ABDOMEN / REPRODUCTIVE FINAL Flashcards
direct hernia
-medial to inferior epigastric
-goes through superficial ring (external oblique aponeurosis)
-within the triangle
-due to weakness -> old age
-less common
-acquired
indirect hernia
-lateral to inferior epigastric
-congenital
-goes through superficial and deep rings
-more common in males
inguinal ligamnet
-from ASIS to pubic tubercle
-within the external aponeurosis
organs
-right kidney is slightly lower
-transverse colon umbilicus area (peritoneal)
-sigmoid/rectum- s3
abdominal wall layers
-skin
-superficial fascia- campers -> yellowy/fatty (superficial), scarpa -> membranous (deep)
-investing fascia
-muscles
-extraperitoneal fat
-parietal peritoneum
abdomen landmarks
-subphrenic space- between liver and diaphragm -> fluid collects -> drain inferior to rib 12
-paracolic gutters- fluid / infection medial and lateral to ascending/descending colon
nerves of abdomen
-anterior rami of lower 6 thoracic and L1
-iliohypogastric and ilioinguinal - L1
L1 dermatome
-just above inguinal ligament at pubic symphysis
lymph drainage
-above umbilicus drains- anterior axillary lymph nodes
-below umbilicus- superficial inguinal nodes
-stomach- celiac nodes
caput medusae
-paraumbilical veins drain into portal vein
-if backup in portal system
-pressure increased
-veins distend in umbilical region
-stomach, esophagus, anal area -> same effect
spigelian hernia
-where arcuate line meet semilunaris
-area of herniation -> lateral ventral wall hernia
-at level of ASIS laterally
arcuate line
-hematomas collect here at post op bc no strong posterior fascia
-below arcuate line is WEAKER -> subpubic incision
-looks thicker tho!
peritoneal cavity
-parietal peritoneum lines cavity- secretes fluid for lubrication
-cavity is space between peritoneum and viscera
-parietal and visceral layers are continuous with each other (hand in balloon)
-organs covered with visceral layer are NOT in the cavity
retroperitoneal
-not within peritoneal cavity
-only partially covered with parietal peritoneum
-from 12th rib to iliac crest/sacrum
greater and lesser sac
-greater from diaphragm into pelvis
-less sac is behind stomach -> Allows expansion
-sacs connect via epiploic foramen behind portal triad
umbilical folds
-median- bladder to umbilicus
-medial- sides of bladder to umbilicus
-lateral- deep inguinal ring to arcuate line
epiploic foramen boundaries
-anteriorly- free border of lesser omentum, bile duct, hepatic artery, and portal vein -> portal triad
-posteriorly- inferior vena cava
-superiorly- caudate process of caudate lobe of liver
-inferiorly- first part of duodenum
omentum
-greater omentum- hangs from greater curvature of stomach and proximal duodenum -> comes back up to connect to transverse colon
-lesser omentum- from lesser curvature of stomach to ligamentum venosum
-lesser omentum contains- hepatoduodenal and hepatogastric ligaments
ligamentum venosum
-within hepatoduodenal ligament
-between caudate and left lobe of liver
-remnant of ductus venosus - shunt that allows oxygenated blood in the umbilical vein to IVC to bypass the liver
mesentary
-transverse mesocolon
-sigmoid mesocolon
parietal peritoneum / visceral nerves
-peritoneum- pain, temp, touch, pressure -> lower 6 thoracic and 1st lumbar nerves
-parietal peritoneum- supplied by vicerator nerve
-visceral peritoneum- stretch, chemical irritation (ischemia) -> autonomic nerves traveling in mesenteries (same as organs)
-visceral pain is first at dermatome -> then somatic (peritoneum) as it worsens
esophagus
-10 in (25) long
-muscular
-right and left vagus nerves come with it
-upper 1/3- skeletal muscle
-middle 1/3- skeletal and smooth
-distal 1/3- smooth
-5 constrictions: cricoid, aortic arch, left main bronchus (carina), LA, esophageal hiatus
-UES and LES (cardiac orifice)
-fistula can form at left main bronchus constriction -> sign of lung cancer
esophagus VAN
-left gastric a&v
-thoracic aorta
-azygos vein
-portal hypertension -> distend the left gastric vein -> varices -> hemorrhage -> emergency
-cervical- recurrent laryngeal & sympathetic
-thoracic and lumbar- vagus nerve & sympathetic
-auerbachs (motility) and meissners plexus (mucus)
diabetes / vagus nerve
-gastroparesis
-slows vagus nerve
-if food sits long enough -> emesis / reflux
-can also be caused from damage during surgery, cannabis use, medications
