ANATOMY - ABDOMEN & PELVIS

15- Hepatobiliary System/Foregut

1. GI Embryology a. Mesentery: formed when liver penetrates mesenchyme of septum transversum i. Dorsal mesentery: connecting liver to terminal part of esophagus down to initial part of duodenum (lesser omentum) ii. Ventral mesentery: connecting liver to ventral body wall (falciform ligament) b. Rotation of the Stomach (90 degrees clockwise) i. Original left side becomes the VENTRAL SURFACE ii. Original right side becomes the DORSAL SURFACE 1. Greater curvature comes to lie caudally and to left a. Lesser sac (omental bursa): space behind the stomach i. Ulcerated Gastric Ulcer: gastric juices & stomach contents leak into lesser sac iii. Lesser curvature located cranially and to right iv. Left vagal trunk will be pulled anteriorly v. Right vagus pushed posteriorly (LARP left anterior, right posterior)

c. Pancreas develops from two buds: i. Ventral bud (from duodenum) forms - uncinate process, part of pancreas head, main pancreatic duct 1. Annular Pancreas: ventral pancreas of two lobes migrate around
duodenum in opposite directions to fuse with dorsal bud

a. Infants: feeding intolerance, bilious vomiting, abd. distension b. Adults: abdominal pain, nausea, vomiting, upper GI bleed (stomach ulceration), acute/chronic pancreatitis ii. Dorsal bud (from liver bud origin) forms - rest of pancreas, distal main pancreatic duct d. Midgut elongation forms intestinal loop connected at its apex to vitelline duct i. Cephalic limb: rest of duodenum, jejunum, part of ileum ii. Caudal limb: rest of ileum, cecum & appendix, ascending colon, proximal 2/3 of transverse colon iii. Physiological umbilical herniation: loop elongates rapidly; because of enlargement of liver, abdominal cavity temporarily cannot accommodate the loop and it herniates into extraembryonic cavity

2. Nothing is in the peritoneal cavity a. Parietal peritoneum: sensitive to somatic pain b. Visceral peritoneum: insensitive to somatic pain c. Intra-peritoneal organs: i. Mesentary: double layer peritoneum between body wall & organ; convey all neurovascular structures to abdominal & pelvic organs ii. Ligament: double layer of peritoneum between organs iii. Omentum: double layer peritoneum between stomach & another organ d. Retroperitoneal organs: fixed in position
i. Anterior covered by visceral peritoneum (serosa) continuous w/ parietal peritoneum ii. Posterior surface covered by connective tissue (adventitia) iii. Covered by nearly transparent parietal peritoneum

3. Peritoneal reflections: a. Lesser omentum (hepatogastric ligament): from liver to stomach lesser curvature & first part duodenum i. Hepatogastric lig.: (superiorly) from liver to lesser curvature of stomach ii. Hepatoduodenal lig.: (inferiorly) free lesser
omentum margin from liver to first part duodenum

1. Contains Portal Triad and forms roof of epiploic foramen of Winslow (connecting the greater & lesser sacs) b. Greater omentum (gastrocolic ligament): i. Gastrocolic lig.: stomach greater curvature to transverse colon 1. Nerves & vessels serving the stomach course between the two layers of the lesser omentum & the gastric-colic ligament ii. Gastrosplenic lig.: stomach greater curvature to spleen iii. Gastrophrenic lig.: stomach fundus to diaphragm

4. Foregut: distal 1/3 esophagus to duodenum at bile duct entrance; pain in foregut is referred to epigastric region a. ESOPHAGUS: starts at C6 i. Right crus of the diaphragm wraps around where esophagus enters stomach, forming the esophageal hiatus 1. Hiatal hernia: hernia of stomach through esophageal hiatus a. Sliding hernia: common in patients with GERD (Right crus is weakened allowing herniation, reflux) b. Paraesophageal hernia: (uncommon) normal Z-line & cardia;
herniation of fundus - portion may become strangulated

ii. Lower esophageal sphincter: both inner circular & outer longitudinal layers iii. Cardiac orifice: esop opening into stomach (T10); no muscle sphincter iv. Zigzag (Z) line (esophageal-gastric junction): T11 tip xiphoid process; transition of stratified squamous to simple columnar epithelium v. Gastro-esophageal reflux disease (GERD): acid reflux to esophagus 1. Esophagitis (acute) 2. Esophageal strictures: (chronic) scar tissue reduces lumen & peristaltic functioning 3. Barretts esophagus: metaplasia; adenocarcinoma precursor b. STOMACH: i. Greater & Lesser curvatures: ii. Fundus: superior to line connecting cardiac notch to greater curvature iii. Body: inferior to this line, & superior to line connecting incisura angularis to greater curvature 1. Superior region produces acid & pepsin 2. Inferior region produces alkali & gastrin a. Gastrectomy: surgical removal of gastrin producing stomach part {gastric ulcers}; stomach reconnected to duodenum iv. Pylorus: muscular area right of L1 made of pyloric sphincter & canal 1. Antrum: small area between the body and the pylorus 2. Congenital Pyloric Stenosis: non-bilious projectile vomiting, abdominal pain, dehydration, failure to gain weight v. Ligament of Treitz: fibro-muscular band attaches duodenum to diaphragm; duodenal-jejunal junction landmark, palpable through peritoneum vi. Parasympathetic inn. via Left vagus: (anterior) & Right vagus : (posterior) vii. Sympathetic inn. via Celiac plexus: & Greater splanchnic nerves: 3

c. SPLEEN: triangular organ left & posterior of the stomach i. Lienal-renal ligament: attaches spleen to posterior abdominal wall ii. Rests on (but is not connected to) Phrenico-colic ligament: connects left colic flexure & diaphragm; where the spleens inferior border rests 1. Effective barrier (along w/ mesentery root) to infection spread
iii. Medial surface: smooth fossae where rests against each organ (kidney, stomach, colon)

