1 Topographic Anatomy of the Stomach and Duodenum

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1 1 Topographic Anatomy of the Stomach and Duodenum H.D. BECKER, W. LIERSE, and H.W. SCHREIBER The upper abdominal cavity contains the stomach and duodenum; the liver, gallbladder, and pancreas, which arise from the embryonic duodenum; and the spleen, which arises embryonically in the dorsal mesogastrium. Topographic Anatomy of the Stomach Three-fourths of the gastric organ is located in the left hypochondriac region and one-fourth in the epigastric regio;!. Normally the field for operative exposure of the stomach is relatively small, being bounded by the left costal arch, the liver, and the transverse colon. The position of the stomach depends on its state of fullness and contraction and also on the position of the diaphragm. For convenience the stomach is subdivided into the cardia, which is adjacent to the esophagus; the fundus, whose proximal end is termed the gastric fornix; the body, the portion that contains the greater and lesser curvatures and is chiefly responsible for acid secretion; and, distal to the angular inci ur, the antrum, the pylorus, and pyloric canal (Fig. 1.1). The proximal duodenum consists of the duodenal bulb, which is about 2 em in length, and the descending portion of the duodenum. The posterior surface of the stomach, the gastrocolic ligament, and the lesser omentum form the anterior wall of the omental bursa (lesser peritoneal sac). This cavity is bounded behind by the parietal peritoneum of the posterior abdominal wall; the pancreas, the superior pole of the left kidney, and the adrenal gland are palpable on the left (Fig. 1.6). The roof of the omental bursa is formed by the lower margin of the liver in the region of the quadrate lobe and by part of the diaphragm in the region of the cardia; the transverse mesocolon forms the floor. The omental bursa can be reached by any of several routes: Through the gastrocolic ligament, Through the lesser omentum, Between the greater omentum and transverse colon, Through the foramen of Winslow, Through the transverse mesocolon. Esophagus Visceral peritoneum Mediastinal pleura Fundus Duodenal bulb Body Fig Schematic illustration of the parts of the terminal esophagu, tomach, and duodenum. (After Las rich and Prevot 1981) H. D. Becker et al. (eds.), Surgery of the Stomach Springer-Verlag Berlin Heidelberg 1988

2 2 H.D. BECKER et al a b c d e Fig. 1.2 a-f. Position of the duodenum as a function of its ligamentous fixation. a Normal position. The pylorus and duodenal bulb are higher than the antrum and are normally fixed by the hepatogastric and hepatoduodenal ligaments. The ligament of Treitz is normally developed. b Horizontal position of the duodenal bulb and superior part of duodenum with a short hepatoduodenal ligament. c The superior duodenal flexure is indented by the gallbladder. d Elevation of the duodenojejunal flexure. e The ligament of Treitz is absent, and the whole duodenum is to the right of the spine. f Short ligament of Treitz with kinking of the duodenum toward the right side. (Source see Fig. 1.1) Because the approach through the gastrocolic ligament is the widest, it is the most frequently used. Positional Anomalies of the Proximal Duodenum Positional anomalies of the proximal duodenum (Fig. 1.2 a-f) are not uncommon and relate to its variable fixation by the hepatogastric and hepatoduodenal ligaments. The ligament of Treitz may be present in varying degrees, or it may be completely absent (Fig. 1.2 d-f). Blood Supply of the Stomach and Proximal Duodenum The celiac axis arises from the abdominal aorta at the level of the 12th thoracic vertebra and quickly divides into its three major branches: the com-

