Preface

Agam is a group of budding medicos, who are currently doing their under graduation in
various Medical Colleges across Tamil Nadu and Pondicherry. The group was initiated on 18th
November 2017, in the vision of uniting medicos for various social and professional causes.

We feel delighted to present you Agam Anatomy notes prepared by Agam Divide and Rule
2020 Team to guide our fellow medicos to prepare for university examinations.

This is a reference work of 2017 batch medical students from various colleges. The team
took effort to refer many books and make them into simple notes. We are not the authors of the
following work. The images used in the documents are not copyrighted by us and is obtained from
various sources.

Dear readers, we request you to use this material as a reference note, or revision note, or
recall notes. Please do not learn the topics for the 1st time from this material, as this contain just the
required points, for revision.
Acknowledgement

On behalf of the team, Agam would like to thank all the doctors who taught us Anatomy. Agam
would like to whole heartedly appreciate and thank everyone who contributed towards the making
of this material. A special thanks to Srivardhany Bhaskar and M. Snaha, who took the responsibility
of leading the team. The following are the name list of the team who worked together, to bring out
the material in good form.

• Amrutha Sivakumar
• Prasanna Pandian
• Rifkhaa J
• Bharani VY
• Pranav LV
• Ram Girythar VRS
• Thamizhazhagan G
• Shaziya Mohan
• Sri Kamali G
• Tharshna Priya B
• Ajithvass VC
• Harsha M
• Lehak Agarwal
• Geethik Yallanti
• Athira Sunilkumar
• Balamurugan S
• Sanjana singh
• Varshini R
• Yashi Awasthi
• Tanushree Kumaresan
 1

ABDOMEN ESSAY QUESTIONS

SR. PAGE
QUESTION
NO. NO.
1. INGUINAL CANAL 2
2. DUODENUM 10
3. STOMACH 18
4. PORTAL VEIN 29
5. VERMIFORM APPENDIX 35
6. SUPERIOR MESENTERIC ARTERY 42
7. EXTRAHEPATIC BILIARY APPARATUS 48
8. LIVER 57
9. SPLENIC ARTERY 65
10. PANCREAS 67
11. KIDNEY 75
12. SUPRA RENAL GLAND 81
13. DIAPHRAGM 84
 2

1. INGUINAL CANAL

INTRODUCTION
• It is an oblique intermuscular passage in the lower part of the anterior
abdominal wall.
• It’s about 4 cm long & is directed downwards.
• It is formed due to the descent of testis into the scrotum and ovary into
the pelvis during fetal development.
EXTENT
• From the deep inguinal ring to superficial inguinal ring.
• DEEP INGUINAL RING is an oval opening in the fascia transversalis half
inch above the mid inguinal point.
• SUPERFICIAL INGUINAL RING is a triangular gap in the aponeurosis of
external oblique and lies above and lateral to the public crest.
• BASE OF THE TRIANGLE is formed by pubic crest.
• The two sides of triangle form the lateral & medial margins of opening. It’s
2.5 cm long & 1.2 cm broad at the base.
• The margins are referred to as CRURA which beyond the Apex of triangle
are united by intercrural fibres.
 3

BOUNDARIES OF INGUINAL CANAL

ANTERIOR
• IN WHOLE EXTENT:
1. Skin
2. Superficial fascia
3. External oblique aponeurosis
• IN IT’S LATERAL 1/3RD:
1. Internal oblique aponeurosis and muscle fibers

POSTERIOR
• IN WHOLE EXTENT:
1. Fascia transversalis
2. Extraperitoneal tissue
3. Parietal peritoneum
• IN IT’S MEDIAL 2/3RD:
1. Conjoint tendon, medial two third
2. At its medial end by reflected part of inguinal ligament.

ROOF
• Arched fibers of internal oblique and transversus abdominis muscles.

FLOOR
• Grooved upper surface of inguinal ligament
• Abdominal surface of the lacunar ligament in the medial end.

CONTENTS OF INGUINAL CANAL

IN MALE:

1. SPERMATIC CORD – complete content

2. ILIOINGUINAL NERVE – partial content
 4

IN FEMALE:

1. ROUND LIGAMENT OF UTERUS – complete content

2. ILIOINGUINAL NERVE – partial content
 5

SPERMATIC CORD
• It consists of all the structures that pass to and fro from the testis through
inguinal canal.
CONTENTS:
1. DUCTUS DEFERENS
2. CAT ARTERIES - Cremasteric artery (branch of inferior epigastric A.),
artery to ductus deferens (branch of inferior vesical artery), testicular
artery (branch of abdominal aorta)
3. Pampiniform venous plexus
4. Remains of processus vaginalis
5. NERVE SUPPLY - Genital branch of genitofemoral nerve, sympathetic
fibres accompanying arteries to ductus deferens, visceral afferent nerve
fibres.
6. LYMPHATICS – from testis & drain into pre & para-aortic lymph nodes.

COVERINGS:
1. INTERNAL SPERMATIC FASCIA – derived from fascia transversalis
2. CREMASTERIC FASCIA – it consists of loops of skeletal muscle fibres
united by areolar tissue. The muscle fibres are derived from internal
oblique muscle
3. EXTERNAL SPERMATIC FASCIA – derived from aponeurosis of external
oblique muscle.
 Inguinal Ligament, Inguinal Canal and Hernias 383

Inguinal Hernia 00:30:56 ----- Active space -----

Mechanism of Inguinal Canal :

(BS2F)
These are normal mechanisms preventing occurrence of hernia.
1. Ball valve mechanism.
2. Shutter mechanism.
3. Slit valve mechanism.
4. Flap valve mechanism.

1. Flap valve mechanism :

• Refers to the oblique nature of the inguinal canal.
• Thus, when intra-abdomal pressure ↑es, anterior &
posterior walls approximate ↓Space.
• The canal is straight in kids, and gradually becomes more oblique.

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2. Shutter mechanism : gm
• Due to internal oblique muscle having a triple relation (Anterior wall, roof,
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06

posterior wall).
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• Therefore, during IOM contraction, there is narrowing of the canal from these
gkk

sides.
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• This can be compared to a shutter.

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3. Ball Valve mechanism :

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• Contraction of the cremasteric muscle pulls the testes upward.

• This corrugates the cremasteric fascia around the SIR, and plugs it.

4. Slit valve mechanism :

• Due to the external oblique aponeurosis.
• Attached to the lateral and medial crura of the SIR Contraction of EOM pulls
on the crura ↑es the structural integrity of SIR and the canal.

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 7

HESSELBACH’S TRIANGLE OR INGUINAL TRIANGLE

BOUNDARIES:
• MEDIAL- lower 5 cm of rectus abdominis muscle,
• LATERAL- inferior epigastric artery,
• INFERIOR-medial half of the inguinal ligament
• The FLOOR OF TRIANGLE is covered by peritoneum, extraperitoneal
tissue, fascia transversalis. Medial part of floor – strengthened by conjoint
tendon & lateral part of floor is weak, hence direct inguinal hernia usually
occurs through this part.
• The MEDIAL UMBILICAL LIGAMENT divides the triangle into medial and
lateral parts

CLINICAL ANATOMY

INGUINAL HERNIA

• Protrusion of abdominal viscera through inguinal wall or inguinal canal is

called inguinal hernia.
• There are two types of inguinal hernias, direct and indirect.
• Further direct is divided into medial and lateral based on its position with
respect to the medial umbilical ligament. (obliterated umbilical arteries)
 Inguinal Ligament, Inguinal Canal and Hernias 385

TYPES ----- Active space -----

Indirect Hernia :
• Herniates through the deep ring, travels the
Deep ring
entire length of the inguinal canal, and exits
through the superficial ring.
• Arises outside the hesselbach’s triangle, Superficial ring
herniating through DIR.

Coverings :
1. Skin. 4. Internal spermatic fascia (From FT).
2. External spermatic fascia. 5. Extraperitoneal connective tissue.
3. Cremasteric fascia.
Direct Inguinal Hernia :
Deep ring
• Intestine directly pushes through a weakened

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posterior wall of the inguinal canal, and exits

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through the superficial ring. gm
Superficial
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• It takes the posterior wall of the canal with it. ring

06

• Arise from within the Hesselbach’s triangle.

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Types & their contents :

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1. Lateral direct hernia :

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• From lateral part of Hesselbach’s triangle.

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• Contents :
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i. Skin.
ii. External spermatic fascia.
iii. Cremasteric fascia (TA +IOM).
iv. Fascia transversalis (As it is directly pushing the posterior wall of
inguinal canal).
v. Extraperitoneal connective tissue.

2. Medial direct hernia :

• From medial part of Hesselbach’s triangle.
• Contents :
i. Skin.
ii. External spermatic fascia.
iii. Conjoint tendon (TA + 10M forms CT on the medial side)
iv. Fascia transversalis.
v. Extraperitoneal connective tissue.

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 10

2. DUODENUM
• The duodenum is the 1st, widest & shortest part of small
intestine.
• It extends from pylorus to duodenojejunal flexure.
• It is 25 cm in length.it is retroperitoneal except the proximal
2.5cm.
• Its main function is digestion and mixing of chyme with bile
and pancreatic juices.

SHAPE AND LOCATION

➢ It is ‘c shaped, its concavity encloses the head of pancreas.
➢ It is located in the abdominal cavity above the level of umbilicus opposite
to l1, l2, l3 vertebrae.

PARTS
It is divided into 4 parts,
1. Superior /1st part [2 in]
2. Descending/2nd part [3 in]
3. Horizontal/3rd part [4 in]
4. Ascending/4th part [1 in]

1st PART

COURSE
It begins at pylorus runs upward, backward and reaches the neck of the
gallbladder, where it curves downwards [Superior duodenal flexure] and
continuous with 2nd part.

FEATURES
➢ It develops from foregut
➢ It is retroperitoneal, so freely movable.
➢ It is devoid of circular folds
➢ It is supplied by the branches of coeliac trunk.
 11

RELATIONS:
➢ Anterior: quadrate lobe of liver.
➢ Posterior: portal vein, gastroduodenal artery, common bile duct.
➢ Superior: epiploic foramen
➢ Inferior: head and neck of pancreas

2ND PART:
COURSE:
➢ It begins at superior duodenal flexure, passes downward till the
lower border of L3 vertebrae.
➢ It curves towards the left [inferior duodenal flexure] to
continuous with the 3rd part

AGAM
 12

FEATURES:
➢ Upper half develops from foregut and lower half from midgut
➢ It lies behind the transverse mesocolon.
➢ It receives bile duct, the chief and accessory pancreatic duct.
➢ It is the only part of intestine supplied by double rows of vasa recta
from anterior and posterior pancreaticoduodenal arterial arcades.

RELATIONS:
1. ANTERIOR: gallbladder, right lobe of liver, transverse mesocolon
(commencement), coils of small intestine.
2. POSTERIOR: right kidney, right renal vessels, inferior vena cava [IVC],
right psoas major muscle.
3. MEDIAL: head of pancreas.
4. LATERALLY: from below upward ascending colon, right colic flexure,
right lobe of liver.

3RD PART
COURSE:
➢ It runs horizontally to the left side over the lower part of
L3vertebrae, the curves upward and continuous with 4th part.
RELATION:
➢ ANTERIOR: Root of mesentery, superior mesenteric vessels,
coils of jejunum
➢ POSTERIOR: right psoas major, right ureter, right gonadal vessels,
IVC, abdominal aorta
➢ SUPERIOR: head of pancreas with its uncinate process
➢ INFERIOR: coils of jejunum.

