Human Anatomy Synopsis: Thorax, Abdomen, Pelvis

GERARD GORNIAK & WILLIAM CONRAD HUMAN ANATOMY SYNOPSIS: THORAX, ABDOMEN, PELVIS

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CONTENTS

Preface 7

1 Thoracic Cage 8 1.1 Boundaries 8 1.2 Osteology 8 1.3 Muscles of the Thorax 16 1.4 Intercostal Nerves (Fig. 1-13) 30 1.5 Intercostal Arteries and Veins (Figs. 1-13, 1-16, 1-17) 31

2 The Lungs 35 2.1 The Pleura (Fig. 2-2) 36 2.2 Lobes of the Lung (Figs 2-3, 2-4) 38 2.3 Pulmonary Vessels (Figs. 2-9, 2-10) 45

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3 Heart 49 3.1 Mediastinum (Fig. 3-1) 49 3.2 Pericardium (Fig. 3-2) 51 3.3 Heart Overview (Fig. 3-3) 51 3.4 Structure of Arteries and Veins (Fig. 15-14) 67

4 Superior And Posterior Mediastina 72 4.1 Superior Mediastinum 72 4.2 Posterior Mediastinum 76

5 Abdominal Wall 84 5.1 Boundaries 84 5.2 Abdominal Planes (Table 4.1 and Fig. 4-1) 84 5.3 Anterior and Lateral Abdominal Walls 87 5.4 Inguinal Region (Figs. 4-3, 4-4, 4-7, 4-8) 95 5.5 Posterior Abdominal Wall (Figs. 4-10, 4-11, 4-12) 99

6 Abdominal Viscera 105 6.1 Peritoneum (Fig. 5-1) 105 6.2 Abdominal Organ Overview (Fig. 5-3) 107 6.3 Liver (Figs. 5-3, 5-4, 5-5, 5-6, 5-7, 5-9) 108 6.4 Gallbladder (Figs. 5-3, 5-4, 5-7, 5-8, 5-9) 114 6.5 Pancreas (Figs. 5-3, 5-7, 5-8, 5-9) 116 6.6 Spleen (Figs. 5-7, 5-10, 5-13) 119 6.7 Esophagus (Figs. 5-3, 5-5, 5-10) 119 6.8 Stomach (Figs. 5-3, 5-6, 5-7, 5-9, 5-10, 5-11) 119 6.9 Small Intestine 122 6.10 Large Intestine (Figs. 5-2, 5-11, 5-12) 125 6.11 Kidneys (Figs. 5-13, 5-14, 5-15, 5-16) 127 6.12 Suprarenal Glands (Figs. 5-13, 5-14) 131 6.13 Abdominal Arteries (Figs. 5-9, 5-12, 5-11, 5-12, 5-17, 5-18) 133 6.14 Systemic Abdominal Veins (Fig. 5-19) 137

7 Pelvis 140 7.1 Bony Pelvis Osteology (Fig. 6-1) 140 7.2 Pelvic Boundaries (Fig. 6-1) 143 7.3 Contents 144 7.4 Pelvic Diaphragm (Fig. 6-4) 144 7.5 Pelvic Arteries (Figs. 6-6, 6-7) 149 7.6 Pelvic Nerves 151

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7.7 Sacral Plexus (Figs. 1-15, 1-16) 154 7.8 Urinary Bladder (Figs. 6-9, 6-16, 6-17, 6-18, 6-20, 6-22, 6-23) 160 7.9 Pelvic Organ Support Structures (Table 6.1, Figs. 6-15, 6-16, 6-17) 161 7.10 Male Reproductive System (Figs. 6-18, 6-19, 6-20, 6-21) 170 7.12 Female Reproductive System (Figs. 6-22, 6-23, 6-24, 6-25) 176

8 Perineum 182 8.1 Boundaries (Fig. 7-1) 182 8.2 Anal Triangle (Figs. 7-1, 7-2, 7-3, 7-4) 183 8.3 Urogenital Triangle (Figs. 7-1, 7-2, 7-3, 7-4, 7-5, 7-6) 188

Study Question Answers 194

References 210

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PREFACE

This is one of a series of 4 Human Anatomy Synopses that are based on over 40 years of Anatomy course notes used in the graduate education of health care professions. This series started as a detailed content outline for a course developed for medical students back in 1983. Since that time, it has undergone many revisions and additions. In 2008 and 2014, text and illustrations were reviewed and revised, and study sections were added throughout the text. In 2017, the 4 Synopses were developed, and the text and illustrations formatted to be used by students as a supplement to anatomy courses.

The 4 Human Anatomy Synopses in this series are: Spine and Neck, Axilla and Upper Limb, Pelvic Girdle and Low Limb, and Thorax, Abdomen, and Pelvis. This THORAX, ABDOMEN, AND PELVIS SYNPOSIS contains the organs of the Thorax, Abdomen and Pelvis, and the thoracic, abdominal and pelvic arteries, veins, and nerves. There are numerous drawings and dissection photographs. In this Synopsis, major structures are CAPTILIZED. This feature allows students to make a study outline by linking together these words under each title or subtitle. After each content area, there are short answer Study Questions to help students relate and apply the anatomy. The answers to these questions are included at the end of the Synopsis.

These Synopses are only possible because of the works of the many anatomists and other basic scientists as well as numerous clinicians who have contributed to our knowledge and understanding of the human body. I am most grateful to them for sharing what they learned. I am also grateful to the many students who over the years, have made comments and suggestions about the content of this work. I am also grateful to Drs. Hilmir Augustsson, Jeff Rot, Ed Kane, Sue Curfman, Jim Viti, and Mrs. Jackie Nelson and to the University of St Augustine for Health Sciences for help with this publication.

This book is dedicated to all those people who have so generously donated their body to science so that we may learn. Thank you for the unselfish gift of yourself to others. May God bless you for your contribution to mankind.

Unless otherwise indicated, all materials on these pages are copyrighted. All rights reserved. No part of these pages, either text or image may be used for any purpose other than personal use. Therefore, reproduction, modification, storage in a retrieval system or retransmission, in any form or by any means, electronic, mechanical or otherwise, for reasons other than personal use, is strictly prohibited without prior written permission.

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1 THORACIC CAGE

1.1 BOUNDARIES • THORAX is commonly referred to as the CHEST. • Anterior: MAMMARY GLANDS, PECTORAL MAJOR AND MINOR MUSCLES, the STERNUM and the COSTAL CARTILAGES. • Posterior: 12 THORACIC VERTEBRAE, posterior part of the 12 RIBS, the INTERCOSTAL MUSCLES, ILIOCOSTALIS LUMBORUM AND THORACIS, LONGISSIMUS THORACIS, LEVATOR COSTARUM, SERRATUS POSTERIOR, SUPERIOR AND INFERIOR MUSCLES. • Lateral: RIBS, INTERCOSTAL MUSCLES, SERRATUS ANTERIOR, ABDOMINAL MUSCLES. • Superior: FIRST RIB and SUPERIOR THORACIC APERTURE. • Inferior: DIAPHRAGM and INFERIOR THORACIC APERTURE.

1.2 OSTEOLOGY

STERNUM

○○ Three parts: MANUBRIUM, BODY, and XIPHOID PROCESS (Fig. 1-1). ○○ Notches of manubrium. 1) a CLAVICULAR NOTCH for the articulation of the medial clavicle. 2) a COSTAL NOTCH for the attachment of the costal cartilage of the first rib. ○○ STERNAL ANGLE where manubrium and superior body connect and the costal cartilage of the second rib attaches a costal notch. ○○ COSTAL NOTCHES on the body of the sternum for the attachment of the costal cartilages from ribs three to six. ○○ XIPHISTERNAL JOINT where the body of the sternum joins the xiphoid process.

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Fig. 1-1. Thorax: Drawings of A) an anterior view of the thoracic cage showing the ribs, sternum and costal cartilage and B) lateral view of a rib and its articulation with a vertebra and the sternum. (Modified from Gray 1918)

RIBS

○○ 12 PAIRS of ribs (Fig. 1-1). ○○ TRUE RIBS are the upper seven pairs of ribs attach directly to the sternum. ○○ FALSE RIBS are the lower five pairs of ribs.

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○○ FLOATING RIBS are ribs 11 and 12. ○○ Costal cartilage of ribs eight, nine and ten attaches to the rib above and not directly to the sternum. ○○ Ribs 11 and 12 have no costal cartilage and do not attach to other ribs.

Fig. 1-2. Thorax: (Top) posterior aspect of a typical rib and (Bottom) the superior surface of the first rib. 1. Neck of rib, 2. Angle of rib, 3. Costal groove, 4. Anterior costal notch, 5. Costal tubercle, 6. Head of rib, 7. Inferior demifacet for vertebra, 8. Crest of rib head for intervertebral disc, 9. Superior demifacet for vertebra. (Modifies from Gray’s 1918)

○○ RIBS 3 THROUGH 10 the same basic configuration(Figs. 1-1, 1-2) ANTERIOR COSTAL NOTCH for the attachment of the costal cartilage. HEAD of ribs 3-9 has two articular surfaces to articulate with the vertebral bodies above and below the rib and the CREST that attaches to of the intervertebral disc. Rib 10 has only one articular surface and no crest. COSTAL TUBERCLE that articulates with the transverse process of the vertebrae.

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NECK lies between the head of the rib and its tubercle and the BODY. BODY extends from the neck to the anterior costal notch and has a COSTAL GROOVE for the INTERCOSTAL NERVE and VESSELS. ANGLE is the sharp curvature of the body between tubercle and anterior costal notch. ○○ FIRST RIB (Fig. 1-2) This rib flat, short rib is very curved. Its HEAD has a single articular surface for the body of the T1vertebra. It has prominent RIB TUBERCLE that articulates with the transverse process of T1. It has a prominent superior SCALENE TUBERCLE for the attachment of the SCALENUS ANTERIOR muscle. Medial to this scalene tubercle is a GROOVE for the SUBCLAVIAN VEIN. Lateral to the scalene tubercle is a GROOVE for the SUBCLAVIAN ARTERY. Posterior to the scalene tubercle is the INFERIOR TRUNK of the BRACHIAL PLEXUS. All three structures cross the SUPERIOR THORACIC APERTURE to reach the first rib. ○○ SECOND RIB The second rib is short and curved, but slightly longer, and more rounded than the first rib. Its HEAD has a single articular surface for T2. It has a prominent RIB TUBERCLE for articulation with the T2 transverse process. There is a distinct superior POSTERIOR TUBERCLE for the attachment of the SCALENUS POSTERIOR muscle. ○○ RIBS 11-12 Ribs 11 and 12 are short and less curved than the other ribs. The head has a single, vertebral articular surface. There is no prominent rib tubercle. The anterior ends have no costal notch but are covered with hyaline cartilage.. ○○ THORACIC VERTEBRAE (Fig. 1-3) • long and narrow spinous processes ○○ SUPERIOR AND INFERIOR COSTAL FACETS for the head of the rib on the vertebral body to form the COSTOVERTEBRAL JOINT. ○○ COSTAL TUBERCLE FACET on the transverse processes for the rib tubercle to form the COSTOTRANSVERSE JOINTS.

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Fig. 1-3. Back: Drawings showing the structural parts of a thoracic vertebra in superior (A) and lateral (B) view (Modified from Gray’s 1918) and a radiograph of the thoracic spine in frontal view (C). Notice the articulation of the ribs with the body and transverse process. The numbers in the image indicate: 1. Vertebral body. 2. Transverse processes. 3. Vertebral foramen. 4. Spinous process. 5. Pedicle. 5b. Laminae. 6. Costal tubercle facet. 7. Superior articular facet. 8. Inferior articular facet. 9. Costal facets on vertebral body. 10. Inferior intervertebral notch. 11. Heart. 12. Diaphragm. 13. Rib

THORAX JOINTS (FIGS. 1-1, 1-4, 1-5)

• CARTILAGINOUS SYNCHONDROSIS JOINT connects the costal cartilage of the rib to the sternum ○○ ANTERIOR AND POSTERIOR RADIATE STERNOCOSTAL LIGAMENTS of ribs 1-7 strengthen the thin joint capsule. ○○ INTERARTICULAR STERNOCOSTAL LIGAMENT is found in rib 2. ○○ INTERARTICULAR LIGAMENT connects ribs 1, 2, and 3 to each other and to the sternum. ○○ ANTERIOR AND POSTERIOR COSTOXIPHOID LIGAMANTS attaches the costal cartilage rib 7 to the xiphoid process.

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• COSTOVERTEBRAL JOINT (Figs 1-4, 1-5) ○○ A SYNOVIAL JOINT between the HEAD OF THE RIB and the COSTAL FACETS on the vertebral body. ○○ the RADIATE LIGAMENT fans out from the head of the rib to the body of the vertebra. ○○ INTERARTICULAR LIGAMENT extends from the crest of the head of the rib to the intervertebral disc. • COSTOTRANSVERSE JOINT (Figs 1-4, 1-5) ○○ A SYNOVIAL JOINT between the TUBERCLE OF THE RIB and the COSTAL TUBERCLE FACET on the transverse process of the vertebra. ○○ SUPERIOR COSTOTRANSVERSE LIGAMENT extends downward from the transverse process of the vertebra directly above to the crest of the neck of the rib below. ○○ COSTOTRANSVERSE LIGAMENT PROPER extends from the transverse process to the dorsal neck of the adjacent rib. ○○ LATERAL COSTOTRANSVERSE LIGAMENT extends from the tip of the transverse process to the tubercle of the adjacent rib.

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Fig. 1-4. Thorax. Drawing showing the ligaments supporting the costovertebral and costotransverse joints in lateral (A) and superior (B) view. 1. Superior articular process. 2. Superior articular facet of costovertebral joint. 3. Costal tubercle facet of costotransverse joint. 4. Vertebral body. 5. Superior costotransverse ligaments. 6. Radiate ligaments. 7. Rib. 8. Costovertebral joint. 9. Intervertebral disc. 10. Costotransverse ligament proper. 11. Lateral costotransverse ligament. 12. Spinous process. 13. Vertebral foramen. 14. Superior articular facet. 15. Costal tubercle. (Modified from Gray 1918)

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Fig 1-5. Thorax. Dissection of costovertebral (TOP) and costotransverse (BOTTOM) joints. 1. Anterior longitudinal ligament, 2. Radiate ligament, 3. Intercostal nerves, 4. Superior costotransverse ligament, 5. Levator costarum muscle, 6. Lateral costotransverse ligament, 7. Iliocostalis thoracis, 8. Intertransverse ligament.

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1.3 MUSCLES OF THE THORAX

EXTRINSIC MUSCLES OF THE THORAX

○○ EXTRINSIC MUSCLES attach to the thoracic cage as well as to the humerus, scapula, vertebrae or pelvis. 1) ILIOCOSTALIS LUMBORUM (Fig. 1-6) ○○ Inferior Attachment (Origin): transverse processes of L1-L4, posterior iliac crest, sacrum, thoracolumbar fascia. ○○ Superior Attachment (Insertion): angles of ribs 6-12. ○○ Nerve: dorsal rami of lumbar spinal nerves crossed by muscle. ○○ Actions: extends (both sides), laterally flexes (same side), rotates (same side) the lumbar spine. 360° 2) ILIOCOSTALIS THORACIS (Fig. 1-6) ○○ Inferior Attachment (Origin): posterior aspect of ribs 6-12. ○○ Superior Attachment (Insertion):360° posterior aspects of ribs 1-6. thinking. ○○ Nerve: dorsal rami of thoracic spinal nerves crossed by muscle. ○○ Actions: extends (both sides) and laterally flexes and rotates (same side) the thoracic spine. thinking.

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3) ILIOCOSTALIS CERVICIS (Fig. 1-6) ○○ Inferior Attachment (Origin): angles of ribs 3-6. ○○ Superior Attachment (Insertion): transverse processes of C4-C6. ○○ Nerve: dorsal rami of upper thoracic and lower cervical spinal nerves crossed by muscle. ○○ Actions: extends (both sides), laterally flexes (same side) and rotates (same side) the cervical neck. 4) LONGISSIMUS THORACIS (Fig. 1-6) ○○ Inferior Attachment (Origin): posterior medial iliac crest, posterior sacrum, spinous processes of L3-S3. ○○ Superior Attachment (Insertion): transverse processes of T1-T12; ribs 3-12. ○○ Nerve: dorsal rami of lumbar and thoracic spinal nerves crossed by muscle. ○○ Actions: extends (both sides) and laterally flexes (same side) the lumbar spine; laterally flexes thoracic spine. 5) LEVATOR COSTARUM (Fig. 1-6) ○○ Superior Attachment (Origin): transverse process from C7-T11. ○○ Inferior Attachment (Insertion): angle of rib directly below vertebra of origin. ○○ Nerve: dorsal ramus from C8-T11 spinal nerves. ○○ Actions: raises ribs; extends (both sides), laterally flexes (same side) and rotates (opposite side) the thoracic spine.

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Fig 1-6. Back Muscles: Drawing of the erector spinae group and the transversospinalis group. 1. Muscles of the suboccipital region, 2. Semispinalis cervicis, 3. Semispinalis thoracis, 4. Levator costorum, 5. Multifidus thoracis, 6. Quadratus lumborum, 7. Multifidus lumborum, 8. Tendon of the erector spinae, 9. Iliocostalis lumborum, 10. Longissimus thoracis, 11. Spinalis thoracis, 12. Iliocostalis thoracis, 13. Longissimus thoracis, 14. Ilioicostalis cervicis, 15. Longissimus capitis, 16. Semispinalis capitis. (Modified from Grays 1918)

6) PECTORALIS MAJOR (Fig. 1-7) ○○ Medial attachment (Origin): medial half of the clavicle, manubrium and body. of the sternum; costal cartilage of upper 6 ribs. ○○ Lateral attachment (Insertion): lateral lip of the intertubercular groove of humerus.

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○○ Nerve: lateral pectoral nerve and medial pectoral nerve. ○○ Action: adducts and internally rotates the humerus; flexes extended humerus; extends flexed humerus. 7) PECTORALIS MINOR (Fig. 1-7) ○○ Medial attachment (Origin): mid-clavicular region of ribs 2 through 5. ○○ Lateral attachment (Insertion): medial surface of the coracoid process of scapula. ○○ Nerve: medial pectoral nerve. ○○ Action: depresses the scapula; downward scapular rotation. 8) SUBCLAVIUS (Fig. 1-7) ○○ Medial attachment (Origin): superior surface of rib 1. ○○ Lateral attachment (Insertion): subclavius groove on clavicle. ○○ Nerve: nerve to subclavius. ○○ Action: depresses and stabilize clavicle. 9) SERRATUS ANTERIOR (Fig. 1-7) ○○ Lateral attachment (Origin): muscular slips from the axillary border of ribs 1-9. ○○ Medial attachment (Insertion): medial costal edge of the scapula. ○○ Nerve: long thoracic. ○○ Action: protraction of the scapula, upward rotation of the scapula which elevates glenoid fossa.

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Fig. 1-7. Shoulder: Drawing showing the serratus anterior under the cut pectoralis major and intact pectoralis minor. Note the serratus anterior passes anterior to the subscapularis to attach on the medial border of the scapula. 1. Tendon of short head of biceps, 2. Coracobrachialis, 3. Subscapularis, 4. Coracoid process, 5. Subclavius, 6. Clavicular and sternal heads of the pectoralis major (cut), 7. Pectoralis minor, 8. Internal intercostal, 9. External intercostals, 10. Brachialis,11. Radius, 12. Short head of biceps, 13. Serratus anterior, 14. Latissimus dorsi, 15. Long head of biceps, 16. Pectoralis major tendon cut and reflected. 17. Tendon of long head of biceps, 18. Subacromial – deltoid bursa, 19. Deltoid. (Modified from Gray’s 1918)

10) SCALENUS ANTERIOR (Fig. 1-8) ○○ Proximal attachment (Origin): Anterior tubercle of the transverse process of C3-C6. ○○ Distal attachment (Insertion): Scalenus tubercle and ridge of the first rib. ○○ Nerve: Cervical nerves C5-C8. ○○ Action: Elevation of the first rib, flexion of the cervical neck (both sides), rotation of the cervical spine (opposite side). 11) SCALENUS MEDIUS (Fig. 1-8) ○○ Proximal attachment (Origin): Posterior tubercle of the transverse processes of (C2), C3-C7. ○○ Distal attachment (Insertion): Superior border of the first rib, posterior to the groove for the subclavian artery. ○○ Nerve: Cervical nerves C3-C8. ○○ Action: Elevation of the first rib, flexion of the cervical spine (both sides), rotation of the cervical spine (opposite side).

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12) SCALENUS POSTERIOR (Fig. 1-8) ○○ Proximal attachment (Origin): Posterior tubercle of the transverse processes of C4-C6. ○○ Distal attachment (Insertion): Outer posterior border of the second rib. ○○ Nerve: Cervical nerves (C5), (C6), C7, C8. ○○ Action: Elevation of the second rib, flexion of the cervical region (both sides), lateral bending of the cervical region (same side).

Fig. 1-8. Thorax: Diagram of scalenus anterior (Left), scalenus medius (Middle), and scalenus posterior (Right) showing the bony attachments and the position of these muscle to the subclavian artery.

13) EXTERNAL ABDOMINAL OBLIQUE (See ABDOMINAL WALL; Abdominal Muscles; Figs. 4-3, 4-4, 4-5). 14) INTERNAL ABDOMINAL OBLIQUE (See ABDOMINAL WALL; Abdominal Muscles; Figs. 4-3, 4-4, 4-5). 15) TRANSVERSE ABDOMINIS (See ABDOMINAL WALL; Abdominal Muscles; Figs. 4-3, 4-4, 4-5). 16) RECTUS ABDOMINIS (See ABDOMINAL WALL; Abdominal Muscles; Figs. 4-3, 4-4, 4-5).

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INTRINSIC MUSCLES OF THE THORAX

○○ INTRINSIC MUSCLES attach only to the thoracic cage. 1) ILIOCOSTALIS THORACIS (Fig. 1-6) ○○ Inferior Attachment (Origin): posterior aspects of ribs 6-12, thoracolumbar fascia. ○○ Superior Attachment (Insertion): posterior ribs 1-6 and transverse process of C7. ○○ Nerve: dorsal rami of thoracic spinal nerves crossed by muscle. ○○ Actions: extends (both sides), laterally flexes (same side) and rotates (same side) the thoracic spine. 2) SERRATUS POSTERIOR SUPERIOR (Fig. 1-9) ○○ Medial Attachment (Origin): caudal part of ligamentum nuchae, spinous processes of C7-T3. ○○ Lateral Attachment (Insertion): ribs 2-4 or 5. ○○ Nerve: intercostal nerves T2-T4. ○○ Actions: elevates upper ribs during ventilation, stabilizes upper costovertebral joints of ribs 2-4. 3) SERRATUS POSTERIOR INFERIOR (Fig. 1-9) ○○ Medial Attachment (Origin): spinous processes of T11-L2 or L3. ○○ Lateral Attachment (Insertion): ribs 9-12.

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○○ Nerve: intercostal nerves T9-T11. ○○ Actions: depresses lower ribs during ventilation; stabilizes costovertebral joints of ribs 9-12.

Fig. 1-9. Back Muscles: (LEFT) Drawing of the superficial back muscles and (RIGHT) diagram showing the attachment sites of these muscles. 1a. Upper trapezius; 1b. Middle trapezius; 1c. Lower trapezius; 2. Latissimus dorsi; 3. Levator scapulae; 4. Rhomboid minor; 5. Rhomboid major; 6. Serratus posterior inferior; 7. Thoracolumbar fascia; 8. Splenius cervicis; Splenius capitis, 10. Serratus posterior superior.

4) EXTERNAL INTERCOSTAL (Figs. 1-10, 1-11, 1-13) ○○ Superior attachment (Origin): Inferior body of the rib above, extending from the tubercle of the rib to the costal cartilage; from the costal cartilage junction of the rib to the sternum the muscle is replaced by the external intercostal membrane. ○○ Inferior attachment (Insertion): Superior body and costal cartilage of the rib directly below. ○○ Nerve: Intercostal nerve of that intercostal space. ○○ Action: Lifts the lower rib to expand the anteroposterior diameter of the thoracic cavity during normal and forced inspiration; stabilizes bony thorax. 5) INTERNAL INTERCOSTAL (Figs. 1-10,1-11, 1-13) ○○ Superior attachment (Insertion): Inferior body of the rib above, extending along the costal groove from the angle of the rib to the sternum; from the rib angle posteriorly, the muscle is replaced by the internal intercostal membrane. ○○ Inferior attachment (Origin): Superior border of the rib below, extending from the angle of the rib to the sternum; from the angle posteriorly, the

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internal intercostal membrane attaches to the rib deep to the attachment of external intercostal. ○○ Nerve: Intercostal nerve of that intercostal space. ○○ Action: Depression of the rib above to decrease the thoracic space during forced expiration; may also be active in forced inspiration, stabilizes the bony thorax.

Fig. 1-10. Thorax: Drawing of an anterior view of the thoracic cage showing the intercostal muscles, and location of the intercostal nerve, artery and vein in the intercostal space. (Modified from Gray 1918)

Fig 1-11. Thorax. Dissection of rib cage. 1. Long thoracic nerve, 2. External intercostals muscles, 3. External intercostals membrane (see probe lifting membrane), 4. Radiate sternocostal ligaments, 5. Internal intercostal muscle with external intercostal membrane removed, 6. Sternoclavicular joint. PMj = Pectoralis major, SA = Serratus anterior.

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Fig. 1-12. Thorax. Dissection of posterior internal rib cage. 1. Innermost intercostals muscle, 2. Intercostals nerve lying on internal intercostal membrane, 3. Anterior longitudinal ligament. PPL = parietal pleura.

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6) TRANSVERSUS THORACIC MUSCLE (Figs. 1-10, 1-13) ○○ Inferior attachment (Origin): Internal surface of the costal cartilages from the second through the sixth ribs; inferior body of the sternum and xiphoid process. ○○ Superior attachment (Insertion): Four to five slips of muscle attaching along the inner surface of the costal cartilage of ribs 2-6. ○○ Nerve: Intercostal nerves of the intercostal space. ○○ Action: depresses the ribs during expiration. 7) INNERMOST INTERCOSTAL (Figs. 1-12, 1-13) ○○ Superior attachment (Origin): Along the internal surface of the rib above, extending from the angle of the rib to the costal cartilage. ○○ Inferior attachment (Insertion): On the inner surface of the body of the rib below, from the angle of the rib to the costal cartilage. ○○ Nerve: Intercostal nerve of that intercostal space. ○○ Action: Depression of the rib above to decrease the size of the thoracic cavity during forced expiration; may also be active in forced inspiration, stabilizes the bony thorax. 8) SUBCOSTAL MUSCLE (Fig. 1-13) ○○ Superior attachment (Origin): Inner surface of the angle of the rib above. ○○ Inferior attachment (Insertion): Internal surface of either the rib below or the second rib below the superior attachment. ○○ Nerve: Intercostal nerve at the intercostal space. ○○ Action: Elevation of the ribs below to increase the size of the thoracic cavity for inspiration.

