Abdomen Flashcards
(228 cards)
1
Q
Origin Insertion Action Nerve Special features External oblique
A
Anterior angle of lower 8 ribs. Upper four slips interdigitate with serratus anterior, lower 4 with latissimus dorsi.
Outer lip of iliac crest, inguinal ligament, pubic tubercle and crest, rectus sheath, linea alba and xiphisternum (as aponeurosis)
Support, expiration, raises intraabdominal pressure and abducts and rotates trunk
Anterior primary rami (T7-T12)
Runs down and forwards
Free posterior muscular border
Free upper aponeurotic border
Aponeurosis below line from ASIS to umbilicus
Forms 3 ligaments; pectineal, inguinal, lacunar
2
Q
What is the only structure in the anterior rectus sheath above the costal margin?
A
Free horizontal upper border of external oblique aponeurosis
3
Q
List the layers of the abdomen from superficial to deep above the arcuate line
A
Skin Subcutaneous fat Camper's fascia Scarper's fascia External oblique/anterior rectus sheath (medial) Internal oblique Transversus abdominus/ rectus abdominus (medial) Posterior rectus sheath Transversalis fascia Peritoneum
4
Q
Origin Insertion Action Nerve Special features Internal oblique
A
Lumbar fascia, anterior 2/3/ of iliac crest and lateral 2/3 of inguinal ligament
Linea alba, rectus sheath conjoint tendon to pubic crest and pectineal line
Support, expiration, raises intraabdominal pressure and with muscles on opposite side abducts and rotates trunk
Anterior primary rami (T7-T12)
Conjoint tendon supplied by ilioinguinal nerve
Anterior configuration changes at arcuate line. A free lower border arches over the spermatic cord
Aponeurotic medial tip of 9th costal cartilage. Forms conjoint tendon. Forms floor of lumbar triangle. Upwards and inwards
5
Q
What are the borders of the lumbar triangle?
A
Anterior-external oblique
Floor-internal oblique
Medial-latissimus dorsi
Inferior-iliac crest
6
Q
Origin Insertion Action Nerve Special features Transversus abdominus
A
Costal margin (lower 6 ribs), lateral 1/3 of inguinal ligament, ant 2/3 of iliac crest, 12th rib
Aponeurosis of rectus sheath, conjoint tendon to pubic crest and pectineal line
Support, expiration, conjoint tendon supports inguinal canal
Ant primary rami (T7-T12) Conjoint tendon supplied by ilioinguinal nerve
Interdigitates with diaphragm. Lies horizontally.
Becomes conjoint tendon
7
Q
Where is the arcuate line?
A
Halfway between pubic symphysis and umbilicus
8
Q
Origin Insertion Action Nerve Special features Rectus abdominus
A
Pubic crest and pubic symphysis by two heads
5th, 6th, 7th costal cartilages
Flexes trunk, aids forced expiration and increases abdominal pressure
Ant primary rami
3 tendinous intersections, umbilicus, xiphisternum and in between
9
Q
Where is the superficial inguinal ring?
A
Just above and lateral to pubic tubercle (a triangular gap in the external oblique aponeurosis)
10
Q
Origin Insertion Action Nerve Special features Pyramidalis
A
Pubic crest anterior to rectus abdominus origin
Lower linea alba
Reinforces rectus sheath
Subcostal nerve (T12)
11
Q
Where does the linea alba attach?
A
Xiphisterum and pubic symphysis
12
Q
What forms the rectus sheath?
A
Internal oblique splits into anterior and posterior layers to enclose the rectus muscle
External oblique fuses with anterior layer (only medially)
Transversus fuses with posterior layer
Posterior layer has a free lower margin. Nil posterior rectus sheath below arcuate line.
13
Q
What is the contents of the rectus sheath?
A
Intercostal nerves
Rectus muscle
Pyramidalis muscle
Superior epigastric artery (supplies rectus abdominus)
Inferior epigastric artery (anastomosis with superior within sheath)
14
Q
What is the blood supply to the muscles of the anterior abdominal wall?
A
Intercostal
Epigastric
Deep circumflex iliac artery
15
Q
How long is the inguinal canal?
A
Runs from superficial to deep ring
4cm
16
Q
What are the boundaries of the inguinal canal?
A
Anterior external oblique aponeurosis
Lateral internal oblique
Roof, lower edges of internal oblique and transversus
Floor inguinal ligament
Posterior conjoint tendon medially and transversalis fascia throughout
17
Q
Where is the deep inguinal ring?
A
1.25cm above the midpoint of the inguinal ligament and is an opening in the transversalis fascia
18
Q
How does the inguinal nerve enter the inguinal canal?
A
Pierces the internal oblique muscle, not through deep ring
Supplies inguinal region skin, upper thigh anterior 1/3 of scrotum and root of the penis
19
Q
What are the boundaries of Hesselbach’s triangle? What occurs there?
A
Lateral inferior epigastric vessels
Medially Rectus abdominus
Inferior inguinal ligament
DIRECT hernias
20
Q
What passes through the deep ring?
A
Male: Vas deferens Artery to vas deferens Testicular artery Testicular veins Degenerated processus vaginalis Genital branch of genitofemoral nerve Autonomic nerves Lymphatics Female: Degenerated processus vaginalis Round ligament Lymphatics from uterus
21
Q
What are the three layers of the spermatic cord?
A
Internal spermatic fascia (derived from transveralis fascia at deep ring)
Cremaster muscle and fascia (arises from inguinal ligament, internal oblique and transverse abdominis muscles)
External spermatic fascia (arises from external oblique aponeurosis)
22
Q
What are the contents of the spermatic cord?
A
Vas deferens Artery to vas deferens Testicular artery Cremasteric artery Pampiniform plexus Lymphatics Genital branch of genitofemoral nerve Sympathetic twigs Processus vaginalis
23
Q
Where is the epididymus in relation to the testis?
A
Attached to posterolateral service
There is an anastomosis of between testicular, cremasteric and ductal arteries
24
Q
What is the name of the membrane that covers the testis?
A
Tunica albuginea
Tunica vaginalis
25
Why does varicocele occur more often on the left than the right?
