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Renal Anatomy (Surface anatomy (Major blood vessels (Celiac: Upper L1, SMA…

- - - - 3 central regions (epigastric, umbilical, pubic)
      - Three regions on ea side: hypochondrium, flank and groin
- - - - Origin: anterior ramus L1
        Function: internal oblique and transversus abdominis (motor)
        Posterolateral gluteal skin and skin in pubic region (sense)
      - Cross anterior to quadratus lumborum, forming lateral cutaneous branch (posterolateral gluteal skin) above the iliac crest, and anterior cutaneous branch )skin in pubic region
    - - Origin: anterior L1
        Function: internal oblique and transversus abdominis (motor)
        Skin in upper medial thigh, skin over root of penis and anterior scrotum / mons pubis and labium majus
      - cross quadratus lumborum, smaller and inferior than iliohypo, course is more oblique, crossing part of iliacus muscle, going through inguinal ring along with spermatic cord, to upper medial thigh, root of penis and anterior scrotum
    - - Origin: anterior L1 and L2
        Function: Genital branch- male cremasteric muscle (motor)
        Genital branch - skin of anterior scrotum / mons pubis and labium majus
        Femoral branch -skin of upper anterior thigh (sense)
      - Down in substance of psoas major and descends on surface, passing from posterior to ureter, and divides into femoral and genital branch
      - genital - continues down, enters inguinal canal, innervate cremasteric muscle and terminates on skin in anterior upper part of scrotum, in women accompanies round ligament and terminates on skin of mons pubis and labia majus
      - Femoral: lateral side of external iliac artery, posterior to inguinal ligament
    - - Origin: L2 and L3
        function: skin on anterior and lateral thigh to knee (sense)
      - From lateral border of psoas major, obliquely down acros iliacus muscle to ASIS, passes posterior to inguinal ligament and enters thigh (anterior and lateral thigh to knee
    - - Origin: L2-L4
        Function: obturator externus, pectineus, muscles in median compartment of thigh (motor)
        Skin on medial aspect of thigh (sense)
      - Descends in psoas major, emerge from medial side near pelvic brim, continue posterior to common iliac vessels, across lateral wall of pelvic cavity and enter obturator canal through which gain access to medial compartment of thigh
      - In canal, divide into anterior and psoterior branches (separated by obturator externus and adductor brevis muscles)
      - Supply articular branches at hip joint, muscular branches to obturator externus, pectineus, adductor longus, grgacilis, adductor brevis, and adductor magnus muscles, cutaneous branches to medial aspect of thigh and saphenous nerve (upper part of leg and articular branches of knee joint)
    - - Origin: L2 - L4
        Function: iliacus, pectineus, muscle in anterior compartment of thigh (motor)
        Skin on anterior thigh and medial surface of leg (sense)
      - descends through substance of psoas major, emerge from lower lateral border of psoas major, continuin gdown between lateral border of psoas major and anterior surface of illiacus
      - Deep to iliacus fascia and lateral to femoral artery as it passes throguh posterior to inguinal ligament, enters anterior compartment of thigh
      - Medial and intermediate cutaneous nerves (skin of anterior surface of thigh) and saphenous nerve (medial surface of leg), muscles and articular branches of hip and knee joints
    - - From most superior: subcostal, iliohypogastric, ilioinguinal, lateral cutaneous, femoral, genitofemoral(more medial, go through psoas major), obturator (more posterior, goes down pelvis)
- - - - Unpaired
        
        Celiac trunk, SMA and IMA
      - Paired
        
        Middle suprarenal arteries, renal arteries, gonadal arteries
    - - supply diaphragm or body wall
      - Inferior phrenic arteries
        
        From just under hiatus directly from abdominal aorta, common trunk from abdominal aorta or from base of celiac trunk, pass upward
      - Lumbar arteries
        
