Arteries and Veins on the posterior abdominal wall pdf - Abdomen

216

CHAPTER 5

the psoas, following the pelvic brim (Fig. 5.63). It gives off

The external iliac artery runs along the medial border of

riorly by the ureter (Fig. 5.72).

tion, the common iliac artery on each side is crossed ante

into the external and internal iliac arteries. At the bifurca

Each artery ends in front of the sacroiliac joint by dividing

medial border of the psoas muscle (Figs. 5.63 and 5.72).

lumbar vertebra and run downward and laterally along the

branches of the aorta. They arise at the level of the 4th

The right and left common iliac arteries are the terminal

These branches are summarized in Diagram 5.1.

and the median sacral artery (Fig. 5.72)

Three terminal branches: the two common iliac arteries

phrenic artery and four lumbar arteries

Five lateral abdominal wall branches: the inferior

renal artery, and testicular or ovarian artery

Three lateral visceral branches: the suprarenal artery,

The Abdomen: Part II—The Abdominal Cavity

■

Common Iliac Arteries

-
-

External Iliac Artery

Development of the Suprarenal Glands

pathetic nerve fibers grow into the medulla and influence the

tion and is arranged in cords and clusters. Preganglionic sym

By this means, the medulla comes to occupy a central posi

of the neural crest. These invade the cortex on its medial side.

The cortex develops from the coelomic mesothelium covering

the posterior abdominal wall. At first, a fetal cortex is formed;

later, it becomes covered by a second final cortex. After birth,

the fetal cortex retrogresses, and its involution is largely com-

pleted in the first few weeks of life.

The medulla is formed from the sympathochromaffin cells

activity of the medullary cells.

Susceptibility to Trauma at Birth
At birth, the suprarenal glands are relatively large because of

the presence of the fetal cortex; later, when this part of the

cortex involutes, the gland becomes reduced in size. During

the process of involution, the cortex is friable and susceptible

to damage and severe hemorrhage.

E M B R Y O L O G I C N O T E S

inferior vena cava

hepatic veins

renal vein

testicular artery

external iliac

artery

inferior epigastric artery

median sacral artery

internal iliac artery

common iliac artery

inferior mesenteric artery

lumbar arteries

renal artery

superior mesenteric artery

suprarenal artery

celiac artery

sympathetic trunk

cisterna chyli

inferior phrenic artery

suprarenal vein

deep circumflex iliac artery

FIGURE 5.72

Aorta and inferior vena cava.

Basic Anatomy

217

celiac artery

artery

internal iliac

vessels

xiphisternal joint

plane (L1)

(T9)

(L4)

inter

intercristal plane

cristal plane

transpyloric

(T12)

mesenteric

inferior mesenteric

(L3)

inferior vena cava

iliac

vessels

anterior superior

iliac spine

common iliac

vessels

aorta

external

superior

(L1)

symphysis pubis

FIGURE 5.73

Surface markings of the aorta and its branches and the inferior vena cava on the anterior abdominal wall.

superior pancreatico-
duodenal artery

1. Three anterior
visceral branches

2. Three lateral
visceral branches

3. Five lateral
abdominal
wall branches

4. Three terminal
branches

a. Celiac artery

b. Superior
mesenteric
artery

c. Inferior
mesenteric
artery

a. Suprarenal artery

b. Renal artery

c. Testicular or ovarian artery

a. Inferior phrenic artery

b. Four lumbar arteries

a. Two common iliac arteries

b. Median sacral artery

left gastric artery

splenic artery

hepatic artery

jejunal and ileal arteries

inferior pancreaticoduodenal artery

middle colic artery

right colic artery

ileocolic artery

left colic artery

sigmoid arteries (two or three)

superior rectal artery

external iliac artery

internal iliac artery

short gastric arteries (six)

splenic arteries (six)
left gastroepiploic artery

cystic artery

right gastric artery
gastroduodenal artery

right hepatic artery
left hepatic artery

anterior cecal artery
posterior cecal artery—appendicular artery

ileal artery
colic artery

right gastroepiploic artery

DIAGRAM 5.1

Branches of Abdominal Aorta

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CHAPTER 5

abdominal portion of the gastrointestinal tract drains to

If one remembers that the venous blood from the

Diagram 5.2.

