Liver: largest gland (4 lobes; 1.5-1.7kg) in R Hypochondriac, Epigastric, and some L Hypochondriac (receives everything absorbed from gut except lipids) - Borders: Superior (ICS 4) and Inferior (711)
- Glisson’s Capsule: thick (thickest @ hilum) protective CT around liver/portal (surrounded by serous visceral peritoneumdynamic); gives off trabeculae lobes/lobules (incomplete in male) - Porta Hepatis: accepts portal triad (HPV, HA, BD) which branches together down to sinusoids
- Lesser Omentum: hepatogastric + hepatoduodenal (Ant. border of Winslow : Portal Triad in R free margin) o Epiploic Foramen (of Winslow): greater <-> lesser sac (bursa);
o Pringle Maneuver: pinch off hepatoduodenal ligament rapidly stems blood loss/bile leakage (may affect hepatocyte metabolism) Aberrant R/L Hepatic Artery: from L Gastric or SMA (does not pass through hepatoduodenal ligament) ineffective Pringle
From L Gastric: careful in stomach cancer resection (liver dysfunction / bleeding) o Posterior Gastic/Duodenal Perforation: compromises bursa structures
- Crush Trauma: fractured ribs or xiphoid perforation
- Falciform Ligament: suspends from ant. wall & diaphtragm (divides left lobe into M/L)
o Round Ligament (of Teres): remnant of L umbilical vein (obliterated fetal liver bypass for 02 bood to IVC as Ductus Venosum posteriorly) Ligamentum Venosum posteriorly o Subphrenic Recess: divided L/R by falciform; continuous w/Morrisson anteriorly
- Bare Area: direct diaphragmatic (capsule but no peritoneum); bound by ant/post coronary ligaments and L/R triangular ligaments (hold liver in place)
o Metastatic Portal: (to thorax) via small lymphatics/veins bronchomediastinal trunk neck root (enlargement of supraclavicular/pre-scalene nodes) - IVC trough (GB ant.): L/R lobes
- Caudate Lobe: (posterior) independent filtration/blood supply; contains both L/R HA and HV and bile to both L/R BD (caution not to tear – bleed out); btw IVC and Lig. Venosum - Quadrate Lobe: (anterior) functionally tied to L lobe; btw GB and Teres / ant. margin and porta hepatis; bile L/R ducts
- Hepatorenal Recess (Pouch of Morrison): most inferior when supine fluid accumulation - Segmentation: based on triad distribution; allows partial resection (down to 1/3 still fxns)
o Hepatic Plexus: largest celiac plexus derivative
- Innervation: via arterial hwy; Vagal and Symp Trunk Celiac Plexus follow celiac branches liver/gullbladder/pancreas
- Central Celiac Nodes (+ proper hepatic/cystic): metastatic traffic indicators (enlargement) btw liver capsule and pancreatic head (virulent) - Portal HTN: cirrhosis/blockage esophageal/rectal (hemorrhoid)/abdominal (caput medusa) varices
o Portal/Caval Graft: (direct s-s / e-e or central splenorenal) temporary life extension for transplant wait questionable bloodrenal filtrates - Hepatitis: inflammation (usually viral)
- Cirrhosis: chronic inflammation (from chronic hepatitis or alcoholism)
- Microanatomy: hepatocytes in hexagon w/central vein that receives percolation from triads in sinusoids (macrophages); bilecanaliculie Gallbladder: bile storage + dehydration↑concentration; neck (2⁰duo)/fundus/body (fossa btw lobes @ TC / sup. Duodenum)
- Bile: alkaline solution of bile salts (from chol)/pigments (bilirubin from heme), cholesterol, neutral fats, phospholipids, and electrolytes - Wall: mucosa / Fibromuscular (enteroendocrine-cholecystokinin responsive smooth + ACT) / perimuscular CT (BV/N/L) / thick CT + serosa - Hepatocystic Triangle (of Calot): contains Mascagni’s Lymph Node (enlarged due to cholecystitis)
o Borders: common hepatic duct (med.), cystic duct (inf.), and cystic artery (sup.) o Caution: may sever structures ( or aberrant R hepatic) bleeding/bile leakage o Aberrance: cystic + ant/post branches may arise from SMA or Left Hepatic - Gallstones: 80% cholesterol / 20% bilirubin (pigments)
