douglas j. gould-clinical anatomy for your pocket -lippincott williams _ wilkins (2008).pdf

Clinical Anatomyfor Your Pocket

Douglas J. Gould, Ph.D.Associate Professor, Division of Anatomy

The Ohio State University College of Medicine

Columbus, Ohio

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Library of Congress Cataloging-in-Publication Data

Gould, Douglas J.Clinical anatomy for your pocket / Douglas J. Gould.

p. ; cm.Includes index.ISBN-13: 978-0-7817-9193-9 (pbk. : alk. paper)ISBN-10: 0-7817-9193-6 (pbk. : alk. paper) 1. Human anatomy

Outlines, syllabi, etc. I. Title.[DNLM: 1. Anatomy. QS 4 G696c 2009]QM31.G68 2009611dc22

2008024080DISCLAIMER

Care has been taken to confirm the accuracy of the information present andto describe generally accepted practices. However, the authors, editors, and pub-lisher are not responsible for errors or omissions or for any consequences fromapplication of the information in this book and make no warranty, expressed orimplied, with respect to the currency, completeness, or accuracy of the contents ofthe publication. Application of this information in a particular situation remains theprofessional responsibility of the practitioner; the clinical treatments described andrecommended may not be considered absolute and universal recommendations.

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Health professions curricula around the world are continu-ally evolving: new discoveries, techniques, applications, andcontent areas compete for increasingly limited time with tra-ditional basic science topics such as gross anatomy. It is inthis context that the foundations established in grossanatomy become increasingly important and relevant forabsorbing and applying our ever-expanding knowledge ofthe human body. As a result of the progressively morecrowded curricular landscape, students and instructors arefinding new ways to maximize precious contact, preparation,and study time through more efficient, high-yield presenta-tion and study methods.

Clinical Anatomy for Your Pocket is designed to serve thetime-crunched student. The presentation of gross anatomyin bullet and table format streamlines study and exampreparation. This pocket size, quick reference book isportable, practical, and necessary; even at this small size,nothing is omitted and a large number of clinically signifi-cant facts, mnemonics, and easy-to-learn concepts are usedto complement the tables and inform the reader.

I am confident that Clinical Anatomy for Your Pocket willgreatly benefit all students attempting to learn clinically rel-evant anatomy in a variety of settings, including all graduateand professional gross anatomy programs.

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Preface

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I dedicate this book to my motherMargaret.My first teacher.

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Dedication

I would like to thank the student reviewers for their inputinto this book: I hope that I have done you justice and cre-ated the learning tool that you need. I would also like tothank Dr. Robert DePhilip, the faculty reviewer of ClinicalAnatomy for Your Pocket, whose suggestions have provedinvaluable in creating an accurate and functional tool forstudents.

Acknowledgments

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Contents

v

Preface iiiDedication and Acknowledgments iv

1 Thorax . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Abdomen . . . . . . . . . . . . . . . . . . . . . 33

3 Pelvis . . . . . . . . . . . . . . . . . . . . . . . . 77

4 Back . . . . . . . . . . . . . . . . . . . . . . . 113

5 Lower Limb . . . . . . . . . . . . . . . . . . 126

6 Upper Limb . . . . . . . . . . . . . . . . . . 158

7 Head . . . . . . . . . . . . . . . . . . . . . . . . 196

8 Neck . . . . . . . . . . . . . . . . . . . . . . . . 237

List of Mnemonics 260Index 261

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Bone Characteristic SignificanceTypical ribs (39)

Atypical ribs (12, 1012 )

Bones of the thoracic wall

Head

NeckTubercle

Body

1st and 2ndribsheads

Ribs 1012sternalattachments

Bears 2 facets that articulate withvertebra of same number and thevertebra superior to itJoins head with body of rib Articulates with transverse process

of vertebra of same number Located at junction of neck and body Bears pronounced angle Inferior internal border has costal

groove for intercostalneurovascular elements

The heads of the first 2 ribs onlyattach to one vertebral body, unliketypical ribs that attach to two

The 1st and 2nd ribs haveadditional tubercles for muscleattachments

INTRODUCTIONThe thorax is that portion of the trunk inferior to the neck(superior thoracic aperture) and superior to the diaphragm,to which the pectoral girdle and upper limbs are attached.

THORACIC WALLThe bones of the thoracic wall are the ribs and sternum.Ribs 39 possess characteristics common to the majority ofribs and so are considered typical, whereas ribs 12 and1012 have specializations or are lacking typical characteris-tics and so are considered atypical.

1Thorax

1

(continued)

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2 CLINICAL ANATOMY FOR YOUR POCKET

Bone Characteristic Significance

Thoracic vertebrae (12)

Sternum

Bones of the thoracic wall (continued)

Body

Spinous process

Transverseprocess

Laminae andpedicles

Vertebralforamen

Vertebralnotchessuperior andinferior

Articulatingprocessessuperior (2) andinferior (2)

Manubrium

Sternal angle

Body

Xiphoid process

Ribs 1012 attach indirectly (rib 10)or not at all to the sternum (ribs1112, the floating ribs)

Supports weight

Serve for muscle attachments

Form vertebral arch that enclosesspinal cord

Formed from vertebral arch andposterior aspect of vertebral body

Encloses spinal cord Successive vertebral foramen form

vertebral canal

Inferior and superior notches ofadjacent vertebrae formintervertebral foramen that permitspassage of spinal nerves betweenthe vertebral canal and periphery

Form zygapophyseal joints witharticulating processes on adjacentvertebrae

Superior part of sternum Superior border bears jugular notch Clavicular notches (2) are found on

each side of the jugular notch forarticulation with the clavicles

Landmark for the 2nd ribs costalcartilage articulation with thesternum

Marks articulation betweenmanubrium and body

Bears costal notches along lateralborder for articulation with costalcartilages

Most inferior part of sternum Landmark for central tendon of

diaphragm, superior margin of liver,and inferior border of heart


Additional ConceptTrue, False, and Floating RibsRibs 17 are considered true ribs, as they attach to thesternum via their individual costal cartilages; ribs 810 areconsidered false ribs, as they attach indirectly to the ster-num via the costal cartilages of more superior ribs; ribs1112 are considered floating ribs, as they do not connectto the sternum.

Clinical SignificanceRib FractureFracture of the upper ribs may injure the lungs and of lowerribs may damage the liver or spleen or may tear thediaphragm. All rib fractures are painful owing to the brokenpieces moving during respiration, coughing, sneezing, orlaughing.

Sternal PunctureA wide-bore needle may be used to harvest bone marrowfrom the sternum for transplantation or biopsy.

CHAPTER 1 | THORAX 3

Proximal DistalMuscle attachment Attachment Innervation Main ActionsExternal Inferior Superior Intercostal Elevate ribsintercostal aspect of ribs aspect of ribs nervesInternal Depress andinter- elevate ribscostalInnermostintercostalTransverse Posterior inferior Posterior Depress ribsthoracic aspect of aspect of

sternum costal cartilages 26

Subcostal Deep aspect of Superior Depress andlower ribs, near aspect elevate ribsangles of 23 ribs

below proximal attachment

Muscles of the thoracic wall(Figures 1-2 and 1-4)

(continued)



Muscles of the thoracic wall (continued)

Diaphragm Sternum, Central Motor: Increases inferior 6 ribs tendon of phrenic; the volumeand their costal the diaphragm sensory: of the thoraxcartilages, medial phrenic and to cause& lateral arcuate intercostal inspirationligaments, and nerves1st 3 lumbar vertebrae

Levator T7T11 Subjacent ribs C8T11 Elevate ribscostarum transverse between posterior

processes tubercle and ramiangle

Serratus Nuchal ligament, 2nd4th ribs 2nd5th posterior C7T3 spinous superior intercostalssuperior processes bordersSerratus T11L2 spinous 8th12th ribs 9th11th Depress ribsposterior processes inferior borders, intercostalsinferior near angles and subcostal

Lung

Visceral pleura

Parietal pleura

Innermost intercostalmuscleIntercostal vein,artery, nerve

Internal intercostal muscleExternal intercostal muscle

Needle

Tube

Pleural cavity

FIGURE 1-1. Thoracocentesis. An intercostal nerve block (needlein image) produces anesthesia of an intercostal space by introduc-tion of an anesthetic agent around the intercostal nerve and its col-laterals. The tube in the diagram indicates the position for thoraco-centesis. (From Dudek RW, Louis TM. High-Yield Gross Anatomy.3rd ed. Baltimore: Lippincott Williams & Wilkins; 2008:56.)

Proximal DistalMuscle attachment Attachment Innervation Main Actions



Additional ConceptDiaphragmThe diaphragm has three openings that permit passage ofstructures between the thorax and abdomen. These open-ings are found at T8caval foramen, T10esophageal hia-tus, and T12aortic hiatus.

Clinical SignificancePhrenic Nerve InjuryPhrenic nerve injury results in hemiparalysis of thediaphragm and paradoxical movement during inspiration.Instead of descending during inspiration, the paralyzedhalf ascends in response to increased intra-abdominalpressure.

