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Abdomen, Pelvis and Perineum Anatomy - www.jinekolojivegebelik.com

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Information about Abdomen, Pelvis and Perineum Anatomy - www.jinekolojivegebelik.com

Published on March 15, 2008

Author: jinekolojivegebelik

Source: slideshare.net

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Abdomen, Pelvis and Perineum Anatomy - www.jinekolojivegebelik.com
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Abdomen, Pelvis and Perineum Dmitry Goldin [email_address]

Know all Terminology, use to navigate in the body Inferior=caudal, superior=cranial, medial, lateral, dorsal=posterior, ventral=anterior Deep vs. Superficial (think ‘onion’ layers of the body) Proximal vs. Distal= further away from attachment point Median plane= mid -sagittal plane ( skull has a sagittal sutur in the middle but sagittal planes move medial & lateral ) Transverse=axial= horizontal plane ( move sup./inf.) Frontal=coronal plane (“crown”, can move ant.&post .) Hand has dorsal(dorsum) and Palmar surfaces Foot has dorsal (dorsum) and Plantar (sole) surfaces Extension vs. Flexion ( exception w/ dorsiflexion vs. plantarflexion ) Abduction vs. Adduction Opposition, reposition, supination, pronation, retrusion, protrusion, ELEVATION/DEPRESSION, eversion, inversion

Inferior=caudal, superior=cranial, medial, lateral, dorsal=posterior, ventral=anterior

Deep vs. Superficial (think ‘onion’ layers of the body)

Proximal vs. Distal= further away from attachment point

Median plane= mid -sagittal plane ( skull has a sagittal sutur in the middle but sagittal planes move medial & lateral )

Transverse=axial= horizontal plane ( move sup./inf.)

Frontal=coronal plane (“crown”, can move ant.&post .)

Hand has dorsal(dorsum) and Palmar surfaces

Foot has dorsal (dorsum) and Plantar (sole) surfaces

Extension vs. Flexion ( exception w/ dorsiflexion vs. plantarflexion )

Abduction vs. Adduction

Opposition, reposition, supination, pronation, retrusion, protrusion, ELEVATION/DEPRESSION, eversion, inversion

Abdominal Internal Coverings Visceral and Parietal Peritoneum – define peritoneal cavity Ventral mesogastrium Dorsal mesogastrium Dorsal Common Mesentery Transversalis Fascia Extraperitoneal Parietal Peritoneum Intraperitoneal Visceral Peritoneum Gut tube

Visceral and Parietal Peritoneum – define peritoneal cavity

Ventral mesogastrium

Dorsal mesogastrium

Dorsal Common Mesentery

Ventral mesogastrium Dorsal mesogastrium Dorsal Common Mesentery In post-partum age, the ligaments that are the remnants of these membranes still retain their general attachment points (use for IDing in lab). NOTE – The intestines take a 270deg turn counterclockwise and the stomach takes a 90deg turn clockwise

Ventral Mesogastrium Lesser omentum (double serosal layer) Peritoneal reflection extends from porta hepatis to duodenum, and all to lesser curvature of stomach Hepatogastric lig. Hepatoduodenal lig. Portal triad is within it in the free margin laterally Ligaments of the liver Falciform lig. – includes: Ligamentum teres hepatis = round lig. of the liver Inferior aspect of falciform lig. Is the obliterated umbilical vein Coronary lig. Makes the right and left triangular lig.s

Lesser omentum (double serosal layer)

Peritoneal reflection extends from porta hepatis to duodenum, and all to lesser curvature of stomach

Hepatogastric lig.

Hepatoduodenal lig.

Portal triad is within it in the free margin laterally

Ligaments of the liver

Falciform lig. – includes:

Ligamentum teres hepatis = round lig. of the liver

Inferior aspect of falciform lig.

Is the obliterated umbilical vein

Coronary lig.

Makes the right and left triangular lig.s

Dorsal Mesogastrium Gastrosplenic lig. (gastrolienal) Gastrophrenic lig. Gastrocolic lig. (to transverse colon) Spleno(lieno-)renal lig. Contains tail of pancreas and splenic A .--> short gastric AA . and left gastroepiploic A . (splenic br.s inside lig.) Phrenicocolic lig. Greater omentum AKA Omental apron (“abdominal policemen”) Hangs down from the greater curvature of the stomach. It adheres to areas of inflammation, preventing diffuse peritonitis. Also transmits R&L gastroepiploic vessels along greater curvature of the stomach.

Gastrosplenic lig. (gastrolienal)

Gastrophrenic lig.

Gastrocolic lig. (to transverse colon)

Spleno(lieno-)renal lig.

Contains tail of pancreas and splenic A .--> short gastric AA . and left gastroepiploic A . (splenic br.s inside lig.)

Phrenicocolic lig.

Greater omentum AKA Omental apron (“abdominal policemen”)

Hangs down from the greater curvature of the stomach. It adheres to areas of inflammation, preventing diffuse peritonitis. Also transmits R&L gastroepiploic vessels along greater curvature of the stomach.

Dorsal Common Mesentery These transmit vasculature from retroperitoneal Aorta to peritonealized structures of the Mid- and Hindgut. Mesentery (proper) Mesoappendix Transverse mesocolon Sigmoid mesocolon

These transmit vasculature from retroperitoneal Aorta to peritonealized structures of the Mid- and Hindgut.

Mesentery (proper)

Mesoappendix

Transverse mesocolon

Sigmoid mesocolon

Intraperitoneal vs. Retroperitoneal Stomach Part 1 of duodenum Jejunum, Ileum Cecum, Appendix Transverse colon Sigmoid colon Liver, Gallbladder Tail of pancreas Spleen Parts 2,3,4 duodenum Ascending, Descending colon Rectum Head, neck, body of pancreas Kidneys, ureters Suprarenal gland Abdominal Aorta Inferior vena cava *** Rule of Thumb : If it has a mesentery or mesogastrium component => Intraperitoneal

Stomach

Part 1 of duodenum

Jejunum, Ileum

Cecum, Appendix

Transverse colon

Sigmoid colon

Liver, Gallbladder

Tail of pancreas

Spleen

Parts 2,3,4 duodenum

Ascending, Descending colon

Rectum

Head, neck, body of pancreas

Kidneys, ureters

Suprarenal gland

Abdominal Aorta

Inferior vena cava

Primary vs. secondary Retroperitoneal? Primary was always there Secondary became retroperitoneal in development Secondary Retroperitoneal: Pancreas (not tail), most of duodenum (not part 1), ascending & descending colon

Primary was always there

Secondary became retroperitoneal in development

Secondary Retroperitoneal:

Pancreas (not tail), most of duodenum (not part 1), ascending & descending colon

Omental Bursa (lesser peritoneal sac) Result from stomach taking 90 degree clockwise turn Anterior: liver, stomach, & lesser omentum Posterior: diaphragm Right side: liver Left side: gastrosplenic and splenorenal ligs. Communicates with greater peritoneal sac through the omental foramen (of Winslow) [Omental=Epiploic] Posterior= IVC covered by parietal peritoneum; Anterior= Portal Triad in hepatoduodenal lig .; Inferior= 1st part duodenum ; Superior= caudate lobe in visceral peritoneum

Result from stomach taking 90 degree clockwise turn

Anterior: liver, stomach, & lesser omentum

Posterior: diaphragm

Right side: liver

Left side: gastrosplenic and splenorenal ligs.

Communicates with greater peritoneal sac through the omental foramen (of Winslow) [Omental=Epiploic]

Posterior= IVC covered by parietal peritoneum; Anterior= Portal Triad in hepatoduodenal lig .; Inferior= 1st part duodenum ; Superior= caudate lobe in visceral peritoneum

Portal Triad - inside free margin of hepatoduodenal lig . Portal V. Proper hepatic A. Common bile duct Descends posterior to 1 st part of duodenum posterior anterior Lateral/right Medial/left V A D

Portal V.

Proper hepatic A.

