Abdominal anatomy Flashcards
1
Q
At what vertebral level does the abdominal aorta bifurcate?
A
L4 lower border
2
Q
Name the anterior unpaired branches of the abdominal aorta
A
Coeliac trunk (Lower border T12)
SMA (L1)
IMA (L3)
3
Q
At what vertebral level does the coeliac trunk arise?
A
T12 lower border/Upper border L1
4
Q
Which visceral organs do the branches of the coeliac trunk supply?
A
Supplies the foregut. Abdominal oeshagus, liver, gallbladder, spleen, stomach, proximal duodenum (up to second part), part of the pancreas
5
Q
Name the major branches of the coeliac trunk
A
Left gastric artery
Common hepatic artery
Splenic artery
6
Q
At what vertebral level does the SMA arise?
A
Lower border L1
7
Q
Name the branches of the SMA
A
-Inferior pancreaticoduodenal artery (anterior and posterior)
-Intestinal (jejunal and ileal branches
-Middle colic
-Right colic
-Ileocolic
8
Q
Which structures are supplied by the branches of the superior mesenteric artery?
A
Midgut
-Distal to 2nd part duodenum
-DJ flexure
-Head of pancreas
-Jejunum
-Ileum
-Caecum
-Appendix
-Axcending colon
-2/3rd transverse colon
9
Q
At what vertebral level does the IMA arise?
A
L3 lower border
10
Q
Name the major branches of the inferior mesenteric artery
A
-Left colic
-SIgmoidal
-Superior rectal
11
Q
Which structures are supplied by branches of the IMA?
A
Hindgut
-distal 1/3rd of transverse colon, descending and sigmoid colon, superior rectum
12
Q
At what vertebral level do the paried renal arteries arise?
A
L1-2
13
Q
Name the paired arteries of the abdominal aorta
A
-Inferior phrenic (T12)
-Middle suprarenal (T12)
-Lumbar arteries (L1-L4)
-Renal arteries (L1-2)
-Gonadal arteries (L2)
14
Q
What is an arterial aneurysm?
A
-A localised abnormal dilatation of an artery to >1.5x its normal size.
-True aneurysm involves all 3 layers of the vessel
15
Q
Howe do you define a true and a false aneurysm
A
-True aneurysm involves all 3 layers of the vessel
-False aneurysm is characterised by breachg in vessel wall, blood is contained by adventitia. Direct communication exists between vessel lumen and aneurysm, resulting in higher risk of rupture
16
Q
What are the indications for elective repair of an abdominal aortic aneurysm?
A
-Size >5.5cm if asymptomatic
->4.5 if increased by more than 0.5cm in last 6 months
-Symptomatic aneurysms <4.5cm should be followed up with USS every 6 months, aneurysms 4.5-5.5cm should be followed up every 3-6 months
17
Q
Describe how abdominal aortic aneurysms can be anatomically classified?
A
-Suprarenal
-Juxtarenal
-Infrarenal
Can also be classified according to shape (saccular or fusiform)
18
Q
What are the common interventional options for AAA?
A
-Open repair
-EVAR
19
Q
Describe the blood supply to the liver
A
Liver receives blood from two sources: Portal vein (80%) and hepatic artery (20-30%)
–> Hepatic artery provides oxygenated blood from aorta
–> Portal venous blood is oxygen poor but nutrient rich from GI tract–> hepatic sinusoids
20
Q
Describe the vascular segments of the liver
A
-Liver is divided into 8 segments based on branches of hepatic artery, hepatic vein and hepatic duct
-Each segment has its own branch of hepatic artery/portal vein and is drained by branch of bile duct
-Hepatic veins run between the segments and drain them
-Left lobe has segments 1-4, right lobe has segments 5-8
21
Q
What is the function of the hepatic veins?
A
-Run between segments and drain adjacent segments.
-Drain into IVC just below diaphragm
22
Q
Why are the vascular segments of the liver clinically significant?