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Fig. 1-13. Thorax: Drawing of a cross-section of the thoracic cage (Top)) showing the divisions of an intercostal nerve relative to the intercostal muscles, and (Bottom) the divisions of an intercostal artery and vein relative to the intercostal muscles. 1. Dorsal ramus N. 2. Subcostal M. 3. Intercostal N. 4. Innermost intercostals M. 5. Posterior intercostals A. 6. Internal intercostal M. 7. Intercostal V. 8. Anterior cutaneous N. 9. External intercostal M. 10. Lateral cutaneous N. 11. Transversus thoracis M. 12. Anterior intercostal A. 13. External intercostal membrane. 14. Azygos V. 15. Thoracic aorta.

DIAPHRAGM (FIGS. 1-14, 1-15, 1-16)

• Peripheral attachment (Origin): ○○ STERNAL PART from the xiphoid process of the sternum. ○○ COSTAL PART from the internal surface of the lower six ribs and costal cartilages. ○○ VERTEBRAL PART from the upper two to three lumbar vertebrae by way of a muscular crus and a medial and lateral arcuate ligament on each side; the arcuate ligaments are extensions of the thoracolumbar fascia. • Central attachment (Insertion): Central tendon of the diaphragm ○○ Nerve: PHRENIC NERVE C3, C4, C5. ○○ Action: Contraction of the diaphragm lowers the central tendon increasing the volume of the thoracic cavity during inspiration. This motion also decreases pressure around the lungs allowing the inward movement of air.

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Fig. 1-14. Lateral view of the thorax showing the anterior to posterior extent of the diaphragm (Modified from Gray 1918)

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Fig 1-16. Thorax. Dissection of thoracic view of diaphragm. 1. Diaphragm muscle fibers, 2. Central tendon, 3. Phrenic nerve, 4. External abdominal oblique muscle, 5. Linea alba, 6. Rectus abdominis.

• DIAPHRAGMATIC OPENINGS (Fig. 1-15) 1) VENA CAVAL FORAMEN for passage of the inferior vena cava. It lies at the level between the T8 and T9 vertebrae. 2) ESOPHAGEAL HIATUS through which passes the esophagus and the right and left vagal trunks which are continuations of the vagus nerves in the thorax. It lies at the level the T10 vertebra. 3) AORTIC HIATUS through which pass the aorta, thoracic duct and the azygos vein. It is formed by the right and left crus of the diaphragm on the sides, the median arcuate ligament anteriorly, and the T12 vertebra posteriorly. 4) PSOAS GAP through which the psoas major muscle, the genitofemoral and ilioinguinal nerves, and the sympathetic chain pass. It lies at the level of the aortic hiatus and lateral to the crura of the diaphragm.

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Fig. 1-15. Thorax. Drawing of the thoracic diaphragm. 1. Caval foramen, 2. Skeletal muscle of diaphragm, 3. Crus (muscular and tendon parts), 4. Aorta in Aortic hiatus, 5. Medial arcuate ligament at Psoas gap, 6. Psoas major, 7. Quadratus Lumborum, 8. Lateral arcuate ligament, 9. Median arcuate ligament, 10. Esophageal hiatus, 11. Central tendon leaflets. (Modified from Gray’s 1918)

1.4 INTERCOSTAL NERVES (FIG. 1-13) • VENTRAL RAMI of T1-T11 spinal nerves. • SUBCOSTAL NERVE is the ventral ramus of the T12 spinal nerve which emerges below the twelfth rib. • INTERCOSTAL NERVES run with the INTERCOSTAL ARTERIES AND VEINS along the costal groove of each rib. • Intercostal nerves provide MOTOR INNERVATIONS to the INTERCOSTAL MUSCLES and SENSORY INPUTS from THE SKIN of the thoracic region. • LATERAL CUTANEOUS NERVE off each intercostal nerve divides into ANTERIOR and POSTERIOR BRANCHES and is sensory to skin of lateral thorax. • Intercostal nerves terminate as the ANTERIOR CUTANEOUS NERVE near the sternum where it branches into a MEDIAL and LATERAL BRANCHES to the skin in the area.

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1.5 INTERCOSTAL ARTERIES AND VEINS (FIGS. 1-13, 1-16, 1-17) ○○ ANTERIOR INTERCOSTAL ARTERIES Anterior intercostal arteries to the FIRST AND SECOND INTERCOSTAL SPACE arise from the HIGHEST THORACIC ARTERY of the first part of theAXILLARY ARTERY. ○○ Anterior intercostal arteries to the SECOND THROUGH SIXTH INTERCOSTAL SPACES are from the INTERNAL THORACIC ARTERY (internal mammary) that lies internally and laterally to the sternum and deep to the transverse thoracis muscle. ○○ TheINTERNAL THORACIC ARTERY divides into a MUSCULOPHRENIC ARTERY and a SUPERIOR EPIGASTRIC ARTERY at sixth to seventh intercostal space. ○○ Anterior intercostal arteries to the SEVENTH THROUGH NINTH INTERCOSTAL SPACES are from the MUSCULOPHRENIC ARTERY which also supplies the DIAPHRAGM. ○○ The TENTH AND ELEVENTH INTERCOSTAL SPACES have NO ANTERIOR INTERCOSTAL ARTERIES and are supplied by only POSTERIOR INTERCOSTAL ARTERIES. ○○ The SUPERIOR EPIGASTRIC ARTERY supplies the DIAPHRAGM and the upper RECTUS ABDOMINIS MUSCLE of the abdomen.

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Fig. 1-16. Thorax: Drawing showing the intercostal arteries. 1. Common carotid artery, 2. Subclavian artery, 3. Internal thoracic artery (internal mammary) , 4. Anterior intercostal arteries, 5. Posterior intercostal arteries, 6. Superior epigastric artery, 7. Musculophrenic artery, 8. Inferior epigastric artery, 9. External iliac artery. (Modified from Gray’s 1918)

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Fig 1-17. Thorax. Dissection of anterior intercostals vessels. 1. Internal thoracic artery, 2. Paired internal thoracic veins, 3. Radiate posterior sternocostal ligament, 4. Superior epigastric artery (cut), 5. Musculophrenic artery, 6. Anterior intercostal artery off musculophrenic, 7. Internal intercostals muscle, 8. Intercostals nerves, 9. Transversus thoracic muscle, 10. Parietal pleura.

• POSTERIOR INTERCOSTAL ARTERIES ○○ Posterior intercostal arteries to the FIRST AND SECOND INTERCOSTAL SPACES receive blood from the SUPREME (SUPERIOR) INTERCOSTAL ARTERY off theCOSTOCERVICAL TRUNK off the subclavian artery. ○○ Posterior intercostal arteries from the THIRD THROUGH THE ELEVENTH INTERCOSTAL SPACES are from the THORACIC AORTA. • ANTERIOR INTERCOSTAL VEINS ○○ Anterior intercostal veins accompany the corresponding intercostal arteries. ○○ Anterior intercostal veins drain into the MUSCULOPHRENIC VEIN and INTERNAL THORACIC VEIN.

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• POSTERIOR INTERCOSTAL VEINS ○○ The right posterior intercostal veins drain into theAZYGOS VEIN. ○○ The left posterior intercostal veins drain into drain into the HEMIAYZGOS and ACCESORY HEMIAZYGOS VEINS. ○○ The hemiazygos and accessory hemiazygos veins drain into the azygos vein and the azygos vein drains into the SUPERIOR VENA CAVA.

1 – STUDY QUESTIONS

1. What is the difference between the extrinsic and intrinsic muscles of the thorax? 2. What intrinsic muscles are deep to the internal intercostal muscles? 3. What passes through the following: a. esophageal hiatus b. aortic hiatus c. psoas gap 4. What is the origin of the anterior intercostal arteries? 5. For each of the following lesions, what would be affected? a. spinal nerve at T5 b. lateral cutaneous nerve of an intercostal nerve? c. anterior cutaneous nerve of an intercostal nerve?

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2 THE LUNGS

LUNG SURFACES

1) The APEX of the lung lies at the T1 vertebral level and projects superiorly above the medial clavicle and into the superior thoracic aperture. 2) The COSTAL SURFACE extends from the spine to the sternum, following the curvature of the rib cage. 3) TheDIAPHRAGMATIC SURFACE lies at the inferior base of the lung and follows the concave curvature of the diaphragm ○○ The anterior diaphragmatic surface of the ling is more cranial then its posterior surface. ○○ At rest, the inferior border of the lung lies at the 6th rib in the mid-clavicular line, at the 8th rib in the mid-axillary line and at the T10 vertebra posteriorly (Fig. 14-01). 4) The MEDIAL SURFACE of the lung faces the heart ○○ The pulmonary arteries, veins and bronchi enter this surface together at the HILUS OF THE LUNG. ○○ This conduit of pulmonary vessels and bronchi entering the hilus is the ROOT OF THE LUNG.

Fig. 2-1. Lungs: Drawing of the thoracic cage showing the position of the lungs in anterior (Left) and posterior (Right) views. 1. dome of pleura, 2. left upper lobe, 3. oblique fissure of left lung, 4. left lower lobe, 5. costodiaphragmatic recess of pleura, 6. right lower lobe, 7. right upper lobe, 8. right middle lobe, and 9. horizontal fissure. (Modified from Gray 1918)

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2.1 THE PLEURA (FIG. 2-2) • PLEURA is two very thin layers of cells that surround each lung. • VISCERAL PLEURA is the layer that lies on the surface of the lung. • PARIETAL PLEURA is the layer lies along the inner wall of the thoracic cavity. • PLEURAL CAVITY is space between the visceral and parietal pleura of each lung. • PLEURAL REGIONS 1) The COPULA (dome) of the lung covers the apex and extends into the superior thoracic aperture. 2) COSTAL PLEURA lines the anterior, lateral and posterior walls of the rib cage. 3) DIAPHRAGMATIC PLEURA covers the cranial surface of the diaphragm and forms the floor of the pleural cavity. 4) MEDIASTINAL PLEURA covers the medial surface of the lungs, surrounds the pulmonary vessels and bronchi at the root of the lung and is continuous with the costal and diaphragmatic pleura and with the copula of the lung. 5) PULMONARY LIGAMENT is inferior to the root of the lung, where mediastinal parietal pleura fuses with the visceral pleura to form the two- layered ligament.

Fig. 2-2. Lungs: Drawing showing the layers of pleura. 1. trachea, 2. right upper lobe, 3. horizontal fissure, 4. middle lobe, 5. oblique fissure. 6. right lower lobe, 7. costal pleura, 8. costodiaphragmatic recess, 9. diaphragmatic pleura, 10. mediastinal pleura, 11. cardiac notch, 12. lingual of right upper lobe, 13. left lower lobe, 14. oblique fissure, 15. left upper lobe, 16. copula.

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• PLEURAL RECESSES (Fig. 2-2) ○○ The lower limits of the parietal pleura are caudal to those of the lung during quiet breathing. ○○ The parietal pleura lies at the level of the 8TH RIB IN THE MID-CLAVICULAR LINE, at the level of the 10TH RIB IN THE MID-AXILLARY LINE and at the level of the T12 VERTEBRA POSTERIORLY. ○○ PLEURAL RECESSES are the spaces between the parietal plural. ○○ COSTODIAPHRAGMATIC RECESS is formed inferiorly where the costal pleura becomes continuous with the diaphragmatic pleura. ○○ COSTOMEDIASTINAL RECESS lies anteriorly at the 4th and 5th intercostal space where the costal parietal pleura meets the mediastinal parietal pleura.

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2.2 LOBES OF THE LUNG (FIGS 2-3, 2-4)

RIGHT LUNG

○○ Divided into an UPPER, MIDDLE, AND LOWER LOBE by the oblique and horizontal fissures. ○○ TheOBLIQUE FISSURE runs from the vertebral border of the lung to the sternum, approximating the course of the 6th rib, ▪▪ Anterior to the mid-axillary line oblique fissure separates the MIDDLE AND LOWER LOBES. ▪▪ Posterior to the mid-axillary line, there is usually no middle lobe and the oblique fissure separates theUPPER AND LOWER LOBES. ○○ TheHORIZONTAL FISSURE begins in the mid-axillary line from the oblique fissure to the 4th costal cartilage and separates THE UPPER AND MIDDLE LOBES.

Fig. 2-3. Lungs: 1. Right upper lobe, 2. Left upper lobe, 3. Right middle lobe, 4. Right lower lobe, 5. Left lower lobe, A. Trachea, B. Primary bronchus, C. Lobar (secondary) bronchi, D. Segmental (tertiary) bronchi. (Modified from Gray 1918)

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LEFT LUNG

○○ Divided into an UPPER AND LOWER LOBE. ○○ The OBLIQUE FISSURE separates these lobes and approximates the course of the 7th rib. ○○ The CARDIAC NOTCH is an indentation in the medial upper lobe of the left lung because of the heart. ○○ The LINGULA is a tongue-like protrusion in the upper lobe below the cardiac notch.

Fig 2-4. Thorax. Dissection of the RIGHT LUNG on the left side of photo and LEFT LUNG on the right side. 1. Upper lobe of right lung, 2. Horizontal fissure, 3. Oblique fissure of right lung, 4. Lower lobe of right lung, 5. Middle lobe of right lung, 6. Lingual part of left upper lobe of left lung, 7. Lower lobe of left lung, 8. Oblique fissure of left lung, 9. Upper lobe of left lung.

BRONCHIAL TREE (FIGS. 2-5, 2-6)

• Air travels from the nasal cavity into the TRACHEA in which the walls are reinforced by distinct rings of hyaline cartilage. • The trachea divides into a RIGHT and LEFT PRIMARY BRONCHI which also have rings of hyaline cartilage reinforcing the walls.

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• The primary bronchus divides into SECONDARY (LOBAR) BRONCHI, one for each lobe of the lung, containing islands of hyaline cartilage and smooth muscle supporting the walls. • The secondary bronchi divide into TERTIARY (segmental) BRONCHI with islands of hyaline cartilage and smooth muscle supporting the walls, enter BRONCHOPULMONARY SEGMENTS and named by the segment it enters (Figs. 2-7, 2-8). • The tertiary bronchus subdivides into a series of TERMINAL BRONCHIOLES which are supported with smooth muscle. • The terminal bronchioles divide into RESPIRATORY BRONCHIOLES, in in which the walls are smooth muscle and alveoli. • The respiratory bronchioles, in divide into ALVEOLAR DUCTS which are lined with alveoli. • The alveolar ducts continue as ALVEOLAR SACS which are sac-like structures line with alveoli.

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Fig. 2-5. Mirror image drawing of the tachea and bronchi (A) showing their position and the decrease in cartilage as the bronchi divide (modified from Gray’s 1918). Diagram (B) of the terminal bronchiole, respiratory bronchiole, alveolar duct, alveolar sac and (C) alveoli showing type I and type II cells, septa and capillary network.

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Fig. 2-6. Lungs: A) Photomicrograph of lung tissue showing a cross-section of a tertiary bronchus (B), terminal bronchiole (TB) and alveoli (A). B) Photomicrograph of alveoli showing the distribution of blood vessels around alveoli (A).

• ALVEOLI (Figs. 2-5, 2-6) ○○ Alveoli are very thin walled sacs where gas exchange occurs. ○○ The walls contain CAPILLARIES and a single layer of PNEUMOCYTES or TYPE I CELLS. ○○ Alveoli also contain cuboidal TYPE II CELLS which secrete surfactant that enables these thin walled air sacs to remain inflated. • BRONCHOPULMONARY SEGMENTS (Fig. 2-7, 2-8) ○○ Each TERTIARY (segmental) BRONCHI enters a BRONCHOPULMONARY SEGMENT. ○○ The tertiary bronchi and segment have the same name. ○○ Each bronchopulmonary segment contains TERMINAL BRONCHIOLES, RESPIRATORY BRONCHIOLES, ALVEOLAR DUCTS, ALVEOLAR SACS and ALVEOLI.

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Fig. 2-7. Lung: Bronchopulmonary Segments: Striped areas = lower lobes, dotted areas = upper lobes, and non-shaded area = middle lobe. 1. Posterior segment of right upper lobe (RUL), 2. apical (RUL), 3. anterior (RUL), 4. medial of middle lobe (ML), 5. anterior basal of right lower lobe (RLL), 6. lateral basal (RLL), 7. medial basal (RLL), 8. posterior basal (RLL), 9. superior/ (RLL), 10. apical of left upper lobe (LUL), 11. anterior (LUL), 12. superior lingular (LUL), 13. inferior lingular (LUL), 14. medial basal (LLL), 15. anterior basal (LLL), 16. lateral basal (LLL), 17. posterior basal (LLL), 18. superior/ l (LLL), 19. posterior (LUL), and 20. lateral of middle lobe (ML). 10 & 19 are often combined into apicoposterior segment of upper left lobe.

○○ LEFT UPPER LOBE has an APICAL segment and a POSTERIOR segment (or a combined apicoposterior segment); an ANTERIOR segment; SUPERIOR LINGUAL segment, and INFERIOR LINGUAL segment. ○○ RIGHT UPPER LOBE has an APICAL segment, an ANTERIOR segment and a POSTERIOR segment. ○○ MIDDLE LOBE (only right lung) has a MEDIAL segment and a LATERAL segment. ○○ LEFT and RIGHT LOWER LOBES both have a SUPERIOR segment, an ANTERIOR BASAL segment, a POSTERIOR BASAL segment, a MEDIAL BASAL segment, and a LATERAL BASAL segment.

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Fig. 2-8. Dissection showing the bronchopulmonary segments. (TOP) Right and left lungs. (BOTTOM LEFT) Right lung. (BOTTOM RIGHT) Base of lower lobe of right lung. 1.Apical seg., 2. Anterior seg., 3. Lateral seg. of middle lobe, 4. Superior seg., 5. Anterior basal seg. 6. Medial seg. of middle lobe, 7. Superior lingual seg. of left upper lobe, 8. Inferior lingual seg. of left upper lobe, 9. Lateral basal seg., 10. Posterior (apicoposterior) seg. of left lung, 11. Posterior seg. of right upper lung, 12. Posterior basal seg., 13. Lateral basal seg., 14. Middle lobe, 15. Oblique fissure.

2.3 PULMONARY VESSELS (FIGS. 2-9, 2-10) • The PULMONARY TRUNK from the right ventricle of the heart divides into RIGHT and LEFT PULMONARY ARTERIES carrying deoxygenated blood to the lungs ○○ Branches of the pulmonary arteries follow the branches of the bronchial tree to each of the bronchopulmonary segments and alveoli. ○○ These arterial branches are named by the accompanying branches of the bronchial tree.

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• The SUPERIOR and INFERIOR PULMONARY VEINS leave each lung with oxygenated blood and to enter the left atrium of the heart ○○ The right superior pulmonary vein drains the upper and middle lobes of the right lung. ○○ The left superior pulmonary vein drains the upper lobe of the left lung including the lingula and cardiac notch area. ○○ The right and left inferior pulmonary veins drain the respective lower lobe of the lung. ○○ Branches of the pulmonary veins run along with branches of the pulmonary arteries and bronchial tree. ○○ These venous branches are named by the branch of the bronchial tree accompanying the vein and artery.

Fig. 2-9. Lungs: Transverse section of the thorax showing heart, lungs, pleura, pulmonary arteries and veins, bronchi, structures in posterior mediastinum. (Modified Gray’s 1918)

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Fig. 2-10. Thorax. Hilus of lung showing bronchi and pulmonary vessels. 1. Lymph node, 2. Pulmonary veins, 3. Pulmonary artery, 4. Lobar bronchi. Notice the thick cartilage in the walls of the bronchi and the thickness of the walls of the artery compared to the thin walls of the vein.

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• BRONCHIAL ARTERIES to the bronchial tree and tissues of the lung receive blood through arteries usually arise from the THORACIC AORTA but also from POSTERIOR INTERCOSTAL arteries and from the ARCH OF THE AORTA. • BRONCHIAL VEINS from the lung tissue travel with bronchial arteries ○○ From each lung, small bronchial veins converge to form a single bronchial vein. ○○ This single vein enters the azygos vein on the right and the hemiazygos vein on the left.

2 – STUDY QUESTIONS:

1) What is the difference between the parietal and visceral pleura? 2) What bronchopulmonary segments are in the right lung but not in the left? 3) What bronchopulmonary segments are in the left lung but not in the right? 4) What are the differences between the left upper lobe and the right upper lobe? 5) What is the difference in bronchopulmonary segment arrangement between the right lower lobe and the left lower lobe? 6) Beginning with the primary bronchus and ending in the alveolus, what are the sequential divisions of the bronchial tree? 7) What cell in the alveolus is responsible for surfactant production?

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3 HEART

3.1 MEDIASTINUM (FIG. 3-1) • Central region of the thoracic cavity extending between the lungs from the sternum to the thoracic vertebrae. • REGIONS 1) The ANTERIOR MEDIASTINUM is the narrow space between the sternum and the pericardium of the heart ○○ In infants, this space contains part of the THYMUS GLAND. ○○ In adults it is filled mainly with fat and connective tissue. 2) The MIDDLE MEDIASTINUM is the region containing the heart and pericardial sac. 3) The POSTERIOR MEDIASTINUM lies between the vertebral bodies and the posterior aspect of the heart ○○ It contains the thoracic aorta, azygos and hemiazygos veins, esophagus, vagal trunks and sympathetic trunk. 4) The SUPERIOR MEDIASTINUM lies above the heart and overlaps the anterior, middle and posterior mediastinum superiorly ○○ Its inferior border is a line connecting the sternal angle anteriorly with the intervertebral disk between T4 and T5 posteriorly. ○○ Its superior border is the superior thoracic aperture (first rib). ○○ It contains the aorta and its branches, vena cave and brachiocephalic veins, the vagus nerves, the recurrent laryngeal nerves, the phrenic nerves, the trachea, esophagus, and the cranial end of the thoracic duct.

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Fig. 3-1. Heart: Diagram of a lateral view of the thoracic region showing the position of the superior, anterior, middle, and posterior mediastinum.

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3.2 PERICARDIUM (FIG. 3-2) • FIBROUS PERICARDIUM is the outermost layer of the pericardium • Attached inferiorly to the central tendon of the diaphragm. • Attached to the sternum by weak STERNOPERICARDIAL LIGAMENT. • SEROUS PERICARDIUM has two thin layers of cells around the heart ○○ VISCERAL SEROUS PERICARDIUM is the innermost layer and lies directly on the heart. ○○ PARIETAL SEROUS PERICARDIUM is the outer layer and it lies on the internal surface of the fibrous pericardium. • PERICARDIAL CAVITY is between the two serous layers of pericardium.

Fig. 3-2. Heart: Diagram of a lateral view of the heart showing the different layers of the pericardium.

3.3 HEART OVERVIEW (FIG. 3-3) • The heart is in the MIDDLE MEDIASTINUM, extending from the fifth to the eighth thoracic vertebrae. • A muscular pump with four chambers composed of CARDIAC MUSCLE. • RIGHT ATRIUM receives deoxygenated venous blood from the body. • RIGHT VENTRICLE pumps this venous blood to the lungs. • LEFT ATRIUM receives oxygenated blood from the lungs. • LEFT VENTRICLE pumps it to the body.

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• BLOOD FLOW through the heart ○○ Blood from the body enters the inferior and superior venae cava and flows into the right atrium. ○○ Blood then passes through the right atrioventricular valve into the right ventricle. ○○ Blood from the right ventricle travels through the pulmonary valve into the pulmonary trunk and then into the pulmonary arteries to the lungs. ○○ Blood from the lungs returns to the heart through the pulmonary veins to the left atrium. ○○ Blood from the left atrium flows through the left atrioventricular valve into the left ventricle. ○○ Blood from the left ventricle flows through the aortic valve into the aorta and back to the body.

Fig. 3-3. Heart: 1. superior vena cava, 2. aorta, 3. pulmonary artery, 4. aortic valve, 5. left atrium, 6. pulmonary veins, 7. left atrioventricular valve, 8. left ventricle, 9. right ventricle, 10. right atrioventricular valve, 11. inferior vena cava, 12. right atrium, and 13. pulmonary valve. The arrows show the direction of blood.

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ANTERIOR SURFACE OF THE HEART (FIGS. 3-4, 3-11, 3-12)

• On the right side, SUPERIOR AND INFERIOR VENAE CAVAE enter the RIGHT ATRIUM. • Protruding from the right atrium is a small ear-like RIGHT AURICLE. • Just superior to the right auricle is the ASCENDING AORTA that arises from the left ventricle. • The ascending aorta curves posteriorly forming theAORTIC ARCH. • Passing under the aortic arch is the PULMONARY TRUNK that exits from the right ventricle. • Left of the right atrium and is the RIGHT VENTRICLE which forms most of the anterior most part of the heart. • At the left anterior border of the heart, the inferior surface forms the rounded APEX of the LEFT VENTRICLE. • Superior to the apex and left of the pulmonary trunk is the LEFT AURICLE of the LEFT ATRIUM. • Under the right auricle and between the right atrium and right ventricle is the CORONARY SULCUS containing the RIGHT CORONARY ARTERY.

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• At the right inferior margin of the right atrium, the right coronary bends gives off the RIGHT MARGINAL ARTERY that runs along the inferior edge of the right ventricle. • Under the left auricle, is the short LEFT CORONARY ARTERY that divides into the ANTERIOR INTERVENTRICULAR ARTERY and the CIRCUMFLEX ARTERY. • The anterior interventricular artery runs downward between the right and left ventricles with the GREAT CARDIAC VEIN. • TheCIRCUMFLEX ARTERY runs posteriorly between the left atrium and ventricle in the coronary sulcus.

POSTERIOR SURFACE OF THE HEART (FIG. 3-4)

• The RIGHT ATRIUM and the INFERIOR AND SUPERIOR VENA CAVA are at the right limits of the posterior heart. • The LEFT ATRIUM is left and posterior to the right atrium. • The two SUPERIOR and two INFERIOR PULMONARY VEINS enter the left atrium. • Below the left atrium is the LEFT VENTRICLE. • Between the left atrium and left ventricle is the posterior continuation of the CORONARY SULCUS. • The coronary sulcus contains the CIRCUMFLEX ARTERY off the left coronary artery, the RIGHT CORONARY ARTERY and the CORONARY VENOUS SINUS (Figs. 3-4, 3-12). • In the sulcus, the CIRCUMFLEX ARTERY anastomoses with the RIGHT CORONARY ARTERY and the right coronary artery gives off the POSTERIOR INTERVENTRICULAR ARTERY (Figs. 3-4, 3-11, 3-12). • With the posterior interventricular artery is the MIDDLE CARDIAC VEIN (Figs. 3-4, 3-12).

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Fig. 3-4. Heart: Drawings of A) a sternal view and B) a posterior view of the heart, and C) a frontal radiograph of the thorax showing the position of the heart. 1. Left common carotid A., 2. edge of pericardium (cut), 3. pulmonary A., 4. anterior interventricular A. and great cardiac vein, 5. aorta, 6. apex, 7. left ventricle, 8.left auricle, 9. right ventricle, 10. right coronary artery, 11. right auricle, 12. right atrium, 13. superior vena cava, 14. brachiocephalic veins, 15. brachiocephalic trunk, 16. subclavian artery, 17. right common carotid, 18. azygos vein opening, 19. inferior vena cava, 20. small cardiac vein, 21. right marginal vein, 22. posterior interventricular artery with middle cardiac vein, 23. left marginal vein, 24. great cardiac vein, 25. oblique vein of left atrium, 26. left atrium, 27. right atrium, and 28. coronary sinus, 29. pulmonary vein, 30. Pulmonary vessels. (A and B modified from Gray 1918)

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RIGHT ATRIUM (FIGS. 3-5, 3-6, 3-9)

• Internally, the right atrium is smooth along the interatrial septum and where the superior and inferior vena cava and coronary sinus enter the chamber. • TheFOSSA OVALIS is an oval indentation near the center of the interatrial septum ○○ Embryologically, this fossa was a valve-like opening called the FORAMEN OVALIS which permitted blood to flow directly from the right atrium into the left atrium. ○○ At birth the foramen ovalis closes and forms the FOSSA OVALIS. • The MUSCULAE PECTENATI consists of irregular muscular bands lining the other walls of the right atrium. • The CRISTAE TERMINALIS is a distinct ridge separating the musculae pectenati and the smooth wall of the atrium.

