Practical surgery
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Anatomy of Anterior Abdominal Wall and Groin hernia
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260
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Anterior Abdominal WallLayer of anterior abdominal
wall:
A- Lateral:1- Skin.2- Subcutaneous tissue.3- External oblique muscle.4- Internal oblique muscle.5- Transversus abdominis muscle.6- Fascia transversalis.7- Peritoneum.
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Anterior Abdominal Wall
B- Medial:1- Skin.
2- Superficial
fascia.
3- Anterior wall of
rectus sheath.
4- Rectus muscle.
5- Posterior wall
of rectus sheath.
6- Peritoneum.
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1- Skin
A- Lateral
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2- Subcutaneous tissue
A- Lateral
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The external oblique which runs infero-medially, originating on the
external posterior surface of ribs 5-12 (the lower 8 ribs, where its
originating fleshy digitations interlock with the digitations of the serratus
anterior and lattisimus dorsi
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3- External Oblique m.
A- Lateral
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The internal oblique which runs supero-medially (at right angles to the
external oblique). It originates in the thoracolumbar fascia of the lower
back, the anterior 2/3 of the iliac crest and the lateral 2/3 of the inguinal
ligament. Its insertions are on the inferior borders of the 10th-12th ribs
and the linea alba
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4- Internal Oblique m.
A- Lateral
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The transversus abdominus runs medially (horizontally) from the inner aspect of
the costal margin (just medial to the line formed by ribs 7-12), the lumbar fascia,
the anterior 2/3 of the iliac crest and the lateral third of the inguinal ligament. Its
insertion blends into the linea alba, with the lowest fibres inserted on the pubic
crest and the pectineal line (pelvic floor) along with the inferior part of the internal
oblique muscle
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5- Transversus abdominis m.
A- Lateral
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6- Fascia Transversalis m
A- Lateral
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7- Peritoneum
A- Lateral
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Anterior Abdominal WallLayer of anterior abdominal wall:
B- Medial:1- Skin.
2- Superficial fascia.
3- Anterior wall of rectus sheath.
4- Rectus muscle.
5- Posterior wall of rectus sheath.
6- Peritoneum.
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1- Skin
B- Medial
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2- Subcutaneous tissue
B- Medial
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3- Ant. Wall of Rectus
sheath
B- Medial
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The rectus abdominus and the rectus sheath
The rectus abdominus is a long paired vertically running muscle that
extends the entire length of the abdominal wall (narrowing as they
descend), originating at the pubic crest + pubic symphysis and inserting
on the cartilages of ribs 5-7 and the xiphoid process of the sternum
The anterior surface of the muscle is interrupted by 3 transverse fibrous
bands of tissue called transverse tendinuous intersections (the linea alba also
bisects the muscle vertically - this divides the muscle into 6 segments – think
six pack)
Has a special role as powerful flexors of the lumbar spine
The aponeuroses of the 3 sheet-like muscles form the rectus sheaths,
which enclose the rectus abdominus and meet at the middle to form the
linea alba (a tough fibrous band that extends from the xiphoid process to
the pubic symphysis)
o The arrangement of the rectus sheath is different superiorly and inferiorly to
the arcuate line (line ½ way between the umbilicus + pubic symphysis)
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4- Rectus Muscle
B- Medial
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B- Medial
5- Post. Wall of Rectus sheath
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B- Medial
6- Peritoneum
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Rectus Abdominis
Muscle
The muscle is divided into segments by tendinous intersections, Which indicate that the muscle arises from a number of myotomes, fused together
1- Segmental nerve supply.
2- Hematoma of rectus m. is localized
2- In paramedian incision displace m.
laterally (n. supply comes from lateral)
Surgical Importance
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Pyramidalis
Muscle
It is a landmark of linea alba intraoperative
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Actions of Anterior Abdominal
Wall Muscles
They assist in raising the intra-bdominal pressure (so,
they help in vomiting, cough, delivery, etc….)
Keep the abdominal viscera in position.
Rectus abdominis flexes the trunk, while the 2 oblique
muscles bend the trunk laterally.
Act as accessory expiratory muscles.
Lower midline & paramedian incisions.
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The aponeuroses of the 3 sheet-like muscles form the rectus sheaths, which
enclose the rectus abdominus and meet at the middle to form the linea
alba (a tough fibrous band that extends from the xiphoid process to the
symphysis pubis)
o The arrangement of the rectus sheath is different superiorly and inferiorly to
the arcuate line (line ½ way between the umbilicus + pubic symphysis)
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Superior to the arcuate line, the internal oblique aponeurosis splits to envelope the
rectus abdominus
o Inferior to the arcuate line, all 3 aponeuroses lie anterior to the rectus abdominus,
therefore the muscle lies purely on the transversalis fascia
At the lateral margin of the rectus abdominus, the aponeuroses also fuse to form the
linea semilunaris
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Medially
Laterally
Rectus Sheath
Linea Alba
Linea Semilunaris
Arcuate Line
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Rectus Sheath
Falciform Ligament
External Oblique
Internal Oblique
Transversus Abdominis
Ant. Layer of Rectus Sheath
Post. Layer of Rectus Sheath
Rectus Abdominis
Above Arcuate Line
SKIN
PeritoneumTransverslais Fascia
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Rectus Sheath
External Oblique
Internal Oblique
Transversus Abdominis
Ant. Layer of Rectus Sheath
Rectus Abdominis
Below Arcuate Line
Urachus in Median Umbilical Fold
Medial Umbilical Ligament
Transverslais Fascia
SKIN
Peritoneum
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Vessels and nerves
The rectus sheath contains arteries and veins lying posterior to
the muscle. These are the epigastric vessels
There is an anastomosis between the superior epigastric
arteries coming from the internal thoracic (branch of the
subclavian) and the inferior epigastric arteries that ascend
from the external iliac (by-pass of the abdominal aorta)
The nerve supply to all the antero-lateral muscles comes from
T6-L1
The intercostal nerves T6-T12 enter the abdominal wall at the
anterior ends of the intercostal spaces, passing deep to the costal
cartilages where these close the spaces
The main trunks of the nerves lie between the internal oblique
and transversus layers
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Superior epigastric a.
Subcostal a.
Inferior epigastric a.
Deep circumflex iliac a.
- I -Internal Mammary a.
- III -External Iliac a.
- II -Descending Aorta
10th, 11th intercostal a.
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Anatomy of inguinal hernia
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Important definitions
The inguinal region
The inguinal ligament is formed by the inferior folding-under of the external oblique,
and runs straight from the anterior superior iliac spine to the pubic tubercle .
The deep inguinal ring (internal) is an opening in the back wall of the inguinal canal,
which lies just superior and medial to the inguinal ligament. It marks the mid-point of the
length of the inguinal ligament, and provides an entry through which the canal’s contents
enter.
The superficial inguinal ring is a V-shaped slit in the external oblique aponeurosis
that allows the content of the canal to exit e.g. into the scrotum
E.g. the testicles develop from the back of the abdomen at the level of the kidneys,
and then descend through the deep ring into the inguinal canal and into the scrotum
The inguinal canal contains the ilioinguinal nerve in both males + females
In males it also contains the spermatic cord, which is covered in cremester muscle
(cremester reflex raises the testicles when cold) and 2 associated nerves
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The borders of the inguinal canal:
o Floor – inguinal ligament
o Anterior – external oblique aponeurosis + internal oblique
o Roof – internal oblique arching over
o Posterior – transversalis fascia and the conjoint tendon medially
The inguinal region is an area of weakness in the abdominal wall, thus is often the site
of an inguinal hernia
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The inguinal canal :-
The inguinal canal is approximately 4 cm long and is directed
obliquely inferomedially through the inferior part of the
anterolateral abdominal wall. The canal lies parallel and 2- 4 cm
superior to the medial half of the inguinal ligament .
The inguinal canal has openings at either end : –
The deep (internal) inguinal ring is the entrance to the inguinal
canal. It is the site of an outpouching of the transversalis fascia.
This is approximately 1.25 cm superior to the middle of the
inguinal ligament .
The superficial, or external inguinal ring is the exit from the
inguinal canal. It is a slit like opening between the diagonal fibres
of the aponeurosis of the external oblique
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Inguinal canal
walls of The inguinal canal :-
The anterior wall is formed mainly by the aponeurosis of the external
Oblique along its whole length + internal oblique muscle along its
lateral 1/2
. The posterior wall is formed mainly by transversalis fascia along its
whole length + conjoint tendon along its medial 1/2
The roof is formed by the arching fibres of the internal oblique and
transverse abdominal muscles.
The floor is formed by the inguinal ligament. It is reinforced in its most
medial part by the lacunar ligament.
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Contents of inguinal canal :-
1. Spermatic cord ( round ligament of the uterus in
female )
The Cord Itself.—The contents of the spermatic cord are
(a) the ductus (vas) deferens and its artery .
(b) the testicular artery and venous (pampiniform)
plexus.
(c) the genital branch of the genitofemoral nerve.
(d) lymphatic vessels and sympathetic nerve fibers.
(e) fat and connective tissue surrounding the cord and
its coverings in various amounts
2. Ilioinguinal nerve .
3. Ilioinguinal lymph node .
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• Obliterated processusvaginalis
• Parietal layer of tunica vaginalis
• Visceral layer of tunica vaginalis
• Internal spermatic fascia
• Cremasteric fascia and muscle
• External spermatic fascia
• Dartos fascia and muscle• Superficial fascia • Membranous
layer(Scarpa's)• Fatty layer (Camper's)• Skin
Peritoneum
Transversalis fascia
Transversus abdominism.Internal oblique m.
External oblique m.
skin
Covering
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The Hesselbach triangle
The inferior epigastricvessels serve as itssuperolateral border, therectus sheath as medialborder, and the inguinalligament as the inferiorborder. Direct hernias occurwithin the Hesselbachtriangle, whereas indirectinguinal hernias arise lateralto the triangle
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• Indirect Hernia
• Direct Inguinal Hernia
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Femoral Canal
The major feature of the femoral canal is the femoral sheath. This sheath is a
condensation of the deep fascia (fascia lata) of the thigh and contains, from
lateral to medial, the femoral artery, femoral vein, and femoral canal. The
femoral canal is a space medial to the vein that allows for venous expansion
and contains a lymph node (node of Cloquet). Other features of the femoral
triangle include the femoral nerve, which lies lateral to the sheath,
Wall of The Femoral canal
anterior is the inguinal ligament
posterior is the iliopsoas, pectineal, and long adductor muscles (floor).
Medial is lacunar ligament
Lateral is femoral vessle
A femoral hernia occurs through this space and is medial to the femoral
vessels
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Femoral Canal
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Testis
Spermatic cord
Ductus deferens
Testicular artery
Testicular vein (pampiniform plexus)
Epididymis:Head,Body,Tail
Efferent ductules
Rete testis
Seminiferous tubule
Septum
Lobules
Visceral layer of tunica vaginalis
Cavity of tunica vaginalis
Parietal layer of tunica vaginalis
Tunica albuginea
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www.themegallery.comHernia Lecture
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www.themegallery.comHernia Lecture
SCARPA’S FASCIA
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EXTERNAL RING
EXTERNAL SPERMATIC FASCIA
EXTERNAL OBLIQUE APONEUROSES
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ILIOHYPOGASTRICILIOINGUINAL
INTERNAL OBLIQUE APONEUROSES
CREMASTIC MUSCLE
INTERNAL OBLIQUE MUSCLE
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RECTUS MS
TRANSVERSUS ABDOMINUS MS
TRANSVERSUS ABDOMINUS APPONEUROSES
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INFERIOR EPIGASTRIC A. &V.
