Download anatomy review notes

ANATOMY
REVIEW
NOTES
SPLANCHNOLOGY I & II
2006
DEC5TH
1 Nasal cavity (bony+soft tissue) & paranasal sinuses
NASAL CAVITY (BONY) “Bony nasal cavity is 1st semester material”



Inlet:
o Apertura piriformis (pear-shaped aperture). Borders:
 Nasal bone, the frontal process of the maxilla, and by the body of the
maxilla.
Outlet:
o Choanae. Borders:
 LATERAL: medial plate of pterygoid process.
 INFERIOR: horizontal plate of the palatine bone.
 MEDIAL: vomer.
 SUPERIOR: body of the sphenoid bone (having the ala vomeris on it).
The nasal cavity has four walls:
o Anterior: nasal bone.
o Superior: nasal part of the 1frontal bone (ant.), 2cribiform plate (mid.), and 3body of
the sphenoid bone (post.).
o Inferior: The hard palate = palatine process of the maxilla (ant) & horizontal plate of
palatine bone (pos).
o Medial: Nasal septum = perpendicular plate of ethmoid & vomer. V-shaped space in
front, filled with cartilage forming the cartilaginous part of the nasal septum.
o Lateral: Anterior  Posterior.
 Frontal process of the maxilla.
 Lacrimal bone
 Ethmoidal bone. (Beneath the middle nasal concha are the uncinate process
and ethmoidal bulla. Between them, we have the semilunar hiatus)
 Inferior nasal concha
CONNECTIONS OF THE NASAL CAVITY:
PARANASAL SINUSES (4) are cavities surrounding the nasal cavity, filled by air, and layered by
mucous membrane. They open into the nasal cavity.
a) Frontal sinus: opens into the middle nasal meatus through the anterior part of the
semilunar hiatus.
b) Maxillary sinus: opens into the middle nasal meatus through the posterior part of the
semilunar hiatus.
c) Ethmoidal sinuses: anterior and middle groups of air cells open into the middle nasal
meatus, and the posterior group opens into the superior nasal meatus.
d) Sphenoid sinus: open into common nasal meatus via sphenoethmoidal recess.
Sphenopalatine foramen: Nasal cavity - pterygopalatine fossa.
Page |2
Incisive canal: Nasal cavity- Oral cavity. It transmits the nasopalatine nerve and artery.
Cribriform plate: It transmits fibers from olfactory nerve (CNI)
Nasolacrimal canal: Orbital cavity - inferior nasal meatus
NASAL CAVITY (Soft tissue)



nasal vestibule
proper nasal cavity
The borderline between them is the limen nasi.
The mucous membrane of the nasal cavity is divided into two parts:
1. Olfactory region
a. The olfactory mucous membrane covers the superior nasal concha and the septum
(the superior part of the septum and the top of the nasal cavity).
b. The epithelium of the olfactory region is of a special type which gives the origin of the
fila olfactoria.
c. It is a primary neuroepithelium. The fila olfactoria are running through the lamina cribrosa and form the olfactory nerve.
2. Respiratory region.
a. Rest of the nasal cavity is the respiratory region
b. Pseudo-stratified columnar kinociliated epithelium having mucous glands inside.
BLOOD SUPPLY AND INNERVATION:

This is given from two arteries and two nerves.
o anterior ethmoidal nerve  nasociliary nerve  Olfactory nerve ( CNI)
o ophthalmic artery  internal carotid
 Kiesselbach point: the anastomosis between the two arteries. These
structures begin in the orbit; pass through the anterior ethmoidal foramen
to the anterior cranial fossa, then down to the nasal cavity through the
cribriform plate. They innervate and supply the superior part of the nasal
cavity.
o Posterior nasal nerve  maxillary nerve
o Sphenopalatine artery  maxillary artery.
 Innervates and supplies the inferior, main part of the nasal cavity.
LYMPH DRAINAGE:


Anterior:
Posterior:
Submandibular lymphnodes  Deep cervical lymph nodes
Retropharyngeal lymph nodes
Page |3
2 Cartilages and joints of the larynx
CARTILAGES & (BONE):

o
o

o
o
o

o
o
o
o
o

o
o
o


o
Hyoid bone
Lesser and greater horn
body
Epiglottis
Elastic cartilage
Covered by mucous membrane
Serves as a diverter over the aditus, during swallowing.
Thyroid
Left and right palates
Adams apple in front
Superior and inferior horns
Inferior horn forms joint with cricoid
Thyrohyoid membrane
Cricoid
Broader posterior than anterior
Articulates with both thyroid and small arytenoids
Cricothyroid membrane (conus elasticus)
For relief of respiratory obstruction, it may be pierced (conicotomy)
Arytenoids (2)
Pyramidal shaped (apex + base)
JOINTS

o

o


o

o


o

o

o

Cricothyroid joint
Articulation:
Inferior horn of thyroid – articulating surfaces of cricoid
Ligament function:
Median cricothyroid ligament; anterior/thickened part of cricothyroid
membrane.
Movement – Elevation and depression
Muscles:
Cricothyroid muscle (only laryngeal muscle supplied by the external
laryngeal nerve (rather than the recurrent laryngeal nerve)
Movement:
Tilting the thyroid forward which tenses the vocal cords.
Cricoarytenoid joint
Articulation:
Articulating surfaces of cricoid – base of arytenoids.
Muscles:
Posterior & Lateral cricoarytenoid muscles
Movements:
Abduction & Adduction (intramembranous part) of vocal cords.
Page |4

Cricotracheal joint
Cricoid - 1st tracheal ring by the cricotracheal ligament.
o
3 Cavity and muscles of the larynx
CAVITY

o




o
o
o
o

o

o
o
Inlet (Laryngeal Aditus)
Borders:
Epiglottis
Aryepiglottic folds having cuneiform and corniculate cartilages
Interarytenoid notch
Vestibule
4-5cm
Vestibular/Ventricular/false vocal -folds
Laryngeal ventricles
Vocal fold (Stratified squamos non-keratinized epithelium)
Rima glottidis (Glottis)
Opening between the two vocal folds
Subglottic cavity
Found just under the rima glottidis
Pseudostratified columnar ciliated epithelium
MUSCLES


Extrinsic muscle innervated by external laryngeal nerve
Intrinsic muscles innervated by the recurrent laryngeal nerve

o



o


o


o
Extrinsic :
Cricothyroid:
O&I: Arch of cricoid cartilage  lamina of the thyroid cartilage, having
straight fibers and oblique fibers.
Function: Pulls the two cartilages closer by tilting the thyroid forward.
This tenses the vocal cord.
Intrinsic:
Posterior cricoarytenoid:
O&I: Posterior surface of cricoid lamina  muscular process of
arytenoids.
Function: Abducts the vocal cord by outward rotation of the arytenoids.
Lateral cricoarytenoid:
O&I: Lateral surface of arch of cricoids  muscular process of
arytenoids:
Function: Adducts vocal cord (intramembranous part) by inward rotation
of the arytenoids.
Interarytenoid (Transverse & Oblique)
Page |5


o


o


o

Transverse adducts vocal cord (intercartilagenous part).
Oblique continue to the epiglottis making aryepiglottic folds and may
narrow the aditus.
Vocalis
O&I: Posterior surface of thyroid lamina  vocal process of arytenoids.
Function: Relaxes the ligament. (Fine regulators)
Thyroarytenoid
O&I: Inner surface of thyroid cartilagemuscular process and outer
surface of arytenoids.
Function: Decreases tension on vocal fold (antagonistic to extrinsic
muscle).
Thyroarytenoid (thyroepiglottic part)
Function: Widens vestibule and laryngeal aditus.
Other muscles influencing movement of the larynx:


Depression: Infrahyoid muscle
Elevation: Stylopharyngeal, Digastric, Mylohyoid & Geniohyoid muscle
4 The function, innervation and lymphatic drainage of the larynx
Larynx is an organ of voice production, and the part of the respiratory tract between the pharynx and
trachea
FUNCTION
The intermittent release of expired air between the adducted vocal folds results in their vibration
and the production of sound. The frequency of the voice is determined by changes in the length and
tension of the vocal ligaments. The quality of the voice depends on the resonators above the larynx;
pharynx, mouth and paranasal sinuses. The frequency is controlled by the intrinsic muscles of larynx,
and the quality is determined by the muscles of the soft palate, tongue, floor of mouth, cheeks, lips
and jaws.
Movement
Muscles
Function
Abduction
pos. cricoarytenoid
loudness (increased air)
Adduction
lat. cricoarytenoid
loudness (decreased air)
Trv. Arytenoid
Shortening/relaxation
Thyroarytenoid
Degree of vibration (decreased tension)
Vocalis
Lengthening/tensing
Cricothyroid
Degree of vibration
Page |6
INNERVATION OF THE LARYNX

o
o

o
o
Sensory
Above vocal fold:
Vagus  Sup. Laryngeal nerve  int.
laryngeal nerve
Below vocal fold:
Vagus  recurrent laryngeal nerve
Motor
Intrinsic muscles (all but cricothyroid):
vagus  Recurrent
laryngeal nerve
Extrinsic muscles (only cricothyroid):
vagus  sup. Laryngeal 
ext. laryngeal
LYMPHATIC DRAINAGE
The laryngeal lymph nodes are situated on the cricothyroid ligament; some are found in front of the
thyrohyoid membrane. They receive lymph from adjacent structures, including the thyroid gland.
Draining into deep cervical lymph nodes  jugular trunk  thoracic duct/right lymph duct.
5 The oral cavity (except the teeth). The palate and the floor of the oral cavity
THE ORAL CAVITY




Inlet: Rima Oris
o Surrounded by upper and lower lips
o The lips are connected to the gums by frenulum of upper and lower lips.
Vestibule:
o Anterior
Lips
o Posterior
Teeth and gums
o Lateral
Cheek, + buccinator muscle
Oral cavity proper
o Superior
Hard and soft palate
o Inferior
Tongue & Mylohoid muscle
o Lateral
Teeth
Outlet: Oropharyngeal isthmus
o Lateral
Palatoglossal and palatopharyngeal arches
o Superior
Uvula, soft palate
o Inferior
Root of tongue, terminal sulcus
HARD PALATE
Anterior bony part of the palate, consisting of:


Horizontal plate of palatine bone
Palatine process of maxilla
Page |7

It is covered by mucous membrane
Canals:



Greater palatine foramen
o Maxillary nerve  pterygopalatine ganglion  greater palatine nerve
 Supplies the mucosa and glands of the hard palate and anterior part of soft
palate
Lesser palatine foramen
o Maxillary nerve  pterygopalatine ganglion  lesser palatine nerve
 Supplies the mucosa and glands of the soft palate and uvula
 Contain postsynaptic parasympathetic and sensory fibers of the maxilla
Incisive canal
o Pterygopalatine ganglion  nasopalatine nerve
SOFT PALATE
Posterior muscular part of the palate; forming an incomplete septum between the mouth and
oropharynx & between the oropharynx and nasopharynx
Muscles inserting into it:


Levator veli palatini muscle
o Origin
 cartilage of auditory tube
o Function
 Elevates the soft palate during swallowing and yawning
o Nerve supply
 Vagus nerve
Tensor veli palatini muscle
o Origin
 Medial pterygoid plate
o Function
 Tenses the soft palate during swallowing and yawning.
 Equalize pressure of middle ear.
o Nerve supply
 Mandibular nerve
Muscles originating from soft palate:
Palatoglossal muscle: Forms anterior arch of the tonsillar fossa
Palatopharyngeal muscle: Forms the posterior arch of tonsillar fossa
FLOOR OF THE ORAL CAVITY
Page |8
Diaphragm oris




Genioglossus
o O&I: Superior part of mental spine – Dorsum of tongue
o Hypoglossal nerve (CXII)
o Protrude & depress the tongue
Geniohyoid:
o O&I: Mental spine – body of hyoid bone
o Hypoglossal nerve (CXII)
o Draws hyoid forward or depresses jaw when hyoid is fixed
Mylohyoid
o O&I: Mylohyoid line of mandible – converge and unite, attaches to a median fibrous
raphe and inserts into hyoid
o Mylohyoid branch from mandibular nerve
o Elevates floor of mouth and the tongue
Digastric
o O&I: Anterior belly from the digastrics fossa of mandible & Posterior belly from
mastoid notch of the temporal bone – Greater horn of hyoid bone
o Posterior belly – facial nerve & anterior belly – mylohyoid branch of mandibular nerve
o Elevates the hyoid bone, helps the lateral pterygoid muscle to open mouth
6 The Tongue
The tongue is a muscular organ with muscle fibers in three directions, horizontal, longitudinal and
vertical, covered by mucous membrane: Root (1/3), Body (2/3) and an apex.
It is an organ of taste. Most of the tongue is covered in taste buds. The tongue assists in forming the
sounds of speech. It is sensitive and kept moist by saliva, richly supplied with nerves and blood
vessels to help it be moved.
Papillae and taste buds