Sternum

T8

T10

T12

Superiormesenteric artery

Celiac trunk

Aorta

Esophagus

Inferiorvena cava

Diaphragm

FIGURE 1-2. Holes in diaphragm. There are three large aper-tures in the diaphragm for major structures to pass to and fromthe thorax into the abdomen. The caval opening for the inferiorvena cava (IVC), most anterior, is at the T8 level and to the rightof the midline; the esophageal hiatus, intermediate, is at T10 andto the left of the midline; the aortic hiatus for the aorta passesposterior to the vertebral attachment of the diaphragm in themidline at T12. (From Moore KL, Dalley AF. Clinically OrientedAnatomy. 5th ed. Baltimore: Lippincott Williams & Wilkins;2006:329.)



Artery Origin Description

Internal Subclavian Gives rise to anterior intercostals and thoracic musculophrenic

Anterior Internal Supplies intercostal muscles and intercostals thoracic (16) and parietal pleura

musculophrenic (79)

Posterior Supreme intercostalintercostals (12) and thoracic aorta

Subcostal Thoracic aorta Supplies anterolateral abdominalmusculature

Arterial supply of the thoracic wall(Figures 1-1 and 1-4)

Nerve Origin Structures Innervated

Nerves of the thoracic wall(Figures 1-1 and 1-4)

Intercostals Anterior rami Intercostal muscles and parietal pleuraof T1T11

Subcostal Anterior Abdominal wall musculature and rami of T12 parietal pleura

Rami Connect Whiteconvey presynapticcommunicantes intercostals sympathetic fibers from spinal nerve

and subcostal to sympathetic chain and visceralnerves to afferents to spinal nervessympathetic Grayconvey postsynaptictrunk sympathetic fibers from the

sympathetic chain to spinal nerve

Sympathetic Sympathetic Composed of sympathetic gangliatrunk chain ganglia containing postsynaptic sympathetic

(paravertebral cell bodies connected by ascendingganglia) and descending fibers

Thoracic Sympathetic Convey presynaptic sympathetic fiberssplanchnics chain: to the prevertebral ganglia of the

Greater abdomen; convey visceral afferents to T5T9 the sympathetic chain

LesserT10T11

LeastT12


Additional ConceptVenous DrainageVenous drainage of the thoracic wall generally parallels arte-rial supply. However, the posterior intercostal veins drain tothe azygos system, which is discussed with the posteriormediastinum.


Joint Type Articulation Structure

1st Cartilaginous 1st costal Joint strengthened by sternocostal cartilage sternocostal radiate

with manubrium ligaments

2nd7th Synovial 2nd7th costal sternocostal cartilages with

sternum

Sternoclavicular Synovial Sternal end of Divided into twoclavicle with compartments bymanubrium and articular disc1st costal cartil- Joint strengthened age by anterior and

posterior sternoclavi-cular and costoclavi-cular ligaments

Manubriosternal Cartilaginous Manubrium with Joint often fuses inbody of sternum older people

Xiphisternal Xiphoid process with body of sternum

Interchondral 6th9th: Costal cartilages Strengthened bysynovial of adjacent ribs interchondral

9th10th: 610 ligamentsfibrous

Costochondral Cartilaginous Costal cartilage Bound together bywith end of rib periosteum

Little if any movement permitted

Intervertebral Symphysis Adjacent verte- Strengthened by bral bodies anterior and posterior

longitudinal ligaments and the anular ligament

Joints of the thoracic wall

(continued)


BREASTThe breast extends from the sternum to the midaxillary lineand from ribs 26. It rests on the pectoral fascia and the fas-cia over serratus anterior.


Joint Type Articulation Structure

Joints of the thoracic wall (continued)

Costovertebral Synovial Head of ribs with Strengthened byvertebral bodies radiate and intra-at same level articular ligamentsand the 1st, 11th, 12th, andvertebral body and sometimes 10th superior to it ribs articulate only

with vertebral body of same level

Costotransverse Tubercle of rib Strengthened by with transverse lateral and superiorprocess of costotransverse vertebral body ligamentsat same level 11th and 12th ribs do

not participate in costotransverse joints

Structure Description SignificanceMammary Modified sweat glands Accessory reproductive glands Arranged in 1520 lobules organs in the female

Contained within thebreast

Areola The skin around the nipple Turns a darker color Studded with sebaceous during pregnancy

glands that form eleva- Stimulation from thetions suckling infant triggers

ejection and production of milkthe let-down reflex

Nipple Round, raised area of skin Stimulation from the sucklingin the center of the areola infant triggers erection of

Surrounded by circularly the nipple and the ejectionarranged smooth muscle and production of milkfibers that cause erection on stimulation

Structure of the breast(Figure 1-3)

(continued)


Additional ConceptThe size and shape of the adult female breast is due to itscontained fat, which forms the bulk of the breast tissue.


Structure Description Significance

Structure of the breast (continued)

Suspensory Connective tissue supports Provide support for theligaments that extend from the dermis breast

to the pectoral fascia If invaded by carcinoma, the ligaments shorten and produce skin dimpling and nipple inversion

Lactiferous duct 1520 total, open onto Drain the mammary glandularthe nipple tissue

Lactiferous sinus Expansion of lactiferous duct Function as a milk reservoir near the nipple during lactation

Axillary process Extension of breast tissue High percentage of breast into the axilla tumors occurs here

Externalabdominal

oblique

Serratusanterior

Axillary tail

Areola

Nipple

Lactiferous ducts

Lactiferous sinusLobes Fat

FIGURE 1-3. Breast, anterior view. (From Tank PW, Gest TR.LWW Atlas of Anatomy. Baltimore: Lippincott Williams & Wilkins;2009:39.)


Additional ConceptVenous drainage of the breast parallels the arterial supplyand drains mainly to the axillary vein, whereas some venousdrainage is to the internal thoracic vein.



Medial mammary Internal thoracic Supplies medial aspect of breastbranches

Anterior intercostals

Lateral mammary Lateral thoracic Supplies lateral aspect of breastbranches

Thoracoacromial Axillary Supplies breast through pectoral branches

Posterior Thoracic aorta Supplies lateral aspect of breast intercostals through lateral mammary branches

Arterial supply of the breast

Clinical SignificanceQuadrantsThe breast is divided into four quadrants for the anatomiclocation and description of pathologies. The inferior quad-rants are less vascular and, therefore, the preferred area forsurgical incisions when necessary.

Retromammary SpaceBetween the breast and the pectoral fascia is the retromam-mary space, which permits movement of the breast on thethoracic wall. Diminishment of this movement may indicatepathology.

Nerves of the breast


Anterior cutaneous Intercostal Sensory to skin of breastbranches nerves 46 Postsynaptic sympathetic fibers to Lateral cutaneous the smooth muscle of the nipple and branches blood vessels


Additional ConceptThe contralateral breast receives a significant amount oflymphatic drainage.

MISCELLANEOUSThoracic cavityThe thoracic cavity is bounded by the thoracic walla flexi-ble musculoskeletal cage. It is divided into 2 laterally placedpleural cavities and a central regionthe mediastinum.Thethoracic cavity contains the heart, lungs, thymus, trachea,esophagus, and multiple neurovascular elements.


Lymphatic Structure Description DrainageSubareolar Located deep to the nipple, Drains lymph from the nipple,lymphatic areola, and around the areola, and glandular tissueplexus lobules of the glandular of the breast to regional nodes

tissue of the breastAxillary Composed of pectoral, Drains 75% of lymph from lymph nodes humeral, subscapular, the breastthe lateral

central, and apical nodes quadrant in particularParasternal Located along the sternum Drains mostly lymph from lymph nodes the medial quadrant of the

breastAbdominal Located inferior to the dia- Drains mostly lymph from thelymph nodes phragm in the abdominal inferior quadrants of the breast

cavity; also known as inferior phrenic lymph nodes

Infraclavicular Located inferior to the Drains lymph from the axillarylymph nodes clavicle lymph nodesSupraclavi- Located superior to the cular lymph claviclenodesSubclavian Formed from efferent vessels On the rightjoins withlymphatic of the axillary nodes, apical bronchomediastinal & trunk in particular jugular trunks to form

the right lymphatic duct On the leftjoins the

thoracic duct

Lymphatics of the breastKnowledge of the lymphatic drainage of the breast is impor-tant owing to the high incidence of breast carcinoma.


