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Anatomy_Gray_800 | Anatomy_Gray | How to find the superficial inguinal ring The superficial inguinal ring is an elongate triangular defect in the aponeurosis of the external oblique (Fig. 4.177). It lies in the lower medial aspect of the anterior abdominal wall and is the external opening of the inguinal canal. The inguinal canal and superficial ring are larger in men than in women: In men, structures that pass between the abdomen and the testis pass through the inguinal canal and superficial inguinal ring. In women, the round ligament of the uterus passes through the inguinal canal and superficial inguinal ring to merge with connective tissue of the labium majus. The superficial inguinal ring is superior to the pubic crest and tubercle and to the medial end of the inguinal ligament: | Anatomy_Gray. How to find the superficial inguinal ring The superficial inguinal ring is an elongate triangular defect in the aponeurosis of the external oblique (Fig. 4.177). It lies in the lower medial aspect of the anterior abdominal wall and is the external opening of the inguinal canal. The inguinal canal and superficial ring are larger in men than in women: In men, structures that pass between the abdomen and the testis pass through the inguinal canal and superficial inguinal ring. In women, the round ligament of the uterus passes through the inguinal canal and superficial inguinal ring to merge with connective tissue of the labium majus. The superficial inguinal ring is superior to the pubic crest and tubercle and to the medial end of the inguinal ligament: | [
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Anatomy_Gray_801 | Anatomy_Gray | The superficial inguinal ring is superior to the pubic crest and tubercle and to the medial end of the inguinal ligament: In men, the superficial inguinal ring can be easily located by following the spermatic cord superiorly to the lower abdominal wall—the external spermatic fascia of the spermatic cord is continuous with the margins of the superficial inguinal ring. In women, the pubic tubercle can be palpated and the ring is superior and lateral to it. The deep inguinal ring, which is the internal opening to the inguinal canal, lies superior to the inguinal ligament, midway between the anterior superior iliac spine and pubic symphysis. The pulse of the femoral artery can be felt in the same position but below the inguinal ligament. Because the superficial inguinal ring is the site where inguinal hernias appear, particularly in men, the ring and related parts of the inguinal canal are often evaluated during physical examination. How to determine lumbar vertebral levels | Anatomy_Gray. The superficial inguinal ring is superior to the pubic crest and tubercle and to the medial end of the inguinal ligament: In men, the superficial inguinal ring can be easily located by following the spermatic cord superiorly to the lower abdominal wall—the external spermatic fascia of the spermatic cord is continuous with the margins of the superficial inguinal ring. In women, the pubic tubercle can be palpated and the ring is superior and lateral to it. The deep inguinal ring, which is the internal opening to the inguinal canal, lies superior to the inguinal ligament, midway between the anterior superior iliac spine and pubic symphysis. The pulse of the femoral artery can be felt in the same position but below the inguinal ligament. Because the superficial inguinal ring is the site where inguinal hernias appear, particularly in men, the ring and related parts of the inguinal canal are often evaluated during physical examination. How to determine lumbar vertebral levels | [
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Anatomy_Gray_802 | Anatomy_Gray | How to determine lumbar vertebral levels Lumbar vertebral levels are useful for visualizing the positions of viscera and major blood vessels. The approximate positions of the lumbar vertebrae can be established using palpable or visible landmarks (Fig. 4.178): A horizontal plane passes through the medial ends of the ninth costal cartilages and the body of the LI vertebra—this transpyloric plane cuts through the body midway between the suprasternal (jugular) notch and the pubic symphysis. A horizontal plane passes through the lower edge of the costal margin (tenth costal cartilage) and the body of the LIII vertebra—the umbilicus is normally on a horizontal plane that passes through the disc between the LIII and LIV vertebrae. A horizontal plane (supracristal plane) through the highest point on the iliac crest passes through the spine and body of the LIV vertebra; A plane through the tubercles of the crest of the ilium passes through the body of the LV vertebra. | Anatomy_Gray. How to determine lumbar vertebral levels Lumbar vertebral levels are useful for visualizing the positions of viscera and major blood vessels. The approximate positions of the lumbar vertebrae can be established using palpable or visible landmarks (Fig. 4.178): A horizontal plane passes through the medial ends of the ninth costal cartilages and the body of the LI vertebra—this transpyloric plane cuts through the body midway between the suprasternal (jugular) notch and the pubic symphysis. A horizontal plane passes through the lower edge of the costal margin (tenth costal cartilage) and the body of the LIII vertebra—the umbilicus is normally on a horizontal plane that passes through the disc between the LIII and LIV vertebrae. A horizontal plane (supracristal plane) through the highest point on the iliac crest passes through the spine and body of the LIV vertebra; A plane through the tubercles of the crest of the ilium passes through the body of the LV vertebra. | [
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Anatomy_Gray_803 | Anatomy_Gray | A plane through the tubercles of the crest of the ilium passes through the body of the LV vertebra. Visualizing structures at the LI The LI vertebral level is marked by the transpyloric plane, which cuts transversely through the body midway between the jugular notch and pubic symphysis, and through the ends of the ninth costal cartilages (Fig. 4.179). At this level are: the beginning and upper limit of the end of the duodenum, the hila of the kidneys, the neck of the pancreas, and the origin of the superior mesenteric artery from the aorta. The left and right colic flexures also are close to this level. Visualizing the position of major Each of the vertebral levels in the abdomen is related to the origin of major blood vessels (Fig. 4.180): The celiac trunk originates from the aorta at the upper border of the LI vertebra. The superior mesenteric artery originates at the lower border of the LI vertebra. The renal arteries originate at approximately the LII vertebra. | Anatomy_Gray. A plane through the tubercles of the crest of the ilium passes through the body of the LV vertebra. Visualizing structures at the LI The LI vertebral level is marked by the transpyloric plane, which cuts transversely through the body midway between the jugular notch and pubic symphysis, and through the ends of the ninth costal cartilages (Fig. 4.179). At this level are: the beginning and upper limit of the end of the duodenum, the hila of the kidneys, the neck of the pancreas, and the origin of the superior mesenteric artery from the aorta. The left and right colic flexures also are close to this level. Visualizing the position of major Each of the vertebral levels in the abdomen is related to the origin of major blood vessels (Fig. 4.180): The celiac trunk originates from the aorta at the upper border of the LI vertebra. The superior mesenteric artery originates at the lower border of the LI vertebra. The renal arteries originate at approximately the LII vertebra. | [
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Anatomy_Gray_804 | Anatomy_Gray | The superior mesenteric artery originates at the lower border of the LI vertebra. The renal arteries originate at approximately the LII vertebra. The inferior mesenteric artery originates at the LIII vertebra. The aorta bifurcates into the right and left common iliac arteries at the level of the LIV vertebra. The left and right common iliac veins join to form the inferior vena cava at the LV vertebral level. Using abdominal quadrants to locate The abdomen can be divided into quadrants by a vertical median plane and a horizontal transumbilical plane, which passes through the umbilicus (Fig. 4.181): The liver and gallbladder are in the right upper quadrant. The stomach and spleen are in the left upper quadrant. The cecum and appendix are in the right lower quadrant. The end of the descending colon and sigmoid colon are in the left lower quadrant. | Anatomy_Gray. The superior mesenteric artery originates at the lower border of the LI vertebra. The renal arteries originate at approximately the LII vertebra. The inferior mesenteric artery originates at the LIII vertebra. The aorta bifurcates into the right and left common iliac arteries at the level of the LIV vertebra. The left and right common iliac veins join to form the inferior vena cava at the LV vertebral level. Using abdominal quadrants to locate The abdomen can be divided into quadrants by a vertical median plane and a horizontal transumbilical plane, which passes through the umbilicus (Fig. 4.181): The liver and gallbladder are in the right upper quadrant. The stomach and spleen are in the left upper quadrant. The cecum and appendix are in the right lower quadrant. The end of the descending colon and sigmoid colon are in the left lower quadrant. | [
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Anatomy_Gray_805 | Anatomy_Gray | The stomach and spleen are in the left upper quadrant. The cecum and appendix are in the right lower quadrant. The end of the descending colon and sigmoid colon are in the left lower quadrant. Most of the liver is under the right dome of the diaphragm and is deep to the lower thoracic wall. The inferior margin of the liver can be palpated descending below the right costal margin when a patient is asked to inhale deeply. On deep inspiration, the edge of the liver can be felt “slipping” under the palpating fingers placed under the costal margin. A common surface projection of the appendix is McBurney’s point, which is one-third of the way up along a line from the right anterior superior iliac spine to the umbilicus. Defining surface regions to which pain from the gut is referred | Anatomy_Gray. The stomach and spleen are in the left upper quadrant. The cecum and appendix are in the right lower quadrant. The end of the descending colon and sigmoid colon are in the left lower quadrant. Most of the liver is under the right dome of the diaphragm and is deep to the lower thoracic wall. The inferior margin of the liver can be palpated descending below the right costal margin when a patient is asked to inhale deeply. On deep inspiration, the edge of the liver can be felt “slipping” under the palpating fingers placed under the costal margin. A common surface projection of the appendix is McBurney’s point, which is one-third of the way up along a line from the right anterior superior iliac spine to the umbilicus. Defining surface regions to which pain from the gut is referred | [
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Anatomy_Gray_806 | Anatomy_Gray | McBurney’s point, which is one-third of the way up along a line from the right anterior superior iliac spine to the umbilicus. Defining surface regions to which pain from the gut is referred The abdomen can be divided into nine regions by a midclavicular sagittal plane on each side and by the subcostal and intertubercular planes, which pass through the body transversely (Fig. 4.182). These planes separate the abdomen into: three central regions (epigastric, umbilical, pubic), and three regions on each side (hypochondrium, flank, groin). Pain from the abdominal part of the foregut is referred to the epigastric region, pain from the midgut is referred to the umbilical region, and pain from the hindgut is referred to the pubic region. Where to find the kidneys The kidneys project onto the back on either side of the midline and are related to the lower ribs (Fig. 4.183): The left kidney is a little higher than the right and reaches as high as rib XI. | Anatomy_Gray. McBurney’s point, which is one-third of the way up along a line from the right anterior superior iliac spine to the umbilicus. Defining surface regions to which pain from the gut is referred The abdomen can be divided into nine regions by a midclavicular sagittal plane on each side and by the subcostal and intertubercular planes, which pass through the body transversely (Fig. 4.182). These planes separate the abdomen into: three central regions (epigastric, umbilical, pubic), and three regions on each side (hypochondrium, flank, groin). Pain from the abdominal part of the foregut is referred to the epigastric region, pain from the midgut is referred to the umbilical region, and pain from the hindgut is referred to the pubic region. Where to find the kidneys The kidneys project onto the back on either side of the midline and are related to the lower ribs (Fig. 4.183): The left kidney is a little higher than the right and reaches as high as rib XI. | [
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Anatomy_Gray_807 | Anatomy_Gray | The kidneys project onto the back on either side of the midline and are related to the lower ribs (Fig. 4.183): The left kidney is a little higher than the right and reaches as high as rib XI. The superior pole of the right kidney reaches only as high as rib XII. The lower poles of the kidneys occur around the level of the disc between the LIII and LIV vertebrae. The hila of the kidneys and the beginnings of the ureters are at approximately the LI vertebra. The ureters descend vertically anterior to the tips of the transverse processes of the lower lumbar vertebrae and enter the pelvis. Where to find the spleen The spleen projects onto the left side and back in the area of ribs IX to XI (Fig. 4.184). The spleen follows the contour of rib X and extends from the superior pole of the left kidney to just posterior to the midaxillary line. Fig. 4.1 Abdomen. A. Boundaries. B. Arrangement of abdominal contents. Inferior view. | Anatomy_Gray. The kidneys project onto the back on either side of the midline and are related to the lower ribs (Fig. 4.183): The left kidney is a little higher than the right and reaches as high as rib XI. The superior pole of the right kidney reaches only as high as rib XII. The lower poles of the kidneys occur around the level of the disc between the LIII and LIV vertebrae. The hila of the kidneys and the beginnings of the ureters are at approximately the LI vertebra. The ureters descend vertically anterior to the tips of the transverse processes of the lower lumbar vertebrae and enter the pelvis. Where to find the spleen The spleen projects onto the left side and back in the area of ribs IX to XI (Fig. 4.184). The spleen follows the contour of rib X and extends from the superior pole of the left kidney to just posterior to the midaxillary line. Fig. 4.1 Abdomen. A. Boundaries. B. Arrangement of abdominal contents. Inferior view. | [
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Anatomy_Gray_808 | Anatomy_Gray | Fig. 4.1 Abdomen. A. Boundaries. B. Arrangement of abdominal contents. Inferior view. Fig. 4.2 The abdomen contains and protects the abdominal viscera. Fig. 4.3 The abdomen assists in breathing. InspirationExpirationDiaphragmRelaxation of diaphragmContraction ofdiaphragmContraction of abdominal musclesRelaxation ofabdominalmuscles Fig. 4.4 Increasing intraabdominal pressure to assist in micturition, defecation, and childbirth. Laryngeal cavity closedAir retained in thoraxFixed diaphragmContraction of abdominal wallIncrease inintraabdominalpressureMicturitionChild birthDefecation Fig. 4.5 Abdominal wall. A. Skeletal elements. B. Muscles. Fig. 4.6 The gut tube is suspended by mesenteries. Branch of aortaGastrointestinal tractAortaDorsal mesenteryVentral mesenteryKidney—posterior toperitoneumVisceral peritoneumParietal peritoneum Fig. 4.7 A series showing the progression (A to C) from an intraperitoneal organ to a secondarily retroperitoneal organ. | Anatomy_Gray. Fig. 4.1 Abdomen. A. Boundaries. B. Arrangement of abdominal contents. Inferior view. Fig. 4.2 The abdomen contains and protects the abdominal viscera. Fig. 4.3 The abdomen assists in breathing. InspirationExpirationDiaphragmRelaxation of diaphragmContraction ofdiaphragmContraction of abdominal musclesRelaxation ofabdominalmuscles Fig. 4.4 Increasing intraabdominal pressure to assist in micturition, defecation, and childbirth. Laryngeal cavity closedAir retained in thoraxFixed diaphragmContraction of abdominal wallIncrease inintraabdominalpressureMicturitionChild birthDefecation Fig. 4.5 Abdominal wall. A. Skeletal elements. B. Muscles. Fig. 4.6 The gut tube is suspended by mesenteries. Branch of aortaGastrointestinal tractAortaDorsal mesenteryVentral mesenteryKidney—posterior toperitoneumVisceral peritoneumParietal peritoneum Fig. 4.7 A series showing the progression (A to C) from an intraperitoneal organ to a secondarily retroperitoneal organ. | [
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Anatomy_Gray_809 | Anatomy_Gray | Fig. 4.7 A series showing the progression (A to C) from an intraperitoneal organ to a secondarily retroperitoneal organ. MesenteryVisceral peritoneumGastrointestinal tractGastrointestinal tractGastrointestinal tractParietal peritoneumArtery to gastrointestinal tractRetroperitoneal structuresMesentery before fusion with wallIntraperitoneal part of gastrointestinal tractSecondary retroperitoneal part of gastrointestinal tract ABC Fig. 4.8 Inferior thoracic aperture and the diaphragm. Fig. 4.9 Pelvic inlet. Ala of sacrumS IL VPelvic inletInguinal ligamentPelvic bone Fig. 4.10 Orientation of abdominal and pelvic cavities. Thoracic wallAxis of abdominal cavityAbdominal cavityPelvic cavityPelvic inletAxis of pelvic cavity Fig. 4.11 The abdominal cavity is continuous with the pelvic cavity. RectumPeritoneumPelvic inletBladderUterusShadow of ureterShadow of internal iliac vessels Fig. 4.12 Structures passing between the abdomen and thigh. | Anatomy_Gray. Fig. 4.7 A series showing the progression (A to C) from an intraperitoneal organ to a secondarily retroperitoneal organ. MesenteryVisceral peritoneumGastrointestinal tractGastrointestinal tractGastrointestinal tractParietal peritoneumArtery to gastrointestinal tractRetroperitoneal structuresMesentery before fusion with wallIntraperitoneal part of gastrointestinal tractSecondary retroperitoneal part of gastrointestinal tract ABC Fig. 4.8 Inferior thoracic aperture and the diaphragm. Fig. 4.9 Pelvic inlet. Ala of sacrumS IL VPelvic inletInguinal ligamentPelvic bone Fig. 4.10 Orientation of abdominal and pelvic cavities. Thoracic wallAxis of abdominal cavityAbdominal cavityPelvic cavityPelvic inletAxis of pelvic cavity Fig. 4.11 The abdominal cavity is continuous with the pelvic cavity. RectumPeritoneumPelvic inletBladderUterusShadow of ureterShadow of internal iliac vessels Fig. 4.12 Structures passing between the abdomen and thigh. | [
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Anatomy_Gray_810 | Anatomy_Gray | RectumPeritoneumPelvic inletBladderUterusShadow of ureterShadow of internal iliac vessels Fig. 4.12 Structures passing between the abdomen and thigh. Fig. 4.13 A series (A to H) showing the development of the gut and mesenteries. Fig. 4.14 Innervation of the anterior abdominal wall. Fig. 4.15 Inguinal region. A. Development. B. In men. C. In women. Inferior vena cavaRight testicular arteryLeft testicular arteryRight testicular veinLeft testicular veinAortaPelvic brimLeft ductus deferensDuctus deferensInguinal canalSuperficial inguinal ringDeep inguinal ringSpermatic cordRemnant ofgubernaculumEpididymisTestisTunica vaginalisTesticularartery and veinBInferior vena cavaAortaLeft renal arteryLeft ovarian arteryLeft renal veinLeft ovarian veinPelvic inletUterine tubeRound ligament of uterus (remnantsof gubernaculum)UterusSuperficialinguinal ringC Fig. 4.16 Vertebral level LI. | Anatomy_Gray. RectumPeritoneumPelvic inletBladderUterusShadow of ureterShadow of internal iliac vessels Fig. 4.12 Structures passing between the abdomen and thigh. Fig. 4.13 A series (A to H) showing the development of the gut and mesenteries. Fig. 4.14 Innervation of the anterior abdominal wall. Fig. 4.15 Inguinal region. A. Development. B. In men. C. In women. Inferior vena cavaRight testicular arteryLeft testicular arteryRight testicular veinLeft testicular veinAortaPelvic brimLeft ductus deferensDuctus deferensInguinal canalSuperficial inguinal ringDeep inguinal ringSpermatic cordRemnant ofgubernaculumEpididymisTestisTunica vaginalisTesticularartery and veinBInferior vena cavaAortaLeft renal arteryLeft ovarian arteryLeft renal veinLeft ovarian veinPelvic inletUterine tubeRound ligament of uterus (remnantsof gubernaculum)UterusSuperficialinguinal ringC Fig. 4.16 Vertebral level LI. | [
