Projection of the duodenum onto the anterior abdominal wall. What areas is the abdomen usually divided into?

Division into areas

ANTEROLETAL WALL OF THE ABDOMINAL

TOPOGRAPHIC ANATOMY OF THE ANTERIOR ABDOMINAL WALL. HERNIA SURGERY

Borders: above – costal arches and xiphoid process; below – iliac crests, inguinal ligaments, upper edge of the symphysis; outside - a vertical line connecting the end of the XI rib with the iliac crest.

For practical purposes, the anterolateral wall of the abdomen is divided into three sections using two horizontal lines (the upper one connects the lowest points of the tenth ribs; the lower one – both anterior superior iliac spines) into three sections: the epigastrium, the belly and the hypogastrium. By two vertical lines running along the outer edge of the rectus abdominis muscles, each of the three sections is divided into three regions: the epigastrium includes the epigastric and two subcostal regions; womb – umbilical, right and left lateral areas; hypogastrium - pubic, right and left groin areas.

epigastric region - stomach, left lobe of the liver, pancreas, duodenum; right hypochondrium – right lobe of the liver, gall bladder,

right flexure of the colon, upper pole of the right kidney; left hypochondrium – fundus of the stomach, spleen, tail of the pancreas

breast gland, left flexure of the colon, upper pole of the left kidney; umbilical region – loops of the small intestine, transverse colon

colon, lower horizontal and ascending parts of the duodenum, greater curvature of the stomach, renal hilum, ureters; right lateral region – ascending colon, part

loops of the small intestine, lower pole of the right kidney; pubic region – bladder, lower parts of the ureters, uterus, loops of the small intestine;

right inguinal region – cecum, terminal section of the ileum, vermiform appendix, right ureter; left inguinal region – sigmoid colon, loops of small

intestines, left ureter.

Layer-by-layer topography

Leather– thin, mobile, easily stretched, covered with hair in the pubic area, as well as along the white line of the abdomen (in men).

Subcutaneous fat expressed differently

sometimes reaches a thickness of 10-15 cm. Contains superficial vessels and nerves. In the lower abdomen there are arteries that are branches of the femoral artery:

superficial epigastric artery – goes to the navel

superficial circumflex iliac artery–

goes to the iliac crest;

external genital artery – directed to the external genitalia.

The listed arteries are accompanied by veins of the same name, which flow into the femoral vein.

In the upper parts of the abdomen, the superficial vessels include: the thoracoepigastric artery, the lateral thoracic artery, the anterior branches of the intercostal and lumbar arteries, and the thoracoepigastric veins.

Superficial veins form a dense network in the navel area. Through the thoracoepigastric veins, which flow into the axillary vein, and the superficial epigastric vein, which flows into the femoral vein, anastomoses are carried out between the systems of the superior and inferior vena cava. Veins of the anterior abdominal wall through vv. paraumbilicales, located in the round ligament of the liver and flowing into the portal vein, form porto-caval anastomoses.

Lateral cutaneous nerves - branches of the intercostal nerves, pierce the internal and external oblique muscles at the level of the anterior axillary line, are divided into anterior and posterior branches that innervate the skin of the lateral sections of the anterolateral abdominal wall. Anterior cutaneous nerves – terminal branches of the intercostal, iliohypogastric and ilioinguinal nerves

nerves, pierce the vagina of the rectus abdominis muscle and innervate the skin of unpaired areas.

Superficial fascia thin, at the level of the navel is divided into two layers: superficial (passes to the thigh) and deep (more dense, attached to the inguinal ligament). Between the sheets of fascia there is fatty tissue, and superficial vessels and nerves pass through.

Own fascia– covers the external oblique muscle of the abdomen.

Muscles The anterolateral wall of the abdomen is located in three layers.

External oblique muscle starts from the eight-inferior ribs and, running in a wide layer in the medial-inferior direction, attaches to the crest of the iliac bone, turning inward in the form of a groove, forms the inguinal ligament, takes part in the formation of the anterior plate of the rectus abdominis muscle and, fused with the aponeurosis of the opposite sides, forms the linea alba.

Internal oblique muscle starts from the top

of the lumbar-dorsal aponeurosis, the iliac crest and the lateral two-thirds of the inguinal ligament and runs fan-shaped in the medial-superior direction, near the outer edge of the rectus muscle it turns into an aponeurosis, which above the navel takes part in the formation of both walls of the rectus sheath , below the navel - the anterior wall, along the midline - the white line of the abdomen.

Transverse abdominis muscle starts from the inner surface of the six lower ribs, the deep layer of the lumbodorsal aponeurosis, the iliac crest and the lateral two-thirds of the inguinal ligament. The muscle fibers run transversely and pass along the curved semilunar (Spigelian) line into the aponeurosis, which above the navel takes part in the formation of the posterior wall of the rectus abdominis vagina, below the navel - the anterior wall, along the midline - the white line belly.

