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Transpyloric plane

The transpyloric plane, also known as Addison's plane, is an imaginary horizontal (transverse) plane in human anatomy that extends midway between the jugular notch of the sternum and the upper border of the pubic symphysis, typically at the level of the first lumbar vertebra (L1).^[1] This plane serves as a fundamental surface landmark for dividing the abdomen into regions and localizing internal structures, facilitating clinical examinations, surgical planning, and radiological imaging.^[2] Named after the British anatomist Christopher Addison (1869–1951), who established it through detailed anthropometric studies involving approximately 10,000 measurements on 40 cadavers to map thoracoabdominal topography, the plane provides a reliable reference for the relative positions of visceral organs despite individual variations in body habitus. It intersects a range of critical anatomical features, including the pylorus, duodenum, pancreas, kidneys, spleen, superior mesenteric artery, portal vein, gallbladder, intestinal flexures, and cisterna chyli.^[1] The transpyloric plane is significant in imaging modalities like CT or ultrasound to identify pathologies in associated structures, such as pancreatic or renal abnormalities.^[2] Its position also approximates the termination of the spinal cord and the horizontal midpoint of the kidneys, underscoring its utility in both diagnostic and educational contexts.^[1]

Fundamentals

Definition

The transpyloric plane is an imaginary horizontal (transverse) plane in the abdomen that serves as a key reference for locating internal structures.^[1]^[3] It is positioned at the level of the lower border of the first lumbar vertebra (L1).^[3]^[1] An alternative surface definition places it midway between the suprasternal (jugular) notch and the superior border of the pubic symphysis.^[1]^[3] The plane lies approximately a hand's breadth below the xiphisternum or halfway between the xiphisternum and the umbilicus.^[3]^[4]

Anatomical Location

The transpyloric plane is an imaginary horizontal line that intersects the anterior abdominal wall at a level approximately halfway between the xiphoid process and the umbilicus.^[4] This positioning is determined by its primary surface landmark: a transverse line connecting the tips of the ninth costal cartilages on both sides.^[3] Posteriorly, the plane passes through the body of the first lumbar vertebra (L1) and aligns with its lower border.^[1]^[5] In the midline, the plane approximates the level of the pylorus of the stomach, though the pyloric orifice is typically positioned just to the right of the midline.^[6] Laterally, it extends from the left costal margin to the right mid-clavicular line, where it intersects the costal cartilages of the ninth ribs bilaterally, providing a key reference for abdominal surface anatomy.^[7]^[8] Relative to other major abdominal planes, the transpyloric plane lies superior to the transtubercular plane (which passes through the iliac tubercles at the level of L5) and inferior to the subcostal plane (at the lower border of the tenth costal cartilages, corresponding to L3).^[7] It serves as a central reference, often regarded as the "equator" in topographic mapping of the abdomen due to its midway position between the suprasternal notch and the pubic symphysis.^[5] While standardized for anatomical education, the exact position exhibits slight variability among individuals, influenced by factors such as body habitus and spinal curvature, sometimes shifting between the lower border of L1 and the upper border of L2.^[1]^[2]

Structures Intersected

Vertebral Level and Spinal Cord

The transpyloric plane traverses the vertebral column at the level of the first lumbar vertebra (L1), passing through its body and specifically aligning with the lower border in most individuals. ^[9] This positioning is derived from classical anatomical descriptions and confirmed through imaging studies, where the plane is observed between the lower L1 and upper L2 vertebrae in approximately 75% of cases. ^[10] At this vertebral level, the transpyloric plane intersects the spinal cord at the conus medullaris, the tapered terminal portion of the cord that marks its inferior extent. ^[11] The conus medullaris typically terminates at the L1-L2 intervertebral disc in adults, though anatomical variability results in a range from the lower thoracic twelfth vertebra (T12) to the upper third lumbar vertebra (L3). ^[12] ^[13] This variability in spinal cord termination holds clinical relevance for procedures such as lumbar punctures and spinal anesthesia, where the transpyloric plane serves as an approximate landmark for the cord's end; inferior to this level, the subarachnoid space contains only the cauda equina nerve roots, reducing the risk of cord injury during needle insertion below L2. ^[14] ^[15]

