Last anatomy objectives!!!!!!

celiac, aortic, superior hypogastric and inferior hypogastric plexuses.

Celiac plexus, a.k.a., the "solar plexus": variably defined as including the celiac ganglia along with the aorticorenal or the aorticorenal and superior mesenteric ganglia. This plexus also includes the greater, lesser and least (thoracic) splanchnic nerves that carry preganglionic sympathetic fibers to these ganglia, and branches of the anterior and posterior vagal trunks. The nerve fibers of the celiac plexus distribute to viscera derived from the foregut and midgut portions of the embryonic gut tube, the spleen, the kidneys and proximal aspects of the abdominal portions of the ureters, and the spleen. Aortic plexus: extending from just inferior to the origin of the superior mesenteric artery to the bifurcation of the aorta. This plexus includes the large inferior mesenteric ganglia and many smaller ganglia, in addition to the lumbar splanchnic nerves that carry preganglionic sympathetic fibers to these ganglia. The preganglionic parasympathetic fibers in this plexus are from the vagus nerve (superior part of plexus) and the pelvic splanchnic nerves (inferior part of plexus, including that portion associated with the origin of the inferior mesenteric artery). The nerve fibers in this plexus distribute to viscera derived from the hindgut portion of the embryonic gut tube, the distal aspects of the abdominal portions of the ureters, and the gonads. Inferior hypogastric plexuses (right and left): located on the sides of the pelvic viscera; this plexus includes a number of small pre-aortic sympathetic ganglia and the lumbar and sacral splanchnic nerves that carry preganglionic sympathetic fibers to these ganglia. This plexus also includes preganglionic parasympathetic nerve fibers from the pelvic splanchnic nerves. The nerve fibers within this plexus distribute to the pelvic cavity viscera. Superior hypogastric plexus: located at and just inferior to the bifurcation of the aorta; this plexus includes a number of small pre-aortic sympathetic ganglia and the lumbar and sacral splanchnic nerves that carry preganglionic sympathetic fibers to these ganglia. This plexus also includes preganglionic parasympathetic nerve fibers from the pelvic splanchnic nerves. The superior hypogastric plexus is mostly a conduit for sympathetic fibers to reach inferior hypogastric plexus in the pelvic cavity; and for fibers from pelvic splanchnic nerves to ascend to the subplexus of nerves associated with the inferior mesenteric artery.

Specify the locations of the three natural constrictions of the ureters occur and correlate this to the passage of ureteric calculi (kidney stones).

at the junction of the renal pelvis with the ureter (ureteropelvic junction); where the ureter crosses the pelvic brim; where the ureter enters the wall of the urinary bladder (ureterovesical junction); These three locations represent potential sites where kidney stones cause ureteric obstruction.

Place the coverings of the testicles in order from superficial to deep.

skin dartos fascia and muscle external spermatic fascia cremaster muscle and cremasteric fascia internal spermatic fascia parietal layer of the tunica vaginalis (cavity of the tunica vaginalis) visceral layer of the tunica vaginalis

Describe the relationship of the urinary bladder to the parietal peritoneum, retropubic space, and anterior abdominal wall.

the urinary bladder is located posterior to the pubic bones and pubic symphysis of the pelvis and is separated from the pubis by fat and fascia within the "retropubic space"; the peritoneum passes directly from the internal surface of the anterior abdominal wall onto the superior surface of the urinary bladder. The anterior wall of the urinary bladder is therefore not covered in peritoneum and may be considered "bare" (realize that these same relationships of the urinary bladder to the pubic symphysis and peritoneum exist in females as well).

1. Specify the bony features that determine the obstetric conjugate, diagonal conjugate, and bispinous diameters

true (obstetric) conjugate diameter (Moore Fig. B6.2; see figure to the right): the narrowest dimension of the entrance to the birth canal in the anterior/posterior plane; represented as the chord (straight- line) distance from the sagittal midline of the sacral promontory to the nearest point on the internal (posterior) surface of the pubic symphysis. diagonal conjugate diameter (Moore Fig. B6.2): a surrogate, measureable estimate of the true conjugate diameter; measured as the chord distance between the sagittal midline of the sacral promontory (palpaple from within the vagina) and the inferior margin of the pubic symphysis. bispinous diameter: the narrowest dimension of the pelvic outlet; represented as the chord distance between the right and left ischial spines.

2. Define a mesentery and describe what types of structures may travel within them.

A mesenteryis a double-layer of peritoneum that projects from the posterior aspect of those abdominal organs that are more completely embedded within the peritoneal cavity wall and surrounded by the peritoneal sac. Mesenteries provide a route for nerves and lymph and vessels to reach these organsfrom the aorta, vena cava and pre-aortic ganglia located in the retroperitoneal space. Mesenteries are often said to "suspend" the abdominal viscera within the peritoneal cavity. However it is important to realize that none of these organs are technically within the peritoneal cavity. Even so, abdominal organs suspended from the posterior abdominal wall by mesenteries are said to be "intraperitoneal"

Distinguish the urogenital triangle and anal triangle in terms of location and orientation.

A transverse line connecting the right and left ischial tuberosities of the bony pelvis divides the diamond-shaped perineum into a urogenital triangle anteriorly, and an anal triangle posteriorly. With the pelvis in anatomical position (i.e., with the ASIS and pubic tubercle positioned in the same vertical plane), the urogenital triangle of the perineum faces inferiorly, whereas the anal triangle faces more posteriorly. Both are triangles with base at the 2 ischial tuberosity Urogenital—> apex toward the pubic symphysis (anteriorly) Anal—> apex toward the coccyx

Describe how abdominal aponeuroses relate to one another in the rectus sheath, linea alba, arcuate line, and semilunar line.

A. Rectus sheath—> EAO + 1/2 IAO —> anterior aponeuroses—> anterior portion linea alba P. Rectus sheath—> 1/2 IAO + TA —> posterior aponeuroses—> Posterior linea alba Arcuate line—> Inferior free edge of the posterior rectus sheath (stops) (inferior to that all 3 aponeuroses go anteriorly. transversalis fascia is now under Semilunar line—> lateral side of the anterior rectus sheath.

Specify the bony articulations of the temporomandibular joint and list the movements allowed at this joint.

Acting upon the temporomandibular joint, the four muscles of mastication bring the mandibular dentition into occlusion with that of the maxilla. Placement of the bolus between the occluding mandibular and maxillary dentitions during chewing (mastication) gradually reduces it to a size and consistency optimal for swallowing and digestion. Temporomandibular joint (TMJ): o Thissingularjointoccursbetween the right and left condyles (heads) of the mandible, and the right and left mandibular (glenoid) fossae of the temporal bones, respectively.

Describe the changing pattern of pain typical of an advancing case of appendicitis and specify which pain is visceral and which pain is somatic in origin.

Acute inflammation of the appendix, appendicitis, is a common cause of an acute abdomen (severe abdominal pain arising suddenly). Usually, digital pressure over the McBurney point registers maximum abdominal tenderness. When secretions from the appendix cannot escape, the appendix swells, stretching the visceral peritoneum. The pain of appendicitis usually commences as a vague pain in the peri-umbilical region because afferent pain fibers enter the spinal cord at the T10 level (visceral) (see Fig. B5.12). Later, severe pain in the right lower quadrant results from irritation of the parietal peritoneum lining the posterior abdominal wall (usually formed by the psoas and iliacus muscles in the region of the appendix). Thus, extending the thigh at the hip joint may elicit pain.

Trace the flow of bile from the liver and gallbladder to the duodenum.

Bile is continuously produced by the liver and is stored and concentrated in the gallbladder. gpFollowing a fatty meal, bile stored in the gallbladder is released and conveyed to the duodenum through the biliary duct system. Bile is made in the liver Stored in gallbladder After fatty meal -- the stored bile is released from the gallbladder via cystic duct and then connects with the common hepatic duct to form the common bile duct to the duodenum for digestion. Liver → R and L hepatic duct → common hepatic duct → common hepatic duct joins cystic duct (From gallbladder) to form common bile duct → duodenum

Given an image of the anterior chest wall, be able to describe the location of a lesion in the breast using breast quadrants and the clock face concept

Breast quadrants • For the anatomical location and description of tumor and cysts, the surface of the breast is organized into 4 quadrants via a vertical and a horizontal line through the nipple ‐‐ upper outer, upper inner, lower outer, lower inner quadrants. 60% tumours in upper outer or axillary tail

Explain the surgical significance of the relationship between the uterine artery and the ureter

By virtue of its proximity to the uterine artery, the ureter is at risk of being clamped, tied off and severed during hysterectomies. both in cardinal ligament

List the four cranial nerves that include an autonomic (preganglionic parasympathetic) component.

CN III - Oculomotor Nerve CN VII - Facial Nerve Glossopharyngeal Nerve CN X - Vagus Nerve

Specify the functional modalities specific to each of the following primary branches of CN VII: motor branch, chorda tympani and greater petrosal.