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RIGHT VENTRICLE (FIGS. 3-5, 3-7, 3-8, 3-9)

• TheRIGHT ATRIOVENTRICULAR or TRICUSPID VALVE with its ANTERIOR, SEPTAL, and POSTERIOR CUSPS. is between the right atrium and the right ventricle. • The CHORDAE TENDINEAE are rope-like tendons that attach to the ventricular surfaces of these cusps. • These tendons connect to finger-like muscles called PAPILLARY MUSCLES that arise from the walls of the ventricle and prevent the cusps from moving into the right atrium. • TRABECULAE CARNEAE are distinct ridges of cardiac muscle that line most of the walls of the right ventricle. • The PULMONARY TRUNK exists the right ventricle. • The PULMONARY VALVE guards the exist of the pulmonary trunk to prevent blood from re-entering the right ventricle ○○ The pulmonary valve consists of an anterior, a right, and a left cusp. ○○ Because of the shape of these cusps, the pulmonary valve is described as a SEMILUNAR VALVE.

Fig. 3-5. Heart: Drawing of the right side of the heart showing the inside of the right atrium and right ventricle. 1. Superior vena cava opening, 2. Musculae pectinati at crista terminalis, 3. Atrial septum, 4. Fossa ovalis and limbus, 5. Coronary sinus opening, 6. Inferior vena cava opening 7. Valve of inferior vena cava, 8. Valve of coronary sinus, 9. Trabeculae carneae, 10. Papillary muscles, 11. Chorda tendineae 12. Tricuspid valve cusps, 13. Pulmonary valves. (Modified from Gray’s 1918)

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Fig 3-6. Heart. Dissection showing (A) right atrium and (B) left atrium. 1. Openings for anterior cardiac veins, 2. Fossa ovalis, 3. Opening and valve for coronary sinus, 4. Right coronary artery, 5. Musculae pectinati, 6. Cristae terminalis, 7. Aorta, 8. Pulmonary artery, 9. Smooth wall of left atrium, 10. Coronary sinus, 11. Left ventricle, 12. Posterior interventricular artery, 13. Right atrium, 14. Pulmonary vein.

LEFT ATRIUM (FIGS. 3-6, 3-8, 3-9)

• The most posterior portion of the heart. • Its thin, smooth walls of cardiac muscle are penetrated by the SUPERIOR AND INFERIOR PULMONARY VEINS.

LEFT VENTRICLE (FIGS. 3-6, 3-7, 3-9)

• The most muscular of the four chambers. • The very thick and jagged TRABECULAE CARNEAE line the cardiac muscle walls. • The LEFT ATRIOVENTRICULAR or MITRAL VALVE are between the left atrium and the left ventricle ○○ This valve hasANTERIOR and POSTERIOR CUSPS. ○○ It is also described as a BICUSPID VALVE. • CHORDAE TENDINEAE attach the cusps of the left atrioventricular valve to PAPILLARY MUSCLES from the walls of the ventricle.

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• The ASCENDING AORTA leaves the left ventricle which is guarded by the AORTIC VALVE ○○ The aortic valve has LEFT, RIGHT, and POSTERIOR SEMILUNAR CUSPS which allows blood to leave the left ventricle but not re-enter it. ○○ A concave, bowl-like AORTIC SINUS lies on the superior aortic surface of each cusp and fills with the blood that is not full ejected through the aorta. ○○ The RIGHT AND THE LEFT CORONARY ARTERIES open into the AORTIC SINUS of the RIGHT and the LEFT AORTIC CUSPS respectively. ○○ Blood pooling in the aortic sinuses fills the coronary arteries after the valves close and also prevents the cusps from sticking to the inner walls of the ascending aorta.

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Fig 3-7. Heart. Coronal section through the right and left ventricles showing the internal anatomy of the ventricular chambers. The left ventricle is the left chamber and the right ventricle the right chamber. 1. Papillary muscle, 2. Thick myocardial wall of left ventricle, 3. Interventricular septum, 4. Trabeculae carneae muscle, 5. Ventricular pacemaker lead, 6. Chordae tendineae, 7. Valve leaflets.

Fig 3-8. Heart. Dissection of showing right AV valve on the left and left mitral (AV) valve leaflets on the right. 1. Right AV valve leaflets, 2. Trabeculae carneae muscle, 3. Chordae tendineae, 4. capillary muscle, 5. Right ventricular side wall of interventricular septum, 6. Left ventricle, 7. Aorta, 8. Left AV (Mitral) valve leaflets viewed from the left atrium, 9. Smooth wall of left atrium.

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CONDUCTION SYSTEM OF THE HEART (FIG. 3-9)

• PURKINJE CELLS are modified cardiac muscle cells in the ventricles and papillary muscles that are specialize to conduct impulses to synchronize the contraction of the heart. • Interconnecting PARTS OF THE CONDUCTING SYSTEM of the heart 1) SINOATRIAL (SA) NODE is in the superior right atrium near the opening for the superior vena cava. 2) ATRIOVENTRICULAR (AV) NODE is in the inferior right atrium near the opening for the coronary sinus and receives impulses from the sinoatrial node. 3) ATRIOVENTRICULAR BUNDLE or the BUNDLE OF HIS transmits impulses from the atrioventricular node downward into the upper part of the interventricular septum, just inferior to the atrioventricular valves. 4) RIGHT BUNDLE BRANCH (right crus) and LEFT BUNDLE BRANCH (left crus) of the atrioventricular bundle conducts impulses along the interventricular septum. 5) a SUBENDOCARDIAL BRANCH from the right bundle that goes to the anterior papillary muscle through the SEPTAMARGINAL TRABECULA (MODERATOR BAND) and then the rest of the right ventricle. 6) MULTIPLE SUBENDOCARDIAL BRANCHES from the left bundle go to the anterior and posterior papillary muscles and left ventricular wall. • The conduction system INDEPENDENTLY PRODUCES RHYTHMIC CONTRACTION of the heart muscle. • TheAUTONOMIC NERVOUS SYSTEM can change the rate of these contractions ○○ The AUTONOMIC CARDIAC PLEXUS is a nerve network between the bifurcation of the trachea and the arch of the aorta ▪▪ Both parasympathetic VAGUS NERVES (X) send SUPERIOR and INFERIOR CARDIAC BRANCHES in the neck and several THORACIC CARDIAC BRANCHES in the thorax to the cardiac plexus. ▪▪ From the sympathetic chains, the SUPERIOR CERVICAL GANGLIA give off a SUPERIOR CARDIAC NERVES, the MIDDLE CERVICAL GANGLIA give off a MIDDLE CARDIAC NERVES, and INFERIOR CERVICAL GANGLIA (or THE STELLATE GANGLIA) give off an INFERIOR CARDIAC NERVES to the cardiac Plexus. ▪▪ THORACIC T1-T4 (T5) SYMPATHETIC GANGLIA give off THORACIC CARDIAC NERVES to the cardiac plexus. • The CARDIAC PLEXUS diverges to form two CORONARY PLEXUSES ○○ One coronary plexus runs along the RIGHT CORONARY ARTERY. ○○ The other coronary plexus runs along theLEFT CORONARY ARTERY. ○○ Both coronary plexuses affect the conduction system of the heart.

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Fig. 3-9. Heart: The heart sectioned to show the internal anatomy of the atria and ventricles, and the conduction system of the heart. 1. superior vena cava, 2. sinoatrial (SA) node, 3. inferior vena cava, 4. membranous septum, 5. atrioventricular (AV) node, 6. right atrioventricular valve, 7. right ventricle, 8. ventricular branch, 9. papillary muscle, 10. bundle of His, 11. trabeculae carneae, 12. papillary muscle, 13. left atrioventricular valve, 14. aortic valve, 16. aorta (Modified from Gray 1918)

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Fig 3-10. Heart. Dissection showing (LEFT) the septamarginal trabecula (moderator band) from ventricular wall to the anterior papillary muscle and ventricular muscle. and (RIGHT) leads from a pacemaker to the right atrium and right interventricular septum. 1. Anterior papillary muscle of right ventricle, 2. Interventricular septal surface of right ventricle, 3. Septamarginal trabeculae (moderator band), 4. Pacemaker leads entering right atrium through superior vena cava, 5. Atrial pacemaker lead, 6. Ventricular pacemaker lead, 7. Another atrial pacemaker lead, 8. Musculae pectinati.

CORONARY ARTERIES (FIGS. 3-11, 3-12, 3-13)

• LEFT AND RIGHT CORONARY ARTERIES arise from the ASCENDING AORTA. • LEFT CORONARY ARTERY is short and quickly subdivides ○○ ANTERIOR INTERVENTRICULAR ARTERY that runs along the anterior surface of the heart. ○○ CIRCUMFLEX BRANCH curves posteriorly under the left auricle to run between the left atrium and left ventricle ▪▪ on the posterior heart, circumflex gives it off a LEFT MARGINAL BRANCH to the left ventricle. • RIGHT CORONARY ARTERY runs in the right coronary sulcus between the right atrium and right ventricle ○○ RIGHT MARGINAL BRANCH runs along the anterior-inferior margin of the right ventricle. ○○ POSTERIOR INTERVENTRICULAR ARTERY runs on the posterior aspect of the heart, between the right and left ventricles and anastomoses with the ANTERIOR INTERVENTRICULAR ARTERY from the left coronary.

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○○ Right coronary artery ends by anastomosing with the circumflex artery of the left coronary usually in the area between the left atrium and left ventricle.

Fig. 3-11. Heart: Drawing of the arteries of the heart. Branches of the left coronary artery supply the left atrium, the left ventricle and interventricular septum, the anterior part of the right ventricle, and the interventricular bundle of His. Branches of the right coronary artery supply the right and left atria, right ventricle, posterior part of the left ventricle and interventricular septum, the interatrial septum, and the sinoatrial and atrioventricular nodes.

CARDIAC VEINS (FIGS. 3-4, 3-12)

• CORONARY SINUS lies in the coronary sulcus ○○ It empties into the lower right atrium near the opening of the inferior vena cava. ○○ It receives venous blood from CARDIAC VEINS from the right and left ventricles and left atrium.

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• CARDIAC VEINS TO CORONARY SINUS 1) GREAT CARDIAC VEIN that runs with the anterior interventricular artery. 2) MIDDLE CARDIAC VEIN that runs with the posterior interventricular artery. 3) LEFT AND RIGHT MARGINAL VEINS that run along the corresponding arteries. 4) SMALL CARDIAC VEIN that runs with the right coronary artery and drains into the coronary sinus just before the sinus enters the right atrium. • ANTERIOR CARDIAC VEINS return venous blood supply from the anterior right upper ventricle directly to the right atrium.

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Fig 3-12. Heart. Dissection of coronary arteries and veins. 1. Aorta, 2. Right auricle, 3. Right coronary artery, 4. Left coronary artery, 5. Right ventricle, 6. Anterior interventricular artery, 7. Left ventricle, 8. Left marginal artery, 9. Circumflex coronary artery, 10. Left auricle 11. Pulmonary trunk, 12. Left atrium, 13. Pulmonary veins, 14. Great cardiac vein entering coronary sinus, 15. Coronary sinus, 16. Middle cardiac vein, 17. Posterior interventricular artery, 18. Opening of inferior vena cava, 19. Right atrium.

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Fig 3-13. Heart. Dissection showing coronary artery by-passes (LEFT and UPPER RIGHT) and connections of by- passes to the ascending aorta (LOWER RIGHT). 1. Site of by-passes existing the ascending aorta, 2. Right coronary artery by-pass, 3. Anterior interventricular artery by-pass, 4. By-passes from aorta going to the left coronary artery, 5. Internal thoracic artery feeding into left coronary by-pass, 6. Circumflex coronary by-pass, 7. Aortic valves, 8. Connection of by-passes into ascending aorta.

3.4 STRUCTURE OF ARTERIES AND VEINS (FIG. 15-14) • LAYERS of arteries and veins 1) The innermost layer is the INTIMA and it contains a layer of simple squamous epithelial cells or ENDOTHELIAL CELLS which line the lumen of all blood vessels. 2) The middle layer is the MEDIA and it consists of varying amounts of smooth muscle, collagen and elastics fibers depending on the type of blood vessel. 3) The outermost is layer the ADVENTITIA and it contains mainly collagen fibers but in large and some medium size veins the adventitia also has longitudinal bundles of smooth muscle.

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• ARTERIES 1) LARGE ELASTIC ARTERIES, such as the aorta and pulmonary trunk ○○ thick INTIMA with a distinct layer of elastic fibers. ○○ the MEDIA has an abundance of smooth muscle and elastic fibers. ○○ the ADVENTITIA is primarily collagen fibers. 2) MEDIUM SIZE ARTERIES or MUSCULAR ARTERIES ○○ the INTIMA shows a distinct layer of elastic fibers. ○○ the MEDIA has a thick, distinct layer of circular smooth muscle. ○○ the ADVENTITIA is thick also and composed primarily of collagen fibers with some interweaving elastic fibers. 3) SMALL ARTERIES or ARTERIOLES ○○ the INTIMA has only a few elastic fibers. ○○ the MEDIA has only a few layers of circular smooth muscle. ○○ the ADVENTITIA is thin and contains mostly collagen fibers. • VEINS (Fig. 3-14) 1) LARGE VEINS, such as the superior and inferior vena cava, ○○ the INTIMA is thin and contains endothelial cells, a few elastic fibers, and a thin zone of collagen fibers.

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○○ the MEDIA is thin with primarily of collagen fibers, a few elastic fibers and some smooth muscle cells. ○○ the ADVENTITIA is thick with an abundance of collagen fibers and distinct bundles of smooth muscles running longitudinally along the length of the vein. 2) MEDIUM SIZE VEINS ○○ a very thin INTIMA containing mainly endothelial cells with a few collagen fibers. ○○ the MEDIA is thin with collagen fibers with some smooth muscle cells. ○○ the ADVENTITIA of these veins is distinct with collagen fibers, elastic fibers and some smooth muscle. 3) SMALL VEINS ○○ a very thin INTIMA composed mainly of endothelial cells. ○○ the very thin MEDIA with only a few collagen fibers. ○○ the ADVENTITIA has a few layers of collagen fibers mixed with some elastic fibers. • CAPILLARIES ○○ capillaries communicate between the small arteries and the small veins. ○○ capillaries are small vessels formed mainly by a single layer of endothelial cells. ○○ endothelial cells of CONTINUOUS CAPILLARIES show no pores. ○○ endothelial cells of FENESTRATED CAPILLARIES show thin porous regions called FENESTRA that permit the passage of material easily between the capillary and the surrounding tissue.

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Fig. 3-14. Heart: Photomicrographs of A) the wall of the aorta, B) a neurovascular bundle showing a nerve, medium vein and muscular (medium) artery, C) the wall of the vena cava, and D) continuous capillaries within skeletal muscle.

3 – STUDY QUESTIONS:

1) What are the boundaries of the four mediastina? 2) The pericardial sac (cavity) lies between which two pericardial layers? 3) Describe the flow of blood from the inferior vena cava to the aorta. In your description include the valves. 4) If the anterior chest is crushed inward, what are the anterior (sternal) structures that might be directly damaged? 5) If a large tumor mass were pressing on the posterior heart, what posterior structures of the heart might be compressed?

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6) What structures of the heart cannot be seen with a posterior view of the heart? 7) What structures of the heart cannot be seen with an anterior view of the heart? 8) What veins flow into the coronary sinus? 9) What four veins empty into the right atrium? 10) What artery runs with the following veins: a. Great cardiac vein? b. Middle cardiac vein? c. Small cardiac vein? 12) What is the difference between the coronary sinus and the coronary sulcus? 13) Describe the pathway for conduction in the heart? 14) What are three similarities between arteries and veins? 15) What are three differences between arteries and veins?

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4 SUPERIOR AND POSTERIOR MEDIASTINA

Fig. 3-20. Mediastinum. Drawing showing the posterior mediastinum relative to the superior and middle mediastina. 1. First rib, 2. Arch of aorta, 3. Ascending aorta, 4. Phrenic nerve, 5. Splanchnic nerve, 6. Sympathetic chain, 7. Intercostal nerve, artery, vein, 8. Ramus communicates, 9. Highest intercostals vein, 10. Highest intercostals artery. (Modified from Gray 1918)

4.1 SUPERIOR MEDIASTINUM • BOUNDARIES (Figs. 3-1, 3-20) ○○ superior border is the superior thoracic aperture. ○○ inferior border is a line connecting the sternal angle with the T4-T5 intervertebral disc. ○○ It is continuous inferiorly with the anterior, middle, and posterior mediastinum.

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• CONTENTS (Figs. 3-21, 3-22, 3-23) ○○ the THYMUS is a lymphoid organ that is large in children, but then degenerates with age and which produces T-lymphocytes cells that are important in the immune system. ○○ the RIGHT and LEFT BRACHIOCEPHALIC VEINS ▪▪ INTERNAL JUGULAR VEIN and SUBCLAVIAN VEIN unite to each brachiocephalic vein. ▪▪ the INTERNAL THORACIC VEIN, VERTEBRAL VEINS, INFERIOR THYROID VEIN, and SUPERIOR INTERCOSTAL VEIN Drain into each brachiocephalic vein. ○○ SUPERIOR VENA CAVA ▪▪ formed by the union of the RIGHT AND LEFT BRACHIOCEPHALIC VEINS. ▪▪ the AZYGOS VEIN empties directly into the superior vena cava. ▪▪ enters the right atrium of the heart in the middle mediastinum. ○○ ARCH of the AORTA ▪▪ the RIGHT BRACHIOCEPHALIC TRUNK which arises from the arch gives off the RIGHT SUBCLAVIAN and COMMON CAROTID ARTERIES. ▪▪ the LEFT COMMON CAROTID ARTERY arises from the arch. ▪▪ the LEFT SUBCLAVIAN arises from the arch. ▪▪ the AORTIC ARCH is in the SUPERIOR MEDIASTINUM; the ASCENDING AORTA is in the MIDDLE MEDIASTINUM and the DESCENDING AORTA is in the POSTERIOR MEDIASTINUM. ○○ RIGHT and LEFT VAGUS NERVES ▪▪ Each nerve runs along with the COMMON CAROTID ARTERY and INTERNAL JUGULAR VEIN on its side. ▪▪ The LEFT RECURRENT LARYNGEAL NERVE off the vagus passes under and then behind to AORTIC ARCH. ▪▪ TheRIGHT RECURRENT LARYNGEAL NERVE off the vagus passes around the RIGHT SUBCLAVIAN ARTERY. ▪▪ Both RECURRENT LARYNGEAL NERVES innervate the larynx; send branches to the aortic plexus at the arch of the aorta; and on the anterior and posterior surface of the esophagus as vagal trunks. ▪▪ The RECURRENT LARYNGEAL NERVES lie in the SUPERIOR MEDIASTINUM while the VAGUS NERVES lie in the SUPERIOR, MIDDLE AND POSTERIOR (VAGAL TRUNKS) MEDIASTINA. ○○ PHRENIC NERVES ▪▪ the MOTOR INNERVATION to the DIAPHRAGM. ▪▪ from the CERVICAL PLEXUS and descends of the SCALENUS ANTERIOR muscle into the superior mediastinum.

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▪▪ the LEFT PHRENIC NERVE lies between the SUBCLAVIAN AND COMMON CAROTID ARTERIES. ▪▪ the RIGHT PHRENIC NERVE runs lateral to the RIGHT BRACHIOCEPHALIC VEIN AND SUPERIOR VENA CAVA. ▪▪ Both phrenic nerves enter the middle mediastinum and run along the pericardium to reach the diaphragm. ○○ TRACHEA ▪▪ MAIN RESPIRATORY TUBE that extends from the larynx to the primary bronchi of the lungs. ▪▪ passes through the superior mediastinum ANTERIOR to the ESOPHAGUS. ▪▪ ENDS in the MIDDLE MEDIASTINUM where it divides into primary bronchi. ○○ ESOPHAGUS ▪▪ MUSCULAR TUBE connecting the oral pharynx with the stomach. ▪▪ passes through the SUPERIOR MEDIASTINUM between the TRACHEA and the VERTEBRAL BODIES. ▪▪ lies posterior to the LEFT ATRIUM in the POSTERIOR MEDIASTINUM.

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○○ THORACIC DUCT ▪▪ MAIN LYMPHATIC DUCT begins at about T12, passes through the posterior mediastinum and enters the superior mediastinum. ▪▪ empties into the venous systemic circulation near the union of the LEFT INTERNAL JUGULAR and SUBCLAVIAN VEINS. ○○ SYMPATHETIC TRUNKS (CHAINS) ▪▪ a sympathetic trunk lies on each side of the vertebral column. ▪▪ composed of SYMPATHETIC NERVE FIBERS AND GANGLIA that extends from the NECK to the SACRUM. ▪▪ the sympathetic trunk passes posterior to the esophagus near the costotransverse joints of T1-T4. ▪▪ each trunk exists the superior mediastinum through the superior thoracic aperture. ▪▪ runs through the SUPERIOR AND POSTERIOR MEDIASTINA.

Fig. 3-21: Mediastinum. Picture showing structures located in the superior, middle and posterior mediastina.

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Fig 3-22. Mediastinum. Dissection of the superior mediastinum. 1. Right brachiocephalic vein, 2. Superior vena cava, 3. Brachiocephalic artery, 4. Aortic plexus on arch of the aorta, 5. Phrenic nerve, 6. Trachea and primary bronchi, 7. Esophagus, 8. Vagal trunks and esophageal plexus, 9. Central tendon of diaphragm, 10. Thoracic aorta, 11. Posterior intercostals nerve, artery, vein, 12. Recurrent laryngeal nerve, 13. Vagus nerve 14. Left subclavian artery, 15. Left common carotid artery, 16. Left brachiocephalic vein.

4.2 POSTERIOR MEDIASTINUM • BOUNDARIES (Figs. 3-1, 3-20) ○○ posterior to the fibrous pericardium. ○○ extends from the T4-T5 INTERVERTEBRAL DISC to the vertebral margin of the diaphragm.

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• CONTENTS (Figs. 3-20, 3-22, 3-23, 3-24, 3-25, 3-26) ○○ THORACIC AORTA ▪▪ a continuation of the aortic arch. ▪▪ gives off POSTERIOR INTERCOSTAL ARTERIES, ESOPHAGEAL ARTERIES, BRONCHIAL ARTERIES, a pair of SUBCOSTAL ARTERIES, and ARTERIES to the PERICARDIUM and DIAPHRAGM in the thorax. ▪▪ It leaves the posterior mediastinum through the AORTIC HIATUS of the diaphragm at the level of the TWELFTH THORACIC VERTEBRA ▪▪ enters the abdomen as the ABDOMINAL AORTA. ○○ ESOPHAGUS ▪▪ runs anterior to the thoracic aorta in the posterior mediastinum. ▪▪ enters the posterior mediastinum through the ESOPHAGEAL HIATUS of the diaphragm at the level of the TENTH THORACIC VERTEBRA. ○○ VAGUS NERVE right and left vagus nerves become the ANTERIOR AND POSTERIOR VAGAL TRUNKS. vagal trunks run along the esophagus.

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Fig 15-23. Mediastinum. Dissection of superior and posterior mediastinum. 1. Superior vena cava, 2. Trachea, 3. Esophagus reflected, 4. Azygos vein, 5. Thoracic duct, 6. Thoracic aorta, 7. Phrenic nerve, 8. Sympathetic trunk (chain), 9. Vagus nerve.

○○ AZYGOS VEIN ▪▪ lies on RIGHT SIDE of thoracic aorta. ▪▪ formed by the union of the right SUBCOSTAL and ASCENDING LUMBAR veins. ▪▪ receives blood from POSTERIOR INTERCOSTAL VEINS, the VERTEBRAL VENOUS PLEXUS that surrounds the vertebrae, ESOPHAGEAL VEINS, and the BRONCHIAL VEIN from the right lung. ▪▪ the azygos vein drains directly into the SUPERIOR VENA CAVA. ○○ HEMIAZYGOS VEIN ▪▪ lies on the LEFT SIDE of the thoracic aorta. ▪▪ formed by the union of the left SUBCOSTAL and ASCENDING LUMBAR VEINS. ▪▪ extends from T9-T12.

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▪▪ receives blood from the LEFT POSTERIOR INTERCOSTAL VEINS and the VERTEBRAL VENOUS PLEXUS in that region, lower ESOPHAGEAL VEINS and the ACCESSORY HEMIAZYGOS VEIN. ▪▪ the hemiazygos vein crosses at about T9 to drain into the azygos vein. ○○ ACCESSORY HEMIAZYGOS VEIN ▪▪ cranial continuation of the hemiazygos vein. ▪▪ lies along the LEFT SIDE of the vertebral bodies from T8 through T4. ▪▪ receives blood from the LEFT INTERCOSTAL VEINS in that region.

Fig. 3-24. Mediastinum. Diagram showing the arrangement of the azygos, hemiazygos and accessory hemiazygos veins. Arrows show direction of blood flow.

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○○ THORACIC DUCT ▪▪ begins as the CISTERNA CHYLI which is an enlarged sac ventral to the T12. ▪▪ enters the posterior mediastinum through the AORTIC HIATUS of the DIAPHRAGM. ▪▪ runs cranially between the thoracic aorta and the azygos vein. ▪▪ receives lymphatic drainage from POSTERIOR MEDIASTINAL AND INTERCOSTAL LYMPH NODES, and lymphatic drainage from the ABDOMEN, PELVIS AND LOWER EXTREMITIES through the CISTERNA CHYLI. ▪▪ the duct empties into the LEFT BRACHIOCEPHALIC VEIN or where LEFT SUBCLAVIAN VEIN and INTERNAL JUGULAR VEIN unite to form the left brachiocephalic vein.

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Fig. 3-25: Mediastinum. Diagrams (LEFT) showing the distribution of the lymphatics in the body and (RIGHT) the thoracic duct, cisterna chyli, and right lymphatic duct in the posterior mediastinum.

○○ SYMPATHETIC TRUNKS ▪▪ RIGHT SYMPATHETIC TRUNK lies lateral to the AZYGOS VEIN. ▪▪ LEFT SYMPATHETIC TRUNK lies lateral to the HEMIAZYGOS AND ACCESSORY HEMIAZYGOS VEINS. ▪▪ each sympathetic trunk lies near the costotransverse joints on that side. ▪▪ three SPLANCHNIC NERVES arise from each sympathetic trunk in the posterior mediastinum.

