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CHAPTER 2 The Abdomen, Pelvis and Perineum
Splenic hilar nodes
Subpyloric nodes
Hepatic nodes
Gastric nodes
Coeliac nodes
Suprapyloric nodes
Fig. 2.18 The lymphatic drainage of the stomach.
41
Gastroepiploic nodes
• venous drainage is into the portal system
• stomach has such a rich blood supply that ligation of
three of the four main arteries does not compromise its
blood supply.
Lymphatic Drainage (Fig. 2.18)
• Area of stomach supplied by splenic artery drains via
lymphatics accompanying that artery to lymph nodes at
the hilum of the spleen, and then to those situated along
the upper border of the pancreas and eventually to the
coeliac nodes.
• Cardiac area of the stomach drains along the le gastric
artery to reach the coeliac nodes.
• e remainder of the stomach drains as follows:
• via branches of the hepatic artery through nodes
along the lesser curve to the coeliac nodes
• through nodes along the right gastroepiploic ves-
sels to the subpyloric nodes and then to the coeliac
nodes.
• Retrograde spread of carcinoma may occur into the
hepatic lymph nodes at the porta hepatis—enlargements of these nodes may cause external compression
of the bile ducts with obstructive jaundice.
• Extensive and complex lymphatic drainage of stomach creates problems in dealing with gastric cancer—
involvement of nodes around coeliac axis may render
growth incurable.
Nerve Supply
• Anterior and posterior vagus nerves enter the abdomen
through the oesophageal hiatus.
• Anterior vagus nerve lies close to wall of oesophagus but
posterior nerve is at a little distance from the wall of the
oesophagus.
• Anterior vagus gives o hepatic branch and pyloric
branch to the pyloric sphincter.
• Posterior vagus nerve gives o coeliac branch passing
to coeliac axis before sending a gastric branch to the
posterior surface of the stomach.
• Gastric divisions of both anterior and posterior vagi
reach the stomach at the cardia and descend along the
lesser curve between the anterior and posterior peritoneal attachments of the lesser omentum.
• ese nerves are referred to as the anterior and posterior nerves of Latarjet.
• Nerve supply of stomach has become largely of historical interest, as operations to divide the vagus nerve are
rarely carried out nowadays following the advent of
H2 receptor antagonists, proton pump inhibitors and
the discovery of the role of Helicobacter pylori in the
aetiology of peptic ulceration.
Structure of the Gastric Mucosa (Fig. 2.19)
• e surface of the gastric mucosa is covered by columnar epithelial cells that secrete mucus and alkaline uid
that protect the epithelium from mechanical injury and
from gastric acid.
• e gastric mucosa can be divided into three areas:
• cardiac gland area via gastro-oesophageal junction
containing principally mucus-secreting cells
• acid-secreting region (oxyntic gland area) contain-
ing parietal (oxyntic cells) and chief (zymogen) cells
Surface
Chief (zymogen)
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42
Fig. 2.19 A gastric gland and its cells.
SECTION I Anatomy
mucous cells
Gastric pit
Mucous
neck cells
Parietal
cells
cells
• pyloric end area constituting the distal 30% of the
stomach: contains ‘G’ cells that produce gastrin
together with mucus-secreting cells.
• Histological features of the mucosa in the oxyntic gland
area are shown in Fig. 2.19.
Clinical Points
• An ulcer on the lesser curve of the stomach may erode
into either the right or le gastric arteries, resulting in
haematemesis and melaena.
• A posterior gastric ulcer or carcinoma may erode the
pancreas, giving rise to pain referred to the back.
Duodenum
• ‘C’ shaped.
• Curves round the head of the pancreas and is approximately 25 cm (10 inches) long.
• Divided into four parts.
First Part
• Approximately 5 cm long.
• Ascends from the pylorus, being directed superiorly,
posteriorly and to the right.
• First 2–3 cm has a complete investment of visceral
peritoneum.
• Relations:
• anteriorly: liver and gall bladder
• posteriorly: portal vein, common bile duct, gastro-
duodenal artery; behind these is the IVC.
Second Part
• Descends as a curve around the head of the pancreas.
• Approximately 7.5 cm long.
• Bile ducts and main pancreatic ducts enter the second
part of the duodenum together at the duodenal papilla
on its posteromedial side.
• Point of entry marks junction of foregut and midgut.
• Accessory pancreatic duct of Santorini opens into the
duodenum a little above the papilla.
• e second part of the duodenum is crossed by the
transverse colon and lies anteriorly to the right kidney
and ureter.
