Anatomy Part 3/4 Full NOTES

Liver: largest gland (4 lobes; 1.5-1.7kg) in R Hypochondriac, Epigastric, and some L Hypochondriac (receives everything absorbed from gut except lipids) Borders: Superior (ICS 4) and Inferior (711) Glisson’s Capsule: thick (thickest @ hilum) protective CT around liver/portal (surrounded by serous visceral peritoneumdynamic); gives off trabeculae lobes/lobules (incomplete in male) Porta Hepatis: accepts portal triad (HPV, HA, BD) which branches together down to sinusoids Lesser Omentum: hepatogastric + hepatoduodenal (Ant. border of Winslow : Portal Triad in R free margin) o Epiploic Foramen (of Winslow): greater lesser sac (bursa); o Pringle Maneuver: pinch off hepatoduodenal ligament  rapidly stems blood loss/bile leakage (may affect hepatocyte metabolism)  Aberrant R/L Hepatic Artery: from L Gastric or SMA (does not pass through hepatoduodenal ligament) ineffective Pringle  From L Gastric: careful in stomach cancer resection (liver dysfunction / bleeding) o Posterior Gastic/Duodenal Perforation: compromises bursa structures Crush Trauma: fractured ribs or xiphoid  perforation Falciform Ligament: suspends from ant. wall & diaphtragm (divides left lobe into M/L) o Round Ligament (of Teres): remnant of L umbilical vein (obliterated fetal liver bypass for 02 bood to IVC as Ductus Venosum posteriorly)  Ligamentum Venosum posteriorly o Subphrenic Recess: divided L/R by falciform; continuous w/Morrisson anteriorly Bare Area: direct diaphragmatic (capsule but no peritoneum); bound by ant/post coronary ligaments and L/R triangular ligaments (hold liver in place) o Metastatic Portal: (to thorax) via small lymphatics/veins  bronchomediastinal trunk neck root (enlargement of supraclavicular/pre-scalene nodes) IVC trough (GB ant.): L/R lobes Caudate Lobe: (posterior) independent filtration/blood supply; contains both L/R HA and HV and bile to both L/R BD (caution not to tear – bleed out); btw IVC and Lig. Venosum Quadrate Lobe: (anterior) functionally tied to L lobe; btw GB and Teres / ant. margin and porta hepatis; bile L/R ducts Hepatorenal Recess (Pouch of Morrison): most inferior when supine  fluid accumulation Segmentation: based on triad distribution; allows partial resection (down to 1/3 still fxns) o Hepatic Plexus: largest celiac plexus derivative Innervation: via arterial hwy; Vagal and Symp Trunk Celiac Plexus follow celiac branches  liver/gullbladder/pancreas Central Celiac Nodes (+ proper hepatic/cystic): metastatic traffic indicators (enlargement) btw liver capsule and pancreatic head (virulent) Portal HTN: cirrhosis/blockage esophageal/rectal (hemorrhoid)/abdominal (caput medusa) varices o Portal/Caval Graft: (direct s-s / e-e or central splenorenal) temporary life extension for transplant wait  questionable bloodrenal filtrates Hepatitis: inflammation (usually viral) Cirrhosis: chronic inflammation (from chronic hepatitis or alcoholism) Microanatomy: hepatocytes in hexagon w/central vein that receives percolation from triads in sinusoids (macrophages); bilecanaliculie Gallbladder: bile storage + dehydration↑concentration; neck (2⁰duo)/fundus/body (fossa btw lobes @ TC / sup. Duodenum) Bile: alkaline solution of bile salts (from chol)/pigments (bilirubin from heme), cholesterol, neutral fats, phospholipids, and electrolytes Wall: mucosa / Fibromuscular (enteroendocrine-cholecystokinin responsive smooth + ACT) / perimuscular CT (BV/N/L) / thick CT + serosa Hepatocystic Triangle (of Calot): contains Mascagni’s Lymph Node (enlarged due to cholecystitis) o Borders: common hepatic duct (med.), cystic duct (inf.), and cystic artery (sup.) o Caution: may sever structures ( or aberrant R hepatic)  bleeding/bile leakage o Aberrance: cystic + ant/post branches may arise from SMA or Left Hepatic Gallstones: 80% cholesterol / 20% bilirubin (pigments) o 4Fs: Fat, Female, Fertile, Forty o Hartman’s Pouch: outpouching @ neck (may block GB); may ulcerate into TC or duodenum (Ileocecal o Cholecystitis: right shoulder referred pain (C5) + upper R quadrant (T5/6 in greater splanchnic) o Palpation: @ right hypochondriac at jxn of linea semilunaris and costal margin Innervation: (along arterial