In the name of Allah

Jejunum and ileum

Rest of the small intestine From duodenojejunal flexure To ileocecal junction Intraperitoneal Attached to the posterior

abdominal wall by mesentery of small intestine

Relations- Anterior abdominal wall- Greater omentum- Posterior abdominal wall- Retroperitoneal structures

• In umbilical region of peritoneal cavity

• First 2:5 of small intestine• Diameter 4cm • Mucosal folds are large and

frequent• Thicker wall• More vascular• Redder in life• Arterial arcade less• Aggregated lymphatic follicles

are lesser• Intermesenteric fat less

• In lower part of peritoneal cavity

• Second 3:5 of small intestine• Diameter 3.5 cm• Mucosal folds are small and

few• Thinner wall• Less vascular• Paler in life • Arterial arcade more• Aggregated lymphatic

follicles are more• Intermesenteric fat more

JejunumJejunum Ileum

Ileum Ileum

Ileal or Meckel’s diverticulum Ileal or Meckel’s diverticulum

Large intestine

Large intestine

1.5 m1.5 m From caecum to anusFrom caecum to anus Includes;Includes;- Cecum and appendix Cecum and appendix - Ascending colonAscending colon- Transverse colonTransverse colon- Descending colon Descending colon - Sigmoid colonSigmoid colon- RectumRectum- Anal canalAnal canal

Large Large intestine intestine

Differs from small intestine in Differs from small intestine in the: the:

• More fixed in positionMore fixed in position• Greater caliberGreater caliber• Taeniae coliTaeniae coli• Sacculation (haustration)Sacculation (haustration)• Appendices epiploicAppendices epiploic

Cecum Cecum

In the right iliac fossaIn the right iliac fossa 6.5*7.5 cm6.5*7.5 cm Related posteriorly to the Related posteriorly to the - iliacus & psoas mm iliacus & psoas mm - lateral cutaneous N of thighlateral cutaneous N of thigh- femoral nerve femoral nerve Related anteriorly to the: Related anteriorly to the: • ant. Abdominal wallant. Abdominal wall• Small intestineSmall intestine• Greater omentumGreater omentum

Caecum Caecum

• IntraperitonealIntraperitoneal• sup. & inf. Ileucecal and sup. & inf. Ileucecal and

retrocecal recesses retrocecal recesses

ileocecal valveileocecal valve

• Sup & inf. Lip and Sup & inf. Lip and frenulumfrenulum

• Posteromedial of cecumPosteromedial of cecum• At the level of At the level of

transetubercular and transetubercular and midclavicular linesmidclavicular lines

Vermiform appendixVermiform appendix

In the right iliac fossaIn the right iliac fossa McBurney’s pointMcBurney’s point 2 cm below the ileocecal 2 cm below the ileocecal

junctionjunction Length 2-20cm average 9cmLength 2-20cm average 9cm IntraperitonealIntraperitoneal Position Position - Retrocecal & retrocolic 64%Retrocecal & retrocolic 64%- Pelvic 30%Pelvic 30%- Subcecal 2.5%Subcecal 2.5%- pre and postileal 1.5%pre and postileal 1.5%

Ascending Ascending colon colon

15 cm from cecum to hepatic flexure

Covered in front and sides by peritoneum

Taeniae coli ant., med. & lat. Relation • Posteriorly - Quadratus and iliacus- Lateral cutaneous N of thighLateral cutaneous N of thigh- Iliohypogastric - Ilio-inguinal

Ascending Ascending colon colon

Relations Relations • anteriorly anteriorly - Small intestineSmall intestine- Ant. Abdominal wallAnt. Abdominal wall- Greater omentumGreater omentum

Right or hepatic Right or hepatic flexureflexure

Turns down and forwardTurns down and forward Kidney posteriorKidney posterior Liver anterosuperior and Liver anterosuperior and

laterallateral Duodenum medialDuodenum medial Gall bladder anteromedial Gall bladder anteromedial

Transverse Transverse coloncolon

50 cm, from hepatic to 50 cm, from hepatic to splenic flexuressplenic flexures

From Rt. Lumbar From Rt. Lumbar To Lt. hypochondriumTo Lt. hypochondrium Intraperitoneal and Intraperitoneal and

attached to the post. attached to the post. abdominal wall by meso.abdominal wall by meso.