Third Part
• Approximately 10 cm long.
• Runs horizontally to le.
• Crosses the IVC, the aorta and third lumbar vertebra.
• Crossed anteriorly by the root of the mesentery and
superior mesenteric vessels.
Fourth Part
• Approximately 2.5 cm long.
• Ascends vertically to end by turning abruptly anteriorly
to the le to continue as the jejunum.
• At the DJ exure, the small intestine leaves the posterior
abdominal wall and acquires a mesentery.
• At surgery the DJ exure may be identied by the presence of the suspensory ligament of Treitz—a peritoneal
fold descending from the right crus of the diaphragm to
the termination of the duodenum.
Blood Supply of the Duodenum
• Superior pancreaticoduodenal artery arising from the
gastroduodenal artery.
• Inferior pancreaticoduodenal artery originating from
the superior mesenteric artery.
• ese two arteries lie in the curve between the duodenum and head of the pancreas, supplying both the duodenum and head of the pancreas.
Clinical Point
• e relationship of the gastroduodenal artery to the
rst part of the duodenum is important because erosion
of posterior duodenal ulcers into the gastroduodenal
artery will cause haematemesis and melaena.
Small Intestine
• Variable in length, averaging some 6 m.
• Upper half is termed the jejunum, the remainder the
ileum, although the distinction between the two is not
sharply dened.
• Jejunum and ileum lie in free edge of mesentery.
CHAPTER 2 The Abdomen, Pelvis and Perineum
43
• e mesentery of the small intestine is about 15 cm long
and attached across the posterior abdominal wall.
• Commences at DJ exure to the le of the second lumbar vertebra and passes obliquely downwards to the
right sacroiliac joint.
• From le to right the root of the mesentery crosses anterior to the following structures:
• third part of the duodenum
• aorta
• IVC
• right psoas major muscle
• right ureter
• right gonadal vessels
• right iliacus muscle.
• Mesentery contains:
• the superior mesenteric vessels, which enter the mes-
entery anterior to the third part of the duodenum
• lymph nodes draining the small intestine
• autonomic nerve bres.
• At surgery the following factors serve to distinguish the
jejunum from the ileum:
• the jejunum has a thicker wall owing to circular folds
of mucosa (valvulae conniventes or plicae circulares), which are larger and more numerous than in
the ileum
• the jejunum is of greater diameter than the ileum
• in the mesentery of the jejunum, the arteries form
one or two arcades some distance from the free
edge of the mesentery, and long straight branches
from these arcades run to supply the jejunum. In
the ileum, the arterial supply forms several rows of
arcades in the mesentery, and the nal straight arteries to the ileum are shorter and more numerous than
in the jejunum
• the mesentery becomes thicker and more fat-laden
from above downwards
• in general, the jejunum is most likely to be found at
or above the level of the umbilicus while the ileum
tends to lie below the level of the umbilicus in the
hypogastrium and pelvis.
Large Intestine
e large intestine extends from the ileocaecal junction to
the anus. It is approximately 1.5 m in length in average. It
is divided into:
• caecum with the vermiform appendix
• ascending colon
• hepatic exure
• transverse colon
• splenic exure
• descending colon
• sigmoid colon
• rectum
• anal canal.
Caecum
• Dilated blind-ended pouch situated in the right iliac
fossa.
• Usually completely covered by peritoneum.
• Ileocaecal valve lies on the le side of the junction
between caecum and ascending colon.
• Appendix rises from the posteromedial aspect of the
caecum about 2.5 cm below the ileocaecal valve.
Ascending Colon
• Extends from the caecum to the undersurface of the
liver where, at the hepatic exure, it turns le to become
the transverse colon.
• Covered on anterior and lateral aspects by peritoneum.
• Posterior relations include:
• iliacus
• quadratus lumborum
• perirenal fascia over lateral aspect of kidney.
Transverse Colon
• Passes to the le where it becomes the descending colon
at the splenic exure.
• Attached to the anterior border of the pancreas by the
transverse mesocolon.
• Relations:
• superiorly: liver, gall bladder, greater curvature of
stomach and spleen
• inferiorly: coils of small intestine
• anteriorly: anterior layers of the greater omentum
• posteriorly: right kidney, second part of duodenum,
pancreas, small intestine and le kidney.
Descending Colon
• Passes from splenic exure to sigmoid colon.
• Peritoneum covers its anterior and lateral surfaces.
• Between the splenic exure and diaphragm is a fold of
peritoneum, the phrenicocolic ligament.