3 Topographic Anatomy of the Stomach and Duodenum f---.;:::-..: ~~U ilitt-#'i 14 :::::===::~E~ 13 IIllif,f"----"t-hIlf--- 2 ~ _-----,+-~fi il'----7-"'-*-f-!c"'!1'!l L-:_~---~~~---~~~~ f, a mon hepatic artery, the left gastric artery, and the splenic artery. Often additional arteries pass to the diaphragm. The arterial supply of the stomach is very rich and is composed of four vascular systems (Fig. 1.3 a): 1. The left gastric artery, which passes to the lesser curvature of the stomach in the cardiac region (Figs. 1.3 a, 1.4 a-e). 2. The right gastric artery, which arises from the hepatic artery or the common hepatic artery and passes in the lesser omentum to the lesser curvature of the stomach (Figs. 1.3 a, 1.4 f-h, 1.5 a, b). There are anastomoses with the left gastric artery. Occasionally the right gastric artery may arise from the superior mesenteric artery (Fig. 1.4 f). 3. The right gastroepiploic artery, which branches off the gastroduodenal artery behind the upper portion of the duodenum and extends along the greater curvature of the stomach in the greater Fig. 1.3 a, b. Blood supply of the stomach. a Arterial supply. 1 - Spleen, left gastroepiploic vessels; 2 - short gastric vessels (vasa brevia); 3 - splenic artery, posterior gastric artery (belongs to short gastric arteries); 4 - pancreas, right gastric vein (coronary vein); 5 - jejunal arteries; 6 - pancreaticoduodenojejunal trunk; 7 - superior mesenteric vessels; 8 - middle colic vessels; 9 - right gastroepiploic vessels; 10 - pancreaticoduodenal vein; 11 - pancreaticoduodenal artery; 12 - pyloric artery and vein; 13 - posterior superior pancreaticoduodenal artery and vein; 14 - gastroduodenal artery; 15 - supraduodenal artery; 16 - left gastric artery, common bile duct; 17 - portal vein; 18 - hepatic artery proper; 19 - left gastric artery, left gastric vein (coronary vein); 20 - anterior and posterior esophageal artery; 21 - inferior vena cava; 22 - inferior phrenic vein. b Anastomosis between right and left gastroepiploic artery. 1 - Left gastroepiploic artery; 2 - right gastroepiploic artery

4 4 H.D. BECKER et a! l-ht3. Fig. 1.4a-h. Blood supply of the lesser curvature of the stomach. a Coronary vein in relation to the arterial supply of the lesser curvature from the left and right gastric arteries. b The right gastric artery arises from the hepatic artery proper. c The coronary vein arises partly from the splenic vein. d The coronary vein is anterior to the splenic artery. 1 - Coronary vein; 2 -left gastric vein. e Failure of development of a coronary veinous arcade. f The right hepatic artery arises from the superior mesenteric artery. 1 - Left hepatic artery; 2 - right hepatic artery (arising from the superior mesenteric). g The common hepatic artery arises from the superior mesenteric artery. 1 - Common hepatic artery (branching from the superior mesenteric). h Pancreaticoduodenojejunal trunk with the origin of the hepatic artery proper. 1 - Gastroduodenal artery; 2 - common hepatic artery (arising from pancreaticoduodenojejunal trunk); 3 - hepatic artery proper; 4 - pancreaticoduodenojejunal trunk

5 Topographic Anatomy of the Stomach and Duodenum 5 1aIer-c:=--- 2 d...-=:: omentum. It supplies the greater curvature (Fig. 1.3 a, b). 4. The left gastroepiploic artery, which arises from the splenic artery and supplies the upper portion of the lesser curvature below the fundus (Figs. 1.3 a, 1.7). Frequently there are anasto- h moses to the larger right gastroepiploic artery (Fig. 1.3 a--c). The splenic artery also gives rise to the short gastric arteries, which course around the left margin of the omental bursa to the fundus, and to an occasionally very large posterior gastric artery, which supplies the fundus (Figs. 1.6 and 1.7). The arterial supply is particularly variable in the region of the hepatic artery and gastroduodenal artery (Figs. 1.4 f- h, 1.5 a, b). Particular consideration must be given to these anatomic variants when dissecting the tissue in the region of the duodenal bulb. The duodenal bulb and proximal duodenum derive their arterial supply from branches arising either from the hepatic artery or from the gastroduodenal artery. Usually an anterior supraduodenal artery can be demonstrated (Fig. 1.5 a, b). The backwall of the duodenal bulb is frequently supplied by two or three small posterior duodenal arteries, which must be ligated when the duodenal bulb is skeletonized. Venous drainage of the stomach and proximal duodenum is achieved by the arcade of the left gastric vein in the region of the lesser curvature (Figs. 1.3 a, 1.4 a-e); numerous variations may be encountered. Especially at the cardiac end of the stomach, the left gastric vein forms extensive anastomoses with the partly intramural esophageal veins, which drain into the superior vena cava and are responsible for the development of esophageal varices in portal hypertension. The veins draining the greater curvature empty into the right gastroepiploic vein and thence into the left gastric vein, or they drain into the splenic vein by way of the left gastroepiploic.

