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SMP - GI > Lecture 10 - Retroperitoneum and Posterior Abdominal Wall > Flashcards

Lecture 10 - Retroperitoneum and Posterior Abdominal Wall Flashcards

1
Q

What are the 3 coverings of the kidney from the outside in? In which layer are the suprarenal glands enclosed?

A
  1. Paranephric adipose tissue
  2. Renal fascia***
  3. Perinephric adipose tissue (outside of renal capsule)
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2
Q

What is special about lumbar vertebrae?

A

Larger than any other vertebrae and bodies increase in size as you go down the vertebral column

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3
Q

What are the inferior and superior boundaries of the posterior abdominal wall?

A

L1 and S1 intervertebral discs

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4
Q

Surface of sacrum?

A

Anterior: concave
Posterior: convex

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5
Q

What parts of the pelvic bone are part of the posterior abdominal wall?

A

Medial side of iliac fossae

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6
Q

What ribs are part of the posterior abdominal wall? How are they unique?

A

Ribs 11 and 12

Do not articulate with sternum, one single articular facet on head, no neck, no tubercle

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7
Q

Position of ribs in relation to kidneys?

A

Rib 11: posterior to superior part of left kidney

Rib 12: posterior to superior part of both kidneys

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8
Q

Which of the 2 ribs serves as a point of attachment for numerous muscles and ligaments?

A

Rib 12

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9
Q

Differences between right and left kidneys?

A
  1. Right one is lower than left (because of liver)

2. Left one is longer and more slender

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10
Q

Vertebral levels of kidneys when in supine position?

A

Right: L1 to L4
Left: T12 to L3

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11
Q

What 5 structures are in contact with the anterior surface of the right kidney? Indicate which ones are separate from kidney by a layer of peritoneum.

A
  1. Right suprarenal gland (small part of the superior pole)
  2. ***Liver (a large part of the rest of the upper part)
  3. Descending part of the duodenum (middle medial part)
  4. Right colic flexure (inferior pole on lateral side)
  5. ***Intraperitoneal small intestine (inferior pole on small intestine)
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12
Q

What 6 structures are in contact with the anterior surface of the left kidney? Indicate which ones are separate from kidney by a layer of peritoneum.

A
  1. Left suprarenal gland (small part of the superior pole)
  2. ***Stomach and spleen (a large part of the rest of the upper part)
  3. Pancreas (middle part)
  4. Left colic flexure (middle lateral part)
  5. Descending colon (lower lateral part)
  6. ***Jejunum (lower medial part)
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13
Q

What is in contact with both kidneys on posterior surface? 6 structures. What is posteriorly located but not in direct contact?

A
  1. Diaphragm
  2. Ribs (see other flashcard)
  3. Psoas major, quadratus lomborum, and transversus abdomonis (medial to lateral)
  4. Subcostal VAN
  5. Iliohypogastric nerve
  6. Ilio-inguinal nerve

+ Costodiaphragmatic recesses

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14
Q

How are the kidneys and suprarenal glands separated?

A

Thin septum

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15
Q

What happens to the renal fascia laterally?

A

Anterior and posterior flaps of renal fascia fuse and may connect to the transversalis fascia

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16
Q

What happens to the renal fascia superiorly?

A

Anterior and posterior flaps of renal fascia fuse and blend with the fascia that covers the diaphragm

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17
Q

What happens to the renal fascia medially?

A
  1. Anterior layer: extends over the vessels of the renal hilum and fuses with connective tissue associated with aorta and IVC (may also connect to the renal fascia from the opposite side)
  2. Posterior layer: fuses with fascia covering the quadratus lomborum
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18
Q

What happens to the renal fascia inferiorly?

A

Covers the ureters

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19
Q

Where does adipose tissue accumulate around the kidneys?

A

Postero and posterolaterally

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20
Q

Other name for renal fascia?

A

Gerota’s fascia

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21
Q

Location of laparotomy for kidney surgery?

A

Flank region on the posterior-lateral side of kidneys (sometimes from anterior surface)

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22
Q

4 components of urinary system?

A
  1. Kidneys
  2. Ureters
  3. Urinary bladder
  4. Urethra
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23
Q

Is the urethra shorter in males or females? Implication?

A

Females => more susceptible to UTIs and cystitis

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24
Q

Location of ureters as they descend in posterior abdominal wall? What does displacement mean?

