Download MBBS Kidney Ureter and Suprarenal Gland Lecture PPT

OBJECTIVES

-Anatomical features of the kidneys:

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position, extent, relations, hilum, peritoneal

coverings.

-Internal structure of the kidneys:

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Cortex, medulla and renal sinus.

-The vascular segments of the kidneys.

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-The blood supply and lymphatics of the kidneys.


POSITION OF KIDNEY
Kidneys are retroperitoneal paired

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organs.
? Each kidney lies , on the posterior

abdominal wall, lateral to the

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vertebral column
? In the supine position, the kidneys

extend from approximately T12 toL3.

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? The right kidney is slightly lower

than the left kidney because of the

large size of the right lobe of the liver.

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? With contraction of the diaphragm

during respiration, both kidneys

move downward in a vertical

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direction (high of one vertebra, 1

inch,2.5 cm).

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COLOUR, SHAPE & DIMENSIONS

? The kidney is a reddish brown, bean-sh

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aped organ with the dimensions 12 x 6 x

3cm.
? Although they are similar in size and

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shape, the left kidney is slightly longer

and more slender than the right kidney,

and nearer to the midline.

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? Each kidneys has:Convex upper & lower

ends.
Convex lateral border &Convex medial

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border at both ends, but its middle shows

a vertical slit called the hilum.Internally

the hilum extends into a large cavity called

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the renal sinus.


HILUM & RENAL SINUS

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? The hilum transmits, from ant
erior to posterior, the renal vei
n, renal artery & the ureter (VAU).

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? Lymph vessels & sympathetic
fibers also pass through the hilum.

? The renal sinus contains the upper

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expanded part of the ureter called

the renal pelvis.

? Perinephric fat is continues into the

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hilum and the sinus and
surrounds all these structures.

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COVERINGS

1. Fibrous capsule:
Is closely adherent to its surface
2. Perirenal fat:

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covers the fibrous capsule.
3. Renal fascia:
Condensation of areolar connecti
ve tissue that lies outside the
Perirenal fat and encloses the

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kidney and the suprarenal gland.
4. Pararenal fat:
Lies external to the renal fasci
a, is part of the retroperitoneal fat.

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ANTERIOR RELATIONS

The anterior surface of

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both kidneys are related to

numerous structures, some

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with an intervening layer of
peritoneum and others lie

directly against the kidney

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without peritoneum.


LEFT KIDNEY

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? A small part of the superior

pole,along the medial border , is

covered by left suprarenal gland.

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? The rest of the superior pole is

covered by the intraperitoneal

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stomach and spleen

.
? The retroperitoneal pancreas

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covers the middle part of the kidney.

? Its lower lateral part is directly

related to the left colic flexure and

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beginning of descending colon.

? Its lower medial part is covered by

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the intraperitoneal jejunum.


RIGHT KIDNEY
? A small part of the upper pole

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is covered by right suprarenal gland.

? The rest of the upper part of

anterior surface is related to the

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liver and is separated by a layer of

peritoneum.

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? The 2nd part of duodenum lies

directly in front of the kidney
close to its hilum.
? The lower lateral part is directly

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related to the right colic flexure and,

on its lower medial side, is related to

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the intraperitoneal small intestine


POSTERIOR RELATIONS

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Posteriorly, the right and left kidneys are almost related to similar structures.

Left kidney:

Diaphragm

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Right kidney:

Costodiaphragmatic rec

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? Diaphragm

ess of the pleura

? Costodiaphragmatic

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11th & 12th ribs; last int

recess, of the pleur

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ercostal space

a

Psoas major

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? 12th rib, last interco

Quadratus lumborum tr

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stal space

ansversus abdomini

? Psoas major

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s.

? Quadratus lumboru

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Subcostal (T12),

m, transversus abd

iliohypogastric & ilioin

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ominis.

guinal nerves.

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? Subcostal (T12), ili

ohypogastric & ilioi

nguinal nerves.

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Vertebrocostal & Renal Angles

? The angle between

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the last rib and the

lateral border of erector

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spinae muscle is

occupied by kidney and

is called the `Renal

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angle'

? The Vertebrocostal

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angle is occupied by the

lower part of the pleural

sac.

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INTERNAL STRUCTURE

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INTERNAL STRUCTURE
? Each kidney consists of an

outer renal cortex and an

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inner renal medulla.
? The renal cortex is a

continuous band of pale tissue

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that completely surrounds the

renal medulla.
? Extensions of the renal

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cortex,the renal columns

project into the inner aspect of

the kidney,dividing the renal

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medulla into discontinuous

aggregations of triangular-

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shaped tissue, the renal

pyramids.

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The bases of the renal pyramids are

directed outward, toward the cortex,

while the apex of each renal pyramid

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projects inward, toward the renal

sinus.

