1
Q
vasc of uterus
A
uterine A, then ovarian A
2
Q
caput medusae
A
dilated Cutaneous veins in anterior ab wall due to:
- portal htn
- SVC/IVC obstruction
3
Q
ASIS (anterior superior iliac spine) lies at the level of
A
sacral promontory
4
Q
innervations to bladdar
A
vesical/prostatic plexus
PNS (s2-s4): contract detrusor, relax internal urethral sphincter
SNS: relax detrusor, constrict internal sphincter
5
Q
Mesentery proper
A
dbl fold peritoneum
suspends jejunum and ilieum from post ab wall
- The root extends diagonally from the duodenojejunal flexure to the right iliac fossa.
- Its free border encloses the small intestine.
- Contains the superior mesenteric and intestinal (jejunal and ileal) vessels, nerves, and lymphatics.
6
Q
Transverse colon
A
R hepatic flexure –> L splenic flexure
largest and most mobile
txverse mesocolon attachment to posterior ab wall
N: superior & inferior mesenteric plexus
A: SMA - R, L, middle colic
V: SMV - R, L, middle colic
L: middle colic
7
Q
lymph of duodenum
A
follow A
–pancreaticoduodenal, pyloric, superior mesenteric, and celiac lymph nodes
8
Q
Peri-nephric abscess
A
spread to pelvis due to fascial attachment
- DOES NOT SPREAD TO ADJ KIDNEY
causes:
- UTI
- staph aureus
- DM
- lsions of urinary tract: stones, cyst
9
Q
Intraperitoneal Injection
A
•widely used to administer chemotherapy drugs to treat some cancers, particularly ovarian cancer.
Fluid injected into the peritoneal cavity is absorbed rapidly
10
Q
functional “left liver” inclues
A
L lobe, caudate, quadrate lobes
11
Q
Inguinal ligament
A
lower free border of external oblique
folds backwards on self
ASIS –> pubic tubercle
12
Q
direct inguinal hernia
A
WEAK posterior wall of inguinal canal
No descent into scrotum
medial to inferior epigastric vessels
aquired
Older age
13
Q
basic celiac trunk pic
A
14
Q
Lymphatic drainage of female reproductive organs
A
- ovary, uterine tube, and fundus follow the ovarian artery and drain into the paraaortic nodes/ lateral/ pre/ lumbar.
- uterine body and cervix drain into the internal and external iliac nodes
15
Q
2nd part duodenum
A
descending R of L1–L3
–major duodenal papilla on posteromedial wall = opening of hepatopancreatic ampulla
16
Q
Thoracic esophagus
A
superior mediastium, L of median line
- pass behind and R of aortic arch
- desc posterior mediastinum along the right side of the descending aorta
diagphragm @ T10
- distinct dilation before entering diaphragm
front: trachea, aortic arch, R pulm A, L bronchus, pericardium
behind: v-colum, longus colli M, R aortic intercostal, thoracic duct, hemiazygos V
17
Q
Venous drainage of prostate
A
prostatic venous plexus b/w true and false capsules
connect to Batson plexus (valve less)
•Veins of most of the pelvic organs are connect to Batson plexus ( except for ovaries and testis)
- how pelvic cancer can spread to the vertebral column
18
Q
venous drainage of kidney
A
R & L renal V
- anterior to A
- L receives L suprarenal and L gonadal
drain to IVC
L passes anterior to aorta, posterior to desc SMA
19
Q
NAVL of liver
A
N: hepatic N plexus: SNS from celiac plexus, PNS from vagus
A: portal vein (70%), hepatic (30%)
V: 3 formed by union of central veins –> drain to IVC inferior to diaphragm
L: hepatic –> celiac –> cisterna chyli
20
Q
Subphrenic (Suprahepatic) Recess
A
pocket b/w diaphragm and anterior/superior part of liver
separated into right and left recesses by the falciform ligament.
21
Q
innervation to large intestine
A
PNS - vagus, pelvic splachnic
SNS: T10-L2
22
Q
N, A, V, L of scrotum
A
N:
- anterior 1/3 = ilioinguinal, genitofemoral - genital branch
- posterior 2/3 = pudendal, posterior cut N of thigh
A:
- pudendal –> scrotum
- inferior epigastric –> cremastric
V:
- same as A
L:
- superficial inguinal
23
Q
Rectus sheath
A
•Aponeurosis of int. obl. splits to enclose rectus abdominis to form rectus sheath
anterior
- above arcuate line
- Aponeurosis of external and internal oblique
- Below arcuate line
- Aponeurosis of external oblique, internal oblique and transverse abdominis
posterior
- •Above arcuate line
- •Aponeurosis of internal oblique and transverse abdominis
- •Below arcuate line
- •Deficient, rectus abdominis lie on fascia transversalis
24
Q
Nerve supply to stomach
A
PNS
- From anterior and posterior vagal trunks.
- Increase peristalsis and relax pyloric sphincter.
SNS
- From T6–T9 spinal cord segments via great splanchnic nerve to celiac plexus.
- Inhibit peristalsis and contract pyloric sphincter.
25
Visceral referred pain of stomach
poorly localized --\> radiates to dermatome lvl
## Footnote
•Parietal peritoneum pain is severe and localized
26
innervation to rectum
pns - pelvic splanchnic
27
Paracolic Recesses (Gutters)
•Lie lateral to the ascending colon (right paracolic gutter) and lateral to the descending colon (left paracolic gutter).