Common bile duct

Descends posterior to 1 st part of duodenum

Greater Peritoneal Sac This is the remainder of peritoneal cavity Greater omentum found here Paracolic gutters are channels along ascending and descending colon CLINICAL: Peritonitis or Ascites cause excess peritoneal fluid that flows downward through paracolic gutters to rectovesical pouch (males) or rectouterine pouch (females) when patient is sitting or standing. When patient is in supine position the fluid runs upwards through gutters to subphrenic and hepatorenal recesses .

This is the remainder of peritoneal cavity

Greater omentum found here

Paracolic gutters are channels along ascending and descending colon

CLINICAL: Peritonitis or Ascites cause excess peritoneal fluid that flows downward through paracolic gutters to rectovesical pouch (males) or rectouterine pouch (females) when patient is sitting or standing. When patient is in supine position the fluid runs upwards through gutters to subphrenic and hepatorenal recesses .

Quick embryo: Fore-, Mid-, and Hind- Gut These are the divisions of the primitive gut tube, which divide the gut nicely anatomically and functionally Epithelial lining and glands of mucosa= endoderm Lamina propria, muscularis mucosae, submucosa, muscularis externa = mesoderm Foregut = esophagus, stomach, liver, gallbladder, pancreas, duodenum (up to major papilla in the 2 nd part) Midgut = lower duodenum, jejunum, ileum, cecum, appendix, ascending colon, proximal 2/3 of transverse colon Hindgut = distal 1/3 transverse colon, descending and sigmoid colon, rectum, and upper anal canal (above pectinate line )

These are the divisions of the primitive gut tube, which divide the gut nicely anatomically and functionally

Epithelial lining and glands of mucosa= endoderm

Lamina propria, muscularis mucosae, submucosa, muscularis externa = mesoderm

Foregut = esophagus, stomach, liver, gallbladder, pancreas, duodenum (up to major papilla in the 2 nd part)

Midgut = lower duodenum, jejunum, ileum, cecum, appendix, ascending colon, proximal 2/3 of transverse colon

Hindgut = distal 1/3 transverse colon, descending and sigmoid colon, rectum, and upper anal canal (above pectinate line )

Foregut VAGUS N. provides preganglionic parasympathetic ( posterior vagal trunk passes thru celiac ganglion but does not synapse, the anterior vagal trunk courses on the stomach’s surface) Greater Thoracic Splanchnic Ns . (T5-T9) provides preganglionic sympathetic, which synapse in celiac ganglion Autonomics travel with vasculature from celiac trunk to organs Celiac ganglion found on the crura of diaphragm in the vicinity of celiac trunk, (bulbous and has nerves!) Blood supply : CELIAC TRUNK Upper LV1 Splenic A.-largest, tortuous On Sup. Border of pancreas Common hepatic A. Left gastric A.-smallest

VAGUS N. provides preganglionic parasympathetic ( posterior vagal trunk passes thru celiac ganglion but does not synapse, the anterior vagal trunk courses on the stomach’s surface)

Greater Thoracic Splanchnic Ns . (T5-T9) provides preganglionic sympathetic, which synapse in celiac ganglion

Autonomics travel with vasculature from celiac trunk to organs

Celiac ganglion found on the crura of diaphragm in the vicinity of celiac trunk, (bulbous and has nerves!)

Blood supply : CELIAC TRUNK

Upper LV1

Splenic A.-largest, tortuous

On Sup. Border of pancreas

Common hepatic A.

Left gastric A.-smallest

Celiac trunk branches Left gastric A. -> esophageal br.s Splenic A.: Brs. to pancreas: dorsal pancreatic a ., A. pancreatica magna, caudal pancreatic as. Brs. in splenorenal lig: short gastric as . and left gastroepiploic a . Common hepatic A. -> right gastric a ., gastroduodenal A . (trunk for ant. and post.), and proper hepatic A .=>left hepatic a. + right hepatic a . (right gives off cystic a .)

Left gastric A. ->

esophageal br.s

Splenic A.:

Brs. to pancreas: dorsal pancreatic a ., A. pancreatica magna, caudal pancreatic as.

Brs. in splenorenal lig: short gastric as . and left gastroepiploic a .

Common hepatic A. -> right gastric a ., gastroduodenal A . (trunk for ant. and post.), and proper hepatic A .=>left hepatic a. + right hepatic a . (right gives off cystic a .)

Foregut embryo clinicals Esophageal atresia associated with polyhydramnios and tracheoesophageal fistula. Occurs when esophagus ends in blind tube from malformation of tracheoesophageal septum Hypertrophic pyloric stenosis associated with projectile nonbilious vomiting and small palpable mass at right costal margin Muscularis externa hypertrophies narrowing pyloric lumen Extrahepatic biliary atresia associated with jaundice after birth, pale stool, and dark urine When incomplete recanalization leads to occlusion of biliary ducts Annular pancreas cause obstruction of duodenum when ventral and dorsal pancreatic buds form ring around duodenum Macrosomia (increased birth weight) occurs when fetal islets are exposed to high glucose levels (uncontrolled diabetic) which stimulates insulin secretion causing increased fat and glycogen deposition

Esophageal atresia associated with polyhydramnios and tracheoesophageal fistula.

Occurs when esophagus ends in blind tube from malformation of tracheoesophageal septum

Hypertrophic pyloric stenosis associated with projectile nonbilious vomiting and small palpable mass at right costal margin

Muscularis externa hypertrophies narrowing pyloric lumen

Extrahepatic biliary atresia associated with jaundice after birth, pale stool, and dark urine

When incomplete recanalization leads to occlusion of biliary ducts

Annular pancreas cause obstruction of duodenum when ventral and dorsal pancreatic buds form ring around duodenum

Macrosomia (increased birth weight) occurs when fetal islets are exposed to high glucose levels (uncontrolled diabetic) which stimulates insulin secretion causing increased fat and glycogen deposition

Midgut Blood supply: SMA at lower LV1 SMA starts posterior to neck of pancreas and descends across anterior uncinate process and crosses anterior to 3 rd part of duodenum VAGUS N. provides preganglionic parasympathetic Postganglionic sympathetics from sup. mesenteric ganglion

Blood supply: SMA at lower LV1

SMA starts posterior to neck of pancreas and descends across anterior uncinate process and crosses anterior to 3 rd part of duodenum

VAGUS N. provides preganglionic parasympathetic

Postganglionic sympathetics from sup. mesenteric ganglion

SMA and branches Inferior pancreaticoduo-denal A./trunk (splits into ant. & post. arteries) Middle rectal A. Right colic A. Intestinal brs. Ileocolic A. -> appendicular a. Marginal A. CLINICALS: SMA syndrome – SMA is obstructed in some way Nutcracker syndrome - SMA compresses left renal v. (crosses ant. to aorta and inf. to SMA) leading to varicocele in left testis

Inferior pancreaticoduo-denal A./trunk (splits into ant. & post. arteries)

Middle rectal A.

Right colic A.

Intestinal brs.

Ileocolic A. -> appendicular a.

Marginal A.

CLINICALS:

SMA syndrome – SMA is obstructed in some way

Nutcracker syndrome - SMA compresses left renal v. (crosses ant. to aorta and inf. to SMA) leading to varicocele in left testis

Midgut embryo clinicals Duodenal atresia is associated with polyhydroamnios, bile-containing vomit, and distended stomach Results from failure of recanalization Same process for intestinal atresia or stenosis but Sx are not Omphalocele : a light gray shiny sac protruding form the base of the umbilical cord Results from the midgut loop failing to return to abdominal cavity Ileal (Meckel’s) diverticulum is often asymptomatic but can become inflamed or ulcerated Occurs when a remnant of the vitelline duct persists, forming a blind pouch on the antimesenteric border of the ileum Rule of two’s: 2 in. long, 2 ft. proximal of ileocecal JXN, 2% pop. Vitelline fistula is associated with fecal discharge from umbilicus Occurs when the vitelline duct (connects yolk sac with gut) persists forming a direct connection b/w lumen and outside of body Malrotation of the midgut is associated with volvulus which can compromise blood flow and result in gangrene Result of midgut undergoing only partial rotation

Duodenal atresia is associated with polyhydroamnios, bile-containing vomit, and distended stomach

Results from failure of recanalization

Same process for intestinal atresia or stenosis but Sx are not

Omphalocele : a light gray shiny sac protruding form the base of the umbilical cord

Results from the midgut loop failing to return to abdominal cavity

Ileal (Meckel’s) diverticulum is often asymptomatic but can become inflamed or ulcerated

Occurs when a remnant of the vitelline duct persists, forming a blind pouch on the antimesenteric border of the ileum

Rule of two’s: 2 in. long, 2 ft. proximal of ileocecal JXN, 2% pop.