Four types of papillae:
o filiform (thread-shape)
o fungiform (mushroom-shape)
o foliate (leaf-shape)
o Circumvallate (ringed-circle).
 All papillae except the filiform have taste buds on their surface. The circumvallate are the
largest of the papillae. There are 8 to 14 circumvallate papillae arranged in a V-shape in front
of the sulcus terminalis, creating a border between the oral and pharyngeal parts of the
tongue.
The upper side of the posterior tongue (pharyngeal part) has no visible taste buds, but it is bumpy
because of the lymphatic nodules lying underneath. These follicles are known as the lingual tonsil.
Page |9
The human tongue can detect four basic taste components, sweet, sour, salty and bitter.
The tongue is the strongest muscle in the human body proportional to size.
NERVE INNERVATIONS



Motor
o Hypoglossal nerve for both extrinsic and intrinsic muscles
General sensory
o Anterior 2/3: lingual nerve
o Posterior 1/3: Glossopharyngeal nerve
Taste
o Anterior 2/3: Chorda tympani from facial nerve (VII)
o Posterior 1/3: Glossopharyngeal nerve
MUSCLES


Intrinsic
o Superior & Inferior longitudinal:
Rolls tongue up and down
o Transverse:
Makes the tongue more narrow and thick
o Vertical:
Flattens and widens tongue
Extrinsic
o Genioglossus
 From mandible to the lingual fascia
 It depresses and protrudes the tongue
o Hyoglossus
 From body and greater horn of hyoid bone to the side of the tongue
 Depresses and retracts tongue to the floor of the mouth
o Styloglossus
 From styloid process to the tongue
 Retracts and draws it upwards during swallowing
o Palatoglossus
 From oral surface of soft palate to the tongue
 Forms anterior arch of tonsillar fossa
 It draw tongue backwards and upwards
 Innervated by Accessory nerve (IX) via the Vagus (X)
BLOOD SUPPLY



Greater palatine artery  maxillary artery
o Supplies gum and mucous membrane of the hard palate
Lingual artery  external carotid artery
o Floor of mouth and extrinsic muscles of tongue
Descending palatine artery  maxillary artery
o Soft palate, gums, bones and mucous membrane of hard palate
P a g e | 10

Facial artery
o Ascending palatine, tonsillar branch, inferior & superior labial
 Tonsils and soft palate
7 Description of the teeth, their types, blood supply and innervations
GENERAL DESCRIPTION
The teeth posses a:



Crown covered by enamel
Neck, where the gingival connects to it
Root
They have four surfaces:




Masticatory
Buccal
Lingual
Contact, mesial and distal
When describing the teeth, we consider them in four quadrants
MILK TEETH
20 total. 5 teeth in each quadrant



2 incisors
1 canine
2 molar
The teeth erupt in average 6-8 months, starting with the medial incisors. The exchange for
permanent teeth starts in average 6 years.
PERMANENT TEETH
32 total. 8 teeth in each quadrant

o
o
o
o

o
o

2 incisors
Upper ones has a wider crown
Labial and lingual surfaces are flattened
Lingual surface is excavated
Have a single root, the upper is more rounded
1 canine
Longest root of all teeth
Its crown is columnar shaped
2 premolar
P a g e | 11
o
o
Its crown has two tubercles, 1 large buccal and 1 lingual
It has one root, except, upper first which is divided to two roots
3 molar
Lower: 2 roots; 1 mesial & 1 distal
Upper: 3 roots; 2 buccal & 1 lingual
Lower: 1st has 5 tubercles, the others usually have 4, 2-3 buccal and 2

o
o
o
lingual
o
Upper: 2 first have 4 tubercles, 2 buccal & 2 lingual. 3rd molar (wisdom)
has 3 tubercles
BLOOD SUPPLY





Upper teeth – Maxillary artery  Superior alveolar artery
Anterior/
Middle/
Posterior alveolar branches
Lower teeth – Maxillary artery  Inferior alveolar artery
NERVE SUPPLY

Upper teeth – Maxillary nerve (V2)  infraorbital nerve  alveolar
branches
o




o
In individual nerve canals
Anterior branch from infraorbital
Middle branch from infraorbital
Posterior sup. Alveolar branch comes directly from maxillary nerve
Lower teeth – Mandibular nerve (V3)  inferior alveolar nerve
In a common canal
CLINICAL IMPORTANCE
When giving anesthetics the upper teeth may be individual affected, but the lower teeth must be
anesthetized together, the needle is set at the opening of the mandibular foramen.
8 Lymphatic drainage of the oral and nasal cavities
Waldeyer's tonsillar ring is an anatomical term describing the lymphoid tissue ring located in the
nasopharynx
The ring consists of (superior to inferior):

o
o
o

Pharyngeal tonsil (adenoids)
Roof of nasopharynx
Function and size decrease with age
Hypertrophy may obstruct airways
Tubal tonsils
P a g e | 12
o
Pharyngeal recess behind opening of auditory tube
Palatine tonsils
In tonsillar fossa between Palatoglossal & palatopharyngeal arch
Drain to upper deep cervical lymph nodes
Lingual tonsils
Dorsal surface at the base of the tongue in posterior region

o
o

o
LYMPHATIC DRAINAGE OF THE ORAL AND NASAL CAVITIES
(According to paper given by Professor Kovacs which was copied and distributed within 2nd grp)
1.
i.
ii.
iii.
iv.
2.
i.
ii.
iii.
iv.
3.
i.
ii.
iii.
iv.
v.
Submental lymph nodes. Primary lymph nodes for:
Lower lip
Lower incisor
Tip of the tongue
Anterior part of the sublingual region
Submandibular lymph nodes. Primary lymph nodes for:
Middle part of tongue and sublingual region
Soft & hard palate
Upper & lower teeth
a. Except lower incisor & lower wisdom teeth
Nasal vestibule
Deep cervical lymph nodes. Primary lymph nodes for:
Root of tongue
Palatine tonsils
Lower wisdom teeth
Nasal cavity proper
Also secondary lymph nodes for submental & submandibular lymph
nodes
Lymph filtered by deep cervical lymph nodes is collected by the right/left jugular trunk  right/left
venous angle.
9 Cavity and parts of the pharynx
Pharynx is a common tube for food and air, 7-7.5cm long. It is lined by mucous membrane, and it has
posterior and lateral walls. It has no anterior wall because, it communicates with the nasal, oral
cavity, and larynx.
The muscles forming the lateral and the posterior wall arise from the pterygoid process of the
sphenoidal bone.
Part of the pharynx (sup  inf)
P a g e | 13

Pharyngobasilar fascia
 O&I: Basilar part of the occipital bone & superior constrictor muscle.
 Superior pharyngeal constrictor muscle.

It has four origins: 1 pterygopharyngeal part (pterygoid process); 2
buccopharyngeal part (pterygomandibular raphe ); 3 mylopharyngeal part
(mylohyoid line); 4 glossopharyngeal part (root of the tongue).
 Middle pharyngeal constrictor muscle which overlaps the superior.
 It arises from the greater and lesser horns of the hyoid bone. The borderline
between the superior and the middle pharyngeal constrictor muscle is
marked by the stylopharyngeus muscle (entering the pharynx between
them). The glossopharyngeal nerve runs along the stylopharyngeus muscle.
 Inferior pharyngeal constrictor muscle (two parts):
 thyropharyngeal and cricopharyngeal parts (according to their origins,
thyroid and cricoid cartilages). The inferior constrictor overlaps the middle
constrictor muscle.

All three constrictors are inserted to the PHARYNGEAL RAPHE, a connective
tissue septum on the posterior wall of the pharynx.
CAVITY
The cavity of the pharynx has three parts: Nasopharynx (epipharynx), Oropharynx (mesopharynx),
and Laryngopharynx (hypopharynx).
NASOPHARYNX (EPIPHARYNX) – Upper 1/3






It starts from the roof of the pharynx, which is formed by the basilar part of the occipital
bone, until the soft palate.
Anteriorly, it communicates with the nasal cavity through the choanae.
Inferiorely, it communicates with the oropharynx.
Superiorly, it communicates with the roof of the pharynx,
Laterally with the tympanic cavity through the auditory tube.
Structures:
o
Opening for auditory tube
o
Torus tubarius, formed by the cartilaginous part of the auditory tube.
o
Behind and a little above this tubal elevation, the pharyngeal recess is
where the tubal tonsils are located. The fornix of the pharynx is between the
superior and posterior walls of the pharynx, and in the fornix, we have the
pharyngeal tonsils (adenoids).
 If enlarged, it can obstruct airway.
OROPHARYNX (MESOPHARYNX) – Middle 1/3


From the soft palate to superior part of the epiglottis.
It communicates with the oral cavity through the oropharyngeal isthmus/isthmus faucium.
P a g e | 14
o


Its borders are the palatoglossal and palatopharyngeal arches (laterally),
Root of tongue (inferior); and Uvula (superior).
Tonsilar fossa, where the palatine tonsils are located. Supratonsillar fossa where fish bone
may get stuck.
Epiglottic vallecula: between the root of the tongue and the epiglottis. It is bordered by the
median glossoepiglottic fold and the lateral glossoepiglottic folds.
o
Another fish bone site
LARYNGOPHARYNX (HYPOPHARYNX) – Lower 1/3



From the epiglottis until the esophagus.
Communicates with larynx via laryngeal aditus (inlet of the larynx)
o
Bordered by: 1 epiglottis (in front), 2 aryepiglottic fold (laterally), 3
interarytenoid notch, 4 tuberculum cuneiforme + corniculatum (not important).
The food from the oral cavity passes through the piriform recess which is in the two sides of
the epiglottis, then it goes to the esophagus.
10 Muscles and wall of the pharynx
Pharynx is a common tube for food and air, 7-7.5cm long. It is lined by mucous membrane.
Layers:



Mucous and submucous layers
Fibrous layer
Muscular layer
MUSCLES
Constrictor muscles:



Superior pharyngeal constrictor muscle.

It has four origins: 1 pterygopharyngeal part (pterygoid process); 2
buccopharyngeal part (pterygomandibular raphe ); 3 mylopharyngeal part
(mylohyoid line); 4 glossopharyngeal part (root of the tongue).
Middle pharyngeal constrictor muscle which overlaps the superior.
 From greater and lesser horns of hyoid bone.
 The borderline between the superior and the middle pharyngeal constrictor
muscle is marked by the stylopharyngeus muscle (entering the pharynx
between them).
 The glossopharyngeal nerve runs along the stylopharyngeus muscle.
Inferior pharyngeal constrictor muscle (two parts):
 thyropharyngeal and cricopharyngeal parts (according to their origins,
thyroid and cricoid cartilages).
P a g e | 15

The inferior constrictor overlaps the middle constrictor muscle.

