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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
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Peritoneal coverings: The spleen is completely covered by peritoneum expect for the hilum
through which the splenic vessels enter.
Holotopy:
The spleen projects into the epigastrium in the left hypochondriac region.
Syntopy:
1. Externally; Costal part of the diaphragm.
2. Frontally; Posterior and lateral surface of the fundus of the stomach.
3.Posteriolry and Inferiorly;
Lumbar part of the diaphragm and the superior pole of the left kidney and adrenal
4. Anteriorly and inferiorly;
1. Flexura coli sinistra.
2. The tail of the pancreas.
Skeletopy of the spleen:
Fig. 109: Syntopy of the spleen. Source [109].
9th – 11th rib along the axillary lines.
Fig. 110: Skeletopy of the spleen. Source [110].
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6) The pancreas:
Parts:
1.HEAD:
It is the thickest and broadest part of the pancreas is flattened in the anteroposterior plane, adjacent
to superior and inferior pancreaticoduodenal arteries.
Posteriorly, the common bile duct is partially embedded within the head of the gland just proximal
to where it joins the pancreatic duct near the major duodenal papilla.
Fig.111: The parts of the pancreas. Source [111].
2.NECK:
Defined as that part of the pancreas lying anterior to the formation of the portal vein in the
transpyloric plane.
The superior mesenteric vein and portal vein groove the posterior aspect of the neck.
The anterior superior pancreaticoduodenal branch of the gastroduodenal artery descends in front
of the gland at the junction of the head and neck.
3.BODY:
The body of the pancreas has anterior and posterior surfaces and superior and inferior borders.
Anterior surface:
The two layers of the transverse mesocolon diverge along this surface.
Above the attachment of the transverse mesocolon, the anterior surface of the pancreas is
separated from the stomach by the lesser sac. Inferiorly, it lies within the infracolic compartment.
Posterior surface:
It lies on fascia (the fusion fascia of Toldt).
The splenic vein runs from left to right directly on this surface of the gland and indents the
parenchyma.
Superior border:
An omental tuberosity usually projects from the right end of the superior border above the level of
the lesser curvature of the stomach.
Inferior border:
Laterally, the inferior mesenteric vein runs behind the inferior border to join the splenic vein or
the confluence of the splenic and superior mesenteric veins. This is a useful site for identification
of the inferior mesenteric vein on computed tomographic (CT) imaging and during left-sided
colonic resections.
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Fig.112: Surfaces and borders of the pancreas. Source [112].
4.TAIL:
It may terminate at the base of the splenorenal ligament or extend up to the splenic hilum, when it
is at risk of injury at splenectomy during ligation or stapling of the splenic vessels. The splenic
artery and its branches, and the splenic vein and its tributaries, lie posterior to the tail.
UNCINATE PROCESS:
The uncinate process is a hook-shaped continuation of the inferomedial part of the head of the
gland. The superior mesenteric vein and the superior mesenteric artery descend on its anterior
surface before running forwards into the root of the mesentery of the small intestine.
Fig.113: The uncinate process. Source [113].
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PANCREATIC DUCTS:
A) The main pancreatic duct (of Wirsung):
Origin:
It is formed by the junction of several lobular (secondary) ducts in the tail and increases in caliber
within the body of the gland as it receives further lobular ducts that join it almost at right angles
to its axis, forming a ‘herringbone pattern’.
Course:
Runs within the substance of the gland from left to right, lies midway between the superior and
inferior borders of the pancreas towards the posterior surface of the gland.
Termination:
As it reaches the neck of the gland, it turns inferiorly and posteriorly towards the bile duct, which
lies on its right side. The two ducts unite to form a short common channel, which enters the wall
of the descending part of the duodenum obliquely; it may contain a dilation known as the
hepatopancreatic ampulla of Vater.
B) The accessory (dorsal) pancreatic duct (of Santorini):
Origin:
Formed within the substance of the head from several lobular ducts, drains the upper part of the
anterior portion of the pancreatic head.
Course:
Communicates with the main pancreatic duct near the neck of the gland.
Termination:
The accessory duct usually opens on to a small, rounded minor duodenal papilla, which lies
about 2 cm proximal to the major papilla.
Fig.114: Pancreatic ducts. Source [114].