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FASCIA TRANSVERSALIS
INFERIOR EPIGASTRIC Vs.
INTERNAL RING
CREMASTRIC Vs
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PERITONEUM
CONTENTS OF CORD
TSETICULAR VEIN
PAMPINEFORM PLEXUS
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ARTERY OF VAS
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VAS
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FEMORAL TRIANGLE
SARTORIUS
ADDUCTOR LONGUS
INGUINAL LIGAMENTS
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FEMORAL NERVE
FEMORAL SHEATH
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CONTENTS OF THE FEMORAL SHEATH
LYMPH NODE
FEMORAL ARTERYFEMORAL VEIN
FEMORAL NERVE
FEMORAL BRANCH OF GENITO FEMORAL NERVE
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Liver
The liver is the largest gland in the body and has a wide variety offunctionsWeight: 1/50 of body weight in adult & 1/20 of body weight in infantIt is exocrine(bile) & endocrine organ(Albumen , prothrombin &fibrinogen)
Function of the liver
Secretion of bile & bile saltMetabolism of carbohydrate, fat and proteinFormation of heparin & anticoagulant substancesDetoxicationStorage of glycogen and vitaminsActivation of vita .D
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Location …
•Occupies righthypochondrium +epigastrium &extends toleft hypochondrium
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Apex of the heart Xiphisternum. 5th rib MCL
7th rib MAL
9th rib
Upper Border
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Lower Border
5th intercostal space
8th costal cartilage
Rt 9th costal cartilage
Midway between xiphisternum & umbilicus
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Rt. Border
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Surface anatomy of the liver
-The greater part of the liver is situated under cover of the right costal margin
- Diaphragm separates it from the pleura, lungs, pericardium, and heart.
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Surfaces of the liver, their relations &
impressions
Postero - inferior surface= visceral surfaceSuperior surface = Diaphragmatic surfaceAnterior surfacePosterior surfaceRight surface
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Ant. View of the liver
Right lobe
Cut edge of the Falciform ligament
left lobe
Diverging cut edges of the superior
part of the coronary ligament
Fundus of the gall bladder
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Relations of the liver Anteriorly
Diaphragm
Rt & Lt pleura and lung
Costal cartilage
Xiphoid process
Ant. abdominal wall
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Postero- infero surface= visceral surface
RelationsI.V.Cthe esophagusthe stomachthe duodenumthe right colic flexurethe right kidneyRt. Suprarenal glandthe gallbladder.Porta hepatic( bile duct,H.a.H.V)Fissure for lig. Venoosum & lesser omentumLig.teres
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Postero-inferior surface of the liver
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Sup. Surface of the liver
Right & left lobes Cut edge of the Falciform ligament The cut edges of the superior and inferior parts of the coronary ligament The left triangular ligament The right triangular ligament Bare area of the liver (where there is no peritoneum covering the liver Groove for the inferior vena cava and the hepatic veins Caudate lobe of the liver more or less wrapping around the groove of the inferior vena cava Lig.teres
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Relations of Sup. surface of liver
Diaphragm
Pleura & lung
Pericardium & heart
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Posterior relation of the liver
DiaphragmRt. KidneySupra renal glandT.colon(hepatic flexureDuodenumGall bladderI.V.CEsophagusFundus of stomach
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Lobes of the liver
Rt. Lobe
Lt .lobe
Quadrate lobe
Caudate lobe
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Rt. Lobe-Largest lobe - Occupies the right hypochondrium
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Left Lobe
Varied in size
Lies in the epigastric and left
hypochondrial regions
Divided into lateral and
medial segments by the left
hepatic vein
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Lobes of the liver…..cont
Rt. & Lt lobe separated by
Falciform ligament
Ligamentum Venosum
Ligamentum teres
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Caudate Lobe
-present in the posterior surface
from the Rt. Lobe
Relations of caudate lobe
- Inf. the porta hepatis
- The right the fossa for
the inferior vena cava
- The left the fossa for
the lig.venosum.
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Quadrate lobe
Present on the inferior surface
from the Rt. Lobe
Relation- Ant. anterior margin of the
liver
- Sup. porta hepatis
- Rt. fossa for the gallbladder
- Lt by the fossa for lig.teres
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Falciform ligament
Fissure of ligamentum teres
Fissure of Ligamentum venosum
Ligamentum teres
Rt. lobe Lt. lobe
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Superior surface: Related to the diaphragm
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Anterior surface
Xiphoid process
Diaphragm
Ant. abdominal wall
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Right lateral surface
Rt. Lung &pleura
6 -11 ribs
Diaphragm
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Inferior surface:
Esophagus
StomachDuodenum
Lesser omentum
Transverse colon
Gall bladder
Rt. colic flexureRt. kidney
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Peritoneal Coverings:
Bare area of the liver
Fossa for gall bladder
Groove for IVC
Porta hepatis
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Peritoneum of the liver
The liver is covered by
peritoneum
(intraperitoneal organ)
except at bare area.
Inferior surface covered
with peritoneum of greater
sac except porta hepatis,
G.B & Lig.teres fissure
Rt. Lateral surface
covered by peritoneum,
related to diaphragm
which separate it from Rt.
Pleura , lung and the Rt
Ribs (6-11)
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Falciform lig.
Coronary ligaments
Rt. triangular lig.
Lesser omentum
Lt. triangular lig.
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1- The Falciform ligament of liver
2- The Ligamentum teres hepatis
3- The coronary ligament
4- The right triangular ligament
5- The left triangular ligament
6- The Hepatogastric ligament
7- The hepatoduonedenal ligament
8- The Ligamentum Venoosum
1. The ligaments of the liver
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Falciform ligament of liver Consists of double peritoneal layer Sickle shapeExtends from anterior abdominal wall (umbilicus) to liverFree border of the ligament contains Ligamentum teres (obliterated umbilical vein)
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Hepatogastric ligamentHepatoduodenal ligament
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Liver anatomy
Historically, the liver was divided into right and left lobes by the external marking of the falciform ligament.
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Segmental anatomy of the liver
Rt .& Lt. lobes anatomically no morphological significance. Separation by ligaments (Falciform, lig. Venoosum & Lig.teres)True morphological and physiological division by a line extend from fossa of GB to fossa of I.V.C each has its own arterial blood supply, venous drainage and biliary drainageNo anastomosis between divisions 3 major hepatic veins Rt, Lt & central8 segments based on hepatic and portal venous segments
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Cantlie’s lineRt Lobe Lt Lobe
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Segmental anatomy of the liver
Liver segments are based on the portal and hepatic venous segments
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Schematic diagram of the segmental anatomy of the liver.
Each segment receives its own portal pedicle (triad of portal vein, hepatic artery, and bile duct).
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The Right Lobe The Left Lobe
VIII
V
IV
IV
III
II
VII
VI
I
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Blood supply of the liver
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Blood supply of the liver
Proper hepatic artery
The right and left hepatic
arteries enter the porta
hepatis.
The right hepatic artery
usually gives off the cystic
artery, which runs to the
neck of the gallbladder.
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Blood Circulation through the Liver
The blood vessels conveying bloodto the liver are the hepatic artery(30%) and portal vein (70%).The hepatic artery brings
oxygenated blood to the liver, and theportal vein brings venous blood richin the products of digestion, whichhave been absorbed from thegastrointestinal tract.The arterial and venous blood isconducted to the central vein of eachliver lobule by the liver sinusoids.The central veins drain into the rightand left hepatic veins, and theseleave the posterior surface of the liverand open directly into the inferiorvena cava.
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Vein drainage of the liver
The portal vein divides
into right and left
terminal branches that
enter the porta hepatis
behind the arteries.
The hepatic veins (three
or more) emerge from
the posterior surface of
the liver and drain into
the inferior vena cava.
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Portal v. 70%
Hepatic a. 30%
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Hepatic veins
IVC
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The anatomy of the portal vein
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Lymphatic drainage of the liver
Liver produce large amount of lymph~ one third – one half of total body lymphLymph leave the liver and enters several lymph nod in porta hepatis efferent vessels pass to celiac nodsA few vessels pass from the bare area of the liver through the diaphragm to the posterior Mediastinal lymph nodes.
Nerve supply
Sympathetic hepatic plexus>>> celiac plexuses thoracic ganglion chain T1-T12Parasympathetic vagous nerve( anterior part)
Sympathetic and parasympathetic nerves form the celiac plexus.The anterior vagal trunk gives rise to a large hepatic branch, which passes
directly to the liver
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Porta hepatis
-It is the hilum of the liver-It is found on the posteroinferior surface - lies between the caudate and quadrate lobes-Lesser omentum attach to its margin
Contents- Hepatic ducts ant.- Hepatic. Art + nerve+ lymphatic node middle.- Portal vein post.
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GALLBLADDER
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Anatomical position of
GB
- Epigastric - Right hypochondrium
region
- At the tip of the 9th RT . C.C
- Green muscular organ
- Pear-shaped, hollow structure
- On inferior surface of liver
- Between quadrate and right lobes
- Has a short mesentery
- Capacity 40- 60 cc
- Body and neck
Directed toward porta hepatis
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Structure of GB
Fundus
-Ant:ant.abdominal wall
- Post.inf: transverscolon
Body
sup: liver
post.inf: Tr.colon. End of 1st part of
doudenum , begins of 2nd part of doudenum
Neck
- Form the cystic duct, 4cm
Hartmann’s Pouch1. Lies between body and neck of gallbladder
2. A normal variation
3. May obscure cystic duct
4. If very large, may see cystic duct arising from
pouch
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Cystic
duct
- It joins common hepatic
duct
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Arterial Supply to the Gallbladder
Cystic artery
Right hepatic arteryProper hepatic arteryCommon hepatic artery
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Blood supply of GB:
- Cystic artery branch of Rt. Hepatic artery
- Cystic vein end in portalvein
- Small branches ( arteries and veins run between liver and gall bladder
Common Hepatic Artery
Proper Hepatic Artery
Gastroduodenal Artery
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Lymphatic drainage of GB
1. Terminate @ celiac nodes
2. Cystic node at neck of GB
a. Actually a hepatic nodeb. Lies at junction of cystic & common hepatic ducts
3. Other lymph vessels also drain into hepatic
nodes
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Nerve supply
Sympathetic and parasympathetic from celiac plexus
Parasympathetic ---- vagous nerve
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Extra hepatic biliary system
Rt. hepatic duct+Lt hepatic duct↓Common hepatic duct+Cystic duct↓Common bile duct
- 4cm- Descend in free edge of lesser omentum- Supra duodenal part
Retro duodenal partRetro pancreatic part
Common bile duct
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Bile duct……. parts
and relations
-3 inc long
-1st part-Located in right free margin of lesser omentum
- in front of the opening into the lesser sac
(Epiploic opening)
-Rt to hepatic artery and portal vein
- 2nd part-Behind the 1st part of the duodenum
-Rt to the gastroduodenal artery
-3 rd part
-Posterior surface of the head of the pancreas
-Contact with main pancreatic duct
-Related with IVC, gastroduodenal artery, portal
vein
-End in the half second part of duodenum at
ampulla of Vater
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Ampulla of Vater with CBD and Pancreatic Duct
Ampulla of Vater
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Hepaticopancreatic ampulla
(Ampulla of Vater)
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Pyriform in shape
30-50 ml
8x12x3cm
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Cut section
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Fundus
Body
Neck
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Cystic artery
Rt. hepatic artery
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cystic vein
Portal vein
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cystic LNs
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Rt. hepatic duct Lt. hepatic duct
Common hepatic duct Cystic duct
Common bile duct
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Extra-hepatic biliary tract
The common bile duct is about 7.5 cm long and is
formed by the junction of the cystic and common
hepatic ducts. It is divided into four parts:
•the supraduodenal portion, about 2.5 cm long, running
in the free edge of the lesser omentum;
• the retroduodenal portion;
• the infraduodenal portion, which lies in a groove, but
at times in a tunnel, on the posterior surface of the
pancreas;
• the intraduodenal portion, which passes obliquely
through the wall of the second part of the duodenum,
where it is surrounded by the sphincter of Oddi, and
terminates by opening on the summit of the ampulla of
Vater.
