-
Abdominal Cavity
- between thoracic diaphragm and pelvic inlet
- lined by peritoneum (parietal and visceral with the peritoneal cavity between)
- viscera include digestive organs, spleen, kidneys, and ureters
-
Abdominopelvic cavity
- between thoracic diaphragm and pelvic diaphragm
- separated into abdominal and pelvic cavitys by a plane thru the superior pelvic aperature
-
Anterolateral abdominal wall
- inferior to ribs 7-10 costal cartilages and xiphoid
- superior to inguinal ligament and pelvic bones
-
superficial fascia later of anterolateral abdominal wall
- superficial fatty layer (camper's fascia)
- superficial fascia just below dermis
- equal to hypodermis
- deep membranous layer (scarpa's fascia)
- thin layer of dense irregular CT
- separated from deep fascia by a layer of loose CT for separate movements of the two layers
-
deep fascia of anterolateral abdominal wall
- investing fascia
- dense irregular CT surrounding abdominal muscles
- equal to epimysium
-
Endoabdominal fascia
- loose CT between muscles and parietal peritoneum
- provides a potential surgical dissection plane
-
liposuction
removal of unwanted fat from superficial fatty layer
-
which layer of fascia is sutured during surgeries
deep membranous (scarpa's) too add strength
-
External oblique muscle
- most superficial, fibers oriented inferoanteriorly
- O: ribs 5-12
- I: linea alba, pubic tubercle, anterior 1/2 of iliac crest
- N: T6-T11 thoracoabdominal N and Subcostal N
- A: compress abdominal viscera, flex and rotate trunk
- Aponeurosis: begins at Linea Semilunaris, decussates at linea alba. inferior margin thickens into inguinal ligament
-
inguinal lig
- thickening of inferior external oblique aponerosis
- extends from ASIS to pubic tubercle
- attachement for fascia lata
-
Internal oblique muscle
- intermediate layer, fibers fan out anteromedially
- O: thoracolumbar fascia, anterior 2/3 of iliac crest and inguinal lig
- I: ribs 10-12, linea alba, and pectin pubis
- N: T6-T11 Thoracoabdominal N and Subcostal N
- A: compress abdominal viscera, flex and rotate trunk
- Aponeurosis: begins at linea semilunaris, join with fibers of transversus abdominis to form conjoint tendon
-
Conjoint tendon
- attaches to pubic crest and pectin pubis
- fibers of transversus abdominis and internal oblique aponeurosis
-
Transversus abdominis muscle
- innermost layer, fibers run transversomedially
- O: thoracolumbar fascia, costal cartilages 7-12, iliac crest and inguinal lig
- I: linea alba, pubic crest, pectin pubis via conjoint tendon
- N: T6-T11 Thoracoabdominal N and Subcostal N
- A: compress and support abdominal viscera
- apponeurosis: starts at linea semilunaris, forms conjoint tendon
-
Rectus abdominis muscle
- vertical muscle in anterior wall
- O: puubic symphysis and pubic crest
- I: xiphoid process and costal cartilages 5-7
- N: T6-T11 Thoracoabdominal N and Subcostal N
- A: flex trunk, compress abdominal viscera
- Attached to anterior rectus sheath by 3 tendinous intersections
-
Pyramidalis Muscle
- small, triangular, overlapping inferior portion of Rectus Abdominis muscle
- between pubis and linea alba
- A: tense linea alba
-
Rectus sheath and landmarks
- surrounds rectus abdominis muscle
- linea alba: midline
- umbilical ring: defect, all aponeuroses fuse here
- linea semilunaris: lateral edges
- arcuate line: structural change in posterior sheath, 1/4 up from pubic crest
- decussation: fibers intertwine at linea alba
-
layers of ANTERIOR rectus sheath SUPERIOR to arcuate line
external oblique aponeurosis and anterior portion of internal oblique aponeurosis
-
layers of POSTERIOR rectus sheath SUPERIOR to arcuate line
transversus abdominis aponeurosis, postior portion of internal oblique aponeurosis and endoabdominal fascia
-
layers of ANTERIOR rectus sheath INFERIOR to arcuate line
external oblique, internal oblique, and transversus abdominis aponeurosis
-
layers of POSTERIOR recuts sheath INFERIOR to arcuate line
endoabdominal fascia ONLY
-
Combined function of anterolateral wall muscles
- move trunk
- maintain posture
- protect abdominal viscera
- compress abdominal viscera
-
causes of an abdominal protuberance
- food
- fluid
- feces
- flatus
- fat
- fetus
- -an everted umbilicus is a sign of increased intraabdominal pressure
-
striae gravidarum
stretch marks
-
Congenital umbilical hernia
due to incomplete aponeurotic fusion around umbilical ring
-
acquired umbilical hernia
- more common in women and the obese
- occur as weakness in the anterior abdominal wall arises
-
epigastric hernia
- in midline between xiphoid process and umbilicus
- consist of peritoneal sac covered by skin and fatty tissue
-
Thoracoabdominal N
- anterior branch of ventral rami T6-T11
- between internal oblique and transversus abdominis
- innervate lateral abdominal wall muscles and skin
- branch to lateral cutaneous N and terminate as anterior cutaneous N
-
Subcostal N
- anterior ventral primary ramus of T12
- innervates lateral abdominal wall muscles and skin over ASIS and hip
- sensory for T12 dermatome via lateral and anterior cutaneous N
-
Iliohypogastric N
- superior terminal branch of ventral primary ramus of L1
- -anterior cutaneous pierces External Oblique aponeurosis
- innervates internal oblique and transversus abdominus muscle
- innervates hypogastric skin and skin over iliac crest
-
Ilioinguinal N
- inferior terminal branch of L1 ventral ramus
- -thru inguinal canal
- innervates internal obliqu and transversus abdominis muscle
- innervates skin of anterior scrotum/labia majora, mons pubis and medial thigh