Left testicular vein drains into left renal vein at a right angle
Right vein drains inferior vena cava at an acute angle
26
What is the lymph drainage from the testicles?
Para aortic nodes
27
What is the nerve supply to the testis?
Sympathetic nerves (mostly from T10)
28
Where is the vas deferens in relation to the epididymus?
The vas deferens is a continuation of the epididymus. Pierces the prostate and opens by the ejaculatory duct into the urethra.
29
Describe the course of the developing testis
Starts at gonadal ridge
Develops from yolk sac with mesonephros
Remaining mesonephros becomes paradidymis
Mesodermal cells called gubernaculum connect the lower pole of the testis to the abdominal wall( becomes the scrotum)
Processus vaginalis protrudes down inguinal canal into scrotum
7th month of fetal life testis is in the deep ring
30
What are the boundaries of the lesser sac?
Anterior: posterior wall lesser omentum, visceral peritoneum over posterior stomach and posterior layer of greater omentum, portal triad
Posterior: Pancreas, gastrosplenic/splenorenal ligaments anterior layer of greater omentum (which is attached to transverse colon)
Cavity doesn't extend below greater omentum
31
How many layers in the greater omentum?
4
| A double sheet of peritoneum folded in on itself
32
What are the attachments of the lesser omentum?
Attached along the stomach from right side of oesophagus and along first 2cm of duodenum
Right free margin (foramen of winslow).
Liver attachment is L-shaped to the fissure for ligamentum venosum and porta hepatis
Contains portal triad (common bile duct, portal vein and hepatic artery)
33
What are the boundaries of the epiploic foramen of winslow?
Upper boundary caudate process of liver
Lower boundary first part duodenum
Posterior inferior vena cava
Anterior portal triad in lesser omentum
34
Where does the fluid collect in the abdomen and why?
Pelvis
Hepatorenal pouch
Lowest parts of abdomen
35
```
Which of the following are intraperitoneal?
Common iliac artery
Inferior vena cava
Ureters
Testicular arteries
Superior mesenteric vessels
Root of mesentery
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Inferior vena cava
Root of mesentery
Superior mesenteric vessels
36
What is the root of the mesentery and where does it begin?
Duodenojejunal junction. Crosses the 3rd part of duodenum where superior mesenteric vessels enter, crosses aorta, inferior vena cava, right psoas muscle and ureter. Attachment is 15cm.
37
What does the foregut become and which artery supplies these structures?
Liver
Pancreas
Supplied by coeliac artery (also supplies stomach and spleen)
Boundary is the bile duct entrance into duodenum
38
What defines the midgut?
The section of gut which physiologically herniates into the umbilical cord at 6 weeks
Supplied by the superior mesenteric artery
Becomes duodenum, ileum, caecum and transverse colon
39
What are the branches of coeliac trunk?
Left gastric artery: gives oesophageal branches and supplies stomach
Splenic artery: tortuous. Gives short gastric and left gastroepiploic artery. Supplies spleen and pancreas.
Common hepatic artery: gives right gastric and gastroduodenal artery (gives right gastroepiploic and superior pancreatoduodenal artery)
40
What is the venous drainage of foregut?
Portal vein
Passes through liver
Inferior vena cava
41
What is the origin of the SMA
From aorta 1cm below coeliac trunk
Level of L1 vertebra
Posterior to pancreas
42
What are the branches of the SMA
```
Inferior pancreaticoduodenal
Middle colic artery
Jejunal and ileal arteries
Right colic artery
Ileocolic artery (caecal and appendicular artery)
```
43
What is the venous drainage of the midgut?
Superior mesenteric vein
44
Where does the IMA arise from?
Level of L3 vertebrae
3-4cm above aortic bifurcation
Level of umbilicus
45
What are the branches of the IMA?
Left colic artery (crossed anteriorly by IMV)
Sigmoid arteries
Superior rectal arteries
46
What is the venous drainage of the hindgut?
Inferior mesenteric vein
Lies on left psoas muscle
Drains into superior mesenteric vein
47
What are the three groups of lymph nodes which supply the small and large intestine?
1. Within the peritoneum-mural (SI) and paracolic (LI)
2. Lymph vessels which lie with blood supply
3. Preaortic lymph nodes
48
Where does the enteric nervous system lie?
Myenteric plexus- between 2 layers of the gut
| Submucous plexus- in submucosa
49
What are the three layers of the alimentary tube?
Epithelium
Lamina propria
Muscularis mucosae
50
Describe the cell types found in oeseophagus
Stratified squamous non keritinising
Muscularis mucosae absent from top but thicker than any other part of alimentary tract
Mucus secreting glands in both upper and lower ends
51
Describe the cells found in the stomach
Single layer columnar epithelium
Parietal cells (intrinsic factor binds B12, pepsin and Hydrochloric acid)
G cells secrete gastrograffin
D cells secrete somatostatin
52
Describe the cells found in the small intestine
Villi
Mucus secreting goblet cells
Only duodenum has mucus secreting glands- first part (ampulla) has no circular folds
Only terminal ileum has peyers patches
53
Describe the cells found in the large intestine
No villi
Only glands with goblet cells
Anal canal goes back to stratified squamous
54
What does the stomach lie anterior to?
```
Pancreas
Splenic artery
Transverse colon
Upper left kidney
Spleen
Aorta and coeliac trunk
```
55
What is the blood supply to the stomach?
```
Coeliac trunk
Left gastric artery
Right gastric artery
Short gastric arteries
Gastroepiploic vessels
```
56
What is the key difference between the anterior and posterior vagal trunks at the oesophagus?
Anterior vagal trunk is in contact with anterior oesophageal wall
Posterior vagal trunk is not in contact with oesophagus
57
What are the layers of the stomach?
Outer longitudinal
Middle circular
Inner oblique muscle layer
58
How do the parts of the duodenum relate to vertebral levels and the peritoneum?
1st part: L1 ant to bile duct, portal vein and gastroduodenal artery
2nd part: right side of L2, ant to right kidney, receives bile duct and pancreatic duct
3rd part: crosses in front of L3, ant to l+r psoas muscle, inferior vena cava and aorta
4th part: left of L2, ant to left psoas muscle
First 2.5 cm intraperitoneal
59
What is the blood supply to the duodenum?