The tributaries of the inferior vena cava are summarized in

median sacral vein

Three veins of origin: two common iliac veins and the

phrenic vein and four lumbar veins

Five lateral abdominal wall tributaries: the inferior

drains into the left renal vein)

veins, and right testicular or ovarian vein (the left vein

vein (the left vein drains into the left renal vein), renal

Three lateral visceral tributaries: the right suprarenal

Two anterior visceral tributaries: the hepatic veins

(Fig. 5.72):

The inferior vena cava has the following tributaries

Tributaries

in Figure 5.73.

The surface markings of the inferior vena cava are shown

from the portal vein (Fig. 5.7).

entrance into the lesser sac separates the inferior vena cava

gin and the right ureter lies close to its right border. The

The right sympathetic trunk lies behind its right mar

of the heart.

the 8th thoracic vertebra, and drains into the right atrium

pierces the central tendon of the diaphragm at the level of

vertebra (Fig. 5.72). It ascends on the right side of the aorta,

the right common iliac artery at the level of the 5th lumbar

It is formed by the union of the common iliac veins behind

body below the diaphragm to the right atrium of the heart.

The inferior vena cava conveys most of the blood from the

Location and Description

Inferior Vena Cava

Wall

Veins on the Posterior Abdominal

described on page 256.

front of the sacroiliac joint (Fig. 5.72). Its further course is

The internal iliac artery passes down into the pelvis in

abdominal wall.

and the iliac crest, supplying the muscles of the anterior

5.72). It ascends laterally to the anterior superior iliac spine

iliac artery arises close to the inferior epigastric artery (Fig.

behind the rectus abdominis muscle. The deep circumflex

deep inguinal ring (Fig. 4.4) and enters the rectus sheath

passes upward and medially along the medial margin of the

epigastric artery arises just above the inguinal ligament. It

nal ligament to become the femoral artery. The inferior

The artery enters the thigh by passing under the ingui

(Fig. 5.72).

branches

deep circumflex iliac

inferior epigastric

The Abdomen: Part II—The Abdominal Cavity

the

and

Internal Iliac Artery

■

Aortic Aneurysms

denly narrows may be a lodging site for an embolus discharged

Localized or diffuse dilatations of the abdominal part of the

aorta (aneurysms) usually occur below the origin of the renal

arteries. Most result from atherosclerosis, which causes

weakening of the arterial wall, and occur most commonly

in elderly men. Large aneurysms should be treated by open

surgical repair. Endovascular repair can also be used by the

introduction of a stent graft through one of the iliac arteries

with access through the femoral arteries in the groin.

Embolic Blockage of the Abdominal Aorta

The bifurcation of the abdominal aorta where the lumen sud-

from the heart. Severe ischemia of the lower limbs results.

C L I N I C A L N O T E S

1. Two anterior visceral tributaries—the hepatic veins

2. Three lateral visceral tributaries

4. Three tributaries of origin

a. Right suprarenal vein
(the left drains into the left renal vein)

b. Renal veins

c. Right testicular or ovarian vein
(the left drains into the left renal vein)

a. Inferior phrenic vein

b. Four lumbar veins

a. Two common iliac veins

b. Median sacral vein

external iliac vein

internal iliac vein

3. Five lateral abdominal wall
tributaries

DIAGRAM 5.2

Tributaries of Inferior Vena Cava

Basic Anatomy

lumbar) chain (Fig. 5.76).

a preaortic and a right and left lateral aortic (para-aortic or

The lymph nodes are closely related to the aorta and form

Lymph Nodes

Abdominal Wall

Lymphatics on the Posterior

The portal vein is described on page 194.

Portal Vein

epiploic vein (Fig. 5.22).

the inferior pancreaticoduodenal vein and the right gastro

branches of the superior mesenteric artery and also receives

the portal vein. It receives tributaries that correspond to the

neck of the pancreas, where it joins the splenic vein to form

in front of the third part of the duodenum and behind the

on the right side of the superior mesenteric artery. It passes

within the root of the mesentery of the small intestine and

junction and runs upward on the posterior abdominal wall

culation (Figs. 5.22, 5.26, and 5.48). It begins at the ileocecal

The superior mesenteric vein is a tributary of the portal cir

Superior Mesenteric Vein

enteric vein.

joined by veins from the pancreas and the inferior mes

the neck of the pancreas to form the portal vein. It is

the pancreas. It joins the superior mesenteric vein behind

right within the splenicorenal ligament and runs behind

gastroepiploic veins (Figs. 5.22 and 5.48). It passes to the

eral veins and is then joined by the short gastric and left

It begins at the hilum of the spleen by the union of sev

The splenic vein is a tributary of the portal circulation.

