Gross Exam II Flashcards by Carson Spornhauer

Q

What are the three major cavities and their lines of demarcation?

A

Thoracic- deep to rib cage above the diaphragm
abdominal - diaphragm to pelvic inlet
pelvic - pelvic inlet down

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Q

If you want to organize the abdomen into quadrants what are the two lines crossing the body?

A

vertically is the median plane from the xyphoid process to the pubic symphysis and horizontally is the transumbilical plane

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Q

What are the lines that divide the abdomen to make the 9 regions of the abdomen?

A

2 midclavicular planes (right and left), subcostal plane and intertubercular plane

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Q

What are the names of the 9 regions of the abdomen?

A

R & L hypochondrium
Epigastric region
R & L flank
Umbilical region
R & L groin
Pubic Region

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Q

What is the purpose of dividing the abdomen into 9 regions?

A

regions are important clinically for patients describing pain and for the viscera in the regions

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Q

From superficial to deep what are the layers of the anterolateral abdominal wall?

A

skin, campers fascia, scarpa fascia, external oblique muscle, internal oblique m., transversus abdominis m., transversalis fascia, extraperitoneal fat and finally parietal peritoneum
** all of the mm. have investing fascia

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Q

What is the difference in campers vs. scarpa fascia?

A

campers fascia is a fatty layer of subcutaneous tissue that is variable from person to person with vessels flowing throughout whereas scarpa fascia is a “thicker” membranous layer of subcutaneous tissue

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Q

What direction do the external oblique mm. fibers run?

A

superior/lateral to inferior/medial (hands in the pocket)

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Q

What direction do the internal oblique mm. fibers run?

A

90 degrees to the ext. oblique mm. fibers

inferior/lateral to superior/medial

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Q

What direction do the transversus abdominis mm. run?

A

same direction as the internal oblique mm. fibers (inf/lat to sup/med)

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Q

What muscles insert on the linea alba?

A

external oblique, internal oblique and transversus abdominis mm.
** all go into respective aponeurosis

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Q

What gives people the “6 pack” appearance?

A

the tendinous intersections between each of the rectus abdominis mm.

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Q

What mm. does the rectus sheath envelope?

A

rectus abdominus and pyramidalis mm. (superior to rectus abdominus but can’t see and perform same action)

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Q

Where is the line of demarcation in the rectus sheath?

A

arcuate line

**midway between the umbilicus and pubic symphysis

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Q

What is in the anterior and posterior layer of the rectus sheath SUPERIOR to the arcuate line?

A

anterior - ext. oblique and half the int. oblique aponeurosis
posterior - half int. oblique and transversus abdominus aponeurosis and transversalis fascia

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Q

What is in the anterior and posterior layer of the rectus sheath INFERIOR to the arcuate line?

A

anterior - EO, IO and TA aponeurosis

posterior - transversalis fascia

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Q

What is the median umbilical fold?

A

infraumbilical peritoneal fold in ant. abdominal wall
from urinary bladder to the umbilicus
covers the median umbilical ligament
remnant of the fetal urachus

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Q

what are the medial umbilical folds?

A

infraumbilical peritoneal fold in the ant. abdominal wall
covers the medial umbilical ligaments
occluded portions of umbilical aa.

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Q

what are the lateral umbilical folds?

A

infraumbilical peritoneal fold in the ant. abdominal wall

- covers the inferior epigastric vessels (**useful vessel)

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Q

What are the superficial arteries contained in campers fascia?

A

superficial circumflex illiac (inguinal ligaments) and superficial epigastric aa. (abdomen inferior to umbilicus)
-both comes from the femoral a.

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Q

What are the superficial veins contained in campers fascia?

A

superficial circumflex illiac (inguinal ligaments) and superficial epigastric vv. (abdomen inferior to umbilicus)
-both drains into the femoral v.

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Q

Where does the external illiac a. change its name?

A

passing under the inguinal ligament to the femoral a.

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Q

Deep circumflex illiac vessels

A

br. of external illiac
runs between the IO and TA
supplies inferior/lateral ab mm.
*veins and arteries similarly placed

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Q

Inferior epigastric vessels

A

br of the external illiac
enters the posterior rectus sheath at the arcuate line
supplies lower rectus abdominus mm.
anastomoses with sup. epigastric
*veins and arteries similarly placed

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Superior epigastric vessels

- br. of internal thoracic - enters the posterior rectus sheath lateral to the sternum - supplies upper rectus abdominus mm. - anastomoses with inf. epigastric * *veins and arteries similarly placed

Musculophrenic vessels

- br. internal thoracic - runs along the costal cartilages (under the costal cartilage) - supplies upper abdominal mm. and diaphragm * *veins and arteries similarly placed

What are the nerves of the abdominal wall?

ventral rami of spinal nn. T7-L1 | T7-9 (above umbilicus) T10 (at) and T11,12 and L1 (below umbilicus)

where do the nerves of the abdominal wall run?

between the inferior oblique and transversalis abdominus mm.

