Sobotta atlas of human anatomy vol 2

A t l a s of H u m a n A n a t o m y Internal Organs

v T 'v V \i

15th Edition Edited try F Paulsen and J Waschko English Version with Latin Nomenclature

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G eneral Anatom y

and

M u s c o lo s k e le ta l S y s te m

The fo llo w in g contents can be found in the other tw o volumes: 1 G e n e ra l A n a t o m y O rie n ta tio n on th e B o d y -► S u rfa ce A n a to m y -► D e v e lo p m e n t -► M u s k u lo s k e le ta l S yste m -»Vessels a nd N e rves -► Im a g in g T e c h n iq u e s -► In te g u m e n ta ry S ystem

2 T ru n k S u rfa ce A n a to m y -► D e v e lo p m e n t -► S k e le to n -► Im a g in g Vessels and N e rves -► T o p o g ra p h y , Back -> F em ale B reast A b d o m e n and A b d o m in a l W all

M u s c le s -♦ T o p o g ra p h y ,

3 U p p e r E x t r e m it y S u rfa ce A n a to m y -► D e v e lo p m e n t -► S k e le to n -► Im a g in g -► M uscles T o p o g ra p h y -> S e ctio n s

Vol. 1

4 L o w e r E x t r e m it y S u rfa ce A n a to m y -► S ke le to n -> Im a g in g -► M u s c le s -► T o p o g ra p h y S e ctio n s

8 Head O v e rv ie w -* S ke le to n and J o in ts -*■ M u s c le s -► T o p o g ra p h y -► Vessels and N e rves -► N ose M o u th and O ral C a v ity S a liv a ry G la nd s

9 Eye

Vol. 3

Head, Neck, and

N euroanatom y

D e v e lo p m e n t -► S ke le to n -► E ye lid s -► L a c rim a l A p p a ra tu s -► M u scle s o f th e Eye -► T o p o g ra p h y -► E yeball -► V isu a l P a th w a y

10 Ear O v e rv ie w -► O u te r Ear -► M id d le Ear -► A u d ito r y Tube -► In n e r Ear H e a rin g and E q u ilib riu m

11 N eck M u scle s -► P h a ryn x -► L a ry n x -► T h y ro id G la nd -► T o p o g ra p h y

12 B ra in a n d S p in a l C o rd G e ne ra l -► M e n in g e s and B lo o d S u p p ly -» B rain -► S e c tio n s C ra nia l N e rve s S p in a l C ord

Paulsen, Waschke

Sobotta Atlas of Human Anatom y Latin Nomenclature Internal Organs

Translated by T. Klonisch and S. Hombach-Klonisch

Sobotta Atlas of Human Anatomy

Internal Organs

15th edition Edited by F. Paulsen and J. Waschke Translated by T. Klonisch and S. Hombach-Klonisch, Winnipeg, Canada 363 Coloured Plates with 441 Figures

U R B A N & FISCHER M Ăźnchen

Editors

Prof. Dr. Friedrich Paulsen

Prof. Dr. Jens Waschke

D issecting Courses fo r S tudents

M ore Clinical Relevance in Teaching

In his teaching, Friedrich Paulsen puts great emphasis on the fact that students can actually dissect on cadavers o f body donors. "The hands-on experience in dissection is extrem ely im portant not only for the three-dimensional understanding o f anatomy and as the basis for virtually every medical profession, but for many students also clearly addresses the issue o f death and dying for the first time. The members o f the dissection team not only study anatomy but also learn to deal with this special issue. A t no other time medical students w ill have such a close contact to their classmates and teachers again." "The dissection links in the atlas lead to online images that are relevant for the dissection. You can print them and take them along. The offered dissection tips are not instructions, but make sure that you are oriented exceptionally well and not 'cutting in the dark'."

From March 2011 on, Professor Jens Waschke is Chairman of Department I at the Institute o f Anatomy and Cell Biology at the Ludwig-Maximilians-Universitat (LMU) Munich. " For me, teaching at the department o f vegetative anatomy, which is responsible for the dissection courses o f both Munich's large universities LMU andTU, emphasizes the importance o f teaching anatomy with clear clinical relevance", says Jens Waschke. "The clinical aspects in the Atlas introduce students to anatomy in the first semesters. A t the same time, it indicates the importance o f this subject for future clinical practice, as understanding human anatomy means more than ju st memorization o f structures."

P ro fe s s o r F rie d rich P au lse n (b orn 1 9 6 5 in Kiel) p a sse d th e 'A b itu r ' in B ru n s w ic k a nd tra in e d s u c c e s s fu lly as a n u rse . A fte r s tu d y in g hum a n m e d ic in e in Kiel, he b e c a m e s c ie n tific a s s o c ia te a t th e In s titu te o f A n a to m y , D e p a rtm e n t o f O ral a nd M a x illo fa c ia l S u rg e ry a nd th e D e p a rtm e n t o f O to la ry n g o lo g y , Flead a nd N e c k S u rg e ry o f th e C h ris tia n -A lb re c h ts -U n iv e rs itĂ¤ t Kiel. In 2 0 0 2 , to g e th e r w it h his c o lle a g u e s , he w a s a w a rd e d th e T e a ch in g A w a rd fo r o u ts ta n d in g te a c h in g in th e fie ld o f a n a to m y a t th e M e d ic a l F a cu lty o f th e U n iv e rs ity o f Kiel. O n se v e ra l o c c a s io n s he g a in e d w o r k e x p e rie n c e a broad in th e a c a d e m ic s e c tio n o f th e D e p a rtm e n t o f O p h th a lm o lo g y , U n iv e rs ity o f B ris to l, UK, w h e re he d id re se a rch fo r se v e ra l m o n th s . F ro m 2 0 0 4 to 2 0 1 0 as a U n iv e rs ity P ro fe sso r, he w a s h ead o f th e M a c ro s c o p ic A n a to m y a nd P ro s e c to r S e c tio n a t th e D e p a rtm e n t o f A n a to m y a n d Cell B io lo g y o f th e M a rtin -L u th e r-U n iv e rs itĂ¤ t H alleW itte n b e rg . S ta rtin g in A p ril 2 0 1 0 , P ro fe s s o r P au lse n b e c a m e th e C ha irm an a t th e In s titu te o f A n a to m y II o f th e F rie d ric h -A le x a n d e rU n iv e rs itĂ¤ t E rlan g e n. S in ce 2 0 0 6 , P ro fe s s o r P au lse n is a boa rd m e m b e r o f th e A n a to m ic a l S o c ie ty a nd 2 0 0 9 he w a s e le c te d th e g e n e ra l s e c re ta ry o f th e In te rn a tio n a l F e d e ra tio n o f A s s o c ia tio n s o f A n a to m y (IFAA). H is m a in re se a rch area c o n c e rn s th e in n a te im m u n e s y s te m . T o p ic s o f s p e cia l in te re s t are a n tim ic ro b ia l p e p tid e s , tre fo il fa c to r p e p tid e s , s u rfa c ta n t p ro te in s , m u c in s , co rn e a l w o u n d h e a ling , as w e ll as s te m c e lls o f th e lacrim a l g la n d a nd d is e a s e s su ch as e ye in fe c tio n s , d ry e ye , o r o s te o a rth ritis .

P ro fe s s o r J e n s W a s c h k e (born in 1974) h a b ilita te d in 2 0 0 7 a fte r g ra d u a tio n fro m M e d ic a l S c h o o l a nd c o m p le tin g a d o c to ra l th e s is a t th e U n iv e rs ity o f W u e rz b u rg . F ro m 2 0 0 3 to 2 0 0 4 he jo in e d P ro fe s s o r Fitz-R oy C u rry a t th e U n iv e rs ity o f C a lifo rn ia in D avis fo r a n in e m o n th s re s e a rc h v is it. S ta rtin g in J u n e 2 0 0 8 , he b e c a m e th e C h a irm a n a t th e In s titu te o f A n a to m y a nd C ell B io lo g y III a t th e U n iv e rs ity o f W u e rz b u rg , in 2 0 0 5 , to g e th e r w ith h is co lle a g u e s , P ro fe s s o r W a s c h k e w a s a w a rd e d th e A lb e rt K o e llik e r T e a c h in g A w a rd o f th e F a c u lty o f M e d ic in e in W u e rz b u rg . In 2 0 0 6 , he w a s a w a rd e d th e W o lfg a n g B a rg m a n n Prize o f th e A n a to m ic a l S o c ie ty . H is m a in re s e a rc h area c o n c e rn s c e llu la r m e c h a n is m s th a t c o n tro l th e a d h e s io n b e tw e e n c e lls a nd th e c e llu la r ju n c tio n s e s ta b lis h in g th e o u te r a nd in n e r b a rrie rs o f th e h u m a n body. T h e a tte n tio n is fo c u s e d on th e re g u la tio n s o f th e e n d o th e lia l b a rrie r in in fla m m a tio n a n d th e m e c h a n is m s , w h ic h lead to th e fo rm a tio n o f fa ta l d e rm a l b lis te rs in p e m p h ig u s , an a u to im m u n e d is e a s e . T h e goal is to gain a b e tte r u n d e rs ta n d in g o f c e ll a d h e s io n as a basis fo r th e d e v e lo p m e n t o f n e w th e ra p e u tic s tra te g ie s .

A ll b u sin e ss c o rre s p o n d e n c e s h o u ld b e m a d e w ith : E ls e v ie r G m b H , U rba n & F isch e r V e rla g , H a c k e rb ru c k e 6, 8 0 3 3 5 M u n ic h , G e rm a n y , m a il to : m e d iz in s tu d iu m @ e ls e v ie r.d e

T h is a tla s w a s fo u n d e d b y J o h a n n e s S o b o tta t , fo r m e r P ro fe s s o r o f

A d d re s s e s o f th e e d ito rs : P ro fe s s o r Dr. m e d . F rie d rich Paulsen

A n a to m y a n d D ire c to r o f th e A n a to m ic a l In s titu te o f th e U n iv e rs ity in B o n n, G e rm a ny.

In s titu t fü r A n a to m ie II (V orstand) U n iv e rs itä t E rla n g e n -N ü rn b e rg

German editions:

U n iv e rs itä ts s tra ß e 19 9 1 0 5 4 E rlan g e n G e rm a n y

1st e d itio n : 1 9 0 4 -1 9 0 7 J . F. L e h m a n n s V e rla g , M u n ic h 2 nd—1 1th e d itio n : 1 9 1 3 -1 9 4 4 J. F. L e h m a n n s V e rla g , M u n ic h 12th e d itio n : 1 9 4 8 a nd fo llo w in g e d itio n s U rban & S c h w a rz e n b e rg , M u n ic h

P ro fe s s o r Dr. m e d . J e n s W a s c h k e In s titu t fü r A n a to m ie L u d w ig -M a x im ilia n s -U n iv e rs itä t P e tte n k o fe rs tra ß e 11 80333 M ünchen G e rm a n y A d d re s s e s o f th e tra n s la to rs : P ro fe s s o r Dr. m e d . S a bine F lo m ba ch -K lon isch P ro fe s s o r Dr. m e d . T h o m a s K lon isch F a cu lty o f M e d ic in e D e p a rtm e n t o f H u m a n A n a to m y a nd C ell S cie n ce

15th E d itio n 2011 © E ls e v ie r G m b H , M u n ic h U rba n & F is c h e r V e rla g is an im p rin t o f E ls e v ie r G m b H . 15

H. H. H. H.

B echer B echer B echer B echer

17th 18th 19th 2 0 th

e d itio n : e d itio n : e d itio n : e d itio n :

1 97 2 , 1 98 2 , 1 98 8 , 1 99 3 , U rban

e d ito rs H. F e rn e ra n d J . S ta u b e s a n d e d ito rs H. F e rn e ra n d J . S ta u b e s a n d e d ito r J. S ta u b e s a n d e d ito rs R. P utz a nd R. P a b st & S c h w a rz e n b e rg , M u n ic h

Foreign editions:

A ll rig h ts res e rve d

e d ito r e d ito r e d ito r e d ito r

A ra b ic e d itio n

T h e D e u ts c h e N a tio n a lb ib lio th e k lis ts th is p u b lic a tio n in th e D e u ts c h e N a tio n a lb ib lio g ra fie ; d e ta ile d b ib lio g ra p h ic data are availa ble in th e In te rn e t a t h ttp ://w w w .d - n b .d e .

1 95 3 , 1 95 6 , 1 95 7 , 1 96 7 ,

2 3 rd e d itio n : 2 0 1 0 , e d ito rs F. P aulsen a nd J. W a s c h k e E lsevie r, M u n ic h

B ib lio g ra p h ic in fo r m a tio n p u b lis h e d b y th e D e u ts c h e N a tio n a lb ib lio th e k

e d itio n : e d itio n : e d itio n : e d itio n :

2 1 st e d itio n : 2 0 0 0 , e d ito rs R. P u tz a nd R. P a b st U rban & F isch er, M u n ic h 2 2 nd e d itio n : 2 0 0 6 , e d ito rs R. P u tz a nd R. P a b st U rba n & F is c h e r, M u n ic h

U n iv e rs ity o f M a n ito b a 7 4 5 B a n n a tyn e A v e n u e W in n ip e g M a n ito b a R3E 0J9 C anada

13th 14th 15th 16th

For c o p y rig h t c o n c e rn in g th e p ic to ria l m a te ria l se e p ic tu re c re d its . A ll rig h ts , in c lu d in g tra n s la tio n , are re s e rv e d . N o p a rt o f th is p u b lic a tio n m a y be re p ro d u c e d , s to re d in a re trie v a l s y s te m , o r tr a n s m itte d in a n y o th e r fo rm o r b y a ny m e a n s, e le c tro n ic , m e ch a n ica l, p h o to c o p y in g , re c o rd in g , o r o th e rw is e w it h o u t th e p rio r w r itte n p e rm is s io n o f th e p u b lis h e r. A c q u is itio n e d ito r: A le x a n d ra F rn tic, M u n ic h D e v e lo p m e n t e d ito r: D r. A n d re a B e ilm a n n , M u n ic h E d itin g : U lrik e K rieg e l, b u c h u n d m e h r, M u n ic h P ro d u c tio n m a n a g e r: S ib ylle H a rtl, M u n ic h ; R e n a te H a u s d o rf, b u c h u n d m e h r, G rä fe lfin g C o m p o s e d by: M itte rw e g e r & P artner, P la n ksta d t P rin te d a nd b o u n d by: F irm e n g ru p p e app l, W e m d in g Illu s tra to rs : D r. Katja D a lk o w s k i, B u c k e n h o f; S onja Klebe, A y in g G ro ß h e lfe n d o rf; J ö rg M a ir, M u n ic h ; S te p h a n W in k le r, M u n ic h C o v e r illu s tra tio n : N icola N eu b a ue r, P u ch h e im C o v e r d e s ig n : S p ie szD e sig n , N e u -U lm P rin te d on 1 1 5 g Q u a d ro Silk ISBN 9 78 -0 -7 23 4 -3 73 2 -1

M o d e rn T e c h n ic a l C e n te r, D a m a s k u s C h in e s e e d itio n (c o m p le x c h a ra c te rs ) H o-C hi B o o k P u b lis h in g Co, T a iw a n C h in es e e d itio n (s im p lifie d C h in e s e e d itio n ) E lsevie r, H e a lth S c ie n c e s A s ia , S in g a p o re C ro a tia n e d itio n N aklada Slap, J a s tre b a rs k o C zec h e d itio n Grada P u b lis h in g , Prague D u tc h e d itio n B o h n S ta fle u va n L o g h u m , H o u te n E ng lish e d itio n (w ith n o m e n c la tu re in E n g lis h ) E ls e v ie r Inc., P hila d elp hia E ng lish e d itio n (w ith n o m e n c la tu re in La tin ) E ls e v ie r G m b H , U rba n & F isch e r F rench e d itio n T e c & D o c L a v o is ie r, Paris G re e k e d itio n (w ith n o m e n c la tu re in G re e k) M a ria G. P a rissia n os, A th e n G re e k e d itio n (w ith n o m e n c la tu re in La tin ) M a ria G. P a rissia n os, A th e n H u n g a ria n e d itio n M e d ic in a P u b lis h in g , B u d a p e s t In d o n e s ia n e d itio n P e n e rb it B u ku K e d o k te ra n EGC, Ja karta Ita lia n e d itio n E ls e v ie r M a s s o n STL, M ila n J a p a n e s e e d itio n Igaku S h o in L td ., T o k y o K o re a n e d itio n E ls e v ie r Korea LLC P olish e d itio n E ls e v ie r U rba n & P a rtn e r, W ro c la w P o rtu g u e s e e d itio n (w ith n o m e n c la tu r e in E ng lish) E ditora G uanabara K oogan, R io de J a n e iro P o rtu g u e s e e d itio n (w ith n o m e n c la tu r e in L a tin ) E ditora G uanabara K oogan, R io de J a n e iro R ussian e d itio n R eed E ls e v ie r LLC , M o s c o w S p a n is h e d itio n E dito ria l M e d ic a P an am e rican a , B u e n o s A ire s /M a d rid T u rk is h e d itio n B e ta B a s im Y a y im D a g itim , Is ta n b u l U k ra in ia n e d itio n E ls e v ie r U rba n & P a rtn e r, W ro c la w

C u r r e n t in f o r m a tio n b y w w w .e ls e v ie r .d e a n d w w w .e ls e v ie r .c o m

fable of contents V is c e r a

o f th e

T h o ra x

Heart.......................................................................................

Lungs......................................................................................

Oesophagus ..........................................................................

Thym us..................................................................................

Topography............................................................................

Sections .................................................................................

V is c e r a

o f th e

A b d o m e n

Development..........................................................................

Stomach .................................................................................

Intestines ...............................................................................

Liver and Gallbladder.............................................................

102

Pancreas................................................................................. 120 Spleen ....................................................................................

128

Topography ............................................................................

130

Sections ................................................................................. 148

P e lv is

a n d

R e tr o p e r it o n e a l S p a c e

Kidney and Adrenal Gland.....................................................

160

Efferent Urinary System ........................................................

174

Genitalia ................................................................................. 182 Rectum and Anal Canal..........................................................

220

Topography ............................................................................ 228 Sections ................................................................................. 236

Translators

Prof. Dr. T h o m a s Klonisch

Prof. Dr. Sabine H om ba ch -K lo n isch

P ro fe s s o r T h o m a s K lo n isch (b orn 196 0 ) s tu d ie d h u m a n m e d ic in e a t

T e a c h in g c lin ic a lly re le v a n t a n a to m y a nd c lin ic a l ca se-b a se d a n a to m y le a rn in g a re th e m a in te a c h in g fo c u s o f S a b in e H o m b a c h -K lo n is c h a t th e M e d ic a l F a c u lty o f th e U n iv e rs ity o f M a n ito b a . S in c e h er a p p o in tm e n t in 2 0 0 4 , P ro fe s s o r H o m b a c h h as b e e n n o m in a te d

th e R u h r-U n iv e rs itä t B o c h u m a nd th e J u s tu s -L ie b ig -U n iv e rs itä t (JLU) G ie s s e n . He s u c c e s s fu lly c o m p le te d his d o c to ra l th e s is a t th e In s titu te o f B io c h e m is try a t th e F a c u lty o f M e d ic in e o f th e JL U G ie s s e n and b e c a m e a s c ie n tific a s s o c ia te a t th e In s titu te o f M e d ic a l M ic ro b io lo g y ,

a n n u a lly fo r te a c h in g a w a rd s b y th e M a n ito b a M e d ic a l S tu d e n t A s s o c ia tio n .

U n iv e rs ity o f M a in z (1 9 8 9 -1 9 9 1 ). A s an A le x a n d e r vo n H u m b o ld t F e llo w he jo in e d th e U n iv e rs ity o f G u e lp h , O n ta rio , C anada, fro m

S a bine H o m b a c h (born 1963) g ra d u a te d fro m M e d ic a l S c h o o l a t th e

1 9 9 1 -1 9 9 2 and, in 1 9 9 3 -1 9 9 4 , c o n tin u e d his re se a rch a t th e O n ta rio

J u s tu s -L ie b ig -U n iv e rs itä t G ie s s e n in 1991 a n d s u c c e s s fu lly c o m p le te d h e r d o c to ra l th e s is in 1 99 4 . F o llo w in g a c a re e r b re a k to a tte n d to h er

V e te rin a ry C o lle g e , G u e lp h , O n ta rio . F ro m 1 9 9 4 -1 9 9 6 , he jo in e d th e im m u n o p ro te in e n g in e e rin g g ro u p a t th e D e p a rtm e n t o f Im m u n o lo g y , U n iv e rs ity C o lle g e L o n d o n , UK, a s a s e n io r re se a rch fe llo w . F ro m 1 9 9 6 - 2 0 0 4 he w a s a s c ie n tific a s s o c ia te a t th e D e p a rtm e n t o f A n a to m y a nd Cell B io lo g y , M a rtin -L u th e r-U n iv e rs itä t H a lle -W itte n b e rg , w h e re he re c e iv e d his a c c re d ita tio n as a n a to m is t (1999), c o m p le te d his h a b ilita tio n (2000), a n d h e ld c o n tin u o u s n a tio n a l re se a rch fu n d in g b y th e G e rm a n R ese a rch C o u n cil (DFG) a nd G e rm a n C a n c e r R esearch F o u n d a tio n (D e u ts c h e K re b sh ilfe ). In 2 0 0 4 , he w a s a p p o in te d Full P ro fe s s o r a nd H ead a t th e D e p a rtm e n t o f H u m a n A n a to m y a n d Cell S c ie n c e a t th e F a cu lty o f M e d ic in e , U n iv e rs ity o f M a n ito b a , W in n ip e g , C anada, w h e re he is c u rre n tly s e rv in g his s e c o n d te rm as d e p a rtm e n t ch a irm a n . H is re se a rch a rea s c o n c e rn th e m e c h a n is m s e m p lo y e d b y ca n c e r c e lls a nd th e ir c a n c e r s te m /p ro g e n ito r c e lls t o e n h a n c e tis s u e in v a s iv e n e s s

t w o c h ild re n s h e re -e n g a g e d a s a s e s s io n a l le c tu re r a t th e D e p a rtm e n t o f A n a to m y a nd C ell B io lo g y o f th e M a rtin -L u th e r-U n iv e rs itä t H a lle -W itte n b e rg in 1 997 a n d re c e iv e d a p o s t-d o c to ra l fe llo w s h ip by th e p ro v in c e o f S a x o n y -A n h a lt fr o m 1 9 9 8 -2 0 0 0 . T h e re a fte r, s h e jo in e d th e D e p a rtm e n t o f A n a to m y a n d C ell B io lo g y as a s c ie n tific a s s o c ia te . P ro fe s s o r H o m b a c h re c e iv e d h e r a c c re d ita tio n a s a n a to m is t in 2 0 0 3 b y th e G e rm a n S o c ie ty o f A n a to m is ts a nd b y th e M e d ic a l A s s o c ia tio n o f S a x o n y -A n h a lt a n d c o m p le te d h e r h a b ilita tio n a t th e M e d ic a l F a c u lty o f th e M a rtin -L u th e r-U n iv e rs itä t H a lle -W itte n b e rg in 2 0 0 4 . In 2 00 4 , P ro fe s s o r H o m b a c h w a s a p p o in te d A s s is ta n t P ro fe s s o r a t th e D e p a rtm e n t o f H u m a n A n a to m y a nd C ell S c ie n c e , F a c u lty o f M e d ic in e o f th e U n iv e rs ity o f M a n ito b a . S h e has b e e n th e re c ip ie n t o f th e M e rc k E u rop e a n T h y ro id v o n B a s e d o w R ese a rch Prize b y th e G e rm a n E n d o c rin e S o c ie ty in 2 0 0 2 a nd re c e iv e d th e M u rra y L. B a rr Y o u n g In v e s tig a to r A w a rd b y th e C anadian A s s o c ia tio n fo r A n a to m y , N e u ro b i o lo g y a nd C ell B io lo g y in 2 00 9 .

a nd su rviva l s tra te g ie s in re s p o n s e t o a n tic a n c e r tre a tm e n ts . O n e

H er m a in re s e a rc h in te re s ts are in th e fie ld o f c a n c e r re s e a rc h a nd

p a rtic u la r fo c u s is o n th e ro le o f e n d o c rin e fa c to rs , su ch as th e

e n v iro n m e n ta l to x ic a n ts . H er fo c u s in c a n c e r re s e a rc h is to id e n tify th e m o le c u la r m e c h a n is m s th a t re g u la te c a n c e r c e ll m ig ra tio n a nd m e ta s ta s is . S h e e m p lo y s u n iq u e c e ll a n d a n im a l m o d e ls a n d h u m a n p rim a ry c e lls to s tu d y e p ig e n e tic a n d tra n s g e n e ra tio n a l e ffe c ts fa c ilita te d b y e n v iro n m e n ta l c h e m ic a ls .

re la x in -like lig a n d -re c e p to r s y s te m , in p ro m o tin g c a rc in o g e n e s is .

Preface In th e p re fa c e to th e fir s t e d itio n o f his A tla s , J o h a n n e s S o b o tta w r o te

a lso a d o p te d , a lth o u g h s lig h tly m o d ifie d , th e a p p ro a c h m e n tio n e d al

in M a y 1904: " M a n y y e a rs o f e x p e rie n c e in a n a to m ic a l d is s e c tio n led

re ad y in th e p re fa c e o f th e fir s t e d itio n , i.e. c o m b in in g th e fig u re s in th e

th e a u th o r to p ro c e e d w it h th e p re s e n ta tio n o f th e p e rip h e ra l n e rv o u s

a tlas w ith e x p la n a to ry te x t w h ic h is an o ld tre n d b e in g c u rre n tly back

s y s te m a nd th e b lo o d v e s s e ls su ch th a t th e illu s tra tio n s o f th e b o o k are

in to fa s h io n o n c e m o re . Each im a g e is a c c o m p a n ie d b y a s h o rt e x p la n a

p re s e n te d to th e s tu d e n t e x a c tly in th e sa m e m a n n e r as b o d y p a rts are

to r y te x t, w h ic h s e rv e s to in tro d u c e s tu d e n ts to th e im a g e , e x p la in in g

p re s e n te d to th e m in th e d is s e c tio n la b o ra to rie s , i.e. s im u lta n e o u s

w h y th e p a rtic u la r p re p a ra tio n a nd p re s e n ta tio n o f a re g io n w a s s e le c t

p re s e n ta tio n o f b lo o d v e s s e ls a nd n e rv e s o f th e s a m e re g io n . A lte rn a t

e d . T h e in d iv id u a l c h a p te rs w e r e s y s te m a tic a lly o rg a n is e d in te r m s o f

ing d e s c rip tiv e a nd im a g e m a te ria ls are d is tin c tiv e fe a tu re s o f th is atlas.

c u rre n t s u b je c t m a tte r a nd p re v a ilin g s tu d y h a b its ; o m itte d a nd in c o m

T h e im a g e s are th e co re p ie c e o f th e a tla s. A p a rt fro m ta b le le g e n d s ,

p le te illu s tra tio n s - p a rtic u la rly th e s y s te m a tic s o f th e n e u ro v a s c u la r

a u xilia ry a nd s c h e m a tic d ra w in g s , th e d e s c rip tiv e m a te ria l in c lu d e s

p a th w a y s - w e r e s u p p le m e n te d o r re p la c e d . T h e m a jo rity o f th e s e n e w

s h o rt a nd c o n c is e te x t p a rts s u ita b le fo r use o f th is b o o k in th e g ro s s

fig u re s are c o n c e p tu a lis e d to fa c ilita te s tu d y in g th e re le v a n t p a th w a y s

a n a to m y la b o ra to ry ."

o f b lo o d s u p p ly a nd in n e rv a tio n b y d id a c tic a l a s p e c ts . W e have a lso

A s w ith fa s h io n s , re ad in g a nd s tu d y h a b its o f s tu d e n ts c h a n g e p e rio d i

re v ie w e d m a n y e x is tin g fig u re s , re d u c e d fig u re le g e n d s , a nd h ig h lig h t

cally. T h e m u ltim e d ia p re s e n c e a n d a v a ila b ility o f in fo rm a tio n as w e ll as

ed k e y w o rd s b y b o ld p rin t to s im p lify a c c e s s to th e a n a to m ic a l c o n

s tim u li are c e rta in ly th e m a in re a s o n s o f e v e r ch a n g in g s tu d y h a b its.

te n ts . N u m e ro u s c lin ic a l e x a m p le s are used to e n h a n c e th e " life le s s

T h e s e d e v e lo p m e n ts a nd ch a n g in g d e m a n d s o f s tu d e n ts to te x tb o o k s

a n a to m y " , p re s e n t th e re le v a n c e o f a n a to m y fo r th e fu tu r e c a re e r to

a nd a tla se s, w h ic h th e y u tilis e , a s w e ll as th e a v a ila b ility o f d ig ita l m e d ia

th e s tu d e n t, a nd p ro v id e a ta s te o f w h a t's to c o m e . In tro d u c tio n s to th e

o f te x tb o o k c o n te n ts , is a c c o u n te d fo r b y e d ito rs a nd p u b lis h e rs . A p a rt

in d iv id u a l c h a p te rs re c e iv e d a n e w c o n c e p tu a l d e s ig n , c o v e rin g in b rie f

fr o m in te rv ie w s a nd s y s te m a tic s u rv e y s o f s tu d e n ts , th e te x tb o o k s e c

a s u m m a ry o f th e c o n te n t, th e a s s o c ia te d c lin ic a l a s p e c ts , a nd re le v a n t

to r is o cc a s io n a lly an in d ic a to r e n a b lin g th e e v a lu a tio n o f e x p e c ta tio n s

d is s e c tio n s te p s fo r th e c o v e re d to p ic . It s e rv e s as a c h e c k lis t fo r th e

o f s tu d e n ts . D e ta ile d te x tb o o k s w ith th e a b s o lu te c la im o f c o m p le te

re q u ire m e n ts o f th e In s titu te o f M e d ic a l a nd P h a rm a c e u tic a l E xa m in a

n ess are e x c h a n g e d in fa v o u r o f e d u c a tio n a l b o o k s th a t are ta ilo re d to

tio n Q u e s tio n s (IM P P ) a nd is b a s e d on th e G e rm a n oral p a rt o f th e

th e d id a c tic n e e d s o f s tu d e n ts a nd th e c o n te n ts o f th e s tu d y o f h u m a n

p re c lin ic a l m e d ic a l e x a m in a tio n (P h y s ik u m ). A ls o n e w are b rie f in tro

m e d ic in e , d e n tis try , a nd b io m e d ic a l s c ie n c e s , as w e ll a s th e c o rre

d u c tio n s to each to p ic in e m b ry o lo g y a nd th e o n lin e c o n n e c tio n s o f th e

s p o n d in g e x a m in a tio n s . S im ila rly, illu s tra tio n s in a tla s e s s u c h a s th e

a tlas w it h th e a b ility to d o w n lo a d all im a g e s fo r re p o rts , le c tu re s , a nd

S o b o tta , w h ic h c o n ta in e x a c t n a tu ra lis tic d e p ic tio n o f real a n a to m ic a l

p re s e n ta tio n s .

s p e c im e n s , fa s c in a te d o c to rs a nd a s s o c ia te d m e d ic a l p ro fe s s io n s fo r m a n y g e n e ra tio n s th ro u g h o u t th e w o rld . H o w e v e r, s tu d e n ts s o m e

W e w a n t to e m p h a s is e t w o p o in ts :

tim e s p e rc e iv e th e m as to o c o m p lic a te d a n d d e ta ile d . T h is a w a re n e s s

1. T h e " n e w " S o b o tta in th e 2 3 rd e d itio n is n o t a s tu d y atlas, c la im in g

re q u ire s th e c o n s id e ra tio n o f h o w th e s tre n g th o f th e a tla s , w h ic h is

c o m p le te n e s s o f a c o m p re h e n s iv e k n o w le d g e and, th u s , d o e s n o t

k n o w n fo r its sta n d a rd s o f a c c u ra c y a nd q u a lity d u rin g its c e n te n n ia l

tr y to c o n v e y th e in te n tio n to re pla ce an a c c o m p a n y in g te x tb o o k .

e x is te n c e fe a tu rin g 2 2 e d itio n s , can be a d a p te d to m o d e rn e d u c a tio n a l

2. N o m a tte r h o w g o o d th e d id a c tic a p p ro a c h , it c a n n o t re lie v e th e s tu

c o n c e p ts w it h o u t c o m p ro m is in g th e o e u v re 's u n iq u e c h a ra c te ris tic s

d e n ts o f s tu d y in g , b u t aid in v is u a lis a tio n . A n a to m y is n o t d iffic u lt to

a nd a u th e n tic ity . A fte r c a re fu l c o n s id e ra tio n , E ls e v ie r a nd th e e d ito rs

s tu d y , b u t v e ry tim e -c o n s u m in g . S a c rific in g th is tim e is w o r th w h ile ,

P ro fe s s o r R einhard Putz a nd P ro fe s s o r R einhard P abst, w h o w e r e in

s in c e p h y s ic ia n s a nd p a tie n ts w ill b e n e fit fr o m it.

c h a rg e o f th e a tlas u p to its 2 2 nd e d itio n , c a m e to th e c o n c lu s io n th a t a n e w e d ito ria l te a m w it h th e sa m e g re a t e n th u s ia s m fo r a n a to m y and

T h e goal o f th e 2 3 rd e d itio n o f S o b o tta is n o t o n ly to fa c ilita te lea rn in g ,

te a c h in g w o u ld m e e t th e n e w re q u ire m e n ts b e s t. T o g e th e r w ith th e

b u t a ls o t o m a k e le a rn in g e x c itin g a nd a ttra c tin g , so th a t th e a tlas is

E ls e v ie r p u b lis h in g h o u se , w e are e x tre m e ly p le a se d to b e ch arg e d

c o n s u lte d d u rin g th e s tu d y p e rio d as w e ll as in th e c o u rs e o f p ro fe s

w ith th e n e w c o m p o s itio n o f th e 2 3 rd e d itio n o f S o b o tta . In re d e s ig n in g ,

sio n a l p ra c tic e .

a v e ry c le a r o u tlin e o f c o n te n ts a n d a d id a c tic in tro d u c tio n to th e p ic tu re s w a s ta k e n in to a c c o u n t. N o t e v e ry fa s h io n is a c c o m p a n ie d w ith

E rlan g e n a nd W u e rz b u rg , s u m m e r 2 0 1 0 , e x a c tly 1 06 y e a rs a fte r th e

s o m e th in g e n tire ly n e w . U n d e r d id a c tic a l a s p e c ts w e have re v is ite d th e

fir s t e d itio n .

o ld c o n c e p t o f a th re e -v o lu m e atlas, as u se d in S o b o tta 's fir s t e d itio n , w ith : G e n e ral A n a to m y a nd M u s c u lo s k e le ta l S y s te m (vol. 1), In te rn a l O rg a n s (vol. 2), a nd H ead, N e ck, a n d N e u ro a n a to m y (vol. 3). W e have

F rie d ric h P aulsen a nd J e n s W a s c h k e

Acknow ledgem ents F irs t, w e w o u ld like to e x p re s s th a t th e w o rk on th e S o b o tta w a s e x c it

M e d ic a l S ch o ol, a nd c o lle a g u e s P rof. Dr. m e d . P e te r K ugler, J u liu s -

ing a nd ch a lle n g in g . D u rin g sta g e s , a t w h ic h o n e c o u ld se e th e p ro g re s s

M a x im ilia n s -U n iv e rs itä t W u e rz b u rg , a nd P rof. Dr. rer. nat. G o ttfrie d Bo-

o f d e v e lo p m e n t o f in d ivid u a l c h a p te rs a nd n e w ly d e v e lo p e d p ic tu re s

g u s c h , C h a rité B e rlin , s u p p o rte d u s s tro n g ly w it h a d v ic e a nd c ritic a l

w ith a s lig h t d e ta c h m e n t, o n e o b ta in e d s a tis fa c tio n , w a s e la te d w ith

c o m m e n ts . W e w o u ld like to s p e c ific a lly e m p h a s is e th e e ffo r t o f M s .

p rid e a nd id e n tifie d o n e s e lf e v e rm o re w ith th e S o b o tta .

R en a te Putz, w h o c o rre c te d th e m a n u s c rip t v e ry c a re fu lly ; h e r c o m

T h e re d e s ig n o f S o b o tta is o b v io u s ly n o t th e s o le w o r k o f t w o in e x p e ri

m e n ts w e r e o f cru c ia l im p o rta n c e fo r th e c o n s is te n c y o f th e w o r k in it

e n c e d e d ito rs , b u t ra th e r re q u ire s m o re th a n e v e r a w e ll-a ttu n e d te a m

s e lf a nd w ith th e e a rlie r e d itio n s .

u n d e r th e c o o rd in a tio n o f th e p u b lis h e r. W ith o u t th e lo n g e x p e rie n c e o f

For s u p p o rt w ith c o rre c tio n s a nd re v is io n s , w e e x p re s s o u r s in c e re

D r. A n d re a B e ilm a n n , w h o s u p e rv is e d se v e ra l e d itio n s o f th e S o b o tta

th a n k s to M s . S te p h a n ie B e ilic k e , Dr. rer. nat. Lars B rä ue r, M s . A n e tt

a nd e x e rte d th e c a lm in g in flu e n c e o f th e S o b o tta te a m , m a n y th in g s

D ike r, M r. Fabian G arreis, M s . E lisa b e th G e o rg e , M s . P atricia M aake ,

w o u ld have b e e n im p o s s ib le . W e th a n k h e r fo r all th e h e lp a nd s u p p o rt.

M s . S usann M ö s c h te r, M r. J ö rg P e k a rs k y a nd M r. M a rtin S c h ic h t.

M s . A le x a n d ra F rn tic, w h o is a lso p a rt o f th e fo u r-m e m b e r S o b o tta

For a s s is ta n c e in c re a tin g c lin ic a l fig u re s , w e e x p re s s o u r g ra titu d e to

te a m , p u rs u e d th e fir s t m a jo r p ro je c t o f h e r ca re e r a nd ta c k le d it w ith

P riv.-D oz. D r. m e d . H an n e s K u tta , C lin ic a nd P o ly c lin ic fo r O to -R h in o -

p assio n a nd e n th u s ia s m . H er liv e lin e s s a nd m a n a g e m e n t b y m o tiv a tio n

L a ry n g o lo g y a t th e U n iv e rs ity H o s p ita l H a m b u rg -E p p e n d o rf, P ro f. Dr.

have e n liv e n e d a nd ch e e re d th e e d ito rs . W e e x p re s s o u r g ra titu d e to

m e d . N o rb e rt K lein sa sser, U n iv e rs ity C lin ic fo r O to-R h in o -L a ry n g o -P a -

M s . F rn tic. W e like to re fle c t b ack on th e S o b o tta in itia lis a tio n w e e k in

th o lo g y , J u liu s -M a x im ilia n s -U n iv e rs itä t W u e rz b u rg , P ro f. Dr. m e d . A n

P arsberg a nd w e e k ly c o n fe re n c e ca lls, in w h ic h Dr. B e ilm a n n a nd M s .

d re a s D ie tz , H ead o f C lin ic a nd P o ly c lin ic fo r O to -R h in o -L a ry n g o lo g y a t

F rn tic s u p p o rte d us in th e c o m p o s itio n o f th e S o b o tta a nd p re s e n te d an

th e U n iv e rs ity Leip zig, Dr. m e d . D ie tric h S to e v e s a n d t, C lin ic fo r D iag

a d m ira b le w a y to m e rg e th e v a rie ty o f tw o p e rs o n a litie s to a c h ie v e a

n o s tic

s in g le la yo u t. W ith o u t th e a s s e rtiv e n e s s , th e calls fo r p e rs e v e ra n c e and

P rof. Dr. m e d . S te p h a n Zierz, D ire c to r o f th e U n iv e rs ity H o s p ita l and

R a d io lo g y a t th e

M a rtin -L u th e r-U n iv e rs itä t H a lle -W itte n b e rg ,

th e p ro te c tiv e h and o f Dr. D o ro th e a H e n n e s s e n , w h o d ire c te d th e

P o ly c lin ic fo r N e u ro lo g y a t th e M a rtin -L u th e r-U n iv e rs itä t H a lle -W itte n -

p ro je c t o f th e " 2 3 rd e d itio n o f S o b o tta " a nd a lw a y s b e lie v e d in h e r So

b erg , Dr. m e d . B e rit J o rd a n , H o s p ita l a n d P o ly c lin ic fo r N e u ro lo g y a t th e

b o tta te a m a n d th e tig h t s c h e d u le , th is e d itio n w o u ld have n o t b e e n

M a rtin -L u th e r-U n iv e rs itä t H a lle -W itte n b e rg , D r. m e d . S a a d e ttin Sei,

p u b lis h e d . L ike a n u m b e r o f p re v io u s p ro d u c tio n s , th e ro u tin ie r R en a te

U n iv e rs ity H o s p ita l fo r O p h th a lm o lo g y a t th e M a rtin -L u th e r-U n iv e rs itä t

H a u s d o rf led th e s u c c e s s fu l re p ro d u c tio n o f th e a tla s. O th e r p e o p le in

H a lle -W itte n b e rg , M r. ca nd . m e d . C h ris tia n S c h ro e d e r, E c k e rn fö rd e ,

v o lv e d in th e e d itin g p ro c e s s a nd th e s u c c e s s o f th e 2 3 rd e d itio n o f th e

a nd M r. D e n is H ille r, Bad L a u c h s tä d t.

S o b o tta a nd w h o m w e s in c e re ly th a n k are M s . S u sa n n e S zcze p an e k

W e a ls o w o u ld lik e to e x p re s s o u r th a n k s to o u r a n a to m ic a l m e n to rs

(m a n u s c rip t e d itin g ), M s . Ju lia Baier, M r. M a rtin K o rte n h a u s a nd M s .

P rof. Dr. m e d . B e rn h a rd T illm a n n , C h ris tia n -A lb re c h ts -U n iv e rs itä t Kiel,

U lrik e K rieg e l (e d itin g ), M s . A m e lie G u ts m ie d l (fo rm a l te x t e d itin g ), M s .

a nd P ro f. D r. m e d . D e tle v D re n c k h a h n , J u liu s -M a x im ilia n s -U n iv e rs itä t

S ib y lle H artl (in te rn a l p ro d u c tio n ), M s . C laudia A d a m a nd M r. M ic h a e l

W u e rz b u rg , w h o m w e n o t o n ly o w e o u r a n a to m ic a l tra in in g , th e m o ti

W ie d o rn (fo rm a l fig u re e d itin g a nd ty p e s e ttin g ), M s . N icola N e u b a u e r

v a tio n fo r s u b je c t m a tte r, a nd th e s e n s e o f m is s io n , b u t a lso have b e e n

(la y o u t d e v e lo p m e n t a nd re fin in g th e ty p e s e ttin g data) a nd th e s tu

g re a t role m o d e ls in th e ir d e s ig n o f te x tb o o k s a nd a tla s e s , as w e ll as in

d e n ts D o ris B ind l, D e rkje H o c k e rtz , Lisa Link, S ophia P oppe, C orn e lia

th e ir te a c h in g e x c e lle n c e .

R ippl a nd K a th e rin a a nd Florian S tu m p fe . For th e c o m p ila tio n o f th e in

O u r d e e p e s t g ra titu d e to o u r p a re n ts , D r. m e d . U rsula P aulsen and

d e x , w e e x p re s s o u r g ra titu d e to Dr. U rsula O s te rk a m p -B a u s t. S pecial

P rof. D r. m e d . K a rste n P aulsen, a nd a lso A n n e lie s W a s c h k e a nd Dr.

th a n k s are e x p re s s e d to th e illu s tra to rs D r. Katja D a lk o w s k i, M s . Sonja

m e d . D ie te r W a s c h k e , w h o in te n s e ly s u p p o rte d a nd s u s ta in e d th e So

K lebe, M r. Jö rg M a ir a nd M r. S te p h a n W in k le r, w h o in a d d itio n to re v is

b o tta p ro je c t. K a rste n P aulsen, w h o p a s s e d a w a y in M a y 2 0 1 0 , s tu d ie d

ing e x is tin g illu s tra tio n s have d e v e lo p e d a v a rie ty o f e x c e lle n t fig u re s .

a n a to m y as a m e d ic a l s tu d e n t fr o m th e 4 th e d itio n o f S o b o tta . D ie te r

P riv.-D oz. Dr. rer. n a t. H e lm u t W ic h t, S e n k e n b e rg A n a to m y , G o e th e -

W a s c h k e u s e d th e 16th e d itio n o f S o b o tta a nd c o n tin u e s to a tta in

U n iv e rs itä t F ra n k fu rt/M a in , has re v iv e d th e life le s s n e s s o f th e in tro d u c

k n o w le d g e w ith m e d ic a l lite ra tu re e v e n d u rin g re tire m e n t. T h e 2 3 rd e d i

tio n s to th e c h a p te rs in d ite d b y th e tw o e d ito rs th ro u g h his u n iq u e s ty le

tio n is d e d ic a te d to o u r fa th e rs .

o f w ritin g . W e e x p re s s o u r g ra titu d e to P riv.-D oz. Dr. rer. nat. W ic h t.

L a s t b u t n o t lea st, w e th a n k o u r w iv e s D r. m e d . D ana P aulsen a nd Su

A big h e lp to us w a s th e a d v is o ry c o u n c il, w h ic h in a d d itio n to th e

sa n n e W a s c h k e , w h o n o t o n ly had to s h a re u s w ith th e S o b o tta in th e

fo r m e r e d ito rs P ro f. D r. m e d . Dr. h. c. R einhard Putz, L u d w ig -M a x im il-

la s t ye ar, b u t a ls o w e r e on h and w ith h e lp a nd a d v ic e on m a n y is s u e s

ia n s -U n iv e rs itä t M u n ic h , a nd P ro f. Dr. m e d . R einhard P abst, H a n n o v e r

a n d have b e e n s tro n g ly s u p p o rtiv e .

Viscera of the Thorax H e a r t ..........................................................

L u n g s ........................................................

O esophagus ........................................... 42 T h y m u s ....................................................

T o p o g r a p h y ............................................. 52 Sections ................................................... 62

The Thorax Partly Intricate Organs T h e th o ra c ic c a g e (Cavea th o ra c is ) c o n ta in s th e h e a rt (Cor) a n d th e

th e re is th e d e lic a te th o ra c ic d u c t, th e D u c tu s th o ra c ic u s , w h ic h c a r

lu n g s (P u lm o n e s). In a n c ie n t tim e s , it w a s b e lie v e d th a t life s p irits a lo n g w it h th e in h a le d a ir re a ch e d th e lu n g s , m ix e d w it h b lo o d in th e hea rt,

rie s m ilk y ly m p h (c o n ta in in g a b s o rb e d fa ts fr o m m e a ls ) fr o m th e lo w e r body.

w h ic h w a s a t th a t tim e th o u g h t to b e th e s e a t o f th e s o u l, a nd d is trib u te d th ro u g h o u t th e w h o le b o d y b y th e b lo o d v e s s e ls . E ven to d a y , th e h e a rt is s till c o n s id e re d to be th e e n g in e o f life a nd in c o llo q u ia l te r m s it is a lso re fe rre d to a s th e c e n tre o f e m o tio n s . S c ie n tific a lly , th e h e a rt is d e fin e d a s a h o llo w m u s c le w h ic h p u m p s b lo o d th ro u g h th e le s s e r c irc u la tio n o f th e lu n g s (p u lm o n a ry c irc u la tio n ) a nd th e g re a te r c irc u la tio n o f th e b o d y (s y s te m ic c irc u la tio n ): T h e le ft s id e o f th e h e a rt p u m p s o x y g e n a te d b lo o d in to th e s y s te m ic c irc u la tio n w h ic h tra n s p o rts th e b lo o d to th e o rg a n s via a rte rie s (le a vin g th e h e a rt). B lo o d v e s s e ls o f th e m ic ro c irc u la tio n b ra n ch o u t t o a llo w th e n u trie n t a nd gas e x c h a n g e a t th e c a p illa ry le ve l. T h e v e in s re tu rn d e o x y g e n a te d b lo o d to th e r ig h t s id e o f th e h e a rt fr o m w h e re th e b lo o d is fo rw a rd e d to th e p u lm o n a r y c irc u la tio n . P u lm o n a ry a rte rie s tra n s p o rt d e o x y g e n a te d b lo o d to th e lu n g s. In a n e tw o rk o f p u lm o n a ry ca p illa rie s th e d e o x y g e n a te d b lo o d fin a lly re a c h e s th e a lve o li, is e n ric h e d w it h o x y g e n a nd tra n s fe rre d via p u lm o n a ry v e in s to th e le f t a triu m . T h is c o m p le te s th e b lo o d c irc u la tio n .

T h e h e a rt d o m in a te s in th e M e d ia s tin u m in fe riu s w h ic h is d ire c te d to w a rd s th e d ia p h ra g m . It is lo c a te d in a s e p a ra te , th in -w a lle d s e ro u s c a v ity , th e C a v ita s p e ric a rd ia c a , a nd e x te n d s th e M e d ia s tin u m to w a rd s th e le ft s id e . T h e h e a rt is o n ly e x p o s e d a fte r in c is io n o r re m o v a l o f th e c a v ity w a ll, th e p e ric a rd iu m . A large area o f th e h e a rt re s ts o n th e d ia p h ra g m w it h its a p e x (A p e x c o rd is ) p o in tin g to th e lo w e r le ft s id e to w a rd s th e le f t fifth in te rc o s ta l s p a c e . H o ld in g th e h e a rt b y th e a p e x , it can be fr e e ly m o v e d in th e c a v ity . Its o n ly a tta c h m e n ts are th e large v e s s e ls th a t e m e rg e a t th e u p p e r p o le (A o rta , A . p u lm o n a lis ) a nd e n te r a t th e its re a r s u rfa c e (Vv. p u lm o n a le s , V v. ca vae s u p e rio r e t in fe rio r). T h e base o f th e h e a rt (B asis c o rd is ) w it h th e o rig in o f th e b lo o d v e s s e ls is o p p o s ite to th e apex. Im m e d ia te ly b e h in d th e P e ric a rd iu m - m o re e x a c tly : b e h in d th e le ft a t riu m o f th e h e a rt - th e O e s o p h a g u s d e s c e n d s to th e o e s o p h a g e a l hia

T h e fu n c tio n o f th e h e a rt a s a p u m p is e s p e c ia lly fa s c in a tin g : O n a v

tu s (H ia tu s o e s o p h a g e u s ) in th e d ia p h ra g m . S lig h tly le ft s id e to th e O e s o p h a g u s , a ls o b e h in d th e P e ric a rd iu m , th e A o r ta a nd th e D u c tu s th o ra c ic u s d e s c e n d a nd p ass th ro u g h th e H ia tu s a o rtic u s in th e dia

e ra g e th e h e a rt ra te is 7 0 b e a ts p e r m in u te a n d w it h e v e ry s y s to lic c o n tra c tio n th e h e a rt fo rc e s 7 0 m l o f b lo o d in to th e c irc u la tio n . E ven

p h ra g m . T h e V. c a v a in fe r io r tra v e rs e s th e d ia p h ra g m th ro u g h a s e p a ra te o rific e (F o ra m e n v e n a e cavae), lo c a te d s lig h tly to th e rig h t a nd d o r

w it h o u t fu r th e r s tim u la tio n o f th e h e a rt in " e x c ite m e n t" , it b e a ts m o re th a n 1 0 0 ,0 0 0 tim e s p e r d a y a nd 3 6 m illio n tim e s p e r ye a r. T h e v o lu m e o f b lo o d (2 0 6 ,0 0 0 m 3), w h ic h is p u m p e d b y th e h e a rt in th e c o u rs e o f 80

sal s id e o f th e c e n tre o f th e d ia p h ra g m , a n d e n te rs th e p e ric a rd iu m and th e B asis c o rd is fr o m in fe rio r. A d d itio n a lly , n u m e ro u s o th e r s tru c tu re s ,

ye a rs, w o u ld be s u ffic ie n t to fill 8 0 O ly m p ic s w im m in g p o o ls . C on v e rs e ly , n o fu n c tio n o f th e b o d y w o u ld be p o s s ib le w it h o u t th e h e a rt:

s u c h as th e A a. th o ra c ic a e in te rn a e , N n. p h re n ic i, N n. v a gi, V v. a zygo te s , a n d g a n g lia a nd n e rv e s o f th e s y m p a th e tic tru n k (p a rt o f th e a u to n o m ic n e rv o u s s y s te m ) d e s c e n d in th e m e d ia s tin u m .

in m o s t c a s e s ca rd ia c a rre s t is an im m e d ia te c a u s e o f d e a th . In th e d is s e c tio n c o u rs e , th e o p e n in g o f th e th o ra c ic c a v ity is p e rc e iv e d w it h m ix e d fe e lin g s o f a w e , e x c ite m e n t a n d in te re s t b y te a c h in g p ro fe s s io n a ls a nd s tu d e n ts . T h e e x p o s u re o f h e a rt a n d lu n g s as w e ll a s th e e n title m e n t to to u c h a nd o b s e rv e th e s e vita l o rg a n s is p e rc e iv e d a s a

T h e la rg e r trilo b u la r r ig h t lu n g a nd th e s m a lle r b ilo b u la r le ft lu n g are lo

g re a t p riv ile g e d u rin g th e s e tra in in g s e s s io n s .

to th e r ig h t a nd le ft s id e o f th e M e d ia s tin u m , re s p e c tiv e ly . B o th lu n g s a re c o v e re d b y a th in , tra n s p a re n t, s e ro u s m e m b ra n e (P leura v is c e ra -

c a te d in s e p a ra te s e ro u s c a v itie s (C a v ita te s p le u ra le s , p le u ra l c a v itie s )

The M e d ia s tin u m

lis), th ro u g h w h ic h a b lack, n e t-lik e p ig m e n t p a tte rn is v is ib le . T h is anth ra c o tic p ig m e n t c o n s is ts m a in ly o f s o o t, th e c a rb o n w h ic h e m a n a te s

A s a g itta l m a s s iv e s e p a ra tio n c ro s s e s th e T h o ra x fr o m th e re a r a s p e c t

fr o m e x h a u s t fu m e s a n d c ig a re tte s m o k e . N u m e ro u s ly m p h n o d e s n e a r th e h ilu m o f th e lu n g s (se e b e lo w ) s h o w an a b u n d a n c e o f th is

o f th e S te rn u m to th e v e n tra l a s p e c t o f th e th o ra c ic v e rte b ra e . It is ca lle d th e M e d ia s tin u m (fro m L a tin " in m e d io s ta n s " = "s ta n d in g in th e

p ig m e n t.

m id d le " ) . C ra n ia lly th e M e d ia s tin u m is c o n tin u o u s w it h o u t sh arp b o u n d a rie s w it h th e v is c e ra o f th e n e c k th ro u g h th e s u p e rio r th o ra c ic

T h e lu n g s are s u p p o s e d to m o v e fr e e ly in th e ir p le u ra l c a v itie s . T h e y are a tta c h e d o n ly a t th e h ilu m w h e r e th e b ro n c h i, th e A a. p u lm o n a le s , and th e V v. p u lm o n a le s e n te r th e lu n g s fr o m th e M e d ia s tin u m . O fte n , as a

a p e rtu re . C a u d a lly it re s ts on th e d ia p h ra g m a nd is s h a rp ly d e fin e d . T h e lu n g s are lo c a te d w ith in in d iv id u a l p le u ra l c a v itie s (C a v ita te s p le u ra le s ) to b o th s id e s o f th e M e d ia s tin u m .

re s u lt o f in fla m m a tio n , th e p le u ra c o v e rin g th e lu n g s (P leura v is c e ra lis )

In th e M e d ia s tin u m , se v e ra l o rg a n s a re in te rtw in e d . T h e T h y m u s is

a d h e re s to th e s e ro u s p le u ra o f th e rib s (P leura c o s ta lis ), th e M e d ia s ti n u m (P leura m e d ia s tin a lis ), o r th e d ia p h ra g m (P leura d ia p h ra g m a tic a ), all o f w h ic h c o m p ris e th e P le u ra p a rie ta lis . In e x h a le d c o n d itio n , th e

lo c a te d in th e M e d ia s tin u m s u p e riu s ju s t b e h in d th e S te rn u m . It is an o rg a n o f th e im m u n e s y s te m b u t s o o n a fte r p u b e rty re g re s s e s to b e

p a rie ta l p le u ra is m o re s u b s ta n tia l th a n th e v is c e ra l p le u ra a n d re a c h e s b e y o n d th e m a rg in s o f th e lu n g s . T h e v irtu a l s p a c e s in w h ic h th e lu n g s

c o m e an a d ip o s e body. T h e V. cava s u p e rio r is d is p la c e d to th e rig h t fr o m th e m e d ia n p la n e . Its tr ib u ta rie s - b o th V v. b ra c h io c e p h a lic a e -

m a y e x p a n d d u rin g d e e p in s p ira tio n are ca lle d th e p le u ra l re c e s s e s o f th e P leura. D u rin g re s p ira tio n , th e lu n g s a d a p t to th e s h a p e o f th e th o

c o v e r th e la rg e a rte ria l tru n k s to th e n e c k a n d th e a rm s th a t e m e rg e fro m th e a o r tic a rc h . T h e ca n e -lik e c u rv e d m a in a rte ry (A o rta ) d o m in a

ra c ic w a ll a nd d ia p h ra g m . T h e lu n g s e x p a n d a nd re tra c t as th e y s lid e in a n d o u t o f th e re c e s s e s . T h e re fo re , a d h e s io n s o f th e P leura p a rie ta lis to th e P leura v is c e ra lis re s tra in lu n g fu n c tio n .

te s on th e le ft s id e o f th e M e d ia s tin u m . H id d e n b e n e a th th e v e in s a nd th e a rch o f th e A o rta , th e T ra ch e a d e s c e n d s in th e M e d ia s tin u m s u p e riu s a n d b ra n c h e s in to rig h t a nd le f t m a in b ro n c h i, B ro n c h i p rin c ip a le s . T h e O e s o p h a g u s d e s c e n d s d o rsa l o f th e T ra c h e a a nd in fr o n t o f th e v e rte b ra e . B e tw e e n th e O e s o p h a g u s a n d th e v e rte b ra e

The Lungs and th e ir Cavities

-C lin ic a l R em arks----------------------------------Th e e le c tro c a rd io g ra m (ECG) is a sta n d a rd d ia g n o s tic to o l and p ro v id e s in fo rm a tio n on th e m u s c u la r fu n c tio n o f th e h e a rt and on its size and p o s itio n . T h e ECG m a y be in d ic a tiv e o f a s te n o s is o f ce rta in c o ro n a ry a rte rie s . C o n v e n tio n a l ra d io g ra p h y , c o m p u te d to m o g ra p h y (CT) and m a g n e tic re s o n a n c e to m o g ra p h ic im a g in g (M R I) o f th e T h o ra x are e s s e n tia l d ia g n o s tic to o ls to id e n tify d is e a s e s o f th e lu n g a nd th e M e d ia s tin u m and p ro v id e in fo rm a ti o n o n th e size and fu n c tio n o f th e h e a rt. S p e c ific d ia g n o s tic p ro c e d u re s , s u c h as c ard ia c c a th e te ris a tio n , re q u ire d e ta ile d a n a to m ic a l k n o w le d g e . T h e ca rdia c c a th e te r is u sed to in je c t a c o n tra s t a g e n t in to th e c o ro n a ry a rte rie s (co ro n a ry a n g io g ra m ) to vis u a lis e a nd p o te n tia lly d ila te s te n o s e s . Th e e c h o c a rd io g ra p h y e n a b les v is u a lis a tio n o f th e ca rdia c v a lv e s and th e ir fu n c tio n . T h e s e d ia g n o s tic m e th o d s are c a rrie d o u t b y s p e c ia lis ts in in te rn a l m e d ic in e o r ra d io lo g is ts . C a rd io th o ra c ic s u rg e ry is p e rfo rm e d fo r lun g re s e c tio n (or p a rts o f th e lung), tr e a tm e n t o f d e fe c ts o f th e g re a t v e s s e ls , tra n s p la n ta tio n o f th e h e a rt o r lun g s, o r o th e r in d ic a tio n s .

— ►

D issection Link

T h e Vasa th o ra c ic a in te rn a , w h ic h are d e s c e n d in g parallel to th e S te r n u m , are p re s e n te d b y fe n e s tra tio n o f th e in te rc o s ta l s p a c e s to a void d am a g e d u rin g o p e n in g o f th e th o ra c ic ca vity. A fte r re m o v a l o f th e S te r n u m w it h th e a n te rio r p o rtio n s o f th e ribs, th e lu n g s are s e p a ra te d a t th e h ilu m and re m o v e d . N o w , th e m e d ia s tin u m is d is s e c te d : F irs t th e p e ric a rd iu m and th e a d ja c e n t N. p h re n ic u s are e x p o s e d . Th e p e ric a rd i u m is o p e n e d v e n tra lly . Th e h e a rt can b e d is s e c te d in s itu o r a fte r s e pa ra tion fro m th e g re a t v e s s e ls . Th e re m o v a l o f e pica rd ia l a d ip o s e tis s u e s e rv e s th e p u rp o s e o f tra c in g th e b ra n c h e s o f th e c o ro n a ry a rte rie s . U sin g s c is s o rs , th e v e n tric le s are o p e n e d fro m th e d ire c tio n o f th e a o r ta a nd th e p u lm o n a ry tru n k , re s p e c tiv e ly , a nd th e rig h t a triu m is o p e n e d fro m th e d ire c tio n o f b o th V v. cavae. A fte r re m o v a l o f th e p e ric a rd iu m , th e O e s o p h a g u s and th e c o u rs e o f th e A o rta th o ra c ic a , th e V v. a zygo s a nd h e m ia z y g o s , th e N. v a g u s , a nd th e D u c tu s th o ra c ic u s are p re s e n te d in th e p o s te rio r m e d ia s tin u m . T h e p arie ta l p le u ra is re m o v e d to fa c ilita te th e d is s e c tio n o f th e s y m p a th e tic tru n k w it h th e c o rre s p o n d in g N n. s p la n c h n ic i as w e ll as in te rc o s ta l n e u ro v a s c u la r s tru c tu re s . Finally, th e p re p a ra tio n o f th e s u p e rio r m e d ia s tin u m e x p o s e s th e re sid u a l T h y m u s a nd th e p a s s a g e w a y s to th e n e c k are tra c e d .

E X A M CHECK LIST • D e v e lo p m e n t: c a r d ia c c h a m b e r s a n d s e p t a tio n , fo e ta l c ir c u la tio n , m a lf o r m a tio n s • h e a rt: s itu s w it h p r o je c tio n s in r a d io lo g y a n d a u s c u lta tio n o f t h e v a lv e s , p e r ic a r d ia l c a v it y a n d N . p h r e n ic u s , o r g a n is a t io n ( in n e r r e lie f a n d v a lv e s , c o n d u c tin g s y s te m ), A a . c o r o n a r ia e in c lu d in g im p o r t a n t b ra n c h e s a n d a u t o n o m ic in n e r v a tio n • lu n g s : C a v ita s p le u r a lis w it h re c e s s e s , p r o je c tio n s o f p u lm o n a r y b o r d e r s , o r g a n is a t io n in lo b e s a n d s e g m e n ts , N o d i ly m p h o id e i • o r g a n is a t io n a n d c o n t e n t o f th e m e d ia s tin u m : b ra n c h e s o f th e a o rta . O e s o p h a g u s w it h p a rts , c o n s t r ic t io n s a n d b lo o d v e s s e ls , T ra c h e a w it h b if u r c a t io n , D u c tu s t h o r a c ic u s w it h d e p e n d e n t ly m p h a tic d r a in a g e , o r g a n is a t io n o f t h e a u t o n o m ic n e r v o u s s y s te m in c lu d in g t h e c o u rs e s o f t h e T ru n c u s s y m p a t h ic u s a n d N . v a g u s [X ]

T horacic Viscera

Heart -► Lungs -► Oesophagus

P rojection o f th e heart

Fig. 5.1

C o n to u rs o f t h e h e a rt, c a rd ia c v a lv e s a n d a u s c u lta tio n

a re a s p ro je c te d o n to t h e v e n tra l th o ra c ic w a ll. T h e r ig h t h e a rt c o n to u r p ro je c ts fr o m th e th ird to th e s ix th c o s ta l c a r tila g e o n to a lin e 2 c m la te ra l o f th e rig h t s te rn a l b o rd e r. T h e c o n to u r o f t h e le ft h e a rt p ro je c ts o n to a c o n n e c tin g lin e b e tw e e n th e lo w e r b o rd e r o f rib III ( 2 - 3 c m p a ra s te rn a l) a nd th e le ft m id c la v ic u la r lin e . O n each s id e , th e h e a rt c o n ta in s an a trio v e n tric u la r v a lv e b e tw e e n th e Valva atrioventricularis sinistra Valva atrioventricularis dextra

Apex cordis

a triu m a n d th e v e n tric le a n d a s e m ilu n a r v a lv e b e tw e e n th e v e n tric le a n d th e re s p e c tiv e a rte ry. T h e p ro je c tio n o f t h e fo u r c a rd ia c v a lv e s fo r m s a c ro s s w h ic h is s lig h tly d e v ia tin g to th e le f t s id e fr o m th e m e d ia n a xis. T h e p ro je c tio n o f th e ca rd ia c v a lv e s is o f m in o r im p o rta n c e in clin ical p ra c tic e s in c e th e h e a rt s o u n d s a n d p o te n tia l m u rm u rs tra v e l w it h th e b lo o d flo w a nd are a u s c u lta te d a t th e p o in ts o f m a x im a l in te n s ity (circ les).

S u rfa c e P ro je c tio n o f C a rd ia c V a lv e s

A u s c u lta tio n S ite s o f C a rd ia c V a lv e s

P u lm o n a ry v a lv e

le f t (!) s te rn a l b o rd e r, 3 rd c o s ta l ca rtila g e

p a ra s te rn a l le ft 2 nd ICS

A o r tic v a lv e

le ft s te rn a l b o rd e r, 3 rd ICS

p a ra s te rn a l rig h t 2 nd ICS

M itr a l v a lv e

le f t 4 th t o 5th c o s ta l c a rtila g e s

in th e m id c la v ic u la r lin e 5th ICS

T ric u s p id v a lv e

re tro s te rn a l 5th c o s ta l c a rtila g e

p a ra s te rn a l rig h t 5th ICS

ICS = intercostal space Recessus costomediastinales

Fig. 5 .2

P ro je c tio n o f th e h e a rt o n to th e th o ra x ; v e n tra l v ie w

(a c c o rd in g to [2]) W e d is tin g u is h fo u r s u rfa c e s o f th e h e a rt: T h e v e n tra lly o rie n te d Facies s te rn o c o s ta lis p re d o m in a n tly re p re s e n ts th e rig h t v e n tric le . T h e Facies d ia p h ra g m a tic a p o in ts in fe rio rly a nd c o n s is ts o f p a rts o f b o th v e n tric le s . T h e F a cies p u lm o n a lis is fo rm e d b y th e rig h t a triu m on th e r ig h t s id e a nd b y th e le ft v e n tric le o n th e le ft sid e . T h u s , th e rig h t v e n tric le d o e s n o t c o n trib u te t o a n y o f th e ca rd ia c b o rd e rs . T h e m a jo r p a rt o f th e F a cies s te rn o c o s ta lis is c o v e re d b y th e Pleura.

Ventriculus sinister

T h e s e a rea s re p re s e n t th e R ecessu s c o s to m e d ia s tin a le s o f th e p le u ral ca vity. T h e p le u ra l b o rd e rs se p a ra te fr o m e a ch o th e r in fe rio r to rib IV a nd fo rm th e b o u n d a ry o f th e T rig o n u m p e ric a rd ia c u m w h e re th e

Trigonum pericardiacum

P e ric a rd iu m is d ire c tly a d ja c e n t to th e v e n tra l w a ll o f th e T h o rax.

Atrium dextrum

Pleural folds or mesopneumonium

Ventriculus dexter

i- Clinical Remarks D u rin g a u s c u lta tio n o f th e h e a rt u s in g a s te th o s c o p e h e a rt s o u n d s are d e te c te d a t se v e ra l lo c a tio n s . T h e s e s o u n d s are th e re s u lt o f th e n o rm a l h e a rt a c tio n : • T h e fir s t h e a rt s o u n d (S 1 ) is g e n e ra te d a t th e b e g in n in g o f th e

•

s y s to le d u e to v e n tric u la r c o n tra c tio n a nd c lo s u re o f th e a trio v e n tric u la r v a lve s. T h e s e c o n d h e a rt s o u n d (S 2 ) is g e n e ra te d a t th e b e g in n in g o f th e d ia s to le d u e to th e c lo s u re o f th e s e m ilu n a r v a lve s.

T h e p ro je c tio n o f th e h e a rt c o n to u rs , w h ic h are c o v e re d b y th e R e c e s s u s c o s to m e d ia s tin a le s , e q u a ls th e re la tiv e c a rd ia c d u lln e s s s in c e th e p e rc u s s io n s o u n d is le s s a b s o rb e d . If th is area e x te n d s to th e le f t s id e b e y o n d th e m id c la v ic u la r lin e , le f t v e n tric u la r h y p e rtro p h y is like ly. T h e T rig o n u m p e ric a rd ia c u m is th e area in w h ic h th e h e a rt is d ire c tly a d ja c e n t t o th e v e n tra l th o ra c ic w a ll. T h is is re fe rre d to as th e area o f th e a b s o lu te c a rd ia c d u lln e s s s in c e th e p e rc u s s io n s o u n d is m a x im a lly a b s o rb e d . A lth o u g h th e T rig o n u m p e ric a rd ia c u m h as o n ly

In c o n tra s t, h e a rt m u r m u rs are a lw a y s p a th o lo g ic a l p h e n o m e n a a nd are g e n e ra te d b y m a lfu n c tio n o f h e a rt v a lv e s . N a rro w in g (s te n o

m in o r d ia g n o s tic v a lu e , it m a y be re le v a n t to d e te rm in e th e p o s itio n o f th e r ig h t v e n tric le fo r e m e rg e n c y in tra c a rd ia c in je c tio n s . H ere,

sis) a s w e ll as in s u ffic ie n t c lo s u re (in s u ffic ie n c y ) o f th e v a lv e s m a y c a u s e h e a rt m u rm u rs . T h e tim e p o in t a nd th e lo c a tio n o f th e m u rm u r

th e ris k o f in ju rin g th e P leura a n d th u s in d u c in g a p n e u m o th o ra x is m in im a l. In tra c a rd ia c in je c tio n s are p e rfo rm e d in th e fo u r th o r fifth

p ro v id e in fo rm a tio n a b o u t th e n a tu re o f th e d y s fu n c tio n o f th e a f fe c te d va lve . T h e p e rc u s s io n o f th e h e a rt is u s e d to a s s e s s its size.

in te rc o s ta l s p a c e a p p ro x im a te ly 2 c m le ft p a ra s te rn a l. H o w e v e r, th is p ro c e d u re is h aza rd o us a n d n o t re c o m m e n d e d a n y m o re .

Thym us -► Topography -► Sections

P rojection o f th e heart

Trachea

Arcus ao rtae

Truncus pulm onalis

Auricula sinistra

Ventriculus sinister

Diaphragma

Recessus costodiaphragmaticus

Fig. 5 .3 T h o ra c ic c a g e , C a v e a th o ra c is , w it h th o ra c ic v is c e ra ; ra d io g ra p h in p o s te ro -a n te rio r (PA) b e a m p ro je c tio n .

T h e ra d io g ra p h ca n b e u s e d to a s s e s s th e size o f th e h e a rt. In a d d itio n to th e a b s o lu te size, k n o w le d g e o f th e s tru c tu re s c o n trib u tin g to th e h e a rt c o n to u rs is o f im p o rta n c e .

Fig. 5 .4 S c h e m a tic d r a w in g o f th e h e a rt c o n to u rs in th e ra d io g ra p h . F ro m cranial to ca ud a l, th e r ig h t b o rd e r o f th e h e a rt is fo rm e d b y th e fo llo w in g s tru c tu re s : • s u p e rio r v e n a cava (V. cava su p e rio r) •

rig h t a triu m (A triu m d e x te r)

F ro m cra nia l t o ca ud a l, th e le ft b o rd e r o f th e h e a rt is fo r m e d b y th e fo llo w in g s tru c tu re s : • •

a o rtic a rch (A rc u s a o rta e) T ru n c u s p u lm o n a lis

• •

le ft a u ric le (A u ricu la s in istra ) le f t v e n tric le (V e n tric u lu s sin is te r)

T h u s , th e rig h t v e n tric le d o e s n o t c o n trib u te to a n y o f th e ca rd ia c b o r d e rs ! M = M e d ia n a xis o f th e b o d y

i- Clinical R em arks-------------------------------------T h e c o n v e n tio n a l ra d io g ra p h o f th e T h o ra x p ro v id e s in fo rm a tio n on th e size o f th e h e a rt. T h e tra n s v e rs e d ia m e te r o f th e h e a rt s h o w s in

v a lv e s , re s p e c tiv e ly , m a y be c a u s a lly in v o lv e d . In c o n tra s t, an e n la rg e m e n t o f th e rig h t v e n tric le , as in p u lm o n a ry h y p e rte n s io n , c h ro

d iv id u a l d iffe re n c e s . H o w e v e r, if it is la rg e r th a n h a lf o f th e d ia m e te r o f th e T h o ra x , an e n la rg e m e n t o f th e h e a rt is p re s e n t w h ic h m a y be

nic o b s tru c tiv e p u lm o n a ry d is e a s e (C O P D ), o r p u lm o n a ry e m b o li are n o t re c o g n is e d w ith a s a g itta l ra d io g ra p h o f th e T h o ra x . T h is is e x p

c a u s e d b y h y p e r tro p h y o f th e ca rd ia c m u s c le o r b y d ila tio n o f th e c a rd ia c w a ll. F re q u e n tly , th e h e a rt is e n la rg e d to th e le ft s id e (Facies

lain e d b y th e fa c t th a t th e rig h t v e n tric le d o e s n o t c o n trib u te to a n y o f th e c a rd ia c c o n to u rs . In th is ca se, la te ra l ra d io g ra p h ic p ro je c tio n s o r

p u lm o n a lis sin is tra ) in d ic a tiv e o f le ft v e n tric u la r p a th o lo g ie s . A r t e r i al h y p e rte n s io n , s te n o s is , o r in s u ffic ie n c y o f th e a o r tic o r m itr a l

to m o g ra p h ic m e th o d s s u c h as c o m p u te d to m o g ra p h y (CT) o r m a g n e tic re s o n a n c e to m o g ra p h ic im a g in g (M R I) a re re q u ire d .

T horacic Viscera

Heart -► Lungs -» Oesophagus

D e ve lo p m e n t

Day 15

Day 21 Saccus aorticus Aortic arches

Ventriculus dexter

Atrium dextrum

Fig. 5 .5

Canalis atrioventricularis

Atrium sinistrum

S ta g e s o f c a rd ia c d e v e lo p m e n t d u rin g w e e k s 3 t o 5.

(a cco rd in g to [2])

w it h th e S in u s v e n o s u s c o lle c tin g in c o m in g b lo o d , o n e v e n tric le , and th e C o n u s a rte rio s u s as th e o u t flo w s e g m e n t. C a u s e d b y d iffe re n tia l

A t w e e k 3 , th e in itia lly h o rs e s h o e -s h a p e d e n d o c a rd ia l t u b e d e v e lo p s fr o m a v a s c u la r p le x u s in th e c a rd io g e n ic m e s o d e rm . S e v e ra l gap s

lo n g itu d in a l g r o w th a nd re o rg a n is a tio n o f th e re s p e c tiv e s e g m e n ts , d u rin g w e e k s 4 - 5 th e ca rd ia c tu b e d e v e lo p s in to th e S -sh ap e d h e a rt

a ro u n d th e e n d o c a rd ia l tu b e m e rg e to e s ta b lis h th e p e ric a rd ia l c a v ity w h ic h c o n n e c ts w it h th e g e n e ra l b o d y ca vity. T h e in n e r la y e r o f th e

lo o p . T h e tra n s itio n b e tw e e n a triu m a nd v e n tric le is c o n s tric te d to fo rm th e u n p a ire d a trio v e n tric u la r canal. T h e la tte r o rig in a lly o p e n s in to th e

p e ric a rd ia l c a v ity c o n d e n s e s to fo r m th e M y o c a rd iu m . T h e E p ic a rd iu m d e v e lo p s fr o m c e lls w h ic h m ig ra te fr o m th e S e p tu m tra n s v e rs u m a nd

le ft p a rt o f th e v e n tric le , b u t is la te r s h ifte d to th e m id lin e a nd p a rtiti o n e d in to a rig h t a n d le ft a trio v e n tric u la r o p e n in g th ro u g h e n d o c a rd ia l c u s h io n s . T h e s e e n d o c a rd ia l c u s h io n s la te r fo r m th e a trio v e n tric u la r

th e liv e r p rim o rd iu m . T h e la te ra l c ru s o f th e e n d o c a rd ia l tu b e fu s e to b u ild th e c a rd ia c tu b e w h ic h c o n tra c ts rh y th m ic a lly fro m th e e n d o f w e e k 3 o n w a rd s . T h e ca rd ia c tu b e in itia lly c o m p ris e s a p a ire d a triu m

v a lve s.

from week 8

Aa. carotides communes A. subclavia Arcus aortae A. subclavia Ductus arteriosus A. pulmonalis sinistra V. cava superior Truncus pulmonalis Valva aortae Foramen ovale Valva atrioventricularis sinistra [Valva mitralis] Valva trunci pulmonalis Valva atrioventricularis dextra [Valva tricuspidalis]

Pars m em branacea' Septum interventriculare Pars muscularis Ventriculus sinister

V. cava inferior

Ventriculus dexter

Fig. 5 .6 S ta g e s o f c a rd ia c d e v e lo p m e n t d u rin g w e e k s 5 t o 7. (a c c o rd in g to [2])

T h e p rim itiv e a o r tic a rc h e s (a rte rie s o f th e p h a ry n g e a l a rc h e s ) d e riv e

D u rin g w e e k s 5 - 7 , th e in te r v e n tric u la r s e p tu m d e v e lo p s (Pars m u s

fr o m th e S a ccu s a o rtic u s . F ro m th e o rig in a l s ix a o rtic a c h e s , o n ly th e th ird , fo u rth a nd s ix th c o n trib u te to th e d e v e lo p m e n t o f th e g re a t v e s

cu la ris), w h ic h in c o m p le te ly s e p a ra te s th e t w o v e n tric le s . T h e la tte r c o m m u n ic a te u n til th e e n d o f w e e k 7 w h e n th e fo rm a tio n o f th e Pars

s e ls . T h e A . c a ro tis c o m m u n is d e riv e s fr o m th e th ird a o rtic a rc h . P arts o f th e A . s u b c la v ia a nd th e a o rtic a rch d e v e lo p fr o m th e fo u r th a o rtic

m e m b ra n a c e a o f th e s e p tu m c o m p le te s th e v e n tric u la r s e p a ra tio n . T h e C o n u s a rte rio s u s o f th e o u t flo w tr a c t is s e p a ra te d s p ira lly and, to g e th e r

a rc h e s on th e rig h t a n d le ft s id e , re s p e c tiv e ly . T h e p ro x im a l p a rts o f th e r ig h t a nd le f t p u lm o n a ry a rte ry a nd th e D u c tu s a rte rio s u s d e v e lo p fro m

w it h th e a d ja c e n t S a ccu s a o rtic u s , fo r m s th e T ru n c u s p u lm o n a lis a nd th e A o r ta .

th e rig h t a n d le ft s ix th a o rtic a rc h e s , re s p e c tiv e ly .

Thym us -► Topography -► Sections

D e ve lo p m e n t Septum spurium »

Ostium secundum

Septum primum

Ostium secundum

Ostium primum

Sinus valves Septum secundum

Septum secundum

Foramen ovale Valvula venae cavae inferioris

Sinus septum

Figs. 5 .7 a t o f

D e v e lo p m e n ta l s te p s in s e p tu m fo r m a tio n d u rin g

Valvula sinus coronarii

c, e

w e e k s 5 (a, b ), 6 (c, e ), 7 a n d 8 (d , f); v ie w fr o m th e o p e n e d rig h t a tri u m (a -d ) a nd in th e fo u r-c h a m b e r p la n e (e a nd f). (a c c o rd in g t o [2]) a

S e p tu m fo rm a tio n in th e a tria o c c u rs d u rin g w e e k s 5 - 7 a n d b e g in s w it h th e g ro w th o f th e S e p tu m p r im u m fro m d o rsa l a nd cranial

d, f

O n th e r ig h t s id e o f th e S e p tu m p r im u m , th e S e p tu m s e c u n d u m d e v e lo p s . B o th s e p ta lie a d ja c e n t to e a c h o th e r a nd o u tlin e th e F o ra m e n o vale . T h e S e p tu m p rim u m fo r m s th e V a lv u la fo r a m in is o v a lis w h ic h fa c ilita te s th e d ire c tio n a l b lo o d flo w fr o m th e rig h t in to th e le ft a triu m (-► Fig. 5.8 ). A ft e r b irth , th e V a lvu la fo ra m in is o v a lis c lo s e s

u n til th e O s tiu m p r im u m is fo rm e d , b W ith in th e u p p e r p a rt o f th e S e p tu m p rim u m , th e O s tiu m s e c u n

th e F o ra m e n o v a le d u e to th e in c re a s e d b lo o d p re s s u re in th e le ft a triu m (-» Fig. 5.1 0 ).

d u m is c re a te d th ro u g h p ro g ra m m e d c e ll d e a th (a p o p to sis). *

s e c tio n a l p la n e in e, f

i- Clinical re m a rk s --------------------------------------C o n g e n ita l c a rd ia c d e fe c ts are d e te c te d in 0 .7 5 % o f all n e w b o rn s

•

a n d th u s re p re s e n t th e m o s t c o m m o n d e v e lo p m e n ta l d e fe c ts . L u c kily, n o t all ca rd ia c d e fe c ts h a ve fu n c tio n a l re le v a n c e a n d re q u ire th e ra p e u tic in te rv e n tio n . T o u n d e rs ta n d th e c a u s e a nd th e s y m p

D e fe c ts w ith

a r ig h t-to -le ft s h u n t (F A L L O T 's te tra lo g y 9 % ,

tra n s p o s itio n o f th e g re a t v e s s e ls 5 % ) are c h a ra c te ris e d b y a b lu ish tin g e o f th e s k in a n d m u c o u s m e m b ra n e s (c ya no sis) b e c a u s e d e o x y g e n a te d b lo o d e n te rs th e s y s te m ic c irc u la tio n .

to m s o f h e a rt d e fe c ts in c h ild re n a nd a d o le s c e n ts , o n e h as to be fa m ilia r w it h th e b a sic s te p s in ca rd ia c d e v e lo p m e n t. B e ca u se o f th e ir

•

c lin ic a l s ig n ific a n c e a nd th e re le v a n c e fo r e x a m s in d iffe r e n t d is c i p lin e s , th e m o s t im p o rta n t d e v e lo p m e n ta l ca rd ia c d e fe c ts are b rie fly

in th e h y p e rtro p h y o f th e a ffe c te d v e n tric le . T h e F A LL O T's t e t r a lo g y c o m p ris e s a c o m b in a tio n o f a v e n tric u la r

e x p la in e d . T h e y are d iv id e d in th re e p a th o p h y s io lo g ic a l g ro u p s : • T h e m o s t fre q u e n t d e fe c ts are th o s e w it h re s u ltin g le ft-to -r ig h t

s e p ta l d e fe c t, p u lm o n a ry s te n o s is , rig h t v e n tric u la r h y p e rtro p h y , a nd " o v e r r id in g " a o rta . D u e to a s y m m e tric s e p ta tio n o f th e C o n u s a rte

s h u n t (v e n tric u la r s e p ta l d e fe c t 2 5 % , a tria l s e p ta l d e fe c t 1 2 % , p a te n t d u c tu s a rte rio s u s [-» p. 9] 1 2 % ). D u e to th e h ig h e r b lo o d

rio s u s , th e p u lm o n a ry v a lv e is to o n a rro w a nd th e a o rta is to o w id e a n d s h ifte d to th e rig h t s id e a b o v e th e s e p tu m (" o v e r r id in g " ) . U n tre

p re s s u re in th e s y s te m ic c irc u la tio n , th e b lo o d s h u n ts fr o m th e le ft h e a rt to th e rig h t h e a rt a n d in to th e p u lm o n a ry c irc u la tio n .

a te d , th e p u lm o n a ry s te n o s is c a u s e s h y p e rtro p h y o f th e rig h t v e n tric le w ith s u b s e q u e n t r ig h t-to -le ft s h u n t via th e v e n tric u la r s e p ta l

If th is s h u n t is n o t c o rre c te d s u rg ic a lly th e d e v e lo p in g p u lm o n a ry h y p e rte n s io n m a y c a u s e a s e c o n d a ry rig h t v e n tric u la r in s u ffi

d e fe c t a n d c y a n o s is .

cie n cy.

H e a rt d e fe c ts c a u s in g o b s tru c tio n (p u lm o n a ry v a lv e s te n o s is , a o rtic v a lv e s te n o s is , a o rtic c o a rc ta tio n [ - * p. 9 ] 6 % each) re s u lt

T horacic Viscera

Heart -► Lungs -» Oesophagus

Prenatal circulation

Arcus aortae

Ductus arteriosus Truncus pulmonalis V. cava superior Atrium sinistrum

Foram en ovale Atrium dextrum Ventriculus sinister

Septum interventriculare V. cava inferior

Ventriculus dexter

V. hepaticae ------ ^

Aorta thoracica

Ductus venosus

Ductus

V. cava inferior

Vesica b ilia ris ------ r

V. umbilicalis

V. portae hepatis

V. um bilicalis

Fig. 5 .9

Aa. um bilicales

F o e ta l liv e r; d o rs a l v ie w .

A r r o w s m a rk th e d ire c tio n o f b lo o d flo w . T h e D u c tu s v e n o s u s o b lite ra te s p o s tn a ta lly and A. iliaca communis

re m a in s a s Lig. v e n o s u m a t th e h ilu m o f th e liver.

A. iliaca externa A. iliaca interna

Vesica urinaria

Fig. 5 .8

P re n a ta l c irc u la tio n (fo e ta l c irc u la tio n ); s c h e m a tic

o x y g e n a tio n th e b lo o d fr o m th e p la c e n ta re a c h e s th e fo e tu s via th e V.

illu s tra tio n . T h is illu s tra tio n d is tin g u is h e s th e d iffe r e n t o x y g e n c o n te n ts o f th e

u m b ilic a lis a nd b y p a s s e s th e liv e r th ro u g h th e D u c tu s v e n o s u s d u e to th e h ig h f lo w re s is ta n c e o f th e fo e ta l liv e r. A v a lv e a t th e o p e n in g o f th e

b lo o d b y c o lo u r c o d in g s : o x y g e n a te d b lo o d (red), d e o x y g e n a te d b lo o d (blue), m ix e d b lo o d (p urp le ). T h e a rro w s m a rk th e d ire c tio n o f b lo o d flo w .

in fe rio r v e n a cava (V alvula v e n a e ca vae in fe rio ris ) d ire c ts th e in c o m in g b lo o d p re d o m in a n tly th ro u g h th e F o ra m e n o v a le to th e le ft a triu m .

T h e fo llo w in g a s p e c ts d is tin g u is h th e fo e ta l c irc u la tio n fr o m th e p o s tn a

T h is w a y , th e o x y g e n a te d b lo o d ta k e s th e s h o r te s t w a y to re ach th e fo e ta l o rg a n s . B lo o d fr o m th e s u p e rio r v e n a cava e n te rs th e rig h t a triu m

ta l c irc u la tio n : u m b ilic a l b lo o d v e s s e ls , D u c tu s v e n o s u s , D u c tu s a rte rio su s, F o ra m e n o v a le (-► Fig. 5.1 0 ).

a nd rig h t v e n tric le . F ro m th e r ig h t v e n tric le it re a c h e s th e T ru n c u s p u l m o n a lis a nd is s h u n te d th ro u g h th e D u c tu s a rte rio s u s d ire c tly in to th e

D e o x y g e n a te d b lo o d fr o m th e fo e tu s is c o n v e y e d to th e p la c e n ta b y th e A a . u m b ilic a le s w h ic h d e riv e fr o m th e A a. ilia cae in te rn a e . A fte r

A o rta , th u s b y p a s s in g th e n o n -fu n c tio n a l lu n g c irc u la tio n .

Thym us -► Topography -► Sections

Postnatal circulation

Arcus aortae

Lig. arteriosum

Aa. pulmonales

Vv. pulmonales sinistrae V. cava superior Foramen ovale

■Atrium sinistrum Truncus pulmonalis

Atrium dextrum Ventriculus sinister Ventriculus dexter

Vv. hepaticae Hepar Lig. venosum

V. portae hepatis

Aorta abdominalis V. cava inferior

Umbilical cord

(Ligg. um bilicalia m edialia)

Fig. 5 .1 0

S c h e m a tic illu s tra tio n o f th e p o s tn a ta l c irc u la tio n .

A fte r b irth th e p la c e n ta l c irc u la tio n is in te rru p te d . In fla tio n o f th e lu n g s d u e to b re a th in g o p e n s th e p u lm o n a ry c irc u la tio n a nd c a u s e s an in

T h e D u c tu s a rte rio s u s fu n c tio n a lly c lo s e s w ith in a f e w d ays a n d la te r o b lite ra te s to th e Lig. a rte r io s u m (-► Fig. 5.1 3 ).

c re a s e in b lo o d p re s s u re in th e le ft a triu m . T h e s w itc h fr o m p re n a ta l to

T h e D u c tu s v e n o s u s o b lite ra te s p o s tn a ta lly a nd re m a in s as Lig. v e n o s u m a t th e h ilu m o f th e live r.

p o s tn a ta l c irc u la tio n in c lu d e s th e fo llo w in g ch a n g e s : T h e v a lv e -lik e o p e n in g o f th e F o ra m e n o v a le b e tw e e n th e rig h t a nd le ft a triu m is

T h e u m b ilic a l v e in o b lite ra te s a nd re m a in s as Lig. te re s h e p a tis b e tw e e n liv e r a n d v e n tra l a b d o m in a l w a ll.

c lo s e d p a s s iv e ly d u e to th e in c re a s e d b lo o d p re s s u re in th e le ft a triu m . L a te r, th e V a lvu la fo ra m in is o v a lis fu s e s w it h th e S e p tu m s e c u n d u m le a v in g th e p e rs is te n t Fossa o v a lis in th e rig h t a triu m .

T h e d is ta l p a rts o f th e u m b ilic a l a rte rie s fo r m th e Lig. u m b ilic a le m e d i ate on th e rig h t a n d le ft s id e , w h ic h c o n trib u te to th e fo rm a tio n o f th e re s p e c tiv e Plica u m b ilic a lis m e d ia lis a t th e in te rn a l re lie f o f th e v e n tra l a b d o m in a l w a ll.

P Clinical R em arks-------------------------------------P a te n t D u c tu s a rte rio s u s : S in ce p ro s ta g la n d in E2 d ila te s th e d u c

A o r tic c o a rc ta tio n : If th e c lo s u re o f th e D u c tu s a rte rio s u s e x te n d s

tu s , p ro s ta g la n d in s y n th e s is in h ib ito rs m a y b e s u c c e s s fu lly a p p lie d to c lo s e th is v e s s e l a nd p re v e n t su rg ic a l in te rv e n tio n . H o w e v e r, th e ir

to th e a d ja c e n t p a rts o f th e a o rtic a rch th is m a y c a u s e an a o rtic c o a rc ta tio n . A s a re s u lt, a le ft v e n tric u la r h y p e rtro p h y d e v e lo p s w ith

use as a n ti-in fla m m a to ry a g e n ts in p re g n a n t w o m e n m a y re s u lt in p re m a tu re c lo s u re o f th e D u c tu s a rte rio s u s in th e fo e tu s . P a te n t F o ra m e n o v a le : A p p ro x im a te ly 2 0 % o f th e a d u lt p o p u la tio n

c o n c o m ita n t a rte ria l h y p e rte n s io n in th e u p p e r b o d y a nd lo w a rte ria l b lo o d p re s s u re in th e lo w e r body. P h ysica l e x a m in a tio n re v e a ls a

have a re m a in in g o p e n in g in th e area o f th e F o ra m e n o va le . U s u

s y s to lic h e a rt m u r m u r b e tw e e n b o th sca p u la e . R a d io lo g ic a l fin d in g s m a y in c lu d e n o tc h in g o f th e rib s d u e to a s tro n g c o lla te ra l c irc u la tio n

a lly, th is has no fu n c tio n a l re le v a n c e . In s o m e ca se s, h o w e v e r, th is o p e n in g m a y fa c ilita te a s c e n d in g e m b o li d is lo d g e d fr o m cru ral

fro m th e A . th o ra c ic a in te rn a via th e in te rc o s ta l a rte rie s . T h e s te n o s is is tre a te d s u rg ic a lly o r w ith d ila tio n to p re v e n t h e a rt fa ilu re o r

th r o m b i to re ach th e s y s te m ic c irc u la tio n a nd c a u s e an o rg a n in fa rc tio n o r s tro k e .

s tro k e s w h ic h o c c u r a lre a d y a t a y o u n g age.