Vitelline fistula is associated with fecal discharge from umbilicus

Occurs when the vitelline duct (connects yolk sac with gut) persists forming a direct connection b/w lumen and outside of body

Malrotation of the midgut is associated with volvulus which can compromise blood flow and result in gangrene

Result of midgut undergoing only partial rotation

Hindgut Blood supply: IMA at LV3 Preganglionic parasympathetics from pelvic splanchnic ns. (S2-4) Postganglionic sympathetics from inferior mesenteric ganglion

Blood supply: IMA at LV3

Preganglionic parasympathetics from pelvic splanchnic ns. (S2-4)

Postganglionic sympathetics from inferior mesenteric ganglion

IMA and its branches Left colic A. Sigmoid As. Superior rectal A. Terminal br. Marginal A.

Left colic A.

Sigmoid As.

Superior rectal A.

Terminal br.

Marginal A.

Hindgut embryo clinicals Aganglionic megacolon (Hirschsprung’s disease) is associated with the loss of peristalsis, fecal retention, and abdominal distention Results from failure of neural crest cells to form the myenteric plexus in the sigmoid colon and rectum Proximal to this the colon is distended with fecal material and the distal colon is narrow where plexus is missing Anorectal agenesis is when the rectum ends as a blind sac above the puborectalis m. owing to abnormal formation of the urorectal septum Anal agenesis is when the anal canal ends as a blind sac below the puborectalis m. Rectovesical, rectourethral, or rectovaginal fistulas can accompany the above two disorders (fistula = abnormal lumen connections)

Aganglionic megacolon (Hirschsprung’s disease) is associated with the loss of peristalsis, fecal retention, and abdominal distention

Results from failure of neural crest cells to form the myenteric plexus in the sigmoid colon and rectum

Proximal to this the colon is distended with fecal material and the distal colon is narrow where plexus is missing

Anorectal agenesis is when the rectum ends as a blind sac above the puborectalis m. owing to abnormal formation of the urorectal septum

Anal agenesis is when the anal canal ends as a blind sac below the puborectalis m.

Rectovesical, rectourethral, or rectovaginal fistulas can accompany the above two disorders (fistula = abnormal lumen connections)

Referred pain overview Table 4-5. Referred pain pathways (visceral afferents) Left and right flanks and groins, lateral and anterior thighs L1,L2 Lumbar splanchnic nerves Hindgut (organs supplied by inferior mesenteric artery) Flanks (lateral regions) and pubic region T12 Least splanchnic nerve Kidneys and upper ureter Umbilical region T9,T10 (or T10,T11) Lesser splanchnic nerve Midgut (organs supplied by superior mesenteric artery) Lower thorax and epigastric region T5 to T9 (or T10) Greater splanchnic nerve Foregut (organs supplied by celiac trunk) Upper thorax and medial arm T1 to T4 Thoracic splanchnic nerves Heart Referral area Spinal cord level Afferent pathway Organ

Portal Venous System Portal V. = Splenic V. + SMV Posterior to neck of pancreas IMV => splenic usually PORTAL HTN (portal-caval anastomoses) 1) Esophageal venous plexus -left gastric v.  esophageal v. 2) Rectal venous plexus -sup. rectal v.  Middle & Inf. Rectal vv. =>internal iliac v. 3) Paraumbilical vv. -paraumbilical v.  supf. & inf. Epigastric vv. 4) colic, testicular vv. Results in: Esophageal varices Hemorrhoids Caput Medusae History for portal HTN : vomiting blood, alcoholism, liver cirrhosis, schistosomiasis, ascites, splenomegaly

Portal V. = Splenic V. + SMV

Posterior to neck of pancreas

IMV => splenic usually

PORTAL HTN (portal-caval anastomoses)

1) Esophageal venous plexus

-left gastric v.  esophageal v.

2) Rectal venous plexus

-sup. rectal v.  Middle & Inf. Rectal vv. =>internal iliac v.

3) Paraumbilical vv.

-paraumbilical v.  supf. & inf. Epigastric vv.

4) colic, testicular vv.

Results in:

Esophageal varices

Hemorrhoids

Caput Medusae

Abdominal Aorta Abdominal Aortic Aneurysms (AAA): Severe, central abdominal pain=> to the back; pulsatile tender mass below ~LV2; if rupture occurs then hypotension and delirium Types: Saccular, Fusiform, Dissection Common site: Below level of renal as. and SMA (IMA is in it) Ruptured AAA most commonly below renal a. in the left posterolateral wall (retroperitoneal) Need to compress above celiac a., in surgery the L. renal V. is in jeopardy

Abdominal Aortic Aneurysms (AAA):

Severe, central abdominal pain=> to the back; pulsatile tender mass below ~LV2; if rupture occurs then hypotension and delirium

Types: Saccular, Fusiform, Dissection

Common site: Below level of renal as. and SMA (IMA is in it)

Ruptured AAA most commonly below renal a. in the left posterolateral wall (retroperitoneal)

Need to compress above celiac a., in surgery the L. renal V. is in jeopardy

Abdominal aortic branches PAIRED UNPAIRED Inf. Phrenic a. Celiac trunk at upper LV1 Middle suprarenal A. 1 st lumbar A. SMA at lower LV1 Renal A.(right one lower) upper LV2 Testicular/ovarian A. 2 nd lumbar A. IMA at LV3 3 rd lumar A. 4 th lumbar A. Middle (median) sacral A. at upper LV4 Common Iliacs bifurcate at LV4 Right common Iliac A. crosses anterior to lower IVC at LV5 The 5 th lumbar As. come off median sacral A. The perivascular plexus has postganglionic sympathetic fibers

PAIRED UNPAIRED

Inf. Phrenic a.

Celiac trunk at upper LV1

Middle suprarenal A.

1 st lumbar A.

SMA at lower LV1

Renal A.(right one lower)

upper LV2

Testicular/ovarian A.

2 nd lumbar A.

IMA at LV3

3 rd lumar A.

4 th lumbar A.

Middle (median) sacral A. at upper LV4

Common Iliacs bifurcate at LV4

Right common Iliac A. crosses anterior to lower IVC at LV5

The 5 th lumbar As. come off median sacral A.

The perivascular plexus has postganglionic sympathetic fibers

Abdominal Venous Drainage Azygous V. drains blood from IVC to SVC Hemiazygous V. drains L renal v. to azygous Ascending lumbar vv. => azygous &hemiazy IVC forms at LV5 Posterior to aorta, ascends anterior Testicular/ovarian, suprarenal, Inf. Phrenic vv. Right ones into IVC Left ones into left renal v.

Azygous V. drains blood from IVC to SVC

Hemiazygous V. drains L renal v. to azygous

Ascending lumbar vv. => azygous &hemiazy

IVC forms at LV5

Posterior to aorta, ascends anterior

Testicular/ovarian, suprarenal, Inf. Phrenic vv.

Right ones into IVC

Left ones into left renal v.

Occlusion of IVC This is more common than occlusion of SVC Reroutes: Azygous > SVC > right atrium Lumbar vv. > external and internal vertebral venous plexuses > cranial dural sinuses > internal jugular v. > brachiocephalic v. > SVC External iliac v. > Inf. Epigastric v. > sup. Epigastric v. > int. thoracic v. > brachiocephalic v. >SVC Femoral v. > Greater saphenous v. > supf. Epigastric v. > thoracoepigastric v. > lat. Thoracic v. > axillary v. > subclavian v. > brachiocephalic v.