-
Segmental branches from Descending Aorta
- Posterior intercostal As
- Subcostal As
- Lumbar As
- supply lateral hypochondriac, flank, and lumbar regions
-
Musculophrenic A
- from internal thoracic A in 6th intercostal space
- supplies hypochondriac region
-
superior epigastric A
- from internal thoracic A in 6th intercostal space
- between posterior rectus sheath and rectus abdominis muscle
- supplies rectus abdominis muscle and upper umbilical region
- anastomoses with inferior epigastric A
-
inferior epigastric A
- from external iliac A
- in transversalis fascia, enters rectus sheath inferior to arcuate line
- supplies rectus abdominis muscle and lower umbilical region
-
deep circumflex iliac A
- from external iliac A
- paralles inguinal lig toward ASIS
- supplies deep inguinal region
-
superficial circumflex A
- from femoral A
- paralles inguinal lig toward ASIS
- supplies skin in inginal region
-
superficial epigastric A
- from femoral A
- ascends in superficial fascia toward umbilicus
- supplies skin in pubic and lower umbilical regions
-
Venous drainage of anterolateral abdominal wall superior to the unbilicus
- lateral thoracic V to axillary V to subclavian V
- internal thoracic V to subclavian V
-
Venous drainage of the anterolateral abdominal wall inferior to the umbilicus
- inferor epigastric V to external iliac V
- superficial epigastric V to great saphenous V to femoral V to external iliac V
-
parumbilical Vs
small superficial tributaries of hepatic portal V
-
Thoracoepigastric V
between lateral thoracic V and superficial epigastric V
-
Lymphatics of anterolateral abdominal wall
- superficial lymphatics into axillary nodes (some parasternal nodes)
- superficial below unbilicus to superficial inguinal nodes
- deep lymphatics to external iliac A nodes
-
Abdominal palpation
- done in supine position with thicks and knees bent to relax the abdominal wall
- cold hands cause involunatary spasm called guarding
- guarding also occurs when an organ is inflamed
-
inguinal region
- between ASIS and pubic tubercle
- potential site for herniations
-
Inguinal canal
- parallel and just superior to inguinal lig
- connects extraperitoneal space of abdomen to scrotum/labia majora
-
what does the inguinal canal contain
- males- spermatic cord
- females- round lig of uterus
- blood vessels, lymphatics, linioinguinal N
-
Deep inguinal ring
- internal opening of the canal
- 1 cm superior to the middle portion of inguinal lig
- lateral to inferior epigastric A
- inferior to transversus abdominis muscle
- location of evaginated trasversalis fascia
-
superficial inguinal ring
- external opening
- in inferomedial portion of external oblique aponeurosis
- superolateral to pubic tubercle
- lateral margins are called CRURA
-
crura of superficial inguinal ring
- lateral crus- to pecting tubercle
- medial crus- to pectin crest
- internal crural fibers- between two crura
-
walls of inguinal canal
- anterior wall- external oblique aponeurosis
- posterior wall- endoabdominal fascia and conjoint tendom
- roof- internal obluiq and transversus abdominis muscle/aponeuroses
- flool- inguinal lig
-
development of male inguinal canal
- testes develop in endoabdominal fascia on posterior abdominal wall
- attached to anterior abdominal wall at deep ring by gubernaculum
- -persists as scrotal lig
- -pulls testes thru the canal into the scrotal sac
-
processus vaginalis
- peritoneum transversing the inguinal canal
- carries things thru the canal and persists as fascia around the spermatic cord
- distal sacular portion persistas as the tunica vaginalis
-
development of female inguinal canal
- ovaries develop in endoabdominal fascia of posterior abdominal wall
- processus vaginalis protrudes into labia majora
- gubernaculum- connects ovaries and uterus to labia majora
-
remnants of female gubernaculum
- ovarian lig- between ovary and uterus, prevents ovaries from descending
- round lig of the uterus- between uterus and labia majora
-
palpation of male superficial inguinal ring
- superolateral to pubic tubercle
- invaginate skin of upper scrotum, adjacent to spermatic cord with index finger
- turn your head a cough
-
spermatic cord
- contains structures to/from the testis
- begins at deep inguinal ring, thru inguinal canal and superficial ring, ends at testis
-
Fascia layers of spermatic cord
- external spermatic fascia- evaginated external oblique aponeurosis and investing fascia
- cremasteric fascia- evaginated internal oblique investing fascia
- internal spermatic fascia- evaginated transversalis fascia
-
Cremaster M
- evaginated internal oblique muscle
- raises/lowers testis in response to temperature
- innervated by genital branch of genitofemoral N (L1,2)
-
cremaster reflex
- contraction of muscle elicited by lightly stroking the skin of superomedial thigh (ilioinguinal N- L1)
- highly active reflexes simulate undescended testes
-
Ductus deferens
- muscular tube
- carries spermatozoa from tail of epidiymis to ejaculatory duct
-
testicular A
- branches from abdominal aorta inferior to renal A
- retroperitoneal where it crosses the ureter and external iliac As
- enters inguinal canal at deep inguinal ring, exits at superficial inguinal ring
- supplies testis and epididymis
-
ductus deferens A
branched from inferior vesical A
-
cremaster A
from inferior epigastric A
-
pampiniform venous plexus
- 8-12 veins surrounding testicular A
- anteror to ductus deferense
- thermoregulator
- converge to form testicular V
- -R drains to inferior vena cava