AGAM
 13

4TH PART
COURSE:
It runs upward upto the upper border of L2 vertebrae.

It runs ventrally to become continuous with the jejunum.

RELATION:
➢ Anterior: transverse colon, transverse mesocolon.
➢ Posterior: left psoas major, inferior mesenteric vein, left
sympathetic chain, left gonadal vessels
➢ Superior: body of pancreas
➢ On the left: left kidney and ureter
➢ On the right: upper part of root of mesentery.

INTERIOR OF DUODENUM:
➢ The mucous membrane of the duodenum presents circular
folds [valves of Kerckring], from 2nd part.
➢ The interior part of duodenum presents the following
features,
➢ Major duodenal papilla: It is a conical projection on the
posteromedial wall, situated 8-10 cm distal to pylorus. Common
hepatopancreatic duct opens here.
➢ Minor duodenal papillae: It is small conical projection 2cm proximal
to major duodenal papilla. The accessory pancreatic duct opens
here.
➢ Arch of plica semicircularis: The plica semicircularis forms an
arch above the major duodenal papilla.
➢ Plica longitudinalis: It is a vertical tortuous fold of mucous
membrane extending downwards from major duodenal papillae.

AGAM
 14

DUODENAL RECESSES
➢ At duodenojejunal junction, small pockets of peritoneum called the
recesses occur.
➢ SUPERIOR DUODENAL RECESS: it lies in the left upper end of the
fourth part of duodenum behind the superior duodenojejunal
peritoneal fold with its orifice looking downwards.
➢ INFERIOR DUODENAL RECESS: it lies below the superior recess
behind the inferior duodenojejunal peritoneal fold with its
orifice looking upward.

➢ PARADUODENAL RECESS: it is the lowest one, present behind the

Paraduodenal fold of the peritoneum, left of the fourth part with
its orifice facing medially. Paraduodenal fold contains inferior
mesenteric vein.

➢ RETRODUODENAL RECESS: it is the largest one, it lies behind the

3rd and 4th part of duodenum with its orifice looking down and left

ARTERIAL SUPPLY:

➢ The upper part of duodenum as develops from foregut it is supplied by

branches of coeliac trunk
➢ The lower part as develops from midgut supplied by branches of superior
mesenteric artery.

SUPERIOR PANCREATICODUODENAL ARTERY:

➢ It is a branch of gastroduodenal artery.
➢ [ coeliac trunk → hepatic artery → gastroduodenal artery
→ pancreaticoduodenal artery]

INFERIOR PANCREATICODUODENAL ARTERY:

➢ A branch of superior mesenteric artery.
➢ The above two arteries divides into anterior and posterior
branches.

AGAM
 15

➢ The respective branches of superior and inferior

pancreaticoduodenal arteries anastomose to form anterior
and posterior arterial arcades.
➢ Anterior arcade supplies the anterior part & posterior arcade
supplies the posterior part.

SUPRADUODENAL ARTERY OF WILKIE:

➢ It is a branch of gastroduodenal artery and supplies anterosuperior
& posterosuperior surfaces of 1st part of duodenum.

RETRODUODENAL BRANCHES OF THE GASTRODUODENAL ARTERY

➢ It supply first part of duodenum.

BRANCHES FROM THE RIGHT GASTROEPIPLOIC ARTERY

➢ It supply first part of duodenum.

AGAM
 16

ARTERY FROM THE FIRST JEJUNAL BRANCH OF SUPERIOR

MESENTERIC ARTERY
➢ It supplies fourth part of duodenum.

VENOUS DRAINAGE:
➢ The veins are corresponding to the arteries and superficial to them
➢ They drain into splenic, superior mesenteric, portal veins

LYMPHATIC DRAINAGE:
➢ Lymph vessels follows the arteries and drains into the
pancreaticoduodenal nodes along the inner curve of duodenum.
➢ From there, efferents drain into coeliac, superior mesenteric
lymph nodes, ultimately into cisterns chyli via intestinal lymph
trunk.

NERVE SUPPLY:
➢ Sympathetic nerves are from T6-T9 segments of spinal cord.
➢ Parasympathetic nerves from coeliac and superior mesenteric plexus.

CLINICAL:

DUODENAL ULCER:
➢ It is an inflammatory erosion of duodenal mucosa. It commonly occurs in
1stpart, as it receives acidic chyme from stomach as it is supplied by series
of end arteries. In barium meal X Ray of abdomen, first part of duodenum
presents as triangular shadow called as duodenal cap / bulb.

➢ When duodenal ulcer is present, duodenal cap becomes deformed.

AGAM
 17

DUODENAL INJURIES:

➢ The 3rd pat is more vulnerable to external injury as it is crushed

between the vertebral column and the anterior abdominal wall.
DUODENAL DIVERTICULUM:

➢ It is congenital and mostly occurs in the medial wall of 2nd part of

duodenum.
REFERRED PAIN:
The pain arising from duodenum is poorly localized & referred to the central
epigastrium.

AGAM
 18

3. STOMACH

PRESENTING FEATURES
LOCATION
• Epigastric region
• Left hypochondrium
• Umbilical region

EXTERNAL FEATURES OF STOMACH

TWO ENDS:
A. CARDIAC END – upper/proximal end
• Joins with lower end of Oesophagus
• Left of midline at the level of T11 vertebra
B. PYLORIC END – lower / distal end
• Joins with first part of duodenum
• Just right to midline at the level of L1 vertebral level
• Thicker due to presence of pyloric sphincter

TWO CURVATURES:
A. GREATER CURVATURE – represents left border of stomach
• Gives attachment to greater omentum
B. LESSER CURVATURE – represents right border
• Gives attachment to lesser omentum
• ANGULAR NOTCH (incisura angularis)- most dependent part

TWO SURFACES:
A. ANTEROSUPERIOR SURFACE – forward and upward
B. POSTEROINFERIOR SURFACE – backward and downward

AGAM
 19

THREE PARTS:

A. FUNDUS
• Upper part of stomach (above the horizontal imaginary line drawn at
cardiac end)
• Normally filled with air
• Located just below left dome of diaphragm

B. BODY OF STOMACH
• Main part of stomach
• Between fundus and pylorus
• Can be distended along greater curvature

C. PYLORUS

AGAM
 20

• Lower part of stomach from angular notch to gastroduodenal junction

• Pylorus has 3 parts

PYLORIC ANTRUM

PYLORIC CANAL – lies on head and neck of pancreas

PYLORIC SPHINCTER – circular muscles thickening in this region

AGAM
 21

PERITONEAL RELATIONS
A. BARE AREA OF STOMACH – Part of stomach where blood vessels run
along its curvatures and a small area near cardiac orifice – are not
related to peritoneum
B. RELATED TO LEFT CRUS OF DIAPHRAGM

C. 4 PERITONEAL RELATIONS
1. LESSER OMENTUM – Attached from lesser curvature of stomach to
liver
2. GREATER OMENTUM – Attached from lower 2/3rd of greater
curvature to transverse colon
3. GASTROSPLENIC LIGAMENT – Attached from upper 1/3rd of greater
curvature (fundus) to hilum of spleen
4. GASTROPHRENIC LIGAMENT – Attached from uppermost part of
fundus to diaphragm

AGAM
 418 Abdomen

----- Active space ----- Relations of Stomach 00:23:35

Peritoneal Relations :
1. Lesser omentum.
2. Greater omentum.
3. Gastro - splenic ligament.
4. Gastro - phrenic ligament.

Visceral Relations :
Anterior : Liver

Diaphragm

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Xiphoid process & costal cartilage

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gm Anterior abdomen wall :
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Surgical importance Stomach

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Gastric : surgeries are approached from here

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• Bounded by : to avoid injury to diaphragm & liver.

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1. Inferior border of liver.

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2. Left costal margin.

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3. Transverse colon.
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• Uses : Gastrostomy (Peg tube).

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Posterior Relations :
Structures of stomach bed :
Mnemonic : Dr. SSS Kills Patients Mercilessly.

Diaphragm : Left crus

Left Kidney & suprarenal gland
Spleen
Splenic artery
Splenic flexure of colon
Pancreas

Mesocolon

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 23

POSTERIOR VISCERAL RELATIONS

STOMACH BED STRUCTURES

1. Diaphragm (left dome)

2. Spleen
3. Splenic artery
4. Splenic flexure of colon
5. Suprarenal gland (left)
6. Kidney (left)
7. Pancreas (body)
8. Mesocolon (Transverse mesocolon)

(Mnemonic: Dr. S4 Kills Patient Mercilessly)

BLOOD SUPPLY OF STOMACH

AGAM
 24

ARTERIAL SUPPLY = 5 arteries

1. LEFT GASTRIC ARTERY
• Direct branch from coeliac trunk
2. RIGHT GASTRIC ARTERY
• Branch from Common hepatic artery -branch of coeliac trunk
• Anastomose with left gastric artery along lesser curvature of stomach
3. RIGHT GASTROEPIPLOIC ARTERY
• Branch from gastroduodenal artery – branch of common hepatic
artery of coeliac trunk
4. LEFT GASTROEPIPLOIC ARTERY
• Branch of splenic artery – branch of coeliac trunk
• Anastomoses with right gastroepiploic artery along greater curvature
5. SHORT GASTRIC ARTERIES
• Branch of splenic artery – branch of coeliac trunk
• Supply fundus of stomach.

VENOUS DRAINAGE
1. All veins of stomach directly or indirectly drains into PORTAL VEIN
2. Right and left gastric veins – portal vein
3. Left gastroepiploic and short gastric veins – SPLENIC VEIN
4. Right gastroepiploic vein -SUPERIOR MESENTERIC VEIN
5. PREPYLORIC VEIN /VEIN OF MAYO – drains into Right gastric vein. It
runs in front of pylorus & helps to identify it during surgery.

