DEC5TH

ANATOM
Y
REVIEW
NOTES
SPLANCHNOLOGY I & II
2006
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1 Nasal cavity (bony+soft tissue) & paranasal sinuses
NASAL CAVITY (BONY) Bony nasal cavity is 1
st
semester material
Inlet:
o Apertura piriformis (pear-shaped aperture). Borders:
Nasal bone, the frontal process of the maxilla, and by the
body of the maxilla.
Outlet:
o Choanae. Borders:
LATERAL: medial plate of pterygoid process.
INFERIOR: horizontal plate of the palatine bone.
MEDIAL: vomer.
SUPERIOR: body of the sphenoid bone (having the ala vomeris
on it).
The nasal cavity has four walls:
o Anterior: nasal bone.
o Superior: nasal part of the
1
frontal bone (ant.),
2
cribiform plate
(mid.), and
3
body of the sphenoid bone (post.).
o Inferior: The hard palate = palatine process of the maxilla (ant) &
horizontal plate of palatine bone (pos).
o Medial: Nasal septum = perpendicular plate of ethmoid & vomer. V-
shaped space in front, filled with cartilage forming the cartilaginous
part of the nasal septum.
o Lateral: Anterior Posterior.
Frontal process of the maxilla.
Lacrimal bone
Ethmoidal bone. (Beneath the middle nasal concha are the
uncinate process and ethmoidal bulla. Between them, we
have the semilunar hiatus)
Inferior nasal concha
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CONNECTIONS OF THE NASAL CAVITY:
CPARANASAL SINUSES (4) are cavities surrounding the nasal cavity, filled by
air, and layered by mucous membrane. They open into the nasal cavity.
a) Frontal sinus: opens into the middle nasal meatus through the anterior
part of the semilunar hiatus.
b) Maxillary sinus: opens into the middle nasal meatus through the
posterior part of the semilunar hiatus.
c) Ethmoidal sinuses: anterior and middle groups of air cells open into the
middle nasal meatus, and the posterior group opens into the superior
nasal meatus.
d) Sphenoid sinus: open into common nasal meatus via sphenoethmoidal
recess.
CSphenopalatine foramen: Nasal cavity - pterygopalatine fossa.
CIncisive canal: Nasal cavity- Oral cavity. It transmits the nasopalatine nerve
and artery.
CCribriform plate: It transmits fibers from olfactory nerve (CNI)
CNasolacrimal canal: Orbital cavity - inferior nasal meatus
NASAL CAVITY (Soft tissue)
nasal vestibule
proper nasal cavity
The borderline between them is the limen nasi.
The mucous membrane of the nasal cavity is divided into two parts:
1. Olfactory region
a. The olfactory mucous membrane covers the superior nasal concha
and the septum (the superior part of the septum and the top of the
nasal cavity).
b. The epithelium of the olfactory region is of a special type which
gives the origin of the fila olfactoria.
c. It is a primary neuroepithelium. The fila olfactoria are running
through the lamina cribrosa and form the olfactory nerve.
2. Respiratory region.
a. Rest of the nasal cavity is the respiratory region
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b. Pseudo-stratified columnar kinociliated epithelium having mucous
glands inside.
BLOOD SUPPLY AND INNERVATION:
This is given from two arteries and two nerves.
o anterior ethmoidal nerve nasociliary nerve Olfactory nerve
( CNI)
o ophthalmic artery internal carotid
Kiesselbach point: the anastomosis between the two arteries.
These structures begin in the orbit; pass through the anterior
ethmoidal foramen to the anterior cranial fossa, then down to
the nasal cavity through the cribriform plate. They innervate
and supply the superior part of the nasal cavity.
o Posterior nasal nerve maxillary nerve
o Sphenopalatine artery maxillary artery.
Innervates and supplies the inferior, main part of the nasal
cavity.
LYMPH DRAINAGE:
Anterior: Submandibular lymphnodes Deep cervical lymph nodes
Posterior: Retropharyngeal lymph nodes
2 Cartilages and joints of the larynx
CARTILAGES & (BONE):
Hyoid bone
o Lesser and greater horn
o body
Epiglottis
o Elastic cartilage
o Covered by mucous membrane
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o Serves as a diverter over the aditus, during swallowing.
Thyroid
o Left and right palates
o Adams apple in front
o Superior and inferior horns
o Inferior horn forms joint with cricoid
o Thyrohyoid membrane
Cricoid
o Broader posterior than anterior
o Articulates with both thyroid and small arytenoids
o Cricothyroid membrane (conus elasticus)
For relief of respiratory obstruction, it may be pierced
(conicotomy)
Arytenoids (2)
o Pyramidal shaped (apex + base)
JOINTS
Cricothyroid joint
o Articulation:
Inferior horn of thyroid articulating surfaces of cricoid
o Ligament function:
Median cricothyroid ligament; anterior/thickened part of
cricothyroid membrane.
Movement Elevation and depression
o Muscles:
Cricothyroid muscle (only laryngeal muscle supplied by the
external laryngeal nerve (rather than the recurrent laryngeal
nerve)
o Movement:
Tilting the thyroid forward which tenses the vocal cords.
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Cricoarytenoid joint
o Articulation:
Articulating surfaces of cricoid base of arytenoids.
o Muscles:
Posterior & Lateral cricoarytenoid muscles
o Movements:
Abduction & Adduction (intramembranous part) of vocal
cords.
Cricotracheal joint
o Cricoid - 1
st
tracheal ring by the cricotracheal ligament.
3 Cavity and muscles of the larynx
CAVITY
Inlet (Laryngeal Aditus)
o Borders:
Epiglottis
Aryepiglottic folds having cuneiform and corniculate
cartilages
Interarytenoid notch
Vestibule
o 4-5cm
o Vestibular/Ventricular/false vocal -folds
o Laryngeal ventricles
o Vocal fold (Stratified squamos non-keratinized epithelium)
Rima glottidis (Glottis)
o Opening between the two vocal folds
Subglottic cavity
o Found just under the rima glottidis
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o Pseudostratified columnar ciliated epithelium
MUSCLES
Extrinsic muscle innervated by external laryngeal nerve
Intrinsic muscles innervated by the recurrent laryngeal nerve
Extrinsic :
o Cricothyroid:
O&I: Arch of cricoid cartilage lamina of the thyroid
cartilage, having straight fibers and oblique fibers.
Function: Pulls the two cartilages closer by tilting the thyroid
forward. This tenses the vocal cord.
Intrinsic:
o Posterior cricoarytenoid:
O&I: Posterior surface of cricoid lamina muscular process of
arytenoids.
Function: Abducts the vocal cord by outward rotation of the
arytenoids.
o Lateral cricoarytenoid:
O&I: Lateral surface of arch of cricoids muscular process of
arytenoids:
Function: Adducts vocal cord (intramembranous part) by
inward rotation of the arytenoids.
o Interarytenoid (Transverse & Oblique)
Transverse adducts vocal cord (intercartilagenous part).
Oblique continue to the epiglottis making aryepiglottic folds
and may narrow the aditus.
o Vocalis
O&I: Posterior surface of thyroid lamina vocal process of
arytenoids.
Function: Relaxes the ligament. (Fine regulators)
o Thyroarytenoid
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O&I: Inner surface of thyroid cartilagemuscular process and
outer surface of arytenoids.
Function: Decreases tension on vocal fold (antagonistic to
extrinsic muscle).
o Thyroarytenoid (thyroepiglottic part)
Function: Widens vestibule and laryngeal aditus.
Other muscles influencing movement of the larynx:
Depression: Infrahyoid muscle
Elevation: Stylopharyngeal, Digastric, Mylohyoid & Geniohyoid muscle
4 The function, innervation and lymphatic drainage of the
larynx
Larynx is an organ of voice production, and the part of the respiratory tract
between the pharynx and trachea
FUNCTION
The intermittent release of expired air between the adducted vocal folds results
in their vibration and the production of sound. The frequency of the voice is
determined by changes in the length and tension of the vocal ligaments. The
quality of the voice depends on the resonators above the larynx; pharynx, mouth
and paranasal sinuses. The frequency is controlled by the intrinsic muscles of
larynx, and the quality is determined by the muscles of the soft palate, tongue,
floor of mouth, cheeks, lips and jaws.
Movement Muscles Function
Abduction pos. cricoarytenoid loudness (increased air)
Adduction lat. cricoarytenoid loudness (decreased air)
Trv. Arytenoid
Shortening/relaxation Thyroarytenoid Degree of vibration
(decreased tension)
Vocalis
Lengthening/tensing Cricothyroid Degree of vibration
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INNERVATION OF THE LARYNX
Sensory
o Above vocal fold: Vagus Sup. Laryngeal nerve int.
laryngeal nerve
o Below vocal fold: Vagus recurrent laryngeal nerve
Motor
o Intrinsic muscles (all but cricothyroid): vagus Recurrent
laryngeal nerve
o Extrinsic muscles (only cricothyroid): vagus sup.
Laryngeal ext. laryngeal
LYMPHATIC DRAINAGE
The laryngeal lymph nodes are situated on the cricothyroid ligament; some are
found in front of the thyrohyoid membrane. They receive lymph from adjacent
structures, including the thyroid gland.
Draining into deep cervical lymph nodes jugular trunk thoracic duct/right
lymph duct.
5 The oral cavity (except the teeth). The palate and the floor of
the oral cavity
THE ORAL CAVITY
Inlet: Rima Oris
o Surrounded by upper and lower lips
o The lips are connected to the gums by frenulum of upper and lower
lips.
Vestibule:
o Anterior Lips
o Posterior Teeth and gums
o Lateral Cheek, + buccinator muscle
Oral cavity proper
o Superior Hard and soft palate
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o Inferior Tongue & Mylohoid muscle
o Lateral Teeth
Outlet: Oropharyngeal isthmus
o Lateral Palatoglossal and palatopharyngeal arches
o Superior Uvula, soft palate
o Inferior Root of tongue, terminal sulcus
HARD PALATE
Anterior bony part of the palate, consisting of:
Horizontal plate of palatine bone
Palatine process of maxilla
It is covered by mucous membrane
Canals:
Greater palatine foramen
o Maxillary nerve pterygopalatine ganglion greater palatine
nerve
Supplies the mucosa and glands of the hard palate and
anterior part of soft palate
Lesser palatine foramen
o Maxillary nerve pterygopalatine ganglion lesser palatine
nerve
Supplies the mucosa and glands of the soft palate and uvula
Contain postsynaptic parasympathetic and sensory fibers of
the maxilla
Incisive canal
o Pterygopalatine ganglion nasopalatine nerve
SOFT PALATE
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Posterior muscular part of the palate; forming an incomplete septum between
the mouth and oropharynx & between the oropharynx and nasopharynx
Muscles inserting into it:
Levator veli palatini muscle
o Origin
cartilage of auditory tube
o Function
Elevates the soft palate during swallowing and yawning
o Nerve supply
Vagus nerve
Tensor veli palatini muscle
o Origin
Medial pterygoid plate
o Function
Tenses the soft palate during swallowing and yawning.
Equalize pressure of middle ear.
o Nerve supply
Mandibular nerve
Muscles originating from soft palate:
Palatoglossal muscle: Forms anterior arch of the tonsillar fossa
Palatopharyngeal muscle: Forms the posterior arch of tonsillar fossa
FLOOR OF THE ORAL CAVITY
Diaphragm oris
Genioglossus
o O&I: Superior part of mental spine Dorsum of tongue
o Hypoglossal nerve (CXII)
o Protrude & depress the tongue
Geniohyoid:
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o O&I: Mental spine body of hyoid bone
o Hypoglossal nerve (CXII)
o Draws hyoid forward or depresses jaw when hyoid is fixed
Mylohyoid
o O&I: Mylohyoid line of mandible converge and unite, attaches to a
median fibrous raphe and inserts into hyoid
o Mylohyoid branch from mandibular nerve
o Elevates floor of mouth and the tongue
Digastric
o O&I: Anterior belly from the digastrics fossa of mandible & Posterior
belly from mastoid notch of the temporal bone Greater horn of
hyoid bone
o Posterior belly facial nerve & anterior belly mylohyoid branch of
mandibular nerve
o Elevates the hyoid bone, helps the lateral pterygoid muscle to open
mouth
6 The Tongue
The tongue is a muscular organ with muscle fibers in three directions, horizontal,
longitudinal and vertical, covered by mucous membrane: Root (1/3), Body (2/3)
and an apex.
