Trunk and Thorax Anatomy Flashcards
At what level does coeliac trunk come off aorta
T12
Branches of coeliac trunk
Left gastric
Splenic
Common hepatic
What level does SMA come off
L1
Branches of SMA
R colic
Middle colic
What level IMA comes off
L3
Branches of IMA
Left colic
Sigmoid arteries
Superior rectal
2 - coeliac trunk
11 - left gastric artery
20 - head of pancreas
19 - body of pancreas
29 - SMA
30 - SMV
5 - IMA
1 - Aorta
14 - sigmoid branches
16 - superior rectal
6 - left colic
Demonstrate surface marking of abdominal aorta
T12 - 4cm above the transpyloric plane in midline - transpyloric plane is halfway between suprasternal notch and the upper border of pubic symphysis
L4 - supra crestal line- line above iliac crests
A - abdominal aorta
B - Right common iliac
C - left common iliac
D - Left renal
E - right renal
G - Common hepatic artery
J - left hepatic
K - right hepatic
I - gastroduodenal
F - splenic
H - SMA
L - IMA
What does this CT show
AAA - suprarenal saccular aneurysm
Define aneurysm
Abnormal dilatation of artery
Pathogenesis of aneurysm
True - cystic medial necrosis
False - post traumatic
Risk factors for aneurysms
HTN, smoking, Marfan syndrome, syphilis, bicuspid aortic valve
What is an arterial dissection
Separation of the layers of the arterial wall with propagation proximally and distally
Right gonadal vein level
L2
Renal veins level
L1
Where does the left suprarenal vein drain
Left renal
Right drains directly to aorta
What level does the IVC receive hepatic and inferior phrenic veins
T8
Blood supply of adrenal glands
Superior suprarenal artery - from inferior phrenic
Middle suprarenal artery - from aorta
Inferior suprarenal artery - from renal
What are the anterior relations of the renal veins
Right - 2nd part of duodenum
Left - Body of pancreas, splenic vein, SMA
Blood supply of spleen
Splenic artery from coeliac trunk
It passes along the upper border of the pancreas
It is separated from the stomach by the lesser sac and then enters the lienorenal ligament to supply the spleen
What does the splenic vein drain to
Joins the IMV to form the portal vein
What ribs are the spleen related to
9,10,11
What does the splenic artery supply
Spleen
Upper border of pancreas
Short gastric and left gastroepiploic arteries
What are the parts of the pancreas
Head, uncinate process, neck, body, tail
What are the functions of the different islet cells of pancreas
alpha cells - glucagon
beta cells - insulin
D cells - somatostatin
Blood supply of pancreas
Head of pancreas
1 - superior pancreaticoduodenal artery from GDA
2 - Inferior pancreaticoduodenal - from SMA
Body and tail
1 - pancreatic branches of splenic artery
Which ducts drain the pancreas
- main pancreatic duct - duct of Wirsung- drains head, neck, body and tail - opens major duodenal papilla
- accessory pancreatic duct drains uncinate process and lower part of head - duct of santorini - opens minor duodenal papilla
6 - fundus
2 - body
18 - pyloric antrum
29 - pyloric canal
23 - D1
Embryology of pancreas
Ventral and dorsal parts
Ventral - from hepatic diverticulum and ties rise to lower part of head and uncinate process
Dorsal - Dorsal aspect of the duodenum and gives rise to upper part of head, neck, body and tail
3 - head
9 - neck
14 - SMA
15 - SMV
What are the first 2 organs injured in a stab to epigastrium
left lobe of the liver
Stomach
What demarcates left and right lobes of liver
Anatomical - falciform ligament anteriorly
Postero inferiorly - fissure for ligamentum teres and fissure of ligamentum venosum
Surgical - Imaginary line passing from the IVC to the gallbladder fossa
Structures in the porta hepatis
Anterior - right and left hepatic duct
Intermediate - hepatic artery
Posterior - portal vein
5 - common hepatic duct
11 - hepatic artery
20 - portal vein
17 - ligamentum teres
21 - quadrate lobe
2 - caudate lobe
9 -gallbladder
13 - IVC
25 - right triangular ligament
15 - left triangular ligament
23 - attached border of lesser omentum