Stomach and Duodenum

The transpyloric plane intersects the pylorus, the outlet of the stomach, near the midline at the level of the first lumbar vertebra. This intersection occurs at the pyloric sphincter, a thickened ring of smooth muscle that regulates the passage of partially digested food (chyme) from the stomach into the duodenum. The alignment of the pyloric sphincter with the transpyloric plane serves as a key anatomical landmark for the distal stomach, facilitating the controlled transition of gastric contents into the small intestine.^[16]^[17] The plane then traverses the proximal duodenum, specifically crossing the first part (also known as the duodenal bulb or cap) and the superior aspect of the second (descending) part. The first part of the duodenum, approximately 5 cm in length, extends superiorly and slightly to the right from the pylorus, remaining largely intraperitoneal for its initial 2.5 cm before becoming retroperitoneal. The second part descends along the right side of the vertebral column, where the transpyloric plane passes through its upper portion, near the entry of the common bile and main pancreatic ducts at the major duodenal papilla. These intersections highlight the plane's role in delineating the proximal small intestine's C-shaped configuration around the head of the pancreas.^[18]^[1] Further along, the transpyloric plane encounters the duodenojejunal flexure approximately 2.5 cm to the left of the midline, marking the junction where the duodenum transitions to the jejunum and the beginning of the mobile small intestine proper. This flexure is suspended by the suspensory muscle (ligament of Treitz), which anchors it to the posterior abdominal wall, and its position on or near the plane underscores the transpyloric level's significance in defining the upper gastrointestinal tract's anatomical divisions. Overall, the plane's passage through these structures emphasizes its utility in mapping the stomach-to-small-intestine continuum, aiding in clinical assessments of upper abdominal pathology.^[19]^[20]

Pancreas

The transpyloric plane intersects the pancreas at its neck, which serves as a narrow constriction connecting the wider head to the body of the organ. This intersection effectively divides the pancreas into its head portion, located to the right of the plane, and the body and tail, which lie to the left and superiorly. The neck itself measures approximately 2 cm in width and is positioned such that the plane traverses it transversely, highlighting the pancreas's oblique orientation across the upper abdomen.^[21]^[22] Anatomically, the neck of the pancreas is situated anterior to the superior mesenteric vessels, including the superior mesenteric vein and artery, at the level of the first lumbar vertebra (L1). This precise location underscores the transpyloric plane's utility as a reliable landmark for the pancreas, as it aligns closely with the vertebral body of L1 and facilitates the organ's identification in both clinical and surgical contexts. The plane's passage through this region also approximates the overall horizontal span of the pancreas, which extends from the duodenum laterally to the splenic hilum medially.^[21]^[23]^[24] This relationship enhances the transpyloric plane's role in delineating pancreatic anatomy, particularly in distinguishing the head—adjacent to the duodenum—from the more proximal body, thereby supporting accurate localization during procedures such as imaging or resection. The plane's approximation of the pancreas's full transverse course further aids in conceptualizing its retroperitoneal position and mixed exocrine-endocrine functions without requiring detailed sectional imaging.^[1]^[22]

Gallbladder

The transpyloric plane intersects the fundus of the gallbladder, marking a key anatomical landmark in the right upper quadrant of the abdomen.^[1]^[4] This intersection occurs at the level of the first lumbar vertebra (L1), where the plane traverses the biliary system's most distal portion on the right side.^[1] The gallbladder fundus is positioned inferior to the liver, nestled within the gallbladder fossa on the visceral surface of the right lobe, and it typically projects below the right costal margin, making it the organ's most dependent part in the supine position.^[25] This anterior and inferior orientation allows the fundus to lie in close proximity to the anterior abdominal wall, often at the intersection of the right midclavicular line and the transpyloric plane's right lateral extent.^[25] In anatomical studies, this positioning facilitates its palpability during clinical examination when the organ is distended, such as in cases of cholecystitis.^[26] As the widest and most anterior segment of the gallbladder, the fundus serves as a reservoir for bile and is visible along the transpyloric plane in supine individuals due to its superficial projection beneath the costal arch.^[26] This relation underscores the plane's utility in localizing biliary pathology during imaging modalities like ultrasound or CT scans.^[1]

Kidneys

The transpyloric plane intersects the hila of both kidneys, with each hilum positioned approximately 5 cm lateral to the midline. The left renal hilum lies just above the plane, while the right renal hilum is situated just below it. This slight asymmetry arises because the right kidney is positioned inferiorly to the left, primarily due to the mass effect of the overlying liver. The plane thus marks the middle third of each kidney, transecting it horizontally near the hilum region. The renal hilum represents the medial concavity of the kidney, serving as the entry site for the renal artery and vein, as well as the exit point for the ureter. This configuration facilitates the vascular and excretory connections essential to renal function. The adrenal glands, which overlie the superior poles of the kidneys, are positioned entirely superior to the transpyloric plane.