It is an organ of taste. Most of the tongue is covered in taste buds. The tongue
assists in forming the sounds of speech. It is sensitive and kept moist by saliva,
richly supplied with nerves and blood vessels to help it be moved.
Papillae and taste buds
Four types of papillae:
o filiform (thread-shape)
o fungiform (mushroom-shape)
o foliate (leaf-shape)
o Circumvallate (ringed-circle).
All papillae except the filiform have taste buds on their surface. The
circumvallate are the largest of the papillae. There are 8 to 14
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circumvallate papillae arranged in a V-shape in front of the sulcus
terminalis, creating a border between the oral and pharyngeal parts of the
tongue.
The upper side of the posterior tongue (pharyngeal part) has no visible taste
buds, but it is bumpy because of the lymphatic nodules lying underneath. These
follicles are known as the lingual tonsil.
The human tongue can detect four basic taste components, sweet, sour, salty
and bitter.
The tongue is the strongest muscle in the human body proportional to size.
NERVE INNERVATIONS
Motor
o Hypoglossal nerve for both extrinsic and intrinsic muscles
General sensory
o Anterior 2/3: lingual nerve
o Posterior 1/3: Glossopharyngeal nerve
Taste
o Anterior 2/3: Chorda tympani from facial nerve (VII)
o Posterior 1/3: Glossopharyngeal nerve
MUSCLES
Intrinsic
o Superior & Inferior longitudinal: Rolls tongue up and down
o Transverse: Makes the tongue
more narrow and thick
o Vertical: Flattens and widens tongue
Extrinsic
o Genioglossus
From mandible to the lingual fascia
It depresses and protrudes the tongue
o Hyoglossus
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From body and greater horn of hyoid bone to the side of the
tongue
Depresses and retracts tongue to the floor of the mouth
o Styloglossus
From styloid process to the tongue
Retracts and draws it upwards during swallowing
o Palatoglossus
From oral surface of soft palate to the tongue
Forms anterior arch of tonsillar fossa
It draw tongue backwards and upwards
Innervated by Accessory nerve (IX) via the Vagus (X)
BLOOD SUPPLY
Greater palatine artery maxillary artery
o Supplies gum and mucous membrane of the hard palate
Lingual artery external carotid artery
o Floor of mouth and extrinsic muscles of tongue
Descending palatine artery maxillary artery
o Soft palate, gums, bones and mucous membrane of hard palate
Facial artery
o Ascending palatine, tonsillar branch, inferior & superior labial
Tonsils and soft palate
7 Description of the teeth, their types, blood supply and
innervations
GENERAL DESCRIPTION
The teeth posses a:
Crown covered by enamel
Neck, where the gingival connects to it
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Root
They have four surfaces:
Masticatory
Buccal
Lingual
Contact, mesial and distal
When describing the teeth, we consider them in four quadrants
MILK TEETH
20 total. 5 teeth in each quadrant
2 incisors
1 canine
2 molar
The teeth erupt in average 6-8 months, starting with the medial incisors. The
exchange for permanent teeth starts in average 6 years.
PERMANENT TEETH
32 total. 8 teeth in each quadrant
2 incisors
o Upper ones has a wider crown
o Labial and lingual surfaces are flattened
o Lingual surface is excavated
o Have a single root, the upper is more rounded
1 canine
o Longest root of all teeth
o Its crown is columnar shaped
2 premolar
o Its crown has two tubercles, 1 large buccal and 1 lingual
o It has one root, except, upper first which is divided to two roots
3 molar
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o Lower: 2 roots; 1 mesial & 1 distal
o Upper: 3 roots; 2 buccal & 1 lingual
o Lower: 1
st
has 5 tubercles, the others usually have 4, 2-3 buccal and
2 lingual
o Upper: 2 first have 4 tubercles, 2 buccal & 2 lingual. 3
rd
molar
(wisdom) has 3 tubercles
BLOOD SUPPLY
Upper teeth Maxillary artery Superior alveolar artery
Anterior/
Middle/
Posterior alveolar branches
Lower teeth Maxillary artery Inferior alveolar artery
NERVE SUPPLY
Upper teeth Maxillary nerve (V2) infraorbital nerve alveolar
branches
o In individual nerve canals
Anterior branch from infraorbital
Middle branch from infraorbital
Posterior sup. Alveolar branch comes directly from maxillary
nerve
Lower teeth Mandibular nerve (V3) inferior alveolar nerve
o In a common canal
CLINICAL IMPORTANCE
When giving anesthetics the upper teeth may be individual affected, but the
lower teeth must be anesthetized together, the needle is set at the opening of
the mandibular foramen.
8 Lymphatic drainage of the oral and nasal cavities
Waldeyer's tonsillar ring is an anatomical term describing the lymphoid tissue
ring located in the nasopharynx
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The ring consists of (superior to inferior):
Pharyngeal tonsil (adenoids)
o Roof of nasopharynx
o Function and size decrease with age
o Hypertrophy may obstruct airways
Tubal tonsils
o Pharyngeal recess behind opening of auditory tube
Palatine tonsils
o In tonsillar fossa between Palatoglossal & palatopharyngeal arch
o Drain to upper deep cervical lymph nodes
Lingual tonsils
o Dorsal surface at the base of the tongue in posterior region
LYMPHATIC DRAINAGE OF THE ORAL AND NASAL CAVITIES
(According to paper given by Professor Kovacs which was copied and distributed
within 2
nd
grp)
1. Submental lymph nodes. Primary lymph nodes for:
i. Lower lip
ii. Lower incisor
iii. Tip of the tongue
iv. Anterior part of the sublingual region
2. Submandibular lymph nodes. Primary lymph nodes for:
i. Middle part of tongue and sublingual region
ii. Soft & hard palate
iii. Upper & lower teeth
a. Except lower incisor & lower wisdom teeth
iv. Nasal vestibule
3. Deep cervical lymph nodes. Primary lymph nodes for:
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i. Root of tongue
ii. Palatine tonsils
iii. Lower wisdom teeth
iv. Nasal cavity proper
v. Also secondary lymph nodes for submental & submandibular
lymph nodes
Lymph filtered by deep cervical lymph nodes is collected by the right/left jugular
trunk right/left venous angle.
9 Cavity and parts of the pharynx
Pharynx is a common tube for food and air, 7-7.5cm long. It is lined by mucous
membrane, and it has posterior and lateral walls. It has no anterior wall because,
it communicates with the nasal, oral cavity, and larynx.
The muscles forming the lateral and the posterior wall arise from the pterygoid
process of the sphenoidal bone.
Part of the pharynx (sup inf)
Pharyngobasilar fascia
O&I: Basilar part of the occipital bone & superior constrictor
muscle.
Superior pharyngeal constrictor muscle.
It has four origins:
1
pterygopharyngeal part (pterygoid
process);
2
buccopharyngeal part (pterygomandibular
raphe );
3
mylopharyngeal part (mylohyoid line);
4
glossopharyngeal part (root of the tongue).
Middle pharyngeal constrictor muscle which overlaps the superior.
It arises from the greater and lesser horns of the hyoid bone.
The borderline between the superior and the middle
pharyngeal constrictor muscle is marked by the
stylopharyngeus muscle (entering the pharynx between
them). The glossopharyngeal nerve runs along the
stylopharyngeus muscle.
Inferior pharyngeal constrictor muscle (two parts):
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thyropharyngeal and cricopharyngeal parts (according to
their origins, thyroid and cricoid cartilages). The inferior
constrictor overlaps the middle constrictor muscle.
All three constrictors are inserted to the PHARYNGEAL RAPHE, a connective
tissue septum on the posterior wall of the pharynx.
CAVITY
The cavity of the pharynx has three parts: Nasopharynx (epipharynx),
Oropharynx (mesopharynx), and Laryngopharynx (hypopharynx).
NASOPHARYNX (EPIPHARYNX) Upper 1/3
It starts from the roof of the pharynx, which is formed by the basilar part of
the occipital bone, until the soft palate.
Anteriorly, it communicates with the nasal cavity through the choanae.
Inferiorely, it communicates with the oropharynx.
Superiorly, it communicates with the roof of the pharynx,
Laterally with the tympanic cavity through the auditory tube.
Structures:
o Opening for auditory tube
o Torus tubarius, formed by the cartilaginous part of the auditory
tube.
o Behind and a little above this tubal elevation, the pharyngeal recess
is where the tubal tonsils are located. The fornix of the pharynx is
between the superior and posterior walls of the pharynx, and in the
fornix, we have the pharyngeal tonsils (adenoids).
If enlarged, it can obstruct airway.
OROPHARYNX (MESOPHARYNX) Middle 1/3
From the soft palate to superior part of the epiglottis.
It communicates with the oral cavity through the oropharyngeal
isthmus/isthmus faucium.
o Its borders are the palatoglossal and palatopharyngeal arches
(laterally), Root of tongue (inferior); and Uvula (superior).
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Tonsilar fossa, where the palatine tonsils are located. Supratonsillar fossa
where fish bone may get stuck.
Epiglottic vallecula: between the root of the tongue and the epiglottis. It is
bordered by the median glossoepiglottic fold and the lateral
glossoepiglottic folds.
o Another fish bone site
LARYNGOPHARYNX (HYPOPHARYNX) Lower 1/3
From the epiglottis until the esophagus.
Communicates with larynx via laryngeal aditus (inlet of the larynx)
o Bordered by:
1
epiglottis (in front),
2
aryepiglottic fold (laterally),
3
interarytenoid notch,
4
tuberculum cuneiforme + corniculatum (not
important).
The food from the oral cavity passes through the piriform recess which is
in the two sides of the epiglottis, then it goes to the esophagus.
10 Muscles and wall of the pharynx
Pharynx is a common tube for food and air, 7-7.5cm long. It is lined by mucous
membrane.
Layers:
Mucous and submucous layers
Fibrous layer
Muscular layer
MUSCLES
Constrictor muscles:
Superior pharyngeal constrictor muscle.
It has four origins:
1
pterygopharyngeal part (pterygoid
process);
2
buccopharyngeal part (pterygomandibular
raphe );
3
mylopharyngeal part (mylohyoid line);
4
glossopharyngeal part (root of the tongue).
Middle pharyngeal constrictor muscle which overlaps the superior.
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From greater and lesser horns of hyoid bone.
The borderline between the superior and the middle
pharyngeal constrictor muscle is marked by the
stylopharyngeus muscle (entering the pharynx between
them).
The glossopharyngeal nerve runs along the stylopharyngeus
muscle.
Inferior pharyngeal constrictor muscle (two parts):
thyropharyngeal and cricopharyngeal parts (according to
their origins, thyroid and cricoid cartilages).
The inferior constrictor overlaps the middle constrictor
muscle.
All three constrictors are inserted to the PHARYNGEAL RAPHE, a connective
tissue septum on the posterior wall of the pharynx.
Levator muscles of pharynx:
Stylopharyngeal muscle (IX)
o From styloid process to sup. & inf. Pharyngeal constrictor muscles.
o Elevates pharynx towards base of skull.
Salpingopharyngeal muscle (IX+X)
o From cartilage of auditory tube, soft palate and pterygoid hamulus.
o Opens auditory tube during swallowing and yawning
o inside the salpingopharyngeal fold
Palatopharyngeal muscle (X)
o Pulls pharynx upward and lowers soft palate
o Palatopharyngeal arch, which is posterior to the palatine tonsils
INNERVATION:
The muscles of the pharynx and the mucous membrane are innervated by
the glossopharyngeal nerve (upper part) and the vagus nerve (lower part).
The pharyngeal plexus is formed by the two nerves and by some
sympathetic fibers of the sympathetic trunk (cervical part).
BLOOD SUPPLY:
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The main artery that supplies the pharynx is the ascending pharyngeal
artery (from the external carotid).
11 Para & retropharyngeal spaces
PARAPHARYNGEAL SPACE
Lateral to the pharynx, we have the parapharyngeal spaces. Its also called the
peritonsilar space because only the pharyngeal wall separates it from palatine
tonsils, and the lymphatic vessels of the palatine tonsils going through this space
into the deep cervical lymph nodes.