This is more common than occlusion of SVC

Reroutes:

Azygous > SVC > right atrium

Lumbar vv. > external and internal vertebral venous plexuses > cranial dural sinuses > internal jugular v. > brachiocephalic v. > SVC

External iliac v. > Inf. Epigastric v. > sup. Epigastric v. > int. thoracic v. > brachiocephalic v. >SVC

Femoral v. > Greater saphenous v. > supf. Epigastric v. > thoracoepigastric v. > lat. Thoracic v. > axillary v. > subclavian v. > brachiocephalic v.

Lymph Pre-aortic nodes: Celiac nodes receive from inferior & superior mesenteric nodes Drain GI tract Celiac nodes empty into cisterna chyli (trunk that is the beginning of the thoracic duct)

Pre-aortic nodes:

Celiac nodes receive from inferior & superior mesenteric nodes

Drain GI tract

Celiac nodes empty into cisterna chyli (trunk that is the beginning of the thoracic duct)

Lymph - lateral aortic or lumbar lymph nodes receive lymphatics from the body wall, the kidneys, the suprarenal glands, and the testes or ovaries. - Pre-aortic nodes receive from GI tract (rectum too), as well as the spleen, pancreas, gallbladder, and liver -Finally, the lateral aortic or lumbar nodes form the right and left lumbar trunks , while the pre-aortic nodes form the intestinal trunk . These trunks come together and form a confluence that, at times, appears as a saccular dilation (the cisterna chyli ). This confluence of lymph trunks is posterior to the right side of the abdominal aorta and anterior to the bodies of vertebrae LI and LII . It marks the beginning of the thoracic duct .

Abdominal viscera - Esophagus Enters at TV 10 , passing through sup. & post. Mediastinum Upper esophageal sphincter is skeletal musc.;relaxes upon swallowing ( cricopharyngeus & inf. Pharyngeal constrictor ms. ) Lower esophageal sphincter is smooth musc.; prevents reflux Constricted at 3 sites: pharynx-esophagus JXN, bifurcation of trachea, and gastroesophageal JXN Clinicals: Enlarged left atrium can constrict esophagus Sliding hiatal hernia occurs when stomach and GE JXN herniate through diaphragm into thorax (heartburn, reflux, burning retrosternal pain; all of which are worse in supine position) Paraesophageal hiatal hernia is only when stomach herniates (no reflux but can have strangulation) ACHALASIA is failure of the LES to relax during swallowing (dysphagia, “bird’s beak deformity”, Chagas disease) Esophageal reflux is from dysFXN of LES Barrett esophagus - there’s gastric instead of strat. Squamous epithelium in distal esophagus due to reflux (can lead to cancer)

Enters at TV 10 , passing through sup. & post. Mediastinum

Upper esophageal sphincter is skeletal musc.;relaxes upon swallowing ( cricopharyngeus & inf. Pharyngeal constrictor ms. )

Lower esophageal sphincter is smooth musc.; prevents reflux

Constricted at 3 sites: pharynx-esophagus JXN, bifurcation of trachea, and gastroesophageal JXN

Clinicals:

Enlarged left atrium can constrict esophagus

Sliding hiatal hernia occurs when stomach and GE JXN herniate through diaphragm into thorax (heartburn, reflux, burning retrosternal pain; all of which are worse in supine position)

Paraesophageal hiatal hernia is only when stomach herniates (no reflux but can have strangulation)

ACHALASIA is failure of the LES to relax during swallowing (dysphagia, “bird’s beak deformity”, Chagas disease)

Esophageal reflux is from dysFXN of LES

Barrett esophagus - there’s gastric instead of strat. Squamous epithelium in distal esophagus due to reflux (can lead to cancer)

Stomach Cardia, fundus (tympanic percussion from air), body, antrum, pylorus and canal Pyloric antrum crosses midline and is most anterior part Transpyloric plane at LV1 Stomach bed (rests on in supine position): left leaflet of diaphragm, left kidney, left suprarenal gland, transverse colon and mesocolon, spleen, and pancreas

Cardia, fundus (tympanic percussion from air), body, antrum, pylorus and canal

Pyloric antrum crosses midline and is most anterior part

Transpyloric plane at LV1

Stomach bed (rests on in supine position): left leaflet of diaphragm, left kidney, left suprarenal gland, transverse colon and mesocolon, spleen, and pancreas

Stomach clinicals Gastric ulcers – presents with epigastric and left hypochondriac pain after a meal. Most common in the body of the stomach along lesser curvature. H. Pylori, say no more… If ulcerates posteriorly then can damage pancreas and splenic a. and potentially cause fatal hemorrhage GERD can cause cancer of esophagus Hypertrophic pyloric stenosis – see earlier Dumping sydrome is rapid emptying of hyperosmotic contents (high carb) into the jejunum and occurs after partial gastrectomy or vagotomy (diarrhea, hypoglycemia, dizziness, borborygmi=rumbling from gas Cancer of the stomach can metastasize to the supraclavicular lymph nodes (Virchow nodes) on the left

Gastric ulcers – presents with epigastric and left hypochondriac pain after a meal. Most common in the body of the stomach along lesser curvature. H. Pylori, say no more…

If ulcerates posteriorly then can damage pancreas and splenic a. and potentially cause fatal hemorrhage

GERD can cause cancer of esophagus

Hypertrophic pyloric stenosis – see earlier

Dumping sydrome is rapid emptying of hyperosmotic contents (high carb) into the jejunum and occurs after partial gastrectomy or vagotomy (diarrhea, hypoglycemia, dizziness, borborygmi=rumbling from gas

Cancer of the stomach can metastasize to the supraclavicular lymph nodes (Virchow nodes) on the left

Duodenum 1 st or superior part – LV1 (AKA duodenal cap) Only part that is peritonealized DUODENAL ULCERS: most common anteriorly but can ulcerate into gastroduodenal A. posteriorly -> severe bleed Common bile duct also crosses posteriorly 2 nd or descending part – LV2/3 Plicae circulares begin Receives CBD and main pancreatic duct posteriorly or medially at hepatopancreatic ampulla (of Vater) CBD is narrowest here -> gallstone obstruction -> obstructive jaundice Spincter of oddi In the lumen major duodenal papilla marks this 3 rd or horizontal part – crosses LV3 at midline SMA crosses anterior and IVC and aorta posteriorly Abdominal injury can crush this part against vertebra 4 th or ascending part – up to LV2 Suspensory lig. (of Trietz) = cranial end of the dorsal mesentery Supports duodenojejunal flexure

1 st or superior part – LV1 (AKA duodenal cap)

Only part that is peritonealized

DUODENAL ULCERS: most common anteriorly but can ulcerate into gastroduodenal A. posteriorly -> severe bleed

Common bile duct also crosses posteriorly

2 nd or descending part – LV2/3

Plicae circulares begin

Receives CBD and main pancreatic duct posteriorly or medially at hepatopancreatic ampulla (of Vater)

CBD is narrowest here -> gallstone obstruction -> obstructive jaundice

Spincter of oddi

In the lumen major duodenal papilla marks this

3 rd or horizontal part – crosses LV3 at midline

SMA crosses anterior and IVC and aorta posteriorly

Abdominal injury can crush this part against vertebra

4 th or ascending part – up to LV2

Suspensory lig. (of Trietz) = cranial end of the dorsal mesentery

Supports duodenojejunal flexure

Jejunum Villi long larger crypts (glands) Many large plicae circulares Initial 2/5 small intestine Long vasa recta Main absorbtion site Often empty Thicker, more vascular, and redder than ileum Located in umbilical region on the left Villi short smaller crypts Small and few plicae circulares that diappear distally Terminal 3/5 small intestine Short vasa recta Site of VIT B12 absorbtion Prominent peyer patches Ends at cecum Located in hypogastric and inguinal region on right More arcades Ileum

Villi long

larger crypts (glands)