T horacic Viscera

Heart -► Lungs -» Oesophagus

The heart in-situ

(Nodi lymphoidei mediastinales anteriores) N. vagus [X]

N. laryngeus recurrens V. cava superior

Lig. arteriosum A. pulmonalis dextra V. pulmonalis sinistra superior

A. pulmonalis sinistra

Pars ascen d en s ao rtae V. pulmonalis sinistra inferior

V. pulmonalis dextra

Truncus pulm onalis Ventriculus sinister

A trium dextrum

A p ex cordis Nodi lymphoidei phrenici superiores

Fig. 5.11

P o s itio n o f th e h e a rt. C or, w ith in th e th o r a x . S itu s

fo r m s an a n g le o f 4 5 ° w it h all t h r e e a n a to m in a l p la n e s . T h e h e a rt

c o rd is ; v e n tra l v ie w ; a fte r o p e n in g o f th e P e ric a rd iu m .

h as fo u r s u rfa c e s (-► Fig. 5.2 ). T h e a n te rio r s u rfa c e (Fa cies s te rn o c o s ta -

T h e h e a rt is p o s itio n e d w ith in th e p e rica rd ia l c a v ity (C avita s p e ric a rd ia ca) in th e in fe rio r m id d le m e d ia s tin u m . T h e b ro a d b a se o f th e h e a rt is

lis) is p re d o m in a n tly fo rm e d b y th e r ig h t v e n tric le s . T h e in fe rio r s u rfa c e is a d ja c e n t to th e d ia p h ra g m a nd c o n s is ts o f p a rts o f th e r ig h t a nd le ft

o rie n te d in an o b liq u e d ire c tio n to w a rd s th e s u p e rio r rig h t s id e a nd c o r re s p o n d s to th e v a lv u la r p la n e a t th e b a se o f th e g re a t v e s s e ls . T h e

v e n tric le s . T h e in fe rio r s u rfa c e c lin ic a lly re p re s e n ts th e " p o s te r io r w a ll" in th e d ia g n o s tic e le c tro c a rd io g ra m (ECG) w h e n re fe rre d to as p o s te rio r

a p e x o f th e h e a rt (A p e x co rd is ) p o in ts to th e in fe rio r le ft s id e a nd v e n trally. Base a nd a p e x a re c o n n e c te d b y th e lo n g itu d in a l a x is (12 c m ) w h ic h s h o w s an o b liq u e c o u rs e in th e T h o ra x d ire c te d fr o m th e dorsa l

m y o c a rd ia l in fa rc tio n . T h e F a cies p u lm o n a lis is d e te rm in e d b y th e rig h t a triu m on th e rig h t s id e a nd b y th e le f t v e n tric le on th e le f t s ide .

rig h t s id e to th e v e n tra l le f t s id e . T h u s, th e lo n g itu d in a l a x is o f th e h e a rt

Thym us -► Topography -► Sections

Pericardium

Arcus aortae N. phrenicus A.; V. pericardiacoph renica

Pulmo sinister V. cava superior Plexus aorticus thoracicus N. vagus [X] Pleura parietalis, Pars mediastinalis

N. laryngeus recurrens

Pulmo dexter

A. pulmonalis

Sinus transversus pericardii

Bifurcatio trunci pulmonalis

V. pulmonalis dextra superior

Pleura parietalis, Pars m ediastinalis

V. pulmonalis dextra inferior

V. pulmonalis sinistra superior

V. pulmonalis sinistra inferior

Sinus obliquus pericardii

P ericardium serosum , Lam ina parietalis Pleura parietalis, Pars diaphragmatica

V. cava inferior Pericardium fibrosum

Fig. 5 .1 2

P e ric a rd iu m , P e ric a rd iu m ; v e n tra l v ie w ; a fte r re m o v a l o f

S in u s tra n s v e rs u s p e ric a rd ii: a b o v e th e h o riz o n ta l fo ld b e tw e e n

th e a n te rio r p a rt o f th e P e ric a rd iu m a n d th e h e a rt.

th e V. cava s u p e rio r (p o s te rio r) a nd th e A o rta a nd T ru n c u s p u lm o n a lis (a nte rio r)

T h e P e ric a rd iu m s u rro u n d s th e h e a rt, s ta b ilis e s its p o s itio n a nd e n a b le s th e h e a rt to c o n tra c t w it h o u t fric tio n . T h e o u te r la ye r o f d e n s e c o n n e c tiv e tis s u e is th e P e ric a rd iu m fib ro s u m . A d ja c e n t to th e P e ric a rd iu m fib ro s u m o n th e in n e r s id e is th e T u n ica se ro s a o r P e ric a rd iu m s e ro s u m w h ic h c o m p ris e s th e p a rie ta l la ye r (L am in a p a rie ta lis) o f th e P eri c a rd iu m s e ro s u m . T h is L am in a p a rie ta lis is a c o n tin u a tio n o f th e Lam in a v is c e ra lis o f th e P e ric a rd iu m (= E p ic a rd iu m ) fo ld in g b a c k a t th e v e n tra l

S in u s o b liq u u s p e ric a rd ii: b e lo w th e h o riz o n ta l fo ld b e tw e e n th e p u lm o n a ry v e in s on b o th s id e s T h e P e ric a rd iu m fib r o s u m is c o n n e c te d to : • th e C e n tru m te n d in e u m o f th e d ia p h ra g m • •

th e p o s te rio r a s p e c t o f th e S te rn u m (L ig g . s te rn o p e ric a rd ia c a ) th e tra c h e a l b ifu rc a tio n (M e m b ra n a b ro n c h o p e ric a rd ia c a )

s id e o f th e ro o ts o f th e g re a t ca rd ia c v e s s e ls . A t th e p o s te rio r s id e o f th e a tria , th e re fle c tio n b e tw e e n th e E p ic a rd iu m a nd th e p a rie ta l P eri

A t th e o u te r s id e , th e fib ro u s P e ric a rd iu m is c o v e re d b y th e P le u ra p a rie ta lis . P ars m e d ia s tin a lis . T h e N. p h re n ic u s a n d th e V asa p e ric a r

c a rd iu m fo r m s a v e rtic a l fo ld b e tw e e n th e V. cava in fe rio r a n d s u p e rio r a n d a h o riz o n ta l fo ld b e tw e e n th e u p p e r p u lm o n a ry v e in s o f th e rig h t

d ia c o p h re n ic a c o u rs e b e tw e e n th e s e t w o laye rs. T h e E p ic a rd iu m is th e v is c e ra l la y e r o f th e P e ric a rd iu m s e ro s u m .

a n d le ft sid e . T h e s e fo ld s o f th e P e ric a rd iu m c re a te t w o s in u s e s o f th e p e ric a rd ia l c a v ity a t th e p o s te rio r s id e (S inu s p e ric a rd ii, a rro w s ):

i-C linical R em arks-------------------------------------T h e p e ric a rd ia l c a v ity u su a lly c o n ta in s 15 - 3 5 m l o f s e ro u s flu id . The

F o llo w in g ru p tu re o f th e ca rd ia c w a ll d u e to m y o c a rd ia l in fa rc tio n o r

P e ric a rd iu m h as a to ta l v o lu m e o f 7 0 0 - 1 1 0 0 m l, in c lu d in g th e h e a rt. W ith d is e a s e s a c c o m p a n ie d b y in fla m m a to ry re a c tio n s o f th e p e ri

in ju ry (sta b w o u n d s ), b lo o d m a y ra p id ly a c c u m u la te in th e p e ric a rd ia l c a v ity a nd in h ib it th e ca rd ia c fu n c tio n s re s u ltin g in d e a th (p e ric a rd ia l ta m p o n a d e ).

c a rd iu m (p e ric a rd itis ) o r w it h in s u ffic ie n c y o f th e h e a rt, a d d itio n a l flu id m a y a c c u m u la te (p e ric a rd ia l e ffu s io n ) w h ic h m a y e v e n im p e d e th e ca rd ia c fu n c tio n .

T horacic Viscera

Heart -► Lungs -» Oesophagus

Heart

carotis communis sinistra subclavia sinistra Truncus brachiocephalicus

Arcus aortae

V. cava superior

Lig. arteriosum A. pulmonalis sinistra

Truncus pulm onalis A. pulmonalis dextra

Pericardium serosum, Lamina parietalis

Pericardium serosum, Lamina parietalis Auricula sinistra

Auricula dextra V. cardiaca [cordis] magna

Conus arteriosus

A. coronaria sinistra, R. circumflexus

Atrium dextrum

A. coronaria sinistra, R. interventricularis anterior

Sulcus coronarius V. interventricularis anterior

V. cardiaca [cordis] parva

Ventriculus sinister A. coronaria dextra

Ventriculus dexter

Pericardium serosum, Lamina visceralis [Epicardiumj A p ex cordis Pericardium serosum, Lamina parietalis Sulcus interventricularis an terior

Fig. 5 .1 3

H e a rt, C or; v e n tra l v ie w .

S u lc u s in te r v e n tric u la r is p o s te r io r (-* Fig. 5.1 4 ). P rio r t o th e tra n s i

T h e h e a rt w e ig h s 2 5 0 -3 0 0 g a nd has a p p ro x im a te ly th e size o f th e f is t

tio n in to th e T ru n c u s p u lm o n a lis , th e rig h t v e n tric le is d ila te d as C o n u s

o f th e re s p e c tiv e p e rs o n . T h e a p e x o f th e h e a rt (A p e x co rd is ) is d ire c te d to th e in fe rio r le ft sid e . T h e b a se o f th e h e a rt re p re s e n ts th e p o s itio n o f th e S u lc u s c o ro n a riu s w h ic h h a rb o u rs , a m o n g o th e r s tru c tu re s , th e A.

a rte rio s u s . T h e o rig in o f th e A o rta fr o m th e le ft v e n tric le is n o t v is ib le fr o m th e o u te r s u rfa c e d u e to th e s p ira l c o u rs e o f th e A o rta b e h in d th e

c o ro n a ria d e x tra . T h e h e a rt c o n s is ts o f a v e n tric u la r c h a m b e r (v e n tric le ) a nd an a tria l c h a m b e r (a triu m ) o n th e rig h t a nd le ft sid e , re s p e c tiv e ly . A t th e a n te rio r s u rfa c e (Facies s te rn o c o s ta lis ), th e S u lcu s in te r v e n tric u laris a n te rio r is v is ib le . It d e p ic ts th e p o s itio n o f th e in te rv e n tric u la r s e p tu m (S e p tu m in te rv e n tric u ia re ) a n d c o n ta in s th e R. in te rv e n tric u la ris a n te rio r o f th e A . c o ro n a ria s in is tra . A t th e in fe rio r s u rfa c e (Fa cies diap h ra g m a tic a ), th e b o rd e r b e tw e e n th e t w o v e n tric le s is m a rk e d b y th e

T ru n c u s p u lm o n a lis . T h e re fo re , th e A o rta a p p e a rs a t th e rig h t s id e o f th e T ru n c u s p u lm o n a lis . T h e a o rtic a rch is c o n n e c te d w ith th e p u lm o n a ry tru n k th ro u g h th e L ig . a rte rio s u m , a d e v e lo p m e n ta l re lic t o f th e D u c tu s a rte rio s u s o f th e fo e ta l c irc u la tio n (-* Fig. 5.8). B o th a tria have an a n te rio r p o u c h w h ic h is re fe rre d to as a u ric le (A u ric u la e d e x tra and sin is tra ). T h e V. cava s u p e rio r a n d in fe rio r e n te r th e rig h t a triu m , th e fo u r p u lm o n a ry v e in s e n te r th e le ft a triu m .

Thym us -► Topography -► Sections

Heart

V. brachiocephalica dextra

A. subclavia sinistra

V. brachiocephalica sinistra

A. carotis communis sinistra

Truncus brachiocephalicus Arcus aortae

Pars descendens aortae [Aorta descendens] Lig. arteriosum V. cava sup erior Pars ascendens aortae [Aorta ascendens] A. pulmonalis sinistra Pericardium A. pulmonalis dextra

Sinus transversus pericardii Vv. pulmonales dextrae

Truncus pulm onalis Vv. pulmonales sinistrae

Sinus obliquus pericardii

Auricula sinistra

Atrium sinistrum V. cardiaca [cordis] magna Pericardium serosum, Lamina parietalis

A. coronaria sinistra, R. circumflexus

Atrium dextrum

Pericardium serosum, Lamina visceralis [Epicardium]

Sulcus terminalis

V. cava inferior Ventriculus sinister Sinus coronarius Sulcus coronarius

A p ex cordis

A. coronaria dextra, R. interventricularis posterior Ventriculus dexter V. cardiaca [cordis] media, [V. interventricularis posterior]

Sulcus interventricularis posterior

Fig. 5 .1 4

H e a r t, C or; d o rs a l v ie w (e x p la n a tio n -» Fig. 5.1 3 ).

P Clinical R em arks-------------------------------------M o s t h e a rts s e e n in th e g ro s s a n a to m y d is s e c tio n c o u rs e are e n larg e d . T h is c le a rly s h o w s h o w fr e q u e n tly d is e a s e s o c c u r th a t p re s e n t w it h e ith e r h y p e r tro p h y (e.g. a rte ria l h y p e rte n s io n ) o r d ila tio n (a lco h o l a b u s e , viral in fe c tio n s ) o f th e hea rt.

T h e w e ig h t o f th e h e a rt in p ro fe s s io n a l a th le te s (tra in in g , a n a b o lic s u b s ta n c e s ) m a y re ach 5 0 0 g. T h is is c o n s id e re d th e c ritic a l h e a rt w e ig h t s in c e s u ffic ie n t b lo o d s u p p ly is n o t w a rra n te d a b o v e th is w e ig h t w it h re s u ltin g ris k o f m y o c a rd ia l in fa rc tio n . S o m e p a th o lo g ic c o n d itio n s m a y c a u s e th e h e a rt to w e ig h up to 1 1 0 0 g, a c o n d itio n re fe rre d to a c o r b o v in u m (b o v in e heart).

T horacic Viscera

Heart -► Lungs -» Oesophagus

Cardiac w all

Fig. 5 .1 5 S tr u c tu r e o f th e c a rd ia c w a ll; m ic ro s c o p ic d e ta il fr o m th e rig h t a triu m , (a c c o rd in g to [2])

E p ic a rd iu m : T u n ic a s e ro s a a nd T e la s u b s e ro s a a t th e o u te r s u rfa c e o f th e h e a rt, re p re s e n tin g th e v is c e ra l la y e r o f th e P e ric a rd iu m s e

T h e w a ll o f th e h e a rt is c o m p o s e d o f th re e laye rs: E n d o c a rd iu m : in n e r s u rfa c e c o n s is tin g o f e n d o th e liu m a nd c o n n e c

ro s u m . In th e h u m a n , th e T e la s u b s e ro s a c o n ta in s p le n ty o f w h ite a d ip o s e tis s u e in w h ic h th e c o ro n a ry b lo o d v e s s e ls a n d n e rv e s are

tiv e tis s u e M y o c a r d iu m : ca rd ia c m u s c le w it h c a rd io m y o c y te s

em bedded.

Thym us -► Topography -► Sections

Cardiac m uscle

Truncus pulmonalis V. cava superior Sinus trunci pulmonalis Sulcus interventricularis anterior

Auricula sinistra

Vortex cordis

Atrium dextrum

Ventriculus sinister

Apex cordis

dexter Sulcus interventricularis posterior Sulcus interventricularis anterior

A. pulmonalis dextra V. cava superior — Vv. pulmonales dextrae

Vv. pulmonales sinistrae

A trium dextrum

A trium sinistrum V. cava inferior Sulcus coronarius

Sinus coronarius

------Ventriculus dexter

Ventriculus sinister

Fig. 5 .1 6 t o Fig. 5 .1 8

C a rd ia c m u s c le . M y o c a r d iu m ; v e n tra l v ie w

Sulcus interventricularis posterior

(-* Fig. 5 .1 6 ), v ie w fr o m th e a p e x (-» Fig. 5 .1 7 ), a n d d o rs o c a u d a l v ie w

fo rm th re e la ye rs. T h u s , th e M y o c a rd iu m a n d th e ca rd ia c w a ll are m u c h th ic k e r in th e re g io n o f th e le ft v e n tric le . In c o m p a ris o n to th e rig h t

(-* Fig. 5.1 8 ). T h e c a rd ia c m u s c le fib re s c o n s is t o f c a rd io m y o c y te s a n d have a spiral

v e n tric le , th is a rra n g e m e n t r e fle c ts th e m u c h h ig h e r p re s s u re re q u ire d in th e le ft v e n tric le to p u m p th e b lo o d in to th e s y s te m ic c irc u la tio n . T h e

a rra n g e m e n t w ith in th e ca rd ia c w a ll. In th e w a ll o f th e a tria a nd th e rig h t v e n tric le th e y fo r m t w o la ye rs, in th e w a ll o f th e le ft v e n tric le th e y e v e n

rig h t v e n tric u la r w a ll is 3 - 5 c m th ic k , th e le ft v e n tric u la r w a ll is 8 - 1 2 c m th ic k .

[- Clinical re m a rk s --------------------------------------If th e th ic k n e s s o f th e le ft v e n tric u la r w a ll e xc e e d s 15 m m , th e te r m h y p e r tro p h y is u se d . A le f t v e n tric u la r h y p e rtro p h y m a y be

th e w a ll th ic k n e s s e x c e e d s 5 m m . T h is m a y be c a u s e d b y a s te n o s is o f th e p u lm o n a ry v a lv e o r b y p u lm o n a ry h y p e rte n s io n , re s u ltin g fro m

c a u s e d fo r e x a m p le b y s te n o s is o f th e a o rtic v a lve o r a rte ria l h y p e r te n s io n . In th e r ig h t v e n tric le , a h y p e rtro p h y is a lre a d y d ia g n o s e d if

c h ro n ic o b s tru c tiv e p u lm o n a ry d is e a s e s (C O P D ; e .g . a s th m a ) o r re c u rre n t p u lm o n a ry e m b o li.

T horacic Viscera

Heart -► Lungs -» Oesophagus

H eart valves and skeleto n o f th e heart

Valvula semilunaris dextra Valva trunci pulm onalis

Valvula semilunaris anterior Valvula semilunaris sinistra

Valvula semilunaris sinistra Valvula semilunaris dextra

Valva ao rtae

Valvula semilunaris Trigonum fibrosum sinistrum Trigonum fibrosum dextrum Anulus fibrosus sinister fibrosus dexter

Valva atrioventricularis sinistra [Valva m itralis]

Cuspis commissuralis sinistra

posterior an anterior septalis

Cuspis posterior Cuspis anterior

, Valva atrioventricularis v d ex tra [Valva tricuspidalis]

Cuspis commissuralis dextra

Fig. 5 .1 9

H e a r t v a lv e s , V a lv a e c o rd is ; cra nia l v ie w ; a fte r re m o v a l o f

th e a tria , A o rta a nd p u lm o n a ry tru n k . T h e h e a rt has t w o a trio v e n tric u la r

In a d d itio n , b e tw e e n th e v e n tric le s a n d th e g re a t a rte rie s lie th e a o rtic

c u s p id a le s )

v a lv e (Valva a o rta e ) o n th e le ft s id e a n d th e p u lm o n a r y v a lv e (Valva p u lm o n a lis ) o n th e rig h t s id e , b o th o f w h ic h c o n s is t o f th re e s e m ilu n a r

b e tw e e n th e a tria a nd th e v e n tric le s o f e a ch sid e . T h e rig h t a trio v e n tri c u la r v a lv e (Valva a trio v e n tric u la ris d e x tra ) c o n s is ts o f th re e c u s p s (tr i

c u s p s (V a lvu la e s e m ilu n a re s ). W h e n b lo o d is e je c te d fr o m th e v e n tri c le s in to th e g re a t a rte rie s d u rin g th e s y s to le th e s e m ilu n a r v a lv e s a re

c u s p id v a lv e ). T h e le ft a trio v e n tric u la r v a lve (Valva a trio v e n tric u la ris si n istra) has t w o c u s p s (b ic u s p id v a lv e , m itr a l v a lv e ). T h e c u s p s are a n c h o re d to th e p a p illa ry m u s c le s b y te n d in o u s c o rd s (C h o rd a e te n d i-

o p e n a n d th e a trio v e n tric u la r v a lv e s are c lo s e d . W h e n th e v e n tric le s are fille d w it h b lo o d fr o m th e a tria d u rin g th e d ia s to le th e a tr io v e n tr i c u la r v a lv e s a re o p e n a nd th e s e m ilu n a r v a lv e s are c lo s e d .

v a lv e s

(Valvae

neae) t o p re v e n t a p ro la p s e o f th e v a lv e s d u rin g v e n tric u la r c o n tra c tio n .

A ortic ring Pulm onary ring

Trigonum fibrosum sinistrum

Valva atrioventricularis dextra [Valva tricuspidalis]

Valva atrioventricularis sinistra [Valva mitralis] Trigonum fibrosum dextrum

Anulus fibrosus sinister Anulus fibrosus dexter Bundle of HIS

Fig. 5 .2 0

F ib ro u s s k e le to n o f th e h e a rt; cra nia l v ie w , s c h e m a tic

illu s tra tio n , (a c c o rd in g to [2]) T h e va lv e s are a n c h o re d t o th e ca rd ia c s k e le to n . T h e la tte r c o n s is ts o f c o n n e c tiv e tis s u e fo rm in g a rin g (A n u li fib ro s i d e x te r a n d s in is te r) a ro u n d th e a trio v e n tric u la r v a lv e s (V alvulae a trio v e n tric u la re s ) a nd a f i b ro u s rin g a ro u n d th e s e m ilu n a r va lv e s (V alvulae s e m ilu n a re s ). B e t w e e n th e A n u li fib ro s i lie s th e T rig o n u m fib ro s u m d e x tru m . H ere , th e b u n d le o f H IS b e lo n g in g to th e c o n d u c tin g s y s te m o f th e h e a rt p a s s e s

TODARO's tendon

o v e r fr o m th e r ig h t a triu m to th e in te rv e n tric u la r s e p tu m . In a d d itio n to th e s ta b ilis a tio n o f th e v a lv e s , th e fib ro u s s k e le to n o f th e h e a rt s e rv e s a s an e le c tric a l in s u la to r b e tw e e n th e a tria a nd th e v e n tric le s b e c a u s e all c a rd io m y o c y te s are a tta c h e d to th e c a rd ia c s k e le to n . S in c e th e r e is n o c o n n e c tio n b e tw e e n a tria a nd v e n tric le s via c a rd io m y o c y te s , th e e le c tric a l im p u ls e re a c h e s th e v e n tric le s e x c lu s iv e ly th ro u g h th e b u n d le o f H IS.

i- Clinical R em arks-------------------------------------If th e va lv e s are c o n s tric te d (s te n o s is ) o r d o n o t c lo s e p ro p e rly (in

area d u rin g d ia s to le , a s te n o s is o f th e re s p e c tiv e v a lv e can b e s u

s u ffic ie n c y ), h e a rt m u r m u rs d e v e lo p . T h e s e are m o s t n o tic e a b le a t th e a u s c u lta tio n s ite s o f th e re s p e c tiv e va lv e s ( - * Fig. 5.1 ). If a

s p e c te d s in c e th e A V v a lv e s are fu lly o p e n e d d u rin g d ia s to le . The o p p o s ite is tr u e fo r th e s e m ilu n a r v a lv e s . V a lv u la r s te n o s e s are

m u rm u r is d e te c te d d u rin g s y s to le (b e tw e e n th e fir s t a nd s e c o n d h e a rt s o u n d s ) in th e area o f o n e o f th e a trio v e n tric u la r (A V ) v a lv e s ,

e ith e r c o n g e n ita l o r a c q u ire d (rh e u m a tic d is e a s e s , b a c te ria l e n d o c a r d itis ). V a lv u la r in s u ffic ie n c ie s a re m o s tly a c q u ire d a nd m a y a ls o be

an in s u ffic ie n c y o f th e re s p e c tiv e v a lv e is like ly, s in c e A V v a lv e s are n o rm a lly c lo s e d d u rin g s y s to le . If th e m u rm u r is d e te c te d in th is

th e re s u lt o f a m y o c a rd ia l in fa rc tio n if o n e o r m o re o f th e p a p illa ry m u s c le s are a ffe c te d b y th e in fa rc tio n .

Thym us -► Topography -► Sections

C ham bers o f th e heart Ostium atrioventriculare dextrum Septum interatriale Pars ascendens aortae Fossa ovalis Mm. pectinati V. cava sup erior Auricula dextra

Foramina venarum minimarum

A. coronaria dextra Atrium dextrum

Limbus fossae ovalis C rista term inalis Valva atrioventricularis dextra, Cuspis an terior TODARO's tendon Chordae tendineae M . papillaris septalis

M . papillaris anterior V. cava inferior Valva atrioventricularis dextra, Cuspis septalis

Valvula ven ae cav ae inferioris O stium sinus coronarii Valvula sinus coronarii

K O C H ‘s triang le

Valva atrioventricularis dextra, Cuspis posterior M m . papillares posteriores Ventriculus dexter

Septum interventriculare, Pars muscularis

Myocardium Pericardium serosum, Lamina visceralis [Epicardium]

Fig. 5.21 R ig h t a tr iu m , A triu m d e x tr u m , a n d r ig h t v e n tric le , V e n tric u lu s d e x te r ; v e n tra l v ie w .

Apex cordis

are n o t a b le to c lo s e th e re s p e c tiv e lu m e n . S m a lle r ca rd ia c v e in s e n te r

T h e rig h t a triu m c o n s is ts o f a p a rt w it h a s m o o th in n e r s u rfa c e , th e si

th e rig h t a triu m d ire c tly (F o ra m in a v e n a ru m m in im a ru m ). A n e x te n s io n o f th e V a lvu la v e n a e ca vae in fe rio ris is th e T O D A R O 's te n d o n (Tendo

n u s o f v e n a e ca vae (S inu s v e n a ru m c a va ru m ), a nd o f a m u s c u la r p a rt w it h a ro u g h in n e r s u rfa c e c o n s is tin g o f th e p e c tin a te m u s c le s (M m .

v a lv u la e v e n a e ca vae in fe rio ris ). It s e rv e s a s a la n d m a rk and, to g e th e r w ith th e o p e n in g o f th e S in u s c o ro n a riu s a n d th e tric u s p id v a lv e (Valva

p e c tin a ti). B o th p a rts are s e p a ra te d b y th e C ris ta te m in a lis , w h ic h s e rv e s as im p o rta n t la n d m a rk fo r th e lo c a lis a tio n o f th e s in u -a tria l n o d e (SA n o d e ) o f th e ca rd ia c c o n d u c tin g s y s te m (-» p p . 2 0 -2 2 ). T h e SA

a trio v e n tric u la ris d e x tra ), it fo r m s th e K O C H 's t r ia n g le w h ic h h a rb o u rs th e A V n o d e (-» Fig s. 5 .2 5 to 5 .2 7 ). In th e rig h t v e n tric le , th e th re e

n o d e is p o s itio n e d a t th e o u ts id e (su b e p ica rd ia l) o f th is d e m a rc a tio n lin e b e tw e e n th e e n try o f th e V. cava s u p e rio r a nd th e rig h t a u ricle (A u ricu la d e x tra ). T h e in te ra tria l s e p tu m (S e p tu m in te ra tria le ) s h o w s a re m n a n t o f th e fo r m e r F o ra m e n o vale , th e Fossa o v a lis w it h its rim , th e L im b u s fo s s a e o va lis. T h e o p e n in g o f th e S in u s c o ro n a riu s (O s tiu m s in u s c o ro na rii), w h ic h re p re s e n ts th e la rg e s t ca rd ia c v e in , has a v a lv e (Valvula s in u s c o ro n a rii) a nd th e o p e n in g o f th e V. cava in fe rio r is a lso d e m a r

c u s p s are a tta c h e d via C h o rd a e te n d in e a e t o th e th re e p a p illa r y m u s cles (M m . p a p illa re s a n te rio r, p o s te rio r a n d s e p ta lis ). O f th e in te rv e n tri c u la r s e p tu m (S e p tu m in te rv e n tric u la re ) o n ly th e m u s c u la r p a rt is v is ib le in th is illu s tra tio n . S ta rtin g fr o m th e in te rv e n tric u la r s e p tu m , s p e c ific fib re s o f th e ca rd ia c c o n d u c tin g s y s te m (m o d e ra to r b a n d d e s c rib e d b y L E O N A R D O D A V IN C I, n o t v is ib le h e re ) c o u rs e to th e a n te rio r p a p illa ry m u s c le (M . p a p illa ris a n te rio r ). T h is c o n n e c tio n is re fe rre d to as th e T ra b e c u la s e p to m a r g in a lis (-» Fig. 5.2 7 ).

c a te d b y a v a lv e (Valvula v e n a e ca vae in fe rio ris ). B o th v a lv e s , h o w e v e r,

Ventriculus sinister

Fig. 5 .2 2

Ventriculus dexter

L e ft a n d r ig h t v e n tric le s , V e n tric u lu s s in is te r a n d

V e n tric u lu s d e x te r ; c ro s s -s e c tio n , cra nia l v ie w . B e c a u se o f th e s u b s ta n tia lly s tro n g e r m u s c le layer, th e w a ll o f th e le ft v e n tric le is th ic k e r th a n th e w a ll o f th e rig h t v e n tric le .

T horacic Viscera

Heart -► Lungs -» Oesophagus

C ham bers o f th e heart

V. pulm onalis sinistra superior Myocardium Auricula sinistra

Vv. pulm onales dextrae

V. cardiaca [cordis] magna

Atrium sinistrum, Septum interatriale

Anulus fibrosus sinister

O stium atrioventriculare sinistrum V. pulmonalis sinistra inferior Valvula foram inis ovalis M. papillaris anterior

Anulus fibrosus sinister Valva atrioventricularis sinistra, Cuspis posterior Pericardium serosum, Lamina visceralis [Epicardium] Chordae tendineae M. papillaris posterior Ventriculus sinister Myocardium Septum interventriculare, Pars muscularis T rabeculae c arn e ae Apex cordis

Fig. 5 .2 3

L e ft a tr iu m , A triu m s in is te r, a n d le ft v e n tric le ,

V e n tric u lu s s in is te r; latera l v ie w .

d u rin g th e d e v e lo p m e n t o f th e h e a rt (-» Fig. 5.7). T h e O s tiu m a trio v e n tric u la re s in is tru m is th e ju n c tio n to th e le ft v e n tric le a n d c o n ta in s th e

T h e a u ric le (A u ricu la sin is tra ) re p re s e n ts th e m u s c u la r p a rt o f th e le ft a triu m . T h e fo u r p u lm o n a ry v e in s (Vv. p u lm o n a le s ) e n te r th e s m o o th -

V alva m itra lis . T h e w a ll o f th e le ft v e n tric le is n o t s m o o th b u t s tru c tu re d b y tra b e c u la e o f th e v e n tric u la r M y o c a rd iu m (T ra b ecu la e ca rneae).

w a lle d p a rt o f th e le ft a triu m . T h e s e p ta l w a ll s h o w s th e c re s c e n t sh a p e d V a lvu la fo ra m in is o va lis, a re m n a n t o f th e S e p tu m p rim u m

Thym us -â&#x2013;ş Topography -â&#x2013;ş Sections

C ham bers o f th e heart

Lunula valvulae semilunaris sem ilunaris sinistra A. coron aria sinistra A. coronaria sinistra, R. interventricularis anterior Bulbus aortae Sinus ao rtae

Septu m interventriculare, Pars m em b ran ac ea Myocardium Chordae tendineae

Truncus M . papillaris posterior Valvula sem ilunaris A. coron aria dextra Nodulus valvulae semilunaris Auricula dextra Valvula sem ilunaris dextra Valvula sem ilunaris posterior Ostium atrioventriculare sinistrum

atrioventricularis sinistra, Cuspis anterior

M . papillaris an terior

Ventriculus sinister

L e ft v e n tric le , V e n tric u lu s s in is te r; la te ra l v ie w .

c o n s is ts o f ca rd ia c m u s c le fib re s (Pars m u s c u la ris ). B lo o d fr o m th e le ft

T h e m itra l v a lv e (Valva a trio v e n tric u la ris s in is tra ) o n ly c o n s is ts o f t w o

Fig. 5 .2 4

v e n tric le is p u m p e d th ro u g h th e a o rtic v a lv e (Valva a o rta e) in to th e d ila te d p a rt o f th e A o rta (B u lb u s a orta e ). T h e a o r tic v a lv e c o n s is ts o f

c u s p s . T h u s, o n ly t w o p a p illa ry m u s c le s are re q u ire d (M m . p a p illa re s a n te rio r a nd p o s te rio r). B e n e a th th e m itra l v a lve , th e a p p ro x im a te ly 1 c m 2 la rg e area o f th e P a rs m e m b r a n a c e a o f th e in te rv e n tric u la r s e p Â tu m is lo c a te d . H o w e v e r, th e m a jo r p a rt o f th e in te rv e n tric u la r s e p tu m

th re e s e m ilu n a r v a lv e s (V a lvu la e s e m ilu n a re s ) w h ic h c o v e r th e S inu s a o rta e fr o m w h ic h th e r ig h t a n d le ft c o ro n a ry a rte rie s o rig in a te (Aa. c o ro n a ria e d e x tra a nd sin is tra ).

T horacic Viscera

Heart -► Lungs -► Oesophagus

Electrical stim u la tio n and cond u ctin g s yste m o f th e heart

Aorta

Fasciculus atrioventricularis

V. cava superior

Nodus sinuatrialis Crus sinistrum

Nodus atrioventricularis Crus dextrum

K O C H 's triangle

Septum interventriculare Rr. subendocardiales

Fig. 5 .2 5

E le c tric a l s tim u la tio n a n d c o n d u c tin g s y s te m

[C o m p le x u s s tim u la n s e t c o n d u c e n te c o rd is ] a lo n g t h e a xis o f th e s e c tio n e d h e a rt. T h e h e a rt h a rb o u rs an e le c tric a l s tim u la tio n a nd c o n d u c tin g s y s te m w h ic h c o n s is ts o f m o d ifie d c a rd io m y o c y te s in s te a d o f n e rv e fib re s . T h is s y s te m is d iv id e d in to th e fo llo w in g p arts: •

•

s in u -a tr ia l n o d e (N o d u s sin u a tria lis , S A -n o d e ; n o d e o f KEITHFLAC K) a trio v e n tric u la r n o d e (N o d u s a trio v e n tric u la ris ; A V -n o d e , n o d e o f TAW ARA) a trio v e n tric u la r b u n d le (F a scicu lu s a trio v e n tric u la ris , b u n d le o f

d e x tra in m o s t c a s e s . T h e e le c tric a l sig n a l s p re a d s fr o m th e S A n o d e th ro u g h th e M y o c a rd iu m o f b o th a tria (m y o g e n ic c o n d u c tio n ) and re a c h e s th e A V n o d e . T h e la tte r s lo w s d o w n th e fre q u e n c y o f th e e le c tric a l sig n a l t o a llo w a s u ffic ie n t fillin g o f th e v e n tric le s . T h e A V n o d e , a p p ro x im a te ly 5 x 3 m m in size, is e m b e d d e d w ith in th e M y o c a rd iu m o f th e a trio v e n tric u la r s e p tu m a t K O C H 's tria n g le . T h e K O C H 's tria n g le is c o n fin e d b y th e T O D A R O 's te n d o n , th e e n try o f th e S in u s c o ro n a riu s , a n d th e s e p ta l c u s p o f th e tric u s p id v a lv e (-» Fig. 5.2 1 ). T h e A V n o d e is a ls o s u p p lie d b y a s e p a ra te b ra n c h (R. n o d i a trio v e n tri cu la ris) w h ic h u s u a lly d e riv e s fr o m th e d o m in a n t c o ro n a ry a rte ry (in

HIS) r ig h t a n d le ft b u n d le b ra n c h (C rus d e x tru m a n d s in is tru m n o d e o f

m o s t c a s e s th e A . c o ro n a ria d e x tra ) n e a r th e b ra n c h in g o f th e R. in te rv e n tric u la ris p o s te rio r. F ro m th e A V n o d e th e e le c tric a l sig n a l is c o n v e y e d b y th e b u n d le of

TAW ARA) T h e e le c tric a l s tim u la tio n is in itia te d in d e p e n d e n tly w ith in th e s in u

H IS (a pp ro x. 4 x 2 0 m m ) th ro u g h th e T rig o n u m fib ro s u m d e x tru m to th e in te rv e n tric u la r s e p tu m .

a tria l n o d e b y s p o n ta n e o u s d e p o la ris a tio n in th e s p e c ia lis e d m y o c a rd i al c e lls a nd has a fre q u e n c y o f a p p ro x im a te ly 7 0 /m in . T h e S A -n o d e has

In th e Pars m e m b ra n a c e a o f th e in te rv e n tric u la r s e p tu m th e b u n d le o f H IS d iv id e s in to th e r ig h t a n d le ft b u n d le b ra n c h . T h e le f t b u n d le

a size o f a p p ro x im a te ly 3 x 1 0 m m a nd is lo c a te d w ith in th e w a ll o f th e rig h t a triu m in a g ro o v e (S u lcu s te rm in a lis co rd is ) b e tw e e n th e e n try o f

b ra n c h s p lits in to th e a n te rio r, s e p ta l a n d p o s te rio r s u b e n d o c a rd ia l fa s c i c u li to th e re s p e c tiv e p a rts o f th e M y o c a rd iu m in c lu d in g th e p a p illa ry

th e V. cava s u p e rio r a n d th e rig h t a u ric le . T h is g ro o v e c o rre s p o n d s to th e C rista te rm in a lis a t th e in n e r s u rfa c e o f th e rig h t a triu m . T h e S A

m u s c le s a n d th e a p e x o f th e h e a rt. T h e rig h t b u n d le b ra n c h d e s c e n d s s u b e n d o c a rd ia lly in th e s e p tu m to th e a p e x o f th e h e a rt a n d re a c h e s

n o d e is o c c a s io n a lly c o v e re d b y an area o f su b e p ic a rd ia l a d ip o s e tis s u e m a k in g it v is ib le fro m o u ts id e . T h e S A n o d e is s u p p lie d b y th e s in u -a tri

th e a n te rio r p a p illa ry H Fig. 5.2 7 ).

al n od a l b ra n ch (R. n o d i s in u a tria lis ) w h ic h d e riv e s fro m th e A . c o ro n a ria

m u s c le

via

th e

T ra b e c u la

s e p to m a rg in a lis

Thym us -► Topography -► Sections

Electrical stim u la tio n and co n d u ctin g syste m o f th e heart

Nodus Crus sinistrum

Nodus atrioventricularis

Fasciculus atrioventricularis

Crus dextrum

Fig. 5 .2 6

E le c tric a l s tim u la tin g a n d c o n d u c tin g s y s te m o f th e

h e a rt; s c h e m a tic illu s tra tio n .

Pars ascendens aortae V. cava superior

Truncus pulmonalis

Atrium dextrum

Fasciculus atrioventricularis Nodus sinuatrialis Crista terminalis

C rus dextrum

Ostium venae cavae inferioris

Valvula venae cavae inferioris

Nodus atrioventricularis

I U-------Trabecula septom arginalis

Valvula sinus coronarii M. papillaris anterior

Fig. 5 .2 7 h e a rt.

E le c tric a l s tim u la tio n a n d c o n d u c tin g s y s te m o f th e

T h e e le c tric a l s tim u la tio n a nd c o n d u c tin g s y s te m is o rg a n is e d in fo u r p a rts (-» Fig. 5.25).

T h e illu s tra tio n d e m o n s tra te s h o w a p a rt o f th e rig h t b u n d le bran ch (C rus d e x tru m ) re a c h e s th e rig h t a n te rio r p a p illa ry m u s c le via th e T ra b e cu la s e p to m a rg in a lis .

T horacic Viscera

Heart -► Lungs -► Oesophagus

Electrical stim u la tio n and cond u ctin g s yste m o f th e heart

1 Sinus node depolarisation (no ECG signal) 2 Depolarisation delay in AV node (PQ interval) P Atrial depolarisation Q Depolarisation o f the ventricular septum R Depolarisation o f the distal third of the ventricular septum (vector in longitudinal cardiac axis) S Depolarisation o f remaining parts of the ventricles ST Complete depolarisation of ventricles (no potential difference = isoelectric) T Repolarisation of ventricles mV 0.5 -,

-0 .5 -I

Fig. 5 .2 8

A n a to m ic a l p rin c ip le s o f th e e le c tro c a r d io g r a m (E C G ).

I------- 1------- 1------- 1------- 1------- 1------- 1 0 0.1 0.2 0.3 0.4 0.5 0.6

sec

d e p o la ris a tio n o f th e in te rv e n tric u la r s e p tu m is illu s tra te d b y th e Q

(a cco rd in g to [2])

w a v e . D e p o la ris a tio n o f th e v e n tric u la r m y o c a rd iu m to w a rd s th e a p e x

T h e e le c tric a l sig n a l s p re a d s fr o m th e sin u -a tria l n o d e t o th e A V n o d e w h ic h c a u s e s a d e la y in e le c tric a l c o n d u c tio n b e fo re re a c h in g th e in te r

o f th e h e a rt is re p re s e n te d b y th e a s c e n d in g lim b o f th e R w a v e , w h e re a s th e p ro p a g a tio n o f th e d e p o la ris a tio n a w a y fro m th e a p e x re

v e n tric u la r s e p tu m via th e b u n d le o f H IS . T h e rig h t a n d le ft b u n d le bran c h e s th e n d iv id e a n d s tim u la te th e v e n tric u la r M y o c a rd iu m . T h is c o n

s u lts in th e d e s c e n d in g lim b o f th e R w a v e a nd in th e s h o rt S w a v e . D u rin g th e ST s e g m e n t th e e n tire v e n tric u la r M y o c a rd iu m is d e p o la rized . S in c e th e re p o la ris a tio n o f th e v e n tric u la r m y o c a rd iu m o c c u rs in

d u c tio n o f e le c tric a l im p u ls e s w ith in th e h e a rt can be d e te c te d b y e le c tro d e s on th e s u rfa c e o f th e b od y. If th e e le c tric a l sig n a l tra v e ls to

th e s a m e d ire c tio n as th e d e p o la ris a tio n , th e T w a v e a lso s h o w s a p o

w a rd s th e e le c tro d e a t th e s u rfa c e o f th e b o d y, it re s u lts in a p o s itiv e u p w a rd a m p litu d e o f th e b a se lin e v o lta g e . B e ca u se o f th e s m a ll v o lu m e

s itiv e (u p w a rd ) a m p litu d e . U sua lly, th re e lim b le a d s are re c o rd e d to d e te r m in e th e e le c tric a l a x is o f th e h e a rt a c c o rd in g to th e la rg e s t a m p litu

o f th e sin u -a tria l n o d e , th e S A e x c ita tio n is n o t d e te c ta b le in th e ECG. T h e d e p o la ris a tio n o f th e a tria is re p re s e n te d b y th e P w a v e . T h e d e

de o f th e R w a v e . H o w e v e r, th is e le c tric a l a x is is in flu e n c e d b y th e th ic k n e s s o f th e M y o c a rd iu m in b o th v e n tric le s a n d b y th e e x c ita b ility

p o la ris a tio n d e la y b y th e A V n o d e o c c u rs d u rin g th e PQ s e g m e n t. T h e la tte r d e p ic ts th e lack o f p o la ris a tio n c h a n g e s d u rin g th e d e p o la ris a tio n o f th e e n tire a tria l M y o c a rd iu m . T h e rapid re tro g ra d e d ire c tio n o f th e

o f th e tis s u e a n d is th e re fo re n o t id e n tic a l w it h th e a n a to m ic a l a x is o f th e hea rt.

i- Clinical R em arks-------------------------------------T h e ECG is u se d to d e te c t c a rd ia c a rr h y th m ia s , fo r e x a m p le if th e h e a rt b e a ts to o fa s t (ta c h y c a rd ia , > 1 0 0 / m in ), to o s lo w (b ra d y

If a tria l fib re s b y p a s s th e A V n o d e a n d d ire c tly lin k t o th e b u n d le

c a rd ia , < 6 0 /m in ) , o r in an irre g u la r w a y (a rr h y th m ia ). In a d d itio n ,

o f H IS o r th e v e n tric u la r m y o c a rd iu m (KEN T'S b u n d le s ), c a rd ia c a r rh y th m ia s are th e re s u lt (W O L F F -P A R K IN S O N -W H IT E s y n d ro m e ).

re d u c e d a rte ria l p e rfu s io n d u e to c o ro n a ry a rte ry d is e a s e (e.g. m y o ca rdia l in fa rc tio n ), a nd o th e r d is e a s e s s u c h as m y o c a rd ia l in fla m m a

If th e s e a rh y th m ia s c a u s e s e v e re s y m p to m s a n d re s is t p h a rm a c o lo g ic a l tr e a tm e n t, it m a y b e n e c e s s a ry to in te rru p t th e a c c e s s o ry

tio n re s u lt in a lte ra tio n s o f th e e le c tric a l c o n d u c tio n . T h e ECG is o f p a rtic u la r im p o rta n c e fo r th e id e n tific a tio n o f m y o c a rd ia l in fa rc tio n .

b u n d le s u s in g a ca rd ia c c a th e te r d e v ic e .

Thym us -► Topography -► Sections

Innervation o f th e heart

N. vagus [X] Ganglion cervicale superius

N. cardiacus cervicalis superior

Ganglion cervicale medium N. laryngeus recurrens N. laryngeus recurrens

Ganglion cervicothoracicum [Ganglion stellatum]

R. cardiacus cervicalis inferior

N. cardiacus cervicalis medius

R. cardiacus thoracicus N. cardiacus cervicalis inferior

G anglion cardiacum

Plexus cardiacus

Fig. 5 .2 9

In n e rv a tio n o f th e h e a rt: P le x u s c a rd ia c u s w ith

s y m p a th e tic (g re e n ) a n d p a r a s y m p a th e tic (p u rp le ) n e rv e fib re s ; s c h e m a tic illu s tra tio n . T h e fu n c tio n o f th e e le c tric a l c o n d u c tin g s y s te m a nd th e M y o c a rd iu m ca n be m o d ifie d b y a u to n o m ic in n e rv a tio n to a d ju s t to th e n e e d s o f th e w h o le b od y. T h is is th e p u rp o s e o f th e P le xu s c a rd ia c u s a s p a rt o f th e

(p o s itiv e c h ro n o tro p ic e ffe c t), th e s p e e d o f c o n d u c tio n (p o s itiv e d ro m o tro p ic e ffe c t), a nd th e e x c ita b ility (p o s itiv e b a th m o tro p ic e ffe c t) o f th e c a rd io m y o c y te s . In a d d itio n , s y m p a th e tic s tim u la tio n e n h a n c e s th e c o n tra c tile fo rc e (p o s itiv e in o tro p ic e ffe c t) d u e to a c c e le ra te d re la x a tio n (p o s itiv e lu s itro p ic e ffe c t). P a ra s y m p a th e tic s t im u la tio n e lic its n e g a ti

a u to n o m ic n e rv o u s s y s te m . T h e P lexu s c a rd ia c u s c o n s is ts o f s y m p a th e tic a n d p a ra s y m p a th e tic n e rv e fib re s . T h e c e ll b o d ie s (P erikarya) o f

v e c h ro n o tro p ic , d ro m o tro p ic , a nd b a th m o tro p ic e ffe c ts a nd , a d d itio n ally, has n e g a tiv e in o tro p ic e ffe c ts o n th e a tria l M y o c a rd iu m . T h e p a r a s y m p a th e tic n e rv e fib re s d e riv e a s p re g a n g lio n ic n e rv e fib re s fro m

th e p o s tg a n g lio n ic s y m p a th e tic n e rv e fib re s re s id e w ith in th e ce rv ic a l gan g lia o f th e s y m p a th e tic tru n k (T ru n cu s s y m p a th ic u s ) a nd re ach th e

th e N. v a g u s [X] a nd re a c h th e P le x u s c a rd ia c u s a s Rr. ca rdia ci c e rv ic a les s u p e rio r a n d in fe rio r a n d as Rr. c a rd ia c i th o ra c ic i. In th e P le x u s car

P le x u s c a rd ia c u s via th re e n e rv e s (N n. c a rd ia ci c e rv ic a le s s u p e rio r, m e d iu s a nd in fe rio r). S y m p a th e tic s tim u la tio n in c re a s e s th e h e a rt rate

d ia c u s , th e y are s y n a p s e d w ith in n u m e ro u s (up to 500 ) tin y gan g lia (G anglia cardiaca) o n to p o s tg a n g lio n ic n e u ro n s .

i- Clinical R em arks-------------------------------------In c re a se d s y m p a th e tic to n u s , a s in s tre s s s itu a tio n s , is a c c o m p a n ie d b y in c re a s e d h e a rt ra te (ta c h y c a rd ia ) a nd e le v a te d a rte ria l b lo o d p re s s u re (a rte ria l h y p e rte n s io n ). In ju ry to th e p a ra s y m p a th e tic

h e a rt a ls o in c re a s e s th e o x y g e n c o n s u m p tio n b y th e c a rd io m y o c y te s . T h is m a y c a u s e an a ng in a p e c to ris a n d m y o c a rd ia l in fa rc tio n in th e c a s e o f a p re -e x is tin g c o ro n a ry a rte ry s te n o s is (c o ro n a ry a rte ry

fib re s m a y a ls o re s u lt in ta c h y c a rd ia . T h e in c re a s e d a c tiv ity o f th e

d ise a se ).

T horacic Viscera

Heart -► Lungs -» Oesophagus

C oronary arteries

Arcus aortae

Truncus pulmonalis

Pars ascendens aortae

A. coron aria sinistra Atrium sinistrum, Auricula sinistra

A. coronaria sinistra, R. circum flexus

A. coron aria dextra

Conus arteriosus Atrium dextrum

A. coron aria sinistra, R. interventricularis an terior

R. marginalis dexter

Fig. 5 .3 0

C o ro n a ry a rte rie s , A a . c o ro n a ria e ; v e n tra l v ie w .

T h e r ig h t c o ro n a ry a rte r y (A. c o ro n a ria d e xtra ) has its o rig in a t th e

a n te rio r , w h ic h c o u rs e s t o th e a p e x o f th e h e a rt, a nd th e R. c ir c u m fle x u s . T h e la tte r c o u rs e s in th e S u lc u s c o ro n a riu s a ro u n d th e le ft ca rd ia c

rig h t a o rtic s in u s a n d c o u rs e s in th e S u lcu s c o ro n a riu s to th e in fe rio r m a rg in (M a rg o d e x te r). It c o n tin u e s to th e F a cies d ia p h ra g m a tic a

m a rg in to re ach th e p o s te rio r a s p e c t o f th e h e a rt. C o n v e n tio n a lly , th e c o ro n a ry d o m in a n c e is d e te rm in e d b y th e a rte ry

w h e re in m o s t c a s e s th e R. in te r v e n tric u la r is p o s te r io r b ra n c h e s o ff as a te rm in a l b ran ch . T h e le ft c o ro n a ry a rte r y (A. c o ro n a ria sin is tra ) o rig in a te s a t th e le ft

th a t s u p p lie s th e R. in te rv e n tric u la ris p o s te rio r. In m o s t c a s e s th e rig h t c o ro n a ry a rte ry is d o m in a n t (in th e " c o - d o m in a n t" a n d th e " r ig h t-d o m in a n t" p e rfu s io n ty p e , to g e th e r in 7 5 % o f all c a s e s -» p a g e s 2 6 a n d 27).

a o rtic s in u s a nd d iv id e s a fte r 1 c m to fo r m th e R. in te rv e n tric u la ris

Im p o r ta n t B ra n c h e s o f th e R ig h t C o ro n a ry A rte r y (A . c o ro n a ria d e x tra ) R. nodi sinuatrialis

• •

R. c o n i a rte rio s i R. n o d i sin u a tria lis (tw o -th ird s o f all

• • •

ca ses): to th e S A n o d e R. m a rg in a lis d e x te r R. p o s te ro la te ra lis d e x te r R. n o d i a trio v e n tric u la ris :

•

to th e A V n o d e (if " r ig h t d o m in a n t") R. in te rv e n tric u la ris p o s te rio r (if " r ig h t d o m in a n t") w ith Rr. in te rv e n tric u la re s s e p ta le s , s u p p ly in g th e b u n d le o f H IS

Im p o r ta n t B ra n c h e s o f th e L e ft C o ro n a ry A rte r y (A . c o ro n a ria s in is tra ) R. in te r v e n tric u la r is a n te rio r: • R. c o n i a rte rio s i • • R. •

R. la te ra lis (clin ical te rm : R. d ia g o n a lis) Rr. in te rv e n tric u la re s se p ta le s c irc u m fle x u s : R. n o d i s in u a tria lis (o n e -th ird o f all

• •

ca ses): to th e S A n o d e R. m a rg in a lis s in is te r R. p o s te rio r v e n tric u li s in is tri

A. coron aria dextra R. interventricularis an terior A. coron aria R. circum flexus

Fasciculus atrioventricularis R. marginalis

R. marginalis dexter Ostium sinus coronarii A. coron aria dextra, R. interventricularis posterior

Fig. 5.31

C o ro n a ry a rte r ie s , A a . c o ro n a ria e ; cranial v ie w .

Thym us -► Topography -► Sections

Veins o f th e heart

Fig. 5 .3 2 C a rd ia c v e in s , V v . c o rd is ; v e n tra l v ie w . [8] T h e v e n o u s b lo o d fr o m th e h e a rt is c o lle c te d in th r e e m a jo r s y s te m s .

d ra in in to th e r ig h t a triu m . T h e re m a in in g 2 5 % o f th e v e n o u s b lo o d d ra in in to th e a tria a nd v e n tric le s d ire c tly via th e tr a n s m u r a l a nd th e

7 5 % o f th e v e n o u s b lo o d are c o lle c te d in th e S in u s c o ro n a riu s a nd

e n d o m u ra l s y s te m (-» p a g e s 1 7 -1 9 ).

Arcus aortae A. pulmonalis dextra V. cava superior

A. pulmonalis sinistra

Vv. pulmonales dextrae

Atrium sinistrum

C a rd ia c V e in s (V v . c ordis) Vv. pulmonales sinistrae

C o ro n a ry s in u s s y s te m : •

V. ca rd ia ca m a g n a (g re a t ca rd ia c ve in ): c o rre s p o n d s to th e s u p p ly area o f th e A. -

• • •

c o ro n a ria s in is tra V. in te rv e n tric u la ris a n te rio r V. m a rg in a lis s in is tra V v. v e n tric u li s in is tri p o s te rio re s

V. ca rd ia ca m e d ia : in th e S u lcu s in te rv e n tric u la ris p o s te rio r V. ca rd ia ca parva: in th e rig h t S u lcu s c o ro n a riu s , p re s e n t in 5 0 % V. o b liq u a a trii s in is tri

Sinus venarum cavarum Auricula sinistra V. obliqua atrii sinistri cardiaca [cordis] m agna A. coronaria R. circumflexus Sinus coronarius

Atrium dextrum

V. ventriculi sinistri posterior V. cava inferior Sulcus coronarius

T ra n s m u ra l s y s te m : • V v. v e n tric u li d e x tri a n te rio re s •

V. cardiaca [cordis] parva

V v. a tria le s A. coronaria dextra

E n d o m u ra l s y s te m : •

V v. c a rd ia ca e m in im a e (T H E B E S IA N v e in s)

Ventriculus dexter V. cardiaca [cordis] m edia [V. interventricularis posterior] Ventriculus sinister

Fig. 5 .3 3

Sulcus interventricularis posterior

C a rd ia c v e in s , V v . c o rd is ; d o rs o c a u d a l v ie w .

T horacic Viscera

Heart -► Lungs -► Oesophagus

C oronary a rte ry dom inance

A. coron aria sinistra

A. coron aria dextra

«55%

R. circum flexus R. interventricularis an terior R. nodi sinuatrialis R. coni arteriosi R. coni arteriosi

R. lateralis R. marginalis sinister

R. atrial is

A. coronaria sinistra, R. circumflexus

R. lateralis atriales

R. nodi atrioventricularis

A. coronaria sinistra, R. posterior ventriculi sinistri

interventriculares septales

R. marginalis dexter (R. posterolateralis dexter)

R. posterior ventriculi sinistri

R. interventricularis posterior

A. coronaria dextra

Rr. atrioventriculares

A. coronaria dextra, R. interventricularis posterior

Rr. interventriculares septales

5 .3 4

Fig. 5 .3 4 a n d Fig. 5 .3 5 " B a la n c e d " o r c o -d o m in a n t c o ro n a ry c irc u la tio n b e tw e e n th e c o ro n a ry a rte r ie s , A a . c o ro n a ria e ; v e n tra l (-» Fig. 5 .3 4 ) a nd d o rsa l (-» Fig. 5 .3 5 ) v ie w s .

i. / I

A. coronaria dextra v X /Ä ü r

In 5 5 % o f all c a s e s , th e R. in te rv e n tric u la ris p o s te rio r o rig in a te s fro m th e A . c o ro n a ria d e x tra b u t d o e s n o t s u p p ly th e p o s te rio r a s p e c t o f th e le f t v e n tric le . T h is is re fe rre d to as a " b a la n c e d " o r " c o - d o m in a n t" p e r fu s io n ty p e .

/ A . coronaria sinistra

«25%

X / / R. circumflexus R. interventricularis anterior

Rr. interventriculares septales

A. coronaria R. circumflexus A. coronaria R. posterior ventriculi

R. interventricularis posterior

A. coronaria dextra

5 .3 6

Fig. 5 .3 6 a n d Fig. 5 .3 7

coronaria sinistra, R. interventricularis posterior

" L e ft d o m in a n t" c o ro n a ry c irc u la tio n

b e tw e e n th e c o ro n a ry a rte r ie s , A a . c o ro n a ria e ; v e n tra l {-» Fig. 5 .3 6 ) a nd d o rsa l (-» Fig. 5 .3 7 ) v ie w s .

In 2 5 % o f all c a s e s , th e R. in te rv e n tric u la ris p o s te rio r o rig in a te s fro m th e A . c o ro n a ria s in is tra ,

A. coronaria sinistra

« 20%

R. circumflexus

A. coronaria

R. interventricularis anterior

Rr. atrioventriculares A. coronaria R. circumflexus

R. nodi atrioventricularis

A. coronaria R. posterior ventriculi

(R. posterolateralis dexter) R. interventricularis posterior

Rr. interventriculares septales A. coronaria dextra

5 .3 8

Fig. 5 .3 8 a n d Fig. 5 .3 9 " R ig h t-d o m in a n t" c o ro n a ry c irc u la tio n b e tw e e n th e c o ro n a ry a rte r ie s , A a . c o ro n a ria e ; v e n tra l (-» Fig. 5.38) a nd d o rsa l

{-*

Fig. 5 .3 9 ) v ie w s .

A. coronaria dextra, R. interventricularis posterior

In 2 0 % o f all c a s e s , th e A . c o ro n a ria d e x tra n o t o n ly b ra n c h e s o ff th e R. in te rv e n tric u la ris p o s te rio r b u t a ls o s u p p lie s p a rts o f th e p o s te rio r a s p e c t o f th e le f t v e n tric le .

Thym us -► Topography -► Sections

C oronary a rte ry dom inance

coronaria sinistra

A. coronaria dextra

55%

interventricularis anterior

R. interventricularis anterior

lateralis

Area supplied by the A. coronaria dextra

supplied by the A. coronaria sinistra

R. interventricularis posterior

interventricularis anterior

R. lateralis

R. interventricularis posterior

Figs. 5 .4 0 a to c A re a s s u p p lie d b y th e A . c o ro n a ria d e x tra (lig h t re d ) a n d s in is tra (d a rk re d ) in th e c ro s s -s e c tio n ; ca ud a l v ie w , (a c c o rd in g to [2] a B a la n c e d o r c o -d o m in a n t p e rfu s io n ty p e : T h e le ft c o ro n a ry a rte ry

Figs. 5 .4 1 a to d a

s u p p lie s th e a n te rio r tw o -th ird s o f th e s e p tu m via th e Rr. in te rv e n tri c u la re s s e p ta le s o f th e R. in te rv e n tric u la ris a n te rio r (le ft a n te rio r d e s c e n d in g [L A D ] b ra n ch ). C o rre s p o n d in g b ra n c h e s d e riv e d fro m th e

R. in te rv e n tric u la ris p o s te rio r o f th e rig h t c o ro n a ry a rte ry s u p p ly th e p o s te rio r th ird o f th e s e p tu m , L e ft-d o m in a n t p e rfu s io n ty p e : T h e le ft c o ro n a ry a rte ry s u p p lie s

th e e n tire s e p tu m a n d th e A V n od e , R ig h t-d o m in a n t p e rfu s io n ty p e : T w o th ird s o f th e s e p tu m and

In fa rc tio n p a tte rn o w in g t o t h e o c c lu s io n o f th e

c o ro n a ry a rte rie s . Is o la te d o c c lu s io n o f th e R. in te rv e n tric u la ris a n te rio r (le ft a n te rio r d e s c e n d in g [L A D ] b ran ch ) re s u lts in an a n te rio r m y o c a rd ia l in fa rc tio n . b

D is ta l o c c lu s io n o f th e R. in te rv e n tric u la ris a n te rio r re s u lts in m y o c a rdia l in fa rc tio n o f th e a p e x o f th e h e a rt, o fte n re fe rre d to as a pical in fa rc tio n .

If o n ly th e R. la te ra lis is o c c lu d e d th e m y o c a rd ia l in fa rc tio n is re

s tric te d t o th e la te ra l w a ll o f th e v e n tric le , O c c lu s io n o f th e R. in te rv e n tric u la ris p o s te rio r re s u lts in a p o s te rio r m y o c a rd ia l in fa rc tio n (P M I) o f th e F a cies d ia p h ra g m a tic a .

la rg e a rea s o f th e p o s te rio r a s p e c t o f th e le ft v e n tric le a re su p p lie d b y th e A . c o ro n a ria d e xtra . T h e p e rfu s io n ty p e h as e ffe c ts on th e s e v e rity o f a m y o c a rd ia l in fa rc tio n d u e to an o c c lu s io n o f o n e o f th e c o ro n a ry a rte rie s .

i- Clinical R em arks-------------------------------------T h e c o ro n a ry a rte r y d is e a s e (C AD) is ca u s e d b y a s te n o s is o f th e

in fa rc tio n (P M I) is o fte n a c c o m p a n ie d b y b ra d y c a rd ia c a rrh y th m ia s

c o ro n a ry a rte rie s re s u ltin g fro m a rte rio s c le ro s is . D u e to in s u ffic ie n t m y o c a rd ia l p e rfu s io n th is m a y c a u s e pain in th e c h e s t (a n g in a p e c

b e c a u s e th e a rte ry s u p p ly in g th e A V n o d e o rig in a te s n e a r th e o u t le t o f th e R. in te rv e n tric u la ris p o s te rio r (-» Fig. 5.3 8 ). M o s tly , th e R.

to ris ) w h ic h m a y ra d ia te in to th e a rm (m o s tly th e le ft a rm ) o r in to th e n e c k . T o ta l o c c lu s io n o f an a rte ry re s u lts in n e c ro s is o f th e d e p e n d e n t M y o c a rd iu m (m y o c a rd ia l in fa rc tio n . M l). F u n c tio n a lly , c o

in te rv e n tric u la ris p o s te rio r is th e te rm in a l b ra n c h o f th e A . c o ro n a ria d e x tra (in th e b a la n c e d a nd th e rig h t-d o m in a n t p e rfu s io n ty p e s ). D ue

ro n a ry a rte rie s are te rm in a l a rte rie s a nd a d is tin c t in fa rc tio n p a tte rn re s u lts fr o m th e o c c lu s io n o f th e s u p p ly in g a rte rie s . T h e s e p a tte rn s m a y b e d e te c te d in v a rio u s le a d s in th e ECG. T h e m o s t d e fin itiv e e v id e n c e is a c h ie v e d th ro u g h c o ro n a ry c a th e te ris a tio n u s in g a ra d io c o n tra s t a g e n ts (co ro n a ry a n g io g ra m ). T h e p o s te r io r m y o c a rd ia l

to th e lo w p re s s u re s y s te m o f th e rig h t h e a rt, th e M y o c a rd iu m o f th e rig h t v e n tric le re q u ire s le s s o x y g e n w h e n c o m p a re d to th e le ft v e n tric le . T h u s , e v e n a p ro x im a l o c c lu s io n o f th e A . c o ro n a ria d e x tra m a y o n ly re s u lt in an is o la te d p o s te rio r m y o c a rd ia l in fa rc tio n . In th is c a s e , th e b ra d y c a rd ia m a y be s e v e re d u e to th e in s u ffic ie n t p e rfu s io n o f th e S A n od e .

T horacic Viscera

Heart -► Lungs -» Oesophagus

P rojection o f trachea and bronchi

Sinus paranasales

C avitas nasi Vestibulum nasi

Pars nasalis pharyngis Pars oralis pharyngis

Pharynx

laryngea pharyngis Larynx Jrprh oa

Bronchi principales Lobus superior f Lobus superior Pulm o sinister

Pulm o d e x te r < Lobus medius Lobus inferior

[ Lobus inferior

Fig. 5 .4 2

U p p e r a n d lo w e r r e s p ira to ry tr a c t; s c h e m a tic illu s tra tio n .

T h e lo w e r re s p ira to ry tr a c t c o m p ris e s :

T h e re s p ira to ry s y s te m is d e v id e d in u p p e r a nd lo w e r p arts. T h e u p p e r re s p ira to ry tr a c t c o m p ris e s :

• •

• lu n g s (P u lm o n e s ) T h e rig h t lu n g (P u lm o d e x te r) h as th re e lo b e s , th e le ft lu n g (P u lm o s in is

nasal c a v ity (C avita s nasi) p a rts o f th e P h a ryn x

L aryn x w in d p ip e (Trachea)

te r) h as t w o lob e s.

Trachea

Bronchus principalis sinister Bronchus lobaris superior dexter Bronchus lobaris superior sinister

Bronchus principalis dexter Bronchus lobaris inferior sinister Bronchus lobaris medius dexter

Bronchus lobaris inferior dexter

Fig. 5 .4 3 P ro je c tio n o f th e T ra ch e a a n d m a in b ro n c h i o n to th e a n te rio r c h e s t w a ll. T h e T ra ch ea is 1 0 - 1 3 c m lo n g a nd e lo n g a te s up to 5 c m d u rin g d e e p in s p ira tio n . T h e o rig in o f th e T ra ch e a a t th e c ric o id c a rtila g e p ro je c ts o n to th e 7th c e rv ic a l v e rte b ra ; th e b ifu rc a tio n o f th e T ra ch ea in to th e

to III). T h e a n g le b e tw e e n th e m a in b ro n c h i is 5 5 ° to 65°. T h e r ig h t m a in b ro n c h u s (B ro n c h u s p rin c ip a lis d e x te r) is larg e r, 1 - 2 .5 c m in le n g th , a nd is p o s itio n e d n e a rly v e rtic a lly . T h e le ft m a in b ro n c h u s (B ro n c h u s p rin c ip a lis s in is te r) is a lm o s t tw ic e a s lo n g a nd lo c a te d m o re h o riz o n ta lly .

t w o m a in b ro n c h i p ro je c ts o n to th e 4th a nd 5th th o ra c ic v e rte b ra e (rib II

Clinical R em arks-----------------------------------------------------------------------------------------------------------B e ca u se o f th e a lm o s t v e rtic a l p o s itio n o f th e rig h t m a in b ro n c h u s

tio n (a s p ira tio n ). T h is k n o w le d g e m a y p ro v id e th e c ru c ia l tim e ad-

fo re ig n b o d ie s m o re fre q u e n tly e n te r th e r ig h t lu n g d u rin g in s p ira -

v a n ta g e w h e n d e a lin g w ith m e d ic a l e m e rg e n c ie s .

Thym us -► Topography -► Sections

P rojection o f th e lungs Scapular line

Midclavicular line Paravertebral line Midaxillary line

Sternal line

Midaxillary line

Vertebra cervicalis VII [prominens] Lobus superior

Cupula pleurae

Spina scapulae

Lobus superior

Fissura obliqua

Fissura horizontalis

Lobus medius pulmonis dextri

Lobus inferior Fissura obliqua

Fissura obliqua

Recessus costodiaphragmaticus

Lobus inferior

Recessus costodiaphragmaticus

5 .4 4

5 .4 5

Fig. 5 .4 4 a n d Fig. 5 .4 5 P ro je c tio n o f th e b o rd e rs o f th e lu n g s a n d P le u ra o n to th e a n te rio r (-» Fig. 5 .4 4 ) a n d p o s te r io r (-» Fig. 5 .4 5 )

T h e le ft lu n g o n ly has t w o lo b e s w h ic h are s e p a ra te d b y th e Fissura

th o ra c ic w a lls .

o b liq u a . B e c a u s e th e h e a rt e n la rg e s th e M e d ia s tin u m to th e le ft s id e (In cisura ca rdia ca ), th e v o lu m e o f th e le f t lu n g is s m a lle r a n d th e p o s i

T h e r ig h t lu n g has th re e lo b e s w h ic h are s e p a ra te d b y th e Fissura o b liq u a a nd th e Fissura h o riz o n ta lis . O n th e d o rsa l sid e , th e Fissura

tio n o f th e le ft lu n g d iffe r s in th e s te rn a l a nd m id c la v ic u la r lin e s (see ta b le ).

o b liq u a fo llo w s rib IV a nd , th u s , s e p a ra te s th e s u p e rio r a n d th e in fe rio r lo b e s . F ro m th e m id a x illa ry lin e o n w a rd s , th e Fissu ra o b liq u a d e s c e n d s

E ach p le u ra l c a v ity (C avita s p le u ra lis ) is lin e d b y th e p a r ie ta l p le u ra (P leura p a rie ta lis ). T h e P leura p a rie ta lis is d iv id e d in to Pars m e d ia s tin a -

m o re s te e p ly to re ach rib VI a t th e m id c la v ic u la r lin e . A n te rio rly , th e Fissu ra o b liq u a s e p a ra te s th e m id d le a n d in fe rio r lo b e s (-► Figs. 5 .5 3 a n d 5 .5 4 ). T h e Fissu ra h o riz o n ta lis p ro je c ts a lo n g rib IV on th e a n te rio r

lis, Pars c o s ta lis , a n d Pars d ia p h ra g m a tic a (-» Fig. 5 .6 5 ). T h e p le u ra l c a v itie s have fo u r p le u ra l re c e s s e s (R e c e s s u s p le u ra le s ). T h e la rg e s t re c e s s u s is th e R ecessu s c o s to d ia p h r a g m a tic u s w h ic h e x p a n d s

c h e s t w a ll a n d s e p a ra te s th e s u p e rio r a nd th e m id d le lo b e s.

la te ra lly up to 5 c m in th e m id a x illa ry lin e .

B o rd e rs o f th e R ig h t L u n g

B o rd e rs o f t h e L e ft Lung

S te rn a l lin e

c ro s s e s rib VI

c ro s s e s rib IV

M id c la v ic u la r lin e

p a ra lle l to rib VI

c ro s s e s rib VI

M id a x illa r y line

c ro s s e s rib VIII

as rig h t side

S c a p u la r line

c ro s s e s rib X

as rig h t side

P a ra v e rte b a l lin e

c ro s s e s rib XI

as rig h t s id e

p le u ra l b o rd e rs : o n e rib lo w e r each

[- Clinical R em arks-------------------------------------Id e n tify in g lu n g a n d p le u ra l b o rd e rs is im p o rta n t d u rin g p h y s ic a l e x a m in a tio n in o rd e r to d e te rm in e th e s ize a n d m o b ility o f th e lu n g s

N o c ic e p tiv e in n e rv a tio n a n d re s u ltin g p a in s e n s a tio n is re s tric te d to th e P le u ra p a rie ta lis . C h e s t pain a c c o m p a n y in g p n e u m o n ia s o r

d u rin g re s p ira tio n . In a d d itio n , th e s e b o rd e rs a re in va lu a b le fo r th e lo c a lis a tio n o f p a th o lo g ic a l c h a n g e s su ch a s p u lm o n a ry in filtra

b ro n c h ia l c a rc in o m a s th e re fo re in d ic a te s an in v o lv e m e n t o f th e P leu

tio n s in p n e u m o n ia o r in c re a s e d flu id in th e p le u ra l c a v ity (pleural e ffu s io n ). P le u ra l e ffu s io n s are d ra in e d fro m th e R e c e s s u s c o s to d ia p h ra g m a tic u s b y th o ra c o c e n te s is .

ra p a rie ta lis . If a ir e n te rs th e p le u ra l c a v ity , th e lu n g c o lla p s e s c o m p le te ly o r par tia lly (p n e u m o th o r a x ). T h is is d e te c te d b y a lo u d (h y p e rs o n o ric ) s o u n d d u rin g p e rc u s s io n .

T horacic Viscera

Heart -► Lungs

Oesophagus

D e ve lo p m e n t

Day 32 Day 25

Fig. 5 .4 6 a n d Fig. 5 .4 7

D e v e lo p m e n t o f th e lo w e r r e s p ira to ry

tr a c t o n d a y 2 5 (-» Fig 5 .4 6 ) a n d d a y 3 2 (-» Fig 5 .4 7 ). (a c c o rd in g to

In w e e k 4, th e e p ith e lia l tis s u e s o f L a ryn x, T ra c h e a , a n d lu n g s b e g in to d e v e lo p fr o m th e e n d o d e rm o f th e fo re g u t. C o n n e c tiv e tis s u e , s m o o th

[3])

m u s c le s , a n d b lo o d v e s s e ls d e riv e fro m th e s u rro u n d in g m e s o d e rm .

Clinical R em arks-------------------------------------In c o m p le te se p a ra tio n o f th e O e s o p h a g u s a nd th e T ra c h e a m a y re s u lt in th e fo rm a tio n o f p a th o lo g ic a l c o n n e c tio n s (tra c h e o -o e s o p h a -

re s u lts in a re s p ir a to ry d is tre s s s y n d ro m e (RDS) w h ic h a c c o u n ts fo r th e m o s t c o m m o n c a u s e o f d e a th in p re m a tu re in fa n ts . U p to

g e a l fis tu la s ) w h ic h are fr e q u e n tly a s s o c ia te d w it h an o e s o p h a g e a l b lin d -e n d in g p o u c h (o e s o p h a g e a l a tre s ia ).

6 0 % o f in fa n ts b o rn b e fo re w e e k 3 0 d e v e lo p RDS. It is o n ly a fte r b irth w it h th e fir s t c ry o f th e n e w b o rn , th a t th e lu n g s

F ro m w e e k 2 8 o n w a rd s , th e a lv e o li p ro d u c e a nd s e c re te s u rfa c ta n t, a lip o p ro te in m ix tu re w h ic h re d u c e s th e s u rfa c e te n s io n o f th e a lv e

in fla te w it h air. T h u s , in fo re n s ic m e d ic in e th e flo a tin g lu n g te s t is u s e d to d iffe r e n tia te w h e th e r a c h ild w a s b o rn a liv e (lung flo a ts ) o r

oli. F ro m w e e k 3 5 o n , s u rfa c ta n t p ro d u c tio n is u s u a lly s u ffic ie n t to e n a b le s p o n ta n e o u s b r e a th in g . In s u ffic ie n t s u rfa c ta n t p ro d u c tio n

d e a d (lu n g sinks).

Thym us -► Topography -► Sections

D e ve lo p m e n t

Septum oesophagotracheale

Primitive laryngeal inlet

Laryngotracheal "anlage" or primordium

Fig. 5 .4 8

D e v e lo p m e n t o f t h e S e p tu m o e s o p h a g o tr a c h e a le . [20]

D u rin g w e e k 4 a n d 5, m e s e n c h y m a l fo ld s d e v e lo p on b o th s id e s w h ic h fu s e to th e S e p tu m o e s o p h a g o tra c h e a le a nd s e p a ra te th e p rim o rd iu m o f th e lo w e r re s p ira to ry tr a c t fro m th e O e s o p h a g u s . Bronchial buds

Day 28

Right bronchial trunk

A right upper (superior) lobe B right middle lobe C right lower (inferior) lobe

Figs. 5 .4 9 a to d

S ta g e s o f th e lu n g d e v e lo p m e n t. [20]

T h re e s ta g e s o f th e lu n g d e v e lo p m e n t are re c o g n is e d w h ic h p a rtly o v e rla p : p s e u d o g la n d u la r p e r io d (w e e k s 7 -1 7 ): d e v e lo p m e n t o f th e a ir c o n d u c tin g p a rt o f th e re s p ira to ry tra c t

Left bronchial trunk

D left upper (superior) lobe E left lower (inferior) lobe

•

c a n a lic u la r p e r io d (w e e k s 1 3 -2 6 ): e a rly d e v e lo p m e n t o f th e re s p i ra to ry p a rt (gas e x c h a n g e ) o f th e re s p ira to ry tr a c t a lv e o la r p e rio d (w e e k 2 3 to 8 y e a rs o f life ): d e v e lo p m e n t o f a lv e o li

T horacic Viscera

Heart -► Lungs -» Oesophagus

Trachea and bronchi

B ro n c h u s p rin c ip a lis d e x te r Bronchus lobaris sup erior d ex ter 1 = Bronchus segmentalis apicalis [B I] 2 = Bronchus segmentalis posterior [B II] 3 = Bronchus segmentalis anterior [B III]

Cartilago thyroidea

Bronchus lobaris m edius dexter 4 = Bronchus segmentalis lateralis [B IV] 5 = Bronchus segmentalis medialis [B V] Bronchus lobaris inferior d ex ter 6 = Bronchus segmentalis superior [B VI] 7 = Bronchus segmentalis basalis medialis [B VII] 8 = Bronchus segmentalis basalis anterior [B VIII] 9 = Bronchus segmentalis basalis lateralis [B IX] 10 = Bronchus segmentalis basalis posterior [B X]

Cartilago cricoidea

B ro n c h u s p rin c ip a lis s in is te r

Cartilagines tracheales

Bronchus lobaris sup erior sinister 1 , 2 = Bronchus segmentalis apicoposterior [B l+ll] 3 = Bronchus segmentalis anterior [B III] 4 = Bronchus lingularis superior [B IV] 5 = Bronchus lingularis inferior [B V] Bronchus lobaris inferior sinister 6 = Bronchus segmentalis superior [B VI] 8 = Bronchus segmentalis basalis anterior [B VIII] 9 = Bronchus segmentalis basalis lateralis [B IX] 10 = Bronchus segmentalis basalis posterior [B X]

Ligg. anularia

B ifurcatio tra ch eae Bronchus

1 Bronchus lobaris superior dexter

Bronchus lobaris superior sinister

3 Cartilagines Bronchus lobaris medius dexter Bronchus lobaris inferior sinister 4

Bronchus lobaris inferior dexter 8

Fig. 5 .5 0 L o w e r re s p ir a to ry tr a c t w it h la ry n x . L a ry n x , tra c h e a . T ra c h e a a n d b ro n c h i, B ro n c h i; v e n tra l v ie w . T h e T ra ch ea is 1 0 - 1 3 c m lo n g a n d e x te n d s fr o m th e c ric o id c a rtila g e o f th e L a ry n x to its d iv is io n (B ifu rc a tio tra ch e a e ) in to th e t w o m a in (p rim a ry) b ro n c h i (B ro n c h i p rin c ip a le s ). T h e T ra ch ea is o rg a n is e d in a ce rv ic a l

T h e m o re d e ta ile d s y s te m a tic d e s c rip tio n o f th e b ro n c h ia l tre e is n o t illu s tra te d h e re . T h e b ro n c h i fu r th e r d iv id e s ix - to tw e lv e tim e s b e fo re c o n tin u in g as b ro n c h io le s . B ro n c h io le s have a d ia m e te r s m a lle r th a n 1 m m a n d lack c a rtila g e a n d g la n d s w ith in th e ir w a lls . Each b ro n c h io le

p a rt (Pars c e rvica lis) a nd a th o ra c ic p a rt (Pars th o ra c ic a ). P ro je c tio n a nd to p o g ra p h y are d e s c rib e d in - * Fig 5 .4 3 . T h e m a in b ro n c h i fu r th e r d iv id e

is a s s o c ia te d w it h a p u lm o n a ry lo b u le (L o b u lu s p u lm o n is ) a nd fu r th e r d iv id e s th re e - to fo u r tim e s b e fo re c o n tin u in g as te rm in a l b ro n c h io le s (B ro n c h io li te rm in a le s ). T h e s e re p re s e n t th e la s t s e g m e n t o f th e a ir

in th re e a nd tw o lo b a r b ro n c h i (B ro n c h i lo b a re s ) on th e rig h t a nd le ft s id e s , re s p e c tiv e ly . T h e lo b a r b ro n c h i g iv e rise to th e s e g m e n ta l b ro n c h i

c o n d u c tin g p a r t o f th e re s p ira to ry s y s te m w h ic h has a v o lu m e o f 1 5 0 1 7 0 m l. Each B ro n c h io lu s te r m in a lis o p e n s in to a p u lm o n a ry a c in u s

(B ro n c h i s e g m e n ta le s ). T h e rig h t lu n g has 10 s e g m e n ts and, th u s , 10 s e g m e n ta l b ro n c h i. In th e le ft lu n g , h o w e v e r, s e g m e n t 7 a nd th e re s

(A cin u s p u lm o n is ) w h ic h g e n e ra te s 10 a d d itio n a l g e n e ra tio n s o f B ro n c h io li re s p ira to rii w it h D u c tu s a nd S a c c u li a lv e o la re s . A ll p a rts o f th e

p e c tiv e B ro n c h u s are m is s in g .

a c in u s c o n ta in a lv e o li a nd , th u s , th e a c in u s b e lo n g s to th e g a s-e xc h a n g in g p a rt o f th e re s p ira to ry s y s te m .

i- Clinical R em arks-------------------------------------T h e v o lu m e o f th e a ir c o n d u c tin g p a rt o f th e re s p ira to ry s y s te m (1 5 0 -1 7 0 m l) is e q u iv a le n t t o th e a n a to m ic a l d e a d -s p a c e a n d has an im p o rta n t p ra ctica l re le v a n c e fo r r e s u s c ita tio n . D u rin g v e n tila tio n

re ach th e a lv e o li a nd a vo id ju s t m o v in g th e a ir c o lu m n w ith in th e c o n d u c tin g p a rt. T h u s , a rtific ia l v e n tila tio n is m o re e ffe c tiv e w h e n p e rfo rm e d s lo w e r w it h la rg e r v o lu m e th a n w ith h ig h fre q u e n c y and

th e v o lu m e o f o x y g e n a te d a ir n e e d s to e x c e e d 1 70 m l to e ffe c tiv e ly

s m a lle r v o lu m e .

Thym us -â&#x2013;ş Topography -â&#x2013;ş Sections

S tru ctu re o f trachea and bronchi

Fig. 5.51

L o w e r r e s p ira to ry tr a c t w it h la ry n x , L a ry n x , tra c h e a .

T ra c h e a , a n d b ro n c h i. B ro n c h i; d o rs a l v ie w . T h e s y s te m a tic c o m p o s itio n o f th e b ro n c h ia l tre e is d e s c rib e d in - * F ig u re 5 .5 0 . T h e d o rs a l v ie w c le a rly s h o w s th a t th e d o rs a l w a lls o f

m e m b ra n a c e u s ) b u t p re d o m in a n tly o f s m o o th m u s c le s (M . tra c h e a lis ). T h e in c o m p le te tra c h e a l c a rtila g e s are c o n n e c te d b y Lig g . anu la ria . T h e Â s e c o m p ris e e la s tic c o n n e c tiv e tis s u e a nd e n a b le th e e lo n g a tio n o f th e tra c h e a fo r u p to 5 c m d u rin g d e e p in s p ira tio n .

th e T ra ch ea a nd th e m a in b ro n c h i d o n o t c o n s is t o f c a rtila g e (Paries

Cartilago trachealis

Tunica adventitia

Epithelium

Tunica mucosa

Glandulae tracheales

Fig. 5 .5 2

T ra c h e a , T ra ch e a; c ro s s -s e c tio n , m ic ro s c o p ic v ie w .

T h e w a lls o f th e tra c h e a a n d th e m a in b ro n c h i c o m p ris e a m u c o u s m e m b ra n e (T unica m u c o s a ) o n th e lu m in a l s id e fo llo w e d b y th e T u n ica

Paries membranaceus

M. trachealis

fib ro m u s c u lo c a rtila g in e a a nd th e T u n ic a a d v e n titia . T h e T u n ic a fib ro m u s c u lo c a rtila g in e a c o n s is ts o f 16 to 20 h o rs e s h o e -s h a p e d in c o m p le te tra c h e a l c a rtila g e s o f h y a lin e c a rtila g e , w h ic h are b rid g e d p o s te rio rly b y a s m o o th m u s c le (M . tra c h e a lis ).

T horacic Viscera

Heart -► Lungs -» Oesophagus

Lungs A p ex pulm onis

Lobus superior

Fissura obliqua

Lobus superior, Facies costalis

Margo anterior

Margo posterior Fissura horizontalis

Lobus medius, Facies costalis

Lobus inferior, Facies costalis

Fissura obliqua

Lobus inferior Margo inferior

Basis pulm onis

A p ex pulm onis

Fig. 5 .5 3 a n d Fig. 5 .5 4

R ig h t lu n g , P u lm o

d e x te r (-» Fig. 5 .5 3 ), a n d le ft lu n g , P u lm o s in is te r (-» Fig. 5 .5 4 ); latera l v ie w .

Lobus superior, Facies costalis

T h e rig h t lu n g h as th re e lo b e s (L o b i su p e rio r, m e d iu s a nd in fe rio r) w h ic h are s e p a ra te d by th e Fissu ra o b liq u a a n d th e Fissu ra h o riz o n ta -

Fissura obliqua

lis. T h e le ft lu n g has o n ly t w o lo b e s (Lobi s u p e rio r a n d in fe rio r) s e p a ra te d b y th e Fissura o b liq u a . T h e L in g u la p u lm o n is o f th e s u p e rio r lo b e is e q u iv a le n t t o th e m id d le lo b e o f th e rig h t lu n g a n d fo r m s a to n g u e -lik e e x te n s io n in fe rio r to th e In cisu ra cardiaca.

Margo anterior Lobus superior

T h e v o lu m e o f th e rig h t lu n g e n c o m p a s s e s 2 - 3 I, d u rin g m a x im a l in s p ira tio n e v e n 5 - 8 I.

Margo posterior

T h is v o lu m e is e q u iv a le n t to a g as e x c h a n g e area o f 7 0 - 1 4 0 m 2. D u e to th e le ft-s h ifte d p o

Lobus inferior, Facies costalis

s itio n o f th e h e a rt th e v o lu m e o f th e le ft lung is s m a lle r b y 1 0 -2 0 % . T h e a p e x o f th e lu n g (A p e x p u lm o n is ) is cranial p a rt, th e b ro a d base o f th e lu n g (B a sis p u lm o nis) is th e ca ud a l p a rt o f th e lu n g . T h e s u rfa c e o f th e lu n g is c o v e re d b y th e P leu ra v is c e ra lis a nd h as th re e s u rfa c e a lig n m e n ts . T h e F a cies

Incisura cardiaca

c o s ta lis is lo c a te d la te ra lly a nd c o n tin u e s at th e M a rg o in fe rio r as th e F a cies d ia p h ra g m a tica (-» Figs. 5 .5 5 a nd 5 .5 6 ). A t th e M a rg o a n te rio r a nd th e b lu n t M a rg o p o s te rio r it c o n tin u e s

Lingula pulmonis

as th e F a cies m e d ia s tin a lis to w a rd s th e M e d i a s tin u m . Fissura obliqua

5 .5 4

Margo inferior Basis pulm onis

Thym us -»Topography -► Sections

Lungs Apex pulmonis (Sulcus arteriae subclaviae)

Lobus superior

(Sulcus venae brachiocephalicae) Fissura obliqua Lobus superior Bronchus lobaris superior dexter A. pulm onalis dextra Bronchus principalis dexter

Bronchus lobaris medius dexter et inferior dexter

Margo anterior

Nodus lym phoideus tracheob ro nchialis inferior

Vv. pulm onales d extrae

Pleura parietalis, Pars mediastinalis Im p ressio cardiaca Hilum pulm onis Lobus inferior

Fissura horizontalis

Lig. pulm onale Lobus medius

Facies diaphragmatica; Basis pulmonis Fissura obliqua Margo inferior

Fig. 5 .5 5 a n d Fig. 5 .5 6 R ig h t lu n g , P u lm o d e x te r (-» Fig. 5 .5 5 ), a n d le ft lu n g , P u lm o Apex pulmonis

s in is te r (-* Fig. 5 .5 6 ); m e d ia l v ie w . T h e H ilu m p u lm o n is is th e m e d ia lly p o s itio n e d e n try fo r th e m a in b ro n c h i a nd th e n e u ro v a s

(Sulcus arteriae subclaviae)

Fissura obliqua

c u la r s tru c tu re s to th e lu n g s , w h ic h to g e th e r are re fe rre d to as th e ro o t o f th e lu n g (R adix

(Sulcus venae brachiocephalicae)

A. pulm onalis sinistra

p u lm o n is ). A t th e h ilu m , th e P leura v is c e ra lis is b le n d s in to th e P leura p a rie ta lis a nd b o th p a rts lin e th e p le u ra l c a v ity . T h is p le u ra l fo ld

V. pulm onalis sinistra superior Bronchus principalis sinister

e x te n d s in fe rio rly in to th e Lig. p u lm o n a le . T h e to p o g ra p h ic a l o rie n ta tio n o f th e m a in

Pleura parietalis, Pars mediastinalis

V. pulm onalis sinistra inferior

b ro n c h i in re la tio n to th e g re a t b lo o d v e s s e ls a t th e h ilu m o f th e lu n g is d iffe r e n t fo r b o th lu n g s . A t th e r ig h t lu n g , th e B ro n c h u s p r in c ip a lis is th e m o s t s u p e rio r s tru c tu re a nd th e

Margo anterior

Vv. p u lm o n a le s are p o s itio n e d a n te rio rly . In c o n tra s t, th e m a in b ro n c h u s o f th e le ft lu n g is

Hilum pulm onis

Nodi lym phoidei tra cheob ro nchiale s Lig. pulm onale

p o s itio n e d b e lo w th e A . p u lm o n a lis . W h e n d is s e c tin g th e ro o t o f th e lu n g , th e h ilu m fre q u e n tly s h o w s s e v e ra l ly m p h n o d e s (N odi ly m p h o id e i tra c h e o b ro n c h ia le s ), w h ic h are n o rm a lly b la c k d u e t o d e p o s its o f c a rb o n d u s t. T h e F a cies m e d ia s tin a lis is c o n c a v e -s h a p e d

Impressio cardiaca Lobus inferior

(m o re p ro n o u n c e d a t th e le ft s id e ) b y th e h e a rt (Im p re s s io ca rdia ca ). B o th lu n g s s h o w

Facies mediastinalis Incisura cardiaca (Sulcus aorticus)

im p re s s io n s w h ic h are c a u s e d b y a d ja c e n t b lo o d v e s s e ls or, on th e le ft s id e , th e o e s o

(Impressio oesophagea)

p h a g u s . T h e s e im p re s s io n s n ic e ly d e m o n s tra te th e to p o g ra p h ic a l re la tio n s o f th e lu n g s to n e ig h b o u rin g o rg a n s b u t th e y are, s im ila r to

Lingula pulmonis

th e m a rg in s o f th e lu n g s , o n ly a p p a re n t in th e fix e d lu n g s (fix a tio n a rte fa c ts ).

Margo inferior

5 .5 6

Fissura obliqua Facies diaphragmatica; Basis pulmonis

P Clinical R em arks-------------------------------------T h e a p e x o f th e lu n g e x te n d s u p to 5 c m a b o v e th e le ve l o f th e s u p e rio r th o ra c ic a p e rtu re . T h u s , w it h p la c e m e n t o f a c e n tra l v e n o u s c a th e te r (CVC) via th e V. su b cla via , in ju ry to th e lu n g m a y o c c u r and a c c id e n ta l in ju ry o f th e ce rv ic a l p le u ra m a y c a u s e a p n e u m o th o r a x w it h re s u ltin g c o lla p s e o f th e lun g . B u t in c a th e te ris a tio n o f th e V. ju g u la ris in te rn a a t th e n e c k th e re is a lso a ris k o f p n e u m o th o ra x

s in c e d u rin g th is p ro c e d u re th e c a th e te r is d ire c te d to w a r d s th e s te rn o c la v ic u la r jo in t n e a r th e a p e x o f th e lu n g . B u t th is ris k is m u c h h ig h e r w h e n u s in g th e V. s u b c la v ia fo r a CVC s in c e th e la tte r d ire c tly c o n ta c ts th e P leura phalica.

