TRANSPOSITION OF ABDOMINAL VISCERA

BY PROFESSOR N. PANProfessor of Anatomy, Medical College, Calcutta

IN an adult female subject brought into the dissecting room of the MedicalCollege, Calcutta, during the winter term of 1928-4, transposition of some ofthe abdominal viscera was noticed. As such cases are comparatively rare andas pathological conditions of these transposed organs during life are apt tomislead the clinicians, I am publishing a short account of the peculiaritiesnoted.

Gastro-intestinal Tract. The size of the stomach is small, being 71 inchesin length and 2j inches in breadth. The cardiac orifice is situated at the levelof the 11th thoracic vertebra on its right side. The left vagus nerve lies in frontof and the right vagus nerve behind the cardiac orifice. The pyloric orifice issituated on the left side of the body of the 12th thoracic vertebra. The lessercurvature extending from the left margin of the oesophagus has the concavitydirected upwards and to the left and gives attachment to the hepato-gastricligament. The greater curvature extending from the right margin of theoesophagus is directed at first upwards and to the right, then downwards andforwards and finally downwards and to the left. The antero-superior surfaceof the stomach is in relation with the inferior surface of the right lobe of theliver, the gall bladder, the quadrate lobe of the liver and the anterior abdominalwall. The antrum cardiacum of the oesophagus grooves the posterior surface ofthe right lobe of the liver to the left of the fossa for the inferior vena cava.

Duodenum. The duodenum is horseshoe-shaped, with the convexitydirected to the left. It is 4 inches in length and situated to the left side of thevertebral column, extending from the left side of the 12th thoracic vertebra tothe left side of the body of the 2nd lumbar vertebra. The concavity of theduodenal curve embraces the head of the lower pancreas. The bile duct and thepancreatic ducts open separately on the postero-medial aspect ofthe duodenum,the opening of the bile duct lying half an inch lateral to the opening of the lowerpancreatic duct. The hepato-duodenal ligament is attached to the commence-ment of the duodenum.

Jejunum and Ileum. The coils of the jejunum and the ileum are chieflyplaced on the left side of the abdominal cavity. They measure only 9 feet inlength.

Caecum. The caecum is situated in the lower part of the umbilical regionon the right side of the middle line.

Ascending Colon. The ascending colon, 7 inches in length, passes upwardand slightly lateralwards towards the spleen, lying in front of the upper limb

Tran8po8ition of Abdominal Vi8cera

of the transverse colon and right kidney. The upper end of the ascending colonturns backwards and downwards forming the right colic flexure.

Transverse Colon. The transverse colon begins on the right side of the 2ndlumbar vertebra, passes towards the left in front of the 3rd -lumbar vertebraand forms a bend on the left side of the body of the 4th lumbar vertebra. Then

CmcumAppendix

Transverse ColonyLower fold

CoLon

Fig. 1. Superficial View

it crosses the middle line to the right in front of the body of the 4th lumbarvertebra, lying below and parallel to the upper limb of the transverse colon.Then it passes upwards and to the right to form the splenic flexure. It has nomesocolon and its anterior surface lies under cover of the coils of the ileum,caecum and the ascending colon. The length of the transverse colon is 18 inches.

14-2

203

204 N. Pan

Descending Colon. It passes downwards and medialwards on the right sideof the abdomen towards the afa of the sacrum. It measures 8 inches in length.

Sigmoid Colon. It is situated on the right side. It has no mesocolon. Itmeasures 4 inches in length.

Liver. The caudate lobe is very prominent, measuring 2 inches by 1 inchby 1 inch. It hangs downwards in front of the vertebral column to the left sideof the oesophagus above the lesser curvature of the stomach and the lower

R;qht u nq-q

Funduscef S-hr.wieh / ~ -Left Lung

Dz1 ;; b -, - L . 3rPon~ripD Py''Luc Art. D eonst-ric

A<; s-Cyv 5ptee ) CO OpenInq of

Lienni FtireX;r Trur

Hepatic FlexutlreAscend'n9 Colo Xodenum

Desc endin Colon Inferior VerTr ans.C at - - Abdnminat

a O d c'C.Lon c -rE_\\~~~~~~~~~~~~~ w, P[n~r- P ro a- Append'i xOvaryUterine Tub

- Uterus

yloric:tion

,t eryPi le-Duc tncneot ic-Du dtnk of L~el'Hepaoc

bno- Cova I

Aorta

Ef 11 e; r

be

-s B I adder

Fig. 2. Deep View, small intestines removed and stomach thrown upwards

pancreas but to the left of the upper pancreas. The inferior surface of the rightlobe has the gastric impression but the splenic impression takes the place ofthe colic and renal impressions. The bare area is very small and the oesophagealimpression lies on the posterior surface of the right lobe. The gall bladder liesin the cystic fossa in the right lateral line of the body. The inferior surface ofthe left lobe of the liver bears the renal impression for the left kidney.