Injury to T11-L1 spinal nerve ventral rami can cause what?

-weakens the inguinal region and predisposes to developing direct inguinal hernias

what are the borders of the inguinal region?

* *inferior lateral abdominal region from the ASIS to the pubic tubercle - superior to thigh - medial to ilium - lateral to pubic bone

Inguinal ligament

- from ASIS to pubic tubercle | - formed by the folded inferior border of the external oblique aponeurosis

inguinal canal

- obliquely set tunnel - only 3-5 cm long - traverses (in to out) the abdominal wall - runs parallel, BUT superior to the inguinal ligament

Contents of the MALE inguinal canal

- spermatic cord (vas deferens, testicular nn and vessels, cremasteric m and fascia) - ilioinguinal n. (L1) --> supplies the upper medial thigh

contents of the FEMALE inguinal canal

- round ligament of the uterus | - ilioinguinal n. (L1)

abdominal hernia

- outpouching of abdominal viscera within a sac (usually intestines) - hernial sac composed of three layers: peritoneum, extraperitoneal fat and transversalis fascia - 90% of hernias occur here

Inguinal canal Rings composition and placement

deep ring- opening in the transversalis fascia (subtle piercing lateral to the inferior epigastric vessels superficial ring - opening in the EO aponeurosis (obvious triangle opening lateral to the pubic tubercle

The inguinal canal extends from what to what?

the deep ring to the superficial ring

Walls of the inguinal canal

anterior wall - EO aponeurosis posterior wall - transversalis fascia and the conjoint tendon roof - IO and TA mm. floor - inguinal ligament

conjoint tendon

fusion of the IO and TA aponeurosis medially onto the pubic tubercle

Indirect Inguinal hernia

- extends through ENTIRE inguinal canal (starts at the deep ring) - LATERAL to inferior epigastric vessels - commonly enters the scrotum or the labia majora - most COMMON type of hernia (more in males) - FROM the presistent processus vaginalis (males) and canal of nuck (females)

Direct Inguinal hernia

- thru inguinal triangle - MEDIAL to inferior epigastric vessels - more common in males - WEAKENED abdominal walls (T11-12, L1 nn.) - EMERGES at conjoint tendon or superficial ring

What is the inguinal triangle? (Hesselbachs)

inferior epigastric a., rectus abdominus m. and inguinal ligament

Femoral hernia

- thru the femoral ring/canal | - more common in females (because larger femoral ring)

Umbilical hernia

- thru umbilical ring - most common in newborns and obese patients - more common in females - umbilical pressure and the intestines leaving the abdominal cavity during fetal development cause this

Epigastric hernia

- thru the linea alba | - most common in obese and over than 40 patients

What is the most common type of hernia in males and females?

Indirect Inguinal hernia

Organs that are behind the peritoneum are called?

retroperitoneal

what are the two layers of peritoneum in the abdominal cavity?

parietal (lines inner abd. wall) and | visceral (covers organs)

describe peritoneum

thin, translucent, serous membrane

describe peritoneal sac

all visceral and parietal peritoneal membranes

describe peritoneal cavity

- potential space within the sac that contains some serous fluid - allows the organs to move freely (without friction)

Ascites

when the potential space in the peritoneal cavity becomes an actual space and can contain several liters of fluid (blood, bile, pus and feces)

What surrounds all of the anterior viscera?

Greater sac

What vessels travel between the peritoneal layers?

bile duct, hepatic artery proper, portal vein and gastric vessles

Greater omentum

- greater curvature to the transverse colon (4 layers of peritoneum) "gastrocolic ligament" - drapes over the small intestine like an apron - large fat stores, walls off infections and inflammation - if infected, can cause adhesions that restrict mobility

Lesser omentum

- from the lesser curvature of the stomach and duodenum to the liver - 2 ligaments together make the lesser omentum: hepatogastric and hepatoduodenal ligament

Portal triad

- contained in the hepatoduodenal ligament | - made up of hepatic a., protal v. and bile duct

Mesentery proper

- anchors most SI to the post. ab wall - runs diagonally from duodenal jejunal jxn to illiocecal jxn - 15-20 cm long

Suspensory ligament of Treitz

"duodenal ligament" - strong anchor to prevent the duodenojejunal jxn from sagging, separates the actions of the stomach and the SI (peristalsis) - fibromuscular ligament that descends from the right crus of the diaphragm and crosses the left to go to the distal duodenum