CN VII Facial Nerves. Very mixed. Three branches Motor branch. Facial Nerves. Somatic efferent innervation to muscles including the muscles of facial expression, muscle of the middle ear and some of the suprahyoid muscles in the neck. Also carries somatic afferent fibers carry sensory info from the skin of the external ear. exits stylomastoid foramen stapedius of ear Chorda tympani.Facial Nerves. Caries preganglionic parasympathetic fibers from the submandibular ganglion inervate the submandibular and sublingual salivary glands. The chorda tympani also carries taste sensation from receptors located in the mucosa of the anterior 2/3 of the tongue. Submandibular ganglion parasympathic post Greater (superficial) petrosal nerve.Facial Nerves. Preganglionic parasympathetic fibers to the pterygopalatine ganglia enervate the lacrimal gland and mucus producing glands in nose and palate. Also carries taste sensation from the soft palate. Pterygopalatine ganglion para post

Explain the anatomical basis of caput medusae and esophageal varices.

Cirrhosis resulted obstruction of the hepatic portal vein, thereby increasing the hydrostatic blood pressure in the hepatic portal vein and its tributaries (or portal hypertension). Portal hypertension can dilate these veins and predispose them to rupture, causing significant blood loss. There are four major sites of portal-systemic venous anastomoses. The first is the esophageal anastomosis between the left gastric vein, which is part of the portal system and the esophageal vein, which drains into the azygos vein, part of systemic venous system. Portal hypertension can cause esophageal varices. These enlarged veins can rupture, causing severe hemorrhage which is difficult to control surgically and can be life threatening. Esophageal varices commonly develop in individuals with alcoholic cirrhosis of the liver. The second anastomosis is between the paraumbilical veins and the hepatic portal vein. This links the inferior and superior epigastric veins, internal iliac vein, and superficial epigastric vein to the hepatic portal vein. Portal hypertension affecting these veins can cause Caput Medusa, which is visibly dilated veins around the umbilicus. Caput Medusa is named for the snake like appearance these veins take on within the anterior abdominal wall.

Explain the anatomical basis of the Valsalva maneuver and relate that to changes in intra-abdominal pressure.

Contraction of the abdominal wall with the diaphragm fixed and the glottis of the larynx closed - referred to clinically as the "Valsalva Maneuver" - increases intra‐abdominal pressure, which assists in voiding the contents of the bladder and rectum, and in childbirth. Clinicians use the the Valsalva maneuver to test their patient's ability to compensate for the changes in the amount of blood that returns to the heart under these conditions.

Explain the nervous control of defecation and specify the muscles and somatic nerves involved; distinguish the roles of sympathetic and parasympathetic nerves in this process.

Defecation is initiated when feces is driven into the distal rectum by mass colonic contractions. Upon distension of the rectal ampulla (widened portion of distal rectum) a reflex contraction of the rectum occurs, the internal anal sphincter (normally maintained by the sympathetic system in a contracted state) relaxes in response to parasympathetic stimulation, and the fecal material is pushed into the anal canal. Stretch receptors in the distal rectum signal the rectum (via visceral afferent fibers) that it is full and the conscious decision is made whether to expel the feces by simultaneously relaxing the external anal sphincter and pelvic floor, and contracting the abdominal musculature, or to postpone defecation by contracting the external anal sphincter (inferior rectal branch of pudendal nerve). In the case of the latter decision, active contraction of the external anal sphincter is required only until colonic contractions cease and retrograde rectal peristalsis moves feces out of the distal rectum.

Explain the anatomical basis of the spread of infection, blood, and urine between the different perineal spaces, the abdominal wall, penis, scrotum, and thigh.

Determine by the relations of the superficial and deep fascia layers in the anterior abdo wall, perineum and thigh. The Scarpas fascia (abdo) is continuous to the deep facia of thigh and also the dartos (penis) and colle's fascia of the perineum. they are continuous so they it can spread.

Specify the structures that may be palpated on digital rectal exam in males.

Digital rectal exams are useful clinical tools that rely on palpation, In a patient the tone of the external anal sphincter is noted, and the rectal walls are examined for irregularities. Anteriorly the prostate gland and seminal vesicles are palpated. Posteriorly and posterolaterally the sacrum, coccyx, ischioanal fossa, and ischial spine can all be palpated.

Specify the organs and vessels at risk of injury in a ruptured duodenal ulcer as well as a gastric ulcer.

Duodenal ulcers most often occur on the anterior wall of the duodenal cap. Perforations of duodenal ulcers at this location may erode the gastroduodenal artery, causing severe hemorrhage. gastric occurs upper lesser curvature hurts left gastric artery

1. Compare the somatic and autonomic motor systems with respect to effector tissues innervated and the number of motor neurons required to innervate effector organs.

Effectors: somatic effectors are skeletal muscles. Autonomic effectors are smooth muscle, cardiac muscle and glands. one for somatic two for autonomic. (pre and post)

Explain the nervous control of erection, emission and ejaculation and specify the muscles and somatic nerves involved.

Erection of the penis occurs through dilation of the blood vessels that supply the erectile tissues. Dilation of these blood vessels is under the control of parasympathetic neurons which pass through the prostatic plexus (located within the fibrous capsule of the prostate) on their way to the erectile tissues. These parasympathetic nerves travel through the prostatic plexus and are at risk of injury during prostatectomy. Ejaculation consists of two processes: emission and ejaculation. Emission is the transmission of seminal fluid from the vasa, prostate and seminal vesicles into the prostatic urethra. Emission is under sympathetic control. Ejaculation is the onward transmission of seminal fluid from the prostatic urethra to the exterior and has both autonomic and somatic components. The somatic component consists of contraction of the bulbospongiosus muscle via the somatic efferent fibers in the pudendal nerve. The autonomic component consists of the contraction of the urethral smooth muscle as controlled by parasympathetic fibers from the inferior hypogastric plexus (originating from the pelvic splanchnic nerves), and the closure of the internal urethral sphincter at the neck of the urinary bladder as controlled by sympathetic fibers of the inferior hypogastric plexus.

Distinguish the regions of the GI tract that receive parasympathetic innervation from the vagus nerve versus pelvic splanchnic nerves.

FOREGUT MID GUT VAGUS HINDGUT PELVIC SPLANCHNIC

Relate the vaginal fornices to the following clinical proce dures: palpation of the ovaries, palpation of pulsations of ureter, palpation of uterine arteries, draining the rectouterine pouch, harvesting oocytes.

Fluids collecting in the rectouterine pouch (of Douglas) can be drained by inserting an aspirating needle through the posterior part of the posterior vaginal fornix. Such an approach is also used to harvest oocytes from the ovaries for in vitro fertilization. anterior palpate The ureter and pulsations of uterine artery can be felt through lateral fornices the lateral fornix of the vagina is related to the ureter and uterine artery

Specify the group of lymph nodes to which lymph from each of the following will first travel: foregut organs, midgut organs, hindgut organs, and abdominal wall.

Foregut organs first drain to: celiac nodes Midgut organs: superior mesenteric nodes Hindgut organs: inferior mesenteric nodes Abdominal wall: lumbar trunks (inferior to umbilicus), (upper abdominal wall - subclavian trunks)

Specify the pre-aortic (prevertebral) ganglia that contain the postganglionic sympathetic neuronal cell bodies that supply the foregut, midgut, and hindgut components of the GI system and the kidneys.

Foregut: the postganglionic sympathetic neurons are located primarily in the celiac prevertebral ganglia of the pre-aortic plexus. Midgut: the postganglionic sympathetic neurons are located primarily in the superior mesenteric prevertebral ganglia (and aorticorenal) of the pre-aortic plexus. Hindgut: the postganglionic sympathetic neurons are located primarily in the inferior mesenteric ganglia of the pre-aortic plexus, and ganglia of superior hypogastric plexus.

Distinguish the functions of the following cranial nerves in the oral cavity and tongue: V2, V3, VII, IX, X, XII and specify how each of these nerves is assessed clinically.

IX elicits swallow reflex (pharyngeal phase) gag reflex. innervates sensory of mucosa. patorid gland X efferent gag relex ( reflex contraction of the elevator of the soft palate and the palatoglossus and palatopharyngeus muscles,) V2: Upper dentition sensory pinpricks V3: general sensory of ant 2/3 of tongue / All muscle of mastication, lower dentition sensory pinpricks VII: chorda tympani: sensory and taste on 2/3 of the tongue (L) (submandibular ganglion)—> sublingual and submandibular) facial movements taste facial motor buccinator orbicularis oris IX: sensory and taste on posterior 1/3 of the tongue afferent gag reflex test parotid X: sensory in epiglottis, larynx // swallowing + innervation of the folds.®—> Say AAh and see if uvula moves efferent gag reflex XII: intrinsic and extrinsic muscles of the tongue.

Distinguish among direct, indirect, and femoral hernias as they relate to the deep inguinal ring, the inguinal triangle, and the subinguinal space.