- -L drains to L renal V
-
Autonomic N fibers
- sypathetics (T10-11) to testicular A and ductus deferens
- -efferent and visceral afferent
- -contraction of ductus deferens during emission
- parasympathetics (Vagus) to ductus deferens
- -relaxes ductus deferens after emission
-
Genital branch of Genitofemoral N
innervates cremaster muscle
-
lymphatics of the spermatic cord
- drain testis and epididymis to lumbar lymph nodes
- scrotum drainage goes to superficial inguinal nodes
-
contents of spermatic cord
- ductus deferens
- testicular A
- ductus deferens A
- cremaster A
- pampiniform venous plexus
- autonomic nerve fibers
- genital branch of genitofemoral N
- lymphatics
-
layers of the scrotum
- skin- pigmented, hairless
- dartos fascia- continuation of scarpas fascia and colles fascia
- site for smooth muscle attachement
- -contracts when cold
- forms scrotal septum at scrotal raphe
-
Tunica vaginalis
- parietal and visceral layers
- parietal layer fuses to internal surface of internal spermatic fascia
- visceral layer fuses to external surface of testis and epididymis
- -posterior surface is uncovered
- mesorchium- from extensive tunica vaginalis, allows twisting of testis
-
vasculature of scrotum
- anterior scrotal A- off deep external pudendal A
- posterior scrotal A- off perineal A
- veins accompany As
-
nerves of the scrotum
- genital branch of genitofemoral N- (L1-2) to anterolateral surface of scrotum
- anterior scrotal N- from ilioinguinal N (L1) to anterior surface of the scrotum
- posterior scrotal N- from perineal N (S2-4) to posterior surface of the scrotum
- posterior femoral cutaneous N- (S2-3) to inferior surface of the scrotum
-
Epididymis
- tightly convoluted duct on posterior surface of testis
- covered by visceral tunica vaginalis
- head is superiorly, tail is inferiorly
- ductus deferens begins at the tail
- connected to the testis by efferent ductules
- function- storage/maturation of sperm
-
Testis
- ovoid organ suspended in scrotum by spermatic cord
- -L is usually lower
- tunica albuginea capsule covered by visceral tunica vaginalis
-
cryptorchidism
- undescended testis
- usually located in inguinal canal
- risk of malignancy is high if left uncorrected
-
hydrocele
- excess fluid in a processus vaginalis
- -indirect inguinal hernia
- excessive secretion by visceral tunica vaginalis
- adjacent to testis or in the spermatic cord
-
hematocele
- blood between visceral/parietal tunica vaginalis
- caused by traumatic injury
- hematoma- accumulation of blood in any extravascular location
-
varicocele
- tortuous dilation in pampiniform venous plexus
- valve insufficiency or venous return problems
- -more common on L becuase of testicular V drainage
-
vasectomy
- bilateral excision of ductus deferens thru superioranterior scrotum
- prevents sperm from passing
- doesnt affect secretions from accessory glands
-
parietal peritoneum
- lining internal surface of abdominopelvic wall
- somatic sensory innervation via dermatome
-
visceral peritoneum
- covering abdominopelvic viscera
- no somatic sensory innervation
- visceral afferent innervation causing refered pain
- same as serosa
-
peritoneal cavity
- spave between parietal and visceral peritoneum
- thin fil of peritoneal fluid to lubricate surfaces and fight infection
- open to exterior in females via uterine tubes, uterus and vagina
- completely closed in males
-
intraperitoneal organs
- almost completely covered by visceral peritoneum
- NOT inside peritoneal cavity
- embryonically suspended by mesentery and remain suspended
-
retroperitoneal organs
- partiall covered by parietal peritoneum, external to peritoneal cavity
- primary retroperitoneal- embryonically behind peritoneun
- secondary retroperitoneal- become retroperitoneal due to return of gut
-
peritonitis
- painful, inflammation of peritoneum
- develop ascites (excess fluid)
- fluid flows along paracolic gutters and is reabsorbed in pelvis (best resprtion in thoracic diaphragm)
- commonly causes adhesions
-
Umbilical folds of anterolateral abdominal wall
- median umbilical fold- from apex of urinary bladder to umbilicus
- contains median umbilical lig
- medial umbilical fold- lateral to median fold
- contains medial umbilical lig
- lateral umbilical fold- lateral to medial fold
- contains inferiro epigastric A/V
-
depressions between umbilical folds
- supravesical fossa- between median and medial folds
- location of parietal peritoneum reflection to urinary bladder
- medial inguinal fossa- between medial and lateral folds
- site of a direct hernia out superficial inguinal ring
- lateral inguinal fossa- lateral to lateral fold
- site of indirect inguinal hernia thru deep inguinal ring into the spermatic cord
-
femoral hernias
- more common in females
- protrusion inferior to inguinal lig thru the femoral ring and canal
- extends into upper medial thigh
-
Mesentary
- double layer of peritoneum connecting intraperitoneal organ to posterior abdominal wall
- froms as intraperitoneal organ invaginates into peritoneal cavity
- contains nerves and vasculature to the organ
-
lesser omentum
- double layer of peritoneum from lesser curvature of the stomach and proximal duodenum to the liver
- remnant of ventral mesentary
-
hepatogastric lig
lesser omentum from liver to lesser curvature of the stomach
-
hepatoduodenal lig
- thick right side of lesser omentum
- from liver to proximal duodenum and surrounds the portal triad
-
greater omentum
- aprom from greater curvature of sotmach and then folding back on itself to transverse colon
