Lab I Vertebrae & Muscles of

the back
Positional terminology:

Medial vs. lateral

Distal vs. Proximal
Superior/Cranial/Cephalad vs. Inferior Caudal

Vertebrae: (33 Total)

7 cervical (Atlas/C1, Axis/C2, & C3-C7)
12 thoracic (T1-T12)
5 lumbar (L1-L5)
5 sacral (S1-S5)
4 coccygeal

Spine has 2 Sets of Curvatures:

Primary Concave; Thoracic & Sacral
Secondary Convex; Cervical & Lumbar; (form later, thus secondary)

Common parts of vertebrae: spinous processes, transverse processes, veretebral foramen,

pedicles, lamina, body, vertebral notches - 2 combine to form intervertebral foramen, articular
facets.

Identify all vertebrae

parts and be able to
distinguish between

1
Cervical Vertebra
Distinguishing Characteristics: tranverse foramen in C1-C7; C1-C6 transverse
foramen carry vertebral arteries and veins (X back of brain); C7 also carries vertebral
veins; C2-C6 have bifid spinous processes; zygapophysial joints in ~Transverse Plane
C1: the Atlas - articulates with the occipital chondyles, has no body, no spinous process,
no rotation
C2: the Axis - skull rotates on it, has the Dens
C7 is vertebra prominens (due to identifiable spinous process)

Thoracic Vertebrae
Distinguishing Characteristics: demifacets for articulation with head of ribs;
transverse facet for articulation with tubercle of rib in T1-T12; inferior-pointing spinous
processes; zygapophysial joints in ~Coronal Plane
T1: no superior demi facet; T12: no inferior demi facet

Lumbar vertebrae
Distinguishing Characteristics: massive bodies; zygapophysial joints in ~Sagittal
Plane
Spinal cord extends down to L2
Spinal taps performed between L3 & L4 (third lumbar interspace)

Sacral vertebrae
Distinguishing Characteristics: fused

Vertebrae are separated by intervertebral disks, consisting of nucleus pulposus inside and
annulus fibrosus outside. They make up 1/5 of the length of the spine (Sym physis joint)

2
Ligaments
Anterior Longitudinal Ligament: Anterior to bodies
Ligamentum Flavum
Posterior Longitudinal Ligament: Posterior to bodies in spinal canal
(yellow), Supraspinous,
Ligamentum Flavum: Anterior to Lamina in spinal canal - connects and Intraspinous are
adjacent laminae
Supraspinous - covers spinal processes
Interspinous - between spinous processes

Review Joints of Spine in Lecture 3

Disorders of the Column:

Kyphosis: convexity of thoracic region, dowagers hump (Primary)
Scoliosis: lateral curvature
Lordosis: concavity in lumbar (Secondary)

Parts of the Scapula: spine, acromion, superior and inferior angles,

Know all edges
medial/vertebral border of the scapula
Parts of Iliac Crest: Posterior superior iliac spine

Back Muscles

Two types
Extrinsic: superficial and intermediate; innervated by ventral rami as they migrated from
the front (embryologically)
Intrinsic: deep muscles, innervated by dorsal rami as they were here all along.

Note: skin of the back is also innervated by dorsal rami

SUPERFICIAL MUSCLES OF THE BACK

Purpose: connect back to the upper limb
Trapezius squares shoulder; fibers run towards acromion, diamond shaped
o Attachments: Ligamentum nuchae (over C1-C7), spinous process of C7-T12 (via
aponeuroses), acromion, spine of the scapula, medial 1/3 of clavicle
o Innervation: Spinal accessory nerve CN XI and C2-C4
Latissimus dorsi erects back; widest of back; fibers run toward humerus
o Attachments: T6-T12, iliac crest, thoracolumbar fascia, humerus
Rhom boids pull shoulders down; Minor and major fibers run inferolaterally from
spine to scapula. Major is inferior to minor
o Attachments: Medial border of scapula to spine
Levator scapula raises scapula

INTERMEDIATE MUSCLES OF THE BACK

Purpose: aid in respiration
Serratus posterior inferior and superior
o Attachments: from spine to ribs
o Looks like aponeurosis, named because attachments to each rib look like
serrations on a knife

DEEP MUSCLES OF THE BACK

Erector Spinae (sacrospinalis)
o Mnemonic: I Love Sex (lateral to medial)
o Iliocostalis

3
 o Longissimus
o Spinalis
Transversospinalis - between transverse and spin. Processes
o Mnemonic: Suck My Rod" (superficial to deep)
o Semispinalis
o Multifidius
o Rotares

Bold Text of Lab I: Mastoid Process

Primary and secondary curvatures of the
Vertebral Column back
Thoracic Vertebra Superficial muscles of the back (upper limb)
Pedicles Intermediate group (respiration)
Laminae Deep Group (dorsum, dorsal nerve rami)
Transverse Process Greater Occipital Nerve (dorsal ramus of
Articular Processes (superior and inferior) C2)
Spinous process Occipital Artery
Vertebral foramen Trapezius muscle (superior, middle, inferior)
Vertebral canal Latissimus dorsi
Intervertebral disc (annulus fibrosus, suboccipital triangle
nucleus pulposis) triangle of auscultation
Intervertebral foramen lumbar triangle
Cervical vertebrae (prominant 7th cervical Accessory Nerve (trapezius innervation)
spine) rhomboideus (major/minor)
Foramen Transversarium (Vertebral artery Levator scapulae
through C1-6) Serratus posterior superior
Atlas (Posterior tubercle) Serratus posterior inferior
Axis (first thoracic spine) splenius capitis and cervicis
Scapula (spine, acromion, superior/inferior semispinalis capitis
angle, medial/vertebral border) erector spinae (sacrospinalis)
Iliac crest transversospinalis
Posterior superior iliac spine iliocostalis
Occipital bone longissimus
External Occipital Protuberance (inion) spinalis
Nuchal lines

4
Appendix I: Joints
Two Classes
DIARTHROSIS (synovial) - most movable
o Requirements
Has a capsule, also called capsular ligament
Inner layer -- synovial membrane, which secretes synovial fluid
Has hyaline cartilage on bone surfaces
o Common Examples
Zygapophyseal joint - between articular processes of vertebrae
Atlanto-occipital joint
Atlantoaxial joint
Costovertebral joint - between head of rib and bodies of vertebrae
Costotransverse - between tubercle of rib and transverse process
Sternocostal joints
Interchondral (except for 9 & 10)
Acromionclavicular
Sternoclavicular
SYNARTHROSIS
o Sutures - fibrous connection
Examples: cranial plates
o Synchondrosis cartilage connection
Examples: Xiphoidsternal, Chondracostal, Interchondral 9 & 10
o Syndesmosis ligaments connection
Exam ples: Interspinous, Intertraverse
o Symphysis - subdivision of syndesmosis; ligaments w/ a fibrocartilaginous
disc in-between
Examples: Intervertebral discs, Pubic Symphysis, Sternomanubrial

5
Appendix II: Cardiovascular System

6
Major Branches of the Aorta: (note, coronary arteries are first, minor branch)
A ortic arch gives rise to:
B rachiocephalic trunk
Left C ommon Carotid
Left S ubclavian

THORACIC AORTA:
Posterior intercostals (9 pairs; intercostal spaces 3-11)
Bronchials (2)
Esophageals (2)
Subcostals (1 pair)

BRANCHES OF THE BRACHIOCEPHALIC TRUNK:

Common Carotid (Right)
Subclavian (Right)

BRANCHES OF THE SUBCLAVIAN: (Very Im portant To Com e Dressed)

Vertebral artery
I nternal thoracic artery
-m usculophrenic
-superior epigastric
-pericardiophrenic
Th y r o c e r v i c a l t r u n k
-Suprascapular
-Transverse cervical
-Ascending cervical
-Inferior thyroid
C o s t o c e r v ic a l
- Superior (supreme) intercostal (left)
- Deep cervical
D o rsa l S ca pu la r

BRANCHES OF THE AXILLARY:

S u p erior th ora cic
T h o r a c o a c r o m i a l (C A lifornia P olice D epartm ent")
- C lavicular (2)
- A cromial (1)
- P ectoral (3)
- D eltoid (4)
L a tera l th oracic

BRANCHES OF THE ABDOMINAL AORTA

Please Call Someone So Returning Today Is Less Intrusive, Sarah
P hrenic
C eliac
S uprarenal Artery (m iddle)
S uperior Mesenteric
R enal Artery
Testicular/Ovarian Artery
I nferior Mesenteric
L umbars 1-4
I liac, common
S acral, median

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BRANCHES OF THE INTERNAL ILIAC
"I L ove G oing P laces I n M y V ery O wn U nderwear"
I leolumbar
L ateral sacral
G luteal (superior and inferior)
P udendal (internal)
I nferior vesicle (uterine in fem ales)
M iddle rectal
V aginal
O bturator
U mbilical

AORTA: Ascending Arch Descending (thoracic)

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Lab II: The Spinal Cord
Meninges Coverings - SPINAL-PAD (from inside-out)
SPINAL cord
o Cord is enlarged at C3-T2 for upper limbs and T9-
12 for lower limbs
Pia Mater
o Tender mother; intimate with cord
o Forms denticulate ligaments pierce arachnoid
and link w/ dura to suspend cord
o After L2, continues as filum terminale
Arachnoid Mater
o Spiderlike mother; filamentous layer
Dura Mater
o Hard mother; fibrous sack; continues outside
canal to cover nerves
o Also continues after L2

Intermeningeal Spaces
Epidural Space: above dura and below canal
Subdural space: above arachnoid and under dura
o Contains thin film of fluid
Subarachnoid Space: above pia and under arachnoid
o Actual space containing CSF

Conus medularis - narrowing at end of cord at L1-L2

Cauda equina horses tail; ventral and dorsal roots caudal to end of cord
Filum terminale - continuation of pia

Bold Terms of Lab II: subarachnoid space

denticulate ligaments
Atlas (posterior arch, posterior tubercle, ventral/dorsal roots
transverse process, foramen transversarium, blood vessels in intervertebral foramina
groove for the vertebral artery) (spinal branches of intercostal lumbar or
Axis (dense, spinous process, transverse vertebral arteries)
process, foramen transversarium, vertebral intervertebral foramen
foramen) spinal ganglion (DRG)
Greater occipital nerve Cervical(upper limb)/Lumbar(lower limb)
Skipped suboccipital triangle (pgs. 137-138) enlargement of Spinal Cord
Vertebral canal Conus medullaris (L1/L2)
Spinal cord Cauda Equina
supraspinous ligaments Filum terminale
interspinous ligaments Spinal nerves
ligamenta flava Review:
laminae Nerve plexuses
epidural (extradural) space Dermatomes/myotomes
dural sac Blood supply of Spinal cord
dura mater
arachnoid mater

9
Appendix III: The Nervous System
Axons: Tract in CNS, Nerve in PNS
Nerve coverings: endoneurum, perineurum, & epineurum
Bodies: Nucleus in CNS, Ganglion in PNS

General Nerve Fibers

Somatic (derived from som ites)
o AFFERENT (GSA) Skin (sensory)
o EFFERENT (GSE) Skeletal Muscle (motor)
Visceral (Autonomic)
o AFFERENT (GVA) sensory
o EFFERENT (GVE) Sm ooth Muscle, Cardiac Muscle, Glands (motor)
Sym pathetic (Thoracolumbar)
T1-L2
Parasympathetic (Craniosacral)
Cranial Nerves III, VII, IX, X
S2-4 (Pelvic Splanchnics)
Gut innervated by Vagus (CN X) proximal to left colic flexure and the
pelvic splanchnics distal to this

Dorsal Root (Pure AFFERENT) + Ventral Root (Pure EFFERENT) =

Spinal Nerve (MIXED joins & exits at intervertebral foramen)

Dorsal Root Ganglion (DRG) - cell bodies of dorsal root; no synapses here!