Superior and inferior pancreatoduodenal arteries- but first 2cm receives blood hepatic, gastroduodenal, supraduodenal, right gastric and right gastroepiploic arteries
60
Key differences between jejunum and ileum
Jejunum feels thick- 2 walled, ileum feels thin
Ileum-peyers patches and meckels' diverticulum 2% population, 2 inches long, 2 feet from caecum
Both supplied by SMA, forms arterial arcades, much more arcades in ileum
61
How do the teniae coli of the caecum relate to the appendix?
All 3 teniae coli converge on the base of the appendix
62
What is the blood supply to the appendix?
Appendicular artery (branch of inferior division of ileocolic artery)
63
Which parts of the colon have mesenteries?
Transverse and sigmoid
64
What does the colon sit anteriorly to?
Ascending- right kidney and inferior liver
Transverse- right kidney, small intestine, left kidney, pancreas
Descending- left kidney, tail of pancreas, spleen
Sigmoid- rectum
65
What is the blood supply to the colon?
Ascending and proximal 2/3rd of transverse are supplied by SMA; ileocolic, right colic and middle colic
Remainder from IMA; left colic and sigmoid
Anastomic branches between the two are marginal artery.
66
How big is the liver?
1.5kg
1500ml of blood per minute
Anterior surface covers ribs 6-10 on the right and 6+7 on the left
Right surface extends from ribs 7-11
67
Where is the falciform ligament?
Over anterior surface, near the middle, down to the notch made by ligamentum teres. To the left of gall bladder fundus. Upper attachment of falciform ligament sweeps to the left and is known as triangular ligament, sweeps to the right and becomes upper layer of coronary ligament.
68
Describe the posterior surface of the liver (H shaped pattern)
Right limb of H- inferior vena cava and gall bladder
Cross piece of H- porta hepatis
Left limb- ligamentum venosum and ligamentum teres
69
What is the only part of the posterior surface of the liver that is in the lesser sac?
Caudate lobe
70
What is in the porta hepatis?
Right and left hepatic ducts
Right and left branches of hepatic artery
Portal vein
Surrounded by lesser omentum
Lie in order vein artery duct with ducts in front
71
What are the lobes of the liver?
Left- left of falciform ligament
Caudate- posteriorly between inferior vena cava and fissure for ligamentum venosum
Quadrate- between gall bladder fossa and fissure for ligamentum teres
Right- right of falciform ligament
72
Describe the liver segments from right to left, top to bottom
Anterior: 7, 8 4, 2, 6, 5, 4 ,3
Posterior: 2,4, 1, 8, 3 4, 5, 6
73
Describe the blood supply to the liver
2 sources
Hepatic artery (arterial) (divides into right and left in porta hepatis- Y shaped). Right branches-> anterior and posterior segmental branches
Left branch-) medial and lateral segmental branches
```
Portal vein (venous)
also divides into right and left in porta hepatis but T shaped
```
Venous drainage by 3 main hepatic veins which drain into IVC
74
What are the anatomical variations of blood supply to the liver?
Common hepatic artery may arise form SMA or aorta (instead of coeliac trunk), in which case it runs BEHIND the portal vein
Right and left hepatic branches may arise from SMA or left gastric arteries which may either replace existing arteries or exist in addition
75
What is the lymph drainage of the liver?
nodes in porta hepatis (also receive gall bladder)
| Drains into retropyloric nodes and then coeliac nodes
76
Describe the histology of the liver
hexagonal lobule
Central vein
Corners have small branches of hepatic artery and bile duct
Acinus- diamond shaped area with ventral veins and portal canals
77
Describe the flow of bile
```
Produced in liver
Collected by bile canliculi in lobules
Drains into left and right hepatic ducts
Drains into common hepatic duct
Joined by cystic duct to form common bile duct
```
78
Why do you get RUQ pain in cholecystitis
Gallbladder fundus projects beyond lower border of liver and touches parietal peritoneum around right costal margin
Fundus lies just to the left of hepatic flexure
79
What is the body of the gallbladder in contact with?
Liver
| Duodenum
80
What does the gall bladder neck become?
Cystic duct-> joins common bile duct
81
What is the blood supply to the gall bladder?
Small hepatic vessels
Cystic artery (usually from right hepatic but may be from main hepatic, left hepatic or gastroduodenal)
Thrombosis of cystic artery DOES NOT lead to ischaemia (in contrast to appendiceal artery)
82
Where is the cystic artery found?
Calot's triangle
| Formed by liver, common hepatic duct and cystic duct
83
What is the usual anatomy of the common hepatic duct in relation to blood supply
4cm long 4mm wide
Lies on free edge of lesser omentum
Right branch of hepatic artery passes behind
Cystic duct meets common hepatic 1cm above duodenum
84
What is the usual anatomy of the bile duct in relation to blood supply
8cm long 8mm wide
Upper 1/3 lies in free edge lesser omentum in front of poertal vein and to the right of hepatic artery
Middle 1/3 runs behind 1st part of duodenum, IVC behind
Lower 1/3 between head of pancreas and second part of duodenum in front of right renal vein. Joins pancreatic duct at hepatopancreatic ampulla
85
What is the nerve supply to the biliary tract?
Parasympathetic from vagal trunk
Sympathetic from coeliac ganglia
Hormonal
Some fibres run with phrenic nerve (reason for referred shoulder pain)
86
Describe the course of the portal vein
Superior mesenteric vein becomes portal vein when it receives splenic vein behind pancreas
Lies in front of IVC
Travels between two layers of lesser omentum. Lies behind bile duct and hepatic artery. Bile duct curves BEHIND the pancreas and hepatic artery curves IN FRONT of pancreas.
87
What is the ligamentum teres?
