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CHAPTER 2 The Abdomen, Pelvis and Perineum
31
• Relations:
• anterior from above down: lesser omentum, stomach, coeliac plexus, pancreas, splenic vein, le renal
vein, third part of duodenum, root of mesentery,
coils of small intestine, aortic plexus, peritoneum
• posterior: bodies of upper four lumbar vertebra, le
lumbar veins, cisterna chyli
• right side: IVC, thoracic duct, azygos vein, right
sympathetic trunk
• le side: le sympathetic trunk.
e branches of the aorta are:
• Anterior unpaired branches passing to the viscera:
• coeliac axis: giving o the hepatic artery, splenic
artery, le gastric artery
• superior mesenteric artery
• inferior mesenteric artery.
• Lateral paired branches:
• suprarenal artery
• renal artery
• go nad al ar ter y.
• Paired branches to the parietes:
• inferior phrenic arteries
• four lumbar arteries.
• Terminal branches:
• common iliac arteries
• median sacral artery.
Common Iliac Artery
• Arises at bifurcation of aorta at level of body of fourth
lumbar vertebra.
• Bifurcates at level of sacroiliac joint into internal and
external iliac artery.
• Anterior relations:
• peritoneum
• small intestine
• ureters
• sympathetic nerves.
• Dierences between right and le common iliac arteries:
• right common iliac artery is the longer, the aorta
being on the le side of the spine
• on the right side lie the IVC and right psoas
• right common iliac vein is at rst behind but to the
right at upper part
• le common iliac vein crosses behind right common
iliac artery
• le common iliac artery is crossed anteriorly by infe-
rior mesenteric artery
• le common iliac vein is below and medial to le
common iliac artery.
External Iliac Artery
• Runs along brim of pelvis on medial side of psoas
major.
• Passes below the inguinal ligament to form the femoral
ar tery.
• Gives o inferior epigastric artery immediately before
passing below the inguinal ligament.
Internal Iliac Artery
• Passes backwards and downwards into the pelvis between
ureter anteriorly and internal iliac vein posteriorly.
• At upper border of greater sciatic notch divides into anterior and posterior branch.
• Branches supply:
• pelvic organs
• perineum
• buttock
• anal canal.
Inferior Vena Cava
• Formed by junction of two common iliac veins behind
the right common iliac artery at the level of the h lumbar vertebra.
• Lies to the right of the aorta as it ascends.
• Separated from aorta by right crus of diaphragm when
aorta passes behind the diaphragm.
• IVC passes through diaphragm at level T8, traverses the
pericardium and drains into the right atrium.
• Anterior relations include:
• mesentery
• third part of duodenum
• pancreas
• rst part of duodenum
• portal vein
• posterior surface of liver
• diaphragm
• from above down the following arteries: hepatic,
right testicular, right colic, right common iliac.
• Posterior relations include:
• vertebral column
• right crus of diaphragm and psoas major
• right sympathetic trunk
• right renal artery
• right lumbar arteries
• right suprarenal arteries
• right inferior phrenic artery
• right suprarenal gland
• to the le: the aorta.
e IVC receives the following tributaries:
• lumbar branches
• right gonadal vein
• right renal vein
• le renal vein
• right suprarenal vein
• phrenic vein
• hepatic vein.
32
r
Median fibrous raphe
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SECTION I Anatomy
Lumbar Sympathetic Chain
• Commences deep to the medial arcuate ligament of the
diaphragm as a continuation of the thoracic sympathetic chain.
• Lies against the bodies of the lumbar vertebrae overlapped on the right side by the IVC and on the le side
by the aorta.
• e lumbar arteries lie deep to the chain but the lumbar
veins may cross supercial to it.
• Below the chain passes deep to the iliac vessels to continue as the sacral trunk in front of the sacrum.
• Inferiorly the right and le chain converge and unite in
front of the coccyx to end in the ganglion impar.
• Branches from the sympathetic chain pass as follows:
• to the plexuses around the abdominal aorta
• to the hypogastric plexus (presacral nerves) to
supply the pelvic viscera via plexuses of nerves
distributed along the internal iliac artery and its
branches.
