GASTROINTESTINAL

TRACT
(GIT)
By: Agumas Sh. (BSc., MSc.)
1
❖OUTLINES
• Mouth (Oral cavity)
• Pharynx (Throat)
• Esophagus (Food pipe/Gullet)
• Anterior abdominal wall
• Posterior abdominal wall
• Abdominal cavity
• Peritoneum
• Inguinal region/Groin
• Abdominal visceral organs
• Neurovascular structures
• Clinical correlations 2
 OBJECTIVES
❖ AT THE END OF THIS MODULE, EVERYONE SHOULD UNDERSTAND:
• The structural and functional components of each organ from the
mouth to the anus and accessory organs, along with their clinical
significance.
• A brief explanation of the innervation, blood supply, and lymphatic
drainage of the gastrointestinal tract (GIT) and accessory organs.
• A clear and concise overview of the gross and clinical anatomy of the
abdomen in detail.
• The developmental and histological structures of the GIT and
accessory organs.
• The demonstration and practice on cadaveric parts of the abdomen.3
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INTRODUCTION TO ANATOMY OF GIT
• GIT- A long, twisting tube that runs from the mouth to the anus and is part of
the digestive system. It's also known as the alimentary tract or digestive
tract. It’s length around 9-10m.
▪ A. The GIT includes the following organs:
➢ Mouth, pharynx, esophagus, stomach, small intestine, large intestine,
rectum, and anus.
▪ B. The GIT also includes these organs/ accessory organs:
➢ Teeth, tongue, salivary glands, liver, gallbladder, and pancreas, which
produce digestive juices and enzymes.
• The main functions of GIT’s are:
✓ To digest food and liquids
✓ To absorb nutrients into the bloodstream
✓ To remove waste from the bloodstream
✓ To excrete waste from the body 5
Functions of
GIT:
➢ Ingestion
➢ Mastication
➢ Deglutition
➢ Digestion
➢ Secretion
➢ Absorption
➢ Peristalsis
➢ Defecation

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 READING Assignment
• Anatomy of the Oral Cavity
➢ Teeth
➢ Salivary Glands
➢ Tongue
➢ Pharynx
• Development of the Oral Cavity
➢ Teeth
➢ Salivary Glands
➢ Tongue
➢ Pharynx
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 ESOPHAGUS
• A fibromuscular tube that begins in the neck and ends in stomach.
• Approximately 25 cm long with an average diameter of 2 cm.
• Conveys food from the pharynx to the stomach.
• Esophagus contains:
✓ The upper 1/3rd of the skeletal muscle
✓ The middle 1/3rd both skeletal & smooth muscles
✓ The lower 1/3rd only smooth muscle
• Follows the curve of the vertebral column as it descends through the neck and
mediastinum.
• It originates from inferior border of the cricoid cartilage (C6) to terminates
by entering the stomach at the cardiac orifice of the stomach to the left of the
midline at the level of the T11 vertebra. 8
 CERVICAL ESOPHAGUS
• A part of the voluntary upper one third.
• Begins immediately at the level of the inferior border of the
cricoid cartilage (C6 vertebra).
• Lies between the trachea and the cervical vertebral column.
• The pharyngo-esophageal junction (the superior esophageal
sphincter) is the narrowest part of the esophagus.
– Externally, appears as a constriction produced by the
cricopharyngeal part of the inferior pharyngeal constrictor
muscle.
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 Structures related to cervical esophagus
• Between the trachea and esophagus:
- Recurrent laryngeal nerves- lie in or near the tracheo-esophageal
grooves between the trachea and esophagus.
• On the right: Right lobe of the thyroid gland and the right
carotid sheath.
• On the left:
- Left lobe of the thyroid gland and the left carotid sheath.
• At the root of the neck:
- Its in contact with the cervical pleura.
• The thoracic duct adheres to the left side of the esophagus and lies
between the pleura and the esophagus.
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Neurovascular supply of Cervical Esophagus
Vascular supply
• Arteries: Are branches of the inferior thyroid arteries.
• Each artery gives off ascending and descending branches that
anastomose with each other and across the midline.
• Veins: Are tributaries of the inferior thyroid veins.
• Lymphatics: Drain into the paratracheal lymph nodes and inferior
deep cervical lymph nodes.
Nerve supply
• Somatic fibers: Via branches from the recurrent laryngeal nerves
• Vasomotor fibers: From the cervical sympathetic trunks through
the plexus around the inferior thyroid artery.
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Posterior view 12
 Thoracic Esophagus
• Descends into the posterior mediastinum from the superior
mediastinum.
• Passing posterior and to the right of the arch of the aorta and
posterior to the pericardium and left atrium.
• Constitutes the primary posterior relationship of the base of the
heart.
• Near the diaphragm, it deviates to the left and passes through the
esophageal hiatus in the diaphragm at the level of the T10
vertebra, anterior to the aorta.

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 CONSTRICTIONS OF THORACIC ESOPHAGUS
• Thoracic part of esophagus compressed by three structures and may have
three impressions or “constrictions”.
• These may be observed as narrowing's of the lumen in oblique chest
radiographs that are taken as barium is swallowed.
• These three structures are:
– The arch of the aorta
– The left main bronchus
– The diaphragm
• The first two impressions occur in close proximity.
• No constrictions are visible in the empty esophagus; however, as it
expands during filling, the structures noted above compress its walls. 14
 In the superior
mediastinum:
• It lies anterior to the
bodies of the T1–T4.
• It is compressed
anteriorly by the root of
the left lung.
• The thoracic duct
usually lies on the left side
of the esophagus, deep
(medial) to the arch of the
aorta. 15
 In the posterior
mediastinum:
• Passing posterior and to
the right of the arch of the
aorta and posterior to the
pericardium and left
atrium.
• Passes through
the esophageal hiatus in
the diaphragm at the level
of the T10 vertebra,
anterior to the aorta. 16
 ABDOMEN
• Abdomen: A roughly cylindrical chamber that extending from the
inferior margin of the thorax to the superior margin of the pelvis
and the lower limb.
• The inferior thoracic aperture forms the superior opening to the
abdomen and is closed by the diaphragm.
• Inferiorly, the deep abdominal wall is continuous with the pelvic wall at
the pelvic inlet.
• Superficially, the inferior limit of the abdominal wall is the superior
margin of the lower limb.
• The chamber enclosed by the abdominal wall contains a single large
peritoneal cavity, which freely communicates with the pelvic cavity.
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▪ Abdominal viscera includes:
• Major elements of the gastrointestinal system: the
distal end of the esophagus, stomach, small and large
intestines, liver, pancreas, and gallbladder.
• The spleen
• Components of the urinary system—kidneys and
upper major part of ureters.
• The suprarenal glands
• Major neurovascular structures. 19
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FUNCTIONS of Abdomen
• Houses and protects major viscera.
• The abdomen houses major elements of the gastrointestinal system,
the spleen, and parts of the urinary system.
• Much of the liver, gallbladder, stomach, spleen, and parts of the
colon are under the domes of the diaphragm, which project
superiorly above the costal margin of the thoracic wall, and as a
result these abdominal viscera are protected by the thoracic wall.
• The superior poles of the kidneys are deep to the lower ribs.
• Viscera not under the domes of the diaphragm are supported and
protected predominantly by the muscular walls of the abdomen.
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• Breathing
• One of the most important roles of the abdominal wall is
to assist in breathing:
• It relaxes during inspiration to accommodate expansion of the
thoracic cavity and the inferior displacement of abdominal
viscera during contraction of the diaphragm.
• During expiration, it contracts to assist in elevating the
domes of the diaphragm, thus reducing thoracic volume.
• Material can be expelled from the airway by forced expiration
using the abdominal muscles, as in coughing or sneezing.

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Abdomen assists in breathing

23
• Changes in intraabdominal pressure
• Contraction of abdominal wall muscles can
dramatically increase intraabdominal pressure when the
diaphragm is in a fixed position.
• Air is retained in the lungs by closing valves in the
larynx in the neck.
• Increased intraabdominal pressure assists in voiding
the contents of the bladder and rectum and in giving
birth.
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SURFACE ANATOMY
• Key Landmarks
• Key surface anatomy features of the anterolateral abdominal wall
include the following:
• Rectus sheath: A fascial sheath containing the rectus abdominis
muscle, which runs from the pubic symphysis and crests to the
xiphoid process and fifth to seventh costal cartilages.
• Linea alba: Literally the “white line”; a relatively avascular
midline subcutaneous band of fibrous tissue where the fascial
aponeuroses of the rectus sheath from each side interdigitate in the
midline.
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• Semilunar line: The lateral border of the rectus abdominis muscle in
the rectus sheath.
• Tendinous intersections: Transverse skin grooves that demarcate
transverse fibrous attachment points of the rectus sheath to the
underlying rectus abdominis muscle.
• Umbilicus: The site that marks the T10 dermatome, lying at the level
of the intervertebral disc between L3 and L4; the former attachment site
of the umbilical cord.
• Iliac crest: The rim of the ilium, which lies at about the level of the L4
vertebra.
• Inguinal ligament: A ligament composed of the aponeurotic fibers of
the external abdominal oblique muscle, which lies deep to a skin crease
that marks the division between the lower abdominal wall and upper
thigh of the lower limb.
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 Anterior View

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▪ Surface Topography
• Clinically, the abdominal wall is divided descriptively into
quadrants or regions so that both the underlying visceral
structures and the pain or pathology associated with these
structures can be localized and topographically described.
• Common clinical descriptions use either quadrants or the
nine descriptive regions, demarcated by two vertical
midclavicular lines and two horizontal lines: the subcostal
and intertubercular planes.

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Clinical Planes of Reference for Abdomen
• Median: Vertical plane from xiphoid process to pubic
symphysis.
• Transumbilical: Horizontal plane across umbilicus at the L4
disc; these planes divide the abdomen into quadrants.
• Subcostal: Horizontal plane across inferior margin of 10th
costal cartilage.
• Intertubercular: Horizontal plane across tubercles of ilium.
• Midclavicular: Two vertical planes through midpoint of
clavicles; these planes divide the abdomen into nine regions.
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ABDOMINAL QUADRANTS
• Right Upper Quadrant:
Major part of liver, stomach,
gallbladder, duodenum, right
kidney, pancreas, and the right
adrenal gland.
• Left Upper Quadrant: Minor
part of liver, stomach,
pancreas, left kidney, spleen,
and the left adrenal gland.
• Right Lower Quadrant:
appendix, reproductive organs,
right ureter.
• Left Lower Quadrant: left
ureter, reproductive organs
• N.B: Small and large
intestines are found in all four
quadrants.
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 Nine-region organizational pattern
• Based on two horizontal and two vertical planes:
• The superior horizontal plane (the subcostal plane)
– Immediately inferior to the costal margins, at the lower border of the costal
cartilage of rib 10th and posteriorly passes through the body of vertebra L3.
• Sometimes the transpyloric plane can be also used.
– Midway between the superior borders of the manubrium of the sternum and
the pubic symphysis.
– Passing posteriorly through the lower border of vertebrae L1.
▪ Transpyloric plane: transects many other important structures:
• The fundus of the gallbladder
• Neck of the pancreas, origins of the superior mesenteric artery (SMA)
• Hepatic portal vein
• Root of the transverse mesocolon
• Duodenojejunal junction
• Hilum of the kidneys 33
▪ The inferior horizontal plane (the intertubercular plane)
– Connects the tubercles of the iliac crests, which are palpable
structures 5cm posterior to the ASIS.
– Passes through the upper part of the body of vertebra L5.
• Sometimes the interspinous plane can be also used which passes
through the easily palpated ASIS on each side.
▪ The vertical planes (midclavicular planes)
– Pass from the midpoint of the clavicles (approximately 9 cm from
the midline) to the midinguinal points, midpoints of the lines.
joining the anterior superior iliac spine (ASIS) and the pubic
tubercles on each side.
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 Contents of abdominal regions

• 1. Right Hypochondriac
Region: liver, gallbladder,
right kidney, and portions of
the small and large intestine.
• 2. Epigastric Region: liver,
stomach, pancreas,
duodenum, spleen, and
adrenal glands.
• 3. Left Hypochondriac
Region: spleen, large/small
intestines, left kidney,
pancreas, stomach, and tip of
the liver. 35
• 4. Right Lumbar Region: ascending colon, small intestine, and
right kidney.
• 5. Umbilical Region: duodenum, the small intestine, and the
transverse colon.
• 6. Left Lumbar Region: descending colon, small intestine, and
left kidney.
• 7. Right Iliac Region: appendix, cecum, ascending colon, and
small intestine.
• 8. Hypogastric Region: bladder, portions of the sigmoid colon,
small intestine, and reproductive organs.
• 9. Left Iliac Region: sigmoid colon, descending colon, and small
intestine. 36
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FOUR QUADRANTS AND NINE REGIONS OF ABDOMEN

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 Clinical Correlation
• If abdominal pain or signs of peritonitis are localized in the LLQ, colitis,
diverticulitis, ureteral colic or pain due to ovarian cysts or pelvic
inflammatory disease may be suspected.
• Examples of tumors in the left lower quadrant include colon cancer and
ovarian tumor.
• The LUQ may be painful or tender in the case of intestinal malrotation.
• The RUQ may be painful or tender in hepatitis, cholecystitis, and peptic
ulcer.
• The RLQ, in particular the right inguinal region or right iliac fossa may
be painful and tender in conditions such as appendicitis.
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 Anterolateral Abdominal Wall
• The anterior abdominal wall is a musculoaponeurotic structure confined to the
anterior and lateral aspects of the abdomen.
• Boundaries:
• Superiorly: Cartilages of the 7th–10th ribs and the xiphoid process of sternum.
• Inferiorly: Inguinal ligament, the anterior part of the iliac crest, fold of groin,
pubic tubercle, pubic crest, and pubic symphysis; and on each side it is separated
from the posterior abdominal wall by the midaxillary line.
• The anatomy of anterior abdominal wall is clinically very important due to:
➢The physical examination of the abdomen is mostly performed through the
anterior abdominal wall.
➢Access to the abdomen and its contents is usually obtained through the incisions
in the anterior abdominal wall.
➢Abdominal hernias mostly occur through the anterior abdominal wall.
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Layers OF THE Anterior ABDOMINAL WALL

• Skin: Epidermis and dermis.

• Superficial fascia (subcutaneous tissue): A single, fatty connective
tissue layer below the level of the umbilicus that divides into a more
superficial fatty layer (Camper’s fascia) and a deeper membranous
layer (Scarpa’s fasciae).
• Investing fascia: Connective tissue that covers the muscle layers.
• Abdominal muscles: Three lateral layers, similar to the thoracic wall
musculature, except in the anterior mid region where the vertically
oriented rectus abdominis muscle lies in the rectus sheath.