Internal carotid artery sometimes forms a loop which is close to the pharyngeal
wall. If you operate on the palatine tonsil, be careful not to cut too deep because
we may cut the pharyngeal wall and the internal carotid artery.
Borders:
Medial wall: pharynx
Lateral wall: medial pterygoid muscle, ramus mandibulae, and masseter
muscle,
Anterior: Bichat's fat pad; encapsulated mass of fat in the cheek.
Especially marked in infants
Posterior: styloid muscles, digastric, and sternocleidomastoid muscles
Inferior: submandibular triangle.
Structures:
Glossopharyngeal nerve (CN IX)
Most anterior structure
Vagus nerve (CN X)
Lying behind the carotid arteries and next to CNIX
Accessory nerve (CN XI)
Most posterior nerve, attached to sternocleidomastoid muscle
Hypoglossal nerve (CN XII)
Turns anterior and lies superior to mylohyoid muscle
Internal jugular vein
Formed as a continuation of the sigmoid sinus
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Superior cervical ganglion of the sympathetic trunk,
Internal carotid artery.
RETROPHARYNGEAL SPACE
It is located behind the pharynx; Any infection on the posterior wall of the
pharynx could be spread to the retropharyngeal space. From this space,the
thoracic cavity (posterior mediastinum) is accessible.
Borders:
Anterior Pos. wall of pharynx; buccopharyngeal fascia
Posterior prevertebral fascia
Lateral Carotid sheath and muscles of the styloid process
Inferiorly Posterior mediastinum
Superior Base of skull
There are no structures in the retropharyngeal space, but it is rich in lymphatic
vessels.
12 Surface projections of the pleura, lungs & the heart.cardiac
dullnesses. Points of auscultation of the valves of the heart
The lungs are surrounded by two membranes of the pleurae. Parietal pleura &
Visceral pleura. Between the two is a thin space, pleural cavity. It is filled with
pleural fluid, a serous fluid produced by the pleura.
Parietal pleura has three main parts: a) Costal (or sternocostal), b)
Diaphragmatic, and c) Mediastinal
Phrenicocostal recess: between the diaphragmatic and costal layers of the
parietal pleura.
Phrenicomediastinal recess: between the diaphragmatic and mediastinal
layers.
Costomediastinal recess: between the costal and mediastinal layers.
The phrenicocostal recess is the most important because:
CLINICAL: It is the lowest point of the pleural cavity, so the fluid inside the cavity
is collected there. We can drain this fluid and examine the quality (serous, blood,
etc.)
PHYSIOLOGICAL: The lower margin of the lung descends into this sinus during
inspiration. The inferior border of the lung descends into this sinus.
P a g e | 25
SURFACE PROJECTIONS OF THE PLEURA
Superior: Pleural dome, 3cm above the first rib
Middle: The two runs toward each other, the closest at the level
of the 2
nd
rib
Parasternal: 6
th
rib
Medioclavicular line: 7
th
rib
Ant. Axillary line:8
th
rib
Mid. Axillary line: 9
th
rib
Pos. Axillary line:10
th
rib
Scapular line: 11
th
rib
Paravertebral line: 12
th
rib
Cardiac notch: left 4-6
th
rib, into the medioclavicular line
SURFACE PROJECTIONS OF THE LUNGS
The lungs cover the heart except at one part, where the insisura cardiaca
of the left lung is.
The apex of the lung is above the clavicle, approximately 1-3 cm above
the 1
st
rib.
The medial borders of the lungs run toward each other.
o The closest point is at the level of the 2
nd
ribs. At this point, the
border of the right lung is in the midline of the sternum, and the
medial border of the left lung is at the left margin of the sternum.
Left lung. From the 2
nd
rib, the medial border descends until the 4
th
rib,
where the left lung makes a notch between the 4
th
and 6
th
ribs, called the
cardiac notch.
The medial border of the right lung descends straight down until the 6
th
rib.
So, a part of the heart is not covered by lung (between the 4
th
and 6
th
ribs,
left side).
The inferior border of the lung starts from the 6
th
rib (upper border) and
descends a little.
Medioclavicular line, it crosses the inferior border of the 6
th
rib.
Anterior axillary line, level = 7
th
rib. At the middle axillary line, it is at the
level of the 8
th
rib. At the posterior axillary line, it is at the level of the 9
th

P a g e | 26
rib. At the scapular line, it is at the level of the 10
th
rib. At the vertebral
column, it is at the level of the 11
th
rib (10
th
vertebra).
SURFACE PROJECTIONS OF THE HEART
Superior border roots of great vessels
o 2
nd
left costal cartilage, 1,3cm from the sternum
Right superior - entrance of the superior vena cava
o 2
nd
intercostal space, 1cm to the right
Right inferior Right inferior end of coronary sulcus
o 1cm right to 6
th
sternocostal joint
Right border - right atrium
o From sternal junction of 3
rd
rib to sterna junction of 6
th
in parallel to
the sternum
Left superior left superior end of coronary sulcus
o 2
nd
intercostals space, 3cm left of sternum
Left inferior Apex of heart
o 5
th
intercostals space, left 9cm
Left border left ventricle
o A straight line from a point 3cm left of 3
rd
sternocostal joint and
down to the apex
Inferior border right ventricle & apical part of left ventricle
o A line from 6
th
sternocostal joint to apex
ABSOLUTE AND RELATIVE DULLNESS OF THE HEART:
Percussion of the chest above the lungs produces a sound, resulting from
resonance within the air-filled lung (1
st
and 2
nd
intercostal spaces).
Third intercostal space
o Dull resonance due to fluid-filled heart being behind the lung.
o Sound changes to relative dullness.
Fourth intercostal space (near the sternum),
P a g e | 27
o More dull because the lung does not cover the heart. The sound
reaches only the blood-filled heart, and therefore no resonance.
This sound is called absolute dullness.
o The region of absolute dullness is at the level of the 4
th
-5
th

intercostal spaces (left side).
o The size of the absolute dullness area gives the size of the cardiac
notch.
Relative dullness marks the upper border of the heart. If you hear the
relative dullness at the 2
nd
intercostal space instead of the 3
rd
, it means
that the heart is enlarged superiorly.
For the right border, place your finger parallel to the expected border, and you
will hear the dullness at the right side of the sternum. If you hear the dullness
farther from the right side of the sternum, it means that the heart is enlarged to
the right.
For the left border, place your finger parallel to the expected border. Normally,
you can find it left of the medioclavicular line. If the heart is enlarged, it will
exceed the medioclavicular line to the left.
PROJECTIONS OF OSTIA ON THE CHEST WALL & Points of Auscultation
Ostium of the Pulmonary Trunk:
o Left side, at the level of the third sternocostal joint.
Auscultation: right 2
nd
intercostal space next to sternum
Ostium of the Aorta:
o Right below the third rib, behind the sternum.
Auscultation: Left 2
nd
intercostal space next to sternum
Ostium Bicuspid/Mitral:
o Level of the 4
th
sternocostal joint, left side.
Auscultation: Left 5
th
intercostal space 9cm left of sternum
Ostium Tricuspid:
o Level of the 5
th
sternocostal joint, right side
Auscultation: Sternal junction of right 5
th
rib
Ostium of the pulmonary trunk (most superficial)
The deepest is the left venous ostium.
P a g e | 28
Aortic valve will be auscultated at 2
nd
intercostal space, 2 cm right to the
sternum.
o The aorta comes from the left ventricle, but we hear it on the right
side because it crosses the pulmonary trunk (embryology).
13 The mediastinum. Anterior mediastinum. Intercostal
topography
The mediastinum is the middle part of the thoracic cavity which is bordered
laterally by the mediastinal pleura, anteriorly by the sternum, and posteriorly by
the vertebral column (thoracic part).
Separated into anterior and the posterior mediastinum, and the borderline
between these two is the hilus and the pulmonary ligament. The anterior
mediastinum is also divided into two parts: the cardiac, and the supracardiac
mediastinum, which contain the heart, thymus, the great vessels of the heart,
trachea, and lymph nodes of the central chest.
o Anterior to the hilus & pulmonary ligament, the anterior
mediastinum;
o Posterior to the hilus, the posterior mediastinum.
SUPRACARDIAC MEDIASTINUM
The supracardiac mediastinum has four layers:
Adipose thymus (just behind the sternum)
Layer of main veins (tributaries of the superior vena cava)
o left brachiocephalic vein (oblique and long) approx. 10-12 cm.
o right brachiocephalic vein (straight and short) approx. 2-3 cm.
these drain into the superior vena cava
Into the left brachiocephalic vein, drains the inferior thyroid vein (from the
thyroid gland).
Main arteries (branches of the aortic arch):
o brachiocephalic trunk
right common carotid & right subclavian
o left common carotid artery
o left subclavian artery
P a g e | 29
Between the layers of the main arteries and main veins, the vagus nerve and
phrenic nerve enter the thoracic cavity
14 The pleura and the pericardium
THE PLEURA
Serous membrane enveloping the lungs and lining the walls of the pleural cavity
Visceral pleura
Parietal pleura
The two parts of the pleura meets at the roots of the lungs where the pulmonary
arteries and veins, and the bronchi enter the lungs. An inferior elongation forms
the pulmonary ligament. The cavity between the two pleura is filled with serous
fluid. The lungs and the cavity are not a perfect match and recesses are found.
Phrenicocostal/costodiaphragmatic
o If fluid enters the cavity, it can be drained from this recess
Phrenicomediastinal
Costomediastinal
THE PERICARDIUM
Fibrous membrane, covering the heart and beginning of the great vessels. It is a
closed sac having two layers; Visceral layer & Parietal layer.
Reflections of the parietal layer onto the visceral layer:
Arterious reflection
o At the division of the pulmonary trunk
o The ascending aorta and pulmonary trunk remains inside
Venous reflection
o Superior vena cava, below the entrance of zygomatic vein.
o Inferior vena cava, phrenic entrance, therefore, entire inferior vena
cava is inside
o Pulmonary veins (ca 1-2cm are inside the pericardiac cavity). These
reflections form a letter "T" which is called Sappey's T.
Transverse sinus
o Formed during heart tube folding
P a g e | 30
venous end migrates upward and behind the arterious end,
and if forms a "U" shaped tube
o Separates the ascending aorta and the pulmonary trunk from the
superior vena cava
Oblique sinus
o A blind recess posterior to the base of the heart
o Between left and right pulmonary veins
15 Atria of the Heart
The portion of the blood that receives blood from the systemic & pulmonary
circulation
RIGHT ATRIUM
Right atrium (having right border), forms the anterior surface of the heart.
Two main parts: Auricle & Atrium proper
Separated by sulcus terminalis (outside) and crista terminalis (inside). The
crista terminalis develops from the septum spurium (see embryology).
Pectinate muscles only inside the auricle.
The atrium proper, has smooth inner surface (no pectinate muscles)
The main part of the atrium proper is the sinus venarum cavarum
(receives the superior and inferior venae cavae).
Openings of right atrium
Superior vena cava
o No valves
Inferior vena cava
o Eustachian valve (non-functional).
In fetal life this valve guided the blood from the inferior vena
cava through the oval foramen to the left atrium. When
pointing, note the direction
Coronary Sinus
o Thebesian valve
P a g e | 31
o Drains the blood from the heart wall. When pointing, note the
direction
Fetal remnant:
Oval fossa (from oval foramen)
o Surrounded by limbus fossae ovalis
o Patent foramen ovale (Atrial septal defect)
When the foramen doesnt entirely close
Pacemaker of the heart, called the sinoatrial node or the sinus node. This node is
located in the upper end of the terminal sulcus at the inlet of the superior vena
cava
LEFT ATRIUM
The left atrium is located on the posterior surface (or mediastinal) of the
heart, and has a close relation with the esophagus.
o During esophagoscopy (or gastroscopy) it is possible to accidently
pierce the wall of the esophagus, risking injuring the left atrium of
the heart.
Two parts: the AURICLE and the ATRIUM PROPER.
o The auricle has the pectinate muscles.
Only part of the left atrium which is visible at the left margin
of the heart.
o The smooth part is the atrium proper.