Area Structure SignificanceSuperior Boundaries: Also known as the thoracicthoracic Anteriormanubrium inletaperture PosteriorT1 Allows passage of the

Lateral1st ribs and their trachea, esophagus, andcostal cartilages neurovascular elements

between the thoracic cavity and the neck

Inferior Boundaries: Also known as the thoracicthoracic Anteriorxiphisternal outletaperture joint Closed by the diaphragm

Anterolateralcostal Allows for passage of cartilages of ribs 710 the inferior vena cava, aorta,the costal margin and esophagus between the

PosteriorT12 thoracic cavity and abdomen Posterolateral11th and

12th ribsIntercostal Space between adjacent ribs Contains intercostal musclesspace and costal cartilages and intercostal neurovascular

elementsSuperior Superior bordersuperior Contains superior vena cava,mediastinum thoracic aperture brachiocephalic veins, arch of

Inferior borderplane aorta, thoracic duct, esophagus,passing from sternal angle trachea, left & right vagusthrough the T4T5 nerves, left recurrent laryngealvertebral level nerve and left & right phrenic

Lateral borderspleural nerves, and the thymuscavities

Inferior Superior borderplane Subdivided by the pericardial mediastinum passing from sternal angle sac into anterior, middle, and

through the T4T5 posterior mediastinavertebral level

Inferior borderdiaphragm Lateral borderspleural

cavitiesAnterior Most anterior part of the Contains the thymus, loose mediastinum inferior mediastinum connective tissue, sternoperi-

Bounded anteriorly by the cardial ligaments, lymphsternum and transverse nodes, and fatthoracic muscle and post-eriorly by the pericardium

Middle Middle part of inferior Contains the heart, pericardialmediastinum mediastinum sac, roots of the great vessels,

arch of the azygos vein, and primary bronchi

Posterior Most posterior part of the Contains the thoracic aorta,mediastinum inferior mediastinum esophagus, azygos and

hemiazygos veins, vagus nerves, thoracic duct, sympathetic trunks, and splanchnic nerves

12

Thoracic cavity (continued)


MnemonicV-A-N: Intercostal neurovascular elements are arrangedfrom superior to inferior as:

intercostal Veinintercostal Arteryintercostal Nerve

Clinical SignificanceThoracic Outlet SyndromeObstructions in the root of the neck may affect structurespassing through the superior thoracic aperture; problems areoften manifested in the upper limb.


Structure Significance

Organ

Esophagus Located posterior to the trachea, anterior to vertebral bodies Begins at inferior aspect of pharynx (C6) Terminates by entering the stomach after passing through the

esophageal hiatus (T10) of the diaphragm

Nerve

Esophageal Formed of parasympathetic fibers from the vagus nerves andplexus sympathetic fibers from sympathetic chain ganglia and the

greater splanchnic nerve Supply glands and musculature of inferior 2/3 of esophagus

Sympathetic Located on either side of the vertebral column along posterior trunks wall of the thorax

Chain of paravertebral ganglia containing presynaptic sympathetic cell bodies

Ganglia connected by presynaptic sympathetic and visceral afferent fibers

Connected to thoracic spinal nerves by rami communicantes

Thoracic Greater, lesser, and leastsplanchnic Convey presynaptic sympathetic fibers from T5T12nerves to prevertebral ganglia of the abdomen

Convey visceral afferents from the abdomen

Vessel

Thoracic Continuation of the arch of the aorta; becomes abdominal aorta aorta after passing through the aortic hiatus (T12) of the

diaphragm Found to the left of thoracic vertebral bodies

Posterior mediastinum

(continued)


Clinical SignificanceEsophageal ConstrictionsThree constrictions of the esophagus occur where it is compressed by, from superior to inferior: (1) arch of theaorta, (2) left main bronchus, and (3) the diaphragm.These constrictions are areas susceptible to damage from swallow-ing caustic substances and are places where ingested objects



Posterior mediastinum (continued)

Bronchial Left: branches of thoracic aortaarteries Right: branches of posterior intercostal arteries

Supply oxygenated blood to the tissues of the lungPericardial Branches of thoracic aorta and pericardiophrenic arteriesarteries Supply the pericardiumPosterior Branches of thoracic aortaintercostal Supply intercostal spaces 311arteries9 pairsSuperior Branches of the thoracic aortaphrenic Supply the diaphragmarteriesEsophageal Branches of the thoracic aortaarteries Supply the esophagusSubcostal Branches of the thoracic aortaarteries Supply body wall inferior to the 12th ribsThoracic Conveys lymph from entire body, except the right upper limb,duct right aspect of the thorax and right side of head & neck

Begins in abdomen at chyle cistern and empties into the junction of left internal jugular vein and left subclavian vein

Found along the vertebral column between the azygos vein and esophagus

Azygos vein Drains mediastinum and posterior thoracic & abdominal walls on the right; found on right side of vertebral bodies

Begins in the abdomen and terminates by emptying into superior vena cava

Receives hemiazygos and accessory hemiazygos veins at the T8T9 vertebral level

Hemiazygos Drains mediastinum and posterior thoracic and abdominal vein walls on the left as high as T9 vertebral level, where it

crosses to the right side to enter the azygos veinAccessory Drains mediastinum and posterior upper thoracic wall on the hemiazygos left as far inferiorly as T8 vertebral level where it crosses tovein the right side to enter the azygos vein

The trachea is presented with the superior mediastinum.


may become lodged; the constrictions are visible on radi-ographs and are useful landmarks.

Azygos VeinsThe azygos system provides a collateral pathway for venousblood that connects the superior and inferior vena cavae.

MnemonicFour birds of the thorax:

esophaGOOSEvaGOOSE nerve azyGOOSE veinthoracic DUCK


Sympatheticchain

Azygosvein

Rightprimary

bronchus

Intercostalvein, artery,

and nerve

Cut edgeof costal

pleura

Esophagus

Trachea

Leftprimarybronchus

Thoracicduct

Diaphragm

FIGURE 1-4. Posterior mediastinum viewed from the right: parietalpleura is intact on left side and partially removed on right. A portion ofesophagus, between bifurcation of trachea and diaphragm, is alsoremoved. (From Agur AMR, Dalley AF. Grants Atlas of Anatomy, 12th

ed. Baltimore: Lippincott Williams & Wilkins; 2009:82.)



(continued)

Superior mediastinum(Figure 1-5)

Structure SignificanceLigamentum Remnant of the ductus arteriosus (shunt for blood from the arteriosum fetal pulmonary trunk to aorta)

Connects left pulmonary artery to the arch of the aorta Left recurrent laryngeal nerve wraps around to then ascend to

the larynxOrganThymus Located mostly in the superior mediastinum

Lymphatic organ that involutes after puberty and is replacedby fat

Trachea Located anterior to the esophagus Begins at cricoid cartilage of the larynx Terminates at the level of the sternal angle into 2 main bronchi Skeleton of posteriorly oriented U-shaped rings, posterior

deficiency spanned by the trachealis muscleEsophagus Located posterior to the trachea and anterior to the vertebral

bodies Begins at inferior aspect of the pharynx, terminates by entering

the stomach after passing through the esophageal hiatus (T10) of the diaphragm

NerveLeft vagus Found anterior to the arch of the aorta where it gives off the

left recurrent laryngeal nerve Passes posterior to the root of the lung, where it ramifies

to contribute to the pulmonary, cardiac, and esophageal plexuses

Right vagus Found anterior to the right subclavian artery, where it gives off the right recurrent laryngeal nerve

Passes posterior to the root of the lung, where it ramifiesto contribute to the pulmonary, cardiac, and esophageal plexuses

Left Branch of left vagus nerve as it passes over the anterior recurrent surface of the arch of the aortalaryngeal Ascends to the larynx between the trachea and esophagusRight Branch of the right vagus nerve as it passes over the anteriorrecurrent surface of the right subclavian arterylaryngeal Ascends to the larynx between the trachea and esophagus in

the tracheoesophageal grooveLeft phrenic Passes anterior to the root of the lung, found between thenerve fibrous pericardium and mediastinal pleuraRight Sole motor supply to the diaphragmphrenic Sensory to central aspects of diaphragmnerve


Additional ConceptLymphatic DrainageIn addition to the brachiocephalic veins forming at the junc-tion of the internal jugular and subclavian veins, it is also thepoint where the right lymphatic duct joins the venous sys-tem on the right and the thoracic duct on the leftknownas the jugular angle.



Superior mediastinum (continued)

Vessel

Left Formed by junction of the internal jugular and subclavian veinsbrachioce- The left and right brachiocephalic veins join to form the phalic vein superior vena cava

Right brachioce-phalic vein

Superior Drains most venous blood from structures superior to the vena cava thorax into the right atrium

Arch of the Continuation of the ascending aorta; becomes the thoracic aorta aorta as it descends

Gives off 3 branches in the superior mediastinum:1. brachiocephalic trunk2. left common carotid artery3. left subclavian artery

Left vagus nerve courses on its anterior surface

Brachioce- 1st branch of the arch of the aortaphalic trunk Terminates by dividing into the right common carotid and right

subclavian arteries Indirectly supplies the right side of head and neck and right

upper limb through its branches

Left 2nd branch of the arch of the aortacommon Terminates in the neck by dividing into internal & external carotid carotid arteriesartery Indirectly supplies left side of head and neck through its

branches

Left sub- 3rd branch of the arch of the aortaclavian Continues as it passes over the lateral border of the 1st rib toartery become the left axillary artery

Supplies the left upper limb

The thoracic duct is presented with the posterior mediastinum.


MEDIASTINUMAdditional ConceptPericardiumThe pericardium receives its arterial supply from the peri-cardiacophrenic arteries, which run with the phrenic nervebetween the mediastinal pleura and the fibrous pericardium.Sensory innervation to the pericardium is carried via thephrenic nerves.


