Anatomy Regional:

Thorax and Abdomen

Anatomy in clinical context

Dr MBA
Faculty of Medicine Sriwijaya University
 Heart and Lungs
Surface anatomy
Origin of great vessels
Coronary arteries
Auscultation of valve sounds
Thoracocentesis and Chest Tubes
Muscles of Respiration
Referred Pain
Position of Heart, Great Vessels, etc. in the Thorax
and Mediastinum

Heart is about the

length of
the body of the
sternum:

-- ribs 2-6
-- from sternal angle
to xiphoid process

Sternal angle is at T4-5

level. It marks:

Origin of great vessels

Bifurcation of trachea
Downloaded from: StudentConsult (on 6 May 2008 02:36 PM)
2005 Elsevier
Superior : trachea, thymus,
brachiocephalic vein, aortic arch,
esophagus thoracic duct

Middle: heart, ascending aorta,

pulmonary trunk and veins, phrenic
nerves

Posterior: esopahagus vagus nerves,

descending aorta, thoracic duct,
sympathetic trunks

Anterior: fat, connective tissue,

thymus in child
 Brachiocephalic Anterior Schematic
veins
Left pulmonary
Superior artery
vena cava Pulmonary veins
Aorta
R. pulmonary Pulmonary
artery trunk
Left ventricle is the
left margin
Right atrium
is the right
margin of the heart Right ventricle Left atrium is
is anterior posterior against
Inferior vena cava esophagus.

Grants Atlas of Anatomy,

Descending aorta Williams & Wilkins, 9th ed., 1991
 Coronary Arteries :They run in the atrio-ventricular and
interventricular grooves
.
Left coronary artery
SA
node Circumflex
Right coronary branch

artery
Anterior
AVnode Interventricular

LAD

Marginal branch
Grants Atlas of Anatomy,
Posterior interventricular Williams & Wilkins, 9th ed., 1991
 apex
Costal surface

Mediastinal
surface

Diaphragmatic
Costodiaphragmatic base
surface
recess
 Anatomy of the
Intercostal Space

Vein
Artery
Nerve
Immediately
below rib

Intercostal Space
Secondary
(lobar) bronchi Superior lobar
Rt. Superior lobar

Middle lobar MAIN

Inferior lobar
Inferior lobar

Tertiary bronchione for

each BPS

Inhaled objects generally are found in right bronchus due

to straighter pathway
 Muscles of Respiration

Scalenes & SCM

Pec minor

Serr. Ant. Int. intercostal

Ext. intercostal

Diaphragm
C3-5 phrenic
nerve abdominals

Inspiration Expiration
Referred pain from angina
radiates down medial side
of arm

Ventricular sensory fibers

enter the stellate ganglion

(Heart sensation is from mid

cervical to mid thoracic
levels.)

T1 is the lowest ventral ramus

of the brachial plexus (C5-
T1).
 3

2
1

Major Lymphatic Pathways of the Lung

 Lymph Drainage of Breast

1. Upper lateral breast

to axillary nodes (75%)

2. To opposite breast

3. Parasternal nodes
deep to body wall

4. Superficial inguinal
nodes.
 Abdomen
Hernias
3D Relationships of organs (CT)
Arterial supply to gut
Portal-Caval anastomoses
Visceral autonomic pathways
Bile duct system
DIRECT INDIRECT
 Indirect (Congential)
Follows path of processus
vaginalis through inguinal canal
Passes through both deep and
superficial inguinal rings.
Distended mass is in spermatic
cord (often found in
scrotum/labia)
Mass is lateral to inferior
epigastric artery.
20x more in males
Direct (Acquired)
NOT through the inguinal
canal
Passes through weakness
in abdominal wall
Mass is adjacent to
spermatic cord (rarely
enters scrotum or labia)
Medial to inferior epigastric
artery
Allen is a 30-year-old bachelor who frequents "singles"
bars. He has a large palpable structure in the left upper
abdomen indicated by the asterisk in the accompanying
radiograph. It is?
Celiac trunk =foregut

