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6.Right gastroepiploic artery:
Origin: Gastroduodenal artery.
Course: It passes inferiorly towards the midline just below the pylorus and then runs laterally along
the greater curvature between the layers of the gastrocolic omentum about 1–2 cm from the greater
curvature of the stomach.
Branches:
1.Gastric branches to body of the stomach.
2.Epiploic branches.
3.Branches to the first part of the duodenum.
Anastomoses with the left gastroepiploic artery.
7.Pyloric arteries:
Are branches of the right gastric and right gastroepiploic arteries. They pierce the duodenal wall
around its entire circumference just distal to the sphincter and reach the submucosa. Here, they
divide into two or three rami that run towards the stomach in the submucosa of the pyloric canal
and terminate in the mucosa of the pyloric antrum.
Arterial anastomoses of the stomach:
1.Oesophageal arteries originating from the thoracic aorta anastomose with vessels supplying the
fundus of the stomach in the region of the cardiac orifice.
2.At the pyloric orifice, duodenal arteries anastomose with branches of the superior mesenteric
artery and pyloric vessels derived from arteries arising from the coeliac trunk.
3.The right and left gastroepiploic arteries and left and right gastric arteries anastomose along the
greater and lesser curvatures, respectively.
4.Anastomoses in the fundus between the short gastric and left gastric arteries.
5.In the antrum between the right gastric and right gastroepiploic arteries.
6. Pyloric arteries anastomose with submucosal arteries in the duodenum and gastric antrum close
to their origin and termination, respectively.
B) Venous drainage:
1.Short gastric veins (3-5); drain the gastric fundus and the upper part of the greater curvature
into the splenic vein.
2.Left gastroepiploic vein; drains both anterior and posterior surfaces of the body of the stomach
and the adjacent greater omentum via and drains into the splenic vein within the gastrosplenic
ligament.
3.Right gastroepiploic vein; drains the greater omentum, distal body and antrum of the stomach.
Drains into the superior mesenteric vein.
4. Left gastric vein; drains the upper body and fundus of the stomach. Drains into the portal vein.
5.Right gastric vein; Drains the medial end of the lesser curvature. It drains directly into the portal
vein.
6.Posterior gastric veins; draining the middle of the posterior surface of the stomach into the
splenic vein.
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Fig.101: Blood supply of the stomach. Source [101].
Lymphatic drainage:
Lymphatics follow the course of the arteries supplying the stomach.
At the gastro-oesophageal junction, the lymphatics are continuous with those draining the lower
oesophagus.
In the region of the pylorus, they are continuous with those draining the duodenum and pancreas.
Innervations:
A) Sympathetic innervation:
1.Greater and lesser splanchnic nerves and the coeliac plexus (T5-T12).
2.Peri-arterial plexuses form along the arteries arising from the coeliac trunk.
3.Fibres of the hepatic plexus.
B) Parasympathetic innervation:
1.The anterior vagal trunk:
Supplies the cardiac orifice.
Divides near the gastro-oesophageal junction into gastric, pyloric, hepatic and upper gastric
branches which supply the body and antrum and terminates near the angular incisure.
2.The posterior vagal trunk:
It divides into gastric branches and coeliac branches.
One or two small hepatic branches may also originate from the coeliac division of the nerve.
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Fig.102: Vagal rami of the stomach. Source [102].
Peritoneal coverings: The stomach is completely intraperitoneal
expect for sites of origin on the gastroheaptic and gastrocolic ligaments in the origin of the lesser
and greater omentum respectively.
Holotopy: The stomach projects to the epigastric & left hypochondrium.
1.Cardia;
A. Anteriorly; one inch to the left of the margin of the sternum at the level of the attachment of the
VI-VII ribs to the sternum.
B. Posteriorly; XI thoracic vertebra, being connected to the lower end of the esophagus.
The Cardia is closer to the posterior abdominal wall than the anterior one.