Structure Description SignificancePericardial Formed of 2 layers: Double-layered fibroseroussac 1. outerfibrous sac that encloses the heart

pericardium Fused with adventitia of the2. innerparietal layer of great vessels

serous pericardium Attached to the deep surface of the sternum by the sterno-pericardial ligament

Fuses with the central tendon of the diaphragm; therefore, moves during respiration

Visceral layer Mesotheliumsimple Also known as the of serous squamous epithelium epicardiumthe outer layer pericardium of the heartParietal layer Lines inner surface of fibrousof serous peri- pericardiumcardiumPericardial Potential space between Filled with serous fluidcavity the layers of serous peri- Allows heart to beat in a

cardium friction free environmentFibrous peri- Strong collagenous outer Inflexible nature preventscardium layer of the pericardial overfilling of the heart

sac Phrenic nerve travels Fuses with adventitia of inferiorly through the thorax

great vessels, central on its lateral surfacetendon of the diaphragm, and sternum

Transverse Extension of the pericardial Allows for control of blood out sinus cavity posterior to the pul- of the heart during surgery

monary trunk and aortaOblique sinus Extension of the pericardial Ends as a cul-de-sac between

cavity on the posterior the pulmonary veinsaspect of the heart

Structure of the pericardial cavity(Figure 1-5)



Clinical SignificancePericarditisInflammation of the pericardium that may cause chest painand pericardial friction rub, which can be detected duringauscultation.Pericardial TamponadeAn increase in fluid in the pericardial cavity (e.g., fromchronic inflammation) may decrease the efficiency of theheart as it is compressed. Pericardiocentesis is the drainageof excess fluid from the pericardial sac.

Structure of the heart(Figure 1-6)

The heart is contained within the pericardial sac. It islocated within the middle mediastinum, left of the medianplane in the thorax. The heart is essentially a cone-shapedmuscular pump, the apex of which is directed anteroinferi-orly to the left and the base posterolaterally to the right.Thebase of the heart is the location of the superior vena cava,ascending aorta and pulmonary trunk.

Structure Description SignificanceHeart Anterior (sternocostal) Anteriorformed mainly by surfaces Inferior (diaphragmatic) right ventricle

Right and left pulmonary Diaphragmaticformedsurfaces mainly by left ventricle

(some right ventricle) related to central tendon of diaphragm

Left pulmonaryformed mainly by left ventricle, related to cardiac notch of left lung

Right pulmonaryformed mainly by right atrium

Pectinate Muscular ridges found on Found in primitive parts of muscles the walls of the atria both atria

Presence indicates rough part of atrial walls

Trabeculae Muscular ridges found on Found in primitive parts of carneae the walls of the ventricles both ventricles

Serve to increase mechanical advantage during ventricularcontraction

Presence indicates rough part of ventricular walls

(continued)



Structure Description SignificancePapillary Conical muscular projections Contract immediately beforemuscles from the ventricular wall ventricular contraction to pull

that attach to chordae chordae tendineae taut to tendineae prevent backflow during

ventricular contraction (systole)

Chordae Attached to margins of Hold valve cusps taut duringtendineae atrioventricular valves and ventricular contraction to

papillary muscles prevent backflow (regurgitation)Interatrial Muscular septum separating Right sidelocation of fossa septum the atria ovalis: remnant of foramen

ovale, an embryologic shunt for blood from the right atrium to the left atrium

Interventricular Composed of a membranous Separates right and left septum (superior) part and a muscular ventricles

(inferior) partRight and Right3 cusps Rightpermits passage of left atrioventri- (tricuspid) blood from right atrium to cular valves Left2 cusps right ventricle and prevents

(bicuspid, mitral) backflow in the reverse direction

Leftpermits passage of blood from left atrium to left ventricle and prevents backflow in the reverse direction

Fibrous Collagenous skeleton of Provides stability and attach-skeleton heart ment for valve cusps and

Forms fibrous rings that muscle fiberssurround heart orifices Provides electrical insulation

Fibrous trigones connect between the atria and rings ventricles

Right atrium Forms right border of heart Receives deoxygenated blood from the superior and inferior vena cavae & coronary sinus

Sinus venarum Smooth-walled part of right Formed from incorporation of atrium the embryonic sinus venosus

during developmentSulcus Groove on outside of right External representation of terminalis atrium meeting of primitive atrium and

sinus venarum derived tissuesCrista Ridge on inside of right Internal representation of terminalis atrium meeting of primitive atrium and

sinus venarum derived tissues

Structure of the heart (continued)

(continued)



Structure Description SignificanceRight auricle Small, conical projection Remnant of primitive right

from right atrium atriumLeft atrium Forms most of base of heart Receives oxygenated blood

from 4 pulmonary veinsLeft auricle Finger-like projection from Remnant of primitive left

left atrium atriumRight Forms inferior border of Receives blood from right ventricle heart atriumConus Smooth-walled superior Entry to the pulmonary trunkarteriosus aspect of right ventricle(infundibulum)Supraventri- Muscular ridge on inside of Separates rough part of cular crest right ventricle chamber from smooth-walled

part of chamberSeptomarginal Muscular ridge that extends Conveys right atrioventricular trabecula from the inferior aspect of bundlepart of conduction (moderator the interventricular septum system, to the anterior band) to the base of the anterior- papillary muscle

most papillary musclePulmonary 3 semilunar cusps Prevents backflow valve Located at apex of conus (regurgitation) of blood during

arteriosus ventricular relaxation (diastole)Pulmonary Located between cup-shaped Prevent valve cusps from sinuses semilunar valve leaflets and sticking to pulmonary trunk

dilated pulmonary trunk wall wall during ventricular contraction

Left ventricle Forms apex and left border Thicker wall (4) than right of heart ventricle because it pumps

against greater pressureAortic vesti- Smooth-walled superior Entry to ascending aortabule aspect of left ventricleAortic valve 3 semilunar cusps Prevent backflow

Located near origin of (regurgitation) of blood during ascending aorta ventricular relaxation (diastole)

Aortic sinuses Located between cup- Prevent valve cusps from shaped semilunar valve sticking to ascending aorta leaflets and dilated ascend- wall during ventricular ing aorta wall contraction

Right and left sinus give origin to the right and leftcoronary arteries respectively

Structure of the heart (continued)


Additional ConceptHeart is a Double PumpRight side of the heart: right atrium receives deoxygenatedblood from the vena cavae; the right ventricle pumps thisblood to the lungs for oxygenation via the pulmonary trunk.Left side of the heart: left atrium receives oxygenated bloodfrom the pulmonary veins; the left ventricle pumps thisblood to the body via the aorta.

Walls of the HeartThe walls of all 4 chambers of the heart consist of the samethree layers from superficial to deep:

epicardiumlayer of mesothelium; also known as viscerallayer of serous pericardium

myocardiummiddle layer composed of cardiac muscletissue

endocardiumlayer of endothelium that lines heartchambers and valves


Right brachiocephalic vein

Left brachiocephalic veinSuperior vena cava

Reection ofpericardium

Right auriclePectinatemuscles

Fossaovalis

Rightatrium

Inferiorvena cava

Tricuspid valvePapillary

muscle

Rightcoronary

artery

Left subclavian arteryLeft common carotid artery

Brachiocephalic trunkArch of aorta

Ligamentumarteriosum

Pulmonarytrunk

ConusarteriosusLeft auricle

Leftventricle

Abdominalaorta

Apex of heart

Muscularinter-ventricularseptum

Chordaetendineae

Moderatorband

Anterior inter-ventricularartery

FIGURE 1-5. Heart. Right interior view. (Asset provided byAnatomical Chart Company.)


AuscultationAuscultation of the valves: each of the 4 valves of the heartis heard best at specific locations on the thoracic wall:

bicuspid valve5th intercostal space on the lefttricuspid valve4th intercostal space to the left of the

sternumpulmonary valve2nd intercostal space to the left of the

sternumaortic valve2nd intercostal space to the right of the

sternum

VentriclesVentricle characteristicsfewer, larger papillary muscles,more numerous trabeculae carneae, fewer, thicker atrioven-tricular valve cusps and fewer, thicker chordae tendineae arecharacteristics of the left ventricle owing to its increasedworkload relative to the right ventricle.

Clinical SignificanceForamen OvaleIncomplete closure of the foramen ovale occurs in15%25% of adults, it is typically asymptomatic.

Septal DefectsThe membranous part of the interventricular septum isthe most common site of interventricular septal defects;severe defects may result in hypertension and cardiac failure.


Nerves of the heart

Nerve Origin Structures InnervatedSuperficial Sympathetic Sympatheticterminate on SA and cardiac plexus sympathetic AV nodes, increases heart rate and

trunks force of contraction, produces vasodi- Parasym- lation of coronary arteries

patheticvagus Parasympatheticterminate on SA nerves and AV nodes and coronary arteries,

Located inferior decreases heart rate and force ofto the aortic arch contraction, causes vasoconstrictionand anterior to of coronary arteriesthe right pulmo-nary artery

(continued)



Nerves of the heart (continued)

Nerve Origin Structures InnervatedDeep cardiac Sympatheticplexus sympathetic

trunks Parasym-

patheticvagus nerves

Located posterior to the aortic arch and anterior to the tracheal bifurcation

Visceral Fibers travel with Fibers traveling with sympatheticsafferents of sympathetics and convey pain information to T1T5 cardiac plexuses in the vagus nerve spinal cord segments; these fibers are

involved in pain referred to the left upper limb during heart attack

Fibers traveling in the vagus nerve innervate baroreceptors and chemoreceptors that monitor pressureand gas concentrations in the blood

Sinuatrial (SA) Group of self- Pacemaker of the heart, gives an node excitable cardiac impulse ~70 times per minute

muscle cells located near the junction of the superior vena cava and the right atrium

Atrioventricular Located on the Receives impulse from wall of atria(AV) node right side of the that was initiated in the SA node

atrial septum near Passes impulse to ventricles via the the opening of the AV bundlecoronary sinus

AV bundle Fiber bundle pass- Only bridge of conduction system(Bundle of His) ing from the AV between atria and ventricles

node to membran-ous part of inter-ventricular septum, where it terminates by dividing into bundle branches

Right and left Formed by termina- Supply cardiac muscle cells ofbundle branches tion of AV bundle, ventricular walls through ramifications

follow interventri- (subendocardial branches)cular septum to Right bundle branch sends a branchventricular walls through the septomarginal trabeculaewhere they ramify of the right ventricle to the anterior

papillary muscle


Additional ConceptPostsynaptic parasympathetic ganglia are located near theSA and AV nodes.