A
-Lobectomy can be carried out without excessive bleeding
-Individual segments can be removed alone
23
Q
Describe the ligaments of the liver
A
Falciform ligament
–> connects anterior liver to anterior abdominal wall
–> encloses round ligament in its free edge
Round ligament
–> remnant of umbilical vein (carries nutrient rich/oxygenated blood from placenta to the foetus
–> Joints ligamentum venosum (ductus venosus in fetus–> allows umbilical blood from placenta to bypass liver and drain directly into ivc)
Coronary ligament
–>Reflections of peritoneum onto the diaphragmatic surface of the liver
–> meet on right and left lobes to form the triangular ligaments
–> Enclose the bare area on the right side
–> has anterior and posterior layers: anterior layer is continuous with falciform ligament, posterior layer continuous with lesser omentum
24
Q
What is the bare area of the liver?
A
-Part of the liver on right lobe not covered by peritoneum as it is in direct contact with the diaphragm
-Enclosed by anterior and posterior layers of the coronary ligament
25
What are the porto-systemic anastamoses
-Communications between portal venous system and systemic venous system
-Normally these channels are not open, but they can open in portal hypertension causing engorgement of portal veins and subsequent bleeding
26
Name some anatomical sites of porto-systemic anastamosis
Rectal
--> Portal: superior rectal vein --> IMV
--> Systemic: Middle and inferior rectal veins
Oesophageal
-Portal: Oesophageal branches left gastric vein --> splenic vein
-Systemic: Oesophageal branches left azygous
Retroperitoneal:
--> Portal: colic veins
--> Systemic: retroperitoneal veins
Paraumbilical
--> Portal: portal veins of liver
--> Systemic: Veins of anterior abdominal wall
27
What is the management of acute oesophageal variceal bleeding?
-ALS protocols
-A-E, resuscitation
-Terlipressin
-Endoscopic banding
-TIPS if endoscopic banding unsuccessful
-Sengstaken blakemore tube to temporise prior to endoscopy or between failed banding and TIPS
28
29
30
31
32
(RS) describe the surface anatomy of the liver
Line between 4th space midclavicular line
33
(RS) Describe the course of the portal vein
-Originates from confluence of SV and SMV
-Runs in free edge of lesser omentum, passes through foramen of wilmslow
-Receives tributaries from gastric veins, cystic vein
-Divides into left and right
34
Describe the borders of the inguinal canal
-Anterior: external oblique aponeurosis, reinforced by fibres of internal oblique lateral 1/3rd
-Posterior: Transversalis fascia, conjoint tendon medial 1/3rd
-Superior: arching fibres of internal oblique and transversus abdominis
-Inferior: Inguinal ligament, lacunar ligament medial 1/3rd
35
Where is the superficial ring located?
Defect in external oblique, superolateral to pubic tubercle. 'Exit' from inguinal canal
36
Where is the deep ring located?
-Defect in transversalis fascia
-~ 1.5-2cm above midpoint of inguinal ligament (midway between pubic tubercle and anterior superior iliac spine)
-'Entrance' to canal
37
What are the contents of the inguinal canal?
-Round ligament in females
-Spermatic cord
-Ilioinguinal nerve
38
What are the contents of the spermatic cord?
3 fascia
-External spermatic fascia (external oblique aponeurosis)
-Cremasteric fascia (Internal oblique aponeurosis)
-Internal spermatic fascia (Transversalis fascia)
3 nerves
-genital branch genitofemoral nerve
-Sympathetic fibres
-ilioinguinal nerve (lies outside spermatic cord)
3 arteries
-Cremastic artery
-Testicular artery
-Artery to vas deferens
3 other things
-Pampiniform plexus of veins
-Vas deferens
-Lymphatics
39
What is the difference between a direct and an indirect inguinal hernia?