In a femoral hernia abdominal viscera protrude through the subinguinal space and enter the femoral canal (medial-most compartment) of the femoral sheath. The two inguinal rings are natural points of weakness in the anterior abdominal wall. The area of the abdominal wall bounded medially by the lateral border of the rectus abdominis muscle, laterally by the inferior epigastric vessels and inferiorly by the inguinal ligament is referred to as the inguinal (Hasselbach's) triangle. The inguinal triangle is an additional area of natural weakness in the anterior abdominal wall through which loops of bowel may herniate when the inguinal triangle is torn. This type of hernia, which bypasses the deep inguinal ring and inguinal canal, is referred to as a direct This type of hernia in which the protruded abdominal contents pass into the inguinal canal via the deep inguinal ring is also referred to as an indirect inguinal hernia.

Describe the developmental basis of horseshoe kidney, pelvic kidney, duplicated ureters and typical anomalous renal arteries.

In addition, the inferior poles of the two kidneys may come into contact and fuse during ascent, forming a U- shaped horseshoe kidney. During ascent, this single kidney becomes caught under the inferior mesenteric artery and therefore never reaches its normal location. duplicated ureters—> when ureteric bud splits prematurely leading 2 metaphrenic tissues each associated with their own renal pelvis and ureter. Typical anomalous renal arteries—> during the ascension of the kidney, the inferior transient renal arteries fail to regress (accessory renal arteries) Pelvic kidney—> kidney fails to ascend and remain in the pelvis horseshoe kidney—> While ascending the 2 inferior poles of the 2 kidney may fuse together forming a U-shape kidney.

Explain the developmental basis of hypospadias and epispadias.??

In hypospadias, fusion of the urethral folds is incomplete and abnormal openings of the urethra occur along the inferior aspect of the penis. These openings usually occur near the glans, along the shaft, or near the base of the penis. epispadias

Specify the main branches of the aorta which supply the foregut, midgut, and hindgut regions of the gut tube.

In the abdomen, foregut derivatives all receive their blood supply from the celiac trunk of the abdominal aorta. Although not a derivative of the foregut tube, the spleen (derived from a population of splanchnic mesoderm within the dorsal mesentery of the foregut) receives its blood supply from the celiac trunk as well. Midgut These organs all receive their blood supply from the superior mesenteric artery.

Explain the embryological and anatomical basis of varicocele, hydrocele, cryptorchidism, and testicular torsion and describe the clinical complications associated with each.

Isolated remnants of the processus vaginalis can fill with serous fluid to produce hydroceles. Hydroceles have little clinical consequence. Varicocele refers to the dilatation of the pampiniform venous plexus within the scrotum. This plexus surrounds the testicular artery where it presumably helps reduce the temperature of the arterial blood to the testis. Varicoceles are more common in infertile men, but how the condition impairs sperm production, structure and function is currently unknown. Cryptorchidism is the failure of one or both testes to descend. If the undescended testis is relocated into the scrotum (orchiopexy) before age 2, it may retain the ability to produce sperm. Undescended testes have higher rates of developing cancer if left undescended. Testicular torsion refers to the twisting of spermatic cord structures that results from rotation of the testis in the scrotum. Testicular torsion is a urological emergency as it can result in loss of blood supply to the testis. Testicular torsion is most common in neonates and adolescents.

Explain the significance of the processus vaginalis to congenital hernias and hydrocele.

Isolated remnants of the processus vaginalis can fill with serous fluid to produce hydroceles. Hydroceles have little clinical consequence. Retention of the processus vaginalis can result in the herniation of abdominal contents into it and potentially into the spermatic cord and scrotum depending on how much has been retained. This form of hernia is termed a congenital inguinal hernia. This type of hernia in which the protruded abdominal contents pass into the inguinal canal via the deep inguinal ring is also referred to as an indirect inguinal hernia.

Describe where along its course the pudenda l nerve is targeted when performing a pudendal nerve block and the region of anesthesia this procedure provides

It is also possible to perform only a pudendal nerve block (needle directed toward its location at the ischial spine, usually from within the vagina; Moore Fig. B6.35, see online) to block pain from the lower vagina and the majority of the perineum. In this type of anesthesia the mother is aware of both cervical dilation and uterine contractions.

List the structures that enter/exit the liver through the porta hepatis.

L/R hepatic ducts, L/R proper hepatic arteries and hepatic portal vein.

Specify the male homologues of the following features of the female genitalia; labia majora and minora, clitoris.

Labia majora scrotum libia minora Urethral surface of penis spongy urethra clitoris penis

Define the following terms relating to the anatomy of the larynx: laryngeal inlet, vestibule, vestibular folds, vocal folds, ventricle, glottis, infraglottic space.

Laryngeal inlet: opening to the larynx; formed by the mucosa-covered epiglottis posteriorly, the superior free edge of the vestibular membranes (i.e., aryepiglottic folds) laterally, and small cartilages located superior to the arytenoid cartilages and within the aryepiglottic folds posteriorly. The portion of the cavity of the larynx above the vocal folds is called the laryngeal vestibule; it is wide and triangular in shape Vestibular fold (a.k.a., false vocal cord/fold): formed by the inferior free edge of the vestibular membrane. Vocal fold (a.k.a., true vocal cord/fold): formed by the vocal ligament of the conus elasticus. Ventricle: deep space intervening between the vestibular fold superiorly and the vocal fold inferiorly. The term "glottis" refers to the paired vocal folds and the space between them. The region of the larynx inferior to the glottis is termed the "infraglottic space".

List the layers of the anterolateral abdominal wall from superficial to deep.

Laterally the abdominal wall consists of three layered muscles (external abdominal oblique, internal abdominal oblique, transversus abdominis). Anterolaterally, roughly in the mid-clavicular line, each abdominal muscle transitions to its flat, tendinous aponeurosis. Anteriorly the aponeuroses of the abdominal muscles form the rectus sheath, within which is the rectus abdominis muscle. In the anterior midline of the abdomen the aponeuroses of abdominal muscles from opposite sides meet and fuse. This site of fusion is the linea alba. skin campers scarpas mucles with deep fascia and endoabdominal fascia

Describe the organization and boundaries of the abdominal cavity and its relationship to the pelvis including key bony features and surface landmarks.

Lateral—> piriformis (sacrum to greater trochanter) and obturator internus (interior of obturator) Pelvic diaphragm—> Coccygeus (on the internal surface of sacrospinous big) + levator ani (from obturator internus muscle fascia internally—> tendinous arch. Perineum membrane—> Triangular sheet from ischiopubic rams to the other one (only urogenital triangle diaphragm to pelvic brim partial peritonem top of bladder and rectum forms the recesses to diaphragm asis and pubic tubericle (inguinal ligament) made from external abdominal oblique pelvic brim seperates abdomin from pelvis.

Specify the muscular components of the walls of the true pelvis and relate these to the pelvic diaphragm.

Levator ani (anteriorly) (iliococcygeus, pubococcygeus and puborectalis) + ischio-coccygeus (posteriorly)—> They all form the pelvic diaphragm Pelvic diaphragm—> Coccygeus (on the internal surface of sacrospinous lig) + levator ani (from obturator internus muscle fascia internally—> tendinous arch) fascia of obturator inturnes conncects to leavator ani makes tendionsu arch coccygeus attached to sacrospinous lig

Specify the regions of the body wall to which visceral pain from the following abdominal organs is typically referred: liver, gallbladder, stomach, pancreas, spleen, small intestine, appendix, kidney.

Liver, gallbladder, stomach, pancreas spleen —> T5-T9/T10 dermatomes small intestine, appendix and kidney —> T10-T12 dermatomes

Describe the primary lymphatic drainage pathways of breast tissue; explain how breast cancer can metastasize to the adjacent breast or intern al organs

Lymphatic drainage of the breast Lymph formed in the nipple, areola, and mammary gland lobes/lobules drains into the subareolar lymphatic plexus which then enters either the Axillary Lymph Node Group OR Parasternal Lymph Nodes. More than 75% of the total lymph (mostly the lateral breast quadrants and axillary tail), drains to the axillary lymph nodes . Less than 25% of the total lymph (mostly from the medial breast quadrants) enters the R/L parasternal lymph nodes adjacent to the R/L internal thoracic vein. Parasternal nodes are found along the internal thoracic artery on the inside of the anterior thorax, lateral to the sternal midline. Subcutaneous nodes (from just deep to the areola)‐ drain minimal lymph usually, however lymph flow may increase dramatically if a tumor blocks the usual axillary pattern. • These vessels have copious anastomoses: (1) can cross midline to lymphatics of other breast (2) may travel superiorly across clavicle to supraclavicular area (3) may travel caudally to abdominal wall (4) can give rise to widespread location of malignancy (other breast, lymph nodes of crossing, opposite axilla.)

Explain the anatomical basis of the following changes in the breast that occur secondary to pathology: Peau d'Orange, skin dimpling, decreased mobility.