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Anatomy_Gray_811 | Anatomy_Gray | Fig. 4.16 Vertebral level LI. Jugular notchRightkidneyLI (transpyloric)planePubic symphysisCostal marginPyloric orifice betweenstomach and duodenumPosition of umbilicus Fig. 4.17 Blood supply of the gut. A. Relationship of vessels to the gut and mesenteries. B. Anterior view. Fig. 4.18 Left-to-right venous shunts. Fig. 4.19 Hepatic portal system. Fig. 4.20 Prevertebral plexus. Sympathetic inputParasympathetic inputPrevertebral plexusLumbar splanchnicnerves (L1, L2)Pelvic splanchnic nerves (S2 to S4)Anterior and posterior vagus trunks (cranial)Greater, lesser, and least splanchnic nerves(T5 to T12) Fig. 4.21 Boundaries of the abdominal cavity. Fig. 4.22 Four-quadrant topographical pattern. Fig. 4.23 Nine-region organizational pattern. Fig. 4.24 Layers of the abdominal wall. Fig. 4.25 Superficial fascia. | Anatomy_Gray. Fig. 4.16 Vertebral level LI. Jugular notchRightkidneyLI (transpyloric)planePubic symphysisCostal marginPyloric orifice betweenstomach and duodenumPosition of umbilicus Fig. 4.17 Blood supply of the gut. A. Relationship of vessels to the gut and mesenteries. B. Anterior view. Fig. 4.18 Left-to-right venous shunts. Fig. 4.19 Hepatic portal system. Fig. 4.20 Prevertebral plexus. Sympathetic inputParasympathetic inputPrevertebral plexusLumbar splanchnicnerves (L1, L2)Pelvic splanchnic nerves (S2 to S4)Anterior and posterior vagus trunks (cranial)Greater, lesser, and least splanchnic nerves(T5 to T12) Fig. 4.21 Boundaries of the abdominal cavity. Fig. 4.22 Four-quadrant topographical pattern. Fig. 4.23 Nine-region organizational pattern. Fig. 4.24 Layers of the abdominal wall. Fig. 4.25 Superficial fascia. | [
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] |
Anatomy_Gray_812 | Anatomy_Gray | Fig. 4.22 Four-quadrant topographical pattern. Fig. 4.23 Nine-region organizational pattern. Fig. 4.24 Layers of the abdominal wall. Fig. 4.25 Superficial fascia. Superficial fasciaFatty layer(Camper's fascia)Membranous layer(Scarpa's fascia)SkinPubic symphysisPenisDartos fasciaScrotumInguinal ligamentAponeurosis of external obliqueFascia lata of thigh Fig. 4.26 Continuity of membranous layer of superficial fascia into other areas. Continuity with superficialpenile fasciaContinuity withdartos fasciaExternal oblique muscleand aponeurosisMembranous layer ofsuperficial fascia (Scarpa's fascia)Attachment to fascia lataSuperficial perinealfascia (Colles' fascia)Attachment toischiopubic rami Fig. 4.27 External oblique muscle and its aponeurosis. Linea albaLatissimus dorsi muscleExternal oblique muscleAbdominal part ofpectoralis major muscleAponeurosis of external obliqueInguinal ligamentAnterior superior iliac spine Fig. 4.28 Ligaments formed from the external oblique aponeurosis. | Anatomy_Gray. Fig. 4.22 Four-quadrant topographical pattern. Fig. 4.23 Nine-region organizational pattern. Fig. 4.24 Layers of the abdominal wall. Fig. 4.25 Superficial fascia. Superficial fasciaFatty layer(Camper's fascia)Membranous layer(Scarpa's fascia)SkinPubic symphysisPenisDartos fasciaScrotumInguinal ligamentAponeurosis of external obliqueFascia lata of thigh Fig. 4.26 Continuity of membranous layer of superficial fascia into other areas. Continuity with superficialpenile fasciaContinuity withdartos fasciaExternal oblique muscleand aponeurosisMembranous layer ofsuperficial fascia (Scarpa's fascia)Attachment to fascia lataSuperficial perinealfascia (Colles' fascia)Attachment toischiopubic rami Fig. 4.27 External oblique muscle and its aponeurosis. Linea albaLatissimus dorsi muscleExternal oblique muscleAbdominal part ofpectoralis major muscleAponeurosis of external obliqueInguinal ligamentAnterior superior iliac spine Fig. 4.28 Ligaments formed from the external oblique aponeurosis. | [
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Anatomy_Gray_813 | Anatomy_Gray | Fig. 4.28 Ligaments formed from the external oblique aponeurosis. Fig. 4.29 Ligaments of the inguinal region. Fig. 4.30 Internal oblique muscle and its aponeurosis. External oblique muscleRib XInternal oblique muscleand aponeurosisLinea albaExternal oblique muscleAponeurosis of external obliqueAnterior superior iliac spine Fig. 4.31 Transversus abdominis muscle and its aponeurosis. External oblique muscleRib XTransversus abdominismuscle and aponeurosisLinea albaExternal oblique muscleAponeurosis of internal obliqueAponeurosis of external obliqueAnterior superior iliac spine Fig. 4.32 Rectus abdominis and pyramidalis muscles. External oblique musclePosterior wall of rectus sheathRectus abdominis muscleTendinous intersectionInternal oblique muscle Arcuate lineTransversalis fasciaLinea albaPyramidalis muscle | Anatomy_Gray. Fig. 4.28 Ligaments formed from the external oblique aponeurosis. Fig. 4.29 Ligaments of the inguinal region. Fig. 4.30 Internal oblique muscle and its aponeurosis. External oblique muscleRib XInternal oblique muscleand aponeurosisLinea albaExternal oblique muscleAponeurosis of external obliqueAnterior superior iliac spine Fig. 4.31 Transversus abdominis muscle and its aponeurosis. External oblique muscleRib XTransversus abdominismuscle and aponeurosisLinea albaExternal oblique muscleAponeurosis of internal obliqueAponeurosis of external obliqueAnterior superior iliac spine Fig. 4.32 Rectus abdominis and pyramidalis muscles. External oblique musclePosterior wall of rectus sheathRectus abdominis muscleTendinous intersectionInternal oblique muscle Arcuate lineTransversalis fasciaLinea albaPyramidalis muscle | [
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Anatomy_Gray_814 | Anatomy_Gray | External oblique musclePosterior wall of rectus sheathRectus abdominis muscleTendinous intersectionInternal oblique muscle Arcuate lineTransversalis fasciaLinea albaPyramidalis muscle Fig. 4.33 Organization of the rectus sheath. A. Transverse section through the upper three-quarters of the rectus sheath. B. Transverse section through the lower one-quarter of the rectus sheath. Fig. 4.34 Transverse section showing the layers of the abdominal wall. Fig. 4.35 Subdivisions of the extraperitoneal fascia. Fig. 4.36 Innervation of the anterolateral abdominal wall. External oblique muscleand aponeurosisIliohypogastric nerve (L1)Xiphoid processIlio-inguinal nerve (L1)Iliac crestAnterior cutaneousbranches T7 to T12Lateral cutaneousbranches T7 to T12 Fig. 4.37 Path taken by the nerves innervating the anterolateral abdominal wall. Fig. 4.38 Dermatomes of the anterolateral abdominal wall. Fig. 4.39 Arterial supply to the anterolateral abdominal wall. | Anatomy_Gray. External oblique musclePosterior wall of rectus sheathRectus abdominis muscleTendinous intersectionInternal oblique muscle Arcuate lineTransversalis fasciaLinea albaPyramidalis muscle Fig. 4.33 Organization of the rectus sheath. A. Transverse section through the upper three-quarters of the rectus sheath. B. Transverse section through the lower one-quarter of the rectus sheath. Fig. 4.34 Transverse section showing the layers of the abdominal wall. Fig. 4.35 Subdivisions of the extraperitoneal fascia. Fig. 4.36 Innervation of the anterolateral abdominal wall. External oblique muscleand aponeurosisIliohypogastric nerve (L1)Xiphoid processIlio-inguinal nerve (L1)Iliac crestAnterior cutaneousbranches T7 to T12Lateral cutaneousbranches T7 to T12 Fig. 4.37 Path taken by the nerves innervating the anterolateral abdominal wall. Fig. 4.38 Dermatomes of the anterolateral abdominal wall. Fig. 4.39 Arterial supply to the anterolateral abdominal wall. | [
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Anatomy_Gray_815 | Anatomy_Gray | Fig. 4.38 Dermatomes of the anterolateral abdominal wall. Fig. 4.39 Arterial supply to the anterolateral abdominal wall. Fig. 4.40 Superior and inferior epigastric arteries. Fig. 4.41 Descent of the testis from week 7 (postfertilization) to birth. Fig. 4.42 Inguinal canal. Linea albaSuperficialinguinal ringDeep inguinal ringExternal oblique muscleAponeurosis of external obliqueInguinal ligamentSpermatic cordAnterior superioriliac spine Fig. 4.43 Deep inguinal ring and the transversalis fascia. Fig. 4.44 Superficial inguinal ring and the aponeurosis of the external oblique. Inguinal ligamentFemoral artery and veinExternal oblique muscleAponeurosis of external oblique Spermatic cordSuperficial inguinal ringAnterior superior iliac spine Fig. 4.45 Internal oblique muscle and the inguinal canal. Inguinal ligamentFemoral artery and veinInternal oblique muscleAponeurosis of internal oblique Spermatic cordConjoint tendonAnterior superior iliac spine | Anatomy_Gray. Fig. 4.38 Dermatomes of the anterolateral abdominal wall. Fig. 4.39 Arterial supply to the anterolateral abdominal wall. Fig. 4.40 Superior and inferior epigastric arteries. Fig. 4.41 Descent of the testis from week 7 (postfertilization) to birth. Fig. 4.42 Inguinal canal. Linea albaSuperficialinguinal ringDeep inguinal ringExternal oblique muscleAponeurosis of external obliqueInguinal ligamentSpermatic cordAnterior superioriliac spine Fig. 4.43 Deep inguinal ring and the transversalis fascia. Fig. 4.44 Superficial inguinal ring and the aponeurosis of the external oblique. Inguinal ligamentFemoral artery and veinExternal oblique muscleAponeurosis of external oblique Spermatic cordSuperficial inguinal ringAnterior superior iliac spine Fig. 4.45 Internal oblique muscle and the inguinal canal. Inguinal ligamentFemoral artery and veinInternal oblique muscleAponeurosis of internal oblique Spermatic cordConjoint tendonAnterior superior iliac spine | [
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Anatomy_Gray_816 | Anatomy_Gray | Inguinal ligamentFemoral artery and veinInternal oblique muscleAponeurosis of internal oblique Spermatic cordConjoint tendonAnterior superior iliac spine Fig. 4.46 Transversus abdominis muscle and the inguinal canal. Fig. 4.47 A. Spermatic cord (men). B. Round ligament of uterus (women). Internal spermatic fasciaParietal layer of the tunica vaginalisAVisceral layer of the tunica vaginalisCavity of the tunica vaginalisExternal spermatic fasciaCremasteric fasciaDeep inguinal ringInternaloblique muscleSuperficial inguinal ringTesticular artery andpampiniform plexus of veinsParietal peritoneumArtery to ductus deferensCremasteric vesselsGenital branch of genitofemoral nerveInferior epigastric vesselsDuctus deferensExternal obliqueaponeurosisTransversusabdominis muscleConjoint tendonExternal obliqueaponeurosisTransversalisfasciaIlioinguinalnerveIlioinguinal nerveExtraperitoneal fascia | Anatomy_Gray. Inguinal ligamentFemoral artery and veinInternal oblique muscleAponeurosis of internal oblique Spermatic cordConjoint tendonAnterior superior iliac spine Fig. 4.46 Transversus abdominis muscle and the inguinal canal. Fig. 4.47 A. Spermatic cord (men). B. Round ligament of uterus (women). Internal spermatic fasciaParietal layer of the tunica vaginalisAVisceral layer of the tunica vaginalisCavity of the tunica vaginalisExternal spermatic fasciaCremasteric fasciaDeep inguinal ringInternaloblique muscleSuperficial inguinal ringTesticular artery andpampiniform plexus of veinsParietal peritoneumArtery to ductus deferensCremasteric vesselsGenital branch of genitofemoral nerveInferior epigastric vesselsDuctus deferensExternal obliqueaponeurosisTransversusabdominis muscleConjoint tendonExternal obliqueaponeurosisTransversalisfasciaIlioinguinalnerveIlioinguinal nerveExtraperitoneal fascia | [
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Anatomy_Gray_817 | Anatomy_Gray | Internaloblique muscleParietal peritoneumGenital branch ofgenitofemoral nerveGenital branch ofgenitofemoral nerveInferior epigastric vesselsRound ligament of uterusExternal obliqueaponeurosisTransversusabdominis muscleMembranous layerof superficial fasciaSuperficial fascia(fatty layers) Fine connectivetissue strandsBConjoint tendonExternal obliqueaponeurosisSkin of mons pubisIlioinguinalnerveIlioinguinal nerveExtraperitoneal fascia Fig. 4.48 Indirect inguinal hernia. Fig. 4.49 Direct inguinal hernia. Fig. 4.50 Right inguinal triangle. A. Internal view. B. Laparoscopic view showing the parietal peritoneum still covering the area. Inferior epigastricvesselsDirect herniaTesticular vesselsPosition of deepinguinal ringBLateralMedialExternal iliac vesselsDuctus deferens Fig. 4.51 Coronal CT shows a large inguinal hernia containing loops of large and small bowel (arrow) on the left side of a male patient. | Anatomy_Gray. Internaloblique muscleParietal peritoneumGenital branch ofgenitofemoral nerveGenital branch ofgenitofemoral nerveInferior epigastric vesselsRound ligament of uterusExternal obliqueaponeurosisTransversusabdominis muscleMembranous layerof superficial fasciaSuperficial fascia(fatty layers) Fine connectivetissue strandsBConjoint tendonExternal obliqueaponeurosisSkin of mons pubisIlioinguinalnerveIlioinguinal nerveExtraperitoneal fascia Fig. 4.48 Indirect inguinal hernia. Fig. 4.49 Direct inguinal hernia. Fig. 4.50 Right inguinal triangle. A. Internal view. B. Laparoscopic view showing the parietal peritoneum still covering the area. Inferior epigastricvesselsDirect herniaTesticular vesselsPosition of deepinguinal ringBLateralMedialExternal iliac vesselsDuctus deferens Fig. 4.51 Coronal CT shows a large inguinal hernia containing loops of large and small bowel (arrow) on the left side of a male patient. | [
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Anatomy_Gray_818 | Anatomy_Gray | Fig. 4.51 Coronal CT shows a large inguinal hernia containing loops of large and small bowel (arrow) on the left side of a male patient. Fig. 4.52 Right indirect inguinal hernia. T2, fat saturated, weighted magnetic resonance image in the coronal plane of a male groin. Fig. 4.53 A. Intraperitoneal. B. Retroperitoneal. Fig. 4.54 Greater and lesser sacs of the peritoneal cavity. Fig. 4.55 Transverse section illustrating the continuity between the greater and lesser sacs through the omental (epiploic) foramen. Fig. 4.56 Coronal CT shows ascites fluid in abdominal cavity. Fig. 4.57 Peritoneal metastasis on the surface of the liver. Computed tomogram in the axial plane of the upper abdomen. Peritoneal metastasison surface of liverAortaInferior vena cavaLiverSpleenLeft kidney Fig. 4.58 Radiograph of subdiaphragmatic gas. Fig. 4.59 Greater omentum. Fig. 4.60 Lesser omentum. | Anatomy_Gray. Fig. 4.51 Coronal CT shows a large inguinal hernia containing loops of large and small bowel (arrow) on the left side of a male patient. Fig. 4.52 Right indirect inguinal hernia. T2, fat saturated, weighted magnetic resonance image in the coronal plane of a male groin. Fig. 4.53 A. Intraperitoneal. B. Retroperitoneal. Fig. 4.54 Greater and lesser sacs of the peritoneal cavity. Fig. 4.55 Transverse section illustrating the continuity between the greater and lesser sacs through the omental (epiploic) foramen. Fig. 4.56 Coronal CT shows ascites fluid in abdominal cavity. Fig. 4.57 Peritoneal metastasis on the surface of the liver. Computed tomogram in the axial plane of the upper abdomen. Peritoneal metastasison surface of liverAortaInferior vena cavaLiverSpleenLeft kidney Fig. 4.58 Radiograph of subdiaphragmatic gas. Fig. 4.59 Greater omentum. Fig. 4.60 Lesser omentum. | [
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Anatomy_Gray_819 | Anatomy_Gray | Peritoneal metastasison surface of liverAortaInferior vena cavaLiverSpleenLeft kidney Fig. 4.58 Radiograph of subdiaphragmatic gas. Fig. 4.59 Greater omentum. Fig. 4.60 Lesser omentum. Liver (retracted )GallbladderStomachLesser omentumDuodenumDescending colonAscending colonOmental foramenLesser curvature of the stomachHepatogastric ligamentHepatoduodenal ligament Fig. 4.61 Peritoneal reflections, forming mesenteries, outlined on the posterior abdominal wall. Root of the transverse mesocolonRoot of the sigmoid mesocolonRoot of the mesentery Fig. 4.62 Abdominal esophagus. RightvagusnerveTracheaArch of aortaAortaThoracicesophagusAbdominal esophagusRight crus ofdiaphragmLeft vagus nerve Fig. 4.63 Arterial supply to the abdominal esophagus and stomach. Fig. 4.64 Stomach. Fig. 4.65 Radiograph, using barium, showing the stomach and duodenum. A. Double-contrast radiograph of the stomach. B. Double-contrast radiograph showing the duodenal cap. | Anatomy_Gray. Peritoneal metastasison surface of liverAortaInferior vena cavaLiverSpleenLeft kidney Fig. 4.58 Radiograph of subdiaphragmatic gas. Fig. 4.59 Greater omentum. Fig. 4.60 Lesser omentum. Liver (retracted )GallbladderStomachLesser omentumDuodenumDescending colonAscending colonOmental foramenLesser curvature of the stomachHepatogastric ligamentHepatoduodenal ligament Fig. 4.61 Peritoneal reflections, forming mesenteries, outlined on the posterior abdominal wall. Root of the transverse mesocolonRoot of the sigmoid mesocolonRoot of the mesentery Fig. 4.62 Abdominal esophagus. RightvagusnerveTracheaArch of aortaAortaThoracicesophagusAbdominal esophagusRight crus ofdiaphragmLeft vagus nerve Fig. 4.63 Arterial supply to the abdominal esophagus and stomach. Fig. 4.64 Stomach. Fig. 4.65 Radiograph, using barium, showing the stomach and duodenum. A. Double-contrast radiograph of the stomach. B. Double-contrast radiograph showing the duodenal cap. | [
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Anatomy_Gray_820 | Anatomy_Gray | Fig. 4.64 Stomach. Fig. 4.65 Radiograph, using barium, showing the stomach and duodenum. A. Double-contrast radiograph of the stomach. B. Double-contrast radiograph showing the duodenal cap. Fundus of stomachPyloric orificeSuperior part of duodenumABPyloric antrumEsophagusNormal duodenal capPyloric antrum of stomachInferior duodenumDuodenal jejunal flexureBody of stomachDescending part of duodenumPyloric canalPyloric sphincter Fig. 4.66 Duodenum. PancreasDuodenum—superior partDuodenum—descending partDuodenum —ascending partDuodenum—inferior partDescending colonAscending colonSpleenAbdominal aortaEsophagusL1L2L3Bile ductRight suprarenal glandRight kidneyGallbladderPosition of majorduodenal papillaPosition of minorduodenal papillaLeft kidneySuperior mesenteric vein and arteryPortal veinInferior vena cava Fig. 4.67 Arterial supply to the duodenum. Fig. 4.68 Radiograph, using barium, showing the jejunum and ileum. | Anatomy_Gray. Fig. 4.64 Stomach. Fig. 4.65 Radiograph, using barium, showing the stomach and duodenum. A. Double-contrast radiograph of the stomach. B. Double-contrast radiograph showing the duodenal cap. Fundus of stomachPyloric orificeSuperior part of duodenumABPyloric antrumEsophagusNormal duodenal capPyloric antrum of stomachInferior duodenumDuodenal jejunal flexureBody of stomachDescending part of duodenumPyloric canalPyloric sphincter Fig. 4.66 Duodenum. PancreasDuodenum—superior partDuodenum—descending partDuodenum —ascending partDuodenum—inferior partDescending colonAscending colonSpleenAbdominal aortaEsophagusL1L2L3Bile ductRight suprarenal glandRight kidneyGallbladderPosition of majorduodenal papillaPosition of minorduodenal papillaLeft kidneySuperior mesenteric vein and arteryPortal veinInferior vena cava Fig. 4.67 Arterial supply to the duodenum. Fig. 4.68 Radiograph, using barium, showing the jejunum and ileum. | [
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Anatomy_Gray_821 | Anatomy_Gray | Fig. 4.67 Arterial supply to the duodenum. Fig. 4.68 Radiograph, using barium, showing the jejunum and ileum. Fig. 4.69 Differences in the arterial supply to the small intestine. A. Jejunum. B. Ileum. Fig. 4.70 Ileocecal junction. A. Radiograph showing ileocecal junction. B. Illustration showing ileocecal junction and the ileocecal fold. C. Endoscopic image of the ileocecal fold. Fig. 4.71 Arterial supply to the ileum. Fig. 4.72 The endoscope is a flexible plastic tube that can be controlled from the proximal end. Through a side portal various devices can be inserted, which run through the endoscope and can be used to obtain biopsies and to perform minor endoluminal surgical procedures (e.g., excision of polyps). Fig. 4.73 Endoscopic images of the gastroesophageal junction. A. Normal. B. Esophageal cancer at esophageal junction. Fig. 4.74 Endoscopic image of the pyloric antrum of the stomach looking toward the pylorus. | Anatomy_Gray. Fig. 4.67 Arterial supply to the duodenum. Fig. 4.68 Radiograph, using barium, showing the jejunum and ileum. Fig. 4.69 Differences in the arterial supply to the small intestine. A. Jejunum. B. Ileum. Fig. 4.70 Ileocecal junction. A. Radiograph showing ileocecal junction. B. Illustration showing ileocecal junction and the ileocecal fold. C. Endoscopic image of the ileocecal fold. Fig. 4.71 Arterial supply to the ileum. Fig. 4.72 The endoscope is a flexible plastic tube that can be controlled from the proximal end. Through a side portal various devices can be inserted, which run through the endoscope and can be used to obtain biopsies and to perform minor endoluminal surgical procedures (e.g., excision of polyps). Fig. 4.73 Endoscopic images of the gastroesophageal junction. A. Normal. B. Esophageal cancer at esophageal junction. Fig. 4.74 Endoscopic image of the pyloric antrum of the stomach looking toward the pylorus. | [