Vessels of the heart

Artery Origin DescriptionRight coronary Right aortic Supplies right atrium & ventricle, left

sinus ventricle, SA and AV nodes, and inter-ventricular septum

SA nodal branch Right coronary Supplies SA nodeRight marginal artery Supplies right ventricle and apex of branch heartPosterior Supplies both ventricles and posterior interventricular aspect of interventricular septumAV nodal branch Supplies AV nodeLeft coronary Left aortic sinus Supplies left atrium and ventricle, right

ventricle, and interventricular septumAnterior interven- Left coronary Supplies right and left ventricles andtricular (left artery interventricular septumanterior descendingLeft circumflex Supplies left atrium and ventriclebranchLeft marginal Left circumflex Supplies left ventriclebranch branchPosterior interven- Left coronary Supplies interventricular septumtricular branch arteryVein Termination DescriptionCoronary sinus Right atrium Large vein on posterior aspect of heart

in coronary sulcus; accepts most venousblood from the heart before emptying into right atrium

Great cardiac Coronary sinus Runs with anterior interventricular artery in anterior interventricular sulcus;becomes coronary sinus on posterior aspect of heart

Middle cardiac Runs with posterior interventricular artery in posterior interventricular sulcus

Small cardiac Runs with right marginal branchOblique vein of Remnant of primordial left superior left atrium vena cavaLeft posterior Drains posterior aspect of left ventricleventricularLeft marginal Drains left margin of heartAnterior cardiac Right atrium Drains right ventricleSmallest cardiac Chambers of Drains walls of all 4 chambers of heart

heart


Additional ConceptVenous DrainageVenous drainage of the heart is said to be indirect becausemost venous blood enters the coronary sinus before beingemptied into the right atrium.

Clinical SignificanceCoronary ArteriesCoronary artery disease is a leading cause of death, typicallyas a result of decreased blood flow to the heart. An area ofmyocardium that has undergone necrosis (as a result of lackof blood) constitutes a myocardial infarction or heart attack.

LUNGS AND PLEURA


Structure Description SignificanceEndothoracic Fibroareolar layer between Invests muscular and skeletalfascia parietal pleura and thoracic elements of thoracic wall and

wall adheres parietal pleura to inner surface of thoracic wall

Costal pleura Parietal pleura adherent to Intercostal and phrenic nervesthe inner surface of the ribs provide sensory innervation; and costal cartilages via the therefore, pain may be referred endothoracic fascia to the thoracic wall and neck

Mediastinal Parietal pleura adherent topleura the outer surface of the

mediastinum via the endothoracic fascia

Diaphragmatic Parietal pleura adherent topleura the superior surface of the

diaphragm via the endotho-racic fascia

Cervical pleura Parietal pleura extending into the root of the neck

Covered by the supra-pleural membranea regional thickening of the endothoracic fascia

Pulmonary Double-layered fold of pleura Area of reflectionvisceralligament extending inferiorly from the pleura from the surface of

root of the lung the lung is continuous with parietal pleura

Structure of the pleural cavities(Figures 1-4, 1-6 and 1-7)

(continued)




Structure of the pleural cavities (continued)

Visceral pleura Covers all surfaces of each Continuous with parietal lung pleura at the root of the

lung No or very limited pain

afferents

Pleural cavity Potential space between the Contains capillary layer of visceral and parietal pleura serous fluid

Negative pressure here maintains lungs in inflated state

Left and right Potential space between During inspiration the lungscostodiaphrag- costal and diaphragmatic enter the recessesmatic recesses pleura

Left and right Potential spaces betweencostomediastinal costal and mediastinalrecess pleura

IVC andpericardium

Pericardium

Left ventricle

Pulmonary trunk

Right atrium

Superiorvena cava

FIGURE 1-6. Anteroposterior chest radiograph. Radiographshows the various components of the heart and great vessels. (FromDudek RW, Louis TM. High-Yield Gross Anatomy. 3rd ed. Baltimore:Lippincott Williams & Wilkins; 2008:85.)


Clinical SignificanceCervical PleuraThe cervical pleura and apex of the lung are subject toinjury from neck wounds because the pleural cavity extendsinto the root of the neck.


FIGURE 1-7. Pneumothorax. A pneumothorax is air in the pluralcavity; this has the effect of collapsing the elastic lung as the negativepressure maintaining it in its expanded state is lost. Posteroanteriorradiograph shows a left apical (straight arrows) and subpulmonic(curved arrow) pneumothorax in a 41-year-old woman with respira-tory distress syndrome. (From Dudek RW, Louis TM. High-YieldGross Anatomy. 3rd ed. Baltimore: Lippincott Williams & Wilkins;2008:64.)


Tracheal rings 20 U-shaped hyaline Keep trachea patentcartilages Posteriorly oriented opening

of U-shaped cartilage allowsfor expansion of the esoph-agus during swallowing

Tracheobronchial tree(Figure 1-4)

(continued)




Tracheobronchial tree (continued)

Trachealis Layer of smooth muscle Spans posterior deficiency of tracheal rings

Right and left Extend from tracheal bifur- Form part of root of the lungmain bronchi cation to hilum of lungs Enter lung at hilum

Supported by U-shaped Right main bronchus is shor-hyaline cartilage ter, wider and more vertically

Terminate by dividing into oriented than the leftlobar bronchi Hyaline cartilage keeps both

main bronchi patent

Carina Keel-like septum projecting Visible on radiographs; superiorly at the bifurcation displacement may indicate of the trachea thoracic pathology

Lobar (secondary) Supported by hyaline Hyaline cartilage keeps bronchi (3; right) cartilage lobar bronchi patent

Lobar (secondary) Extend from main bronchi Each lobar bronchusbronchi (2; left) until termination as seg- corresponds to a lobe

mental bronchi of the lung

Segmental Supported by hyaline Supply bronchopulmonary (tertiary) bronchi cartilage segmentsright lung: 10

Formed from terminal segmental bronchibranches of lobar bronchi Left lung: 810 segmental

bronchi

Bronchopulmo- Pyramidal-shaped with Each receives a segmental nary segments apex directed toward root of bronchus and a branch of

lung and base toward outer both pulmonary andsurface of lung bronchial arteries

Intersegmental veins help identify boundaries between segments for resection

Additional ConceptBronchopulmonary Segments

Right lungSuperior lobe: Apical, Posterior, AnteriorMiddle lobe: Lateral, MedialInferior lobe: Superior, Anterior basal, Posterior basal,Lateral basal, Medial basal

Left lungSuperior lobe: Superior divisionApicoposterior,Anterior; Lingular divisionSuperior, Inferior

Inferior lobe: superior, Anterior basal, posterior basal,Lateral basal, Medial basal




Right lung 3 lobes (superior, middle, The right lung is larger than and inferior) separated by the lefta horizontal and oblique fissure

Left lung 2 lobes (superior and inferior) The left lung is smaller thanseparated by an oblique the right owing to the positionfissure of the heart

Cardiac notch Indentation of superior lobe Result of the heart and of left lung along the pericardial sac bulging to theanteroinferior border left

Lingula Tongue-like process of superior lobe of the left lung inferior to the cardiac notch

Root of lung Formed by pulmonary and Located on medial aspect of bronchial arteries, pulmo- lung, site at which structuresnary and bronchial veins, enter and leave the lunglymphatics, nerves, and main bronchi

Enclosed by pleural sleeve

Hilum of lung Located on medial aspect of Root of lung enters lung herelungs

Horizontal and Right lung has 1 horizontal Separate lungs into lobes:oblique fissures and 1 oblique fissure right lung 3, left lung 2

Left lung has 1 oblique fissure

MnemonicInhale a Bite, Goes Down the Right Inhaled objects more likely to enter right bronchus, as it iswider, shorter, and more vertical than the left.

Structure of the lungsThe lungs are the elastic organs of respiration. Their function depends upon surface tension in the pleural cavity keeping the parietal and visceral layers of pleuratogether.


Additional ConceptPostsynaptic parasympathetic ganglia are found distributedthroughout both plexuses.