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SUPERFICIAL FASCIA
• Fatty layer or fascia of camper- continuous with the superficial fat over
the rest of the body and may be extremely thick in obese patients.
• The membranous layer or scarpa’s fascia- a thin and fades out laterally
and above.
• Becomes continuous with the superficial fascia of the back and the
thorax.
• Inferiorly the membranous layer passes onto the front of the thigh,
where it fuses with the deep fascia.
• In the midline inferiorly forms a tubular sheath for the penis or clitoris.
• Below in the perineum, enters the wall of the scrotum or labia majora.
• From there it passes to be attached on each side to the margins of pubic
arch, here it is called Colle’s fascia. 44
• Posteriorly it fuses with the perineal body and the margin
of the perineal membrane.
• The fatty layer is represented as a smooth muscle in the
scrotum, the dartos muscle.
• The membranous layer persists as a separate layer.
• Deep fascia
• Deep fascia in the anterior abdominal wall is merely a thin
layer of connective tissue covering the muscles.
• It lies immediately deep to the membranous layer of the
superficial fascia.
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• Endoabdominal fascia: Tissue that is unremarkable except for a thicker portion called the
transversalis fascia, which lines the inner aspect of the transversus abdominis muscle.

• It is continuous with fascia on the underside of the respiratory diaphragm, fascia of the
posterior abdominal muscles, and fascia of the pelvic muscles.

• Extraperitoneal (fascia) fat: Connective tissue that is variable in thickness and contains a
variable amount of fat.

• Peritoneum: Thin serous membrane that lines the inner aspect of the abdominal wall
(parietal peritoneum) and occasionally relects of the walls as a mesentery to invest
partially or completely various visceral structures.

• It then encircles the viscus as visceral peritoneum.

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Muscles
• The muscles of the anterolateral abdominal wall include three lateral layers that
are continuations of the three layers in the thoracic wall.

• These include two abdominal oblique muscles and the transversus abdominis
muscle.

• In the midregion a vertically oriented pair of rectus abdominis muscles lies

within the rectus sheath and extends from the pubic symphysis and crest to the
xiphoid process and costal cartilages 5th to 7th superiorly.

• The small pyramidalis muscle just superior to the pubis is inconsistent and
clinically less significant.
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Muscles of anterolateral abdominal wall

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 50
Layers of anterior abdominal wall
Rectus Sheath
• Durable, resilient, and long fibrous sheath compartment that encloses both the rectus
abdominis muscle and the pyramidalis muscle (if present).
• Contains the anterior rami of lower six thoracic nerves and the superior and inferior epigastric
vessels and lymph vessels.

• Contents of rectus sheath:

- Rectus abdominis and pyramidalis muscles.
- Inferior and superior epigastric arteries.
- Inferior and superior epigastric veins.
- Lymphatic vessels.
- Distal portions of the thoracic-abdominal nerves (abdominal portions of the anterior rami of
spinal nerves T7–T12). 51
• Rectus sheath is formed mainly by aponeurosis of three lateral abdominal
muscles.
• Above the costal margin:
• Anterior wall: formed by the aponeurosis of the external oblique
• Posterior wall: formed by the thoracic wall, these are the 5th, 6th, and 7th costal
cartilages and the intercostal spaces.
• Below costal margin & up to the level of anterior superior iliac spine: Internal
oblique aponeurosis split to enclose rectus muscle.
• Anterior wall: aponeurosis of external oblique & half of internal oblique
aponeurosis.
• Posterior wall: half of internal oblique aponeurosis & transverses aponeurosis.
52
• Between the level of the anterosuperior iliac spine and the pubis, the
aponeurosis of all three muscles form the anterior wall.

• The posterior wall is absent.

• The rectus muscle lies in contact with the fascia transversalis.

• The posterior wall of the rectus sheath is not attached to the rectus
abdominis muscle.

• The anterior wall is firmly attached to it by the muscle’s tendinous

intersections.
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• The posterior wall has a
free curved line called
arcuate line at level of
anterior superior iliac
spine (ASIS).
• The inferior epigastric
artery enters rectus sheath
at this level and
anastomoses with superior
epigastric artery.
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• The rectus sheath
is separated from
each other by
linea alba which
extends from
xiphoid process to
symphysis pubis
and separated
laterally from
lateral muscles at
linea semilunaris.
57
• Arcuate line- a horizontal line that demarcates the inferior portion of the posterior
rectus sheath and is also the point where inferior epigastric vessels pierce the rectus
abdominis muscle.

• Inferior one quarter is supported posteriorly only by the transversalis fascia, extra
peritoneal fat, and peritoneum

▪ RECTUS SHEATH ABOVE AND BELOW ARCUATE LINE:

• Above the arcuate line, the anterior sheath consists of the external oblique and internal
oblique aponeurosis and the posterior sheath consists of the internal oblique and
transverse abdominis aponeurosis.

• Below the arcuate line, the anterior sheath consists of external oblique, internal oblique,
and transverse abdominis aponeurosis, there is no posterior sheath. 58
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LINEA ALBA
• The rectus sheath is separated from its fellow on the
opposite side by a fibrous band called the linea alba.
• Extends from the sternum (xyphoid process) to the
symphysis pubis, pubic bones.
• Cord of connective tissue.
• Aponeurotic parts of oblique muscles attaches to the linea
alba at the midline.
• One of the surgical approaches to the peritoneal cavity
(midline incision).
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▪ The nine layers of the anterolateral
abdominal wall. 6. Transversus abdominis muscle
1. Skin
7. Lining deep fascia (transversalis fascia,
2. Subcutaneous fat
iliacus fascia, psoas fascia, etc.)
a. Fatty Camper fascia
8. Preperitoneal fat
b. Membranous Scarpa fascia
9. Parietal peritoneum
3. Investing deep fascia (external
oblique fascia) ▪N.B: In the central region of the anterior

4. External abdominal oblique muscle abdomen, the rectus abdominis muscle and

5. Internal abdominal oblique muscle rectus sheath replace the three muscle layers of

the anterolateral wall.

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Layers of anterior abdominal wall

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BLOOD VESSELS OF THE ANTERIOR ABDOMINAL WALL
Superior epigastric artery
• Arises from the internal thoracic artery which is a branch of first part of
the subclavian artery, enters the rectus sheath, and descends on the
posterior surface of the rectus abdominis.
• Anastomoses with the inferior epigastric artery within the rectus
abdominis.
Inferior epigastric artery
• Arises from the external iliac artery above the inguinal ligament and
ascends between the rectus abdominis and the posterior layer of the rectus
sheath.
• Anastomoses with the superior epigastric artery, providing collateral
circulation between the subclavian and external iliac arteries.
• Give arise to the cremasteric artery which is a branch of inferior
epigastric artery, which accompanies the spermatic cord. 65
Deep circumflex iliac artery
• Arises from the external iliac artery and runs laterally along the
inguinal ligament and the iliac crest between the transverse and
internal oblique muscles.
• Forms an ascending branch that anastomoses with the
musculopherenic artery which is originate from lateral side of the
internal thoracic artery at the level of the sixth costal cartilage.
Superficial epigastric arteries
• Arise from the femoral artery and run superiorly toward the
umbilicus over the inguinal ligament.
• Anastomose with branches of the inferior epigastric artery.
66
Superficial circumflex iliac
artery
• Arises from the femoral artery
and runs laterally upward,
parallel to the inguinal
ligament.
• Anastomoses with the deep
circumflex iliac and lateral
femoral circumflex arteries.
Superficial (external)
pudendal arteries.
• Arise from the femoral
artery, pierce the cribriform
fascia, and run medially to
supply the skin above the
pubis. 67
Cutaneous/superficial
arteries of anterior
abdominal wall
• Anterior cutaneous part are
branches of superior & inferior
epigastric artery.
• Lateral cutaneous part are branches
of posterior intercostal artery.
• Below umbilicus supply is from
three superficial branches of
femoral artery
• Superficial epigastric artery
• Superficial external pudendal artery
• Superficial circumflex iliac artery
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Cutaneous veins anterior
abdominal wall
• Accompany arteries
• Below the umbilicus they drain in to great
saphenous vein, eventually into inferior
vena cava.
• Above umbilicus they pass to axilla & in to
superior vena cava.
• Both group anastomose through small veins,
which open up in case of obstruction in liver,
giving a appearance called caput medusae.
• Thoracopigastric veins
• Are longitudinal venous connections
between the lateral thoracic vein and the
superficial epigastric vein.
• Provide a collateral route venous return if a
caval or portal obstruction occurs.
69
 Innervation of
anterolateral
abdominal wall
• The segmental innervation of the
anterolateral abdominal skin and
muscles is by anterior rami of
T7-L1. It gives:
➢Thoraco-abdominal nerves-
(T7-T11)
➢Subcostal nerve- (T12)
➢Iliohypogastric and
ilio-inguinal nerves -(L1)
70
Cutaneous innervation of
anterior abdominal wall
➢Nerves T7 to T9 supply the
skin from the xiphoid process to
just above the umbilicus;
➢T10 supplies the skin around
the umbilicus.
➢T11, and cutaneous branches of
T12 and L1 (iliohypogastric
and ilio-inguinal) supply the
skin inferior to the umbilicus.
➢Additionally, the ilio-inguinal
nerve supplies the anterior
surface of the scrotum or labia
majora, and sends a small
cutaneous branch to the thigh. 71
Nerves Origin Course Distribution
Run between second and third layers of
Continuation of lower abdominal muscles; branches enter
Thoraco- Muscles of anterolateral
(7th–11th) intercostal subcutaneous tissue as lateral cutaneous
abdominal abdominal wall and overlying
nerves distal to costal branches of T10–T11 (in anterior axillary line)
(T7–T11) skin
margin and anterior cutaneous branches of T7–T11
(parasternal line)
7th–9th lateral 7th–9th intercostal nerves
Anterior divisions continue across costal margin Skin of right and left
cutaneous (anterior rami of spinal
nerves T7–T9) in subcutaneous tissue hypochondriac regions
branches
Runs along inferior border of 12th rib; then Muscles of anterolateral abdominal wall
Subcostal (anterior passes onto subumbilical abdominal wall (including most inferior slip of external
Spinal nerve T12 oblique) and overlying skin, superior to
ramus of T12) between second and third layers of abdominal
iliac crest and inferior to umbilicus
muscles
Pierces transversus abdominis muscle to course Skin overlying iliac crest, upper
As superior terminal
Iliohypogastric between second and third layers of abdominal inguinal, and hypogastric
branch of anterior ramus
(L1) of spinal nerve L1 muscles; branches pierce external oblique regions; internal oblique and
aponeuroses of most inferior abdominal wall transversus abdominis muscles

As inferior terminal Skin of lower inguinal region, mons

Passes between second and third layers of pubis, anterior scrotum or labium
branch of anterior
Ilio-inguinal (L1) abdominal muscles; then traverses inguinal majus, and adjacent medial thigh;
ramus of spinal nerve inferiormost internal oblique
canal 72 and
L1 transversus abdominis
Arteries of Anterior Abdominal Wall

73
VEINs of Anterior Abdominal Wall

74
Nerves of Anterior Abdominal Wall

75
Skeleton of the anterior
abdominal wall
▪ The skeleton of the abdomen includes;
➢Xiphoid process, X
➢Costal cartilages (ribs 7th -10th)
➢Tips of ribs, 11th and 12th
➢Lumbar vertebrae, L1-L5
➢Iliac crests, IC
➢Tubercle of the crest, TC
➢Anterior superior iliac spine, ASIS
➢Anterior inferior iliac spine, AIIS
➢Inguinal ligament, IL
➢Pubic tubercle, PT
➢Pubic crest, PC
➢Pubic symphysis, PS
➢The separation of the abdomen from the
pelvis, the pelvic brim, PB 76
Peritoneum
• A thin serous membrane lines the walls of the abdominal cavity
and covers much of the visceral organs.
• The parietal peritoneum lines the walls of the cavity and the
visceral peritoneum covers the viscera.
• Between the parietal and visceral layers of peritoneum is a
potential space (the peritoneal cavity).
• Abdominal viscera either are suspended in the peritoneal cavity by
folds of peritoneum (mesenteries) or are outside the peritoneal
cavity.
• Organs suspended in the cavity are referred to as intraperitoneal;
organs outside the peritoneal cavity, with only one surface or part of
one surface covered by peritoneum, are retroperitoneal.
77
PERITONEAL CAVITY
• Within the abdominal cavity which is continuous with the pelvic cavity.
• Potential space of capillary thinness between the parietal and visceral layers of
peritoneum.
• Completely closed in males.
• A communication pathway in females to the exterior of the body through the
uterine tubes, uterine cavity, and vagina (potential pathway of infection from
exterior).
• Contains peritoneal fluid which lubricates the peritoneal surfaces, enabling
the organs to move each other without friction and allowing the movements of
digestion.
• Peritoneal fluid contains leukocytes and antibodies that resist infection
absorbed by lymphatic vessels on the inferior surface of diaphragm.
78
• The peritoneal cavity is subdivided into the greater sac and the lesser
sac (omental bursa).

• The greater sac accounts for most of the space in the peritoneal cavity,
beginning superiorly at the diaphragm and continuing inferiorly into the
pelvic cavity. It is entered once the parietal peritoneum has been
penetrated.

• The omental bursa is a smaller subdivision of the peritoneal cavity

posterior to the stomach and liver and is continuous with the greater sac
through an opening, the omental (epiploic) foramen. 79
• Surrounding the omental (epiploic) foramen are numerous structures

covered with peritoneum.

▪ BOUNDARIES OF OMENTAL (EPIPLOIC) FORAMEN:

• Anteriorly: Portal vein, hepatic artery proper, and bile duct

• Posteriorly: The inferior vena cava

• Superiorly: The caudate lobe of the liver

• Inferiorly: The first part of the duodenum

80
81
82
• An intraperitoneal organ is • A retroperitoneal organ is typically anchored to
completely surrounded by visceral the posterior abdominal wall and is covered by
peritoneum and is suspended a layer of parietal peritoneum.
within the peritoneal cavity by a
mesentery. • Organs that are not enclosed with visceral
• Intra peritoneal organs: peritoneum.
➢1. Stomach ▪ Retro peritoneal organs:
➢2. Appendix ➢ 1. Aorta
➢ 2. Inferior vena cava
➢3. Liver
➢ 3. Adrenal glands
➢4. Spleen ➢ 4. Kidneys
➢5. Duodenum- 1st part ➢ 5. Ureter
➢6. Small intestine, jejunum, and ileum ➢ 6. Ascending colon
➢7. Pancreas- tail ➢ 7. Descending colon
➢8. Transverse colon ➢ 8. Duodenum - 2nd,3rd, and
➢9. Sigmoid colon ➢ 4th parts.
➢10. Rectum- upper 3rd ➢ 9. Pancreas
➢ 10. Rectum
➢ 11. Esophagus 83
• RELATIONSHIPS OF THE ORGANS TO THE PERITONEUM:

• Intraperitoneal organs: Are almost completely covered with visceral

peritoneum or those suspended from the abdominal wall by mesenteries.

