2691285 anatomia pancreasului si splinei
TRANSCRIPT
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ANATOMIA PANCREASULUI SI SPLINEI
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PANCREASUL
Glanda cu secretie
• interna(endocrina) • externa (digestiva)
! asemanari cu glandele salivare (“glanda salivara abdominala”
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PANCREASUL• Situat profund, inaintea coloanei vertebrale,
inapoia stomacului si micului epiploon• Ocupa planul cel mai profund al regiunii
celiace, depasind-o spre stanga
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PANCREASUL
• Culoare roz- cenusie/ rosie in timpul activitatii
• Aspect lobulat
• Consistenta ferm-elastica, aspect carnos pe sectiune (pan= tot, creas=carne)
• Dimensiuni: L: 15-20 cm, H: 4-5 cm, G: 2 cm; greutate: 80 g
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PANCREASUL
• La nivelul peretelui abdominal anterior : proiectie la 5-10 cm deasupra ombilicului
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De la duoden pana la splinaCoada- extraperitonealPlasat transversal pe coloana vertebrala- T10, T11, L1, L2Directie oblica: capul: L1, L2, L3
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Mijloace de fixare
•Conexiunea cu dd•Fascia Treitz•Peritoneul parietal posterior•Conexiunile vasculare, canalele biliare si pancreatice•Radacina mezocolonului transvers•Presa abdominala
LA NIVELUL COZII PANCREASULUI ELEMENTELE SALE DE FIXARE DISPAR,SEGMENTUL ESTE IN INTREGIME INTRAPERITONEAL (ligamentul frenico-lienal)
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CAPUL PANCREASULUI
• Segmentul cel mai voluminos
• Plasat inaintea si la dr. L1, L2, L3
• Formeaza cu duodenul un complex inseparabil
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CAPUL PANCREASULUI
3 margini– Superioara: raport cu bulbul duodenal, pedicului
hepatic; intra in raport intim cu D1, la 3 cm de pilor, unde artera GD incruciseaza D1
– Dreapta – Inferioara: contact intim cu D2, D3,
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CAPUL PANCREASULUI
2 fete:– Anterioara, impartita de radacina mezocolonului
transvers in • Supramezocolica (rap cu fata post a stomacului si
artera gastroduodenala)• Submezocolica (rap cu radacina mezenterului si vasele
mezenterice superioare)
– Posterioara, in raport cu fascia Treitz; raporturi cu:• L1, L2, L3• Pilierul dr. al diafragmului• Arcada psoasului• Vena cava inferioara• Artera renala dreapta
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CAPUL PANCREASULUI
• Un raport special: CBP abordeaza pancreasul la mijlocul D1• Plasata intr-un sant tisular• In drumul spre ampula Vater (unirea 1/3 superioare cu 2/3
inferioare) devine net intraglandulara
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CAPUL PANCREASULUI
• Procesul uncinat: de la nivelul extremitatii inferioare stangi , o prelungire de tesut pancreatic care merge spre stanga, inapoia VMS (uneori si inapoia arterei)
• ! Detasarea procesului uncinat de vena mezenterica superioara este unul dintre timpii delicati ai DPC!
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CAPUL PANCREASULUI
In 12 % din cazuri , in acelasi plan cu procesul uncinat, insa mai profund, pe fata posterioara se desprinde prelungirea retroportala a pancreasului, fixata printr-o lama conjunctiva constituita de elemente nervoase si limfatice de:
Aorta/Trunchi celiac/Artera mezenterica superioara cuprinzand vena mezenterica superioara ca intr-o potcoava
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ISTMUL PANCREASULUI• Situat pe linia mediana• La dreapta unghiului duodeno-jejunal• Incruciseaza originea AGD, artera hepatica si splenica• In jos: rap cu vasele mezenterice sup• Post: rap cu originea venei porte
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CORPUL PANCREASULUI
• Supramezocolic
• Pe sectiune: prismatic– 2 fete– 2 margini
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CORPUL PANCREASULUI
Fata anterioara: raport cu fata posterioara a stomacului
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CORPUL PANCREASULUI
Fata posterioara raport cu : Ao abdominala, plexul celiac,vena renala stanga, suprarenala stanga, rinichiul stang
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PENSA AORTO-MEZENTERICA
• Vena renala stanga se orienteaza spre dreapta, in pensa aorto-mezenterica pentru a se varsa in vena cava inferioara
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CORPUL PANCREASULUI
• Marginea superioara este relativ libera
• Vine in raport cu micul epiploon si artera splenica
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CORPUL PANCREASULUI
• Marginea inferioara se desprinde de duoden, intra in raport cu unghiul duodeno-jejunal si mezocolonul transvers, flancata de artera pancreatica inferioara
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COADA PANCREASULUI
• Segmentul intraperitoneal
• In grosimea epiploonului pancreatico-splenic
• Pe marginea sup: artera splenica (inainte de a emite vasele scurte, gastro-epiploica stanga)
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CANALELE EXCRETORIICanalul pancreatic principal- WIRSUNG