iv. Splenic a.: {celiac trunk} reaches spleen by way of lienorenal ligament d. LIVER: largest internal organ i. Bare area: superior surface touching diaphragm, not covered by peritoneum 1. Bordered by coronary ligament (reflected peritoneum): extreme ends are the right & left triangular ligaments: angular in shape ii. Ligamentum venosum: obliterated ductus venosus iii. Falciform ligament: (ventral mesentery) anterior abdominal wall to liver 1. Ligamentum teres (round ligament of the liver): obliterated left umbilical vein in free margin of falciform ligament iv. Liver is divided into left & right halves via: 1. Anterior Falciform ligament a. Right & Left Lobe 2. Posterior Fossa made by IVC & gallbladder a. Quadrate lobe: between (& anterior)
gall bladder fossa & ligamentum teres b. Caudate lobe: between (& anterior) IVC & ligamentum venosum

v. Living donor liver transplants: 70% removed w/o

complication; regrowth compensates but not true regeneration

vi. Portal Triad: consists of: 1. Portal vein: union of SMV & splenic vein; receives material from
gut, spleen, pancreas; lipids collected by lymphatics & reach liver via hepatic arteries

a. Divides into right & left hepatic portal veins at the porta hepatis (transverse fissure of the liver) IVC b. No venous valves - if veins become damaged, liver cannot process & clear incoming blood fast increased portal pressure esophageal varices c. Cirrhosis: liver parenchyma atrophy & CT hypertrophy i. Sx: epigastric pain, hematemesis, jaundice, tachycar. low
BP; ascites, splenomegaly, caput medusa, hemorrhoids

ii. Tx: shunt to IVC {temporarily relieve por. hypertension} 2. Common hepatic duct: a. Jaundice: bile pigment accumulation in blood stream
b. Liver frequent site for secondary metastasis (great vascularity)

3. Proper hepatic artery: vii. Portocaval anastomoses: with reduced portal blood flow (portal hypertension)
blood can return to systemic circulation via:

1. Esophageal, Rectal, Paraumbilical, Retroperitoneal veins a. Esophageal varices: stretched v. may rupture
hemorrhage

b. Caput Medusae: dilated periumbilical v. 4

e. GALL BLADDER: pear-shaped organ in liver fossa which

stores bile; develops as an outpouching of hepatic diverticulum

i. Fundus: at junction of 9th rib & linea semilunaris ii. Body; Neck: iii. Cystic duct: series of pouches separated by cystic folds (act like valves {Spiral valve of Heister} to prevent spontaneous bile release); Hartmans pouch: possible site for gall bladder stones to lodge 1. Joins hepatic duct at porta hepatis to form common bile duct, which then joins the pancreatic duct before entering duodenum 2. Gall stones: stretching, twisting & bile release stone trapping a. Lodged in cystic duct Cholecystitis: stagnant bile trapped in gallbladder leading to inflammation b. Lodged in common bile duct Jaundice (yellow color) c. Lodged in hepatopancreatic ampulla (where bile mixes with pancreatic enzymes) Pancreatitis iv. Cystic artery (arises from right hepatic artery)

f. PANCREAS: posterior to stomach & abdominal cavity peritoneum i. Head: lies in the C-shaped portion of the duodenum 1. Uncinate process: extends posterior to superior mesenteric vessels ii. Neck: more constricted than the head iii. Body: runs from the right to left connecting the neck to the tail iv. Tail: lies at the spleen hilus v. Main pancreatic duct (Duct of Wirsung): enters duodenum with the common bile duct, forming Ampulla of Vater at duodenal papilla through Sphincter of Oddi: controls bile & pancreatic secretions in duodenum 1. Spasms of Sphincter of Oddi may result in regurgitation of bile into pancreas acute & severe inflammation, pancreatitis vi. Accessory pancreatic duct (Duct of Santorini): vii. Usually not subject to trauma damage - exception of gastric surgery g. DUODENUM: 1st & of 2nd Parts is foregut: i. First: (5cm) mucous membrane is smooth (vs. rest of duodenum where it is thrown into folds [plicae circulares]) ii. Hepatopancreatic ampulla (ampulla of Vater): dilatation from junction of
common bile & pancreatic ducts proximal to opening in duodenal; located at 1. Major duodenal papilla: location of initial formation outgrowth a. Tissue proximal to this (foregut) supplied by celiac trunk

b. Tissue distal to this (midgut) supplied by SMA iii. Second: (8cm) descending iv. Third: (8cm) inferior, horizontal v. Fourth: (5cm) ascending 5

5. Abdominal aorta: bifurcates at L4 (umbilicus {L3} aorta palpation) a. Left and right common iliac a.s:
i. Internal iliac a. (2): external genitalia, anal canal, perineum ii. External iliac a. (2): ext genitalia, abd. wall ( femoral a.)