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1) a large GREATER SPLANCHIC NERVE arises from sympathetic ganglia at T5-T9. 2) a small LESSER SPLANCHNIC NERVE arises from ganglia at T9-T10. 3) a very small LEAST SPLANCHNIC NERVE arises from the ganglion at T11 and occasionally also from T12. ▪▪ the GREATER AND LESSER SPLANCHNIC NERVES pass through the CRUS OF THE DIAPHRAGM and end in the CELIAC GANGLION of the AUTONOMIC NERVOUS SYSTEM in the abdomen. ▪▪ the LEAST SPLANCHNIC NERVE passes through the CRUS OF THE DIAPHRAGM, but it ends in the RENAL AUTONOMIC PLEXUS to the kidney.

Fig. 3-26. Mediastinum. Dissection of posterior media showing sympathetic trunk. 1. Vagus nerve, 2. Thoracic aorta, 3. Accessory hemiazygos and hemiazygos veins, 4. Ramus communicans from sympathetic trunk lifted by probe, 5. Posterior intercostal nerve, artery, vein, 6. sympathetic trunk ganglion, 7. Ramus communicans to intercostals nerve, 8. Phrenic nerve reflected, 9. Sympathetic trunk.

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4 – STUDY QUESTIONS:

1) What structures in the superior mediastinum do not enter the middle or posterior mediastina? 2) What structures are common to the superior and middle mediastina? 3) What structures are common to the superior and posterior mediastina? 4) In which mediastina do each of the three parts of the aorta lie? 5) What drains into the azygous and hemiazygos veins? 6) What are the differences between the azygous, hemiazygos, and accessory hemiazygos veins? 7) Into which vein does the azygous vein drain? How about the hemiazygos vein? 8) The thoracic duct receives lymphatic drainage from what area of the body? 9) What happens to the lymphatic drainage in the thoracic duct?

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5 ABDOMINAL WALL

5.1 BOUNDARIES • superior: DIAPHRAGM. • anterior and lateral: ABDOMINAL MUSCLES. • posterior: LUMBAR VERTEBRAE, QUADRATUS LUMBORUM MUSCLE. • inferior: the ILIAC CRESTS, the SUPERIOR ILIAC SPINE, INGUINAL LIGAMENT, PUBIC TUBERCLE, PUBIC CREST, and PUBIC SYMPHYSIS.

5.2 ABDOMINAL PLANES (TABLE 4.1 AND FIG. 4-1)

TABLE 4.1: Planes of the abdomen showing vertebral levels and structures through which the plane passes

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Fig. 4-1 Abdomen: Diagram showing the abdominal planes.

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ABDOMINAL REGIONS (FIG. 4-2)

• the SUBCOSTAL, TRANSTUBERCULAR, and two MID-CLAVICULAR PLANES divide the abdomen into nine regions. • these regions are used to describe the LOCATION OF PAIN and ABDOMINAL VISCERAL PATHOLOGIES. • SUPERIOR to the SUBCOSTAL PLANE are the RIGHT and LEFT HYPOCHONDRIAC REGIONS and the middle EPIGASTRIC REGION. • between the SUBCOSTAL and TRANSTUBERCULAR PLANES are the RIGHT and LEFT LUMBAR REGIONS and the middle UMBILICAL REGION. • below the TRANSTUBERCULAR PLANE are the RIGHT and LEFT ILIAC REGIONS and the middle HYPOGASTRIC REGION. 360° 360° thinking. thinking.

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Fig. 4-2. Abdomen: Abdominal Planes and Contents.

5.3 ANTERIOR AND LATERAL ABDOMINAL WALLS

MUSCLES OF THE ABDOMINAL WALL (FIGS. 4-3, 4-4, 4-5)

○○ the RECTUS ABDOMINIS forms anterior abdominal wall with the RECTUS SHEATH which form a fibrous sleeve around the right and left rectus muscles. ○○ between the two rectus abdominis muscles is the LINEA ALBA which is a fibrous strip that provides an attachment site for the rectus abdominis, and the external, internal and transverse abdominal muscles.

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Fig. 4-3. Abdomen: Drawing of the anterior abdominal wall showing the muscles of this region. 1. Serratus anterior, 2. latissimus dorsi, 3. external and internal obliques (cut), 4. transverse abdominis, 5. spermatic cord, 6. superficial inguinal ring, 7. umbilicus, 8. internal oblique, 9. linea alba, 10. tendinous intersection, 11. rectus abdominis, and 12. pectoralis major.

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Fig. 4-4. A. Dissection of abdominal wall muscles. (A) Rectus Abdominis and External Abdominal Oblique. 1. Rectus sheath, 2. Rectus abdominis m., 3. Tendinous intersection, 4. Aponeurosis of external abdominal oblique m., 5. Inguinal ligament, 6. Superficial inguinal ring, 7A. External abdominal oblique m., 8. Diaphragm m.

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Fig. 4-4. B-C. Dissection of abdominal wall muscles. (B) Rectus Abdominis and Internal Abdominal Oblique. (C) Rectus Abdominis and Transverse Abdominis. 1. Rectus sheath, 2. Rectus abdominis m., 3. Tendinous intersection, 4. Aponeurosis of external abdominal oblique m., 5. Inguinal ligament, 6. Superficial inguinal ring, 7A. External abdominal oblique m., 7B. Retracted external abdominal oblique m., 8. Diaphragm m., 9. Internal abdominal oblique m. 9C Retracted internal abdominal oblique m., 10. Posterior rectus sheath, 11. Linea alba, 12. Transverse abdominis .

1) RECTUS ABDOMINIS • Inferior attachment (origin): Pubic symphysis and pubic crest. • Superior attachment (insertion): Xiphoid process and the costal cartilages of ribs five through seven. • Nerve: Intercostal nerves from T6 through T11, subcostal nerve. • Actions: Forward flexion of the trunk, posterior tilting of the pelvis, stabilization of the pelvis and trunk, flattening of the abdomen, supports abdominal viscera, increases intra-abdominal pressure. 2) EXTERNAL ABDOMINAL OBLIQUE • Superior/Lateral attachment (origin): Bodies of the lower eight ribs (ribs 5-12) interdigitating with the attachment sites of the lower serratus anterior muscle. • Inferior/Medial attachment (insertion): Linea alba, anterior half of the iliac crest, anterior superior iliac spine and pubic tubercle via the inguinal ligament. • Nerve: Intercostal nerves from T6-T11, subcostal nerve, iliohypogastric nerve. • Actions: Forward flexion of the trunk (bilateral action), lateral bending of the trunk to the same side (unilateral action), rotation of the trunk to the opposite side, posterior tilting of pelvis, stabilization of the pelvis and trunk, supports abdominal viscera, increases intra-abdominal pressure.

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3) INTERNAL ABDOMINAL OBLIQUE • Inferior/Lateral attachment (origin): Thoracolumbar fascia, anterior 2/3 of iliac crest, and lateral 1/2 to 2/3 of the inguinal ligament. • Superior/Medial attachment (insertion): Costal margin of ribs nine through twelve, linea alba, abdominal aponeurosis from the costal cartilage of rib 10 to the superior pubic ramus along the pectineal line. • Nerve: Intercostal nerves from T6-T11, subcostal nerve, ilioinguinal nerve, iliohypogastric nerve. • Actions: Forward flexion of the trunk (bilateral), lateral bending to the same side (unilateral), rotation of the trunk to the same side, stabilization of the pelvis and trunk, supports abdominal viscera, increases intra-abdominal pressure. 4) TRANSVERSE ABDOMINIS • Lateral attachment (origin): Thoracolumbar fascia, anterior 2/3 of the iliac crest, lateral 1/2 of the inguinal ligament, costal cartilages of the lower six ribs (ribs 7-12). • Medial attachment (insertion): Linea alba, pubic crest, forms conjoint tendon with internal oblique aponeurosis. • Nerve: Intercostal nerves from T6-T11, subcostal nerve, ilioinguinal nerve, iliohypogastric nerve. • Actions: Stabilization of the pelvis and trunk, supports abdominal viscera, increases intra-abdominal pressure.

• RECTUS SHEATH (Figs. 4-4, 4-5) ○○ a FIBROUS ENVELOPE that surrounds the rectus abdominis muscle. ○○ In the EPIGASTRIC REGION, the aponeurosis of the EXTERNAL ABDOMINAL OBLIQUE splits to form the anterior and posterior parts of the rectus sheath. ○○ In the UMBILICAL AREA, the anterior part of the rectus sheath is formed by the aponeurosis of the EXTERNAL AND INTERNAL ABDOMINAL OBLIQUES and the posterior part by the aponeurosis of the INTERNAL ABDOMINAL OBLIQUE AND THE TRANSVERSE ABDOMINIS. ○○ In the HYPOGASTRIC REGION, the anterior part of the rectus sheath is formed by the aponeurosis of the EXTERNAL ABDOMINAL OBLIQUE, INTERNAL ABDOMINAL OBLIQUE AND THE TRANSVERSE ABDOMINIS, and the posterior part by a thin layer of connective tissue called the FASCIA TRANSVERSALIS.

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Fig. 4-5. Abdomen: Drawings showing the attachments of the A) the rectus abdominis and the components of the rectus sheath in transverse section, B) the external abdominal oblique, C) internal abdominal oblique, and D) transversus abdominis. Numbers in part A: 1. Uppermost section of rectus abdominis, 2. tendinous intersections, 3. linea alba, 4. external oblique, 5. internal oblique, 6. transverse abdominis, 7. rectus abdominis, 8. anterior rectus sheath, 9. posterior rectus sheath, 10. linea alba, 11. transversus fascia.

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BLOOD VESSELS TO ABDOMINAL WALL (FIG. 4-6)

• The mainARTERIES to the anterior abdominal wall ○○ the SUPERIOR EPIGASTRIC ARTERY off the INTERNAL THORACIC ARTERY to the region ABOVE THE UMBILICUS. ○○ the INFERIOR EPIGASTRIC and the DEEP CIRCUMFLEX ILIAC ARTERIES off theEXTERNAL ILIAC ARTERY to the region BELOW THE UMBILICUS. ○○ the SUPERIOR AND INFERIOR EPIGASTRIC ARTERIES of each side anastomose within the rectus abdominis muscle in the area of the umbilicus. • Other arteries to abdominal wall ○○ the POSTERIOR INTERCOSTAL ARTERIES from T10 and T11, SUBCOSTAL ARTERIES and LUMBAR ARTERIES from the aorta. • VEINS accompany each of these arteries of the abdominal wall ○○ the SUPERIOR EPIGASTRIC VEINS drain into the INTERNAL THORACIC VEIN. ○○ the INFERIOR EPIGASTRIC and DEEP CIRCUMFLEX ILIAC VEINS drain into the corresponding EXTERNAL ILIAC VEIN.

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○○ the POSTERIOR INTERCOSTAL and SUBCOSTAL VEINS drain into the AZYGOS and HEMIAZYGOS VEINS. ○○ the LUMBAR VEINS drain into the INFERIOR VENA CAVA.

Fig. 4-6. Abdomen: Drawing showing the arteries of the anterior abdominal wall and thorax. 1. Common carotid a., 2. Subclavian a., 3. Internal thoracic a., 4. Anterior intercostals a., 5. Posterior intercostals a., 6. Superior epigastric a., 7. Musculophrenic a., 8. Inferior epigastric a., 9. External iliac a. (Modified from Gray’s 1918)

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5 – STUDY QUESTIONS:

1) For each of the following planes describe which vertebral level they cross: a. Transtubercular b. Interspinous c. Supracrestal d. Subcostal 2) Name the abdominal region in which each of these organs lie: a. Stomach b. Spleen c. Ascending colon d. Urinary bladder e. Pancreas f. Gall bladder g. Descending colon 3) Which abdominal muscles are innervated by the following nerves? a. Subcostal? b. Iliohypogastric? c. Ilioinguinal? 4) In the umbilical region, aponeuroses from what muscle form the anterior part of the rectus sheath? How about the posterior part of the sheath? 5) In the hypogastric region, aponeuroses from what muscle form the anterior part of the sheath? How about the posterior part of the sheath?

5.4 INGUINAL REGION (FIGS. 4-3, 4-4, 4-7, 4-8) • INGUINAL LIGAMENT is an enfolding of the aponeurosis of the EXTERNAL ABDOMINAL OBLIQUE ○○ runs from the ANTERIOR SUPERIOR ILIAC SPINE to the PUBIC TUBERCLE. ○○ used as the boundary between the anterior abdomen and leg. • INGUINAL CANAL ○○ superior to the inguinal ligament. ○○ formed by the aponeuroses of the EXTERNAL AND INTERNAL ABDOMINAL OBLIQUES, AND THE TRANSVERSE ABDOMINIS. ○○ SUPERFICIAL INGUINAL RING is the external opening of the inguinal canal near the public tubercle ▪▪ the superficial ring is formed anteriorly by the aponeurosis of the EXTERNAL OBLIQUE MUSCLE. ▪▪ the superficial ring is bound posteriorly by the CONJOINT TENDON which is formed by fusion of the aponeuroses of the INTERNAL OBLIQUE AND TRANSVERSUS ABDOMINIS MUSCLES.

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○○ DEEP INGUINAL RING is the internal opening of the inguinal canal into the abdominal cavity ▪▪ The deep ring lies near the middle of the inguinal ligament.

Fig. 4-7. Abdomen: Drawing of the inguinal ligament and canal. 1. symphysis pubis, 2. intracrural fibers, 3. external oblique, 4. anterior superior iliac spina, 5. inguinal ligament, 6. deep inguinal ring, 7. inguinal canal, 8. superficial inguinal ring, 9. conjoint tendon, and 10. pubic tubercle.

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Fig. 4-8. Abdomen. Male inguinal region: 1. Aponeurosis of the external abdominal oblique m., 2. Inguinal ligament, 3. Superficial inguinal ring, 4. Spermatic cord, 5. Cremaster m., 6. Testicular a., 7. Testicular v., 8. Vas deferens, 9. Suspensory ligament of the penis.

• INGUINAL CANAL CONTENTS ○○ MALES (Figs. 4-8, 4-11, 4-12) ▪▪ ILIOINGUINAL NERVE. ▪▪ SPERMATIC CORD which is a conduit by which structures in the abdomen reach the testes. ▪▪ SPERMATIC CORD contains ∗∗ VAS DEFERENS. ∗∗ TESTICULAR ARTERY. ∗∗ PAMPINIFORM VENOUS PLEXUS of the testicular vein. ∗∗ CREMASTER MUSCLE that moves the scrotum to control testicular temperature for sperm health. ∗∗ GENITAL BRANCH of the GENITOFEMORAL NERVE. ○○ FEMALES (Figs. 4-9, 4-11) ▪▪ ROUND LIGAMENT OF THE UTERUS. ▪▪ ILIOINGUINAL NERVE. ▪▪ GENITAL BRANCH of the GENITOFEMORAL NERVE.

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Fig 4-9. Pelvis: (TOP) Drawing of the uterus. 1. Ovarian (Fallopian) tube, 2. Round lig. of the uterus, 3. Broad lig. of uterus, 4. Transverse cardinal lig. of cervix, 5. Cervix, 6. Vagina, 7. Ovary, 8. Fimbriae of ovarian tube, 9. Ovarian lig., 10. Uterus.

○○ INGUINAL CANAL HERNIAS ▪▪ INDIRECT INGUINAL HERNIA involves the herniation of small intestine into the deep inguinal ring, through the inguinal canal and out the superficial inguinal ring. ▪▪ DIRECT INGUINAL HERNIA involves the herniation of small intestine through the conjoint tendon and directly out the superficial inguinal ring.

6 – STUDY QUESTIONS:

1) What forms the inguinal ligament? 2) What structures pass through the inguinal canal in both men and women? 3) What lies in the spermatic cord? 4) What type of inguinal hernia enters the deep inguinal ring and passes through the inguinal canal?

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5.5 POSTERIOR ABDOMINAL WALL (FIGS. 4-10, 4-11, 4-12)

CONTENTS • LUMBAR VERTEBRAE ○○ large vertebral bodies. ○○ short and wide spinous processes. ○○ absence of articular surfaces for the ribs and transverse foramen.

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Fig. 4-10. Back: Drawings showing the structural parts of a lumbar vertebra in superior (A) and lateral (B) view (Modified from Gray 1918). Radiographs of the lumbar spine and sacrum in frontal (C) and lateral (D) view: 1. Vertebral body. 2. Transverse processes. 3. Vertebral foramen. 4. Spinous process. 5. Lamina. 6. Pedicle. 7. Superior articular facet. 8. Inferior articular facet. 9. Mammillary process. 10. Inferior intervertebral notch. 11. Pars interarticularis. 12. Sacroiliac joints. 13. Sacrum, 14. Vertebral disc

• QUADRATUS LUMBORUM MUSCLE ○○ Inferior Attachment (Origin): iliac crest, iliolumbar ligament. ○○ Superior Attachment (Insertion): rib12; transverse processes of L1-L4. ○○ Nerve: ventral rami L1-L4. ○○ Actions: extends (both sides), laterally flexes (same side), and controls lateral flexion (opposite side) of the lumbar spine.

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Fig. 4-11. Abdomen: Drawings of the posterior abdominal wall showing the muscles and the nerves of the lumbar plexus. 1. Iliohypogastric N., 2. ilioinguinal N., 3. femoral N., 4. obturator N., 5. intervertebral disc, 6. sciatic N., 7. genitofemoral N., 8. iliacus muscle, 9. lateral femoral cutaneous N., 10. subcostal N., 11. psoas major and 12. iliopsoas tendon

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• NERVES OF LUMBAR PLEXUS 1) ILIOHYPOGASTRIC NERVE (L1): This nerve is SENSORY to the skin of the lateral gluteal region, and hypogastric region of the abdominal wall. It is MOTOR to the external and internal abdominal obliques and transverse abdominis. 2) ILIOINGUINAL NERVE (L1): This nerve passes through the superficial inguinal ring and is SENSORY to the skin of the pubic symphysis, inguinal region, anterior scrotum and anterior labia majora. It is MOTOR to the internal abdominal oblique and transverse abdominis. 3) GENITOFEMORAL NERVE (L1; anterior division of L2): This SENSORY nerve runs along the anterior surface of the psoas major muscle. It divides into a FEMORAL BRANCH to the skin over the femoral triangle and a GENITAL BRANCH which runs through the inguinal canal and is sensory to the anterior scrotum and anterior labia majora. 4) LATERAL FEMORAL CUTANEOUS NERVE (posterior divisions of L2, L3): This nerve isSENSORY to the skin over the lateral thigh. 5) FEMORAL NERVE (posterior divisions of L2, L3, L4): This nerve is SENSORY to the skin of the anterior thigh, medial leg, and medial ankle.

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It is MOTOR to the quadriceps femoris, psoas major, iliacus, pectineus, and sartorius. 6) OBTURATOR NERVE (anterior divisions of L2, L3, L4): This nerve is SENSORY to the skin of the medial thigh and MOTOR to the adductor muscles of the hip. Occasionally, branches from the posterior divisions of L3 and L4 form an ACCESSORY OBTURATOR NERVE to the adductor muscles. 7) LUMBOSACRAL TRUNK (anterior division of L4; L5): This nerve trunk contains SENSORY and MOTOR fibers that descend into the pelvis to join the sacral plexus.

Figure 4-12. Abdomen: Photograph to a dissection of the posterior abdominal and pelvis. 1. Iliohypogastric nerve, 2. Ilioinguinal nerve, 3. Lateral femoral cutaneous nerve, 4. Femoral nerve, 5. External iliac artery, 6. Obturator nerve, 7. Urinary bladder, 8. Uterus, 9. Superior hypogastric plexus, 10. Genitofemoral nerve, 11. Inferior vena cava, 12. Abdominal aorta, 13. Quadrates lumborum muscle, 14. Psoas major muscle, 15. Ureter, 16. Iliolumbar ligament, 17. Iliacus muscle.

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7 – STUDY QUESTIONS:

1) What muscles form the posterior wall of the abdomen? 2) A lesion of the L1 spinal nerve would affect which nerves of the lumbar plexus? What sensory and motor impairments might you expect to find? 3) A lesion of the L2 spinal nerve would affect which nerves of the lumbar plexus? What sensory and motor impairments might you expect to find? 4) A lesion of the L4 spinal nerve would affect which nerves of the lumbar plexus? What sensory and motor impairments might you expect to find?

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6 ABDOMINAL VISCERA

6.1 PERITONEUM (FIG. 5-1) • A serous membrane that lines the abdominal a wall and most abdominal organs. • PARIETAL PERITONEUM The internal abdominal wall is lined by a thin membrane callede the • VISCERAL PERITONEUM coverers totally or in part most of the abdominal organs ○○ the stomach, small intestines and transverse colon are encased totally by this visceral peritoneum. ○○ only part of the liver, ascending colon and descending colon are covered. ○○ the kidneys and pancreas are RETROPERITONEAL as both lie outside of the parietal peritoneum.

Fig. 5-1. Abdomen: Diagram of a sagittal section through the abdomen showing the arrangement of the peritoneum, the greater and lesser peritoneal sacs and omenta and the mesentery. 1. diaphragm, 2. liver, 3. superior recess of lesser sac, 4. pancreas, 5. stomach, 6. sigmoid mesocolon, 7. duodenum, 8. transverse colon, 9. mesentery, 10. small intestine, 11. sigmoid colon, 12. rectum, 13. greater peritoneal sac, 14. posterior lamina of greater omentum, 15. inferior recess of lesser sac, 16. anterior lamina of greater omentum, 17. parietal peritoneum, and 18. lesser omentum.

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• MESENTERIES and LIGAMENTS (Fig. 5-1) ○○ Both of these supportive structures are formed by two layers of peritoneum and both provide a passageway for blood vessels, nerves and lymphatics. ○○ the small intestines are connected to the posterior abdominal wall by a MESENTERY. ○○ the transverse colon is also suspended by the MESOCOLON mesentery. ○○ the liver is connected to the anterior abdominal wall by the FALCIFORM LIGAMENT. ○○ the stomach is connected to the spleen by a GASTROLIENAL LIGAMENT. ○○ the spleen is connected to the left kidney by the LIENORENAL LIGAMENT. • OMENTUM (Figs. 5-1, 5-2) ○○ a fold of fat filled peritoneum. ○○ GREATER OMENTUM is attached to the stomach and transverse colon and drapes over the intestines. ○○ the LESSER OMENTUM is connects the stomach and liver. ○○ that can migrate to support and protect abdominal organs.

Fig. 5-2. Abdomen: Dissection of abdominal cavity after removal of anterior muscular wall. 1. Greater omentum, 2. Lesser omentum, 3. Stomach, 4. Liver, 5. Diaphragm, 6 Hepatic flexure of colon, 7. Transverse colon.

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6.2 ABDOMINAL ORGAN OVERVIEW (FIG. 5-3) • LIVER, GALLBLADDER, STOMACH, SPLEEN, PANCREAS, and KIDNEYS lie in the upper half of the abdominal cavity. • Most of the SMALL and LARGE INTESTINES occupy the lower half of the cavity. • Arteries to these organs arise off theABDOMINAL AORTA. • VENOUS HEPATIC PORTAL SYSTEM drains blood from the stomach, pancreas, spleen, small intestines and large intestines and delivers it to the liver for processing. • VENOUS SYSTEMIC SYSTEM receives blood from the liver, kidneys, suprarenal glands, testes, ovaries, lumbar vertebrae, and muscles of the abdomen and returns it directly into the inferior vena cava.

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Fig. 5-3. Abdomen: Drawing of the abdominal organs in situ. 1. Salivary glands, 2. teeth, 3. esophagus, 4. gallbladder, 5. duodenum, 6. jejunum, 7. ileum, 8. cecum, 9. appendix, 10. stomach, 11. liver, 12. pancreas, 13. colon, 14. rectum, and 15. anus.

6.3 LIVER (FIGS. 5-3, 5-4, 5-5, 5-6, 5-7, 5-9) • located in the UPPER RIGHT QUARTER of the abdomen, adjacent to the DIAPHRAGM, and right of the STOMACH and PANCREAS. • divided into a RIGHT LOBE, LEFT LOBE, a small CAUDATE LOBE, and a small QUADRATE LOBE. • connected by the FALCIFORM LIGAMENT to the anterior abdominal cavity and the parietal peritoneum lining the diaphragm by CORONARY and TRIANGLE LIGAMENTS.

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• BARE AREA of the liver is not covered with peritoneum ○○ on the superior diaphragmatic surface of the liver. ○○ bordered by the coronary and triangular ligaments. • on the INFERIOR SURFACE, are the GALLBLADDER, INFERIOR VENA CAVA, HEPATIC TRIAD, QUADRATE LOBE and CAUDATE LOBE ○○ GALLBLADDER lies between the QUADRATE and RIGHT LOBES of the liver. ○○ INFERIOR VENA CAVA lies superior to the gallbladder between the CAUDATE and RIGHT LOBES. ○○ HEPATIC ARTERIES and the HEPATIC PORTAL VEIN enter the liver near the superior end of the gallbladder. • COMMON HEPATIC DUCT joins the CYSTIC DUCT from the gallbladder to form the COMMON BILE DUCT. • HEPATIC TRIAD consists of the HEPATIC ARTERY, HEPATIC PORTAL VEIN, and BILE DUCT. • HEPATIC ARTERIRS (Figs. 5-4, 5-18) ○○ RIGHT and LEFT HEPATIC ARTERIRS are off thePROPER HEPATIC ARTEY which is a continuation of the COMMON HEPATIC ARTERY. ○○ COMMON HEPATIC ARTERY begins at the CELIAC TRUNK which is off the abdominalAORTA.

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○○ A MIDDLE HEPATIC ARTERY may arise from either the RIGHT or the LEFT HEPATIC ARTERY.

Fig. 5-4. Abdomen: Superior (top left) and posteroinferior (bottom left) surfaces of the liver showing the lobes of the liver, gallbladder, and hepatic triad. The picture at the below is a photomicrograph of the liver showing the portal vein, hepatic artery and bile duct. 1. Inferior vena cava, 2. Falciform ligament, 3. Lt. Triangular ligament, 4. Caudate lobe, 5. Inferior vena cava, 6. Rt. Triangular ligament, 7. Lt. lobe, 8. Hepatic artery, 9. Hepatic portal vein, 10. Hepatic bile duct, 11. Rt. Lobe, 12. Bare area of liver. (Partly modified from Gray 1918)

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Fig. 5-5. (TOP) Drawing od the abdominal aorta entering the abdomen through the Aortic Hiatus. Note the Celiac trunk and its branches. The Celiac trunk is the main artery to the organs of the upper abdomen. (BOTTOM) Drawing showing the branches off the celiac trunk to the liver, gallbladder, stomach, spleen, and pancreas.

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• HEPATIC PORTAL VEIN (Figs. 5-6, 5-7, 5-8, 5-9) ○○ union of the SPLENIC VEIN and SUPERIOR MESENTERIC VEIN. ○○ SPLENIC VEIN from the SPLEEN, STOMACH, and PANCREAS. ○○ SUPERIOR MESENTERIC VEIN from the STOMACH, SMALL INTESTINES, ASCENDING COLON, and the RIGHT HALF of the TRANSVERSE COLON . ○○ INFERIOR MESENTERIC VEIN enters SPLENIC VEIN and drains the LEFT HALF of the TRANSVERSE COLON, the DESCENDING COLON, SIGMOID COLON, and the RECTUM. ○○ GASTRIC and ESOPHAGEAL VEINS drain into HEPATIC PORTAL SYSTEM. ○○ HEPATIC PORTAL vein enters the LIVER. ○○ Blood is processed by the cells of the liver and processed blood is then removed from the liver through HEPATIC VEINS that empty into the INFERIOR VENA CAVA.