• Relations:
• posteriorly: le kidney, quadratus lumborum and
iliacus
• anteriorly: coils of small intestine.
Sigmoid Colon
• Commences at pelvic brim and extends to rectosigmoid
junction.
• Has a mesentery which is occasionally extensive, allowing sigmoid colon to hang down into pelvis.
• Root of sigmoid colon crosses the external iliac vessels
and le ureter.
44
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SECTION I Anatomy
• e sigmoid loop rests on the bladder in the male and is
related to the uterus and posterior fornix of the vagina
in the female.
Taenia Coli
• ree attened bands of longitudinal muscle which pass
from the caecum to rectosigmoid.
• Converge at the base of the appendix.
• e taenia are shorter than the length of the bowel,
hence the sacculated appearance of the large bowel.
• ere are no taenia coli on the appendix or rectum.
Appendices Epiploicae
• Fat-lled tags scattered over the surface of the colon.
• Most numerous in the sigmoid colon.
• Absent on the appendix, caecum and rectum.
Appendix
• Attached to posteromedial aspect of the caecum below
the ileocaecal valve.
• Variable in length but usually 5–10 cm.
• Position is variable:
• 75% lies behind the caecum or colon, i.e. retrocaecal
or retrocolic
• 20% pelvic
• 5% preileal or retroileal.
• Bears a mesentery containing the appendicular artery,
which is a branch of the ileocolic artery.
• Appendix mesentery descends behind the ileum as a
triangular fold containing the appendicular artery in its
free edge.
Clinical Points
• e appendicular artery is an end-artery and therefore,
in acute appendicitis, if it thromboses there is a consequent rapid development of gangrene with perforation
of the appendix.
• e lumen of the appendix is relatively wide in infancy
and oen obliterated in the elderly. Since obstruction of
the appendicular lumen is a usual precipitating cause
of acute appendicitis, it is therefore uncommon at the
extremes of life.
• A long pelvic appendix may hang down and irritate the
bladder, giving rise to frequency of micturition, simulating cystitis.
Rectum
e rectum is about 12 cm (5 inches) long, commencing
anterior to the third segment of the sacrum and ending
about 2.5 cm in front of the coccyx, where it bends sharply
backwards to become the anal canal.
• Peritoneal coverings:
• extraperitoneal on its posterior aspect
• upper third: covered by peritoneum on its front and
sides
• middle third: covered by peritoneum only on its
anterior aspect
• lower third: completely extraperitoneal, lying below
the pelvic peritoneum.
• Curved to follow the contour of the sacral hollow.
• ree lateral inexions projected to the le, right and
le again from above downwards.
• Each inexion is capped by a valve of Houston.
Relations
• Anteriorly:
• in the male lie the rectovesical pouch, base of blad-
der, seminal vesicles and prostate
• a layer of fascia (of Denonvilliers) lies in front of the
rectum, separating it from the prostate
• in the female lie the rectouterine pouch (of Douglas)
and posterior wall of the vagina
• the upper two-thirds of the rectum is covered with
peritoneum anteriorly and related to coils of small
bowel and the sigmoid colon in the rectovesical or
rectouterine pouch.
• Posteriorly: sacrum, coccyx, lower sacral nerves, middle
sacral artery.
• Laterally: below peritoneal reexion lie the levator ani
and coccygeus.
Blood Supply of the Large Intestine (Fig. 2.20)
• Supplied by branches of both the superior and inferior
mesenteric artery.
• e branches of the superior mesenteric artery are:
• the ileocolic artery, supplying the caecum and com-
mencement of the ascending colon
• the right colic artery, supplying the ascending colon
• the middle colic artery, supplying the transverse colon.
• e branches of the inferior mesenteric artery supplying
the colon are:
• the le colic artery, supplying the descending colon
• the sigmoid branches, supplying the sigmoid colon
• the superior rectal artery, supplying the rectum.
• Each branch of the superior and inferior mesenteric
artery anastomoses with its neighbour above and below,
establishing a continuous chain of anastomosis along
the length of the colon known as the marginal artery (of
Drummond).
• e superior rectal artery supplies the whole of the
rectum and the upper half of the canal, while the inferior rectal artery supplies the lower half of the anal
canal.
Superior mesenteric artery
Right colic artery
Middle colic artery
Ileocolic artery
CHAPTER 2 The Abdomen, Pelvis and Perineum
Marginal artery
Inferior mesenteric artery
Left colic artery
Sigmoid branches
Superior rectal artery
45
Fig. 2.20 The arterial blood supply of the large intestine.
