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1
2 Retroperitoneum
3 Position, fixation and renal covers
4
5 Aorta abdominalis origin: hiatus oesophageus diaphragmatis end: bifurcatio aortae L4 retroperitoneum, slightly left to vertebral column v. cava inferior + ductus thoracicus right to aorta abdominalis
6 Aorta abdominalis parietal branches: paired a. phrenica inf. aa. lumbales 1st - 4th rr. retroperitoneales (6-7) visceral branches: paired a. suprarenalis media a. renalis a. renalis accessoria (30%) a. testicularis / ovarica
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8 enters upper pole (less), hilum or inferior pole (more) of kidney incidence 30%
9 Aorta abdominalis terminal branches: paired a. iliaca communis terminal branches : unpaired a. sacralis mediana visceral branches : unpaired truncus coeliacus a. mesenterica superior a. mesenterica inferior
10 Arteria iliaca communis 4 cm long 1 cm wide origin: L4 medial to m. psoas major dorsal to ureter end: bifurcation ventral to articulatio sacroiliaca a. iliaca externa a. iliaca interna
11 Arteriae iliacae
12 Transplanted kidney to AIC
13 Arteria iliaca externa articulatio sacroiliaca lacuna vasorum ( a. femoralis) dorsal to ureter a. circumflexa ilium profunda a. epigastrica inferior r. pubicus a. obturatoria accessoria/aberrans = corona mortis Hesselbachi a. crematerica / a. lig. teretis uteri r. medialis + lateralis cutaneous perforators clinical abbreviation DIEP cutaneous / musculo-cutaneous flaps
14 Two separate pancreas transplantations at different times d = donor's, r = right, l = left CIA = common iliac artery, CIVB = common iliac vein bifurcation, DPA = dorsal pancreatic artery, EIA external iliac artery, IIA = internal iliac artery, IMA = inferior mesenteric artery, SA = splenic artery, SMA = superior mesenteric artery, asterisk = renal graft. Three-dimensional volume-rendering image of contrast-enhanced MDCT during dominant arterial phase, obtained 5 days after sequential pancreas-after-kidney retransplantation after vascular failure and pancreatectomy of initial pancreatic graft, shows normal posttransplantation arterial anatomy, residual arterial conduit (RAC) after pancreatectomy of initial pancreatic graft, hyperdense staple line (single arrowheads) of donor's duodenum, and hyperdense circular staple line (double arrowheads) of duodenojejunostomy (intestinal wall structures and grafted pancreatic parenchyma are not seen because of applied electronic thresholds).
15
16 Arteria iliaca interna lesser pelvis + buttocks obsolete term a. hypogastrica short (3-4 cm) anterior division 3 branches posterior division all organs of lesser pelvis ligation in postpartal haemorrhage
17 Arteria iliaca interna - branches parietal branches: 5 a. iliolumbalis r. iliacus, lumbalis, spinalis a. obturatoria canalis obturatorius aa. sacrales laterales sup. + inf. ( 2) foramina sacralia anteriora rr. spinales a. glutea superior foramen suprapiriforme r. superficialis + profundus a. glutea inferior foramen infrapiriforme a. comitans nervi ischiadici
18 Arteria obturatoria 2nd ventral branch from anterior division of AII caudal to nerve r. pubicus corona mortis canalis obturatorius r. acetabularis r. anterior + posterior medial side of thigh
19 Arteria iliaca interna - branches visceral branches: 6 a. umbilicalis aa. vesicales superiores a. ductus deferentis a. vesicalis inferior rr. prostatici a. uterina r. ovaricus r. tubarius ventral to ureter a. rectalis media rr. prostatici / rr. vaginales a. vaginalis a. pudenda interna
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21 Arteria umbilicalis pars patens aa. vesicales superiores a. ductus deferentis pars occlusa fetal vessel with unoxygenated blood leading to placenta lig. umbilicale mediale (chorda a. umbilicalis) fascia vesicoumbilicalis
22 Arteries of female internal genital organs Ao. abdominalis: a. ovarica A. iliaca interna: a. uterina a. vaginalis (a. pudenda int.)