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Fig. 5-6. Abdomen: (Left) Drawing showing the arterial and venous blood flow pattern relative to the liver. Arrows show the direction to blood flow from the portal system through the liver and into the inferior vena cava. (Right) Drawing showing the veins of the portal system. 1. heart, 2. hepatic vein, 3. liver, 4. bile duct, 5. gallbladder, 6. common bile duct, 7. duodenum, 8. portal vein, 9. mesenteric artery, 10. intestines, 11. aorta and 12. hepatic artery.

Each of the veins of the portal system drains only those organs associated with gastrointestinal system. Each of these veins also has an accompanying artery that goes to the same area of the gastrointestinal system. If you know the arterial blood supply to these organs, which will be covered below, you also know the veins that drain that area into the portal system.

8 – STUDY QUESTIONS:

1) What forms the portal vein? 2) What is the difference between the portal vein and the hepatic vein? 3) What organs are drained by the superior mesenteric vein? 4) What organs are drained by the splenic vein and the inferior mesenteric vein?

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6.4 GALLBLADDER (FIGS. 5-3, 5-4, 5-7, 5-8, 5-9) • THIN WALLED SACK on the inferior surface of the liver and right of the quadrate lobe. • STORES BILE produced in the liver. • BILE is leaves the liver through HEPATIC DUCTS to the COMMON HEPATIC DUCT. • COMMON HEPATIC DUCT joins with the CYSTIC DUCT of the gallbladder to form the COMMON BILE DUCT. • SPHINCTER OF BOYDEN regulates the outflow of bile from the common bile duct. • COMMON BILE DUCT and the MAIN PANCREATIC DUCT meet at the HEPATOPANCREATIC AMPULLA (AMPULLA OF VATER) located in DUODENUM. • HEPATOPANCREATIC SPHINCTER (SPHINCTER OF ODDI) regulate the flow of bile and pancreatic juices into the duodenum. • ARTERIAL SUPPLY to the GALLBLADDER (Fig. 5-5) ○○ CYSTIC ARTERY to the gallbladder typically is off the RIGHT HEPATIC ARTERY. • VENOUS BLOOD from the GALLBLADDER ○○ small veins into the HEPATIC PORTAL VEIN or sometimes directly into the liver.

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Fig. 5-7. Abdomen: Drawing of the gallbladder, stomach, duodenum, spleen, and pancreas (top) showing their blood supply and the ducts of the gallbladder and pancreas. Photomicrographs of the pancreas (bottom) showing a low magnification of the pancreatic exocrine glands and the pancreatic islets (left) and a high magnification of a pancreatic islet (right). (Top image modified from Gray 1918)

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Fig 5-8. Abdomen: Dissection showing the superior mesenteric vein and the splenic vein joining to form the hepatic portal vein. 1. Pancreas, 2. Duodenum, 3. Hepatic portal vein, 4. Superior mesenteric vein, 5. Jejunum, 6. Splenic vein, 7. Superior mesenteric artery, 8. Pylorus of stomach, 9. Round ligament of the liver, GB = Gall Bladder, S = Stomach.

6.5 PANCREAS (FIGS. 5-3, 5-7, 5-8, 5-9) • LONG, PEG-SHAPED GLAND that is inferior to the stomach and extends from the DUODENUM TO THE SPLEEN 1) a rounded HEAD that lies in the “C”-shaped curve of the duodenum. 2) a narrow NECK that lies superficial to the superior mesenteric vessels. 3) the UNCINATE PROCESS that extends from the head and is deep to the superior mesenteric vessels. 4) a cylindrical shaped BODY that crosses the aorta. 5) a tapered TAIL that reaches the spleen. • pancreas has both an EXOCRINE and an ENDOCRINE FUNCTIONS. • PANCREATIC ENZYMES (exocrine function) are produced by glandular cells and the enzymes transported through the MAIN PANCREATIC DUCT to the HEPATOPANCREATIC AMPULLA of the duodenum.

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• INSULIN, GLUCAGON, and SOMATOSTATIN (endocrine function) are produced by cells in the PANCREATIC ISLETS (ISLETS OF LANGERHANS) and secreted directly into the blood.

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Fig 5-9. Abdomen:. (Top) Liver, gall bladder, stomach, pancreas. (Bottom). Gall bladder. 1. Falciform lig. of liver, 2. Round lig. of liver, 3. Quadrate lobe, 4. Gall bladder, 5. Common bile duct, 6. Pyloric sphincter, 7. Pancreas, 8. Celiac trunk, 9. Cystic a., 10. Cystic duct, 11. Hepatic duct, 12. Hepatic a. D = Diaphragm, LLL = Left lobe of liver, RLL = Right lobe of liver, SB = Body of stomach, SP = Pylorus of stomach.

• ARTERIAL BLOOD SUPPLY to the PANCREAS (Figs. 5-5, 5-18) 1) PANCREATIC ARTERIES off the splenic artery. 2) branches off the SUPERIOR PANCREATICODUODENAL ARTERY from the GASTRODUODENAL ARTERY. 3) branches off the INFERIOR PANCREATICODUODENAL ARTERY from the SUPERIOR MESENTERIC ARTERY. • VENOUS BLOOD from the PANCREAS (Fig 5-6) ○○ enters the HEPATIC PORTAL SYSTEM. ○○ veins draining the HEAD AND NECK of the pancreas ▪▪ PANCREATICODUODENAL VEINS of the SUPERIOR MESENTERIC VEIN. ▪▪ RIGHT GASTROEPIPLOIC VEIN. ▪▪ HEPATIC PORTAL VEIN directly. ○○ veins drain the BODY and TAIL into the SPLENIC VEIN.

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6.6 SPLEEN (FIGS. 5-7, 5-10, 5-13) • largest LYMPHOID ORGAN in the body. • important component of the IMMUNE SYSTEM. • located against the left POSTERIOR ABDOMINAL WALL at the level of ribs 9, 10 and 11. • ARTERIAL BLOOD from the SPLENIC ARTERY off the CELIAC ARTERY (Figs. 5-5, 5-10, 5-18). • VENOUS BLOOD empties into the SPLENIC VEIN that ends by joining the SUPERIOR MESENTERIC VEIN to form the HEPATIC PORTAL VEIN (Figs. 5-6, 5-7, 5-8).

6.7 ESOPHAGUS (FIGS. 5-3, 5-5, 5-10) • MUSCULAR TUBE begins in the ORAL CAVITY. • passes through the ESOPHAGEAL HIATUS of the diaphragm at vertebral level T10. • ends at the CARDIAC portion of the STOMACH. • ARTERIAL BLOOD to the ESOPHAGUS (Figs. 5-5, 5-10) ○○ branches directly off the THORACIC AORTA. ○○ LEFT GASTRIC ARTERY off theCELIAC TRUNK. ○○ LEFT INFERIOR PHRENIC ARTERY off theABDOMINAL AORTA. • VENOUS BLOOD from the ESOPHAGUS (Fig. 5-6) ○○ esophageal veins in the thorax to the AZYGOS VEIN. ○○ esophageal veins in the neck to INFERIOR THYROID VEIN. ○○ LEFT GASTRIC VEIN which enters the HEPATIC PORTAL SYSTEM.

6.8 STOMACH (FIGS. 5-3, 5-6, 5-7, 5-9, 5-10, 5-11) • hollow J-SHAPED MUSCULAR ORGAN with circular, longitudinal and obliquely running smooth muscle fibers. • CARDIAC REGION is where the esophagus opens into the stomach. • FUNDUS is the superior dome of the stomach that rises above the cardiac region and is separated form cardiac region by the CARDIAC NOTCH. • BODY is the largest part of the stomach, extending from the fundus to the pylorus. • PYLORUS is the tubular inferior end of the stomach ○○ PYLORIC SPHINCTER is a large circular muscle that surrounds the PYLORIC CANAL. ○○ PYLORUS connect with the DUODENUM, which is the first part of the small intestine.

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• LESSER CURVATURE is the short superior medial curvature of the stomach. • GREATER CURVATURE is the long inferior lateral curve of the stomach. • ARTERIAL BLOOD to the STOMACH (Figs. 5-5, 5-10, 5-18) 1) LEFT GASTRIC ARTERY off theCELIAC TRUNK to the LEFT part of the LESSER CURVATURE. 2) RIGHT GASTRIC ARTERY from the COMMON OR PROPER HEPATIC ARTERY to the RIGHT part of the LESSER CURVATURE. 3) LEFT GASTROEPIPLOIC ARTERY from the SPLENIC ARTERY to the LEFT part of the GREATER CURVATURE. 4) RIGHT GASTROEPIPLOIC ARTERY from the GASTRODUODENAL ARTERY to the RIGHT part of the GREATER CURVATURE. 5) SHORT GASTRIC ARTERIES from the SPLENIC ARTERY to the FUNDUS. • VENOUS BLOOD from the STOMACH (Figs. 5-6, 5-7) 1) RIGHT AND LEFT GASTRIC VEINS into the PORTAL VEIN. 2) SHORT GASTRIC and LEFT GASTROEPIPLOIC VEINS to the SPLENIC VEIN and then the PORTAL VEIN. 3) RIGHT GASTROEPIPLOIC VEIN to the SUPERIOR MESENTERIC VEIN and then the PORTAL VEIN.

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Fig. 5-10. Abdomen: Drawings of the stomach showing (LEFT) the blood supply and (RIGHT) orientation of the muscle fibers. (Modified from Gray 1918)

9 – STUDY QUESTIONS:

1) What arteries go to the pancreas and from where do they originate? 2) What arteries go to the lesser curvature of the stomach and from where do they originate? 3) What arteries go to the greater curvature of the stomach and from where do they originate?

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6.9 SMALL INTESTINE

Fig. 5-11. Abdomen: Overview of Intestines, showing the jejunum and ilium of the small intestines and the cecum, ascending colon, transverse colon, sigmoid colon of the large intestines. The duodenum of the small intestines is hidden by the liver and transverse colon. The descending colon of the large intestines is hidden by the jejunum. (Modified from Gray 1918)

DUODENUM (FIGS. 5-3, 5-7, 5-10, 5-12)

• a short C-shaped loop of intestine that extends from the pylorus of the stomach to the jejunum. • the C-shaped duodenum frames the head of the pancreas 1) SUPERIOR PART that is continuous with the pylorus of the stomach and lies above the head of the pancreas. 2) VERTICAL DESCENDING PART that lies to the right of the pancreas and is where the common bile and pancreatic ducts enter the descending part of the duodenum. 3) HORIZONTAL PART that lies below the head of the pancreas. 4) a short ASCENDING PART that joins the jejunum.

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• ARTERIAL BLOOD to the DUODENUM (Figs. 5-5, 5-10, 5-18) 1) SUPRADUODENAL ARTERY off theGASTRODUODENAL ARTERY. 2) SUPERIOR PANCREATICODUODENAL ARTERY from the GASTRODUODENAL ARTERY. 3) INFERIOR PANCREATICODUODENAL ARTERY from the SUPERIOR MESENTERIC ARTERY. 4) branches from the RIGHT GASTROEPIPLOIC ARTERY from GASTRODUODENAL ARTERY. 5) branches from the RIGHT GASTRIC ARTERY from COMMON HEPATIC ARTERY. • VENOUS BLOOD from the DUODENUM (Fig. 5-6) ○○ SUPERIOR PANCREATICODUODENAL VEIN that empties into the PORTAL VEIN. ○○ INFERIOR PANCREATICODUODENAL VEIN that empties into the SUPERIOR MESENTERIC VEIN of the PORTAL VEIN.

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Fig. 5-12. Abdomen: Intestines. 1. Hepatic flexure, 2. Pancreas, 3. Superior mesenteric v., 4. Superior mesenteric a., 5. Splenic flexure, 6. Jejunum, 7. Ileum, 8. Ileocecal junction, 9. Duodenum, AC = Ascending colon, C = Cecum, TC = Transverse colon.

JEJUNUM AND ILEUM (FIGS. 5-11, 5-12)

• DUODENOJEJUNAL FLEXURE is at T12 where the ascending part of the duodenum turns sharply anteriorly to join the jejunum. • JEJUNUM extends from the DUODENUM to the ILIUM and lies mainly in the umbilical region of the abdomen. • ILEUM continues from the JEJUNUM and ends at the ILEOCECAL JUNCTION of the CECUM of the ascending colon. • ILEUM lies in the hypogastric and right iliac regions. • a MESENTERY, containing arteries and veins, suspends the jejunum and the ileum from the posterior abdominal wall.

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• ARTERIAL BLOOD to JEJUNUM and ILEUM (Figs. 5-12, 5-17, 5-18) ○○ JEJUNAL and ILEAL ARTERIES branch off the SUPERIOR MESENTERIC ARTERY, which is off the ABDOMINAL AORTA. • VENOUS BLOOD from the JEJUNUM and ILEUM (Fig. 5-6) ○○ accompany the jejunal and ileal arteries. ○○ JEJUNAL AND ILEAL VEINS drain into the SUPERIOR MESENTERIC VEIN of the PORTAL SYSTEM.

6.10 LARGE INTESTINE (FIGS. 5-2, 5-11, 5-12) • begins at the CECUM in the RIGHT ILIAC REGION as a large pouch. • the APPENDIX extends from the posterior CECUM. • ASCENDING COLON runs from the CECUM superiorly toward the LIVER where the colon bends to form the HEPATIC or RIGHT COLIC FLEXURE. • TRANSVERSE COLON transverses the abdomen from the HEPATIC FLEXURE to the SPLEEN where it bends downward forming the SPLENIC or LEFT COLIC FLEXURE. • DESCENDING COLON runs from the SPLENIC FLEXURE inferiorly toward the pelvis. • SIGMOID COLON curves (like an “S”) from the DESCENDING COLON to lie in the PELVIS where it straightens to run in the midsagittal plane as the RECTUM. • ANAL CANAL is short and continues from RECTUM to the ANUS. • ARTERIAL BLOOD to the large intestine (Figs. 5-7, 5-8, 5-17, 5-18, 5-20) ○○ SUPERIOR MESENTERIC ARTERY 1) ILEOCOLIC (ILEOCECAL) ARTERY supplies the ileocecal junction, cecum, appendix and inferior ascending colon. 2) RIGHT COLIC ARTERY supplies the ascending colon. 3) MIDDLE COLIC ARTERY supplies the hepatic flexure and the right half to two-thirds of the transverse colon. ○○ INFERIOR MESENTERIC ARTERY 1) LEFT COLIC ARTERY that divides into a SUPERIOR LEFT COLIC ARTERY supplying the left half to one-third of the transverse colon and the splenic flexure and an INFERIOR LEFT COLIC ARTERY supplying the descending colon. 2) SIGMOID ARTERIES supply the sigmoid colon. 3) SUPERIOR RECTAL ARTERY supplies the superior part of the rectum. • VENOUS BLOOD (Figs. 5-6, 5-7, 5-8) ○○ SUPERIOR MESENTERIC VEIN to PORTAL SYSTEM 1) ILEOCOLIC VEIN from the cecum.

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2) RIGHT COLIC VEIN from ascending colon. 3) MIDDLE COLIC VEIN from hepatic flexure, and right half to two- thirds of the transverse colon. ○○ INFERIOR MESENTERIC VEIN to PORTAL SYSTEM 1) LEFT COLIC VEIN from right half to one-third of the transverse colon. 2) SIGMOID VEINS from sigmoid colon. 3) SUPERIOR RECTAL VEIN from superior rectum.

10 – STUDY QUESTIONS:

1) What are the branches of the superior mesenteric artery and what areas do each of these branches supply? 2) What are the branches of the inferior mesenteric artery and what areas do each of these branches supply? 3) What veins drain into the superior mesenteric vein and what areas do each of these veins drain? What does the superior mesenteric vein drain into? 4) What veins drain into the inferior mesenteric vein and what areas do each of these veins drain? What does the inferior mesenteric vein drain into?

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6.11 KIDNEYS (FIGS. 5-13, 5-14, 5-15, 5-16) • BOUNDARIES • located behind the parietal peritoneum against the POSTERIOR ABDOMINAL WALL. • LEFT KIDNEY lies between T11 and L2. • RIGHT KIDNEY lies between T12 to L3. • ELEVENTH AND TWELFTH RIBS and a thick PARARENAL FAT PAD protect both kidneys posteriorly. • QUADRATUS LUMBORUM MUSCLE and DIAPHRAGM lie posterior to the kidneys. • TRANSVERSE ABDOMINIS MUSCLE is lateral and the PSOAS MAJOR MUSCLE is medial to the kidneys. • SUPRARENAL GLAND is superior to the kidneys. • ANTERIOR to the LEFT KIDNEY are the SPLEEN, STOMACH, PANCREAS, LEFT COLIC (SPLENIC) FLEXURE, AND JEJUNUM. • ANTERIOR to the RIGHT KIDNEY are the LIVER, RIGHT COLIC (HEPATIC) FLEXURE AND DUODENUM. • ARTERIAL BLOOD (Figs. 5-15, 5-17) ○○ RENAL ARTERY to the kidneys off theABDOMINAL AORTA with the artery entering the kidney at the RENAL HILUS. • VENOUS BLOOD (Figs. 5-13, 5-15, 5-19) ○○ RENAL VEIN from the kidneys to INFERIOR VENA CAVA with the vein entering the hilus anterior to the renal artery.

Fig. 5-13. Abdomen: Drawing showing the relationships of the kidneys to surrounding organs and muscles, renal blood vessels and path of the ureter over the psoas major muscle. (Modified from Gray 1918)

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• KIDNEY COMPOSITION (Figs. 5-14, 5-15, 5-16) ○○ the outer CORTEX extends inwardly as RENAL COLUMNS that run between the renal pyramids in the medulla. ○○ CORTEX contains the GLOMERULI, BOWMAN’S CAPSULE and THE CONVOLUTED TUBULES which are parts URINIFEROUS TUBULE. ○○ the MEDULLA contains distinct pyramidal shaped RENAL PYRAMIDS. ○○ PYRAMIDS contain the DESCENDING and ASCENDING LIMBS of the LOOP OF HENLE and COLLECTING TUBULES and PAPILLARY DUCTS. ○○ PAPILLARY DUCTS exit the tip of the renal pyramid at the RENAL PAPILLA ○○ each PAPILLA protrudes into a small funnel shaped MINOR CALYX with several minor calyxes empty into a large funnel shaped MAJOR CALYX. ○○ the major calyxes converge to empty into the large cone-shaped RENAL PELVIS that narrows to become the URETER. ○○ the ABDOMINAL URETER runs downward on the psoas major muscle and is crossed by the testicular or ovarian vessels. ○○ the PELVIS URETER enters the urinary bladder.

Fig 5-14. Abdomen: (Left) Photograph of the surface of a left kidney. (Right) Sagittal section through the kidney on the left. 1. Suprarenal gland, 2. Suprarenal v., 3. Renal v. 4. Testicular v. 5. Ureter, 6. Renal a., 7. Renal fat pad, 8. Renal pelvis, 9. Major calyx, 10. Minor calyx, 11. Renal column, 12. Renal pyramid, 13. Renal cortex.

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○○ the URINIFEROUS TUBULE is the functional and structural unit of the kidney and consists of the NEPHRON and COLLECTING TUBULE. ○○ NEPHRON contains the GLOMERULUS which is a capillary bed. ○○ an AFFERENT ARTERIOLE brings blood to the glomerulus and an EFFERENT ARTERIOLE removes blood from the glomerulus. ○○ BOWMAN’S CAPSULE surrounds the glomerulus and drains into a series of tubules 1) the PROXIMAL CONVOLUTED TUBULE begins at Bowman’s capsule and is continuous with the DESCENDING LIMB of the thin, U-shaped LOOP OF HENLE which is continuous with the ASCENDING LIMB of the LOOP OF HENLE. 2) the ASCENDING LIMB of the LOOP OF HENLE LOOP OF HENLE is continuous with the DISTAL CONVOLUTED TUBULE 3) the DISTAL CONVOLUTED TUBULE ends at the COLLECTING TUBULE. 4) several COLLECTING TUBES then join to form large PAPILLARY DUCTS which the drain into the MINOR CALYX.

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Fig. 5-15. Abdomen: Drawings of A) a frontal section through the kidney (modified from Gray 1918) and B) a uriniferous tubule.

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Fig. 5-16. Abdomen: Photomicrographs of the kidney at a low magnification (above) and at a high magnification (below) showing the glomerulus, proximal and distal convoluted tubules and collecting duct.

6.12 SUPRARENAL GLANDS (FIGS. 5-13, 5-14) • lies on the medial superior pole of each kidney. • an outer CORTEX that secretes CORTISOL, ALDOSTERONE, CORTICOSTERONE, ESTROGEN and PROGESTERONE. • an inner MEDULLA that secretes EPINEPHRINE and NOREPINEPHRINE.

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• ARTERIAL BLOOD to suprarenal gland (Fig. 5-17) 1) SUPERIOR SUPRARENAL ARTERY off the inferior phrenic artery. 2) MIDDLE SUPRARENAL ARTERY off the aorta. 3) INFERIOR SUPRARENAL ARTERY off the renal artery. • VENOUS BLOOD from suprarenal gland ○○ RIGHT SUPRARENAL VEIN drains into the INFERIOR VENA CAVA. ○○ LEFT SUPRARENAL VEIN drains into the LEFT RENAL VEIN.

11 – STUDY QUESTIONS:

1) What muscles lie posterior, medial, and lateral to each kidney? 2) What is the difference between the uriniferous tubule and the nephron? 3) From what three arteries do the three suprarenal arteries arise? 4) What is the difference between the right and the left suprarenal veins?

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6.13 ABDOMINAL ARTERIES (FIGS. 5-9, 5-12, 5-11, 5-12, 5-17, 5-18) 1) INFERIOR PHRENIC ARTERIES • paired arteries that arise at the level of the AORTIC HIATUS. • gives off a DIAPHRAGMATIC ARTERY to the inferior surface of the diaphragm and a SUPERIOR SUPRARENAL ARTERY to the suprarenal gland. 2) CELIAC TRUNK • short unpaired artery from the aorta just below the origin of the inferior phrenic arteries. • DIVIDES into ○○ LEFT GASTRIC ARTERY supplies the left lesser curvature of the stomach and gives offESOPHAGEAL ARTERIES to the esophagus. ○○ SPLENIC ARTERY gives off PANCREATIC ARTERIES to the pancreas, SHORT GASTRIC ARTERIES to the fundus of the stomach, and the LEFT GASTROEPIPLOIC ARTERY to the greater curvature of the stomach before it ends in the spleen. ○○ COMMON HEPATIC ARTERY gives off the GASTRODUODENAL ARTERY which supplies blood to the pancreas and duodenum through SUPERIOR PANCREATICODUODENAL ARTERY, to the duodenum through the SUPRADUODENAL ARTERY and to the greater curvature of the stomach by the RIGHT GASTROEPIPLOIC ARTERY. ▪▪ COMMON HEPATIC ARTERY becomes the PROPER HEPATIC ARTERY which then divides into RIGHT and LEFT HEPATIC ARTERIES. ▪▪ CYSTIC ARTERY to the gallbladder is from the RIGHT HEPATIC ARTERY. • RIGHT GASTRIC ARTERY to the right lesser curvature of the stomach is from either the COMMON OR the PROPER HEPATIC artery.

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Fig. 5-17. Abdomen: Diagrams of the abdominal aorta showing its branches.

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Fig. 5-18. Abdomen: The branches off the (A) celiac trunk, (B) the superior mesenteric artery (C) and the inferior mesenteric artery showing the gastrointestinal structures these supply.

3) SUPERIOR MESENTERIC ARTERY • large unpaired artery off the aorta that arises below the celiac trunk. • gives off an INFERIOR PANCREATICODUODENAL ARTERY to the pancreas and duodenum. • gives off several JEJUNAL and ILEAL ARTERIES to those parts of the small intestines. • gives off anILEOCECAL ARTERY to the cecum and the appendix. • gives off aRIGHT COLIC ARTERY to the ascending colon. • gives off a MIDDLE COLIC ARTERY to the right colic (hepatic) flexure and right half to two-thirds of the transverse colon.

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4) MIDDLE SUPRARENAL ARTERIES • paired arteries that arise from the abdominal aorta to the suprarenal glands. 5) RENAL ARTERIES • paired arteries that arise from the abdominal aorta to the kidneys. • gives off anINFERIOR SUPRARENAL ARTERY to the suprarenal gland. 6) TESTICULAR OR OVARIAN (GONADAL) ARTERIES • paired, small diameter arteries off the abdominal aorta to either the testes or ovaries. 7) INFERIOR MESENTERIC ARTERY • unpaired artery from the abdominal aorta. • gives off a LEFT COLIC ARTERY which divides into a SUPERIOR LEFT COLIC ARTERY to the left half to one-third of the transverse colon and the left colic (splenic) flexure and an INFERIOR LEFT COLIC ARTERY to the descending colon. • gives offSIGMOIDAL ARTERIES to the sigmoid colon. • ends as the SUPERIOR RECTAL ARTERY to the upper part of the rectum.

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8) LUMBAR ARTERIES • paired L1 to L4 segmental arteries to vertebrae arise from the sides of the abdominal aorta. • each gives off aDORSAL and VENTRAL BRANCH. • DORSAL BRANCH gives off a SPINAL ARTERY to the vertebra and then continues dorsally to the MUSCLES OF THE BACK. • VENTRAL BRANCH supplies the PSOAS MAJOR, QUADRATUS LUMBORUM and the muscles of the LATERAL ABDOMINAL WALL. 9) COMMON ILIAC ARTERIES • ABDOMINAL AORTA divides into COMMON ILIAC ARTERIES at the intervertebral disc between L4 and L5. • unpaired MEDIAN SACRAL ARTERY arises near the division to the ventral surface of L5 and the sacrum. • each COMMON ILIAC ARTERY DIVIDES ○○ INTERNAL ILIAC ARTERY that supplies pelvic organs, muscles and the perineum. ○○ EXTERNAL ILIAC ARTERY that gives off the DEEP CIRCUMFLEX ILIAC ARTERY and the INFERIOR EPIGASTRIC ARTERY to the abdominal wall and FEMORAL ARTERY of the lower limb.

6.14 SYSTEMIC ABDOMINAL VEINS (FIG. 5-19) • SYSTEMIC VEINS drain non-gastrointestinal viscera into the INFERIOR VENA CAVA and not the hepatic portal system. • the INTERNAL ILIAC VEIN from the pelvis and the EXTERNAL ILIAC VEIN which is a continuation of the FEMORAL VEIN in the lower limb join to form the COMMON ILIAC VEIN. • COMMON ILIAC VEINS join to form the INFERIOR VENA CAVA. • the RIGHT TESTICULAR or OVARIAN VEIN empties directly into the inferior vena cava. • the LEFT TESTICULAR or OVARIAN VEIN and the LEFT SUPRARENAL VEIN drain into the LEFT RENAL VEIN. • the RIGHT SUPRARENAL VEIN empties directly into the inferior vena cava • both RENAL VEINS empty into the inferior vena cava. • the RIGHT, LEFT, and MIDDLE HEPATIC VEINS drain directly into the inferior vena cava as vena cava passes through the liver.

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Fig. 5-19. Abdomen: Diagram of the inferior vena cave in the abdomen showing its branches.