The atrium proper receives oxygenated blood from the 4
pulmonary veins (no valves) on the posterior surface
16 Orifices of the heart. The valves and their function
Atrioventricular orifices:
Right
o Tricuspid valve (ant, pos & septal cusps)
Attached to chorda tendinae and further papillary muscle
Regulates flow from atrium to ventricle
P a g e | 32
Closed during systole & Opened during diastole
Left
o Bicuspid/Mitral valve (ant & pos cusps)
See above
Venous openings:
Superior vena cava
o No valves
Inferior vena cava
o Eustachian valve, located anterior inferior
Coronary orifice
o Thebesian valve
Pulmonary orifice:
Pulmonary veins (4)
o Open into left atrium, draining oxygenated blood from lungs
Pulmonary trunk
o Divide into right/left pulmonary artery and run from right ventricle
to lungs.
o Semilunar valve with 3 semilunar shaped cusps (ant, right pos & left
pos)
Aortic orifice
From left ventricle into the aorta
Aortic semilunar valve with posterior, anterior right & anterior left cusps
VALVES
There are cuspid and semilunar valves
Cuspid valves are composed of mesothelium on both surfaces.
o Between the mesothelium layers, we have fibrous cutaneous tissue.
o These valves arise from the annulus fibrosus, the skeleton of the
heart.
P a g e | 33
Semilunar valves
o Function of the nodules is to close the orifice.
o There are 6 lunulae and 3 nodules in one valve.
o Dense part &flexid part.
The dense part is the peripheral part (arising from the fibrous
ring), and the flexid part is the central part (loose).
Above the valve of the aorta, there is a dilated part which is called the aortic
sinus. This aortic sinus has the orifice of the coronary arteries (right and left).
FIBROUS RINGS:
The muscles of the atria and ventricles arise from this fibrous ring, and it has the
orifices. Between the left and right venous ostia and the aorta there is a right
fibrous trigone. The left one is between the aorta and the left venous ostium.
Through the right fibrous trigone, we have the His bundle. From the atrium, the
impulse goes through the fibrous ring into the ventricle.
17 Ventricles of the heart. Radiogram of the heart
Generally, the ventricles have three muscular layers and the atria have two
muscular layers; therefore, the ventricles are thicker than the atria. The papillary
muscles form the inner layer of the ventricle together with the bridges and ridges
or the trabeculae carneae (Rathke's bundles).
The border between atrium and ventricle is the coronary sulcus.
The border between the ventricles are the anterior interventricular groove.
RIGHT VENTRICLE
V-shaped
In flowing part
o The portion from which blood flows from the atrium to the ventricle
via tricuspid.
The out flowing part forms a cone on the outer surface which is called the
conus arteriosus. From the conus, the pulmonary trunk starts.
Crista supraventricularis separates the inflowing and out flowing parts of the
ventricles from each other.
P a g e | 34
The largest papillary muscle has a muscular cord from the interventricular
septum. This cord is called Moderator band of septomarginal trabecula
LEFT VENTRICLE
Forms the left surface, diaphragmatic surface and apex of the heart.
Bicuspid valve attached to the anterior and posterior papillary muscle by
chorda tendinae.
Thicker wall than that of the right ventricle (about 1-1.5cm), and the
interventricular septum is also formed by this thick wall of the ventricle.
o In cross section, the left ventricle is round.
Aortic orifice (the origin of the aorta).
RADIOGRAM
The X-ray of the heart has two arches on the right side and four arches on the
left side.
The superior arch on the right side is formed by the superior vena cava
and the ascending aorta.
The inferior arch on the right side is formed by the right atrium.
On the left side, the arches are formed by
1
aortic arch,
2
pulmonary trunk,
3
left auricle, and
4
left ventricle.
Inferior border is not visible because below, we have the liver, and the
density of the heart and liver is the same.
(Netter plate 209)
18 Blood supply of the heart
ARTERIES:
The coronary arteries arise from the sinus (ascending) aorta, which is the first
dilated portion of the aorta just above the valves. The coronary arteries and their
major branches are distributed over the surface of the heart, lying within
subepicardial connective tissue
Right coronary artery:
Runs forward between the pulmonary trunk and the right auricle
It descends in the posterior interventricular groove
P a g e | 35
It anastomose with the left one coronary artery
Branches supplies the right atrium, 1cm into the right ventricle and
posterior part of interventricular septum (by posterior septal artery)
Branches:
o Right conus artery
o Anterior ventricular branch
o Posterior ventricular branch
o Atrial branch
o S-A nodal branch
Left coronary artery:
It runs forward between the pulmonary trunk and the left auricle
It divides into circumflex branch and anterior interventricular branch
o Anterior interventricular branch descends in anterior interventricular
groove
Supplies major part of the heart:
Left atrium and left ventricle
Anterior part of Interventricular septum
1cm or the right ventricular wall
VENOUS DRAINAGE OF THE HEART
Great cardiac vein
o Begins at apex and ascends in the anterior interventricular groove
o Runs with the anterior interventricular branch of the left coronary
artery, then with circumflex branch of the left coronary artery, and it
enters the coronary sinus from the left side
o Oblique/Marshal vein of left atrium joins great cardiac vein
Middle Cardiac vein
o Begins at apex and ascends in the posterior interventricular groove
o Runs together with the posterior interventricular branch of the right
coronary artery
P a g e | 36
o Joins small cardiac vein before draining to coronary sinus on the
right side
Small cardiac vein
o Right ventricle
o Runs with Right coronary artery
o Joins middle cardiac vein before draining to the coronary sinus.
Between the right and left ends, the coronary sinus opens into the right atrium of
the heart.
In addition to these three veins, there are also tiny veins on the right ventricle
(anterior surface) called venae cordis anterioris. They cross the coronary sulcus
to enter the right atrium directly. There are also the tiny veins called venae
cordis minimae (thebesian veins) from the atria which also directly drain to the
atria.
19 The structure of cardiac wall. The conducting system and
innervation of the heart
LAYERS OF THE HEART:
3 main layers:
OA serous layer: epicardium (visceral layer is the pericardium).
OA muscular layer: myocardium.
OAn inner layer: endocardium.
Epicardium
o Layered by mesothelium
o Connected to the muscle by a fibrous connective tissue which has
fat
o The coronary artery and cardiac veins lie beneath this epicardium.
Myocardium
VENTRICLE
o The external oblique
P a g e | 37
Starts from the right end of the coronary sulcus on the
anterior surface and descends toward the apex from right and
superior to left and inferior.
On the posterior surface, it starts from the left side to the
right side.
At the apex, these fibers meet each other and form a turn
which is called vortex cordis.
o The middle circular layer
Parallel to the coronary sulcus.
This layer is missing on the apex, where there is only the
vortex cordis.
o The internal longitudinal layer
The fibers turning inward and upward continue into the inner
muscular layer of the heart forming papillary muscle and
trabeculae carneae.
ATRIUM
The muscle of the atrium is not so regular and it is thin (just two layers). The
outer is longitudinal and the inner is circular.
Around the inlet of the veins (sup & inf vena cava) the muscle fibers are regular
arranged in circles around the inlet of them.
Endocardium has 2 layers:
Fibrous layer & epithelial (endothelial layer)
Fibrous layer connects the endothelium
(innermost layer) to the myocardium
The valves are also layered by endocardium,
both inferior and superior surfaces, and between
these endothelial layers, there is the fibrous
layer.
CONDUCTING SYSTEM:
Sinoatrial node
o Natural pacemaker
o Situated at upper end of terminal sulcus, near the anterior margin of
inlet superior vena cava
P a g e | 38
o Impulses travel by intermodal pathways in right atrium towards
Atrioventricular node.
Atrioventricular node
o In interatrial septum below oval fossa and left to the orifice of
coronary sinus
His bundle
o Pierces right fibrous trigone (entering ventricle)
o Divide into left and right tawara bundles moving in the interseptal
surface.
Right bundle is located inside the moderator
band/septomarginal trabeculae
Purkinje Fibers
o Fibers from tawara bundles from interventricular septum runs
upwards again along inner ventricular wall.
INNERVATION OF THE HEART:
The heart is supplied by both sympathetic and parasympathetic fibers. These
fibers reach the heart in three plexuses called superior, middle, and inferior
cardiac plexuses.
Sympathetic innervation:
Postganglionic fibers from the cervical and upper thoracic portions of the
sympathetic trunk
The fibers reach the heart through superior, middle and inferior cardiac
branches.
The fibers pass through and terminate on the sinoatrial and
atrioventricular nodes
Stimulate increased heart rhythm, increased contraction force and dilation
of the coronary arteries.
Parasympathetic innervation:
Vagus nerve
Terminate by synapsing on neurons in the cardiac plexus.
Postganglionic fibers terminate on the sinoatrial, atrioventricular nodes
and on the coronary arteries.
P a g e | 39
Stimulate decreased heart rate, force and constriction of the coronary
vessels.
20 The lungs, pulmonary roots, bronchopulmonary segments
THE LUNGS
Paired visceral organs occupying the pulmonary cavities of the thorax. They are
the organs in which respiration, gas exchange of blood happens. They are
covered by pleura.
Right lung:
3 lobes (superior, middle & inferior)
impressions for the azygos vein (below and above the hilus) and also the
superior vena cava. Because the azygos vein drains into the superior vena
cava, we also have the impressio cardiaca pulmonis (impression for the
heart).
Horizontal and oblique fissure
Inferior lobe is mainly behind the superior and inferior lobes
Left lung:
2 lobes (superior & inferior)
It has a wide impression called the aortic sulcus. It is made by the
descending thoracic aorta and the aortic arch. It also has the sulcus of the
subclavian artery that is next to the apex.
Oblique fissure
Surface projections
The horizontal fissure follows the fourth rib.
The oblique starts from the horizontal fissure in the axillary line and
crosses the 5
th
rib, terminating at the 6
th
rib (at the 6
th
sternocostal joint).
PULMONARY ROOT
The site where the visceral and parietal pleura meet. A fold descends and forms
the pulmonary ligament. The pulmonary root consist of the structures passing
through the hilum of the lung.
Structures:
Pulmonary artery
P a g e | 40
2 Pulmonary veins
Main/Principal bronci
Lymphnodes
Nerves
Structures in the lung:
From superior to inferior:
o Left lung (artery, bronchus, vein) - ABV
o Right lung (Bronchus, artery, vein) - BAV
From anterior to posterior:
o Vein, artery, bronchus (in both lungs)
BRONCOPULMONARY SEGMENTS
The segments are the morphological, functional, pathological, and surgical units
of the lung. We can remove one segment surgically if there is a disease or tumor
10 segments in each lung
o Right: three in the superior lobe, two in the middle, and five in the
inferior lobe.
o Left: five in the superior lobe and five in the inferior
Pyramidal shaped
The apex of the pyramid is facing toward the hilus
At the apex of this pyramid, the segmental bronchus enters the segment
together with the segmental branch of the pulmonary artery.
Center of the segment is the bronchus tree and the pulmonary artery (next
to each other).
Segments separated by connective tissue septa.
o Inside this septa are the pulmonary veins and lymph vessels running
toward the hilus.
Segment is composed of smaller units called lobules.
Pyramidal shape
P a g e | 41
One lobule belongs to one terminal bronchus which is branching inside the
lobule forming bronchioli.
The difference between bronchi and bronchioli-- no cartilage, no glands,
but there is smooth muscle.
On the surface of the lung, you can see small, approximately 1-2cm areas
bordered by black color (surrounded) that are the lobules. We can only see the
base because the base is facing toward the surface. The black area is pollution
inside the connective tissue that separates the lobules from each other.
Double circulation (functional and nutritive)
21 Posterior mediastinum
The mediastinum is the middle part of the thoracic cavity which is bordered by:
Laterally: mediastinal pleura
Anteriorly: sternum
Posteriorly: vertebral column (thoracic part).
Superiorly: Thoracic outlet & root of the neck
Inferiorly: The diaphragm
Anterior and the posterior mediastinum
Borderline = hilus & pulmonary ligament.
Structures:
o esophagus
25cm
3 parts: Cervical, thoracic & small abdominal part (T11)
o vagus nerve
Right: vagus behind the esophagus. Left: vagus in front of
the esophagus.
o Descending aorta (thoracic part)
o Thoracic duct
Between azygos vein and thoracic aorta, in right pos.
mediastinum.
