腹部解剖图谱.ppt

Abdominal wall山东大学医学院山东大学医学院 解剖教研室解剖教研室李振华李振华Anterior wall Layers ( from superficial to deep)Skin Superficial fasciaAnterolateral musclesTransversalis fascia 腹横腹横筋膜筋膜Extraperitoneal fascia 腹膜腹膜下筋膜下筋膜Parietal peritoneum 壁腹壁腹膜膜 Superficial fascia－divisions below umbilicusSuperficial fatty layer (Camper’s)Membranous layer (Scarpa’s) Muscles of abdomenAnterolateral groupObliquus externus absominis 腹外斜肌腹外斜肌Oblequus enternus abdominis腹内斜肌腹内斜肌Transversus abdominis腹横肌腹横肌Rectus abdominis 腹直腹直肌肌Posterior group Quadiatus lumborum 腰方腰方肌肌Psoas major 腰大肌腰大肌Obliquus externus absominis 腹外斜肌腹外斜肌General direction of fibers: downward, forward and medially (run down and inward)StructuresInguinal ligament 腹腹股沟韧带股沟韧带Lacunar ligament 腔隙腔隙韧带韧带Superficial inguinal ring 腹股沟浅环腹股沟浅环 －－triangular-shaped defect in aponeurosis of obliquus externus abdominis above pubic tubercleObliquus internus abdominis 腹内斜肌腹内斜肌Deep to obliquus externus abdominisGeneral direction of fibres: upwards, forwards and mediallyTransversels abdominis 腹横肌腹横肌Deep to obliquus internus Inguinal falx 腹股沟镰腹股沟镰: arch over spermatic cord, inserted with transverses abdominis fiber into medial part of pecten of pubis Cremaster 提睾肌提睾肌: around the spermatic cord and testisRectus abdominis 腹直肌腹直肌Position: lie on to either of midlineOrigin: pubic crest and symphysisInsertion: xiphoid and 5th-7th costal cartilagesHas 3-4 tendinous intersections 腱腱划划linea semiluaris 半月线半月线 Similar functions for above four pairs of musclesSupport and compress the abdominal visceraIncrease intra-abdominal pressure, aid in expulsive efforts-vomiting, coughing, sneezing, defecation, urination and childbirth.Depress ribs, assist in (the act of force(4)expiration.Flex, lateral flex, and rotate vertebral columnSheath of rectus abdominis 腹直肌鞘腹直肌鞘Ant layer－formed by fusion of aponeurosis of obliquus externus abdominis and anterior leaf of aponeurosis of obliquus internus abdominisPost layerFormed by fusion of posterion leaf of aponeurosis of obliquus internus abdominis and aponeurosis of transverses abdominisAbsent in about 4-5cm below the umbilicus, where aponeuroses of all three muscles form anterior layer the lower free border named arcuate lineBelow this line rectus abdominis in contact with transverse fasciaLinea alba 白线白线－－tendinous raphe between right and left recti from xiphoid to pubic symphysis.Inguinal region 腹股沟区腹股沟区Boundaries Inguinal ligament Lateral margin of rectus abdominisA horizontal line stretching from anterior iliac spine to laeral margin of rectus abdominisDescent of testesSeven-week embryo showing the testis before its descent from the dorsal abdominal wallFetus at 28 week the testis passing through the inguinal canalNewborn Inguinal canal 腹股沟管腹股沟管Position: oblique passage, 4cm long, located 1.5cm above medial half of inguinal lig.BoundariesAnt wallAponeurosis of obliquus externus abdominisObliquus internus abdominis (lateral third of wall)Post wallTransverse fascia Inguinal flax mediallyRoof－arched lower fibers of obliquus internus and transversua abdominisFloor－－inguinal lig．Two openingsSuperficial inguinal ring 腹股沟浅腹股沟浅环环Deep inguinal ring 腹股沟深环腹股沟深环 －defect in transverse fascia 1.5cm above midpoint of inguinal ligamentStructures passing through the inguinal canal Spermatic cord 精索精索 and ilioinguinal nerve髂腹股沟神经髂腹股沟神经 in males Round ligament of uterus 子宫圆韧带子宫圆韧带and ilioinguinal nerve髂腹股沟神髂腹股沟神经经 in females Inguinal Triangle (of Hesselbach) 腹股沟三角腹股沟三角 Boundaries Inguinal ligament inferiorlyLateral border of rectus abdominis medially Inferior epigastric artery laterallyIndirect inguinal heinia and direcet inguinal heinia Superficial vessels and cutaneous nerves Arteries Superficial epigastric a.Superficial iliac circumflex a.Veins Thoracoepigastric v.Superficial epigastric v.Cutaneous nervesAnterior and lateral cutaneous n. of lower six thoracic Iliohypogastric n. (first lumb nerves)Deep vessels and nervesArteres Superior and inferior epigastric arterisLower posterior intercostal a.Subcostal a.Four lumbar a. Nerves Iliohypogastric n. 