All three constrictors are inserted to the PHARYNGEAL RAPHE, a connective
tissue septum on the posterior wall of the pharynx.
Levator muscles of pharynx:



Stylopharyngeal muscle (IX)
o
From styloid process to sup. & inf. Pharyngeal constrictor muscles.
o
Elevates pharynx towards base of skull.
Salpingopharyngeal muscle (IX+X)
o
From cartilage of auditory tube, soft palate and pterygoid hamulus.
o
Opens auditory tube during swallowing and yawning
o
inside the salpingopharyngeal fold
Palatopharyngeal muscle (X)
o
Pulls pharynx upward and lowers soft palate
o
Palatopharyngeal arch, which is posterior to the palatine tonsils
INNERVATION:

The muscles of the pharynx and the mucous membrane are innervated by the
glossopharyngeal nerve (upper part) and the vagus nerve (lower part). The pharyngeal
plexus is formed by the two nerves and by some sympathetic fibers of the sympathetic trunk
(cervical part).
BLOOD SUPPLY:

The main artery that supplies the pharynx is the ascending pharyngeal artery (from the
external carotid).
11 Para & retropharyngeal spaces
PARAPHARYNGEAL SPACE
Lateral to the pharynx, we have the parapharyngeal spaces. It’s also called the peritonsilar space
because only the pharyngeal wall separates it from palatine tonsils, and the lymphatic vessels of the
palatine tonsils going through this space into the deep cervical lymph nodes.
Internal carotid artery sometimes forms a loop which is close to the pharyngeal wall. If you operate
on the palatine tonsil, be careful not to cut too deep because we may cut the pharyngeal wall and
the internal carotid artery.
Borders:





Medial wall: pharynx
Lateral wall: medial pterygoid muscle, ramus mandibulae, and masseter muscle,
Anterior: Bichat's fat pad; encapsulated mass of fat in the cheek. Especially marked in infants
Posterior: styloid muscles, digastric, and sternocleidomastoid muscles
Inferior: submandibular triangle.
P a g e | 16
Structures:







Glossopharyngeal nerve (CN IX)
 Most anterior structure
Vagus nerve (CN X)
 Lying behind the carotid arteries and next to CNIX
Accessory nerve (CN XI)
 Most posterior nerve, attached to sternocleidomastoid muscle
Hypoglossal nerve (CN XII)
 Turns anterior and lies superior to mylohyoid muscle
Internal jugular vein
 Formed as a continuation of the sigmoid sinus
Superior cervical ganglion of the sympathetic trunk,
Internal carotid artery.
RETROPHARYNGEAL SPACE
It is located behind the pharynx; Any infection on the posterior wall of the pharynx could be spread
to the retropharyngeal space. From this space,the thoracic cavity (posterior mediastinum) is
accessible.
Borders:





Anterior
Posterior
Lateral
Inferiorly
Superior
Pos. wall of pharynx; buccopharyngeal fascia
prevertebral fascia
Carotid sheath and muscles of the styloid process
Posterior mediastinum
Base of skull
There are no structures in the retropharyngeal space, but it is rich in lymphatic vessels.
12 Surface projections of the pleura, lungs & the heart.cardiac dullnesses.
Points of auscultation of the valves of the heart
The lungs are surrounded by two membranes of the pleurae. Parietal pleura & Visceral pleura.
Between the two is a thin space, pleural cavity. It is filled with pleural fluid, a serous fluid produced
by the pleura.
Parietal pleura has three main parts: a) Costal (or sternocostal), b) Diaphragmatic, and c) Mediastinal



Phrenicocostal recess: between the diaphragmatic and costal layers of the parietal pleura.
Phrenicomediastinal recess: between the diaphragmatic and mediastinal layers.
Costomediastinal recess: between the costal and mediastinal layers.
The phrenicocostal recess is the most important because:
P a g e | 17
CLINICAL: It is the lowest point of the pleural cavity, so the fluid inside the cavity is collected there.
We can drain this fluid and examine the quality (serous, blood, etc.)
PHYSIOLOGICAL: The lower margin of the lung descends into this sinus during inspiration. The
inferior border of the lung descends into this sinus.
SURFACE PROJECTIONS OF THE PLEURA










Superior:
Pleural dome, 3cm above the first rib
Middle:
The two runs toward each other, the closest at the level of the 2nd rib
Parasternal:
6th rib
Medioclavicular line: 7th rib
Ant. Axillary line:
8th rib
Mid. Axillary line:
9th rib
Pos. Axillary line:
10th rib
Scapular line:
11th rib
Paravertebral line: 12th rib
Cardiac notch:
left 4-6th rib, into the medioclavicular line
SURFACE PROJECTIONS OF THE LUNGS



The lungs cover the heart except at one part, where the insisura cardiaca of the left lung is.
The apex of the lung is above the clavicle, approximately 1-3 cm above the 1st rib.
The medial borders of the lungs run toward each other.
nd





o The closest point is at the level of the 2 ribs. At this point, the border of the right
lung is in the midline of the sternum, and the medial border of the left lung is at the
left margin of the sternum.
Left lung. From the 2nd rib, the medial border descends until the 4th rib, where the left lung
makes a notch between the 4th and 6th ribs, called the cardiac notch.
The medial border of the right lung descends straight down until the 6th rib. So, a part of the
heart is not covered by lung (between the 4th and 6th ribs, left side).
The inferior border of the lung starts from the 6th rib (upper border) and descends a little.
Medioclavicular line, it crosses the inferior border of the 6th rib.
Anterior axillary line, level = 7th rib. At the middle axillary line, it is at the level of the 8th rib.
At the posterior axillary line, it is at the level of the 9th rib. At the scapular line, it is at the
level of the 10th rib. At the vertebral column, it is at the level of the 11th rib (10th vertebra).
SURFACE PROJECTIONS OF THE HEART




Superior border – roots of great vessels
o 2nd left costal cartilage, 1,3cm from the sternum
Right superior - entrance of the superior vena cava
o 2nd intercostal space, 1cm to the right
Right inferior – Right inferior end of coronary sulcus
o 1cm right to 6th sternocostal joint
Right border - right atrium
o From sternal junction of 3rd rib to sterna junction of 6th in parallel to the sternum
P a g e | 18




Left superior – left superior end of coronary sulcus
o 2nd intercostals space, 3cm left of sternum
Left inferior – Apex of heart
o 5th intercostals space, left 9cm
Left border – left ventricle
o A straight line from a point 3cm left of 3rd sternocostal joint and down to the apex
Inferior border – right ventricle & apical part of left ventricle
o A line from 6th sternocostal joint to apex
ABSOLUTE AND RELATIVE DULLNESS OF THE HEART:

Percussion of the chest above the lungs produces a sound, resulting from resonance within
the air-filled lung (1st and 2nd intercostal spaces).
 Third intercostal space
o
Dull resonance due to fluid-filled heart being behind the lung.
o
Sound changes to relative dullness.
 Fourth intercostal space (near the sternum),
o
More dull because the lung does not cover the heart. The sound reaches
only the blood-filled heart, and therefore no resonance. This sound is called
absolute dullness.
o
The region of absolute dullness is at the level of the 4th -5th intercostal
spaces (left side).
o
The size of the absolute dullness area gives the size of the cardiac notch.

Relative dullness marks the upper border of the heart. If you hear the
relative dullness at the 2nd intercostal space instead of the 3rd, it means that the heart is
enlarged superiorly.
For the right border, place your finger parallel to the expected border, and you will hear the dullness
at the right side of the sternum. If you hear the dullness farther from the right side of the sternum, it
means that the heart is enlarged to the right.
For the left border, place your finger parallel to the expected border. Normally, you can find it left of
the medioclavicular line. If the heart is enlarged, it will exceed the medioclavicular line to the left.
PROJECTIONS OF OSTIA ON THE CHEST WALL & Points of Auscultation



Ostium of the Pulmonary Trunk:
o
Left side, at the level of the third sternocostal joint.
 Auscultation: right 2nd intercostal space next to sternum
Ostium of the Aorta:
o
Right below the third rib, behind the sternum.
 Auscultation: Left 2nd intercostal space next to sternum
Ostium Bicuspid/Mitral:
o
Level of the 4th sternocostal joint, left side.
 Auscultation: Left 5th intercostal space 9cm left of sternum
P a g e | 19




Ostium Tricuspid:
o
Level of the 5th sternocostal joint, right side
 Auscultation: Sternal junction of right 5th rib
Ostium of the pulmonary trunk (most superficial)
The deepest is the left venous ostium.
Aortic valve will be auscultated at 2nd intercostal space, 2 cm right to the sternum.
o
The aorta comes from the left ventricle, but we hear it on the right side
because it crosses the pulmonary trunk (embryology).
13 The mediastinum. Anterior mediastinum. Intercostal topography
The mediastinum is the middle part of the thoracic cavity which is bordered laterally by the mediastinal pleura, anteriorly by the sternum, and posteriorly by the vertebral column (thoracic part).
Separated into anterior and the posterior mediastinum, and the borderline between these two is the
hilus and the pulmonary ligament. The anterior mediastinum is also divided into two parts: the
cardiac, and the supracardiac mediastinum, which contain the heart, thymus, the great vessels of the
heart, trachea, and lymph nodes of the central chest.
o
o
Anterior to the hilus & pulmonary ligament, the anterior mediastinum;
Posterior to the hilus, the posterior mediastinum.
SUPRACARDIAC MEDIASTINUM
The supracardiac mediastinum has four layers:




Adipose thymus (just behind the sternum)
Layer of main veins (tributaries of the superior vena cava)
o left brachiocephalic vein (oblique and long) approx. 10-12 cm.
o right brachiocephalic vein (straight and short) approx. 2-3 cm.
 these drain into the superior vena cava
Into the left brachiocephalic vein, drains the inferior thyroid vein (from the thyroid gland).
Main arteries (branches of the aortic arch):
o brachiocephalic trunk
 right common carotid & right subclavian
o left common carotid artery
o left subclavian artery
“Between the layers of the main arteries and main veins, the vagus nerve and phrenic nerve enter
the thoracic cavity”
14 The pleura and the pericardium
P a g e | 20
THE PLEURA
Serous membrane enveloping the lungs and lining the walls of the pleural cavity


Visceral pleura
Parietal pleura
The two parts of the pleura meets at the roots of the lungs where the pulmonary arteries and veins,
and the bronchi enter the lungs. An inferior elongation forms the pulmonary ligament. The cavity
between the two pleura is filled with serous fluid. The lungs and the cavity are not a perfect match
and recesses are found.



Phrenicocostal/costodiaphragmatic
o If fluid enters the cavity, it can be drained from this recess
Phrenicomediastinal
Costomediastinal
THE PERICARDIUM
Fibrous membrane, covering the heart and beginning of the great vessels. It is a closed sac having
two layers; Visceral layer & Parietal layer.
Reflections of the parietal layer onto the visceral layer:




Arterious reflection
o At the division of the pulmonary trunk
o The ascending aorta and pulmonary trunk remains inside
Venous reflection
o Superior vena cava, below the entrance of zygomatic vein.
o Inferior vena cava, phrenic entrance, therefore, entire inferior vena cava is inside
o Pulmonary veins (ca 1-2cm are inside the pericardiac cavity). These reflections form
a letter "T" which is called Sappey's T.
Transverse sinus
o Formed during heart tube folding
 venous end migrates upward and behind the arterious end, and if forms a
"U" shaped tube
o Separates the ascending aorta and the pulmonary trunk from the superior vena cava
Oblique sinus
o A blind recess posterior to the base of the heart
o Between left and right pulmonary veins
15 Atria of the Heart
The portion of the blood that receives blood from the systemic & pulmonary circulation
RIGHT ATRIUM
Right atrium (having right border), forms the anterior surface of the heart.
P a g e | 21





Two main parts: Auricle & Atrium proper
Separated by sulcus terminalis (outside) and crista terminalis (inside). The crista terminalis
develops from the septum spurium (see embryology).
Pectinate muscles only inside the auricle.
The atrium proper, has smooth inner surface (no pectinate muscles)
The main part of the atrium proper is the sinus venarum cavarum (receives the superior and
inferior venae cavae).
Openings of right atrium



Superior vena cava
o No valves
Inferior vena cava
o Eustachian valve (non-functional).
 In fetal life this valve guided the blood from the inferior vena cava through
the oval foramen to the left atrium. “When pointing, note the direction”
Coronary Sinus
o Thebesian valve
o Drains the blood from the heart wall. “When pointing, note the direction”
Fetal remnant:

Oval fossa (from oval foramen)
o Surrounded by limbus fossae ovalis
o Patent foramen ovale (Atrial septal defect)
 When the foramen doesn’t entirely close
Pacemaker of the heart, called the sinoatrial node or the sinus node. This node is located in the
upper end of the terminal sulcus at the inlet of the superior vena cava
LEFT ATRIUM


The left atrium is located on the posterior surface (or mediastinal) of the heart, and has a
close relation with the esophagus.
o During esophagoscopy (or gastroscopy) it is possible to accidently pierce the wall of
the esophagus, risking injuring the left atrium of the heart.
Two parts: the AURICLE and the ATRIUM PROPER.
o The auricle has the pectinate muscles.
 Only part of the left atrium which is visible at the left margin of the heart.
o The smooth part is the atrium proper.
 The atrium proper receives oxygenated blood from the 4 pulmonary veins
(no valves) on the posterior surface
16 Orifices of the heart. The valves and their function
Atrioventricular orifices:
P a g e | 22