• Examples; Stomach, ampulla of duodenum, jejunum, ileum, cecum,

appendix, transverse colon, sigmoid colon, liver, spleen, ovaries, uterine
tubes, and uterus.

• Retroperitoneal: Structures that are not suspended in the abdominal cavity

by a mesentery and that lie between the parietal peritoneum and abdominal
wall in position. 84
• Retroperitoneal can be primary or secondary:
• Primarily retroperitoneal organs: Which develop in the region between the
peritoneum and the abdominal wall and remain in this position in the adult.

• Examples; Kidneys, ureters, suprarenal glands, urinary bladder (subperitoneal), and

prostate (sub peritoneal).

• Secondary retroperitoneal organs: Are suspended initially in the abdominal cavity

by a mesentery.

• Later become retroperitoneal secondarily by fusing with the abdominal wall.

• Examples; Duodenum (without ampulla), ascending, descending colon, and

pancreas.
85
86
Midsagittal section of visceral organs of abdomen

87
• OMENTA, MESENTERIES, AND LIGAMENTS
• Throughout the peritoneal cavity numerous peritoneal folds connect
organs to each other or to the abdominal wall.
• These folds (omenta, mesenteries, and ligaments) develop from the
original dorsal and ventral mesenteries, which suspend the developing
gastrointestinal tract in the embryonic coelomic cavity.
• Some contain vessels and nerves supplying the viscera, while others help
maintain the proper positioning of the viscera.
• Omenta
• The omenta consist of two layers of peritoneum, which pass from the
stomach and the first part of the duodenum to other viscera.
• There are two:
• Greater omentum, derived from the dorsal mesentery.
• Lesser omentum, derived from the ventral mesentery.
88
Greater omentum
• The greater omentum is a large, apron-like, peritoneal fold that attaches to the greater
curvature of the stomach and the first part of the duodenum.
• It drapes inferiorly over the transverse colon and the coils of the jejunum and ileum.
• Turning posteriorly, it ascends to associate with, and become adherent to, the peritoneum on
the superior surface of the transverse colon and the anterior layer of the transverse mesocolon
before arriving at the posterior abdominal wall.
• Usually a thin membrane, the greater omentum always contains an accumulation of fat, which
may become substantial in some individuals.
• Additionally, there are two arteries and accompanying veins, the right and left gastro-omental
vessels, between this double-layered peritoneal apron just inferior to the greater curvature of
the stomach.
89
• Prevents the visceral
peritoneum from adhering
to the parietal peritoneum
lining the anterolateral
abdominal wall.
• "Abdominal policeman"
wraps around an
inflamated organ walling it
off and thereby protecting
other viscera from this
organ.
• Cushions the abdominal
organs against injury.
• Forms insulation against
loss body heat.
90
Lesser omentum
• It extends from the lesser curvature of the stomach and the first part of
the duodenum to the inferior surface of the liver.
• A thin membrane continuous with the peritoneal coverings of the
anterior and posterior surfaces of the stomach and the first part of the
duodenum, the lesser omentum is divided into:
• A medial hepatogastric ligament, which passes between the stomach
and liver, and a lateral hepatoduodenal ligament, which passes
between the duodenum and liver.
• The hepatoduodenal ligament ends laterally as a free margin and
serves as the anterior border of the omental foramen.
• Enclosed in this free edge are the hepatic artery proper, the bile duct,
and the portal vein.
• Additionally, the right and left gastric vessels are between the layers of
the lesser omentum near the lesser curvature of the stomach.
91
Lesser Omentum

92
 MESENTERIES
• Mesenteries are peritoneal folds that attach viscera to the posterior abdominal
wall.
• They allow some movement and provide a conduit for vessels, nerves, and
lymphatics to reach the viscera and include:
➢The mesentery—associated with parts of the small intestine.
➢The transverse mesocolon—associated with the transverse colon
➢The sigmoid mesocolon—associated with the sigmoid colon.
➢All of these are derivatives of the dorsal mesentery.
• MESENTERY
• The mesentery is a large, fan-shaped, double-layered fold of peritoneum that
connects the jejunum and ileum to the posterior abdominal wall.
• Its superior attachment is at the duodenojejunal junction, just to the left of the
upper lumbar part of the vertebral column.
93
• It passes obliquely downward and to the right, ending at the ileocecal
junction near the upper border of the right sacro-iliac joint.
• In the fat between the two peritoneal layers of the mesentery are the
arteries, veins, nerves, and lymphatics that supply the jejunum and
ileum.
• TRANSVERSE MESOCOLON
• The transverse mesocolon is a fold of peritoneum that connects the
transverse colon to the posterior abdominal wall.
• Its two layers of peritoneum leave the posterior abdominal wall
across the anterior surface of the head and body of the pancreas and
pass outward to surround the transverse colon.
• Between its layers are the arteries, veins, nerves, and lymphatics
related to the transverse colon.
• The anterior layer of the transverse mesocolon is adherent to the
posterior layer of the greater omentum.
94
• SIGMOID MESOCOLON
• The sigmoid mesocolon is an inverted, V-shaped peritoneal fold that attaches the
sigmoid colon to the abdominal wall.
• The apex of the V is near the division of the left common iliac artery into its internal
and external branches, with the left limb of the descending V along the medial border
of the left psoas major muscle and the right limb descending into the pelvis to end at
the level of
• The sigmoid and sacral vertebra S3, superior rectal vessels, along with the nerves and
lymphatics associated with the sigmoid colon, pass through this peritoneal fold.
• LIGAMENTS
• Peritoneal ligaments consist of two layers of peritoneum that connect two organs to
each other or attach an organ to the body wall, and may form part of an omentum.
• They are usually named after the structures being connected. For example, the
splenorenal ligament connects the left kidney to the spleen and the gastrophrenic
ligament connects the stomach to the diaphragm.
95
96
98
INGUINAL REGION
• The inguinal region (groin) is the area
where the anterior abdominal wall and
thighs unite/meet.
• Located between the anterior superior
iliac spine and the pubic tubercle.
• Surgically and anatomically, it is a very
important area where structures enter and exit
the abdominal cavity.
• It is a potential site for Herniation.
• Clinically: the inguinal region includes area
along and around the inguinal ligament.
• This region is important both anatomically and
clinically.
• Anatomically: Structures exit and enter into
the abdominal cavity.
• Clinically: Exit and entry are potential sites
of herniation. 99
INGUINAL CANAL
• The inguinal canal is situated parallel and superiorly to the
inguinal ligament.
• The canal is a tube formed during gonad development which
spans the region between the deep and superficial inguinal
rings.
• Begins at the deep inguinal ring and terminates at the
superficial ring.
• The aponeuroses of the external abdominal oblique and internal
abdominal oblique muscles form the anterior wall of the
inguinal canal.
• The conjoint tendon, the combined tendon of the internal
abdominal oblique and transversus abdominis muscles,
forms the medial portion of the posterior wall of the inguinal
canal, and the transversalis fascia forms the lateral portion.
100
• Transmits the spermatic cord
or the round ligament of the
uterus and the genital branch of
the genitofemoral nerve, both of
which run through the deep
inguinal ring and the inguinal
canal.
• An indirect inguinal hernia (if
present) passes through this
canal.
• Although the inguinal nerve
runs through part of the inguinal
canal and the superficial
inguinal ring, it does not pass
through the deep inguinal ring. 101
BOUNDARIES OF THE INGUINAL CANAL
• Anterior wall: Formed from superficial to deep by:
➢Skin
➢Superficial fascia in the whole extent
➢External oblique aponeurosis
➢Internal oblique muscle fibers, in lateral one-third.
• Posterior wall: Formed from deep to superficial by:
➢Fascia transversalis, in the whole extent
➢Conjoint tendon, in medial two-third
➢Reflected part of the inguinal ligament, in medial-most part.
102
• Superior (Roof): Formed by:
➢The lower arched fibers of internal oblique and transversus
abdominis muscles.
• Inferior (Floor): Formed by:
➢Grooved upper surface of the inguinal ligament in the whole
extent.
➢Abdominal surface of the lacunar ligament at the medial end.
❖CONTENTS OF INGUINAL CANAL
• In male: Spermatic cord and ilioinguinal nerve.
• In female: Round ligament of the uterus and ilioinguinal nerve.

103
CONTENTS OF INGUINAL CANAL: ▪ 3 Nerves:
▪ 3 Coverings/Layers:
➢ Iloingunal nerve
➢External spermatic fascia- EOF
➢Cremasteric fascia- IOM ➢ Genital branch of genitofemoral
➢Internal spermatic fascia- TF
nerve
▪ 3 Arteries: ➢ Sympathetic branches from
➢Testicular artery, T10-T11 spinal segments.
➢Artery to vas deference ▪ 3 Other structures:
➢Cremasteric artery ➢ Vas deference
▪ 3 Veins:
➢ Lymphatic vessels
➢Pampinform plexus of veins
➢Veins of vas deference ➢ A patent processus vaginalis in
➢Cremasteric vein
patients with indirect inguinal
hernia. 104
105
 INGUINAL RINGS
• A. DEEP INGUINAL RING/Entry
➢The deep inguinal ring is an oval opening in the fascia transversalis and
lies about 1.25 cm (1/2 inch) above the mid inguinal point.
➢From its margins, the fascia transversalis is prolonged into the canal
like a sleeve, the internal spermatic fascia, around the structures that
pass through the ring.
• B. SUPERFICIAL INGUINAL RING/Exit
➢The superficial inguinal ring is a triangular gap in the aponeurosis of
external oblique and lies above and lateral to the pubic crest.
➢The pubic crest forms the base of the triangle.
➢The sides (upper/medial and lower/lateral margins) of the triangle are
called crura, which unite laterally to form an obtuse apex.
➢Near the apex, the two crura are united by the inter crural fibers.
➢It is 2.5 cm long and 1.2 cm broad (at the base).
106
107
INGUINAL TRIANGLE
(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 OF THE INGUINAL
TRIANGLE;
➢Medial: Lower 5 cm of the lateral
border of the rectus abdominis muscle.
➢Lateral: Inferior epigastric artery.
➢Inferior: Medial half of the inguinal
ligament.
• The floor of the triangle is covered by
the peritoneum, extra peritoneal tissue, 108
and fascia transversalis.
109
INGUINAL HERNIA
• An inguinal hernia is the protrusion or passage of a peritoneal sac, with or
without abdominal contents, through a weakened part of the abdominal
wall in the groin.
• It occurs because the peritoneal sac enters the inguinal canal either:
• Indirectly, through the deep inguinal ring, or directly, through the
posterior wall of the inguinal canal.
• Inguinal hernias are therefore classified as either indirect or direct.
• INDIRECT INGUINAL HERNIA
• The indirect inguinal hernia is the most common of the two types of
inguinal hernia and is much more common in men than in women .
• It occurs because some part, or all, of the embryonic processus vaginalis
remains open or patent.
• It is therefore referred to as being congenital in origin.
110
• The protruding peritoneal sac enters
the inguinal canal by passing through
the deep inguinal ring, just lateral to the
inferior epigastric vessels.
• The extent of its excursion down the
inguinal canal depends on the amount
of processus vaginalis that remains
patent.
• If the entire processus vaginalis
remains patent, the peritoneal sac may
traverse the length of the canal, exit the
superficial inguinal ring, and continue
into the scrotum in men or the labia
majus in women.
• In this case, the protruding peritoneal
sac acquires the same three coverings
as those associated with the spermatic
cord in men or the round ligament of
the uterus in women.
111
• Direct inguinal hernias
• A peritoneal sac that enters the medial end of the inguinal canal directly
through a weakened posterior wall is a direct inguinal hernia.
• It is usually described as acquired because it develops when abdominal
musculature has been weakened, and is commonly seen in mature men.
• The bulging occurs medial to the inferior epigastric vessels in the
inguinal triangle (Hesselbach’s triangle), which is bounded:
➢Laterally: the inferior epigastric artery
➢Medially: the rectus abdominis muscle
➢Inferiorly: the inguinal ligament.
• Internally, thickening of the transversalis fascia (the iliopubic tract)
follows the course of the inguinal ligament.
112
• A direct inguinal
hernia does not
traverse the entire
length of the inguinal
canal but may exit
through the superficial
inguinal ring.
• When this occurs, the
peritoneal sac acquires
a layer of external
spermatic fascia and
can extend, like an
indirect hernia, into the
scrotum.
113
❖Reading Assignment
➢Femoral hernia
➢Umbilical hernia
➢Epigastric hernia
➢Hiatal hernia
➢Incisional hernia
➢Spigelian hernia
➢Diaphragmatic hernia
➢Muscle hernia