6 6 H.D. B ECKER et al '----tkld -F~- 3 4 ~~~~YJ!)--- 5 ' b a Fig ~~, _ ---, ,----7"'---,J", ;' 'tt:---""7i'"

7 Topographic Anatomy of the Stomach and Duodenum , Fig View of the omental bursa and retrogastric space from the left lateral aspect. Note the posterior gastric artery arising from the splenic. 1 - Gastric fornix; 2 - esophageal hiatus; 3 - gastrophrenic ligament; 4 - posterior gastric artery (ramifies and divides in the gastrophrenic ligament); 5 - splenic artery; 6 - short gastric arteries; 7 - arteries of splenic pedicle; 8 - left gastroepiploic artery; 9 - tail of pancreas; 10 - mesocolon; 11 - splenocolic ligament; 12 - left colic flexure H~ ~~~WJ_ 't Lymphatic Drainage of the Stomach and Proximal Duodenum <I Fig. 1.5a, b. Blood supply of the proximal duodenum and duodenal bulb. 1 - Posterior supraduodenal artery; 2 - common hepatic artery; 3 - gastroduodenal artery; 4 - posterior duodenal arteries; 5 - right gastroepiploic artery; 6 - pancreaticoduodenal artery; 7 - anterior supraduodenal artery <I Fig View into the omental bursa. The stomach is retracted upward to show the sites of attachment of the greater omentum on the greater curvature (drawn from a specimen at the Anatomic Institute of the University of Hamburg). 1 - Gastrosplenic ligament, spleen; 2 - left gastroepiploic vessels, posterior wall of stomach; 3 - tail of pancreas, pancreaticosplenic ligament; 4 - phrenocolic ligament; 5 - gastrocolic ligament; 6 - transverse colon; 7- pancreas, attachment of transverse mesocolon (cut away), transverse mesocolon; 8 - duodenojejunal flexure; 9 - jejunal arteries; 10 - superior mesenteric vessels; 11 - middle colic vein; 12 - attachment of mesenteric root (cut away); 13 - attachment of mesocolon (cut away); 14 - gastroduodenal artery; 15 - duodenal bulb; 16 - right gastroepiploic vessels; 17 - pylorus; 18 - inferior margin of stomach, greater omentum cut away; 19 - anterior wall of stomach The lymphatic drainage of the stomach follows the course of the four gastric arteries. The greater curvature is drained by the pancreaticosplenic lymph nodes and the right gastric nodes, and the lesser curvature by the left gastric nodes and hepatic nodes (Fig. 1.8 a, b). Lymph drains through the nodes of the celiac axis to reach the thoracic duct. Additional connections exist with the mediastinal nodes and with the retropancreatic nodes along the mesenteric vessels. The lymphatics of the duodenum are closely associated with those of the pancreas, which lie anterior and posterior to the pancreatic head; these likewise drain into the celiac nodes. Numerous lymph vessels occur along the hepatic artery, and they are closely associated with the intrahepatic lymphatics. The cardiac region and proximal part of the lesser curvature are drained by the nodes of the left gastric artery; the rest of the lesser curvature is drained primarily by the nodes accompanying the hepatic vessels (Fig. 1.8 b). The lymph nodes of the spleen receive most of their drainage from the superior part of the body and fundus of the stomach, while the lymph vessels along the left gastroepiploic artery drain the major portion of the greater curvature.