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Anatomy_Gray_822 | Anatomy_Gray | Fig. 4.74 Endoscopic image of the pyloric antrum of the stomach looking toward the pylorus. Fig. 4.75 Endoscopic image showing normal appearance of the second part of the duodenum. Fig. 4.76 Small bowel visualization using MRI in coronal plane. Fig. 4.77 Axial CT shows sigmoid colon wall thickening caused by tumor. Fig. 4.78 Vasculature associated with a Meckel’s diverticulum. A. Surgical image of Meckel’s diverticulum. B. Digital subtraction angiography. Fig. 4.79 Large intestine. Transverse colonSigmoid colonAscending colonRight colic flexureAppendixCecumHaustra of colonOmental appendicesLeft colic flexureAnal canalRectumIleumTaeniae coli Fig. 4.80 Radiograph, using barium, showing the large intestine. Fig. 4.81 Position of the large intestine in the nine-region organizational pattern. Fig. 4.82 Cecum and appendix. Fig. 4.83 Mesoappendix and appendicular vessels. Fig. 4.84 Positions of the appendix. Fig. 4.85 Arterial supply to the cecum and appendix. | Anatomy_Gray. Fig. 4.74 Endoscopic image of the pyloric antrum of the stomach looking toward the pylorus. Fig. 4.75 Endoscopic image showing normal appearance of the second part of the duodenum. Fig. 4.76 Small bowel visualization using MRI in coronal plane. Fig. 4.77 Axial CT shows sigmoid colon wall thickening caused by tumor. Fig. 4.78 Vasculature associated with a Meckel’s diverticulum. A. Surgical image of Meckel’s diverticulum. B. Digital subtraction angiography. Fig. 4.79 Large intestine. Transverse colonSigmoid colonAscending colonRight colic flexureAppendixCecumHaustra of colonOmental appendicesLeft colic flexureAnal canalRectumIleumTaeniae coli Fig. 4.80 Radiograph, using barium, showing the large intestine. Fig. 4.81 Position of the large intestine in the nine-region organizational pattern. Fig. 4.82 Cecum and appendix. Fig. 4.83 Mesoappendix and appendicular vessels. Fig. 4.84 Positions of the appendix. Fig. 4.85 Arterial supply to the cecum and appendix. | [
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] |
Anatomy_Gray_823 | Anatomy_Gray | Fig. 4.82 Cecum and appendix. Fig. 4.83 Mesoappendix and appendicular vessels. Fig. 4.84 Positions of the appendix. Fig. 4.85 Arterial supply to the cecum and appendix. Fig. 4.86 Inflamed appendix. Ultrasound scan. Fig. 4.87 Axial CT shows inflamed appendix. Fig. 4.88 Colon. Fig. 4.89 Right and left colic flexures. Fig. 4.90 Arterial supply to the colon. Fig. 4.91 Rectum and anal canal. Fig. 4.92 Arterial supply to the rectum and anal canal. Posterior view. Fig. 4.93 Small bowel malrotation and volvulus. Radiograph of stomach, duodenum, and upper jejunum using barium. Fig. 4.94 Small bowel malrotation. Radiograph of stomach, duodenum, and jejunum using barium. | Anatomy_Gray. Fig. 4.82 Cecum and appendix. Fig. 4.83 Mesoappendix and appendicular vessels. Fig. 4.84 Positions of the appendix. Fig. 4.85 Arterial supply to the cecum and appendix. Fig. 4.86 Inflamed appendix. Ultrasound scan. Fig. 4.87 Axial CT shows inflamed appendix. Fig. 4.88 Colon. Fig. 4.89 Right and left colic flexures. Fig. 4.90 Arterial supply to the colon. Fig. 4.91 Rectum and anal canal. Fig. 4.92 Arterial supply to the rectum and anal canal. Posterior view. Fig. 4.93 Small bowel malrotation and volvulus. Radiograph of stomach, duodenum, and upper jejunum using barium. Fig. 4.94 Small bowel malrotation. Radiograph of stomach, duodenum, and jejunum using barium. | [
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Anatomy_Gray_824 | Anatomy_Gray | Fig. 4.94 Small bowel malrotation. Radiograph of stomach, duodenum, and jejunum using barium. Fig. 4.95 This radiograph of the abdomen, anteroposterior view, demonstrates a number of dilated loops of small bowel. Small bowel can be identified by the plicae circulares that pass from wall to wall as indicated. The large bowel is not dilated. The cause of the small bowel dilatation is an adhesion after pelvic surgery. Dilation of small bowelPlicae circulares Fig. 4.96 Coronal CT demonstrates dilated and fluid-filled loops of small bowel in patient with small bowel obstruction. Dilated and fluid-filledloops of small bowel Fig. 4.97 Coronal CT of abdomen shows fluid-filled and dilated ascending and transverse colon in patient with large bowel obstruction. Fig. 4.98 This oblique radiograph demonstrates contrast passing through a colonic stent that has been placed to relieve bowel obstruction prior to surgery. | Anatomy_Gray. Fig. 4.94 Small bowel malrotation. Radiograph of stomach, duodenum, and jejunum using barium. Fig. 4.95 This radiograph of the abdomen, anteroposterior view, demonstrates a number of dilated loops of small bowel. Small bowel can be identified by the plicae circulares that pass from wall to wall as indicated. The large bowel is not dilated. The cause of the small bowel dilatation is an adhesion after pelvic surgery. Dilation of small bowelPlicae circulares Fig. 4.96 Coronal CT demonstrates dilated and fluid-filled loops of small bowel in patient with small bowel obstruction. Dilated and fluid-filledloops of small bowel Fig. 4.97 Coronal CT of abdomen shows fluid-filled and dilated ascending and transverse colon in patient with large bowel obstruction. Fig. 4.98 This oblique radiograph demonstrates contrast passing through a colonic stent that has been placed to relieve bowel obstruction prior to surgery. | [
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Anatomy_Gray_825 | Anatomy_Gray | Fig. 4.98 This oblique radiograph demonstrates contrast passing through a colonic stent that has been placed to relieve bowel obstruction prior to surgery. Fig. 4.99 This double-contrast barium enema demonstrates numerous small outpouchings throughout the distal large bowel predominantly within the descending colon and the sigmoid colon. These small outpouchings are diverticula and in most instances remain quiescent. Fig. 4.100 Axial CT of inflamed sigmoid colon in patient with diverticulitis. Fig. 4.101 Position of the liver in the abdomen. Fig. 4.102 Surfaces of the liver and recesses associated with the liver. Fig. 4.103 Diaphragmatic surface of the liver. Fig. 4.104 Visceral surface of the liver. A. Illustration. B. Abdominal computed tomogram, with contrast, in the axial plane. | Anatomy_Gray. Fig. 4.98 This oblique radiograph demonstrates contrast passing through a colonic stent that has been placed to relieve bowel obstruction prior to surgery. Fig. 4.99 This double-contrast barium enema demonstrates numerous small outpouchings throughout the distal large bowel predominantly within the descending colon and the sigmoid colon. These small outpouchings are diverticula and in most instances remain quiescent. Fig. 4.100 Axial CT of inflamed sigmoid colon in patient with diverticulitis. Fig. 4.101 Position of the liver in the abdomen. Fig. 4.102 Surfaces of the liver and recesses associated with the liver. Fig. 4.103 Diaphragmatic surface of the liver. Fig. 4.104 Visceral surface of the liver. A. Illustration. B. Abdominal computed tomogram, with contrast, in the axial plane. | [
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Anatomy_Gray_826 | Anatomy_Gray | Fig. 4.103 Diaphragmatic surface of the liver. Fig. 4.104 Visceral surface of the liver. A. Illustration. B. Abdominal computed tomogram, with contrast, in the axial plane. Left lobe of liverLeft lobe of liverRight lobeof liverCaudate lobeRight lobe of liverQuadrate lobeQuadrate lobeGallbladderAnteriorPosteriorFundusBodyNeckCystic ductPorta hepatisPortal veinFissure for ligamentum teresFissure for ligamentumvenosumHepatic artery properHepatic ductsBile ductABGallbladderPortal veinInferior vena cavaStomachNeck of pancreasSpleenLeft kidneyAortaRight crusLeft crus Fig. 4.105 Posterior view of the bare area of the liver and associated ligaments. Inferior vena cavaSuprarenal impressionLeft lobe of liverRight lobe of liver Renal impressionCaudate lobeGastric impressionEsophageal impressionColic impressionQuadrate lobeFalciform ligamentGallbladderPorta hepatisAnterior coronary ligamentPosterior coronary ligamentRight triangularligamentLeft triangular ligamentBare areaFundusBodyNeck | Anatomy_Gray. Fig. 4.103 Diaphragmatic surface of the liver. Fig. 4.104 Visceral surface of the liver. A. Illustration. B. Abdominal computed tomogram, with contrast, in the axial plane. Left lobe of liverLeft lobe of liverRight lobeof liverCaudate lobeRight lobe of liverQuadrate lobeQuadrate lobeGallbladderAnteriorPosteriorFundusBodyNeckCystic ductPorta hepatisPortal veinFissure for ligamentum teresFissure for ligamentumvenosumHepatic artery properHepatic ductsBile ductABGallbladderPortal veinInferior vena cavaStomachNeck of pancreasSpleenLeft kidneyAortaRight crusLeft crus Fig. 4.105 Posterior view of the bare area of the liver and associated ligaments. Inferior vena cavaSuprarenal impressionLeft lobe of liverRight lobe of liver Renal impressionCaudate lobeGastric impressionEsophageal impressionColic impressionQuadrate lobeFalciform ligamentGallbladderPorta hepatisAnterior coronary ligamentPosterior coronary ligamentRight triangularligamentLeft triangular ligamentBare areaFundusBodyNeck | [
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Anatomy_Gray_827 | Anatomy_Gray | Fig. 4.106 Arterial supply to the liver and gallbladder. A. Schematic. B. Laparoscopic surgical view of cystic duct and cystic artery. Fig. 4.107 Pancreas. Fig. 4.108 Abdominal images. A. Abdominal computed tomogram, with contrast, in the axial plane. B. Abdominal ultrasound scan. GallbladderPancreasPortal veinSplenic veinStomachLeft colonic flexureSpleenLeft kidneyAortaInferior vena cavaRight lobe of liverRight crusALeft crus Left lobe of liverBSplenic arterySuperior mesenteric arteryPancreasLeft renal veinAortaInferior vena cavaVertebra Fig. 4.109 Pancreatic duct system. Fig. 4.110 Arterial supply to the pancreas. Posterior view. Fig. 4.111 Bile drainage. A. Duct system for passage of bile. B. Percutaneous transhepatic cholangiogram demonstrating the bile duct system. GallbladderCystic ductBile ductBile ductRight hepatic ductLeft hepatic ductCommon hepatic ductCystic ductNeedleCommonhepatic ductMain pancreatic ductDescending part of duodenumDescending part of duodenumAB | Anatomy_Gray. Fig. 4.106 Arterial supply to the liver and gallbladder. A. Schematic. B. Laparoscopic surgical view of cystic duct and cystic artery. Fig. 4.107 Pancreas. Fig. 4.108 Abdominal images. A. Abdominal computed tomogram, with contrast, in the axial plane. B. Abdominal ultrasound scan. GallbladderPancreasPortal veinSplenic veinStomachLeft colonic flexureSpleenLeft kidneyAortaInferior vena cavaRight lobe of liverRight crusALeft crus Left lobe of liverBSplenic arterySuperior mesenteric arteryPancreasLeft renal veinAortaInferior vena cavaVertebra Fig. 4.109 Pancreatic duct system. Fig. 4.110 Arterial supply to the pancreas. Posterior view. Fig. 4.111 Bile drainage. A. Duct system for passage of bile. B. Percutaneous transhepatic cholangiogram demonstrating the bile duct system. GallbladderCystic ductBile ductBile ductRight hepatic ductLeft hepatic ductCommon hepatic ductCystic ductNeedleCommonhepatic ductMain pancreatic ductDescending part of duodenumDescending part of duodenumAB | [
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Anatomy_Gray_828 | Anatomy_Gray | Fig. 4.112 Spleen. Fig. 4.113 Splenic ligaments and related vasculature. Fig. 4.114 Surfaces and hilum of the spleen. Fig. 4.115 Arterial supply to the spleen. Fig. 4.116 Division of the liver into segments based upon the distributions of the bile ducts and hepatic vessels (Couinaud’s segments). Fig. 4.117 Gallbladder containing multiple stones. Ultrasound scan. Fig. 4.118 Magnetic resonance cholangiopancreatography (MRCP) in the coronal plane. Fig. 4.119 Endoscopic retrograde cholangiopancreatography (ERCP) of biliary system. Endoscope with side-viewing optic mechanismStent in common bile duct Fig. 4.120 Coronal CT of the abdomen containing a massively enlarged spleen (splenomegaly). Fig. 4.121 Anterior branches of the abdominal aorta. Fig. 4.122 Divisions of the gastrointestinal tract into foregut, midgut, and hindgut, summarizing the primary arterial supply to each segment. | Anatomy_Gray. Fig. 4.112 Spleen. Fig. 4.113 Splenic ligaments and related vasculature. Fig. 4.114 Surfaces and hilum of the spleen. Fig. 4.115 Arterial supply to the spleen. Fig. 4.116 Division of the liver into segments based upon the distributions of the bile ducts and hepatic vessels (Couinaud’s segments). Fig. 4.117 Gallbladder containing multiple stones. Ultrasound scan. Fig. 4.118 Magnetic resonance cholangiopancreatography (MRCP) in the coronal plane. Fig. 4.119 Endoscopic retrograde cholangiopancreatography (ERCP) of biliary system. Endoscope with side-viewing optic mechanismStent in common bile duct Fig. 4.120 Coronal CT of the abdomen containing a massively enlarged spleen (splenomegaly). Fig. 4.121 Anterior branches of the abdominal aorta. Fig. 4.122 Divisions of the gastrointestinal tract into foregut, midgut, and hindgut, summarizing the primary arterial supply to each segment. | [
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Anatomy_Gray_829 | Anatomy_Gray | Fig. 4.121 Anterior branches of the abdominal aorta. Fig. 4.122 Divisions of the gastrointestinal tract into foregut, midgut, and hindgut, summarizing the primary arterial supply to each segment. Fig. 4.123 Celiac trunk. A. Distribution of the celiac trunk. B. Digital subtraction angiography of the celiac trunk and its branches. Fig. 4.124 Arterial supply to the pancreas. Fig. 4.125 Distribution of the common hepatic artery. Fig. 4.126 Initial branching and relationships of the superior mesenteric artery. Fig. 4.127 Superior mesenteric artery. A. Distribution of the superior mesenteric artery. B. Digital subtraction angiography of the superior mesenteric artery and its branches. Fig. 4.128 Inferior mesenteric artery. A. Distribution of the inferior mesenteric artery. B. Digital subtraction angiography of the inferior mesenteric artery and its branches. Fig. 4.129 Arterial supply to the abdominal parts of the gastrointestinal system and to the spleen. | Anatomy_Gray. Fig. 4.121 Anterior branches of the abdominal aorta. Fig. 4.122 Divisions of the gastrointestinal tract into foregut, midgut, and hindgut, summarizing the primary arterial supply to each segment. Fig. 4.123 Celiac trunk. A. Distribution of the celiac trunk. B. Digital subtraction angiography of the celiac trunk and its branches. Fig. 4.124 Arterial supply to the pancreas. Fig. 4.125 Distribution of the common hepatic artery. Fig. 4.126 Initial branching and relationships of the superior mesenteric artery. Fig. 4.127 Superior mesenteric artery. A. Distribution of the superior mesenteric artery. B. Digital subtraction angiography of the superior mesenteric artery and its branches. Fig. 4.128 Inferior mesenteric artery. A. Distribution of the inferior mesenteric artery. B. Digital subtraction angiography of the inferior mesenteric artery and its branches. Fig. 4.129 Arterial supply to the abdominal parts of the gastrointestinal system and to the spleen. | [
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Anatomy_Gray_830 | Anatomy_Gray | Fig. 4.129 Arterial supply to the abdominal parts of the gastrointestinal system and to the spleen. Fig. 4.130 Enlarged marginal artery connecting the superior and inferior mesenteric arteries. Digital subtraction angiogram. Fig. 4.131 Portal vein. Fig. 4.132 Venous drainage of the abdominal portion of the gastrointestinal tract. Fig. 4.133 Portosystemic anastomoses. LiverSpleenSplenic veinSuperior mesenteric veinSuperior rectal veinInferior rectal veinsInferior vena cavaInferior mesenteric veinLeft gastric veinPortal veinRectumStomachTributaries to azygos veinSuperficial veinson abdominal wallExternal iliac veinInternal iliac veinCommon iliac veinPara-umbilical veinsthat accompany theligamentum teres Fig. 4.134 Lymphatic drainage of the abdominal portion of the gastrointestinal tract. Fig. 4.135 Sympathetic trunks. Fig. 4.136 Splanchnic nerves. Fig. 4.137 Abdominal prevertebral plexus and ganglia. | Anatomy_Gray. Fig. 4.129 Arterial supply to the abdominal parts of the gastrointestinal system and to the spleen. Fig. 4.130 Enlarged marginal artery connecting the superior and inferior mesenteric arteries. Digital subtraction angiogram. Fig. 4.131 Portal vein. Fig. 4.132 Venous drainage of the abdominal portion of the gastrointestinal tract. Fig. 4.133 Portosystemic anastomoses. LiverSpleenSplenic veinSuperior mesenteric veinSuperior rectal veinInferior rectal veinsInferior vena cavaInferior mesenteric veinLeft gastric veinPortal veinRectumStomachTributaries to azygos veinSuperficial veinson abdominal wallExternal iliac veinInternal iliac veinCommon iliac veinPara-umbilical veinsthat accompany theligamentum teres Fig. 4.134 Lymphatic drainage of the abdominal portion of the gastrointestinal tract. Fig. 4.135 Sympathetic trunks. Fig. 4.136 Splanchnic nerves. Fig. 4.137 Abdominal prevertebral plexus and ganglia. | [
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Anatomy_Gray_831 | Anatomy_Gray | Fig. 4.135 Sympathetic trunks. Fig. 4.136 Splanchnic nerves. Fig. 4.137 Abdominal prevertebral plexus and ganglia. Fig. 4.138 Parasympathetic innervation of the abdominal portion of the gastrointestinal tract. Fig. 4.139 The enteric system. Fig. 4.140 Posterior abdominal region. Fig. 4.141 Osteology of the posterior abdominal wall. Fig. 4.142 Muscles of the posterior abdominal wall. Fig. 4.143 Diaphragm. Left phrenic nerveRight phrenic nerveInferior phrenicarteryAortaThoracic ductEsophagus with anteriorand posterior vagal trunksLIVLIIILIILISuperior epigastric arteryCentral tendonInferior vena cavaHemi-azygos veinGreater splanchnic nerveLesser splanchnic nerveLeast splanchnic nerveLeft crusSympathetic trunkRight crus Fig. 4.144 Crura of the diaphragm. Fig. 4.145 Right and left domes of the diaphragm. Chest radiograph. Fig. 4.146 Fetal diaphragmatic hernia in utero. T2-weighted MR image. Fetus in coronal plane, mother in sagittal plane. | Anatomy_Gray. Fig. 4.135 Sympathetic trunks. Fig. 4.136 Splanchnic nerves. Fig. 4.137 Abdominal prevertebral plexus and ganglia. Fig. 4.138 Parasympathetic innervation of the abdominal portion of the gastrointestinal tract. Fig. 4.139 The enteric system. Fig. 4.140 Posterior abdominal region. Fig. 4.141 Osteology of the posterior abdominal wall. Fig. 4.142 Muscles of the posterior abdominal wall. Fig. 4.143 Diaphragm. Left phrenic nerveRight phrenic nerveInferior phrenicarteryAortaThoracic ductEsophagus with anteriorand posterior vagal trunksLIVLIIILIILISuperior epigastric arteryCentral tendonInferior vena cavaHemi-azygos veinGreater splanchnic nerveLesser splanchnic nerveLeast splanchnic nerveLeft crusSympathetic trunkRight crus Fig. 4.144 Crura of the diaphragm. Fig. 4.145 Right and left domes of the diaphragm. Chest radiograph. Fig. 4.146 Fetal diaphragmatic hernia in utero. T2-weighted MR image. Fetus in coronal plane, mother in sagittal plane. | [
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Anatomy_Gray_832 | Anatomy_Gray | Fig. 4.145 Right and left domes of the diaphragm. Chest radiograph. Fig. 4.146 Fetal diaphragmatic hernia in utero. T2-weighted MR image. Fetus in coronal plane, mother in sagittal plane. Fetal vertebralcolumnFetal abdominalcontents (fluid-filledloops of intestine)in left side ofthoracic cavityFetal headNormal fetal lung development on rightside of thoracic cavityFetal diaphragmdeveloped onright sideMaternal lumbarvertebra Fig. 4.147 Lower esophagus and upper stomach showing a hiatal hernia. Radiograph using barium. Fig. 4.148 Coronal CT of hiatal hernia. Fig. 4.149 Retroperitoneal position of the kidneys in the posterior abdominal region. Inferior vena cavaDiaphragmRight suprarenal glandLeft suprarenal glandRight kidneyLeft kidneyCut edges of peritoneumAbdominal aortaEsophagus Fig. 4.150 Structures related to the anterior surface of each kidney. | Anatomy_Gray. Fig. 4.145 Right and left domes of the diaphragm. Chest radiograph. Fig. 4.146 Fetal diaphragmatic hernia in utero. T2-weighted MR image. Fetus in coronal plane, mother in sagittal plane. Fetal vertebralcolumnFetal abdominalcontents (fluid-filledloops of intestine)in left side ofthoracic cavityFetal headNormal fetal lung development on rightside of thoracic cavityFetal diaphragmdeveloped onright sideMaternal lumbarvertebra Fig. 4.147 Lower esophagus and upper stomach showing a hiatal hernia. Radiograph using barium. Fig. 4.148 Coronal CT of hiatal hernia. Fig. 4.149 Retroperitoneal position of the kidneys in the posterior abdominal region. Inferior vena cavaDiaphragmRight suprarenal glandLeft suprarenal glandRight kidneyLeft kidneyCut edges of peritoneumAbdominal aortaEsophagus Fig. 4.150 Structures related to the anterior surface of each kidney. | [
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] |
Anatomy_Gray_833 | Anatomy_Gray | Fig. 4.150 Structures related to the anterior surface of each kidney. StomachLiverPancreasDescending colonSmall intestineSpleenJejunumRight colic flexureLeft colic flexureDescending part of duodenumRight suprarenal glandLeft suprarenal gland Fig. 4.151 Structures related to the posterior surface of each kidney. Fig. 4.152 Organization of fat and fascia surrounding the kidney. Fig. 4.153 Internal structure of the kidney. Renal arteryRenal veinPyramid in renal medullaRenal sinusMinor calyxRenal cortexRenal papillaRenal columnRenal pelvisMajor calyxUreterHilum of kidney Fig. 4.154 A. Renal vasculature. B. CT image showing long left renal vein crossing the midline. Fig. 4.155 Ureters. Internal iliac arteryExternal iliac arteryCommon iliac arteryGonadal arteriesLeft kidneyLeft renal arteryRight renal arteryRight kidneyAbdominal aortaBladderUreterThird constriction—entrance to bladderSecond constriction—pelvic inletFirst constriction—ureteropelvic junctionUreter | Anatomy_Gray. Fig. 4.150 Structures related to the anterior surface of each kidney. StomachLiverPancreasDescending colonSmall intestineSpleenJejunumRight colic flexureLeft colic flexureDescending part of duodenumRight suprarenal glandLeft suprarenal gland Fig. 4.151 Structures related to the posterior surface of each kidney. Fig. 4.152 Organization of fat and fascia surrounding the kidney. Fig. 4.153 Internal structure of the kidney. Renal arteryRenal veinPyramid in renal medullaRenal sinusMinor calyxRenal cortexRenal papillaRenal columnRenal pelvisMajor calyxUreterHilum of kidney Fig. 4.154 A. Renal vasculature. B. CT image showing long left renal vein crossing the midline. Fig. 4.155 Ureters. Internal iliac arteryExternal iliac arteryCommon iliac arteryGonadal arteriesLeft kidneyLeft renal arteryRight renal arteryRight kidneyAbdominal aortaBladderUreterThird constriction—entrance to bladderSecond constriction—pelvic inletFirst constriction—ureteropelvic junctionUreter | [