(-*

Fig. 5 .9 9 ) b e fo re c o n tin u in g as V. b ra c h io c e -

T horacic Viscera

Heart -► Lungs

Oesophagus

B ro n ch opulm o nary se g m e n ts

P u lm o d e x te r

P u lm o s in is te r

Lobus superior

Segmentum apicale [Sl] Segmentum apicoposterius [SI + II] Segmentum posterius [Sil] Segmentum anterius [Sill]

Segmentum anterius [Sill] Segmentum lingulare superius [SIV]

Lobus m edius

Segmentum lingulare inferius [SV]

Segmentum laterale [SIV] Segmentum mediale [SV]

Lobus inferior Segmentum superius [SVI]

Lobus inferior

Segmentum basale anterius [SVIII]

Segmentum superius [SVI]

Segmentum basale laterale [SIX]

Segmentum basale mediale [cardiacum] [S VII]

Segmentum basale posterius [SX]

Segmentum basale anterius [SVI11] Segmentum basale laterale [SIX] Segmentum basale posterius [SX]

Fig. 5 .5 7 a n d Fig. 5 .5 8

B ro n c h o p u lm o n a ry s e g m e n ts , S e g m e n ta

b r o n c h o p u lm o n a lia , o f th e r ig h t lu n g (-* Fig. 5 .5 7 ) a n d t h e le ft (-» Fig. 5 .5 8 ) lu n g ; latera l v ie w . T h e lo b e s o f th e lu n g are o rg a n is e d in co n e -s h a p e d lu n g (b ro n c h o p u l m o n a ry) s e g m e n ts w h ic h are in c o m p le te ly d iv id e d b y s e p ta tio n s o f c o n n e c tiv e tis s u e . T h e s e g m e n ta l b o rd e rs are n o t v is ib le o n th e s u rfa c e o f th e lu n g . T h e lu n g s e g m e n ts are a s s o c ia te d w it h s e g m e n ta l b r o n c h i a nd s e g m e n ta l b ra n c h e s o f th e p u lm o n a ry a rte ry. T h e r ig h t lu n g

has te n s e g m e n ts , th re e in th e s u p e rio r, t w o in th e m id d le , a nd fiv e in th e in fe rio r lo b e . T h e le ft lu n g o n ly has n in e s e g m e n ts s in c e s e g m e n t V II (S e g m e n tu m b a sa le m e d ia le - * Fig. 5 .5 9 ) o n th e le f t s id e is m is s in g o r d ra s tic a lly re d u c e d a nd fu s e d w ith s e g m e n t V III d u e to th e la rg e r e x te n s io n o f th e M e d ia s tin u m . T h e o rg a n is a tio n o f th e o th e r lu n g s e g m e n ts is s im ila r on b o th s id e s s in c e th e s e g m e n ts o f th e m id d le lo b e o f th e rig h t lu n g are e q u iv a le n t to th e t w o s e g m e n ts o f th e L in g u la p u lm o n is in th e le ft lun g .

Thym us -► Topography -► Sections

B ro n ch o p u lm o n a ry se g m e n ts

Fig. 5 .5 9 a n d Fig. 5 .6 0 B ro n c h o p u lm o n a ry s e g m e n ts , S e g m e n ta b r o n c h o p u lm o n a lia , o f th e r ig h t lu n g (-* Fig. 5 .5 9 ) a n d th e le ft

T h e rig h t lu n g has te n s e g m e n ts . T h e le ft lu n g o n ly has n in e s e g m e n ts ; s e g m e n t V II (S e g m e n tu m b a sa le m e d ia le ) is m is s in g .

(-» Fig. 5 .6 0 ) lu n g ; m e d ia l v ie w .

Bronchus segmentalis apicoposterior [Bl, Bll]; Bronchus segmentalis anterior [BUI]

Bronchus lobaris superior sinister

Bronchi lingulares superior et inferior [BIV, BV]

Bronchus segmentalis basalis anterior [BVI 11]

Bronchus segmentalis superior [BVI]

Bronchus segmentalis basalis lateralis [BIX]

Bronchus segmentalis basalis posterior [BX]

Fig. 5.61

B ro n c h i, B ro n c h i; b ro n c h o s c o p y s h o w in g th e s e g m e n ta l

b ro n c h i o f th e le ft s id e . It is a p p a re n t th a t th e s e g m e n ta l b ro n c h u s VII is m is s in g on th e le f t s id e (-* Fig. 5.6 0 ).

Clinical Remarks T h e k n o w le d g e o f th e lu n g s e g m e n ts is cru cia l fo r o rie n ta tio n d u rin g

o r d ia g n o s e a tu m o u r. A n o th e r in d ic a tio n fo r b ro n c h o s c o p y is to ac

b ro n c h o s c o p y . A b ro n c h o s c o p y is p e rfo rm e d if ra d io lo g ica l im a g in g re v e a le d a s u s p ic io u s n o d u le a n d b io p s ie s are n e e d e d to ru le o u t

q u ire m a te ria l fo r p a th o g e n id e n tific a tio n in c a s e s o f d ru g r e s is te n t p n e u m o n ia .

T horacic Viscera

Heart -► Lungs -» Oesophagus

Blood vessels o f th e Lungs

Lung alveoli

Bronchiolus terminalis

V. pulmonalis

A. pulmonalis

R. bronchialis

Intersegmental connective tissue (septum) Bronchioli respiratorii

Capillary network o f the lung alveoli

Pleura w ith subpleural blood vessel plexus

Fig. 5 .6 2

A c in u s o f th e lu n g . A c in u s p u lm o n is , w it h b lo o d

v essels.

p le u ra l c o n n e c tiv e tis s u e a n d tra n s p o rt th e d e o x y g e n a te d b lo o d fro m th e rig h t h e a rt to th e a lv e o li. T h e V v. p u lm o n a le s are lo c a te d in th e in

T h e lu n g h as t w o b lo o d v e s s e l s y s te m s w h ic h c o m m u n ic a te th ro u g h th e ir te rm in a l b ra n c h e s in th e w a ll o f th e a lve o li (a lve o la r se p ta ). T h e Aa.

te rs e g m e n ta l c o n n e c tiv e tis s u e a nd tra n s p o rt th e o x y g e n a te d b lo o d to th e le ft a triu m .

p u lm o n a le s a n d V v. p u lm o n a le s o f th e p u lm o n a ry c irc u la tio n c o n s titu te th e V a s a p u b lic a w h ic h s e rv e fo r th e g as e x c h a n g e o f th e b lo o d .

T h e V a s a p r iv a ta o f th e lu n g s u p p ly th e lu n g tis s u e its e lf. T h e a rte ria l Rr. b ro n c h ia le s a n d th e Vv. b ro n c h ia le s c o u rs e to g e th e r w it h th e b ro n -

B ra n c h e s o f th e A a. p u lm o n a le s c o u rs e in th e p e rib ro n c h ia l a nd s u b-

Trachea A. carotis com munis sinistra

A. subclavia sinistra

Arcus aortae

A. subclavia dextra

A. intercostalis dextra III Bronchus principalis dexter

Bronchus principalis sinister

R. bronchialis d ex ter Rr. bronchiales sinistri

Fig. 5 .6 3

V a s a p r iv a ta o f th e lu n g ; d o rsa l v ie w .

T h e a rte ria l Rr. b ro n c h ia le s d e riv e d ire c tly fr o m th e A o rta th o ra c ic a on th e le f t sid e , b u t u s u a lly b ra n ch o f f th e th ird in te rc o s ta l a rte ry (A. in te r c o s ta lis d e x tra III) on th e rig h t sid e . T h e V v. b ro n c h ia le s d ra in in to th e a zyg o s s y s te m (n o t s h o w n here).

Pars thoracica aortae

Thym us -► Topography -► Sections

Lym ph vessels and lym ph nodes o f th e lung

V. jugularis interna dextra Confluence Ductus lym phaticus dexter

V. jugularis interna sinistra Confluence of the Ductus thoracicus

V. subclavia dextra V. subclavia sinistra Truncus bronchom ediastinalis d ex ter N odi lym phoidei p a ratrach e ales

Ductus thoracicus

Nodi lym phoidei tra ch eo b ro n ch iale s superiores Nodi lym phoidei tra cheob ro nchiale s inferiores N odi lym phoidei in trap ulm on ales

Nodus lym phoideus bronchopulm onalis

Subpleural lym ph vessels

Peribronch ial lym ph vessels S e p ta l lym ph vessels

Fig. 5 .6 4

L y m p h v es s e ls , V a s a ly m p h a tic a , a n d ly m p h n o d e s .

tio n a b o v e a n d b e lo w th e tra c h e a l b ifu rc a tio n . F ro m h e re th e ly m p h

N o d i ly m p h o id e i, o f th e lu n g ; v e n tra l v ie w ; s c h e m a tic illu s tra tio n .

p a s s e s on t o th e N o d i ly m p h o id e i p a ra tra c h e a le s o r to th e T ru n c i b ro n -

T h e lu n g has t w o ly m p h v e s s e l s y s te m s w h ic h c o n v e rg e a t th e h ilu m . T h e p e rib ro n c h ia l s y s te m fo llo w s th e b ro n c h i a nd fe e d s in to se v e ra l ly m p h n o d e s ta tio n s . T h e fir s t s ta tio n are th e N o d i ly m p h o id e i in tra p u l

c h o m e d ia s tin a le s o n b o th s id e s . T h u s , th e re is no s tr ic t s e p a ra tio n o f th e ly m p h d ra in a g e fr o m th e d iffe r e n t s id e s . T h e s u b p le u ra l a nd th e s e p ta l ly m p h s y s te m drain in to th e N o d i ly m

m o n a le s a t th e tra n s itio n fro m lo b a r to s e g m e n ta l b ro n c h i. T h e s e c o n d s ta tio n c o m p ris e s th e N o d i ly m p h o id e i b ro n c h o p u lm o n a le s a t th e h ilu m

p h o id e i tra c h e o b ro n c h ia le s as th e fir s t s ta tio n . T h e ir d e lic a te ly m p h v e s s e ls fo rm a p o ly g o n a l n e tw o r k a t th e s u rfa c e o f th e lun g . T h is n e t

o f th e lu n g . T h e s u b s e q u e n t N o d i ly m p h o id e i tra c h e o b ro n c h ia le s are lo c a te d a lre a d y a t th e ro o t o f th e lu n g . N o d i ly m p h o id e i tra c h e o b ro n c h i

w o r k re p re s e n ts th e b o u n d a rie s o f d is tin c t p u lm o n a ry lo b u le s . D u e to c a rb o n d u s t d e p o s its (e x h a u s t fu m e s a n d c ig a re tte s m o k e ) th e s e ly m p h

a le s s u p e rio re s a nd in fe rio re s are d is tin g u is h e d a c c o rd in g to th e ir loca

v e s s e ls a n d th e b o u n d a rie s o f th e p u lm o n a ry lo b u le s are c le a rly v is ib le .

Clinical Remarks C lin icia n s u s u a lly s u m m a ris e all ly m p h n o d e s o f th e lu n g w it h th e te r m h ila r ly m p h n o d e s . H o w e v e r, th is d is re g a rd s th e fa c t th a t th e

o f p a re n c h y m a l p ro c e s s e s a s s e p a ra te d is e a s e e n titie s a nd n e g le c t th e a s s o c ia tio n w it h ly m p h n o d e e n la rg e m e n t w h ic h m a y in itia te un

N o d i ly m p h o id e i in tra p u lm o n a le s are lo c a te d d e e p w ith in th e lung p a re n c h y m a . T h is lin g u is tic b lu rrin g m a y e n ta il th e m is in te rp re ta tio n

n e c e s s a ry d ia g n o s tic p ro c e d u re s .

T horacic Viscera

Heart -► Lungs -» Oesophagus

Lungs and pleural cavities

Vv. brachiocephalicae Clavicula V. thoracica interna

A p ex pulm onis

Thymus

(Trigonum thym icum )

Pleura parietalis, Pars costalis

Pulm o sinister, Lobus superior

Pulmo dexter, Margo anterior Margo anterior

(Trigonum pericardiacum )

Lobus superior Pulm o d e x te r •

Lobus medius

Incisura cardiaca

Lobus inferior

Lingula pulmonis

Pleura parietalis, Pars diap h rag m atica

Pulm o sinister, Lobus inferior Margo inferior

Recessus co s tod iaph ragm aticus

Pericardium Recessus costom ed iastinalis

Fig. 5 .6 5 L u n g s , P u lm o n e s , a n d p le u ra l c a v itie s . C a v ita te s p le u ra le s , o f an a d o le s c e n t; v e n tra l v ie w ; a fte r re m o v a l o f th e a n te rio r th o ra c ic w a ll. T h e p le u ra l c a v ity (C a v ita s p le u ra lis ) is c o v e re d b y th e p a rie ta l P leura (Pleura p a rie ta lis). T h e p a rie ta l P leura is d iv id e d in to Pars m e d ia s tin a lis , Pars c o s ta lis , a nd Pars d ia p h ra g m a tic a . T h e v is c e ra l P leura (P le u ra visc e ra lis) c o v e rs th e o u te r s u rfa c e o f th e lu n g s . T h e c a p illa ry s p a c e b e tw e e n b o th p le u ra l la ye rs c o n ta in s 5 m l o f a s e ro u s flu id w h ic h lu b ri c a te s th e p le u ra l s u rfa c e s a n d re d u c e s fric tio n d u rin g b re a th in g . T h e p le u ra l cu p u la (C u p u la p le u ra e ) e x te n d s up to 5 c m a b o v e th e s u p e rio r th o ra c ic a p e rtu re . T h e s u p e rio r a nd in fe rio r m e d ia l b o rd e rs o f th e P leura fo r m th e b o u n d a rie s o f th e T rig o n u m th y m ic u m a n d th e Tri-

g o n u m p e ric a rd ia c u m , re s p e c tiv e ly . T h e p le u ra l c a v itie s p o s s e s s e s fo u r p le u ra l re c e s s e s (R e c e s s u s p le u ra le s ) in to w h ic h th e lu n g s ca n e xpa n d d u rin g d e e p in s p ira tio n : R ecessus c o s to d ia p h ra g m a tic u s : latera l, in th e m id a x illa ry lin e u p to 5 c m d e e p R ecessus c o s to m e d ia s tin a lis : v e n tra l, to b o th s id e s o f th e M e d ia s tin u m a n d c h e s t w a ll R ecessus p h re n ic o m e d ia s tin a lis : ca ud a l, b e tw e e n d ia p h ra g m a nd M e d ia s tin u m R ecessus v e r te b r o m e d ia s tin a lis : d o rs a l, a d ja c e n t to th e v e rte b ra l c o lu m n (-» Fig. 5 .1 0 4)

i- Clinical R em arks-------------------------------------in th e p le u ra l c a v ity (p le u ra l e ffu s io n ) m a y be

e n te rs th e p le u ra l c a v ity . P leural e ffu s io n s c a u s e a d u ll p e rc u s s io n

ca u s e d b y in fla m m a to ry re a c tio n s in p n e u m o n ia (p le u ritis ), b y c o n g e s tio n in th e p u lm o n a ry c irc u la tio n d u e to a (le ft) v e n tric u la r in s u f

In c re a s e d flu id

s o u n d . D ia g n o s tic p u n c tu re o f a p le u ra l e ffu s io n fr o m th e R e c e s s u s c o s to d ia p h ra g m a tic u s is p e rfo rm e d to s a m p le flu id fo r d ia g n o s is and

fic ie n c y , o r b y tu m o u rs o f th e lu n g o r th e P leura. In a d d itio n , th e re are c h y lo u s p le u ra l e ffu s io n s if ly m p h fr o m th e D u c tu s th o ra c ic u s

to im p ro v e b re a th in g .

dissection link

Thym us -► Topography -► Sections

Thoracic viscera, radiography

Bifurcatio tracheae

Bronchus principalis dexter Truncus pulmonalis

V. pulmonalis

Bronchus principalis sinister

Nodi lymphoidei bronchopulm onales**

Auricula sinistra Bronchi

V. pulmonalis Ventriculus sinister Atrium dextrum

V. pulmonalis

Diaphragma, (Cupula sinistra)

Diaphragma, (Cupula dextra) Recessus costodiaphragmaticus

Fig. 5 .6 6 T h o ra c ic c a g e , C a v e a th o ra c is , w ith th o ra c ic v is c e ra ; ra d io g ra p h in p o s te ro -a n te rio r (PA) b e a m p ro je c tio n . [2 7 ]

T h e c o u rs e o f th e b ro n c h i is p a rtly v is ib le . O n th e r ig h t s id e , c lu s te rs o f ly m p h n o d e s in th e area o f th e h ilu m o f th e lu n g a re v is ib le . * **

c o n to u r o f th e b re a s t (m a m m a ) c lin ic a l te r m : h ila r ly m p h n o d e s

Clinical Remarks C h e s t ra d io g ra p h s are fre q u e n tly ta k e n if p a th o lo g ic a l p ro c e s se s o f th e lu n g s o r th e p le u ra are s u s p e c te d , su ch a s in fla m m a tio n s (p n e u

o f th e ra d ia tio n th a n th e in ta c t lu n g tis s u e . In th e u p rig h t p o s itio n , a p le u ra l e ffu s io n b lu n ts th e R e c e s s u s c o s to d ia p h ra g m a tic u s a nd

m o n ia , p le u ritis ) o r tu m o u rs (b ro n ch ia l ca rc in o m a ). P a re n c h y m a l a lte ra tio n s are o fte n p re s e n t as " s h a d o w s " b e c a u s e th e y a b s o rb m o re

fo r m s a h o riz o n ta l flu id leve l.

Thoracic Viscera

Heart -► Lungs -*• Oesophagus -►

P rojection o f th e oesophagus

Cavitas oris propria Os { Vestibuium oris Rima oris Pars oralis pharyngis Pharynx Pars laryngea pharyngis

O esophagus

Hepar

G aster

Pancreas

Vesica biliaris [fellea] Intestinum tenue

Intestinum crassum

Fig. 5 .6 7

O v e r v ie w o f th e d ig e s tiv e tr a c t.

T h e O e s o p h a g u s is a m u s c u la r tu b e c o n n e c tin g th e P h a ry n x w it h th e s to m a c h (G aster). It tra n s p o rts th e in g e s te d fo o d .

Fig. 5 .6 8 w a ll.

P ro je c tio n o f t h e O e s o p h a g u s o n to t h e v e n tra l th o ra c ic

T h e O e s o p h a g u s is 2 5 c m lo n g a n d o rig in a te s a t th e c ric o id c a rtila g e w h ic h p ro je c ts o n to th e 6 th c e rv ic a l v e rte b ra . It e n d s a t th e C ardia o f th e s to m a c h a t th e le v e l o f th e 10th th o ra c ic v e rte b ra (b e n e a th th e P roc. x ip h o id e u s o f th e S te rn u m ).

i- Clinical R em arks-------------------------------------T h e p ro je c tio n o f th e O e s o p h a g u s e x p la in s w h y an in fla m m a tio n o f

a t th e s a m e sp in a l c o rd s e g m e n ts . T h e brain c a n n o t d iffe re n tia te

th e o e s o p h a g e a l m u c o s a b y g a s tric a cid re flu x (g a s tro -(o )e s o p h a g e a l re flu x d is e a s e , G E R D ) c a u s e s a re tro s te rn a l b u rn in g s e n s a ti on a n d pain a t a s im ila r lo c a tio n as a m y o c a rd ia l in fa rc tio n . A ffe r e n t

w h e th e r th e pain o rig in a te s fr o m in te rn a l o rg a n s o r th e b o d y s u rfa c e . T h e s e o rg a n -a s s o c ia te d d e rm a to m e s are re fe rre d to as H E A D 'S

n e rv e fib re s fr o m b o th o rg a n s a n d th e v e n tra l c h e s t w a ll c o n v e rg e

z o n e s , th e p h e n o m e n o n is ca lle d " re fe r r e d p a in ".

Thym us -► Topography -► Sections

O esophagus

Trachea

A. carotis communis

A. carotis communis A. subclavia A. subclavia O esophagus, Pars cervicalis Truncus brachiocephalicus Arcus aortae O esophagus, Pars cervicalis

carotis communis dextra A. carotis communis sinistra

Bronchus principalis dexter

Bifurcatio tracheae

A. subclavia dextra

Bronchus principalis sinister

Bronchus lobaris superior dexter

Truncus brachiocephalicus Trachea

Pars thoracica aortae O esophagus, Pars thoracica

Arcus aortae

Diaphragma, Centrum tendineum

Hiatus oesophageus

Foramen venae cavae

O esophagus, Pars abdom inalis

Bronchus lobaris superior dexter Pars thoracica aortae

Gaster, Pars cardiaca Pars lumbalis diaphragmatis, Crus dextrum

O esophagus, Pars thoracica

Hiatus aorticus

Pars abdominalis aortae

5 .6 9

Fig. 5 .6 9 a n d Fig. 5 .7 0

O e s o p h a g u s , O e s o p h a g u s , tra c h e a ,

T ra c h e a , a n d th o ra c ic a o r ta , P ars th o ra c ic a a o rta e ; v e n tra l v ie w (-» Fig. 5 .6 9 ) a n d v ie w fr o m th e rig h t s id e (-* Fig. 5.7 0 ). T h e O e s o p h a g u s is 2 5 c m lo n g a n d is o rg a n is e d in th re e p arts: • • •

Pars c e rv ic a lis (5 -8 cm ) Pars th o ra c ic a (16 cm ) Pars a b d o m in a lis ( 1 - 4 cm )

T h e P ars c e rv ic a lis is a d ja c e n t to th e v e rte b ra l c o lu m n . T h e P ars t h o rac ica c ro s s e s th e a o rtic a rch w h ic h is a d ja c e n t on th e d o rs a l le f t s ide . T h is p a rt ru n s a lo n g th e le ft m a in b ro n c h u s a n d d e s c e n d s v e n tra lly w ith in c re a s in g d is ta n c e to th e v e rte b ra l c o lu m n . T h e d o rs a l v ie w s h o w s c lo s e p r o x im ity o f th e Pars th o ra c ic a to th e P e ric a rd iu m a nd to th e a triu m (-» Fig. 5 .7 1 ). A ft e r tra v e rs in g th e H ia tu s o e s o p h a g e u s o f d ia p h ra g m , th e s h o rt in tra p e rito n e a lly lo c a te d P ars a b d o m in a lis g in s.

th e le ft th e be

T horacic Viscera

Heart -► Lungs -*• Oesophagus -►

S tru ctu re o f th e oesophagus

A. carotis communis A. carotis communis

V. jugularis interna A. subclavia

V. jugularis interna

O esophagus, Pars cervicalis

A. subclavia V. subclavia

V. subclavia

A. subclavia Truncus brachiocephalicus

Arcus aortae

V. cava superior

Bifurcatio tracheae

Bronchus principalis dexter A. pulmonalis dextra

A. pulmonalis sinistra

Bronchus principalis sinister Vv. pulmonales dextrae

Vv. pulmonales sinistrae

Ventriculus cordis sinister

O esophagus, Pars thoracica Pars thoracica aortae Diaphragma Hiatus oesophageus

Fig. 5.71 O e s o p h a g u s , O e s o p h a g u s , p e ric a rd iu m . P e ric a rd iu m , T h e c a ud a l p a rt o f th e Pars th o ra c ic a o f th e O e s o p h a g u s is s e p a ra te d a n d th o ra c ic a o r ta . P a rs th o ra c ic a a o r ta e ; d o rs a l v ie w . fr o m th e le ft a triu m o n ly b y th e p e ric a rd iu m .

Glandulae oesophageae

Tunica mucosa

Fig. 5 .7 2

S tr u c tu r e o f th e w a ll o f th e o e s o p h a g u s . O e s o p h a g u s ;

Epithelium Lamina propria mucosae Lamina muscularis mucosae

m ic ro s c o p ic v ie w . S im ila r to th e e n tire g u t, th e w a ll o f th e O e s o p h a g u s c o n s is ts o f a lu m i nal m u c o u s m e m b ra n e (Tu nica m u c o s a ) w h ic h is s e p a ra te d fr o m th e m u s c u la r la ye r (T u n ic a m u s c u la ris ) b y a lo o s e c o n n e c tiv e tis s u e laye r (Tela s u b m u c o s a ). T h e P a rte s c e rv ic a lis a nd th o ra c ic a are c o v e re d by th e T u n ic a a d v e n titia . T h e o u te r s u rfa c e o f th e in tra p e rito n e a l Pars a b d o m in a lis is c o v e re d b y v is c e ra l p e rito n e u m (P e rito n e u m vis c e ra le ) w h ic h c o n s titu te s th e T u n ic a s ero sa.

Stratum circulare Tunica muscularis Stratum longitudinale

Thym us -► Topography -► Sections

C o n strictio n s and diverticula o f th e oesophagus

M m . pharyngis Mm. pharyngis Larynx P h a ry n g o -o e s o p h a g e a l c o n strictio n

■k

Trachea

** Truncus brachiocephalicu s

A o rto b ro n ch ial c o n strictio n

Pars d e sce ndens aortae [A orta descendens] Pars ascen dens aortae [A orta ascendens]

Oesophagus, Pars thoracica Bronchus prin cip a lis d e xte r

Pars th o ra c ic a aortae [A orta thoracica]

*** D iap h ra g m atic constriction Diaphragma Hiatus oesophageus

Gaster, Cardia

Fig. 5 .7 3 v ie w .

C o n s tric tio n s , A n g u s tia e , o f th e O e s o p h a g u s ; v e n tra l

Oesophagus, Pars abdominalis

Fig. 5 .7 4

D iv e rtic u la o f t h e O e s o p h a g u s ; v ie w fr o m th e rig h t

d o rs a l s id e .

T h e O e s o p h a g u s has th re e c o n s tric tio n s : •

c e rv ic a l c o n s tric tio n a t th e c ric o id c a rtila g e (A n g u s tia c ric o id e a ; pha ry n g o -o e s o p h a g e a l c o n s tric tio n )

•

th o ra c ic c o n s tric tio n a t th e A o rta (A n g u s tia a o rtic a ; a o rto b ro n c h ia l c o n s tric tio n )

* c lin ic a l te r m : Z E N K E R 's d iv e rtic u lu m * * c lin ic a l te r m : tra c tio n d iv e rtic u lu m * * * c lin ic a l te r m : e p ip h re n ic d iv e rtic u lu m

• d ia p h ra g m a tic c o n s tric tio n (A n g u s tia d ia p h ra g m a tic a ) T h e c e rv ic a l c o n s tric tio n has th e s m a lle s t lu m e n a n d is lo c a te d a t th e le ve l o f th e u p p e r o e s o p h a g e a l s p h in c te r a nd th e 6 th c e rv ic a l v e rte b ra .

o f th e 10th th o ra c ic v e rte b ra ). T h e re is no tru e s p h in c te r m u s c le b u t an a n g io m u s c u la r m e c h a n is m th a t a c ts lik e a v a lv e u n d e r e x te n s io n (lo w e r

T h e th o ra c ic c o n s tric tio n is c re a te d b y th e d ire c t p ro x im ity o f th e a o r tic a rch fr o m th e le ft a nd d o rsa l s id e (le ve l o f th e 4 th th o ra c ic v e rte b ra ).

o e s o p h a g e a l s p h in c te r, LES). E la stic c o n n e c tiv e tis s u e (Lig. p h re n ic o o e s o p h a g e a le ) a tta c h e s th e o u ts id e o f th e O e s o p h a g u s t o th e H ia tu s

T h e d ia p h r a g m a tic c o n s tric tio n lie s in th e H ia tu s o e s o p h a g e u s (level

oesophageus.

[- Clinical R em arks-------------------------------------S w a llo w e d fo re ig n b o d ie s (e.g. fis h b o n e s ) m a y g e t s tu c k a t th e

s tr ic to r (Pars c ric o p h a ry n g e a ). T ra c tio n d iv e rtic u la (2 2 % ) a re " t r u e ”

o e s o p h a g e a l c o n s tric tio n s . T ru e d iv e rtic u la (o u tp o u c h in g s ) o f th e e n tir e o e s o p h a g e a l w a ll m a y o c c u r a t s e v e ra l lo c a tio n s . ZE N K E R 's d i

d iv e rtic u la a n d in v o lv e th e e n tire o e s o p h a g e a l w a ll. T h e y are e ith e r c a u s e d b y in c o m p le te s e p a ra tio n b e tw e e n O e s o p h a g u s a nd T ra ch ea d u rin g d e v e lo p m e n t (-» Fig. 5 .4 8 ) o r th y re s u lt fr o m in fla m m a to ry

v e r tic u la (7 0 % ) are m o s t c o m m o n . T h e s e d iv e rtic u la b u lg e th ro u g h th e K IL L IA N 's tria n g le o f th e h y p o p h a ry n g e a l m u s c le s a nd are w r o n g ly c a te g o ris e d as o e s o p h a g e a l d iv e rtic u la . R e s p o n s ib le fo r th e se d iv e rtic u la is a d e fe c tiv e re la x a tio n o f th e in fe rio r p h a ry n g e a l c o n

re a c tio n s in v o lv in g a d ja c e n t s tru c tu re s . E p ip h re n ic d iv e rtic u la (8 % ) are b e lie v e d to be e v o k e d b y a d is tu rb e d fu n c tio n o f th e a n g io m u s c u la r lo w e r o e s o p h a g e a l s p h in c te r.

T horacic Viscera

Heart -► Lungs -*• Oesophagus -►

Blood vessels o f th e oesophagus A. thyroidea inferior, Rr. oesophageales

Fig. 5 .7 5

A rte r ie s o f t h e O e s o p h a g u s ; v e n tra l v ie w .

T h e d iffe r e n t p a rts o f th e O e s o p h a g u s are s u p p lie d b y s u rro u n d in g A. vertebralis

A. carotis communis dextra

a rte rie s : P ars c e rv ic a lis : A . th y ro id e a in fe rio r

A. subclavia

P ars th o ra c ic a : Rr. o e s o p h a g e a le s o f th e A o rta P ars a b d o m in a lis : A . g a s tric a s in is tra a nd A . p h re n ic a in fe rio r T h e a rte ria l a n d v e n o u s s u p p ly o f th e T ra ch ea is e q u iv a le n t to th e b lo o d v e s s e ls o f th e c e rv ic a l a n d th o ra c ic p a rts o f th e O e s o p h a g u s .

Oesophagus Pars th o ra c ic a aortae, Rr. oesophageales

Diaphragma A. g astrica sinistra, Rr. oesophageales Truncus coeliacus

V. thyroidea inferior

Oesophagus, Pars cervicalis

V. vertebralis V. jugularis interna

Fig. 5 .7 6

V e in s o f th e o e s o p h a g u s , V v . o e s o p h a g e a e ; v e n tra l

V. brachiocephalica sinistra

v ie w . T h e c o m p le x v e n o u s n e tw o rk o f th e T u n ica a d v e n titia d ra in s in to d if fe re n t v e in s: P ars c e rv ic a lis : V. th y ro id e a in fe rio r

V. hemiazygos accessoria

P ars th o ra c ic a a nd P a rs a b d o m in a lis : via V. a zyg o s a n d V. h e m i a zyg o s in to th e V. cava s u p e rio r T h e in fe rio r p a rts g a in access t o th e p o rta l v e n o u s s y s te m via th e g a s tric v e in s (V. g a s tric a sin istra ). T h e s e v e in s m a y b e u tilis e d as p o rto c a v a l a n a s to m o s e s w ith in c re a s e d p re s s u re in th e p o rta l v e in (p ortal h y p e rte n s io n ) (-► Fig. 5.7 7 ).

Vv. o es o phageae

V. hem iazygos

Diaphragma

V. phrenica inferioi Gaster V. cava inferior V. g as trica sinistra

V. gastroomentalis sinistra

i- Clinical R em arks----------------------------------------------------------------------------------------------------------In c o n tra s t to o th e r o rg a n s o f th e g a s tro in te s tin a l tra c t, th e O e s o p h a g u s has n o d e d ic a te d a rte rie s b u t is s u p p lie d b y b lo o d v e s s e ls

fr o m th e s u rro u n d in g o rg a n s . T h is has im p lic a tio n s fo r s u rg ic a l p ro c e d u re s a n d p o s e s c h a lle n g e s to o e s o p h a g e a l s u rg e ry .

Thym us -► Topography -► Sections

Veins o f th e oesophagus

Vv. oesophageae

V. hemiazygos

V. azygos (Plexus venosus subm ucosus)

(R. oesophagealis)

(R. oesophagealis) V. phrenica inferior V. g astrica sinistra

V. cava inferior

V. po rtae hepatis

Fig. 5 .7 7 V e in s o f th e o e s o p h a g u s , V v . o e s o p h a g e a e , w ith illu s tr a tio n o f t h e p o rto c a v a l a n a s to m o s e s b e tw e e n p o rta l v e in , V . p o rta e h e p a tis , a n d V. c a v a s u p e rio r; v e n tra l v ie w . T h e e x te n s iv e v e n o u s n e tw o rk in th e T u n ica a d v e n titia is c o n n e c te d to th e s u b m u c o s a l v e in s (P lexu s v e n o s u s s u b m u c o s u s ). T h e b lo o d d ra in s

via V. a z y g o s (rig h t s id e ) a nd V. h e m ia z y g o s (le ft side ) u p w a rd s to th e V. cava s u p e rio r. T h e lo w e r p a rts o f th e O e s o p h a g u s a ls o c o n n e c t to th e V. p o rta e h e p a tis via th e v e in s a t th e le s s e r c u rv a tu re o f th e s to m a c h (V. g a s tric a sin is tra ).

i- Clinical R em arks-------------------------------------If p re s s u re in th e p o rta l v e n o u s s y s te m in c re a s e s (p o rta l h y p e r te n s io n ), e .g . d u e to in c re a s e d liv e r p a re n c h y m a l re s is ta n c e (cirrh o s is

o e s o p h a g e a l s u b m u c o s a l v e in s (o e s o p h a g e a l v a ric e s - * Fig. 5.81). R u p tu re o f th e s e v a ric e s is a s s o c ia te d w ith a m o rta lity o f a p p ro x i

o f th e liver), th e v e n o u s b lo o d is re d ire c te d to th e V v. ca vae s u p e rio r a n d in fe rio r via p o rto c a v a l a n a s to m o s e s . C lin ica lly, th e m o s t

m a te ly 5 0 % a n d is, th u s , th e m o s t fr e q u e n t c a u s e o f d e a th in pa tie n ts w it h liv e r c irrh o s is . R u p tu re in to th e lu m e n le a d s to th e a c c u

im p o rta n t p o rto c a v a l a n a s to m o s e s a re th e c o n n e c tio n s o f th e O e s o p h a g u s to th e g a s tric v e in s . T h is m a y re s u lt in d ila tio n s o f th e

m u la tio n o f d a rk e n e d b lo o d in th e s to m a c h , th e ra re e x te rn a l ru p tu re re s u lts in b le e d in g in to th e p e rito n e a l ca vity.

T horacic Viscera

Heart -► Lungs -*• Oesophagus -►

Lym ph vessels o f th e oesophagus thyroidea, Lobus dexter carotis communis

Oesophagus, Pars cervicalis

Truncus brachiocephalicus

A. carotis communis Nodi lym phoidei cervicales

A. subclavia

A. V. cava superior Nodi lym phoidei juxtao eso p h ag ea les Trachea Arcus aortae Pars descendens aortae

Nodi lym phoidei tra ch eo b ro n ch iale s superiores V. azygos

Nodi lym phoidei tra ch eo b ro n ch iale s superiores

Nodi lym phoidei tra ch eo b ro n ch iale s inferiores

Nodi lym phoidei m ediastinales posteriores

Oesophagus, Pars thoracica (Nodi lym phoidei m ediastinales posteriores) Pericardium fibrosum

Diaphragma Hiatus oesophageus

Fig. 5 .7 8 L y m p h n o d e s . N o d i ly m p h o id e i, o f th e p o s te r io r m e d ia s tin u m ; d o rs a l v ie w .

P ars th o ra c ic a a n d P ars a b d o m in a lis : ly m p h n o d e s o f th e M e d ia s tin u m (N o d i ly m p h o id e i m e d ia s tin a le s p o s te rio re s , N o d i ly m p h o id e i

T h e ly m p h o f th e O e s o p h a g u s d ra in s in to th e ly m p h n o d e s d ire c tly a d

tra c h e o b ro n c h ia le s a n d p a ra tra c h e a le s ) a n d o f th e p e rito n e a l c a v ity (N odi ly m p h o id e i p h re n ic i in fe rio re s on th e a b d o m in a l s id e o f th e

ja c e n t to th e O e s o p h a g u s (N o d i ly m p h o id e i ju x ta o e s o p h a g e a le s ): P ars c e rv ic a lis : N o d i ly m p h o id e i c e rv ic a le s p ro fu n d i

d ia p h ra g m a n d N o d i ly m p h o id e i g a s tric i o n th e le s s e r c u rv a tu re o f th e s to m a c h )

Drainage via the Trunci jugulares

Drainage via the Trunci bronchomediastinales

Oesophagus, Pars cervicalis

Lymph drainage directed cranially Lymph drainage directed caudally

Fig. 5 .7 9

L y m p h d r a in a g e o f th e O e s o p h a g u s ; v e n tra l v ie w .

Oesophagus, Pars thoracica

T h e ly m p h o f th e Pars c e rv ic a lis re a c h e s th e T ru n c u s ju g u la r is via th e d e e p c e rv ic a l ly m p h n o d e s . T h e Pars th o ra c ic a d ra in s in tw o d ire c tio n s : th e u p p e r p a rt a b o v e th e tra c h e a l b ifu rc a tio n d ra in s via th e m e d ia s tin a l ly m p h n o d e s in to th e T ru n c u s b ro n c h io m e d ia s tin a lis ; th e lo w e r p a rt b e n e a th th e tra c h e a l b ifu rc a tio n c o n n e c ts to th e a b d o m in a l ly m p h n o d e s w h ic h are th e re g io n a l ly m p h n o d e s fo r th e Pars a b d o m in a lis . F ro m h e re th e ly m p h p a sse s th e N o d i ly m p h o id e i co e lia c i to re ach th e

Oesophagus, Pars abdominalis

T ru n cu s in te s tin a lis .

I- Clinical R em arks-------------------------------------T h e d ire c tio n o f ly m p h a tic d ra in a g e in flu e n c e s th e lo c a tio n o f m é ta s ta s é s in o e s o p h a g e a l a n d g a s tric c a rc in o m a s . M é ta s ta s é s

th e v e n o u s b lo o d s in c e o e s o p h a g e a l c a rc in o m a s b e lo w th e tra c h e a l b ifu rc a tio n fr e q u e n tly c a u s e liv e r m é ta s ta s é s , w h e re a s c a rc in o m a s

o f c a rc in o m a s o f th e lo w e r o e s o p h a g u s are lik e ly t o o c c u r in th e a b d o m in a l ly m p h n o d e s . S im ila r d ra in a g e w a y s a p p e a r to e x is t fo r

a b o v e th e tra c h e a l b ifu rc a tio n u s u s a lly m e ta s ta s is e in to th e lun g s.

Thym us -► Topography -► Sections

O esophagus, oeso phag oscopy

Fig. 5.81

O esoph ag us, O esophagus; oesophagoscopy,

o e s o p h a g e a l v a ric e s in liv e r c irrh o s is . [12] *

c lin ic a l te r m : v a ric o s e v e in

Clinical Remarks In p o rta l h y p e rte n s io n , th e d ila tio n o f p o rto c a v a l a n a s to m o s e s in v o lv in g th e v e in s o f th e O e s o p h a g u s m a y d e v e lo p in to o e s o p h a g e a l v a ric e s . T h e ru p tu re o f th e s e v a ric e s fr e q u e n tly re s u lts in life -th re a te n in g b le e d in g s . T h e re fo re , p ro p h y la c tic tr e a tm e n t is p e r

fo rm e d in o e s o p h a g e a l v a ric e s in c lu d in g b a n d in g lig a tio n (e n d o s c o p ic b and lig a tio n ) o r th e e n d o s c o p ic in je c tio n o f s c le ro s in g a g e n ts (s c le ro th e ra p y ).

T horacic Viscera

Heart -► Lungs -► Oesophagus

Vv. brachiocephalicae

V. thoracica interna

(Trigonum thymicum) Thym us

Pulmo sinister, Lobus superior Lobus superior

Pulmo dexter

Lobus medius

Incisura cardiaca pulmonis Lobus inferior Lingula pulmonis

Pulmo sinister, Lobus inferior

Recessus costodiaphragmaticus

Recessus costomediastinalis

Fig. 5 .8 2

T h y m u s , T h y m u s , m e d ia s tin u m a n d p le u ra l c a v itie s .

y o u n g a d u lt. In an o ld e r in d iv id u a l it is a lm o s t c o m p le te ly re p la c e d w ith

C a v ita te s p le u ra le s , o f a n a d o le s c e n t; v e n tra l v ie w ; a fte r re m o v a l o f th e a n te rio r th o ra c ic w a ll.

a d ip o s e tis s u e . T h u s , in th e d is s e c tio n o f a n a to m ic a l s p e c im e n s o n ly re s id u a l th y m ic tis s u e is fo u n d w h ic h is id e n tifie d o n ly d u e to s m a lle r

T h e T h y m u s is lo c a te d in th e T rig o n u m th y m ic u m b e tw e e n th e m e d ia s tin a l b o rd e rs o f th e p le u ra l c a v itie s . T h e T h y m u s is re la tiv e ly la rg e in a

a rte ria l b ra n c h e s d e riv e d fr o m th e A . th o ra c ic a in te rn a o r v e n o u s c o n n e c tio n s to th e V v. b ra c h io c e p h a lic a e .

Thym us -* Topography -► Sections

T hym us V. thyroidea inferior

Trachea

Truncus brachiocephalicus

N. laryngeus recurrens

V. subclavia

A. carotis communis

A. subclavia V. brachiocephalica sinistra Plexus brachialis V. thoracica interna N. vagus [X]

Vv. pericardiacophrenicae

A. subclavia

V. brachiocephalica dextra N. phrenicus

Pleura parietalis, Pars mediastinalis

V. cava superior

N. phrenicus

Pulmo dexter, Lobus superior

Thym us

Pulmo sinister

Pericardium fibrosum

(Nodi lymphoidei mediastinales anteriores)

Sternum

Fig. 5 .8 3

T h y m u s , T h y m u s , o f an a d o le s c e n t; v e n tra l v ie w .

T h e T h y m u s is a p rim a ry ly m p h a tic o rg a n . It s e rv e s fo r th e p ro life ra tio n

T h e c o m p o s itio n o f th e th y m ic tis s u e c h a n g e s c o n tin u o u s ly d u rin g life . S in c e its v o lu m e re m a in s a lm o s t th e s a m e , its re la tiv e size is la rg e r in

a n d s e le c tio n o f T -ly m p h o c y te s w h ic h th e n le a ve th e T h y m u s to s e ttle in s e c o n d a ry ly m p h a tic o rg a n s to fu n c tio n in th e a d a p tiv e im m u n e re

th e n e w b o rn th a n in th e a d u lt (-» Fig. 5.8 4 ). A ft e r p u b e rty , th e s p e c ific th y m ic p a re n c h y m a is g ra d u a lly s u b s titu te d b y a d ip o s e tis s u e a nd th e

sponses. T h e T h y m u s d e v e lo p s fr o m

re s id u a l th y m u s is h a rd ly v is ib le in e ld e r p e rs o n s . H o w e v e r, fu n c tio n a l th y m ic tis s u e re m a in s p re s e n t a t all tim e s to w a rra n t a d e q u a te im m u n e

th e e n d o d e rm o f th e th ird p h a ry n g e a l

p o u c h a nd th e e c to d e rm o f th e th ird p h a ry n g e a l c le ft. It c o n s is ts o f tw o lo b e s (L o b i d e x te r a nd s in is te r) w h ic h c o v e r th e g re a t v e s s e ls o f th e s u p e rio r M e d ia s tin u m . M ic ro s c o p ic a lly , th e s e lo b e s a re s u b d iv id e d in to

re a c tio n s .

s m a lle r lo b u le s.

Fig. 5 .8 4

P o s itio n o f th e th y m u s , T h y m u s , in a n e w b o r n ; v e n tra l

v ie w ; a fte r re m o v a l o f th e v e n tra l th o ra c ic w a ll.

T horacic Viscera

Heart -► Lungs -► Oesophagus

M e d ia stin u m

Mediastinum superius Mediastinum posterius Mediastinum medium

Mediastinum inferius

Mediastinum anterius

Fig. 5 .8 5

O rg a n is a tio n o f th e M e d ia s tin u m .

T h e m e d ia s tin u m is d iv id e d in to a M e d ia s tin u m in fe riu s w h ic h c o n ta in s th e h e a rt, a nd a M e d ia s tin u m s u p e riu s . T h e M e d ia s tin u m in fe riu s is

fu r th e r d iv id e d in to th e M e d ia s tin u m a n te riu s in fr o n t o f th e h e a rt, th e M e d ia s tin u m m e d iu m , c o n ta in in g th e P e ric a rd iu m , a nd th e M e d ia s ti n u m p o s te riu s b e h in d th e P e ric a rd iu m .

Truncus sympathicus, Ganglion thoracicum N. laryngeus recurrens N. vagus [X], Rr. cardiaci thoracici

N. vagus [X], Plexus pulmonalis V. azygos Bronchus principalis dexter R. bronchialis (Aorta); V. bronchialis N. vagus [X], Rr. cardiaci thoracici V. intercostalis posterior

A. thoracica interna N. phrenicus V. brachiocephalica dextra Thymus V. cava superior Aa. pulmonales

N. thoracicus [T7], N. intercostalis Truncus sympathicus, Rr. communicantes

N. phrenicus; A.; V. pericardiacophrenica Vv. pulmonales Pericardium fibrosum; Pleura parietalis, Pars mediastinaiis

N. splanchnicus major

Lig. pulmonale

N. vagus [X], Plexus oesophageus

Aa. intercostales posteriores

Pleura parietalis, Pars costalis

Oesophagus Diaphragma, Centrum tendineum

Fig. 5 .8 6

M e d ia s tin u m a n d p le u ra l c a v ity , C a v ita s p le u ra lis , o f an

T h e V. a z y g o s c ro s s e s th e ro o t o f th e rig h t lu n g s u p e rio rly a nd e n te rs

a d o le s c e n t; v ie w fr o m th e rig h t s id e ; a fte r re m o v a l o f th e lateral th o ra c ic w a ll a nd th e rig h t lun g .

th e V. cava s u p e rio r fr o m d o rs a l a t th e le ve l o f th e 4 th / 5th th o ra c ic v e r te b ra e . A ft e r b ra n c h in g o ff th e N. v a g u s [X], th e N. la ry n g e u s re c u rre n s

T h e v ie w fr o m th e rig h t s id e d e m o n s tra te s c le a rly th e V. a z y g o s w h ic h a s c e n d s n e x t to th e v e rte b ra l c o lu m n in th e M e d ia s tin u m p o s te riu s .

w in d s a ro u n d th e A . s u b c la v ia o n th e rig h t s id e .

dissection link

Thym us -► Topography -► Sections

M e d ia stin u m

O esophagus, Pars thoracica N. vagus [X], R. cardiacus thoracicus

Du ctu s thoracicus, Pars tho racica N. laryngeus recurrens (N. vagus)

Truncus sympathicus, R. cardiacus thoracicus Lig. arteriosum A. carotis communis

Nodi lymphoidei tracheobronchiales

V. brach iocephalica V. hem iazygos accessoria N. vagus [X] N. phrenicus

O esophagus, Pars thoracica

Plexus aorticus thoracicus, Plexus cardiacus N. vagus [X ], Plexus pulmonalis Plexus pulmonalis Pars tho racica ao rtae

A. pulmonalis sinistra Thym us

Plexus aorticus thoracicus

V. pulmonalis sinistra A.; V. intercostalis posterior Bronchus principalis sinister N. splanchnicus m ajor N. phrenicus V. pulmonalis sinistra

V. hem iazygos

Pericardium fibrosum

A.; V. intercostalis posterior; N. intercostalis

V. pericardiacoph renica

N. splanchnicus m inor A. pericardiacoph renica Truncus sym pathicus, Ganglion thoracicum Pleura parietalis, Pars costalis

Fig. 5 .8 7

M e d ia s tin u m a n d p le u ra l c a v ity , C a v ita s p le u ra lis , o f an

a d o le s c e n t; v ie w fr o m th e le ft sid e ; a fte r re m o v a l o f th e latera l th o ra c ic w a ll a n d th e le ft lung.

F u rth e r latera l, n e x t to th e h e a d s o f th e rib s , th e g a n g lia o f th e T ru n c u s s y m p a th ic u s are p o s itio n e d w h ic h b ra n c h o f f th e N. s p la n c h n ic u s m a jo r

T h e v ie w fr o m th e le ft s id e d e m o n s tra te s c le a rly th e A o rta th o ra c ic a w h ic h d e s c e n d s on th e le ft s id e o f th e v e rte b ra l c o lu m n in th e M e d ia s

a nd th e N. s p la n c h n ic u s m in o r. T h e N. v a g u s [X] d e s c e n d s b e h in d th e ro o t o f th e lu n g n e x t to th e O e s o p h a g u s a fte r re le a s in g th e N . laryn g e u s re c u rre n s . O n th e le ft s id e , th e N. la ry n g e u s re c u rre n s w in d s

tin u m p o s te riu s . T h e V. h e m ia z y g o s a s c e n d s o n th e la te ra l a s p e c t o f th e v e rte b ra l b o d ie s a n d d ra in s in o th e V. a zyg o s a t th e le ve l o f th e

a ro u n d th e a o rtic a rc h . T h e M e d ia s tin u m m e d iu m h a rb o u rs th e P e rica r d iu m a nd th e a d ja c e n t N. p h re n ic u s a c c o m p a n ie d b y th e V asa p e ric a r

th o ra c ic v e rte b ra e 10th to 7 th. F re q u e n tly , th e V. h e m ia z y g o s c o m m u n i c a te s w it h th e V. h e m ia z y g o s a c c e s s o ria w h ic h c o lle c ts th e b lo o d fro m

d ia c o p h re n ic a . In th e M e d ia s tin u m s u p e riu s th e T h y m u s c o v e rs th e g re a t v e s s e ls v e n tra lly .

th e s u p e rio r in te rc o s ta l v e in s.

C o n te n ts o f th e M e d ia s tin u m s u p e riu s

C o n te n ts o f t h e M e d ia s tin u m in fe riu s

• • •

Thym us T ra ch ea O esophagus

•

• • • •

A o rta a nd T ru n c u s p u lm o n a lis V v. b ra c h io c e p h a lic a e a nd V. cava s u p e rio r L y m p h v e s s e ls : ly m p h a tic tru n k s (D u c tu s th o ra c ic u s , T ru n c i b ro n c h io m e d ia s tin a le s ) a n d m e d ia s tin a l ly m p h n o d e s A u to n o m ic n e rv o u s s y s te m (T ru n cu s s y m p a th ic u s , N. v a g u s [X]

•

w it h N. la ry n g e u s re cu rre n s) N. p h re n ic u s

• •

M e d ia s tin u m a n te riu s : re tro s te rn a l ly m p h d ra in a g e o f th e m a m m a ry g la n d M e d ia s tin u m m e d iu m : p e ric a rd iu m w it h g re a t v e s s e ls , N. p h re n ic u s a nd V asa p e ric a rd ia c o p h re n ic a M e d ia s tin u m p o s te riu s : A o rta , O e s o p h a g u s w it h P lexu s o e s o p h a g e u s fr o m th e N . v a g u s , D u c tu s th o ra c ic u s , T ru n c u s s y m p a th ic u s w ith N n. s p la n c h n ic i, V. a z y g o s a n d V. h e m ia z y g o s a nd in te rc o s ta l n e u ro v a s c u la r s tru c tu re s

dissection link

T horacic Viscera

Heart -► Lungs -♦ Oesophagus

N. phrenicus Truncus brachiocephalicus

Trachea

V. jugularis interna

Glandula thyroidea

N. laryngeus recurrens Clavicula V. subclavia A. carotis communis N. vagus [X] M. scalenus anterior V. brachiocephalica dextra laryngeus recurrens V. brachiocephalica sinistra A. thoracica interna Pulmo dexter, Lobus superior N. vagus [X] Arcus aortae Pulmo sinister, Lobus superior V. cava superior N. vagus [X], Rr. cardiaci thoracici Plexus cardiacus

N. phrenicus

A.; V. p ericardiacoph renica

N. phrenicus, R. pericardiacus

Pulmo dexter, Lobus medius Pericardium

Pulmo dexter, Lobus inferior

Recessus costodiaphragmaticus Pleura parietalis, Pars diaphragmatica

Fig. 5 .8 8

Diaphragma

M id d le m e d ia s tin u m ; v e n tra l v ie w ; a fte r re m o v a l o f th e

v e n tra l th o ra c ic w a ll, th e lu n g s w e re d is s e c te d in th e fro n ta l pla n e .

M. scalenus anterior N. phrenicus A. subclavia dextra V. subclavia dextra

Costa I

V. cava superior

P e ric a rd iu m -^ ^

Fig. 5 .8 9

C o u rs e o f th e N . p h re n ic u s .

, jj'ïà ;

/ /

/ N. phrenicus, R. pericardiacus

N. phrenicus, Rr. phren icoabdom inales

T h e N . p h re n ic u s o rig in a te s fro m th e sp in a l co rd s e g m e n ts C3 to C5 (p re d o m in a n tly C4) o f th e P lexu s c e rv ic a lis a nd d e s c e n d s on th e n eck a n te rio r to th e M . s c a le n u s a n te rio r (g u id in g m u s c le !). N e x t th e p h re n ic n e rv e c o u rs e s a n te rio r to th e ro o t o f th e lu n g a n d d e s c e n d s to g e th e r w it h th e Vasa p e ric a rd ia c o p h re n ic a b e tw e e n th e P e ric a rd iu m a nd th e P leura m e d ia s tin a lis to th e d ia p h ra g m . T h e N . p h re n ic u s p ro v id e s m o to r in n e rv a tio n to th e d ia p h ra g m a nd s e n s o ry in n e rv a tio n to th e P e rica r d iu m (R. p e rica rd ia cu s), th e P leura d ia p h ra g m a tic a , a nd th e P e rito n e u m p a rie ta le a t th e a b d o m in a l s id e o f th e d ia p h ra g m (Rr. p h re n ic o a b d o m inales). T h e Rr. p h re n ic o a b d o m in a le s a lso c o n v e y s e n s o ry fib r e s to th e P e rito n e u m v is c e ra le on liv e r a n d g a llb la d d e r.

i- Clinical R em arks-------------------------------------T h e d e v e lo p m e n ta l^ b a s e d c o u rs e o f th e N. p h re n ic u s has im p o r ta n t c lin ica l im p lic a tio n s in c e rv ic a l s p in a l c o rd in ju rie s (te tra p le g ia ). In ju rie s o f th e sp in a l c o rd b e lo w C 4 d o n o t c o m p ro m is e b re a th in g , w h e re a s in ju rie s in v o lv in g s e g m e n t C 4 b e a r th e ris k o f s u ffo c a tio n a nd m a y re q u ire a s s is te d v e n tila tio n .

S e n s o ry in n e rv a tio n o f th e liv e r a nd g a llb la d d e r b y th e Rr. p h re n ic o a b d o m in a le s m a y c a u s e re fe r r e d p a in in t h e r ig h t s h o u ld e r (e.g. in liv e r b io p s ie s , in fla m m a tio n o f th e g a llb la d d e r). S im ila rly , ru p tu re s o f th e s p le e n m a y c a u s e re fe rre d pain in th e le ft s h o u ld e r.

Thym us -► Topography -► Sections

A o rtic arch A. carotis externa dextra A. carotis interna dextra

A. vertebralis dextra

A. carotis externa sinistra A. carotis interna sinistra

A. vertebralis sinistra A. carotis com m unis sinistra

A. carotis communis dextra

A. subclavia sinistra

A. subclavia

Truncus brach iocephalicus Arcus aortae Lig. arteriosum

V. cava superior

Truncus pulmonalis Atrium sinistrum, Auricula

Pars ascendens aortae

Fig. 5 .9 0 H e a rt, C or, a n d a o r tic a rc h . A rc u s a o r ta e , w it h b ra n c h in g o f t h e g r e a t ves s e ls ; v e n tra l v ie w . T h e Pars a s c e n d e n s a o rta e c o n tin u e s as th e a o rtic a rch w h ic h is c o n n e c te d to th e T ru n c u s p u lm o n a lis via th e Lig. a rte rio s u m . T h e a o rtic a rch c o n tin u e s w ith th e d e s c e n d in g p a rt (Pars d e s c e n d e n s ) o f th e A o r

Atrium dextrum

Ventriculus sinister

ta th o ra c ic a {-» Fig. 5 .9 2 ). T h e a o rtic a rch has th e fo llo w in g b ra n c h e s : • T ru n c u s b ra c h io c e p h a lic u s (rig h t s id e ) w h ic h d iv id e s in to th e A . s u b clavia d e x tra a nd A . c a ro tis c o m m u n is d e x tra • •

A . c a ro tis c o m m u n is s in is tra A . s u b c la v ia s in is tra

V. cava inferior Ventriculus dexter

.13%

A. carotis externa dextra A. carotis interna dextra

A. carotis externa sinistra A. carotis interna sinistra

A. vertebralis dextra A. carotis communis dextra A. subclavia dextra

A. vertebralis sinistra A. subclavia sinistra A. subclavia sinistra

Truncus brachiocephalicus A. carotis communis sinistra

=3 %

<1C

Arcus aortae Pars ascendens aortae

Pars descendens aortae, Pars thoracica aortae

Figs. 5 .9 1 a to e

B ra n c h in g v a r ia tio n s o f th e g r e a t v es s e ls fro m

t h e a o r tic arch. a " te x tb o o k c a s e " b c o m m o n o rig in o f T ru n c u s b ra c h io c e p h a lic u s a n d A . c a ro tis c

c o m m u n is s in is tra c o m m o n s te m fo r T ru n c u s b ra c h io c e p h a lic u s a n d A . c a ro tis

c o m m u n is s in is tra in d e p e n d e n t b ra n c h in g o f th e A . v e rte b ra lis s in is tra o f f th e A rc u s a o rta e

e b ra n c h in g o f th e A . s u b c la v ia d e x tra as th e la s t b ra n c h o f th e A rc u s a o rta e . T h is u n u s u a l a rte ry m o s tly c o u rs e s b e h in d th e O e s o p h a g u s to th e rig h t s id e a nd m a y c a u s e p ro b le m s w it h s w a llo w in g (d y s p h a g ia lusoria). T h e e x is te n c e o f an in d e p e n d e n t A . th y r o id e a im a c o u rs in g to th e th y ro id g la n d is u n c o m m o n . W h e n e x is te n t, it e ith e r d e riv e s fro m th e T ru n c u s b ra c h io c e p h a lic u s o r as a s e c o n d b ra n c h fr o m th e a o rtic a rch.

T horacic Viscera

Heart -► Lungs -► Oesophagus

A rte rie s o f th e p o ste rio r m ed ia stin u m

Truncus brachiocephalicus N. vagus [X] A. cervicalis profunda

Trachea N. laryngeus recurrens N. vagus [X]

Truncus costocervicalis

N. phrenicus

A. intercostalis suprema

A. subclavia

A. thoracica interna N. laryngeus Arcus aortae Pars thoracica aortae, Rr. bronchiales

Pars ascendens aortae [Aorta ascendens]

N. laryngeus recurrens N. vagus [X], Rr. bronchiales

Bronchus principalis dexter Bronchus principalis sinister V. azygos Pars thoracica aortae, Rr. oesophageales

Truncus sympathicus

N. laryngeus recurrens, Rr. oesophageales

Mm. intercostales interni

Oesophagus, Pars thoracica Vv. intercostales posteriores

Mm. intercostales externi

Aa. intercostales posteriores

Truncus sympathicus, Ganglion Pars tho racica ao rtae

Nn. thoracici, Nn. intercostales Ductus thoracicus, Pars thoracica

N. splanchnicus minor

N. splanchnicus major

V. azygos

Pars lumbalis diaphragmatis

Costa XI

Pars abdom inalis aortae

Fig. 5 .9 2

A o r ta a n d its b ra n c h e s ; v e n tra l

B ra n c h e s o f t h e P ars th o ra c ic a a o rta e

v ie w o n to th e p o s te rio r w a ll o f th e tru n k . T h e Pars d e s c e n d e n s o f th e A o rta d e s c e n d s in th e M e d ia s tin u m p o s te riu s (Pars th o ra cica )

P a rie ta l b ra n c h e s

• •

a nd tra v e rs e s th e d ia p h ra g m (Pars a b d o m in a lis). V is c e ra l b ra n c h e s to th e th o ra c ic v is c e ra

dissection link

•

to th e w a ll o f th e tru n k

A a. in te rc o s ta le s p o s te rio re s : 9 p a irs (th e fir s t t w o are b ra n c h e s o f th e T ru n c u s c o s to c e rv ic a lis fr o m th e A . s u b c la v ia A . s u b c o s ta lis : th e la s t p a ir b e lo w rib XII A . p h re n ic a s u p e rio r: to th e u p p e r s id e o f th e d ia p h ra g m

•

Rr. b ro n c h ia le s : V asa p riv a ta o f th e lu n g (on th e rig h t s id e m o s tly fr o m th e A . in te rc o s ta lis p o s te rio r d e x tra III)

• •

Rr. o e s o p h a g e a le s : 3 - 6 b ra n c h e s to th e O e s o p h a g u s Rr. m e d ia s tin a le s : s m a ll b ra n c h e s to M e d ia s tin u m and P e ric a rd iu m

Thym us -► Topography -► Sections

Veins o f th e p o ste rio r m e d ia stin u m

V. brachiocephalica sinistra V. brachiocephalica dextra V. subclavia Oesophagus, Pars thoracica V. cava superior

Ductus thoracicus, Pars thoracica Aa. intercostales posteriores

Mm. intercostales interni V. azygos

V. hem iazygos accessoria V. hem iazygos

Aa.; Vv. intercostales posteriores Truncus sympathicus, Ganglia

Nn. thoracici, Nn. intercostales

Lig. longitudinale anterius N. splanchnicus major

Vv. intercostales posteriores V. hem iazygos

Cisterna chyli

A.; V. subcostalis

Pars lumbalis diaphragmatis, Crus dextrum et Crus sinistrum

V. lum balis ascendens

V. cava inferior

Fig. 5 .9 3

V e in s o f th e a z y g o s s y s te m ; v e n tra l v ie w o n to th e

p o s te rio r w a ll o f th e tru n k ; a fte r re m o v a l o f th e d ia p h ra g m . T h e a zyg o s s y s te m c o n n e c ts th e V v. ca vae s u p e rio r a nd in fe rio r a nd its

h e m ia z y g o s a c c e s s o ria . B e n e a th th e d ia p h ra g m , th e V. lu m b a lis as c e n d e n s o n each s id e c o n tin u e s th e c o u rs e o f th e a z y g o s v e in a nd

trib u ta rie s are e q u iv a le n t to th e b ra n c h e s o f th e A o rta . T h e V. a z y g o s a s c e n d s on th e r ig h t s id e o f th e v e rte b ra l c o lu m n a nd d ra in s in to th e V.

c o n n e c ts to th e V. cava in fe rio r. T rib u ta rie s : • V v. m e d ia s tin a le s : fr o m th e m e d ia s tin a l o rg a n s (Vv. o e s o p h a g e a le s ,

cava s u p e rio r fr o m d o rsa l on th e le ve l o f th e 4 ,h/5 th th o ra c ic v e rte b ra e . T h e e q u iv a le n t b lo o d v e s s e l on th e le ft s id e is th e V. h e m ia z y g o s

•

w h ic h m e rg e s w it h th e V. a z y g o s a t th e le v e l o f th e th o ra c ic v e rte b ra e 7th t o 10th. B lo o d fr o m th e u p p e r in te rc o s ta l v e in s d ra in s in to th e V.

V v. b ro n c h ia le s , V v. p eric a rd ia c a e ) V v. in te rc o s ta le s p o s te rio re s a nd V. s u b c o s ta lis : fr o m th e p o s te rio r w a ll o f th e tru n k

T horacic Viscera

Heart -► Lungs -► Oesophagus

N erves o f th e p o ste rio r m ed ia stin u m Ganglion cervicothoracicum [stellatum] A. carotis communis

Trachea

N. vagus [X] Truncus sympathicus, Ganglion cervicale medium

N. laryngeus recurrens A. subclavia

Ansa subclavia

A. subclavia

N. vagus [X]

Truncus sympathicus, Ganglion thoracicum II

Plexus aorticus thoracicus; Plexus cardiacus

N. vagus [X] N. laryngeus recurrens

N. laryngeus recurrens N. vagus [X], Rr. bronchiales Pars ascendens aortae [Aorta ascendens]

Bronchus principalis sinister

N. vagus (X), Rr. bronchiales Nn. thoracici, Nn. intercostales

Bronchus principalis dexter

Truncus sympathicus

Oesophagus, Pars thoracica

Pars thoracica aortae [Aorta thoracica]

N. vagus [X], Plexus oesophageus

Truncus sym pathicus, G anglia thoracica

N. splanchnicus m ajor

Truncus sympathicus, Rr. communicantes

N. splanchnicus m inor

Oesophagus, Pars abdominalis

Diaphragma

Gaster

Pars pylorica

Duodenum

Pars abdominalis aortae [Aorta abdominalis]

Fig. 5 .9 4

N e rv e s o f th e p o s te r io r m e d ia s tin u m ; v e n tra l v ie w o n to

Truncus vag alis anterior, Rr. gastrici anteriores

th e p o s te rio r w a ll o f th e tru n k ; a fte r re m o v a l o f th e d ia p h ra g m .

lio n ic n e u ro n s . A x o n s o f th e p o s tg a n g lio n ic n e u ro n s jo in th e s p in a l n e rv e s a nd th e ir b ra n c h e s again via th e Rr. c o m m u n ic a n te s g ris e i.

T h e p o s te rio r m e d ia s tin u m c o n ta in s th e in te rc o s ta l n e rv e s (N n. in te r c o s ta le s ) o f th e s o m a tic n e rv o u s s y s te m a nd p a rts o f th e s y m p a th e tic

S o m e p re g a n -g lio n ic fib r e s are n o t s y n a p s e d in th e g a n g lia o f th e s y m p a th e tic tr u n k b u t c o n tin u e a s N n. s p la n c h n ic i m a jo r a n d m in o r to th e

(T ru n cu s s y m p a th ic u s ) a n d p a ra s y m p a th e tic s y s te m s (N n. va gi) as c o m p o n e n ts o f th e a u to n o m ic n e rv o u s s y s te m . T h e s y m p a th e tic

n e rv e p le x u s a ro u n d th e A o rta a b d o m in a lis w h e r e th e y e v e n tu a lly s y n a p s e . T h e p re g a n g lio n ic fib r e s o f th e N n . v a g i c o u rs e b e h in d th e ro o t

tr u n k (T ru n cu s s y m p a th ic u s ) fo r m s a p a ra v e rte b ra l ch a in o f tw e lv e th o ra c ic g a n g lia w h ic h a re c o n n e c te d via Rr. in te rg a n g lio n a re s . T h e p re

o f th e lu n g a d ja c e n t to th e O e s o p h a g u s a n d fo r m th e P le x u s o e s o p h a g e u s . T h e la tte r is th e o rig in fo r th e t w o vagal tru n k s (T ru n ci va ga le s a n te rio r a nd p o s te rio r) w h ic h tra v e rs e th e d ia p h ra g m to g e th e r w it h th e

g a n g lio n ic s y m p a th e tic n e u ro n s are lo c a te d in th e la te ra l h o rn s (C8 L3) o f th e sp in a l c o rd a nd e x it th e v e rte b ra l canal w ith th e sp in a l n e rv e s . T h e Rr. c o m m u n ic a n te s a lb i g u id e th e p re g a n g lio n ic fib re s to th e g an glia o f th e T ru n c u s s y m p a th ic u s w h e re th e y are s y n a p s e d to p o s tg a n g

O e s o p h a g u s to re ach th e a u to n o m ic n e rv e p le x u s o f th e A o rta a b d o m i nalis. H o w e v e r, s y n a p s e s to th e p o s tg a n g lio n ic p a ra s y m p a th e tic n e u ro n s m o s tly o c c u r in c lo s e r p r o x im ity to th e re s p e c tiv e ta r g e t o rg a n s .

Thym us -► Topography -► Sections

Lym ph vessels and lym ph nodes o f th e m e d ia stin u m

Nodi lymphoidei supraclaviculares

Nodi lymphoidei paratracheales

(Nodi lymphoidei mediastinales anteriores)

Nodi lymphoidei tracheobronchiales

Nodi lymphoidei intercostales

Nodi lymphoidei parasternales

Ductus thoracicus

Nodi lymphoidei pericardiaci

Nodi lymphoidei juxtaoesophageales

Nodus lymphoideus phrenicus superior

Nodus lymphoideus phrenicus inferior

Fig. 5 .9 5

L y m p h v es s e ls a n d ly m p h n o d e s o f th e m e d ia s tin u m ;

v ie w fr o m th e rig h t v e n tro la te ra l s id e a fte r re m o v a l o f th e la te ra l c h e s t w a ll, (a c c o rd in g t o [2]) T h e M e d ia s tin u m h a rb o u rs se v e ra l d iffe r e n t g ro u p s o f ly m p h n o d e s w h ic h are c a te g o ris e d in to p a rie ta l ly m p h n o d e s (d rain a ge o f th e w a ll o f th e tru n k ) a nd v is c e ra l ly m p h n o d e s (d rain a ge o f th e th o ra c ic vis c e ra ). T h e s e d ra in in to th e la rg e ly m p h a tic tru n k s . P a rie ta l ly m p h no des:

Nodus lymphoideus lumbalis

•

N o d i ly m p h o id e i m e d ia s tin a le s p o s te rio re s : a t b ro n c h i a n d T ra ch ea (N o d i ly m p h o id e i tra c h e o b ro n c h ia le s a nd p a ra tra c h e a le s ) a nd O e s o

p h a g u s (N o d i ly m p h o id e i ju x ta o e s o p h a g e a le s ) L y m p h a tic tru n k s : T h e D u c tu s th o ra c ic u s tra v e rs e s th e d ia p h ra g m a n te rio r to th e v e rte b ra l c o lu m n (-* Fig. 5 .9 3 ) a n d a s c e n d s in th e M e d ia s tin u m p o s te riu s , fir s t b e h in d th e A o rta th e n b e h in d th e O e s o p h a g u s , to re ach th e 7th c e rv ic a l

N o d i ly m p h o id e i p a ra s te rn a le s : o n b o th s id e s o f th e S te rn u m . T h e y

v e rte b ra . N e x t, th e d u c tu s c ro s s e s th e le f t p le u ra l c u p u la a nd o p e n s in to th e le ft ju g u la r-s u b c la v ia n ju n c tio n o f v e in s fr o m d o rs a l (b e tw e e n V.

drain ly m p h fr o m th e a n te rio r c h e s t w a ll, th e m a m m a ry g la n d s and th e d ia p h ra g m in to th e T ru n c u s s u b c la v iu s .

s u b c la v ia a n d V. ju g u la ris in te rn a ). S h o rtly b e fo re d ra in in g in to th e ju g u la r-su b cla via n ju n c tio n , it c o lle c ts th e ly m p h o f th e T ru n c u s b ro n c h io -

N o d i ly m p h o id e i in te rc o s ta le s : b e tw e e n th e h e a d s o f th e ribs. T h e y drain ly m p h fr o m th e p o s te rio r c h e s t w a ll. T h e ir e ffe r e n t ly m p h v e s

M e d ia s tin a lis s in is te r, w h ic h c o u rs e s in d e p e n d e n tly in th e M e d ia s ti n u m , th e T ru n c u s s u b c la v iu s s in is te r (fro m th e a rm ), a n d th e T ru n c u s

s e ls d ra in d ire c tly in to th e D u c tu s th o ra c ic u s . V is c e ra l ly m p h n o d e s w it h c o n n e c tio n to th e T ru n c i b r o n c h o m e d ia stin a le s :

ju g u la ris s in is te r (fro m th e neck). O n th e r ig h t s id e , a s h o rt (1 c m ) D u c tu s ly m p h a tic u s d e x te r c o n n e c ts th e re s p e c tiv e ly m p h a tic tru n k s a nd e n te rs th e rig h t ju g u la r-s u b c la v ia n ju n c tio n o f v e in s .

•

N o d i ly m p h o id e i m e d ia s tin a le s a n te rio re s : o n b o th s id e s o f th e g re a t v e s s e ls , trib u ta rie s fro m lu n g s a n d P leura, d ia p h ra g m (N o d i ly m p h o ide i p h re n ic i s u p e rio re s ), h e a rt a nd P e ric a rd iu m (N odi ly m p h o id e i p e rica rd ia ci), a n d T h y m u s .

T horacic Viscera

Heart -► Lungs -► Oesophagus

S uperior th o ra cic aperture

Plexus brachialis A. axillaris dextra V. axillaris dextra Truncus inferior (Plexus brachialis) A. subclavia dextra A. cervicalis ascendens M. scalenus anterior N. intercostalis I A. transversa cervicis A. suprascapularis

A. profunda cervicis

V. jugularis interna dextra A. thyroidea inferior V. subclavia dextra Truncus costocervicalis

Truncus jugularis d ex ter C o nfluen ce of the Ductus lym phaticus dexter

A. vertebralis A. intercostalis suprema

Truncus bronchom ediastinalis dexter Truncus thyrocervicalis

G anglion cervicothoracicum [stellatum ]

N. phrenicus Truncus sym pathicus A. tho racica interna N. cardiacus cervicalis inferior

Truncus bronchom ediastinalis dexter V. b rach iocephalica dextra

Trachea N. vagus [X] Nodi lymphoidei paratracheales

Fig. 5 .9 6

N e u ro v a s c u la r s tru c tu re s o f th e s u p e rio r th o ra c ic

a n d d iv id e s in to th e A . p ro fu n d a c e rv ic is a nd th e A . in te rc o s ta lis s u p re

a p e rtu re , r ig h t s id e ; ca ud a l v ie w ; a fte r re m o v a l o f th e c e rv ic a l p le u ra l cu p u la .

m a . T h e N. p h re n ic u s is lo c a te d v e n tra l to th e V. b ra c h io c e p h a lic a . The N. v a g u s c o u rs e s d o rs a l to th e V. b ra c h io c e p h a lic a a n d re le a s e s th e N.

T h e V .su b clavia c ro s s e s th e p le u ra l cu p u la a n te rio r to th e M . s c a le n u s , w h e re a s th e A . s u b cla via a nd th e P le xu s b ra ch ia lis c o u rs e p o s te rio r to

la ry n g e u s re c u rre n s w h ic h w in d s a ro u n d th e A . s u b c la v ia t o a s c e n d to th e n e c k . P o s te rio r to th e A . s u b c la v ia , th e T ru n c u s s y m p a th ic u s w ith its G a n g lio n c e rv ic o th o ra c ic u m (s te lla tu m ) is fo u n d . M o s t d iffic u lt to

th e M . s c a le n u s (s c a le n e g a p ). B ra n ch e s o f th e A . s u b c la v ia are th e A. th o ra c ic a in te rn a d e s c e n d in g to th e latera l a s p e c t o f th e S te rn u m , th e A . v e rte b ra lis , a n d th e T ru n c u s th y re o c e rv ic a lis w it h its b ra n c h e s . T h e T ru n c u s c o s to c e rv ic a lis b ra n c h e s o ff d o rsa l o f th e M . s c a le n u s a n te rio r

60— ►

dextra

dissection link

id e n tify is th e s h o rt D u c tu s ly m p h a tic u s d e x te r w h ic h d ra in s in to th e r ig h t v e n o u s a n g le (b e tw e e n V. s u b c la v ia a n d V. ju g u la ris in te rn a ) a fte r m e rg in g th e T ru n c u s b ro n c h o m e d ia s tin a lis a n d th e T ru n c u s s u b c la v iu s .

Thym us -► Topography -► Sections

S uperior th o ra cic aperture

A. axillaris sinistra V. axillaris sinistra

Plexus brachialis M. scalenus anterior A. subclavia sinistra

A. thyroidea Truncus inferior (Plexus brachialis) A. cervicalis ascendens V. jugularis interna sinistra N. intercostalis I A. transversa cervicis A. profunda cervicis

Truncus subclavius sinister A. suprascapularis

Truncus thyrocervicalis

Truncus costocervicalis

V. subclavia sinistra

A. intercostalis suprema

C o nfluence o f the Du ctu s thoracicus

G anglion cervicothoracicum [stellatum ] Ansa subclavia Truncus bronchom ediastinalis

Truncus sym pathicus

V. brachiocephalica sinistra

A. vertebralis Ductus thoracicus

A. th o ra c ic a interna N. cardiacus cervicalis inferior

A. carotis communis sinistra

N. laryngeus recurrens

N. v a g u s [X ]

lymphoidei mediastinales anteriores

Fig. 5 .9 7

N e u ro v a s c u la r s tru c tu re s o f th e s u p e rio r th o ra c ic

a p e rtu re , le ft s id e ; ca ud a l v ie w ; a fte r re m o v a l o f th e p le u ra l cu p u la . H ere , o n ly s tru c tu re s a re d e s c rib e d w h ic h d iffe r in th e ir c o u rs e fr o m th e

paid to th e D u c tu s th o ra c ic u s w h ic h is o fte n in ju re d d u rin g d is s e c tio n in th is re g io n . T h e D u c tu s th o ra c ic u s a s c e n d s in th e M e d ia s tin u m p o s te riu s a nd c ro s s e s th e le ft p le u ra l c u p u la b e fo re e n te rin g th e le f t ju g u la r-su b cla via n ju n c tio n o f v e in s (ju n c tio n b e tw e e n V. s u b c la v ia a n d V.

n e u ro v a s c u la r s tru c tu re s o f th e rig h t s id e (-» Fig. 5.9 6 ). O n th e le ft sid e , th e N . v a g u s [X ] d e s c e n d s fu r th e r b e fo re re le a s in g

ju g u la ris in te rn a ) fr o m d o rs a l. J u s t b e fo re re a c h in g th e ju g u la r-s u b c la v i-

th e N. la ry n g e u s re c u rre n s w h ic h th e n w in d s a ro u n d th e a o rtic arch (n o t v is ib le h ere ) a n d a s c e n d s to th e n e c k . P a rticu la r a tte n tio n m u s t be

an ju n c tio n , it jo in s w it h th e T ru n c u s b ro n c h o m e d ia s tin a lis , th e T ru n c u s s u b c la v iu s , a n d th e T ru n c u s ju g u la ris (n o t v is ib le here).

dissection link

T horacic Viscera

Heart -â&#x2013;ş Lungs -â&#x2013;ş Oesophagus

Thoracic cavity, m idsag itta l section

Trachea, Paries membranaceus

Oesophagus, Pars cervicalis

Nodi lymphoidei tracheobronchiales superiores

Glandula thyroidea Cartilagines tracheales

Vertebra cervicalis VII [prominens], Proc. spinosus Truncus brachiocephalicus Bifurcatio tracheae, Carina tracheae

V. brachiocephalica sinistra Arcus aortae Corpus sterni

Nodus lymphoideus tracheobronchialis inferior

Pars ascendens aortae [Aorta ascendens]

Plexus venosus vertebralis internus posterior

Valva aortae, Valvulae semilunares sinistra, posterior et dextra

A. pulmonalis dextra

A. coronaria sinistra

O esophagus, Pars tho racica Valva atrioventricularis dextra [Valva tricuspidalis]

V. pulmonalis sinistra Sinus transversus pericardii V. hemiazygos

C avitas p ericardiaca

A trium sinistrum A. coronaria dextra; V. cardiaca media

Sternum, Proc. xiphoideus

Medulla spinalis

O esophagus P ericardium serosum Pars lumbalis diaphragmatis Atrium dextrum

Fig. 5 .9 8

T h o ra c ic c a v ity , C a v ita s th o ra c is ; m id s a g itta l s e c tio n ;

la te ra l v ie w fr o m th e rig h t side .

In th is s e c tio n , th e c lo s e p r o x im ity o f th e O e s o p h a g u s to th e le ft a triu m o f th e h e a rt (A triu m s in is tru m ) in th e M e d ia s tin u m p o s te riu s is o b v io u s . B o th s tru c tu re s are o n ly s e p a ra te d b y th e p e ric a rd ia l c a v ity (C avita s p erica rd ia ca ).

i- Clinical R em arks----------------------------------------------------------------------------------------------------------T h e sp a tia l p ro x im ity o f th e O e s o p h a g u s to th e h e a rt is u s e fu l w h e n p e rfo rm in g a tr a n s o e s o p h a g e a l e c h o c a rd io g ra p h y . W ith th e u ltra s o u n d tra n s d u c e r in th e O e s o p h a g u s , m o re d e ta ile d im a g e s o f th e

h e a rt a n d in p a rtic u la r, th e h e a rt v a lv e s , can b e a c q u ire d th a n fro m o u ts id e o f th e c h e s t w a ll,

Thym us -► Topography -► Sections

Thoracic cavity, tran sverse section s V. subclavia

M. sternocleidomastoideus

5.99b

N. vagus dexter [X]

M. scalenus anterior M. pectoralis major

A. carotis communis

M. subclavius Plexus brachialis M. serratus anterior

A. subclavia Caput humeri

Pulm o dexter, A pex Scapula Pleura parietalis

Pleura visceralis M. infraspinatus Vertebra thoracica III, Proc. spinosus

Clavicula

V. subclavia

M. sternocleidomastoideus

M. scalenus anterior M. omohyoideus

M. sternohyoideus

A. subclavia M. pectoralis major M. deltoideus

Oesophagus

Pulm o sinister, A pex

Plexus venosus vertebralis internus

Spatium subarachnoideum

Medulla spinalis

M. infraspinatus N. suprascapularis M. trapezius

Figs. 5 .9 9 a a n d b

P le u ra l c u p u la , C u p u la p le u ra e ; tra n s v e rs e

s e c tio n s ; a t th e le v e l o f th e s h o u ld e r jo in t; ca ud a l v ie w .

Spina scapulae

T h e s e s e c tio n s d e m o n s tra te th a t th e p le u ra l c u p u la e x te n d s b e h in d th e n e u ro v a s c u la r b u n d le o f th e a rm a b o v e th e s u p e rio r th o ra c ic a p e rtu re . T h u s , th e a p e x o f th e lu n g is p o s itio n e d im m e d ia te ly p o s te rio r to th e V. a nd A . su b c la v ia .

I- Clinical R em arks-------------------------------------T h e e x te n s io n o f th e p le u ra l cu p u la n e e d s to be c o n s id e re d w h e n p la cin g a c e n tra l v e n o u s c a th e te r (ce n tra l lin e , CVC) in th e V . s u b c la v ia . For th is p ro c e d u re th e c a n n u la is p la ce d ju s t b e lo w th e a n te rio r c o n v e x ity o f th e c la v ic le in th e d ire c tio n to w a rd s th e s te rn o c la

v ic u la r jo in t. If th e c a n n u la is p o s itio n e d to o s te e p th e p le u ra l c a v ity m a y b e in ju re d w h ic h le a d s to an in tru s io n o f a ir in to th e p le u ra l c a v ity a n d re s u lts in c o lla p s in g o f th e lu n g (p n e u m o th o r a x ).

T horacic Viscera

Heart -► Lungs -► Oesophagus

Thoracic cavity, tran sverse sectio n s

Manubrium sterni Nodi lymphoidei paratracheales

Truncus brachiocephalicus M. sternothyroideus A. carotis communis sinistra

V. thoracica interna

Trachea

N. phrenicus dexter

N. phrenicus sinister

V. cav a superior M. pectoralis major

A. subclavia sinistra N. vagus sinister [X]

M. pectoralis minor

Costa I

O esophagus

Pulmo sinister, Lobus superior N. thoracicus longus

N. thoracicus longus V. axillaris

Plexus brachialis

Humerus Arcus aortae

A. axillaris Nodus lymphoideus axillaris, Nodus apicalis

A. subscapularis

M. subscapularis M. teres major

M. serratus anterior N. intercostalis

M. infraspinatus

I icura visceral is

Scapula Pars costalis

5 .1 0 0

M. trapezius

Truncus sympathicus

V. azygos Lig. longitudinale anterius

Corpus sterni Recessus costomediastinalis A. thoracica interna

Du ctu s thoracicus Vertebra thoracica II, Proc. spinosus

Truncus brachiocephalicus A. carotis com munis sinistra Arcus aortae N. phrenicus sinister

N. phrenicus dexter

M. pectoralis major

V. cava sup erior Nodi lymphoidei paratracheales

M. pectoralis minor Pulm o sinister, Lobus superior

V. azygos

Trachea

N. intercostalis

M. serratus anterior N. thoracicus longus N. thoracicus longus Pulmo dexter, Lobus superior O esophagus M. intercostalis externus A. thoracodorsalis N. vagus dexter [X] M. teres major M. subscapularis N. vagus sinister [X] V. azygos

Scapula

M. infraspinatus

Fissura obliqua Costa IV

Pulmo sinister, Lobus inferior

Truncus sympathicus

5.101

M. trapezius Vertebra thoracica IV

Fig. 5 .1 0 0 a n d Fig. 5 .1 0 1

T h o ra c ic c a v ity , C a v ita s th o ra c is ;

Pars tho racica aortae R e cessu s vertebrom ediastin alis Du ctu s thoracicus

tra n s v e rs e s e c tio n s a t th e le ve l o f th e a o rtic a rch ; ca ud a l v ie w .

O e s o p h a g u s a nd th e th o ra c ic a o rta . P o s te rio rly , th e A o rta b o rd e rs at th e R e c e s s u s v e rte b ro m e d ia s tin a lis o f th e p le u ra l c a v ity . P o s itio n e d d i

In th e M e d ia s tin u m s u p e riu s , th e a o rtic a rch is lo c a te d v e n tra lly a nd th e V. cava s u p e rio r is lo c a te d a t th e rig h t s id e o f th e a o rtic a rch. P o s itio n e d

re c tly on th e v e rte b ra l c o lu m n are th e V. a z y g o s on th e rig h t s id e and th e D u c tu s th o ra c ic u s o n th e le ft s id e .

d o rs a l to th e s e b lo o d v e s s e ls a re th e T ra ch e a a nd , t o th e le ft s id e , th e

Thym us -► Topography -► Sections

Thoracic cavity, tran sverse section s Corpus sterni A. pulm onalis dextra N. phrenicus dexter

Pars ascen d en s ao rtae Cavitas pericardiaca Cartilago costalis

V. cava superior

Truncus pulm onalis

M. pectoralis major N. phrenicus sinister A. lobaris superior V. pulmonalis sinistra superior Pulmo dexter, Lobus superior Bronchus principalis sinister Nodi lymphoidei bronchopulmonales

Bronchus lobaris superior

M. serratus anterior Glandula mammaria Costa III N. thoracicus longus

N. thoracicus longus

Fissura obliqua A. lobaris superior Bronchus principalis dexter

M. serratus anterior

Pulmo dexter, Lobus inferior Fissura obliqua M. teres major Scapula N. vagus dexter [X] sympathicus

5 .1 0 2

N. vagus sinister [X] M. trapezius Vertebra thoracica V

O esophagus Ductus thoracicus

Bronchus principalis dexter

Sternum Pleura parietalis, Pars mediastinalis M. pectoralis major Pars ascendens aortae [Aorta ascendens] V. cava superior Bronchus principalis sinister Pars descendens aortae [Aorta descendens] Bronchus lobaris superior dexter

Scapula M. infraspinatus

Oesophagus Vertebra thoracica IV, Corpus vertebrae Vertebra thoracica IV, Proc. transversus

5 .1 0 3

Fig. 5 .1 0 2 a n d Fig. 5 .1 0 3

T h o ra c ic c a v ity , C a v ita s th o ra c is ;

n alis w h ic h b ra n c h e s in to th e p u lm o n a ry a rte rie s . T h e V. cava s u p e rio r

tra n s v e rs e s e c tio n a t th e le v e l o f th e A o rta d e s c e n d e n s (-» Fig. 5 .1 0 2) a n d c o m p u te d to m o g ra p h ic c ro s s -s e c tio n (CT; - * Fig. 5 .1 0 3 ); caudal

is lo c a te d a t th e r ig h t s id e o f th e A o rta . B e h in d th e p u lm o n a ry a rte rie s (Aa. p u lm o n a le s ) are th e m a in b ro n c h i (B ro n c h i p rin c ip a le s ) a nd th e

v ie w . In th e M e d ia s tin u m s u p e riu s , th e A o rta a s c e n d e n s is p o s itio n e d m o s t

O e s o p h a g u s . T h e A o rta d e s c e n d e n s is v is ib le o n th e le f t s id e o f th e v e rte b ra l c o lu m n , th e V. a z y g o s on th e r ig h t s ide .

v e n tra lly fo llo w e d p o s te rio rly a nd to th e le ft s id e b y th e T ru n c u s p u lm o -

[- Clinical R em arks-------------------------------------C ro ss s e c tio n a l im a g in g w it h c o m p u te d to m o g r a p h y (CT; -» Fig. 5 .1 0 3 ) o r m a g n e tic re s o n a n c e to m o g r a p h ic im a g in g (M R I) is o f h ig h re le v a n c e in m e d ic a l d ia g n o s tic s . It is th e g e n e ra l c o n v e n tio n th a t th e s e im a g e s are a lw a y s d is p la y e d w it h a v ie w fr o m caudal. T h e a d v a n ta g e in c o m p u te d to m o g r a p h y (C T ) is b a se d o n th e fa c t th a t all s tru c tu re s w it h th e ir s p a tia l d is trib u tio n are im a g e d in a s ta c k o f s e c tio n s w ith a th ic k n e s s o f a f e w m illim e te rs . In c o n tra s t, in c o n

v e n tio n a l ra d io g ra p h y th e s tru c tu re s are p ro je c te d o n to p o f each o th e r. In to m o g ra p h y , th e d e n s ity o f p a th o lo g ic a l s tr u c tu re s a lre a d y p ro v id e s in fo rm a tio n re g a rd in g th e tis s u e c o m p o s itio n . U s in g CTc o n tr o lle d p u n c tu re s , b io p s ie s can be o b ta in e d fr o m in d iv id u a l e n la rg e d ly m p h n o d e s w h ic h e n a b le s m ic ro b io lo g ic a l a n d p a th o lo g ic a l d ia g n o s is .

T horacic Viscera

Heart -â&#x2013;ş Lungs -â&#x2013;ş Oesophagus

Thoracic cavity, tran sverse section V. cava superior A. thoracica interna

Corpus sterni Pars ascendens aortae A trium sinistrum

V. pulmonalis dextra superior

Sinus transversus pericardii

N. phrenicus dexter

Truncus pulmonalis

M. pectoralis major

Costa III

Bronchus lobaris medius

N. phrenicus sinister Auricula atrii sinistri

Pulmo dexter, Lobus medius

Pulm o sinister, Lobus superior Bronchus lobaris medius Glandula mammaria Bronchus lobaris inferior O esophagus Nodi lymphoidei bronchopulmonales

N. thoracicus longus

Fissura obliqua Cavitas pleuralis

Pulmo dexter, Lobus inferior

M. serratus anterior V. pulmonalis sinistra inferior

M. latissim us dorsi V. pulmonalis dextra inferior Ductus thoracicus

M. intercostalis externus N. vagus dexter [X] V. intercostalis M. trapezius

Fig. 5 .1 0 4 T h o ra c ic c a v ity , C a v ita s th o ra c is ; tra n s v e rs e s e c tio n a t th e le v e l o f th e le ft a triu m ; ca ud a l v ie w .

Pars descendens aortae

R e cessu s vertebrom ediastin alis V. azygos Vertebra thoracica VI

T h e le ft a triu m o f th e h e a rt (A triu m s in is tru m ) re a c h e s fu r th e r cranial th a n th e r ig h t a triu m a n d is p o s itio n e d b e h in d th e g re a t v e s s e ls . T h e O e s o p h a g u s is d ire c tly a d ja c e n t to th e d o rs a l a s p e c t o f th e le ft a triu m .

(

Atrium sinistrum

Ostium atrioventriculare sinistrum Cuspis anterior Cuspis posterior Valvula semilunaris sinistra Valva aortae

Valvula semilunaris posterior

1 Va|vg at rj0ventricularis

J sinistratValvamitralisl

Ventriculus sinister

Valvula semilunaris dextra

Septum interventriculare Ventriculus dexter

Fig. 5 .1 0 5 H e a r t, C or; u ltra s o u n d im a g e ta k e n fr o m w ith in th e O e s o p h a g u s (tra n s o e s o p h a g e a l e c h o c a rd io g ra p h y ).

