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Renal #4 Mon, 03/17/03, 1pm Dr. Rosales Brian Anderson Page 1 of 6 Renal Gross Anatomy Lecture 1 I. Bony Parts of the Post. Abdominal Wall 1. median plane - bodies, intervertebral discs, and transverse processes of the 5 lumbar vertebrae 2. laterally - from the twelfth pair of ribs above to the pelvic brim below; divided into upper and lower parts by the iliac crests. The region of the abdomen between the iliac crests and pelvic brim is the pelvis major. II. Muscles 1. Psoas major a. arises from the sides of vertebral bodies, transverse processes, and intervertebral discs of TV12 and all the lumbar vertebrae b. fibers run downward and laterally to enter the thigh behind the inguinal ligament and insert into lesser trochanter of femur c. enclosed in a fibrous sheath derived from the lumbar fascia which is thickened above to form the medial arcuate ligament of the diaphragm d. flexes the thigh at the hip joint on the trunk; if the thigh is fixed, it flexes the trunk on the thigh, as in sitting up from lying position e. nerve supply: lumbar plexus 2. Psoas minor a. either absent (40-50%) or insignificant [ the other 3 that are sometimes absent are: upper limb – palmaris longis; lower limb – plantaris; anterior abd. wall pyramidalis] b. when present, its narrow tendon may be mistaken for the genitofemoral nerve on the surface of the psoas major; the belly is small and the tendon is very long 3. Quadratus lumborum a. quadrate but not rectangular, for its lateral border is oblique, a landmark when exposing the kidney from behind b. lies alongside the vertebral column; lateral to the psoas major c. origin - lower lumbar vert. ; insertion - iliac crest d. fibers run upward and medially and insert into the lower border of 12th rib and transverse processes of upper 4 lumbar vertebrae e. anterior surface covered by the lumbar fascia which is thickened to form lateral arcuate ligament above and iliolumbar ligament below Renal #4 Mon, 03/17/03, 1pm Dr. Rosales Brian Anderson Page 2 of 6 f. fixes the 2th rib during inspiration; depresses the 12th rib during forced expiration; laterally flexes vertebral column (trunk) on same side g. nerve supply: lumbar plexus 4. Transversus abdominis a. b. c. d. becomes aponeurotic at lateral border of quadratus lumborum helps form a sheath for the deep back muscles action: compresses abdominal contents nerve supply: lower 6 thoracic nerves; iliohypogastric nerve (L1); ilioinguinal nerve (L1) 5. Iliacus a. occupies the iliac fossa b. joins lateral side of psoas major tendon to be inserted into lesser trochanter of femur; combined muscles referred to as iliopsoas c. action: together with the psoas, most powerful flexor of the thigh d. flexes the thigh on the trunk; if the thigh is fixed, it flexes the trunk to the thigh, as in sitting up from lying position e. nerve supply: femoral nerve 6. Diaphragm – forms the upper portion of the posterior abd. wall III. Fascial Lining [N236] - one continuous layer of connective tissue that lies between the parietal peritoneum and the muscles; continuous below with a similar fascial layer lining the pelvic walls; named according to the structure it overlies: diaphragmatic fascia, transversalis fascia, psoas fascia, quadratus lumborum fascia, fascia iliaca [-abdominal blood and lymph vessels lie within this fascial lining, whereas the principal nerves lie outside the fascia. This fact is important in the understanding of the femoral sheath which is simply a downward prolongation of the fascial lining around the femoral vessels and lymphatics, for about 4 cm into the thigh, behind the inguinal ligament. Since the femoral nerve lies outside the fascial lining, it has no sheath.] IV. Great Vessels of the abdomen 1. Abdominal aorta (runs from TV12 – LV4) Renal #4 Mon, 03/17/03, 1pm Dr. Rosales Brian Anderson Page 3 of 6 a. enters the abdomen in the median plane at the disc between TV12 and LV1 b. branches to: 1. GIT and 3 unpaired glands (liver, pancreas, spleen) a. celiac trunk- arises at level of disc TV12-LV1 b. sup. mesenteric a.-prevents ascent of left renal vein c. inf. mesenteric a.-arrests ascent of horseshoe kidney 2. 3 paired glands (kidneys, suprarenal glands, gonads) a. suprarenal aa. (hard to find) b. renal aa. c. testicular (ovarian) aa. 3. roof and walls of the abdomen a. inf. phrenic aa. -the most superior of these, supplies under surface of diaphragm b. lumbar aa. – 4 pairs but 5 LV (the 5th pair comes from the internal iliac a.) c. median sacral a. – unpaired, was once large during development; the tiny "continuation" of the aorta. c. termination - in front of LV4 by bifurcating into the right and left common iliac aa; each common iliac a.-bifurcates into an internal and an external iliac a.; external iliac a. (main trunk to the thigh) runs on the psoas to the midinguinal point where its changes its name to femoral a.; 2 branches arise from the external iliac a. just before it passes behind the inguinal ligament - the inf. epigastric and deep circumflex iliac aa. (anastomose with iliolumbar aa. from int. iliac aa. on iliac crest) 2. Inferior vena cava (runs from LV5 – TV8) a. largest vein in the body, found on right side of abd. aorta; formed by the right and left common iliac veins b. begins in front of LV5 below the aortic bifurcation & behind the right common iliac a. c. pierces the central tendon of the diaphragm at the level of TV8 to join the right atrium of the heart d. extends across 8 vertebrae and is about twice the length of the abdominal aorta. e. Tributaries draining 1. blood from the GIT, after circulating in the liver leaves it via the right and left hepatic veins (most superior tributaries) to enter the last part of the IVC 2. 