve in females
Inguinal Triangle (of Hesselbach)

Boundaries
 Inguinal ligament
inferiorly
 Lateral border of
rectus abdominis
medially
 Inferior epigastric
artery laterally
Indirect inguinal heinia and direcet inguinal heinia
Superficial vessels and cutaneous nerves
 Arteries
 Superficial epigastric a.
 Superficial iliac circumflex a.
 Veins
 Thoracoepigastric v.
 Superficial epigastric v.
 Cutaneous nerves
 Anterior and lateral
cutaneous n. of lower six
thoracic
 Iliohypogastric n. (first lumb
nerves)
Deep vessels and nerves
Arteres
 Superior and inferior epigastric arteris
 Lower posterior intercostal a.
 Subcostal a.
 Four lumbar a.
Nerves
 Iliohypogastric n.
 Arises from lubar plexus
 Passes forward in the interval
between obliquus internus and
tranversus abdominis
 Pieces obliquus internus
abdominis 2.5 cm medial to
anterior superior iliac spine
 Pieces aponeurosis of obliquus
externus abdominisabout 2.5
cm above superficial inguinal
ring
 Ilioinguinal n.
 Runs parallel with
iliohypogastric n. at a lower
level
 Enters inguinal canal and
emerges through superficial
inguinal ring
 Genitofemoral n.
Abdomen
Abdominal aorta

 Continuation of
thoracic aorta at aortic
hiatus of diaphragm in
front of T12
 Terminates at lower
border of L4 vertebra
by dividing into right
and left common iliac
arteries
Parietal branches
 Inferior phrenic a.
(one pair)
 Lumbar a. (four pairs
of arteries that supply
the posterior
abdominal wall)
 Median sacral a.
Visceral branches
 Paired branches
 Middle suprarenal
artery
 Renal artery
 Testicular (ovarian)
artery
 Unpaired branches
 Celiac trunk
－a short thick vessel
that arises from the front
of aorta, at the level of
T12
 Superior mesenteric a.
－arises from the front of
aorta, at the level of L2
 Inferior mesenteric a.
－arises from the front of
aorta, at level of L3
 Celiac trunk
Left branch Left gastric a.

Right branch Short gastric a.

Common
hepatic a.
Cystic a. Splenic a.
Right gastric a.

Proper hepatic a.

Gastroduodenal a.
Splemic branches

Left gastrioeploic a.
Right gastroepiploic a.
Superior pancreaticoduodenal a.
Celiac trunk
 Middle colic a. Superior
Mesenteric v.

Inf. pancresticodudenal a.
Superior
mesenteric a.
Right colic a.

Ileocolic a. Jejunal and ileal a.

Appendicular a.
Inferior mesenteric v.

Inferior mesenteric a.
Left colic a.

Sigmoid a.

Superior rectal a.
Colic marginal artery
Relations of abdominal aorta
 Anteriorly (from above
downward)
 Pancreas
 Ascending part of
duodenum
 Radix of mesentery
 Posteriorly
 Upper four lumber
vertebrae
 On its right
 Inferior vena cava
 On its left
 Left sympathetic trunk
Veins of abdomen and pelvis

Internal iliac vein

 Parietal tributaries: accompany with arteries
 Visceral tributaries

→superior rectal vein→inferior mesenteric v.

①Rectal venous plexus →inferior rectal vein→internal iliac v.
→anal vein→internal pudendal v.
②Vesical venous plexus → vesical v.
③Uterine venous plexus → uterine v.
 External iliac vein
– accompany the artery
 Common iliac vein
– formed by union of
internal and external
iliac veins in front of
sacroiliac joint, end
upon L4~L5 by uniting
each other to form
inferior vena cava
Inferior vena cava
 Formed by union of two
common iliac veins anterior
to and just to the right of
L4~L5
 Ascends on the right side of
aorta, pierces vena cava
foramen of diaphragm
opposite the T8 and drains
into the right atrium
 Conveys blood from the
whole body below the
diaphragm to the right
atrium
Chief tributaries
 Parietal
 Paired inferior phrenic v.
 paired lumbar v. (four)
 Visceral
 Right and left renal veins
 Right suprarenal vein
(left drain into left renal vein)