Mesocolon

- anchors parts of the colon to the posterior ab. wall - transverse and sigmoid mesocolon * *ascending and descending colon have no mesentery (attached directly to post wall)

Falciform ligament

- divides liver into Right and Left | - anchors liver ANTERIORLY to diaphragm and ant. body wall

Round ligament of the liver

inferior extent of the falciform ligament | -contains the obliterated umbilical vein

Coronary Ligament

- reflections of peritoneum around the bare area of the liver - attaches liver to the inf. surface of the diaphragm

bare area of the liver

upper posterior liver that does not have any peritoneum covering

peritoneal pouches

- potential spaces in standing patients - actual spaces in recumbent patients - pathological fluids can accumulate in these recesses (and possible spill over the pelvic brim into eachother)

Hepatorenal pouch

- bounded by liver, right kidney, colon and duodenum - lowest part of the peritoneal cavity when laying down - fluids can move from here to the retrovesical/retrouterine pouch when reclining or sitting up * * Pouch of Morrison

Rectouterine/rectovesical pouch

- low point of peritoneal cavity when recumbent - diff name in males vs. females - fluids may move up to the hepatorenal pouch when in trendelenburg position

vesicouterine pouch

- extra peritoneal cavity in females between the bladder and uterus - shallower than the rectovesical pouch

Explain the flow of bile into the duodenum

Right and Left hepatic ducts get bile from the right and left lobes to for the common hepatic duct, this joins with the cystic duct from the gallbladder to form the common bile duct; the common bile duct and main pancreatic duct joins to empty into the major duodenal papilla

Where is the gall bladder located?

inferior surface of the liver

Describe the parts and placement of the pancreas

head, neck, body, tail and uncinate process (overlaps in vasculature, no real difference) - retroperitoneal (traverses the post abdominal wall) - surrounded by C-shaped duodenum on the Right and spleen on the Left

Pancreas drainage

- drains via the main pancreatic duct (with the main bile duct) OR - drains via the accessory pancreatic duct (2 cm superior to major papilla)

Location of spleen

contacts the diaphragm along ribs 9-11 | -left side

What is the hilum of the spleen?

concave, visceral surface on the medial posterior wall where vasculature comes in

What does the celiac trunk supply?

liver, gall bladder, esophagus, stomach, pancreas and spleen | *1st major branch off abdominal aorta

What are the three main branches of the celiac trunk?

splenic artery, L. gastric artery, and common hepatic a.

What are the terminal branches of common hepatic a?

common hepatic branches off to proper hepatic a. and gastroduodenal a.; proper hepatic a. branches off into Right and Left hepatic artery; gastroduodenal branches off into superior pancreaticduodenal aa.and right gastro-omental (gastroepiploic a.)

What does the Left gastric a. supply?

runs left to lesser curvature of the stomach to supply the stomach and inferior esophagus

R. gastric artery variations

usually comes off the proper hepatic a. - can come off common hepatic or gastroduodenal aa. - anastomose with L. gastric artery to supply lesser curvature

What are the branches off of the splenic a.?

- short gastric arteries - left gastroepiploic artery (greater curve) * * supplies the body and tail of the spleen

Variations in the hepatic arteries

- right hepatic from the SMA - L hepatic artery off L. gastric a. - both R and L hepatic arteries off celiac trunk * *accessory hepatic arteries common

Cystic artery variations and supply

- supplies the gallbladder and cystic duct - comes off of the R. hepatic a. - 3/4 of the time it runs posterior to the common hepatic duct (1/4 time is anterior) - 1% there are double cystic arteries

explain the parts of the stomach

cardiac orifice (from the esophagus) then the fundus (area above the cardiac notch) then the body (between the greater and lesser curve) then angular incisure then pyloric antrum then pyloric canal to the pyloric orifice *with the pyloric sphincter surrounding it)

What are rugae?

give the stomach the "ruffled appearance" | -temporary folds that help with the expansion so that the stomach can function properly

What are plicae circularis?

- permanent folds within the intestine - help with absorption - become more diffuse distally (b/c less absorption)

Why is the duodenum fixed and relatively immobile?

because its retroperitoneal

The duodenum is anterior and posterior to what?

anterior to : kidney, IVC, aorta, portal triad | posterior to: transverse colon

What are the parts of the duodenum?

superior part - L1 descending part - L2-L3 (contains the major and minor papillae) inferior part - going across L3 **SMA and SMV are anterior to this portion ascending part - L3-L2 (goes into the jxn with the jejenum)

What part of the Small Intestine has the largest diameter? and why?

the duodenum because starting to take materials out of the digestive tract??