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Anatomy_Gray_834 | Anatomy_Gray | Fig. 4.156 Low-dose axial CT of urinary tract (CT KUB) displays stone in left renal pelvis. Fig. 4.157 Tumor in the right kidney growing toward, and possibly invading, the duodenum. Computed tomogram in the axial plane. Fig. 4.158 Tumor in the right kidney spreading into the right renal vein. Computed tomogram in the axial plane. Fig. 4.159 Transitional cell carcinoma in the pelvis of the right kidney. Coronal computed tomogram reconstruction. Fig. 4.160 This radiograph demonstrates a double-J stent (anteroposterior view). The superior aspect of the double-J stent is situated within the renal pelvis. The stent passes through the ureter, describing the path of the ureter, and the tip of the double-J stent is projected over the bladder, which appears as a slightly dense area on the radiograph. | Anatomy_Gray. Fig. 4.156 Low-dose axial CT of urinary tract (CT KUB) displays stone in left renal pelvis. Fig. 4.157 Tumor in the right kidney growing toward, and possibly invading, the duodenum. Computed tomogram in the axial plane. Fig. 4.158 Tumor in the right kidney spreading into the right renal vein. Computed tomogram in the axial plane. Fig. 4.159 Transitional cell carcinoma in the pelvis of the right kidney. Coronal computed tomogram reconstruction. Fig. 4.160 This radiograph demonstrates a double-J stent (anteroposterior view). The superior aspect of the double-J stent is situated within the renal pelvis. The stent passes through the ureter, describing the path of the ureter, and the tip of the double-J stent is projected over the bladder, which appears as a slightly dense area on the radiograph. | [
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Anatomy_Gray_835 | Anatomy_Gray | Fig. 4.161 Kidney transplant. A. This image demonstrates an MR angiogram of the bifurcation of the aorta. Attaching to the left external iliac artery is the donor artery for a kidney that has been transplanted into the left iliac fossa. B. Abdominal computed tomogram, in the axial plane, showing the transplanted kidney in the left iliac fossa. AAbdominal aortaCommon iliac arteryExternal iliacarteryInternal iliacarteryThe left external iliac arteryhas been used to connectto the donor kidneyTransplant kidneyin the left iliacfossa Fig. 4.162 Coronal view of 3-D urogram using multidetector computed tomography. Fig. 4.163 Arterial supply to the suprarenal glands. Fig. 4.164 Abdominal aorta. | Anatomy_Gray. Fig. 4.161 Kidney transplant. A. This image demonstrates an MR angiogram of the bifurcation of the aorta. Attaching to the left external iliac artery is the donor artery for a kidney that has been transplanted into the left iliac fossa. B. Abdominal computed tomogram, in the axial plane, showing the transplanted kidney in the left iliac fossa. AAbdominal aortaCommon iliac arteryExternal iliacarteryInternal iliacarteryThe left external iliac arteryhas been used to connectto the donor kidneyTransplant kidneyin the left iliacfossa Fig. 4.162 Coronal view of 3-D urogram using multidetector computed tomography. Fig. 4.163 Arterial supply to the suprarenal glands. Fig. 4.164 Abdominal aorta. | [
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Anatomy_Gray_836 | Anatomy_Gray | Fig. 4.162 Coronal view of 3-D urogram using multidetector computed tomography. Fig. 4.163 Arterial supply to the suprarenal glands. Fig. 4.164 Abdominal aorta. Fig. 4.165 Volume-rendered reconstruction using multidetector computed tomography of patient with an infrarenal abdominal aortic aneurysm before (A) and after (B) endovascular aneurysm repair. Note the image only demonstrates the intraluminal contrast and not the entire vessel. White patches in the aorta represent intramural calcium. Fig. 4.166 Inferior vena cava. Fig. 4.167 Lumbar veins. Fig. 4.168 Abdominal lymphatics. Inferior vena cavaIntestinal trunkRight lumbar trunk with lateral aortic (lumbar) nodesLeft lumbar trunk withlateral aortic (lumbar) nodesExternal iliac nodesExternal iliac nodesInternal iliac nodesCommon iliac nodesCeliac nodesSuperior mesenteric nodesInferior mesenteric nodesCisterna chyliPre-aortic nodes Fig. 4.169 Sympathetic trunks passing through the posterior abdominal region. | Anatomy_Gray. Fig. 4.162 Coronal view of 3-D urogram using multidetector computed tomography. Fig. 4.163 Arterial supply to the suprarenal glands. Fig. 4.164 Abdominal aorta. Fig. 4.165 Volume-rendered reconstruction using multidetector computed tomography of patient with an infrarenal abdominal aortic aneurysm before (A) and after (B) endovascular aneurysm repair. Note the image only demonstrates the intraluminal contrast and not the entire vessel. White patches in the aorta represent intramural calcium. Fig. 4.166 Inferior vena cava. Fig. 4.167 Lumbar veins. Fig. 4.168 Abdominal lymphatics. Inferior vena cavaIntestinal trunkRight lumbar trunk with lateral aortic (lumbar) nodesLeft lumbar trunk withlateral aortic (lumbar) nodesExternal iliac nodesExternal iliac nodesInternal iliac nodesCommon iliac nodesCeliac nodesSuperior mesenteric nodesInferior mesenteric nodesCisterna chyliPre-aortic nodes Fig. 4.169 Sympathetic trunks passing through the posterior abdominal region. | [
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Anatomy_Gray_837 | Anatomy_Gray | Fig. 4.169 Sympathetic trunks passing through the posterior abdominal region. Fig. 4.170 Prevertebral plexus and ganglia in the posterior abdominal region. Fig. 4.171 Nerve fibers passing through the abdominal prevertebral plexus and ganglia. Fig. 4.172 Prevertebral ganglia associated with the prevertebral plexus. Fig. 4.173 Lumbar plexus. T12L1L2L3L4To lumbosacral trunkObturator nerveFemoralnerveTo iliacusmuscleLateral cutaneousnerve of thighGenitofemoralnerveIlio-inguinal nerveIliohypogastricnerve Fig. 4.174 Lumbar plexus in the posterior abdominal region. Subcostal nerveIliohypogastric nerveIlio-inguinal nerveLateral cutaneous nerve of thighFemoral nerveGenitofemoral nerveObturator nerveSubcostal nerve (T12)Iliohypogastric nerve (L1)Psoas major muscleIlio-inguinal nerve (L1)Lateral cutaneous nerve of thigh (L2,L3)Femoral nerve (L2 to L4)Genitofemoral nerve (L1,L2)Iliacus muscleObturator nerve (L2 to L4)Lumbosacral trunks(L4,L5) | Anatomy_Gray. Fig. 4.169 Sympathetic trunks passing through the posterior abdominal region. Fig. 4.170 Prevertebral plexus and ganglia in the posterior abdominal region. Fig. 4.171 Nerve fibers passing through the abdominal prevertebral plexus and ganglia. Fig. 4.172 Prevertebral ganglia associated with the prevertebral plexus. Fig. 4.173 Lumbar plexus. T12L1L2L3L4To lumbosacral trunkObturator nerveFemoralnerveTo iliacusmuscleLateral cutaneousnerve of thighGenitofemoralnerveIlio-inguinal nerveIliohypogastricnerve Fig. 4.174 Lumbar plexus in the posterior abdominal region. Subcostal nerveIliohypogastric nerveIlio-inguinal nerveLateral cutaneous nerve of thighFemoral nerveGenitofemoral nerveObturator nerveSubcostal nerve (T12)Iliohypogastric nerve (L1)Psoas major muscleIlio-inguinal nerve (L1)Lateral cutaneous nerve of thigh (L2,L3)Femoral nerve (L2 to L4)Genitofemoral nerve (L1,L2)Iliacus muscleObturator nerve (L2 to L4)Lumbosacral trunks(L4,L5) | [
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Anatomy_Gray_838 | Anatomy_Gray | Fig. 4.175 Cutaneous distribution of the nerves from the lumbar plexus. L1T12T12T12T11T11T10T10Ilio-inguinal nerve (L1)Ilio-inguinal nerve (L1)Genitofemoral nerve (L1,L2)Lateral cutaneous nerve of thigh (L2,L3)Obturator nerve (L2 to L4)Cutaneous branch of obturator nerve (L2 to L4)Femoral nerve (L2 to L4)Lateral cutaneous branchof iliohypogastric nerve (L1)Anterior cutaneous branchof iliohypogastric nerve (L1)Femoral branch of genitofemoral nerve (L1,L2)Lateral cutaneous nerve of thigh (L2,L3)Intermediate cutaneous from femoral nerveMedial cutaneous fromfemoral nerveSaphenous nerve from femoral nerve Fig. 4.176 Interior view of the abdominal region of a man. Palpable bony landmarks, the inguinal ligament, and the position of the diaphragm are indicated. Fig. 4.177 Groin. A. In a man. B. In a woman. C. Examination of the superficial inguinal ring and related regions of the inguinal canal in a man. | Anatomy_Gray. Fig. 4.175 Cutaneous distribution of the nerves from the lumbar plexus. L1T12T12T12T11T11T10T10Ilio-inguinal nerve (L1)Ilio-inguinal nerve (L1)Genitofemoral nerve (L1,L2)Lateral cutaneous nerve of thigh (L2,L3)Obturator nerve (L2 to L4)Cutaneous branch of obturator nerve (L2 to L4)Femoral nerve (L2 to L4)Lateral cutaneous branchof iliohypogastric nerve (L1)Anterior cutaneous branchof iliohypogastric nerve (L1)Femoral branch of genitofemoral nerve (L1,L2)Lateral cutaneous nerve of thigh (L2,L3)Intermediate cutaneous from femoral nerveMedial cutaneous fromfemoral nerveSaphenous nerve from femoral nerve Fig. 4.176 Interior view of the abdominal region of a man. Palpable bony landmarks, the inguinal ligament, and the position of the diaphragm are indicated. Fig. 4.177 Groin. A. In a man. B. In a woman. C. Examination of the superficial inguinal ring and related regions of the inguinal canal in a man. | [
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] |
Anatomy_Gray_839 | Anatomy_Gray | Fig. 4.177 Groin. A. In a man. B. In a woman. C. Examination of the superficial inguinal ring and related regions of the inguinal canal in a man. Deep inguinal ringAponeurosis of external obliqueAponeurosis of external obliqueSuperficial inguinal ringPosition of pubic symphysisABCAnterior superior iliac spineSpermatic cordInguinal ligamentFemoral arteryDeep inguinal ringSuperficial inguinal ringPosition of pubic symphysisAnterior superior iliac spineRound ligament of uterusInguinal ligamentFemoral artery Fig. 4.178 Landmarks used for establishing the positions of lumbar vertebrae are indicated. Anterior view of the abdominal region of a man. End of ninth costal cartilageLower edge of tenthcostal cartilageHighest point on iliac crestLILIILIIILIVLVPubic symphysisTubercle of crest of iliumJugular notchTranspyloric planeSubcostal planeSupracristal planeIntertubercular planeUmbilicus910 | Anatomy_Gray. Fig. 4.177 Groin. A. In a man. B. In a woman. C. Examination of the superficial inguinal ring and related regions of the inguinal canal in a man. Deep inguinal ringAponeurosis of external obliqueAponeurosis of external obliqueSuperficial inguinal ringPosition of pubic symphysisABCAnterior superior iliac spineSpermatic cordInguinal ligamentFemoral arteryDeep inguinal ringSuperficial inguinal ringPosition of pubic symphysisAnterior superior iliac spineRound ligament of uterusInguinal ligamentFemoral artery Fig. 4.178 Landmarks used for establishing the positions of lumbar vertebrae are indicated. Anterior view of the abdominal region of a man. End of ninth costal cartilageLower edge of tenthcostal cartilageHighest point on iliac crestLILIILIIILIVLVPubic symphysisTubercle of crest of iliumJugular notchTranspyloric planeSubcostal planeSupracristal planeIntertubercular planeUmbilicus910 | [
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Anatomy_Gray_840 | Anatomy_Gray | Fig. 4.179 LI vertebral level and the important viscera associated with this level. Anterior view of the abdominal region of a man. KidneyEnd of ninth costal cartilageLI9Pubic symphysisJugular notchDuodenumTranspyloric planeNeck of pancreasSuperior mesenteric artery Fig. 4.180 Major vessels projected onto the body’s surface. Anterior view of the abdominal region of a man. Upper border of LICeliac trunkAortaLower border of LISuperior mesenteric arteryLIII Inferior mesenteric arteryLIV Bifurcation of aortaLV Joining of common iliacveins to form the inferiorvena cavaLII Approximate originof renal arteryLITXIILIILIIILIVLVPubic symphysisJugular notchTranspyloric planeSubcostal planeSupracristal planeIntertubercular planeUmbilicusInferior vena cava910 Fig. 4.181 Abdominal quadrants and the positions of major viscera. Anterior view of a man. Fig. 4.182 The nine regions of the abdomen. Anterior view of a woman. | Anatomy_Gray. Fig. 4.179 LI vertebral level and the important viscera associated with this level. Anterior view of the abdominal region of a man. KidneyEnd of ninth costal cartilageLI9Pubic symphysisJugular notchDuodenumTranspyloric planeNeck of pancreasSuperior mesenteric artery Fig. 4.180 Major vessels projected onto the body’s surface. Anterior view of the abdominal region of a man. Upper border of LICeliac trunkAortaLower border of LISuperior mesenteric arteryLIII Inferior mesenteric arteryLIV Bifurcation of aortaLV Joining of common iliacveins to form the inferiorvena cavaLII Approximate originof renal arteryLITXIILIILIIILIVLVPubic symphysisJugular notchTranspyloric planeSubcostal planeSupracristal planeIntertubercular planeUmbilicusInferior vena cava910 Fig. 4.181 Abdominal quadrants and the positions of major viscera. Anterior view of a man. Fig. 4.182 The nine regions of the abdomen. Anterior view of a woman. | [
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Anatomy_Gray_841 | Anatomy_Gray | Fig. 4.181 Abdominal quadrants and the positions of major viscera. Anterior view of a man. Fig. 4.182 The nine regions of the abdomen. Anterior view of a woman. Fig. 4.183 Surface projection of the kidneys and ureters. Posterior view of the abdominal region of a woman. Fig. 4.184 Surface projection of the spleen. Posterior view of a man. eFig. 4.187 Transjugular liver biopsy needle in the right hepatic vein. Radiograph. eFig. 4.188 Subphrenic collection of pus and gas. Computed tomogram in the axial plane. Subphrenic collection of pus and gas eFig. 4.189 Position of a transjugular intrahepatic portosystemic shunt stent. Radiograph. eFig. 4.190 Functioning transjugular intrahepatic portosystemic shunt. Venogram. Fig. 4.185 Tumor in the head of the pancreas. Computed tomogram in the axial plane. eFig. 4.191 A computed tomogram, in the axial plane, of the pelvis demonstrates a loop of sigmoid colon with numerous diverticula and a large abscess in the pelvic cavity. | Anatomy_Gray. Fig. 4.181 Abdominal quadrants and the positions of major viscera. Anterior view of a man. Fig. 4.182 The nine regions of the abdomen. Anterior view of a woman. Fig. 4.183 Surface projection of the kidneys and ureters. Posterior view of the abdominal region of a woman. Fig. 4.184 Surface projection of the spleen. Posterior view of a man. eFig. 4.187 Transjugular liver biopsy needle in the right hepatic vein. Radiograph. eFig. 4.188 Subphrenic collection of pus and gas. Computed tomogram in the axial plane. Subphrenic collection of pus and gas eFig. 4.189 Position of a transjugular intrahepatic portosystemic shunt stent. Radiograph. eFig. 4.190 Functioning transjugular intrahepatic portosystemic shunt. Venogram. Fig. 4.185 Tumor in the head of the pancreas. Computed tomogram in the axial plane. eFig. 4.191 A computed tomogram, in the axial plane, of the pelvis demonstrates a loop of sigmoid colon with numerous diverticula and a large abscess in the pelvic cavity. | [
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] |
Anatomy_Gray_842 | Anatomy_Gray | eFig. 4.191 A computed tomogram, in the axial plane, of the pelvis demonstrates a loop of sigmoid colon with numerous diverticula and a large abscess in the pelvic cavity. Fig. 4.186 This postcontrast computed tomogram, in the axial plane, demonstrates two metastases situated within the right lobe of the liver. The left lobe of the liver is clear. The larger of the two metastases is situated to the right of the middle hepatic vein, which lies in the principal plane of the liver dividing the left and right sides of the liver. Table 4.1 Abdominal wall muscles Table 4.2 Posterior abdominal wall muscles Table 4.3 Branches of the abdominal aorta Table 4.4 Lymphatic drainage Table 4.5 Referred pain pathways (visceral afferents) Table 4.6 Branches of the lumbar plexus In the clinic | Anatomy_Gray. eFig. 4.191 A computed tomogram, in the axial plane, of the pelvis demonstrates a loop of sigmoid colon with numerous diverticula and a large abscess in the pelvic cavity. Fig. 4.186 This postcontrast computed tomogram, in the axial plane, demonstrates two metastases situated within the right lobe of the liver. The left lobe of the liver is clear. The larger of the two metastases is situated to the right of the middle hepatic vein, which lies in the principal plane of the liver dividing the left and right sides of the liver. Table 4.1 Abdominal wall muscles Table 4.2 Posterior abdominal wall muscles Table 4.3 Branches of the abdominal aorta Table 4.4 Lymphatic drainage Table 4.5 Referred pain pathways (visceral afferents) Table 4.6 Branches of the lumbar plexus In the clinic | [
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Anatomy_Gray_843 | Anatomy_Gray | Table 4.3 Branches of the abdominal aorta Table 4.4 Lymphatic drainage Table 4.5 Referred pain pathways (visceral afferents) Table 4.6 Branches of the lumbar plexus In the clinic Access to the abdomen and its contents is usually obtained through incisions in the anterior abdominal wall. Traditionally, incisions have been placed at and around the region of surgical interest. The size of these incisions was usually large to allow good access and optimal visualization of the abdominal cavity. As anesthesia has developed and muscle-relaxing drugs have become widely used, the abdominal incisions have become smaller. Currently, the most commonly used large abdominal incision is a central craniocaudad incision from the xiphoid process to the symphysis pubis, which provides wide access to the whole of the abdominal contents and allows an exploratory procedure to be performed (laparotomy). In the clinic | Anatomy_Gray. Table 4.3 Branches of the abdominal aorta Table 4.4 Lymphatic drainage Table 4.5 Referred pain pathways (visceral afferents) Table 4.6 Branches of the lumbar plexus In the clinic Access to the abdomen and its contents is usually obtained through incisions in the anterior abdominal wall. Traditionally, incisions have been placed at and around the region of surgical interest. The size of these incisions was usually large to allow good access and optimal visualization of the abdominal cavity. As anesthesia has developed and muscle-relaxing drugs have become widely used, the abdominal incisions have become smaller. Currently, the most commonly used large abdominal incision is a central craniocaudad incision from the xiphoid process to the symphysis pubis, which provides wide access to the whole of the abdominal contents and allows an exploratory procedure to be performed (laparotomy). In the clinic | [
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Anatomy_Gray_844 | Anatomy_Gray | In the clinic Laparoscopic surgery, also known as minimally invasive or keyhole surgery, is performed by operating through a series of small incisions no more than 1 to 2 cm in length. As the incisions are much smaller than those used in traditional abdominal surgery, patients experience less postoperative pain and have shorter recovery times. There is also a favorable cosmetic outcome with smaller scars. Several surgical procedures such as appendectomy, cholecystectomy, and hernia repair, as well as numerous orthopaedic, urological, and gynecological procedures, are now commonly performed laparoscopically. | Anatomy_Gray. In the clinic Laparoscopic surgery, also known as minimally invasive or keyhole surgery, is performed by operating through a series of small incisions no more than 1 to 2 cm in length. As the incisions are much smaller than those used in traditional abdominal surgery, patients experience less postoperative pain and have shorter recovery times. There is also a favorable cosmetic outcome with smaller scars. Several surgical procedures such as appendectomy, cholecystectomy, and hernia repair, as well as numerous orthopaedic, urological, and gynecological procedures, are now commonly performed laparoscopically. | [
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Anatomy_Gray_845 | Anatomy_Gray | During the operation, a camera known as a laparoscope is used to transmit live, magnified images of the surgical field to a monitor viewed by the surgeon. The camera is inserted into the abdominal cavity through a small incision, called a port-site, usually at the umbilicus. In order to create enough space to operate, the abdominal wall is elevated by inflating the cavity with gas, typically carbon dioxide. Other long, thin surgical instruments are then introduced through additional port-sites, which can be used by the surgeon to operate. The placement of these port-sites is carefully planned to allow optimal access to the surgical field. | Anatomy_Gray. During the operation, a camera known as a laparoscope is used to transmit live, magnified images of the surgical field to a monitor viewed by the surgeon. The camera is inserted into the abdominal cavity through a small incision, called a port-site, usually at the umbilicus. In order to create enough space to operate, the abdominal wall is elevated by inflating the cavity with gas, typically carbon dioxide. Other long, thin surgical instruments are then introduced through additional port-sites, which can be used by the surgeon to operate. The placement of these port-sites is carefully planned to allow optimal access to the surgical field. | [