28
prostate secretes
PSA
PGs
citric acid
acid phosphatase
proteolytic enz
29
Ascending colon
R posterior ab walll
cecum --\> liver: turns @ R colic flexure (hepatic flexure)
secondarily retroperitoneal
N: superior mesenteric plexus
A: ileocolic, R colic
V: ileocolic, R colic
L: epicolic, paracolic nodes
30
Xiphoid process: located at T\_\_\_\_
T9
31
complications of gastric ulcers
bleeding, perforation
if on posterior wall of stomach: can erod large splenic A
32
Scrotum
* Cutaneous bag containing testis, epididymis and lower part of spermatic cord
* Has six layers-skin, dartos muscle, Colles fascia, external spermatic fascia, cremasteric fascia and internal spermatic fascia
* Dartos m. is supplied by sympathetic fibers passing through genital branch of genitofemoral nerve
33
Subhepatic Recess
* Hepatorenal Recess (Morrison’s Pouch)
* ■ Is a deep peritoneal pocket between the liver anteriorly and the kidney and suprar-enal gland posteriorly.
* It communicates with the lesser sac via the epiploic foramen and the right paracolic gutter, thus the pelvic cavity.
34
Innervation to Adrenal glands
myelinated presynp SNS --\> celiac plexus, thoracic splanchnic --\> chromaffin cells (SNS postgang)
35
•Mesosalpinx
•Suspends the uterine tube
36
NAVL of Large intestines
N: from superior mesenteric plexus: PNS - vagus, SNS - lower thoracic SC seg
A: ileocolic
V: ileocolic
L: ileocolic
37
Suspensory ligament of the ovary
•connects ovary to the lateral pelvic wall
38
FIRST PART OF DUODENUM
•Superior
–Neck of gallbladder
–Hepatoduodenal ligament (lesser omentum)
•Inferior
–Neck of pancreas
–Greater omentum
39
Iliacus
O:Iliac fossa
I: lesser trochanter, femoral shaft, psoas major tendon
N: femoral
A: flex thigh, stab hip
40
•SMA syndrome
–Compression of the third part of the duodenum by the SMA and AA
Symptoms
* include early satiety, nausea, vomiting,
* extreme "stabbing" postprandial abdominal pain (due to both the duodenal compression and the compensatory reversed peristalsis
* severe malnutrition accompanying spontaneous wasting
* "Food fear" is a common development among patients with the chronic form of SMA syndrome
41
Coverings of spermatic cord
Ensheathed in three layers of tissue:
* External spermatic fascia, an extension of the aponeurosis of the external oblique muscle
* Cremasteric muscle and fascia, formed from a continuation of the internal oblique muscle and its fascia
* Internal spermatic fascia, continuous with the transversalis fascia
42
•Vermiform appendix
–Arises from the posteromedial side of cecum
–Usually retrocecal
–Has a short mesentery from cecum: mesoappendix
–Supplied by appendicular artery from ileocolic artery
43
Hesselbach’s triangle
Boundaries:
•Medially
* •Rectus abdominis
•Laterally
* •Inferior epigastric artery
•Inferiorly
* •Inguinal ligament
•Direct inguinal hernia occur through this
44
Intraperitoneal organs are...
enclosed by peritoneum on all sides
45
Uterine and vaginal plexus
-drains into the uterine vein
46
Iliac crest @ what lvl of vert?
L4
47
portosystemic anatomoses
48
Secondary retroperitoneal organs are
start intraperitoneal
fold
end up pressed against posterior body wall
lose mesentery --\> become retroperitoneal
49
Neuromuscular plane is located...
•Between internal oblique and transverse abdominis
50
Pudendal block
- sacrospinous ligament attaches from sacrum to ischial spine
- Pudendal n. crosses the sacrospinous ligament on its lateral aspect near its attachment to the ischial spine
- Locate the spine, find location of the nerve for injection
-
-
51
internal oblique
O: thoracolumbar fascia, anterior 2/3 of iliac crest, lateral 1/2 inguinal ligament
I: ribs 10-12, linea alba, conjoint tendon to pubis
N: thoracoabdominal anterior rami of inferior 6 thoracic N, L1
A: compress, support ab viscera, flex and rotate trunk
52
•3 superficial artery from femoral artery for cutaneous anterior abdominal wall
* Superficial epigastric
* Superficial external pudendal
* Superficial circumflex iliac
53
Intestine in Omental Bursa
uncommon
omental foramen --\> omental bursa: may become strangulated
boundaries of foramen cannot by incised due to bv
MUST decompress intestines --\> return
54
3 main branches of celiac trunk
1. common hepatic
* gastroduodenal
* supraduodenal
* superior pancreaticoduodenal
* R gastro-omental
* R gastric
* con't as proper hepatic
* R hepatic
* cystic
* L hepatic
2. L gastric
* esophageal
3. splenic
* short gastrics
* L gastro-omental
55
general parts duodenum
4 parts: 2-4 are retroperitoneal, anterolateral to L1
56
•Lateral or Transverse Cervical (Cardinal or Mackenrodt) Ligaments of the Uterus
extend from cervix and the vagina to the pelvic walls
extend laterally below the base of the broad ligament
support the uterus
•Main ligament that prevents the prolapse
57
hepatorenal recess
subhepatic recess
## Footnote
potential space b/w liver and R kidney
58
Rectal venous plexus
drains into any rectal vein
59
Abdominal Paracentesis
anterolateral ab wall: superior to empty bladder
avoids inferior epigastric A
60
Vesical venous plexus
-drains the bladder, prostate (m), deep and dorsal veins of the penis/clitoris and will drain into the inferior vesical vein
61
Sacral Plexus
62
Lesser omentum
dbl layer
porta hepatis --\> lesser curv of stomach and 1st part of duodenum
* Hepato gastric and hepatoduodenal ligaments.
* Right free margin contains the portal triad.
63
Need to be careful during hysterectomy
Ureter and uterine artery relationship
64
Lesser Sac (Omental Bursa)
* ■ Is an irregular space that lies behind the liver, lesser omentum, stomach, and upper anterior part of the greater omentum.