Many large plicae circulares

Initial 2/5 small intestine

Long vasa recta

Main absorbtion site

Often empty

Thicker, more vascular, and redder than ileum

Located in umbilical region on the left

Villi short

smaller crypts

Small and few plicae circulares that diappear distally

Terminal 3/5 small intestine

Short vasa recta

Site of VIT B12 absorbtion

Prominent peyer patches

Ends at cecum

Located in hypogastric and inguinal region on right

More arcades

Large intestine No villi Largest crypts No plicae circulares Teniae coli (3 bands of smooth musc. that used to be longitudinal musc. layer before) Epiploic appendages (fatty tags, fat is in extraperitoneal space ) Haustra (sacculations of the wall, separated by plicae semilunaris)

No villi

Largest crypts

No plicae circulares

Teniae coli (3 bands of smooth musc. that used to be longitudinal musc. layer before)

Epiploic appendages (fatty tags, fat is in extraperitoneal space )

Haustra (sacculations of the wall, separated by plicae semilunaris)

Small and large intestine– clinicals Ileus – obstruction of small intestine Celiac disease – hypersensitivity to gluten and gliadin protein found in wheat; causes immunologic damage to mucosa Crohn disease – chronic inflammatory bowel disease, mostly in ileum (mass in right lower quadrant, strictures, & fistulas) Appendicitis – caused by obstruction of lumen by fecal concretion and lymphoid hyperplasia. INITIALLY referred pain is paraumbilical (T9-10) LATER (after appendix touches parietal peritoneum) pain is at MCBURNEY’S POINT = 1/3 the way from ASIS going to umbilicus

Ileus – obstruction of small intestine

Celiac disease – hypersensitivity to gluten and gliadin protein found in wheat; causes immunologic damage to mucosa

Crohn disease – chronic inflammatory bowel disease, mostly in ileum (mass in right lower quadrant, strictures, & fistulas)

Appendicitis – caused by obstruction of lumen by fecal concretion and lymphoid hyperplasia.

INITIALLY referred pain is paraumbilical (T9-10)

LATER (after appendix touches parietal peritoneum) pain is at MCBURNEY’S POINT = 1/3 the way from ASIS going to umbilicus

Sigmoid colon Intraperitoneal Begins at SV1 (sacral promontory) & ends at SV3 Stores feces Left ureter & left common iliac lie at apex of sigmoid mesocolon At rectosigmoid JXN sigmoid colon bends anterior & to left Clinicals Diverticulosis  Diverticulitis Often used in colostomy (it is diverted out through rectus abdominis m.) Colonic Adenocarcinoma – accounts for 98% of all cancers in the large intestine; metastasis most common to liver Right sided – iron def. anemia Left sided – obstruction, bloody stools Extraperitoneal Begins at SV3 Ends at tip of coccyx Puborectalis m. forms u-shaped sling and cause a 90deg perineal flexure 3 transverse rectal folds (folds of Houston) Clinicals Polyps (FAP) Ulcerative colitis – idiopathic inflammatory bowel disease (always in rectum & extends proximally) Rectal prolapse – protrusion of the full thickness of rectum through anus Rectum

Intraperitoneal

Begins at SV1 (sacral promontory) & ends at SV3

Stores feces

Left ureter & left common iliac lie at apex of sigmoid mesocolon

At rectosigmoid JXN sigmoid colon bends anterior & to left

Clinicals

Diverticulosis  Diverticulitis

Often used in colostomy (it is diverted out through rectus abdominis m.)

Colonic Adenocarcinoma – accounts for 98% of all cancers in the large intestine; metastasis most common to liver

Right sided – iron def. anemia

Left sided – obstruction, bloody stools

Extraperitoneal

Begins at SV3

Ends at tip of coccyx

Puborectalis m. forms u-shaped sling and cause a 90deg perineal flexure

3 transverse rectal folds (folds of Houston)

Clinicals

Polyps (FAP)

Ulcerative colitis – idiopathic inflammatory bowel disease (always in rectum & extends proximally)

Rectal prolapse – protrusion of the full thickness of rectum through anus

Anal Canal Sup. Rectal A. (IMA) Sup. Rectal v. > IMA > portal system Deep nodes drain lymph Autonomic motor innervation & stretch sensation (no pain) Endoderm (hindgut) Simple columnar Int. hemorrhoids (sup. Rectal vs., no pain) Has anal columns (of Morgagni) that at the base have anal sinuses (*anal fistula) Inf. Rectal A. (int. pudendal A.) Inf. Rectal v. > int. pudendal v. > int. iliac v. > IVC Supf. Inguinal nodes drain Somatic innervation (pudendal n. to ext. sphincter) Ectoderm (proctodeum) Stratified squamous Ext. hemorrhoids (inf. Rectal vs., with pain) Lower Upper -divided by pectinate line -Surrounded by int. & ext. anal sphincter

Sup. Rectal A. (IMA)

Sup. Rectal v. > IMA > portal system

Deep nodes drain lymph

Autonomic motor innervation & stretch sensation (no pain)

Endoderm (hindgut)

Simple columnar

Int. hemorrhoids (sup. Rectal vs., no pain)

Has anal columns (of Morgagni) that at the base have anal sinuses (*anal fistula)

Inf. Rectal A. (int. pudendal A.)

Inf. Rectal v. > int. pudendal v. > int. iliac v. > IVC

Supf. Inguinal nodes drain

Somatic innervation (pudendal n. to ext. sphincter)

Ectoderm (proctodeum)

Stratified squamous

Ext. hemorrhoids (inf. Rectal vs., with pain)

Gallbladder and biliary ducts Fundus, body, neck (posterior part) Common hepatic duct + cystic duct (spiral valve of Heister) = common bile duct Cystic A. off of right hepatic a. Ampulla of Vatar (CBD is narrowest here and gallstones commonly get stuck  obstr. Jaundice & pancreatitis) Spincter of oddi Cholecystitis – pain in right flank (fundus is at 9 th costal cartilage) and radiates to right shoulder Pain first along T5-T9 before touch parietal peritoneum Could be from gallstone in cystic duct (Mirizzi syndrome when also blocks hepatic duct)

Fundus, body, neck (posterior part)

Common hepatic duct + cystic duct (spiral valve of Heister) = common bile duct

Cystic A. off of right hepatic a.

Ampulla of Vatar (CBD is narrowest here and gallstones commonly get stuck  obstr. Jaundice & pancreatitis)

Spincter of oddi

Cholecystitis – pain in right flank (fundus is at 9 th costal cartilage) and radiates to right shoulder

Pain first along T5-T9 before touch parietal peritoneum

Could be from gallstone in cystic duct (Mirizzi syndrome when also blocks hepatic duct)

Liver Understand the H Left side formed by line through gallbladder and IVC (anatomical division of R + L lobes) Right side formed by ligamentum teres & ligamentum venosum Horizontal line formed by porta hepatis (hilum, no visc. Peritoneum) FXNally (quadrate is left lobe & caudate is in R+L lobes) Anatomically they are in left lobe Ligamentum venosum (=obliterated ductus venosus) Subphrenic & hepatorenal recesses Bare area of liver = gap in coronory lig. (nothing b/w diaphragm & liver) If hepatic A. comes off SMA then it passes post. To portal v.

Understand the H

Left side formed by line through gallbladder and IVC (anatomical division of R + L lobes)

Right side formed by ligamentum teres & ligamentum venosum

Horizontal line formed by porta hepatis (hilum, no visc. Peritoneum)

FXNally (quadrate is left lobe & caudate is in R+L lobes)

Anatomically they are in left lobe

Ligamentum venosum (=obliterated ductus venosus)

Subphrenic & hepatorenal recesses

Bare area of liver = gap in coronory lig. (nothing b/w diaphragm & liver)

If hepatic A. comes off SMA then it passes post. To portal v.