2. The fundus;
Inferior level of the V rib along the Midclavicular line.
3. The pylorus;
One inch to the right of the median plan at the level of the VIII costal cartilage and L1.
(Transpyloric plan).
With full stomach the pylorus is shifted 3-5 cm to the right of the midline.
4. The lesser curvature;
The arcuate line circumflexing the xiphoid process from the left and inferiorly upon the ALAW.
5. The greater curvature;
Extends as an arcuate arch extending from the inferior margin of the V rib along the midclavicular
line, crosses the lateral border of the left rectus muscle reaching the median plan superior to the
level of the umbilicus (8
th
intercostal space).
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Syntopy:
1.The anterior wall;
A. Right; the right lobe of the liver.
B. Left; Costal part of the diaphragm and the left lobe of the liver.
C. ALAW.
2. The posterior wall;
A. The pancreas.
B. The left kidney (Superior Pole).
C. The left suprarenal (adrenal) gland.
3. Posteriorly to the left; The spleen.
4. The lesser curvature; The left hepatic lobe.
5. The grater curvature; The transverse colon.
Fig. 103: Syntopy of the stomach. Source [103].
Skeletopy: T11- L1.
1. Cardia;
T11 to the left of the backbone.
2.Pylorus;
T12-L1 to the right side.
3. Fundus;
5th intercostal space on the left midclavicular line.
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4) The duodenum:
Vascular supply:
A) Arterial supply:
1.Gastroduodenal artery:
Origin: Common hepatic artery.
Course: It descends behind the retroperitoneal portion of the first part of the duodenum to the left
of the CBD.
Branches:
1.The posterior superior pancreaticoduodenal artery.
2. Retroduodenal branches supplying the first part and proximal portion of the second part of the
duodenum.
3.A supraduodenal artery that supplies the anterosuperior part of the proximal duodenum.
4. The right gastroepiploic artery and several pyloric branches.
5.The anterior superior pancreaticoduodenal artery and pancreatic branches.
2.Superior pancreaticoduodenal arteries:
A) The posterior superior pancreaticoduodenal artery; supplies branches to the head of the
pancreas, the first and second parts of the duodenum, and several branches to the lowest part of
the common bile duct. Anastomoses with the posterior division of the inferior pancreaticoduodenal
artery.
B) The anterior superior pancreaticoduodenal artery; supplies branches to the first and second parts
of the duodenum and to the head of the pancreas, and anastomose with the anterior division of the
inferior pancreaticoduodenal artery.
3. Inferior pancreaticoduodenal artery:
Origin: superior mesenteric artery
Course: It crosses behind the superior mesenteric vein and passes behind the uncinate process of
the pancreas, where it divides into anterior and posterior branches.
Branches:
1.The anterior branch anastomoses with the anterior superior pancreaticoduodenal artery.
2.The posterior branch anastomoses with the posterior superior pancreaticoduodenal artery.
Both branches supply the pancreatic head, its uncinate process, and the second and third parts of
the duodenum.
4.Jejunal artery branches:
The first jejunal branch of the superior mesenteric artery supply the fourth part of the duodenum
and anastomose with a terminal branch of the anterior superior pancreaticoduodenal artery.
B) Venous drainage:
1.The superior pancreaticoduodenal vein drains into the portal vein.
2.The inferior pancreaticoduodenal vein drains into the superior mesenteric vein.
3.Small veins from the first and upper second parts of the duodenum drain into the portal vein.
4.Veins from the third and fourth parts drain into the superior mesenteric vein.
5. Multiple anastomoses present between veins of the 2
nd
and 3rd parts of the duodenum and
retroperitoneal veins.
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Fig.104: Arterial supply of the duodenum. Source [104].
Lymphatic drainage:
Duodenal lymphatics run to superior and inferior pancreaticoduodenal lymph nodes, and from
there to supra- and infrapyloric, hepatoduodenal, common hepatic, coeliac, superior mesenteric
and para-aortic nodes.