b. Somatic/Parietal Branches
i. Lumbar a.: 1st - 4th lumbar a.; posterior intercostal a. ii. Median sacral a.: gives rise to 5th lumbar arteries iii. Inferior phrenic a.s: diaphragm; gives off 2-3 1. Superior suprarenal arteries: adrenal glands

c. Paired Visceral Branches i. Renal a.s: Inferior adrenal branch: adrenal glands
ii. Gonadal a.s: iii. Middle suprarenal a.s: adrenal glands

d. Unpaired Visceral Branches i. Celiac trunk: from aorta ventral surface just below diaphragm at T12; supplies most of the foregut via: 1. Left gastric: lower esophagus, less. cur. stomach a. Esophageal branch: 2. Splenic: (left) spleen, pancreas, stomach a. Left gastroepiploic: stomach greater curvature; greater omentum b. Short (left) gastric: stomach fundus 3. Common hepatic: (right) a. Right gastric: stomach lesser curvature b. Gastro-duodenal: duodenum i. Right gastroepiploic: through greater omentum;
anastomose w/ left gastroepiploic along greater curvature

ii. Superior pancreatico-duodenal: pancreas, duodenum Common hepatic becomes. 4. Hepatic Artery Proper: extends up towards liver, enclosed in lesser omemtum (hepato-duodenal ligament / Portal triad) a. Right hepatic: right lobe, caudate lobe, gall bladder i. Cystic artery: gall bladder; passes through Triangle Of Calot (cystic-hepatic triangle: bounded
by cystic duct, hepatic duct, liver lower edge)

b. Left hepatic: left lobe, quadrate, caudate (caudate ~ fish tail) ii. Superior mesenteric a.: ventral aorta 1cm below celiac L1 level; supplies midgut 1. Inferior pancreaticoduodenal a.: pancreas head, uncinate process 2. Right colic a.: ascending colon 3. Middle colic a.: proximal 2/3 transverse colon (part of marginal a.) a. Vasa recta: do not anastomose; long in jejunum, short in ileum 4. Jejunal a.: small intestine jejunum 5. Ileocolic a.: terminal ileum, cecum, appendix, ascending colon 6. SMA Syndrome: compression of the 3rd part duodenum by SMA;
dilation of 1st & 2nd parts, nausea & billous vomiting (curdled milk & bile); relieved by leaning forward iii. Inferior mesenteric a.: aorta 3cm above L3 bifurcation; supplies hindgut
may also compress left renal vein

1. Left colic a.: transverse colon (part of marginal a.), descending & sigmoid colon 2. Sigmoid a.: sigmoid colon; lower descending colon 6

6. Inferior Vena Cava: a. Hepatic veins: receive blood from the liver and terminate in the IVC b. Union of Superior Mesenteric Vein & Splenic Vein {at L2 level} i. Portal Vein: right & left branches enter the porta hepatis 1. Splenic v.:
a. b. c. d. 3. 4. 5. Left gastroepliploc v.: Inferior mesenteric v.: Pancreatic v.: Short gastric v.:

2. Superior mesenteric v.: ileum, jejunum, cecum, sigmoid, ascending, transverse

Left & Right gastric v.: Paraumbilical v.: Cystic v.:

7. Nerves: the major innervation of the visceria is autonomic a. Sympathetic Innervation: i. Preganglionic fibers: greater splanchnic n. (T5-T9) ii. Post-ganglionic fibers: accompany blood vessels iii. Sympathetic trunk (Thoracocolumbar): 1. Esophageal Nervous Plexus: esophagus, stomach fundus, left colic flexure a. Anterior & Posterior Vagal Trunks: Synapse in the Celiac & Superior Mesenteric Plexuses: 2. Thoracic Splanchnic Nerves (T5-12): Foregut & Midgut a. Greater splanchnic n. (T5-T9): i. Branches to: descending thoracic aorta, suprarenal glands b. Lesser splanchnic n. (T9-10): i. Renal branches c. Least splanchnic n. (T12): 3. Lumbar Splanchnic nerves (L1-3): Hindgut b. Parasympathetic innervation via Vagus n. (CNX): Stimulates bile production &
glycogen synthesis, but hormones control most functions via enteric NS - 50x more preganglionic neurons

i. Pelvic splanchnic nerves (ventral primary rami S2-4): hindgut 1. Passes to the Rectal plexus c. Subcostal n. (ventral primary rami T12): abdominal muscles d. Lumbar Plexus (ventral primary rami T12-L4): i. Iliohypogastric n (L1-T12): suprapubic skin ii. Ilioinguinal (L1): skin of: penis, scrotum, mons pubis, labium major iii. Genitofemoral n. (L1-2): cremaster muscle, same skin as ilioinguinal
iv.

v. vi. vii.

Lateral femoral cutaneous n. (dorsal branches of ventral rami L2-3): Femoral n. (L2-4): Obturator n. (L2-4): Lumbosacral trunk (L4-5):

8. Lymphatics:
a. Foregut drains into nodes named after their structure drain superior mesenteric n. to celiac

i. Pre-aortic nodes = inferior mesenteric, superior mesenteric, & celiac nodes ii. Celiac nodes drain to the cisterna chyli, and then into the thoracic duct 7

16- Midgut/Hindgut
1. Midgut: from opening of bile duct into duodenum until 2/3 through transverse colon a. SMALL INTESTINE: i. Jejunum: [ULQ] upper 2/5 excluding duodenum; greater diameter & thicker wall (large plicae circulares); longer vasa recta (versus ileum) ii. Ileum: [LRQ] lower 3/5 of small intestine 1. Meckles diverticulum: persistence of the yolk stalk in adult in ileum ~3 ft from terminal end; usually asymptomatic but may become inflamed & give appendicitis-like symptoms a. May contain pancreatic/gastric tissue, and develop ulcer 2. Omphalocele: small intestine fails to be completely drawn into abdomen after rotation hernia filled w/ small bowel covered with amniotic membrane protruding out of abdomen 3. Volvulus: incomplete gut rotation midgut loosely suspended by long mesentery - may become twisted or tangled iii. Mesenteric Ischemia: arteries supplying small intestines (from SMA) blocked
1. Sx: Sudden mid-abdominal pain; normal bowel sounds, minimal tenderness