114
SPERMATIC CORD
• Contains structures running to and from the testis and suspends the
testis in the scrotum.
• Coverings of the spermatic cord include the following:
• External spermatic fascia: derived from the external oblique
aponeurosis and its investing fascia.
• Cremasteric fascia: derived from the investing fascia of the
internal oblique muscle.
• Cremaster muscle: loops of muscle, which is formed by the
lowermost fascicles of the internal oblique muscle contained in
cremasteric fascia.
• Internal spermatic fascia: derived from the transversalis fascia.
115
▪Contents of spermatic cord;
• Ductus deferens (vas deferens), testicular artery, artery of ductus
deferens: arising from the inferior vesical artery, cremasteric artery:
arising from the inferior epigastric artery.
• Pampiniform venous plexus: a network formed by up to 12 veins
that converge superiorly as right or left testicular veins.
• Sympathetic nerve fibers on arteries and sympathetic and
parasympathetic nerve fibers on the ductus deferens.
• Genital branch of the genitofemoral nerve: supplying the cremaster
muscle.
• Lymphatic vessels: draining the testis and closely associated
structures and passing to the lumbar lymph nodes.
116
117
•Surface Anatomy of Anterolateral Abdominal
Wall
• Umbilicus: is an obvious feature of the anterolateral abdominal
wall.
• At the level of the IVD between the L3-L4.
• Its position varies with the amount of subcutaneous fat present.
• Indicates the level of the T10 dermatome.
• Epigastric fossa (pit of the stomach):
• A slight depression in the epigastric region
• Just inferior to the xiphoid process.
• Particularly noticeable in the supine position.
• Pyrosis (“heartburn,”) resulting from reflux of gastric acid into
the esophagus is often felt at this site. 118
• Linea alba is visible in lean individuals because of the vertical skin
groove superficial to this raphe.
• Inguinal fold: is a shallow oblique groove overlying the inguinal
ligament.
• Semilunar lines (L. lineae semilunares): are slightly curved, linear
impressions in the skin that extend from the inferior costal margin
near the 9th costal cartilages to the pubic tubercles.
• 5–8cm from the midline
• Are clinically important because they are parallel with the lateral
edges of the rectus sheath.
• Inguinal groove
• Indicate site of the inguinal ligament
• A skin crease that is parallel and just inferior to the inguinal
ligament.
119
120
 Abdominal SURGICAL Incision
LONGITUDINAL INCISIONS
• Such as median and paramedian incisions, are preferred for exploratory operations
because they offer good exposure and access to the viscera, and can be extended as
necessary with minimal complication.
• Median or midline incisions: Can be made rapidly without cutting muscle, major blood
vessels, or nerves.
• Because the linea alba transmits only small vessels and nerves to the skin, a midline
incision is relatively bloodless, and avoids major nerves.
• Paramedian incisions
• May extend from the costal margin to the pubic hairline.
• Oblique McBurney: Incision is made at the McBurney point, approximately 2.5 cm
superomedial to the ASIS on the spino-umbilical line.
• HIGH-RISK INCISIONS
• Include pararectus and inguinal incisions.
• Pararectus incisions: along the lateral border of the rectus sheath are undesirable
because they may cut the nerve supply to the rectus abdominis.
• Inguinal incisions for repairing hernias may injure the ilio-inguinal nerve. 121
122
 Visceral
parts of GIT
organs in the
abdomen 123
 Abdominal Part of Esophagus (1.25 cm)
• Passes from the esophageal hiatus in the right crus of the
diaphragm.
• Become widen as it approaches to cardiac orifice of the
stomach to the left of the midline at the level of the 7th left
costal cartilage and T11 vertebra.
• Passing anteriorly and to the left as it descends inferiorly.
• Its anterior surface is covered with peritoneum of the greater
sac.
• It fits into a groove on the posterior (visceral) surface of the
liver.
• Its posterior surface is covered with peritoneum of the omental
bursa. 124
ESOPHAGOGASTRIC JUNCTION
• Lies to the left of the T11 on the horizontal plane that
passes through the tip of the xiphoid process.
• Z-line: where the mucosa abruptly changes.
• Inferior esophageal sphincter: physiological sphincter by
diaphragmatic musculature forming the esophageal hiatus.
• Just superior to Z-line.

125
Esophagogastric junction
• Lies to the left of T11 vertebra on the horizontal plane that passes through
the tip of the xiphoid process.
• The diaphragmatic musculature forms the esophageal hiatus physiological
esophageal sphincter that contracts and relaxes.
• Surgeons and endoscopists designate as the Z-lineal jagged line where the
mucosa abruptly changes from esophageal to the gastric.
THE PHRENOESOPHAGEAL LIGAMENT (MEMBRANE)
• An extension of inferior diaphragmatic fascia.
• Attaches the esophagus to the margins of the esophageal hiatus in the diaphragm.
• Stabilizes and maintains the esophagogastric junction in intrabdominal position.
• Permits independent movement of the diaphragm and esophagus during
respiration and swallowing.
126
127
128
• Physiological esophageal sphincter
• Prevents reflux of gastric contents into esophagus. The lumen of the esophagus when one is not
eating is normally collapsed above this sphincter. It is made up of two parts:

• Upper esophageal sphincter (UES)

➢Located between the pharynx and the upper esophagus

➢Made of muscles and cartilage

➢Prevents food from regurgitating/backflow into the airways

➢Prevents air from entering the digestive tract

➢Contracts at rest to create a high-pressure zone

➢Relaxes during swallowing

129
Lower esophageal sphincter (LES)
✓Located between the esophagus and the stomach

✓Made of esophageal muscle fibers and other components

✓Protects the esophagus from stomach acid and digestive juices

✓Relaxes during swallowing

✓Can also relax without swallowing

✓When it opens when it shouldn't, it's called acid reflux

130
Arterial supply of esophagus
• Esophageal branches (from the thoracic aorta)
• Left gastric artery (from celiac trunk)
• Left inferior phrenic artery (from the abdominal aorta)
Venous drainages of esophagus
• To the portal venous system through the left gastric vein
• To the systemic venous system through esophageal veins
entering the azygos vein.
Lymphatic drainages of esophagus
• The posterior mediastinal lymph nodes into the left gastric
nodes (efferent lymphatic vessels from these nodes drain
mainly to the celiac nodes).
131
132
133
Innervation of esophagus

• The vagal trunks

• The thoracic sympathetic
trunks.
• The splanchnic nerves (the
greater and lesser).
• The esophageal nerve plexus
around the left gastric and
inferior phrenic arteries.

134
 STOMACH/GASTRO
• The stomach is an enlarged segment of the digestive tract in the left
superior part of the abdomen. The most distensible part of GIT.
• Links the esophagus to the first part of the small intestine, the
duodenum.
• An empty stomach is only of slightly larger caliber than the large
intestine; however, it is capable of considerable expansion and can
hold 2–3L of food.
• Size, shape, and position can vary markedly in persons of different
body types and may change even in the same individual as a result of:
– Diaphragmatic movements
– It's contents, and the position of the person.
• Its a highly active structure, contracting continually to provide
mechanical assistance to digestion.
135
136
 Parts of the stomach
• It has four parts:
• Cardia: surrounding the cardial orifice.
– In the supine position, it lies posterior to the 6th left costal cartilage, 2–4 cm
from the median plane at the level of the T11.
• Fundus: the dilated superior part
– Related to the left dome of the diaphragm,
– Limited inferiorly by the horizontal plane of the cardial orifice.
– In the supine position, it lies posterior to the left 6th rib in the plane of the
MCL.
– There is cardial notch is between the esophagus and the fundus
• Body: the major part.
• Pyloric part: the funnel-shaped outflow region;
– pyloric antrum: its wider proximal part
– pyloric canal: narrower distal part. 137
138
• Pylorus (G., gatekeeper): is the distal, sphincter region.
–marked thickening of the circular layer of smooth muscle that
surrounds pyloric orifice.
• In the supine position, lies at the level of the transpyloric plane
(L1).
• When erect its location varies from the L2 –L4.

139
•Pyloric sphincter: Guards the
outlet of the stomach.
- Thickened ring of gastric
circular muscle.
-The pyloric orifice is just to
the right of midline in a plane
that passes through the lower
border of vertebra LI (the
transpyloric plane).
–Pyloric orifice:
Approximately 1.25 cm
right of the midline.
140
• Other features:
• Lesser curvature: concave right
border.
• Angular incisure (notch): the most
inferior part of the curvature.
– indicates the junction between body
and pyloric part.
– lies just to the left of the midline.
• Greater curvature: longer convex left
border.
– Passes inferiorly to the left from the
junction of the 5th ICS and MCL,
then curves to the right, passing
deep to the 9th or 10th left cartilage
as it continues medially to reach the
pyloric antrum.
141
 INTERIOR OF STOMACH
• The smooth surface of the gastric mucosa is reddish brown
during life, except in the pyloric part, where it is pink.
• Gastric folds (gastric rugae): longitudinal ridges when
contracted.
– Are most marked toward the pyloric part and along the
greater curvature.
• Gastric canal: A temporary groove or furrow that forms
between the longitudinal gastric folds along the lesser
curvature.
– Forms because of the firm attachment of the gastric mucosa
to the muscular layer. 142
143
 RELATIONS OF STOMACH
• Anteriorly: Related to the diaphragm, left lobe of liver, and anterior
abdominal wall.
• Posteriorly: Related to the omental bursa and pancreas.
• Inferolaterally: To transverse colon as it courses along the greater
curvature.
• Bed of the stomach:
– The structures forming the posterior wall of the omental bursa.
– From superior to inferior:
• Left dome of the diaphragm, spleen, left kidney and suprarenal
gland, splenic artery, pancreas, and transverse mesocolon.
144
 Bed of stomach

145
146
 Small Intestine/EntErOn
• This hollow tube, which is approximately 6-7m long with a narrowing
diameter from beginning to end.
• Its the longest part of the GIT. It extends from the pylorus to the ileocecal
junction.
• It is the portion of the GIT b/n the pyloric sphincter of the stomach
and the ileocecal valve opening into the large intestine.
– The site where digestion is completed and nutrients are absorbed.
– The surface area of the intestinal wall is increased by villi, and
microvilli.
– It is supported, except for the first portion, by the mesentery.
– Enclosed within the mesentery are blood vessels, nerves and
lymphatic vessels that supply the intestinal wall. 147
▪ FUNCTION OF THE SMALL INTESTINE:
➢The reception of the secretions from the liver and pancreas
➢Mechanical breakdown of chime
➢Absorption of nutrients
➢Transportation of the remaining undigested material to the
large intestine.
▪ PARTS OF THE SMALL INTESTINE:
➢Duodenum- upper part
➢Jejunum- middle part
➢Ileum- lower part
148
149
 DUODENUM
• A relatively fixed C- shaped tube (25cm long)
• The widest, most fixed, and shortest part.
• Extend from the pyloric sphincter to the duodenojejunal flexure
(junction), approximately at the level of the L2, 2–3 cm to the left of
the midline.
• It has four parts:
• Superior (first) part (5cm): lies anterolateral to the body of the L1
vertebra.
– ascends from the pylorus and is overlapped by the liver and
gallbladder.
– passes anterior to the bile duct, gastroduodenal artery, portal
vein, and inferior vena cava. 150
151
• Descending (second) part (7–10 cm):
– descends along the right sides of the L1–L3 vertebrae.
– runs inferiorly, curving around the head of the pancreas.
• Initially, it lies to the right of and parallel to the IVC.
• Contains: over its posteromedial wall
– major duodenal papilla: which is the common entrance for the bile and
pancreatic ducts,
– minor duodenal papilla: for entrance for the accessory pancreatic duct,
• The junction of the foregut and the midgut just below the major duodenal
papilla;
• Crossed anteriorly by the transverse colon.
• Posterior to it is the right kidney, and medial to it is the head of the
pancreas.
152
• Inferior (third) part (6–8 cm): crosses the L3 vertebra.
– runs transversely to the left, passing over the IVC, aorta, and L3.
• Crossed by the superior mesenteric artery and vein and the root of the
mesentery of the jejunum and ileum.
• Superior to it is the head of the pancreas and its uncinate process.
• Posteriorly it is separated from the vertebral column by the right psoas
major, IVC, aorta, and the right gonadal vessels.
• Ascending (fourth) part (5 cm): begins at the left of the L3 and extends
superiorly to superior border of the L2.
– runs superiorly and along the left side of the aorta.
– curves anteriorly to join the jejunum at the duodenojejunal flexure
• Ampulla(duodenal cap): the first 2 cm part of the duodenum, has a
mesentery and is mobile. 153
154
• Suspensory muscle of the
duodenum (ligament of
Treitz):
– Supports duodenojejunal
flexure.

155
– Composed of a slip
of skeletal muscle
from the
diaphragm and
smooth muscle
from the third and
fourth parts of the
duodenum.
– Its contraction
widens the angle of
the duodenojejunal
flexure.
156
157
 Functions of Duodenum
• To transform the partially digested food it receives from your
stomach into nutrients your body can use.
• Digestive juices from your liver, gallbladder and pancreas empty
into your duodenum, helping with digestion and absorption.
• Its left concave surface receives bile secretions through the
common bile duct from the liver and gallbladder, and pancreatic
secretions through the duct of the pancreas.
• Both ducts unite to form a common entry into the duodenum called
the hepatopancreatic ampulla (or ampulla of Vatter), which
pierces the duodenal wall and drains into the duodenum from an
elevation called the duodenal papilla.
• Duodenal glands (Brunner’s glands)
- Produce mucus and buffers 158
159
 JEJUNUM AND ILEUM
• Begins at the duodenojejunal flexure ends at the ileocecal junction.
• Jejunum
➢middle region of the small intestine.
➢approximately 2.5 meters (7.5 feet)
➢makes up approximately two-fifths of the small intestine’s total length.
➢most of the jejunum lies in the left upper quadrant (LUQ) of the infracolic
compartment GIT.
➢primary region for chemical digestion and nutrient absorption
• Ileum
➢The last region of the small intestine.
➢About 3.6 meters (10.8 feet) in length
➢Forms approximately three-fifths of the small intestine.
➢Most of the ileum lies in the right lower quadrant (RLQ)
➢The terminal ileum usually lies in the pelvis
➢Terminates at the ileocecal valve
• Sphincter that controls the entry of materials into the large intestine. 160
• Although no clear line of demarcation between jejunum and ilium, they
have distinctive characteristics that are surgically important.
Characteristic Jejunum Ileum
Color Deep red Pale pink
Caliber 2-4cm 2-3cm
Wall Thick and heavy Thin and light
Vascularity greater less
Vasa recta Long Short
Arcades A few loops Many short loops
Fat in mesentery Less More
Circular folds Large, tall, and densely packed Low and sparse, absent in distal part

Lymphoid nodules few many 161

162
 Large Intestine/Colon
• Approximately 1.5 meters in length and 6.5 cm in diameter.
• Watery material that first enters the large intestine soon solidifies and becomes
feces.
• Distinguished from the small intestine by:
– Omental appendices: small, fatty, omentum-like projections.
– Teniae coli: three distinct longitudinal bands:
1. Mesocolic tenia: to which the transverse and sigmoid mesocolons attach
2. Omental tenia: to which the omental appendices attach
3. Free tenia: to which neither mesocolons nor omental appendices are
attached.
• Haustra: sacculations of the wall of the colon between the teniae
• A much greater caliber (internal diameter). 163
164
 • The mesocolon, a specialized portion of the mesentery, supports the
transverse portion of the large intestine along the posterior
abdominal wall.
• The large intestine has little or no digestive functions.
Functions of Colon:
➢Absorption of water, minerals, and vitamins from the remaining
chyme.
➢Forms, stores, and elimination of indigestible material from the body.
▪ PARTS OF LARGE INTESTINE:
➢Cecum
➢Colon
➢Rectum
➢Anal canal
165
166
 CECUM
• The first part of the large intestine and continuous with the ascending colon.
• Almost entirely enveloped by peritoneum and can be lifted freely.
• It has no mesentery.
• B/c of its relative freedom, it may be displaced from the iliac fossa, but it is
commonly bound to the lateral abdominal wall by one or more cecal folds of
peritoneum.
• Ileocolic lips (superior and inferior): surrounds ileal orifice as ileum enters to
cecum.
– Meet laterally forming ridges ➔ frenula of the ileocecal orifice.
– It was believed that it act as sphincter. However, direct observation by
endoscopy in living persons does not support this description.
– The papilla probably serves as a relatively passive flap valve, preventing
reflux from the cecum into the ileum.
• The orifice is usually closed by tonic contraction
167
168
169
 Appendix (vermiform appendix; L. vermis, worm-like)
• A blind intestinal diverticulum (6–10 cm in length)
• Contains masses of lymphoid tissue.
• It arises from the posteromedial aspect of the cecum inferior to the ileo-cecal
junction.
• It has a short triangular mesentery, the meso-appendix, which derives from the
posterior side of the mesentery of the terminal ileum.
– Attaches to the cecum and the proximal part of the appendix.
• Position of the appendix is variable, but it is usually retrocecal.
• Anatomical position of the appendix determines the symptoms and the site of
muscular spasm and tenderness when the appendix is inflamed.
• The base of the appendix lies deep to a point that is 1/3rd of the way along the
oblique line joining the right ASIS to 2/3rd the umbilicus (McBurney point). 170
Neurovascular supply of appendix
• Artery: The appendicular artery, a branch of the ileocolic
artery.
• Venous drainage: Both cecum and appendix drain into the
ileocolic vein, a tributary of the SMV.
• Lymphatic drainage: The cecum and appendix: passes to lymph
nodes in the meso-appendix and to the ileocolic lymph nodes that
lie along the ileocolic artery.
• Nerve supply: To the cecum and appendix: derives sympathetic
and parasympathetic nerves from the superior mesenteric
plexus.