Clinical Remarks T h e s p a tia l p ro x im ity o f th e O e s o p h a g u s to th e h e a rt is u s e fu l w h e n p e rfo rm in g a tra n s o e s o p h a g e a l e c h o c a rd io g ra p h y (-> Fig. 5.9 8 ). W ith th e u ltra s o u n d tra n s d u c e r in th e O e s o p h a g u s , m o re d e ta ile d

im a g e s o f th e h e a rt a n d p a rtic u la rly th e h e a rt v a lv e s , can be ta k e n th a n fro m o u ts id e o f th e c h e s t w a ll.

Thym us -► Topography -► Sections

Thoracic cavity, tran sverse section s A trium dextrum

Sternum, Proc. xiphoideus A. coron aria sinistra

Cartilago costalis

Sinus aortae Valva aortae

N. phrenicus dexter

Ventriculus dexter Pulmo dexter, Lobus medius A. coronaria sinistra, R. interventricularis anterior

Papilla mammaria

Ventriculus sinister Glandula mammaria Valva atrioventricularis sinistra [Valva mitralis] Pulmo sinister, Lobus superior

Fissura obliqua

Atrium sinistrum M. serratus anterior N. phrenicus sinister

V. cardiaca magna Nodus lymphoideus bronchopulmonalis Costa VI

N. vagus dexter [X] M. latissimus dorsi

Pulmo sinister, Lobus inferior Pars descendens aortae

Pulmo dexter, Lobus inferior

Truncus sympathicus

N. intercostalis

5 .1 0 6

Oesophagus

M. pectoralis major

Ductus thoracicus

Sternum, Proc. xiphoideus

V. pulmonalis sinistra inferior

A. coronaria sinistra

M. transversus thoracis

/ Atrium dextrum /

Pulmo dexter, Lobus medius

Valva atrioventricularis dextra [Valva tricuspidalis] Ventriculus d ex ter

Fissura obliqua Ventriculus sinister Costa

Pulmo sinister, Lobus superior

N. intercostalis Mamma

---------------:ï ;:Æ

Recessus costomediastinalis

Fissura obliqua M. serratus anterior

Nodi lymphoidei tracheobronchiales inferiores

N. phrenicus A. coron aria dextra

Pulmo dexter, Lobus inferior

Pulmo sinister, Lobus inferior

M. intercostalis externus

Pars descendens aortae

Bronchus segmentalis basalis lateralis [B IX]

M. latissim us dorsi

Nodus lymphoideus juxtaoesophagealis N. vagus dexter [X]

5 .1 0 7

Fig. 5 .1 0 6 a n d Fig. 5 .1 0 7

Vertebra thoracica VIII '

/ Oesophagus V. azygos

T h o ra c ic c a v ity , C a v ita s th o ra c is ;

Truncus sympathicus

A. intercostalis

Ductus thoracicus

Vertebra thoracica VII, Proc. spinosus

In th e P e ric a rd iu m , a th ic k la y e r o f s u b e p ic a rd ia l a d ip o s e tis s u e is e v i

tra n s v e rs e s e c tio n s a t th e le ve l o f th e a o rtic v a lv e {-» Fig. 5 .1 0 6 ) and b e n e a th th e a o rtic v a lv e ( - * Fig. 5 .1 0 7 ); ca ud a l v ie w .

d e n t in w h ic h th e c o ro n a ry a rte rie s are e m b e d d e d . T h e la te ra l a s p e c t o f th e h e a rt (Fa cies p u lm o n a lis o f th e h e a rt) a t th is s e c tio n a l le ve l is c o n

T h e s e s e c tio n s s h o w th a t th e M e d ia s tin u m m e d iu m , w h ic h c o n ta in s th e h e a rt a nd th e p e ric a rd iu m , e x te n d s fu r th e r to th e le ft s id e th a n to

fin e d b y th e rig h t a triu m o n th e rig h t s id e a n d th e le ft v e n tric le o n th e le ft s id e . T h e r ig h t v e n tric le d o e s n o t p a rtic ip a te in th e b o rd e rs o f th e

th e rig h t sid e . T h is re s u lts in a s m a lle r v o lu m e o f th e le ft lun g .

h e a rt b u t, in s te a d , fo r m s th e a n te rio r a s p e c t o f th e h e a rt (Fa cies s te rn o c o s ta lis ).

T horacic Viscera

Heart -â&#x2013;ş ...

Sections

Thoracic cavity, fro n ta l sectio n s

M. trapezius

M. serratus anterior

Clavicula. M. supraspinatus Articulatio acromioclavicularis

M. erector spinae

M. subscapularis Scapula, Cavitas glenoidalis

M. splenius capitis

Caput humeri

M. deltoideus

Vertebra thoracica II

axillaris) Cupula pleurae N. axillaris Pleura visceralis A. circumflexa humeri posterior M. intercostalis internus M. teres major Plexus brachialis, Fasciculus posterior

Costa III

A. axillaris Aorta

Plexus brachialis, Fasciculus medialis

V. anterior, Pars intrasegmentalis

brachialis, Fasciculus lateralis

Bronchus anterior

M. coracobrachialis M. serraius anterior

5 .1 0 8

M. scalenus medius

lymphoideus axillaris

A. circumflexa scapulae

V. jugularis interna V. cephalica Proc. coracoideus M. biceps brachii, Caput longum, Tendo Acromion

Caput humeri Plexus brachialis M. deltoideus Nodi lymphoidei paratracheales A. axillaris

Costa I

M. subscapularis A. carotis communis sinister V. axillaris Nodus lymphoideus tracheobronchialis M. teres major Arcus aortae

N. thoracicus longus M. serratus anterior

Pulm o sinister

Costa IV

5 .1 0 9

Fig. 5 .1 0 8 a n d Fig. 5 .1 0 9

T h o ra c ic c a v ity , C a v ita s th o ra c is ,

a x illa r y fo s s a . A x illa , a n d s h o u ld e r jo in t, A rtic u la tio h u m e ri; fro n ta l s e c tio n s a t th e le ve l o f th e s h o u ld e r jo in t (-Âť Fig. 5 .1 0 8 ) a nd a n te rio r to th e s h o u ld e r jo in t (-* Fig. 5 .1 0 9 ); v e n tra l v ie w .

T h e s e illu s tra tio n s s h o w th a t th e n e u ro v a s c u la r s tru c tu re s s u p p ly in g th e a rm , A . a n d V. a x illa ris a nd th e P le x u s b ra c h ia lis , c o u rs e v e n tra l to th e s h o u ld e r jo in t in c lo s e to p o g ra p h ic a l re la tio n to th e a p e x o f th e lun g .

Viscera of the Abdomen D e v e lo p m e n t .........................................

S tom ach ................................................

In te s tin e s .................................................

Liver and G a llb la d d e r .........................

102

P a n c r e a s ................................................. 120 S p le e n ......................................................

128

T o p o g r a p h y ........................................... 130 S e c tio n s ................................................... 148

The Abdomen Concealed Organs T h e o rig in o f th e te r m s a b d o m e n a n d a b d o m in a l fo r th e o rg a n s th a t lie in its c a v ity (C avita s a b d o m in a lis ), are d e riv e d fr o m th e Latin v e rb " a b d o " - " I h id e " . In fa c t, th e a b d o m e n d o e s n o t o n ly h id e m a n y o r g an s, b u t e ve n m o re c a u s e s fo r d ise a se s.

" M e s o s " and Peritoneal R elationships S o m e o f th e o rg a n s o f th e S itu s v is c e ru m (e.g. In te s tin u m te n u e ) are a tta c h e d to planar, a d ip o s e -ric h d u p lic a tio n s o f th e P e rito n e u m ( " M e sos") w h ic h p ro je c t in to th e lu m e n o f th e b o d y c a v ity . T h e M e s o s ca rry

A t a First Glance

b lo o d v e s s e ls a nd n e rv e s fo r th e p a rtic u la r V is c e ra . D e p e n d in g on th e o rg a n a s s o c ia te d w it h th e M e s o , it is re fe rre d to a s th e M e s o c o lo n (of th e C o lo n tra n s v e rs u m ), th e m e s e n te ry (o f th e s m a ll in te s tin e ) o r th e

O n c e o p e n e d , o n e lo o k s in to an a b d o m in a l c a v ity w h ic h is tig h tly fille d w it h s o ft a n d s o lid o rg a n s (V iscera). T h is is ca lle d th e s itu s , " th e p o s i

M e s o g a s triu m (o f th e s to m a c h ). T h e " M e s o s " can be p ic tu re d a s s o ca lle d " p la n a r s te m s " th a t s e rv e to s u s p e n d th e re s p e c tiv e o rg a n s

tio n in g " o f th e o rg a n s in re la tio n to o n e a n o th e r. T h e in s id e o f th e ab d o m in a l w a ll as w e ll a s th e s u rfa c e s o f th e a b d o m in a l o rg a n s are c o

fr o m th e a b d o m in a l w a ll. A s a re s u lt, th e e n tire o rg a n s are c o v e re d b y P e rito n e u m , e x c e p t o n th e " s e a m - lin e " to th e M e s o . T h e y are th e r e fo re ca lle d in tra p e r ito n e a l.

v e re d w it h s o ft, m o is t, a nd s h in y lin in g s, k n o w n a s th e P e rito n e u m . T h e w a ll-c o v e rin g P e rito n e u m is th e p a rie ta l laye r; th e o rg a n -c o v e rin g P e rito n e u m is th e v is c e ra l laye r. T h e s m o o th p e rito n e u m e n a b le s fo r e x a m p le th e p e ris ta ltic m o v e m e n ts o f s to m a c h a nd in te s tin e s , a llo w in g in te s tin a l lo o p s to s lid e a g a in s t each o th e r.

p la ce b y c o n n e c tiv e tis s u e ; h e n c e th e y have no " s ta lk s " . T h e re fo re th e s e o rg a n s are less m o b ile , th e y are c o v e re d b y P e rito n e u m o n ly on

U p p e r A b d o m in a l Situs

th e ir v e n tra l s u rfa c e s fa c in g th e a b d o m in a l c a v ity , a n d are re fe rre d to as r e tr o p e r ito n e a l. In c o n tra s t to th e o rg a n s o f th e re tro p e rito n e a l s itu s

T h e o rg a n s o f th e u p p e r a b d o m e n lie b e n e a th a nd b e tw e e n th e a rc h e s

(se e b e lo w ), th e s e o rg a n s s h ifte d to th e d o rs a l b o d y w a ll d u rin g d e v e lo p m e n t a n d are, th e re fo re , ca lle d s e c o n d a ry re tro p e rito n e a l.

o f th e rib ca ge , b e n e a th th e d o m e o f th e d ia p h ra g m , in th e R e g io n e s h y p o c h o n d ria c a e a n d th e R eg io e p ig a s tric a . T h is re g io n c o n ta in s th e liv e r (H epar) a n d th e P a n c re a s , th e la rg e s t g la n d s in th e h u m a n body. T h e liv e r o c c u p ie s th e e n tire R e g io h y p o c h o n d ria c a d e x tra a nd p a rts o f th e R eg io e p ig a s tric a , w h e re its s u rfa c e c lin g s c lo s e ly to th e d ia p h ra g m . A t its in fe rio r s u rfa c e it b e a rs th e re s e rv o ir fo r its s e c re tio n , th e g a ll b la d d e r (V esica b ilia ris). T h e s to m a c h (G a ste r) is ju s t b e lo w th e rib s o f th e R eg io h yp o c h o n d ria c a s in is tra . A t th e rig h t R eg io e p ig a s tric a , th e s to m a c h tr a n s itio n s in to th e D u o d e n u m (th e fir s t p a rt o f th e s m a ll in

T h e p o s itio n o f th e s e t w o g ro u p s o f o rg a n s is n o t o n ly o f a c a d e m ic in te re s t, b u t e s s e n tia l fo r all s u rg ic a l d is c ip lin e s : in c o n tra s t to th e o rg a n s o f th e re tro p e rito n e a l s itu s , in tra p e rito n e a l o rg a n s ca n o n ly be re ach e d o n c e th e a b d o m in a l c a v ity is o p e n e d a n d th is in c re a s e s th e ris k o f in fe c tio n a n d c o m p lic a tio n s .

R etro pe rito n ea l Situs

te s tin e ) a t th e P ylo ru s (M . s p h in c te r p y lo ric u s ). B e tw e e n th e D u o d e n u m a nd s to m a c h on o n e s id e a nd th e in fe rio r s u rfa c e o f th e liv e r on

If th e s p a c e o c c u p ie d b y th e g a s tro -in te s tin a l tra c t, in c lu d in g its a c c e s

th e o th e r s p a n s a p e rito n e a l d u p lic a tio n , ca lle d th e O m e n tu m m in u s . T h e P a n c re a s a nd a g re a te r p a rt o f th e D u o d e n u m are lo c a te d d o rs a l

s o ry g la n d s , w e r e " c le a r e d " , th e o rg a n s b e h in d th e P e rito n e u m parie ta le w o u ld b e c o m e v is ib le on th e d o rs a l w a ll o f th e C a v ita s a b d o m in a

a nd s lig h tly ca ud a l to th e s to m a c h a t th e d o rs a l w a ll o f th e a b d o m in a l ca vity. L a te ra l a n d p o s te rio r to th e s to m a c h , in th e " o u te r le ft c o rn e r"

lis, w h ic h re s e m b le s th e re tro p e rito n e a l s p a c e (-» p. 158). T h e k id n e y s (R enes) are lo c a te d v e n tra l t o th e lo w e s t rib s . T h e V. cava in fe rio r a s

o f th e R eg io h y p o c h o n d ria c a s in is tra , th e s p le e n (S plen) is lo c a te d in its " n ic h e " . It is a lso n o t v is ib le a t firs t, b u t e a s ily p a lp a b le w h e n o n e g lid e s

c e n d s ju s t to th e rig h t s id e o f th e v e rte b ra l c o lu m n . It a ris e s a t th e level o f th e lo w e s t lu m b a r v e rte b ra fro m th e c o n flu e n c e o f th e t w o V v. ilia-

th e h a n d o v e r th e s to m a c h to w a rd s th e s p le e n .

ca e c o m m u n e s . N o ta b e n e , th e V. cava in fe rio r re c e iv e s n o d ir e c t v e n o u s in flo w fr o m th e a b d o m in a l v is c e ra . In s te a d th e ir v e n o u s b lo o d is

L o w e r A b d o m in a l Situs

c o lle c te d in th e h e p a tic p o rta l v e in , th e V. p o rta e h e p a tis , a nd flo w s th ro u g h th e c a p illa ry b e d o f th e liv e r b e fo re it e n te rs th e V. cava in fe rio r. T h e A o r ta a b d o m in a lis d e s c e n d s in th e m e d ia n p la n e a lo n g th e v e rte

In th e re m a in in g la rg e r p a rt o f th e a b d o m e n , in th e R e g io n e s a b d o m in a -

bral b o d ie s , a nd d iv id e s in to th e A a. ilia cae c o m m u n e s v e n tra l to th e

les la te ra le s, in g u in a le s , u m b ilic a lis , a n d p u b ic a , th e in te s tin e s (In te s tin u m ) are lo c a te d - h a rd ly v is ib le a t firs t. H a n g in g d o w n fr o m th e lo w e r m a rg in o f th e s to m a c h , th e O m e n tu m m a ju s re s e m b le s an a p ro n c o n

fo u r th lu m b a r v e rte b ra . T h re e larg e , u n p a ire d a rte ria l tru n k s , w h ic h le a ve th e A o rta v e n tra lly , s u p p ly th e o rg a n s o f th e u p p e r a b d o m e n

ta in in g a d ip o s e tis s u e . L iftin g it, o n e o b s e rv e s th e c o n v o lu tio n o f th e in te s tin e s . T h e lo w e r s e g m e n ts o f th e s m a ll in te s tin e (In te s tin u m te -

O th e r o rg a n s (su ch as th e C o lo n a s c e n d e n s , th e C o lo n d e s c e n d e n s o r th e P a n cre a s) are lo c a te d a t th e d o rs a l w a ll o f th e a b d o m e n a nd fix e d in

(T ru n c u s c o e lia c u s ) a n d th e in te s tin e s (Aa. m e s e n te ric a e s u p e rio r and in fe rio r).

nue), J e ju n u m a nd Ile u m , are s tro n g ly w o u n d a n d se v e ra l m e te r s lon g . If th e s m a ll in te s tin e s are s lig h tly m o v e d b a c k a nd fo r th , o n e n o tic e s

A b d o m in a l Pain

th a t th e y are fra m e d b y th e C o lo n (In te s tin u m c ra s s u m ) lik e an in v e rte d " U " : th e C olo n a s c e n d e n s on th e rig h t h and sid e , th e C olo n tra n s v e r-

A b d o m in a l p a in has s e v e ra l c a u s e s w h ic h ra n g e fr o m in n o c u o u s s itu a

s u m (w h e re th e O m e n tu m m a ju s is a tta c h e d to in a s im ila r w a y as to th e s to m a c h ) m a rk s th e b o rd e r to th e E p ig a s triu m , a n d th e C o lo n d e-

tio n s to im m in e n t d is a s te rs . T h e a b d o m in a l w a ll ca n be s o ft a nd h a rd ly te n d e r to p a lp a tio n , b u t a ls o s h o w b o a rd -lik e rig id ity a n d re b o u n d te n

s c e n d e n s on th e le ft h and sid e . T h e n , w it h an e le g a n t s w in g , th e C olon s ig m o id e u m d is a p p e a rs in th e lo w e r p e lv is w h e re it tra n s itio n s in to th e R e c tu m .

d e rn e s s . It ta k e s a s k ille d in te rn is t o r s u rg e o n to a c c u ra te ly d ia g n o s e th e ca u s a l p a th o lo g y o f an " a c u te a b d o m e n " , w h ic h p e r s e is o n ly a s y m p to m , to p ro v id e a p p ro p ria te th e ra p e u tic o p tio n s . T h is w ill o n ly be s u c c e s s fu l, if o n e h as a c le a r p ic tu re o f th e c o m p o s itio n o f th e a b d o m en.

-C lin ic a l R em arks----------------------------------R e le v a n c e fo r th e P hysician D ise a se s o f a b d o m in a l o rg a n s are o f hig h im p o rta n c e n o t o n ly fo r th e g e n e ra l p ra c titio n e r, b u t a lso fo r th e s p e c ia lis t in intern a l m e d ic in e , a m o n g th e m g a s tro e n te ro lo g is ts and h e p a to lo g is ts . In fla m m a to ry d is e a s e s o f th e s to m a c h (g a s tritis ) o r g a s tric ulcers are c o m m o n . P e p tic u lc e rs m a y p e rfo ra te and e ro d e th e b lo o d v e s s e ls o f th e s to m a c h ca u s in g p o te n tia lly life -th re a te n in g c o m p lic a tio n s . B ile s to n e s w ith in fla m m a tio n o f th e g a llb la d d e r (c h o le c y s titis ) and P ancreas (p a n c re a titis ) are in th e W e s te rn w o rld as c o m m o n as liv e r d is e a s e s , fro m th e fa tt y d e g e n e ra tio n to fib

— ►

Dissection Link

A fte r o p e n in g th e a b d o m in a l c a v ity , in itia lly th e u n d is s e c te d s itu s w ith th e B ursa o m e n ta lis and th e O m e n ta m a ju s and m in u s s h o u ld b e d e m o n s tra te d , as d is s e c tio n s ig n ific a n tly c h a n g e s th e re la tiv e p o s itio n s o f th e s tru c tu re s . A lte rn a tiv e ly , o n ly th e o rg a n s o f th e lo w e r a b d o m e n or all o rg a n s o f th e p e rito n e a l c a v ity as a b lo c k s h o u ld b e re m o v e d to d is s e c t th e re tro p e rito n e u m a nd p e lv ic s itu s . P rio r to re s e c tio n , th e th re e u n p a ire d b lo o d v e s s e ls o f th e a b d o m in a l a orta (Tru n cus c o e lia c u s , Aa. m e s e n te ric a e s u p e rio r and in fe rio r) m u s t fir s t b e id e n tifie d a nd c u t, if n e e d e d . A ft e r tra n s e c tio n and lig a tio n o f th e O e s o p h a g u s o r D u o d e n u m p ro x im a lly , and o f th e te rm in a l ile u m and th e R e c tu m d is ta lly , th e

ro u s d e s tru c tio n (live r c irrh o s is ), d ue to a lc o h o l a b u s e and e x c e s s iv e n u tritio n . L iv e r c irrh o s is m a y c a use h y p e rte n s io n in th e p orta l v e n o u s s y s te m (p ortal h y p e rte n s io n ) p o te n tia lly re s u ltin g in p o rto -

in tra p e rito n e a l and s e c o n d a ry re tro p e rito n e a l o rg a n s are m o b ilis e d b lu n tly . In a d d itio n , th e liv e r sh o u ld be s e p a ra te d fro m th e V. cava in fe

caval a n a s to m o s e s a nd s u b s e q u e n tly in life -th re a te n in g b le e d in g fro m o e s o p h a g e a l v a ric e s . O rg a n s su ch as th e s to m a c h o r th e

s itu a nd th e re m o v e d o rg a n s m u s t be tra c e d . A t s to m a c h , s p le e n , and

C olon are c o m m o n s ite s fo r m a lig n a n t tu m o u rs . In th e s e cases, th e a n a to m ic a l k n o w le d g e o f th e s u p p ly in g b lo o d v e s s e ls and th e ly m p h a tic d ra in a g e p a th w a y s is o f c lin ical im p o rta n c e fo r d ia g n o s tic s ta g in g as w e ll as su rg ic a l th e ra p y . O th e r o rg a n s s u c h as th e sp le e n a re a t ris k o f ru p tu rin g d u e t o a b lu n t a b d o m in a l tra u m a a nd m a y b e th e s o u rc e o f life -th re a te n in g in te rn a l b le e d in g s .

rior. A fte rw a rd s , n e u ro v a s c u la r s tru c tu re s o f th e o rg a n s re m a in in g in in te s tin e s , p rim a rily th e b lo o d v e s s e ls a re to be d is s e c te d a nd d is p la ye d . Th e e x tra h e p a tic bile d u c ts are d is s e c te d in th e re g io n o f th e h ilu m o f th e liv e r and th e g a llb la d d e r.

E X A M CHECK LIST • Development: abdom inal situs, Pancreas w ith m alform ations • topography: positions of the organs w ith ligam ents, recessus of the peritoneal cavity w ith Bursa om entalis, CT sectional diag nostics • organs: all organs including neurovascular structures and lym phatic drainage pathw ays (particularly Gaster and Intestinum crassum), live r segm ents and structures o f the liver hilum • portal venous system • portocaval anastom oses w ith clinical relevance • Vesica biliaris w ith CALOT's triangle • course and junctions o f the extrahepatic bile ducts • secretory ducts of the Pancreas

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder

D e ve lo p m e n t o f th e upper abdom inal situs

Peritoneal cavity Bursa omentalis Peritoneal cavity Recessus pneumatoentericus

Gaster

Hepar Pericardial cavity

Hepar Septum transversum

V. cava inferior

Hepar

Area of adhesion between pancreas and ventral abdominal wall Lig. splenorenale

Bursa omentalis

Splen [Lien]

Omentum minus

Pancreas Bursa omentalis Lig. gastrosplenicum

Peritoneal cavity Gaster

Duodenum Colon transversum

Omentum minus

Intestinum tenue Lig. coronarium

Figs. 6 .1 a t o d D e v e lo p m e n t o f th e u p p e r a b d o m in a l s itu s a t th e e n d o f w e e k 4 (a ), a t th e b e g in n in g o f w e e k 5 (b ), a n d a t th e b e g in n in g o f w e e k 7 (c); tra n s v e rs e s e c tio n s (a to c) a nd p ara m e d ia n s e c tio n (d) o f th e u p p e r a b d o m e n . P e rito n e u m (g ree n ); P e rito n e u m o f th e R e ce ssu s p n e u m a to e n te ric u s a n d th e B ursa o m e n ta lis (dark red), re s p e c tiv e ly , (a cco rd in g to [1]) T h e p r im o r d ia l g u t p re d o m in a n tly d e riv e s fr o m th e e n d o d e rm a nd p a rts o f th e y o lk sa c. In th e s u rro u n d in g m e s o d e rm , d e v e lo p in g gap s fu s e to fo r m th e b o d y ca vity. T h e m e s o d e rm c o v e rin g th e p rim o rd ia l g u t la te r fo r m s th e P e rito n e u m v is c e ra le a nd , a s P e rito n e u m p a rie ta le ,

Omentum majus

th e Lig. c o ro n a riu m c ra n ia lly a n d th e Lig. fa lc ifo r m e h e p a tis caud ally. T h e Lig. te re s h e p a tis a t th e c a ud a l m a rg in is a re m n a n t o f th e u m b ilic a l v e in . T h e M e s o h e p a tic u m d o rs a le b e c o m e s th e O m e n tu m m in u s . 2. In th e M e s o g a s triu m d o rs a le a g a p a p p e a rs a t th e rig h t s id e (R e c e s s u s p n e u m a to e n te ric u s ) w h ic h la te r fo r m s th e B ursa o m e n ta lis (a a n d b). 3 . T h e s to m a c h ro ta te s 9 0 ° in a c lo c k w is e d ire c tio n (cranial v ie w ) and th u s is lo c a te d in a fr o n ta l p o s itio n a t th e le f t s id e o f th e b o d y (c).

lin e s th e a b d o m in a l ca vity. T h e P e rito n e u m v is c e ra le a ls o fo r m s th e m e s e n te rie s w h ic h c o n ta in th e s u p p ly in g n e u ro v a s c u la r s tr u c tu re s a nd

T h e O m e n tu m m in u s c o n n e c ts th e liv e r a nd le s s e r c u rv a tu re o f th e s to m a c h a ls o in a fro n ta l p la n e a nd fo r m s th e v e n tra l b o rd e r o f th e B ursa o m e n ta lis w h ic h has re a c h e d a p o s itio n o n th e le ft s id e b e h in d

s e rv e as a tta c h m e n ts . T h e d o rs a l m e s e n te ry c o n n e c ts th e p rim o rd ia l g u t w ith th e d o rs a l w a ll o f th e tru n k . T h e u p p e r a b d o m e n a ls o c o n ta in s

th e s to m a c h . 4 . In th e M e s o g a s triu m d o rs a le , th e P a n c re a s a nd th e s p le e n d e v e lo p .

a v e n tra l m e s e n te ry . A t th e b e g in n in g o f w e e k 4 , an e n d o d e rm a l o u tg ro w th d e v e lo p s v e n tra l

T h e P a n cre a s s u b s e q u e n tly a c q u ire s a re tro p e rito n e a l p o s itio n , and th e s p le e n re m a in s in tra p e rito n e a l.

to th e p rim o rd ia l g u t a t th e le v e l o f th e la te r D u o d e n u m a n d g iv e s rise to th e e p ith e lia l tis s u e s o f liv e r, g a llb la d d e r, b ile d u c ts a n d P ancreas.

5. T h e M e s o g a s triu m d o rs a le e v e n tu a lly s e p a ra te s in to th e Lig. g a s tr o s p le n ic u m (fro m th e g re a te r c u rv a tu re o f th e s to m a c h to th e

S u b s e q u e n tly , th e fo llo w in g re s tru c tu rin g o c c u rs : 1. T h e liv e r e x p a n d s in to th e M e s o g a s triu m v e n tra le a nd , th u s , c re a te s

sp le e n ) a nd th e Lig. s p le n o re n a le (fro m th e s p le n ic h ilu m to th e d o rs a l a b d o m in a l w a ll) a n d fo r m s th e o th e r p o rtio n s o f th e O m e n

a d iv is io n in to th e M e s o h e p a tic u m v e n tra le (b e tw e e n v e n tra l w a ll o f th e tru n k a n d live r) a n d th e M e s o h e p a tic u m d o rs a le (b e tw e e n liv e r a nd s to m a c h ) (a a n d b). T h e M e s o h e p a tic u m v e n tra le la te r fo rm s

tu m m a ju s (a p ro n -lik e a t th e g re a te r c u rv a tu re o f th e s to m a c h ; d). T h e re fo re , d u e to its d e v e lo p m e n t a nd th e n e u ro v a s c u la r s u p p ly , th e O m e n tu m m a ju s is a s s o c ia te d w it h th e u p p e r a b d o m in a l s itu s .

Pancreas -► Spleen -> Topography -► Sections

D e ve lo p m e n t o f th e lo w e r abdom inal situs

Primary Ductus

Primary intestinal loop

c d

Figs. 6 .2 a t o d

S c h e m a tic illu s tra tio n s o f th e in te s tin a l ro ta tio n .

In te s tin a l s e g m e n ts a nd th e ir m e s e n te rie s are h ig h lig h te d in d iffe r e n t

D u c tu s v ite llin u s . If th e in te s tin e s fa il to re lo c a te e n tire ly in to th e e m b ry o , a c o n g e n ita l u m b ilic a l h e rn ia (o m p h a lo c e le ) re m a in s w h ic h

c o lo u rs : G a s te r a nd M e s o g a s triu m (p urp le ), D u o d e n u m a nd M e s o d u o d e n u m (blue), J e ju n u m a nd Ile u m w it h a s s o c ia te d m e s e n te rie s

c o n ta in s p o rtio n s o f th e in te s tin a l s e g m e n ts a nd th e ir m e s e n te rie s . B e c a u s e th is c o n g e n ita l h e rn ia tra v e rs e s th ro u g h th e la te r u m b ilic a l

(orange), C olo n a nd M e s o c o lo n (o chre ), (a c c o rd in g to [1]) 1. C au se d b y th e lo n g itu d in a l g ro w th o f th e p rim o rd ia l g u t, a v e n tra lly o rie n te d lo o p fo r m s (p r im a ry in te s tin a l lo o p ). T h e p ro x im a l (upper)

ring , it is c o v e re d b y a m n io n o n ly b u t n o t b y m u s c le s o f th e a b d o m in a l w a ll.

lim b o f th is lo o p d e v e lo p s in to th e m a jo r p a rt o f th e s m a ll in te s tin e , th e d is ta l (lo w e r) lim b d e v e lo p s in to th e c o lo n in c lu d in g th e C olon tra n s v e rs u m . T h e d is ta l large in te s tin e d e v e lo p s fr o m th e h in d g u t a nd , th u s , d iffe rs in its n e u ro v a s c u la r s u p p ly. 2. D u e to a lack o f sp a ce , th e p rim a ry in te s tin a l lo o p is te m p o ra rily lo c a te d o u ts id e o f th e e m b ry o in th e u m b ilic a l co rd (p h y s io lo g ic a l

3. R e m n a n ts o f th e D u c tu s v ite llin u s m a y re m a in as M E C K E L 's d iv e r tic u lu m lo c a te d a t th e s m a ll in te s tin e . 4. T h e e lo n g a tio n o f th e in te s tin e s in itia te s a 2 7 0 ° c o u n te r-c lo c k w is e ro ta tio n , re s u ltin g in th e c o lo n to s u rro u n d th e s m a ll in te s tin e like a fra m e . 5. C olo n a s c e n d e n s a n d C olo n d e s c e n d e n s are s e c o n d a rily re lo c a te d in a re tro p e rito n e a l p o s itio n .

u m b ilic a l h e rn ia ) a nd re m a in s c o n n e c te d to th e y o lk sa c via th e

i- Clinical R em arks-------------------------------------M E C K EL 's d iv e rtic u la are c o m m o n (3 % o f th e p o p u la tio n ) a n d are

on ca n c a u s e a m a lr o ta tio n (h y p o - a nd h y p e rro ta tio n ). T h e s e m a y

u s u a lly lo c a te d in th e p a rt o f th e s m a ll in te s tin e th a t is lo c a te d ap

re s u lt in in te s tin a l o b s tru c tio n (ileus) o r an a b n o rm a l p o s itio n in g o f

p ro x im a te ly 1 00 c m cra nia l o f th e ilio ca e ca l v a lve . D u e to th e fa c t th a t th e s e d iv e rtic u la fre q u e n tly c o n ta in d is s e m in a te d g a s tric m u

th e re s p e c tiv e in te s tin a l s e g m e n ts , a c o n d itio n th a t m a y im p e d e th e d ia g n o s is o f an a p p e n d ic itis . A S itu s in v e rs u s d e s c rib e s a c o n d itio n

c o s a , in fla m m a tio n a n d s u b s e q u e n t b le e d in g th e re o f m a y m im ic s y m p to m s o f an a p p e n d ic itis . D is tu rb a n c e s o f th e in te s tin a l ro ta ti-

w h e re all o rg a n s are p o s itio n e d m irro r-in v e rte d .

Viscera of the A b d o m e n

Developm ent -» Stomach -► Intestines -► Liver and gallbladder

P rojection o f th e stom a ch

Fossa jugularis

Proc. xiphoideus

Pylorus

Cardia [Pars cardiaca]

Costa X Corpus gastricum

Gaster, Pars pylorica

Spina iliaca anterior superior

Symphysis pubica

Fig. 6 .3

P ro je c tio n o f th e s to m a c h , G a s te r, o n to th e v e n tra l w a ll

o f th e tru n k .

th e le ve l o f th e 2 nd to 3 rd lu m b a r v e rte b ra . T h e P y lo ru s , on th e o th e r hand, re g u la rly lo c a te s h a lfw a y a lo n g a v irtu a l lin e c o n n e c tin g th e p u b ic

T h e ca rd ia c o rific e (C ardia) p ro je c ts o n to th e le v e l o f th e 10th th o ra c ic v e rte b ra , th u s , v e n tra lly b e lo w th e P roc. x ip h o id e u s o f th e s te rn u m .

s y m p h y s is (S y m p h y s is pub ica ) a n d th e ju g u la r fo s s a (Fossa ju g u la ris ), p ro je c tin g o n to th e 1st lu m b a r v e rte b ra .

T h e p o s itio n o f th e ca ud a l p a rt o f th e s to m a c h is re la tiv e ly v a ria b le at

Oesophagus

Pulmo

Diaphragma' — Hepar -— — G aster Splen [Lien] — Pancréas — — Duodénum — Jéjunum R en-----— Colon —

Appendix vermiformis

Rectum

Figs. 6 .4 a a n d b

P ro je c tio n o f th e in te r n a l o rg a n s o n to t h e b o d y

s u rfa c e ; v e n tra l (a) a n d d o rs a l (b) v ie w s . T h e s to m a c h is p o s itio n e d in tr a p e r ito n e a lly in th e le ft E p ig a s triu m b e tw e e n th e le f t lo b e o f th e liv e r a nd th e s p le e n . T h e s to m a c h is m o s t

ly c o v e re d b y th e le ft c o s ta l a rch b u t a s m a ll area is d ire c tly a d ja c e n t to th e v e n tra l a b d o m in a l w a ll. T h is area is c lin ic a lly re le v a n t s in c e PEGtu b e s (p e rc u ta n e o u s e n d o s c o p ic g a s tro s to m y ) ca n be p la c e d here fo r p a re n te ra l n u tritio n .

Pancreas -► Spleen -> Topography -► Sections

D ivisions o f th e stom a ch

Incisura cardialis

Oesophagus, Pars abdominalis

Fundus gastricus

Pars cardiaca Curvatura minor

C o rpus gastricum

Duodenum, Pars superior

Curvatura major Duodenum, Pars descendens

Incisura cardialis

Oesophagus

Fig. 6 .5 a n d Fig. 6 .6

S to m a c h , G a s te r; v e n tra l v ie w {-► Fig. 6.5) and

Card ia [Pars cardiaca]

s c h e m a tic illu s tra tio n (-* Fig. 6.6 ). (Fig. 6 .6 a c c o rd in g to [1]) T h e s to m a c h has th re e p a rts: P ars c a rd ia ca : e n tra n c e to th e s to m a c h • C o rp u s g a s tric u m : m a in p a rt w it h s u p e rio r F u n d u s g a s tric u s P ars p y lo ric a : e x it o f th e s to m a c h w h ic h c o n tin u e s a s A n tru m p ylo ric u m a nd C an a lis p y lo ric u s , th e la tte r b e in g s u rro u n d e d b y th e s p h in c te r m u s c le (M . s p h in c te r p y lo ric u s ). T h e s to m a c h h as an a n te rio r a nd p o s te rio r w a ll (P aries a n te rio r and p o s te rio r). T h e le s s e r c u rv a tu re (C u rva tu ra m in o r) is d ire c te d to th e rig h t s ide , th e g re a te r c u rv a tu re (C u rva tu ra m a jo r) to th e le ft sid e . T h e k in k in th e le s s e r c u rv a tu re (In cisura a n g u la ris) m a rk s th e b e g in n in g o f th e Pars

Duodenum

C orpus gastricum

p y lo ric a . T h e g re a te r c u rv a tu re a lso b e g in s w it h an in d e n ta tio n (In cisura ca rdia lis) w h ic h m a rk s th e a n g le o f H IS b e tw e e n th e O e s o p h a g u s and th e s to m a c h (ca rdia c n o tc h ). A t th e in s id e o f th e s to m a c h , th is tra n s i tio n b e tw e e n b o th o rg a n s is m a rk e d b y a m u c o s a l fo ld w h ic h , to g e th e r w it h th e a n g io m u s c u la r g a s tro -o e s o p h a g e a l va lve , c o n trib u te s to th e c lo s u re o f th e s to m a c h .

Incisura angularis

Canalis pyloricus Pars pylorica Antrum pyloricum

i- Clinical R em arks-------------------------------------If th e ca rd ia c n o tc h is s tra ig h te n e d a nd th e a n g le o f H IS is lo s t, s u c h as in s lid in g h iatal h e rn ia s, th e re s u ltin g re flu x o f g a s tric ju ic e in to th e O e s o p h a g u s m a y c a u s e g a s tro -(o )e s o p h a g e a l re flu x d ise a s e (G E R D ) w it h in fla m m a tio n o f th e o e s o p h a g e a l m u c o s a . If th e ra p e u

tic a p p ro a c h e s w it h p ro to n p u m p in h ib ito rs (a nta cid s) to re d u c e th e g a s tric a c id p ro d u c tio n are n o t s u c c e s s fu l, s u rg ic a l p ro c e d u re s , su ch as fix in g th e fu n d u s a ro u n d th e O e s o p h a g u s (N IS S E N fu n d o p lic a tio n ) are p e rfo rm e d , to re s to re th e g a s tro -o e s o p h a g e a l v a lv e m e c h a n is m .

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder

M u scle s o f th e stom a ch

Fundus gastricus

Tunica m uscularis, S tratum longitudinale

Oesophagus, Tunica muscularis

Curvatura major Tunica m uscularis, S tratum longitudinale

Tunica m uscularis, S tratum circulare Pylorus

Tunica m uscularis, S tratum circulare

Oesophagus, Tunica muscularis

Tunica m uscularis, S tratum circulare Tunica m uscularis, Fibrae obliquae

Pylorus Duodenum

6.8

Fig. 6.7 a n d Fig. 6 .8

O u te r (-* Fig. 6 .7 ) a n d in n e r ( - * Fig. 6 .8 ) m u s

c u la r la y e rs o f th e s to m a c h , G a s te r; v e n tra l v ie w .

nal lo n g itu d in a l la y e r (S tra tu m lo n g itu d in a le ) is a d ja c e n t to th e c irc u la r

T h e w a ll o f th e s to m a c h c o m p ris e s th re e m u s c u la r la ye rs (T unica m u s

la y e r (S tra tu m c irc u la re ). T h e in n e rm o s t la y e r c o n s is ts o f th e o b liq u e m u s c le fib r e s (Fibrae o b liq u a e ) w h ic h are m is s in g a t th e le s s e r c u r

cu la ris) n o t c o n s is te n tly fo u n d in all re g io n s o f th e s to m a c h . T h e e x te r

v a tu re .

Pancreas -► Spleen -► Topography -► Sections

Inner relief o f th e stom a ch

Fornix gastricus

Incisura cardialis

Fundus gastricus

Oesophagus, Pars abdominalis Cardia [Pars cardiaca], Ostium cardiacum

Corpus gastricum

Curvatura major

Duodenum, Pars superior,

Plicae circulares Duodenum, Pars descendens Pars pylorica, Canalis pyloricus, Antrum pyloricum M . sph incter pyloricus

Fig. 6 .9 v ie w .

S to m a c h , G a s te r, a n d d u o d e n u m . D u o d e n u m ; v e n tra l

T h e g a s tric m u c o s a h as a c h a ra c te ris tic re lie f s e rv in g th e e n la rg e m e n t o f th e in n e r s u rfa c e . T h e m a c ro s c o p ic a lly re c o g n is a b le g a s tric fo ld s (Pli ca e g a s tric a e ) are lo n g itu d in a lly o rie n te d a nd fo r m th e fu n c tio n a l canal

a lo n g th e le s s e r c u rv a tu re (g a s tric canal). T h e m u c o s a l fo ld s re vea l s m a ll m ic ro s c o p ic a rea s (A re ae g a s tric a e ; -» Fig. 6 .1 0 ). A t th e e x it o f th e s to m a c h (P yloru s), th e c irc u la r m u s c le la y e r is th ic k e n e d to fo rm th e p y lo ric s p h in c te r m u s c le (M . s p h in c te r p y lo ric u s ).

Viscera of the A b d o m e n

Developm ent -> Stomach -► Intestines -► Liver and G allbladder

S tru ctu re o f th e w a ll o f th e stom a ch

Areae gastricae Foveolae gastricae

Tunica m ucosa Lamina propria mucosae Nodulus lymphoideus solitarius Glandulae gastricae „ Lamina muscularis Tela subm ucosa

Tunica m uscularis

Tela subserosa

Fig. 6 .1 0

W a ll o f th e s to m a c h , G a s te r; m ic ro s c o p ic v ie w .

S im ila r to th e w h o le in te s tin e s , th e w a ll o f th e s to m a c h c o m p ris e s an in n e r m u c o s a l la y e r (T unica m u c o s a ) w h ic h is s e p a ra te d fr o m th e m u s c u la r la ye r (T unica m u s c u la ris , - * Figs. 6 .7 a n d 6 .8 ) b y a la y e r o f lo o se

Fig. 6.11

c o n n e c tiv e tis s u e (Tela s u b m u c o s a ). A s an in tra p e rito n e a l o rg a n th e o u te r s u rfa c e o f th e s to m a c h is c o v e re d b y v is c e ra l p e rito n e u m (P e rito n e u m v is c e ra le ) w h ic h fo r m s th e T u n ic a se ro sa .

G a s tric u lc e r (U lc u s v e n tric u li). [5]

G a s tric u lc e rs are p e p tic d e fe c ts w h ic h a ffe c t th e e n tire w a ll o f th e s to m a c h . A s te ris k s m a rk th e p y lo ric rin g , a rro w s m a rk th e rim o f th e u lce r.

i- Clinical R em arks-------------------------------------M o re th a n 8 0 % o f all g a s tric a n d d u o d e n a l u lcers are c a u s e d by th e b a c te riu m H e lic o b a c te r p y lo ri. In a d d itio n , an in c re a s e d p ro d u c

tr e a tm e n t a n d a n ta c id s . C o m p lic a tio n s m a y in c lu d e a p e rfo ra tio n

tio n o f g a s tric a cid o r a re d u c e d p ro d u c tio n o f m u c u s , e .g . c a u s e d

in to a d ja c e n t o rg a n s o r th e a b d o m in a l c a v ity w it h re s u ltin g life th re a te n in g p e rito n itis , o r th e e ro s io n o f a g a s tric a rte ry (-♦ p. 80)

b y pain tr e a tm e n t w ith a c e ty ls a lic y lic a cid , m a y p ro m o te th e fo rm a tio n o f p e p tic u lc e rs . T h u s , th e ra p e u tic a p p ro a c h e s in c lu d e a n tib io tic

w it h s u b s e q u e n t s e v e re b le e d in g . T h e s e c o m p lic a tio n s re q u ire s u r g ica l in te rv e n tio n .

Pancreas -► Spleen -► Topography -► Sections

Topographical relations o f th e stom a ch

Diaphragma

Splen [Lien]

—

Glandula suprarenalis

Pancreas

Hepar

Fig. 6 .1 2 a n d Fig. 6 .1 3 C o n ta c t a re a s . F acies, o f th e a n te rio r w a ll (-» Fig. 6 .1 2 ) a n d th e p o s te r io r w a ll (-» Fig. 6 .1 3 ) o f th e s to m a c h w it h a d ja c e n t o rg a n s : •

T h e s to m a c h is m o b ile a nd , d e p e n d in g o n th e fillin g s ta te , has d iffe r e n t c o n ta c t a rea s w it h its a d ja c e n t o rga n s,

v e n tra l: live r, d ia p h ra g m , a b d o m in a l w a ll d o rs a l: s p le e n , k id n e y, a d re n a l g la n d , P a n cre a s, M e s o c o lo n tra n s v e rs u m

P Clinical R em arks----------------------------------------------------------------------------------------------------------T h e c o n ta c t a rea s h a ve clin ic a l re le v a n c e s in c e p e p tic u lc e rs m a y re s u lt in p e r fo r a tio n in to a d ja c e n t o rg a n s re s u ltin g in s e v e re

d a m a g e to th e s e o rg a n s a n d th e fo rm a tio n o f a d h e s io n s w h ic h im p o s e d iffic u ltie s fo r th e s u rg ic a l re m o v a l o f tu m o u rs .

Viscera of the A b d o m e n

Developm ent -» Stomach -► Intestines -► Liver and gallbladder ->

A rte rie s o f th e stom a ch Lobus hepatis sinister

A. hepatica propria Truncus coeliacus A. g astrica sinistra Vesica biliaris [fellea]

Gaster g astrica posterior

Splen [Lien] g as tricae breves A. hepatica communis

V. portae hepatis A. splenica [lienalis] A. g astrica dextra A. g astroom en talis sinistra Duodenum A. mesenterica superior A. gastroduodenal

A. g astroom en talis dextra

A.; V. gastrica sinistra, Rr. Cardia [Pars A.; V. g astrica sinistra A. hepatica propria V. portae hepatis

Aa.; Vv. g astricae breves

A. hepatica communis A.; V. gastroom en talis sinistra

Pylorus

A.; V. g as trica dextra Omentum majus A.; V. g astroom en talis dextra A.; V. g astroom en talis dextra, Rr. om entales

Fig. 6 .1 4 a n d Fig. 6 .1 5

A rte rie s o f th e s to m a c h , G a s te r, as

s c h e m a tic illu s tr a tio n (-» Fig. 6 .1 4 ) a n d t h e ir c o u rs e a lo n g t h e c u rv a tu re s o f th e s to m a c h (-* Fig. 6 .1 5 ); v e n tra l v ie w .

T h e th r e e m a in b ra n c h e s o f th e T ru n c u s c o e lia c u s (A. g a s tric a sin is tra , A . h e p a tic a c o m m u n is , A . s p le n ic a ) c o lle c tiv e ly g iv e ris e to s ix g a s tric a rte rie s (-► Table).

A rte r ie s o f th e S to m a c h

L e s s er c u rv a tu re

• •

G r e a te r c u rv a tu re

• •

A . g a s tro o m e n ta lis s in is tra (d e riv e d fr o m th e A . s p le n ic a ) A . g a s tro o m e n ta lis d e x tra (d e riv e d fr o m th e A . g a s tro d u o d e n a lis o f th e A . h e p a tic a c o m m u n is ) T h e s e v e s s e ls a ls o s u p p ly th e O m e n tu m m a ju s !

Fu n d u s

•

A a. g a s tric a e b re v e s (d e riv e d fr o m th e A . s p le n ic a in th e area o f th e s p le n ic h ilu m )

P o s te rio r sid e

•

A . g a s tric a p o s te rio r (p re s e n t in 3 0 - 6 0 % , d e riv e s fr o m th e A . s p le n ic a b e h in d th e s to m a c h )

A . g a s tric a s in is tra (d ire c t b ra n c h o f th e T ru n c u s c o e lia c u s ) A . g a s tric a d e x tra (d e riv e d fr o m th e A . h e p a tic a prop ria )

Pancreas -► Spleen -» Topography -► Sections

Veins o f th e stom a ch Oesophagus Vv. o es o phageae

V. cava inferior

Gaster

Hepar

V. splenica [lienalis] V. g astrica sinistra

Vv. g as tricae breves V. po rtae hepatis

Splen [Lien] V. g astrica dextra

V. g astroom en talis sinistra Vesica biliaris [fellea]

V. mesenterica superior

V. mesenterica inferior

g astroom en talis dextra

Colon ascendens

Duodenum

Colon descendens

Rectum

Fig. 6 .1 6

V e in s o f th e s to m a c h , G a s te r, in r e la tio n t o th e p o rta l

v e in , V. p o rta e h e p a tis ; v e n tra l v ie w .

c u rv a tu re d ire c tly e n te r th e p o rta l v e in , w h e re a s th e v e in s a t th e g re a te r c u rv a tu re d ra in in to th e la rg e r b ra n c h e s o f th e p o rta l v e in .

T h e v e in s a re c o rre s p o n d in g to th e a rte rie s , b u t th e v e in s a t th e le s s e r

V e in s o f t h e S to m a c h Lesser c u rv a tu re

•

V. g a s tric a s in is tra

• V. g a s tric a d e x tra D ra in a g e in to th e V. p o rta e h e p a tis : th e s e v e in s a n a s to m o s e via th e V v. o e s o p h a g e a e w it h th e a zyg o s s y s te m a n d th u s , w it h th e V. cava s u p e rio r! G r e a te r c u rv a tu re

• •

V. g a s tro o m e n ta lis s in is tra (to V. sp le n ica) V. g a s tro o m e n ta lis d e x tra (to V. m e s e n te ric a s u p e rio r)

Fu n d u s

•

V v. g a s tric a e b re v e s (to V. sp le n ica)

P o s te rio r sid e

•

V. g a s tric a p o s te rio r (p re s e n t in 3 0 - 6 0 % , to V. sp le n ica)

P Clinical R em arks----------------------------------------------------------------------------------------------------------In c a s e s o f in c re a s e d b lo o d p re s s u re in th e p o rta l v e in s y s te m (p o rta l h y p e rte n s io n ), su ch as in liv e r c irrh o s is , p o rto c a v a l a n a s to m o s e s m a y fo r m via th e o e s o p h a g e a l v e in s w h ic h m a y s u b s ta n tia lly d ila te

(o e s o p h a g e a l v aric e s ) a nd b e a r th e ris k fo r ru p tu re w it h s u b s e q u e n t p o te n tia lly life -th re a te n in g h a e m o rrh a g e (-* Fig. 5 .8 1 )!

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines

Liver and gallbladder

Lym ph vessels o f th e stom ach

Lobus hepatis sinister

Nodi lym phoidei gastrici sinistri

Nodus lym phoideus splenicus

Nodi lym phoidei hepatici

Gaster

Lobus hepatis dexter

Nodi lym phoidei gastrici dextri

Pancreas Nodi lym phoidei pylorici Nodi lym phoidei g astroom en tales sinistri

Nodi lym phoidei gastro o m en tales dextri

Fig. 6 .1 7 L y m p h v es s e ls a n d ly m p h n o d e s o f th e s to m a c h , G a s te r, a n d th e live r, H e p a r; v e n tra l v ie w .

Omentum majus

N o d i ly m p h o id e i s p le n ic i a nd c a ud a l th e r e o f th e

N o d i ly m p h o id e i

T h e ly m p h v e s s e ls a n d ly m p h n o d e s o f th e s to m a c h a re lo c a te d a lo n g

g a s tro o m e n ta le s . T h e N o d i ly m p h o id e i p y lo ric i in th e re g io n o f th e Py lo ru s c o n n e c t to th e N o d i ly m p h o id e i h e p a tic i a t th e h ilu m o f th e live r.

s id e b o th c u rv a tu re s a nd a ro u n d th e P y lo ru s : th e le s s e r c u rv a tu re s h o w s th e N o d i ly m p h o id e i g a s tric i, th e g re a te r c u rv a tu re h a rb o u rs th e

T h re e m a jo r ly m p h a tic d ra in a g e p a th w a y s w it h th re e ly m p h n o d e s ta tio n s are d is tin g u is h e d (-» Fig. 6.1 8 ).

subsequent

i- Clinical R em arks-------------------------------------T h e ly m p h a tic d ra in a g e s ta tio n s ( - * Fig. 6 .1 9 ) o f th e s to m a c h are o f clin ic a l re le v a n c e in th e s u rg ic a l th e r a p y o f g a s tric c an cer. T h e ly m p h n o d e s o f th e fir s t a n d s e c o n d s ta tio n s are u s u a lly re m o v e d to

g e th e r w it h th e s to m a c h . If ly m p h n o d e s o f th e th ird s ta tio n are a lso a ffe c te d b y m e ta s ta tic c a n c e r c e lls , c u ra tiv e th e ra p y is n o t p o s s ib le . In th e s e c a s e s , to ta l g a s tre c to m y w ill n o t be p e rfo rm e d .

Pancreas -► Spleen -► Topography -► Sections

Lym ph vessels o f th e stom a ch

A. gastrica sinistra

A. hepatica propria

A. gastrica

Nodi lym phoidei splenici

Nodi lym phoidei gastrici

A. splenica [lienalis]

A. gastroduodenalis

Nodi lym phoidei

A. gastroomentalis sinistra

Nodi lym phoidei g astroom en tales A. gastroomentalis dextra

Fig. 6 .1 8 L y m p h a tic d r a in a g e a n d re g io n a l ly m p h n o d e s o f th e s to m a c h , G a s te r; v e n tra l v ie w , (a c c o rd in g to [1]) T h e th re e p rin c ip le ly m p h a tic d ra in a g e p a th w a y s w h ic h e x is t fo r th e

c a rd ia c a re a a n d le s s e r c u rv a tu re : N o d i ly m p h o id e i g a s tric i •

s to m a c h are m a rk e d b y d a sh e d lin e s in th is illu s tra tio n :

u p p e r le ft q u a d ra n t: N o d i ly m p h o id e i s p le n ic i lo w e r t w o - t h ir d s o f t h e g r e a te r c u r v a tu r e a n d P y lo ru s : N o d i ly m p h o id e i g a s tro o m e n ta le s a nd N o d i ly m p h o id e i p y lo ric i

A. gastrica sinistra Nodi lym phoidei coeliaci

Nodi lym phoidei gastrici

A. hepatica Nodi lym phoidei splenici

A. gastrica dextra A. splenica [lienalis]

A. gastroduodenalis

Nodi lym phoidei pylorici

A. gastroomentalis sinistra

Nodi lym phoidei gastro o m en tales A. gastroomentalis dextra

Fig. 6 .1 9 L y m p h a tic d ra in a g e s ta tio n s o f th e s to m a c h ; v e n tra l v ie w , (a c c o rd in g to [1])

•

s e c o n d s ta tio n (y e llo w ): ly m p h n o d e s a lo n g th e b ra n c h e s o f th e

W ith in th e th re e p rin c ip le ly m p h a tic d ra in a g e p a th w a y s th e re are th r e e s u b s e q u e n t s ta tio n s :

•

T ru n c u s c o e lia c u s th ird s ta tio n (blue): ly m p h n o d e s a t th e o rig in o f th e T ru n c u s co e lia

•

fir s t s ta tio n (g ree n ): ly m p h n o d e s a lo n g th e c u rv a tu re s (-» Fig. 6 .1 8 )

c u s [N o d i ly m p h o id e i c o e lia c i]; fro m h e re th e ly m p h is d ra in e d via th e T ru n c u s in te s tin a lis in to th e D u c tu s th o ra c ic u s .

Viscera of the A b d o m e n

Developm ent -» Stomach -► Intestines -► Liver and gallbladder ->

A u to n o m ic in nervation o f th e stom a ch

vagalis posterior Truncus vagalis anterior R. coeliacus Ganglia coeliaca

N. splanchnicus

Postganglionic sym pathetic nerve fibres

Rr. hepatici

Preganglionic parasympathetic nerve fibres

Rr. gastrici

Fig. 6 .2 0

A u to n o m ic in n e rv a tio n o f th e s to m a c h , G a s te r;

s e m is c h e m a tic illu s tra tio n . S y m p a th e tic in n e rv a tio n (green), para

w ith in th e m u s c u la r la y e rs o f th e s to m a c h . T h e p a r a s y m p a th e tic in

s y m p a th e tic in n e rv a tio n (p urp le ), (a c c o rd in g to [1]) P re g a n g lio n ic p a r a s y m p a th e tic fib re s (Rr. g a s tric i) re ach th e s to m a c h

n e rv a tio n s tim u la te s th e p ro d u c tio n o f g a s tric a c id s a nd p ro m o te s th e g a s tric p e ris ta ls is . P re g a n g lio n ic s y m p a th e tic fib re s tra v e rs e th e d ia p h ra g m on b o th

as T ru n c i va g a le s a n te rio r a nd p o s te rio r d e s c e n d in g a lo n g th e O e s o p h a g u s a n d c o u rs e a lo n g th e le s s e r c u rv a tu re . A s a re s u lt o f th e g a s tric

s id e s as N n . s p la n c h n ic i m a jo r a nd m in o r a nd are s y n a p s e d to th e p o s t g a n g lio n ic s y m p a th e tic n e u ro n s in th e G an g lia c o e lia c a lo c a te d a t th e

ro ta tio n d u rin g d e v e lo p m e n t, th e a n te rio r T ru n c u s v a g a lis is p re d o m i n a n tly d e riv e d fr o m th e le ft, th e p o s te rio r T ru n c u s va ga lis fr o m th e rig h t

o rig in o f th e T ru n c u s c o e lia c u s . T h e s e p o s tg a n g lio n ic s y m p a th e tic f i b re s re ach th e s to m a c h a s p e ri-a rte ria l n e rv e p le x u s . T h e s y m p a th e tic

N. v a g u s [X]. T h e Pars p ylo rica is in n e rv a te d b y se p a ra te b ra n c h e s (Rr. h e p a tici) o f th e T ru n c i va g a le s. T h e p o s tg a n g lio n ic n e u ro n s are lo c a te d

in n e rv a tio n c o u n te rb a la n c e s th e p a ra s y m p a th e tic in flu e n c e b y re d u c in g g a s tric a c id p ro d u c tio n , p e ris ta ls is , a n d p e rfu s io n .

i- Clinical R em arks-------------------------------------A fo r m e r th e ra p y in p a tie n ts w it h p e p tic u lc e rs w a s to s e v e r th e e n tire N. v a g u s [X] in fe rio r to th e d ia p h ra g m (to ta l v a g o to m y ) o r its b ra n c h e s to th e s to m a c h (s e le c tiv e v a g o to m y ) to re d u c e th e p ro-

d u c tio n o f g a s tric a cid . N o w a d a y s , w it h th e s u c c e s s o f oral tr e a t m e n ts w it h a n ta c id s a n d a n tib io tic s to e ra d ic a te th e causa l H e lic o b a c te r p y lo ri b a c te ria , th e s u rg ic a l v a g o to m y is o n ly ra re ly p e rfo rm e d .

Pancreas -► Spleen -► Topography -► Sections

S tom ach, gastroscopy

Fig. 6.21

T e c h n iq u e fo r o e s o p h a g o s c o p y a n d g a s tro s c o p y .

* **

g a s tro s c o p e g a s tro s c o p e , tip in th e C o rp u s g a s tric u m (-» Fig. 6.22a)

***

g a s tro s c o p e , tip in th e A n tru m p y lo ric u m (-» Fig. 6 .2 2 b)

Gaster, Paries anterior

Plicae gastricae Pylorus

Gaster, Pars pylorica, Antrum pyloricum

Gaster, Paries posterior

Figs. 6 .2 2 a a n d b S to m a c h , G a s te r; g a s tro s c o p y ; cranial v ie w . a v ie w o n to th e C o rp u s g a s tric u m s h o w in g th e lo n g itu d in a l m u c o s a l

b v ie w o n to th e A n tru m p y lo ric u m s h o w in g p re d o m in a n tly s m o o th m ucosa

fo ld s (P licae g a strica e )

i- Clinical R em arks----------------------------------------------------------------------------------------------------------G a s tro s c o p y

e n a b le s

th e

in s p e c tio n

th e

g a s tric

m ucosal

lin in g . P a th o lo g ic a l fin d in g s su ch as e ro s iv e g a s tric le s io n s o r u lc e rs (-* Fig. 6 .1 1 ) re q u ire tis s u e b io p s ie s fo r fu r th e r p a th o lo g ic a l d ia g -

n o s tic s to d is tin g u is h b e tw e e n a b e n ig n p e p tic u lc e r a n d a g a s tric c a rc in o m a .

Viscera of the A b d o m e n

Developm ent -» Stomach -► Intestines -► Liver and gallbladder

P rojection o f th e sm all in te stin e

Oesophagus

Hepar

Gaster

Pancreas

Vesica biliaris [fellea]

D uodenum

Colon transversum Colon ascendens

Intestinum tenue Jejunum

Colon descendens Intestinum crassum

Colon sigmoideum

—

Ileum

Caecum Rectum Appendix vermiformis Canalis analis Anus

Fig. 6 .2 3

P ro je c tio n o f th e a b d o m in a l v is c era o n to t h e b o d y

s u rfac e ; v e n tra l v ie w .

T h e D u o d e n u m s ta rts a t th e P y lo ru s o f th e s to m a c h a n d e n d s a t th e F lexura d u o d e n o je ju n a lis . E x c e p t fo r its fir s t p a rt (Pars s u p e rio r), th e

T h e s m a ll in te s tin e (4 -6 m ) h as th re e p a rts: • D u o d e n u m , 2 5 - 3 0 cm

D u o d e n u m is fix e d in its re tro p e rito n e a l p o s itio n a nd w e ll s e p a ra te d fr o m th e o th e r p a rts o f th e s m a ll in te s tin e . In c o n tra s t, th e in tra p e r i-

• •

t o n e a l c o n v o lu te d p a rts o f th e J e ju n u m a n d Ile u m are n o t s e p a ra b le m a c ro s c o p ic a lly a n d re ach d is ta lly t o th e V alva ilio c a e c a lis (B A U H IN 's

J e ju n u m , tw o - fifth s o f th e to ta l le n g th Ile u m , th re e -fifth s o f th e to ta l le n g th

v a lv e ) a t th e tra n s itio n to th e large in te s tin e .

Duodenum, Pars superior

Duodenum, Pars descendes Pancreas, Cap

Pancreas, Cauda Pancreas, Corpus lexura duodenojejunalis Duodenum, Pars ascendens

Duodenum, Pars horizonta

Fig. 6 .2 4

P ro je c tio n o f th e d u o d e n u m , D u o d e n u m , a n d p a n c re a s ,

P a n c re a s , o n to th e v e n tra l a b d o m in a l w a ll. T h e in tra p e r ito n e a l P ars s u p e rio r o f th e D u o d e n u m p ro je c ts o n to th e le ve l o f th e 1st lu m b a r v e rte b ra . A ll o th e r p a rts are lo c a te d s e c o n d a ry r e tr o p e r ito n e a lly a n d e n c o m p a s s th e h ead o f th e P a n cre a s in a C-

sh a p e d m a n n e r. T h e h ead o f th e P a n cre a s is a d ja c e n t to th e Pars d e s c e n d e n s o f th e D u o d e n u m . T h e Pars h o riz o n ta lis lies a t th e le ve l o f th e 3 rd lu m b a r v e rte b ra a nd c o n tin u e s as Pars a s c e n d e n s to th e Flexura d u o d e n o je ju n a lis a t th e le ve l o f th e 2 nd lu m b a r v e rte b ra . T h is fle x u re m a rk s th e tra n s itio n to th e in tra p e rito n e a l J e ju n u m .

Pancreas -► Spleen -» Topography -► Sections

S tru ctu re o f th e w a ll o f th e sm all in te stin e

Mesenterium

Tela subm ucosa Lamina muscularis mucosae Tunica m ucosa

Tunica Villi intestinales

Peritoneum viscerale Tela subserc

Nodulus lymphoideus solitarius

Tunica m uscularis

Fig. 6 .2 5

S m a ll in te s tin e , In te s tin u m te n u e ; c ro s s -s e c tio n .

T h e la y e rs are d e s c rib e d in

F ig u re 6 .2 6 .

Villus intestinalis

Tela subm ucosa

Tunica m uscularis

Tela subserosa Tunica serosa

Fig. 6 .2 6

W a ll s tru c tu re o f th e s m a ll in te s tin e , In te s tin u m te n u e ;

th e o u te r lo n g itu d in a l la y e r (S tra tu m lo n g itu d in a le ). T h e in tra p e rito n e a l

m ic ro s c o p ic v ie w . S im ila r to o th e r p a rts o f th e in te s tin e s , th e w a ll o f th e s m a ll in te s tin e

p a rts (Pars s u p e rio r o f th e D u o d e n u m , J e ju n u m a n d Ile u m ) are c o v e re d on th e ir o u te r s u rfa c e w it h p e rito n e u m (P e rito n e u m v is c e ra le ) w h ic h

c o n s is ts o f th e in n e rm o s t m u c o s a l la ye r (Tu nica m u c o s a ) w it h in te s ti nal v illi (Villi in te s tin a le s ) fo r s u rfa c e e n la rg e m e n t. S e p a ra te d b y a lo o se c o n n e c tiv e tis s u e la y e r (Tela s u b m u c o s a ), th e m u s c u la r la y e r (Tunica

fo r m s th e T u n ic a s e ro s a . R e tro p e rito n e a l p a rts o f th e D u o d e n u m are a n c h o re d b y a T u n ic a a d v e n titia w ith in th e c o n n e c tiv e tis s u e o f th e

m u s c u la ris ) c o n s is ts o f th e in n e r c irc u la r la y e r (S tra tu m circ u la re ) and

re tro p e rito n e a l sp a ce .

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder

D ivisions o f th e duo denu m Duodenum, Ampulla [Bulbus] Pylorus

Gaster, Pars pylorica

D uodenum , Pars superior

Jejunum

Duodenum , Pars descendens

D uodenum , Pars ascendens

D uodenu m , Pars horizontalis

Ductus hepaticus communis Plica spiralis

Ductus cysticus

Collum vesicae biliaris

D uodenum , Pars superior

D uodenum , Pars descendens

Corpus vesicae Du ctu s pancreaticus accessorius

Fundus vesicae

Papilla duodeni Du ctu s choledo chus [biliaris] Papilla duodeni

D uodenum , Pars ascendens

D uodenum , Pars horizontalis

Fig. 6 .2 7 a n d Fig. 6 .2 8

D iv is io n s o f th e d u o d e n u m . D u o d e n u m ,

T h e e x c re to ry d u c t o f th e P a n cre a s (D u c tu s p a n c re a tic u s , d u c t o f

is o la te d (-* Fig. 6 .2 7 ) a n d to g e t h e r w it h th e e x tr a h e p a tic b ile d u c ts (-» Fig. 6 .2 8 ); v e n tra l v ie w .

W IR S U N G ) e n te rs th e P a rs d e s c e n d e n s o f th e D u o d e n u m fr e q u e n tly to g e th e r w it h th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ) o n a m u c o

T h e D u o d e n u m h as fo u r p a rts: • Pars s u p e rio r

sal pap illa (Papilla d u o d e n i m a jo r, a m p u lla o f V A TE R ) w h ic h is fo u n d 8 - 1 0 c m d is ta l to th e P y lo ru s . O fte n , 2 c m p ro x im a l to th e la tte r, a

•

Pars d e s c e n d e n s

• •

Pars h o riz o n ta lis Pars a s c e n d e n s

s m a lle r P apilla d u o d e n i m in o r is fo u n d in to w h ic h th e D u c tu s p a n c re a ti c u s a c c e s s o riu s (S A N T O R IN I'S d u c t) e m p tie s its s e c re tio n . T h e P a rs h o riz o n ta lis c ro s s e s th e v e rte b ra l c o lu m n a nd c o n tin u e s as P ars a s c e n d e n s .

T h e P ars s u p e rio r is th e o n ly in tra p e rito n e a l p a rt a nd its w id e r p ro x im a l lu m e n is re fe rre d to as A m p u lla (B u lb u s) d u o d e n i.

Pancreas -► Spleen -► Topography -► Sections

S tructu re o f th e duo denu m

D uodenum , Pars superior, Am pulla [Bulbus]

M. sphincter pyloricus

Pylorus, Ostium pyloricum Canalis pyloricus pyloricum

Plicae circulares

Pars pylorica M . suspensorius duodeni

D uodenum , Pars descendens Flexura duodenojejunalis Papilla duodeni m ajor

Jejunum

Tunica muscularis D uodenu m , Pars ascendens D uodenu m , Pars horizontalis

Fig. 6 .2 9

In n e r r e lie f o f th e d u o d e n u m . D u o d e n u m ; fr o n ta l

s e c tio n ; v e n tra l v ie w . T h e D u o d e n u m has th e fo llo w in g fo u r p a rts : 1. Pars s u p e rio r, 2. Pars

c re a tic u s (d u c t o f W IR S U N G ) a nd th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ), b o th o f w h ic h u s u a lly m e rg e to fo r m th e A m p u lla h e p a to p a n -

d e s c e n d e n s , 3. Pars h o riz o n ta lis , a nd 4 . Pars a s c e n d e n s . T o in cre a se

c re a tic a . T h e Pars a s c e n d e n s is a tta c h e d t o th e a orta nea r th e o rig in o f th e A . m e s e n te ric a s u p e rio r b y s m o o th m u s c le fib r e s (M . s u s p e n s o riu s

th e a b s o rp tiv e s u rfa c e , th e in n e r re lie f o f th e D u o d e n u m s h o w s c irc u la r m u c o s a l fo ld s (P licae circ u la re s , K E R C K R IN G 's fo ld s ) s im ila r to o th e r

d u o d e n i, m u s c le o f TR EITZ) a n d d e n s e c o n n e c tiv e tis s u e (Lig. s u s p e n s o riu m d u o d e n i), ju s t b e fo re th e D u o d e n u m tr a n s itio n s in to th e in tra p e -

p a rts o f th e s m a ll in te s tin e . T h e Pars d e s c e n d e n s c o n ta in s th e Papilla d u o d e n i m a jo r (a m pu lla o f VA TE R ) a t th e e n tra n c e o f th e D u c tu s pan -

rito n e a l J e ju n u m a t th e F lexura d u o d e n o je ju n a lis .

G landulae duodenales

Tela submucosa

Tunica muscularis, Stratum circulare Tunica muscularis, Stratum longitudinale

Fig. 6 .3 0

W a ll s tru c tu re o f th e d u o d é n u m , D u o d e n u m , w ith

G la n d u la e d u o d e n a le s ; v ie w fr o m o u ts id e .

T h e m u c o u s -p ro d u c in g G la n d u la e d u o d e n a le s (B R U N N E R 's g la n d s) are lo c a te d in th e Tela s u b m u c o s a a nd a llo w th e id e n tific a tio n o f th e D u o d e n u m in h is to lo g ic a l s e c tio n s .

Clinical Remarks T h e m u s c le o f TR E IT Z d e fin e s th e b o rd e r b e tw e e n u p p e r a n d lo w e r in te s tin a l tr a c t h a e m o rrh a g e s . T h is c la s s ific a tio n is o f c lin i

cal re le v a n c e s in c e b o th fo r m s o f h a e m o rrh a g e have d iffe r e n t c o m m o n c a u s e s a nd re q u ire d iffe r e n t d ia g n o s tic s te p s .

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder

D uodenum , im aging

Vertebra thoracica XII Gaster, Curvatura minor Costa XII Gaster, Incisura angularis Flexura duodenojejunalis Duodenum, Pars superior, Ampulla

Pylorus

Duodenum, Pars descendens

Duodenum, Pars ascendens

Duodenum, Pars horizontalis Jejunum Vertebra lumbalis III

Plicae

Fig. 6.31

D u o d e n u m , D u o d e n u m ; ra d io g ra p h in a n te ro p o s te rio r

(AP) b e a m p ro je c tio n a fte r o ra l a p p lic a tio n o f a c o n tra s t m a te ria l; p a tie n t in u p rig h t p o s itio n ; v e n tra l v ie w .

Fig. 6 .3 2

D u o d e n u m , D u o d e n u m ; e n d o s c o p ic im ag e .

T h e c irc u la r m u c o s a l fo ld s (Plicae circ u la re s , K E R C K R IN G 's fo ld s ) are c le a rly vis ib le .

i- Clinical R em arks-------------------------------------S im ila r to th e s itu a tio n in th e s to m a c h , d u o d e n a l u lce rs are c o m m o n a nd c lin ic a lly th e y c a n n o t cle a rly be d is tin g u is h e d fr o m g a s tric u lc e rs

d io lo g y w it h c o n tr a s t im a g in g is le s s fr e q u e n tly u s e d b e c a u s e d ia g n o s tic e n d o s c o p y (d u o d e n o s c o p y ) n o t o n ly e n a b le s th e d ire c t

(-» p. 78). M a lig n a n t tu m o u rs , h o w e v e r, are ra re in th e D u o d e n u m . S e ve ra l d ia g n o s tic a p p ro a c h e s ca n be e m p lo y e d . C o n v e n tio n a l r a

in s p e c tio n o f th e m u c o s a b u t a ls o a llo w s th e s a m p lin g o f tis s u e bi o p s ie s .

Pancreas -► Spleen -► Topography -► Sections

S tructu re o f th e w a ll o f je ju n u m and ileum

Tela subserosa Tela subserosa Tunica serosa

Tunica muscularis Tunica serosa

Plicae circulares P lic ae circulares

N oduli lym phoidei

Fig. 6 .3 3

D e ta il o f th e je ju n u m . J e ju n u m .

T h e s tru c tu re o f th e J e ju n u m is v e ry s im ila r to th e D u o d e n u m b u t d o e s n o t c o n ta in th e G la n d u la e d u o d e n a le s (B R U N N E R 's g la n d s).

Fig. 6 .3 4

D e ta il o f t h e p r o x im a l ile u m . Ile u m .

T h e P licae c irc u la re s (K E R C K R IN G 's fo ld s ) are m u c h le s s fre q u e n t in th e Ile u m w h e n c o m p a re d to th e u p p e r s m a ll in te s tin e .

Mesenterium

Ileum

Mesenterium diverticuli

(Diverticulum ilei)

Fig. 6 .3 5

D e ta il o f th e d is ta l ile u m . Ile u m .

Fig. 6 .3 6

M E C K E L 's d iv e r tic u lu m , D iv e r tic u lu m ilei.

T h e la rg e a s s e m b lie s o f ly m p h fo llic le s are c h a ra c te ris tic fo r th e te r m i

U p to 3 % o f p e o p le h a v e b e e n d ia g n o s e d w it h a d iv e rtic u lu m , w h ic h

nal Ile u m . T h e y are a p a rt o f th e m u c o s a -a s s o c ia te d ly m p h o id tis s u e (M A L T ). T h e ly m p h n o d e s are e ith e r lo c a te d in d iv id u a lly (N odi ly m p h o -

e x is ts a s a re m n a n t o f th e e m b ry o lo g ic a l D u c tu s v ite llin u s (-» Fig. 6.2). It is u s u a lly lo c a te d in th e Ile u m a b o u t 1 00 c m p ro x im a l to th e ile o ca e ca l

id e i s o lita rii; - * Fig. 6 .3 4 ) in th e T e la s u b m u c o s a o r are a s s e m b le d in g ro u p s (N o d u li ly m p h o id e i a g g re g a ti; P E Y E R 's p la q u e s) u n d e rn e a th th e

v a lv e a t th e o p p o s ite s id e o f th e m e s e n te ry . M E C K E L 's d iv e rtic u la m a y c o n ta in d is s e m in a te d g a s tric m u c o s a and,

e le v a te d m u co sa .

w h e n in fla m e d o r b le e d in g , ca n m im ic th e s y m p to m s o f an a p p e n d ic i tis .

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder

P rojection o f th e large in testin e

Flexura coli sinistra

Flexura coli dextra

C olon descenden s

C olon ascendens

Ileum

C aecum Appendix vermiformis C olon sigm oideum

C analis analis

•

C olo n w it h C olo n a s c e n d e n s , C o lo n tra n s v e rs u m , C olo n d e s c e n

v e n tra l v ie w . T h e large in te s tin e is a b o u t 1.5 m lo n g a n d c o n s is ts o f fo u r p a rts:

Fig. 6 .3 7

D iv is io n s o f th e la rg e in te s tin e , In te s tin u m c ra s s u m ;

•

d e n s , a nd C o lo n s ig m o id e u m R e c tu m

•

C analis a nalis

C a e c u m (b lin d g u t) w ith A p p e n d ix v e rm ifo rm is

Flexura coli sinistra Flexura coli dextra Colon transversum

Colon ascendens

Colon descendens

Ileum Colon sigmoideum Caecum Appendix vermiformis

Rectum Canalis analis

Fig. 6 .3 8 P ro je c tio n o f th e la rg e in te s tin e , In te s tin u m c ra s s u m , o n to th e v e n tra l a b d o m in a l w a ll.

R e c tu m are u s u a lly s e c o n d a rily re tro p e rito n e a l o rg a n s , th e d is ta l R ec

C a e cu m w it h A p p e n d ix v e rm ifo rm is , C olo n tra n s v e rs u m , a nd C olon

tu m a n d th e anal canal are s u b p e rito n e a l. T h e p ro je c tio n s a nd th e le n g th o f th e in d iv id u a l s e g m e n ts o f th e large in te s tin e are h ig h ly v a ri

s ig m o id e u m are p o s itio n e d in tra p e rito n e a lly a nd have in d iv id u a l m e s e n te rie s . C a e cu m a nd A p p e n d ix v e r m ifo rm is m a y a ls o b e lo c a te d

a b le a n d th e re tro p e rito n e a l s e g m e n ts are u s u a lly in c o n s is te n tly fu s e d w it h th e p o s te rio r a b d o m in a l w a ll. D u e to th e p o s itio n o f th e liv e r on th e

re tro rito n e a lly (C a e cu m fix u m ); in th is ca se th e y d o n o t have a m e s e n te ry . C olo n a s c e n d e n s , C o lo n d e s c e n d e n s , a nd th e m a jo r p a rt o f th e

r ig h t s id e , th e le ft c o lic fle x u re (F le xura c o li s in is tra ) is p o s itio n e d fa rth e r cranial th a n th e rig h t c o lic fle x u re (F le xura c o li d e x tra ; -» Fig. 6.5 3 ).

Pancreas -► Spleen -► Topography -► Sections

P rojection and positional variations o f th e A p p e n d ix v e rm ifo rm is

Colon ascendens Anulus umbilicalis

Ileum

Colon ascendens Appendix vermiformis Ileum Spina iliaca anterior superior

McBURNEY's point Spina iliaca anterior superior Appendix vermiform is Caecum LA N Z's point

Fig. 6 .3 9 P ro je c tio n o f th e c a e c u m . C a e c u m , a n d A p p e n d ix v e r m ifo r m is o n to th e v e n tra l a b d o m in a l w a ll. T h e b a se o f th e A p p e n d ix v e rm ifo rm is p ro je c ts o n to th e M c B U R N E Y 's p o in t (th e tra n s itio n b e tw e e n th e la te ra l th ird a n d th e m e d ia l tw o - th ir d s on a lin e c o n n e c tin g th e u m b ilic u s w it h th e S pina iliaca a n te rio r s u p e ri or). T h e lo c a tio n o f th e tip o f th e a p p e n d ix is m o re v a ria b le a n d p ro je c ts o n to th e L A N Z 's p o in t (th e tra n s itio n b e tw e e n th e rig h t th ird a nd th e

Figs. 6 .4 0 a to d

P o s itio n a l v a r ia n ts o f th e A p p e n d ix v e r m ifo r m is ;

v e n tra l v ie w . a d e s c e n d in g in to th e s m a ll p e lv is b c

re tro c a e c a l (m o s t c o m m o n p o s itio n ) p re-ileal

re tro -ile a l

le ft tw o -th ird s o n a lin e c o n n e c tin g b o th S p in a e iliacae a n te rio re s s u p e rio re s ; 3 0 % ; - * Figs. 6 .4 0 a nd 6.4 1 ). Splen [Lien] Lobus hepatis dexter

Gaster

Omentum majus Vesica biliaris Colon transversum Duodenum, Pars descendens

Duodenum, Pars ascendens

Caput pancreatis

Colon ascendens

Colon descendens

Ileum C aecum Colon sigmoideum

A ppendix verm iform is

Ampulla tubae uterinae

Uterus Ovarium Vesica urinaria

Fig. 6.41

P o s itio n a l v a r ia n ts o f t h e A p p e n d ix v e r m ifo r m is ; v e n tra l

v ie w .

i- Clinical R em arks------------------------------------------------------------------------------------------------------------T h e d ia g n o s is o f a p p e n d ic itis is o fte n n o t e a s y s in c e rig h t lo w e r

pain in d u c e d b y p re s s in g a nd re le a s in g (re b o u n d te n d e rn e s s ) th e

a b d o m in a l pain ca n a lso be c a u s e d b y e n te ritis or, in w o m e n , b y in fla m m a to ry c o n d itio n s o f th e o v a ry o r th e fa llo p ia n tu b e . T h u s , th e

M c B U R N E Y 's o r th e L A N Z 's p o in t is an im p o rta n t d is c rim in a to ry s ign .

Viscera of the A b d o m e n

Developm ent -» Stomach -► Intestines -► Liver and gallbladder

S tru ctu re o f th e large in te stin e

Plicae semilunares coli

Omentum majus

Taenia omentalis

Haustra coli

Mesocolon transversum

Taenia mesocolica Taenia libera

Appendices epiploicae

Fig. 6 .4 2 S tr u c tu r a l c h a ra c te ris tic s o f th e la rg e in te s tin e , In te s tin u m c ra s s u m , th e tr a n s v e r s e c o lo n ta k e n as an e x a m p le ;

H a u s tra a n d P lica e s e m ilu n a re s : th e h a u s tra (H a u s tra co li) are sacc u la tio n s o f th e in te s tin a l w a ll w h ic h c o rre s p o n d to c re s c e n t-s h a p e d

v e n tra l ca ud a l v ie w .

m u c o s a l fo ld s (P licae s e m ilu n a re s ) a t th e in n e r s u rfa c e . A p p e n d ic e s e p ip lo ic a e : fa tty p ro je c tio n s fr o m th e a d ip o s e tis s u e

T h e large in te s tin e has fo u r c h a ra c te ris tic d iffe re n c e s to th e s m a ll in te s tin e : • la rg e r d ia m e te r ( " th ic k " ra th e r th a n " th in " )

o f th e Tela s u b s e ro s a .

T a e n ia : th e lo n g itu d in a l m u s c le la y e r is re d u c e d to th re e b a n d s . O f th e s e , th e Ta e n ia libera is v is ib le , w h e re a s th e Ta e n ia m e s o c o lic a a tta c h e s to th e M e s o c o lo n tra n s v e rs u m a nd th e Ta e n ia o m e n ta lis c o n n e c ts to th e g re a te r o m e n tu m (O m e n tu m m a ju s).

Glandulae intestinales

Tunica m ucosa

Lamina propria mucosae Nodulus lymphoideus solitarius Lamina muscularis mucosae

Tela subm ucosa Stratum circulare Tunica m uscularis

Stratum longitudinale

Tela subserosa

Fig. 6 .4 3

S tr u c tu r e o f th e w a ll o f th e la rg e in te s tin e , In te s tin u m

c ra s s u m ; m ic ro s c o p ic v ie w .

Taenia

le ). H o w e v e r, th e lo n g itu d in a l la y e r is n o t c o n tin u o u s b u t is re d u c e d to

S im ila r to th e o th e r p a rts o f th e in te s tin e s , th e w a ll o f th e la rg e in te s tin e c o n s is ts o f an in n e r m u c o s a l la y e r (Tu nica m u c o s a ) w h ic h , in c o n tra s t

th re e b a n d s (T a e n ia ). A t th e o u ts id e , th e in tra p e rito n e a l p a rts (C ae cu m w it h A p p e n d ix v e rm ifo rm is , C olo n tra n s v e rs u m , a nd C olo n s ig m o id e u m ) are c o v e re d b y p e rito n e u m (P e rito n e u m v is c e ra le ) fo r m in g th e

t o th e D u o d e n u m , has no m u c o s a l v illi. S e p a ra te d fr o m th e T u n ic a m u co sa b y a c o n n e c tiv e tis s u e laye r (Tela s u b m u c o s a ) is th e m u s c u la r

T u n ic a s ero s a . In c o n tra s t, th e re tro p e rito n e a l p a rts (C olon a s c e n d e n s , C olo n d e s c e n d e n s , a n d u p p e r re c tu m ) are a n c h o re d b y th e T u n ic a a d

la ye r (T u n ic a m u s c u la ris ). It c o n s is ts o f an in n e r c irc u la r la y e r (S tr a tu m c irc u la re ) a nd an o u te r lo n g itu d in a l la ye r (S tr a tu m lo n g itu d in a -

v e n titia in th e c o n n e c tiv e tis s u e o f th e re tro p e rito n e a l sp a ce .

Pancreas -► Spleen -» Topography -► Sections

C aecum and A p p e n d ix v e rm ifo rm is

Taenia omentalis Taenia

Haustra coli Colon ascendens

A ppendix verm iform is

Ileum

Taenia libera

Fig. 6 .4 4

C a e c u m w ith A p p e n d ix v e r m ifo r m is , a n d te r m in a l

ile u m . P ars te rm in a lis ilei; d o rsa l v ie w . T h e C a e c u m is a p p ro x im a te ly 7 c m lo n g . T h e 8 - 9 c m lo n g A p p e n d ix

s h o w n h ere ) w it h s u p p ly in g n e u ro v a s c u la r s tru c tu re s . T h e ta e n ia o f th e C o lo n c o n v e rg e a t th e a p p e n d ix to fo r m a c o n tin u o u s lo n g itu d in a l m u s c u la r layer.

v e r m ifo rm is is a tta c h e d to th e C a e cu m a nd has its o w n m e s e n te ry (n o t

Taenia lit* " * Colon ascendens Haustra coli

Plicae semilunares coli

(Valva ileocaecalis) Ileum N oduli lym phoidei agg regati O stium ileale

Frenulum ostii ilealis

C aecum Taenia libera

A p pendix verm iform is

Ostium appendicis vermiformis

Fig. 6 .4 5

C a e c u m w ith A p p e n d ix v e r m ifo r m is , a n d te r m in a l

ile u m . P ars te rm in a lis ilei; v e n tra l v ie w ; a fte r re m o v a l o f th e a n te rio r

ale). L a te ra lly , th e lips c o n tin u e in th e F re n u lu m o s tii ile a lis. T h e te r m i nal ile u m c o n ta in s a g g re g a tio n s o f ly m p h fo llic le s (N odi ly m p h o id e i

p a rts o f th e w a ll. T h e C a e cu m is s e p a ra te d fr o m th e te rm in a l ile u m b y th e ile o c a e c a l

a g g re g a ti), re fe rre d to a s PE Y ER 's p la q u e s , w h ic h are p a rt o f th e m u c o s a -a s s o c ia te d ly m p h o id tis s u e (M A L T ). S im ila rly , th e A p p e n d ix v e r

v a lv e (Valva ile o ca e ca lis, B A U H IN 's va lve ). In te rn a lly , th e t w o lip s o f th e v a lve fo r m th e Papilla ile a lis a nd b o rd e r th e ile a l o rific e (O s tiu m ile-

m ifo rm is c o n ta in s large a g g re g a tio n s o f ly m p h fo llic le s a n d s e rv e s th e im m u n e d e fe n c e .

i- Clinical R em arks-------------------------------------T h e a p p e n d ic itis is a c o m m o n d is e a s e in th e 2 nd a n d 3 rd d e c a d e s o f

ile u m are th e a b s o rp tio n o f v ita m in B 12 a n d b ile a c id s as w e ll as

life . T h e a p p e n d ic itis is an e n d o g e n o u s in fla m m a tio n ca u s e d u s u a lly b y th e o b s tru c tio n o f th e lu m e n o f th e a p p e n d ix b y fa e c e s or, in rare c a s e s, b y fo re ig n b o d ie s w it h a re s u ltin g tra n s m u ra l in fla m m a tio n

its im m u n o lo g ic a l fu n c tio n s . It is fr e q u e n tly a ffe c te d b y C R O H N 's d is e a s e , a c h ro n ic in fla m m a to ry d is e a s e o f th e in te s tin e w ith

d u e to in te s tin a l m ic ro -o rg a n is m s . A p e rfo ra tio n m a y c a u se a p o te n tia lly life -th re a te n in g p e rito n itis . Im p o rta n t ta s k s o f th e te rm in a l

a u to im m u n e c o m p o n e n t, w h ic h , d u e to a v ita m in B 12 d e fic ie n c y , m a y c a u s e a n a e m ia .

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder -►

A rte rie s o f th e sm all in testin e A. hepatica communis A. hepatica propria

Truncus coeliacus A. gastrica sinistra

A. gastroduodenalis A. pancreaticoduodenalis superior posterior A. pancreaticoduodenalis superior anterior

Fig. 6 .4 6

A rte r ie s o f th e d u o d e n u m , D u o d e n u m ; v e n tra l v ie w ,

A.; V. m esenterica superior

(a cco rd in g to [1]) T h e b lo o d s u p p ly o f th e D u o d e n u m is a c c o m p lis h e d b y a v e n tra l a nd d o rs a l d o u b le a rte ria l a rch . T h is a rch is s u p p lie d c ra n ia lly b y th e A a. p a n c re a tic o d u o d e n a le s s u p e rio re s a n te rio r a nd p o s te rio r w h ic h b ra n c h o f f th e T ru n c u s c o e lia c u s . C au d a lly, th e a rc h e s are s u p p lie d b y th e A . p a n c re a tic o d u o d e n a lis in fe rio r (R. a n te rio r a n d R. p o s te rio r) o f A. pancreaticoduodenalis inferior

th e A . m e s e n te ric a su p e rio r.

Colon ascendens A. colica media

A. m esen terica superior A. colica dextra A. A a. jejun ales

R. colicus R. A. caecalis

A. appendicularis A a. ileales Caecum

Appendix vermiformis

Fig. 6 .4 7

A rte r ie s o f th e je ju n u m . J e ju n u m , a n d ile u m , Ile u m ;

th e A . m e s e n te ric a s u p e rio r w h ic h d is trib u te s its b ra n c h e s (u s u a lly fo u r

v e n tra l v ie w ; C olo n tra n s v e rs u m re fle c te d s u p e rio rly , (a c c o rd in g to [1 ])

to fiv e A a. je ju n a le s a n d tw e lv e A a. ile a le s) w ith in th e m e s e n te ry o f th e

T h e in tra p e rito n e a l c o n v o lu te o f th e J e ju n u m a nd Ile u m is s u p p lie d b y

s m a ll in te s tin e (-» Fig. 6 .1 1 5 ).

Pancreas -► Spleen -» Topography -► Sections

A rte rie s o f th e large in te stin e

Colon transversum R IO LA N 's anastom osis

DRUMMOND'S anastomosis

Colon descendens Colon ascendens

A. co lic a m edia

m esen terica sup erior

m esen terica inferior A. colica dextra A. colica sinistra

R. colicus

A. caecalis

A a. sigm oid eae

sigmoideum Caecum

A. rectalis superior

Appendix vermiformis A. appendicularis

Rectum

Fig. 6 .4 8 A rte rie s o f th e la rg e in te s tin e , In te s tin u m c ra s s u m ; v e n tra l v ie w ; C olo n tra n s v e rs u m re fle c te d s u p e rio rly , (a cco rd in g to [1]) C a e c u m a n d A p p e n d ix v e r m ifo r m is : A . ile o c o lic a w it h a R. ile a lis to th e te rm in a l ile u m (a n a s to m o s e s w it h th e la s t A . ilealis) and w it h a R. c o lic u s (a n a s to m o s e s w ith th e A . co lic a d e x tra ). T h e a rte ry th e n d iv id e s in to th e A . c a e ca lis a n te rio r a n d th e A . c a e ca lis p o s te rio r o n b o th s id e s o f th e C a e cu m a nd in to th e A . a p p e n d ic u la ris w h ic h c o u rs e s in th e m e s o -a p p e n d ix to s u p p ly th e A p p e n d ix v e rm ifo rm is . C o lo n a s c e n d e n s a n d C o lo n tra n s v e rs u m : A . c o lica d e x tra and A . colica m e d ia (fro m th e A . m e s e n te ric a s u p e rio r) a n a s to m o s e w it h each o th e r. T h e A . co lic a m e d ia c o n n e c ts to th e A . co lica s in is tra (R IO L A N 's a n a s to m o s is ). A n o c c a s io n a lly e x is tin g a n a s to m o s is

w ith o n e o f th e a rc a d e s a t th e le f t c o lic fle x u re is re fe rre d to as •

D R U M M O N D 's a n a s to m o s is . C o lo n d e s c e n d e n s a n d C o lo n s ig m o id e u m : A . colica s in is tra and A a . s ig m o id e a e fro m th e A . m e s e n te ric a in fe rio r. T h e A . re c ta lis s u p e rio r a ls o d e riv e s fr o m th e A . m e s e n te ric a in fe rio r a nd s u p p lie s th e u p p e r re c tu m .