-Direct: Does not enter inguinal canal, occurs as weakness within transversalis fascia. Lies above and medial to pubic tubercle
-Indirect: passes through deep ring to enter inguinal canal. Lies within inguinal region or in scrotum
40
Name the boundaries of hasselbach's triangle
Lateral: inferior epigastric arteries
Medial: lateral border of rectus abdominis
Inferior: inguinal ligament
41
Describe the relationship of direct and indirect hernias in relation to hasselbach's triangle
Direct hernia lies medial to inferior epigastric, protruding into hasselbach's triangle
Indirect commences lateral to inferior epigastric artery
42
Describe where femoral hernias occur in relation to the pubic tubercle
Below and lateral to pubic tubercle
43
What is the femoral canal?
-Most medial compartment of the femoral sheath
-Femoral canal extends from femoral ring proximally to level of saphenous opening distally
44
Describe the contents of the femoral canal
-Fat
-Lymphatics
-Cloquet's node
45
Describe the borders of the femoral ring
-Anterior: inguinal ligament
-Posterior: pectineal ligament overlying superior ramus of pubis
-Medial: lacunar ligament
-Lateral: femoral vein
46
What are the indications for repair of inguinal hernia?
Elective repair
-Symptomatic
-Asymptomatic to prevent complications
Emergency repair:
-Obstruction
-Strangulation
-Incarceration
47
Describe the regions of the anterior abdominal wall
Abdomen is divided into 9 regions by 4 lines:
-1st horizontal line: Transpyloric plane (corresponds to 9th costal cartilage/L1 vertebral body)
-Transtubercular planes (joining iliac tubercles, corresponds to lower border L4 body, upper border L5 body)
-Midclavicular planes: 2x vertical lines joining midinguinal points and middle of clavicle
-Right and left hypochondrium
-Epigastric region
-Right and left flank
-Umbilical region
-Left and right iliac fossa
-Pubic region
48
At what vertebral level does the umbilicus lie?
In a flat and muscular abdomen, umbilicus lies at L4 level. This can vary in a pendulous abdomen
49
At what vertebral level does the transpyloric plane lie?
Midway between suprasternal (jugular) notch and pubic symphysis. Usually corresponds to lower border L1
50
Name some important anatomical structures which frequently lie on the transpyloric plane
Right to left:
1. Upper pole of right kidney
2. Right and left colic flexures
3. Fundus of the gallbladder
4. Head of the pancreas
5. Pylorus of the stomach
6. 2nd part of the duodenum
7. Formation of portal vein by joining of SMV and Splenic vein
8. DJ flexure
9. Origin of SMA from aorta
10. End of spinal cord in adults
11: hilum of spleen
12: hilum of left kidney
51
Name the layers of abdominal wall you would go through when performing an open appendicectomy
Skin
Subcutaneous tissue
Camper's fascia
Scarpa's fascia
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Parietal peritoneum
52
Name the two vertical muscles of the anterior abdominal wall
The two vertical muscles of the anterior abdominal wall are both contained within the rectus sheath. They are the:
-Rectus abdominis
-Pyramidalis
53
What are the contents of the rectus sheath?
Rectus abdominis
Pyramidalis
Superior and inferior epigastric arteries and veins
Ventral rami of T7-T12 nerve roots
Lymphatics
Fibro-fatty connective tissue
54
Describe the arterial supply to the anterolateral abdominal wall
Internal thoracic
--> superior epigastric artery
External iliac
--> inferior epigastric artery
--> Deep circumflex iliac artery
Femoral artery
-->Superficial circumflex iliac
--> Superficial epigastric
55
Describe location at which spigelian hernia occurs:
-Also known as a lateral ventral hernia
-Herniation through the aponeurotic layer between the rectus abdominis medially and the linea semilunaris laterally
-Linea semilunaris is aponeurotic layer which corresponds with border of rectus abdominis laterally
56
Name the layers you would go through when performing a midline laparotomy
Skin
Subcutaneous tissue
Camper's fascia
Scarpa's fascia
Linea alba
Transversalis fascia
Preperitoneal fat
Parietal peritoneum
57
Describe the blood supply to the stomach
Blood supply is derived from coeliac trunk
Lesser curvature:
--> right gastric artery (from common hepatic artery)
--> Left gastric artery (Hepatic artery proper)
Greater curvature:
--> Left gastro-epiploic artery (from splenic artery
--> right gastro-epiploic artery (from gastroduodenal artery)
Fundus and posterior:
--> short and posterior gastric arteries (from splenic)
58
Branches of common hepatic artery
Common hepatic
--> gastroduodenal (then continues as hepatic artery proper)
Hepatic artery proper
--> right gastric (terminates in right and left hepatic)
Right hepatic
--> cystic
59
Name the vessels that an ulcer in the lesser curve of the stomach may erode into
-Right and left gastric arteries
60
What is the lesser sac?