• e middle rectal artery is small and supplies only the
muscle coats of the rectum.
• When the superior rectal artery reaches the rectum, it
rst divides into two branches, which run either side of
the rectum, then the right branch divides into two further branches. ese branches descend to the level of
the anal valves, where they anastomose with branches
of the inferior rectal artery.
• ey are accompanied by tributaries of the superior rectal vein draining into the portal system.
• e position of these vessels, one on the le and two on
the right, explain why haemorrhoids occur at 3, 7 and
11 o’clock when the anal canal is viewed with the patient
in the lithotomy position.
Clinical Points
• e marginal artery is weakest and sometimes decient where the superior and inferior mesenteric artery
distributions meet just proximal to the splenic exure.
Diminution of the blood supply in this region may lead
to the condition known as ischaemic colitis.
• e marginal artery is also important in allowing the
surgeon to transpose large segments of colon as far as
the neck or thorax to replace segments of oesophagus,
the bowel depending on the marginal artery for its
blood supply.
Lymphatic Drainage of the Large Intestine
• Lymphatics drain to small lymph nodes lying near to or
even on the bowel wall.
• ese drain to further groups lying along the blood vessels.
• ese then drain to nodes near the origins of the superior and inferior mesenteric arteries.
• Eerent vessels from these join to drain into the cisterna
chyli.
• e eld of lymphatic drainage of each segment of bowel
corresponds more or less to its arterial blood supply.
• High ligation of the vessels to the involved segment of
bowel with the removal of a wide surrounding segment
of mesocolon and bowel wall will result in the removal
of lymph nodes draining that particular area, e.g. division of the inferior mesenteric artery and resection of
sigmoid mesocolon would be performed for carcinoma
of the sigmoid colon.
Anal Canal
e anal canal is about 4 cm long and passes downwards
and backwards.
46
f
External anal
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SECTION I Anatomy
• Surrounded by a complex arrangement of sphincters
consisting of smooth and striated muscle.
• At the midpoint of the canal there is a series of vertical
columns in the mucosa (the columns of Morgagni).
• At the distal end of the vertical columns are some valvelike folds (the anal valves of Ball).
• Behind these valves are the anal sinuses into which open
the anal glands.
• e upper half of the anal canal is lined with columnar
epithelium.
• e lower half is lined with stratied squamous epithelium transforming into skin near the anal verge.
• e boundaries between these zones are not clear-cut.
• e upper half of the anal canal is derived from endoderm; the lower half is derived from ectoderm. ere
are some important anatomical facts with clinical significance resulting from this derivation of the anal canal.
ey are as follows:
• the upper half is lined by columnar epithelium and
the lower half with stratied squamous epithelium;
consequently, carcinoma of the upper anal canal is
adenocarcinoma while that of the lower part is a
squamous cell carcinoma
• the upper half of the anal canal is supplied by the
autonomic nervous system; the lower part has
somatic innervation from the inferior rectal nerve.
e lower part of the anal canal is sensitive to pinprick sensation while the upper part is not. is is an
important factor when injecting haemorrhoids
• the upper half of the anal canal drains into the portal
venous system whereas the lower half drains into the
systemic venous system. is therefore is an important site of portosystemic anastomosis in portal
hypertension
• the lymphatic drainage of the upper half of the
anal canal is along the superior rectal vessels to the
abdominal nodes; whereas below this site, drainage
is to the inguinal nodes. is is clinically important
as a carcinoma of the rectum which invades the
lower anal canal may metastasize to inguinal lymph
nodes.
Anal Sphincters
• e anal canal is surrounded by a complex arrangement
of muscles.
• e internal anal sphincter is composed of smooth
muscle continuous above with the circular muscle of the
rectum. It surrounds the upper two-thirds of the canal
and is supplied by sympathetic nerves.
• e external anal sphincter is composed of striated
muscle, which surrounds the internal anal sphincter but
extends further distally (Fig. 2.21).
• e external anal sphincter is divided into three
parts:
• subcutaneous
• supercial, which is attached to the coccyx behind
and the perineal body in front
• deep, which is continuous with the puborectalis part
of levator ani.
• e deep part of the external sphincter where it blends
with levator ani together with the internal anal sphincter is termed the anorectal ring.
• e anorectal ring is palpable with a nger in the anal
canal where it forms a ring, immediately above which
the nger enters the ampulla of the rectum.
• e subcutaneous part of the external anal sphincter
is traversed by a fan-shaped expansion of longitudinal
muscle bres of the anal canal.