o 4Fs: Fat, Female, Fertile, Forty
o Hartman’s Pouch: outpouching @ neck (may block GB); may ulcerate into TC or duodenum (Ileocecal o Cholecystitis: right shoulder referred pain (C5) + upper R quadrant (T5/6 in greater splanchnic) o Palpation: @ right hypochondriac at jxn of linea semilunaris and costal margin
- Innervation: (along arterial hwy) splanchnic (symp) and vagus (para) - Duodenal Relationships: neck (1st), body (2nd), fundus (TC)
o Duct System: hepatic + cystic (spiral)common bile duct >>> + Duct of Wirsung (insulin + amylase)Ampulla of VaterMajor Duodenal Ampulla (@ sphincter of Oddi) o Biliary Blockage: Liver dysfxn, Jaundice (Bilirubenemia), Steatorrhea (no ADEK uptake), Bilirubin Urea (Bilirubinemiakidney filter), and Pruritus (itching)
Pancreas: endo/exocrine; dorsal/ventral developmentallyduodenal rotationmerger; thin CT capsule w/septa (interlobular ducts)lobules - Head/Uncinate: nestled in duodenum curve (↑dual BS); uncinate is behind SMA
- Neck/Body/Tail: fed via anastomosing dorsal and greater pancreatic arteries (from inf. pancreatic via splenic) - Lymphatics: SMN, Cel N, Pyloric Nod Metastatic Variance
- Tumors: @ head HPV + SMA + BD + duod : @ neck SMV/SV jxn to HPV : @ body/tail Splenic Vessels - Splenic Artery/Vein: post/sup spleen; convoluted artery / straight distensible vein (occlusion)
- Hilum: highly vascular (important in splenectomy)
- Annular Pancreas: split ventral bud (head/unc.)wraps/constricts duodenumabsence or obstruction (vomiting) o Polyhydramnios: baby can’t swallow amniotic fluidtoo much amniotic fluid
- Islets of Langerhans: B-insulin, glucagon, somatostatin (more in tail)
- Acinar Cells: enzyme secretion (storage in granules as proenzymes); activation acute pancreatitis - Ducts of Wirsung (mainmaj ampulla – mp of 2nd) + Santorini (accessorymin ampulla – 2cm above) - PP Cells: pancreatic polypeptide
Spleen: r>w; fed by splenic artery (4 branches @ hilum); w/weak capsule (ribperforationsplenectomy) - 1 x 3 x 5 in… 7oz…. ribs 9-11
- Ligaments: (@ pedicle btw spleen and pancreatic tail) must be ligated during splenectomy
o Gastrosplenic: (greater omentum)GC of stomach; contains short gastric and gastroepiploic arteries o Colosplenic:
o Splenorenal: (greater omentum) kidney; splenic vessels o Phrenocolic:
- Splenomegaly: due to lymph diseases (palpable at left hypochondria) - Terminal End Arteries: divide into segments (partial splenectomy)
Kidney: retroperitoneal blood ultrafiltration and metabolic control (12 fetal lobules fuse by adulthood) - L Kidney (ICS 11) [slightly longer/narrower] v. R Kidney (12th rib-L3)
- Cortex: (outer) nephrons [glomerulus, bowman’s capsule, PCT/DCT) renal columns - Medulla: (inner) drainage [henle] renal sinuses (slits)
o Pyramids: 10-18; apexcollecting duct opening - Calyces: minor (8-9)major (3) pelvis (expanded ureter @ hilum) - Sinus: fat-filled concavity at medial hilum border
- Nutcracker: SMA distention L Renal Vein impingement throbbing pain, haematuria (rupture of congested renal veins) , pampiniform varicocoele - SMA Syndrome: impingement of duodenum
- Suprarenal Arteries: inf. (renal), middle (aorta), sup. (inf. phrenic)
- Ureter: ( ID via squeeze contraction) opportunistic blood supply (kidneys, gonadal, aorta, common Iliac, Internal Iliac) o Right: medial to IVC (crosses over R Colic and Ileocolic aa)
o Left: lateral to Aorta (crosses over L Colic and Sigmoid Colon) o 90⁰ Drop: @ linea terminalis bladder
o Trigone: post. entrance to blatter - Surfaces: rests on QL, Psoas, Diaphragm, Trans Colon
- Non-metabolic Fat: capsule / perirenal fat / renal fascia (of Gerota) / pararenal fat o Bulimia/Dietary Disorders: sunken eyes and lower back depressions - Renal Plexus: Aorticorenal ganglia mix of symp/para fibers renal plexus (mostly symp)