Nerves of the lungs


Anterior Sympathetic Sympatheticinhibit bronchialpulmonary plexus sympathetic smooth muscle (bronchodilate) and

trunks glands, motor to vessels Parasym- (vasoconstrict)

patheticvagus Parasympatheticinhibit vessel nerves musculature (vasodilate), motor to

Located anterior smooth muscle of bronchial tree to root of lung (bronchoconstrict) and glands

(stimulates mucous secretion)

Vessels of the lungs


Right and left Pulmonary Give rise to lobar arteries; carrypulmonary trunk deoxygenated blood to the lungs

Lobar Pulmonary 3 right and 2 left lobar arteries carry arteries deoxygenated blood to each lobe of the

lung; accompany secondary bronchi

Right and left Right Supply oxygenated blood to the tissuesbronchial posterior of the bronchial tree

intercostal artery

Leftthoracic aorta

Vein Termination DescriptionRight and left Left atrium 2 pairs of pulmonary veins convey pulmonary oxygenated blood to the left atrium

(continued)

Posterior Sympatheticpulmonary plexus sympathetic

trunks Parasym-

patheticvagus nerves

Located posterior to root of lung

Visceral afferents Fibers travel in Sensory to tissues of the lungs andof pulmonary vagus nerve bronchitouch, stretch, temperature,plexuses and chemical irritants


Additional ConceptThe superficial and deep lymphatic plexuses of the lungscommunicate freely.

Clinical SignificanceBronchopulmonary nodes are an early site of tumormetastases in bronchogenic carcinoma.

Additional ConceptLigamentum ArteriosumThe ligamentum arteriosum is the remnant of the ductusarteriosusan embryologic shunt connecting the arch ofthe aorta and the left pulmonary artery.


Lymphatic structure Description Drainage

Superficial Located immediately deep to Drains to bronchopulmonary lymphatic plexus visceral pleura lymph nodes

Deep lymphatic Located in the submucosa of Drains to pulmonary lymph plexus bronchi and connective nodes

tissue around the bronchi

Pulmonary Located along the lobar Drain to bronchopulmonary lymph nodes (secondary) bronchi lymph nodes

Bronchopul- Located in the hilum of the Drain to tracheobronchialmonary (hilar) lung(s) lymph nodeslymph nodes

Superior and Located at the bifurcation of Drain to bronchomediastinal inferior tracheo- the trachea trunks (right and left)bronchial lymph nodes

Lymphatics of the lungs

Vessels of the lungs (continued)

Vein Termination Description

Right and left Right Drain deoxygenated blood from the bronchial azygos vein bronchial tree

Leftaccessory hemiazygos vein


INTRODUCTIONThe abdomen is that portion of the trunk inferior to thediaphragm and superior to the pelvis with which it is con-tinuous. The abdomen extends inferiorly to the superiorpelvic aperture.

AREAS AND FASCIA OF THE ABDOMEN

2Abdomen

33

Area Structure SignificanceAbdominal cavity

Regions (9)

Areas of the abdomen

Boundaries: Superior

diaphragm Inferior

continuous withpelvic cavity atsuperior pelvicaperture

Anterolateralmuscular abdominalwall

Posteriorvertebral column

Divided into regionsby: 2 horizontal

planessubcostaland transtubercular

2 vertical-midclavicularplanes

Larger, superior part of theabdominopelvic cavity

Regions: Right and left

hypochondriac Right and left inguinal Right and left lateral Epigastric Umbilical Pubic

Used for description oforgan location or locationof pathologic processes

(continued)



Area Structure SignificanceQuadrants (4)

Inguinal canal

Subinguinal space

Areas of the abdomen (continued)

Divided intoquadrants by ahorizontal(transumbilical) and avertical (median)plane 46 cm long,

inferomediallydirected passageextending betweenthe deep andsuperficial inguinalrings

Walls of canal: Anterior

external obliqueaponeurosis

Posteriortransversalisfascia andmedially theconjoint tendon

Rooftransversalisfascia and archingfibers of theinternal obliqueand transversusabdominis

Flooriliopubictract, inguinalligament, andlacunar ligamentfrom lateral tomedial

Space located deep tothe inguinal ligamentand iliopubic tract

Quadrants: Right and left upper Right and left lower

Used for description oforgan location or locationof pathologic processes

Transmits the spermaticcord or round ligament ofthe uterus, ilioinguinalnerve, and the genitalbranch of thegenitofemoral nerve

One result of the obliquenature of canal is that thesuperficial and deep ringsdo not overlap; therefore,increases in intra-abdominal pressure forcethe canal closed toprevent herniation

Serves to connect theabdominopelvic cavity withthe lower limb

Additional ConceptsDeep Inguinal RingThe deep inguinal ring, the internal opening of the inguinalcanal, is an evagination of transversalis fascia, just superiorto the middle of the inguinal ligament and immediately lat-eral to the inferior epigastric vessels.


Superficial Inguinal RingThe superficial inguinal ring is the slitlike external open-ing of the inguinal canal in the aponeurosis of the externaloblique muscle, just superior to the public tubercle. Themedial and lateral margins of the opening are the medialand lateral crura, which are prevented from spreadingapart by intercrural fibers.

CHAPTER 2 | ABDOMEN 35

Feature DescriptionSuperficial fascia

Investing fascia

Endoabdominal fascia

Parietal peritoneum

Rectus sheath

Structures of the abdominal wall

Inferior to umbilicus, it is composed of 2 layers: A superficial fatty layer (Campers fascia) A deep membranous layer (Scarpas fascia)

Covers the muscles (4) forming the muscular wall ofthe abdomen Lines inner surface of abdominal wall Named according to muscle it lines:

Transversalis fascia lines the transverseabdominal muscle Divided into anterior, middle, and posterior

layers Middle and posterior layers enclose the

intrinsic muscles of the backrelativelythick, provides attachment for anterolateralabdominal wall muscles

Anterior layer is fascia of quadratuslumborum musclethickened superiorly toform lateral arcuate ligament, inferiorlyattaches to iliolumbar ligament

Lumbar fascia lines the quadratus lumborum Psoas fascia lines the psoas major muscle

It is thickened superiorly to form the medialarcuate ligament

It is continuous with the thoracolumbarfascia

Lines abdominopelvic cavity Located deep to the endoabdominal fascia

from which it is separated by extraperitoneal fat

Formed by the aponeuroses of the external andinternal oblique and transverse abdominal

The sheath contains the rectus abdominis, the superior and inferior epigastric vessels, the pyramidalis, segmental nerves, andlymphatics

(continued)


Additional ConceptRectus SheathRectus sheathAbove a line midway between thepubic symphysis and umbilicus the anterior layer of thesheath is formed by the external oblique and the ante-rior portion of the internal oblique, which splits to con-tribute to the posterior layer of the sheath with thetransverse abdominal muscle. Below this line, thesheath is deficient posteriorly, with the aponeurosis ofall three muscles forming the anterior layer of thesheath, with only the transversalis fascia separating therectus abdominis from the parietal peritoneum. Thelower edge of the aponeurotic line of the posteriorsheath is the arcuate line.


Feature Description

Conjoint tendon

Inguinal ligament

Iliopubic tract

Lacunar ligament

Pectineal ligament

Structures of the abdominal wall (continued)

Fused tendons of internal oblique and transverseabdominal at their attachment to the pubis

Forms medial portion of posterior wall of inguinalcanal

Free, fibrous inferior edge of external oblique,extending between the anterior superior iliacspine and pubic tubercle

Laterally provides attachment for transverseabdominal and internal oblique

Thickened inferior margin of the transversalisfascia

Forms portion of floor and posterior wall ofinguinal canal

Located posterior and parallel to the inguinalligament

Forms the anterior boundary of the subinguinalspace

Medial-most internally directed portion of theinguinal ligament

Forms portion of floor of inguinal canal Attaches to superior pubic ramus

Continuation of lacunar ligament as it runs alongthe pectin pubis



Proximal Distal Muscle Attachment Attachment Innervation Main ActionsAnterolateral Abdominal WallExternal oblique

Internal oblique

Transverse abdominal

Rectus abdominis

Pyramidalis

Spermatic Cord and ScrotumCremaster

Dartos

Posterior Abdominal WallPsoas minor

Muscles of the abdominal wall

Ribs 512

Thoracolumbarfascia,anterior iliaccrest, inguinalligamentCostalcartilages712,thoracolumbarfascia, iliaccrest, inguinalligamentPubicsymphysis andpubic crest

Pubis

T12L1vertebrae andintervertebraldiscs

Linea alba,pubic crestandtubercle,anterior iliaccrest

Ribs 1012,linea alba,pectin pubis(via conjointtendon)Linea alba,pubic crest,pectin pubis(via conjointtendon)

Xiphoidprocess,costalcartilages57

Linea alba

Pectin pubis

T5T12

T6T12 andL1

T6T12

T12

Genitofemo-ralAutonomic

L1

Compress,protect, andsupportabdominalcontents; flexand rotatetrunkCompress,protect, andsupportabdominalcontents

Compress,protect, andsupportabdominalcontents; flextrunk (lumbarregion)Tenses lineaalba

Draws testescloser to bodyWrinkles skinof scrotum

Weak trunkflexor; oftenabsent

Found within cremaster fascia

Found within superficialfascia of scrotum

ABDOMINAL WALL

(continued)



Skeletal elements (attachments) discussed above are presentedwith the thorax and pelvis.