P: vagus
S: thoracic splanchnics

Superior mesenteric
=midgut
P: vagus
S: thoracic splanchnics

Inferior mesenteric
=hindgut
P: pelvic splanchnic
S: lumbar splanchnics
A patient complained of severe abdominal pain on several occasions, but
no cause could be identified. ..On her arteriogram there is a tortuous
vessel indicated by the arrow. What is this vessel?
 Important Sites of Portal-Caval Anastomosis
Inferior vena cava Esophageal veins
(caval systemic azygous system
venous return) (hemorrhage)

Para-umbilical Portal system of veins

veins from GI capillaries to
liver sinusoids
superficial
epigastric veins
(caput
medusa) Superior rectal veins
branches of internal iliacs
(hemorrhoids)
 Anal Canal
Note:

-- Anal glands opening

into crypts
-- Pectinate line at bottom
of columns (site of
cloacal membrane)
-- White line where
epithelium changes
-- Three parts (colored)
of external sphincter
(subcutaneous,
Clinical Symposia, Vol. 37, superficial, deep) White line
No. 6, CIBA-Geigy, 1985
PARASYMPATHETIC SYMPATHTETIC

Vagus foregut thoracic splanchnics

Vagus midgut
thoracic splanchnics

Pelvic splanchnic hindgut lumbar splanchnics

 King & Showers,
Spinal cord segments for Human Anatomy &
Physiology, 6th ed.,

visceral sensory innervation Saunders,

1969

of the gut.
Note: T1
-- Thoracic splanchnics do
foregut and midgut T7-9
-- Lumbar (and pelvic
splanchnics) do hindgut/ L1
pelvis

-- Few spinal segments for

all of small intestine T10 L5
Areas of referred pain
 Bile and Pancreatic Duct System

Left and right hepatic ducts

Cystic Common hepatic duct

duct
(Common) bile duct

Main pancreatic duct

from ventral bud

Gall stones lodge at sphincter

Of Oddi/major duodenal papilla
Branches of descending arota?
 Pelvic Organs

Kidney stones
Urogenital diaphragm
Pelvic diaphragm
Common sites for kidney
stones to lodge:

Renal pelvis

Common iliac vessels

Entrance to bladder

Clinical Symposia, Vol. 38,

No. 3, CIBA-Geigy, 1986
 rectouterine

rectovesical
Male bladder, urethra, superficial and deep
perineal pouches
Injury to urethra ABOVE the
perineal membrane (fracture of
pelvic girdle) results in
blood/urine accumulating in the
DEEP PERINEAL POUCH AND IN
THE LOWER PELVIC CAVITY

Injury to the urethra BELOW the

perineal membrane (straddle
injuries) result in blood/urine
accumulating in the SUPERFICIAL
PERINEAL POUCH, SCROTUM, AND
DEEP TO SCARPAS FASCIA BUT
NOT INTO THE THIGH OR ANAL
TRIANGLE
Contents of
superficial
pouch
Autonomic Innervation of Pelvic
Organs
The sympathetic supply comes
primarily from the superior
hypogastric plexus and its
continuation, the hypogastric
nerve. A smaller contribution
comes from the sacral
splanchnic nerves arising from
the continuation of the
sympathetic trunk.

The parasympathetic supply

comes primarily from the
pelvic splanchnic nerves (S2-4)
Lymphatics
Lymphatic drainage of
any structure in the
pelvis or perineum
generally follows the
course of its blood
supply and venous
drainage.
Therefore, drainage of
pelvic organs is mainly
into nodes distributed
along the branches of
the internal iliac artery.
Drainage of perineal
structures may be to
superficial or deep
inguinal nodes.
How do lymphatics
from the testis reach
the thoracic duct?
Lymph Node Group structures
Lumbar Gonads, uterine tube, fundus of uterus
Internal Iliac Anal canal (above pectinate line)
Inferior rectum
Base of bladder
Lower uterus
Upper vagina, cervix
Prostate

External Iliac Superior bladder

Mid-uterus

Superficial Inguinal Lower limb

Perineumscrotum
Anal canal below pectinate line
Deep inguinal Glans
Thank you very much for your kind attention