- Kidney Stones: crystalized (Ca, oxalate, P03, urea, cysteine) masses irritation, bleeding (haemeturia), and obstruction vomiting/nausea, urinary frequency/urgency, pain o Common Locations: @ Pelvis (kidney-ureter), 90⁰ bend, and Tragone region of bladder
o Hydronephrosis: fluid-filled enlargement of renal pelvis/calyces o Stag Horn: filling pelvis + calyces (requires ultrasound)
- Renal Agenesis: renal bud fails to attach to ureters and develop (bilateral = life threatening)
o Potter’s Sequence: ↓urine oligohydramnios (<400mL) compression (club foot, facial disfigurement) + pulmonary hypoplasia Anhydramniosis: total lack
- Berry Aneurysms: intima breakdown due to polycystic kidney (or liver/pancreas) disease growing thrombosis (usually In circle of willis – ant. comm)berry aneurysm - Cysts: everyone has some; many = pathology (improper DCT collecting tubule linkage)
- Horseshoe Kidney: Kidneys fuse @ sup/inf poleIMA-blocked ascension’pelvic’ kidney Posterior Abdominal Wall:
- Retroperitoneal Viscera: (properitoneal = ant.) btw peritoneum and transveralis, which lines QL and Psoas - Psoas Major: (L1-4) + Iliacus lesser trochanter
o Psoas Abcess: lumbar tuberculosispsoas sheath (abcess)pusinferiorlyLinea terminalis
o Post. Abdominal Pain upon movement: indicates kidney, cecum, ureter, pancreas, or appendix inflammation - Quadratus Lumborum: 12 rib + Lumbar TPs Iliac Crest (lateral spine flexion)
- Lumbar Plexus:
o Subcostal: T12 ant. rami o Obturator: medial thigh adductors
o Femoral: Iliacus + thigh flexors + knee extensors o Lumbosacral: (L4/5)ala + S1-4 = sacral plexus o Iliohypogastric: Ant Rami L1 (post to medial arcuate) o Ilioinguinal: Ant Rami L1 (post to medial arcuate)
o Genitofemoral: (L1/L2) ant. psoas (deep to psoas fascia)divides (lat to common/ex. Iliac aa)femoral / genital branches o Lateral Cutaneous: (L2/3) inferolateral on Iliacusanterolateral thigh
o Lumbar Symp Trunks: receive L1-3 (found in psoas major groove o Gray Rami communicantes: post-gang synapticsant. rami Inguinal Region:
- Gubernaculum: ligamentous structure btw gonad pole and labial/scrotal fold; pulls retroperitoneal developing testes through canal (just round ligament in females) o Ovaries: Pelvis by 3rd month (considered ‘Definite’ @ deep pelvis trailing vessels/nerves)
o Testis:
Processus Vaginalis: peritoneal pouch evaginates into developing scrotum ahead of testes (DIR @ 7mo; canal @8mo; scrotum by birth) Obliteration: @ birthtunica vaginalis (parietal and visceral); if patentcongenital indirect inguinal hernias
Spermatic Cord:
Ext Spermatic Fascia: (from EO fascia) Cremaster: (from IO/fascia)
Int. Spermatic Fascia: (from transversalis) Components:
o Ductus Deferens o Testicular Artery o Artery of Ductus Deferens o Pampiniform Venous Plexus o Autonomic nerves (para/symp) o Lymphatics
o Genital branch of genitofemoral Inguinal Canal: spermatic cord/round ligament + Ilioinguinal
Boundaries: o SIR: ∆ in EO
o DIR: in transversalis fascia (Indirect Hernias) o Ant. Wall: IO (lat) + EO apo (med) o Roof: falx inguinalis (arches of IO) o Floor: Inguinal Lig + Lacunar Lig (med)
o Post. Wall: transveralis (lat) and conjoint tendon (medially) Inguinal Triangle (of Hesselbach): d
Border: DIRECT Inguinal Hernias o Medial: linea semilunaris o Laterally: inf epigastric o Inferiorly: inguinal lig - Femoral Hernia: below I-lig
- Obturator Hernia:
Innervation:
- Intrinsic: CNS visceral aff/eff GI, spleen, pancreas, gallbladder & liver
o Sympathetic Trunks: // cords of pre/post-synaptic symp. + viscera aff in neck (c-sheath), thorax (rib necks/lat. to VB), lumbar (VB ant/lat), pelvic (ant. to sacrum) Paravertebral Symp. Ganglia: raised clumps of soma outside CNS
3 cervical 11-12 thoracic 4 lumbar 4-5 sacral