 Right testicular or ovarian v

(left drain into left renal vein)

 Hepatic veins : right, left

and intermediate
Relations of inferior vena cava
 Anteriorly (cranially to caudally)
 Liver
 Head of pancreas
 Horizontal part of duodenum
 Right testicular (or ovarian) a.
 Radix of mesentery
 Posteriorly
 Right crus of diaphragm
 Upper four lumber vertebrae
 Left sympathetic trunk
 Parietal branches of abdominal aorta
 On its right
 Psoas major
 Right kidney
 Right suprarenal gland
 On its left
 Abdominal aorta
Hepatic portal vein
General features
 Formed behind the neck of
pancreas by the union of
superior mesenteric vein and
splenic vein
 Ascends upwards and to the
right, posterior to the first part
of duodenum and then enters
the lesser omentum to the
porta hepatis, where it divides
into right and left branches
 There are no functioning
valves in hepatic portal system
 Drains blood from
gastrointestinal tract from the
lower end of oesophagus to
the upper end of anal canal,
pancreas, gall bladder, bile
ducts and spleen
Variation and anomalies
of hepatic portal vein
Tributaries of
hepatic portal
vein
1. Superior mesenteric v.
2. Inferior mesenteric v.
3. Splenic v.
4. Left gastric v.
5. Right gastric v.
6. Cystic v.
7. Paraumbilical v.
Portal-systemic anastomoses
1. At the lower end of the oesophagus
Hepatic portal vein → left gastric vein → esophageal
venous plexus → esophageal vein → azygos vein
→ superiorvena cava
2. At rectal venous plexus
Hepatic portal vein → splenic vein → inferior mesenteric
vein → superior rectal vein → rectal venous plexus →
inferior rectal and anal veins → internal iliac vein →
inferior vena cava
3. At periumbilical venous plexus
Hepatic portal vein→paraumbilical vein→periumbilical
venous plexus→
 thoracoepigastric and superior epigastric vein →
superiorvena cava
 superficial epigastric and inferior epigastric veins →
inferior vena cava
4. Portal-retroperitoneal anastomosis
Between the retroperitoneal branches of the colic
veins and the lumbar veins, pancreaticoduodenal
veins with the renal veins and the subcapsular
veins of the liver with the phrenic veins twigs of
colic veins (portal) anastomosing with systemic
retroperitoneal veins
The lymphatic drainage of abdomen

Lymphatic drainage of
abdominal wall
 To axillary lymph node from
region above umbilicus
 To superficial inguinal
lymph node from region
below umbilicus
 To lumbar lymph node from
post wall of abdomen
Lymphatic drainage of
abdominal viscera
 Lumbar lymph nodes
 Lie on posterior abdominal
wall, along the abdominal
aorta and inferior vena cava
 Receive lymph from kidneys,
suprarenal glands, testes,
ovarirs, fundus of uterus,
ovary, and common iliac
nodes
 Right and left lumbar trunks
formed by efferent vessel
 Paired viscera－drain to the
lumbar lymph nodes
 Celiac lymph nodes
－situated around the celiac
trunk
 Superior mesenteric lymph
node
－situated around superior
mesenteric a.
 Inferior mesenteric lymph
node
－situated around inferior
mesenteric a.
 Intestinal trunk
－formed by efferent vessel of
celiac, superior and inferior
lymph nodes
Thoracic duct
 Begins in front of L1 as a dilated sac, the
cisterna chyli, which formed by joining of left
and right lumbar trunks and intestinal trunk
 Enter thoracic cavity by passing through the
aortic hiatus of the diaphragm and ascends
along on the front of the vertebral column,
between thoracic aorta and azygos vein
 Travels upward, veering to the left at the
level of T5
 At the roof of the neck, it turns laterally and
arches forwards and descends to enter the
left venous angle
 Just before termination, it receives the left
jugular, subclavian and bronchomediastinal
trunks
 Drains lymph from lower limbs, pelvic cavity,
abdominal cavity, left side of thorax, and left
side of the head, neck and left upper limb
 Spleen