        4 pairs, run laterally and posteriorly over bodies of lumbar VB continue laterally
      - Median sacral artery
        
        arise from psoterior surface just superior to bifurcation and pass inferior direction
  - - - Common iliac veins
      - Lumbar veins
      - right gonadal veins
      - renal veins
      - Right suprarenal vein
      - Inferior phrenic veins
      - Hepatic veins
    - - 5TH generally drains into iliolumbar vein -> common iliac vein
      - 3 and 4 drain into IVC
      - 1 and 2 into ascending lumbar veins
        
        long anastamosing venous channels that connect common iliac, iliolumbar and lumbar veins with azygos and hemiazygos veins of thorax
- - - - drains to pre-aortic nodes
      - Receive from Superior and inferior mesenteric, enters cisterna chyli
    - - Drains to pre-aortic nodes near origin of SMA
      - Receive from inferior
      - Drains to celiac nodes
    - - To pre-aortic near origin of IMA
      - To superior mesenteric nodes
  - - - Pass from sympathetic trunk or sympathetic ganglia associated with the trunk, to the prevertebral plexus and ganglia anterior to the abdominal aorta
    - - Greater Splanchnic nerve arises from 5th to 9/10th thoracic ganglia, travel to celiac ganglion in abdomen
      - Lesser splanchnic nerve arises from 9th and 10th (or 10 and 11) thoracic ganglia, travels to the aorticorenal ganglion
      - Least splanchnic nerve, when present, arises from 12th thoracic ganglion and travels to renal plexus
    - - 2 to 4 lumbar splanchnic nerves pass to prevertebral plexus
      - Sacral splanchnic nerves pass to the inferior hypogastric plexus, an extension of prevertebral plexus into the plexus
    - - The only splanchnic nerves that carry parasympathetic fibers
    - - surrounds abdominal aorta
      - three major division
        
        Celiac plexus:
        Large accumulation of nerve fibers and ganglia, associated w roots of celiac trunk and SMA immediately below the aortic hiatus of diaphragm
        
        Aortic Plexus:
        Anterior and lateral surfaces of abdominal aorta, extending from below origin of SMA to bifurcation of aorta, major ganglion here is IM ganglion
        
        Superior hypogastric plexus:
        Final part before it continues into pelvic cavity
      - Secondary plexuses usually named after vessels they are associated with
        
        Celiac -> SM plexus, renal plexus and other celiac trunks
        
        Aortic -> IM plexus, spermatic plexus, external iliac plexus
        
        Superior hypogastric -> inferior hypogastric or pelvic plexus
      - Receives
        
        Vagus nerves (X)
        
        Thoracic and splanchnic nerves, pelvic splanchnic nerves
    - - Vagus nerves
        
        enter abdomen associated w esophagus as it pass through diaphragm, to foregut and midgut, as the anterior and posterior vagal trunks
- - - - L1 to L5
      - S1 to S5
      - Pelvic bones
        
        Ilia attach laerally to sacrum and sacro-iliac joints
        
        Upper part of each ilium expands outward into a wing-like area -> iliac fossa
      - Ribs
        
        11 and 12
        
        Do not articulate w sternum or other ribs
    - - Medially: Psoas major and minor
        Laterally: quadratus lumborum
        Inferiorly: iliacus muscle
        Superiorly Diaphragm
      - Psoas Major
        
        Origin: Lateral surface of VB T12 to L5. TP of lumbar, IV discs between T12 and L5
        
        Insertion: lesser trochanter of the femur
        
        Innervation: anterior Rami of L1 to L3
        
        Flex of thigh at hip joint when trunk is stabilized, flex trunk against gravity when supine
      - Psoas Minor
        
        Origin: Lateral surface of VB of T12 and L1 and intervening IV disc
        
        Insertion: Pectineal line of pelvic brim and iliopubic eminence
        
        Innervation: anterior Rami of L1
        
        Weak flexor of lumbar vertebral column
      - Quadratus Lumborum
        
        Origin: TP of L5 vertera, iliolumbar ligament and iliac crest
        
        Insertion: TP of L1 to L4 and inferior border of rib 12
        
        Innervation: anterior rami of T12 to L4
        
        Depress and stabilize rib 12 and some lateral bending of trunk
      - Iliacus
        
        Origin: Upper 2/3 of iliac fossa, anterior sacro-iliac and iliolumbar ligaments, and upper lateral surface of sacrum
        
        Insertion: Lesser trochanter of femur
        
        Innervation: femoral nerve (L2 to L4)
        
        Flex thigh at hip joint when trunk is stabilized, flex trunk against gravity when body is supine
      - Diaphragm
        
        Anchored to lumbar vertebrae by muculotendinous crura which blend with ALL
        
        Right crus is longest and broadest of crura, attached to VB of L1 to L3 and intervening IV discs
        
        left crus attached to VB L1 and L2 and associated IV discs
        
        Crura connacted across midline by tendinous arch (median arcuate ligament), which pass anterior to aorta
        