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Anatomy_Gray_846 | Anatomy_Gray | Laparoscopic surgery has been further enhanced with the use of surgical robots. Using these systems the surgeon moves the surgical instruments indirectly by controlling robotic arms, which are inserted into the operating field through small incisions. Robot-assisted surgery is now routinely used worldwide and has helped overcome some of the limitations of laparoscopy by enhancing the surgeon’s dexterity. The robotic system is precise, provides the surgeon with a 3D view of the surgical field, and allows improved degree of rotation and manipulation of the surgical instruments. Several procedures such as prostatectomy and cholecystectomy can now be performed with this method. | Anatomy_Gray. Laparoscopic surgery has been further enhanced with the use of surgical robots. Using these systems the surgeon moves the surgical instruments indirectly by controlling robotic arms, which are inserted into the operating field through small incisions. Robot-assisted surgery is now routinely used worldwide and has helped overcome some of the limitations of laparoscopy by enhancing the surgeon’s dexterity. The robotic system is precise, provides the surgeon with a 3D view of the surgical field, and allows improved degree of rotation and manipulation of the surgical instruments. Several procedures such as prostatectomy and cholecystectomy can now be performed with this method. | [
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Anatomy_Gray_847 | Anatomy_Gray | Laparoendoscopic single-site surgery, also known as single-port laparoscopy, is the most recent advance in laparoscopic surgery. This method uses a single incision, usually umbilical, to introduce a port with several operating channels and can be performed with or without robotic assistance. Benefits include less postoperative pain, a faster recovery time, and an even better cosmetic result than traditional laparoscopic surgery. In the clinic | Anatomy_Gray. Laparoendoscopic single-site surgery, also known as single-port laparoscopy, is the most recent advance in laparoscopic surgery. This method uses a single incision, usually umbilical, to introduce a port with several operating channels and can be performed with or without robotic assistance. Benefits include less postoperative pain, a faster recovery time, and an even better cosmetic result than traditional laparoscopic surgery. In the clinic | [
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Anatomy_Gray_848 | Anatomy_Gray | In the clinic In men, the cremaster muscle and cremasteric fascia form the middle or second covering of the spermatic cord. This muscle and its associated fascia are supplied by the genital branch of the genitofemoral nerve (L1/L2). Contraction of this muscle and the resulting elevation of the testis can be stimulated by a reflex arc. Gently touching the skin at and around the anterior aspect of the superior part of the thigh stimulates the sensory fibers in the ilio-inguinal nerve. These sensory fibers enter the spinal cord at level L1. At this level, the sensory fibers stimulate the motor fibers carried in the genital branch of the genitofemoral nerve, which results in contraction of the cremaster muscle and elevation of the testis. | Anatomy_Gray. In the clinic In men, the cremaster muscle and cremasteric fascia form the middle or second covering of the spermatic cord. This muscle and its associated fascia are supplied by the genital branch of the genitofemoral nerve (L1/L2). Contraction of this muscle and the resulting elevation of the testis can be stimulated by a reflex arc. Gently touching the skin at and around the anterior aspect of the superior part of the thigh stimulates the sensory fibers in the ilio-inguinal nerve. These sensory fibers enter the spinal cord at level L1. At this level, the sensory fibers stimulate the motor fibers carried in the genital branch of the genitofemoral nerve, which results in contraction of the cremaster muscle and elevation of the testis. | [
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Anatomy_Gray_849 | Anatomy_Gray | The cremasteric reflex is more active in children, tending to diminish with age. As with many reflexes, it may be absent in certain neurological disorders. Although it can be used for testing spinal cord function at level L1 in men, its clinical use is limited. In the clinic Masses around the groin Around the groin there is a complex confluence of anatomical structures. Careful examination and good anatomical knowledge allow determination of the correct anatomical structure from which the mass arises and therefore the diagnosis. The most common masses in the groin are hernias. The key to groin examination is determining the position of the inguinal ligament. The inguinal ligament passes between the anterior superior iliac spine laterally and the pubic tubercle medially. Inguinal hernias are above the inguinal ligament and are usually more apparent on standing. A visual assessment of the lump is necessary, bearing in mind the anatomical landmarks of the inguinal ligament. | Anatomy_Gray. The cremasteric reflex is more active in children, tending to diminish with age. As with many reflexes, it may be absent in certain neurological disorders. Although it can be used for testing spinal cord function at level L1 in men, its clinical use is limited. In the clinic Masses around the groin Around the groin there is a complex confluence of anatomical structures. Careful examination and good anatomical knowledge allow determination of the correct anatomical structure from which the mass arises and therefore the diagnosis. The most common masses in the groin are hernias. The key to groin examination is determining the position of the inguinal ligament. The inguinal ligament passes between the anterior superior iliac spine laterally and the pubic tubercle medially. Inguinal hernias are above the inguinal ligament and are usually more apparent on standing. A visual assessment of the lump is necessary, bearing in mind the anatomical landmarks of the inguinal ligament. | [
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Anatomy_Gray_850 | Anatomy_Gray | In men, it is wise to examine the scrotum to check for a lump. If an abnormal mass is present, an inability to feel its upper edge suggests that it may originate from the inguinal canal and might be a hernia. By placing the hand over the lump and asking the patient to cough, the lump bulges outward. An attempt should be made to reduce the swelling by applying gentle, firm pressure over the lump. If the lump is reducible, the hand should be withdrawn and careful observation will reveal recurrence of the mass. The position of an abnormal mass in the groin relative to the pubic tubercle is very important, as are the presence of increased temperature and pain, which may represent early signs of strangulation or infection. As a general rule: An inguinal hernia appears through the superficial inguinal ring above the pubic tubercle and crest. A femoral hernia (see below) appears through the femoral canal below and lateral to the pubic tubercle. | Anatomy_Gray. In men, it is wise to examine the scrotum to check for a lump. If an abnormal mass is present, an inability to feel its upper edge suggests that it may originate from the inguinal canal and might be a hernia. By placing the hand over the lump and asking the patient to cough, the lump bulges outward. An attempt should be made to reduce the swelling by applying gentle, firm pressure over the lump. If the lump is reducible, the hand should be withdrawn and careful observation will reveal recurrence of the mass. The position of an abnormal mass in the groin relative to the pubic tubercle is very important, as are the presence of increased temperature and pain, which may represent early signs of strangulation or infection. As a general rule: An inguinal hernia appears through the superficial inguinal ring above the pubic tubercle and crest. A femoral hernia (see below) appears through the femoral canal below and lateral to the pubic tubercle. | [
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Anatomy_Gray_851 | Anatomy_Gray | A femoral hernia (see below) appears through the femoral canal below and lateral to the pubic tubercle. A hernia is the protrusion of a viscus, in part or in whole, through a normal or abnormal opening. The viscus usually carries a covering of parietal peritoneum, which forms the lining of the hernial sac. Hernias occur in a variety of regions. The commonest site is the groin of the lower anterior abdominal wall. In some patients, inguinal hernias are present from birth (congenital) and are caused by the persistence of the processus vaginalis and the passage of viscera through the inguinal canal. Acquired hernias occur in older patients and causes include raised intraabdominal pressure (e.g., from repeated coughing associated with lung disease), damage to nerves of the anterior abdominal wall (e.g., from surgical abdominal incisions), and weakening of the walls of the inguinal canal. | Anatomy_Gray. A femoral hernia (see below) appears through the femoral canal below and lateral to the pubic tubercle. A hernia is the protrusion of a viscus, in part or in whole, through a normal or abnormal opening. The viscus usually carries a covering of parietal peritoneum, which forms the lining of the hernial sac. Hernias occur in a variety of regions. The commonest site is the groin of the lower anterior abdominal wall. In some patients, inguinal hernias are present from birth (congenital) and are caused by the persistence of the processus vaginalis and the passage of viscera through the inguinal canal. Acquired hernias occur in older patients and causes include raised intraabdominal pressure (e.g., from repeated coughing associated with lung disease), damage to nerves of the anterior abdominal wall (e.g., from surgical abdominal incisions), and weakening of the walls of the inguinal canal. | [
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Anatomy_Gray_852 | Anatomy_Gray | One of the potential problems with hernias is that bowel and fat may become stuck within the hernial sac. This can cause appreciable pain and bowel obstruction, necessitating urgent surgery. Another potential risk is strangulation of the hernia, in which the blood supply to the bowel is cut off at the neck of the hernial sac, rendering the bowel ischemic and susceptible to perforation (Fig. 4.51). The hernial sac of an indirect inguinal hernia enters the deep inguinal ring and passes through the inguinal canal. If the hernia is large enough, the hernial sac may emerge through the superficial inguinal ring. In men, such a hernia may extend into the scrotum (Fig. 4.52). The hernial sac of a direct inguinal hernia pushes forward through the posterior wall of the inguinal canal immediately posterior to the superficial inguinal ring. The hernia protrudes directly forward medial to the inferior epigastric vessels and through the superficial inguinal ring. | Anatomy_Gray. One of the potential problems with hernias is that bowel and fat may become stuck within the hernial sac. This can cause appreciable pain and bowel obstruction, necessitating urgent surgery. Another potential risk is strangulation of the hernia, in which the blood supply to the bowel is cut off at the neck of the hernial sac, rendering the bowel ischemic and susceptible to perforation (Fig. 4.51). The hernial sac of an indirect inguinal hernia enters the deep inguinal ring and passes through the inguinal canal. If the hernia is large enough, the hernial sac may emerge through the superficial inguinal ring. In men, such a hernia may extend into the scrotum (Fig. 4.52). The hernial sac of a direct inguinal hernia pushes forward through the posterior wall of the inguinal canal immediately posterior to the superficial inguinal ring. The hernia protrudes directly forward medial to the inferior epigastric vessels and through the superficial inguinal ring. | [
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Anatomy_Gray_853 | Anatomy_Gray | The differentiation between an indirect and a direct inguinal hernia is made during surgery when the inferior epigastric vessels are identified at the medial edge of the deep internal ring: An indirect hernial sac passes lateral to the inferior epigastric vessels. A direct hernia is medial to the inferior epigastric vessels. Inguinal hernias occur more commonly in men than in women possibly because men have a much larger inguinal canal than women. | Anatomy_Gray. The differentiation between an indirect and a direct inguinal hernia is made during surgery when the inferior epigastric vessels are identified at the medial edge of the deep internal ring: An indirect hernial sac passes lateral to the inferior epigastric vessels. A direct hernia is medial to the inferior epigastric vessels. Inguinal hernias occur more commonly in men than in women possibly because men have a much larger inguinal canal than women. | [
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Anatomy_Gray_854 | Anatomy_Gray | A direct hernia is medial to the inferior epigastric vessels. Inguinal hernias occur more commonly in men than in women possibly because men have a much larger inguinal canal than women. A femoral hernia passes through the femoral canal and into the medial aspect of the anterior thigh. The femoral canal lies at the medial edge of the femoral sheath, which contains the femoral artery, femoral vein, and lymphatics. The neck of the femoral canal is extremely narrow and is prone to trapping bowel within the sac, so making this type of hernia irreducible and susceptible to bowel strangulation. Femoral hernias are usually acquired, are not congenital, and most commonly occur in middle-aged and elderly populations. In addition, because women generally have wider pelvises than men, they tend to occur more commonly in women. | Anatomy_Gray. A direct hernia is medial to the inferior epigastric vessels. Inguinal hernias occur more commonly in men than in women possibly because men have a much larger inguinal canal than women. A femoral hernia passes through the femoral canal and into the medial aspect of the anterior thigh. The femoral canal lies at the medial edge of the femoral sheath, which contains the femoral artery, femoral vein, and lymphatics. The neck of the femoral canal is extremely narrow and is prone to trapping bowel within the sac, so making this type of hernia irreducible and susceptible to bowel strangulation. Femoral hernias are usually acquired, are not congenital, and most commonly occur in middle-aged and elderly populations. In addition, because women generally have wider pelvises than men, they tend to occur more commonly in women. | [
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Anatomy_Gray_855 | Anatomy_Gray | The groin can loosely be defined as the area where the leg meets the trunk near the midline. Here the abdominal muscles of the trunk blend in with the adductor muscles of the thigh, the medial end of the inguinal ligament attaches to the pubic tubercle, the pubic symphysis attaches the two pubic bones together, and the superficial (external) inguinal ring occurs. It also is in and around this region where there is considerable translation of force during most athletic and sporting activities. Pain in the groin or pubic region can be due to numerous causes, which include inflammatory changes at the pubic symphysis, insertional problems of the rectus abdominis/adductor longus, and hernias. | Anatomy_Gray. The groin can loosely be defined as the area where the leg meets the trunk near the midline. Here the abdominal muscles of the trunk blend in with the adductor muscles of the thigh, the medial end of the inguinal ligament attaches to the pubic tubercle, the pubic symphysis attaches the two pubic bones together, and the superficial (external) inguinal ring occurs. It also is in and around this region where there is considerable translation of force during most athletic and sporting activities. Pain in the groin or pubic region can be due to numerous causes, which include inflammatory changes at the pubic symphysis, insertional problems of the rectus abdominis/adductor longus, and hernias. | [
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Anatomy_Gray_856 | Anatomy_Gray | Umbilical hernias are rare. Occasionally, they are congenital and result from failure of the small bowel to return to the abdominal cavity from the umbilical cord during development. After birth, umbilical hernias may result from incomplete closure of the umbilicus (navel). Overall, most of these hernias close in the first year of life, and surgical repair is not generally attempted until later. Para-umbilical hernias may occur in adults at and around the umbilicus and often have small necks, so requiring surgical treatment. Incisional hernias occur through a defect in a scar of a previous abdominal operation. Usually, the necks of these hernias are wide and do not therefore strangulate the viscera they contain. A spigelian hernia passes upward through the arcuate line into the lateral border at the lower part of the posterior rectus sheath. It may appear as a tender mass on one side of the lower anterior abdominal wall. | Anatomy_Gray. Umbilical hernias are rare. Occasionally, they are congenital and result from failure of the small bowel to return to the abdominal cavity from the umbilical cord during development. After birth, umbilical hernias may result from incomplete closure of the umbilicus (navel). Overall, most of these hernias close in the first year of life, and surgical repair is not generally attempted until later. Para-umbilical hernias may occur in adults at and around the umbilicus and often have small necks, so requiring surgical treatment. Incisional hernias occur through a defect in a scar of a previous abdominal operation. Usually, the necks of these hernias are wide and do not therefore strangulate the viscera they contain. A spigelian hernia passes upward through the arcuate line into the lateral border at the lower part of the posterior rectus sheath. It may appear as a tender mass on one side of the lower anterior abdominal wall. | [
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Anatomy_Gray_857 | Anatomy_Gray | Abdominopelvic cavity hernias can also develop in association with the pelvic walls, and sites include the obturator canal, the greater sciatic foramen and above and below the piriformis muscle. In the clinic A small volume of peritoneal fluid within the peritoneal cavity lubricates movement of the viscera suspended in the abdominal cavity. It is not detectable on any available imaging such as ultrasound or computed tomography. In various pathological conditions (e.g., in liver cirrhosis, acute pancreatitis, or heart failure) the volume of peritoneal fluid can increase; this is known as ascites. In cases of high volume of free intraperitoneal fluid, marked abdominal distention can be observed (Fig. 4.56). The peritoneal space has a large surface area, which facilitates the spread of disease through the peritoneal cavity and over the bowel and visceral surfaces. Conversely, this large surface area can be used for administering certain types of treatment and a number of procedures. | Anatomy_Gray. Abdominopelvic cavity hernias can also develop in association with the pelvic walls, and sites include the obturator canal, the greater sciatic foramen and above and below the piriformis muscle. In the clinic A small volume of peritoneal fluid within the peritoneal cavity lubricates movement of the viscera suspended in the abdominal cavity. It is not detectable on any available imaging such as ultrasound or computed tomography. In various pathological conditions (e.g., in liver cirrhosis, acute pancreatitis, or heart failure) the volume of peritoneal fluid can increase; this is known as ascites. In cases of high volume of free intraperitoneal fluid, marked abdominal distention can be observed (Fig. 4.56). The peritoneal space has a large surface area, which facilitates the spread of disease through the peritoneal cavity and over the bowel and visceral surfaces. Conversely, this large surface area can be used for administering certain types of treatment and a number of procedures. | [
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Anatomy_Gray_858 | Anatomy_Gray | Patients with obstructive hydrocephalus (an excessive accumulation of cerebrospinal fluid within the cerebral ventricular system) require continuous drainage of this fluid. This is achieved by placing a fine-bore catheter through the skull into the cerebral ventricles and placing the extracranial part of the tube beneath the scalp and skin of the neck and chest wall, and then through the abdominal wall into the peritoneal cavity. Cerebrospinal fluid drains through the tube into the peritoneal cavity, where it is absorbed. People who develop renal failure require dialysis to live. There are two methods. | Anatomy_Gray. Patients with obstructive hydrocephalus (an excessive accumulation of cerebrospinal fluid within the cerebral ventricular system) require continuous drainage of this fluid. This is achieved by placing a fine-bore catheter through the skull into the cerebral ventricles and placing the extracranial part of the tube beneath the scalp and skin of the neck and chest wall, and then through the abdominal wall into the peritoneal cavity. Cerebrospinal fluid drains through the tube into the peritoneal cavity, where it is absorbed. People who develop renal failure require dialysis to live. There are two methods. | [
