Clinical Anatomy of the Large Intestine - Ohio University

Clinical Anatomy of theClinical Anatomy of theLarge IntestineLarge Intestine

Lawrence M. Witmer, PhDLawrence M. Witmer, PhDProfessor of AnatomyDepartment of Biomedical SciencesCollege of Osteopathic MedicineOhio UniversityAthens, Ohio 45701 [email protected]

Handout download:http://www.oucom.ohiou.edu/dbms-witmer/gs-rpac.htm

23 January 2007

ileum

free (anterior)taenia

omental taenia

mesenterictaenia

right colic(hepatic)flexure

left colic(splenic)flexure

epiploicappendages

haustra

appendix

cecum

ascendingcolon

transversecolon

descendingcolon

sigmoidcolon

rectum

Moore & Dalley 2005

AnatomicalAnatomicalOverviewOverview

Skandalakis’ Surgical Anatomy 2004

free taenia

omental taenia

mesenterictaenia

epiploicappendage

epiploicappendage

mesenterymarginal a.

shortbranch

long branch

AnatomicalAnatomicalOverviewOverview

www.bondisalud.com.ar/1a%20diverticulosis.jpg

DiverticulosisDiverticulosis

http://www.pathology.pitt.edu/lectures/gi/colon-b/06.jpghttp://www.pathology.pitt.edu/lectures/gi/colon-b/06.jpg

diverticula(internal view)

diverticula(internal view)

mucosalherniationmucosal

herniation

Moore & Dalley 2005

diverticula(external view)


mucosa

normalepiploic

appendage

taenia (longitudinal muscularis)

diverticulum intodiverticulum intoepiploic appendageepiploic appendage

fat

circularmuscularis

serosa

vasa rectus& branches

DiverticulosisDiverticulosisantimesenteric anastomosis

injury to injury to vasa rectusvasa rectus

branchbranch

distal ischemiadistal ischemia

DimensionsDimensions

cecum5 cm

ascendingcolon10 cm

transverse colon50 cm

descendingcolon10 cm

sigmoid colon50 cm

anal canal4 cm

rectum15 cm

8cm8

cm

5 cm5 cm

6cm6

cm

5cm5

cm

5cm5

cm

4 cm4 cmwidest:widest:likelylikely

site forsite forperforationperforation

narrowest: likelynarrowest: likelysite for site for obstructionobstruction


transversemesocolon

mesenteryof smallintestine

sigmoidmesocolon

greateromentum

IMV

Paraduodenal fossae: 1) Superior & 2) Inferior

fossae of Trietz3) Mesentericoparietal

fossa of Waldeyer4) Intermesocolic fossa

of Brooke 5) Paraduodenal fossa

of Landzert

• Mobility• Vascularization• Compartments• Volvulus• Internal hernias• many more

Peritoneal RelationsPeritoneal Relations


Paraduodenal fossae: 1) Superior & 2) Inferior

fossae of Trietz3) Mesentericoparietal

fossa of Waldeyer4) Intermesocolic fossa

of Brooke 5) Paraduodenal fossa

of Landzert

SMA

Internal HerniaRight

ParaduodenalHernia

hernialsac


free taeniasuperior &

inferiorileocecal

fossa

mesoappendixcecum

superior ileocecalinternal hernia(a pericecal hernia;

6-13% of all internal hernias) Skandalakis’ Surgical Anatomy 2004

appendix


Position Nonapp-endicitis

Appendicitis Total %

ABCDEFG

Preileal 1 5 6 4Postileal 7 3 10 8Subileal 11 8 19 15Pelvic 14 11 25 19

Subcecal 9 5 14 11Paracecal 4 9 13 10Retrocecal 18 24 42 33

GGF

ED

C

BA

anterior

post.

AppendixAppendixPositionPosition


data from O’Connor & Reed (1994)


Moore’s Developing Human 1988

• Elongation of gut tube• Herniation into umbilical cord• Counterclockwise rotations


Moore’s Developing Human 1988

• Retraction & return of gut• Final counterclockwise rotation• Descent of cecum• Fixation to posterior abdominal wall




peritoneum

cecum

appendix

ileum

peritoneum

retroperitonealtissue

paracolic groove

para-colicgutter

mesentery

normalnormal

unfixed,unfixed,mobilemobile



Fixation of cecumFixation of cecumFixation of cecum

areas of fixation shown in black areas of fixation shown in black

asc colmesent

ileum

appendix cecum pelvic brim

Type I 11.2% Ia 8.3% Type Ib 22.7%

Type II 9.7% IIa 7.3% III 11.3% III 5.7%

Type IV 17.3% V 4.7% VI 2.7%

stomach aorta

umbilicus

cecum

celiac trunk (foregut)

superior mesenteric A.(midgut)

inferior mesenteric A.(hindgut)

VasculatureVasculature




marginal a.

m. colic a. SMA

r. colic a.

ileocolic a.

cecal a.

appendiculara.

ileal a.

IMA

acc. left colica. (~ 40%)

marginal a.

l. colic a.

sigmoid aa.

sup. rectal a.

RCARCA--IleocolicIleocolicanastomosisanastomosis

absent 5%absent 5%AnastomosisAnastomosis•• poor 32%poor 32%•• absent 7%absent 7%



occluded SMAoccluded SMA meanderingmesenteric a.(arc of Riolan)dilateddilated

marginal a.marginal a.

MCA

RCA

ileocolic a. Gourley & Gering 2005

Lymphatic DrainageLymphatic Drainage


Nodes NA Ileocolic 29B Right colic 11.1C Midcolic 22.4D Left colic 25.2E Sigmoid &

rectal 32.8

mesenteric nodes

l. lumbar

mesocolic

paracolic

epicolicnodes

AA

BB

CCDD

EE

Lymphatic DrainageLymphatic Drainagelesion

Arterial & lymphatic territoryassociated with a lesion

Arterial & lymphatic territoryArterial & lymphatic territoryassociated with a lesionassociated with a lesion


ReferencesReferences

• Gourley, E. J. and S. A. Gering. 2005. The meandering mesenteric artery: a historical review and surgical implications. Diseases of the Colon and Rectum 48(5):996-1000.

• Mathieu, D. and A. Luciani. 2004. Internal abdominal herniations. American Journal of Roentgenology 183:397-404.

• Moore, K. L. 1988. The Developing Human. Clinically Oriented Embryology, 4th Ed. Lippincott, Williams & Wilkins, Baltimore.

• Moore, K. L. and A. F. Dalley. 2006. Clinically Oriented Anatomy, 5th Ed. Lippincott, Williams & Wilkins, Baltimore.

• O'Connor, C. E. and W. P. Reed 1994. In vivo location of the human vermiform appendix. Clinical Anatomy 7:139-142.

• Skandalakis, J. E., G. L. Colborn, T. A. Weidman, R. S. Foster, A.N. Kingsnorth, L. J. Skandalakis, N. P. Skandalakis, P. Mirilas(Editors). 2004. Surgical Anatomy: The Embryologic And Anatomic Basis Of Modern Surgery. McGraw-Hill, New York.

Clinical Anatomy of the Large Intestine - Ohio University

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