-Area of peritoneal cavity situated in upper abdomen
-Lies posterior to lesser omentum, stomach and associated structures
61
Name the borders of the lesser sac
Anterior
-Quadrate lobe, lesser omentum, posterior stomach, Gastrocolic ligament
Superior
-Superior recess lies behind caudate lobe of the liver
Inferior:
-Inferior recess lies between layers of the greater omentum (superior part)
Posterior:
-Pancreas, left kidney, left adrenal
Right:
-Epiploic foramen (of wilmslow)
Left
-Gastrosplenic
-Lienorenal
62
What is the epiploic foramen?
-Opening through which the lesser sac communicates with the greater sac
63
Name the boundaries of the epiploic foramen
Anterior: Free edge of lesser omentum enclosing CBD/Hepatic artery/portal vein
Inferior: 1st part duodenum
Posterior: IVC and right crus of diaphragm
Superior: Caudate lobe of the liver
64
What are the boundaries of Calot's triangle?
Superior: inferior border of liver
Lateral: Cystic duct
Medial: hepatic duct
65
What is pringle's maneuver?
Compression of the hepatic artery and portal vein between the index finger in the epiploic foramen and the thumb anteriorly, to prevent liver haemorrhage, usually secondary to trauma
66
Describe what layers you would go through when performing an open cholecystectomy
Skin
Subcut tissue
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Parietal peritoneum
67
Why is the anatomy of the second part of the duodenum clinically significant?
-Main pancreatic duct and common bile duct open into the small bowel here
-Site of embryological transition between foregut and midgut
68
Describe the blood supply to the duodenum
-Up to the second part duodenum is supplied by superior pancreaticoduodenal artery from the gastroduodenal artery
-Beyond the second part duodenum is supplied by the inferior pancreaticoduodenal artery from the SMA
69
Name the artery into which an ulcer in the posterior duodenum can erode?
-Gastroduodenal artery-close proximity to 1st part of the duodenum
70
Describe the male urethra
Pre-prostatic urethra
-->vertical course from bladder to prostate
Prostatic urethra
--> Widest part of urethra
--> Contains urethral crest with prostatic sinuses on both sides, seminal colliculus centrally
Membranous urethra
-->Narrowest part of urethra
--> surrounded by external urethral sphincter
--> bulbourethral glands posteriorly
Spongy urethra
-->Longest part of urethra
-->Bulbourehtral glands empty into it proximally
--> Has two expansions: intrabulbar fossa in bulb of penis, navicular fossa in glans
71
Why is understanding of bladder anatomy important in suprapubic catheterisation?
-When empty, bladder is tetrahedral in shape, with apex anteriorly and body between apex and fundus
-Fundus meets remaining surfaces of bladder at the bladder neck
-As it fills with urine, it extends superiorly betrween rectus abdominis and peritoneum but without entering peritoneal cavity
-Therefore in normal patient suprapubic catheterisation can be performed safely extra-peritoneal
-However in pt with previojs abdominal surgery, adhesions can cause loop of bowel to lie anterior to bladder
72
Describe the relations of the bladder in the male
Superior: peritoneum
Inferior: pubic bones, obturator internus, levator ani
Fundus: rectum
Bladder neck: prostate, with seminal vesicles posteriorly
73
Describe the blood supply to the bladder
Branches of the anterior division internal iliac
Males:
--> superior vesical artery (superior)
--> inferior vesical (inferior)
Females:
--> superior vesical (superior
--> vaginal (inferior)
Contributions also from obturator and inferior gluteal arteries
74
Describe the layers of the bladder
In to out:
-Mucosa (transitional cells)
-Lamina propria
-Detrusor muscle
75
Where are the seminal vesicles located?