A

Medially at the level of the vertebral transverse processes anterior to the psoas major

Displacement = pathology

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25
Q

Implication of fact that left kidney is higher than right one?

A
  1. Left one is more protected by the ribs
  2. Right one lies mostly under liver
  3. Left one lies mostly under stomach
  4. Right one is closer to the right iliac crest than the left one is the left iliac crest
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26
Q

What color do the kidneys appear on a CT scan?

A

Grey, unless they have contrast in them (white)

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27
Q

What 3 structures enter/exit the kidney at the renal hilum? Describe their location.

A
  1. Renal vein (superior/anterior)
  2. Renal artery (superior/posterior)
  3. Renal pelvis (inferior)
  4. Lymphatics
  5. Nerves
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28
Q

What is the renal pelvis?

A

Funnel shaped superior portion of ureter

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29
Q

7 structures of the kidney?

A
  1. Renal Fascia
  2. Cortex
  3. Medulla
  4. Renal sinus
  5. Minor calyces
  6. Major calices
  7. Renal pelvis
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30
Q

What is the renal capsule?

A

Fibrous tissue covering the kidney

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31
Q

What is the renal hilum continuous with internally?

A

Renal sinus

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32
Q

What is the renal cortex?

A

Continuous band of pale tissue that completely surrounds the renal medulla

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33
Q

What are renal columns?

A

Extensions of renal cortex into the renal medulla and dividing the medulla into renal pyramids

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34
Q

What are renal pyramids?

A

Discontinuous aggregations of triangular-shaped tissue with bases facing outward and apexes (aka renal papilla) facing inward toward the renal sinus

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35
Q

What are the renal papilla surrounded with?

A

Minor calyx

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36
Q

What are the minor calices of the kidneys? What about the major calices? How does this relate to the renal pelvis?

A

These receive urine and represent the proximal parts of the tube that will eventually form the ureter

In the renal sinus, several minor calices unite to form a major calyx, and two or three major calices unite to form the renal pelvis

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37
Q

What are both kidneys in contact with superiorly?

A

Diaphragm

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38
Q

Kidney poles’ location?

A

Superior medial side

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39
Q

% of CO received by kidneys?

A

25%

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40
Q

At what vertebral levels do the renal arteries arise from the abdominal aorta?

A

L1 to L2

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41
Q

Which renal artery is longer than the other? Which one arises higher?

A

Right one is longer

Left one arises higher

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42
Q

What is located anterior to right renal artery?

A

IVC

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43
Q

Position of renal veins relative to renal arteries?

A

Anterior

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44
Q

Which renal vein is longer than the other?

A

Left one is longer

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45
Q

Position of aorta with regards to left renal vein?

A

Posterior

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46
Q

What vein drains into the left renal vein? Does this happen on the right?

A

Left gonadal vein and left suprarenal

NOPE, right gonadal vein and right suprarenal veins drain into IVC directly

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47
Q

Describe the branching of the renal arteries. What do we call these?

A

Renal artery =>

  1. Apical segmental artery
  2. Anterosuperior segmental artery
  3. Anteroinferior segmental artery
  4. Posterior segmental artery
  5. Inferior segmental artery

= segmental arterial support to each of the 5 segments of each kidneys (like lungs, like liver)

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48
Q

What are accessory renal arteries? What are these called?

A

These are common and arise from the abdominal aorta either above or below the primary renal arteries (can also supply kidneys without passing through hilum)

= extrahilar arteries

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49
Q

Position of SMA with regards to left renal vein?

A

Anterior

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50
Q

Aneurysms in what 2 vessels could cause compression of the left renal vein? What do we call this? What would this cause?

A
  1. Aorta
  2. SMA

Nutcracker angle

Can cause enlargement of the left renal vein leading to enlargement of the left gonadal vein (leading to enlarged left scrotum in males = varicocele)

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51
Q

Lymph drainage of kidneys?

A

Lateral aortic (aka lumbar) nodes around the origin of the renal arteries

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52
Q

What is “special” about renal arteries?

A

They are END arteries

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53
Q

What does the segmentation of the kidneys allow for?

A

Partial nephrectomies

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54
Q

What do the suprarenal glands consist of? What does each contain?

A
  1. Outer cortex with cells to make steroid hormones

2. Inner medulla with cells that make catecholamine hormones

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55
Q

Shape of suprarenal glands? Is one larger than the other?