2. Hx: myocardial ischemia, peripheral vascular disease b. LARGE INTESTINE: greater diameter than S.I.; performs some absorption (water) i. Iliocecal junction: functionless ileocecal valve: forms frenulum ridge) 1. Colon Intussusception: invagination of ileum into cecum through ileo-cecal valve intestinal obstruction; usu. 1y/os a. Causes: benign/malignant growths, adhesions (scars), motility disorders, long-term diarrhea ii. Cecum: sac lying below the ilio-cecal junction 1. Carcinoma of the Cecum: 2nd leading cause of cancer death; mass protruding into lumen usually arising from mucosa; neoplastic, hyperplastic, or inflammatory in etiology iii. Vermiform appendix: at McBurneys point; base attached to cecum, appendix itself attached to ileums mesentery (via mesoappendix) 1. Appendicitis: causes deep pain in right iliac fossa (RLQ) a. Pain severe & localized once peritoneum involved
b. Afferent nerves enter T10 referred pain around umbilicus

iv. Ascending colon: when reaches right (hepatic) colic flexure becomes 1. Transverse colon: to left (splenic) colic flexure (more superior) v. Diverticulosis: (sigmoid) outpouchings (herniation) of colonic mucosa & submucosa through muscle wall layer weaknesses; due to low-fiber diet, constipation which increases intra-luminal pressure vi. Crohns Disease: chronic relapsing inflammatory condition
1. Sx: diarrhea, abdominal pain, weight loss, constitutional symptoms

c. Taenia coli: colon external longitudinal muscle division into 3 bands; pursestring effect & colonic out-pouching (Haustra coli) d. Epiploic appendages: small fat pouches along colon except cecum, appendix, & rectum 8

2. Hindgut: posterior (caudal) part of the alimentary canal a. Splenic (left) flexure of colon: transverse descending colon b. Descending colon: to the pelvic brim where it becomes the.. i. Sigmoid (pelvic) colon: which continues to the rectum c. Upper 1/3 rectum: terminates at levator ani attachment (pectinate line/anorectal junction) i. Inside of the rectum is thrown into folds (rectal valves) ii. Internal hemorrhoids: above pectinate line & outside rectal columns iii. External hemorrhoids: below pectinate line; seen when enlarged d. Inferior mesenteric artery: from aorta ~4cm above bifurcation i. Left colic: 1. Ascending (superior) branch: distal 1/3 transverse, superior descending 2. Descending (inferior) branch: lower descending colon ii. Sigmoid branches: iii. Superior rectal (hemorrhoidal a.): branches obliquely encircle rectum 1. Middle rectal (internal iliac b.) & inferior rectal (internal pudendal b.) arteries anastomosis in rectum wall - can supply entire rectum if IMA (& superior rectal a.) clamped e. Marginal Artery of Drummond: anastomosing ends of superior & inferior mesenteric a. f. Rectal plexus of veins: i. Upper tributaries form superior rectal vein inferior mesenteric vein ii. Middle passes to internal iliac vein (with tributaries from bladder, prostate, seminal vesicle) iii. Inferior part drains into internal pudendal vein g. Lymphatics i. Rectum: inferior mesenteric group of pre-aortic lymph nodes ii. Anal canal: internal iliac nodes (along middle rectal a.) lateral aortic nodes iii. Anus: (below white line of Hilton) join those of perineum & scrotum superficial inguinal nodes

16b- Autonomic Innervation of GI track

1. SYMPATHETIC: regulation of blood flow a. Greater Splanchnic nerves (T5-T9): from intermediolateral cell columns, travel along spinal ventral roots, synapse celiac ganglia i. Then along blood vessels to foregut b. Lesser Splanchnic nerves (T10-T11): synapses in superior mesenteric ganglia i. Supplies midgut c. Least Splanchnic nerves (T12): synapses in aortico-renal ganglia i. Regulate blood flow to kidneys d. Lumbar Splanchnic nerves (L1-L2): synapse in inferior mesenteric ganglia i. Regulate blood flow to hindgut 9

2. PARASYMPATHETIC: peristalsis a. Vagus nerve: thorax, abdomen, GI tract up to transverse colon boundary b. Craniosacral: Pelvic splanchnic nerves (S2, 3, 4): hindgut c. Hirschsprungs Disease: congenital absence enteric PS ganglia in distal colon i. Absence of peristalsis, dilation of proximal colon, constipation, failure to pass meconium, abdomen distension d. Motility of the Large Intestine i. Haustra sequentially contract as they are stimulated by distension ii. Presence of food in stomach gastrocolic reflex & peristalsis iii. Defecation 1. Fecal distension of rectal walls rectal contraction a. Relaxes internal anal sphincter (Pelvic splanchnic n) 2. Voluntary relaxation external anal sphincter (Pudendal n) 3. Autonomic nervous system is a visceral motor system a. Somatic sensation: conscious, sharp, well-localized i. Touch, pain, temperature, pressure, proprioception b. Visceral sensation: often unconscious; if conscious dull & poorly localized i. Distension, blood gas, blood pressure, cramping, irritants c. Visceral afferent sensory nerves (GVA): sensory CNS feedback about autonomic requirement
i. Run with sympathetic & parasympathetic nerves ii. Cell bodies in dorsal root ganglion; Nerve ending in viscera

iii. Referred pain: pain originating in visceral structure

perceived as from area of skin innervated by same segmental level as the visceral afferent

1. From convergence of somatic & visceral afferents on same segmental level - Cross-talk in dorsal horn
Organ Stomach Duodenum Jejunum Ileum Caecum Appendix Ascending colon Sigmoid colon Spleen Liver & gallbladder Pancreas Spinal Level T5T9 T5T8 T6T10 T7T10 T10T11 T10T11 T10T12 L1L2 T6T8 T6T9 T7T9 Site of Referred Pain Epigastric or left hypochondrium Epigastric or right hypochondrium Periumbilical Periumbilical Periumbilical or right lower quadrant Periumbilical, then to right iliac fossa Periumbilical or right lumbar Left lower quadrant Left hypochondrium Epigastric, later to right hypochondrium Inferior epigastrium