Ganglion Impar: trunks unite ant. to coccyx
Gray Rami Communicantes: (full length) connect ganglia to spinal nerves White Rami Communicantes: (T1-L2) connect ganglia to spinal nerves o Splanchnic Nerves: (trunk/gangliaprevertebral Plexuses/ganglia)
Preganglionic Symp + VA: Trunk/ganglia ant. aortic plexuses Thoracic Splanchnics:
o Greater Splanchnic: (TG 5-9/10 Celiac Ganglion) o Lesser Splanchnic: (TG 9/10/11 Aorticorenal Ganglion) o Least Splanchnic: (TG 12 Renal Plexus)
Lumbar Splanchnics: (2-4) lumbar plexus
Sacral Splanchnics: Inf. Hypogastric Plexus (extansion into plexus) Preganglionic Para: S2-4 Ant. Rami pelvic prevertebral plexus (Inf. Hypogastric)
Pelvic Splanchnics: Inf. Hypogastric Plexus
o Ascending Fibers: (to abd. Plexus) hindgut o Abdominal Prevertebral Plexuses: surrounds abdominal aorta
Celiac: @ celiac trunk/SMA 2⁰ SM, Renal, other branches of celiac 2 Celiac Ganglia:
SM Ganglion: 2 Aorticorenal Ganglia:
Aortic: (SMA rootAortic bifurcation) 2⁰ IM, Spermatic, Ext. Iliac IM Ganglion:
Sup. Hypogastric: transition to pelvic; several small ganglia
Hypogastric Nerves: pelvis Inf. Hypogastric/Pelvic Plexus Receives:
Vagus: pregang para + VA
Thoracic/Lumbar Splanchnic: pregang symp + VA Pelvic Splanchnic: pregang para
o Parasympathetic:
Ant/Post Vagus: along esophagus/thru diaphragm pregang para + VA abdominal pervert. Plexus foregut + midgut Pelvic Splanchnic: hindgut
- Enteric (Extrinsic): self-sufficient motor/sensory in walls of G gastric secretion, blood flow, and peristalsis o Myenteric Plexus: (btw long/circ)
o Submucosal Plexus: (btw circ/sumbucosa) o Receives: postgagng symp + pregang para - Sympathetic Innervation of the Stomach:
o T6 pregang ant. root spinal nerve white ramus communicante symp trunk greater splanchnic celiac ganglion (SYNAPSE) postgang celiac plexus 2⁰ plex stomach
- Lumbar Plexus: (from ant. rami of T12-L3/4)
Subcostal: (T12) [P] lat. LS arch (arcuate lig) / [A] QL thru TA {IO/EO/TA/RA/pyramidalis}
Iliohypogastric: (L1) lat psoas [A] QL thru TA thru IO {IO/TA} ant. cut. (suprapubic) + lat. cut.(gluteal)
Ilioinguinal: (L1) [A] QL thru {TA/IO} fem. cut. (↑med. thigh) + ant. scrotal/labial (follows spermatic cord/round ligament) Genitofemoral: (L1/2) ant. psoas fem. cut. (fem. ∆) + genital (DIRIcan {cremaster} + scrotum/labium majora
Lat. Fem. Cut: (L2/3) lat. psoas [A] Iliacus /[P] I-lig skin of ant./lat. thigh
Femoral: (L2-4) lat. psoas psoas/Iliacus groove [P] I-lig / [L] fem. V/A fem. ∆ (outside sheath)↑branches: - Ant. Fem. Cut. + Saphenous (medial) + {quads, pectineus, sartorius} + hip/knee joints
Obturator: (L2-4) [M] psoas along lat. pelvic wallthru obturator foramen ant./post. branches{adductors, pectineus} + hip/knee joints + med. thigh Acc. Obturator: (L3/4) (only 9% pop.) [M] psoasover sup. Pubic ramus {pectineus} + hip join
Lumbosacral Trunk: (↓L4 +L5)sacral plexus Autonomic Ganglia:
- Sympathetic Chain (Paravertebral) Ganglia: ascending/descending preganglionic symp. GVE+GVA (soma in DRG)
- Lumbar: (from lumbar symp. Trunks)celiac, mesenteric, aortic, and sup. Hypogastric plexuses (preganglionic symp. GVE + GVA) Autonomic Plexuses:
- Celiac: (splanchnic + vagus) + ganglia (from splanchnic) [A]crura + AA @ CT, SMA, RA trunks o Subsidiary Plexuses: along branches of CTgastric, splenic, hepatic, suprarenal, and renal - Aortic: (from Celiac plexus) [A] aorta; branches along arteries SM, gonadal (T/O), and IM - Sup./Inf. Hypogastric: (from Aortic [A] aorta) just below aortic bifurcation
Enteric Division: pre/postganglionic parasymp., postganglionic symp., GVA, and soma of postganglionic para - Symp. Nerves (inhibit GI motility/secretion + constrict sphincters)
- Para Nerves (stimulate GI motility/secretion + relax sphincters) - Myenteric (Auerbach’s) Plexus: (btw long./circ.)