P a g e | 42
At the level of 4
th
thoracic vertebra, it turns left behind
esophagus in front of the vertebral column, to the left venous
angle
Before entering, it collects: Cleft jugular trunk (left
side, head and neck), Cleft subclavian trunk (drains the
left upper limb), and Cleft bronchomediastinal trunk
(drains the lung and the thoracic cavity mediastinum,
so the left part of the whole thoracic cavity).
Arises from the CISTERNA CHYLI (in abdominal cavity behind
aorta ,L1)
Collects lymph from right/left lumbar trunks &
intestinal trunk
Drains 3/4 of the body
Last of the body is drained by right lymphatic trunk
having the same 3 trunks (right)
Runs through diaphragm behind aorta
o Azygos & hemiazygos vein
Azygos vein originate in abdominal cavity as ascending
lumbar vein
Collects segmental lumbar vein (drain posterior abdominal
wall).
Via diaphragm with greater & lesser splanchnic nerves
between medial and intermediate crus.
Collects intercostals vein in posterior mediastinum
Drain thoracic wall), the bronchial veins from the lungs, the
esophageal veins, and the external vertebral venous plexus
Only the intercostal veins are visible and dissectible
Azygos vein receives the hemiazygos vein from the left side
which collects the same veins from the left side plus the
accessory hemiazygos
o Sympathetic trunk
composed of 12 paravertebral ganglia
interganglionic fibers
1
st
thoracic 3
rd
lumbar: Autonomic nervous system:
Sympathetic neuron cell bodies
P a g e | 43
Sacral part contains parasympathetic neuron cell bodies
White rami communicants:
Preganglionic fibers with myelin sheath
Originate from lateral horns of grey matter
Contain synapses to neuron cell bodies within the
ganglion that further sends axon fibers to the periphery
Grey rami communicants:
Postganglionic fibers without myelin sheath
Innervate glands & smooth muscles of vessels and
skin(Arrestor pile)
Ventral root contains sympathetic motor and
somatomotor fibers
Dorsal root (sensory): Only sensory ganglions that has
pseudounipolar neuron cell bodies.
Splanchnic nerves are formed by sympathetic fibers
that run through ganglia without synapsing.
6-9
th
ganglia greater splanchnic
10-11
th
ganglia lesser splanchnic
Preganglionic fibers terminate in celiac ganglion
where they synapse: Their postganglionic fibers
innervate:
Blood vessels of viscera
Smooth muscles of abdominal viscera
22 Lymphatic drainage of the thoracic wall and thoracic viscera
Thoracic duct
o Between azygos vein and thoracic aorta, in right pos. mediastinum.
o At the level of 4
th
thoracic vertebra, it turns left behind esophagus in
front of the vertebral column, to the left venous angle
Before entering, it collects: Cleft jugular trunk (left side, head
and neck), Cleft subclavian trunk (drains the left upper limb),
and Cleft bronchomediastinal trunk (drains the lung and the
P a g e | 44
thoracic cavity mediastinum, so the left part of the whole
thoracic cavity).
o Arises from the CISTERNA CHYLI (in abdominal cavity behind aorta ,L1)
Collects lymph from right/left lumbar trunks & intestinal
trunk
o Drains 3/4 of the body
o Last of the body is drained by right lymphatic trunk having the
same 3 trunks (right):
Right bronchomediastinal trunk (drains the lung and the
thoracic cavity mediastinum, so the right part of the whole
thoracic cavity).
Primary lymph nodes?
Axillary lymph nodes?
o Drains lateral half of breast
o Investigated regularly as a part of the clinical investigation of breast
cancer
23 The lymphatic system and lymphatic circulation. The main
lymphatic trunks
LYMPHATIC SYSTEM (See topic 22 for Main lymphatic trunks)
Network of lymphoid organs, lymph nodes, lymph ducts, and lymph vessels that
produce and transport lymph fluid from tissues to the circulatory system. The
lymphatic system is a major component of the immune system.
The lymphatic system has 3 functions:
o Removal of excess fluids from body tissues
o Absorption of fatty acids and subsequent transport of fat, chyle, to
the circulatory system
o Production of immune cells (such as lymphocytes, monocytes, and
antibody producing cells called plasma cells).
Lymph originates as blood plasma that leaks from the capillaries of the
circulatory system, becoming interstitial fluid, and filling the space between
individual cells of tissue.
P a g e | 45
Plasma is forced out of the capillaries by oncotic pressure gradients, and as it
mixes with the interstitial fluid, the volume of fluid accumulates slowly. The
proportion of interstitial fluid that is returned to the circulatory system by
osmosis is about 90% of the former plasma; with about 10% accumulating as
overfill.
The excess interstitial fluid is collected by the lymphatic system by diffusion into
lymph capillaries, and is processed by lymph nodes prior to being returned to the
circulatory system. Once within the lymphatic system the fluid is called lymph,
and has almost the same composition as the original interstitial fluid.
LYMPHATIC CIRCULATION
Acts as a secondary circulatory system, except that it collaborates with
white blood cells in lymph nodes.
Unlike the circulatory system, the lymphatic system is not closed and has
no central pump;
o The lymph moves slowly and under low pressure due to peristalsis,
the operation of semilunar valves in the lymph vessels, and the
milking action of skeletal muscles. Lymph vessels have one-way,
semilunar valves and depend mainly on the movement of skeletal
muscles to squeeze fluid through them.
This fluid is then transported to progressively larger lymphatic vessels
culminating in the right lymphatic trunk (1/4
th
right upper body) and the
thoracic duct (3/4
th
); these ducts drain into the circulatory system at the
right and left venous angles.
The lymph goes through minimum 1 lymph node before it enters the blood
circulation
SPLANCHNOLOGY II
24 Regions of the abdomen. Projections and
peritoneal relations of the abdominal viscera
REGIONS OF THE ABDOMEN
11 regions by two longitudinal lines (right and left
midclavicular lines) and two transverse planes (subcostal
P a g e | 46
and interspinous planes). +2 regions, lateroposterior to each of the
hypochondriac regions called renal regions (not seen in picture).
PROJECTIONS AND PERITONEAL RELATIONS OF THE ABDOMINAL VISCERA
Viscera: An organ of the digestive, respiratory, urogenital, and endocrine systems
as well as the spleen, heart and great vessels; Hollow multilayered walled
organs.
Right hypochondrium
o Liver
Highest of the level of upper 5
th
rib behind costal arch
If felt below right costal arch, it is enlarged
Intra
o Gallbladder
Crossing midclavicular line and right costal arch
Painful during palpation if infected
Intra
o Right colic flexure
Intra
Epigastric region
o Stomache
Cardia (T11, right), Pylorus (L1, left)
When full of food, it can reach down to umbilicus
Intra
o Left lobe of liver
Intra
o Pancreas
Head (L1,L2), Body runs in front of L1 & tail reach T12
Head & Body (Retro), Tail (Intra)
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o Duodenum
Sup. Hor. (L1), Descending (L1-L3), Inf. Hor. (L3), Ascending
(L3-L2)
Sup. Horizontal (intra), The rest is retroperitoneal
o Abdominal aorta & Inferior vena cava
Left Hypochondrium
o Spleen
9
th
-11
th
Rib
If felt below left costal arch, it is enlarged
Intra
o Fundus of stomach
Intra
o Left colic flexure
Related to the spleen
Intra
Umbilical region
o Small intestine
Retro
o Transverse colon
Related to the spleen on left side, and liver on right side
Intra
o Abdominal aorta & Inferior vena cava
Right lumbar region
o Ascending colon
Intra/retro
Left lumbar region
o Descending colon
Intra/retro
P a g e | 48
o Small intestine (jejunum)
Right iliac region
o Cecum
Intra/Retro
o Appendix
McBurneys point: Line between umbilicus & ant. Sup. Iliac
spine. The point is 1/3
rd
from ant. Sup. Iliac spine
Intra
o Terminal part of Ileum
Intra
Left Iliac region
o Sigmoid colon
Intra/retro
o Small intestine
Pubic region
o Urinary bladder
Infraperitoneal
o Uterus after 12 weeks of pregnancy
o Part of small intestine
Kidneys and suprarenal glands are found in the left/right renal region, right/left
hypochondriac or right/left lumbar region depending on textbook.
25 The peritoneum and the peritoneal cavity
P a g e | 49
The serous sac, consisting of mesothelium and a thin
layer of irregular connective tissue, that lines the
abdominal cavity and covers most viscera contained
therein. It forms the greater & lesser sac, connected by
the epiploic foramen.
PERITONEAL RELATIONS OF VISCERA
Stomache Intra
Duodenum
o Superior horizontal intra
o Descending retro
o Inferior horizontal retro
o Ascending retro
Colon
o Cecum intra/retro
o Ascending intra/retro
o Transverse intra
o Descending intra/retro
Small intestine intra
Liver intra (except bare area)
Spleen intra
Kidney retro
Pancreas
o Head & body retro
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o Tail intra
Uterus infra
Urinary bladder infra
Rectum
o upper 1/3 intra
o middle 1/3 retro
o lower 1/3 infra
LIGAMENTS (Taken from Kovacs notes)
Diaphragm is layered by parietal peritoneum which reflects onto the liver,
forming the posterior layer of the coronary ligaments (left and right)
Another reflection of the parietal peritoneum onto the liver is the falciform
ligament (double layer.
o The left layer of the falciform ligament continues into the anterior
layer of the left coronary ligament, and the right layer of the
falciform ligament continues in the right coronary ligament.
The posterior layer of the coronary ligament comes from the parietal
peritoneum from the diaphragm above. This way, the two layers are next
to each other, forming a double layer at the left coronary ligament. The
right ligament remains as separate layers.
The peritoneum reflecting to the liver covers both surfaces of the liver, and the
two layers meet each other again at the porta hepatis along side the fissura
ligamenti venosi.
This double layer descends in the stomach and duodenum forming the
hepatogastric and hepatoduodenal ligaments that are together called the lesser
omentum. The hepatogastric ligament, reaching the lesser curvature of the
stomach, divides into two layers that cover the stomach and meet each other
again at the greater curvature.
The new double layer descends into the lesser pelvis and turns back, forming
four layers which is the greater omentum. These four layers go up until the
transverse colon. Here, the third layer of the four runs back to the posterior
abdominal wall and continues with the parietal peritoneum covering the pancreas
(posterior wall of the lesser sac). The fourth layer also turns back to the posterior
abdominal wall, but it comes forward again, forming the visceral layer of the
transverse colon, then turns back again. These four layers then form the
transverse mesocolon. Comes forward again to form the mesenterium (layering
the small intestine). After this, it reflects onto the posterior abdominal wall.
P a g e | 51
BURSA OMENTALIS (lesser sac):
Superior wall: liver and superior recess of the lesser sac,
Anterior wall has three parts:
1
lesser omentum,
2
stomach,
3
gastrocolic ligament.
Posterior wall: parietal peritoneum (covering the pancreas)
Splenic recess: the left recess of the lesser sac (at the hilus of the spleen
between the gastrolienal and phrenicolienal ligaments.
Epiploic (Winslow's) foramen:
o Right side of the hepatoduodenal ligament, behind the ligament
o Hepatoduodenal ligament (front)
o Liver (above)
o Hepatorenal ligament (behind)
o Duodenorenal ligament (below)
26 Parts, topography and peritoneal relations of the stomach
Fragments of food are chemically broken down in the stomach by the gastric
juice to produce chyme. Stomach controls the rate of delivery of chyme to the
small intestine. Capacity: 1200-1600ml.
