1 Department of Anatomy Digestive system – Part II MUDr. Marek Joukal, Ph.D. SMALL INTESTINE 3–5 m, intestinal loops DUODENUM JEJUNUM ILEUM SMALL INTESTINE DUODENUM Pars superior (ampulla, bulbus duodeni) Flexura duodeni sup. Pars descendens Flexura duodeni inf. Pars horizontalis Pars dextra et sinistra Pars ascendens Flexura duodenojejunalis 12 inches (25-30 cm)-Herofilos, makes a loop around L2 Plica longitudinalis duodeni Papilla duodeni major (Vateri) ampulla hepatopancreatica (m. sphincter papillae hepatopancreaticae, m. sphincter Oddi) ductus choledochus (m. sphincter ductus choledochi) ductus pancreaticus major (m. sphicter ductus pancreatici) Papilla duodeni minor ductus pancreaticus accessorius Pars sup. duodeni - intraperitoneally (lig. hepatoduonenale) Other parts - secondary retroperitoneally JEJUNOILEUM Ansae intestinales Mesenterium Radix mesenterii (12-15 cm) Flexura duodenojejunalis Ostium ileocaecale 2 Morphology of the jejunoiluem Mucous membrane: Plicae circulares Villi intestinales Gll. Intestinales Succus entericus Folliculi lymphatici Submucosal tissue Tissue fibres, neurovascular bundle Muscular layer Str. longitudinale, circulare Serosa (intraperitoneally) Diverticulum ilei - Meckeli 0,5 – 1m from the ostium iliocaecale (ductus omphaloentericus = yolk stalk) JEJUNUM ILEUM Upper left part of inframesocolic space Lower right part of inframesocolic space wider (3- 4 cm), 2/5 of length narrower (2- 3 cm), 3/5 of length Numerous circular folds Less circular folds 1- 2 arterial arcades 2- 3 arterial arcades folliculi lymphatici solitarii folliculi lymphatici aggregati Large interstine intestinum caecum colon ascendens flexura coli dextra (hepatica) colon transversum flexura coli sinistra (lienalis) colon descendens colon sigmoideum rectum Plicae semilunares Haustra coli Taenia mesocolica Taenia omentalis Taenia libera Appendices epiploicae Gll. Intestinales Folliculi lymphatici 3 INTESTINUM CAECUM Ostium ileocaecale Appendix vermiformis Mesoappendix Recessus retrocaecalis Ostium ileocaecale Valva ileocaecalis Appendix vermiformis Tonsilla abdominalis Positio pelvina (lig. appendiculoovaricum) Positio retrocaecalis Positio ileocaecalis Positio praecaecalis Positio laterocaecalis Positio subcaecalis APPENDIX VERMIFORMIS - POSITION Monroe´s line (linea spinoumbilicalis dextra) – Mac Burney´s point Linea bispinalis – Lanz´s point COLON ASCENDENS Flexura coli dextra (hepatica) cartilage of 10th – 11th rib impressio colica (lobus hepaticus dx.) secondary retroperitoneally COLON TRANSVERSUM Flexura coli sinistra (lienalis) cartilage of 8th – 9th rib impressio colica (facies visceralis lienis) lig. phrenicocolicum Mesocolon transversum Omentum majus lig. gastrocolicum 4 COLON DESCENDENS, SIGMOIDEUM Mesosigmoideum Recessus intersigmoideus RECTUM flexura sacralis flexura perinealis ampulla recti canalis analis linea anorectalis Plicae transversae Plica transversa media (Kohlrausch) 6 - 7cm Columnae anales Sinus anales Valvulae anales Zona haemorrhoidalis Pecten analis Linea anocutanea (zona intermedia) Zona cutanea RECTUM Plexus venosus rectalis (corpus cavernosum recti) Musculus sphincter ani internus Musculus sphincter ani externus Excavatio rectovesicalis Excavatio rectouterina Liver (HEPAR) 5 FACIES DIAPHRAGMATICA HEPATIS Pars superior Pars anterior Pars posterior (area nuda) Margo inferior lig. falciforme hepatis lig. teres hepatis appendix fibrosa hepatis lig. triangulare dx. et sin. lig. coronarium FACIES VISCERALIS HEPATIS Fissura sagittalis sin. lig. teres hepatis lig. venosum Fissura sagittalis