Innervations:
1.Preganglionic sympathetic neurones (T5-T12).
Greater and lesser splanchnic nerves to the coeliac plexus and synapse in the coeliac and superior
mesenteric ganglia;
2.Postganglionic axons; via peri-arterial plexuses on the branches of the coeliac trunk and superior
mesenteric artery.
3.The preganglionic parasympathetic supply; vagal fibres that travel from the coeliac plexus and
synapse on neurones in the duodenal wall.
Peritoneal coverings:
1. Superior part;
Coated from 3 sides, expect for the site of attachment of the lig. Hepatoduodenale and the
inferioposterior area of the duodenal surface adjoining the head of the pancreas.
2. Descending part,
Is covered in its upper third anterolaterally.
3. The inferior third of the descending and the initial part of the ascending part;
Are covered by peritoneum only anteriorly
Holotopy:
1. Frist (Superior) part; length 5 cm, projects to L1
IS horizontal and extends from the pylorus to the right lateral line.
2. Descending part; length 7.5 cm, projects to L1-L3
Extends from the transpyloric line to a point midway between the transpyloric (L1) and the
transtrabecular lines (L5).
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3. Horizntal part; length 10 cm, projects to L3
To the left of the midline.
4. Ascending part; length 2.5 cm, projects to L3-L2
Reaches the midline one inch to the left of the midline.
Syntopy of the duodenum:
1. Pars superior duodenai;
A. Superiorly; The liver.
B. Antriosuperiorly; GB.
C. Infromedially; The head of the pancreas, ductus choledochus, v. portae, a. et v.
gastroduodenales and v. cava inferioris.
D. Posterior; right kidney and right adrenal gland.
2. Pars descends duodenai;
A. Posteriorly, The superior third of the right kidney, hepatic vessels and the ureter.
B. Posteriorly and laterally; The inferior third of the left kidney.
C. Laterally; Ascending colon.
D. Medially; v. cava inferior and ductus choledochus.
E. Anteriorly and medially; The head of the pancreas.
F. Anteriorly; Transverses colon with its mesentery and loops of the small intestine.
3. Pars horizentalis;
The head of the pancreas (superiorly).
4. Pars ascendens duodenai;
Posteriorly from right to left; The ureter, vasa testicularis (ovirca), the IVC and abdominal aorta.
Skeletopy of the duodenum:
The duodenum projects to L1-L3.
Fig. 105: Syntopy of the duodenum. Source [105].
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5) The spleen:
Surfaces of the spleen:
1The convex, smooth diaphragmatic surface:
Faces superiorly and laterally, although the posterior part may face posteriorly.
Separated from the left pleural costodiaphragmatic recess, lower lobe of the left lung and the tenth
to twelfth left ribs by the underside of the left dome of the diaphragm, therefore, splenic
inflammation or surgery may lead to a left-sided basal pleural effusion and left lower lobe
atelectasis.
2. The irregular visceral surface:
Faces infromedially towards the abdominal cavity and is marked by gastric, renal and colic
impressions.
A) The gastric impression; lies adjacent to the posterior aspect of the fundus, upper body and
upper greater curvature of the stomach. It is separated from the stomach by a peritoneal recess,
limited by the gastrosplenic ligament.
B) The renal impression; separated from the gastric impression above by a ridge of splenic tissue
and the splenic hilum. Related to the upper lateral area of the anterior surface of the left kidney
and sometimes to the superior pole of the left suprarenal gland.
C)The colic impression related to the splenic flexure of the colon and the phrenicocolic ligament.
Poles of the spleen:
The superior pole corresponds to the posterior extremity and usually faces the vertebral column.
The inferior pole is longer and less angulated than the superior pole and connects the
anterosuperior and posteroinferior borders anteriorly; it is related to the colic impression and often
lies adjacent to the splenic flexure and phrenicocolic ligament.
