Hover for "Lumen"

The term [lumen] is Latin and means "light". It is an international measure of light intensity. The plural form is either [lumens] or the Latin version [lumina].

The question is how did this term end up meaning the "internal opening or cavity of a hollow organ"? Dr. J. Dirckx (1976) explains that the term [lumen] in gastrointestinal anatomy was not used until the late 19th century, but it was initially used by microscopists looking at cross sections of small vessels. Since the empty interior of the vessel was represented on the histological slide as a clear, lighted region, they started calling that the "light" of the vessel, or [lumen].

The root term for [lumen] is [-lumin-] and can be found in over 30 words in English and related to light, such as luminosity, luminaria, luminescent, luminous, illumination,  illuminator, intraluminal, transluminal, endoluminal, etc.

The correct adjective form for [lumen] is [luminal], as stated by Haubrich (1997). The point is that the use of the term "lumenal" as an adjective form for lumen is not correct. This term can be seen wrongly used in many textbooks today. The proper form for the NOTES acronym is "Natural Orifice Transluminal Endoscopic Surgery"

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Original image courtesy of Wikipedia.org

An esophageal hiatus hernia (also known as a hiatal hernia) eventually may require surgery. In this case, the objective is three-fold: To bring the abdominal viscera to its proper intraabdominal position (reduction) , to create a pseudovalve to prevent gastroesophageal reflux, and to prevent a recurrence of the herniation.

There have been different  procedures developed to this effect. One of the most popular has been the Nissen fundoplication either trough the open surgery approach or by way of a minimally invasive laparoscopic procedure.

This procedure was pioneered by Dr. Rudolf Nissen (1896 - 1981) in 1955.  After reducing the hiatal hernia and repairing the dilated esophageal hiatus, the surgeon creates a gastric wrap around the abdominal esophagus by bringing the fundus of the stomach through a retroesophageal passage, and suturing the fundus to the stomach. (see image). One of the concerns of the procedure is the ligation and transection of the short gastric vessels that pass within the gastrosplenic ligament to allow greater mobility of the gastric fundus and prevent potential avulsion of the short gastric vessels.

Since the introduction of this open procedure in 1955 there have been several variations, such as the "Nissen-Rosetti" procedure, a "loose" fundoplication; the "Toupet" procedure, an "incomplete" fundic wrap, and others, including laparoscopic procedures.

The advent of NOTES (Natural Orifice Transluminal Endoscopic Surgery) has brought a new procedure: Transoral Incisionless fundoplication (TIF), where a pseudovalve is created using an endoscope inserted into the esophagus and stomach through the oral cavity without abdominal  incisions or trocar ports. For more information on this procedure, click here. Clicking on the inferior image will start a six-minute video of the TIF procedure and the EsophX device.

The term [hiatus] derives from the Latin word [hiare], meaning to "gape" or to "yawn". In human anatomy this term is used to mean an "opening" or a "defect". It must be pointed out that in anatomy (and surgery) the term "defect" does not necessarily mean "defective". In most cases a "defect" is a normal opening in a structure, such as the esophageal hiatus. The plural form is either [hiatus] or [hiatuses].

There are many hiatuses in the human body, such as:

• Hiatus semilunaris: a crescent-shape opening in the lateral aspect of the nasal wall
• Esophageal hiatus: an opening in the muscular posterior aspect of the respiratory diaphragm, bound by two muscular crura
• Aortic hiatus: an opening in the posterior aspect of the respiratory diaphragm, bound by two tendinous crura
• Hiatus Fallopii: the entrance to the facial canal, an opening in the temporal bone allowing for passage of the facial nerve (CN V). Named after Gabrielle Fallopius

Respiratory diaphragm

The respiratory diaphragm is a musculotendinous dome-shaped shelf that divides the thoracic cavity from the abdominal cavity. It is one of the four named diaphragms in human anatomy. This is why it is proper to call it the "respiratory diaphragm" instead of just "diaphragm".

The name comes from the Greek, where the prefix [dia-] means "complete" or "through" and [phragm] means "a partition". In Latin, Celsus called it the "septum transversum", meaning "the transverse partition". The root term for [diaphragm] is [-phren-], as in phrenic nerves and cardiacophrenic vessels.

The respiratory diaphragm has a club-shaped central tendon (as in a card suit) which has a large hiatus for the inferior vena cava. The muscular portion is formed by skeletal (voluntary) muscle and descends skirt-like to attach to the internal aspect of the sternum and ribs anterolaterally, and a complex system of lumbocostal tendinous arches posteriorly.

It receives its blood supply through branches of the intercostal arteries, the musculophrenic artery, and the pericardiacophrenic arteries. It is innervated by the phrenic nerves, which descend through the mediastinum in relation to the pericardium.