Splenic Vein

that correspond to the branches of the artery.

the splenic vein behind the pancreas. It receives tributaries

mesenteric artery and the duodenojejunal flexure and joins

the posterior abdominal wall on the left side of the inferior

superior rectal vein (Figs. 5.22, 5.26, and 5.48). It passes up

circulation. It begins halfway down the anal canal as the

The inferior mesenteric vein is a tributary of the portal

Inferior Mesenteric Vein

to the branches of the abdominal portion of the aorta.

utaries of the inferior vena cava correspond rather closely

first into the left renal vein, then it is apparent that the trib

that the left suprarenal and testicular or ovarian veins drain

the liver by means of the tributaries of the portal vein, and

219

Trauma to the Abdominal Aorta

pression and eventual blockage of the inferior vena cava. This

uterus during the later stages of pregnancy. This produces edema

The inferior vena cava is commonly compressed by the enlarged

Because of the multiple anastomoses of the tributaries of the

difficult. Moreover, the thin wall of the vena cava makes it prone

presence of the right costal margin make a surgical approach

denum, and mesentery of the small intestine and the blocking

anatomic inaccessibility of the vessel behind the liver, duo

the fact that the contained blood is under low pressure. The

Injuries to the inferior vena cava are commonly lethal, despite

However, the collateral blood flow does prevent tissue death in

circulation is established, but it is physiologically inadequate.

Because the progress of the disease is slow, some collateral

thromboendarterectomy or a bypass graft should be considered.

arteries. In otherwise healthy individuals, surgical treatment by

impotence, the latter caused by lack of blood in the internal iliac

cal symptoms of pain in the legs on walking (claudication) and

Gradual occlusion of the bifurcation of the abdominal aorta,

caused by the aortic blood pressure. Unless quickly diagnosed

vertebral column, while the delayed rupture of the adventitia is

caused by the sudden compression of the aorta against the

tia. The initial rupture of the intima and media is probably mainly

on automobile crashes. Rupture of the tunica intima and media

Blunt trauma to the aorta is most commonly caused by head-

occurs and is quickly followed by rupture of the turnica adventi-

by MRI, and surgical treatment instituted, death follows.

Obliteration of the Abdominal Aorta and Iliac Arteries

produced by atherosclerosis, results in the characteristic clini-

both lower limbs, although skin ulcers may occur.

The collateral circulation of the abdominal aorta is shown in

Figure 5.74.

Trauma to the Inferior Vena Cava

to extensive tears.

inferior vena cava (Fig. 5.75), it is impossible in an emergency to

ligate the vessel. Most patients have venous congestion of the

lower limbs.

Compression of the Inferior Vena Cava

of the ankles and feet and temporary varicose veins.

Malignant retroperitoneal tumors can cause severe com-

results in the dilatation of the extensive anastomoses of the

tributaries (Fig. 5.75). This alternative pathway for the blood

to return to the right atrium of the heart is commonly referred

to as the caval–caval shunt. The same pathway comes into

effect in patients with a superior mediastinal tumor compressing

the superior vena cava. Clinically, the enlarged subcutaneous

anastomosis between the lateral thoracic vein, a tributary of

the axillary vein; and the superficial epigastric vein, a tributary

of the femoral vein, may be seen on the thoracoabdominal wall

(Fig. 5.75).