Lymphedema‐ Edema from lymphatic blockage causes a leathery, dimpled appearance of the skin, known as orange peel surface (Peau d'orange sign) Cancer invasion of the GLANDULAR tissue and fibrous degeneration (not a degeneration per se; fibrous tissue forms or replaces other tissues) causes shortening, or places traction on the suspensory ligaments. This leads to dimpling of the skin (fingertip size or bigger). If breast mobility is lost, a tumor is suspected to be in the retromammary space, attached to both fascial planes (deep investing fascia and retromammary fascia) to prevent motion.

Explain the significance of the embryonic milk lines to breast cancer development in men and women

Mammary ridges‐ Origins of the glands are down growths of epidermis into the deeper mesenchyme during the 6th week of development. 1. these invaginations are along a thickened mammary ridge (line) ‐‐two lines that exist from axillary to inguinal regions, each lateral to midline. 2. usually these ridges appear in the 4th week but regress by the 6th week except over the pectoral region where the breasts will develop 3. the ridges are known clinically as the "milk lines" 4. occasionally a ridge or some part of a ridge may mistakenly persist. In cases where these persist, a nipple with or without underlying breast tissue can form and be present (and functional) in the adult (supernumerary breast/nipple). In males they may be mistaken for a mole. 5. supernumerary breast tissue, as well as the normal breast tissue, can harbor a malignant tumor.

List the four muscles of mastication; specify their action(s) at the temporomandibular joint and their innervation.

Masseter Elevation of mandible Temporalis some Elevation of mandible retraction of mandible Lateral Pterygoid protrusion of mandible Medial Pterygoid Elevation of mandible, helps protrude mandible Innervation of the muscles of mastication: all four muscles of mastication are innervated by the mandibular nerve (CN V3). All mandibular nerves (CN V3) Masseter—> elevation suprahyoid muscles or gravity—> depression Temporalis—> Anterior=> elevation // posterior=> retraction Medial pterygoid—> elevation Lateral pterygoid—> protraction

List the structures through which urine will travel beginning at the renal papilla and ending at the external urethral orifice.

Minor calyx—> major calyx—>renal pelvis—> ureter—> (through ureteric openings) urinary bladder (internal urethral orifices)—> urethra (pre/pros/mem/spongy)—> external urethral orifice.

1. Relate the following surface features of the breast to the anterior chest wall: nipple, areola, inframammary fold

Nipples • Located at 4th intercostal interspace (between rib 4 and 5) in males and young women. However, this is an unreliable landmark as the female ages and due to variation in breast size. • Anatomy of the nipple is variable and does not represent a pathology unless it is a change from previous • Contained within the T4 dermatome Areola • Small nodular elevations on the surface of the areola represent areolar glands (of Montgomery), which are intermediate in their structure between true mammary glands and sweat glands. folds Represents inferior margin of base of the breast where a significant change in skin curvature occurs‐ generally anterior to rib 6 or 7 the fatty superficial fascia becomes abruptly thinner (like skin over the rest of trunk) and the dermis attaches directly to the membranous superficial fascia inferiorly, forming the inframammary fold. Elsewhere, the transition is gradual and the breast contours smoothly blends into neighboring tissue.

Identify the surface anatomy associated with the T6, T10, and L1 dermatomes.

Note the dermatomes of the xiphoid process (T5/T6), umbilicus (T10), and the inguinal ligament (L1) in this figure as well.

celiac, aorticorenal, superior mesenteric and inferior mesenteric ganglia,

Numerous pre-aortic ganglia exist within the abdominopelvic autonomic plexuses. The larger of these ganglia are clustered around the origins of the major branches of the abdominal aorta and are named accordingly (i.e., celiac, aorticorenal, superior mesenteric, and inferior mesenteric ganglia). The smaller para-aortic ganglia are scattered between the superior and inferior mesenteric ganglia, on the anterior surface of the aorta, or just inferior to the bifurcation of the aorta.

List the three phases of swallowing and describe the major events of each; specify the cranial nerves involved in each of these major events.

Oral Phase: At the end of the oral preparatory stage voluntary movements of the tongue position the food bolus against the forward bulge of the uvula of the soft palate in preparation for swallowing. This phase is approximately one second in duration. hypoglossal Pharyngeal Phase: This short, involuntary phase is triggered by the glossopharyngeal nerve when the food bolus contacts the posterior third of the tongue and the palatoglossal arches. The following events occur simultaneously during the pharyngeal phase: Velopharyngeal closure: The soft palate and uvula elevate, closing off the nasopharynx and preventing nasopharyngeal regurgitation. Pharyngeal peristalsis: Contraction of the pharyngeal musculature assists in velopharyngeal closure (by forming a rigid posterior pharyngeal wall) and propels the bolus through the oropharynx and piriform recesses of the laryngopharynx. Laryngeal closure: Respiration ceases during swallowing and the airway closes to prevent aspiration of the swallowed bolus. Active dilation of the upper esophageal sphincter (located at the boundary between the pharynx and esophagus) allows the bolus to pass from the pharynx into the upper esophagus. Esophageal Phase: In this involuntary phase the bolus is propelled about 25 cm from the upper esophageal sphincter through the thoracic esophagus via peristaltic contractions. The lower esophageal sphincter (at the thoracic diaphragm) relaxes and the bolus moves into the gastric cardia. Esophageal transit varies from 8-20 seconds. Stimulation of the esophageal wall, as by a retained foot bolus, will result in a secondary peristaltic wave. vagus

List the structures derived from the foregut, midgut, and hindgut region of the embryonic gut tube.

Organs derived from the foregut tube include the esophagus, stomach, liver, gallbladder, pancreas, and the proximal duodenum. Organs derived from the midgut include the distal half of the duodenum, the jejunum, ileum, cecum, appendix, ascending colon, and the proximal 2/3 of the transverse colon Hindgut- distal third of the transverse colon and the splenic flexure, the descending colon, sigmoid colon and rectum. distal third of anal canal

Explain the anatomical basis of the varied referred pain patterns of the pancreas.

Pancreatic pain is usually percieved as a severe discomfort in the epigastric region often described by patients as "boring". Due to the deep placement of the pancreas in the abdomen, pancreatic pain will often radiate to the back.

List the three pairs of major salivary glands and the parasympathetic ganglion associated with each; specify the cranial nerve that carries the preganglionic parasympathetic fibers to each of these ganglia.

Parotid glossopharnygeal otic ganglion submandibular chorda tympani submandibular ganglion sublingual chorda tympanu submandibular

Describe the location of the kidneys in relation to the liver, spleen, and the rib cage. hamdi!!

Posteriorly​:​ (ribs and muscles) ● the ​superior​ poles of the kidney and adrenal glands are related to the diaphragm and lower ribs. ● Also related to the psoas major and quadratus lumborum muscle and subcostal, iliohypogastric and ilioinguinal nerves (L1 ventral rami nerves). Anteriorly: (organs) ● Superior Right kidney → liver ● Superior and lateral Left kidney → spleen

Utilizing the concept of the pelvic pain line, specify the dermatomes and regions of the body to which visceral pain from male pelvic viscera, or parts thereof, will be referred.

Principle—> if in contact with parietal peritoneum= T12-L1/L2 // if not S2-S4 Proximal (p)/medial(M) portion of the ureter follow symp pathways retrograde (T12 (P) -L1/L2 (M)) // distal—> para sym (S2-S4) Referred pain from flank —> down abdomen—> perineum, thigh and genitalia. The relationship of the peritoneum to the pelvic organs is of particular significance as it determines the pathway of visceral pain from these organs. In the pelvis, visceral pain sensation from the parts of organs in contact with the peritoneum (i.e., the "pelvic pain line; typically travels retrograde along sympathetic routes to refer pain to the hypogastric region (T12-L1/L2 dermatomes).

3. Describe the relationship of the processus vaginalis and gubernaculum to the development of the inguinal canal and the formation of the deep and superficial inguinal rings.

Processus vaginalis—> attach to the inferior end of the gubernaculum and push it along with tissues of the anterior abdo wall in to the labioscrotal. Therefore it pushes the aponeurosis of the EAO toward the labioscrotal area where it form a circularized rim—> superficial inguinal ring Pushes the transversalis fascia (internal fascia) toward labioscrotal where it form a circularized rim—> deep inguinal ring. Gubernaculum—> ligamentous cord attached superiorly to the inferior pole of developing gonad.

Describe how damage to the pudendal nerve and or prostatic plexus of nerves may affect the penis.

Pudendal nerve—> difficulty ejaculating and controlling urination prostatic plexus—> difficulty with erection

Utilizing the concept of the pelvic pain line, specify the dermatomes and regions of the body to which visceral pain from female pelvic viscera, or parts thereof, will be referred.