A

Left: semilunar and LARGER
Right: pyramid

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56
Q

What is located anterior to the right suprarenal gland?

A
  1. Right liver lobe

2. IVC

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57
Q

What is located anterior to the left suprarenal gland?

A
  1. Stomach
  2. Pancreas
  3. Sometimes spleen
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58
Q

What is located posterior to suprarenal glands?

A

Diaphragm

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59
Q

Arterial blood supply to suprarenal glands? Asymmetry?

A
  1. Superior suprarenal arteries from the inferior phrenic arteries
  2. Middle suprarenal artery from the abdominal aorta
  3. Inferior suprarenal arteries from the renal arteries

Shorter on the left, longer on the right

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60
Q

Venous drainage of suprarenal glands?

Asymmetry?

A

Single vein leaving hilum of each gland:

  • Right one drains into IVC directly and is short
  • Left one drains into left renal vein and is longer
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61
Q

What is meant by gonadal veins?

A

Testicular or ovarien veins

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62
Q

Is left or right varicocele more common?

A

LEFT

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63
Q

What part of the kidney is the peristaltic pacemaker? Rate?

A

Minor calices that have special smooth muscle

4 waves/min

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64
Q

What are ureters?

A

Muscular ducts with narrow lumens

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65
Q

How serious is blocked uretic flow?

A

VERY

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66
Q

What do patients develop with renal failure?

A

Uremia

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67
Q

Where does the renal pelvis become continuous with the ureters?

A

Ureteropelvic junction

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68
Q

What do the ureters pass anteriorly to inferiorly? At what level?

A

Beginning of external iliac artery or end of common iliac artery at the level of the pelvic brim

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69
Q

At what 3 levels are ureters constricted? What happens here?

A
  1. Ureteropelvic junction
  2. Pelvic brim
  3. Where the ureters enter the wall of the bladder

High risk of kidney stones getting stuck

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70
Q

Blood supply of ureters? What to note?

A

Branches from:

  1. Renal arteries (upper end)
  2. Abdominal aorta or gonadal arteries or common iliac arteries (middle part)
  3. Internal iliac arteries (lower end)

=> arteries reaching the ureters divide into ascending and descending branches, which form longitudinal anastomoses

In the abdomen, blood supply to ureters arrives from their medial side, whereas in the pelvis blood arrives from their lateral side

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71
Q

Lymphatic drainage of ureters?

A
  1. Upper part: lateral aortic (lumbar) nodes
  2. Middle part: lymph nodes associated with the common iliac vessels => lumbar LNs => cistern chylo
  3. Inferior part: lymph nodes associated with the external and internal iliac vessels
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72
Q

On what bladder surface do the ureters connect?

A

Posterior/inferior surface of the bladder

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73
Q

How to see kidneys/ureters on X-ray? Can you see the whole length of the ureters?

A

Inject contrast via IV, which is then excreted by kidneys

Cannot see whole length of the ureters because of the peristalsis taking place NORMALLY

If you do see this => pathology (pressure backing up the system)

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74
Q

Uteric innervation?

A

From the renal, aortic, superior hypogastric, and inferior hypogastric plexuses through nerves that follow the blood vessels with visceral efferent fibers from both sympathetic and parasympathetic sources, and visceral afferent fibers returning to T11 to L2 spinal cord levels

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75
Q

Uretic pain?

A

Referred to cutaneous areas supplied by T11 to L2 spinal cord levels (LLQ or LRQ)), most likely includes:

  1. Posterior and lateral abdominal wall below the ribs and above the iliac crest
  2. Pubic region
  3. Scrotum in males and labia majora in females
  4. Proximal anterior aspect of the thigh
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76
Q

Kidney pain?

A

Referred to anterior and posterior flank

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77
Q

What 2 pains are often hard to distinguish for physicians? How to distinguish?

A

Referred pain of kidney stone in right ureter and direct pain from parietal peritoneum due to appendicitis would both be in LRQ and both in waves due to peristalsis

Appendicitis: patients do not want to move because it makes the pain worse and will bend their knees toward the abdomen to try and relax it and also you can do the rebound sign test

Kidney stones: very agitated and moving and do not guard their abdomen

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78
Q

What is a uteric colic?

A

Paroxysm of pain due to abrupt obstruction of ureter from a calculus or blood clot in most instances

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79
Q

What is the rebound sign test? What is this pain called?