Rectum
Deep
sphincter
Fig. 2.21 The anal sphincters.
Superficial
Subcutaneous
Circular muscle coat o
the rectum
Levator ani
Internal anal
sphincter
CHAPTER 2 The Abdomen, Pelvis and Perineum
47
• e nerve supply of the external sphincter is via the
inferior rectal branch and the pudendal nerve (S2, S3)
and the perineal branch of S4.
Rectal Examination
e following structures can be palpated by the nger
passed per rectum in the normal patient.
• Both sexes:
• anorectal ring
• coccyx
• sacrum
• ischiorectal fossae
• ischial spines.
• Male:
• prostate
• rarely, the seminal vesicles.
• Female:
• perineal body
• cervix
• occasionally, the ovaries.
e following abnormalities can also be detected.
• Lumen:
• faecal impaction
• foreign bodies.
• In the wall:
• rectal tumours
• rectal strictures
• thrombosed haemorrhoids (haemorrhoids are not
palpable unless thrombosed).
• Outside rectal wall:
• prostatic abnormalities
• abnormalities of the uterine cervix
• ovarian enlargement
• masses in the pouch of Douglas
• tenderness in the pouch of Douglas with peritonitis
• pelvic bony tumours
• foreign bodies in the vagina, e.g. tampon, pessary or
others.
Liver
e liver is the largest organ in the body. It lies across the
right hypochondrium, epigastrium and le hypochondrium. It is divided into two unequal lobes by a fold of
peritoneum, the falciform ligament. It has the following
features.
• Superior surface: dome-shaped; related to the diaphragm, which separates it from the pleura, lungs, pericardium and heart.
• Posteroinferior surface is related to the abdominal
oesophagus, stomach, duodenum, hepatic exure of the
colon, right kidney and right suprarenal gland.
• e posteroinferior surface is covered with peritoneum
except where the gall bladder is attached and at the porta
hepatis and the ssure for the ligamentum venosum.
• e posterior surface is connected to the diaphragm
over the right lobe of the liver by the coronary ligament,
between the two layers of which is a non-peritonealized
area, i.e. the bare area.
• To the le of the bare area is the caudate lobe, which
bounds the lesser sac in front.
• e anatomical right and le lobes of the liver are separated anteriorly and superiorly by the falciform ligament,
and posteroinferiorly by the H-shaped arrangement of
the fossae (Fig. 2.22).
Porta Hepatis
• Gateway to and from the liver.
• Contains the following structures:
• common hepatic duct anteriorly
• hepatic artery in the middle
• portal vein posteriorly.
• Contains lymph nodes which, when enlarged by malignancy, may compress the bile ducts and cause obstructive jaundice.
Peritoneal Relations of the Liver (Fig. 2.23)
• e liver is almost completely covered by peritoneum,
except for the bare area in which the IVC is embedded.
• Bare area is between upper and lower leaves of coronary
ligament.
• Upper and lower leaves of coronary ligament fuse to
form the right triangular ligament.
• Falciform ligament passes upwards from umbilicus to
right of midline, the ligamentum teres running in its
free border.
• Falciform ligament passes over dome of liver and separates, its right part joining the upper leaf of the coronary
ligament, while the le part forms part of the le triangular ligament, the latter being attached to the peritoneum on the undersurface of the diaphragm.
• e le triangular ligament, when traced to the right
and posteriorly, joins the lesser omentum in the ssure
for the ligamentum venosum.
• e le triangular ligament contains no major blood vessels and therefore may be divided safely so that the le lobe
of the liver may be retracted to expose the oesophagus.
• e lesser omentum arises from the ssure for the ligamentum venosum and porta hepatis and passes as a sheet
to be attached along the lesser curve of the stomach.
• e free edge of the lesser omentum contains the common bile duct to the right, the hepatic artery to the le
and the portal vein posteriorly.
48
Porta hepatis
Quadrate lobe
Caudate lobe
Fissure for the
Portal vein
Porta hepatis
Left triangular ligament
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SECTION I Anatomy
ligamentum venosum
IVC
Renal
Gastric
Duodenal
Colic
Ligamentum teres
Gall bladder
Fig. 2.22 The inferior aspect of the liver. The H-shape (dotted line) demonstrates the various fissures, the
groove for the inferior vena cava (IVC) and the fossa for the gall bladder. The sites of impressions of the various relations are indicated in italics.
Fig. 2.23 The liver—posterior view.