What is the difference in the vessels of the mesentery of the jejunum and ileum?

- in the jejunum the vasa recta are long, regularly spaced and the arterial arcades are short - in the ileum the vasa recta are short and complex the arterial arcades are larger

Meckel's (ileal) diverticulum

- remnant of the embryonic yolk sac - appears as a finger-like pouch - 1 meter proximal to ileocecal valve - usually occluded, but digestive material can pack in and it can become inflammed (mimic appendicitis) - can create its own vascular supply

What are the 5 segments and 2 flexures of the colon?

- cecum, asc, trans, decs, sigmoid (terminates in the rectum) - R. colic (hepatic flexure) and L. colic (splenic flexure) * *L. colic flexure mark for change in the colon

What holds the appendix in place and carries the vessels that supply it?

mesoappendix (triangular mesentary)

Veriform appendix

- opens into cecum inferiorly to the ileocecal jxn - normally retrocecal, but varies considerably (bifid around ileum) - vestigal structure

The levels of appendicitis

- vague pain in the periumbilical region (referred pain to T10) - severe pain (peritonitis) in lower R quadrant (from irritation of the peritoneum of post. ab wall) - pain most severe between ASIS and umbilicus at the spinoumbilical point (ER WORTHY)

What anchors the colon to the posterior abdominal wall so that it can frame the small intestine?

transverse mesocolon

Tenia coli

-3 smooth mm. longitudinal bands through the length of the colon

Haustra coli

the outpouchings formed by the teniae coli on the colon

epiploic appendages

-fat tags found along the colon

At what vertebral body level does the celiac trunk branch off?

T12 (above pyloric stomach)

At what vertebral body level does the SMA branch off?

L1 (1 cm inferior to the celiac trunk branching off)

What does the SMA supply?

2/3 of transverse colon and most of the SI (duodenum)

What are the branches of the SMA?

- 15-18 intestinal aa. (leads to the arterial arcades and the vasa recta) - ileocolic a., R. colic, middle colic and inferior pancreaticduodenal

What vertebral body level does the IMA branch off?

L3 (posterior to the inferior duodenum) | -5 cm superior to the aortic bifurcation

what does the IMA supply?

distal 1/3 transverse colon to the superior rectum

what are the branches off of IMA?

L. colic, sigmoid (normally 4) and superior rectal

Where is a lot of anastomoses in the colon?

-the marginal a. of drummond (form a consistent vascular arc around the colon)

pancreatic arterial anastamoses

- gastrodudoneal gives superior pancreaticoduodenal aa. and SMA gives inferior pancreaticoduodenal aa. (supply head of pancreas and desc and inferior portion of duodenum) - splenic a. supplies the rest of the pancreas

Renal aa.

- lateral br. of the ab. aorta (lateral to the SMA) - enter the hilum of each kidney to supply - sends off br. to the adrenal glands and ureters * *adrenal br. from inferior phrenic aa. and aorta

Gonadal aa.

-lateral branches off the abdominal aorta (bwtn the SMA and IMA) -inferior to renal aa. -one br. normally superior to the other on the midline (ovarian and gonadal aa.)

Path of the Ovarian aa.

crosses over the ureters and iliac vessels into the pelvis to supply the ovaries

Path of the testicular aa.

crosses over the ureters and enters the inguinal canal to descend into the scrotum to supply the testes

Where does the IVC start?

at L5 (where the common iliac vv. join)

Where does the IVC drain?

into the Right atrium of the heart

where is the bifruc of the aorta?

L4

What does the IVC drain?

poorly oxygenated blood from the LL, most of the back, ab wall and abdominopelvic viscera **largest vein in the body

What forms the portal vein?

union of the splenic (IMV drains into splenic) and the SMV | ** at L2

portal vein drainage

- returns nutrient rich, oxygen-poor blood to the liver from the spleen, pancreas, gall bladder, stomach and intestines - then via the IVC (from the liver) drains into the right atrium of the heart

What are the 4 portal/caval anastomoses?

- gastric vv. (P) with esophageal vv. (C) - paraumbilical vv. (P) with epigastric vv. (C) - superior rectal vv. (P) with middle and inferior rectal vv. (C) - colic vv. (P) with retroperitoneal vv. (C)

What is the problem with portosystemic anastomoses?

- there are no valves so there is backflow into caval veins - leads to portal hypertension restricting blood flow, causing the caval veins to become enlarged (varicose) which can lead to vascular rupture and severe hemorrhoids

Dilated esophageal, epigastric and infr/mid rectal vv. produce what respectively?

- esophageal varices - caput medusae - hemorrhoids

what is included in the celiac plexus?