- Submucosal (Meissner’s) Plexus: (submucosa)
Sacral Plexus: (lumbosacral trunk + VR S1-4) internal surface of piriformis muscle -
Pudendal Nerve: (S2-4) Greater Sciatic Foramen btw piriformis/coccygeusIschial spinelesser Sciatic foramen (w/pud artery)pudendal canal - Inferior Rectal: branchesischiorectal fossa (comm. w/perineal from post. femoral cutaneous) {sphincter ani externus} + anal skin - Perineal: deep branch {perineal muscles} + superficial scrotal/labial branch
- Dorsal Nerve of Penis/Clitoris: thru perineumbtw suspensory ligs (deep to deep fascia)skin, prepuce, glands -
Sympathetic Nervous Supply: - Greater Splanchnic (T5-9) - Lesser Splanchnic (T9-10) - Lowest/Least Splanchnic (T12) - Lumbar Splanchnic (L1-3) - Sacral Splanchnic Parasympathetic Nervous Supply:
- Vagus
- Pelvic Splanchnic (S2-4)
Coeliac Plexus: @ T12-L1 (surrounds Coeliac Trunk and SMA)
- Aorticorenal Plexus: bottom half of Coeliac plexus (partially detached) - Secondary Plexuses:
o Phrenic: accompanies Inf. Phrenic Artery diaphragm + suprarenal gland
o Splenic: coeliac + left coeliac ganglion + right vagus BV + smooth of splenic capsule and trabeculae o LG: lesser curvature of the stomach
o Intermesenteric (abdominal): supplies IVC + testicular plexuses (comm. w/IM and SM) o Suprarenal: medulla of suprarenal gland
o Renal: coeliac + aorticorenal + lowest/least splanchnic + 1st lumbar splanchnic + aortic plexus
Gonadal (ovarian/testicular): follows gonadal artery Ureter: follows ureter
o SM: downward extension of Coeliac along SMApancreas, SI, colon (R 2/3 trans) o IM: from aortic plexus + 2/3 lumbar splanchnics (rest of colon)
o Hepatic Plexus: coeliac + L/R vagus + phrenic follow hepatic artery/portal vein Cystic Plexus: gallbladder
Branches: pylorus, GC, lower bile duct, head of pancreas, ½ duodenum Superior Hypogastric Plexus: (aortic plexus + 3/4 lumbar splanchnic) ant. to aortic bifurcation (L5/sacral promontory)
- L/R hypogastric nerves2 inferior hypogastric plexuses (ant. to sacrum) o Inf. Hypogastric Plexus: (pelvic splanchnic + sacral splanchnic)
Middle Rectal Plexus Vesical Plexus Prostatic Plexus Uterovaginal Plexus Segmental Sympathetic Supplies/Referred Pain
- Esophagus (T5-6): epigastric/retrosternal - Stomach (T6-10):
Pelvic Neurovasculature: retroperitoneal; Lat- N/V/A – Med (lymph // veins) - Arteries True Pelvis:
o Paired Internal Iliac:
Internal Iliac: medially over linea terminalis Anterior Division: along lat. pelvic wall
o Umbilical superior vesicle (superior bladder)
Medial Umbilical Ligament (obliterated artery
o Obturatorobturator canal Pelvic muscles, Ilium, Femoral Head, Medial Thigh Muscles Aberrant Obturator Pubic Branch Inf Epigastric
o Uterine/Ductus Deferens
Ascending (uterine) and Superior Vaginal in Females: runs through roots of broad lig o Vaginal/Inf. Vesicle:
Females: middle/inferior vagina Inf. Vesicle is a branch Males: fundus of bladder
Prostatic branch Prostate + prostatic urethra SeminalSeminal Vesicles
o Middle Rectal: (anastomoses with sup. Rectal) seminal glands and inf rectum
o Inferior Gluteal: exits via infrapiriform part of greater sciatic pelvic diaphragm (coccygeus and levator ani), piriformis, QG, hamstrinkgs, gluteus maximus, sciatic nerve
Ant: anastomoses w/ circumflex femoral
Post: muscle and skin of posterior thigh and buttocks