-Between the fundus of the bladder and the rectum, superior to the prostate
note: above the seminal vesicles is a fold of peritoneum: the rectovesical pouch
76
Describe the lobes of the prostate
Anterior lobe: Anterior to urethra
Posterior lobe: Posterior to urethra (part palpated during DRE)
Lateral lobes: form bulk of prostate
Median lobe: between urethra and ejaculatory ducts, close to bladder neck
77
Where do most prostate cancers occur?
Lateral lobe
Peripheral zone
78
What are the zones of the prostate?
Peripheral zone--> lateral lobe
Central zone --> median lobe (close to ejaculatory ducts)
Transitional zone --> surrounding prostatic urethra (where BPH is most common)
79
What is the most common prostatic malignancy?
Adenocarcinoma (75% occur in peripheral zone of the prostate)
80
Describe the gleason staging system for adenocarcinoma
-Cancer is microscopically graded 1-5 according to differentiation (1 is well differentiated, 5 is poorly differentiated)
-Prostate cancers tend to be multifocal: therefore the most common is given a primary grade, and the next most common a secondary grade.
-If there are 3 patterns, the dominant pattern is the first number, and the second is the highest grade
81
How does prostate cancer metastasise?
-Local invasion is perineural, following the autonomic nerves
Other sites:
-->via lymphatic channels to sacral, iliac and para-aortic nodes
--> haematological to bone (pelvis, femur, vertebra) and distant viscera: liver, lungs
82
Describe the location of the umbilical peritoneal folds
One peritoneal fold is located in the midline: median umbilical fold
One peritoneal fold either side (medial and lateral umbilical folds)
83
What is the median umbilical fold?
Ridge of peritoneum covering the median umbilical ligament, which is the remnant of the urachus (connected the bladder to the umbilicus in foetal life)
84
What are the medial umbilical folds?
peritoneal coverings over the medial umbilical ligaments, which are remnants of the occluded foetal umbilical arteries
85
Name the structure which lies in the lateral umbilical fold
Inferior epigastric vessels
86
What is an intraperitoneal organ?
Organ almost entirely covered in visceral peritoneum
87
Name the intraperitoneal organs
-Stomach, first and 4th parts of duodenum
-DJ flexure, jejunum, ileum
-liver, spleen, tail of pancreas
-transverse colon, sigmoid colon, upper 1/3rd of rectum
88
What is the difference between a primarily and secondarily retroperitoneal organ?
Primarily: developed in retroperitoneum
Secondarily: Initially intraperitoneal, developed suspended by a mesentery. Became retroperitoneal when mesentery fused with peritoneum. Covered on anterior surface only by peritoneum.
89
What are the retroperitoneal organs?
Primarily:
-Kidneys
-Adrenal glands
-IVC
-Aorta
-Oesophagus
Secondarily
-2nd and 3rd parts duodenum
-Ascending and descending colon
-Pancreas (exceept tail)
-Middle 1/3rd of rectum
90
What is morrison's pouch and why is it clinically significant?
-Right hepatorenal space
Boundaries
-Anteriorly: liver and gallbladder
-Posteriorly: posterior abdominal wall and kidney surrounded by Gerota's fascia
-Inferiorly: duodenum
Clinical significance: most dependent part of the abdomen, collections can accumulate here
91
Name the infraperitoneal/subperitoneal organs
-Lower 1/3rd of the rectum
-Distal ureter
-Urinary bladder
92
Describe the embryological development of the testes
-Develop in superior posterior abdominal wall, extraperitoneally, from where they descend to the region of the inguinal canal later in foetal development, before reaching scrotum around the time of birth
-Therefore, this is the path along which an undescended testicle may lie
-Undescended testes commonly lie at the level of the superficial ring/inguinal canal
93
What is cryptorchidism?