10

Kidney Ureter

T10L1 T11L1

Small of back, flank Loin to groin

17- Posterior Abdominal Wall/Urinary System

1. Lumbar vertebrae location markers a. Transpyloric (L1) b. Subcostal (L2) along lowest part of rib cage (rib 10) c. Transiliac (L4) upper edge of iliac crest 2. Anal canal: lining continuous with skin at white line of Hilton (intersphincteric line: small indentation between internal a.sphincter & subcutaneous external a.sphincter) a. White line of Hilton: anus transition point nonkeratinized to keratinized st. sq. epi. b. Internal anal sphincter: involuntary circular fibers i. Innervated by PS ns. from S2, 3, 4; not innervated by pudendal n. (somatic n.) a. External anal sphincter: voluntary; always in tonic contraction

3. DIAPHRAGM: a. Openings: i. Caval orifice (T8): inferior vena cava ii. Esophageal sphincter (T10): formed by arching fibers of right crus iii. Aortic orifice (T12): aorta passes behind diaphragm between R & L crus b. Left crura: from vertebrae L1-L2 c. Right crura: from vertebrae L1-L3 d. Lumbocostal arches (arcuate ligaments): diaphragm crosses quad.lumborum & psoas i. Medial arcuate ligament: (over psoas major m.) ii. Lateral arcuate ligament: (over quadratus lumborum m.) over subcostal n. (T12) iii. Median arcuate ligament: (between R & L crus) over aorta & cysterna chyli e. Congenital Diaphragmatic Hernia: abdominal organs push into lung formation f. Eventration of Diaphragm: elevation of diaphragm due to congenital malformation or phrenic nerve interruption from birth or operative trauma a. Phrenic nerve: motor fibers & also sensory fibers to central diaphragm b. Intercostal nerves: sensory fibers to peripheral part c. Blood supply: musculophrenic, pericardiophrenic, superior & inferior phrenic

4. POSTERIOR ABDOMINAL WALL: a. Psoas major: passes with iliacus under inguinal ligament (iliopsoas: covered by dense fascia muscles & lumbar plexus behind fascia, iliac vessels in front) i. Flexes hip joint; Innervated by L1, 2, 3 inside abdomen ii. Psoas Sign: pain on passive extension of right thigh 11

b. c. d. e.

1. Inflamed appendix is in a retroperitoneal location in contact with the psoas muscle which is stretched by this maneuver Psoas minor: small muscle belly whose long tendon lays over psoas major Quadratus lumborum: lateral to psoas, running between iliac crest & R12 i. Side trunk flexor; Innervated segmentally by adjacent lumbar nerves Transverse abdominus: arises from the thoracolumbar fascia ADRENAL GLANDS: embedded in perinephric fat i. Cortex: production of steroids ii. Medulla: source of epinephrine secreted by chromaffin cells 1. Derived from neural crest cells: where preganglionic abdomino-pelvic splanchnic nerves synapse 2. Pheochromocytoma: tumor of the chromaffin cells; large suprarenal mass, sympathetic system overdrive iii. Right adrenal gland: triangular shape 1. Posterior diaphragm 2. Medially anterior IVC; Laterally anterior - liver 3. Between the adrenal glands are the celiac trunk & celiac plexus 4. Left adrenal gland: crescent shape; descend to the hilus of the L kidney a. Posterior diaphragm left crus b. Anterior stomach; Inferior pancreas 5. Only one large venous branch leaving each adrenal gland at the hilus a. Left adrenal v. left renal vein; Right adrenal v. IVC

f. KIDNEYS: lie on psoas major, quadratus lumborum and transversus abdominis; develop in pelvis, ascend to T12 level; lie in a paravertebral gutter i. Perirenal space: inside fascia, around kidneys; Pararenal space: around fascia ii. Signs of Retroperitoneal bleeding: 1. Cullens Sign: tracking of liberated pancreatic enzymes to ant. abd wall from gastrohepatic ligament across falciform ligament 2. Grey-Turners Sign: tracking of blood-stained pancreatic exudate from anterior pararenal space through tissue planes (including posterior renal fascia) to the abdominal wall iii. Hilum: where renal arteries enter the kidneys iv. Major, minor calices: minor form major calices, form pelvis ureter part v. Ureters: pass anterior to psoas m. & common iliac a. bifurcation into pelvis vi. Pelvic kidney: fails to ascend to the abdomen from the pelvic vii. Ectopic kidney: has migrated to an abnormal position viii. Horseshoe kidney: primordial kidneys fuse, usually at inferior poles ix. Kidney stone: passage may give rise to referred pain from the testis (testicular plexus at T10) since afferents from the kidney enter at T12 x. Surgical access to kidney through lumbar triangle (fewer muscle layers) 5. Lymphatics a. Pre-aortic nodes: in front of the aorta i. Celiac nodes: ii. Superior mesenteric nodes: 12

iii. Inferior mesenteric nodes: iv. all unite to form the intestinal trunk enters the cisterna chyli (a dilated sac marking the inferior end of the thoracic duct) b. Para-aortic (lateral aortic) nodes: in front of vertebral bodies, near aorta
i. Drains: posterior abd. wall, kidneys, adrenal glands, pelvic organs, lower limb