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12 – STUDY QUESTIONS:

1) Describe the areas involved when the following arteries are blocked: a. Common hepatic a. b. Gastroduodenal a. c. Splenic a. d. Left colic a. e. Left renal a. f. Middle colic a. 2) What is the difference between the portal system and the systemic system? 3) Describe the areas involved when the following veins are blocked: a. Right hepatic v. b. Right colic v. c. Splenic v. d. Right gastroepiploic v. e. Left renal v. f. Inferior mesenteric v. g. L4 lumbar v.

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7 PELVIS

7.1 BONY PELVIS OSTEOLOGY (FIG. 6-1) • SACRUM and COCCYX posterior part of bony pelvis. • ILIUM superior lateral part of pelvis and innominate bone ○○ ILIAC FOSSA where the iliacus muscle. ○○ TUBEROSITY of the ILLIUM. ○○ AURICULAR SURFACE for sacroiliac joint. ○○ ANTERIOR SUPERIOR ILIAC SPINE. ○○ ANTERIOR INFERIOR ILIAC SPINE. ○○ ILIAC CREST and TUBERCLE. ○○ POSTERIOR SUPERIOR ILIAC SPINE. ○○ Superior part of ACETABULUM. • ISCHIUM inferior lateral part of pelvis and innominate bone ○○ ISCHIAL TUBEROSITY. ○○ ISCHIAL SPINE. ○○ GREATER SCIATIC NOTCH. ○○ LESSER SCIATIC NOTCH. ○○ SUPERIOR ISCHIAL RAMUS. ○○ INFERIOR ISCHIAL RAMUS. ○○ OBTURATOR FORAMEN formed by ischial rami. ○○ Posterior part of ACETABULUM. • PUBIC BONE anterior part of pelvis and innominate bone ○○ INFERIOR PUBIC RAMUS. ○○ SUPERIOR PUBIC RAMUS. ○○ OBTURATOR FORAMEN for by pubic rami. ○○ PUBIC CREST. ○○ PUBIC TUBERCLE. ○○ anterior part of ACETABULUM. • SACROILIAC JOINT is the articulation of innominate bone with the sacrum. • PUBIC SYMPHYSIS ○○ Fibrocartilage plate between anterior ends of pubic bone. ○○ PUBIC ARCH is angle formed below public symphysis by both inferior pubic rami. • INNOMINATE BONE formed by fusion of the ilium, ischium, and pubic bones on one side.

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Fig. 6-1. Pelvis: superior view: 1. superior articular facets of S1, 2. sacroiliac joint, 3. iliac fossa, 4. greater sciatic notch, 5. ischial spine of ischium, 6. superior pubic ramus 7. symphysis pubis, 8. inferior pubic ramus 9. Iliopectineal line, 10. coccyx, 11, anterior inferior iliac spine, 12. anterior superior iliac spine 13. iliac crests, 14. sacral ala, 15. body of S1. (Modified from Gray 1918)

Fig. 6-2. Back: Images, in anterior (A) and posterior (B) view, showing the iliolumbar and sacroiliac ligaments. 1. Ventral longitudinal ligament. 2. and 3. Iliolumbar ligament. 4. Ventral sacroiliac (SI) ligament. 5. Sacrospinous ligament. 6. Sacrotuberous ligament. 7. Pubic symphysis 8. Short dorsal SI ligaments. 9. Long dorsal SI ligament. 10. Supraspinous ligament. (Modified from Gray 1918)

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PELVIC JOINTS • SACROILIAC JOINT ○○ AURICULAR SURFACE of the SACRUM. ○○ AURICULAR SURFACE of the ILIUM. • PUBIC SYMPHYSIS (Figs. 6-1, 6-2) ○○ fibrous type joint with fibrocartilage disc. ○○ interconnects the anterior ends of the pubic bone.

LIGAMENTS • SACROILIAC JOINT (Figs. 6-2, 6-3) ○○ SHORT DORSAL SACROILIAC LIGAMENTS. ○○ LONG DORSAL SACROILIAC LIGAMENTS. ○○ STRONG INTEROSSEOUS LIGAMENTS. ○○ VENTRAL SACROILIAC LIGAMENTS. ○○ SACROSPINOUS and SACROTUBEROUS LIGAMENTS. • PUBIC SYMPHYSIS ○○ SUPERIOR PUBIC LIGAMENT between the pubic tubercles. ○○ ARCUATE LIGAMENT connects to the pubic arch and the disc.

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Fig. 6-3. Sacroiliac Joint (LEFT) Drawing of an oblique transverse section of the sacroiliac joint (modified from Gray 1918). (RIGHT) Photograph of an oblique sagittal section of the sacroiliac joint. 1. Sacrum, 2. Iliolumbar ligament, 3. Fibrous interosseous part od the joint, 4. Ilium, 5. Hyaline cartilage part of the joint.

7.2 PELVIC BOUNDARIES (FIG. 6-1) • PELVIS MAJOR (false pelvis) ○○ between the iliac fossae. ○○ separated from the minor by the PELVIC BRIM which runs from the sacrum to the pubic symphysis ▪▪ composed of the ALA and PROMONTORY of the sacrum, the ARCUATE LINE of the ilium, and the PECTINEAL LINE and PUBIC TUBERCLE of the pubic bone. ▪▪ ARCUATE LINE and PECTINEAL LINE make up the ILIOPECTINEAL LINE. • PELVIS MINOR (true pelvis) ○○ bound inferiorly by the PELVIC DIAPHRAGM and the PERINEUM.

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7.3 CONTENTS • PELVIS MAJOR is a continuation of the abdominal cavity 1) lower ILIUM,) CECUM,3) APPENDIX, 4) SIGMOID COLON, 5) the upper RECTUM, 6) COMMON ILIAC VESSELS, 7) LUMBAR NERVE PELEXUS, 9) SYMPATHETIC TRUNK and AUTONOMIC GANGLIA and NERVES, 10) URETER, and 11) PSOAS MAJOR, PSOAS MINOR and ILIACUS MUSCLES • PELVIS MINOR • 1) URINARY BLADDER, 2) REPRODUCTIVE ORGANS, 3) RECTUM and ANUS, 4) LUMBAR NERVE PLEXUS, 5) SACRAL NERVE PLEXUS, 6) SACRAL SYMPATHETIC TRUNK and AUTOMONIC GANGLIA and NERVES, 8) EXTERNAL ILIAC VESSELS, 9) INTERNAL ILIAC VESSELS, 10) OBTURATOR INTERNUS MUSCLE, 11) PIRIFORMIS MUSCLE, and 12) PELVIC DIAPHRAGM

7.4 PELVIC DIAPHRAGM (FIG. 6-4) • the muscular pelvic diaphragm closes the floor of the inferior bony pelvis and provides support for the pelvic viscera. • consists of the LEVATOR ANI muscle group and the COCCYGEUS MUSCLE (ischiococcygeus muscle). • LEVATOR ANI COMPONENTS OF PELVIC DIAPHRAGM 1) PUBOCOCCYGEUS MUSCLE ○○ Lateral attachment: Superior ramus of pubic bone, tendinous arch of the levator ani. ○○ Medial attachment: Coccyx and anococcygeal ligament. ○○ Nerve: nerve to the pelvic diaphragm. ○○ Actions: Elevates the pelvic floor, supports pelvic viscera. 2) PUBORECTALIS MUSCLE ○○ Anterior attachment: Medial fibers of thePUBOCOCCYGEUS. ○○ Posterior attachment: Right and left puborectalis form a U-shaped sling around the ano-rectal junction. ○○ Nerve: nerve to the pelvic diaphragm. ○○ Actions: Elevates ano-rectal junction restricting defecation. 3) FEMALE PUBOVAGINALIS MUSCLE ○○ Anterior attachment: Medial fibers from the PUBOCOCCYGEUS that curve around the vagina. ○○ Posterior attachment: Perineal body of perineum. ○○ Nerve: nerve to the pelvic diaphragm. ○○ Actions: virginal sphincter, supports vagina.

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4) LEVATOR PROSTATE MUSCLE ○○ Anterior attachment: Medial fibers from the PUBOCOCCYGEUS that curve around prostate. ○○ Posterior attachment: Perineal body. ○○ Nerve: nerve to the pelvic diaphragm. ○○ Actions: elevates and supports prostate. 5) ILIOCOCCYGEUS MUSCLE ○○ Lateral attachment: Ischial spine, thick TENDINOUS ARCH OF THE LEVATOR ANI which is a thickening in the fascia covering the obturator internus muscle. ○○ Medial attachment: Coccyx and anococcygeal ligament. ○○ Nerve: nerve to the pelvic diaphragm. ○○ Actions: Elevates the pelvic floor, supports pelvic viscera.

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Fig. 6-4: (TOP) Drawing of superior view of the female pelvic floor muscles and (BOTTOM) Photograph of superior view of male pelvic floor. 1. Urethra, 2. Vagina, 3. Tendinous arch of the pelvic fascia, 4. Iliococcygeus m., 5. Tendinous arch of the levator ani, 6. Rectum, 7. Pubococcygeus m., 8. Piriformis m. 9. Coccygeus m. 10. Puborectalis m., 11. Obturator internus m., 12. Tendinous arch of the levator ani, 13. Iliococcygeus m., 14. Pubovaginalis m and Pubococcygeus m., 15. Tendinous arch of the pelvic fascia cut, 16. Perineal membrane, 17. Seminal vesicles

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• COCCYGEUS MUSCLE OF PELVIC DIAPHRAGM ○○ Lateral attachment: Ischial spine, sacrospinous ligament. ○○ Medial attachment: Lower lateral sacrum and upper coccyx. ○○ Nerve: nerve to the pelvic diaphragm, sacral nerve five. ○○ Actions: Stabilizes the coccyx, supports pelvic viscera.

OTHER PELVIC MUSCLES (FIGS. 6-4, 6-5)

• PSOAS MAJOR MUSCLE ○○ Superior attachment (origin): Transverse processes of L1-L5; intervertebral disks and bodies of the vertebrae from T12 to L5. ○○ Inferior attachment (insertion): Joins the iliacus muscle to attach onto to the lesser trochanter of the femur. ○○ Nerve: Femoral nerve. ○○ Action: Flexion of the femur; flexion and lateral bending of the lumbar spine. • PSOAS MINOR MUSCLE ○○ Superior attachment (origin): Bodies of vertebrae T12 and L1. ○○ Inferior attachment (insertion): Iliopectineal eminence. ○○ Nerve: L1. ○○ Action: Weak flexion of lumbar spine. • ILIACUS MUSCLE ○○ Superior attachment (origin): Iliac crest and fossa, ala of the sacrum, sacroiliac ligaments, anterior inferior iliac spine. ○○ Inferior attachment (insertion): Joins psoas major to form ILIOPSOAS and attaches to the lesser trochanter. ○○ Nerve: Femoral nerve. ○○ Action: Flexion of the femur. • PIRIFORMIS ○○ Medial attachment (origin): Ventral sacrum; sacrotuberous ligament. ○○ Lateral attachment (Insertion): Superior greater trochanter of the femur. ○○ Nerve: Nerve to the piriformis. ○○ Action: External rotation of the femur with the hip extended; internal rotation of the femur with the hip flexed greater than 90 degrees. • OBTURATOR INTERNUS ○○ Medial attachment (origin): Pelvic side of the obturator foramen. ○○ Lateral attachment (insertion): Medial greater trochanter with superior and inferior gemelli. ○○ Nerve: Nerve to the obturator internus. ○○ Action: External rotation of the femur.

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Fig. 6-5. Pelvic Girdle: Diagrams of the psoas major, psoas minor and iliacus showing bony attachments

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13 – STUDY QUESTIONS:

1) What is difference between the major pelvis and the minor pelvis? What general statements can you make about the organs contained in each? 2) What is the difference between the pelvic diaphragm and the levator ani? 3) What muscles, besides the pelvic diaphragm, lie in the pelvic region?

7.5 PELVIC ARTERIES (FIGS. 6-6, 6-7) EXTERNAL ILIAC ARTERY • off COMMON ILIAC from ABDOMINAL AORTA. • DEEP CIRCUMFLEX ILIAC ARTERY to abdominal wall. • INFERIOR EPIGASTRIC ARTERY to the abdominal wall. • FEMORAL ARTERY to the lower limb. INTERNAL ILIAC ARTERY • ANTERIOR DIVISION 1. UMBILICAL ARTERY gives offSUPERIOR VESICAL ARTERIES to the superior aspect of the bladder. 2. OBTURATOR ARTERY to muscles of the medial thigh. 3. MIDDLE RECTAL ARTERY to the rectum in both genders and the prostate and seminal vesicles in males, and vagina in females. 4. INTERNAL PUDENDAL ARTERY gives off theINFERIOR RECTAL ARTERY to rectum arteries to the perineum. 5. INFERIOR GLUTEAL ARTERY to muscles in the gluteal region and posterior thigh. 6. INFERIOR VESICAL ARTERY (male) to inferior bladder, prostate, and seminal vesicles. 7. UTERINE ARTERY (female) to the uterus and upper vagina. 8. VAGINAL ARTERIES (female) to the vagina, inferior bladder, and pelvic urethra. 9. MEDIAN SACRAL ARTERY to sacral spinal roots and posterior rectum.

• POSTERIOR DIVISION ○○ ILIOLUMBAR ARTERY to iliacus, psoas major, and quadratus lumborum muscles. ○○ SUPERIOR GLUTEAL ARTERY to the gluteal muscles in that region. ○○ LATERAL SACRAL ARTERY to meninges and sacral spinal nerve roots.

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Fig. 6-6. Pelvis: Diagram of the internal iliac artery with its branches on one side in the pelvic region.

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Figure 6-7. Female Pelvis: Photographs of the branches off the anterior division (LEFT) and posterior division (RIGHT) of the internal iliac artery.1. Internal iliac artery, 2. External iliac artery, 3. Obturator nerve, 4. Umbilical artery, 5. Superior vesicular arteries, 6. Obturator artery, 7. Urinary bladder, 8. Pubic symphysis, 9. Ureter, 10. Uterine (vaginal artery comes off near the uterus and is not shown), 11. Uterus and Uterine tube, 12. Middle rectal artery, 13. Inferior gluteal artery, 14. Pelvic splanchnic nerves, 15. Superior gluteal artery, 16. S3 spinal nerve, 17. S2 spinal nerve, 18. S1 spinal nerve, 19. Lateral sacral artery, 20. Iliolumbar artery.

7.6 PELVIC NERVES LUMBAR PLEXUS (Figs. 6-8, 6-9) • VENTRAL RAMI of L1 through L5 spinal nerves. • ILIOHYPOGASTRIC NERVE (L1) ○○ SENSORY to the lateral gluteal region, and hypogastric abdominal region. ○○ MOTOR to the external and internal abdominal obliques and transverse abdominis. • ILIOINGUINAL NERVE (L1) ○○ SENSORY to the pubic symphysis, inguinal region, anterior scrotum and labia majora. ○○ MOTOR to the internal abdominal oblique and transverse abdominis. • GENITOFEMORAL NERVE (L1; L2) ○○ SENSORY by FEMORAL BRANCH to femoral triangle and by GENITAL BRANCH to the anterior scrotum and anterior labia majora. ○○ MOTOR none.

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• LATERAL FEMORAL CUTANEOUS NERVE (L2, L3) ○○ SENSORY to the skin over the lateral thigh. ○○ MOTOR none. • FEMORAL NERVE (L2, L3, L4) ○○ SENSORY to the anterior thigh, medial leg, and medial ankle. ○○ MOTOR to the anterior thigh muscles. • OBTURATOR NERVE (L2, L3, L4) ○○ SENSORY to the medial thigh. ○○ MOTOR to the hip adductor muscles. • LUMBOSACRAL TRUNK (L4, L5) ○○ SENSORY to join the sacral plexus. ○○ MOTOR to join the sacral plexus.

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Fig. 6-8. Drawings of the posterior abdominal wall showing the muscles and the nerves of the lumbar plexus. 1. Iliohypogastric N., 2. ilioinguinal N., 3. femoral N., 4. obturator N., 5. intervertebral disc, 6. sciatic N., 7. genitofemoral N., 8. iliacus muscle, 9. lateral femoral cutaneous N., 10. subcostal N., 11. psoas major and 12. iliopsoas tendon

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Figure 6-9. Photograph to a dissection of the posterior abdominal and pelvis. 1. Iliohypogastric nerve, 2. Ilioinguinal nerve, 3. Lateral femoral cutaneous nerve, 4. Femoral nerve, 5. External iliac artery, 6. Obturator nerve, 7. Urinary bladder, 8. Uterus, 9. Superior hypogastric plexus, 10. Genitofemoral nerve, 11. Inferior vena cava, 12. Abdominal aorta, 13. Quadrates lumborum muscle, 14. Psoas major muscle, 15. Ureter, 16. Iliolumbar ligament, 17. Iliacus muscle.

7.7 SACRAL PLEXUS (FIGS. 1-15, 1-16) • LUMBOSACRAL TRUNK (L4 and L5) and VENTRAL RAMI of S1-S4. • SCIATIC NERVE (L4-S3) to the posterior thigh, lower leg, ankle, and foot. • SUPERIOR GLUTEAL NERVE (L4-S1) to the gluteus medius and minimus and hip. • INFERIOR GLUTEAL NERVE (L5-S2) to the gluteus maximus and hip. • NERVE TO THE QUADRATUS FEMORIS (L4-S1) to quadratus femoris muscle. • NERVE TO THE OBTURATOR INTERNUS (L5-S2) to the obturator internus muscle. • PUDENDAL NERVE (S2-S4) to the muscles of the perineum, the external anal sphincter, and to the external genitalia. • NERVE TO THE PIRIFORMIS (S1-S2) to the piriformis muscle. • NERVE TO THE PELVIC DIAPHRAGM (S3-S4) to the levator ani and coccygeus muscles.

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360° 360° thinking. thinking. Fig. 6-10. Pelvis: Diagram of the sacral plexus.

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Fig 6-11. Dissections of the sacral plexus. (LEFT) Low magnification view of the pelvic floor showing the nerves and muscle in this region. (RIGHT) High magnification of the sacral plexus. 1. Obturator nerve. 2. Lumbosacral nerve trunk, 3. S1 nerve, 4. S2 nerve, 5. Piriformis muscle, 6. S3 nerve, 7. Pelvic splanchnic nerves off of S4 (probe), 8, Coccygeus muscle, 9. Levator ani, 10. Obturator internus muscle, 11. Uterus and Uterine tube.

PELVIC AUTONOMIC NERVES (FIGS. 6-12, 6-13, 6-14)

• SYMPATHETIC innervation to the pelvic viscera arrives by LUMBAR and SACRAL SPLANCHNIC NERVES from the sympathetic chain. • PARASYMPATHETIC innervation by PELVIC SPLANCHNIC NERVES from S2-S4 spinal cord segments.

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Fig. 6-12. Nerve: Schematic showing the sympathetic (LEFT) and parasympathetic (RIGHT) innervations of the body.

• LUMBAR SPLANCHNIC NERVES (sympathetic nerves) from L1-L2 (L3) travel to the SUPERIOR HYPOGASTRIC PLEXUS and then to the HYPOGASTRIC PLEXUS. • HYPOGASTRIC NERVES from the HYPOGASTRIC PLEXUS join SACRAL SPLANCHNIC NERVES (sympathetic nerves) to enter the INFERIOR HYPOGASTRIC PLEXUS. • PELVIC SPLANCHNIC NERVES (parasympathetic nerves) from the SACRAL PLEXUS enter the INFERIOR HYPOGASTRIC PLEXUS and then the HYPOGASTRIC PLEXUS. • SYMPATHETIC AND PARASYMPATHETIC NERVES from the INFERIOR HYPOGASTRIC PLEXUS follow the internal iliac vessels to form other nerve plexuses.

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○○ in MALES AND FEMALES, the INFERIOR HYPOGASTRIC PLEXUS gives rise to a RECTAL PLEXUS to the rectum and VESCIAL PLEXUS to the bladder. ○○ in FEMALES, the INFERIOR HYPOGASTRIC PLEXUS gives rise to the UTEROVAGINAL PLEXUS to the uterus and vagina. ○○ in MALES, the VESICAL PLEXUS gives rise to the DEFERENTIAL PLEXUS to the vas deferens and epididymis and the PROSTATIC PLEXUS to the prostate. ○○ in MALES, the PROSTATIC PLEXUS give rise to the CAVERNOUS PLEXUS of the penis. ○○ in FEMALES, the VESICAL PLEXUS give rise to CAVERNOUS PLEXUS of the clitoris. • SYMPATHETIC NERVES to the ovaries, uterine tubes and testes are from SACRAL SPLANCHIC NERVES off the sacral sympathetic chain to form OVARIAN or TESTICULAR PLEXUSES. • PARASYMPATHETIC NERVES to the ovaries and testes are from the VAGUS NERVE.

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Fig. 6-13. Pelvis: Flow chart of the Autonomic Nervous System showing sympathetic (solid arrows) and parasympathetic (dashed arrows) efferent contributions to the pelvic plexuses and viscera.

Fig. 6-14. Pelvis: Flow chart of the Autonomic Nervous System showing afferent sympathetic (solid arrows) and parasympathetic (dashed arrows) contributions to the pelvic plexuses and viscera.

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14 – STUDY QUESTIONS:

1) Which arteries arise form the posterior division of the internal iliac artery? 2) Which artery off the internal iliac artery is found only in males? 3) Describe what structures would be affected with blockage of the following arteries: a. Umbilical artery b. Middle rectal artery c. Uterine artery d. Lateral sacral artery 4) What is the difference in spinal nerve contribution between the lumbar and the sacral plexuses? Is there any overlap? 5) What are the nerves involved when there is a lesion to the following spinal nerves? a. L2 b. L4 c. L5 d. S1 e. S2 6) Where do sympathetic and parasympathetic efferent nerves go to from the Inferior Hypogastric Plexus? 7) Where do sympathetic and parasympathetic afferent nerves go to from the Inferior Hypogastric Plexus?

7.8 URINARY BLADDER (FIGS. 6-9, 6-16, 6-17, 6-18, 6-20, 6-22, 6-23) • URINARY BLADDER is a hollow muscular organ that stores urine transported through the ureters from the kidneys. • PELVIC URETER ends by opening into the upper posterior urinary bladder. • In FEMALES, the bladder lies posterior to the pubic symphysis, inferior and anterior to the uterus, and anterior to the vagina. • In MALES, the bladder lies posterior to the pubic symphysis, superior to the prostate, and anterior to the seminal vesicle, ampulla of the vas deferens and the rectum. • Urine leaves the bladder through the URETHRA. • In FEMALES, the urethra is short and passes through a muscular UROGENITAL DIAPHRAGM to opens externally into the vestibule of the vagina, anterior to the vaginal opening. • In MALES, the urethra passes through the prostate as the PROSTATIC URETHRA, then through the UROGENITAL DIAPHRAGM as the MEMBRANOUS URETHRA, and lastly through the penis as the SPONGY URETHRA.

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7.9 PELVIC ORGAN SUPPORT STRUCTURES (TABLE 6.1, FIGS. 6-15, 6-16, 6-17) • fascial and muscular support structures of the urinary bladder, and male, and female reproductive structures are complex. • PARIETAL AND VISCERAL PERITONEUM cover the superior urinary bladder. • URACHUS is a fibrous cord attaching the apex of the bladder to the anterior abdominal wall where it forms the MEDIAN UMBILICAL LIGAMENT that ends at the umbilicus. • LATERAL LIGAMENTS OF THE BLADDER lie on the posterior-lateral aspect of the superior bladder. • PUBOVESICAL LIGAMENTS run anteriorly from the inferior-lateral neck of the bladder to connect to the lower posterior body of the pubis. • In males, the PUBOPROSTATIC LIGAMENTS lie inferior to the pubovesical ligament connecting the pubic bone to the anterior-lateral prostate.

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• SACROGENITAL LIGAMENTS (rectovesical, uterovesical, uterorectal ligaments) begin from the posterior lateral bladder ○○ In MALES, this sacrogenital ligament connect the bladder and rectum to the lower sacrum. ○○ In FEMALES, the sacrogenital ligament connects the bladder, vagina, and rectum to the lower sacrum. • PELVIC DIAPHRAGM and the TENDINOUS ARCH OF THE PELVIC FASCIA support the inferior bladder ○○ PELVIS DIAPHRAGM is composed the LEVATOR ANI and COCCYGEUS MUSCLES. ○○ TENDINOUS ARCH OF THE PELVIC FASCIA is a thickening in the medial superior fascia of the pelvic diaphragm that runs from the posterior inferior pubic body, medial and superior to the pelvic floor and inserts at the spine of the ischium.

NAME GENDER DISCRIPTION FUNCTIONS

Tendinous Both This bilateral structure attaches to su- Provides attachment Arch of perior body of the pubic bone lateral for the anterior part Levator Ani to the symphysis and superior lateral of the pubococygeus (TALA) to the Tendinous Arch of Pelvic Fas- and the entire iliococ- cia and the pubococcygeus muscle. cygeus mucels of the Runs laterally as the thick band across levator ani. the central aspect of the Obturator Internus muscle fascia to attach posteriorly on the ischial spine.

Tendinous Both This arch is bilateral and attaches Provides support for Arch of Pelvic to superior body of the pubic bone the visceral structure Fascia (TAPF) lateral to the symphysis and infe- lying in the urogenital rior medial to the Tendinous Arch hiatus and closes areas of the Levator Ani and superior to between the viscera in the puboccocygeus muscle. This fi- this region and the me- brous bands runs posteriorly along dial edge of the hiatus. the edge of the urogenital hiatus and Restricts hypermobile connects medially to visceral struc- movements in all direc- tures in the hiatus. The band ends tions of the bladder posteriorly at the ischial spine with neck, urethra, and va- the TALA. gina in female and the prostate and membranous urethra in males.

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NAME GENDER DISCRIPTION FUNCTIONS

Pubovesical Both This short strong bilateral ligament In females, this liga- ligament attaches lateral to the pubic symphy- ment holds the blad- sis on the inferior aspect of the pubic der, urethra and va- body and inferior to the TAPF. It has gina upward and two and maybe 3 bands. A superior anteriorly. Because of band runs horizontally and an inferior the attachment of the band vertically. These two bands may urethra and vagina and be connected by a thin third band. In because this ligament females, the superior band attaches connects to the TAPF, to the sides of the bladder neck and it will restrict hyper- TAPF while the inferior band attaches mobile posterior, in- to the urethra and vagina complex. ferior, sideward and It is also referred to as the parau- rotational movements rethral and pubourethral ligaments of these structures. in females. In males, The pubovesical ligament is commonly called the puboprostatic ligament. See below for description and function.

Sacrogenital Both This bilateral thick, fibromuscular Holds the lower uter- ligament ligament connects the sides of the us, cervix, upper va- lower uterus, cervix and upper vagina, prostate poste- gina in the female and the sides of riorly while restricting the prostate in the male to the S1- hypermobile anterior, S4 segments of the sacrum and the upward, downward, sacrospinous ligament. sideward and rotational movements.

Lateral Both This bilateral endopelvic fascial fold Holds the body of the ligament of lies deep to the overlying perito- bladder posteriorly, bladder neum. It attaches to the posterior restricting hypermo- lateral aspect of the bladder and lat- bile anterior, upward, eral wall of the pelvis. These bilateral downward, sideward fibrous bands run lateral and poste- and rotational move- riorly towards the sacrum to join the ments. sacrogenital ligament.