PARTS OF STOMACH
Cardiac orifice: Continuation of the esophageal orifice
Cardia: Transition between esophagus and stomach
Fundus: Arises on the left superior part of stomach
Pylorus
SURFACE PROJECTIONS
Upper part of abdomen in epigastric region
Extend from beneath left costal margin into the umbilical region
Majority lies under the cover of lower ribs
J shaped organ
SKELETOPY
Cardia: T11, left (fixed point)
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Fundus: 7
th
rib, 2cm left of the midline
Pylorus: L1, right (fixed point)
Lesser and greater curvature runs between cardia and pylorus
PERITONEAL RELATIONS
Stomach is intraperitoneal, and the peritoneum forms several ligaments
connecting it to the viscera:
Along the lesser curvature: Hepatogastric ligament
Along the greater curvature:
o Gastrosplenic ligament
o Gastrophrenic ligament
o Gastrocolic ligament
o Greater omentum
RELATIONS OF STOMACH
Superior
o Liver
o Diaphragm
Inferior
o Transverse colon
o Mesocolon
Anterior
o Abdominal wall
o Left costal arch
o Diaphragm
o Left lobe of liver
Posterior
o Omental bursa
o Diaphragm
o Left adrenal gland
P a g e | 53
o Left kidney
Left lateral
o Spleen
27 Blood supply of the stomach
Left gastric artery:
Abdominal aorta-celiac trunk-left gastric artery
Extend left to esophagus, then descend along lesser curvature
Supplies upper right part of stomach
Supplies lower third of esophagus
Right gastric artery:
Abdominal aorta-celiac trunk-common hepatic-hepatic artery proper-right
gastric artery
Runs along lesser curvature
Supplies lower right part of stomach
Anastomose with left gastric artery
Short gastric artery:
Abdominal aorta-celiac trunk-Splenic-short gastric artery
Arise at splenic hilum and run in gastrosplenic ligament
Supply fundus of stomach
Left gastroomental artery
Abdominal aorta-celiac trunk-splenic-left gastroomental artery
Arise at splenic hilum and runs along greater curvature
Supply stomach along the upper part of greater curvature
Right gastroomental artery
Abdominal aorta-celiac trunk-common hepatic-gastroduodenal-right
gastroomental artery
Ascends along greater curvature
Anastomose with left gastroomental artery
P a g e | 54
Supply lower part of the greater curvature
Veins
From lesser curvature:
o Right and left gastric veins-portal vein
From Greater curvature
o Right and left gastroomental-sup. Mesenteric-splenic-portal vein
The left gastric vein anastomose with the esophageal venous plexus that drain
into the azygos vein which drains to the superior vena cava. This anastomoses is
also an anastomoses between the portal and cava venous systems.
LYMPHATIC DRAINAGE
The lymph vessels follow the arteries into the left and right gastric node,
gastroomental nodes and the short gastric nodes. All lymph from the stomach
eventually passes to the celiac nodes.
NERVE SUPPLY
Sympathetic Celiac ganglion
Parasympathetic Vagus nerve
28 The hepatoduodenal ligament and its content. The lesser sac
THE HEPATODUODENAL LIGAMENT
The portion of the lesser omentum which connects the liver and duodenum. The
hepatoduodenal ligament have 3 structures:
Bile duct
o Formed by the union of common hepatic duct and cystic duct. It
discharges bile at the major duodenal (vaters) papilla.
o Bile: Secretum for fat digestion
Hepatic artery proper
o Celiac trunk-common hepatic artery-hepatic artery proper
Portal vein
o Drains the unpaired viscera of the abdomen
LESSER SAC
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The lesser sac or omental bursa is found behind the lesser omentum and is
connected to the greater sac via the epiploic (Winslows) foramen, which is found
behind the hepatoduodenal ligament and in front of the inferior vena cava. The
lesser sac is developed as the stomach, duodenum and lesser omentum turns 90
degrees.
Superior
o Liver & superior recess of lesser sac
Anterior
o Lesser omentum
o Stomach
o Gastrocolic ligament
Posterior
o Parietal peritoneum
Lateral right
o Open space (epiploic foramen)
Lateral left
o Splenic recess
29 Topography and peritoneal connections of the liver
Skeletopy
Superior level: Upper & lower border of 5
th
rib depending on right or left
lobe or liver
Inferior level: Right costal arch
PERITONEAL RELATION (Kovacs notes)
Diaphragm is layered by parietal peritoneum which reflects onto the liver,
forming the posterior layer of the coronary ligaments (left and right)
Another reflection of the parietal peritoneum onto the liver is the falciform
ligament (double layer.
o The left layer of the falciform ligament continues into the anterior
layer of the left coronary ligament, and the right layer of the
falciform ligament continues in the right coronary ligament.
P a g e | 56
The posterior layer of the coronary ligament comes from the parietal
peritoneum from the diaphragm above. This way, the two layers are next
to each other, forming a double layer at the left coronary ligament. The
right ligament remains as separate layers.
The peritoneum reflecting to the liver covers both surfaces of the liver, and the
two layers meet each other again at the porta hepatis along side the fissura
ligamenti venosi.
This double layer descends in the stomach and duodenum forming the
hepatogastric and hepatoduodenal ligaments that are together called the lesser
omentum. The hepatogastric ligament, reaching the lesser curvature of the
stomach, divides into two layers that cover the stomach and meet each other
again at the greater curvature.
The new double layer descends into the lesser pelvis and turns back, forming
four layers which is the greater omentum. These four layers go up until the
transverse colon. Here, the third layer of the four runs back to the posterior
abdominal wall and continues with the parietal peritoneum covering the pancreas
(posterior wall of the lesser sac). The fourth layer also turns back to the posterior
abdominal wall, but it comes forward again, forming the visceral layer of the
transverse colon, then turns back again. These four layers then form the
transverse mesocolon. Comes forward again to form the mesenterium (layering
the small intestine). After this, it reflects onto the posterior abdominal wall.
30 Parts and surfaces of the liver
The liver has a diaphragmatic & a visceral surface
The visceral surface has a right and left lobe, separated by the falciform
ligament. Between the right left lobes, the caudate and quadrate lobes are found.
Superior
o Diaphragm via bare area
Right lobe
o Costal arch
o Colic impression
o Renal impression
o Suprarenal impression
o Duodenal impression
Quadrate lobe
o Gallbladder
P a g e | 57
o Pylorus
o Groove for inferior vena cava
Left lobe
o Esophageal impression
o Gastric impression, lesser curvature and anterior surface
o Diaphragm through the bare area
Caudate lobe
o Inferior vena cava
LIGAMENTS OF LIVER
Falciform ligament
o Inferior part of falciform Round ligament of the liver
(remnant of left umbilical vein)
Right layer of falciform continues to right coronary ligament, and the left
layer to left coronary ligament.
o The coronary ligaments on each side form the right and left
triangular ligaments.
Ligamentum venosum
Hepatoduodenal ligament
Between the 4 lobes of the liver, the H-fissure is found
Longitudinal part
o Left
Superior: Ligamentum venosum (fissure for venous ligament)
Inferior: Round ligament (fissure for round ligament
o Right
Superior: Fissure for inferior vena cava
Inferior: Fissure for gallbladder
o Horizontal part
Hepatoduodenal ligament + portal triad (Portal fissure)
Ligaments connecting the liver to other viscera
P a g e | 58
Hepatoduodenal
Hepatorenal
Hepatogastric
31 The spleen
A large vascular lymphatic organ lying in the upper left part of the abdominal
cavity, between the stomach, pancreas and kidney medially and the diaphragm
posterolaterally.
SKELETOPY
Level of 9
th
-11
th
rib
SURFACES
Diaphragmatic surface (convex)
Anterior visceral surface
o Superiorly: Gastric impression
o Inferiorly: Colic impression
Posterior visceral surface
o Renal impression
RELATIONS OF SPLEEN
Anterior: Stomache. Posteromedial: Kidney. Posterolateral: Diaphragm. Inferior:
Left colic flexure. Hilus: Tail of pancreas
HILUS
Splenic artery
Splenic vein
LIGAMENTS
Splenorenal (lienorenal)
o Contain splenic vessels
Gastrosplenic
o Contain short gastric vessels
Phrenicocolic
P a g e | 59
o It forms a nest for the spleen that prevent it from descending
NERVE INNERVATION
Splenic plexus branches of celiac plexus the left celiac ganglion
Vagus nerve (right)
32 The duodenum and the pancreas
DUODENUM
It is the first division of the small intestine, connected to the pylorus of the
stomach superiorly (proximal end) and the jejunum inferiorly (distal end).
Superior horizontal part
Intraperitoneal
L1
Descending part
Retroperitoneal
L1-L3
Inferior horizontal part
Retroperitoneal
L3
Ascending part
Gradually becomes intraperitoneal at the duodenaljejunal flexure
L3-L2
BLOOD SUPPLY
Arterial
o Gastroduodenal artery
o Superior pancreaticoduodenal artery
o Inferior pancreaticoduodenal artery
Venous
o Superior and Inferior Pancreaticoduodenal veins
Nerve
P a g e | 60
o Celiac ganglia & Vagus
PANCREAS
It is an elongated, lobulated and retroperitoneal gland. Devoid of capsule.
Extending from concavity of duodenum to spleen. The gland secretes part of
the pancreatic juice that is discharged into the intestine, and from its endocrine
part, insulin, glucagons, etc.
The pancreas posses a head, body, tail
SKELETOPY
Head: L3-L2
Body: L1
Tail: L1-T12
Main pancreatic duct
The duct unites with the common bile duct in the hepatopancreatic
ampulla
Opens into the major duodenal (Vaters) Papilla
Accessory pancreatic ducts opens into the minor duodenal papilla
Blood supply
Arterial:
o Superior & Inferior pancreaticoduodenal arteries
o Pancreatic arteries (from splenic artery)
Venous:
o Pancreaticoduodenal veins
Nerve supply
Pancreatic plexus
Celiac ganglia
Vagus
33 The intestines (except the duodenum and rectum)
THE INTESTINES
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The intestines start with the duodenum, which is connected to the pylorus of
stomach. It then continues as jejunum, ileum and colon. The greater omentum
covers the intestines.
Jejunum:
o Located in the upper left part of the abdomen
o The coils runs horizontally
o 6m long together with Ileum
Ileum
o Located in the lower part of the abdomen, umbilical region and
sometimes the right and left lumbar regions.
o The coils runs vertically
o Iliocecal (iliocolic) junction in right iliac region
The small intestines have a long mesenterium carrying the blood vessels
supplying it
Colon: To differentiate between the small and large intestine, look for the tenia,
epiploic appendices.
Cecum
o Iliocecal junction (in right iliac fossa)
o Appendix is found below this junction
Tonsil of intestine
Ascending colon
o Right lumbar region
o Retro & partly intraperitoneal
Right colic flexure
o Related to liver and found in right hypochondriac region
Transverse colon
o Umbilical region ( middle part at level of L3)
o Connected to posterior abdominal wall by transverse mesocolon
o Greater omentum is attached to the superoanterior part
Left colic flexure
P a g e | 62
o Related to the spleen and found in the left hypogastric region
o Phrenicocolic ligament connects it with the diaphragm forming the
nest of spleen.
Descending colon
o Left lumbar region
o Related to kidney
o Retro & partly intraperitoneal
Sigmoid colon
o Intraperitoneal
o Connected to posterior abdominal wall by sigmoidal mesocolon
o Left iliac region
Tenia of the colon:
Mesocolic, Omental & Free tenia
o = Longitudinal muscle bands
Nerve supply
Intestines are supplies by celiac ganglia and vagus
34 The celiac trunk and its branches
Celiac trunk is a direct branch from the abdominal aorta and can be found at the
superior border of the pancreatic neck at the approximate level of T12-L1.
(See Netter; Plate 290-295)
Celiac trunk
o Left gastric
o Common hepatic
Hepatic artery proper
Right gastric
Right/Left hepatic
Gastroduodenal
P a g e | 63
Right gastroduodenal
Superior pancreaticoduodenal
o Splenic
Pancreatic branches (greater, dorsal & tail)
Left gastroomental
Short gastric
Splenic branches
35 Superior and inferior mesenteric arteries and their
anastomoses. Blood supply of the intestines
SUPERIOR MESENTERIC ARTERY (SMA)
It supplies the intestines from the lower part of the duodenum to the left colic
flexure and the pancreas (inferior pancreaticoduodenal artery). Located at level
of L1 (1cm below celiac trunk)
Branches
Inferior pancreaticoduodenal artery
o Head of pancreas
o 2
nd
& 3
rd
part of duodenum
Middle colic artery
o Transverse colon
Right colic artery
o ascending
Intestinal (jejunal & ileal)arteries
o Ileum & jejunum
Iliocolic/cecal
o Terminal branch of SMA
o Ileum, cecum and appendix
INFERIOR MESENTERIC ARTERY (IMA)
It supplies the large intestine from the left colic flexure to the upper part of the
rectum.
