Abdomen

Stany Lobo, PhD

stany.lobo@touro.edu

Anterior Abdominal Wall and the Inguinal region

 Anterior wall of the abdomen extends from the xiphoid process and the costal margin
above, to the iliac crest, anterior superior iliac spine, the inguinal ligament, pubic
tubercle, pubic crest and the pubic symphysis below. Posterolaterally is the 10th costal
cartilage in the midaxillary line.
 Abdominal cavity is located between the diaphragm and the inlet of the pelvis.
 However, the superior limit of the abdominal cavity is formed by the diaphragm which
extends as high as 4th intercostal space
 Umbilicus (disc between L3 & L4) is an important landmark on the anterior wall
 Costal margin is at the level of L1 in the mid-clavicular line (9th costal cartilage) and at
the level of L3 in the mid-axillary line (11th costal cartilage or 10th rib)
 Costodiaphragmatic recess crosses 12th rib posteriorly
 Pubic symphysis is at the level of coccyx
 Anterior wall is normally soft to palpate. It becomes rigid because of reflex contraction of
muscles of the anterior abdominal wall when there is some pathology inside the
abdominal cavity. This reflex contraction is called “guarding”
 When a cold hand or object is kept on the anterior wall, it makes the abdominal wall
muscles to contract reflexly. That is the reason why abdomen is palpated very gently with
the knees and hip semiflexed. This position keeps the abdominal wall muscles relaxed.
 Whenever abdominal incisions are made, due care should be given to the Langer’s lines.
Langer’s lines are usually horizontal in the anterior wall of the abdomen. Any incision
perpendicular to the Langer’s lines leaves a large scar. Sometimes it may lead to
development of keloids. When the abdominal wall is distended it may form reddish
streaks. These are especially marked in a pregnant woman called, Linea gravidarum.
They may permanently remain as white streaks called Linea albicantes.
 Superficial fascia of the anterior wall of the abdomen has two layers:
 Superficial fatty layer(Camper’s fascia), deep membranous layer (Scarpa’s fascia)
 Deep membranous layer is called Colles fascia in the perineum and dartos fascia in the
scrotum
 There is no demonstrable deep fascia in the anterior wall of the abdomen. If there were to
be thick deep fascia, then women would not have conceived and next meal of ours would
not have been a welcome thing.
 Caput medusae: In portal hypertension, the anastomosis between tributaries of portal
vein and the superficial veins of the abdominal wall open up and the veins radiate from
the umbilicus giving the appearance of the spokes of a wheel.
 Weeping umbilicus
 Umbilical hernia: Congenital, infantile and acquired types.
 Linea alba appear as a slight groove in the anterior abdominal wall. It is wide above. It is
formed by the underlying tendinous raphe formed by the interlacing fibers of the oblique
muscles
 Linea semilunaris is a curved groove extending from the tip of the 9th costal cartilage
(position of the fundus of the Gall bladder on the right) along the lateral margin of the
rectus sheath
 Midinguinal point: is the midpoint of the line between the symphysis pubis and the
anterior superior iliac spine. Below this point Femoral artery pulse can be palpated.
Immediately above and lateral to this point is the deep inguinal ring (land mark for
palpation of indirect inguinal hernial sac)
 Midpoint of the inguinal ligament: Midpoint between pubic tubercle and the anterior
superior iliac spine. It lies directly lateral to the origin of the inferior epigastric vessels

Nerve supply of the anterior abdominal wall:

 Skin over xiphoid process is supplied by the anterior cutaneous branches of
T7
 Skin around the umbilicus is supplied by the anterior cutaneous branches of T10
 Skin around the pubic symphysis is supplied by the branches of L1
 Therefore totally seven nerves- lower five intercostals, subcostal and L1 through
iliphypogastric and ilioinguinal nerves supply the anterior abdominal wall.
 The nerve trunks which supply the anterior wall of the abdomen are obliquely placed
while the dermatomes are relatively horizontal. This is because the lateral cutaneous
branches descend for some distance before they supply the skin.
 Iliohypogastric is at a higher level and ilioinguinal nerve is below it. Watch the names
of the nerves and visualize this in your memory
 Iliohypogastric and ilioinguinal nerves have the same root value L1. These nerves can
be anaesthetized by injecting one inch superior to the anterior superior iliac spine on a
spinoumbilical plane

Arterial supply of the anterior abdominal wall:

Important superficial arteries which come from the femoral artery are:
1. Superficial epigastric
2. superficial circumflex iliac
These two arteries do not lie in the neurovascular plane
Important deep arteries are the following:
1. superior epigastric
2. musculophrenic branches
3. lower posterior intercostal arteries
4. deep circumflex iliac artery
5. inferior epigastric

Venous drainage of the anterior abdominal wall:

It can be divided into two streams:
1. above the level of umbilicus which eventually drains into the superior vena cava
2. below the level of umbilicus which eventually drains into the inferior vena cava
Therefore the umbilicus is known as the plane of venous water-shed.
Superior to the level of umbilicus, the anterior wall of the abdomen is drained into:
 superior epigastric vein and musculophrenic veins which drain into the internal
thoracic and eventually into the superior vena cava.
 It also drains into the lateral thoracic vein which is a tributary of the axillary vein.
Axillary vein eventually opens into the superior vena cava.
The veins which drain the anterior abdominal wall below the level of umbilicus
eventually drain into the inferior vena cava. Therefore, the veins of the anterior wall are
enlarged when the superior or inferior vena cavae are occluded. During this enlargement,
a new channel opens up connecting the superficial epigastric vein to the lateral thoracic
vein. This communicating vein is called the “thoracoepigastric vein”. Blockage of
venous drainage through liver cause backflow & caput medusae

Lymphatic drainage of the anterior abdominal wall:

In the case of lymphatic drainage also there is umbilical water shed. Lymph vessels go
in two directions.
1) above the level of umbilicus, lymph is mainly drained into axillary group of lymph
nodes
2) below the level of umbilicus, lymph vessels drain into the superficial group of
inguinal lymph nodes mainly
In cancer of buttock the superficial inguinal lymph nodes are enlarged.

Quadrants of the anterior abdominal wall

It is divided into four quadrants by the umbilical and median plane
They are right upper quadrant, left upper quadrant, right lower quadrant and left lower
quadrant (refer to the power point for the diagram)

Nine regions of the anterior abdominal wall

Two vertical and two horizontal planes are employed:
Vertical planes are:
 midclavicular planes (right and left)

Horizontal planes are:

1) Transpyloric plane – L1
2) intertubercular plane – L5

Nine regions are:

1) Right hypochondrium
2) Left hypochondrium
3) Epigastric (all these lie superior to the transpyloric plane plane)

4) Right lumbar
5) Left lumbar
6) Umbilical (all these lie between the transpyloric and intertubercular planes)

7) Right iliac (inguinal)

8) Left iliac (inguinal)
 9) Hypogastric (all these lie inferior to the intertubercular plane)

Important clinical point:

 Pain arising out of the foregut derived structures is referred to the epigastric
region. Therefore, the pain of the stomach is referred to the epigastric region.
 Pain arising out of the midgut derived structures is referred to the umbilical
region. Therefore the pain of the small intestine is referred to this region.
 Pain arising out of the hindgut derived structures is referred to the hypogastric
region. Therefore the pain of the large intestine is referred to this region.

Muscles of the anterior abdominal wall:

There are five muscles:

Three flat muscles in the anterolateral part of the anterior abdominal wall are:
1) external oblique abdominis
2) internal oblique abdominis
3) transversus abdominis

Two vertical muscles lie on the anterior aspect

1) rectus abdominis
2) pyramidalis

External oblique abdominis: It arises from 5th to 12 ribs.

Fibers run downwards and medially and are inserted into the linea alba, pubic tubercle,
anterior superior iliac spine and ventral part of the iliac crest. It forms the inguinal
ligament between the pubic tubercle and anterior superior iliac spine.
Muscle fibers do not extend below the level of line connecting the anterior superior iliac
spine to the umbilicus.
Nerve supply: it is supplied by the lower 6 thoracic nerves
Action:while standing it acts at its origin and turns the trunk to the opposite side.
It assists the opposite internus abdominis while rotating the trunk to the opposite side.
Internal oblique abdominis:
It arises from the thoracolumbar fascia, iliac crest and lateral half of the inguinal
ligament.
It is expanded like a fan and is inserted into the lower ribs (10th to 12th), linea alba and
lower fibers join the lower fibers of the transversus abdominis to form the conjoint
tendon to be attached to the pubic crest.
Action: while standing, it acts at its insertion and turns the trunk to the same side.
When both external and internal oblique muscles of the same side contract, the opposite
rotation actions of these two muscles get cancelled and the trunk is bent to the same side.
This is an example of synergic action.
Nerve supply: lower six thoracic nerves and L1 through ilioinguinal and iliohypogastric
nerves

Transversus abdominis:
 This muscle arises from the lower six costal cartilages, from the thoracolumbar fascia, the
inner lip of the iliac crest, lateral ⅓ of the inguinal ligament.
It runs horizontally and is inserted into the linea alba. The lower fibers join the lower
fibers of the internal oblique abdominis to form the conjoint tendon to be attached to the
pubic crest.
Nerve supply: lower six thoracic nerves and L1 through ilioinguinal and iliohypogastric
nerves
Action: its contraction increases the intra-abdominal pressure and it protects the
underlying viscera. All three flat muscles contract when diaphragm relaxes. They relax
when diaphragm contracts. The contractions of these muscles help in explosive cough,
parturition, defecation and micturition.

Neurovascular plane:
This plane lies between the internal oblique abdominis and transversus abdominis
muscles. This is comparable to the neurovascular plane of the intercostal spaces
The neurovascular plane of the anterior abdominal wall contains the lower intercostal
nerves, lower intercostal arteries, iliohypogastric nerve, ilioinguinal nerve, deep
circumflex iliac artery.

Rectus sheath:
 This is the connective tissue sheath which encloses the rectus abdominis muscle.
Formation of sheath:
It is explained at three levels.
First level extends from above till the costal margin
Second level extends from the costal margin to a point midway between the umbilicus and pubic
symphysis
Third level extends from the level of the point midway between the umbilicus and pubic
symphysis to the lower end of the rectus abdominis.
First level:
Anteriorly: The aponeurosis of external oblique abdominis.
Posteriorly it directly rests on the 5th,6th and 7th costal cartilages and there is no aponeurosis
here.
Second level:
Anteriorly: it is covered by the aponeurosis of the external oblique and the anterior lamina of
internal oblique muscle aponeurosis.
Posteriorly: It is formed by the posterior lamina of the internal oblique and aponeurosis of the
transversus abdominis.
Third level:
Anteriorly: Aponeurosis of all the three muscles (E.O, I.O & T.O)
Posteriorly: Deficient, the rectus abdominis lies directly on fascia transversalis
Arcuate line: Represents lower edge of the transverse abdominis and posterior lamina of internal
oblique. Inferior epigastric vessels enter rectus sheath at its lateral corner
Contents:
2 arteries ( superior epigastric and inferior epigstric)
2 veins ( superior epigastric and inferior epigstric)
2 muscles ( rectus abdominis and pyramidalis)
6 nerves ( anterior branches of lower six thoracic nerves)

Rectus abdominis:
 It arises from below from the pubic crest and area in front of it
 It is inserted into the 5th,6th and 7th costal cartilages
 It has three tendinous intersections which bind the anterior surface of the muscle
to the anterior wall of the rectus sheath
Action: it flexes the vertebral column
It helps to protect the anterior abdominal wall
It helps prevent the breaking of the vertebrae during hyperextension
Nerve supply: all the nerves which lie inside the rectus sheath supply it (lower six
thoracic nerves)
Pyramidalis: It arises with the rectus abdominis muscle
It lies in front of it and is inserted into the linea alba
It acts as a guide for the surgeon to identify the midline.
It is often absent
Nerve supply: it is supplied by the subcostal nerve (T12)
Divarication of the Recti: Thinning and widening of the upper linea alba as a result of obesity
of chronic straining. Increased intraabdominal pressure causes the abdominal viscera to protrude
beneath the thinned tissue as a broad midline bulge. This is not true herniation as all the layers of
the abdominal wall are intact.

Inguinal region (groin)

Superficial inguinal ring:

 It is an triangular opening in the aponeurosis of the external oblique abdominis muscle.
 It lies superomedial to the pubic tubercle.
 Spermatic cord and ilioinguinal nerve pass through it in male.
 Round ligament of uterus and ilioinguinal nerve pass through it in female.
Deep inguinal ring:
 It is an opening in the transversalis fascia 1.25 cm superior to the middle point of the inguinal
ligament.
 Spermatic cord begins here.
 Therefore, ductus deferens, artery to ductus deferens, testicular artery, pampiniform plexus of
veins, sympathetic plexus of nerves & lymph vessels, remnant of the processus vaginalis pass
through this to form the spermatic cord.
 Inferior epigastric artery lies medial to the deep inguinal ring

Inguinal canal:
 It is 4 cm in length.
 It lies superior to the medial part of the inguinal ligament
 It extends from the deep to the superficial inguinal ring.
Definition: It is an oblique musculo-fascial passage above the medial end of the inguinal
ligament between the deep and superficial inguinal rings.
 Spermatic cord traverses it from the deep inguinal to the superficial inguinal ring
 Ilioinguinal nerve lies between the internal oblique and transversus abdominis muscles
and passes through the superficial inguinal ring.
 Ilioinguinal nerve does not pass through the deep inguinal ring.
Walls of the inguinal canal:
 It has a floor, anterior wall, posterior wall and a roof

Floor is formed by the grooved upper surface of the medial end of the inguinal ligament, and
medially by the
lacunar ligament.

Anterior wall is divided into medial and lateral parts.

 Medial part of the anterior wall is formed by the aponeurosis of external oblique
abdominis muscle only
 Lateral part of the anterior wall is formed by the aponeurosis of external oblique
abdominis and the origin of internal oblique muscle from the lateral half of the inguinal
ligament.
 Therefore, the lateral part of the anterior wall is strong and medial part of the anterior
wall is weak.
Posterior wall of the inguinal canal:
 It is divided into the medial and lateral parts.
 Medial part is formed by the conjoint tendon and transversalis fascia
 Lateral part is formed by the transversalis fascia only.
 Therefore, the lateral part of the posterior wall is weak and medial part of the posterior
wall is strong.
 Now visualize that the strong medial part of the posterior wall is placed opposite the
weak medial part of the anterior wall.

Roof is formed by the arching fibers of the internal oblique muscle assisted by a few fibers of the
transversus abdominis muscle.
 A hernia is a bulging of internal organs or tissues, which protrude through an
abnormal opening in the muscle wall. Hernias can occur in the abdomen, groin, and at the
site of a previous surgery.

Inguinal herniae:

 Abnormal protrusion through inguinal canal or through its superficial ring is called
inguinal hernia. This may occur due to the weakness of the inguinal region (acquired) or
may be congenital. It may be complete or incomplete. Complete hernia projects to the
scrotum.
 Inguinal hernia is more common in males because of relatively wide inguinal canal in
male. This is due to the spermatic cord present in the male. Femoral hernia is more
common in female because of wide femoral ring. This is due to the wider pelvis and
smaller vessels
 There are two types of inguinal hernia:
1. Direct inguinal hernia
2. Indirect inguinal hernia

Direct inguinal hernia:

It pierces the posterior wall directly and appears at the superficial inguinal ring
The hernial sac lies medial to the inferior epigastric artery
Therefore the pulsations of the inferior epigastric artery are felt lateral to the
hernial sac.

Indirect inguinal hernia:

 It passes through the deep inguinal ring, inguinal canal and superficial inguinal ring.
 The hernial sac lies lateral to the inferior epigastric artery. Therefore the pulsations of the
inferior epigastric artery are felt medial to the hernial sac.
 Indirect inguinal hernia may be congenital when the processus vaginalis persists or may
be acquired.

Inguinal and Femoral hernia differential: In inguinal hernia, the neck of the hernia is
superomedial to the pubic tubercle. In femoral hernia, the neck of the hernia is inferolateral to the
pubic tubercle.

Descent of testis:
 Testis develops in the lumbar region of the abdomen
 It develops between the transversalis fascia and peritoneum
 Lower end of the testis is connected to the gubernaculum which connects the testis to the
wall of scrotum and passes through the site of future inguinal canal.
 A diverticulum of peritoneum called the processus vaginalis follows the gubernaculum
and forms the inguinal canal as it runs through this part of the anterior abdominal wall.
 Processus vaginalis is completely obliterated except its terminal part which surrounds
the testis as the tunica vaginalis testis.
  If testis does not descend then it is called “cryptorchidism”(Crypto-hidden)
Note: cryptorchidism is often associated with tumor of testis
 If testis descends to an abnormal location it is called, “ectopic testis”
 If there is only one testis it is called “monarchism”
 The inflammation of testis is called “orchitis”.
Spermatic cord:
 It extends from the deep inguinal ring to the testis
It is made up of the following structures:
1. Ductus deferens
2. Artery to ducts deferens
3. Testicular artery
4. Pampiniform plexus of veins
5. Lymph vessels of testis and epididymis
6. Testicular plexus of nerves
 The nerves mainly come from T10 thoracic segment which hitchhike the
testicular artery is mainly sympathetic. However, the parasympathetic and
sympathetic hitchhike the ductus deferens. These autonomic fibers give that
sickening feeling when testis is hit. Pain of the testis may be referred to the
anterior abdominal wall.
7. Remnant of the processus vaginalis
Coverings of the spermatic cord:
 Innermost covering is the internal spermatic fascia derived from the transversalis fascia
 The next layer is the cremasteric fascia and cremasteric muscle derived from the internal
oblique abdominis muscle. This layer also contains the genital branch of the
genitofemoral nerve and the cremasteric artery.
 The most superficial layer is given by the aponeurosis of the external oblique muscle of
the abdomen. It is called the external spermatic fascia.
Note:
 Testicular artery is a branch of the abdominal aorta
 Artery to dutus deferens is a branch of the inferior vesical artery
 Cremasteric artery is a branch of the inferior epigastric artery

Testes:
 They lie in the scrotum
 Epididymis lies posterolateral to it
 Testis is suspended by the spermatic cord
 As testis descends from the abdomen it draws its artery along with it
 Therefore the testicular artery is a branch of the abdominal aorta
 Pampinifrom plexuses surround the ductus deferens till the deep inguinal ring. At the
level of the deep inguinal ring, pampiniform plexuses join together to form one testicular
vein. The left testicular vein opens into the left renal vein while the right testicular vein
opens into the inferior vena cava.
 Lymph vessels of testis hitchhike the testicular artery. Therefore lymph from the testis is
drained into the lateral aortic lymph nodes. These are also called the lumbar lymph nodes.
 Cancer of the testis is spread to the aortic lymph nodes via these lymph vessels.
Note the following clinical anatomy of the processus vaginalis:
 It may completely persist making way for the indirect congenital inguinal hernia
 It may persist partially along the spermatic cord and might result in the hydrocele of the
spermatic cord.
 In female it may persist in the inguinal canal as Canal of Nuck. It might pave way for the
indirect inguinal hernia.

-Pampiniform plexus might dilate resulting in their varicosities. This is called the varicocele.
When there is varicocele, dilated and tortuous plexus of veins are like a bag of worms when they
are palpated.
-Hydrocele of testis can be easily diagnosied by observing the transilluminated light. It appears
reddish.
-Hematocele of testis (collection of blood following trauma to testis) does not allow the light to
pass through it.

Torsion of spermatic cord:

This is a surgical emergency where the spermatic cord is wound around itself like the twisted
hose pipe. It obstructs the venous drainage causing edema and hemorrhage & results in
compression of the testicular artery and compromises the blood supply to the testis. Operation
has to be done within six hours and the torsion has to be removed. Otherwise the involved testis
degenerates.

Scrotum:
 It is a bag of skin which houses testis in it
 There is no fat in its superficial fascia
 It has tough crispy hairs and sebaceous glands which give characteristic smell
 Sebaceous cysts are common in the skin of the scrotum
Layers of the scrotum
1. Skin
2. Superficial fascia containing dartos muscle and fascia
3. Colles fascia
4. External spermatic fascia
5. Cremasteric muscle and fascia
6. Internal spermatic fascia
7. Parietal layer of the tunica vaginalis

Nerve supply of the scrotum:

 Anterior ⅓ of the scrotum is supplied by L1 segment through ilioinguinal
and genital branch of genitofemoral nerves
 Posterior ⅔ part of the scrotum is supplied by S2 and S3 segments by the
posterior scrotal branches of pudendal nerve and posterior cutaneous nerve
of thigh.
  Therefore when the anterior part of the scrotum is supposed to be
anaesthetized, the anesthetic solution is injected at a higher level above the
level of L1

Blood supply of the scrotum:

 The anterior part is supplied by the external pudendal branches of the femoral artery
 The posterior part is supplied by the posterior scrotal branches of the internal pudendal
artery.
 Veins accompany the corresponding arteries

Lymphatic drainage:

 Lymph from the scrotum terminates in the superficial inguinal lymph nodes.
 Therefore cancer of the scrotum metastasizes to the superficial inguinal lymph nodes
while testicular tumors spread to lumbar lymph nodes in the abdomen.