髂腹下神经髂腹下神经Arises from lubar plexusPasses forward in the interval between obliquus internus and tranversus abdominisPieces obliquus internus abdominis 2.5 cm medial to anterior superior iliac spinePieces aponeurosis of obliquus externus abdominisabout 2.5 cm above superficial inguinal ringIlioinguinal n. 髂腹股沟神经髂腹股沟神经Runs parallel with iliohypogastric n. at a lower levelEnters inguinal canal and emerges through superficial inguinal ringGenitofemoral n. 生殖股神经生殖股神经Subcostal incision Muscle-splitting incisionTransverse incision Median or midline incisionLeft paramedian incisionLayer ?Suprapubic incisionAbdomen 2山东大学医学院山东大学医学院 解剖教研室解剖教研室李振华李振华Abdominal aorta 腹主腹主动脉脉Continuation of thoracic aorta at aortic hiatus of diaphragm in front of T12 Terminates at lower border of L4 vertebra by dividing into right and left common iliac arteries Parietal branchesInferior phrenic a. 膈下膈下动脉动脉(one pair)Lumbar a. 腰动脉腰动脉(four pairs of arteries that supply the posterior abdominal wall)Median sacral a. 骶正中骶正中动脉动脉Visceral branches Paired branches Middle suprarenal artery 肾上腺中动脉肾上腺中动脉Renal artery 肾动脉肾动脉Testicular (ovarian) artery 睾丸（卵巢）动脉睾丸（卵巢）动脉Unpaired branches  Celiac trunk 腹腔干腹腔干 －－a short thick vessel that arises from the front of aorta, at the level of T12Superior mesenteric a. 肠系肠系膜上动脉膜上动脉－－arises from the front of aorta, at the level of L2Inferior mesenteric a. 肠系肠系膜下动脉膜下动脉 －－arises from the front of aorta, at level of L3Left gastric a.Common hepatic a.Splenic a.Gastroduodenal a.Proper hepatic a.Right gastric a.Left branchRight branchCystic a. Short gastric a. Left gastrioeploic a.Right gastroepiploic a.Superior pancreaticoduodenal a.Splemic branches Celiac trunk Celiac trunk Superior mesenteric a. Inf. pancresticodudenal a.Jejunal and ileal a.Ileocolic a.Appendicular a.Right colic a.Middle colic a. Superior Mesenteric v.Inferior mesenteric a.Left colic a.Sigmoid a.Superior rectal a. Inferior mesenteric v.Colic marginal arteryRelations of abdominal aortaAnteriorly (from above downward) Pancreas Ascending part of duodenum Radix of mesenteryPosteriorly Upper four lumber vertebrae On its right Inferior vena cavaOn its left Left sympathetic trunkVeins of abdomen and pelvisInternal iliac vein 髂内静脉内静脉Parietal tributaries: accompany with arteriesVisceral tributaries →superior rectal vein→inferior mesenteric v.①Rectal venous plexus →inferior rectal vein→internal iliac v.直直肠静脉静脉丛 →anal vein→internal pudendal v. ②Vesical venous plexus 膀胱静脉膀胱静脉丛→vesical v.③Uterine venous plexus 子子宫静脉静脉丛→uterine v.  External iliac vein 髂外髂外静脉静脉– accompany the arteryCommon iliac vein 髂总髂总静脉静脉– formed by union of internal and external iliac veins in front of sacroiliac joint, end upon L4~L5 by uniting each other to form inferior vena cavaInferior vena cava 下腔静脉下腔静脉Formed by union of two common iliac veins anterior to and just to the right of L4~L5Ascends on the right side of aorta, pierces vena cava foramen of diaphragm opposite the T8 and drains into the right atriumConveys blood from the whole body below the diaphragm to the right atrium Chief tributariesParietalPaired inferior phrenic v. 膈下膈下静脉静脉paired lumbar v. 