Spinal Nerve: splits into

Dorsal Ram us (branch)
o Deep muscles of skin and back
Ventral Ram us (branch)
o Extrinsic muscles of the back &
everything else

31 spinal nerves:
8 Cervical (C1-C7 exit above vertebrae; C8
& rest below)
12 Thoracic
5 Lumbar
5 Sacral
1 Coccygeal

Plexus is a group of nerves; Dermatomes are areas of skin innervated by a nerve

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Spinal Nerve >>Ventral ramus >>Lateral Cutaneous branch >>Ant/Post Branches
>>Anterior Branch >>Lat/Med branches

SYM PATH ETIC PAR ASYM PATH ETIC

Preganglionic Cell Bodies Thoracolum bar (T1-L2); Craniosacral; Cranial nerves III, VII,
interm ediolateral nucleus IX, X; pelvic splanchnics (S2-S4)
Characteristics of Short; W hite Ram us; m yelinated Long; m yelinated
Preganglionic Fibers
Postganglionic Cell Bodies Sym pathetic chain (paravertebral At effector structure
ganglia) or prevertebral ganglia
(celiac, sup. Mesenteric, or inf.
M esenteric)
Characteristics of Long; Gray Ram us; unm yelinated Short; unm yelinated
Postganglionic Fibers
Function Fight or Flight; vasoconstriction, Rest and D igest; vasodilation, heart
heart (excitatory), gut (inhibitory), (inhibitory), gut (excitatory), papillary
papillary dilation, ejaculation, constriction, penile erection
piloerection

11
Lab III: Thoracic Body Wall
Rib parts:
Head
o Demifacets
Rib 1 articulates w/ T1
Remaining ribs (x) articulate
with T(x) and T(x-1)
o Interarticular crest
Neck
o Articular part of tubercle
articulates with transverse process
Angle (curve)
Costal groove
o Covers VAN (Vein, Artery, Nerve), in order of top to bottom

Rib Types:
True ribs (1 through 7) cartilage attaches directly to sternum
False ribs (8 through 10) fuse to Rib 7
Floating ribs (11 and 12) do not come in contact with sternum

Sternum parts:
Manubrium Upper part @ T3-T4
o Jugular notch, articulates with clavicle
Manubriosternal Joint
o Sternal angle (angle of Louis)
Body Middle part @ T5-T9
Xiphoidsternal Joint
Xiphoid process - Lower part @ T10

Layers of thorax:
Skin - epidermis and dermis which has glands and
vessels
Superficial fascia - adipose tissue, loose layer
Deep fascia - dense, intimate with muscles

Breasts:
Mammary glands - sweat glands in superficial fascia
o Mammillary papillae (nipples), areolae, and
Montgomerys glands (like large goose bumps in
areola) that lubricate
Lactiferous ducts run from glands to nipple
(lactiferous sinuses)
Suspensory (Coopers) ligaments from gland to skin
Retromam mary space between superficial and deep fascia; no tethering of breasts, so
mobile
Innervation: anterior and lateral cutaneous branches of 4 th -6 th intercostals
Vasculature: 2, 3, 4 anterior and posterior intercostals, lateral thoracic and
thoracoacromial arteries

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Muscles:
Platysma - grimace muscle; runs superiomedially to clavicle
o Attachments: Inferior portion @ fascia of pectoralis
minor, Superior portion at lower mandible
o Innervation: CN VII (facial nerve)
Pectoralis Major moves the humerus
o Two Parts: Clavicular Head (Clavicle to hum erus) &
Sternocastal Head (Manubrium and body of sternum
to humerus)
o Innervation: Lateral & Medial Pectoral Nerves; C5-T1
o Deltapectoral Triangle
Boundaries: Pectoralis Major, Deltoid, & Clavicle
Cephalic Vein runs here; joins axillary vein
Pectoralis Minor stabilizes the scapula
o Attachments: 3 rd to 5 th ribs (Inferior), Coracoid process
of Scapula (Superior)
o Innervation: Lateral and Medial Pectoral Nerves; C8-T1
Subclavius protects subclavian artery
o Attachments: Ribs 1-8; Anterior surface of medial
border of scapula
o Innervation: C5 & C6
Serratus anterior anchors scapula;
o Attachments: Ribs 1-8; Anterior surface of medial border of scapula
o Innervation: C5, C6, & C7

Nerves:
Mnem onic: Medial more, Lateral less
Positional information relative to brachial plexus; opposite of actual positions
Medial pectoral nerve - pierces pectoralis minor & major (actually lateral)
Lateral pectoral nerve pierces only pectoralis minor (actually medial)

Intercostal Space

Muscles:
External Elevate ribs
o Direction: hands in pockets; become membrane anteriorly
Internal Depress ribs
o Direction: at right angle to externals
Innermost Probably elevate
o Direction: same as internal
o Among the innermost are the Transversus thoracus (depress; hold internal
thoracic to body wall) and Subcostalis (elevate; best developed between ribs 6-
12, medial and inferior on the anterior thoracic wall)

RIB-VAN (Sup. to Inf.); Rib, Vein, Artery, Nerve

Until rib angle, run between parietal pleura and internal intercostal membrane
After rib angle, run between internal and innermost muscles

Vessels:
Internal Thoracic Artery and Vein - run on either side of sternum
Intercostal Arteries
o ANTERIOR
Top 6 internal thoracic artery

13
 7-9 musculophrenic internal thoracic
10-11 (None)
o POSTERIOR
Top 2 superior intercostal Costocervical Subclavian
3-11 Aorta (directly)
Subcostal also from Aorta

Nerves:
Ventral rami of T1-11 Intercostal nerves 1-11
Ventral rami of T12 Subcostal nerve

Endothoracic Fascia Separates innermost intercostal muscles and pleural membrane

Bold terms of Lab III: (anterior/posterior branches)

Vertebra (body, pedicle, lamina, Serratus anterior
transverse process, articular processes, Cutaneous branch of intercostobrachial
spinous processes, vertebral foramen) nerve (T2; referred pain and angina
Vertebral canal pectoris)
Ribs (head, neck, tubercle, body, costal Pectoralis major (sternocostal head,
groove (van)) clavicular head)
Distinctive first rib Deltopectoral triangle
I.V. Disk Cephalic vein
Interventricular foramen Lateral Pectoral Nerve (innervaton?)
Sternum (manubrium, body, xiphoid Medial Pectoral Nerve (pec minor/part
process) of pec major)
Costal cartilages Clavipectoral fascia (envelops pec
Jugular notch minor/subclavius)
Sternal angle (manubrium-body) Subclavius
Clavicle Cephalic vein >>Axillary vein
Sternoclavicular joint Thoracoacromial artery
Acromion Axillary artery
Coracoid process Lateral thoracic artery (lateral to pec
Skin minor)
Subcutaneous tissue (superficial fascia) External intercostals
Deep fascia Internal intercostals
Retinacula cutis (connective tissue Innermost intercostal
attachment from skin to deep fascia) Internal thoracic (Internal mammary)
Mammary glands vessels
Retromammary space (between deep Intercostal nerve
fascia and gland) Intercostal artery (anterior/posterior)
Suspensory (Coopers) ligaments Intercostal vein
Nipple Parietal pleura (gray, glistening)
Areola Transversus thoracis (continuous with
Lactiferous ducts internal intercostals)
Lactiferous sinuses Sternocostal joint (synovial cavity)
Platysma (Facial nerve (CN VII)
Lateral cutaneous branch of spinal nerve

14
Lab IV: Abdominal Body Wall
Abdominal Wall Layers:
Skin
Superficial fascia (superior to inguinal ligament)
o Campers fascia fatty, superficial tissue
o Scarpas fascia - fibrous tissue, continuous with fascia lata of thigh
Deep fascia - intimate with the superior muscle

Muscles:
External oblique
o Direction: hands into pockets
o Anterior becomes aponeurosis over rectus
abdominus
o Folds back upon itself to form inguinal ligament.
Internal oblique
o Direction: at right angles to external oblique
(inferolaterally)
Transversus Abdominus
o Direction: horizontally
o Transversalis fascia - between transversus and
peritoneum (or peritoneal fat)
Rectus abdominus - 2 muscle bundles
o Direction: vertical fibers, from pubic symphysis to Xiphoid process
o Innervation: Ventral Ram i of T7-T12
o Linea Alba
Medial fibrous band separating both bundles
Jessica Alba has sweet abs!
Formed from pyramidal muscle (?)

Sheath of rectus abdominus:

ABOVE the arcuate line (line btw. crests of Iliacs)
o Anteriorly: aponeurosis of external oblique and
anterior lamina of internal oblique
o Posteriorly: posterior lamina of internal oblique and
aponeurosis of transversus abdominus
BELOW the arcuate line
o Only transversalis fascia posterior to rectus abdominus
The entire sheath runs anterior to the muscle, below the arcuate line
(imaginary line between anterior superior iliac spine)

Conjoint tendon- formed by int oblique and transversus abdominus

Int oblique and transversus strengthens post wall of inguinal canal
Transversalis fascia- between transversus and peritoneum (or Endoabdominal Fat)

15
Nerves: (run between Internal oblique and Transversus abdom inus)
T7-T9: skin and muscle above the umbilicus
T10: Umbilicus
T11-L1: skin inferior to umbilicus
o L1 also branches into 2 nerves:
Iliohypogastric - skin of groin (skin of hypogastric region and over iliac
crest; internal oblique and transverse abdominal)
Ilioinguinal - skin of medial thigh, skin of scrotum or labium majus and
mons pubis internal oblique and transverse abdom inal - exits @
superficial ring of inguinal canal

16
Vessels:
ARTERIES
o Deep Circum flex Iliac External iliac
o Inferior Epigastric External iliac
Runs superiorly in transversalis fascia until enters rectus sheath @
arcuate line - runs deep to the rectus abdominus in the sheath
Anastomosizes with superior epigastric near umbillicus
o Superior epigastric Internal thoracic
Anastomosizes with inferior epigastric near umbillicus
Also runs in rectus sheath
VEINS
o Superficial epigastric vein and Lateral Thoracic they anastomose

Inguinal Region:
Inguinal canal - superior and parallel to medial portion of inguinal ligament
o OPENINGS (2)
Deep (internal) ring - entrance
Superior to midpoint of inguinal ligament
Lateral to Inferior Epigastric Artery
Outpouching of transversalis fascia
Superficial (external) inguinal ring - exit

17
 Triangular opening in the aponeurosis of external oblique
o WALLS (2)
Anterior: aponeurosis of external oblique
Posterior: transversalis fascia
Conjoint tendon - formed by
merging of internal oblique and
transversus abdominus
aponeuroses; strengthens
posterior wall
o ROOF
TIE arch (Transversus abdom inus,
Internal Oblique, External Oblique)
o FLOOR
Inguinal Ligament - runs from
anterior superior portion of iliac crest to
pubic symphysis

Descent of the Testes:

Testes develop between peritoneum and transversalis fascia
(in lumbar region)
Processus vaginalis, outpouching of peritoneum, migrates
through fascia & 3 muscle layers into the scrotum; becomes
tunica vaginalis after separation of pouch
Tunica vaginalis covers only the testis
No obliquity to canal during infancy & descent

Spermatic Cord:
Ductus Deferens duct between epididymis and
ejaculatory duct
Arteries
o Testicular Artery Aorta
o Cremasteric Artery Inferior Epigastric
Veins
o Pam piniform plexus venous network around testis
Nerves
o Genitofemoral nerve innervates cremaster muscle; lumbar plexus (L1, L2)
o Autonomic Nerves Sympathetic (on arteries) & Parasympathetic (on ductus
deferens)
T10 (sympathetic) innervates testes
Vagal (parasym pathetic) innervates testes (?)
o Scrotum Innervation
Genital branch of genitofemoral nerve (L1-L2) (travels in the cord)
Ilioinguinal - branch of L1 (Does NOT travel in cord - travels through
inguinal canal and exits superficial ring)
Pudendal - S2-S4
Posterior femoral cutaneous S1-S3
Lymph nodes
Fascial Coverings
o Internal spermatic fascia - from transversalis fascia
o Cremaster fascia and muscle - from internal oblique
o External spermatic fascia - from external oblique