Rectus abdominis muscle starts from the anterior surface of the cartilages of the V, VI, VII ribs and the xiphoid process and attaches to the pubic bone between the symphysis and tubercle. Along the length of the muscle there are 3-4 transversely running tendon bridges, closely connected with the anterior wall of the vagina. IN

In the epigastric and umbilical regions proper, the anterior wall of the vagina is formed by the aponeurosis of the external oblique and the superficial layer of the aponeurosis of the internal oblique muscles, the posterior wall is formed by the deep layer of the aponeurosis of the internal oblique and the aponeurosis of the transverse abdominal muscles. At the border of the umbilical and pubic regions, the posterior wall of the vagina breaks off, forming an arcuate line, since in the pubic region all three aponeuroses pass in front of the rectus muscle, forming only the anterior plate of its vagina. The posterior wall is formed only by the transverse fascia.

Linea alba is a connective tissue plate between the rectus muscles, formed by the interweaving of tendon fibers of the broad abdominal muscles. The width of the white line in the upper part (at the level of the navel) is 2-2.5 cm; below it narrows (up to 2 mm), but becomes thicker (3-4 mm). There may be gaps between the tendon fibers of the linea alba, which are where hernias emerge.

Navel is formed after the umbilical cord falls off and epithelialization of the umbilical ring and is represented by the following layers - skin, fibrous scar tissue, umbilical fascia and parietal peritoneum. Four connective cords converge to the edges of the umbilical ring on the inside of the anterior wall of the abdomen:

superior cord – overgrown umbilical vein of the fetus, heading towards the liver (in an adult it forms the round ligament of the liver);

the three lower cords represent empty urine

duct and two obliterated umbilical arteries. The umbilical ring may be the exit point for the umbilical

Transversalis fascia is a conditionally allocated part of the intra-abdominal fascia.

Preperitoneal tissue separates the transverse façade

tion from the peritoneum, as a result of which the peritoneal sac easily peels off from the underlying layers. Contains deep arteries

superior gastric artery is a continuation of the internal thoracic artery, going down, penetrates the vagina of the rectus abdominis muscle, passes behind the muscle

tsy and in the navel area it connects with the inferior artery of the same name;

inferior epigastric artery is a branch of the external iliac artery, heading upward between the transverse fascia and the parietal peritoneum, entering the sheath of the rectus abdominis muscle;

deep circumflex ilium artery is-

It is a branch of the external iliac artery, and parallel to the inguinal ligament in the tissue between the peritoneum and the transverse fascia is directed to the iliac crest;

five inferior intercostal arteries, arising from the thoracic part of the aorta, go between the internal oblique and transverse abdominal muscles;

four lumbar arteries located between the indicated

ny muscles.

Deep veins of the anterolateral abdominal wall (vv. epiga-

stricae superiores et inferiores, vv. intercostales and vv. lumbales) co-

accompany (sometimes two by) arteries of the same name. The lumbar veins are the source of the azygos and semi-gypsy veins.

Parietal peritoneum in the lower parts of the anterolateral abdominal wall it covers anatomical formations, forming folds and pits.

Folds of peritoneum:

median umbilical fold - runs from the top of the bladder to the navel above the overgrown urinary duct;

medial umbilical fold (paired) - runs from the lateral walls of the bladder to the navel above the obliterated umbilical arteries;

lateral umbilical fold (paired) - runs above the lower epigastric arteries and veins.

Between the folds of the peritoneum are located pits:

supravesical fossae - between the median and medial umbilical folds;

medial inguinal fossae - between the medial and lateral folds;

lateral inguinal fossae - outside the lateral umbilical folds.

Below the inguinal ligament is the femoral fossa, which projects onto the femoral ring.

These pits are weak points of the anterolateral abdominal wall and are important when hernias occur.

STOMACH, ventriculus (Greek gaster, inflammation - gastritis). Stomach dimensions : length of the stomach is 24-26 cm, the distance between the greater and lesser curvature is 10-12 cm, the capacity of the adult stomach is on average 3 liters (1.5-4 liters). I. General structure. The stomach is a pouch-like extension of the digestive tract. In the stomach, food turns into a mushy mixture. In the stomach distinguish the front wall And back wall, which are connected by edges - major and minor curvature. Small curvature, in curved and facing up and to the right. Greater curvature- convex and facing down and to the left. At the lesser curvature there is corner cut, where available stomach angle. The place where the esophagus enters the stomach is called cardiac opening, the part of the stomach adjacent to it is called cardiac part. To the left of the cardiac part, the dome-shaped part of the stomach is called bottom (or vault) of the stomach. The stomach has body. The place where the stomach exits is called pyloric hole, the part adjacent to it is called pyloric (pyloric) part. There is a wide part in it - gatekeeper cave and the narrower part - gatekeeper channel.

II. Topography of the stomach . The stomach is located in the upper part of the abdominal cavity, under the diaphragm, in epigastric region, most of the stomach is in the left hypochondrium, greater curvature is projected in the umbilical region. Entrance cardiac foramen located behind the cartilage VII left rib, at a distance of 2.5-3 cm from the edge of the sternum. The gastric vault reaches the lower edge V ribs along the midclavicular line. The pylorus lies in the midline or to the right of it against the VIII costal cartilage.

Stomach comes into contact with the following organs - above– the left lobe of the liver and the left dome of the diaphragm; behind- upper pole of the kidney and adrenal gland, spleen, anterior surface of the pancreas; from below- transverse colon; front- abdominal wall. When the stomach is empty, it goes deep and the transverse colon is located in front of it.

