Mediastinum

• inside thoracic cavity
• contains heart
• in between and infererior to lungs 

Types of Ribs

• True Ribs (1-7)
• False Ribs (8-10)
• Floating Ribs (11-12)

Synovial Joint

• permits free movement
• synovial fluid
• hyaline/articular cartilage

Synchondroses Joint

• primary cartilaginous joint
• may permit bending but usually not movement
• hyaline cartilage
• cartilage may be replaced by bone(syntosis) 

Symphyses Joint

• secondary cartilagenous joints
• slight to no movement
• fibrocartilage(intervertebral disk, pubic symphasis)

Thoracic Synovial Joint

Thoracic Synchondrosis Joints

• sternocostal between sternum and 1st rib
• costochondrol between sternal end of rib and with costal cartilage
• Xiphisternal sternum with xiphoid process (changes with age to synostosis)

Thoracic Symphasis Joint

• manubriosternal joint
• intervertebral joint (fibrocartilage)

Superior Thoracic Aperture

• inlet for anatomists and outlet for clinicians
• contains trachea, esophagus, aortic arch and its branches, and superior vena cava 

Inferior Thoracic Aperture 

• contains diaphragm, esophagus, aorta, inferior vena cava

Lymph Nodes 

• 75% of breast lymph nodes drain to axilary lymph nodes
• thus these are tested for cancer metastisis

Sentinel Node Biopsy

• radioopaque dye is injected into cancer site and tracked backed to first lymph node of drainage
• that node and any others nearby are biopsied or removed 

External Intercostal Muscles

• fibers course infermedial and are found on lateral sides of ribs
• most active during inspiration 
• become external intercostal membranes as you go anteriorly 

Internal Intercostal Muscles

• fibers course inferolaterally
• most active during expiration
• become internal intercostal membrane as they run posteriorly (medial to angle or ribs)

Innermost Intercostal Muscles

• fibers course inferolaterally
• only present in lateral parts of the intercostal space
• neurovascular runs in plane between these and internal intercostal muscle (Vein, Artery and Nerve)

Intercostal Arteries

• anterior and posterior branches
• anterior from internal thoracic artery(branch of subclavian)
• Posterior Branches mostly from descending aorta (1st and 2nd from subclavian via supreme intercostal a.)

Subcostales

• run on deep surface of ribs near their angles
• they skip a rib in there attachments

Transversus Thoracis 

• run between the deep surface of the sternal body and costal cartilage 2-6
• fibers course inferomedially like external intercostal muscles

Levatores costarum

• runs from transverse process of vertebrae to the subjacent (next lower) rib

Abdominal Diaphragm

• domed shaped muscle
• between abdominal and thoracic cavity
• large aponeurotic central tendon provides insertion for peripherally aranged muscle fibers
• caval hiatus, esophageal hiatus, aortic hiatus
• innervated by phrenic nerve(c3-c5)

How Inhalation Works

• thoracic respiratory pressure must be less then atmospheric pressure
• chest volume must increase

How Exhalation Works

• respiratory pressure is greater than atmospheric pressure 
• volume must decrease

Inhalation(Quiet): Bucket Handle

• diaphragm contracts
• scalene muscle fixes first and second ribs
• upper intercostal muscles restrain the lungs at the intercostal spaces
• lower intercostal muscles expand the expand the thoracic cavity out laterally(abduction/adduction plane)

Inhalation(forced): Pump Handle

• diaphragm contracts, ect

• Higher intercostal muscles produce movement of ribs in pump handle movement

   

  Aided by scalene, sternocleidomastoid,

  quadratus lumborum, and erector spinae

  muscles

  increases in flexion/extension plane

   

  
  

  
  

  
  

  
  

Inhalation (Forced): Spreading Calipers

• side affect of bucket handle movement on false ribs (11-12)
• anterior ends of the ribs to spread laterally like the arms of a calliper 

Trachea and Bronchi

• begins below circoid cartilage
• divides into right and left main bronchi at sternal angle(T4)
• right main bronchi is wider/ shorter and more vertical 
• foreign  objects become trapped easier in right 
• carina is at the split 

Carina

• cartilaginous projection of the last tracheal ride associated with cough reflex

Pneumothorax and hemothorax

• pneumo is entry of air/collapsed lung
• hemothorax is entry of blood into pleural cavity

Thoracocentesis (Pleural Tap)

• needle inserted into mid axilary line in 9th intercostal space
• avoids lung and liver
• must be a little superior to 10th rib to avoid neurovasculature 

Lingula

• on left lung 
• a remnant of the middle lobe

Pulmonary plexus 

• innervates lung and visceral pleura
• formed by vagus nerve (CN X)
• reflexes visceral afferent and trachea pain
• pain from bronchi and visceral pleura
• no nerves of general sensation

