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FIGURE 1-11 Midline sagittal view of the (A) male pelvis and (B) and female pelvis. The

male pelvis is narrow compared to that of the female. Anteriorly, the prostate is found in the male; the vagina is found in the female.

Cecum and Appendix

The word “cecum” is derived from the Latin intestinum caecum or “blind gut.” The first part of the large intestine, in the lower right quadrant, inferior to the ileocecal opening, is the cecum. Attached inferiorly to the cecum is the appendix, located at the confluence of the taeniae coli. The cecum is covered by peritoneum and is mobile.

Ascending Colon

The ascending colon continues superiorly to the right colic flexure just inferior to the liver. Although in most cases, it has no mesentery and is fixed to the posterior abdominal wall, in some cases, it has its own mesentery. Immediately lateral to the ascending colon is the right paracolic gutter. The arterial supply to the ascending colon consists of the colic branch of the ileocolic artery (from the superior mesenteric artery). The origin of the right colic artery variably arises from the superior mesenteric artery, the ileocolic artery, or the right branch of the middle colic artery (MCA).

Transverse Colon

Beginning at the right colic flexure and continuing to the left colic flexure is the transverse colon. This structure is intraperitoneal and suspended from the posterior abdominal wall by the transverse mesocolon. The arterial supply to the transverse colon is the right colic artery and MCA from the superior mesenteric artery and left colic artery from the inferior mesenteric artery. Variant origin of the MCA from the gastroduodenal artery has been reported.

Descending Colon

Beginning at the left colic flexure and extending to the area of the crest of the ileum is the descending colon (Fig. 1-12). In most cases, it also has no mesentery and is fixed, to varying degrees, to the posterior abdominal wall. As was the case with the ascending colon, lateral to the descending colon is the left paracolic gutter. The arterial supply to the descending colon is the left colic artery from the inferior mesenteric artery.

FIGURE 1-12 The anus. There are two anal sphincters. The internal sphincter is an

extension of the rectal smooth muscle. The external sphincter is an extension of the levator ani. The anus receives blood from the superior, middle, and inferior rectal arteries. The lining of the anus involves four epithelia. The columnar epithelium of the gut joins the anal transitional zone at the anorectal line. Within the anal transitional zone are the internal hemorrhoids, located beneath the columns and sinuses of Morgagni. The distal border of the anal transitional zone is the dentate line, aka pectinate line, so named for its toothlike or scalloped (pectinate) appearance. Inferior to the dentate line is the pecten, hairless nonkeratinized squamous epithelium. The pecten joins perianal skin (with hair) at the anal verge.

Sigmoid Colon

The origin of the word “sigmoid” is from the 18th letter of the Greek alphabet “Σ,σ” and the Latin “S.” Near the crest of the ileum, the sigmoid colon begins (Fig. 1-12). It continues inferiorly until the mesentery is lost, usually anterior to vertebra S3. This marks the beginning of the rectum. The sigmoid colon is attached where it begins and ends, but is mobile throughout its length being suspended by the sigmoid mesocolon. Important structures posterior to the sigmoid colon and the sigmoid mesocolon include the left external and internal iliac vessels, left gonadal vessels, left ureter, and the roots of the sacral plexus. The arterial supply to the sigmoid colon consists of

several sigmoidal arteries from the inferior mesenteric artery (Fig. 1-8).

Rectum

The word “rectum” is derived from the Latin intestinum rectum or “straight intestine.” The retroperitoneal rectum extends from the sigmoid colon to the anal canal with the rectosigmoid junction defined as either the level of vertebrae S3 or at the end of the sigmoid mesocolon (Fig. 1-11A and B). The arterial supply to the rectum consists of the superior rectal artery from the inferior mesenteric artery, middle rectal artery from the internal iliac artery, and inferior rectal artery from the internal pudendal artery, a branch of the inferior iliac artery.

Anus

The word “anus” is derived from the Latin anus or “ring.” The anal canal is the final portion of the large intestine. It begins at the terminal end of the rectal ampulla as it passes through the pelvic floor. The anal canal ends as the anus after it has passed through the perineum. The arterial supply to the anal canal consists primarily of the inferior rectal artery from the internal pudendal artery, a branch of the inferior iliac artery (Fig. 1-12).

Suggested Readings

Bellamy E. The Student’s Guide to Surgical Anatomy. 3rd ed. London, England: J. & A. Churchill;

1885:vi. In his introduction, Dr. Bellamy attributed this quote to Professor Spence.

Drake RL, Vogl AW, Mitchell AWM, Tibbitts R, Richardson P. Gray’s Atlas of Anatomy.

Philadelphia, PA: Churchville Livingstone; 2007.

Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 3rd ed. Philadelphia, PA:

Churchville Livingstone/Elsevier; 2014. Etymonline. Anus. Available at: https://www.etymonline.com/word/anus. Accessed May 26, 2018. Etymonline. Caecum. Available at: https://www.etymonline.com/word/caecum. Accessed May 26,

2018.

Etymonline. Duodenum. Available at: https://www.etymonline.com/word/duodenum. Accessed May

26, 2018. Etymonline. Ileum. Available at: https://www.etymonline.com/word/ileum. Accessed May 26, 2018. Etymonline. Jejunum. Available at: https://www.etymonline.com/word/jejunum. Accessed May 26,

2018.

Etymonline. Rectum. Available at: https://www.etymonline.com/word/rectum. Accessed May 26,

2018.

Garćia-Ruiz A, Milsom JW, Ludwig KA, Marchesa P. Right colonic arterial anatomy. Implications for

laparoscopic surgery. Dis Colon Rectum. 1996;39:906-911. Gray H. Anatomy of the Human Body. 20th ed. Thoroughly revised and re-edited by Lewis WH.

Philadelphia, PA: Lea & Febiger; 1918:1157-1158. Haywood M. Molyneux C, Mahadevan V, Lloyd J, Srinivasaiah, N. The right colic artery: an

anatomical demonstration and its relevance in the laparoscopic era. Ann R Coll Surg Engl.

2016;98:560-563. Indrajit G, Ansuman R, Pallab B. Variant origin of the middle colic artery from the gastroduodenal

artery. Int J Anat Var. 2013;6:13-17. Thomas TT. A Syllabus of Surgical Anatomy. 2nd ed. College Agency of U.P., F. W. S. Langmaid,

einige andere anatomische Verhältnisse. Vierteljahrsschrift Praktisch Heilkund (Prague).

1853;37:113-144.

Chapter 2

Tools of the Trade: Retractors, Scopes, Probes, and More

DAVID LISKA

Outpatient Office Equipment

General Equipment (Fig. 2-1)

FIGURE 2-1 Examination room.

Desk and computer with access to electronic medical record and imaging studies Chairs for patient and companion Curtain for privacy during examination Poster with illustration of gastrointestinal anatomy Sink Sharps container Used instrument containers