Clinical Points
• Resection of abdominal aortic aneurysm and extensive
pelvic dissection may remove aortic and hypogastric
plexuses and hence compromise ejaculation.
• Lumbar sympathectomy may be carried out for plantar
hyperhidrosis or vasospastic conditions of the lower
limb. Usually the second, third and fourth ganglia are
excised with the intermediate chain.
PELVIC FLOOR AND WALL
e muscles of the pelvic oor and wall comprise:
• Pelvis:
• levator ani
• coccygeus.
• Pelvic wall:
• piriformis (on the front of the sacrum)
• obturator internus (on the lateral wall of the true
pelvis).
Piriformis and obturator internus act on the femur and
are described with the muscles of the lower limb.
Levator Ani
e levator ani muscles arise from the side wall of the pelvis
and are thin sheets of muscle which meet in the midline
and close the greater part of the outlet of the pelvis (posterior part of the pelvic diaphragm) (Fig. 2.12).
Origin
• Back of body of pubis.
• Spine of ischium.
• Between these from the fascia covering obturator internus along a thickening between the above two points.
Levator prostatae
(sphincter vaginae)
Coccygeus
Fig. 2.12 Levator ani viewed from below.
External anal sphincte
Puborectalis
CHAPTER 2 The Abdomen, Pelvis and Perineum
Superficial transverse
33
Insertion
• Forms a sling around the prostate (levator prostatae) or
vagina (sphincter vaginae) inserting into the perineal body.
• Forms a sling around the rectum and anus inserting into
and reinforcing the deep part of the anal sphincter at the
anorectal ring (puborectalis).
• Into the sides of the coccyx and to a median brous
raphe stretching between the apex of the coccyx and the
anorectal junction.
Nerve supply
• Perineal branch of S4 on pelvic surface, and branch of
the inferior rectal and perineal division of the pudendal
nerve on the perineal surface.
Actions
• Acts as principal support of pelvic oor.
• Supports pelvic viscera and resists downwards pressure
of abdominal muscles.
• Has a sphincter action on the rectum and vagina.
• Assists in increasing intra-abdominal pressure during
defecation, micturition and parturition.
Coccygeus
• Small triangular muscle behind and in the same plane as
levator ani.
Origin
• Spine of ischium.
Insertion
• Side of coccyx and lowest part of sacrum.
• Muscle has same attachments as sacrospinous ligament.
Nerve supply
• Perineal branch of S4.
Action
• Holds the coccyx in its natural forwards position.
• Pelvic fascia.
• Parietal pelvic fascia is a strong membrane covering the
muscles of pelvic wall and is attached to bones at margins of muscles.
• Visceral pelvic fascia is loose and cellular over movable
structures, e.g. levator ani, bladder, rectum.
• It is strong and membranous over xed or nondistensible structures, e.g. prostate.
PERINEUM
e perineum comprises:
• e anterior (urogenital) perineum.
• e posterior (anal) perineum.
Urogenital Triangle (The Anterior Perineum)
• Triangle formed by the ischiopubic inferior rami and a
line joining the ischial tuberosities which passes just in
front of the anus (Fig. 2.13).
Fig. 2.13 The male perineum viewed from below. On the right side the muscles have been removed to display
the crus and bulb of the penis.
Corpus cavernosum
Corpus spongiosum
Crus of penis
Bulb of penis
perineal muscle
Gluteus maximus
Ischiocavernosus
Bulbospongiosus
Perineal membrane
Levator ani
External anal sphincter
Coccyx
34
r
Superficial transverse
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SECTION I Anatomy
Fig. 2.14 The female perineum. On the right side the muscles have been removed to display the bulb of the
vestibule and Bartholin’s glands.