* ■ Is a closed sac, except for its communication with the greater sac through the epiploic (omental) foramen.
•
65
indirect inguinal hernia
deep inguinal ring --\> scrotum
* lateral to inferior epigastric vessels
Congenital: incomplete closing of (embryonic) process vaginalis
Younger age
66
•Prostatectomy may lead to....
erectile dysfunction
67
•Sacrocervical Ligaments
•Extend from the lower end of the sacrum to the cervix and the upper end of the vagina
68
NAVL of ureters
N:
* abdominal, aortic and superior hypogastric plexuses
* pain fibers follow SNS T11-L2: referred pain to lower quad of anterior ab wall
A: branches of renal, gonadal, aorta, common iliac
V: renal, gonadal
L:
* follow renal V --\> lumbar lymph nodes (caval &aortic)
* middle --\> common iliac nodes
* inferior --\> common, external, iliac nodes
69
vasc supply to adrenal glands
A:
* superior suprarenal A (6-8) from inferior phrenic
* middle suprarenal artery from the aorta
* inferior suprarenal artery from the renal artery
V: suprarenal vein --\>
* R: IVC
* L: L renal
70
lymph drainage to rectum
upper rectum: superior rectal --\> inferior mesenteric --\> aortic
lower: internal iliac
71
Epiploic or Omental (Winslow’s) Foramen
and boundaries
* natural opening between the lesser and greater sacs.
* ■ Is bounded superiorly by peritoneum on the caudate lobe of the liver, inferiorly by peritoneum on the first part of the duodenum, anteriorly by the free edge of the lesser omentum, and posteriorly by peritoneum covering the IVC.
72
inguinal ring: superficial and deep
* Superficial inguinal ring
* Triangular gap in external oblique aponeurosis situated superomedial to pubic tubercle
* Deep inguinal ring
* Lies in fascia transversalis just lateral to inferior epigastric vessels
73
Peritonitis
* Bacterial contamination of the peritoneum.
* Causes: Trauma, infection, appendicitis, perforation an ulcer.
* Generalized peritonitis is dangerous.
74
Parietal peritoneum
internal surface of the abdominal and pelvic wall.
same NAVL as region of the wall it lines
pain, heat, cold and laceration.
Pain = well localized
75
0Anterior abdominal wall
* Part of trunk below diaphragm
* Divided by plane of pelvic inlet
* •Larger upper part abdomen proper
* •Smaller lower part true pelvis
•Contents
* •Large part of the digestive and urogenital system
76
celiac A supply
77
recesses of lesser sac
* Presents three recesses:
* (1) superior recess, which lies behind the stomach, lesser omen-tum, and left lobe of the liver;
* (2) inferior recess, which lies behind the stomach, extending into the layers of the greater omentum.
* (3) splenic recess, which extends to the left at the hilus of the spleen.
78
recesses of liver
subphrenic: split yb falciform ligament, sep liver from diaphragm
hepatorenal: R side, sep anterior from kidney, post by adrenal gland
79
Hiatal hernia
stomach to mediastinum via esophageal hiatus
•More common in middle aged people.from weak muscles.
1. paraesophageal
* cardia remains in normal position, only esophagus moves
2. sliding
* clamping of R crus of diaphragm = weak
* ab esophagus, cardia, parts of fundus of stomach
* esp when person lying down, bends over
80
Constituents of spermatic cord
* Ductus deferens
* Testicular, cremasteric, and artery to ductus deferens
* Pampiniform plexus of veins
* Lymph vessels from testis
* Genital branch of genitofemoral nerve and sympathetic plexus
* Remains of processus vaginalis
81
Cryptorchidism
•Undescended testis
82
ligaments of liver
•Falciform ligament
–Peritoneal reflection from upper anterior abdominal wall from umbilicus to liver
–Has ligamentum teres hepatis (round ligament) in free edge
•Ligamentum teres hepatis (round ligament of liver)
–Fibrous remnant of umbilical vein
–Extended from umbilicus to liver
•Ligamentum venosum
–Remnant of the ductus venosus
–Extended in fetus between the umbilical vein and inferior vena cava (IVC)
83
LIVER general characteristics
covered by peritoneum except @ porta hepatis and bed of gall bladder
related to:
–Right side of anterior stomach
–First part of duodenum
–Gall bladder
–Right colic flexure and transverse colon
–Right kidney and suprarenal glands
84
•Round Ligament of the Uterus
•Attached to the uterus in front of and below the attachment of the uterine tube
**•Remnant of Gubernaculum!**
* Holds the fundus of the uterus forward, keeping the uterus anteverted and anteflexed
* Enters the inguinal canal at the deep inguinal ring, emerges from the superficial inguinal ring, and becomes lost in the subcutaneous tissue of the labia majora
85
Esophagus in general
extends what on vertebrae
C6 --\> T11/12
most narrow @ start and when it passes through diaphragm
86
Vagina fornix
forms the recess between the cervix and the wall of the vagina
87
INTERNAL STRUCTURE OF KIDNEYS
Cortex
* Outer layer
* Contains: glomerulus, renal corpuscle, proximal and distal convoluted tubules, proximal collecting ducts
Medulla
* Inner layer
* Divided into medullary pyramids
* Contains: thick and thin limbs of loops of Henle, distal parts of proximal and distal convoluted tubules, distal collecting ducts
88
lobes of prostate
* Anterior lobe (or isthmus): front of the urethra, no glandular substance
* Middle (median) lobe: between the urethra & ejaculatory ducts, prone to BPH = block internal urethral orifice
* Posterior lobe: behind the urethra & below ejaculatory ducts, prone to carcinomatous transformation
* Right and left lateral lobes: either side of the urethra = main mass of the gland
89
where is the Site for portocaval anastomoses
Hemorrhoids
hemorrhoids
90
Posterior Branch of internal iliac
91
Porta hepatis
txverse fissure on visc surf b/w caudate and quadrate lobes
## Footnote
•Provides entrance/exit for:
–Portal vein
–Hepatic artery
–Hepatic ducts (left and right converge to form the common hepatic duct)
–Hepatic nerve plexus
–Lymphatic vessels
92
Ureters
retroperitoneal
surface marking: 5cm lateral to L1 SP and PSIS
constricted @ 3 sites:
* jxn ureter and renal pelvis
* cross pelvic brim, external iliac A
* wall of urinary bladdar
93
Pelvic Inlet vs. Pelvic Outlet
94
Peptic ulcer: palp in what region of the ab?
