Indmedica Home | About Indmedica | Medical Jobs | Advertise On Indmedica
Search Indmedica Web
Indmedica - India's premier medical portal

Journal of the Anatomical Society of India

An Anatomical Study Of The Phrenoesophageal Ligament

Author(s): Al-Motabagani, M.A.H.

Vol. 51, No. 1 (2002-01 - 2002-06)

Department of Anatomy, College of Medicine, King Faisal University, Damman, SAUDI ARABIA.

Abstract

The phrenoesophageal ligament (POL) has been considered an important contributor to gastroesophageal competence. The particular role that the phrenoesophageal ligament plays in the prevention of the pathologic gastroesophageal reflux has received little attention. Although the mechanism responsible for gastroesophageal competence remains controversial, most evidence suggests an important role for the inferior oesophageal sphincter. Many studies suggest that the phrenoesophageal ligament may be an important component of this sphincter. The aim of this study was to examine the macroscopic and microscopic anatomy of the phrenoesophageal ligament.

Twenty preserved cadavers from the Anatomy Department, King Faisal University were used for dissection of the gastroesophageal region. Eight cadavers were used for histological examination. The POL was found in all cadavers. It was identified bridging the space between the hiatal margin and the oesophagus. It appeared as white glistening structure formed mainly by a circumferential continuation of fascia transversalis. On both side of the oesophagus, the ligament is divided into a thicker upper leaf and a thinner lower leaf. The upper leaf passes upwards obliquely to be inserted into the wall of the oesophagus just above the oesophageal hiatus. The lower leaf passes downwards to be attached to the oesophagus above the oesophagogastric angle. Between the two leaves, there was a triangular space bounded by the upper and lower leaves and the wall of the oesophagus. Histologically, the POL was composed of abundant elastic and collagen fibres which were arranged in an alternative interwoven manner. In addition, the POL is richly supplied with blood vessels.

This study serves to highlight a structure that has been given little attention in the teaching of anatomy, but is of physiological and surgical importance.

Key words: Gastroesophageal competence, inferior oesophageal sphincter, oesophageal hiatus.

Introduction:

Gastroesophageal reflux with its complication of peptic oesophagitis is an extremely common clinical problem which at times is severely life threatening. An understanding of the oesophagogastric junctional area which normally contains the sphincteric mechanism for preventing reflex has proved to be extremely elusive (Dillard, 1964; Paulen et al. 1962).

The phrenoesophageal ligament has been considered an important contributor to gastroesophageal competence. Although the mechanism responsible for gastroesophageal competence remains controversial, most evidence suggests an important role for the inferior oesophageal sphincter. Many studies suggest that the phrenoesophageal ligament may be an important component of this sphincter (Kwok et al. 1999: Patnaik & Mukerjee, 2000). It appears highly probable that the phrenoeosophageal ligament serves to prevent the superior displacement of the oesophagus into the thoracic cavity by drawing it down by elastic recoil of its ascending limb (Bremner et al. 1970). The anatomic structure of the gastroesophageal junction consists of the following: The tubular thoracic oesophagus progresses inferiorly bounded in the lower thorax by the pericardium anteriorly, the aorta posteriorly and the pleura laterally. Two to three centimeters above the hiatus of the diaphragm, the oesophagus is anchored at its lower end by the insertion of a tough skirt like prolongation of the fascia transversalis from the undersurface of the diaphragm which is the phrenoesophageal ligament (Bombeck et al. 1966). The attachment of the ligament to the oesophagus is about 2 cm above the oesophagogastric junction, where the oesophageal tube suddenly widens out into the stomach pouch (Zeifer and Kisco, 1967). However, Patnaik & Mukerjee (2000) found the distance between caudal leaf of POL & angle of His to be 4.3 cm on an average.

The anatomical basis and functional significance of the attachment of the oesophagus to the oesophageal hiatus in human receive little attention in most anatomy textbooks although it is an important contributor to gastroesophageal competence.

The aim of this study was to examine the macroscopic and microscopic anatomy of the phrenoesophageal ligament. This study serves to highlight a structure that has been given little emphasis, but is of physiological and surgical importance.