Liver clinicals Liver biopsy – at 10th intercostal space with patient exhaled Resection of liver – hepatic vs. are landmarks that mark periphery in liver segment resection Congenital biliary atresia – present within weeks after birth, jaundice doesn’t start immediately (bile duct proliferation, with dilation of bile canaliculi and bile plugs) Alcoholism and Cirrhosis –cause Portal HTN

Liver biopsy – at 10th intercostal space with patient exhaled

Resection of liver – hepatic vs. are landmarks that mark periphery in liver segment resection

Congenital biliary atresia – present within weeks after birth, jaundice doesn’t start immediately (bile duct proliferation, with dilation of bile canaliculi and bile plugs)

Alcoholism and Cirrhosis –cause Portal HTN

Pancreas Retroperitoneal (except tail) Receives dorsal pancreatic A. (sometime off celiac trunk), great pancreatic A., and caudal pancreatic as. From splenic A. Main pancreatic duct (of Wirsung); Accessory (of Santorini) 5 parts Uncinate process (ventral pancreatic bud) Head (ventral pancreatic bud & dorsal pancreatic bud) – in duodenal C-loop Neck (dorsal pancreatic bud) – anterior to joining of SMV with splenic  portal v. Body (dorsal pancreatic bud) Tail (dorsal pancreatic bud) – toward spleen Clinical Acute pancreatitis – epigastric pain that radiates to back (biliary tract disease or alcoholism) Pancreatic adenocarcinoma (very aggressive)– same pain + blocks common bile duct (obstructive jaundice) Treatment – pancreaticoduodenectomy (Whipple procedure), which removes head of pancreas, duodenum, distal CBD, gallbladder, and distal stomach.

Retroperitoneal (except tail)

Receives dorsal pancreatic A. (sometime off celiac trunk), great pancreatic A., and caudal pancreatic as. From splenic A.

Main pancreatic duct (of Wirsung); Accessory (of Santorini)

5 parts

Uncinate process (ventral pancreatic bud)

Head (ventral pancreatic bud & dorsal pancreatic bud) – in duodenal C-loop

Neck (dorsal pancreatic bud) – anterior to joining of SMV with splenic  portal v.

Body (dorsal pancreatic bud)

Tail (dorsal pancreatic bud) – toward spleen

Clinical

Acute pancreatitis – epigastric pain that radiates to back (biliary tract disease or alcoholism)

Pancreatic adenocarcinoma (very aggressive)– same pain + blocks common bile duct (obstructive jaundice)

Treatment – pancreaticoduodenectomy (Whipple procedure), which removes head of pancreas, duodenum, distal CBD, gallbladder, and distal stomach.

Spleen Left hypochondriac region, anterior to ribs 9, 10, and 11 Does not extend below costal margin normally; palpable only in spenomegaly Attached to stomach by gastrosplenic lig. Attached to left kidney by splenorenal lig. (  left gastroepiploic vessels & short gastric as.) Tail of the pancreas Clinicals: Splenic vein thrombosis associated w/ pancreatitis (gastric varices & upper GI bleed) Splenectomy – removal of spleen can damage pancreas or left kidney depending on what lig.s and their respective as. That are damaged. Most commonly, atelectasis occurs (collapse) of the left lower lobe of lung. Splenic A. aneurysm – particularly likely to rupture in pregnant women (resected from when present in women of childbearing age)

Left hypochondriac region, anterior to ribs 9, 10, and 11

Does not extend below costal margin normally; palpable only in spenomegaly

Attached to stomach by gastrosplenic lig.

Attached to left kidney by splenorenal lig. (  left gastroepiploic vessels & short gastric as.)

Tail of the pancreas

Clinicals:

Splenic vein thrombosis associated w/ pancreatitis (gastric varices & upper GI bleed)

Splenectomy – removal of spleen can damage pancreas or left kidney depending on what lig.s and their respective as. That are damaged. Most commonly, atelectasis occurs (collapse) of the left lower lobe of lung.

Splenic A. aneurysm – particularly likely to rupture in pregnant women (resected from when present in women of childbearing age)

Urinary System - Kidneys 5 segmental arteries (limited collateral circulation) Ligation of one will cause necrosis of whole segment Accessory (supernumerary) segmental as., if ligated cause necrosis of whole segment Hilar if arise off renal a. and polar if directly from aorta Segmental a.> interlobar a.> arcuate a.(base of pyramid, corticomedullary JXN) > interlobular a.> afferent arteriole Surrounded by true renal capsule, perirenal fat, renal fascia (=false renal capsule), pararenal fat, then parietal peritoneum anteriorly and transversalis fascia posteriorly Perirenal fat packs in structures in the hilus Renal papilla > minor calyx > major calyx > renal pelvis Superior poles are closer together Left – 11 th + 12 th rib, right at 12 th rib 12 th rib can get removed in kidney surgery Left kidney transplanted more common because of longer renal v.

5 segmental arteries (limited collateral circulation)

Ligation of one will cause necrosis of whole segment

Accessory (supernumerary) segmental as., if ligated cause necrosis of whole segment

Hilar if arise off renal a. and polar if directly from aorta

Segmental a.> interlobar a.> arcuate a.(base of pyramid, corticomedullary JXN) > interlobular a.> afferent arteriole

Surrounded by true renal capsule, perirenal fat, renal fascia (=false renal capsule), pararenal fat, then parietal peritoneum anteriorly and transversalis fascia posteriorly

Perirenal fat packs in structures in the hilus

Renal papilla > minor calyx > major calyx > renal pelvis

Superior poles are closer together

Left – 11 th + 12 th rib, right at 12 th rib

12 th rib can get removed in kidney surgery

Left kidney transplanted more common because of longer renal v.

ANTERIOR POSTERIOR Renal pelvis Vein then artery

* Clinical * -Abscess internal to renal fascia in one kidney CAN NOT spread to other kidney b/c although renal fascia is continuous across midline, it wraps around central vessels very tightly

Kidney clinicals Renal agenesis –when the ureteric bud fails to develop Unilateral type is relatively common and asymptomatic Bilateral (relatively uncommon, incompatible w/ life) causes oligohydramnios during pregnancy, which allows uterine wall to compress the fetus  Potter’s Syndrome Horseshoe kidney – inferior poles fuse and kidney gets trapped at IMA Urachal fistula – allantois persists forming direct connection b/w bladder lumen and outside at umbilicus Urine drainage from the umbilicus! Wilm’s tumor – most common primary renal tumor of childhood (displays 3 areas of embryological development: stromal, blastemal, and tubular areas) Polycystic disease of kidneys – loops of Henle dilate forming large cysts

Renal agenesis –when the ureteric bud fails to develop

Unilateral type is relatively common and asymptomatic

Bilateral (relatively uncommon, incompatible w/ life) causes oligohydramnios during pregnancy, which allows uterine wall to compress the fetus  Potter’s Syndrome

Horseshoe kidney – inferior poles fuse and kidney gets trapped at IMA

Urachal fistula – allantois persists forming direct connection b/w bladder lumen and outside at umbilicus

Urine drainage from the umbilicus!

Wilm’s tumor – most common primary renal tumor of childhood (displays 3 areas of embryological development: stromal, blastemal, and tubular areas)

Polycystic disease of kidneys – loops of Henle dilate forming large cysts

Ureters Begin at ureteropelvic JXN, then descend retroperitoneally and anterior to psoas musc.. Then cross pelvic inlet into minor (true) pelvis where they are still retroperitoneal and cross anterior to common iliac bifurcation and follow internal iliac a. Could be compromised by aneurysm of common iliac End at ureterovesical JXN and open into bladder and define upper border of urinary bladder trigone. “ Water under the bridge!” Males – pass posterior to ductus deferens Females – pass posterior & inferior to uterine A. ***During hysterectomy ureter can be ligated with uterine A. (it is posterior to artery near cervix) Pass posterior to testicular/ovarian vessels 3 normal constrictions (kidney stones get stuck): (1) at ureteropelvic JXN (2) where ureters cross pelvic inlet (3) and at ureterovesical JXN (intramural)

Begin at ureteropelvic JXN, then descend retroperitoneally and anterior to psoas musc.. Then cross pelvic inlet into minor (true) pelvis where they are still retroperitoneal and cross anterior to common iliac bifurcation and follow internal iliac a.

Could be compromised by aneurysm of common iliac

End at ureterovesical JXN and open into bladder and define upper border of urinary bladder trigone.

“ Water under the bridge!”

Males – pass posterior to ductus deferens

Females – pass posterior & inferior to uterine A.