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Anatomy_Gray_859 | Anatomy_Gray | People who develop renal failure require dialysis to live. There are two methods. In the first method (hemodialysis), blood is taken from the circulation, dialyzed through a complex artificial membrane, and returned to the body. A high rate of blood flow is required to remove excess body fluid, exchange electrolytes, and remove noxious metabolites. To accomplish this, either an arteriovenous fistula is established surgically (by connecting an artery to a vein, usually in the upper limb, and requiring approximately six weeks to “mature”) and is cannulated each time the patient returns for dialysis, or a large-bore cannula is placed into the right atrium, through which blood can be aspirated and returned. | Anatomy_Gray. People who develop renal failure require dialysis to live. There are two methods. In the first method (hemodialysis), blood is taken from the circulation, dialyzed through a complex artificial membrane, and returned to the body. A high rate of blood flow is required to remove excess body fluid, exchange electrolytes, and remove noxious metabolites. To accomplish this, either an arteriovenous fistula is established surgically (by connecting an artery to a vein, usually in the upper limb, and requiring approximately six weeks to “mature”) and is cannulated each time the patient returns for dialysis, or a large-bore cannula is placed into the right atrium, through which blood can be aspirated and returned. | [
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Anatomy_Gray_860 | Anatomy_Gray | In the second method (peritoneal dialysis), the peritoneum is used as the dialysis membrane. The large surface area of the peritoneal cavity is an ideal dialysis membrane for fluid and electrolyte exchange. To accomplish dialysis, a small tube is inserted through the abdominal wall and dialysis fluid is injected into the peritoneal cavity. Electrolytes and molecules are exchanged across the peritoneum between the fluid and blood. Once dialysis is completed, the fluid is drained. Peritoneal spread of disease | Anatomy_Gray. In the second method (peritoneal dialysis), the peritoneum is used as the dialysis membrane. The large surface area of the peritoneal cavity is an ideal dialysis membrane for fluid and electrolyte exchange. To accomplish dialysis, a small tube is inserted through the abdominal wall and dialysis fluid is injected into the peritoneal cavity. Electrolytes and molecules are exchanged across the peritoneum between the fluid and blood. Once dialysis is completed, the fluid is drained. Peritoneal spread of disease | [
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Anatomy_Gray_861 | Anatomy_Gray | Peritoneal spread of disease The large surface area of the peritoneal cavity allows infection and malignant disease to spread easily throughout the abdomen (Fig. 4.57). If malignant cells enter the peritoneal cavity by direct invasion (e.g., from colon or ovarian cancer), spread may be rapid. Similarly, a surgeon excising a malignant tumor and releasing malignant cells into the peritoneal cavity may cause an appreciable worsening of the patient’s prognosis. Infection can also spread across the large surface area. The peritoneal cavity can also act as a barrier to, and container of, disease. Intraabdominal infection therefore tends to remain below the diaphragm rather than spread into other body cavities. | Anatomy_Gray. Peritoneal spread of disease The large surface area of the peritoneal cavity allows infection and malignant disease to spread easily throughout the abdomen (Fig. 4.57). If malignant cells enter the peritoneal cavity by direct invasion (e.g., from colon or ovarian cancer), spread may be rapid. Similarly, a surgeon excising a malignant tumor and releasing malignant cells into the peritoneal cavity may cause an appreciable worsening of the patient’s prognosis. Infection can also spread across the large surface area. The peritoneal cavity can also act as a barrier to, and container of, disease. Intraabdominal infection therefore tends to remain below the diaphragm rather than spread into other body cavities. | [
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Anatomy_Gray_862 | Anatomy_Gray | The peritoneal cavity can also act as a barrier to, and container of, disease. Intraabdominal infection therefore tends to remain below the diaphragm rather than spread into other body cavities. A perforated bowel (e.g., caused by a perforated duodenal ulcer) often leads to the release of gas into the peritoneal cavity. This peritoneal gas can be easily visualized on an erect chest radiograph—gas can be demonstrated in extremely small amounts beneath the diaphragm. A patient with severe abdominal pain and subdiaphragmatic gas needs a laparotomy (Fig. 4.58). In the clinic The greater omentum | Anatomy_Gray. The peritoneal cavity can also act as a barrier to, and container of, disease. Intraabdominal infection therefore tends to remain below the diaphragm rather than spread into other body cavities. A perforated bowel (e.g., caused by a perforated duodenal ulcer) often leads to the release of gas into the peritoneal cavity. This peritoneal gas can be easily visualized on an erect chest radiograph—gas can be demonstrated in extremely small amounts beneath the diaphragm. A patient with severe abdominal pain and subdiaphragmatic gas needs a laparotomy (Fig. 4.58). In the clinic The greater omentum | [
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Anatomy_Gray_863 | Anatomy_Gray | In the clinic The greater omentum When a laparotomy is performed and the peritoneal cavity is opened, the first structure usually encountered is the greater omentum. This fatty double-layered vascular membrane hangs like an apron from the greater curvature of the stomach, drapes over the transverse colon, and lies freely suspended within the abdominal cavity. It is often referred to as the “policeman of the abdomen” because of its apparent ability to migrate to any inflamed area and wrap itself around the organ to wall off inflammation. When a part of bowel becomes inflamed, it ceases peristalsis. This aperistaltic area is referred to as a local paralytic ileus. The remaining noninflamed part of the bowel continues to move and “massages” the greater omentum to the region where there is no peristalsis. The localized inflammatory reaction spreads to the greater omentum, which then adheres to the diseased area of bowel. | Anatomy_Gray. In the clinic The greater omentum When a laparotomy is performed and the peritoneal cavity is opened, the first structure usually encountered is the greater omentum. This fatty double-layered vascular membrane hangs like an apron from the greater curvature of the stomach, drapes over the transverse colon, and lies freely suspended within the abdominal cavity. It is often referred to as the “policeman of the abdomen” because of its apparent ability to migrate to any inflamed area and wrap itself around the organ to wall off inflammation. When a part of bowel becomes inflamed, it ceases peristalsis. This aperistaltic area is referred to as a local paralytic ileus. The remaining noninflamed part of the bowel continues to move and “massages” the greater omentum to the region where there is no peristalsis. The localized inflammatory reaction spreads to the greater omentum, which then adheres to the diseased area of bowel. | [
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Anatomy_Gray_864 | Anatomy_Gray | The greater omentum is also an important site for metastatic tumor spread. Direct omental spread by a transcoelomic route is common for carcinoma of the ovary. As the metastases develop within the greater omentum, it becomes significantly thickened. In computed tomography imaging and during laparotomy, the thickened omentum is referred to as an “omental cake.” In the clinic Epithelial transition between the abdominal esophagus and stomach | Anatomy_Gray. The greater omentum is also an important site for metastatic tumor spread. Direct omental spread by a transcoelomic route is common for carcinoma of the ovary. As the metastases develop within the greater omentum, it becomes significantly thickened. In computed tomography imaging and during laparotomy, the thickened omentum is referred to as an “omental cake.” In the clinic Epithelial transition between the abdominal esophagus and stomach | [
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Anatomy_Gray_865 | Anatomy_Gray | In the clinic Epithelial transition between the abdominal esophagus and stomach The gastroesophageal junction is demarcated by a transition from one epithelial type (nonkeratinized stratified squamous epithelium) to another epithelial type (columnar epithelium). In some people, the histological junction does not lie at the anatomical gastroesophageal junction but occurs more proximally in the lower third of the esophagus. This may predispose these people to esophageal ulceration and is also associated with an increased risk of adenocarcinoma. In certain conditions, like gastroesophageal reflux, the stratified squamous epithelium in the esophagus can undergo metaplasia and the epithelium in the lower esophagus is replaced by columnar epithelium, a condition called Barrett’s esophagus. The presence of Barrett’s esophagus predisposes these people to the development of esophageal malignancy (adenocarcinoma). In the clinic | Anatomy_Gray. In the clinic Epithelial transition between the abdominal esophagus and stomach The gastroesophageal junction is demarcated by a transition from one epithelial type (nonkeratinized stratified squamous epithelium) to another epithelial type (columnar epithelium). In some people, the histological junction does not lie at the anatomical gastroesophageal junction but occurs more proximally in the lower third of the esophagus. This may predispose these people to esophageal ulceration and is also associated with an increased risk of adenocarcinoma. In certain conditions, like gastroesophageal reflux, the stratified squamous epithelium in the esophagus can undergo metaplasia and the epithelium in the lower esophagus is replaced by columnar epithelium, a condition called Barrett’s esophagus. The presence of Barrett’s esophagus predisposes these people to the development of esophageal malignancy (adenocarcinoma). In the clinic | [
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Anatomy_Gray_866 | Anatomy_Gray | Duodenal ulcers usually occur in the superior part of the duodenum and are much less common than they were 50 years ago. At first, there was no treatment and patients died from hemorrhage or peritonitis. As surgical techniques developed, patients with duodenal ulcers were subjected to extensive upper gastrointestinal surgery to prevent ulcer recurrence and for some patients the treatment was dangerous. As knowledge and understanding of the mechanisms for acid secretion in the stomach increased, drugs were developed to block acid stimulation and secretion indirectly (histamine H2-receptor antagonists) and these have significantly reduced the morbidity and mortality rates of this disease. Pharmacological therapy can now directly inhibit the cells of the stomach that produce acid with, for example, proton pump inhibitors. Patients are also screened for the bacteria Helicobacter pylori, which when eradicated (by antibiotic treatment) significantly reduces duodenal ulcer formation. | Anatomy_Gray. Duodenal ulcers usually occur in the superior part of the duodenum and are much less common than they were 50 years ago. At first, there was no treatment and patients died from hemorrhage or peritonitis. As surgical techniques developed, patients with duodenal ulcers were subjected to extensive upper gastrointestinal surgery to prevent ulcer recurrence and for some patients the treatment was dangerous. As knowledge and understanding of the mechanisms for acid secretion in the stomach increased, drugs were developed to block acid stimulation and secretion indirectly (histamine H2-receptor antagonists) and these have significantly reduced the morbidity and mortality rates of this disease. Pharmacological therapy can now directly inhibit the cells of the stomach that produce acid with, for example, proton pump inhibitors. Patients are also screened for the bacteria Helicobacter pylori, which when eradicated (by antibiotic treatment) significantly reduces duodenal ulcer formation. | [
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Anatomy_Gray_867 | Anatomy_Gray | Anatomically, duodenal ulcers tend to occur either anteriorly or posteriorly. Posterior duodenal ulcers erode either directly onto the gastroduodenal artery or, more commonly, onto the posterior superior pancreaticoduodenal artery, which can produce torrential hemorrhage, which may be fatal in some patients. Treatment may involve extensive upper abdominal surgery with ligation of the vessels or by endovascular means whereby the radiologist may place a very fine catheter retrogradely from the femoral artery into the celiac artery. The common hepatic artery and the gastroduodenal artery are cannulated and the bleeding area may be blocked using small coils, which stem the flow of blood. | Anatomy_Gray. Anatomically, duodenal ulcers tend to occur either anteriorly or posteriorly. Posterior duodenal ulcers erode either directly onto the gastroduodenal artery or, more commonly, onto the posterior superior pancreaticoduodenal artery, which can produce torrential hemorrhage, which may be fatal in some patients. Treatment may involve extensive upper abdominal surgery with ligation of the vessels or by endovascular means whereby the radiologist may place a very fine catheter retrogradely from the femoral artery into the celiac artery. The common hepatic artery and the gastroduodenal artery are cannulated and the bleeding area may be blocked using small coils, which stem the flow of blood. | [
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Anatomy_Gray_868 | Anatomy_Gray | Anterior duodenal ulcers erode into the peritoneal cavity, causing peritonitis. This intense inflammatory reaction and the local ileus promote adhesion of the greater omentum, which attempts to seal off the perforation. The stomach and duodenum usually contain considerable amounts of gas, which enters the peritoneal cavity and can be observed on a chest radiograph of an erect patient as subdiaphragmatic gas. In most instances, treatment for the ulcer perforation is surgical. In the clinic Examination of the upper and lower It is often necessary to examine the esophagus, stomach, duodenum, proximal jejunum, and colon for disease. After taking an appropriate history and examining the patient, most physicians arrange a series of simple blood tests to look for bleeding, inflammation, and tumors. The next steps in the investigation assess the three components of any loop of bowel, namely, the lumen, the wall, and masses extrinsic to the bowel, which may compress or erode into it. | Anatomy_Gray. Anterior duodenal ulcers erode into the peritoneal cavity, causing peritonitis. This intense inflammatory reaction and the local ileus promote adhesion of the greater omentum, which attempts to seal off the perforation. The stomach and duodenum usually contain considerable amounts of gas, which enters the peritoneal cavity and can be observed on a chest radiograph of an erect patient as subdiaphragmatic gas. In most instances, treatment for the ulcer perforation is surgical. In the clinic Examination of the upper and lower It is often necessary to examine the esophagus, stomach, duodenum, proximal jejunum, and colon for disease. After taking an appropriate history and examining the patient, most physicians arrange a series of simple blood tests to look for bleeding, inflammation, and tumors. The next steps in the investigation assess the three components of any loop of bowel, namely, the lumen, the wall, and masses extrinsic to the bowel, which may compress or erode into it. | [
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Anatomy_Gray_869 | Anatomy_Gray | Examination of the bowel lumen Barium sulfate solutions may be swallowed by the patient and can be visualized using an X-ray fluoroscopy unit. The lumen can be examined for masses (e.g., polyps and tumors) and peristaltic waves can be assessed. Patients may also be given carbon dioxide–releasing granules to fill the stomach so that the barium thinly coats the mucosa, resulting in images displaying fine mucosal detail. These tests are relatively simple and can be used to image the esophagus, stomach, duodenum, and small bowel. For imaging the large bowel, a barium enema can be used to introduce barium sulfate into the colon. Colonoscopy and CT colonography are also used. Examination of the bowel wall and extrinsic masses | Anatomy_Gray. Examination of the bowel lumen Barium sulfate solutions may be swallowed by the patient and can be visualized using an X-ray fluoroscopy unit. The lumen can be examined for masses (e.g., polyps and tumors) and peristaltic waves can be assessed. Patients may also be given carbon dioxide–releasing granules to fill the stomach so that the barium thinly coats the mucosa, resulting in images displaying fine mucosal detail. These tests are relatively simple and can be used to image the esophagus, stomach, duodenum, and small bowel. For imaging the large bowel, a barium enema can be used to introduce barium sulfate into the colon. Colonoscopy and CT colonography are also used. Examination of the bowel wall and extrinsic masses | [
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Anatomy_Gray_870 | Anatomy_Gray | Examination of the bowel wall and extrinsic masses Endoscopy is a minimally invasive diagnostic medical procedure that can be used to assess the interior surfaces of an organ by inserting a tube into the body. The instrument is typically made of a flexible plastic material through which a light source and eyepiece are attached at one end. The images are then projected to a monitor. Some systems allow passage of small instruments through the main bore of the endoscope to obtain biopsies and to also undertake small procedures (e.g., the removal of polyps). In gastrointestinal and abdominal medicine an endoscope is used to assess the esophagus, stomach, duodenum, and proximal small bowel (Figs. 4.72 to 4.75). The tube is swallowed by the patient under light sedation and is extremely well tolerated. | Anatomy_Gray. Examination of the bowel wall and extrinsic masses Endoscopy is a minimally invasive diagnostic medical procedure that can be used to assess the interior surfaces of an organ by inserting a tube into the body. The instrument is typically made of a flexible plastic material through which a light source and eyepiece are attached at one end. The images are then projected to a monitor. Some systems allow passage of small instruments through the main bore of the endoscope to obtain biopsies and to also undertake small procedures (e.g., the removal of polyps). In gastrointestinal and abdominal medicine an endoscope is used to assess the esophagus, stomach, duodenum, and proximal small bowel (Figs. 4.72 to 4.75). The tube is swallowed by the patient under light sedation and is extremely well tolerated. | [
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Anatomy_Gray_871 | Anatomy_Gray | Assessment of the colon (colonoscopy) is performed by passage of the long flexible tube through the anus and into the rectum. The endoscope is then advanced into the colon to the cecum and sometimes to the terminal ileum. The patient undergoes bowel preparation before the examination to allow good visualization of the entire large bowel. Specially designed solutions are taken orally to help clear the bowel of fecal material. Air, water, and suction may be used during the examination to improve visualization. Biopsies, polyp removal, cauterization of bleeding, and stent placement can also be performed using additional instruments that can be passed through special openings in the colonoscope. | Anatomy_Gray. Assessment of the colon (colonoscopy) is performed by passage of the long flexible tube through the anus and into the rectum. The endoscope is then advanced into the colon to the cecum and sometimes to the terminal ileum. The patient undergoes bowel preparation before the examination to allow good visualization of the entire large bowel. Specially designed solutions are taken orally to help clear the bowel of fecal material. Air, water, and suction may be used during the examination to improve visualization. Biopsies, polyp removal, cauterization of bleeding, and stent placement can also be performed using additional instruments that can be passed through special openings in the colonoscope. | [
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Anatomy_Gray_872 | Anatomy_Gray | Cross sectional imaging using computed tomography or magnetic resonance is another way to assess the bowel lumen and wall. Magnetic resonance is particularly useful in assessment of the small bowel because it allows dynamic assessment of bowel distention and motility and provides good visualization of segmental or continuous bowel wall thickening and mural or mucosal ulcerations and also can demonstrate increased vascularity of the small bowel mesentery (Fig. 4.76). It is usually performed in patients with inflammatory bowel diseases, such as Crohn’s disease. | Anatomy_Gray. Cross sectional imaging using computed tomography or magnetic resonance is another way to assess the bowel lumen and wall. Magnetic resonance is particularly useful in assessment of the small bowel because it allows dynamic assessment of bowel distention and motility and provides good visualization of segmental or continuous bowel wall thickening and mural or mucosal ulcerations and also can demonstrate increased vascularity of the small bowel mesentery (Fig. 4.76). It is usually performed in patients with inflammatory bowel diseases, such as Crohn’s disease. | [