171
• Shows surface projection of the
base of the appendix .
• People with appendicular
problems may describe pain near
this location. 172
173
 COLON
• It has four parts—ascending, transverse, descending, and sigmoid colon.
• It encircles the small intestine.
Ascending colon
• Lying to the right of the small intestine.
• The second part of the large intestine.
• Passes superiorly on the right side of the abdominal cavity
• Secondarily retroperitoneal along the right side of the posterior abdominal
wall.
• Covered by peritoneum anteriorly and on its sides; however, in
approximately 25% of people, it has a short mesentery.
• It turns to the left at the right colic flexure (hepatic flexure).
• Hepatic flexure lies deep to the 9th and 10th ribs and is overlapped by the
inferior part of the liver. 174
• Paracolic gutter: a deep vertical groove lined with parietal
peritoneum.
– Lies between the lateral aspect of the ascending colon and the
adjacent abdominal wall.
Transverse colon
• The longest and most mobile part of the large intestine
• It crosses from the right colic flexure to the left colic flexure.
• Being freely movable, its position is variable, usually hanging to the
level of the umbilicus (L3).
• However, in tall thin people, it may extend into the pelvis.
• Transverse colon and its mesentery loops down, often inferior to the
level of the iliac crests.
175
• Left colic flexure (splenic flexure): is usually more
superior, more acute, and less mobile than the right colic
flexure.
–Lies anterior to the inferior part of the left kidney and
attaches to the diaphragm through the phrenicocolic
ligament.
Transverse mesocolon
• Fused with the posterior wall of the omental bursa.
• Its root lies along the inferior border of the pancreas and is
continuous with the parietal peritoneum posteriorly.
176
177
 Descending colon
• Occupies a secondarily retroperitoneal
• Between the left colic flexure and the left iliac fossa.
• Peritoneum covers the colon anteriorly and laterally.
• Has a short mesentery in approximately 33% of people
in the iliac fossa; however, it is usually not long enough
to cause volvulus (twisting) of the colon.
• Has left paracolic gutter on its lateral aspect.

178
 sigmoid colon
• Characterized by its S-shaped loop of variable length.
• Extends from the iliac fossa to the S3.
• Termination of the teniae coli, approximately 15 cm from the anus,
indicates the rectosigmoid junction.
• Has a long mesentery—the sigmoid mesocolon
• Its omental appendices are long.
sigmoid mesocolon
• Its root has an inverted V-shaped attachment, extending first
medially and superiorly along the external iliac vessels and then
medially and inferiorly from the bifurcation of the common iliac
vessels to the anterior aspect of the sacrum.
179
 Rectum
• Anterior to, and follows the concave contour of the sacrum.
• The most posterior element of the pelvic viscera.
• Continuous:
➢ Above: with the sigmoid colon
➢ Below: with the anal canal near pelvic floor.
• Lacks distinct taeniae coli muscles, omental appendices, and
sacculations (haustra).
• Has three lateral curvatures;
➢The upper and lower curvatures to the right
➢The middle curvature to the left.
• Rectal ampulla: lower expanded part of the rectum.
180
181
Parts of rectum covered by peritoneum:
• Upper 1/3rd: anterior and lateral surfaces
• Middle 1/3rd: only the anterior surface
• Lower 1/3rd: no peritoneum because it is subperitoneal.
ANAL CANAL:
• Begins at the terminal end of the rectal ampulla.
• Terminates as the anus after passing through the perineum.
The internal and external anal sphincters:
• Surrounded along its entire length of anus as it passes through the pelvic
floor, normally keep it closed.
182
183
– Lining of the anal canal:
• Bears the transition from gastrointestinal mucosa to skin:
• Upper part: lined by mucosa similar to that lining the rectum
– Shows number of longitudinally oriented folds known as
anal columns.
– Are united inferiorly by crescentic folds termed anal valves.
– Anal sinus: depression superior to each valve.
– Pectinate line: formed by united anal valves.
• Circle around the anal canal.
• Marks the approximate position of the anococcygeal membrane.

184
• Anal pecten: inferior to the pectinate line
– A transition zone known
– Lined by non-keratinized stratified squamous epithelium.
– Ends inferiorly at the anocutaneous line ('white line'),
• where the lining of the anal canal becomes true skin.

185
 Diverticulosis
• A disorder in which
multiple false diverticula
(external evaginations or
out-pocketing of the
mucosa of the colon).
• Primarily affects middle-
aged and elderly people.
• Commonly found in the
sigmoid colon.
• Diets high in fiber have
proven beneficial in
reducing the occurrence
of diverticulosis.
186
 Spleen
• An ovoid, usually purplish, pulpy mass about the size and shape of one’s
fist.
• Varies considerably in size, weight, and shape; however, it is usually
approximately 12 cm long and 7 cm wide.
• It is relatively delicate and considered the most vulnerable abdominal organ
• Located in the superolateral part of the left upper quadrant, or left
hypochondrium of the abdomen.
• In the adult, lies against the diaphragm, in the area of rib 9 to 11, and rests
on the left colic flexure.
• A mobile organ but it normally does not descend inferior to the costal (rib)
region.
• It is the largest of the lymphatic organ.
• It is not a vital organ (not necessary to sustain life).
187
• Functions;
– Prenatally, it is a hematopoietic organ
– Production of immunological response
• Participates in the body’s defense system
– Serves as a blood reservoir/blood bank, storing RBCs and platelets
– Remove old RBCs and broken-down platelets
❖Analogous to lymph node, lymph is replaced by blood.
• Relationships to the spleen:
– Anteriorly: stomach
– Posteriorly: left part of the diaphragm, which separates it from the pleura,
lung, and ribs 9–11.
– Inferiorly: left colic flexure
– Medially: left kidney
188
 Surfaces and borders of spleen
• Surfaces: has two surfaces
• Diaphragmatic surface: is convexly curved to fit the concavity
of the diaphragm.
• Visceral surface: molded by the adjacent structures:
– The left kidney posteriorly
– The left colonic flexure inferiorly
– The stomach superiorly
• Borders:
• The anterior and superior borders: are sharp and often notched
• The posterior (medial) end and inferior border: are rounded.
189
190
• The spleen is connected:
–To the greater curvature of the stomach by the gastrosplenic
ligament, which contains the short gastric and gastro-
omental vessels.
–To the left kidney by the splenorenal ligament, which
contains the splenic vessels.
• Both these ligaments are parts of the greater omentum.
• The spleen is surrounded by visceral peritoneum except in the
area of the hilum on the medial surface of the spleen.
• The splenic hilum is the entry point for the splenic vessels and
occasionally the tail of the pancreas reaches this area.
191
192
Structure of spleen
• Supporting tissue
– Enclosed by dense fibro-elastic capsule which send septa
– Capsule continue to ensheath blood vessels
– Network of reticular tissue forms skeleton
• Parenchyma
– Macroscopically white spots (white pulp) embedded in a red
matrix (red pulp)

193
 Pancreas
• An elongated, accessory digestive gland.
• Lies retroperitoneally, overlying and transversely crossing the bodies of the L1
and L2.
• Lies posterior to the stomach.
• Extends from duodenum on the right and the spleen on the left.
• Transverse mesocolon attaches to its anterior margin.
• FOUR PARTS OF PANCREAS:
– Head: the expanded part
• Embraced by the C-shaped curve of the duodenum.
• It firmly attaches to the medial aspect of the descending colon and
horizontal parts of the duodenum.
• Rests posteriorly on the IVC, right renal artery and vein, and left renal
vein. 194
– Uncinate process: a projection from the inferior part of the pancreatic head
• Extends medially to the left, posterior to the SMA.
– Neck: short (1.5–2 cm)
• Overlies the superior mesenteric vessels, which form a groove in its
posterior aspect.
• Posterior to it SMV joins the splenic vein to form the hepatic portal vein.
– Body: Lies to the left of the superior mesenteric vessels.
• Pass over the aorta and L2 vertebra, continuing just above the transpyloric
plane.
• Its posterior surface is in contact with the aorta, SMA, left suprarenal
gland, left kidney, and renal vessels.
– Tail: Lies anterior to the left kidney
• It is closely related to the splenic hilum and the left colic flexure.
• Relatively mobile and passes between the layers of the splenorenal
ligament. 195
 Pancreatic ducts
• Main pancreatic duct:
– Begins in the tail and runs through the parenchyma of the gland to the
pancreatic head.
– Then it turns inferiorly and is closely related to the bile duct.
– Usually unite with the bile duct ➔ to form the short, hepatopancreatic
ampulla (of Vater).
– Opens into the descending part of the duodenum at major duodenal papilla
– At least 25% of the time, the ducts open into the duodenum separately.
• Accessory pancreatic duct: opens into minor duodenal papilla.
– Usually, communicates with the main pancreatic duct.
– In some cases, its larger than main pancreatic duct and the two may not be
connected. 196
197
198
 Sphincters of pancreatic and bile ducts
• Are smooth muscle sphincters that control the flow of
bile and pancreatic juice into the ampulla and prevent
reflux of duodenal content.
–sphincter of the pancreatic duct: around the terminal
part of the pancreatic duct
–sphincter of the bile duct: around the termination of
the bile duct
–hepatopancreatic sphincter (of Oddi): around the
hepatopancreatic ampulla
199
 LIVER/HEPATOLOGY
• The largest soft, solid gland, and internal organ in the body.
• A reddish-brown in color because of its great vascularity.
• Approximately 1.5kg (appr. 2.5% of Bwt.) adult.
• In a mature fetus—when it serves as a hematopoietic organ—(5% of
body weight).
• Wedge Shaped (Resemble 4-sided pyramid & apex on left).
• Lies mainly in the right hypochondrium and epigastrium and extends
into the left hypochondrium.
• Protected by the thoracic cage and diaphragm, its greater part lies deep to
ribs 7-11 on the right side and crosses the midline toward the left below the
nipple.
• Moves with the diaphragm and is located more inferiorly when on is erect
(standing) because of gravity. 200
Peritoneal Reflections of the Liver
• Completely surrounded by a peritoneal membrane, known as Glisson's(fibrous)
capsule and completely covered by peritoneum (except the bare area).
• The bare area of the liver is a triangular area on the posterior (diaphragmatic)
surface of right lobe where there is no intervening peritoneum between the liver
and the diaphragm.
RELATIONSHIPS TO THE LIVER:
Anterior:
➢ Diaphragm
➢ Right & left pleura and lower margins of both lungs
➢ Right and left costal margins
➢ Xiphoid process
➢ Anterior abdominal wall in the subcostal angle 201
Posterior:
➢Diaphragm
➢Inferior vena cava
➢Right kidney and right
suprarenal gland
➢Hepatic flexure of the
colon
➢Duodenum (beginning),
gallbladder, esophagus and
fundus of the stomach

202
BOUNDARIES OF
BARE AREA:
➢ Anterior: superior
(anterior) layer of
coronary ligament.
➢ Posterior: inferior
(posterior) layer of
coronary ligament.
➢ Laterally: right and
left triangular
ligaments.
• Other bare areas
include:
➢ Porta hepatis, fossa
of gall bladder, &
grooves for IVC.
203
 Surface anatomy,
surfaces, peritoneal
reflections, and
relationships of
liver
204
 Surface anatomy
• Lies mainly in the right upper quadrant of the abdomen
and protected by the thoracic (rib) cage and the diaphragm.
• Normally lies deep to ribs 7th–11th on the right side and
crosses the midline toward the left nipple.
• Moves with the excursions of the diaphragm.
• Occupies most of the right hypochondrium and upper
epigastrium and extends into the left hypochondrium.
• Located more inferiorly when one is erect because of
gravity.
205
206
207
 Surfaces of liver
• Has two surfaces:
– Diaphragmatic (convex diaphragmatic surface (Antero-superior)
– Visceral, relatively flat or even concave (Postero-inferior)
The diaphragmatic surface of the liver
• Convex (anterior, superior, and some posterior)
• Smooth and dome-shaped and related to the concavity of the inferior
surface of the diaphragm.
• Separates from the pleurae, lungs, pericardium, and heart by diaphragm.
• Covered with visceral peritoneum, except posteriorly in the bare area of
the liver.
208
209
• BARE AREA:
–Area located posteriorly on the diaphragmatic surface of
the liver where there is no intervening peritoneum
between the liver and the diaphragm.
–Indirect contact with the liver.
–Demarcated by the reflection of the peritoneum from
the diaphragm to it as the anterior (upper) and posterior
(lower) layers of the coronary ligament.
• Groove for the vena cava: over the bare area of the liver.
210
Posterior surfaces
211
212
 visceral surfaces
• Covered with visceral peritoneum except in the fossa for
the gallbladder and the porta hepatis.
• Relatively flat or even concave posteroinferior aspect of
liver.
• Bears multiple fissures and impressions from contact
with other organs.
• Separated anteriorly by its sharp inferior border that
follows the right costal margin.

213
214
215
 Letter H-shaped area on the visceral surface
• Formed by two sagittally oriented right and left fissures, linked
centrally by the transverse fissure of porta hepatis.
• Right sagittal fissure: the continuous groove formed:
– Anteriorly: fossa for the gallbladder
– Posteriorly: groove for the inferior vena cava.
• Umbilical (left sagittal) fissure: the continuous groove
formed:
– Anteriorly: fissure for the round ligament
– Posteriorly: fissure for the ligamentum venosum
216
 Impressions on the visceral surface
• Reflect the liver's relationships to:
– Right side of the anterior aspect of the stomach
(gastric and pyloric areas).
– Superior part of the duodenum (duodenal area).
– Lesser omentum (extends into the fissure for the ligamentum
venosum).
– Gallbladder (fossa of gallbladder).
– Right colic flexure and right transverse colon (colic area).
– Right kidney and suprarenal gland (renal and suprarenal areas).