What are the ligaments supporting the liver
1 - falciform ligament
2 - lesser omentum
3 - right and left triangular ligaments
4 - upper and lower coronary ligaments
Which structures pass through the free border of lesser omentum
portal vein
Common hepatic artery
Common bile duct
Why shoulder tip pain in cholecystitis
Inflamed GB irritates the diaphragm. The diaphragm nerve supply is the phrenic nerve which shares the the same nerve roots as the supraclavicular nerve supplying the shoulder tip
What is the surface marking of the gallbladder
At the angle between the 9th costal cartilage and the lateral margin of the rectus sheath
Blood supply of the stomach
Arteries along lesser curvature - left gastric (from coeliac), right gastric (from common hepatic)
Greater curvature - right gastroepiploic (from gastroduodenal artery), left gastroepiploic (from splenic) and sort gastric (from splenic)
Where is the GDA located and what is the clinical relevance
Posterior to D1 - posterior duodenal ulcer can cause bleeding from GDA
Venous drainage of stomach
Lesser curvature - left and right gastric vein - drain to portal vein
Greater curvature - right gastroepiploic (to SMV) and left gastroepiploic (splenic vein - joins portal vein)
Peritoneal relations of duodenum
First part is intra peritoneal
Other 3 parts are retro peritoneal
Blood supply of duodenum
1 - superior pancreatic duodenal artery (from GDA)
2 - inferior pancreatic duodenal artery (from SMA)
3 - branches from hepatic, right gastric, right gastroepiploic and supraduodenal arteries
Anterior relations of D1
Gallbladder and quadrate lobe of liver
Posterior relations of D1
Portal vein
GDA
CBD
Superior relations of D1
Epiploic foramen
Inferior relations of D1
Head and neck of pancreas
D2 anterior relations
Gallbladder, right lobe of liver, transverse colon, transverse mesocolon, jejunum
Posterior relations of D2
R kidney, right renal vessels, right edge of IVC, right psoas major
Medial and lateral relations of D2
Medial - head of pancreas
Lateral - same as anterior
Anterior relations of D3
Root of mesentery containing superior mesenteric vessels
Coils of jejunum
Posterior relations of D3
R psoas major
R ureter
R gonadal vessels
IVC (separated by r gonadal artery)
Abdominal aorta (separated by IMA)
IMA
Superior relations of D3
Head and uncinate process of pancreas
Inferior relation of D3
Coils of jejunum
D4 anterior relations
Transverse colon and its mesocolon
D4 posterior relations
L psoas major
L gonadal vessels
IMV
L sympathetic chain
Where do the major and minor duodenal papillae open
Posteromedial part of D2
Where is the major duodenal papilla located in relation to stomach
8-10cm distant to pylorus
Different positions of appendix by incidence
Retrocecal
Pelvic
Subcecal
Pre ileal
Post ileal
Blood supply of appendix
Appendicular artery (from ileocolic artery)
Appendicular vein (to SMV)
Why does appendicitis pain refer to umbilicus
Visceral pain from distension of the appendix is conveyed in nerve fibres entering the spinal cord at T10 level. The T10 dermatome covers the level of the umbilicus
Later irritation of the parietal peritoneum by inflammation of the appendix causes localisation to RIF
Urinary bladder blood supply
Superior and inferior vesical arteries from the internal iliac artery
Venous drainage to vesical venous plexus to internal iliac vein
Nerve supply to detrusor muscle
Sympathetic - from L1 and L2 - inhibits contraction of muscle
Parasympathetic - from S2-S4 - stimulates contraction of muscle
Most common bladder cancer
TCC
SCC
Mixed
Adenocarcinoma
Presenting complaint of bladder cancer
Painless haematuria
Risk factors of bladder cancer
Aniline dyes
Smoking
B-naphthalmine
Schistosome haematobium
How does the urteters enter the bladder
The base of the bladder at the corner of the trigone
Peritoneal relations of bladder
Superior and posterior surface are covered by peritoneum
What are the layers encountered during suprapubic catheterisation
1 skin