18
Hesselbachs triangle - inguinal ligament, inferior
epigastric, rectus abdominus

Passage of sperm:
Testes Epididymis Ductus deferens (Joins seminal
vesicles) Ejaculatory ducts Prostatic urethra
Membranous urethra Bulb of penis (Joins Bulbourethral
glands) Spongy urethra

19
Bold terms of Lab IV: gap; prevent crura from spreading apart)
1. Skin Inguinal ligament
Epidermis Spermatic cord
Dermis Round Ligament
2. Superficial fascia Ilioinguinal nerve (L1; emerges from
Campers (fatty) superficial ring)
Scarpa (membranous) Internal obique (forms second arch of
3. External Oblique the arcade)
4. Internal Oblique Cremaster muscle
5. Transversus Muscle Conjoint tendon (merging of pubic aponeurosis
of transversus abdominus and internal oblique)
6. Transversalis fascia
Transversus abdominis (third and
7. Extraperitonial fatty areolar tissue
deepest arch of the arcade)
8. Peritoneum
Deep inguinal ring (transversalis fascia)
Transversalis fascia
Xiphisternal jnc
Inferior Epigastric Vessels (hugging
Costal margin (upturned ends of
deep to rectus abdominis; inferior)
cartilages 7-10)
Superior Epigastric Vessels (hugging
Pubic Symphysis
deep to rectus abdominis; superior
Pubic crest (extends laterally from
Walls of the inguinal canal
symphysis)
Rectus abdominis
Pubic tubercle (lateral end of pubic
Rectus sheath (aponeurosis of Ext/Int Oblique
crest) and aponeurosis of transverse abdominis)
Inguinal ligament three Tendinous insertions (connects
Ant. Sup. Iliac Spine (ant end of Iliac rectus muscle to rectus sheath)
Spine) Arcuate line
Iliac Crest Linea alba (joining of the rectus sheath)
Tubercle of the crest (most lateral point Spermatic Cord
of crest) External Spermatic Fascia
Cutaneous Nerves (of abdomen are T7- Cremasteric Fascia
L1) Internal Spermatic Fascia
Anterior cutaneous branch of Ductus (vas) deferens
iliohypogastric nerve (L1; 4 cm superior Testicular artery
to pubic crest) Pampiniform plexus of veins
External oblique (First and most Testis
superficial arch of the arcade) Tunica vaginalis testis
Superficial inguinal ring Tunica albuginea (dense, white connective
Lateral (inferior) crus (portion of aponeurosis tissue capsule of the testis; deep to tunica vaginalis)
attaching to pubic tubercle via inguinal ligament; Seminiferous tubules >> rete testis >>
spermatic cord rests on inferior part of lateral crus)
efferent ductules >> epididymis >>
Medial (superior) crus (portion of aponeurosis
that diverges to attach to pubic bone and crest medial ductus (vas) deferens
to pubic tubercle)
Intercrural fibers (lateral to apex of triangular

20
Appendix IV: Hernias
Definition: Protrusion of viscous thru an abnormal opening

Main reasons for hernias:

1. Weak Areas: protected only by fascia
a. Direct bulging in weak area (Acquired); Medial to Inferior Epigastric; often
protrude at or near the conjoint tendon to push through the superfici ring
b. Fluid pressure throughout abdom en further weakens walls
c. Gravity pulls organs down, putting weight on hernia-prone region
d. Hesselbachs Triangle - only transversalis fascia is posterior to rectus
abdominus
2. Improper Development: Improper closing Openings
a. Indirect needs to follow oblique path of canal to outpouch (Congenital);
Lateral to Inferior Epigastric
b. Processus vaginalis does not fuse completely after descent of testes; herniation
could end up in tunica vaginalis region anterior to testis
c. Umbilical hernia thru patent umbilicus or hiatal hernia through esophageal hiatus

Mnemonic: M Ds Love Insurance

Medial to inferior epigastric Direct; Lateral to inferior epigastric Indirect

Fluid pressure throughout abdomen will push greatest on weakest areas. Also gravity will push
down towards groin where standing.

The processus vaginalis should fuse after desent of the testes, forming only a small hole for
spermatic cord

ORCHOS is root for testes.

21
Lab V: Thorax: Pleura and Lungs
The thorax consists of two pleural sacs and the mediastinum.

Types of Pleura:
VISCERAL PLEURA no nerve fibers; no pain
o Adheres to all surfaces of lung; reflects at root of lung to become parietal pleura
PARIETAL PLEURA intercostal and phrenic nerves; therefore, local and referred pain
o Costal pleura internal surface of thoracic wall
Endothoracic fascia separates ribs and costal pleura
o Mediastinal pleura lateral aspects of mediastinum
o Diaphragmatic pleura covers superior (thoracic) surface of diaphragm
o Cervical pleura - extends through superior thoracic aperture to root of neck
Pleura meets behind esophagus to form the mesoesophagus

Pleural Recesses:
Costodiaphragmatic recesses where costal parietal meets diaphragmatic parietal
o During inspiration, lungs descend here
o During expiration, lungs ascend here
o Pleural tap occurs here midaxially at intercostal space 6, 7, or 8 (above rib)
Costomediastinal recesses where costal parietal meets mediastinal parietal
o During inspiration, lungs enter recesses
o During expiration, lungs exit recesses
o Left is larger because of cardiac notch

The Lungs:
Hilus point where root of the lung enter and leave the lung (only To help identify each:
attachment point) bronchi have
o Mnemonic: Are Brides Vain? Right, Brides Are Vain! cartilaginous rings,
pulmonary arteries
o
have thick walls, and
LEFT LUNG pulmonary veins have
o Two lobes: upper and lower flexible, thin walls

22
 o Fissures: oblique fissure
o Bronchi: two secondary bronchi
o Other: cardiac notch, lingula substitute for middle lobe
o Hilus (superior to inferior): Artery, Bronchiole, Vein
o Contact impressions: Aortic arch, cardiac notch, desc. aorta
RIGHT LUNG
o Three lobes: upper, middle, and lower
o Fissures: oblique fissure and horizontal fissure
o Bronchi: three secondary bronchi
o Other: cardiac notch, lingula substitute for middle lobe
o Hilus (superior to inferior): Bronchiole, Artery, Vein
o Contact impressions: Esophagus and superior vena cava
Bronchial arteries - supply lungs, directly from aorta > venous return with the
pulmonary veins
-For each lung, the inferior lobe occupies the majority of the posterior surface of the lungs
(frontal chest x-ray imaging issues - inferior lobe and superior lobe overlap)
-Note: fibers of the phrenic nerve are somatic efferent because the diaphragm is striated
voluntary muscle

Innervation (??):
PARASYMPATHETIC
o Pulmonary plexus cell bodies of postsynaptic PS neurons
o Vagus Nerve
Left vagus passes
Source: CN X over lateral aspect of
Targets: Bronchi smooth muscle (bronchoconstrictor), aortic arch
pulmonary vessels (vasodilator), glands of the bronchial
tree (secretomotor)
LEFT VAGUS
Gives rise to left recurrent laryngeal nerve
Crosses aortic arch posterior to hilus anterior to
esophagus
RIGHT VAGUS
Arch of azygous posterior to hilus posterior to
esophagus
Great Mnemonic: Left Anterior, Right Posterior
SYMPATHETIC
o Paravertebral Sympathetic Ganglia cell bodies of postsynaptic S neurons
MOTOR
o Phrenic nerve - innervates lungs (??)
C3-C5; passes anterior (phrenic, front) to the root of each lung
Fibers are General Somatic Efferent (GSE)

SPLANCHNIC NERVES:
Greater Splanchnic (T5-T9)
Lesser Splanchnic (T10-T11)
Least Splanchnic (T12)
Lumbar Splanchnic (L1, L2)

Where on the esophagus do the respective vagus nerves form their plexi?

23
Bold terms of Lab V: Pulmonary artery
Superior thoracic aperture (thoracic inlet) Superior mediastinum (Sternal angle and IV
Inferior thoracic aperture (thoracic outlet) disk of T4-T5)
Pleural cavities -superior border of fibrous
Mediastinum pericardium
Lung -level of bifurcation of the trachea
Pulmonary (Visceral) pleura Anterior mediastinum (between sternum and
Parietal pleura (Costal pleura, diaphragmatic pericardium; thymus)
pleura, mediastinal pleura, cupula (cervical) Middle mediastinum (pericardium/roots of
pleura)) great vessels)
Root of the lung Posterior mediastinum (between
Pleural reflections pericardium and bodies of vertebrae)
Pleural recesses Fibrous pericardium
Costomediastinal recess (Left) Serous pericardium (parietal, inner layer of
Costodiaphragmatic recesses fibrous pericard.)
Endothoracic fascia (separates rib cage and Serous pericardium (visceral layer;
parietal pleura) epicardium)
Oblique fissure of the lungs Pericardial cavity (between parietal and
Horizontal fissure of right lung visceral serous pericardium)
Lobes of lungs Superior vena cava
Pulmonary ligament Ascending aorta
Phrenic nerves Arch of aorta
Esophagus Pulmonary trunk
Descending aorta Ligamentum arteriosum
Sympathetic trunk Left vagus
Apex of lung Left recurrent laryngeal nerve (posterior to
Superior (upper) lobe ligamentum arteriosum)
Inferior (lower) lobe Transverse pericardial sinus (between sup vena
Middle lobe cava and ascending aorta then posterior to pulmonary
artery)
Cardiac notch (superior lobe of left lung)
Oblique pericardial sinus (Posterior to heart;
Lingula (inf/ant left superior lobe) bound by inf vena cava and the four pulmonary veins)
Lung surfaces (costal, medial, basal Left Vagus
(diaphragmatic)) Right Vagus
Borders (anterior and inferior) -observe esophageal plexus
Cardiac impression (mediastinal surface of Vagal trunks (anterior and posterior)
left/right lung) Azygous system of veins (right intercostals
Groove for the Esophagus (mediastinal right are tributeries)
lung) Azygous vein
Groove for aortic arch and descending aorta Thoracic duct (between azygos vein and
(mediastinal left lung) descending aorta)
Hilus (bronchus, pulmonary artery, Bronchial arteries
pulmonary veins) Thoracic greater splanchnic nerve (T5-T10)
Main bronchus Thoracic lesser splanchnic nerve (T10-T11)
Superior and inferior lobar bronchi (left)
Superior, middle, inferior bronchi (right)
Segmental bronchi

24
Lab VI: Mediastinum

Inferior Mediastinum : subdivided by the pericardium; superior border is the line between the
manubrosternal joint and intervertebral space 4 (level of tracheal bifurcation, hilum of lungs, and
end of fibrous pericardium)

1. Anterior mediastinum:
Thymus gland (children), lumph nodes, fat, connective tissue

2. Middle Mediastinum:
Consists of the pericardium, phrenics, and roots of the great vessels, arch of the azygous,
and main bronchi

Pericardium: 3 layers
1. Fibrous- tough outer pericardium.
2-3. Serous- smooth; potential space with scant fluid exists between these layers
2. parietal pericardium
3. visceral pericardium

The inferior of the pericardial sac is continuous with the diaphragm.

Behind the heart inside the pericardium are two sinuses.

Transverse sinus- behind aorta and pulmonary trunk (passes between SVC and aorta)
Oblique sinus- posterior to heart; serous lined sac bound by IVC and pulmonary veins

3. Posterior Mediastinum:
Consists of the esophagus, thoracic aorta, azygous and hemiazygous veins, thoracic duct,
vagus nerves, sympathetic trunks, and splanchnic nerves.