LYMPH DRAINAGE
• Clinically lymph drainage is important, carcinoma of stomach mainly
spreads through lymphatics to regional lymph nodes
Stomach is divided into 4 regions

1. First imaginary vertical line divides stomach into right 2/3rd & left 1/3rd
2. Horizontal imaginary line divides right 2/3rd into upper 2/3rd (REGION 1) and
(REGION 3) lower 1/3rd
3. Left 1/3rd into (REGION 2) upper 1/3rd and (REGION 4) lower 2/3rd

AGAM
 25

AREA 1 = left gastric nodes

AREA 2 = pancreaticosplenic nodes

AREA 3 = right gastric nodes

AREA 4 = right gastroepiploic nodes

and pyloric nodes

• All these will drain into COELIAC

NODES which in turn is drained in to
cisterna chyli via intestinal lymph
trunk

INTERIOR OF STOMACH
• GASTRIC RUGAE – temporary mucous folds of stomach. They are
longitudinal along lesser curvature & irregular in remaining part.
• GASTRIC PITS – small depressions on mucosal surface in which gastric
glands open

AGAM
 26

• GASTRIC CANAL /CANAL OF MAGENSTRASSE -Longitudinal furrow

between longitudinal folds of mucosa along lesser curvature
• Allows rapid passage of swallowed liquids along lesser curvature
• Vulnerable part to ulceration

MICROANATOMY OF STOMACH
• Wall of stomach has 4 coats:
1. SEROUS COAT – formed by peritoneum
2. MUSCULAR COATS
3. OUTER LONGITUDINAL MUSCLE- at pyloric end divides into
superficial and deep fibres
4. MIDDLE CIRCULAR MUSCLE- at pyloric end thickens to form pyloric
sphincter along with deep fibres of longitudinal coat
• Inner oblique muscle layer
• Submucosal coat
• Inner mucous coat

AGAM
 27

APPLIED ASPECTS
GASTRIC ULCER – more common along lesser curvature (around angular
notch)

GASTRIC CANCER- mainly spreads through lymphatics

• More common along greater curvature
• Enlarged and palpable left supraclavicular nodes called VIRCHOW'S
NODES -TROISIER'S SIGN
GASTRECTOMY- surgical removal of stomach in carcinoma

AGAM
 28

VAGOTOMY- surgical procedure of CUTTING VAGAL NERVES

TO CURE CHRONIC DUODENAL ULCER - 2 types

1. TRUNCAL VAGOTOMY – anterior and posterior Vagal trunks are cut at
lower end of esophagus above origin of hepatic and coeliac branches
2. SELECTIVE VAGOTOMY- anterior and posterior vagal trunks are cut
below origin of hepatic and coeliac branches
Gastric emptying is affected

HIGHLY SELECTIVE VAGOTOMY-

• PARIETAL CELLS OF STOMACH ARE DENERVATED BY CUTTING.
• Anterior gastric branches of anterior nerve of latarjet
• Posterior gastric branches of posterior nerve of latarjet and nerve of
Grassi
• ADVANTAGES: Nerves of Latarjet and their antral branches are preserved,
so gastric emptying remains normal
GASTRIC PAIN – Referred to epigastric region supplied by T6 to T10 spinal
segments.

AGAM
 29

4. PORTAL VEIN:

The blood from

1. Abdominal part of alimentary canal
2. Pancreas
3. Gallbladder
4. Spleen
Is conveyed to the liver by the portal vein
It is called the portal vein because its main tributary, the superior mesenteric
vein, begins in one set of capillaries and a portal vein ends another set of
capillaries in the liver.

FORMATION
It is formed by the union of superior mesenteric and splenic veins behind the
neck of pancreas at the level of 2nd lumbar vertebrae.

AGAM
 30

COURSE
It runs upwards and little to the right, first behind the neck of the pancreas,
next behind the first part of the duodenum, and lastly in the right free margin
of the lesser omentum.

Blood of superior mesenteric vein drains into right lobe. Blood of splenic and
inferior mesenteric vein drains into left lobe. This is called 'streamline flow'.

TERMINATION
• The vein insert the right end of the porta hepatis by dividing into right and
left branches which enter the liver.

RELATIONS
INTRADUODENAL PART
ANTERIORLY: neck of pancreas
POSTERIORLY: inferior vena cava

AGAM
 31

RETRODUODENAL PART
ANTERIORLY
1. First part of duodenum
2. Bile duct
3. Gastroduodenal artery
POSTERIORLY: Inferior vena cava

SUPRADUODENAL PART
ANTERIORLY
1. Hepatic artery
2. Bile duct (within free margin of the lesser omentum)
POSTERIORLY: inferior vena cava separated by epiploic foramen

INTRAHEPATIC COURSE
After entering the liver each branch divides and redivides along with the
hepatic artery to end ultimate clean the hepatic sinusoids where the portal
venous blood mixes with the hepatic arterial blood.

BRANCHES
1. The right branch is shorter and wider then the left branch. After receiving
the systemic vein, it enters the right lobe of the liver
2. The left branch is longer and narrower than the right branch. It traverses
the porta hepatis from its right end to the left end and furnishes branches
to the caudate and quadrate lobe. Just before entering the left lobe of the
liver it receives during fetal life
a. Paraumbilical vein along
the ligamentum teres
b. Ductus venosus along
the ligamentum venosum

AGAM
 32

TRIBUTARIES
1. Left gastric vein
2. Right gastric vein
3. Superior pancreaticoduodenal vein
4. Cystic vein in its right branch
5. Para umbilical veins in its left branch

PORTOSYSTEMIC/PORTOCAVAL COMMUNICATION

AGAM
 Portal Vein & Portocaval Anastomosis 403

Sites of Portocaval Anastomosis 00:21:30 ----- Active space -----

Anterior view with sites of anastomosis :

: Portocaval anastomosis Patent ductus venosus :
• Persistent ductus venosus.
• Connection formed between left
Inferior vena
Left cava (IVC) branch of portal vein & IVC.
branch

Right
Paraumbilical
branch
vein

Umbilicus
Portal vein

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Caput medusae Portal

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Veins of anterior gm(Engorged veins) hypertension.
abdominal wall
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Posterior view of liver with sites of anastomosis

006
r2
kk

Accessory hemiazygos V.
g
vr

Azygous V.
|
w
ro

Hemiazygos V.
ar
M

Oesophageal branch of hemiazygos v.

©

Right branch
Portal hypertension Oesophageal varices.
Oesophageal V.
Left gastric V.

Splenic V.

Inferior mesenteric V.

Superior rectal V.

Portal hypertension Haemorrhoids.

Middle rectal V.
Internal iliac V.
Inferior rectal V.
Inferior vena cava
Sites of anastomosis

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 34

There is some
anastomosis
BARE AREA OF Portal
5 Diaphragmatic between portal vein
LIVER radicles
and systemic veins.
No significance

FALCIFORM Para
6 Diaphragmatic
LIGAMENT umbilical

It may be
Left
LIGAMENTUM accompanied by
7 branch of Inferior vena cava
VENOSUM other congenital
portal
anomalies

APPLIED ANATOMY
1. PORTAL PRESSURE: normal pressure in the portal vein is about 5-15 mm
Hg. It is usually measured by splenic puncture and recording the
intrasplenic pressure
2. PORTAL HYPERTENSION (pressure above 40 mm Hg). It can be caused by
a. Cirrhosis of liver
b. Banti's disease
c. Thrombosis of portal vein
3. Since the blood flow in portal vein is slow and streamlined the toxic
infective substances absorbed from small intestine pass via the superior
mesenteric vein into the right lobe of liver leading to toxic changes for
amoebic abscess in right lobe. The blood lacking in amino acids which is
absorbed via the inferior mesenteric vein affect the left lobe leading to its
fibrosis or cirrhosis

AGAM
 35

5. VERMIFORM APPENDIX
DESCRIPTION
• Vermiform appendix is a narrow worm-like diverticulum.
• Arises from the posteromedial wall of the caecum about 2 cm below the
ileocecal junction

DIMENSIONS
• LENGTH: from 2 to 20 cm (average 9 cm)
• AVERAGE WIDTH: about 5 mm.
• DIAMETER of lumen varies with age and is more in children than adult
and often obliterated after mid-adult life.
• Length varies with age- longer in children than in adults.

PARTS
It presents three parts—base, body, and tip

o BASE: The base is attached to the posteromedial wall of the caecum

about 2 cm below the ileocecal junction.
o All the three taeniae of caecum converge to the base of the appendix
guiding to the surgeon to search for the appendix during
appendicectomy.
o BODY: The body is a narrow tubular part between the base and the tip.
o TIP: The tip is the least vascular distal blind end. It may be directed in
various directions.

SURFACE ANATOMY
• The base of the appendix is marked on the surface by a point 2 cm
below the intersection between the transtubercular plane and the right
midclavicular line (right lateral plane)
• The point representing the base on the surface (vide supra) and
McBurney’s point are in close approximation topographically

AGAM
 36

• Therefore, clinicians equate the surface marking of the appendix to

McBurney’s point.

POSITIONS
• Usually lies in the right iliac fossa.
• Base of appendix is fixed

POSITION OF TIP OF APPENDIX

1. PARACOLIC (11 O’CLOCK) POSITION: The appendix passes upward on the

right side of the
ascending colon in 2%
of the cases.

2.
RETROCAECAL/RETRO
COLIC (12 O’CLOCK)
POSITION:

• The appendix
passes upward
behind the
caecum and the
ascending colon
• commonest
position (65.28%)

3. SPLENIC (2 O’CLOCK) POSITION:

• The appendix passes upward and medially in front of (pre-ileal) or

behind (post-ileal) the terminal part of the ileum.
• The tip of appendix points toward the spleen.
• The pre-ileal position is the most dangerous because inflammation
from the appendix spreads into the general peritoneal cavity.
• pre-ileal - 1% of the cases
• post-ileal in 0.4% of the cases.

AGAM
 37

4. PROMONTERIC (3 O’CLOCK) POSITION: The appendix passes horizontally

toward the sacral promontory. very rare (less than 1%).

5. PELVIC (4 O’CLOCK) POSITION:

• The appendix descends downward and medially, and crosses the pelvic
brim to enter the true pelvis.
• In females, it may be related to the right uterine tube
• second commonest position (31.01%).

6. MIDINGUINAL/SUBCAECAL (6 O’CLOCK) POSITION:

• The appendix passes vertically downward below the caecum

(subcaecal) and points toward the inguinal ligament.
• in 2% of the cases.

DEVELOPMENT
• The caecum and appendix develop from caecal bud that arises from
postarterial segment of midgut loop (near its apex).
• After the return of herniated midgut loop in the abdominal cavity, the
caecal bud occupies the subhepatic position.
• When the postarterial segment of midgut loop elongates to form
ascending colon, the caecal bud gradually descends to reach the right
iliac fossa.
• arrest of its descent leads to subhepatic position of caecum and
appendix.
• The inflammation of subhepatic appendix causes pain and tenderness
in the right hypochondrium and may mimic acute cholecystis
(inflammation of the gall bladder).

PERITONEAL RELATIONS
• It is suspended by a small triangular fold of the peritoneum derived
from the posterior/left layer of mesentery of the ileum- mesentery of
appendix or mesoappendix.
• appendicular vermiform appendix is an intraperitoneal structure

AGAM
 38

• artery runs within the free margin of mesoappendix

• Occasionally the mesoappendix fails to reach the apex of appendix.

ARTERIAL SUPPLY

• The appendix is supplied by a single appendicular artery, a branch of inferior

division of ileocolic artery
• It passes behind the terminal part of the ileum to enter the mesoappendix and
runs in its free margin to reach the tip of appendix which is the least vascular
part.
• When the mesoappendix is short, the appendicular artery rests directly on
the appendicular wall near the tip of appendix.
• In appendicitis, this part of the artery is affected and thrombosed, leading to
gangrenous change in the tip which may perforate.

AGAM
 39

VENOUS DRAINAGE
➢ The vein corresponds to the artery and drains into the superior mesenteric
vein which in turn drains into the portal vein.

LYMPHATIC DRAINAGE
➢ The lymph vessels of the appendix drain into ileocolic lymph nodes directly
or through appendicular nodes in the mesoappendix.

NERVE SUPPLY
• Sympathetic nerve supply carries the pain sensations from the appendix-
derived from the T10 spinal segment via lesser splanchnic nerve and
superior mesenteric plexus.
• Hence, pain referred to the umbilical region.
• Parasympathetic nerve supply is derived from both vagus nerves.

APPLIED ANATOMY

APPENDICITIS:
• The inflammation of the appendix is called appendicitis.
• Acute appendicitis is a common occurrence and is a surgical emergency.
• commonly occurs due to obstruction of its lumen by fecaliths or edema.
• The initial pain of appendicitis is the referred pain and is felt in the
umbilical region because both have same segmental nerve supply (i.e., T10
spinal segment).
• Gradually the pain is localized in the right iliac fossa.
• It is due to involvement of local parietal peritoneum in the region of right
iliac fossa.