2 subcutaneous fascia
3 scarpas fascia
4 linea alba
5 fascia trasversali
6 preperitoneal fat
Posterior relations of bladder
Males:
rectovesical pouch
Vas deferens
Seminal vesicles
Terminal ureter entering to trigone
Females:
Vesicouterine pouch
Terminal ureters
Attachments of diaphragm
Sternal - posterior part of xipohoid
Costal - inner surface of lower 6 costal cartilages B/L
Vertebral -
Right crus - L1-3
Left crus - L1 and L2
Median arcuate ligament - between 2 currie
L and R Medial arcuate ligaments - between L/R crus and L1 TP
L and R Lateral arcuate ligaments - L1 TP and 12th rib
Central attachment - central tendon
Openings of the diaphragm
T8 Caval hiatus - IVC, R phrenic nerve
T10 Oesophageal hiatus - oesphagus, vagus trunks (ant and post)
T12 Aortic hiatus - aorta, azygous vein, thoracic duct
- How can you tell this is viewed from below
- Liver is on the left side
- can see the cauda equina which is between L1 and L2
External oblique origin and insertion, nerve supply, direction of fibres
Origin - outer surfaces of 5th to 12th ribs
Insertion - xiophoid process, rectus sheath, ASIS and 1st half of iliac crest, pubic tubercle
Direction of fibres - downwards, forwards and medially
Nerve supply - lower 6 thoracic nerves (T7-T12)
Internal oblique origin and insertion, nerve supply, direction of fibres
Origin - lumbar fascia, iliac crest, inguinal ligament
Insertion- inferior borders of ribs 10-12, linea alba, inguinal ligament and conjoint tendon
Direction - upwards, forwards and medial
Nerve supply - lower 6 thoracic nerves and 1st lumbar nerve (T7-L1)
Walls of inguinal canal
Anterior - external oblique aponeurosis, internal oblique muscle (lateral 1/3 only)
Posterior - fascia trasversalis, cojoint tendon (medial 1/3 only) and reflected part of inguinal ligament(medial 1/3 only)
Roof - lower arched fibres of internal oblique and transversus abdominis
Floor - inguinal ligament
Where does the oesophagus begin and end
begins - lower border of cricoid cartilage (T6)
ends - cardia of stomach (T11)
Blood supply of oesophagus
Arterial:
Neck - inferior thyroid artery
Thorax - branches from aorta
Abdomen - left gastric and inferior phrenic
Venous
Neck - inferior thyroid vein
Thorax - azygous veins
Abdomen - azygous vein (systemic) and left gastric vein (portal)
Cells lining the oesophagus
Stratified squamous epithelium
What is Barretts oesophagus
Columnar metaplasia of stratified squamous epithelium with increased risk of developing adenocarcinoma
What is achalasia
Oesophageal motility disorder involving the smooth muscle layer of oesophagus and lower oesophageal sphincter
There is incomplete LOS relaxation, increased LOS tone and lack of peristalsis of oesophagus
Cause of achalasia
Absent myenteric plexus (Erbach’s plexus) causes hypertrophied musculature (due to repeated contraction of oesophagus against unrelaxed LOS)
Lymphatic drainage of oesophagus
Neck - deep cervical LNs
Thorax - posterior mediastinal LNs
Abdomen - left gastric LNs
Which structures make an indent on the oesophagus (areas of constriction where swallowed foreign bodies likely to lodge)
Left bronchus
Aortic arch
Left atrium
Complication of perforated oesophagus
Mediastinitis
What is the last rib at the mid axillary line
11th rib
18 - right atrium
12 - right ventricle
5 - auricle of right atrium
11- left ventricle
17 - pulmonary trunk
3 - ascending aorta
25 - SVC
1 - tricuspid valve
5 - chordae tedninae
2 - papillary muscle
12 - opening of pulmonary trunk
7 - infundibulum (beginning of pulmonary trunk)
How many cusps does the pulmonary valve has and what’s the vertebral level
3 cusps
T6
What level does pulmonary trunk divide
T5
Where to auscultate pulmonary valve
Second intercostal space left parasternal edge
1 - azygous vein
24 - SVC
9 - R atrium
23 - right main bronchus
27 - sympathetic trunk
3 - greater splanchnic nerves
Tributaries of azygous vein
R superior intercostal vein
Hemiazygous vein
Accessory hemiazygous vein
8 Right posterior intercostal veins