Right
o
Tricuspid valve (ant, pos & septal cusps)
 Attached to chorda tendinae and further papillary muscle
 Regulates flow from atrium to ventricle
 Closed during systole & Opened during diastole
o
Bicuspid/Mitral valve (ant & pos cusps)
 See above
Left
Venous openings:



Superior vena cava
o No valves
Inferior vena cava
o Eustachian valve, located anterior inferior
Coronary orifice
o Thebesian valve
Pulmonary orifice:


Pulmonary veins (4)
o Open into left atrium, draining oxygenated blood from lungs
Pulmonary trunk
o Divide into right/left pulmonary artery and run from right ventricle to lungs.
o Semilunar valve with 3 semilunar shaped cusps (ant, right pos & left pos)
Aortic orifice


From left ventricle into the aorta
Aortic semilunar valve with posterior, anterior right & anterior left cusps
VALVES
There are cuspid and semilunar valves


Cuspid valves are composed of mesothelium on both surfaces.
o Between the mesothelium layers, we have fibrous cutaneous tissue.
o These valves arise from the annulus fibrosus, the skeleton of the heart.
Semilunar valves
o Function of the nodules is to close the orifice.
o There are 6 lunulae and 3 nodules in one valve.
o Dense part &flexid part.
 The dense part is the peripheral part (arising from the fibrous ring), and the
flexid part is the central part (loose).
Above the valve of the aorta, there is a dilated part which is called the aortic sinus. This aortic sinus
has the orifice of the coronary arteries (right and left).
P a g e | 23
FIBROUS RINGS:
The muscles of the atria and ventricles arise from this fibrous ring, and it has the orifices. Between
the left and right venous ostia and the aorta there is a right fibrous trigone. The left one is between
the aorta and the left venous ostium. Through the right fibrous trigone, we have the His bundle.
From the atrium, the impulse goes through the fibrous ring into the ventricle.
17 Ventricles of the heart. Radiogram of the heart
Generally, the ventricles have three muscular layers and the atria have two muscular layers;
therefore, the ventricles are thicker than the atria. The papillary muscles form the inner layer of the
ventricle together with the bridges and ridges or the trabeculae carneae (Rathke's bundles).


The border between atrium and ventricle is the coronary sulcus.
The border between the ventricles are the anterior interventricular groove.
RIGHT VENTRICLE
V-shaped


In flowing part
o The portion from which blood flows from the atrium to the ventricle via tricuspid.
The out flowing part forms a cone on the outer surface which is called the conus arteriosus.
From the conus, the pulmonary trunk starts.
Crista supraventricularis separates the inflowing and out flowing parts of the ventricles from each
other.
 The largest papillary muscle has a muscular cord from the interventricular septum. This cord is
called Moderator band of septomarginal trabecula
LEFT VENTRICLE




Forms the left surface, diaphragmatic surface and apex of the heart.
Bicuspid valve attached to the anterior and posterior papillary muscle by chorda tendinae.
Thicker wall than that of the right ventricle (about 1-1.5cm), and the interventricular septum
is also formed by this thick wall of the ventricle.
o In cross section, the left ventricle is round.
Aortic orifice (the origin of the aorta).
RADIOGRAM
The X-ray of the heart has two arches on the right side and four arches on the left side.
P a g e | 24




The superior arch on the right side is formed by the superior vena cava and the ascending
aorta.
The inferior arch on the right side is formed by the right atrium.
On the left side, the arches are formed by 1 aortic arch, 2 pulmonary trunk, 3 left auricle, and 4
left ventricle.
Inferior border is not visible because below, we have the liver, and the density of the heart
and liver is the same.
(Netter plate 209)
18 Blood supply of the heart
ARTERIES:
The coronary arteries arise from the sinus (ascending) aorta, which is the first dilated portion of the
aorta just above the valves. The coronary arteries and their major branches are distributed over the
surface of the heart, lying within subepicardial connective tissue
Right coronary artery:





Runs forward between the pulmonary trunk and the right auricle
It descends in the posterior interventricular groove
It anastomose with the left one coronary artery
Branches supplies the right atrium, 1cm into the right ventricle and posterior part of
interventricular septum (by posterior septal artery)
Branches:
o Right conus artery
o Anterior ventricular branch
o Posterior ventricular branch
o Atrial branch
o S-A nodal branch
Left coronary artery:



It runs forward between the pulmonary trunk and the left auricle
It divides into circumflex branch and anterior interventricular branch
o Anterior interventricular branch descends in anterior interventricular groove
Supplies major part of the heart:
 Left atrium and left ventricle
 Anterior part of Interventricular septum
 1cm or the right ventricular wall
VENOUS DRAINAGE OF THE HEART
P a g e | 25



Great cardiac vein
o Begins at apex and ascends in the anterior interventricular groove
o Runs with the anterior interventricular branch of the left coronary artery, then with
circumflex branch of the left coronary artery, and it enters the coronary sinus from
the left side
o Oblique/Marshal vein of left atrium joins great cardiac vein
Middle Cardiac vein
o Begins at apex and ascends in the posterior interventricular groove
o Runs together with the posterior interventricular branch of the right coronary artery
o Joins small cardiac vein before draining to coronary sinus on the right side
Small cardiac vein
o Right ventricle
o Runs with Right coronary artery
o Joins middle cardiac vein before draining to the coronary sinus.
Between the right and left ends, the coronary sinus opens into the right atrium of the heart.
In addition to these three veins, there are also tiny veins on the right ventricle (anterior surface)
called venae cordis anterioris. They cross the coronary sulcus to enter the right atrium directly.
There are also the tiny veins called venae cordis minimae (thebesian veins) from the atria which also
directly drain to the atria.
19 The structure of cardiac wall. The conducting system and innervation of the
heart
LAYERS OF THE HEART:
3 main layers:
A serous layer: epicardium (visceral layer is the pericardium).
A muscular layer: myocardium.
An inner layer: endocardium.


Epicardium
o Layered by mesothelium
o Connected to the muscle by a fibrous connective tissue which has fat
o The coronary artery and cardiac veins lie beneath this epicardium.
Myocardium
VENTRICLE
o
The external oblique
P a g e | 26

o
o
Starts from the right end of the coronary sulcus on the anterior surface and
descends toward the apex from right and superior to left and inferior.
 On the posterior surface, it starts from the left side to the right side.
 At the apex, these fibers meet each other and form a turn which is called
vortex cordis.
The middle circular layer
 Parallel to the coronary sulcus.
 This layer is missing on the apex, where there is only the vortex cordis.
The internal longitudinal layer
 The fibers turning inward and upward continue into the inner muscular layer
of the heart forming papillary muscle and trabeculae carneae.
ATRIUM
The muscle of the atrium is not so regular and it is thin (just two layers). The outer is longitudinal
and the inner is circular.
Around the inlet of the veins (sup & inf vena cava) the muscle fibers are regular arranged in circles
around the inlet of them.

Endocardium has 2 layers:
 Fibrous layer & epithelial (endothelial layer)
 Fibrous layer connects the endothelium (innermost layer) to
the myocardium
 The valves are also layered by endocardium, both inferior
and superior surfaces, and between these endothelial layers,
there is the fibrous layer.
CONDUCTING SYSTEM:




Sinoatrial node
o Natural pacemaker
o Situated at upper end of terminal sulcus, near the anterior margin of inlet superior
vena cava
o Impulses travel by intermodal pathways in right atrium towards Atrioventricular
node.
Atrioventricular node
o In interatrial septum below oval fossa and left to the orifice of coronary sinus
His bundle
o Pierces right fibrous trigone (entering ventricle)
o Divide into left and right tawara bundles moving in the interseptal surface.
 Right bundle is located inside the moderator band/septomarginal trabeculae
Purkinje Fibers
o Fibers from tawara bundles from interventricular septum runs upwards again along
inner ventricular wall.
INNERVATION OF THE HEART:
P a g e | 27
The heart is supplied by both sympathetic and parasympathetic fibers. These fibers reach the heart
in three plexuses called superior, middle, and inferior cardiac plexuses.
Sympathetic innervation:




Postganglionic fibers from the cervical and upper thoracic portions of the sympathetic trunk
The fibers reach the heart through superior, middle and inferior cardiac branches.
The fibers pass through and terminate on the sinoatrial and atrioventricular nodes
Stimulate increased heart rhythm, increased contraction force and dilation of the coronary
arteries.
Parasympathetic innervation:




Vagus nerve
Terminate by synapsing on neurons in the cardiac plexus.
Postganglionic fibers terminate on the sinoatrial, atrioventricular nodes and on the coronary
arteries.
Stimulate decreased heart rate, force and constriction of the coronary vessels.
20 The lungs, pulmonary roots, bronchopulmonary segments
THE LUNGS
Paired visceral organs occupying the pulmonary cavities of the thorax. They are the organs in which
respiration, gas exchange of blood happens. They are covered by pleura.
Right lung:




3 lobes (superior, middle & inferior)
impressions for the azygos vein (below and above the hilus) and also the superior vena cava.
Because the azygos vein drains into the superior vena cava, we also have the impressio
cardiaca pulmonis (impression for the heart).
Horizontal and oblique fissure
Inferior lobe is mainly behind the superior and inferior lobes
Left lung:



2 lobes (superior & inferior)
It has a wide impression called the aortic sulcus. It is made by the descending thoracic aorta
and the aortic arch. It also has the sulcus of the subclavian artery that is next to the apex.
Oblique fissure
Surface projections


The horizontal fissure follows the fourth rib.
The oblique starts from the horizontal fissure in the axillary line and crosses the 5th rib,
terminating at the 6th rib (at the 6th sternocostal joint).
P a g e | 28
PULMONARY ROOT
The site where the visceral and parietal pleura meet. A fold descends and forms the pulmonary
ligament. The pulmonary root consist of the structures passing through the hilum of the lung.
Structures:





Pulmonary artery
2 Pulmonary veins
Main/Principal bronci
Lymphnodes
Nerves
Structures in the lung:


From superior to inferior:
o Left lung (artery, bronchus, vein) - ABV
o Right lung (Bronchus, artery, vein) - BAV
From anterior to posterior:
o Vein, artery, bronchus (in both lungs)
BRONCOPULMONARY SEGMENTS
The segments are the morphological, functional, pathological, and surgical units of the lung. We can
remove one segment surgically if there is a disease or tumor






10 segments in each lung
o Right: three in the superior lobe, two in the middle, and five in the inferior lobe.
o Left: five in the superior lobe and five in the inferior
Pyramidal shaped
The apex of the pyramid is facing toward the hilus
At the apex of this pyramid, the segmental bronchus enters the segment together with the
segmental branch of the pulmonary artery.
Center of the segment is the bronchus tree and the pulmonary artery (next to each other).
Segments separated by connective tissue septa.
o Inside this septa are the pulmonary veins and lymph vessels running toward the
hilus.
Segment is composed of smaller units called lobules.