Material and Methods:

Macroscopic study

Twenty preserved cadavers free from sliding hiatal hernia, obtained from the dissection room of the Anatomy Department, faculty of medicine, King Faisal University were used in this study. These cadavers were used for dissection of the gastroesophageal region. The abdominal cavity was opened and the liver was reflected to expose the gastroesophageal region. The parietal peritoneum was carefully dissected and reflected away from the lower oesophagus and gastroesophageal junction to expose the fascia transversalis on the inferior surface of the diaphragm. The parietal pleura was similarly dissected from the oesophagus to expose the endothoracic fascia. The space between the margin of the oesophageal hiatus and the oesophageal wall was examined.

Microscopic study

Eight cadavers were used for histological examination. The gastroesophageal junction was excised with the muscular hiatus and paraoesophageal tissue. They were fixed in 10% buffered formal-saline solution then sectioned longitudinally and transversally (10 mm thickness) for examination by light microscopy. The sections were stained with haematoxylin and eosin, Masson‘s trichrome stain (for collagen) and Verhoff's Van Giesons stain (for elastin) (Kwok et al, 1999; Bremner et al. 1970).

Results:

Anatomical Study

The phrenoesophageal ligament was found in all cadavers. The lower oesophagus passes through the oesophageal hiatus of the diaphragm which is formed by the right crus of the diaphragm (fig. 1, 2).

As the lower part of the oesophagus passes through the diaphragmatic hiatus, it is attached to the diaphragm by the phrenoesophageal ligament (fig. 3, 4, 5). This ligament was identified bridging the space between the hiatal margin and the oesophagus. It appeared as white glistening structure formed mainly by a circumferential continuation of fascia transversalis which could be dissected as a separate layer from the lower surface of the hiatus (Fig. 4, 5, 6).

The endothoracic fascia surrounded the part of the oesophagus just above the hiatus forming the second component of the ligament. This fascia formed a thin sheath that could not be separated from the upper surface of the hiatus.

The phrenoesophageal ligament has a thickness of 0.8 – 2.3 mm. It is widest on either side of the oesophagus (1.6 – 2.3 cm) and narrowest anteriorly and posteriorly (1.0 – 1.6 cm).

On the left side of the oesophagus the ligament is divided into a thicker upper leaf and a thinner lower leaf. The upper leaf passes upwards obliquely to be inserted into the wall of the oesophagus just above the oesophageal hiatus. In addition to the point of insertion of the upper leaf of the ligament, a diffuse network of fibres passed from the main insertion to the wall of the oesophagus in all cases.

The lower leaf passes downwards to be attached to the oesophagus above the oesophagogastric angle by 1 to 2 cm.

Between the two leaves there was a triangular space bounded by the upper and lower leaves and the wall of the oesophagus (Fig. 6, 7, 8, 9). The interval between the two leaves of the ligament was 0.5 – 0.8 cm. On the right side of the oesophagus the ligament has the same arrangement as the left side dividing into upper and lower leaves with a triangular space separating them (Fig. 10).

Histological Study

Histologically, the ligament was found to be composed of two closely applied layers that are derived from the endothoracic fascia and a thicker layer derived from the fascia transversalis. The upper leaf arises from the medial end of the ligament and tapers obliquely and superiorly towards the oesophagus. It is composed of collagen, elastic fibres and fibroblasts. The elastic and collagen fibres are arranged in an alternating interwoven manner (Fig. 12, 13, 14, 15, 16, 17, 18, 19, 20).

The fibroblasts were seen running in the direction of the connective tissue fibres. Towards the diaphragmatic end, isolated groups of skeletal muscle fibres can be identified (Fig. 21, 22, 23). When compared with the upper leaf, the lower leaf was found to be thinner with considerably less collagen & elastic fibres and blood capillaries (Fig. 15, 16, 17, 18, 19).

In general, the phreneosophageal ligament was found to be richly supplied with blood vessels, nerves fibres and adipose tissues that extensively infiltrates the ligament in old cadavers (Fig. 14, 20, 24).

The Paraesophageal space between the upper and lower leaves was found to be triangular in shape with the apex directed laterally and the base formed by the oesophageal wall. The space was found to be filled with adipose tissues and traversed by blood vessels.

The POL was studied by three stains.

I. Haematoxylin and eosin stain (H & E): By H & E stain, the POL was found to be composed of collagen fibres and fibrablasts which were running in the direction of the collagen fibres (Fig. 12, 13).

II. Verhoff's Van Giesons stain (VVG): By VVG stain, elastic fibres (black colour) were seen running in an alternating manner with the collagen fibres (red colour). When compared with the upper leaf, the lower leaf has considerably less elastic fibres (Fig. 14, 15, 16, 17, 18, 19).

