The appendix is a narrow, hollow, blind-ended tube connected to the cecum. It has large aggregations of lymphoid tissue in its walls and is suspended from the terminal ileum by the mesoappendix (Fig. 4.83), which contains the appendicular vessels. Its point of attachment to the cecum is consistent with the highly visible free taeniae leading directly to the base of the appendix, but the location of the rest of the appendix varies considerably (Fig. 4.84). It may be: posterior to the cecum or the lower ascending colon, or both, in a retrocecal or retrocolic position; suspended over the pelvic brim in a pelvic or descending position; below the cecum in a subcecal location; or anterior to the terminal ileum, possibly contacting the body wall, in a pre-ileal position or posterior to the terminal ileum in a postileal position.
The surface projection of the base of the appendix is at the junction of the lateral and middle one-third of a line from the anterior superior iliac spine to the umbilicus (McBurney’s point). People with appendicular problems may describe pain near this location.
The arterial supply to the cecum and appendix (Fig. 4.85) includes: the anterior cecal artery from the ileocolic artery (from the superior mesenteric artery), the posterior cecal artery from the ileocolic artery (from the superior mesenteric artery), and the appendicular artery from the ileocolic artery (from the superior mesenteric artery).
The colon extends superiorly from the cecum and consists of the ascending, transverse, descending, and sigmoid colon (Fig. 4.88). Its ascending and descending segments are (secondarily) retroperitoneal and its transverse and sigmoid segments are intraperitoneal.
At the junction of the ascending and transverse colon is the right colic flexure, which is just inferior to the right lobe of the liver (Fig. 4.89). A similar, but more acute bend (the left colic flexure) occurs at the junction of the transverse and descending colon. This bend is just inferior to the spleen, is higher and more posterior than the right colic flexure, and is attached to the diaphragm by the phrenicocolic ligament.
Immediately lateral to the ascending and descending colon are the right and left paracolic gutters (Fig. 4.88). These depressions are formed between the lateral margins of the ascending and descending colon and the posterolateral abdominal wall and are gutters through which material can pass from one region of the peritoneal cavity to another. Because major vessels and lymphatics are on the medial or posteromedial sides of the ascending and descending colon, a relatively blood-free mobilization of the ascending and descending colon is possible by cutting the peritoneum along these lateral paracolic gutters.
The final segment of the colon (the sigmoid colon) begins above the pelvic inlet and extends to the level of vertebra SIII, where it is continuous with the rectum (Fig. 4.88). This S-shaped structure is quite mobile except at its beginning, where it continues from the descending colon, and at its end, where it continues as the rectum. Between these points, it is suspended by the sigmoid mesocolon.
The arterial supply to the ascending colon (Fig. 4.90) includes: the colic branch from the ileocolic artery (from the superior mesenteric artery), the anterior cecal artery from the ileocolic artery (from the superior mesenteric artery), the posterior cecal artery from the ileocolic artery (from the superior mesenteric artery), and the right colic artery from the superior mesenteric artery.
The arterial supply to the transverse colon (Fig. 4.90) includes: the right colic artery from the superior mesenteric artery, the middle colic artery from the superior mesenteric artery, and the left colic artery from the inferior mesenteric artery.