AGAM
 40

• The overlying musculature undergoes spasm causing guarding of anterior

abdominal wall.
• On palpation maximum tenderness is elicited at McBurney’s point which is
marked on the surface by a point at the junction of medial two-third and
lateral one-third of a line extending from the umbilicus to the right anterior
superior iliac spine.

PSOAS TEST IN APPENDICITIS:

• When the appendix is retrocaecal in position it lies on and irritates the
right psoas major when inflamed (appendicitis).
• The forced extension of the right thigh in such patients causes increase in
pain in the right iliac fossa.

OBTURATOR TEST IN APPENDICITIS:

When the appendix is pelvic in position, it may irritate the obturator internus
muscle. The flexion and medial rotation of the right thigh on the abdomen
causes pain in the lower abdomen.

APPENDECTOMY:
The incision for appendectomy is purely based on the anatomy of the anterior
abdominal wall. A gridiron (5 shape of a cross beam) incision is given in the
right iliac fossa.

1. The three flat muscles are split along the direction of their fibres.
2. The fascia transversalis and parietal peritoneum are incised together.
3. The appendix is delivered through the wound and cut at its base and
removed.

MICROSCOPIC STRUCTURE
• The appendix has relatively small angulated circular lumen as compared to
its thick wall.

AGAM
 41

• The wall of the appendix consists of four layers from within outwards,
these are: mucosa, submucosa, muscular layer, and serosa.
A. MUCOSA: The surface of the mucous membrane is lined by the
simple columnar cells and numerous goblet cells.
a. It is devoid of villi.
b. The intestinal glands (crypts of Lieberkühn) are few and short.
B. SUBMUCOSA: It contains a ring of large lymphoid follicles with
germinal centers. Hence, the appendix is commonly considered as
an abdominal tonsil.
C. MUSCLE LAYER: It consists of outer longitudinal and inner circular
layers of smooth muscle.
D. SEROSA: It is made up of visceral peritoneum.
• Muscularis mucosa is disrupted by lymphatic nodules.

AGAM
 410 Abdomen

----- Active space ----- EXTRAHEPATIC BILIARY APPARATUS

Overview 00:00:30

Components : Rt hepatic duct Lt hepatic duct

1. Rt & Lt hepatic ducts.
2. Common hepatic ducts. Cystohepatic Common hepatic
3. Gall bladder. angle duct (2.5 cm)
4. Cystic duct.
Cystic duct Common bile duct
5. Bile duct (CBD).

Gall bladder

om
2nd part of

l.c
duodenum

ai
gm Extrahepatic biliary apparatus
@
06

Cystohepatic Angle :
0
r2

• Angle between cystic duct & common hepatic duct.

gkk

• Acute angle.
vr
|
w

Accessory Hepatic Duct :

ro
ar

• Present in 15% population.

M
©

• Originates from Right lobe of liver.

Openings of accessory hepatic duct :

Into cystic duct Into common hepatic duct

• Surgically problematic
• Crowding of Calot’s triangle
Into gall bladder

Into common bile duct

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 Extrahepatic Biliary Apparatus 411

Features of Gall Bladder  00:06:52 ----- Active space -----

Pear shaped sac.

Capacity : 30-50 ml.

Function : Stores & concentrates bile.

Location :
In gall bladder fossa in the inferior surface of liver.

RELATION
Anterior Relations :

Porta hepatis

om
l.c
ai
gm
@
006

Quadrate lobe
r2
kk

GB
g
vr

Upper end : Related to porta hepatis on right margin.

|
w

Rt margin of gall bladder : Along quadrate lobe.

ro
ar

Lower end : Beyond inferior margin of liver.

M
©

Posterior Relations :

N
Gall bladder
B 1st part of duodenum

F 2nd part of duodenum

Transverse colon

Posterior relations

Fundus (F) Body (B) Neck (N)

Posteriorly related to Transverse colon 2nd part of duodenum 1st part of duodenum

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 412 Abdomen

----- Active space ----- Peritoneum

Liver
Hartman’s pouch
Neck
1st part of duodenum
Body
Fundus
Transverse colon
Transverse mesocolon
Sagital section
PARTS
Fundus :
Completely covered with peritoneum.

Location :

om
• Transpyloric plane.

l.c
ai
• Lower border of L1. gm
@
06

Anterior relation : Anterior abdominal wall.

0
r2

Posterior relation : Transverse colon.

gkk
vr

Body :
|
w

Extends upward, backward, and to the left.

ro
ar
M

Upper surface : Liver (Devoid of peritoneum).

©

Lower surface :
• 2nd part of duodenum.
• Covered by peritoneum.
Neck :
Joins with cystic duct.

Upper surface : Liver.

Lower surface : 1st part of duodenum.
Hartman’s pouch :
• Postero-medial dilatation of neck.
• Significance : Gall stones lodged at Hartman’s pouch

Adhesion of gall bladder to 1st part of duodenum

Perforate duodenum.
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 Extrahepatic Biliary Apparatus 413

Blood Supply of Gall Bladder 00:27:07 ----- Active space -----

ARTERIAL SUPPLY Cytic A.

L Branch
R Branch
HA
CHA
Coeliac trunk
GDA

Superior pancreatico duodenal A

Arterial supply
Coeliac trunk

om
Common hepatic A (CHA)

l.c
ai
gm
@

Hepatic artery proper (HPA) Gastroduodenal artery (GDA)

06
0
r2
kk

Left branch Superior pancreotico Retroduodenal A

g

Right branch Rt gastroepiploic A

vr

duodenal A
|
w

Supplies
ro

Cystic A. Supplies
ar

Supplies Lower part of bile

M

Common bile duct

©

• Gall bladder duct (Major supply)

• Upper part of
common bile duct
VENOUS DRAINAGE
• Cystic vein Portal vein.
• Veins in gall bladder fossa Hepatic vein Inferior vena cava.

Lymphatics & Nerve Supply of Gall Bladder 00:32:38

LYMPHATIC DRAINAGE
Cystic Lymph Node of Lund :
• Sentinal node.
• Enlarged in cholecystitis.

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 414 Abdomen

----- Active space ----- NERVE SUPPLY

Supply Referred pain
T7-T11 (Sympathetic) Inferior angle of scapula
Rt & Lt vagus (Parasympathetic) Stomach
Rt phrenic N. Rt shoulder tip

Cystic Duct 00:36:46

Mucous membrane lining cystic duct

Present as cresenteric fold (5-10)

Spiral valve of heister

om
l.c
Keeps the duct open Spiral valve of Heister

ai
gm
Function of Valve of Heister :
@
06

Bile from liver Flow blocked d/t closed sphincter (Eg : Choledochal Sphincter)
0
r2
gkk
vr

Reverse flow into gall bladder through cystic duct

|
w
ro

Concentration of bile
ar
M
©

Contractrion of smooth muscle of gall bladder

Release of bile into duodenum

Common Bile Duct  00:40:00

PARTS
Supraduodenal part

Retroduodenal part
Infraduodenal part
Intraduodenal part

Parts of cystic duct

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 Extrahepatic Biliary Apparatus 415

SPHINCTERS ----- Active space -----

Major duodenal Bile duct

papilla

1
2
3
Ampulla of vater
4
Main pancreatic duct

4 sphincters :
1. Superior choleodochal sphincter.
Boyden/Bile duct sphincter.
2. Inferior choleodochal sphincter.
3. Pancreatic sphincter.
4. Sphincter of Oddi : Common sphincter.

om
l.c
Cystohepatic Triangle of Calot
ai
00:45:46
gm
@
06

BOUNDARIES
0
r2
gkk
vr
|
w
ro

Inferior border of liver (Superior)

ar
M

Common hepatic duct (Medial)

©

Cystic duct (Lateral)

Calot triangle
Boundaries of Calot’s triangle

CONTENTS

Rt branch of hepatc A
Lymph node of Lund
Cystic A

Contents of Calot’s triangle

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 Liver 405

LIVER ----- Active space -----

Features & Anatomical Divisions of Liver 00:00:55

FEATURES
Weight & Size :
Weight :
• Males : 1.8 kg.
• Females : 1.4 kg.
Size : Liver is bigger in intrauterine life d/t haematopoietic action.

Surfaces & Borders of Liver :

om
l.c
ai
gm
@

Diaphragmatic surface : Visceral surface :

06

• Right lateral surface. Inferior surface.

0
r2
kk

• Superior surface.
g
vr

• Posterior surface.
|
w

• Anterior surface.
ro
ar
M
©

Superior surface Posterior surface

Right lateral Anterior surface

surface
Inferior surface : Visceral surface

Inferior border
Surfaces & borders of liver

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 406 Abdomen

----- Active space ----- ANATOMICAL DIVISION OF LIVER

Anterior Surface :
Left lobe (LL)

Falciform ligament (FL) :

Lies at level of left hepatic vein.
Right lobe (RL)
Notch for ligamentum teres :
Obliterated left umbilical vein.
Gall bladder
Cystic notch
(Gall bladder)
Schematic representation of anatomical division of liver

om
l.c
ai
gm
@
006
r2
gkk
vr
|
w
ro
ar
M

Divisions of liver based on hepatic veins

©

Falciform ligament : Divides liver morphologically into right & left lobes.

Anatomical division of liver

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 Liver 407

Posterior - Inferior Surface : ----- Active space -----

Holds ductus venosus

Receives
Blood from left umbilical vein • Hilum of liver.
• Bile duct, portal
vein, hepatic artery.

Remnant of left umbilical v.

Posterior inferior surface of liver

Fissure for ligamentum venosum

om
l.c
Groove for IVC

ai
gm
Left lobe LL
@

CL Caudate lobe
006
r2

Porta hepatis
RL Right lobe
gkk
vr

Fissure for ligamentum teres

QL
|

Quadrate lobe
w
ro
ar
M

Fossa for gall bladder

©

Schematic representation of posterior - inferior view of liver

Bare area :
• The posterior surface of liver devoid of peritoneum d/t zygosis.
• Directly adherent to posterior abdominal wall.
Groove for inferior vena cava
Bare area

CL

Gall bladder
Posterior inferior surface of liver
Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024
 408 Abdomen

----- Active space ----- Visceral Relations :

Oesophageal impression
Bare area
Gastric impression

Renal impression
Pyloric impression

Colic impression
Posterior view of liver with its visceral relations

Surgical Division of Liver 00:25:23

om
l.c
ai
gm Cantlie’s line :
IVC • Lies at level of middle
@

hepatic vein.
06

• Divides liver into 2

0
r2

surgical/physiological lobes.
kk

Right lobe
g
vr

Left lobe
|
w
ro

GB
ar
M
©

Surgical division of liver

Note : Hepatic veins are not visualized from outside.