Intercostal and Phrenic Nerves

• innervates parietal pleura
• sensitive to pain

Structures of the superficialo Mediastium

• thymus
• esophagus
• superior vena cava
• aorta
• trachea

Aorta and Aortic Branches

• componets: ascending, arch, descending
• brachiocephalic
• r common carotid, right subclavian, left common carotid, left subclavian

Aortic Aneurysm

• localized dialation of the aorta due to a weakening of the aortic wall
• usually observed as an enlarged aorta on radiographs or other images of thorax
• patients complain of chest pain that radiates to back

Right and Left recurrent laryngeal 

• branches of vagus nerve
• if both laryngeal nerves are damaged  then voice will be altered and swallowing safely will be a problem

Bronchogenic Carcinoma

• produces enlargement of the trachea
• bronchial lymph nodes
• this alters position and immobilizes the carina
• these changes to carina can be used as a diagnostic signs

Hiatal Hernia

• protrusions of stomach into mediastinum through esophageal hiatus
• in people after middle age due to weakening of diaphragm and widening of esophageal hiatus 

Thymus 

• primarily pediatric
• diminishes at puberty
• immune system organ
• can compress trachea and seldom seen in adults

Azygous Vein

• T12-T4
• recieves posterior intercostal vein
• drains SVC at t4 and IVC at T12

Hemiazygous Vein

• T12-T9
• recieves left posterior intercostal vein
• drains into azygous vein at T7/T8

Accessory Hemiazygous Vein

• T5 to T8
• recieves left posterior intercostal veins
• drains into azygous vein at T7/T8

Thoracic Duct

• cisterna chyli at T12
• right side btw aorta and azygous
• crosses left side at T4/T5
• drains junction of left internal jugular and subclavain l?
• 75% of lymphatic drainage

Pericardium

• surrounds heart
• fibrous pericardium surrounds outer layer
• parietal and visceral layer of serous pericardium
• pericardial cavity in between containing serous fluid

Crista Terminalis 

• seperates rough anterior wall from smooth posterior wall
• musculi pectinate is rough wall(internal muscular ridges)
• sinus venarum is smooth walled cavity
• right atrium

Right and Left Auricle

• small, conical, muscular puchlike structure on the atriums
• floppy ears
• pectinate muscle?

Fossa Ovale and

Valvule of foramen ovale

• remnant of fetal foreamen
• this had carried oxygenated blood from placenta to left atrium 
• seals at birth through several hormones ect

Conus Arteriosus (infundibulum)

• Right Ventricle
• superior anterior part of ventricle
• tapers into smooth walls, coneshaped structure that gives rise to plumonary trunk

Trabeculae Corneae

• muscle ridges and buldges 
• lines the right ventricle

Septomarginal Trabeculae

(Moderator Band)

• muscle ridge crossing cavity from interventricular  septum to base of anterior papillary muscle
• Right Ventricle
• carries right band of AV bundle

Papillary Muscles

• irregular muscle bundles on ventricle wall that connect to atrioventricular valve by chordae tendinae

Ventricular Diastole and Systole

• diastole is relaxing (valves closed)
• Systole is contraction (Valves open) blood pumping

Heart Conduction System

• Sinuatrial Node(SA)=Leads to AV node in atrial myocardium
• Atrioventricular Bund of His
• Left and right Septal (bundle) branches located in septomarginal trabecula
• purkinje fibers on ventricular wall of papilary muscles

Aortic Auscultation Point

• 2nd intercostal space to right of sternal border

Pulmonary Auscultation Point

• 2nd intercostal space to left of sternal border

Tricuspid Auscultation

• 5th and 6th intercostal space near left sternal border

Mitral Auscultation Point

• near the apex of the heart in the 5th and 6th intercostal space in midclavicular line

External Abdominal Oblique

O: external surface of ribs 5-12

I: Linea alba, pubic tubercle and iliac crest

striations follow hands in pockets (inferior medial)

A: works as digastric(2belly muscle) flex and rotate trunk(as in twist crunches) and increase intraabdominal pressure

IN:T7-T11 anterior rami(thoracoabdominal nerve)

Internal Abdominal Oblique (IAO)

Transversus abdmoninus

O: internal surfaces of ribs 7-12, thoracolumbar fascia, iliac crest

I: linea alba, pubic crest, pecten pubis via conjoint tnedon with Internal abdominal oblique

striations run perpindicular to body line (deepest of three muscles)

A: increases intra=abdominal pressure and supports abdominal viscera 

IN: thoracoabdominal nerves and iliohypogastric and ilioinguinal

Rectus Abdominus

Pyramidalis

Umbilical Folds

• lateral formed by inferior epigastric vessels
• medial formed by the obliterated umbilical artery (fetal structure)
• median formed by obliterated urachus(channel by which bladder empties in a fetus)