– Rectiliniu la nivelul corpului si cozii– Strabate in intregime glanda– La nivelul capului emite in “Y” canalul Santorini care dreneaza
partea sup. a capului pancreatic– Se indreapta in jos si se deschide separat/ comun in coledoc, in
ampula mare Vater, in D2
– Plasarea canalului: centrala la nivelul cozii/ ant in corp/ posterioara
cefalic (calibru de 2,5-3 cm)
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CANALELE EXCRETORIICanalul Santorini
– Dreneaza partea superioara a capului– De la origine se indreapta spre dreapta– Mai superficial dacat Wirsungul– Se deschide in caruncula mica
– !canal inferior al capului– !canale accesorii
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VASCULARIZATIA PANCREASULUI• La nivelul capului
Arcada superioara:
• Pancreatico-duodenala superioara dreapta (ram din gastro-duodenala)
– Incruciseaza fata ant a coledocului– Inapoia D1– Coboara inapoia pancreasului si fetei post a coledocului– Se anastomozeaza cu
• Pancreatico-duodenala stanga din mezenterica superioara
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VASCULARIZATIA PANCREASULUI
La nivelul capului:• Arcada inferioara:
– Pancreatico-duodenala inferioara dreapta (din gastro-duodenala) se anastomozeaza cu pancreatico-duodenala stanga (din mezenterica superioara)
– Pancreatico-duodenalele inferioare stangi-din prima sau a 2-a artera jejunala
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VASCULARIZATIA PANCREASULUI
La nivelul capului• O a 3-a arcada: din artera pancreatica dorsala cu origine
in artera splenica, trunchiul celiac sau a. hepatica• La nivelul istmului emite 2 rr pentru capul pancreasului
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VASCULARIZATIA PANCREASULUI
La nivelul corpului pancreasului– Vascularizatia este variabila, cu originea in a.
splenica, mezenterica superioara sau hepatica
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VENELE PANCREASULUI
• Vena pancreatico-duodenala dreapta se varsa (retrocefalo-pancreatic si retrocoledocian) pe flancul drept al venei porte
• Vena pancreatico-duodenala inferioara stanga se varsa pe fata posterioara a trunchiului mezenteric superior
• Vena pancreatico-duodenala inferioara dreapta se uneste cu vena gastro-epiploica dreapta si colica dreapta superioara pe fata ant a pancreasului , rezulta un trunchi gastro-colic ce se varsa in mezenterica sup
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LIMFATICELE PANCREASULUI
• Cap: spre ggl subpancreatici, la marginea inferioara a corpului
• Corp, coada: in ggl subpilorici
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Relee limfatice
1. Suprapancreatic (de-a lungul vaselor splenice)2. Subpancreatic (intre foitele mezocolonului transvers3. Ggl mezenterici superiori4. Ai mezocolonului transvers5. Ai hilului splenic6. Pancreatico-duodenal (ggl constant in spatele
genunchiului superior)7. subpilorici8. Ai lig gastro-pancreatic (! Ggl de-a lungul a hep)9. juxtaaortici
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Relee limfatice centrale
• Ggl latero-aortici
• Ggl intercavo-aortici
• Ggl trunchiului celiac
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INERVATIA
• PLEXUL CELIAC– SIMPATIC– PARASIMPATIC
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ANATOMIA SPLINEI
• Forma ovoidala
• Polul superior: in apropierea unghiului costo-vertebral 9
• Polul inferior: pe sustenacului lienal, linia axilara medie, sp. X intercostal
• Dimensiuni de 13/7/3 cm
• G: 180-200g
• Culoare rosie – bruna
• Friabila
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CONFIGURATIE SI RAPORTURI
• Fata ext: convexa, acoperita de diafragm, intre coastele 9 si 11
• Fata interna: – Fateta antero-interna (prehilara, rap cu
stomacul si retrohilara, rap cu pancreasul)– Fateta postero-interna (rap cu rinichiul si
suprarenala stanga)– Fateta infero-interna (rap cu colonul)
• 2 poli, 2 margini
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• Acoperita in intregime de peritoneu
• In zona hilului este lipsita de peritoneu
• Elemente de sustinere:– Lig gastro-splenic– Lig pancreatico-splenic– Lig spleno-lienal– Lig freno-colic
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LOJA SPLENICA
• DELIMITARE:– CUPOLA DIAFRAGMATICA– LIGAMENTUL FRENO-COLIC STANG
(SUSTENACULUL LIENAL)– DESCHISA IN PARTEA INTERNA
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VASCULARIZATIA
• ARTERA SPLENICA
Ram din trunchiul celiac
Emite ramuri:– Polare, superioare si inferioare– Pancreatice (5-6)– Cardio-tuberozitare posterioare– Gastro-epiploica stanga– Vasele scurte
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VENELE
• Retroarterial
• 6-8 rr
• Formeaza vena splenica; aceasta primeste vena gastro-epiploica stanga, venele pancreatice
• Traiect lung
• Se uneste cu VMinf= trunchiul spleno-mezenteric (+ VMS= vena porta)
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LIMFATICELE
• Origine in pulpa alba• Din retelele profunde perivasculare• Se varsa in ggl hilului splenic la care
converg – Limfaticele marii curburi gastrice– Limfaticele marelui epiploon– Limfaticele cozii pancreasului
• Se varsa in ggl pancreatico-splenici si celiaci
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