The hilum of the spleen:
It is a long fissure pierced by the splenic vessels, nerves and lymphatics, and lies on the visceral
surface closer to the posteroinferior border
Fig.106: Surfaces, borders and poles of the spleen. Source [106].
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Splenic ligaments:
The superior pole of the spleen is connected to the stomach via the gastrosplenic ligament
(contains the short gastric and superior polar arteries, and the left gastroepiploic artery), and to the
posterior abdominal wall by phrenicosplenic ligament.
The inferior pole of the spleen is connected to the posterior abdominal wall by the splenorenal
ligament (contains the terminal portions of the splenic artery and vein, and the tail of the pancreas)
and to the splenic flexure of the colon by the phrenicocolic ligament.
Fig.107: Splenic ligaments. Source [107].
The splenic artery (8-32 cm in length; caliber 3-12 mm):
Origin:
The coeliac trunk. However, it may originate from the common hepatic artery or the left gastric
artery, or rarely directly from the aorta.
Course:
Runs inferiorly before turning to the left behind the stomach to run horizontally posterior to the
upper border of the body and tail of the pancreas. The splenic artery courses anterior to the left
kidney and left suprarenal gland, and runs in the splenorenal ligament behind or above the tail of
the pancreas.
Branches:
1.Pancreatic branches (dorsal pancreatic, greater pancreatic artery, and arteries to the tail).
2.Short gastric arteries and the left gastroepiploic artery
3.Posterior gastric artery in 40% of individuals.
4.Small retroperitoneal branches.
Terminal branches:
The splenic artery usually divides into two, or occasionally three, branches before entering the
hilum of the spleen. The superior and inferior branches are sometimes known as superior and
inferior polar arteries; as they enter the hilum, they divide into four or five segmental arteries that
each supply a segment of splenic tissue.
Segmental arteries: divide within the splenic trabeculae and give rise to follicular arterioles, which
are surrounded by a thick lymphoid sheath of white pulp.
The superior pole of the spleen; gains an additional arterial supply from the splenic hilar vessels,
from the short gastric arteries in the gastrosplenic ligament.
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Splenic vein:
Origin:
Blood from the parenchyma of the spleen is collected by trabecular veins which join to form
segmental veins which join to form two (superior and inferior) or three (superior, middle and
inferior) lobar veins that emerge from the splenic hilum and unite to form the splenic vein within
the splenorenal ligament.
Course:
The splenic vein runs medially below the splenic artery and posterior to the tail and body of the
pancreas, crosses the posterior abdominal wall anterior to the left kidney, renal hilum and
abdominal aorta, separated from the left sympathetic trunk and left crus of the diaphragm by the
left renal vessels, and from the abdominal aorta by the superior mesenteric artery and left renal
vein.
Tributaries:
Along its course it receives the short gastric veins, left gastroepiploic veins, retroperitoneal veins
(Retzius’s retroperitoneal venous plexus), pancreatic veins, posterior gastric vein, left gastric vein
(occasionally) and the inferior mesenteric vein.
Termination:
It ends posterior to the neck of the pancreas, where it joins the superior mesenteric vein to form
the portal vein.
Fig.108: The splenic artery and vein. Source [108].
Lymphatic drainage:
Begins in the white pulp. Lymphatics travel with the blood vessels towards a lymphatic
subcapsular plexus, which drains via larger lymphatic channels to lymph nodes at the splenic hilum
and around the tail of the pancreas. From here, lymph drains to suprapancreatic, infrapancreatic
and omental lymph nodes, and from there to coeliac nodes and the cisterna chyli.
Innervations:
1.Postganglionic sympathetic nerves from the coeliac plexus (innervate also trabecular arteries,
therefore can influence splenic blood flow).
2.Parasympathetic nerves from the vagal trunks travel with the splenic vessels.
3.Motor innervation of the human splenic capsule is largely vestigial; it contains minimal
quantities of smooth muscle and therefore does not contract.
4. The capsule and parenchyma are innervated by sensory fibers that convey pain.
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