3 paired glands - the right suprarenal, right renal, and right testicular (ovarian) veins enter the IVC; the left renal vein drains all three organs on the left side. Renal #4 Mon, 03/17/03, 1pm Dr. Rosales Brian Anderson Page 4 of 6 3. veins of body wall- 4 lumbar vv. irregularly linked together on each side by an ascending lumbar v.(joins with the subcostal vein which is found in the neurovascular bundle inferior to the 12th rib), which lies in front of the lumbar transverse processes; ascending lumbar vein becomes the azygos v. on the right and the hemiazygos v. on the left in the thorax; median sacral v. - ends in the left common iliac v. 4. pregnant women are asked to lay on their left side to relieve the pressure on the IVC and increase the venous return to the heart. V. Lymphatics 1. preaortic nodes (anterior surface of the aorta) lie around origin of celiac, SMA, and IMA --> drain the GIT from lower 3rd of esophagus to upper half of anal canal, spleen, pancreas, gall bladder, liver; efferent vessels form the intestinal trunk 2. right and left paraaortic nodes (on the side of the aorta) drain the kidneys, suprarenals, testes, ovaries, uterine tubes, and uterine fundus; efferent vessels form the right and left lumbar trunks; and lumbar trunks drain into the cisterna chyli (enlarged 1st portion of the thoracic duct; not always present) - located in front of LV 1&2 to the right of the aorta 3. intestinal lymph trunk and lumbar lymph trunk form the thoracic duct which drains into the left subclavian and left internal jugular vv. Junction 4. on the right: the junction of the right subclavian and right internal jugular forms the right lymphatic duct which drains the right side of head and neck and right upper limb VI. Lumbar Plexus 1. formed by the ventral rami of L1, L2, L3, and upper half of L4. 2. first ramus is joined by a branch of T12. 3. lower half of L4 joins L5 near the anterior border of the ala of the sacrum to form the lumbosacral trunk which is the nerve supply to the lower limbs 4. branches: a. iliohypogastric n. (L1) – supplies the hypogastric area b. ilioinguinal n. (L1) – located on the surface of the spermatic cord c. genitofemoral n. (L1, L2) 1. femoral branch – (sensory) pierces the fascia lata and supplies the skin of the femoral triangle 2. genital branch (motor) supplies the cremaster muscle and traverses the inguinal canal to end in the skin of scrotum Renal #4 Mon, 03/17/03, 1pm Dr. Rosales Brian Anderson Page 5 of 6 a. (cremasteric reflex – stroke the inner surface of thigh causes cremaster muscle to contract which causes the scrotum on that side to rise) d. lateral (femoral) cutaneous n. (L2, L3) – supplies the skin on lateral aspect of thigh e. femoral n. (post. division of L2, L3, L4) – supplies the anterior muscles of the thigh which flex the thigh and extend the knee f. obturator n. (ant. division of L2,L3, L4) – supplies the medial muscles of the thigh which are the adductors To identify the nerves, use the psoas major as a landmark and where they exit lateral aspect – iliohypogastric, ilioinguinal, lat cutaneous, femoral anterior aspect – genitofemoral medial aspect – obtuator which exits the obturator foramen VII. Abdominal autonomics 1. Sympathetic trunk a. enters from the thorax behind the medial arcuate ligament and follows faithfully the medial border of the psoas b. passes into the pelvis behind the common iliac vessels. c. right trunk is concealed by IVC and crossed by the right renal a. d. left trunk is crossed by the left renal vessels, left testicular a., & inferior mesenteric a. e. each trunk receives a white ramus from each of the upper 2 (or 3) lumbar nerves (L1, 2, [3]) and sends one or more gray rami to each of the 5 lumbar nerves to be distributed with nerves to somatic structures f. 4 postganglionic lumbar splanchnic nerves (visceral branches) run medially to the intermesenteric and superior hypogastric plexuses to be distributed largely with blood vessels to viscera. 2. Prevertebral plexuses a. Celiac plexus (solar plexus) 1. connects celiac ganglia; encircle the celiac trunk; branches radiate like the rays of the sun 2. each celiac ganglion lies behind the peritoneum, between the celiac trunk and the suprarenal gland and, therefore, on the crus of the diaphragm; IVC largely conceals the right celiac ganglion, while the pancreas and splenic artery largely conceal the left one; joined by the greater splanchnic n. at its upper part and by the lesser splanchnic n. at its lower part b. Intermesenteric and superior hypogastric plexuses 1. celiac plexus reinforced by the lumbar splanchnics c. Renal plexus 1. an offshoot of the celiac plexus 2. joined by the lowest splanchnic nerve 3. Parasympathetic nerves Renal #4 Mon, 03/17/03, 1pm Dr. Rosales Brian Anderson Page 6 of 6 a. fibers of both vagus nn., via a large branch of the posterior vagal trunk, pass through the celiac plexus to be distributed with arteries (celiac, superior mesenteric, and renal) to the abdominal viscera; control the gut as far as the left colic flexure b. fibers of pelvic splanchnic nerves (S2-4) ascend from the pelvis in the hypogastric plexus to be distributed with the inferior mesenteric a. to the gut; innervate the descending colon, sigmoid colon, rectum, and internal anal sphincter