가로막, 간, 쓸개 (Diaphragm, Liver, Gall bladder) 가로막 (Diaphragm) 가장자리 : 근육, 가운데 : 널힘줄로구성 둥근천장모양의구조물 가로막근육의세부분 복장부분 (Sternal part) 갈비부분 (Costal part): 왼 / 오른지붕 허리부분 (Lumbar part) 닿는곳 ( 대정맥공 : caval foramen) 가로막다리 이는곳 오른다리 (right crus) : 위 3 개의허리뼈몸통 (body of lumbar vertebrae) 에서일어남. 왼다리 (left crus) : 위 2 개의허리뼈몸통오름쪽에서일어남. ** 식도가지나가는식도구멍은중간선의왼쪽에위치하지만식도구멍은오른다리가형성한다 (70%) 이는곳 1
허리갈비삼각 가로막 2
활꼴인대 (Arcuate ligaments) : 큰허리근 (psoas major) 과허리네모근 (quadratus lumborum) 을덮고있는근막이두꺼워져형성 안쪽활꼴인대 : 허리뼈몸통과가로돌기사이인대 큰허리근과교감신경줄기가지나감 가쪽활꼴인대 : 가로돌기와 12번째갈비뼈사이인대 허리네모근이지나감 정중활꼴인대 : 양쪽다리 (crura) 사이인대 대동맥구멍의앞과옆둘레만듬 복장갈비삼각 (Sternocostal triangles) : 갈비뼈부분과복장뼈부분사이에생기는삼각형의틈새 허리갈비삼각 (Lumbocostal triangle) : 가로막근육의시작부분중에서갈비뼈부분과허리뼈부분사이에틈이생긴것 3
선청성가로막탈장 (Congenital diaphragmatic hernia,cdh) : lumbocostal trigone 간이오른쪽에있기때문에왼쪽에서주로탈장 신생아 2200 명당 1 명꼴 허파가형성되지않을가능성이높으며 ( 폐형성부전증, pulmonary hypoplasia) 으로사망률이높다 4
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Thoracic diaphragm - The diaphragm is a dome-shaped, musculotendinous partition separating the thoracic and abdominal cavities. Its mainly convex superior surface faces the thoracic cavity, and its concave inferior surface faces the abdominal cavity. The diaphragm, the chief muscle of inspiration, descends during inspiration; however, only its central part moves because its periphery, as the fixed origin of the muscle, attaches to the inferior margin of the thoracic cage and the superior lumbar vertebrae. - The muscular part of the diaphragm is situated peripherally with fibers that converge radially on the trifoliate central aponeurotic part - the central tendon. The central tendon has no bony attachments and is incompletely divided into three leaves, resembling a wide cloverleaf. - The crura of the diaphragm are musculotendinous bundles that arise form the anterior surfaces of the bodies of the superior three lumbar vertebrae, the anterior longitudinal ligament, and the IV discs. - The entire motor supply to the diaphragm is from the phrenic nerves, each of which is distributed to half of the diaphragm and arises from the ventral rami of C3 through C5 segments of the spinal cord. The phrenic nerves also supply sensory fibers (pain and proprioception) to most of the diaphragm. 가로막 6
위자국 (Gastric impression) ㅍ ㅍ 날문자국 (pyloric area 오른시상틈새 왼쪽시상틈새 ( 간원인대틈새 ) ( 정맥관인대틈새 ) 7
시계방향 오른간, 왼간 간세동의일차가지에따라안쪽, 가쪽구역 오른간문틈새, 왼간문틈새 오른, 왼간정맥에따라 2 차가지앞, 뒤구역 3 차가지 8
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Inf view ** 간엽절제술 (hepatic lobectomy): Hepatic a. 과, hepatic duct( 간관 ), portal v( 문맥 ) 이일차가지를낸후서로연결되지않기때문 10
Portal vein and Portal-Systemic anastomoses - The portal vein is the main channel of the portal venous system. It collects poorly oxygenated but nutrient-rich blood from the abdominal part of the GI tract, including gallbladder, pancreas, and spleen, and carries it to the liver. There it branches to end in expanded capillaries - the venous sinusoids of the liver. - The portal venous system communcates with the systemic venous system in the following locations - between the esophageal veins draining into either the azygos vein (systemic system) or the left gastric vein (portal system) esophageal varix - between the rectal veins, the inferior and middle draining into the IVC (systemic system), and the superior rectal vein continuing as the IMV (portal system). The submucosal veins involved are normally dilated (varicose in appearance), even in newborns; when the mucosa containing them prolapses, they form hemorrhoids - paraumbilical veins of the anterior abdominal wall (portal system) anastomosing with superficial epigastric veins (systemic system); when dilated, these veins produce caput medusae - varicose veins radiating from the umbilicus - twigs of colic veins (portal system) anastomosing with retroperitoneal veins (systemic system) Right Left Gastric a. Gastric a. Hepatic a. Celiac trunk Gastro Duodenal a. Aorta Common Hepatic a. Splenic a. 11
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Functional parts of the liver - The liver has functionally independent right and left parts (portal lobes) that are approximately equal in size. Each part has its own blood supply from the hepatic artery and portal vein and its own venous and biliary drainage. On the visceral surface, the right (part of the) liver is demarcated from the left (part of the) liver by the gallbladder fossa inferiorly and the fossa for IVC superiorly. An imaginary line over the diaphragmatic surface of the liver that runs from the fundus of the gallbladder to the IVC separates the parts. Both the right and left parts of the liver have medial and lateral divisions; those of the left liver are separated by the falciform ligament. In current terminology, the left liver includes the caudate lobe and most of the quadrate lobe. - The round ligament of the liver is the fibrous remnant of the umbilical vein that carried well-oxygenated and nutrient-rich blood from the placenta to the fetus. The umbilical vein remains patent in infants for a while. In individuals with portal hypertension (abnormally increased blood pressure in the portal venous system), there may be enlarged paraumbilical veins that course along the round ligament. 간 - The ligamentum venosum is the fibrous remnant of the fetal ductus venosus that shunted blood from the umbilical vein to the IVC, short-circuiting the liver. - The porta hepatis (hepatic portal) is a transverse fissure on the visceral surface of the liver between the caudate and quadrate lobes, where the portal vein and hepatic artery enter the liver and the hapatic ducts leave. The porta hepatis gives passage to the portal vein, hepatic artery, hepatic nerve plexus, hepatic ducts, and lymphatic vessels. - The portal vein, a short, wide vein, is formed by the superior mesenteric and splenic veins posterior to the neck of the pancreas, ascends anterior to the IVC, and divides at the right end - The liver is a major lymph-producing organ: between one-quarter and one-half of the lymph received by the thoracic duct comes from the liver. - hepatic LNs celiac LNs cisterna chyli (a dilated sac at the inferior end of the thoracic duct) 간 13
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Biliary ducts and gallbladder - bile canaliculi interlobular biliary ducts large collecting bile ducts right & left hepatic ducts common hepatic duct common bile duct - The common bile duct forms in the free edge of the lesser omentum by the union of the cystic duct and the common hepatic duct. The bile duct descends posterior to the superior (first) part of the duodenum and lies in a groove on the posterior surface of the head of the pancreas. On the left side of the descending (second) part of the duodenum, the bile duct comes into contact with the main pancreatic duct. These ducts run obliquely through the wall of this part of the duodenum, where they unite to form the hepatopancreatic ampulla (ampulla of Vater) - the dilation within the major duodenal papilla. Gallbladder - fundus - body - neck - spiral valve 간 15