Urachus Both This fibromuscular cord attaches to Holds the anterior most the apex of the urinary bladder and part of the bladder in runs superiorly along the anterior ab- a upward and forward dominal wall to the umbilicus under position. It would re- the peritoneum. It forms the middle sist downward and umbilical ligament. posterior movement of the bladder but not sideward or rotational movements.

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NAME GENDER DISCRIPTION FUNCTIONS

Perineal Both A horizontal sheet of connective tis- In females, this mem- membrane sue lying in the urogenital triangle brane supports the of the perineum. It fibers connect bladder upwardly, and the anterior inferior aspect of the stabilizes the opening ischiopubic rami and to the perineal of the urethra and va- body. This membrane closes most of gina. It restricts down- the anterior urogenital hiatus and is ward movement of the a completely solid sheet in males but bladder and down- has openings for the urethra and va- ward, anterior – pos- gina in females. terior, sideward movement of the urethra and vagina. In males, it supports the prostrate upwardly, restricting downward movement of the prostate and bladder.

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NAME GENDER DISCRIPTION FUNCTIONS

Perineal body Both This fibrous vertical column lies cen- Provides attachments trally in the perineal region at the for the perineal mem- anal and urogenital triangles. It is brane, bulbocanvero- torn or cut during vaginal childbirth sus, the superficial and to enlarge the vaginal opening. deep transverse perineal muscles, and external anal sphincter.

Anococcygeal Both An short, strong, elongated central Provides support for ligament ligament in median part of the anal the anus and holds it triangle of the perineum that connects posteriorly, restricting the posterior aspect of the external anterior movement of anal sphincter to the coccyx bone. the anus and anal canal. Provides a secure attachment for contraction of the external anal sphincter to voluntarily close the anal opening.

Broad Female A large vertical oriented sheet on Holds the uterus up ligament each side of the uterus that runs and centrally, restrict- of uterus in the frontal plane to connect the ing downward, lateral uterus with the pelvic wall. This liga- and twisting movement consists of anterior and poste- ments. Its orientation rior layers that permit neurovascular in the frontal plane al- structures and the uterine tubes to lows it to act as a hinge reach the uterus. The inferior edge for anterior to pos- of this ligament is continuous with terior uterine move- transverse cardinal lig. of cervix. ments relative to the secure cervix. Protects the uterine nerves and blood vessels and allows these to move with movements and enlargement of the uterus.

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NAME GENDER DISCRIPTION FUNCTIONS

Transverse Female Inferior part of the broad ligament Holds cervix and upper cardinal where the anterior and posterior lay- vagina up and centrally ligament ers of the broad ligament are fused. and stabilizes this area of cervix This bilateral ligament runs with the laterally and restricts broad ligament to attach to the cervi- downward movement cal ring (fascia around cervix and up- and twisting of these per vagina from transverse cardinal structures. Because lig. and sacrogential lig.) and upper this lig. attaches to the 1/3 of the sides of the vagina. cervical ring, there is restriction of anterior movement of the cervix and upper vagina and expansion of the upper vagina.

Suspensory Female This long tubular like ligament con- Provides passage and ligament nects the lateral pole of the ovary to protection for the neu- of ovary the pelvic wall. rovascular elements going to the ovary.

Ovarian Female This short, round bilateral ligament Supports the ovary ligament connects the fundic area of the uterus and limits the move- with the medial pole of the ovary on ments of the ovary that side. relative to the fimbriae of the uterine tubes.

Round Female This bilateral ligament arises from the Holds the uterus up ligament fundic area of the uterus at the site of and forward and re- of uterus attachment of the ovarian ligament. stricting sideward and It runs forward and posterior laterally twisting movements through the upper part of the broad of the fundic area of lig. to reach the pelvic wall and then the uterus. enters the deep inguinal ring. It then passes through the inguinal canal to attach to the labia majora.

Puboprostate Male This bilateral ligament has 2 and Holds the prostate and ligament sometimes 3 bands lying on each side prostatic urethral junc- of the pubic symphysis and attaching tion up and forward to the inferior aspect of the pubic and restricts hypermo- body. The horizontal superior band bile downward, pos- attaches to the sides of the inferior terior, sideward and prostate and TAPF while the vertical rotational movement inferior band attaches to the pros- of the lower prostate tatic urethral junction. If a third band and connected mem- is present, it attaches to the superior branous urethra. and inferior bands.

Table 6-1: Support structures for the pelvic viscera

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Fig 6-15. Pelvis: (LEFT). Photograph of a superior view of female pelvis. The sacrum is at the top of the photo, the pubic symphysis at the bottom, the thumb is holding female viscera and the iliac crest is on the left. (RIGHT). Photograph of a superior view of a male pelvis. The posterior aspect of the pelvis is at the top of the photo, the pubic symphysis at the bottom, the probe is holding urinary bladder and the iliac crest is on the left. 1. Obturator fascia covering obturator internus m., 2. Obturator internus m., 3. Tendinous arch of the levator ani, 4. Pubic symphysis, 5. Tendinous arch of the pelvic fascia, 6. Female pelvic viscera (bladder, Uterus) 7. Iliococcygeus m., 8. Sacrum, 9. Pubococcygeus m., 10. Levator prostate m. 11. urinary bladder at junction with prostate showing urethral opening.

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Fig, 6-16. Pelvis: Drawing of the male urogenital system showing the supporting ligaments and muscles. 1. rectum, 2. sacrogenital ligament, 3. puborectalis m., 4. pubococcygeus m., 5. tendinous arch of pelvic fascia, 6. external anal sphincter m., 7. compressor urethrae m., 8. perineal body, 9. deep transverse perineal m., 10. superficial transverse perineal m., 11. bulbospongiosus m., 12. external sphincter urethrae m., 13. perineal membrane, 14. tendinous arch of the levator ani, 15. puboprostate ligament, 16. prostate gland, 17. pubovesical ligament, 18. pubic symphysis, 19. urachus, 20. lateral ligament of the urinary bladder, 21. urinary bladder, 22. levator prostate m.

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Fig. 6-17 Pelvis: Drawing of the female urogenital system showing the supporting ligaments and muscles. 1. rectum, 2. sacrogenital ligament, 3. puborectalis m., 4. pubococcygeus m., 5. tendinous arch of pelvic fascia, 6. external anal sphincter m., 7. compressor urethrae m., 8. perineal body, 9. deep transverse perineal m., 10. superficial transverse perineal m., 11. bulbospongiosus m., 12. urethrovaginal sphincter m., 13. perineal membrane, 13. perineal membrane, 14. external sphincter urethrae m., 15. tendinous arch of the levator ani, 16. and 17. pubovesical ligament, 18. pubic symphysis, 19. urachus, 20. urinary bladder, 21. lateral ligament of the urinary bladder, 22. uterus, 23. broad ligament of uterus, 24. transverse cervical (cardinal) ligament, 25. vagina.

15 – STUDY QUESTIONS:

1) What are the fibrous structures support the urinary bladder? 2) What are the parts of the male ureter? 3) What makes up the pelvic diaphragm?

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7.10 MALE REPRODUCTIVE SYSTEM (FIGS. 6-18, 6-19, 6-20, 6-21)

TESTIS AND EPIDIDYMIS (FIG. 6-18, 6-19)

• testicles develop in the abdomen, near the kidney, and migrate after birth through the inguinal canal and into the sac-like SCROTUM ○○ DARTOS MUSCLE is smooth muscle layer in the wall of the scrotum that contracts to help maintain testicular temperature needed for sperm development . ○○ In the scrotum, the testis is covered by 1) the EXTERNAL SPERMATIC FASCIA from the aponeurosis of the external abdominal oblique. 2) the CREMASTER MUSCLE is from the internal oblique muscle which the testis towards the pelvis to help maintain testicular temperature. 3) the INTERNAL SPERMATIC FASCIA is from the transversalis fascia of the abdomen.

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Fig. 6-18. Pelvis: The male reproductive system. Sagittal view of the male pelvis showing reproductive organs. 1. urinary bladder, 2. pubic symphysis, 3. prostate, 4. corpus cavernosum, 5. spongy urethra, 6. bulb of penis and corpus spongiosum, 7. glans penis, 8. scrotum, 9. bulbospongiosum muscle, 10. external anal sphincter, 11. internal anal sphincter, 12. rectum-anus junction, 13. prosthetic urethra, and 14. seminal vesicle.

• TUNICA ALBUGINEA is the thick white outer fibrous coat of the testis. • SEMINIFEROUS TUBULES internal tubules in the testis where sperm develops. • Sperm from the seminiferous tubules are transported through a series of EFFERENT DUCTULES to the head of the EPIDIDYMIS that lies on the outer surface of the testis. • EPIDIDYMIS has a head, body, and tail ○○ head and body containing single highly coiled duct. ○○ the duct in the tail straightens and becomes continuous with the VAS (DUCTUS) DEFERENS.

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Fig 6-19. Pelvis: Drawing of the testis (A) showing the seminiferous tubules, epididymis and vas deferens. photomicrograph of the testis (B) showing seminiferous tubules and efferent ductules.

VAS DEFERENS, SEMINAL VESICLES, PROSTATE GLAND (FIGS. 6-18, 6-20)

• VAS DEFERENS travels from the scrotum in the spermatic cord and through inguinal canal to reach the pelvic cavity. • both VAS DEFERENS reach the lower posterior urinary bladder and enlarges to form the AMPULLA of the VAS DEFERENS which lie between the SEMINAL VESICLES.

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• SEMINAL VESICLE is a gland that secretes an alkaline fluid which forms a large volume of the semen. • SEMINAL VESICLE consists of a long-coiled tube that straightens inferiorly to form the DUCT of the SEMINAL VESICLE. • DUCT of the SEMINAL VESICLE joins the DUCT of the VAS DEFERENS to form the EJACULATORY DUCT. • EJACULATORY DUCT enters the PROSTATE GLAND and empties into the PROSTATIC URETHRA. • PROSTATE GLAND is a hard golf ball-size gland that consists of a mixture of glandular and fibromuscular tissue and its milky secretion enters the prostatic urethra and mixes with the sperm and seminal fluid. • PROSTATE GLAND lies inferior to the urinary bladder, anterior to the rectum and superior to the urogenital diaphragm and the bulb of the penis. • PROSTATE GLAND surrounds the EJACULATORY DUCTS and the PROSTATIC URETHRA.

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Fig. 6-20. Pelvis: Drawing of the posterior aspect of the urinary bladder showing vas deferens, seminal vesicles and prostate relative to the bladder and U-G diaphragm.

PENIS (FIGS. 6-18, 6-21)

• PENIS contains three cylinders of erectile tissue that are surrounded by a dense fibrous TUNICA ALBUGENIA ○○ CORPUS SPONGIOSUM contains the spongy urethra ▪▪ it is enlarged proximally forming the BULB OF THE PENIS which is covered externally by the BULBOSPONGIOSUS MUSCLE (skeletal muscle). ▪▪ enlarged distally forming the GLANS OF THE PENIS. ○○ the paired CORPUS CAVERNOSUM arises from the inferior pubic ramus as the CRUS OF THE PENIS. ○○ each CRUS is covered externally by the ISCHIOCAVERNOSUS MUSCLE (skeletal muscle). ○○ the paired CORPUS CAVERNOSUM meet distal to the bulb of the penis, lie together on the dorsum of the penis and end at the glans. ○○ CORPUS CAVERNOSUM contains the DEEP ARTERY OF THE PENIS . ○○ DORSAL ARTERY, DORSAL NERVE, and the DEEP DORSAL VEIN of the PENIS reach the penis by traveling between the crura of the corpora cavernosa and the pubic symphysis.

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Fig. 6-21. Pelvis: Drawing of the parts of the penis from a lateral view (left) and in cross-section (right).

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7.12 FEMALE REPRODUCTIVE SYSTEM (FIGS. 6-22, 6-23, 6-24, 6-25)

UTERUS (FIGS. 6-22, 6-23, 6-24)

• a cone-shaped, smooth muscule organ. • FUNDUS is the round superior part of the uterus into which the uterine tubes enter. • CERVIX is the inferior end of the uterus that bulges into the vagina. • BODY is the large middle part of the uterus. • ISTHMUS is the narrow region between the cervix and the body of the uterus. • EXTERNAL OS is the vaginal opening in the cervix that opens into the CERVICAL CANAL that connects the vagina and the uterine cavity. • INTERNAL OS in the cervical canal opening into the uterine cavity.

Fig 6-22. Pelvis: Sagittal view of the female pelvis showing reproductive organs. 1. Uterine tube, 2. ovary, 3. urinary bladder, 4. pubic symphysis, 5. clitoris, 6. labium minora, 7. labium majora, 8. urethra, 9. vagina, 10 external anal sphincter, 11. cervix, and 12. uterus.

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• LAYERS OF THE UTERINE WALL 1) PERIMETRIUM is the thin outer layer composed of peritoneum and connective tissue. 2) MYOMETRIUM is the thick middle layer composed of smooth muscle. 3) ENDOMETRIUM is the inner layer that is lined with simple columnar epithelium and contains tubular uterine glands.

Fig 6-23. Pelvis: Photograph of a sagittal section through female pelvic. 1. Peritoneum, 2. Urachus, 3. Pubic symphysis, 4. Pubovesical lig. 5. Urethra exiting urinary bladder, 6. Urethra, 7. Vagina, 8. Rectum, 9. Cervix of uterus, 10. Anterior layer of the broad ligament joining transverse cardinal lig. of cervix, 11. Transverse cardinal lig. of cervix, 12. Lateral lig. of the urinary bladder.

FEMALE REPRODUCTIVE SYSTEM LIGAMENTS (TABLE 6-1, FIGS. 6-17, 6-23, 6-24)

• large BROAD LIGAMENT suspends the UTERUS from the sides of the pelvis ○○ the broad ligament covers the anterior and posterior surfaces of the uterus. ○○ the broad ligament is divided into an anterior and posterior lamina making a space for the uterine tubes and uterine blood vessels. • SUSPENSORY LIGAMENT of the OVARY is the lateral continuation the broad ligament that surrounds and contains the ovarian vessels ○○ this ligament extends from the pelvic brim to the lateral pole or TUBAL EXTREMITY of the ovary.

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• OVARIAN LIGAMENT attaches the medial pole or UTERINE EXTREMITY of the ovary to the body of the uterus. • ROUND LIGAMENT of the UTERUS is continuous with the OVARIAN LIGAMENT and runs from the body of the uterus, through the inguinal canal and ends in the labia majora. • TRANSVERSE CERVICAL (CARDINAL) LIGAMENT extends from the base of the broad ligament to the paracervical fascia that surrounds the cervix and the proximal lateral vagina.

UTERINE (FALLOPIAN) TUBES (FIGS. 6-23, 6-24)

• each tube extends from an OVARY to the FUNDIC AREA of the uterus on that side • FIMBRIAE are numerous small finger-like processes at the ovarian end of the uterine tube. • INFUNDIBULAR part of the uterine tube is a funnel-shaped structure lying next to the fimbriae that collects the ovulated ovum into the uterine tube caused by sweeping movements of the fimbriae.

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• AMPULLA is the enlarged part of the uterine tube that is medial to the infundibulum and where fertilization usually occurs. • ISTHMUS is a narrow part of the tube that extends from the ampulla but then enlarges as the UTERINE part of the tube. • UTERINE OSTIUM is the opening of the UTERINE PART of the tube that passes through the thick uterine wall to open into the uterine cavity.

Fig 6-24. Pelvis: (TOP) Drawing of the uterus and its associated structures and (Bottom) photograph of a superior view of a pelvis with uterus in a female cadaver. 1. Ovarian (Fallopian) tube, 2. Round lig. of the uterus, 3. Broad lig. of uterus, 4. Transverse cardinal lig. of cervix, 5. Cervix, 6. Vagina, 7. Ovary, 8. Fimbriae of ovarian tube, 9. Ovarian lig., 10. Uterus, 11. Urinary bladder opened.

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OVARIES (FIGS. 6-22, 6-24, 6-25)

• paired, oval-shaped GONADS lie lateral to the uterus and inferior to the fimbriae of the uterine tubes. • OVARIAN LIGAMENT attaches ovary to the uterus. • SUSPENSORY LIGAMENT of the OVARY contain the ovarian vessels, lymphatics, and nerves. • the ovaries are where ova (eggs) develop and mature and hormones are secreted.

Fig. 6-25. Pelvis: Photomicrograph of a cat ovary (bottom) showing a Graafian follicle and other follicles in various stages of development.

VAGINA (FIGS. 6-22, 6-23, 6-24)

• a muscular-elastic tube that lies posterior to the urinary bladder and urethra, and anterior the rectum and anal canal. • VESTIBULE OF THE VAGINA is where the vagina opens externally ○○ the vestibule lies between the skeletal BULBOSPONGIOSUS MUSCLE of the perineum and posterior to the URETHRAL ORIFICE. ○○ the lower urethra is fused to the anterior vagina where these SHARE SPHINCTER AND COMPRESSOR MUSCLES of the UROGENTIAL DIAPHRAGM of the perineum. • FORNIX is where the vagina ends superiorly as a recess surrounding the cervix of the uterus. • Supporting structures of the vagina are the TRANSVERSE CERVICAL LIGAMENTS, SACROGENITAL LIGAMENTS, PUBOVAGINAL MUSCLE of the PUBOCOCCYGEUS and the MUSCLES OF THE UROGENTIAL DIAPHRAGM.

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CLITORIS (FIG. 6-22)

• two CORPOA CAVERNOSA but no corpus spongiosum as in the penis. • the CRUS of each corpus cavernosum attaches to the inferior pubic ramus and is covered externally by the skeletal ISCHIOCAVERNOSUS MUSCLE. • the BODY of the CLITORIS is where both corpora cavernosa meet at the inferior border of the pubic symphysis. • GLANS is the distal end of the body of the clitoris.

16 – STUDY QUESTIONS:

1) What is the epididymis and what is its relationship to the vas deferens? 2) What parts of the penis are covered externally by muscle and what are the names of these muscles? 3) Enlargement of the uterus during pregnancy would tend to compress what two neighboring structures? 4) What two ligaments support the ovaries and what two ligaments support the uterus? Through which of these do the ovarian blood vessels run?

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8 PERINEUM

8.1 BOUNDARIES (FIG. 7-1) • PERINEUM is diamond-shaped. • ANTERIOR: the pubic symphysis. • POSTERIOR: the tip of the coccyx. • LATERAL: the pubic rami, ischial tuberosity, and sacrotuberous ligaments. • CRANIAL: the pelvic diaphragm. • UROGENITAL TRIANGLE region is bound by the pubic symphysis and pubic rami, and is anterior to a line passing through the ischial tuberosity and the centrally located perineal body. • ANAL TRIANGLE region is bound by the sacrotuberous ligaments and coccyx and is posterior to a line passing through the ischial tuberosity and the centrally located perineal body.

Fig. 7-1. Pelvis: Diagram showing the orientation of the urogenital and anal triangles in inferior (A) and lateral (B) views. The superficial and deep spaces and perineal membrane are shown in lateral view. The pelvic diaphragm lies superior to the superior perineal fascia and deep space.

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8.2 ANAL TRIANGLE (FIGS. 7-1, 7-2, 7-3, 7-4) • MEDIAN (CENTRAL) PART of the anal triangle ○○ ANAL CANAL extends from the rectum. ▪▪ ANUS is external opening. ▪▪ ANAL VALVES are epithelial folds in the canal. ○○ PERINEAL BODY is a small, centrally located, fibrous mass ▪▪ in females, it is between the ANUS and the VAGINA. ▪▪ in males, it is between the ANUS and BULB OF THE PENIS. ▪▪ the superficial transverse perineal muscle, bulbospongiosum, and outer layer of the external anal sphincter attach to the perineal body. ○○ ANOCOCCYGEAL LIGAMENT is a median fibrous band ▪▪ extends from the posterior ANAL CANAL to the tip of the COCCYX. ▪▪ the pubococcygeus and iliococcygeus of the Levator Ani and the external anal sphincter attach to this ligament. ○○ INTERNAL and EXTERNAL ANAL SPHINCTERS control the opening and closing of the anus. ○○ INTERNAL ANAL SPHINCTER is SMOOTH MUSCLE ▪▪ Controlled involuntary through by pelvic parasympathetic and sympathetic nerves. ▪▪ lies within the walls of the anal canal. ○○ EXTERNAL ANAL SPHINCTER is SKELETAL MUSCLE ▪▪ controlled voluntarily through the inferior rectal nerve off the pudendal nerve. ▪▪ lies outside of the wall of the anal canal. ▪▪ runs from the perineal body to the coccyx and anococcygeal ligament. • ISCHIOANAL (ischiorectal) FOSSA is wedge-shaped and located on each side of the median part of the anal triangle ○○ BOUNDARIES of the fossa ▪▪ MEDIAL: the anal canal, anal sphincters and anus. ▪▪ LATERAL: the obturator internus muscle and its fascia. ▪▪ ANTERIOR: the urogenital triangle. ▪▪ POSTERIOR: the sacrotuberous ligament. ▪▪ CRANIAL: the levator ani. ○○ TRANSVERSE ARCH OF THE LEVATOR ANI is a thickening of the superior fascia covering the superior part of the obturator internus muscle and provides attachment for the levator ani muscle. ○○ PUDENDAL CANAL is a tunnel on the lateral side of the ischioanal fossa formed by splitting of inferior fascia of the covering the obturator internus muscle.

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○○ PUDENDAL NERVE, and INTERNAL PUDENDAL ARTERY and VEIN Run through this canal ▪▪ PUDENDAL NERVE gives off theINFERIOR RECTAL NERVE which is motor to the external anal sphincter, and sensory to skin around the anus. ▪▪ INTERNAL PUDENDAL ARTERY and VEIN give off an INFERIOR RECTAL ARTERY and VEIN. ▪▪ INFERIOR RECTAL ARTERY supplies blood to the rectum and anus, and the VEIN returns blood from these areas to the internal pudendal vein.

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Fig. 7-2. Pelvis: (TOP) Male and (BOTTOM) Female superficial space of the urogenital triangle and anal triangle. 1. Bulbospongiosus m., 2. Ischiocavernosus m., 3. Superficial transverse perineal m., 4. Perineal body 5. External anal sphincter m. 6. Anus, 7. Coccyx, 8. Anococcygeal lig., 9. Gluteus maximus m., 10. Levator ani in ischioanal fossa, 11. Obturator internus m., 12. Perineal membrane, 13. Spongy urethra, 14. Vagina.

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A B

Fig. 7-3. Pelvis: Photographs of the superficial urogenital space from (A) Male and (B) Female cadavers. Because of the advanced age of cadavers, the muscles of this space can be difficult to identify, especially in females when often only a few muscle fibers can be found. 1. Bulbospongiosus m., 2. Perineal body, 3. Ischiocaverosus m., 4. Perineal membrane, 5. Superficial perineal m., 6. Ischioanal fossa, 7.External anal sphincter, 8. Anus, 9. Labia majora (cut), 10. Vestibule, 11. Clitoris, 12. Labia majora.

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A B

Fig 7-4. Pelvis: Frontal cross-section of (A) the male pelvis at the level of the bladder and prostate; (B) the female pelvic at the level of the bladder and vagina; and (C) the pelvis at the level of the rectum and anal canal. These drawing show the relationships of the levator ani, tendinous arch of the levator ani, tendinous arch of the pelvic fascia, ischioanal fossa, and perineum. 1. Urinary bladder, 2 and 5. Fascia of the obturator internus m., 3. Obturator internus m., 4. Tendinous arch of the levator ani, 6) Levator ani m. of pelvic diaphragm, 7. Tendinous arch of the pelvic fascia, 8. Prostate and prostatic urethra, 9. Compressor urethrae m. 10. Perineal membrane, 11. Corpus spongious and bulbospongiosus m., 12. corpus cavernous and ischiocaverosus m. 13. Deep transverse perineal m., 14. External urethral sphincter, 15. Superior perineal fascia, 16. ischioanal fossa, 17. inferior fascia of pelvic diaphragm, 18. superior fascia of the pelvic diaphragm, 19. Vagina, 20. Urethrovaginal sphincter m., 21. Uterus and broad lig., 22. Pudendal canal, 23. Inferior rectal N. A. V., 24. External anal sphincter m., 25. Rectum.

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8.3 UROGENITAL TRIANGLE (FIGS. 7-1, 7-2, 7-3, 7-4, 7-5, 7-6)

BOUNDARIES

• ANTERIOR: the pubic symphysis. • LATERAL: the inferior public ramus and ischium. • POSTERIOR: the anal triangle. • CRANIAL: the levator ani muscle. • PERINEAL MEMBRANE subdivides the urogenital triangle into SUPERFICIAL and DEEP PERINEAL SPACES which contain muscles, nerves, arteries, and veins. • CONTENTS OF SUPERFICIAL AND DEEP PERINEAL SPACES.

MALE SUPERFICIAL SPACE FEMALE SUPERFICIAL SPACE

Bulb of penis and bulbospongiosus m. Vagina and bulbospongiosus m.

Crura of penis and ischiocaverosus m. Crura of clitoris and ischiocaverosus m.

Superficial transverse perineal m. Superficial transverse perineal m.

Perineal body Perineal body

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MALE SUPERFICIAL SPACE FEMALE SUPERFICIAL SPACE

Perineal nerve and artery Perineal nerve and artery

Posterior scrotal nerve, artery, vein Posterior labial nerve, artery, vein

Deep artery and vein of the penis Deep artery and vein of the clitoris

MALE DEEP SPACE FEMALE DEEP SPACE

Membranous urethra Urethra

External sphincter urethrae m. External sphincter urethrae m.

Compressor urethrae m. Compressor urethrae m.

Urethrovaginal sphincter m.

Deep transverse perineal m. Deep transverse perineal m.

Dorsal nerve, artery, vein of penis Dorsal nerve, artery, vein of clitoris

UROGENITAL MUSCLES

▪▪ SUPERFICIAL TRANSVERSE PERINEAL MUSCLE ○○ in the SUPERFICIAL PERINEAL SPACE. ○○ runs transversely between the ischial tuberosity and the perineal body. ▪▪ BULBOSPONGIOSUS MUSCLE and ISCHIOCAVERNOSUS MUSCLES ○○ in the SUPERFICIAL PERINEAL SPACE. ○○ MALES: the BULBOSPONGIOSUS MUSCLE covers the bulb of the penis and an ISCHIOCAVERNOSUS MUSCLE covers each crus of the corpus cavernosum of the penis. ○○ FEMALES: the BULBOSPONGIOSUS MUSCLE surrounds the vagina and the ISCHIOCAVERNOSUS MUSCLE covers each crus of the clitoris.

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Fig. 7-5. Pelvis: Drawing of an oblique frontal view of the male deep perineal space of the urogenital triangle 1. Deep transverse perineal muscle, 2. Compressor urethrae muscle, 3. External sphincter urethrae muscle, 4. Perineal membrane, 5. Perineal body, 6. Bulb of penis, 7. Prostate, 8. Urinary bladder

Fig. 7-6: Drawing of an oblique frontal view of the female deep perineal space of the urogenital triangle. 1. Deep transverse perineal muscle, 2. Compressor urethrae muscle, 3. External sphincter urethrae muscle, 4. Vagina, 5. Urethrovaginal sphincter muscle, 6. Perineal membrane, 7. Urinary bladder.