Cryptorchidism is the absence of one or more testis from the scrotum
Note: a retractile testis is a testicle which can be brought into the scrotum with manipulation, but retracts spontaneously or with gentle pressure
94
Name some causes of cryptorchidism
Agenesis
Intra-abdominal arrest
Incomplete descent
Ectopic descent
95
What is the difference between orchidopexy and orchidectomy?
Orchidopexy is a procedure to bring and fix an undescended testicle into the scrotum
Orchidectomy is the surgical removal of one or both testicles
96
Name some indications for orchidopexy
-Treatment of testicular torsion (usually during adolescence)
-Cryptorchidism (usually in children)
Orchidopexy is performed to reduce risks of infertility, testicular malignancy, traumatic injury to the testis, development of inguinal hernia, testicular torsion in adolescents and to maintain appearance of normal scrotum
97
What is a varicocele
Dilatation of the pampiniform plexus of veins
98
Where do the left and right testicular veins drain?
Left testicular vein: left renal vein
Right testicular vein: IVC at a more oblique angle. Therefore left sided varicoceles are more common
99
What is a hydrocele?
A hydrocele is a collection of fluid in the tunica vaginalis, the double layer of peritoneum that invests the testes.
Hydroceles can be primary (idiopathic) or secondary
100
Name some differential diagnoses for scrotal swellings
-Epididymal cyst
-Sebaceous cyst
-Testicular malignancy
-Epididymo-orchitis
-Inguinal hernia
-Hydrocele
-Varicocele
101
Describe the course of the ureter
-Originates at renal pelvis
-Runs anterior to transverse processes of L1-L5 towards SI joint
-Enters pelvis at bifurcation of common iliac vessels (at pelvic brim) then courses anterior to internal iliac down lateral pelvic sidewall
-Enters bladder posterolaterally at level of ischial spine, courses in wall for 1-2cm before opening into bladder at internal ureteric orifice
102
Name the vessel that crosses the ureter as it enters pelvic brim
External iliac artery
103
Describe the relationship of the ureter to the uterine artery in the female pelvis
Ureter passes beneath the uterine artery, lateral to the cervix
In males passes beneath the ductus deferens as the ductus courses along lateral wall of pelvis
104
Describe how you would quickly identify the ureter during intra-abdominal surgery
-Courses along sacroiliac joints
-Crosses external iliac just distal to iliac bifurcation
-Lies medial to internal iliac on posterolateral pelvic sidewall
-visible peristalsis
105
Name the constrictions of the ureter
Pelviureteric junction
Pelvic brim
VUJ
106
Describe the blood supply to the ureter
Segmental supply from 4 sources:
-Renal
-Gonadal
-Internal iliac
-Superior and inferior vesical
107
What type of epithelium lines the ureter?
Transitional epithelium
108
What serious complication can arise following ureteric obstruction?
-Hydronephrosis and renal dysfunction
-Drainage of the kidney is usually required via percutaneous nephrostomy or retrograde ureteric stenting
109
Describe where ureteric calculi may be identified on a plain radiograph of the kidney, ureters and bladder (XR KUB)
Course of the ureter can be correlated with bony anatomy visible on a plain film radiograph
--> Passing inferiorly over tips of transverse processes of lumbar vertebrae
--> Passing over SI joint to level of ischial spines then turning medially to enter bladder
110
Name the most common type of ureteric stone (by composition)
Calcium oxalate (85% of stones)
111
Name the type of stone (by composition) that is most commonly responsible for staghorn calculi
Struvite (can also be calcium oxalate or uric acid)
112
Name the radiolucent stone that occurs in acidic urine
Urate stones
113
Other than calculi, name some other causes of unilateral hydronephrosis
Intrinsic:
-Stricture
-TCC renal pelvis/ureter
Extrinsic
-Tumour (colonic, cervical, prostatic)
-Abnormal vasculature at PUJ
-Retroperitoneal fibrosis
-Post radiation fibrosis
-AAA
114
What are the functions of the pancreas?