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Anatomy_Gray_873 | Anatomy_Gray | CT colonography (also called virtual colonoscopy or CT pneumocolon) is an alternative way to visualize and assess the colon for abnormal lesions such as polyps or strictures with the use spiral CT to produce high-resolution 3D views of the large bowel. It is less invasive than traditional colonoscopy, but to achieve good-quality images the patient needs to take bowel preparations to ensure bowel cleansing, and the colon needs to be insufflated with CO2. If a tumor is present (Fig. 4.77), both CT and MRI are used to assess regional disease (MRI), abnormal lymph nodes (MRI, CT), and distant metastases (CT). In the clinic | Anatomy_Gray. CT colonography (also called virtual colonoscopy or CT pneumocolon) is an alternative way to visualize and assess the colon for abnormal lesions such as polyps or strictures with the use spiral CT to produce high-resolution 3D views of the large bowel. It is less invasive than traditional colonoscopy, but to achieve good-quality images the patient needs to take bowel preparations to ensure bowel cleansing, and the colon needs to be insufflated with CO2. If a tumor is present (Fig. 4.77), both CT and MRI are used to assess regional disease (MRI), abnormal lymph nodes (MRI, CT), and distant metastases (CT). In the clinic | [
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Anatomy_Gray_874 | Anatomy_Gray | In the clinic A Meckel’s diverticulum (Fig. 4.78) is the remnant of the proximal part of the yolk stalk (vitelline duct) that extends into the umbilical cord in the embryo and lies on the antimesenteric border of the ileum. It appears as a blind-ended tubular outgrowth of bowel. Although it is an uncommon finding (occurring in approximately 2% of the population), it is always important to consider the diagnosis of Meckel’s diverticulum because it does produce symptoms in a small number of patients. It may contain gastric mucosa and therefore lead to ulceration and hemorrhage. Other typical complications include intussusception, diverticulitis, and obstruction. In the clinic | Anatomy_Gray. In the clinic A Meckel’s diverticulum (Fig. 4.78) is the remnant of the proximal part of the yolk stalk (vitelline duct) that extends into the umbilical cord in the embryo and lies on the antimesenteric border of the ileum. It appears as a blind-ended tubular outgrowth of bowel. Although it is an uncommon finding (occurring in approximately 2% of the population), it is always important to consider the diagnosis of Meckel’s diverticulum because it does produce symptoms in a small number of patients. It may contain gastric mucosa and therefore lead to ulceration and hemorrhage. Other typical complications include intussusception, diverticulitis, and obstruction. In the clinic | [
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Anatomy_Gray_875 | Anatomy_Gray | In the clinic These imaging techniques can provide important information about the wall of the bowel that may not be obtained from barium or endoscopic studies. Thickening of the wall may indicate inflammatory change or tumor and is always regarded with suspicion. If a tumor is demonstrated, the locoregional spread can be assessed, along with lymphadenopathy and metastatic spread. Endoscopic ultrasound (EUS) uses a small ultrasound device placed on the end of the endoscope to assess the upper gastrointestinal tract. It can produce extremely high-powered views of the mucosa and submucosa and therefore show whether a tumor is resectable. It also provides guidance to the clinician when taking a biopsy. In the clinic Carcinoma of the stomach | Anatomy_Gray. In the clinic These imaging techniques can provide important information about the wall of the bowel that may not be obtained from barium or endoscopic studies. Thickening of the wall may indicate inflammatory change or tumor and is always regarded with suspicion. If a tumor is demonstrated, the locoregional spread can be assessed, along with lymphadenopathy and metastatic spread. Endoscopic ultrasound (EUS) uses a small ultrasound device placed on the end of the endoscope to assess the upper gastrointestinal tract. It can produce extremely high-powered views of the mucosa and submucosa and therefore show whether a tumor is resectable. It also provides guidance to the clinician when taking a biopsy. In the clinic Carcinoma of the stomach | [
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Anatomy_Gray_876 | Anatomy_Gray | In the clinic Carcinoma of the stomach Carcinoma of the stomach is a common gastrointestinal malignancy. Chronic gastric inflammation (gastritis), pernicious anemia, and polyps predispose to the development of this aggressive cancer, which is usually not diagnosed until late in the course of the disease. Symptoms include vague epigastric pain, early fullness with eating, bleeding leading to chronic anemia, and obstruction. | Anatomy_Gray. In the clinic Carcinoma of the stomach Carcinoma of the stomach is a common gastrointestinal malignancy. Chronic gastric inflammation (gastritis), pernicious anemia, and polyps predispose to the development of this aggressive cancer, which is usually not diagnosed until late in the course of the disease. Symptoms include vague epigastric pain, early fullness with eating, bleeding leading to chronic anemia, and obstruction. | [
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Anatomy_Gray_877 | Anatomy_Gray | The diagnosis may be made using barium and conventional radiology or endoscopy, which allows a biopsy to be obtained at the same time. Ultrasound scanning is used to check the liver for metastatic spread, and, if negative, computed tomography is carried out to assess for surgical resectability. If carcinoma of the stomach is diagnosed early, a curative surgical resection is possible. However, because most patients do not seek treatment until late in the disease, the overall 5-year survival rate is between 5% and 20%, with a mean survival time of between 5 and 8 months. In the clinic | Anatomy_Gray. The diagnosis may be made using barium and conventional radiology or endoscopy, which allows a biopsy to be obtained at the same time. Ultrasound scanning is used to check the liver for metastatic spread, and, if negative, computed tomography is carried out to assess for surgical resectability. If carcinoma of the stomach is diagnosed early, a curative surgical resection is possible. However, because most patients do not seek treatment until late in the disease, the overall 5-year survival rate is between 5% and 20%, with a mean survival time of between 5 and 8 months. In the clinic | [
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Anatomy_Gray_878 | Anatomy_Gray | In the clinic Acute appendicitis is an abdominal emergency. It usually occurs when the appendix is obstructed by either a fecalith or enlargement of the lymphoid nodules. Within the obstructed appendix, bacteria proliferate and invade the appendix wall, which becomes damaged by pressure necrosis. In some instances, this may resolve spontaneously; in other cases, inflammatory change (Figs. 4.86 and 4.87) continues and perforation ensues, which may lead to localized or generalized peritonitis. Most patients with acute appendicitis have localized tenderness in the right groin. Initially, the pain begins as a central, periumbilical, colicky type of pain, which tends to come and go. After 6 to 10 hours, the pain tends to localize in the right iliac fossa and becomes constant. Patients may develop a fever, nausea, and vomiting. The etiology of the pain for appendicitis is described in Case 1 of Chapter 1 on p. 48. The treatment for appendicitis is appendectomy. In the clinic | Anatomy_Gray. In the clinic Acute appendicitis is an abdominal emergency. It usually occurs when the appendix is obstructed by either a fecalith or enlargement of the lymphoid nodules. Within the obstructed appendix, bacteria proliferate and invade the appendix wall, which becomes damaged by pressure necrosis. In some instances, this may resolve spontaneously; in other cases, inflammatory change (Figs. 4.86 and 4.87) continues and perforation ensues, which may lead to localized or generalized peritonitis. Most patients with acute appendicitis have localized tenderness in the right groin. Initially, the pain begins as a central, periumbilical, colicky type of pain, which tends to come and go. After 6 to 10 hours, the pain tends to localize in the right iliac fossa and becomes constant. Patients may develop a fever, nausea, and vomiting. The etiology of the pain for appendicitis is described in Case 1 of Chapter 1 on p. 48. The treatment for appendicitis is appendectomy. In the clinic | [
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Anatomy_Gray_879 | Anatomy_Gray | The treatment for appendicitis is appendectomy. In the clinic Congenital disorders of the gastrointestinal tract The normal positions of the abdominal viscera result from a complex series of rotations that the gut tube undergoes and from the growth of the abdominal cavity to accommodate changes in the size of the developing organs (see pp. 265-268). A number of developmental anomalies can occur during gut development, many of which appear in the neonate or infant, and some of which are surgical emergencies. Occasionally, such disorders are diagnosed only in adults. | Anatomy_Gray. The treatment for appendicitis is appendectomy. In the clinic Congenital disorders of the gastrointestinal tract The normal positions of the abdominal viscera result from a complex series of rotations that the gut tube undergoes and from the growth of the abdominal cavity to accommodate changes in the size of the developing organs (see pp. 265-268). A number of developmental anomalies can occur during gut development, many of which appear in the neonate or infant, and some of which are surgical emergencies. Occasionally, such disorders are diagnosed only in adults. | [
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Anatomy_Gray_880 | Anatomy_Gray | Malrotation is incomplete rotation and fixation of the midgut after it has passed from the umbilical sac and returned to the abdominal coelom (Figs. 4.93 and 4.94). The proximal attachment of the small bowel mesentery begins at the suspensory muscle of duodenum (ligament of Treitz), which determines the position of the duodenojejunal junction. The mesentery of the small bowel ends at the level of the ileocecal junction in the right lower quadrant. This long line of fixation of the mesentery prevents accidental twists of the gut. If the duodenojejunal flexure or the cecum does not end up in its usual site, the origin of the small bowel mesentery shortens, which permits twisting of the small bowel around the axis of the superior mesenteric artery. Twisting of the bowel, in general, is termed volvulus. Volvulus of the small bowel may lead to a reduction of blood flow and infarction. | Anatomy_Gray. Malrotation is incomplete rotation and fixation of the midgut after it has passed from the umbilical sac and returned to the abdominal coelom (Figs. 4.93 and 4.94). The proximal attachment of the small bowel mesentery begins at the suspensory muscle of duodenum (ligament of Treitz), which determines the position of the duodenojejunal junction. The mesentery of the small bowel ends at the level of the ileocecal junction in the right lower quadrant. This long line of fixation of the mesentery prevents accidental twists of the gut. If the duodenojejunal flexure or the cecum does not end up in its usual site, the origin of the small bowel mesentery shortens, which permits twisting of the small bowel around the axis of the superior mesenteric artery. Twisting of the bowel, in general, is termed volvulus. Volvulus of the small bowel may lead to a reduction of blood flow and infarction. | [
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Anatomy_Gray_881 | Anatomy_Gray | In some patients, the cecum ends up in the midabdomen. From the cecum and the right side of the colon a series of peritoneal folds (Ladd’s bands) develop that extend to the right undersurface of the liver and compress the duodenum. A small bowel volvulus may then occur as well as duodenal obstruction. Emergency surgery may be necessary to divide the bands. In the clinic A bowel obstruction can be either functional or due to a true obstruction. Mechanical obstruction is caused by an intraluminal, mural, or extrinsic mass which can be secondary to a foreign body, obstructing tumor in the wall, or extrinsic compression from an adhesion, or embryological band (Fig. 4.95). | Anatomy_Gray. In some patients, the cecum ends up in the midabdomen. From the cecum and the right side of the colon a series of peritoneal folds (Ladd’s bands) develop that extend to the right undersurface of the liver and compress the duodenum. A small bowel volvulus may then occur as well as duodenal obstruction. Emergency surgery may be necessary to divide the bands. In the clinic A bowel obstruction can be either functional or due to a true obstruction. Mechanical obstruction is caused by an intraluminal, mural, or extrinsic mass which can be secondary to a foreign body, obstructing tumor in the wall, or extrinsic compression from an adhesion, or embryological band (Fig. 4.95). | [
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Anatomy_Gray_882 | Anatomy_Gray | A functional obstruction is usually due to an inability of the bowel to peristalse, which again has a number of causes, and most frequently is a postsurgical state due to excessive intraoperative bowel handling. Other causes may well include abnormality of electrolytes (e.g., sodium and potassium) rendering the bowel paralyzed until correction has occurred. The signs and symptoms of obstruction depend on the level at which the obstruction has occurred. The primary symptom is central abdominal, intermittent, colicky pain as the peristaltic waves try to overcome the obstruction. Abdominal distention will occur if it is a low obstruction (distal), allowing more proximal loops of bowel to fill with fluid. A high obstruction (in the proximal small bowel) may not produce abdominal distention. Vomiting and absolute constipation, including the inability to pass flatus, will ensue. | Anatomy_Gray. A functional obstruction is usually due to an inability of the bowel to peristalse, which again has a number of causes, and most frequently is a postsurgical state due to excessive intraoperative bowel handling. Other causes may well include abnormality of electrolytes (e.g., sodium and potassium) rendering the bowel paralyzed until correction has occurred. The signs and symptoms of obstruction depend on the level at which the obstruction has occurred. The primary symptom is central abdominal, intermittent, colicky pain as the peristaltic waves try to overcome the obstruction. Abdominal distention will occur if it is a low obstruction (distal), allowing more proximal loops of bowel to fill with fluid. A high obstruction (in the proximal small bowel) may not produce abdominal distention. Vomiting and absolute constipation, including the inability to pass flatus, will ensue. | [
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Anatomy_Gray_883 | Anatomy_Gray | Vomiting and absolute constipation, including the inability to pass flatus, will ensue. Early diagnosis is important because considerable fluid and electrolytes enter the bowel lumen and fail to be reabsorbed, which produces dehydration and electrolyte abnormalities. Furthermore, the bowel continues to distend, compromising the blood supply within the bowel wall, which may lead to ischemia and perforation. The symptoms and signs are variable and depend on the level of obstruction. Small bowel obstruction is typically caused by adhesions following previous surgery, and history should always be sought for any operations or abdominal interventions (e.g., previous appendectomy). Other causes include bowel passing into hernias (e.g., inguinal) and bowel twisting on its own mesentery (volvulus). Examination of hernial orifices is mandatory in patients with bowel obstruction (Fig. 4.96). | Anatomy_Gray. Vomiting and absolute constipation, including the inability to pass flatus, will ensue. Early diagnosis is important because considerable fluid and electrolytes enter the bowel lumen and fail to be reabsorbed, which produces dehydration and electrolyte abnormalities. Furthermore, the bowel continues to distend, compromising the blood supply within the bowel wall, which may lead to ischemia and perforation. The symptoms and signs are variable and depend on the level of obstruction. Small bowel obstruction is typically caused by adhesions following previous surgery, and history should always be sought for any operations or abdominal interventions (e.g., previous appendectomy). Other causes include bowel passing into hernias (e.g., inguinal) and bowel twisting on its own mesentery (volvulus). Examination of hernial orifices is mandatory in patients with bowel obstruction (Fig. 4.96). | [
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Anatomy_Gray_884 | Anatomy_Gray | Large bowel obstruction is commonly caused by a tumor. Other potential causes include hernias and inflammatory diverticular disease of the sigmoid colon (Fig. 4.97). The treatment is intravenous replacement of fluid and electrolytes, analgesia, and relief of obstruction. The passage of a nasogastric tube allows aspiration of fluid from the stomach. In many instances, small bowel obstruction, typically secondary to adhesions, will settle with nonoperative management. Large bowel obstruction may require an urgent operation to remove the obstructing lesion, or a temporary bypass procedure (e.g., defunctioning colostomy) (Fig. 4.98). In the clinic | Anatomy_Gray. Large bowel obstruction is commonly caused by a tumor. Other potential causes include hernias and inflammatory diverticular disease of the sigmoid colon (Fig. 4.97). The treatment is intravenous replacement of fluid and electrolytes, analgesia, and relief of obstruction. The passage of a nasogastric tube allows aspiration of fluid from the stomach. In many instances, small bowel obstruction, typically secondary to adhesions, will settle with nonoperative management. Large bowel obstruction may require an urgent operation to remove the obstructing lesion, or a temporary bypass procedure (e.g., defunctioning colostomy) (Fig. 4.98). In the clinic | [
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Anatomy_Gray_885 | Anatomy_Gray | In the clinic Diverticular disease is the development of multiple colonic diverticula, predominantly throughout the sigmoid colon, though the whole colon may be affected (Fig. 4.99). The sigmoid colon has the smallest diameter of any portion of the colon and is therefore the site where intraluminal pressure is potentially the highest. Poor dietary fiber intake and obesity are also linked to diverticular disease. The presence of multiple diverticula does not necessarily mean the patient requires any treatment. Moreover, many patients have no other symptoms or signs. Patients tend to develop symptoms and signs when the neck of the diverticulum becomes obstructed by feces and becomes infected. Inflammation may spread along the wall, causing abdominal pain. When the sigmoid colon becomes inflamed (diverticulitis), abdominal pain and fever ensue (Fig. 4.100). | Anatomy_Gray. In the clinic Diverticular disease is the development of multiple colonic diverticula, predominantly throughout the sigmoid colon, though the whole colon may be affected (Fig. 4.99). The sigmoid colon has the smallest diameter of any portion of the colon and is therefore the site where intraluminal pressure is potentially the highest. Poor dietary fiber intake and obesity are also linked to diverticular disease. The presence of multiple diverticula does not necessarily mean the patient requires any treatment. Moreover, many patients have no other symptoms or signs. Patients tend to develop symptoms and signs when the neck of the diverticulum becomes obstructed by feces and becomes infected. Inflammation may spread along the wall, causing abdominal pain. When the sigmoid colon becomes inflamed (diverticulitis), abdominal pain and fever ensue (Fig. 4.100). | [