• e perineal membrane (the inferior fascia of the uro-
• e perineal membrane is pierced by:
• Deep to the perineal membrane is the external urethral
• e deep perineal pouch encloses the external urethral
• Below the external urethral sphincter is the perineal
• In the male, the deep perineal pouch contains the
• e pouch also contains the deep transverse perineal
• Supercial to the perineal membrane is the supercial
Superficial Perineal Pouch
In the male, this contains:
• e bulb of the penis, which is attached to the undersur-
Crus of the clitoris
Bulb
Bartholin’s gland
perineal muscle
Gluteus maximus
genital diaphragm) is a strong fascial sheath attached to
the sides of this triangle.
• urethra in the male
• urethra and vagina in the female.
sphincter composed of striated muscle bres which surrounds the membranous urethra.
sphincter.
membrane, while above is an indenite layer of fascia,
i.e. the superior fascia of the urogenital diaphragm.
bulbourethral glands (of Cowper) whose ducts pierce
the perineal membrane to open into the bulbous
urethra.
muscles.
perineal pouch.
face of the perineal membrane; bulbospongiosus muscle
covers the corpus spongiosum.
Clitoris
Urethra
Bulbospongiosus
Ischiocavernosus
Perineal membrane
External anal sphincte
Levator ani
Coccyx
• e crura of the penis, which are attached at the angle
between the insertion of the perineal membrane and
ischiopubic rami; each crus is surrounded by an ischiocavernous muscle.
• Supercial transverse perineal muscle running transversely from the perineal body to the ischial ramus.
• e same muscles are present in the female but are less
well developed (Fig. 2.14).
Perineal Body
• Fibromuscular nodule lying in the midline between
anterior and posterior perineum.
• Attached to it are:
• anal sphincter
• levator ani
• bulbospongiosus
• transverse perineal muscles.
• Important site of insertion of levator ani; tearing of perineal body during childbirth will considerably weaken
the pelvic oor.
The Posterior (Anal) Perineum
• Triangular area lying between the ischial tuberosities on
each side and the coccyx.
• It contains the following:
• anus and its sphincters
• levator ani
• ischiorectal fossa.
CHAPTER 2 The Abdomen, Pelvis and Perineum
35
Ischiorectal Fossa
is is a space between the anal canal and side wall of the
pelvis.
• Its boundaries are:
• medially: fascia over levator ani and the external anal
sphincter
• laterally: fascia over obturator internus
• anteriorly: extends forwards as a prolongation deep
to the urogenital diaphragm
• posteriorly: limited by the sacrotuberous ligaments
and the origin of gluteus maximus from this ligament.
• Floor is formed from skin and subcutaneous fat.
• Contains mainly fat and is crossed by the inferior rectal
vessels and nerves from lateral to medial side.
• e internal pudendal vessel and pudendal nerve lie on
the lateral wall of the fossa in the pudendal canal (of
Alcock), a tunnel of fascia which is continuous with the
fascia overlying obturator internus.
Clinical Points
• Infection of the ischiorectal space may occur from boils
or abscesses on the perianal skin, from lesions within
the rectum and anal canal, from pelvic collections
bursting through levator ani.
• e fossae communicate with one another behind the
anus, allowing infection to pass readily from one fossa
to another.
• e pudendal nerves can be blocked in Alcock’s canal
on either side, giving regional anaesthesia in forceps
delivery.
Penis
e penis is divided into:
• root
• body
• glans.
Root
• e root is attached at:
• perineal membrane
• the pubic rami by two strong processes, the crura
• the symphysis pubis by the suspensory ligament.
Glans
• Forms the extremity of the penis.
• At its summit is the opening of the urethra—the external meatus.
• Passing from the lower margin of the glans is a fold of
mucous membrane continuous with the prepuce called
the frenulum.
• At the base of the glans is a projecting edge or corona,
behind which is a constriction.
• e skin of the penis is attached to the neck of the glans
and doubles up on itself forming the prepuce or foreskin.
Body
• Part of the penis between the root and glans. e body
comprises:
• corpora cavernosa
• corpus spongiosum.
Corpora cavernosa
• Placed dorsally.
• Connected together in anterior three-quarters with septum of penis intervening.
• Separated behind to form the two crura, which are
attached along the medial margins of the ischial and
pubic rami.
