Anatomy FNM

Epiploic foramen

entrance to the lesser sac

The FLOOR of the inguinal canal is the....

floor = the horizontal surface of the LACUNAR ligament

Epididymis: - an extremely long thin duct wound into a head, body and tail portion, which becomes continuous with ..(a)...... @ the inferior pole of the testis posteriorly *what is the final destination of the vas deferens? What is the head of the epididymis attached to/formed from? What forms the "sinus of the epididymis"?

(a) joins onto the VAS DEFERENS, which then runs up the spermatic cord *and finally to the PROSTATE gland The head is formed from the efferent ductules that pass from the lobules of the seminiferous tubules of the testis to the upper pole of the testis on its posterior surface. Sinus of the epididymis: formed by the tunica vaginalis pressing btwn the epididymis & the testis on the lateral side

Kidneys The hilum of the kidney lies roughly in the..... plane? One kidney is a bit above this level and one is below - which? What lies behind the kidneys? T/F : Anteriorly, the R kidney is directly related to: - the 1st part of the duodenum - the gall bladder - splenic flexure of the colon - liver T/F : The L kidney is directly related to: - the body of the pancreas - splenic flexure of the colon - spleen - stomach - small intestine

- Transpyloric - L slightly above, R slightly below Behind: psoas, quadratus lumborum, transverse abdominis + lower edge of diaphragm, pleura, costodia-recess Corrected version: Anteriorly, the R kidney is related to: - the 2ND part of the duodenum - the gall bladder - HEPATIC flexure of the colon - small intestine (through peritoneum) - liver (through peritoneum) *only top 3 are directly related through renal fascia L kidney: Yes all of these, but only body of pancreas & splenic flexure by renal fascia. Rest are through periotoneal coverings.

Describe the path of the subcostal nerve Arises from? Passes beneath what ligament? What muscle does it pierce? Where does it become cutaneous?

- arises behind the diaphragm just below the 12th rib - passes beneath the lateral arcuate ligament onto the anterior surface of the QL - lies behind the kidney - pierces the TA muscle - travels round the neurovascular plane to enter the rectus sheath! - becomes cutaneous just above the pubic symphisis

On the lateral side of the ascending colon is the right paracolic gutter - what does it run from & to?

- it runs from the pelvic brim to the hepato-renal pouch

Pancreas - is retroperitoneal apart from its... - which parts lie in the curvature of the duodenum? - what important structures lie behind the head & neck? - what is the "uncinate process" of the pancreas? - the tail lies behind the leaves of which ligament? -which mesentery is in front of the pancreas? 3 sources of blood to the pancreas?

- tail - head & neck lie in curvature of duodenum - behind head & neck: IVC, aorta, common bile duct, portal vein, SMA - "uncinate process" = small part of the pancreas that hooks behind the SMA - lienorenal ligament - transverse mesocolon is in front of the pancreas Blood supply: 1. inferior pancreaticoduodenal 2. superior pancreaticodudoneal 3. splenic artery (runs along the upper border of the pancreas towards the spleen)

Name retroperitoneal structures in the abdomen

-duodenum (except 1st 5 cm and the 4th part) -ascending & descending colon -middle 1/3 of the rectum -pancreas (except tail) -kidneys -adrenal glands -proximal ureters -renal vessels SAD PUCKER Mnemonic S: suprarenal (adrenal) gland A: aorta/IVC D: duodenum (second and third part) P: pancreas (except tail) U: ureters C: colon (ascending and descending) K: kidneys E: (o)esophagus R: rectum (lower 1/3)

What is a femoral hernia? *More common in females than males - why?

. The femoral canal is a space beside the femoral artery and vein as they enter the leg. *Because the female pelvis is wider than that of the male, the femoral canal is larger. A loop of gut or fat can be pushed into the top of the leg if the abdomen is under pressure.

The gall bladder The gall bladder lies directly against the liver in the ..... Where is the gall bladder's fundus? The body of the gall bladder lies against the .....colon & the .....part of the duodenum What are found in the free margin of the lesser omentum? The common bile duct passes behind the 1st part of the duodenum & into the head of the pancreas. What is the name of the place where the cbd joins with the pancreatic duct? & then they both enter the duodenum at the.... What sphincter controls bile entry at this papilla?

...cystic fossa The gall bladder's fundus lies @ the margin of the liver opposite the tip of the 9th costal cartilage. The body of the gall bladder lies against the TRANSVERSE colon & the 1ST part of the duodenum In free margin of lesser omentum: 1. cystic duct (joins with common hepatic to become the common bile duct) 2. portal vein 3. hepatic artery Hepatopancreatic ampulla. Duodenal papilla. Sphincter of Oddi

Where the sigmoid colon loses its mesentery, it becomes the... What parts of the colon are retroperitoneal?

...rectum Retroperitoneal: descending & ascending colon

Two subphrenic pockets/spaces lie between the ... and ... on either side of the falciform ligament. In a patient w/ intraabdominal sepsis, what can collect here? Knowing that the right kidney lies behind the liver, what is another pouch where pus may collect in a supine patient?

..btwn the diaphragm & liver Pus can collect in the subphrenic spaces. Hepatorenal/subhepatic space

ABCD of 4 parts of duodenum Duodenum can perforate, but the consequences are different depending on whether the duodenum perforates anteriorly or posteriorly?

1. A= acid 2. B= bile 3. C= crossed by SMA 4. D= duodeno-jejunal junction Anteriorly: free fluid & air in the abdomen --> forms duodenal ulcer Posteriorly: gastroduodenal artery runs behind 1st part of duodenum so ulcer can erode into artery! causes massive bleeding! Need urgent endoscopy

3 layers of fascia around spermatic cord What are they derived from? What does the genitofemoral nerve supply?