For d e v e lo p m e n ta l re a s o n s , th e le ft c o lic fle x u re is th e w a te rs h e d fo r th e n e u ro v a s c u la r s u p p ly . W ith re s p e c t to th e a rte rie s : th e s u p p ly b y th e A . m e s e n te ric a s u p e rio r fo r th e C o lo n a s c e n d e n s a n d C o lo n tra n s v e rs u m s h ifts to th e s u p p ly b y th e A . m e s e n te ric a in fe rio r fo r th e C olon d e s c e n d e n s a nd u p p e r R e c tu m .

i- Clinical R em arks-------------------------------------T h e c o n n e c tio n s b e tw e e n th e A . co lic a m e d ia a nd th e A . co lica s in is

Even th e c o m p le te occlu sio n o f o n e o f th e th re e unpaired a b d o m i

tra , c o lle c tiv e ly re fe rre d to as R IO L A N 's a n a s to m o s is , are c lin ic a lly im p o rta n t in m a lp e rfu s io n s su ch as in c a se s o f a rte rio s c le ro s is o r fo llo w in g an a rte ria l o c c lu s io n b y an e m b o lu s . S im ila r c o n n e c tio n s

nal a rte rie s (T ru n c u s c o e lia c u s , A . m e s e n te ric a s u p e rio r, a nd A. m e s e n te ric a in fe rio r) ca n la rg e ly b e c o m p e n s a te d fo r w it h o u t in te s

e x is t in th e area o f th e D u o d e n u m a n d th e R e c tu m (-* Fig. 6 .1 1 1 ).

tin a l in fa rc tio n . In te s tin a l m a ïp e rfu s io n fr e q u e n tly c a u s e s a b d o m in a l pain a fte r m e a ls (p o s tp ra n d ia l pain).

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder

Veins o f th e sm all and large in testin e Oesophagus Vv. oesophageae

V. cava inferior Vv. hepaticae

Gaster

Hepar

V. splenica [lienalis]

V. gastrica sinistra

V. portae hepatis Vv. gastricae breves

V. gastrica dextra Splen [Lien] V. cystica V. gastroomentalis sinistra Vesica biliaris [fellea]

V. m esen terica superior

V. m esen terica inferior

V. gastroomentalis dextra V. colica media Vv. pancreaticoduodenales

V. colica sinistra Colon

Duodenum V. colica Vv. jejunales; Vv. ileales V. Colon descendens

Vv. sigmoideae V. appendicularis V. rectalis superior Rectum

Fig. 6 .4 9 V e in s o f th e s m a ll in te s tin e , In te s tin u m t e n u e , a n d th e la rg e in te s tin e , In te s tin u m c ra s s u m ; v e n tra l v ie w .

B ra n c h e s o f t h e V. m e s e n te ric a s u p e rio r:

N a m e a n d c o u rs e o f th e in te s tin a l v e in s are s im ila r to th o s e o f th e ar

• •

V. g a s tro o m e n ta lis d e x tra w it h V v. p a n c re a tic o d u o d e n a le s V v. p a n c re a tic a e

te rie s . T h e v e in s e n te r o n e o f th e th re e m a in tr ib u ta rie s o f th e p o rta l v e in (V. p o rta e h e p a tis): th e V. m e s e n te ric a s u p e rio r m e rg e s w it h th e V.

• •

V v. je ju n a le s a n d ile a le s V. ile o co lica

s p le n ic a b e h in d th e p a n c re a tic h e a d to fo r m th e V. p o rta e h e p a tis . T h e V. m e s e n te ric a in fe rio r d ra in s in to th e V. s p le n ic a (7 0 % o f all ca se s) o r

• V. co lic a d e x tra • V. co lic a m e d ia B ra n c h e s o f t h e V. m e s e n te ric a in fe rio r:

in to th e V. m e s e n te ric a s u p e rio r (3 0 % ). D e v e lo p m e n ta l^ , th e le ft c o lic fle x u re is th e w a te rs h e d fo r th e n e u ro v a s c u la r s u p p ly . W ith re s p e c t to th e v e in s : fro m th e C o lo n a s c e n d e n s a nd C olo n tra n s v e rs u m v e n o u s b lo o d d ra in s in to th e V. m e s e n te ric a s u p e rio r a nd fr o m th e C olo n d e s c e n d e n s a nd th e u p p e r R e c tu m th e v e n o u s b lo o d d ra in s in to th e V. m e s e n te ric a in fe rio r.

• •

V. co lic a s in is tra V v. s ig m o id e a e

•

V. re c ta lis s u p e rio r: th is v e in has c o n n e c tio n s to th e V. re c ta lis m e dia a n d th e V. re c ta lis in fe rio r, w h ic h are trib u ta rie s o f th e V. cava in fe rio r.

i- Clinical R em arks-------------------------------------In c a se s o f h ig h b lo o d p re s s u re in th e p o rta l s y s te m (p o rta l h y p e rte n sio n ), su ch as in liv e r c irrh o s is , a n a s to m o s e s b e tw e e n th e v e n o u s

T h e y a re c lin ic a lly le s s im p o rta n t a nd are n o t, as p re v io u s ly a s s u m e d , th e c a u s e o f h a e m o rrh o id s . W h e n a p p ly in g re c ta l s u p p o s ito

s y s te m s o f th e V. p o rta e h e p a tis a nd th e V. cava (p o rto c a v a l a n a s to m o s e s ) m a y d e v e lo p ( - * Fig. 6 .7 0 ). T h e s e in c lu d e c o n n e c tio n s

ries, it is h e lp fu l t o k n o w th a t th e d ru g s are a b s o rb e d b y th e re cta l v e in s t o b y p a s s th e liv e r a n d to e n te r th e g e n e ra l c irc u la tio n via th e

b e tw e e n th e V. re c ta lis s u p e rio r a nd th e V. re c ta lis m e d ia , a nd V. re c ta lis in fe rio r, re s p e c tiv e ly , w h ic h drain in to th e V. cava in fe rio r.

V. cava in fe rio r, th u s , p re v e n tin g h e p a tic m e ta b o lis m a nd p o te n tia l d e g ra d a tio n o f th e d ru g s in th e liver.

Pancreas -► Spleen -> Topography -► Sections

Lym ph vessels o f th e in te stin e s

Truncus intestinalis

Cisterna chyli Nodi lym phoidei m esen terici superiores Trunci lum bales

Nodi lymphoidei mesocolici Nodi lymphoidei colici medii

Nodi lymphoidei colici sinistri

Nodi lymphoidei paracolici

Nodi lym phoidei m esen terici inferiores Nodi lymphoidei colici dextri

Nodi lymphoidei ileocolici Nodi lym phoidei iliaci interni

Nodi lymphoidei juxtaintestinales

Nodi lym phoidei lum bales

Nodi lym phoidei

Fig. 6 .5 0

L y m p h v es s e ls a n d re g io n a l ly m p h n o d e s o f th e s m a ll

•

F ro m th e C o lo n d e s c e n d e n s . C o lo n s ig m o id e u m , a nd p r o x im a l

in te s tin e , In te s tin u m te n u e , a n d th e la rg e in te s tin e , In te s tin u m c ra s s u m .

r e c tu m , th e ly m p h re a c h e s th e N o d i ly m p h o id e i m e s e n te ric i in ferio re s a t th e o rig in o f th e A . m e s e n te ric a in fe rio r (y e llo w ) a nd fu r th e r

T h e re s p e c tiv e g ro u p s o f ly m p h n o d e s (a to ta l o f 1 0 0 to 2 0 0 ly m p h

via th e re tro p e rito n e a l para -a o rta l ly m p h n o d e s (N odi ly m p h o id e i

n o d e s ) are c o lo u re d d iffe re n tly a c c o rd in g to th e ir d ra in a g e a rea s, (ac c o rd in g to [1])

lu m b a le s , g re y ) in to th e T ru n c i lu m b a le s (grey).

L o c a te d d ire c tly a d ja c e n t to th e s m a ll in te s tin e are th e N o d i ly m p h o id e i ju x ta in te s tin a le s , a d ja c e n t to th e large in te s tin e th e N o d i ly m p h o id e i

T h e d is ta l r e c tu m a nd th e a n a l c a n a l a ls o drain in to th e T ru n c i lu m b a

p a ra c o lici. A ft e r filtra tio n in se v e ra l s u c c e s s iv e ly m p h s ta tio n s a lo n g th e v a s c u la r a rc a d e s (e.g. N o d i ly m p h o id e i c o lic i d e x tri, co lic i m e d ii, c o lic i

iliaci in te rn i, a nd th e N o d i ly m p h o id e i in g u in a le s (pink, tu rq u o is e ) fo r th e te rm in a l s e g m e n t o f th e anal canal, re s p e c tiv e ly .

s in is tri, ile o c o lic i, m e s o c o lic i), th e ly m p h e n te rs in to t w o m a jo r d ra in a g e s y s te m s : • F ro m th e e n tire s m a ll in te s tin e as w e ll as C a e c u m , C o lo n a s c e n d e n s , a nd C o lo n tr a n s v e r s u m , th e ly m p h d ra in s in to th e N o d i ly m

D e v e lo p m e n ta l^ , th e le ft c o lic fle x u re is th e w a te rs h e d fo r th e n e u ro v a s c u la r s u p p ly . W ith re s p e c t to th e ly m p h a tic d ra in a g e : th e N o d i ly m

p h o id e i m e s e n te ric i s u p e rio re s a t th e o rig in o f th e A . m e s e n te ric a s u p e rio r a n d fu r th e r via th e T ru n c u s in te s tin a lis in to th e D u c tu s th o ra c ic u s (green).

le s . T h e fir s t ly m p h n o d e s ta tio n s , h o w e v e r, are th e N o d i ly m p h o id e i

p h o id e i m e s e n te ric i s u p e rio re s are th e re g io n a l ly m p h n o d e s fo r th e C olo n a s c e n d e n s a nd C olo n tra n s v e rs u m , w h e re a s th e N o d i ly m p h o ide i m e s e n te ric i in fe rio re s d ra in th e C olo n d e s c e n d e n s .

i-C linical R em arks-------------------------------------T h e ly m p h a tic d ra in a g e p la ys a c lin ic a lly im p o rta n t ro le in th e d ia g

C a rc in o m a s in th e C olo n d e s c e n d e n s , h o w e v e r, m e ta s ta s is e in to

n o s is o f c o lo n c a rc in o m a s s in c e th e th e ra p e u tic a p p ro a c h d e p e n d s on th e s ta g e o f th e d is e a s e (sta g in g ). L y m p h n o d e m e ta s ta s e s o f tu

th e N o d i ly m p h o id e i m e s e n te ric i in fe rio re s a lo n g th e re tro p e rito n e a l A . m e s e n te ric a in fe rio r a n d o fte n c o n n e c t to o th e r re tro p e rito n e a l

m o u rs in th e area o f th e C o lo n a s c e n d e n s o r C olo n tra n s v e rs u m are e x p e c te d to a p p e a r in th e N o d i ly m p h o id e i m e s e n te ric i s u p e rio re s .

ly m p h n o d e s .

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder -►

Innervation o f th e in te stin e s

N. splanchnicus major dexter Truncus vagalis anterior

Truncus vagalis posterior Plexus hepaticus N. splanchnicus major sinister

G anglia coeliaca

Plexus

N. splanchnicus minor Plexus splenicus G anglion m esen tericum superius

Ganglion aorticorenale Plexus renalis

Plexus intermesentericus

Plexus m esen tericus superior Plexus uretericus Truncus sympathicus G anglion m esen tericum inferius Plexus hypogastricus superior

Plexus m esen tericus inferior

N. hypogastricus dexter

B ranches of th e Plexus hypogastricus inferior to th e Co lon descendens and Co lon sigm oideum

Nn. splanchnici pelvici (S 2-4)

Plexus hypogastricus inferior

N. hypogastricus sinister

Fig. 6.51

A u to n o m ic in n e rv a tio n o f th e s m a ll in te s tin e ,

In te s tin u m te n u e , a n d la rg e in te s tin e , In te s tin u m c ra s s u m ; v e n tra l v ie w , (a c c o rd in g to [1]) T h e a u to n o m ic n e rv e s o f th e s y m p a th e tic (g ree n ) a nd p a ra s y m p a th e tic (p urp le ) n e rv o u s s y s te m g e n e ra te a p le x u s a t th e a n te rio r s id e o f th e A o rta (P le x u s a o rtic u s a b d o m in a lis ). T h e s e n e rv e fib re s c o n tin u e a lo n g th e m a jo r b ra n c h e s o f th e A o rta to re ach th e ta rg e t o rg a n s . S m a ll a nd la rg e in te s tin e s are in n e rv a te d b y fib re s d e riv e d fr o m th e p le x u s a ro u n d th e th re e m a jo r v is c e ra l b ra n c h e s o f th e A o rta (P lexus c o e lia cu s . P le x u s m e s e n te ric u s s u p e rio r a nd P le x u s m e s e n te ric u s in fe r i or). T h e p e rika rya o f th e p re g a n g lio n ic s y m p a th e tic n e u ro n s are lo c a te d in th e in te rm e d io la te ra l c e ll c o lu m n o f th e sp in a l c o rd . T h e ir a x o n s re ach th e s y m p a th e tic tru n k (T ru n cu s s y m p a th ic u s ) a nd c o u rs e w it h o u t s y n a p s in g in th e N n. s p la n c h n ic i m a jo r a n d m in o r to th e p le x u s a ro u n d

th e p o s tg a n g lio n ic n e u ro n s w ith in th e w a ll o r in th e v ic in ity o f th e ta rg e t o rg a n s . T h e in n e rv a tio n area o f th e N n. v a g i [X] e n d s in th e P lexu s m e s e n te ric u s s u p e rio r a nd , th u s , in th e area o f th e le ft c o lic fle x u re . T h e C o lo n d e s c e n d e n s is in n e rv a te d b y th e sac ra l d iv is io n o f th e p a r a s y m p a th e tic n e rv o u s s y s te m . T h e p re g a n g lio n ic p a ra s y m p a th e tic n e u ro n s are lo c a lis e d a t th e S 2 -S 4 sp in a l c o rd le ve l a n d th e n e rv e fib re s le a ve th e sp in a l n e rv e s as N n. s p la n c h n ic i p e lv ic i. T h e y are s y n a p s e d in th e g a n g lia o f th e P le x u s h y p o g a s tric u s in fe rio r in th e v ic in ity o f th e R e c tu m . T h e p o s tg a n g lio n ic n e rv e fib re s e ith e r a s c e n d to th e P lexu s m e s e n te ric u s in fe rio r (n o t s h o w n ) o r d ire c tly re ach th e C olo n d e s c e n d en s. T h e p a r a s y m p a th e tic in n e rv a tio n s tim u la te s , a n d th e s y m p a th e tic in n e rv a tio n in h ib its p e ris ta ls is a n d p e rfu s io n o f th e in te s tin e s .

th e A o rta , w h e re th e y fin a lly s y n a p s e in th e re s p e c tiv e g a n g lia (G a n g lio n c o e lia c u m . G a n g lia m e s e n te ric a s u p e riu s and in fe riu s ) to

For d e v e lo p m e n ta l re a s o n s , th e le ft c o lic fle x u re is th e w a te rs h e d fo r th e n e u ro v a s c u la r s u p p ly . W ith re s p e c t to th e a u to n o m ic in n e rv a tio n :

p o s tg a n g lio n ic n e u ro n s . A x o n s o f th e p o s tg a n g lio n ic n e u ro n s tra v e l a lo n g th e a rte rie s to re ach th e in te s tin e s . P re g a n g lio n ic p a r a s y m p a th e tic n e u ro n s o f th e N n . v a g i [X ] c o u rs e

C olo n a s c e n d e n s a nd C olo n tra n s v e rs u m are in n e rv a te d fr o m th e Ple x u s m e s e n te ric u s s u p e rio r, w h e re a s th e C o lo n d e s c e n d e n s is in n e rv a

a lo n g th e O e s o p h a g u s as T ru n c i va g a le s a n te rio r a n d p o s te rio r, pass

100

th ro u g h th e d ia p h ra g m a n d re ach th e v is c e ra l n e rv e p le x u s o f th e A o rta a b d o m in a lis . T h e y p ass th ro u g h th e g a n g lia w it h o u t s y n a p s in g to reach

te d b y th e P le x u s m e s e n te ric u s in fe rio r (cra nia l/sa cra l d iv is io n o f th e p a ra s y m p a th e tic s y s te m ).

Pancreas -♦ Spleen

Topography -► Sections

Large in testin e, im aging Flexura coli dextra

Flexura coli sinistra

Caecum Appendix vermiformis

Colon transversum Haustrae coli

Colon sigmoideum Colon descendens

Fig. 6 .5 2

L a rg e in te s tin e , In te s tin u m c ra s s u m ; ra d io g ra p h in

a n te ro p o s te rio r (AP) b e a m p ro je c tio n a fte r a p p lic a tio n o f c o n tra s t

m e d iu m a n d a ir (d o u b le c o n tra s t b a riu m e n e m a ). P o s itio n a l v a ria tio n s o f th e C o lo n tra n s v e rs u m ca n be d e te c te d (-» Fig. 6.5 3 ).

Figs. 6 .5 3 a t o d

P o s itio n a l v a r ia tio n s o f t h e tr a n s v e r s e c o lo n .

C o lo n tr a n s v e r s u m ; v e n tra l v ie w .

Fig. 6 .5 4

A s c e n d in g c o lo n . C o lo n a s c e n d e n s ; e n d o s c o p y o f th e

c o lo n (c o lo s c o p y ). In c o n tra s t to th e c irc u la r m u c o s a l fo ld s o f th e s m a ll in te s tin e , th e m u c o s a l fo ld s o f th e large in te s tin e are c re s c e n t-s h a p e d (P licae s e m ilunares).

[- Clinical R em arks-------------------------------------M a lig n a n t tu m o u rs o f th e c o lo n (c o lo n c a rc in o m a s ) are a m o n g

e n a b le th e in s p e c tio n o f th e m u c o s a b u t it a ls o a llo w s ta k in g b io p

th e m o s t c o m m o n m a lig n a n c ie s in b o th , m e n a nd w o m e n , and th e re fo re c o n trib u te s u b s ta n tia lly to th e c a u s e s o f d e a th in th e

s ie s fo r d e fin ite d ia g n o s tic s b y a p a th o lo g is t. T h e im p o rta n c e o f th e ra d io lo g ic a l c o n tra s t im a g in g has d e c lin e d . H o w e v e r, th is c o n v e n

W e s te rn w o rld . W ith p re v e n tiv e m e d ic a l c h e c k -u p s th e n u m b e r o f d e a th s c o u ld b e re d u c e d . C o lo s c o p y is re c o m m e n d e d as d ia g n o s tic

tio n a l ra d io lo g ic a l m e th o d a llo w s to o b ta in a re lia b le d ia g n o s is b a s e d on c h a ra c te ris tic a lte ra tio n s o f th e s h a p e a n d p o s itio n o f th e lu m e n

m e th o d o f c h o ic e fo r th e d e te c tio n o f c o lo n c a rc in o m a a nd th e c o s ts are c o v e re d b y th e p u b lic h e a lth s y s te m . N o t o n ly d o e s c o lo s c o p y

in c a s e s w h e re e n d o s c o p y is n o t p o s s ib le (e.g. o b s tru c tin g tu m o u rs o r d is e a s e s lo c a te d b e n e a th th e m u c o s a l lin ing ).

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines

Liver and gallbladder

P rojection o f liver and gallbladder

Pulmo

Diaphragma — H e p a r— — Gaster — Splen [Lien] — Pancréas — Duodenum — Jejunum

-------C o lo n ------------------Vesica biliaris [feliea] --------Ile u m --------------------

Appendix vermiformis-

Figs. 6 .5 5 a a n d b

P ro je c tio n o f th e v is c era o n to th e b o d y

s u rfa c e ; v e n tra l (a) a n d d o rs a l (b) v ie w s . T h e liv e r a n d g a llb la d d e r are lo c a te d in tr a p e r ito n e a lly in th e rig h t e p i g a s triu m . T h e fu n d u s o f th e g a llb la d d e r p ro je c ts o n to th e rig h t m id c la v ic u la r lin e a t th e le ve l o f rib IX. T h e le ft lo b e o f th e liv e r is lo c a te d in th e le ft E p ig a s triu m (up to th e le ft m id c la v ic u la r line) a n te rio r to th e s to m a c h . T h e p o s itio n o f th e liv e r v a rie s w it h re s p ira tio n (lo w e r w it h in s p ira tio n , h ig h e r w ith e x p ira tio n ) b e c a u s e its A re a n uda is a tta c h e d to th e dia

lu n g . B e c a u s e o f th e d o m e -s h a p e d d ia p h ra g m , th e a n te rio r a n d p o s te rio r s id e o f th e liv e r is c o v e re d in p a rt b y th e p le u ra l c a v ity (-» Fig. 6 .1 2 4 ). U p to th e m id c la v ic u la r lin e , th e in fe rio r m a rg in o f th e liv e r u s u a lly c o -lo c a te s w it h th e r ig h t in fe rio r c o s ta l m a rg in and, th u s , th e liv e r is n o t p a lp a b le . W ith an e n la rg e d lu n g , s u c h a s w ith p u lm o n a ry e m p h y s e m a in a s m o k e r, th e liv e r m a y be p a lp a b le w it h o u t b e in g e n la rg e d . T h e to p o g ra p h y o f th e liv e r is a ls o im p o rta n t fo r d ia g n o s tic p ro c e d u re s s u c h a s liv e r b io p s ie s (-» Fig. 6.7 5 ).

p h ra g m . T h e re fo re , its p o s itio n is a lso d e p e n d e n t on th e size o f th e

i- Clinical R em arks-------------------------------------A c o m p le te p h ysica l e x a m in a tio n in c lu d e s th e p a lp a tio n o f th e liv e r to d e te rm in e its size. C h a n g e s in c o n s is te n c y a n d s iz e m a y a lre a d y s u g g e s t ce rta in c o n d itio n s su ch as a fa t t y liv e r (d ia b e te s m e llitu s , a lc o h o l a b u se ), in fla m m a tio n (h e p a titis ) d u e to v ira l in fe c tio n s o r a lc o h o lis m , o r liv e r c irrh o s is as th e te rm in a l s ta g e o f a lm o s t all liv e r p a th o lo g ie s . P a lp a tio n o f th e liv e r m a rg in a lo n e is n o t s u ffic ie n t to d e te rm in e th e size o f th e live r, s in c e th e a n a to m y o f th e lu n g a n d th e

102

p o s itio n o f th e d ia p h ra g m in flu e n c e th e p o s itio n o f th e liv e r m a rg in s . T h e re fo re th e p a lp a tio n o f th e in fe rio r liv e r m a rg in d u rin g in h a la tio n is c o m p le m e n te d b y th e p e rc u s s io n o f th e liv e r t o d e te rm in e th e u p p e r m a rg in o f th e liv e r u n d e rn e a th th e rib c a g e . T h e c ra n io c a u d a l d ia m e te r o f a n o rm a l liv e r s h o u ld n o t e x c e e d 12 c m in th e m id c la v ic u la r line.

Pancreas -♦ Spleen

Topography -► Sections

D e ve lo p m e n t o f th e liver and gallbladder

H epar Dorsal pancreatic bud Ductus choledochus [biliaris] Duodenum

V esica biliaris [fellea]

Dorsal mesentery

Gaster Ren Mesogastrium dorsale O m entu m m inus

H epar

Splen [Lien]

Truncus coeliacus

Ventral and dorsal pancreatic buds Lig. falc ifo rm e V. umbilicalis

Figs. 6 .5 6 a to c

D e v e lo p m e n ta l s ta g e s o f th e live r, H e p a r, a n d

t h e g a llb la d d e r. V e s ic a b ilia ris , in w e e k s 4 t o 5 . [20]

in w h ic h is le ts o f h a e m a to p o ie s is d e v e lo p . T h is w a y , th e c o n n e c tiv e tis s u e c o m p o n e n ts a nd th e in tra h e p a tic b lo o d v e s s e ls (s in u s o id s ) in te r

T h e e p ith e lia l tis s u e s o f liv e r a nd g a llb la d d e r d e riv e fr o m th e e n d o d e rm o f th e p rim o rd ia l g u t a t th e le v e l o f th e fu tu r e D u o d e n u m . In w e e k 4 (fro m d ay 2 2 o n) th e e n d o d e rm fo r m s a th ic k e n in g (h e p a tic d iv e r tic u

m in g le w it h th e liv e r p rim o rd iu m . T h e liv e r th e n g r o w s in to th e M e s o g a s triu m v e n tra le (c) and, th u s , s p lits it in to a M e s o h e p a tic u m v e n tra le a nd a M e s o h e p a tic u m d o rs a le (-» Fig. 6 .1 ). T h e M e s o h e p a tic u m v e n

lu m ) w h ic h d iv id e s in to a s u p e rio r liv e r p rim o rd iu m a nd an in fe rio r p rim o rd iu m fo r th e b ile s y s te m (a a nd b). T h e e p ith e liu m o f th e liv e r p ri

tra le d e v e lo p s in to th e Lig. fa lc ifo r m e h e p a tis a n d c o n n e c ts to th e

m o rd iu m g ro w s in to th e c o n n e c tiv e tis s u e o f th e S e p tu m tra n s v e rs u m

v e n tra l b o d y w a ll. T h e M e s o h e p a tic u m d o rs a le b e c o m e s th e O m e n t u m m in u s c o n n e c tin g th e liv e r w it h th e s to m a c h a nd th e D u o d e n u m .

103

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder -►

Liver, o v e rv ie w

Lig. coronarium

Diaphragma

Lig. triangulare sinistrum Lig. triangulare dextrum

Lobus hepatis sinister, Facies d iaphragm atica

Lobus hepatis dexter, Facies d iaphragm atica Lig. falciforme

Lig. teres hepatis Vesica biliaris [fellea] Margo inferior

V. cava inferior

Appendix fibrosa hepatis Impressio suprarenalis

Impressio oesophagea Lobus cau datus

Lig. coronarium Impressio gastrica V. portae hepatis

Impressio renalis

A. hepatica propria

Ductus choledochus [biliaris]

Lobus hepatis sinister

A. lobi caudati Impressio duodenalis

P orta hepatis A. cystica

Margo inferior

Impressio colica Fissura ligamenti teretis Lobus h ep atis d ex ter

6 .5 8 Incisura ligamenti Lig. teres hepatis

Fig. 6 .5 7 a n d Fig. 6 .5 8

Liver, H e p a r; v e n tra l {-» Fig. 6 .5 7 ) a nd d o rs a l

ca ud a l (-» Fig. 6 .5 8 ) v ie w s . F o r e x p la n a tio n s

104

-*•

F ig u re 6 .5 9 .

Lobus quadratu s

Vesica biliaris [fellea]

Pancreas -► Spleen -► Topography -► Sections

Liver, o v e rv ie w

falciforme

Lobus hepatis dexter, Tunica serosa

Lobus h ep atis sinister, Tunica serosa

Lig. coronarium

Appendix fibrosa hepatis

Peritoneum V. cava inferior cavae)

Fig. 6 .5 9

Liver, H e p a r; cranial v ie w .

T h e liv e r is th e la rg e s t g la n d (1 2 0 0 -1 8 0 0 g) a n d th e m a in m e ta b o lic o r g an o f th e b od y. T h e F a cies d ia p h ra g m a tic a is a d ja c e n t to th e d ia p h ra g m a nd th e F a cie s v is c e ra lis w ith th e a n te rio r lo w e r m a rg in (M a rg o

to th e P orta h e p a tis w h ic h h a rb o u rs th e v a s c u la r s tr u c tu re s to a n d fro m th e liv e r (V. p o rta e h e p a tis , A . h e p a tic a p ro p ria , D u c tu s h e p a tic u s c o m m u n is ). C ran ially, th e Lig. v e n o s u m (re m n a n t o f th e p re n a ta l D u c tu s

in fe rio r) p o in ts to w a rd s th e a b d o m in a l v is c e ra (-» Figs. 6 .5 7 a n d 6.5 8 ). T h e F a cies d ia p h r a g m a tic a is p a rtly a d h e re n t to th e d ia p h ra g m and

v e n o s u s ) is s h o w n . O n th e r ig h t s id e o f th e P orta h e p a tis (h ilu m o f th e liver), th e V. cava in fe rio r is lo c a te d in a s u p e rio r g ro o v e a n d th e g a llb la d d e r (V esica b ilia ris ) is e m b e d d e d in th e in fe rio r Fossa v e s ic a e biliaris.

lacks th e p e rito n e a l lin in g in th is area (A re a n u d a ). T h e liv e r is d iv id e d in a la rg e r rig h t a nd a s m a lle r le ft lo b e (Lo bus d e x te r a nd L o b u s s in is

T h e Lig. te re s h e p a tis , L ig . v e n o s u m , V. cava in fe rio r, a nd g a llb la d d e r d e lin e a te t w o re c ta n g u la r a rea s on b o th s id e s o f th e P orta h e p a tis a t

te r) w h ic h are s e p a ra te d v e n tra lly b y th e L ig . fa lc ifo rm e . T h e la tte r c o n tin u e s a s Lig. c o ro n a riu m w h ic h th e n b e c o m e s th e rig h t a n d le ft Lig.

th e in fe rio r s id e o f th e rig h t h e p a tic lo b e , th e v e n tra l L o b u s q u a d ra tu s a nd th e d o rs a l L o bus c a u d a tu s . T h e liv e r is n o t c o v e re d b y p e rito n e u m

tria n g u la re c o n n e c tin g to th e d ia p h ra g m . T h e Lig. tria n g u la re s in is tru m c o n tin u e s in to th e fib ro u s A p p e n d ix fib ro s a h e p a tis . T h e fre e m a rg in o f

in fo u r la rg e r a reas: A re a n ud a , P orta h e p a tis , b e d o f th e g a llb la d d e r, a nd g ro o v e o f th e V. cava in fe rio r.

th e Lig. fa lc ifo rm e c o n ta in s th e L ig . te re s h e p a tis (re m n a n t o f th e p re nata l V. u m b ilic a lis ). B o th lig a m e n ts c o n n e c t to th e v e n tra l a b d o m in a l

In v iv o , th e liv e r is d e fo rm a b le a nd a d ju s ts to th e sh a p e o f th e s u rro u n d ing o rg a n s . In fix e d c o n d itio n , a d ja c e n t o rg a n s c a u s e im p re s s io n s

w a ll. A t th e Facies v is c e ra lis th e F issu ra lig a m e n ti te re tis h e p a tis c o n tin u e s

w h ic h are fix a tio n a rtifa c ts w it h o u t fu r th e r re le v a n c e , a lth o u g h th e y p ro v id e p o s itio n a l in fo rm a tio n a b o u t th e live r.

105

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder -►

S tru ctu re o f th e liver Lig. coronarium Area nuda

Lig. coronarium Vv. hep aticae

triad

Fig. 6 .6 0 Facies visceralis

Liver, H e p a r; s a g itta l s e c tio n th ro u g h th e rig h t lo b e o f th e

live r. T h e v a s c u la r a nd b ile d u c t s tru c tu re s e n te rin g th e liv e r a t th e h ilu m (V. p o rta e h e p a tis , A . h e p a tic a p ro p ria , D u c tu s h e p a tic u s c o m m u n is ) are s u rro u n d e d b y c o n n e c tiv e tis s u e . T h e y b ra n c h w ith in th e p a re n c h y m a

Facies diaphragmatica, Pars anterior

o f th e live r, a n d c re a te th e G L IS S O N 's tria d (p ortal tria d ) in th e p o rta l tra c ts (p o rta l canals) H Fig. 6.6 1 ). T h e liv e r v e in s (Vv. h e p a tic a e ) a nd th e ir trib u ta rie s w h ic h d ra in th e b lo o d fr o m th e liv e r in to th e V. cava in fe rio r c o u rs e s e p a ra te ly fro m th e v e s s e ls o f th e G L IS S O N 's tria d .

Margo inferior

Fig. 6.61

S tr u c tu r e o f th e live r, H e p a r; m ic ro s c o p ic v ie w . [24]

T h e s tru c tu ra l u n it o f th e liv e r p a re n c h y m a is th e h e p a tic lo b u le w h ic h c o n s is ts o f ra d ia lly o rie n te d tra b e c u la e o f h e p a to c y te s . T h e c la ssica l

c e n tre o f th e h e p a tic lo b u le a nd c o lle c ts th e b lo o d fro m th e liv e r s in u s o id s w h ic h o rig in a lly d e riv e s th e a rte rie s a nd v e in s a t th e p e rip h e ry o f th e lo b u le . T h e c e n trilo b u la r v e n u le th e n d ra in s in to th e Vv. s u b lo b u la -

a lm o s t h e xa g o n a l h e p a tic lo b u le is s u rro u n d e d b y p o rta l tr a c ts a t th re e to s ix c o rn e rs . T h re e s tr u c tu re s re fe rre d to c o lle c tiv e ly as

re s , w h ic h are b ra n c h e s o f th e V v. h e p a tic a e . T h e s lo w radial b lo o d flo w in th e s in u s o id s e n a b le s h e p a to c y te s to a b s o rb n u trie n ts a n d m e ta b o li

G L IS S O N 's tr ia d (p o rta l tr ia d ) are a lw a y s fo u n d in th e p o rta l tra c t, e m b e d d e d in c o n n e c tiv e tis s u e (A. a n d V. in te rlo b u la ris , D u c tu s b ilife r

te s a nd to s e c re te s y n th e s is e d p ro te in s as fo r e x a m p le p la s m a p ro te -

in te rlo b u la ris ). T h e c e n trilo b u la r v e n u le (V. c e n tra lis ) is lo c a te d in th e

i- Clinical R em arks-------------------------------------T h e b lo o d flo w in th e h e p a tic lo b u le s is e x tre m e ly im p o rta n t fo r th e liv e r fu n c tio n . In liv e r c irrh o s is , th e s tru c tu re o f th e h e p a tic lo b u le s is a lte re d b y n o d u la r c o n n e c tiv e tis s u e re m o d e llin g o f th e p a re n c h y m a w h ic h c o m p ro m is e s th e b lo o d flo w . T h e h ig h p a re n c h y m a l re s is

106

ta n c e in th e liv e r re s u lts in an in c re a s e d b lo o d p re s s u re in th e p o rta l v e in (p o rta l h y p e rte n s io n ). T h is c o n d itio n m a y re -c a n a lis e o r o p e n p o rto c a v a l a n a s to m o s e s (-» Fig. 6.7 0 ).

Pancreas -♦ Spleen

Topography -► Sections

S e g m e n ts o f th e liver

Fig. 6 .6 2 a n d Fig. 6 .6 3

S e g m e n ts o f th e liv e r, H e p a r; v e n tra l

(-» Fig. 6 .6 2 ) a n d d o rs a l (-» Fig. 6 .6 3 ) v ie w s . In d ivid u a l liv e r s e g m e n ts are c o lo u re d d iffe re n tly . T h e t h r e e a lm o s t v e rtic a lly

o rie n te d

liv e r

v e in s

(Vv.

liv e r v e in . T h e S e g m e n tu m m e d ia le is lo c a te d b e tw e e n th e Lig. fa lc i fo r m e a nd th e g a llb la d d e r a t th e le ve l o f th e m id d le liv e r v e in . T o th e rig h t s id e , th e S e g m e n tu m a n te riu s a nd th e S e g m e n tu m p o s te riu s

h e p a tic a e ,

fo llo w a n d a re s e p a ra te d b y th e rig h t liv e r v e in , w h ic h is n o t v is ib le on

-» Fig. 6 .6 4 ) d iv id e th e liv e r in to fo u r a d ja c e n t s e g m e n ts . T h e S e g m e n tu m la te ra le c o rre s p o n d s to th e a n a to m ic a l le ft lo b e o f th e liv e r a nd is

th e liv e r s u rfa c e . T h e s tru c tu re s o f th e p o rta l tr ia d o rg a n is e th e s e liv e r s e g m e n ts in to e ig h t fu n c tio n a l a n d c lin ic a lly im p o rta n t liv e r s e g

b o rd e re d b y th e L ig . fa lc ifo rm e h e p a tis , w h ic h is a d ja c e n t to th e le ft

m e n ts (-» Fig. 6 .6 4 ) w h ic h are in d ic a te d h e re b y d iffe r e n t c o lo u ra tio n s .

107

Viscera of the A b d o m e n

Developm ent

Stomach

Intestines

Liver and gallbladder -►

S e g m e n ts o f th e liver

V. cava inferior V. hepatica intermedia

V. hepatica sinistra

V. hepatica dextra

Ductus hepaticus communis Lig. falciforme hepatis Lig. teres hepatis Vesica biliaris [fellea]

V. cava inferior A. hepatica propria Ductus choledochus V. portae hepatis Ductus cysticus

I II III IVa IVb V VI VII VIII

Lig. hepatoduodenale

Lobus caudatus Segmentum laterale superius Segmentum laterale inferius Segmentum mediale superius Segmentum mediale inferius Segmentum anterius inferius Segmentum posterius inferius Segmentum posterius superius Segmentum anterius superius

Fig. 6 .6 4

S c h e m a tic illu s tr a tio n o f th e liv e r s e g m e n ts a n d th e ir

re la tio n s t o th e in tra h e p a tic b lo o d v es s e ls a n d th e b ile du cts; v e n tra l v ie w , (a c c o rd in g to [1])

It is o f fu n c tio n a l im p o rta n c e th a t s e g m e n ts I t o IV are s u p p lie d by b ra n c h e s o f th e le ft p o rta l tria d a n d can be c o m b in e d to a fu n c tio n a l le ft

T h e liv e r is d iv id e d in to e ig h t fu n c tio n a l s e g m e n ts w h ic h are s u p p lie d

liv e r lo b e . T h e s e g m e n ts V to V III are s u p p lie d b y b ra n c h e s o f th e rig h t p o rta l tria d a nd re p re s e n t th e fu n c tio n a l r ig h t liv e r lo b e . A s a

b y o n e b ra n c h o f th e p o rta l tria d (V. p o rta e h e p a tis , A . h e p a tic a p rop ria , D u c tu s h e p a tic u s c o m m u n is ) e a ch a nd th e re fo re are fu n c tio n a lly in d e

re s u lt, th e b o rd e r b e tw e e n th e fu n c tio n a l rig h t a nd le ft liv e r lo b e s is lo c a te d in th e s a g itta l p la n e b e tw e e n th e V. cava in fe rio r a nd g a llb la d d e r

p e n d e n t. T w o s e g m e n ts each are c o m b in e d b y th e v e rtic a lly o rie n te d th re e liv e r v e in s to fo u r a d ja c e n t liv e r s e g m e n ts (-» Figs. 6 .6 2 a n d 6.6 3 ).

a n d n o t a t th e le ve l o f th e Lig. fa lc ifo rm e h e p a tis .

i- Clinical R em arks--------------------------------------

108

In v is c e ra l s u rg e ry , th e liv e r s e g m e n ts are c lin ic a lly o f g re a t re le

in d iffe r e n t p a rts o f th e liv e r w it h o u t c o m p ro m is in g th e liv e r fu n c tio n

v a n c e . T h e e x is te n c e o f liv e r s e g m e n ts a llo w s th e re s e c tio n o f in d iv id u a l s e g m e n ts a n d th e ir s u p p ly in g v e s s e ls w it h o u t e x te n s iv e

a s a w h o le . T h e lig a tio n o f th e in d iv id u a l b ra n c h e s o f th e s u p p ly in g v e s s e ls a n d th e s u b s e q u e n t d is c o lo u ra tio n o f th e re s p e c tiv e s e g

b lo o d lo ss. L o ca lise d liv e r p a th o lo g ie s , s u c h as s o lita ry liv e r m é ta s ta sé s, ca n b e tre a te d b y th e su rg ic a l re s e c tio n o f in d iv id u a l s e g m e n ts

m e n t d u e to lack o f p e rfu s io n e n a b le s th e s u rg e o n to id e n tify each s e g m e n t.

Pancreas -► Spleen -► Topography -► Sections

S e g m e n ts o f th e liver

Lobus dexter Lobus sinister

Lobus caudatus

Fig. 6 .6 5 t o Fig. 6 .6 7

S e g m e n ts o f th e live r, H e p a r; v e n tra l

{-» Fig. 6 .6 5 ), d o rs o c a u d a l (-* Fig. 6 .6 6 ), a n d d o rs o c ra n ia l (-» Fig. 6.67) v ie w , (a c c o rd in g to [1]) B e c a u se o f th e ir clin ic a l re le v a n c e fo r v is c e ra l s u rg e ry , th e liv e r s e g m e n ts are m a rk e d in th is fig u re w ith R o m a n n u m e ra ls (-» Fig. 6 .6 4 ) on th e liv e r s u rfa c e . T h e L o b u s c a u d a tu s re p re s e n ts s e g m e n t I a t th e un d e rs id e o f th e a n a to m ic a l rig h t lo b e o f th e live r. H o w e v e r, th is s e g m e n t fu n c tio n a lly b e lo n g s to th e le ft lo b e o f th e liver.

109

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder -►

A rte rie s o f th e liver and gallbladder

=50

Lobus hepatis sinister Ductus hepaticus communis

Lig. teres hepatis

A. h ep atica propria Truncus coeliacus A. gastrica sinistra

Vesica biliaris [fellea]

Gaster A. cystica

Splen [Lien]

Ductus cysticus

A. h ep atica com m unis

V. portae hepatis A. splenica [lienalis] Ductus choledochus [biliaris] A. gastroomentalis sinistra

A. gastrica dextra Duodenum

A. mesenterica superior A. gastroomentalis dextra

«10 %

«3%

A. mesenterica superior A. hepatica communis

A. hepatica propria, R. dexter

=12 %

=70%

Figs. 6 .6 8 a t o f

A rte r ie s o f th e live r, H e p a r, a n d t h e g a llb la d d e r.

V e s ic a b ilia ris . T h e liv e r is s u p p lie d b y th e A . h e p a tic a p ro p ria d e riv e d fr o m th e A. h e p a tica c o m m u n is , a d ire c t a rte ria l b ra n ch o f th e T ru n c u s c o e lia c u s .

c o n trib u tio n o f th e A . m e s e n te ric a s u p e rio r to th e b lo o d s u p p ly o f th e rig h t liv e r lobe

A ft e r g iv in g o f f th e A . g a s tric a d e x tra , th e A . h e p a tic a p ro p ria c o u rs e s w ith in th e L ig . h e p a to d u o d e n a le to g e th e r w it h th e V. p o rta e h e p a tis

c d

o rig in o f th e A . h e p a tic a c o m m u n is b y th e A . m e s e n te ric a s u p e rio r b lo o d s u p p ly o f th e le ft liv e r lo b e b y th e A . g a s tric a s in is tra

a nd th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ) to th e h ilu m o f th e live r. H ere , th is a rte ry d iv id e s in to th e R. d e x te r a nd th e R. s in is te r to

c o n trib u tio n o f a b ra n c h o f th e A . g a s tric a s in is tra to th e b lo o d s u p p ly o f th e le ft liv e r lo b e in a d d itio n to th e R. s in is te r o f th e

th e liv e r lo b e s. T h e R. d e x te r g iv e s rise to th e A . c y s tic a to th e g a llb la d d e r. In 1 0 - 2 0 % o f all ca se s, th e A . m e s e n te ric a s u p e rio r c o n trib u te s to th e b lo o d s u p p ly o f th e rig h t liv e r lob e , a n d th e A . g a s tric a s in is tra c o n trib u te s to th e s u p p ly o f th e le ft liv e r lob e .

110

V a ria tio n s o f th e b lo o d s u p p ly o f th e liver: a te x tb o o k case

A . h e p a tic a p rop ria b lo o d s u p p ly o f th e le s s e r c u rv a tu re o f th e s to m a c h b y an a c c e s s o ry b ra n c h o f th e A . h e p a tic a p rop ria

Pancreas -♦ Spleen

Topography -► Sections

Veins o f th e liver and gallbladder

Oesophagus

Vv. oesophageae

V. cava inferior Vv. hep aticae G aster

Hepar

V. splenica [lienalis]

V. g astrica sinistra

V. po rtae hepatis Vv. gastricae breves

V. g astrica dextra Splen [Lien] V. cystica V. gastroomentalis sinistra Vesica biliaris [fellea]

V. m esen terica sup erior

V. m esen terica inferior

V. gastroomentalis dextra V. colica media Vv. pancreaticoduodenales

V. colica sinistra Colon ascendens

Duodenum V. colica dextra Vv. jejunales; Vv. ileales V. ileocolica Colon descendens

Vv. sigmoideae V. appendicularis V. rectalis superior Rectum

Fig. 6 .6 9 V e in s o f th e live r, H e p a r, a n d th e g a llb la d d e r. V esica b ilia ris ; v e n tra l v ie w .

B ra n c h e s o f t h e V. m e s e n te ric a s u p e rio r (c o lle c tin g b lo o d fr o m p a rts

T h e liv e r h as an in c o m in g a nd an o u tg o in g v e n o u s s y s te m . T h e p o rta l

o f th e s to m a c h a n d P a n cre a s, fro m th e e n tire s m a ll in te s tin e , th e C olon a s c e n d e n s , a n d C olo n tra n s v e rs u m ):

v e in (V. p o rta e h e p a tis ) c o lle c ts th e n u trie n t-ric h b lo o d fr o m th e u n p a ire d a b d o m in a l o rg a n s (s to m a c h , in te s tin e s . P a n cre a s, sp le e n ) and

• •

V. g a s tro o m e n ta lis d e x tra w it h Vv. p a n c re a tic o d u o d e n a le s V v. p a n c re a tic a e (fro m th e p a n c re a tic h ead a n d body)

fe e d s th is b lo o d , to g e th e r w it h th e a rte ria l b lo o d fr o m th e A . h e p a tic a c o m m u n is , in to th e s in u s o id s o f th e liv e r lo b u le s . T h re e liv e r v e in s (Vv. h e p a tic a e , -» Fig. 6 .6 0 ) tra n s p o rt th e b lo o d fr o m th e liv e r to th e V. cava

• • •

V v. je ju n a le s a nd ile a le s V. ile o c o lic a V. c o lic a d e x tra

in fe rio r. T h e p o rta l v e in h as th re e m a in trib u ta rie s : B e h in d th e h ead o f th e Pan

• V. c o lic a m e d ia B ra n c h e s o f t h e V. m e s e n te ric a in fe r io r (c o lle c tin g b lo o d fr o m th e

c re a s , th e V. m e s e n te ric a s u p e rio r m e rg e s w ith th e V. s p le n ic a to fo rm th e V. p o rta e h e p a tis . In m o s t c a se s (70 % ), th e V. m e s e n te ric a in fe rio r

C olo n d e s c e n d e n s , a n d th e u p p e r R e c tu m ): • V. c o lic a s in is tra

d ra in s in to th e V. s p le n ic a ; in th e re m a in in g c a s e s (3 0 % ) it d ra in s in to th e V. m e s e n te ric a su p e rio r.

• •

V v. s ig m o id e a e V. re c ta lis s u p e rio r: th e v e in a n a s to m o s e s w it h th e V. re c ta lis m e d ia a nd th e V. re c ta lis in fe rio r, w h ic h drain in to th e V. cava in fe rio r.

B ra n c h e s o f th e V. s p le n ic a (c o lle c tin g b lo o d fr o m th e s p le e n and fr o m p a rts o f th e s to m a c h a nd Pancreas):

In a d d itio n , th e re are v e in s w h ic h d ra in d ire c tly in to t h e p o rta l v e in

• •

Vv. g a s tric a e b re v e s V. g a s tro o m e n ta lis s in is tra

o n c e th e m a in v e n o u s b ra n c h e s have m e rg e d : • V. c y s tic a (fro m th e g a llb la d d e r)

•

Vv. p a n c re a tic a e (fro m th e p a n c re a tic ta il a n d body)

•

V v. p a ra u m b ilic a le s (via v e in s in th e Lig. te re s h e p a tis fr o m th e ab d o m in a l w a ll a ro u n d th e U m b ilic u s )

•

V v. g a s tric a e d e x tra a n d s in is tra (fro m th e le s s e r c u rv a tu re o f th e s to m a c h )

111

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder -►

Portocaval ana stom ose s V. hem iazygos

V. azygos

(Plexus venosus submucosus)

Vv. o es o phageae

V. phrenica inferior V. hepatica

V. g astrica sinistra

V. po rtae hepatis V. splenica [lienalis]

V. renalis sinistra V. mesenterica superior V. testicu laris/o varica

V. m esen terica inferior V. paraum bilicalis

V. cava inferior V. colica sinistra V. epigastrica superficialis

V. iliaca communis V. sigmoidea

V. rectalis sup erior

V. epigastrica inferior V. iliaca interna

Vv. rectales inferiores

Fig. 6 .7 0 P o rto c a v a l a n a s to m o s e s (c o n n e c tio n s b e t w e e n th e p o rta l v e in a n d th e V. c a v a s u p e r io r /in fe rio r ). T rib u ta rie s to th e V.

•

e p ig a s tric a e s u p e rio r a n d in fe rio r; s u p e rfic ia l: V. th o ra c o e p ig a s tric a a nd V. e p ig a s tric a s u p e rfic ia lis ) to th e V. cava s u p e rio r a nd in fe rio r.

cava s u p e rio r/in fe rio r (blue), trib u ta rie s to th e V. p o rta e h e p a tis (purple). T h e re are fo u r p o s s ib le c o lla te ra l c irc u la tio n s via p o rto c a v a l a n a s to m o s e s (m a rk e d b y b la c k c ircle s):

•

V v. g a s tric a e d e x tra e a nd s in is tra e via o e s o p h a g e a l v e in s a nd v e in s o f th e a zyg o s s y s te m to th e V. cava s u p e rio r. T h is m a y re s u lt in

V v. p a ra u m b ilic a le s via v e in s o f th e v e n tra l a b d o m in a l w a ll (d e e p : Vv.

D ila tio n o f th e s u p e rfic ia l v e in s m a y a p p e a r as C a p u t m e d u s a e . V. re c ta lis s u p e rio r via v e in s o f th e d is ta l re c tu m a n d anal canal and via th e V. iliaca in te rn a to th e V. cava in fe rio r re tro p e rito n e a l a n a s to m o s e s via th e V. m e s e n te ric a in fe rio r t o th e V. te s tic u la ris /o v a ric a w it h c o n n e c tio n to th e V. cava in fe rio r

th e d ila tio n o f s u b m u c o s a l v e in s o f th e O e s o p h a g u s (o e s o p h a g e a l v a ric e s ).

i- Clinical R em arks--------------------------------------

112

In cre a se d b lo o d p re s s u re in th e p o rta l s y s te m (p o rta l h y p e r te n sion ; e .g . in liv e r c irrh o s is ) m a y c a u se th e d ila tio n o r th e o p e n in g o f

m o n c a u s e o f d e a th in p a tie n ts w it h liv e r c irrh o s is . T h e c o n n e c tio n s to s u p e rfic ia l v e in s o f th e v e n tra l a b d o m in a l w a ll a re o n ly o f d ia g

th e a b o v e m e n tio n e d v e n o u s c o n n e c tio n s to th e s y s te m ic v e n o u s s y s te m (p o rto c a v a l a n a s to m o s e s ). C lin ic a lly im p o rta n t are th e c o n

n o s tic v a lu e . A lth o u g h th e C a p u t m e d u s a e is rare, th e a pp e a ra n c e is s o c h a ra c te ris tic th a t a liv e r c irrh o s is c a n n o t be o v e rlo o k e d . T h e

n e c tio n s to th e o e s o p h a g e a l v e in s b e c a u s e ru p tu re o f o e s o p h a g e a l v a ric e s m a y re s u lt in life -th re a te n in g h a e m o rr h a g e , th e m o s t c o m

a n a s to m o s e s to th e re tro p e rito n e a l v e in s a n d to th e v e in s o f th e in fe rio r re c tu m a nd anal canal are c lin ic a lly n o t im p o rta n t.

Pancreas -♦ Spleen

Topography -► Sections

Lym ph vessels o f th e liver and gallbladder

Nodi lymphoidei phrenici superiores

Nodi lymphoidei phrenici inferiores

Cran ial lym ph drain ag e*

S ubperitoneal I)'m ph vessel system

C audal lym ph drainage* Intrap arenchym al lym ph vessel system Nodi lymphoidei coeliaci

Nodus lymphoideus cysticus Nodi lymphoidei hepatici

Fig. 6.71 L y m p h v es s e ls a n d ly m p h n o d e s o f th e liv e r a n d b ile d u c t s y s te m . T h e liv e r has t w o ly m p h v e s s e l s y s te m s : • •

th e s u b p e rito n e a l s y s te m a t th e s u rfa c e o f th e live r th e in tra p a re n c h y m a l s y s te m a lo n g s id e th e s tru c tu re s in th e p o rta l

tria d to th e h ilu m o f th e live r W ith re s p e c t t o th e re g io n a l ly m p h n o d e s , th e re are t w o m a jo r ly m p h d r a in a g e ro u te s : •

•

in c a u d a l d ire c tio n to th e h ilu m o f th e liv e r (m o s t im p o rta n t) via

d ia s tin a le s a n te rio re s a n d p o s te rio re s w h ic h d ra in in to th e T ru n c i b ro n c h o m e d ia s tin a le s ; u s in g th is d ra in a g e p a th w a y , c a rc in o m a s o f th e liv e r m a y a ls o m e ta s ta s is e in to th o ra c ic ly m p h n o d e s . T h e re are t w o m in o r ly m p h d ra in a g e ro u te : • to th e a n te rio r a b d o m in a l w a ll via th e ly m p h v e s s e ls in th e Lig. te re s •

h e p a tis to th e in g u in a l a nd a x illa ry ly m p h n o d e s to th e s to m a c h a nd P a ncreas fr o m th e le ft lo b e o f th e liv e r

T h e g a llb la d d e r u s u a lly has its o w n N o d u s ly m p h o id e u s c y s tic u s in th e area o f th e n e c k , w h ic h d ra in s in to th e ly m p h n o d e s a t th e h ilu m o f th e

th e N o d i ly m p h o id e i h e p a tic i a t th e h ilu m o f th e liv e r (-► Fig. 6.17) a nd fr o m th e re via th e N o d i ly m p h o id e i c o e lia c i to th e T ru n c u s in

liv e r (in th e caudal d ire c tio n ).

te s tin a lis in c ra n ia l d ire c tio n p a s s in g th e d ia p h r a g m via th e N o d i ly m p h o

• T h e a rro w s d e p ic t th e d ire c tio n o f ly m p h d ra in a g e fr o m th e p a re n c h y m a via th e c ra nia l o r c a ud a l ro u te .

ide i p h re n ic i in fe rio re s a nd s u p e rio re s in to th e N o d i ly m p h o id e i m e -

113

Viscera of the A b d o m e n

Developm ent

Stomach -* Intestines

Liver and gallbladder -»

Liver, im aging

V. hepatica sinistra V. hepatica intermedia

V. hepatica dextra

V. cava inferior

Diaphragma Pulmo dexter, Lobus inferior

Fig. 6 .7 2

C o n flu e n c e o f th e liv e r v e in s , V v . h e p a tic a e , w it h th e

V. c a v a in fe rio r; u ltra s o u n d im a g e ; ca ud a l v ie w . * a b d o m in a l w a ll

V. portae hepatis, R. dexter V. portae hepatis V. portae hepatis, R. sinister R. anterior V. portae hepatis, R. dexter Pars abdominalis aortae

R. posterior

Pars lumbalis diaphragmatis

V. cava inferior

Pars costalis diaphragmatis

Fig. 6 .7 3

L ive r, H e p a r, V. p o rta e h e p a tis ; d e m o n s tr a tio n o f th e

b ra n c h in g o f th e p o rta l v e in ; u ltra s o u n d im a g e ; ca ud a l v ie w . * a b d o m in a l w a ll

Clinical R em arks-----------------------------------------------------------------------------------------------------------

114

U ltra s o n ic e x a m in a tio n (so n o g ra p h y) o f th e liv e r is a s ta n d a rd d i

ty liv e r d e g e n e ra tio n in h e p a titis o r liv e r c irrh o s is . Focal tu m o u rs o r

a g n o s tic to o l u s e d b y s p e c ia lis ts in in te rn a l m e d ic in e a nd b y ra d io lo g is ts . S o n o g ra p h y e n a b le s a n o n in v a s iv e in v e s tig a tio n o f th e liv e r

c y s ts are a ls o d e te c ta b le . S u b s e q u e n tly , liv e r b io p s ie s (-» Fig. 6.75) o r a la p a ro s c o p ic in v e s tig a tio n o f th e liv e r (-► Fig. 6 .7 6 ) m a y b e p e r

p a re n c h y m a a n d a llo w s th e d e te c tio n o f s tru c tu ra l c h a n g e s , fo r e x a m p le b y th e local o r g en e ra l in cre a se d e c h o g e n ic ity in c a s e s o f a fa t-

fo rm e d to re ach a d ia g n o s is .

Pancreas -► Spleen -> Topography -► Sections

Liver biopsy

Costa V Diaphragma

Hepar, Lobus sinister

Hepar, Lobus dexter

Lig. teres hepatis

* Vesica biliaris [fellea]

Fig. 6 .7 4

P ro je c tio n o f t h e live r, H e p a r, a n d t h e g a llb la d d e r.

V e s ic a b ilia ris , o n to t h e v e n tra l a b d o m in a l w a ll in m id -re s p ira tio n p o s itio n . * p o s itio n o f th e n e e d le d u rin g liv e r p u n c tu re

Pulmo

M. intercostalis externus M. intercostalis internus

Fig. 6 .7 5

L a y e rs o f th e c h e s t w a ll a n d th e live r, H e p a r; fro n ta l

s e c tio n ; liv e r p u n c tu re b io p sy.

fo rm e d a t th e s u p e rio r c o s ta l m a rg in . T h e p e rito n e a l lin in g c o v e rin g th e liv e r c a p s u le re c e iv e s s e n s o ry in n e rv a tio n b y th e N. p h re n ic u s (C 3 -

T h e u ltra s o u n d -g u id e d p u n c tu re is p e rfo rm e d in e x p ira tio n th ro u g h o n e o f th e lo w e r in te rc o s ta l sp a ce s. S in ce th e liv e r is p a rtly c o v e re d b y th e

C5) fr o m th e P le x u s c e rv ic a lis . T h is e x p la in s w h y p a tie n ts o fte n e x p e ri e n c e re fe rre d p a in in th e area o f th e rig h t s h o u ld e r.

p le u ra l c a v ity th is a c c e s s re d u c e s th e ris k o f a p n e u m o th o ra x . T o sp are th e in te rc o s ta l n e u ro v a s c u la r s tru c tu re s , th e p u n c tu re is a lw a y s p e r

p o s itio n o f th e n e e d le d u rin g liv e r p u n c tu re

I- Clinical R em arks----------------------------------------------------------------------------------------------------------A liv e r p u n c tu re b io p s y is p e rfo rm e d t o d e te rm in e th e n a tu re o f re s p e c tiv e ly . O n ly th e b io p s y e n a b le s th e d e fin itiv e d ia g n o s is b y a s u s p ic io u s tu m o u r s , o r th e s ta g e o f a h e p a titis o r liv e r c irrh o s is , p a th o lo g is t.

Viscera of the A b d o m e n

Developm ent -► Stomach

Intestines -► Liver and gallbladder -►

Liver and gallbladder, im aging

Fundus vesicae biliaris

Colon transversum Hepar, Lobus dexter

Omentum majus

Fig. 6 .7 6

Liver, H e p a r, a n d g a llb la d d e r. V e s ic a b ilia ris ;

la p a ro s c o p ic im a g e ; o b liq u e ca ud a l v ie w fr o m th e le f t s ide .

A.; V. cystica Fundus vesicae biliaris Lobus hepatis sinister

Corpus vesicae biliaris

Peritoneum parietale

Collum vesicae biliaris Lobus hepatis dexter Duodenum, Pars superior

Fundus gastricus Flexura coli dextra Omentum majus

Fig. 6 .7 7

Liver, H e p a r, a n d g a llb la d d e r. V e s ic a b ilia ris ;

la p a ro s c o p ic im a g e ; v e n tra l v ie w .

Clinical Remarks

116

L a p a ro s c o p y is th e fin a l o p p o r tu n ity to in s p e c t th e liv e r o r to ta k e

lig h t s o u rc e s , c a m e ra , o r b io p s y in s tru m e n ts , th e e n tire a b d o m in a l

b io p s y m a te ria l p rio r to th e s u rg ica l o p e n in g o f th e a b d o m in a l w a ll. U s in g a la p a ro s c o p e a n d o n e o r t w o a d d itio n a l e n tra n c e p o rts fo r

c a v ity can be in s p e c te d a nd b io p s ie s ca n be ta k e n u n d e r v is u a l c o n tro l.

Pancreas -► Spleen -> Topography -► Sections

S tru ctu re o f th e gallbladder and e xtra hepa tic bile ducts Ductus hepaticus dexter

Ductus hepaticus sinister

Collum vesicae biliaris

Ductus h ep aticus com m unis Ductus cysticus

Plicae mucosae

Plica spiralis

Tunica mucosa

Ductus choledochus [biliaris] Tunica serosa

Fundus vesicae biliaris

Fig. 6 .7 8

G a llb la d d e r, V e s ic a b ilia ris , a n d e x tr a h e p a tic b ile du cts;

v e n tra l v ie w . Ductus pancreaticus

T h e g a llb la d d e r u s u a lly h o ld s a p p ro x im a te ly 4 0 - 7 0 m l o f b ile . It c o n s is ts o f a b o d y (C o rp u s v e s ic a e b iliaris) w it h a fu n d u s a n d a n e c k p a rt (C o llu m v e s ic a e biliaris). A sp ira l fo ld (Plica s p ira lis H EISTER ) a t th e te rm in a l e nd o f th e n e c k c lo s e s th e o p e n in g o f th e e x c re to ry c y s tic d u c t (D u c tu s c y s tic u s ), w h ic h th e n fu s e s w it h th e c o m m o n h e p a tic d u c t (D u c tu s h e p a tic u s c o m m u n is ) to fo r m th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ).

Papilla duodeni major

Du ctu s hepaticus com m unis Plica spiralis

Du ctu s cysticus

Collum vesicae biliaris

Duodenum, Pars superior

Duodenum, Pars descendens

Corpus vesicae

Fundus vesicae biliaris

Ductus pancreaticus accessorius

Duodenum, Pars ascendens Papilla duodeni minor

Papilla duodeni m ajo r

Duodenum, Pars horizontalis

Fig. 6 .7 9 G a llb la d d e r, V e s ic a b ilia ris , e x tr a h e p a tic b ile d u c ts and d u o d e n u m , D u o d e n u m ; v e n tra l v ie w .

w it h th e D u c tu s p a n c re a tic u s to fo r m th e A m p u lla h e p a to p a n c re a tic a , w h ic h e n te rs th e D u o d e n u m a t th e Papilla d u o d e n i m a jo r (Papilla V A TE -

T h e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ) is u s u a lly 6 c m lo n g and 0 .4 - 0 .9 c m in d ia m e te r. It c o u rs e s w ith in th e Lig. h e p a to d u o d e n a le

R l). A t its d is ta l e nd , s m o o th m u s c le s o f th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ) c re a te th e M . s p h in c te r d u c tu s c h o le d o c h i. T h e in fe rio r

v e n tra l to th e p o rta l v e in , th e n ru n s b e h in d th e Pars s u p e rio r o f th e D u o d e n u m to tra ve rse th e head o f th e Pancreas and reach th e d esce n d in g

p a rt th e re o f, a ls o re fe rre d to as M . s p h in c te r a m p u lla e (O D D I), e n c o m p a s s e s th e a m p u lla a nd th e e n tra n c e o f th e D u o d e n u m .

p a rt o f th e D u o d e n u m . In 6 0 % o f all ca se s, th e c o m m o n b ile d u c t fu s e s

Viscera of the A b d o m e n

Developm ent -» Stomach

Intestines

Liver and gallbladder -►

C A LO T 's triangle

Vesica biliaris [fellea] Ductus h ep aticus com m unis

A. cystica

A. h ep atica propria Trigonum cholecysto hepaticum [CA LO T's triang le]

V. portae hepatis

A. hepatica communis

Du ctu s cysticus

A. gastroduodenalis

Ductus choledochus [biliaris]

Fig. 6 .8 0

C A L O T 's tr ia n g le , T rig o n u m c h o le c y s to h e p a tic u m ;

ca ud a l v ie w , (a c c o rd in g t o [1])

re fe rre d to a s C A L O T 's tria n g le . In 7 5 % o f all c a s e s , th e A . c y s tic a o ri g in a te s in th is tria n g le fr o m th e R. d e x te r o f th e A . h e p a tic a p ro p ria and

T h e D u c tu s c y s tic u s , th e D u c tu s h e p a tic u s c o m m u n is a nd th e in fe rio r area o f th e liv e r to g e th e r fo r m th e T rig o n u m c h o le c y s to h e p a tic u m , a lso

c o u rs e s p o s te rio rly th ro u g h th is tria n g le to re ach th e D u c tu s c y s tic u s a n d th e n e c k o f th e g a llb la d d e r.

Lig. falciforme Vesica biliaris [fellea]

Lobus hepatis dexter

Ductus cysticus Ductus

Lobus hepatis sinister

Lig. hepatoduodenale

Duodenum

Ductus choledochus [biliaris] Papilla duodeni major

Figs. 6 .8 1 a t o c V a ria tio n s o f th e b ile d u c ts re g a rd in g th e c o n flu e n c e o f th e D u c tu s h e p a tic u s c o m m u n is a n d D u c tu s c ys ticu s. a b c

h ig h ju n c tio n lo w ju n c tio n lo w ju n c tio n w it h c ro s s in g

i- Clinical R em arks-------------------------------------T h e C A L O T 's tria n g le is an im p o rta n t la n d m a rk d u rin g th e s u rg ic a l r e m o v a l o f th e g a llb la d d e r. P rior to re m o v a l o f th e g a llb la d d e r, all s tru c tu re s are id e n tifie d b e fo re th e A . c y s tic a a nd th e D u c tu s c y s ti

118

c u s are lig a te d . T h is w a y , th e ris k o f an a c c id e n ta l lig a tio n o f an th e D u c tu s c h o le d o c h u s w it h s u b s e q u e n t s ta s is o f th e b ile (c h o le s ta s is ) is re d u c e d .

Pancreas -► Spleen -► Topography -► Sections

G allbladder and e xtra hepa tic bile ducts, im aging

Fig. 6 .8 2

G a llb la d d e r, V e s ic a b ilia ris , e x tr a h e p a tic b ile d u cts ;

ra d io g ra p h in a n te ro p o s te rio r (AP) b e a m p ro je c tio n a fte r a p p lic a tio n o f c o n tra s t m e d iu m ; p a tie n t in u p rig h t p o s itio n ; v e n tra l v ie w .

Ductus hepaticus sinister

Ductus hepaticus dexter

Ductus hepaticus communis

Ductus cysticus

Vesica biliaris [fellea]

Ductus choledochus [biliaris]

Duodenum

Fig. 6 .8 3

G a llb la d d e r, V e s ic a b ilia ris , as w e ll as in tra - a n d

e x tr a h e p a tic b ile d u cts ; ra d io g ra p h in a n te ro p o s te rio r (AP) b e a m p ro je c tio n a fte r a p p lic a tio n o f c o n tra s t m e d iu m ; p a tie n t in u p rig h t p o s itio n ; v e n tra l v ie w .

Clinical Remarks R a d io g ra p h y a fte r in tra v e n o u s a p p lic a tio n o f c o n tra s t m e d iu m al lo w s th e v is u a lis a tio n o f th e g a llb la d d e r a n d b ile d u c ts , in c lu d in g th e d e te c tio n o f n o n c a lc ifie d b ile c o n c re m e n ts . M a lig n a n t tu m o u rs o f

th e b ile d u c ts (c h o la n g io c a rc in o m a s ) o r o f th e P a n cre a s (p a n c re a tic c a rc in o m a s ) m a y c a u s e c h o le s ta s is w h ic h a p p e a rs as d ila tio n o f th e b ile d u c ts .

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder

P rojection o f th e pancreas

Duodenum, Pars superior

Duodenum, Pars descendens Caput pancreatis

Cauda pancreatis Corpus pancreatis Flexura duodenojejunalis Duodenum, Pars ascendens

Duodenum, Pars horizontalis

Fig. 6 .8 4

P ro je c tio n o f th e p a n c re a s . P a n c re a s , a n d th e

d u o d e n u m . D u o d e n u m , o n th e v e n tra l a b d o m in a l w a ll. T h e P a n cre a s is in a s e c o n d a ry r e tr o p e r ito n e a l p o s itio n a nd p ro je c ts ro u g h ly o n to th e 1st o r 2 nd lu m b a r v e rte b ra . T h e h ead (C ap u t p a n c re a tis )

Figs. 6 .8 5 a a n d b

is a d ja c e n t to th e Pars d e s c e n d e n s o f th e D u o d e n u m a nd c o n tin u e s as p a n c re a tic b o d y (C o rp u s p a n c re a tis ) w h ic h c ro s s e s th e v e rte b ra l c o lu m n to c o n tin u e as p a n c re a tic ta il (C auda p a n c e a tis ) to th e h ilu m o f th e s p le e n .

P ro je c tio n o f th e v is c era o n to th e b o d y

s u rfa c e ; v e n tra l (a) a n d d o rs a l (b) v ie w s .

i- Clinical R em arks----------------------------------------------------------------------------------------------------------T h e in fla m m a tio n o f th e P a n c re a s (p a n c re a titis ) is m o s t c o m m o n ly c a u s e d b y an o b s tru c tio n o f th e d u o d e n a l pap illa b y a g a lls to n e

120

w it h re s u ltin g s ta s is o f b ile o r b y c h ro n ic a lc o h o l a b u s e . It fr e q u e n tly c a u s e s a b e lt-lik e ra d ia tin g a b d o m in a l pain.

Pancreas -► Spleen -* Topography -► Sections

D e ve lo p m e n t o f th e pancreas

Figs. 6 .8 6 a to f D e v e lo p m e n t o f th e p a n c re a s , P a n c re a s , in w e e k s 5 t o 8. [20] a to c Dorsal pancreatic bud Hepar----Ductus choledochus [biliaris]

Sectional plane in d

Vesica biliaris [fellea]

v e n tra l v ie w

d to f s c h e m a tic c ro s s -s e c tio n s th ro u g h to D u o d e n u m a nd P a ncreas p rim o rd iu m ; ro ta tio n s m a rk e d b y a rro w s O n d a y 2 8 , a v e n tra l a nd a d o rs a l p a n c re a tic b u d e m e rg e fr o m th e e nd o d e rm o f th e p rim o rd ia l g u t (a, d) in fe rio r to th e p rim o rd iu m o f liv e r a nd g a llb la d d e r a t th e le ve l o f th e fu tu r e D u o d e n u m . T h e v e n tra l p an c re a tic b u d m o v e s d o rs a lly (b,e) and, in w e e k s 6 to 7, fu s e s w it h th e d o rs a l p a n c re a tic b ud , in c lu d in g th e ir re s p e c tiv e e x c re to ry d u c ts (d, f). T h e e x c re to ry p a n c re a tic d u c t is fo rm e d b y th e u n io n o f th e d is ta l d o rs a l p a n c re a tic d u c t a n d th e v e n tra l p a n c re a tic d u c t a nd e n te rs th e Papilla d u o d e n i m a jo r. T h e p ro x im a l p o rtio n o f th e d o rs a l p a n c re a tic d u c t d e

Ventral pancreatic

v e lo p s (6 5 % o f all ca se s) in to th e a c c e s s o ry p a n c re a tic d u c t w h ic h jo in s th e D u o d e n u m a t th e Papilla d u o d e n i m in o r.

Sectional

Caput pancreatis

Ventral

Caput

Cauda pancreatis

uctus pancreaticu

Ductus choledochus [biliaris]

Corpus pancreatis Ductus choledochus [biliaris]

Dorsal pancreatic bud

C o nfluen ce of Du ctu s choledochus and Ductus p an creaticus

Ductus pancreaticus accessorius

r—Clinical R em arks-------------------------------------If th e fu s io n o f b o th p a n c re a tic b u d s is in c o m p le te (P a n c re a s d iv is u m ) th e d o rs a l p a n c re a tic d u c t m a y c o n s titu te th e m a in e x c re to ry

c irc u la r g la n d a ro u n d th e D u o d e n u m (a n n u la r p a n c re a s ), ile u s w ith

d u c t (1 0 % o f all ca se s) w h ic h m a y c a u s e re p e titiv e p a n c re a titis d ue to a s ta s is o f s e c re tio n s . If th e p a n c re a tic p a re n c h y m a g ro w s as a

c a s e s , th e D u o d e n u m is m o b ilis e d , c u t, a nd p o s itio n e d n e x t to th e P a n cre a s o r s u rg ic a lly b y p a s s e d .

v o m itin g m a y o c c u r w h ic h is p a rtic u la rly e v id e n t in n e w b o rn s . In th e s e

121

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and G allbladder

S tru ctu re and topographical relatio nships o f th e pancreas

V. cava inferior A. hepatica propria V. portae hepatis

Pars thoracica aortae

Glandula suprarenalis

Diaphragma Glandula suprarenalis

A.; V. splenica [lienalis]

Ductus hepaticus communis Ductus cysticus C auda pancreatis

Truncus coeliacus

C a p u t pancreatis

Duodenum, Pars descendens

Duodenum, Pars horizontal is

A. hepatica communis

C o rpus pancreatis

Jejunum

V. m esen terica superior

Fig. 6 .8 7

R e tr o p e r ito n e a l o rg a n s o f th e e p ig a s triu m : p a n c re a s .

P a n c re a s , d u o d e n u m . D u o d e n u m , a n d o n b o th s id e s k id n e y , R en, a n d a d re n a l g la n d , G la n d u la s u p ra re n a lis ; v e n tra l v ie w . T h e P a n cre a s is in a s e c o n d a ry r e tr o p e r ito n e a l p o s itio n . T h e head (C a p u t p a n cre a tis) is a d ja c e n t to th e Pars d e s c e n d e n s o f th e D u o d e n u m a n d h as a d o rs a l u n c in a te p ro c e s s (P roc. u n c in a tu s ) w h ic h e m b ra c e s th e A . a n d V. m e s e n te ric a s u p e rio r. C au d a lly, th e Pars h o riz o n ta lis o f th e D u o d e n u m is a d ja ce n t. T o th e le ft s id e , th e p a n c re a tic h ead c o n tin u e s a s th e p a n c re a tic b o d y (C o rp u s p a n c re a tis ) w h ic h tra v e rs e s th e v e rte b ra l c o lu m n . T h e s u b s e

T h e P a n cre a s has an a n te rio r a n d a p o s te rio r s u rfa c e (Fa cies a n te rio r a nd F a cies p o s te rio r) w h ic h are s e p a ra te d b y th e d ull u p p e r a nd lo w e r b o rd e r (M a rg o s u p e rio r a nd M a rg o in fe rio r). T h e a n te rio r a s p e c t o f th e P a n cre a s is c o v e re d b y p a rie ta l p e rito n e u m a nd fo r m s th e p o s te rio r w a ll o f th e B u rsa o m e n ta lis . T h e p o s te rio r a s p e c t o f th e P a n cre a s is fu s e d to th e o rig in a l p a rie ta l p e rito n e u m o f th e p o s te rio r a b d o m in a l w a ll b e c a u s e th e P a n cre a s w a s re p o s itio n e d in to th e re tro p e rito n e a l sp ace d u rin g its d e v e lo p m e n t. T h e fu s e d area a p p e a rs as a fa s c ia d u rin g d is s e c tio n .

q u e n t p a n c re a tic ta il (C auda p a n cre a tis) p a s s e s o v e r th e le f t k id n e y to re ach th e h ilu m o f th e s p le e n .

i- Clinical R em arks-------------------------------------T h e c lo s e to p o g ra p h ic a l re la tio n s h ip o f th e p a n c re a tic h ead w ith th e A . a nd V. m e s e n te ric a s u p e rio r a n d th e p o rta l v e in im p o s e s th e risk o f in ju ry to th e s e v e s s e ls d u rin g e n d o s c o p ic m a n ip u la tio n of th e P a p illa d u o d e n i m a jo r. D a m a g e to th e s e s tru c tu re s m a y o c c u r

122

d u rin g e n d o s c o p ic p ro c e d u re s w h e n re m o v in g a b ile c o n c re m e n t o r d u rin g a p p lic a tio n o f c o n tra s t m e d iu m fo r an e n d o s c o p ic re tro g ra d e c h o la n g io p a n c re a to g ra p h y (ERCP) to v is u a lis e th e b ile a nd p a n c re a tic d u c ts . In ca se o f in ju ry e m e rg e n c y su rgica l tr e a tm e n t is re q u ire d .

Pancreas -► Spleen -» Topography -► Sections

S tru ctu re o f th e pancreas

Duodenum, Pars superior V. portae hepatis V. splenica [lienalis]

Ductus hepaticus communis Ductus cysticus

Du ctu s ch o ledo chus [biliaris] Corpus pancreatis

Ductus pancreaticus

Duodenum, Pars descendens V. m esen terica sup erior

C a p u t p an creatis

A. m esen terica sup erior Proc. uncinatus

Duodenum, Pars horizontalis

Fig. 6 .8 8

P a n c re a s , P a n c re a s , a n d d u o d e n u m . D u o d e n u m ; dorsa l

v ie w . T h e fig u re illu s tra te s th e p a n c re a tic h ead (C ap u t p a n c re a tis ) lo c a te d in th e C -sha p e d Pars d e s c e n d e n s o f th e d u o d e n u m w h e re it is o b liq u e ly

p ie rc e d b y th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ) in its c o u rs e to th e P apilla d u o d e n i m a jo r. D o rs a lly , th e u n c in a te p ro c e s s (P roc. u n c in a tu s ) o f th e p a n c re a tic h e a d e m b ra c e s th e A . a n d V. m e s e n te ric a s u p e ri-

Insula pancreatica Acini pancreatici

Ductus excretorius

Fig. 6 .8 9

S tr u c tu r e o f th e p a n c re a s . P a n c rea s ; m ic ro s c o p ic v ie w .

[26]

T h e e n d o c rin e p a rt c o n s is ts o f th e is le ts o f L A N G E R H A N S (In su la e p a n c re a tic a e ) a n d is e m b e d d e d w ith in th e p a re n c h y m a o f th e e x o c rin e

T h e p a n cre a s is a m ix e d e x o c rin e a n d e n d o c rin e g la n d . In th e acin i, th e e x o c rin e p a rt p ro d u c e s d ig e s tiv e e n z y m e s w h ic h are d e liv e re d a s in a c tiv e p re c u rs o rs via th e d u c t s y s te m to re ach th e lu m e n o f th e in te s tin e .

g la n d , p a rtic u la rly in th e p a n c re a tic ta il. B e s id e s o th e r h o rm o n e s , th e is le ts p ro d u c e in s u lin a nd g lu c a g o n w h ic h are s e c re te d in to th e b lo o d a nd s e rv e th e re g u la tio n o f th e b lo o d g lu c o s e leve l.

i- Clinical R em arks-------------------------------------T h e fu n c tio n o f th e P a n cre a s e x p la in s w h y tis s u e d a m a g e (n e c ro

re s u lt in d ig e s tiv e p ro b le m s a nd fa tty s to o ls a nd m a y in c a s e s o f

s is) in th e p a n c re a tic p a re n c h y m a has e x o c rin e a n d e n d o c rin e c o n s e q u e n c e s ; in fla m m a to ry d is e a s e s (p a n c re a titis ) fo r e x a m p le , w ill

s e v e re tis s u e lo s s ( 8 0 -9 0 % ) a ls o c a u s e d ia b e te s m e llitu s d u e to th e in s u ffic ie n t in s u lin p ro d u c tio n .

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder -►

E xcretory ducts o f th e pancreas

Canalis pyloricus M. sphincter pyloricus Corpus pancreatis

Ductus choledochus [biliaris]

Cauda pancreatis

Du ctu s p an creaticus accessorius

Papilla duodeni m inor Ductus choledochus [biliaris] Duodenum, Pars descendens

Proc. uncinatus

Plica longitudinaiis duodeni Flexura duodenojejunalis Papilla duodeni m ajor

Plicae circulares

Duodenum, Pars ascendens

Caput pancreatis Duodenum, Pars horizontalis

Fig. 6 .9 0

E x c re to ry d u c t s y s te m o f th e p a n c re a s . P a ncreas;

v e n tra l v ie w ; D u c tu s p a n c re a tic u s a fte r p a rtia l re s e c tio n o f th e D u o d e n u m a n d th e v e n tra l P ancreas. T h e m a in e x c re to ry d u c t (D u c tu s p a n c re a tic u s [d u c t o f W IR S U N G ]) fu s e s w it h th e te rm in a l s e g m e n t o f th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ) in 6 0 % o f all c a se s to fo r m th e A m p u lla h e p a to p a n c re a tic a .

T h e la tte r e n te rs th e Pars d e s c e n d e n s o f th e D u o d e n u m a t th e Papilla d u o d e n i m a jo r (papilla o f V A TE R ). D e v e lo p m e n ta l^ (-* Fig. 6 .8 6 ), an a c c e s s o ry d u c t (D u c tu s p a n c re a tic u s a c c e s s o riu s [S A N T O R IN I'S d u c t]) e x is ts in 6 5 % o f all c a s e s w h ic h o p e n s in to th e D u o d e n u m 2 c m p ro x i m a l to th e P apilla d u o d e n i m in o r.

Ductus choledochus [biliaris] Duodenum

Ductus pancreaticus Ampulla hepatopancreatica Pancreas

Papilla duodeni major

Ductus pancreaticus accessorius

Papilla duodeni minor

Figs. 6 .9 1 a t o f

V a ria tio n s o f th e ju n c tio n o f th e D u c tu s

p a n c re a tic u s a n d D u c tu s c h o le d o c h u s . a lo n g c o m m o n p o rtio n b

a m p u lla ry d ila tio n o f th e te rm in a l p a rt (6 0 %

c s h o rt c o m m o n p o rtio n d s e p a ra te e n tra n c e e c o m m o n e n tra n c e w ith s e p ta te d

o f all ca se s)

com m on duct

f a c c e s s o ry d u c t (D u c tu s p a n c re a tic u s a c c e s s o riu s , 6 5 % o f all ca ses)

i- Clinical R em arks-------------------------------------T h e v a ria tio n s in th e c o n flu e n c e o f th e e x c re to ry p a n c re a tic d u c ts

a u to d ig e s tio n o f th e g la n d b y p re m a tu re ly a c tiv a te d e n z y m e s o f th e

a nd th e b ile d u c ts in flu e n c e th e c o u rs e o f p a n c re a tic dise a s es . B e s id e s a lc o h o l a b u se , an o b s tru c tiv e b ile c o n c re m e n t in th e Pa pilla d u o d e n i m a jo r is th e m o s t c o m m o n c a u s e fo r in fla m m a to ry

e x o c rin e P a n cre a s. In th e c a s e s o f o b s tru c tio n o f th e pap illa o f V A TER , a s e p a ra te D u c tu s p a n c re a tic u s a c c e s s o riu s m a y a llo w s u ffi

c o n d itio n s o f th e P a n cre a s (p a n c re a titis ). T h e m a in risk h e re is th e

124

c ie n t s e c re tio n and, th u s , p re v e n t a p a n c re a titis .

Pancreas -► Spleen -» Topography -► Sections

A rte rie s o f th e pancreas

Truncus coeliacus A. hepatica A. hepatica propria

A. gastrica sinistra

A. gastroduodenalis A. p an creatico d u o d en alis superior

A. pan creaticod uoden alis su p erio r posterior A. gastroomentalis dextra

A. pan creaticod uoden alis sup erior an terior

pan creatica inferior

A. pan creatica dorsalis

A. pancreaticoduodenalis inferior

pan creaticod uoden alis inferior R. posterior

Fig. 6 .9 2

A rte rie s o f th e p a n c re a s . P a n c rea s ; s c h e m a tic

illu s tra tio n , (a c c o rd in g t o [1]) T h e P a n cre a s is s u p p lie d b y t w o s e p a ra te a rte r ia l s y s te m s fo r th e p a n c re a tic h ea d , a nd th e p a n c re a tic b o d y a nd ta il, re s p e c tiv e ly .

A. mesenterica superior

b o d y a n d ta il: Rr. p a n c re a tic i fr o m th e A . s p le n ic a w h ic h g iv e ris e to an A . p a n c re a tic a d o rs a lis b e h in d th e P a n cre a s a nd an A . p a n c re a tic a in fe rio r a t th e in fe rio r b o rd e r o f th e gla n d . T h is e x te n s iv e p e rfu s io n o f th e g la n d m a y e x p la in w h y in fa rc tio n o f th e

h e a d : d o u b le a rte ria l a rc h e s fr o m th e A a. p a n c re a tic o d u o d e n a le s s u p e rio re s a n te rio r a nd p o s te rio r (fro m th e A . g a s tro d u o d e n a lis ) and

P a ncreas is rare. T h e v e in s o f th e P a ncreas c o rre s p o n d to th e a rte rie s a nd d ra in via th e

fr o m th e A . p a n c re a tic o d u o d e n a lis in fe rio r w it h a R. a n te rio r a n d a R. p o s te rio r (fro m th e A . m e s e n te ric a s u p e rio r).

V. m e s e n te ric a s u p e rio r a n d th e V. s p le n ic a (-* Fig. 6.6 9 ).

in to th e

p o rta l v e in

125

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder

Lym ph vessels o f th e pancreas

Nodi lymphoidei coeliaci

Nodi lymphoidei splenici

Nodi lymphoidei hepatici

Nodi lymphoidei pancreatici superiores

Nodi lymphoidei pancreatici inferiores

Nodi lymphoidei mesenterici superiores

Nodi lymphoidei pancreaticoduodenales

Fig. 6 .9 3 L y m p h a tic d r a in a g e p a th w a y s o f th e p a n c re a s . P a n c rea s ; v e n tra l v ie w .

b o d y : N o d i ly m p h o id e i p a n c re a tic i s u p e rio re s a nd in fe rio re s a lo n g th e A . a nd V. s p le n ic a ; fr o m th e re to th e N o d i ly m p h o id e i c o e lia c i a nd to th e N o d i ly m p h o id e i m e s e n te ric i s u p e rio re s . T h e re are a lso

T h e d is tin c t p a rts o f th e p a n cre a s have s e p a ra te re g io n a l ly m p h n o d e s , h e a d : N o d i ly m p h o id e i p a n c re a tic o d u o d e n a le s a n te rio re s a n d p o s te rio re s a lo n g th e id e n tic a lly n a m e d a rte rie s (Aa. p a n c re a tic o d u o d e

•

c o n n e c tio n s to th e re tro p e rito n e a l N o d i ly m p h o id e i lu m b a le s . t a il s e g m e n t: N o d i ly m p h o id e i s p le n ic i

n a le s s u p e rio re s a n te rio r a n d p o s te rio r), th e n via N o d i ly m p h o id e i h e p a tic i to th e N o d i ly m p h o id e i co e lia c i o r d ire c tly to th e N o d i ly m p h o id e i m e s e n te ric i s u p e rio re s a nd fin a lly t o th e T ru n c u s in te s tin a lis

i- Clinical R em arks----------------------------------------------------------------------------------------------------------T h e d iv e rs e ly m p h a tic d ra in a g e p a th w a y s e xp la in w h y in c a s e s o f p a n c re a tic c a rc in o m a u su a lly e x te n s iv e ly m p h n o d e m é ta s ta s é s

126

e x is t a t th e tim e o f d ia g n o s is . S in c e th e s e m é ta s ta s é s c a n n o t be c o m p le te ly re m o v e d , c u ra tiv e s u rg e ry is n o t p o s s ib le .

Pancreas -► Spleen -» Topography -► Sections

Pancreas, im aging r V. portae hepatis, R. sinister Hepar, Lobus sinister

1 V. I

A. mesenterica superior

Lig. teres hepatis

A. splenica [lienalis]

Corpus pancreatis V. portae hepatis Hepar; Caput pancreatis

Corpus pancreatis V. splenica [lienalis] V. renalis sinistra V. cava inferior Cauda pancreatis

Pars abdominalis aortae

Ren sinister

Vertebra lumbalis I

Fig. 6 .9 4 P a n c re a s , P a n c rea s ; u ltra s o u n d im a g e ; o b liq u e ca ud a l v ie w in d e e p in s p ira tio n .

T h e u ltra s o n ic e x a m in a tio n o f th e P a n cre a s fr e q u e n tly is u n s a tis fa c to ry as th e re tro p e rito n e a l P a n cre a s is u s u a lly o b s c u re d b y a ir-fille d b o w e ls *

a b d o m in a l w a ll

Ductus pancreaticus; Cauda pancreatis

Ductus hepaticus communis Ductus cysticus

Jejunum Vesica biliaris

Ductus choledochus [biliaris] Ampulla hepatopancreatica

Duodenum, Pars descendens Ductus pancreaticus

Fig. 6 .9 5 P a n c re a s , P a n c re a s , a n d b ile d u c ts ; e n d o s c o p ic r e tr o g ra d e c h o la n g io p a n c re a to g r a p h y (ER CP); v e n tra l v ie w .

th e P a n cre a s a n d th e D u c tu s c h o le d o c h u s w e r e fille d w it h c o n tra s t m e d iu m fr o m th e Papilla d u o d e n i m a jo r via an e n d o s c o p e .

T o v is u a lis e th e d u c t s y s te m s in th e ra d io g ra p h , th e e x c re to ry d u c t o f

Clinical Remarks For th e im a g in g o f th e P a n c re a s u ltra s o u n d is p e rfo rm e d in itia lly to d e te c t a p o te n tia l s w e llin g o f th e o rg a n as an in d ic a tio n fo r p a n c re a titis . In c a se s o f a n o n -c o n c lu s iv e u ltra s o u n d im a g e , c o m p u te r to m o g ra p h y is p e rfo rm e d . W ith ERCP th e d ia g n o s is o f a Pancreas

d iv is u m a s p o te n tia l re a s o n fo r re c u rre n t p a n c re a titis is p o s s ib le . C o n tra s t fillin g d e fe c ts o f th e p a n c re a tic d u c t m a y in d ic a te a p an c re a tic c a rc in o m a .

Viscera of the A b d o m e n

Developm ent -► Stomach -+ Intestines

Liver and gallbladder -►

P rojection o f th e spleen

6 .9 6 a

6 .9 6 b

Pulmo

Cor

Diaphragma

Hepar Gaster

Fig. 6 .9 6 a n d Fig. 6 .9 7

Splen [Lien]

P ro je c tio n o f th e v is c era o n to t h e b o d y

s u rfa c e ; v e n tra l (-► Fig. 6 .9 6 a) a n d d o rs a l (-» Fig. 6 .9 6 b ) v ie w s , and v ie w fr o m th e le ft s id e (-► Fig. 6.9 7 ). T h e sp le e n is lo c a te d in tra p e r ito n e a lly in th e le f t e p ig a s triu m . Its lo n g itu d in a l a x is p ro je c ts o n to rib X. A n o rm a l-s iz e d sp le e n is n o t p alp a b le b e y o n d th e c o s ta l m a rg in . D u e t o its large c o n ta c t area w it h th e d ia p h ra g m , th e p o s itio n o f th e s p le e n is d e p e n d e n t on re s p ira tio n . T h e s p le e n lie s in th e s o -ca lle d s p le n ic n ic h e w h ic h is c o n fin e d in te rio rly b y th e Lig. p h re n ic o c o lic u m b e tw e e n th e le ft c o lic fle x u re a nd d ia p h ra g m (-» Fig. 6 .1 0 2 ).

128

Colon

Intestinum tenue

Pancreas -► Spleen -» Topography -► Sections

S tru ctu re o f th e spleen

Margo superior

V. splenica [lienalis]

Facies visceralis, Facies colica

A. splenica [lienalis]

Hilum splenicum

Facies visceralis, Facies gastrica

Lig. splenorenale Lig. gastrosplenicum

Extremitas anterior

Extremitas posterior

Facies visceralis, Facies renalis

inferior Margo superior

Facies d iaphragm atica

Extremitas anterior Extremitas posterior

Margo inferior

Fig. 6 .9 8 a n d Fig. 6 .9 9

S p le e n , S p le n [L ie n ]; m e d ia l v e n tra l

or) s h o w s in d e n ta tio n s , w h e re a s th e in fe rio r b o rd e r (M a rg o in fe rio r) is

(-» Fig. 6 .9 8 ) a nd la te ra l cranial ( - * Fig. 6 .9 9 ) v ie w s . T h e s p le e n is a s e c o n d a ry ly m p h a tic o rg a n a nd p la ys a ro le in th e im m u n e s y s te m as w e ll a s in filte r in g o f th e b lo o d . T h e s p le e n w e ig h s 1 5 0 g, is 11 c m lo n g , 7 c m w id e a n d 4 c m h ig h . Its c o n v e x sid e , Facies

ra th e r s m o o th . T h e b lo o d v e s s e ls e n te r a nd e x it a t th e s p le n ic h ilu m (H ilu m s p le n ic u m ). T h e b ra n c h in g p a tte rn o f th e b lo o d v e s s e ls re fle c ts th e s e g m e n ta tio n o f th e s p le e n , a lth o u g h th e s e g m e n ts can n o t be id e n tifie d a t th e s u rfa c e . T h e s p le e n is a n c h o re d to th e s u rro u n d in g s b y

d ia p h ra g m a tic a , is a d ja c e n t to th e d ia p h ra g m , its c o n c a v e sid e , Facies v is c e ra lis , is fa c in g th e a b d o m in a l v is c e ra , e s p e c ia lly th e le f t k id n e y , th e

tw o p e r ito n e a l d u p lic a tu re s , b o th o f w h ic h in s e rt a t th e s p le n ic h ilu m . T h e Lig. g a s tro s p le n ic u m c o n n e c ts th e s p le e n to th e s to m a c h a n d c o n

le ft c o lic fle x u re , a nd th e s to m a c h . T h e s u p e rio r b o rd e r (M a rg o s u p e ri

tin u e s a s Lig. s p le n o re n a le to th e p o s te rio r w a ll o f th e tru n k .