A

To test whether parietal peritoneum is affected , press down (pain stays constant), and remove pressure (if affected, pain should get much worse due to friction between visceral and parietal peritoneum)

=> 2nd level of pain

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80
Q

If you put a catheter in the urethra, can you reach the renal pelvis?

A

YUP

81
Q

What kind of kidney stones are better to not break down with waves?

A

When they are in the lower pole as they may not be able to be excreted by peristalsis

82
Q

What does diabetes increase the risk of?

A

Infections

83
Q

What can recurrent UTIs be indicative of?

A
  1. Congenital malformation

2. Foreign object

84
Q

Describe the pathway of the innervation of the adrenal medulla. What to note?

A

Preganglionic neuron in lateral ventral horn T5 to T9 spinal cord => anterior root => spinal nerve => white ramus communicans => paravertebral ganglion (no synapse) => greater thoracic splanchnic nerve exits => unpaired prevertebral (preaortic) celiac ganglion (no synapse) => periarterial plexus => synapse on adrenal medulla => release of NE and EPI

Note: some pregranglionic fibers do synapse at the celiac ganglion and postganglionic fibers innervate the blood vessels of the suprarenal glands

85
Q

First branches of the abdominal aorta?

A

R and L inferior phrenic arteries

86
Q

4 unpaired branches of the abdominal aorta? Which ones are visceral? Which ones are parietal? From where do they branch? At what level does each branch?

A

VISCERAL:
1. Celiac trunk (anterior) - immediately inferior to aortic hiatus at L1 upper border
2. SMA (anterior) - L1 lower border
3. IMA (anterior) - L3
PARIETAL:
4. Median sacral artery (posterior) - just superior to aortic bifurcation

87
Q

6 paired branches of the abdominal aorta? Which ones are visceral? Which ones are parietal? From where do they branch? At what level does each branch?

A

VISCERAL:
1. Middle suprarenal arteries (lateral) - superior to renal arteries
2. Renal arteries (lateral) - L2
3. Gonadal arteries (anterior) - inferior to renal arteries
PARIETAL:
1. Inferior phrenic arteries (posterior) - immediately superior to celiac trunk
2. Lumbar arteries (posterior) - 2 sets: one superior to IMA and one inferior to IMA
3. Common iliac arteries (terminal) - L4

88
Q

Location of median sacral artery in regards to the sacrum, coccyx, and sacral vertebrae?

A

Anterior

89
Q

What are the 3 posterior branches of the abdominal aorta?

A
  1. Inferior phrenic arteries
  2. Lumbar arteries
  3. Median sacral artery
90
Q

Level of IVC entering diaphragm? Most inferior level?

A

T8 to L5

91
Q

Vertebral levels of abdominal aorta?

A

T12 to L4

92
Q

Location of coming together of 2 common iliac veins to form IVC?

A

L5: posterior/inferior to abdominal aorta branching

93
Q

2 unpaired branches of IVC? Which ones are visceral? Which ones are parietal?

A
  1. Right suprarenal
  2. Right gonadal

Both visceral

94
Q

5 paired branches of IVC? Which ones are visceral? Which ones are parietal?

A 
VISCERAL:
1. Hepatic veins (right, middle, left)
2. Renal veins
PARIETAL:
1. Inferior phrenic veins
2. Lumbar veins (5 of them)
3. Common iliac veins
95
Q

Do all lumbar veins drain into the IVC?

A

NOPE

Only the 3rd and 4th do

5th: drains into iliolumbar vein
1st and 2nd drain into ascending lumbar veins connecting common iliac veins, iliolumbar veins, and lumbar veins with azygos and hemiazygos veins

96
Q

Branches of the common hepatic artery? List in branching order.

A

SAME BRANCHING POINT:

  1. Gastroduodenal artery
  2. Hepatic proper artery
97
Q

Branches of the gastroduodenal artery? List in branching order.

A

SAME BRANCHING POINT:

  1. Right gastro-epiploic artery
  2. Superior pancreatico-duodenal artery
98
Q

What artery runs the risk of being perforated by a duodenal ulcer?

A

Gastroduodenal artery

99
Q

What structures pass anteriorly to abdominal aorta?

A
  1. Pancreas and its splenic vein
  2. Left renal vein
  3. Inferior part of the duodenum
100
Q

What structures pass posteriorly to abdominal aorta?