epigastrium
95
Pouch of Douglas
rectouterine pouch
fold of peritoneum b/w rectum and uterus
behind posterior fornix of vagina
contains peritoneal fluid and some of small intestines
96
cremasteric reflex test
L1-L2
The genital branch of genitofemoral n. innervates the cremasteric muscle
97
Bone marrow harvest
Posterior aspect of iliac crest
98
•Pheochromocytoma
uusally benign tumor of adrenal medulla
exaggerated SNS activity: excess secr of epi, NE
99
Innervation of Kidneys
renal plexus
formed from:
* celiac plexus
* aorticorenal ganglia
* least splanchnic N
* aortic plexus
100
Planes of abdomen
Subcostal plane:
* Passes below costal margin of each side (10th cc)
* Post. passes through L3 (upper border)
Transtubercular plane:
* Passes through tubercles of iliac crest and body of L5 near its upper border
Midclavicular plane:
* Crosses the tip of 9th cc and midinguinal point
101
Visceral peritoneum
same NAVL as organ it covers
stretching, chemical irritation
* insensitive to touch, heat and cold, and laceration (pareital)
pain = poorly localized
* dermatomes of sensory fibers.
102
pancreatic duct
main: tail --\> head
* joins common bile duct --\< hepatopancreatic ampulla (of Vater)
* surr by sphincter of Oddi
* major duodenal papilla
accessory:
* connect to main 60% time
* can be main duct for panc secr
* opens at summit of minor duodenal papilla
variations due to fusion/lack of fusion of dorsal and ventral panc ducts during emb
103
Cremasteric reflex
what N lvl is tested?
stroking the skin of upper part of medial side of thigh, testis are elevated
L1
104
•Skin of ant. abd wall is supplied by
* T7-T11 intercostal and T12 as subcostal and L1 as Iliohypogastric
* Ant. cut nerves pierce the ant. surface of rectus sheath close to median plane
* •T7 near xiphoid process
* •T10 around umbilicus
* •Iliohypogastric 1 inch above the sup. ing. ring
105
Transpyloric plane
* Passes anteriorly to the tip of 9th cc
* Post. lower border of L1 vertebra
* Marks the midway of suprasternal notch and pubic symphysis
106
ligaments of the liver
107
anterior ab wall layers
skin
camper fascia: superficial fatty laterof subcut tissue
scarpa fascia: deep membranous layer of subcut tissue
investing fascia
external oblique
intermediate investing fascia
internal oblique
deep investing fascia
transversus abdominis
transversalis fascia
extraperitoneal fat
pareital peritoneum
108
Calot's triangle
cystic duct, the common hepatic duct, and the cystic artery
•Mascagni's lymph node or Lund's node
* freq enlarged due to colescystitis or cholangitis (biliary tract)
can contain aberrant/accessory R hepatic A or anomalous sectoral bile ducts
dissection = #1 cause of common bile duct injuries
109
Orchitis
•Inflammation of testes
110
blood supply to bladdar
* Superior and inferior vesical arteries (and from the vaginal artery in females)
* Venous blood is drained by the prostatic (or vesical) plexus of veins, which empties into the internal iliac vein
111
Inguinal ligament runs
from
ASIS to pubic
tubercle
112
Jejunum
* Approximately two fifths of the length of jejunum/ileum
* Mainly LUQ
* Thick-walled and very vascular
* Plicae circularis
* No peyers patches
* Less prominent arterial arcades
113
Megacolon
•abnormal dilation of the colon --\> paralysis of the peristaltic movements of bowel
* Congenital or aganglionic
•Fecolomas are common
acute or chronic
acquired:
* idiopathic, toxic, secondary to infection (c. diff)
114
Pyrosis
"heartburn"
## Footnote
* most common type of esophageal discomfort.
* Is usually the result of regurgitation of small amounts of food or gastric fluid into the lower esophagus.
* Causes: certain foods, GERD, hiatal hernia, certain drugs
115
Umbilicus
* Scar of umbilical cord
* Lies at junction of L3&L4
* Not a constant landmark
116
Esophagogastric junction
L of T11
z-line: muscosa from esophageal to gastric
diaphragmatic musculature forming esophageal hiatus functions as a physiological inferior esophageal sphincter that contracts and relaxes
117
common iliac Arterial Circulation
118
general rectum
sigmoid colon --\> anal canal
Ampulla: lower dilated part, above the pelvic diaphragm, stores feces
no Peritoneal covering for distal third
anterior to the sacral plexus ( Sciatic nerve) and piriformis
119
Pancreas
retroperitoneal
exocrine: dig jucies
endocrine: insulin, glucagon
head:
* encircled by c-shaped curve of duodenum
* overlies IVC, R & L renal V, R renal A
* uncinate process
neck:
* overlies SMA/SMV
* adj to pylorus
* SMV joins splenic V --\> portal V posterior to neck
body:
* crosses body of l2, aorta
* floor = omental bursa
* post to stomach
* anterior to: SMA, L adrenal, L kidney
120
NAVL to pancreas
N: vagus, thoracic splanchnic
A: splenic (main),
–gastroduodenal\> superior pancreaticoduodenal
– superior mesenteric\>inferior pancreaticoduodenal arteries
V: splenic (main) --\> SMV --\> portal
L: pancreaticosplenic
121
Pampiniform plexus
-(m)
forms around the testicular artery in the scrotum and drains into the testicular vein
122
NAVL of testis and epididymis
N: autonomic: PNS - vagus, SNS - T7
A: testicular
V: pampiniform plexus --\> becomes testicular as it ascends through inguinal canal
* R into IVC
* L into L renal
L: paraortic
123
Suprarenal glands
right gland
* pyramidal
* anterior to R crus diaphragm
* contacts IVC, liver
left gland
* cresent/semilunar
* contacts: spleen, stomach, L crus of diaphragm
enclosed by renal fascia --\> attach to crura of diaphragm
* sep from kidneys via septum (part of fascia)
124
Pylorus
* Begins at level of angular incisure: indentation 2/3 of way along lesser curvature.