o Internal Pudendal: Greater Sciatic (exit) Lesser Sciatic (reenter)pudendal canalUrogenital Triangle Perineal Artery
Dorsal Artery of Clitoris or Penis Inferior Rectal
Posterior Division:
o Iliolumbar: Iliac Branch (Iliacus Muscle/Ilium) along anteromedial piriformispelvic sacral foraminapiriformis, erector spinae, overlying skin o Lateral Sacral:
Parietal Branches: (Spinal Meninges, Roots of Sacral Nerves, Erector Spinae, Skin) Visceral Branches:
Superior Rectal Middle Rectaln
o Superior Glueteal: (Largest) supplies gluteal muscles
o Unpaired Median Sacral: (post AA) descends medially over L4/5 and tailbone inf. lumbar vertebrae, sacrum, and coccyx Anastomoses: lateral sacral artery (via medial sacral artery)
o Unpaired Superior Rectal: (from IMA) crosses L common and descends in sigmoid mesocolondivides (to each side of rectum) Internal Anal Sphincter Anastomoses: middle rectal and inferior rectal
o (Females Only) Paired Ovarian Arteries: (from AA) descends in suspensory ligament of oary abdominal/pelvic ureter, ovary, ampulla of uterine tube Anastomoses: uterine arter (via tubal/ovarian branches)
- Testicular Arteries: (lat AA) inguinal canal abdominal ureter, testis, and epididymis o Anastomoses: cremasteric, ductus deferens artery
- External Iliac: deep circumflex artery, femoral artery, inferior epigastric artery
- Pelvic Venous Plexus: drains mainly into Internal Iliac Vein (some to superior rectalportal system) [few drainlateral sacral (to internal vertebral plexus), parietal sacral, ovarian veins) - Lymph Node Groups: Common Iliac Nodes Aortic Nodes
o External Iliac: above linea terminalis along artery (does not // venous) Common Iliac Nodes Inguinal, Sup/Middle Pelvic Viscera
o Internal Iliac: clustered at ant/post divisions and gluteal arteries Common Iliac Nodes Inferior Pelvic Viscera, Deep Perineum, Gluteal
o Sacral: in concavity near medial sacral vessels Common Iliac Nodes Posterio/Inferior Pelvic Viscera
- Nerves: sacral and coccygeal spinal nerves + pelvic ANS
o Obturator: (Ant. Rami L2-4) extraperitoneal fatobturator canal/foramenmid thigh o Lumbosacral Trunk: (L4 + L5 @ brim trunk + lumbosacral plexus @ ala o Sacral Plexus:
Sciatic: (L4-S3) largest in body foot, leg, and post. thigh (flexors)
Pudendal: (S2-4) Main perineal nerve; chief sensory nerve of external genitalia Superior Gluteal: (L4-S1) Gluteus Medius/Minimus
Inferior Gluteal: (L5-S2) Superior gluteal muscle
o Coccygeal Plexus: small network @ S4-S5 coccygeal muscle, part of levator ani, sacrococcygeal joint, skin - Autonomic Nerves:
Urinary Organs:
- Ureters: 25-30cm muscular tubes w/opportunistic BS and VD; (over CIA bif) (obliquely) bladder wall o Lymphatics Common and Internal Iliac Nodes
o Innervation: adjacent autonomic plexuses (opportunistic): inf. hypogastric/pelvic plexus and pelvic splanchnic nerves Afferent Pain Fibers: T11-L1/2 (ureteric calculi)
o BS: renal, gonadal, aorta, common iliac (all abdominal) + internal iliac, superior vesical, uterine, middle rectal, vaginal/inf. vesical (pelvis) o Calculi: renal pelvis, ureteric bend (@LT), bladder tragone
- Urinary Bladder: hollow distensible viscus
o Dynamic: only median and two lateral ligaments @ neck movement Lat: puboprostatic (M) / pubovesical (F)
o Retropubic (Retzius) Space: btw bladder / pubis
o Detrussor Muscle: walls + internal urethral sphincter (contraction during ejaculation) o Trigone: ureteric orifices