hwy) splanchnic (symp) and vagus (para) Duodenal Relationships: neck (1st), body (2nd), fundus (TC) o Duct System: hepatic + cystic (spiral)common bile duct >>> + Duct of Wirsung (insulin + amylase)Ampulla of VaterMajor Duodenal Ampulla (@ sphincter of Oddi) o Biliary Blockage: Liver dysfxn, Jaundice (Bilirubenemia), Steatorrhea (no ADEK uptake), Bilirubin Urea (Bilirubinemiakidney filter), and Pruritus (itching) Pancreas: endo/exocrine; dorsal/ventral developmentallyduodenal rotationmerger; thin CT capsule w/septa (interlobular ducts)lobules Head/Uncinate: nestled in duodenum curve (↑dual BS); uncinate is behind SMA Neck/Body/Tail: fed via anastomosing dorsal and greater pancreatic arteries (from inf. pancreatic via splenic) Lymphatics: SMN, Cel N, Pyloric Nod  Metastatic Variance Tumors: @ head HPV + SMA + BD + duod : @ neck SMV/SV jxn to HPV : @ body/tail  Splenic Vessels Splenic Artery/Vein: post/sup spleen; convoluted artery / straight distensible vein (occlusion) Hilum: highly vascular (important in splenectomy) Annular Pancreas: split ventral bud (head/unc.)wraps/constricts duodenumabsence or obstruction (vomiting) o Polyhydramnios: baby can’t swallow amniotic fluidtoo much amniotic fluid Islets of Langerhans: B-insulin, glucagon, somatostatin (more in tail) Acinar Cells: enzyme secretion (storage in granules as proenzymes); activation  acute pancreatitis Ducts of Wirsung (mainmaj ampulla – mp of 2nd) + Santorini (accessorymin ampulla – 2cm above) PP Cells: pancreatic polypeptide Spleen: r>w; fed by splenic artery (4 branches @ hilum); w/weak capsule (ribperforationsplenectomy) 1 x 3 x 5 in… 7oz…. ribs 9-11 Ligaments: (@ pedicle btw spleen and pancreatic tail) must be ligated during splenectomy o Gastrosplenic: (greater omentum)GC of stomach; contains short gastric and gastroepiploic arteries o Colosplenic: o Splenorenal: (greater omentum) kidney; splenic vessels o Phrenocolic: Splenomegaly: due to lymph diseases (palpable at left hypochondria) Terminal End Arteries: divide into segments (partial splenectomy) Kidney: retroperitoneal blood ultrafiltration and metabolic control (12 fetal lobules fuse by adulthood) L Kidney (ICS 11) [slightly longer/narrower] v. R Kidney (12th rib-L3) Cortex: (outer) nephrons [glomerulus, bowman’s capsule, PCT/DCT)  renal columns Medulla: (inner) drainage [henle] renal sinuses (slits) o Pyramids: 10-18; apexcollecting duct opening Calyces: minor (8-9)major (3)  pelvis (expanded ureter @ hilum) Sinus: fat-filled concavity at medial hilum border Renal Vessels: hilumterminal/segmental branches (Ant./Pos./Sup./Inf. - to pelvis)  o Interlobar  Arcuate  Interlobular  aff arterioles  glomerulus caps eff arteriole peritubular caps/vasa rectainterlobular varcuate vinterlobar vrenal veinIVC o Capsular o Pelvic o Ureteric

Nutcracker: SMA distention  L Renal Vein impingement  throbbing pain, haematuria (rupture of congested renal veins) , pampiniform varicocoele SMA Syndrome: impingement of duodenum Suprarenal Arteries: inf. (renal), middle (aorta), sup. (inf. phrenic) Ureter: ( ID via squeeze  contraction) opportunistic blood supply (kidneys, gonadal, aorta, common Iliac, Internal Iliac) o Right: medial to IVC (crosses over R Colic and Ileocolic aa) o Left: lateral to Aorta (crosses over L Colic and Sigmoid Colon) o 90⁰ Drop: @ linea terminalis  bladder o Trigone: post. entrance to blatter Surfaces: rests on QL, Psoas, Diaphragm, Trans Colon Non-metabolic Fat: capsule / perirenal fat / renal fascia (of Gerota) / pararenal fat o Bulimia/Dietary Disorders: sunken eyes and lower back depressions Renal Plexus: Aorticorenal ganglia  mix of symp/para fibers renal plexus (mostly symp) Kidney Stones: crystalized (Ca, oxalate, P03, urea, cysteine) masses  irritation, bleeding (haemeturia), and obstruction  vomiting/nausea, urinary frequency/urgency, pain o Common Locations: @ Pelvis (kidney-ureter), 90⁰ bend, and Tragone region of bladder o Hydronephrosis: fluid-filled enlargement of renal pelvis/calyces o Stag Horn: filling pelvis + calyces (requires ultrasound) Renal Agenesis: renal bud fails to attach to ureters and develop (bilateral = life threatening) o Potter’s Sequence: ↓urine oligohydramnios (