腰静脉腰静脉 (four)VisceralRight and left renal veins 左、左、右肾静脉右肾静脉Right suprarenal vein 右肾右肾上腺静脉上腺静脉 (left drain into left renal vein) Right testicular or ovarian v右右睾丸（卵巢）静脉睾丸（卵巢）静脉. (left drain into left renal vein)Hepatic veins 肝静脉肝静脉: right, left and intermediateRelations of inferior vena cavaAnteriorly (cranially to caudally)LiverHead of pancreasHorizontal part of duodenumRight testicular (or ovarian) a.Radix of mesenteryPosteriorly Right crus of diaphragmUpper four lumber vertebraeLeft sympathetic trunkParietal branches of abdominal aorta On its right Psoas majorRight kidneyRight suprarenal glandOn its left Abdominal aortaHepatic portal vein 肝肝门静脉静脉General featuresFormed behind the neck of pancreas by the union of superior mesenteric vein and splenic vein Ascends upwards and to the right, posterior to the first part of duodenum and then enters the lesser omentum to the porta hepatis, where it divides into right and left branches There are no functioning valves in hepatic portal system Drains blood from gastrointestinal tract from the lower end of oesophagus to the upper end of anal canal, pancreas, gall bladder, bile ducts and spleenVariation and anomalies of hepatic portal veinTributaries of hepatic portal vein 1. Superior mesenteric v. 肠系膜上静脉肠系膜上静脉2. Inferior mesenteric v. 肠系膜下静脉肠系膜下静脉3. Splenic v. 脾静脉脾静脉4. Left gastric v. 胃左静脉胃左静脉5. Right gastric v.胃右静脉胃右静脉6. Cystic v. 胆囊静脉胆囊静脉7. Paraumbilical v. 附脐附脐静脉静脉Portal-systemic anastomoses1. At the lower end of the oesophagus Hepatic portal vein → left gastric vein → esophageal venous plexus → esophageal vein → azygos vein → superiorvena cava2. At rectal venous plexus Hepatic portal vein → splenic vein → inferior mesenteric vein → superior rectal vein → rectal venous plexus → inferior rectal and anal veins → internal iliac vein → inferior vena cava3. At periumbilical venous plexus Hepatic portal vein→paraumbilical vein→periumbilical venous plexus→thoracoepigastric and superior epigastric vein → superiorvena cavasuperficial epigastric and inferior epigastric veins → inferior vena cava4. Portal-retroperitoneal anastomosis Between the retroperitoneal branches of the colic veins and the lumbar veins, pancreaticoduodenal veins with the renal veins and the subcapsular veins of the liver with the phrenic veins twigs of colic veins (portal) anastomosing with systemic retroperitoneal veins The lymphatic drainage of abdomenLymphatic drainage of abdominal wallTo axillary lymph node from region above umbilicusTo superficial inguinal lymph node from region below umbilicusTo lumbar lymph node from post wall of abdomenLymphatic drainage of abdominal visceraLumbar lymph nodes 腰淋腰淋巴结巴结Lie on posterior abdominal wall, along the abdominal aorta and inferior vena cavaReceive lymph from kidneys, suprarenal glands, testes, ovarirs, fundus of uterus, ovary, and common iliac nodesRight and left lumbar trunks formed by efferent vesselPaired viscera－drain to the lumbar lymph nodesCeliac lymph nodes 腹腔淋腹腔淋巴结巴结 －situated around the celiac trunk Superior mesenteric lymph node 肠系膜上淋巴结肠系膜上淋巴结 －situated around superior mesenteric a. Inferior mesenteric lymph node 肠系膜下淋巴结肠系膜下淋巴结 －situated around inferior mesenteric a. Intestinal trunk 腹腔干腹腔干 －formed by efferent vessel of celiac, superior and inferior lymph nodesThoracic duct 胸导管胸导管Begins in front of L1 as a dilated sac, the cisterna chyli, which formed by joining of left and right lumbar trunks and intestinal trunkEnter thoracic cavity by passing through the aortic hiatus of the diaphragm and ascends along on the front of the vertebral column, between thoracic aorta and azygos veinTravels upward, veering to the left at the level of T5At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angleJust before termination, it receives the left jugular, subclavian and bronchomediastinal trunksDrains lymph from lower limbs, pelvic cavity, abdominal cavity, left side of thorax, and left side of the head, neck and left upper limbSpleen 脾脾Location: lies in the left hypochondriac region (between stomach and diaphragm) deep to the 9th to 11th rib, its long axis corresponds roughly to the 10th ribShape－reddish in colourTwo surfaces Diaphragmatic: smooth, convexVisceral: concave, hilum of spleenTwo extremities Anterior－widerPosterior－rounderTwo border Superior－has 2-3 splenic notch 脾切迹脾切迹, which serve as a landmark on palpation when it is enlarge; normally it is not palpableInferior－rounderFunctions: the spleen is considered to be important in:Formation of lymphocytes and monocytePhagocytosis of bacteria, inert particles and white blood cells and plateletsDestroying effete or abnormal red blood cellsMaking antibodiesRalationships of spleenDiaphragmatic surface－diaphragmVisceral surfaceAnteriorly－fundus of stomachPosteriorly－left suprarenal gland and kidneyInferiorly－tail of pancreas and left colic flexure Nervers of abdomen Lumbar plexus 腰丛腰丛Formation: formed by anterior rami of L1-L3, a part of anterior rami of T12and L4Position: lies within substance of psoas majorBranches Iliohypogastric n. 髂腹下神经髂腹下神经Supplies lower part of anterior abdominal wallIlioinguinal n. 髂腹股沟神经髂腹股沟神经Passes through inguinal canal to supply skin of the groin and scrotum Lateral femoral cutaneous 股股外侧皮神经外侧皮神经Femoral n. 股神经股神经Obturator n. 闭孔神经闭孔神经Genitofemoral n. 生殖股神经生殖股神经Lumbar sympathetic trunk 腰交感干腰交感干Made up of paired chains with four to five lumbar ganglia anterolateral to vertebral columnEnters abdomen via the diaphragm and as a continuation of he thoracic partPasses inferiorly behind common iliac vessels and terminations by joining to form unpaired ganglion impar, anterior to sacrumAbdomen 3山东大学医学院山东大学医学院 解剖教研室解剖教研室李振华李振华Relationships of abdominal viscera First layer－live, gallbladder, stomach Second layer－duodenum, pancreas, spleenThird layer－suprarenal gland, kidney, ureter, inferior vena cava, abdominal aorta, nerves and lymphatics Relationships of the stomachAnterior:Live (right part) Diaphragm (left upper part) Anterior abdominal wall (left lower part) Posterior－separated by peritonum of lesser sac from the following (“stumach-bed”) Pancreas Left suprarenal glandLeft kidneySpleen Transverse colon and transvers mesoclonArteries of stomachLeft and right gastric arteries arise from celiac trunk and proper hepatic artery, repectively. These two vessels run in lesser omentum along lesser curvature , and anastomose end-to-end.Right and left gastroepiploic arteries arise from the gastroduodenal and splenic artery, repectively. These two vessels pass into the greater omentum, run parallel to the greater curvature, and anastomose end-to-end.Short gastric arteries, branches of splenic artery, course through the gastrosplenic ligament and supply the fundus of stomach. Posterior gastric artery (72%) arise from the splenic artery, course through the gastrophrenic ligament and supply the posterior wall of fundus of stomach.Venous drainageRight and left gastric veins empty directly into hepatic portal vein.Left gastroepiploic and short gastric veins drain into hepatic portal vein via the splenic vein.Right gastroepiploic vein join either superior mesenteric vein.Lymphatics of stomach Right and left gastric ln. lie along the same vessels and finally to the celiac ln.Right and left gastroomental ln. lie along the same vessels, the former drain into subpyloric ln., the latter drain into splinic ln.Supra- and subpyloric ln. receive lymphatics from pyloric part and finally to the celiac ln.Splenic ln. receive lymphatics from fundus and left third of stomach, and finally to the celiac ln. Nerve supplyParasympathetic innervation by anterior (left) and posterior (right) vagal trunksThe anterior trunk divides into anterior gastric