GIT - Posterior Abdominal Wall and Retroperitoneal Viscera 2024 Upload.pdf

Posterior Abdominal Wall & Retroperitoneal Viscera Dr Rex Barton-Smith BSc (Clin Sci), MHSc (Osteo), Grad.Cert.Tert.Ed 1  Learning Outcomes Identify and describe the muscles of the posterior abdominal wall Describe the attachments and...

Posterior Abdominal Wall & Retroperitoneal Viscera Dr Rex Barton-Smith BSc (Clin Sci), MHSc (Osteo), Grad.Cert.Tert.Ed 1  Learning Outcomes Identify and describe the muscles of the posterior abdominal wall Describe the attachments and actions of the posterior abdominal wall muscles Understand the basic relationship between thoracolumbar fascia and abdominal wall musculature Identify major neurovasculature structures closely associated with the posterior abdominal wall Identify and describe the features, vasculature and anatomical relationships of the kidneys Identify suprarenal glands with reference to their shape, position and anatomical relationships Describe the pathway, common constrictions and anatomical relationships of the ureters within the abdomen Comprehend basic applied anatomy of the posterior abdominal wall and retroperitoneal viscera 3  Bony Framework for Abdominal Musculature Posterior abdominal wall muscles anchor to: Thoraco-lumbar vertebrae Inferior rib (Rib 12) Iliac bone (iliac crest and fossa) T12 to L5 Rib 12 Femur (lesser trochanter) Iliac crest and fossa Lesser trochanter 4 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #240 Posterior Abdominal Wall Musculature Right Diaphragm Posterior Crus Attachments Left Crus Arcuate ligaments Medial x 2 Lateral x 2 Median x 1 Lateral Crura Arcuate Median Latin for ‘leg’ Arcuate Right crus L3-4 Medial Arcuate Left crus L2-3 5 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #255  Posterior Abdominal Wall Musculature Psoas major Anchors strongly onto T12-L5 (transverse process and bodies) and associated intervertebral discs. Contributes to vertebral flexion and lateral flexion Diaphragm Innervation – L1-3 anterior rami branches Psoas Major Iliacus Quadratus Arises from the iliac fossa and distally blends with psoas major to Lumborum form ‘iliopsoas’ → anchors to lesser trochanter The iliopsoas muscle is the primary hip flexor Psoas Iliacus Innervation – Femoral nerve Minor* Pelvic Cavity Quadratus Lumborum Attaches to the iliac crest, transverse processes of lumbar vertebrae and superiorly to rib 12 Iliopsoas Quadratus lumborum assists in stabilizing rib 12 and producing trunk lateral flexion 6 Innervation – T12-L4 anterior rami branches Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #255  Antalgic Posture https://www.youtube.com/watch?v=E9RzYbbf3B0 7  Posterior Abdominal Wall Musculature Which muscles can you identify? 8 Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #255 Williams & Wilkins 2010 p335  Posterior Abdominal Wall Musculature Abdominal Cross Section EO IO TA Quadratus Thoracolumbar fascia Psoas Lumborum layers major 9 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #255 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #337  Thoracolumbar Fascia (TLF) TA tendinous origin Internal External Oblique Oblique TLF 10 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #246A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #246B  Posterior Abdominal Wall – Neurovascular Relationships **Neurovascular lecture will also explore structures closely associated with the posterior abdominal wall Neural Arterial Venous Lymphatic 11 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #259 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #256 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #257 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #258  *LOWER LIMB: Major Innervation Lumbar Plexus Overview Iliohypogastric nerve Genitofemoral nerve Genital Femoral Ilioinguinal branch branch nerve Iliohypogastric nerve Ilioinguinal nerve Genital 12 branch RL Drake, AW Vogl, AWM Mitchell, Gray's Anatomy for Students, 2nd Edition, Churchill Livingston Elsevier, Philadelphia PA, 2010. ISBN 978-0-443-06952-9. Fig. 2.59  CUTANEOUS INNERVATION Iliohypogastric nerve Genitofemoral nerve Ilioinguinal nerve Genital Femoral branch branch Iliohypogastric nerve Ilioinguinal nerve Genital Orrego, Esteban & Robla-Costales, Javier & Rodriguez Aceves, Carlos Alberto & Martín, Rubén & Álvarez, Adán & Socolovsky, Mariano. (2021). Neuropathic inguinal pain due to nerve injury after a branch laparoscopic appendectomy: first pediatric case described in the literature. Child's Nervous System. 37. 1-6. 10.1007/s00381-021-05177-w. 13  Kidney Revision Location Lateral to T12-L3 lying in the paravertebral gutter Retroperitoneal Function Blood filtration to create urine Anatomical Relationships Close proximity with other viscera, fat, fascia, muscles and skeletal tissue Drake R L, Vogl W, Mitchell A W M. Gray’s Anatomy For Students. Churchill Livingstone; 2005. ISBN 0808923064. p.221, Fig. 4.1 & p.292, Fig. 4.53 14 Kidney – External Features (Anterior View) Superior Pole Capsule Medial Border Lateral Border Renal Artery Entering hilum with Renal Vein nerves and lymphatics Renal Pelvis Inferior Pole 15 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #321A  Kidney – Internal Features (Anterior view) Tubular System Solid Tissues 1. Minor Calyx 2. Major Calyx 1. Renal Cortex Renal Columns Renal Cortex 3. Renal Pelvis 2. Renal Medulla Medullary Pyramid Medullary Papilla Renal fat within renal sinus 16 Moore, Dalley & Agur. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2013 Fig 2.80 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #321B Kidney Vessels Renal vessels typically originate at the level of L2 and follow a horizontal path to/from the hilum Given the respective positions of the abdominal aorta and inferior vena cava, the renal vessels vary in length The typical order of the renal tubular structures at the hilum from anterior to posterior is: Renal Vein Renal Artery Renal Pelvis The kidneys are a heavily vascular organ, receiving Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #319A approximately 1 litre of blood every minute! 17  Renal Artery Branching 2 1 2 3 4 5 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #323A 1. Renal artery 2. Segmental arteries 3. Interlobar arteries 4. Arcuate Arteries 5. Cortical arteries 18  Renal Artery Segmental Branches SEGMENTAL BRANCH SUPPLY Segmental Anterior View Posterior View Renal a. Segmental Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #323B Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #323A Renal artery Segmental arteries Interlobar arteries Arcuate Arteries Cortical arteries 19  Renal Vascular Variation Examples Split renal vein Segmental Early division branch Renal arteries may have variations in their origin, Renal veins can also have similar variations pathway and entry into the kidney The left renal vein is particularly of Despite this, the renal artery segments are consistent as importance due to its longer path, demonstrated in the previous slide tributaries and relationship with the aorta 20 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #324A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #324B  Kidney Fascia and Fat The kidneys are surrounded by perinephric fat which help maintain the kidney in it’s position Renal fascia encloses the kidneys, suprarenal glands and perinephric fat Drake R L, Vogl W, Mitchell A W M. Gray􀀁 s Anatomy For Students. Churchill Livingstone; 2nd ed, 2010. ISBN 978-0-443-06952-9, figures 4.138, p357 21  Kidney Fascia and Fat Sagittal Section Liver Suprarenal gland ANTERIOR POSTERIOR Renal Fascia Drake R L, Vogl W, Mitchell A W M. Gray􀀁 s Anatomy For Students. Churchill Livingstone; 2nd ed, 2010. ISBN 978-0-443-06952-9, figures 4.138, p357 22  Kidney Anterior Relations - Peritoneum Anterior View: Peritoneum Removed Anterior View: Parietal Peritoneum 23 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #319A Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #319B  Kidney Anterior Relations Both Kidneys: Oesophagus are retroperitoneal and have sections where Peritoneum cut the peritoneum has reflected of their anterior surface have viscera in close proximity to their hilum (right – duodenum, left – pancreas) have a suprarenal gland closely relate to colic flexures inferiorly Duodenum The right kidney has a major relationship with the Pancreas liver while the left is in contact with the stomach and spleen 24 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #319B  Kidney Posterior Relations Major Posterior Relations Clinical Significance Costodiaphragmatic recess 25 Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 3rd Ed. Churchill Livingstone Elsevier, 2015 Fig 4.139 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #320A  Kidney Additional Relations Sagittal Section Liver Suprarenal gland ANTERIOR POSTERIOR Renal Fascia Drake R L, Vogl W, Mitchell A W M. Gray􀀁 s Anatomy For Students. Churchill Livingstone; 2nd ed, 2010. ISBN 978-0-443-06952-9, figures 4.138, p357 26 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #332B  Kidneys in situ – Transverse and Sagittal Sections Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7 th Ed. Lippincott Williams & Wilkins 2010 p324 27 Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Williams & Wilkins 2010 p325  Suprarenal Glands Right Suprarenal Gland* Left Suprarenal Gland* Liver Pyramidal shape Crescent shape * Closely relates to Closely relates * superior pole of to supero- kidney medial surface of kidney Wedged Deep to body between the of pancreas kidney, liver and IVC IVC Right kidney Left kidney Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #333A 28 Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #333B  Ureter Revision Smooth muscle tubes that are Microscopic Cross Section retroperitoneal and transport urine from the kidneys to the urinary bladder Peristaltic contractions to transport urine Lumen wall has folds in relaxed state, capable of expansion during peristaltic action Burkitt, Young & Heath Wheater’s Functional Histology 3rd ed. 29 Wolters Kluwer, Lippincott Williams & Wilkins, Atlas of Anatomy, 2009, ISBN Churchill Livingstone Figure 16.23 9780781785051, Chapter 5, plate 5-30  Ureter – Abdominal Components Ureters have a long pathway (~25cm) from the kidneys to the urinary bladder 1 Abdominal pathway closely relates to psoas major Psoas (posteriorly) and gonadal vasculature (anteriorly) major Ureters have common compression sites Gonadal vessels 1. Origin – Renal Pelvis →Ureter 2 2. Pelvic Brim 3. *Entering urinary bladder (covered in pelvic lectures) 3* Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #328 30 Bifid and Double Ureters Bifid ureters are fairly common and can be present on one or both kidneys Double ureters with complete separate pathways from the kidney and entry into the bladder are uncommon Moore, Dalley & Agur. Clinically Oriented Anatomy. 7th Ed. Wolters Kluwer, 2013 Fig B2.32 31  Revision Suggestions Below are images and activities suggested for your revision When revising, consider what activities help you understand the content to be able to reproduce your knowledge 32 Revision Labeling 33  Posterior Abdominal Wall Musculature Which muscles can you identify? 34 Rohen JW & Yokochi C, Color Atlas of Anatomy, A Photographic Study of the Human Body. 7th Ed. Lippincott Netter, FH. Atlas of Human Anatomy. 3rd Ed. New Jersey, Icon Learning Systems Plate #255 Williams & Wilkins 2010 p335