The obliterated remains of the left umbilical vein (often not completely obliterated)
88
Describe the structures immediately surrounding the pancreas
Head: anterior to; IVC, right and left renal veins, level of L2, bile duct
Neck: Superior mesenteric vein, transverse mesocolon attached
Body: Anterior to; left renal vein and aorta, left crus of diaphragm, left psoas muscle, hilum of left kidney. Crosses origin of superior mesenteric artery
Tail: touches hilum of spleen, accompanied by splenic artery and vein
89
Which parts of the pancreas are drained by the pancreatic duct?
All except uncinate process and lower part of the head which are drained by accessory duct
(pancreas develops as 2 different buds)
90
What is the blood supply to the pancreas?
Splenic artery
| Superior and inferior pancreatoduodenal arteries
91
What size is the spleen?
1x3x5 inches weighs 7 ounces and lies between the 9th and 11th ribs
92
What is the blood supply to the spleen?
Splenic artery (branches at hilum into 3-4 branches)
93
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Origin
Insertion
Action
Nerve
Special features
Psoas major
```
Transverse process of L1-5 and intervertebral discs of T12-L4
Middle surface of lesser trochanter of femur
Flexes hip/laterally flexes spine
Anterior primary rami of L1,2,3. Mainly L2
Lumbar plexus lies within
External vertebral venous plexus behind. Genitofemoral nerve emerges from in front of muscle, iliohypogastric, ilioinguinal, lateral femoral cutaneous and femoral nerves from its lateral border
94
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Origin
Insertion
Action
Nerve
Special features
Psoas minor
```
Bodies of T12-L1 and intervening vertebral discs
Pectineal line of pubis and fascia over iliopsoas
Weak flexor of trunk
Anterior primary rami of L1
Only present in 2/3 individuals. Sits on top of psoas major
95
```
Origin
Insertion
Action
Nerve
Special features
Quadratus lumborum
```
Transverse process of upper four lumbar vertebrae and inferior border of 12th rib
Transverse process of L5, iliolumbar ligament and iliac crest.
Depresses 12th rib and laterally flexes lumbar spine
Anterior primary rami T12-L3
Innermost of 3 layers of posterior wall. Edge to edge with psoas. Lumbar fascia forms lateral arcuate ligament- subcostal neurovascular bundle emerges beneath this
96
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Origin
Insertion
Action
Nerve
Special features
Iliacus
```
Iliac fossa and anterior SI ligament
Lesser trochanter of femur
Flexes hip
Femoral nerve in the abdomen L2,3
Joins tendon of psoas
Covered by iliac fascia
97
Describe the course of the abdominal aorta
Thoracic aorta becomes abdominal after passing behind median arcuate lligament and between the crura of the diaphragm at T12.
Passes along bodies of lumbar vertebrae, left sympathetic trunk alongside. Divides into 2 common iliac arteries at L4. Between coeliac trunk and SMA is crossed by pancreas and splenic vein
98
Describe the branches of the abdominal aorta
```
Inferior phrenic arteries (T12)
Coeliac trunk (T12)
SMA (L1)
Suprarenal arteries (L1)
Renal arteries (between L1 and L2, left shorter than right)
Gonadal arteries (L2)
IMA (L3)
Median sacral artery (L4)
Lumbar arteries (L1-L4)
```
99
What happens to the common iliac arteries?
Pass in front of sacroiliac joint, left common iliac is crossed by inferior mesenteric vessels and splits into internal and external.
Internal iliac enters pelvis. External iliac passes beneath inguinal ligament to become the femoral artery.
100
Describe the course of the inferior vena cava
Begins L5 at joining of 2 common iliac veins behind right common iliac artery.
Lies behind liver and duodenum.Travels up and pierces diaphragm at T8
101
What is the key difference between the aortic branches and the inferior vena cava tributaries?
There are no veins directly from the gut, pancreas and spleen straight into the IVC, this blood first passes through the liver and reaches the vena cava via the hepatic veins.
102
What forms the azygous and hemiazygous veins?
1st and 2nd lumbar veins join the ascending lumbar vein.
On the right it passes through the aortic opening forming azygous vein and on the left perforates the left crus becoming the hemiazygous vein
103
What is the key difference between renal arteries and veins?
Both at L2
Arteries: left shorter than right
Veins: Left is 3x longer than right because it has to cross in front of the aorta and receives left suprarenal vein, left gonadal vein, left inferior phrenic vein and is connected to left ascending lumbar and lumbar azygos veins. Right renal vein just drains right kidney.
104
Which spinal nerves supply the anterior abdominal wall?
Only T12 and L1
105
Which spinal nerves make up the lumbar plexus?
L1, L2, L3, L4
| Lies within psoas major
106
Describe the course of T12 (subcostal nerve)
Passes from thorax behind lateral arcuate ligament beneath a+v
Passes through transversus abdominus to reach neurovascular plane. Supplies anterior abdominal wall including rectus abdominus and pyramidalis. Also supplies anterior buttock via lateral cutaneous branch
107
Describe the course of iliohypogastric and ilioinguinal nerves
Both from anterior rami L1
Lie in front of quadratus lumborum
Emerge from border of psoas major behind anterior lumbar fascia
Iliohypogastric supplies skin of upper buttock, skin over rectus abdominus and mons pubis
Ilioinguinal supplies anterior 1/3 of scrotum, root of penis and upper and medial part of the groin plus motor supply of internal oblique and transversus
108
Describe the course and supply of the lateral femoral cutaneous nerve
Posterior divisions of anteropr rami L2 and L3. Emerges from lateral border of psoas major travels on top of iliacus deep to iliac fascia. Perforates inguinal ligament. May arise as a branch of femoral nerve. Supplies parietal peritoneum and lateral thigh.
109
Describe the course and supply of the femoral nerve in the abdomen
Posterior divisons of anterior rami L2, L3, L4 (obturator formed by ant divisions of same nerve)
Emerges from lateral border os psoas, supplies iliacus and passes beneath inguinal ligament to enter thigh
110
Describe the course and supply of the genitofemoral nerve
Formed within psoas major by L1 and L2. Emerges from anterior surface of psoas major. On the left it is covered by ureter, gonadal vessels, inferior colic arteries and inferior mesenteric vein. Right nerve overlaid by ureter, gonadal vessels and ileocolic artery. Divides into genital and femoral branches. Genital supplies cremaster, spermatic fascia and tunica vaginalis. Femoral supplies skin of groin.