• Anteriorly, the corpora cavernosa t into the base of the
glans.
• ere is a groove on the upper surface for the dorsal
vein of the penis and another groove on the lower surface for the corpus spongiosum.
• Corpora cavernosa are attached to the pubic symphysis
by the suspensory ligament.
Corpus spongiosum
• Commences at the perineal membrane by an enlargement, i.e. the bulb.
• Runs forward in the groove on the undersurface of the
corpora cavernosa, expanding over their extremities to
form the glans.
• e bulb lies below the perineal membrane and is surrounded by the bulbospongiosus muscle.
• e urethra pierces the bulb on its upper surface and
runs forwards in the middle of the corpus spongiosum.
URETHRA
Male Urethra
e male urethra is 20 cm long and is divided into:
• prostatic urethra
• membranous urethra
• spongy urethra.
Prostatic Urethra
• Passes through the prostate gland from base to apex.
• ree centimetres long.
• Bears the urethral crest on the posterior wall, on each
side of which is the shallow depression, the prostatic
sinus, into which 15–20 prostatic ducts empty.
• In the centre of the urethral crest is a prominence (verumontanum), into which opens the prostatic utricle.
• e ejaculatory ducts formed by the union of the duct
of the seminal vesicle and the terminal part of the vas
deferens open on either side of the prostatic utricle.
36
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SECTION I Anatomy
Membranous Urethra
• Two centimetres in length.
• Contained between perineal membrane and pelvic fascia.
• Surrounded by and pierces the external sphincter
urethrae.
Spongy Urethra
• Fieen centimetres long.
• Traverses corpus spongiosum of penis.
• Passes upwards and forwards to lie below pubic symphysis and then in accid state, bends downwards and
forwards.
• e ducts of the bulbourethral glands open on its oor.
• e urethral canal enlarges just behind the external
meatus, i.e. the fossa navicularis.
• e lumen of this part of the urethra is transverse except
at its meatus (narrowest part) where it is vertical, hence
the spiral stream of urine.
Clinical Point
• Where the urethra passes beneath the pubis, it may be
ruptured by a fall astride an object which crushes it
against the edges of the symphysis (straddle injury).
Female Urethra
• Four centimetres long.
• Traverses the sphincter urethrae and lies immediately in
front of the vagina.
• Its external meatus opens 2.5 cm behind the clitoris and
between the labia minora.
The Vulva
e vulva is the term applied to the female external genitalia.
• e mons pubis is the eminence in front of the pubis
covered in hair.
• e labia majora:
• two prominent folds extending from the mons to the
perineum
• externally covered with hair and skin, internally with
mucous membrane
• they are the equivalent of the male scrotum.
• e labia minora:
• lie between the labia majora as lips of so skin which
meet posteriorly in a sharp fold at the fourchette
• surround the clitoris, the upper fold forming the pre-
puce of the clitoris, the lower ones attached to the
glans, being the frenulum of the clitoris.
• Vestibule:
• area enclosed by the labia minora
• contains the urethral orice, which lies immediately
behind the clitoris
• contains the vaginal orice.
• Vaginal orice:
• guarded in the virgin by a thin mucosal fold—the
hymen
• hymen is perforated to allow menstruation
• following childbirth, the only remnants of the hymen
are a few tags named the carunculae myrtiformes.
• Clitoris:
• corresponds somewhat in structure to the penis
• contains two corpora cavernosa attached to the pubic
rami
• free extremity or glans is formed by the corpus
spongiosum.
• e greater vestibular glands (Bartholin’s glands):
• analogous to bulbourethral glands in male
• pea-sized mucus-secreting glands lying deep to the
posterior part of the labia majora
• ducts open on the labia minora external to the hymen
• impalpable when healthy but obvious and palpable
when inamed or distended
• each gland is overlapped by the bulb of the vestibule,
a mass of erectile tissue equivalent to bulbospongiosus of the male
• this erectile tissue passes forward under cover of
bulbospongiosus around the sides of the vagina to
the root of the clitoris.