Facies diaphragmatica Tunica serosa; Tunica fibrosa Facies renalis T rabeculae splenicae

Pulpa splenica

Fig. 6 .1 0 0

S p le e n , S p le n [L ie n ]; c ro s s -s e c tio n th ro u g h th e h ilu m ;

m e d ia l c ra nia l v ie w . T h e s p le e n is c o v e re d b y a fir m c a p s u le w h ic h p ro je c ts tra b e c u la tio n s o f c o n n e c tiv e tis s u e to w a r d s th e c e n tre o f th e p a re n c h y m a (Pulpa s p le nica). E m b e d d e d w ith in th e s e tra b e c u la e are th e la rg e r b ra n c h e s o f th e V. splenica

A . a n d V. s p le n ic a . T h e s p le n ic p u lp c o n s is ts o f th e b lo o d -fille d re d p u lp a n d d is s e m in a te d " w h i t e " n o d u le s w h ic h are c o lle c tiv e ly re fe rre d to as A. splenica

Facies gastrica H ilum splenicum

w h it e p u lp . T h e w h ite p u lp c o n ta in s ly m p h a tic tis s u e .

Clinical Remarks F o llo w in g a tra u m a tic in ju ry to th e a b d o m e n , a r u p tu re o f th e s p le e n m a y o c c u r. A ru p tu re m a y re s u lt in life -th re a te n in g h a e m o r rh ag e . B e ca u se o f th e s e g m e n ta l s tru c tu re o f th e s p le e n , lo n g itu d in a l la c e ra tio n s w ill a ffe c t se v e ra l s p le n ic s e g m e n ts a nd c a u s e in

te n s e b le e d in g ; tra n s v e rs e la c e ra tio n s b le e d w e a k ly s in c e s p le n ic a rte rie s are te rm in a l a rte rie s . T h is a ls o e x p la in s th e w e d g e -s h a p e d area o f in fa rc tio n b e tw e e n th e s e g m e n ta l b o rd e rs .

129

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder

G reater o m e n tu m

Lig. falciforme

Lobus hepatis sinister Gaster, Curvatura major

Pars pylorica Corpus gastricum

Lobus hepatis dexter

M. rectus abdominis

Lig. teres hepatis

Fundus vesicae biliaris

Lig. gastroco licum

Colon transversum Taenia omentalis

O m entu m m ajus

Colon ascendens, Taenia libera

sigmoideum Caecum

Peritoneum parietale

Ileum

Fig. 6.101 P o s itio n o f th e v is c e ra , S itu s v is c e ru m , in th e E p ig a s triu m a n d th e g r e a te r o m e n tu m . O m e n tu m m a ju s ; v e n tra l

130 — ►

a s s o c ia te d

w it h

th e

E p ig a s triu m

because

its

b lo o d

s u p p ly

v ie w .

d e riv e d fr o m th e v e s s e ls o f th e g re a te r c u rv a tu re o f th e s to m a c h (Rr. o m e n ta le s o f th e A a. g a s tro o m e n ta le s ; - * Fig. 6 .1 1 6 ). T h e O m e n

T h e a b d o m in a l c a v ity is o p e n e d a n d th e U m b ilic u s w a s c u t fr o m th e le ft s id e t o p re s e rv e th e Lig. te re s h e p a tis b e tw e e n th e liv e r a n d th e v e n tra l

tu m m a ju s is a p e rito n e a l d u p lic a tu re c o m p o s e d o f th e L ig . g a s -tro c o lic u m , th e Lig. g a s tro s p le n ic u m a n d a fr e e a p ro n -lik e p o rtio n . T h e g re a te r

a b d o m in a l w a ll. T h e h o riz o n ta l C o lo n tra n s v e rs u m d iv id e s th e a b d o m e n in e p ig a s triu m a nd h y p o g a s triu m . T h e v is c e ra o f th e lo w e r a b d o m e n

o m e n tu m p la y s a ro le n o t o n ly in th e m e c h a n ic a l p ro te c tio n a nd th e rm a l in s u la tio n b u t a ls o in th e s e c re tio n a nd a b s o rp tio n o f p e rito n e a l flu id s . It

are a lm o s t c o m p le te ly c o v e re d b y th e g re a te r o m e n tu m w h ic h is a t ta c h e d to th e g re a te r c u rv a tu re o f th e s to m a c h . T h e O m e n tu m is

a ls o c o n ta in s ly m p h a tic tis s u e a nd has im m u n o lo g ic a l fu n c tio n s .

dissection link

Pancreas -► Spleen -* Topography -► Sections

Epigastrium

Lig. falciforme

Lig. coronarium

Diaphragma Lobus hepatis sinister, Facies diaphragmatica

Lig. teres hepatis

hepatis sinister, Facies visceralis

Lobus hepatis dexter, Facies diaphragmatica

O m entu m m inus, Lig. h ep ato gastricum

Vesica biliaris gastricum, anterior

O m entu m m inus, Lig. h ep ato duodenale

[Lien] Foram en o m entale

Gaster, Curvatura minor Lig. gastrosplenicum phrenicocolicum Curvatura major

O m entu m m ajus

Colon transversum O m entu m m ajus, Lig. gastroco licum

Fig. 6 .1 0 2

P o s itio n o f th e v is c e ra , S itu s v is c e ru m , in th e

E p ig a s triu m ; v e n tra l v ie w . T h e liv e r w a s re fle c te d c ra n ia lly to v is u a lis e th e le s s e r o m e n tu m (O m e n tu m m in u s ). It s p a n s b e tw e e n th e liv e r a nd th e le s s e r c u rv a tu re o f th e s to m a c h a nd th e Pars s u p e rio r o f th e D u o d e n u m . T h e O m e n tu m m in u s c o n s is ts o f th e Lig. h e p a to g a s tric u m a n d th e Lig. h e p a to d u o d e nale . T h e la tte r g u id e s th e c o m m o n b ile d u c t (D u c tu s c h o le d o c h u s ), th e p o rta l v e in (V. p o rta e h e p a tis), a n d th e A . h e p a tic a p ro p ria to th e P orta h e p a tis (th e h ilu m o f th e liver). B e h in d th e Lig. h e p a to d u o d e n a le is th e

e n tra n c e to th e B u rsa o m e n ta lis (F o ra m e n o m e n ta le , m a rk e d h e re b y a p ro b e ), a s lid in g s p a c e b e tw e e n s to m a c h a nd p a n c re a s a n te rio rly c o n fi n e d b y th e O m e n tu m m in u s . T h e O m e n tu m m a ju s is a tta c h e d to th e g re a te r c u rv a tu re o f th e s to m a c h a nd to th e Ta e n ia o m e n ta lis o f th e tra n s v e rs e c o lo n . It is s u b d iv id e d in to th e L ig . g a s tro c o lic u m (to th e C olo n tra n s v e rs u m ) a n d th e Lig. g a s tro s p le n ic u m (to th e s p le e n ). T h e s p le e n re s id e s in th e s p le n ic n ic h e a n d re s ts o n th e Lig. p h re n ic o c o lic u m b e tw e e n th e le f t c o lic fle x u re a n d d ia p h ra g m .

dissection link

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder

Epigastrium w ith Bursa o m e ntalis

Bursa om entalis, Vestibulum Lobus hepatis dexter, Facies diaphragmatica

Lobus hepatis sinister, Facies diaphragmatica Bursa om entalis, R e cessu s sup erior

Lig. teres hepatis

Splen [Lien], Margo superior Plica g as tro p a n creatica Lobus Bursa om entalis, R e cessu s splenicus Vesica biliaris

Bursa om entalis (m ain space)

Foramen omentale

Corpus gastricum, Paries anterior

Omentum minus, Lig. hepatoduodenale

Omentum minus, Lig. hepatogastricum

M esocolon transversum Plica hep ato p an creatica Gaster, Curvatura major Pancreas

Omentum majus, Lig. gastrocolicum

Fig. 6 .1 0 3

Bursa om entalis, Recessus inferior

P o s itio n o f th e v is c e ra . S itu s v is c e ru m , in th e

V e s tib u lu m : T h e v e s tib u le is c o n fin e d b y th e O m e n tu m m in u s v e n -

E p ig a s triu m ; v e n tra l v ie w . T h e le s s e r o m e n tu m (O m e n tu m m in u s ) b e tw e e n th e liv e r a nd th e les

tra lly a nd its R e c e s s u s s u p e rio r e x te n d s b e h in d th e liver. Is th m u s : T h e n a rro w in g b e tw e e n v e s tib u le a nd m a in s p a c e is c o n

s e r c u rv a tu re o f th e s to m a c h w a s s e p a ra te d to s h o w th e B u rsa o m e n

fin e d b y t w o p e rito n e a l fo ld s : o n th e rig h t s id e b y th e Plica h e p a to p a n c re a tic a w h ic h is c re a te d b y th e A . h e p a tic a c o m m u n is , a n d on

ta lis. T h e B ursa o m e n ta lis is a s lid in g s p a c e b e tw e e n s to m a c h a n d P a ncreas a nd e x c lu s iv e ly c o m m u n ic a te s w it h th e a b d o m in a l c a v ity th ro u g h th e F o ra m e n o m e n ta le b e h in d th e Lig. h e p a to d u o d e n a le . D u e to its c o n fin e d p o s itio n , th e B ursa o m e n ta lis is a lso re fe rre d to a s th e " le s s e r sac o f th e p e rito n e a l c a v ity " . T h e B u rsa o m e n ta lis is s u b d iv id e d in to fo u r p a rts: • F o ra m e n o m e n ta le : T h e e n tra n c e to th e B u rsa o m e n ta lis is c o n fin e d a n te rio rly b y th e L ig . h e p a to d u o d e n a le , c ra n ia lly b y th e L o b u s c a u d a tu s , c a u d a lly b y th e B u lb u s d u o d e n i, a n d p o s te rio rly b y th e V. cava in fe rio r.

dissection link

•

th e le ft s id e b y th e Plica g a s tro p a n c re a tic a w h ic h m a rk s th e c o u rs e o f th e A . g a s tric a s in is tra . M a in s pace: T h is s p a c e is lo c a te d b e tw e e n th e s to m a c h (a n te ri or) a n d th e P a n cre a s a n d th e M e s o c o lo n tra n s v e rs u m (p o s te rio r), re s p e c tiv e ly . O n th e le f t s id e , th e R e c e s s u s s p le n ic u s e x te n d s to th e h ilu m o f th e s p le e n ; th e R e c e s s u s in fe rio r lie s b e h in d th e Lig. g a s tro c o lic u m a nd e x te n d s to th e o rig in o f th e M e s o c o lo n a t th e C olo n tra n s v e rs u m .

Pancreas -> Spleen -» Topography -► Sections

E pigastrium w ith Bursa o m e ntalis

Plica g as tro p a n creatica

Bursa omentalis, Vestibulum

Plica hep ato p an creatica

Splen [Lien], Margo superior

Pylorus

Lig. gastrosplenicum

Corpus pancreatis Colon transversum Colon transversum

Mesocolon transversum

Omentum majus, Lig. gastrocolicum

Fig. 6 .1 0 4

P o s itio n o f th e v is c e ra , S itu s v is c e ru m , in th e

Bursa om entalis, Recessus inferior

E p ig a s triu m ; v e n tra l v ie w .

o f th e b u rs a is c re a te d b y th e P a n cre a s a n d th e M e s o c o lo n tra n s v e r s u m . O n th e le ft s id e , it e x te n d s t o th e h ilu m o f th e s p le e n (R e c e s s u s

T h e Lig. g a s tro c o lic u m w a s s e c tio n e d a nd th e s to m a c h re fle c te d cra nia lly to s h o w th e m a in s p a ce o f th e B u rsa o m e n ta lis . T h e p o s te rio r w a ll

s p le n ic u s ), in fe rio rly to th e o rig in o f th e M e s o c o lo n a t th e C o lo n tra n s v e rs u m (R e c e s s u s in fe rio r).

P Clinical R em arks-------------------------------------S im ila r t o th e o th e r re c e s s e s o f th e p e rito n e a l c a v ity , th e B ursa

D u rin g s u rg ic a l t r e a t m e n t in th e e p ig a s triu m (e.g. in te rv e n tio n s a t

o m e n ta lis is o f clin ic a l re le v a n c e . H e rn ia tio n o f s m a ll in te s tin a l lo o p s (in te rn a l h e rn ia s ), d is s e m in a tio n o f m a lig n a n t tu m o u rs (p e rito n e a l

th e P ancreas), th e s u rg e o n can a c c e s s th e B u rsa o m e n ta lis in th r e e d iffe r e n t w a y s :

c a rc in o s is ), o r b a c te ria (p e r ito n itis ) ca n in v o lv e th e o m e n ta l b ursa . T h e re fo re , d u rin g a b d o m in a l s u rg e ry , th e s u rg e o n u s u a lly in s p e c ts

• • •

th e B u rsa o m e n ta lis .

via th e O m e n tu m m in u s (-* Fig. 6 .1 0 3) via th e Lig. g a s tro c o lic u m via th e M e s o c o lo n tra n s v e rs u m

dissection link

133

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder

H ypogastricum

Omentum majus

Co lon transversum

Taenia libera

Flexura coli dextra

Flexura coli sinistra

Jejunum

Co lon ascendens

Taenia libera

Co lon descenden s Co lon sigm oideum

Appendices omentales [epiploicae]

C aecum

Fig. 6 .1 0 5

134 — ►

P o s itio n o f th e v is c e ra . S itu s v is c e ru m , in th e

Ileum

H y p o g a s triu m ; v e n tra l v ie w .

fig u re a ls o s h o w s th a t th e re tro p e rito n e a l s e g m e n ts o f th e c o lo n are re lo c a te d to th e p o s te rio r w a ll o f th e a b d o m e n to a v a ria b le e x te n t. In

T h e O m e n tu m m a ju s w a s re fle c te d c ra n ia lly to v is u a lis e th e s m a ll a nd la rg e in te s tin e s in th e H y p o g a s triu m . T h u s, th e in tra p e rito n e a l s e g

th is c a s e , th e C o lo n a s c e n d e n s is c le a rly v is ib le , b u t th e C olo n d e s c e n d e n s is s h ifte d fu r th e r d o rs a lly a nd is p a rtia lly c o v e re d b y th e s m a ll in

m e n ts are v is ib le : J e ju n u m a n d Ile u m o f th e s m a ll in te s tin e , C a e c u m , C olo n tra n s v e rs u m , a nd C olo n s ig m o id e u m o f th e la rg e in te s tin e . T h is

te s tin e . T h e la rg e in te s tin e fra m e s th e c o n v o lu te o f J e ju n u m a n d Ile u m .

dissection link

Pancreas -► Spleen -» Topography -► Sections

H ypogastricum

Omentum majus

Fundus vesicae biliaris

Mesocolon transversum Lobus hepatis dexter Pancreas D uodenum , Pars horizontalis

Jejunum

Plica cae calis vascularis

Ileum , Pars term inalis R e cessu s ileocaecales sup erior et inferior

Ileum

Plica

C aecum

Mesoappendix

Appendix vermiformis

Fig. 6 .1 0 6

P o s itio n o f th e v is c e ra . S itu s v is c e ru m , in th e

H y p o g a s triu m ; v e n tra l v ie w .

sus ile o c a e c a lis s u p e rio r is c o v e re d b y th e Plica c a e c a lis v a s c u la ris (c o n ta in s a b ra n c h o f th e A . ile o c o lic a ), th e R ec e s su s ile o c a e c a lis in fe

T h e O m e n tu m m a ju s w a s re fle c te d cra n ia lly a n d th e lo o p s o f th e s m a ll in te s tin e w e r e re fle c te d t o th e le ft s id e t o v is u a lis e th e s e c o n d a ry re

rio r is c o v e re d b y th e Plica ile o c a e c a lis b e tw e e n th e Ile u m a nd th e A p p e n d ix v e rm ifo rm is . S im ila r to th e B ursa o m e n ta lis a nd o th e r a b d o m i

tro p e rito n e a l Pars h o riz o n ta lis o f th e D u o d e n u m . A t th e tra n s itio n b e tw e e n th e Ile u m a nd th e C a e cu m th e re are t w o sp a ce s: th e R eces-

nal re c e s s u s , s m a ll in te s tin a l lo o p s m a y be tra p p e d h e re (in te rn a l h e rn i as).

dissection link

135

Viscera of the A b d o m e n

Developm ent -> Stomach

Intestines -► Liver and gallbladder -►

H ypogastricum

Colon transversum

Omentum majus

Pancreas

Mesenterium

Recessus duodenales su p erio r e t inferior

Intestinum tenue

Flexura duodenojejunalis

sigmoideum

Recessus iieocaecalis inferior Recessus intersigmoideus Caecum

Mesoappendix A p pendix verm iform is

Fig. 6 .1 0 7

P o s itio n o f th e v is c e ra . S itu s v is c e ru m , in th e

H y p o g a s triu m ; v e n tra l v ie w .

d e n u m in to th e in tra p e rito n e a l J e ju n u m . T h is area a ls o c o n ta in s tw o re c e s s e s : R ecessu s d u o d e n a le s s u p e rio r a nd in fe rio r. In th e r ig h t H y

T h e O m e n tu m m a ju s w a s re fle c te d c ra n ia lly a n d th e lo o p s o f th e s m a ll in te s tin e w e re re fle c te d to th e rig h t s id e to d e m o n s tra te th e Flexura

p o g a s triu m , th e A p p e n d ix v e r m ifo r m is is v is ib le , th e tip o f w h ic h d e s c e n d s in to th e s m a ll p e lv is (d e s c e n d in g ty p e ).

d u o d e n o je ju n a lis w h ic h m a rk s th e tra n s itio n o f th e re tro p e rito n e a l D u o

i- Clinical R em arks----------------------------------------------------------------------------------------------------------T h e R e c e s s u s d u o d e n a le s s u p e rio r a nd in fe rio r are th e m o s t c o m m o n s ite s fo r th e h e rn ia tio n o f s m a ll in te s tin a l lo o p s (T R E IT Z 's h e r-

136 — ►

dissection link

n ias ). T h is h e rn ia tio n m a y re s u lt in an in te s tin a l a b s tru c tio n (ileus) o r in te s tin a l in fa rc tio n .

Pancreas -► Spleen -» Topography -► Sections

M e se n te rie s

Omentum majus

Colon transversum

Mesocolon transversum

Colon descendens Colon ascendens

Duodenum, Pars ascendens

Duodenum, Pars horizontalis

Jejunum

Plica duodenalis inferior

M esenterium Recessus ileocaecalis superior Colon descendens Recessus ileocaecalis inferior

Caecum

Mesoappendix Colon sigmoideum Appendix vermiformis

Rectum

Fig. 6 .1 0 8

M e s e n te r ie s o f th e s m a ll in te s tin e , M e s e n te r iu m , a n d

Vesica urinaria

la rg e in te s tin e , In te s tin u m c ra s s u m ; v e n tra l v ie w .

w a s re s e c te d a t th e m e s e n te ry . T h e m e s e n te ry c o n s is ts o f a d u p lic a tu re o f th e p e rito n e a l m e m b ra n e s , c o n ta in s th e n e u ro v a s c u la r s tru c

T h e O m e n tu m m a ju s a n d th e C olo n tra n s v e rs u m w e re re fle c te d cra nially. T h e in tra p e rito n e a l s m a ll in te s tin a l c o n v o lu te o f J e ju n u m a n d Ile u m

tu re s to s u p p ly th e s m a ll in te s tin e , a nd s e rv e s a s m o b ile a tta c h m e n t o f th e s m a ll in te s tin e to th e p o s te rio r a b d o m in a l w a ll.

dissection link

137

Viscera of the A b d o m e n

Developm ent -* Stomach -► Intestines -► Liver and gallbladder ->

S econdary re trope rito neal organs

Lig. Lobus hepatis

hepatis sinister cardiacum

Lig. teres hepatis

Omentum minus Fundus vesicae biliaris C auda pancreatis Lig. hepatoduodenale C o rpus pancreatis

Duodenum, Pars superior Ren

O m entu m m ajus Gaster, Pars pylorica Colon transversum

Duodenum Omentum majus Co lon ascendens

C olon descenden s

Colon transversum Mesenterium

lleum

Colon sigmoideum

Caecum

Appendix vermiformis

Mesoappendix Rectum Excavatio rectovesicalis

Fig. 6 .1 0 9

P o s itio n o f th e s e c o n d a ry r e tr o p e r ito n e a l o rg a n s ;

Vesica urinaria

v e n tra l v ie w .

T h e s e in c lu d e th e D u o d e n u m (e x c e p t fo r th e Pars s u p e rio r), th e Pan c re a s , th e C olo n a s c e n d e n s , a n d th e C olo n d e s c e n d e n s , a nd th e R ec

T h e s to m a c h w a s re m o v e d , J e ju n u m a nd Ile u m w e r e re s e c te d a t th e m e s e n te ry , a nd C o lo n tra n s v e rs u m a n d C o lo n s ig m o id e u m w e r e s e c

tu m to th e F lexura s a cralis. A n te rio r to th e R e c tu m , th e o p e n in g o f th e E x c a v a tio re c to v e s ic a lis can b e s e e n . T h is p e rito n e a l p o u c h is th e m o s t

tio n e d . M o s t o f th e s e c o n d a ry re tro p e rito n e a l o rg a n s are n o w v is ib le .

in fe rio r p a rt o f th e p e rito n e a l c a v ity in m e n .

Clinical Remarks In an u p rig h t p o s itio n (s e ld o m in b e d rid d e n p a tie n ts ), in th e m o s t in fe rio r e x te n s io n o f th e p e rito n e a l c a v ity , th e E x c a v a tio re c to v e s i c a lis in m e n , a nd th e E x c a v a tio re c to u te r in a (p o u c h o f D O U G L A S ) in w o m e n (-» Fig. 6 .1 1 0 ), m a y a c c u m u la te in fla m m a to ry e x u d a te o r

138 — ►

dissection link

p u s in c a s e s o f in fla m m a to ry e v e n ts in th e H y p o g a s triu m . B y u ltra s o u n d (a b d o m in a l, tra n s v a g in a l) e x a m in a tio n , th is ca n be d e te c te d a s fre e flu id in th e a b d o m e n .

Pancreas -> Spleen -» Topography -► Sections

P osterio r w a ll o f th e peritoneal cavity

Lig. gastrophrenicum Plica gastropancreatica Bursa omentaiis, Recessus superior

Ostium cardiacum Lig. coronarium, Lig. triangulare sinistrum

Plica hepatopancreatica

Bursa om entaiis Lig. gastrosplenicum

Glandula suprarenalis

Lig. coronarium Bursa om entaiis, R e cessu s splenicus

Cauda pancreatis

Lig. hepatoduodenale Ren

M esocolon transversum Duodenum, Pars superior Duodenum, Flexura duodenojejunalis

R e cessu s duodenales sup erior e t inferior

Plica duodenalis inferior

D uodenu m , Pars horizontalis

Radix m esenterii

Plica ileocaecalis

R e cessu s ileocaecalis superior Recessus intersigm oideus R e cessu s ileocaecalis inferior

Mesoappendix

Mesocolon sigmoideum

U reter

Ovarium

Colon sigmoideum

Tuba uterina

Excavatio rectouterin a Excavatio vesicouterina

Fundus uteri

Vesica urinaria, Fundus vesicae

Fig. 6 .1 1 0

D o rs a l w a ll o f th e p e r ito n e a l c a v ity , C a v ita s

p e r ito n e a lis , w it h re c e s se s , R ecessu s, a n d s p le e n , S p le n [L ien ];

in fe rio r). F u rth e r re c e s s e s (p e rito n e a l g u tte rs ) are lo c a te d a t th e e n tra n c e o f th e te rm in a l ile u m in to th e C a e c u m (R ecessus ilio c a e c a le s

v e n tra l v ie w . L ive r, s m a ll a n d la rg e in te s tin e s w e r e re m o v e d e x c e p t fo r th e D u o d e

s u p e rio r a nd in fe rio r) a nd o c c a s io n a lly a n o th e r re c e s s is lo c a te d in fe ri o r to th e M e s o c o lo n s ig m o id e u m (R ecessu s in te rs ig m o id e u s ).

n u m to e x p o s e th e d o rs a l w a ll o f th e p e rito n e a l ca vity. T h e p e rito n e a l lin in g o v e r th e rig h t k id n e y a n d th e Pars d e s c e n d e n s o f th e D u o d e n u m

A n te rio r to th e re c tu m , a d e e p p e rito n e a l s p a c e e x is ts w h ic h is c o n fin e d b y th e u te ru s a nd th e b ro a d lig a m e n t a t th e v e n tra l s id e . T h is

is c le a rly v is ib le d u e to its s h in y s u rfa c e . T h e a tta c h m e n t a rea s o f th e s e c o n d a ry re tro p e rito n e a l C olo n a s c e n d e n s a nd C olo n d e s c e n d e n s are

E x c a v a tio re c to u te r in a (p o u c h o f D O U G L A S ) is th e m o s t c a ud a l re c e s s o f th e p e rito n e a l c a v ity in w o m e n . T h e v e n tra lly p o s itio n e d E x c a v a tio v e s ic o u te rin a b e tw e e n u rin a ry b la d d e r a n d U te ru s d o e s n o t e x

lackin g th is p e rito n e a l lin ing . T h e p e rito n e a l d u p lic a tu re s fo r m th e re lie f o f th e d o rs a l w a ll o f th e

te n d d o w n w a r d s a s d e e p ly as th e E x c a v a tio re c to u te rin a . B e tw e e n th e

p e rito n e a l c a v ity as fo ld s (Plicae) a n d lig a m e n ts a nd c re a te d iv e rs e re c e s s e s (R e ce ssu s). T h e la rg e s t o f th e m is th e B ursa o m e n ta iis

F lexura d u o d e n o je ju n a lis a n d th e rig h t Fossa iliaca, th e 1 2 - 1 6 c m lo n g ro o t o f th e m e s e n te ry (R adix m e s e n te rii) is a tta c h e d . It c o n ta in s th e

( - * Fig. 6 .1 0 3 ), th e p o rtio n s a nd e x te n s io n s th e r e o f are v is ib le h ere . A t th e area o f th e F lexura d u o d e n o je ju n a lis , th e P licae d u o d e n a le s s u p e ri o r a nd in fe rio r fo r m t w o re c e s s e s (R ecessu s d u o d e n a le s s u p e rio r a nd

b lo o d v e s s e ls s u p p ly in g th e s m a ll in te s tin e (A7V- m e s e n te ric a s u p e ri or). T h e ro o t o f th e m e s e n te ry tra v e rs e s th e Pars h o riz o n ta lis o f th e D u o d e n u m a nd th e rig h t U re te r.

dissection link

139

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder -►

A rte rie s o f th e abdom en

Pars abdominalis aortae [Aorta abdominalis]

Truncus coeliacus

R. oesophagealis A. splenica [lienalis]

A. hepatica communis

A. gastrica sinistra

Aa. gastricae breves

A. cystica A. gastroomentalis sinistra

A. hepatica propria

A. gastrica dextra A. pancreatica magna A. gastroduodenalis A. caudae pancreatis A. supraduodenalis

A. gastroomentalis dextra A. pancreatica dorsalis

A. p an creatico duodenalis sup erior p o s terior A. pan creatico duodenalis sup erior an terior

A. m esen terica superior

A. p an creatico duodenalis inferior

A. m esen terica inferior

A. colica media A. colica dextra

A. colica sinistra

A. ileocolica

Aa. sigmoideae

A. rectalis superior

A. rectalis inferior

Fig. 6.1 1 1 A rte r ie s o f th e a b d o m in a l v is c e ra ; s e m is c h e m a tic illu s tra tio n ; v e n tra l v ie w .

T h e a n a s to m o s e s are: •

c o n n e c tio n s b e tw e e n th e T ru n c u s c o e lia c u s a nd th e A . m e s e n te ric a s u p e rio r via A a. p a n c re a tic o d u o d e n a le s (*).

•

c o n n e c tio n s b e tw e e n th e A a. m e s e n te ric a e s u p e rio r a n d in fe rio r: R IO L A N 's a n a s to m o s is b e tw e e n th e A . co lic a m e d ia a nd A . co lica

T h e m o s t im p o rta n t a n a s to m o s e s a re m a rk e d b y b la c k c irc le s . T h e th re e u n p a ire d a rte rie s to th e a b d o m in a l v is c e ra d e riv e d fr o m th e A o rta a b d o m in a lis a re th e T ru n c u s c o e lia c u s , th e A . m e s e n te ric a s u p e rio r, a nd th e A . m e s e n te ric a in fe rio r. T h e A . m e s e n te ric a s u p e rio r has its o rig in d ire c tly b e lo w th e T ru n c u s c o e lia c u s (h ere n o t s h o w n d u e to s e m is c h e m a tic p re s e n ta tio n ). Its re s p e c tiv e b ra n c h e s are d e s c rib e d on th e fo llo w in g p a g e s. A ll th re e a rte rie s a n a s to m o s e w it h e a c h o th e r a nd w it h b ra n c h e s o f th e A . iliaca in te rn a . T h is m a y p re v e n t is c h e m ic in fa rc tio n in c a se s o f an o c c lu s io n o f o n e o f th e s e v e s s e ls .

140

•

s in is tra ( * * ) . P le x u s o f re c ta l a rte rie s : h e re th e A . re c ta lis s u p e rio r fro m th e A . m e s e n te ric a in fe rio r c o n n e c ts to th e A a. re c ta le s m e d ia a n d in fe rio r fr o m th e A . iliaca in te rn a ( * * * ) .

Pancreas -► Spleen -> Topography -► Sections

Veins o f th e abdom en

Vv. hepaticae

Vv. oesophageae

V. gastrica sinistra Vv. gastricae breves

V. portae hepatis, R. dexter

V. splenica [lienalis]

V. cystica V. gastroomentalis [gastroepiploica] sinistra

V. po rtae hepatis

V. gastrica dextra V. splenica [lienalis] V. m esen terica sup erior

Vv. pancreaticae V. gastroomentalis [gastroepiploica] dextra

V. m esen terica inferior V. pancreaticoduodenalis superior posterior

V. colica medii

V. colica sinistra

V. colica dextra

V. rectal is superior

V. ileocolica

Vv. sigmoideae

Vv. rectales mediae

Vv. rectales inferiores

Vv. jejunales

Fig. 6 .1 1 2

P o rta l v e in , V. p o rta e h e p a tis , w it h trib u ta rie s ;

s e m is c h e m a tic illu s tr a tio n ; v e n tra l v ie w . T h e tr ib u ta rie s o f th e p o rta l v e in are d e s c rib e d in d e ta il in -» F ig u re 6 .6 9 .

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder -►

T runcus coeliacus

Pars lumbalis diaphragmatis Vesica biliaris A. g astrica sinistra

Lobus hepatis dexter

Truncus coeliacus

A. splenica [lienalis]

A.; V. cystica A. hepatica propria

Splen [Lien] V. portae hepatis

V. gastrica sinistra

Ductus choledochus [biliaris] A. gastroduodenalis

A.; V. gastroomentalis sinistra

A. h ep atica com m unis Omentum majus A. gastrica dextra

Pancreas

Gaster A.; V. gastroomentalis dextra

Rr. omentales

Fig. 6 .1 1 3 T ru n c u s c o e lia c u s ; v e n tra l v ie w ; a fte r re m o v a l o f th e O m e n tu m m in u s . T h e T ru n c u s c o e lia c u s d e riv e s as fir s t u n p a ire d b ra n ch fr o m th e A o rta a b d o m in a lis . In th e re tro p e rito n e a l s p a ce b e h in d th e B u rsa o m e n ta lis its s h o rt (m o s tly 2 - 3 c m ) tru n k d iv id e s in to th e th re e m a jo r a rte rie s w h ic h s u p p ly th e v is c e ra o f th e E p ig a s triu m (G a ste r, D u o d e n u m , H e-

teres hepatis Lobus hepatis sinister A. cystica

par, V e sica b ilia ris, P a n cre a s a nd S plen):

A. hepatica propria

A . g a s tric a s in is tra : b ra n c h e s o f f t o th e le ft a n d s u p e rio r s id e . It a n a s to m o s e s w it h th e A . g a s tric a d e x tra a t th e le s s e r c u rv a tu re o f

Vesica biliaris [fellea]

Truncus coeliacus A. g astrica sinistra

th e s to m a c h a nd is u su a lly th e s tro n g e r ve sse l. A . h e p a tic a c o m m u n is : tu rn s to th e rig h t s id e a nd d iv id e s in to : -

A. gastrica posterior

A . h e p a tica p ro p ria : re le a se s th e A . g a s tric a d e x tra a nd s u p p lie s liv e r a nd g a llb la d d e r (A. cystica ) A . g a s tro d u o d e n a lis : d e s c e n d s b e h in d th e P ylo ru s o r D u o d e n u m ,

Splen [Lien] Aa. gastricae breves

d iv id e s in to th e A . g a s tro o m e n ta lis d e x tra to th e g re a te r c u rv a tu re o f th e s to m a c h a nd th e A a. p a n c re a tic o d u o d e n a le s s u p e rio re s

hepatica

a n te rio r a nd p o s te rio r w h ic h a n a s to m o s e w it h th e A . p a n c re a tic o d u o d e n a lis in fe rio r fr o m th e A . m e s e n te ric a s u p e rio r to s u p p ly th e •

h ead o f th e P a ncreas a n d th e D u o d e n u m . A . s p le n ic a : c o u rs e s to th e in fe rio r le ft s id e a t th e s u p e rio r b o rd e r o f th e P a n cre a s a nd re le a s e s th e fo llo w in g b ra n c h e s d u rin g its c o u rs e to th e s p le e n : -

142

—♦

splenica [lienalis] Duodenum

A. mesenterica superior A. gastroduodenalis A. gastroomentalis dextra

Rr. p a n c re a tic i fo r th e P a ncreas A . g a s tric a p o s te rio r to th e s to m a c h (3 0 -6 0 % o f all ca ses) A . g a s tro o m e n ta lis s in is tra : c o u rs e s fr o m th e le ft s id e to th e g re a te r c u rv a tu re o f th e s to m a c h a nd a n a s to m o s e s w it h th e A. g a s tro o m e n ta lis d e xtra A a. g a s tric i b re v e s : s h o rt b ra n c h e s to th e fu n d u s Rr. s p le n ic i: te rm in a l b ra n c h e s to th e sp le e n

dissection link

o f th e s to m a c h

gastroomentalis sinistra

A. gastrica dextra

Fig. 6 .1 1 4

B ra n c h e s o f th e T ru n c u s c o e lia c u s .

Pancreas -> Spleen -» Topography -► Sections

A. m e se nterica supe rior

RIOLAN's anastomosis

A. colica

A. colica dextra

A. m esen terica superior

R. colicus A. ileocolica jejun ales R. ilealis

A. ileocolica A. appendicularis

Caecum

Appendix vermiformis

Ileum

Fig. 6 .1 1 5

A . m e s e n te ric a s u p e rio r; v e n tra l v ie w ; C olon

B ra n c h e s o f t h e A . m e s e n te ric a s u p e rio r:

tra n s v e rs u m re fle c te d cra nia lly. (a cco rd in g to [1])

A . p a n c re a tic o d u o d e n a lis in fe rio r: b ra n c h e s o ff to th e s u p e rio r

T h e u n p a ire d A . m e s e n te ric a s u p e rio r b ra n c h e s o ff th e A o rta a b d o m i n a lis d ire c tly b e lo w th e T ru n c u s c o e lia c u s , c o u rs e s re tro p e rito n e a lly

rig h t s id e ; R. a n te rio r a nd R. p o s te rio r a n a s to m o s e w ith th e A a. panc re a tic o d u o d e n a le s s u p e rio re s a n te rio r a n d p o s te rio r (-» Fig. 6 .1 1 6 ).

b e h in d th e P a ncreas a n d th e n e n te rs th e m e s e n te ry . Its b ra n c h e s can be d is p la y e d if th e m e s e n te ry is o p e n e d a nd th e a d ip o s e tis s u e

A a . je ju n a le s (4 -5 ) a nd A a . ile a le s (12): d ire c te d to th e le ft s id e A . c o lic a m e d ia : o rig in a te s on th e rig h t s id e a nd a n a s to m o s e s w ith

b e tw e e n th e v a s c u la r a rc a d e s is re m o v e d . It s u p p lie s p a rts o f th e Pan c re a s a nd D u o d e n u m , th e e n tire s m a ll in te s tin e , a nd th e large in te s tin e

th e A . co lic a d e x tra a n d w it h th e A . co lic a s in is tra (R IO L A N 's ana s to m o s is )

u p to th e le ft c o lic fle x u re . •

A . c o lica d e x tra : c o u rs e s to th e C o lo n a s c e n d e n s A . ile o c o lic a : s u p p lie s th e d is ta l Ile u m , C a e c u m a nd A p p e n d ix v e r m ifo rm is (A. a p p e n d ic u la ris )

143

Viscera of the A b d o m e n

Developm ent -* Stomach -► Intestines -► Liver and gallbladder ->

A. m e se nterica supe rior

Truncus coeliacus A. gastrica sinistra A.; V. gastroomentalis sinistra

A. gastrica brevis A. hepatica communis

A.; V. splenica [lienalis] V. cava inferior

Rr. splenici

A.; V. gastroomentalis dextra

A. gastroduodenalis V. portae hepatis A. pancreaticoduodenalis superior anterior

Corpus pancreatis

A. p an creaticod uoden alis inferior

Caput pancreatis V. m esen terica superior

A. m esen terica superior

Proc. uncinatus Mesocolon transversum

Lig. gastrocolicum

Fig. 6 .1 1 6

O rig in s o f th e A . m e s e n te ric a s u p e rio r a n d T ru n cu s

c o e lia c u s ; v e n tra l v ie w ; a fte r re fle c tin g th e s to m a c h cra n ia lly a nd

144 — ►

a n d e n te rs th e m e s e n te ry a n te rio r t o th e D u o d e n u m . T h e P a ncreas

d is s e c tin g th e P ancreas.

w a s s e c tio n e d to s h o w th e A . a nd V. m e s e n te ric a s u p e rio r v e n tra l to th e P roc. u n c in a tu s o f th e P a n cre a s. T h e A . m e s e n te ric a s u p e rio r s u p

F o llo w in g its o rig in fr o m th e A o rta a b d o m in a lis in fe rio r to th e T ru n c u s c o e lia c u s , th e A . m e s e n te ric a s u p e rio r d e s c e n d s b e h in d th e P a ncreas

p lie s th e A . p a n c re a tic o d u o d e n a lis in fe rio r a s its fir s t b ra n c h t o th e rig h t s ide .

dissection link

Pancreas -► Spleen -* Topography -► Sections

A. m e se nterica supe rior

M esocolon transversum

A. m esen terica superior RIOLAN's anastomosis

V. mesenterica superior

anastomosis

A. colica m edia

A.; V. colica sinistra

Colon

Aa. jejun ales

V. colica

Jejunum A.; V. colica dextra Vv. jejunales

A a. ileales

■

A. ileocolica

Colon sigmoideum Caecum

Ileum

Appendix vermiformis

Fig. 6 .1 1 7

C o u rs e o f th e A . a n d V . m e s e n te ric a s u p e rio r; v e n tra l

v ie w ; a fte r o p e n in g o f th e m e s e n te ry w it h th e C o lo n tra n s v e rs u m

a n a s to m o s is ) w ith th e A . c o lic a s in is tra fro m th e A . m e s e n te ric a in fe

re fle c te d cranially.

rio r. T h is fa c ilita te s th e fo rm a tio n o f c o lla te ra l c irc u la tio n s in th e ca se o f o c c lu s io n o f o n e o f th e a rte rie s . T h e a n a s to m o s is b e tw e e n th e t w o ar

W ith in th e m e s e n te ry , th e A . m e s e n te ric a s u p e rio r g iv e s rise to th e fo llo w in g b ra n c h e s : A a. je ju n a le s a n d A a. ile a le s to th e le f t sid e , A . c o

te rie s in o n e o f th e a rc a d e s c lo s e to th e in te s tin e s is o c c a s io n a lly re fe r re d to a s D R U M M O N D 's a n a s to m o s is . In th e c lin ic a l ja rg o n , all a n a s to

lica m e d ia , A . co lica d e x tra , a nd A . ile o c o lic a to th e rig h t sid e . A ll a rte ries fo r m a rc a d e s a t d iffe r e n t le v e ls o f th e ir d iv is io n s . T h is a llo w s th e

m o s e s in th e area o f th e le ft c o lic fle x u re are s u m m a ris e d a s R IO L A N 's a n a s to m o s is .

m o b ility o f th e in te s tin a l lo o p s. A t th e le ft c o lic fle x u re , th e A . co lica m e d ia fo r m s a fu n c tio n a lly im p o r ta n t a n a s to m o s is (R IO L A N 's

T h e v e n o u s b ra n c h e s c o rre s p o n d to th e a rte rie s .

dissection link

145

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder

A. m e se nterica inferio r

Colon transversum anastomosis

DRUMMOND'S anastomosis

descendens Colon

A. colica media

mesenterica superior

m esen terica inferior A. colica dextra A. colica sinistra

R. colicus

A. A. caecalis anterior Aa. sigm oid eae

Colon sigmoideum Caecum

A. appendicularis

A. rectalis superior

Appendix vermiformis Rectum

Fig. 6 .1 1 8

A . m e s e n te ric a in fe rio r; v e n tra l v ie w ; C olo n tra n s v e rs u m

A . c o lic a s in is tra : a s c e n d s a lo n g th e C olo n d e s c e n d e n s a n d ana s

T h e u n p a ire d A . m e s e n te ric a in fe rio r b ra n c h e s o ff th e a b d o m in a l aorta a p p ro x im a te ly 5 c m a b o v e its b ifu rc a tio n a nd tu rn s to th e le ft s id e . W ith

to m o s e s via th e A . co lic a s in is tra w it h th e A . c o lic a m e d ia fr o m th e A . m e s e n te ric a s u p e rio r (R IO L A N 's a n a s to m o s is ) A a . s ig m o id e a e : s e v e ra l b ra n c h e s to th e C olo n s ig m o id e u m

th e e x c e p tio n o f a s h o rt te rm in a l s e c tio n , th e A . m e s e n te ric a in fe rio r d e s c e n d s in to th e re tro p e rito n e a l s p a c e to s u p p ly th e C olo n d e s c e n d e n s a n d th e u p p e r R e c tu m .

146

B ra n c h e s o f t h e A . m e s e n te ric a in fe rio r:

re fle c te d cra n ia lly. (a c c o rd in g to [1])

A . re c ta lis s u p e rio r: d e s c e n d s to th e u p p e r R e c tu m a n d s u p p lie s th e re c ta l c a v e rn o u s b o d ie s in th e s u b m u c o s a (C o rp u s c a v e rn o s u m re c ti) w h ic h are a p a rt o f th e c o n tin e n c e m e c h a n is m .

Pancreas -► Spleen -» Topography -► Sections

A. m e se nterica in fe rio r

A. pancreaticoduodenalis inferior

Pars abdominalis aortae

V. mesenterica superior anastomosis

Pancreas

anastomosis

Mesocolon transversum

A.; V. colica m edia

A.; V. colica sinistra

Ren

V. mesenterica inferior Bifurcatio aortae A. m esen terica inferior

A. colica sinistra Aa.; Vv. jejunales Colon descendens

Aa.; Vv. sigm oid eae

A.; V. rectalis superior

Rectum

Fig. 6 .1 1 9

Colon sigmoideum

C o u rs e o f th e A . a n d V . m e s e n te ric a in fe r io r in th e

T h e A . c o lic a s in is tra a s c e n d s a lo n g th e C olo n d e s c e n d e n s , fo r m s ar

r e tr o p e r ito n e a l s pace; v e n tra l v ie w ; C olo n tra n s v e rs u m re fle c te d c ra n ia lly a nd s m a ll in te s tin a l lo o p s to th e rig h t side .

c a d e s a nd a n a s to m o s e s w it h th e A . co lic a m e d ia d e riv e d fr o m th e A. m e s e n te ric a s u p e rio r (R IO L A N 's a n a s to m o s is ). T h e a n a s to m o s is

F o llo w in g its o rig in a b o v e th e a o rtic b ifu rc a tio n , th e A . m e s e n te ric a in fe r io r d e s c e n d s in th e re tro p e rito n e a l s p a c e a n d re le a s e s fir s t th e A.

b e tw e e n th e t w o a rte rie s in o n e o f th e a rc a d e s c lo s e t o th e in te s tin e s is o c c a s io n a lly re fe rre d to as D R U M M O N D 'S a n a s to m o s is .

co lic a s in is tra t o th e le ft sid e , th e n se v e ra l A a. s ig m o id e a e a nd fin a lly th e u n p a ire d A . re c ta lis su p e rio r.

dissection link

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder -►

A b d o m e n and pelvis, m edian section

Oesophagus Hepar, Area nuda Aorta, Pars abdominalis Diaphragma, Centrum tendineum

Hepar, Lobus sinister

G aster, Cardia Fornix gastricus

A. mesenterica superior

P ancreas, Ductus pancreaticus Bursa om entalis

Pars lumbalis diaphragmatis

Colon transversum V. renalis dextra

A. renalis dextra Jejunum V. mesenterica superior Omentum majus Peritoneum viscerale Peritoneum parietale

A. iliaca communis dextra Anulus umbilicalis

V. iliaca communis dextra

C avitas peritonealis Cauda equina

Promontorium

Colon sigmoideum Ileum Plica transversa recti Os sacrum

Vesica urinaria

Glandula vesiculosa Ampulla recti

Os pubis

Os coccygis M. levator ani, M. pubococcygeus Prostata M. transversus perinei profundus M. sphincter ani externus

M. sphincter ani internus

Fig. 6 .1 2 0

148

A b d o m e n , A b d o m e n , a n d p e lv is . P e lv is , o f a m a n ;

m e d ia n s e c tio n ; v ie w fr o m th e rig h t side .

b e tw e e n th e in tra p e rito n e a l v is c e ra . A ls o th e B ursa o m e n ta lis b e tw e e n th e s to m a c h a nd th e P a ncreas is o n ly a n a rro w s p a c e w it h p e rito n e a l

T h is illu s tra tio n s h o w s cle a rly th a t th e p e rito n e a l c a v ity (C avita s p e rito nealis) is n o t a w id e e m p ty sp a ce , b u t ra th e r c o n s is ts o f s m a ll re c e s s e s

lin in g . A la rg e p o rtio n o f th e a b d o m in a l c a v ity is o c c u p ie d b y th e m e s e n te r y w h ic h m a y a c c u m u la te p le n ty o f a d ip o s e tis s u e .

Pancreas -> Spleen -» Topography -► Sections

A b d o m e n and pelvis, sagittal section

V. h ep atica dextra Atrium cordis dextrum Pulmo dexter, Lobus inferior V. h ep atica sinistra Lig. falciforme Hepar, Lobus sinister Pars lumbalis diaphragmatis V. cava inferior Gaster A. hepatica propria C a p u t pancreatis; Ductus pancreaticus

Ductus choledochus [biliaris] V. renalis dextra

V. po rtae hepatis

A. renalis dextra

Omentum majus, Lig. gastrocolicum

Caput pancreatis, Proc. uncinatus

Colon transversum

Duodenum

Omentum majus

V. mesenterica superior M. erector spinae A. mesenterica superior

A. iliaca communis V. iliaca communis

Os sacrum

Rectum Ileum

M. piriformis Excavatio rectovesicalis Ductus deferens

Cavitas peritonealis Vesica urinaria

Corpus ossis pubis

Glandula vesiculosa Rectum M. gluteus maximus

M. levator ani, M. iliococcygeus M. levator ani, M. pubococcygeus

Fig. 6.1 2 1

A b d o m e n , A b d o m e n , a n d p e lv is . P e lv is , o f a m a n ;

s a g itta l s e c tio n ; v ie w fr o m th e le ft side .

v e n o u s b lo o d fro m th e live r, is c le a rly v is ib le . T h e p o rta l v e in (V. p o rta e h e p a tis ), w h ic h b rin g s th e n u trie n t-ric h b lo o d fr o m th e u n p a ire d v is c e ra

T h is is a rig h t p a ra m e d ia n s e c tio n a t th e le ve l o f th e V. cava in fe rio r. T h u s , th e c o n flu e n c e o f th e liv e r v e in s (Vv. h e p a tica e ), w h ic h d ra in th e

to th e liv e r, a ris e s fr o m th e c o n flu e n c e o f th e t w o m a in trib u ta rie s be h in d th e p a n c re a tic head.

Viscera of the A b d o m e n

Developm ent -► Stomach -► Intestines -► Liver and gallbladder -►

A b d o m e n and pelvis, fro n ta l section

V. cava inferior Hepar, Lobus caudatus V. hepatica sinistra V. portae hepatis

Atrium cordis dextrum Ventriculus cordis dexter Lig. triangulare sinistrum

V. portae hepatis, R. dexter Gaster, Ostium cardiacum A. hepatica propria A.; V. gastrica sinistra Duodenum, Pars superior Colon transversum Hepar, Lobus dexter

Cauda pancreatis

Colon transversum

A. gastroduodenalis V. splenica [lienalis]

C a p u t pancreatis Duodenum, Flexura duodenojejunalis Colon ascendens A. mesenterica superior A.; V. mesenterica superior Aa. jejunales

Jejunum

Colon ascendens

Ileum Cavitas peritonealis Os ilium Colon descendens

Symphysis pubica Colon sigmoideum Os pubis

Fig. 6 .1 2 2

A b d o m e n , A b d o m e n , a n d p e lv is . P e lv is , o f a m a n ;

fr o n ta l s e c tio n th r o u g h th e a n te rio r p a rt; v e n tra l v ie w .

T h is is a fro n ta l s e c tio n th ro u g h th e p o rta l v e in (V. p o rta e h e p a tis ) w h ic h c o u rs e s a b o v e th e p a n c re a tic h ead (C a p u t p a n c re a tis ) to th e h ilu m o f th e liv e r a nd d iv id e s in to a r ig h t a nd a le ft b ran ch .

150

Pancreas -> Spleen -» Topography -► Sections

Epigastrium , fro n ta l section

Oesophagus, Pars thoracica

Pulmo dexter, Lobus inferior

Ostium cardiacum I Lobus superior Pulmo sinister < [ Lobus inferior

Pulmo dexter, Lobus medius

Lobus hepatis sinister

Pleura parietalis, Pars diaphragmatica

Lig. triangulare sinistrum

Diaphragma Lobus hepatis dexter

Diaphragma Lig. gastrosplenicum

Ductus thoracicus C o rpus gastricum lymphoideus mediastinalis posterior)

Spien [Lien] G landula suprarenalis

Pars abdominalis aortae Lig. splenorenale Nodi lymphoidei splenici

Nn. splanchnici major et minor

A.; V. splenica [lienalis] G landula suprarenalis

P ancreas

Truncus sympathicus

Ren, Capsula adiposa

Pars lumbalis diaphragmatis

Fig. 6 .1 2 3

A b d o m in a l c a v ity , C a v ita s a b d o m in a lis , a n d in fe rio r

t h o r a x , C a v ita s th o ra c is ; fro n ta l s e c tio n a t th e le v e l o f th e k id n e y s ;

th e r ig h t a d re n a l g la n d (G la nd u la s u p ra re n a lis ) a t its caudal a s p e c t. On th e le ft s id e , th e c ra nia l p a rt o f th e le ft h e p a tic lo b e c o v e rs th e s to m a c h

d o rs a l v ie w . T h e s e c tio n s h o w s th e to p o g ra p h ic a l re la tio n s h ip s o f th e e p ig a s tric v is

(G a ste r) w h ic h , in tu rn , c o n ta c ts th e s p le e n a n d c a u d a lly th e le ft k id n e y , th e le ft a dre n a l g la n d a nd th e P a n cre a s. T h e p a n c re a tic ta il e x te n d s

c e ra . T h e rig h t E p ig a s triu m is e n tire ly o c c u p ie d b y th e rig h t lo b e o f th e liv e r (L o b u s h e p a tis d e x te r) w h ic h c o n ta c ts th e rig h t k id n e y (R en) and

to w a rd s th e s p le e n .

151

Viscera of the A b d o m e n

Developm ent -â&#x2013;ş Stomach -â&#x2013;ş Intestines -â&#x2013;ş Liver and gallbladder

Epigastrium , sagittal section

Pulmo dexter, Lobus inferior

Costa V

Pleura visceralis [pulmonalis] Pleura parietalis, Pars costalis

Hepar, Lobus dexter

Pars costalis d iaphragm atis

Costa XI

M. erector spinae

Recessus costodiaphragmaticus

Medulla renalis Peritoneum viscerale M. quadratus lumborum

G aster

Omentum majus Fascia renalis

Fig. 6 .1 2 4

A b d o m e n , A b d o m e n ; s a g itta l s e c tio n th ro u g h th e rig h t

e p ig a s triu m a t th e le ve l o f th e k id n e y ; v ie w fr o m th e rig h t s id e . T h e rig h t e p ig a s triu m c o n ta in s th e rig h t lo b e o f th e liv e r (H epar, L o b u s d e x te r) w h ic h has e x te n s iv e c o n ta c ts w it h th e in fe rio r a s p e c t o f th e

152

Colon transversum

d ia p h ra g m . D o rs a l a nd in fe rio r to th e live r, th e k id n e y (R en) is lo c a te d in th e re tro p e rito n e a l s p a c e ; v e n tra l th e r e o f th e Pass p y lo ric a o f th e s to m a c h (G a ste r) is lo c a te d in th e in tra p e rito n e a l ca vity.

Pancreas -> Spleen -Âť Topography -â&#x2013;ş Sections

Epigastrium , sagittal section

G aster, Card ia, O stium cardiacum

Fornix gastricus Pulmo sinister, Lobus inferior

Pericardium

Lig. phrenicosplenicum

Pleura visceralis [pulmonalis]

Costa VI

Pleura parietalis, Pars costalis Pars costalis diaphragmatis Splen [Lien] Hepar, Lobus sinister Lig. gastrosplenicum

Bursa om entalis

Recessus costodiaphragmaticus M. erector spinae

Costa IX

Costa XII

G aster, Pars pylorica, A ntrum pyloricum M. quadratus lumborum

Fascia renalis

Omentum majus, Lig. gastrocolicum M. rectus abdominis

M. psoas major Cavitas peritonealis

Omentum majus Colon transversum

Fig. 6 .1 2 5

A b d o m e n , A b d o m e n ; s a g itta l s e c tio n th ro u g h th e le ft

e p ig a s triu m a t th e le v e l o f th e s p le e n ; v ie w fr o m th e le ft sid e . T h e s to m a c h (G a ste r) o c c u p ie s th e m a jo r p a rt o f th e le ft E p ig a s triu m . It is c o v e re d v e n tra lly b y th e le ft lo b e o f th e liv e r (H ep a r, L o b u s sin is te r)

a nd c o n ta c ts th e s p le e n a nd th e le ft k id n e y (R en) a t its d o rs a l s id e ; th e le ft k id n e y is lo c a te d in th e re tro p e rito n e a l sp a ce . L in e d b y p e rito n e u m , th e B ursa o m e n ta lis fo r m s a s m a ll re c e s s b e h in d th e s to m a c h .

Viscera of the A b d o m e n

Developm ent -* Stomach -► Intestines -► Liver and gallbladder

Epigastrium , tran sverse sectio n s M. rectus abdominis

Lig. falciforme

Costa VII —■J't

“V----- j ----- j K. \

i T-

Pleura parietalis, Pars costalis

C ° sta

Ductus thoracicus Pars thoracica aortae

Pleura parietalis, Pars diaphragmatica

’' \

Linea alba Hepar, Lobus sinister

G aster

Pars costalis diaphragmatis

Cavitas pleuralis, Recessus costodiaphragmaticus

Costa VI Peritoneum parietale Peritoneum viscerale

M. obliquus externus abdominis

Costa VII

Mm. intercostales

Splen [Lien] Cavitas peritonealis

Costa VIII

V. splenica [lienalis]

V. hepatica dextra

A. splenica [lienalis] M. latissim us dorsi N. intercostalis (T9)

Costa IX

Bursa om entalis

V. portae hepatis, R. dexter, R. posterior

Pars lumbalis diaphragmatis, Crus sinistrum

V. cava inferior

Truncus sympathicus

Vertebra thoracica XI, Proc. articularis superior Vertebra thoracica XI

6 .1 2 6

Medulla spinalis

M. erector spinae N. intercostalis (T10) Spatium epidurale

Proc. xiphoideus

M. rectus abdominis

Pars costalis diaphragmatis

Hepar, Lobus sinister Costa VII

Gaster

Hepar, Lobus dexter

Splen [Lien]

Vertebra thoracica

Pars thoracica aortae

Pars lumbalis diaphragmatis

M. erector spinae

6 .1 2 7

Fig. 6 .1 2 6 a n d Fig. 6 .1 2 7 A b d o m in a l c a v ity , C a v ita s a b d o m in a lis ; tra n s v e rs e s e c tio n a t th e le ve l o f th e 1 1th th o ra c ic v e rte b ra (-* -*

Fig. 6 .1 2 6 ) a n d c o rre s p o n d in g c o m p u te d to m o g ra p h ic s e c tio n (CT; Fig. 6 .1 2 7 ); ca ud a l v ie w .

T h e liv e r o c c u p ie s th e e n tire r ig h t e p ig a s triu m a nd w ith its le ft lobe e x te n d s t o th e le ft a n te rio r s id e o f th e s to m a c h (G a ste r). P o s te rio r to th e s to m a c h a n d lin e d b y p e rito n e u m s p le e n is c u t in th e le ft E p ig a s triu m .

is th e B ursa o m e n ta lis . T h e

i- Clinical R em arks-------------------------------------S e c tio n a l im a g in g as s h o w n h e re fo r c o m p u te d to m o g r a p h y (CT) is e s ta b lis h e d ro u tin e ly in d ia g n o s tic p ro c e d u re s . It a llo w s th e im a g in g o f s o ft tis s u e s w it h o u t c o n tra s t m e d iu m a nd is le s s p ro n e to d is tu rb a n c e s th a n u ltra s o u n d im a g in g w h ic h m a y s u ffe r fr o m d e c re a s e d re s o lu tio n b y c e rta in c o n d itio n s s u c h a s a ir-fille d in te s tin a l

lo o p s . T h e re fo re , C T im a g in g is u s e d as a d d itio n a l d ia g n o s tic to o l a n d in p re o p e ra tiv e p la n n in g . A c c o rd in g to c o n v e n tio n , CT im a g e s are a lw a y s s h o w n in c a u d a l v ie w . F o r d id a c tic a nd p ra c tic a l p u rp o s e s , it is a d v is a b le to s tu d y a n a to m ic a l s e c tio n s a ls o in c a ud a l v ie w .

Pancreas -► Spleen -» Topography -► Sections

Epigastrium , tran sverse section s Lig. teres hepatis; Lobus hepatis sinister

Lig. M. rectus abdominis, Vagina musculi recti abdominis

A. hepatica communis

M. transversus abdominis minus, Lig. hepatogastricum

Hepar, Lobus quadratus Ductus cysticus; choledochus [biliaris]

A.; V. gastrica sinistra; Ganglion coeliacum; Nodi lymphoidei gastroomentales

Lig. hepatoduodenale A. hepatica propria, R. dexter; V. portae hepatis

Bursa om entalis G aster

Lobus caudatus, Proc. papillaris; Bursa omentalis, Recessus superior

Omentum majus Recessus splenicus

V. portae hepatis, R. dexter r Pars costalis; Diaphragma < Pars lumbalis, [ Crus dextrum

Hilum splenicum; Nodi lymphoidei splenici

Lobus hepatis dexter

Splen [Lien]

V. cava inferior C auda pancreatis

Ductus thoracicus V. azygos

Peritoneum viscerale

Cavitas pleuralis

Cavitas peritonealis

Pleura Pars diaphragmatica

Peritoneum parietale A.; V. splenica [lienalis]

Pleura parietalis, Pars costalis Mm. intercostales externi et interni

Ren; Glandula suprarenalis

Ren

Ren, Capsula adiposa hemiazygos; N. splanchnicus major

M. latissim us dorsi

Aorta; Diaphragma; N. splanchnicus minor

M. serratus posterior inferior

N. thoracicus [T12] M. iliocostalis thoracis

Conus medullaris

N. splanchnicus minor

6 .1 2 8

M. longissimus

Vertebra thoracica XII, Proc. spinosus “ multifidi

“

Peritoneum

Peritoneum in the area of the Bursa omentalis

Hepar, Lobus sinister Colon transversum Lig. falciforme Lig. teres hepatis Pancreas Hepar, Lobus caudatus Colon descendens Hepar, Lobus dexter V. portae hepatis

Aorta

V. cava inferior Vertebra lumbalis, Corpus vertebrae

Pars lumbalis diaphragmatis Costa X

Splen [Lien]

M. latissimus dorsi

Ren sinister

Costa XI M. erector spinae

Ren dexter

Costa XII

6 .1 2 9

A b d o m in a l c a v ity , C a v ita s a b d o m in a lis ;

A t th e le v e l o f th e 1st lu m b a r v e rte b ra , a d d itio n a l v is c e ra are v is ib le ,

tra n s v e rs e s e c tio n a t th e le v e l o f th e 1st lu m b a r v e rte b ra (-* Fig. 6 .1 2 8) a nd c o rre s p o n d in g c o m p u te d to m o g ra p h ic s e c tio n (CT; -» Fig. 6 .1 2 9 );

Fig. 6 .1 2 8 a n d Fig. 6 .1 2 9

s u c h as th e s u p e rio r p o le s o f th e k id n e y s (Ren) a n d th e P a n cre a s. The P a n cre a s is lo c a te d p o s te rio r to th e s to m a c h , s e p a ra te d b y th e B ursa

c a ud a l v ie w .

o m e n ta lis , a nd e x te n d s to th e le ft s id e u n til it re a c h e s th e h ilu m o f th e s p le e n .

[- Clinical R em arks-------------------------------------For th e e x a m in a tio n o f th e P a n cre a s, u ltra s o u n d im a g in g is o fte n

s u c h as in fla m m a to ry d is e a s e (p a n c re a titis ), w h e n o e d e m a to u s o r

n o t v e ry in fo rm a tiv e d u e to th e a ir-fille d in te s tin a l lo o p s. T h e CT is p e rfo rm e d t o fin d o r c o n firm th e d ia g n o s is o f p a n c re a tic c o n d itio n s

c y s tic s w e llin g o f th e o rg a n is d e te c te d . C T im a g in g is a ls o u s e d to m o n ito r th e p ro g re s s o f p a n c re a tic d is e a s e s .

Viscera of the A b d o m e n

Developm ent

... -> Sections

Epigastrium , tran sverse sectio n s

fcizd-

Hepar, Lobus sinister

Kt \ I

.V f

Gaster

V. portae hepatis

V. splenica [lienalis] transversum

Costa !

Costa VIII

rectus abdominis

Peritoneum

A. mesenterica superior

Cavitas peritonealis

Pancreas

Pars costalis diaphragmatis Nodus lymphoideus pancreaticus Recessus costodiaphragmaticus Pleura parietalis, Pars diaphragmatica Pleura parietalis, Pars costalis

Costa VIII

Costa IX

Vesica biliaris [fellea]

Hepar, Lobus dexter C olon descenden s Costa X

A. renalis Costa XI M. latissimus dorsi V. cava inferior H ilum renale Pars lumbalis diaphragmatis Costa

6 .1 3 0

renalis renalis minor

Truncus sympathicus

renalis

M. erector spinae

â&#x20AC;˘Cortex renalis Cauda equina renalis A. mesenterica inferior

abdominalis aortae

mesenterica superior Hepar, Lobus sinister Jejunum Vesica biliaris A. renalis V. cava inferior

Pars abdominalis aortae

V. renalis Corpus vertebrae lumbalis I Hepar, Lobus dexter

Sinus renalis

6.1 3 1

Fig. 6 .1 3 0 a n d Fig. 6.1 3 1

A b d o m in a l c a v ity , C a v ita s a b d o m in a lis ;

tra n s v e rs e s e c tio n a t th e le ve l o f th e 1st lu m b a r v e rte b ra (-* Fig. 6 .1 3 0 ) a nd c o rre s p o n d in g c o m p u te d to m o g ra p h ic s e c tio n (CT; - * Fig. 6 .1 3 1 ); ca ud a l v ie w .

T y p ic a lly , th e h ilu m o f th e k id n e y (R en) is lo c a te d a t th e le ve l o f th e fir s t t w o lu m b a r v e rte b ra e (re c o g n is e d b y th e c o n flu e n c e o f th e le ft V. re n a Â lis). T h e g a llb la d d e r (V esica b iliaris) is s e c tio n e d a t th e in fe rio r b o rd e r o f th e liv e r (H ep a r). In th e le ft E p ig a s triu m , p o rtio n s o f th e s m a ll in te s tin a l L o o p s (J e ju n u m ) a nd p o rtio n s o f th e la rg e in te s tin e (C olon tra n s v e rs u m a n d C olo n d e s c e n d e n s ) are v is ib le .

156

Pelvis and Retroperitoneal Space K id ne y and A d re n a l Gland

.............

160

Efferent U rin a ry S y s t e m ...................

174

G e n ita lia ..................................................

182

Rectum and A nal Canal ...................

220

T o p o g r a p h y ........................................... 228 S ections ................................................. 236

Pelvis and Retroperitoneal Situs T h e p e lv is (P elvis) is d e s ig n e d to fu lfil t w o p u rp o s e s : O n th e o n e hand, it has t o b e a r th e w e ig h t o f th e v is c e ra in h u m a n s e x h ib itin g an e re c te d p o s tu re . H e n c e , a s o lid , w e ig h t b e a rin g , p o s s ib ly b o n y flo o r w o u ld be

p ro s ta te g la n d [P ro s ta ta ] a nd th e s e m in a l v e s ic le s [G la n d ula e v e s ic u lo sae]), re s p e c tiv e ly . B ra n c h e s o f th e A . iliaca in te rn a a nd n u m e ro u s n e rv e s th a t s u p p ly th e p e lv ic o rg a n s , b u t a ls o th e lo w e r e x tre m itie s ,

re a s o n a b le a t th e ca ud a l a s p e c t o f th e a b d o m in a l c a v ity (C avita s a b d o m in a lis). O n th e o th e r h an d , w ith re g a rd s to th e e lim in a tio n o f p ro d u c ts

e x te n d in to th is s u b p e rito n e a l c o n n e c tiv e tis s u e .

b y th e in te s tin e s a n d th e k id n e y s , th e a c t o f p ro c re a tio n , a nd in p a rtic u lar c h ild b irth , a rig id c lo s u re is n o t p ra c tic a l. T h e " c o n s tr u c tiv e " c o m p ro m is e is th e D ia p h ra g m a p e lv is : a fu n n e l-s h a p e d g ro u p o f m u s c le s a t th e

M o b ilis a tio n o f th e b lo o d v e s s e ls a nd o rg a n s e x p o s e s a m u s c u la r p e lv ic flo o r, th e D ia p h r a g m a p e lv is , w h ic h is p e rfo ra te d b y th e U re th ra and

b o tto m o f th e p e lv is , w h ic h is p e rfo ra te d in th e m id s a g itta l p la n e b y th e U re th ra , th e R e c tu m , a n d th e V a gina in fe m a le s .

V a gina (if p re s e n t). It is lik e a d e e p , la te ra lly c o m p a c te d fu n n e l. A t th e d e e p e s t p o in t o f th e c o n e , th e R e c tu m p e rfo ra te s th e fu n n e l. T h e M . le v a to r ani is th e m u s c le th a t fo r m s a la rg e p a rt o f th e p e lv ic flo o r, and is a b le to (v o lu n ta rily !) ra is e a nd lo w e r th e A n u s b y a f e w c e n tim e tre s .

T o re v ie w th e r e tr o p e r ito n e a l s itu s o f th e a b d o m e n - in c lu d in g th e o rg a n s, w h ic h are n o t s itu a te d in th e a b d o m in a l c a v ity , b u t a t th e d o rs a l w a ll - a lo n g w it h th e p e lv is , has a g o o d (o n to g e n e tic ) re a s o n . T h e kid n e ys, th e m a jo r o rg a n s o f th e re tro p e rito n e a l sp a ce , in itia lly o rig in a te fro m th e p e lv is a nd a s c e n d to a le ve l ju s t in fe rio r to th e rib s . C o n v e rs e ly, th e g o n a d s , i.e. te s tic le s (T e ste s) a nd o v a rie s (O varia), d e s c e n d fro m th e a b d o m e n in to th e p e lv is a nd in m e n e v e n fu r th e r d o w n in to th e S c ro tu m . T h u s, th e s u b p e rito n e a l (se e b e lo w ) c o n n e c tiv e tis s u e s p a c e s o f th e p e lv is a nd th e re tro p e rito n e a l s p a c e fo r m a c o n tin u u m . In o rd e r to g a in in s ig h t in to th e re g io n s a d d re s s e d in th e fo llo w in g , radi

B e lo w th e w a lls o f th e p e lv ic d ia p h ra g m , v irtu a lly in th e " b a s e m e n t" o f th e p e lv is , lie s th e p e rin e a l re g io n (R egio p e rin e a lis ): T ra c in g th e u re th ra (U re th ra ) o n e re a c h e s th e a n te r io r p e r in e u m , th e u ro g e n ita l tr i a n g le (R eg io u ro g e n ita lis ). T h e ro o ts o f th e c a v e rn o u s b o d ie s o f th e P enis, w h ic h b e a rs th e m a le U re th ra , o rig in a te in a nd p ro tru d e fr o m th is re g io n . T h is re g io n a ls o e n c o m p a s s e s th e c a v e rn o u s b o d ie s o f th e C li to ris e n c lo s in g th e o p e n in g o f th e s h o rt fe m a le U re th ra . T h e p o s te rio r p e rin e u m , th e anal tria n g le (R eg io a nalis), is lo c a te d b e lo w th e p e lv ic d ia p h ra g m to th e rig h t o r le ft s id e o f th e R e c tu m . It c o n ta in s large, a d i

cal d is s e c tio n s te p s are n e c e s s a ry to s o m e e x te n t: T h e s m a ll a nd large in te s tin e s h a ve to be re m o v e d o r a t le a s t m o b ilis e d so th a t th e y ca n be

p o s e -fille d p its ca lle d Fo ssa e is c h io a n a le s . T h e y re s e m b le c ra n ia lly p o in tin g p y ra m id s w it h th e ir b a s e s d ire c te d c a u d a lly w it h re s p e c t t o th e R e c tu m . M a jo r n e rv e s a nd b lo o d v e s s e ls are tra c e a b le in th e Fossae

cle a re d fr o m th e p o s te rio r a b d o m in a l w a ll. S o m e d is s e c to rs e v e n re m o v e all o rg a n s o f th e e p ig a s tric re g io n a t o nce .

is c h io a n a le s , s u p p ly in g th e o rg a n s o f th e p e rin e a l re g io n (i.e. P enis, C lito ris , Labia m a jo ra a nd m in o ra , V e s tib u lu m va g in a e , a nd A n u s ).

The V ie w into the Pelvis

V ie w o f th e R etroperitoneal Situs

T h e s o -ca lle d g r e a te r p e lv is (P e lvis m a jo r, b e tw e e n th e w in g s o f th e iliu m ) s e e m s to b e a lm o s t e m p ty a fte r th e re m o v a l o f th e in te s tin e s . T h e p so a s m a jo r m u s c le (M . p so a s m a jo r) is a c c o m p a n ie d b y th e V asa

R e m o v a l o f th e p a rie ta l p e rito n e u m a n d th e u n d e rly in g a d ip o s e tis s u e fir s t re v e a ls th e in fe rio r v e n a cava (V. cava in fe rio r, s lig h tly to th e rig h t

iliaca e x te rn a a nd s p a n s fr o m th e lu m b a r s p in e d o w n to th e in g u in a l re g io n fla n k in g th e e n tra n c e to th e le s s e r p e lv is (P e lvis m in o r).

s id e o f th e v e rte b ra l c o lu m n ) a nd th e a b d o m in a l a o rta (A o rta a b d o m in a lis, im m e d ia te ly to th e le ft side ). B o th are re m in is c e n t o f an "u p s id e -

In c o n tra s t, th e c a u d a lly n a rro w in g fu n n e l-s h a p e d le s s e r p e lv is is n o t

d o w n Y " , b ifu rc a tin g a t th e le v e l o f th e lo w e r lu m b a r v e rte b ra e in to th e A a. a nd Vv. ilia cae c o m m u n e s , i.e. th e iliac a rte rie s a n d v e in s . T h e V.

v a c a n t, e s p e c ia lly in w o m e n . V e n tra lly , im m e d ia te ly b e h in d th e S y m p h y s is p u b ic a , lie s th e fu n d u s o f th e u rin a ry b la d d e r (V esica u rin a ria ). In

c ava in fe r io r h as s e v e ra l trib u ta rie s ; in th e u p p e r th ird e s p e c ia lly th e t w o renal v e in s (Vv. re na le s) a n d th e s h o rt h e p a tic v e in s (Vv. h ep a tica e)

w o m e n , th e F u n d u s o f th e U te ru s is lo c a te d im m e d ia te ly p o s te rio r to th e u rin a ry b la d d e r. B ila te ra lly, t w o u te rin e (F A L L O P IA N ) tu b e s (Tubae

are re m a rk a b le . T h e A o r ta a b d o m in a lis has lik e w is e m a n y b ra n c h e s . T h e la rg e v e s s e ls are d e n s e ly c o v e re d w ith ly m p h n o d e s a n d ly m p h

u te rin a e ) a s c e n d fro m th e U te ru s to w a rd s th e o v a rie s (O varia), w h ic h th e y e m b ra c e w it h th e ir fim b ria te d p ro je c tio n s . T h e o v a rie s are lo c a te d

v e s s e ls th a t ris e as p a ire d T ru n ci lu m b a le s fr o m th e p e lv is . A t th e level o f th e b ra n c h in g renal v e s s e ls , th e T ru n c i lu m b a le s m e rg e in th e C is te r-

b ila te ra lly a t th e p e lv ic w a ll, ju s t in fe rio r to th e b o u n d a ry b e tw e e n th e g re a te r a n d th e le s s e r p e lv is . T h e re c tu m (R e ctu m ) is p o s itio n e d

na c h y li, w h ic h a ls o re c e iv e s th e ly m p h o f th e in te s tin e s , t o fo r m th e th o ra c ic d u c t (D u c tu s th o ra c ic u s ).

b e tw e e n th e u rin a ry b la d d e r, th e U te ru s , a n d th e d o rs a l p e lv ic w a ll (i.e. th e s a c ru m ), re s p e c tiv e ly .

T h e k id n e y s (R enes) a n d th e a d re n a l g la n d s are lo c a te d b ila te ra lly in a

T h e b o d y o f th e U te ru s as w e ll as th e u te rin e tu b e s a n d th e o v a rie s are lo c a te d in s e p a ra te p e rito n e a l d u p lic a tu re s /m e s e n te rie s ( " M e s o s " ) in th e a b d o m in o p e lv ic c a v ity (C a v ita s p e r ito n e a lis p e lv is ) w h ic h p ro je c t a t v a rio u s d e p th s to w a rd s th e a c tu a l p e lv ic flo o r. In w o m e n , th e re is a

lu m d e s c e n d in g in to th e p e lv is a lo n g w it h th e v e s s e ls o f th e g o n a d s . The v e s s e ls o f th e g on a d s arise fro m th e A o rta a nd e n te r - in a fa s c in a t

p a rtic u la rly d e e p re c e s s b e tw e e n th e re ar w a ll o f th e U te ru s a nd th e fr o n ta l w a ll o f th e R e c tu m , th e E xca va tio re c to u te rin a . T h e fu n d u s o f

in g a s y m m e tric a l fa s h io n (and th e re fo re p o p u la r a s an e x a m q u e s tio n ) - th e le ft re n a l v e in a nd th e V. cava in fe rio r. A b o v e a n d m e d ia l to th e

th e b la d d e r a nd th e u p p e r p o rtio n o f th e R e c tu m are c o v e re d b y p e rito n e u m . In c is in g th e p e rito n e u m a nd d is s e c tin g th e a b o v e -m e n tio n e d

u p p e r p o le o f th e k id n e y s are th e a d re n a l (s u p ra re n a l) g la n d s (G lan d u la e s u p ra re n a le s ) w h ic h c o n s titu te e n d o c rin e g la n d s th a t p ro d u c e

p e lv ic o rg a n s re v e a ls th e s u b p e rito n e a l s p a ce o f th e p e lv is (S p a tiu m e x tr a p e r ito n e a le p e lv is ). T h e lo w e r p a rts o f u rin a ry b la d d e r, U te ru s ,

s te ro id h o rm o n e s (e.g. c o rtis o l) a nd c a te c h o la m in e s (a d re n a lin e [e p in e p h rin e ]).

a nd R e c tu m are lo c a te d w ith in th is c o n n e c tiv e tis s u e , a s w e ll as th e fe m a le V a gina a n d th e m a le a c c e s s o ry s e x g la n d s (in p a rtic u la r th e

158

p e rire n a l fa t c a p s u le (C apsula a dip o sa) ju s t b e lo w th e d ia p h ra g m a tic d o m e . D o rs a l to th e u p p e r p o le o f e a c h k id n e y lies rib X II. M e d ia lly , th e V asa re na lia e n te r th e k id n e y s a t th e h ilu m . T h e U r e t e r e x its a t th e hi-

Clinical R em arks----------------------------------T w o m e d ic a l s p e c ia lis ts , th e g y n a e c o lo g is t a nd th e u ro lo g is t, are in v o lv e d in th e tr e a tm e n t o f d is e a s e s o f th e u ro g e n ita l tra c t. D e ta ile d k n o w le d g e o f th e to p o g ra p h ic a l a n a to m y is re q u ire d fo r th e in te rp re ta tio n o f ra d io lo g ica l and u ltra s o n ic im a g e s and d u rin g s u rg e ry , su ch as re s e c tio n o f th e k idn e y, th e U te ru s , or th e p ro s ta te g la n d in c a se s o f m a lig n a n t tu m o u rs . P ro s ta tic car c in o m a s are a m o n g th e th re e m o s t c o m m o n m a lig n a n c ie s in m e n . B e ca u se th e y u s u a lly d e v e lo p fro m th e p e rip h e ra l z o ne o f th e p ro s ta te g la n d , th e s im p le d ig ita l re c ta l e x a m in a tio n a lre a d y p ro v id e s im p o rta n t d ia g n o s tic in fo rm a tio n . Even m o re c o m m o n are th e b e n ig n tu m o u rs o f th e p ro s ta te g la n d (b e n ig n p ro s ta tic h y p e rp la s ia ) w h ic h o c c u r in a lm o s t all m a le in d iv id u a ls o v e r 70 y e a rs o f a ge. S ince th e h y p e rp la s ia o c c u rs in th e tra n s itio n a l zone o f th e g la n d s u rro u n d in g th e U re th ra , p ro b le m s w it h m ic tu ritio n are e a rly s y m p to m s . In w o m e n , in fla m m a to r y p rocesses o f th e u te rin e (F A L L O P IA N ) tu b e a n d th e o v a ry n ee d to be c o n s id e red in a d d itio n to an a p p e n d ic itis as p o te n tia l c a u s e s o f pain in th e rig h t lo w e r a b d o m e n . T h e s e e x a m p le s d e m o n s tra te th e c lin i cal re le v a n c e o f to p o g ra p h ic a l a n a to m y o f th e p elvis.

— ►

D issection Link

exam

: h e c k l is t

It is u s e fu l to d is s e c t th e p e lv is fr o m th e o u ts id e a nd fro m th e in s id e in o rd e r to tra c e p a th w a y s th a t e m e rg e fr o m th e p e lv is . T h e R eg io g lu te alis, th e R eg io p e rin e a lis w it h th e Fossa is ch io a n a lis, a nd th e p e rin e a l

• D e v e lo p m e n t: k id n e y , in t e r n a l a n d e x te r n a l g e n ita lia ( m a jo r

c a v itie s in c lu d in g all p a th w a y s are d is s e c te d fr o m th e o u ts id e . F ro m t h e in s id e , th e p a rie ta l p e rito n e u m is re m o v e d to g e th e r w it h th e p e

flo o r , o r g a n is a t io n o f t h e R e g io p e r in e a lis , s e c tio n a l im a g in g w it h C T • o r g a n s : a ll o r g a n s w it h n e u r o v a s c u la r p a th w a y s in c lu d in g

rire n a l fa t c a p s u le in c lu d in g th e a n te rio r fa scia up to th e le s s e r p e lv is . K id n e y s a n d a d re n a l g la n d s are e x p o s e d fr o m th e C apsula a d ip o s a ;

t h e ly m p h a tic d r a in a g e (in p a r t ic u la r T e s tis a n d O v a r iu m ) , A n u s ( in c lu d in g z o n e s ) a n d c o n tin e n c e o r g a n , o r g a n is a t io n o f th e

th e U r e te r a nd th e re tro p e rito n e a l n e u ro v a s c u la r s tru c k tu re s w it h th e ir b ra n c h e s are tra c e d . For p ro p e r d is s e c tio n o f th e p e lv is , it is u s e fu l to

U r e te r a n d U r e th r a w it h c o n s t r ic t io n s , U te r u s a n d lig a m e n ts . C o r p o r a c a v e r n o s a p e n is w it h e r e c tio n , m a le a c c e s s o r y s e x g la n d s w it h e x c r e t o r y d u c ts • v a s c u la r p a th w a y s : A o r ta w it h

p e rfo rm a m id s a g itta l c u t in o rd e r to s p lit th e p e lv is in to t w o e qu a l p arts. T h e u rin a ry b la d d e r a nd th e R e c tu m are m o b ilis e d fr o m th e c o n n e c tiv e tis s u e o f th e s u b p e rito n e a l s p a c e b u t re m a in a tta c h e d to th e b lo o d v e s s e ls . T h e b ra n c h e s o f th e A . iliaca in te rn a a re to b e p re s e n te d as a

s te p s ) • t o p o g r a p h y : p o s itio n a l r e la tio n s h ip s o f t h e o r g a n s in th e r e tr o p e r ito n e a l s p a c e a n d th e p e lv is , c o m p o s itio n o f t h e p e lv ic

b r a n c h e s , V. c a v a in f e r io r w it h tr ib u t a r ie s , D u c tu s t h o r a c ic u s w it h ly m p h a tic tr u n k s , P le x u s lu m b o s a c r a lis w it h in d iv id u a l n e r v e s a n d a u t o n o m ic n e r v e p le x u s e s a r o u n d t h e A o r ta

w h o le . S o m e b ra n c h e s e x it th e p e lv is via th e F o ra m in a s u p ra p irifo rm e a nd in fra p irifo rm e a n d e n te r th e R eg io g lu te a lis a nd th e R e g io p e rin e a lis. A t last, th e p e lv ic flo o r w it h its m u s c le la ye rs is e x p o s e d .

159

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d

O rganisation o f th e urinary syste m Fig. 7.1 a n d F ig .'7 .2

O rg a n is a tio n o f th e

m a le ( - * Fig. 7 .1 ) a n d th e fe m a le (-» Fig. 7 .2 ) u r in a r y s y s te m ; la te ra l v ie w fr o m th e

Ren [Nephros]

le ft s ide.

Pelvis renalis

T h e u rin a ry s y s te m c o m p ris e s th e p a ire d kid n e y s (Ren [N e p h ro s ]), p ro d u c in g th e u rin e , a n d th e e ffe re n t u rin a ry tra c ts . T h e s e c o n s is t o f: • •

renal p e lv is (P e lvis rena lis) U re te r

• •

u rin a ry b la d d e r (V esica urinaria) U re th ra

O rgana urinaria

U reter

Ductus deferens

E x c e p t fo r th e U re th ra , th e u rin a ry s y s te m is c o n s tru c te d id e n tic a lly in b o th s e x e s . T h e U re

Vesica urinaria Glandula vesiculosa Ductus deferens Prostata

th ra w ith in th e m a le p e n is p ro v id e s th e e x it o f u rin e as w e ll as s e m e n . T h u s , th e m a le U re th ra a lso b e lo n g s to th e e x te rn a l m a le g e n ita lia .

_ U rethra m asculina

Glandula bulbourethralis

( Organa genitalia masculina interna

Epididymis Ductus deferens

Ren [Nephros] Pelvis renalis

U reter O rgana urinaria Tuba uterina [Salpinx] ----- Ovarium Uterus Vesica urinaria Vagina

U rethra fem inina

Hypothalamus Glandula pinealis [Corpus pineale] Hypophysis [Glandula pituitaria]

Glandulae parathyroideae superior et inferior Glandula thyroidea Thymus

Figs. 7 .3 a a n d b

M a le a n d fe m a le

e n d o c rin e o rg a n s ; v e n tra l v ie w . T h e a d re n a l g la n d (G landula su p ra re n a lis) d o e s n o t b e lo n g to th e u rin a ry o rg a n s b u t to

Gaster

th e e n d o c rin e g la n d s . S e ve ra l v ita l s te ro id h o r m o n e s s u c h as a ld o s te ro n e (m in e ra lo c o rtic o -

G landula suprarenalis

id) a n d c o rtis o l (g lu c o c o rtic o id ), a s w e ll as c a te c h o la m in e s (e p in e p h rin e a nd n o re p in e p h

Insulae pancreaticae

rine ) are p ro d u c e d in th e c o rte x a n d m e d u lla , re s p e c tiv e ly , a n d re le a s e d in to th e b lo o d .

Ovarium

S ince th e a d re n a l g la n d s are a d ja c e n t to th e k id n e y s a nd a re , in p a rt, s u p p lie d b y th e s a m e

Intestinum

n e u ro v a s c u la r s tru c tu re s , th e a d re n a l g la n d is d is c u s s e d h ere , to o .

Testis

160

Organa genitalia feminina interna

Efferent urinary system -► Genitalia -► Rectum and anal canal -► Topography -► Sections

P rojection o f kidney and adrenal gland

Oesophagus Glandula thyroidea Trachea

Pulmo

Diaphragm — Hepar G landula suprarenalis ----------------Gaster ------------Splen [Lien] ------------- Pancreas ------------ Duodenum ---------------Jejunum

Colon

-----------Ile u m -------------

Appendix vermiformis

Rectum

Figs. 7 .4 a a n d b

P ro je c tio n o f th e v is c era o n to th e b o d y s u rfac e ;

v e n tra l (a) a nd d o rsa l (b) v ie w s . K id n e y s a nd a d re n a l g la n d s are lo c a te d in a r e tr o p e r ito n e a l p o s itio n .

are e m b e d d e d in th e c o m m o n a d ip o s e c a p s u le (C apsula adiposa), w h ic h is fu r th e r e n c lo s e d in a s h e a th o f c o n n e c tiv e tis s u e (Fascia renalis, G E R O T A 's fa scia).

T h e a d re n a l g la n d s are a d ja c e n t to th e s u p e rio r p o le o f th e k id n e y s and

Fig. 7 .5

P ro je c tio n o f th e k id n e y o n to th e d o rs a l b o d y w a ll.

• •

s u p e rio r p o le : 12th th o ra c ic v e rte b ra , rib XI h ilu m : 2nd lu m b a r v e rte b ra

•

in fe rio r p o le : 3 rd lu m b a r v e rte b ra

T h e s e p o s itio n s o n ly a p p ly fo r th e le ft kidney. D u e to th e size o f th e live r, th e rig h t k id n e y is lo c a te d a b o u t h a lf a v e r te b ra fu r th e r d o w n . T h e s u p e rio r p o le is th u s p o s itio n e d ju s t b e lo w rib XI B e c a u s e o f th e p ro x im ity o f th e d ia p h ra g m , th e p o s itio n o f b o th k id n e y s c h a n g e s d u rin g re s p ira tio n a nd m o v e s a b o u t 3 c m lo w e r d u rin g in s p ira tio n . T h e a d re n a l g la n d s p ro je c t o n to th e h e a d s o f rib s XI a n d XII.

p Clinical R em arks-------------------------------------D u rin g p h y s ic a l e x a m in a tio n a fir s t s te p in a s s e s s in g th e pain s e n s iti

th e im p a c t. In th e case o f an in fla m m a tio n o f th e renal p elvis (pyelo

v ity o f th e k id n e y s m a y b e a w e ll-d o s e d p u n c h in to th e re g io n o f th e k id n e y s in th e fla n k s ju s t b e lo w th e in fe rio r m a rg in o f th e rib ca ge .

n e p h ritis ), th e p a tie n t w ill w in c e a n d re p o rt c o n s id e ra b le pain in re s p o n s e to th e p u n c h . E ve n if c a rrie d o u t c o rre c tly , th is e x a m in a tio n ca n c h a lle n g e th e re la tio n s h ip b e tw e e n p a tie n t a nd p h y s ic ia n .

H o w e v e r, th e p a tie n ts m u s t n o t be w a rn e d in a d va n ce to p re v e n t te n s io n o f th e b a c k m u s c le s w h ic h w o u ld re s u lt in a c u s h io n in g o f

Pelvis and Retroperitoneal Space

Kidney and adrenal gland -►

D e ve lo p m e n t o f th e kidney

Pronephros system

Intestine

Mesonephric system w ith mesonephric excretory units WOLFFIAN duct

Metanephric system Ureteric bud

Fig. 7 .6

D e v e lo p m e n t o f th e k id n e y s in w e e k 5 . (a c c o rd in g to [1])

T h e k id n e y s a nd th e e ffe re n t u rin a ry tr a c t d e riv e fr o m th e m e s o d e rm w h ic h , n e x t to th e s o m ite s , fo r m s n e p h ro g e n ic c e ll c lu s te rs re fe rre d to as n e p h ro to m e s . T h e s e s u c c e s s iv e ly g iv e rise to th r e e k id n e y g e n e r a tio n s w h ic h are fr o m cra nia l to caudal: • p ro n e p h ro s : fir s t g e n e ra tio n o f a ru d im e n ta ry k id n e y w h ic h c o m p le te ly re g re s s e s .

m e s o n e p h ro s : te m p o ra ry e x c re to ry tu b u le s a re fo rm e d , b u t w ith th e e x c e p tio n o f th e m e s o n e p h ric d u c t (W O L F F IA N d u c t) th e m e s o n e p h ro s a ls o re g re s s e s . Its d is ta l p a rt c o n trib u te s to th e fo rm a tio n o f th e e ffe r e n t d u c tu le s b e tw e e n T e s tis a n d E p id id y m is , m e ta n e p h ro s : b e g in n in g in w e e k 5, th e u re te ric b u d fr o m

th e

W O L F F IA N d u c t in d u c e s th e d e v e lo p m e n t o f th e p a re n c h y m a o f th e p e rm a n e n t k id n e y (n e p h ro n s ) in th e m e ta n e p h ric m e s o d e rm . T h e c o lle c tin g d u c ts a nd th e p ro x im a l p a rts o f th e e ffe r e n t u rin a ry tra c t (renal p e lv is a n d U re te r) d e v e lo p fr o m th e u re te ric b ud .