Recall the significance of the peritoneum in determining the pathway of visceral pain from pelvic viscera and the regions of the body to which this pain is referred. Visceral pain from those regions of pelvic viscera in contact with the peritoneum travels via sympathetic pathways to the L1-L2/3 region of the spinal cord and is referred to the corresponding dermatomes of the body wall. Visceral pain from those regions of pelvic viscera not in contact with the peritoneum travels via parasympathetic pathways to the S2-S4 spinal cord and is referred to the S2-S4 dermatomes.

Relate the locations of the seminal vesicles, prostate, bulbourethral glands, bladder, urethra and rectum to each other.

Rectum is posterior to all seminal vesicles are posterior to the bladder and all the rest except rectum Prostate is inferior to the bladder and surrounding the prostatic urethra urethra is inferior to all Bulbourethral glands—> inferoposterior to prostate

Specify the anatomical locations where the superior and recurrent laryngeal nerves are susceptible to injury. hamdi!

Right recurrent laryngeal nerve—> thyroidectomy + right side of the neck just superior to the clavicle. Left recurrent laryngeal nerve—> tuck away between the trachea and esophagus superior laryngeal nerve—> swallow fish bone that will get lodged in the piriform recess In its course through the superior larynx the internal branch of the superior laryngeal nerve lies deep to the mucosa of the piriform recess. Sharp objects (e.g., fish or chicken bones) that pass through the piriform recess may pierce the mucous membrane and injure this nerve. damage or injury to the external laryngeal nerve, which can occur during thyroidectomy By virtue of the close anatomical relationship of the right recurrent laryngeal nerve to the inferior thyroid artery, the former is at risk of injury in thyroidectomy. On the left, the recurrence of the recurrent laryngeal nerve in the thorax allows the nerve to reach the relative protection of the tracheoesophageal groove more inferiorly.

. Describe the developmental basis of the lesser sac of the peritoneal cavity, omphalocele, gastroschisis, Meckel's (ileal) diverticulum, volvulus, and pyloric stenosis.

Rotation of the stomach and fusion of the duodenum to the posterior abdominal wall create a small alcove posterior to the stomach and adjacent structures. This alcove is the lesser sac of the peritoneal cavity. The lesser sac enlarges as a result of progressive expansion of the dorsal mesentery (dorsal mesogastrium) connecting the stomach to the posterior body wall. Failure of the intestinal loops to return to the abdomen results in an omphalocele. This large protrusion of the umbilicus consists of intestinal loops covered by amnion. Failure of the opposing sides of the body wall to fuse in the anterior midline can result in a variety of closure defects. Gastroschisis refers to the condition in which abdominal contents herniate through an opening lateral to the umbilicus. Normally, the connection between the ileum and umbilicus (vitelline duct) degenerates during development. In approximately 2% of the population, a remnant of the duct persists, forming an ilieal (Meckel's) diverticulum. The diverticulum may contain gastric or pancreatic tissue. Clinical complications can occur if this tissue secretes hydrochloric acid (ulcer, bleeding, inflammation), if an intestinal loop becomes wrapped around the vitelline ligament (intestinal obstruction) or if a fistula is present (resulting in fecal material passing through the umbilicus). Inflammation of an ilieal diverticulum produces symptoms similar to appendicitis. Abnormally positioned intestinal loops are prone to twisting around their mesenteries (volvulus), which can interrupt blood supply or venous/lymphatic drainage. Pyloric stenosis is the narrowing of the pyloric opening of the stomach that results from hypertrophy of the circular layer of smooth muscle in that region. Infants with this congenital anomaly violently vomit the contents of a meal several hours after eating

List the structures through which ejaculate will travel, beginning in the testis and ending at the external urethral orifice.

Sperm produced in the testis of the scrotum are conveyed to the urethra through the ductus (vas) deferens, which takes a lengthy course from the epididymis in the scrotum through the spermatic cord, through the inguinal canal of the anterior abdominal wall, to the posterior aspect of the urinary bladder. Posterior to the bladder the ductus deferens receives the duct of the nearby seminal gland. At this point the combined seminal duct and the ductus deferens form the ejaculatory duct. The ejaculatory duct passes through the substance of the prostate gland to join the urethra located within it. The male urethra then passes out of the pelvic cavity and through the deep perineal pouch to enter the root or "bulb" of the penis where it receives the duct of the bulbourethral gland. The urethra then continues the full length of the penis to open in the glans of the penis.

Describe the relationship of the superior mesenteric vessels to the pancreas.

Superior mesentery artery and vein pass posteriorly to the neck of the pancreas. The celiac trunk is the artery of the foregut; all of its branches distribute to derivatives of the embryonic foregut in the abdomen. The superior mesenteric artery is the artery of the midgut; all of its branches distribute to derivatives of the embryonic midgut. Within the substance of the pancreas branches of the celiac circulation anastomose with branches of the superior mesenteric circulation.

Explain where excess fluid would pool in a supine position versus the erect position and how this relates to identifying that fluid in radiographic imaging.

Supine—> Hepatorenal recess (morrison's pouch) + splenorenal recess Erect—> Rectouterine (of Douglas)/ Rectovesical pouch (male)

3. Compare the sympathetic and parasympathetic subdivisions of the autonomic nervous system with respect to the anatomical locations of the cell bodies of their preganglionic and postganglionic neurons.

Sympathetic is T1-L2/L3 only for preganglionic. Post is either in para vertebral or sympathetic chain or pre aortic para sympathetic is brain stem orS2-S4 for pre and post is by organs (terminal) cilliary otic submandibular pterygopalatine

5. Specify the spinal cord level of origin of preganglionic sympathetic neuron cell bodies that innervate 1) thoracic viscera, and 2) abdominopelvic viscera.

T1-T5/T6 T5/T6-L2/L3

List the primary functions of the abdominal wall musculature.

The abdominal wall serves several functions. In addition to laterally flexing and rotating the thoracolumbar vertebral column, the abdominal wall supports the abdominal viscera, especially when sitting or standing. The abdominal wall relaxes during inspiration to allow for the expansion of the thoracic cavity, and contracts during forced expiration.

Distinguish the caval venous system from the (hepatic) portal venous system.

The caval system is the systemic venous network that drains into the inferior vena cava. Blood from the lower limbs, pelvic viscera, kidneys, and posterior abdominal wall -in short all blood inferior to the thoracoabdominal diaphragm-will drain into the inferior vena cava, which then drains directly into the right atrium of the heart. Blood from hepatic portal system will eventually enter the caval system after it passes through the liver. Most of the blood entering the liver is venous blood which is carried to the liver by the hepatic portal vein. The hepatic portal vein is formed by the confluence of the splenic vein and the superior mesenteric vein.

1. Describe the surface anatomy of the anterior abdominal wall that relates to the following structures: celiac trunk & celiac plexus; superior, renal arteries, mesenteric artery, inferior mesenteric artery.

The celiac trunk originates from the aorta at the upper border of the LI vertebra. The superior mesenteric artery originates at the lower border of the LI vertebra. The renal arteries originate at approximately the LII vertebra. The inferior mesenteric artery originates at the LIII vertebra. The aorta bifurcates into the right and left common iliac arteries at the level of the LIV vertebra. The left and right common iliac veins join to form the inferior vena cava at the LV vertebral level.

Explain the nervous control of micturition and specify the muscles and somatic nerves involved; distinguish the roles of sympathetic and parasympathetic nerves in this process.

The control of urination (micturition) has both voluntary and involuntary components. Stretch receptors in the bladder wall signal when the bladder is full via visceral afferent fibers. A conscious decision is then made to empty the bladder (if appropriate) and somatic efferent fibers in the pudendal nerve causes relaxation of the external urethral sphincter. Concurrently, parasympathetic fibers from the inferior hypogastric plexus (originating from the pelvic splanchnic nerves) cause the detrusor muscle to contract and the internal urethral sphincter to relax. The role of the sympathetic fibers is not completely clear, but they are thought to have the opposite effect of the parasympathetics (i.e., they relax the detrusor and contract the internal urethral sphincter). There are also visceral afferents carrying pain sensations (from overdistention) traveling with the visceral efferent fibers.

Describe the cremasteric reflex and specify the sensory and motor nerves involved.

The cremaster muscle of the spermatic cord is innervated by the genital branch of the genitofemoral nerve. The cremasteric reflex is the reflexive contraction of the cremaster muscle elicited by stroking the skin of the superomedial aspect of the thigh. The afferent limb of the cremasteric reflex is the ilioinguinal nerve; the efferent limb is the genital branch of the genitofemoral nerve.

Disting uish the pathways of visceral and somatic pain from different regions of the uterus and the birth canal and correlate this variation with the effects of spinal blocks, caudal epidural blocks, and pudendal blocks

The different patterns of visceral pain transmission associated with different regions of the uterus and birth canal provide several options to reduce the pain experienced during childbirth (see Moore Fig. B6.27 online). In a spinal block, c section anesthetic is injected directly into the subarachnoid space at the L3/L4 disc space. Since the anesthetic flows freely within this space this procedure anesthetizes all spinal nerves below the level of T9, resulting in an inability to sense uterine contractions and the temporary loss of motor and sensory functions of the lower limbs. In a caudal epidural block, anesthetic is administered using an in-dwelling catheter into the epidural space of the sacral canal, thus restricting the effect to the sacral spinal nerves. As a result, the entire birth canal, pelvic floor and most of the perineum are anesthetized (the anterior portions of the perineum are innervated by the ilioinguinal and genitofemoral nerves and are therefore unaffected). The mother is, however, aware of her contractions and lower limb function is maintained.