c. Thoracic duct: starts at L2 & extends to root of the neck

i. Origin in abdomen from confluence of R & L lumbar & intestinal trunks

6. Abdominal aorta: enters abdomen under median arcuate ligament at T12, ends at L4 left of midline a. Lateral branches (suprarenal glands, kidneys, gonads) i. Renal arteries: of cardiac output; arise just below SMA; enter kidneys at the hilus posterior to renal veins 1. Right renal a.: passes posterior to inferior vena cava; longer 2. Left renal a.: 3. Inferior adrenal a.: ii. Middle suprarenal branch: to suprarenal glands iii. Gonadal (ovarian or testicular) a.: arise from aorta just below renal a. 1. Descend anterior to surface of psoas to reach ovary, or 2. Pass into the inguinal canal to go to the scrotum b. Branches to the body wall i. Inferior phrenic a.: ramify on inferior diaphragm surface 1. Superior adrenal branches (6-8): suprarenal glands ii. Lumbar a. (4): 1. Anterior branch: between transversus & internal oblique m. 2. Posterior branch: goes through the back giving a spinal branch iii. Median sacral a.: midline, anterior to sacrum; main continuation of aorta c. Repair of Abdominal Aortic Aneurysms: put in stent (clamp aorta above & below), insert catheter into femoral & ext. iliac, then aorta; stent distributes blood from aorta 7. Inferior Vena Cava: begins in front of L5, ascends to diaphragm, pierces central tendon at T8 a. Renal veins: i. Above veins lie anterior to corresponding arteries ii. Below arteries lie anterior to the veins b. Tributaries may be deduced from branches of the aorta i. Ventral branches: drain to the portal system 1. Hepatic veins: drain to IVC ii. Lateral tributaries: correspond to the named arteries except on the left where the suprarenal & gonadal veins open in the left renal vein iii. Body wall tributaries: 1. Inferior phrenic & lumbar veins: drains into IVC 2. Median sacral: drains into left common iliac vein 8. Lumbosacral plexus: roots L1-L5 are the ventral primary rami of spinal nerves a. L1: iliohypogastric & ilioinguinal nerves: both course along quadratus lumborum to anterior abdominal wall, with iliohypogastric lateral 13

b. L1 + L2: genitofemoral nerve: courses through and more medially along the psoas muscle to turn laterally to the anterior abdominal wall i. Motor innervation to cremaster m. c. L2 + L3: lateral femoral cutaneous d. L2 + L3 + L4: femoral & obturator nerves e. L4 + L5: lumbosacral trunk, which joins sacral nerves to form sacral plexus

18- Cross-Sectional Anatomy

1. X-rays beam attenuation affected by: tissue density & thickness, x-ray energy (kV) a. Structural elements that attenuate the beam to a greater extend than air (black) or are less attenuating than bone (white) show in various shades of gray b. Four basic densities: i. Air least absorbing {black} ii. Soft tissue {gray} iii. Fat iv. Bone - most absorptive {white} 2. Approach to plain film interpretation a. What is the normal & variant anatomy? i. Situs inversus: congenital invariant where heart and aortic arch are rotated to the right side (normally left-sided structures) b. Check for clues in the skin & soft tissues c. Evaluate bones (Position/alignment, cortex, density, internal architecture, focal lesions) 3. Ultrasonography: a. Uses sound waves of frequencies 2 to 17 MHz b. Images from propagation & surface reflection of sound waves through body c. Time it takes sound waves to return provides information on tissue position d. No ionizing radiation - Uses sound waves to visualize structures e. Very operator dependent f. Can not penetrate bone g. Mainstay of diagnosis for: i. Ob-gyn; Pediatric / Young women ii. Screening for vascular, abdominal & renal pathology iii. Thyroid/neck pathology; Palpable lesions: Breast & Musculoskeletal h. Colour Doppler: velocity & direction 4. CT (Computer Tomography)
a. Cross-sectional with multiplanar reconstruction & 2D imaging to assess vascularity

b. Tube rotates around body and stationary circle detects penetrating x-rays c. Limitations: $$$ i. Ionizing radiation ii. Requires contrast: IV and oral - prep time (1-2 hours) 1. Nephrotoxic; fatality rate 1:50,000 (even with low osmolar contrast) iii. Patient must be supine (prone) 14

5. MRI (Magnetic Resonance Imaging) a. Rapidly switching magnetic field gradients align H protons (water and fat) b. When the gradients are turned off, a faint radiofrequency signal is produced
i. Different tissues absorb & give off different amounts of RF energy (different resonances)

c. d. e. f.

Image is reconstructed using Fourier transforms Multiplanar and vascular assessment possible Offers greatest contrast in tissue imaging technology (knee, ankle diagnosis) Mainstay of diagnosis for: i. Neurologic imaging ii. Musculoskeletal imaging (after plain film) iii. Magnetic Resonance Angiography 1. Angiography without iodinated contrast: no arterial puncture (no
risk of vascular damage); 3D view of arteries & adjacent organs

iv. Expanding applications in chest, abdominal, breast, & pelvic imaging g. Advantages: i. True multiplanar imaging ii. Intravenous contrast not usually required; No ionizing radiation iii. Minimize problems with claustrophobia h. Limitations: $$$$ {$1450 - $2000} i. Ferromagnetic objects cause artifacts that limit imaging ii. Contraindicated for patients with 1. Implantable devices: cochlear implants, pacemakers* 2. Metal shavings in orbits 3. Severe renal failure iii. Requires more cooperation and longer time than CT {30 min - 2 hrs}