Vascular Structures

The transpyloric plane intersects several key vascular structures in the abdomen, primarily at the level of the L1 vertebra. The superior mesenteric artery (SMA) originates from the anterior surface of the abdominal aorta at this level, approximately 1 cm inferior to the celiac trunk and superior to the renal arteries.^[27] This origin aligns closely with the plane's passage, occurring immediately posterior to its midline trajectory and serving as a critical landmark for midgut vascular supply.^[28] The portal vein forms posterior to the neck of the pancreas within the transpyloric plane, by the union of the superior mesenteric vein and the splenic vein.^[22] This confluence occurs at the lower margin of L1, marking the transition of venous drainage from the midgut and foregut to the hepatic portal system.^[29] Additionally, the plane traverses the transverse portions of the renal arteries and veins at the hila of the kidneys, where these vessels enter and exit the renal pelvis.^[30] The left renal hilum typically aligns directly with the plane, while the right is slightly inferior, reflecting the kidneys' vertical positioning relative to L1.^[31]

Spleen

The transpyloric plane intersects the spleen along its lower border, marking a key anatomical landmark in the left upper quadrant of the abdomen.^[1] The spleen, an intraperitoneal organ situated posterior to the stomach and anterior to the left hemidiaphragm, has its hilum at the level of this plane, while the lower pole typically extends inferiorly.^[32]^[33] Protected by the overlying ribs 9 through 11, which shield its diaphragmatic surface, the transpyloric plane delineates the normal inferior limit of the spleen, aiding in clinical assessments of organ size and position.^[34]

Other Structures

The left colic flexure, also known as the splenic flexure, is typically intersected by the transpyloric plane. At the renal hila, the origins of the renal pelvis and proximal ureters are positioned at or near the transpyloric plane level, extending briefly from the kidney's medial border where the pelvis funnels into the ureter.^[10] Lymphatic nodes along major abdominal vessels, such as the superior mesenteric and celiac groups, are intersected by or lie adjacent to the transpyloric plane, facilitating drainage from foregut and midgut structures.^[35] The transverse colon exhibits positional variability relative to the transpyloric plane, with its midportion often crossed by the plane while the full extent may shift superiorly or inferiorly based on individual habitus and peritoneal attachments.^[8] The transpyloric plane also intersects the cisterna chyli, the origin of the thoracic duct.^[1] In rare anatomical descriptions, the transpyloric plane may intersect the inferior margin of the left lobe of the liver or involve omental attachments, such as those of the greater omentum connecting the stomach and transverse colon.^[36]

Clinical Significance

Surgical Landmarks

The transpyloric plane serves as a vital anatomical reference in abdominal surgery, facilitating precise localization of key structures during operative procedures. In pancreaticoduodenectomy, commonly known as the Whipple procedure, the plane approximates the level of the pancreatic neck and the origin of the superior mesenteric artery, aiding surgeons in resecting the pancreatic head while preserving critical vascular supply.^[1]^[37] This positioning is essential for minimizing intraoperative complications in this complex operation targeting periampullary malignancies. As a surface landmark corresponding to the L1 vertebral level, the transpyloric plane guides the extent of midline laparotomy incisions, providing optimal access to mid-abdominal contents without unnecessary extension superiorly or inferiorly.^[38]^[1] In splenectomy, the plane marks the approximate lower border of the spleen, helping delineate the organ's inferior extent for safe mobilization and removal, particularly in laparoscopic approaches.^[1] Similarly, during nephrectomy, it indicates the hila of the kidneys, serving as a reference for identifying vascular and ureteral entry points to the renal pelvis.^[1]^[39] In the context of abdominal trauma, the transpyloric plane demarcates the supracolic and infracolic compartments of the peritoneal cavity, assisting in the systematic evaluation of intraperitoneal hemorrhage—supracolic injuries often involve the liver, spleen, or stomach, while infracolic ones affect the small bowel or colon—thus informing decisions on exploratory laparotomy or focused assessment.^[40]^[1]