Left Vagus- crosses aortic arch and goes posterior to hilus of lung, winds up anterior to
esophagus

25
 Right Vagus- can be found at arch of azygous, then goes posterior to root of lung and
winds up posterior to the esophagus
LARP- left anterior, right posterior to remember where on the esophagus the
respective vagus nerves form their plexi
Thoracic Duct- lymph drainage. The duck is between two gooses- the thoracic duct is
between the esophagus and azygous.
Bronchial arteries supply lungs- theyre directly from aorta

Superior Mediastinum :
SVC, brachiocephalic veins, arch of aorta, trachea, esophagus, the vagi, phrenic nerves,
thoracic duct, left recurrent laryngeal

Ligamentum arteriosum- connects aortic arch to pulmonary artery

Left recurrent laryngeal nerve- branch of the left vagus, it hooks around lig art and travels up
to innervate larynx (curves around and runs deep to lig art and arch of aorta)
Right recurrent laryngeal nerve - curves around right subclavian and runs superiorly (distal
part of right sixth aortic arch degenerates, right recurrent moves superiorly) (pg. 365 of embryo
text)
Left vagus- passes over lateral aspect of aortic arch

Bold terms of Lab VI: -Posterior interventricular branch

-Anterior right atrial branch (small; SA
Brachiocephalic veins nodal artery?)
Superior vena cava Coronary (atrioventricular) groove (sulcus)
Brachiocephalic trunk Anterior and Posterior interventricular
Left common carotid artery grooves
Left subclavian artery Right border of the heart
Lymph nodes of main bronchi Left border of the heart
Rght vagus (small cardiac branches cross Apex of the heart
anterior to trachea) Auricle of the left atrium
Tracheobronchial lymph nodes Inferior border of the heart
Bifurcation of the trachea Aorta and its valve
Tracheal rings Pulmonary trunk and its valve
Carina Three aortic valvules (cusps)
Right atrium Orifice of the left coronary artery (left
Right ventricle valvule)
Left coronary artery Cardiac veins >> most drain to Coronary
-Anterior interventricular branch (LAD) Sinus >> empties to RA
-Circumflex branch (coronary sulcus Great Cardiac Vein
and around the left border of the heart) Middle Cardiac Vein
Right coronary artery
-Marginal branch (right border)

26
Labs VII & VIII: The Heart
Layers of the Heart:
Epicardium - same as visceral layer of serous pericardium
M yocardium - muscle of the heart
Endocardium - lines the lumen on the heart

Fibrous pericardium
Parietal pericardium
Serous pericardium Pericardial cavity
Visceral pericardium Epicardium
Myocardium (muscles)
Heart
Endocardium
(lines lumen)

excess pericardial fluid in the cavity can result in cardiac tamponade (heart
compression)
pericardium mainly supplied by the pericardiophrenic artery coming out of the
internal thoracic
infection in the endocardium = endocarditis

Radiography
PA Chest X-Ray
1 = right brachiocephalic vessels
2 = ascending aorta and superimposed SVC
3 = right atrium (RA)
4 = inferior vena cava (IVC)
5 = left brachiocephalic vessels
6 = aortic knob/arch
7 = pulmonary trunk
8 = left atrial appendage (LA)
9 = left ventricle (LV)

Surfaces of the Heart:

Apex: blunt inferior point formed by LV
Anterior-sternocostal: RV
Diaphragmatic: 2/3 of LV, 1/3 RV
Base-vertebral: - LA, some RA
Right border: RA
Left border: LV
Superior: RA & LA

Sulcus Lines:
Purpose: separate the chambers of the heart; fat and vessels run here
Coronary Sulcus - encircles the heart, separates atria from the ventricles
Anterior and Posterior Interventricular Sulcus - separates the ventricles. Starts
anteriorly at pulmonary trunk, wraps around to posterior up to coronary sulcus

27
RIGHT ATRIUM collects bodys deoxygenated blood
Venous Sources
o Superior Vena Cava - drains above diaphragm
o Inferior Vena Cava - drains below diaphragm
IVC has a valve w/ value only in fetus
o Coronary Sinus drains hearts deoxy blood (
Entrance of the coronary sinus is just inferior to
the entrance of the SVC )
Two Walls
o Posterior: sinus venarum smooth; IVC and
SVC drain into this
o Anterior: pectinate (comb) muscles; rough; This is the right auricle
(appendage)
o Separated by vertical ridge crista terminalis
Notable structures
o Fossa Ovalis remnant of foramen ovale; thumb print sized area, slight
discoloration; interatrial septum ( just medial to entrance of SVC; momentum of
blood carries it through the foramen ovale in the fetus)
o Limbus Fossae Ovalis ridge around the fossa ovalis in the RA; margin of the
septum secundum
o Right Auricle leaf/appendage; rough w/ pectinate muscles

TRICUSPID VALVE between RA and RV

Three cusps: septal, anterior, posterior
Attached to three papillary muscles via chordae tendinae in RV
Each muscle is linked to two cusps; S SA, A AP; P PS (SAPS)
Septal Pap > Septal and anterior cusps
Anterior Pap > Anterior and posterior cusps
Posterior Pap > Posterior and septal cusps

RIGHT VENTRICLE pumps deoxy blood into lungs for oxygenation

Notable structures
o Conus Arteriosis (infundibulum) smooth region right below pulmonary valve
o Trabeculae carneae - elevated muscles in ventricle
o Moderator Band (Septomarginal trabeculae) - a trabeculae carneae between
septum to ventricular wall; carries conductive impulses
Flow is U-shaped out to the pulmonic valve
PULMONIC VALVE between RV and pulmonary trunk (semilunar)
Three cusps: anterior, left, and right

LEFT ATRIUM
Wall is smooth (from absorption of the pulmonary veins), except for small pectinate muscles
in left auricle
Connected to left ventricle by way of mitral valve (bicuspid):

MITRAL VALVE - (left atrioventricular/bicuspid valve)

Has an anterior and posterior cusp, which are each attached to both papillary muscles.

LEFT VENTRICLE
Twice as thick as RV
Has trabeculae carneae (though interior is smoother than RV)

28
 Has no moderator band, it is not needed because the papillary muscles are adjacent to the
septum.
2 papillary muscles (anterior and posterior)
Superior part of left ventricle gives rise to aorta
Aortic vestibule - smooth surface leading to the aortic orifice

AORTIC VALVE
Three cusps, posterior, left and right
o Posterior is noncoronary
o Left and right give off coronary arteries
The coronary arteries fill during disatole from aortic backflow (gravity), since valvules are
closed, entrances to the coronaries are accessible.

ANS ACTION ON THE HEART:

Sympathetic
o Dialates coronaries
o Accellerates the heart
o Increases force of contraction
Parasympathetic
o Constricts coronaries
o Decelerates heart
o Decreases force of contraction

Note: papillary muscles of RV and LV contract before RV and LV

1. Pull tendinae chordae tight and pull valves from walls of ventricle
2. To prevent prolapse of valves into atria

29
CORONARY ARTERIES:
Right coronary artery- runs in the coronary sulcus, at the right border gives off (right)
marginal branch which runs to the apex. As it continues around the posterior in the
coronary sulcus, it gives off its posterior interventricular branch, which descends in the
Postrior IV sulcus to possibly anastamose with LAD- left anterior descending artery. The
right coronary continues in coronary sulcus to possibly anastamose with left circumflex.
Also gives of SA nodal which travels up the anterior side of the auricle and the AV nodal
which branches superiorly at the level of the posterior IV suclus)

Left coronary artery- almost immediately terminally branches into the LAD (Anterior
Interventricular) which runs in the anterior IV sulcus, and the circumflex branch which
runs in the coronary sulcus to the left. The circumflex might also give off a marginal
branch which would run towards the apex.

30
 CARDIAC VEINS:
Coronary sinus- posterior part of coronary
sulcus, drains into the right atrium
Great Cardiac Vein- drains anterior IV
sulcus into coronary sinus (travels around left
side of atrioventricular sulcus)
M iddle cardiac vein- runs in posterior IV
sulcus towards coronary sulcus (and sinus)
Small cardiac vein- runs with (right)
marginal artery, runs in coronary sulcus
Oblique vein of LA: approaches LA from
posterior and drains to coronary sinus
Anterior Cardiac Veins: from anterior RA,
drain to RA
Venae cordis minimae: from capillary beds
of myocardium > drain deoxygenated blood
to chambers of the heart.

31
CONDUCTION:(by specialized cardiac muscle, not nervous tissue)
SA node- superior to crista terminalis in RA (jnc of SVC and RA)
AV node- in the interatrial septum (near opening of coronary sinus)
Bundle of His (AV bundle)- gives off right and left bundle branches @ muscular parts of the
septum
Purkinje fibers - extend into the walls of the respective ventricles (subendocardial branches)
o right Purkinje - stimulate septum, anterior papillary muscle (via the septomarginal
trabecula), and RV
o left Purkinje - stimulate septum, anterior and posterior papillary muscles, and LV
AV node and the rest of the conduction system has intrinsic beat, but it is much slower than
that of SA node. May be ~40 bpm rather than the SA nodes 60-70 bpm.

32
Heart has a cardiac skeleton that provides rigidity.

OTHER USEFUL HEART FACTS:

The coronary sinus and anterior cardiac veins drain directly into the right atrium
Smallest cardiac veins (L. venae cordis minimae) begin in capillary beds in
myocardium and drain into chambers of the heart. May mix deoxy with oxy
blood.
Coronary arteries are functional end-arteries as their anastomoses do not provide
adequate collateral circulation.
LAD (left anterior descending) also termed the widowmaker for acute arterial
stenosis leading to sudden death.
o Myocardial Infarction/Angina Pectoris
Coronary occlusion most common @ proximal RCA, proximal LAD, and
proximal circumflex
Referred pain to chest, shoulder, inner aspect of arm, and possible neck and
chin (most commonly on left side)

INNERVATION OF THE HEART

T1-T5 (from cervical paravertebral ganglia) for sympathetic and vagus for parasympathetic
(superficial and deep cardiac plexuses - anterior to bifurcation of trachea and posterior to
ascending aorta)
*Sympathetic
T1-T5 Intermediolateral cell column > cervical and superior thoracic paravertebral ganglia >
post-synaptics end in SA and AV nodal regions and coronary arteries
*Parasympathetic
Brain stem > preganglionics leave via vagus (CN X) > postganglionics end on SA and AV nodal
regions and coronary arteries

Bold terms: anterior and posterior cusps)

-Posterior papillary muscles (small;
Coronary Sinus irregular)
Great Cardiac Vein -Septal papillary muscles (small;
Middle Cardiac Vein multiple)
Right Atrium Trabeculae carneae
Pectinate muscles of RA Septomarginal trabecula
Crista terminalis (vertical ridge that joins posterior Orifice of the pulmonary trunk
and anterior walls of RA) Conus arteriosus (infundibulum)
Entrance of superior vena cava Valve of the pulmonary trunk
Entrance of inferior vena cava -anterior, right, and left valvules
Entrance of coronary sinus Left atrium
Valve of coronary sinus -entrances of 4 pulmonary veins
Right atrioventricular (tricuspid) orifice Left atrioventricular (mitral) orifice
Fossa ovalis Opening of tubular left auricle
Right ventricle Fossa ovalis
Right atrioventricular (tricuspid) valve Pectinate muscles (in left auricle)
-anterior, posterior, and septal cusps Left ventricle
Chordae tendinae Left atrioventricular (mitral/bicuspid) valve
Papillary muscles -anterior and posterior cusps
-Anterior papillary muscle (attached to Chordae tendineae

33
Trabeculae carneae Orifices of two coronary arteries
Aortic valve Muscular part of interventricular septum
-right cusp, left cusp, and posterior membranous part of the interventricular
(noncoronary) cusp septum
Nodule (thickening at middle of free margin of each
cusp)

Lecture 4- heart
COARCTATIONS AND ANASTAMOSES
A. Coarctation distal to subclavian
1. Subclavian internal thoracicsuperior epigastricinferior
epigastricexternal iliaccommon iliacaorta
B. Coarctation of arch
1. Right subclavian internal thoracicanterior intercostalsposterior
intercostals aorta
C. Other anastamoses:
1. Celiaccommon hepaticright gastroduodenalant/post sup.
Pancreoduodenalant/post inf. PancreoduodenalSMA
2. R GastroduodenalR gastroepiploicL
gastroepiploicSplenicCeliac
3. SMAmidcolicleft colicIMA

Coronary arteries:
1 st branch of aorta
fill during disatole/rest
are functional end arteries- not strong enough to anastamose

RCA: SA Nodal, R marginal, post. Interventricular

LCA: AV Nodal, LAD, circumflex

Coronary veins:
Great cardiac travels with LAD
Middle cardiac travels with Post descending branch
Small cardiac travels with R marginal

Lecture 6: Clinical aspects of heart

Tetralogy of Fallot:
Stenosis of pulmonary artery (narrowing)
High ventricular septal defect (VSD)
Dextropositioned aorta (Overriding aorta)
Right ventricular hypertrophy: more a result of the first 3 defects
Sequelae (affection of disease) are decreased flow of blood to lungs, and mixing of blood from
both sides, blue baby!
Patent ductus arteriosus can provide additional pulmonary bloodflow - patient appears ok as
long as patent ductus arteriosus remains

34
 Can operate by attaching R subclavian artery to R pulmonary artery in order to shunt to lungs
(Blalock-Taussig)
Ventricular septum has both muscular and membranous parts. Teratology of Fallot is an
abnormality in the membranous part of the septum.