TaeniaeTaeniae

Transverse Transverse coloncolon

RelationsRelations• anterioranterior- OmentumOmentum- Ant. abdominal wallAnt. abdominal wall• posteriorposterior- PancreasPancreas- 22ndnd part of duodenum part of duodenum

Lt. colic Lt. colic flexure flexure

Higher than rightHigher than right relationsrelations- SpleenSpleen- Pancreas Pancreas - Lt. kidneyLt. kidney- Phrenicocolic Phrenicocolic

Descending colonDescending colon 25 cm 25 cm from splenic flexure to pelvic brimfrom splenic flexure to pelvic brim Two parts Two parts Covered anterioly by peritineumCovered anterioly by peritineum

Descending Descending coloncolon

Relations:Relations:• Anterior same as the right Anterior same as the right • Posterior: Posterior: - Kidney Kidney - Subcostal nerveSubcostal nerve- IliohypogastricIliohypogastric- IlioinguinalIlioinguinal- Lateral cutaneous N of thighLateral cutaneous N of thigh

Sigmoid colonSigmoid colon

25- 40 cm from pelvic 25- 40 cm from pelvic brim to S3brim to S3

Has meso.Has meso.• Lateral limb Lateral limb • Medial limb in front of Medial limb in front of

sacrumsacrum• Intersigmoid recessIntersigmoid recess

Sigmoid colonSigmoid colon

Relations Relations • PosteriorPosterior- Rectum Rectum - SacrumSacrum- UreterUreter• Anterior Anterior - UterusUterus- bladderbladder

Rectum Rectum 10-15 cm From S3 To tip of coccyx continuous

as the anal canal Piercing pelvic diaphragm Passing downward following

the curve of sacrum Deviate to the left and turns

right Rectal ampulla Anorectal angle

RectumRectum Peritonial coveringPeritonial covering Muscular coatMuscular coat Transverse foldTransverse fold

RectumRectum Relations:Relations:

Posteriorly;Posteriorly;- SacrumSacrum- CoccyxCoccyx- PiriformisPiriformis- CoccygeusCoccygeus- Lavator aniLavator ani- Sacral plexusSacral plexus- Sympathetic chain Sympathetic chain

RectumRectum

RelationsRelations

AnteriorlyAnteriorly

In male In male - Sigmoid colonSigmoid colon- IleumIleum- BladderBladder- Vas deferens Vas deferens - Seminal vesicleSeminal vesicle- prostate prostate

RectumRectum RelationsRelations

AnteriorlyAnteriorly

In femaleIn female- Sigmoid colonSigmoid colon- Ileum Ileum - Rectouterine Rectouterine

(Douglas) pouch(Douglas) pouch- Uterus Uterus - Vagina Vagina

Small and large intestine ArteryArtery- Superior mesenteric (small & Superior mesenteric (small &

large)large)- Inferior mesenteric (large)Inferior mesenteric (large)- Internal iliac (rectum & anal canal)Internal iliac (rectum & anal canal) Vein Vein - Superior mesenteric (small & Superior mesenteric (small &

large)large)- Inferior mesenteric (large)Inferior mesenteric (large)- Internal iliac (same as artery)Internal iliac (same as artery)

Anal canalAnal canal 4-5 cm4-5 cm From the rectal ampulla From the rectal ampulla To the anusTo the anus RelationsRelations

Posteriorly Posteriorly - Anococcygeal bodyAnococcygeal body

AnteriorlyAnteriorly

MaleMale- Perineal body Perineal body - Urogenital diaphragmUrogenital diaphragm- UrethraUrethra- Bulb of penisBulb of penis

Anal canalAnal canal

Female- Perineal body Perineal body - Urogenital diaphragmUrogenital diaphragm- VaginaVagina

Laterally Laterally

- Ischiorectal fossae- Ischiorectal fossae

Anal canalAnal canal Upper halfUpper half- Derived from endodermDerived from endoderm- Anal culumnsAnal culumns- Anal valvesAnal valves- Anal sinusesAnal sinuses

- Autonomic nerveAutonomic nerve- Sensitive to stretch Sensitive to stretch - Artery and vein from and to Artery and vein from and to inferior mesenteric inferior mesenteric

Anal canalAnal canal

Lower halfLower half- Derived from ectodermDerived from ectoderm- Has no anal columnsHas no anal columns- Somatic nerve, inferior rectalSomatic nerve, inferior rectal

- Sensitive to pain, Sensitive to pain, temperature, touch, pressure temperature, touch, pressure

- Art. And vein from and to Art. And vein from and to internal iliac internal iliac

- Pectinate linePectinate line

Anal canalAnal canal Muscle coat - Internal sphincter

(smooth muscle)- External sphincter

Subcutaneous

Superficial

Deep- Puborectalis- Anorectal ring

Puborectalis + internal sphincter + deep part of ext. sphincter

innervationinnervation

Autonomic Somatic- Inferior rectal

Rectum and anal canalRectum and anal canal

Blood supplyBlood supply

Arteries: Arteries: - Superior rectalSuperior rectal- Middle rectalMiddle rectal- Inferior rectalInferior rectal

Veins:Veins:- Superior rectalSuperior rectal- Middle rectalMiddle rectal- Inferior rectalInferior rectal