Material to Learn

Abdomen

Anterior Abdominal Wall

Camper's fascia: The fatty layer of superficial fascia that is continuous with the
superficial fascia superior to the umbilicus and with superficial fascia of the thigh. It
continues over the pubic bones into the perineum as the subcutaneous tissue of the
perineum. Camper’s fascia contains vessels and nerves including the superficial
epigastric, superficial circumflex and thoracoepigastric vessels, and the cutaneous
branches of the thoracoabdominal nerves (ventral rami of T5-L1).

Superficial epigastric vessels: The superficial epigastric artery branches from the
femoral artery and passes superficial to the inguinal ligament running obliquely
superiorly toward the umbilicus. The accompanying vein empties into the great
saphenous vein.

Thoracoepigastric veins: These are the venous connections between the lateral
thoracic veins that drain into the axillary vein and the superficial epigastric veins that
drain into the great saphenous/femoral vein. They provide a collateral route for venous
return in cases of a caval or portal obstruction.

Superficial circumflex iliac vessels: The superficial circumflex iliac artery branches
from the femoral artery and runs laterally upward and parallel to the inguinal ligament. It
anastomoses with the deep circumflex iliac and lateral femoral circumflex arteries. The
vein empties into the great saphenous vein.

Scarpa's fascia: Membranous deep layer of superficial abdominal fascia. It ends along
the inferior border of the inguinal ligament by fusing with the fascia lata (deep fascia) of
the thigh, but continues inferiorly across the pubic bones to become the Colles’ fascia
(membranous layer of the superficial fascia) of the perineum, and dartos fascia of the
penis and scrotal sac.

Linea alba: tendinous raphe formed by fusion of the left and right aponeuroses of the
external oblique, internal oblique and transversus abdominis muscles. It extends from
the xiphoid process to the pubic symphysis.

Fundiform ligament of the penis: arises from the linea alba as dense collagen fibers
from the local connective tissue. It splits and surrounds the proximal part of the
pendulus penis blending with the dartos fascia on its ventral surface.

Linea semilunaris: curved line parallel to the lateral border of the rectus abdominis
muscle. It demarcates the lateral extent of the rectus sheath. It crosses the costal

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margin at the 9th costal cartilage and is a landmark on the right side for the fundus of the
gallbladder.

Rectus sheath: medial portion of the three paired anterolateral abdominal wall
aponeuroses (tendons of the muscles) that envelop the right and left rectus abdominis
muscles.

External oblique muscle:

• Attachments: Origin: external surface of lower eight ribs (5-12)
Insertion: anterior half of iliac crest, ASIS, pubic tubercle and linea alba
• Innervation: intercostal nerves (T7-T11) and subcostal nerve (T12)
• Actions: compress the abdominal viscera, flex the trunk and (unilaterally) rotate the
trunk to the opposite side.

Internal oblique muscle:

• Attachments: Origin: anterior 2/3 of iliac crest, lateral half of inguinal ligament
Insertion: ribs and costal cartilages 10-12, linea alba, and pecten pubis (via the
conjoint tendon)
• Innervation: intercostal nerves (T6-T11), subcostal nerve (T12), iliohypogastric (L1)
and ilioinguinal nerves (L1)
• Action: compress abdominal viscera, flex the trunk and (unilaterally) rotate it to the
same side

Transversus abdominis muscle

• Attachments: Origin: internal surface 7-12 costal cartilages, thoracolumbar fascia,
iliac crest, lateral third of the inguinal ligament
Insertion: linea alba, pubic crest and pecten pubis (via the conjoint tendon)
• Innervation: intercostal nerves (T7-T11), subcostal nerve (T12), iliohypogastric (L1)
and ilioinguinal nerves (L1)
• Action: compress and support abdominal viscera

Thoracoabdominal anterior cutaneous nerves: lowest 5 intercostal nerves (T7-T11)

and the subcostal nerve (T12). These are the terminal portions of the ventral rami of
spinal nerves T7 to T12.

Iliohypogastric and ilioinguinal nerves (L1): iliohypogastric innervates the internal

oblique and transversus abdominis muscles and provides cutaneous innervation in the
pubic region. It divides into a lateral cutaneous branch that supplies skin over the lateral
side of the buttocks and an anterior cutaneous branch that supplies skin superior to the
pubis. The ilioinguinal nerve innervates the internal oblique and transversus abdominis
muscles and provides cutaneous innervation to the pubic region, specifically the mons
pubis, anterior scrotum or labium majus and medial thigh.

Inguinal (Poupart's) ligament: thickened inferior border of the external abdominal

oblique aponeurosis that extends between the ASIS and the pubic tubercle. Attachment
site for Scarpa’s fascia superiorly and fascia lata inferiorly.

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Superficial inguinal ring: triangular opening in the aponeurosis of the external oblique
muscle. It is anchored by medial and lateral crura to the pubic crest and tubercle
respectively and supported by intercrural fibers proximally. It transmits the spermatic
cord and ilioinguinal nerve in males and the round ligament of the uterus and
iliolinguinal nerve in females. The opening is larger in males than females.

Deep inguinal ring: a sleeve of transversalis fascia that evaginates and surrounds the
vas deferens and testicular vessels in males and the round ligament and its vessels in
females as they pass through the deepest part of the inguinal canal.

Inguinal canal: a cylindrical channel running between the deep and superficial
inguinal rings. It transmits the spermatic cord in the male and the round ligament of
the uterus in the female. And, in both males and females, the ilioinguinal nerve (L1)
and various amounts of fatty loose connective tissue are present in the inguinal
canal. The walls of the inguinal canal are:
• Anterior: aponeurosis of external oblique and on the lateral side a small part of the
internal oblique
• Posterior: transversalis fascia and the conjoint tendon
• Superior (roof): arches of transversus abdominis and internal oblique muscles
• Inferior (floor): inguinal and lacunar ligaments

Spermatic cord: conduit to and from the testes and abdominal wall that contains the
ductus (vas) deferens, testicular artery, pampiniform plexus, lymphatics and nerves
wrapped in layers of connective tissue (external and internal spermatic fascia) and
muscle (cremaster muscle).