Superfical fossae

• between median and medial folds
• provides room for bladder to expand

medial inguinal fossae

• also known as hesselbachs triangles
• between medial and lateral folds
• site of superficial inguinal ring and direct inguinal hernias

Lateral inguinal fossae

• located lateral to lateral folds
• site of deep inguinal ring and indirect inguinal hernias

Layers of Spermatic Cord

• EAO aponeurosis= External Spermatic Fascia
• IAO muscle = cremaster muscle
• Transversalis fascia = Internal Spermatic Fascia
• Peritnoneum = Tunica Vaginalis
• Gubernaculum = Scrotal ligament (at inferior pole of testi)

Cremaster Muscle

• interposed between external and internal spermatic fascia
• draws testicle superiorly into scrotum
• inervated by the genitofemoral nerve 
• test by lightly stroking skin on superomedial thigh (cremaster reflex)

Spermatic Cord Contents

• cremaster muscle
• ductus deferens (muscular tube carying sperm from epididymis to the ejaculatory duct
• testicular artery ( off aorta and supplies testis and epididymis)
• artery of ductus deferens (internal iliac a)
• cremasteric artery(inferior epigastric a
• pampiniform venous plexus (coalesce to form testicular vein, which then drains into IVC(right) or left renal vein (left)
• genital branch of genitofemoral nerve and ilioinguinal nerve that isexternal to spermatic cord

Ovarian and Round Ligament

• ovarian ligament is between the ovary and uterus 
• round ligament is between the uterus and anterior abdominal wall
• formed by the spliting of the gubernaculum by the uterus

Inguinal Canal

• pruduct of gubernaculums retraction during development
• intraabdominal pressure closes canal because it is oblique. preventing hernias
• deep inguinal ring in transversalis fascia (proximal)
• superfical inguinal ring in EAO aponeurosis in distal exit (spermatic chord males and round ligament females here)

 Structures of 

Superfical Inguinal Canal

• superficial inguinal ring
• lacunar ligament
• reflected ligament
• medial and lateral crura
• intercrural fibers

Indirect Hernia

• congenital 
• due to a fully or semi-patent processus vaginalis
• hernia enters deep inguinal ring and protrudes into spermatic cord itself
• exits abdominal cavity lateral to the inferior epigastric artery(lateral inguinal triangle)

Direct Hernia

• acquired
• due to weakness of abdominal wall, bowel with peritoneal covering pushes through transversalis fascia to exit superfical inguinal ring
• exits superficial inguinal ring medial to inferior epigastric a (in medial inguinal triange

Femoral Hernia

• exits thorugh the femoral ring inferolateral to the inguinal ligament 
• travels through fascia lata until the saphanous opening where it presents  

Pathway of Sperm productin

• seminiferous tubules
• straight tubules
• rete testes in mediastinum of testes
• efferent ductules
• body then tail of epididymis
• ductus deferens (vas deferens)

Scarpas Fascia

• tough membranous fascia
• continuous with colles fascia in perineum and tunica dartos in scrotum and superfical fascia of penis

Transversalis Fascia

• deepest layer of anterior abdominal wall
• equivalent to internal deep fascia of the Transversalis muscle

Rectus Sheath

• Created by interweaving of aponeuroses of three flat muscles of Abdominal wall 
• superior to umbilicis: EAO and anterior lamina of IAO make up anterior sheath and posterior lamina and TA make up posterior sheath
• btw arcuate line: EAO and IAO make up anterior and TA make up posterior
• AFter arcuate line IAO, EAO and TA make up anterior and is no posterior

Internal Thoracic Artery

• branches off into musculophrenic along costal margin
• and superior epigastric artery that descends through rectus sheath

Inferior Epigastric Artery

Deep Circumflex Iliac Artery

• runs parallel to inguinal ligament and deep to transversalis fascia
• branch of external iliac artery

Abdominal Branches of 

Femoral Artery

• superficial epigastric artery is found in superficial fascia parallel to inferior epigastric artery
• superficial circumflex Iliac Artery is in superficial tissue, parallel to deep circumflex artery

Lymphatics and Transumbilical

Plane

• most superior to line drain into axillary lymph nodes
• most inferior drain into superficial inguinal lymph 
• some midline drain into parasternal or anterior diaphragmatic lymph nodes

Thoracoepigastric Vein

• runs from superficial epigastric to lateral thoracic 
• provides venus flow to heart if IVC or SVC is occluded
• presents as grosely dialated veins on superficial thorax
• superficial epigastric is from femoral vein

Iliohypergastric Nerve

• main branch (biggest)
• pierces IAO to run under EAO
• at midline (superior to pubic symphasis) pierces EAO to innervate skin surrounding skin