C L I N I C A L N O T E S

220

CHAPTER 5

descend from the lower part of the thorax.

and left lumbar trunks, and some small lymph vessels that

The cisterna chyli receives the intestinal trunk, the right

on the right side of the aorta (Fig. 5.76).

diaphragm in front of the first two lumbar vertebrae and

This lies just below the

cisterna chyli.

gated lymph sac, the

commences in the abdomen as an elon

thoracic duct

The

Lymph Vessels

(see Fig. 1.18 and below).

lumbar trunks

left

right

nodes. The efferent lymph vessels form the

vessels of the abdominal walls; and from the common iliac

fundus of the uterus in the female; from the deep lymph

testes in the male and from the ovaries, uterine tubes, and

drain lymph from the kidneys and suprarenals; from the

lateral aortic (para-aortic or lumbar) lymph nodes

The

large intestinal trunk (see Fig. 1.18 and below).

greater part of the liver. The efferent lymph vessels form the

anal canal, and from the spleen, pancreas, gallbladder, and

the lower one third of the esophagus to halfway down the

the lymph from the gastrointestinal tract, extending from

respectively. They drain

inferior mesenteric lymph nodes,

celiac, superior mesenteric,

and are referred to as the

celiac, superior mesenteric, and inferior mesenteric arteries

lie around the origins of the

preaortic lymph nodes

The

The Abdomen: Part II—The Abdominal Cavity

and

right subclavian artery

left subclavian artery

internal thoracic
artery

posterior intercostal
arteries

thoracic part of aorta

musculophrenic artery

diaphragm

superior epigastric
artery

phrenic artery

left renal artery

middle colic artery

superior mesenteric
artery

marginal artery

abdominal aorta

lumbar arteries

ileocolic artery

left colic artery

inferior mesenteric
artery

sigmoid arteries

superior rectal
artery

middle rectal artery

inferior rectal artery

median
sacral
artery

internal iliac artery

deep circumflex
iliac artery

fourth lumbar
artery

inferior epigastric artery

right colic artery

thoracic

posterior intercos
arteries

thoracic part of

c artery

diaph

phre

sig

superio
artery

middle rectal arter

inferior rectal a

median
sacral
artery

l iliac artery

FIGURE 5.74

The possible collateral circulations of the abdominal aorta. Note the great dilatation of the mesenteric arteries

black bar

and their branches, which occurs if the aorta is slowly blocked just below the level of the renal arteries (

Basic Anatomy

lateral cutaneous nerve of the thigh

labium majus. The

canal to supply the skin of the groin and the scrotum or

wall, and the ilioinguinal nerve passes through the inguinal

supplies the skin of the lower part of the anterior abdominal

abdominal walls (see page 124). The iliohypogastric nerve

(L1) enter the lateral and anterior

ilioinguinal nerves

iliohypogastric

above downward (Fig. 5.34). The

from the lateral border of the psoas, in that order from

cutaneous nerve of the thigh, and femoral nerve emerge

The iliohypogastric nerve, ilioinguinal nerve, lateral

borders of the muscle and from its anterior surface.

branches of the plexus emerge from the lateral and medial

white rami communicantes to the sympathetic trunk. The

from the sympathetic trunk, and the upper two give off

(Fig. 5.77). The anterior rami receive gray rami
communicantes

cle from the anterior rami of the upper four lumbar nerves

ways supplying the lower limb, is formed in the psoas mus

The lumbar plexus, which is one of the main nervous path

Wall

emphasized on page 132.

The importance of the lymph drainage of the testis was

Lymphatic Drainage of the Gonads

221

Nerves on the Posterior Abdominal

Lumbar Plexus

-
-

and

brachiocephalic

vein

subclavian vein

first rib

axillary vein

azygos vein

internal thoracic vein

lateral thoracic vein

diaphragm

ascending lumbar

vein

inferior epigastric vein

superficial epigastric

vein

external iliac vein

inguinal ligament

femoral vein

great saphenous

vein

superior vena cava

hemiazygos veins

inferior vena cava

lumbar veins

inferior mesenteric
vein ascending to
portal vein

superior rectal vein

internal iliac vein

middle rectal vein

inferior rectal vein

FIGURE 5.75

The possible collateral circulations of the superior and inferior venae cavae. Note the alternative pathways that

). Note also the connections that exist between the portal circulation and systemic veins in the anal canal.

black bar

lower

). Similar pathways exist if the inferior vena cava becomes blocked below the renal veins (

upper black bar

azygos vein (

exist for blood to return to the right atrium of the heart if the superior vena cava becomes blocked below the entrance of the