8 8 H.D. BECKER et al. 4b ill ill IT I a Fig. 1.8a, b. Lymphatic drainage of the stomach (after Sarrazin et al. 1980). a Lymph nodes of the stomach and proximal duodenum. 1,2 - Paracardial lymph nodes ; 3a - left gastric lymph nodes ; 3b - right gastric lymph nodes ; 4a - left gastro-omentallymph nodes ; 4b - right gastro-omental lymph nodes; 5 - pyloric lymph nodes ; 6 - gastroduodenal artery; 7 - celiac lymph nodes ; 8 - hepatic lymph nodes ; 9 - celiac lymph nodes ; 10 - splenic lymph nodes ; 11 - superior pancreatic lymph nodes ; 12 - hepatic lymph nodes, foraminic lymph nodes ; 1 - subpyloric lymph nodes; II - superior mesenteric lymph nodes ; IIJ - juxtaintestinal lymph nodes ; IV - inferior pancreaticoduodenal lymph nodes ; V - suprapyloric lymph nodes. b Lymph drainage zones of the different regions of the stomach : liver (I and II), cardia (III), spleen (II and IV) ~ V\i), _"'~:-:'-:: '''''''' ''.~\ Y /,,.. r \... \\ 1': '. \. I ITT " A... /...: ', / \ I l..y..~\ ( ~ \, \_.-._... : ill..., 1 m, \ /", 1 ~! ' Ii \ I \... I! Ir... I! I' I ia I! I llri 1/ /. ~,.. -:1.'1 I / I ~fi-' ' /! -"l'" / /," I /! / / I " /.,,,. ",. '"./. '. II,..' /....",- ~ , ~ "'/ b

9 Topographic Anatomy of the Stomach and Duodenum t~~~ ' ~""'i'i~:ft1~e::l ~~~~\ ~~~--~r Nerve Supply of the Stomach and Proximal Duodenum The nerves of the upper abdominal cavity are derived from the sympathetic or parasympathetic (vagal) system (Fig. 1.9). The abdominal vagal trunks arise from the esophageal plexus and contain fibers of the right and left vagus nerves. They are termed the anterior vagal trunk (left vagus) and posterior vagal trunk (right vagus). They enter the abdominal cavity through the esophageal hiatus of the diaphragm. The anterior vagal trunk is distributed to the anterior surface of the stomach. In the cardiac region and superior portions of the lesser curvature, the trunk forms the anterior gastric plexus, which sends numerous branches to the anterior surface of the stomach (gastric branches) and to the liver (hepatic branches) (Fig. 1.10). The posterior vagal trunk courses toward the posterior aspect of the stomach, forming the posterior gastric plexus on the lesser curvature. From there some fibers are distributed to the posterior wall of the stomach (gastric branches), but the majority pass to the celiac plexus (celiac Fig The extragastric parasympathetic ganglia (from Hollender and Marrie 1977). 1 - Left gastric artery; 2 - celiac branch of vagus nerve; 3 - posterior antral branch (posterior branch of Latarjet's nerve); 4 - anterior vagal trunk; 5 - anterior antral branch (anterior branch of Latarjet's nerve); 6 - left greater splanchnic nerve; 7 - left lesser splanchnic nerve; 8 - splenic plexus; 9 - superior mesenteric ganglion; 10 - superior mesenteric artery; 11 - pancreatic plexus; 12 - gastroduodenal plexus; 13 - hepatic artery proper; 14 - celiac ganglion; 15 - right greater/lesser splanchnic nerve branches), whence they are conveyed to the liver, spleen, pancreas, small intestine, kidneys, and adrenals either directly or via the prevertebral ganglia. The sympathetic innervation of the stomach and proximal duodenum is derived from the 6th- 9th thoracic cord segments, with the splanchnic nerves conveying fibers to the celiac plexus. From there the nerve fibers pass to the stomach with the branches of the celiac trunk. The topographic anatomy of the vagus nerve is of particular interest from a surgical standpoint, because certain operations on the stomach involve