Ilioinguinal Nerve

• collateral Branch
• in 30 % of people, ends after piercing IAO
• in most, exits by superficial inguinal ring to innervate skin near genetalia and inner thigh

Faliciform Ligament

• encloses ligamentum teres of the liver
• obliterated umbilical vein
• directly superior median fold

Gubernaculum

• cord made up of connective tissue and smooth muscle that runs from site of future scrotum or labium major to embryological gonads
• also attaches to lower front peritoneal sac forming processes vaginalis

Action of Gubernaculum

• happens around 7 months
• pulls testes through transversalis fascae, nicks inferior IAO, through EAO aponeurosis, and ends up in subcutaneous layer around scrotum
• in women, uterus splits gubernaculum

Tunica Albigenia

• light colored, tough fibrous coating of testes

Supercolic Compartment

• section of greater sac
• contains stomach, liver and spleen
• greater sac diveded by transverse mesocolon

Infracolic Compartment

• part of greater sac(divided by transverse mesocolon)
• contains small intestines and the ascending and descending colon

Lesser Sac (omental Bursa)

• lies posterior to the stomach, lesser omentum and djoining structures
• communicates with greater sac through the epiploic foramen

Esophagus

• travels 10 inches from pharynx to stomach
• passes through esophageal hiatus of diaphragm to enter abdominal cavity at T10
• abdominal part only about 1.25 cm long before emptying into stomach

Parts of the Stomach

• cardiac notch
• fundus
• body
• pyloric antrum
• pyloric canal
• ends at pyloric spincter

 Descending Part of Duodenum

• major duodenal papilla(of vater)
• receives common bie and main pancreatic ducs via hepatopancreatic ampulla
• surrounded by circular smooth muscle (spincter of oddi)

Distinguishing

Jejunum and Ileum 

• Jejunum has fewer arcades
• jejunum have long vasa recta
• ileum has more arcades and shorter vasa recta
• ilum has alot of fat on them coming from mesentary
• if you can see bowel usually jejunum

Large Intestine (colon) Parts

• cecum (intraperitoneal)
• ascending colon (secondarily retroperitoneal)
• transverse colon (intraperitoneal)
• descending colon (secondarily retroperitoneal
• sigmoid colon (intraperitoneal with long mesentary)

Spleen

• largest lymphatic organ in body
• identifies, removes and destroys expended RBCS and broken down platelets
• also serves as blood reservoir
• gastrosplenic ligament
• splenorenal ligament
• intraperitoneal
• levels of 9th and 11th ribs

Pancreas

• exocrine(digestive) gland secreting pancreatic juice into duodenum
• endocrine( hormonal) gland secreting glucogon and insulin into blood
• five parts: uncinate process(behind blood vessels), head, neck, body, tail(passes to hlum of spleen)
• secondarily retroperitoneal

Liver

• largest gland in body and accepts all nutrients from GI tract except Fat (bile emulsificates fat)
• stores glycogen and secretes bile
• coronary ligament, falciform ligament
• hepatic veins drain into IVC which is posterior to liver
• intraperitoneal

Porta Hepatis

• passage of right and left portal vein, right and left hepatic arteries, right and left hepatic ducts, lymph vessels and nerves
• portal triad travels inferior with hepatoduodenal ligament and contains common bile duct, portal vein, and proper hepatic artery

Branches of the Celiac Artery

• splenic artery 
• common hepatic artery
• left gastric that goes to lesser curvature and has esophageal branches (ascends retroperitoneally

Splenic Artery

• branch of celiac artery that runs left along neck and tail of pancreas then enters the spleen between folds of lienorenal ligament
• direct pacreatic branches
• short gastric arteries that go to funds of stomach
• left gastro-omental artery that goes to greater curvature and is also called gastroepiploic

Common hepatic artery

• branch of celiac artery that goes rightward superior to neck of pacreas before dividing into proper hepatic and gastroduodenal
• proper hepatic forms left side of portal triad and gives off right gastric, r and l hepatic and cystic artery
• gastroduodenal artery gives off supraduodenal, right gastroomental, ant/post superior pancreaticoduodenal
• last one supplys 1st and 2nd parts of duodenum and head of pancreus

Peritoneum

• serous membrane lining the abdominopelvic cavity and enclosing the viscera
• peritoneal cavity is the fluid filled space between parietal and visceral layers
• completely closed in males but uterine tubes create opening in females

Mesentary

• fold of peritoneum that anchors organs to posterior abdominal wall

Primary and Secondary

Retroperitoneal

• primary always been deep to peritoneal
• secondary under pressure of surrounding organs, an orgen loses its dorsal mesentary and becomes fixed to posterior abdominal wall
• fusion fascia is remnants of mesentary that adheres these organs to posterior abdominal wall

Ascites

• peritoneum secretes fluid and cells in response to the trauma of the peritoneum.
• leads to excessive fluid accumulation
• fluid accumulation can also be caused by cancer