-celiac ganglion, SM ganglion and aorticorenal ganglion

where is the aortic plexus?

- SMA to the bifruc of the aorta | * *IM ganglia here

Where is the superior hypogastric plexus?

-inferior to the aortic bifrucation

What are the levels for the sympathetic fibers of the abdomen?

Thoracolumbar T5 to T12 (splanchnic) **L1 an 2 (3) got to the hindgut

what is the differentiation between greater, lesser and least thoracic splanchnic nerves?

greater - T5-9 lesser - T10-11 least - T12

explain the route of the sympathetic nerves to the viscera of the abdomen

originate in the lateral horn of the cell bodies (T1-L2) - preganglionic fibers pass thru the chain ganglion to form the thoracic splanchnic nerves (greater, lesser, least) - synapse in the celiac plexus to become postganglionic fibers and innervate the effector organs (along main arterial branches) * *cross talk between post ganglionic chain ganglia

What is the difference between the sympathetic nerves path to the viscera vs. the lumbar levels?

- the lumbar levels synapse in the aortic plexus and travel on the IMA * *all the symp nerves T5-L2 synapse in the collateral ganglia (paraaortics)

preganglionic nerves for the parasymp of the abdomen come from?

CN X and pelvic splanchnics (S2-4)

What does CN X travel on and supply for the abdomen?

all the abdominal viscera through 2/3 of the transverse colon (roughly at splenic flexure) -travels on celiac trunk, SMA, renal aa and their branches

What do the pelvic splanchnic nerves supply and travel on in the pelvis/abdomen?

- supplies pelvic viscera and distal 1/3 trans. colon (roughly splenic flexure) - travels on the IMA and branches

difference between parasympathetics and sympathetics in the abdomen/pelvis?

parasym synapse in effector cell

Where is the caval opening/ vena cava formamen in the diaphragm ??

T8

where is the esophageal hiatus in the diaphragm??

T10

Where is the aortic hiatus in the diaphragm?

T12

Phrenic Nerve

- from C3,4,5 (motor and sensory) - runs along ant. scalene mm. - supplies the central 2/3 of the diaphragm - RIGHT phrenic passes through the IVC opening and the LEFT phrenic passes through the diaphragm mm.

Where do the intercostal nn. anastomose with the phrenic nn.?

laterally only (sensory and motor)

If the phrenic nerve is injured what can happen?

* *injuries anywhere along the path from the cervical cord - paralysis of respiration - INHALATION specifically because contraction part - a paralyzed hemidiaphragm cannot descend (only one side contracts) and seen ONLY on a radiographic inhalation chest film

Crus of the diaphragm?

demarcation of the R and L diaphragm - post/inferior attachment of the diaphragm - goes until about L3 - right side broader and longer

median arcuate ligament (lumbocostal)

arches over the aorta

medial arcuate ligaments (lumbocostal)

arches over the psoas mm.

lateral arcuate ligaments (lumbocostal)

arches over the quadratus lumborum mm.

Vessels that supply the diaphragm?

- pericardiophrenic (sup surface) via int. thoracic - superior phrenic (sup surface) via thoracic aorta - inf phrenic (inf surface) via abdominal aorta - musculophrenic (periphery) via internal thoracic * *aa. and vv. of similar name

Where are the kidneys located?

The R kidney is at the 12th rib and the Left kidney is at the 11th rib (more superior)

paranephric fat

fat on the external surface of the renal capsule (outside the renal fascia)

perinephric fat

fat around the kidney inside the renal capsule (inside the fascia) and into the renal sinus

Why are the vessels reaching the kidneys different lengths?

because the aorta and IVC are not on top of one another

From anterior to posterior what enters the hilum of the kidneys?

renal vein, renal artery and then the pelvis of the ureter

Renal capsule

the tough fibrous tissue that surrounds the kidneys

How much of the kidney is renal cortex vs. renal medulla?

cortex is outer 1/3 and medulla is inner 2/3

What makes up the renal medulla?

renal pyramids and coulumns

Which renal vein is longer? renal artery?

Left renal vein is longer and Right renal artery is longer

What is the pathway of the drainage of urine?

renal papillae (from apex of pyramid) to minor calyces to major calyces to renal pelvis to ureter to urinary bladder to urethra

Pathway of the ureters

-cross the psoas mm. anteriorly obliquely posterior to the gonadal vessels and anterior to the external iliac a. to descend into the true pelvis over the pelvic brim to the posterolateral aspect of the bladder (trigone)

Are bifid renal pelvises and ureters common?

yes

what is a retrocaval ureter?

- uncommon | - ureter passes posterior to either common or external illiac vessesls

Where can ureter vasculature arise from?