and hepatic branchesThe posterior trunk divides into posterior gastric and celiac branchesThe anterior and posterior gastric branches descend on the anterior and posterior surfaces of the stomach as a rule about 1 to 2 cm from the lesser curvature and parallel to it in the lesser omentum as far as thr pyloric antrum to fan out into branches called “crow’s foot” to supply the pyloric partSympathetic innervationMainly from celiac gangliaAffent and effent fibers derives from thoracic segments (T5 －L1The duodenumRelationships of superior part AnteriorlyQuadrate lobe of liveGallbladderPosteriorlyCommom bile duct Gastroduodenal a.Hepatic portal v.Inferior vena cavaSuperioely Omental foramenInferiorly Head of pancreas Relationships of descending partAnteriorlyLive Transverse colon and mesocolonLoops of small intestine Posteriorly Right renal hilum and ureterRight renal vesselsMediallyHead of pancreasCommon bile duct and pancreatic ductLaterally Right colic flexureRelationships of horizontal partSuperiorlyHead of pancreasInferiorly Loops of small intestine AnteriorlyRadix of mesenterySuperior mesenteric a. and v. PosteriorlyRight ureterInferior vena cavaAbdominal aorta Relationships of ascending partRight Head of pancreas and abdominal aortaLeft Left kidney and ureterRelationships of liverDiaphragmatic surface－separated by diaphragm from the following Right costodiaphramatic recess and lungCardiac baseVisceral surfaceLeft lobe is related to the stomach and abdominal part of esophagus Right lobe is related to the right colic flexure anteroly, gallbladder and superior duodenal flexure medially, right kidney, superarenal gland posteriorlyBlood supply Arteries Superior pancreaticoduodenal a.Inferior pancreaticoduodenal a.Veins－follow arteries, draining directly into superior mesenteric and hepatic portal veins Divisions and relations of common bile ductSupraduodenal segment Descends along the right margin of hepatoduodenal lig.To the right of proper hepatic a.Anterior to hepatic portal v.Retroduodenal segment Behind the superior part of duodenumAnterior to the vena cavaTo the right of the hepatic portal v.Pancreatic segmentLies in a groove between posterior surface of head of pancreas and duodenum Intraduodenal segment Enters the wall of descending part of duodenum obliquely where jions the pancreatic duct to form the hepatopancreatic ampulla opens at the major duodenal papillaDivisions and relations of pancreasHead of pancreasLocated in C-shapes curvature of doudenumAnteriorly Transverse mesocolon Posteriorly Inferior vena cavaRight renal vesselsCommon bile duct Neck of pancreas Anteriorly－pylorusPosteriorly－commencement pf hepatic portal v. (formed by union of splenic and superior mesenteric veinsBody of pancreasAnteriorly Separated from stomach by omental bursaPosteriorlyAbdominal aortaLeft suprarenal glandLeft kidneyLeft renal vesselsSpleen veinSuperiorly Celiac trunk Celiac plexusSplenic a.Tail of pancreeasRuns in spleicorenal ligament to reach hilum of spleenAccompanies with splenic vessels Relationships of spleenDiaphragmatic surface－diaphragmVisceral surfaceAnteriorly－fundus of stomachPosteriorly－left suprarenal gland and kidneyInferiorly－tail of pancreas and left colic flexure Left gastric a.Common hepatic a.Splenic a.Gastroduodenal a.Proper hepatic a.Right gastric a.Left branchRight branchCystic a. Short gastric a. Left gastrioeploic a.Right gastroepiploic a.Superior pancreaticoduodenal a.Splemic branches Celiac trunk Superior mesenteric a. Inf. pancresticodudenal a.Jejunal and ileal a.Ileocolic a.Appendicular a.Right colic a.Middle colic a. Superior Mesenteric v.Inferior mesenteric a.Left colic a.Sigmoid a.Superior rectal a. Inferior mesenteric v.。