1. External spermatic fascia derived from...external oblique 2. Cremasteric fascia derived from...internal oblique 3. Internal spermatic fascia derived from...trasnverse abdominis Genitofemoral nerve: motor supply for the CREMASTER muscle

Quadratus Lumborum 1. Where is it located? (which muscles is it lateral to and in front of?) 2. Where does it arise from? 3. Where is it insterted on to? 4. What movement does it assist? 5. Where does it get its nerve supply from?

1. Just lateral to the psoas muscle, in front of the erector spinae muscles. 2. Arises from the 12th rib & the upper transverse processes of the upper 3 lumbar vertebrae 3. The iliac crest & transverse process of L5 4. Allows LATERAL FLEXion of the lumbar spine (side bend) 5. Lumbar nerves L1 to L4

3 main branches of the IMA (L3)?

1. L Colic a. 2. Sigmoid a. 3. Superior rectal a.

What are the 3 branches of the coeliac trunk? What are the 3 branches of the common hepatic?

1. L gastric 2. Splenic 3. Common hepatic Common hepatic branches into: 1. Proper hepatic (goes on to R+L hepatic + cystic) 2. Gastroduodenal 3. R gastric

Inguinal canal is an opening for the spermatic cord = the life support system for the testes Name 5 components of the spermatic cord Why are the testes kept outside the abdominal cavity? What also contributes to this? The Ilioinguinal nerve is also in the spermatic cord. T/F?

1. Nerves - sympathetics, genitofemoral (genital branch innervates the cremaster muscle - testes rise when thigh is stroked, as well as the dartos muscle - temperature regulation of scrotum ) 2. Arteries (3) - testicular artery, cremasteric artery, artery of ductus deferens 3. Pampiniform plexus of veins 4. Vas deferens 5. Lymphatics The testes like to be cool, so are kept outside the abdominal cavity. Cool venous blood (pampiniform plexus) also cools the arterial blood down on its way to the testes! - keep optimum temp for spermatogenesis. FALSE. Ilioinguinal nerve is in the inguinal canal but is not part of the spermatic cord

1. At the level of the ribcage, which muscle runs in front of the rectus abdominis? 2. What about just above the umbilicus? 3. Below the umbilicus?

1. ONLY the external oblique (nothing else) 2. EO in front IO in front & behind TA behind 3. All three aponeuroses lie in front of the rectus. Behind the rectus there is only the transversalis fascia.

Rectus abdominis 1 .Where does it arise from? and insert? 2. What are the 3 lines on each side? 3. RA flexes or rotates the trunk? 4. Where is the arcuate line? 5. Above the arcuate line, which important vessels are found behind the rectus abdominus? 6. Below the arcuate line, what is the only thing behind the RA?

1. Originates from the PUBIS (between the pubic tubercle and symphysis) and inserts at the 5th to 7th costal cartilage and the xiphoid process of the sternum 2. 3 tendinous intersections. These are attached to the rectus sheath. 3. FLEXOR of the trunk 4. Arcuate: 1/2 way between umbilicus & pubis 5. behind RA: INFERIOR EPIGASTRIC vessels! (also some internal oblique muscle layer & transverse abdominis muscle! EO is only in front of the RA) 6. Below arcuate: only transversalis FASCIA! Aponeuoroses of EO, IO & TA is in front

Which 2 important arteries does the rectus sheath contain? What are these 2 branches off of ? These 2 arteries anastomose within the rectus sheath. Branches from this anastomosis (+from lower intercostal arteries + lumbar branches of the abdominal aorta) supply what?

1. Superior epigastric - terminal branch of internal thoracic artery 2. Inferior epigastric - branch of external iliac artery? Supply the anterior & lateral abdominal wall

Which 2 important arteries does the "rectus sheath" contain? 1. SE - 1 of the terminal branches of what artery? 2. IE Where do they anastomose?

1. Superior epigastric artery - 1 of the terminal branches of the internal thoracic artery (as well as the musculophrenic artery) 2. Inferior epigastric artery They run towards each other & then anastomose w/in the rectus sheath. It's branches off this anastomosis which supply the anterior & lateral abdominal wall

Name the 2 arteries which supply the duodenum. (Hint: combo of foregut/midgut supply) Where do they come from?

1. Superior pancreaticoduodenal artery --- from the coeliac trunk --- the gastroduodenal branch of the common hepatic artery divides into the R gastroepiploic artery & the superior pancreaticoduodenal artery 2. Inferior pancreaticoduodenal artery --- direct branch of the SMA

The rectus sheath (enclosing the rectus abdominus muscle) 1. Is formed by the aponeuroses of which 3 anterior abdominal wall muscles? 2. What is the "linea alba" ? 3. "Linea semilunaris" ? 4. How come the rectus sheath is easy to see in lean patients? 5. At the midpoint between the umbilicus & the pubic symphysis, what do all the aponeuroses now do? 6. Why is the linea alba significant in emergency surgery?

1. Transverse abdominis, external oblique, internal oblique 2. "Linea alba" = where the fibres of these 3 aponeuroses meet. They form a fibrous band in the midline. 3. They also all fuse at the lateral border of the rectus sheath along this line. 4. It fuses with the tendinous intersections on its anterior surface. 5. Now all the fibres pass in FRONT of the rectus abdominis muscle. This happens at the "arcuate line" 6. Linea alba has no nerves or blood vessels so it's an easy place to make an emergency opening into the abdominal cavity?