III. Structure of the stomach wall: 1. mucous membrane, has a reddish-gray color and is covered with single-layer columnar epithelium. In the mucous membrane there are gastric glands that produce gastric juice, succus gastricus (the main cells secrete pepsinogen, and the parietal cells secrete hydrochloric acid). Distinguish three types glands: 1. cardiac glands - in the area of the cardiac part; 2. gastric glands– they are numerous, located in the area of the fornix and body of the stomach (consist of main and parietal cells); 3. pyloric glands, consist only of chief cells. In the mucosa there are single lymphatic follicles.

Mucous membrane going to folds, due to its muscle layer and the presence of loose submucosa. Along the lesser curvature mucous membrane forms longitudinal folds, forming "stomach track" for the passage of the liquid part of food, bypassing the body of the stomach. The mucous membrane forms roundish elevations - gastric fields, on the surface of which holes are visible gastric pits. The glands of the stomach open into these pits. In the area of the pyloric opening, the mucous membrane forms a fold - the pyloric valve, delimiting the acidic environment of the body from the alkaline environment intestines. 2. Muscular membrane, - consists of three layers: 1. outer – longitudinal layer; 2. middle - circular, more developed than the longitudinal layer, in the area of the outlet it thickens and forms pyloric sphincter, m. sphincter pyloricus; 3. internal – oblique fibers. Oblique fibers spread across the cardiac part of the stomach and descend along the anterior and posterior surfaces of the stomach and pull the greater curvature of the stomach towards the cardiac opening. 3. Serosa - represents the serous membrane of the peritoneum, which from all sides covers the stomach ( intraperitoneally), with the exception of the greater and lesser curvature of the stomach.

IV. X-ray anatomical secreted in the stomach - digestive sac, saccus digestorius(includes the fornix and body of the stomach) and excretory canal, canalis egestorius(includes the pyloric part). Distinguish three shapes and positions of the stomach: 1. horn-shaped stomach- the stomach is located transversely (in people of the brachymorphic type); 2. fishhook-shaped stomach– the stomach is located obliquely (mesomorphic type); 3. stocking-shaped stomach- the stomach is located vertically (dolichomorphic type).

Age-related features of the stomach. Stomach newborn has a cylindrical shape. The cardial part, fundus and pylorus are poorly defined, the pylorus is wide. The volume of a newborn's stomach is 50 cm 3 , length 5 cm, width 3 cm. The entrance hole is located at the level of the VIII-IX thoracic vertebrae. By the end 1 year life, the stomach lengthens, the volume increases to 300 cm 3, length 9 cm, width 7 cm. At 2 years old the volume of the stomach is 490-590 cm 3, at 3 years old-580-680cm 3, by 4 years-750cm 3, at 12 years old-1300-1500cm 3. IN 7-11 years the stomach takes on the shape of an adult. The formation of the cardiac part is completed at 8 years of age. As development progresses, the stomach descends and at 7 years of age its inlet is projected between the XI-XII thoracic vertebrae. The mucous membrane of the stomach in a newborn is thick, the folds are high, there are 200,000 gastric pits. The number of pits by 3 months increases to 700,000, by 2 years to 1,300,000, by 15 years - 4 million. The muscular lining of the stomach of a newborn has all three layers, the longitudinal layer and oblique fibers are poorly developed. The muscular membrane reaches its maximum thickness by 15-20 years.

SMALL INTESTINE, intestinum tenue (Greek enteron, inflammation - enteritis), begins at the pylorus and ends at the beginning of the colon. Length – 5-6 m. The small intestine is divided into three departments: 1. duodenum, duodenum; 2. jejunum, jejunum; 3. ileum, ileum. I. Duodenum, duodenum , bends around the head of the pancreas in a horseshoe shape. Its length is 25-30 cm. It distinguishes 4 parts: 1. top part – comes into contact with the quadrate lobe of the liver, is directed at the level of the first lumbar vertebra to the right, forming a downward bend, flexura duodeni superior; 2. descending part– descends down to the right from the spine to the third lumbar vertebra, here it forms a bend, flexura duodeni inferior. Posterior to it are the right kidney and the common bile duct, and in front it is crossed by the root of the mesentery of the transverse colon; 3. horizontal part- goes transversely to the left in front of v. cava inferior and aorta; 4. ascending part, rising to the level of the I–II lumbar vertebra. When the ascending part passes into the jejunum, it turns out duodenojejunal flexure, flexura duodenojejunalis, which is fixed on the left side II lumbar vertebra (suspensory ligament of Treitz and muscle), which is identifying the beginning of the small intestine. X-ray anatomical the initial part of the duodenum is called bulb, bulbus (ampule). On the inner surface of the wall of the duodenum are visible circular folds, characteristic of the entire small intestine. On the descending part of the duodenum there is longitudinal fold, which has major papilla, papilla duodeni major (Papilla of Vater), in the thickness of which there is sphincter of Oddi, the papilla opens into the opening pancreatic duct and common bile duct. Above the major papilla is the minor duodenal papilla, papilla duodeni minor, where the opening of the accessory duct of the pancreas is located.