        Lateral to crura, covering upper part of psoas major: medial arcuate ligament
        
        Attached medially to sides of L1 and L2 and laterally to TP of L1
        
        Lateral arcuate ligament:
        
        Formed by thickening in fascia covering quadratus lumborum
        
        Attached medially to TP of L1 and laterally to Rib 12
        
        Medial and lateral arcuate ligaments serve as points of origin for some muscular components of diaphragm
        
        Structure passing through diaphragm
        
        Aorta at T12, between crura, just left of midline
        
        Thoracic duct and sometimes, azygous vein, accompanies it
        
        Esophagus and T10, just left of aortic hiatus
        
        together with anterior and posterior vagal trunks, esophageal branches of left gastric artery and vein and a few lymphatic vessels
        
        IVC at T8, central tendinous part of diaphragm
        
        right phrenic nerve tgt
        
        Left phrenic pass through muscular part of diaphragm just anterior to central tendon on left side
        
        Smaller openings
        
        Greater, lesser and least (if present) splanchnic nerves pass through crura on either side
        
        Hemi-azygous vein pass through left crus
        
        Sympathetic trunk posterior to medial arcuate ligament
        
        Superior epigastric vessels just anterior to diaphragm, deep to ribs
        
        Domes
        
        Liver on the right, w some contribution from right kidney and suprarenal gland
        
        Fundus of stomach, spleen on left, w contributions from left kidney and suprarenal gland
        
        Although height varies during breathing, reasonable estimate in normal expiration place left dome at 5th ic space and right dome and rib 5 (impt when percussing thorax)
        
        Blood supply
        
        Superiorly: musculophrenic and pericardiacophrenic arteries, both branches of internal thoracic artery and superior phrenic artery (from thoracic aorta)
        
        Inferiorly, inferior phrenic arteries, branches of abdominal aorta
        
        Venous drainage is through accompanying veins
        
        Innervation
        
        Phrenic nerves (C3 to C5)
- - - - Right kidney
        
        Small part of superior pole covered by right suprarenal gland
        
        Large part of rest of upper anterior surface is against the liver, separated from it by a layer of PERITONEUM
        
        Medially, descending part of duodenum is retroperitoneal and contact directly to kidney (near hilum)
        
        Inferior pole of kidney, on its lateral side, directly associated with right colic flexure and on its medial side, is covered by a segment of intraPERITONEAL small intestine
      - Left Kidney
        
        Small part of superior pole, on medial side, covered by left suprarenal gland
        
        Rest of superior pole is covered by intraPERITONEAL stomach and spleen
        
        retroperitoneal pancreas covers middle part of kidney directly
        
        Lateral side, lower half of kidney is covered by left colic flexure and beginning descending colon directly, medial side by parts of intraPERITONEAL jejunum
      - Posteriorly
        
        Superiorly related to diaphragm
        
        from medial to lateral: Psoas major, quadratus lumborum, transversus abdominis muscle
        
        Also subcostal vessels and nerves, and iliohypogastric and ilio-inguinal nerves
    - - Immediately outside of renal capsule is an accumulation of extraperitoneal fat -> perinephric fat (perirenal fat) which completely surrounds the kidney
      - Enclosing perinephric fat is extraperitoneal fascia (renal fascia)
        
        suprarenal gland also enclosed in this fascial compartment, suually separated from kidneys by a thin septum
        
        Renal fascia must be incised in any surgical approach to kidney
      - At lateral margins of ea kidney, anterior and posterior layers of renal fascia fuse -> connect w transversalis fascia on lateral abdominal wall
      - Above ea suprarenal gland, anterior and posterior layers fuse and blend w fascia that covers diaphragm
      - medially, anterior layer of renal fascia continues over vessels in hilum and fuse with CT associated w abdominal aorta and IVC. In some casess, anterior layer may cross midline to opp side and blend its companion layer
      - Posterior layer pass medially between kidney and fascia covering quadratus lumborum to fuse w fascia covering the psoas major
      - Final layer: paranephric fat (pararenal fat)
        
        Accumulates posterior and posterolateral to ea kidney
    - - Smooth anterior and posterior surface covered by a fibrous capsule which is easily removable except during disease
      - In medial margin: hilum of kidney, a deep vertical slit through which renal vessels, lymphatics and nerves enter and leave
      - Internally, hilum is continuous with renal sinus, perinephric fat continues into hilum and sinus and surrounds all structures
      - each kidney consist of an outer renal cortex and an inner renal meduula
        