Pyramidal shape
One lobule belongs to one terminal bronchus which is branching inside the lobule forming
bronchioli.
The difference between bronchi and bronchioli-- no cartilage, no glands, but there is smooth
muscle.
P a g e | 29
On the surface of the lung, you can see small, approximately 1-2cm areas bordered by black color
(surrounded) that are the lobules. We can only see the base because the base is facing toward the
surface. The black area is pollution inside the connective tissue that separates the lobules from each
other.
Double circulation (functional and nutritive)
21 Posterior mediastinum
The mediastinum is the middle part of the thoracic cavity which is bordered by:





Laterally: mediastinal pleura
Anteriorly: sternum
Posteriorly: vertebral column (thoracic part).
Superiorly: Thoracic outlet & root of the neck
Inferiorly: The diaphragm
Anterior and the posterior mediastinum
Borderline = hilus & pulmonary ligament.
Structures:
o
o
o
o
o
esophagus
 25cm
 3 parts: Cervical, thoracic & small abdominal part (T11)
vagus nerve
 Right: vagus behind the esophagus. Left: vagus in front of the esophagus.
Descending aorta (thoracic part)
Thoracic duct
 Between azygos vein and thoracic aorta, in right pos. mediastinum.
 At the level of 4th thoracic vertebra, it turns left behind esophagus in front of
the vertebral column, to the left venous angle
 Before entering, it collects: left jugular trunk (left side, head and
neck), left subclavian trunk (drains the left upper limb), and left
bronchomediastinal trunk (drains the lung and the thoracic cavity
mediastinum, so the left part of the whole thoracic cavity).
 Arises from the CISTERNA CHYLI (in abdominal cavity behind aorta ,L1)
 Collects lymph from right/left lumbar trunks & intestinal trunk
 Drains 3/4 of the body
 Last ¼ of the body is drained by right lymphatic trunk having the
same 3 trunks (right)
 Runs through diaphragm behind aorta
Azygos & hemiazygos vein
 Azygos vein originate in abdominal cavity as ascending lumbar vein
 Collects segmental lumbar vein (drain posterior abdominal wall).
P a g e | 30

o
Via diaphragm with greater & lesser splanchnic nerves between medial and
intermediate crus.
 Collects intercostals vein in posterior mediastinum
 Drain thoracic wall), the bronchial veins from the lungs, the esophageal
veins, and the external vertebral venous plexus
 Only the intercostal veins are visible and dissectible
 Azygos vein receives the hemiazygos vein from the left side which collects
the same veins from the left side plus the accessory hemiazygos
Sympathetic trunk
 composed of 12 paravertebral ganglia
 interganglionic fibers
 1st thoracic – 3rd lumbar: Autonomic nervous system: Sympathetic neuron
cell bodies
 Sacral part contains parasympathetic neuron cell bodies
 White rami communicants:
 Preganglionic fibers with myelin sheath
 Originate from lateral horns of grey matter
 Contain synapses to neuron cell bodies within the ganglion that
further sends axon fibers to the periphery
 Grey rami communicants:
 Postganglionic fibers without myelin sheath
 Innervate glands & smooth muscles of vessels and skin(Arrestor
pile)
 Ventral root contains sympathetic motor and somatomotor fibers
 Dorsal root (sensory): Only sensory ganglions that has
pseudounipolar neuron cell bodies.
 Splanchnic nerves are formed by sympathetic fibers that run through
ganglia without synapsing.
 6-9th ganglia – greater splanchnic
 10-11th ganglia – lesser splanchnic
 Preganglionic fibers terminate in celiac ganglion where they
synapse: Their postganglionic fibers innervate:
 Blood vessels of viscera
 Smooth muscles of abdominal viscera
22 Lymphatic drainage of the thoracic wall and thoracic viscera

Thoracic duct
o Between azygos vein and thoracic aorta, in right pos. mediastinum.
o At the level of 4th thoracic vertebra, it turns left behind esophagus in front of the
vertebral column, to the left venous angle
 Before entering, it collects: left jugular trunk (left side, head and neck), 
left subclavian trunk (drains the left upper limb), and left
P a g e | 31
o
o
o


bronchomediastinal trunk (drains the lung and the thoracic cavity
mediastinum, so the left part of the whole thoracic cavity).
Arises from the CISTERNA CHYLI (in abdominal cavity behind aorta ,L1)
 Collects lymph from right/left lumbar trunks & intestinal trunk
Drains 3/4 of the body
Last ¼ of the body is drained by right lymphatic trunk having the same 3 trunks
(right):
 Right bronchomediastinal trunk (drains the lung and the thoracic cavity
mediastinum, so the right part of the whole thoracic cavity).
Primary lymph nodes?
Axillary lymph nodes?
o Drains lateral half of breast
o Investigated regularly as a part of the clinical investigation of breast cancer
23 The lymphatic system and lymphatic circulation. The main lymphatic trunks
LYMPHATIC SYSTEM
(See topic 22 for Main lymphatic trunks)
Network of lymphoid organs, lymph nodes, lymph ducts, and lymph vessels that produce and
transport lymph fluid from tissues to the circulatory system. The lymphatic system is a major
component of the immune system.

The lymphatic system has 3 functions:
o Removal of excess fluids from body tissues
o Absorption of fatty acids and subsequent transport of fat, chyle, to the circulatory
system
o Production of immune cells (such as lymphocytes, monocytes, and antibody
producing cells called plasma cells).
Lymph originates as blood plasma that leaks from the capillaries of the circulatory system, becoming
interstitial fluid, and filling the space between individual cells of tissue.
Plasma is forced out of the capillaries by oncotic pressure gradients, and as it mixes with the
interstitial fluid, the volume of fluid accumulates slowly. The proportion of interstitial fluid that is
returned to the circulatory system by osmosis is about 90% of the former plasma; with about 10%
accumulating as overfill.
The excess interstitial fluid is collected by the lymphatic system by diffusion into lymph capillaries,
and is processed by lymph nodes prior to being returned to the circulatory system. Once within the
lymphatic system the fluid is called lymph, and has almost the same composition as the original
interstitial fluid.
LYMPHATIC CIRCULATION


Acts as a secondary circulatory system, except that it collaborates with white blood cells in
lymph nodes.
Unlike the circulatory system, the lymphatic system is not closed and has no central pump;
P a g e | 32
o


The lymph moves slowly and under low pressure due to peristalsis, the operation of
semilunar valves in the lymph vessels, and the milking action of skeletal muscles.
Lymph vessels have one-way, semilunar valves and depend mainly on the movement
of skeletal muscles to squeeze fluid through them.
This fluid is then transported to progressively larger lymphatic vessels culminating in the
right lymphatic trunk (1/4th right upper body) and the thoracic duct (3/4th); these ducts drain
into the circulatory system at the right and left venous angles.
The lymph goes through minimum 1 lymph node before it enters the blood circulation
SPLANCHNOLOGY II
24 Regions of the abdomen. Projections and peritoneal relations of the
abdominal viscera
REGIONS OF THE ABDOMEN
11 regions by two longitudinal lines (right and left midclavicular lines)
and two transverse planes (subcostal and interspinous planes). +2
regions, lateroposterior to each of the hypochondriac regions called
renal regions (not seen in picture).
PROJECTIONS AND PERITONEAL RELATIONS OF THE ABDOMINAL
VISCERA
Viscera: An organ of the digestive, respiratory, urogenital, and endocrine
systems as well as the spleen, heart and great vessels; Hollow
multilayered walled organs.

Right hypochondrium
o Liver
 Highest of the level of upper 5th rib behind costal arch
 If felt below right costal arch, it is enlarged
 Intra
o Gallbladder
 Crossing midclavicular line and right costal arch
 Painful during palpation if infected
P a g e | 33







Intra
o Right colic flexure
 Intra
Epigastric region
o Stomache
 Cardia (T11, right), Pylorus (L1, left)
 When full of food, it can reach down to umbilicus
 Intra
o Left lobe of liver
 Intra
o Pancreas
 Head (L1,L2), Body runs in front of L1 & tail reach T12
 Head & Body (Retro), Tail (Intra)
o Duodenum
 Sup. Hor. (L1), Descending (L1-L3), Inf. Hor. (L3), Ascending (L3-L2)
 Sup. Horizontal (intra), The rest is retroperitoneal
o Abdominal aorta & Inferior vena cava
Left Hypochondrium
o Spleen
 9th-11th Rib
 If felt below left costal arch, it is enlarged
 Intra
o Fundus of stomach
 Intra
o Left colic flexure
 Related to the spleen
 Intra
Umbilical region
o Small intestine
 Retro
o Transverse colon
 Related to the spleen on left side, and liver on right side
 Intra
o Abdominal aorta & Inferior vena cava
Right lumbar region
o Ascending colon
 Intra/retro
Left lumbar region
o Descending colon
 Intra/retro
o Small intestine (jejunum)
Right iliac region
o Cecum
 Intra/Retro
o Appendix
P a g e | 34



McBurney’s point: Line between umbilicus & ant. Sup. Iliac spine. The point
is 1/3rd from ant. Sup. Iliac spine
 Intra
o Terminal part of Ileum
 Intra
Left Iliac region
o Sigmoid colon
 Intra/retro
o Small intestine
Pubic region
o Urinary bladder
 Infraperitoneal
o Uterus after 12 weeks of pregnancy
o Part of small intestine
Kidneys and suprarenal glands are found in the left/right renal region, right/left hypochondriac or
right/left lumbar region depending on textbook.
25 The peritoneum and the peritoneal cavity
The serous sac, consisting of mesothelium and a thin layer of
irregular connective tissue, that lines the abdominal cavity and
covers most viscera contained therein. It forms the greater & lesser
sac, connected by the epiploic foramen.
PERITONEAL RELATIONS OF VISCERA


Stomache
Duodenum
o Superior horizontal
o Descending
o Inferior horizontal
o Ascending
Intra
intra
retro
retro
retro
P a g e | 35

Colon
o








Cecum
o Ascending
o Transverse
o Descending
Small intestine
Liver
Spleen
Kidney
Pancreas
o Head & body
o Tail
Uterus
Urinary bladder
Rectum
o upper 1/3
o middle 1/3
o lower 1/3
intra/retro
intra/retro
intra
intra/retro
intra
intra (except bare area)
intra
retro
retro
intra
infra
infra
intra
retro
infra
LIGAMENTS (Taken from Kovacs notes)



Diaphragm is layered by parietal peritoneum which reflects onto the liver, forming the
posterior layer of the coronary ligaments (left and right)
Another reflection of the parietal peritoneum onto the liver is the falciform ligament (double
layer.
o The left layer of the falciform ligament continues into the anterior layer of the left
coronary ligament, and the right layer of the falciform ligament continues in the right
coronary ligament.
The posterior layer of the coronary ligament comes from the parietal peritoneum from the
diaphragm above. This way, the two layers are next to each other, forming a double layer at
the left coronary ligament. The right ligament remains as separate layers.
The peritoneum reflecting to the liver covers both surfaces of the liver, and the two layers meet each
other again at the porta hepatis along side the fissura ligamenti venosi.
This double layer descends in the stomach and duodenum forming the hepatogastric and
hepatoduodenal ligaments that are together called the lesser omentum. The hepatogastric
ligament, reaching the lesser curvature of the stomach, divides into two layers that cover the
stomach and meet each other again at the greater curvature.
The new double layer descends into the lesser pelvis and turns back, forming four layers which is the
greater omentum. These four layers go up until the transverse colon. Here, the third layer of the
four runs back to the posterior abdominal wall and continues with the parietal peritoneum covering
the pancreas (posterior wall of the lesser sac). The fourth layer also turns back to the posterior
abdominal wall, but it comes forward again, forming the visceral layer of the transverse colon, then
turns back again. These four layers then form the transverse mesocolon. Comes forward again to
P a g e | 36
form the mesenterium (layering the small intestine). After this, it reflects onto the posterior
abdominal wall.
BURSA OMENTALIS (lesser sac):
Superior wall: liver and superior recess of the lesser sac,
Anterior wall has three parts: 1 lesser omentum, 2 stomach, 3 gastrocolic ligament.
Posterior wall: parietal peritoneum (covering the pancreas)
Splenic recess: the left recess of the lesser sac (at the hilus of the spleen between the gastrolienal
and phrenicolienal ligaments.

