Right colic flexure.

Right colic flexure- it is a place where the colon bends forwards, downwards and
to the left. It lies at the junction of the ascending colon and transverse colon, on the
lower part of the right kidney. The right colic flexure attaches to the vertebral
surface of the right lobe of the liver.
Transverse colon.
It passes from right to left, (from the L2 vertebra up to the Th12 vertebra) crosses
the descending part of the duodenum, head and neck of the pancreas. It is related
inferiorly to the loops of the small intestine. It covers with the peritoneum from all
sides- infraperitoneally which forms a wide mesentery, attaching to the posterior
wall of the parietal peritoneum.
Left colic flexure.
In the left part of the peritoneal cavity the transverse colon bends downwards and
backwards and forms the left flexure. It lies on the lower part of the left kidney,
behind the stomach and below the spleen. T the level of the 11 th rib the flexure is
attached to the diaphragm with phrenicocolic ligament. This ligament separates the
pregastric burse and left lateral canal.
Descending colon.
This colon connects the left colic flexure to the sigmoid colon. It runs from the
Th12 vertebra up to the iliac crest. The descending colon covers with peritoneum
mesoperitoneally (from left anterior and right sides). Its posterior wall lies in the
retroperitoneal fat and is covered with the Toldi’s fascia.
The descending colon is narrower and shorter than ascending colon. It is related to
the coils of small intestine- anteriorly, and to the left kidney and muscles of the
posterior abdominal wall (psoas muscle, iliacus muscle, quadratus lumborum
muscle).
Sigmoid colon.
Large intestine.
The large intestine is supplied with the superior and inferior mesenteric arteries.
The right part of the large intestine is supplied with the superior mesenteric artery.
The ileocaecal part caecum and lower part of ascending colon supplied with the
iliocolic artery. The most part of ascending colon is supplied with the right colic
artery.
The right colic flexure and right halp of the transverse colon are supplied with the
right middle artery.
The left part of the large intestine is supplied with the inferior mesenteric artery.
Left part of the transverse colon, left colic flexure and descending colon are
supplied with the left colic artery. The sigmoid artery and partly the descending
colon are supplied with the sigmoid arteries (4 in number).
The retroperitoneal space.
Retroperitoneal space is situated between the endoabdominal fascia (posteriorly)
and the posterior peritoneal wall. Superiorly it is bordered with the diaphragm,
inferiorly- the terminal line of the pelvis. It consists of three layers of the fat. The
retroperitoneal fascia which origin from the unite of the endoabdominal fascia and
peritoneum passes posteriorly and divides into two parts, covers the kidney and
unites with the same fascia of the other side. When we pass from posterior to
anterior direction the
-first part is- textus cellulosus retroperitonealis (retroperitoneal proprial fat);
-second part is- parenephrom. It’s a layer of the fat between the kidney and the
retroperitoneal fascia. It is a fat sheath of the kidney.
-third part – paracolon. It’s a narrow fat’s clift between the posterior walls of the
ascending and descending colic and retroperitoneal space. All of them locate in the
proprial cellular space.
There are the next organs:
- the descending part of the duodenum
- pancreas
- the origin of the thoracic duct.
Arteries nerves and veins of the retroperitoneal cavity.
They are:
- abdominal aorta and its branches
 - inferior cava vein and its tributaries
- portal vein
- the origin of the azygos and hemiazygos veins
- lumbal nerve plexuses.
The topography of the abdominal aorta.
It enters the abdominal cavity through the aortic opening of the diaphragm at the
level of the Th12 vertebra. Then it lies along the left side of the vertebra column
and passes downward up to the L4 where it divides into to common iliac arteries.
It relates anteriorly with the loops of the small intestine, the body of the pancreas,
transverse colon, ascending part of the duodenum.
From the left side it attaches to the left renal vein, from the right side- to the
inferior cava vein with the sympathetic chain.
The branches of the abdominal aorta.
They may be pairs and single. They arise as following
1. the inferior phrenic arteries. They give two suprarenal arteries.