Clinical SignificanceGuarding ReflexIn addition to the functions mentioned previously, the flatabdominal wall muscles provide protection to abdominalviscera through involuntary contraction when touched orwhen an underlying structure is inflamed, becoming rigid;this is known as the guarding reflex.

MnemonicsOrientationHands-in-your-pockets orientation:

When you put your hands in your pants pockets, your fin-gers have the orientation of fibers of the externaloblique inferomedially.

Internal oblique fibers are at right angles to externaloblique fibers.

Psoas MajorInnervation of psoas major: Hitting L2, L3, and L4 makesthe psoas sore.

Vessels of the abdominal wall

Artery Origin DescriptionMusculophrenic Internal thoracic Supplies: diaphragm, anterolateral Superior epigastric abdominal wall

Inferior epigastric External iliac Supplies: rectus abdominis, antero-lateral abdominal wall

(continued)

Proximal Distal Muscle Attachment Attachment Innervation Main ActionsPsoas major

IliacusQuadratus lumborum

Muscles of the abdominal wall (continued)

T12L5vertebrae andintervertebraldiscsIliac fossa12th rib

Lessertrochanterof femur

Iliolumbarligament andiliac crest

L2L4

FemoralT12L4

Together formiliopsoasthechief flexor ofthe thigh

Extends andlaterally rotatesvertebral column


Additional ConceptAbdominal AortaThe abdominal aorta is the continuation of the thoracic aortaafter it passes through the aortic hiatus of the diaphragm.Theabdominal aorta terminates by dividing into common iliacarteries at L4 vertebral level.The abdominal aorta gives:

paired visceral branches: suprarenal, renal, and gonadal unpaired visceral branches: celiac trunk, superior mesen-

teric and inferior mesenteric arteries paired parietal: inferior phrenic and lumbar unpaired parietal: median sacral artery.

Venous DrainageVeins generally parallel arteries and drain into the inferiorvena cava, with the notable exception of the portal system,which drains to the liver.


Vessels of the abdominal wall (continued)

Artery Origin DescriptionSuperficial Femoral Supplies: region between umbilicusepigastric and pubisSuperficial circum- Supplies: inguinal region and flex iliac anterosuperior thighDeep circumflex External iliac Supplies: iliacus and anterolateraliliac abdominal wallSubcostal Thoracic aorta Supplies: anterolateral abdominal wallLumbar Abdominal aorta Supplies: back and posterior (45 pairs) abdominal wallTesticular Supplies: testes and epididymisArtery of the Inferior vesical Supplies: ductus deferensductus deferens arteryCremasteric Inferior epigastric Supplies: cremaster muscle and

artery fasciaVein Termination DescriptionPampiniform Plexus converges Drains the spermatic cord and testesplexus to form the

testicular veins

Nerves of the abdominal wall

Nerve Origin Structures InnervatedThoracoabdominals T7T11 Anterolateral abdominal wall superior Subcostal T12 to iliac crest

(continued)


MnemonicLumbar PlexusLumbar plexus nerve roots: 2 from 1, 2 from 2, 2 from 3:

2 nerves from 1 root: ilioinguinal (L1), iliohypogastric (L1).2 nerves from 2 roots: genitofemoral (L1L2), lateral cuta-

neous nerve of the thigh (L2L3). 2 nerves from 3roots: obturator (L2L4), femoral (L2L4).


Feature Description SignificanceWall Double layered: skin and Outpouching of lower

superficial fascia (dartos): anterior abdominal wallcontains smooth muscle Dartos muscle receives fibersdartos muscle autonomic innervation and

functions to wrinkle the skinArterial SupplyPosterior scrotal Origin: perineal artery Supplies posterior aspectbranchesAnterior scrotal Origin: external pudendal Supplies anterior aspectbranches arteryCremaster Origin: inferior epigastric Supplies the superior aspectartery artery

Structure of the scrotum

Nerves of the abdominal wall (continued)


Lumbar PlexusIliohypogastric L1 Anterolateral abdominal wall of

inguinal and hypogastric regionsIlioinguinal Scrotum/labia majorum, mons pubis,

medial thigh, and lower-most aspect of anterolateral abdominal wall

Genitofemoral L1, L2 Divides into genital and femoral branches;genital branch supplies cremaster and cutaneous innervation to anterior aspectof scrotum; femoral branch is sensoryto anteromedial aspect of thigh

Lateral cutaneous L2, L3 Supplies sensory innervation to nerve of the thigh anterolateral aspect of thighObturator L2L4 Supplies adductor compartment of thighFemoral Supplies hip flexors and knee extensorsLumbosacral trunk L4, L5 Participates in formation of sacral

plexus (L4S4)

(continued)


The testes and epididymis are presented with the reproductiveorgans in the pelvis and perineum chapter.

Clinical SignificanceSensory Innervation of the ScrotumAs the anterior aspect of the scrotum is supplied bybranches of the ilioinguinal nerve and the posterior aspectby the branches of the perineal and posterior femoral cuta-neous nerves, care must be taken to properly anesthetize thescrotum for surgical procedures.

Structure of the spermatic cordThe spermatic cord runs through the inguinal canal into thescrotum.The cord contains structures coursing between thescrotum and the abdominopelvic cavity.


Feature Description SignificanceNerve Supply

Genital branch Origin: genitofemoral nerve Supplies anterolateral of genitofemoral (L1L2) surfacenerve

Anterior scrotal Origin: ilioinguinal nerve Supplies anterior surfacenerves (L1)

Posterior scrotal Origin: perineal branches of Supplies posterior surfacenerves pudendal nerve (S1S4)

Perineal Origin: posterior femoral Supplies inferior surfacebranches of cutaneous nerve (S2S3)posterior femoralcutaneous

Structure of the scrotum (continued)


Fascial coverings Internalinternal Internal spermaticof spermatic spermatic fascia derived from transversalis cord Middlecremaster fascia fascia

Externalexternal Cremasterderivedspermatic fascia from internal oblique

External spermaticderived from external oblique

(continued)


Clinical SignificanceTemperature RegulationThe cremaster muscle (skeletal muscle), found with thecremaster fascia, draws the testes toward the body in coldtemperatures as part of the cremasteric reflex. The dartosmuscle (smooth muscle) causes wrinkling of the scrotum todraw the testes nearer the body and reduce the surface areaof the scrotum in cold temperatures.

PERITONEAL CAVITY


Structure of the peritoneal cavity(Figure 2-1)

The peritoneal cavity is a potential, fluid-filled spacebetween adjacent layers of peritoneum in the abdomen. It isdivided into a lesser and a greater sac that correspond totheir embryologic origins as the right and left halves of theintraembryonic cavity.

Structure Description SignificanceComponentsDuctus deferens Tube composed of smooth Conveys sperm from the

muscle epididymis to the ejaculatory duct

Testicular artery Arises from abdominal aorta Supplies testes andepididymis

Artery of the Arises from inferior vesical Supplies ductus deferensductus deferens arteryCremasteric Arises from inferior Supplies cremaster muscle artery epigastric artery and fasciaPampiniform Venous plexus that drains the Converges to form the plexus of veins testes and spermatic cord testicular veinsAutonomics Sympathetic and Innervates dartos and

parasympathetic nerve vessels of regionnetwork Responsible for peristaltic

contractions during emission

Genital branch Origin: L1L2; divides into Supplies cremaster muscleof genitofemoral genital and femoral

branches

Structure of the spermatic cord (continued)



Bounded by: Anteriorliver,

stomach and lesseromentum

Posteriordiaphragm Rightliver Leftgastrosplenic

and gastrorenalligaments

Limited by diaphragm andposterior leaf of coronaryligament of the liverLimited by fusion ofanterior and posteriorleafs of greater omentumAll of the peritonealcavity that is not thelesser sac

Located posterior to theportal triad and anteriorto the inferior vena cavaDepressions runningparallel with theascending anddescending colon alongthe posterior abdominalwallFormed by the mesenteryof the transverse colonthe transverse mesocolon

Superior extensions of theperitoneal cavity betweenthe diaphragm and liverExtension of peritonealcavity inferior to the liverand anterior to the kidneyand suprarenal gland

Smaller portion of theperitoneal cavity

Formed by embryologicrotation of the gut

Superior extent of thelesser sac

Inferior extent of thelesser sac

Larger portion of theperitoneal cavity

Formed by embryologicrotation of the gut

Connection between thelesser and greater sac

Function as channelsthat convey peritonealfluid

Communicationbetween supra- andinfracolic compartments

Part of the peritonealcavity superior to thetransverse mesocolonPart of the peritonealcavity inferior to thetransverse mesocolonSeparated into right andleft by the falciformligament Communicates

anteriorly with the rightsubphrenic space

Communicates withomental bursa (lessersac)fluid may draininto recess from herewhen supine

Structure of the peritoneal cavity (continued)

Feature Description SignificanceLesser sac (omental bursa)

Superior recess of lesser sac

Inferior recess of lesser sac

Greater sac

Omental foramen

Paracolic gutters

Supracolic compartment

Infracolic compartment

Subphrenic spaces

Hepatorenal recess

(continued)



Feature Description SignificancePeritoneal FossaeSupravesical fossaeMedial inguinal fossae (related to inguinal triangles)Lateral inguinal fossae

Between the median andmedial umbilical foldsBetween the medial andlateral umbilical folds

Lateral to the lateralumbilical folds

Potential site for a hernia

Potential site for a directinguinal hernia

Deep inguinal rings foundwithin fossae, potentialsite for indirectinguinal hernia

Peritoneal pouches are presented with the pelvis.