111
Where does the obturator nerve emerge from in the abdomen?
MEDIAL side of psoas
112
Where is the lumbar part of the sympathetic trunk in the abdomen?
Left: along left margin of aorta
Right: Behind inferior vena cava
113
What is the sympathetic supply to the abdominal organs?
Right and left hypogastric nerves
Coeliac plexus
Greater and lesser splanchnic nerves
114
How big is a kidney?
12x6x3 cm
130 grams
Left kidney sits as high as rib 11, right kidney rib 12
115
What lies posterior to the kidneys?
Costodiaphragmatic recess of pleura
Diaphragm
Quadratus lumborum
116
What is the difference between the two suprarenal glands?
Right-pyramidal in shape behind IVC
| Left- cresenteric behind peritoneum
117
What lies anterior to the kidneys?
Right- duodenum, hepatic flexure, jejunum ascending branch of right colic artery, peritonuem of hepatorenal pouch
Left-tail of pancreas, splenic flexure, jejunum, left ascending colic artery, peritoneum of lesser sac forming stomach bed
118
What is the renal pelvis?
The funnel shaped commencement of the ureter
Posterior to artery and vein
Lined with transitional epithelium
119
What is the blood supply to the kidneys?
Renal arteries 1 litre per minute
| 5 segments based on blood supply
120
Describe the internal structure of the kidney
```
Outer renal capsule
Renal cortex
Medulla
Minor calyces
Major calyces
Nephrons are functional unit (proximal convoluted tubule then loop of henle then distal convoluted tubule then collecting tubule and collecting duct)
```
121
Which one of the three embyrological excretory ducts forms the kidney proper?
Metanephros
122
How long is a ureter?
25cm
123
What is the course of the ureter?
Runs on psoas major
Crosses in front of genitofemoral
Crossed by testicular, colic and sigmoid arteries
Crosses over common iliac arteries and into pelvis
124
What is the blood supply to the suprarenal (adrenal) glands?
Aorta
Renal arteries
Phrenic arteries
125
Describe the inner structure of the adrenal glands
Cortex -zona glomerulosa (aldosterone) zona fasciculata (cortisol) and zona fasciculata (androgens)
Medulla- adrenaline and noradrenaline
126
What are the muscles of the "true pelvis" below the pelvic brim?
Obturator internus- side wall of pelvis
Piriformus -posterior wall of pelvis
Levator ani
Coccygeus
127
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Origin
Insertion
Action
Nerve
Special features
Piriformis
```
S2,3,4 costotransverse bars of anterior sacrum
Medial aspect of greater trochanter of femur
Lateral rotation and stabilisation of hip
Anterior rami S1,2
Emerging nerves and plexus lies on the muscle. Runs transversely to greater sciatic foramen.
128
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Origin
Insertion
Action
Nerve
Special features
Obturator internus
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Inner surface of obturator membrane, pelvic brim to the margin of greater sciatic notch
Middle part of medial aspect of greater trochanter of femur
Laterally rotates and stabilises the hip
Nerve to obturator internus L5, S1. S2
Covered with obturator fascia. Separated from lesser sciatic notch
129
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Origin
Insertion
Action
Nerve
Special features
Levator ani: ilieococcygeus
```
Posterior tendinous arch and ischial spine
Anococcygeal body
Supports pelvic viscera
S3,4
Does not attach to ileum
130
```
Origin
Insertion
Action
Nerve
Special features
Levator ani: pubococcygeus
```
Anterior tendinous arch and body of pubis
Anococcygeal body and coccyx
S3,4
Muscle proper: posterior fibres, forms midline tendinous plate (which is attached to coccyx posteriorly)
Puborectalis part: forms U shaped sling
- Puboanalis: fibres that blend with rectum
Puboprostaticus/urethralis
Pubovaginalis
131
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Origin
Insertion
Action
Nerve
Special features
Coccygeus
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Sacrospinous ligament and ischial spine
Annocooygeal body and sacrum
Supports pelvic viscera
S3 S4
Gluteal surface is sacrospinous ligament
132
Why does the rectum appear curved?
Three transverse rectal valves incorporate circular muscle of the wall
Middle valve is largest and is useful landmark during sigmoidoscopy as sits 8cm in
133
How does the rectum differ from the rest of the colon?
No mesentery
No sacculations
No appendices epiplocae
Has visceral fat called mesorectum (contains superior rectal artery
Peritoneum covers upper 1/3 of rectum at sides and front and middle 1/3 only at the front
134
What/where is the rectovesical fascia of Denonvilliers?
Between the bladder seminal vesicles prostate and rectum
Runs between floor of rectovesicle pouch and apex of prostate
Closer to rectum
Distinct white appearance
135
What is the blood supply to the rectum?
Superior rectal artery (inferior mesenteric artery becomes superior rectal artery on entering pelvic brim divides at S3 into two)
Contributions from middle and inferior rectal arteries and median sacral vessels
136
When does the bladder enter the abdominal cavity?
It sits entirely in pelvic cavity but domes up into abdominal cavity when distended
137
Where does the neck of the bladder sit in males vs females?
Males sits against base of prostate
Females sits in connective tissue of anterior vaginal wall
Bladder neck surrounded by circular muscle
138
What is the trigone of the bladder?
Triangular area at the base of the bladder lying between the two urethral orifices and the internal urethral orifice
Openings 2.5cm apart in empty bladder but 5cm when distended
Histologically different to rest of bladder-predominantly sympathetic fibres
139
What is the blood supply to the bladder?
Superior and inferior vesical arteries
| Venous drainage- vesicoprostatic plexus
140
What is the nerve supply to the bladder?
Parasympathetic-pelvic splanchnic- responsible for feeling of bladder distension
Sympathetic- L1 and L2 superior and inferior hypogastric plexus
141
How does micturation occur?
Contraction of detrusor muscle and relaxation of external sphincter and levator ani
Initially bladder wall accomodates, then tension stimulates pelvic splachnic nerves which stimulate cells within bladder wall to contract. This is how an infant empties their bladder, eventually higher centres become superimposed on spinal activity and bladder emptying becomes voluntary.
