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Great Vessels
What are the branches of the aorta?
enters at T12 via aortic hiatus and bifurcates at level of L4
1) paired inferior phrenics inferior diaphragm & superior portion of adrenal
2) celiac trunk stomach, liver, spleen, GB, duodenum
common hepatic, L gastric, & splenic arteries
- gastroduodenal a. comes off common hepatic, then gives off R gastroepiploic a.
- L gastroepiploic a. comes off splenic artery
3) paired adrenals
4) SMA entire small bowel & majority of colon
communicates with celiac trunk vasculature via pancreaticoduodenal artery
- this can supply liver retrogradely if celiac trunk tied off (trauma)
5) paired renals overlie L2
6) paired gonadals can be ligated due to collaterals (deferential & cremasteric; uterine)
7) IMA distal end of transverse colon, descending, sigmoid, & rectum
can be ligated due to collaterals (SMA, middle hemorrhoidal, inferior hemorrhoidal)
8) 4 paired lumbars posterior body wall & spine
9) middle sacral posterior branch just before bifurcation
supplies rectum & anterior sacrum
What is the course of the gonadal artery?
- male crosses anterior to IVC on right
crosses over ureter and exits retroperitoneum at internal inguinal ring
- female crosses anterior to IVC on right
crosses over ureter moving laterally then crosses back over external iliacs into
pelvis, where it proceeds via suspensory ligament to ovary
Nervous System
What autonomic nerves lie within the retroperitoneum?
- sympathetic
preganglionic fibers originate from T and L spine (T1-L3)
enter retroperitoneum via paired sympathetic chains & lumbar spinal nerves
from sympathetic chain, preganglionic fibers have 3 different courses;
1) travels into autonomic plexuses (splanchnic nerves) where they synapse
with postganglionic fibers
these proceed to the abdo viscera
2) synapses within sympathetic chain, where postganglionic fibers are sent to body
wall & lower extremities
3) travels directly to adrenal medulla, controlling release of catecholamines
- parasympathetics
preganglionic fibers originate from C and S spine
also get input from vagus nerve
travel into aortic autonomic plexuses, where they synapse with postganglionic fibers that
are distributed to the viscera and organs
What are the major autonomic nerve plexuses?
1) celiac } largest plexus; innervates kidney, adrenal, renal pelvis, and ureter
2) superior hypogastric } innervates pelvic urinary and genital tract
} lies on aorta anterior to bifurcation, extending down on anterior surface of L5
3) inferior hypogastric } contiguous with superior hypogastric plexus and extends into pelvis
What somatic nerves lie within the retroperitoneum?
arises from the lumbosacral plexus (T12-L5)
superior branches form within and pierce the psoas inferior branches pass medial to the psoas
- Subcostal (T12) extends laterally beneath 12th rib
- Iliohypogastric (L1) motor to internal oblique & transversus
sensory to posterolateral gluteal skin
- Ilioinguinal (L1) motor to internal oblique & transversus
sensory to upper medial thigh & base of penis/anterior scrotum/mons pubis
- Lateral Cutaneous nerve of thigh (L2-L3) sensory to anterior and lateral thigh to knee
- Genitofemoral (L1-L2) lies directly atop and parallels psoas
motor to cremaster & dartos muscles in scrotum (genital branch only)
sensory to scrotum/mons/labia majora & skin of upper thigh
(genital & femoral branches)
- Femoral (L2-L4) hidden by psoas until it exits abdomen just lateral to femoral artery
motor to psoas, iliacus, and large muscles of anterior thigh (quads)
sensory to anterior thigh & medial leg
can be injured by retractor placed on inguinal ligament (cant extend knee,
numb on anterior thigh)
- Obturator (L2-L4) motor to adductor muscles of thigh (longus, brevis, gracilis, pectineus)
sensory to medial thigh
can be injured during RP pelvic LN dissection (cant adduct leg)
- Sciatic (L4-S3) bodys largest nerve
motor & sensory to legs (common peroneal + tibial)
- Pudendal (S2-S4) branches include inferior rectal, perineal, dorsal penile nerves
THE ADRENALS
Describe the gross anatomy of the adrenal glands
- 3-5cm in adults, weighing about 5g and yellow-gold in colour
- enclosed within Gerotas fascia and separated from the UP of the kidney by a layer of connective tissue
- R more superior & pyramidal in shape; often has a retrocaval wing
- L more inferior & crescentic; lies more medial to upper pole
What is the composition of the adrenal gland?