(3-4 sources) - renal a. - gonadal a. - abdominal aorta - internal illiac a. (within the pelvic cavity) * *veins drain similarly

intravenous urogram

(IVU) - patient injected with iodinated contrast medium and is extracted by the glomerular filtration so that the pathway of the ureters and bladder can be followed * *for kidney stones

Calculi/ Kidney stones

- spontaneously pass from ureter to bladder - pain associated (cutaneous levels T11-12) - peristalsis pushes the stone down (referred pain with level of obstruction) - larger stones surgically removed and small stones ultrasonic crushing - side and back (btwn ribs) to pelvis to inguinal (inferoanteriorly)

What is the difference in the right and left adrenal (suprarenal) glands?

R gland is triangular, superior to R kidney and post to IVC | L gland is semilumar (superomedial to L kidney) and curves down to hilum

Adrenal cortex

outer portion of the adrenal gland that produces steroids

Adrenal medulla

inner portion that acts as a symp ganglion - modified neuronal cell bodies (postganglionic symp cell bodies) with no axons - medullary/chromatin cells produce epinephrine and norepinephrine

Adrenal vascularization

-richly vascularized because of the endocrine function!! 3 sources -superior suprarenal a. (off inf. phrenic a.) -middle suprarenal a. (off of the abdominal aorta) -inferior suprarenal a. (off of the renal a.)

Posterior abdominal wall mm.

illiacus, quadratus lumborum, diaphragm, psoas mm. and transversus abdominus

what supplies the posterior abdominal wall mm?

- 4 pairs of Lumbar aa. | - in umbilicus region of the abdominal aorta between renal a. and bifruc of the aorta (L4)

innervation of the posterior abdominal wall

lumbar plexus of nerves (like brachial plexus) - T12 to L4 - beneath the fascia of the posterior ab. mm. (follow psoas mm. to figure them out) * *all are motor and sensory

Subcostal n.

- T12 - 1 cm inferior to the 12th rib - supplies sensory to ant./lat abd wall and lateral hip - supplies EO, IO, TA, pyramidalis, RA and QL - the cutaneous dermatome is really inferior

Illiohypogastric/illioinguinal n.

- arise from common trunk (L1) - descend anterior to quad lumb. m. - illiohypogastric supplies skin around the suprapubic regions and illioinguinal runs through the inguinal canal to supply it - both supply ant. ab. mm.

Genitofemoral n.

L1-L2 - pierces psoas major mm. and goes along ant. surface - splits into a femoral and genital br. - supplies skin inf and med to inguinal ligament and cremaster m.