* Widest region = pyloric antrum --\> leads to pyloric canal.
* Pyloric sphincter
–Thick, circular middle layer of muscularis externa.
–Controls passage of chime into duodenum.
–Normally closed in tonic contraction, except during peristalsis.
125
Peritoneal Adhesions
dmg --\> imflammed peritoneal surf --\> sticky with fibrin --\> healing --\> fibrin replaced with fibrous tissue --\> adhesions --\> chronic pain
126
NAVL to gallbladder
N: SNS - celiac plexus, PNS - vagus, sensory from R phrenic
A: cystic A from R hepatic
V: cystic --\>
* neck and biliary ducts --\> portal vein
* body/fundus --\> directly into liver
L: hepatic
127
Adhesiotomy
* Adhesiotomy refers to the surgical separation of adhesions.
* Adhesions are often found during dissection of cadavers.
128
Greater omentum
dbl layered: greater curvature --\> txverse colon
embryonic dorsal mesentery
right and left gastroepiploic vessels
ligaments: gastro--
* phrenic
* lineal
* colic
129
Lymphatics of stomach
gastric, gastroepiploic, pancreaticosplenic, and pyloric nodes.
130
kidney stones
Pain in pararenal region-
* close relation of kidneys to psoas muscle
* extension of hip
Renal ureteric CALCULI-
* severe intermittent pain (ureteric colic)
* referred to inguinal, lumbar or external genitals as stone progresses
131
lienorenal ligament
splenic A
splenic V
tail of pancreas
132
Sigmoid Mesocolon
* Connects the sigmoid colon to the pelvic wall and contains the sigmoid vessels.
* Its line of attachment may form an inverted V.
133
NAVL of esophagus
N:
* vagus, SNS trunks
* lower portion surr by esophageal N plexus
A:
* upper 1/3 - inferior thyroid
* middle 1/3 - desc thoracic aorta
* lower 1/3 - L gastric
V:
* upper 1/3 - inferior thyroid
* middle 1/3 - azygos
* lower 1/3 - L gastric
L:
* upper 1/3 - deep cervical
* middle 1/3 - mediastinal
* lower 1/3 - nodes along L gastric bv, celiac
134
H. pylori infection
* Infection of the stomach mucosa
* Causes : abdominal pain, gas, bloating, badbreath, heart burn, nausea and gastric ulcer
135
Ileum
approx 3/5 length of jejunum/ileum
## Footnote
mainly RUQ
thin-walled, less vasc than jejunum
term @ ileocecal jxn
PEYERS PATCHES
more artieral arcardes, more fat than jejunum
136
gastrosplenic ligament contains
left gastro-epiploic
short gastric A
137
N supply to duodenum
PNS: vagus via celiac and superior mesenteric plexuses
SNS: celiac and superior mesenteric plexuses, traveling on pancreaticoduodenal arteries
138
innervation to vagina
uterovaginal plexus = upper 3/4
deep perineal branch of pudendal N = lower 1/4
139
Inferior mesenteric artery
L2-3
•Left colic artery
–Runs to the left and divides into ascending and descending branches
•Sigmoid arteries
–2-3 in number
•Superior rectal artery
–Divides into two
–Branches that run along the sides of the rectum and anastamoses with middle rectal arteries
140
Large intestines characteristics
teniae coli: 3 thickened long bands of M
* Haustra: sac of the colon caused by teniae coli
•Appendices epiploicae: fatty lobules of omentum
* Cecum Blind pouch, approximately 7.5 cm in diameter
* No mesentery, but may be bound to the abdominal wall by cecal folds of peritoneum
* Invaginated by ileum to form the ileocecal valve—does not prevent reflux
141
Cervical esophagus
front: trachea
back: v-column, longus colli M
sides: common carotid A, lobes of thyroid
* L: thoracic duct
recurrent nerves ascend between it and the trachea
142
Medulla of suprarenal glands
emb: neural crest
secretes:
* catecholamines- epinephrine and norepinephrine
* SNS response: increase HR & BP, dilates bronchioles
143
x-sec layers of kidney
144
Costal margin:
Formed by
•7th, 8th, 9th, 10th costal cartilages
145
•Prostate cancer
•Slow-growing cancer that occurs particularly in the posterior lobe
146
Hilum of kidney
Renal artery enters
Renal vein (artery posterior to vein) and renal pelvis (posterior to vessels) exit
* renal pelvis: expansion of prox end of ureter
renal sinus
147
Linea semilunaris
* Curved groove marks the lateral border of rectus abdominis
* Extends from tip of 9th costal cartilage to pubic tubercle
148
4th part of duodenum
ascending
* ascends to L2 of L side
* Curves anteriorly at duodenojejunal flexur
* supported by the ligament of Treitz
–posterior to the root of the mesentery, parts of the jejunum;
–anterior to the left psoas muscle;
–lateral to the head of the pancreas (on the left side); and
–inferior to the body of the pancreas.