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Anatomy_Gray_886 | Anatomy_Gray | Because of the anatomical position of the sigmoid colon there are a number of complications that may occur. The diverticula can perforate to form an abscess in the pelvis. The inflammation may produce an inflammatory mass, obstructing the left ureter. Inflammation may also spread to the bladder, producing a fistula between the sigmoid colon and the bladder. In these circumstances patients may develop a urinary tract infection and rarely have fecal material and gas passing per urethra. The diagnosis is based upon clinical examination and often CT scanning. In the first instance, patients will be treated with antibiotic therapy; however, a surgical resection may be necessary if symptoms persist. In the clinic It is occasionally necessary to surgically externalize bowel to the anterior abdominal wall. Externalization of bowel plays an important role in patient management. These extraanatomical bypass procedures use our anatomical knowledge and in many instances are life saving. | Anatomy_Gray. Because of the anatomical position of the sigmoid colon there are a number of complications that may occur. The diverticula can perforate to form an abscess in the pelvis. The inflammation may produce an inflammatory mass, obstructing the left ureter. Inflammation may also spread to the bladder, producing a fistula between the sigmoid colon and the bladder. In these circumstances patients may develop a urinary tract infection and rarely have fecal material and gas passing per urethra. The diagnosis is based upon clinical examination and often CT scanning. In the first instance, patients will be treated with antibiotic therapy; however, a surgical resection may be necessary if symptoms persist. In the clinic It is occasionally necessary to surgically externalize bowel to the anterior abdominal wall. Externalization of bowel plays an important role in patient management. These extraanatomical bypass procedures use our anatomical knowledge and in many instances are life saving. | [
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Anatomy_Gray_887 | Anatomy_Gray | Gastrostomy is performed when the stomach is attached to the anterior abdominal wall and a tube is placed through the skin into the stomach. Typically this is performed to feed the patient when it is impossible to take food and fluid orally (e.g., complex head and neck cancer). The procedure can be performed either surgically or through a direct needlestick puncture under sedation in the anterior abdominal wall. Similarly the jejunum is brought to the anterior abdominal wall and fixed. The jejunostomy is used as a site where a feeding tube is placed through the anterior abdominal wall into the proximal efferent small bowel. An ileostomy is performed when small bowel contents need to be diverted from the distal bowel. An ileostomy is often performed to protect a distal surgical anastomosis, such as in the colon to allow healing after surgery. | Anatomy_Gray. Gastrostomy is performed when the stomach is attached to the anterior abdominal wall and a tube is placed through the skin into the stomach. Typically this is performed to feed the patient when it is impossible to take food and fluid orally (e.g., complex head and neck cancer). The procedure can be performed either surgically or through a direct needlestick puncture under sedation in the anterior abdominal wall. Similarly the jejunum is brought to the anterior abdominal wall and fixed. The jejunostomy is used as a site where a feeding tube is placed through the anterior abdominal wall into the proximal efferent small bowel. An ileostomy is performed when small bowel contents need to be diverted from the distal bowel. An ileostomy is often performed to protect a distal surgical anastomosis, such as in the colon to allow healing after surgery. | [
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Anatomy_Gray_888 | Anatomy_Gray | There are a number of instances when a colostomy may be necessary. In many circumstances it is performed to protect the distal large bowel after surgery. A further indication would include large bowel obstruction with imminent perforation wherein a colostomy allows decompression of the bowel and its contents. This is a safe and temporizing procedure performed when the patient is too unwell for extensive bowel surgery. It is relatively straightforward and carries reduced risk, preventing significant morbidity and mortality. An end colostomy is necessary when the patient has undergone a surgical resection of the rectum and anus (typically for cancer). | Anatomy_Gray. There are a number of instances when a colostomy may be necessary. In many circumstances it is performed to protect the distal large bowel after surgery. A further indication would include large bowel obstruction with imminent perforation wherein a colostomy allows decompression of the bowel and its contents. This is a safe and temporizing procedure performed when the patient is too unwell for extensive bowel surgery. It is relatively straightforward and carries reduced risk, preventing significant morbidity and mortality. An end colostomy is necessary when the patient has undergone a surgical resection of the rectum and anus (typically for cancer). | [
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Anatomy_Gray_889 | Anatomy_Gray | An end colostomy is necessary when the patient has undergone a surgical resection of the rectum and anus (typically for cancer). An ileal conduit is an extraanatomical procedure and is performed after resection of the bladder for tumor. In this situation a short segment of small bowel is identified. The bowel is divided twice to produce a 20-cm segment of small bowel on its own mesentery. This isolated segment of bowel is used as a conduit. The remaining bowel is joined together. The proximal end is anastomosed to the ureters, and the distal end is anastomosed to the anterior abdominal wall. Hence, urine passes from the kidneys into the ureters and through the short segment of small bowel to the anterior abdominal wall. | Anatomy_Gray. An end colostomy is necessary when the patient has undergone a surgical resection of the rectum and anus (typically for cancer). An ileal conduit is an extraanatomical procedure and is performed after resection of the bladder for tumor. In this situation a short segment of small bowel is identified. The bowel is divided twice to produce a 20-cm segment of small bowel on its own mesentery. This isolated segment of bowel is used as a conduit. The remaining bowel is joined together. The proximal end is anastomosed to the ureters, and the distal end is anastomosed to the anterior abdominal wall. Hence, urine passes from the kidneys into the ureters and through the short segment of small bowel to the anterior abdominal wall. | [
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Anatomy_Gray_890 | Anatomy_Gray | When patients have either an ileostomy, colostomy, or ileal conduit it is necessary for them to fix a collecting bag onto the anterior abdominal wall. Contrary to one’s initial thoughts these bags are tolerated extremely well by most patients and allow patients to live a nearly normal and healthy life. In the clinic The pancreas develops from ventral and dorsal buds from the foregut. The dorsal bud forms most of the head, neck, and body of the pancreas. The ventral bud rotates around the bile duct to form part of the head and the uncinate process. If the ventral bud splits (becomes bifid), the two segments may encircle the duodenum. The duodenum is therefore constricted and may even undergo atresia, and be absent at birth because of developmental problems. After birth, the child may fail to thrive and may vomit due to poor gastric emptying. | Anatomy_Gray. When patients have either an ileostomy, colostomy, or ileal conduit it is necessary for them to fix a collecting bag onto the anterior abdominal wall. Contrary to one’s initial thoughts these bags are tolerated extremely well by most patients and allow patients to live a nearly normal and healthy life. In the clinic The pancreas develops from ventral and dorsal buds from the foregut. The dorsal bud forms most of the head, neck, and body of the pancreas. The ventral bud rotates around the bile duct to form part of the head and the uncinate process. If the ventral bud splits (becomes bifid), the two segments may encircle the duodenum. The duodenum is therefore constricted and may even undergo atresia, and be absent at birth because of developmental problems. After birth, the child may fail to thrive and may vomit due to poor gastric emptying. | [
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Anatomy_Gray_891 | Anatomy_Gray | Sometimes an annular pancreas is diagnosed in utero by ultrasound scanning. The obstruction of the duodenum may prevent the fetus from swallowing enough amniotic fluid, which may increase the overall volume of amniotic fluid in the amniotic sac surrounding the fetus (polyhydramnios). In the clinic | Anatomy_Gray. Sometimes an annular pancreas is diagnosed in utero by ultrasound scanning. The obstruction of the duodenum may prevent the fetus from swallowing enough amniotic fluid, which may increase the overall volume of amniotic fluid in the amniotic sac surrounding the fetus (polyhydramnios). In the clinic | [
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Anatomy_Gray_892 | Anatomy_Gray | In the clinic Pancreatic cancer accounts for a significant number of deaths and is often referred to as the “silent killer.” Malignant tumors of the pancreas may occur anywhere within the pancreas but are most frequent within the head and the neck. There are a number of nonspecific findings in patients with pancreatic cancer, including upper abdominal pain, loss of appetite, and weight loss. Depending on the exact site of the cancer, obstruction of the bile duct may occur, which can produce obstructive jaundice. Although surgery is indicated in patients where there is a possibility of cure, most detected cancers have typically spread locally, invading the portal vein and superior mesenteric vessels, and may extend into the porta hepatis. Lymph node spread also is common and these factors would preclude curative surgery. | Anatomy_Gray. In the clinic Pancreatic cancer accounts for a significant number of deaths and is often referred to as the “silent killer.” Malignant tumors of the pancreas may occur anywhere within the pancreas but are most frequent within the head and the neck. There are a number of nonspecific findings in patients with pancreatic cancer, including upper abdominal pain, loss of appetite, and weight loss. Depending on the exact site of the cancer, obstruction of the bile duct may occur, which can produce obstructive jaundice. Although surgery is indicated in patients where there is a possibility of cure, most detected cancers have typically spread locally, invading the portal vein and superior mesenteric vessels, and may extend into the porta hepatis. Lymph node spread also is common and these factors would preclude curative surgery. | [
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Anatomy_Gray_893 | Anatomy_Gray | Given the position of the pancreas, a surgical resection is a complex procedure involving resection of the region of pancreatic tumor usually with part of the duodenum, necessitating a complex bypass procedure. In the clinic Segmental anatomy of the liver For many years the segmental anatomy of the liver was of little importance. However, since the development of liver resection surgery, the size, shape, and segmental anatomy of the liver have become clinically important, especially with regard to liver resection for metastatic disease. Indeed, with detailed knowledge of the segments, curative surgery can be performed in patients with tumor metastases. | Anatomy_Gray. Given the position of the pancreas, a surgical resection is a complex procedure involving resection of the region of pancreatic tumor usually with part of the duodenum, necessitating a complex bypass procedure. In the clinic Segmental anatomy of the liver For many years the segmental anatomy of the liver was of little importance. However, since the development of liver resection surgery, the size, shape, and segmental anatomy of the liver have become clinically important, especially with regard to liver resection for metastatic disease. Indeed, with detailed knowledge of the segments, curative surgery can be performed in patients with tumor metastases. | [
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Anatomy_Gray_894 | Anatomy_Gray | Indeed, with detailed knowledge of the segments, curative surgery can be performed in patients with tumor metastases. The liver is divided by the principal plane, which divides the organ into halves of approximately equal size. This imaginary line is defined by a parasagittal line that passes through the gallbladder fossa to the inferior vena cava. It is in this plane that the middle hepatic vein is found. Importantly, the principal plane divides the left half of the liver from the right half. The lobes of the liver are unequal in size and bear only little relevance to operative anatomy. The traditional eight-segment anatomy of the liver relates to the hepatic arterial, portal, and biliary drainage of these segments (Fig. 4.116). The caudate lobe is defined as segment I, and the remaining segments are numbered in a clockwise fashion up to segment VIII. The features are extremely consistent between individuals. | Anatomy_Gray. Indeed, with detailed knowledge of the segments, curative surgery can be performed in patients with tumor metastases. The liver is divided by the principal plane, which divides the organ into halves of approximately equal size. This imaginary line is defined by a parasagittal line that passes through the gallbladder fossa to the inferior vena cava. It is in this plane that the middle hepatic vein is found. Importantly, the principal plane divides the left half of the liver from the right half. The lobes of the liver are unequal in size and bear only little relevance to operative anatomy. The traditional eight-segment anatomy of the liver relates to the hepatic arterial, portal, and biliary drainage of these segments (Fig. 4.116). The caudate lobe is defined as segment I, and the remaining segments are numbered in a clockwise fashion up to segment VIII. The features are extremely consistent between individuals. | [
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Anatomy_Gray_895 | Anatomy_Gray | The caudate lobe is defined as segment I, and the remaining segments are numbered in a clockwise fashion up to segment VIII. The features are extremely consistent between individuals. From a surgical perspective, a right hepatectomy would involve division of the liver in the principal plane in which segments V, VI, VII, and VIII would be removed, leaving segments I, II, III, and IV. In the clinic Gallstones are present in approximately 10% of people over the age of 40 and are more common in women. They consist of a variety of components but are predominantly a mixture of cholesterol and bile pigment. They may undergo calcification, which can be demonstrated on plain radiographs. Gallstones may be visualized incidentally as part of a routine abdominal ultrasound scan (Fig. 4.117) or on a plain radiograph. | Anatomy_Gray. The caudate lobe is defined as segment I, and the remaining segments are numbered in a clockwise fashion up to segment VIII. The features are extremely consistent between individuals. From a surgical perspective, a right hepatectomy would involve division of the liver in the principal plane in which segments V, VI, VII, and VIII would be removed, leaving segments I, II, III, and IV. In the clinic Gallstones are present in approximately 10% of people over the age of 40 and are more common in women. They consist of a variety of components but are predominantly a mixture of cholesterol and bile pigment. They may undergo calcification, which can be demonstrated on plain radiographs. Gallstones may be visualized incidentally as part of a routine abdominal ultrasound scan (Fig. 4.117) or on a plain radiograph. | [
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Anatomy_Gray_896 | Anatomy_Gray | The easiest way to confirm the presence of gallstones is by performing a fasting ultrasound examination of the gallbladder. The patient refrains from eating for 6 hours to ensure the gallbladder is well distended and there is little shadowing from overlying bowel gas. The examination may also identify bile duct dilation and the presence of cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) is another way to image the gallbladder and biliary tree. MRCP uses fluid present in the bile ducts and in the pancreatic duct as a contrast agent to show stones as well as filling defects within the gallbladder and intrahepatic or extrahepatic bile ducts. It can demonstrate strictures in the biliary tree and can also be used to visualize liver and pancreatic anatomy (Fig. 4.118). | Anatomy_Gray. The easiest way to confirm the presence of gallstones is by performing a fasting ultrasound examination of the gallbladder. The patient refrains from eating for 6 hours to ensure the gallbladder is well distended and there is little shadowing from overlying bowel gas. The examination may also identify bile duct dilation and the presence of cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) is another way to image the gallbladder and biliary tree. MRCP uses fluid present in the bile ducts and in the pancreatic duct as a contrast agent to show stones as well as filling defects within the gallbladder and intrahepatic or extrahepatic bile ducts. It can demonstrate strictures in the biliary tree and can also be used to visualize liver and pancreatic anatomy (Fig. 4.118). | [
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Anatomy_Gray_897 | Anatomy_Gray | From time to time, gallstones impact in the region of Hartmann’s pouch, which is a bulbous region of the neck of the gallbladder. When the gallstone lodges in this area, the gallbladder cannot empty normally and contractions of the gallbladder wall produce severe pain. If this persists, a cholecystectomy (removal of the gallbladder) may be necessary. Sometimes the gallbladder may become inflamed (cholecystitis). If the inflammation involves the related parietal peritoneum of the diaphragm, pain may not only occur in the right upper quadrant of the abdomen but may also be referred to the shoulder on the right side. This referred pain is due to the innervation of the visceral peritoneum of the diaphragm by spinal cord levels (C3 to C5) that also innervate skin over the shoulder. In this case, one somatic sensory region of low sensory output (diaphragm) is referred to another somatic sensory region of high sensory output (dermatomes). | Anatomy_Gray. From time to time, gallstones impact in the region of Hartmann’s pouch, which is a bulbous region of the neck of the gallbladder. When the gallstone lodges in this area, the gallbladder cannot empty normally and contractions of the gallbladder wall produce severe pain. If this persists, a cholecystectomy (removal of the gallbladder) may be necessary. Sometimes the gallbladder may become inflamed (cholecystitis). If the inflammation involves the related parietal peritoneum of the diaphragm, pain may not only occur in the right upper quadrant of the abdomen but may also be referred to the shoulder on the right side. This referred pain is due to the innervation of the visceral peritoneum of the diaphragm by spinal cord levels (C3 to C5) that also innervate skin over the shoulder. In this case, one somatic sensory region of low sensory output (diaphragm) is referred to another somatic sensory region of high sensory output (dermatomes). | [
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Anatomy_Gray_898 | Anatomy_Gray | From time to time, small gallstones pass into the bile duct and are trapped in the region of the sphincter of the ampulla, which obstructs the flow of bile into the duodenum. This, in turn, produces jaundice. | Anatomy_Gray. From time to time, small gallstones pass into the bile duct and are trapped in the region of the sphincter of the ampulla, which obstructs the flow of bile into the duodenum. This, in turn, produces jaundice. | [
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Anatomy_Gray_899 | Anatomy_Gray | Endoscopic retrograde cholangiopancreatography (ERCP) can be undertaken to remove obstructing gallstones within the biliary tree. This procedure combines endoluminal endoscopy with fluoroscopy to diagnose and treat problems in the biliary and pancreatic ducts. An endoscope with a side-viewing optical system is advanced through the esophagus and stomach and placed in the second part of the duodenum where the major papilla (the ampulla of Vater) is identified. This is where the pancreatic duct converges with the common bile duct. The papilla is initially examined for possible abnormalities (stuck stone or malignant growth) and a biopsy may be taken if necessary. Then either the bile duct or pancreatic duct is cannulated and a small amount of radiopaque contrast medium is injected to visualize either the bile duct (cholangiogram) or pancreatic duct (pancreatogram) (Fig. 4.119). If a stone is present, it can be removed with a stone basket or an extraction balloon. Usually, a | Anatomy_Gray. Endoscopic retrograde cholangiopancreatography (ERCP) can be undertaken to remove obstructing gallstones within the biliary tree. This procedure combines endoluminal endoscopy with fluoroscopy to diagnose and treat problems in the biliary and pancreatic ducts. An endoscope with a side-viewing optical system is advanced through the esophagus and stomach and placed in the second part of the duodenum where the major papilla (the ampulla of Vater) is identified. This is where the pancreatic duct converges with the common bile duct. The papilla is initially examined for possible abnormalities (stuck stone or malignant growth) and a biopsy may be taken if necessary. Then either the bile duct or pancreatic duct is cannulated and a small amount of radiopaque contrast medium is injected to visualize either the bile duct (cholangiogram) or pancreatic duct (pancreatogram) (Fig. 4.119). If a stone is present, it can be removed with a stone basket or an extraction balloon. Usually, a | [
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