A

Lumbar veins that drain in IVC (3rd and 4th)

101
Q

Structures located to the right of the abdominal aorta?

A
  1. Cisterna chyli
  2. Thoracic duct
  3. Azygos vein
  4. Right crus of diaphragm
  5. IVC
102
Q

Structures located to the left of the abdominal aorta?

A

Left crus of diaphragm + sympa chain

103
Q

What structures pass anteriorly to the SMA?

A
  1. Splenic vein

2. Neck of pancreas

104
Q

What structures pass posteriorly to the SMA?

A
  1. Left renal vein
  2. Uncinate process of pancreas
  3. Inferior part of duodenum (actually marks the junction with the 4th part of the duodenum)
105
Q

5 branches of the superior mesentery artery? From what side do they branch? List in branching order.

A
  1. Inferior pancreaticoduodenal artery - right side
  2. Middle colic artery - right side
  3. Jejunal ileal branches - left side
  4. Right colic artery - right side
  5. Ileocolic artery - right side
106
Q

Which of the 3 visceral unpaired branches of the abdominal aorta is the smallest?

A

IMA

107
Q

3 branches of the IMA? From what side do they branch? List in branching order.

A
  1. Left colic artery
  2. Branches to sigmoid colon (2-5)
  3. Superior rectal artery

ALL on left side

108
Q

2 branches of left colic artery?

A
  1. Ascending branches

2. Descending branches

109
Q

What are the 3 venous networks in the abdominal cavity?

A
  1. Portal
  2. Caval
  3. Azygos
110
Q

What veins would drain the abdomen if the IVC was occluded?

A

Ascending lumbar veins

111
Q

What does the median sacral vein drain into?

A

Left common iliac vein

112
Q

2 types of abdominal LNs? What do each form?

A
  1. Pre-aortic: anterior to the aorta near celiac, SMA, and IMA => intestinal trunk
  2. Para-aortic = lumbar: right and left lateral => right and left lumbar trunks
113
Q

What abdominal structures drain to the lumbar LNs?

A
  1. Body wall
  2. Kidneys
  3. Suprarenal glands
  4. Testes or ovaries
114
Q

What abdominal structures drain to the pre-aortic LNs?

A

The viscera supplied by those vessels

115
Q

What happens to the intestinal trunk and the R/L lumbar trunks? Where is this located?

A

Come together and form a confluence that, at times, appears as a saccular dilation (the cisterna chyli) => posterior to the right side of the abdominal aorta and anterior to the bodies of vertebrae L1 and L2

116
Q

2 types of innervation to viscera? Describe each.

A
  1. Extrinsic innervation: ANS

2. Intrinsic innervation: ENS

117
Q

Describe the pathway of the greater splanchnic nerve.

A

5th to 9th/10th thoracic ganglia => crus of diaphragm to abdomen => prevertebral plexus => ends in celiac ganglion

118
Q

Describe the pathway of the lesser splanchnic nerve.

A

9th and 10th OR 10th and 11th thoracic ganglia => crus of diaphragm to abdomen =>prevertebral plexus => ends in aorticorenal ganglion

119
Q

Describe the pathway of the least splanchnic nerve.

A

12th thoracic ganglion => crus of diaphragm to abdomen => prevertebral plexus => ends in renal plexus

120
Q

What does the greater splanchnic innervate?

A

Foregut/midgut and adrenal medulla

121
Q

What does the lesser splanchnic innervate?

A
  1. Foregut/midgut

2. Kidneys and upper ureters

122
Q

What does the least splanchnic innervate?

A

Foregut/midgut

123
Q

Parasympathetic innervation of the abdomen?

A

From the vagus nerve up to the left colic flexure and the

pelvic splanchnic nerves from left colic flexure to rectum (pelvic splanchnics from S2-S4 to the pelvic plexus)

124
Q

Describe the parasympathetic autonomic motor innervation pathway to the foregut and midgut.

A

Vagus nerve => unpaired prevertebral celiac ganglion (no synapse) => synapse in intramural ganglion => postganglionic enteric neuron => viscera

125
Q

What is the 1st level of pain?

A

Referred pain

126
Q

6 muscles of the posterior abdominal wall?

A
  1. Psoas major
  2. Psoas minor
  3. Iliacus
  4. Quadratus lomborum
  5. Transversus Abdominis
  6. Diaphragm
127
Q

What does the psoas major become when it is joined by the iliacus?