1. SMA branch middle colic artery - what does it supply? 2. What is the marginal artery formed by? 3. Where does the L colic artery come from? 4. What does the IMA become, after it has given off the sigmoid artery? 5. Where does the appendicular artery come from?

1. Transverse colon 2. Anastomoses from the colic arteries 3. IMA 4. IMA becomes the "superior rectal artery" 5. It's a terminal branch of the ileocolic artery (ileocolic comes from SMA)

Erector Spinae Muscles 1. Are the main (?) of the rectus abdominis muscles 2. Extensor of flexor muscles? 3. Describe where they lie 4. What are they enclosed in/covered in? 5. Which muscle lies in FRONT of the erector spinae muscles and their fascia?

1. agonist 2. extensor 3. between the spinous & transvere processes of the vertebrae in the back (each one lies lateral to the midline of the lumbar vertebrae, like 2 columns) 4. Thoracolumbar fascia 5. Quadratus lumborum

Which rib and 3 important nerves pass over the kidneys ?

12th rib (+costodia recess + pleura) 1. subcostal 2.iliohypogastric 3.ilioinguinal

Duodenum 1st part: Where does the 1st part of the duodenum lie? What is attached to its upper surface? Think of the duodenum like a horse-shoe. What is tucked into the curvature? 2nd part: (descending) What does it cross over? What is in front of it? What enters the duodenal lumen here? 3rd part: Lies just above the level...? Which important vessels lie behind it? + what is behind them? What vessels lie in FRONT of the 3rd part of the duo? 4th part: What is the "suspensory ligament of the duodenum" / "ligament of Treitz?" What are the superior & inferior duodenal fossae?

1st part: L1. Is also continuous w the stomach at the pylorus. - Lesser omentum = attached to its upper surface (remember the rest of the duodenum, besides this part, is retroperitoneal) Head of pancreas = tucked into the curvature. 2nd part: -crosses R kidney - transverse mesocolon in front -combined pancreatic & biliary duct enters here @ the duodenal papilla 3rd part: -L3 - just above the level of the umbilicus - behind it: IVC, aorta, R gonadal vein + artery (behind them is the R ureter lying on the R psoas muscle) - in front: SMA/SMV 4th part: - suspended here from the vertebral bodies by the "suspensory ligament/of Treitz" - fossae = fold of peritoneum around the 4th part of the duodenum that form pouches as it reenters the peritoneal cavity (*note you can get an internal hernia if small bowel gets trapped in one of these pouches)

What are the crura? What does the R crus curl around? What does it contribute to here? Which ligament binds the 2 crura together? Where?

2 muscle slips that rise up into the diaphragm from the vertebral bodies (L1, L2 on left & L2,L3 on right)? R crus rises up into the diaphragm and curls around the OESOPHAGEAL opening at the level of T10. - contributes to the sphincteric action of the oesophagus! MEDIAN ARCUATE LIGAMENT binds the 2 crura together @T12 (in front of aortic opening) (it's that blue loop around the aorta where the 2 crura meet)

SMA gives off 3 branches that go up & 3 branches that go down Name them

3 branches go up: -inferior pancreaticoduodenal a. -jejunal a. -ileal a. 3 branches go down: -middle colic a. -r colic a. -ileocolic a.

The abdominal aorta gives of (1,2,3,4,5,6,?) pairs of lumbar arteries that immediately run behind which muscles? These quickly gain entry to the neurovascular plane between the ...(2 muscles)? What do these lumber arteries supply? Which artery kind of represents the 5th pair of lumbar arteries fused together? What do the lumbar VEINS drain into?

4 pairs - behind psoas & quadratus lumborum Neurobascular plane btwn TA & IO Supply the muscles & skin of the abdominal wall in exactly the same way as the intercostal arteries do MEDIAN SACRAL ARTERY - 1 long line going down from bifurcation @L5. Supplies muscles on posterior pelvic wall. Lumbar VEINS drain into the abdominal parts of the azygos & hemiazygos veins, AKA the "ascending lumbar veins" in the abdomen

A. What are the 2 terminal branches of the internal thoracic artery? B. Which artery hooks under the ductus deferens before turning upwards towards the rectus sheath? (clue: it is a branch of the external iliac artery)

A. 1. Superior epigastric artery (passes through rectus sheath) 2. Musculophrenic artery B. Inferior epigastric

A. What is the processus vaginalis? What are some problems that can result when the processus vaginalis fails to close? B. What is the name of the double-layered serous lined sac that covers the testis to allow frictionless movement of the testis within the scrotum? C. What are 2 layers deep to the tunica vaginalis? The testis is intraperitoneal. T/F?

A. Processus vaginalis = outpouch of the peritoneum, that closes once the testes has travelled down to the scrotum "hydrocele" - peritoneal fluid travels down "haematocele" - ^ blood accumulates "indirect inguinal hernia" "testicular torsion" - testicles free to twist due to lack of attachment to inner lining B. Tunica vaginalis - allows frictionless movement of testis within scrotum *N.B you can also get hydrocele in the tunica vaginalis (not just in the processus vaginalis) - see pic C. Tunica vaginalis -> tunica albuginea (the actual fibrous covering of the testis)-> tunica vasculosa False. Testis = retroperitoneal

Anterior abdominal wall: VENOUS DRAINAGE Superficial veins ABOVE the umbilicus drain to.... whereas superficial veins BELOW the umbilicus drain to.. *What can a "caput Medusae" around the umbilicus indicate? **Why do these veins get distended?