149
Testicular torsion
* Twisting of spermatic cord and testis within scrotum
* Result in blockage of blood supply to testis
* Causes severe pain, swelling and reddening of scrotum
150
psoas minor
O: vert-body of T12
I: iliacus M --\> forms iliopsoas M
N: anterior ramus of L1
A: flex trunk
151
landmarks of kidney
152
Varicocele
•Dilated pampiniform plexus of veins
153
arc of Riolan
meandering mesenteric artery or central anastomotic mesenteric artery.
connects middle colic branch of SMA --\> L colic branch of IMA
can be occluded, sig stenosis
* prox SMA: collat flow from IMA --\> SMA
* prox IMA: collat flow from SMA --\> IMA
154
psoas major
O: TP L1-5
I: lesser trochanter of femur
N: anterior rami L1-3
A: flex thigh, stab hip joint
155
Mesoappendix
•Connects the appendix to the mesentery of the ileum and contains the appendicular vessels.
156
Congenital hypertrophic pyloric stenosis
hypertrophy of pylorus --\> narrowing pyloric canal -- slow gastric empty --\> dilation of prox stomach
forceful vomitting, dehydration, wt loss
babies may seem to be hungry all the time
157
Gastric ulcer
dull aching pain, often right after eating
* upper ab, below breastbone
not relieved by eating
* LIKE OVER TYPES OF ULCERS
indigestion, heartburn, acid reflux, episodic nausea, loss of apetite
158
common clinical of scrotum
* Common site of edema due to laxity of skin and dependent position
* Common site of sebaceous cyst due to abundance of sebaceous gland
* Hydrocele: Accumulation of fluid in tunica vaginalis
elephantitis
159
NAVL to spleen
N: celiac plexus
A: splenic (twisted from celiac trunk)
V: splenic --\> SMV --\> portal
L: pancreaticosplenic
160
3rd part duodenum
horizonal:
* crosses IVC, aorta, L3, R psoas major M
* crossed by SMA, SMV, root of mesentery, head of pancreas (R side)
161
Appendicitis: palp in what ab region?
right inguinal
162
Innominate Bone
hip bone
163
quadratus lumborum
O: 12th rib
I: iliolumbar lig, iliac crest
N: ventral rami T12-L3
A: extension and lateral flex of trunk
164
Fluid in omental
bursa
perforation of posterior wall of stomach
inflammed/injured pancreas --\> panc pseudocyst
165
Muscles of the Posterior Abdominal Wall
Iliopsoas:
Psoas Major
Psoas Minor
Iliacus
Quadratus lumborum
166
boundaries of inguinal canal
Ant. Wall:
•External oblique aponeurosis, reinforced laterally by internal oblique aponeurosis
Post wall:
•Fascia transversalis laterally & conjoint tendon medially
Roof:
•Arching fibers of internal oblique and transverse abdominis
Floor:
•Inguinal lig and lacunar ligament medially
Structures passing:
* Spermatic cord in males and round lig. of uterus in female
* Ilioinguinal nerve
167
Ascites
* Excessive fluid in the peritoneal cavity.
* Causes: portal hypertension, metastasis of cancer cells, starvation.
* The excessive fluid interferes with movement of the viscera.
168
Cortex of suprarenal glands
emb: mesoderm:
secretes:
–Glucocorticoids
–Mineralocorticoids
–Androgens
–Maintains blood volume and blood pressure
169
Epididymis
highly coiled tubes lying posterior to testis
## Footnote
* Head is composed of highly coiled efferent ductules. Body and tail has a single duct
* At lower end of tail duct become continuous with ductus deferens
170
Retroperitoneal organs are
organs that are only covered on their anterior surface by peritoneum (think kidneys)
171
transverse abdominal
O: costal cartilages ribs 7-12, thoracolumbar fascia, iliac crest, lateral 1/3 inguinal ligament
I: linea alba, aponeurosis of internal oblique, conjoing tendon to pectin pubis
N: thoracoabdominal anterior rami of inferior 6 thoracic N, L1
A: compress and support ab viscera
172
fissures of liver
* H shaped fissures made up of the following
* Round ligament
* Fissure of the ligamentum venosum
* Fossa for the gallbladder
* Fissure for IVC
173
Secondary Retroperitoneal Organs examples
Pancreas
Duodenum (parts 2-4)
Ascending Colon \*
Descending Colon\*
**\* The appendix, lower end of the cecum and sigmoid colon are not considered retroperitoneal.**
174
•Ileocecal Fold
•Extends from the terminal ileum to the cecum.
175
Kidneys
* Remove excess water, salts, products of protein metabolism
* Kidneys, ureters, their vessels, and the suprarenal glands are primary retroperitoneal structures of the posterior abdominal wall
T12-L3, ribs 11-12
L kidney higher than R
perirenal fat: continuous at hilum with fat in the renal sinus
pararenal fat: external to renal fascia
176
•Umbilical Folds
five folds of peritoneum below the umbilicus
177
vasc supply to duodenum
A:
* Gastroduodenal artery, branch of common hepatic → superior anterior and posterior pancreaticoduodenal arteries
* SMA → anterior and posterior inferior pancreaticoduodenal arteries
* Important anastomoses between celiac trunk and SMA via duodenal arteries
V:
* follow A
* Drain directly or indirectly into the portal vein
178
Cholecystitis: palp in what region of the ab
right hypochondriac
179
•Pubocervical Ligaments
•posterior surface of the pubis to the cervix of the uterus
180
Pelvic Sexual Dimorphism
181
•Hypertrophy of the prostate
BPH
most often in middle lobe
obstructs internal urethral orifice --\> nocturia, dysuria, urgency
may compress the ejaculatory duct and may have problem in emission!