Pancreas is an accessory digestive gland with both endocrine and exocrine function s
Endocrine:
-Insulin and glucagon are secreted by the islets of langerhans
Exocrine:
-Secretions from pancreatic acinar cells pass into pancreatic ducts and into duodenum
115
Describe the blood supply to the pancreas
Receives supply from coeliac trunk and superior mesenteric artery
Head:
-Superior pancreaticoduodenal: (common hepatic --> gastroduodenal)
-Inferior pancreaticoduodenal: From SMA
Neck, body, tail:
-Branches from splenic artery which runs along superior pancreas
116
What are the posterior relations of the head of the pancreas?
-IVC
-Renal veins
-Right renal artery
-Bile duct lies on posterosuperior surface
117
Name the posterior relations of the body of the pancreas?
Aorta
SMA
Left kidney, renal vessels, left adrenal
118
Name the posterior relations of the tail of the pancreas
Left kidney
Hilum of the spleen
Left colic (splenic) flexure
119
What is the significance of the ampulla of vater?
-Marks transition from foregut to midgut
-Is formed by convergence of main pancreatic duct and common bile duct
-Empties via major duodenal papilla into second part of the duodenum
120
What is the most common type of pancreatic malignancy, where is it most commonly anatomically?
Adenocarcinoma
70% head
20% body
10% tail
Cancers in head of pancreas may present with obstructive jaundice due to close relation of head with bile duct. Cancers elswhere present late
121
Describe the relations of the spleen
Anterior: stomach
Posterior: Left part of diaphragm (separates it form rib 9-11 and lung)
Medial: left kidney
Inferior: Splenic flexure
122
What are the splenic ligaments?
Gastrosplenic ligaments
-hilum of spleen --> greater curvature of stomach
-Contains short gastric/left gastroepiploic vessels
Splenorenal ligament
-Runs from hilum of spleen to left kidney
-Contains splenic vessels
Splenocolic
-Spleen--> transverse colon
Splenophrenic
-Spleen--> diaphragm
123
Describe the course of the splenic artery
-Originates from coeliac trunk
-Passes along superior pancreas
-Anterior to left kidney
-Divides into 5 branches in splenorenal ligament and enters hilum
124
Describe how splenic injuries may be graded
-American association for the surgery of trauma (AAST) has produced grading system based on findings of CT
-Haematoma and laceratinos are graded from:
-Grade 1 (<10% subcapsular haematoma/<1cm capsular tear) to grade V (completely shattered spleen)
125
Describe the management of splenic injuries
-Isolated AAST 1/2 injury may be managed conservatively
3-5:
-Haemodynamically stable with signs of bleeding (dropping serial hb)--> IR +/- surgery
-If haemodynamically unstable: resuscitation and emergency laparotomy +/- splenectomy
126
What are current recommendations for post splenectomy prophylaxis?