Cremasteric reflex:
 By stroking the upper medial side of the thigh, the testis is retracted upwards.
 This is called the cremasteric reflex. The afferent limb of the reflex is through the
ilioinguinal nerve. The efferent limb passes through the genital branch of genitofemoral
nerve which innervates the cremaster muscle. This reflex demonstrates the integrity of L1
segment.

Inner side of the anterior abdominal wall:

-It presents one median fold and two folds on either side in the lower part below the level of
umbilicus
-Median fold is called the median umbilical fold which represents the urachus of embryo
-Medial umbilical fold is the peritoneal fold which covers the obliterated umbilical artery
-Lateral umbilical fold is the peritoneal fold which covers the inferior epigastric artery.
Therefore, only the lateral umbilical fold is vascular
-The space of the anterior abdominal wall between the median umbilical fold and medial
umbilical fold is called the “supravesical fossa” as it lies above the urinary bladder.
Any hernia through this fossa is called the supravesical hernia.
-The space between the medial and lateral umbilical folds is called the medial inguinal fossa.
Direct inguinal hernia traverses this fossa.
The space lateral to the lateral umbilical fold is called the lateral inguinal fossa. Indirect inguinal
hernial sac passes through this fossa.

Hesselbach’s triangle (Inguinal triangle):

 This triangle is bounded by the rectus abdominis muscle medially, inferior epigastric
vessels laterally and medial part of the inguinal ligament inferiorly.
 Direct inguinal hernial sac passes through this triangle.

TESTES
Testis is the male gonad that produces spermatozoa and male hormones. There are two testes
housed in the scrotum and suspended by the spermatic cord. Left testis is lower than the right.
They are separated from each other by a septum of superficial fascia (dartos fascia).
Upper pole is more anterior than the lower. Scrotal ligament (remnant of gubernaculums)
attaches the lower pole to the scrotal skin. .Anterior border is convex and posterior border is
straight. Laterally, the sinus of epididymis separates the testis from the posteriorly situated
epididymis.

Macroscopic structure of testes:

The testis is invested by three tunics: the tunica vaginalis, tunica albuginea, and tunica
vasculosa.
The Tunica Vaginalis (tunica vaginalis propria testis) is the serous covering of the testis. It is a
pouch of serous membrane, derived from the processus vaginalis of the peritoneum, which in the
fetus preceded the descent of the testis from the abdomen into the scrotum. After its descent, that
portion of the pouch which extends from the deep inguinal ring to near the upper part of the
gland becomes obliterated; the lower portion remains as a shut sac, which invests the surface of
the testis, and is reflected on to the internal surface of the scrotum; hence it may be described as
consisting of a visceral and a parietal lamina between which there is a small amount of fluid.

The Tunica Albuginea is the fibrous covering of the testis. It is covered by the tunica vaginalis,
except at the points of attachment of the epididymis to the testis, and along its posterior border,
where the spermatic vessels enter the gland. It is applied to the tunica vasculosa over the
glandular substance of the testis, and, at its posterior border, is reflected into the interior of the
gland, forming an incomplete vertical septum, called the mediastinum testis.

The mediastinum testis: From its front and sides numerous imperfect septa (trabeculæ) are
given off, which radiate toward the surface of the organ, and are attached to the tunica albuginea.
They divide the interior of the organ into a number of incomplete spaces (lobes).
Each lobe is contained consists of from one to three, or more, minute convoluted tubes, the
seminiferous tubule.
In the apices of the lobes, the tubules become less convoluted, assume a nearly straight course,
and unite together to form from twenty to thirty larger ducts, of about 0.5 mm. in diameter, and
these, from their straight course, are called tubuli recti.
The tubuli recti enter the fibrous tissue of the Mediastinum and anatomoses with the tubuli recti
of the neighbouring lobules to form a network called the rete testis.
Arising from the rete testes are 10 -12 efferent ductules which become highly convoluted and
continue as the head of the epididymis.

Epididymis:
It is a comma- shaped elongated structure located on the posterior aspect of the testis. It is
formed by the duct of the epididymis which is a single tightly coiled tube, held like a solid mass
by the connective tissue. It stores the sperms which are transported from the testes through the
efferent ductules. It becomes progressively narrow inferiorly where it continues as the ductus
deferens. Sinus of the epididymis is a space which opens laterally and separates the testis from
the epididymis.
Parts: Head is the upper expanded end. Body is the middle part. Tail is the lower narrow end.
Ductus deferens begins from this end.

Clinical Anatomy:
Hydrocele: accumulation of excessive fluid in a persistent processus vaginalis.
Hydrocele of the testis: Confined to the scrotum. Tunica vaginalis is distended due to excessive
secretion of serous fluid from the visceral layer of the tunica vaginalis around testis.
Hydrocele of the spermatic cord: It is confined to the spermatic cord and is due to
accumulation of fluid in the persistent part of the processus vaginalis.
Spermatocele: A cyst near the upper end of the epididymis.
Appendix of the testis: is a rudimentary structure which is a remnant of the paramesonephric
duct
Appendix of the epididymis: is a developmental remnant of the mesonephric duct.
Varicocele: Left varicocele is more common.

Mr. PENIS

The penis is a pendulous organ suspended from the front and sides of the pubic arch and
containing the greater part of the urethra. In the flaccid condition it is cylindrical in shape, but
when erect assumes the form of a triangular prism with rounded angles, one side of the prism
forming the dorsum. It is composed of three cylindrical masses of cavernous tissue bound
together by fibrous tissue and covered with skin. Two of the masses are lateral, and are known as
the corpora cavernosa penis; the third is median, and is termed the corpus spongiosum. The
urethra runs in the corpus spongiosum.

For descriptive purposes it is convenient to divide the penis into three regions: the root, the body,
and the extremity.
The root (radix penis) of the penis is situated in the superficial perineal pouch. It is triradiate
in form, consisting of the diverging crura, one on either side, and the median urethral bulb. Each
crus is covered by the Ischiocavernosus, while the bulb is surrounded by the Bulbospongiosus.
The crura become corpus cavernosum and the bulb continues as corpus spongiosum. The root of
the penis lies in the perineum (in the superficial perineal pouch - between the inferior fascia of
the urogenital diaphragm and the fascia of Colles). In addition to being attached to the fasciæ and
the ischiopubic rami, it is bound to the front of the
symphysis pubis by the fundiform and suspensory ligaments.

The body (corpus penis) extends from the root to the ends of the corpora cavernosa penis, and
in it these corpora cavernosa are intimately bound to one another by the tunica albugenia. A
shallow groove which marks their junction on the upper surface lodges the deep dorsal vein of
the penis, while a deeper and wider groove between them on the under surface contains the
corpus spongiosum (cavernosum urethræ). The body is ensheathed by fascia, which is
continuous above with the fascia of Scarpa, and below with the dartos tunic of the scrotum and
the fascia of Colles.

The extremity is formed by the glans penis, the expanded anterior end of the corpus
spongiosum. It is separated from the body by the constricted neck.
The skin covering the penis is remarkable for its thinness, its dark color, its looseness of
connection with the deeper parts of the organ, and its absence of adipose tissue. At the root of the
penis it is continuous with that over the pubis, scrotum, and perineum. At the neck it leaves the
surface and becomes folded upon itself to form the prepuce or foreskin. The internal layer of
the prepuce is directly continuous, along the line of the neck, with the integument over the glans.
Immediately behind the external urethral orifice it forms a small secondary reduplication,
attached along the bottom of a depressed median raphé, which extends from the meatus to the
neck; this fold is termed the frenulum of the prepuce.

Mechanism of Erection
In the presence of mechanical stimulation, erection is initiated by the parasympathetic division of
the autonomic nervous system (ANS) with minimal input from the central nervous system.
Parasympathetic branches extend from the sacral autonomic plexus into the arteries supplying
the erectile tissue; upon stimulation, these nerve branches initiate the release of nitric oxide, a
vasodilating agent, in the target arteries. The arteries dilate, filling the corpora spongiosum and
cavernosa with blood. Erection subsides when parasympathetic stimulation is discontinued;
baseline stimulation from the sympathetic division of the ANS causes constriction of the penile
arteries, forcing blood out of the erectile tissue.

Arterial supply of the penis:

The penis is supplied by the dorsal artery of the penis, deep artery of the penis and by artery to
the bulb of the penis- branches of the internal pudendal artery.

The deep arteries of the penis are the main vessels supplying the cavernous spaces in the erectile
tissue of the corpora cavernosa and are therefore involved in the erection of penis. When the
penis is flaccid these arteries are coiled hence they are called as helicine arteries.

Venous drainage:

Deep dorsal vein of penis drains the blood from the cavernous spaces. It drains into the prostatic
venous plexus by passing through the retropubic space. Superficial dorsal vein drains superficial
coverings and drain into the superficial external pudendal veins.
Lymphatic drainage from the skin of the penis is into the superficial inguinal lymph nodes.
Lymph from the glans penis and distal urethra drains into the deep inguinal lymph nodes.
Lymph From the corpora & the proximal urethra drain into the internal iliac lymph nodes.

Innervation of the Penis:

Dorsal nerve of the penis, the terminal branch of the pudendal nerve supplies most of the skin
and glans penis (sensory) and sympathetic fibers. Ilioinguinal nerve supplies the skin at the root
of the penis.
Parasympathetic is from S2 – S4 segments (nervi erigentes) of the spinal cord (pelvic splanchnic
nerves which form the prostatic plexus). They supply helicine arteries (relax the smooth muscles
and thus enlarging their lumen to allow more blood to enter the cavernous spaces).
Ilio inguinal nerve supplies skin of the root of the penis.

Clinical Anatomy

Phimosis:
A condition where the prepuce of the penis fits tightly over the glans and cannot be retracted
easily
Paraphimosis: A condition where retraction of the prepuce over the glans constricts the neck of
the glans so much that there is interference with the drainage of blood and tissue fluid.
Epispadias: External urethral orifice is on the dorsum of the penis
Hypospadias: External urethral orifice is on the ventral surface of the penis

FEMALE EXTERNAL GENITAL ORGANS

The external genital organs of the female are: the mons pubis, the labia majora et minora
pudendi, the clitoris, the vestibule of the vagina, the bulb of the vestibule, and the greater
vestibular glands. The term pudendum or vulva, as generally applied, includes all these parts.

The Mons Pubis (commissura labiorum anterior; mons Veneris), the rounded eminence in front
of the pubic symphysis, is formed by a collection of fatty tissue beneath the integument. It
becomes covered with hair at the time of puberty.

The Labia Majora (labia majora pudendi) are two prominent longitudinal cutaneous folds
which extend downward and backward from the mons pubis and form the lateral boundaries of a
fissure or cleft, the pudendal cleft or rima, into which the vagina and urethra open. Anterior 1/3rd
is supplied by Ilioinguinal nerve and posterior 2/3rd by the posterior labial nerve.

The Labia Minora (labia minora pudendi; nymphæ) are two small cutaneous folds, situated
between the labia majora.

The Clitoris is an erectile structure, homologous with the penis, partially hidden between the
anterior ends of the labia minora. It consists of two corpora cavernosa, composed of erectile
tissue enclosed in a dense layer of fibrous membrane. The clitoris is provided like the penis, with
two small muscles, the Ischiocavernosi, which are inserted into the crura of the clitoris.

The Vestibule (vestibulum vaginæ).—The cleft between the labia minora and behind the glans
clitoridis is named the vestibule of the vagina: in it are seen the urethral and vaginal orifices and
the openings of the ducts of the greater vestibular glands. The external urethral orifice (orificium
urethræ externum; urinary meatus) is placed about 2.5 cm. behind the glans clitoridis and
immediately in front of that of the vagina; it usually assumes the form of a short, sagittal cleft
with slightly raised margins.
The vaginal orifice is a median slit below and behind the opening of the urethra; its size varies
inversely with that of the hymen.
The hymen is a thin fold of mucous membrane situated at the orifice of the vagina.

The Bulb of the Vestibule (bulbus vestibuli; vaginal bulb) is the homologue of the bulb and
adjoining part of the corpus cavernosum urethræ of the male, and consists of two elongated
masses of erectile tissue, placed one on either side of the vaginal orifice. Their deep surfaces are
in contact with the inferior fascia of the urogenital diaphragm and superficially they are covered
by the Bulbocavernosus. It is situated in the superficial perineal pouch

The Greater Vestibular Glands (glandulæ vestibularis major [Bartholini]; Bartholin’s glands)
are the homologues of the bulbo-urethral glands in the male. They are situated in the superificial
perineal pouch. They consist of two small, roundish bodies of a reddish-yellow color, situated
one on either side of the vaginal orifice in contact with the posterior end of each lateral mass of
the bulb of the vestibule. Each gland opens by means of a duct immediately lateral to the hymen,
in the groove between it and the labium minus.

ClinicalAnatomy

The greater vestibular glands are usually not palpable but are so when infected. The greater
vestibular gland is the site of origin of most vulvar adenocarcinomas. Inflammation of the greater
vestibular glands is called – Bartholinitis

The highly vascular bulbs of the vestibule are susceptible to disruption of vessels as the result of
trauma (e.g athletic injuries, sexual assault and obstetrical injury). These injuries often result in
vulvar hematomas in the labia majora.

Peritoneum
 It is a thin translucent serous membrane which lines the abdominal wall and the viscera.
 It consists of squamous epithelium (mesothelium) lying over a thin layer of connective
tissue.
 It reduces friction and helps the motility of abdominal organs
 It is divided into two layers
 The outer parietal layer which lines the abdominal body wall
 The inner visceral layer which lines the outer surfaces of the viscera
 The potential cavity present between the parietal and visceral layers is the peritoneal
cavity
 In the male, it is a closed sac. In femeles, it opens to the exterior through the uterine tube,
uterus & cervix, vagina. Thus in females, pathogens can enter to the peritoneal cavity
 It contains a thin film of fluid called peritoneal fluid.

Parietal layer of the peritoneum:

-It is the outer layer of peritoneum which lines the body wall
-It is developed from the somatopleuric mesoderm
-It is supplied by the following somatic nerves:
1) Phrenic nerve
2) Lower intercostal nerves
 3) Subcostal nerve
4) Iliohypogastric nerve
5) Ilioinguinal nerve
 It is supplied by the somatic blood vessels which supply the body wall
 It is sensitive to touch and cutting.
 It has rich innervation and that is the reason why large incisions in abdominal
operations are very painful. The latest endoscopic devices help reduce the trauma
to the peritoneum and thereby making the operation relatively pain-free
 When parietal peritoneum is inflamed, it usually results in “rebound tenderness”.
(When the inflamed area is pressed gently by the hand and then if it is suddenly
lifted from the abdominal wall, it results in severe pain owing to the stimulation
of the inflamed parietal peritoneum)

Visceral peritoneum:
 This is the peritoneum which lines the outer surfaces of the organs of the abdomen. It is
almost inseparably blended with the outer surface of the viscera. This layer is termed
serosa in histology sections.
 Visceral peritoneum is derived from the splanchnopleuric mesoderm
 It is supplied by the autonomic nerves
 It is not sensitive to touch and cuts
 It is sensitive to distention that is stretch

Intra – peritoneal organs (almost completely covered by peritoneum)

Organs completely or almost completely enclosed by peritoneum
-stomach
-liver
-gallbladder
--jejunum
-ileum
-transverse colon
-caecum & appendix
-Sigmoid colon

Retro-peritoneal organs:
Organs that are located mostly or completely behind the posterior Parietal peritoneum
-greater part of Duodenum
-ascending colon
-descending colon
(front & sides covered)
-pancreas
-kidneys
-great vessels and their primary branches:
abdominal aorta, IVC, origins of the Celiac,
superior &i nferior mesenteric
Greater omentum:
 It develops from the dorsal mesogastrium
 It is attached to the greater curvature of the stomach
 It is made up of four layers and theoretically lesser sac lies between its anterior two and
posterior two layers.
 Right and left gastroepiploic vessels lie between the anterior two layers of the greater
omentum about one inch away from the greater curvature.
 It covers the front of the transverse colon
 It lies in front of the small intestine largely covering the infracolic compartment of the
greater sac.
 It stores fat
 It moves to the location of inflammation and restricts its expansion
 It has macrophages.
 It is called as the policeman of the abdomen
 Posterior surface of the stomach is approached by cutting through its posterior layers in
front of the transverse colon
 Superiorly it is continuous with the gastrosplenic ligament

Lesser omentum:
 It is developed from that part of the ventral mesogastrium which lies between the
stomach and the liver
 It is a fold of peritoneum which connects the stomach and first part of the duodenum with
the liver.
 It is divided into two parts.
1. Hepatogastric ligament
2. Hepatoduodenal ligament
Attachments:
-Superiorly it is attached to the fissure for ligamentum venosum and the margins of porta hepatis.
This attachment is in the form of a hockey stick.
-Inferiorly it is attached to the lesser curvature of the stomach and the first part of the
duodenum.-- Right and left gastric vessels lie between the two layers of the lesser omentum
along the lesser curvature
-It describes a free margin which contains the hepatic artery, bile duct and portal vein
-The free margin forms the anterior boundary of the epiploic foramen
-It forms the anterior wall of the lesser sac

Mesentery:
 It is the fold of peritoneum which covers the small intestine
 It is attached to the posterior wall of the abdomen
 Its posterior attachment is 6 inches in length
 Its free margin contains the coils of jejunum and ileum. The length of its free border is
approximately 6 meters
 The average breadth of the mesentery is 6 inches

It contains the following:

 1. Superior mesenteric artery and its branches
2. Superior mesenteric vein and its tributaries
3. Accompanying lymph vessels and lymph nodes
4. Nerve plexuses surrounding superior mesenteric vessels
5. Connective tissue
Note: right layer of mesentery can be traced upwards and to the right, left layer is traced
downwards and to the left by examining hand. This helps to identify the proximal and distal parts
of the small intestine during exploratory surgery of the abdominal cavity.

Transverse mesocolon:
1. This is attached to the anterior surface of the body of the pancreas transversely
2. It is a fold of peritoneum which divides the greater sac into supracolic and infracolic
compartments
-It contains the middle colic artery and its branches.

 Ascending colon:
As a rule, it has no mesentery. It is a retroperitoneal structure. Similarly, the descending colon
also has no mesentery. But one important point is to be noted here. To start with both ascending
and descending colons had mesocolon during development. Later because of rotation one layer
of peritoneum gets opposed to the posterior abdominal wall and subsequently disappears. This
process of disappearance of one layer of peritoneum is called zygosis and it makes the ascending
and descending colons retroperitoneal and relatively immobile. Nevertheless, when a surgeon
wants to mobilize these parts of the colon, it is possible to lift them along this line of fusion
without disturbing any vessels.
Phrenicocolic ligament: Extends from the left colic flexure to the diaphragm.

Mesoappendix:
 Appendix has a fold of peritoneum called mesoappendix. Appendicular artery runs along
its free margin. Appendicular artery is a branch of ileocolic artery.
Inflammation of appendix might result in the occlusion of the appendicular artery which is an
end artery and thereby causing gangrene of the tip of the appendix. Bursting of inflamed
appendix is one of the most common causes of peritonitis.

Sigmoid mesocolon:
 It is inverted “V” shaped.
 It encloses the sigmoid colon
 The apex of “V” overlies the bifurcation of left common iliac artery and the left ureter.
 It has two limbs, the lateral and medial. The lateral limb overlies the left external iliac
artery and the medial limb extends to the front of the S3 vertebra

In the pelvis: There is rectovesical pouch in male. This is the most dependent space of the
greater sac in the pelvis in males.
In female: There is rectouterine pouch (pouch of Douglas) between the rectum and uterus.This
is the most dependent of the greater sac in female. The other pouch is uterovesical pouch which
lies anterior to the rectouterine pouch
Ligaments:

Falciform ligament is a sickle shaped fold of peritoneum which connects the anterior abdominal
wall to the liver. The round ligament of the liver which is the obliterated remains of the left
umbilical vein lies along its free margin from the fissure for the ligamentum teres to the
umbilicus. It is accompanied by the paraumbilical veins within the fold of falciform ligament.
These paraumbilical veins connect the veins of the liver (portal vein) with the systemic veins of
the anterior abdominal wall around the umbilicus (site of portocaval anastomosis).
Therefore, in portal hypertension, the back pressure in the portal vein dilates the paraumbilical
veins and eventual dilatation of veins around the umbilicus like a hood of a snake. This
enlargement is called “caput medusae”.

Gastrosplenic ligament:
 It is a fold of peritoneum which connects the spleen with the upper part of the greater
curvature of the stomach.
 It contains the short gastric vessels, left gastroepiploic (gastroomental) vessels and
accompanying lymph vessels.

Splenorenal ligament: (Lienorenal ligament)

 It connects the front of the left kidney with the hilum of the spleen.
 It contains the tail of the pancreas, splenic vessels and the accompanying lymph vessels
and nodes.