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Blood supply of the pancreas:
A) Arterial supply:
1.The head and adjoining duodenum are supplied mainly by four arteries:
A) Two from the coeliac trunk via the gastroduodenal artery:
1) Anterior superior pancreaticoduodenal artery:
Origin: Arises as the smaller terminal branch of the gastroduodenal artery, together with the
right gastroepiploic artery.
Course: It originates behind the first part of the duodenum and runs inferiorly on the anterior aspect
of the pancreatic head medial to the groove between the descending duodenum and pancreatic
head. It passes inferiorly around the right or inferior border of the pancreatic head, often piercing
the gland to reach the posterior surface of the uncinate process, where it joins the anterior inferior
pancreaticoduodenal artery to form the anterior pancreaticoduodenal arcade.
2) Posterior superior pancreaticoduodenal artery:
Origin: arises as the first branch of the gastroduodenal artery at the superior edge of the first
part of the duodenum.
Course: It runs to the right, anterior to the supraduodenal portion of the bile duct, before spiraling
posteriorly around the CBD and descending on the posterior surface of the pancreatic head.
Branches:
1.To the duodenum.
2.To the head of the pancreas, and bile duct before anastomosing with the posterior inferior
pancreaticoduodenal artery to form the posterior pancreaticoduodenal arcade.
3.Retroduodenal and supraduodenal arteries, which supply the duodenum.
B) Two from the superior mesenteric artery via the inferior pancreaticoduodenal artery:
1, Inferior pancreaticoduodenal artery:
Origin: Arises either directly from the superior mesenteric artery at the inferior border of the
pancreas or as a common vessel with the first jejunal artery from the posterior or left aspect of the
superior mesenteric artery.
Course: It runs to the right, posterior to the superior mesenteric vein, to reach the posterior surface
of the uncinate process, where it divides into anterior and posterior inferior pancreaticoduodenal
arteries.
A. The smaller anterior inferior pancreaticoduodenal artery; runs to the right on the posterior
surface of the uncinate process to join the anterior superior pancreaticoduodenal artery and form
the anterior pancreaticoduodenal arcade.
B. The larger posterior inferior pancreaticoduodenal artery; runs on the posterior surface of
the head of the pancreas, parallel and superior to the anterior inferior pancreaticoduodenal artery.
It joins the posterior superior pancreaticoduodenal artery to form the posterior
pancreaticoduodenal arcade.
2.The body and tail of the pancreas: are supplied by multiple branches from the splenic artery,
including the dorsal pancreatic artery.
3.The superior and inferior borders of the pancreas: Runs small arteries, lying in a deep groove
or within the parenchyma. They are fed along their length by the pancreaticoduodenal and splenic
arteries.
4.Communicating arteries: Multiple small arteries run between the anterior and posterior
pancreaticoduodenal arcades. The largest and most consistent of these is the communicating artery
(sometimes known as the middle pancreaticoduodenal arcade), which passes between the main
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and accessory pancreatic ducts and connects the anterior pancreaticoduodenal arterial arcade and
the posterior superior pancreaticoduodenal artery. This artery gives rise to the majority of small
arteries that supply the major duodenal papilla.
5.Other arterial arcades in the head of the pancreas:
1.Kirk’s arcade; is formed by a right branch of the dorsal pancreatic artery that emerges on to the
anterior surface of the head of the gland and anastomoses with a branch of either the
gastroduodenal or the anterior pancreaticoduodenal arcade, supplies the ventral surface of the head
and neck of the pancreas.
2.Splenic artery; arises from the coeliac trunk and runs behind the superior border of the pancreas
to the splenic hilum, gives multiple small branches along its course that penetrate and supply the
pancreatic parenchyma.
3.Dorsal pancreatic artery; arises from the initial 2 cm of the splenic artery, although it may take
origin from the common hepatic or superior mesenteric artery or the coeliac trunk, gives off
numerous branches, including a terminal left branch near the inferior border of the gland. Several
right-sided branches run to the head of the pancreas which anastomose with arteries of the
pancreaticoduodenal arcade
4.Transverse pancreatic artery (inferior pancreatic artery);
Origin:
From the left terminal branch of the dorsal pancreatic artery.
Course:
It runs to the left on the posterior surface of the gland close to its inferior border.
Branches:
Gives multiple branches to the body and tail, and anastomoses with other pancreatic branches of
the splenic artery.