pyloric sphincter
physiological
-circular muscle
stomach
-cardia, fundus, body, antrum, pylorus
-longitudinal muscle coat, circular muscle coat
-oblique muscle coat (allowed for churning)
-rugae- ridges-> allows for expansion
nerve innervation to stomach
-sympathetic -> T6-T9- sympathetic trunk from celiac plexus and greater splanchnic nerves
-parasympathetic -> vagus
major duodenal papilla
-bile and pancreatic duct
-sphincter of oddi
-opens into small ampulla in duodenal wall -> hepatopancreatic ampulla (ampulla of Vater)
jejunum vs ilieum
-jejunum- wider, thicker, redder (more vascular), shorter overall (8)
-ileum- longer (12)
VASA RECTA / ARCADES
-jejunum has longer vasa recta and less arcades
-ileum shorter vasa recta and more arcades
cecum
-no mesentery
-completely covered with peritoneum
transverse colon
-phrenocolic ligament - binds to diaphragm on left
-most mobile
incontinence
-anal rectal flexor- maintained by contraction of puborectalis muscle
-weakening -> 80 angle changes -> incontinence
-valves of Houston (transverse folds)- hold stool up
rectum portal hypertension
-not to be confused with hemorrhoids
pectinate line
-above is painless- visceral - autonomic -> sensitive to stretch
-below is painful - somatic
absorption of nutrients
-duodenum- iron
-ileum- B12, bile salts
triangle of calot (cystohepatic triangle)
-stones obstruct cystic duct
-stone can pass into small bowel
-cystic or common bile duct or in gal bladder
-where the hepatic ducts and neurovascular structures enter/exit the liver
-located at the porta hepatis of the liver
-accessory ducts etc. here that need be to removed first
-where gal bladder is removed
pancreatic cancer
-retroperitoneal
-caught late
-back pain
-painless jaundice
-bile duct obstruction
-symptoms free often bc retroperitoneal
ischemic colitis: watershed areas
-intestinal ischemia due to hypoperfusion / occlusion from most distal arteries
-griffith’s point- marginal artery at splenic flexure
-sudeck’s point- rectosigmoid junction (inferior and hypogastric arteries)
-MC SMA
-intense pain, tenesmus, bloody stool, gas
-aortic surgery (clamping off blood), hypertension, diabetes, a fib
diverticulosis
-large and small intestine
-MC in sigmoid due to smaller diameter = higher pressure -> laplace law
-painless
-areas of weakness - where blood vessels traverses muscle layer
-most people have this
-asymptomatic - sometimes blood in stool
-where vasa recta penetrate circular layer in colon (weakness) -> bleeds
diverticulitis
-LLQ
-diverticulum tears and causes inflammation and infection
-ruptured diverticula can cause fistula with bladder -> air in poop and bladder
-constipation, gas, low grade fever
-drain abscess - IV antibx
hiatal hernia: sliding
-esophagus and stomach slides through diaphragm
-esophagus, cardia, and part of fundus can go through
-common if pt bends down or lays down
-regurgitation of stomach contents into esophagus -> reflux
-aggravated by weight gain -> pushes things up
-GERD
hiatal hernia: paraesophageal
-widening of opening where esophagus goes through diaphragm
-stomach goes through
-esophagus doesnt move
-no regurgitation -> cardia is in place
-more dangerous -> can cause strangulation
-painful
-surgery usually indicated
-GERD
incisional hernia
-omentum through surgical incision
gallstones
-MC site hepatopancreatic ampulla
-epigastric pain -> hypochondriac region 9th rib lateral border of rectus sheath -> right shoulder (diaphragm irritation)
-cholecystitis- stone blocks gallbladder causing inflammation -> bile accumulation causes enlargement
-cholecystectomy
cholangitis
-infection of gallbladder due to blockage in bile duct
-Charcot’s triad - RUQ pain, fever,
jaundice (yellowing of skin, eyes)
-tube cholecystectomy (to drain
fluid out of the gallbladder
pancreatitis
-Epigastric pain
-radiates to back
-Pain relieved on positional changes
(relieved with leaning forward)
-MCC - alcohol abuse or gallstones
-fever, tachycardia, nausea, vomiting
-Acute onset
-Elevated serum LIPASE
-Hypocalcemia - chvosteks and
trousseau sign
pyloric stenosis
-Baby
-Projectile Vomiting
-Pylorius (sphincter that allows food
to pass from stomach → intestine) is
stenosed (or narrowed)
-Due to thickened muscle
-food cannot empty into duodenum
→ goes back into esophagus →
vomit
innervation and blood to ureters