Peritoneal cavity:
 The potential space between the parietal and visceral layers is the peritoneal cavity.
 The sac which lines immediately deep to the parietal peritoneum of the anterior
abdominal wall is the greater sac. When the parietal peritoneum is opened, the visceral
peritoneum lining the viscera is seen as the outer shining layer covering the viscera.

Lesser sac:
 It is a diverticulum of the greater sac
 It communicates with the greater sac at the epiploic foramen
 Its anterior wall is formed by the liver, lesser omentum, posterior surface of the stomach
and anterior two layers of the greater omentum.
 It has a superior recess which is limited superiorly by the diaphragm and posterior layer
of the coronary ligament
 Its inferior recess extends into the greater omentum
 Splenic recess extends to the left side towards the spleen
 It separates the structures which form the stomach bed from the stomach. Therefore it is
called “Omental bursa”
Following structures lie behind the lesser sac:
1. Body of the pancreas
2. Splenic artery
3. Left kidney
4. Left suprarenal gland
 5. Celiac trunk surrounded by the celiac plexus of nerves and its branches
6. Crura of diaphragm

Pancreatic pseudocyst: Since pancreas forms the immediate posterior relation of the lesser sac,
any pathological exudates from the pancreas tend to collect in the lesser sac forming a pancreatic
pseudocyst.

Lesser sac development in brief:

 This is formed due to the rotation of the stomach to the right side.
 To start with the stomach is connected with the anterior abdominal wall by the ventral
mesogastrium in the early stages of the development of foregut
 Liver develops in the ventral mesogastrium; thereby ventral mesogastrium is divided into
two parts.
 The part between the liver and the anterior abdominal wall becomes the falciform
ligament while the part between the stomach and the liver becomes the lesser omentum.
Stomach rotates towards the right side, thereby; anteroposteriorly running lesser
omentum becomes horizontal.
 There is no ventral peritoneal fold of peritoneum for the midgut as it herniates through
the umbilical cord. This leaves a free margin of the ventral mesogastrium at the level of
duodenum. After rotation, this free margin forms the anterior wall of the epiploic
foramen.
 Lesser omentum is developed from the ventral mesogastrium and greater omentum is
developed from the dorsal mesogastrium.

Epiploic foramen: (foramen of winslow or aditus to the lesser sac)

 It lies at the level T12 vertebra

 It connects the greater sac with the lesser sac

Its boundaries are:

Anterior: free margin of lesser omentum which contains the hepatic artery proper, bile duct and
portal vein.
Posterior: inferior vena cava covered by the peritoneum
Superior: caudate lobe of the liver
Inferior: first part of the duodenum (there are gastroduodenal artery, bile duct, portal vein and
inferior vena cava behind the first part of the duodenum)

Internal Hernia
Any abnormal protrusion of viscus through the epiploic foramen into lesser sac forms an internal
hernia. While reducing this hernia, no part of wall of epiploic foramen can be cut. Therefore,
surgeon punctures the wall of herniated gut, releases the pressure and then reduces it to its
normal position

Peritoneal recesses or pouches:

Subphrenic recesses:
These are pocket like recesses between the diaphragm and the liver. They are two in number
1) right subphrenic space
2) left subphrenic space
These two spaces are separated from each other by the falciform ligament. Right subphrenic
space is continuous with the right subhepatic space.

Subhepatic recesses:
There are recesses behind the liver. They are called subhepatic recesses. The right subhepatic
recess is a deep one and it lies between the liver and right kidney. It is also known as the
hepatorenal space or Morrison’s space. Peritoneal fluid tends to collect here in the supine
position as it is most dependent part in that position.
Left subhepatic space is the lesser sac. It is connected with the right subhepatic space through the
epiploic foramen.
Fluid collected in the right subhepatic space drains towards the pelvis along the right paracolic
gutter which lies on the right side of the ascending colon. Similarly fluid collected on the left
side of the supracolic compartment drains into pelvis through the left paracolic gutter.

Clinical points:
In the supine position, fluid collected in the Morrison’s pouch is drained by inserting a tube. It is
important to note that the absorption of fluid is quick in the peritoneum around the diaphragm
than in the pelvic region. If physician suspects toxins in the peritoneal fluid, then he prefers to
raise the bed to 45 degrees inclined position so that the fluid is collected in the pelvis. In the
setting of acute trauma, this is one of the most dependent portions of the abdominal cavity
and should be scrutinized closely for the possibility of free intraperitoneal fluid.
A tube to drain the peritoneal fluid can be inserted through the linea alba below the umbilicus
taking care to avoid piercing the urinary bladder and inferior epigastric vessels.

Duodenal recess:
As the fourth part of the duodenum ascends and abruptly bends down to form the duodenojejunal
junction, there are peritoneal depressions on the left side of the fourth part of the duodenum.
These recesses are called duodenal recesses. There is a possibility of internal hernia here. What
is important to note here is the presence of inferior mesenteric vein along the fold of this recess.
Care should be taken to identify these vessels first.

Clinical notes:

Peritoneal cavity

The attachment of the transverse mesocolon and the mesentery of the small intestine to the
posterior abdominal wall provide a natural barrier by hindering the movement of infected
peritoneal fluid from one part to the other in the peritoneal cavity.

Irritation of the peritoneal diaphragm:

Irritation of peritoneum on the undersurface of the diaphragm may be referred to the

shoulder (the skin of the shoulder is supplied by the supraclavicular nerve C3, C4, which
have the same segmental origin as the phrenic nerve which supplies the peritoneum deep to
the diaphragm.
Ascites: abnormal collection of perironeal fluid the the peritoneal cavity

Stomach
 It is the proximal dilated part of the gastrointestinal system
 It lies in the epigastric, left hypochondriac and umbilical regions
 Its upper end called cardiac end lies one inch to the left on the 7th left costal cartilage
which is at the level of T11 vertebra
 It lower end called the pyloric end lies half inch to the right of the midline on the
transpyloric plane which corresponds to L1 vertebra
 Fundus extends upto the 5th rib in the left midclavicular plane

Stomach is divided into:

Fundus (superior to the horizontal line drawn at the level of cardio-esophageal junction)
Body extends from the line given above to the line connecting the incisura angularis along the
lesser curvature to the maximum convexity along the greater curvature.
Pyloric part:
The remaining part looks like a horizontally placed funnel .The wide end of the funnel is towards
the left side and is called the pyloric antrum
It is succeeded by the pyloric canal
The pyloric sphincter is also called the pylorus. During surgery, prepyloric vein acts like a
guide to the pylorus. It is here pylorus ends and duodenum begins. This junction is called the
pyloroduodenal junction.
Gastroesophageal junction: Left of T11 (endoscopic Z-line). Immediately superior to this is
inferior esophageal sphincter, which is a physiological sphincter, formed by the contraction and
relaxation of the diaphragmatic musculature around the esophagus. Normally efficient in
preventing gastric reflux regurgitation
It has two curvatures, two surfaces and two ends.
Two curvatures are:
Lesser curvature: It is a short curve along the right border of the stomach
Lesser omentum is attached to it
Left gastric vessels and right gastric vessels and branches of vagus nerves lie between the two
layers of lesser omentum
Greater curvature: It is three to four times longer than the lesser curvature
Greater omentum is attached to the greater curvature
Short gastric vessels, left gastroepiploic vessels, right gastroepiploic vessels lie between the two
layers of greater omentum.

Anterosuperior surface is related to the following:

1) diaphragm
2) anterior abdominal wall
3) left lobe of liver ( dull American lady)
Posteroinferior surface (stomach bed) is related to the following:
1) splenic artery
2) suprarenal gland(left)
3) Spleen (remember this should be treated as special relation of the stomach bed as this is
the only structure of the stomach bed that is separated from the stomach by the greater
sac. All the other stomach bed structures are separated from the stomach by the lesser
sac)
4) Diaphragm
5) Pancreas
6) Kidney(left)
7) Colon
8) transverse mesocolon

Interior of Stomach: Gastric folds or rugae seen when stomach is empty

Gastric canal: along the lesser curvature. It can be observed radiographically and
endoscopically.
Blood supply of the stomach:
Arterial supply:
Left gastric artery ----------------------- a branch of celiac trunk
Right gastric artery --------------------- a branch of hepatic artery proper
Short gastric arteries (four to five) ----branches of splenic artery
Left gastroepiploic artery---------------- a branch of splenic artery
Right gastroepiploic artery ------------- a branch of gastrodudenal artery

Venous drainage:
Left gastric and right gastric veins drain into the portal vein
Short gastric and left gastroepiploic veins drain into the splenic vein
Right gastroepiploic vein opens into the superior mesenteric vein

Lymphatic drainage:
Stomach is divided into upper 2/3 and lower 1/3
The upper 2/3 is again divided into right half and left half.
The lower 1/3 is divided into right 2/3 and left 1/3
Right half of upper 2/3 is drained into left gastric lymph nodes
Left half of upper 2/3 is drained into pancreaticosplenic group of lymph nodes passing along the
short gastric and left gastro epiploic vessels
Right 2/3 of lower 1/3 is drained into pyloric group of lymph nodes lying along the
gastroduodenal artery
Left 1/3 of the lower 1/3 is drained into pancreatico duodenal group of lymph nodes placed along
the right gastroepiploic vessels.
All the above said nodes are drained into the celiac group of lymph nodes
Celiac nodes drain into the cisterna chyli which continues as thoracic duct.
Thoracic duct opens into the angle at the junction of left subclavian vein with the left internal
jugular vein.

Clinical anatomy:
Cancer of the stomach is one of the major killers. Cancer cells pass through the thoracic duct and
may overflow at the angle of its opening and infect the surrounding left supraclavicular lymph
nodes. These are sentinel nodes which herald the possibility of cancer of the stomach. These
nodes are called Virchow’s nodes. Therefore any enlarged nodes at the root of the neck on the
left side should force a physician to do further investigations on the stomach.

Nerve supply of the stomach:

It is supplied by the parasympathetic and sympathetic nerves
Parasympathetic nerves come from anterior and posterior gastric nerves
Anterior gastric nerve is the continuation of the left vagus
Posterior gastric nerve is the continuation of the right vagus
Anterior gastric nerve gives hepatic branch and pyloric branch which reach their destinations by
passing between the two layers of the lesser omentum and it also supplies the stomach
Posterior gastric nerve supplies the stomach and then gives branches to celiac and superior
mesenteric plexus. Through this plexus, vagus nerve supplies the other derivatives of the foregut
and midgut.
Sympathetic fibers of T6-T9 segments come through greater splanchnic nerves
They contribute to the celiac plexus. Branches of celiac plexus reach the stomach wrapping
around the branches of the celiac artery
Vagi are responsible for the acid secretion in the stomach. Therefore, if there is gastric ulcer, the
part of the stomach ulcerated is removed (gastrectomy) and it is followed by the vagotomy.
These days highly selective vagotomies (parietal cell vagotomy) are performed. This means only
that part of the vagus which is actually responsible for the secretion of that area is resected.
A posterior gastric ulcer may erode through the stomach wall into the pancreas resulting in
referred pain to the back. In such cases, erosion of the splenic artery results in severe hemorrhage
into the peritoneal cavity.
Visceral reffered pain from a gastric ulcer is reffered to the epigastric region because the
stomach is supplied by pain afferents that reach the T7 and T8 spinal sensory ganglia and spinal
cord segments through the greater splanchic nerve.The pain is interpreted by the brain as though
irritation occurred in the skin of the epigastric region, which is also supplied by the same spinal
segments.
Congenital Hypertrophic pyloric stenosis: Marked thickening of the smooth muscle in the
pylorus.
Gasterectomy, Gasric ulcers & vagotomy
Hiatal hernia (paraesophageal hiatal hernia & Sliding hiatal hernia) through esophageal hiatus
Congenital diaphragmatic hernia: through foramen of Bochdalek. Associated with pulmonary
hypoplasia

Duodenum:
It is the proximal part of the small intestine
It is shaped like “U” placed sidewards
It is called duodenum because it is of the width of two hands + 2 fingers ie, 12 fingers (10
inches)
It has plica circularis
It is divided into four parts.
First part - (superior part) two inches long
Its first inch is covered by the peritoneum. Therefore, it is movable. It moves up as a distinct cap
in barium meal x-rays and it is called “duodenal cap”
Lesser omentum is attached to this part superiorly
Greater omentum is attached to this part inferiorly
The second inch of the first part of the duodenum is retroperitoneal and does not move
Relations of the first part:
Anteriorly: body of the gallbladder and quadrate lobe of the liver
Posteriorly: gastroduodenal artery, bile duct, portal vein & inferior vena cava
Superiorly: epiploic foramen
Inferiorly: head and neck of pancreas

Second part of the duodenum:

It extends from the superior duodenal flexure at the level of neck of gallbladder to the inferior
duodenal flexure at the level of L3 vertebra
It is three inches long
Two ducts open into it on the posteromedial wall
Hepatopancreatic ampulla (ampulla of vater) opens on the top of major duodenal paplilla about 8
to 10 cm distal to the pyloroduodenal junction. This is the common opening of the bile duct and
major pancreatic duct. It has a sphincter at its distal end- sphincter of oddi. Spasm of the
sphincter may regurgitate the bile contents to the pancreas
Accessory pancreatic duct opens on the top of minor duodenal papilla which is about 2 to 3 cm
proximal to the opening of the major duodenal papilla

Relations of the second part: (descending part)

Medial: head of the pancreas
Anterior: transverse mesocolon, transverse colon, coils of jejunum
Posterior: medial part of the anterior surface of the right kidney
Pelvis of the ureter
Right psoas major
Right renal vessels

Third part (horizontal) of the duodenum:

It is roughly 4 inches long
It lies at the level of L3 vertebra
Relations:
Anterior: root of the mesentery
Superior mesenteric artery and vein

Posterior:
Right ureter, right gonadal vessels, inferior vena cava, origin of the inferior mesenteric artery and
abdominal aorta and right psoas major.
Superiorly: head and uncinate process of pancreas
Inferiorly: coils of small intestine

Fourth part of duodenum (ascending part)

Shortest part: one inch long
It continues as the jejunum at the duodenojejunal junction which lies to the left of L2 vertebra
Relations: superior: body of the pancreas
Inferior: coils of small intestine
Posterior: left psoas major and left edge of the abdominal aorta
Anterior: greater omentum and transverse mesocolon
Paraduodenal hernia: Internal hernia may occur by the side of the 4th part of duodenum. During
repair of the hernia care must be taken not to injure the inferior mesenteric vein or the ascending
branch of the left colic artery which are related to the paraduodenal fold of peritoneum.
Ligament of Treitz:
Blood supply: supplied by the anterior and posterior pancreaticoduodenal arterial arches
Superior pancreaticoduodenal artery is a branch of the gastroduodenal artery
Inferior pancreatioduodenal artery is a branch of superior mesenteric artery.
Superior pancreaticoduodenal artery divides into anterior and posterior branches; similarly the
inferior pancreaticoduodenal artery divides into anterior and posterior branches.

Duodenal Ulcers

Most common in the posterior wall of superior part of the duodenum

Ulcer perforating through duodenal wall allows contents to enter the peritoneal cavity and
produce peritonitis. Because of its close relationship with liver and gall bladder, either of them
can be ulcerated by a duodenal ulcer.
Erosion of gastroduodenal artery by a duodenal ulcer can result in severe hemorrhage into the
peritoneal cavity.

Mesentery:
It is the fold of peritoneum which connects the small intestine with the posterior abdominal wall.
It has two borders, a free border which contains the jejunum and ileum and an attached border
which is called its root is attached to the posterior abdominal wall.
Its root is 6 inches long
Its free margin is 6 meters long
Its average breadth is 6 inches
It begins on the left side of the L2 vertebra and ends in front of the right sacroiliac joint
The root is obliquely attached to the posterior abdominal wall. It crosses the horizontal part of
the duodenum, aorta, inferior vena cava, right gonadal vessels, right ureter and right psoas major.

Mesentery contains the following structures:

1. superior mesenteric artery and its branches
2. superior mesenteric vein and its tributaries
3. lymph nodes, lymph vessels
4. plexus of nerves
5. connective tissue

Differences between the jejunum and ileum:

Jejunum Ileum
It has wide lumen the lumen is not so wide

Wall is thick wall is relatively thin

(similar to the feeling of shirt sleeve & (similar to the feeling of shirt sleeve
coat sleeve together) only)

Plenty of plicae circularis (circular folds) Very few plicae circularis or absent

Less fat in the mesentery more fat in the mesentery

Only one tier of arterial arcades more than one tier of arterial arcades

Long vasa recta short vasa recta

When light is allowed to pass through light does not easily pass through this
mesentery it gives because of fat
the resemblance of a window

Solitary lymph nodes Peyer’s patches

It is proximal part It is distal part

Large intestine:
Following are the parts of the large intestine:
Cecum and appendix
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anal canal

Cecum:
It is the proximal dilated part of the large intestine
Its breadth is more than its height
It is large in herbivores
It lies in the right iliac fossa below the level of tranastubercular plane

Relations:
Anterior:
Anterior abdominal wall
Greater omentum
Coils of the small intestine
Posterior:
Psoas major
Iliacus
Femoral nerve
Lateral cutaneous nerve of the thigh

In its interior there is ileocecal valve which has two lips.

Appendix opens into the cecum 2 to 3 cm inferior to the ileocecal valve
The opening of the appendix corresponds to the junction of lateral one third with the middle third
of the spinoumbilical line (spinoumbilical line connects the anterior superior iliac spine with the
umbilicus)
Blood supply: it is supplied by the anterior and posterior branches of ileocolic artery
Ileocolic vein drains the venous blood into the superior mesenteric vein
Lymph vessels of the cecum are drained into the ileocolic lymph nodes around the ileocolic
artery in the mesentery of the ileum and from there they are drained into the superior mesenteric
lymph nodes.
Paracolic gutter: On the lateral side of the ascending colon there is paracolic gutter. This is
important as the fluid collected in the hepatorenal recess is gravitated down through this into the
pelvis. Cancer cells might follow this route to the lower part of the abdomen and pelvis.
Cecotomy
Because of its mobility,it can be brought to the anterior abdominal wall. An opening in anterior
abdominal wall is made. Contents of the large intestine then can be drained via this route. This is
used to relieve the distal obstruction

Appendix:

Vestigial hollow tube attached to the cecum of the large intestine.

The human appendix, usually 3–4 in. (8–10 cm) long and less than 0.5 in. (1.3 cm) wide, has no
digestive function. Its muscular walls expel their own mucous secretions or any intestinal
contents that enter it.
-base is attached to the posteromedial surface of the cecum
About 1 inch below the ileocecal junction
-is completely covered with peritoneum
-Attached to the lower part of mesentery of small intestine -by the mesoappendix - which
contains appendicular vessels.

*Mc Burney’s point:

Point at which the base of the appendix is located one third of the way up the line, joining the
ASIS to the umbilicus.
The tip position is widely variable.

Common positions of the tip of the appendix:

1- Coiled up behind the cecum in the retrocecal fossa (the most common)
2- Hanging down into the pelvis against the Rt pelvic wall
3- Projecting upward along the lateral side of the cecum
4- In front or behind the terminal part of the ileum.
Blood supply
Appendicular artery (br.of the posterior cecal artery) or iliocolic?
It passes to the tip of the appendix in the mesoappendix
End artery?
Venous drainage
Appendicular veinpost.cecal v. SMV

Nerve supply
SM- Plexus
Afferent fibers visceral pain fiber with sympathetic fibers enter the spinal cord at the level of
T10

Clinical anatomy
Blockage of the opening may prevent expulsion and cause appendicitis: fluids collect, bacteria
propagate, and the appendix becomes distended and inflamed; tissue in the appendix begins to
die, and the organ may burst, causing peritonitis. Its symptoms may begin with moderate pain in
the upper abdomen, about the umbillicus, because afferent pain fibres enter the spinal cord at the
T10 level. Nausea and vomiting may then develop. The pain may shift to the right lower
abdomen resulting from the irritation of the parietal peritoneum. Treatment is removal of the
appendix (appendectomy).

Ascending colon:
It extends from the level of transtubercular plane to the right colic flexure (hepatic flexure).

It has no mesentery
Anterior relations:
Anterior abdominal wall
Greater omentum
Coils of small intestine

Posterior relations:
Quadratus lumborum muscle
Ilioinguinal nerve
Iliohypogastric nerve
Subcostal nerve
Lower part of the front of the right kidney

Blood supply:
It is supplied by the right colic branches of the superior mesenteric artery and the branches of the
ileocolic artery which is the continuation of the superior mesenteric artery
Nerve supply: both sympathetic and parasympathetic come from the celiac and superior
mesenteric plexus. Parasympathetic fibers are contributed by the vagus nerve through the above
said plexus.
Lymph vessels of the ascending colon are drained into the paracolic and epicolic lymph nodes
and from them they pass to the superior mesenteric lymph nodes.