Diagnostic Imaging

The transpyloric plane serves as a key reference line in computed tomography (CT) and magnetic resonance imaging (MRI) scans of the abdomen, standardizing axial slices at the approximate level of the L1 vertebra to facilitate consistent evaluation of midline structures.^[4] This alignment enables radiologists to systematically assess organs such as the pylorus, pancreatic neck, and hilar vessels in cross-sectional views, as demonstrated in contrast-enhanced CT protocols where slices at this plane highlight vascular origins like the superior mesenteric artery.^[41] In MRI, the plane aids in multiplanar reconstructions for detailed soft-tissue differentiation, particularly useful for detecting abnormalities in the portal triad.^[42] In diagnostic contexts, the transpyloric plane assists in identifying specific pathologies by providing a reproducible anatomical benchmark for lesion localization. For instance, tumors in the pancreatic neck, which lies within this plane, appear as hypodense masses on CT or T1-hypointense lesions on MRI, allowing for early detection and staging when scans are oriented accordingly.^[43] Similarly, stones in the gallbladder fundus—positioned at or near the plane—can be visualized as echogenic foci with posterior shadowing on ultrasound or as calcified densities on CT, correlating surface projections with internal findings to guide management.^[44] Ultrasound imaging leverages the transpyloric plane to approximate probe placement for targeted assessments, such as evaluating the kidney hilum where vascular structures enter at this level, revealing flow patterns via Doppler to detect stenosis or thrombosis.^[45] For pyloric stenosis in infants, real-time sonography with the transducer positioned at the transpyloric plane visualizes the hypertrophied pylorus as a thickened hypoechoic ring, measuring muscle thickness greater than 3 mm to confirm diagnosis.^[46] This approach ensures dynamic evaluation of antral and duodenal motility without radiation exposure.^[47] Accounting for variability is essential in diagnostic imaging, as the transpyloric plane's position relative to surface landmarks can shift due to differences in body habitus, such as in obese patients where it may descend slightly below the L1-L2 interspace on CT.^[2] This correlation between external anatomy and internal imaging planes helps mitigate discrepancies, improving accuracy in pathology localization across diverse patient populations.^[45]

Therapeutic Interventions

Transpyloric feeding tubes, also known as postpyloric or nasojejunal tubes, are commonly inserted via the nasal or oral route to deliver enteral nutrition directly into the duodenum, bypassing the stomach in patients with conditions such as gastroparesis or severe gastroesophageal reflux. The transpyloric plane serves as a key anatomical landmark for estimating insertion depth, as it approximates the level of the pylorus; in adults, the tube is typically advanced to a depth of approximately 50-60 cm from the nares to reach the duodenum beyond this plane.^[48]^[49] This guided placement reduces risks of mispositioning and complications like aspiration, with techniques such as water injection or electromagnetic guidance often employed to confirm transpyloric passage.^[50] Percutaneous nephrostomy involves the insertion of a catheter into the renal pelvis to drain urine in cases of obstruction, while renal biopsies obtain tissue samples for diagnosis; both procedures target the renal hilum, which lies at the level of the transpyloric plane approximately 5 cm lateral to the midline.^[24] This anatomical alignment aids in precise fluoroscopic or ultrasound-guided access through the lumbar region, minimizing vascular injury by aligning with the relatively avascular Brodel's plane within the kidney parenchyma.^[51]^[52] Endoscopic retrograde cholangiopancreatography (ERCP) is a therapeutic procedure for managing biliary and pancreatic duct disorders, such as stone removal or stent placement, where the endoscope is advanced through the pylorus into the second portion of the duodenum. The transpyloric plane provides a reference for the positions of the gallbladder fundus and pancreatic neck, facilitating orientation during cannulation of the ampulla of Vater and contrast injection into the relevant ductal systems.^[53]^[22] Chemotherapy and drainage catheters for mid-abdominal access, such as those used for intraperitoneal delivery in ovarian cancer or ascites management, are often placed percutaneously at the transpyloric plane level to target the peritoneal cavity effectively while avoiding major viscera.^[54] This plane's intersection with key structures like the superior mesenteric artery origin guides safe entry points, typically under imaging to ensure optimal positioning for therapeutic fluid administration or evacuation.^[55]

History

Discovery and Measurements

The transpyloric plane was established through systematic anthropometric studies conducted by British anatomist and surgeon Christopher Addison in the late 19th and early 20th centuries.^[56] Addison's work focused on mapping the topographical anatomy of the abdominal viscera, particularly the gastrointestinal tract, to provide reliable references for clinical practice.^[57] These studies were based on over 10,000 precise measurements taken from 40 human cadavers, enabling a detailed empirical foundation for abdominal topography.^[58] The data derived from dissections and linear assessments correlated external surface landmarks with the positions of internal organs, accounting for variations in body habitus.^[59] This framework positioned the transpyloric plane as a key transverse reference, typically aligning with the body of the first lumbar vertebra.^[24] The initial emphasis of this research was on enhancing surgical accuracy by linking palpable surface features, such as the midpoint between the jugular notch and pubic symphysis, to the locations of viscera like the pylorus and duodenum, thereby reducing risks in abdominal procedures.^[59] Addison's findings were detailed in a series of papers published in the Journal of Anatomy and Physiology from 1899 to 1901, and presented as Hunterian lectures at the Royal College of Surgeons in 1901.^[60]