Lesser Omentum

• connects lesser curvature of stomach and proximal duodenum to liver
• hepatogastric and hepatoduodenal ligament

Greater Omentum

• hangs down like apron from greater curvature of stomach and proximal duodenum
• gastrophrenic ligament: anterior lateral stomach
• gastrosplenic ligament: to spleen
• gstrocolic ligament: goes all the way around stomach to connect

Paracolic Gutters

• provide space for the ascitic fluid to flow and provide pathways for the spread of tumors
• right and left paracolic spaces
• right and left infracolic spaces inside

Foregut

• esophagus, stomach, and duodenum up to common bile duct
• liver, gall bladder, pancreus
• blood supplied by celiac trunk

Midgut

• duodenum distal to opening of bile duct, jejunum, ileum, cecum, apendix, ascending colon, and 2/3 transverse colon
• blood supply from superior mesenteric artery

Hindgut

• distal 1/3 transverse colon, descending colon, sigmoid collon, and rectum 
• blood supplied by inferior mesenteric artery

Small intestine Parts

• duodenum: 4 parts: superior, descending, horizontal, and ascending; also suspensory muscle
• jejunum (about 8 feet long)
• ileum (about 12 feet long)

Teniae Coli

• longitudinal muscle bands on large intestines
• haustra are sacculations between teniae 
• also apendices epiploicae are fat filled pouches of peritoneum on large intestine
• Plicae semilunares are infoldings of intestinal wall between haustra

Coronary and falciform Ligament

• coronary ligament converges form left and right triangular ligament
• falciform ligament connects liver to anterior abdominal wall (ligamentum teres)

Gallstones (cholelithiasis)

• formed chiefly of cholesterol crystals. 
• may be asymptomatic until the stones are large enough to cause billary blockage

Celiac Artery

• artery of foregut
• rarely more then 1" long
• branchs off ventral side of aorta(t12)
• this is right after aortic hiatus
• gives off branches splenic artery, common hepatic artery and left gastric artery

Superior and Inferior Mesenteric Artery

SMA and IMA

• SMA is the artery of the midgut and branches off the ventral side of abdominal aorta at L1
• IMA is the artery of the hindgut and branches off the ventral side of the abdominal aorta at L3

Superior Mesenteric Artery (SMA):

Branches

• middle colic artery supplies the transverse colon 
• inferior pancreaticoduodenal artery supplie 3rd and fourth duodenum
• intestinal and ileocolic artery supplies distal and terminal ilium, apendix and ascending colon
• right colic artery supples other part of ascending colon 

Inferior Mesenteric Artery (IMA)

Branches

• left colic artery
• sigmoid branches
• superior rectal artery 

Marginal Artery (of Drummond)

• large anastomatic channel between superior and inferior mesenteric arteries
• can supply to hind gut in event IMA is obstructed 

(Hepatic) Portal Vein

• takes blood to liver before Inferior Vena Cava
• formed by Superior Mesenteric Vein and splenic vein 
• the Inferior Mesenteric Vein is variable on where it drains (40% splenic, 27% SMV and 33% junction

Portal Hypertension

• restriction of blood flow to liver(blood must find way to IVC)
• drains backward (valvless) into portocaval way 
• left gastric v. drains to esophageal branches of azygous and hemiazygous(presents as dialated)
• superior rectal vein to inferior rectal vein(hemroids)
• paraumbilical v. drains to subcutaneous vein(caput medusa)
• colic branches of IMV drains to retroperitoneal veins of posterior abdominal wall

Primary Peaortic Lymph nodes

• subordinate lymph nodes in gut drain into these
• they are located at the 3 main aortic branches in abdomin
• these then drain into Cisterna Chyli that is a large sac like structure (takes everything abdomin and lower)
• this drains into thoracic duct which enters abductor hiatus

Abdomin Sympathetic NS

(energy expenditure)

• halts peristalsis and restricts blood flow to gut 
• stimulates glucose metabolism
• uses splanchnic nerves to get to abdomen (preganglionic nerve fibers)
• postganglion cell bodies in prevertebral ganglion and travel via periarterial plexus
• 4 thoracic splanchnic and some lumbar

Nerves for Guts

• foregut = greater splanchnic N. (T5-T9)
• Midgut=mostly lesser splanchnic (some greater and least) (T9-T12)
• Hindgut = least splanchnic with some lesser and lumbar (T12-L2/3)
• more distal recieves innervation from lower spinal levels

Parasympathetic Gut  Nerves

(Energy Conservation)

• stimulates peristalsis and digestion
• increases secretion of bile
• either cranial or sacral nerves
• preganglionic bodies in brainstem or S2-S4
• preganglionic N fibers vagus X to periarterial plexus or pelvic splanchnic nerves (S2-S4)
• postganglionic on walls of organ themselves(axons inside)

