📚 Question Bank

The area marked on the given image of the visceral surface of the spleen is related to the left kidney.

The various anatomical relations of the visceral surface of the spleen are shown below.

The splenorenal ligament contains the splenic artery. So during splenectomy, it is ligated at the splenorenal ligament.

Splenic ligament Gastrosplenic ligament

Phrenicosplenic ligament

Splenorenal(lienorenal) ligam ent

Phrenicocolic ligament

Attachments

Greater curvature of the stom ach to the upper pole of the s pleen

Posterior abdominal wall to t he upper pole of the spleen

Hilum of the spleen to the an terior surface of the left kidn ey

Diaphragm to the splenic flex ure of the colon

Contents

Short gastric vesselsLeft gast roepiploic vessels

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Tail of pancreasSplenic arter yand vein

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The downward displacement of the spleen towards the left iliac fossa is prevented due to the presence of the phrenicocolic ligament. So the spleen usually enlarges towards the right iliac fossa.

The phrenicocolic ligament connects the splenic flexure of the colon to the diaphragm. It is not attached to the spleen. However, it lies below the spleen and supports its lower pole. When the spleen gets enlarged, the phrenicocolic ligament along with the splenic flexure of the colon restricts its downward displacement.

The phrenicocolic ligament functions as a potential barrier to the spread of infection between the left paracolic gutter and the left subphrenic space.

The right renal vein forms the posterior relation of the head of the pancreas. So it is invaded by posterior expansion of the carcinoma of the head of the pancreas.

Relations of the head of the pancreas:

• Anterior:
• 1st part of the duodenum
• Origin of the transverse mesocolon
• Posterior:
• Right renal vein
• Right renal artery
• Inferior vena cava
• Common bile duct (which is embedded in the head)
• Right crus of the diaphragm
• Termination of the right gonadal vein
• Relations of the neck of the pancreas:
• Anterior:
• Lesser sac
• pylorus
• The anterior superior pancreaticoduodenal branch of the gastroduodenal artery
• Posterior:
• Portal vein
• Superior mesenteric vein
• Inferior mesenteric vein (in 1/3rd individuals)

Clinical note: Cancers arising from the head or neck of the pancreas are difficult to operate on due to the confluence of so many vessels near them. This also makes blood-borne spread faster.

The structure marked A in the image is the ampulla of Vater.

The bile duct and the pancreatic duct unite to form the hepatopancreatic ampulla (ampulla of Vater) within the second part of the duodenum, which opens at the major duodenal papilla.

Sometimes an accessory pancreatic duct is present, and opens into the minor duodenal papilla. It is about 2 cm proximal to the major duodenal papilla in the second part of the duodenum.

Clinical Note:

• Familial adenomatous polyposis [APC gene defect] is associated with carcinoma of the Ampulla of Vater.
• Duodenal villous adenomas are commonly found around the ampulla of Vater and they are premalignant.
• Duodenal injuries with tissue loss distal to the major duodenal papilla and proximal to the superior mesenteric vessels are best treated by Roux-en-Y duodenojejunostomy.

The entire posterior surface of the pancreas is devoid of the peritoneum.

The posterior surface of the pancreas lies over the fascia of Toldt in front of the aorta. The splenic vein traverses directly on this surface.

Only parts of the uncinate process (where the superior mesenteric vessels descend on it) are also devoid of the peritoneum. The entire anterior surface of the body is covered by peritoneum and the tail lies between the layers of the splenorenal ligament, which is formed from the peritoneum.

Note that the pancreas is a retroperitoneal organ(except for the tail), in that it is not enveloped with the peritoneum but the anterior surface is in contact with the peritoneum.

The arterial supply of the pancreas is mainly by branches of the coeliac trunk and the superior mesenteric artery.

Arterial supply of the pancreas:

• Head and uncinate process
• Anterior and posterior superior pancreatoduodenal arteries [branches of the gastroduodenal artery, which is a branch of the celiac trunk]
• Anterior and posterior inferior pancreaticoduodenal arteries [branches of the inferior pancreaticoduodenal artery, which is a branch of the superior mesenteric artery]
• Body and tail [branches of the splenic artery, which is a branch of the celiac trunk]
• Dorsal pancreatic artery
• Great pancreatic artery
• Artery to the tail of the pancreas

Options A and C: While all the given branches of the coeliac trunk do supply the pancreas, these options do not include branches from the superior mesenteric artery. So, option D is more complete and thus it is the better option.