        Renal Cortex is a continuous band of pale tissue that complete surrounds renal medulla
        
        extensions of renal cortex (renal columns) project into inner aspect of kidney, dividing renal medulla into discontinuous aggregations of triangular shaped tissue (renal pyramids)
      - Apical projection (renal papilla) is surrounded by minor calyx, which receives urine and represent proximal parts of the tube that wille ventually form ureter
      - In renal sinus, several minor calices unite to form a major calyx, and 2 or 3 major calices unite to form renal pelvis -> funnel shaped superior end of ureters
    - - Single large renal artery (lateral branch of abdominal aorta)
        
        Rise inferior to origin of SMA between L1 and L2
        
        Left renal artery usually arises a little higher than the right, and right renal artery is longer and passses posterior to the IVC
        
        As each renal artery approach the hilum, divides into anterior and posterior branches (into the 5 surgically resectable lobes)
        
        Accessory renal arteries are common, origniate from lateral aspect of abdominal aorta and enter the hilum w the primary arteries or directly into the kidney at some other levels (extrahilar arteries)
      - Renal veins
        
        Multiple renal veins contribute to left and right renal veins, both of which are anterior to renal arteries
        
        Longer left renal vein crosses the midline anterior to abdominal aorta, posterior to SMA and can be compressed by an aneurysm in either of these 2 vessels
        
        Left renal vein goes to renal vein (same for left suprarenal vein) whereas right renal vein goes straight to IVC
      - Lymphatics
        
        to lateral aortic (lumbar) nodes around origin of renal artery
    - - Muscular tubes that transport urine from kidneys to bladder
      - Renal pelvis narrows, becomes continuous with the ureter at ureteropelvic junction
      - Goes inferior retroperitoneally on medial aspect of psoas major, at pelvic brim cross either end of common iliac artery or beginning of external iliac artery, enter pelvic cavity and continue down
      - 3 points of constrictions
        
        ureteropelvic junction
        
        Ureters cross the common iliac vessels at the pelvic brim
        
        Ureters enter wall of kidney bladder
      - Kidney stones can be lodged at these constrictions
      - Vasculature and lymphatics
        
        renal arteries supply upper end
        
        Middle part may receive from branches of abdominal aorta, testicular or ovarian arteries and the common iliac arteries
        
        In pelvic cavity, ureters supplied by one or more arteries from branches of the internal iliac arteries
        
        Lymph drainage follows same pattern as arterial supply
        
        Upper part of ureter -> lateral aortic nodes
        
        Middle part-> common iliac vessels
        
        inferior: external and internal iliac vessels
      - Innervation
        
        Visceral efferent fibers from both sympathetic and parasympathetic
        
        Visceral afferent return to T11 to L2 levels
        
        Uteric pain, usually related to distension of ureter, thus referred to cutaneous areas supplied by T11 to L2:
        
        posterior and lateral ab wall below ribs and above iliac crest, pubic region, scrotum/labia majora and proximal aspect of thigh
      - Nephrostomy
        
        Tube placed through lateral or posterior abdominal wall into renal cortex, lie within renal pelvis
        
        Function is to allow drainage of urine from renal pelvis through tube
        
        Access visualized under ultrasound guidance
      - Kidney transplant
        
        Ideal place for transplant is in left or right iliac fossa
        
        New space can be created without compromise to other structures, easy US visualization, extraperitoneal approach allows swift recovery
    - - Right gland shaped like pyramid
        Left gland semilunar in shape and larger of the 2
      - anterior to right suprarenal gland is part of right lobe of liver and IVC
        Anterior to left suprarenal gland is part of stomach, pancreas and on occasion, the spleen
      - Parts of diaphragm posterior to both glands
      - Surrounded by perinephric fat and enclosed in renal fascia, though a thin septum separates it from its associated kidney
      - Vasculature
        
        As bilateral inferior phrenic arteries pass upward from abdominal aorta to diaphragm, give off multiple branches (superior suprarenal arteries) to suprarenal glands
        
        Middle branch (middle suprarenal artery) arise directly from abdominal aorta
        
        Inferior branch (inferior suprarenal arteries) from renal arteries pass upward to suprarenal glands
        
        Venous supply: single vein leave hilum of each gland, right suprarenal vein is short and almost immediately enter IVC, left suprarenal vein pass inferiorly to enter left renal vein