Round ligament of the uterus: remnant of the gubernaculum. It is attached at one end
to the uterus, passes through the inguinal canal accompanied by its artery (the artery of
the round ligament or Sampson’s artery), and is attached at the other end to the deep
fascia on the anterior aspect of the body of the pubis.

Cremaster muscle
• Attachments: Origin: inferior-most fibers of the internal oblique m., descends into
the spermatic cord and forms loops in the cremasteric fascia
• Innervation: genital branch of the genitofemoral nerve (L1-2)
• Actions: is involved in the cremasteric reflex which changes position of the testes
in the scrotum in response to temperature - elevates in cold, descends in heat

Transversalis fascia: connective tissue layer between the peritoneum and the
transversus abdominis muscle and aponeurosis. It is part of a larger fascia layer, the
endoabdominal fascia, that lines the entire abdominal cavity similar to the endothoracic
fascia of the pleural cavities. It is specialized in some regions and given specific names
such as transversalis fascia, internal spermatic fascia, renal fascia, psoas fascia and the
anterior lamina of the femoral sheath.

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Rectus sheath: formed by fusion of the aponeuroses of the external and internal
oblique muscles anteriorly and transversus abdominis aponeurosis posteriorly. The
rectus sheath encloses the rectus abdominis and pyramidalis muscles. It also contains
the superior and inferior epigastric vessels and the ventral primary rami of T7-T12
nerves and their accompanying vessels.

Rectus abdominis muscle:

• Attachments: Origin: pubic symphysis and crest
Insertion: xiphoid process and costal cartilages 5-7
• Innervation: intercostal nerves (T7-T11) and subcostal nerve (T12)
• Actions: compress the abdominal contents, flex the trunk, stabilize pelvis

Pyramidalis muscle:
• Attachments: Origin: pubic crest
Insertion: linea alba
• Innervation: T12
• Action: tenses linea alba

Arcuate line: line located midway between the symphysis pubis and umbilicus that
marks the termination of the posterior layer of the rectus sheath. At this point all of the
anterolateral abdominal aponeuroses run anterior to the rectus abdominis muscle.

Inferior epigastric artery: arises from the external iliac artery superior to the inguinal
ligament, enters the rectus sheath and ascends between the rectus abdominis muscle
and the posterior layer of the rectus sheath. It forms the lateral boundary of the inguinal
triangle and supplies the rectus abdominis muscle.

Superior epigastric artery: arises as one of two terminal branches from the internal
thoracic artery. It enters the rectus sheath and descends on the posterior surface of the
rectus abdominis to anastomose with the inferior epigastric artery within the rectus
abdominis muscle.

Scrotum and Testes

Dartos fascia: superficial fascia of the scrotum. It is a membranous, fat-free fascia that
is continuous with Scarpa's fascia in the anterior abdominal wall and Colles’ fascia in
the perineum. The fatty layer of fascia in the abdomen (Camper's fascia) becomes
dartos (smooth) muscle in the scrotum. It contracts at cold temperatures, wrinkling the
skin of the scrotum and decreasing its surface area to reduce heat loss. At higher
temperatures, the dartos muscle relaxes increasing the surface area of the scrotum to
facilitate cooling.

Scrotal ligament: remnant of the gubernaculum testis – the fetal ‘ligament’ that
connects the inferior pole of the testis to the developing scrotum. It is important in
testicular (and ovarian) descent. In females, both the ovarian ligament and the round
ligament of the uterus are remnants of the gubernaculum.

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External spermatic fascia: external covering of the spermatic cord derived from both
external abdominal oblique aponeurosis and investing fascia.

Internal spermatic fascia: derived from the transversalis fascia.

Ductus (vas) deferens: thick-walled muscular tube that transports sperm from the
testis to the prostate gland where it continues as the ejaculatory duct to the urethra.

Testicular artery and vein: vessels from the abdomen (artery from the aorta, veins
return to the IVC or the left renal vein) that serve the testes and accompany them
through the inguinal canal and into the scrotum.

Pampiniform venous plexus: plexus of communicating veins that surrounds the

testicular artery and converges in the superior part of the spermatic cord to form the
testicular vein. This plexus is important in thermoregulation.

Tunica vaginalis: a membranous serous sac that covers all but the posterior aspect of
the testis. It is a remnant of the processus vaginalis derived from peritoneum. It has
parietal and visceral layers with a potential space between them that, in a pathological
state, may become filled with fluid. With blood = hematocele, serous fluid = hydrocele.

Epididymis: coiled tubular structure that consists of a head, body and tail. The head
consists of 12-14 efferent ductules that receive sperm from the rete testis. The body
and tail form a highly coiled duct (4-6 m long when uncoiled) that is continuous with the
ductus deferens. The functions of the epididymis are maturation and storage of sperm,
and propulsion of sperm into the ductus deferens.

Tunica albuginea: thick fibrous capsule, that encloses the testis. It is derived from the
cortical tissue of the developing gonad.

Mediastinum testis: located at the posterior border of the testis, is the site where
vessels enter and leave the testis.

Septa: connective tissue bands that arise from the tunica albuginea and incompletely
divide the internal testis into lobules.

Seminiferous tubules: site of spermatogenesis (see your histology book!).

Internal Anterior Abdominal Wall / Peritoneal Folds

Falciform ligament: reflection of peritoneum from the anterior (diaphragmatic) surface
of the liver onto the internal surface of the anterior abdominal wall. It contains the
ligamentum teres.

Ligamentum teres of the liver: obliterated umbilical vein, travels in the inferior free
border of the falciform ligament.

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Median umbilical fold: peritoneum that covers the obliterated allantoic duct (urachus).
It lies in the midline ascending from the apex of the bladder to the umbilicus.