Skeletal muscle of sphincter urethrae is controlled by perineal branch of pudendal nerve (S2). In spinal cord transection above S2 bladder automatically empties
142
Where do the ureters run in both sexes within the pelvis?
Male: Enters bladder wall at oblique angle.Crossed by vas deferens. Seminal vesicles lie just below point where ureter enters bladder wall.
Female: Ureter lies in broad base ligament, crossed by uterine artery
143
Describe the relations of prostate
Base is fused with neck of bladder
Anterior surface is connected to bodies of pubic bones by puboprostatic ligaments
Posterior surface is in front of rectum separated by rectovesical fascia. Ejaculatory ducts pierce posterior surface
Prostatic urethra passes through prostate closer to anterior than posterior
144
Why does seminal fluid not regurgitate into the bladder during ejaculation?
Within the prostatic urethra there is a cylinder of smooth muscle (an extension from the neck of bladder) which contracts to seal off the bladder during ejaculation
145
Describe the various zones of the prostate
Peripheral zone 70%- always where carcinoma is
Central zone 20%- wedge shaped
Transition zone 5%-affected by BPH
146
What is the blood supply to the prostate?
Prostatic branch of inferior vesical artery
147
What is the nerve supply of the prostate?
Parasympathic via pelvic splachnic
| Sympathetic from inferior hypogastric plexus- causes glands to empty during ejaculation
148
Describe the course of the vas deferens
Continuation of epididymis
Enters abdomen at deep inguinal ring, crosses external iliac artery and vein, obturator n/a/v
Travels along base of bladder, joins seminal vesicle to form ejaculatory duct
149
Which structure produces the majority of seminal fluid?
Seminal vesicle (60%)
150
How do you tell the difference between the seminal vesicles and the vas deferens on cross section?
Vas deferens has a very thick muscular wall
| Seminal vesicles have a very thin wall
151
What are the relations of the uterus?
Enclosed by peritoneum which laterally becomes the broad ligament
Intestinal surface faces upwards with coils of intestine on it
Vesicle surface faces downward resting on bladder
Posterior part of cervix has peritoneum, anterior does not
152
What are the different sections of the uterine/fallopian tubes/
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Isthmus
Ampulla
Infundibulum
Fimbriae
10cm long
Cilia beat towards the uterus
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153
What is the blood supply of the uterus?
Uterine artery (branch of internal iliac)
Passes medially in the broad ligament above the ureter
Forms anastomosis supplying cervix and vagina
At junction of uterus and fallopian tube anastomoses with tubal branch of ovarian artery which supplies fallopian tube
154
What is the nerve supply of the uterus?
Inferior hypogastic plexus
Sympathetic-vasoconstrictor. But division of all uterine nerves or high transection of spinal cord does not affect uterine contractility even in labour. Cord segments are T10-L1 and pain can be referred to corresponding dermatomes. Abolition of uterine sensation requires transection of cord above T10
155
Describe the muscular structure of the uterus
Myometrium in 3 layers but ill defined
Outer more longitudinal and expulsive
Deeper are circular
Mucous membrane colomnar epithelium
156
What are the ligaments of the uterus
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Broad ligament (suspensory ligament of the ovary)
Round ligament- passes through deep inguinal ring and inguinal canal. Continuous with ligament of the ovary
Transverse cervical ligament- ureter, uterine artery and inferior hypogastric plexus travel on this
Uterosacral ligament- attached to sacrum and maintains anteroversion
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157
What is the mesovarium?
The double fold of peritoneum which is attached around the ovary and attaches it to the broad ligament
158
What is the blood supply to the ovary?
```
Ovarian artery (branch of abdominal aorta)
Crosses ureter obliquely on psoas muscle
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159
What is the lymph drainage of the ovary?
Para aortic nodes L2
160
What is the nerve supply to the ovary?
Sympathetic via aortic plexus. T10 T11 cell bodies. Parasympathetic via inferior hypogastric
Autonomic fibres DO NOT reach ovarian follicles, an intact nerve supply is not required for ovulation
161
What is the nerve supply of the kidneys?
Sympathetic T12 to L1
| Parasympathatic from vagus
162
What is the nerve supply to the ureters?
T11-L2
163
What is the lymph drainage of the ureters?
Para aortic
164
What is the nerve supply of the spleen?
Sympathetic fibres only from coeliac plexus
165
What is the lymph drainage of the spleen?
Coeliac nodes
166
What is the nerve supply to the pancreas?
Parasympathetic via vagal
| Sympathetic from T6-10 via splanchnic
167
What is the nerve supply to the billiary tract?
Parasympathetic- anterior vagal trunk
Sympathetic coeliac ganglia
T7-9
168
What is the lymph drainage of the gall bladder?
Porta hepatis
Cystic node
and a node situated in epiploic foramen
Coeliac nodes
169
What is the nerve supply to the liver?
Sympathetic from coeliac ganglia
| Parasympathetic from vagus via porta hepatis
170
What is the lymph drainage of the liver?
Hepatic nodes in porta hepatis
Drain to coeliac nodes
In carcinoma of pylorus the disease may spread retrograde and effect hepatic nodes
Liver communicates with extraperitoneal lymphatics
171
What is the nerve supply to the colon?
Midgut and hindgut so parasympathetic partly from vagus partly from pelvic splachnic
Sympathetic from spinal cord segments T10-L2
172
What is the lymph drainage of the colon?
Either superior or inferior mesenteric nodes
173
What is the lymph drainage of the appendix and caecum?
Lymph nodes associated with ileocolic artery
174
What is the nerve supply to the small intestine?
Parasympathetic vagal
| Sympathetic (inhibits peristalsis) T9-10
175
What is the lymph drainage of the small intestine?
Superior mesenteric nodes
176
What is the nerve supply to the stomach?
Motility and secretion controlled by parasympathetic
Anterior vagal trunk- in contact with oesophagus, sometimes double
Posterior vagal trunk- not in contact with oesophagus
Vomiting reflex controlled by vagus nerve- fibres pass to chemoreceptor trigger zone of postrema (part of reticular formation). Reticular formationis linked to cerebral cortex to account for vomiting of emotional origin
177
What is the lymph drainage of the stomach?