10 10 H.D. BECKER et al ~ T- I I I I L_ I. ' Fig Vagal innervation of the stomach, anterior (left) and posterior (right) divisions of the vagus. 1 - Right vagus nerve; 2 - left vagus nerve; 3 - branch to fornix (anterior gastric plexus); 4 - branch to fornix!" criminal branch" (posterior gastric plexus); 5 - branches to fundus (anterior and posterior branches; latter is "criminal branch" of posterior gastric plexus); 6 - branch to body (anterior and posterior gastric plexus); 7 - anterior antral branch (anterior branch of Latarjet's nerve); 8 - pes anserinus ("crow's foot," anterior antral branch); 9 - pancreas ; 10 - posterior gastric branches on the greater curvature; 11 - duodenal branches (of anterior vagal trunk); 12 - antral branches (of anterior vagal trunk); 13 - duodenal branch (of anterior vagal trunk); 14 - common bile duct; 15 - pancreatic and hepatic branches (of posterior vagal trunk); 16 - duodenal and antral branches (of anterior vagal trunk); 17 - choledochal branches (of anterior vagal trunk); 18 - duodenal branches (of anterior vagal trunk); 19 - celiac plexus (posterior antral branch/posterior branch of Latarjet's nerve); 20 - hepatic branches (of anterior vagal trunk), branches to cardia (with anterior branch and posterior branch); 21 - posterior vagal trunk; 22 - anterior vagal trunk; 23 - right crus of lumbar part of diaphragm; 24 - diaphragm

11 Topographic Anatomy of the Stomach and Duodenum ~ Fig Cross-section of the esophagus showing the roof of the omental bursa. 1 ~ Anterior vagal trunk; 2 ~ branches to fundus (anterior gastric plexus); 3 ~ left crus of lumbar part of diaphragm (inferior phrenic artery); 4 ~ branch to fornix (anterior gastric plexus), gastrophrenic ligament; 5 ~ posterior gastric artery (belongs to short gastric arteries); 6 ~ spleen; 7 ~ short gastric arteries, gastrosplenic ligament, spleen; 8 ~ splenic artery; 9 ~ left gastroepiploic artery; 10 ~ gastrocolic ligament ; 11 ~ pancreas; 12 ~ transverse colon; 13 ~ branch to fornix (posterior gastric plexus!" crim- inal branch"); 14 ~ branches to fornix/body (posterior gastric plexus!" criminal branches") coursing on the posterior wall of the terminal esophagus and stomach; 15 ~ intramural plexus of esophagus; 16 ~ left gastric artery; 17 ~ celiac branch (of posterior vagal trunk); 18 ~ posterior antral branch (posterior branch of Latarjet's nerve) ; 19 ~ posterior vagal trunk ; 20 ~ anterior antral branch (anterior branch of Latarjet's nerve); 21 ~ hepatic branches (of anterior vagal trunk); 22 ~ peritoneum; 23 ~ terminal esophagus Fig Detailed cross-sectional view of the esophagus with intramural nerve elements. 1 ~ Anterior vagal trunk; 2 ~ branches to fundus (anterior gastric plexus); 3 ~ intramural plexus of anterior esophagus; 4 ~ branch to fornix (anterior gastric plexus); 5 ~ longitudinal layer of muscularis; 6 ~ circular layer of muscularis ; 7 ~ submucosa; 8 ~ gastrophrenic ligament; 9 ~ branch to fornix!" criminal branch" (posterior gastric plexus), peritoneum; 10 ~ intramural plexus of posterior esophagus; 11 ~ branches to posterior fundus!" criminal branch" (posterior gastric plexus); 12 ~ posterior antral branch (posterior branch of Latarjet's nerve); 13 ~ left gastric artery; 14 ~ celiac branch (of posterior vagal trunk); 15 ~ posterior vagal trunk; 16 ~ intramural plexus of esophagus; 17 ~ terminal esophagus, peritoneum ,...,,~~ 'tt' ;---\ 13---ii