Clinical SignificancePeritoneal PunctureOccasionally it is necessary to puncture the peritoneum toremove excess fluid (ascites) that accumulates duringinflammation, to conduct peritoneal dialysis or administeranesthetic agents through intraperitoneal injection.

Peritoneum (Figure 2-1)

Structure Description SignificanceParietal peritoneumVisceral peritoneumMesentery

Peritoneal FoldsMedian umbilical fold

Medial umbilical folds (2)

Serous membrane liningthe peritoneal cavity

Double layer ofperitoneum connectingintraperitoneal organs tothe abdominal wall

Conveys neurovascularelements and lymphatics

Allows movement of theorgan to which it isattached

Fold of parietal peritoneumextending from the apex ofthe bladder to the umbilicusFold of parietal peritoneumfound lateral to the medianumbilical fold

Lines internal surface ofabdominal wallLines external surfaces ofabdominal organs The mesentery refers

specifically to the mes-entery of the small intestine

Other mesenteries arenamed specifically for theorgans to which they areassociated (e.g., transversemesocolon ormesoappendix)

Covers the medianumbilical ligamenttheremnant of the urachusCovers the medial umbilicalligamentsthe obliteratedpart of the umbilical arteries

(continued)



Peritoneum (continued)

Fold of parietal peritoneumfound lateral to the medialumbilical folds

Double layer of peritoneumconnecting greater curvatureof stomach and proximalduodenum to adjacent organs

Double layer ofperitoneum connectinglesser curvature of thestomach and proximalduodenum to adjacentorgans

Forms anterior wall oflesser sac

Double layer ofperitoneum extendingfrom umbilicus to liver onanterior abdominal wall

Continuous superiorly asleft and right coronaryligament

Anterior formed byseparation of leafs offalciform ligament

Posterior is formed ofperitoneal reflexion fromdiaphragm to liver

Formed of anterior andposterior coronaryligaments

Connective tissue cord ininferior border of falciformligament

Covers the inferiorepigastric vessels

3 parts: 1. Gastrophrenic

ligamentconnectsstomach to diaphragm

2. Gastrosplenicligamentconnectsstomach to spleen

3. Gastrocolic ligamentconnects stomach totransverse colon, largestpart, anterior and posteriorlayers are fused to form a4-layered structure

2 parts:1. Hepatogastric

ligamentconnectsstomach to liver

2. Hepatoduodenalligamentconnectsduodenum to liver, containsportal triad: portal vein,hepatic artery and bile duct

Embryologic remnant ofthe ventral mesentery

Contains round ligament ofthe liver in its inferior,crescentic border

Bound the bare area of theliver

Formed of a peritonealreflexion between anteriorand posterior leafs ofcoronary ligamentsEmbryologic remnant of theumbilical vein

Structure Description SignificanceLateral umbilical folds (2)

OmentaGreater

Lesser

Associated with the LiverFalciform ligament

Coronary ligaments (anterior and posterior)

Triangular ligaments (right and left)

Round ligament of liver


Liver

Lesser omentum

Pancreas

Falciformligament

Stomach

Duodenum

Transversemesocolon

Transverse colon

Mesentery ofsmall intestine

Greater omentum

Jejunum

Ileum

Visceral peritoneum

Parietal peritoneum

Rectovesical pouch

Urinary bladder

Rectum

Superior recess of omental bursa

Inferior recess of omental bursa

Transversemesocolon

Left colicflexure

A Right lateral view

B Anterior view

Transversecolon

Right colicflexure

Supracoliccompartment

Ascendingcolon

Tenia coli

Descendingcolon

Root ofmesentery ofsmall intestine

Leftparacolicgutter

Leftinfracolicspace

Rightparacolicgutter

Rightinfracolicspace

Phrenicocolicligament

Infracolic compartment

Subhepaticspace

Supracoliccompartment(greater sac)

Omentalbursa(lesser sac)Infracoliccompartment(greater sac)

FIGURE 2-1. Subdivisions of peritoneal cavity. A: This mediansection of the abdominopelvic cavity shows the subdivisions of theperitoneal cavity. B: The supracolic and infracolic compartments ofthe greater sac are shown after removal of the greater omentum.Theinfracolic spaces and paracolic gutters determine the flow of asciticfluid when inclined or upright. (From Moore KL, Dalley AF.Clinically Oriented Anatomy. 5th ed. Baltimore: Lippincott Williams& Wilkins; 2006:239.)46


Additional ConceptsPeritoneal RelationsOrgans that are suspended by a mesentery are said to beintraperitoneal. Organs that lack a mesentery and are onlypartially covered with peritoneum are said to be extraperi-toneal (retroperitoneal or subperitoneal provides more indi-cation of their location).

Median Umbilical LigamentThe median umbilical ligament is formed by the urachus,the obliterated portion of the allantois, connecting the apexof the bladder with the umbilicus.

Medial Umbilical LigamentsThe medial umbilical ligaments are formed by the oblit-erated portions of the umbilical arteries distal to the supe-rior vesical arteries.

Clinical SignificanceHerniaeA direct inguinal hernia (acquired) exits the abdomen viathe medial inguinal fossa or inguinal triangle, which isbounded medially by the semilunar line (lateral border ofrectus abdominis), laterally by the lateral umbilical folds andinferiorly by the inguinal ligament.

An indirect inguinal hernia (congenital) exits theabdomen via the deep inguinal ring and passes through theinguinal canal into the scrotum.

AdhesionsAdhesions may develop in the peritoneal cavity as a result ofinflammation of the peritoneum (peritonitis) or previoussurgery, which may need to be removed if they compromisethe function of the viscera.

MnemonicStructures forming folds: IOU:From lateral to medial:

lateral umbilical ligament: Inferior epigastric vesselsmedial umbilical ligament: Obliterated umbilical arterymedian umbilical ligament: Urachus



ESOPHAGUS


Feature Description SignificanceSphincters

Innervation

Arterial supply

Venous drainage

Structure of the esophagusThe esophagus is a muscular tube extending from the cricoidcartilage to the gastroesophageal junction; it enters theabdomen through the esophageal hiatus of the diaphragm.The nature of the musculature of the esophagus changesthroughout its course:

upper thirdskeletal muscle middle thirdmixture of smooth and skeletal muscle lower thirdsmooth muscle

2 sphincters: 1. Upper esophageal

sphincterskeletalmuscle

2. Lower esophagealsphinctersmoothmuscle and skeletalmuscle of diaphragm

Skeletal muscle partrecurrent branches ofthe vagus nerve

Smooth muscle partesophageal plexus

Inferior thyroid,esophageal, bronchial,left gastric and leftinferior phrenic arteriesEsophageal veins emptyinto the inferior thyroid,azygos, hemiazygos andgastric veins

Upper sphinctercomposed mainly ofcricopharyngeus

Lower sphinctersmooth muscle andmuscular diaphragmaticesophageal hiatusprevent gastroe-sophageal reflux

Esophageal plexusparasympathetic fibersfrom the vagus nerves andsympathetic fibers fromsympathetic chain andgreater splanchnic nerveArterial supply is generallyvia whatever arteries lienear this long longitudi-nally oriented structureImportant contributor tothe portal-cavalanastomosis

Clinical SignificanceEsophageal VaricesEsophageal varices are dilated esophageal veins that mayrupture in cases of portal hypertension.

PyrosisPyrosis (heartburn) is usually the result of regurgitation ofstomach contents into the lower esophagus.


STOMACH


Structure of the stomach(Figure 2-3)

The stomach is the muscular organ of digestion; it produceschyme through enzymatic digestion.

Part surrounding cardialorifice

Part superior to cardialorificePart between fundus andpyloric antrum Distal-most part of the

stomach Possesses smooth

muscle sphincterpyloric sphincter,which guards thepyloric orifice thatopens into theduodenum

Funnel-shaped Divided into the

pyloric antrum (wide)and pyloric canal(narrow)

Directed inferior and tothe leftDirected superior and tothe right

Longitudinal folds ofgastric mucosa

Cardial orificefunnel-shaped opening ofstomach that receives theesophagusTypically dilated and gas-filledMajor part of thestomachPyloric sphincter controlsrelease of gastriccontents into theduodenum and preventsreflux from duodenuminto stomach

Longer, convex curvature

Shorter, concavecurvature

Bears the angularincisureouterrepresentation of thejunction of the bodyand pyloric part

Function to increasesurface area and allowfor distension

Feature Description SignificancePartsCardia

Fundus

Body

Pylorus

CurvaturesGreater

Lesser

InteriorRugae (gastric folds)


Clinical SignificancePylorospasmPylorospasm is the failure of the pyloric sphincter torelax, which prevents food from passing from the stomachto the duodenum, often occurs in infants and may resultin vomiting.


Vessels of the stomach (Figure 2-4)

Supplies embryologicforegut

Gives rise to: splenic,hepatic and left gastricarteries

Supplies the spleen Gives rise to left gastro-

omental and short gastricarteries to the stomach

Supplies the liver Gives rise to gastroduodenal

and right ga

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