The POL was found to be richly supplied by blood vessels and nerves (Fig. 14).

III. Mallory trichrome stain. The collagen fibres were demonstrated, taking the blue colour surrounded by adipose tissues (Fig. 20, 21).

In old cadavers, extensive infiltration by adipose cells was found (Fig. 24).

Discussion:

This study examined the phrenoesophageal ligament macroscopically and microscopically.

Macroscopically, the phrenoesophageal ligament was identified bridging the space between the hiatal margin and the oesophagus. It is formed mainly by a circumferential continuation of fascia transversalis and is inserted into the wall of the oesophagus by two limbs as described by Kwok et al. 1999 & Patnaik & Mukerjee, 2000).

In this study the endothoracic fascia was found surrounding the part of the oesophagus just above the hiatus forming the second component of the ligament but could not be separated from the upper surface of the hiatus. This result was in line with those obtained by Patnaik & Mukerjee, (2000); Kwok et al. (1999), Bremner et al. (1970) and De Nardi and Riddell (1991).

Dillard (1964) stated that the phrenoesophageal ligament is comprised of a number of components including the supradiaphragmatic fascia and the infradiaphragmatic fascia. The most substantial components of this membrane are contributed by fibres from the endoabdominal fascia (fascia transversalis). This finding supported the result of this study.

Bombeck et al. (1966) stated that in 22 of 56 cases, the ligament arose exclusively from the endoabdominal fascia and in 24 cases, it arose from the endoabdominal fascia primarily but with some minor contribution from the endothoracic fascia. Thus it arose primarily from the endoabdominal fascia in 46 cases (82%). In ten cases, the contribution of endothoracic fascia was significant and in two cases there were two ligaments, one arose from the endothoracic fascia and the other from the endoabdominal fascia.

In this study, on both sides of the oesophagus, the phrenoesophageal ligament was divided into two leaves, an upper thicker leaf and a lower thinner leaf. The upper leaf passed upwards to be inserted into the wall of the oesophagus just above the oesophageal hiatus. This concept is supported by the study done by Bremner et al. (1970); Kwok et al. (1999) & Patnaik & Mukerjee, (2000).

Bombeck et al. (1966) found in two specimens out of 56 cases, two well defined upper ligaments present, one arising from the endoabdominal or transveralis fascia and one from the endothoracic fascia.

In this study the actual point of insertion of the upper leaf was determined by placing it on the stretch and tracing the bundle of fibres which was carrying the most tension to its inserton. This method was also carried out by Bombeck et al. (1966).

In the present study, the lower leaf was found to pass downwards to be attached to the oesophagus above te oesophago-gastric angle by 1 – 2 cm in all specimens. This was consistant with Hayward (1961) who stated that he could palpate the ligament with a finger up the oesophagus and said that it extended for about 1 cm above the oesophagogastric junction. However, Patnaik & Mukerjee (2000) found the average distance between lower leaf of POL & angle of His to be 4.3 cm. On the contrary, Bremner et al. (1970) had found that actual attachment of the lower leaf of the ligament to the stomach just below the oesophagogastric angle which was not found in this study. At the same time Bombeck et al. (1966) stated that the lower leaf was found as well defined layer in only five of 56 cases. In the remainder, it was represented by a diffuse collection of areolar fibres but its insertion could be identified on stretching. It was absent in seven cases and so diffuse that its insertion could not be identified. This author could identify the actual insertion of the lower leaf of the ligament below the oesophago-gastric junction in most of his specimens, at the junction in 13 cases and in no case did this ligament insert above the junction. This was not in agreement with the results of this study.

In the present study, there was a triangular space between the two leaves of the ligament and the wall of the oesophagus. The interval between the two leaves was 0.5 – 0.8 cm. This was in line with Bremner et al. (1970) and Patti et al. (1997). But Patnaik & Mukerjee (2000) reported it to be 1.7 cm on an average.

Kwok et al. (1999) and Kahrilas (1997) stated that the practical role that the phrenoesophageal ligament plays in the competence of the gastroesophageal junction and prevention of the pathologic reflux has received little attention. Although the circumferential attachment of the elastic ligament in the region of the lower oesophageal sphincter may appear to counteract it and promote reflux, the maintenance of the lower oesophagus below the hiatus may overcome this by the effect of positive pressure within the abdomen. Whereas reattachment of the ligament above the region of the lower oesophageal sphincter would increase the effectiveness of antireflux surgery.