Medial umbilical folds: peritoneum that covers the right and left obliterated umbilical
arteries.

Lateral umbilical folds: peritoneum that covers the right and left inferior epigastric
vessels bilaterally.

Peritoneal Structures and Spaces

Subphrenic recess: potential space between the inferior surface of the diaphragm and
the diaphragmatic surface of the liver lined with peritoneum.

Coronary ligament: reflection of the hepatic peritoneum that encircles the superior
surface of the liver. The right and left triangular ligaments are parts of the coronary
ligament. They connect the right and left 'corners' of the liver to the inferior surface of
the diaphragm.

Greater omentum: flap of peritoneum that hangs from the greater curvature of the
stomach and the anterior surface of the transverse colon. The four layers of
peritoneum from which it is formed are fused. The greater omentum wraps itself around
areas of inflammation caused by disease, trauma or surgery.

Lesser Omentum: double layer of peritoneum that spans the distance between the
visceral surface of the liver and the lesser curvature of the stomach and proximal
duodenum. It lies anterior to the lesser sac of the abdomen. It is formed from:
• hepatogastric ligament - left portion of the lesser omentum between the liver and
lesser curvature of the stomach
• hepatoduodenal ligament - right portion of the lesser omentum between the liver
and the duodenum, contains the portal triad

TIP: Ligaments are often named by the two structures that

they attach – e.g. hepatogastric ligament attaches the liver
and stomach. Don't memorize these ligaments – you can
work out the names by observing the organs to which they
attach.

Lesser sac or omental bursa: part of the peritoneal cavity that lies posterior to the
liver, lesser omentum, stomach and superior part of the greater omentum. Contains two
recesses:
• superior recess – bordered by the diaphragm posteriorly, the caudate lobe of the
liver anteriorly, the esophagus on the left and the inferior vena cava on the right
• inferior recess – lies posterior to the stomach and extends in between the two
double layers of the greater omentum


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Hepatorenal recess (subhepatic pouch of Morrison): lowest point of the peritoneal
cavity when a person is lying in the supine position. Excess intrabdominal fluid will
accumulate there when the person is supine.

Diaphragm: musculotendinous dome that forms the roof of the abdominal cavity and
the floor of the thorax. It has three large openings for passage of structures between the
thorax and abdomen. They are the vena caval foramen, the esophageal hiatus and the
aortic hiatus.
• Attachments: Origin: xiphoid process, inferior six costal cartilages and ribs, L1-3
vertebrae
Insertion: central tendon
• Innervation: phrenic nerve (C3-5) and T5-T12 (sensory only)
• Action: expand the thoracic cavity in the vertical direction by descending during
inspiration

Abdominal Organs and Peritoneal Structures in situ

Liver: largest internal organ, located in the upper right quadrant and a small part of
the upper left quadrant. It is a major metabolic organ with numerous functions
including, glycogen storage, plasma protein synthesis, hormone production and
detoxification. The liver produces bile which it excretes to the duodenum via the left
and right hepatic ducts and (common) bile duct.

Gallbladder: located in a depression on the visceral surface of the liver. The

gallbladder stores and concentrates bile, and excretes it through the cystic duct into
the common bile duct.

Stomach: expanded proximal part of the abdominal gastrointestinal tract. Its function is
to receive and store ingested food and prepare it for digestion in the duodenum. It has
cardiac and fundic regions proximally. The body is the largest part of the stomach. It
crosses the midline of the abdomen and leads into the pylorus where the thick pyloric
sphincter regulates gastric emptying. The greater curvature of the stomach defines its
inferior border. The lesser curvature lies superior to the greater curvature and receives
the lesser omentum.

Portal triad: includes the hepatic artery, portal vein and common bile duct that lie
between the layers of peritoneum that constitute the hepatoduodenal ligament.

Duodenum: proximal portion of the small intestine. Most of it lies deep to the
peritoneum (retroperitoneal).

Spleen – largest lymphatic organ. Resides in the posterior portion of the left upper
quadrant against the diaphragm and lower ribs.

Gastrosplenic and splenorenal ligaments: are double layers of peritoneum that

connect the spleen to the stomach and left kidney, and mark the left boundary of the
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lesser sac. The gastrosplenic ligament contains the short gastric vessels and the
splenorenal ligament contains the splenic vessels and the tail of the pancreas.

Small intestine: is about 7 meters long. It has three parts:

• Duodenum: the most proximal part of the small intestine is continuous with the
pylorus of the stomach. It is divided into four parts. The first is attached to the
hepatoduodenal ligament and is mobile. The remaining three parts make a C-
shaped configuration that cradles the head and neck of the pancreas
retroperitoneally. The duodenum ends at the duodenojejunal junction marked by
the suspensory ligament of the duodenum (ligament of Treitz).
• Jejunum: constitutes the next 2/5 of the small intestine. Internally it has large
circular folds known as plicae circulares. (Review histology!!) You will see these
during dissection of the small intestine.
• Ileum: terminal 3/5 of the small intestine. It empties into the cecum at the ileocecal
junction.

Suspensory muscle (ligament) of the duodenum (ligament of Treitz): suspends the

duodenojejunal junction from the posterior abdominal wall. Contains muscle from both
the right crus of the diaphragm and the duodenum.

Mesentery of jejunum and ileum: mesentery is composed of two layers of

peritoneum with varying amounts of fat, blood and lymphatic vessels and nerves
between them. This mesentery suspends the jejunum and ileum from the posterior
abdominal wall.

Meckel's diverticulum: an embryonic remnant of the relation of the ileum to the yolk
stalk. It is present in about 2% of the population and may contain both gastric and
intestinal mucosa. It can ulcerate causing intestinal bleeding.