Transverse colon:
It is the largest and most mobile part of the large intestine
It is about 45 cm in length
It extends from the right colic flexure (hepatic) to the left colic (splenic) flexure
It forms a loop which may extend as low as pelvis inferiorly
It is suspended to posterior abdominal wall by the transverse mesocolon
The transverse mesocolon is fused to the posterior wall of the grater omentum
Blood supply:
It is supplied mainly from the middle colic artery, a branch of the superior mesenteric A. It also
receives branches from the right colic branches of the superior mesenteric artery and left colic
branch from the inferior mesenteric artery. These arteries form anastomotic arcades called
‘marginal artery’ (juxtacolic artery)

The junction of the right two thirds with the left one third of the transverse colon indicates the
junction of the midgut with the hindgut. That is the reason why both midgut and hindgut arteries
supply this.
Veins of the transverse colon are drained into the superior mesenteric vein
Lymph vessels drain into the superior mesenteric lymph nodes

Nerve supply: Superior mesenteric plexus transmit both sympathetic and parasympathetic fibers
to the right two thirds of the transverse colon. Parasympathetic is from Vagus for this part.
The left one third of the transverse colon is supplied by the inferior mesenteric plexus which
carries both sympathetic fibers and parasympathetic fibers. The parasympathetic fibers to this
plexus comes from S2, 3 & 4 through hypogastric plexus
Note: transverse mesocolon is attached to the front of the second part of the duodenum, head of
the pancreas and body of the pancreas. Transverse colon and its mesocolon separate the greater
sac of the peritoneum into the supracolic and infracolic compartments.
Clinical: Due to its proximity to the Gall bladder, gall stone may get lodged into it.
Descending colon:
It extends from the left colic (splenic) flexure to the left pelvic brim
It is usually narrower than the other parts of the large intestine
It is retroperitoneal
Anterior relation:
Anterior abdominal wall
Greater omentum
Small intestine coils
Posterior relation:
Lower part of the anterior surface of the left kidney
Subcostal
Iliohypogastric nerve
Ilioinguinal nerve
Iliacus
Lateral cutaneous nerve of thigh
Femoral nerve
Psoas major

Blood supply:
It is supplied by left colic artery which is a branch of the inferior mesenteric artery
Veins drain into the inferior mesenteric vein
Lymphatic drainage: It is drained into the inferior mesenteric group of lymph nodes
Nerve supply:
It is supplied by the branches of inferior mesenteric plexus.
Sympathetic fibers come from the inferior mesenteric plexus and the parasympathetic fibers join
this plexus from the hypogastric plexus (S2, 3&4 - parasympathetic)

Sigmoid colon:
It has sigmoid mesocolon
Sigmoid mesocolon is shaped like inverted “V”
The apex of “V” overlies the left ureter and termination of left common iliac artery
Sigmoid branches of inferior mesenteric artery supplies this.
Nerve supply is the same as descending colon as it is also derived from the hindgut

Tenia coli begin at the junction of the appendix with the cecum and extends upto the junction of
the sigmoid colon with the rectum. No appendices epiploicae in the appendix and rectum.

Colostomy
A colostomy is a surgical procedure that involves connecting a part of the colon onto the anterior
abdominal wall, leaving the patient with an opening on the abdomen called a stoma. This
opening is formed from the end of the large intestine drawn out through the incision and sutured
to the skin. After a colostomy, feces leave the patient's body through the stoma, and collect in a
pouch attached to the patient's abdomen which is changed when necessary.
There are two main reasons for this procedure: either the lower end of the colon has had to be
removed, for example due to a colon cancer or an injury, so that it is no longer possible for feces
to pass out via the anus; or a portion of the colon has been operated upon and needs to be 'rested'
until it is healed. In the latter case, the colostomy is temporary and is usually reversed at a later
date, leaving the patient with a small scar where the stoma was.

Differences between the small and large intestine:

Large intestine Small intestine

It has greater distensible capacity it cannot be distended so much

It has tenaia coli it has no tenia coli

It has appenidicis epiploicae no appendices epiploicae

It has sacculations(haustrations) no sacculations

It has no plicae circularis plicae circularis present in jejunum

Solitary lymph nodes peyer’s patches in ileum

Marginal artery connects all the vessels there is no marginal artery

Clinical anatomy of the intestines

Crohn's disease is a type of inflammatory bowel disease (IBD), resulting in swelling and
dysfunction of the intestinal tract. The inflammation of Crohn's disease most commonly affects
the last part of the ileum (a section of the small intestine), and often includes the large intestine
(the colon).

Ulcerative colitis is a form of inflammatory bowel disease (IBD). It causes swelling, ulcerations,
and loss of function of the large intestine.
It is thought that the inflammation begins sigmoid colon. This inflammation may spread through
the entire large intestine, but only rarely affects the very last section of the small intestine
(ileum).

Crohn's disease differs from ulcerative colitis, in two important ways:

1) The inflammation of Crohn's disease may be discontinuous, meaning that areas of

involvement in the intestine may be separated by normal, unaffected segments of intestine. The
affected areas are called "regional enteritis," while the normal areas are
called "skip areas."
2) The inflammation of Crohn's disease affects all the layers of the intestinal wall, while
ulcerative colitis affects only the lining of the intestine

Irritable bowel syndrome (IBS) is a common intestinal condition characterized by abdominal

pain and cramps; changes in bowel movements (diarrhea, constipation, or both); gassiness;
bloating; nausea; and other symptoms. IBS is best described as a functional disease.

Meckel’s diverticulum:
It is the remnant of the vitellointestinal duct.
It is present in 2% of subjects and is roughly about 2 inches in length and is about 2 metres from
the ileocecal junction. It may contain gastric mucosa or pancreatic tissue
Meckel’s diverticulum might lead to volvulus .In complete persistence of diverticulum, fecal
matter might ooze out of umbilicus

Megacolon is an abnormal dilatation of the colon (a part of the large intestines) that is not
caused by mechanical obstruction. The dilatation is often accompanied by a paralysis of the
peristaltic movements of the bowel, resulting in chronic constipation.

Aganglionic megacolon
Also called Hirschsprung's disease, it is a congenital disorder of the colon in which nerve cells of
the myoenteric or Auerbach's plexus in its walls, also known as ganglion cells, are absent.
Volvulus
A volvulus is a loop of the bowel whose nose has twisted on itself. It results in ischemia (loss of
blood flow) and the accumulation of gas and fluid in the portion of the bowel obstructed.
Ultimately, this can result in the death of tissues (necrosis, gangrene) of the blood starved tissue
and requires immediate surgical intervention (jejunectomy, ileostomy, colostomy, bowel
resection).

Intussusception: Part of the intestine is prolapsed into another section of the intestine (ex: ileum
prolapse into the cecum)

Diverticulitis refers to the development of inflammation and infection in one or more

diverticula. Diverticula are outpouchings or bulges which occur when the inner, lining layer of
the large intestine (colon) bulges out (herniates) through the outer, muscular layer. The presence
of diverticula indicates a condition called diverticulosis.

Laparoscopy
Cplonoscopy
Sigmoidoscopy

Spleen
It is a lymphoid organ present in the left hypochondrium

Remember all the odd numbers from 1 to 11

It is one inch thick- 1
It is three inches wide 3
It is five inches long 5
It weighs 7 ounces 7
th th
It lies between 9 &11 ribs 9 & 11

It has two surfaces, two borders and two ends.

Two surfaces; visceral surface and diaphragmatic surface
Two borders: superior border and inferior border
Two ends: anterior end and posterior end
It lies in the long axis of the 10th rib.
It has two ligaments attached to the margins of the hilum:
1 gastrosplenic ligament
2 splenorenal ligament

Gastrosplenic ligament connects the spleen with the upper end of the greater curvature of the
stomach. It contains the short gastric vessels, left gastroepiploic vessels and accompanying
lymph vessels
Splenorenal ligament; it connects the spleen with the left kidney. It contains the tail of the
pancreas, splenic artery, splenic vein and accompanying lymph vessels and nerves.

Spleen rests on the phrenicocolic ligament.

Superior border is sharp and has notches. Posterior end is pointed and anterior end is rounded
and flattened.
Dipahragmatic surface is related to the diaphragm, 9-11th ribs, intervening intercostal spaces and
costodiaphrgmatic recess of pleura.
Visceral surface is related to the following structures:
Stomach separated by the greater sac
Kidney
Tail of the pancreas
Left colic flexure

Blood supply – Splenic vessels

Lymphatic drainage - pancreaticosplenic lymph nodes

Clinical anatomy:
When spleen is ruptured, it cannot be sutured therefore removal is preferred. The operation is
called splenectomy. While performing splenectomy, one has to be careful in preserving the tail
of the pancreas. As the tail of the pancreas contains more beta cells, there is a possibility of
developing iatrogenic diabetes following inadvertent removal of tail of the pancreas with the
spleen.
When spleen is ruptured, blood collected deep to the diaphragm irritates the phrenic nerve. The
pain is referred to the left shoulder as the left shoulder is supplied by the supraclavicular nerves
which have the same root value as the phrenic nerve. This sign is known as “Kehr’s sign”
Removal of spleen is indicated in certain blood disorders. In those cases accessory spleens
should be identified if any and be removed. Accessory spleens are present as small nodules of
splenic tissue in the splenorenal ligament, gastrosplenic ligament or greater omentum.

Splenomegaly is a condition where spleen is enormously enlarged. Normally spleen is not

palpable as it lies deep to the left costal margin. Nevertheless, the enlarged spleen can easily be
felt. When there is a mass inferior to the left costal margin, this might have come from the
stomach, left kidney or spleen. Splenic enlargement can always be identified if notches of
superior border are felt on palpation.

Spleen moves with respiration as it is intimately related to the diaphragm. If spleen has to be
punctured, as in the case of splenoportography, the patient is asked to hold his breath in exhaled
position. This maneuver keeps the costodipahragmatic recess at a higher level and spleen can be
safely punctured in the 10th intercostal space in the left midaxillary plane
Spleen is not very essential for life. However, latest research shows that absence of spleen has
immunological problems. That is the reason; the spleen is not removed unless it is extremely
necessary to do so.

Pancreas:
This endocrine and exocrine organ lies transversely in the posterior abdominal wall at the level
of L2 vertebra
It is retroperitoneal. Only the end of the tail of the pancreas is in the splenorenal ligament
It has the following parts:
Head, neck, body and tail.

Head

Head of the pancreas lies within the concavity of the duodenum.

Head has anterior and posterior surfaces.
Anterior surface of the head is related to the transverse mesocolon , transverse colon .
Posterior surface of the head is related to the inferior vena cava, left renal vein, right renal artery
and right renal vein. It is also related to the bile duct which remains actually embedded in the
substance often.
Superiorly the first part of the duodenum
To the right side lies the second part of the duodenum
Inferiorly lies the horizontal part of the duodenum.
The lower end of the head extends as a hook shaped process (uncinate process) behind the
superior mesenteric vessels.
In the groove between the head of the pancreas and the duodenum there are anterior and
posterior pancreaticoduodenal vascular arches.

Neck of the pancreas:

Anteriorly there is gastroduodenal artery and posteriorly splenic vein and superior mesenteric
veins join to form the portal vein.

Body of the pancreas:

Transverse mesocolon is attached to the anterior border of the body of the pancreas.
Anterior surface of the body of the pancreas is related to the stomach separated by the lesser sac
Posterior surface of the body of the pancreas is related to the abdominal aorta, the origin of the
superior mesenteric artery, left psoas major, left kidney, left suprarenal gland. The splenic vein
lies behind the body of the pancreas.
Superior border of the pancreas has an elevation called “tuber omentale”
Celiac artery lies just superior to the tuber omentale and common hepatic artery lies to the right
side of the tuber omentale. Splenic artery is related to the superior border to the left of the tuber
omentale. Splenic artery is tortuous and very conspicuous artery lying along the upper border of
the pancreas and it supplies pancreatic branches.

Tail of the pancreas:

It lies within the splenorenal ligament. It is accompanied by the splenic vessels and
accompanying lymph vessels in the ligament. Tip of the tail is related to the hilum of the spleen.

Ducts of the pancreas:

The major pancreatic duct is shaped like a herring fish bone. It receives smaller ducts at right
angles. It turns inferiorly in the head and pierces the wall of the duodenum where it receives the
bile duct. Both bile duct and main pancreatic ducts have independent sphincters. Later both the
ducts join and form a common hepatopancreatic ampulla. This ampulla opens on the top of major
duodenal papilla which lies on the posterior medial wall about 8 to 10 cm away from the
pyloroduodenal junction.
Accessory pancreatic duct which is runs horizontally opens onto the top of the minor duodenal
papilla which is about 2cm proximal to the major duodenal papilla on the posteromedial wall of
the duodenum.

Blood supply:
Pancreatic arteries from splenic artery (one branch is large and called arteria pancreatica magna),
superior pancreatico duodenal and inferior pancreatico duodenal.
Corresponding veins drain the pancreas

Lymphatic drainage:
Pancreaticosplenic lymph nodes and pyloric lymph nodes. Efferents from these pass to celiac,
hepatic, and superior mesenteric lymph nodes.

Clinical anatomy:
Cancer of the head of the pancreas compresses the bile duct and it results in obstructive type of
jaundice. This type of jaundice is not usually associated with pain or fever. Hepatitis also causes
jaundice but is associated with the fever
Jaundice followed by the obstruction in the duodenum will have symptoms of duodenal
obstruction.
Sphincter of oddi is the sphincter of the hepatopancreatic ampulla. When it is thrown into spasm
or obstructed, bile regurgitates into the pancreatic duct resulting in the pancreatitis.
Pain of the pancreas is referred to the back. Pancreatitis may cause pancreatic pseudocyst in the
lesser omentum.
During removal of pancreas, small part of the head along the duodenum is retained to assure
blood supply to the duodenum.
Annular pancreas: developmental anomaly.
Splenectomy: One has to be careful in not removing the tail of the pancreas during splenectomy
operations.

Liver:
-Aids in many metabolic activities
How it is maintained in its normal anatomical position:
The rest of the viscera prevent it from falling
Intra-abdominal pressure
Opening of hepatic veins into IVC
Peritoneal ligaments and peritoneal folds; do not offer as much support, but aids in it

General feautures
Situated in the R-hypochondrium, extends to epigastrium and left hypochondrium
Normally, liver cannot be palpated; it is within the costal margin
Weight: 1.5 kg, the largest organ in the body; 1/40th of body weight
-In newborn, 1/20th of body weight
Covered by CT capsule – Glisson’s capsule which is the visceral peritoneum around the liver
Left lobe is smaller than the right lobe because it has to accommodate for the size of the stomach
It is directly related to the diaphragm

External Features
Lobes
Anatomical lobes – Right and left lobes. The liver is divided anatomically into right and left by
the falciform ligament and the fissure for ligamentum teres and ligamentum venosum. The right
lobe includes the caudate lobe and quadrate lobe.

Physiological lobes – Right and left lobes. The liver is divided physiologically based on the
distribution of the right and left branches of portal vein and hepatic artery. The line of
demarcation between the two physiological lobes is, over the diaphragmatic surface of the liver
an imaginary line from the fundus of gall bladder to IVC and on the visceral surface by the fossa
for gall bladder and the fossa for inferior vena cava.
The different hepatic segments of the liver are
Right lobe – upper anterior, upper posterior, lower anterior and lower posterior
Left lobe – upper lateral, upper medial, lower lateral and lower medial

Surfaces
Superior Surface : Related to the diaphragm which separates it from the bases of the right pleura
and left pleura at the sides and fibrous pericardium in the middle

Right lateral surface – Related to diaphragm

Anterior surface – Related to diaphragm

Posterior surface – In the middle is a depression for the vertebral column, there is a fissure for
ligamentum venosum and groove for inferior vena cava. The posterior surface of the left lobe has
a groove for oesophagus
Bare area – region with no peritoneum covering it, on posterior surface of right lobe
-Directly related to diaphragm, veins of liver belonging to the portal system communicate
with veins of diaphragm
-This is one of the portosystemic anastomosis sites
Boundaries:
-base is formed by groove of IVC
-Anterior: anterior (upper) layer of coronary ligament
-Posterior: posterior (lower) layer of coronary ligament
-Right side: right triangular ligament
Sometimes related to the right kidney and right suprarenal gland.
Inferior surface
On the left lobe related to stomach
On the right lobe is fossa for gall bladder,
to the right of the fossa this surface is related to second part of duodenum,
Lateral to duodenum is hepatic flexure of colon
Behind colic area is area for right kidney
Caudate lobe: lies on the posterior aspect of liver & forms anterior wall of superior recess of
lesser sac
- Limited by diaphragm superiorly
- the epiploic foramen lies inferior to the caudate lobe
-Boundaries – right side: IVC
left side: fissure for ligamentum venosum
anterior: porta hepatis
The caudate process:
-Separates the IVC posteriorly and the portal vein anteriorly
-Forms the superior boundary of the epiploic foramen
Quadrate lobe – quadrate in shape, closer to inferior border
-It has clear cut-out boundaries
- fissure for ligamentum teres lies to the left side and fossa for gallbladder lies to
its right side
superiorly it is bounded by the porta hepatis
anteriorly it ends in the inferior border
Related to Transverse colon, Pylorus, First part of duodenum

Porta hepatis:
-It is a transverse slit between caudate (posteriorly) and quadrate lobe (anteriorly)
-Contains structures that enter and leave liver
-it is surrounded by free edge of lesser omentum
-Most anterior – hepatic ducts (Right. & Left)
-Most posterior – portal vein (right and left branches)
-In the middle – hepatic artery (right and left branches)

Prenatal circulation:
The liver is basically bypassed
* Ductus venosus in the embryo
it connects the left umbilical vein with the Inferior vena cava (IVC).
It shunts blood going through the liver so that it really doesn’t perfuse the liver, but rather
bypasses it to reach the IVC
[Actually left umbilical vein opens into the left branch of portal vein, Opposite to the opening
of ductus venosus. So blood from Lt. Umbilical Vein directly enters into the ductus venosus]
after birth
the ductus venosus closes during the first week of life and its remnants become the
Ligamentum venosum on the inferior, posterior aspect of the liver (because it does not
completely closes at the time of birth, umbilical vein catheterization can be done in a neonate)
* ligamentum teres of the liver:
is what remains of the left umbilical vein .
it hangs down from the falciform ligament

Important for taking liver biopsies

Right lateral side of the liver (along mid-axillary line)
Found between 7th and 11th ribs. Needle puncture normally goes through the right 10th
intercostals space in the midaxillary line
Ask patient to hold breath out to reduce the costodiaphragmatic rescess.
Ligaments of Liver: Falciform, coronary, Right and Left triangular, lesser omentum

Blood supply of the liver

1-proper Hepatic artery (30% )
Celiac trunkcommon hepatic artery proper hepatic  at porta hepatis divides intoRt.
And Lt. hepatic arteries.

Callot’s triangle: borders- common hepatic duct, cystic duct and base of the porta hepatis.
Cystic artery is the content of this triangle.

2-Portal vein (70%)

is formed posterior to the neck of the pancreas by the union of the SMV + splenic vein
reaches the liver through the hepatoduodenal ligament at porta hepatis divides
into Rt. And Lt. Branches delivers venous blood from the GIT.

Venous drainage of the liver:

Hepatic veins

1. Are usually 3 in number

2. Drain the hepatic sinusoids
3. Emerge from the posterior surface and empty directly into the IVC
Nerves:
Coeliac plexus
Parasympathetic stimulation from vagus nerve causes a slight increase in the synthesis of
glycogen (glycogenesis).
Sympathetic (T6-T9) stimulation causes the release of glucose from the liver (glycogenolysis).

Clinical anatomy:
Removal of surgical right or left lobe of the liver is called hepatic lobectomy
If severe injury or tumor involves the one segment or adjacent segments it may be possible to
resect only the affected segment which is called as segmentectomy.
Hepatitis, inflammation of the liver is caused mainly by various viruses and also by some
poisons, autoimmunity or hereditary conditions.
Cirrhosis is the formation of fibrous tissue in the liver, replacing dead liver cells. The death of
the liver cells can for example be caused by viral hepatitis, alcoholism or contact with other
liver-toxic chemicals.

Excretory Apparatus of the Liver:

The excretory apparatus of the liver consists of (1) Right and Left hepatic ducts, (2) common
hepatic duct (formed by the junction of the two hepatic ducts, which pass out of the liver at the
porta) (3) the gall-bladder, which serves as a reservoir for the bile (4) the cystic duct, or the duct
of the gall-bladder; and (5) the common bile duct, formed by the junction of the common hepatic
and cystic ducts.
The Hepatic Duct (ductus hepaticus).—Two main trunks of nearly equal size issue from the liver
at the porta, one from the right, the other from the left lobe; these unite to form the common
hepatic duct, which passes downward and to the right for about 4 cm., between the layers of the
lesser omentum, where it is joined at an acute angle by the cystic duct, and so forms the common
bile duct. The common hepatic duct is accompanied by the hepatic artery and portal vein.
The Gall-bladder (vesica fellea)
The gall-bladder is a conical or pear-shaped musculomembranous sac, lodged in a fossa on the
under surface of the right lobe of the liver, and extending from near the right extremity of the
porta to the anterior border of the organ. It is from 7 to 10 cm. in length, 2.5 cm. in breadth at its
widest part, and holds from 30 to 35 c.c. It is divided into a fundus, body, and neck.
The fundus, or broad extremity, is directed downward, forward, and to the right, and projects
beyond the anterior border of the liver; the body and neck are directed upward and backward to
the left.