***During hysterectomy ureter can be ligated with uterine A. (it is posterior to artery near cervix)

Pass posterior to testicular/ovarian vessels

3 normal constrictions (kidney stones get stuck):

(1) at ureteropelvic JXN (2) where ureters cross pelvic inlet (3) and at ureterovesical JXN (intramural)

Ureter clinicals -Ureteric caliculi – obstruction of flow most often occurs at 2 nd and 3 rd constrictions causing unilateral hydronephrosis -Passing of kidney stones is an excruciating pain -ectopic openings (urine leakage)

Posterior surface (fundus/base) In males related to rectovesical pouch, rectum, seminal vesicles, and ampulla of ductus deferens In females related to anterior wall of vagina Anterior surface Related to pubic symphysis and retropubic space of Retzius Superior surface In males - peritoneal cavity In females – vesicouterine pouch (peritoneal cavity) Apex – related to median umbilical lig. or urachus Urinary bladder Neck – in males related to prostatic urethra and prostate while in females related to urogenital diaphragm Trigone of the bladder – on posterior surface of bladder and defined superiorly by ureters and inferiorly by urethra (internal urethral meatus)

Posterior surface (fundus/base)

In males related to rectovesical pouch, rectum, seminal vesicles, and ampulla of ductus deferens

In females related to anterior wall of vagina

Anterior surface

Related to pubic symphysis and retropubic space of Retzius

Superior surface

In males - peritoneal cavity

In females – vesicouterine pouch (peritoneal cavity)

Apex – related to median umbilical lig. or urachus

Neck – in males related to prostatic urethra and prostate while in females related to urogenital diaphragm

Trigone of the bladder – on posterior surface of bladder and defined superiorly by ureters and inferiorly by urethra (internal urethral meatus)

Bladder clinicals In infants, empty bladder lies within abdominal cavity In adults, empty bladder is within minor pelvis, but when full can rise above pelvic inlet. Suprapubic cystostomy (drain in acute retention) Needle is passed through the ant ab wall [skin, supf. Fascia (camper + scarpa), linea alba, transversalis fascia, extraperitoneal fat, bladder wall) Avoids entering peritoneal cavity Incontinence (total, stress, urge, overflow types)

In infants, empty bladder lies within abdominal cavity

In adults, empty bladder is within minor pelvis, but when full can rise above pelvic inlet.

Suprapubic cystostomy (drain in acute retention)

Needle is passed through the ant ab wall [skin, supf. Fascia (camper + scarpa), linea alba, transversalis fascia, extraperitoneal fat, bladder wall)

Avoids entering peritoneal cavity

Incontinence (total, stress, urge, overflow types)

Urethra (male) Males (3 parts) Prostatic – post. wall has urethral crest that contains 2 openings of ejaculatory ducts. Prostatic ducts are lateral to urethral crest. Membranous – crosses urogenital diaphragm and surrounded by deep tranverse perineal m. and sphincter urethrae m. (external sphincter) Both musc. by pudendal n. Penile (spongy/cavernous) – surrounded by corpus spongiosum, enlarges into fossa navicularis, and ends as external urethral meatus. Openings of bulbourethral glands just below urogenital diaphragm. (vulnerable to catheter penetration)

Males (3 parts)

Prostatic – post. wall has urethral crest that contains 2 openings of ejaculatory ducts. Prostatic ducts are lateral to urethral crest.

Membranous – crosses urogenital diaphragm and surrounded by deep tranverse perineal m. and sphincter urethrae m. (external sphincter)

Both musc. by pudendal n.

Penile (spongy/cavernous) – surrounded by corpus spongiosum, enlarges into fossa navicularis, and ends as external urethral meatus. Openings of bulbourethral glands just below urogenital diaphragm. (vulnerable to catheter penetration)

Females Courses through urogenital diaphragm and is surrounded by deep transverse perineal m. and sphincter urethrae m. (latter musc. doesn’t completely surround urethra and is the reason for high incidence of stress incontinence in women) Posterior surf. fuses with ant. wall of vagina External urethral orifice opens into vestibule of vagina b/w labia minora Urethra (female)

Females

Courses through urogenital diaphragm and is surrounded by deep transverse perineal m. and sphincter urethrae m. (latter musc. doesn’t completely surround urethra and is the reason for high incidence of stress incontinence in women)

Posterior surf. fuses with ant. wall of vagina

External urethral orifice opens into vestibule of vagina b/w labia minora

Urine extravasation (from trauma) Rupture of superior bladder wall (compression of full bladder) – INTRAPERITONEAL urine! Rupture of anterior wall (from fractured pelvis, car accident) – EXTRAPERITONEAL in retropubic space of Retzius Rupture of urethra above urogenital diaphragm (from fractured pelvis or catheter complication) – same as above Rupture below urogenital diaphragm Most common, happens in STRADDLE INJURY Extraperitoneal, urine in supf. Perineal space  scrotal, penile, and ant. Ab wall areas (not thigh and anal triangle) Internal to : colles fascia & dartos m. in scrotum, supf. Fascia (camper and scarpa) in ab wall, and supf. Fascia of penis External to : external spermatic fascia in scrotum, external oblique m. in ab wall, and Buck’s fascia in penis Rupture of penile urethra – urine is in penis only, beneath deep fascia (Buck’s) unless it is also torn then urine goes throughout supf. Perineal space

Rupture of superior bladder wall (compression of full bladder) – INTRAPERITONEAL urine!

Rupture of anterior wall (from fractured pelvis, car accident) – EXTRAPERITONEAL in retropubic space of Retzius

Rupture of urethra above urogenital diaphragm (from fractured pelvis or catheter complication) – same as above

Rupture below urogenital diaphragm

Most common, happens in STRADDLE INJURY

Extraperitoneal, urine in supf. Perineal space  scrotal, penile, and ant. Ab wall areas (not thigh and anal triangle)

Internal to : colles fascia & dartos m. in scrotum, supf. Fascia (camper and scarpa) in ab wall, and supf. Fascia of penis

External to : external spermatic fascia in scrotum, external oblique m. in ab wall, and Buck’s fascia in penis

Rupture of penile urethra – urine is in penis only, beneath deep fascia (Buck’s) unless it is also torn then urine goes throughout supf. Perineal space

 

Suprarenal glands Covered by renal fascia Right is pyramid shaped, left is half-moon Cortex makes steroids (mineral-, gluco-, sex) gets postganglionic sympathetic (vasomotor) Medulla (NorE, 90% Epi) has chromaffin cells=modified postganglionic sympathetic neurons (from neural crest cells) Gets preganglionic sympathetics from splanchnic nn. Blood supply: (1) sup. suprarenal a. (from inf. Phrenic a.) (2) middle suprarenal a. (off aorta) (3) inf. suprarenal a. (off renal a.)

Covered by renal fascia

Right is pyramid shaped, left is half-moon

Cortex

makes steroids (mineral-, gluco-, sex)

gets postganglionic sympathetic (vasomotor)

Medulla (NorE, 90% Epi)

has chromaffin cells=modified postganglionic sympathetic neurons (from neural crest cells)

Gets preganglionic sympathetics from splanchnic nn.

Blood supply:

(1) sup. suprarenal a. (from inf. Phrenic a.)

(2) middle suprarenal a. (off aorta)

(3) inf. suprarenal a. (off renal a.)

Posterior abdominal wall Diaphragm Retroperitoneum Inf. Fascia = transversalis fascia Inf. Phrenic aa. Right crus: LV1-3 origin Spincteric to esophagus, if enlarged  stomach can herniate Left crus: LV1-2 origin Central GSA pain (C3,4,5 dermatomes) refers to neck & shoulder lateral arcuate lig. (quadratus) medial arcuate lig. (over psoas & sympathetic trunk) Quadratus lumborum m. Psoas m. (Psoas Sign – flex thigh and psoas m. should irritate inflamed appendix) Iliacus m.

Diaphragm

Retroperitoneum

Inf. Fascia = transversalis fascia

Inf. Phrenic aa.