ABOVE the umbilicus: drain to internal thoracic vein -> subclavian veins -> SVC BELOW the umbilicus: femoral veins --> IVC *"Caput Medusae" - distended veins due to liver disease look like the head of Medusa. **Liver disease can cause obstruction of the portal vein, so epigastric veins (the alternative route to the SVC) become distended!

Which lymph nodes drain the thoracic wall (above the umbilical layer)? vs. the abdomen (below the umbilicus?

Above umb: AXILLARY nodes (armpit) Below umb (abdomen): INGUINAL nodes

What do the lateral & medial arcuate ligaments (2 fibrous arches that span across the psoas & quadratus lumborum) allow for? These 2 ligaments r acc part of the .....margin of the diaphragm

Allow the psoas & quadratus lumborum muscles to move independently from the diaphragm! (Diaphragm muscle fibres run over their anterior surface as far down as L1 and L2) Posterior inferior margin

Spleen is always behind which line? Its anterior border has...

Always behind the mid-axillary line Anterior border has notches in it

Inguinal canal - what forms each of these structures? a.) anterior wall b.) posterior wall c.) roof

Anterior wall: aponeouroses of EO & IO Roof: IO, TA & conjoint tendon Posterior wall: Transversakus FASCIA & conjoint tendon

Aponeurosis

Aponeurosis Versus Tendon Although the term 'aponeurosis' sounds like the name for a psychological disorder peculiar to apes, it is actually a type connective tissue. Connective tissues support the body and help it move. Aponeuroses are important for human movement and posture and are found all over your body, from the tip of your head to the soles of your feet. What, exactly, is an aponeurosis? An aponeurosis is a type of connective tissue that provides a point for a muscle to attach to a bone or cartilage. You may be thinking that a tendon also attaches muscle to bone, and you are correct. So, how is an aponeurosis different than a tendon? An aponeurosis looks quite different than a tendon. If you placed them next to each other, you would have no trouble telling them apart. An aponeurosis is made of layers of delicate, thin sheaths. Tendons, in contrast, are tough and rope-like. An aponeurosis is made primarily of bundles of collagen fibers (collagen is the primary component of your body's connective tissues) distributed in regular parallel patterns, which makes an aponeurosis resilient. Aponeuroses, also called aponeurotica, function differently than tendons. When a muscle moves by flexing or extending, an aponeurosis acts like a spring to bear the extra pressure and tension. A tendon, on the other hand, moves a bone when a muscle contracts. Tendons allow the body to move and be flexible while aponeuroses allow the body to be strong and stable. Aponeuroses can act as fascia. Fascia is a fibrous tissue that envelopes muscles or organs, to bind muscles together or to other tissues.

The lowermost fibres of both the IO & the TA arch over ...(what structure?)

Arch over the SPERMATIC CORD before they pass down into the pubic crest to fuse to form the conjoint tendon

What is the coronary ligament? The ...... of the liver becomes the coronary ligament.

Attaches the liver to the diaphragm. The BARE AREA of the liver becomes the coronary ligament. The edges of the c.l. are the triangular ligaments

The aortic hiatus in the diaphragm (T12) lies behind what?

Behind the MEDIAN ARCUATE LIGAMENT that connects the 2 CRURA

The intercostal nerves run between the internal & innermost intercostal muscles. What muscles do the lower six intercostal nerves (T7-L1) which supply the anterior abdominal wall lie between? However, some of the lower nerves can't get in between these 2 muscles at first so they travel.... These intercostal nerves all reach the midline (top ones running up towards the xiphoid cartilage T7, bottom ones running down towards the umbilicus T10) except...

Between IO & TA ....around the abdominal wall, cross linea semilunaris & enter rectus sheath & finally become cutaneous here L1 just fails to reach the midline!

Hepato-renal pouch

Between R lobe of the liver & R kidney - place where pus, abcess or fluid from infection in peritoneal cavity would accumulate in a supine a patient Where would infection (or other fluids) accumulate? e.g. ascites

Where is the transpyloric plane located?

Bottom of L1 vertebrae. 1/2 way btwn the xiphisternal joint & the umbilicus! (also 1/2 way between suprasternal joint & pubic symphysis) Separates hypochondriac and lumbar regions of stomach, as well as epigastric and umbilical

Which 2 derivatives of the foregut begin to develop in the dorsal mesentery? vs. in the ventral mesentery? The dorsal mesentery that passes from the greater curvature of the stomach below the gastrosplenic ligament to the posterior abdominal wall is known as the greater omentum. T/F?

Dorsal: spleen & dorsal bud of the pancreas Ventral: liver & ventral bud of pancreas False...passes from the greater curvature of the stomach ABOVE the gastrosplenic ligament

Meckel's diverticulum

Embryonic remnant 2% of people 2 feet from I/C junction 2 inches long 2 types of epithelium (gastric is significant)

Which muscle is a principal agonist of the rectus abdomonis muscle & is a powerful EXTENSOR of the trunk? What processes in your lumbar vertebrae do they lie between?

Erector spinae Lie between transverse and spinous processes

Renal veins lie behind the renal arteries as they run into the IVC. T/F?

False. Renal veins run in FRONT of the renal arteries. - cos IVC pierces the diaphragm anterior to the aorta VAU

Lymphatics from the scrotum and testis drain to the inguinal nodes. T/F?