Large intestine: consists of cecum, vermiform appendix, colon (4 parts), rectum

and anal canal. (The anal canal and rectum will be studied with the pelvis and
perineum.)
• The cecum is the proximal part of the colon. It is a blind-ended sac lying in the
right anterior iliac fossa inferior to the ileocecal junction.
• The vermiform appendix is a blind-ended finger- or worm-like muscular tube
projecting from the cecum. It has a mesentery, the mesoappendix, which
attaches it to the terminal ileum. It is most often located posterior to the cecum
(retrocecal) but may be found in a variety of positions. The appendix commonly
becomes inflamed and requires surgical removal.
• The ascending colon runs from the cecum to the right colic (hepatic) flexure
near the inferior aspect of the right lobe of the liver. It has no mesentery and is a
secondarily retroperitoneal organ.
• The transverse colon continues from the right colic flexure to the left colic
flexure. It has a mesentery, the transverse mesocolon, and is therefore
classified as an intraperitoneal organ. The transverse colon turns caudally at the
left colic (splenic) flexure. This flexure is held to the diaphragm by the
phrenicocolic ligament that doubles as a support for the spleen.
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 • The descending colon runs inferiorly from the left colic flexure and becomes the
sigmoid colon in the hollow of the left anterior iliac fossa. The descending colon
is secondarily retroperitoneal.
• The sigmoid colon has a mesentery and so is classified as intraperitoneal. It
ends at the level of S3 where the rectum begins in the pelvic cavity.

Tenia coli: three thickened longitudinal bands of smooth muscle unique to the colon.
They constitute a variation in morphology of the outer layer of the muscularis externa.
They are shorter than the rest of the large intestine which is sacculated as a result.

Haustra: bulgings or sacculations of the colon due to the shorter length of the teniae
coli in comparison to the other layers of colon wall.

Appendices epiploicae: collections of fat contained in peritoneal bags that hang off the
colon.

Peritoneal gutters: four channels formed by reflections of peritoneum from the

abdominal wall across the surface of organs. They are the right and left paracolic
gutters adjacent to the ascending and descending parts of the colon, and the gutters
to the right and left of the mesentery of the small intestine. The gutters direct the
flow of fluids and infectious materials, when they are in excess.

Neurovasculature of the Midgut

Superior mesenteric artery (SMA): arises from the abdominal aorta 1 cm inferior to
the celiac trunk, branches of the SMA include the anterior and posterior inferior
pancreaticoduodenal arteries, intestinal arteries, ileocolic artery, right colic artery
and middle colic artery. The SMA arises deep to the body of the pancreas then
passes anterior to both the uncinate process of the pancreas and the third part of the
duodenum.

Superior mesenteric nerve plexus: a dense network of autonomic axons that

surrounds the SMA and its branches.

Intestinal arteries: branches of the SMA that supply the jejunum and ileum.

Arcades: anastomoses between the intestinal arteries within the mesentery of the small
intestine. The arcades give rise to the vasa recta that directly supply the small intestine.
The arcades in the jejunum are simple (one row of ‘windows’). Those in the ileum are
complex featuring several rows of ‘windows’.

Vasa recta: the straight terminal branches of the intestinal arteries. The vasa recta to
the jejunum are long. Those to the ileum are short and smaller in diameter.
Ileocolic artery: supplies the ileum, cecum and ascending colon, and gives rise to the
appendicular artery to the vermiform appendix. The ileocolic artery anastomoses
with the right colic artery via the ascending colic artery.

Superior mesenteric lymph nodes: between 100 and 200 lymph nodes are present in
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the mesentery. They may be enlarged due to inflammation or malignancy. Lymphatic
vessels drain into the superior mesenteric lymph nodes near the origin of the SMA.
Lymph ultimately drains to the cisterna chyli and the thoracic duct.

Structures of the Deep Foregut

Hepatoduodenal and hepatogastric ligaments: folds of peritoneum that form the
lesser omentum. The hepatoduodenal ligament encloses the portal triad.

Portal triad: the portal vein, hepatic artery and (common) bile duct.

Left and right hepatic ducts: drain bile from the left and right sides of the liver into the
common hepatic duct.

Common hepatic duct: originates from the joining of the left and right hepatic ducts
and continues to the bile duct, a distance of a few centimeters.

Cystic duct: runs from the gallbladder to the bile duct. It contains spiral valves (valves
of Heister) that keep it patent. The valves are arranged in such a way that bile can
travel from the common bile duct up into the gallbladder, but NOT back into the liver.
Backflow of bile to the cystic duct occurs when the sphincter of Oddi at the distal end of
the bile duct is closed (e.g. between meals when bile is not needed for digestion).
Gallstones are often found in the cystic duct.

(Common) Bile duct: passes to the right of the proper hepatic artery and anterior to the
portal vein in the hepatoduodenal ligament. It receives the cystic duct from the
gallbladder and the common hepatic duct from the right and left hepatic ducts that
leave the liver. The bile duct enters the second part of the duodenum along with the
main pancreatic duct.

Common hepatic artery: branch of the celiac trunk that travels to the right toward the
liver and gives the hepatic artery proper and the gastroduodenal artery.

Hepatic artery proper: gives rise to the right and left hepatic arteries that supply the
liver and the right gastric artery that supplies the right side of the lesser curvature of
the stomach.

Right and left hepatic arteries: usually give additional branches before entering the
porta hepatis of the liver. The right hepatic artery typically gives the cystic artery to the
gallbladder.

Cystic artery: a branch of the right hepatic artery that supplies the gallbladder.

Right gastric artery: a branch of the hepatic artery proper that supplies the right side of
the lesser curvature of the stomach. It anastomoses with the left gastric artery, a
branch of the celiac trunk, in the lesser omentum.
Gastroduodenal artery: descends from the common hepatic artery opposite the
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origin of the hepatic artery proper. It gives supraduodenal arterial branches to the
duodenum and the right gastroepiploic artery to the greater curvature of the stomach.
Hepatic nerve plexus: autonomic nerves arising from the celiac ganglia and the vagal
trunks. These axons travel along the vessels to their organs.
Portal vein: main vessel bringing blood into the liver from the GI tract. It is part of the
portal triad. It is formed from the union of the superior mesenteric and splenic veins
with contributions from the inferior mesenteric and the gastric veins. It delivers
nutrient-rich deoxygenated blood to the liver.