2. the coeliac trunk
3. the superior mesenteric artery
4. the middle suprarenal arteries
5. the kidney’s arteries. They give to inferior-uprarenal arteries
6. the ovaric arteries
7. first and second lumbal arteries
8. the inferior mesenteric artery
9. third and fourth lumbal arteries
10.median sacral artery
The lumbal plexus of nerves.
It is in the posterior part of the psoas major, anterior to the lumbar transverse
processes. This nerve network is composed of the anterior rami of L1-L4 nerves.
All rami receive gray communication branches from sympathetic trunks. They are
as following:
1. subcostal nerve (Th12-L1)
 2. ilioinguinal nerve (L1)
3. iliohypogastric nerve (L1)
4. lumbosacral trunk (L4 L5) passes over the ala of the sacrum and descends
into the pelvis to participate in the formation of the sacral plexus along with
the anterior rami of the S1-S4 nerves
5. the lateral cutaneous nerve of the thigh (L2 L3)
6. the femoral nerve (L2-L4)
7. the genital ramus of the genitofemoral nerve (L1 L2)
8. the obturator nerve (L2-L4)
Inferior vena cava.
The inferior cava vein is formed by the union of the right and left common iliac
veins on the right side of the body of vertebra L5. It ascends along the vertebra
column, grooves the posterior surface of the liver, pierces the central tendon of the
diaphragm and opens into the lower and posterior part of the right atrium.
Relation:
Anteriorly: 1) small intestine; 2) portal vein; 3) second part of the duodenum; 4)
head of the pancreas; 5) right common iliac artery.
Posteriorly: 1) right renal, middle suprarenal and inferior phrenic arteries; 2) the
right suprarenal gland; 3) the right sympathetic chain; 4) medial border of the right
psoas muscle.
Tributaries of the inferior cava vein.
1. the common iliac veins which form the inferior cava vein. The median sacral
vein joins the left common iliac vein.
2. the lumbar veins run with the same name arteries. All these veins open into
the posterior aspect of the left side cross behind the aorta to reach the vena
cava. The first and the second lumbar veins end in the third lumbar vein in
the azygos or hemiazygo vein.
3. the right gonadal (testicular or ovarium vein) opens into the inferior vena
cava, just below the entarence of the renal veins.
 The left gonadal vein drains into the left renal vein and forms the angle
between the left godanal vein and left renal vein. That’ why it is a hard way
for the blood and varices (dilated veins from pampiniform plexus) forms
more often in the left part of scrotum or greater labium.
4. the renal vein joins the inferior vena cava just below the transpiloric plane.
Each renal vein lies in front of the corresponding artery. The right vein is
shorter than the left. The left vein crosses in front of aorta and lies behind
the pancreas and the splenic vein. It receives the left suprarenal and gonadal
veins. The right suprarenal vein opens into the inferior vena cava.
5. the hepatic veins open directly into the anterior surface of the inferior vena
cava just before it pierces the diaphragm.
The portal vein.
This is a large vein which collects blood from the nonpare organs: 1) the stomach;
2) the pancreas; 3) the spleen; 4) the gall bladder; 5) the small intestine; 6) the
large intestine. It collects poorly oxygenated but nutrient rich blood from the
abdominal part of the alimentary tract.
It is formed at the level L1-2 vertebra behind the head of the pancreas by the union
of the superior mesenteric, inferior mesenteric and splenic veins.
It runs upwards behind the head of the pancreas, then behind the superior
horizontal part of the duodenum and then in the liver porte. It is situated between
the biliary duct and pronprial hepatic artery and covered with the hepaduodenal
ligament. It enters the liver where it is divided into the 5 sectoral and then 8
segmental veins.
Relation of the porta vein.
Anteriorly: head and neck of the pancreas, first part of the duodenum, common bile
duct, gastroduodenal artery.
Posteriorly: inferior cava vein.
Tributaries.
It receives the following veins: 1. splenic; 2. superior mesenteric; 3. left gastric; 4.
right gastric; 5. superior pancreatoduodenal; 6. cystic; 7. paraumbilical veins.
 Portocaval anastomoses.
There are the following portocaval anastomosis.