Explain the anatomical basis of biliary occlusion leading to pancreatitis and/or jaundice. HAMDI

The distal end of the hepatopancreatic ampulla is the narrowest part of the biliary passages and is a common site for impaction of gallstones. Impaction at this location, or anywhere along the common bile duct, results in obstruction of bile flow from the liver and obstructive jaundice0billriubn in blood Only pain blocks cystic duck Pancreatis jaundice hepatopancreatic ampulla jaundice common bile duct Pancreases main pancreatic duct

Compare internal and external hemorrhoids in terms of the veins involved; specify the signs & symptoms of hemorrhoids and the risk factors that lead to their development.

The fourth major anastomosis is between the rectal veins. The superior rectal vein drains into the inferior mesenteric vein which is part of the portal system. The inferior rectal veins drain into the systemic venous system. Portal hypertension can contribute to the development of hemorrhoids within these rectal veins. There are two different types of hemorrhoids. Internal hemorrhoids affect the internal rectal veins. Internal hemorrhoids occur when the rectal mucosa, which contains the internal rectal venous plexus veins prolapses into the anal canal. These veins are normally dilated, but they can become even more varicose if portal hypertension occurs. The veins can become strangulated and ulcerated if they are compressed by the sphincter muscles. This can cause bleeding which is typically bright red. However, because the rectal mucosa and the internal rectal venous plexus are located superior to the pectinate line, internal hemorrhoids are not typically painful because they are innervated by visceral nerve fibers. In contrast, external hemorrhoids are caused by blood clots in the external rectal venous plexus veins. This is characterized by swelling, irritation, and pain inferior to the pectinate line of the anal canal. The tissue inferior to the pectinate line receive somatic sensory innervation so external hemorrhoids are quite painful. In addition to portal hypertension, the risk factors for developing hemorrhoids include pregnancy, chronic constipation, straining during defecation, and other types venous return disorders.

List the 3 zones of the prostate gland and indicate which of these are typically involved in benign prostatic hyperplasia vs prostate cancer.

The glandular tissue of the prostate is divided into three zones: The peripheral zone (PZ) contains the majority of prostatic glandular tissue. (prostate cancer.) The central zone (CZ) is the area that surrounds the ejaculatory ducts. The transition zone (TZ) surrounds the urethra as it enters the prostate gland (benign prostatic hyperplasia )

2. Explain the relationship of the external abdominal oblique to the inguinal ligament and specify the ligament's medial and lateral attachments.

The inguinal ligament is the thickened, reinforced inferior free edge of the aponeurosis of the external oblique muscle of the anterior abdominal wall. Laterally the inguinal ligament attaches to the anterior superior iliac spine (ASIS). Medially the fibers of the inguinal ligament attach to the pubic tubercle and to the pectineal line of the pubic bone. Those fibers that attach to the pectineal line are referred to as the lacunar ligament.

1. Describe the location of the inguinal region.

The inguinal region (groin) is the area of junction between the anterior abdominal wall and the anterior thigh. Anatomically it is a region where structures pass to and from the abdominopelvic cavity and lower limb.

Describe the boundaries and contents of the ischioanal fossae and their continuity of the deep perineal pouch.

The ischioanal fossae are filled with fat in vivo. Ischioanal fossa—> space on either side of the anal canal Lateral boundery—> Ischium and obturator internees Medial—>anal canal + external anal sphincter posterior—> sacrotuberous lig + gluteus maximus anterior—> inferior aspect of the pubic bone—> within the deep perineal pouch of urogenital triangle is the anterior recess of the ischioanal fossa

Explain how the fascial layers impact the clinical presentation of urethral ruptures at common locations.

The most common site of urethral rupture of the urethra and extravasation of urine is in the bulb of the penis, most often as a result of a forceful blow to the perineum (i.e., a "straddle" injury). In such cases rupture of both the corpus spongiosum and the spongy urethra results in urine spreading into adjacent, continuous spaces. If the deep fascia of the penis (Buck's fascia) remains intact in these injuries then the extravasated urine will remain confined to the penis. If the trauma also tears Buck's fascia then the extravasated urine can spread into the superficial perineal space defined by Scarpa's, Colles' and the dartos fascias. In these injuries extravasated urine can pass around the penis and into both the urogenital triangle and the loose connective tissues of the scrotum; it can also pass into the inferior aspect of the anterior abdominal wall.

Explain the anatomical basis of the pain and numbness experienced in the lower limb during late pregnancy and childbirth

The obturator nerves and branches of the sacral plexus are susceptible to compression during childbirth. This would result in pain in the lower limbs.

Specify the male homologues of the following female structures: clitoris, vestibular bulbs, greater vestibular glands

The paired (right and left) bulbs of the vestibule (vestibular bulbs)are the developmental homologs of the bulb of the penis and the corpus spongiosum. The greater vestibular glands (Bartholin's glands) are the developmental homologs of the male bulbourethral glands. The clitoris is the homolog of the male penis.

Describe the location and shape of the pelvic diaphragm (the pelvic floor) in relation to the bony pelvis, pelvic cavity, and perineum.

The pelvic cavity ("lesser" or "true" pelvis) is the most inferior portion of the continuous abdominopelvic cavity. The superior boundary of the pelvic cavity is the pelvic inlet/brim. The floor of the pelvic cavity is formed by an incomplete sheet of skeletal muscle known as the pelvic diaphragm. bony pelvis holds pelvic cavity floor of the pelvic cavity is the pelvic diaphragm perienuem is the region of the body wall located betewenn the inferior surfcae of the pelvic diaphragm and the skin b/w yor thighs and butt pelvic dia seperates pelvic cavity and perinuem

Describe the function of the pelvic diaphragm.

The pelvic diaphragm is a fibromuscular, funnel-shaped, sling which forms the pelvic floor. It provides the major support for the pelvic viscera and resists increases in intra-abdominal pressure that occur during forced expiration, coughing, vomiting, sneezing, urinating, defecating and lifting heavy objects which requires trunk fixation. Weaknesses of the pelvic diaphragm can lead to prolapse of pelvic organs and urinary and/or fecal incontinence.

Explain the location and anatomical significance of the perineal membrane.

The perineal membrane divides the urogenital triangle into deep (between the pelvic diaphragm and perineal membrane) and superficial (between the perineal membrane and skin) pouches. The perineal membrane is a thick fascial membrane that attaches to the inferior surfaces of the ischiopubic rami. The perineal membrane has free (unattached) anterior and posterior margins.

Describe the division of the peritoneal cavity into greater and lesser sacs and the locations of the epiploic foramen and the lesser sac.

The peritoneal cavity is divided into two primary regions: the greater sac and the lesser sac. The greater sacis the largest subdivision of the peritoneal cavity and is further divided into the supracolic and infracolic compartments by the transverse colon.The lesser sac(omental bursa) is the smaller subdivision of the peritoneal cavity. The lesser sac is located posterior to the stomach. The greater and lesser sacs are continuous with one another through the epiploic (omental) foramen

Explain how prostatic carcinoma can metastasize to the spine and central nervous system.

The prostatic venous plexus drains to the internal iliac veins and communicates with other nearby venous plexuses. It also communicates with the internal vertebral venous plexus (Batson's plexus) of the spinal canal. Cancers of the prostate may spread to the vertebral column and cranial cavity via this route.

Ex plain the anatomical basis of the groin pain experienced during pregnancy

The round ligament is stretched during pregnancy, resulting in the sensation of a "pulling" in the groin area.

Describe the relationship of the spleen to the rib cage, diaphragm, and left kidney and relate this to splenic rupture.

The spleen is related anteriorly to the stomach, inferiorly to the splenic flexure of the colon (left colic flexure), medially to the left kidney and posteriorly to the diaphragm, which separates it from the costodiaphragmatic recess of the left pleural cavity and ribs 9-11. The spleen is the most frequently injured abdominal organ. Blunt trauma to the left side of the abdomen, or fracture of the adjacent ribs can result in a laceration of the fibrous capsule of the spleen and disruption of its internal soft pulp. Fracture of the ribs adjacent to the spleen can also damage the left kidney.

Explain the significance of supraclavicular lymph nodes (signal lymph nodes) as it pertains to metastasis of abdominopelvic organ carcinomas

The supraclavicular lymph nodes of the deep cervical chain (palpable in the greater supraclavicular fossa of the neck when enlarged) take part in filtering the lymph passing through the thoracic duct. Enlargement of these nodes can therefore be the first sign of cancer that originates deep within the abdomen or pelvis.

