6-4

Posterior Abdominal Wall and the Diaphragm

Disclaimer: There is extra detail here for completions sake. Theyre in the notes section.

Summary
Diaphragm and things relating to it Muscles of the posterior abdominal wall Neurovascular supply to abdominal cavity
Arterial supply Spinal nerves, sympathetics and visceral plexuses Venous return

Suprarenal glands
Kidney

Diaphragm
Fact sheet
Innervation
Phrenic n. (C3-5)
C3,4,5 keeps the diaphragm alive

Action
Chief muscle of inspiration
Contraction causes diaphragm to flatten downwards, expanding thoracic cavity. Compresses the abdominal cavity.

Blood supply
Thoracic aorta
Superior phrenic a.

Internal thoracic a.
Musculophrenic a. Pericardiophrenic a.

Abdominal aorta
Inferior phrenic a.

Diaphragm
Things to ID
Central tendon Median, medial and lateral arcuate ligaments Vertebrocostal trigones Right crus Left crus

Trigones
The vertebrocostal trigones:
Synonyms
Lumbocostal triangle of the diaphragm Bochdalek gap

What is it?
A triangular area in the diaphragm near the lateral arcuate ligament, devoid of muscle fibers, and covered by pleuraabove and by peritoneum below.

Significance?
Potential site of diaphragmatic herniation involving abdominal viscera

Diaphragmatic apertures
Caval opening T8
Location
Found in central tendon Inferior vena cava Right phrenic nerve vena cava = 8 letters

Contents

Mnemonic

Esophageal hiatus T10

Location
Musculature of right crus Esophagus Anterior and Posterior Vagal trunks - CN X (Vagus nn.) Esophageal branches of left gastric a. & v. Oesophagus = 10 letters

Contents

Mnemonic

Aortic hiatus T12

Location
Between the 2 crura of the diaphragm and posterior to median arcuate ligament, left of midline Aorta Thoracic duct Azygos vein Aortic hiatus = 12 letters

Contents

Mnemonic

Note: Splanchnic nerves under the lesser apertures of the crus. Sympathetic trunk behind medial lumbocostal arches

Diaphragm
Quiz
Describe the neurovascular supply to the diaphragm. What vessels give rise to the vessels supplying the diaphragm? What is its action? What passes through its apertures?

Muscles of the posterior abdominal wall

Muscles
Quadratus lumborum Iliacus Psoas major Psoas minor

Muscles
Fracture of the lesser trochanter would greatly impair what action? What is the action of quadatrus lumborum? What is the innervation of quadratus lumborum?

Major branches of the abdominal aorta

Singular arteries
1. 2. 3. 4. Celiac trunk (foregut) SMA (midgut) IMA (hindgut) Median sacral artery
Posterior branch

Paired arteries
Inferior phrenic arteries (diaphragm) Middle suprarenal arteries (adrenal glands) Renal arteries (kidneys) Lumbar arteries (posterior abdominal wall and spinal cord) Common iliac arteries

Vessels off of the abdominal aorta summary

ANS plexuses found in the abdomen

Intermesenteric plexus
Location
Between SMA and IMA

Functional component
Sympathetic GVA Pain from descending colon, sigmoid colon and rectum (does not carry parasympathetic GVA)

Superior hypogastric plexus

Functional component
Sympathetic GVA from pelvis (pain sensation)

Clinical correlate
A nerve block here can diminish pelvic pain

Sympathetic splanchnic nerves

Greater splanchnic: T5-T9
Associated with celiac ganglion

Lesser Splanchnic: T10-T11

Associated with superior mesenteric ganglia

Least Splanchnic: T12

Associated with renal ganglia

Lumbar splanchnic: L1-L2

Associated with inferior mesenteric plexus
What should you notice about the sympathetic ganglias names?

SUMMARY OF MAJOR DIVISIONS OF GI TRACT

REGION STRUCTURES BLOOD SUPPLY AUTONOMIC INNERVATION Greater Splanchnic Nerve (T5-9) Vagus

Foregut

stomach, first and second part of duodenum, liver, gall bladder, spleen, 1/2 head plus body and tail of pancreas remainder of duodenum and pancreas, jejunum, ileum, cecum, appendix, ascending colon, 2/3 of transverse colon 1/3 of transverse colon, descending and sigmoid colons, rectum, upper1/2 anal canal

Celiac Artery

Midgut

Superior Mesenteric Artery

Lesser Splanchnic Nerve (T10-11) Vagus

Hindgut

Inferior Mesenteric Artery

Lumbar Splanchnic Nerves (L1-2) Pelvic Splanchnic Nerves (S2-4)

Nervous system lumbar plexus

Subcostal n.: T12 Iliohypogastric and ilioinguinal nn.: L1 Genitofemoral n.: L1-L2 Lateral femoral cutaneous n: L2-L3 Femoral n.: L2-4 Obturator nerve: L2-4 Lumbosacral trunk: L4L5

Lumbosacral plexus relationships

Ilioinguinal n. courses along pelvic brim Lateral femoral cutaneous n. courses along iliac fossa Femoral n. dives between the iliacus and psoas major Genitofemoral n. lies on top of the psoas major

Venous system
IVC: Formed by the union of common iliac veins Azygos v. = right subcostal + ascending lumbar veins. Testicular/ovarian vv.:
Right: joins IVC directly Left: joins left renal vein

Venous system relationships

Notice left renal vein crosses between the abdominal aorta and SMA.
Nutcracker syndrome

Right kidney lower than left

Liver pushes right kidney down

IVC is right-posterior to aorta

Lymphatics
Cisternae chyli
Beginning of thoracic duct, which starts in thorax What does the thoracic duct drain? Why? Right lymphatic duct?

Lumbar lymph nodes

Youre looking at them

Kidneys
Function:
Excretory system to maintain fluid concentrations

Fascia:
Invested by renal capsule and surrounded by renal fascia

Levels:
T12-L3

Anterior relationships:
Right kidney liver, duodenum,

ascending colon
Left kidney stomach, spleen, pancreas, jejunum, descending colon.

Hilum:
Contents
Renal artery, vein and ureter Superior to most inferior, respectively Ureter is most anterior

Relationship

Kidneys
Kidneys are the most posterior viscera
Notice the ureters cross over the common iliac artery at its division into the external iliac and internal iliac aa. (most infero-anterior)

Bladder is the most anterior viscera found in its area.

Uterus lies behind it.

Kidney cross section

Structures Relationship in hilum
Renal artery is superoposterior Renal Vein is in medialanterior Ureter is inferior most structure

How can this be used?

If shown a coronal section of the kidney and asked to side it, able to side based on this relationship.

Adrenal glands
Structure:

Invested in renal capsule and fascia. Is in contact with the diaphragm. Contains a hilum
Veins and lymphatics exit Arteries and nerves enter

Divided into cortex and medulla Cortex

Cortisol Androgens Aldosterone Adrenaline/epinephrine Noradrenaline (NE)

Function: production of stress hormones

Medulla

Appearance: looks like fat on top of the kidneys. Its not. Relationships
Superior to kidneys Right adrenal gland lateral to IVC; left adrenal gland lateral to abdominal aorta At level T12 (just inferior to diaphragm) Inferior phrenic a Superior suprarenal artery Abdominal aorta middle suprarenal artery Renal a. inferior suprarenal artery

Arterial supply

Why the extensive blood supply?