Celiac Trunk: is the first major unpaired branch of the abdominal aorta. It arises at the
level of T12, just inferior to the median arcuate ligament. It gives rise to the common
hepatic artery, the splenic artery and the left gastric artery.

Common hepatic artery: branch of the celiac trunk that runs toward the right side of
the body along the superior margin of the pylorus and proximal duodenum. It gives rise
to the gastroduodenal artery and the hepatic artery proper.

Gastroduodenal artery: large branch of the common hepatic artery that descends
posterior to the pyloric sphincter and duodenum, and gives the supraduodenal,
superior pancreaticoduodenal and right gastroepiploic arteries.

Right gastroepiploic artery: a large branch of the gastroduodenal artery that supplies
the right side of the greater curvature of the stomach and related parts of the greater
omentum. It anastomoses with the left gastroepiploic artery along the greater
curvature of the stomach, and sends branches to the duodenum and pancreas.

Left gastric artery: smallest branch of the celiac trunk. It loops superiorly to give the
esophageal artery then inferiorly to supply the left border of the lesser curvature of the
stomach. It anastomoses with the right gastric artery along the lesser curvature.

Splenic artery: largest branch of the celiac trunk. It gives rise to the dorsal pancreatic,
short gastric and left gastroepiploic arteries on its way to the spleen. It has a
tortuous course along the superior margin of the pancreas.

Hepatic Portal System

Hepatic portal venous system: brings nutrient-rich blood from the GI tract to the liver.
These veins have no valves.

Hepatic portal vein: large diameter vein that originates at the junction of the splenic
and superior mesenteric veins.

Splenic vein: drains the spleen and parts of the stomach and pancreas. It joins the
superior mesenteric vein to form the (hepatic) portal vein.

Superior mesenteric vein: the largest tributary of the (hepatic) portal vein, it drains the
midgut organs.

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Inferior mesenteric vein: drains the hindgut organs into the hepatic portal system. Its
termination is variable but most often is in the superior mesenteric vein. It may terminate
in the splenic vein or all three veins may join at a common site to form the hepatic portal
vein.

Left gastric vein: drains the left side of the lesser curvature of the stomach directly into
the portal vein. It receives esophageal veins which anastomose with the azygos
system of veins.

Portocaval anastomoses: sites where tributaries of the hepatic portal system of veins
anastomose with tributaries of the vena caval system of veins. When venous flow is
reduced in the portal system due to blockage of a vein or congestion in the liver, blood
can pass through these anastomoses and return to the heart via the vena caval system
of veins. The anastomoses are often thin-walled tortuous (varicose) vessels that easily
rupture e.g. hemorrhoids.

Small Intestine (deep dissection, also see page 8)

Duodenum: widest and shortest part of small intestine, mostly retroperitoneal.
Receives the bile duct, main and accessory pancreatic ducts. Contains
numerous tall plicae circulares.

Suspensory ligament of the duodenum (Treitz): supports the duodenojejunal

junction

Jejunum and Ileum: long mobile part of the small intestine that begins at the
duodenojejunal junction and terminates in the cecum at the ileocecal junction. The
jejunum and ileum are continuous with each other but each has distinct characteristics.
• Jejunum: more numerous and tall plicae circulares, simple arcades and longer vasa
recta, absence of encroaching fat
• Ileum: fewer, shorter plicae circulares (often none in its distal part), complex
arcades and shorter vasa recta, presence of encroaching fat in related mesentery

Blood supply and venous drainage: superior mesenteric artery supplies both the
jejunum and ileum. The superior mesenteric vein drains these regions of the gut directly
into the portal vein

Innervation: sympathetic preganglionic axons from spinal cord segments T8-T10

synapse in the superior mesenteric ganglia and postganglionic axons travel to the gut
via branches of the SMA. Parasympathetic axons come from the posterior vagal trunk
and distribute via the superior mesenteric plexus. The intestine is insensitive to pain
stimuli but is sensitive to distension.

Lymphatics: three groups of lymph nodes serve the jejunum and ileum - juxta-
intestinal, mesenteric and superior central nodes. Lymphatic efferent vessels drain into
the ileocolic lymph nodes.

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Liver and Gallblader (deep dissection)
Liver: largest gland in the body. It produces and secretes bile, removes and stores
nutrients from GI venous blood, and detoxifies harmful metabolites. The liver receives
blood from both the hepatic artery (20%) and the portal vein (80%). It is drained by
hepatic veins and an extensive system of lymphatics. It receives autonomic nerves via
the hepatic plexus.

Peritoneal relations: the coronary ligament surrounds the bare area of the liver and is
drawn out into right and left triangular ligaments at its far right and left extremities. The
falciform ligament attaches the diaphragmatic surface of the liver to the anterior
abdominal wall and the lesser omentum attaches the porta hepatis to the lesser
curvature of the stomach and duodenum.

Lobes of the liver: anatomic subdivisions are the right, left, caudate and quadrate
lobes. Functionally there are right, left and posterior lobes.

Left sagittal fissure: (left post of the “H”) separates the left lobe from the caudate and
quadrate lobes. It contains the round ligament (ligamentum teres hepatis, remnant of
the umbilical vein) between the left and quadrate lobes, and the ligamentum venosum
(remnant of the ductus venosus) between the left and caudate lobes.

Right sagittal fissure: (right post of the “H”) divides the right lobe from the caudate and
quadrate lobes. It forms a groove for the inferior vena cava between the caudate and
right lobe, and a bed for the gallbladder between the quadrate and right lobe.