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• UROGENITAL DIAPHRAGM ○○ in the DEEP PERINEAL SPACE. ○○ COMPOSITION ▪▪ EXTERNAL SPHINCTER URETHRAE MUSCLE that encircles the urethra. ▪▪ COMPRESSOR URETHRAE MUSCLE that runs from the inferior pubic rami to the external urethral sphincter. ▪▪ bilateral DEEP TRANSVERSE PERINEAL MUSCLE that attaches to the ischial rami and centrally to each other. ▪▪ FEMALES: URETHROVAGINAL SPHINCTER MUSCLE that encircles the vagina and the urethra is present. ○○ Female URETHRA and male MEMBRANOUS URETHRA pass through the urogenital diaphragm.

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UROGENITAL NERVES (FIG. 7-7)

• PUDENDAL NERVE gives off the PERINEAL NERVE to the muscles of the superficial and deep muscles of the urogenital triangle. • PERINEAL NERVE gives offPOSTERIOR SCROTAL or LABIAL NERVES ○○ in the superficial space. ○○ sensory to the posterior scrotum or posterior labia major. • PERINEAL NERVE give off the DORSAL NERVE of the PENIS or CLITORIS ○○ enters the deep perineal space. ○○ sensory to the dorsum and glans of the penis or clitoris.

UROGENITAL ARTERIES AND VEINS (FIG. 7-7)

• INTERNAL PUDENDAL ARTERY gives off aPERINEAL ARTERY. • PERINEAL ARTERY divides ○○ TRANSVERSE PERINEAL ARTERY to the subcutaneous region around the perineal body. ○○ POSTERIOR SCROTAL or LABIAL ARTERIES which run with the posterior scrotal or labial nerves and veins. • PERINEAL ARTERY divides into the DEEP and DORSAL ARTERIES of the PENIS or CLITORIS near the urogenital diaphragm ○○ DEEP ARTERY of the PENIS or CLITORIS ▪▪ enters the superficial space. ▪▪ penetrates the crus of the penis or clitoris to supply the corpus cavernosum. ○○ DORSAL ARTERY of the PENIS or CLITORIS ▪▪ runs with the dorsal nerve and vein on the dorsum of the penis or clitoris. ▪▪ supplies blood to the body and glans of the penis or clitoris. ▪▪ anastomoses with the deep artery of the penis or clitoris. • POSTERIOR SCROTAL or LABIAL VEIN and the DEEP DORSAL VEIN of the PENIS or CLITORIS drain into the INTERNAL PUDENDAL VEIN ○○ POSTERIOR SCROTAL VEIN drains the posterior scrotum and the POSTERIOR LABIAL VEIN drains the labia majora. ○○ DEEP DORSAL VEIN of the PENIS or CLITORIS drains the erectile tissue. ○○ SUPERFICIAL DORSAL VEIN of the PENIS or CLITORIS drains the skin of the penis or clitoris and the scrotum or labia majora into the EXTERNAL PUDENDAL VEIN that empties into the GREAT SAPHENOUS VEIN of the leg.

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Fig.7-7: Pelvis: Diagrams showing the distribution of the nerves and arteries of the anal and urogenital triangles.

17 – STUDY QUESTIONS:

1) What structures lie in the median part of the anal triangle? 2) What muscles form the lateral and superior boundaries of the ischioanal fossa? 3) What nerves and arteries lie in the ischioanal fossa? 4) What muscles lie in the superficial perineal space in men and women? 5) What muscles lie in the deep perineal space in men and women? 6) What muscles make up the UG diaphragm? How is it different from the pelvic diaphragm? 7) What muscles in the perineal region attach to the perineal body? 8) Damage to which nerve would result in anal incontinence, but not urinary incontinence? 9) Damage to which nerve would result in urinary incontinence, but not anal incontinence? 10) Damage to which nerve could produce urinary and anal incontinence? Where would this lesion have to be to have this effect?

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STUDY QUESTION ANSWERS

1 – STUDY QUESTIONS What is the difference between the extrinsic and intrinsic muscles of the thorax? A = Extrinsic muscles attach to the thorax and to another areas of the body whereas the intrinsic muscles muscle attach only to the thorax.

What intrinsic muscles are deep to the internal intercostal muscles? A = Transversus thoracic muscle, innermost intercostal muscle, subcostal muscle

What passes through the following: a. Esophageal hiatus. A = Esophagus, vagal trunks (X) b. Aortic hiatus. A = Abdominal aorta, azygos vein, thoracic duct c. Psoas gap. A = sympathetic trunk, genitofemoral nerve, ilioinguinal nerve

What is the origin of the anterior intercostal arteries? A = Axillary A. (highest thoracic A.); internal thoracic A.; musculophrenic A.

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For each of the following lesions, what would be affected? a. Spinal nerve at T5. A = intercostal muscles and skin on the lateral and anterior aspects of the of the 5th intercostal space. b. Lateral cutaneous nerve of an intercostal nerve? A = Skin along the lateral but not anterior aspect of the intercostal space of the lesion. c. Anterior cutaneous nerve of an intercostal nerve? A = Skin along the anterior but not lateral aspect of the intercostal space of the lesion.

2 – STUDY QUESTIONS What is the difference between the parietal and visceral pleura? A = The visceral pleural lies adjacent to the lung tissue and the parietal pleura lies adjacent to the inner surface of the thoracic rib cage.

What bronchopulmonary segments are in the right lung but not in the left? A = Medial and lateral segments

What bronchopulmonary segments are in the left lung but not in the right? A = Superior and inferior lingual

What are the differences between the left upper lobe and the right upper lobe? A = The left upper lobe is larger than the right and the left has 5 segments while the right has 3.

What is the difference in bronchopulmonary segment arrangement between the right lower lobe and the left lower lobe? A = The segments of the right lower lobe and the left lower lobe are the same. There is no difference.

Beginning with the primary bronchus and ending in the alveolus, what are the sequential divisions of the bronchial tree? A = Secondary (lobar) bronchi > tertiary (segmental) bronchi > terminal bronchi > respiratory bronchioles > Alveolar duct > alveolar sac

What cell in the alveolus is responsible for surfactant production? A = Type II cells

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3 – STUDY QUESTIONS What are the boundaries of the four mediastina? A = The superior is above a line connecting the sternal angle and the T4-T5 vertebrae to the top of the thoracic cavity. The anterior is below the superior, above the diaphragm and between the sternum and the pericardium covering the heart. The middle is below the superior, above the diaphragm, and behind the anterior and consists of the region of the heart and the pericardium. The posterior is below the superior, above the diaphragm, and between the heart and the spine.

The pericardial cavity lies between which two pericardial layers? A = The visceral serous pericardium and the parietal serous pericardium

Describe the flow of blood from the inferior vena cava to the aorta. In your description include the valves. A = Inferior vena cava > Right atrium > Right A-V valve > Right ventricle > pulmonary valve > pulmonary trunk > pulmonary arteries > lung > pulmonary veins > Left atrium > Left A-V valve > Left ventricle > aortic valve > aorta

If the anterior chest is crushed inward, what are the anterior (sternal) structures that might be damaged? A = Right atrium and ventricle, Left ventricle, Right and Left auricles, superior vena cava, pulmonary trunk and arteries, aorta, Right and Left coronary A., Right marginal artery, small cardiac vein, ant. cardiac vein, anterior interventricular A., great cardiac vein

If a large tumor mass were pressing on the posterior heart, what posterior structures of the heart might be compressed? A = Pulmonary veins, Left and Right atria, Left and Right ventricle, superior and inferior vena cava, pulmonary arteries, Right coronary A., post. interventricular A., circumflex A., Left marginal A., coronary sinus, small cardiac V., middle cardiac V., great cardiac V.

What structures of the heart cannot be seen with a posterior view of the heart? A = Right and Left auricles, anterior interventricular A., Right marginal A., anterior cardiac veins, pulmonary trunk, ascending aorta, Left coronary A.

What structures of the heart cannot be seen with an anterior view of the heart? A = Pulmonary veins, Left atrium, circumflex A., Left marginal A., posterior interventricular A., coronary sinus, middle cardiac vein, inferior vena cava

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What areas of the heart could be damaged with an occlusion of the right coronary artery? Answer the same question for the left coronary artery and each of its main branches. A = Right coronary A. occlusion would reduce blood flow to the Right and left atrium, and the Right and Left ventricle. The Right marginal would reduce blood to the anterior Right ventricle, the posterior interventricular A. to the posterior Right and Left ventricle. Left coronary A. occlusion would reduce blood to the Left atrium and ventricle and to the Right ventricle. The anterior interventricular A. would reduce blood to the anterior Left and Right ventricles, the circumflex to the Left atrium and Left ventricle, and the Left marginal to the Left ventricle.

What veins flow into the coronary sinus? A = Great cardiac, small cardiac, and middle cardiac veins.

What four veins empty into the right atrium? A = Inferior vena cava, superior vena cava, coronary sinus, ant. cardiac veins.

What artery runs with the following veins: – Great cardiac vein? A = Ant. interventricular A. – Middle cardiac vein? A = Posterior interventricular A. – Small cardiac vein? A = Right coronary A.

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What is the difference between the coronary sinus and the coronary sulcus? A = The coronary sinus is a tube the connects venous blood from the heart and empties into the Right atrium while the coronary sulcus is a groove between the atrium and ventricle. The coronary sulcus on the posterior surface of the heart contains the coronary sinus, circumflex A. and the end of the Right coronary A. The sulcus on the anterior surface of the heart between the Right atrium and ventricle contains the Right coronary A. and small cardiac vein.

Describe the pathway for conduction in the heart? A = SA node > AV node > Bundle of His > Right and Left bundle branches to the ventricles

What are three similarities between arteries and veins? A = 3 sizes (small, medium, large), 3 layers (intima, media, adventitia) and all are lined with simple squamous epithelium (endothelium)

What are three differences between arteries and veins? A = The intima and media of arteries contain many elastic fibers and veins do not. The intima and media of arteries contain many smooth muscle cells but veins do not. The adventitia of arteries consists of connective tissue but the adventitia of large veins contain longitudinal bundles of smooth muscle cells.

4 – STUDY QUESTIONS What structures in the superior mediastinum do not enter the middle or posterior mediastina? A = Brachiocephalic veins, internal jugular and subclavian veins, brachiocephalic artery, common carotid and subclavian arteries, arch of the aorta, and recurrent laryngeal nerve.

What structures are common to the superior and middle mediastina? A = Superior vena cava, vagus nerve, phrenic nerve, trachea

What structures are common to the superior and posterior mediastina? A = esophagus, sympathetic trunk, azygos vein, vagus nerve, thoracic duct (aorta)

In which mediastina do each of the three parts of aorta lie? A = The ascending is in the middle mediastinum, the arch in the superior mediastinum, and descending aorta in the posterior mediastinum.

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What drains into the azygos and hemiazygos veins? A = Posterior intercostals veins, vertebral venous plexus, esophageal and bronchial veins.

What are the differences between the azygos, hemiazygos, and accessory hemiazygos veins? A = The azygos lies on the right side of the spine, draining structure on the right side and empting into the superior vena cava while the hemiazygos and accessory hemiazygos lie on the left side. The accessory drains structures in the upper left thoracic levels into the hemiazygos and the hemiazygos drains structures for the lower thoracic levels into the azygos vein.

Into which vein does the azygos vein drain? How about the hemiazygos vein? A = The azygos vein drains into the superior vena cava and hemiazygos vein in the azygos vein.

The thoracic duct receives lymphatic drainage from what area of the body? A = It receives lymph from the abdomen, pelvis and lower limb into the cisterna chili, and directly from the left thoracic structures. Right thoracic structures drain mainly into the small right lymphatic duct.

What happens to the lymphatic drainage in the thoracic duct is blocked? If the thoracic duct is blocked, extracellular fluids from the regions drained by these lymphatics are not removed and the result is edema in those regions.

5 – STUDY QUESTIONS For each of the following planes describe which vertebral level they cross: – Transtubercular. A = Body of L5 – Interspinous. A = Promontory of sacrum – Supracrestal. A = Body of L4 – Subcostal. A = Disc between L2-L3

Name the abdominal region in which each of these organs lie: a. Stomach. A = Left hypochondriac, epigastric b. Spleen. A = Left hypochondriac c. Ascending colon. A = Right lumbar d. Urinary bladder. A = Hypogastric e. Pancreas. A = Left hypochondriac, epigastric f. Gall bladder. A = Epigastric, Rt. Hypogastric g. Descending colon. A = Left lumbar

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Which abdominal muscles are innervated by the following nerves: a. Subcostal. A = External oblique, internal oblique and transverse abdominis b. Iliohypogastric. A = External oblique, internal oblique and transverse abdominis c. Ilioinguinal. A = Internal oblique and transverse abdominis

In the umbilical region, aponeuroses from what muscles form the anterior part of the rectus sheath? How about the posterior part of the sheath? A = The anterior sheath is formed the external and internal obliques and the posterior sheath is formed the internal oblique and transverse abdominis.

In the hypogastric region, aponeuroses from what muscles form the anterior part of the sheath? How about the posterior part of the sheath? A = The anterior sheath is formed the external obliques, internal obliques and transverse abdominis. The posterior sheath is formed by the transversalis fascia.

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6 – STUDY QUESTIONS What forms the inguinal ligament? A = Aponeurosis of the external abdominal oblique muscle.

What structures pass through the inguinal canal in both men and women? A = Ilioinguinal N. and genital branch of the genitofemoral N.

What lies in the spermatic cord? A = Vas deferens, testicular A., pampiniform venous plexus, and genital branch of the genitofemoral N.

What type of inguinal hernia enters the deep inguinal ring and passes through the inguinal canal? A = Indirect hernia

7 – STUDY QUESTIONS What muscles form the posterior abdominal wall? A = Psoas major, psoas minor, quadratus lumborum muscles.

A lesion of the L1 spinal nerve would affect which nerves of the lumbar plexus? What sensory and motor impairments might you expect to find? A = The iliohypogastric, ilioinguinal, and genitofemoral nerves are involved. The sensory involvement would be the lateral gluteal region, hypogastric region of the abdomen, inguinal region, pubic symphysis, scrotum, labia majora, and upper anterior thigh. The motor involvement is the abdominal obliques and transverse abdominus.

A lesion of the L2 spinal nerve would affect which nerves of the lumbar plexus? What sensory and motor impairments might you expect to find? A = The genitofemoral, lateral femoral cutaneous, femoral and obturator nerves. (NOTE Saphenous nerve off femoral is L3-L4 and would not be involved.) The sensory involvement would be the scrotum, labia majora, anterior thigh, medial thigh and lateral thigh. The motor involvement is the quadriceps, psoas major, iliacus, pectineus, sartorius, and the adductors of the hip (adductor longus, brevis and magnus).

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A lesion of the L4 spinal nerve would affect which nerves of the lumbar plexus? What sensory and motor impairments might you expect to find from involvement of these lumbar nerves? A = The femoral, obturator and lumbosacral trunk. Sensory involvement would be anterior thigh, medial thigh, medial leg and foot. The motor involvement is the quadriceps, psoas major, iliacus, pectineus, sartorius, and the adductors of the hip (adductor longus, brevis and magnus). Because the L4 spinal nerve contributes to the lumbosacral trunk and thus the sacral plexus, sensory involvement could occur in the L4 component of the Sciatic nerve to the leg and foot and the L4 component of the Superior Gluteal nerve to the post gluteal region and hip. Likewise, motor involvement could occur to the L4 component of the Sciatic nerve, the gluteus medius and minimus from the Superior Gluteal nerve and the Quadratus Femoris from the N. to the Quadratus Femoris.

8 – STUDY QUESTIONS What forms the portal vein? A = The union of the splenic and superior mesenteric veins.

What is the difference between the portal vein and the hepatic vein? A = The portal vein brings blood along with digested material to the liver for processing and the hepatic vein returns processed blood from the liver into the inferior vena cava via the left, right and middle hepatic veins.

What organs are drained by the superior mesenteric vein? A = Pancreas, stomach, small intestines, ascending colon and Right half of the transverse colon.

What organs are drained by the splenic vein and the inferior mesenteric vein? A = Stomach, pancreas, spleen, left transverse colon, descending colon, sigmoid colon and superior rectum.

9 – STUDY QUESTIONS What arteries go to the pancreas and from where do they originate? A = Pancreatic arteries from the splenic A., superior pancreaticoduodenal a. from the gastroduodenal artery, inferior pancreaticoduodenal from the superior mesenteric artery.

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What arteries go to the lesser curvature of the stomach and from where do they originate? A = Left gastric form the celiac trunk and the Right gastric for the common hepatic or proper hepatic artery.

What arteries go to the greater curvature of the stomach and from where do they originate? A = Left gastroepiploic from the splenic artery and the Right gastroepiploic from the gastroduodenal a.

10 – STUDY QUESTIONS What are the branches of the superior mesenteric artery and what areas do each of these branches supply? A = Inferior pancreaticoduodenal to the pancreas and duodenum, jejunal and ileal arteries to the small intestines, ileocolic to the cecum, appendix and beginning of the ascending colon, Right colic to the ascending colon, and the middle colic to the hepatic flexure of the colon and the Right 1/2 to 2/3 of the transverse colon

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What are the branches of the inferior mesenteric artery and what areas do each of these branches supply? A = Left colic to the Left 1/2 to 1/3 of the transverse colon, the splenic flexure of the colon and the descending colon, sigmoid arteries to the sigmoid colon, and superior rectal artery to the upper rectum

What veins drain into the superior mesenteric vein and what areas do each of these veins drain? What does the superior mesenteric vein drain into? A = Veins of the same name accompany the superior mesenteric arteries as listed above. These veins drain the same areas fed by the arteries with the same name. Blood from the superior mesenteric vein drains directly into the hepatic portal vein.

What veins drain into the inferior mesenteric vein and what areas do each of these veins drain? What does the inferior mesenteric vein drain into? A = Veins of the same name accompany the inferior mesenteric arteries as listed above. These veins drain the same areas fed by the arteries with the same name. Blood from the inferior mesenteric vein usually drains into the splenic vein.

11 – STUDY QUESTIONS What muscles lie posterior, medial, and lateral to each kidney? A = Quadratus lumborum (posterior), psoas major (medial), transverse abdominis (lateral).

What is the difference between the uriniferous tubule and the nephron? A = The nephron is part of the uriniferous tubule. The nephron and collecting tubule form the uriniferous tubule.

From what three arteries do the three suprarenal arteries arise? A=The superior suprarenal is from the inferior phrenic A., the middle suprarenal from the aorta, and the inferior suprarenal is from the renal A.

What is the difference between the right and the left suprarenal veins? A = The Right suprarenal vein drains directly into the inferior vena cava while the Left suprarenal vein drains into the Left renal vein.

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12 – STUDY QUESTIONS Describe the areas involved when the following arteries are blocked: a. Common hepatic a. A = liver, gallbladder, stomach, pancreas, duodenum b. Gastroduodenal a. A = stomach, pancreas, duodenum c. Splenic a. A = spleen, stomach, pancreas d. Left colic a. A = Left 1/2 to 1/3 of the transverse colon, splenic flexure, descending colon e. Left renal a. A = Suprarenal gland, kidney f. Middle colic a. A = hepatic flexure, Right1/2 to 2/3 of the transverse colon

What is the difference between the portal system and the systemic system? A = Blood from the portal system goes to the liver for processing. Veins associated with the portal system are from organs involved in digestion (stomach, pancreas, spleen, large intestine, small intestine and gallbladder). Systemic veins go to the inferior vena cava. Blood in these veins does not have to go to the liver as in does not contain materials from digestion.

Describe the areas involved when the following veins are blocked: a. Right hepatic v. A = Right lobe of liver b. Right colic v. A = Ascending colon c. Splenic v. A = Spleen, great curvature of stomach, pancreas unless inferior mesenteric vein ends in the splenic then those organs drained by this vein would be included (See f. below). d. Right gastroepiploic v. A = Greater curvature of stomach e. Left renal v. A = Left kidney, Left suprarenal gland, Left testis or ovary f. Inferior mesenteric v. A = Lt 1/2 to 1/3 of transverse colon, splenic flexure, descending colon, sigmoid colon, upper rectum g. L4 lumbar v. A = L4 lumbar vertebral body and disc and paraspinal muscles in the region

13 – STUDY QUESTIONS What is difference between the major (false) pelvis and the minor (true) pelvis? What general statements can you make about the organs contained in each? A = The major pelvis is superior to the minor pelvis lying between the iliac fossae. The major pelvis is a continuation of the abdominal cavity containing parts of the small and large intestines. The minor pelvis lies behind the pubic symphysis and contains the urinary bladder and reproductive organs.

What is the difference between the pelvic diaphragm and the levator ani? A = The levator ani is only part of the pelvic diaphragm. It is made up of the pubococcygeus and the iliococcygeus. The coccygeus muscle and the levator ani form the pelvic diaphragm.

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What muscles, besides the pelvic diaphragm, lie in the pelvic region? A = Piriformis, obturator internus, psoas major, iliacus

14 – STUDY QUESTIONS Which arteries arise from the posterior division of the internal iliac artery? A = Iliolumbar, lateral sacral, superior gluteal

Which artery off the internal iliac artery is found only in the male? A = Inferior vesical artery

Describe what structures would be affected in the blockage of the following arteries: a. Umbilical. A = Urinary bladder b. Middle rectal. A = Rectum, prostate and seminal vesicles in male, vagina in female c. Uterine. A = Urinary bladder, uterus, vagina d. Lateral sacral. A = Ventral rami, spinal nerve root of sacral nerves and meninges of sacral canal

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What is the difference in spinal nerve contribution between the lumbar and the sacral plexuses? Is there any overlap? A = The lumbar plexus is from L1-L5 spinal nerves while the sacral plexus has contributions for L4-S3 spinal nerves. Spinal nerves L4-L5 overlap both plexuses and both of these unite to form the lumbosacral trunk.

What are the nerves involved when there is a lesion to the following spinal nerves: a. L2. A = Genitofemoral, lateral femoral cutaneous, femoral and obturator b. L4. A = Femoral, obturator, sciatic, superior gluteal, nerve to the quadratus femoris c. L5. A = Sciatic, superior gluteal, inferior gluteal, nerve to the quadratus femoris, nerve to the obturator internus d. S1. A = Sciatic, superior gluteal, inferior gluteal, nerve to the quadratus femoris, nerve to the obturator internus, nerve to piriformis e. S2. A = Sciatic, inferior gluteal, nerve to the obturator internus, pudendal, nerve to the piriformis

Where do sympathetic and parasympathetic efferent nerves go to from the Inferior Hypogastric Plexus? A = Rectal plexus, uterovaginal plexus, vesical plexus, prosthetic plexus, differential plexus

Where do sympathetic and parasympathetic afferent nerves go to from the Inferior Hypogastric Plexus? A = Hypogastric nerve, pelvic splanchnic nerves

15 – STUDY QUESTIONS What are the fibrous structures that support the urinary bladder? A = Pubovesical lig., lateral lig. of the blabber, urachus, perineal membrane, tendinous arch of pelvic fascia, puboprostatic lig., sacrogenital lig.

What are the three parts of the male urethra and why is each part named as it is? A = The prostatic urethra because it passes through the prostate gland, the membranous urethra is named because it passes through the muscular urogenital diaphragm and the spongy urethra because it passes through the corpus spongiosum of the penis.

What makes up the pelvic diaphragm? A = levator ani and coccygeus muscles

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16 – STUDY QUESTIONS What is the epididymis and what is its relationship to the vas deferens? A = It is highly coiled tube connected to the testis. The vas deferens is a continuation of this tube of the epididymis that is not coiled. The vas deferens leaves the scrotum through the spermatic cord to enter the pelvis.

What parts of the penis are covered externally by muscle and what are the names of these muscles? A = The bulb of the penis is covered by the bulbospongiosus muscle and the crua of the penis are covered by the ischiocavernous muscles.

Growth of the uterus during pregnancy would tend to compress what two neighboring structures? A = Urinary bladder and rectum

What two ligaments support the ovaries and what two ligaments support the uterus? Through which of these do the ovarian blood vessels run? A = The ovaries are supported by the ovarian lig. and the suspensory lig. The uterus is supported by the broad lig. and the round lig of the uterus. The suspensory lig. contains the blood vessels to the ovary.

17 – STUDY QUESTIONS What structures lie in the median part of the anal triangle? A = Anal canal, external and internal anal sphincter, perineal body, and anococcygeal lig.

What muscles form the lateral and superior boundaries of the ischioanal fossa? A = The lateral boundary is the obturator internus and the superior boundary is the levator ani

What nerves and arteries lie in the ischioanal fossa? A = Inferior rectal N. A. V., pudendal N., internal pudendal A. V.

What muscles lie in the superficial perineal space in men and women? A = Bulbospongiosus, ischiocavernosus, superficial transverse perineal muscles

What muscles lie in the deep perineal space in men and women? A = Deep transverse perineal, sphincter urethra, compressor urethra muscles

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What muscles make up the UG diaphragm? How is it different from the pelvic diaphragm? A = Deep transverse perineal m., the sphincter urethra m., compressor urethra m. (+ urethrovaginal sphincter in females) = urogenital (UG) diaphragm whereas the pelvic diaphragm consists of the coccygeus m. and levator ani.

What muscles in the perineal region attach to the perineal body? A = Superficial and deep transverse perineal muscles, bulbospongiosus, external anal sphincter

Damage to which nerve would result in anal incontinence, but not urinary incontinence? A = Inferior rectal N.

Damage to which nerve would result in urinary incontinence, but not anal incontinence? A = Perineal N.

Damage to which nerve could produce urinary and anal incontinence? Where would this lesion have to be to have this effect? A = Pudendal N before it gives off the inferior rectal in the ischioanal fossa

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REFERENCES

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Basmajian, J.V. Grant’s Method of Anatomy, (ed.8), William & Wilkins, Baltimore. 1971

Cundiff GW. Anatomy of the pelvic viscera. In: Ostergard’s Urogynecology and Pelvic Floor Dysfunction. (Ostergard, DR., Bent, AE., Cundiff GW., Swift SE. eds) (ed.6) Lippincott, Williams & Wilkins. 3–26, 2008.

Gorniak GC and Conrad W. An anatomical and functional perspective of the pelvic floor and urogenital organ support system. J Women’s Health Physical Therapy. 39(2): 65–82, 2015.

Gorniak GC and King PM. The peripheral neuroanatomy of the pelvic floor. J Women’s Health Physical Therapy. 40 (1):3–14, 2016.

Gray H. Gray’s Anatomy of the Human Body. (ed 20), Lea & Febiger, Philadelphia. 1918.

Gray H and Goss CM. Gray’s Aantomy of the Human Body. (ed 28), Lea & Febiger, Philadelphia. 1966.

Herschorn, S. Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs. Rev in Urology 2004: 6(suppl. 5):S2-S10.

Hollingshead, W.H. and Rosse, C. Textbook of Anatomy. (ed. 4), Harper and Row Publ., Philadelphia. 1985.

Moore KL, Dalley AF. Agur MR. Clinically Oriented Anatomy. (ed 7), Lippincott Williams & Wilkins. 2013.

Shoja, M.M., Sharma, A., Mirzayan, N., Groat, C., Watanabe, K., Loukas, M., & Shane Tubbs, R. Neuroanatomy of the female abdominopelvic region: A review with application to pelvic pain syndromes. Clinical Anatomy. 26(1), 66–76, 2013.

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