Fig.115: Arterial supply of the pancreas. Source [115].
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B) Venous drainage:
1.The anterior superior pancreaticoduodenal vein; joins either the confluence of the right
gastroepiploic and right colic
veins (the gastrocolic trunk of Henle) or the right gastroepiploic vein
alone, to drain into the superior mesenteric vein at the inferior border of the neck of the pancreas
2.The posterior superior pancreaticoduodenal vein; drains cranially into the portal vein.
3.Veins from the body and tail of the pancreas; drain directly into the splenic vein.
4.A transverse (or inferior) pancreatic vein; may be present, running along the inferior border
of the pancreas to join the inferior mesenteric vein.
5.A few pancreatic veins; communicate with systemic veins in the retroperitoneum (veins of
Retzius’s); these may form retroperitoneal varices in portal hypertension.
Fig.116: Venous drainage of the pancreas. Source [116].
Lymphatic drainage:
1.Lymphatics from the tail and body drain into nodes along the splenic artery and inferior border
of the gland to pre-aortic nodes between the coeliac trunk and superior mesenteric artery.
2.Lymphatics from the neck and head drain into nodes along the pancreaticoduodenal, superior
mesenteric and hepatic arteries, into pre-aortic nodes.
Fig.117: lymphatics of the pancreas. Source [117].
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Innervation:
1.Parasympathetic afferents convey sensory information from pancreatic ducts, acini and islets via
the vagus nerve.
2.Preganglionic vagal efferents reach the pancreas via hepatic, gastric and coeliac branches of the
nerve. They synapse with postganglionic parasympathetic pancreatic neurones.
3.Pancreatic ganglia are most abundant in the head and neck, containing cholinergic, nitrergic,
peptidergic and dopaminergic neurons, modulating both exocrine and endocrine secretion.
4.Visceral afferents transmit pain and other sensory information to cell bodies in the sixth to
twelfth thoracic dorsal root ganglia via the coeliac plexus and thoracic splanchnic nerves.
5.Postganglionic sympathetic nerves innervate the blood vessels, ganglia and ducts within the
pancreas, causing vasoconstriction and inhibiting exocrine secretion.
Fig.118: Innervations of the pancreas. Source [118].
Peritoneal coverings:
The pancreas is a retroperitoneal organ expect for the tail, which is intraperitoneal (covered by
peritoneal from anterior and inferior surface but deficient posteriorly).
Holotopy:
The pancreas projects into the Epigastric, umbilical, paraumbilical and left hypochondriac
regions.
The superior border; extending from left to right through the middle of the distance between the
xiphoid process (T10) and the umbilicus(L4). (L1-L2).
Skeletopy: T12-L2.
Head of the pancreas; L2
Body of the pancreas; L1
Tail of the pancreas; T12
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Syntopy:
1.The duodenum envelopes the head of the pancreas superiorly, externally and inferiorly.
2.Posteriorly to the head; IVC, ductus choledochus, a et v. mesentrica superior.
Fig. 119: Syntopy of the pancreas. Source [119].
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(II) Lower abdominal floor organs:
Bounded from above the transverse colon and its mesentery and from below by the pelvic inlet.
1. Lower half of the duodenum.
2. Jejunum.
3. Ileum.
4. Vermiform appendix.
5. The colon.
1.The jejunum:
Has an external diameter of about 4 cm and an internal diameter of about 3 cm.
It has a thicker wall than the ileum and a rich arterial blood supply.
The plicae circulares are most pronounced in the proximal jejunum, where they are more numerous
and deeper than elsewhere in the small bowel.
They frequently branch around the lumen and stacked on top of each other, giving the jejunum a
characteristic appearance during single contrast radiography, computed tomographic (CT),
magnetic resonance (MR) and capsule endoscopy.
Fig.120: Plicae circulares. Source [120].
CLINICAL NOTE: (JEJUNAL FEEDING)
x Definition:
It is a maneuver of enteral feeding done for patients with a functioning intestine who cannot
tolerate adequate oral or intragastric feeding.
x Indications:
1.Prolonged anorexia.
2.Severe protein-energy undernutrition.
3.Coma or depressed sensorium.
4.Liver failure.
5.Inability to take oral feedings due to head or neck trauma.
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