-renal and hypogastric plexuses, gonadal nerve
-symp- decrease; parasymp- increase
-stimulated by stretch receptors
-arterial supply- proximal ureter- renal artery
-middle ureter- ovarian/testicular artery
-distal ureter- superior vesical artery
kidney layers
-fibrous capsule
-perirenal fat- around vessels too
-renal capsule- around adrenal gland and continuous with transversalis fascia -> infection spreads to abdomen
-pararenal fat- lion
lobar artery
-end artery -> cut this and cuts off everything distal
-each segmental artery supplies its own segment -> preserves the kidneys
sympathetic innervation to kidney
-regulate blood flow and pressure
-stimulate renin release
-stimulate sodium and water reabsorption
suprarenal glands
-endocrine- cortex and medulla
-cortex steroid hormones- aldosterone (Na, K, H2O), cortisol (glucose metabolism, immune), androgens (male sexual development)
-medulla -epinephrine and norepinephrine
ureters
-25cm
-smooth muscle
-3 constrictions:
-renal pelvis meets the ureter
-at the pelvic brim- at bifurcation of common iliac arteries
-at junction with the bladder
bladder
-500cc
-covered in peritoneum (retroperitoneal)- endopelvic fascia surrounds
-apex- highly distensible, covered in the extraperitoneal fat, connected to umbilicus via median umbilical ligament
-neck is anchored by puboprostatic (males) pubovesicula (females) ligaments
-rugae (except trigone)
-2 ureteric and 1 internal urethral orifice
-detrusor muscle surrounds orifices to prevent backflow
-vesicular arteries and veins
bladder innervation
-inferior hypogastric plexus
-sympathetic (L1-L2 lumbar ganglia):
-inhibit contraction of detrusor
-stimulates contraction of urethral sphincter
-parasympathetic fibers (splanchnic nerves from S2-S4):
-stimulates contraction of detrusor muscle
-inhibits action of urethral sphincter
male urethra
-prostatic- widest, distensible, crest, sinus (prostatic ducts), prostatic utricle (ejaculatory duct)
-intermediate (membranous)- least distensible, shortest, external urethral sphincter
-spongy- bulbourethral glands
-external meatus- fossa terminalis (navicular fossa)
innervation to spongy urethra and external sphincter (male and female)
-external sphincter has voluntary control via perineal branch of pudendal nerve (S2-S4)
-dorsal nerve of penis (branch of pudendal) provides somatic innervation to spongy urethra (S2-S4)
kidney stone
-pain- T10-L2
-lion to groin
-pts move around a lot (sitting still is uncomfortable)
-visceral afferent fibers conveying pain sensation to CNS
-pain caused by distention of lumen of ureter
-stone pressure -> increase lumen size -> renal colic
-pain can extend from lower lumber, inguinal region, external genitalia, inner thigh -> all same T10-L2 innervation
-4ml can pass usually
-5ml cant
perinephric abscess
-renal fascia determine path of extension of abscess
-pus from abscess (or blood) may force its way into pelvis between loosely attached anterior and posterior layers of pelvic fascia
-can spread to abdomen bc renal fascia is continuous to transversalis
-occurs due to bacterial infection in the perinephric fat and fascia
-renal fascia towards anterior -> Gerota’s fascia
-can extend to Gerota’s fascia, the abdominal cavity, and the pelvis
-ex. fascia at renal hilum firmly attaches to renal vessels and ureter -> preventing spread of pus to contralateral side
polycystic kidney disease
-cysts in kidney
-1 or many
-common, unknowingly
-adult polycystic disease- important cause of renal failure
-inherited autosomal dominant trait- enlarged and distorted by cysts as large as 5
cm
nephrolithiasis
-kidney stones
-calcium oxalate or calcium phosphate- high calcium -> MC
-uric acid stones- gout (excessive protein)
-cystine stone- defect in amino acid (metabolism)
-struvite stone- associated with infection -> can become enlarged and take on the shape of the calyces
-renal pelvis stone- asymptomatic, no obstruction
-in the ureter- stretch, pain
-bladder stones- chronic bladder irritation, can bounce around for a while until drains into urethra, painful
-dx tool- strainer -> obtain stone -> labs -> identify stone type -> treat
iatrogenic injury to ureters
-ligation of gonadal vessels- ovary- pelvic brim
-ligation of uterine vessel- hysterectomy (water under bridge)
-dissection of bladder/vagina
-pelvic dissection- lymph node removal
-identify ureter!!!