False. Yes, lymph from the scrotum drains to the inguinal nodes, but lymph from the TESTIS drains through the spermatic cord to the PARA-AORTIC lymph nodes

The liver: T/F a. lies beneath the dome of the diaphragm on the right as well as under the central tendinous portion of the diaphragm beneath the interior surface of the part b. a functional division of the liver into r+l lobes can be defined by the falciform ligament c. the ligamentum venousum is a remnant of the l umbilical vein, and the ligamentum teres is the obliterated remnant of the ductus venosus d. the lesser omentum merges w/ the visceral peritoneum of the liver in the floor of the fissure formed by these two ligaments (the ligamentum teres & ligamentum venosum) e. the visceral peritoneum of the liver that formed from the 2 layers of the ventral mesentery completely encapsulates the liver What part of the liver does the coronary ligament enclose? (on the r side) Name 3 things the bare area is in direct contact with.

False: b. a functional division of the liver into r+l lobes can be defined by a LINE drawn btwn the FOSSA for the GALL BLADDER in front to the FOSSA w/ the IVC in it behind c. swap them around. Teres=L.umbilical vein e. it does NOT completely encapsulate the liver Coronary lig encloses the BARE AREA Bare area is in direct contact with (posteriorly): 1. diaphragm 2. IVC 3. suprarenal gland

Name 2 nerves who are formed from fibres whose segmental origin is L2 to L4. What is the difference? Which nerve travels lateral to the internal iliac arteries and ureter, and leaves the pelvis through the obturator foramen?

Femoral & obturator nerves! Femoral: forms from DORSAL divisions Obturator: ANTERIOR divisions (of the ventral rami of these nerve segments) Obturator nerve

What passes through the gap beneath the free lower border of the inguinal ligament and the rim of the bony pelvis below it?

Femoral nerve, artery & vein (NAV) in that order top to bottom. Also ilipsoas muscle!

Linea alba

Fibrous band which separates either side of the rectus sheath

Where does the rectus abdominis attach from?

From the costal margin all the way down to the pubic crest

Gastric arteries supply lesser curvature. Gastroepiploic arteries supply the greater curvature. Where do the L+R of each of these come from?

Gastric arteries: L comes off coeliac trunk R comes off hepatic a. Gastroepiploic arteries: L comes off splenic a. R comes off gastroduodenal a.

Tell me about the dual (arterial) blood supply of the pancreas

Head & neck: - coeliac trunk through superior pancreaticoduodenal artery - SMA through inferior pancreaticoduodenal artery Body & tail: splenic artery

Internal oblique origin & insertion? Tranverse abdominis? What is found on the surface of the transverse abdominis?

IO origin: thoracolumbar fascia, iliac crest & lateral 2/3 of inguinal ligament, inner margin of lower ribs IO insertion: ribs 10-12, xiphoid process, linea alba TA origin: also thoracolumbar fascia, anterior iliac crest, lateral 1/3 of inguinal ligament, inner margin of lower ribs, TA insertion: xiphoid process, and by linea alba to conjoint tendon The intercostal nerves - the ventral rami of T7-T12 (supply all the muscles of the abdominal wall) It is important to know the neurovascular plane if you are going to cut the abdominal wall! You don't want to damage these nerves and paralyse the muscles!

Stomach What is the incisura angularis in the stomach? What thickens the pyloric sphincter & what does this do? Is the cardiac sphincter the same? The stomach is free to move around and expand as far as the greater & lesser omenta will allow, but at which 2 points is the stomach fixed? What does the cardiac sphincter do & where is it? What lies in front of the stomach (3)? And what lies behind it in the stomach bed (6)? SHORT GASTRIC arteries run up the greater curvature of the stomach to the fundus. What artery do these arise from? All gastric veins, as well as veins from the distal portion of the oesophagus drain to the portal vein. Thus, any venous obstruction in the portal vein or liver may result in..... Lymph: chains of lymph nodes lie along the arteries of the stomach & are named after them (e.g. coeliac trunk group, splenic group, left gastric group etc). All of these groups eventually drain into ....

Incisura angularis: groove/notch in the lesser curvature where the body meets the antrum Pyloric sphincter = thickened by circular smooth muscle which controls the flow of the stomach contents into the duodenum No - cardiac sphinct has no circ smooth muscle Fixed @ pyloric & cardiac sphincter Cardiac sphincter (L of 6th costal cartilage @ midline) prevents regurgitation of food back up the oesophagus (remember the right crus also assists w this) Anterior relations: liver, diaphragm, anterior abdominal wall Posterior relations: L crus of diaphragm, pancreas, L kidney, suprarenal gland, transverse colon, spleen Short gastric arteries come from the SPLENIC artery Oesophageal varices (+poss bleeding into the lower oesophagus) Lymph: eventually drain into the THORACIC DUCT via the COELIAC GROUP of nodes. (coeliac froup -> paraaortic nodes -> cysterna chyli -> thoracic duct)

The inferior vena cava - which are incorrect? a.) After passing through the diaphragm at T8, passes through the liver & emerges to the R of the abdominal aorta with the R crus lying between the 2. b.) The IVC then stays on the L side of the vertebral bodies of the lumbar vertebrae, on the L of the aorta as it descends through the abdomen c.) At its bifurcation, the IVC passes behind the R gonadal artery. d.) From here on, the L & R common iliac veins travel on the inferomedial surfaces of the corresponding common iliac arteries. e.) All blood from the gut returns to the heart via the IVC f.) Because the IVC lies to the right of the abdo, certain veins that "should" drain into it on the left empty into the left gonadal vein instead. Which has more branches/tributaries - the IVC or the aorta? What are the tributaries of the IVC?