o Arterial Supply: Superior / Inferior Vesical, Obturator, Inferior Gluteal Arteries o Innervation:
Somatic: pelvic splanchnic
Symp: Inf. Thoracic + Upper Lumbar Hypogastric Plexus/Nerves Para: Pelvic Splanchnic + inferior hypogastric plexus (detrusor) Sensory: visceral; above pain line
- Urethra: o Male:
Proximal: prostatic branches of inf. vesical / middle rectal prostatic venous plexus [prostatic plexus – symp/para/visceral eff] Intramural: (1cm) vert @ bladder neck within internal urethral sphincter
Prostatic: (3.5cm) through ant. prostate; trough of external urethral sphincter anteriorly (seminal coliculus)
Intermediate (membranous): (1cm) through deep perineal pouch within cicular ext. urethral sphincter (penetrates perineum) Spongy: (15cm) through corpus spongiosum (widens @ bulb and navicular fossa – glans – of penis) – accepts bulbourethral glands @ bulb o Femal: (4cm) poor internal sphincter w/vestibular external sphincter (ant to vagina)
Paraurethral (Skene’s) Glands: (prostate equivalent) Vestibular (Bartholin) Glands: in perineum BS: internal pudendal / vaginal arteries (VD = same) Innervation: pudendal nerve + vesicle nerve plexus Rectum:
- Peritoneal Covering: ant / lat of sup 1/3 AND ant of middle 1/3 - Rectovesical Pouch (M)
- Vesicouterine Pouch + Rectovesical Pouch (F)
- BS: sup. Rectal / middle rectal (↓2/3) / inf. rectal (anorectal jxn and anal canal) - VD: sup Rectal (portal) + mid/inf.
- Portal / Caval: Internal Rectal “anal” venous plexus (deep to anorectal jxn mucosa) + External Rectal “anal” Venous Plexus (ext to muscular rectal wall) - Innervation:
o Symp: lumbar hypogastric/pelvic plexus + IMA/SMA plexuses o Para: pelvic splanchnic + L/R hypogastric plexuses
o Visceral Aff: below pain line (para fibers to S2-4)
Testes: (germinal cells and testosterone) surrounded by tunica albuginea and cupped ant. by tunica vaginalis - Tubules: SeminiferousStraightRete TestisEfferent Ductules
- BS: testicular artery (anast w/ductus deferens) - VD: pampiniform testicular vein
- Lymph: right/left aortic + preaortic nodes - Nerves: testicular plexus (vagal para/VA) + T7 (symp)
Epidydimis: long convoluted on post. testis that transports sperm (headbodytail Vas Def)
Vas Deferens: (main part of spermatic cord) thick muscular walls w/narrow lumen seminal ducts (forms ejaculatory ducts) - BS: superior vesicle
- VD: pampiniform - LD: external Iliac
- Vasectomy: cut and separated (highly regenerated)
Seminal Glands: elongated (rectovesical pouch & peritoneum superiorly, oblique over prostate) alkaline w/fructose + anticoag ductus deferens (forms ejaculatory duct) - AS: inf. vesical + middle rectal
- VD: inf. vesical + middle rectal - LD: External Iliac (sup) + Internal Iliac (inf)
- Palpation: rectal exam massage detects gonococci infection Ejaculatory Ducts: @ bladder neckprostatic urethra
- AS: sup. Vesical
- VD: prostatic/vesical plexus - LD: external Iliac
Prostate: largest accessory (2/3 glandular, 1/3 fibromuscular) in FECT w/dense neurovascular all in visceral prostatic sheath (cont with puboprostatic ligs) - Ducts: milky/thinsinuses 20% semen
- Lobules/Zones: Peripheral, Central, Transitional, Periurethral - AS: Internal Iliac (Inf Vesical, Int Pudendal, Middle Rectal) - VD: prostate and vesical plexuses and internal Iliac vein - LD: internal iliac and sacral nodes