Right subcostal veins
Pericardial, mediastinal, oesophageal and bronchial veins
Branches of ascending aorta
Right and left coronary arteries arising from aortic sinus opposite aortic valve
What connects the sympathetic chain to corresponding spinal nerves
Preganglionic (white rami communicantes) and postganglionic (grey rami communicantes) fibres
How do sympathetic nerves leave the sympathetic chain
Cardiac plexus and pulmonary plexus
Greater and lesser splanchnic nerves
How can you identify the right lung from left lung
right lung has 3 lobes (2 fissures)
left lung has 2 lobes (1 fissure)
Right lung has azygous groove
Left lung has impression for aorta and cardiac impression
Structures in hilum form anterior to posterior
Pulmonary veins
Pulmonary artery
Main bronchus
What other structures enter the hilum
Bronchopulmonary lymph nodes and bronchial vessels
9 - pulmonary vein
2 - pulmonary arteries
1 - right main bronchus
8 - pulmonary ligament
What is the pulmonary ligament
Pleural fold from mediastinal pleura
Goes around the hilum then join together to form pulmonary ligament
Allows for the expansion of pulmonary vein when it has increased venous return
Surface anatomy of lung on skeleton
Apex - curved line drawn from sternoclavicular joint to a point 3 cm above the junction between the medial 1/3 and lateral 2/3 of the clavicle
Anterior border - from sternoclavicular joint to xiphisternal joint on right. On left lung it deviates laterally from the 4th intercostal cartilage to the 6th to form the cardiac notch
Inferior border - Line between 3 points
1. 6th rib midclavicular line
2. 8th rib midaxillary line
3. 10th rib at vertebral column
Posterior border - line from TP of 7th cervical to TP of 10th thoracic vertebra
Level of the hilum
T5,6,7
Level of carina
T4
How many bronchopulmonary segments in each lung
10
What is the nerve relation anterior and posterior to the lung
Phrenic nerve anterior
Sympathetic chain posterior
What is the course of a clot from deep veins of the calf to the pulmonary artery
Pop vein -> fem vein -> EIV -> CIV -> IVC -> Right atrium -> AV valve -> RV -> pulmonary valve -> pulmonary artery
Nerve supply of. intercostal muscles
Intercostal nerves
Branches of aortic arch
Brachiocephalic trunk -> r subclavian and r common carotid
Left common carotid
Left subclavian artery
Which veins drain to SVC
IJV and subclavian join to form brachiocephalic veins which join the SVC
L brachiocephalic vein is longer than R brachiocephalic
Relations of vagus nerves
Right vagus - Right subclavian artery - gives right RLN
Left vagus - aortic arch - arches around and gives left RLN
12 - thyroid gland
7 - inferior thyroid vein
13 - left brachiocephalic vein
8 - left IJV
24 - left subclavian vein
18 - right brachiocephalic vein
26 - SVC
4 - brachiocephalic trunk
19 - right common carotid
21 - right subclavian
20 - right vagus
22 - right RLN
14 - left common carotid
15 - left vagus nerve
What is subclavian steal syndrome
Stenotic or occlusive disease of subclavian artery proximal to origin of vertebral artery
Subclavian has colateral circulation and flow continues
When doing arm exercises there is increased demand of the subclavian artery so blood flow is brought through the vertebral artery from the circle of willis
This results in syncope during arm exercises
What is thoracic outlet syndrome
Compression of the neurovascular bundle passing between scalenus medius and anterior - brachial plexus and subclavian artery
Leads to neurological and vascular symptoms in the arm
Where is a chest drain inserted
5th intercostal space mid axillary line
What are the boundaries and structures passing through posterior mediastinum
Anterior - pericardium and vertical part of diaphragm
Posterior - T5-T12 VBs
Laterally - pleura
Contents -
Vessels - aorta, azygous vein, hemiazygous vein, thoracic duct
Nerves - thoracic sympathetic trunk and thoracic splanchnic nerves, oesophageal plexus
Oesophagus
Posterior mediastinal LNs