SCROTUM
• Contains the testicles suspended by the spermatic cord.
• e skin shows a median raphe.
• A brous septum divides the scrotum into two cavities.
• e le cavity is longer than the right, the le testicle
hanging lower.
• Skin is thin, pigmented, rugose and contains numerous
sebaceous glands.
• e subcutaneous tissue is devoid of fat but contains the
dartos muscle.
Clinical Points
• Scrotal subcutaneous tissue is continuous with the fascia of
the abdominal wall and perineum; extravasation of urine
or blood deep to this plane gravitates into the scrotum,
hence frequent bruising of scrotum following hernia repair.
• Tissues of scrotum are extremely lax and because of its
dependent position it lls with oedema uid in cardiac
or renal failure.
TESTIS AND EPIDIDYMIS
• Each testis is ovoid, measuring 4 cm from upper to lower
pole, 3 cm anteroposteriorly and 2.5 cm from medial to
lateral surface.
CHAPTER 2 The Abdomen, Pelvis and Perineum
37
• Le testis lies at a lower level than the right within the
scrotum.
• Covered by a brous white capsule, the tunica albuginea.
• Covering this is a double serous membrane into which
the testis became invaginated in fetal life, i.e. the tunica
vaginalis testis.
• Septae pass from the tunica albuginea dividing the testis
into lobules, each lobule containing one to three tightly
coiled tubules, i.e. the seminiferous tubules, in which
sperm is produced.
• Testes lie outside the body because spermatogenesis
requires a temperature below that of the body. Failure of
the testes to descend properly leads to a malfunction in
spermatogenesis and relative infertility.
• At the hilum of the testis, the seminiferous tubules
drain into an irregular series of ducts called the rete
testis from which aerent tubules arise, transporting
the sperm into the head of the epididymis.
• Epididymis lies along posterior border of testis to its lateral side.
• Epididymis divided into head, body and tail inferiorly.
• Medially, there is a distinct groove, the sinus epididymis, between it and the testis.
• e epididymis is covered by the tunica vaginalis except
at its posterior margin which is free.
• Sperm passes from the epididymis through the vasa,
which join with the seminal vesicles prior to forming
the common ejaculatory ducts.
• Testis and epididymis each may bear, at their upper
extremities, a small stalked body named, respectively,
the appendix testis and the appendix epididymis (hydatid of Morgagni).
Blood Supply
• Testicular artery arising from the aorta at the level of the
renal vessels.
• Testicular artery anastomoses with artery to vas (which
supplies the vas deferens and epididymis), which arises
from the inferior vesical branch of the internal iliac
ar tery.
• Anastomosis between these two arteries means that
ligation of the testicular artery is not necessarily followed by testicular atrophy.
• Venous drainage is via the pampiniform plexus of veins,
which usually becomes a single vessel, the testicular
vein, at the deep inguinal ring.
• Right testicular vein drains into the IVC; the le into the
le renal vein.
Lymphatic Drainage
• Accompany testicular veins to drain into para-aortic
nodes.
Coverings of the Testis
In the surgical approach to the testis via the scrotum the
following structures are encountered:
• scrotal skin
• dartos muscle
• external spermatic fascia
• cremaster muscle in cremasteric fascia
• internal spermatic fascia
• parietal layer of tunica vaginalis
• once the parietal layer of the tunica vaginalis has been
incised, the visceral layer of the tunica vaginalis is seen
covering the white tunica albuginea.
Clinical Points
• e testis arises at the level of L2/3 on the posterior
abdominal wall. In its development it takes its vascular supply, lymphatic supply and nerve supply from this
region; hence lymphatic drainage is to the para-aortic
nodes, and pain from the kidney may radiate down to
the scrotum and, conversely, testicular pain may radiate
to the loin.
• A rapidly developing varicocele may be a presenting
sign of tumour of the le kidney; tumour invades the
le renal vein and blocks the drainage of the le testicular vein into the le renal vein.
• Congenital anomalies of descent of the testis are
explained under embryology at the beginning of this
chapter.