Right crus: LV1-3 origin

Spincteric to esophagus, if enlarged  stomach can herniate

Left crus: LV1-2 origin

Central GSA pain (C3,4,5 dermatomes) refers to neck & shoulder

lateral arcuate lig. (quadratus)

medial arcuate lig. (over psoas & sympathetic trunk)

Quadratus lumborum m.

Psoas m. (Psoas Sign – flex thigh and psoas m. should irritate inflamed appendix)

Iliacus m.

Lumbar plexus (somatic, ventral primary rami) Table 4-6. Branches of the lumbar plexus Skin on anterior thigh and medial surface of leg Iliacus, pectineus, and muscles in anterior compartment of thigh L2 to L4 Femoral Skin on medial aspect of the thigh Obturator externus, pectineus, and muscles in medial compartment of thigh L2 to L4 Obturator Skin on anterior and lateral thigh to the knee   L2,L3 Lateral cutaneous nerve of thigh Genital branch-skin of anterior scrotum or skin of mons pubis and labium majus; femoral branch-skin of upper anterior thigh Genital branch-male cremasteric muscle L1,L2 Genitofemoral Skin in the upper medial thigh , and either the skin over the root of the penis and anterior scrotum or the mons pubis and labium majus Internal oblique and transversus abdominis L1 Ilio-inguinal Posterolateral gluteal skin and skin in pubic region Internal oblique and transversus abdominis L1 Iliohypogastric Function: sensory Function: motor Spinal segments Branch

Lumbar plexus cont. Subcostal n. not part of plexus (T12) Plexus forms posterior to psoas Lumbosacral trunk (part of L4, all of L5) crosses ala of sacrum Cremasteric Reflex (genitofemoral n.) -Know how nerves are in relation to psoas for lab IDing

Subcostal n. not part of plexus (T12)

Plexus forms posterior to psoas

Lumbosacral trunk (part of L4, all of L5) crosses ala of sacrum

Cremasteric Reflex (genitofemoral n.)

Pelvis – men and women Female : male Inlet oval : heart shaped Outlet larger in female b/c of everted ischial tuberosities Cavity is wider and shallower in female Subpubic angle larger and greater sciatic notch is wider in female Female sacrum is shorter and wider Obturator foramen is oval/triangular in female : round in male

Female : male

Inlet oval : heart shaped

Outlet larger in female b/c of everted ischial tuberosities

Cavity is wider and shallower in female

Subpubic angle larger and greater sciatic notch is wider in female

Female sacrum is shorter and wider

Obturator foramen is oval/triangular in female : round in male

Pelvic musc. Lateral rotation of the extended hip joint; abduction of flexed hip Branches from L5, S1, and S2 Medial side of superior border of greater trochanter of femur Anterior surface of sacrum between anterior sacral foramina Piriformis Lateral rotation of the extended hip joint; abduction of flexed hip Nerve to obturator internus L5, S1 Medial surface of greater trochanter of femur Anterolateral wall of true pelvis (deep surface of obturator membrane and surrounding bone) Obturator internus Function Innervation Insertion Origin Muscles of pelvic wall

Pelvic Diaphragm ***Childbirth can injure perineum, levator ani, & pelvic fascia. Usually pubococcygeus is torn. -Get urinary stress incontinence - sacrospinous lig . Is immediately external (posterolateral) of coccygeus m.

Pouches PERITONEALIZED Recto-uterine pouch (pouch of douglas) lowest point in peritoneal cavity collects fluid in supine position (can palpate/ access with digital exam) Recto-vesical (same as above but in males) Vesico-uterine pouch EXTRAPERITONEAL Retropubic space of Retzius

PERITONEALIZED

Recto-uterine pouch (pouch of douglas)

lowest point in peritoneal cavity

collects fluid in supine position (can palpate/ access with digital exam)

Recto-vesical (same as above but in males)

Vesico-uterine pouch

EXTRAPERITONEAL

Retropubic space of Retzius

Pelvic nerves From sacral plexus: -sciatic n. (infrapiriform) -pudendal n. (infrapiriform) -obturator n. -pelvic splanchnic ns. -Sup. & inf. Gluteal ns. (supra & infrapiriform) -lumbosacral trunk (part L4 and all L5) -Hypogastric N . (connects sup. & inf. Hypogastric plexuses) -Sympathetic trunk (grey rami here only) *** Caudal Epidural block : anesthesia given in sacral canal (S2-S4) [entire birth canal, pelvic floor, & perineum is anesthetized]

Posterior trunk of Int. Iliac A. -iliolumbar A. -Lateral sacral As. (anastomose with median sacral a.) -sup. Gluteal A. (suprapiriform)

Anterior trunk of Int. Iliac a. -umbilical A.  sup. Vesical A. -obturator A. -Inf. Vesical A. -middle rectal A. -Int. Pudendal A. (infrapiriform) -Inf. Gluteal A. (infrapiriform)

Lymph from pelvis Lymphatics from most pelvic viscera drain mainly into lymph nodes distributed along the internal iliac and external iliac arteries and their associated branches, which drain into nodes associated with the common iliac arteries and then into nodes associated with the lateral surfaces of the abdominal aorta. In turn, these lateral aortic nodes drain into the lumbar trunks , which continue to the origin of the thoracic duct at approximately vertebral level T12. Lymphatics from the testes , ovaries and related parts of the uterus and uterine tubes leave the pelvic cavity superiorly and drain, via vessels that accompany the ovarian/testicular arteries, directly into lateral aortic nodes and, in some cases, into the pre-aortic nodes on the anterior surface of the aorta. In addition to draining pelvic viscera, nodes along the internal iliac artery also receive drainage from the gluteal region of the lower limb and from deep areas of the perineum .

Lymphatics from most pelvic viscera drain mainly into lymph nodes distributed along the internal iliac and external iliac arteries and their associated branches, which drain into nodes associated with the common iliac arteries and then into nodes associated with the lateral surfaces of the abdominal aorta. In turn, these lateral aortic nodes drain into the lumbar trunks , which continue to the origin of the thoracic duct at approximately vertebral level T12.

Lymphatics from the testes , ovaries and related parts of the uterus and uterine tubes leave the pelvic cavity superiorly and drain, via vessels that accompany the ovarian/testicular arteries, directly into lateral aortic nodes and, in some cases, into the pre-aortic nodes on the anterior surface of the aorta.

In addition to draining pelvic viscera, nodes along the internal iliac artery also receive drainage from the gluteal region of the lower limb and from deep areas of the perineum .

Lymph from perineum -Lymphatic vessels from deep parts of the perineum accompany the internal pudendal blood vessels and drain mainly into internal iliac nodes in the pelvis. -Lymphatic channels from superficial tissues of the penis or the clitoris accompany the superficial external pudendal blood vessels and drain mainly into superficial inguinal nodes , as do lymphatic channels from the scrotum or labia majora. -The glans penis, the glans clitoris, labia minora, and the terminal inferior end of the vagina drain into deep inguinal nodes and external iliac nodes .

Perineum Part of pelvic outlet inferior to pelvic diaphragm Diamond shaped divided into anal and urogenital triangles by line b/w ischial tuberosities Deep perineal space Bounded by sup. fascia of the urogenital diaphragm and perineal membrane (inf. fascia) Supf. Perineal space Bounded by perineal membrane and supf. Perineal fascia (continuous w/ colles fascia) Ischioanal fossa and recesses, know if probe is in it *Clinical* - Episiotomy = incision in perineum to enlarge vaginal opening during childbirth Median episiotomy : starts at frenulum of labia minora and cuts down through skin, vaginal wall, perineal body, and supf. Transverse perineal musc. (may cut ext. anal sphincter inadvertently) Mediolateral episiotomy : starts at frenulum and cuts at 45deg angle through skin, vaginal wall, and bulbospongiosus m. Creates more room than median type

Part of pelvic outlet inferior to pelvic diaphragm

Diamond shaped divided into anal and urogenital triangles by line b/w ischial tuberosities

Deep perineal space

Bounded by sup. fascia of the urogenital diaphragm and perineal membrane (inf. fascia)

Supf. Perineal space

Bounded by perineal membrane and sup

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