Specify the branches of the maxillary and mandibular nerves that innervate the upper and lower dentition.

The teeth in the lower jaw are all innervated by the inferior alveolar nerve (branch of CN V3); the teeth of the upper jaw are innervated by posterior, middle and anterior superior alveolar branches of the infraorbital nerve (branch of CN V2).

Specify where along the esophagus impaction is most likely to occur.

The upper esophageal sphincter has a high resting tone and relaxes during swallowing to allow the bolus to pass into the esophagus. The lower esophageal sphincter is located where the esophagus passes through the thoracic diaphragm. The upper and lower esophageal sphincters represent two of the three natural constrictions of the esophagus where the bolus can be impacted. The third natural constriction of the esophagus occurs where the esophagus is crossed by the aortic arch and the left main bronchus.

Specify and explain the dynamic and passive support m echanisms that maintain the uterus in position in the pelvic cavity.

The uterus is supported in its position in the pelvic cavity through a variety of different mechanisms. Contraction of the pelvic diaphragm provides dynamic support to the uterus, whereas passive support is provided by both the "ligaments" of the endopelvic fascia (some of which contain small amounts of smooth muscle), and its anteverted and anteflexed position on top of the bladder. cardinal lateral uterosacal back

Specify the boundaries of the inguinal triangle and explain its relationship to inguinal hernias.

This triangle is bounded superolaterally by the inferior epigastric vessels, medially by the lateral border of the rectus abdominis muscle and inferolaterally by the inguinal ligament. The inguinal triangle is an area of natural weakness (easily torn) in the anterior abdominal wall through which loops of bowel may herniate. This type of hernia is referred to as a direct (acquired) inguinal hernia. A second type of hernia, an indirect inguinal hernia, occurs when loops of bowel pass into the deep inguinal ring and through the inguinal canal. Indirect hernias are the most common type of abdominal hernias. They are often associated with a persistent and patent processus vaginalis.

Specify the boundaries of the inguinal triangle and explain its relationship to inguinal hernias.

This triangle is bounded superolaterally by the inferior epigastric vessels, medially by the lateral border of the rectus abdominis muscle and inferolaterally by the inguinal ligament. The inguinal triangle is an area of natural weakness (easily torn) in the anterior abdominal wall through which loops of bowel may herniate. This type of hernia is referred to as a direct (acquired) inguinal hernia. A second type of hernia, an indirect inguinal hernia, occurs when loops of bowel pass into the deep inguinal ring and through the inguinal canal. Indirect hernias are the most common type of abdominal hernias. They are often associated with a persistent and patent processus vaginalis.

LOOK AT HAMDIS AND TABLEA FTERRelate the following structures to the pathways of sympathetic and parasympathetic innervation to viscera located in the abdomen and pelvis: thoracic, lumbar and sacral splanchnic nerves, celiac, aorticorenal, superior mesenteric and inferior mesenteric ganglia, celiac, aortic, superior hypogastric and inferior hypogastric plexuses.

Thoracic splanchnic nerves (greater, lesser & least): emerge from sympathetic chain (paravertebral) ganglia associated with the lower thoracic spinal nerves. The fibers within these nerves are involved in the innervation of abdominal viscera. Lumbar splanchnic nerves: emerge from sympathetic chain (paravertebral) ganglia associated with lumbar spinal nerves. The fibers within these nerves are involved in the innervation of abdominal and pelvic viscera. Sacral splanchnic nerves: emerge from sympathetic chain (paravertebral) ganglia associated with sacral spinal nerves. The fibers within these nerves are involved in the innervation of pelvic viscera.

List the three divisions of the trigeminal nerve and specify the functional modalities specific to each.

Trigeminal Nerve. Ophthalmic (CNV1) somatic afferent fibers. the ophthalmic nerve carries sensory information from the eye, the nose and upper face, scalp, ethmoidal, frontal and sphenoidal sinuses and portions of the dura mater in the cranial cavity. Goes through Superior orbital fissure then the supraorbital foramen. Trigeminal Nerve. Maxillary (CN V2) also consists exclusively of somatic afferent fibers; the maxillary nerve carries sensory information from the posteroinferior aspect of the nose, the midface and temple region of the scalp, palate and upper jaw, maxillary dentition, maxillary sinus and portions of the dura mater in the cranial cavity. Goes through infraorbital foramen. After passing through foramen rotundum and the pterygopalatine fossa the nerve gives off several branches Trigeminal Nerve. Mandibular (CN V3) carries sensory information from the lower face, scalp, tongue mucosa (anterior 2/3), mandibular dentition and portions of the dura in the cranial cavity, as well as proprioceptive information about the muscles of mastication and, thereby, jaw position; • carries somatic efferent fibers to a number of muscles including all four muscles of mastication. Goes through foramen ovale than mental foramen. auricotemporal. tensor tympani

. Define intraperitoneal, retroperitoneal, and secondarily retroperitoneal and list the organs that belong in each category.

True retro NEVER invested by a dorsal mesentery during fetal development Only ant. surface partly/completely covered by peritoneum Kidneys adrenal glands Ureters Abdominal aorta Inferior vena cava AKA u werent invested Secondarily Retroperitoneal • Had a mesentery but lost it by end of fetal development Head, neck, and body of pancreas middle of the duodenum Ascending colon Descending colon 2nd place dad Intraperitoneal Organs Project into cavity & almost completely invested by visceral peritoneum Suspended / attached to abdominal wall by mesentery in abdominal cavity Stomach first of duodenum Duodenojejunal junction Jejunum Ileum Cecum Appendix Transverse colon Sigmoid colon Liver Gallbladder Tail of pancreas Spleen

Distinguish the functions of the following nerves in the larynx: superior laryngeal nerve (internal and external branches), & recurrent laryngeal nerve and describe the symptoms secondary to injury of each.

Vagus gives off → superior laryngeal n. → gives off internal and external branches. Internal branch → pierces the thyrohyoid membrane; SENSORY to the larynx above the level of the vocal ligament. → Injury here (fishbone) result in absence of cough reflex. External branch → MOTOR to cricothyroid muscle and UES, can be injured during a thyroidectomy but doesn't affect voice. Recurrent laryngeal nerve → innervates the larynx below the cricoid cartilage and below the vocal ligament. Innervates all the remaining intrinsic laryngeal muscles and mucosa. → Right recurrent laryngeal n. - loops around the R. subclavian so it can be injured in a thyroidectomy. ***injury to a recurrent laryngeal nerve will significantly impact movements of one of the vocal ligaments, resulting in hoarseness voice.

Specify the location of the gut tube pain line and explain its significance with respect to the pathways visceral pain information is projected to the CNS; relate this information to the dermatomes and regions of the body to which visceral pain from hindgut organs can be referred.

Visceral pain sensation from the proximal half of the sigmoid colon travels retrograde along its sympathetic outflow tract and is therefore referred to T12-L2/L3 dermatomes of the body wall along with that of distal third of the transverse colon, and the descending colon. Visceral pain from the distal half of the sigmoid colon, the rectum and the portion of the anal canal derived from the hindgut portion of the embryonic gut tube travels retrograde along parasympathetic outflow paths to these organs. Visceral pain from these organs will therefore be referred to the S2-S4 dermatomes of the body wall.

8. Relate sympathetic and parasympathetic motor pathways to the transmission of visceral sensation to the central nervous system (CNS).

With respect to visceral pain pathways, the general rule is that visceral pain fibers travel along sympathetic pathways to reach the CNS (visceral reflex fibers, on the other hand, travel along parasympathetic routes). A significant exception to this rule concerns the pelvic viscera. Pain from the inferiormost portions of these viscera (portions inferior to the peritoneum) travel retrograde along parasympathetic nerves to reach the CNS (sacral region of the spinal cord).

Using proper a natomical terms describe the typical position of the uterus

Within the pelvic cavity the uterus is typically oriented in an anterverted (tipped anterosuperiorly relative to the axis of the vagina) and anteflexed (bent anteriorly relative to the cervix) disposition such that it rests on the empty urinary bladder

Define the terms anteversion, retroversion, anteflexion, retroflexion in relation to the disposition of the uterus within the pelvic cavity.

anterverted (tipped anterosuperiorly relative to the axis of the vagina the uterus may also be tipped more superiorly or posterosuperiorly relative to the axis of the vagina (retroverted), and/or bent posteriorly relative to the cervix (retroflexed). anteflexed (bent anteriorly relative to the cervix) disposition such that it rests on the empty urinary bladder

List the three pairs of salivary glands; indicate the anatomical location of each and the location in the oral cavity where each drains.

drains?? The submandibular and sublingual salivary glands receive their postganglionic parasympathetic innervation from the submandibular ganglion located between them, in the floor of the mouth. The chorda tympani branch of the facial nerve provides the preganglionic parasympathetic fibers that innervate these glands. submandibular either side of the lingual frenulum along with the major sublingual duct (Bartholin) parotid facial nerve Secretes serous saliva through the parotid duct into the mouth subling in sublingual fold submand either side of the lingual frenulum parotid vestibule of mouth adjacent to second maxillary molar

List the contents of the spermatic cord.

ductus (vas) deferens testicular artery pampiniform plexus of veins (testicular veins) sympathetic and visceral afferent nerve fibers remnants, if any, of the processes vaginalis

List the layers and contents of the spermatic cord.

ductus (vas) deferens testicular artery pampiniform plexus of veins (testicular veins) sympathetic and visceral afferent nerve fibers remnants, if any, of the processes vaginalis Transversalis fascia = internal spermatic fascia Internal oblique muscle = cremaster muscle and cremasteric fascia External oblique aponeurosis = external spermatic fascia

Describe the course of the ductus deferens from the epididymis to the seminal vesicles.

ductus (vas) deferens, which takes a lengthy course from the epididymis in the scrotum through the spermatic cord, through the inguinal canal of the anterior abdominal wall, to the posterior aspect of the urinary bladder. Posterior to the bladder the ductus deferens receives the duct of the nearby seminal gland.