12 12 H.D. BECKER et al ~ ~~~~ ,-- --, ,." ~----~~~ Fig. 1.13a, b. Pattern of vagus nerve ramification in the anterior and posterior gastric plexus. a lliustration of the most common anatomic relationships. 1 - Posterior vagal trunk; 2 - anterior vagal trunk; 3 - branch to fornix (anterior gastric plexus), passing in the gastrophrenic ligament to the fornix over the posterior gastric wall; 4 - branch to fornix (posterior gastric plexus!" criminal branch "), arising in thorax from posterior vagal trunk and passing to posterior gastric wall (see 11 for origin); 5 - gastrophrenic ligament; 6 - anterior antral branch (anterior branch of Latarjet's nerve), branch to body of stomach; 7 - posterior antral branch (posterior branch of Latarjet's nerve); 8 - hepatic branches; 9 - branch to cardia, arising here from a recurrent hepatic branch (see also Fig. 1.14a, c); 10 - branch to fundus (posterior gastric plexus; "criminal branch "), arising from posterior vagal trunk in region of esophageal hiatus; 11 - branch to fornix (posterior gastric plexus!" criminal branch "), arising in thorax from posterior vagal trunk (see 4 for course). b The posterior nerve of Latarjet arises very late from the posterior vagal branch. 1 - Posterior vagal trunk; 2 - posterior vagal branch (posterior branch of Latarjet's nerve), variant origin b a a more or less selective division of the vagus nerve. After the hepatic branches arise from the anterior vagal trunk, a major branch continues in the direction of the angular incisure (Latarjet's nerve) (see Fig. 1.10). An identical branch from the posterior vagal trunk runs parallel to the anterior branch in the posterior portion of the lesser omentum. Latarjet's nerve gives off smaller branches to the lesser curvature. At the angular incisure it further ramifies into the "crow's foot," which usually consists of three parts. For certain operations it is essential that the surgeon be familiar with the topographic anatomy of the vagus nerve at the cardia (Figs ). Owing to a relatively early subdivision of the vagal trunks, some fibers pass on the left side of the esophagus to the body and fundus of the stomach; a branch to the fornix from the posterior gastric plexus is called the "criminal branch" (Fig. 1.11). Small vagal branches may also course within the esophageal wall and can be identified only by meticulous dissection (Fig. 1.12). In addition, numerous variations may exist in the region of the anterior and posterior gastric plexus (Figs.l.13 a, band 1.14 a-c), and this must be taken into consideration when the various types of vagotomy are performed.

13 Topographic Anatomy of the Stomach and Duodenum 13 a b c Fig. 1.14a-c. Patterns of vagal innervation of the cardia. a Cardiac branches arising from the anterior vagal trunk. b Cardiac branches arising from the hepatic vagal fibers. c Cardiac branches arising from Latarjet's nerve. 1 - Vagal branches to the cardia References Hollender LF, Marrie A (1977) La vagotomie supra-selective. Masson, Paris, pp Lassrich R, Prevot P (1981) Rontgendiagnostik des Verdauungstraktes beim Kind und Erwachsenen, 2nd edn. Thieme, Stuttgart Pernkopf E (1980) Atlas der topographischen und angewandten Anatomie des Menschen. In: Ferner H (eds) vol. 2, 2nd edn. Urban & Schwarzenberg, Miinchen Platzer W (1982) Atlas der topographischen Anatomie. Thieme, Stuttgart Sarrazin R, Pissas A, Dyon IF, Bouchet Y (1980) Lymphatic drainage of the stomach. Anat Clin 2: (Springer, Berlin Heidelberg New York) Waldeyer A, Mayet A (1980) Anatomie des Menschen. Part I, 14th edn. De Gruyter, Berlin Zenker R, v Bary S, Feifel G, Oehl R, Rueff F, Spelsberg F, Pichlmayr R, Seidel W (1975) Die Eingriffe am Magen und Zwolffingerdarm. In: Zenker R, Berchthold R, Hamelmann H (eds) Die Eingriffe in der Bauchhohle. Springer, Berlin Heidelberg New York (Allgemeine und spezielle Operationslehre, vol 7, 1. Part, 3rd edn., pp )