Spleen. It is of a flattened oval shape and is situated in the right hypo-

Transposition of Abdominal Vi8cera

chondriac region. Its anterior surface is in relation with the inferior surfaceof the right lobe of the liver, the postero-inferior surface of the stomach andthe tail of the lower pancreas. The hilum occupies the lower fourth of theanterior surface near the right lateral border and is so deep as to subdividepartially the spleen into an anterior and a posterior portion. It looks down-ward and to the right and transmits the branches of the lienal vessels. Theposterior surface of the spleen is in relation with the right suprarenal gland andthe upper end of the right kidney, and the diaphragm separates it from the10th and 11th ribs and the 9th and 10th intercostal spaces of the right side. Thespleen measures 4 inches in length, 3 inches in breadth and 1t inches in thickness.

Accessory Spleens. There are five accessory spleens, four being situatedtowards the upper end of the spleen and the fifth one at the lower end. Theyare all separate from the spleen and are contained between the two layers ofthe gastro-lienal ligament. Their sizes vary from 2 inch by I inch by i inch to12 inches by 1 inch by i inch.

Pancreas. There are two pancreatic organs, an upper and a lower. Theupper pancreas lies obliquely across the vertebral column passing from abovedownwards and to the left in the epigastric region. Its upper end is on theright side of the body of the 10th thoracic vertebra and its lower end is on theleft side of the body of the 11th thoracic vertebra, where it lies in appositionwith the head of the lower pancreas. It is prismatic in shape, the upper endbeing larger than the lower. It measures 3 inches by 1 inch by I inch. Itsanterior surface is covered by the peritoneum of the omental bursa. Itsposterior surface is uncovered by peritoneum. Its duct opens into the duode-num by a minute orifice separate from and above the orifices of the bile ductand the duct of the lower pancreas. It receives its blood supply from the pan-creatic branches of the lienal artery, which arises directly from the front ofthe abdominal aorta above the origin of the coeliac artery, and passes towardsthe right below the upper pancreas.

The lower pancreas is larger than the upper pancreas. It measures 4 inchesby 1 inch by i inch. It is also prismatic in shape. It is placed transverselyacross the vertebral column in front of the body of the 12th thoracic vertebra.A triangular interval separates its body and tail from the upper pancreas butits head is in close apposition with the lower end of the upper pancreas. It iscovered anteriorly by peritoneum but uncovered posteriorly. It is suppliedby branches derived from the lienal artery. Its duct begins near the tail onthe right side and traverses its substance nearer to its posterior surface andthen opens into the duodenum by a separate aperture unconnected with thatof the bile duct.

The upper pancreas represents the dorsal pancreas which has failed to fusewith the lower one representing the ventral pancreas.

Abdominal Aorta. It lies in front of the vertebral column on the right sideof the inferior vena cava. The following peculiarities are noted about itsbranches:

205

206 N. Pan

(1) The lienal artery arises separately and passes towards the right to thehilum of the spleen.

(2) The hepatic, left gastric and superior mesenteric arteries arise by acommon trunk-representing the coeliac artery below the lower pancreas andthe origin of the lienal artery.

(3) The inferior mesenteric artery passes towards the right.(4) There are two renal arteries, in the left side of which the lower one

passes to the lower end of the left kidney.Inferior Vena Cava. It is formed by the union of the two common iliac

veins in front of the body of the 5th lumbar vertebra behind the left commoniliac artery. It ascends on the left side of the abdominal aorta and at the upperpart of the abdomen slightly inclines forwards and to the right to reach thetaval fossa on the posterior surface of the right lobe of the liver; on enteringhe thorax it opens into the right atrium. It receives the usual tributaries buthe left ovarian vein opens into it direct and the right ovarian vein opens intothe right renal vein.

Uterus and Ovaries. The uterus is retroverted. The ovaries and the fim-briated ends of the uterine tubes are situated in the iliac fossae above the backpart of the brim of the pelvis.

There is no transposition of heart or lungs or of the large blood vessels ofthe thorax.

My thanks are due to Dr Bepin Behari Basak, Demonstrator of Anatomy,for carefully dissecting the abnormalities noted. I thank also Mr DayanidhiMisra, student of the fourth year class of this College, for making the drawingsfor me.