Haemophilus influenza type b vaccine
Meningococcal group c vaccine
Pneumococcal vaccine
Antibiotics for minimum 2 years, preferably lifelong (oral pen v/clarithromycin if pen allergic)
Children: until minimum age 16 (as well as minimum 2 years and preferebly lifelong)
127
Describe the relations of the uterus
Anterior: Vesicouterine pouch, bladder
Posterior: recto-uterine pouch (of douglas) and rectum
Lateral: transverse cervical ligament, broad ligament, ureters
128
Describe the arterial supply to the uterus
-Predominantly from uterine artery (from internal iliac anterior division)
-Also from ovarian arteries (from abdominal aorta just inferior to renal arteries)
129
Describe the course of the internal iliac artery
-Originates at L5-S1 vertebral level at bifurcation of the common iliac artery anterior to sacroiliac joint
-Enters pelvis medial to external iliac vein and obturator nerve
-Terminates into anterior and posterior divisions superior to greater sciatic foramen
130
What territory is supplied by the anterior branch of the internal iliac artery
pelvic organs, muscles of pelvis, medial thigh, perineum
131
Name the branches of the anterior division of the internal iliac artery and the territory they supply
3 visceral, 3 parietal, 3 urinary
3 parietal
-Inferior gluteal
-Obturator
-internal pudendal
3 visceral
-Uternine
-vaginal
-MIddle rectal
3 urinary
-Superior vesical
-inferior vesical
-umbilical (foetal only)
132
Name the branches of the posterior division of the internal iliac artery and the territory they supply?
pILS
Iliolumbar
-Psoas major, iliacus, quadratus lumborum
Lateral sacral
-Piriformis, sacral canal, erector spinae
Superior gluteal
-Piriformis, gluteal muscles, tensor fascia lata
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Describe the broad ligament of the uterus
Double layer of peritoneum within which is folded:
-Uterine tube
-Ligament of ovary
-Round ligament of uterus
-Broad ligament helps fix uterus in place in the pelvis
-Peritoneum which forms broad ligament passes from uterus laterally to side walls + floor of pelvis
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Describe the course of the ovarian artery
-Branch of abdominal aorta, originating inferior to renal arteries
-Descends on posterior abdominal wall where it lies anterior to ureter and gives branches to it
-It then crosses external iliac close to its origin and enters pelvis, where it runs in suspensory ligament of ovary and broad ligament of uterus
-Terminates in branches to ovary and fallopian tube
135
Describe the relations of the vagina
Anterior: bladder and urethra
Supero-lateral: ureter
Posterior: ampulla of rectum, pouch of douglas, perineal body, anal canal
Inferiorly: anal canal is seprated from vagina by perineal body
Lateral: levator ani, uterine artery, urogenital diaphragm
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Which muscles form the pelvic floor?
Formed by 3 components of levator ani (pubococcygeus, iliococcygeus and puborectalis)
And coccygeus
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What are the origins of levator ani?
-Originates from posterior of body of pubis bone, spine of ischium, fascia covering obturator internus
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What are the attachments of the ligaments of the pelvis?
Sacrospinous ligament: Sacrum ischial spine
Sacrotuberous ligament: Sacrum ischial tuberosity
Sacrospinous ligament lies medial to and in front of sacrotuberous ligament
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-Obturator internus and piriformis arise within the pelvis and then exit pelvis via the sciatic foramina
Oburator internus arises from obturator membrane (covers obturator foramen)
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-They exit pelvis through sciatic foramina to insert onto the GT of the femur
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Describe the insertion of levator ani
-Pubococcygeus: forms sling around vagina in female, prostate in male. Inserts into perineal body
-Puborectalis: forms sling around rectum and anus, inserts into anal sphincter
-Iliococcygeus: coxxyx, ano-coccygeal ligament
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What is innervation to the pelvic floor?
Levator ani + coccygeus --> S3+S4 nerve roots
Perineal muscles, external urethral and anal sphincter --> pudendal nerve
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What is the origin of the pudendal nerve?
S2-S4
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What is the distribution of the pudendal nerve?
-Perineum, including perineal muscles and external urethral and anal sphincters
-Sensation to genitalia
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Pudendal nerve block
-Performed for childbirth
-Ischial spines can be palpated inside vagina between 4 and 8 o'clock
-Pudendal nerve passes behind sacrospinous ligament and is found 1cm anteromedial and 1cm posteromedial to ischial spine
-Can be accessed here for anaesthetic blockade
151
Describe orientation of structures in renal hilum vs lung hilum
Anterior to posterior:
-renal: VAP (vein, artery, pelvis)
-Lung: VAB (vein, artery, bronchus)