Ribs notch from extra work load in intercostal arteries from collateral circulation.

Use internal thoracic or great saphenous (make sure you reverse the valves) for a CABG.

Lab X: Unpaired abdominal aortic vessels

LIVER - ITEMS OF INTEREST
Porta hepatis- the door to the liver. The portal triad enters here. Transverse fissure on the
visceral side of the liver.
Portal triad-
o portal vein is posterior
o bile duct is dexter(lateral)
o hepatic artery proper must be to the left (medial).
Bile duct- caliber of a pencil, connects to gall bladder by cystic duct. Continues as the
common hepatic duct where it splits into L and R in the liver.

CELIAC TRUNK - Three branches

I. Common hepatic artery- to the left of the bile duct; from celiac trunk
A. Gastroduodenal (inf)
1. Right gastro-omental artery
2. Superior pancreaticoduodenal (anastamoses with inferior
pancreaticoduodenal off SMA)
B. Right gastric (sup, curves)
C. Becomes hepatic proper.
II. Left gastric- gives off esophogeal branch; anastamoses with right gastric
III. Splenic- supplies spleen

35
 A. left gastro-omental (anastomoses with right gastro-omental)
B. pancreatic arteries
C. short gastric banches

PORTAL VEIN
Arises where SMV meets splenic vein.
IMV also often enters splenic, but where this joins is varied.
Left gastric vein also enters directly into PV.

SUPERIOR MESENTERIC ARTERY

Supplies parts 2-4 of duodenum up to of transverse colon.
It crosses anterior to third part of duodenum; it can occlude this organ.
Superior mesenteric vein drains whatever the SMA supplies
o Intestinal arteries- duodenum, ileum, jejunum
o Ileocolic artery- cecum and appendix
o Right colic- ascending colon
o Middle colic- of transverse
o Inferior pancreaticoduodenal

INFERIOR MESENTERIC ARTERY

Origin is 3 cm superior to aortic bifurcation.
Supplies 1 half of transverse colon, to top of rectum.
o left colic- transverse and descending colons
o sigmoid artery- sigmoid colon
o superior rectal- top part of rectum

Right colic of SMA and left colic of IMA anastamose at marginal

Bold Terms of Lab X: Right gastric artery

Splenic artery
hepatoduodenal ligament Left gastric artery
-bile passages Right gastric artery
-hepatic artery Right gastroomental artery
-portal vein Left gastroomental artery
-autonomic nerves Splenic vein (inferior to splenic artery)
-lymphatics Portal vein
bile duct Superior Mesenteric vein
cystic duct Inferior Mesenteric vein
Portal vein Gastric veins (carry blood from esophagus and
Common hepatic duct lesser curvature to portal vein)
-Right hepatic duct Superior mesenteric artery
-Left hepatic duct -Intestinal arteries (15-18 arteries to
Hepatic lymph nodes (around bile duct and portal ileum and jejunum)
vein) -vasa recta
Hepatic artery proper -Ileocolic artery (supplies cecum and
-Right gastric artery appendix)
-Left hepatic artery -Right colic artery (supplies ascending
colon)
-Right hepatic artery
-Middle colic artery (right half of
-Cystic artery transverse colon)
Common hepatic artery Superior mesentery plexus
Gastroduodenal artery

36
Superior mesenteric vein (immediately to the -Sigmoid arteries (usually four branches)
right of the artery) -Superior rectal artery (proximal
Lymph nodes (in mesentery) rectum)
Superior mesenteric nodes (near origin of Inferior mesenteric vein
artery) -Inferior lymph nodes
Inferior mesenteric artery -Mesenteric nodes
-Left colic artery (runs towards left colic -branches correspond to IMA
flexure; supplies descending colon and left
half of transverse)

Lab XI: Abdomen in Situ

Peritoneal cavity- totally closed sack in males; in females, the uterine tubes open into the
peritoneal cavity and create 2 small communications with the outside.
The peritoneal cavity is a potential space between the parietal and visceral layers of peritoneum.
There are NO viscera in the peritoneum.

Viscera can be intraperitoneal or extraperitoneal (retroperitoneal)

Structures formed from peritoneum

1. Mesentery: double layer of peritoneum; constitutes a continuity of the visceral and parietal
peritoneum.
2. Peritoneal ligament: also a double layer of peritoneum, but often more limited in extent or a
subdivision of a mesentery.
3. Omentum: a broad, double-layered sheet of peritoneum passing from the stomach to another
abdominal organ.

GUTTERS:
A. Right paracolic: (lateral)- to the right of the ascending colon; connects the pelvis
and hepatorenal pouch. Can transfer fluids from lesser sac or hepatorenal
B. Left paracolic: to the left of the descending colon. Closed cranially by
phrenicolic ligament.
C. Left Paramesenteric gutter: between small intestine and colon; communicates with
pelvis
D. Right Paramesenteric gutter: limited by surrounding mesenteries; between small
intestine and colon

Gutter to the right of the mesentery- closed cranially and caudally

Gutter to the left of the mesentery- open to the pelvis

POUCHES:
A. Hepatorenal pouch- behind the liver in front of the kidney; usually potential
space. Most dorsal point when supine; communicates with omental bursa
B. Rectouterine (Rectovesical)- behind the uterus or bladder in men, an actual
space. Most inferior point when standing. Can be approached with a rectal exam.

37
Bold Terms of this lab: Left lateral (paracolic)
Gutter to the right of the mesentery
Falciform ligament Gutter to the left of the mesentery
Ligamentum teres (inferior free border of Gallbladder
falciform) Stomach (Gaster)
Median umbilical ligament (obliterated urachus) Greater Curvature
Medial umbilical ligaments (obliterated Lesser Curvature
umbilical arteries) Pyloris (exit to duodenum)
Peritoneum Spleen (Lien)
Parietal Peritoneum Splenorenal ligament
Visceral Peritoneum Gastrosplenic ligament
Peritoneal Cavity Small Intestine
Retroperitoneal organs Duodenum
Lesser Omentum Jejunum
Hepatogastric ligament Ileum
Hepatoduodenal ligament (passing to Duodenojejunal junction (where immobile
porta hepatis)
duodenum ends and mobile jejunum begins)
Hepatic artery Suspensory ligament of the duodenum
Portal vein (Ligament of Treitz)
Bile passages Ileocecal orifice (or junction)
Omental foramen Root of the mesentery (Spreads diagonally)
Omental Bursa (lesser sac) Large Intestine
Inferior recess Cecum and vermiform appendix
Superior recess AC
Greater Omentum Right Colic Flexure (Hepatic
Mesenteries Flexure)
Peritoneal Ligaments TC
Folds or Plicae (blood vessels and ducts lifting Left Colic Flexure (Splenic Flexure)
peritoneum off the body wall)
DC
Diaphragm
SG
Liver (divided into right and left by falciform)
Rectum
Diaphragmatic surface
Anal Canal
Visceral surface
Phrenicocolic ligament (attaches LCF to
Porta Hepatis
diaphragm and forms shelf to support spleen)
Subphrenic recess Transverse Mesocolon
Bare Area Sigmoid Mesocolon
Coronary (hepatorenal) Ligament Teniae Coli (3 longitudinal muscles of colon)
(superior and inferior) Haustra (bulging of colon created by teniae coli)
Left and right Triangular ligaments Appendices epiploicae (omental tags)
Hepatorenal recess
Peritoneal Gutters
Right lateral (paracolic)

38
Discussion: Peritoneum
Its a sack within a sack
Greater sac = peritoneal sac
Lesser sac = omental bursa (formed by rotation/migration)
-upper recess bound by lesser omentum
-lower recess bound by greater omentum

Ventral mesentery (basically, the ventral mesogastrium)

A. LESSER OMENTUM-
1. Attaches to lesser curvature of stomach and first part of duodenum.
2. Ligaments
a. Hepatogastric ligament
b. Hepatoduodenal ligament
B. Falciform ligament
1. Contains ligament teres - remnant of umbilical vein.
2. Connects liver to stomach and to ant ab wall
C. Coronary ligament- comes around top and right of liver
D. Right triangular - flexure of liver
E. Left Triangular- flexure of liver
F. No ventral mesentery for intestines due to the outpouching of yolk sac

Dorsal mesentery:
A. Dorsal Mesogastrium
1. Greater Omentum
a. From rotation of stomach, dorsal mesogastrium becomes ventral
apron of 4 layers. If transverse mesocolon fuses, it becomes 6
layers.
b. Ligaments:
(1) Gastrophrenic ligament (2 layers)
(2) Gastrolienal ligament (2 layers)
(3) Gastrocolic ligament (stomach-transverse colon) (4 or 6
layers)
2. Transverse Mesocolon (anterior lamina)- mesentery of transverse colon,
divides greater sac into supra and infra colic
3. Lienorenal ligament
B. The Mesentery of the small intestine- has a ligament on either end:
1. The ligament of treitz: slip of muscle from right crus of the diaphragm to
the duodenojejunal flexure
2. Ileocecal ligament:
C. Mesenteries of the Colon
1. Transverse Mesocolon (posterior lamina)
2. Sigmoid colon has mesentery
3. Ascending, descending, and cecum do not have mesentery
4. Mesoappendix- behind vermiform appendix

Parietal Mesentery

39
 A. Suspensory ligament of duodenum/jejunum juncture (suspended from
diaphragm)- Lig of treitz (smooth muscle from duodenum and skeletal from diaphram)
B. Phrenicolic ligament- left colic flexure to diaphragm, forms shelf for spleen
C. Broad ligament of uterus- consists of mesometrium, mesosalpinx, mesoovarium,
lig teres uteri
D. Suspensory ligament of ovary (infundibulopelvic)- not the round ligament
--Round ligament of Uterus- analogous to gubernaculum of men
E. Tunica vaginalis- surrounds the teste

Portal Triad: portal vein, hepatic artery, and bile duct;

enclosed by the hepatoduodenal ligament

Classification of Organs
Intraperitoneal- completely enclosed in visceral peritoneum
Liver
Gall bladder
Spleen
Stomach
1 st part of duodenum
jejunum
ileum
vermiform appendix
transverse colon
sigmoid colon
infundibulum and fimbriae of ovary

Primarily Retroperitoneal- anterior surface covered by parietal

mesentery; developed retroperitoneal
Kidney
Adrenal glands
IVC
Aorta
Testes (due to tunica vaginalis)

Secondarily Retroperitoneal- adherent to posterior parietal wall,

anterior surface is covered by visceral peritoneum; migrated towards
retroperitoneal during development
2-4 Duodenum
Cecum
Ascending colon
Descending colon
Rectum
Pancreas

Extraperitoneal- outside but not posterior to peritoneum

Urinary bladder
Prostate
Seminal vesicles
Uterus
Ovaries (when they migrate they pick up the mesovarium, this is parietal peritoneum)

40
**Slight error in above diagrams - greater omentum should not envelop the transverse colon; it
should run superior to the TC (between the stomach and the TC); the greater omentum often fuses
with the transverse mesocolon on the superior side.