217
218
 Recess (spaces) related to the liver
• Subphrenic recesses: superior extensions of greater sac
– exist between diaphragm and the anterior and superior aspects of the
diaphragmatic surface of the liver.
– separated into right and left recesses by the falciform ligament.
– a gravity-dependent part of the peritoneal cavity in the supine position.
– fluid draining from the omental bursa flows into this recess.
– communicates anteriorly with the right subphrenic recess.
• Hepatorenal recess: (hepatorenal pouch; Morison pouch):
– the posterosuperior extension of the subhepatic space.
– lying between the right part of the visceral surface of the liver and the right
kidney and suprarenal gland.
• Subhepatic space: a portion of the supra-colic compartment of the peritoneal
cavity immediately inferior to the liver.

219
 Anatomical Lobes of the Liver
• Externally divided into two anatomical lobes and two accessory
lobes.
• Rt. and Lt. lobes defined by the attachment of the falciform
ligament and the left sagittal fissure.
• Two accessory lobes (parts of the anatomic right lobe): On the
visceral surface by right and left sagittal fissures and the transverse
porta hepatis.
– Quadrate lobe:
• Visible on the inferior/lower part
• Bounded on the left by the fissure for ligamentum teres and
on the right by the fossa for the gallbladder.
• Functionally it is related to the left lobe of the liver.
220
Caudate lobe:
– Visible on the superior/upper part
– Bounded on the left by the fissure for the ligamentum venosum and on the
right by the groove for the inferior vena cava.
– So-named because it often gives rise to a “tail” in the form of an elongated
papillary process
– Functionally, it is separate from the right and the left lobes of the liver.
Caudate process:
• Extends to the right, between the IVC and the porta hepatis,
connecting the caudate and right lobes.
• These superficial “lobes” are not true lobes as the term is generally used in
relation to glands and are only secondarily related to the liver's internal
architecture.
221
• The liver is divided into a large right lobe and a small left lobe by the
attachment of the falciform ligament.
• The right lobe is further divided into a quadrate lobe and a caudate lobe
by the presence of: the gallbladder, the fissure for the ligamentum teres,
the inferior vena cava, and the fissure for the ligamentum venosum.
• The caudate lobe is connected to the right lobe by the caudate process.
• The quadrate and caudate lobes are a functional part of the left lobe of the
liver.
• The functional anatomy divides the liver into left and right lobes based on
their relation to the division of common hepatic duct, hepatic portal vein,
and hepatic artery proper into right & left branches, so the areas of the
liver supplied by these branches constitute the functional left or right
lobes.
222
Lobes of the Liver

223
▪ Anatomically:
• The caudate and quadrate lobes are separated by the porta
hepatis.
• The right lobe is 6x bigger than the left with the quadrate and
caudate lobe belonging to the right lobe.
▪ Physiologically:
• The liver is divided into right and left halves by an imaginary line
that passes along the fossa for the gall bladder and inferior vena
cava.
• With this division, each half receives equal amount of blood and
equal drainage of bile and the quadrate and caudate lobes belong
to the left half.
224
 Functional subdivision of liver
• Not distinctly demarcated internally, where the parenchyma appears
continuously.
• Has independent right and left livers (portal lobes) that are much
more equal in size than the anatomical lobes.
• Each have its own primary branch of the HA & HPV and hepatic
duct.
• Caudate lobe:
– may in fact be considered a third liver.
– its vascularization is independent of the bifurcation of the portal triad (it
receives vessels from both bundles).
– drained by one or two small hepatic veins, which enter directly into the
IVC distal to the main hepatic veins. 225
• Liver can be
further subdivided
into four
divisions and then
into eight
surgically
resectable hepatic
segments:
– Each served
independently by
a secondary or terti
ary branch of the
portal triad,
respectively. 226
Liver segments and lobules
Parietal surfaces Visceral surfaces

227
 Hepatic (Surgical) Segments of Liver
Right and left functional livers:
• Based on the primary (1°) division of the portal triad into right and left branches
• The plane between the right and the left livers is the main portal fissure in which
the middle hepatic vein lies.
• On the visceral surface demarcated by the right sagittal fissure.
• On the diaphragmatic surface: demarcated by an imaginary line—the Cantlie
line (Cantlie, 1898)—from the notch for the fundus of the gallbladder to the IVC.
• The right and left livers are subdivided vertically into medial and lateral
divisions: by the right portal and umbilical fissures, in which the right and left
hepatic veins lie.
– The right portal fissure has no external demarcation.
• Each of the four divisions receives a secondary (2°) branch of the portal triad.
228
229
• Transverse hepatic plane: at the level of the horizontal
parts of the right and left branches of the portal triad
–Subdivides three of the four divisions (all but the left
medial division), creating six hepatic segments.
–Each receiving tertiary branches of the triad.
–Left medial division is also counted as a hepatic
segment, so that the main part of the liver has seven
segments (segments II–VIII, numbered clockwise.
–Caudate lobe (segment I) is supplied by branches of
both divisions and is drained by its own minor hepatic
veins.
230
 Blood supply of vessels of liver
• Liver has a dual blood supply a dominant venous source and a lesser arterial
one.
• A. Hepatic Portal Vein (HPV):
– Brings 75–80% of the blood to the liver.
– Containing about 40% more oxygen than blood returning to the heart from the
systemic circuit.
– Carries virtually all of the nutrients absorbed by the alimentary tract “except
lipids” to the sinusoids of the liver.
– The portal vein brings venous blood rich in the products of digestion, which
have been absorbed from the lower third of the esophagus to lower half of the
anal canal and also drains blood from the spleen, pancreas, and gallbladder
to liver.
• B. Hepatic artery, accounting for only 20–25% of blood received by the liver.
• The hepatic artery brings oxygenated blood to the liver.
• The venous blood is drained by right & left hepatic veins into the inferior vena
231
cava.
232
233
• At or close to the porta hepatis, the hepatic artery and portal vein terminate by
dividing into right and left primary branches which supply the right and left
parts of liver, respectively.
• Within the liver, the primary branches divide to give secondary and tertiary to
supply the hepatic segments independently.
• The hepatic veins, are intersegmental in their distribution and function, draining
parts of adjacent segments.
• The attachment of these veins to the IVC helps hold the liver in position.
• The peritoneal ligaments and the tone of the abdominal muscles play a minor role
in the support of liver.

234
235
Lymph Drainage
• The liver produces a large amount of lymph—about one third to one
half of all body lymph.
• The lymph vessels leave the liver and enter several lymph nodes in the
porta hepatis.
• The efferent vessels pass to the celiac nodes mainly.
• A few vessels pass from the bare area of the liver through the
diaphragm to the posterior mediastinal lymph nodes.
Nerve supply
• Sympathetic and parasympathetic nerves.
• Sympathetic from the celiac plexus.
• Parasympathetic nerves: the anterior vagal trunk gives rise to a
large hepatic branch, which passes directly to the liver.
236
• Portal-systemic (portacaval) anastomoses
• It is a specific type of anastomosis that occurs between the veins of portal circulation
and those of systemic circulation.
• In portal hypertension, these anastomosis open and form venous dilatation called
varices.
Sites:
➢ Esophagus (lower one-third part).
➢ Upper Anal canal (immediately under rectum).
➢ Paraumbilical region.
➢ Retroperitoneal.
➢ Intrahepatic (Patent ductus venosus) = rare.
• In portal hypertension (as from cirrhosis or hepatitis) the anastomosis areas dilate
causing variant effects depending on the site, for example:
➢ Esophageal- causes esophageal varices and hematemesis (vomiting blood).
➢ Para umbilical- causes caput medusa.
➢ Upper anal canal- cause hemorrhoids when the dilation burst and bleed.
237
• A portocaval anastomosis or porto-systemic anastomosis is a
specific type of anastomosis that occurs between the veins of the
portal circulation and those of the systemic circulation.
• When there is a blockage of the portal system, portocaval
anastomosis enables the blood to still reach the systemic venous
circulation.
• The inferior end of the esophagus and the superior part of the
rectum are potential sites of a harmful portocaval anastomosis.
• In portal hypertension, as in the case of cirrhosis of the liver, the
anastomoses become congested and form venous dilatations.
• Such dilatation can lead to esophageal varices, anorectal varices,
and caput medusae can also result.
238
• Porto-systemic anastomosis also known as portocaval
anastomosis is the collateral communication between the portal
and the systemic venous system.
• The portal venous system transmits deoxygenated blood from most
of the gastrointestinal tract and gastrointestinal organs to the liver.
• When there is a blockage of the portal system, portocaval
anastomosis enable the blood to still reach the systemic venous
circulation.
• Even though this is useful, bypassing the liver may be dangerous,
since it is the main organ in charge for detoxication and breaking
down of substances found in the gastrointestinal tract, such as
mediactions but the poisons as well.

239
▪ SITES OF PORTOCAVAL ANASTOMOSIS:
1. Lower third part of esophagus- The left gastric vein (portal tributaries)
anastomosis with esophageal veins (systemic tributaries) draining into azygous vein
at the lower third part of esophagus.
2. Upper Anal canal (immediately under rectum)- The superior rectal vein
(portal tributaries) draining the upper half of anal canal anastomoses with the
middle and inferior rectal veins (systemic tributaries), which are tributaries
internal iliac and internal pudendal veins, respectively.
3. Paraumbilical region- The left part of portal vein anastomosis with superficial
veins of anterior abdominal wall (systemic tributaries) .
4. Retroperitoneal- The veins of ascending colon, descending, duodenum colon,
pancreas, and liver (portal tributaries) anastomoses with the renal, lumbar, and
phrenic veins (systemic tributaries).
5. Bare area of the liver (patent ductus venosus)- There is some anastomosis
between portal veins channels in the liver and azygous systems of veins above the
diaphragm across the bare area of the liver. 240
241
242
243
• The importance of portosystemic anastomoses is to provide
alternative routes of circulation when there is a blockage in the liver or
portal vein.
• These routes ensure that venous blood from the gastrointestinal tract
still reaches the heart through the inferior vena cava without going
through the liver.
• The anastomosis between the left gastric veins, which are portal veins,
and the lower branches of esophageal veins that drain into the azygos
and hemiazygos veins, which are systemic veins.
• The site of this anastomosis is the lower esophagus. 244
• The anastomosis between the superior rectal veins, which are portal veins, and the
inferior and middle rectal veins, which are systemic veins. The site of this anastomosis
is the upper part of the anal canal.
• The anastomosis between the paraumbilical veins, which run in the ligamentum teres as
portal veins, and small epigastric veins, which are systemic veins. The site of this
anastomosis is the umbilicus.
• The anastomosis between the intraparenchymal branches of the right division of the
portal vein and retroperitoneal veins (systemic veins) that drain into the azygos,
hemiazygos and lumbar veins (systemic veins). The site of this anastomosis is the bare
area of the liver.
• The anastomosis between omental and colonic veins (portal veins) with the
retroperitoneal veins (systemic veins) in the region of hepatic and splenic flexure.
245
 Biliary Ducts and Gallbladder
• Bile canaliculi: formed between hepatocytes receive bile from them.
• Then drain into the small interlobular biliary ducts ➔ into large collecting bile
ducts of the intrahepatic portal triad➔ merges to form the hepatic ducts➔
right and left hepatic ducts ➔ unite to form the common hepatic duct➔
joined by cystic duct➔ to form the bile duct (part of the extrahepatic portal
triad.
BILE DUCT
• Formerly called the common bile duct.
• Length varies from 5-15 cm, depending on where the cystic duct joins the
common hepatic duct.
• Descends posterior to the superior part of the duodenum and lies in a groove
on the posterior surface of the head of the pancreas.
• Join with the main pancreatic duct➔ forming a dilation, the hepatopancreatic
ampulla.
246
247
 Gall bladder
• 7–10 cm long lies in the fossa for the gallbladder.
• Superior part of the duodenum is usually stained with bile in the cadaver.
• Pear-shaped can hold up to 50 ml of bile.
• Its hepatic surface attaches to the liver by connective tissue of the fibrous capsule
of the liver.
• Has three parts:
– Fundus: Projects from the inferior border of the liver at the tip of the right 9th
costal cartilage in the MCL.
– Body: Main portion that contacts liver, transverse colon, and superior part of
the duodenum.
• Lies anterior to the superior part of the duodenum.
– Neck: Narrow, tapering end, directed toward the porta hepatis.
• It and cystic duct are immediately superior to the duodenum.
• Spiral fold (spiral valve): spiral formation of mucosa of the neck.
• Helps to keep the cystic duct open. 248
249
250
• Also offers additional resistance to sudden dumping of bile when the sphincters are
closed, and intra-abdominal pressure is suddenly increased.
• Cystic duct (3–4 cm long) connects the neck of the gallbladder to the common hepatic
duct.

251
Vascular supply of the gallbladder
and cystic duct
Arterial supply
• From the cystic artery which commonly arises from the right
hepatic artery in the triangle between the common hepatic
duct, cystic duct, and visceral surface of the liver, the
cystohepatic triangle (of Calot).
• Variations in the origin and course of the cystic artery occur in
24.5% of people which is of clinical significance during
cholecystectomy—surgical removal of the gallbladder.
252
 Venous drainage
• Venus drainage from the neck of the gallbladder and cystic
duct
– Flows via small and usually multiple the cystic veins.
– Enter the liver directly or drain through the hepatic portal
vein to the liver, after joining the veins draining the hepatic
ducts and proximal bile duct.
• Veins from the fundus and body of the gallbladder
– pass directly into the visceral surface of the liver and drain
into the hepatic sinusoids.

• Lymphatic drainage: to the hepatic lymph nodes.