II-III.Jejunum and ileum . The jejunum and ileum are combined under the general name - mesenteric part of the small intestine, intestinum tenue mesenteriale, since this entire section is completely covered by the peritoneum (intraperitoneal) and is attached to the posterior abdominal wall by its mesentery. A sharply defined boundary between jejunum, jejunum And ileum, ileum - No, but differences There is: 1. jejunum, jejunum - located above and to the left, and ileum, ileum - located below and to the right; 2. the jejunum, jejunum, has a larger diameter (4 cm) than the ileum (2 cm); 3. the wall of the jejunum is thicker than that of the ileum; 4. The jejunum is bright pink, because it is richer in vessels; 5. on the ileum (in 2% of cases) at a distance of about 1 m from its end there is a 5-7 cm Meckel’s diverticulum (a remnant of the embryonic vitelline duct); 6. Differences from the mucous membrane will be indicated below.

The structure of the wall of the small intestine .

1. Mucosa , has a velvety appearance due to intestinal villi, villi intestinalis. Villi are processes of the mucous membrane 1 mm long, in the center of which there is a lymphatic capillary (lacteal sinus) and blood capillaries. The function of the villi is to absorb nutrients. The number of villi is greater in the jejunum. On the villi there is microvilli, due to which intrawall digestion occurs. The mucous membrane and its submucosa form circular folds, plicae circulares, increasing the suction area. Folds are permanent formations and do not disappear when stretched. The height and frequency of folds in the ileum are less than in the jejunum. The mucous membrane contains tubular intestinal glands, glandulae intestinales, highlighting intestinal juice. To neutralize harmful substances in the mucous membrane of the small intestine there are single lymphoid nodules, noduli lymphatici solitarii, and in the ileum their accumulations are observed - group lymph nodes, noduli lymphatici aggregati (Peyer's patches). 2. Muscular membrane – consists of two layers: outer longitudinal layer And inner circular layer. The circular layer contains spiral muscle fibers, forming a continuous layer. Muscle contractions wear peristaltic character, they sequentially spread to the lower end, with the circular layer narrowing the lumen, the longitudinal layer expanding as it shortens, and the spiral fibers contribute to the advancement of the peristaltic wave. 3. Serosa - the visceral layer of the peritoneum covers the duodenum from the front (extraperitoneal), the jejunum and ileum - from all sides (intraperitoneal).

Age characteristics. Small intestine newborn has a length of 1.2-2.8 m, in 2 -3 years its average length is 2.8 m. The width of the clearance is 1 year- 16 mm, and at 3 years old-23.2 mm. The duodenum in a newborn has a ring shape, its bends are formed later. Its beginning and end are located at the level of the first lumbar vertebra. After 5 months The upper part of the duodenum is at the level of the XII thoracic vertebra; by the age of 7, the descending part descends to the II lumbar vertebra. Duodenal glands in newborn small in size and weakly branched and develop most intensively in the first years of life. The folds and villi of the mucous membrane are poorly expressed. The number of intestinal glands intensively increases by 1 year life. The newborn already has lymphoid nodules. The muscular layer, especially its longitudinal layer, is poorly developed.

LARGE INTESTINE, intestinum crassum (inflammation - colitis), stretches from the end of the small intestine to the anus, where food digestion ends, feces are formed and excreted. In the large intestine there is a cecum with a vermiform appendix; the ascending, transverse, descending, sigmoid parts of the colon and the rectum ending in the anus. The total length of the colon ranges from 1.0 to 1.5 m. The width of the colon is 4 - 7 cm.

Distinctive features of the large intestine from the small intestine: 1. Colon bands, teniae coli - formed by a longitudinal muscle layer, starting at the base of the appendix and extending to the beginning of the rectum. Available three ribbons: 1. loose tape, tenia libera- runs along the anterior surface of the ascending and descending colon, and on the transverse colon along the lower surface; 2. mesenteric ribbon, tenia mesocolica– goes along the line of attachment of the mesentery of the transverse colon and the line of attachment of other parts to the posterior abdominal wall; 3. omental tape, tenia omentalis– goes along the line of attachment of the greater omentum on the anterior surface of the transverse colon and the continuation of this line in other parts of the colon 2. Haustra (swelling) of the colon, haustra coli – pouch-like protrusions of the wall of the colon, they are formed due to the fact that the ribbons are shorter than the intestine itself; 3. Omental processes, appendices epiploicae – represent finger-like protrusions of the serous membrane, containing adipose tissue and located along the free and omental bands.

The structure of the colon wall :

1. Mucosa the intestines are smooth, shiny, and have no villi. Inside between the haustra there are semilunar folds, plicae semilunares coli, in the formation of which all layers of the wall take part, so when stretched they are smoothed out. The mucosa contains intestinal glands and single lymphoid nodules.

2. Muscular membrane – consists of two layers: an outer longitudinal layer (in the form of tapes) and an inner circular layer (solid layer).