Couinaud’s Classification :
Based on portal vein & hepatic vein.
Division of liver 2 lobes 4 sectors 8 segments.
Sectors Segments
Right Lateral (RL) sector/Right Posterior sector VI & VII
Right Medial (RM) sector/Right Anterior sector V & VIII
Left Medial (LM) sector/Left Anterior sector I & IV
Left Lateral (LL) sector/Left Posterior sector II & III

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 Liver 409

Inferior vena cava ----- Active space -----

I II
VIII III
VII IV 4
V
3
VI
2
1
Right Middle Left
hepatic V. hepatic V. hepatic v.
Cantlie’s line
Right surgical lobe Left surgical lobe
Falciform ligament
Right anatomical lobe Left anatomical lobe

om
Schematic representation of segmentation of liver

l.c
ai
Drainage of bile : gm
@

Caudate lobe : Only lobe draining bile into both right & left hepatic ducts.
0 06
r2

Summary of divisions of liver :

gkk
vr

Anatomical division of liver Surgical division of liver

|
w

Dividing factor Falciform ligament Cantlie’s line

ro
ar

Level of hepatic vein Left hepatic vein Middle hepatic vein

M
©

II
VII IVA
VIII
III
IVB

VI V LL
LM

RL RM
Segments & sectors of Liver

Caudate lobe : Segment I on posterior side.

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 60

PERITONEAL RELATIONS:
• Most of the liver is covered by peritoneum.
• Areas not covered by peritoneum:
A. Bare area of liver: Triangular area on posterior aspect of right lobe
B. Fossa for gallbladder: On inferior surface of liver between right &
quadrate lobes
C. Groove for IVC: On posterior surface of right lobe
D. Groove for ligamentum venosum
E. Porta hepatis.

LIGAMENTS:

FALSE LIGAMENTS:
FALCIFORM LIGAMENT

➢ Sickle-shaped fold of peritoneum connecting the liver to undersurface of

diaphragm and anterior abdominal wall up to umbilicus
CORONARY LIGAMENT

➢ Triangular fold of peritoneum

➢ Connecting bare area of liver to diaphragm
➢ Consists of 2 layers-
A. Upper
B. Lower
➢ Upper layer is reflected from diaphragm to live
➢ Lower layer is reflected from liver to upper end of kidney
➢ When traced on right side- layers continuous with right triangular ligament
➢ When traced on left side-
A. Upper layer continuous with right layer of falciform ligament
B. Lower layer continuous with peritoneal reflection along right border of
caudate lobe

AGAM
 63

ARTERIAL SUPPLY:
HEPATIC ARTERY

• In a normal adult- nearly 1/3rd of cardiac output passes through the liver
• 20% is delivered through hepatic artery.

VENOUS DRAINAGE:
• Venous blood to liver is supplied by portal vein.
• 80% blood supplied is delivered through portal vein

AGAM
 64

• Most of the venous blood from liver is drained by 3 hepatic veins:

1. LEFT HEPATIC VEIN- between medial & lateral segments of Lt true lobe
2. MIDDLE HEPATIC VEIN- between true right & true left lobes
3. RIGHT HEPATIC VEIN- between anterior and posterior segments of the
true right lobe.
• These veins do not have extrahepatic course.
• Emerge in upper part of groove for IVC  open directly in the IVC  just
below the central tendon of the diaphragm.
• 3 veins may enter IVC independently- left & middle veins usually join 
only 2 major veins join IVC

PERISINUSOIDAL CELLS:
• Hepatic stellate cells (or) Ito cells
• Pericytes found in the perisinusoidal space of liver (or) space of Disse- a
small area between the sinusoids and hepatocytes.
• Major cell type involved in liver fibrosis  formation of scar tissue in
response to liver damage.

AGAM
 65

9. SPLENIC ARTERY

INTRODUCTION:
• Supplies the spleen
• Largest branch of celiac trunk
• Tortuous in its course to allow for movement of spleen

COURSE:
• Arises from celiac trunk  Passes through the lienorenal ligament 
Reaches the hilum of the spleen  Divides into 5 or more branches 
Enter spleen to supply it  Divides repeatedly to form straight vessels-
PENICILLI  Divide into ELLIPSOIDS & ARTERIAL CAPILLARIES 
• CLOSED THEORY:  Capillaries continuous with venous sinusoids in red
pulp  sinusoids join together to form veins
• OPEN THEORY:  Capillaries- end  Open into red pulp  Blood enters
sinusoids through walls
• Compromise theory:

CIRCULATION
▪ OPEN- Distended spleen
▪ CLOSED- Contracted spleen

SEGMENTATION
• On the basis of its blood supply- spleen- segmented-
1. Superior Vascular
2. Inferior Vascular
• 2 segments are separated by an avascular plane.
• Each segment may be subdivided into
▪ 1-2 disc-like middle segments
▪ 1 cap-like pole segment

AGAM
 66

BRANCHES
Apart from terminal branches, Splenic artery gives the following branches:
• Numerous branches to pancreas
• 5-7 short gastric branches
• Left gastroepiploic artery

CLINICAL CORRELATION
SPLENIC INFARCTION:
• Smaller branches of splenic artery are end arteries.
• Their obstruction  embolism results in splenic infarction.
• Causes referred pain in left shoulder KEHR’S SIGN

AGAM
 67

10. PANCREAS
INTRODUCTION:
• Pancreas is a J-shaped or Retort shaped organ.
• It lies transversely across the posterior abdominal wall at the level of L1
and L2.
• Entire organ lies posterior to stomach separated from it by lesser sac.
• It is partly exocrine -secretes digestive juice
• And partly endocrine- secrets hormone insulin.

PARTS OF PANCREAS (FROM RIGHT TO LEFT):

HEAD OF PANCREAS:
• It is enlarged and lies in the concavity of duodenum.
• External features:
➢ Three borders:
1. Superior
2. Right lateral
3. Inferior border
➢ Two surfaces:
1. Anterior
2. Posterior
➢ Uncinate process: Projects from lower part of head towards left.
• Relations:
✓ Superior Border- related to first part of duodenum and superior
pancreaticoduodenal artery.
✓ Inferior border – related to third part of duodenum and inferior
pancreatico-duodenal artery
✓ Right lateral border- related to second part of duodenum, terminal
part of bile duct, anastomosis between two pancreatico-duodenal
arteries.
✓ Relations of surfaces of follows:

AGAM
 68

ANTERIOR SURFACE:

POSTERIOR SURFACE:

AGAM
 69

NECK OF PANCREAS
➢ It is a constricted part between head and body.
➢ It is directed forwards, upwards and to left
➢ It has two surfaces – Anterior and posterior and its relations are us follows.

BODY OF PANCREAS:
• It is elongated and passes towards left with slight upward and backward
inclination.
• Features:
➢ It is triangular in cross-section.
➢ Three borders:
✓ Anterior
✓ Superior
✓ Inferior
➢ Tuber omentale: A part of body of pancreas that projects upwards
beyond the rest of a superior border, a little left to the neck.
• Relations of the borders:
➢ Anterior border- Related to root of transverse mesocolon
➢ Superior Border- Related to coeliac trunk, hepatic artery, splendid
artery.
➢ Inferior border – Related to superior mesenteric vessels.

AGAM
 70

• It has three surfaces:

a) Anterior surface – concave, covered by peritoneum and related to
lesser sac and to stomach.
b) Posterior surface – Devoid of peritoneum and its relations are
c) Inferior surface – covered by peritoneum and related to duodeno-
jejunal flexure, jejunum, left colic flexure.

AGAM
 72

BLOOD SUPPLY
✓ Mentioned in diagram:

DEVELOPMENT
❖ It arises as a
a) LONG DORSAL BUD -Part of head, Neck, tail.
b) SMALL VENTRAL BUD -Inferior part of head, uncinate process.
❖ The ventral bud rotates dorsally to fuse with dorsal bud forming
pancreas.
❖ The duct of ventral bud tap the duct of dorsal pancreatic bud near its
neck and opens into duodenum as main pancreatic duct.
❖ The proximal part of dorsal pancreatic duct forms accessory duct.

AGAM
 74

APPLIED ASPECTS:
1. CARCINOMA OF PANCREAS – common in head of pancreas, it gives a
pressure over bile duct placed posteriorly causes obstructive jaundice
also pressure in portal vein causes ascites.
2. ANNULAR PANCREAS- It is a congenital anomaly where ring of
pancreatic tissue surrounds the duodenum and obstruct it...

AGAM
 75

11.KIDNEY

INTRODUCTION
• Kidneys are retroperitoneal organs resting on posterior abdominal wall
• Located in lumbar region
• Vertebral levels - T12 to L3
• Right kidney is slightly lower than left kidney due to the position of liver

EXTERNAL FEATURES
TWO POLES (ENDS)
• Upper pole (Broad) - T12 level; Related to suprarenal gland
• Lower pole (Narrow) - L3 level

TWO BORDERS
• Medial border - Convex near poles and concave at the middle; Presents
hilum in the middle
• Lateral border - Concave

TWO SURFACES
• Anterior surface - convex
• Posterior surface - Flat; Lies on Posterior abdominal wall

HILUM
• Vertical slit in the middle of medial border at L1 level
• Structures arranged from anterior to posterior - (VAP)

RENAL VEIN

RENAL ARTERY

RENAL PELVIS

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INTERIOR OF KIDNEY

OUTER CORTEX
• Located below renal capsule
• Forms renal columns b/w renal pyramids

INNER MEDULLA
Renal pyramids
↓
Renal papillae (Apex of renal pyramids)
↓
Minor calyces
↓
Major calyces
↓
Renal pelvis
↓
Ureter

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COVERINGS OF KIDNEY
A. FIBROUS CAPSULE (TRUE CAPSULE)
• Formed by condensation of connective tissue
• Stripped off in normal kidneys
• Tightly adherent in inflamed kidneys

B. PERIRENAL FAT (PERINEPHRIC FAT)

• Lies b/w fibrous capsule and renal fascia
• Depletion causes floating kidneys (hypermobility) leading to ureter
kinking

C. RENAL FASCIA (FALSE CAPSULE/FASCIA OF GEROTA)

• Anterior layer - Fascia of Toldt; Posterior layer - Facia of
Zuckerkandl
• Tracing of renal facia /Extension of renal fascia
1. SUPERIOR - Two layers encloses adrenal gland; Continues with
diaphragmatic fascia
2. INFERIOR - Fuses with iliac fossa
3. LATERAL - Fuses with fascia transversalis
4. MEDIAL - Fuses with connective tissue of abdominal aorta and
inferior Vena Cava
D. PARARENAL FAT (PARANEPHRIC FAT)
❖ Forms cushion of kidneys (fills paravertebral gutter)

RELATIONS OF KIDNEY

ANTERIOR RELATIONS

COMMON RELATIONS RIGHT KIDNEY LEFT KIDNEY

Suprarenal area Right suprarenal gland Left suprarenal gland
Jejunal area(medial) Jejunum Jejunum
Colic area (Lateral) Hepatic colic flexure Splenic colic flexure
Right lobe of liver Spleen
SPECIFIC RELATIONS Second part of Stomach
duodenum Pancreas

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POSTERIOR RELATIONS

FOUR MUSCLES THREE NERVES ONE OR TWO RIBS

Diaphragm Subcoastal nerve Right kidney - 12th rib
Quadratus lumborum Iliohypogastric nerve Left kidney - 11th and
Psoas major Ilioinguinal nerve 12th ribs
Transversus abdominis

BLOOD SUPPLY
• RENAL ARTERY - Direct branch of abdominal aorta
• RENAL VEIN - Drains into inferior Vena Cava

Renal artery
↓
Segmental arteries
↓
Interlobar arteries
↓
Arcuate arteries
↓
Interlobular arteries
↓
Afferent arteriole
↓
Glomerulus
↓
Efferent arteriole
↓
Peritubular capillaries
↓
Renal vein