- remnant of dorsal mesentary
- prevents abdominal viscera from adhearing to anterolataeral wall, protection
-
gastrocolic lig
- largest portion of greater omentum
- from greater curvature of stomach to transverse colon
-
gastrosplenic lig
from greater curvature of stomach to spleen
-
gastrophrenic lig
from greater curvature of stomach to thoracic diaphragm
-
greater sac of the peritoneal cavity
- main, large portion
- supracolic compartment- anterosuperior to greater omentum and transverse colon (stomach, liver, spleen)
- infracolic compartment- posteroinferior to greater omentum and transverse colon, right and left sides (small intestine, up and down colon)
- paracolic gutters- grooves between lateral sides of up/down colon and posterolateral abdominal wall
-
lateral sac of peritoneal cavity
- posterior to stomach and lesser omentum
- superiorly behind liver and up to diaphragm
- inferiorly between superior layers of gastrocolic lig
-
Epiploic foramen
- communication between greater and lesser sacs
- posterior to hepatoduodenal lig
-
Esophagus
- muscular tube from pharynx to stomach
- follows curvature of vertebral column
- covered by adventitia above diaphragm, serosa below
-
upper esophageal sphincter
crossed by cricopharyngeus muscle
-
lower esophageal sphincter
passes thru diaphragm
-
esophageal hiatus
- thru right crus of the diaphragm at T10
- phrenicoesophageal ligs- esophagus to diaphragm at hiatus, allow independent movement and seal off cavities
-
esophagogastric junction
- left of midline at T11
- right border is continuous with lesser curvature of the stomach
- left border separated by cardiac notch
- cardiac sphincter prevents gastric reflux
-
arterial supply to esophagus
- esophageal branch of L gastric A
- left inferior phrenic A
-
venous drainage of esophagus
- superiorly thru esophageal Vs (to azygos veins)
- inferiorly thru L gastric Vs (to hepatic portal v)
-
lymphatic drainage of esophagus
primary nodes are LEFT GASTRIC LYMPH NODES
-
innervation of esophagus
- from esophageal plexus
- parasympathetics via vagal trunks
- sympathetic via greater splanchnic N
- -presynaptic- ciliac ganglion
- -postsynaptic- periarterial plexus
-
esophageal varices
- enlarged submucosal Vs with portal hypertension
- rupture is a potentially fatal condition
- associated with cirrhosis
-
pyrosis
- heartburn
- acid reflux thru cardiac sphincter
-
stomach
- intraperitoneal in uppermost left adbominal quadrant
- food blender, resorvoir, initiates digestion
- gastric juice begins digesting into chyme
- adult stomach holds 2-3 liters
- newborn stomach holds 30 mls
-
regions of stomach
- cardai- T11, entrance of esophagus
- fundus- under left dome of diaphragm
- cardiac notch- between esophagus and fundus
- body
- pyloris- exit of stomach
- lesser curvature- right side
- angular incisure- indentation at junction of body and pyloris
- greater curvature- longer left side
-
Pyloric part of stomach
- pyloric antrun- funnel- shapped extension of body
- pyloric canal- leading to sphincter
- pyloric sphincter- regulates exit
-
hiatal hernia
protrusion of stomach into mediastinum via esophageal hiatus
-
sliding hiatal hernia
- esophagus, cardia and parts of fundus slide thru esophageal hiatus
- associated with acid reflux
-
paraesophageal hiatal hernia
- esophagus and cardia normal
- pouch of peritoneum extends thru hiatus
- acid reflux not an issue
-
Arterial supply to stomach
- left gastric A- primary, along lesser curvature
- R gastric A- anastomoses with L gastric along lesser curvature
- R gastroepiploic A- greater curvature, in greater omentum
- L gastroepiploic A- anastomoses with R gastroepiploic A
- Short gastric As- 4-5, supplying fundus
-
venous drainage of stomach
- parallel arteries
- drain to liver
- L/R gastric Cs to hepatic portal V
- short gastric and gatroepiploic to splenic C
- r gastroepiploic to superior mesenteric V
-
lymphatic drainage of stomach
- primary gastric nodes on lesser curvature
- gastroepiploic nodes on greater curvature
- ciliac nodes secondary
-
innervation of stomach
- parasymapthetic presynaptic- from vagal trunks. enter abdomen via esophageal hiatus, synapse on myenteric/submucosal ganglia
- sympathetic presynaptic- via greater splanchnic. synapse on postsynaptic neurons in ciliac ganglion. pass in tunica adventitia of arterial vessels into stomach
-
stomach cancer
- if in body or pyloric part may be palpable
- evaluated by gastroscopy
- extensive lymphatic drainage and number of nodes creates surgical problems
-
gastrectomy
- total is uncommon
- partial may be done
- extensive arterial anastomoses provides good vascular support
-
gastric ulcers
- 90% caused by infection with helicobater pylori and treatable by antibiotics
- -gastric mucous breaks down
- -if complete perforation occurs, peritonitis may be life threatening
- acid secretion by parasympathetic innervation
- vagotomy at esophageal hiatus is sometimes done for chronic ulces
-
Duodenum
- pylorus to duodenaljejunal junction
- -C shaped around head of pancreas
- mostly retroperitoneal
-
Superior duodenum
- ascends slightly from pylorus
- retroperitoneal
- attached to liver by hepatoduodenal lig
-
descending duodenum
- curves around right side of head of pancreas
- major duodenal papilla- internal opening of common bild duct and main pancreatic duct at hepatopancreatic ampulla
-
inferior duodenum
- crosses to left side of body
- superior mesenteric A/V- anterior to this portion
-
ascending duodenum
- ends at duodenojejunal junction