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Anterior:Free border of lesser omentum
Caudate process
1st part of duodenum
IVC
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Caudate process
1st part of duodenum
IVC
PV
CBD
Hepatic artery
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Variations in the anatomy of the cystic artery, duct , and Variations in the
anatomy of the hepatic duct.
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Ext. 308
Office 308
Dr. AMR EL HEFNI
Ass. Prof. of General Surgery
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Breast and axilla anatomy
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Anatomy of the breast
Shape : hemispherical with its base applied to the anterior chest wall and its
apex at the nipple.
Extent of the breast :
2nd rib
6th rib
4th rib
The axillary tail of the breast is of surgicalimportance. In some normal subjects it ispalpable and, in a few, it can be seenpremenstrually or during lactation. Itpierces the deep facsia to enter the axilla
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Areas of the breast
upper medial,lower medial,upper lateral, lowerlateral, nipple andarola and theaxillary tail of thebreast it is ofsurgicalimportance.
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Deep relation of the breast
It lies on
Pectoralis major m. with its deep fascia
Serratus anterior m.
External abd. Oblique m.
The upper most part of rectus abd. And sheath
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Pectoralis major m.&
fascia
The breast lies over
Serratus anterior m.
External oblique m.
Rectus sheath
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Pectoralis major m.
Serratus anterior m.
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Pectoralis minor m. & fascia
Suspensory lig. of axilla
Clavipectoral fascia
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Architecture of the breast
The breast consists of :1- the covering skin including the nipple and areola2- the superficial fascia 3- the mammary gland ( modified sweat glandectodermal in origin).The lobule is the basic structural unit of themammary gland (ducts and alveoli).The number and size of the lobules varyenormously: they are most numerous in youngwomen.From 10 to over 100 lobules empty via ductules intoa lactiferous duct, of which there are 15–20converging towards the nipple.The lobules of the breast are separated by fibrous septa ( coopers ligaments)
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The ligaments of Cooper are hollow conical projectionsof fibrous tissue filled with breast tissue; the apices of thecones are attached firmly to the superficial fascia andthereby to the skin overlying the breast to the deepfascia . These ligaments account for the dimpling of theskin overlying a carcinoma.
The areola contains involuntary muscle arranged inconcentric rings as well as radially in the subcutaneoustissue. The areolar epithelium contains numerous sweatglands and sebaceous glands, the latter of which enlargeduring pregnancy and serve to lubricate the nipple duringlactation (Montgomery’s tubercles).
The male breast differs from the female breast in beingrudimentary and its glandular tissue consists only ofducts with no alveoli.
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Lobe of mammary gland(breast fat)
Suspensory lig. of breast
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Lobe of mammary gland
Suspensory lig. of breast
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Blood supply of the breast
Arterial supply:
1- pectoral branch of thoraco acromial artery supply the
upper part (axillary)
2- Perforating branches of internal thoracic artery: 2nd,
3rd, 4th, supplying the medial part of the breast.( 1st part
of subclavian ar.)
3- Branches of the lateral thoracic artery supplying the
lateral part (axillary)
4- Lateral branches of posterior intercostals arteries
supply the lower and lateral parts.
Venous drainage :
1- axillary vein. 2-Intarnal thoracic vein. 3-Intercostal
veins
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Axillary a.
Internal mammary a.
Superior thoracic a.
Lateral thoracic a.
Thoracodorsal a.
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Axillary v.
Brachial plexus
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Internal mammary artery
Medial perforators(artery, vein, nerve & lymph)
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Axillary a.
Lateral thoracic a.
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Aorta
3rd intercostal a.
Intercostal arteries
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Accessory hemiazygos v.
Intercostal v.
Hemiazygos v.
Azygos v.
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Azygos v.
S.V.C
Sympatheticchain
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Nerve supply of the breast
By the anterior and lateral branches of the 4th, 5th and 6th intercostals nerves
which supply
A- sensory fibers to the breast.
B- autonomic fibers to the smooth muscles and blood vessels.
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Lymphatic drainage of the breast
The lymphatic vessels arranged in four plexuses:
1- subcutaneous plexus
2- subareoral plexus of sappy
3- interlobular plexus
4- submammary plexus
The regional lymph nodes draining the breast:
1- axillary lymph nodes
2- internal mammry lymph nodes
3- posterior intercostal subscapular and supraclavicular .
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Lymphatic drainage of the breast
The lymphatics of the breast drain predominantly into the axillary and internal mammary lymph nodes.
The axillary nodes receive approximately 85% of the drainage and are arranged in the following groups:
• lateral, ,,,,,,along the axillary vein;
• anterior,,,,,,, along the lateral thoracic vessels;
• posterior,,,,,,,,, along the subscapular vessels;
• central,,,,,,,,,,, embedded in fat in the centre of the axilla;
• interpectoral, The apical nodes are also in continua few nodes lying between the pectoralis
major and minor muscles;
• apical, which lie above the level of the pectoralis minor tendon in continuity with the lateral nodes
and which receive the efferents of all the other groups.
The internal mammary nodes are fewer in number. They lie along the internal mammary vessels deep to
the plane of the costal cartilages, drain the posterior third of the breast and are not routinely dissected.
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Lymphatic drainage of different parts of the breast:A- nipple and areola: drained by the subareolar plexus to pectoral and apical
groups
B- skin and subcutaneous tissue and parenchyma :
1- upper lat. Quadrant + upper ½ of breast : pectoral lymph nodes
2- lower lat. Quadrant : subscapular // //
3- upper medial // : internal mammary (both sides)
4- lower medial // : mediastinal L.ns then pass through the rectus sheath
to the falciform lig. Then spread to the liver , umbilicus and peritoneum.
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Recently the axillary Lns are classified into 3 levels:
1- lymph nodes above the level of pectoralis minor ( medial) : apical
infraclavicular
2- lymph nodes deep to pectoralis minor: central
3- lymph nodes below the level of pectoralis minor ( lateral ) : the ant and post
and lateral
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Pectoral node II
Pectoral node I
Pectoral node III
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Pectoral node II
Pectoral node I
Pectoral node III
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Major nervous structures in the axilla is required
to avoid their sacrifice during surgery
Coursing close to the chest wall on the medial sideof the axilla is the long thoracic nerve, or theexternal respiratory nerve of Bell, which innervatesthe serratus anterior muscle. Division may result inthe winging scapula deformity.
The second major nerve trunk encountered duringaxillary dissection is the thoracodorsal nerve to thelatissimus dorsi muscle at the lateral border of theaxilla. Enters the axillary space under the axillaryvein, close to the entrance of the long thoracicnerve. Its sacrifice leads to loss of latissimusfunction and atrophy of the muscle.
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Axillary v.
Axillary a.
Nerve to serratus anterior
Serratus anterior
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AxillaIt is a 4 sided pyramidal shaped space
between the upper part of arm and the
upper part of the side of the thorax
Boundaries : it has apex, base, 4 wall
and content
Base : formed by the skin of the arm ,
superficial and deep fascia
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What is axilla?Medial side of the arm
Lateral side of chest wall
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ApexConnects the axilla with the posterior triangle of the neck
Bounded by :
Medial : outer border of the 1st rib
Posterior: upper border of the scapula
Anterior: middle 1/3 of clavicle
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Neurovascular bundle
Clavicle
1st ribAcromion
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Anterior wall of axilla
3ms + fascia
Superficial layer : pectoralis major ms
Deep layer : pectoralis minor and subclaivus ms
Claveipectoral fascia.
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Pectoralis major m.
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Pectoralis minor m. & fascia
Suspensory lig. of axilla
Clavipectoral fascia
Subclavius m. & fascia
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Posterior & medial wall of axilla
Posterior : subscapularis , teres major and latissmus dorsi
Medial :
1- upper 4 or 5 ribs and intercostal ms
2- serratus anteroir ms
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Subscapularis m.
Teres major m.
Serratus anterior m.(medial wall)
Posterior wall
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Lateral wall of axilla
Upper part of humerus
Coracobrachialis ms
Short head of biceps
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Coracobrachialis m.
Short head of biceps brachii m.
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Contents of axilla
Axillary artery
Axillary vein
Cords and branches of the brachial plexus
Axillary lymph nodes , fat and axillary tail of the breast.
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Axillary artery
Axillary vein
Brachial plexus
Lymphatics
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THYROID EMBRYOLOGY AND ANATOMY
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Company Logo
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Triangles of the neck
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Company Logo
STERNO MASTOID
POSTERIOR BELLY OF DIGASTRIC
ANTERIOR BELLY OF DIGASTRIC
CLAVICLE
MANDIBLE
MID LINE
TRAPEZIUS
Posterior triangle Superior belly of omohyoid
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Company Logo
ANTERIOR BELLY OF DIGASTRIC
MANDIBLE
POSTERIOR BELLY OF DIGASTRIC
ANTERIOR BELLY OF DIGASTRIC
HYOID BONE
ANTERIOR BELLY OF DIGASTRIC
STERNOMASTOID
SUPERIOR BELLY OF OMOHYOID
MID LINE
STERNOMASTOID
SUPERIOR BELLY OF OMOHYOID
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THYROID EMBRYOLOGY AND ANATOMY
The tissue bud that ultimately becomes the
thyroid gland arises initially as a midline
diverticulum in the floor of the pharynx.
The original attachment in the pharynx is in
the buccal cavity at the foramen cecum, and
this becomes the thyroglossal duct, which
after 6 weeks of age is usually absorbed. The
very distal end of this remnant may
occasionally be retained and mature as a
pyramidal lobe in the adult thyroid.(50%)
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Congenital malformations
A-These include the thyroglossal cyst, which
result from retained tissue along the thyroglossal
duct. These cysts are almost in the midline. They
usually occur as a cyst found in the midline on
physical examination moving up and down with
swallowing and protrusion of the tongue .B- lingual thyroid .In most of these cases, this may be the only thyroid tissue that
remains.