Histologically, this study showed that the ligament is composed of elastic and collagen fibres richly supplied with blood vessels. These findings were in line with Patnaik & Mukerjee, (2000); Kwok et al. (1999), Bremner et al. (1970) and Dillard (1964). But Kwok et al. (1999) stated that in each leaf there are scattered smooth muscle fibres which were not found in this study.

Kwok et al. (1999) stated that the histological composition of phrenoesophageal ligament is that of substantial amounts of elastin intertwined with thick collagen bundles. This high elastin content of the ligament must contribute to its elasticity and flexibility. These thick collagen bundles must be the basis of its strength. Thus it appears appropriate to consider this structure as an elastic ligament rather than a membrane.

Kwok et al. (1999) also stated that the attachment of the ligament to the oesophagus is striking, particularly that of the ascending limb which inserts obliquely through multiple collagenous slips into the oesophageal submucosa. It appears highly probable that the phrenoesophageal ligament serves to prevent the superior displacement of the oesophagus into the thoracic cavity by drawing it down by the elastic recoil of its ascending limb. It is noticed that during such an action, the obliquity of the upper limb is of mechanical advantage because it maximizes the downward pull while minimizing circumferential traction on the oesophageal wall. Thus the arrangement of the two limbs of the ligament serves to limit upward and downward mobility of the oesophagus within the hiatus.

Dillard and Anderson (1966) and Anderson et al. (1967) believe that sphincteric failure is the result of malposition of the phrenoesophageal membrane to a point lower on the oesophagus than normal.

Bombeck et al. (1966) stated that when there is a competent lower oesophageal sphincter, the presence or absence of gastroesophageal reflux depends on the heights of the insertion of the upper limb of the phrenoesophageal ligament into the lower oesophageal sphincter area.

Zeifer and Kisco (1967) and Farrell et al. (1999) have employed the phrenoeosophagealcardia- crural suture technique in hiatus hernia repair. The silk suture is passed through the anterior remnant of phrenoesophageal ligament, the seromuscular layer of the cardia and the posterior remnant of the phrenoesophageal ligament. This stitch is then passed through the crura to approximate it. This technique is safe and effective for use in securing the cardia and terminal oesophagus well within the abdominal cavity.

Hayward (1961) stated that in cases of hiatal hernia, the phrenoesophageal ligament becomes infiltrated with fat and so stretched and tenuous that it becomes useless as a means of repair of the hernia.

Hill et al. (1990) recently advanced a concept to explain those cases of sphincter incompetence in which the sphincter itself is capable of fusion. In normal individual, the phrenoesophageal ligament inserts into the lower end of the oesophagus a short distance above the diaphragmatic hiatus. The normal sphincter is found to reside in that portion of the oesophagus below this insertion. If the ligamentous insertion was to be somehow displaced lower on the oesophagus, it would then insert directly into the body of the sphincter. The sphincter must combat not only by the pressure created by intragastric forces, but also by the action of the membrane itself which in restraining the oesophagus against further herniation, it also acts partially in opposition to the sphincter. This opinion was in line with Dillard (1964).

Smith et al. (1999) demonstrated that the primary etiology of the sliding hiatal hernia is thought to be degeneration of the phrenoesophageal ligament.

Mittal (1990) stated that the lower oesophageal sphincter, the diaphragmatic crura and the phrenoesophageal ligament are the anatomic structures that constitute the antireflux barrier.

References:

  1. Anderson, H.N; May, K.J; Steinmetz, G.P; Ofstun, M; Harrison, H.G; Leyse, R.M. and Dillard, D.H. (1967): The lower oesophageal intrinsic sphincter and the mechanism of reflux: Experimental observations supporting a new concept. Annals of Surgery 166: 102.
  2. Bombeck, C.T; Dillard, D.H. and Nyhus, L.M. (1966): Muscular anatomy of the gastroesophageal junction and role of phrenoesophageal ligament. Annals of Surgery 164: 643-54.
  3. Bremner, C; Schlegel, J.F. and Ellis, F.H. (1970): Studies of the gastroesophageal sphincter mechanism. The role of the phrenoesophageal membrane. Surgery, 67, 735-40.
  4. Brember, C; Shorter, R.G. and Ellis, F.H. (1970): Anatomy of feline oesophagus with special reference to its muscular wall and phrenoesophageal membrane. Journal of Surgical research, 10: 327 - 31.
  5. De Nardi, F.G. and Riddell, R.H. (1991): The normal oesophagus. Annals Journal of surgical pathology 15: 296309.
  6. Dillard, D.H; Anderson, H.N. (1966): A new concept of hiatal hernia. Surgery, Gynecology and Obstetrics. 122: 1030.
  7. Dillard, D.H; (1964): Oesophageal sphincter and reflux. Surgical clinics of North America 44, 1201-9.
  8. Farrell, T.M; Smith, C.D; Metreveli, R.E. (1999): Fundoplications resist reflux independent of in vivo anatomic relationship. American Journal of Surgery 177, 107-10.
  9. Hayward, J. (1961): The lower end of the oesophagus. Thorax 16: 36.
  10. Hill, L.D; Aye, R.W. and Ramel, S. (1990): Antireflux Surgery. A surgeon's book. Gastroenterology Clinics of North America 19: 745 - 75.
  11. Kahrilas, P.J. (1997) Anatomy and Physiology of gastroesophageal junction. Gastroenterology Clinics of North America 26, 467-86.
  12. Kwok, H; Marriz, Y; Al-Ali, S. and Windsor, J.A. (1999): Phrenoesophageal ligament re-visited. Clinical Anatomy 12: 164-70.
  13. Mittal, R.K. (1990): Current concepts of the antireflux barrier. Gastroenterology Clinics of North America 19(3): 501-16.
  14. Patnaik, V.V.G. & Mukherjee, R.N. (2000): Role of Phrenooesophageal' membrane & mucosal flaps in the functioning of the gastroesophageal junction-Morphologic & microanatomic study in mammals including man. Journal of Anatomical Society of India. 49(1): 31-39.
  15. Patti, M.G; Gantert, W. and Way, L.W. (1997): Surgery of the oesophagus. Anatomy and Physiology. Surgical clinics of North America 77, 959-70.
  16. Paulen, D.L; Shaw, R.R. and Kee, J.L. (1962): Oesophageal hiatal diaphragmatic hernia and its complications. Annals of surgery 155: 957-68.
  17. Smith, A.B; Dickerman, R.D; East, J.W; McConathy, W.J. and McGuire, C.S. (1999): Pressure – overload – induced sliding hiatal hernia in power athletes. Journal of clinical gastroenterology 28(4): 352-4.
  18. Zeifer, H.D. and Kisco, M. (1967): Phrenoesophageal-Cardia- Crural fixation in hiatus hernia repair. Annals of surgery 114, 480-81.

Missing Image

Fig. 1. A photograph showing a specimen of the gastro-oesophageal junction. It shows the passage of the oesophagus (O) through the oesophageal hiatus (H). On the left side, the upper (U) and lower (L) leaves of POL are seen.

Missing Image

Fig. 2: A photograph showing the lower part of the oesophagus (O) (an incision was given in its anterior wall) and the stomach (S). The diaphragmatic crus is seen surrounding the lower part of the oesophagus forming the oesophageal hiatus. : Gastroesophageal junction

Missing Image

Fig. 3. A photograph showing the phrenoesophageal ligament (POL) bridging the space between the hiatal margin (H) and the oesophagus (O).

Missing Image

Fig. 4. A photograph showing the white glistening POL as a circumferential continuation of the fascia transversalis (FT) beyond the margin of the muscular diaphragmatic crus and attaches to the oesophageal wall (O). ® : Gastroesophageal junction

Missing Image

Fig. 5. A photgraph showing the anterior part (A) of POL after separation of the diaphragmatic crus (C) of the oesophageal hiatus. The posterior part (P) of the POL is also seen passing behind the oesophagus (O) . FT : Fascia transversalis.

Missing Image

Fig. 6. A photograph showing the left side of the oesophagus (O). The POL originates from the fascia transversalis (FT) that covers the diaphragmatic crus (C). The POL is directed medially to be inserted into the wall of the oesophagus (O) by a thicker upper leaf (U) and a thinner lower leaf (L). ® : Gastroesophageal junction.

Missing Image

Fig. 7. A photograph of another specimen showing the left side of the oesophagus (O) after separation of its anterior part (A). The POL is inserted into the wall of the oesophagus (O) by an upper (U) and a lower (L) leaf. A triangular space (T) is seen separating the two leaves. ® : Gastroesophageal junction.