Appendicitis

• inflamation of the appendix resulting from conclusion, causing bacteria to grow in appendix
• can rupture causing bacteria to spread to peritoneal cavity causing peritinitis and death 
• pain begins begins at belly button (T10)
• then irratation of parietal peritoneum causes localized somatic pain in lower right quadrant
• intense at McBurneys point(1/3 of way btw ASIS and umbilicis) (rebound pain)

Diaphragm

• o: inner aspects of xiphoid, lower 6 costal cart and ribs, upper lumbar vert, fascia overlying psoas major and quadratus lumborum
• central tendon attached to pericardial sac superiorly
• threa hiatuses (cavalT8, esoph T10, aortic T12)
• two crura (left and right, tendinous around aorta
• median, 2medial, 2 lateral arcuate ligaments
• sup pericardiacophrenic and musculophrenic art, and inferior phrenic a (aorta)
• inervated by phrenic nerve C3-5

Psoas Major

O: centra and ventral transvers processes of T12-L5 vert

I: lesser trochanter of femur (unites with iliacus to form iliopsoas

A: primary and strongest thigh flexor

in: lumbar ventral rami (L1-L3)

Psoas Minor

O:centra of T12 and L1 vert

I: pectineal line of hip bone

unimportant muscle missing in 50% of people

a: maybe trunk stabilizer

in:lumbar ventral rami (L1, L2)

Iliacus

Quadratus Lumborum

O: 12 rib and transverse processes of L1-L4 transverse processes

I:iliac crest (deep to latissimus dorsi

most posterior of the long muscle of the posterior wall

A: lateral trunk flexion

In: ventral rami of T12-L4

Paired Lateral Branches of

Abdominal Aorta

• middle suprarenal artery
• renal artery (right one passes deep to IVC)
• Gonadal Artery (testicular/ovarian)

Paired Posterolateral Branches of

Abdominal Aorta

• inferior phrenic artery
• subcostal artery
• lumbar artery (four of them)
• at bifurcation medial sacral artery 

Asymmetric Gonadal and Suprarenal Veins

• right gonadal and suprarenal vein drain to IVC
• left gonadal and suprarenal veins drain to left renal vein

Iliohypogastric and Ilioinguinal Nerve

• common trunk (L1 ramus) passes laterally from underneath the medial arcuate lig to pierce TA just above ASIS
• may maintain identity as a single trunk
• part of the lumbar plexus

Genitofemoral Nerve

• pierces and passes down the anterior surface of psoas major before dividing into genital and femoral branches

Obturator N

• descends medial to psoas major to the obturator foramen
• exits to innervate medial thigh
• L2-L4

Lumbosacral Trunk

• medial to psoas major and obturator n
• joins with s1-s4 to participate in the sacral plexus

Suprarenal Glands

• endocrine glands involved in secreting hormones (corticosteroids, androgens and epinephrine) as part of HPA axis
• form in retroperitoneal space above kidneys
• more on medial side of kidney
• enclosed in renal fascia attaching to diaphragm crura
• right one pyramid left is crescent
• sup, middle, inf suprarenal art and suprarenal vein

Boundary and Contents of

Posterior Abdominal Wall

• boundary lumbar vert., abd diaphragm, trans versus abd, psoas major and mino, illiacus, quadratus lumborum
• contents two paired kidneys and suprarenal glands
• abdominal aorta and inf vena cava
• somatic and autonomic nerve complex(lumbar plexus, lumbosacral trunk, symp trunk)

Psoas Abscess and

Psoas Test

• psoas major susceptible to infection
• most common from s. aureas, before TB
• pain from inf or nearby structures  presents w/ pain during hip flexion, abduction and lower back pain
• positive psoas sign abd pain w/ flexing or extending hip 
• if untreated can become inferior  and spread below inguinal ligament onto thigh and through femoral ring
• mistaken for femoral hernia

Abdominal Aortic Aneurysm

• in aortic diameter ≥3cm or in need of repair ≥5cm as there is an increased risk in rupture
• most common in males ≥60 with family history; increased by smoking 
• sudden severe abdominal pain, pulsatile abd mass, and hypotension suggest immediate repair 

Testicular Varicocele

• large dialation of veins in paminiform plexus, resulting from veins in plexus becoming vericose
• 15% of adolescent and left side bias 90% of time
• left bias due to perpindicular jnx btw left testicular vein and left renal vein

Lumbar Lymphatic Trunks

• lymph from kidneys and other post abd structures
• also recieves from pelvic  viscera, descending colon, and lower limbs via IM and common iliac lymph
• lumbar lymph trunk combine w/ the intestinal lymph trunks to form thoracic duct (cisterna chyli first)