P a g e | 64
Branches
Left colic artery
o Descending colon
Sigmoid arteries
o Sigmoid
Superior rectal artery
o Terminal branch of IMA
o Superior 1/3
rd
of rectum
Anatstomeses of SMA & IMA
Arcus Riolani
o Middle colic (SMA) & left colic (IMA)
Marginal artery (IMA & SMA)
Sudech point (IMA)
o Point of where the lowest branch of sigmoid artery usually join
branches of the superior rectal artery.
36 Lymphatic drainage of the stomach and the intestines
(Netter, plate 304A)
LYMPHATIC DRAINAGE OF STOMACH
Left gastroepiploic & Short gastric nodes Splenic right gastric nodes
celiac nodes
Gastroduodenal & right gastroepiploic nodes pyloric nodes celiac
nodes
The celiac nodes drains into cistern chili, a dilated sac at the lower end of
thoracic duct (approx. L1)
LYMPHATIC DRAINAGE OF INTESTINES
Duodenum
o The lymph vessels follow the arteries:
P a g e | 65
Pancreaticoduodenal gastroduodenal celiac nodes
cisterna chyli
Ileum & Jejunum
o The lymph is drained through many mesenteric nodes
Superior mesenteric nodes intestinal lymph trunk
cisterna chili
Colon
o Mainly to the paraaortic lymph nodes
Rectum
o Upper: via superior rectal vessels to paraaortic lymph nodes
o Middle: via middle rectal vessels to internal iliac lymph nodes
o Lower: via inferior rectal vessels to internal iliac lymph nodes
Anus
o Superficial inguinal lymph nodes
37 Portal vein, porto-systemic shunts, and their medical
importance
There are two systems draining the abdomen; vena cava system and the portal
system. The portal venous system is responsible for directing blood from parts of
the gastrointestinal tract (unpaired organs in abdomen) to the liver. Things
absorbed in the small intestine, will be taken to the liver for processing.
The system extends from lower esophagus to upper 1/3
rd
of rectum. It also
includes venous drainage from the spleen and pancreas. This explains why
certain drugs can only be taken via certain routes. For example, nitro-glycerin
cannot be swallowed, but it can be taken under the tongue. The detoxification
powers of the liver are strong enough to inactivate the medication before it
reaches the heart.
It is formed by the union of
Superior mesenteric vein and
Splenic vein
Coronary vein (drains to portal)
P a g e | 66
Inferior mesenteric vein, (indirect)
The portal vein branches into many generations of vessels that open into hepatic
sinusoids. Blood is recollected into the hepatic vein and enters the inferior vena
cava.
Portal vein interlobular sinusoids central sublobular hepatic
IFC
PS = Portal system CS = Cava system
1. Esophageal veins drains to:
a. Azygos (CS)
b. Coronary veins (PS)
i. If circulation is blocked in the liver, the blood will be drained
only by the esophageal veins (IVC route), causing them to
enlarge, and finally they may burst and cause massive
internal bleeding. They may also rupture during eating,
causing vomiting of blood.
2. Superior rectal vein drains to:
a. Inferior mesenteric vein (PS)
b. Middle rectal vein (CS via internal iliac)
i. Hemorrhoids due to increased pressure in rectal veins
ii. Rectal bleeding
3. Inferior epigastric drains to:
a. Paraumbilical veins (PS)
b. External iliac vein (CS)
i. If the inferior epigastric vein is blocked the paraumbilical
veins will enlarge and it looks like the veins are radiating from
the umbilicus (caput medusa)
4. Retroperitoneal anastomoses between pancreas and kidney
a. The veins of the pancreas are drained to the portal (via splenic)
b. The veins of the kidney are drained to the IVC
38 Coronal section of the kidney
P a g e | 67
RENAL HILUS
Is the entrance to a cavity, renal sinus, within the kidney, located on the medial
border.
Renal vein
Renal artery
Ureter
RENAL SINUS
A cavity surrounded by the parenchyma (functional part) of the kidney
Lesser and greater calyces
Renal pelvis
o Belonging to the urinary system that collects urine from the calyces
and continues as the ureter
Branches of renal vessels
o Interlobular arcuate interlobar segmental renal artery
abdominal aorta
Filled with fatty tissue (continuation of the adipose capsule)
CORTEX
The cortex is located just beneath the fibrous capsule
It has medullary rays; ascending or descending loops of a nephron.
Cortex corticis does not possess these rays
Renal columns are formed between the pyramids
MEDULLA
15-25 pyramids
The base of pyramid faces the cortex
Apex of pyramid contain renal papilla where urine is dismissed through the
cribriform area into the lesser calyces.
Functional unit of kidney
39 Topography and capsules of the kidney
P a g e | 68
Left, T12-L2 & right, L1-L3
11
th
and 12
th
rib partially protects the kidneys
VISCEROTOPY
Right kidney
Superior:
o Suprarenal gland
Anterior:
o Descending duodenum & right colic flexure
Posterior:
o Diaphragm (with phrenicocostal recess behind it). M. Psoas, M.
quadratus lumborus
Medial:
o Inferior Vena Cava
Left kidney
Superior:
o Suprarenal gland
Anterior:
o Spleen, stomach (through lesser sac), pancreas, left colic flexure,
coils of jejunum
Posterior:
o Diaphragm (with phrenicocostal recess behind it), M. Psoas, M.
quadratus lumborum
Medial:
o Abdominal aorta
CAPSULES
Renal fascia
o The outermost fascia
P a g e | 69
o Covers anterior surface, goes around the kidneys laterally &
superiorly.
o The posterior part runs behind aorta and IVC and is continues with
one another.
(opens medially & inferiorly)
o Anterior layer is continues with the peritoneum
Adipose capsule
o Adipose connective tissue, filling the space between the two fibrous
capsules
Fibrous capsule
o The innermost layer, situated directly onto the kidney
40 The ureter
The ureter conducts urine from the kidneys to the urinary bladder . As it
descends it is attached to the posterior wall and retroperitoneum. The ureters
pierce the urinary bladder from posterolaterally to inferomedially at the ureteric
orifices (2 upper angles of trigone). This oblique direction is important because
the mucous membrane will form a fold inside that prevents urinary backflow.
It is crossed at 3 points:
Behind gonadal vessel
In front of Junction between common iliac & external iliac vessels
Behind uterine artery or ductus deferens
Layered by smooth muscle
Inner longitudinal
Outer circular
In the distal part of the ureter an outermost longitudinal muscle layer may
appear.
41 Content of the retroperitoneum (except the viscera).
Abdominal venous systems
On posterior body wall behind peritoneum
P a g e | 70
MUSCLES
Quadratus Lumborum muscle
Major psoas muscle
Transverse abdominis muscle
Diaphragm
NERVE PLEXUS
Lumbar nervous plexus (lower T12 upper L4): The psoas muscles arises from
the bodies and processes of the lumbar vertebraes. At the level of this origin,
between the fibers, the lumbar plexus surface and divides into branches.
Subcostal nerve (T12)
o Most inferior intercostal nerve
Iliohypgastric nerve (T12-L1)
o Enter and runs between transverse abdominis and internal oblique
muscles
Innervate the above mentioned muscles
o End branch pierce the muscles and innervate the skin
Ilioinguinal nerve (L1)
o Passes between the muscles, then joins the spermatic cord
anteriorly through inguinal canal.
o Comes out through superficial inguinal ring and innervates the skin
of the scrotum and the medial surface of the thigh that faces
towards the scrotum
Lateral cutaneous femoral nerve (L2-L3)
o From quadratus lumborum towards anterior superior iliac spine
o Leaves abdominal cavity ca 1cm below the spine
Femoral nerve (L2-L4)
o Leaves abdominal cavity through lacuna musculonervosa with
iliopsoas muscle
Genitofemoral nerve (L1-L2)
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o Pierces major psoas
o Divides into genital & femoral branch
Genital branch enters inguinal canal and passes inside
spermatic cord
Innervates cremaster & the layers of scrotum
Femoral branch passes through lacuna vasorum and
innervates a small of the skin below the inguinal ligament.
Obturator nerve (L2-L4)
o Medial to iliopsoas
o Innervates adductor muscles and a medial region of the thigh
o Leave abdominal cavity through obturator canal together with A.
obturator
Dont forget about the lumbosacral trunk. Frequently asked during exam
according to Kovacs
ABDOMINAL VENOUS SYSTEM
There are two systems draining the abdomen. The vena cava system and the
portal system. The portal system drains the unpaired viscera and the vena cava
system drains the rest.
There are 4 anastomoses between these two systems. See topic earlier topic!
I DONT KNOW IF BRANCHES OF THE ABDOMINAL AORTA IS INCLUDED IN THIS
TOPIC, SAME THING WITH LUMBAR PLEXUS! See Kovacs notes p.86-88
42 The diaphragm, its apertures and their traversing structures
The diaphragm is a large muscle separating the abdominal and thoracic cavitites.
It has a muscular part (arising from sternum, ribs and lumbar vertebrae) and a
tendinous part, called centrum tendineum, which is the insertion of the muscle
fibers.
Central tendon
o Three foliated shape
Pericardium fused with anterior folium
Hiatus for IVC located between the two posterior folium, a
little to the right
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Sternal part
o Between the sternal and costal part, the two internal thoracic artery
and superior epigastric artery is located.
Costal part
Lumbar part
o Left, arise from L2-L3 & Right, arise from L3-L4
3 Cruses
Medial crus (lumbar part)
o Esophageal hiatus (T10) for esophagus + vagal nerves
Lateral crus
o Median arcuate ligament
Aortic hiatus (T12) + thoracic duct
o Medial acrcuate ligament
Psoas major & minor
o Lateral arcuate ligament
Quadratus lumborum
Intermediate crus (L2)
o Separates two hitatuses (between medial and lateral crus).
Between medial and intermediate crura, there are two
openings for the splanchnic nerves and azygos/hemiazygos
(ascending lumbar) vein
Between intermediate and lateral crura the sympathetic trunk
passes
43 Topography, blood supply, and lymphatic drainage of the
urinary bladder
The urinary bladder is a musculomembranous elastic bag serving as a storage
place for the urine, produced by the kidney. It is located in the lesser pelvis.
base
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apex
o The peritoneum is only reflected onto the apex and posterior wall
Infraperitoneal
o Continues with median umbilical fold, with urachus (remnant of
alantois).
Trigone of bladder is a smooth area at the base of the bladder between the 2
ureteric orifices and the internal urethral orifice.
RELATIONS
Anterior:
o The pubic symphysis
Posterior:
o Male: Rectum via rectovesicular pouch
o Female: Posterosuperiorly: Uterus via vesicouterine pouch
BLOOD SUPPLY
Arteries: Internal iliac (anterior division) umbilical artery superior
vesical artery inferior vesicle
Veins: Inferiorly, vesicle venous plexus towards internal iliac
LYMPHATIC DRAINAGE
Drain into the internal and external iliac nodes common iliac nodes
SUPPORT
The urinary bladder is fixed to the pubic symphysis by the pubovescial
(puboprostatic) ligament.
Most important support in males is through the prostate gland by the
pelvic fascia
o The superior pelvic diaphragmatic fascia reflects onto the prostate
gland. As the gland is attached to the bladder, the bladder is
supported with the pelvic fascia through the prostate
44 Topography, blood supply, and lymphatic drainage of the
rectum
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The rectum (S3) is the continuation of sigmoid colon and the final portion of the
large intestine, descending in front of the sacrum, leaving the pelvis by piercing
the pelvic diaphragm and ending in front of the tip of the coccyx. It then
continues as the anal canal. The lower part of rectum is dilated to form the rectal
ampulla.
Peritoneum covers the anterior and lateral surfaces of the upper 1/3
rd
of the
rectum and only anterior in the middle 1/3
rd
leaving the lower 1/3
rd
devoid of
peritoneum. Therefore:
Upper 1/3
rd
Intraperitoneal
Middle 1/3
rd
Retroperitonal
Lower 1/3
rd
Infraperitoneal
Muscular coat: Inner circular and outer longitudinal layer of smooth muscle
The 3 free teniae coli of sigmoid come together and form a broad band on
the anterior and posterior surface of rectum
RELATIONS
Posterior:
o Sacrum and coccyx
o Piriformis, Coccygeus, and levator ani muscles, sacral plexus and
sympathetic trunk
Anterior:
o Male: Superior to inferior
Rectovesicular pouch
Urinary bladder
Seminal vesicle
Prostate
o Femlale: Superior to inferior
Rectouterine pouch (cul de sac Douglas)
Posterior surface of vagina
BLOOD SUPPLY
Arteries: Superior, Middle and Inferior rectal arteries
Veins: Superior rectal vein (PS), middle and inferior rectal veins.