Incorrect: b.) stays on the RIGHT side of the v bodies, on the RIGHT of the aorta c.) behind the R COMMON ILIAC artery e.) portal vein -> liver f.) empty into the left RENAL vein N.B.Even the median sacral vein drains into the left common iliac vein & not into the bifurcation of the IVC, because it lies too far over to the right! The aorta -- -^see above how a lot from the L of the abdo acc drains into the left renal vein Tributaries of the IVC: - 2/3 hepatic veins (drain into IVC from liver) - R/L renal veins but ONLY: - R inferior phrenic - R suprarenal - R gonadal (left supr + gonadal obvs go into the left renal vein, but for some reason the left inf phrenic drains into the left suprarenal)

Indirect vs direct inguinal hernia? Which is more common in people with weakened abdominal walls? Which is more common in people with a patent processus vaginalis? *Finding the pubic tubercle & the position of the inferior epigastric artery helps diagnose which type of hernia it is! How?

Indirect: hernia follows the path of the the inguinal canal into the superficial ring - more common in young boys & occurs if the processus vaginalis remains connected to the peritoneal cavity (patent pv = extension of peritoneum into inguinal canal). Loops of gut may enter the scrotal sac. Direct: Passes directly through abdominal wall (posterior wall of inguinal canal = conjoint tendon) into SUPERFICIAL RING (doesn't go along the inguinal canal!) - common in obesity & old age when too much pressure is exerted on the abdomen & the muscle walls (conjoint tendon) are weakened *Direct: hernia passes MEDIAL to the inferior epigastric artery Indirect: hernia passes LATERAL to the inferior epigastric artery

The inguinal ligament is also the INFERIOR MARGIN of which muscle's aponeurosis? The inguinal ligament runs from and to which structures?

Inferior margin of the EXTERNAL Oblique aponeurosis From the anterior superior iliac spine to the pubic tubercles

In the same way the intercostal nerves run between the innermost and intenal incercostal muscles, what do the anterior abdominal nerves run between? L1 - the lowest nerve to supply anterior abdominal wall muscles -- runs down towards the legs but just fails to reach...

Internal oblique & transversus abdominis fails to reach the midline

Where does blood from the superior epigastric artery originally come from? Where does the inferior epigastric artery's blood come from?

Internal thoracic artery The external iliac artery

What does the L gastric vein drain? What drains the middle of the oesophagus? If the blood in the HPV can't pass through the liver and get to the IVC and hence back to the heart, what happens?

L gastric vein - drains stomach & lower oesophagus c.f. L gastric artery supplies the lower part of the oesophagus. The azygos vein --> SVC (by arching over the root of the right lung) "Porto-caval anastomoses" Portal hypertension causes blood to go back down L. gastric vein into oesophagus & to SVC via the azygos vein. (Blood flows through oesophagus through an enlarged L. gastric vein) Oesophagus gets enlarged + may cough up blood.

Stomach has a vagal nerve on either side (L+R) - then in embryo stomach twists to the right. So L side becomes anterior side & R side becomes posterior side. Which side of the stomach do the L+R vagus nerves supply in the adult then?

L vagus nerve supplies anterior aspect of stomach R vagus nerve supplies posterior aspect of stomach

Where is the supracristal line & what happens here?

L4 Bifurcation of aorta Umbilicus "Cauda equina" = safe for lumbar puncture Superior aspect of iliac crest

Transtubercular plane - where?

L5 - crosses iliac tubercules

Genitofemoral nerve - made up of which nerve fibres? vs. lateral cutaneous femoral nerve? Where does the genitofemoral nerve divide into 2, and what does each branch supply?

Nerve fibres from L1-L2 Lat cutaneous: L2-L3 Genitofemoral branches at the inguinal ligament -> femoral branch passes under the inguinal ligament to supply skin on the front of the thigh -> genital branch passes into DEEP INGUINAL ring to supply the cremaster muscle *lateral cut fem art supplies skin of lateral aspect of the thigh (shock)

What does the lesser omentum lie between? How does the greater omentum communicate with the lesser omentum? What do you find in this space? Lesser sac is AKA? The space between the posterior abdominal wall & the posterior surface of the stomach is called the....

Liver <- lesser omentum -> lesser curvature of stomach Via the epiploic foramen - portal triad runs through the epiploic foramen LARD (artery on left, bile duct on right) Lesser sac = omental bursa That's the lesser sac!

Medial arcuate ligament Lateral arcuate ligament Which lumbar vertebra is the R crus is attached to? And which/how many is the L crus attached to? Which crus encircles the oesophagus?

Medial arcuate: thickening of psoas fascia Lateral arcuate: thickening of quadratus lumborum fascia The R crus is attached to the upper 3 lumbar vertebral bodies; Vs. the L crus to the upper 2, (both are attached to the invertebral discs) The R crus encircles the oesophagus

Medial umbilical ligament Lateral umbilical ligament What are they remnants of?

Medial umbilical ligament: obliterated umbilical artery Lateral umbilical ligament: inferior epigastric artery

What organ lies between the coeliac trunk & SMA? And which arteries branch off just below the SMA?

Pancreas Renal arteries branch off just below SMA.

Psoas muscle 1. Arises from? 2. It enters the thigh under which ligament? Iliacus muscle 1. Arises from and where do its fibres go? 2. Where does this combine muscle go? Iliopsoas 1. Both psoas & iliacus are powerful flexors/extensors of the thigh? 2. Where do they get their nerve supply from?

Psoas 1. lumbar intervertebral discs & vertebral bodies 2. Inguinal ligament Iliac 1. Iliac blade and its fibres pass downwards & medially to meet the psoas fibres + there is a groove @ this junction. 2. Combined "iliopsoas muscle" enters the thigh under the inguinal ligament & converges to a tendon which meets the lesser trochanter of the femur. Iliopsoas 1. Flexors 2. L2-L3

Iliacus can only flex the hip, but psoas can also flex what else?? Nerve supply of psoas & iliacus? Where is the lumbar flexus?