lateral femoral cutaenous n.

``` L2-L3 -descends anterior to illiacus m. -deep to inguinal ring inferior to ASIS -ant/lateral skin of the thigh supply ```

Femoral n.

(L2-4) - runs between illiacus and psoas major mm. - passes deep to the inguinal ligament - inferior to ASIS - supplies the anterior thigh

Obturator n.

(L2-4) - medial to psoas major mm. (remove psoas to see) - passes through the obturator foramen - supplies medial thigh

Lumbosacral trunk

(L4-5) - combines with sacral nerves to make the sciatic trunk - crosses over the ala of the sacrum - provides to both the lumbar and sacral plexuses

True pelvis

below the pelvic brim to the muscular pelvic floor | **also known as the lesser pelvis

False pelvis

from the ilium to the pelvic brim - continuous with the abdominal cavity * * also known as the greater pelvis

Where is the pelvic brim?

from posterior sacrum to the anterior pubic symphisis

pelvic diaphragm

inferior musculature that supports the true pelvis | -made of pelvic floor (levator ani and coccygeous mm.) and pelvic wall (piriformis and obturator internus mm.)

What perineum is inferior to the pelvic diaphragm?

anal and urogenital peritoneum (triangles)

What makes up the Os coxae?

ilium, ischium and pubis

What is the area where the ilium, ischium and pubis intersect?

acetabulum

What makes up the pelvis (bones)?

1 sacrum ( 5 fused sacral vertebrae) and 2 os coxae

ilium inserts where?

the superior portion of the S1 body

what makes up the pelvic brim?

promontory, margin of the ala, arcuate line, pacten pubis and pubic crest

What makes up the linea terminalis?

pubic crest, pacten pubis and the arcuate line

differences in male and female pelvis

- oval in females **ant/post larger, heart shaped pelvic brim in males - F shorter pubic symphysis - F larger pubic arch - F flared illiac wings - F ischial tuberosities are further apart - F sacrum is shorter and less curved * **to accomodate childbirth

ligaments of the pelvis

pubic symphysis, anterior and posterior sacroilliac, sacrotuberous, sacrospinous and obturator membrane

Whats the interosseous ligament?

ligament deep to both anterior and posterior sacroiliac that helps to make a STRONG joint to support the upper body

Greater sciatic formamen

- lower border is the sacrospinous ligament | - piriformis m. passes through

Lesser sciatic foramen

- lower border is the sacrotuberous ligament | - obturator mm. passes through

Piriformis mm.

- anterior sacrum (SII, III, IV foramina) to femur (act on the hip joint) - passes through greater sciatic foramen - innervation S1.S2 - passes behind the greater sciatic notch - closes off the post/sup pelvic outlet

obturator internus mm.

- fans across the obturator foramen and attaches to femur - covered with thick fascia that attaches to levator ani - passes through lesser sciatic foramen - innervated by L5, S1

What makes up the levator ani mm. ?

iliococcygeous, pubococcygeous and puborectalis mm.

what makes up the pelvic floor and what is its purpose?

Levator ani mm. and coccygeous mm. (anterior side of sacrospinous ligament * *holds up the pelvic and abdominal viscera * *connects open bones

What is the function of the puborectalis mm?

- most medial | - holds the rectum up like a sling and must relax for defication

what is the function of the illiococcygeous and pubococcygeous mm?

hold the large bowel up

How does the pelvis open?

anteriorly

what are the differences bwtn the urogenital and anal traingle

- urogenital is passage of urinary and genital systems, its anterior and contains UG diaphragm - the anal triangle passes the rectum and anus, lies posterior, contains a lot of fat and has the pelvic floor mm.

Deep transverse perineal mm./ UG diaphragm

- ant/inf to pelvic diaphragm - composed of deep transverse perineal mm. that are continuous with the external sphincters of the urethra and vagina - puborectalis (of the pelvic diaphragm) will will cut out and not overly these openings - extends between the pelvis arches and attaches posteriorly to the perineal body (CT) * ***perineum not part of the pelvic diaphragm

Perineal membrane

inferiorly lines the deep perineal pouch

How does the bladder fill?

superiorly because already at the pelvic diaphragm

What crosses over the ureter (male and female)

-uterine a. in female and ductus deferens (at insertion on the bladder) in males

Bladder

- stores urine prior to explosion by urethra - smooth detrusor mm. (dense) - retroperitoneal - trigone is smoother surface on the bladder

prosectomy

- removal of the prostate causes the smooth mm. of the bladder to form a pouch - need to "retrain" mm. how to evacuate urine

Female urethra

- very short (3.5 to 5 cm) - between the bladder (internal urethral orifice) and the external urethral orifice - pierces the UG diaphragm

Male urethra

1. preprostatic urethra 2. prostatic urethra 3. membranous urethra - through the perineal membrane and external urethral sphincter that is continuous with the mm. 4. spongy urethra

where is the rectum located?

in the true pelvis above the pelvic floor

Anal canal

- emerges in anal triangle inf to pelvic floor - continuous with the rectum at the anorectal jxn that produces a curvature * *puborectalis mm.

external anal sphincter

- skeletal mm. | - has three layers: deep, superficial and subcutaneous

Why is the descent of the spermatic cord from the abdominal pelvic cavity into the scrotum important?

because it takes the anterior abdominal wall fascia sheaths with it - the IO fasica is the outer layer and TA is the inner fascial sheath * *so if a bleed in between the IO and TA will go down into the spermatic cord and into the inguinal canal into the scrotum

How does the uterus sit?

anteverted and at a right angle to the vaginal canal | **position changes with a full bladder and pregnancy