6. Fluoroscopy: a. Dynamic radiography i. Permits real-time evaluation of the gastrointestinal tract ii. Barium Swallow (esophagus) iii. Upper GI Series (stomach); Small Bowel Follow-through iv. Barium Enema (colon) b. Barium appears white on images (high density attenuates the x-ray beam) c. Assess both intrinsic (mucosal) & some extrinsic (mass-effect) abnormalities 7. Nuclear Medicine GI Bleeding Scan 15

a. Radiopharmaceutical = Tc99m in-vitro labelled RBCs b. Sequential 5 minute images acquired over an hour c. Looking for progressive accumulation of tracer 8. Gallium Scan: used for lymphoma staging & response a. Baseline imaging determines whether the tumor is gallium-avid
b. Serial scans assess response to treatment - can distinguish scar from residual tumor

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19- Male/Female Pelvis & Perineum

1. PERINEUM: region inferior to pelvic diaphragm between the legs a. Boundaries: i. Anterior - Pubic symphysis: fibrocartilage; Posterior Coccyx: ii. Lateral Ischial tuberosities: hamstrings origin; Obturator internus m. iii. Anterolateral Ischiopubic ramus: iv. Posterolateral - Sacrotuberous ligament: b. Diamond-shaped area subdivisions i. Urogenital triangle (anterior): anus, external
anal sphincter, levator ani, obturator internus muscle

ii. Anal triangle (posterior): area bounded by ischial tuberosities laterally and the coccyx posteriorly; perineal body, anal opening, midline anococcygeal raphe 2. Pelvic brim: divides greater (false) from lesser (true) pelvis
from sacrum, ilium arcuate line, pectineal line (pectin of pubis) & pubic crest

3. Pelvic Floor: made up of a. Pelvic diaphragm: dividing line between pelvis & perineum; forms floor of abdominal & pelvic cavities, consists of paired levatores ani & coccygeus muscles b. Urogenital diaphragm: 4. Sacrospinous ligament: posteriorly holds hip to sacrum a. Prevents upward motion; crossing of these two ligaments (Sacrotuberous/sacrospinous) forms sciatic foramen on either side of ischial spine 5. Obturator foramen: passage for obturator nerve 6. Lesser sciatic notch: from pelvis into perineum (pudendal nerve) 7. Greater sciatic notch: from pelvis to gluteal region (sciatic nerve, piriformis) 8. Ala: attachment of piriformis muscles 9. Blood vessels: a. Ovarian a.: branches directly form the aorta just inferior to renal a. b. Common iliac artery: i. Internal iliac a.: pelvis & perineum 1. Obturator a: pelvic muscles, hip joint 2. Superior & Inferior gluteal a.s.: 3. Obturator a.: medial thigh 4. Uterine & Umbilical a.: (near broad ligament) cervix, vagina, uterine tube, round ligament 5. Middle Rectal (hemorrhoidal a.): lower rectum 6. Internal pudendal a.: perineum a. Inferior Rectal: c. Veins form an anastomotic basket lining pelvic cavity functionally one network i. Unite to form internal iliac veins (2), which unite with corresponding external iliac veins to form common iliac veins to the IVC 18

10. Nerves: a. Pudendal n.: (S2-4) provides the only TTPP & voluntary efferent fibers to anal canal i. Passes through greater & then lesser sciatic foramen to enter ischiorectal fossa where it enters the pudendal (Alcock's) canal ii. Posterior scrotal n.: innervate posterior scrotum wall iii. Perineal b.: Motor to bulbospongiosus, perineal, sphincter urethra 1. Somatic sensory innervation to the labia via Ilioinguinal, genitofemoral, & Posterior Labial nerves iv. Deep perineal b.: to muscles of the UG diaphragm & superficial pouch v. Inferior rectal b.: cross medially to sphincter ani muscles b. Sacral plexus (lumbosacral S2-4): pelvis, lower limb c. Pelvic splanchnic n. (efferent PS fibers from S2-4): motor to wall of bladder & rectum, inhibitory to bladder sphincter, vasodilator fibers to erectile tissue 11. Muscles: a. Levator ani: supportive muscles for midline pelvic organs i. Iliococcygeus: {posterior} arises from the fascia of internal obturator 1. Ischiorectal (ischioanal) fossa: fat-filled space between obturator internus & levator ani; accommodates rectal filling & emptying related to defecation
a. b. c. Lateral wall obturator internus; Medial wall external anal sphincter Superior levator ani; Inferior superficial fascia & skin Floor UG diaphragm

ii. Pubococcygenus: {anterior} attaches to inner surface of pubic bone & obturator fascia; passes back lateral to anal canal to reach the coccyx 1. Puborectalis: part of the pubococcygeus muscle that wraps around posterior rectum, forming a sling around anorectal junction that maintains flexure & holds rectum forward b. (Ischio-) Coccygeus: fused with sacrospinous lig; attaches to spine of ischium c. Obturator internus: forms the pelvis lateral wall 12. Urinary bladder: sac on the pelvic floor {true pelvis} - shape affected by age, sex, urine vol. i. Males: superior to prostate; separated from rectum by restovesical pouch ii. Females: inferior to uterus, anterior to vagina; separated rectum by vesicouterine pouch b. Detrusor muscle: smooth m. fibers in spiral, longitudinal, & circular bundles i. Stretch receptors - Afferent (sensory) impulses enter spinal cord (S2-S4) via Pelvic Splanchnic n. PNS contracts expel urine via 1. Internal sphincter (autonomic) & external sphincter (voluntary) ii. Parasympathetic fibers: 1. Preganglionic: pelvic splanchnic n. synapse in inferior hypogastric plexus 2. Posganglionic: to bladder m. induce reflex contraction of detrusor muscle & relaxation of internal sphincter 3. Pudendal n. somatic fibers: voluntary relaxation ext sphincter iii. Sympathetic fibers: relax bladder, contract internal sphincter {inhibit emptying}; also prevent reflux retrograde ejaculation into bladder c. Trigone: smooth triangular region at bladder base where ureters enter; very sensitive to expansion stretching sends emptying signals to brain 19