The greater sac is the abdominal sac, the lesser sac is the omental bursa
Omental bursa- (fat skinned purse) bounded by lesser omentum anteriorly. Extends into and is
bounded by inferiorly the greater omentum. If layers of the greater omentum are not fused, it can
extend between them.
Bounded by gastrolienal and lienorenal ligaments on left. On right has opening: the epiploic
(omental) foramen. Inferior= greater omentum. Posterior= peritoneum

Lecture 7: Clinical aspects of the abdomen

REFERRED PAIN - the picking up of a visceral impulse by a somatic afferent root in DRG.
A. A muscle will localize pain from any inflamed parietal peritoneum below it and
send impulses by GSAs.
B. Diaphragm has parietal pleura and peritoneum. If enflamed, patient will take
shallow respirations. Diaphragm- any inflammation can develop referred pain to
C3,4,5: the shoulder.
C. Hollow organs can produce colic (acute abdominal pain)
D. Biliary colic (pain associated with passage of gall stones)- referred to T8, the tip
of scapula
E. Appendicitis- appendix gets blocked and so it distends. This sends GVA signals
back to DRG. Since appendix originally developed at T10, this is where the GVAs
go. In the DRG, somatic afferent roots pick up this signal and trick the brain into
thinking that the midumbilical region is feeling pain. Eventually infection travels
from outside of appendix to visceral and then to parietal peritoneum. At this point,
GSAs at the position of the appendix (L1 and L2) will pick up the signal and

41
 locate the pain exactly; usually at McBirneys point. Appendix has variable
positioning, can even be in pelvis against obdurator muscle, so having patient flex
thigh can produce pain in appendicitis.
F. Transverse colon: starts in hypogastrium, moves to epigastrium.

Discussion: Nervous System Review

I. CNS- brain and spine
II. PNS- spinal and cranial nerves and their branches
A. Somatic- GSE and GSA 1 neuron system
B. Autonomic- GVE a 2 neuron system
C. GVA- think of them as separate from autonomic system

Be aware that the levels of the sacral and coccygeal portions do not correspond with the vertebrae.

The different fiber types arise from different places inside the cord:
o Ventral horn- somatic efferent fibers
o Dorsal horn- afferent fibers
o Lateral horn- Intermediolateral Cell Column - visceral efferents, they exit through
ventral horn

The primary fiber type of a cutaneous nerve is always GSA.

The primary fiber type of a nerve to a skeletal muscle is GSE.
The primary fiber type of a nerve to viscera is always GVE (Symp or Parasymp).
GVAs piggyback with GVEs on the sympathetic highway and cause referred pain.

Sympathetic System
A. Parabertebral Ganglia (Sympathetic Chain)
1. Where cell bodies of most postganglionic sympathetics exist
2. White and gray rami communicans
3. Superior, middle, and inferior cervical ganlia extend into the cervical area
B. Prevertebral Ganglia (Preaortic Ganglia)
1. Celiac, SMA, IMA: ganglia live in a plexus around the roots of these great
vessels
2. Splanchnic Nerves go to the prevertebral ganglia
a. Greater T5-T9
b. Lesser T10-T11
c. Least T12
d. Lumbar L1-L2

Parasympathetic system also has pelvic splanchic nerves (S2-S4)

Cardiac Splanchnics: only talking about fibers going to the heart
T1-L2 has white rami communicans, all vertebrae have gray rami communicans as well as
ganglia in the sympathetic trunk (dont forget fibers can run up and down chain and synapse very
high or low)

Root level- spinal cord level of origin of a nerve

42
Dermatome- area of skin that feeds to a specific root level
Note: sensory nerves do not synpase in DRG
Note: GSAs always outrank GVAs

PAIN:
I. Somatic- direct, with pinpoint localization
II. Visceral- extremely diffuse, poorly localized pain from stretch receptors
III. Referred- irritation of a viscous is perceived somatically; sympathetic phenomenon
A. Somatic to somatic
1. Diaphragm - odd case
2. Diaphragm is skeletal muscle
3. The pain receptors are going to their own dermatome
4. The muscle has just migrated
B. Visceral to somatic - what were interested in
1. Basis is shared space of cell bodies in DRG
2. Visceral Afferents use sympathetic highway to travel back to spine
3. Brain perceives problem in GVA as problem in GSA
4. Pain in heart sometimes perceived in neck
a. Superior, middle, and inferior cervical ganglia in the neck
b. Visceral afferents coming back with cardiac nerves from the
cervical region
c. Some of these visceral afferents are living in the cervical DRG
5. Examples:
a. Appendix
(1) Innervation of the appendix comes from T10 because it
started midgut before gut rotation, so its GVA goes into
the DRG at T10.
(2) Next to it in the DRG, are GSAs of T10.
b. Heart
(1) Innervation of the heart is T1-T5. When the heart is in
pain, it sends signals to T1-T5 DRG.
(2) The upper arm is innervated by T1-T5. So pain from
angina or heart attack is felt in upper arm and shoulder.
(3) The heart also has cervical ganglia at C4 that go to the
DRG in the cervical region, touching the GSAs of the
jaw. These are called cervical nerves.
c. Transverse Colon
(1) Transverse colon originally got its innervation below
T10, but after gut rotation it came to rest above T10.
(2) Early pain from transverse is felt hypogastric and late
pain is felt epigasric (irritation of the parietal plura -
somatic)
d. Kidney/Testes
(1) Testicular pain (T10) is felt on back near kidneys
(2) Kidney pain is first felt in the scrotum, since somatic of
scrotum is L1-L2.
6. Posterior structures often refer to the back (Kidney, spleen...)

43
 Somatic Landmarks Sympathetic Innervation
Nipples T4 Caudal Esophagus T5-T6
Umbilicus T10 Stomach T6-10 (xiphoid - umbilical)
Scrotum L1-L2 Small Bowel T9-T10
Cecum and appendix- T10
AC - Splenic Flexure T11-L1
Splenic Flexure to Rectum L1 - L2

Pancreas and Spleen T6-T10

Gall bladder and Liver T7-T9 (T8 Hotspot)
Kidney T10-L1
Ureter T11-L2
Testicle T10
Heart T1-5

Parasympathetic innervation
o Thorax - Vagus
o Pre-Left Colic Flexure - Vagus
o Post-Left Colic Flexure - Pelvic Splanchnics

Lab XI: GI Tract and glands

STOMACH-
A. Has lesser and greater curvature.
B. Fundus
C. Body
D. Pyloric canal, sphincter, and orifice leading to duodenum.
E. Has ruggae- folds in interior
F. Arterial supply:
1. Left Gastric-from celiac trunk
2. Right gastric and from common hepatic
3. right gastroepiploic- from gastroduodenal (branch of common hepatic)
4. Left gastro-epiploic and short gastrics- from splenic

PANCREAS-
A. Posterior to the stomach.

44
 B. Resembles an upside down pipe
C. Head and neck of pancreas is a fist punching 2 nd part of duodenum and holding the
SMA and SMV in its hand.
D. retroperitoneal except for its tail

LIVER-
A. The H:
1. Right sagittal fossa: IVC and the bed for
gall bladder
2. Left sagittal fissure: ligamentum teres
leading to the ligamentum veinosum
3. Transverse fissure: the porta hepatis.
4. The H divides the liver into lobes:
a. There is the larger right lobe, and
the left lobe.
b. Also considered part of the left
lobe are the caudate lobe (has a
small tail) and the quadrate lobe.
B. On its right posterior portion is the triangular bare
area where the liver is in direct communication
with the diaphragm without any peritoneum.
Surrounding this are are the coronary ligaments.
C. Cirrhosis liver (tawny orange)- leads to portal
hypertension

GALL BLADDER-
Stores bile
Cystic duct communicates with the bile duct.

SPLEEN- lien
o Has hilus where vessels enter
o If a knife is stabbed through ICS 9, it will first hit pleura,
then diaphragm and then the spleen.
o The spleen forms in dorsal mesogastrium called the
gastrolienal ligament.
o Attached to left kidney by lienorenal ligament.

SMALL INTESTINE
A. Duodenum-
1. Latin for 12, since it has 12 fingerbreadths
2. Has 4 parts. 1 st three form a C and last part is junction to jejunum.
a. 1 st part- intraperitoneal, supplied by the celiac artery
b. 2 nd part- bile and pancreatic ducts enter here. It has the apulla of
Vater and the Sphincter of oddi. Covered by hood-like plica.
c. 3 rd part- crossed by SMA and SMV.
d. 4 th part- supportd by ligament of Treitz, attached to diaphragm
B. Jejunum- (L. empty)
1. Has plica circlares (folds)

45
 2. Longer vasa recta (vessel from plexus to intestine)
3. Joins 4 th part of duodenum
C. Ileum-
1. has less plica circulares
2. shorter vasa recta
3. shorter arcades
D. Ligaments of note
1. Ligament of treitz
2. Ileocecal junction

COLON
A. Has plica semilunares
B. Has teniae coli- bands of longitudinal muscle
C. Omental appendages (appendices epiploicae)- hanging fat
D. Parts of the Colon:
1. Cecum (blind)
a. Has vermiform (wormlike) appendix- which has mesoappendix
b. There is a retrocecal recess
2. Ascending Colon- right side of body
3. Transverse- intraperitoneal
(1) Phrenicolic ligament from left colic flexure to diaphragm
4. Has transverse mesocolon which can fuse with greater omentum
5. Descending- secondarily retroperitoneal
6. Sigmoid- s-shaped
7. Rectum- straight

Nutcracker between SMA and Aorta: constriction of LRV > can back up into testicular/ovarian
vein, accumulation of fluid in testicle/ovary.
o LRV
o Duodenum
o small lobe of pancreas

INNERVATION
Greater Splanchnic: T5-T9, synapses at and for celiac trunk
Lesser Splanchnic: T10-11, SMA
Least Splanchnic, T12, IMA

46
Bold terms of this lab: Portal Vein
Superior Mesenteric Vein
Hepatoduodenal ligament Inferior Mesenteric Vein (may drain
bile passages into splenic, SMV, or portal)
hepatic artery Splenic Vein
portal vein Gastric Veins (esophagus and less curve
autonomic nerves > Portal)
lymphatics SMA plexus
Bile duct Vasa recta to SI
Cystic Duct SMA
Common hepatic duct Ileocolic artery (caecum and appendix)
Right hepatic duct Right colic artery (arises from SMA or
ileocolic; supplies AC)
Left hepatic duct
Middle colic artery (right half of TC)
Hepatic Lymph nodes
SMV
Common hepatic artery
Lymph nodes of the mesentery
Gastroduodenal artery
SM nodes (near origin of SMA)
Right Gastroomental
IMA
Hepatic artery proper
Left Colic artery (runs towards LCF;
Right Gastric artery supplies DC and left half of TC)
Right Hepatic artery Sigmoid Arteries
Cystic artery Superior rectal artery (proximal rectum)
Left Hepatic artery IMV
Splenic Artery IM nodes
Left Gastroomental
Left Gastric Artery