Lumbar Plexus

• iliohypogastric and ilioinguinal nerve
• genitofemoral n
• lateral femoral cutaneous n
• femoral n
• obturator
• lumbosacral trunk

Kidneys

• primarily retroperitoneal structure (T12-13)
• right kidney usually lower
• surrounded by renal fascia that forms renal capsul (has perinephric fat)
• renal hilum leads to renal sinus
• ant-post renal vein, renal artery, renal pelvis
• renal pyramid to renal papilla (columns in btw)
• mino calyx and major calyces
• renal pelvis and ureters

Renal Calculi

• kidney stones are acumulation of salts from inorganic and organic acids filtered from the blood 
• stores formed in kidney pass to pelvis, to ureter, where they can get slowly passed down or caught
• causes intermitant but severe abd pain and digestive upset
• treated w/ nephoscope or lithotripsy(shock waves)

Internal Pudendal Artery and

Pudendal Nerve

• IPA from internal iliac art and PN from s2-s4
• both leave pelvis through greater sciatic foramen
• both enter perineum thru lesser sciatic foramen
• both located in pudendal canal which is a tunnel of CT continuous with the fascia of obturator internus
• deep pouch branches: dorsal n of penis and deep and dorsal artery of penis/clit
• superficial pouch has perineal art and n, including posterior scrotal n and a

Inferior Rectal Artery and Nerve

• branch of internal pudendal artery and pudendal n.
• arterery perineal branches to superficial pouch and remainder enters deep pouch
• nerve inv. exter anal sphincter, sensory to Anal triangle and posterior part of UG triange
• perineal branches of N motor and sensory
• remainder enters deep pouch

Below Pectinate Line

• ectoderm derived(strat squamous epithelium that keratinize as it goes inferior)
• supplied by body wall arteries(inf rectal from int pudendal art from int iliac artery)
• somatic nervs (inf rectal n. from pudendal nerve) for pain and tempature
• lymph drains to superficial inguinal nodes in the groin

Above Pectinate Line

• endoderm derived(simple columnar epithelium)
• supplied by gut arteries (sup recal from inf mesenteric)
• autonomic nerves (prevertebral symp ganglia near aorta) for mostly stretch reception
• lymph drains to inter iliac nodes which lie inside the sacrum around the rectum, near the auto. plexus

Colon Cancer

• cancer of large intestine which is one of most common
• spread in the anal canal follows lymph
• tumor above pectinate line spreads to internal iliac nodes which are hard to get at and operate because of autonomic plexus
• tumor below spreads to inguinal nodes, can be easily palpated and removed

Hemorrhoids

• dialation of anal vessels (10 million US have sympt)
• internal hemorrhoids are prolapse of venous and art vasculature and initally not painful; will eventually bleed and become painful when pulls pectinate line
• external hemorrhoids are venous clots that prolapse below pectinate line; result of high pelvic presure and are painful and covered by skin. usually disapear after a few days

Ischioanal Abscesses

• may spread from a leasion in the mucosa of the anal canal
• cause discomfort in the buttocks that results in symptoms similar to those of hemorrhoids
• draining these can put the prances of the pudendal nerve and nerve of obt internus at risk
• cryptitis can leade to ischioanal abscess

Superficial Pouch of Female

• bulbospongiosus(perineal body, covers buldb laterally)
• ischiocavernosus(ramus of pubis, covers crus)
• superficial transverse perinei(ramus of pubis to perineal body
• 2 erecile bodies: bulb of vestibule in wall of vag, and clitoris
• crus is against pubic ramus and glans projects from skin (parts of clitoris, crus paired) 

Superficial Pouch of Male

• Bulbospongiosus (perineal body covers bulb laterally)
• ischiocavernosus (ramus of pubis, covers crus)
• superficial transverse perinel (ramus of pubis to perineal body)
• Erectile bodies: corpus spongiosum and cavernosum
• spong forms tube around urethra (bulb post and glans of penis anterior)
• cavernosum ant forms most of penis and posterior forms paired crus

Anatomy of penis

• contains coprus sponginosum (with bulb and glans of penis) and corpus cavernosum
• penis also contains the prepuce (foreskin)-33% of newborns circ. in 2009 (might not be covered by medicaid) outlawed in a state in germany  
• has dorsal and deep artery of the penis that branch of internal pudendal art
• dorsal vein of penis drains to groin(ext pudendal to great saphaneous to femoral)
• deep dorsal vein of penis drains to pelivs (prostatic venous plexus)
• dorsal vein above deep fascia(bucks fascia). under this veins midline and arteriers lateral (superfical to tunica albuginea)