23 Arteria pudenda interna topography: foramen infrapiriforme foramen ischiadicum minus fossa ischioanalis (canalis pudendalis Alcocki) branches: a. rectalis inferior rr. vaginales a. perinealis rr. scrotales / labiales anteriores a. urethralis a. bulbi penis / vestibuli a. dorsalis penis / clitoridis a. profunda penis / vestibuli
24
25 Rectum a. mesenterica inf. a. rectalis sup. a. iliaca int. a. rectalis media present in 50%, insignificant for rectum a. iliaca int. a. pudenda int. a. rectalis inf
26 Vena cava inferior origin: confluence of vv. iliacae communes (L4) right to aorta abdominalis, in retroperitoneum no valves, rarely doubled sulcus venae cavae hepatis foramen venae cavae diaphragmatis caliber: 2 cm at liver, 3.5 cm at heart end: atrium dextrum (T8)
27 Vena cava inferior
28 Vena cava inferior - tributaries variation of VCI course, arrangement and tributaries parietal: vv. iliacae communes, vv. lumbales I-IV (interconnected with v. lumbalis ascendens), vv. phrenicae inf., v. sacralis mediana visceral: vv. renales v. testicularis / ovarica dx. (begins as plexus pampiniformis) v. suprarenalis dx. vv. hepaticae dextra, intermedia, sinistra (ductus venosus Aranzii)
29 Variability of formation of VCI visceral tributaries
30 VCI clinical relevance compression aortal aneurysm pregnant uterus abdominal tumours thrombosis prevention of fatal pulmonary embolism Greenfield s filter in venous thromboembolic disease + contraindication of anticoagulation treatment
31 Vena iliaca communis course corresponds to artery tributaries: v. lumbalis ascendens v. sacralis mediana into VICsin. May-Thurner s syndrome compression of VICsin. by artery (AICdx.) thrombosis follows treatment: stent
32 Vena iliaca externa branches correspond to arterial venous corona mortis present in 75% valves present in 20% usually rudimentary
33 Vena iliaca interna pelvic veins parietal: correspond to arteries visceral: plexuses plexus venosus pudendus (Santorini) within spatium retropubicum (Retzii) p.v. vesicalis + prostaticus p.v. uterinus + vaginalis (uterovaginalis) p.v. rectalis p.v. rectalis externus (within tunica adventitia) p.v. rectalis internus = p. haemorrhoidalis (within tunica submucosa) p.v. sacralis (interconnected with vv. sacrales lat. + mediana)
34 Veins of pelvis v. lig. teretis uteri vv. lig. lati uteri vv. suprapubicae v. ischiadica
35
36
37 Direction of venous outflow from pelvis
38 Veins of pelvis clinical relevance pelvis fractures heavy bleeding slowed blood flow thrombosis embolism uptake of calcium in thrombi phleboliths (visible in X- ray snaps) pelvic varices connections with LL veins v.iliaca int. and its tributaries are not moveable easy bleeding and difficult closure in surgery
39 Site od connections between pelvic and LL veins canalis inguinalis canalis obturatorius foramen infrapiriforme perineum change of flow direction in varices
40 Cavo-caval anastomoses VCI VCS vv. lumbales v. azygos + hemiazygos v. epigastrica inf. v. epigastrica sup. v. epigastrica spf. vv. thoracoepigastricae plexus venosi vertebrales (Batson s)
41 Vena azygos system v. azygos + hemiazygos accompany aorta thoracica no valves mediastinum posterius inferius m. superius origin: v. lumbalis ascendens + v. subcostalis pass through diaphragm: via pars lumbalis or hiatus aorticus end: v. hemiazygos opens into do v. azygos at level of T7-9 v. azygos opens into VCS arcus v. azygos
42
43 Tributaries of vena azygos system parietal: vv. intercostales posteriores v. intercostales sup. dx. v. hemiazygos accessoria vv. phrenicae sup. visceral: vv. oesophageales, bronchiales, mediastinales
44 Lymph vessels general arrangement lymph capillaries lymph vessels limbs (collectors): superficial deep vessels organs: plexuses (subcapsular + deep) lymph trunks lymph ducts lymph nodes put in vessels
45
46 Main lymph trunks
47 cholagiography CISTERNA CHYLI
48 Abdomen origin of ductus thoracicus (cisterna chyli) L1, between crura diaphragmatis n.l. parietales n.l. lumbales sinistri n.l. aortici lat., preaortici, retroaortici n.l. lumbales intermedii n.l. lumbales dextri n.l. cavales lat., precavales, retrocavales = paraaortal nodes n.l. phrenici inf., epigastrici inf.