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3. PELVIC KIDNEY - Kidneys are retained in pelvic region

4. ACCESSORY RENAL ARTERIES (More than one renal artery) - Most

common renal vascular anomaly

CLINICAL NOTES

1. RENAL TRANSPLANTATION - Left kidney is preferred as the left renal vein

is longer

2. NUTCRACKER SYNDROME - Compression of left renal vein and duodenum

(D 3) b/w superior mesenteric artery and abdominal aorta

3. RENAL SURGERY - Approach from posterior abdominal wall

4. RENAL ANGLE -
• Angle between lower border of 12th rib and lateral border of erector spinae
• Site of tenderness in renal pathologies (Murphy's punch sign)

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12. SUPRA RENAL GLAND:

MICROSCOPIC STRUCTURE:
• Connective tissue surrounds the capsule.
• Cortex and medulla are differentiated.
• Cortex with the outer zona glomerulosa, middle zona fasciculata and
inner zona reticularis.
• Medulla has large chromaffin cells in groups separated by sinusoids.
• Hormone produced are
1. Mineralocorticoid called aldosterone
2. Glucocorticoid called cortisone and cortisol
3. Sex hormones are estrogen and androgen
4. Catecholamines are adrenaline and noradrenaline

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DEVELOPMENT
● The adrenal gland is composed of two embryologically distinct tissues,
the cortex and medulla, arising from the mesoderm and
neuroectoderm, respectively.
● An isolated clump of cells appears within the urogenital ridge, known as
the adrenal-gonadal primordium.
● This tissue gives rise to the fetal adrenal cortex and to Leydig cells.
● At 7 weeks of gestation, sympatho-adrenal cells migrate into the
adrenal primordium.
● In later stages of embryonic development, the cortex engulfs, and
ultimately encapsulates the entire medulla.

CLINICAL ANATOMY
ADDISON’S DISEASE:

• It occurs due to chronic insufficiency of cortical secretion.

• Clinically, it presents as (a) muscle weakness and wasting, (b) increased
pigmentation of skin, (c) low blood pressure, and (d) restlessness and
tiredness, etc.

CUSHING SYNDROME:

• It occurs due to hypersecretion of the adrenal cortex.

CAUSES:

1. Obesity involving the face (moon face), neck, and abdomen

2. Hypertension
3. Hirsutism
4. Masculization (virilism) in female and feminization in male, and
5. Adrenogenital syndrome in children.

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ADRENALECTOMY: (bilateral removal of the adrenal glands)

• It is sometimes done in advanced and inoperable cases of carcinoma

breast and prostate.
• The suprarenal vein must be ligated before manipulating the gland so that
catecholamines do not escape in the circulation.
• The right adrenal gland is more difficult to approach than the left because
part of it lies posterior to the inferior vena cava.
• Pheochromocytoma is a tumor of the adrenal medulla.
• The signs and symptoms are produced due to bursts of epinephrine and
norepinephrine.
• CAUSES:
1. Paroxysms of hypertension
2. Palpitation
3. Headache
4. Excessive sweating and pallor of the skin

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13. DIAPHRAGM
● DIAPHRAGM is a fibromuscular sheet, is a dome shaped muscle.
● Separate thoracic cavity from abdominal cavity.
● Important function is respiration.

PARTS AND ATTACHMENT

ORIGIN - group into three parts

1. Sternal
2. Costal
3. Lumbar

STERNAL PARTS COSTAL PARTS LUMBAR PARTS

Arise from lower six ribs, Arise by means of right
Arise from back of
cartilage, forms right and and left crura and
xiphoid process.
left dome. arcuate ligament.

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CRURA AND ARCUATE LIGAMENT

1. RIGHT CRUS arise from upper 3 lumbar vertebrae and intervening
intervertebral disc.
2. LEFT CRUS arise from the corresponding part of upper two lumbar
vertebrae.
3. MEDIAN ARCUATE LIGAMENT: arched fibrous band stretching between
upper ends of crura.
4. MEDIAL ARCUATE LIGAMENT – Upper margin of psoas sheath. Extends
from body of L2 to transverse process of L1.
5. LATERAL ARCUATE LIGAMENT- upper margin of fascia covering
quadratus lumborum. Extend from tip of transverse process of L1 to 12th
rib.

INSERTION - Central tendon of diaphragm - trifoliate in shape (3 leaflet -

Central, right and left posterior leaflets)

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OPENING - MAJOR AND MINOR

MAJOR STRUCTURE
SITUATION SHAPE LOCATION
OPENING PASSING

IVC, right Right of

VENA CAVAL T8 Quadrangular
phrenic nerve median plane

Oesophagus,
Vagal trunks,
Esophageal Left of median
OESOPHAGEAL T10 Elliptical
branches of plane.
left gastric
artery.

Aorta, thoracic
AORTIC T12 Rounded duct, azygos In the midline
vein

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MINOR OPENING
● Sympathetic trunk-pass behind medial arcuate ligament
● Superior epigastric vessel – Through Space of Larry.
● Musculophrenic artery - Gaps between slips of origin from 7th to 8th ribs.
● Intercostal nerve and vessels pass through gaps between adjoining
costal slips.
● Subcostal nerves and vessels – deep to lateral arcuate ligament.
● Hemiazygos vein – through left crus of diaphragm.
● Greater, lesser and least splanchnic nerve - pierce crus of diaphragm.

SURFACE AND RELATION

SUPERIOR SURFACE- pleura and lung, pericardium

INFERIOR SURFACE - liver (R), fundus of stomach (L), spleen, kidney,

suprarenal

BLOOD SUPPLY AND NERVE SUPPLY

VASCULAR SUPPLY
• Superior and inferior phrenic artery.
• Pericardiophrenic arteries.
• Musculophrenic arteries.
• Superior epigastric artery.
• Lower five intercostal and subcostal artery.
• Phrenic vein

NERVES SUPPLY
• Motor by phrenic nerve.
• Sensory by lower six intercostal nerves.
DEVELOPMENT

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• Septum transversum
• Pleuroperitoneal membrane
• Lateral thoracic wall
• Dorsal mesentery of esophagus

ACTION
• Muscle of inspiration.
• Muscle of abdominal strain.
• Weight lighting muscle.
• Thoraco- abdominal pump.
• Compress the blood in inferior vena cava.
• Compress lymph vessel in thoracic duct - prevent backflow.

APPLIED
HICCUP
• Shoulder tip pain.
• Unilateral paralysis of diaphragm – Damage to phrenic nerve.
• Diaphragmatic hernia: either congenital or acquired.

CONGENITAL HERNIA

• Retrosternal hernia.
• Posterolateral hernia.
• Para esophageal hernia.

ACQUIRED HERNIA

• Traumatic hernia.
• Hiatal hernia.

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ABDOMEN –SHORT ANSWERS

SR. PAGE
QUESTION
NO. NO.
14. TRIANGLE OF MARCILLE 91
15. MUSCLES WITHIN RECTUS SHEATH 92
16. CONTENTS OF SPERMATIC CORD 93
17. CRYPTORCHIDISM 94
18. STRUCTURES IN THE FREE BORDER OF LESSER OMENTUM 95
19. TAENIA COLI 96
20. ARTERIAL SUPPLY OF TRANSVERSE COLON 96
21. HESSELBACH’S TRIANGLE 97
22. CALOT’S TRIANGLE 98
23. DARTOS MUSCLE 99
24. CONJOINT TENDON 100
25. SCROTUM - LAYERS & NERVE SUPPLY 100
26. DIFFERENCE BETWEEN JEJUNUM AND ILEUM 102
27. MCBURNEY’S POINT 103
28. MURPHY’S SIGN 103
29. COURVOISIER’S SIGN / LAW 103
30. POLICEMAN OF ABDOMEN: GREATER OMENTUM 103

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31. BRANCHES OF EXTERNAL ILIAC ARTERY 104

32. TRANSPYLORIC PLANE 104
33. STRUCTURES CROSSED BY THIS PLANE 104
34. SPACE OF RETZIUS 105

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1. TRIANGLE OF MARCILLE
• Also called as LUMBOSACRAL TRIANGLE
• A triangular interval on each side of the body of L5 vertebra
• Apex directed upward

BOUNDARIES:
1. MEDIALLY - body of L5 vertebra
2. LATERALLY - medial border of psoas major
3. INFERIORLY / BASE - Ala of sacrum
4. APEX - junction of psoas and body of L5 vertebra
5. FLOOR/POSTERIOR WALL - Transverse process of L5 vertebra and
iliolumbar ligament

CONTENTS:
• From medial to lateral sides, these are:
1. Sympathetic trunk
2. Lumbosacral trunk
3. Iliolumbar artery
4. Obturator nerve

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2. MUSCLES WITHIN RECTUS SHEATH

• Rectus sheath is an aponeurotic sheath enclosing
1. Rectus abdominis
2. Pyramidalis (if present)

NERVE
MUSCLE ORIGIN INSERTION
SUPPLY
By 2 tendinous heads: (a) 5th, 6th and Lower 6 or 7
(a) lateral head from 7th costal thoracic
RECTUS lateral part of pubic crest cartilages (along nerves
ABDOMINIS (b) medial head from a horizontal line) (anterior rami
anterior surface of pubic (b) xiphoid of T7 - T12)
symphysis process

(a) anterior surface of

body of pubis Subcostal
PYRAMIDALIS Into linea alba
(b) anterior pubic nerve (T12)
ligament

• Rectus abdominis flexes the trunk or lumbar spine

• Pyramidalis is said to be tensor of linea alba, but the need for such action
is not clear

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3. CONTENTS OF SPERMATIC CORD

• The spermatic cord is a collection of structures that pass to and fro from
testis through the inguinal canal.
• It extends from the deep inguinal ring to the posterior border of the testis
and is covered by three fascial layers.
• The spermatic cord consists of the following six groups of structures:
1. Ductus deferens, in the posterior part.
2. Three arteries:
a. Testicular artery, from abdominal aorta.
b. Cremasteric artery, from inferior epigastric artery.
c. Artery to ductus deferens, from inferior vesical artery
3. Veins, the pampiniform venous plexus.
4. Lymphatics, especially from testis draining into pre- and para-aortic
nodes, and some from the coverings draining into external iliac
nodes.
5. Nerves, genital branch of genitofemoral nerve and sympathetic
fibres which accompany the arteries.
6. Remains of processus vaginalis.

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4. CRYPTORCHIDISM
• Incomplete descent of testis
• In this condition, the testis, during its descent, although it travels through
its normal path but fails to reach the base of the scrotum
• Thus, it may be found:
1. Within the abdomen
2. At the deep inguinal ring
3. Within the inguinal canal
4. At the superficial inguinal ring
5. High up in the scrotum

COMPLICATIONS OF CRYPTORCHIDISM:
• Spermatogenesis often fails to occur in undescended testis.
• An undescended testis is more likely to develop a malignant tumor than a
normal testis. The condition may be surgically corrected.

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5. STRUCTURES IN THE FREE BORDER OF LESSER

OMENTUM
• The right free margin of the lesser omentum contains:
1. Portal vein
2. Hepatic artery and bile duct anterior to the portal vein, with duct to the
right of the artery.
3. Autonomic nerves.
4. Lymphatic and lymph nodes.

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6. TAENIA COLI
• These are ribbon-like bands of the longitudinal muscle coat.
• These bands converge proximally at the base of the appendix and spread
out distally to become continuous with the longitudinal muscle coat of
rectum.
• Thus, taeniae coli are present on all parts of colon and caecum.