Epiploic (Winslow's) foramen:
o Right side of the hepatoduodenal ligament, behind the ligament
o Hepatoduodenal ligament (front)
o Liver (above)
o Hepatorenal ligament (behind)
o Duodenorenal ligament (below)
26 Parts, topography and peritoneal relations of the stomach
Fragments of food are chemically broken down in the stomach by the gastric juice to produce chyme.
Stomach controls the rate of delivery of chyme to the small intestine. Capacity: 1200-1600ml.
PARTS OF STOMACH




Cardiac orifice: Continuation of the esophageal orifice
Cardia: Transition between esophagus and stomach
Fundus: Arises on the left superior part of stomach
Pylorus
SURFACE PROJECTIONS




Upper part of abdomen in epigastric region
Extend from beneath left costal margin into the umbilical region
Majority lies under the cover of lower ribs
“J” shaped organ
SKELETOPY




Cardia: T11, left (fixed point)
Fundus: 7th rib, 2cm left of the midline
Pylorus: L1, right (fixed point)
Lesser and greater curvature runs between cardia and pylorus
PERITONEAL RELATIONS
P a g e | 37
Stomach is intraperitoneal, and the peritoneum forms several ligaments connecting it to the viscera:


Along the lesser curvature: Hepatogastric ligament
Along the greater curvature:
o Gastrosplenic ligament
o Gastrophrenic ligament
o Gastrocolic ligament
o Greater omentum
RELATIONS OF STOMACH





Superior
o Liver
o Diaphragm
Inferior
o Transverse colon
o Mesocolon
Anterior
o Abdominal wall
o Left costal arch
o Diaphragm
o Left lobe of liver
Posterior
o Omental bursa
o Diaphragm
o Left adrenal gland
o Left kidney
Left lateral
o Spleen
27 Blood supply of the stomach
Left gastric artery:




Abdominal aorta-celiac trunk-left gastric artery
Extend left to esophagus, then descend along lesser curvature
Supplies upper right part of stomach
Supplies lower third of esophagus
Right gastric artery:




Abdominal aorta-celiac trunk-common hepatic-hepatic artery proper-right gastric artery
Runs along lesser curvature
Supplies lower right part of stomach
Anastomose with left gastric artery
Short gastric artery:
P a g e | 38



Abdominal aorta-celiac trunk-Splenic-short gastric artery
Arise at splenic hilum and run in gastrosplenic ligament
Supply fundus of stomach
Left gastroomental artery



Abdominal aorta-celiac trunk-splenic-left gastroomental artery
Arise at splenic hilum and runs along greater curvature
Supply stomach along the upper part of greater curvature
Right gastroomental artery




Abdominal aorta-celiac trunk-common hepatic-gastroduodenal-right gastroomental artery
Ascends along greater curvature
Anastomose with left gastroomental artery
Supply lower part of the greater curvature
Veins


From lesser curvature:
o Right and left gastric veins-portal vein
From Greater curvature
o Right and left gastroomental-sup. Mesenteric-splenic-portal vein
The left gastric vein anastomose with the esophageal venous plexus that drain into the azygos vein
which drains to the superior vena cava. This anastomoses is also an anastomoses between the portal
and cava venous systems.
LYMPHATIC DRAINAGE
The lymph vessels follow the arteries into the left and right gastric node, gastroomental nodes and
the short gastric nodes. All lymph from the stomach eventually passes to the celiac nodes.
NERVE SUPPLY
Sympathetic – Celiac ganglion
Parasympathetic – Vagus nerve
28 The hepatoduodenal ligament and its content. The lesser sac
THE HEPATODUODENAL LIGAMENT
The portion of the lesser omentum which connects the liver and duodenum. The hepatoduodenal
ligament have 3 structures:

Bile duct
o Formed by the union of common hepatic duct and cystic duct. It discharges bile at
the major duodenal (vaters) papilla.
P a g e | 39
o


Bile: Secretum for fat digestion
Hepatic artery proper
o Celiac trunk-common hepatic artery-hepatic artery proper
Portal vein
o Drains the unpaired viscera of the abdomen
LESSER SAC
The lesser sac or omental bursa is found behind the lesser omentum and is connected to the greater
sac via the epiploic (Winslow’s) foramen, which is found behind the hepatoduodenal ligament and in
front of the inferior vena cava. The lesser sac is developed as the stomach, duodenum and lesser
omentum turns 90 degrees.





Superior
o Liver & superior recess of lesser sac
Anterior
o Lesser omentum
o Stomach
o Gastrocolic ligament
Posterior
o Parietal peritoneum
Lateral right
o Open space (epiploic foramen)
Lateral left
o Splenic recess
29 Topography and peritoneal connections of the liver
Skeletopy


Superior level: Upper & lower border of 5th rib depending on right or left lobe or liver
Inferior level: Right costal arch
PERITONEAL RELATION



(Kovacs notes)
Diaphragm is layered by parietal peritoneum which reflects onto the liver, forming the
posterior layer of the coronary ligaments (left and right)
Another reflection of the parietal peritoneum onto the liver is the falciform ligament (double
layer.
o The left layer of the falciform ligament continues into the anterior layer of the left
coronary ligament, and the right layer of the falciform ligament continues in the right
coronary ligament.
The posterior layer of the coronary ligament comes from the parietal peritoneum from the
diaphragm above. This way, the two layers are next to each other, forming a double layer at
the left coronary ligament. The right ligament remains as separate layers.
P a g e | 40
The peritoneum reflecting to the liver covers both surfaces of the liver, and the two layers meet each
other again at the porta hepatis along side the fissura ligamenti venosi.
This double layer descends in the stomach and duodenum forming the hepatogastric and
hepatoduodenal ligaments that are together called the lesser omentum. The hepatogastric
ligament, reaching the lesser curvature of the stomach, divides into two layers that cover the
stomach and meet each other again at the greater curvature.
The new double layer descends into the lesser pelvis and turns back, forming four layers which is the
greater omentum. These four layers go up until the transverse colon. Here, the third layer of the
four runs back to the posterior abdominal wall and continues with the parietal peritoneum covering
the pancreas (posterior wall of the lesser sac). The fourth layer also turns back to the posterior
abdominal wall, but it comes forward again, forming the visceral layer of the transverse colon, then
turns back again. These four layers then form the transverse mesocolon. Comes forward again to
form the mesenterium (layering the small intestine). After this, it reflects onto the posterior
abdominal wall.
30 Parts and surfaces of the liver
The liver has a diaphragmatic & a visceral surface
The visceral surface has a right and left lobe, separated by the falciform ligament. Between the right
left lobes, the caudate and quadrate lobes are found.





Superior
o Diaphragm via bare area
Right lobe
o Costal arch
o Colic impression
o Renal impression
o Suprarenal impression
o Duodenal impression
Quadrate lobe
o Gallbladder
o Pylorus
o Groove for inferior vena cava
Left lobe
o Esophageal impression
o Gastric impression, lesser curvature and anterior surface
o Diaphragm through the bare area
Caudate lobe
o Inferior vena cava
LIGAMENTS OF LIVER

Falciform ligament
o Inferior part of falciform  Round ligament of the liver
 (remnant of left umbilical vein)
P a g e | 41



Right layer of falciform continues to right coronary ligament, and the left layer to left
coronary ligament.
o The coronary ligaments on each side form the right and left triangular ligaments.
Ligamentum venosum
Hepatoduodenal ligament
Between the 4 lobes of the liver, the H-fissure is found

Longitudinal part
o Left
 Superior: Ligamentum venosum (fissure for venous ligament)
 Inferior: Round ligament (fissure for round ligament
o Right
 Superior: Fissure for inferior vena cava
 Inferior: Fissure for gallbladder
o Horizontal part
 Hepatoduodenal ligament + portal triad (Portal fissure)
Ligaments connecting the liver to other viscera



Hepatoduodenal
Hepatorenal
Hepatogastric
31 The spleen
A large vascular lymphatic organ lying in the upper left part of the abdominal cavity, between the
stomach, pancreas and kidney medially and the diaphragm posterolaterally.
SKELETOPY

Level of 9th-11th rib
SURFACES



Diaphragmatic surface (convex)
Anterior visceral surface
o Superiorly: Gastric impression
o Inferiorly: Colic impression
Posterior visceral surface
o Renal impression
RELATIONS OF SPLEEN
Anterior: Stomache. Posteromedial: Kidney. Posterolateral: Diaphragm. Inferior: Left colic flexure.
Hilus: Tail of pancreas
HILUS
P a g e | 42


Splenic artery
Splenic vein
LIGAMENTS



Splenorenal (lienorenal)
o Contain splenic vessels
Gastrosplenic
o Contain short gastric vessels
Phrenicocolic
o It forms a nest for the spleen that prevent it from descending
NERVE INNERVATION


Splenic plexus  branches of celiac plexus  the left celiac ganglion
Vagus nerve (right)
32 The duodenum and the pancreas
DUODENUM
It is the first division of the small intestine, connected to the pylorus of the stomach superiorly
(proximal end) and the jejunum inferiorly (distal end).




Superior horizontal part
 Intraperitoneal
 L1
Descending part
 Retroperitoneal
 L1-L3
Inferior horizontal part
 Retroperitoneal
 L3
Ascending part
 Gradually becomes intraperitoneal at the duodenaljejunal flexure
 L3-L2
BLOOD SUPPLY



Arterial
o Gastroduodenal artery
o Superior pancreaticoduodenal artery
o Inferior pancreaticoduodenal artery
Venous
o Superior and Inferior Pancreaticoduodenal veins
Nerve
o Celiac ganglia & Vagus
P a g e | 43
PANCREAS
It is an elongated, lobulated and retroperitoneal gland. Devoid of capsule. Extending from
“concavity” of duodenum to spleen. The gland secretes part of the pancreatic juice that is discharged
into the intestine, and from it’s endocrine part, insulin, glucagons, etc.
The pancreas posses a head, body, tail
SKELETOPY



Head: L3-L2
Body: L1
Tail: L1-T12
Main pancreatic duct



The duct unites with the common bile duct in the hepatopancreatic ampulla
Opens into the major duodenal (Vaters) Papilla
Accessory pancreatic ducts opens into the minor duodenal papilla
Blood supply


Arterial:
o Superior & Inferior pancreaticoduodenal arteries
o Pancreatic arteries (from splenic artery)
Venous:
o Pancreaticoduodenal veins
Nerve supply



Pancreatic plexus
Celiac ganglia
Vagus
33 The intestines (except the duodenum and rectum)
THE INTESTINES
The intestines start with the duodenum, which is connected to the pylorus of stomach. It then
continues as jejunum, ileum and colon. The greater omentum covers the intestines.


Jejunum:
o Located in the upper left part of the abdomen
o The coils runs horizontally
o 6m long together with Ileum
Ileum
o Located in the lower part of the abdomen, umbilical region and sometimes the right
and left lumbar regions.
P a g e | 44
o The coils runs vertically
o Iliocecal (iliocolic) junction in right iliac region
The small intestines have a long mesenterium carrying the blood vessels supplying it
Colon: To differentiate between the small and large intestine, look for the tenia, epiploic appendices.







Cecum
o Iliocecal junction (in right iliac fossa)
o Appendix is found below this junction
 Tonsil of intestine
Ascending colon
o Right lumbar region
o Retro & partly intraperitoneal
Right colic flexure
o Related to liver and found in right hypochondriac region
Transverse colon
o Umbilical region ( middle part at level of L3)
o Connected to posterior abdominal wall by transverse mesocolon
o Greater omentum is attached to the superoanterior part
Left colic flexure
o Related to the spleen and found in the left hypogastric region
o Phrenicocolic ligament connects it with the diaphragm forming the nest of spleen.
Descending colon
o Left lumbar region
o Related to kidney
o Retro & partly intraperitoneal
Sigmoid colon
o Intraperitoneal
o Connected to posterior abdominal wall by sigmoidal mesocolon
o Left iliac region
Tenia of the colon:

Mesocolic, Omental & Free tenia
o = Longitudinal muscle bands
Nerve supply
Intestines are supplies by celiac ganglia and vagus
34 The celiac trunk and its branches
Celiac trunk is a direct branch from the abdominal aorta and can be found at the superior border of
the pancreatic neck at the approximate level of T12-L1.
P a g e | 45
(See Netter; Plate 290-295)

Celiac trunk
o Left gastric
o Common hepatic
 Hepatic artery proper
 Right gastric
 Right/Left hepatic
 Gastroduodenal
 Right gastroduodenal
 Superior pancreaticoduodenal
o Splenic
 Pancreatic branches (greater, dorsal & tail)
 Left gastroomental
 Short gastric
 Splenic branches
35 Superior and inferior mesenteric arteries and their anastomoses. Blood
supply of the intestines
SUPERIOR MESENTERIC ARTERY (SMA)
It supplies the intestines from the lower part of the duodenum to the left colic flexure and the
pancreas (inferior pancreaticoduodenal artery). Located at level of L1 (1cm below celiac trunk)
Branches





Inferior pancreaticoduodenal artery
o Head of pancreas
o 2nd & 3rd part of duodenum
Middle colic artery
o Transverse colon
Right colic artery
o ascending
Intestinal (jejunal & ileal)arteries
o Ileum & jejunum
Iliocolic/cecal
o Terminal branch of SMA
o Ileum, cecum and appendix
INFERIOR MESENTERIC ARTERY (IMA)
It supplies the large intestine from the left colic flexure to the upper part of the rectum.
Branches

Left colic artery
o Descending colon
P a g e | 46


Sigmoid arteries
o Sigmoid
Superior rectal artery
o Terminal branch of IMA
o Superior 1/3rd of rectum
Anatstomeses of SMA & IMA