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Anatomic Considerations
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The normally developed thyroid is a bilobed structure
that lies immediately next to the thyroid cartilage in a
position .
The two lateral lobes are joined at the midline by an
isthmus. The pyramidal lobe represents the most distal
portion of the thyroglossal duct and in the adult may be a
prominent structure.
A thin layer of connective tissue surrounds the thyroid is
part of the fascial layer, which invests the trachea. This
fascia is different from the thyroid capsule. This is why
thyroid gland moves up and down with digulitaion
This fascia coalesces with the thyroid capsule posteriorly
and laterally to form a suspensory ligament, known as
the ligament of Berry. The ligament of Berry is closely
attached to the cricoid cartilage and has important
surgical implications because of its relation to the
recurrent laryngeal nerve.
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Right & left lobes connected by an isthmus • Occasional pyramidal lobe • Levator glandulaethyroideae• Slightly larger in women; may enlarge during menstruation & pregnancy • Extends from oblique line on thyroid cartilage down to 4th or 5th tracheal ring • Attaches to cricoidcartilage via suspensoryligament
thyroid lobes
isthmus
thyroid cartilage
common carotid a.
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skin
fat
Platysma
deep fascia
Deep Fascia &
Spaces
prevertebral fascia
pretracheal fascia
carotid sheath
investing fascia
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The arterial supply to the thyroid gland is supplied by
four main arteries, two superior and two inferior. And
additional thyroid ema
Three pairs of venous systems drain the thyroid.
Superior venous drainage is immediately adjacent to
the superior arteries and joins the internal jugular vein
at the level of the carotid bifurcation.
The middle thyroid veins exist in more than half of
patients and course immediately laterally into the
internal jugular vein.
The inferior thyroid veins are usually two or three in
number and descend directly from the lower pole of
the gland into the innominate and brachiocephalic
veins.
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Recurrent Laryngeal Nerve
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The recurrent laryngeal nerves ascend on
either side of the trachea, and each lies
just lateral to the ligament of Berry as they
enter the larynx. There are a number of
important variations. Then disappearing
beneath the inferior border of the
cricothyroid muscle. The nerve can
usually be found immediately anterior or
posterior to a main arterial trunk of the
inferior thyroid artery at this level.
The motor function of the recurrent
laryngeal nerve is abduction of the vocal
cords from the midline.
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Damage to a recurrent laryngeal nerve
results in paralysis of the vocal cord on the
side affected. Such damage might result in a
cord that remains in a medial position or just
lateral to the midline.
If the vocal cord remains paralyzed in an
abducted position and closure cannot occur,
a severely impaired voice and ineffective
cough can be the result.
If recurrent laryngeal nerves are damaged
bilaterally partialy , complete loss of voice
and airway obstruction requiring emergency
intubation and tracheostomy may be
necessary.
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Superior Laryngeal Nerve
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Parathyroid Glands
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Lymphatic drainage of thyroid gland
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Anatomical
position - Epigastric
- left upper
hypochondrium region
Right lobe of liver
Falciform ligament
Gallbladder
Pancreas
Duodenum
L-3
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Common relation
Anterior
-Transverse colon
-Transvers mesocolon
-Lesser sac
-Stomach
-Posterior
--Bile duct
-Portalvein
-Splenic vein
-IVC
-Aorta
- origin of Sup.mesentric.a
-Lt.Psoas muscle
-Lt.Suuprarenal gland
-Left kidney
-Hilum of the spleen
PANCREAS
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Parts of the pancreas
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Parts
Head
Neck
body
Tail
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The head
-It is disc shaped
- lies within the
concavity of the
duodenum
- A part of the head
extends to the left
behind the superior
mesenteric vessels
and is called the
Uncinate process.
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The neck
- It is the
constricted portion
of the pancreas
- connects the
head to the body.
- It lies in front of
the
beginning of the
portal vein the
origin of the
superior
mesenteric artery
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The body
-Runs upward
and to the left
across the
midline
- It is
somewhat
triangular in
cross section.
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Body of pancreas…cont
-Three surfaces: anterior, posterior,
and inferior.
-Three borders: ant ,post & inf
The anterior surface
1- Covered by peritoneum of post. Wall
of lesser sac
2- Tuber omental :
where the ant. surface of pancreas join
the neck
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Body of
pancreas…cont
The posterior surface
- devoid of peritoneum
- in contact with
1- the aorta
2- the splenic vein
3- the left kidney and its
vessels
4- the left suprarenal
gland
5- the origin of the
superior mesenteric
artery
6- and the crura of the
diaphragm.
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Body of pancreas…cont
The inferior surface
- Narrow on the right but broader on the left
-Covered by peritoneum of greater omentum
- lies upon the duodenojejunal flexure
- Some coils of the jejunum
- its left extremity rests on the left colic
flexure
The superior border
-Blunt and flat to the right;
- Narrow and sharp to the left near the tail
It commences on the right in the omental
tuberosity
In relation with
1- The celiac artery
2- Hepatic artery
3- The splenic artery runs toward
the left in a groove along this border.
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Body of pancreas…cont
The anterior border
separates the anterior surface from the inferior surface
along this border the two layers of the transverse mesocolon diverge from one
another; one passing upward over the anterior surface, the other backward
over the inferior surface.
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Body of pancreas
The inferior border
separates the posterior from the inferior surface
the superior mesenteric vessels emerge under its
right extremity.
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The Tail
- Passes forward in
the splenicorenal
ligament and
comes in contact
with the hilum of
the spleen
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Pancreatic ducts
The main duct-Begins in the tail and runs the lengthof the gland-Receiving numerous tributaries on theway .- It opens into the second part of theduodenum at about its middle with thebile duct on the major duodenal papilla
Accessory duct- When present, drains the upper part of
the head-Then opens into the duodenum a shortdistance above the main duct on the minorduodenal papilla .- The accessory duct frequentlycommunicates with the main duct
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Blood Supply of pancreas
ArteriesThe splenic.a The superior pancreaticoduodenal .aInferior pancreaticoduodenal arteries.a
VeinsThe corresponding veins drain into the portal system.
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Lymphatic drainage of pancreas
Lymph nodes are situated along the arteries that supply the gland. The efferent vessels ultimately drain into the celiac and superior mesenteric lymph nodes.
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Nerve supply
Sympathetic and parasympathetic chain
Parasympathetic = vagus nerve
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Congenital defects of
pancreas
Annular Pancreas (pancreas
encircles duodenum) (rare)
Ectopic Pancreas (very common)=
Outside the gastrointestinal tract
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Clinical notes
Cancer head of pancreas Obstruction jaundices
Cancer body of pancreas pressure I.V.C & portal vein
Acute pancreatitis= inflammation of pancreas
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Colon
Posterior
CBD
IVC
Head
Anterior
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Neck
Pyloroduodenal junction
Anterior
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Neck
Posterior
SMV
Splenic v.
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Posterior
Splenic artery
Splenic vein
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Tail
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CBD
Main pancreatic duct Accessory pancreatic duct
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Superior pancreaticoduodenal artery
Inferior pancreaticoduodenal artery
Splenic a.
Superior mesenteric a.
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Celiac LNs
Superior mesenteric LNs
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Anatomical position - Epigastric
- left upper hypochondrium
region
Right lobe of liver
Falciform ligament
Gallbladder
Pancreas
Duodenum
L-3
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Common relation
Anterior
-Transverse colon
-Transvers mesocolon
-Lesser sac
-Stomach
-Posterior
--Bile duct
-Portalvein
-Splenic vein
-IVC
-Aorta
- origin of Sup.mesentric.a
-Lt.Psoas muscle
-Lt.Suuprarenal gland
-Left kidney
-Hilum of the spleen
PANCREAS
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Parts of the pancreas
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Parts
Head
Neck
body
Tail
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The head
-It is disc shaped
- lies within the
concavity of the
duodenum
- A part of the head
extends to the left
behind the superior
mesenteric vessels
and is called the
Uncinate process.
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The neck
- It is the
constricted portion
of the pancreas
- connects the
head to the body.
- It lies in front of
the
beginning of the
portal vein the
origin of the
superior
mesenteric artery
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The body
-Runs upward
and to the left
across the
midline
- It is
somewhat
triangular in
cross section.
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Body of pancreas…cont
-Three surfaces: anterior, posterior,
and inferior.
-Three borders: ant ,post & inf
The anterior surface
1- Covered by peritoneum of post. Wall
of lesser sac
2- Tuber omental :
where the ant. surface of pancreas join
the neck
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Body of
pancreas…cont
The posterior surface
- devoid of peritoneum
- in contact with
1- the aorta
2- the splenic vein
3- the left kidney and its
vessels
4- the left suprarenal
gland
5- the origin of the
superior mesenteric
artery
6- and the crura of the
diaphragm.
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Body of pancreas…cont
The inferior surface
- Narrow on the right but broader on the left
-Covered by peritoneum of greater omentum
- lies upon the duodenojejunal flexure
- Some coils of the jejunum
- its left extremity rests on the left colic
flexure
The superior border
-Blunt and flat to the right;
- Narrow and sharp to the left near the tail
It commences on the right in the omental
tuberosity
In relation with
1- The celiac artery
2- Hepatic artery
3- The splenic artery runs toward
the left in a groove along this border.
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Body of pancreas…cont
The anterior border
separates the anterior surface from the inferior surface
along this border the two layers of the transverse mesocolon diverge from one
another; one passing upward over the anterior surface, the other backward
over the inferior surface.
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Body of pancreas
The inferior border
separates the posterior from the inferior surface
the superior mesenteric vessels emerge under its
right extremity.
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The Tail
- Passes forward in
the splenicorenal
ligament and
comes in contact
with the hilum of
the spleen
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Pancreatic ducts
The main duct-Begins in the tail and runs the lengthof the gland-Receiving numerous tributaries on theway .- It opens into the second part of theduodenum at about its middle with thebile duct on the major duodenal papilla
Accessory duct- When present, drains the upper part of
the head-Then opens into the duodenum a shortdistance above the main duct on the minorduodenal papilla .- The accessory duct frequentlycommunicates with the main duct
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Blood Supply of pancreas
ArteriesThe splenic.a The superior pancreaticoduodenal .aInferior pancreaticoduodenal arteries.a
VeinsThe corresponding veins drain into the portal system.
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Lymphatic drainage of pancreas
Lymph nodes are situated along the arteries that supply the gland. The efferent vessels ultimately drain into the celiac and superior mesenteric lymph nodes.
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Nerve supply
Sympathetic and parasympathetic chain
Parasympathetic = vagus nerve
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Congenital defects of
pancreas
Annular Pancreas (pancreas
encircles duodenum) (rare)
Ectopic Pancreas (very common)=
Outside the gastrointestinal tract
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Clinical notes
Cancer head of pancreas Obstruction jaundices
Cancer body of pancreas pressure I.V.C & portal vein
Acute pancreatitis= inflammation of pancreas
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Colon
Posterior
CBD
IVC
Head
Anterior
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Neck
Pyloroduodenal junction
Anterior
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Neck
Posterior
SMV
Splenic v.