3. Serosa – the visceral layer of the peritoneum covers the large intestine in different ways: the transverse and sigmoid parts of the colon - on all sides and form their mesenteries (intraperitoneal); cecum (does not have a mesentery) with a vermiform appendix (has a mesentery) on all sides (intraperitoneal); ascending and descending colon on three sides (mesoperitoneal); the rectum in different ways - in the upper part - on all sides (intraperitoneal), in the middle - on three sides (mesoperitoneal) and in the lower part - not covered by the peritoneum (extraperitoneal).

1. Cecum, caecum, with appendix vermiformis - located in the right iliac fossa and goes from the beginning to the confluence of the ileum. At the point where the ileum enters the cecum, the mucous membrane forms the ileocecal valve, valva ileocaecalis (Bauhinian valve). In the thickness of the valve lies a circular muscle layer - m. sphincter ileocaecalis. The ileocecal valve regulates the movement of food from the small intestine (where the environment is alkaline) to the large intestine (where the environment is acidic) and prevents the reverse passage of food, while on the side of the small intestine the mucous membrane has villi, but on the side of the colon there are none. Vermiform appendix, appendix vermiformis(inflammation - appendicitis) - usually located in the right iliac fossa, but can be located above or below. The direction of the appendix can be different - descending (into the pelvic cavity), lateral, medial and ascending (behind the cecum). It is clinically important to know the projection of the base of the appendix onto the anterior abdominal wall: 1. McBurney point- on the border of the outer and middle thirds of the line connecting the navel with the right anterior superior iliac spine; 2. Lanza point– on the border of the right third from the middle third of the line connecting the right and left anterior superior spines. The mucous membrane of the appendix is rich in lymphoid tissue (“intestinal tonsil”, immune, protective function); 2. Ascending colon, colon ascendens- is a continuation of the cecum (from the junction of the small intestine). It goes up to the liver and turns to the left, forming right flexure of the colon, flexura coli dextra and passes into the transverse colon; 3. Transverse colon, colon transversum – goes from the right flexure of the colon to the left flexure of the colon, flexura coli sinistra. Between these bends the intestine does not go strictly transversely, but forms an arc with its convexity downward; 4. Descending colon, colon descendens – goes from the left flexure of the colon to the left iliac fossa, where it passes into the sigmoid colon;

5. Sigmoid colon, colon sigmoideum – located in the left iliac fossa; 6. Rectum, rectum (Greek proctos, inflammation - proctitis) - has no features of the colon, is located in the pelvic cavity, its length is 15 cm, diameter -2.5-7.5 cm. The sacrum and coccyx are located behind the rectum, in front - in men bladder, prostate gland, seminal vesicles and ampoules of the vas deferens, among women- uterus and vagina. The rectum has two bends- 1. sacral bend, flexura sacralis, corresponds to the concavity of the sacrum; 2. perineal bend, flexura perinealis– convex forward, located in the perineum. The upper part of the rectum is called pelvic part, pars pelvina, then continues in ampulla recti, which has transverse folds, plicae transversales (3-7) having a helical stroke. Next, the rectum goes down and continues into anal canal, canalis analis which ends anal opening, anus. In the anal canal, the mucous membrane forms longitudinal folds in the form anal columns, columnae anales, between them there is anal sinuses (anal crypts), sinus anales. From below, the anal sinuses are limited by the elevations of the mucous membrane - anal valves, valvulae anales. Mucus accumulates in the anal sinuses, facilitating the passage of contents. In the thickness of the submucosa and mucous membrane between the sinuses and the anus there is rectal venous plexus (hemorrhoidal), plexus venosus rectalis. Muscularis comprises two layers- inner circular layer and outer longitudinal layer. In the area of the anal canal, the inner circular layer thickens and forms internal (involuntary) sphincter of the anus, m. sphincter ani internus. The external (voluntary) sphincter of the anus is part of the muscles of the perineum.

Age-related features of the colon. The large intestine of a newborn is short, its length is 63 cm, there are no haustra and omental processes. At 6 months the haustra appear, at 2 years the omental processes appear. By the end of 1 year, the large intestine lengthens to 83 cm, and by 10 years it reaches 118 cm. The colon bands, haustra and omental processes are finally formed by 6-7 years. The cecum of a newborn is not clearly demarcated from the appendix, its width prevails over its length. The cecum takes on its typical appearance for an adult by the age of 7 years. The cecum is located high; the intestine descends into the right iliac fossa by the age of 14. The ileocecal opening in a newborn is ring-shaped and gapes. The length of the appendix of the newborn is 2 cm, the diameter is 0.5 cm, its lumen communicates with the cecum, and the valve closing the entrance appears by 1 year. The length of the process at 1 year is 6 cm, at 10 years - 9 cm, by 20 years - 20 cm. The ascending colon is poorly developed in a newborn and is covered by the liver. By 4 months, the liver is attached only to its upper part. By the age of 7 years, the ascending colon is covered in front by an omentum. The structure characteristic of an adult acquires by adolescence. Transverse colon - in a newborn has a short mesentery (up to 2 cm). At 1.5 years, the width of the mesentery increases to 8 cm, which helps to increase intestinal motility. By 1 year the length is 25 cm, by 10 years it is 35 cm. Its greatest size is in old people. The descending colon is 5 cm long in a newborn, by 1 year its length doubles, at 5 years it is 15 cm, at 10 years it is 16 cm. Its greatest value is in old people. The sigmoid colon is located high in the abdominal cavity and has a long mesentery. The rectum in a newborn is cylindrical in shape, has no ampulla or bends, folds are not pronounced, its length is 5-6 cm. The anal columns and sinuses in children are well developed. Significant growth is observed after 8 years. By the age of 14, it has a length of 15-18 cm, and its diameter is 5 cm.