Missing Image

Fig. 8. A photograph showing the left part of POL arising from the fascia transversalis (FT) and inserting into the oesophageal wall (O) by upper (U) and lower (L) leaves separated by a triangular space (T). ® : Gastroesophageal junction.

Missing Image

Fig. 9. A photograph of the same specimen in figure (8) after separation of the lower (L) leaf. The upper leaf (U) of POL is seen inserted into the oesophageal wall (O). The posterior (P) part of POL is seen passing behind the oesophagus (O). ® : Gastroesophageal junction.

Missing Image

Fig. 10. A photograph showing the details of the POL on the right side of the lower oesophagus (O). The upper (U) and lower (L) leaves of the ligament extend obliquely upward and downward to be attached to the wall of the oesophagus (O) with a triangular space (T) in between.

Missing Image

Fig. 11. A diagram of the normal anatomy of the oesophageal hiatal structure. It shows the phrenoesophageal ligament (POL) in relation to the oesophagus (O), stomach (S), the diaphragmatic crus (C) and fascia transversalis (FT). It shows that the POL divides into an upper (U) and a lower leaf (L). OS : Oesophageal sphincter.

Missing Image

Fig. 12. A photomicrograph of a histological section demonstrating the diaphragmatic end of the POL. Note the collagen fibres (C) that are scattered in the ligament. Sm : Smooth muscles of the diaphragm. (H & E x 40).

Missing Image

Fig. 13. A photomicrograph of a high power view of the phrenoesophageal ligament showing the collagen fibres (c). Fibrablasts

(f) are running in the direction of the connective tissue fibres. (H & E x 100).

Missing Image

Fig. 14. A photomicrograph showing the diaphragmatic end of the POL that is richly supplied with blood vessels (C) and nerves.

Missing Image

Fig. 15. A photomicrograph of a histological section demonstrating the lower leaf of the POL. Note the interwoven collagen (c) (red) and elastic (E) (black) fibres. (VVG x 100)

Missing Image

Fig. 16. A photomicrograph of a high power view of the previous section of the POL. Collagen (c) (red) and elastic (E) (black) fibres are seen running in the same direction. (VVG x 400)

Missing Image

Fig. 17. A photomicrograph of a histological section demonstrating the upper leaf of the POL. The collagen and elastic fibres are seen arranged in an alternating interwoven manner. The upper leaf contains more elastin than the lower leaf when compared with figure (15). (VVG x 100)

Missing Image

Fig. 18. A photomicrograph of the diaphragmatic end of the upper leaf of the POL demonstrating the abundant collagen (c) and elastic (E) fibres which are arranged in an interwoven manner.
Sm : Striated muscles of the diaphragm (VVG x 40)

Missing Image

Fig. 19. A photomicrograph of a higher power view of the previous section. (VVG x 100)

Missing Image

Fig. 20. A photomicrograph of a histological section of the diaphragmatic end of the POL. The striated muscles of the diaphragm (Sm) (brown) and the collagen fibres of the POL (c) (blue) are demonstrated. Adipose tissues (A) are seen surrounding the collagen fibres of the ligament. (Mallory trichrome x 100).

Missing Image

Fig. 21 The diaphragmatic end of the POL (blue) demonstrating isolated groups of skeletal muscle fibres (Sm) (brown). (Mallory trichorme x 40) C : Collagen fibres; V : Blood vessel.

Missing Image

Fig. 22. A photomicrograph of a close up view of the previous photograph. (Mallory trichrome x 100).

Missing Image

Fig. 23. A photomicrograph of a higher power view of figure (21). (Mallory trichrome x 400)

Missing Image

Fig. 24. A photomicrograph of the POL of an old cadaver showing an extensive infiltration by adipose cells (A). (Mallory trichrome x 100).

List of abbreviations:

P : Posterior part of POL
U : Upper leaf of POL
L : Lower leaf of POL
FT : Fascia transversalis
T : Triangular space between the two leaves of the POL
® : Gastroesophageal junction
O : Oesophagus
S : Stomach
POL : Phrenoeosophageal ligament
C : Diaphragmatic crus
H : Oesophageal hiatus
A : Anterior part of POL

Access free medical resources from Wiley-Blackwell now!

About Indmedica - Conditions of Usage - Advertise On Indmedica - Contact Us

Copyright © 2005 Indmedica