- embryologically distinct from kidney
- adrenal cortex makes up 90% of adrenal mass and is of mesodermal origin
- zona glomerulosa mineralocorticoids (eg aldosterone)
- zona fasciculate glucocorticoids (eg cortisol) & sex steroids
- zona reticularis sex steroids (eg androgens)
- adrenal medulla is made up of chromaffin cells derived from neural crest origin
- innervated directly by preganglionic sympathetic fibers
- catecholamine release is controlled by sympathetics
What is the blood supply to the adrenals?
- arterial branches from inferior phrenic artery, aorta and renal artery
- venous single vein that exits anteromedially into aorta on R and renal vein on L
What is the lymphatic drainage of the adrenals?
- follows the adrenal vein and empties into the para-aortic nodes
THE KIDNEYS
\
\ can drain psoas/retroperitoneal abscess
/
via Petits triangle
/
Renal Vasculature
Describe the renal pedicle
- at level of L2 vertebra } vein anterior, artery posterior, renal pelvis and ureter most posterior (VAP)
Describe the arterial blood supply of the kidney *** no collaterals end arteries ***
- renal artery } gives off branches (adrenal, renal pelvis, ureter)
- segmental most commonly;
1 posterior (branches before entering hilum, so posterior to renal pelvis)
*** can cause UPJO if crosses anterior to ureter ***
4 anterior (apical, upper, middle, lower/basilar variability)
- lobar
- interlobar (run through columns of Bertin)
- arcuate (run along corticomedullary jxn)
- interlobular
- afferent (to glomerulus) efferent to vasa recta
Describe the venous drainage of the kidney *** ++ collaterals ***
- efferent arteriole to vasa recta
- interlobular (communicate freely via subcapsular plexus)
- arcuate
- interlobar
- lobar
- segmental (parallels segmental arteries } due to collaterals, can be sacrificed)
- renal vein
THE URETERS
Describe the 3 layers of the ureter
- generally 22-30cm, ~5mm in diameter
1) inner layer transitional epithelium overlying lamina propria
2) muscle layer smooth muscle layer contiguous with muscle covering renal calyces & renal pelvis
consists of inner longitudinal & outer circular layer; provides peristalsis
3rd outer smooth muscle layer exists in distal ureter
3) outer layer adventitial layer that encompasses blood vessels & lymphatics that travel along ureter
Describe the course of the ureters?
- begins at UPJ, which lies posterior to renal artery
- travels inferiorly along anterior surface of psoas muscle
- 1/3 of way to bladder, the ureter crosses under the gonadal vessels then crosses over the iliac vessels,
generally marking the bifurcation of common iliacs into internal & external
- in F pelvis, the ureter is crossed anteriorly by the uterine artery & is closely related to cervix
common locations for ureteric injury during gyne OR
- head toward bladder underneath obliterated umbilical artery (branch of internal iliac)
List structures that cross over the ureter in the female
- gonadal vein
- round ligament
- obliterated umbilical artery
- uterine artery
- superior vesical artery
- inferior vesical artery
What are the 3 narrowest parts of the ureter?
1) UPJ
2) crossing over the iliac vessels
3) UVJ narrowest part
Describe the ureteral segments
1) abdominal ureter (UPJ to iliacs) and pelvic ureter (iliacs to UVJ)
2) upper (UPJ to upper border of sacrum), middle (upper to lower border of sacrum) & lower (lower
border of sacrum to bladder)
What is the blood supply to the ureters?
- arterial supply from multiple branches along its course (venous follows arterial)
- MEDIAL supply to abdominal ureter & LATERAL supply to pelvic ureter
- upper renal artery, gonadal artery, aorta, common iliac artery
- lower internal iliac artery or its branches (vesical, uterine, middle rectal, vaginal arteries)
- ureteric arterial vessels travel longitudinally within periureteral adventitia
What is the lymphatic drainage of the ureters?
- abdominal para-aortic for L ureter; right paracaval & inter-aortocaval nodes for R
- pelvic internal, external & common iliac nodes
- upper & renal pelvis joins renal lymphatics