49 Colorectal metastasis Tuberculosis
50 Testis Ovary n.l. lumbales L2 development scrotum n.l. inguinales superficiales! no puncture!
51 Pelvis n.l. parietales communes externi (obturatorii) interni gluteales sup.+inf. sacrales (rectum, prostata, cervix uteri, fornix vaginae) n.l. viscerales paravesicales parauterini, paravaginales pararectales
52 Abdomen and pelvis clinical relevance lymphography para-aortal lymphadenectomy pelvic lymphadenectomy classical (open) approach laparoscopic
53 Uterus anatomical classification: n.l. lumbales fundus + corpus n.l. iliaci interni (iliaci externi, iliaci communes, obturatorii) corpus, isthmus + cervix n.l. sacrales isthmus, cervix n.l. inguinales superficiales margines + cornua (exceptionally!) clinical classification: according to corpus and cervix cancer corpus uteri n.l. iliaci int.+ lumbales + (inguinales superficiales) cervix uteri n.l. iliaci int.+ sacrales
54 Uterus Lymph drainage from uterus
55 Cervix cancer lymph nodes involvement
56 Prostate n.l. iliaci int. + ext. n.l. sacrales
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58 Rectum + anal canal ampulla oral part: n.l. rectales sup. n.l. mesenterici inf. aboral part: n.l. pararectales n.l. iliaci interni n.l. obturatorii, sacrales canalis analis n.l. pararectales + n.l. inguinales superficiales
59 Nerves of retroperitoneum
60
61 Sympathetic trunk
62 Plexus aorticus abdominalis sympathetic fibers: nn. splanchnici thoracici (major, minor, imus), lumbales 1-3 parasympathetic fibers: rr. coeliaci nn. vagorum mixed plexus around aorta abdominalis + prevertebral ganglia paired ggl. coelicum + ggl. aorticorenale unpaired ggl. mesentericum sup. + inf. along arteries homonymous plexuses stomach oral majority of rectum (enteric system), pancreas, liver spleen, suprarenal glands, kidneys, ureters, testes / ovaries, uterine tubes (1/2)
63 ggl. coelicum ggl. aorticorenale ggl. mesentericum sup. ggl. mesentericum inf.
64 Plexus aorticus abdominalis continuation plexus hypogastricus superior (pure sympathetic (from bifurcatio across promontorium) n. hypogastricus dx. + sin. plexus hypogastricus inferior s. pelvicus (mixed plexus) pelvic organs except ovaries, uterine tubes (1/2), fundus uteri and urinary bladder plexus iliacus dx. + sin. (pure sympathetic) lower limb
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66
67 Plexus hypogastricus inferior s. pelvicus mixed plexus AF-PS: nn. splanchnici pelvici S2-4 (obsoletely nn. erigentes) AF-S: truncus sympathicus plexus aorticus abdominalis plexus hypogastricus superior nn. hypogastrici AF-S: truncus sympathicus ganglia sacralia nn. splanchnici sacrales pelvic organs except ovaries, uterine tubes (1/2), fundus of uterus and fundus of urinary bladder EF (mixed): plexus rectalis (aboral minority of rectum) parasympathetic fibers ascend as orally as Cannon-Bőhm s point = hindgut plexus prostaticus + deferentialis / uterovaginalis plexus vesicalis - m. sphincter urethrae (nucleus n. pudendi Onufi in spinal cord segments S2-4) n. cavernosus penis / clitoridis (erectile bodies)
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69 Plexus hypogastricus inferior s. pelvicus
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