GI Tract and Unpaired organs: Sphincter of the hepatopancreatic ampulla

(Sphincter Oddi)
IVC Lobes of the liver
Esophageal Vein (from portal) Right
Gastric Vein (from portal) Left
Celiac Trunk and branches Quadrate
Pancreaticosplenic nodes (along splenic Caudate
artery) Right sagittal fossa
Left Gastric artery Left sagittal fissure
Gastroduodenal artery Transverse fissure (porta hepatis)
Pancreaticoduodenal arches (anterior Hepatic veins
and posterior superior) Hepatic lymph nodes (@ porta hepatis)
SMA Celiac nodes (drain hepatic nodes)
Inferior pancreaticoduodenal arteries Spleen
(anterior and posterior) Hilus
Plicae semilunares (large intestine; crescent anterior/superior borders sharp
mucosal folds between haustra) posterior/inferior borders rounded
Major duodenal papilla (opening of common bile Visceral surface
duct into duodenum)
Diaphragmatic surface (convex and
Plica (hoodlike, often covers major duodenal papilla)
smooth)
Plicae circulares (folds of mucosa; large in Stomach
duodenum/jejunum, small in ileum )
Longitudinal ridges (along lesser
Meckels diverticulum (remnant of yolk stalk
near ileocecal valve) curvature)
Main pancreatic duct (normally joins terminal bile Pyloric antrum and canal
duct) Pyloric Sphincter

47
Lecture 8: Venous and
Lymphatics of Thorax/Abd
(Excellent section in Not the Syllabus - pgs 45 - 49)

4 main divisions of circulation:

systemic circulation
pulmonary circulation
hepatoportal- 2 capillary bed system; brings
products of digestion to liver
lymphatic system
systemic routes: baby moore 78

VENOUS SYSTEM: (refer to pg 46 of Not the Syllabus)

A. Internal Jugulars + Subclavians >
brachiocephalic veins > brachiocephalics +
azygous > SVC
B. SVC drains everything above the diaphragm;
does not have valves (due to gravity)
1. Azygous System: drains thoracic and
abdominal body wall
a. Azygous vein- begins at
junction of right ascending
lumbar and subcostal veins.
Receives posterior intercostal veins on right side; Azygous drains
into SVC. Collateral pathway between SVC and IVC.
b. Hemiazygous vein- receives lower posterior intercostals on left
and then crosses over to azygous
c. Accessory azygous- drains upper posterior intercostals and cross
over near the hemiazygous to join azygous (hemiazygous does
this also)
d. Vertebral venous plexus, esophagus (via esophageal veins), lungs
(via bronchial veins)
e. Collateral pathway between IVC and SVC
2. The bronchial veins of the left side drain into posterior intercostals. On
right, they drain directly into azygous.
3. Also drains: esophagus, body wall, vertebral venous plexus, lower
extremities if IVC is blocked
C. IVC drains everything below diaphragm
1. Pierces diaphragm at T8
2. Common Iliacs > IVC
3. 4 lumbar veins
4. Right testicular/ovarian veins
5. Right renal
a. Azygous connection
6. Left renal
a. Left testicular/ovarian veins > hemiazygous connection?
b. Left suprarenal

48
 7. Inferior Phrenics
8. Hepatic Veins
9. Ascending lumbar vein connects to IVC (connects to right renal?) >
becomes azygous

LYMPHATICS: (Refer to diagrams in Not the Syllabus pgs 48-49)

A. It is an accessory janitorial system consisting of blind ended blood sacuoles; has
valves. Consists of
1. Lymph organs and tissues
a. Thymus
b. Lymph nodes
(1) Efferent lymphatic (concave side)
(2) Afferent lymphatic (convex side)
(3) Filtering of lymph
c. Spleen
d. Tonsils
e. Lymphatic nodules
2. Lymph Vessels
B. Transport of Chyle from SI (Lymph = clear water, Chyle = milky, creamy lymph)
1. Lymph capillaries (lacteals) - absorb chylomicrons (lipoprotein)
2. Lymph vessels - running in mesentery
3. Intestinal lymph trunk - ends at cysterna chyli
4. Cysterna chyli
a. Expansion of lymphatic vessel (L1, L2)
b. Dilation of lower end of thoracic duct
5. Thoracic duct
C. Thoracic duct: begins in Abdomen from cysterna chyli, runs through thorax on
left side to junction of left internal jugular and subclavian; it drains everything
but the right upper quadrant of the body.
D. The Right Lym phatic trunk drains the right upper quadrant. It empties into
junction of right internal jugular and subclavian
E. Nodes:
1. Aortic nodes - testes/ovaries
2. Parasternal nodes
3. Supraclavicular
4. Inguinal- scrotum and penis
5. Iliac- vagina
6. Axillary- arms and breasts
7. Cervical- head
8. Visceral
F. Lymphography-
1. Lymphangiogram- shows lymph vessels
2. Lymphadenogram- shows nodes
G. Elephantitus- a parasitic worm can lay eggs in lymph nodes, causing gross edema
H. Testes- drain along testicular artery to aortic node
I. Scrotum and penis- drain to inguinal node
J. Cancer likes to travel in lymph vessels- called metastasis

49
Discussion: Hepatoportal system
Vessels of aorta can be divided into four categories-
A. Ventral- celiac, SMA, IMA
B. Lateral- Inferior phrenics, suprarenals, renals, gonadal
C. Dorsal- lumbars and median sacral
D. Terminal- common iliacs

Portal system-
I. 25% of cardiac output is in the portal system at any given time
II. portal vein formed at juction of SMV and Splenic Vein. (IMV usually drains into splenic)
Also, L gastric and paraumbilical drain into portal vein.
III. 2 capillary bed system
IV. blockages:
A. prehepatic- thrombus or aneurysm of portal vein
B. intrahepatic- cirrhosis
C. extra-hepatic blockages of hepatic veins or IVC
D. any of the above results in portal hypertension

V. Very important anastamoses (Portal system is valveless)

A. Esophageal- most important because most dangerous
a. PortalL Gastric Esophogeal (portal) esophageal
(systemic)azygous+hemiSVC
b. Results in esophageal varices
B. Rectal
1. portalsplenicIMVSuperior rectal (portal) rectal plexus which
goes to either
a. middle rectal (systemic)internal iliac veincommon iliac
veinIVC or
b. inferior rectal (systemic)internal pudendalinternal
iliaccommon iliacIVC
(1) causes Hemrrhoids and Melena
C. Umbilical (External)
1. left portal veinligamentum teres paraumbilical vein superficial
epigastric vein (systemic) which goes to either
a. great saphenous veinfemoralexternal iliaccommon
iliacIVC OR
(1) Results in Caput Medusa (Medusas head): a spidery network of
veins on ABD.
b. Thoracoepigastriclateral thoracic
axillarysubclavianbrachiocephalicSVC
(1) Tend to see thoracoepigastric vein only during portal hypertension
VI. Treatment
A. Can attach portal vein directly IVC
1. Direct portacaval anastamoses
2. Not detoxifying anything (palliative)
B. Could attach splenic vein to renal
1. Compromise
2. Dont divert all blood
C. Trans-jugular Intrahepatic Portocaval Shunt (TIPS)
1. Done by interventional radiologist

50
 2. Funnel tube down jugular and through liver
3. Can make a channel for blood to go through

Surgical treatment is to create a shunt from the portal vein to IVC just posterior

Lab XII: Posterior Abdominal Wall

Vessels:
Male-
Right testicular vein drains into IVC
Left testicular drains into left renal, which drains into IVC
Note: left renal crosses between SMA and aorta
Left and right testicular arteries come off aorta, locate them exiting superficial
ring
Female-
Ovarian vessels same as males, they cross external iliacs

THE KIDNEY-
I. Coverings of the kidney
A. Embedded in perirenal capsule, this fat and kidney enclosed in Renal Fascia
B. Fibrous tissue surrounding kidney called renal fascia is separated from the fibrous
capsule of the kidney by perirenal fat.
C. Kidneys are not rigidly attached to the
abdominal wall
D. Left kidney at T11, right kidney at T12 because
liver pushes it down
II. Parts of the kidney
A. Renal cortex- glomeruli, convoluted tubules
B. Renal medulla- consists of renal columns and
pyramids
C. Renal columns- straight, support cortex
D. Renal pyramids- triangular, drain into papillae
E. Renal papillae- project into small cups below
renal pyramids; site where collecting ducts
empty
F. Minor calices- under each pyramid and papilla
G. Major calices- only 2 or 3, the minor drain into
them
H. Renal pelvis- drains the major calices and is
continuous with the ureter

51
Retroperitoneal approach to kidney- you hit Ureter, Artery, Vein, then Peritoneum
You Are Very Pretty

ADRENAL (SUPRARENAL) GLANDS-

A. Above the kidneys
B. Right is triangular/ left is semilunar
C. Vascularization
1. Superior portion
supplied by inferior
phrenics
2. Middle by suprarenals
off aorta
3. Inferior by branch of
renal arteries

MUSCLES OF THE POSTERIOR ABDOMINAL WALL-

o Psoas major (loin muscle)- runs superior to inferior adjacent to the bodies of lumbar
iliacus- fills iliac fossa
o Quadratus lumborum- from iliac crest to lumbar transverses. Horizontally along posterior
wall

Nerves
o Subcostal (T12)- runs just inferior to 12 th rib. Anterior to quad lumborum
o Iliohypogastric (L1)- emerges from lateral border of psoas anterior to quad
o Ilioinguinal (L1)- shares trunk with hypogastric but splits off inferiorly
o Obdurator (L2,3,4)- medial border of psoas into obdurater foramen
o Lateral fem oral cutaneous (L2,3)- lateral of psoas and aerior to iliacus
o Genitofem oral (L1,2)- pierces and emerges from ventral surface of psoas. Supplies
cremaster and medial portion of thigh
o Fem oral nerve (L2,3,4)- big nerve. Emerges from lateral border of psoas and descends in
groove of psoas and iliacus.

52
THORACIC DIAPHRAGM
A. Parts of the diaphragm
1. Muscular Parts
a. Lumbar Part
(1) Left Crura and Right Crura (leg)- musculotendinous bundles that extend
down two or three lumbar vertebrae bodies, right longer than left.
United by median arcuate ligament, which passes over aortic hiatus.
b. Costal Part
c. Sternal Part
2. Arcuate Ligaments
a. Median
b. Medial
c. Lateral
3. Central Tendon
B. 3 openings
1. Vena caval formen T8, T9
a. IVC, right phrenic nerve, lymph vessels and occasionally the right
hepatic vein
b. most ant and furthest on right
2. Esophogeal hiatus- T10
a. esophagus, anterior and posterior vagal trunks, and esophageal
branches of left gastric artery and vein
b. middle

53
 3. Aortic hiatus- T12, L1
a. aorta, thoracic duct, azygous vein, and lymph
b. Note: aortic hiatus is not actually in diaphragm but is in arcuate ligament,
therefore not affected by resp (furthest left and most posterior)
4. Blood Supply
a. Inferior phrenic arteries
b. Musculophrenic arteries
c. Pericardiophrenic arteries

C. Nerve Supply
1. Motor - phrenic nerves
2. Sensory - phrenic and intercostal nerves

Important: the higher the hole the more ventral ivc esoph aorta
I Remember Very Easily All These Aids I8 Ten Eggs At 12 (levels of openings)

Bold terms of this lab: Right kidney (in contact with RCF at inferior
portion)

54
Left kidney (in contact with pancreas and LCF) -middle suprarenals from aorta
Left testicular/ovarian vein > L. Renal vein -infeior suprarenals from renals
Right testicular/ovarian vein > IVC Lumbar arteries
R and L testicular arteries Lumbar nerve plexus (T12-L5)
Venous channels from left suprarenal (drain Subcostal
into LRV) Iliohypogastric and ilioinguinal
Renal Arteries Genitofemoral
Renal pelvis Lateral cutaneous nerve of thigh
Ureter Femoral nerve
Abdominal Part Obturator nerve
Pelvic Part Lumbosacral trunk (ventral rami of part
Transversus abdominus of L4 and all of L5)
Quadratus lumborum Sympathetic trunk
Psoas major Diaphragm
Iliacus Sternal
Kidney Costal
Fibrous capsule Lumbar
Renal cortex Right crus
Renal medulla Left crus
Renal Pyramids Arcuate ligaments
Renal columns Medial
Renal Papillae Lateral
Calyces minores Central tendon
Calyces majores Vena caval foramen
Renal pelvis Esophageal hiatus
Ureter Aortic hiatus
Adrenal Glands Right and left phrenic nerves
Inferior Phrenic arteries Greater splanchnic nerves
Suprarenal blood supply
-superior suprarenals from inf phrenics