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Posterior
Splenic artery
Splenic vein
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Tail
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CBD
Main pancreatic duct Accessory pancreatic duct
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Superior pancreaticoduodenal artery
Inferior pancreaticoduodenal artery
Splenic a.
Superior mesenteric a.
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Celiac LNs
Superior mesenteric LNs
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Vascular anatomy
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Vascular supply of upper limb
Vascular supply of lower limb
Vascular supply of head and neck
Abdominal aorta
Lymphatic system
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VASCULAR SUPPLY TO UPPER EXTREMITY
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Subclavian Artery
Right Subclavian Artery:
Arises from brachiocephalic artery
(Behind right sternoclavicular joint)
At outer border of 1st rib it becomes Axillary Artery
Left Subclavian Artery:
Arsis from Arch of Aorta in the thorax
Runs upwards to the root of the neck & arches
laterally
At outer border of 1st rib it becomes Axillary Artery
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Subclavian Artery
Scalenus Anterior muscle passes anterior to the
artery on each side and divides it into 3 parts.
1. 1st part of subclavian artery
2. 2nd part of subclavian artery
3. 3rd part of subclavian artery
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1st part of Subclavian Artery
Extends from the origin of the subclavian artery to
the medial border of the Scalenus anterior muscle.
Branches:
1. Vertebral artery
2. Thyrocervical Trunk
3. Internal thoracic artery
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1st part of Subclavian Artery
Branches:
1. Vertebral artery
Spinal and muscular branches in neck
Branches in skull
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1st part of Subclavian Artery
Branches:
2. Thyrocervical Trunk
Inferior thyroid artery
Superficial cervical artery
Suprascapular artery
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1st part of Subclavian Artery
Branches:
3. Internal thoracic artery
Superior epigastric artery
Musculophrenic artery
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2nd part of Subclavian Artery
Lies behind the Scalenus anterior muscle.
Branches:
1. Costocervical trunk
Superior intercostal artery
Deep cervical artery
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3rd part of Subclavian Artery
Extends from the lateral border of the Scalenus
anterior muscle to the lateral border of 1st rib.
It gives no Branches
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Left is a branch of
the arch of the aortaRight is a branch of
innominate artery
Subclavian ArteryBegins
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Subclavian Artery
Formed behind
Sternoclavicular
joint
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Outer border of
the 1st rib
Subclavian ArteryEnds
Axillary
artery
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Scalenus anterior divides
it into 3 parts
Subclavian ArteryDivisions
Scalenus
anterior
123
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1st Part
Subclavian ArteryBranches
Thyrocervical
Trunk
Vertebral
artery
Internal
Mammary
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Thyrocervical
Trunk
Subclavian ArteryBranches
Transverse
Cervical
Inferior
Thyroid
Suprascapular
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2nd Part
Subclavian ArteryBranches
Costocervical
Trunk
![Page 545: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/545.jpg)
3rd Part
Subclavian ArteryBranches
Gives no
branches
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Anterior
Subclavian ArteryRelations
Internal Jugular
vein
![Page 547: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/547.jpg)
Lies on
Subclavian ArteryRelations
Suprapleural
Membrane
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Axillary Artery
Begins at inferior border of first rib.Divided into thirds by pectoralis minor muscle:First part superior to muscle.Second part deep to muscle.Third part inferior to muscle.
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First Part of Axillary Artery
Superior thoracic
artery
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Second Part of Axillary Artery
Thoracoacromial
artery (trunk)
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Second Part of Axillary Artery
Lateral thoracic
artery
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Third Part of Axillary Artery
Posterior circumflex
humeral
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Third Part of Axillary Artery
Posterior circumflex
humeral
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Third Part of Axillary Artery
Anterior circumflex
humeral
Subscapular
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Axillary ArteryCourse
1
3
2
outer border of the 1st rib
lower border of the teres major
Brachial
artery
Pectoralis minor
divides the axillary artery
into 3 parts
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Axillary ArteryRelations
Lateral to Axillary Vein
Medial to short head of biceps
& coracobrachialis
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Axillary Artery
Branches
Brachial
artery
1ST PARTSuperior thoracic artery
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Axillary Artery
Branches
Brachial
artery
2ND PART Thoracoacromial artery
Lateral thoracic artery
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Axillary Artery
Branches
Brachial
artery
3RD PARTPosterior circumflex
humoral
Anterior circumflex
humoral
Subscapular
![Page 561: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/561.jpg)
Brachial Artery
Continuation of
axillary artery at
inferior border of
teres major muscle.
![Page 562: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/562.jpg)
Branches of Brachial Artery
Deep brachial (profunda
brachii):Wraps around posterior
surface of humerus.
Runs in radial groove with
radial nerve.
Supplies posterior
compartment of brachium.
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Branches of Brachial Artery
Deep brachial (profunda
brachii):
![Page 564: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/564.jpg)
Branches of Brachial Artery
Nutrient humeral artery.
Superior ulnar collateral
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Branches of Brachial Artery
Inferior ulnar collateral
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Brachial Artery
Runs medial to median nerve in upper part of arm.Runs lateral to median nerve in lower part of arm.Passes deep to bicipital aponeurosis lateral to median nerve and medial to bicipital tendon.
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Brachial Artery
Branches into radial and
ulnar arteries.
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Radial Artery
Gives off radial recurrent
to radial collateral from
deep brachial.
Enters wrist and hand to
form deep palmar arch.
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Ulnar Artery
Gives off common
interosseous artery (trunk)
near its origin.
Runs through
antebrachium with ulnar
nerve.
Enters wrist and hand to
form superficial palmar
arch.
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Ulnar Artery
Common interosseous
artery gives off anterior
and posterior
interosseous arteries:Run on either side of the
interosseous membrane in the
forarm
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Blood Vessels of lower limb
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Femoral Artery
It is the continuation of the
external iliac artery at the
mid inguinal point
It descends in the femoral
triangle
Then, it continues in the
adductor canal
It reaches the adductor
hiatus where it becomes
the popliteal artery
It supplies all structures in
the thigh
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Femoral Artery
In the femoral triangle, it gives the
following branches:
Superficial circumflex iliac artery
Superficial epigastric artery
External pudendal artery
Deep artery of the thigh
Muscular branches
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Deep Artery of the Thigh( profanda
femoris artery)
It is the main artery of the thigh
It gives the following branches
Medial circumflex femoral artery
Lateral circumflex femoral artery
which gives a descending branch
Perforating arteries
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Femoral Artery
BeginsContinuation of the
external iliac arteries
Behind the midinguinal point
Femoral
artery
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Femoral Artery
Course
Enters
Femoral Triangle
Lies deep to Sartorius
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Femoral Artery
EndsPassing through an opening in the
adductor magnus muscles
between its 2 insertions
entering Adductor canal
Becoming the popliteal artery
Vastus Medialis anterolateral
to it
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Femoral ArterySurface AnatomyCorresponds to the upper ⅔ of a
line drawn from the
mid-inguinal point to the
adductor tubercle
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Femoral ArteryBranches
3 Superficial
Superficial epigastric
Superficial circumflex iliac
Superficial external pudendal
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Femoral ArteryBranches
3 Deep
Deep Femoral
Deep External Pudendal
Descending Genicular
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Popliteal Artery
It is the continuation of the femoral
artery at the adductor hiatus
It runs through the popliteal fossa
It ends at the lower border of the
popliteus muscle by dividing into its
terminal branches
It gives the following branches:
Medial superior genicular artery
Lateral superior genicular artery
Medial inferior genicular artery
Lateral inferior genicular artery
Middle genicular artery
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Popliteal Artery
At the lower end of the
popliteus muscle, it
divides into:
Anterior tibial artery
Posterior tibial artery
which gives the
peroneal artery
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Anterior Tibial Artery
It is one of the two terminal branches of the popliteal arteryIt supplies all structures in the anterior compartment of the leg and perforating branches to lateral compartmentIt ends at the midpoint between the malleoliIt continues as Drorsalis PedisArteryIt gives anterior medial and lateral malleolar branches
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Posterior Tibial Artery
It is one of the two terminal branches of the popliteal arteryIt supplies all structures in the posterior and lateral compartment of the legIt runs behind and inferior to lateral malleolusIt then divides into Medial and Lateral plantarbranchesIt gives the following branches:
Peroneal artery which gives lateral malleolarand calcaneal branches
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Drorsalis Pedis Artery
It is the direct continuation of the anterior tibial artery at the midpoint between the malleoliIt gives the following branches:
Lateral tarsalMedial tarsalArcuate1st dorsal metatarsalDeep plantar
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Plantar Arteries
The posterior tibial artery divides
into:
Lateral plantar
Medial plantar artery which gives
the first plantar metatarsal artery
Deep plantar arch is formed by the
deep plantar branch of dorsalis
pedis artery and lateral plantar
artery
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Veins of the Lower Limb
Deep veins accompany arteries of the
lower limb internal to the deep fascia
Superficial veins are not accompanied by
arteries in the subcutaneous tissue
Deep veins of the foot are drained to the
dorsal venous arch
Medial and lateral marginal veins emerge
from the sides of the arch
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Veins of the Lower Limb Cont.,
The medial marginal vein continues
as great (large) saphenous vein
It ascends in front of the medial
malleolus to the leg and thigh
It passes through the
saphenous opening
to end in the femoral
vein
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Tributaries of great saphenous vein:
Below knee:
1- anterior vein of leg
2- posterior arch vein
Above knee:
1- anterolateral vein of
thigh
2- postromedial vein of
thigh
At inguinal region:
1- superficial epigastric
2- superficial circumflex
iliac
3- Superficial external
pudendal
4- super ficial dorsal
vein of penis
Perforating veins.
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Veins of the Lower Limb Cont.,
The lateral marginal vein
continues as lesser (small)
saphenous vein
It ascends on the posterior
aspect of the leg
It ends in the popliteal vein
Perforating veins connect the
lesser saphenous vein with
deep veins (One way valve)
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Arterial pulse
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BLOOD SUPPLY TO HEAD
AND NECK
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ARCH OF AORTA
Branches of Arch
of Aorta1. Left Subclavian artery.
2. Left Common Carotid
artery.
3. Brachiocephalic trunk.
-Right subclavian artery.
-Right common carotid
artery.
BLOOD SUPPLY TO HEAD AND NECK 595
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COMMON CAROTID ARTERY
– The right common carotid artery arises from the brachiocephalic artery behind the sternoclavicularjoint.
-- The left artery arises directly from the arch of aorta behind the manubrium sternum.
BLOOD SUPPLY TO HEAD AND NECK 596
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COMMON CAROTID
ARTERY
– In the neck, each CCA
extends upwards & laterally with
in the carotid sheath to the level
of upper border of lamina of
thyroid cartilage.
-- The bifurcation takes place in
carotid triangle opposite the disc
between c3 & c4 vertebra.