Psoas can also flex the trunk. (Iliacus & psoas flex the hip together) The lumbar plexus is INSIDE the psoas. Psoas is innervated by branches from the lumbar plexus. Iliacus is also supplied by direct branches from the lumbar plexus & also the FEMORAL nerve

Lobe between gall bladder & falciform ligament? Liver is covered by visceral peritoneum everywhere but the... Which lobe is bigger? Where is the dividing line between the distrib of the L & R branches of the hepatic arteries? Liver goes below the level of the costal margin on the right & extends as high up as the ....th intercostal space

Quadrate lobe ..bare area Right = bigger (informal division is by the falciform ligament) More over to the right. (sometimes the R hepatic artery arises from SMA or the L hepatic artery arises from the L gastric artery) 5th intercostal space

Pubic crest - which muscle attaches onto the pubic crest?

Rectus abdominis

Below arcuate line of rectus sheath? *Where is the neurovascular plane? What travels through it?

Rectus sheath • EO forms anterior layers, IO splits, Trans abdominis forms posterior layers • Below arcuate line: all muscle layers go to front! Now back is only covered by Transversalis fascia! *Neurovascular plane: between IO & transversalis - intercostal nerves travel here

List the layers of the anterior abdominal wall from outside to inside in order What does the transversalis fascia split into when it reaches the kidneys? What 2 more layers surround the kidneys within the fascia?

Skin Superficial fascia (fatty and membranous) Muscles - external oblique, internal oblique, transversus abdominus + rectus abdominus Transversalis fascia Extraperitoneal fat Parietal PERITONEUM TF splits into 2 layers of renal fascia which surround the kidneys RF-> perirenal fat -> renal capsule -> kidney

Spleen Where does the spleen lie? (on what organ & on the long axis of which rib?) When the spleen is enlarged, at the edges of which ribs can you feel it? The spleen has a Y-shaped central region. Which 3 organs lie in each region?

Spleen lies posterolaterally on the diaphragm in the long axis of the 10th rib (on L) Enlarged: palpate at 9th, 10th & 11th rib edges on inspiration Y-shaped centre: top = in contact with stomach, kidneys lie on it posteriorly, an splenic flexure of the colon lies on its anterior surface

Venous Drainage of the Anterior Abdominal Wall The superficial veins ABOVE the umbilicus drain to.... Vs. the superficial veins BELOW the umbilicus drain to... Distension of the epigastric veins around the umbilicus can occur due to ?? AKA?

Superficial veins ABOVE umbilicus: internal thoracic vein --> subclavain veins -> SVC Superficial veins BELOW umbilicus: femoral veins -> IVC Caput medusae: obstruction of the PORTAL vein (liver disease) leads to distension of epigastric veins around the umbilicus as these offer an alternative route to the SVC!

Nerve supply to the stomach Where is its sympathetic nerve supply from? Where do these sympa fibres synapse? And para? The L vagus contributes to the plexus on the anterior side of the oesophagus in its lower third., whereas the right contributes to the plexus on its posterior surface. T/F? These para oesophageal plexuses then REFORM where/as what?

Sympathetic: thoracic SPLANCHNIC nerves (T5-T9) . Fibres synapse @ coeliac ganglia near coeliac trunk. Para: from the VAGAL trunks that innervate the stomach True. Reform as ANTERIOR & POSTERIOR GASTRIC NERVES as they enter the abdomen (then go through fundus, body and pylorus of stomach obvs)

Conjoint tendon - is a fusion of.... - inserts behind the.... What does it protect from/why is it so important? *Which structures of the inguinal canal does it help form? What does the conjoint tendon attach to?

The conjoint tendon is a fusion of the IO & TA aponeurosis - lies behind the superficial ring Conjoint tendon protects the abdomen by stopping things from popping out of the superficial inguinal ring! *Helps form roof & posterior wall of inguinal canal The 2 aponeurotic sheets which form the conjoint tendon attach to the pubic CREST medial to the pubic tubercle

What is the lower free border of the EO aponeurosis? (where the EO comes to an end) What is the origin of the EO? Inserts into what?

The inguinal ligament (extends between ASIS & pubic tubercle) Originates from the lower 8th ribs (5-12) Inserts into iliac crest, linea alba & obvs its lower free border forms the inguinal canal

Why are the ureters so long? The ureters run down on the surface of what muscle? They look as if they're running down across the tips of the... Name 3 sources of blood supply to the ureters as they travel down? The ureters are an important posterior relation of the (g) and the (d) on the right Where do kidney stones often lodge in the ureters? (think about some major vessels the ureters run across) The ureter opens out into the kidney to become the.... This structure bifurcates or trifurcates to form the... How many renal pyramids are in the medulla of the kidney and what do their apices (papillae) point towards?

The kidneys developed in the pelvis & then rose up to L1,2,3 bringing the ureters with them. Psoas. ...lumbar transverse processes - then across the bifurcation of the common iliac arteries Blood supply: renal arteries, aorta, common iliac arteries (g) = gonadal vessels (d) = duodenum Kidney stones often lodge where the ureters run across the common iliac vessels becomes the RENAL PELVIS = (along w the other vessels and fat - renal sinus) Major CALYCES ---> minor calyces 5-10 renal pyramids in the medulla whose papillae point towards the minor calcyes

Lesser sac What lies in front of it? What is the name of the entrance into the lesser sac?