LOCATION:
• In the caecum, and descending colon, the positions of taeniae are anterior
(taeniae libera), posteromedial (taeniae mesocolica), and posterolateral
(taeniae mentalis).
• But in the transverse colon the corresponding positions are inferior,
posterior, and superior, respectively.

7. ARTERIAL SUPPLY OF TRANSVERSE COLON

1. RIGHT 2/3RD - middle colic artery
2. LEFT 1/3RD - left colic artery

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8. HESSELBACH’S TRIANGLE
• The inguinal triangle is situated deep to the posterior wall of the inguinal
canal;
• Hence, it is seen on the inner aspect of the lower part of the anterior
abdominal wall.

BOUNDARIES:
1. MEDIALLY - lower 5 cm of lateral border of rectus abdominis muscle
2. LATERALLY - inferior epigastric artery
3. INFERIORLY - medial half of inguinal ligament
4. FLOOR - peritoneum, extraperitoneal tissue and fascia transversalis

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9. CALOT’S TRIANGLE
• Also known as CYSTOHEPATIC TRIANGLE.
• It is in this triangle that most of aberrant segmental right hepatic ducts
and arteries are usually encountered.
• Identification of calot’s triangle and its contents helps the surgeon to
locate the pedicle of gallbladder and its ligation in cholecystectomy.
• Errors in gallbladder surgery often occur from failure to appreciate the
common variations of the extrahepatic biliary system.
• This occurs especially when the right hepatic artery in this triangle
presents a caterpillar-like loop called MOYNIHAN’S HUMP, which may be
inadvertently clamped, ligated along with cystic pedicle, and cut leading to
profuse bleeding.

BOUNDARIES:
1. RIGHT - cystic duct
2. LEFT - common hepatic duct
3. ABOVE - inferior surface of liver
4. APEX - faces downwards; between cystic and common bile duct
CONTENTS:
• Right hepatic artery
• Cystic artery
• Cystic lymph node of Lund

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10. DARTOS MUSCLE

• Replaces the superficial fascia of scrotal wall
• Made of smooth muscles
• Helps to regulate the temperature of testicle
• It is supplied by the sympathetic fibres through genital branch of the
genitofemoral nerve

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11. CONJOINT TENDON

• The fleshy fibres of internal oblique muscle, arises from inguinal ligament,
arch over the inguinal canal and its contents, and then descend to be
inserted on to the pubic tubercle and pecten pubis.
• These fibres fuse with the corresponding tendinous fibres of the
transverse abdominis muscle to form the conjoint tendon.
• This conjoint tendon is inserted into the pubic crest and medial part of the
pecten pubis.

12. SCROTUM - LAYERS & NERVE SUPPLY

• The scrotal wall from without inward is made up of the following 5 layers:
1. Skin
2. Dartos muscle (which replaces the superficial fascia)
3. External spermatic fascia
4. Cremasteric muscle and fascia
5. Internal spermatic fascia

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NERVE SUPPLY:
1. Anterior one-third of the scrotum is supplied by ilioinguinal nerve (L1) and
genital branch of genitofemoral nerve (L1).
2. Posterior two-third of the scrotum is supplied by the posterior scrotal
branches of the perineal nerve (S3) and perineal branch of the posterior
cutaneous nerve of the thigh (S3).
3. The involuntary dartos muscle is supplied by the sympathetic fibres
through genital branch of the genitofemoral nerve.

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 102

13. DIFFERENCE BETWEEN JEJUNUM AND ILEUM

FEATURES JEJUNUM ILEUM

Thinner and less

WALLS Thicker and more vascular
vascular

Narrower and often

Wider and often found empty
LUMEN (diameter=4cm)
found full
(diameter=3.5cm)

CIRCULAR
FOLDS / Smaller and sparsely
Longer and closely set
VALVES OF set
KERCKRING

More, larger, thicker and leaf Less, shorter, thinner

VILLI like and finger like

Large, oval, and more in

number, and found
Small, circular, and few in
PEYER'S throughout the extent
number, and found only in
PATCHES distal part of jejunum
of ileum being
maximum in the distal
part

Contains less fat and Contains more fat and

becomes semi translucent there are no peritoneal
MESENTERY between the vasa recta called windows between the
peritoneal windows vasa recta

ARTERIAL 1 or 2 rows with long vasa 4 or 5 rows with short

ARCADES recta vasa recta

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14. MCBURNEY’S POINT

• It is a point at the junction of medial 2/3rd and lateral 1/3rd of the line
extending from the umbilicus to the anterior superior iliac spine
(spinoumbilical line).
• The base of appendix lies deep to this point.

15. MURPHY’S SIGN

• It is a point where linea semilunaris meets the right subcostal margin. It
corresponds to the tip of the 9th costal cartilage.
• The fundus of gall bladder lies deep to this point.

16. COURVOISIER’S SIGN / LAW

• This law states that the obstructive jaundice with distended and palpable
gallbladder is most likely due to extrinsic obstruction of CBD (e.g.,
carcinoma of head of pancreas).
• On the contrary, obstructive jaundice with non-distended, non-palpable
gallbladder is due to an intrinsic obstruction of CBD (e.g., impaction by
gallstones) because in this case previous cholecystitis makes the
gallbladder fibrotic and contracted.

17. POLICEMAN OF ABDOMEN: GREATER OMENTUM

• It protects the peritoneal cavity from infection due to the presence of a
large number of macrophages.
• It limits the spread of infection.
• The greater omentum moves to the site of infection and seals it off from
the surrounding areas.
• It also moves to the site of perforation of gut to plug the gap to prevent the
leakage of contents of gut in the peritoneal cavity.
• For this reason, greater omentum is often termed the “policeman of
abdomen.”

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18. BRANCHES OF EXTERNAL ILIAC ARTERY

1. Inferior epigastric
2. deep circumflex iliac arteries

19. TRANSPYLORIC PLANE

• The transpyloric plane, also known as ADDISON'S PLANE, is an IMAGINARY
HORIZONTAL PLANE, located halfway between the suprasternal notch of
the manubrium and the upper border of the symphysis pubis at the level of
the first lumbar vertebrae, L1.

20. STRUCTURES CROSSED BY THIS PLANE

1. Pylorus of stomach
2. Fundus of stomach
3. Neck of pancreas
4. Hila of kidneys
5. Origin of Superior Mesenteric artery
6. Formation of portal vein
7. Root of transverse colon
8. Cisterna chyli
9. DJ flexure
10. Termination of spinal cord
11. Fundus of gallbladder
12. 2nd part of duodenum

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21. SPACE OF RETZIUS

• Also called the RETROPUBIC SPACE.

BOUNDARIES
• The posterior aspect of symphysis pubis & adjoining posterior wall of
rectus sheath ANTERIORLY
• The pubic rami & obturator internus muscle LATERALLY
• Inferolateral surfaces of the urinary bladder POSTERIORLY
• SUPERIORLY by the reflection of peritoneum from the Superior surface of
urinary bladder to posterior aspect of anterior abdominal wall upto
umbilicus.
• INFERIORLY by puboprostatic / pubovesical ligaments

CONTENTS
1. Retropubic pad of fat & prostatic venous plexus in males
2. The anterior aspects of the proximal urethra and extraperitoneal portions
of the bladder are seen upon exposure of the retropubic space.

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 Inguinal Ligament, Inguinal Canal and Hernias 385

TYPES ----- Active space -----

Indirect Hernia :
• Herniates through the deep ring, travels the
Deep ring
entire length of the inguinal canal, and exits
through the superficial ring.
• Arises outside the hesselbach’s triangle, Superficial ring
herniating through DIR.

Coverings :
1. Skin. 4. Internal spermatic fascia (From FT).
2. External spermatic fascia. 5. Extraperitoneal connective tissue.
3. Cremasteric fascia.
Direct Inguinal Hernia :
Deep ring
• Intestine directly pushes through a weakened

om
l.c
posterior wall of the inguinal canal, and exits

ai
through the superficial ring. gm
Superficial
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• It takes the posterior wall of the canal with it. ring

06

• Arise from within the Hesselbach’s triangle.

0
r2
gkk

Types & their contents :

vr
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1. Lateral direct hernia :

w
ro

• From lateral part of Hesselbach’s triangle.

ar
M

• Contents :
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i. Skin.
ii. External spermatic fascia.
iii. Cremasteric fascia (TA +IOM).
iv. Fascia transversalis (As it is directly pushing the posterior wall of
inguinal canal).
v. Extraperitoneal connective tissue.

2. Medial direct hernia :

• From medial part of Hesselbach’s triangle.
• Contents :
i. Skin.
ii. External spermatic fascia.
iii. Conjoint tendon (TA + 10M forms CT on the medial side)
iv. Fascia transversalis.
v. Extraperitoneal connective tissue.

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 Abdominal Aorta And Its Branches 387

Coeliac Trunk 00:09:54 ----- Active space -----

Oesophageal
branch of LGA
1 L gastric A. Short gastric A.
(LGA) (SGA)
R branch A)
L branch ic A. (Sp
3 Splen
Cystic A. CT
c Hilar branches
(CA) 2
Gall bladder Common a to spleen
b
hepatic A.
Hepatic artery proper
(CHA) R gastric A.
(HAP)

om
Gastroduodenal A (GDA) L gastroepiploic A.
( L GEA)

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Superior gm
pancreaticoduodenal A.
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Pancreatic branches :
06

R gastroepiploic A. a Dorsal pancreatic A.

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A P
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b Arteria pancreatica magna.

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c Arteria pancreatica caudae.

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Branches of :
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Right hepatic A. Cystic A.

• Hepatic A. proper
Left hepatic A.
Right gastric A.
Anterior branch A .
Sup. pancreaticoduodenal A.
• Gastroduodenal A. Posterior branch P .
Right gastroepiploic A.
Important Points :
Artery to fundus of stomach : Short gastric artery.
Largest artery to stomach : Left gastric artery.
M/c origin of RGA : Hepatic artery proper (Rarely from CHA).
M/c variation of cystic A. : Origin from hepatic artery proper.
Note : Cystic artery m/c originates from right hepatic artery.
Main artery of bile duct : Retroduodenal branch of GDA.
Artery eroded in duodenal ulcers : GDA.

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 388 Abdomen

----- Active space ----- Mesenteric Arteries 00:27:56

SUPERIOR MESENTERIC ARTERY (SMA)

• Artery of midgut.
• From major duodenal papilla upto right 2/3rd of transverse colon.

Hilar

L GEA

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l.c
ai
Posterior gm
@
06

Inferior pancreaticoduodenal A.
0
r2
gkk

Middle colic A.
vr
|
w
ro
ar

R colic A.
M
©

Ileocolic A.

Branches of superior mesenteric artery

Supplies :
• Duodenum. • Caecum & appendix.
• Jejunum. • Ascending colon.
• Ileum. • R 2/3rd of transverse colon.

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 Abdominal Aorta And Its Branches 389

Arteries : ----- Active space -----

1. Inferior pancreaticoduodenal artery :
• 1st branch.
• Anastomosis with superior pancreaticoduodenal A.
2. Jejunal & ileal branch.
3. Middle colic artery : Main artery of transverse colon.
4. Right colic artery : Supplies ascending colon.
Caecal branch.
5. Ileocolic artery
Appendicular branch.