- supported by suspensory muscle of duodenum, facilitates movement upon contraction
-
arterial supply to duodenum
- superior pancreatioduodenal A- from gastroduodenal A. supplies proximal to major duodenal papilla
- inferior pancreaticoduodenal A- from superior mesenteric A. supplies distal to major duodenal papilla. anastomoses with ciliac trunk and superior mesenteric A
-
Celiac trunk
- supplies distal esophagus to major duodenal papilla
- artery of the foregut
-
superior mesenteric A
- supplies major duodenal papilla to near left colic flexure
- arter of the midgut
-
venous drainage of duodenum
hepatic portal v
-
lymphatic drainage of duodenum
- anteriorly: pancreaticoduodenal nodes to pyloric nodes
- posteriorly: superior mesenteric nodes
- secondary: celiac nodes
-
innervation of duodenum
- parasympathetic- posterior vagal trunk
- sympathetic- greater and lesser splanchnic thru celiac and superior mesenteric plexuses
-
Liver
- largest gland
- upper right quadrant
- critical metabolic organ
-
diaphragmatic surface of the liver
- subphrenic recess- extension of greater sac between liver and diaphragm, separated by falciform lig
- hepatorenal recess- inferir extension of greater sac b/t liver and right kidney. bare area of the liver posteriorly
- coronary lig- anterior and posterior peritoneal reflections
- -triangular lig- right is anterior and posterior coronary ligs, left is falciform lig and lesser omentum
-
visceral surface of the liver
- posteriorinferior flat/concave aspect
- visceral peritoneum
- porta hepatis
- transverse fissure between caudate and quadrate lobes
-
liver lobes
- left lobe
- right lobe
- caudate lobe- between ligamentum venosum and IVC
- -caudate process- extension of caudate lobe connecting it to the right lobe
- quadrate lobe- b/t gall bladder fossa and ligamentum teres
-
ligamentum teres
- remnant of fetal umbilical V
- on free edge of falciform lig
-
ligamentum venosum
- remnant of fetal ductus venosus
- on visceral surface between caudate lobe and left lobe
-
blood delivery to liver
- hepatic portal v- 75% of blood to liver
- nutrient rich, bilirubin rich, pooly oxygenated
- confluence of superior mesenteric V and splenic V
- proper hepatic A- 25% of blood
- highly oxygenated
- off of common hepatic A, splits into right and left hepatic As
-
Blood removal from liver
- right, middle, and left hepatic vs
- drain into IVC
-
lymphatic drainage of liver
- primary nodes= hepatic nodes
- secondary nodes= celiac nodes
-
innervation of liver
- via celiac plexus
- sympathetics- greater splanchnic N, synapse in celiac ganglion
- parasympathetics- vagal trunk
- visceral afferents- T6-9 cord levels, via R greater splanchnic N
-
Cirrhosis of the liver
- loss of hepatocytes and their replacement with fibrous CT
- surface appears nodular
- seen in chronic alcoholics
- associated with hepatomegaly and portal hypertension
-
biliary duct systems
- produces bile continuously
- gall bladder stores and concentrates bile
-
components of biliary duct system
bile canaliculi to bile ducts to R/L hepatic ducts to common hepatic duct. joins with cystic duct to form common bile duct
-
gallbladder
- in gallbladder fossa on visceral surface of liver
- at junction of R/L functional lobes
- on superior part of duodenum
-
structur of gallbladder
- fundus- projecting from anteroinferior border of liver, just below tip of right 9th costal cartilage
- body- adjacent to visceral surface of liver
- neck- narrow, mucosa in this section spirals to form the spiral valve of the gallbladder
- cystic duct- neck of gallbladder to common hepatic duct
-
arterial supply to gallbladder
cystic A off of right hepatic A
-
venous drainage of gallbladder
cystic Vs to hepatic portal v
-
lymphatic drainage of gallbladder
- primary nodes= cystic and hepatic nodes
- secondary nodes= celiac nodes
-
innervation of the gallbladder
- via celiac plexus
- parasympathetics- vagal trunk
- sympathetics- greater splanchnic N, synapse in celiac ganglion
- visceral afferents- in splanchnic nerves back to T6-9
-
gallstones
- cholesterol based
- small stones are most problematic because they get out of the gallbladder and get stuck somewhere
- cause jaundice and pancreatitis
- stones may be lodged in cystic duct causing liliary colic
- large stones usually asymptomatic
-
cholecystectomy
gallbladder removal
-
spleen
- largest lymphatic organ
- intraperitoneal
- filters blood
- not vital
-
Gastrosplenic lig
from spleen to greater curvature of stomach
-
splenorenal lig
from spleen to posterior wall near kidney
-
arterial supply to spleen
- splenic A
- largest branch off celiac trunk
-
venous drainage of spleen
- splenic v
- joined by inferior mesenteric V to superior mesenteric V to form hepatic portal v
-
lymphatic drainage of spleen
- primary nodes= pancreaticosplenic nodes
- secondary nodes= celiac or superior mesenteric nodes
-
innervation of spleen
- via celiac plexus
- sympathetics- greater splanchnic N (synapse in celiac ganglion)
- no parasymp innervation
-
rupture of spleen
- protected by ribs 9-12
- injured due to trauma or rib fracture
- if ruptured= hemorrhage= bad
-
splenectomy
- surgical repair of ruptured spleen is difficult
- some regeneratio possible if only partially removed
- functions taken over by liver and bone marrow
-
accessory spleen
one or more usually present near hilum in 10%
-
pancreas
- retroperitoneal
- exocrine function: digestive enzymes into duodenum
- endocrine function: insulin/glucagon secretion to blood
-
structure of pancreas
- head- right side, surrounded by duodenum.
