Abdomen 4: Posterior Abdominal Wall,
Neurovascular Sructures and Lymphatics
and the Urinary System
Lecture by: Doc DJ
Quick Trans by: Alyssa Balt
Date: January 22, 2018
These structures are located on the
Posterior Abdominal Wall behind the
peritoneum (retroperitoneal)
Blood Vessels - abdominal aorta, inferior
vena cava, azygos and hemiazygos veins
Lymphatic - pre-aortic and para-aortic lymph
nodes
Nerves - aortic plexus and lumbar plexus
NOTE: “Retroperitoneal” space is the space
behind the peritoneal cavity — covered by
Transversalis Fascia. Transversalis Fascia
has different names.
Example: Diaphragmatic Fascia, Quadratus
Lumborum Fascia, Iliacus Fascia.
Endoabdominal Fascia — still within
abdominal cavity
Blood Vessels of the Posterior
Abdominal Wall
Inferior Vena Cava (R) and Aorta (L)
NOTE: “there was one incidence wherein
IVC and Aorta were interchanged.”
Abdominal Aorta
● The abdominal aorta is the distal
continuation of the thoracic aorta
below the diaphragm.
● It enters the abdomen through the
aortic hiatus (​T12​) of the diaphragm.
● It ends at the level of ​L4 ​vertebra
where it bifurcates into 2 terminal
branches, the right and left common
iliac arteries.
Branches:
● Visceral - paired and unpaired
● Parietal - paired and unpaired
● Terminal branches (R and L
Common Iliac Arteries)
Inferior Vena Cava (IVC)
Union of 2 Common Iliac Veins (R
and L) at ​L5 ​forms IVC — IVC ascends in
front of the vertebral column on the right
side of the abdominal aorta — ends
superiorly where it enters thorax through
piercing caval hiatus (central tendon) of
diaphragm at​ T8 ​— terminates/ends into
Right Atrium
Branches of Abdominal Aorta
PAIRED Visceral Branches
● Renal Artery
● Gonadal Artery (Testicular/Ovarian)
● Middle Suprarenal Artery
UNPAIRED Visceral Branches
● Celiac Trunk
● Superior Mesenteric Artery
● Inferior Mesenteric Artery
PAIRED Parietal Branches
● Inferior phrenic
● 4 pairs of Lumbar Arteries
UNPAIRED Parietal Branches
● Median Sacral Artery
Tributaries of the Inferior Vena Cava
● Median Sacral
● Lower 2 Lumbar Veins
● Renal Veins
 ● Right Suprarenal Veins
● Right Inferior Phrenic Veins
● Hepatic Veins
● Right Gonadal Veins
Azygos and Hemiazygos Veins
● Azygos Vein​ is formed by the union
of the (R) Upper 2 Lumbar Veins
with the (R) Subcostal Veins
● It ascends to the thorax through the
aortic hiatus of the diaphragm with
the aorta
● Hemiazygos Vein​ is formed on the
left side of the vertebral column by
the union of the (L) upper 2 lumbar
veins and the (L) Subcostal Veins.
Lymphatic of Posterior Abdominal Wall
● Pre-Aortic Nodes
○ Celiac Nodes
○ Superior Mesenteric Nodes
○ Inferior Mesenteric Nodes
● Para-Aortic (Lumbar) Nodes
Pre-Aortic Nodes ​are located around the
origin of the main arteries.
NOTE: in front of abdominal aorta; closely
associated with UNPAIRED Visceral
Branches.
● Celiac Nodes - drain the abdominal
viscera derived from the ​foregut​.
○ Foregut: Liver, lower part of
Pancreas, Stomach,
Esophagus, middle half of
Duodenum
● Superior Mesenteric Nodes - drain
the abdominal viscera derived from
the ​midgut​.
○ Midgut: Duodenum, Jejunum,
Ileum, Cecum, Appendix,
Ascending Colon,
Transverse Colon up to its
distal 2/3
● Inferior Mesenteric Nodes - drain the
abdominal viscera derived from the
hindgut​.
○ Hindgut: Distal 3rd of
Descending Colon, Sigmoid,
Rectum, Upper 1/2 of Anal
Canal
Para-aortic (Lumbar) Nodes
● These are the lymph nodes along
the lateral side of the abdominal
aorta.
● These nodes receive the lymph from
the lower extremity, the posterior
abdominal wall structures like the
kidneys, and ureters, ovary or testis,
then end into the ​cysterna chyli​.
Ascending Lumbar Trunk + Intestinal Trunk
= Cysterna Chyli
● Cysterna Chyli is at the Left side of
Proximal portion of Aorta — goes to
Thoracic Duct.
○ The thoracic duct
commences at its upper end
and after which ascends to
the thorax through the aortic
hiatus (T12) of diaphragm
posterior to the aorta and
azygos vein.
● Cysterna Chyli is oval/triangular
dilatation containing lymph in front of