Transverse fissure or porta hepatis: (crossbar of the “H”) as its Latin name suggests,
this is the “door to the liver” and thus contains right and left hepatic ducts, right and left
hepatic arteries, and right and left branches of the portal vein. Lymph vessels near the
porta hepatis drain into hepatic lymph nodes and ultimately into the cisterna chyli.
Some lymphatics of the liver drain into the right lymphatic duct system.

Gallbladder fossa: lies between the right and quadrate lobes and houses the
gallbladder.

Gallbladder: pear-shaped muscular organ that stores and concentrates bile. It

connects to the common hepatic duct via the cystic duct and ejects bile under the
guidance of nerve and hormone signals.

Large Intestine, SMA and IMA (deep dissection)

Superior mesenteric artery: unpaired artery that arises from the abdominal aorta 1 cm
inferior to the celiac artery. Its branches that serve the large intestine include ileocolic,
appendicular, right and middle colic arteries. They arise from the right side of SMA.
Inferior mesenteric artery: unpaired artery that arises from the abdominal aorta at the
level of the L3 vertebra (about 3 cm superior to the aortic bifurcation). Its branches
include the left colic artery, the sigmoidal arteries and the superior rectal artery.

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Superior rectal artery (hemorrhoidal artery): is the last branch of the IMA. It supplies
the superior rectum. The superior rectal vein anastomoses with the middle and inferior
rectal veins which are systemic veins. These anastomoses may become dilated and
form internal hemorrhoids.

Marginal artery (of Drummond): is the name given to the series of anastomoses
between branches of the superior and inferior mesenteric arteries located along the
mesenteric margin of the colon. The anastomosis between the middle and left colic
arteries accommodates blood flow between the superior and inferior mesenteric arterial
fields.

The large intestine can be distinguished from the small intestine by its width, teniae
coli, haustra and omental (epiploic) appendages. There are several parts of the large
intestine: cecum, vermiform appendix, colon and rectum and anal canal.
• Cecum: is the thinnest-walled part of the large intestine. It is intraperitoneal and lies
on the right iliacus muscle. It receives the ileum and gives rise to the vermiform
appendix.
• Vermiform appendix: is an intraperitoneal organ that contains lymphoid tissue. It
can be located by following the teniae coli toward the cecum. The teniae coli begin
at the appendix. The position of the appendix varies.
• Ascending colon: is retroperitoneal on the right posterolateral abdominal wall. It
turns left to become the transverse colon. The right colic (hepatic) flexure occurs
adjacent to the liver near the second part of the duodenum. It is held in place by a
peritoneal ligament, the right colic ligament, sometimes called the duodenocolic
ligament.
• Transverse colon: is intraperitoneal via the transverse mesocolon. It crosses the
abdominal cavity from right to left. The left colic (splenic) flexure occurs more
superiorly than the right and is held to the diaphragm by the phrenicocolic (left colic)
ligament.
• Descending colon: is retroperitoneal on the left posterolateral abdominal wall.
• Sigmoid colon: is intraperitoneal via the sigmoid mesocolon. It is quite variable in
length and how it folds.
• Rectum – a primarily retroperitoneal organ. The upper one-third receives its blood
supply from the IMA and is drained via the IMV. The caudal two-thirds is supplied by
vessels from the pelvic region and will be considered with that dissection.

Ileocecal valve: is at the site where the ileum joins the large intestine. It prevents the
passage of intestinal contents from the large intestine back into the small intestine.

Appendicular artery: is a branch of the iliocolic artery and supplies the vermiform
appendix. Thrombosis in this artery causes necrosis of the appendix.

Superior mesenteric nerve plexus: contains parasympathetic, sympathetic and

visceral afferent axons. Superior mesenteric ganglia receive preganglionic sympathetic
axons from thoracic splanchnic nerves (T9-12) and give postganglionic axons to organs
supplied by the SMA and its branches. Preganglionic parasympathetic axons come from
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the posterior vagal trunk.

Inferior mesenteric nerve plexus: contains parasympathetic, sympathetic and visceral

afferent axons. The intermesenteric and inferior mesenteric ganglia receive
preganglionic sympathetic axons from lumbar splanchnic nerves and send
postganglionic axons to organs supplied by the IMA and its branches. Preganglionic
parasympathetic axons come from pelvic splanchnic nerves (S2, 3, 4).

Visceral afferents: pain sensation is carried via sympathetic nerves back to the dorsal
horn of the spinal cord. Reflex information is carried via parasympathetic pathways.

Stomach and Duodenum (deep dissection)

Pylorus of the stomach: region to the right of the body demarcated by the angular
notch (indentation on lesser curvature).The two parts of the pylorus are the pyloric
antrum and pyloric canal.

Pyloric sphincter: is a thickened circular layer of muscularis externa (inner circular

layer) that controls the discharge of chyme into the duodenum via the pyloric orifice.

Rugae: longitudinal folds of gastric mucosa most numerous in the pylorus.

Duodenum: widest and shortest part of small intestine. It is mostly retroperitoneal and
contains numerous tall plicae circulares. It has four sections: first (superior), second
(descending), third (horizontal) and fourth (ascending). The second part receives the
bile duct and the main pancreatic duct via the major duodenal papilla. Most people
also have a minor duodenal papilla for the accessory pancreatic duct.

Blood supply to duodenum: gastroduodenal and superior pancreaticoduodenal

arteries (from the celiac region) supply the duodenum proximal to the major duodenal
papilla. The inferior pancreaticoduodenal artery (from the SMA) supplies the
duodenum distal to the major duodenal papilla.

Innervation of the duodenum: vagus and sympathetic nerves via the celiac and
superior mesenteric plexuses.

Lymphatics: anterior channels drain into the pancreaticoduodenal and pyloric lymph
nodes, posterior channels drain into superior mesenteric lymph nodes.