Naming and Etymology

The term transpyloric plane originates from the Latin prefix trans-, meaning "across" or "through," combined with pyloric, which pertains to the pylorus—the distal opening of the stomach into the duodenum—derived from the Greek pylōros (πυλωρός), meaning "gatekeeper." This nomenclature reflects the plane's anatomical significance as an imaginary horizontal line that transverses the body at the level of the pylorus, serving as a key landmark in surface anatomy.^[61]^[62] The plane was first formally described and named by British anatomist Christopher Addison (later Viscount Addison) in his series of papers On the Topographical Anatomy of the Abdominal Viscera in Man, Especially the Gastro-Intestinal Canal, published in the Journal of Anatomy and Physiology between 1899 and 1901, beginning with volume 33 in 1899.^[63] Addison's work emphasized the plane's utility in mapping abdominal structures, establishing it as a standard reference in anatomical studies. It is alternatively known as Addison's plane, an eponym recognizing Addison's pioneering contributions to the topographical anatomy of the abdomen.^[1]^[63] This naming convention evolved within the broader context of 19th- and early 20th-century advancements in surface anatomy, where horizontal planes such as the subcostal, transtubercular, and intertubercular lines were proposed to correlate external body landmarks with internal viscera, as seen in contemporary texts like those by Henry Gray and Treves.^[4] The transpyloric plane, in particular, gained prominence as a reliable horizontal divider amid these developments, integrating empirical data from dissections to aid clinical localization.^[24]

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May 4, 2025 · Percutaneous nephrostomy is a minimally invasive procedure used to drain the renal collecting system, typically in cases of urinary tract obstruction.
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Jan 23, 2019 · The reason for its relative avascularity is that it represents the plane where the anterior and posterior segmental renal artery branches meet.
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ERCP is a combined endoscopic and fluoroscopic procedure in which an endoscope is advanced into the second part of the duodenum.Missing: transpyloric | Show results with:transpyloric
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Tunnelled Peritoneal Catheter for Malignant Ascites—An Open ... - NIH
Jun 11, 2021 · Tunnelled peritoneal PleurX catheters are implanted in the abdominal cavity as a permanent solution to drain ascites and can be used by the patient or nursing ...Missing: transpyloric plane
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Percutaneous Nephrostomy - an overview | ScienceDirect Topics
Patients are placed on the fluoroscopy table in a prone oblique position to access the renal collecting system via the avascular plane.
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On the topographical anatomy of the abdominal viscera, especially ...
On the topographical anatomy of the abdominal viscera, especially the gastro-intestinal canal in man. Christopher Addison ... abdomen at present in general ...
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Reviews - The BMJ
His discovery of. " Addison's transpyloric plane " and his papers and books on anatomy made him a leading authority on the subject. As other British ...
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The Bunterian Lectures ON THE TOPOGRAPHICAL ANATOMY OF ...
The Bunterian Lectures ON THE TOPOGRAPHICAL ANATOMY OF THE ABDOMINAL VISCERA IN MAN. ... Author links open overlay panel. Christopher Addison M.D. LOND., F.R.C S.
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Topographical Anatomy of the Abdominal Viscera in Man ... - NIH
Topographical Anatomy of the Abdominal Viscera in Man, especially the Gastro-Intestinal Canal. Part III. Christopher Addison. Christopher Addison. 1 ...
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transpyloric - Wiktionary, the free dictionary
Watch · Edit. English. Etymology. From trans- +‎ pyloric. Adjective. transpyloric (not comparable). (anatomy) Through the pylorus. Derived terms. transpyloric ...
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Pylorus - Etymology, Origin & Meaning
"orifice of communication between the stomach and intestines," 1610s, from Late Latin pylorus "the lower orifice of the stomach," from Greek pylōros "lower ...
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Topographical Anatomy of the Abdominal Viscera in Man, especially the Gastro-Intestinal Canal. Part II. Christopher Addison ... Anatomical Society of Great ...Missing: 1903 | Show results with:1903