Option B: Right gastric and right renal arteries do not supply the pancreas. The image given below shows the blood supply of the pancreas.

The given clinical scenario and the renal angle tenderness are suggestive of acute pyelonephritis. The renal angle is formed by the lower border of the 12th rib and the lateral border of the erector spinae.

The lower pole of the kidney occupies this angle. Tenderness in this angle is usually suggestive of infection in and around the kidney or renal stones.

The angle shown in the image is the costovertebral angle, formed between the lower border of the 12th rib and the vertebral column.

Causes for pain/tenderness at the costovertebral angle include:

• Nephrolithiasis
• Pelviureteric junction obstruction
• Pyelonephritis
• Hemorrhagic fever with renal syndrome (HFRS) - caused by Hantavirus.

The 4 coverings of the kidney from within outwards are as follows:

• True or fibrous capsule - formed by the collagen-rich connective tissue.
• Perinephric fat or adipose capsule - consists of fat and occupies the space between the fibrous capsule and the renal fascia.
• Renal fascia
• Paranephric fat - occupies the space between the renal fascia and the anterior layer of the thoracolumbar fascia.

The lateroconal fascia attaches the perirenal fascia to the peritoneum. It extends from the lateral margin of perirenal fascia and attaches to the parietal peritoneum.

Option A: Gerota's fascia is the perirenal fascia. The kidney and the suprarenal gland are enclosed within anterior and posterior lamina of the perirenal fascia. The anterior lamina of the perirenal fascia blends with the connective tissue surrounding the great vessels behind the duodenum and pancreas. The posterior lamina continues as the lateroconal fascia.

Option C: Thoracolumbar fascia is a complex arrangement of multiple fascial layers in the thoracolumbar region. This fascia encloses the paraspinal muscles, quadratus lumborum muscle and the lattisimus dorsi muscle.

Option D: Treitz's fascia has been used to refer to the fusion fascia behind the head of pancreas.

The marked structure in the image is the right kidney. The pylorus of the stomach is not related to the anterior surface of the right kidney.

The anterior relations of the right kidney:

The below image shows the cross-section of the abdomen at the level of kidney.

Intraperitone al

Retroperitone al

Right lobe of liverSmall intes tine

Right suprarenal gland2ndpa rt of duoednumHepatic flexu re of colon

The marked area in the image of the left kidney is related to the stomach. The anterior relations of the right kidney:

The anterior relations of the left kidney:

The posterior relations of the kidneys:

• One vessel - subcostal vessels
• Two ligaments - medial and lateral arcuate ligaments
• Three nerves - subcostal, iliohypogastric, and ilioinguinal nerves
• Four muscles - diaphragm, psoas major, quadratus lumborum, and transverse abdominis.
• The right kidney is related to the 12th rib and the left kidney is related to the 11th and 12th
• ribs

Intraperitone al

Retroperitone al

Right lobe of liverSmall intes tine

Right suprarenal gland2ndpa rt of duoednumHepatic flexu re of colon

Intraperitone al

Retroperitone al

StomachJejunumSpleen

Left suprarenal glandPancrea sSplenic vesselsSplenic flexur e and beginning of descendin g colon

The marked structure in the given image is the left kidney. The sympathetic chain is not a posterior relation of the left kidney.

The posterior relations of the kidneys are as follows:

• One vessel - subcostal vessels
• Two ligaments - medial and lateral arcuate ligaments
• Three nerves - subcostal, iliohypogastric, and ilioinguinal nerves
• Four muscles - diaphragm, psoas major, quadratus lumborum, and transverse abdominis.
• The right kidney is related to the 12th rib and the left kidney is related to the 11th and 12th
• ribs
• The below image shows the cross section of the abdomen at the level of kidney.

The marked area is the hilum of the kidney. It contains the following structures from anterior to posterior:

• Renal vein
• Renal artery
• Renal pelvis

The renal papillae open into the minor calyces.

The papilla is the conical apex of a renal pyramid, where the urine from the collecting ducts enters into the minor calyces. The minor calyces unite to form the major calyces, which further unite to form the renal pelvis.

The kidney is divided into an outer cortex and an inner medulla. The renal medulla contains many striated and conical pyramids. The base of the pyramid is peripherally located, whereas the apex is directed towards the renal sinus (hilum). The renal cortex is subcapsular and arches over the bases of the pyramids. It extends between the pyramids towards the renal sinus as renal columns.