(Common) bile duct: a continuation of the common hepatic duct from the right and left
hepatic ducts. It passes to the right of the proper hepatic artery, anterior to the portal
vein in the hepatoduodenal ligament. It receives the cystic duct from the gallbladder and
descends deep to the second part of the duodenum and head of the pancreas to enter
the duodenum half way down its second (descending) part. The bile duct has its own
sphincter, the choledochus (sphincter of Boyden) present at the site where it enters the
duodenum.

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Main pancreatic duct: joins the terminal portion of the bile duct external to the
posteromedial surface of the descending duodenum to form the hepatopancreatic
ampulla (of Vater). The hepatopancreatic ampulla is thickened with a smooth muscle
sphincter: the sphincter of Oddi.

Major duodenal papilla: lies in the second part of the duodenum and receives the
hepatopancreatic ampulla. Gallstones passing through the common bile duct may
become impacted here.

Minor duodenal papilla: lies 1-2cm superomedial to the major duodenal papilla. It
receives the accessory pancreatic duct.

Plicae circulares: numerous tall transverse folds of intestinal mucosa (review your
histology!). They are most numerous and prominent in the duodenum and jejunum,
becoming fewer and shorter toward the termination of the ileum.

Retroperitoneum
Parietal peritoneum: lines the abdominal and pelvic walls and the inferior surface of
the diaphragm.

Gonadal vessels: testicular and ovarian arteries branch from the abdominal aorta
inferior to the renal arteries. They are thin and fragile arteries but travel with the
accompanying gonadal veins which are larger and provide support. The left testicular
and ovarian veins drain into the left renal vein. The right gonadal veins drain into the
IVC. On the anterior surface of the psoas muscle the testicular vessels cross the ureter
and pass through the deep inguinal ring. They never enter the pelvis. The ovarian
vessels cross the ureter at the point where the common iliac vessels branch into the
external and internal iliac arteries, then drop into the pelvis just lateral to the ureters.

TIP: It is important to know the drainage route of the

gonadal veins. This communication can become very
important when assessing for hematogenous spread
of testicular or ovarian cancer.

Ureter: muscular tube that transmits urine from the kidneys to the urinary bladder. It is a
retroperitoneal structure and its path and relationships along the posterior abdominal
wall and into the pelvis are clinically significant.

Kidney, renal fat and fascia: The kidneys, ureters and suprarenal glands are enclosed
in a fatty layer of variable thickness which is surrounded by renal fascia. The right
kidney sits lower than the left (T12- L3 vs T11-L2). The spleen sits superolateral to the
left kidney. A suprarenal gland lies on the superomedial pole of each kidney. The renal
vessels and ureter enter and leave the hilum located of the medial side of the kidney.

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Suprarenal gland: endocrine gland that lies on the superior pole of each kidney. It is
embedded in perirenal fat and enclosed by renal fascia. It lies within the perirenal fat
and is enclosed by renal fascia. The suprarenal glands receive blood supply from three
suprarenal arteries – superior, middle and inferior, and give only one suprarenal vein.
They receive pre-ganglionic axons directly from the greater splanchnic nerve.

Renal vessels: run transversely between the hilum of each kidney and the abdominal
aorta and IVC. The renal veins lie anterior to the renal arteries. The left renal vein drains
the left gonadal and left suprarenal veins as well as the left kidney. The renal arteries
are branches of the abdominal aorta.

Abdominal sympathetic chain: bilateral continuation of the thoracic sympathetic chain

that sits on the anterolateral surface of the lumbar vertebral bodies. It descends into the
pelvis.

Superior hypogastric plexus: mat-like collection of autonomic axons draped over the
bifurcation of the abdominal aorta. Sympathetic axons include those from lumbar
splanchnic nerves and the inferior and intermesenteric ganglia. They descend into the
pelvis. Parasympathetic axons arise from pelvic splanchnic nerves (S2, 3, 4 and ascend
out of the pelvis into the retroperitoneum.

Kidney
Renal fascia: is a specialization of the transversalis fascia that encloses the kidney,
suprarenal gland and perirenal fat. It separates the perirenal fat (inside the renal fascia
adjacent to the kidney capsule) and the pararenal fat (external to the renal fascia). It is
continuous across the midline of the body and creates a potential space in which
infectious material can communicate between right and left kidneys.

Perirenal fat: mass of fatty tissue within the renal fascia that surrounds the kidney and
suprarenal gland.

Pararenal fat: mass of fatty tissue posterior to the renal fascia lying on the muscular
posterior wall.

Extraperitoneal fat: fatty tissue between the renal fascia and the peritoneum. It is
highly variable in quantity.

Renal veins: exit the hilum of the kidney and drain into the inferior vena cava. They lie
anterior to the renal arteries. The left renal vein is longer than the right and receives the
left suprarenal and left gonadal veins.

Renal arteries: paired branches of the abdominal aorta just inferior to the superior
mesenteric artery. The renal arteries lie posterior to the renal veins. The right renal
artery branches a little more superiorly and is longer than the left one. The inferior
suprarenal and ureteric arteries are branches of the renal arteries. The renal arteries
have little collateral blood supply.

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Kidneys: bean-shaped bilateral organs approximately 11-12 cm long, 5-8 cm wide, 3-4
cm thick. The right kidney sits lower than the left (R superior border lies at the level of
12th rib, L superior border lies at the level of the 11th rib). The kidneys are encased in a
layer of perirenal fat surrounded by renal fascia. They sit on a posterior bed of pararenal
fat. Anteriorly they are covered by a variable amount of extraperitoneal fat.

Structures visible in the cut surface of the kidney:

• Cortex: distinct peripheral rim of kidney parenchyma that contains the glomeruli,
proximal and distal convoluted tubules and cortical portion of the collecting ducts.
• Medulla: inner portion of kidney that includes a variable number of renal pyramids
and columns.
• Renal pyramids: contain the straight tubules (Henle’s loops) and distal collecting
ducts.
• Renal papillae: tip or apex of a renal pyramid.
• Minor calyx: collects urine from each pyramid and transfers it into the major
calyxes.
• Major calyx: empties urine into the renal pelvis.