External Genitalia of the Female

• opening called the vestibule; surrounded on both sides by labia minura (folds, no fat, no hair)
• labium majora (surround all, thick, fat, have hair), continuous ant to mons pubis
• ant-post: clit, urethra orfice, orfice of vagina
• hymin is thin fold of mucous covering opening of vagina(sep UG sinus from vag in embryo) (variable in thickness, if very thick can be surgically removed)
• this normally becomes perforated at birth, allowing menstrual flow

Episiotomy

• surgical enlargement of the vaginal opening during childbirth as the head of the infant is already visible
• done in order to prevent tearing of perineum (perineal body)
• surgical cut more easily sutured after and direction more easily controlled than a jagged tear

Fornix

• anterior, posterior and lateral fornix is rim or indentation that surrounds the cervix
• posterior fornix is clothed by peritoneum and is pierced easily by instruments
• this can lead to infections in abdominal cavity and can be used for access to rectouterine pouch

Arterial Supply of Female Genitalia

• ovarian artery from aorta
• uterine artery and vaginal artery from the internal iliac artery. (usually have single common trunk
• all these anastomos together

Lithopedion

• means stone baby
• sometimes there can be an ectopic pregnancie in the abdominal cavity
• the embryo can implant on a well perfused organ like the liver and grow
• eventually it will die and calcify

Measuring of the Pelvis

• transverse diameter from pelvic brim to pelvic brim
• obstetrical conjugate from s1 to pubic symphasis (more important because dimension will not change)
• transvese changes during child birth (hormone increases 10-15% wider by relaxing sacro-iliac joints and pubic symphasis

Pelvic Diaphragm

• divided into two parts, coccygeus and levator ani
• coccygeus is next to sacrospinous ligament and is not very strong
• levator ani is very muscular and divided into iliococcygeus that attaches to tendinous arc and the coccyx and pubococcygeus that attaches to tendinous arc and posteriorly is slinged around anal canal and also attaches at coccyx and anaococcygeal raphe (this is strongest)
• sling part can also be called puborectalis

Anal Triangle

• contains anal canal, external anal sphincter, branches of pudendal nerve and internal pudendal artery and vein
• top of triangle ends at ischiotuberosity and perineal body (mass of CT)

3 Mucles that close Anal Canal

• external anal sphincter - central tendon of perineum attached to this (voluntary)
• internal anal sphincter (smooth muscle)
• puborectalis that is part of pelvic diaphragm and wraps around anal canal like a sling (voluntary)

Anal Valve

• consists of anal columns (w/ veins) and anal sinuses
• these interlock when it is contracted
• anal valve the lowerst part of sinus(column)

Pectinate Line

• at end of greater intestine
• differs on ever level above and below this line
• 2 sides are connected by a venous plexus
• inf rectal to internal iliac anstomos to superior rectal to inferior mesenteric vein

Superficial Pouch

• contains paired erectile bodies that can fill w/ blood
• theree paired muscles in both sexes
• greater vestibular gland(Bartholins) in females

Hematocolpometra

• condition where menstrual fluids accumulate in vagine
• occurs because hymen lacks perforations at puberty

Deep Pouch 

• dorsal nerve of penis/clitoris and deep and dorsal artery of penis
• deep transverse perinei(pubic ramus to perineal body) (voluntary)
• sphincter urethrae
• males also have bulbourethral gland

Median Umbilical Ligament

• in front of bladder that pulls peritoneum up towards umbilicus
• the paravesical pouch is on either side of this ligament

Anatomy of Bladder

• orfices of ureter come together at oblique angle to form trigone
• outgoing urethra indented posteriorly and indented portion refered to as seminal colliculus
• contains right and left ejaculatory duct and prostatic utricle
• prostate has many little ducts into the urethra
• 30% of men 75 or old have enlarged prostate

Anatomy of Micturation (Urination)

• kidneys produce urine that fills bladder
• stretch receptors in bladder will cause parasympathetic reflex
• back flow prevented by oblique curse of ureters
• sm. muscles contract and stay contracted 
• pushes on voluntary sphincters (levator Ani and sphincter urethrae) letting one know 
• when relaxed smooth muscles open up neck of bladder and abdominal muscles help

Uterian (falopian tubes)

• consists of infundibulum at the ovary that has many fimbrae
• then funnel shaped ampulla
• flows to fundus (top of uterus)
• ampula not in peritoneum posteriorly 

Ligaments of Uterus and Ovary

• round ligament goes around the uterus all the way to labia majora
• in young woman the round ligament is continuous with the ovarian ligament that goes to ovary
• suspensory ligament brings ovarian artery and vein from high in abdominal wall
• broad ligament is peritoneum in which everything lies
• mesovarium covers ovary and uterine tube in mesosulpinx

Uterine Prolapse

• common after multiple child births
• uterus slides down the vagina(painful and bleeding)
• pulls bladder, deforming it (cystocele)
• ballder has trouble emptying, leading to infections
• hysterectomy often performed to remedy