Functional Anatomy of the Liver
• e gross anatomical division of liver into right and le
lobes demarcated by falciform ligament anteriorly and
ssure for ligamentum teres and ligamentum venosum
Lesser omentum
(cut) in the
fissure for
ligamentum venosum
Hepatic artery
Left hepatic duct
Quadrate lobe
Caudate lobe
Left lobe
Caudate process
Inferior vena cava
Superior layer of
coronary ligament (cut)
Bare area
Inferior layer of coronary ligament (cut)
Right triangular ligament
Right
lobe
Gall bladder
Common bile duct
Common hepatic duct
posteroinferiorly is not pertinent to understanding of
the surgical anatomy of the liver.
• Functional anatomy is based on the description of
hepatic segmentation, which divides the liver into
CHAPTER 2 The Abdomen, Pelvis and Perineum
IVC
Falciform ligament
49
segments according to the distribution of portal pedicles and location of hepatic veins.
• Functional division of liver into right and le lobes is
not demarcated by any visible line on the surface of the
liver.
• e division is through a plane which passes through
the gall bladder fossa and fossa for the IVC.
• Each of these two functional lobes has its own arterial and portal venous blood supply and its own biliary
drainage.
• Surgical division of the right hepatic artery and the right
branch of the portal vein is followed by a clear demarcation on the liver surface running anteroposterior from
the gall bladder fossa to the IVC in the principal vascular
plane.
• ese two functional lobes are further subdivided into
segments, each lobe being divided into four segments
(Fig. 2.24).
II
VIII
V
A
VIII
VII
V
VI
B
V
VI
VII
C
IV
Gall bladder
IV
Gall bladder
Gall bladder
IV
I
III
Falciform ligament
II
III
Falciform ligament
III
II
Fig. 2.24 The functional division of the liver into seg-
ments. (A) Anterior view, as seen in the patient. (B)
Anterior view with the liver ‘flattened’ in the ex-vivo
position (note that segments VI and VII may now be
seen—in vivo they appear more laterally and posteriorly). (C) Inferior view.
Hepatic Veins
• ere are three main hepatic veins:
• right
• central
• le.
• ey pass backwards and upwards from the substance
of the liver, draining into the IVC at the superior limit
of the liver.
• e caudate lobe of the liver has independent hepatic
veins which drain directly into the IVC.
• ree main hepatic veins divide the liver into four
sectors, each of which receives a portal pedicle, with an
alternation between hepatic veins and portal pedicles
(Fig. 2.25).
• e middle hepatic vein lies at the line of the principal
plane of the liver between its right and le functional
lobes.
• Terminology in liver resection is based on function and
segmental anatomy.
• A right hemihepatectomy would involve segments V,
VI, VII and VIII.
• A le hemihepatectomy would involve segments II, III
and IV.
• Excision of the anatomical le lobe of the liver would
involve only segments II and III.
• Excision of the functional le lobe of the liver would
involve segments II, III, IV and possibly I.
Extrahepatic Biliary System (Fig. 2.26)
Right and le hepatic ducts join at the porta hepatis to form
the common hepatic duct.
• Common hepatic duct is joined by cystic duct to form
bile duct (common bile duct).
• Bile duct is about 9 cm long, commencing approximately
4 cm above the duodenum then passing behind it.
• Bile duct runs in a groove on the posterior aspect of the
head of the pancreas before opening into the medial
aspect of the second part of the duodenum.
• In 90% of individuals, the main pancreatic duct joins
the common bile duct to form a common dilated channel, i.e. the ampulla of Vater.
• e opening of the ampulla of Vater into the duodenum
is guarded by the sphincter of Oddi (periampullary
sphincter).
• Occasionally bile duct and pancreatic ducts open separately into the duodenum.
• ere may be an additional duct, which receives ducts
from the lower part of the head of the pancreas, known
as the accessory pancreatic duct. It opens into the
medial wall of the second part of the duodenum about
2 cm proximal to the main duodenal papilla (endoscopists should be aware of these anatomical variations).
50
Left hepatic vein
IVC
Portal vein
t
Duodenum (2nd part)
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SECTION I Anatomy
IV III
Middle hepatic vein
II
Right hepatic vein
VI
I
VIII VII
V
Fig. 2.25 A schematic representation of the functional anatomy of the liver. The three main hepatic veins
divide the liver into four sectors, each of which receives a portal pedicle.
Right hepatic duct
Cystic duct
Gall bladder
Fig. 2.26 Magnetic resonance cholangiopancreatogram (MRCP).
Left hepatic duct
Common hepatic duc
Common bile duct
Pancreatic duct
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