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? The apical projection (renal
papilla) is surrounded by a minor

calyx

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? In the renal sinus, several
minor calices unite to form a major

calyx, and two or three major calices

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unite to form the renal pelvis, which
is the funnel-shaped superior end of

the ureters

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ARTERIAL SUPPLY

The renal artery arises from the aorta

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at the level of the second lumbar

vertebra.
? Each renal artery divides into 5

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segmental arteries that enter the hilum

of the kidney, 4 in front of the renal

pelvis and one behind it.

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? They are distributed to the different

segments of the kidney.
? Each segmental artery gives rise to

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number of lobar arteries, each supplies

a renal pyramid.
? Before entering the renal substance,

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each lobar artery gives off two or three

interlobar arteries.

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? The interlobar arteries run

toward the cortex on each side

of the renal pyramid.

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? At the junction of the cortex

and the medulla, the Interlobar

arteries give off the arcuate

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arteries, which arch over the

bases of the pyramids.

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? The arcuate arteries give off

several interlobular arteries

that ascend inthe cortex and

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give off the afferent glomerular

arterioles

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Segmental branches &

vascular segments of

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kidneys(e.g. Left)

Each kidney has 5

segmental branches and is

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divided into 5 vascular

segments:

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1. Apical.
2. Caudal/Lower
3. Anterior

Superior/Upper

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4. Anterior Inferior/Middle
5. Posterior.


BLOOD SUPPLY

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Abdominal

aorta

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? Inferior

? Renal artery

vena cava

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? Segmental

? Renal vein

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arteries

? Interlobar

? lobar arteries

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veins

? Interlobar

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? Arcuate

arteries

? Arcuate

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veins

arteries

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?Interlobular

? Interlobular

veins

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arteries

? Afferent

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glomerular

arterioles

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Venous Drainage

Both renal veins drain to the inferi

or vena cava.

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? The right renal vein is behind the 2nd p

art of the duodenum and sometimes

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behind the lateral part of the head of t

he pancreas

? The left renal vein is three times longer t

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han the right (7.5 cm and 2.5 cm).

? So, for this reason the left kidney is the pr

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eferred side for live donor nephrectomy.

? It runs from its origin in the renal hilum,

posterior to the splenic vein and the bod

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y of pancreas, and then across the anteri

or aspect of the aorta, just below the ori

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gin of the superior mesenteric artery.

? The left gonadal vein enters it from belo

w and the left suprarenal vein, usually re

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? The right renal vein is behind the 2nd p

ceiving one of the left inferior phrenic vei

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art of the duodenum and sometimes

ns, enters it above but nearer the midline

behind the lateral part of the head of the

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? The left renal vein enters the inferior vena pancreas.

cava a little above the right vein.

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Lymphatic

Drainage:

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? The lymph

vessels follow the arteries.

? Lymph drains to the

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lateral aortic lymph nodes

around the origin of the

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renal artery.

Nerve Supply:

The nerve supply is the

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renal sympathetic plexus.

The afferent fibers that

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travel through the renal

plexus enter the spinal

cord in the

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10th, 11th, and 12th

thoracic nerves.
URETER

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INTRODUCTION

? The ureter is a narrow, thick

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walled, expansile muscular

tube.

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? Conveys urine from the kidney

to the urinary bladder.

? The urine is propelled from the

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kidney to the urinary bladder

by the peristaltic contractions

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of the smooth muscle of the

wall of the ureter.
Measurements

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? Length: 25 cm (10 inches).

? Diameter: 3 mm.

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COURSE IN ABDOMINAL PART

? The ureter begins as a

downward continuation of a

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funnel shaped renal pelvis at

the medial margin of the

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lower end of the kidney.

? The ureter passes

downward and slight medially

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on the psoas major, which

separates it from the

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transverse processes of the

lumbar vertebrae.

? Enters the pelvic cavity by

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crossing in front of the

bifurcation of the common

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iliac artery at the pelvic brim

in front of the sacroiliac joint.

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COURSE IN PELVIS

? In the pelvis, the ureter first runs

downward, backward, and laterally

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along the anterior margin of the

greater sciatic notch.

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? Opposite to the ischial spine, it

turns forward and medially to reach

the base of the urinary bladder.

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? Where it enters the bladder wall

obliquely.

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? Within the bladder wall, it narrows

down,takes a sinuous course, and

opens into the cavity of the bladder

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at the lateral angle of its trigone as

ureteric orifice.
PARTS AND RELATIONS

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? The ureter is generally divided into two parts: abdominal

and pelvic.

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? Each part is about the same length, i.e., 12.5 cm (5 inches).

? The abdominal part of ureter extends from the renal pelvis

to the bifurcation of the common iliac artery.

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? The pelvic part of the ureter extends from the pelvic brim

(at the level of bifurcation of the common iliac artery) to the

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base of the urinary bladder.


RELATIONS OF ABDOMINAL PART

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Medially the right ureter is related to inferior vena

cava and left ureter is related to left gonadal vein

and inferior mesenteric vein.

