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The inferior vena cava (IVC) is formed by the confluence of the common iliac veins, just anterior to the L5 vertebral body, and posterior to the right common iliac artery. As it courses superiorly towards the diaphragm, it lies to the right of the lumbar and thoracic vertebral bodies. It enters the thorax at T8, where the right crus of the diaphragm separates the IVC and aorta. In most individuals, there is a small segment of suprahepatic IVC, about 1 cm in length, between the liver and diaphragm, which is amenable to cross clamping.
The IVC receives four or five pairs of lumbar veins, the right gonadal vein, the renal veins, the right adrenal vein, the hepatic veins, and the phrenic veins. It is of practical importance to remember that all lumbar veins are below the renal veins and that between the renal veins and the hepatic veins, besides the right adrenal vein, there are no other venous branches. The left lumbar veins pass behind the abdominal aorta.
The confluence of the renal veins with the IVC lies posterior to the duodenum and the head of the pancreas.
The retrohepatic IVC is about 8–10 cm in length and is adhered to the posterior liver, helping to anchor the liver in place. In this liver “tunnel,” several accessory veins from the caudate lobe and right lobe drain directly into the IVC.
There are three major hepatic veins which drain the liver into the IVC. The extrahepatic portion of these veins is short, measuring about 0.5–1.5 cm in length. The right hepatic vein is the largest. In about 70% of individuals, the middle vein drains into the left hepatic vein to enter the IVC as a single vein.
The thoracic IVC is almost entirely in the pericardium.
The spleen lies under the ninth to eleventh ribs, under the diaphragm. It is lateral to the stomach and anterosuperior to the left kidney. The tail of the pancreas is in close anatomical proximity to the splenic hilum and amenable to injury during splenectomy or hilar clamping.
The spleen is held in place by four ligaments, which include the splenophrenic and splenorenal ligaments posterolaterally, the splenogastric ligament medially, and the splenocolic ligament inferiorly. The splenorenal ligament begins at the anterior surface of Gerota’s fascia of the left kidney and extends to the splenic hilum, as a two-layered fold that invests the tail of the pancreas and splenic vessels. The splenophrenic ligament connects the posteromedial part of the spleen to the diaphragm, and the splenocolic ligament connects the inferior pole of the spleen to the splenic flexure of the colon. The splenogastric ligament is the only vascular ligament and contains five to seven short gastric vessels that originate from the distal splenic artery and enter the greater curvature of the stomach. Excessive retraction of the splenic flexure or the gastrosplenic ligaments can easily tear the splenic capsule and cause troublesome bleeding.
The mobility of the spleen depends on the architecture of these ligaments. In patients with short and well-developed ligaments, mobilization is more difficult and requires careful dissection in order to avoid further splenic damage.
The splenic hilum contains the splenic artery and vein and is often intimately associated with the tail of the pancreas. The extent of the space between the tail of the pancreas and the splenic hilum varies from person to person.
The splenic artery is a branch of the celiac axis that courses superior to the pancreas towards the splenic hilum where it divides into upper and lower pole arteries. There is significant variability in where this branching occurs. Most people, approximately 70%, have a distributed or medusa like branching that occurs 5–10 cm from the spleen. Simple branching occurs in approximately 30%, 1–2 cm from the spleen.
The splenic vein courses posterior and inferior to the splenic artery, receives the inferior mesenteric vein, and joins the superior mesenteric vein to form the portal vein.