Vas Deferens (Ductus Deferens)
• Commences at the inferior pole of the testis as the continuation of the epididymis.
• Approximately 45 cm long.
• ick muscular tube, which transports sperm from the
epididymis to the ejaculatory ducts within the prostate
gland.
• Passes through the scrotum and inguinal canal, and
comes to lie on the lateral wall of the pelvis.
• At this point, lies immediately below the peritoneum of
the lateral wall of the pelvis.
• en runs towards tip of ischial spine.
• Turns medially to base of bladder.
• Vas ends by uniting with the ducts of the seminal vesicles to become the common ejaculatory duct.
• is occurs at the most superior and posterior aspect of
the prostate gland.
• e common ejaculatory duct traverses the prostate to
open into the prostatic urethra at the verumontanum on
either side of the utricle.
38
Transverse colon
Inferior vena cava
Superior mesenteric
Inferior vena cava
Superior mesenteric
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SECTION I Anatomy
ABDOMINAL VISCERA
e relationships of abdominal viscera to one another in
the upper abdomen are shown in Figs. 2.15 and 2.16.
Oesophagus
Although only a small part of this is contained within the
abdominal cavity, it will be dealt with here in its entirety.
e oesophagus extends from the lower border of the
Duodenum
Liver
Hepatic artery
Portal vein
Right suprarenal
gland
Right crus of
diaphragm
cricoid cartilage to the cardiac orice of the stomach. It is
about 25 cm long. It has three parts:
• cervical
• thoracic
• abdominal.
Cervical
• Passes downwards and slightly to le.
Pancreas
Superior
mesenteric
artery
Aorta
Spleen
Diaphragm
Fig. 2.15 CT scan passing through the body of the 11th thoracic vertebra.
Colon
Head of pancreas
Liver
Right renal vein
Right kidney
Fig. 2.16 CT scan passing through the body of the second lumbar vertebra.
vein
artery
Jejunum
Left renal vein
Abdominal aorta
Body of L2 vertebra
CHAPTER 2 The Abdomen, Pelvis and Perineum
39
• Anterior relations:
• trachea
• thyroid gland.
• Posterior relations:
• lower cervical vertebrae
• prevertebral fascia.
• To the le:
• le common carotid artery
• le inferior thyroid artery
• le subclavian artery
• thoracic duct.
• To the right:
• right common carotid artery
• recurrent laryngeal nerves lie on either side in the
groove between trachea and oesophagus.
Thoracic
• Oesophagus passes downwards through the superior
and posterior mediastinum.
• Initially passes to the right to reach the midline opposite
T5.
• en passes downwards, forwards and to the le to
reach to the oesophageal hiatus in the diaphragm at
T10.
• e two vagus nerves form a plexus on the surface of the
oesophagus in the posterior mediastinum, the le being
anterior and the right posterior.
• Anterior relations:
• le common carotid artery
• trachea
• le main bronchus, which constricts it
• pericardium separating it from le atrium and the
diaphragm.
• Posterior relations:
• thoracic vertebrae
• thoracic duct
• hemiazygos vein
• the descending aorta below.
• To the le side:
• le subclavian artery
• aortic arch
• le vagus nerve and its recurrent laryngeal branch
• thoracic duct
• le pleura.
• To the right side:
• right pleura
• azygos vein.
Abdominal
• Passes through oesophageal opening in the right crus of
the diaphragm at level T10.
• Lies in a groove on the posterior surface of the le lobe
of the liver with the le crus of the diaphragm behind.
• Covered anteriorly and to le with peritoneum.
• Anterior vagus nerve is closely applied to the surface
behind its peritoneal covering.
• Posterior vagus nerve is at a little distance from the posterior surface of the oesophagus.
Blood Supply
• In the neck: from the inferior thyroid arteries.
• In the thorax: from branches of the aorta.
• In the abdomen: from the le gastric and inferior
phrenic arteries.
• Venous drainage:
• cervical part to inferior thyroid veins
• thoracic part to azygos veins
• abdominal part to azygos vein (systemic) and partly
to the le gastric veins (portal).