Hilum: indentation on the medial border of each kidney where the renal vessels, ureter
and nerves enter and leave the kidney.

TIP: Know the relationship of the structures in the

hilum. The renal vein is most anterior, the ureter/renal
pelvis is most posterior, and the renal artery lies
between them.

Ureter: muscular tube that transmits urine from the kidneys to the urinary bladder. Its
blood supply comes from multiple sources along its long path (25-30 cm) including the
aorta, renal, gonadal, common and internal iliac, umbilical, superior and inferior vesical
and middle rectal arteries.

Posterior Abdominal Wall

Posterior abdominal wall: the muscular part of the posterior abdominal wall is formed
by the psoas major, iliacus, transversus abdominis and quadratus lumborum muscles;
the bony part consists of T12-L5 vertebrae, the 12th rib and the iliac ala.

Psoas major muscle:

• Attachments: Superior: transverse processes, intervertebral disks and bodies of
T12-L5
Inferior: lesser trochanter of the femur
• Innervation: ventral rami L2-L4
• Action: flex the femur relative to the pelvis and, in reverse, flex the lumbar vertebrae
relative to the femur, as in performing a sit-up

Psoas fascia: specialization of transversalis fascia that encloses the psoas muscle all
the way into the thigh, can constrain inflammatory fluids.
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Psoas minor (inconsistent):
• Attachments: Superior: bodies and intervertebral disks T12-L1
Inferior: pectineal line and iliopubic eminence
• Innervation: ventral rami L1
• Action: assists in flexion of the trunk and posterior pelvic tilt

Quadratus lumborum muscle:

• Attachments: Superior: the inferior border of the 12th rib
Inferior: iliolumbar ligament, iliac crest, lumbar transverse processes
• Innervation: ventral rami T12 –L4
• Action: stabilize the 12th rib during respiration, laterally flex the vertebral column to
the same side, in reverse, elevate the pelvis on the same side (hip hiking)

Quadratus lumborum fascia: anterior lamina of the thoracolumbar fascia

Iliacus muscle:
• Attachments: Superior: anterior iliac fossa
Inferior: lesser trochanter of the femur
• Innervation: femoral nerve, L2-4 spinal levels
• Action: flex the thigh (femur), anteriorly tilt the pelvis

Iliopsoas: a compound muscle, consisting of the iliacus and psoas major

Transversus abdominis (transverse abdominal) muscle:

• Attachments: Origin: lower six costal cartilages, thoracolumbar fascia, iliac crest,
lateral 1/3 of inguinal ligament
Insertion: linea alba and pubic crest
• Innervation: ventral rami T7-L1
• Action: compress abdominal contents

Lumbosacral Plexus
Subcostal nerve (T12): innervates the external oblique, internal oblique, transversus
abdominis, rectus abdominis and pyramidalis muscles and overlying skin.

Iliohypogastric (L1): innervates the internal oblique and transversus abdominis

muscles and branches into an anterior cutaneous branch that supplies the skin above
the pubis, and a lateral cutaneous branch that travels posteriorly and innervates skin
over the superior gluteal region.

Ilioinguinal nerve (L1): innervates the internal oblique and transversus abdominis
muscles and gives femoral cutaneous branches to the upper medial part of the thigh
and anterior scrotal or labial branches.

Lateral cutaneous nerve of thigh (L2, L3): innervates the skin over the anterolateral
thigh.

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Femoral nerve (L2, 3, 4): innervates the skin of the anterior thigh, the muscles of the
anterior compartment of the thigh and the hip and knee joints.

Genitofemoral nerve (L1, 2): innervates the cremaster muscle, the skin of the lateral
scrotum (in females the labium majus) and a small portion of skin inferior and medial to
the inguinal ligament.

Obturator nerve (L2, L3, L4): innervates the adductor group of muscles in the medial
thigh, the hip joint and the pectineus muscle.

Diaphragm
Diaphragm: principal muscle of inspiration, consists of sternal, costal and lumbar
muscular components that insert into a central tendon.
• Attachments: Origin: xiphoid process (sternal part), cartilages of the lower
six ribs (costal part), medial and lateral lumbocostal arches, right crus
(vertebrae L1-L3) and left crus (vertebrae L1-L2) (lumbar part)
Insertion: central tendon
• Innervation: the left and right sides of the diaphragm are innervated by the left and
right phrenic nerves, respectively. The lower intercostal nerves provide sensory
innervation to pleura and peritoneum around the margin of the diaphragm.
• Action: contraction causes the central tendon to descend and the lower ribs to
expand in the coronal plane

Right crus: larger than the left, arises from vertebrae L1-L3, encircles the esophagus,
contributes to the ligament of Treitz.

Left crus: originates from L1-L2.

Median arcuate ligament: formed from the right and left crura and their associated
fascia.

Medial arcuate ligament: passes over the psoas muscle and sympathetic trunk,
extends from the body of L1 to the transverse process of L1.

Lateral arcuate ligament: passes over the quadratus lumborum muscle, extends from
the transverse processes of L1 to the tip of rib 12.

Vena caval foramen (hiatus): opening in the central tendon of the diaphragm at level
T8 for the passage of the IVC and the right phrenic nerve.

Esophageal hiatus: opening in the muscular part of the diaphragm at the level of T10,
transmits the esophagus and the anterior and posterior vagal trunks.

Aortic hiatus: lies posterior to (or between) the two crura of the diaphragm at the level
of T12, transmits the aorta and thoracic duct and sometimes the azygos and
hemiazygos veins.

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Greater splanchnic nerves: pierce the right and left crura of the diaphragm and distribute to
prevertebral ganglia in the abdomen, in particular the celiac and aorticorenal ganglia and the
medulla of the suprarenal glands.

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