- uncinate process- inferomedial extension of head
- Neck- short
- body- elongated left side
- tail- anterior to L kidney, near hilum of spleen
-
exocrine duct system of the pancreas
- main pancreatic duct- from tail to head of pancreas
- merges with common bile duct at hepatopancreatic ampula
- opens into duodenum at major duodenal papilla
- accessory pancreatic duct- may be pressent
-
arterial supply of pancreas
- pancreatic As- along splenic A, supply body and tail
- anterior/posterior superior pancreaticoduodenal A- off gastroduodenal A, supplys superior head
- anterior/posterior inferior pancreatioduodenal A- off superior mesenteric, supplys inferior head
-
venous drainage of pancreas
pancreatic veins- drain to plenic V and superior mesenteric V
-
lymphatic draingae of pancreas
- primary nodes= pancreaticoplenic nodes
- secondary nodes= celiac, superior mesenteric and hepatic nodes
-
innervation of pancreas
- sympathetics- greater and lesser splanchnic N, synapse in celiac and superior mesenteric ganglia
- parasympathetic- vagal trunks and celiac and superior mesenteric plexuses
- -most secretions stimulated via hormones
-
pancreatitis
- inflammation of pancreas/blockage of pancreatic duct
- pancreatectomy is performed
- -impossible to completely remove the head of the pancreas
-
pancreatic cancer
- leads to obstructive jaundice
- causes duct obstruction
-
jejunum
- beings at duodenojejunal flexure
- intraperitoneal
-
ileum
- ends at ileocecal junction
- suspended in mesentary
- absorption of food stuffs
-
arterial supply to jejunum and ileum
- superior mesenteric A- off abdominal aorta, in mesentery
- -jejunal/ileal As- 15-18 brances off left side of superior mesenteric
- -unite to form arcades
- -branches off arcades are vasa recta
-
venous drainage of jejunum and ileum
superior mesenteric V
-
lymphatic drainage of jejunum and ileum
- primary nodes= mesenteric nodes
- secondary nodes= superior mesenteric nodes
-
innervation of jejunum and ileum
- perivascular nerve plexus to arteries
- sympathetics- greater lesser splanchnic N. synapse in celiac and superior mesenteric ganglia
- parasympathetic- vagal trunks, synapse in myenteric and submucosal plexuses
- visceral afferents to T8-10
-
ileal diverticulum
- remnant of omphaloenteric duct
- fingerlike puch on anterior ileum
-
large intestine
- completes absorption, compacts and stores feces
- tenia coli- 3 longitudinal strips of smooth muscle
- haustra- sacculations in wall of colon
- epiploic appendages- fatty projections on outside of large intestine
-
cecum
- beginning of large intesting
- pouch at inferior portion of scending
- at ileocecal junction
- intraperitoneal
-
appendix
- intestinal diverticulum on cecum
- contains large amounts of GALT
- mesoappendix- short triangular mesentery of appendix
-
appendicitis
- inflammation of appendix
- obstruction leads to swelling and pain
- rupture results in peritonitis, nausea, pain
- appendecomy to remove
-
arterial supply to cecum and appendix
- ileocolic A- terminal branch of superior mesenteric A
- -appendicular A- branch off ileocolic
-
venous drainage of cecum and appendix
ileocolic V- to superior mesenteric V
-
lymphatics of cecum and appendix
- primary nodes= ileocecal nodes
- secondary nodes= superior mesenteric nodes
-
innervation of cecum and appendix
- sympathetics- lesser splanchnic N, synapse of superior mesenteric ganglion
- parasympathetics- vagal trunks, synapse in myenteric and submucosal plexuses
- visceral afferents- to T10
-
Ascending colon
- right colic flexure- bend into transverse colon
- retroperitoneal
-
arterial supply to ascending colon
- right colic A- from superior mesenteric A
- -marginal A- paralles inner length of colon
- ileocolic A- terminal branch of superior mesenteric A
-
venous drainage of ascending colon
ileocolic V and right colic V to superior mesenteric V
-
lymphatic drainage of ascending colon
- primary nodes= paracolic, ileocolic, right colic nodes
- secondary nodes= superior mesenteric nodes
-
innervation of ascending colon
- sympathetics- lesser splanchnic N, synapse in superior mesenteric ganglion
- parasympathetics- vagal trunks, synapse in myenteric and submucosal plexuses
- visceral afferents- T10
-
transverse colon
- largest portion
- right colic flexure to left colic flexure
- suspended transverse mesocolon
-
arterial supply to transverse colon
middle colic A- branch from superior mesenteric, helps form marginal A
-
venous drainage of transverse colon
middle colic V drains to superior mesenteric V
-
lymphatic drainage of transverse colon
- primary nodes= middle colic nodes
- secondary nodes= superior mesenteric nodes