Nerve Supply
• Upper third: parasympathetics via recurrent laryngeal
nerve and sympathetic nerves from the middle cervical
ganglion via the inferior thyroid artery.
• Below the root of the lung, the vagi and sympathetic
nerves contribute to the oesophageal plexus.
Microscopic Structure
e oesophagus consists of:
• Mucous membrane lined by stratied squamous epithelium (occasionally there is gastric mucosa in the
lower part of the oesophagus).
• Submucosa containing mucous glands.
• Muscular layer consisting of inner circular and outer
longitudinal muscle.
• In the upper third, muscle is striated, producing rapid
contraction and swallowing.
• In the lower two-thirds, it is composed of smooth muscle exhibiting peristalsis.
• Outer layer of loose areolar tissue.
Clinical Points
• ere are three narrow points in the oesophagus at
which foreign bodies may impact:
• commencement of the oesophagus (17 cm from the
upper incisor teeth)
• point at which it is crossed by le main bronchus
(28 cm from incisor teeth)
• termination (43 cm from upper incisor teeth).
• In the lower oesophagus there is a site of portosystemic anastomosis; between the azygos vein (systemic)
and the oesophageal tributary of the le gastric vein
40
Coeliac trunk
Right gastroepiploic artery
Gastroduodenal artery
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SECTION I Anatomy
(portal). Oesophageal varices may arise at this site in
portal hypertension.
• Le atrial enlargement owing to mitral stenosis may be
noted on a barium swallow, which shows marked backwards displacement of the oesophagus by the dilated
atrium.
Stomach
• Approximately ‘J’ shaped.
• Two surfaces: anterior and posterior.
• Two curvatures: greater and lesser curve.
• Two orices: cardia and pylorus.
• Initially projects to the le, the dome-like gastric fundus
projecting above the level of the cardia.
• In the erect living subject, the vertical part of the ‘J’
shape of the stomach represents the upper two-thirds of
the stomach.
• Lesser curve of stomach is vertical in its upper twothirds but then turns upwards and to the right where it
becomes the pyloric antrum.
• Junction of body with pyloric antrum marked along the
lesser curve by a notch—the incisura angularis.
• Body of stomach lies between cardia and pylorus.
• Pyloric antrum is a narrow area immediately before the
pylorus.
• Le margin of stomach is the greater curvature.
• In the erect subject, this may reach or lie below the
umbilicus.
• Greater curvature then passes upwards to the right as
the lower margin of the pyloric antrum.
• e lesser omentum is attached to the lesser curvature
of the stomach.
• e greater omentum is attached to the greater curvature of the stomach.
• e thickened pyloric sphincter surrounds the pyloric
canal.
• Junction of pylorus with duodenum is marked by a constant prepyloric vein of Mayo, which crosses it vertically.
Relations
• Anteriorly: from le to right, the diaphragm, abdominal
wall and le lobe of the liver.
• Posteriorly: separated from diaphragm, aorta, pancreas,
spleen, le kidney and suprarenal gland, transverse
mesocolon and colon by lesser sac of peritoneum.
Blood Supply
e blood supply (Fig. 2.17) is via:
• the le gastric artery, which is derived from the coeliac
axis and runs along the lesser curvature of the stomach
where it anastomoses with the right gastric branch of
the hepatic artery
• the right gastric artery from the hepatic artery
• the right gastroepiploic artery: arises from the gastroduodenal branch of the hepatic artery and anastomoses along the greater curve with the le gastroepiploic
artery
• le gastroepiploic artery arises from splenic artery
• the short gastric arteries arise from the splenic artery
• venous drainage follows the arteries
Common hepatic artery
Hepatic artery
Hepatic portal vein
Cystic artery
Common bile duct
Right gastric artery
Left gastric artery
Body of
stomach
Pyloric part
of stomach
Fig. 2.17 The arterial blood supply of the stomach.
Fundus of stomach
Short gastric arteries
Splenic artery
Spleen
Left gastroepiploic artery
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