57. Liver - location, projection onto the anterior abdominal wall (borders), functions. Structural and functional unit of the liver. Structure of the hepatic lobule

The liver (hepar) is a large organ, weighing about 1.5 kg. The liver is located in the upper abdominal cavity - in the right and partially in the left hypochondrium. In the liver, there is an upper convex and lower concave surface, a posterior blunt and anterior sharp edge. With its upper surface the liver is adjacent to the diaphragm, and its lower surface faces the stomach and duodenum. A fold of peritoneum passes from the diaphragm to the liver - the falciform ligament; it divides the liver from above into two lobes: the larger right and smaller left. On the lower surface of the liver there are two longitudinal (right and left) and one transverse grooves. They divide the liver from below into four lobes: right and left, quadrate and caudal. The right longitudinal groove of the liver contains the gallbladder and the inferior vena cava, and the left one contains the round ligament of the liver. The transverse groove is called the porta hepatis; Nerves, the hepatic artery, the portal vein, lymphatic vessels and the hepatic bile duct pass through it.

The liver is covered with peritoneum on all sides, with the exception of the posterior edge, with which it is fused with the diaphragm. The anterior edge of the liver is adjacent to the anterior abdominal wall and covered by the ribs. In some diseases, the liver can be enlarged. In such cases, it protrudes from under the ribs and can be palpated (the liver is “palpated”).

The liver consists of many lobules, and the lobules are made of glandular cells. Between the lobules of the liver there are layers of connective tissue in which nerves, small bile ducts, blood and lymphatic vessels pass. Interlobular blood vessels are branches of the hepatic artery and portal vein. Inside the lobules, they form a rich network of capillaries that flow into the central vein located in the middle of the lobule. Unlike other organs, not only arterial blood flows into the liver through the hepatic artery, but also venous blood through the portal vein. Both blood in the liver lobules passes through the system of blood capillaries and collects in the central veins. The central veins merge with each other and form 2 - 3 hepatic veins, which leave the liver and flow into the inferior vena cava.

Liver functions. The liver plays a very important role in the functioning of the body. It produces bile, which is involved in the digestion process (the importance of bile will be discussed in detail below). In addition to secreting bile, the liver performs many other functions. These include: participation in the metabolism of carbohydrates, as well as in the metabolism of fats and proteins; protective (barrier) function.

The participation of the liver in carbohydrate metabolism is that glycogen is formed and deposited in it. Nutrients absorbed into the blood from the small intestine travel through the portal vein to the liver. Here, glucose entering the blood is converted into animal sugar - glycogen. It is deposited in liver cells (as well as in muscles) as a reserve nutrient material. Only part of the glucose is contained in the blood and is gradually consumed from it by the organs. At the same time, liver glycogen breaks down into glucose, which enters the blood. Thus, the blood glucose level does not change.

The participation of the liver in fat metabolism lies in the fact that when there is a lack of fat in food, some of the carbohydrates in the liver are converted into fats.

The importance of the liver in protein metabolism is determined by the fact that it produces urea from the breakdown products of proteins (ammonia), which is part of urine. In addition, the liver appears to convert excess protein into carbohydrates.

One of the important functions of the liver is the synthesis of blood plasma proteins (albumin, fibrinogen) and prothrombin.

The protective function of the liver is that some toxic substances are neutralized in the liver. In particular, with the blood flow through the portal vein, toxic substances (indole, skatole, etc.) formed during the decay of proteins enter the liver from the colon. In the liver, these substances are converted into non-toxic compounds, which are then excreted from the body in the urine.

, IHD. Modern aspects of the clinic, diagnosis, treatment, prevention, textbook masonry.docx, ! Training manual on labor protection (1).doc, Methodological manual. Tests on pathological anatomy for medical and pediatrics, 2016_VSMK_textbook.pdf.

Chapter 3. Projection of the abdominal organs onto the surface of the abdominal wall.

The anterior abdominal wall can be roughly divided into nine regions.

Figure 6. Abdominal areas.

Table 3. Topography of the gastrointestinal tract.

Stomach

Pancreas

Duodenum.

Small and large intestine.

Liver

Gallbladder.

Figure 7. Projection points of the sphincters of the gastrointestinal tract onto the anterior abdominal wall.

Chapter 4. General principles of visceral osteopathy.

Normal biomechanics of an internal organ is characterized by :

The location of the organ within the anatomical boundaries.

2. Mobility.

Mobility depends on the mobility of the nearest diaphragm, peritoneum, surrounding structures and organs.

3. Motility.

Motility is the “embryonic mobility of an organ.” It does not depend on diaphragmatic breathing and the mobility of nearby organs and structures. The movement of an organ towards the central line of the body is expir, and from the central line of the body is inspira. Normally, inspira is equal to expir in amplitude, duration, and quality of movement.