Relations:
The body is in relation, by its upper surface, with the liver;
by its under surface, with the commencement of the transverse colon, 1st and 2nd parts of the
duodenum, or pyloric end of the stomach.
The fundus is completely invested by peritoneum; it is in relation, in front, with the abdominal
wall, immediately deep to the the ninth costal cartilage; and behind, with the transverse colon.
The neck is narrow, and curves upon itself like the letter S; at its point of connection with the
cystic duct it presents a well-marked constriction. Hartmann’s pouch is an out pouching of the
wall of the gall bladder at the junction of the neck and cystic duct. It is not usually found in the
normal anatomy.

The Cystic Duct (ductus cysticus).—The cystic duct about 4 cm. long, runs backward,
downward, and to the left from the neck of the gall-bladder, and joins the hepatic duct to form
the common bile duct. The mucous membrane lining its interior is thrown into a series of
crescentic folds, from five to twelve in number, similar to those found in the neck of the gall-
bladder. They project into the duct in regular succession, and are directed obliquely around the
tube, presenting much the appearance of a continuous spiral valve.

The Common Bile Duct (ductus choledochus).—The common bile duct is formed by the
junction of the cystic and common hepatic duct; it is about 7.5 cm. long, and of the diameter of a
goose-quill.
It descends along the right border of the lesser omentum and then behind the 1st part of the
duodenum, in front of the portal vein, and to the right of the hepatic artery; it then runs in a
groove near the right border of the posterior surface of the head of the pancreas; here it is
situated in front of the inferior vena cava, and is occasionally completely imbedded in the
pancreatic substance. At its termination it lies for a short distance along the right side of the
terminal part of the pancreatic duct and the two ducts unite and open by a common orifice upon
the summit of the major duodenal papilla, situated at the medial side of the descending portion of
the duodenum, a little below its middle and about 7 to 10 cm. from the pylorus.
The short tube formed by the union of the two ducts is dilated into an ampulla, the ampulla of
Vater.

OBSTRUCTIVE JAUNDICE:
 Obstruction of the biliary ducts with a gallstone or by compression by a tumor of the pancreas
results in the backup of the bile in the ducts and the development of jaundice. The impaction of
the stone in the ampulla of Vater may result in the passage of infected bile into the pancreatic
duct, producing pancreatitis
-Gallstones present in the gallbladder have been known to ulcerate through the wall into the
transverse colon passing naturally per rectum or into the duodenum holding up at the ileocecal
junction , producing intestinal obstruction.
-has many stretch receptors, so it is sensitive to swelling. However, it is
relatively insensitive to a direct cut
-cholecystitis
the infection of the GB it is clinically determined by Palpating along the Rt costal margin , along
the liver .this is Murphy’s sign

Murphy's sign in the physical examination:

Classically, it is performed by asking the patient to breathe out and then palpating below the
costal margin on the right side at the mid-clavicular line (the approximate location of the
gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration,
the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand).
If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in
contact with the examiner's fingers) the test is considered positive.

Blood supply of the Gut:

Coeliac trunk

 Celiac trunk is the unpaired ventral branch of the abdominal aorta at the level of T12
vertebra behind the lesser sac
 It is the artery of the foregut.
 It is surrounded by the celiac plexus of nerves. It lies between the right and left crura of
diaphragm and the right and left celiac ganglia
 It lies superior to the tuber omentale of the superior border of the body of the pancreas.

It divides into three branches:

1. left gastric artery
2. splenic artery
3. common hepatic artery

 Left gastric artery ascends behind the lesser sac and later lies between the two layers of
the lesser omentum
It gives branches to the lower part of the esophagus

 Splenic artery is tortuous and lies along the superior border of the body of the pancreas
and forms one of the stomach bed structures.
It gives the following branches:
1. pancreatic (many branches-out of which one is large)
 2. splenic
3. short gastric
4. left gastroepiploic

 Common hepatic artery lies behind the lesser sac and divides into the following two
branches at the free margin of the lesser omentum

1. hepatic artery proper

2. gastroduodenal artery

Hepatic artery proper gives the right gastric artery at its origin. Then it divides into right
and left hepatic arteries
Right hepatic artery gives a branch to the gall bladder - the cystic artery

Gastroduodenal artery gives a supraduodenal branch and then runs downwards behind the
1st part of the duodenum and divides into two terminal branches:
1. superior pancreatico duodenal
2. right gastroepiploic

Superior mesenteric artery:

 This is an unpaired ventral branch of abdominal aorta at the level of L1 vertebra

 It is the artery of the midgut
 The origin lies behind the body of the pancreas
 Left renal vein lies between the superior mesenteric artery and the abdominal aorta
 It runs downwards along with the vein in front of the uncinate process of the pancreas
 The uncinate process separates the abdominal aorta from the superior mesenteric artery
 Lower down, the 3rd part of duodenum separates the abdominal aorta from the SMA
 It enters between the two layers of the mesentery to supply the intestine with branches
It gives the following branches:
1. inferior pancreatico duodenal
2. Middle colic
3. Right colic
4. ileocolic
5&6 jejunal and ileal branches (15-20)

 Its ileocolic branch anastomoses with the terminal branch of the superior mesenteric
artery.
 The ileocolic artery gives an ascending branch and a descending branch.
 The ileocolic artery gives anterior and posterior cecal branches.
 Apendicular artery usually is a branch of posterior cecal artery
 The ascending branch of ileocolic artery anastomoses with the descending branch of
the right colic
 The ascending branch of right colic artery anastomoses with the right branch of the
middle colic
  The left branch of middle colic anastomoses with the ascending branch of the left
colic (a branch of inferior mesenteric artery) at the junction of right two thirds with
the left one third of the transverse colon which is the junction of the midgut with the
hindgut. They form a longitudinal anastomosis in the transverse mesocolon- marginal
artery

Note: jejunal and ileal branches are given from the convex left side of the superior mesenteric
artery.

Compression of the left renal vein between the superior mesenteric artery and the abdominal
aorta- “Nut- cracker syndrome”

Inferior mesenteric artery:

 It is the ventral unpaired branch of the abdominal aorta at the level of L3 vertebra behind
the third part of the duodenum.
 It is the artery of the hindgut.
 It runs downwards and to the left, medial to the inferior mesenteric vein
It gives the following branches:
1. Left colic artery
2. Sigmoid branches
 It continues as the superior rectal artery.
 Superior rectal artery crosses the left common iliac artery and descends in the medial
limb of the sigmoid mesocolon
 The artery lies medial to the inferior mesenteric vein.
 The inferior mesenteric vein ascends lateral to the artery and terminates in the splenic
vein behind the body of the pancreas.

Portal vein:
It is formed behind the neck of the pancreas by the union of superior mesenteric vein with the
splenic vein.
It is 3 inches long (about 8 cm)
It begins like a vein but ends like an artery
It lies behind the first part of the duodenum
It is one of the contents of the free margin of the lesser omentum behind the hepatic artery and
bile duct
It divides into right and left branches.
Each branch supplies the corresponding functional physiological lobe of the liver
Tributaries of the portal vein:
Superior pancreaticoduodenal vein
Right gastric vein
Left gastric vein
Cystic vein drains into its right branch
Paraumbilical veins are connected to the left branch of the portal vein.

In portal hypertension, the following portocaval (portosystemic) veins open up:

 1. Anastomoses between the tributaries of the left gastric vein and the tributaries of the
azygos vein in the wall of the lower end of the esophagus. In portal hypertension these
anastomotic veins enlarge in the wall of the esophagus and later burst into the lumen of
the esophagus resulting in hematemesis.
2. Anastomoses between the paraumbilical vein and the systemic veins of the anterior
abdominal wall around the umbilicus. In portal hypertension, this anastomosis gets
enlarged and dilated veins form “caput medusae” around the umbilicus.
3. Anastomoses between the superior rectal vein (which drains to the inferior mesenteric &
eventually into the portal vein) and inferior rectal vein which drains into internal
pudendal → into the internal iliac vein which eventually drains into the inferior vena
cava. In portal hypertension this anastomoses gets dilated resulting in hemorrhoids and
bleeding per anus.
Internal hemorrhoids:
In the upper anal canal caused by varicosities of the superior rectal vein.
They are innervated by autonomic nerves and hence are not painful
External Hemorrhoids:
Varicosities of the inferior and middle rectal veins
They are innervated by somatic nerves and are painful
4. there is another portosystemic anastomoses between the veins of the ascending and
descending colons and veins of the posterior abdominal wall
5. There is also another portosystemic anastomoses between the veins of liver and veins of
diaphragm in the bare area of the liver.

Surgical shunts for treatment of portal hypertension:

- IVC and Portal vein (where they lie close to each other)
- Splenic vein (after splenectomy) and Left Renal vein.
- Intrahepatic vascular shunt between branch of the portal vein and hepatic vein

Kidneys
 They are paired excretory glands placed on the posterior abdominal wall.
 They are retroperitoneal structures.
 They move about 3cm downwards during inspiration.
Surface anatomy:
Anteriorly kidneys can be roughly marked by considering the following facts
1. Transpyloric plane crosses the upper border of the hilum of the right kidney and lower
border of the hilum of the left kidney.
2. the upper pole is one inch away from median plane
3. hilum is two inches away from the median plane
4. lower pole is three inches away from the median plane
Measurements of kidney: Remember 1, 2&3
It is one inch thick, two inches breadth and three inches long.
Surface marking on the posterior wall:
 1. Mark a horizontal line at the level of T11 spine. Mark two points on that. The first point
2.5cm from the midline and the second point 9 cm from the midline.
2. Mark a horizontal line at the level of L3 spine. Mark two points on that. The first point
2.5 cm from the midline and the second point 9cm from the midline.
3. join medial two points by a vertical line
4. join the lateral two points by a vertical line
5. the parallelogram marked is called “Morris parallelogram”
6. Kidney’s lie within this parallelogram.
7. As a rule left kidney is slightly higher than the right kidney.

Renal angle:
It is the angle between the last rib and erector spinae muscle. The tenderness in this angle is
generally attributed to kidney.

As a basic mental drill let us name all the structures that we meet if we approach the kidney from
the back. (Keep the power point diagram open in front of you)
1. skin
2. superficial fascia
3. deep fascia with the posterior layer of the thoracolumbar fascia(attached to the spines of
lumbar vertebrae
4. erector spinae muscle
5. middle layer of thoracolumbar fascia (attached to the tips of transverse processes of
lumbar vertebrae)
6. quadratus lumborum muscle
7. anterior layer of thoracolumbar fascia (attached to the anterior surface of the transverse
processes of the lumbar vertebrae)
8. pararenal fat
9. renal fascia
10. perirenal fat
11. renal capsule ( which immediately surrounds the kidney)

Coverings
• Provide compliance for the movement occuring during respiration.
• Support as a cushion for the kidney.
1- Fibrous capsule
• Applied to its outer surface.
• Enters hilum and walls the sinus.
• Easily separates from kidney unlike covering of spleen
2- Perirenal or perinephric fat(Fatty capsule)
• Covers the fibrous capsule.
• Enters renal sinus through hilum

3-Renal fascia (Fascial or false capsule)

• condensation of connective tissue. It lies outside the perirenal fat.
• encloses the kidneys and suprarenal glands.
 • Called Gerota’s fascia.
• laterally extends with the fascia transversalis.
• medially covers renal vessels.
• inferiorly covers ureter
:
It covers the kidney and suprarenal gland and sends septa between the kidney and suprarenal.
The anterior and posterior layers covering the anterior and posterior surfaces of the kidney
respectively are fused medially but not inferiorly. This is the reason why kidneys float
downwards when fat is suddenly depleted in an individual. This movement of the kidney is
called ‘nephroptosis”
Following nephroptosis, the ureter kinks.
Nephropexy is the operation which fixes the kidney to the posterior abdominal wall.

Applied point: These days, renal transplantation is a very common operation in an individual
whose both kidneys have failed. Harvested kidneys are transplanted to the iliac fossa and the
renal vessels are connected to the external iliac vessels and the ureter is connected to the urinary
bladder. This overcomes the problem of nephroptosis.

4- pararenal fat
• Outside the renal fascia ( large quantity)
• Forms part of retroperitoneal fat.
• Thickest posteriorly where it lies against the transversalis fascia.
• Acts as a packing material

Macroscopic structure of kidney

Parenchyma of kidney
1- cortex
2- medulla
Cortex
• Immediately beneath the capsule.
• Consists of outer and inner (juxtamedullary) parts.
• Extends inward as renal columns b/w the renal pyramids of the medulla.
• Arches over base of pyramids as cortical arch.

Medulla
• Darker in color
• Composed of 8-16 renal pyramids
• Apex of which directed into the renal sinus as renal papillae.
• Surface of papillae perforated by ducts of Bellini.

Renal pelvis

• Is the expanded upper end of the ureter

• Lying within the renal sinus
• Gives rise to 3-4 major calyces
 • Each of which gives rise to several minor calyces

Each minor calyx

• Is associated with a single renal pyramid

• Is cup shaped and surrounds a renal papilla
• Receives urine from the renal papilla for transmission
• Down the ureter to the bladder

Anterior relations of the right kidney:

It is related to the following structures
1. right suprarenal gland
2. second part of duodenum
3. right lobe of liver ( separated by the Morrison’s pouch)
4. right colic flexure
5. coils of small intestine

Anterior relations of left kidney:

1. left suprarenal gland ( along its upper and medial border)
2. spleen
3. stomach ( separated by the lesser sac)
4. tail of the pancreas & splenic vessels
5. coils of the small intestine
6. left colic flexure

Posterior relations of the kidneys:

Note: the only difference between the left and right kidney is the following:
Left kidney is related to the 11th and 12th ribs while the right kidney is related to the 12th
rib only.
The other relations are common to both the kidneys
Four muscles: 1) diaphragm, 2) psoas major, 3)quadratus lumborum,
4) Aponeurosis of origin of transversus abdominis

Three nerves: 1) subcostal 2) ilio hypogastric 3) ilioinguinal

Two arcuate ligaments: 1) medial arcuate ligament (fibrous arch anterior to the psoas
major) 2) lateral arcuate ligament ( fibrous arch anterior to the
quadratus lumborum)
One artery: Subcostal artery

Hilum of the kidney:

Hilum is the entry to the kidney present on the concave medial border.
Structures present in the hilum are:
1. renal vein
2. renal artery
3. pelvis of ureter
 4. renal plexus of nerves
5. lymph vessels
6. connective tissue
Structures are arranged in that order from front to back; (VAU)
Renal vein
Renal artery
Ureter lying most posterior

Blood supply of the kidney

Renal arteries
- paired branches
- arise from the abdominal aorta
- One to each kidney
-between L1 and L2 vertebrae
-each divides into anterior and posterior branches which give rise to segmental arteries to
corresonding kidney segment.
Give rise to lobar and interlobar arteries ---- arcuate arteries
Segmental arteries

• Are essentially end arteries

• If occluded, will result in death (avascular necrosis) of that kidney segment
• Segmental a.lobar a.one for each renal pyramid
• Arcuate arteries lie transversely at the junction of cortex and medulla
Venous drainge of the kidney
Left renal vein
• Is longer than the right
• Passes anterior to the aorta just below the origin of the SMA
• Receives the terminations of the Lt. Suprarenal vein and Lt gonadal vein and may receive
left inferior phrenic vein
• It lies behind the body of the pancreas. It lies sandwiched between the superior
mesenteric artery and abdominal aorta.
The relationships of these are important.
Nutcracker syndrome - Left renal vein is obstructed and causes Varicosities of the left gonadal
vein (pampiniform plexus of veins).
Right renal vein
• Is shorter than the left
• Lies in front of the right renal artery
• Passes posterior to the second part of the duodenum and head of the pancreas. This
relationship is also important.
• It has no other tributaries
Nerve supply: Sympathetic and parasympathetic. Sympathetic fibers come from least splanchnic
nerves through the renal plexus. Sympathetic fibers also carry pain sensation to T11-L2 segments
of the spinal cord.

Brief note on the development:

Secretory part is developed from the metanephric mass and the collecting part is developed from
the ureteric bud (mesonephric duct). Failure of the fusion or improper genetic cue might result in
the polycystic kidney where majority of secretory parts remain unconnected with their respective
collecting parts.

Kidneys develop in the pelvic region and ascend later due to the differential growth of the
anterior abdominal wall.
During ascent, they take branches from the nearby arteries. As ascent continues, it gets new
vessels from the arteries nearby and the old ones disappear. If they fail to disappear, they remain
as accessory renal arteries. They are very common in the kidney. They supply a separate area in
the kidney.
If kidney fails to ascend, it remains as a pelvic kidney. One kidney may ascend normally and the
other may remain as a pelvic kidney. During ascent, if the lower ends of the two kidneys fuse
together, the ascent of this fused mass is prevented from the stem of the inferior mesenteric
artery. Such kidneys resemble a horse shoe and therefore they are called “horse shoe kidneys”

Ureter
 It is the muscular tube which conducts the urine to the urinary bladder from the kidney
 Its dilated upper end is called the pelvis of the ureter. Pelvis is present in the posterior
part of the renal sinus. Renal sinus is the space just beyond the hilum in the kidney.
 It is 10 inches (25 cm long)
 Its upper half lies in the abdomen and lower half lies in the pelvis.
 It lies anterior to the corresponding psoas major muscle and genitofemoral nerve. It
crosses the bifurcation of the corresponding common iliac artery and enters the pelvis.

Anterior relations of the right ureter:

1. Third part of the duodenum
2. Right gonadal vessels
3. Right colic and ileocolic vessels
4. Ileum
5. Root of the small intestine

Anterior relations of left ureter:

1. Left colic vessels
2. Left gonadal vessels
3. Sigmoid colon
4. Sigmoid mesocolon
Remember: the inferior mesenteric vein lies medial to it.
Importance of ureter as it comes close to the vagina/uterus and uterine artery….
It can get clamped during a hysterectomy.

Blood supply of ureter:

It receives branches from the nearby arteries
1. Renal
2. Gonadal
3. Abdominal aorta
 4. Inferior vesical artery in the pelvis
 There is a vertical anastomosis connecting all these branches in the wall of the
ureter.
Point to remember: because of inner longitudinal smooth muscle in the ureter, the milking of
urine towards urinary bladder is possible. This has made the space exploration possible.
Otherwise there is no gravity in the space and urine would not have reached bladder if it were to
be gravity dependent.
Nerve supply of the ureter:
It is supplied by T11 to L2 segments. These are sympathetic nerves. They also carry pain
sensation from the bladder. That is the reason why pain of ureteric colic is referred from the loin
to the groin. It is also referred to the external genitalia as the genital branch of genitofemoral
nerve supplies it. The root value of genitofemoral nerve is L1 and L2
Ureteric colic is an excruciating pain arising out of spasmodic contraction of ureter usually
originated because of impacted stones (hardened minerals). They tend to get lodged at three
constrictions of ureter.
Constrictions of ureter:
 The first constriction is at the pelviureteric junction
 The second constriction lies at the level of pelvic brim
 The third constriction appears where ureter lies obliquely in the wall of urinary bladder
These constrictions are easily seen in special x-rays where radio-opaque material is injected prior
to taking x-ray. (Descending pyelogram)

1. The first constriction lies at the level of transverse process of L1

2. The second constriction lies opposite the sacroiliac joint
3. The third constriction lies at the level of ischial spine

Suprarenal glands
 Suprarenal glands lie superior to the corresponding kidney.
 They lie within the renal fascia but there is septum of renal fascia which separates the kidney
from the suprarenal. That makes removal of kidney easy as suprarenal can be safely left
behind.
 They are endocrine glands having cortex and medulla.
 The cortex secretes the aldosterone, corticosteroids and sex hormones
 The suprarenal cortex is essential for life.
 The medulla secretes the catecholamines

Right suprarenal gland:

 It is triangular in shape
Anterior relations: inferior vena cava medially and right lobe of liver laterally
Posterior relations: diaphragm, kidney
It has only one vein issued from its hilum. This right suprarenal vein opens into the inferior vena
cava
There are three groups of arteries which supply the right suprarenal gland
1. The superior suprarenal come from the right inferior phrenic artery
2. The middle suprarenal comes from the abdominal aorta
3. The inferior suprarenal comes from the right renal artery
Left suprarenal gland:
 It is semilunar in shape
Anterior relations:
From above downwards, they are:
1. Stomach
2. Splenic artery
3. Body of the pancreas
Posterior relation: diaphragm, kidney

Left suprarenal vein opens into the left renal vein

There are three groups of arteries in the left just like the right suprarenal gland.
The space between the two suprarenal glands is about 2 inches long and it contains the following
structures from right to left
1. Right crus of diaphragm
2. Right celiac ganglion
3. Celiac trunk
4. Left celiac ganglion
5. Left crus of diaphragm

Nerve supply: Sympathetic preganglionic fibers from the splanchnic nerves supply the medulla.
The cells of the medulla constitute post-ganglionic neurons

Applied anatomy of suprarenals:

Pheochromocytoma – A tumor of the medulla causes attacks of hypertension with palpitation,

excessive sweating and pallor of skin

Adenoma or carcinoma of the cortex gives rise to cushing’s syndrome ( hypogonadism,

hirsutism, diabetes and obesity)

Insufficiency of the cortex may result due to tuberculosis and gives rise to Addison’s disease –
Hypotension, pigmentation of the skin, anemia and muscular weakness are the signs of this
condition.