A

Iliopsoas which attaches via a common tendon: iliopsoas tendon

128
Q

Iliacus muscle:

  1. Origins
  2. Insertions
  3. Innervation
  4. Actions
A
  1. Upper two-thirds of iliac fossa, anterior sacro-iliac and iliolumbar ligaments, and upper lateral surface of sacrum (ala)
  2. Lesser trochanter of femur
  3. Femoral nerve (L2 to L4)
  4. Flexion of thigh at hip joint and flexion of pelvis if thigh is fixed
129
Q

Psoas major muscle:

  1. Origins
  2. Insertions
  3. Innervation
  4. Actions
A
  1. Lateral surface of bodies of T12 to L5 vertebrae, transverse processes of the lumbar vertebrae, and the intervertebral discs between T12 to L5 vertebrae
  2. Lesser trochanter of the femur
  3. Anterior rami of L1 to L3
  4. Flexion of thigh at hip joint, flexion lateral bend of the lumbar vertebral column, allows us to walk, and to do situps if abdominal are weak (e.g. pregnant women)
130
Q

Psoas minor muscle:

  1. Origins
  2. Insertions
  3. Innervation
  4. Actions
A
  1. Lateral surface of bodies of T12 and L1 vertebrae and intervening intervertebral disc
  2. Pectineal line of the pelvic brim and iliopubic eminence
  3. Anterior rami of L1
  4. Weak flexion and lateral bend of lumbar vertebral column
131
Q

Quadratus lomborum muscle:

  1. Origins
  2. Insertions
  3. Innervation
  4. Actions
A
  1. Transverse process of L5 vertebra, iliolumbar ligament, and iliac crest
  2. Transverse processes of L1 to L4 vertebrae and inferior border of rib 12
  3. Anterior rami of T12 to L4
  4. Depress and stabilize rib 12 and some lateral bending of trunk
132
Q

What nerve pierces the anterior surface of the psoas major?

A

Genitofemoral nerve

133
Q

What is the liopubic eminence?

A

Junction of ilium and superior pubic ramus

134
Q

What posterior abdominal wall muscle is absent in 40% of cases?

A

Psoas minor

135
Q

What crosses the quatratus lomborum anteriorly?

A

Lateral arcuate ligament of the diaphragm

136
Q

Attachments of the diaphragm?

A
  1. Xiphoid process
  2. Costal margin
  3. Ends of ribs 11 and 12
  4. Ligaments that span across structures of the posterior abdominal wall
  5. Vertebrae of the lumbar region
  6. Pericardium through central tendon
137
Q

What is the posterior attachment of the diaphragm called? What does it attach to?

A

Median arcuate ligament to T8/T9

138
Q

Blood supply of diaphragm? Which part is the largest blood supply?

A
  1. Superiorly: pericardiacophrenic and musculophrenic arteries (branching from the internal thoracic arteries), superior phrenic arteries (from thoracic aorta), and intercostal arteries
  2. Inferiorly: inferior phrenic arteries*** branching from the abdominal aorta
139
Q

Innervation of diaphragm? Why?

A

Phrenic nerves that innervate it from its abdominal surface + peripheral areas are innervated by intercostal nerves

Because the tissues that initially give rise to diaphragm are in anterior position on embryological disc before the head fold develops

140
Q

What connects the diaphragmatic crura? Relation to aorta?

A

Median arcuate ligament, anterior to the aorta

141
Q

How is the diaphragm anchored to the lumbar vertebrae?

A

Musculotendinous crura which blend with the anterior longitudinal ligament of the vertebral column (2 of them: L and R)

142
Q

Which diaphragmatic crura is longest and broadest?

A

Right crus

143
Q

Attachement of right crus of diaphragm?

A

L1 to L3 and intervening vertebral discs

144
Q

Attachement of left crus of diaphragm?

A

L1 to L2 and intervening vertebral discs

145
Q

What connects the diaphragmatic crura? Relation to aorta?

A

Median arcuate ligament, anterior to the aorta

146
Q

Origins of the diaphragm?

A
  1. Sternum and xiphoid process anteriorly
  2. L1 to L3 lumbar vertebrae and the arcuate ligaments posteriorly
  3. Costal margin peripherally
147
Q

What are the 3 ligaments of the diaphragm?