Coeliac nodes after passing through gastric nodes, pancreatic nodes
Can also reach supraclavicular nodes in gastric carcinoma
178
What is the lymph drainage of the prostate?
Internal iliac
Sacral nodes
External iliac nodes
179
What is the structure of the ovary?
Fibrous stroma covered with cubical superficial epithelium
A primary follicle-single layer of granulosa cells
When there are multiple layers of granulosa cells- secondary follicle
180
Which is the only part of the vagina to have a peritoneal covering?
Posterior fornix- deepest fornix, covered by peritoneum of rectouterine pouch/pouch of douglas
181
Where are the bladder and urethra in relation to the vagina?
Anterior wall of vagina is in contact with bladder and urethra is buried in vaginal wall
Vagina is 10cm long
182
What is the blood supply of the vagina?
Vaginal branch of internal iliac artery
Uterine
Inferior vesical
Middle rectal
183
What is the lymph drainage of the vagina and urethra?
Vagina
External and internal iliac
Lowest part to superficial inguinal nodes
Urethra: mostly just internal iliac- rarely external iliac
184
What is the nerve supply to the vagina and urethra?
Sensory: pudendal nerve and ilioinguinal nerve
Autonomic from inferior hypogastric plexus
Upper vagina only sensitive to stretch
185
How does the vagina stay moist?
There are no glands within the walls, all mucus comes from cervix
186
What is the length of the female urethra?
4cm
| But vaginal stretching during birth can increase the length to 10cm
187
What is the blood supply of the female urethra?
Inferior vesical and vaginal arteries (from anterior division internal iliac)
Lower end receives some blood from internal pudendal artery
188
Where does the common iliac artery bifurcate into internal and external iliac arteries?
Pelvic brim between L5 and S1
| Internal iliac Splits into short posterior and longer anterior division
189
What are the branches of the anterior division of the internal iliac artery?
superior vesical
obliterated umbilical
inferior vesical/vaginal
Middle rectal
Uterine
Obturator- forms accessory obturator artery with inferior epigastric artery- usually lies lateral to femoral ring but can be medial
internal pudendal -passes through greater sciatic foramen
inferior gluteal- passes through greater sciatic foramen
190
What is the relation between the superior vesical artery and the umbilical artery?
The superior vesical is the persistently patent part of the fetal umbilical artery
Distal part becomes obliterated to form medial umbilical ligament
191
What are the branches of the posterior internal iliac artery?
Iliolumbar-splits into lumbar and iliac branches. Lumbar acts as 5th lumbar segmental artery, supplies psoas, quadratus lumborum and erector spinae. Iliac part supplies iliacus.
Lateral sacral artery-frequently double, supplies spinal cord
Superior gluteal- largest branch passes between lumbosacral trunk and S1 nerve via greater sciatic foramen
192
Where does the internal iliac vein begin?
Greater sciatic notch by confluence of gluteal veins
193
Why can emboli from pelvic viscera into the vertebrae?
There are no valves in pelvic veins
Increases in abdominal pressure can drive blood into the inferior vena cava, up through azygos veins into the superior vena cava bypassing the diaphragm
194
What is the course of the obturator nerve in the pelvis?
Branch of lumbar plexus ant div of L2, L3, L4
Formed in psoas major
Passes through obturator foramen
Runs between internal iliac vessels and is only separated from ovary by parietal peritoneum so referred pain from ovary can go to thigh
At obturator foramen against pubic bone obturator nerve lies highest, with artery and vein beneath
Splits into anterior and posterior divisions
195
Where is the sacral plexus?
Rests on piriformis
Lateral sacral arteries and veins lie on top
Splits into anterior and posterior divisions
196
What are the nerve roots of the two major divisions of the sciatic nerve?
Common peroneal: L4,L5, S1. S2
| Tibial: L4, L5, S1, S2, S3
197
What are the 12 branches of the sciatic plexus?
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Superior gluteal nerve (L4, L5, S1)
Inferior gluteal nerve (L5, S1. S2)
Nerve to piriformis (S1, S2)
Common peroneal division of sciatic L4, L5, S1, S2
Tibial division of sciatic L4 L5 S1 S2 S3
Nerve to quadratus femoris L4, L5, S1
Nerve to obturator internus L5 S1 S2
Posterior cutaneous nerve of thigh S1 S2 S3
Perforating cutaneous nerve S2 S3
Pudendal nerve S2 S3 S4
Nerve to levator ani S3, S4
Perineal branch of S4 S4
Pelvic splachnic nerves S2, S3, S4
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198
What do the pelvic splachnic nerves supply?
Colon from sigmoid onwards
Motor for emptying of bladder
Secretomotor for gut
Vasodilator for erectile tissue in perioneum
Motor for internal anal sphincter
Motor to vas deferns, seminal vesicles and prostatic muscle
Sympathetic to uterine muscle
199
What are the cutaneous nerves of the perineum?
Anal region- inferior rectal nerve (S3,4), perineal branch of S4 and some twigs from coccygeal plexus S5
Ilioinguinal nerve (L1) supplies anterior 1/3 of scrotum/labia majoris
Skin of penis/clitoris is dorsal nerve (S2) branch of pudendal
Posterior 2/3 of scrotum is perineal branch of posterior femoral cutaneous nerve and by pudendal (S3)
200
What is the anorectal ring?
Where the puborectalis part of levator ani fuses with the external sphincter
Also corresponds with upper border of internal sphincter
201
Describe the mucous membrane of the anal canal?
Upper 1/3- anal columns. Join together to form anal valves where anal glands are.
Level of anal valves= pectinate line. Below, stratified sqaumous epithelium, above, columnar and tubular cells. Change is continuous
Anal cushions at 3, 7 and 11 o'clock
202
What is the blood supply to the anal canal?
Superior rectal artery- upper end
Median sacral arteries
Inferior rectal artery
203
What is the lymphatic drainage of the anal canal?
