Ligaments of spleen and splenic circulation give in 5 marks format
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Ligaments of Spleen and Splenic Circulation
(Fischer's Mastery of Surgery, 8th ed.)
A. Ligaments of the Spleen
The spleen is tethered in the posterior left upper quadrant by four peritoneal ligaments:
| Ligament | Course | Contents / Notes |
|---|---|---|
| Gastrosplenic | Lateral greater curve of stomach → superomedial surface of spleen | Short gastric arteries & veins; left gastroepiploic artery & vein; provides collateral blood flow between stomach and spleen |
| Splenorenal (lienorenal) | Posterior surface of spleen → anterior surface of Gerota fascia of left kidney | Contains the splenic artery, splenic vein, and tail of pancreas |
| Splenophrenic | Posterolateral surface of spleen → adjacent diaphragm | Usually avascular; holds the spleen against the diaphragm |
| Splenocolic | Inferior pole of spleen → distal transverse colon / splenic flexure | Usually avascular; must be divided early in splenectomy |
Surgical note: The gastrosplenic ligament is the most vascular and must be carefully ligated during splenectomy to avoid bleeding from short gastric vessels.
B. Splenic Circulation
Arterial Supply
- The splenic artery arises from the celiac axis and courses left laterally along the superior surface of the body and tail of the pancreas toward the spleen.
- In <20% of patients, the artery courses through the pancreatic parenchyma.
- At the hilum, the artery divides into terminal branches (number varies):
- ~91% of patients: two terminal branches (most common)
- ~3%: single terminal branch
- ~6%: more than six terminal branches
- When the hilum is divided close to the parenchyma, each terminal vessel must be ligated separately.
Venous Drainage
- The splenic vein has a variable number of tributaries at the hilum that merge into a single splenic vein.
- The splenic vein runs medially along the posterior surface of the tail and body of the pancreas.
- It joins the superior mesenteric vein (SMV) - and sometimes the inferior mesenteric vein (IMV) - to form the portal vein.
- This confluence occurs posterior to the neck of the pancreas.
Additional Vascular Contributions
- Short gastric arteries and veins (within the gastrosplenic ligament) - arise from the left gastroepiploic vessels and provide collateral flow.
- The spleen receives ~5% of cardiac output at rest; this rises dramatically in portal hypertension and hypersplenism.
Diagram
Anterior view: gastrosplenic ligament, splenocolic ligament, splenic artery, splenic vein, tail of pancreas. Posterior view: splenophrenic ligament, splenorenal ligament, left kidney.
Key points for 5-marks exam:
- Four ligaments: gastrosplenic (vascular), splenorenal, splenophrenic, splenocolic.
- Gastrosplenic ligament carries short gastric vessels - most important surgically.
- Splenic artery from celiac axis, runs along superior border of pancreas.
- Variable terminal branches at hilum (usually 2).
- Splenic vein drains into portal vein posterior to pancreatic neck.
- Fischer's Mastery of Surgery, 8th ed., Chapter 275, pp. 7399-7400
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Types of inguinal hernia and boundaries of inguinal canal
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Types of Inguinal Hernia & Boundaries of Inguinal Canal
(Bailey & Love's Short Practice of Surgery, 28th ed.)
A. Types of Inguinal Hernia
There are two basic types:
1. Indirect (Lateral / Oblique) Hernia
- Most common type; can be congenital or acquired
- Passes through the deep inguinal ring, lateral to the inferior epigastric vessels
- Follows the path of the processus vaginalis - runs obliquely through the canal
- Can descend all the way into the scrotum (scrotal hernia)
- Congenital type: due to failure of obliteration of the processus vaginalis
2. Direct (Medial) Hernia
- Always acquired; due to weakness/stretching of the posterior wall
- Bulges directly through Hesselbach's triangle, medial to the inferior epigastric vessels
- Does not pass through the deep ring; does not descend to the scrotum
- Result of chronic raised intra-abdominal pressure + muscle weakness
| Feature | Indirect | Direct |
|---|---|---|
| Origin | Lateral to inf. epigastric vessels | Medial (Hesselbach's triangle) |
| Type | Congenital or acquired | Always acquired |
| Path | Oblique, through deep ring | Directly through posterior wall |
| Scrotum | Can descend into scrotum | Cannot |
B. Boundaries of the Inguinal Canal
The inguinal canal is an oblique passage (~4 cm long) through the lower abdominal wall.
| Wall | Structure |
|---|---|
| Anterior wall | Aponeurosis of external oblique muscle |
| Posterior wall | Transversalis fascia |
| Roof | Conjoint tendon (fused fibres of transversus abdominis + internal oblique) |
| Floor | Free inferior edge of external oblique aponeurosis - thickened and rolled inward to form the inguinal (Poupart's) ligament |
Openings:
- Deep (internal) ring - defect in transversalis fascia; midpoint between ASIS and pubic tubercle; inferior epigastric vessels lie just medial to it
- Superficial (external) ring - inverted V-shaped defect in external oblique aponeurosis; just above and lateral to pubic tubercle
Contents:
- Males: spermatic cord (testicular artery, veins, vas deferens, lymphatics) + cremasteric muscle
- Females: round ligament
- Both: ilioinguinal nerve, iliohypogastric nerve, genital branch of genitofemoral nerve
Bailey & Love's Short Practice of Surgery, 28th ed., Chapter 64, pp. 1086-1087
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