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RELATIONS OF PELVIC PART

? The pelvic part of the ureter crosses in front of

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all the nerves and vessels on the lateral pelvic wall

except vas deferens, which crosses in front of it.

? Near the uterine cervix, the uterine artery lies

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above and in front of it, a highly important surgical

relationship.
SITES OF ANATOMICAL

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NARROWINGS/CONSTRICTIONS

The lumen of the ureter is not uniform throughout and presents three

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constrictions at the following sites.

1. At the pelviureteric junction where the renal pelvis joins

the upper end of ureter. It is the upper most constriction,

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found approximately 5 cm away from the hilum of kidney.

2. At the pelvic brim where it crosses the common iliac artery.

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3. At the uretero-vesical junction (i.e., where ureter enters

into thebladder).

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? In addition to above

three sites of

constrictions, two more

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sites of constrictions

are described by the

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surgeons.

1. At juxtaposition of

the vas

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deferens/broad

ligament.

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2. At the ureteric orifice.


ARTERIAL SUPPLY

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? The ureter derives its arterial

supply from the branches of all the

arteries related to it. The

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important arteries supplying

ureter from above downward are:

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1. Renal.

2. Testicular or ovarian.

3. Direct branches from aorta.

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4. Internal iliac.

5. Vesical (superior and inferior).

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6. Middle rectal.

7. Uterine.
? VENOUS DRAINAGE

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The venous blood from the ureter is drained into

the veins corresponding to the arteries.

? LYMPHATIC DRAINAGE

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The lymph from the ureter is drained into lateral

aortic and iliac nodes.

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? NERVE SUPPLY

1. The sympathetic supply of the ureter is derived

from T12?L1 spinal segments through renal, aortic,

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and hypogastric plexuses.

2. The parasympathetic supply of ureter is derived

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from S2?S4 spinalsegments through pelvic

splanchnic nerves.
Clinical correlation

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? Mobilization of ureter: Branches of the arteries supplying

the ureter form an anastomosis in the fat and fascia around the ureter.

Therefore, surgeons should bear in their mind that stripping off this

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fascia, while mobilizing the ureter for transplantation, will hamper the

blood supply of the ureter and may cause its necrosis.

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? Identification of ureter: Ureter is a muscular structure, and

in life waves of muscular contractions produce a worm-like rhythmic

movement (peristalsis) thus milking urine toward the bladder. The

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ureter is readily identified in life by its thick muscular wall which is

seen to undergo worm-like writhing movements, especially when it is

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gently stroked or Squeezed.
Clinical correlation

? Ureteric calculus is likely to lodge at one of the sites of anatomical

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narrowings of the ureter particularly:

(a) At the pelvic ureteric junction.

(b) Where it crosses the pelvic brim.

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(c) In the intramural part--the narrowest part.

? Injury to ureters: According to Kenson and Hinman, the ureter may

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be injured at one of the following four dangerous sites:

(a) Point where the ureter crosses the iliac vessels.

(b) In the ovarian fossa.

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(c) Where the ureter is crossed by the uterine artery (most dangerous

site) as damage is likely at this site during hysterectomy.

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(d) At the base of the bladder.
THE ADRENAL

GLAND(SUPRARENAL GLAND)
Position and location

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- The adrenal glands located on the upper poles of

each kidney on the right and left sides.

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-They are covered by peritoneum on the posterior

abdominal wall they are embeddedinto pre renal

fat.

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- The left one is larger and higher than the right


Location:

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Rest superiorly to

kidneys

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Hormones Produced:

~30 steroid hormones!
The right adrenal gland

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-It is triangular in shape located on the upper pole

of the right kidney behind the inferior vena

cava.

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-It is related anterior to the inferior vena cava and

the right lobe of the liver.

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-Posterior it is related to the right crus of diaphragm


The right adrenal gland
The left adrenal gland

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-It is crescent in shape located on the upper pole of

the left kidney behind the stomach

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-Anterior it is related to the stomach, the tail of

pancreas and the lesser sac

- Posterior it is related to the left crus of diaphragm

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Relation of the left gland

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The blood supply

Each adrenal gland supply by three arteries superior ,middle and inferior

supra renal arteries.

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The superior supra renal artery branch from inferior phrenic artery

which is branch from the aorta, the middle supra renal artery branch

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from the aorta and the inferior supra renal artery branch from the renal

artery

The venous drainage by the supra renal vein on the

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right side at the inferior vena cava and on the left side

at the left renal vein
Structure of adrenal gland

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--The adrenal gland formed of outer cortex which is yellow

forming the main mass of the gland

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and inner medulla completely enclosed by the cortex except

at the hilum the gland enclosed by capsule of connective

tissue.

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-The cortex has mesoderm development while the medulla

developed from the neural crest

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The cortex and capsule