13. MALE PELVIS: a. Seminal vesicles: glands postero-inferior to bladder whose secretions are responsible for primary alkalization of semen; duct opens into vas deferens b. Vas (ductus) deferens: transports sperm from epididymis to ejaculatory duct i. Vasectomy: transection/ligation; reliable form of birth control for men c. Ureter: passes inferior & medial to Vas deferens to enter posteolateral bladder d. Prostate: cone-shaped chestnut-sized gland of CT & smooth muscle that rests on superior levator ani with urethra passing through urogenital hiatus e. Ejaculatory Duct: formed at junction of ductus deferens & seminal vesicle i. Prostatic urethra: passes directly through prostate gland 1. External Urethral Sphincter constricts during ejaculation ii. Membranous urethra: passes through the UG diaphragm iii. Penile (spongy) urethra: passes through the corpus spongiosum 1. Compressed by the bulbospongiosus muscle during ejaculation 2. Rupture: urine/blood pass into superficial perineal pouch, scrotum, penis shaft, and lower abdominal wall f. Bulbo-urethral (Cowpers) glands: lie within substance of UG diaphragm g. Sexual episode: i. Erection: blood filling cavernous bodies (parasympathetic Point) 1. Pelvic Splanchnic n.: dilates erectile tissue arteries causing engorgement, compressing veins (impeding venous return) ii. Emission: contraction of smooth muscle deposits semen in urethra iii. Ejaculation: contraction of bulbospongiosus m. (sympathetic Shoot) h. PENIS: i. Bulb of penis: (posterior) located in superficial pouch (inferior to perineal membrane/ UG dia.); covered by the two bulbospongiosus muscles ii. Corpus cavernosum: (dorsal & anterior) formed by the two crura (attached to inferior pubic rami) coming together in the shaft portion of the penis iii. Corpus spongiosum: (ventral) enlarges distally to form glans penis 1. Gland penis: distal end of corpus cavernosum 2. Urethra: passes through the bulb & corpus spongiosum iv. Penis: 1. Posterior femoral cutaneous n. (S1-3): scrotum 2. Pudendal n. (S2-4): a. Dorsal n. of Penis: corpus spongiosum, penile skin b. Perineal n.: bulbospongiosus, sphincter urethra, scrotum 3. External & Internal pudendal a.: genitalia, anal canal, perineum, scrotum a. Deep a.: to the crus; Dorsal a.: gland penis 4. Superficial dorsal vein: along superficial surface of corpus cavernosum external pudendal vein great saphenous vein 5. Deep dorsal vein: ends in the prostatic plexus 6. Superficial inguinal nodes: penis skin & glans, scrotum 7. Internal Iliac nodes: erectile tissue 8. Paraoartic lymph nodes: testes v. Testicular vein: formed by pooling of the pampiniform venous plexus 1. Right test. v.: drains to IVC; Left v.: drains to left renal vein 20

14. FEMALE PELVIS: a. Adnexa: uterine tubes, ovaries, & their associated mesenteries b. Vagina: tubular organ from posterior fornix to opening in vestibule i. Fornix: 1. Anterior & Lateral: digital examination allows palpation of urethra & bladder (A); ovaries, uterine tubes, ureters (L) 2. Posterior: site of Culdocentesis (aspiration of fluid from rectouterine pouch by puncture of the vaginal wall) c. Rectouterine pouch of Douglas: most inferior extent of peritoneum; frequent location for ectopic pregnancy or pooling of fluid (which becomes palpable) d. Uterosacral ligament: form the lateral walls of recto-uterine pouch e. Vestibule: openings of urethra (A) & vagina (P); divides UG triangle into R & L 1. Bulbs of the vestibule: erectile tissue ii. Labium majus: folds of tissue with subcutaneous fat located on either side of the vestibule; receives termination of the round ligaments iii. Labium minus: folds fat-free hairless skin enclosed by labia majora iv. Clitoris: on anterior vestibule; contains erectile tissue pair of corpora cavernosa f. Fallopian (uterine) tubes: enters uterus at each superolateral angle g. Cardinal ligament (transverse cervical lig. of Mackenrodt): normally is what supports the uterine angle (anteversion); cut during hysterectomy h. Uterus: midline pear-shaped organ of a fundus, body, isthmus, & cervix i. Cervical canal: narrow and terminates as the external os ii. Caudal epidural: anesthetizes lower birth cancal (cervix, lower uterus, external genitalia) not fundus & body of uterus iii. Pudendal nerve block: anesthetizes skin of external genitalia i. Broad ligament: double layer of peritoneum holding the uterus to the lateral walls of the true pelvis; also encloses the uterine tube in its upper free border i. Three subcomponents of the broad ligament: 1. Mesosalpinx: (over uterine tube) most superior portion 2. Mesovarium: (over ovary) connects ovary to broad ligament a. Ovarian ligament: {in broad ligament} ovary to uterus 3. Mesometrium: (largest) (over uterus) mesentery of the uterus a. Transmits uterine & ovarian arteries b. Round ligament of uterus: {within broad lig.} maintains uterine anteversion (ventrally) during pregnancy j. Ureter: lies above fornix and is crossed superiorly by uterine vessels; (water {ureter} flows under the bridge {uterine a.}); pelvic surgery injury risk (hysterectomy) k. Superficial perineal space (external genitalia, rectum, bartholins glands): Inguinal lymph nodes superior anterior thigh external iliac nodes l. Deep perineal space (sphincter m., uterus, ovary, bulbourethral glands, pudendal n. & a.) Internal iliac nodes & lateral sacral nodes common iliac

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