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Labs of the Pelvis

BONY PELVIS
A. Os Coxae (2)
1. Ilium
2. Ischium
a. Ischial tuberosity
b. Ischial spine
3. Pubis
a. Retropubic space
(behind pubis but in
front of parietal fascia
- i.e. bladder)
B. Sacrum
1. Anterior sacral foramina
(ventral nerve rami S1-S4)
2. Promontory (prominant body
of 1 st sacral vertebra)
3. Sacral Canal
C. Coccyx

DIVISIONS AND LANDMARKS OF THE PELVIS:

o Greater Pelvis (false pelvis)
o Lesser Pelvis (true pelvis)
o Pelvic brim (surrounds pelvic inlet or superior aperture; separates greater from lesser pelvis)
Sacral part
Iliac part
Pubic part
o Superior Pelvic Aperture (inlet to pelvis minor)
o Inferior Pelvic Aperture (Pelvic outlet)
Pubic symphysis (anteriorly)
Ischial Tuberosities (laterally)
Sacrum and Coccyx (posteriorly)
o Pelvic Fascia
Parietal Pelvic Fascia
Visceral Pelvic Fascia
o Obturator foramen closed by obturator membrane
o Acetabulum - where the three bones of the os coxae meet
o Sacrospinous ligament
o Sacrotuberous ligament
o Lesser Sciatic foramen
o Greater sciatic foramen
o Sacroiliac articulation

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PELVIC DIAPHRAGM
A. Muscles (skeletal, innervated by sacral branches)
1. Coccygeus (ischiococcygeus)
2. Levator ani:
a. Iliococcygeus
b. Pubococcygeus
c. Puborectalis
B. Fascia
1. Superior fascia of the pelvic diaphragm
2. Inferior fascia of the pelvic diaphragm
C. Structures Piercing the diaphragm
1. Female:
a. Rectum (anus)
b. Urethra
c. Vagina
2. Male:
a. Rectum (anus)
b. Membranous Urethra

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DEEP (PERINEAL) POUCH - contains urogenital diaphragm
(UGD)
A. Muscles (skeletal, innervated by pudendal
nerve)
1. Deep transverse perineal muscle
2. Sphincter urethrae
3. Sphincter vaginae (in females)
B. Fascia: perineal fascia/membrane:
1. superior (perineal) fascia
2. inferior (perineal) fascia
C. Other structures contained in or piercing
the UGD
1. Female:
a. Urethra
b. Vagina
2. Male
a. Membranous urethra
b. Bulbourethral glands

SUPERFICIAL (PERINEAL) POUCH or SUPERFICIAL

PERINEAL SPACE:
A. Muscles (striated, innervated by
pudendal)
1. Superficial transverse perineal
muscle
2. Bulbospongiosus muscle
3. Ischiocavernosus muscle
B. Fascia: superficial perineal fascia
C. Other structures within the superficial
pouch
1. Female
a. Clitoris (NO urethra)
b. Bulbs of the vestibule
c. Greater vestibular glands
2. Male
a. Penis
b. Spongy (penile) urethra
c. Scrotal contents

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PERINEUM IS MADE UP OF:
A. Anal triangle
1. Anal Canal
B. Urogenital triangle
1. Urethra
2. Parts of penis and erectile tissue
C. Also Contains
1. Superficial fascia
a. Fatty layer
b. Membranous layer (Colles fascia or superficial perineal
fascia)
(1) continuous with dartos fascia of penis and scrotum
(2) continuous with scarpas fascia of lower abdominal
wall

DIVISIONS OF MALE URETHRA:

o Prostatic urethra (passes through prostate)
o Membranous urethra (passes through diaphragms)
o Spongy/penile urethra (passes through corpus spongiosum)

PUDENDAL NERVE (S2-S4)

A. Branches
1. Inferior anal (rectal)
2. Perineal (travels in perineal canal)
Gives off posterior scrotal branches
3. Dorsal verve of penis
B. Drops straight down, then straight forward
1. Leaves pelvic cavity via greater sciatic foramen
2. Comes back via lesser sciatic foramen
C. Runs anterior along ischial tuberosity
1. Runs in pudendal canal (part of obturator internis fascia)
2. Tightly adherent to ischial tuberosity

ISCHIORECTAL FOSSA:
-Bound by pelvic diaphragm, urogenital diaphragm, and obturator internis laterally
-Its cone-shaped

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COMPARISON OF ERECTILE TISSUES:

Male Female

crus of penis = corpus cavernosum crus of clitoris = corpus cavernosum

body (shaft) of penis = paired corpora body of clitoris = corpus cavernosum

cavernosa and unpaired corpus
spongiosum

glans of penis = corpus spongiosum glans of clitoris = corpus cavernosum

bulb of penis = corpus spongiosum bulb of vestibule = corpus spongiosum

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Introduction to the Pelvis: Uterus and Adnexa:

Parts of the Uterus - terms to remember

o Internal os
o External os
o Fundus
o Corpus
o Extravaginal cervix
o Intravaginal cervix
o Fornices of vagina
o Isthmus
Adnexa (structures attached to or closely associated with the uterus)
A. Uterine (fallopian) tubes
1. Infundibulum and fimbriae
2. Ampulla
3. Isthmus
B. Ovary (and mesovarium)
C. Broad Ligament
1. Mesosalpinx (surrounds the uterine tube)
2. Mesometrium (broad ligament below the mesosalpinx)
3. Mesovarium (contains the ovary)
D. Suspensory (infundibulopelvic) ligament of
the ovary - fold of peritoneum covering
ovarian vessels, lymphatics and nerves
from lateral pelvic wall
E. Proper ligament of ovary - between layers
of broad ligament, making bulge in its
posterior aspect, form ovary to uterus
F. Round ligament of uterus - embryonic
continuation of proper ligament (and
together homologous to gubernaculum
testis); makes a bulge in the anterior leaf
of the broad ligament and follows the
course of the vas deferens in the male
G. Parametrium - connective tissue,
associated with veins, etc. And embryonic
remnants of mesonephric (wolffian)
tubules - epoophoron and paroophoron -
between layers of broad ligament, continuous with endopelvic fascia.

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From Review:

PELVIS
Superficial Pouch (superficial perineal fascia)
Corpus cavernosa (ischiocavernosis)
Corpus spongiousum (bulbospongiosis)
Superficial transverse perineal muscle

Deep Pouch (superior and inferior Perineal Fascia)

Sphincter urethra
Compressor urethra
sphincter vaginae
Deep transverse perineal muscle
Bulbourethral glands (males)

Pelvic Diaphragm (superior and inferior Pelvic Fascia)

Levator ani
Puborectalis
Pubococcygeus
Iliococcygeus
Coccygeus

Penis - review in Netter pg 355

Deep fascia = Bucks Fascia
Superior dorsal and lateral veins
Deep artery
Dorsal artery running with dorsal nerves

Ovarian artery supplies ovary and fallopian tube

Uterine artery supplies uterus and part of the vagina
Anastamoses between Uterine artery (Internal iliac) and Ovarian artery (abdominal aorta)

Gastrophrenic ligament

Be aware of anastamoses between Ovarian and Uterine vessels

Branches of internal iliac artery:

Refer to drawing from review

Bold Terms for Pelvis I: Gluteus maximus

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Sacrotuberous ligament Deep transverse Perineal muscle
Greater and lesser sciatic foramina artery to the bulb
Ischial Spine bulbourethral glands
Ischial tuberosity branches of pudendal nerve
Inferior rectal (hemorrhoidal) nerve and superior fascia
vessels Prostate gland
Sphincter ani externus (external anal Rectovesicle fossa
sphincter) Paravesical fossae
Fascia of the obturator internus Pararectal fossae
Pudendal Canal Ductus deferens
Pudendal Nerve Bladder
Internal Pudendal Vessels Pubovesical ligament (anchors neck of
Superficial fascia bladder to pubis)
Fatty layer Retrorectal (presacral) space
Membranous layer (Colles fascia Pelvic splanchnic nerves
or superficial perineal fascia) Internal iliac artery
Posterior scrotal nerves Obturator canal
Superficial perineal space (pouch) Obturator artery (branch of internal iliac)
Muscles Internal iliac vein
Superficial transverse External iliac vein
perineal Common iliac vein
Ischiocavernosus Vagina
Bulbospongiosus Uterus
Portions of penile erectile tissue Fornix of vagina
crura of penis Labia majora
bulb of penis Labia minora
Perineal membrane Clitoris
Perineal body Glans
Glans penis (distal expansion of corpus Body
spongiosum) Crura
Deep dorsal vein of the penis (unpaired) Prepuce of clitoris
Dorsal arteries of the penis (paired) External urethral orifice
Dorsal nerves of the penis Openings of paraurethral glands
Urethra Round ligament of uterus
Spongy (penile) Posterior labial nerves and vessels
Membranous urethra Suspensory ligament of the clitoris
External urethral orifice Vesicouterine pouch
Suspensory ligament of the penis (attached Rectouterine pouch
anteriorly to symphysis pubis) Paravesical fossa
Penis Pararectal fossa
Corona of glans Adnexa = Uterine appendages
Corpus cavernosum Uterine tube (surrounded by mesosalpinx
Corpus spongiosum - peritoneal fold)
Deep artery of the penis (in corpus Ovary
cavernosum) Broad Ligament of the uterus (separates
-branches of internal pudendal vesicouterine and rectouterine pouches)
Inferior fascia of deep perineal space Mesosalpinx
Deep perineal pouch Mesovarium
Sphincter Urethrae Mosmetrium (broad ligament

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below the mesosalpinx) Sacrouterine ligaments
Parametrium (fatty and areolar tissues Transverse cervical ligament
inside broad ligament) Pelvic Plexus
Round ligament of the uterus Rectal Plexus
Ligament of the ovary Utero-vaginal plexus
Suspensory ligament of the ovary Vesical plexus
(contains vessels)

Bold terms for Pelvis II: Levator ani

tendinous arch
Prostatic urethra Piriformis
Urethral crest Sacral plexus
Colliculus seminalis lumbosacral trunk (L4,L5)
Orifice of ejaculatory duct Sciatic nerve (L4-S3)
Prostatic sinus Pudendal nerve (S2-S4)
Ductus (vas) deferens Uterine artery
Ampulla Ureterovesical junction
Seminal vesicle lateral to each bladder neck
ampulla Vagina
Duct of the seminal vesicle Cervix
(beginning of ejaculatory duct) Cervical canal
Urinary bladder Body of the Uterus
Muscular coat Vesical surface
trigone Superior surface (faces
Ostium: slit-like opening of ureter rectouterine pouch)
into bladder lateral surfaces attached to broad
Internal iliac artery and branches ligament
Umbilical artery Uterine cavity
superior vesical arteries Endometrium
becomes medial umbilical Myometrium
ligament Fundus
Obturator artery Uterine tube
Inferior vesical artery infudibulum with fimbriae
Internal pudendal artery isthmus
Inferior gluteal artery Ovary
Superior gluteal artery Internal Iliac artery and branches
Rectal venous plexus Umbilical
Vesical venous plexus superior vesicals
Prostatic venous plexus becomes medial umbilical
Deep dorsal vein of penis ligament
Anal Canal obturator artery
Anal columns uterine artery (anastamoses
Anal valves between uterine and ovarian arteries)
Sphincter muscles of the anus Vaginal artery

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Middle rectal artery Ureter (between vaginal and uterine
Internal pudendal arteries)
Inferior gluteal artery
Superior gluteal artery

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