A. renalis

Horseshoe kidney

Ren

A. mesenterica inferior

Ureter

Vesica u r in a r ia -

Pelvic kidney

Figs. 7 .7 a t o d A sc e n s u s o f th e k id n e y s , (a c c o rd in g to [1]) T h e m e ta n e p h ro s d e v e lo p s a t th e le ve l o f th e 1st to 4 th sacral v e rte b ra e

c e n d , a p e lv ic k id n e y (c) is p re s e n t. A h o rs e s h o e k id n e y d e v e lo p s if b o th in fe rio r re n a l p o le s p o s itio n in c lo s e p r o x im ity to e a c h o th e r and

a nd a s c e n d s d u rin g w e e k s 6 to 9 o f d e v e lo p m e n t. In fa c t, th is is a rela tiv e a s c e n s u s s in c e th e p a rt o f th e d e v e lo p in g b o d y caudal to th e in fe

fu s e (d). T h e h o rs e s h o e k id n e y d o e s n o t fu lly a s c e n d b e c a u s e th e ro o t o f th e A . m e s e n te ric a in fe rio r p re s e n ts an o b s ta c le .

rio r p o le o f th e k id n e y g ro w s fa s te r (a a nd b). If th e k id n e y s fa il to as

i- Clinical R em arks----------------------------------------------------------------------------------------------------------P e lv ic

k id n e y s a n d

h o rs e s h o e

k id n e y s are

u s u a lly a c c id e n ta l

fin d in g s a nd have no clin ic a l re le v a n c e if th e U re te r is n o t c o m p ro m is e d . H o w e v e r, d is p la c e m e n ts o f th e U re te r m a y c a u s e an u rin e

162

s ta s is w it h re s u ltin g h y d ro n e p h ro s is a nd p o te n tia l a s c e n d in g u rin a ry tr a c t in fe c tio n s . T h e s e m a y c a u s e d a m a g e to th e kidney,

Efferent urinary system -> Genitalia -► Rectum and anal canal -► Topography -► Sections

D e ve lo p m e n t o f th e urogenital organs

Ureter

testis testis duct MÜLLERIAN duct

(mesonephric system)

Sinus urogenitalis

Ureteric orifice Gubernaculum

Opening of the WOLFFIAN duct

Genital tubercle (glans area)

of the Sinus urogenitalis Anus

Fig. 7 .8

D e v e lo p m e n t o f th e u rin a ry o rg a n s a n d e a rly

d e v e lo p m e n t o f th e in te r n a l g e n ita l o rg a n s in b o th s e x e s d u rin g

t w o parallel d u c t s y s te m s e x is t: th e D u c tu s m e s o n e p h ric u s o r W O L F F IA N d u c t a nd th e D u c tu s p a ra m e s o n e p h ric u s o r M U L L E R IA N d u c t. In

w e e k 8. (a cco rd in g to [1]) T h e k id n e y s d e v e lo p fr o m th e m e ta n e p h ro s a nd th e u re te ric b u d w h ic h

c o n tra s t to th e W O L F F IA N d u c t, th e d is ta l e n d s o f th e M U L L E R IA N d u c t fu s e p rio r to e n te rin g th e S in u s u ro g e n ita lis . A t th e e n d o f w e e k 7

a ris e s fro m th e W O L F F IA N d u c t. T h e u re te ric b u d g iv e s rise to th e p ro x im a l e ffe re n t u rin a ry tr a c t (renal p e lv is a n d U re te r) w h e re a s th e

th e in d iffe re n t g o n a d d e v e lo p s in to th e T e s tis a nd in to th e o v a ry , re s p e c tiv e ly . T h e h o rm o n e s p ro d u c e d in th e T e s tis (te s to s te ro n e a nd a n tiM U L L E R IA N h o rm o n e ) in d u c e th e d iffe re n tia tio n o f th e W O L F F IA N

u rin a ry b la d d e r a nd th e U re th ra d e v e lo p fr o m th e S in u s u ro g e n ita lis (v e n tra l p a rt o f th e clo a ca o f th e h in d g u t). U n til w e e k 7, th e in te rn a l g e n ita lia d e v e lo p in a s im ila r m a n n e r in m e n a n d w o m e n (se xu a lly in d iffe r e n t sta g e ). B e s id e s th e in d iffe r e n t g o n a d s ,

d u c t to th e m a le in te rn a l g e n ita lia (-» Fig. 7 .4 3 ) a n d th e s u p p re s s io n o f th e fu r th e r d e v e lo p m e n t o f th e M U L L E R IA N d u c t. If b o th h o rm o n e s are n o t p re s e n t, fe m a le in te rn a l g e n ita lia d e v e lo p (-» Fig. 7.7 3 ).

163

Pelvis and Retroperitoneal Space

Kidney and adrenal gland -►

Topography o f th e kidney and adrenal gland

G landula suprarenalis A. suprarenalis media; V. suprarenalis sinistra

G landula suprarenalis A. suprarenalis inferior; V. suprarenalis dextra Fascia renalis

Ren

A. renalis accessoria

A.; V. renal is

V. cava inferior A.; V. renalis

Costa XI

Ren, Capsula fibrosa

Ureter

Ren, C apsula adiposa

N. subcostalis

N. iliohypogastricus

N. ilioinguinalis M. quadratus lumborum M. psoas major N. genitofem oralis

Fig. 7 .9

P o s itio n o f th e k id n e y , R en [N e p h ro s ], a n d a d re n a l

g la n d , G la n d u la s u p ra re n a lis , in th e r e tr o p e r ito n e a l s p a c e; v e n tra l

P r o x im ity to t h e n e rv e s o f t h e P le x u s lu m b a lis : B e tw e e n th e renal

v ie w .

fa s c ia in th e area o f th e in fe rio r re n a l p o le a nd th e m u s c le s o f th e dorsa l a b d o m in a l w a ll, th e N. ilio h y p o g a s tric u s a n d th e N. ilio in g u in a lis fro m

K id n e y a n d a d re n a l g la n d are lo c a te d in th e re tro p e rito n e a l s p a c e v e n tra lly o f th e M . p so a s a n d th e M . q u a d ra tu s lu m b o ru m . Fascial s y s te m s : T h e s u rfa c e o f th e k id n e y is c o v e re d b y a o rg a n ca p

th e P le x u s lu m b o s a c ra lis d e s c e n d . T h e y p ro v id e s e n s o ry in n e rv a tio n to th e s k in o f th e in g u in a l re g io n . T h e N. g e n ito fe m o ra lis c o u rs e s fu r th e r c a u d a lly a nd th e re fo re h as n o c o n ta c t to th e k id n e y , b u t to th e U re te r.

s u le o f d e n s e c o n n e c tiv e tis s u e (C apsula fib ro s a ). T o g e th e r w it h th e a d re n a l g la n d , th e k id n e y is c o v e re d b y a ca p s u le o f p e rin e p h ric fa t

F u rth e r cra n ia lly , th e 11th a nd 12th in te rc o s ta l n e rv e s (1 2 th in te rc o s ta l n e rv e = N. s u b c o s ta lis ) c o u rs e b e n e a th th e lo w e r rib s a lo n g th e p o s te

(C apsula a d ip o sa ). T h e p e rin e p h ritic a d ip o s e tis s u e is s u rro u n d e d b y a c o n n e c tiv e tis s u e s h e a th (Fascia re na lis). M e d ia lly a nd in fe rio rly , th e

rio r s id e o f th e k idn e y.

renal fa scia re m a in s o p e n fo r th e p a ssa g e o f th e U re te r a n d th e b lo o d v e s s e ls . T h e a n te rio r la m in a o f th e renal fa scia is re fe rre d to b y c lin i c ia n s as G E R O T A 's fa scia .

i- Clinical R em arks--------------------------------------

164

—♦

T h e fa s c ia l s y s te m s a n d th e to p o g ra p h ic a l re la tio n s h ip s o f th e kid

T h e c lo s e p ro x im ity o f th e k id n e y to th e N. ilio h y p o g a s tric u s and

n e y s are c lin ic a lly re le v a n t. In c a s e s o f m a lig n a n t tu m o u r s , th e kid n e y is a lw a y s re m o v e d to g e th e r w it h th e a d re n a l g la n d a nd in c lu d in g

N. ilio in g u in a lis e x p la in s w h y c e rta in d is e a s e s o f th e k id n e y s u c h as in fla m m a tio n o f th e renal p e lv is (p y e lo n e p h ritis ) o r c o n c re m e n ts in

th e G E R O T A 's fa s c ia (n e p h re c to m y ).

th e renal p e lv is (n e p h ro lith ia s is ) m a y c a u s e r a d ia tin g p a in in to th e in g u in a l re g io n .

dissection link

Efferent urinary system -> Genitalia -► Rectum and anal canal -► Topography -► Sections

S e g m e n ts and topographical relatio nships o f th e kidney

Segmentum anterius superius

Segmentum superius

A. renalis V. renalis

Segmentum posterius

Segmentum anterius inferius ■

Segmentum inferius Ureter

Figs. 7 .1 0 a a n d b

R e n a l s e g m e n ts , S e g m e n ta re n a lia , r ig h t side;

Segmentum inferius

p o s te rio r fo r th e p o s te rio r s e g m e n t. In th e ca se o f o c c lu s io n o f o n e o f

v e n tra l (a) a nd d o rs a l (b) v ie w s .

th e b ra n c h e s o f th e A . re n a lis , th e e x te n t o f re n a l in fa rc tio n c o rre la te s

T h e re n a l a rte ry (A. re n a lis) d iv id e s a t th e h ilu m o f th e k id n e y in to a R. p rin c ip a lis a n te rio r, w h ic h s u p p lie s th e s u p e rio r, th e t w o a n te rio r and th e in fe rio r re n a l s e g m e n ts w ith se v e ra l b ra n ch e s, a nd th e R. p rin c ip a lis

to th e area o f th e a ffe c te d renal s e g m e n ts . H o w e v e r, th e b ra n c h in g p a tte rn s a re h ig h ly v a ria b le a m o n g in d iv id u a ls .

Truncus coeliacus

A. mesenterica superior

Pars abdominalis aortae

V. suprarenalis sinistra

V. cava inferior A. renalis sinistra

A. renalis dextra

V. renalis sinistra

V. renalis dextra

Ureter sinister V. testicularis/ovarica sinistra Ureter dexter

V. testicularis/ovarica dextra

Glandulae suprarenales

Colon, Flexura dextra

Splen [Lien]

Hepar

Jejunum

Pancreas

Duodenum, Pars descendens

Gaster

Colon descendens

Fig. 7.11 C o n ta c t a re a s o f th e k id n e y , R en [IM ephros], w ith a d ja c e n t o rg a n s ; v e n tra l v ie w . T h e d o rs a l s id e o f th e k id n e y is a d ja c e n t to th e d o rsa l a b d o m in a l w a ll. T h e a n te rio r s id e has c o n ta c t to se v e ra l o th e r o rg a n s . T o g e th e r w it h th e

a d re n a l g la n d s , th e k id n e y s are s e p a ra te d fro m th e o th e r a b d o m in a l o rg a n s b y th e p a rie ta l p e rito n e u m , th e renal fa s c ia , a nd th e a d ip o s e c a p s u le . T h u s , th e a n te rio r c o n ta c t a re a s h a v e no c lin ic a l re le v a n c e .

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

O rganisation o f th e kidney Aa. suprarenales superiores

Margo superior G landula suprarenalis Glandula suprarenalis, Hilum

Aa. suprarenales mediae

Capsula adiposa Capsula fibrosa

V. suprarenalis, Rr.

Margo medialis

Ren

A. suprarenalis inferior Margo medialis A. renalis

V. renalis

Margo superior

Ureter

Aa. suprarenales superiores

Capsula adiposa Capsula fibrosa Ren

Margo medialis

Aa. suprarenales mediae

G landula suprarenalis V. suprarenalis A. suprarenalis inferior A. renalis, R. posterior

Margo lateralis

V. renalis Hilum renale A. renalis, R. anterior Pelvis renalis V. testicularis/ovarica sinistra

Ureter

Fig. 7 .1 2 a n d Fig. 7 .1 3

K id n e y , R en [N e p h ro s ], a n d a d re n a l g la n d ,

G la n d u la s u p ra re n a lis , r ig h t s id e (-* Fig. 7 .1 2 ) a n d le ft s id e (-* Fig. 7 .1 3 ); v e n tra l v ie w .

166

(H ilu m re na le ) w h ic h c o n n e c ts to th e in n e r s p a c e o f th e k id n e y (S inus re n a lis) a nd c o n ta in s th e renal b lo o d v e s s e ls a nd th e U re te r. T h e adÂ

T h e b e a n -sh a p e d k id n e y has a s u p e rio r a nd an in fe rio r p o le . L o c a te d

re n a l g la n d is a d ja c e n t to th e s u p e rio r p o le o f th e k idn e y. T h e e n tra n c e o f th e b lo o d v e s s e ls a t th e m e d ia l m a rg in is s o m e tim e s a ls o re fe rre d to

b e tw e e n th e p o le s a n d o rie n te d m e d ia lly is th e h ilu m o f th e k id n e y

a s th e h ilu m .

Efferent urinary system -► Genitalia

Rectum and anal canal -► Topography -> Sections

O rganisation o f th e kidney

Papillae renales M ed u lla renalis, Pyram ides renales

C o rtex renalis Calyx renalis major

Columnae renales

Sinus

P elvis re n a lis

Calyx renalis major

Calices renales minores

M edulla renalis

Lobus renalis

M ed u lla renalis, P yram ides renales

Capsula fibrosa C o rte x renalis

Area cribrosa, Foramina papillaria Aa. interlobares

A. V. renalis

C o lum nae renales

Pelvis renalis Sinus renalis

Ureter

arcuata

Fig. 7 .1 4 a n d Fig. 7 .1 5

K id n e y , R en [N e p h r o s ], le ft s id e ; v e n tra l

v ie w ; a fte r v e rtic a l b is e c tio n (-» Fig. 7 .1 4 ) a nd o p e n in g o f th e renal

(C o lu m n a e re na le s). O n e p y ra m id a n d its a d ja c e n t c o rtic a l area is c a lle d a re n a l lo b e (L o b u s re na lis). T h e b o rd e r b e tw e e n th e 14 lo b e s is n o t

p e lv is ( - * Fig. 7.1 5 ). T h e k id n e y c o n s is ts o f a c o r te x (C o rte x re n a lis) a nd a m e d u lla (M e d u l

v is ib le a t th e s u rfa c e o f an a d u lt h u m a n k id n e y . T h e tip s o f th e p y ra m id s (P apillae re na le s) e n te r th e re n a l c aly ce s (C alices re n a le s m a jo re s a nd

la re na lis). T h e m e d u lla is s u b d iv id e d in to se v e ra l p a rts w h ic h , a c c o r d in g to th e ir s h a p e , are re fe rre d to as renal p y r a m id s (P y ra m id e s re na -

m in o re s ) to re le a s e th e u rin e (a rro w s ). T o g e th e r w it h a d ip o s e tis s u e a nd th e re n a l b lo o d v e s s e ls , th e re n a l p e lv is (P e lvis re n a lis) is lo c a te d

les). L o c a te d b e tw e e n th e s e renal p y ra m id s are th e renal c o lu m n s

in a m e d ia l re c e s s o f th e p a re n c h y m a o f th e k id n e y (S inu s renalis).

167

Pelvis and Retroperitoneal Space

Kidney and adrenal gland -â&#x2013;ş

O rganisation o f th e kidney

C o rte x renalis

Capsula fibrosa

M edulla renalis

V. renalis

Aa. interlobares

Pyramides renales

Papilla renali:

Calyx renalis minor

Fig. 7 .1 6

K id n e y , R en [N e p h ro s ]; tr a n s v e r s e s e c tio n th r o u g h th e

re n a l s in u s (S in u s re n a lis ); ca ud a l v ie w .

T h e p a re n c h y m a o f th e k id n e y is c o m p o s e d o f a c o rte x (C o rte x renalis) a n d a m e d u lla (M e d u lla renalis).

Urinary pole Space of the BOWMAN'S capsule

Corpusculum renale

Tubulus proximalis

Tubulus distalis

Fig. 7 .1 7

R e n a l c o te x (C o rte x re n a lis ); m ic ro s c o p ic s e c tio n ,

1 0 0 -fo ld . [26] T h e e n tire p a re n c h y m a

168

s p a c e o f th e B O W M A N 'S c a p s u le (p rim a ry u rin e , 1 70 l/day). F ro m th e a nd

u rin a ry p o le o f th e B O W M A N 'S c a p s u le , th e p rim a ry u rin e e n te rs th e p ro x im a l tu b u le (T u b u lu s p ro x im a lis ). In th e tu b u la r s y s te m a nd th e c o lÂ

c o lle c tin g d u c ts . N e p h ro n s c o m p ris e renal c o rp u s c le s a nd a tu b u la r s y s te m . R enal c o rp u s c le s (C o rp u scu la renalia) are lo c a te d in th e renal

le c tin g d u c ts th e m a jo r p a rt o f th e p rim a ry u rin e is re a b s o rb e d a nd th e u rin e c o m p o s itio n is a lte re d b y s e c re tio n b e fo re th e fin a l u rin e is re Â

c o rte x , b u t n o t in th e re n a l m e d u lla . In th e renal c o rp u s c le s , w a te r a nd lo w m o le c u la r w e ig h t c o n s titu e n ts fr o m th e p la s m a are filte r e d in to th e

le a s e d in to th e re n a l p ap illa e a n d th e renal p e lv is (1.7 l/day).

o f th e

k id n e y

c o n s is ts

o f n e p h ro n s

Efferent urinary system -> Genitalia -► Rectum and anal canal -► Topography -► Sections

O rganisation o f th e kidney

Fig. 7 .1 8

O r g a n is a tio n o f n e p h ro n a n d c o lle c tin g d u c t; s c h e m a tic

illu s tra tio n , (a c c o rd in g to [1]) A t th e re n a l c o rp u s c le , w h e re th e p rim a ry u rin e is p ro d u c e d , th e p r o x im a le tu b u le b e g in s w it h a c o n v o lu te d p a rt (Pars c o n v o lu ta ) a nd a c o n s e c u tiv e s tra ig h t p a rt (Pars re cta ). T h is is c o n tin u e d b y th e in te r m e d ia te tu b u le w h ic h c o n s is ts o f a d e s c e n d in g (Pars d e s c e n d e n s ) a nd an a s c e n d in g lim b (Pars a s c e n d e n s ) fo llo w e d b y th e d is ta l t u b u le (again

C onnecting seg m e n t G lom erulus

Proxim al f Pars tubule Pars recta

x ■g

w it h Pars recta and Pars convoluta). The conn ectin g s e g m e n t (collectin g tu b u le ) is th e tra n s itio n to th e c o lle c tin g d u c t w h ic h fin a lly re-

le a s e s th e u rin e in to th e re n a l p elvis.

Pars convoluta' Distal tubule Pars recta

In te rm ed iary tubule

C o llecting duct

A. corticalis

Arterial Vasa recta

A. arcuata

interlobaris

Renal calyx

V. stellata

Vv. c o rtic ales radiatae V. interlobaris Venous Vasa recta

Fig. 7 .1 9

C o u rs e o f a rte rie s (re d ), v e in s (b lu e ), a n d n e p h ro n s

Collecting duct

(g re y ) in th e re n a l p a re n c h y m a ; s c h e m a tic illu s tra tio n , (a c c o rd in g to [ 1 ])

N ephron with short loop

T h e A . a nd V. re n a lis d iv id e a t th e h ilu m a n d a s c e n d as A . a nd V. in te rlo b a ris a t th e e d g e o f th e p y ra m id s . T h e y a rch a ro u n d th e b a se o f th e p y ra m id s as A . a n d V . a rc u a ta a nd fr o m th e re g iv e rise t o th e A . a nd V. c o rtic a lis ra d ia ta to reach th e ca p su le . In c o n tra s t to th e c o m m u n ic a t in g v e in s , th e a rte rie s are te rm in a l a rte rie s . T h e re fo re , th e o c c lu s io n o f an a rte ry , fo r e x a m p le b y a b lo o d c lo t (e m b o lis m ), w ill c a u s e a re n a l in fa rc tio n .

N ephron with long loop N ephron with cortical loop

W ith in th e lo b e s o f th e k id n e y th e n e p h ro n s are a rra n g e d radially.

169

Pelvis and Retroperitoneal Space

Kidney and adrenal gland -â&#x2013;ş

O rganisation o f th e adrenal gland

Margo superior

Facies anterior

Fig. 7 .2 0

A d re n a l g la n d , G la n d u la s u p ra re n a lis , r ig h t s id e ; v e n tra l

v ie w . T h e a d re n a l g la n d c o n s is ts o f c o rte x a nd m e d u lla . B o th have d iffe r e n t d e v e lo p m e n ta l o rig in s a n d fu n c tio n s . T h e c o rte x d e v e lo p s fr o m th e m e s o d e rm o f th e d o rs a l a b d o m in a l c a v ity (in tra -e m b ry o n ic co e lo m a ),

Margo medialis

th e m e d u lla , h o w e v e r, d e riv e s fr o m n e u ra l c re s t c e lls a nd is e q u iv a le n t to a m o d ifie d s y m p a th e tic g a n g lio n . C o rtex

M edulla

Cortex

V. centralis

Fig. 7.21

A d re n a l g la n d , G la n d u la s u p ra re n a lis , r ig h t side;

s a g itta l s e c tio n ; la te ra l v ie w . T h e a d re n a l g la n d is a v ita l e n d o c rin e g la n d . T h e c o r te x p ro d u c e s s te Â ro id h o rm o n e s (m in e ra lo c o rtic o id s , g lu c o c o rtic o id s , a n d ro g e n s ), th e m e d u lla p ro d u c e s c a te c h o la m in e s (e p in e p h rin e a nd n o re p in e p h rin e ) fo r th e re g u la tio n o f m e ta b o lis m a n d b lo o d p re s s u re .

Clinical Remarks

170

If b o th a d re n a l g la n d s h a ve to b e re m o v e d d u e to d is e a s e , th e s u b Â

o r s e v e re ly lo w b lo o d p re s s u re (a rte ria l h y p o te n s io n ). A d re n o c o rtic a l

s titu tio n w it h m in e ra lo c o rtic o id s a n d g lu c o c o rtic o id s is e s s e n tia l to p re v e n t life -th re a te n in g c o n d itio n s su ch as h y p o g ly c a e m ic s h o c k

in s u ffic ie n c y (A D D IS O N 's d is e a s e ) m a y c a u s e th e s a m e s y m p to m s .

Efferent U rinary system -► genitalia -► Rectum and anal canal -► Topography -► Sections

Blood vessels o f th e kidney

A.; V. phrenica inferior A.; V. phrenica inferior Glandula suprarenalis

A. suprarenalis m edia; V. suprarenalis sinistra

Glandula suprarenalis A. suprarenalis inferior; V. suprarenalis dextra

A. renalis accessoria V. cava inferior A.; V. renalis A.; V. renalis Ren, Capsula adiposa Ureter

A.; V. testicu laris

Ren

V.; A. testicu laris

Fig. 7 .2 2

C o u rs e o f th e A . a n d V. re n a lis ; v e n tra l v ie w .

T h e p a ire d A a . re n a le s a rise fr o m th e a b d o m in a l a o rta a nd c o u rs e d o r sal to th e v e in s to th e h ilu m o f th e k id n e y. T h e rig h t A . re n a lis c ro s s e s th e V. cava in fe rio r p o s te rio rly . A t th e h ilu m , th e y d iv id e in to se v e ra l b ra n c h e s. T h e V v . re n a le s d ra in in to th e V. cava in fe rio r o n b o th s id e s . T h e le ft V.

T h e re g io n a l ly m p h n o d e s o f th e k id n e y are th e N o d i ly m p h o id e i lu m b a le s a ro u n d th e a o rta a n d th e V. cava in fe rio r. T h e p o s tg a n g lio n ic s y m p a th e tic n e rv e s to th e k id n e y d e riv e fro m th e G a n g lio n a o rtic o re n a le a n d fo r m th e P lexu s re n a lis a ro u n d th e A . re na lis.

re n a lis re c e iv e s b lo o d fr o m th re e trib u ta rie s , w h e re a s on th e rig h t s id e th e s e v e in s e n te r th e V. cava in fe rio r d ire c tly : • •

V. s u p ra re n a lis s in is tra V. te s tic u la ris /o v a ric a s in is tra

•

V. p h re n ic a in fe rio r s in is tra

Clinical Remarks R enal c e ll c a rc in o m a fre q u e n tly o b s tr u c t th e renal v e in s a nd m a y , in

c o c e le ) in th e le f t S c ro tu m . T h e re fo re , a v a ric o c e le on th e le ft s id e

ca se o f a tu m o u r on th e le ft sid e , c a u s e a v e n o u s b lo o d s ta s is in th e le ft te s tic u la r v e in re s u ltin g in th e d ila tio n o f te s tic u la r v e in s (v a ri

a lw a y s re q u ire s th e e x c lu s io n o f a re n a l c e ll c a rc in o m a !

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d

Blood vessels o f kidney and adrenal gland «7%

»13% Pars abdominalis aortae A. renalis (A. renalis polaris superior)

Figs. 7 .2 3 a to d

V a ria tio n s o f th e a rte r ia l

s u p p ly o f t h e k id n e y : aA . re n a lis w it h a b ra n c h a s s u p e rio r p o la r a rte ry

v e n tra l v ie w . P o la r a rte rie s d o n o t e n te r th e k id n e y a t th e h ilu m , b u t re ach th e renal p a re n c h y m a d ire c tly . A c c e s s o ry a rte rie s in d e p e n d e n tly a ris e fr o m th e

b t w o A a. re n a le s to th e h ilu m o f th e k id n e y c a c c e s s o ry s u p e rio r p o la r a rte ry d a c c e s s o ry in fe rio r p o la r a rte ry

A o rta .

« 34% Aa. suprarenales superiores

A. phrenica inferior

Aa. suprarenales mediae A. suprarenalis inferior

A. renalis Pars abdominalis aortae

Fig. 7 .2 4 a to d

S u p ra re n a l a rte r ie s , A a . s u p ra re n a le s , a n d

s u p ra re n a l v e in , V . s u p ra re n a lis ; v e n tra l v ie w . U s u a lly th e re are th re e a rte rie s to th e a d re n a l gla n d : • A. su p ra re n a lis s u p e rio r: d e riv e s fr o m th e A . p h re n ic a in fe rio r • •

A. A.

su p ra re n a lis m e d ia : a ris e s d ire c tly fr o m th e A o rta su p ra re n a lis in fe rio r: b ra n c h o f th e A . re n a lis

T h is " lu x u r io u s " a rte ria l s u p p ly p re v e n ts in fa rc tio n s o f th e v ita l adrenal gla n d . V a ria tio n s o f th e a rte rie s t o th e a d re n a l g lan d : a

a rte ria l s u p p ly via th re e a rte rie s (te x tb o o k case)

b a rte ria l s u p p ly w it h o u t tr ib u ta ry fro m th e A . re n a lis c a rte ria l s u p p ly w it h o u t a d ire c t b ra n ch o f th e A o rta

172

In c o n tra s t, o n ly o n e s u p ra re n a l v e in e x is ts fo r each a d re n a l g la n d . T h e V. s u p ra re n a lis c o lle c ts th e b lo o d fr o m th e a d re n a l g la n d a n d d ra in s in to th e V. cava in fe rio r on th e rig h t s id e , a nd in to th e V. re n a lis s in is tra on th e le ft s id e (d). T h e re g io n a l ly m p h n o d e s o f th e a d re n a l g la n d are th e N o d i ly m p h o ide i lu m b a le s a ro u n d th e a o rta a nd V. cava in fe rio r. T h e a u to n o m ic in n e rv a tio n d e riv e s fr o m p re g a n g lio n ic (!) s y m p a th e t ic n e rv e fib re s fr o m th e N n. s p la n c h n ic i (th e a d re n a l m e d u lla re p re s e n ts a s y m p a th e tic p ara g a ng lio n ).

Efferent urinary system -► Genitalia

Rectum and anal canal -► Topography -> Sections

Kidney, im aging

Ren, Facies anterior

Hepar Medulla renalis, Pyramis renalis

Pelvis renalis Extremitas superior Diaphragma Extremitas inferior

M. psoas major

Corpus adiposum pararenale Cortex renalis Ren, Facies posterior

Fig. 7 .2 5

K id n e y , R en [N e p h ro s ], r ig h t s id e ; u ltra s o u n d im a g e ;

la te ra l v ie w ; tra n s d u c e r p o s itio n e d a lm o s t v e rtic a lly . *

a b d o m in a l w a ll

Colon

Hepar, Lobus dexter

Cutis

cava inferior

renalis dextra

3ars abdominalis jortae

Ren Sinus renalis Mm. abdominales

Corpus vertebrae

Ren, Capsula adiposa

Fascia renalis

Proc. spinosus Costa XII M. erector spinae

Fig. 7 .2 6 K id n e y , R en [N e p h ro s ]; r ig h t s id e ; c o m p u te d to m o g ra p h ic tra n s v e rs e s e c tio n (CT); ca ud a l v ie w .

d ire c tio n o f th e n e e d le fo r re n a l b io p s y , a ls o n a m e d fin e n e e d le a s p ira tio n b io p s y (FN AB ).

C T -g u id e d renal b io p s ie s are p e rfo rm e d to o b ta in tis s u e s p e c im e n s fo r d ia g n o s tic p u rp o s e s in c a s e s o f o b s c u re d y s fu n c tio n s o f th e kidn e y.

P Clinical R em arks----------------------------------------------------------------------------------------------------------U ltr a s o u n d (so n o g ra p h y) is a s u ita b le im a g in g te c h n iq u e to v is u a li-

o r to a s s e s s ly m p h n o d e m é ta s ta s é s o r th e in v a s io n o f tu m o u rs in to

se th e k id n e y s . It e n a b le s th e d e te c tio n o f s o lid o r c y s tic tu m o u rs . C T -im a g in g is p e rfo rm e d in c a s e s o f u n d e fin e d u ltra s o u n d fin d in g s ,

th e renal v e in s .

Pelvis and Retroperitoneal Space

Kidney and adrenal gland -â&#x2013;ş

Renal pelvis and u reter

Cortex renalis

Medulla renalis, Pyramides renales

Papillae renales

Cortex renalis C alyx renalis m ajor

Sinus renalis

Columnae renales

Pelvis

Calyx renalis major

Medulla renalis C alices renales m inores

Fig. 7 .2 7

R e n a l p e lv is . P e lv is re n a lis , le ft s id e ; v e n tra l v ie w .

U rin e is re le a s e d fro m th e re n a l p y ra m id s to th e renal c a ly c e s (C alices re n a le s ; a rro w s ).

Calyx renalis major

Pelvis renalis

Calices renales minores

Ureter

Figs. 7 .2 8 a a n d b

R e n a l p e lv is . P e lv is re n a lis , le ft s id e ; m o u ld

p re p a ra tio n ; v e n tra l v ie w .

174

A c c o rd in g to th e w id th a nd th e le n g th o f th e re n a l c a ly c e s , a d e n d ritic (a) a n d an a m p u lla ry (b) ty p e o f renal p e lv is are d is tin g u is h e d .

Efferent urinary system -► Genitalia -► Rectum and anal canal

Fig. 7 .2 9

P a rts , c o n s tric tio n s , a n d c o u rs e o f th e u re te r; v e n tra l

v ie w . Parts:

- *

Topography -► Sections

C o n s tric tio n s : • a t th e e x it fr o m th e renal p e lv is

•

Pars a b d o m in a lis : in th e re tro p e rito n e a l sp ace

• •

a t th e c ro s s in g o f th e A . iliaca c o m m u n is o r A . iliaca e x te rn a a t th e p a s s a g e th ro u g h th e w a ll o f th e u rin a ry b la d d e r (m o s t n a rro w

• •

Pars p e lv ic a : in th e le s s e r p e lv is Pars in tra m u ra lis : tra v e rs e s th e w a ll o f th e u rin a ry b la d d e r

part) C ourse: th e u re te r fir s t c ro s s e s o v e r th e N . g e n ito fe m o ra lis , c o u rs e s u n d e r th e A . a nd V. te s tic u la ris /o v a ric a , c ro s s e s o v e r th e A . a nd V. iliaca a n d th e n c ro s s e s u n d e r a nd p a s s e s b e n e a th th e D u c tu s d e fe re n s in m e n and th e A . u te rin a in w o m e n .

Clinical Remarks R e n a l c o n c re m e n ts m a y d is lo d g e , d e s c e n d in th e u re te r a nd g e t s tu c k a t th e u re te ric c o n s tric tio n s . T h is c a u s e s in te n s e , co lic -lik e

T h e c lo s e p r o x im ity o f th e u re te r to th e u te rin e a rte ry has to be c o n s id e re d in h y s te r e c to m ie s to a vo id lig a tio n o f th e u re te r d u rin g

pain (u re te ra l colic).

s u rg e ry . T h e re s u ltin g u rin e s ta s is w o u ld irre v e rs ib ly d a m a g e th e a f fe c te d k idn e y.

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d

Renal pelvis and ureter, im aging

Vertebra thoracica XII Papilla renalis

Papilla renalis

Colon ascendens Pelvis renalis

Calyx renalis major

Calyx renalis minor

Papilla renalis Ren sinister, Extremitas inferior Colon descendens

M. psoas major

Ureter

Fig. 7 .3 0

R e n a l p e lv is . P e lv is re n a lis , a n d u re te r. U re te r;

ra d io g ra p h in a n te ro p o s te rio r (AP) b e a m p ro je c tio n a fte r re tro g ra d e in je c tio n o f c o n tra s t m e d iu m via b o th u re te rs ; v e n tra l v ie w .

Figs. 7 .3 1 a a n d b

C o m m o n v a r ia tio n s o f th e u re te r. U re te r;

ra d io g ra p h s in a n te ro p o s te rio r (AP) b e a m p ro je c tio n a fte r re tro g ra d e in je c tio n o f c o n tra s t m e d iu m via b o th u re te rs ; v e n tra l v ie w . [18] a d o u b le u re te r (U re te r d u p le x) b s p lit u re te r (U re te r fis s u s ) In b o th c a s e s t w o renal p e lv is e s are p re s e n t.

i- Clinical R em arks--------------------------------------

176

T h e U re te r fis s u s o fte n is an a c c id e n ta l fin d in g a nd h as no clin ical re le v a n c e . In c o n tra s t, c a se s o f an U r e te r d u p le x are fr e q u e n tly acÂ

u rin a ry b la d d e r m o re in fe rio rly o r e v e n d ire c tly e n te rs th e U re th ra

c o m p a n ie d w it h m a lfo rm a tio n s o f th e u re te ric o p e n in g in to th e uriÂ n ary b la d d e r, a c o n d itio n p o te n tia lly ca u s in g re flu x o f u rin e o r in c o n tiÂ

p e lv is o fte n has a m u c h s h o rte r in tra m u ra l p a rt w ith in th e w a ll o f th e u rin a ry b la d d e r, fa c ilita tin g re flu x o f u rin e . U rin e re flu x p ro m o te s

n e n c e . F re q u e n tly , b o th u re te rs c ro s s each o th e r (M E Y E R -W E IG E R T rule). A s a ru le , th e U re te r fr o m th e s u p e rio r re n a l p e lv is e n te rs th e

a s c e n d in g u rin a ry tr a c t in fe c tio n s p o te n tia lly re s u ltin g in p e rm a n e n t d a m a g e to th e k id n e y p a re n c h y m a .

re s u ltin g in u rin a ry in c o n tin e n c e . T h e U re te r fro m th e lo w e r renal

Efferent urinary s y s te m -» Genitalia -► Rectum and anal canal -* Topography -► Sections

S tructu re o f th e urinary bladder Lig. umbilicale medianum A p ex vesicae

Tunica muscularis

Tunica mucosa

C o rpus vesicae

O stium ureteris Fundus vesicae Plica interureterica

Trigonum vesicae

Uvula

O stium urethrae internum Prostata

Crista urethralis Urethra masculina, Pars prostatica

Ductuli prostatici

Sinus prostaticus Colliculus Utriculus

Ductus deferentes, Ductus ejaculatorii

Fig. 7 .3 2

U rin a ry b la d d e r. V e s ic a u rin a ria , a n d o p e n in g in to th e

m a le u r e th r a . U re th r a ; v e n tra l v ie w . T h e u rin a ry b la d d e r is lo c a te d in th e s u b p e rito n e a l s p a c e a nd is c o m p o s e d o f a b o d y (C o rp u s ve s ic a e ), a p e x (A p e x v e sica e ), a nd an in fe rio r fu n d u s (F u n d u s v e sica e ). A t th e fu n d u s , th e in te rn a l u re th ra l o rific e (O s tiu m u re th ra e in te rn u m ) a nd th e t w o u re te ric o rific e s (O s tiu m u re te ris ) fo r m th e tr ig o n e o f th e b la d d e r (T rig o n u m v e sica e ). T h e u rin a ry b la d

= M . d e tru s o r v e s ic a e ), a n d th e e x te rn a l T u n ic a a d v e n titia o r th e cranial T u n ic a s e ro s a (p e rito n e u m ), re s p e c tiv e ly . T h e u rin a ry b la d d e r is s u rro u n d e d b y p a ra v e s ic a l a d ip o s e tis s u e and s ta b ilis e d b y s e v e ra l lig a m e n ts . A t th e a pe x, th e Lig. u m b ilic a le m e d ia n u m (c o n ta in s th e u ra c h u s , a re m n a n t o f th e e m b ry o n ic c o n n e c tio n o f th e a lla n to is ) c o n n e c ts to th e U m b ilic u s . In w o m e n , th e b ila te ra l Lig.

d e r h o ld s a b o u t 5 0 0 - 1 5 0 0 m l o f u rin e , a lth o u g h th e u rg e to u rin a te

p u b o v e s ic a le (-» Fig. 7 .1 1 6 ) a n d in m e n th e b ila te ra l Lig. p u b o p ro s ta tic u m (-► Fig. 7 .1 1 5 ) a n c h o r th e b la d d e r to th e b o n y p e lv is . In m e n , th e

s ta rts w h e n a v o lu m e o f 2 5 0 -5 0 0 m l is re a ch e d . T h e w a ll c o n s is ts o f th e in te rn a l m u c o s a l la y e r (T unica m u c o s a ) fo llo w e d b y th re e la y e rs o f

p ro s ta te g la n d is lo c a te d d ire c tly b e n e a th th e fu n d u s o f th e b la d d e r and is tra v e rs e d b y th e U re th ra .

s m o o th m u s c le s w ith p a ra s y m p a th e tic in n e rv a tio n (Tunica m u s c u la ris

Figs. 7 .3 3 a a n d b U re te ric o rific e . O s tiu m u re te ris ; c y s to s c o p y . a o p e n e d u re te ric o rific e , a p e ris ta ltic w a v e has re le a s e d u rin e in to th e b la d d e r b

T h e v a lv e -lik e s h a p e o f th e u re te ric o rific e c o n trib u te s s u b s ta n tia lly to th e p re v e n tio n o f u rin e b a c k flo w w h ic h m a y e n d a n g e r th e k id n e y s via a s c e n d in g u rin a ry tr a c t in fe c tio n s ,

c lo s e d u re te ric o rific e

177

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

U rinary bladder and urethra in m en Apex vesicae

Lig. umbilicale medianum

Fig. 7 .3 4 U rin a ry b la d d e r. V e s ic a u rin a ria , v a s d e fe re n s . D u c tu s d e fe re n te s , s e m in a l v e s ic le , G la n d u la v e s ic u lo s a , a n d p ro s ta te g la n d . P ro s ta ta ; d o rs a l v ie w .

Corpus vesicae, Tunica muscularis

In m e n , th e fo llo w in g p a ire d a n a to m ic a l s tru c tu re s are p o s itio n e d p o s te rio r a nd a d ja c e n t to th e b la d d e r, fro m m e d ia l to la te ra l: • d ila te d p a rt o f th e va s d e fe re n s (A m p u lla • •

d u c tu s d e fe re n tis ) s e m in a l v e s ic le (G la nd u la ve s ic u lo s a ) U re te r

U reter

T h e u rin a ry b la d d e r is p o s itio n e d d ire c tly s u p e rio r to th e p ro s ta te gla n d . Ductus deferens

Am pulla ductus deferentis

Ampulla ductus deferentis, Diverticula ampullae Glandula vesiculosa

G landula vesiculosa

Prostata, Facies posterior

Pars intram uralis

Ostium urethrae internum

Ductus ejaculatorii

Ductuli prostatici Crista urethralis

Pars • m em branacea

Glandula bulbourethralis, Ductus glandulae bulbourethralis

tra l v ie w ; u rin a ry b la d d e r a n d U re th ra o p e n e d v e n tra lly . P a rts o f t h e U re th ra : • •

Corpus cavernosum penis

P ars p ro s ta tic a (3 .5 c m ): tra v e rs e s th e

m o n d u c t o f v a s d e fe re n s a n d s e m in a l v e s ic le ) o n th e C o llic u lu s s e m in a lis a n d th e •

p ro s ta tic d u c ts on b o th s id e s . P ars m e m b r a n a c e a (1 -2 c m ): tra v e rs e s

•

th e p e lv ic flo o r. P ars s p o n g io s a (1 5 c m ): e m b e d d e d in th e C o rp u s s p o n g io s u m o f th e P enis, ru n s to th e e x te rn a l u re th ra l o rific e (O s tiu m u re th rae e x te rn u m ). C O W P E R 's g la n d s (G landu

Corpus spongiosum penis

lae b u lb o u re th ra le s ) a n d L IT T R É 's g la n d s (G la nd u lae u re th ra le s ) e n te r h ere . T h e

Pars spongiosa Lacunae urethrales

te rm in a l p a rt is d ila te d to fo r m th e Fossa n a v ic u la ris . T h e U re th ra has th e fo llo w in g c o n s tric tio n s : • O s tiu m u re th ra e in te rn u m • •

Glans penis Fossa navicularis urethrae Ostium urethrae externum

178

P ars in tra m u r a lis (1 c m ): w ith in th e w a ll o f th e u rin a ry b la d d e r p ro s ta te g la n d . H e re th e fo llo w in g d u c ts e n te r th e U re th ra : D u c tu s e ja c u la to rii (c o m

Ductus glandulae bulbourethralis

U rethra m asculina

U rin a ry b la d d e r. V e s ic a u rin a ria ,

a n d m a le u r e th r a , U re th r a m a s c u lin a ; v e n Colliculus seminalis

Pars prostatica

Fig. 7 .3 5

Pars m e m b ra n a c e a e O s tiu m u re th ra e e x te rn u m

Efferent urinary system -► Genitalia -► Rectum and anal canal -> Topography -► Sections

Urethra in m en

Ostium ureteris

U rethra, Pars intram uralis

Ostium urethrae internum

Prostata Lig. puboprostaticum Urethra, Pars prostatica

U rethra, Pars spongiosa U rethra, Pars m em b ran ac ea

Corpus spongiosum penis Corpus cavernosum Corpus spongiosum penis

Fossa navicularis urethrae

Ostium urethrae externum

Lobuli testis

Fig. 7 .3 6 s ide .

M a le p e lv is . P elvis; m e d ia n s e c tio n ; v ie w fr o m th e le ft

T h e illu s tra tio n s h o w s th e c o u rs e a nd th e p a rts o f th e m a le U re th ra (U re th ra m a scu lin a ): P ars in tra m u r a lis : w ith in th e w a ll o f th e u rin a ry b la d d e r

T h e U re th ra has t w o be n d s: • a t th e tra n s itio n fro m Pars m e m b ra n a c e a to Pars s p o n g io s a • in th e m id d le p a rt o f th e Pars s p o n g io s a

P ars p ro s ta tic a : tra v e rs e s th e p ro s ta te g la n d P ars m e m b ra n a c e a : p e n e tra te s th e p e lv ic flo o r P a rs s p o n g io s a : e m b e d d e d in th e C o rp u s s p o n g io s u m o f th e P enis, e x its a t th e G ians p e n is

dissection link

179

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Urethra in w o m e n

Ampulla recti; Plicae transversae recti

Ostium ureteris

Ostium urethrae internum Urethra

Ostium urethrae externum

Vestibulum vaginae

Fig. 7 .3 7

F e m a le p e lv is . P elvis; m e d ia n s e c tio n ; v ie w fr o m th e le ft

side . T h e illu s tra tio n s h o w s th e c o u rs e a n d th e e x te rn a l o rific e o f th e fe m a le u re th ra . T h e fe m a le u re th ra is 3 - 5 c m lo n g a n d e n te rs d ire c tly in fr o n t o f th e V a gina in th e v e s tib u le (V e s tib u lu m va gin a e).

I- Clinical R em arks-------------------------------------B e ca u se o f th e s h o rte r le n g th o f th e fe m a le U re th ra , a s c e n d in g in fe c tio n s o f th e u rin a ry b la d d e r (c y s titis ) are m o re c o m m o n in w o m e n th a n in m e n . P o s itio n in g o f a tr a n s u re th r a l c a th e te r is e a s ie r in w o m e n d u e to

In m e n , th e b e n d s o f th e U re th ra have to be s tra ig h te n e d p rio r to in s e rtin g a c a th e te r t o a vo id p a in fu l p e rfo ra tio n s in th e area o f th e Pars m e m b ra n a c e a o r th e Pars p ro s ta tic a w ith c o n s e c u tiv e p ro fu s e

th e s tra ig h t c o u rs e o f th e s h o rte r U re th ra . H o w e v e r, it has to be

b le e d in g s . First, th e P e n is is s tra ig h te n e d to c o m p e n s a te fo r th e k in k in th e Pars s p o n g io s a o f th e p e n ile U re th ra , th e n th e c a th e te r

c o n s id e re d th a t th e u re th ra l o rific e in th e v e s tib u le is lo c a te d v e n tra l to th e V agina.

is in s e rte d u n til th e re s is ta n c e fr o m th e s e c o n d b e n d in th e Pars m e m b ra n a c e a is n o tic e d . T o s tra ig h te n it, th e P e n is is p o s itio n e d d o w n w a rd s b e tw e e n th e th ig h s b e fo re th e c a th e te r is c a re fu lly ad v a n c e d fu r th e r in to th e b la d d e r.

180 — ►

dissection link

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

S p h in cte r m e ch a n ism s o f th e urinary bladder

Vesica urinaria

Urethra

M. sphincter urethrae externus

M. transversus perinei profundus M. sphincter urethrae externus

Figs. 7 .3 8 a a n d b S p h in c te r m e c h a n is m s o f u rin a ry b la d d e r. V e s ic a u rin a ria , a n d u r e th r a . U re th r a , in m e n (a) a n d in w o m e n

In a d d itio n , th e s h a p e o f th e p e lv ic flo o r (D ia p h ra g m a p e lv is ) is im p o r ta n t in s u p p o rtin g th e u rin a ry b la d d e r, a n d th u s e n s u rin g u rin a ry c o n ti

(b); m e d ia n s e c tio n ; v ie w fr o m th e le ft side . C o n trib u tin g to th e s p h in c te r m e c h a n is m s are n o t o n ly s m o o th m u s c le

nence. D u rin g u rin a tio n (m ic tu ritio n ) th e s m o o th m u s c le s o f th e w a ll o f th e

fib re s in th e w a ll o f th e u rin a ry b la d d e r b u t a ls o s tria te d m u s c le s o f th e p e rin e u m : • s m o o th m u s c le s o f th e c irc u la r m u s c le la ye r o f th e U re th ra ( " M . s p h in c te r u re th ra e

in te rn u s " ): m o rp h o lo g ic a lly ,

a tru e

b la d d e r (M . d e tru s o r v e s ic a e ) c o n tra c t fo llo w in g p a ra s y m p a th e tic a c ti v a tio n . A t th e s a m e tim e , th e s tria te d m u s c le s o f th e p e lv ic flo o r re la x a llo w in g th e b la d d e r t o d e s c e n d , th e s p h in c te r m u s c le s t o relax, a nd u rin a tio n to o c c u r.

s p h in c te r

m u s c le is n o t id e n tifie d . M . s p h in c te r u r e th r a e e x te rn u s : in m e n a se p a ra tio n o f th e M .

s m o o th m u s c le s o f th e U re th ra

tra n s v e rs u s p e rin e i p ro fu n d u s w h ic h o fte n d o e s n o t e x is t in w o m e n .

Peritoneum parietale

Vesica urinaria Peritoneum parietale

Vesica urinaria

Rectum

Excavatio rectovesicalis

Symphysis pubica

Prostata

Figs. 7 .3 9 a a n d b U rin a ry b la d d e r, V e s ic a u rin a ria , e m p ty (a) a n d u rin e -fille d (b); s c h e m a tic m e d ia n s e c tio n ; v ie w fro m th e le ft.

Excavatio rectovesicalis

th e b la d d e r ris e s a b o v e th e p u b ic s u m p h y s is a nd ca n be a c c e s s e d

T h e u rin a ry b la d d e r is lo c a te d in th e s u b p e rito n e a l s p a c e a nd is c o v e re d

w it h o u t o p e n in g th e p e rito n e a l c a v ity (s u p ra p u b ic c y s to s to m y ) fo r c y s to s c o p y o r in s e rtio n o f a s u p ra p u b ic c a th e te r.

b y p a rie ta l p e rito n e u m on its u p p e r s u rfa c e . T h e e m p ty b la d d e r is p o s i tio n e d b e h in d th e p u b ic s y m p h y s is (S y m p h y s is p ub ica ). W h e n fille d ,

p u n c tu re n e e d le

181

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d ->

External m ale genitalia

Umbilicus

Spina iliaca anterior superior

Lig. inguinale

Pubes

Penis, C orpus

Penis, Dorsum

Scrotum

Preputium penis G ians penis

Fig. 7 .4 0

E x te rn a l m a le g e n ita lia , O rg a n a g e n ita lia m a s c u lin a

e x te r n a ; v e n tra l v ie w . T h e m a le g e n ita lia are c a te g o ris e d as e x te rn a l g e n ita lia (O rg a na g e n ita lia m a s c u lin a e x te rn a ) a n d in te rn a l g e n ita lia (O rg a na g e n ita lia m a s c u lin a in te rn a -» Fig. 7.4 1 ). T h e e x te r n a l m a le g e n ita lia c o m p ris e : • • •

182

Penis U re th ra m a s c u lin a S c ro tu m

T h e e x te rn a l g e n ita lia are th e s e x u a l o rg a n s . T h e P e n is s e rv e s in te r c o u rs e . T h e U re th ra is d e s c rib e d w it h th e e ffe r e n t u rin a ry s y s te m (-» p p . 1 78 a n d 179).

Efferent urinary system -» Genitalia -► Rectum and anal canal -> Topography -♦ Sections

Internal m ale genitalia

_Ureter

Du ctu s deferens Vesica urinaria--------- j

( f l y

S 0 5 t< .

i r * A ------------- G landula vesiculosa

Ik ----- 14-----------Ductus ejaculatorius P ro s ta ta ------------------------------------------~

G landula bulbourethralis Ductus glandulae bulbourethralis

(Paradidymis)

Appendix Testis [Orchis]

Fig. 7.41

M a le u rin a ry a n d s e x o rg a n s . O rg a n a u ro g e n ita lia

m a s c u lin a ; v ie w fr o m th e rig h t sid e . T h e in n e r m a le g e n ita lia c o m p ris e : • T e s tis • •

E p id id y m is D u c tu s d e fe re n s

• •

F u n ic u lu s s p e rm a tic u s a c c e s s o ry s e x gla n d s: -

p ro s ta te g la n d (P ro sta ta ) s e m in a l v e s ic le (G landula ve s ic u lo s a )

C O W P E R 's g la n d s (G landula b u lb o u re th ra lis ), p a ire d

Cauda epididymidis

T e s tis a nd E p id id y m is b e lo n g to th e in te rn a l g e n ita lia b e c a u s e d u rin g d e v e lo p m e n t th e y w e r e re lo c a te d fr o m th e in tra -a b d o m in a l c a v ity in to th e S c ro tu m to g e th e r w it h a p e rito n e a l c o v e rin g (fo rm in g th e C avita s s e ro s a s c ro ti). T h e in te rn a l g e n ita lia are re p ro d u c tiv e o rg a n s a n d s e rv e th e p ro d u c tio n , m a tu ra tio n , a n d tra n s p o rt o f s p e rm a to z o a a n d th e p ro d u c tio n o f s e m in a l flu id . T h e te s te s a ls o p ro d u c e m a le s e x h o rm o n e s ( te s to s te r one).

183

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

D e ve lo p m e n t o f th e external m ale genitalia

Genital tubercle (glans area)

Urogenital groove

Urogenital fold

Labioscrotal fold

Fig. 7 .4 2 D e v e lo p m e n t o f th e e x te r n a l m a le g e n ita lia . O rg a n a g e n ita lia m a s c u lin a e x te rn a .

th e la b io s c ro ta l fo ld s are lo c a te d a n d a n te rio r t o th e g ro o v e lie th e

T h e e x te rn a l g e n ita lia d e v e lo p fr o m th e ca ud a l p a rt o f th e S in u s u ro-

g e n ita l tu b e rc le s . S u b s e q u e n tly , in m e n th e g e n ita l tu b e rc le d e v e lo p s in to th e P e n is (C orp o ra ca v e rn o s a ) d u e to th e in flu e n c e o f th e m a le se x

g e n ita ls . T h e S in u s u ro g e n ita lis d e v e lo p s fr o m th e cloa ca o f th e h in d g u t a nd g iv e s rise t o th e u rin a ry b la d d e r a n d p a rts o f th e U re th ra (-* Fig.

h o rm o n e te s to s te r o n e w h ic h is p ro d u c e d in th e T e s te s . T h e g e n ita l fo ld s m e rg e a b o v e th e u re th ra l g ro o v e to fo r m th e C o rp u s s p o n g io s u m

7.8 ). A ls o c o n trib u tin g are th e e c to d e rm a nd th e c o n n e c tiv e tis s u e (m e s e n c h y m e ) b e n e a th . T h e fir s t p a rt in th e d e v e lo p m e n t o f th e e x te rÂ

a n d th e G ians p e n is . T h is w a y , s im u lta n e o u s ly th e Pars s p o n g io s a o f th e U re th r a d e v e lo p s . T h e Pars p ro s ta tic a a nd th e Pars m e m b ra n a c e a

nal g e n ita lia is id e n tic a l in b o th s e x e s (in d iffe re n t g o n a d ). T h e a n te rio r w a ll o f th e S in u s u ro g e n ita lis in d e n ts to fo rm th e u re th ra l g ro o v e

o f th e U re th ra d e riv e fu r th e r p ro x im a lly fr o m th e S in u s u ro g e n ita lis . T h e la b io s c ro ta l fo ld s e n la rg e a nd fu s e to fo r m th e S c ro tu m .

w h ic h is b o rd e re d on b o th s id e s b y th e u r e th r a l fo ld s . L a te ra l to th o s e

i- Clinical R em arks--------------------------------------

184

If in c o m p le te fu s io n s o f th e u re th ra l fo ld s o c c u r, th e o p e n in g o f th e U re th ra is n o t lo c a te d a t th e tip o f th e G ia ns p e n is b u t fu r th e r p ro x iÂ

In e p is p a d ia s , th e U re th ra o p e n s in to a rid g e a t th e d o rs a l s id e o f th e P enis. In a d d itio n to p ro b le m s w ith u rin a tio n , th is c o n d itio n m a y

m ally. In h y p o s p a d ia s is , th e U re th ra e x its a t th e in fe rio r s id e o f th e P e n is b e tw e e n th e S c ro tu m a n d th e glans.

in v o lv e a d is to rtio n in th e p e n ile b o d y re q u irin g s u rg ic a l c o rre c tio n w ith in th e fir s t y e a rs o f life .

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

D e ve lo p m e n t o f th e internal m ale genitalia

Ureter

Ductuli efferentes testis Testis

Gubernaculum testis

MÜLLERIAN duct

Ductus deferens

Vesica urinaria Glandula vesiculosa

Prostata

Fig. 7 .4 3 D e v e lo p m e n t o f th e in te r n a l m a le g e n ita lia . O rg a n a g e n ita lia m a s c u lin a in te r n a , (a c c o rd in g t o [1])

g u id in g th e d e s c e n t o f th e T e s tis , a p ro c e s s n o rm a lly c o m p le te d a t

U p to w e e k 7, d e v e lo p m e n t o f th e in te rn a l g e n ita lia is id e n tic a l in b o th

b irth . A t b irth , th e P roc. v a g in a lis p e rito n e i c lo s e s a n d o b lite ra te s in th e area o f th e F u n ic u lu s s p e rm a tic u s . T h e d is ta l p a rt o f th e P roc. v a g in a lis

s e x e s (se xua l in d iffe r e n t s ta g e , -» Fig. 7.8 ). In th e m a le , th e p rim o rd iu m o f th e p rim itiv e g o n a d th e n d e v e lo p s in to th e T e s tis . T h e T e s tis d e

re m a in s a nd fo r m s a p a rt o f th e te s tic u la r c o v e rin g s (Tunica v a g in a lis te s tis ).

v e lo p s in th e lu m b a r re g io n a t th e le ve l o f th e m e s o n e p h ro s w h ic h c o n trib u te s se v e ra l c a n a lic u li a s a c o n n e c tio n b e tw e e n th e T e s tis and

T h e s e x h o rm o n e s o f th e T e s tis (m a in ly te s to s te ro n e ) in d u c e th e fin a l d iffe r e n tia tio n o f t h e W O L F F IA N d u c t to th e in te rn a l m a le g e n ita lia

th e E p id id y m is . D u e to th e lo n g itu d in a l g ro w th o f th e b o d y th e T e s tis is th e n re lo c a te d c a u d a lly (D e s c e n s u s te s tis ) b u t re m a in s c o n n e c te d to its v a s c u la r s tru c tu re s . A lo n g th e in fe rio r m e s e n c h y m a l g u b e rn a c u lu m

(E p id id y m is , D u c tu s d e fe re n s ), th e s e m in a l v e s ic le s , a nd o th e r a c c e s s o ry s e x g la n d s (p ro s ta te g la n d , C O W P E R 's g la n d s ) fro m th e S in u s u ro-

(G u b e rn a c u lu m te s tis ) a p e rito n e a l p o u c h is fo r m e d (Proc. va g in a lis p e rito n e i) w h ic h re a c h e s d o w n to th e fu tu r e S c ro tu m a nd s e rv e s in

g e n ita lis . T h e a n ti-M U L L E R IA N h o rm o n e s u p p re s s e s th e d iffe re n tia tio n o f th e M U L L E R IA N d u c ts in to fe m a le g e n ita lia .

P Clinical R em arks-------------------------------------T h e d e s c e n t o f th e T e s tis e x p la in s w h y th e te s tic u la r b lo o d v e s s e ls

te s tic u la r c a n c e r. R e c e n t re s e a rc h in d ic a te s th a t a tim e ly h o rm o n a l

a ris e a t th e le ve l o f th e k id n e y s a nd w h y th e re g io n a l ly m p h n o d e s o f th e T e s tis are p o s itio n e d a t th is le v e l in th e re tro p e rito n e a l sp ace .

o r s u rg ic a l th e ra p y o f c r y p to rc h id is m w ith in th e fir s t y e a r o f life m a y p re v e n t in fe rtility . H o w e v e r, th is tr e a tm e n t d o e s n o t in flu e n c e th e

T h u s, ly m p h n o d e m e ta s ta s e s fr o m te s tic u la r c a n c e r are to be e x p e c te d in th e lu m b a r p e ri-a o rta l re g io n , n o t in th e in g u in a l re g io n .

ris k o f te s tic u la r cancer. If th e Proc. vaginalis p e rito n e i fa ils to o b lit e ra te , a c c u m u la tio n o f flu id s m a y o c c u r (e v e n in a d u lth o o d ) in th e

P e rs is te n t in c o m p le te te s tic u la r d e s c e n t w ith in th e fir s t y e a rs o f life (c ry p to rc h id is m ) m a y re s u lt in in fe r tility a nd in c re a s e s th e ris k o f

S c ro tu m (h y d ro c e le te s tis ) o r a b d o m in a l o rg a n s m a y p ro la p s e in to th e S c ro tu m (c o n g e n ita l in g u in a l h e rn ia ).

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d ->

Penis

Vesica urinaria

Am pulla ductus deferentis Ostium urethrae internum

Glandula vesiculosa

Prostata pubis, Ramus inferior Urethra, membranacea

Glandula bulbourethralis Bulbus penis

Glandula bulbourethralis

C rus penis

C rus penis Bulbus penis

C o rpus cavernosum penis Tunica albuginea corporum cavernosorum

C o rpus spongiosum penis

C o rp o ra cav ernosa penis

A. profunda penis Aa. helicinae

C orpus spongiosum penis

Cavernae corporum cavernosorum

Corona glandis G ians penis Preputium pe Ostium urethrae externum

Corona glandis G lans penis

7 .4 4

Fig. 7 .4 4 a n d Fig. 7 .4 5

7 .4 5

U rin a ry b la d d e r. V e s ic a u rin a ria , p ro s ta te

g la n d . P ro s ta ta , a n d p e n is . P en is , w ith e x p o s e d c a v e rn o u s

in g th e U re th ra . T h e p ro x im a l p a rts (C rura p e n is ) o f th e C orp o ra c a v e rÂ nosa are fix e d to th e in fe rio r p u b ic ra m i. T h e p ro x im a l a nd d is ta l p a rts o f

b o d ie s ; v e n tra l v ie w , u rin a ry b la d d e r a nd U re th ra o p e n e d a nd d o rs a l v ie w (-Âť Fig. 7.4 5 ).

Fig. 7.44)

th e C o rp u s s p o n g io s u m are d ila te d to fo r m th e B u lb u s p e n is a n d th e G la ns p e n is , re s p e c tiv e ly . A ll c a v e rn o u s b o d ie s to g e th e r are e n-

In a fla c c id s ta te , th e P e n is is u s u a lly a b o u t 10 c m lo n g a nd d iv id e d in to th e b o d y (C o rp u s p e n is), g la n s (G ians p en is), a nd b a se o r ro o t (R adix

s h e a th e d b y th e fa s c ia o f th e P e n is (Fascia p en is), w h ic h w a s re m o v e d in th is illu s tra tio n .

p e n is). It c o n s is ts o f th e p a ire d C o rp o ra c a v e rn o s a w h ic h are e n c lo s e d in a d e n s e fib ro u s c o v e rin g (T unica a lb u g in e a ) a nd s e p a ra te d b y a S e p Â

For th e d iffe r e n t p a rts o f th e m a le U re th ra (U re th ra m a s c u lin a ) - * Figs. 7 .3 5 a nd 7 .3 6 .

(-*

tu m p e n is . T h e o th e r c o m p o n e n t is th e C o rp u s s p o n g io s u m s u rro u n d -

r Clinical R em arks-------------------------------------If th e p re p u c e is v e ry n a rro w (p h im o s is ) a nd c a n n o t be re tra c te d , p ro b le m s in m ic tu ritio n a n d in fe c tio n s m a y o c c u r. In th is c a s e , th e

186

re m o v a l o f th e p re p u c e b y c irc u m c is io n is re q u ire d ,

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

Penis and scro tu m

C o rona glandis G lans penis

Ostium urethrae externum

Fascia penis (profunda)

Preputium penis

Fascia penis (superficialis)

Frenulum preputii

Fig. 7 .4 6 P e n is w ith g la n s , G ia n s p e n is , a n d p re p u c e , P re p u tiu m p e n is ; v ie w fr o m th e rig h t side .

T h e d is ta l e n d o f th e P e n is is e n la rg e d to fo r m th e G la ns p e n is a nd s h o w s a rid g e (C orona g la n d is ) a t its b ase . In th e fla c c id s ta te , th e g la n s is c o v e re d b y th e p re p u c e (P re p u tiu m p e n is ). A t its u n d e rs id e , th e p re p u c e is c o n n e c te d b y a s m a ll lig a m e n t (F re n u lu m p re p u tii).

Anulus inguinalis

Canalis inguinalis

Lig. suspensorium penis Fascia sp e rm atica externa

Fascia cremasterica; M. cremaster

Plexus pampiniformis Ductus deferens

A. testicu laris j Caput Epididymis < 1 (Appendix)

Fascia cremasterica; M. cremaster Tunica vaginalis testis, Lam ina visceralis Fascia sp e rm atica externa

Tunica vaginalis testis, Lam ina parietalis Fascia sp erm atica interna

Tunica dartos, M . dartos

M . c rem aster Fascia sp e rm atica externa

Fig. 7 .4 7

Septum scroti

•

Fascia s p e rm a tic a e x te rn a : c o n tin u a tio n o f th e s u p e rfic ia l b o d y

th e P e n is s e c tio n e d in th e fro n t. T h e ro o t o f th e P e n is is a tta c h e d to th e a n te rio r b o d y w a ll b y th e s u p e r

•

fa s c ia (Fascia a b d o m in a lis s u p e rfic ia lis ) M . c re m a s te r w it h Fascia c re m a s te ric a

fic ia l Lig. fu n d ifo rm e p e n is a n d th e d e e p L ig . s u s p e n s o riu m p e n is . T h e S c ro tu m is d iv id e d in te rn a lly b y a s e p tu m w h ic h a t th e o u ts id e c o rre

• Fascia s p e rm a tic a in te rn a : c o n tin u a tio n o f th e Fascia tra n s v e rs a lis In a d d itio n , th e te s tis is c o v e re d w ith th e T u n ic a v a g in a lis te s tis w h ic h

s p o n d s to th e R aphe s c ro tu m o f th e skin . T e s tis a nd F u n ic u lu s s p e rm a tic u s have th e fo llo w in g c o v e rin g s : • s k in o f th e S c ro tu m

c o n s is ts o f an e x te rn a l L am in a p a rie ta lis (p e rio rc h iu m ) a nd an in n e r La m in a v is c e ra lis (e p io rc h iu m ). B o th are c o n n e c te d b y th e m e s o rc h iu m

•

S c ro tu m , S c ro tu m ; v e n tra l v ie w ; th e S c ro tu m o p e n e d and

a nd c re a te b e tw e e n th e m th e C a v ita s s e ro s a s c ro ti.

T u n ica d a rto s : s u b c u ta n e o u s la y e r w it h s m o o th m u s c le s

dissection link

187

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Testis and e p id id ym is

Fascia cremasterica; M. cremaster

Fascia spermatica interna

Tunica vaginalis testis, Lamina parietalis

C a p u t epididym idis Appendix testis

Lig. epididymidis superius

Sinus epididymidis

(Appendix epididymidis)

Extremitas superior

C o rpus epididym idis Facies lateralis

Margo posterior

Testis anterior

Lig. epididymidis inferius

C a u d a epididym idis

Extremitas inferior

Fig. 7 .4 8

T e s tis , T e s tis [O rc h is ], a n d e p id id y m is , E p id id y m is ;

v ie w fro m th e rig h t side .

tis a n d is a tta c h e d to it b y a s u p e rio r a nd an in fe rio r lig a m e n t (Ligg. e p id id y m id is s u p e riu s a n d in fe riu s ). T h e E p id id y m is h as th e fo llo w in g

T h e T e s tis is e g g -s h a p e d a n d 4 x 3 c m in size (2 0 -3 0 g). It h as a s u p e rio r a nd an in fe r io r p o le (E x tre m ita s s u p e rio r a nd in fe rio r). T h e E p id i

p a rts : h e a d (C aput), b o d y (C orp u s), a n d ta il (C auda) w h ic h c o n tin u e s as va s d e fe re n s .

d y m is is lo c a te d a d ja c e n t to th e s u p e rio r a nd d o rs a l a s p e c t o f th e T e s

Caput epididymidis

Funiculus spermaticus

M ediastinum testis

Lobuli testis

S eptula testis

Tunica albuginea Cauda epididymidis

Fig. 7 .4 9

188

T e s tis , T e s tis [O rc h is ], a n d e p id id y m is . E p id id y m is ; s a g it

lo b u le s are th e s ite o f s p e rm p ro d u c tio n . T h e in te rs titia l tis s u e b e tw e e n

ta l s e c tio n ; v ie w fr o m th e rig h t side . T h e d e n s e T u n ic a a lb u g in e a s u rro u n d in g th e T e s tis s e n d s s e p ta in to

th e s e m in ife ro u s tu b u le s h a rb o u rs th e te s to s te r o n e p ro d u c in g te s tic u lar L E Y D IG 's c e lls . A t th e M e d ia s tin u m te s tis n e u ro v a s c u la r s tru c tu re s

th e p a re n c h y m a o f th e T e s tis a nd , th u s , s u b d iv id e s th e p a re n c h y m a in to 3 7 0 lo b u les (Lobuli te s tis ). T h e s e m in ife ro u s tu b u le s w ith in th e s e

e n te r a nd e x it th e te s tis a nd here th e s e m in ife ro u s tu b u le s are c o n n e c t e d to th e h ead o f th e E p id id y m is .

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

T estis and e p id id ym is A. testicu laris

Plexus pam piniform is

Ductuli efferentes testis

C aput epididym idis

Tunica albuginea

Ductus deferens

C o rpus epididym idis

Septula testis

C auda epididym idis

Fig. 7 .5 0

T e s tis , Te s tis [O rc h is ], a n d e p id id y m is , E p id id y m is ,

w it h b lo o d ves s e ls ; v ie w fr o m th e rig h t side .

th e s p e rm a tic c o rd a n d c o u rs e s th ro u g h th e in g u in a l canal to th e d o rs a l a s p e c t o f th e u rin a ry b la d d e r. T h e te rm in a l p a rt o f th e va s d e fe re n s

T h e te s tis is c o n n e c te d to th e h e a d o f th e E p id id y m is (C a p u t e p id id y m is ) via tin y tu b u le s (D u c tu li e ffe r e n te s te s tis ). T h e E p id id y m is its e lf

c o m b in e s w it h th e e x c re to ry d u c t o f th e s e m in a l v e s ic le to fo r m th e D u c tu s e ja c u la to riu s , w h ic h e n te rs th e Pars p ro s ta tic a o f th e m a le

c o n s is ts o f a 6 m lo n g c o n v o lu te d d u c t w h ic h c o n tin u e s as va s d e fe re n s (D u c tu s d e fe re n s ) a t th e ta il o f th e E p id id y m is . W ith a le n g th o f

U re th ra . T e s tis a nd E p id id y m is are s u p p lie d b y th e A . te s tic u la r is and a p le x u s o f v e in s (P le x u s p a m p in ifo r m is ).

3 5 - 4 0 c m a nd a th ic k n e s s o f 3 m m , th e va s d e fe re n s is lo c a te d w ith in

Septum scroti Raphe scroti Lamina

{

Lamina parietalis

Fascia sp e rm atica interna M . crem aster Septula testis Fascia crem asterica Fascia sp e rm atica externa (C avitas serosa scroti) Tunica dartos Mediastinum testis

Tunica dartos

Corpus

C o rpus epididym idis Ductus deferens A. testicu laris Plexus pampiniformis Ductus deferens

Fig. 7.51

T e s tis , Te s tis [O rc h is ], a n d e p id id y m is . E p id id y m is ;

tra n s v e rs e s e c tio n ; cra nia l v ie w .

In a d d itio n to th e te s tic u la r c o v e rin g s (-» Fig. 7 .5 5 ), th e v a s c u la r s tru c tu re s a n d th e va s d e fe re n s (D u c tu s d e fe re n s ) are s e c tio n e d .

189

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

A cce sso ry sex glands in th e m ale

G landula vesiculosa

Am pulla ductus deferentis

Lobus prostatae medius Lobus prostatae d ex ter Lobus prostatae sinister Basis prostatae Urethra masculina

Ductus deferens vesiculosa Vesica urinaria

Periurethral zone Urethra, Pars Peripheral zone (outer zone)

Prostata

Anterior zone (gland-free)

M. transversus perinei profundus

bulbourethralis

Fig. 7 .5 2 a n d Fig. 7 .5 3 S e m in a l v e s ic le s , G la n d u la e v e s ic u lo s a e , a n d p r o s ta te g la n d . P ro s ta ta ; cranial v ie w (-» Fig. 7 .5 2 ) a nd v ie w fr o m th e le ft sid e ; m e d ia n s e c tio n (-» Fig. 7.5 3 ). T h e a c c e s s o ry s ex g la n d s c o n s is t of:

s e m in a l v e s ic le (G landula v e s ic u lo s a ): p a ire d g la n d a t th e d o rs a l a s p e c t o f th e u rin a ry b la d d e r (-» Fig. 7 .3 4 ). T h e s e m in a l v e s ic le s are e lo n g a te d o val g la n d s ( 5 x 1 x 1 c m ). T h e ir e x c re to ry d u c ts c o m b in e

p r o s ta te g la n d : u n p a ire d g la n d b e n e a th th e b a se o f th e b la d d e r.

w it h th e D u c tu s d e fe re n s t o fo r m th e D u c tu s e ja c u la to riu s a n d e n te r th e Pars p ro s ta tic a o f th e U re th ra .

T h e p ro s ta te g la n d m e a s u re s 4 x 3 x 2 c m (20 g) a n d has a s u p e rio r b a se a n d an in fe rio r a p e x. It c o n s is ts o f a rig h t lo b e a n d a le f t lo b e

C O W P E R 's g la n d (G la nd u la b u lb o u re th ra lis ): p a ire d g la n d lo c a te d w ith in th e p e rin e a l m u s c le s (-» Fig. 7 .3 5 ). T h e e x c re to ry d u c ts o f

(L o b u s d e x te r a nd L o b u s s in is te r), d e m a rc a te d b y a s m a ll g ro o v e , a nd a m id d le lo b e (L o b u s m e d iu s ). T h e p ro s ta te g la n d d is c h a rg e s its s e c re tio n s in to th e c e n tra lly tra v e rs in g U re th ra (Pars p ro s ta tic a ).

th e le n til-s iz e d C O W P E R 's g la n d s e n te r th e Pars s p o n g io s a o f th e U re th ra . S e m in a l v e s ic le s a n d p ro s ta te g la n d p ro d u c e th e liq u id c o m p o n e n t o f th e e ja c u la te w h ic h n u rtu re s th e s p e rm a to z o a . T h e s e c re tio n o f th e C O W P E R 's g la n d s e n te rs th e U re th ra p rio r to e ja c u la tio n a nd fu n c tio n s in lu b ric a tio n .

Clinical R em arks--------------------------------------

190

P ro s ta tic c a rc in o m a is o n e o f th e th re e m o s t c o m m o n m a lig n a n t tu m o u rs in m e n . It u s u a lly d e v e lo p s fr o m th e m ic ro s c o p ic a lly d is

e x a m in a tio n in m e n o v e r 50 y e a rs o f a ge . T h e b e n ig n p ro s ta tic h y p e r tro p h y (BPH; h y p e rp la s ia ) is a b e n ig n tu m o u r o f th e p ro s ta te

tin c t p e rip h e ra l z o n e o f th e g la n d . T h e re fo re , s y m p to m s re la te d to m ic tu ritio n are o n ly c a u s e d a t a d v a n c e d s ta g e s . D u e to th e fa c t th a t

g la n d , c a u s in g it to e n la rg e up to a w e ig h t o f 1 00 g. B PH is a c o n d i tio n u s u a lly p re s e n t in v a rio u s d e g re e s in all m e n o v e r 7 0 y e a rs o f

th e p ro s ta te g la n d is s e p a ra te d fr o m th e R e c tu m o n ly b y th e th in re c to p ro s ta tic fa s c ia (D E N O N V IL L IE R 's fa s c ia ; - * Fig. 7 .1 1 5 ) p ro s

a ge . S in c e BPH d e v e lo p s fro m th e c e n tra l z o n e o f th e g la n d , c o n s tr ic tio n o f th e U re th ra a n d re s u ltin g m ic tu ritio n d iffic u ltie s are early

ta tic c a rc in o m a s are u su a lly p a lp a b le th ro u g h th e R e c tu m . T h e d ig ita l re cta l e x a m in a tio n (DRE) is th e re fo re p a rt o f a c o m p le te p hysica l

s ig n s o f th is c o n d itio n .

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

S p erm atic cord <V.; V. crem asterica

Ductus deferens A. ductus deferentis

N. ilioinguinalis

Corpus cavernosum penis

Plexus deferentialis

N. g en itofem oralis, R. genitalis Vasa lym phatica Tunica albuginea corporum cavernosorum A. testicu laris Plexus pam piniform is

Plexus testicu laris Fascia spermatica interna

Fascia penis (profunda) Fascia cremasterica; M. cremaster Vv. pudendae externae Fascia sperm atica externa Corpus spongiosum penis Tunica dartos

Fig. 7 .5 4 S p e r m a tic c o rd . F u n ic u lu s s p e rm a tic u s , le ft s id e ; fro n ta l s e c tio n ; v e n tra l v ie w , m a g n ific a tio n 2 ,5 -fo ld .

• •

T h e s p e rm a tic c o rd c o n ta in s th e fo llo w in g s tru c tu re s ; • va s d e fe re n s (D u c tu s d e fe re n s ) w it h A . d u c tu s d e fe re n tis (fro m th e A . u m b ilic a lis )

• a u to n o m ic n e rv e fib r e s (P lexu s te s tic u la ris ) fr o m th e a o rtic p le x u s E x te rn a lly , th e N. ilio in g u in a lis a n d th e A . a nd V. c re m a s te ric a are adja

•

N. g e n ito fe m o ra lis , R. g e n ita lis (-» Fig. 7 .5 6 ) ly m p h v e s s e ls (Vasa ly m p h a tic a ) to th e lu m b a r ly m p h n o d e s

c e n t t o th e s p e rm a tic c o rd (-* Figs. 7 .5 5 a nd 7.5 6 ).

A . te s tic u la ris fr o m th e a b d o m in a l a orta a nd th e P le xu s p a m p in ifo r m is as a c c o m p a n y in g v e in s

N. ilioinguinalis

Anulus inguinalis superficialis

Fascia sp e rm atica externa

Fascia cremasterica; M. cremaster

Plexus pam piniform is Ductus deferens

A. testicu laris Caput

(

(Appendix)

Appendix testis

Fascia cremasterica; M. cremaster

Tunica vaginalis testis, Lamina visceralis Fascia sp e rm atica externa

Tunica vaginalis testis, Lamina parietalis Fascia sp e rm atica interna

Tunica dartos, M . dartos M . crem aster Cutis

Fascia sp e rm atica externa Raphe scroti

Septum

Fig. 7 .5 5 C o v e rin g s o f th e s p e rm a tic c o rd . F u n ic u lu s s p e rm a ti cu s , a n d th e te s tis . T e s tis ; v e n tra l v ie w ; S c ro tu m o p e n e d .

•

Fascia s p e rm a tic a e x te rn a : c o n tin u a tio n

T e s tis a nd s p e rm a tic c o rd have th e fo llo w in g c o v e rin g s :

•

fa s c ia (Fascia a b d o m in a lis s u p e rfic ia lis ) M . c re m a s te r w it h Fascia c re m a s te ric a

• •

•

Fascia s p e rm a tic a in te rn a : c o n tin u a tio n o f th e Fascia tra n s v e rs a lis

s c ro ta l skin (C utis) T u n ica d a rto s : S u b c u tis w it h s m o o th m u s c le c e lls

o f th e s u p e rfic ia l b o d y

Pelvis and Retroperitoneal Space

Kidney and Adrenal Gland

Blood vessels and nerves o f th e penis A. dorsalis penis

Lig. fundiform e penis

Lig. suspensorium penis

Anulus inguinalis superficialis Funiculus spermaticus

N. ilioinguinalis V. testicularis Funiculus spermaticus N. genitofemoralis, R. genitalis A.; (V.) cremasterica

N. dorsalis penis A.; V. pudenda externa profunda

Plexus pampiniformis V. dorsalis profunda penis

Ductus deferens

A. testicularis

Rr. scrotales anteriores

V. dorsalis profunda penis

V. dorsalis superficialis penis

Fascia penis superficialis

Fig. 7 .5 6

E x te rn a l m a le g e n ita lia . O rg a n a g e n ita lia m a s c u lin a

e x te r n a , w it h n e u ro v a s c u la r s tru c tu re s ; v e n tra l v ie w ; a fte r re m o v a l

T h e v e n o u s b lo o d is c o lle c te d b y t h r e e v e n o u s s ys te m s: • V. d o rs a lis s u p e rfic ia lis p e n is : p a ire d o r u n p a ire d , e p ifa s c ia l c o u rs e ,

o f th e fa s c ia o f th e P enis. T h e P e n is re c e iv e s its a rte ria l b lo o d s u p p ly fr o m th r e e p a ire d a rte rie s

__ d ra in s b lo o d .fro m th e p e n ile s k in to th e V. p u d e n d a e x te rn a • V. d o rs a lis p ro fu n d a p e n is : u n p a ire d , s u b fa s c ia l c o u rs e , d ra in s b lo o d

a risin g fr o m th e A . p u d e n d a in te rn a : • A . d o rs a lis p e n is : s u b fa s c ia l c o u rs e , s u p p lie s th e sk in o f th e P enis

•

fr o m th e C orp o ra ca v e rn o s a to th e P le x u s v e n o s u s p ro s ta tic u s V. b u lb i p e n is : p a ire d , d ra in s b lo o d fr o m th e B u lb u s p e n is to th e

•

a nd th e g la n s p e n is A . p ro fu n d a p e n is : lo c a te d w ith in th e C orp o ra c a v e rn o s a ; re g u la te s

V. d o rs a lis p ro fu n d a p e n is In n e rv a tio n :

•

th e fillin g o f th e c o rp o ra ca ve rn o sa A . b u lb i p e n is : e n te rs th e B u lb u s p e n is , s u p p lie s th e G la nd u la bul-

• •

b o u re th ra lis a nd a s A . u re th ra lis it s u p p lie s th e U re th ra a nd th e C or p u s s p o n g io s u m

s e n s o ry : N. d o rs a lis p e n is (fro m th e N. p u d e n d u s ) a u to n o m ic : N n. c a v e rn o s i p e n is (fro m th e P le x u s h y p o g a s tric u s in fe rior) p e n e tra te th e p e lv ic flo o r a n d c o u rs e a d ja c e n t to th e N . d o rs a lis p e n is (s y m p a th e tic s tim u la tio n c a u s e s v a s o c o n s tric tio n ; p a ra s y m p a th e tic s tim u la tio n c a u s e s v a s o d ila tio n a n d c o n s e c u tiv e e re c tio n ). V. dorsalis profunda penis A. profunda penis V. dorsalis superficialis penis

Fig. 7 .5 7

Fascia penis

P e n is , Penis; c ro s s -s e c tio n a t th e m id le v e l o f th e p e n ile

b o d y ; v e n tra l v ie w . T h e lo c a tio n o f th e b lo o d v e s s e ls is im p o rta n t fo r th e e re c tio n o f th e P e n is. F o llo w in g p a ra s y m p a th e tic in n e rv a tio n , d ila tio n o f th e A . p ro fu n da p e n is c a u s e s th e fillin g o f th e C o rp o ra c a v e rn o s a . T h e s e c o m p re s s th e V. d o rs a lis p ro fu n d a p e n is b e n e a th th e to u g h Fascia p e n is a n d p re v e n t v e n o u s d ra in a g e . S u p p o rte d b y th e c o n tra c tio n o f th e M m . is c h io c a v e rn o s i (in n e rv a te d b y th e N. p u d e n d u s ), th is re s u lts in

A. dorsalis penis Cutis Tunica albuginea corporum cavernosorum

Corpus cavernosum penis

p e n ile e re c tio n . Septum penis Urethra masculina, Pars spongiosa Fascia penis Corpus spongiosum penis

A. urethralis

Clinical Remarks P a ra s y m p a th e tic s tim u la tio n in d u c e s e le v a te d le v e ls o f n itric m o n o x id e (N O ). In tu rn , th is in c re a s e s th e c o n c e n tra tio n o f th e s e c o n d m e s s e n g e r c G M P in th e s m o o th m u s c le c e lls o f th e a rte ria l w a lls

192

w ith re s u ltin g s m o o th m u s c le re la x a tio n . In h ib ito rs o f t h e e n z y m e p h o s p h o d ie s te ra s e (such as Viagra®, Cialis®) d e la y th e m e ta b o lis m o f c G M P a n d im p ro v e e re c tio n .

Efferent urinary system -» Genitalia -► Rectum and anal canal -> Topography -♦ Sections

Blood vessels o f te s tis and e p id id ym is

A.; V. renalis

A. crem asterica

A.; V. testicu laris

cava inferior A. ductus deferentis

Plexus pam pinifo rm is

Ren

A.; V. testicu laris

Caput epididymidis Pars abdominalis aortae

Cauda epididymidis

Fig. 7 .5 8

C o u rs e o f th e A . a n d V. te s tic u la ris ; v e n tra l v ie w .

Fig. 7 .5 9 B lo o d v es s e ls o f t h e in te r n a l m a le g e n ita lia ; v ie w fro m th e r ig h t s ide .

B lo o d V e s se ls o f th e In te r n a l G e n ita lia

A rte rie s

V e in s

O rg a n

B lo o d V essel

T e s tis a n d E p id id y m is

A . te s tic u la ris (fro m th e A o rta a b d o m in a lis )

va s d e fe re n s

A . d u c tu s d e fe re n tis (u su a lly fr o m th e A . u m b ilic a lis )

s p e rm a tic co rd (M . c re m a s te r)

A . c re m a s te ric a (fro m th e A . e p ig a s tric a in fe rio r)

a c c e s s o ry s e x g la n d s

A . v e s ic a lis in fe rio r a nd A . re c ta lis m e d ia (fro m th e A . iliaca intern a )

T e s tis , E p id id y m is , D u c tu s d e fe re n s , s p e rm a tic c o rd

P le x u s p a m p in ifo rm is : p le x u s o f v e in s th a t m e rg e to fo r m th e V. te s tic u la ris w h ic h d ra in s in to th e V. cava in fe rio r o n th e r ig h t s id e a n d th e V. re n a lis s in is tra on th e le ft s id e

a c c e s s o ry s e x g la n d s

P le x u s v e n o s i v e s ic a lis a n d p ro s ta tic u s w it h o u tflo w in to th e V. iliaca in te rn a

i- Clinical R em arks-------------------------------------O b s tru c tio n o f th e v e n o u s d r a in a g e in to th e le ft V. re n a lis o r re n a l

v e in s in th e le ft P le x u s p a m p in ifo rm is (v a ric o c e le ). A le ft-s id e d va ri

cell c a rc in o m a s g ro w in g in to th e renal v e in m a y c a u s e a c o n g e s tio n o f b lo o d as re v e a le d b y a p a lp a b le a n d v is ib le d ila tio n o f th e

c o c e le re q u ire s th e e x c lu s io n o f a renal c e ll c a rc in o m a a s a p o s s ib le c a u s e . A p e rs is te n t v a ric o c e le m a y c a u s e in fe rtility .

193

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Innervation o f th e m ale genitalia

In n e rv a tio n o f th e m a le g e n ita lia ; v e n tra l a nd latera l

P re g a n g lio n ic p a r a s y m p a th e tic fib re s d e riv e fr o m th e sa cral d iv is io n

v ie w ; s c h e m a tic illu s tra tio n . T h e P le xu s h y p o g a s tric u s in fe rio r c o n ta in s s y m p a th e tic (g ree n ) a n d p a ra s y m p a th e tic (p urp le ) n e rv e

Fig. 7 .6 0

o f th e p a ra s y m p a th e tic n e rv o u s s y s te m (S 2 -S 4 ) via th e N n. s p la n c h n ic i p e lv ic i a nd re a c h th e g a n g lia o f th e P lexu s h y p o g a s tric u s in fe rio r. T h e y

fib re s . T h e p re g a n g lio n ic s y m p a th e tic fib re s (T 1 0 -L 2 ) d e s c e n d fro m

th e

are s y n a p s e d e ith e r h e re o r in th e v ic in ity o f th e p e lv ic o rg a n s (G anglia p elvica ) to p o s tg a n g lio n ic n e u ro n s fo r th e a c c e s s o ry g la n d s . T h e Nn.

P le xu s a o rtic u s a b d o m in a lis via th e P le xu s h y p o g a s tric u s s u p e rio r a nd fro m th e sa cral g a n g lia o f th e s y m p a th e tic tru n k (T ru n cu s s y m p a th ic u s )

c a v e rn o s i p e n e tra te th e p e lv ic flo o r a nd c o u rs e to th e C orp o ra c a v e r nosa (p a rtly a d ja c e n t to th e N. d o rs a lis p e n is ) to in d u c e e re c tio n u p o n

via th e N n. s p la n c h n ic i s a cra le s. T h e y are p re d o m in a n tly s y n a p s e d to p o s tg a n g lio n ic s y m p a th e tic n e u ro n s in th e P le xu s h y p o g a s tric u s in fe

p a ra s y m p a th e tic s tim u la tio n . S o m a tic in n e rv a tio n via th e N . p u d e n d u s c o n v e y s s e n s o ry in n e rv a tio n

rio r. T h e s e p o s tg a n g lio n ic fib re s re ach th e p e lv ic v is c e ra , in c lu d in g th e a c c e s s o ry s e x g la n d s . S y m p a th e tic fib re s to th e va s d e fe re n s (P lexus

to th e P e n is via th e N. d o rs a lis p e n is a nd a id s in e ja c u la tio n o f s p e rm a to z o a th ro u g h th e m o to r in n e rv a tio n to th e M . b u lb o s p o n g io s u s a nd M .

d e fe re n tia lis ) a c tiv a te s m o o th m u s c le c o n tra c tio n s fo r th e e m is s io n o f s p e rm a to z o a in to th e U re th ra . S o m e fib re s a lso jo in th e N n. c a v e rn o s i

is c h io c a v e rn o s u s via th e N n. p e rin e a le s in th e p e rin e u m . P a ra s y m p a th e tic s tim u la tio n in d u c e s e re c tio n , w h ile s y m p a th e tic

a nd p e n e tra te th e p e lv ic flo o r to re a ch th e C orp o ra c a v e rn o s a o f th e P e n is. T h e (m o s tly ) p o s tg a n g lio n ic s y m p a th e tic fib re s to th e T e s tis a nd E p id id y m is c o u rs e in th e P le xu s te s tic u la ris a lo n g s id e th e A . te s tic u la ris

fib re s in itia te th e e m is s io n , a nd th e N . p u d e n d u s is in v o lv e d in e ja c u la tio n .

a fte r b e in g a lre a d y s y n a p s e d in th e G an g lia a o rtic o re n a lia o r th e P lexu s h y p o g a s tric u s su p e rio r.

i- Clinical R em arks--------------------------------------

194

D u rin g su rg ic a l re s e c tio n o f para -a o rta l ly m p h n o d e s , as re q u ire d w it h te s tic u la r o r c o lo re c ta l c a rc in o m a s , a nd s u rg ica l p ro c e d u re s in

la tio n m a y b e c o m p ro m is e d re s u ltin g in im p o te n c e . S u rgica l p ro c e d u re s o n th e p ro s ta te g la n d o r th e re c tu m as re q u ire d in p ro s ta tic o r

v o lv in g th e a b d o m in a l a o rta o r th e la rg e r p e lv ic a rte rie s , s y m p a th e tic fib re s m a y be d a m a g e d a n d e m is s io n as w e ll as s u b s e q u e n t e ja c u -

re c ta l c a rc in o m a m a y in ju re th e p a ra s y m p a th e tic fib re s to th e P e n is c a u s in g e re c tile d y s fu n c tio n .

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

Lym ph vessels o f th e m ale genitalia

Nodi lum bales

Nodi lymphoidei iliaci communes

Nodi lymphoidei sacrales Nodi lymphoidei iliaci interni Nodi lymphoidei iliaci externi Nodi lym phoidei inguinales profundi Nodi

Fig. 7.61

L y m p h v es s e ls a n d ly m p h n o d e s o f t h e e x te r n a l a n d

in te r n a l m a le g e n ita lia ; v e n tra l v ie w .

superficiales

T h e re g io n a l ly m p h n o d e s fo r th e e x te rn a l g e n ita lia are th e in g u in a l n o d e s (N o d i ly m p h o id e i in g u in a le s ). In c o n tra s t, th e fir s t re g io n a l ly m p h n o d e s fo r th e T e s te s a n d E p id id y m is are lo c a te d in th e re tro p e ri to n e a l s p a c e a t th e le ve l o f th e k id n e y s (N o d i ly m p h o id e i lu m b a le s ).

Nodi lymphoidei lumbales

lymphoidei sacrales Nodi lymphoidei iliaci communes

lymphoidei iliaci interni Nodi lymphoidei iliaci externi

Nodi lymphoidei inguinales profundi

Nodi lymphoidei inguinales superficiales

Fig. 7 .6 2

L y m p h a tic d ra in a g e p a th w a y s o f th e e x te r n a l a n d

In te r n a l g e n ita lia :

in te r n a l m a le g e n ita lia ; v e n tra l v ie w . In m e n , e x te rn a l a nd in te rn a l g e n ita lia have c o m p le te ly d iffe r e n t ly m

•

T e s te s a n d E p id id y m is : N o d i ly m p h o id e i lu m b a le s a t th e le ve l o f th e k id n e y s

p h a tic d ra in a g e p a th w a y s . E x te rn a l g e n ita lia :

•

v a s d e fe re n s , s p e rm a tic c o rd , a n d a c c e s s o ry s e x g la n d s : N o d i ly m p h o id e i ilia ci in te rn i/e x te rn i a nd N o d i ly m p h o id e i sa c ra le s

•

P e n is a nd S c ro tu m : N o d i ly m p h o id e i in g u in a le s

[- Clinical R em arks-------------------------------------T h e d iffe r e n t ly m p h a tic d ra in a g e p a th w a y s e xp la in w h y ly m p h a tic

la r b io p s y s h o u ld be p e rfo rm e d w h e n s u s p e c tin g te s tic u la r c a rc i

m é ta s ta s é s o f p e n ile c a rc in o m a fir s t a p p e a r in th e in g u in a l re g io n , w h e re a s th o s e o f te s tic u la r c a rc in o m a m a n ife s t in th e re tro p e rito n e

n o m a s in c e th is m a y c a u s e th e d is s e m in a tio n o f m a lig n a n t c e lls in to th e in g u in a l ly m p h n o d e s . In th e s e c a s e s , b io p s ie s m u s t b e ta k e n

al s p a ce . B e ca u se th e ly m p h a tic d ra in a g e p a th w a y s o f th e e x te rn a l a n d in te rn a l g e n ita lia d o n o t c o m m u n ic a te , no tra n s s c ro ta l te s tic u -

fro m th e in g u in a l canal.