Abdominal aorta
 It is the continuation of the thoracic aorta
 It begins at the level of T12 vertebra and terminates at the level f L4 vertebra
 It passes through the aortic opening accompanied by the azygos vein and thoracic
duct
 It lies between the right and left crura above
Anterior relations:
1. Celiac plexus of nerves
2. Superior mesenteric plexus of nerves
3. Body of the pancreas
 4. Left renal vein
5. Uncinate process of pancreas
6. Horizontal part of the duodenum
7. Inferior mesenteric plexus of nerves
8. Peritoneum
Posterior relations:
9. Left psoas major
10. Left sides of the bodies of lumbar vertebrae

Branches:
Unpaired ventral branches:
1. Celiac trunk
2. Superior mesenteric artery
3. Inferior mesenteric artery

Unpaired dorsal branch:

Median sacral artery

Paired dorsal branches:

Four lumbar arteries

Paired lateral branches:

1. Inferior phrenic arteries
2. Middle suprarenal arteries
3. Renal arteries
4. Gonadal arteries

Two terminal branches: common iliac arteries

Inferior vena cava

 It is formed at the level of L5 by the union of two common iliac veins
 It enters thorax by piercing the diaphragm at the level of T8 vertebra. It is accompanied
by the right phrenic nerve in this opening.
Anterior relations:
1. Peritoneum
2. Root of the mesentery
3. Ileum
4. Gonadal vessels
5. Horizontal part of the duodenum
6. Head of the pancreas
7. Epiploic foramen
8. Liver

Posterior relations:
1. Psoas major
2. right suprarenal gland
 3. Diaphragm

Tributaries:
1. Two common iliac veins
2. Right gonadal vein
3. Right and left renal veins
4. Right suprarenal vein
5. Right inferior phrenic vein (occasionally left inferior phrenic vein also)
6. Hepatic veins
7. Third and fourth lumbar veins
The first and second lumbar veins open to the ascending lumbar veins. The fifth enters the
iliolumbar

Lumbar plexus
 It is formed by the union of ventral rami of L1 – L4 in the substance of the muscle
psoas major
It gives the following branches:
1. Iliohypogastric nerve (L1)
2. Ilioinguinal nerve (L1)
3. Genitofemoral nerve (L1 &2)
4. Lateral cutaneous nerve of thigh (dorsal branches of ventral rami of
L2&3)
5. Femoral nerve (dorsal branches of ventral rami of L2, 3&4)
6. Obturator nerve (ventral branches of ventral rami of L2, 3&4)
7. Lumbosacral trunk (L4 and L5) crosses the ala of sacrum and joins the
sacral plexus)
Genitofemoral emerges from the anterior surface of the muscle. The last two emerge from the
medial side of the psoas major. The rest of them from the lateral aspect of the muscle.

Common iliac artery – Terminal branch of the abdominal aorta given out at the level of L4 and
divides into external and internal at the level of the sacroiliac joint. It is crossed in front by the
ureter. On the left side the superior rectal artery and apex of the sigmoid mesocolon cross the
terminal end of the artery

External iliac artery:

It is the terminal branch of the common iliac artery at the level of sacroiliac joint
It is accompanied by the external iliac vein and external iliac group of lymph nodes
It gives two branches:
1. inferior epigastric artery
2. deep circumflex iliac artey
It continues as the femoral artery behind the inguinal ligament
It is crossed on the right side by the following:
1. Right gonadal vessels
2. Right ductus deferens
3. Ileum
 4. Sometimes appendix

It is crossed on the left side by the following:

1. Left gonadal vessels
2. Left ductus deferens
3. Sigmoid colon
4. Sigmoid mesocolon

Lymph nodes of the posterior abdominal wall:

 Lymph vessels from the lower limb open into the inguinal lymph nodes.
 Inguinal lymph nodes continue as the external iliac nodes around the external iliac
vessels. These vessels receive all the lymph from the lower limb, the deeper part
of the anterior abdominal wall and urinary bladder.
 Lymph from the pelvis mainly drains into the internal iliac lymph nodes
 Internal and external lymph nodes open into the common iliac nodes around the
common iliac vessels.
 These will continue as the lumbar lymph nodes on the side of the lumbar
vertebrae. There are two lumbar lymph trunks, the right and left.
 All the lymph from the gastrointestinal tract is drained into the celiac, superior
mesenteric and inferior mesenteric nodes. Lymph from these three groups of
nodes joins to form an unpaired intestinal lymph trunk. These entire nodes lie
anterior to the aorta therefore they are also collectively termed as preaortic nodes.
 Lumbar nodes are called lateral aortic nodes.
 Gonadal lymph is drained into the pre and paraortic lymph nodes
 Two lumbar trunks and one intestinal trunk open into the dilated lymph sac called
“cisterna chyli”
 Cisterna chyli lies at the level of L1 and L2 vertebrae.
 It continues as the thoracic duct.

Muscles of posterior wall:

Psoas major
Quadratus lumborum
Iliacus

Psoas major:
It arises from the bodies and transverse processes of the lumbar vertebrae
It surrounded by a connective tissue sheath called “Psoas fascia”
It is inserted into the lesser trochanter of the femur with the iliacus muscle
Lumbar plexus lies inside the substance of the psoas major muscle
Psoas shadow is seen in the plain X-rays
Exudates from the tuberculosis of the lumbar vertebrae may collect within the psoas fascia
causing psoas abscess.The psoas abscess may descend along the muscle and point in the
upper part of the front of the thigh.
It helps to flex the hip and laterally bend the vertebral column.
Psoas sign
Elicited by the iliopsoas test, the psoas sign is an indicator of irritation to the iliopsoas group of
hip flexors in the abdomen.The test is performed by having a supine patient with knees extended
flex their thighs against resistance. If abdominal pain results, it is a positive psoas sign. Because
the right iliopsoas muscle lies under the appendix when the patient is supine, a "positive psoas
sign" may suggest appendicitis.
Nerve supply: lumbar plexus – anterior branches of L2-L4 nerves
Nerves related to the psoas major:
Medial:
obtuarator nerve

Anterior:
genitofemoral nerve

Lateral: from below upwards:

Femoral nerve
Lateral cutaneous nerve of thigh
Ilioinguinal nerve
Iliohypogastric nerve

Quadratus lumborum:

It is a quadrilateral muscle; origin from the iliac crest and insertion is to the12th rib.
It lies between the anterior and middle layers of the thoracolumbar fascia
Nerve supply: anterior branches of T12 & L1-L4 nerves

The following structures lie anterior to the quadratus lumborum:

Posterior surface of the kidney
Subcostal nerve
Subcostal vessels
Iliohypogastric nerve
Ilioinguinal nerve

Iliacus:
It arises from the iliac fossa and is inserted into the lesser trochanter along with the psoas major
muscle
It flexes the hip.
Nerve supply: Femoral nerve (L2-L4)

The following structures form its anterior relations on the right side:
Femoral nerve between it and psoas major muscle
Lateral cutaneous nerve of thigh
Cecum and appendix

The following structures form its anterior relations on the left side:
Femoral nerve lies between it and psoas major muscle
Lateral cutaneous nerve of thigh
Descending colon.

Thoracolumbar fascia:

Consists of three layers of fascia that envelop the muscles of the lumbar spine, separating them
into three compartments.
Anterior, middle and posterior layers
Anterior layer.
Covers the anterior surface of quadratus lumborum. Attached medially to the anterior surfaces of
the lumbar transverse processes. Lateral to the quadratus lumborum, it blends with the other two
layers of thoracolumbar fascia.

Middle layer.
Lies behind quadratus lumborum .Medially, it is attached to the tips of the transverse processes
and it is directly continuous with the intertransverse ligaments .Laterally, it gives rise to the
aponeurosis of the transversus abdominis.

Posterior layer.
Covers the back muscles from the lumbosacral region through the thoracic region as far rostrally
as the splenius muscle. Arises from lumbar spinous processes posteriorly, and wraps around the
back muscles to blend with the other layers of thoracolumbar fascia along the lateral border of
erector spinae between the 12th rib and iliac crest.

Lumbar sympathetic trunk:

It is bilateral
They lie along the anterior edge of the psoas major muscle
The right trunk is partially covered by the inferior vena cava while the left trunk is partially
covered by the abdominal aorta
Usually, it has four ganglia
It descends into the pelvis in front of the sacrum.

Ganglia and plexus of abdomen:

Autonomic nerves from T5 to T12 segments reach the abdomen through the following
nerves:
Greater splanchnic nerve: From T5 to T9 roots
Lesser splanchnic nerve: From T10 and T11 roots
Least splanchnic nerve: From T12 root

Celiac ganglia and celiac plexus:

Contributed by: sympathetic from spanchnic nerves
Parasympathetic: posterior vagal trunk
 Superior mesenteric plexus: Sympathetic come from splanchnic nerves and sympathetic
trunks
Parasympathetic: vagus nerve

Intermesenteric plexus lies between the superior and inferior mesenteric plexus.
It gives rise to the renal and gonadal plexus of nerves (parasympathetic fibers not clear)

Inferior mesenteric plexus:

sympathetic come from splanchnic nerves and sympathetic trunks
Parasympathetic nerves: they come from the pelvic splanchnic nerves (S2, S3 and S4)

Superior hypogastric plexus:

This is found at the bifurcation of the abdominal aorta.
The sympathetic fibers come from the superior plexuses
The parasympathetic fibers come from the pelvic splanchnic nerves (S2,S3&S4)

Hypogastric nerves:
This is a bilateral nerve which connects the superior hypogastric plexus with the inferior
hypogastric plexus.

Inferior hypogastric plexus:

Lies in the pelvis and has sympathetic fibers coming from the superior hypogastric plexus
and parasympathetic fibers come from the pelvic splanchnic nerves ( S2,S3&S4)

Clinical anatomy of the lumbar sympathetic trunks:

In Raynod’s disease there is vasoconstriction of the tip of the toes following sympathetic
over activity. It may necessitate the lumbar sympathectomy. In this operation, one has to be
careful about the relation of inferior vena cava on the right side and the abdominal aorta on
the left side.

THE PELVIS

BONY PELVIS:

• hip bones (2)

• sacrum
• coccyx
Ligaments
• Sacrotuberous
• Sacrospinous
• Interosseus sacroiliac
 Anatomical position:

Anterior superior iliac spines and pubic tubercles lie in the same coronal plane
Coccyx and the upper margin of the pubic symphysis lie in the same horizontal plane

The pelvis consists of two subdivisions: False or Greater pelvis

True or Lesser pelvis

Pelvic inlet or pelvic brim separates the two parts.

Greater Pelvis:
• Above the pelvic brim
• Forms the lowest part of the abdominal cavity

Lesser Pelvis:
• Below the pelvic brim
• Above is opened into the abdominal cavity
• Below is closed by the pelvic diaphragm

JOINTS OF THE PELVIS

Sacroiliac joint:

• Synovial joint
• Its irregular surface allowing for little movement
• Is reinforced by -interosseous sacroiliac ligament
-dorsal sacroiliac ligament
-ventral sacroiliac ligament
-iliolumbar ligament
-sacrospinous ligament
-sacrotuberous ligament

Pubic symphysis:

• Secondary cartilaginous joint (symphyseal)

• supported by - superior pubic ligament
- Arcuate pubic ligament
• Immovable except in the later stage of pregnancy (hormonal effect- sex hormone &
relaxin)

PELVIC INLET: is formed by:

 The promontory of the sacrum behind
 The arcuate lines & iliopectineal lines in front and sides
TRUE PELVIS:

Bony wall is formed by:

Sacrum behind
Pelvic surfaces of the hip bones in front and sides
Muscles: Piriformis (posteriorly)
Obturator internus and obturator fascia (laterally)
Levator ani and coccygeus (pelvic diaphragm) form the floor

PELVIC OUTLET:

• diamond-shaped area
• is bounded by: - coccyx
-sacrotuberous ligament
-ischial tuberosities
-ishiopubic rami
-pubic symphysis
• Outlet closed by pelvic diaphragm and urogenital diaphragm

SEXUAL DIFFERENCES IN THE BONY PELVIS

Feature Male pelvis Female pelvis

Pelvic inlet Narrow and heart shaped Wide and oval shaped
Subpubic angle < 70 > 80
Sacrum Longer and curved shorter and flatter
Ala width is Lesser greater
Ischiopubic rami Everted not everted
Obturator foramen Oval triangular
Ischial spines Inverted and close together more widely separated

Types of Pelvis:
Pelvis of any person may have some features of the opposite sex. The 4 most common types of
pelves are: Android, Gynecoid, Anthropoid, Platypelloid.
Normal female pelvis is gynecoid type. Atypical female pelvis may not be conducive to a vaginal
birth.

Diameters of the pelvis:

Anteroposterior, oblique and transverse diameters

Inlet of the pelvis-
 A-P diameter- 10cm
  Oblique diameter- 11 cm
 Transverse diameter- 12 cm
Pelvic cavity:
 All diameters are -11cm
Pelvic outlet:
 A-P diameter- 12 cm
 Oblique diameter- 11 cm
 Transverse diameter- 10 cm
True (obstetrical) conjugate is the A-P diameter from the middle of the sacral promontory to the
posterosupeirior margin of the pubic symphysis. Since this cannot be measured directly during
pelvic examination, the diagonal conjugate is measured from the sacral promontory to the
inferior margin of the pubic symphysis by the palpating hand.
During pregnancy, though the diameters increase by 10-15%, the one diameter that remains
unaffected is the true conjugate diameter.

The maximum diameter

Pelvic inlet-transverse
Pelvic outlet-antero-posterior
Thus, during childbirth, the head must rotate 90 degrees B/w the pelvic inlet and outlet
The distance between the two ischial spines (interspinous distance) is normally the narrowest
part of the pelvic canal, but it is not a fixed distance. It is usually taken as a determinant of the
capacity for a vaginal birth.

Pelvic Diaphragm

-forms the floor of the pelvis

-support the pelvic organs
-separates the pelvic cavity from the perineum
-incomplete anteriorly for passage of the urethra + vagina
-forms the medial wall of the ischiorectal fossa
-function as a unit to raise the pelvic floor
-covered by the superior and inferior fascia of the pelvic diaphragm
-Consists of two muscles
1. Levator Ani [Anteriorly] and
2. Coccygeus [posteriorly]

1. Levator Ani consists of

a. Pubo coccygeus
b. Ilio coccygeus
Origin: From the pelvic surface of the body of the pubis, tendinous arch of the obturator fascia

Pubococcygeus Part of the levator ani:

• Anterior component surrounds
- The base of the prostate in male(Levator prostate muscle)
-Lower end of the vagina in the female (Pubovaginalis muscle)
-Anchors to the perineal body
• Posterior component fuses with the opposite muscle at the Anococcygeal ligament and
coccyx
• Inferior component- puborectalis muscle
Inferior fibers of the pubococcygeus part
Forms a sling around the anorectal junction- puborectal sling
Is responsible for the angle formed b/w the rectum and the anal canal
Functions as a sphincter to maintain anal continence reflexes during defecation

Functional significance of the Levator ani muscle:

• Maintain the integrity of the pelvic floor

• Is susceptible to damage during childbirth
• Is important in maintaining the urinary continence
• Prevents the prolapse of the rectum
• Arises from a condensed fascia [tendenous arch] over the obturator internus m.
• Consists of -pubococcygeus
-iliococcygeus

Nerve supply: Is innervated by the Perineal br.of the 4th sacral nerve, Inferior rectal nerve
and direct branches from sacral plexus.

Pelvic fascia: (endopelvic fascia)

Lines the floor and walls of the pelvic cavity & is continuous with extraperitoneal tissue
It is condensed to form- puboprostatic or pubocervical ligaments
-transverse cervical ligament

2. Coccygeus is also known as Ischio coccygeus. Sacrospinous ligament is an atrophied part of

the coccygeus.

URINARY BLADDER
Hollow muscular organ
Empty bladder lies within the true pelvis.
When full, it rises up into the abdominal cavity
In the fetus and newborn, even empty bladder is abdominal in position.
Normal capacity is about 200-300 ml.

Shape: empty bladder is pyramid in shape.

It has:
• 4 angles- apex, neck and two lateral angles
• 4 surfaces- a superior, a posterior and two inferolateral surfaces
• 4 borders- a posterior, an anterior and two lateral borders
Distended bladder is ovoid in shape.
Relations:
• Apex- attached to the umbilicus by median umbilical ligament [urachus], represents
obliterated allantoic diverticulum
• Lateral angles- Receives the ureters
• Neck or inferior angle- Opens into the urethra. Rests on the prostate in the male and
the UG diaphragm in the female
• Superior surface- is completely covered by peritoneum in the male and is related to
the coils of the intestine.
In the female only the anterior 2/3 is covered by peritoneum and is related to
the uterovesical pouch. Posterior 1/3 is not covered with peritoneum and is
related to the cervix (supravaginal part) of the uterus
• Inferolateral surface- related to obturator internus, pelvic diaphragm
• Posterior surface- (fundus of the urinary bladder)
In male: rectovesical pouch, coils of intestine, seminal vesicles and vasa
deferentia. Denonvillier’s fascia (rectovesical septum) separates them from
the rectum.
In female- not covered with peritoneum. Related to the upper part of the
anterior wall of the vagina
• Anterior to the UB, there is no peritoneum-distended bladder may be punctured-
Suprapubic cystotomy

Internal features of the urinary bladder:

Thick muscle wall – Detrusor (stimulated by parasympathetic) – Mucosa is thrown into

irregular folds except at the trigone.

Trigone- triangular region made up of smooth mucous membrane regardless of contractility.

There are no folds in the mucosa
• Highly sensitive area.
• Ureteric orifices form lateral ends of triangle.
• Internal urethral orifice forms inferior angle of triangle.
• Interureteric fold between the ureteral orifices
• Developed from absorbed Mesonephric ducts.

Detrusor muscle at the neck surrounds the urethra forming sphincter vesicae. (Internal
urethral sphincter)
• Uvula is a projection in the trigone, prominent in males formed by Median lobe of
prostate which projects into the interior and causes obstruction to easy flow of urine in
Benign Prostatic Hypertrophy

Ligaments of the bladder: True and false ligaments

• True ligaments are:

 Median umbilical ligament (urachus)
 Lateral true ligament
 Posterior true ligament
  Medial puboprostatic (♂) / Pubovesical ligament (♀)
 Lateral puboprostatic (♂) / Pubovesical ligament (♀)

• False ligaments are:

 Median umbilical fold
 2 medial umbilical folds
 lateral and posterior false ligaments

Blood supply:

• superior and inferior vesical arteries(+Vaginal arteries in female)

• Is drained by the vesical and prostatic venous plexus to the Internal iliac vein- however it
may drain through the sacral veins into the internal vertebral venous plexus.
[Thus, tumor cells may spread to the vertebral column and skull via vertebral venous
plexus]

Nerve supply:

• Vesical and prostatic plexus which are extensions of the inferior hypogastric plexus

The normal bladder

• Sympathetic outflow: from T11 to L2 segments.

Inhibit contraction of detrusor and stimulate contraction of sphincter vesicae. [=holds urine]
[Sympathetic system is less important in control of bladder function relative to
parasympathetic system]

• Parasympathetic outflow: from 2nd, 3rd, and 4th sacral segments of

spinal cord.= pelvic splanchnic nerves
-Inhibit contraction of sphincter vesicae and stimulate contraction of Detrusor. [=voids urine]

* Higher centers in Brain : Automatic reflex of bladder is controlled by toilet training due to
control by higher centers on spinal neurons

• Sensory (pain felt due to overstretching of bladder): enter spinal cord at lumbar and
sacral segments.
• Pass via sympathetic – from fundus of bladder
• Pass via parasympathetic – from neck of bladder

Clinical correlates:
Cystotomy- As the bladder fills up, it extends superiorly above the pubic symphysis into the
space between the parietal peritoneum and the anterior abdominal wall. Thus, the distended
UB can be directly approached by suprapubic cystotomy without the intervention of the
peritoneum.
Cystoscopy
Cystogram- Radiogram obtained with contrast media instilled into the bladder
Cystocele- Hernia of the bladder into the vaginal wall due to damage to the perineal muscles
Ectopia vesicae – congenital anomaly-due to defect in the ant. Abd. Wall
Rupture of the bladder: distended bladder may be ruptured by injury to the inferior part of
the anterior abdominal wall or fracture of the pelvis . Urine may escape extraperitoneally or
intraperitoneally. Extravasation of urine to the peritoneal cavity occure in rupture of the
superior part of the UB.