Location: lies in the left

hypochondriac region
(between stomach and
diaphragm) deep to the
9th to 11th rib, its long
axis corresponds
roughly to the 10th rib
Shape－reddish in colour
Two surfaces
 Diaphragmatic: smooth, convex
 Visceral: concave, hilum of spleen
Two extremities
 Anterior－wider
 Posterior－rounder
Two border
 Superior－has 2-3 splenic notch
, which serve as a landmark on palpation
when it is enlarge; normally it is not palpable
 Inferior－rounder
Functions: the spleen is considered to be
important in:
 Formation of lymphocytes and monocyte
 Phagocytosis of bacteria, inert particles and
white blood cells and platelets
 Destroying effete or abnormal red blood cells
 Making antibodies
Ralationships of spleen
 Diaphragmatic
surface－diaphragm
 Visceral surface
 Anteriorly－fundus of
stomach
 Posteriorly－left suprarenal
gland and kidney
 Inferiorly－tail of pancreas
and left colic flexure
Nervers of abdomen
Lumbar plexus
 Formation: formed by
anterior rami of L1-L3,
a part of anterior rami
of T12and L4
 Position: lies within
substance of psoas
major
Branches
 Iliohypogastric n.
Supplies lower part of
anterior abdominal wall
 Ilioinguinal n.
Passes through inguinal
canal to supply skin of the
groin and scrotum
 Lateral femoral cutaneous
 Femoral n.
 Obturator n.
 Genitofemoral n.
Lumbar sympathetic trunk
 Made up of paired chains
with four to five lumbar
ganglia anterolateral to
vertebral column
 Enters abdomen via the
diaphragm and as a
continuation of he thoracic
part
 Passes inferiorly behind
common iliac vessels and
terminations by joining to
form unpaired ganglion
impar, anterior to sacrum
Relationships of abdominal viscera

 First layer－live, gallbladder, stomach

 Second layer－duodenum, pancreas, spleen
 Third layer－suprarenal gland, kidney, ureter,
inferior vena cava, abdominal aorta, nerves
and lymphatics
Relationships of the stomach
 Anterior:
 Live (right part)
 Diaphragm (left upper part)
 Anterior abdominal wall (left
lower part)
 Posterior－separated by
peritonum of lesser sac from
the following (“stumach-bed”)
 Pancreas
 Left suprarenal gland
 Left kidney
 Spleen
 Transverse colon and
transvers mesoclon
Arteries of stomach
 Left and right gastric
arteries arise from
celiac trunk and
proper hepatic artery,
repectively. These
two vessels run in
lesser omentum along
lesser curvature , and
anastomose end-to-
end.
 Right and left gastroepiploic
arteries arise from the
gastroduodenal and splenic
artery, repectively. These two
vessels pass into the greater
omentum, run parallel to the
greater curvature, and
anastomose end-to-end.
 Short gastric arteries,
branches of splenic artery,
course through the
gastrosplenic ligament and
supply the fundus of stomach.
 Posterior gastric artery (72%)
arise from the splenic artery,
course through the
gastrophrenic ligament and
supply the posterior wall of
fundus of stomach.
Venous drainage
 Right and left gastric veins empty directly into hepatic portal vein.
 Left gastroepiploic and short gastric veins drain into hepatic portal
vein via the splenic vein.
 Right gastroepiploic vein join either superior mesenteric vein.
Lymphatics of stomach
 Right and left gastric ln. lie
along the same vessels and
finally to the celiac ln.
 Right and left gastroomental ln.
lie along the same vessels, the
former drain into subpyloric ln.,
the latter drain into splinic ln.
 Supra- and subpyloric ln.
receive lymphatics from pyloric
part and finally to the celiac ln.
 Splenic ln. receive lymphatics
from fundus and left third of
stomach, and finally to the celiac
ln.
Nerve supply
Parasympathetic innervation by
anterior (left) and posterior (right)
vagal trunks
 The anterior trunk divides into
anterior gastric and hepatic
branches
 The posterior trunk divides into
posterior gastric and celiac
branches
 The anterior and posterior gastric
branches descend on the anterior
and posterior surfaces of the
stomach as a rule about 1 to 2 cm
from the lesser curvature and
parallel to it in the lesser omentum
as far as thr pyloric antrum to fan
out into branches called “crow’s foot”
to supply the pyloric part
Sympathetic innervation
 Mainly from celiac ganglia
 Affent and effent fibers derives from
thoracic segments (T5 －L1
The duodenum