the body of L1 or L1 and L2
vertebrae corresponding to the union
of the intestinal lymph trunks and
lumbar trunks
NERVES OF POSTERIOR ABDOMINAL
WALL
Autonomic Plexuses
 - Aortic Plexus
Lumbar Sympathetic Trunk
Lumbar Plexus
Aortic Plexus
- autonomic innervation of abdomen
- around aorta; formed by meshwork of
nerve fibres; a continuous network of nerves
on the surface of the abdominal aorta from
the aortic hiatus (T12) to its bifurcation (L4).
Branches: (named according to
associated visceral branches of
abdominal aorta)
● Celiac Plexus
Celiac plexus contains nerve fibers derived
from greater thoracic splanchnic nerves
from​ T5 - T9. ​Celiac Plexus has 2 ganglia,
associated with celiac trunk: 1 for Superior
Mesenteric and 1 Inferior Mesenteric
● Aorticorenal Plexus
associated with renal vessels; coming from
lesser splanchnic nerves ​T10 - T11 ​and
lowest splanchnic nerves ​T12;
Supplies kidney and suprarenal
● Renal Plexus
● Superior Mesenteric Plexus
also receives fibers along from T5 to T9
from midgut
● Intermesenteric Plexus
● Inferior Mesenteric Plexus
comes from pelvic splanchnic nerves or
pelvic parasympathetic, ​S2 - S4;
least splanchnic nerves (​T12​)
NOTE: To visualize Aortic Plexus, you need
Spatial Dissection.
Composition and Function of Aortic Plexus
1. The aortic plexus contains efferent and
afferent fibres of sympathetic and
parasympathetic nerves.
2. Parasympathetic (efferent) activity
stimulates glandular ​secretions​ and
peristalsis​ and causes ​dilation​ of blood
vessels.
- Parasympathetic: Vagus / Vagable
nerve
- Parasympathetic visceral afferents
are primarily concerned with general
visceral sensations, like hunger, and
nausea and afferent impulses contributing
to visceral reflexes.
3. Sympathetic Activity ​increases the tone
of sphincters and ​constricts ​the blood
vessels.
- PRE-ganglionic or POST-ganglionic
- Sympathetic visceral afferents are
primarily concerned with pain, that is
induced by tension in the viscera and
mesentery.
NOTE: Somatic distribution of Stomach
Ulcer — lower thoracic anterior wall,
epigastrium
Autonomic Plexus in the Posterior
Abdominal Wall
Lumbar Plexus
Roots of origin: Anterior/Ventral rami of L1,
L2, L3 and L4 Spinal Nerves
Formed within the substance of the psoas
muscle
Terminal branches emerge from the psoas
muscle.
Terminal Branches:
(Subcostal) T12 - giving contribution to L1
L1 ​- gives rise to 2 terminal branches —
Iliohypogastric (L1) and Ilioinguinal (L2)
 Note: 2 (L) side as upper part of
Psoas Muscle behind the kidney
- Iliohypogastric (hypogastrium) and
Ilioinguinal (medial group of thigh, scrotum)
L1 and L2 ​- (A) Anterior division of L1 and
L2 — Genitofemoral nerve (L1) and (L2)
Note: Genitofemoral nerve is a
slender branch on anterior surface of posts
muscle; Distally, it bifurcates into Genital
branch (spermatic cord for male, round
ligament of uterus) and Femoral branch
(goes with femoral nerve in thigh)
Genitofemoral nerve — mid part of
inguinal; lower part supplies internal _____
muscle; supplies (A) thigh muscles
(extensors of knee joint)
L2 and L3 ​- (P) Posterior division of L2 and
L3 — Lateral FemoralCutaneous nerve (L2)
(L3)
Note: Lateral Femoral Cutaneous
Neve is at the lateral border of Psoas
muscle
L2 and L3 and L4​ — (P) Posterior division
of L2, L3 and L4 — Femoral Nerve (L2)
(L3) (L4)
Note: You will not miss Femoral
Nerve because it’s the largest branch
(A) Anterior division of L2, L3 and L4 —
Obturator Nerve (L2) (L3) (L4)
Note: obturator nerve is behind the
vertebral column; medial surface of psoas
(lower border of psoas); lies deep in cleft,
emerges in thigh through obturator foramen;
supplies medial inferior tight muscles
(adduction)
Review: action of the thigh is on the leg
(arm to forearm, forearm to wrist)
(A) thigh - extensor of
the joint
Ex. Sartorius flexes
the leg; lateral rotation of knee joint
Posterior Abdominal Wall (Muscles and
Fascias)
Construction:
found along the Midline — lumbar
vertebral column (5)
Lateral to midline are muscles on
each side of the vertebral column
— Psoas and quadratus lumborum:
iliacus in the iliac region
— Lateral to quadratus lumborum is
transversus abdominis
— Roof: ​diaphragm​, which
completes the wall superiorly.
— Lateral to midline are muscles:
Psoas: minor is not always present; flexion
of hip joint
Quadratus Lumborum: fixator during
inspiration
Quadratus Lumborum
Origin: iliolumbar ligament, iliac crest, tips of
transverse processes of lower lumbar
vertebrae
Insertion: lower border of the 12th rib
Action: fixes the last rib during inspiration
(stabilizes the lower attachments of the
diaphragm)
- during expiration provides a fixed
base for controlled relaxation of diaphragm
need for speech and singing
- laterally flexes the vertebral column
same side
Psoas
Origin: anterior surfaces and lower border of
the transverse processes of the 12 thoracic
and all lumbar vertebrae; bodies of 2 Crura of diaphragm
adjoining lumbar vertebrae and their The ​right crus​ arise from the sides of the
intervertebral discs body of the upper 3 lumbar​ ​vertebra
Insertion: together with the iliac muscle to
the lesser trochanter of the femur The​ left crus ​arise from the sides of the
Action: flexes the thigh upon the pelvis; if body of the upper 2 lumbar vertebrae
thigh is fixed, it flexes the trunk on thigh as
in sitting up from a recumbent position — lateral to the the crura part of the
diaphragm arise from the medial (covering
Iliacus the psoas muscle) and lateral arcuate
Origin: upper 2/3 of the concavity of the iliac ligaments
fossa
Insertion: (with psoas muscle) to the lesser Nerve supply of the diaphragm: Phrenic
trochanter Nerve (C3) (C4) (C5) — supplies also the
Action: flexes the thigh on the trunk; if the shoulder area
thigh is flexed, it flexes the trunk on the
thigh as in sitting up from a recumbent Functions of the diaphragm:
position. — Muscle of Inspiration
— Muscle of Abdominal Straining
Diaphragm — Weightlifiting muscle
— primary muscle of respiration — Thoracoabdominal pump
— L to R crura of diaphragm, in between:
Median ligament Urinary System
Note: Median ligament forms — consists of the following organs:
outer boundary of aortic hiatus (T12) Kidneys
Ureters
It consists of 2 parts: Urinary bladder
- a ​peripheral muscular part​ that Urethra
arises from the margin of the thoracic outlet
and a ​centrally placed tendon​. Kidney
a paired organ;
Three Parts (of different origin) of located behind the peritoneal cavity
Diaphragm (primarily retroperitoneal);
Common insertion: central tendon weighs — in male, 150g and in female,
(a) ​Sternal Part​: the part that arise from the 135g;
posterior surface of the xiphoid process encapsulated;
(b) ​Costal Part​: consists of 6 slips that arise primary function is maintenance of water
from the deep surfaces of the lower 6 ribs and electrolyte balance;
and their costal cartilage
(c) ​Vertebral part​: consists of 2 vertical medial border: concave
columns or crura *has slit: hilus
lateral border: convex
Left kidney lies at 11th rib (higher than the R
kidney); lower border is at L3 (almost the
same as the the R kidney)
External Features of the Kidney
— the kidney has 2 surfaces, 2 borders, an
upper and lower poles
— coverings of the kidney (from outermost
to innermost)
Pararenal fats
Renal fascia
Perirenal fats
- liquid at body temperature, covering of
kidney that separates Suprarenal gland (not
covered by perirenal fats)
Renal Fibrous Capsule
- covers kidney and renal sinus from hilus to
lobe of kidney
— just beneath the cortex
Intraabdominal Pressure​: prevents
descend of the kidney
Transversalis Fascia
— lining the Posterior Abdominal
Wall at (L) border lining of Kidney; it splits
into (P) and (A) layer that crosses to
opposite sides.
— renal fascia (aka: Gerota’s
Fascia) — also covers Suprarenal gland
and Kidney
Hilus of the Kidney
Contents: Renal artery, Renal vein,
renal pelvis
Internal features of the Kidney
(Outer) Cortex​ — a dark brown outer layer
of the kidney just beneath the capsule
(Inner) Medulla​ — inner core which is light
brown
Renal Pyramids​ — about a dozen of
triangular areas in the medulla, with base