PROSTATE

It is a fibromuscular gland present only in the male.

Its secretion adds volume to semen.
In the female, it is represented by the paraurethral glands (of Skene).
It is situated in the pelvic cavity below the neck of the urinary bladder
It is about 8gm
Resembles inverted cone

Relations of the prostate:

It has-
 superior surface (base): related to the neck of the UB & pierced by the prostatic
urethra
 Inferior surface (apex): rests on the UG diaphragm
 Anterior surface: related to the body of pubis and retropubic space, retropubic pad of
fat. Lower part is attached to the pubis by puboprostatic ligaments.
Prostatic urethra emerges out from its lower part
 Posterior surface: related to the Vasa deferentia and the seminal vesicles.
Ejaculatory ducts pierce this surface. Rectovesical septum( denonvillier’s fascia)
intervenes between this surface and the rectum
 2 lateral surfaces: related to the levator ani

Capsules:
It has 2 capsules- true and false capsule.
True capsule is the condensation of connective tissue of the gland
False capsule is formed by the pelvic fascia
Prostatic plexus of veins lie between the true and the false capsule

Lobes of the Prostate:

The prostatic urethra passes vertically through the anterior part of the gland
 The two ejaculatory ducts pierce the post. surface of the gland and open into the posterior
wall of the prostatic urethra.
Thus the gland can be divided into 5 lobes:
 Anterior lobe-fibrous- in front of the urethra
 2 Lateral lobes- on the sides of the urethra
 Posterior lobe- between the lateral lobes, but below the level of the ejaculatory
ducts. It is commonly involved in cancer of prostate
 Median lobe- between the lateral lobes, but above the level of the ejaculatory
ducts. It contains more glandular material than other lobes and is commonly
involved in benign enlargements (hypertrophy) of the prostate.

Blood supply:

Arteries- Branches from internal pudendal, inferior vesical and the middle rectal arteries
Venous drainage- Prostatic venous plexus lies between the 2 capsules. It drains into the
internal iliac veins.

Clinical importance :
There are valveless communications between prostatic and vertebral venous plexuses through
which prostatic carcinoma can spread to the vertebral column and skull.

Lymphatic drainage:
Into the internal iliac and sacral lymph nodes
Some (from post. part) follow those of the UB and drain into the external iliac lymph nodes

Nerve supply:
Prostatic plexus of nerves from the pelvic plexus
Parasympathetic fibres arise from S2,3 & S4 . Sympathetic fibres are from T11-L1 segments of
the spinal cord.

Applied anatomy:

Cancer- commonly affects posterior lobe, which can be palpated in per rectal (PR) examinations
Benign enlargement –due to hormonal imbalance after the age of 50 yrs. usually affects the
median lobe. It stretches the sphincter vesicae leading to leakage of urine into the prostatic
urethra and causes a reflex desire to pass urine frequently.
The enlarged median lobe forms a projection into the bladder - uvula vesicae which may
obstruct the internal urethral orifice.

URETHRA

It extends from the neck of the Urinary bladder to the external urethral orifice.

Female urethra:

3.75 cm in length
Embedded in the anterior wall of the vagina
Passes through the deep perineal pouch
Paraurethral glands open into the wall of the urethra (homologus to the prostate in the male).

Male Urethra:

20 cm in length. ‘S’ shaped in flaccid state of the penis

Parts of the male urethra:

3 parts- prostatic, membranous, spongy part

Prostatic part:
Passes through the prostate
It is the widest and the most dilatable part,
It is spindle shaped (middle part is dilated)
 Its posterior wall presents the following features-
Urethral crest- vertical ridge in the midline
Seminal colliculus- a spherical swelling in the middle of the urethral crest
Openings of the ejaculatory ducts are seen on each side
On the seminal colliculus
Prostatic utricle opens on it in the middle
Urethral sinuses- shallow depressions on each side of the urethral crest.
Ducts of the prostate gland open into the sinuses by minute
Openings

Membranous part:
Passes through the UG diaphragm to enter the bulb of the penis
It is the shortest, narrowest and the least dilatable part
It is surrounded by the sphincter urethrae
Bulbourethral glands lie posterolateral to this part

Spongy part:
15 cm in length
Passes through the bulb and corpus spongiosum of the penis to open at the external
urethral orifice on the tip of the glans penis.
There are two dilatations – bulbar fossa (in the beginning) and Navicular fossa ( in
the glans penis)
Ducts of the bulbourethral glands open into the floor of the spongy part in its
beginning

Sphincters of the urethra:

2- Internal and External urethral sphincters

Internal urethral sphincter is made of smooth muscles and has sympahthetic nerve supply
External urethral sphincter has skeletal muscle fibers and surrounds the membranous part,
Supplied by the perineal branch of the pudendal nerve

Blood supply: arteries to the bulb (from the internal pudendal)

Lymphatic drainage: From the terminal part- to the deep inguinal lymph nodes
From the proximal part- to the external and internal iliac nodes

Clinical correlates:

Hypospadias- urethra opens on the ventral surface of the penis

Epispadias- Urethral opening is seen on the dorsal surface of the penis

DUCTUS DEFERENS

It is also called Vas deferens. It is tubular. 45 cm long

It begins at the tail of the epididymis and ends behind the prostate by uniting with the seminal
vesicle to form the ejaculatory duct.
It has 3 parts- Extra abdominal part
Abdominal part
Pelvic part
Extra abdominal part begins from the tail of the epididymis. At the upper pole of the testis it
enters the spermatic cord in which it lies posteriorly. It passes through the inguinal canal and
enters the abdomen at the deep inguinal ring.
Abdominal part curves round the lateral side of the inferior epigastric artery, crosses the external
iliac vessels to enter the pelvis.
Pelvic part runs medial to the obturator nerve and vessels, crossing the ureter to reach its medial
side to reach the posterior surface of the urinary bladder medial to the seminal vesicle. Here it
presents a dilatation called ampulla. It then descends behind the prostate where it unites with the
seminal vesicle to form the ejaculatory duct. The ejaculatory duct pierces the prostate and ends
by opening into the posterior wall of the prostatic urethra on the colliculus seminalis.
Blood supply: artery to the vas, branch of the Inferior vesical artery
Lymphatic drainage is into the external and internal iliac nodes
Clinical: Vasectomy (male sterilization)

SEMINAL VESICLE

It is a long thin highly coiled tube situated behind the base of the urinary bladder.
It joins with the vas deferens to form the ejaculatory duct.

RECTUM

• Part of the large intestine B/w sigmoid colon and the anal canal
 • Rectum has a complete longitudinal muscle layer instead of tenia coli
• It does not have haustra, appendices epiploicae or mesentery
• 12 cms long
• Not straight but has 3 curvatures
• Rectum begins and ends at the midline.
• Starts from the end of sigmoid colon at S3 vertebral level
• Ends at the anorectal junction at Coccyx level where it pierces the pelvic diaphragm.
• Anorectal flexure (perineal flexure) is an important mechanism for fecal continence
• Perineal flexure is caused by the puborectal sling
• Perineal flexure lies 2-3 cm in front and slightly below the tip of the coccyx
• Its inner surface has three-four transverse folds
• Proximal 1/3 is covered by peritoneum on the anterior and lateral sides
• Middle 1/3 is covered by peritoneum only on the anterior surface
• Distal 1/3 has no peritoneal covering
• Lower part of the rectum is dilated and called rectal ampulla

Curvatures:
Anteroposterior- follows the concavity of the sacrum and coccyx (sacral flexure)
Lateral curvatures- 2 curvatures to the right and 1 to the left.

Relations of the rectum:

Anterior:
• In females Separated from the posterior fornix of the vagina by
recto-uterine pouch of Douglas.
The pouch of Douglas lies 5.5 cm above the anal orifice
Rectovaginal septum separates it from the posterior wall of vagina

• In males separated from the bladder by recto-vesical pouch.

Rectovesical pouch lies at a distance of 7.5 cm above the anal orifice (length of index
finger)
Fundus of the UB, Ureters, ductus deferens, seminal vesicles and prostate.
The rectovesical septum (Denonvilliers fascia) is closely associated with the seminal
vesicles and prostate. The plane of the rectovesical septum extending superiorly from the
perineal body should be identified during rectal resection so as to avoid damage to the prostate
and urethra.

Posterior:
• In both sexes separated from the lower 3 pieces of sacrum by the waldeyer’s fascia,
median sacral vessels and lower end of the sympathetic chain & ganglion impar,
piriformis, sacral nerves & sacral plexus.

Lateral:
On the sides pararectal fossa, levator ani

Interior of the Rectum: Transverse folds of rectum

 • Valves of Houston
• They are usually 3 (some times 4)
• Two are on the left side (superior and inferior folds) and one on the right (middle fold)
• Include mucosa, submucosa, circular muscle
 The folds are permanent
• Are more obvious when the rectum is distended

Blood supply of the rectum

Arterial supply
• Mainly the superior rectal artery [inf. Mesenteric]
• Middle and inferior rectal arteries [internal iliac]
• Median sacral artery (Abdominal aorta)

Venous drainage
• Mainly superior rectal vein (tributary of inferior mesenteric V)
• Middle and inferior rectal veins (tributaries of internal iliac V)
• Form Portal caval anastomosis
• Internal hemarrhoids due to Varicosity of submucous venous plexus.
• Venous columns at 3 o’clock, 7oclock and 11 o’clock positions in submucosa (positions
of internal hemorrhoids while patient is in lithotomy position)

Lymphatic drainage of rectum

 From superior half –along superior rectal vessels >>

Pararectal nodes>>Inferior mesenteric and lumbar nodes.

 From inferior half->>internal iliac nodes

Nerves: Sympathetic and parasympathetic

Sympathetic is from lumbar spinal cord conveyed via lumbar splanchnic nerves and hypogastric
plexus
• Inferior hypogastric plexus [sym + parasym]
• Pelvic splanchnic nerve [parasympathetic fibers] S2-4

Per rectal examination (palpation)

 Prostate and seminal vesicles in males

 Cervix of uterus in females
• In both sexes- pelvic surfaces of the sacrum and coccyx
• Ishcial spines and tuberosities
• Enlarged internal iliac nodes
• Pathological thickening of ureters
• Swellings in the ishchiorectal fossa and Pouch of Douglas ( abscesses)
• Tender inflammed appendix may also be felt
 Proctoscope and sigmoidoscopes may be passed and biopsies are taken.
Curvatures of the rectum must be born in mind while inserting the sigmoidoscope.
Rectal folds are useful landmarks
Rectal prolapse

Anal canal

• Is continuous with the rectum at the pelvic diaphragm

• At its junction with the rectum, it bends posteriorly (the perineal flexure) because of the
forward pull of the puborectalis muscle
• Its beginning is 2-3 cm in front of the tip of the coccyx.
• Opens externally at the anus
 It is 3.8 cms long
• Its anterior wall is shorter than the posterior wall
• Anteriorly it is related to the perineal body, urethra and bulb of penis in males.
• In females, it is related to the perineal body and lower part of vagina.
• Posteriorly it is connected to the coccyx by the anococcygeal ligament.
• Laterally it is related to the ischiorectal fossa, ischial spines, pudendal nerves.

Is kept closed by - the levator ani

- internal and external anal sphincters
except during defecation

Anal Sphincters:

 Internal anal sphincter

thickened ring of circular smooth muscle. Surrounds the upper part of the anal canal
terminating at the level of the white line (of Hilton)
-Is controlled reflexly and involuntarily
1- parasympathetic system promoting relaxation
2-sympathetic system promoting contraction

• External anal sphincter

Is composed of three adjacent rings of skeletal muscles
-subcutaneous
-superficial
-deep parts
Surrounds the entire length of the anal canal
Is controlled voluntarily by
-the inferior rectal nerves from the pudendal nerve which is part of sacral plexus

Interior of the Anal canal:

 • Anal columns:
- 5 to 10 longitudinal columns of mucosa in the upper half of the anal canal
- Columns limited below by anal valves at the pectinate line

• Anal valves:
- crescentric folds of mucosa (remnants of anal membrane)
- join the bases of adjacent anal columns

• Anal sinuses:
- pocket like recesses above the anal valves leading into anal crypts (opening of the mucous
secreting glands in the wall)

• Pectinate line
- Is the serrated line - joining the lower margins of the anal valves

- Marks the junction between -

embryonic hindgut lined by endoderm (above the line) and the proctodeum lined by ectoderm
(below the line)

- Marks the transition from -

the columnar epithelium of the gut tube to the stratified squamous epithelium of the skin

-Marks the divide between -

visceral and somatic arterial supply, venous drainage, lymphatic drainage, and innervations

 Pecten
It is the area between the pectinate line and Hilton’s line.
It is lined by stratified squamous nonkeratinized epithelium.
It has no sweat or sebaceous glands or hair follicles
Numerous nerve endings are present in this area.

• White line
Is also known as the anocutaneous line/Hilton’s line — Lies below the pectinate line
— Marks the palpable intersphincteric groove separating the lower border of the internal anal
sphincter and the subcutaneous part of the external anal sphincter

Blood supply:
Arterial supply:
Inferior rectal arteries-branches of the internal pudendal arteries- below pectinate line
Superior rectal arteries supply the anal canal above the pectinate line

Venous drainage:
Above the pectinate line- drain into the superior rectal vein and thus reach the portal system.
There are no valves
Below the pectinate line- drain into the inferior rectal veins and thus reach the venacaval
system. There are valves.
Thus there is a connection between the portal and the systemic veins- site of portocaval
anastomosis.
Reverse blood flow due to portal obstruction leads to varicosities of which bulge and form the
haemorrhoids.

Lymphatic drainage:
Above the pectinate line- internal iliac lymph nodes, Para rectal lymph nodes
Below the pectinate line- superficial inguinal lymph nodes

Nerve supply:
Above the pectinate line- by the autonomic nerves: Sympathetic- L1 &2
Parasympathetic-S3 &4
Pain insensitive (visceral afferent)

Below the pectinate line- by the somatic nerves: Inferior rectal nerves. Pain sensitive

Anal fissures: it is an elongated ulcer extending from tear of anal valves.

Usually the result of chronic constipation and subsequent injury to mucosa by fecal matter

Peri Anal Abscess: may be subcutaneous, submucous or ischiorectal

Anal fistula:
Spread of infection from an abscess may lead to formation of anal fistula [open at both ends] or
anal sinus [open at only one end]
Fistula extends from lumen to skin surface.
It can be high level or low level fistula
Hemorrhoids: Internal and External
External hemorrhoids: occur below the Hilton’s line and are painful. They do not bleed. It is
caused by the varicosities of the inferior rectal veins covered by the anal skin.

Hemorrhoids:
Piles are prolapse of the mucosa containing the dilated veins of the rectal venous plexus. Any
disorder that impedes the venous return can predispose hemorrhoids- pregnancy, prolonged toilet
sitting and straining, chronic constipation, increased intra-abdominal pressure, portal
hypertension.
Internal hemorrhoids Occur above the pectinate line
- Are relatively insensitive to pain because they are supplied by visceral afferent fibers

External hemorrhoids Occur below the pectinate line

- Are very sensitive to pain because they are supplied by somatic afferent fibers

INTERNAL ILIAC ARTERY

It supplies almost all the pelvic viscera.
Origin: It is the smaller of the two terminal branches of the common iliac artery.
Termination: It ends by dividing into anterior and posterior divisions.
Extent: It starts from in front of the sacroiliac joint and runs to the upper border of the greater
sciatic notch where it terminates by splitting into 2 divisions
Relations:
Anteriorly- 1. ureter
2. ovary and lateral end of the uterine tube in the female
Posteriorly- 1. Internal iliac vein
2. Lumbosacral trunk
3. sacroiliac joint

Laterally- External iliac vein and psoas major and obturator nerve
Medially- covered with peritoneum and on the left side, to the sigmoid colon
Branches: Anterior and posterior division
 Anterior division- Superior vesical and obliterated umbilical
Inferior vesical (in the male)
Middle rectal
Uterine (In the female)
Vaginal (in the female)
Obturator
Inferior gluteal
Internal pudendal
 Posterior division- Iliolumbar
Lateral sacral
Superior gluteal
Note: superior vesical usually arises from the postnatal proximal patent portion of the umbilical
artery

Collateral anastomosis occurs between its branches and adjacent arteries when it is ligated to
control pelvic hemorrhage. It reduces bleeding but does not stop blood flow.

FEMALE REPRODUCTIVE ORGANS

UTERUS

Hollow muscular organ.

Lies in the pelvis between the bladder in front and the rectum behind.
Flat anteroposteriorly.
Pear shaped.
7.5 cm length x 5 cm breadth x 2.5 cm thickness.
During pregnancy it hypertrophies nearly 10 times.

Parts:
 Fundus
Body
Cervix
Cervix has two parts- Vaginal part
Supravaginal part

Fundus is the free rounded upper part of the uterus above the level of the opening of the
uterine tubes.

Isthmus is a constriction that divides the uterus into larger upper part called the body and a
smaller cylindrical lower part called the cervix.

The part of the cervix embedded in the anterior part of the upper end of the vagina is called
vaginal part of the cervix and the part of the cervix above the vagina is called supravaginal
part.

Normal anatomical Position of the uterus:

Anteverted, Anteflexed, Dextrorotated.

Long axis of the cervix is bent forwards over the long axis of vagina-anteversion

The body of uterus is bent forwards over the cervix at the isthmus- anteflexion

Relations:

 Anterior-
Anterior surface of the fundus and body are covered with peritoneum and are related to the
uterovesical pouch and the anterior 2/3 of the superior surface of the urinary bladder.
The supravaginal cervix is not covered by peritoneum and is related to the posterior 1/3 of the
superior surface of the urinary bladder.
 Posterior-
Fundus, body and the supravaginal cervix are covered with peritoneum
Related to- the pouch of Douglas and its contents- coils of ileum and pelvic (sigmoid)
colon. The Douglas pouch separates the uterus from the rectum. It is the lowest (most
dependent part) part of the peritoneal cavity in females.

 Lateral-
Broad ligament extends from the uterus to the side walls of the pelvis
Round ligament of the uterus
Ligament of the ovary
Uterine vessels
Uterine tubes
 Ureters lie at the sides of the cervix on the lateral fornices of the vagina (2cm
above the ischial spine). They are crossed by the uterine arteries which ascend
along the lateral borders of the uterus.
Transverse cervical ligaments (cardinal ligaments or Mackendrodt’s ligaments)
extend from the sides of the cervix and vagina to the lateral walls of the pelvis. It
is a thickening of the endopelvic fascia and is a primary ligament supporting the
cervix of the uterus. Uterine vessels reach the uterus through this ligament.

Interior of the uterus:

The cavity of the uterus is a small cleft like space. Triangular in outline
At the upper lateral angles are the openings of the uterine tubes.
At the lower angle is the internal os or opening of the cervical canal

Cervical canal: spindle shaped.

Above it opens into the uterine cavity at the internal os.
Below it opens into the vagina through the external os.
Median longitudinal ridges are seen in the mucosa of the anterior and posterior walls.
Transverse palmate folds extend laterally from the ridges. This arrangement is called arbor vitae
uteri.

During pregnancy, Upper 1/3of the cervical canal is taken up into the uterine cavity and is called
the lower uterine segment.

Blood supply of the uterus:

Arterial supply:
 Uterine arteries- branches of the internal iliac arteries. They ascend between the layers of
the broad ligament.
Uterine artery crosses above the ureter near the supravaginal cervix to reach the sides of the
uterus. The uterine artery is anterosuperior to the ureter for 2.5 cm and then crosses to its medial
side to ascend alongside of the uterus.
 Ovarian arteries -during pregnancy

Venous drainage:
1. Uterine veins which drain to the internal iliac veins 2. ovarian veins

Lymphatic drainage:
From the cervix- to the External and Internal iliac lymph nodes, and sacral nodes
From the lower part of the body of the uterus- to the External iliac lymph nodes
From the upper part of the body, fundus and fallopian tubes-
Some end in the lateral aortic lymph nodes
Few pass to the external iliac lymph nodes
Lymph vessels near the openings of the fallopian tubes follow the round
ligament to end in the superficial inguinal lymph nodes.
Nerve supply:
Uterovaginal plexus
Sympathetic- T11-L3 segments- cause uterine contraction and vasoconstriction
Parasympathetic- S2, S3, S4- cause uterine inhibition and vasodilatation
Uterus is also under the hormonal influences.

Supports of the uterus:

 Pelvic floor muscles
 Perineal body
 Urogenital diaphragm
 Pubocervical ligaments-medial and lateral
 Transverse cervical ligaments
 Uterosacral ligaments
 Round ligaments of the uterus

Clinical anatomy:
 IUCD- intrauterine contraceptive devices
 Caesarian section
 Retroverted uterus
 Prolapse of the uterus
Clinical:
 Laparoscopic examination
 Hysterosalpingography-radiological examination of uterine tubes
 Hysterectomy is performed through the anterior abdominal wall or
through the vagina. The ureter is in danger of being inadvertently
clamped or severed when the uterine artery is tied off. The left
ureter is more vulnerable because it runs close to the lateral aspect
of the cervix.