INFERIOR MESENTERIC ARTERY (IMA)

• Artery of hindgut.
• From R 2/3rd of transverse colon upto anal canal.

om
Supplies :

l.c
ai
• L 1/3rd of transverse colon. • Rectum.
gm
• Descending colon. • Anal canal.
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06

• Sigmoid colon.
0
r2
kk

Arteries :
g
vr

1. Left colic artery : Supplies descending colon.

|
w

2. Sigmoidal arteries.
ro
ar

3. Superior rectal artery : Continuation of inferior mesenteric artery.

M
©

SCHEMATICS FOR SMA & IMA TERRITORIES

Inferior pancreaticoduodenal A.
3rd part of duodenum
Middle colic A. Superior mesenteric A.
R branch Arcuate arteries
L branch
Ascending branch
Right colic A. Jejunal & ileal branches

Descending branch Ileocolic A.

Terminal ileum
Ant. & post. caecal A.
Appendicular A.
Branches of superior mesenteric artery

Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024

 390 Abdomen

----- Active space -----

Ascending branch
L colic A.
Descending branch
Sigmoidal A.

Inferior mesenteric A.

Superior rectal A.
(Continuation of inferior mesenteric A.)

Branches of inferior mesenteric artery

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Anastomosis of SMA & IMA
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Griffith’s point :
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Middle colic A. • Junction of midgut & hindgut.

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• Area of ischemia.
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• Anastomosis between middle

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R colic A.
Marginal artery of & Lt colic artery is absent in
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Drummond 5% population.
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absent in GIT
Adv : Ensures blood
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supply of colon. Ileocolic A. Direct connection between

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Lt colic A & middle colic A/

L colic A.
Proximal part of SMA & IMA.
Sigmoidal artery Sudeck’s point :
• Rectosigmoidal junction.
Marginal artery of Drummond • No arcuate artery.

Arteries of gut
Anatomy • v1.0 • Marrow 8.0 MBBS - First Year • 2024
MedEd FARRE: Anatomy

50. Write in brief about Murphy’s sign and its clinical importance. (3 marks)

Answer:
€ Murphy’s sign is a specific clinical sign used by healthcare professionals to help
diagnose gallbladder inflammation, medically known as cholecystitis.

PROCEDURE
€ The doctor asks the patient to take a deep breath and relax.

€ Using their fingers, the doctor gently palpates or presses the area just below
the ribcage on the right side of the patient’s abdomen, in the region where the
gallbladder is located. This is typically in the upper right quadrant of the abdomen.
Observation
€ A positive Murphy’s sign is indicated when the patient experiences sudden and
severe pain and, as a reflex, stops breathing in or “catches” their breath while
inhaling. The pain is usually localized to the area where pressure is applied.
Interpretation
€ A positive Murphy’s sign suggests gallbladder inflammation, most commonly due
to gallstones obstructing the gallbladder’s neck or cystic duct. This inflammation
can lead to cholecystitis.
Clinical Significance
€ Murphy’s sign is an important diagnostic clue for gallbladder issues, but it’s not a
definitive diagnosis on its own.
Courvoisier’s law
€ Dilatation of the gallbladder occurs only in extrinsic obstruction of the bile duct
like pressure by carcinoma of the head of pancreas. Intrinsic obstruction by stones
does not cause any dilatation because of associated fibrosis.
€ Biliary obstruction arises when passage of bile into the duodenum is blocked either
completely or partially.
™ Obstruction may be intrahepatic or extrahepatic

™ Causes are:

‘ The gallstones which slip down into the bile duct and block it.

‘ Cancer of the head of pancreas which compresses the bile duct.

Reference: Human Anatomy Lower Limb Abdomen and Pelvis, Volume 2, BD Chaurasia,
8th Edition, Page No. 340, 341
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47. Write a short note on Meckel’s diverticulum. (3 marks)

Answer:

Meckel’s Diverticulum
Definition € A relatively rare congenital anomaly of the gastrointestinal tract,
arising from the persistent proximal part of the vitellointestinal
duct in the embryo.
Location € Typically occurs in the ileum, about 2 feet (60 cm) proximal to
the ileocaecal valve.
Size € Usually around 2 inches (5 cm) long with a caliber equal to that
of the ileum.
Attachment € The apex may be free or attached to various abdominal structures
by a fibrous band (e.g., umbilicus, mesentery).
Incidence € Occurs in approximately 2% of the population, more common
in males than females.
Complications € Gastrointestinal bleeding due to ulceration and acid production.

€ Inflammation with appendicitis-like symptoms.

€ Intestinal obstruction leading to abdominal pain and cramping

Diagnosis € Imaging studies (e.g., CT scans, barium studies) are used to
locate and diagnose Meckel's diverticulum.
Treatment € Symptomatic cases often require surgical removal
(diverticulectomy).

Reference: Human Anatomy Lower Limb Abdomen and Pelvis, Volume 2, BD Chaurasia, 8th
Edition, Page No. 311

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44. Write short notes on (5 marks)

(A) Epiploic Foramen

(B) Hepatorenal Pouch

(C) Rectouterine Pouch

Answer:

EPIPLOIC FORAMEN/OMENTAL FORAMEN/FORAMEN OF WINSLOW

€ Foramen of Winslow- An opening to the lesser sac.

€ This is a vertical slit-like opening through which the lesser sac communicates with
the greater sac.
€ The foramen is situated behind the right free margin of the lesser omentum at
the level of the 12th thoracic vertebra.
Boundaries
€ Anteriorly: Right free margin of the lesser omentum containing

™ The portal vein

™ Proper hepatic artery

™ The bile duct

€ Posteriorly: The inferior vena cava, the right suprarenal gland and T12 vertebra.

€ Superiorly: Caudate process of the liver.

€ Inferiorly: First part of the duodenum.

Function
€ The primary function of the epiploic foramen is to serve as a communication
pathway between two parts of the peritoneal cavity:

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€ The greater sac: This is the main part of the abdominal cavity that contains most
of the abdominal organs, such as the stomach, intestines, liver, and spleen.
€ The lesser sac (omentum bursa): This is a smaller space located behind the stomach.
The epiploic foramen allows for the movement of fluids and structures between
these two compartments.

CLINICAL SIGNIFICANCE

The epiploic foramen is of clinical importance in certain situations:

€ It can be a site for herniation of abdominal organs, which can lead to various
complications.
€ In cases of pancreatitis or other inflammatory conditions, the foramen of Winslow
can become narrowed or obstructed, potentially causing complications.
€ Surgical Access: Surgeons may use the epiploic foramen as an access route for
certain abdominal procedures.
Hepatorenal Pouch (Morrison’s Pouch)
€ The hepatorenal pouch, also known as the pouch of Morrison, is a space within
the abdominal cavity.

BOUNDARIES
Anteriorly
€ The inferior surface of the right lobe of the liver

€ The gallbladder

Posteriorly
€ The right suprarenal gland

€ Right kidney

€ The second part of the duodenum

€ The hepatic flexure of the colon

€ The transverse mesocolon

€ Head of the pancreas.

€ Superiorly: The inferior layer of the coronary ligament.

€ Inferiorly: It opens into the general peritoneal cavity

€ Left: Communicate with omental bursa.

€ Right: Diaphragm.

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Importance of Hepatorenal Pouch

€ Hepatorenal space is of considerable importance as it is the most dependent
(lowest) part of the abdominal cavity proper when the body is supine.

CLINICAL SIGNIFICANCE
€ It’s a potential space where fluid or blood can accumulate, which can be seen
in conditions like ascites (abnormal fluid buildup in the abdominal cavity) or
hemorrhage (bleeding).
€ Surgeons may access this pouch during certain abdominal surgeries to reach
structures in this area, such as the liver, gallbladder, or right kidney.
Rectouterine Pouch (Pouch of Douglas)
€ This is the most dependent part of the peritoneal cavity when the body is in the
upright position.
€ In the supine position, it is the most dependent part of the pelvic cavity.

Boundaries
€ Anteriorly- by the uterus and the posterior fornix of the vagina.

€ Posteriorly- by the rectum

€ Inferiorly (floor)- by the rectovaginal fold of peritoneum.

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CLINICAL SIGNIFICANCE
€ The rectouterine pouch is of clinical importance such as:

™ It’s a common location for fluid accumulation, such as in cases of pelvic

inflammatory disease, endometriosis, or ovarian cyst rupture.

Reference: Human Anatomy Lower Limb Abdomen and Pelvis Volume 2 BD Chaurasia 8th
Edition Page No. 282, 285, 286

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59. Enumerate the course and branches of the abdominal aorta. (3 marks)

Answer:

BEGINNING, COURSE AND TERMINATION

€ The abdominal aorta begins in the midline at the aortic opening of the diaphragm,
opposite the lower border of vertebra T12.
€ It runs downwards and slightly to the left in front of the lumbar vertebrae, and
ends in front of the lower part of the body of vertebrae, by dividing into the right
and left common iliac arteries.

BRANCHES

The branches of the abdominal aorta are:

€ Ventral branches which develop from ventral splanchnic or vitelline arteries and
supply the gut. These are:
™ Coeliac trunk gives left gastric, common hepatic and splenic branches.

™ Superior mesenteric artery gives inferior pancreaticoduodenal, middle colic,

right colic, ileocolic and 12–15 jejunal and ileal branches.
™ Inferior mesenteric artery gives left colic, sigmoid arteries and continues as
superior rectal artery.
€ Lateral branches develop from the lateral splanchnic or mesonephric arteries and
supply the viscera derived from the intermediate mesoderm.
€ These are right and left:

™ Inferior phrenic arteries

™ Middle suprarenal arteries

™ Renal arteries

™ Testicular or ovarian arteries.

€ Dorsal branches represent the somatic intersegmental arteries and are distributed
to the body wall. These are:
™ Lumbar arteries—four pairs.

™ Median sacral artery—unpaired.

€ Terminal branches are a pair of common iliac arteries. They supply the pelvis and
lower limbs.

Reference: Human Anatomy Lower Limb Abdomen and Pelvis, Volume 2, BD Chaurasia, 8th
Edition, Page No. 395, 396

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60. Enumerate the tributaries of Inferior Vena Cava. (3 marks)

Answer:
€ The inferior vena cava is formed by the union of the right and left common iliac
veins on the right side of the body of the vertebra.

RELATIONS
Anteriorly
€ From above downwards, inferior vena cava is related to:

™ Posterior surface of the liver

™ Epiploic foramen
™ First part of the duodenum and the portal vein
™ Head of the pancreas along with the bile duct
™ Third part of duodenum
™ Right gonadal artery
Posteriorly
€ Above, the right crus of the diaphragm is separated from the inferior vena cava
by the right renal artery and the right coeliac ganglion.
€ Below, it is related to the right sympathetic chain.

Tributaries
€ The common iliac veins
€ The third and fourth lumbar veins
€ The right testicular vein and ovarian vein
€ The renal vein and suprarenal Vein
€ The hepatic veins

DEVELOPMENT OF INFERIOR VENA CAVA

Inferior vena cava develops from:

€ Anastomoses of right and left posterior cardinal veins

€ Right supracardinal vein

€ Right supra subcardinal anastomosis

€ Right subcardinal vein

€ Channel between right subcardinal and cranial part of right vitelline vein

€ Right hepatic cardiac channel

Reference: Human Anatomy Lower Limb Abdomen and Pelvis, Volume 2, BD Chaurasia, 8th
Edition, Page No. 397, 398

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