253
ARTERIAL SUPPLY
OF ABDOMINAL
VISCERAL ORGANS
• From anterior
branches, the three
unpaired abdominal
aorta:
A. Celiac trunk
B. Superior
mesenteric artery
C. Inferior
mesenteric artery
254
 A. Celiac trunk
• Arises immediately below the aortic hiatus of the diaphragm, anterior
to the upper part of vertebra L1.
• Divides into three: left gastric, splenic, and common hepatic arteries.
Left gastric artery
• The smallest branch and ascends to the cardio esophageal junction.
• Sends esophageal branches upward to the abdominal part of the
esophagus.
• Then turns to the right and descends along the lesser curvature of the
stomach in the lesser omentum.
• It supplies both surfaces of the stomach in this area anastomoses with
the right gastric artery. 255
256
 Splenic artery
• The largest branch of the celiac trunk.
• Takes a tortuous course to the left along the superior border of the pancreas.
• Travels in the lienorenal ligament.
• Divides into numerous branches, which enter the hilum of the spleen.
• It gives off:
– Numerous small branches to supply the neck, body, and tail of the
pancreas
– Approaching the spleen gives off;
• Short gastric arteries (supply the fundus of the stomach).
• Left gastro-omental/epiploic artery:
–Runs to the right along the greater curvature of the stomach
–Anastomoses with the right gastro-omental artery.
257
258
 Common hepatic artery
• A medium-sized branch.
• Runs to the right and divides into:
– Hepatic artery proper:
• Ascends towards the liver in the free edge of the lesser omentum.
• Divides into the right and left hepatic arteries near the porta hepatis.
• As the right hepatic artery nears the liver, it gives off the cystic artery,
which supplies the gallbladder.
– Gastroduodenal artery:
• Descend posterior to the superior part of the duodenum.
Aberrant Hepatic Arteries
• The most common source of an aberrant right hepatic artery is the SMA.
• The most common source of an aberrant left hepatic artery is the left gastric
artery.
259
• GASTRODUODENAL ARTERY- divided at the terminal branches near the lower
border of the 1st part of the duodenum into:
– right gastro-omental/epiploic artery
– superior pancreaticoduodenal
• Right gastro-omental artery
– passes to the left, along the greater curvature of the stomach,
– anastomose with the left gastro-omental artery.
– sends branches to both surfaces of the stomach and additional branches
descend into the greater omentum.
• Superior pancreaticoduodenal artery
– divides into anterior and posterior branches
– descends and supplies the head of the pancreas and the duodenum.
– anastomose with anterior and posterior branches of the inferior
260
pancreaticoduodenal artery.
 B. Superior mesenteric artery
• Arises from the abdominal aorta immediately below the celiac artery,
anterior to the lower part of LI vertebra .
• Crossed anteriorly by the splenic vein and the neck of pancreas.
• Posterior to the artery are the left renal vein, the uncinate process of the
pancreas, and the inferior part of the duodenum.
Branches
✓Inferior pancreaticoduodenal artery
✓Jejunal and ileal arteries on its left
✓Middle colic, right colic, and ileocolic arteries
– supply the terminal ileum, cecum, ascending colon, and two-thirds of the
transverse colon. 261
Inferior pancreaticoduodenal artery
• The first branch.
• Divides immediately into:
– anterior and posterior branches
– ascend on the corresponding sides of the head of the pancreas.
Jejunal and ileal arteries
• Arising on the left
• Supply the jejunum and most of the ileum.
• Pass between two layers of the mesentery,
Arcades:
– formed anastomoses between branches Jejunal and ileal arteries
– increases distally along the gut.
Vasa recta (straight arteries).
– extend from the terminal arcade,
– provide the final direct vascular supply to the walls of the S1. 262
 Middle colic artery
• The first of the three branches from the right side of SMA.
• Enters the transverse mesocolon and divides into right and left branches.
– Right branch:
• anastomoses with the right colic artery
– Left branch:
• anastomoses with the left colic artery, which is a branch of the inferior
mesenteric artery.
Right colic artery
• The second of the three branches from the right side SMA.
• Passes to the right in a retroperitoneal position to supply the ascending
colon.
• Nearing the colon, it divides into:
– Descending branch: anastomoses with the ileocolic artery
– Ascending branch: which anastomoses with the middle colic artery.
263
 Ileocolic artery
• The final branch of SMA.
• Passes downward and to the right towards the right iliac fossa
• Divides into:
– Superior branch:
• passes upward along the ascending colon to anastomose
with the right colic artery;
– Inferior branch:
• Continues towards the ileocolic junction
• Dividing into colic, cecal, appendicular, and ileal
branches
264
265
266
 C. INFERIOR MESENTERIC ARTERY
• The smallest of the three anterior branches of the abdominal aorta
• Arises anterior to the body of vertebra L3.
• Its branches include the:
– Left colic artery
• The first branch of the inferior mesenteric artery
• Dividing into ascending and descending branches:
– Several sigmoid arteries (3-4)
• Consist of two to four branches
• Supply the lowest part of the descending colon and the sigmoid colon
– Superior rectal artery
• The terminal branch of the inferior mesenteric artery.
• Descends into the pelvic cavity crossing the left common iliac vessels.
• Supply superior one third of rectum 267
268
 Paired parts of abdominal aorta
Inferior Phrenic Arteries: arise just below the diaphragm, at the level of the
T12 vertebra. Supply the diaphragm and give off small branches to the
adrenal glands (suprarenal arteries).
Middle Suprarenal Arteries: arise at the level of the L1 vertebra. supply the
adrenal glands (suprarenal glands).
Renal Arteries: arise at the level of the L1-L2 vertebrae. supply the kidneys.
Testicular Arteries: supply the testes (in male).
Ovarian Arteries: supply the ovaries ( in female). arise at the level of the L2
vertebra and descend to the pelvic region.
Lumbar Arteries: typically, four pairs (sometimes five), arising from the
posterior aspect of the abdominal aorta. supply the posterior abdominal wall,
spinal cord, and muscles of the back. 269
270
 Veins of the Abdomen (Caval System)
• Beginning at the level of the pelvic brim, the common iliac vein is formed by the
internal and external iliac veins.
• The two common iliac veins join to form the inferior vena cava, which receives
venous drainage from the gonads, kidneys, posterior abdominal wall (lumbar
veins), liver, and diaphragm.
• The IVC then drains into the right atrium of the heart.
• The supericial set of veins drain the anterolateral abdominal wall, the supericial
inguinal region, rectus sheath, and lateral thoracic wall.
• Most of itsconnections ultimately drain into the axillary vein, then into the
subclavian vein and the two brachiocephalic veins, which unite to form the
superior vena cava, and then into the heart.
• The inferior epigastric veins (from the external iliac veins) enter the posterior
rectus sheath, course cranially above the umbilicus as the superior epigastric
veins, and then anastomose with the internal thoracic veins that drain into the
subclavian veins.
271
272
• Lymphatic Drainage
• Lymph from the posterior
abdominal wall and
retroperitoneal viscera
drains medially,
following the arterial
supply back to lumbar
and visceral preaortic and
lateral aortic lymph nodes
(Fig. 4.41).
• Ultimately, the lymph is
collected into the
cisterna chyli and
conveyed to the venous
system by the thoracic
duct.
273
 Venous drainage
Portal vein:
• Formed by the union of the splenic vein and the superior mesenteric
vein posterior to the neck of the pancreas at the level of vertebra L2.
• The final common pathway for the transport of venous blood from:
– the spleen, pancreas, and gallbladder.
– the abdominal part of the gastrointestinal tract, except for the inferior part of the
rectum.
• Deliver blood from these structures to the liver.
Its tributaries include:
– Right and left gastric veins: draining the lesser curvature of the stomach and
abdominal esophagus.
– Cystic veins from the gallbladder
– The para-umbilical veins 274
275
 Splenic vein
• Forms from numerous smaller vessels leaving the hilum of the
spleen.
• Passes to the right through the splenorenal ligament posterior
to pancreas.
Its tributaries include:
– Short gastric veins: from the fundus and left part of the greater
curvature of the stomach;
– Left gastro-omental vein: from the greater curvature of the
stomach;
– Pancreatic veins: from body and tail of pancreas;
– Usually the inferior mesenteric vein.
276
 Superior mesenteric vein
• Drains blood from the parts of GIT supplied by SMA.
• Begins in the right iliac fossa
• Ascends in the mesentery to the right of the SMA.
• Its tributaries accompanies each branch of the SMA.
• Additional tributaries include:
–Right gastro-omental vein: from right part of the greater
curvature of the stomach;
–Anterior and posterior inferior pancreaticoduodenal
veins. 277
 Inferior mesenteric vein
• Drains blood from the:
– rectum, sigmoid colon, descending colon, and
splenic flexure.
• Begins as the superior rectal vein
• Its tributaries accompanies each branch of the IMA.
• Usually joins the splenic vein. Occasionally, it ends at
the junction of the splenic and SMV or joins the
SMV.
278
279
280
Posterior abdominal wall
• The posterior abdominal wall extends from the 12th rib above to the pelvic
brim below.
• It is strong and stable (the anterior abdominal wall is soft and distensible)
because it is constructed by bones, muscles, and fasciae.
• It supports retroperitoneal organs, vessels, and nerves.
It consists:
➢Skin
➢Fascia
➢Muscles
➢Ligaments
➢Bones (T12/12th ribs, L1-L5, and Iliac crest and iliac fossa)
➢Kidneys and suprarenal (adrenal) glands
➢Blood vessels, lymphatic vessels, and nerves
281
Fascia and Muscles of Posterior Abdominal Wall
• Deep to the parietal peritoneum, the muscles of the posterior abdominal wall
are enveloped in a layer of investing fascia called the endoabdominal fascia,
which is continuous laterally with the transversalis fascia of the transversus
abdominis muscle.
• For identication, the fascia is named according to the structures it covers
and includes the following layers:
• Psoas fascia: covers the psoas major muscle and is thickened superiorly,
forming the medial arcuate ligament.
• Thoracolumbar fascia: anterior layer covers the quadratus lumborum
muscle and is thickened superiorly, forming the lateral arcuate ligament;
middle and posterior layers of the thoracolumbar fascia envelop the erector
spinae muscles of the back.
• The muscles of the posterior abdominal wall have attachments to the lower
282
rib cage, the T12-L5 vertebrae, and bones of the pelvic girdle.
283
284
Arteries of Posterior abdominal wall

285
VEINs of Posterior abdominal wall

286
Nerves of Posterior abdominal
wall

287
Lymph Nodes and VESSELS of Posterior abdominal wall

288
DEVELOPMENT
OF GIT
289
 Primitive Gut
• The primitive gut tube is a hollow tube that forms
in an embryo during the third or fourth week of
development from endoderm germ layers.
• Formed by the embryonic foldings with the
incorporation of the yolk sac.
• Terminal ends of primitive gut is made by:
➢ Stomodeum: blocked by buccopharyngeal
membrane.
➢ Proctodeum: blocked by cloacal membrane.
• Primitive gut is divided into three:
➢Foregut – supplied by celiac trunk
➢Midgut – supplied by superior mesenteric
artery
➢Hindgut – supplied by inferior mesenteric
artery 290
 Derivatives of Primitive Gut
• Foregut- From the distal end of the esophagus up to the proximal middle of 2nd part
of the duodenum.
• Innervation:
➢ Sympathetic: Greater splanchnic nerve (T5-T9)
➢ Parasympathetic: Vagus (cranial number X)
• Midgut- From end of foregut up to junction of right 2/3rd and left 1/3rd of transverse
colon.
• Innervation:
➢ Sympathetic: Lesser splanchnic nerve (T9-T11)
➢ Parasympathetic: Vagus (cranial number X)
• Hindgut -FROM end of midgut up to upper 1/2 or 2/3rd of anal canal.
• Innervation:
➢ Sympathetic: Least splanchnic nerve (T12), Lumbar splanchnic nerve (L1-L2)
➢ Parasympathetic: Pelvic splanchnic nerve (S2-S4)
291
 Development of Oesophagus
• Initially, at 4th week is short.
• Later elongates because of growth & descent of heart & lung, and
reaches its final relative size by 7th week.
• Epithelium proliferates & temporarily blocks the lumen, but
recanalization takes place by the end of embryonic period.
• Muscles:
– In upper 1/3rd region is skeletal muscle that develops from
mesenchyme of caudal branchial or pharyngeal arches.
– In lower 1/3rd region is smooth muscle that develops from
surrounding splanchnic mesenchyme.
292
Primitive Mesenteries of the GIT
• Made by:
1. Ventral mesentery
– Extends from intra-abdominal region of oesophagus to
upper region of duodenum
– Develops form septum transversum
2. Dorsal mesentery
– Extends from intra-abdominal region of oesophagus, the
whole of midgut to major part of hindgut.
293
 Development of the Stomach
• At 4th week dilates and becomes fusiform with slight dilatation in
the median plane.
• It has:
– Cranial & caudal ends
– Right & left surfaces
– Ventral & dorsal borders
• The posterior border grows faster than the ventral border to
become the greater curvature of the stomach.
• The ventral border becomes the lesser curvature of the stomach.
294
 Rotation of the Stomach
• Rotates around its:
➢900 clockwise to the right around its longitudinal axis.
➢Around its anteroposterior axis
▪ Results of Rotation of the Stomach Around the longitudinal
axis
➢Ventral border (lesser curvature) moves to the right
➢Dorsal border (greater curvature) moves to the left
➢Left surface becomes anterior surface carrying anterior gastric
nerve.
➢Right surface becomes posterior surface carrying posterior
gastric nerve.
295
 Results of Rotation of the Stomach
Around the anteroposterior axis
• Cranial end moves to the left & slightly down
• Caudal end moves to the right & slightly up
• Its longitudinal axis becomes almost transverse
to longitudinal axis of the body.

296
 Development of the Duodenum
• Develops from caudal part of foregut & cranial part of
midgut.
• The site of junction between foregut & midgut grows
rapidly to form “C” shaped loop that projects ventrally.
• Rotates 900 clockwise to the right, with the stomach.
• After rotation, rests by its right side on posterior
abdominal wall & becomes retroperitoneal.

297
 Development of the Midgut
• Gives from second part of duodenum up to junction of right 2/3rd & left 1/3rd of
transverse colon.
• Loop is formed with convexity directed anteriorly and has the superior
mesenteric artery in the axis.
• Apex of the loop is connected to the yolk sac by yolk sac stalk until 10th week.
• Cranial limb elongates much & coils, to give later jejunum & greater part of
ileum.
• Caudal limb elongates moderately & dilates, but do not coil, to give later distal
part of ileum, large intestine up to right 2/3rd of transverse colon.
• Rotates a total of 2700 counter clockwise, initially 900 during herniation and
further twice 900 rotations during return into the abdominal cavity.
• During return from herniation some regions are fixed to the posterior abdominal
wall & lose their mesentery becoming retroperitoneal.
298
Development of the Cecum and Appendix

• Cecum develops from the caudal limb of midgut as a

cecal bud made by small conical dilatation that grows
later.
• Appendix develops as a narrow diverticulum from the
distal end of the cecal bud as the colon descends,
making it to occupy frequently a retrocecal or
retrocolic position.