The presence of a normal organ rhythm (seven to eight movements per minute)

Since internal organs move and change relationships with each other, the term visceral articulation should be introduced. It is a structure similar to a joint, like a joint having sliding surfaces And attachment system, but characterized by the absence of a motor muscle attached to the bone and moving the bone structures.

Sliding surfaces The visceral joints of the abdominal cavity are represented by the serous membrane of the peritoneum. Serous fluid in this case is similar to intra-articular fluid.

The internal organ may be connected:

with skeleton (lungs - chest)
with muscular wall (diaphragm-liver)
with another internal organ (liver-kidney)

The loss of an organ, partially or completely, of its ability to move is called visceral restriction. The following types of visceral restrictions are distinguished:

Articular restrictions:

adhesions - if there is a decrease in motility while maintaining normal mobility
fixation - violation of both mobility and motility

Articular restrictions mainly change axis or axis of mobility.

Weakness of the ligaments (ptosis) is a loss of elasticity of the ligaments due to prolonged overstretching. Ptosis changes axis or the axis and amplitude of mobility.

Muscle fixations (viscerospasms) are characteristic of hollow organs. First of all, the amplitude of mobility is changed.

Attachments:

Organs are kept within their anatomical limits by:

The suction action of the diaphragm, which reduces the weight of the organ.
Systems of a double layer of peritoneum, inside which there is liquid (adhesion effect). “Shells touching one another, but separated by a liquid film, cannot physiologically separate from one another; they can only slide over one another, like two glasses touching one another, but separated by a water film.”
Ligament systems (ligaments are duplications of the peritoneum).
Mesenteric systems (mesenteries are a duplication of the peritoneum with vessels passing there: arteries, veins and lymph nodes).
Omental systems (omentums are elongated mesenteries, between which there are accumulations of adipose tissue and plexuses of blood vessels).
Tone of the lumbar muscles, muscles of the anterior abdominal wall and pelvic floor.
The effect of turgor and intracavitary pressure. The turgor effect is ensured by gas and vascular tensions, determined by the ability of the organ to occupy a minimum volume in a minimum space, and is ensured by the equality of intercavity and intravisceral pressures. Intracavitary pressure must constantly balance the external cavitary pressures caused by gravity, atmospheric pressure and muscle pressure on the walls.

Visceral osteopathy affects:

Mobility and motility of organs.
Circulation of fluids (blood, lymph, cerebrospinal fluid).
Spasms of sphincters and muscles.
Hormonal and chemical production.
Local and systemic immunity.
Emotional sphere.

Indications for visceral osteopathy:

Limitation

Division into areas

For practical purposes, the anterolateral wall of the abdomen is divided into three sections using two horizontal lines (the upper one connects the lowest points of the tenth ribs; the lower one – both anterior superior iliac spines) into three sections: the epigastrium, the belly and the hypogastrium. By two vertical lines running along the outer edge of the rectus abdominis muscles, each of the three sections is divided into three regions: the epigastrium includes the epigastric and two subcostal regions; womb - umbilical, right and left lateral areas; hypogastrium - pubic, right and left groin areas.

Projections of organs onto the anterior abdominal wall

1. epigastric region- stomach, left lobe of the liver, pancreas, duodenum;

2. right hypochondrium- right lobe of the liver, gall bladder, right flexure of the colon, upper pole of the right kidney;

3. left hypochondrium- fundus of the stomach, spleen, tail of the pancreas, left flexure of the colon, upper pole of the left kidney;

4. umbilical region- loops of the small intestine, transverse colon, lower horizontal and ascending parts of the duodenum, greater curvature of the stomach, renal hilum, ureters;

5. right side area- ascending colon, part of the loops of the small intestine, lower pole of the right kidney;

6. pubic area- bladder, lower parts of the ureters, uterus, loops of the small intestine;

7. right groin area- cecum, terminal ileum, appendix, right ureter;

8. left groin area- sigmoid colon, loops of the small intestine, left ureter.

Layer-by-layer topography

1. Leather– thin, mobile, easily stretched, covered with hair in the pubic area, as well as along the white line of the abdomen (in men).

2. Subcutaneous fat expressed differently, sometimes reaching a thickness of 10–15 cm. Contains superficial vessels and nerves. In the lower abdomen there are arteries that are branches of the femoral artery:

* superficial epigastric artery – goes to the navel;

* superficial artery, circumflex ilium - goes to the iliac crest;

* external genital artery - goes to the external genitalia.

The listed arteries are accompanied by veins of the same name, which flow into the femoral vein.

The lateral cutaneous nerves are branches of the intercostal nerves that pierce the internal and external oblique muscles at the level of the anterior axillary line and are divided into anterior and posterior branches that innervate the skin of the lateral sections of the anterolateral abdominal wall. The anterior cutaneous nerves are the terminal branches of the intercostal, iliohypogastric and ilioinguinal nerves, pierce the sheath of the rectus abdominis muscle and innervate the skin of unpaired areas.