A
  1. Median arcuate ligament
  2. Medial arcuate ligament
  3. Lateral arcuate ligament
148
Q

What is the medial arcuate ligament? Attachments?

A

Tendinous arch formed by the fascia covering the upper part of the psoas major muscle

Attachments:

  • Medially: sides of L1 and L2
  • Laterally: transverse process of L1
149
Q

Position of medial arcuate ligament relative to the diaphragmatic crura?

A

Lateral

150
Q

What is the lateral arcuate ligament? Attachments?

A

Tendinous arch formed by a thickening of fascia covering the quadratus lomborum

Attachments:

  • Medially: transverse process of L1
  • Laterally: rib 12
151
Q

What are the domes of the diaphragm produced by?

A
  1. Liver on right + some contribution from right kidney and right suprarenal gland
  2. Fundus of stomach and spleen on left with contribution from left kidney and left suprarenal gland
152
Q

Surface projection of right dome of diaphragm during expiration?

A

Rib 5

153
Q

Surface projection of left dome of diaphragm during expiration?

A

5th ICS

154
Q

Insertion of diaphragm?

A

Central tendon

155
Q

What is an iliopsoas test? What is it used for? What could cause a positive test?

A

Performed when an intra-abdominal inflammation is suspected or to test the
iliopsoas muscle itself.

The patient lies on unaffected side and asked to flex the affected leg against the physician’s hand. If there is pain, it would indicate a positive psoas sign. An acutely
inflamed appendix could produce such a sign.

156
Q

3 names for the covering of the psoas muscle? Pathology associated with it? What is this due to? What does this resemble?

A

“Psoas sock” = psoas fascia = psoas sheath

Can thicken and become like a stocking-shaped tube (usually as a result of an abscess from tuberculosis in the lumbar region) => pus from the psoas abscess may travel down to the inguinal region presenting as a lump in the groin in the femoral triangle (could be due to one of many pathological conditions)

Resembles enlarged inguinal lymph nodes

157
Q

Relation to psoas major and iliacus to inguinal ligament?

A

Posterior

158
Q

7 nerves of posterior abdominal wall? Origin of each?

A
  1. Subcostal nerve - T12
  2. Iliohypogastric nerve - L1
  3. Ilioinguinal nerve - L1
  4. Lateral femoral cutaneous nerve - L2-L3
  5. Genitofemora nerve - L1-L2
  6. Femoral nerve - L2-L4
  7. Obturator nerve - L2-L4
159
Q

Sensory innervation of iliohypogastric nerve?

A

Posterolateral gluteal skin and skin in pubic region

160
Q

Sensory innervation of ilioinguinal nerve?

A

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

161
Q

Sensory innervation of genitofemoral nerve?

A

Genital branch—skin of anterior scrotum or skin of mons pubis and labium majus; femoral branch—skin of upper anterior thigh

162
Q

Sensory innervation of Lateral femoral cutaneous nerve?

A

Skin on anterior and lateral thigh to the knee

163
Q

Sensory innervation of obturator nerve?

A

Skin on medial aspect of the thigh

164
Q

Sensory innervation of femoral nerve?

A

Skin on anterior thigh and medial surface of leg

165
Q

What nerve passes at the corner created by the inguinal ligament and ASIS?

A

Lateral femoral cutaneous nerve

166
Q

Nerve on medial side of psoas?

A

Obturator nerve

167
Q

Is the posterior attachment of the diaphragm superior or inferior to the anterior attachment?

A

Inferior

168
Q

Which 7 structures penetrate the diaphragm? At what vertebral level?

A

CAVAL OPENING: T8 in central tendinous portion
1. IVC
2. Right phrenic nerve
3. Right pericardiacophrenic artery
ESOPHAGEAL HIATUS: T10 to left of midline
4. Esophagus
5. Anterior and posterior vagal trunks
6. Esophageal branches of left gastric artery
OTHER:
6. Left phrenic nerve (through muscular part anterior to central tendon on left side)

169
Q

Which structure passes posteriorly to the diaphragm from the thorax? At what vertebral level or position?

A

AORTIC HIATUS: T12 posterior to median arcuate ligament
1. Aorta
2. Thoracic duct
3. Optional azygos vein
4. Greater, lesser, and least splanchnics
PLUS:
5. Sympathetic trunks (posterior to medial arcuate ligament)
6. Hemiazygos vein (through left crus)
7. Lymphatics

170
Q

Which structure passes anteriorly to the diaphragm from the thorax? Position relative to ribs?