Upper canal- rectal nodes
| Lower- superficial inguinal nodes
204
What is the nerve supply of the anal canal?
Inferior rectal banches of pudendal nerves
Motor from S2
Sympathetic fibres from pelvic plexus
Parasympathetic- pelvic splachnic
205
What are the specialised receptors in the anal canal?
Cells which allow distinction between gas, solid and liquid
206
What are the 3 types of urethra in males?
Prostatic urethra becomes membranous urethra which pierces perineal membrane and becomes penile urethra
207
Where are the bulbourethral glands?
Lie one on each side of the membranous urethra, above perineal membrane
Contribute a small amount to seminal fluid
208
What is the root of the penis?
Bulb and two crus either side
Each crus has a deep artery of the penis, attached to angle between perineal rami and ischiopubic ramus and becomes corpus cavernosum
Bulb is posterior end of corpus spongiosum
209
Where do the corpus cavernosum sit in relation to the urethra?
Corpus cavernosum sit side by side dorsally
| Urethra is within corpus spongiosum which lies ventrally
210
What is the blood supply to the penis?
3 pairs of arteries
Branches of internal pudendals
Artery to bulb supplies corpus spongiosum and glans
Deep artery of penis supplies corpus cavernosum
Dorsal artery supplies skin, fascia and glans
211
What is the lymph drainage of the penis?
Penile skin- to superficial inguinal nodes
| Everything else to deep inguinal nodes
212
What is the nerve supply to the penis?
Main dermatome S2
Skin by pudendal nerves
Small area of skin on dorsum is supplied by ilioinguinal L1
Bulbospongiosus and ischiocavernosus muscle which contract during ejaculation are controlled by perineal nerve of pudendal S2, S3
Sympathetic nerves (ejaculation) - L1 segment of spinal cord and superior and inferior hypogastric plexuses
Pelvic splanchnic S2 S3 provide parasympathetic to allow increased blood flow for erection
213
What are the actions of bulbospongiosus and ischiocavernosus?
Bulbospongiosus: empty urethra after peeing, assists in erection and contracts during ejaculation
ischiocavernosus: Assists and moves erect penis
214
How long is the male urethra?
15cm
215
What type of the epithelium in the male urethra?
All transitional epithelium except an area at the very tip of the glans which has stratified squamous
216
What is the blood supply to the scrotum?
Superficial and deep external pudendal arteries- femoral
| Scrotal branches of perineal artery- from internal pudendal
217
What is the nerve supply of the scrotum?
Anterior 1/3 skin is ilioinguinal nerve L1 and genital branch of genitofemoral L1
Posterior 2/3 is scrotal branch of perineal nerve S3 and perineal branch of posterior cutaneous nerve S2
218
What are the two terminal branches of the internal pudendal artery?
Deep artery of the penis
| Dorsal artery of penis
219
What are the two terminal branches of the pudendal nerve?
Dorsal nerve of the penis
| Perineal nerve
220
What is the nerve supply of erection and ejaculation?
Erection=parasympathetic- splanchnic
| Ejaculation=sympathetic+ somatic T11 to L2
221
What are the ligaments of the sacroiliac joint? (plate 337 netters)
Anterior sacroiliac ligament (stronger in female)
Interosseous sacroiliac ligament (can soften during final months of pregnancy to allow some rotation of pelvis during birth)
Sacrotuberous ligament (pierced by perforating cutaneous nerve and inferior gluteal vessels and coccygeal nerves) and sacrospinous ligament form the lesser sciatic foramen
Iliolumbar ligament (V shaped)
222
What are the branches of the lumbar plexus?
```
L1 iliohypogastric and ilioinguinal
L2 Genitofemoral
L2,3 (post div)Lateral femoral cutaneous
L2,3,4 )post div) Femoral
L2, 3, 4 (ant div) Obturator
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223
What does the lateral femoral cutaneous nerve supply?
Only sensory
| Lateral thigh down to knee
224
What bits are supplied by the femoral nerve and its branches?
Iliacus and pectineus- femoral
Sartorius and skin and fascia lata over front of thigh (nerve to sartorius)
Rectus femoris and hip joint (nerve to rectus femoris)
Vastus lateralis, vastus intermedius, vastus medialis and knee joint
Sartorius and patellar plexus (saphenous)
Skin and periosteum over tibia (saphenous)
225
What bits are supplied by the obturator femoral nerve and its branches?
```
Parietal peritoneum
Obturator externus
Adductor magnus
Knee joint
Hip joint
Adductor brevis
Pectineus (sometimes-accessory obturator)
Gracilis
Medial skin of thigh
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226
Which bits are supplied by the sciatic nerve and its branches?
Common peroneal itself supplies no muscles:
Knee joint (genicular nerves)
Lateral skin from knee to mid calf (lateral cutaneous nerve of calf)
Extensor digitorum longus, tibilias anterior, extensor hallicus longus and peroneus tertius amd extensor digitorum brevis (deep peroneal)
Peroneus longus and brevis. Skin over lower 1/3 of leg and dorsum of foot and toes (superficial peroneal)
Tibial:
Plantaris, gastrocnemius, soleus and popliteus
Plantar medial surface of foot and 1st web space (sural)
Flexor hallicus longus and flexor digitorum longus, tibialis posterior
Flexor digitorum brevis, abductor hallicus, flexor hallicus brevis, and first lumbrical
227
What are the borders of the ischioanal fossa?
Base- skin over perineum
Medial wall-external anal sphincter and levator ani
Lateral wall- ischial tuberosity and obturator internus
Anterior-perineal body
Posterior- Sacrotuberous ligament and gluteus maximus
Fossa contains fat and pudendal nerve and vessels
228
What is the difference between the deep and superficial perineal spaces?
Deep: Contains membranous urethtra, pudendal vessels, dorsal nerve of penis, perineal nerve, bulbourethral glands, sphincter urethrae and deep transverse perineal muscles
Superficial: continuous with scarpa's fascia of abdominal wall. Covered by colles superficial fascia Contains ischiocavernous and bulbospongiosus and cavernous bodies of clitoris and penis. In penile urethral injury can cause urine to travel upward into the anterior abdominal wall