BLOOD SUPPLY TO HEAD AND NECK 597
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BRANCHES OF COMMON CAROTID
ARTERY
External Carotid Artery
Internal Carotid Artery
BLOOD SUPPLY TO HEAD AND NECK 598
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EXTERNAL CAROTID ARTERY
It lies anterior to ICA and is the chief arterial supply to structures in front of
neck and face. Under cover of anterior border of sternocleidomastoid
BLOOD SUPPLY TO HEAD AND NECK 599
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Terminates in the
substance of the
parotid gland behind
the neck of mandible
by dividing into:
Superficial temporal
artery
Maxillary artery
BLOOD SUPPLY TO HEAD AND NECK 600
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Branches
•Anterior :•Superior thyroid•Lingual•Facial •Posterior:•Occipital •Posterior auricular •Medial:•Ascending pharyngeal •Terminal:•Maxillary •Superficial temporal
BLOOD SUPPLY TO HEAD AND NECK 601
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Internal Carotid Artery
Has no branches in the neck and enters the cranial cavity.
Supplies structures inside skull.Arises from the common
carotid at the level of the superior border of the thyroid cartilage
It is embedded in the carotid sheath with internal jugular vein and vagus nerve.
It Supplies:◦ Brain ◦ Nose ◦ Scalp ◦ Eye
BLOOD SUPPLY TO HEAD AND NECK 602
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APPLIED ANATOMY
CAROTID PULSE :
CCA may be
compressed against
the carotid tubercle of
transverse process of
C6 vertebra (
carotid tubercle) about
4cm above the
sternoclavicular joint.
•
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ABDOMINAL AORTA AND
INFERIOR VENA CAVA
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Location
Aorta enters the abdomen through the aortic opening of the diaphragm
The opening lies in front of twelfth thoracic vertebra
It descends behind the peritoneum on the anterior surface of the bodies of the
lumbar vertebrae
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Location
On its right side lies the inferior vena cava, the cisterna chyli and beginning of
the azygos vein
On the left side lies the left sympathetic trunk
It divides into two common iliac arteries at the level of fourth lumbar vertebra
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Branches
Three anterior visceral branches: celiac artery (Upper border L1), superior (
lower border L1) and inferior mesenteric arteries (L3)
Three lateral visceral branches: Middle suprarenal artery L1 , renal artery L2 ,
testicular or ovarian arteryL3
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Branches
Five lateral abdominal wall branches: the inferior phrenic artery and four lumbar
arteries
Three terminal branches: two common iliac and the median sacral artery from
back of aorta at L4.
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Common Iliac Arteries
Right and left common iliac arteries are the
terminal branches of the aorta
They arise at the level of fourth lumbar vertebra
Runs downward and laterally along the medial
border of the psoas muscle
Each artery divides into external and internal iliac
arteries in front of the sacroiliac joint
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External Iliac Artery
It runs along the medial border of psoas, following the pelvic brim
It gives off the inferior epigastric and deep circumflex iliac branches
The artery enters the thigh by passing under the inguinal ligament to become
the femoral artery
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Inferior Epigastric Artery
The inferior epigastric artery arises just above the inguinal ligament
Passes upward and medially along the medial margin of the deep inguinal ring
Enters the rectus sheath behind the rectus abdominis muscle
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Inferior Vena Cava
It conveys most of the blood from the body below the diaphragm to the right atrium of the heart
It is formed by the union of common iliac veins behind the right common iliac artery at the level of fifth lumbar vertebra
It ascends on the right side of the aorta
Pierces the central tendon of the diaphragm at the level of the eighth thoracic vertebra
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Inferior Vena Cava
It drains into the right atrium of the heart
Right sympathetic trunk lies behind its right margin
Right ureter lies close to its right border
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Tributaries
Two anterior visceral tributaries: the hepatic veins
Three lateral visceral tributaries: the right suprarenal vein, renal veins, right testicular or ovarian vein
Lateral abdominal wall tributaries: inferior phrenic vein and four lumbar veins
Three veins of origin: two common iliac veins and the median sacral vein
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vascular lymphatic
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Route of Lymph Flow
Lymphatic capillaries
Collecting vessels: course through many lymph nodes
Lymphatic trunks: drain major portions of bodyCollecting ducts :
right lymphatic duct – receives lymph from R arm, R side of head and thorax;
empties into R subclavian vein
thoracic duct - larger and longer, begins as a prominent sac in abdomen called the
cisterna chyli, receives lymph from below diaphragm, left arm, left side of head, neck
and thorax; empties into L subclavian vein
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The Fluid Cycle
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Lymphatic Drainage of
Mammary and Axillary Regions
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Drainage of Thorax
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Esophagus
A hollow muscular tube
About 25 cm (10 in.) long
and 2 cm (0.80 in.) wide
Conveys solid food and
liquids to the stomach
Begins posterior to cricoid
cartilage
Is innervated by fibers from
the esophageal plexus
A hollow muscular tube
About 25 cm (10 in.) long and 2
cm wide.
Conveys solid food and liquids
to the stomach.
Begins posterior to cricoid
cartilage
Is innervated by fibers from the
esophageal plexus.….
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Starts at the level of:
Body of C6
Cricoid cartilage
Related to:
AnteriorlyPosteriorly
Trachea
Recurrent laryngeal n.
Vertebrae
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Anterior relations:
Trachea
Heart
Lt. bronchus
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Posterior relations:
Vertebrae
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Lateral relations:Left sideRight side
Lt. vagus
Aortic arch
Lt. lung & pleura
Azygos
Rt. vagus
Rt. lung & pleura
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It pierces the diaphragm at T10
Diaphragm
Diaphragm
T10
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It is about 4 – 5 cm. long
It ends at the gastroesophageal junction
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Cricopharyngeus muscle
Aortic arch
Left main bronchus
Opening in diaphragm
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Gastric Anatomy
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Lt. hypochondriumEpigastrium
Umbilical region
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Cardiac orifice at T10
Pyloric orifice at L1
Lesser curvature
Greater curvature
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Angle of Hiss
Incisura angularis Fundus
Body
Pyloric portion
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Anterior
Liver
Diaphragm
Anterior abdominal wall
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Lt. crus of diaphragm
Left kidney
Left suprarenal gland
Spleen
Splenic artery
Body of pancreas
Transverse mesocolon
Transverse colon
Posterior (stomach bed)
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Lt. crus of diaphragm
Left kidney
Left suprarenal gland
Spleen
Splenic artery
Body of pancreas
Transverse mesocolon
Transverse colon
Posterior (stomach bed)
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Blood Supply
The rich arterial supply of the stomach arises from the celiac trunk and its branches Most blood is supplied by anastomoses formed along the lesser curvature by the right and left gastric arteries, and along the greater curvature by the rightand left gastro-omental (gastroepiploic) arteries.The fundus and upper body receive blood from the shortand posterior gastric arteries.The veins of the stomachparallel the arteries in position and course
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Arteries of stomachLeft and right gastric
arteriesArise from celiac trunk and proper
hepatic artery, respectively.
These two vessels run in lesser
omentum along lesser curvature ,
and anastomose end-to-end.
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Arteries of stomachRight and left
gastroepiploic arteriesArise from the gastroduodenal and
splenic artery, respectively.
These two vessels pass into the
greater omentum, run parallel to
the greater curvature, and
anastomose end-to-end.
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Arteries of stomach
Short gastric arteriesBranches of splenic artery
Course through the gastrosplenic
ligament
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.
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Venous drainage of stomach
Right and left gastric veins
empty directly into portal vein.
Left gastroepiploic and short
gastric veins drain into portal
vein via the splenic vein.
Right gastroepiploic vein drain
into superior mesenteric vein.
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Lymph drainage 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 splenic ln.Suprapyloric 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.
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Nerve supply of stomach
Parasympathetic innervationThe anterior vagal trunk divides into anterior gastric and hepatic branchesThe posterior vagal trunk divides into posterior gastric and celiac branchesThe 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 the pyloric antrum to fan out into branches called “crow’s foot” to supply the pyloric partSympathetic innervationMainly from celiac gangliaAfferent and efferent fibers derives from thoracic segments (T5 -L1)
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Short gastric
Lt. gastroepiploic
Rt. gastroepiploic
Rt. gastric
Lt. gastric
Prepyloric vein of MayoIt is an intraoperative landmark of pylorus
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Small Intestine
90% of absorption occurs in the small intestine
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Small Intestine
The Duodenum
The segment of small intestine closest to stomach
25 cm (10 in.) long
“Mixing bowl” that receives chyme from stomach and
digestive secretions from pancreas and liver
Functions of the duodenum
To receive chyme from stomach
To neutralize acids before they can damage the absorptive surfaces of
the small intestine
![Page 654: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/654.jpg)
It forms a C - shaped curve around the head of the pancreas
![Page 655: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/655.jpg)
It is fixed in the front surface of the structures of the posterior abdominal wall
Rt Kidney
Quadratus Lumborum
Vertebrae
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1st Part:Starts at the level of L1
L1
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1st Part:It’s 2 inches long1st inch is the only mobile part
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1st Part:
covered anteriorly by the peritoneum of the greater sac
![Page 659: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/659.jpg)
1st Part:covered posteriorly by the peritoneum of the lesser sac
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1st Part: Relations
1.Superior
Epiploic foramen
![Page 661: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/661.jpg)
1st Part: Relations
2.Posterior
IVC
Portal VeinCBD
Gastroduodenal a.
![Page 662: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/662.jpg)
1st Part: Relations
3.Anterior
1st
Neck of G.BQuadrate lobe
![Page 663: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/663.jpg)
2nd Part:
It is 3 inches long
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2nd Part:
L1
L2
L3
It descends vertically from L1 – L3
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2nd Part:The bile duct units with main pancreatic duct to form ampulla of Vater
Which open in the posteromedial aspect of 2nd part
C.B.D
Ampulla of Vater
Main pancreatic duct
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2nd Part:
The accessory pancreatic duct opens separately 1 inch above the ampulla of Vater
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2nd Part: Relations
1.Anterior
2ndTransverse colon
Liver
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2nd Part: Relations
2nd
2.Posterior
Rt. kidney
Rt. Psoas major m.
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3rd Part:
It is 4 inches long
![Page 670: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/670.jpg)
3rd Part:Relations
1.Anterior
Superior mesenteric vein
Superior mesenteric artery
![Page 671: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/671.jpg)
3rd Part:Relations
2.Superior
Head of pancreas
![Page 672: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/672.jpg)
3rd Part:Relations
3.Posterior
3rd
Aorta
Inferior mesenteric a.
I.V.C
Rt. ureter
Rt. Psoas major m.