299
 Development of the Hindgut
• Gives the left 1/3rd of transverse colon, descending colon, sigmoid colon,
rectum & upper 2/3rd to 1/2 of the anal canal.
• Elongates & forms a loop with its convexity projected dorsally.
• Terminal part dilates and gives cloaca which is blocked by cloacal
membrane.
• Cloaca will be divided by urorectal septum into:
-Urogenital sinus blocked by urogenital membrane ventrally
-Anorectal canal blocked by anal membrane dorsally
Development of the Anal Canal
• Anal membrane ruptures at the end of the 7thweek & anorectal canal gives
upper 2/3rd to 1/2nd of the anal canal up to the level of pectinate line.
• The lower 1/3 – 1/2 of the anal canal develops from the ectoderm lined
proctoderm. 300
 Development of the Liver
• Begins to develop as hepatic (liver) bud from apex of duodenal
loop into septum transversum (ventral mesentery) at the 4th week
• Divides into:
1. Pars hepatica - larger & cranial one
– Gives parenchyma of liver and bilary ducts.
– Liver begins hematopoeitic function by 6th wk and bile
production by 12th wk.
2. Pars cystica - smaller & caudal
– Gives cystic duct & gallbladder
301
 Development of the Pancreas
• By two pancreatic buds:
1. Dorsal pancreatic bud
• Appears 1st slightly cranial to hepatic bud
• Grows in the dorsal mesentery
2. Ventral pancreatic bud
• From proximal region of hepatic bud
• Rotates along with duodenum to come & lie posterior to the dorsal
pancreatic bud and fuse with it.
• Ventral Pancreatic bud
– Gives rise to uncinate process & lower part of head of pancreas
• Dorsal Pancreatic bud
– Gives rise to upper part of the head, neck, body & tail of pancreas 302
 Pancreatic ducts
1. Main Pancreatic Duct (of Wirsung)
• By: 1. Distal part of duct of dorsal pancreatic bud
2. Entire duct of the ventral pancreatic bud
3. Anastomsis between the ducts of dorsal & ventral pancreatic
buds.
• Form hepatopancreatic ampulla (of Vater) with the bile duct and
opens into the major duodenal papilla.
2. Accessory Pancreatic Duct (of Santorini)
• By proximal part of duct of dorsal pancreatic bud
• Opens into minor duodenal papilla, about 2 cm cranial to the
major duodenal papilla.
303
Development of the Islets of Langerhans

• Islets of Langerhans develop during the3rd

month as parenchymal cells that lose their

connection with the duct system.
• Insulin production begins by the 5 month
th

304
Development of the Mesenteries
Ventral mesentery gives:
I. Lesser omentum between liver and stomach & duodenum as:
– Hepatogastric ligament
– Hepatoduodenal ligament
II. Falciform ligament between liver & ventral abdominal wall.
III. Coronary & triangular ligaments between liver &
diaphragm
IV. Stroma & visceral peritoneum of liver
305
 Dorsal mesentery is divided into:

I. Dorsal mesentery of esophagus

– Gives rise to the right & left crura of diaphragm
II. Dorsal mesogastrium
III. Dorsal mesoduodenum
IV. Mesentery proper
V. Dorsal mesocolon

306
Dorsal mesogastrium splits by developing spleen into:
A. Gastrosplenic (gastrolienal) ligament between stomach & spleen
B. Splenorenal (Lineorenal)ligament between spleen & left kidney.
➢ Was initially connected to the dorsal abdominal wall on the midline, but move later to
the left kidney because of stomach’s rotation.
C. Development of the omental bursa (lesser sac of peritoneum)
➢ By coalescence of small cavities in the dorsal mesogastrium and by the effect of
rotation of the stomach.
D. Development of the greater omentum
➢ Double layered apron like fold of dorsal mesogastrium
➢ Made by 4 layers
➢ Hangs down from the greater curvature of the stomach & curves back to get attached
to transverse colon, initially containing the lower recess of the lesser sac.
➢ But this disappears when all the four layers of the greater omentum fuse. 307
 Development of the Dorsal Mesenteries
ii. Dorsal mesoduodenum later largely disappears as duodenum
becomes retroperitoneal.
iii. Mesentery proper
– Develops into the broad fan-shaped fold connecting jejunum &
ileum obliquely to the posterior abdominal wall from left side of
L2 vertebra to right iliosacral joint with a length of 15 cm.
iv. Dorsal mesocolon.
- Develops into mesoappendix, transverse mesocolon and sigmoid
mesocolon with ascending & descending colons becoming
retroperitoneal.
308
Histology
of GIT
309
 Histology of the Esophagus
• Mucosa
• Lined by stratified squamous nonkeratinized epithelium
– Lamina propria has esophageal cardiac glands.
• Compound tubuloalveolar glands that produce a neutral mucus
• Mainly at the terminal portion, but may also at the beginning as well
• Produce a neutral mucus
– Muscularis mucosae
• Make a longitudinal layer of smooth muscle cells
• Muscularis externa
– Mixed skeletal& middle
– As inner circular and outer longitudinal, but show variations
• Adventitia/serosa 310
311
 Histology of the stomach
• Mucosa
➢ Shows three distinct structures:
a. Longitudinal folds (rugae)
• Longitudinal folds of submucosa and lamina propria
b. Shallow grooves that form bulging irregular areas known as mamillated areas
c. Shows gastric pits (foveolae) receive several gastric glands.
• Mucosa
– Lined by surface mucous cells produce visible mucus that:
• Appears cloudy forming a thick, viscous, gel-like coat.
• With high content of the bicarbonates.
– Contains simple branched tubular glands that show isthmus, neck & base (fundus)
– Produce HCl, Pepsin, mucus, intrinsic factor, water, & electrolytes.
• Lamina propria, muscularis mucosae and submucosa of stomach are well developed.
• Muscularis externa made by:
a. Inner oblique
b. Middle circular
• Gives pyloric sphincter
• Poorly developed in the periesophageal region
c. Outer longitudinal
• absent from much of the anterior and posterior surfaces 312
313
 Gastric Glands
In fundus & body region
– With short pit and long gland
– Contains five types of cells
• Stem cells
• Mucous neck cells
• Parietal cells
• Chief cells
• Enteroendocrine cells
Cells of Gastric Glands in Fundus & Body Region
Stem Cells
– Located in upper part
– Low columnar cells with basally located oval nuclei
– Replace all types of epithelial & gastric gland cells every:
• 4–7 days for the surface mucous cells
and mucous neck cells
• 60-90 days for the chief cells and
enteroendocrine cells
• 150-200 days for the parietal cells
314
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Cells of Gastric Glands in Fundus & Body Region
Mucous Neck Cells
– Located in upper part
– Irregular cells with basal nuclei and apical secretory granules
– As compared to the surface mucous cell the mucous neck cells:
• Are much shorter
• Contain less mucinogen which is released in a regulated manner as opposed to constitutive
• Have spherical nucleus as compared to elongate nucleus
• Secrete a soluble mucus as compared to insoluble mucus
Oxyntic (Parietal) Cells
– Eosinophilic cells present mainly in the upper half
– Round or pyramidal shaped cells, with spherical nucleus
– Secrete HCl, KCl, traces of other electrolytes, and gastric intrinsic factor.
Chief (Zymogenic) Cells
– Found mainly in the lower region of the glands.
– Basophilic cells with protein synthesizing & exporting characteristics.
– Secrete pepsinogen and lipase
Enteroendocrine Cells
– Specialized cells accounting for less than 1% cells of the epithelial cells of the GIT, but collectively make the
largest endocrine organ in the body.
– Some are classified functionally as the APUD cells, but differ
embryologically 316
317
318
 Histology of the Small Intestine
• About 5 m long and 2.5 cm wide
• Show three structural modifications that increase the surface area
approximately 600 fold giving a total area of roughly 200 m2
1. Plicae Circularis (Circular Folds or Valves of Kerkring)
2. Villi
3. Microvilli
• Plicae Circularis (Circular Folds or Valves of Kerkring)
• Semilunar, circular or spiral projections
• By mucosa and submucosa
• Most developed in the distal part of duodenum and beginning of jejunum,
but decrease in the middle of ileum.
• Increase the surface area about 3 fold
319
Villi
• Projections by epithelium with lamina propria core
• 0.5 to 1.5 mm long
• Increase the surface area 10fold
• Lamina propria with vessels, lacteals, nerves & smooth myocytes
Microvilli
– Apical plasma membrane projections of the absorptive cells
– 1μm long and 0.1μm wide
– Increase the surface area 20fold
• Cells of the Epithelial lining of the surface and villi
Absorptive cells or enterocytes
-With about 3000 microvilli on each cell containing disaccharides and peptidases
Goblet cells
– Increase in number as they approach the ileum
Neuroendocrine cells
– Produce various types of hormones
320
321
322
Intestinal glands (Crypts of Lieberkühn) of the small Intestine
– Simple tubular glands located in the lamina propria and open in between the villi
– Contain Stem cells, Absorptive cells, Goblet cells, Paneth’s, Microfold (M) cells, and
various types of neuroendocrine cells.
• Cells of the Intestinal glands of the small Intestine
Stem cells
– Located in the lower half of the intestinal glands
– Replace the cells of mucosal surface as well as intestinal glands every 5-7 days for the
absorptive and goblet cells, but 4 weeks for enteroendocrine cells and Paneth cells.
Paneth’s cells
– In the basal portion of the glands
– Show basophilic basal cytoplasm and acidophilic secretory granules in their apical
cytoplasm.
– Secrete the lysozyme and other glycoproteins to control the normal flora of the small
intestine.
Microfold (M) cells
– Overlie lymphoid follicles on Peyer's patches with discontinuous basement membrane.
– Basal membrane invaginations (pits) for immune cells.
323
324
Gut-associated lymphoid tissue (GALT) in the lamina propria and
submucosa of small intestine:
• Peyer's patches
– As dome shaped oval area lined by the M cells & surrounded by lymphatic vessels
– About 30 patches in humans, most are in the ileum
– 10–200 nodules in each patch
Duodenal (Brunner’s) glands
• Located in the submucosa of duodenum.
• Mucoserous branched coiled tubular glands
• Produce neutral and alkaline glycoproteins and bicarbonate ions secretion with a pH of
8.1–9.3
• For protection & optimum pH for the action of pancreatic enzyme.
Histology of the Small Intestine
Muscularis externa
– Well developed with inner circular and outer longitudinal layer
Serosa – outer layer 325
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326
 Histology of the Large Intestine
– About 1.5 m long and 6.5 cm wide
– For absorption of water & ions, formation of the faecal matter, and production mucus.
• Lining epithelium is made by same as the small intestine, except the absence of paneth cells:
– Goblet cells
• Compared to the absorptive cells, have a ratio of approximately 1:4 proximally and 1:1 distally
near the rectum.
• Lamina propria contains:
– Collagen table
• About 5 µm thick layer of collagen and glycoprotein between basal lamina and fenestrated
absorptive venous capillaries
• Regulate water and electrolyte transport.
Muscularis externa of the large intestine is made by:
– Inner circular
– Outer longitudinal – makes teniae coli and a very thin sheet in between
– Cause sacculations (haustra coli) in between which are plicae semilunares.
Serosa/Adventitia
– Serosa contains omental appendices (appendices epiploicae)
• Pendulous fat-filled pouches
327
328
Histology of the Appendix
• Resembles colon, but;
– Small & irregular lumen
– Fewer & shorter intestinal glands
– Many lymphoid nodules in lamina propria & submucosa
– No Taenia coli
Histology of the Rectum
– Longitudinal layer of muscularis externa form anterior & posterior broad bands
– Circular muscle layer of muscularis externa form 3 transverse folds known as Valves of Houston 2
on the left & 1 on right side.
Histology of the Anal Canal
Mucosa of upper 1/2 - 2/3 portion
– Resembles colon
– Also has anal columns (rectal columns) - longitudinal folds
• Anal valves distally
• Anal sinus in between
Mucosa of lower 1/3 - 1/2 portion
– No intestinal glands
– Stratified squamous epithelium that changes from nonkeratinized to keratinized distally
– Has apocrine sweat glands (circumanal glands) 329
Submucosa
– Anal glands - produce mucus through stratified columnar epithelium lined ducts
– Hemorrhoidal plexus
• Internal haemorrhoidal plexus – above pectinate line
• External haemorrhoidal plexus - at the junction of the anal canal with the anus
Muscularis externa
– Inner circular
• Internal anal sphincter in upper 3/4th
– Outer longitudinal
• Blends distally with surrounding connective tissue
External anal sphincter
– Skeletal & voluntary
3 parts:
• Subcutaneous – lower end of anal canal
• Superficial – proximal to subcutaneous part
• Deep – upper end of anal canal
330
331
 Histology of the Pancreas
• Pancreas is a heterocrine gland.
• Has a thin capsule which gives septae to divide the gland into lobules.
• Exocrine Portion of Pancreas
• Similar to parotid, but differs by:
1. Presence of islets of Langerhans
2. No striated duct with the intercalated ducts draining into intralobular
collecting ducts.
3. Presence of centroacinar cells
– Centroacinar cells are
• Acinar penetrated part of initial portion of intercalated duct
• Small flattened cells with a centrally located flattened nucleus
surrounded by pale cytoplasm.
332
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 Histology of the Liver
• Largest organ of the body, next to skin, weighing 1.5 kg.
• With Glisson’s capsule
• As exocrine gland secretes bile
• As endocrine gland synthesizes proteins, such as:
– Albumin, prothrombin, globin, fibrinogen, & lipoproteins into blood.
• Histologically made up of classic liver lobules.
– Polyhedral with 3-6 corners and measuring about 2.0 X 0. 7 mm.
– The unit drained by a central (centerolobular or terminal hepatic) vein located at the
centre and portal canals with portal triads at the corners.
Hepatocytes
• Polyhedral with 6 or more surfaces
• Radiate from the center to the periphery as anastomosing hepatic plates of one cell thick
in the adult, but two cells thick in the young up to 6 yrs. of age.
334
335
Hepatocytes
• 20-30 µm in diameter with large spherical centrally located nuclei
• Many cells in the adult are bi-nucleated each with 1(2) nuclei, and most cells are
tetraploid (4n).
• Eosinophilic because of large number of mitochondria & smooth endoplasmic
reticulum.
• Prominent organelles
• Capable of regeneration.
Bile canaliculi
• Tubular spaces between adjacent hepatocytes surrounding the 4 sides of the hexagonal
hepatocytes.
• 1-2 µm in diameter & anastomose freely. With microvilli & junctional complex.
• Running peripherally, grow into Hering’s canals near portal canal
Canal of Hering
• Are short intrahepatic ductules. Lined by both hepatocytes and cholangiocytes (with
clear cytoplasm and small number of organelles).
• Contain hepatic adult stem cells. It crosses the boundary of the lobule and becomes
intrahepatic bile ductule in the periportal space (of Moll) space located between the
connective tissue stroma and the hepatocytes. 336
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