How much larger can the uterus get during pregnancy?

20X larger

Uterine Cervix

- inferior neck of uterus protruding into the vaginal canal | - opens to vagina as external os and into uterus as internal os

Vaginal Fornix

- circular gutter that surrounds the cervix (extend of the vaginal canal that goes beyond the cervix) - post deeper than anterior to allow for the anterior positioning of the uterus

Suspensory ligament of the uterus

peritoneum covering the ovarian vessels and nerves

Broad ligament of the uterus

peritoneum covering uterus (uterine tube to anterior wall) | - crosses over the Round ligament of the uterus

Ovarian ligament of the uterus

-anchors the ovary to the uterus so its no so free floating

Round ligament of the Uterus

- continuation of the ovarian ligament | - passes thru inguinal canal to fuse with the labia major

What ligament of the uterus is similar to the ductus deferns in the male?

round ligament of the uterus

iliolumbar a.

-between the iliac crest and L5 (post trunk) -supplies the medial ilium and L5

Lateral sacral a.

-a lot of them -enter the ventral sacral foramina -supplies the sacrum and ventral sacral nn. (post trunk)

Superior gluteal a.

- between L5 and S1 - enters the gluteal region SUPERIOR to piriformis m. - supplies gluteal mm. with superior gluteal nn. - exits greater sciatic foramen - continuation of the posterior trunk

Inferior gluteal a.

- btween S2 and S3 (S1 and S2) - INFERIOR to piriformis m. - supplies gluteal mm. with inferior gluteal nerves - exits greater sciatic foramen - off internal illiac (ant trunk)

if you exit the greater sciatic foramen that means..

exiting the pelvic cavity

Internal pudendal a.

- br off internal illiac (ant branch) - runs with the pudendal n. - exits the pelvis through the greater sciatic foramen and enters the gluteal region inferomedial to piriformis, crosses the sacrospinous ligament and re-enters the pelvis through the lesser sciatic foramen - prior to entry thru the lesser foramen, it supplies the perineum of the UG and anal triangles

pudendal canal

- contains internal pudendal a. and pudendal n. - formed by the fascia of the obturator internus mm. - runs anteriorly along the ischiopubic ramus

Umbilical a./superior vesical a.

- branch off int. illiac (ant) - occluded portion runs off towards medial ab wall and terminates as the medial umbilical ligament - umbilical artery sends off 3-4 branches that go to the bladder

obturator a.

- branch off int. illiac (ant) | - runs through obturator canal and supplies medial thigh (ADDucters) with obturator n.

Corona mortis anastomoses

"Crown of Death" - if anastomose btwn inferior epigastric a. and obturator a. is lost then death within minutes because it opens the internal and external illiac systems which is 1/2 the aortic supply - a. and v.

Uterine artery

- in females br. off int illiac (ant) - anastomose with ovarian a. from the aorta - supplies the uterus, cervix, and superior vaginal canal

Vaginal a.

- branch off of the uterine a. (int. illiac) | - -supplies inferior vagina, adjacent bladder and rectum

Middle Rectal a.

- branch off internal illiac (ant) - supplies rectum - anastomose with superior rectal a. from IMA and inferior rectal a. from internal pudendal a.

Inferior vesical a.

- br. off internal illiac (ant) - male equivalent to vaginal a. - supplies the posterior inferior bladder, ureter, seminal vesicle and prostate

Problems Hysterectomy (removal uterus)

The ureter runs below the uterine a. and above the vaginal a. (in btwn) -if the uterine is tied off in a hysterectomy then the ureter can be cut or tied off with the uterine a.

What are the pelvic venous plexuses?

rectal, vesicle, and either prostate or uterus

Somatic innervation of the pelvis and perineum

sciatic n, gluteal n. and pudendal n.

Where does S1 emerge vs. S2&3? (nn.)

S1 above piriformis, and S2&3 thru piriformis

what are the contributions to pudendal n.?

S2-4

what are the contributions to the sciatic and gluteal n.?

L4-S3

Sympathetic plexus in the pelvis

-cell bodies originated in T10 to L2/3 | travel through the sacral splanchnic nerves (S2-4) (preganglionic)

Parasympathetic Fibers in the pelvis

- parasympathetic fibers S2-4 pelvic splanchnic nerves | - supply the hindgut

superior hypogastric plexus

- contains mainly sympathetic fibers - bifurcation of the aorta to upper sacrum (promintory) - condense to form 2 hypogastric nn.

Hypogastric nerve (inferior to plexus)

- contains mainly sympathetic fibers - diverge and curve outward bilateral to the rectum - expands to form inferior hypogastric plexus

Inferior Hypogastric plexus

- contains both symp and parasymp - covers pelvic viscera bilaterally - contains all the autonomics for the pelvis

Ganglion impar

-convergence of the two sympathetic trunks as the move medially on the vertebral bodies to terminate anterior to the coccyx

If the pelvic plexus of nerves is injured, what happens?

-during a removal the nerves are injured (because so mall) and arterial impingement causes impaired bladder control and sexual function

Explain the lymphatic drainage pathway of the abdominopelvic region

** most drainage moves superficial to deep BUT if you are superficial and below the umbilicus you move INFERIORLY to the inguinal region and then deep and up the aortic nodes to meet with the other lymph drainage

Where does the Lymph drain?

Right jugular Lymphatic duct OR the thoracic duct on the left

Cisterna Chyla

- near SMA region * *Lymph drainage - area between the kidneys

Does each organ have its on lymphatic drainage (abdominopelvic)?

YES

explain the flow of Lymph (general)

capillary beds to vessels to nodes to cisterna/ducts

RIght lymphatic vs. Left lymphatic drainage

-right drains the R head, neck, R UL and R upper thorax | and the left (thoracic duct) drains everything else