182
A supply to Kidneys
arterial tree
R & L renal A
* branches of aorta @ L1/L2
* R passes post to IVC
* anterior to renal pelvis
* Renal artery
* Segmental artery
* Lobar artery
* Arcuate
* Interlobular
* Afferent arteriole
* Glomerulus
* Efferent arteriole
183
•Mesovarium
part of broad ligament
connects anterior surf of ovary with post layer of broad lig
184
Nutcracker syndrome
most commonly from the compression of the left renal vein between the abdominal aorta (AA) and superior mesenteric artery (SMA)
•associated with hematuria (which can lead to anemia), abdominal pain(classically left flank pain).
* left testicular pain in men
* •left lower quadrant pain in women.
* Nausea and vomiting can result due to compression of the splanchnic veins
* An unusual manifestation of NCS includes varicocele
185
Spleen
LUQ
largest lymph organ: ribs 9-11 (sep by diaphragm)
ligaments:
* gastrosplenic, splenorenal
* attached to hilum
sits on phrenicocolic ligament (sustentaculum lienis)
Anterior: stomach (gastrosplenic ligament)
Posterior: diaphragm
Inferior: splenic flexure of colon
Medial: left kidney (splenorenal ligament)
Tail of pancreas extends to hilum
186
Uterine Tubes
* Fertilization usually takes place in the ampulla --\> Danger of Tubal pregnancy
* Subdivided into four parts
* Uterine part
* Isthmus
* Ampulla
* Infundibulum
187
blood supply to vagina
uterine A
interal iliac A
188
func of rectus sheath
* Checks bowing of rectus muscle during contraction --\> increase efficiency
* Maintains strength of ant. abd. wall
189
Ejaculatory Ducts
•union of the ductus deferens and the seminal vesicles
peristaltic contractions of musc layer --\> propel sperm with seminal fl --\> urethra
•Open into the prostatic urethra on the seminal colliculus just lateral to the blind prostatic utricle
190
Portal vein
formed by:
1. splenic
* IMV, pancreatic, L gastroepiploic, short gastric
2. SMV
* –Inferior pancreaticoduodenal, R gastroepiploic, R colic, ileocolic, jejunal, ileal
drains directly into:
* cystic, superior pancreaticoduodenal, R & L gastric
191
Broad Ligament
* Two layers of peritoneum, extends from the lateral margin of the uterus to the lateral pelvic wall, and serves to hold the uterus in position
* Contains the uterine tube, uterine vessels, round ligament of the uterus, ligament of the ovary, ureter (lower part), uterovaginal nerve plexus, and lymphatic vessels
192
Ductus Deferens
* Begins from the epididymis
* In the spermatic cord in the inguinal canal
* Enters the pelvis at the deep inguinal ring
* Loops around the ureter near the wall of the bladder, and is dilated to become the ampulla at its terminal part
193
Rectovesical/Vesicouterine Pouch
* Rectovesical pouch
* Peritoneal recess between the bladder and the rectum in males
* Vesicouterine pouch
* Peritoneal sac between the bladder and the uterus in females
194
lymphatics of adrenal glands
plexuses in medulla, deep to gland capsule --\> many to lumbar
195
Transpyloric plane (11)
* lumbar vertebra 1 and hence passes just before the end of the spinal cord in adults.
* the fundus of the gallbladder
* the end of the spinal cord
* the Neck of pancreas
* the origin of the superior mesenteric artery the left and right colic flexure
* the root of the transverse mesocolon
* duodenojejunal flexure
* the 1st part of the duodenum
* the upper part of conus medullaris
* the spleen
* the pylorus of the stomach which will lie at this level approximately 5 cm to the right of the midline.
196
Testes
Male gonad, lie in scrotum suspended by spermatic cord
Produce spermatozoa and testosterone
surrounded by a double layered serous sac, called tunica vaginalis
sep by fibrous septa to divide into 200-300 lobules
* each lobule = 1-3 seminiferous tubules --\> join to form straight tubule --\> netwk called rete testes --\> small efferent ductules to upper end of epididymis
197
* Situated below the peritoneum
* Extends upward above the pelvic brim as it fills
* Apex: anterior end
* Fundus/base: posteroinferior triangular portion
* Neck: where the fundus and inferolateral surfaces come together, leading into the urethra
* Uvula: small eminence at the apex of its trigone, projecting into the orifice of the urethra
* Trigone: bounded by the two orifices of the ureters and the internal urethral orifice, around which is a thick circular layer called the internal sphincter
* Has bundles of smooth-muscle fibers known as the detrusor muscle
198
Rectum Blood Supply
* Superior (IMA), middle( IIA), and inferior rectal arteries(IPA) and the middle sacral artery
* Superior rectal artery pierces the muscular wall and courses in the submucosal layer and anastomoses with branches of the inferior rectal artery
* Middle rectal artery supplies the posterior part of the rectum
* Venous blood returns to the portal venous system via the superior rectal vein and to the caval (systemic) system via the middle and inferior rectal veins
199
Ligament of the ovary
•connect ovary to uterus, remnant of gubernaculum
200
True (Lesser) vs. False(Greater) Pelvic Cavity
201
vasc of ovaries
ovarian A --\> contained in suspensory ligament
ovarian V
* R: --\> IVC
* L --\> left renal vein
202
Linea alba
* Median furrow extending from Xiphoid process to pubic symphysis
* Sometime epigastric hernia occur through it
203
Marginal Artery of Drummond
vasc arcade that connects SMA and IMA
204
NAVL to jejunum and ileum
N:
* PNS: vagus: synpase on postgang cells in myenteric and submucosal plexuses
* SNS: pregang from T5-T9 --\> greater and lesser splanchnic N --\> post gang celiac and superior mesenteric ganglia
A:
* SMA:
* 15-18 branches --\> forms arterial arcades (loops/arches) --\> vasa recta (straight A)
* dbl row of arcades to ileum
V:
* SMV
* Posterior to neck of pancreas joins splenic vein to form portal vein
L:
* lacteals - absorbs fat --\> lymph plexus --\> b/w layers of mesentery --\> mesenteric lymph node --\> superior mesenteric/ileocolic nodes --\> cisterna chyli
205
location of Renal angle
b/w rib 12 and lateral margin of erector spinae
206
Descending colon
L posterior ab wall
splenic flexure --\> sigmoid colon
secondarily retroperitoneal
N: SNS - lumbar sympath trunk & superior hypogastric plexus; PNS = pelvic splanchnic
A: IMA: L colic, superior sigmoid
V: IMV: L colic, superior sigmoid
L: epicolic, paracolic
207
gallbladder
fossa @ jxn of R and L lobes of liver
fundus @ 9th costal cartilage
body @ txverse colon, first part of duodenum
neck: spiral valve (spiral fold of mucosa) that keeps cystic duct open
cystic duct --\> common hepatic duct : becomes common bile duct
208
Conjoint tendon is which line?