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3rd Part:Relations
4.Inferior
3rd
Small intestine
![Page 674: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/674.jpg)
4th Part:
It is 1 inch longIt ends at the duodenojejunal flexureThe duodenojejunal flexure supported by ligament of Treitz from Rt. Crus of diaphragm
Rt. Crus of diaphragm
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Superior pancreaticodudenal
Inferior pancreaticodudenal
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Small Intestine
The Jejunum Is the middle segment of small intestine
2.5 meters (8.2 ft) long
Is the location of mostChemical digestion
Nutrient absorption
Has few plicae circulares
Small villi
![Page 678: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/678.jpg)
Small Intestine
The Ileum
The final segment of small intestine
3.5 meters (11.48 ft) long
Ends at the ileocecal valve, a sphincter that controls flow of material from the
ileum into the large intestine
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Jejunum Ileum
Distal 3/5 Proximal 2/5
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Jejunum Ileum
Has 1 or 2 arterial arcades
Has 2 or 3 arterial arcades
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Jejunum Ileum
Large diameter with few lymphoid follicles Small diameter with Peyer’s patches
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Jejunum Ileum
Large villi Small villi
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Large Intestine
Is horseshoe shaped
Extends from end of ileum to anus
Lies inferior to stomach and liver
Frames the small intestine
Also called large bowel
Is about 1.5 meters (4.9 ft) long and 7.5 cm (3
in.) wide
![Page 685: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/685.jpg)
At the end of ileum
![Page 686: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/686.jpg)
By the anal canal
![Page 687: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/687.jpg)
Appendix
Caecum
Ascending colon
Hepatic flexure
Transverse colon
Splenic flexure
Descending colon
Sigmoid colon
Rectum
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No teniae coli in the rectum
Haustrations
Teniae coli
Appendices epiploicae
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1.Transverse mesocolon attached to anterior border of pancreas
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2. Ascending & descending colons are covered on front & side by peritoneum
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3. Sigmoid mesocolon has 2 limbs forming inverted V-shaped mesentery
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Arterial supply
Superior mesentric artery
Middle colic artery
Rt. colic artery
Ileocolic artery
Inferior mesentric artery
Lt. colic artery
Sigmoid arteries
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Venous drainage
Veins are parallel to arteries & have similar names & drain in portal vein
Portal v.
Superior mesentric vein
Middle colic vein
Rt. colic vein
Ileocolic vein
Inferior mesentric vein
Lt. colic vein
Sigmoid veins
![Page 694: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/694.jpg)
Distal group
Intermediate group
Proximal group
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Parts of Large Intestine
The CecumIs an expanded pouch Receives material arriving from the ileum
Appendix
Also called vermiform appendix
Is a slender, hollow appendage
about 9 cm (3.6 in.) long
Is dominated by lymphoid nodules (a
lymphoid organ)
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Rt. Iliac fossa
![Page 697: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/697.jpg)
Subhepatic
Lt. iliac fossa in Situs inversus totalis
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Attached to posteromedial aspect of caecum 2 cm below the iliocaecal valve
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2 – 20 cm (average 10 cm)
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The tip points to one of the following positions
Paracaecal
Pelvic
Postileal
Preileal Retrocaecal
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Mc Burney’s point: at junction of lateral 1/3 & medial 2/3 of line extending from
A.S.I.S to umbilicus
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Stops shortly at tip of appendix
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Mucosa
Submucosa
(rich in lymphoid tissue)
Musculosa
Serosa
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From appendicular artery
![Page 705: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/705.jpg)
Parts of Large Intestine
The Colon
Has a larger diameter and thinner wall than small intestine
The wall of the colon
Forms a series of pouches (haustrations)
Haustrations permit expansion and elongation of colon
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Parts of Colon
Ascending Colon
Begins at superior border of cecum
Ascends along right lateral and posterior wall of peritoneal cavity
to inferior surface of the liver and bends at right colic flexure
(hepatic flexure)
Transverse Colon
Crosses abdomen from right to left; turns at left colic flexure
(splenic flexure)
Is supported by transverse mesocolon
Is separated from anterior abdominal wall by greater omentum
![Page 707: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/707.jpg)
Parts of Colon
The Descending Colon Proceeds inferiorly along left side to the iliac fossa (inner
surface of left ilium)
Is retroperitoneal, firmly attached to abdominal wall
The Sigmoid Colon Is an S-shaped segment, about 15 cm (6 in.) long
Starts at sigmoid flexure
Lies posterior to urinary bladder
Is suspended from sigmoid mesocolon
Empties into rectum
![Page 708: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/708.jpg)
Parts of Colon
![Page 709: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/709.jpg)
Parts of Large Intestine
The RectumForms last 15 cm (6 in.) of digestive tractIs an expandable organ for temporary storage of fecesMovement of fecal material into rectum triggers urge to defecate The anal canal is the last portion of the rectumContains small longitudinal folds called anal columns
AnusAlso called anal orificeIs exit of the anal canalHas keratinized epidermis like skin
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Begins at S3
Ends 1 inch below & infront of coccyx
Length: 5 inches
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Anteroposteriorly: concave anteriorly Side to side: concave 1st to Rt. Then to Lt. then to Rt. Forming valves of Houston
Valves of Houston
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Upper 1/3: covered by peritoneum from front & side Middle 1/3: covered by peritoneum from front
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Lower 1/3: devoid of peritoneal coverage
![Page 714: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/714.jpg)
Fascia of Denonvillier
Anteriorly Posteriorly
Fascia of Waldeyer
![Page 715: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/715.jpg)
Anterior
1-Male
Coils of ileum &sigmoid colon
Base of bladder
Seminal vesicles
Vas deferens
Prostate
![Page 716: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/716.jpg)
Anterior
2-Female
Coils of ileum & sigmoid colon
Uterus & upper part of vagina(with rectouterine pouch in between)
Lower part of vagina(no peritoneum in between)
![Page 717: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/717.jpg)
Posterior
1-Bones and ligaments
Lower ½ of sacrum
Coccyx
Anoccygeal Ligament
![Page 718: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/718.jpg)
Posterior
2-Muscles
Piriformis
Coccygeus
Levator Ani
![Page 719: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/719.jpg)
Posterior
3- Vessels
Superior Rectal
Lateral Sacral
Median Sacral
![Page 720: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/720.jpg)
Posterior
4- Nerves
Sympathetic Trunk
Lower 3 sacral nerves
Coccygeal nerves
![Page 721: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/721.jpg)
On each side
Para-rectal fossa
![Page 722: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/722.jpg)
On each side
Inferior Hypogastric Nerve Plexus
Coccygeus
Levator Ani
![Page 723: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/723.jpg)
Begins 1 inch below and in front of tip of coccyx
Ends at Anal Verge
Length = 4 cm
![Page 724: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/724.jpg)
724
RectumIn pelvisNo teniaeStrong longitudinal muscle layerHas valvesAnal canalPectinate line*Inferior to it: sensitive to painHemorrhoids (enlarged veins)Superior to pectinate line: internalInferior to pectinate line: externalSphincters (close opening)Internal*smooth muscleinvoluntaryExternal* skeletal musclevoluntary
*
*
*
![Page 725: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/725.jpg)
![Page 726: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/726.jpg)
Mucosa
Pectin
Dentate Line
![Page 727: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/727.jpg)
At the level of puborectalis the anorectal ring is formed of:
1- Internal sphincter
2- Deep external sphincter
3- puborectalis
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![Page 729: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/729.jpg)
Esophagus
A hollow muscular tube
About 25 cm (10 in.) long
and 2 cm (0.80 in.) wide
Conveys solid food and
liquids to the stomach
Begins posterior to cricoid
cartilage
Is innervated by fibers from
the esophageal plexus
A hollow muscular tube
About 25 cm (10 in.) long and 2
cm wide.
Conveys solid food and liquids
to the stomach.
Begins posterior to cricoid
cartilage
Is innervated by fibers from the
esophageal plexus.….
![Page 730: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/730.jpg)
Starts at the level of:
Body of C6
Cricoid cartilage
Related to:
AnteriorlyPosteriorly
Trachea
Recurrent laryngeal n.
Vertebrae
![Page 731: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/731.jpg)
Anterior relations:
Trachea
Heart
Lt. bronchus
![Page 732: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/732.jpg)
Posterior relations:
Vertebrae
![Page 733: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/733.jpg)
Lateral relations:Left sideRight side
Lt. vagus
Aortic arch
Lt. lung & pleura
Azygos
Rt. vagus
Rt. lung & pleura
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It pierces the diaphragm at T10
Diaphragm
Diaphragm
T10
![Page 735: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/735.jpg)
It is about 4 – 5 cm. long
It ends at the gastroesophageal junction
![Page 736: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/736.jpg)
Cricopharyngeus muscle
Aortic arch
Left main bronchus
Opening in diaphragm
![Page 737: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/737.jpg)
![Page 738: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/738.jpg)
Gastric Anatomy
![Page 739: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/739.jpg)
Lt. hypochondriumEpigastrium
Umbilical region
![Page 740: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/740.jpg)
Cardiac orifice at T10
Pyloric orifice at L1
Lesser curvature
Greater curvature
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Angle of Hiss
Incisura angularis Fundus
Body
Pyloric portion
![Page 742: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/742.jpg)
Anterior
Liver
Diaphragm
Anterior abdominal wall
![Page 743: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/743.jpg)
Lt. crus of diaphragm
Left kidney
Left suprarenal gland
Spleen
Splenic artery
Body of pancreas
Transverse mesocolon
Transverse colon
Posterior (stomach bed)
![Page 744: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/744.jpg)
Lt. crus of diaphragm
Left kidney
Left suprarenal gland
Spleen
Splenic artery
Body of pancreas
Transverse mesocolon
Transverse colon
Posterior (stomach bed)
![Page 745: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/745.jpg)
Blood Supply
The rich arterial supply of the stomach arises from the celiac trunk and its branches Most blood is supplied by anastomoses formed along the lesser curvature by the right and left gastric arteries, and along the greater curvature by the rightand left gastro-omental (gastroepiploic) arteries.The fundus and upper body receive blood from the shortand posterior gastric arteries.The veins of the stomachparallel the arteries in position and course
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Arteries of stomachLeft and right gastric
arteriesArise from celiac trunk and proper
hepatic artery, respectively.
These two vessels run in lesser
omentum along lesser curvature ,
and anastomose end-to-end.
![Page 747: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/747.jpg)
Arteries of stomachRight and left
gastroepiploic arteriesArise from the gastroduodenal and
splenic artery, respectively.
These two vessels pass into the
greater omentum, run parallel to
the greater curvature, and
anastomose end-to-end.
![Page 748: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/748.jpg)
Arteries of stomach
Short gastric arteriesBranches of splenic artery
Course through the gastrosplenic
ligament
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.
![Page 749: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/749.jpg)
Venous drainage of stomach
Right and left gastric veins
empty directly into portal vein.
Left gastroepiploic and short
gastric veins drain into portal
vein via the splenic vein.
Right gastroepiploic vein drain
into superior mesenteric vein.
![Page 750: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/750.jpg)
Lymph drainage 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 splenic ln.Suprapyloric 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.