-
innervation of transverse colon
- sympathetics- lesser splanchnic N and superior mesenteric plexus
- parasympathetics- vagal trunks and superior mesenteric plexus
-
descending colon
from L colic flexure to left iliac fossa where it transitions to sigmoid colon
-
sigmoid colon
s shaped segment, transitions to rectum where mesentery dissapears
-
arterial supply to descending and sigmoid colon
- L colic A- branches from inferior mesenteric A to descending colon. Marginal A connects to middle colic
- sigmoidal As- branch from inferior mesenteric A
-
venous drainage of descending and sigmoid colon
inferior mesenteric V- to splenic V and then hepatic portal V
-
lymphatic drainage of descending and sigmoid colon
- primary nodes= paracolic or left colic nodes
- secondary nodes= inferior or superior mesenteric nodes
-
innervation of descending and sigmoid colon
- sympathetic= least and lumbar splanchnic N, synapase in superior or inferior mesenteric ganglia
- parasympathetic= pelvic splanchnic N
-
kidney
- retroperitoneal, right lower than left
- removes salts and waste from blood
- maintains water balance in body
- creates urine
-
perirenal fat
located inside renal fascia
-
suprarenal gland
- superomedially to each kidney in perirenal fat
- produce corticosteroids, androgens, epinephrine, and norepinephrine
-
pararenal fat
located outside the renal fascia
-
renal transplantation
- donor kidney might be removed
- suprarenal gland left in place
- transplanted kidney placed in iliac fossa
-
Structures of the kidney
- hilum- on medial surface entry of renal V, renal A, ureter
- renal sinus- fat filled space housing renal pelvis
- renal pelvis- origin of ureter, collects urine from major calyces, minor calyces, medulla, renal pyramids, and renal columns
-
arterial supply to the kidney
renal a- branches from abdominal aorta, right side longer, posterior to IVC, divides to anterior and posterior
-
venous drainage of kidey
- renal v- union of intrarenal veins.
- -L recieves left inferior phrenic v, left suprarenal v, and left gonadal v
- -on right these drain to IVC
-
lymphatic drainage of kideny
primary drainage= lumbar lymph nodes
-
innervation of kidney
- sympathetic- renal plexus supplied by lesser and least splanchnic N, synapse in aorticorenal ganglion
- parasympathetics- renal plexus supplied by poserior vagal trunk
-
ureter
muscular duct from kidney to urinary bladder, retroperitoneal
-
arterial supply to abdominal ureter
renal A, gonadal A, abdominal A
-
venoud drainage of abdominal ureter
renal v, gonadal v
-
lymphatic drainage of abdominal ureter
primary nodes= lumbar or common iliac nodes
-
innervation of abdominal ureter
sympathetics- T11-L2
-
renal and ureteric calculi
- stones in kidney, ureter, and urinary bladder
- cause fluid backup= hydornephrosis
- refered pain from T11-L2 dermatomes depending on location of stone
- lithotripsy- shockwaves that break up stones
-
bifid pelvis and ureter
duplication of induction process causing double
-
horseshoe kideny
- inferior poles of the kidneys fuse together forming one horseshoe shaped kidney
- at L3-5 level
-
ectopic pelvic kidney
- kidney fails to ascend out of kidney
- may be injured during pregnancy
- blood from common iliac A
-
suprarenal gland
- between kidey and thoracid diaphragm
- enclosed by perirenal fat
- right- pyramidal shaped
- left- semilunar shaped
-
suprarenal cortex
- secretes corticosteroids and androgens
- endocrine related activites
-
suprarenal medulla
- secretes epinephrine and norepinephrine
- sympathetic activities
- regulated by sympathetic innervation
- presynaptic sympathetics innervate medullary cells directly
-
arterial supply to suprarenal gland
- superior suprarenal A- off inferior phrenic
- middle suprarenal A- off abdominal aorta
- inferior suprarenal A- off renal A
-
venous drainage of suprarenal gland
- suprarenal V
- R to IVC, L to L renal V
-
lymphatic drainage of suprarenal gland
efferent only to lumbar nodes
-
innervation of suprarenal gland
- sympathetics- lesser and least splanchnic N and celiac plexus
- parasympathetic- posterior vagal trunk and celiac plexus
-
thoracid diaphragm
- b/t abdominal and throacic cavities
- primary muscle for inspiration
- parietal pericardium attaches to central part of diaphragm by pericardiacophrenic lig
-
muscular regions of thoracic diaphragm
- sternal part- 2 slips of muscle to posterior aspect of xiphoid process
- costal part- wide muscular slips to internal surface of inferior 6 costal cartilages, forms domes of diaphragm
- lumbar part- muscular crura
-
Crura of thoracic diaphragm
- right crus- larger and longer
- L1-3