directed toward the cortex and apex
projecting medially (towards the renal
sinus);
Note: Renal Papilla has tip or
opening: more than 1/2
Renal Columns of Bertin​— part of the
cortex extending between pyramids
NOTE: Inside of kidney is a continuation of
Blood Vessels.
Renal Sinus
— the hilus leads into a wide space inside
the kidney, the space is called the ​renal
sinus.
— the ​renal papilla ​(apex of the pyramid)
projects into the minor calyx in the renal
sinus
Contents of the renal sinus:
1. Minor and Major Calyces
Minor calyx — converts into bigger
receptacles
Major calyx — converts again into a
common receptacle, funnel- shaped, Renal
Pelvis/Infundibulum.
2. Renal Pelvis
3. Blood vessels and nerves of the
kidney
Blood Supply of the Kidney:
1. Segmental arteries
2. Interlobar artery
3. Renal artery
Venous Drainage of the Kidney
1. ​Renal Vein
— the renal vein is the MOST
ANTERIOR of the structures at the hilus of
the kidney
 — the renal veins are direct
tributaries of the Inferior Vena Cava (IVC)
— the left renal vein receives the left
gonadal, left suprarenal and left inferior
phrenic veins before draining into the IVC
(​R — SR IP​)
The left renal vein crosses in front of the
abdominal aorta just beneath the origin of
the superior mesenteric artery.
Significance:
— dilatation/aneurysm of the
proximal part of superior mesenteric artery
will compress the left renal vein
Lymph drainage and innervation of the
kidney
Lymph drainage:
— lymph vessels follow the renal artery to
the lateral aortic (lumbar/paraaortic) nodes
around the origin of the renal artery
Innervation:
— originate in the renal sympathetic plexus
and distributed along the branches of the
renal artery
— afferent fibres travel through the renal
plexus and enter the spinal cord segments
from ​T10 to T12​.
Anterior relations of the right kidney
— Liver
— Right suprarenal gland
— Descending (2nd) part of duodenum
— Colon
— Loops of small intestine
Anterior relations of the left kidney
— Spleen
— Stomach
— Pancreas
— Left suprarenal gland
— Colon
— Loops of small intestine
Posterior Relations of the Kidneys
— The posterior surface of both kidneys is
related to the muscles of posterior
abdominal wall such as:
1. Diaphragm
2. Transversus Abdominis
3. Quadratus Lumborum
4. Psoas
5. Iliacus
Ureter
— 10 inches.
— from its formation at kidney to urinary
bladder
— has muscular wall capable of contraction
or peristaltic movement
Physiologic Constrictions:
1. ​Ureteropelvic Junction ​— level where it
joins the Renal Pelvis;
2. Level where it enters the pelvic cavity at
the level of pelvic brim
3. ​Ureterovesical Junction​ — level where
it enters the wall of urinary bladder
Ureter terminates in the Urinary Bladder.
Urinary Bladder is already in the pelvic
cavity.
Urethral Orifice — opening of the ureter in
the urinary bladder.
500 mL — maximum of the urinary bladder
800 mL — when obstructed;
Blood Supply of the Ureter
— Proximal (upper part) supplied by
branches of the renal artery
— Middle Part — supplied by the ​gonadal
artery
— Lower (pelvic part) — supplied by the
superior vesical artery

Venous and lymphatic drainage and nerve

supply of Ureter
1. Venous drainage
— veins corresponding to the
arteries
2. Lymphatic drainage
— lumbar (para-aortic) nodes
3. Nerve supply
— derived from the renal,
testicular/ovarian and hypogastric (in the
pelvis) plexus
— afferent fibers enter the 1st and
2nd lumbar segments

​ t the back of the ureter, at pelvis it

A
crosses External Iliac Artery.
In the abdomen, it passes in front of the
psoas muscle.

-------------------------xxx-----------------------------

MINI QUIZ:
(relevant questions asked during the
lecture)

1. What covering of kidney is capable of

entering the sinus? Peri-renal fats

2. What structures enter kidney? Renal

Veins (most anterior), Renal Artery and
Renal Pelvis (most posterior)

3. Left renal vein passes the origin of SMA.

If suppressed, what organ is affected? Left
Suprarenal, Left Testicular/Ovarian and Left
side of the Diaphragm because the blood
will not be able to drain.