- Ducts: cross perineum w/spongy urethra (penis) mucus secretion during arousal Ovaries: (~testis) produce ova
- Suspensory (Infundibulopelvic) Ligament of Ovary: direct uterus
- Broad Ligament of Uterus: Mesosalpinx (@ uterine tube), Mesovarium (mesosalpinxovary), and Mesometrium (ovaryuterus) - Uterine Tubes (10cm) conduct oocytes + fert. ; in mesosalpinx of broad ligament
o Infundibulum: fimbriae o Ampulla
o Isthmus
o Cornua (uterine part) - BS: ovarian
- VD: pampiniform plexus, uterine plexus/vein, ovarian vein - LD: lumbar preaortic nodes
- Innervation:
o Ovarian Plexus
o Uterine Plexus: visceral afferent (symp), Lumbar splanchnic (T11-S2), visceral afferent (para S2-4) Uterus: thick, dynamic walls; usually anteverted/anteflexed and resting on bladder (full bladderstraight uterus)
- Body: w/fundus - Isthmus: @ uterine tube - Cervix: supravaginal and vaginal
- Layers: perimetrium, myometrium, endometrium - Ligaments:
o Ovarian Gubernaculums: ovarian and round ligaments o Broad Ligament
o Suspensory Ligament - Principal Support:
o Pelvic Diaphragm: levator ani + coccygeus
Active: sitting, standing, sneezing, or coughin o Ligaments: pubocervical, cardinal, uterosacral
o Pouches: vesicouterine, rectouterine - BS: uterine + ovarian
- VD: uterine plexus + internal Iliac veins - Uterine Triad???
Vagina: distensible musculomembranous tube vestibule btw labia minora (copulation/birth/menstruation); ant. to rectum/post to bladder - Fornices:
- Sphincters: pubovaginalis, external urethral, urethrovaginal, bulbospongiosus - BS: vaginal branch of uterine, vaginal, internal pudendal
- VD: vaginal, vesical, and rectal plexuses + Internal Iliac Innervation of Uterus and Vagina:
- Somatic: (lower vagina) pudendal nerve
- Visceral: (upper vagina + uterus): uterovaginal plexus (symp, para, visceral aff) Male External Reproductive Organs:
- Urogenital Triangle: ant. perineal triangle (pubic sypmh ischia tuberosities) - External Genitalia:
o Scrotum:
Pigmented Skin
Dartos Fascia: covers dartos muscle (T control) *continuous w/scarpa’s + colle’s+ – from labioscrotal folds BS: post. scrotal (from int. pudendal), ant. scrotal (deep ext. pudendal), and cremasteric (inf. epigastric) VD: same
LD: superficial inguinal Nerves:
Genital (of genitofemoral) Ant. Scrotal (ilioinguinal) Post. Scrotal (pudendal) Perineal
Post. Cutaneous of Thigh o Distal Urethra:
BS: dorsal artery of penis (from internal pudendal) VD: same
LD: Intermediate Internal Iliac Spongy Deep Inguinal Innervation:
Prostatic Plexus: symp/para/VA Dorsal nerve branch of pudendal: somatic o Penis: male copulation (root / body / glands)
Three Cylindrical Bodies
Corpus Cavernosa (2): surrounded by tunica albuginea Spongy Corpus: around urethra
Foreskin: frenulum (circumcision) Buck’s Fascia
BV
Lymph nodes Glands: corona and neck
Erectile Muscles: ischiovacernosus (in crus – restricts venous flow – maintain erection) + bulbospongiosus (in bulb – support/enlargement/turgidity) + sup. Transverse perineum (same as bulbospongiosus)
- Anal Canal:
o External and Internal Anal Sphincter: inf. rectal nerve (from pudendal) - Spermatic Cord: DIRICSIRpost. testes
o Deferent Duct o Testicular Artery
o Deferent Duct Artery (from sup. Vesical) o Cremasteric Artery (inf epigastric) o Pampiniform Plexus
o Sympathetic Fibers
o Genital Branch of Genitofemoral Nerve o Lymphatics
o Vaginal Process Remnants (~ round lig) -