what are the other lines?
3rd line = conjoint tendor
2nd line = ilioinguinal N
1st line = illiohypogastric N
forms lowest aponeurosis of internal oblique and transversis abd
attached to pubic crest
suports superficial inguinal ring
209
visc referred pain pic
210
name arrows in inguinal canal
211
Greater Sac
* ■ Extends across the entire breadth of the abdomen and from the diaphragm to the pelvic floor and presents numerous recesses into which pus from an abscess may be drained.
* 1. Subphrenic (Suprahepatic) Recess
* 2. Hepato renal recess (Morrisons pouch)
* 3. Paracolic recess
212
Abdominal esophagus
•esophageal groove on the posterior surface of the left lobe of the liver.
antrum cardiacum
* conical base due to compression by upper orifice of stomach
front and L aspects covered by peritoneum
213
external oblique
O: ribs 5-12
I: linea alba, pubic tubercle, anterior 1/2 iliac crest
N: thoracodbdominal N (T7-T11), subcostal
A: compress, support ab viscera, flex and rotate trunk
214
rectus abdominis
O: pubic symphysis, pubic crest
I: xiphoid, costal cartilages 5-7
N: thoracoabdominal nerves and anterior rami of inferior thoracic N
A: flex trunk (lumbar vert), compress ab viscera, stab & controls tilt of pelvis
215
Anterior Branch of internal iliac
216
Mc Burney’s point
R abdomen: 1/3 distance from ASIS --\> navel
most common loc of base of appendix where it attaches to cecum
217
Transverse Mesocolon
* Connects the posterior surface of the transverse colon to the posterior abdominal wall.
* Fuses with the greater omentum to form the gastrocolic ligament.
* Contains the middle colic vessels, nerves, and lymphatics.
218
contents of rectus sheath
2 muscles: Rectus abd.& pyramidalis
2 arteries: SEA, IEA
2 veins: SEV, IEV
6 nerves: Lower 6 intercostal nerves
219
Sigmoid colon
sigmoid mesocolon
N: SNS - –lumbar sympathetic trunk and superior hypogastric plexus; PNS - pelvic splanchnic
A: IMA: L colic, superior sigmoid
V: IMV: L colic, superior sigmoid
L: epicolic, paracolic
220
lymph drain of vagina
upper 3/4 = internal iliac nodes
lower 1/4, below hymen = down to perineum --\> superficial inguinal
221
Uterus
•Normally:
* anteverted (angle of 90 degrees at the junction of the vagina and cervical canal)
* anteflexed (angle of 160 to 170 degrees at the junction of the cervix and body)
•Retroverted and retroflexed: NOT NORMAL
222
Vasectomy
•Ductus deferens is ligated bilaterally when sterilizing a man
223
cystohepatic triangle
the area bound by the cystic duct, common hepatic duct, and the liver margin.
224
Prostatic urethra receives
ejaculatory duct
225
Testicular cancer
* Common in undescended testis
* Metastasize to paraortic lymph node
226
•Mesometrium
•Below the mesosalpinx and mesovarium
227
lymph drainage of prostate
internal iliac nodes
228
•Rectouterine Fold
e•xtends from the cervix of the uterus, along the side of the rectum, to the posterior pelvic wall, forming the rectouterine pouch (of Douglas).
229
Subphrenic abscess
accumulation pus/fluid in space b/w diaphragm, spleen, and liver
dev after sx: splenectomy, bowel perforation, appendicitis
* 1/2 on R, 1/4 on L, 1/4 on both sides
230
Seminal Vesicles
lower end has ducts --\> join the ampullae of the ductus deferens to form the ejaculatory ducts
inferior and lateral to ampullae of ductus deferens aga fundus of bladder
alkaline portion of seminal fluid : fructose and choline
231
Esophageal constrictions
cervical: upper esophageal sphincter
* pharyngoesophageal jxn: 15cm from incisors
* caused by cricopharyngeus m
Thoracic: broncho-aortic
* arch of aorta: 22.5cm from incisors: anteroposterior view
* L main bronchus: 27.5 cm form incisors: lateral view
* diaphragm: 40cm from incisors
232
Spread of Pathological Fluids
supine: heptorenal
standing: rectouterine pouch
233
Stomach
3 M layers: longitudinal, circ, oblique
rugae
Gastric canal = longitudinal fold along lesser curvature
* Forms during swallowing
* Accommodates the passage of liquid
covered by peritonium except: where bv run, post cardiac orifice
Anatomy Year 1
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