cystocele
-prolapse bladder
-grade 1 (mild)- bladder drops only a short way into vagina
-grade 2 (moderate)- bladder drops to opening of vagina
-grade 3 (severe)- bladder bulges through opening of vagina
-can happen with pudendal nerve injury, child birth
-can cause uti, incontinence
addison’s disease
-do not produce enough hormones cortisol and aldosterone
-autoimmune disorder
-darkened skin
-frail and weak
-low temp
-amenorrhea
-fatigue
cushing’s disease
-high levels of cortisol
-long term use of corticosteroid medications, tumors in pituitary gland or adrenal adenomas
-long term prednisone
-Rosey cheek
-moon face
-purple/red striations on butt/back- from weight gain
-buffalo hump- fat pad on back
male vs female pelvis
-Adult male pelvic girdle:
-thicker and heavier
-greater pelvis is deeper
-lesser pelvis is narrow and deep
-pelvic inlet (superior pelvic aperture)- heart shaped
-pelvic outlet (inferior pelvic aperture)- comparatively small
-pubic arch and subpubic angle (degree)- narrow (<70 degrees)
-obturator foramen- round
-acetabulum- large
-Adult female pelvic girdle:
-thinner and lighter
-greater pelvis is shallow (child birth)
-lesser pelvis is wide and shallow
-pelvic inlet (superior pelvic aperture)- oval or rounded
-pelvic outlet (inferior pelvic aperture)- comparatively large
-pubic arch and subpubic angle (degree)- wide (>80 degrees)
-obturator foramen- oval
-acetabulum- small
pelvic floor muscles
-Levator Ani- Helps support pelvic viscera
-Coccygeus- Forms small part of pelvic diaphragm that support pelvic viscera, flexes coccyx
-Obturator internus- Laterally rotates hip, assists to hold femur in acetabulum
-Piriformis- Laterally rotates, abducts hip joint, holds femur in acetabulum
bulbourethral glands
-fluid production of mucous like secretion enters through urethra during arousal ->
-changes pH of urethra for fluid transmission-> alkaline
-1%
autonomic nerves of pelvis
-pelvis has 4 roots/routes
-sacral sympathetic trunks- sympathetic
-hypogastric plexuses- sympathetic
-pelvic splanchnic nerves- parasympathetic -> S2-S4
-periarterial plexuses- sympathetic
-symp- T11-L1 spinal
semen
-seminal vesicles- 70%
-prostate- 15-30% of semen
-seminiferous tubules in testes creates sperm
uterus / ligaments
-perimetrium, myometrium, endometrium
-broad ligament- lateral support
-ovarian and round- fetal
-suspensory- conveys ovarian vessels, lymphatic and nerves that goes to ovary
-no peritoneum between cervix, inferior uterus, and bladder -> cancer spreads
-mesosalpinx- carry uterine tubes
-mesovarium- carry ovary
-mesometrium
muscles of perineum
-external anal sphincter muscle
-bulbospongiosus
-ischiocavernosus
-superficial transverse perineal
-deep transverse perineal
-external urethral sphincter
-pelvic outlet passes through perineum
anal/urogenital triangle
-anterior ends of ischial tuberosities
perineal fascia
-2 layers:
-subcutaneous tissue of perineum = superficial perineal fascia -> consists of superficial fatty layer and membranous layer (colles fascia)
-deep perineal fascia
-superficial fatty is continuous with campers in females -> replaced with scrotum, dartos muscle in males
-colles fascia is continuous with scarpas fascia
-deep perineal fascia -fused to suspensory ligament of penis or clitoris
-continuous with deep fascia covering the external oblique of the abdomen and rectus sheath
deep perineal pouch
-fat filled anterior recesses of the ischioanal fossa
-contains in both genders -> part of urethra and external urethral sphincter muscles
-urethra traverses
epididymis
-stores and transports sperm form testes to vas deferens
deep fascia of the penis
-bucks fascia
continuation of deep perineal fascia that forms membranous covering of the corpora binding them together
-suspensory ligament of penis binds this to pubic symphisis
internal oblique / cremasteric muscle
-muscle that enters spermatic cord
-Cremasteric Reflex -stroke inside of thigh -> testes rise -> shows damage to cord
ischiocavernosus and bulbospongiosus muscle
few muscles of the penis (otherwise has none)
laminae of vagina
-medial- form frenulum
-lateral- form prepuce
-minora connect posteriorly by transverse fold -> frenulum of labia minora (fourchette)
erection
-veins cant drain
-corpus cavernosum
fornix
refers to the anterior (front) and posterior (back) recesses into which the upper vagina is divided. These vault like recesses are formed by protrusion of the cervix into the vagina.