Trace the path of a bolus from the esophagus to the rectum, listing in order all components of the gastrointestinal tract through which it will pass.

esophagus—>lower esphageal sphincter_____> stomach—>pyloric---->duodenum—>jejunum—>ilieum—>ilioceacal junction---->cecum—>Ascending transverse and descending colon—> sigmoid colon—> rectum---->anal canal

List the contents of the inguinal canal in males and females.

female Ilioinguinal n. (L1) Genital branch of genitofemoral n Round ligament of the uterus male Ilioinguinal n. (L1) • Genital branch of genitofemoral n. Spermatic cord -Testicular a. -Pampiniform venous plexus -Lymphatic vessels. -Ductus (Vas) deferen

2. Compare the general functions of the sympathetic and parasympathetic subdivisions of the autonomic nervous system

fight or flight vs rest and digest

Specify the spinal cord segments that supply preganglionic sympathetic fibers to foregut, midgut, and hindgut components of the GI system and relate this to referred pain patterns from these organs.

foregut preganglionic sympathetic neurons are located in the T5-T9/T10 regions of the spinal cord; Midgut: preganglionic sympathetic neurons are located in the T10-T12 regions of the spinal cord; Hindgut: preganglionic sympathetic neurons are located in the T12-L2/L3 regions of the spinal cord;

Describe the clinical significance of the continuation of superficial fascia from the abdomen into the perineum and thigh.

infections that lie within the fascia can spread to other regions dartos perinum then colles urogential males connects with scarpas all contunues with superfical fascia of thigh

Specify the major lymph node regions that can be involved in pathology from internal abdominopelvic organs, the external genitalia, and the gonads with an emphasis on palpable lymph nodes.HAMDIS

lymph from the superolateral aspects of the uterus, specifically the regions near the attachments of the round ligaments, drains along the routes of the round ligaments to the inguinal region and to the superficial inguinal nodes.From here the lymph drains back to the lumbar trunks through lymphatic vessels that accompany the external and common iliac veins. This latter drainage pattern is clinically significant in that enlargement of the superficial inguinal lymph nodes is an indication of a progressed stage of uterine cancer. external genitalia. drains first to lymph nodes located in the inguinal region of the anterior thigh. gonads.Exceptions include lymph from the testis and epididymis, which travels along the course of the testicular arteries to drain directly to lumbar nodes located at the origin of these arteries. from here the lymph from these tissues travels along the course of the external iliac vessels and abdominal aorta to eventually reach the cisterna chyli and thoracic duct. Exceptions include lymph from the testis and epididymis, which travels along the course of the testicular arteries to drain directly to lumbar nodes located at the origin of these arteries. superficial inguinal lymph node—> progressed stage uterine cancer Lumbar trunk—> retroperineal organ (kidney, adrenal gland, ureter), pelvic organs, external genitalia + gonads (testis) and lower limb Intestinal trunk—> Abdominal GI tract + accessory gland The deep inguinal lymph nodes drain the glans clitoris and receive lymph also from superficial nodes. The internal iliac nodes drain the inferior pel- vic structures, deep perineal structures, and sacral nodes. The paraaortic lymph nodes, or lumbar nodes, receive lymph from the common iliac nodes. The drainage of presacral lymph nodes can pass to the common or internal iliac nodes. Axillary nodes drain body wall structures above the T10 dermatome (or the umbilicus).

Describe the functions of the following muscles of facial expression in mastication: orbicularis oris, buccinator.

o Orbicularis oris: the primary sphincter muscle of the mouth and lips; this muscle is important in preventing drooling and maintaining oral competence. o Buccinator: this muscle maintains muscular tension in the cheeks and thereby prevents ingested food items from collecting in the vestibule of the mouth (i.e., the space between the teeth and cheek).

Specify the organs where major anastomoses between the celiac trunk and the superior mesenteric artery occur and where the anastomoses between the superior mesenteric artery and inferior mesenteric artery occur.

pancreas celiac trunk and superior in the region of the distal portion of the transverse colon and splenic flexure. This point of anastomosis between the superior mesenteric and inferior mesenteric arteries forms the marginal artery.

4. Distinguish the anatomical locations of paravertebral and para-aortic (prevertebral) sympathetic ganglia.

paravertebral next to spinal cord pre-aortic on top of abdominal aorta.

List in order from superficial to deep the layers of the body of the penis.

skin-->Dartos fascia (superficial penile fascia)—> buck's fascia (deep penile fascia)—>areolar tissue--> tunica albuginea

1. Specify the three veins that coalesce to form the hepatic portal vein.

splenic vein, superior and inferior mesenteric veins

Explain where excess fluid would pool in a supine position versus the erect position.

supine-heptorenal recess splenorenal erect- rectouterine in female rectovesical in male

Describe the clinical significance of the submental and submandibular lymph nodes and indicate where they can be palpated in the neck.

the submandibular and submental lymph nodes are located anterior to the submandibular gland and inferior to the body of the mandible and chin, respectively (Gilroy Fig. 38.24; see figure to the right). These groups of lymph nodes drain the tongue and lips and are frequently involved in cancers affecting these structures.

Specify the vascular structures, if any, that are at risk when transecting the following ligaments: transverse cervical, suspensory ligament of the ovary, proper ligament of the ovary

transverse cervical- uterine artery lympathatics suspensory ligament- ovarian vessels

7. Specify the locations of the preganglionic parasympathetic neuron cell bodies whose fibers travel in the vagus nerve and in the pelvic splanchnic nerves.

vagus in the brain stem grey matter splanchnic In the sacral region (S2,3,&4) the nuclei are located in the gray matter,

1. List the planes used to divide the abdomen into 4 quadrants and specify the quadrant(s) in which the following are located: liver, gallbladder, stomach, pancreas, appendix, spleen.

vertical median plane and horizontal trans umbilical plane The liver and gallbladder are in the right upper quadrant. the stomach and spleen pancreas Left upper quadrant The cecum and appendix right lower quadrant

Specify the roles of the following structures in swallowing: palatoglossal arch (anterior tonsillar pillar), soft palate, epiglottis, vocal ligaments, piriform recess, upper esophageal sphincter, lower esophageal sphincter.

when food touches palatoglossal arch the pharyngeal phase happens soft palate food is pushed against it in oral phase in the pharyngeal phase it elevates to close of the nasopharynx to prevent nasopharyngeal regurgitation vocal ligaments during closure of the glottis During swallowing the vocal ligaments are tightly adducted to prevent aspiration of the bolus. Movement at the cricoarytenoid joints rotate or glide the arytenoid cartilages on the cricoid cartilage, resulting in either abduction or adduction of the vocal ligaments. piriform recess Pharyngeal peristalsis: Contraction of the pharyngeal musculature assists in velopharyngeal closure (by forming a rigid posterior pharyngeal wall) and propels the bolus through the oropharynx and piriform recesses of the laryngopharynx. upper esophageal sphincter Active dilation of the upper esophageal sphincter (located at the boundary between the pharynx and esophagus) allows the bolus to pass from the pharynx into the upper esophagus. In this involuntary phase the bolus is propelled about 25 cm from the upper esophageal sphincter through the thoracic esophagus via peristaltic contractions. lower espophageal sphincter The lower esophageal sphincter (at the thoracic diaphragm) relaxes and the bolus moves into the gastric cardia.

Describe the relationship of the gallbladder to the rib cage, diaphragm, and liver.

● Located inferiorly to liver ● At the junction of the 9th rib at the semilunar line is gallbladder when standing up. ● Spleen is at 9-11th rib.

Describe the relationship of the liver to the rib cage, diaphragm, and other foregut organs. hamdi

● Superiorly - Bare area (void of visceral peritoneum) has coronary ligaments, in contact with the diaphragm ● Posteriorly - IVC ● Inferior - Right kidney (creates the hepatorenal recess), right adrenal gland, duodenum, right hepatic flexure, gallbladder ● Medially - stomach