- encircles seophageal hiatus, right side of aortic hiatus
- left crus- L1-2
- left side of aortic hiatus
-
arcuate ligaments of thoracic diaphragm
- median arcuate lig- over anterior aspect of abdominal aorta, unites R and L crura
- medial arcuate lig- superior to psoas major, from L1 body to transverse process
- lateral arcuate lig- superior to quadratus lumborum muscle, L1- 12th rib
-
aperatures inthroacic diaphragm
- caval opening- for IVC, in central tendon, T8/9 IVD, diaphragm facilitates venous return
- esophageal hiatus- in right crus, T10, forms lower esophageal sphincter
- aortic hiatus- posterior to diaphragm, T12
-
action of thoracic diaphragm
- contraction
- diaphragm descent compresses abdominal viscera, decreases intrathoracic pressure, air into lungs
-
arterial supply to diaphragm
- superior surface: pericardiacophrenic A, musculophrenic A, superior phrenic A
- inferior surface: inferior phrenic A
-
venous drainage of diaphragm
- inferior phrenic V
- -Right side drains to IVC
- -Left side drains to left suprerenal V
-
lymphatic drainage of diaphragm
- abdominal surface main absorption for peritoneal fluid
- primary nodes= anterior/posterior diaphragmatic nodes
- secondary nodes= parasternal and posterior mediastinal nodes
-
innervation of diaphragm
- motor- phrenic N
- central sensory- phrenic N
- peripheral sensory- intercostal N and subcostal N
-
paralysis of hemidiaphragm
- due to injury of phrenic N
- permanent elevation and paradoxical movement
- -elevation of paralyzed diaphragm during contraction
-
psoas major muscle
- fusiform, lateral to lumbar vertebra
- O: TPs, bodies, IVDs of T12-L5
- I: lesser trochanter of femur with iliacus
- deep to inguinal lig
- A: flexes thigh, flexes trunk, balance trunk
- N: L1-L3
-
iliacus muscle
- triangular, lateral to inferior psoas major
- O: ala of sacrum, iliac fossa, saroiliac lig
- I: lesser trochanter
- A: flex thigh, stabalize hip
- N: femoral N
-
quadratus lumborum muscle
- O: R12, lumbar TPs
- I: iliolumbar lig, iliac crest
- A: depress/stabilize R12, laterally flex trunk
- N: T12-L4
-
Endoabdominal fascia
- between parietal peritoneum and musculature
- continuous with transversalis fascia
-
thoracolumbar fascia
- transparent in thoracic region
- stron in lujbar region
- spans from R12 to iliac crest
-
posterior abdominal pain
- iliopsoas muscle
- movement causes pain
- iliopsoas test
- patient lays on side, extends affected leg against resistance
-
fascial abscesses
- disease or infection may spread to psoas sheath
- fascia thickens and becomes taut
- pus spreads throughout compartment
- causes pain
-
subcostal N
- ventral rami T12
- to external oblique and T12 dermatome
-
lumbar spinal Ns
- dorsal rami to back muscles
- ventral rami thru psoas major from lumbar plexus
-
lumbar plexus of nerves
- ventral rami L1-4
- postsynaptic from gray rami communicantes
-
iliohypogastric and ilioinguinal Ns
- ventral rami T1
- innervate abdominal oblique muscles and L1 dermatome
-
lateral femoral cutaneous N
- L2-3 ventral rami
- under inguinal lig
- sensory to anterolateral thigh
-
femoral N
- L2-4 ventral rami
- to iliacus, hip flexors and knee extensors
-
genitofemoral N
- L1-2 ventral rami
- genital branch- thru deep inguinal ring
- sensory to anterolateral skin of scrotum/labia majora
- motor to cremaster muscle
- femoral branch- along external iliac A
- sensory over femoral triangle
-
obturator N
- L2-L4 ventral rami
- innervates adductor thigh muscles
-
lumbosacral trunk
- L4-5
- joins wiht S1-4 to form sacral plexus of nerves
-
lumbar sympathetic trunk
- 4 paravertebral ganglia
- presynaptic- lateral horn as low as L2-3
- postsynaptic- thru gray rami communicantes
-
Abdominopelvic splanchnic N
- presynaptic sympathetics- T5-L2
- pass thru sympathetic trunk without synapsing
-
anterior/posterior vagal trunks
- from esophageal plexus thru esophageal hiatus
- presynaptic parasympathetics
- innervate lower esophagus to splenic flexure of colon and viscera
-
pelvic splanchnic N
- ventral rami S2-4
- keep the feces off the floor
-
celiac plexus
- via greater and lesser splanchnic N, posterior vagal trunk
- mainly to foregut
-
superior mesenteric plexus
- lesser and least splanchnic, posterior vagal trunk
- mainly to midgut
-
inferior mesenteric plexus
- lumbar splanchnic, pelvic splanchnic
- mainly to hindgut
-
superior hypogastric plexus
- lumbar splanchnic, pelvic splanchnic
- to ureteric and gonadal plexuses
-
inferior hypogastric plexus
- lumbar and pelvic splanchnic
- to pelvic viscera
-
abdominal aorta aneurysm
enlargement of abdominal aorta
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