Arcus Riolani
o Middle colic (SMA) & left colic (IMA)
Marginal artery (IMA & SMA)
Sudech point (IMA)
o Point of where the lowest branch of sigmoid artery usually join branches of the
superior rectal artery.
36 Lymphatic drainage of the stomach and the intestines
(Netter, plate 304A)
LYMPHATIC DRAINAGE OF STOMACH


Left gastroepiploic & Short gastric nodes Splenic  right gastric nodes  celiac nodes
Gastroduodenal & right gastroepiploic nodes  pyloric nodes  celiac nodes
The celiac nodes drains into cistern chili, a dilated sac at the lower end of thoracic duct (approx. L1)
LYMPHATIC DRAINAGE OF INTESTINES





Duodenum
o The lymph vessels follow the arteries:
 Pancreaticoduodenal  gastroduodenal celiac nodes cisterna chyli
Ileum & Jejunum
o The lymph is drained through many mesenteric nodes
 Superior mesenteric nodes  intestinal lymph trunk  cisterna chili
Colon
o Mainly to the paraaortic lymph nodes
Rectum
o Upper: via superior rectal vessels to paraaortic lymph nodes
o Middle: via middle rectal vessels to internal iliac lymph nodes
o Lower: via inferior rectal vessels to internal iliac lymph nodes
Anus
o Superficial inguinal lymph nodes
37 Portal vein, porto-systemic shunts, and their medical importance
P a g e | 47
There are two systems draining the abdomen; vena cava system and the portal system. The portal
venous system is responsible for directing blood from parts of the gastrointestinal tract (unpaired
organs in abdomen) to the liver. Things absorbed in the small intestine, will be taken to the liver for
processing.
The system extends from lower esophagus to upper 1/3rd of rectum. It also includes venous drainage
from the spleen and pancreas. This explains why certain drugs can only be taken via certain routes.
For example, nitro-glycerin cannot be swallowed, but it can be taken under the tongue. The
detoxification powers of the liver are strong enough to inactivate the medication before it reaches
the heart.
It is formed by the union of




Superior mesenteric vein and
Splenic vein
Coronary vein (drains to portal)
Inferior mesenteric vein, (indirect)
The portal vein branches into many generations of vessels that open into hepatic sinusoids. Blood is
recollected into the hepatic vein and enters the inferior vena cava.

Portal vein  interlobular  sinusoids  central  sublobular  hepatic  IFC
PS = Portal system
CS = Cava system
1. Esophageal veins drains to:
a. Azygos (CS)
b. Coronary veins (PS)
i. If circulation is blocked in the liver, the blood will be drained only by the
esophageal veins (IVC route), causing them to enlarge, and finally they may
burst and cause massive internal bleeding. They may also rupture during
eating, causing vomiting of blood.
2. Superior rectal vein drains to:
a. Inferior mesenteric vein (PS)
b. Middle rectal vein (CS via internal iliac)
i. Hemorrhoids due to increased pressure in rectal veins
ii. Rectal bleeding
3. Inferior epigastric drains to:
a. Paraumbilical veins (PS)
b. External iliac vein (CS)
i. If the inferior epigastric vein is blocked the paraumbilical veins will enlarge
and it looks like the veins are radiating from the umbilicus (caput medusa)
4. Retroperitoneal anastomoses between pancreas and kidney
a. The veins of the pancreas are drained to the portal (via splenic)
b. The veins of the kidney are drained to the IVC
38 Coronal section of the kidney
P a g e | 48
RENAL HILUS
Is the entrance to a cavity, renal sinus, within the kidney, located on the medial border.



Renal vein
Renal artery
Ureter
RENAL SINUS
A cavity surrounded by the parenchyma (functional part) of the kidney




Lesser and greater calyces
Renal pelvis
o Belonging to the urinary system that collects urine from the calyces and continues as
the ureter
Branches of renal vessels
o Interlobular  arcuate  interlobar  segmental  renal artery  abdominal aorta
Filled with fatty tissue (continuation of the adipose capsule)
CORTEX




The cortex is located just beneath the fibrous capsule
It has medullary rays; ascending or descending loops of a nephron.
Cortex corticis does not possess these rays
Renal columns are formed between the pyramids
MEDULLA




15-25 pyramids
The base of pyramid faces the cortex
Apex of pyramid contain renal papilla where urine is dismissed through the cribriform area
into the lesser calyces.
Functional unit of kidney
39 Topography and capsules of the kidney


Left, T12-L2 & right, L1-L3
11th and 12th rib partially protects the kidneys
VISCEROTOPY
Right kidney


Superior:
o Suprarenal gland
Anterior:
P a g e | 49


o Descending duodenum & right colic flexure
Posterior:
o Diaphragm (with phrenicocostal recess behind it). M. Psoas, M. quadratus lumborus
Medial:
o Inferior Vena Cava
Left kidney




Superior:
o Suprarenal gland
Anterior:
o Spleen, stomach (through lesser sac), pancreas, left colic flexure, coils of jejunum
Posterior:
o Diaphragm (with phrenicocostal recess behind it), M. Psoas, M. quadratus lumborum
Medial:
o Abdominal aorta
CAPSULES



Renal fascia
o The outermost fascia
o Covers anterior surface, goes around the kidneys laterally & superiorly.
o The posterior part runs behind aorta and IVC and is continues with one another.
 (opens medially & inferiorly)
o Anterior layer is continues with the peritoneum
Adipose capsule
o Adipose connective tissue, filling the space between the two fibrous capsules
Fibrous capsule
o The innermost layer, situated directly onto the kidney
40 The ureter
The ureter conducts urine from the kidneys to the urinary bladder . As it descends it is attached to
the posterior wall and retroperitoneum. The ureters pierce the urinary bladder from posterolaterally
to inferomedially at the ureteric orifices (2 upper angles of trigone). This oblique direction is
important because the mucous membrane will form a fold inside that prevents urinary backflow.
It is crossed at 3 points:



Behind gonadal vessel
In front of Junction between common iliac & external iliac vessels
Behind uterine artery or ductus deferens
Layered by smooth muscle
P a g e | 50
 Inner longitudinal
 Outer circular
 In the distal part of the ureter an outermost longitudinal muscle layer may appear.
41 Content of the retroperitoneum (except the viscera). Abdominal venous
systems
On posterior body wall behind peritoneum
MUSCLES




Quadratus Lumborum muscle
Major psoas muscle
Transverse abdominis muscle
Diaphragm
NERVE PLEXUS
Lumbar nervous plexus (lower T12 – upper L4): The psoas muscles arises from the bodies and
processes of the lumbar vertebraes. At the level of this origin, between the fibers, the lumbar plexus
surface and divides into branches.






Subcostal nerve (T12)
o Most inferior intercostal nerve
Iliohypgastric nerve (T12-L1)
o Enter and runs between transverse abdominis and internal oblique muscles
 Innervate the above mentioned muscles
o End branch pierce the muscles and innervate the skin
Ilioinguinal nerve (L1)
o Passes between the muscles, then joins the spermatic cord anteriorly through inguinal
canal.
o Comes out through superficial inguinal ring and innervates the skin of the scrotum and
the medial surface of the thigh that faces towards the scrotum
Lateral cutaneous femoral nerve (L2-L3)
o From quadratus lumborum towards anterior superior iliac spine
o Leaves abdominal cavity ca 1cm below the spine
Femoral nerve (L2-L4)
o Leaves abdominal cavity through lacuna musculonervosa with iliopsoas muscle
Genitofemoral nerve (L1-L2)
o Pierces major psoas
o Divides into genital & femoral branch
 Genital branch enters inguinal canal and passes inside spermatic cord
 Innervates cremaster & the layers of scrotum
P a g e | 51

Femoral branch passes through lacuna vasorum and innervates a small of
the skin below the inguinal ligament.
 Obturator nerve (L2-L4)
o Medial to iliopsoas
o Innervates adductor muscles and a medial region of the thigh
o Leave abdominal cavity through obturator canal together with A. obturator
 Don’t forget about the lumbosacral trunk. Frequently asked during exam according to Kovacs
ABDOMINAL VENOUS SYSTEM
There are two systems draining the abdomen. The vena cava system and the portal system. The
portal system drains the unpaired viscera and the vena cava system drains the rest.
There are 4 anastomoses between these two systems. See topic earlier topic!
I DON’T KNOW IF BRANCHES OF THE ABDOMINAL AORTA IS INCLUDED IN THIS TOPIC, SAME THING
WITH LUMBAR PLEXUS! See Kovacs notes p.86-88
42 The diaphragm, its apertures and their traversing structures
The diaphragm is a large muscle separating the abdominal and thoracic cavitites. It has a muscular
part (arising from sternum, ribs and lumbar vertebrae) and a tendinous part, called centrum
tendineum, which is the insertion of the muscle fibers.




Central tendon
o Three foliated shape
 Pericardium fused with anterior folium
 Hiatus for IVC located between the two posterior folium, a little to the right
Sternal part
o Between the sternal and costal part, the two internal thoracic artery and superior
epigastric artery is located.
Costal part
Lumbar part
o Left, arise from L2-L3 & Right, arise from L3-L4
3 Cruses


Medial crus (lumbar part)
o Esophageal hiatus (T10) for esophagus + vagal nerves
Lateral crus
o Median arcuate ligament
 Aortic hiatus (T12) + thoracic duct
o Medial acrcuate ligament
 Psoas major & minor
o Lateral arcuate ligament
 Quadratus lumborum
P a g e | 52

Intermediate crus (L2)
o Separates two hitatuses (between medial and lateral crus).
 Between medial and intermediate crura, there are two openings for the
splanchnic nerves and azygos/hemiazygos (ascending lumbar) vein
 Between intermediate and lateral crura the sympathetic trunk passes
43 Topography, blood supply, and lymphatic drainage of the urinary bladder
The urinary bladder is a musculomembranous elastic “bag” serving as a storage place for the urine,
produced by the kidney. It is located in the lesser pelvis.


base
apex
o The peritoneum is only reflected onto the apex and posterior wall  Infraperitoneal
o Continues with median umbilical fold, with urachus (remnant of alantois).
Trigone of bladder is a smooth area at the base of the bladder between the 2 ureteric orifices and
the internal urethral orifice.
RELATIONS


Anterior:
o The pubic symphysis
Posterior:
o Male: Rectum via rectovesicular pouch
o Female: Posterosuperiorly: Uterus via vesicouterine pouch
BLOOD SUPPLY


Arteries: Internal iliac (anterior division) umbilical artery  superior vesical artery
 inferior vesicle
Veins: Inferiorly, vesicle venous plexus  towards internal iliac
LYMPHATIC DRAINAGE

Drain into the internal and external iliac nodes  common iliac nodes
SUPPORT


The urinary bladder is fixed to the pubic symphysis by the pubovescial (puboprostatic)
ligament.
Most important support in males is through the prostate gland by the pelvic fascia
o The superior pelvic diaphragmatic fascia reflects onto the prostate gland. As the gland
is attached to the bladder, the bladder is supported with the pelvic fascia through
the prostate
P a g e | 53
44 Topography, blood supply, and lymphatic drainage of the rectum
The rectum (S3) is the continuation of sigmoid colon and the final portion of the large intestine,
descending in front of the sacrum, leaving the pelvis by piercing the pelvic diaphragm and ending in
front of the tip of the coccyx. It then continues as the anal canal. The lower part of rectum is dilated
to form the rectal ampulla.
Peritoneum covers the anterior and lateral surfaces of the upper 1/3rd of the rectum and only
anterior in the middle 1/3rd leaving the lower 1/3rd devoid of peritoneum. Therefore:



Upper 1/3rd Intraperitoneal
Middle 1/3rd Retroperitonal
Lower 1/3rd Infraperitoneal
Muscular coat: Inner circular and outer longitudinal layer of smooth muscle

The 3 free teniae coli of sigmoid come together and form a broad band on the anterior and
posterior surface of rectum
RELATIONS


Posterior:
o Sacrum and coccyx
o Piriformis, Coccygeus, and levator ani muscles, sacral plexus and sympathetic trunk
Anterior:
o Male: Superior to inferior
 Rectovesicular pouch
 Urinary bladder
 Seminal vesicle
 Prostate
o Femlale: Superior to inferior
 Rectouterine pouch (cul de sac Douglas)
 Posterior surface of vagina
BLOOD SUPPLY


Arteries: Superior, Middle and Inferior rectal arteries
Veins: Superior rectal vein (PS), middle and inferior rectal veins.
LYMPH DRAINAGE


Upper 2/3rd follow sup. rectal artery and drain into pararectal nodes  inf. mesenteric nodes
Lower 1/3rd follow mid. rectal artery and drain into internal iliac nodes
NERVE SUPPLY
Sympathetic and parasympathetic nerves from inferior hypogastric plexuses
P a g e | 54
45 The lesser pelvis in female. The internal female genitalia
The bony lesser pelvis has an inlet, outlet and a cavity
Border of inlet:



Anterior: Pubic symphysis
Lateral: Iliopectineal line, “Inominate line”
Posterior: Sacral promontory
Border of outlet:



Anterior: pubic arch
Lateral: Ischial tuberosity
Posterior: Coccyx
The cavity:
Curved canal with a short anterior wall and long posterior wall
Gross structures:



Urinary bladder
o Vesicouterine pouch
Uterus
o Rectouterine (Douglas) pouch¨
Rectum
INTERNAL FEMALE GENITALIA
UTERUS
Hollow muscular organ; 7.5cm in the non pregnant woman.