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Nerve supply of stomach
Parasympathetic innervationThe anterior vagal trunk divides into anterior gastric and hepatic branchesThe posterior vagal trunk divides into posterior gastric and celiac branchesThe 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 the pyloric antrum to fan out into branches called “crow’s foot” to supply the pyloric partSympathetic innervationMainly from celiac gangliaAfferent and efferent fibers derives from thoracic segments (T5 -L1)
![Page 752: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/752.jpg)
Short gastric
Lt. gastroepiploic
Rt. gastroepiploic
Rt. gastric
Lt. gastric
Prepyloric vein of MayoIt is an intraoperative landmark of pylorus
![Page 753: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/753.jpg)
Small Intestine
90% of absorption occurs in the small intestine
![Page 754: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/754.jpg)
![Page 755: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/755.jpg)
Small Intestine
The Duodenum
The segment of small intestine closest to stomach
25 cm (10 in.) long
“Mixing bowl” that receives chyme from stomach and
digestive secretions from pancreas and liver
Functions of the duodenum
To receive chyme from stomach
To neutralize acids before they can damage the absorptive surfaces of
the small intestine
![Page 756: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/756.jpg)
It forms a C - shaped curve around the head of the pancreas
![Page 757: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/757.jpg)
It is fixed in the front surface of the structures of the posterior abdominal wall
Rt Kidney
Quadratus Lumborum
Vertebrae
![Page 758: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/758.jpg)
1st Part:Starts at the level of L1
L1
![Page 759: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/759.jpg)
1st Part:It’s 2 inches long1st inch is the only mobile part
![Page 760: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/760.jpg)
1st Part:
covered anteriorly by the peritoneum of the greater sac
![Page 761: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/761.jpg)
1st Part:covered posteriorly by the peritoneum of the lesser sac
![Page 762: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/762.jpg)
1st Part: Relations
1.Superior
Epiploic foramen
![Page 763: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/763.jpg)
1st Part: Relations
2.Posterior
IVC
Portal VeinCBD
Gastroduodenal a.
![Page 764: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/764.jpg)
1st Part: Relations
3.Anterior
1st
Neck of G.BQuadrate lobe
![Page 765: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/765.jpg)
2nd Part:
It is 3 inches long
![Page 766: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/766.jpg)
2nd Part:
L1
L2
L3
It descends vertically from L1 – L3
![Page 767: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/767.jpg)
2nd Part:The bile duct units with main pancreatic duct to form ampulla of Vater
Which open in the posteromedial aspect of 2nd part
C.B.D
Ampulla of Vater
Main pancreatic duct
![Page 768: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/768.jpg)
2nd Part:
The accessory pancreatic duct opens separately 1 inch above the ampulla of Vater
![Page 769: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/769.jpg)
2nd Part: Relations
1.Anterior
2ndTransverse colon
Liver
![Page 770: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/770.jpg)
2nd Part: Relations
2nd
2.Posterior
Rt. kidney
Rt. Psoas major m.
![Page 771: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/771.jpg)
3rd Part:
It is 4 inches long
![Page 772: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/772.jpg)
3rd Part:Relations
1.Anterior
Superior mesenteric vein
Superior mesenteric artery
![Page 773: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/773.jpg)
3rd Part:Relations
2.Superior
Head of pancreas
![Page 774: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/774.jpg)
3rd Part:Relations
3.Posterior
3rd
Aorta
Inferior mesenteric a.
I.V.C
Rt. ureter
Rt. Psoas major m.
![Page 775: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/775.jpg)
3rd Part:Relations
4.Inferior
3rd
Small intestine
![Page 776: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/776.jpg)
4th Part:
It is 1 inch longIt ends at the duodenojejunal flexureThe duodenojejunal flexure supported by ligament of Treitz from Rt. Crus of diaphragm
Rt. Crus of diaphragm
![Page 777: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/777.jpg)
Superior pancreaticodudenal
Inferior pancreaticodudenal
![Page 778: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/778.jpg)
![Page 779: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/779.jpg)
Small Intestine
The Jejunum Is the middle segment of small intestine
2.5 meters (8.2 ft) long
Is the location of mostChemical digestion
Nutrient absorption
Has few plicae circulares
Small villi
![Page 780: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/780.jpg)
Small Intestine
The Ileum
The final segment of small intestine
3.5 meters (11.48 ft) long
Ends at the ileocecal valve, a sphincter that controls flow of material from the
ileum into the large intestine
![Page 781: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/781.jpg)
Jejunum Ileum
Distal 3/5 Proximal 2/5
![Page 782: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/782.jpg)
Jejunum Ileum
Has 1 or 2 arterial arcades
Has 2 or 3 arterial arcades
![Page 783: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/783.jpg)
Jejunum Ileum
Large diameter with few lymphoid follicles Small diameter with Peyer’s patches
![Page 784: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/784.jpg)
Jejunum Ileum
Large villi Small villi
![Page 785: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/785.jpg)
![Page 786: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/786.jpg)
Large Intestine
Is horseshoe shaped
Extends from end of ileum to anus
Lies inferior to stomach and liver
Frames the small intestine
Also called large bowel
Is about 1.5 meters (4.9 ft) long and 7.5 cm (3
in.) wide
![Page 787: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/787.jpg)
At the end of ileum
![Page 788: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/788.jpg)
By the anal canal
![Page 789: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/789.jpg)
Appendix
Caecum
Ascending colon
Hepatic flexure
Transverse colon
Splenic flexure
Descending colon
Sigmoid colon
Rectum
![Page 790: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/790.jpg)
No teniae coli in the rectum
Haustrations
Teniae coli
Appendices epiploicae
![Page 791: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/791.jpg)
1.Transverse mesocolon attached to anterior border of pancreas
![Page 792: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/792.jpg)
2. Ascending & descending colons are covered on front & side by peritoneum
![Page 793: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/793.jpg)
3. Sigmoid mesocolon has 2 limbs forming inverted V-shaped mesentery
![Page 794: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/794.jpg)
Arterial supply
Superior mesentric artery
Middle colic artery
Rt. colic artery
Ileocolic artery
Inferior mesentric artery
Lt. colic artery
Sigmoid arteries
![Page 795: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/795.jpg)
Venous drainage
Veins are parallel to arteries & have similar names & drain in portal vein
Portal v.
Superior mesentric vein
Middle colic vein
Rt. colic vein
Ileocolic vein
Inferior mesentric vein
Lt. colic vein
Sigmoid veins
![Page 796: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/796.jpg)
Distal group
Intermediate group
Proximal group
![Page 797: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/797.jpg)
Parts of Large Intestine
The CecumIs an expanded pouch Receives material arriving from the ileum
Appendix
Also called vermiform appendix
Is a slender, hollow appendage
about 9 cm (3.6 in.) long
Is dominated by lymphoid nodules (a
lymphoid organ)
![Page 798: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/798.jpg)
Rt. Iliac fossa
![Page 799: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/799.jpg)
Subhepatic
Lt. iliac fossa in Situs inversus totalis
![Page 800: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/800.jpg)
Attached to posteromedial aspect of caecum 2 cm below the iliocaecal valve
![Page 801: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/801.jpg)
2 – 20 cm (average 10 cm)
![Page 802: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/802.jpg)
The tip points to one of the following positions
Paracaecal
Pelvic
Postileal
Preileal Retrocaecal
![Page 803: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/803.jpg)
Mc Burney’s point: at junction of lateral 1/3 & medial 2/3 of line extending from
A.S.I.S to umbilicus
![Page 804: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/804.jpg)
Stops shortly at tip of appendix
![Page 805: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/805.jpg)
Mucosa
Submucosa
(rich in lymphoid tissue)
Musculosa
Serosa
![Page 806: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/806.jpg)
From appendicular artery
![Page 807: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/807.jpg)
Parts of Large Intestine
The Colon
Has a larger diameter and thinner wall than small intestine
The wall of the colon
Forms a series of pouches (haustrations)
Haustrations permit expansion and elongation of colon
![Page 808: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/808.jpg)
Parts of Colon
Ascending Colon
Begins at superior border of cecum
Ascends along right lateral and posterior wall of peritoneal cavity
to inferior surface of the liver and bends at right colic flexure
(hepatic flexure)
Transverse Colon
Crosses abdomen from right to left; turns at left colic flexure
(splenic flexure)
Is supported by transverse mesocolon
Is separated from anterior abdominal wall by greater omentum
![Page 809: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/809.jpg)
Parts of Colon
The Descending Colon Proceeds inferiorly along left side to the iliac fossa (inner
surface of left ilium)
Is retroperitoneal, firmly attached to abdominal wall
The Sigmoid Colon Is an S-shaped segment, about 15 cm (6 in.) long
Starts at sigmoid flexure
Lies posterior to urinary bladder
Is suspended from sigmoid mesocolon
Empties into rectum
![Page 810: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/810.jpg)
Parts of Colon
![Page 811: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/811.jpg)
Parts of Large Intestine
The RectumForms last 15 cm (6 in.) of digestive tractIs an expandable organ for temporary storage of fecesMovement of fecal material into rectum triggers urge to defecate The anal canal is the last portion of the rectumContains small longitudinal folds called anal columns
AnusAlso called anal orificeIs exit of the anal canalHas keratinized epidermis like skin
![Page 812: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/812.jpg)
Begins at S3
Ends 1 inch below & infront of coccyx
Length: 5 inches
![Page 813: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/813.jpg)
Anteroposteriorly: concave anteriorly Side to side: concave 1st to Rt. Then to Lt. then to Rt. Forming valves of Houston
Valves of Houston
![Page 814: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/814.jpg)
Upper 1/3: covered by peritoneum from front & side Middle 1/3: covered by peritoneum from front
![Page 815: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/815.jpg)
Lower 1/3: devoid of peritoneal coverage
![Page 816: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/816.jpg)
Fascia of Denonvillier
Anteriorly Posteriorly
Fascia of Waldeyer
![Page 817: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/817.jpg)
Anterior
1-Male
Coils of ileum &sigmoid colon
Base of bladder
Seminal vesicles
Vas deferens
Prostate
![Page 818: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/818.jpg)
Anterior
2-Female
Coils of ileum & sigmoid colon
Uterus & upper part of vagina(with rectouterine pouch in between)
Lower part of vagina(no peritoneum in between)
![Page 819: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/819.jpg)
Posterior
1-Bones and ligaments
Lower ½ of sacrum
Coccyx
Anoccygeal Ligament
![Page 820: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/820.jpg)
Posterior
2-Muscles
Piriformis
Coccygeus
Levator Ani
![Page 821: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/821.jpg)
Posterior
3- Vessels
Superior Rectal
Lateral Sacral
Median Sacral
![Page 822: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/822.jpg)
Posterior
4- Nerves
Sympathetic Trunk
Lower 3 sacral nerves
Coccygeal nerves
![Page 823: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/823.jpg)
On each side
Para-rectal fossa
![Page 824: Practical surgery](https://reader038.fdocuments.us/reader038/viewer/2022103002/55a74e1d1a28abc1638b4675/html5/thumbnails/824.jpg)
On each side
Inferior Hypogastric Nerve Plexus
Coccygeus
Levator Ani
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Begins 1 inch below and in front of tip of coccyx
Ends at Anal Verge
Length = 4 cm
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826
RectumIn pelvisNo teniaeStrong longitudinal muscle layerHas valvesAnal canalPectinate line*Inferior to it: sensitive to painHemorrhoids (enlarged veins)Superior to pectinate line: internalInferior to pectinate line: externalSphincters (close opening)Internal*smooth muscleinvoluntaryExternal* skeletal musclevoluntary
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Mucosa
Pectin
Dentate Line
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At the level of puborectalis the anorectal ring is formed of:
1- Internal sphincter
2- Deep external sphincter
3- puborectalis