The stomach Entrance: epiploic foramen

What is the blood supply of the rectus sheath? Motor supply - what enables it to form its flexion motion?

The superior & inferior epigastric arteries Ventral rami of segmental spinal nerves provide the motor supply

What happens @ L1? it's 1/2 way between what?

The transpyloric plane 1/2 way between jugular notch & pubic symphisis - neck of pancreas - portal vein behind pancreas - end of spinal cord - 9th costal cartilage - transverse mesocolon splits - spleen on L of pancreas, 1st part of duodenum on R

Which nerves mix within the psoas muscle? So it makes sense that each of the nerves that run acorss the posterior abdominal wall first emerge from... - name 5 of these nerves, in order

The ventral rami of L1 to L4 take part in the lumbar plexus here! Party in the psoas #let'sgetlitty emerge from the psoas muscle! - subcostal nerve - ilihypogastric nerve - ilioinguinal nerve - lateral femoral cutaneous nerve - femoral nerve *the 2 femoral nerves pass under the inguinal canal *the ilioinguinal nerve goes through the inguinal canal

What can IVC obstruction lead to?

To avoid the obstructed IVC, blood uses anastomoses between the FEMORAL vein & AXILLARY vein

Which fascia lines the abdominal wall? And what layer is deep to that fascia?

Transversalis fascia (beneath all the muscles E.O, I.O, T.A and R.A) Beneath that is the peritoneum

The suprarenal glands are also covered in renal fascia. T/F? Name the 3 arteries that supply the suprarenal glands + what arteries do they come from? Suprarenal glands are endocrine glands & endocrine glands need a good blood supply! How many suprarenal veins are there, and what do they drain into?

True. 1.Superior suprarenal artery (branch of inferior phrenic) 2. Middle suprarenal (directly off abdo aorta) 3. Inferior suprarenal (branch of renal artery) Only 1 suprarenal vein on each side. L: drains into renal vein R: drains into IVC

When the upper surface of the lacunar ligament lies horizontally, it acts as a ..... to support.... The lacunar ligament is formed by fibres of the inguinal ligament sweeping backwards & horizontally towards the ...... line As it travels along this line, the lacunar ligament continues as another ligament - the ..... ligament

Upper surface of LL acts as a FLOOR to support the SPERMATIC CORD as it passes out into the scrotum. - sweeping towards the PECTINEAL line continues as the PECTINEAL ligament

What could you happen if you damage the nerve supply to your patients' anterior abdominal wall muscles? *which nerves lie behind the RA and innervate the abdominal wall muscles?

Weakness in the abdominal wall muscles: epigastric hernia! *inferior epigastric nerves

3 dermatomes need to know: Xiphoid process Umbilicus Inguinal ligament

Xiphoid process T7 Umbilicus T10 (but L4 verteb) Inguinal ligament L1 e.g. 10th spinal nerve supplies the umbilicus

a. What does the female inguinal canal contain? b. What does the round ligament of the uterus end in? What is it a remnant of? c. What are the muscle layers of the inguinal canal?

a. - round ligament of the uterus (precursor: gubernaculum), - lymphatics and nerves. - smaller than the male inguinal canal due to absence of spermatic cord b. The labia majora (equivalent to the scrotal sac of the male) - remnant of the fetal umilical vein *The gubernaculum degenerates in men, but in women it extends down to the labia majora c. It has the same coverings as in the male - external covering from external oblique aponeurosis, cremasteric layer from internal oblique muscle and internal fascia from the transversalis fascia

a.What are the main trunk and collateral branch of the 1st lumbar ventral ramus? b. How is the path of the iliohypogastric nerve similar to the subcostal nerve? But what additional muscles does the iliohypogastric nerve pierce? + what does it acc innervate? (hint: NOT the rectus abdomonis muscle) c. Likewise, the ilioinguinal also follows this path - running behind the kidney after running on the anterior surface of the QL - but it cannot get into the neurovascular plane until when? ILIOINGUINAL What does it supply? Where does it become cutaneous? What is it sensory to?

a. Main trunk: iliohypogastric nerve Collateral branch: ilioinguinal nerve b. ILIOHYPOGASTRIC Like the subcostal nerve, the iliohypogastric also passes onto the anterior surface of the QL, then pierces the TA to continue into the neurovascular plane! But the iliohypogastric also pierces the IO and EO aponeurosis, before it finally supplies the skin superior to the pubic symphysis! c. ILIOINGUINAL Cannot get into the neurovascular plane until it reaches the TA muscle @ the ASIS! *also pierces the IO & EO aponeur btw (like iliohypo) Supplies: TA & IO muscle fibres Becomes cutaneous once it leaves the superficial ring to pierce the external spermatic fascia Sensory to: - the root of the penis - anterior skin of the scrotum - inner thigh

List the nerve supply for a.) Rectus Abdominis b.) EO c.) IO d.) TA Which muscles arise from the thoracolumbar fascia?

a.) RA: T7-T11 b.) EO: T7-L1 c.) IO: T7-L1 d.) TA: T6-L1

Portal vein is the only in the world that goes from a capillary to .... Where does the portal vein form?

another capillary! (transmits nutrients from bowel to liver) Normally vein goes from capillary to heart. The portal vein forms behind the NECK of the PANCREAS, where the splenic vein joins the SMV (Remember this is L1, the transpyloric plane) *In pic, splenic v is in blue. IMV is joining it on right and then SMV is joining it to left & then it curves up to become the portal vein

The innominate bone is the 'hip bone'. It is formed by the fusion of the ....(3)

pubic bone, illium and ischium.