A

Superior epigastric vessels (just deep to the ribs)

171
Q

Sensory innervation of phrenic nerves with regards to diaphragm?

A

Both pleural and peritoneal surfaces of the diaphragm

172
Q

What 4 abdominal organs can go down in pelvis?

A
  1. Ureters
  2. Ileum
  3. Sigmoid colon
  4. Appendix
173
Q

What 2 pelvic organs can go up in the abdomen?

A
  1. Urinary bladder

2. Pregnant uterus (as high as xiphoid process)

174
Q

Are there variations where the left renal vein passes posterior to the abdominal aorta instead of passing through the nutcracker angle?

A

YUP

175
Q

Other name for jejunal ileal branches of the SMA? How many of these are there?

A

Intestinal arteries

Usually 15-18 of them total

176
Q

What is the marginal artery of the colon?

A

Artery that anastomoses all of the branches of the SMA with IMA

177
Q

What area of the colon is most at risk for becoming ischemic?

A

Splenic flexure because it receives blood supply for the end of the SMA and IMA

178
Q

Are veins in the abdomen overall anterior or posterior to arteries?

A

Posterior

179
Q

Vertebral level of SMV meeting the splenic vein?

A

L2 (slightly inferior to SMA)

180
Q

What is very variable in the portal circulation?

A

Where the IMV meets the other veins

181
Q

Which large vein and artery in the abdomen are not coupled?

A

IMA and IMV (IMV more lateral)

182
Q

Is more cortex or more medulla in the liver?

A

More cortex

183
Q

Other name for lumbar arteries?

A

Spinal arteries

184
Q

What do the lumbar arteries supply?

A

Posterior abdominal wall

185
Q

What part of the duodenum passes anteriorly to the aorta?

A

Inferior (3rd)

186
Q

What 2 veins pass anteriorly to the aorta?

A
  1. Splenic vein

2. Left renal vein

187
Q

Does the IVC receive any tributaries from the gut?

A

NOPE

188
Q

Path of IVC in abdomen?

A

Slightly to the right

189
Q

Which is longer: IVC or abdominal aorta?

A

IVC

190
Q

What nerve passes between the psoas and the iliacus muscles?

A

Femoral nerve

191
Q

What 2 nerves are superior to the lateral cutaneous nerve of the thigh? What to note?

A
  1. Iliohypogastric nerve (highest)
  2. Ilioinguinal nerve (lowest)

They come out as one nerve at L1

192
Q

What muscles do the iliohypogastric and ilioinguinal nerves innervate?

A

Internal oblique and transversus abdominis

193
Q

Possible variation of the suprarenal arteries?

A

Inferior one connects to the middle one

194
Q

What needs to be ligated during a partial nephrectomy?

A
  1. Segmental arteries
  2. Veins
  3. Bile collecting system
195
Q

Describe the parasympathetic autonomic motor innervation pathway to the hindgut and pelvis.

A

Preganglionic neuron in ventral horn of sacral spinal cord (S2-S4) => anterior root => spinal nerve => pelvic splanchnics => unpaired prevertebral ganglion (no synapse) => synapse in intramural ganglion => postganglionic neuron => viscera

196
Q

Pathway of visceral sensory nerves of GIT?

A

Follow the parasympathetic and sympathetic innervation pathways back to spinal nerve => DRG => posterior root => dorsal horn of spinal cord

197
Q

Pathway of abdominopelvic splanchnics to viscera?

A

Preganglionic neuron in lateral ventral horn spinal cord => anterior root => spinal nerve => white ramus communicans => paired paravertebral ganglia (no synapse and same level/up/down the spinal cord) => splanchnic nerve exiting the paravertebral ganglion => synapse in unpaired prevertebral ganglion => postganglionic enteric neuron => viscera

198
Q

Sympathetic nerves inhibiting the ENS? What does each innervate? Vertebral level for each?

A

Abdominopelvic splanchnics:

  1. Greater splanchnic (T5-T9): foregut and midgut
  2. Lesser splanchnic (T10-T11): foregut and midgut
  3. Least splanchnic (T12): foregut and midgut
  4. Lumbar splanchnic (L1-L2): hindgut
199
Q

Where does the right gastric artery branch from?

A

HEPATIC ARTERY PROPER (BUT VERY VARIABLE)

SMP - GI (21 decks)

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