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LYMPH DRAINAGE
Upper 2/3
rd
follow sup. rectal artery and drain into pararectal nodes inf.
mesenteric nodes
Lower 1/3
rd
follow mid. rectal artery and drain into internal iliac nodes
NERVE SUPPLY
Sympathetic and parasympathetic nerves from inferior hypogastric plexuses
45 The lesser pelvis in female. The internal female genitalia
The bony lesser pelvis has an inlet, outlet and a cavity
Border of inlet:
Anterior: Pubic symphysis
Lateral: Iliopectineal line, Inominate line
Posterior: Sacral promontory
Border of outlet:
Anterior: pubic arch
Lateral: Ischial tuberosity
Posterior: Coccyx
The cavity:
Curved canal with a short anterior wall and long
posterior wall
Gross structures:
Urinary bladder
o Vesicouterine pouch
Uterus
o Rectouterine (Douglas) pouch
Rectum
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INTERNAL FEMALE GENITALIA
UTERUS
Hollow muscular organ; 7.5cm in the non pregnant woman.
Body: Main portion
Cervix: elongated lower part
Isthmus: Most narrow part of uterus (upper cervix)
Cavity: triangular shaped
External os: opening into vagina
Uterine ostium: 2 openings where fallopian tube enters the body of uterus
Layers of uterus:
Perimetrium: Serous layered mesothelium
Myometrium: Smooth muscle
Endometrium: Mucous membrane; Undergoing cyclic changes
Fallopian tubes: Intramural, isthmus, ampulla, ifundibulum & fibrae
Ovaries: Only extraperitoneal organ in the body
Ligaments: Round ligament of uterus & ligament of ovary
Broad ligament
o Mesosalphinx
o Mesovarium
o Mesometrium
VAGINA
7-8cm long muscular tube attached to the uterus by anterior-posterior and
lateral fornices
In the upper part, we have the vaginal portion of the uterus.
The lateral fornix of the vagina is related to the ureter
o Ureter runs to the urinary bladder from the posterior abdominal
wall. It runs behind the uterine artery.
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This is important: to operate on the uterus, the artery should
be ligated and cut, but there is danger of cutting the ureter
by accident
46 Position, support, blood supply and lymphatic drainage of
the uterus and the vagina
POSITION
Uterus is intraperitoneal, except for vaginal part
o Peritoneum comes from anterior abdominal wall, covering the apex
of urinary bladder and some of the posterior wall, it then continues
to anterior wall of uterus (not cervix) forming the vesicouterine
pouch
o Peritoneum reflects onto the posterior fornix of vagina and to the
rectum forming the Douglas pouch
The axis of the vagina is 30 posterior from the vertical
Anteversion: Axis of vagina & axis of cervix = 100-110 degrees
Anteflexion: Axis of cervix & axis of body of uterus = 160-170 degrees
Together approximately 90 degrees forward between axis of vagina and
body
RELATIONS
Uterus
Anterioinferiorly: Urinary bladder + Vesicouterine pouch
Inferior: Vagina
Posterior: Small intestine and rectum
Superior: Small intestine
Lateral: Broad ligament
Vagina
Anterior: Urinary bladder
Posterior: Douglas pouch + rectum
Lateral: Levator ani muscle
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SUPPORT
Pelvic diaphragm and urogenital diaphragm
o The vagina pierces urogenital diaphragm and is attached to it
o Superior fascia of pelvic diaphragm reflects onto the vagina and
cervix, fixing them
Retinaculum Uteri
o Connective tissue system that surrounds the uterus at the level of
cervix and continues into the two layers of broad ligament
Pubovesical ligament
Vesicouterine ligament
Sacrouterine ligament (+recto uterine part of sacrouterine
ligament)
Broad ligament
Cardinal ligament (inferior thickening of broad
ligament)
Broad ligament
o Uterus is layered by peritoneum. Anterior and posterior layers meet
at the lateral sides of uterus forming a double layer extending to the
lateral walls of lesser pelvis. Between the double layer, the loose
connective tissue; Parametrium, where the uterine artery runs
superiorly in a wavy manner.
Mesosalpinx
Mesovarium
Mesometrium
BLOOD SUPPLY
Uterus
Uterine artery Internal iliac
o Runs in cardinal ligament and reaches uterus at the isthmus, then
turns superiorly running in the parametrium to finally anastomose
with ovarian artery
o Descending branch supplying cervix and vagina
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Uterine vein
o Follow same path of uterine artery and drains to internal iliac vein
Ovarian artery abdominal aorta
o Supplies ovaries and fallopian tube
Ovarian vein
o Left ovarian drain to renal vein & right drain to IVC
LYMPHATIC DRAINAGE
Three courses of lymphatic drainage:
1. From uterine fundus along side the round ligament, through the inguinal
canal into the inguinal lymph nodes (parallel to the inguinal ligament).
2. From uterine body, along side the uterine artery, to the internal iliac
nodesetc
a. The paraaortic nodes go through the lumbar trunk to the cisterna
chyli
3. From cervix, there are two courses.
a. Same as for the body
b. From posterior fornix of the vagina into the sacral lymph nodes
paraaortic nodes.
Medical importance:
If enlarged inguinal lymph nodes are discovered:
o lower limb, perineal region, anal opening, gluteal region or external
genitalia
must be examined. If no problem is found there, tumors of the uterus may be
indicated. Usually in the case of the uterine cancer, the paraaortic and iliac
lymph nodes are enlarged
Hysterectomi Surgical removement of uterus
47 The lesser pelvis in male
See lesser pelvis for female!
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The Male pelvis is narrower than the female
Pubic arch is narrower
Ischial tuberosities are closer to each other
Iliac wings less flared
Outlet move oval
Cavity is narrowing greatly from inlet to outlet
Gross structures
Urinary bladder (See previous topic)
Rectum (See previous topic)
Ductus deferens
o Tail of epididymis. Consist of 4 parts
Epididymic portion
Funicular portion: running in spermatic cord
Inguinal portion
Pelvic portion: running in lateral wall of lesser pelvis medially
towards the seminal vesicle. Forming ampulla, which joins
seminal vesicle and forms the ejaculatory ducts (Netter 367C)
Seminal vesicle
o Posterior to the urinary bladder
Postate gland
o Below urinary bladder
o Base and Apex
o Fixed by pelvic fascia and related to the rectum
o Prostatic venous plexus internal pudendal internal iliac vein
o Explain Verumontanum on exam!!! (Netter 367A)
48 Parts and flexures of the male urethra
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Internal urethral sphincter muscle, consisting of smooth muscle, surrounds
internal urethral orifice
Parts of male urethra (Proximal to distal):
Intramural part
Prostatic part
o Verumontanum!
Membranous part
o The part running through urogenital diaphragm
Spongy part
o In corpus spongiosum having navicular fossa in glans penis and
urethral glands
FLEXURES
Perineal flexure
o direction, downward to forward
Pubic flexure
o direction, forward to downward
o This flexure is straightened upon lifting the penis
49 The testis, epididymis, and the scrotum. The spermatic cord
and its coverings
THE TESTIS
Located in the scrotum
Paired oval glands
The testis produce spermatozoa
Seminiferous duct Straight duct rete testis efferent duct
epididymic duct spermatic duct (Netter 371B)
THE EPIDIDYMIS
Elongated structure connected to posterior surface of testis
Head, body & tail
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Transports, stores and matures spermatozoa
Attached to testis by superior epididymic and inferior epididymic ligament
THE SPERMATIC CORD
Collection of structures that pass through the inguinal canal to and from the
testis. It begins at the deep inguinal ring lateral to the inferior epigastric vessels
and ends at the testis
In the cord:
Vas deferens (Spermatic duct)
Pampiniform venous plexus
Testicular artery
Autonomic nerves
Genital branch of genitofemoral nerve (innervate cremaster muscle)
On the cord:
Scrotal part of the ilioinguinal nerve (innervate skin of scrotum)
LAYERS OF SCROTUM AND DISTAL PART OF SPERMATIC CORD
Skin
Superficial (Dartos) fascia
o Skin with smooth muscle responsible for folding of scrotum
o superficial abdominal fascia
External spermatic fascia
o External oblique muscle
Cremaster muscle
o Internal oblique & transverse abdominis
Internal spermatic fascia
o Transverse fascia
Tunica vaginalis
o Continuation of peritoneum
o Parietal layer
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o Visceral layer:
Shiny serous layer on testis
o Vestigium of processus vaginalis (dead end)
Tunica albuguinea
50 Pelvic floor and perineum
PELVIC DIAPHRAGM
Superior fascia of pelvic diaphragm
Levator ani muscle
Pubococcygeus
Iliococcygeus
Ischiococcygeus
o This muscle prevents prolapsing of the pelvic content and draws the
anus upward following defecation. It supports the pelvic viscera.
Inferior fascia of pelvic diaphragm
Anal hiatus
UROGENITAL DIAPHRAGM
Superior fascia of pelvic diaphragm
Deep transverse perineal muscle
o From inferior pubic ramus and runs to median line, where it
interlaces in a tendinous raphe
o Sphincter urethrae muscle
These muscles are found just beneath the prostate gland in
males, and deep to the bulb of vestibule in females.
Inferior fascia of urogenital diaphragm
SPACES
Subperitoneal space
o Between peritoneum and pelvic diaphragm
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Connective tissue and blood vessels for the organs of the
lesser pelvis
Deep perineal space
o Between the two diaphragms
Membranous part of urethra
Branch for dorsal nerve and artery for penis and clitoris
(bulbourethral gland in males)
Superficial perineal space
o Between the urogenital diaphragm and superficial perineal fascia
Ischiocavernous muscle
Bulbospongiosus muscle
Superficial transverse perineal muscle
Ischiorectal fossa
Covered by superficial perineal fascia
Medial: Levator ani muscle
Lateral: Obturator internus + obturator fascia
Pudendal (Alcocks) canal
Formed by obturator internus muscle, covered by
obturator fascia surrounding structures running in the
canal
o Internal pudendal artery and vein
o Pudendal nerve
51 The external genital organs
PENIS
Corpus cavernosum
Two parallel columns of erectile tissue forming the dorsal part
Divide into two crura at the root of penis, inserted into ramus of ischial
bone (fallic crest)
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Two deep penile arteries responsible for erection
Composed of lacunae separated by trabeculae (smooth muscle &
connective tissue)
Tunica albuguinea
Pectiniform septum: Separates cavernosum from spongiosum
Corpus spongiosum
Bulbus, corpus & glans penis
Smaller lacunae
Pierced by urethra
Deep fascia of penis surrounds the corpuses and separates (pectiniform) them
BLOOD SUPPLY
2 deep dorsal penile arteries
2 deep penile arteries
1 deep dorsal vein
Superficial dorsal veins
Veins in peripheral part of cavernosum
NERVE SUPPLY
Dorsal penile nerve Pudendal nerve
Pudendohemoroid nerve (Parasympathetic fibers) from sacral plexus
Hypogastric nerve/plexus (sympathetic fibers ) from lumbar sympathetic
trunk
MECHANISM OF ERECTION
During erection, blood from the arteries enters the lacunae, which dilate and
compress the peripheral veins against tunica albuguinea preventing venous
drainage.
Parasympathetic stimulation dilate the arteries and increase blood flow
Sympathetic stimulation constricts the vessels, causing flaccidity of penis
See topic 49 for testis and scrotum!
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EXTERNAL FEMALE GENITALIA (Netter 359-361)
Homologues of external genitalia:
Male Female
Glans penis Glans clitoris
Body of penis Body of clitoris
Corpus spongisum Labia minor
Scrotum Labia major
Bulb of penis Bulb of vestibule
Cowpers gland Bartholins gland
Etc etc
These notes were mostly taken from other exam notes, kovacs notes, snell,
whatever I could remember from class and a little Wiki. Note that this is only a
rough draft, and I havent had time to check for errors. ENJOY
Xie xie Kon for the cover page layout.