1. Umbilicus. The left branch of portal vein anastomosis with the vein of the
anterior abdominal wall (systemic) through the paraumbilical veins. In portal
obstruction the veins around the umbilicus enlarge forming caput medusae.
2. Lower end of esophagus. Esophageal tributaries of the left gastric vein
(portal) anastomose with the esophageal tributaries of the accessory
hemiazygos vein (systemic).
3. Anal canal. The superior rectal vein (portal) anastomosis with the inferior
and middle rectal veins (systemic).
4. Bare area of the liver. Hepatic venules (portal) anastomose with the phrenic
and intercostal veins (systemic).
5. Posterior abdominal wall. Veins of retoperitoneal organs (duodenum,
ascending and descending colon) (portal) anastomose with th retroperitoneal
veins of the abdominal wall and of the renal capsule (systemic). The splenic
vein anastomosis with the renal and azygos veins.
6. Liver. Rarely, the ductus venosus remains patent and connect the left branch
of the portal vein directly to the inferior vena cava.
Kidneys and ureters.
The kidneys are situated in the paranephron between the anterior and posterior
laminae of the retroperitoneal fascia. This fascia forms he external sheath of the
kidney. These sheath is filled in with the cellular perinephric (fat) which is called
paranephron and makes an adiposal (cellular) sheath of the kidney. On the external
surface of the kidney there is a fibrous capsule. It is a third capsule of the kidney.
The kidney’s proection to the anterior abdominal wall is the epigastric,
hypochondriac, lateral and umbilical regions.
The proection of the kidney’s portae to the anterior abdominal wall is the anterior
kidney’s point. It is in the point where the external side of the rectal muscle ancl
hypohondric arch.
Proection of the renal portae to the posterior abdominal wall is in the point where
the latissimus dorsi muscle crosses the external side of the spinal erectal muscle.
The skeletotopy of the kidneys is different in the left and right side. In the right is a
level of Th12-L2 vertebra.
In the left it is a level of the Th11-L1 vertebra.
Relation of the kidneys.
Right kidney.
Superiorly the right suprarenal gland, the right lobe of the liver.
Anteriorly: second part of the duodenum, hepatic flexure of colon, small intestine.
The lateral border of the right kidney is related inferior cava vein.
Posteriorly: the diaphragm, the psoas major, the quadratus lumborum, the
transverse abdominis.
The right kidney is crossed with the 12 rib which divides it as: one third from the
upper and two thirds from lower.
Relation of the left kidney.
Superiorly: the left suprarenal gland spleen, stomach, pancreas, splenic flexure and
descending colon and jejunum.
Laterally: the abdominal aorta.
Posteriorly: the same elements as the posterior surface of the right kidney.
Differences between the small intestine and the large intestine.

teature Small intstine iMrge intestine

1. Appendices epiploicae Absent Present
2. Taeniae coli Absent Present
3. Sacculations Absent Present
4. Caliber Larger Smaller
5. Fixity Greater part is freely Greater part is fixed
mobile
6. Villi Present Absent
7. Transverse mucosal Permanent Obliterated when
folds longitudinal
8. Peyer’s patches Present in ileum Absent.
 Jejunum and ileum.
The jejunum and ileum are suspended from the posterior abdominal wall by the
mesentery. The jejunum begins at the duodenojejunal flexure.
Differences between jejunum and ileum.
Feature Jejunum Ileum
1. Location Occupies upper and left Occupies lower and right
parts of the intestine area parts of the intestinal area
2. Walls Thicker and more Thinner and less vacular
vascular
3. Lumen Wider and often empty Narrower and often
(hence the name) loaded
4. Mesentery (a) Windows present, (b) (a) No windows, (b) Fat
Fat less abundant, (c) more abundant, (c)
Arterial arcades, 1 or 2. arterial arcades, (d) Vasa
(d) Vasa recta longer an recta shorter and more
fewer numerous
5. Circular mucosal fold Larger an more closely set Smaller and sparse
6. Villi Larger, thick (leaf- Shorter, thinner (finger-
like)and more abundant like) and less abundant.
7. Peyer’s patches Absent Present
8. Solitary lymphatic Fewer More numerous
follicles