Broad ligament:

It is a peritoneal fold attaching the lateral borders of the uterus to the lateral pelvic wall.
It has two layers. Its upper free border encloses the fallopian tubes. The posterior layer is
reflected backwards to the ovary as a fold called mesovarium.
It assists in keeping the uterus in position.

Parts of the broad ligament-

Mesometrium: between the uterus and mesovarium
Mesosalphinx: between the fallopian tube and the mesovarium

Infundibulopelvic ligament : (suspensory ligament) is the part stretching between the

infundibulum of the fallopian tube and the lateral wall of the pelvis. Ovarian vessels reach ovary
in this ligament

Contents of the broad ligament:

 Fallopian tube
  Round ligament of the uterus
 Ovarian ligament
 Uterine vessels
 Lymphatics
 Parametrial connective tissue

ROUND LIGAMENT OF THE UTERUS:

Extends from the lateral border of the uterus near the attachment of the fallopian tube, passes
out through the inguinal canal, to be attached to the skin of the labium majus. It corresponds
to the scrotal ligament in the male. It and the ligament of the ovary represent the embryonic
gubernaculum.
Gartners duct: represents remnant of mesonephric duct
FALLOPIAN TUBE
Each tube is 10cm long.
Situated in the upper free margin of the broad ligament
Extends from the upper end of the lateral border of the uterus to the ovary in the lateral pelvic
wall
It has two ends-
Lateral ovarian end: which has an opening into the abdominal cavity called ovarian ostium
Medial uterine end: opening to the uterine cavity
Parts:
1. Infundibulum- expanded funnel shaped lateral end. Has 4-5 finger shaped fimbriae.
One of the fimbria is large and attached to the ovary & called ovarian fimbria.
2. Ampulla- is the dilated part medial to the infundibulum.
3. isthmus- narrow part medial to the ampulla
4. Intrauterine or intramural part- which pierces the muscular wall of the uterus to open
to the uterine cavity by uterine ostium

Note: Fertilization occurs at the junction of the lateral 1/3 and medial 2/3 of the uterine
tube- in the ampulla.
Blood supply: uterine and ovarian blood vessels
Clinical: tubal pregnancy, tubectomy

OVARY
Two in number, situated one on either side of the uterus in the ovarian fossa on the lateral
pelvic wall. Lie behind the broad ligament and suspended by the mesovarium. Connected to
the uterus by the ligament of the ovary.
Ovoid in shape and slightly flattened.
Its upper end is called tubal end. Lower end is called uterine end.
A peritoneal fold- suspensory (infundibulopelvic) ligament stretches from the upper end to
the lateral pelvic wall and transmits the ovarian vessels.
Medial surface is overlapped by the uterine tube
Lateral surface is related to the ovarian fossa.

Ovarian fossa: In the lateral pelvic wall in which ovary is situated

 Boundaries of the ovarian fossa:
Posteriorly- ureter and internal iliac vessels
Anteriorly- obliterated umbilical artery
Superiorly- external iliac vessels
Floor- obturator internus and fascia, obturator nerve and vessels, peritoneum
Ovary is usually dislodged from its fossa during pregnancy
Blood supply:
Ovarian artery- direct branch from abdominal aorta
Ovarian veins- right ovarian vein ends in the inferior vena cava. Left ovarian vein ends in the left
renal vein.
Lymphatic drainage- end in the lateral aortic lymph nodes
Nerve supply- Ovarian plexus-sympathetic T10-T11. Parasympathetic from pelvic splanchnic
(S2-S4) nerve.
Clinical- ovarian cyst
Ovary may get dislodged into the pouch of Douglas, and may cause dyspareunia.
Imperfect decent of ovary
During ovariectomy, while ligating the ovarian vessels in the suspensory ligament, the ureter
which runs along the posterior wall of the ovarian fossa should be identified to avoid its
clamping.

VAGINA
Extends from the cervix of the uterus to the vaginal opening below in the cleft between the
labia minora called the vestibule. Lower end is the narrowest part.
It is a musculomembranous canal.
It is directed downwards and forwards. It makes an angle of 90º with the long axis of uterus.
Lower 1/3 has ‘H’ shaped lumen, middle 1/3 is transverse slit, upper1/3 circular.
Posterior wall is longer(9 cm) than the anterior (7.5 cm) wall.
It has- upper and lower ends, posterior and anterior wall, two lateral walls.
Lower end opens into the vestibule and guarded by the hymen in vergin
Upper end is pierced more anteriorly by the cervix. There are 4 recesses between the cervix
and the wall of the vagina. They are called vaginal fornices. They are – anterior, posterior,
and 2 lateral fornices. Posterior fornix is the deepest.
Relations: Anterior wall- related to the cervix of the uterus, urinary bladder, terminal parts of
the ureters & urethra.
Posterior wall- upper end (posterior fornix) is covered by peritoneum and is
related to the rectovaginal pouch or pouch of Douglas. Below, to the rectum & perineal body
Note: the posterior fornix of vagina is covered by peritoneum and the lower end of the
rectovaginal pouch reaches to the upper part of the posterior wall of vagina
Lateral walls- upper end is related to the ureter crossed by the uterine artery,
transverse cervical ligaments, pubovaginal part of the levator ani, UG diaphragm
Interior of the vagina- has an anterior and a posterior median longitudinal fold from which
transverse ridges extend as rugae
Blood supply:
Uterine arteries, vaginal arteries from the internal iliac arteries. These arteries anastomose
and form two longitudinal arterial chains, one on each of the anterior and posterior wall of
the vagina in the midline. These are called azygous arteries. Posterior azygous artery is better
defined.
Venous drainage into the internal iliac veins
Lymphatic drainage:
From the upper 4/5- to the internal iliac nodes
From the lower1/5- to the superficial inguinal lymph nodes
Nerve supply: upper 4/5 is supplied by sympathetic and parasympathetic nerves
Lower 1/5 is supplied by the pudendal nerve branches

Clinical: A perforating injury through the posterior fornix opens into the peritoneal
cavity and can introduce infection.
Fluid may collect in the pouch of Douglas. In such cases, infected fluids can be drained
through the vagina (colpotomy).
Colposcope: is an endoscope that magnifies the epithelia of vagina and cervix invivo to
allow direct observation and study of these tissues.
Culdoscopy: An endoscope (culdoscope) is introduced ino the vagina and through the
posterior fornix to conduct visual examination of the pelvic viscera & the rectovaginal pouch
Vaginal prolapse

PV- per vaginal examination: urethra, Cervix, ovary, fallopian tube, rectovaginal pouch.
lateral pelvic wall, ischial spines, ureters, pulsations of the uterine arteries,rectum and sacral
promontory can be palpated. Conjugate diameter of the pelvis also can be measured. Ovarian
cysts can be palpated.

The Sacral Plexus

Root value- ventral rami of L4, L5, S1, S2, S3, S4

The sacral plexus is formed by the lumbosacral trunk, the anterior rami of the first, second,
third and fourth sacral nerves.

The lumbosacral trunk is formed by the union of the L4 and L5.

All the nerves entering the plexus, with the exception of the third sacral, split into ventral
and dorsal divisions, and the nerves arising from these are as follows:

Nerve to Quadratus femoris and Gemellus inferior

Nerve to Obturator internus and Gemellus superior
Pudendal nerve.S2, S3, S4
Nerve to Piriformis
Superior gluteal. L.4, 5, S1.
Inferior gluteal .L5, S,1, 2 .
Posterior cutaneous nerve of the thigh
Sciatic:
Tibial…………………… L4, 5, S 1, 2, 3.
 Common peroneal ……… L4, 5, S 1, 2.

The sacral plexus lies on the back of the pelvis between the Piriformis and the pelvic fascia. In
front of it are the hypogastric vessels, the ureter and the sigmoid colon.

The superior gluteal vessels run between the lumbosacral trunk and the first sacral nerve, and
the inferior gluteal vessels between the second and third sacral nerves.

PERINEUM

It is the lower end of the trunk, between the thighs.

It overlies the inferior pelvic aperture or pelvic outlet.
It is clearly seen only in the lithotomy position.
Note that there is no deep fascia in the perineum.

Boundaries:

Diamond shaped.
Outlet of the pelvis forms its bony boundaries:
Anteriorly – Pubic symphysis
Anterolaterally – Ischiopubic rami
Laterally – Ischial tuberosities
Posterolaterally – Sacrotuberous ligaments
Posteriorly – Coccyx

Subdivisions:

The diamond shaped area can be subdivided into 2 triangles by an imaginary line connecting the
ischial tuberosities into –
Anterior urogenital triangle consisting of parts of the external urinary & genital systems
Posterior Anal triangle consisting of the anal canal and ischiorectal fossa

UROGENITAL TRIANGLE

Boundaries:

Pubic symphysis- in front

Ischiopubic rami- on the sides
Imaginary line joining the ischial tuberosities- behind.

It has two pouches or spaces- superficial and deep perineal pouches

Superficial fascia of the urogenital triangle:

Consists of two layers –
Superficial (inferior) fatty layer (fascia camper)
 Deep(superior) membranous layer (Colles fascia)
Fatty layer is absent over the scrotum and penis. It is continuous with the fascia camper in the
anterior abdominal wall.
Membranous layer (colles fascia) – Lies superior to the fatty layer
Posteriorly, the membranous layer is attached to the posterior border of the perineal
membrane. Laterally, is attached to the ischiopubic rami. Anteriorly, is continuous with the deep
membranous layer of the superficial fascia of the anterior abdominal wall.
Membranous layer lies below the perineal membrane. Superficial perineal pouch lies between
the two.

Clinical correlates:

Extravasated urine due to rupture of the membranous urethra collects in the superficial perineal
pouch. It cannot spread behind or laterally, but can ascend into the anterior abdominal wall
between the fascia scarpa and the external oblique muscle. It can ascend as far as the xiphoid
process but cannot descend to the thigh because the fascia scarpa is attached to the fascia lata of
the thigh along the holden’s line (a line about 1 cm below the inguinal ligament).

Perineal membrane:
(Triangular ligament or Inferior fascia of the UG diaphragm)

It is a triangular fibrous sheet. It provides attachment for muscles there.

In the anatomical position, it is horizontally placed and has superior and inferior surfaces.
It lies superior to the Colles fascia (membranous layer of the superficial fascia of the perineum).
It is attached laterally to the ischiopubic rami. Posteriorly, it fuses with the Colles fascia below,
and the superior fascia of the urogenital diaphragm above.
Perineal body lies in the middle of its posterior border.
Anterior border of the perineal membrane is free & thickened to form the transverse perineal
ligament.
Deep dorsal vein of the penis or clitoris passes in the gap between the ligament and the inferior
pubic angle to join the prostatic or vesical plexus respectively.

The inferior surface of the perineal membrane forms the roof of the superficial perineal pouch.
The superior surface forms the floor of the deep perineal pouch.

Structures piercing the perineal membrane:

1. Urethra – in the middle, 2.5 cm behind the pubic angle

2. Arteries to the bulb
3. Deep arteries of the penis or clitoris
4. Dorsal arteries and nerves of the penis or clitoris
5. Posterior scrotal or labial nerves and vessels
6. Ducts of the bulbourethral glands (in the male)
7. Vagina (in the female) in the middle, just behind the urethra
Superficial perineal pouch:

Boundaries:

Roof: Perineal membrane

Floor: Colles fascia
Lateral: Ischiopubic rami
Posterior: Closed- because the perineal membrane and the Colles fascia fuse
Anterior: open – continues to the anterior abdominal Wall deep to the fascia scarpa

Contents:
In the male: 1. Urethra
2. 3 roots of the penis- 2 crura and a bulb
3. 3 pairs of muscles – Ischiocavernosus, Bulbospongiosus and
Transverse perinei superficialis
4. Arteries and nerves-
a. Post. Scrotal vessels and nerves
b. Transverse perineal arteries
c. deep artery of penis
d. Dorsal artery of penis
e. Dorsal nerve of penis

In the female: 1. Urethra

2. Vagina (behind the urethra)
3. Bulbs of the vestibule
4. Greater vestibular glands (Bartholin’s glands)
5. Crura of the clitoris
6. 3 pairs of muscles- Ischiocavernosus, bulbospongiosus, and
Transverse perinei superficialis
7. Post. Labial vessels & nerves,
8. Deep artery of the clitoris
9. Dorsal artery of clitoris
10. Dorsal nerve of clitoris
Clinical: Rupture of urethra or a blood vessel resulting from trauma would result in
accumulation of the material in the superficial perineal pouch.

Deep perineal pouch:

Boundaries:

Roof: Superior fascia of the UG diaphragm

Floor: Perineal membrane
Lateral: Ischiopubic rami
Posterior: Closed- because the perineal membrane and the superior fascia of UG diaphragm fuse
Anterior: Closed- because the perineal membrane and the superior fascia of UG diaphragm fuse
Note- The deep perineal pouch is closed on all sides
Contents:
Membranous part of the urethra
Muscles- Sphincter urethrae, Transverse perinei profundus
Vessels and nerves- Deep artery of penis or clitoris
Dorsal artery of penis or clitoris
Arteries to the bulb
Posterior scrotal or labial arteries
Dorsal nerve of penis or clitoris
Bulbourethral (cooper’s) glands in the male
Vagina in the female

Urogenital diaphragm:

The deep perineal pouch, superior fascia of the UG diaphragm & Perineal membrane (inferior
fascia of UG diaphragm) together form the UG diaphragm.

Sphincter urethrae:
External urethral sphincter
It is more like a tube or trough than like a disc.
It surrounds the membranous urethra in male. In the female it acts more like a “urogenital
Sphincter”.

Origin – from the inferior ramus of pubis & perineal membrane

Insertion – continues with the opposite side by passing around the urethra
Nerve supply- perineal branch of the pudendal nerve
Action: external sphincter for the urethra. It is voluntary

ANAL TRIANGLE

Bounded in front by the imaginary line drawn connecting the ischial tuberosities, on either sides
by the sacrotuberous ligaments, and behind by the coccyx.
It contains the lower end of the anal canal in the midline, and the ischiorectal fossa on either side
of the anal canal.
ISCHIORECTAL FOSSA:

Pair of spaces - one on either side of the lower end of the anal canal
Hence, Ischioanal fossa is the more appropriate name.
The two fossae communicate with each other behind the anal canal.

Shape: Wedge shaped.

Boundaries: It has- an apex, a base, & 4 walls- Lateral, Medial, Posterior, Anterior

Lateral wall: vertical.

Formed by – Obturator internus, obturator fascia (fascia covering obt.int.)
Pudendal canal (Alcock’s canal) with its contents
Medial wall: sloping downwards and medially
Formed by - Levator ani, Sphincter ani externus (in the lower part)
Posterior wall: Formed by – Sacrotuberous ligament, lower border of Gluteus maximus
Anterior wall: Formed by – Post. Border of perineal membrane, transverse perinei
superficialis and profundus muscles.

Apex: Is the edge of the wedge directed superiorly and is formed by the levator ani taking origin
from the obturator fascia on the lateral wall.

Base: directed below. Formed by- Skin and superficial fascia.

Anterior recess is a forward extension of the fossa above the UG diaphragm as far as the body of
pubis.

Deep postanal space: is the space over the anococcygeal ligament where the two ischioanal
fossae communicate behind the anal canal. Anococcygeal ligament (body) is a fibrous mass
located between the anal canal and the tip of the coccyx.

Hiatus of Schwalbe- is a gap seen some times in the apex due to the defective origin of the
levator ani. Ischiorectal hernia may occur in such cases.

Lunate fascia is a dome shaped fascia in the ischiorectal fossa. It starts from the sacrotuberous
ligament laterally and fuse with the anal fascia medially. Its apex is called tegmentum and the
space above it is suprategmental recess.

Contents of the Ischiorectal fossa:

Ischiorectal pad of fat. The pads of two sides help to keep the lower end of the anal canal closed.
Inferior rectal vessels and nerves- cross from lateral to the medial wall to supply the sphincter ani
externus and perianal skin
Perineal branch of the 4th sacral nerve- supplies the sphincter ani externus.

Clinical anatomy:

Prolapse of the rectum- loss of the pad of fat due to wasting, or diarrhea in children
Pudendal nerve block- is performed by injecting an anaesthetic to produce analgesia during
forceps delivery.
Ischiorectal abscess- Ischiorectal fat is susceptible to infections due to poor blood supply and
nearness to the anal canal. The abscess may open into the anal canal or rectum internally, or on
the perianal skin – ischiorectal sinus (open at only one end).
If the pus opens on both ends, then it is called Ischiorectal fistula or Fistula-in-ano.
If it is high level fistula, fecal matter constantly soils the skin.
No fecal matter comes out through the low level fistula.
Ischiorectal hernia- through the hiatus of schwalbe

Pudendal canal:
It runs horizontally in the lateral wall of the ischiorectal fossa.
It is 3.75 cm long and 3.75 cm above the lower end of ischial tuberosity.
It begins posteriorly at the lesser sciatic notch & ends anteriorly in the deep perineal pouch.
The canal is formed by the splitting of the obturator fascia (according to some, between the
obturator fascia laterally and the lunate fascia medially).

Contents: 1. Pudendal nerve and its branches. 2. Internal pudendal vessels

Clinical correlates: Pudendal nerve block.

Pudendal Nerve:

Origin: from the sacral plexus. Root value: ventral rami of S2, S3, S4.

It is the main nerve supply to the perineum.

It enters the perineum through the lesser sciatic foramen along with the Internal pudendal artery
and runs forwards in the pudendal canal on the lateral wall of the ischiorectal fossa.
Its branches are distributed to the anal triangle, UG triangle, scrotum or labium majus, dorsum of
penis or clitoris.

Branches: Inferior rectal nerve,

Perineal nerve,
Dorsal nerve of the penis or clitoris
Inferior rectal nerve runs medially in the ischiorectal fossa to supply sphincter ani externus and
perianal skin.
Perineal nerve divides into superficial and deep branches.
Deep branch supplies the muscles of the perineal pouches, sphincter ani externus and the levator
ani.
Superficial branches run as posterior scrotal or labial nerves to supply posterior parts of the skin
of scrotum or labium majus.
Dorsal nerve of the penis or clitoris supplies glans penis, prepuce and skin of the penis.

Clinical correlates – pudendal nerve block.

Internal pudendal artery:

Origin: from the anterior division of the internal iliac artery
Is the principal blood supply to the perineum
Enters the perineum through the lesser sciatic foramen adjacent to the ischial spine
Lies in the pudendal canal on the lateral wall of the ischiorectal fossa
Is accompanied in its course by the pudendal nerve

Branches:
Inferior rectal artery
Perineal artery
Artery of the bulb of the penis or clitoris
Deep artery of the penis or clitoris (a terminal branch). Runs in the corpus cavernosum
Dorsal artery of the penis or clitoris (a terminal branch)
Venous drainage of the perineum:
• Veins corresponding to the branches of the internal pudendal artery mostly follow the internal
pudendal vein to the internal iliac vein.
Deep dorsal vein of the penis or clitoris: Is unpaired.
It lies in the midline of the penis or clitoris between the paired dorsal arteries.
It enters the pelvis through the gap between transverse perineal ligament and the arcuate pubic
ligament.
- In the male it drains into the prostatic venous plexus
- in the female it drains into the vesical venous plexus (tributaries of the internal iliac veins)

Lymphatic drainage of the perineum:

• Mostly to the superficial inguinal nodes along the external pudendal vessels- includes
the lower part of the anal canal & skin of the penis & vulva
• Deep inguinal lymph nodes receive lymph from the glans penis, glans clitoris, anterior labia
minora
• to the internal iliac nodes along the internal pudendal vessels
for the - deep perineal space
- membranous urethra
- most of the vagina
• From the body of the penis (corpora) may drain directly to the internal iliac nodes
along the deep dorsal vein

Perineal body
(Centrum tendinum)

 It is a central fibromuscular raphe, 1.25 cm long.

 It is situated between the anus behind and the bulb of the penis in the male and the vagina
in the female, infront.
 It forms a very important support for the pelvic floor and pelvic visceral organs.
Muscles converging on it are-
 bulbospongiosus
 Sphincter ani externus
 Transverse perinei superficialis and profundus
 Levator ani
 Smooth muscles from the wall of the rectum & anal canal
Fibrous components converging on it are-
 Perineal membrane
 Colles fascia
 Superior fascia of UG diaphragm
 Fascia of the pelvic diaphragm

Clinical correlates:
In females, it is likely to be torn during child birth (parturition).
The tear tends to increase due to the spasm of muscles attached to it, leading to the herniation or
prolapse of the uterus, vagina and other pelvic viscera through the pelvic floor. Hence, it needs to
be recognized and repaired immediately.
Sometimes an incision is often made in the perineum to ease child birth.
This procedure is called episiotomy.