dx. fossa vesicae biliaris sulcus v. cavae inf. Porta hepatis vena portae a. hepatica propria (plexus hepaticus) ductus hepaticus communis Lobus sinister tuber omentale Lobus dexter Lobus caudatus Lobus quadratus impressio oesophagea impressio gastrica impressio duodenalis impressio colica impressio renalis impressio suprarenalis Lobulus venae centralis (lobulus hepatis) arteriae interlobulares (a. hepatica propria) venae interlobulares (z vena portae) ductus biliferi interlobulares Lobulus venae interlobularis Ductus hepaticus dexter et sinister Ductus choledochus Ductus hepaticus communis Ductus cysticus EXTRAHEPATAL BILIARY PATHWAY Vesica fellea (biliaris) 6 Gallbladder fundus ductus cysticuscorpus infundibulum collum plica spiralis DUCTUS CHOLEDOCHUS FUNCTIONAL AND NUTRITIVE BLOOD SUPPLY 8 Projection of the gallbladder and liver PANCREAS Caput pancreatis incisura pancreatis processus uncinatus Corpus pancreatis facies ant., post., inf. margo ant., sup., inf. Cauda pancreatis Serous tuboalveolar gland Succus pancreaticus Capsula pancreatis Septa Lobi et lobuli pancreatis Intra- a interlobar ducts Ductus pancreaticus acces. Papilla duodeni minor Ductus pancreaticus Papilla duodeni major PARS EXOCRINA PANCREATIS 7 Insulae pancreaticae – Islets of Langerhans Insulin, glukagon PARS ENDOCRINA PANCREATIS Point of Desjardin (6 cm from navel) SPLEEN (LIEN) Supramesocolic part of perironel cavity Storage of blood Erythrocyte degradation Production of lymphocytes Hematopoesis (children) extremitas anterior extremitas posterior facies diaphragmatica facies visceralis hilum lienis margo superior (acutus) crenae lienis margo inferior (obtusus) facies colica facies gastrica facies renalis Linea costoarticularis 8 Peritoneum parietale et viscerale (mesenterium) P – cavitas peritonealis (liguor peritonei) A – spatium praeperitoneale R – spatium retroperitoneale S – spatium subperitoneale (infra-) S PERITONEUM INTRAPERITONEAL ORGANS liver, spleen, stomach pars superior duodeni, jejunum, ileum appendix colon transversum, colon sigmoideum Fixed on the folds RETROPERITONEAL ORGANS Primary retroperitoneal (kidney, suprarenal glands, genital glands) Secondary retroperitoneal: Duodenum (except pars sup.) Pancreas Caecum Colon ascendens Colon descendens Excavatio rectovesicalis Excavatio rectouterina SUBPERITONEAL ORGANS Rectum PERITONEAL FOLDS OF STOMACH Omentum minus lig. hepatoduodenale lig. hepatogastricum lig.hepatooesophageum Omentum majus lig. gastrocolicum Lig. gastrolienale (lig. gastrosplenicum) Omentum majus Lig. gastrocolicum 9 MESOCOLON TRANSVERSUM pars supramesocolica et inframesocolica MESENTERIUM radix mesenterii Pars inframesocolica dextra et sinistra MESOSIGMOIDEUM S3 BURSA OMENTALIS lig. hepatoduodenale plica hepatorenalis lobus quadratus bulbus duodeni Foramen epiploicum (omentale) Recessus duodenales Recessus duodenalis superior Recessus duodenalis inferior Recessus duodenalis sinister (venosus, paraduodenalis) Recessus retroduodenalis (m. suspensorius duodeni) 10 Recessus ileocaecalis superior Recessus ileocaecalis inferior Recessus retrocaecalis Recessus paracolici Recessus intersigmoideus References: Putz, R. (2008): Atlas of Human Anatomy Sobotta. Elsevier Books. Keith L. Moore, Arthur F. Dalley (2005): Clinically Oriented Anatomy. Williams and Wilkins. Platzer, W., Kahle, W., Leonhardt H. (1992): Locomotor system. Georg Thieme Verlag, Stuttgart, New York, 4th edition. Čihák, R. (1987): Anatomie 1. Avicenum, Zdravotnické nakladatelství. Netter, F. H. (1997): Interactive Atlas of Clinical Anatomy. Novartis, USA.