The coeliac plexus contributes to the nerve supply of the kidneys. Nerve supply of the kidney:

• Coeliac ganglion and plexus
• Aorticorenal ganglion
• Lowest thoracic splanchnic nerve
• First lumbar splanchnic nerve
• Aortic plexus

The rami from these structures form a dense network of autonomic plexus around the renal artery called the renal plexus. They control the blood flow between the cortex and medulla.

The most likely cause is compression of the left renal vein between the abdominal aorta and superior mesenteric artery. This manifests as nutcracker syndrome.

Nutcracker syndrome is characterized by left renal vein hypertension, which occurs due to the compression of the left renal vein between the abdominal aorta and the superior mesenteric artery. This is because the left renal vein is posterior and inferior to the superior mesenteric artery.

The left renal vein is longer than the right renal vein. It runs anterior to the aorta just below the origin of the superior mesenteric artery and drains into the inferior vena cava after crossing the midline.

Note: The left kidney is preferred in donor nephrectomy than the right because of the long course of the left renal vein.

The left subcostal vein does not drain into the left renal vein. It drains into the hemiazygos vein. So the occlusion of the left renal vein does not impede the blood flow in the left subcostal vein.

Veins that commonly drain into the left renal vein (which in turn drains into the IVC) are:

• Left inferior phrenic (diaphragmatic) vein,
• Left suprarenal (adrenal) vein,
• Left gonadal vein

On the right side, all the above veins drain into the inferior vena cava directly.

Apart from the veins described above, the first and second left lumbar veins and hemiazygos vein may drain into the left renal vein.

The left gonadal vein does not cross the midline. It is formed from the pampiniform plexus of veins and drains into the left renal vein.

The left renal vein is longer than the right renal vein and it crosses the midline anterior to the aorta. It drains directly into the inferior vena cava. The right renal vein does not cross the midline.

The accessory hemiazygous vein at T7 vertebral level crosses the midline to drain into the azygous vein.

The root of the mesentery extends across a line from the duodenojejunal flexure on the left side to the sacroiliac joint on the right side. This spans a length of 15 cm and crosses the midline in its course.

Vesicoureteric junction is the narrowest part of the ureter. This is the reason why stones as small as 2 to 3 mm get arrested in the vesicoureteric junction.

The ureter is constricted at 5 places:

• Pelvi-ureteric junction
• Brim of the lesser pelvis (as it crosses the common iliac artery)
• Point of crossing of the ureter by ductus deferens or broad ligament of the uterus.
• Vesico-ureteric junction
• Opening in the lateral angle of the trigone

These are regarded as surgical constrictions of the ureter.

However, only 1, 2, and 4 are the anatomical constrictions of the ureter.

The structure marked in the image is the ureter. Quadratus lumborum is not a posterior relation of the ureter.

Posterior relations of the ureter in the abdominal cavity are:

• Psoas major
• Genitofemoral nerve
• End of the common iliac artery or beginning of the external iliac artery

The superior mesenteric artery does not supply the ureters. The ureter receives its blood supply from the following arteries:

• Renal artery
• Gonadal artery
• Common iliac artery
• Internal iliac artery
• Vesical artery
• Uterine artery
• Abdominal aorta

Among these branches, the branch from the renal artery and the branch from the inferior vesical artery are always constant.

Clinical note: The branch of the renal artery that supplies the ureter must be carefully preserved in renal transplantation to maintain good vascularity of the ureters.

The structure marked in the CT abdomen is the left adrenal gland. The superior mesenteric artery does not supply the suprarenal or adrenal gland.

The adrenal gland receives its arterial supply from the superior, middle, and inferior suprarenal arteries. These arteries have some variations in their origin as follows:

Artery

Superior suprarenal Middle suprarenal

Inferior suprarenal (major bl ood supply)

Usual origin

Inferior phrenic artery

Abdominal aorta (as lateral b ranches)

Renal artery

Variation in origin Abdominal aorta

Inferior phrenic arteryRenal artery

Abdominal aortaGonadal art ery

The below CT abdomen shows the right and left adrenal gland.

The right main adrenal vein usually drains into the inferior vena cava.

The left main adrenal vein usually drains into the left renal vein. Variations are common on the right side, where the right adrenal vein may drain into the right inferior phrenic vein.