Relationships of superior part

 Anteriorly
 Quadrate lobe of live
 Gallbladder
 Posteriorly
 Commom bile duct
 Gastroduodenal a.
 Hepatic portal v.
 Inferior vena cava
 Superioely
 Omental foramen
 Inferiorly
 Head of pancreas
Relationships of
descending part
 Anteriorly
 Live
 Transverse colon and
mesocolon
 Loops of small intestine
 Posteriorly
 Right renal hilum and ureter
 Right renal vessels
 Medially
 Head of pancreas
 Common bile duct and
pancreatic duct
 Laterally
 Right colic flexure
Relationships of horizontal
part
 Superiorly

 Head of pancreas

 Inferiorly

 Loops of small intestine

 Anteriorly
 Radix of mesentery
 Superior mesenteric a. and
v.
 Posteriorly
 Right ureter
 Inferior vena cava
 Abdominal aorta
Relationships of ascending part
 Right
 Head of pancreas and abdominal aorta
 Left
 Left kidney and ureter
Relationships of liver
 Diaphragmatic surface－
separated by diaphragm from
the following
 Right costodiaphramatic
recess and lung
 Cardiac base
 Visceral surface
 Left lobe is related to the
stomach and abdominal part
of esophagus
 Right lobe is related to the
right colic flexure anteroly,
gallbladder and superior
duodenal flexure medially,
right kidney, superarenal gland
posteriorly
Blood supply
 Arteries
 Superior
pancreaticoduodenal a.
 Inferior
pancreaticoduodenal a.
 Veins－follow arteries,
draining directly into
superior mesenteric and
hepatic portal veins
Divisions and relations of common bile duct

Supraduodenal segment
 Descends along the right
margin of hepatoduodenal lig.
 To the right of proper hepatic a.

 Anterior to hepatic portal v.

Retroduodenal segment
 Behind the superior part of
duodenum
 Anterior to the vena cava

 To the right of the hepatic

portal v.
Pancreatic segment
 Lies in a groove between
posterior surface of head of
pancreas and duodenum
Intraduodenal segment
 Enters the wall of
descending part of
duodenum obliquely where
jions the pancreatic duct to
form the hepatopancreatic
ampulla
 opens at the major
duodenal papilla
Divisions and relations of pancreas

Head of pancreas
 Located in C-shapes curvature
of doudenum
 Anteriorly
 Transverse mesocolon
 Posteriorly
 Inferior vena cava
 Right renal vessels
 Common bile duct
Neck of pancreas
 Anteriorly－pylorus
 Posteriorly－commencement pf
hepatic portal v. (formed by union of
splenic and superior mesenteric
veins
Body of pancreas
 Anteriorly
 Separated from stomach by
omental bursa
 Posteriorly
 Abdominal aorta
 Left suprarenal gland
 Left kidney
 Left renal vessels
 Spleen vein
 Superiorly
 Celiac trunk
 Celiac plexus
 Splenic a.
Tail of pancreeas
 Runs in spleicorenal
ligament to reach hilum
of spleen
 Accompanies with
splenic vessels
Relationships of spleen

Diaphragmatic surface
－diaphragm
Visceral surface
 Anteriorly－fundus of
stomach
 Posteriorly－left
suprarenal gland and
kidney
 Inferiorly－tail of
pancreas and left colic
flexure
Terima kasih