3. Superficial fascia thin, at the level of the navel is divided into two layers: superficial (passes to the thigh) and deep (more dense, attached to the inguinal ligament). Between the sheets of fascia there is fatty tissue, and superficial vessels and nerves pass through.

4. Own fascia- covers the external oblique muscle of the abdomen.

5. Muscles The anterolateral abdominal wall is located in three layers.

* External oblique muscle The abdomen starts from the eight lower ribs and, running in a wide layer in the medial-inferior direction, attaches to the crest of the ilium, turning inward in the form of a groove, forms the inguinal ligament, takes part in the formation of the anterior plate of the rectus abdominis muscle and, fused with the aponeurosis of the opposite side, forms the linea alba.

* Internal oblique muscle the abdomen begins from the superficial layer of the lumbodorsal aponeurosis, the iliac crest and the lateral two-thirds of the inguinal ligament and goes fan-shaped in the medial-superior direction, near the outer edge of the rectus muscle it turns into an aponeurosis, which above the navel takes part in the formation of both walls of the rectus sheath, below the navel - the anterior wall, along the midline - the white line of the abdomen.

* Transverse abdominis muscle starts from the inner surface of the six lower ribs, the deep layer of the lumbodorsal aponeurosis, the iliac crest and the lateral two-thirds of the inguinal ligament. The muscle fibers run transversely and pass along the curved semilunar (Spigelian) line into the aponeurosis, which above the navel takes part in the formation of the posterior wall of the rectus abdominis vagina, below the navel - the anterior wall, along the midline - the white line of the abdomen.

* Rectus abdominis muscle starts from the anterior surface of the cartilages of the V, VI, VII ribs and the xiphoid process and attaches to the pubic bone between the symphysis and tubercle. Along the muscle there are 3–4 transversely running tendon bridges, closely connected to the anterior wall of the vagina. In the epigastric and umbilical regions proper, the anterior wall of the vagina is formed by the aponeurosis of the external oblique and the superficial layer of the aponeurosis of the internal oblique muscles, the posterior wall is formed by the deep layer of the aponeurosis of the internal oblique and the aponeurosis of the transverse abdominal muscles. At the border of the umbilical and pubic regions, the posterior wall of the vagina breaks off, forming an arcuate line, since in the pubic region all three aponeuroses pass in front of the rectus muscle, forming only the anterior plate of its vagina. The posterior wall is formed only by the transverse fascia.

* Linea alba It is a connective tissue plate between the rectus muscles, formed by the interweaving of tendon fibers of the broad abdominal muscles. The width of the white line in the upper part (at the level of the navel) is 2-2.5 cm, below it narrows (up to 2 mm), but becomes thicker (3-4 mm). There may be gaps between the tendon fibers of the linea alba, which are where hernias emerge.

* Navel is formed after the umbilical cord falls off and epithelialization of the umbilical ring and is represented by the following layers - skin, fibrous scar tissue, umbilical fascia and parietal peritoneum. Four connective tissue cords converge on the edges of the umbilical ring on the inside of the anterior wall of the abdomen:

– superior cord – overgrown umbilical vein of the fetus, heading to the liver (in an adult it forms the round ligament of the liver);

– the three lower cords represent a neglected urinary duct and two obliterated umbilical arteries. The umbilical ring can be the site of umbilical hernia.

6. Transversalis fascia is a conditionally allocated part of the intra-abdominal fascia.

7. Preperitoneal tissue separates the transverse fascia from the peritoneum, as a result of which the peritoneal sac easily peels off from the underlying layers. Contains deep arteries and veins:

* superior gastric artery is a continuation of the internal mammary artery, heading down, penetrates the vagina of the rectus abdominis muscle, passes behind the muscle and in the navel area connects with the inferior artery of the same name;

* inferior epigastric artery is a branch of the external iliac artery, running upward between the transverse fascia and the parietal peritoneum, entering the sheath of the rectus abdominis muscle;

* deep circumflex ilium artery, is a branch of the external iliac artery, and parallel to the inguinal ligament in the tissue between the peritoneum and the transverse fascia is directed to the iliac crest;

* five inferior intercostal arteries, arising from the thoracic part of the aorta, go between the internal oblique and transverse abdominal muscles;

* four lumbar arteries located between these muscles.

The deep veins of the anterolateral abdominal wall (vv. epigastricae superiores et inferiores, vv. intercostales and vv. lumbales) accompany (sometimes two) arteries of the same name. The lumbar veins are the source of the azygos and semi-gypsy veins.

8. Parietal peritoneum in the lower parts of the anterolateral wall of the abdomen it covers anatomical formations, forming folds and pits.

Peritoneal folds:

1. median umbilical fold- goes from the top of the bladder to the navel above the overgrown urinary duct;

2. medial umbilical fold (paired)– goes from the lateral walls of the bladder to the navel above the obliterated umbilical arteries;

3. lateral umbilical fold (paired)- goes above the lower epigastric arteries and veins.

Between the folds of the peritoneum there are pits:

1. supravesical fossae– between the median and medial umbilical folds;

2. medial inguinal fossa– between the medial and lateral folds;

3. lateral inguinal fossa– outside the lateral umbilical folds. Below the inguinal ligament is the femoral fossa, which projects onto the femoral ring.