Body:
Main portion
Cervix:
elongated lower part
Isthmus:
Most narrow part of uterus (upper cervix)
Cavity:
triangular shaped
External os:
opening into vagina
Uterine ostium:
2 openings where fallopian tube enters the body of uterus
Layers of uterus:
 Perimetrium: Serous layered mesothelium
 Myometrium: Smooth muscle
 Endometrium: Mucous membrane; Undergoing cyclic changes
P a g e | 55



Fallopian tubes:
Ovaries:
Ligaments:
Intramural, isthmus, ampulla, ifundibulum & fibrae
Only extraperitoneal organ in the body
Round ligament of uterus & ligament of ovary
 Broad ligament
o Mesosalphinx
o Mesovarium
o Mesometrium
VAGINA



7-8cm long muscular tube attached to the uterus by anterior-posterior and lateral fornices
In the upper part, we have the vaginal portion of the uterus.
The lateral fornix of the vagina is related to the ureter
o Ureter runs to the urinary bladder from the posterior abdominal wall. It runs behind
the uterine artery.
 This is important: to operate on the uterus, the artery should be ligated and
cut, but there is danger of cutting the ureter by accident
46 Position, support, blood supply and lymphatic drainage of the uterus and
the vagina
POSITION

Uterus is intraperitoneal, except for vaginal part
o Peritoneum comes from anterior abdominal wall, covering the apex of urinary bladder
and some of the posterior wall, it then continues to anterior wall of uterus (not
cervix) forming the vesicouterine pouch
o Peritoneum reflects onto the posterior fornix of vagina and to the rectum forming the
Douglas pouch
The axis of the vagina is 30° posterior from the vertical
 Anteversion: Axis of vagina & axis of cervix = 100-110 degrees
 Anteflexion: Axis of cervix & axis of body of uterus = 160-170 degrees
 Together approximately 90 degrees forward between axis of vagina and body
RELATIONS
Uterus





Anterioinferiorly:
Inferior:
Posterior:
Superior:
Lateral:
Urinary bladder + Vesicouterine pouch
Vagina
Small intestine and rectum
Small intestine
Broad ligament
P a g e | 56
Vagina



Anterior:
Posterior:
Lateral:
Urinary bladder
Douglas pouch + rectum
Levator ani muscle
SUPPORT



Pelvic diaphragm and urogenital diaphragm
o The vagina pierces urogenital diaphragm and is attached to it
o Superior fascia of pelvic diaphragm reflects onto the vagina and cervix, fixing them
Retinaculum Uteri
o Connective tissue system that surrounds the uterus at the level of cervix and
continues into the two layers of broad ligament
 Pubovesical ligament
 Vesicouterine ligament
 Sacrouterine ligament (+recto uterine part of sacrouterine ligament)
 Broad ligament
 Cardinal ligament (inferior thickening of broad ligament)
Broad ligament
o Uterus is layered by peritoneum. Anterior and posterior layers meet at the lateral
sides of uterus forming a double layer extending to the lateral walls of lesser pelvis.
Between the double layer, the loose connective tissue; Parametrium, where the
uterine artery runs superiorly in a wavy manner.
 Mesosalpinx
 Mesovarium
 Mesometrium
BLOOD SUPPLY
Uterus




Uterine artery  Internal iliac
o Runs in cardinal ligament and reaches uterus at the isthmus, then turns superiorly
running in the parametrium to finally anastomose with ovarian artery
o Descending branch supplying cervix and vagina
Uterine vein
o Follow same path of uterine artery and drains to internal iliac vein
Ovarian artery  abdominal aorta
o Supplies ovaries and fallopian tube
Ovarian vein
o Left ovarian drain to renal vein & right drain to IVC
LYMPHATIC DRAINAGE
Three courses of lymphatic drainage:
P a g e | 57
1. From uterine fundus along side the round ligament, through the inguinal canal into the
inguinal lymph nodes (parallel to the inguinal ligament).
2. From uterine body, along side the uterine artery, to the internal iliac nodesetc…
a. The paraaortic nodes go through the lumbar trunk to the cisterna chyli
3. From cervix, there are two courses.
a. Same as for the body
b. From posterior fornix of the vagina into the sacral lymph nodes  paraaortic nodes.
Medical importance:
If enlarged inguinal lymph nodes are discovered:
o lower limb, perineal region, anal opening, gluteal region or external genitalia
must be examined. If no problem is found there, tumors of the uterus may be indicated. Usually in
the case of the uterine cancer, the paraaortic and iliac lymph nodes are enlarged
Hysterectomi  Surgical removement of uterus
47 The lesser pelvis in male
See lesser pelvis for female!






The Male pelvis is narrower than the female
Pubic arch is narrower
Ischial tuberosities are closer to each other
Iliac wings less flared
Outlet move oval
Cavity is narrowing greatly from inlet to outlet
Gross structures




Urinary bladder (See previous topic)
Rectum (See previous topic)
Ductus deferens
o Tail of epididymis. Consist of 4 parts
 Epididymic portion
 Funicular portion: running in spermatic cord
 Inguinal portion
 Pelvic portion: running in lateral wall of lesser pelvis medially towards the
seminal vesicle. Forming ampulla, which joins seminal vesicle and forms the
ejaculatory ducts (Netter 367C)
Seminal vesicle
o Posterior to the urinary bladder
P a g e | 58

Postate gland
o Below urinary bladder
o Base and Apex
o Fixed by pelvic fascia and related to the rectum
o Prostatic venous plexus  internal pudendal  internal iliac vein
o Explain Verumontanum on exam!!! (Netter 367A)
48 Parts and flexures of the male urethra
Internal urethral sphincter muscle, consisting of smooth muscle, surrounds internal urethral orifice
Parts of male urethra (Proximal to distal):




Intramural part
Prostatic part
o Verumontanum!
Membranous part
o The part running through urogenital diaphragm
Spongy part
o In corpus spongiosum having navicular fossa in glans penis and urethral glands
FLEXURES


Perineal flexure
o Δdirection, downward to forward
Pubic flexure
o Δdirection, forward to downward
o This flexure is straightened upon lifting the penis
49 The testis, epididymis, and the scrotum. The spermatic cord and its
coverings
THE TESTIS




Located in the scrotum
Paired oval glands
The testis produce spermatozoa
Seminiferous duct  Straight duct  rete testis  efferent duct  epididymic duct 
spermatic duct (Netter 371B)
THE EPIDIDYMIS


Elongated structure connected to posterior surface of testis
Head, body & tail
P a g e | 59


Transports, stores and matures spermatozoa
Attached to testis by superior epididymic and inferior epididymic ligament
THE SPERMATIC CORD
Collection of structures that pass through the inguinal canal to and from the testis. It begins at the
deep inguinal ring lateral to the inferior epigastric vessels and ends at the testis
In the cord:





Vas deferens (Spermatic duct)
Pampiniform venous plexus
Testicular artery
Autonomic nerves
Genital branch of genitofemoral nerve (innervate cremaster muscle)
On the cord:

Scrotal part of the ilioinguinal nerve (innervate skin of scrotum)
LAYERS OF SCROTUM AND DISTAL PART OF SPERMATIC CORD







Skin
Superficial (Dartos) fascia
o Skin with smooth muscle responsible for folding of scrotum
o superficial abdominal fascia
External spermatic fascia
o External oblique muscle
Cremaster muscle
o Internal oblique & transverse abdominis
Internal spermatic fascia
o Transverse fascia
Tunica vaginalis
o Continuation of peritoneum
o Parietal layer
o Visceral layer:
 Shiny serous layer on testis
o Vestigium of processus vaginalis (dead end)
Tunica albuguinea
50 Pelvic floor and perineum
PELVIC DIAPHRAGM


Superior fascia of pelvic diaphragm
Levator ani muscle
P a g e | 60
 Pubococcygeus
 Iliococcygeus
 Ischiococcygeus
o This muscle prevents prolapsing of the pelvic content and draws the anus upward
following defecation. It supports the pelvic viscera.
 Inferior fascia of pelvic diaphragm
 Anal hiatus
UROGENITAL DIAPHRAGM



Superior fascia of pelvic diaphragm
Deep transverse perineal muscle
o From inferior pubic ramus and runs to median line, where it interlaces in a tendinous
raphe
o Sphincter urethrae muscle
 These muscles are found just beneath the prostate gland in males, and deep
to the bulb of vestibule in females.
Inferior fascia of urogenital diaphragm
SPACES



Subperitoneal space
o Between peritoneum and pelvic diaphragm
 Connective tissue and blood vessels for the organs of the lesser pelvis
Deep perineal space
o Between the two diaphragms
 Membranous part of urethra
 Branch for dorsal nerve and artery for penis and clitoris
 (bulbourethral gland in males)
Superficial perineal space
o Between the urogenital diaphragm and superficial perineal fascia
 Ischiocavernous muscle
 Bulbospongiosus muscle
 Superficial transverse perineal muscle
Ischiorectal fossa



Covered by superficial perineal fascia
Medial: Levator ani muscle
Lateral: Obturator internus + obturator fascia
 Pudendal (Alcock’s) canal
 Formed by obturator internus muscle, covered by obturator fascia
surrounding structures running in the canal
o Internal pudendal artery and vein
o Pudendal nerve
P a g e | 61
51 The external genital organs
PENIS
Corpus cavernosum





Two parallel columns of erectile tissue forming the dorsal part
Divide into two crura at the root of penis, inserted into ramus of ischial bone (fallic crest)
Two deep penile arteries responsible for erection
Composed of lacunae separated by trabeculae (smooth muscle & connective tissue)
Tunica albuguinea
Pectiniform septum:
Separates cavernosum from spongiosum
Corpus spongiosum



Bulbus, corpus & glans penis
Smaller lacunae
Pierced by urethra
Deep fascia of penis surrounds the corpuses and separates (pectiniform) them
BLOOD SUPPLY





2 deep dorsal penile arteries
2 deep penile arteries
1 deep dorsal vein
Superficial dorsal veins
Veins in peripheral part of cavernosum
NERVE SUPPLY



Dorsal penile nerve  Pudendal nerve
Pudendohemoroid nerve (Parasympathetic fibers) from sacral plexus
Hypogastric nerve/plexus (sympathetic fibers ) from lumbar sympathetic trunk
MECHANISM OF ERECTION
During erection, blood from the arteries enters the lacunae, which dilate and compress the
peripheral veins against tunica albuguinea preventing venous drainage.


Parasympathetic stimulation dilate the arteries and increase blood flow
Sympathetic stimulation constricts the vessels, causing flaccidity of penis
See topic 49 for testis and scrotum!
EXTERNAL FEMALE GENITALIA (Netter 359-361)
P a g e | 62
Homologues of external genitalia:
Male







Glans penis
Body of penis
Corpus spongisum
Scrotum
Bulb of penis
Cowper’s gland
Etc
Female
Glans clitoris
Body of clitoris
Labia minor
Labia major
Bulb of vestibule
Bartholin’s gland
etc
“These notes were mostly taken from other exam notes, kovacs notes, snell, whatever I could
remember from class and a little Wiki. Note that this is only a rough draft, and I haven’t had time to
check for errors. ENJOY”
Xie xie Kon for the cover page layout.
P a g e | 63