The respiratory diaphragm has not one, but seven openings (hiatuses) to allow for passageway of many structures:

• Esophageal hiatus
• Aortic hiatus
• Inferior vena cava hiatus
• Hiatuses (2) for the superior epigastric vessels, which are the inferior continuation of the internal thoracic (mammary) vessels. Also known as the hiatuses of Morgagni.
• Hiatuses (2) for the splanchnic nerves

The most common site for an internal abdominothoracic herniation is the esophageal hiatus, but there are other respiratory diaphragm hernias, including the retrosternal hernia of Morgagni (through the superior epigastric hiatus), and the hernia of Bochdalek (a congenital hernia through an incomplete central tendon of the respiratory diaphragm).

Sources:
1 "Tratado de Anatomia Humana" Testut et Latarjet 8 Ed. 1931 Salvat Editores, Spain
2. "Anatomy of the Human Body" Henry Gray 1918. Philadelphia: Lea & Febiger Image modified by CAA, Inc.
Original image by Henry Vandyke Carter, MD., courtesy of bartleby.com

Jejunoileal vascular supply

The jejunum is an intraperitoneal organ, it is the second portion of the small intestine and part of the digestive tract. It begins at the duodenojejunal junction  where it is related to the ligament of Treitz, and extends 8 to 9 feet, continuing distally with the ileum.

Being intraperitoneal, it is anchored to the posterior abdominal wall by the double-layered mesentery through which the jejunum receives its blood and nerve supply. At the root (base) of the mesentery are the superior mesenteric vessels.

The Latin word [jejunis] means "empty" or "fasting". The Latin term [jejunum] was used by the Romans to denote the first meal of the day, breakfast, when you have an "empty" stomach. The term was associated with this segment of the small intestine, as it is most of the time found empty in cadavers being dissected.

There is no clear anatomical boundary between the jejunum and ileum, as they blend smoothly one into the other. There are several gross changes from jejunum to ileum, one of them being that the complexity of the mesenteric arterial arches increases from proximal to distal. See the accompanying image. Click on it for a larger depiction.

Two interesting side notes: In English, the term for the first meal of the day is self-explanatory: [break - fast], adding to the Roman concept of "fasting" or "jejunum". In Spanish, the term for breakfast is [desayuno], where the word [ayuno] means "fasting", therefore the word [des-ayuno] also means "the end of fasting". Look at the evolution (in Spanish) from [jejunum] to [yeyuno] (the Spanish term for the organ) to [ayuno], meaning "fasting" or "empty".

Sources:
1. "The Origin of Medical Terms" Skinner, HA 1970 Hafner Publishing Co.
2. "Clinically Oriented Anatomy" Moore, KL. 3r Ed. Williams & Wilkins 1992
3 "Tratado de Anatomia Humana" Testut et Latarjet 8 Ed. 1931 Salvat Editores, Spain
4. "Anatomy of the Human Body" Henry Gray 1918. Philadelphia: Lea & Febiger Image modified by CAA, Inc.
Original image by Henry Vandyke Carter, MD., courtesy of bartleby.com

Click for a larger image

The word [crus] is Latin (cruris) and refers to the leg, or region of the shin. It is commonly used to mean "leg" or "pillar". The plural form is [crura].

Several authors suggest a relation of [crus] with another Latin term [crux] meaning "cross" as if a cross is formed by two [crura] (legs).

The term crus is widely used in human anatomy:

• crus cerebri: there are two crus cerebri in the anterior aspect of the mesencephalon
• crura of the penis: the posterior aspect of the corpora cavernosa firmly attached to the ischiopubic rami
• crura of the clitoris:  the posterior aspect of the corpora cavernosa firmly attached to the ischiopubic rami
• crura fornix cerebrii: the posterior converging bands that form the fornix of the cerebrum

Special mention is deserved by the crura of the diaphragm. There are two pairs of diaphragmatic crura. The esophageal crura (right and left) which bound the passageway of the esophagus from the thorax into the abdomen, the esophageal hiatus. The esophageal crura have a muscular structure. The aortic crura (righ and left) allow for passage of the aorta into the abdomen, and although muscular superiorly, they are mostly tendinous. The accompanying image shows an anteroinferior view of the respiratory diaphragm. Click on the image for a larger picture.

Sources:
1. "The Origin of Medical Terms" Skinner, HA 1970 Hafner Publishing Co.
2. "Medical Meanings - A Glossary of Word Origins" Haubrich, WD. ACP Philadelphia
3 "Tratado de Anatomia Humana" Testut et Latarjet 8 Ed. 1931 Salvat Editores, Spain
4. "Anatomy of the Human Body" Henry Gray 1918. Philadelphia: Lea & Febiger
Image modified by CAA, Inc. Original image by Henry Vandyke Carter, MD., courtesy of bartleby.com