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Pelvic flo o r in m en

M. iliacus M. psoas major

(Foramen suprapiriforme)

M. piriformis M . o b turatoriu s internus

(Foramen infrapiriforme) Ramus superior ossis M . ischiococcygeus [coccygeus]; D iaph ragm a pelvis N. obturatorius; A.; V. obturatoria Foramen ischiadicum minus Canalis M . levator ani, D iaph ra gm a pelvis M . pub ococcygeus

M . iliococcygeus

Symphysis pubica A rcus tendineus m usculi levatoris ani

Rectum

M. gluteus maximus

Fig. 7 .6 3

M u s c le s o f th e p e lv ic flo o r, D ia p h r a g m a p e lv is , th ig h

a n d hip in m e n ; v ie w fr o m th e le ft side . T h e p e lv ic flo o r c lo s e s th e p e lv ic c a v ity caudally. O rg a n is a tio n : •

M . le v a to r ani, c o m p ris in g M . p u b o c o c c y g e u s , M . ilio c o c c y g e u s , a nd

•

M . p u b o re c ta lis M . is c h io c o c c y g e u s

p a s s a g e o f U re th ra a n d R e c tu m , re s p e c tiv e ly . T h e p e lv ic flo o r is in n e rv a te d b y d ire c t b ra n c h e s o f th e P le x u s sa c ra lis (S 3 -S 4 ). F u n c tio n : T h e p e lv ic flo o r s ta b ilis e s th e p o s itio n o f th e p e lv ic v is c e ra

In c o n tra s t to th e M . p u b o c o c c y g e u s a n d th e M . is c h io c o c c y g e u s , th e M . ilio c o c c y g e u s d o e s n o t o rig in a te fr o m th e O s c o x a e b u t fr o m th e

a nd , th u s , is e s s e n tia l fo r u rin a ry a nd fe c a l c o n tin e n c e . P e lv ic flo o r in s u ffic ie n c y w ith re s u ltin g in c o n tin e n c e is ra re in m e n s in c e p o te n tia l

A rc u s te n d in e u s m u s c u li le v a to ris ani, a re in fo rc e m e n t o f th e fa s c ia o f th e M . o b tu ra to riu s in te rn u s .

in ju rie s d u e to re p e titiv e s tra in d u rin g c h ild b irth is lackin g .

T h e m u s c le s o f b o th s id e s s p a re th e le v a to r h ia tu s b e tw e e n th e m (H ia

196

tu s le v a to riu s ) (-* Fig. 7 .8 7 ). T h is m u s c u la r g ap is d iv id e d b y th e c o n n e c tiv e tis s u e o f th e C o rp u s p e rin e a le (C e n tru m p e rin e i) in to th e a n te rio r H ia tu s u r o g e n ita lis a nd th e p o s te rio r H ia tu s a n a lis fo r th e

—► T 20a

Efferent urinary system -► Genitalia -► Rectum and anal canal -> Topography -► Sections

Perineal m u scle s in m en

Symphysis pubica

dorsalis profunda penis A.; N. dorsalis

pubicum inferius transversum perinei

Urethra masculina G landula bulbourethralis

M . sph incter ureth rae externus

transversus perinei profundus Ductus glandulae bulbourethralis A.; V. bulbi penis M . transversus perinei profundus A.; V. perinealis

M em b ran a perinei

N. perinealis

Ramus ossis ischii

A.; V. pudenda interna N . pudendus

perinei superficialis

Fig. 7 .6 4

P e rin e a l m u s c le s in m e n ; caudal v ie w ; a fte r re m o v a l o f all

o th e r m u s c le s . In m e n , th e m u s c u la r g a p o f th e le v a to r h ia tu s (H ia tu s le v a to riu s ) is al

s id e s . T h e s tro n g e r in fe rio r fa s c ia is re fe rre d t o as p e rin e a l m e m b ra n e ( M e m b r a n a p e rin e i). T h e s p a c e b e tw e e n b o th fa s c ia s is th e d e e p p e rin e a l s p a c e (S p atiu m

m o s t e n tire ly c lo s e d b y th e p e rin e a l m u s c le s b e n e a th w h ic h leave o n ly th e p a ssa g e fo r th e U re th ra m a scu lin a .

p ro fu n d u m p e rin e i) a n d is e n tire ly o c c u p ie d b y th e M . tra n s v e rs u s p e ri n e i p ro fu n d u s . T h is s p a c e a ls o c o n ta in s th e U re th ra a nd th e C O W P E R 's

T h e p e rin e a l m u s c le s in m e n c o m p ris e th e s tro n g M . tra n s v e rs u s perin e i p ro fu n d u s a n d th e th in M . tra n s v e rs u s p e rin e i s u p e rfic ia lis lo

g la n d s (G la nd u lae b u lb o u re th ra le s ) a nd is tra v e rs e d b y d e e p b ra n c h e s o f th e N. p u d e n d u s as w e ll as th e A . a n d V. p u d e n d a in te rn a b e fo re th e y

c a te d a t its p o s te rio r m a rg in . T h e s e m u s c le s have fo r m e r ly b e e n re fe rre d to as "D ia p h ra g m a u ro g e n ita le " a n a lo g o u s to th e D ia p h ra g m a

re ach th e R ad ix p e n is . T h e s u p e rfic ia l p e rin e a l s p a c e (S p a tiu m s u p e rfic ia le p e rin e i) lie s ca u

p e lv is . S in ce a tru e d ia p h ra g m d o e s n o t e x is t a nd b e c a u s e a s im ila r m u s c u la r p la te is m is s in g in w o m e n , th is te r m is n o t u s e d a n y m o re . T h e v o lu n ta ry s p h in c te r m u s c le o f th e u rin a ry b la d d e r, th e M . s p h in c te r

dal t o th e p e rin e a l m e m b ra n e a nd c o n ta in s a m o n g s t o th e rs th e M . tra n s v e rs u s p e rin e i s u p e rfic ia lis .

u re th ra e e x te rn u s , is a p a rt o f th e M . tra n s v e rs u s p e rin e i p ro fu n d u s . T h e M . tra n s v e rs u s p e rin e i p ro fu n d u s is c o v e re d b y a fa scia o n b o th

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Pelvic flo o r and perineal m uscles in m en

Articulatio sacrococcygea

Ureter

Os pubis

Lig. puboprostaticum

Glandula vesiculosa

Funiculus spermaticus

Corpus anococcygeum [Lig. anococcygeum] M . levator ani

Ductus deferens Corpus anococcygeum [Lig. anococcygeum]

M. cremaster

Rectum, Flexura anorectalis Crus penis M. sphincter ani externus

A. profunda penis M. ischiocavernosus M . transversus perinei profundus

M . transversus perinei profundus

M . sph in cter urethrae externus Prostata

Fig. 7 .6 5

M. bulbospongiosus bulbourethralis

P e lv ic flo o r, D ia p h r a g m a p e lv is , a n d p e rin e a l m u s cle s

in m e n ; v ie w fr o m th e le ft side . A t its a n te rio r a nd p o s te rio r a s p e c t, th e p e lv ic flo o r c o n s is ts o f th e M . le v a to r ani a nd th e M . is c h io c o c c y g e u s , re s p e c tiv e ly . L o c a te d b e n e a th th e p e lv ic flo o r is th e d e e p p e rin e a l m u s c le (M . tra n s v e rs u s p e rin e i p ro

198

dissection link

fu n d u s ). A p a rtitio n o f th e la tte r, th e M . s p h in c te r u re th ra e e x te rn u s , fu n c tio n s a s s p h in c te r o f th e u rin a ry b la d d e r. E m b e d d e d w ith in th e M . tra n s v e rs u s p e rin e i p ro fu n d u s are th e C O W P E R 's g la n d s. —» T 20

Efferent urinary system -► Genitalia -► Rectum and anal canal

Topography -> Sections

Perineal region in m en

Corpus spongiosum penis M . bulbospongiosus

Raphe perinei

M . ischiocavernosus G landula bulbourethralis

M. gracilis

M . transversus perinei profundus

Membrana perinei

Regio urogenitalis

M . transversus perinei superficialis Fascia obturatoria

Regio perinealis Tuber ischiadicum

Fascia obturatoria Regio analis

Lig. sacrotuberale C analis pudendalis

Fossa ischioanalis

M. gluteus maximus M. sphincter ani externus M. levator ani

Fig. 7 .6 6

Anus

Lig. anococcygeum

Os coccygis

P e rin e a l r e g io n , R e g io p e rin e a lis , in m e n ; ca ud a l v ie w ;

a fte r re m o v a l o f all n e u ro v a s c u la r s tru c tu re s . T h e p e rin e a l re g io n e x te n d s fr o m th e in fe rio r m a rg in o f th e p u b ic s y m p h y s is (S y m p h y s is p ub ica ) to th e tip o f th e c o c c y x (O s c o c c y g is ). The te r m p e rin e u m in m e n , h o w e v e r, e x c lu s iv e ly d e s c rib e s th e s m a ll c o n n e c tiv e tis s u e b rid g e b e tw e e n th e R ad ix p e n is a nd th e A n u s . T h e p e ri neal re g io n is s u b d iv id e d in to th e a n te rio r R eg io u ro g e n ita lis (u ro g e n ita l tria n g le ), c o n ta in in g th e e x te rn a l g e n ita lia a n d th e U re th ra , and th e p o s te r io r R e g io a n a lis (anal tria n g le ) a ro u n d th e A n u s . T h e fo l lo w in g s p a c e s can be fo u n d w ith in th e s e tria n g le s : • T h e R eg io a n a lis c o n ta in s th e Fossa is c h io a n a lis (-► Tab le ), w h ic h c o n s titu te s a p y ra m id -s h a p e d s p a c e on b o th s id e s o f th e A n u s . The c ra nia l b o rd e r is th e M . le v a to r ani o f th e p e lv ic flo o r. T h e latera l w a ll e n c lo s e s th e fa s c ia l d u p lic a tu re o f th e M . o b tu ra to riu s in te rn u s (Fascia o b tu ra to ria ), th e p u d e n d a l canal (A L C O C K 's canal). The p u d e n d a l canal c o n ta in s th e A . a n d V. p u d e n d a in te rn a , a nd th e N. p u d e n d u s a fte r th e ir p a ssa g e fr o m th e g lu te a l re g io n th ro u g h th e F o ra m e n is c h ia d ic u m m in u s .

T h e R e g io u ro g e n ita lis has t w o p e rin e a l spaces: • T h e d e e p p e rin e a l s p a c e (S p a tiu m p ro fu n d u m p e rin e i) c o m p ris e s

•

th e M . tra n s v e rs u s p e rin e i p ro fu n d u s a nd th e C O W P E R 's g la n d s (G la nd u lae b u lb o u re th ra le s ). T h e s u p e rfic ia l p e rin e a l s p a c e (S p a tiu m s u p e rfic ia le p e rin e i) c o m p ris e s th e M . tra n s v e rs u s p e rin e i s u p e rfic ia lis , th e M . b u lb o s p o n g io s u s , a nd th e M . is c h io c a v e rn o s u s , w h ic h s ta b ilis e th e ca v e rn o u s b o d ie s o f th e R ad ix p e n is a n d e n a b le e ja c u la tio n . B o rd e rs o f th e Fossa is c h io a n a lis M e d ia l a n d c ra n ia l

M . s p h in c te r ani e x te rn u s a n d M . le v a to r ani

L a te ra l

M . o b tu ra to riu s e x te rn u s

D o rs a l

M . g lu te u s m a x im u s a n d L ig . s a c ro tu b e ra le

V e n tra l

p o s te rio r m a rg in o f th e s u p e rfic ia l a n d th e d e e p p e rin e a l s p a c e s ; a n te rio r re c e s s re a c h e s th e p u b ic s y m p h y s is

C au d a l

fa s c ia a n d s k in o f th e p e rin e u m

199

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Perineal region in m en A. perinealis, Rr. scrotales posteriores Nn. scrotales posteriores

M. bulbospongiosus A. dorsalis penis

A. bulbi penis M. ischiocavernosus

N. dorsalis penis M. sphincter ani externus

Rr. perineales (N. cutaneus femoris posterior) A. perinealis

M. transversus perinei superficialis Nn. clunium inferiores (N. cutaneus femoris posterior)

N. perinealis

Fossa ischioanalis

N. dorsalis penis N. dorsalis penis

Nn. rectales inferiores A.; V. pudenda interna N. perinealis

Lig. sacrospinale A. rectalis inferior N .p u d e n d u s A. pudenda interna Nn. clunium inferiores (N. cutaneus femoris posterior)

Lig. sacrotuberale

M . levator ani

M. gluteus maximus Lig. anococcygeum

Fig. 7 .6 7

B lo o d v es s e ls a n d n e rv e s o f th e p e rin e a l r e g io n , R eg io

p e rin e a lis , in m e n ; ca ud a l v ie w . C o ve re d b y a fa s c ia l d u p lic a tu re o f th e M . o b tu ra to riu s in te rn u s , th e C analis p u d e n d a lis (A L C O C K 's canal), th e n e u ro v a s c u la r s tru c tu re s e n te r th e Fossa is c h io a n a lis fr o m a d o rs o la te ra l d ire c tio n . T h e p y ra m id

Nn. anococcygei

C o n te n ts o f t h e Fossa is c h io an a lis : • A . a nd V. p u d e n d a in te rn a a n d N. p u d e n d u s : in th e C analis p u d e n d a lis (A L C O C K 's canal) •

A ., V., a n d N. re c ta lis in fe rio r: to th e anal canal

sh a p e d fo s s a is fille d w it h a d ip o s e tis s u e . B ra n c h e s to th e A n u s a nd th e anal canal c o m e o ff fir s t a nd c ro s s th e isch io -a n a l fo s s a to re ach th e a nu s. T h e n e u ro v a s c u la r s tr u c tu re s th e n c o n tin u e v e n tra lly to th e R adix p e n is a nd th e t w o p e rin e a l sp a ce s.

i- Clinical R em arks-------------------------------------T h e Fossa is c h io a n a lis is o f g re a t clin ic a l re le v a n c e b e c a u s e o f its e x p a n s io n to b o th s id e s o f th e a nu s. C o lle c tio n o f p u s (a b sce sse s), e .g . fis tu la s fr o m th e anal canal, m a y e x p a n d w ith in th e e n tire is c h io -

2 0 0 —♦ d i s s e c t i o n l i n k

anal fo s s a , in c lu d in g its a n te rio r re c e s s a n d e v e n e x te n d t o th e p u b ic s y m p h y s is . T h e s e a b s c e s s e s n o t o n ly g e n e ra te n o n -s p e c ific in fla m m a to r y s ig n s b u t a ls o c a u s e in te n s e pain in th e p e rin e a l re g io n .

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

Perineal spaces in m en

(C avitas perito nealis pelvis)

Ampulla ductus deferentis Peritoneum parietale

Glandula vesiculosa

M. obturatorius internus

(Spatium extrap erito n eale pelvis) Prostata Plexus venosus prostaticus M . levator ani Fossa ischioanalis Sp atium profundum perinei

R egio perinealis

Crus penis

A.; V. pudenda interna; N. pudendus

Sp atium superficiale perinei

Crus M. ischiocavernosus

G landula bulbourethralis M . transversus perinei profundus M

Fig. 7 .6 8

................

Bulbus penis

P e rin e a l s p a c es in m e n ; le ft s id e ; fr o n ta l s e c tio n a t th e

le v e l o f th e fe m o ra l h ea d ; d o rs a l v ie w . T h e fro n ta l s e c tio n s h o w s th r e e le v e ls o f th e m a le p e lvis: •

p e rito n e a l c a v ity o f th e p e lv is (C avita s p e rito n e a lis p e lvis), c a u d a lly b o rd e re d b y th e p a rie ta l p e rito n e u m

•

s u b p e rito n e a l s p a ce (S p a tiu m e x tra p e rito n e a le p e lvis), c a u d a lly b o r d e re d b y th e M . le v a to r ani o f th e p e lv ic flo o r

•

p e rin e a l re g io n (R eg io p e rin e a lis) in fe rio r to th e p e lv ic flo o r. The a n te rio r p o rtio n c o n ta in s th e t w o p e rin e a l sp a ce s, a n d in c lu d e s th e

v a ria b ly e x p a n d e d a n te rio r re c e s s o f th e isch io -a n a l fo s s a (illu s tra te d h e re in d iffe re n t w a y s fo r th e rig h t s id e a nd th e le ft side). T h e d e e p p e rin e a l s p a c e (S p a tiu m p ro fu n d u m p e rin e i) c o n s is ts o f th e M . tra n s v e rs u s p e rin e i p ro fu n d u s . It a lso c o n ta in s th e C O W P E R 's g la n d s (G la nd u lae b u lb o u re th ra le s ) a nd th e p a ssa g e o f th e U re th ra (U re th ra m a scu lin a ). It is tra v e rs e d b y th e d e e p b ra n c h e s o f th e N. p u-

d e n d u s (N. d o rs a lis p e n is ), a nd th e A . a n d V. p u d e n d a in te rn a (A. b u lb i p e n is , A . d o rs a lis p e n is , A . p ro fu n d a p e n is ) b e fo re re a c h in g th e R adix p e n is . T h e N n. c a v e rn o s i p e n is p ie rc e th e p e rin e u m a n d e n te r th e C or pora c a v e rn o s a o f th e P enis. T h e s u p e rfic ia l p e rin e a l s p a c e (S p a tiu m s u p e rfic ia le p e rin e i) is lo c a te d b e tw e e n th e p e rin e a l m e m b ra n e (M e m b ra n a p e rin e i) a t th e u n d e rs id e o f th e M . tra n s v e rs u s p e rin e i p ro fu n d u s a n d th e b o d y fa s c ia (Fascia p e rin e i). It c o n ta in s th e M . tra n s v e rs u s p e rin e i s u p e rfic ia lis a nd th e p ro x im a l p a rts o f th e C orp o ra c a v e rn o s a o f th e P e n is. T h e B u lb u s p e n is is e n s h e a th e d b y th e M . b u lb o s p o n g io s u s , th e C rura p e n is b y th e M . is c h io c a v e rn o s u s . T h e s u p e rfic ia l b ra n c h e s o f th e N. p u d e n d u s (N. pe rin e a lis w it h N n. s c ro ta le s p o s te rio re s ) a nd th e A . a nd V. p u d e n d a in te r na (A. p e rin e a lis w ith Rr. s c ro ta le s p o s te rio re s ) a ls o tra v e rs e th is s p a c e to re ach th e S c ro tu m .

201

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

External fe m a le genitalia M ons pubis

Preputium clitoridis Commissura labiorum anterior Frenulum clitoridis G ians clitoridis Labium m ajus pudendi O stium urethrae externum

Labium m inus pudendi Ostium vaginae

G landula vestibularis m ajor, (Ostium)

Hymen Frenulum labiorum pudendi

Vestibulum vaginae

Perineum, Raphe perinei

Commissura labiorum posterior

Anus

Fig. 7 .6 9

E x te rn a l fe m a le g e n ita lia , O rg a n a g e n ita lia fe m in in a

e x te r n a ; ca ud a l v ie w .

• •

Labia m in o ra p u d e n d i C lito ris

T h e fe m a le g e n ita lia can be c a te g o ris e d in to e x te rn a l g e n ita lia (O rgana g e n ita lia fe m in in a e x te rn a ) a n d in te rn a l g e n ita lia (O rg a na g e n ita lia fe m i

• •

v e s tib u le (V e s tib u lu m va gin a e) G la n d u la e v e s tib u la re s m a jo re s (B A R T H O L IN 'S g la n d s ), a n d m in o re s

nina in te rn a -» Fig. 7.7 1 ). T h e e x te r n a l g e n ita lia are re fe rre d to as V u lv a a nd c o m p ris e :

T h e v e s tib u le e x te n d s to th e h y m e n a t th e v a g in a l o rific e (O s tiu m v a g i nae). V e n tra l th e r e o f is th e e x te rn a l u re th ra l o rific e (O s tiu m u re th ra e e x te rn u m ).

• •

M o n s p u b is Labia m a jo ra p u d e n d i

T h e e x te rn a l g e n ita lia are th e s e x o rg a n s a nd s e rv e fo r in te rc o u rs e .

Tuberculum pubicum Lig. suspensorium clitoridis

Symphysis

orpus cavernosum clitoridis Preputium clitoridis

G ians clitoridis

Frenulum clitoridis C rus clitoridis O stium urethrae externum

Labium m inus pudendi

Carunculae hymenales Ostium

M. ischiocavernosus M. bulbospongiosus

Bulbus vestibuli Membrana perinei G landula vestibularis m ajo r*, (Ostium) Tuber ischiadicum Frenulum labiorum pudendi M. sphincter ani externus, Pars subcutanea Anus

Fig. 7 .7 0

E x te rn a l fe m a le g e n ita lia , O rg a n a g e n ita lia fe m in in a

e x te r n a ; ca ud a l v ie w ; a fte r re m o v a l o f b o d y fa s c ia a nd n e u ro v a s c u la r

in fe rio r e n d . T h e c ru ra o f th e c lito ris (C rura c lito rid is ) are a tta c h e d to th e in fe rio r is c h io p u b ic ra m i a n d c o v e re d b y th e M . is c h io c a v e rn o s u s on

s tru c tu re s . T h e Labia m a jo ra p u d e n d i are re m o v e d in th is illu s tra tio n . T h e y c o n ta in

b o th s id e s . T h e M . b u lb o s p o n g io s u s s ta b ilis e s th e b u lb o f th e v e s ti bule .

th e c a v e rn o u s b o d y o f th e v e s tib u le (B u lb u s v e s tib u li). T h e Labia m in o ra p u d e n d i s u rro u n d th e v e s tib u le (V e s tib u lu m v a g in a e ) a nd c o n tin u e

D e v e lo p m e n ta lly , th e o rg a n is a tio n o f th e P e n is a nd th e C lito ris is s im ila r in c lu d in g th e p re s e n c e o f th e p re p u c e (P re p u tiu m c lito rid is ). T h e fillin g

a n te rio rly as F re n u lu m c lito rid is to th e g la n s o f th e c lito ris (G ians c lito ri dis). The v e s tib u la r g la n d s (G la nd u lae v e s tib u la re s m a jo re s

m e c h a n is m s o f th e c a v e rn o u s b o d ie s a nd th e p ro c e s s o f e re c tio n are a ls o s im ila r in b o th s e x e s .

[B A R T H O L IN 'S g la n d s ] a n d m in o re s ) e n te r th e v e s tib u le fr o m lateral. T h e C lito ris is th e s e n s o ry o rg a n fo r se xu a l a ro u sa l. T h e C orp o ra c a v e r

nosa c lito rid is fo r m a s h o rt b o d y (C o rp u s c lito rid is ) w it h th e g la n s a t th e

202

c lin ic a l te r m : B A R T H O L IN 'S g la n d

Efferent urinary system -» Genitalia -► Rectum and anal canal -> Topography -♦ Sections

Internal fe m a le genitalia

Pelvis renalis

Ureter

Tuba uterina [Salpinx]

U terus

Vesica urinaria Infundibulum tubae uterinae

Appendix vesiculosa Ovarium Ureter

Lig. ovarii proprium Lig. teres uteri

Urethra feminina Vagina

Ostium urethrae externum Ostium vaginae

Fig. 7.71

F e m a le u rin a ry a n d g e n ita l o rg a n s . O rg a n a u ro g e n ita lia

fe m in in a ; v e n tra l v ie w . T h e in te r n a l g e n ita lia c o m p ris e : • v a gin a (Vagina) • • •

u te ru s (U te ru s) u te rin e tu b e (Tuba u te rin a ) o v a ry (O va riu m )

T h e in te rn a l g e n ita lia in w o m e n are r e p ro d u c tiv e a nd s e x o rg a n s . F u n c tio n a lly , th e o v a ry s e rv e s fo r th e m a tu ra tio n o f fo llic le s (and ova) a nd th e p ro d u c tio n o f fe m a le s e x h o rm o n e s (o e s tro g e n s a n d p ro g e s te ro n e ). T h e u te rin e tu b e p ro v id e s th e p la ce fo r th e fe r tilis a tio n o f ova a nd tra n s p o rts th e z y g o te to th e U te ru s w h e re th e em b ry o /fe tu s d e v e lo p s a n d g r o w s d u rin g p re g n a n c y . T h e V a gina s e rv e s th e s e x u a l in te rc o u rs e a n d is p a rt o f th e b irth canal.

U te rin e tu b e a nd o va ry are p a ire d o rg a n s a nd are c o lle c tiv e ly re fe rre d to as u te rin e a d n e x a .

203

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

D e ve lo p m e n t o f th e external fe m a le genitalia

Fig. 7 .7 2 D e v e lo p m e n t o f th e e x te r n a l fe m a le g e n ita lia . O rg a n a g e n ita lia fe m in in a e x te rn a .

th e u r e th r a l g ro o v e , a n d is b o rd e re d on b o th s id e s b y th e u re th ra l

T h e e x te rn a l g e n ita lia d e v e lo p fr o m th e ca ud a l p a rt o f th e S in u s u ro g e n ita lis. T h e S in u s u ro g e n ita lis d e v e lo p s fro m th e cloa ca o f th e h in d g u t a nd g iv e s rise t o th e u rin a ry b la d d e r a n d p a rts o f th e U re th ra (-* Fig.

t a l tu b e rc le . S u b s e q u e n tly , th e g e n ita l tu b e rc le d e v e lo p s in to th e C li to r is (C orp o ra ca v e rn o s a ) u n d e r th e in flu e n c e o f th e fe m a le s e x h o r m o n e o e s tro g e n w h ic h is p ro d u c e d in th e ovary. In c o n tra s t to th e d e

7.6 ). C o n trib u tin g to th e s e s tr u c tu re s are a lso th e e c to d e rm a nd th e c o n n e c tiv e tis s u e (m e s e n c h y m e ) lo c a te d b e n e a th th e S in u s u ro g e n ita

v e lo p m e n t in m e n , th e g e n ita l fo ld s a nd th e la b io s c ro ta l fo ld s d o n o t m e rg e . T h e g e n ita l fo ld s d e v e lo p in to th e L a b ia m in o ra a n d th e lab io

lis. F irst, th e e x te rn a l g e n ita lia d e v e lo p id e n tic a lly in b o th s e x e s (in d iffe re n t g o n a d ). T h e a n te rio r w a ll o f th e S in u s u ro g e n ita lis in d e n ts to fo rm

s c ro ta l fo ld s in to th e L a b ia m a jo r a . T h e s h o rt fe m a le U re th ra a n d th e B A R T H O L IN 'S g la n d s d e v e lo p fr o m th e S in u s u ro g e n ita lis .

fo ld s . L a te ra l o f th o s e are th e la b io s c ro ta l fo ld s a n d a n te rio r th e g e n i

I- Clinical R em arks----------------------------------------------------------------------------------------------------------T h e c o m m o n d e v e lo p m e n ta l s ta g e s o f th e e x te rn a l g e n ita lia in b o th in a d r e n o g e n ita l s y n d r o m e (p ro d u c tio n o f a n d ro g e n s in th e c o rte x s e x e s e x p la in s th e d e v e lo p m e n t o f p e n is -lik e h y p e rp la s ia s o f th e C lito ris in c a se s o f e x c e s s iv e p ro d u c tio n o f m a le s e x h o rm o n e s s u c h as

204

o f th e a d re n a l g lands),

Efferent urinary system -► Genitalia -► Rectum and anal canal -> Topography -► Sections

D e ve lo p m e n t o f th e internal fe m a le genitalia

Ureter

Lig. suspensorium ovarii

WOLFFIAN duct Tuba uterina Lig. ovarii proprium

Uterus

Vesica urinaria

Lig. teres uteri

Urethral orifice Vagina

Fig. 7 .7 3

D e v e lo p m e n t o f th e in te r n a l fe m a le g e n ita lia . O rg a n a

g e n ita lia fe m in in a in te r n a , (a c c o rd in g to [1]) T h e in te rn a l g e n ita lia d e v e lo p id e n tic a lly in b o th s e x e s up to w e e k 7

W ith o u t th e s u p p re s s in g e ffe c ts o f th e a n ti-M U L L E R IA N h o rm o n e fro m th e T e s tis , th e M U L L E R IA N d u c ts d iffe r e n tia te in to fe m a le g e n i ta lia . B e g in n in g in w e e k 12, th e M U L L E R IA N d u c ts fo r m th e u te rin e

(s e x u a l in d iffe r e n t s ta g e , -» Fig. 7.8 ). In th e fe m a le , th e p rim o rd iu m o f th e p rim itiv e g o n a d th e n d e v e lo p s in to th e ovary. S im ila r to th e T e s tis ,

tu b e . T h e ir d is ta l p o rtio n s m e rg e a n d g iv e ris e t o th e U te ru s a nd th e u p p e r V a g in a . T h e lo w e r V a gina d e v e lo p s fr o m th e S in u s u ro g e n ita lis . If

th e o v a ry a lso d e v e lo p s in th e lu m b a r re g io n a t th e le v e l o f th e m e s o n e p h ro s . D u e to th e lo n g itu d in a l g ro w th o f th e b o d y th e o v a ry is th e n

th e M U L L E R IA N d u c ts fa il to fu s e , a s e p ta te u te ru s (U te ru s s e p tu s o r s u b s e p tu s ) o r a d o u b le u te ru s (U te ru s d u p le x , U te ru s d id e lp h y s ) m a y

re lo c a te d c a u d a lly to th e le s s e r p e lv is w it h o u t le a vin g th e p e rito n e a l ca vity. T h u s, o v a ry a nd u te rin e tu b e have an in tra p e r ito n e a l p o s itio n .

re s u lt.

205

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

U terus, uterine tu b e and ovary

M esovarium Fimbria ovarica

Ovarium, Extremitas tubaria

Am pulla tubae uterinae

Ampulla tubae uterinae

Margo mesovaricus M esosalpinx

Ostium abdominale tubae uterinae; Infundibulum tubae uterinae

A.; Vv. ovarica(e)

Isthmus tubae uterinae

Fundus uteri

Fimbriae tubae uterinae Tuba uterina [Salpinx] Ovarium, Facies medialis Lig. suspensorium ovarii

Ovarium

A.; Vv. ovarica(e)

Extremitas uterina Lig. ovarii proprium

Ovarium, Margo liber

Ureter

Lig. latum uteri

C o rpus uteri Ureter-

Isthmus uteri C ervix uteri

Lig. cardinale [Lig. transversum cervicis]

Tunica serosa [Perimetrium]

Lig. rectouterinum Plica rectouterina

Fig. 7 .7 4

U te r u s , U te r u s , o v a ry . O v a r iu m , a n d u te r in e t u b e . T u ba

u te r in a , w it h p e r ito n e a l d u p lic a tio n s ; d o rsa l v ie w . T h e U te r u s (M e tra ) is 8 c m lo n g , 5 c m w id e a nd 2 - 3 c m th ic k . It c o n s is ts o f th e b o d y (C o rp u s u te ri) w it h a s u p e rio r fu n d u s (F u n du s u te ri) a nd a n e c k (C ervix u te ri). A c o n s tric tio n (Is th m u s u te ri) m a rk s th e tra n

T h e o v a ry (O v a riu m ) is 3 x 1 .5 x 1 c m in size a n d o val. A tu b a l e x tre m i ty (E x tre m ita s tu b a ria ) a nd an u te rin e e x tr e m ity (E x tre m ita s u te rin a ) are d is tin g u is h e d . T h e m e s o v a riu m is a tta c h e d to th e a n te rio r m a rg in (M a r g o m e s o v a ric u s ), b u t th e p o s te rio r m a rg in is lo o s e (M a rg o liber).

s itio n b e tw e e n b o d y a nd n e c k o f th e U te ru s . T h e u te rin e tu b e (Tuba

U te ru s , u te rin e tu b e , a n d o v a ry h a v e an in tra p e r ito n e a l p o s itio n and th u s , have in d iv id u a l p e r ito n e a l d u p lic a tu re s c o v e re d b y a T u n ic a s e

u te rin a ) e x te n d s o n b o th s id e s fr o m th e u te rin e b o d y to c o n n e c t to th e o va rie s. T h e u te r in e tu b e (Tuba u te rin a ) is 10 - 14 c m lo n g a nd has se v e ra l

ro sa. T h e fo llo w in g lig a m e n ts a nd a tta c h m e n ts are re le v a n t fo r g y n a e c o lo g ic a l s u rg ic a l p ro c e d u re s : • Lig. la tu m u te ri: b ro a d lig a m e n t as fro n ta l p e rito n e a l fo ld

p a rts: • In fu n d ib u lu m tu b a e u te rin a e : 1 - 2 c m lo n g , c o n ta in s th e o p e n in g

•

M e s o v a r a n d M e s o s a lp in x : p e rito n e a l d u p lic a tu re s o f o v a ry and u te rin e tu b e , re s p e c tiv e ly , c o n n e c te d to th e Lig. la tu m

t o th e p e rito n e a l c a v ity (O s tiu m a b d o m in a le tu b a e u te rin a e ) a nd th e fim b ria e (F im b ria e tu b a e u te rin a e ) fo r th e c o lle c tio n o f o v u la te d ova.

•

Lig. c a rd in a le (Lig. tra n s v e rs u m c e rv ic is ): c o n n e c tiv e tis s u e c o n n e c tin g th e C e rv ix to th e la te ra l p e lv ic w a ll

A m p u lla tu b a e u te rin a e : 7 - 8 c m lon g , c re s c e n t-s h a p e d a ro u n d th e o va ry Is th m u s tu b a e u te rin a e : 3 - 6 c m lon g , c o n s tric tio n a t th e tra n s itio n

•

Lig. r e c to u te rin u m (clin ical te r m : L ig . s a c ro u te rin u m ): c o n n e c tiv e tis s u e a tta c h in g th e C e rv ix d o rs a lly

•

Lig. te re s u te ri (clin ical te r m : Lig. ro tu n d u m ): th e ro u n d lig a m e n t c o u rs in g fr o m th e u te ro tu b a l ju n c tio n th ro u g h th e in g u in a l canal to

• •

to th e U te ru s •

in tra m u ra l p a rt (Pars u te rin a tu b a e ), e n te rs th e U te ru s (O s tiu m u te rin u m )

• •

th e Labia m a jo ra Lig. o va rii p ro p riu m : th e o varia n lig a m e n t c o n n e c ts o v a ry a nd U te ru s Lig. s u s p e n s o riu m o v a rii (clin ical te r m : L ig . in fu n d ib u lo p e lv ic u m ): c o n n e c ts o v a ry a nd latera l p e lv ic w a ll, c a rrie s th e A . a n d V. ovarica

206

Efferent urinary system -► Genitalia -► Rectum and anal canal -> Topography -► Sections

U terus and vagina

Lig. ovarii proprium

Mesosalpinx

Isthmus tubae uterinae

Am pulla tubae uterinae

Fundus uteri

Infundibulum tubae uterinae; Fimbriae tubae uterinae

Tunica serosa [Perim etrium ] C avitas uteri; Tunica m ucosa [Endom etrium ]

Fimbria ovarica

Tunica m uscularis [M yo m etrium ]

Vv. ovaricae; A. ovarica Folliculi o v a ric i] C o rpus luteum j Ovarium

C analis cervicis Fornix vaginae Pars uterina; Ostium uterinum uteri

Portio vaginalis cervicis Ostium uteri

Portio supravaginalis cervicis Rugae vaginales

Fig. 7 .7 5

U te r u s , U te r u s , v a g in a . V a g in a , o v a ry . O v a r iu m , a n d

u te r in e tu b e . T u b a u te rin a ; fro n ta l s e c tio n ; d o rs a l v ie w . T h e s p a c e in s id e th e U te r u s is d iv id e d in to th e C avita s u te ri in th e b o d y a n d th e C analis c e rv ic is u te ri in th e u te rin e c e rv ix . T h e lo w e r p o rtio n o f th e C e rv ix e n te rs th e V a g in a a n d is re fe rre d to as P o rtio va g in a lis c e r v ic is . T h e u p p e r p o rtio n is th e P o rtio su p ra v a g in a lis c e rv ic is . T h e V a g i na is a h o llo w m u s c u la r o rg a n o f a b o u t 10 c m le n g th in a s u b p e rito n e al lo c a tio n . T h e F o rn ix v a g in a e s u rro u n d s th e P o rtio va g in a lis c e rv ic is . A t th e in n e r s u rfa c e , b o th th e a n te rio r a n d p o s te rio r w a lls (P aries a n te

T h e fr o n ta l s e c tio n a ls o s h o w s th e s tru c tu re o f t h e u te r in e w a ll: th e in te rn a l m u c o s a l la y e r (Tunica m u c o s a ; e n d o m e triu m ), th e n th e s tro n g m u s c u la r la y e r (T unica m u s c u la ris ; m y o m e triu m ) o f s m o o th m u s c le s , a nd th e o u te r m o s t p e rito n e a l lin in g (T unica s e ro s a ; p e rim e triu m ). E m b e d d e d in th e s tro m a o f th e o v a ry are th e o varia n fo llic le s (F o llicu li o v a ric i) w h ic h c o n ta in th e ova a nd d e v e lo p in to th e C o rp u s lu te u m fo l lo w in g o v u la tio n . F o llic le s a n d C o rp o ra lu te a p ro d u c e th e fe m a le se x h o rm o n e s (o e s tro g e n s a nd p ro g e s te ro n e ) w h ic h re g u la te th e c y c le -d e p e n d e n t d iffe re n tia tio n o f th e e n d o m e triu m .

rio r a nd P aries p o s te rio r) o f th e V a gina re ve a l tra n s v e rs e m u c o s a l fo ld s (R ug a e va g in a le s).

207

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

P osition o f th e uterus and adnexa

Appendix vermiformis

Ureter

Fundus uteri Fimbriae tubae uterinae A.; V. ovarica

Caecum

Lig. suspensorium ovarii

Infundibulum tubae uterinae Ampulla tubae uterinae Am pulla tubae uterinae

Ovarium, Facies medialis

M esosalpinx

Isthmus tubae uterinae Margo mesovaricus M esovarium Lig. latum uteri

Lig. ovarii proprium

Lig. teres uteri Excavatio vesicouterina Plica umbilicalis medialis Vesica urinaria

Uterus, Facies vesicalis

Fig. 7 .7 6 U te r u s , U te r u s , o v a ry . O v a r iu m , a n d u te r in e t u b e . Tuba u te r in a , w it h p e r ito n e a l d u p lic a tu re s ; v e n tra l v ie w . U te ru s , u te rin e tu b e s , a nd o v a ry h a ve an in tra p e r ito n e a l p o s itio n . T h e ir p e r ito n e a l d u p lic a tu re s (Lig. la tu m u te ri, M e s o s a lp in x , M e s o v a riu m ) fo r m a tra n s v e rs e fo ld in th e le s s e r p e lvis. T h e Lig. te re s u te ri

T h e c lo s e to p o g ra p h ic a l re la tio n s h ip b e tw e e n th e a dn e xa (o vary and u te rin e tu b e ) a n d th e A p p e n d ix v e r m ifo r m is o f th e C o lo n e x p la in w h y in fla m m a tio n s o f th e a p p e n d ix (a p p e n d ic itis ) as w e ll as th o s e o f th e u te rin e tu b e (s a lp in g itis ) m a y c a u s e s im ila r pain in th e rig h t lo w e r ab d o m in a l q u a d ra n t. T h e p e rito n e a l p o u c h b e tw e e n th e U te ru s a nd th e u rin a ry b la d d e r is called E x c a v a tio v e s ic o u te rin a . T h e E x c a v a tio re c to -

re a c h e s v e n tra l fr o m th e u te ro tu b a l ju n c tio n to th e la te ra l w a ll o f th e le s s e r p e lv is a nd tra v e rs e s th e in g u in a l ca n a l to m e rg e w it h th e c o n n e c

u te r in a (p o u c h o f D O U G L A S ) b e h in d th e U te ru s is th e m o s t caudal

tiv e tis s u e o f th e Labia m ajora. T h e Lig. ovarii p ro p riu m c o n n e c ts U te ru s a nd ovary. T h e Lig. s u s p e n s o riu m o va rii c o n n e c ts o v a ry a n d la te ra l p e l

e x te n s io n o f th e p e rito n e a l c a v ity in w o m e n a n d m a y c o lle c t flu id s and p u s in c a s e s o f in fla m m a to ry p ro c e s s e s in th e lo w e r a b d o m e n .

v ic w a ll a n d c o n ta in s th e A . a nd V. o varica.

Figs. 7 .7 7 a t o d

P o s itio n o f u te ru s . U te r u s , a n d v a g in a . V a g in a ;

v ie w fr o m th e rig h t s ide . a

N o rm a lly , th e U te ru s is a n g le d in its v e n tra l a s p e c t in re la tio n to th e V a g in a (a n te v e rs io n ) a n d th e b o d y is tilte d a n te r io r ly in re la tio n to th e n e c k (a n te fle x io n ). T h is p o s itio n p re v e n ts a p ro la p s e o f th e U te ru s th r o u g h th e V a g in a d u rin g a b d o m in a l p re s s u re (c o u g h in g , s n e e z in g ),

b a n te v e rs io n , a n te fle x io n = n o rm a l p o s itio n c a n te v e rs io n , lack o f a n te fle x io n d

208

dissection link

re tro v e rs io n , re tro fle x io n

in c re a s e d

in tra

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

P osition o f th e uterus and co n n e ctive tis s u e spaces

(Spatium retrorectale) (Paraproctium ) Rectum Lig. rectouterin um

Excavatio rectouterina

(Param etrium )

Cervix uteri

Excavatio vesicouterina

(Paracystium )

Ureter

Vesica urinaria Spatium retropubicum Ostium urethrae internum

Symphysis pubica

Fig. 7 .7 8

L ig a m e n ts a n d c o n n e c tiv e tis s u e s p a c e s o f th e u te ru s .

U te ru s ; tra n s v e rs e s e c tio n a t th e le ve l o f th e C e rv ix u te ri; caudal v ie w ; s e m is c h e m a tic illu s tra tio n . T h e c o n n e c tiv e tis s u e in th e le s s e r p e lv is is c a te g o ris e d a c c o rd in g to

•

p a r a m e tr iu m : c o n n e c tiv e tis s u e fro m th e c e rv ix to th e p e lv ic w a ll (Lig. c a rdin a le )

p a r a p ro c tiu m : c o n n e c tiv e tis s u e a ro u n d th e R e c tu m p a ra c y s tiu m : c o n n e c tiv e tis s u e a ro u n d th e u rin a ry b la d d e r

th e re la tio n to a d ja c e n t o rg a n s . S o m e o f th e c o n n e c tiv e tis s u e s tra n d s are re fe rre d to a s lig a m e n ts in clin ic a l te r m s a lth o u g h an a n a to m ic a l

p a ra c o lp iu m : c o n n e c tiv e tis s u e a ro u n d th e V agina T h e Lig. r e c to u te r in u m b e tw e e n th e C e rv ix u te ri a nd th e d o rs a l p e lv ic

d e m a rc a tio n is n o t p o s s ib le .

w a ll is th e o n ly s e p a ra b le lig a m e n t a nd is p re s e rv e d d u rin g g y n a e c o lo g ica l s u rg e ry to p r o te c t th e a u to n o m ic n e rv e s o f th e P le x u s h y p o g a s tric u s in fe rio r. Fornix vaginae, Pars anterior

Fornix vaginae, Pars anterior

Cervix uteri

Portio vaginalis cervicis f Labium Ostium I anterius uteri j Labium posterius

LabiumOstium J anterius uteri j Labium I posterius

Rugae vaginales

L Vagina Fornix vaginae, Pars posterior

Figs. 7 .7 9 a a n d b

U te r in e n e c k , P o rtio v a g in a lis c erv ic is ; caudal

For th e in s p e c tio n o f th e P o rtio v a g in a lis c e rv ic is th e V a g in a is d is

v ie w . a u te rin e n e c k o f a y o u n g w o m a n w h o has n o t y e t d e liv e re d a c h ild b

(nullipara) u te rin e n e c k o f a y o u n g w o m a n w h o has d e liv e re d t w o c h ild re n

te n d e d b y t w o s p e c u la . * s p e c u lu m

Clinical Remarks In s p e c tio n a nd c e rv ic a l s w a b s (P A P A N IC O L A O U s m e a r) are ro u tin e ly p e rfo rm e d fo r g y n a e c o lo g ic a l s c re e n in g e x a m in a tio n s a n d th e c o s ts are c o v e re d b y th e p u b lic h e a lth s y s te m fo r w o m e n a b o v e th e a g e o f 2 0 y e a rs . T h is e x a m in a tio n s h o u ld be p e rfo rm e d a n n u a lly to d e te c t p re c a n c e ro u s le s io n s in d ic a tiv e o f th e d e v e lo p m e n t o f c erv ic a l c a rc in o m a a nd to e n a b le e a rly c u ra tiv e su rg e ry . C ervica l c a rc in o m a is a m o n g th e m o s t c o m m o n m a lig n a n c ie s

w o m e n b e lo w th e a ge o f 4 0 y e a rs . It is c a u s e d b y in fe c tio n s w ith v iru s e s o f th e h u m a n p a p illo m a v iru s (HPV) g ro u p . A v a c c in e w a s d e v e lo p e d a nd v a c c in a tio n is re c o m m e n d e d fo r g irls d u rin g p u b e rty to p re v e n t in fe c tio n s . H o w e v e r, d u e to th e lo w e x p e rie n c e w it h th is v a c c in e a n d th e la c k o f e v id e n c e th a t v a c c in a tio n ca n p re v e n t c e rv i cal c a rc in o m a , th e b e n e fit o f th is v a c c in e is c u rre n tly d is p u te d .

209

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

U terus in pregnancy

V. umbilicalis

Fundus uteri

Portio vaginalis cervicis, Ostium uteri

Excavatio rectouterina Placenta

Vagina

Vesica urinaria

Urethra feminina Excavatio vesicouterina

Spatium retropubicum

Symphysis pubica, Discus interpubicus

Fig. 7 .8 0

U te r u s , U te r u s w it h p la c e n ta . P la c e n ta , a n d fe tu s ;

m e d ia n s e c tio n o f th e p e lv is e x c e p t fo r th e fe tu s ; v ie w fr o m th e le ft side .

T h e d e v e lo p in g c h ild in th e U te ru s is n o u ris h e d via th e P la c e n ta w h ic h d e v e lo p s fro m m a te rn a l a nd fe ta l tis s u e s a fte r im p la n ta tio n . T h e C e rv ix u te ri is c lo s e d d u rin g p re g n a n c y b y th e K R IS T E L L E R 's m u c o u s p lu g (*).

Fig. 7.81 v ie w .

L e v e l o f t h e F u n d u s u te r i d u rin g p re g n a n c y ; v e n tra l

T h e n u m b e rs re p re s e n t th e e n d o f th e re s p e c tiv e m o n th o f p re g n a n c y . In th e 6 th m o n th (w e e k 2 4) th e F u n d u s u te ri is a t th e le v e l o f th e u m b iÂ lical re g io n , in th e 9 th m o n th (w e e k 3 6) a t th e c o s ta l m a rg in . U p to p arÂ tu ritio n , th e u te rin e v o lu m e in c re a s e s 8 0 0 - 1 2 0 0 tim e s a n d th e u te rin e w e ig h t in c re a s e s fr o m 3 0 - 1 2 0 g to 1 0 0 0 - 1 5 0 0 g.

210

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

A rte rie s o f th e internal fe m a le genitalia

Lig. ovarii proprium Ovarium

A. uterina, R. tubarius A. uterina, R. ovaricus

A. ovarica A. ovarica

Lig. suspensorium ovarii

Lig. teres uteri*

A. uterina

Rr. vaginales

A. vaginalis

Vagina

Fig. 7 .8 2

A rte rie s o f th e in te r n a l fe m a le g e n ita lia ; d o rsa l v ie w .

T h e in te rn a l fe m a le g e n ita lia are s u p p lie d b y th r e e p a ire d a rte rie s : • U te ru s : A . u te rin a (fro m th e A . iliaca in te rn a ) w it h Rr. h e lic in i O v a riu m : A . o va rica (fro m th e a b d o m in a l a o rta ) a nd A . u te rin a w ith R. o v a ric u s •

T u b a u te rin a : A . u te rin a w it h R. tu b a riu s a nd A . ovarica V a g in a : A . va g in a lis (fro m th e A . iliaca in te rn a ) a n d A . u te rin a w ith

T h e v e n o u s d ra in a g e o c c u rs via t w o v e n o u s s ys te m s: • v e n o u s p le x u s in th e le s s e r p e lv is (P le x u s v e n o s i u te rin u s a nd v a g i •

nalis) w it h d ra in a g e in to th e V. iliaca in te rn a V. o v a ric a ; d ra in s in to th e V. cava in fe rio r o n th e rig h t s id e a nd th e V. re n a lis s in is tra on th e le ft s ide .

•

c lin ic a l te r m : Lig. ro tu n d u m

Rr. va g in a le s

> 90%

Lig. suspensorium ovarii

A. ovarica Ovarium : 90%

R. ovaricus Rr. helicini

Lig. ovarii proprium

A. uterina R. vaginalis

Figs. 7 .8 3 a to f V a ria tio n s o f th e a rte r ia l s u p p ly o f th e in te r n a l fe m a le g e n ita lia ; d o rs a l v ie w .

a rte ria l s u p p ly o f th e U te ru s (te x tb o o k case)

c a nd d e a nd f

a rte ria l s u p p ly o f th e o v a ry (b te x tb o o k case) a rte ria l s u p p ly o f th e F u n d u s u te ri (e te x tb o o k case)

211

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Innervation o f th e fe m a le genitalia

Fig. 7 .8 4

In n e rv a tio n o f th e fe m a le g e n ita lia ; v e n tra l v ie w ;

s c h e m a tic illu s tra tio n . P le xu s h y p o g a s tric u s in fe rio r a n d P lexu s u te ro v a g in a lis c o n ta in s y m p a th e tic (g ree n ) a nd p a ra s y m p a th e tic

a p s e d in th e G an g lia a o rtic o re n a lia o r in th e P le x u s h y p o g a s tric u s s u p e rio r a n d d e s c e n d w ith in th e P le x u s o v a ric u s a lo n g s id e th e A . o varica.

(p urp le ) n e rv e fib re s . P re g a n g lio n ic s y m p a th e tic n e rv e fib re s (T10 - L2) d e s c e n d fro m th e

P re g a n g lio n ic p a r a s y m p a th e tic n e rv e fib re s d e riv e fr o m th e sacral p a ra s y m p a th e tic d iv is io n (S 2 -S 4 ) a nd re ach th e g a n g lia o f th e P lexu s

P le xu s a o rtic u s a b d o m in a lis via th e P le xu s h y p o g a s tric u s s u p e rio r a nd fr o m th e sa cral g a n g lia o f th e s y m p a th e tic tru n k (T ru n cu s s y m p a th ic u s )

h y p o g a s tric u s in fe rio r via th e N n. s p la n c h n ic i p e lv ic i. T h e y are s y n a p s e d to p o s tg a n g lio n ic n e u ro n s e ith e r h e re o r in c lo s e v ic in ity to th e p e lv ic

via th e N n. s p la n c h n ic i s a cra le s to b e s y n a p s e d to p o s tg a n g lio n ic n e u ro n s in th e g a n g lia o f th e P le xu s h y p o g a s tric u s in fe rio r. A x o n s o f th e

v is c e ra (G anglia p elvica ) to in n e rv a te th e U te ru s , T u b a u te rin a a nd V agi na. S o m a tic in n e rv a tio n b y th e N. p u d e n d u s c o n v e y s s e n s o ry in n e rv a tio n

p o s tg a n g lio n ic n e u ro n s c o n tin u e to th e p e lv ic ta rg e t o rg a n s a nd reach th e P le xu s u te ro v a g in a lis (F R A N K E N H A u S E R ' s p le x u s ) fo r th e in n e rv a tio n o f U te ru s , T u b a u te rin a , a n d V a g in a . T h e (p re d o m in a n tly ) p o s tg a n g lio n ic s y m p a th e tic n e rv e fib re s to th e o v a ry have a lre a d y b e e n s y n

212

to th e lo w e r p a rt o f th e V a gina a n d th e Labia m in o ra a nd m a jo ra via th e Rr. lab ia le s p o s te rio re s a n d to th e C lito ris via th e N. d o rs a lis c lito rid is .

Efferent urinary s y s te m -» Genitalia

Rectum and anal canal -» Topography -» Sections

Lym ph vessels o f th e fe m a le genitalia

N odi lym phoidei lum bales Nodi lymphoidei sacrales Nodi lymphoidei iliaci communes Nodi lym phoidei iliaci interni Nodi lymphoidei iliaci externi

Fig. 7 .8 5

L y m p h v es s e ls a n d ly m p h n o d e s o f t h e e x te r n a l a n d

in te r n a l fe m a le g e n ita lia ; v e n tra l v ie w . T h e re g io n a l ly m p h n o d e s fo r th e e x te rn a l fe m a le g e n ita lia are th e in g u in a l n o d e s (N o d i ly m p h o id e i in g u in a le s ). In c o n tra s t, th e fir s t re g io

Nodi lym phoidei inguinales profundi

nal ly m p h n o d e s ta tio n o f th e o v a ry is lo c a te d re tro p e rito n e a lly a t th e le ve l o f th e k id n e y s (N o d i ly m p h o id e i lu m b a le s ) a nd th e re g io n a l ly m p h n o d e s o f th e U te ru s are in th e le s s e r p e lv is (N o d i ly m p h o id e i ilia ci in te rn i).

Nodi lym phoidei inguinales superficiales

Nodi lymphoidei

Nodi lymphoidei sacrales

Nodi lymphoidei iliaci interni Nodi lymphoidei iliaci communes

Nodi lymphoidei inguinales profundi Nodi lymphoidei iliaci externi

Nodi lymphoidei inguinales Nodi lymphoidei inguinales superficiales

Fig. 7 .8 6

L y m p h a tic d ra in a g e p a th w a y s o f th e e x te r n a l a n d

in te r n a l fe m a le g e n ita lia ; v e n tra l v ie w . U n lik e th e s itu a tio n in m e n , th e ly m p h a tic d ra in a g e p a th w a y s o f th e

In te r n a l g e n ita lia : •

e x te rn a l a n d in te rn a l fe m a le g e n ita lia are n o t c o m p le te ly s e p a ra te , and p a rts o f th e ly m p h o f th e in te rn a l g e n ita lia a lso d ra in in to th e ing u ina l

•

ly m p h n o d e s. E x te rn a l g e n ita lia :

•

N o d i ly m p h o id e i in g u in a le s : V u lva

N o d i ly m p h o id e i lu m b a le s a t th e le ve l o f th e k id n e y s : O v a riu m , Tuba u te rin a , U te ru s (u te ro tu b a l ju n c tio n ), ly m p h a tic v e s s e ls w ith in th e L ig . s u s p e n s o riu m o va rii N o d i ly m p h o id e i iliaci in te rn i/e x te rn i a nd N o d i ly m p h o id e i sa crale s: U te ru s , V a g in a , T u b a u te rin a N o d i ly m p h o id e i in g u in a le s : lo w e r V a g in a , U te ru s (u te ro tu b a l ju n c tio n ), ly m p h v e s s e ls w ith in th e Lig. te re s u te ri

[- Clinical R em arks----------------------------------------------------------------------------------------------------------D u e to th e d iffe r e n t ly m p h a tic d ra in a g e p a th w a y s , th e p rim a ry th e ly m p h n o d e m e ta s ta s e s a re : w it h c a rc in o m a o f th e V u lva th e in g u inal ly m p h n o d e s , w it h c a rc in o m a o f th e E n d o m e triu m a n d th e C e rv ix

ly m p h n o d e s in th e le s s e r p e lv is , a nd w ith o v a ria n c a rc in o m a th e re tro p e rito n e a l ly m p h n o d e s ,

213

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Pelvic flo o r in w o m e n

Symphysis pubica urogenitalis I H iatus analis Linea terminalis

> H iatus levatorius

Canalis obturatorius

Corpus ossis pubis

M . levator ani, M .p u b o c o c c y g e u s

M. obturatorius internus

M . levator ani, M . iliococcygeus Arcus tendineus m usculi levatoris ani

M . ischiococcygeus [coccygeus]

Os sacrum

Foramen ischiadicum majus

Lig. sacrotuberale

Os ilium

Fig. 7 .8 7

P e lv ic flo o r, D ia p h r a g m a p e lv is , in w o m e n ; c ra nia l v ie w .

T h e o rg a n is a tio n o f th e p e lv ic flo o r in w o m e n is s im ila r to m e n . T h e

T h e m u s c le s o f b o th s id e s s p a re th e le v a to r h ia tu s b e tw e e n th e m (H ia tu s le v a to riu s ) T h is m u s c u la r g a p is s u b d iv id e d b y th e c o n n e c tiv e tis s u e

p e lv ic flo o r c lo s e s th e p e lv ic c a v ity caudally. O rg a n is a tio n :

o f th e p e rin e u m (C e n tru m p e rin e i) in to th e a n te rio r H ia tu s u ro g e n ita lis fo r th e p a ssa g e o f U re th ra a nd V a g in a a nd th e p o s te rio r H ia tu s a n a lis

•

M . le v a to r a ni, c o m p ris in g th e M . p u b o c o c c y g e u s , M . ilio c o c c y g e u s ,

•

a nd M . p u b o re c ta lis M . is c h io c o c c y g e u s

fo r th e p a s s a g e o f th e R e c tu m . T h e p e lv ic flo o r is in n e rv a te d b y d ire c t b ra n c h e s o f th e P le x u s sa c ra lis (S 3 -S 4 ).

In c o n tra s t to th e M . p u b o c o c c y g e u s a nd M . is c h io c o c c y g e u s , th e M . ilio c o c c y g e u s d o e s n o t o rig in a te fr o m th e b o n e o f th e hip b u t fr o m th e A rc u s te n d in e u s m u s c u li le v a to ris ani, a re in fo rc e m e n t o f th e fa s c ia o f th e M . o b tu ra to riu s in te rn u s .

F u n c tio n : T h e p e lv ic flo o r s ta b ilis e s th e p o s itio n o f th e p e lv ic v is c e ra a nd , th u s , is e s s e n tia l fo r u rin a ry a nd fa e c a l c o n tin e n c e .

—►T 20a

i- Clinical R em arks-------------------------------------W o m e n m o re fre q u e n tly s u ffe r fr o m

p e lv ic flo o r in su ffic ie n c y

d u e to th e e x te n s iv e d ila tio n o f th e le v a to r h ia tu s d u rin g v a g in a l d e liv e rie s . A s a c o n s e q u e n c e , a lo w e rin g (d e s c e n s u s ) o r p ro la p s e o f U te ru s a nd V a g in a m a y o c c u r. T h is c o n d itio n is o fte n c o m b in e d w ith

214

a p ro la p s e o f th e b la d d e r (c y s to c e le ) a nd th e R e c tu m (re c to c e le ) re s u ltin g in u rin a ry a nd fa e c a l in c o n tin e n c e b e c a u s e th e U te ru s is fir m ly c o n n e c te d to th e p o s te rio r w a ll o f th e u rin a ry b la d d e r a n d th e V a gina a d h e re s to th e a n te rio r w a ll o f th e R e c tu m .

Efferent urinary s y s te m -» Genitalia -► Rectum and anal canal -♦ Topography -» Sections

Pelvic flo o r in w o m e n

A. iliaca communis V. iliaca communis

M. piriformis

M. obturatoriu s internus

M . ischiococcygeus [coccygeus] N. obturatorius

M . levator ani A.; V. obturatoria

A rcus tendineus m usculi levatoris ani

Rectum

Vagina

Fig. 7 .8 8

P e lv ic flo o r. D ia p h r a g m a p e lv is , in w o m e n ; v ie w fro m

Centrum perinei

th e le ft side .

b y th e C analis o b tu ra to riu s w ith th e A . a nd V. o b tu ra to ria a nd th e N. o b tu ra to riu s . T h e M . o b tu ra to riu s in te rn u s th e n e x its th e p e lv is la te ra lly

T h e p e lv ic flo o r c o n s is ts o f th e M . le v a to r a n i a n d th e M . is c h io co c cy g e u s . T h e M . ilio c o c c y g e u s o f th e M . le v a to r ani o rig in a te s fr o m th e

th ro u g h th e F o ra m e n is c h ia d ic u m m in u s . T h e M . le v a to r ani e x te n d s to th e s a c ru m a n d th e c o c c y x a n d c lo s e s th e p e lv ic c a v ity ca ud a lly.

A rc u s te n d in e u s m u s c u li le v a to ris a ni. T h e la tte r is a re in fo rc e m e n t o f th e fa s c ia o f th e M . o b tu ra to riu s in te rn u s . O n e o f th e o rig in s o f th e M . o b tu ra to riu s in te rn u s is th e s u p e rio r p u b ic ra m u s w h e re it is p ie rc e d

dissection link

215

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Perineal m u scle s in w o m e n

Os pubis, Ramus Symphysis pubica

V. dorsalis profunda clitoridis A.; N. dorsalis clitoridis

Lig. pubicum inferius Lig. transversum perinei

Vagina

M. sphincter urethrae externus

Os pubis, Ramus inferior

U rethra fem inina

A. bulbi Ramus ossis

M em b ran a perinei

Fig. 7 .8 9

P e rin e a l m u s c le s in w o m e n ; caudal v ie w ; a fte r re m o v a l

o f all o th e r m u s c le s . In w o m e n , th e m u s c u la r g a p o f th e le v a to r h ia tu s (H ia tu s le v a to riu s ) is

p e rin e a l s p a c e s is m o re d iffic u lt in w o m e n . H o w e v e r, s im ila r to m e n th e fe m a le d e e p p e rin e a l s p a c e is c o n fin e d in fe rio rly b y th e p e rin e a l m e m b ra n e ( M e m b r a n a p e rin e i). In a d d itio n , it c o n ta in s th e V a g in a and

a lm o s t e n tire ly c lo s e d b y c o n n e c tiv e tis s u e w h ic h le a v e s o n ly th e p as s a g e fo r th e V a gina a n d th e U re th ra fe m in in a . U n like in m e n , th e p e ri

th e U re th ra a nd is tra v e rs e d b y d e e p b ra n c h e s o f th e N . p u d e n d u s and A . a nd V. p u d e n d a in te rn a b e fo re th e y re ach th e V ulva.

neal m u s c le s in w o m e n are w e a k (-► Fig. 7 .6 4 ). T h e w e a k M . tra n s v e rsus p e rin e i p ro fu n d u s , w h ic h o n ly c o n s is ts o f s in g le m u s c le fib re s

T h e s u p e rfic ia l p e rin e a l s p a c e (S p a tiu m s u p e rfic ia le p e rin e i) is lo c a te d caudal to th e p e rin e a l m e m b ra n e a nd , a m o n g s t o th e rs , c o n ta in s th e M .

e m b e d d e d w ith in c o n n e c tiv e tis s u e (-» Fig. 7.9 0 ), a nd th e M . tra n s v e rsus p e rin e i s u p e rfic ia lis d o n o t fo rm a m u s c u la r p la te . T h e re fo re ,

tra n s v e rs u s p e rin e i s u p e rfic ia lis .

th e te r m "D ia p h ra g m a u ro g e n ita le " is n o t u se d a n y m o re . W h ile in m e n th e d e e p p e rin e a l s p a c e (S p a tiu m p ro fu n d u m p e rin e i) is fille d w ith th e M . tra n s v e rs u s p e rin e i p ro fu n d u s , th e se p a ra tio n o f th e

T 20b

Vesica urinaria

M. sphincter urethrae externus

- M. transversus perinei profundus

M. sphincter urethrovaginalis

Fig. 7 .9 0

V o lu n ta r y s p h in c te r m u s c le s o f th e u rin a ry b lad d e r.

T h e M . tra n s v e rs u s p e rin e i p ro fu n d u s in w o m e n d o e s n o t fo r m a c o n ti n u o u s m u s c u la r p la te . In s te a d , in d iv id u a l s tria te d m u s c le fib re s a ro u n d th e U re th ra fo rm th e M . s p h in c te r u re th ra e e x te rn u s w h ic h c o n s titu te s th e v o lu n ta ry s p h in c te r m u s c le o f th e u rin a ry b la d d e r (-» Fig. 7.8 9 ).

216

S o m e d is ta l fib re s c o n tin u e to s u rro u n d th e d is ta l V a gina a nd are re fe r re d to as M . s p h in c te r u re th ro v a g in a lis .

—►T 20b

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

Perineal region in w o m e n

Ostium urethrae externum Ostium vaginae; Carunculae hymenales

Labium M. gracilis M . ischiocavernosus

Glandula vestibularis major, (Ostium) M. bulbospongiosus

M . bulbospongiosus

Raphe perinei

Perineum

► Regio urogenitalis

perinei Regio perinealis

Tuber M . transversus perinei superficialis

Fascia obturatoria

Regio anaiis

C analis pudendalis Fascia obturatoria

Fossa ischioanalis

sphincter ani externus M. levator ani

M. gluteus maximus Anus Os coccygis

Fig. 7.91

Lig. anococcygeum

P e rin e a l r e g io n , R e g io p e rin e a lis , in w o m e n ; caudal

v ie w ; a fte r re m o v a l o f all n e u ro v a s c u la r s tru c tu re s . T h e p e rin e a l re g io n re a c h e s fro m th e in fe rio r m a rg in o f th e p u b ic s y m p h y s is (S y m p h y s is p ub ica ) to th e tip o f th e c o c c y x (O s c o c c y g is ). The te r m p e rin e u m in w o m e n , h o w e v e r, d e s c rib e s e x c lu s iv e ly th e s m a ll c o n n e c tiv e tis s u e b rid g e b e tw e e n th e p o s te rio r m a rg in o f th e Labia m a jo ra a nd th e A n u s . T h e p e rin e a l re g io n is s u b d iv id e d in to th e a n t e r i o r R e g io u r o g e n ita lis (u ro g e n ita l tria n g le ) c o n ta in in g th e e x te rn a l g e n i

w o m e n , c o n ta in s th e w e a k M . tra n s v e rs u s p e rin e i p ro fu n d u s a nd th e M . s p h in c te r u re th ra e e x te rn u s . T h e s u p e rfic ia l p e rin e a l s p a c e (S p a tiu m s u p e rfic ia le p e rin e i) b e tw e e n th e M e m b ra n a p e rin e i a n d th e b o d y fa s c ia (Fascia pe rinei) c o n ta in s th e M . tra n s v e rs u s p e rin e i s u p e rfic ia lis , th e M . b u lb o s p o n g io s u s , th e M . is c h io c a v e rn o s u s . T h e s e th re e m u s c le s s ta b ilis e th e c a v e rn o u s b o d ie s o f v e s tib u le a nd C lito ris .

ta lia a nd th e U re th ra a n d th e p o s te r io r R eg io a n a iis (anal tria n g le ) a ro u n d th e A n u s . T h e fo llo w in g s p a c e s ca n be fo u n d w ith in th e s e tria n g le s :

B o rd e rs o f t h e Fossa is c h io a n a lis

o T h e R eg io a na iis c o n ta in s th e Fossa is c h io a n a lis (-» T a b le ) w h ic h c o n s titu te s a p y ra m id -s h a p e d s p a c e on b o th s id e s o f th e A n u s . The

M e d ia l u n d c ra n ia l

M . s p h in c te r ani e x te rn u s and M . le v a to r ani

L a te ra l

M . o b tu ra to riu s e x te rn u s

D o rsa l

M . g lu te u s m a x im u s and

Fossa is c h io a n a lis is s im ila r in m e n a nd w o m e n . T h e latera l w a ll c o n ta in s in a fa s c ia l d u p lic a tu re o f th e M . o b tu ra to riu s in te rn u s (Fascia o b tu ra to ria ) th e p u d e n d a l canal (A L C O C K 's canal). T h e p u d e n d a l ca nal h a rb o u rs th e A . a nd V. p u d e n d a in te rn a , a n d th e N. p u d e n d u s a fte r th e ir p a ssa g e fr o m th e g lu te a l re g io n th ro u g h th e F o ra m e n •

is c h ia d ic u m m in u s . T h e R eg io u ro g e n ita lis has t w o p e rin e a l spaces: -

Lig. s a c ro tu b e ra le V e n tra l

p o s te rio r m a rg in o f th e s u p e rfic ia l a nd th e d e e p p e rin e a l s p a c e s ; a n te rio r re c e s s e s re ach th e p u b ic s y m p h y s is

T h e d e e p p e rin e a l s p a c e (S p a tiu m p ro fu n d u m p e rin e i) is b o rd e re d in te rio rly b y th e p e rin e a l m e m b ra n e (M e m b ra n a p e rin e i) a nd , in C auadal

fa s c ia a nd s k in o f th e P e rin e u m

P Clinical R em arks----------------------------------------------------------------------------------------------------------D u rin g v a g in a l d e liv e ry te a rs o f th e p e rin e a l skin a nd th e p e rin e a l te ra lly (e p is io to m y ) are p e rfo rm e d to p re v e n t u n c o n tro lle d p e rin e a l m u s c le s , in c lu d in g th e anal s p h in c te r m u s c le s , m a y o c c u r (p e rin e a l te a rs ). S e le c tiv e in c is io n s e x te n d in g fr o m th e V a g in a m e d ia lly o r la-

te a rs ,

217

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d

Perineal region in w o m e n

M. bulbospongiosus Ostium urethrae externum Labium minus pudendi

A. pudenda interna, Rr. labiales posteriores

V. bulbi vestibuli M. ischiocavernosus A. dorsalis clitoridis

A. perinealis Nn. labiales posteriores N. dorsalis clitoridis

A. pudenda interna

M. transversus perinei superficialis Rr. perineales (N. cutaneus femoris posterior)

Fossa ischioanalis

N. dorsalis clitoridis

M. gluteus maximus

Nn. clunium inferiores (N. cutaneus femoris posterior)

Nn. perineales A.; V. pudenda interna N .p u d e n d u s A. rectalis inferior A. p ud enda interna

Nn. rectales inferiores M. levator ani M. sphincter ani externus

Nn. clunium inferiores (N. cutaneus femoris posterior) Nn. anococcygei

Lig. anococcygeum

Fig. 7 .9 2

B lo o d v es s e ls a n d n e rv e s o f th e p e rin e a l r e g io n , R eg io

p e rin e a lis , in w o m e n ; caudal v ie w . T h e Fossa is c h io a n a lis h as a v e ry s im ila r a n a to m y in m e n a nd w o m e n . T h e p y ra m id -s h a p e d fo s s a is fille d w ith a d ip o s e tis s u e . C o v e re d b y a fa scia l d u p lic a tu re o f th e M . o b tu ra to riu s in te rn u s , th e C analis p u d e n d a lis (A L C O C K 's canal), th e n e u ro v a s c u la r s tru c tu re s e n te r th e Fossa is c h io a n a lis fr o m d o rs o la te ra l. A t fir s t b ra n c h e s to th e A n u s a nd th e anal

canal e x it a n d c ro s s th e isch io -a n a l fo s s a to re a c h th e A n u s . T h e n e u ro v a s c u la r s tru c tu re s th e n c o n tin u e v e n tra lly to th e V u lv a a n d th e tw o p e rin e a l s p a ce s. C o n te n ts o f t h e Fossa is c h io an a lis : • A . a nd V. p u d e n d a in te rn a , a n d N. p u d e n d u s : in th e C analis p u d e n •

d a lis (A L C O C K 's canal) A ., V. a n d N. re c ta lis in fe rio r: to th e anal canal

Clinical Remarks

218 — ♦

S im ila r to m e n , th e F o ssa is c h io a n a lis is o f g re a t clin ic a l re le v a n c e b e c a u s e o f its e x p a n s io n to b o th s id e s o f th e A n u s . C o lle c tio n s of

e x te n d to th e p u b ic s y m p h y s is . T h e s e a b s c e s s e s n o t o n ly c a u s e n o n -s p e c ific in fla m m a to ry s ig n s b u t a ls o re s u lt in in te n s e pain in th e

p u s (a b sce sse s), e .g . fis tu la s fr o m th e anal ca na l, m a y e x p a n d w ith in th e e n tire isch io -a n a l fo s s a , in c lu d in g its a n te rio r re c e s s e s a n d even

p e rin e a l re g io n .

dissection link

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

Perineal spaces in w o m e n

Rectum

Corpus uteri

(C avitas peritonealis pelvis)

Fascia pelvis visceralis

Peritoneum parietale

Cavitas uteri Excavatio vesicouterina Cervix uteri

Vesica urinaria (Spatium extrap erito n eale pelvis)

M. obturatorius internus Plexus venosus vesicalis Fossa ischioanalis N . pudendus

M . levator ani

A. pudenda interna Sp atium profundum perinei

Fossa ischioanalis

C rus clitoridis

Spatium su p erficiale perinei

M. ischiocavernosus M. bulbospongiosus G landula vestibularis m ajor Bulbus vestibuli Ostium vaginae

U rethra fem inina Labium minus pudendi Ostium urethrae externum

Fig. 7 .9 3

P e rin e a l s p a c es in w o m e n ; m e d ia n s e c tio n , a nd fro n ta l

s e c tio n on th e rig h t s id e ; v e n tra l v ie w . T h e fro n ta l s e c tio n s h o w s th r e e le v e ls o f th e fe m a le p e lvis: •

p e rito n e a l c a v ity o f th e p e lv is (C avita s p e rito n e a lis p e lv is ) b o rd e re d c a u d a lly b y th e p a rie ta l p e rito n e u m

•

s u b p e rito n e a l s p a ce (S p a tiu m e x tra p e rito n e a le p e lvis), c a u d a lly b o r d e re d b y th e M . le v a to r ani o f th e p e lv ic flo o r

•

p e rin e a l re g io n (R eg io p e rin e a lis) in fe rio r to th e p e lv ic flo o r. The a n te rio r p o rtio n c o n ta in s th e t w o p e rin e a l sp a ce s, a n d in c lu d e s th e

va ria b ly e xp a n d e d a n te rio r re cesse s o f th e ischio-anal fo s s a (illu stra te d h e re in t w o d iffe r e n t w a y s fo r th e rig h t a n d le ft side s). T h e d e e p p e rin e a l s p a c e (S p a tiu m p ro fu n d u m p e rin e i) c o n s is ts o f c o n n e c tiv e tis s u e a n d s in g le m u s c le fib re s o f th e M . tra n s v e rs u s p e rin e i p ro fu n d u s . It a lso c o n ta in s th e p a ssa g e o f th e V a gina a n d th e U re th ra . T h e d e e p p e rin e a l s p a ce is tra v e rs e d b y th e d e e p b ra n c h e s o f th e N.

p u d e n d u s (N. d o rs a lis c lito rid is ), a nd th e A . a n d V. p u d e n d a in te rn a (A. b u lb i v e s tib u li, A . d o rs a lis c lito rid is , A . p ro fu n d a c lito rid is ) b e fo re th e y re ach th e V u lva . T h e N n. c a v e rn o s i c lito rid is p ie rc e th e P e rin e u m a nd e n te r th e C o rp o ra c a v e rn o s a o f th e C lito ris . T h e s u p e rfic ia l p e rin e a l s p a c e (S p a tiu m s u p e rfic ia le p e rin e i) is lo c a te d b e tw e e n th e p erin e al m e m b ra n e (M e m b ra n a p e rin e i) a nd th e b o d y fa scia (Fascia p e rin e i). It c o n ta in s th e M . tra n s v e rs u s p e rin e i s u p e rfic ia lis , th e p ro x im a l p a rts o f th e C o rp o ra c a v e rn o s a c lito rid is , th e G la n d u la e v e s ti b u lä re s m a jo re s (B A R T H O L IN 'S g la n d s ), a n d th e v e s tib u la r b u lb (B u lb u s v e s tib u li). T h e b u lb o f th e v e s tib u le is e m b ra c e d b y th e M . b u lb o s p o n g io s u s , th e C rura c lito rid is b y th e M . is c h io c a v e rn o s u s on b o th s ide s. T h e s u p e rfic ia l b ra n c h e s o f th e N. p u d e n d u s (N. p e rin e a lis w it h N n. la b ia le s p o s te rio re s ), a n d o f th e A . a nd V. p u d e n d a in te rn a (A. p e rin e a lis w ith Rr. la b ia le s p o s te rio re s ) a ls o tra v e rs e th is s p a c e to re a c h th e labia.

219

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d

P rojection o f th e re ctu m and anal canal

Fig. 7 .9 4 a n d Fig. 7 .9 5

P ro je c tio n o f th e r e c tu m . R e c tu m , a n d of

th e a n a l c a n a l, C a n a lis a n a lis , o n to th e b o d y s u rfa c e ; v e n tra l (-» Fig. 7.9 4 a), d o rs a l (-» Fig. 7 .9 4 b ), a nd la te ra l (-» Figs. 7 .9 5 a a nd b) v ie w s . T h e R e c tu m b e g in s a t th e le ve l o f th e 2 nd o r 3 rd sa cral v e rte b ra e a nd e n d s on th e p e lv ic flo o r w h ic h is tra v e rs e d b y th e anal ca na l. In th e sa

220

g itta l pla n e , th e R e c tu m has t w o b e n d s : th e d o rs a lly c o n v e x Flexura sa c ra lis a n d th e v e n tra lly c o n v e x F lexura p e rin e a lis . T h e u p p e r p o rtio n o f th e R e c tu m a b o v e th e F le xura sa c ra lis is a s e c o n d a rily r e t r o p e r ito ne a l o r g a n , th e d is ta l p o rtio n a n d th e anal canal have a s u b p e rito n e a l p o s itio n .

Efferent urinary system -► Genitalia -► Rectum and anal canal

Topography -► Sections

- *

P osition o f th e rectu m

Peritoneum parietale

Colon sigmoideum

R e ctu m , Flexura sacralis

Excavatio rectovesicalis Vesica urinaria

Ureter Os pubis Glandula vesiculosa

Lig. puboprostaticum

Funiculus spermaticus M. levator ani Corpus anococcygeum [Lig. anococcygeum] R e ctu m , Flexura perinealis

M. sphincter ani externus

Fascia rectoprostatica

M. transversus perinei profundus M. sphincter urethrae Prostata

Fig. 7 .9 6

bulbourethralis*

R e c tu m , R e c tu m , in th e m a le p e lv is ; v ie w fr o m th e le ft

s ide . T h e illu s tra tio n s h o w s th e t w o b e n d s o f th e R e c tu m in th e s a g itta l p la n e . In th e u p p e r s e c o n d a ry re tro p e rito n e a l p o rtio n , th e R e c tu m ad ju s ts to th e c u rv a tu re o f th e s a c ru m a n d d is p la y s th e d o rs a lly c o n v e x F le x u ra s ac ra lis . In fe rio r to th is part, th e R e c tu m is n o t c o v e re d b y

M. transversus perinei profundus

tu m is a d ja c e n t t o th e p o s te rio r w a ll o f th e u rin a ry b la d d e r (V esica uri naria) a n d th e s e m in a l v e s ic le s (G la nd u lae v e s ic u lo s a e ) a nd fu r th e r caud a lly to th e p ro s ta te g la n d . H ere , th e R e c tu m is s e p a ra te d fro m th e p ro s ta te g la n d o n ly b y th e th in Fascia r e c to p ro s ta tic a (D E N O N V IL L IE R 's fa scia). In w o m e n , th e R e c tu m is c lo s e ly a d ja c e n t to th e p o s te rio r as p e c t o f th e V a gina a n d o n ly s e p a ra te d fr o m th e V a g in a b y th e Fascia

p a rie ta l p e rito n e u m , b u t h as a s u b p e rito n e a l p o s itio n . T h e v e n tra lly c o n v e x F le x u ra p e rin e a lis is a t th e le v e l o f th e p e lv ic d ia p h ra g m . In fe

re c to v a g in a lis {-► Fig. 7 .1 1 6 ).

rio r t o th e p e lv ic d ia p h ra g m , th e R e c tu m c o n tin u e s as th e anal canal in an in fe rio r a nd d o rs a l d ire c tio n . In m e n , th e a n te rio r a s p e c t o f th e R ec

* c lin ic a l te rm : C O W P E R 's g la n d s

i- Clinical R em arks-------------------------------------B e ca u se th e p ro s ta te g la n d is s e p a ra te d fr o m th e R e c tu m o n ly b y

to th e high in c id e n c e o f b e n ig n p ro s ta tic h ype rp lasia (BPH) a nd p ro s

th e th in Fascia re c to p ro s ta tic a (D E N O N V IL L IE R 's fa scia ), th e p ro s ta te g la n d ca n b e a s s e s s e d b y d ig ita l re c ta l e x a m in a tio n (D R E ). D ue

ta tic c a rc in o m a , th e d ig ita l re c ta l e x a m in a tio n is p a rt o f a c o m p le te p h y s ic a l e x a m in a tio n in m e n o v e r 5 0 y e a rs o f age.

221

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

S tru ctu re o f th e rectu m

Flexura sacralis

Fig. 7 .9 7

Peritoneum parietale, Excavatio rectovesicalis

R e c tu m , R e c tu m ; v ie w fr o m th e le ft side .

C ran ially, th e R e c tu m fo r m s th e d o rs a lly c o n v e x F lexura sa c ra lis a nd ca u d a lly, a t th e le v e l o f th e p a ssa g e th ro u g h th e p e lv ic flo o r, th e v e n -

Tunica muscularis, Stratum longitudinale

tra lly c o n v e x F le xura p e rin e a lis. U n lik e th e C o lo n , th e m u s c u la r la y e r (Tunica m u s c u la ris ) o f th e R e c tu m n o t o n ly c o n ta in s th e c irc u la r la ye r (S tra tu m circ u la re ) b u t a ls o a c o n ti n u o u s lo n g itu d in a l la ye r (S tra tu m lo n g itu d in a le ). M. levator ani

Flexura perinealis M. sphincter ani externus Tela subcutanea

Tunica muscularis, Stratum longitudinale Plica transversa recti

Fig. 7 .9 8

R e c tu m , R e c tu m , a n d a n a l c a n a l, C a n a lis a n a lis ; v e n tra l

v ie w . T h e in n e r re lie f o f th e R e c tu m s h o w s tra n s v e rs e fo ld s , s o -c a lle d Plicae tra n s v e rs a e re c ti. O n e o f th e th re e fo ld s is p a lp a b le re g u la rly a t a b o u t Plica transversa recti

6 - 7 c m a b o v e th e A n u s (K O H L R A U S C H 's fo ld ). B e lo w th is fo ld , th e R e c tu m is d ila te d to fo r m th e A m p u lla re c ti. T h e L in e a a n o re c ta lis m a rk s th e tra n s itio n to th e anal canal. T h is area is c h a ra c te ris e d b y th e c h a n g e fr o m th e tra n s v e rs e fo ld s o f th e R e c tu m to th e lo n g itu d in a l

Am pulla recti

Noduli lymphoidei solitarii

fo ld s o f th e anal canal a n d re p re s e n ts a tra n s itio n a l z o n e b e tw e e n R ec tu m a nd anal ca n a l (J u n c tio a n o re c ta lis ). T h e a n a l c a n a l is d iv id e d in to t h r e e s e g m e n ts : •

Z o n a c o lu m n a ris : c o n ta in s lo n g itu d in a l fo ld s (C o lu m n a e anales)

•

fo rm e d b y th e u n d e rly in g C o rp u s c a v e rn o s u m re c ti P e c te n a n a lis : th e s tra tifie d n o n -k e ra tin is e d s q u a m o u s e p ith e liu m c re a te s a w h ite z o n e in th e m u c o s a (Z o n a a lb a ); th e s u p e rio r b o rd e r

Jun ctio (Linea) anorectalis levator ani

Sinus anales

Columnae anales Linea p ectinata Pecten analis

Cutis

222

o f th is z o n e is re fe rre d to as L in e a p e c tin a ta (clin ical te rm : Linea d e n ta ta ); h e re , th e V a lv u la e a n a le s a nd th e w h ite s q u a m o u s e p ith e

M. sphincter ani internus k

•

Valvulae anales M. sphincter ani externus Linea an o cutanea

liu m m e e t. Z o n a c u ta n e a : e x te rn a l s k in , in c o n s is te n tly lim ite d b y th e L in e a a n o c u ta n e a

•

h a e m o rrh o id a l k n o ts

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

S tructu re o f th e anal canal

Rectum Sinus anales C o lu m n a e anales (Zona colum naris) Vesica urinaria

C o rpus cavernosum recti Stratum circulare recti longitudinale recti M. pubococcygeus (M. levator ani)

Prostata

M . sph incter ani internus M . puborectalis (M . levator ani)

Pars ' profunda Pars superficialis

M. transversus perinei profundus C o rpus cavernosum recti

M . sphincter ani externus

Pars subcutanea

Valvulae anales Corpus spongiosum penis

P ecten analis

Linea an o cutanea

M. bulbospongiosus

Zon a cutanea

M . co rru g a to r ani

Fig. 7 .9 9

R e c tu m , R e c tu m , a n d a n a l c a n a l, C a n a lis a n a lis , in

Valvula analis

T h is illu s tra tio n d e m o n s tra te s th e s e g m e n ts o f th e anal canal a n d th e

T h e s p h in c te r m u s c le s c o m p ris e : M . s p h in c te r a n i in te rn u s (s m o o th m u s c le s , in v o lu n ta ry s y m p a th e tic in n e rv a tio n ): c o n tin u a tio n o f th e c irc u la r m u s c u la r laye r

o rg a n is a tio n o f th e c o n tin e n c e o rg a n . T h e anal canal is d iv id e d in to t h r e e s e g m e n ts (-* Fig. 7.98):

M . c o r ru g a to r a n i (s m o o th m u s c le s ): c o n tin u a tio n o f th e lo n g itu d i nal m u s c u la r la y e r

T h e p e c tin a te lin e (L in e a p e c tin a ta ) is th e d e v e lo p m e n ta l b o rd e r b e tw e e n th e h in d g u t a nd th e p ro c to d e u m a n d m a rk s th e b o rd e r b e tw e e n th e Zona c o lu m n a ris a nd th e P e c te n a na lis in th e a d u lt. S im ila r to

via th e N. p u d e n d u s ): has d iffe r e n t s e g m e n ts (P a rte s s u b c u ta n e a , s u p e rfic ia lis , p ro fu n d a )

th e le ft c o lic fle x u re , th e p e c tin a te lin e re p re s e n ts th e w a te rs h e d fo r s e v e ra l n e u ro v a s c u la r s tru c tu re s a n d s e rv e s as c lin ic a lly im p o rta n t la n d

M . p u b o re c ta lis (s tria te d m u s c le s , v o lu n ta ry c o n tro l via th e N . pu d e n d u s a nd d ir e c t b ra n c h e s o f th e sa cral p le x u s ): p a rt o f th e M . leva

m a rk in th e anal canal. T h e anal canal p o s s e s s e s a c o n tin e n c e o rg a n c o n tro lle d b y th e C NS

to r a ni; fo r m s a lo o p b e h in d th e R e c tu m to p ull it v e n tra lly a n d c re a te th e F lexura p e rin e a lis . T h e re s u ltin g k in k o f th e R e c tu m e n a b le s th e

m e n ; m e d ia n s e c tio n ; v ie w fr o m th e le ft sid e , (a c c o rd in g to [1 ])

w h ic h is c o m p o s e d o f th e a nu s, s p h in c te r m u s c le s , a nd th e C o rp u s c a v e rn o s u m re c ti. A p a rt fr o m d e fe c a tio n , th e A n u s is c lo s e d b y th e

M . s p h in c te r a n i e x te rn u s (s tria te d m u s c le s , v o lu n ta ry c o n tro l

s to ra g e o f fa e c e s in th e re c ta l a m p u lla . For ly m p h a tic d ra in a g e - * p a g e 99.

p e rm a n e n t c o n tra c tio n s o f th e in te rn a l anal s p h in c te r m u s c le s . T h e C o rp u s c a v e rn o s u m re c ti is s u p p lie d b y th e A . re c ta lis s u p e rio r a n d th is w a rra n ts a g a s -tig h t c lo s u re o f th e anal canal.

i- Clinical R em arks-------------------------------------S in ce th e R e c tu m has tra n s v e rs e fo ld s (P licae tra n s v e rs a e re c ti) and

D ila tio n s o f th e C o rp u s c a v e rn o s u m re c ti are re fe rre d to as h a e m o r

th e anal canal has lo n g itu d in a l fo ld s (C o lu m n a e a nales), in s p e c tio n o f th e m u c o s a o f a p ro la p s e a llo w s th e vis u a l d is c rim in a tio n b e tw e e n a

rh o id s (-» Figs. 7 .1 0 4 a n d 7 .1 0 5 ). B e h in d th e V a lv u la e ana le s, th e S in u s a n a le s are lo c a te d as d e p re s s io n s in w h ic h p ro c to d e a l g la n d s

re c ta l v e rs u s an a n a l p ro la p s e . B o th re s u lt in fa e ca l in c o n tin e n c e . D u e to th e d iffe r e n t n e u ro v a s c u la r s u p p ly o f th e A n u s , th e Linea

(G la nd u lae ana le s) e n te r th e anal canal. T h e s e g la n d s m a y tra v e rs e th e s p h in c te r m u s c le s a nd c a u s e fis tu la s w h e n in fla m e d a nd , th u s ,

p e c tin a ta s e rv e s as c lin ic a lly re le v a n t la n d m a rk d u rin g s u rg e ry of a n a l c an cer. P ro xim a l tu m o u rs m e ta s ta s is e to th e p e lv ic ly m p h

p o te n tia lly fa c ilita tin g th e s p re a d o f th e in fla m m a tio n in to th e is c h io anal fo s s a .

n o d e s , d is ta l c a rc in o m a s s p re a d fir s t to th e in g u in a l ly m p h n o d e s . N e v e rth e le s s , th e tu m o u rs are s ta g e d a c c o rd in g to th e ir p ro x im ity to th e Linea a n o c u ta n e a .

dissection link

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

A rte rie s o f th e re ctu m and anal canal

Pars abdominalis aortae A. rectalis su p erio r*

Aa. sigmoideae

Colon sigmoideum

A. glutea superior

Canalis obturatorius A. iliaca interna

A. iliaca externa

A. glutea inferior

M. obturatorius internus

A. pudenda interna M. levator ani A. obturatoria

A. rectalis m edia M. sphincter ani externus A. rectalis inferior

Fig. 7 .1 0 0

R e c ta l a rte r ie s , A a . rec ta le s ; d o rs a l v ie w .

R e c tu m a nd anal canal are s u p p lie d b y th re e a rte rie s : A . re c ta lis s u p e rio r (u np a ire d ): fr o m th e A . m e s e n te ric a in fe rio r A . re c ta lis m e d ia (paired): fr o m th e A . iliaca in te rn a a b o v e th e p e lv ic flo o r (M . le v a to r ani)

n ata w h e r e n u m e ro u s a n a s to m o s e s b e tw e e n th e s e a rte rie s e x is t. T h e A . re c ta lis s u p e rio r is th e la s t b ra n c h o f th e A . m e s e n te ric a in fe rio r and p ro v id e s a b ra n c h fo r th e a n a s to m o s is w it h th e A a. s ig m o id e a e . F ro m

A . re c ta lis in fe r io r (paired): fr o m th e A . p u d e n d a in te rn a b e n e a th

th is p o in t o n w a rd s (clin ical te r m : S U D E C K 's p o in t [* ]), th e A . re c ta lis s u p e rio r is c o n s id e re d a te rm in a l a rte ry . T h e C o rp u s c a v e rn o s u m re c ti is p rim a rily s u p p lie d b y th e A . re c ta lis s u p e rio r. T h e re fo re , b le e d in g s o f

th e p e lv ic flo o r T h e b o rd e r b e tw e e n th e c o rre s p o n d in g a rte ria l s u p p ly fr o m th e A . m e Â

h a e m o rrh o id s , w h ic h re p re s e n t d ila te d re c ta l c a v e rn o u s b o d ie s , are arÂ te ria l b le e d in g s as s h o w n b y th e b rig h t re d c o lo u r.

â&#x20AC;˘

s e n te ric a in fe rio r a n d th e A . iliaca in te rn a is lo c a te d a t th e Linea p e c ti-

224

Anus

Efferent urinary system -» Genitalia -► Rectum and anal canal -> Topography -♦ Sections

Veins o f th e re ctu m and anal canal

V. iliaca communis V. cava inferior V. mesenterica inferior

Vv. sigmoideae

V. rectalis superior Colon sigmoideum

V. glutea superior

Canalis obturatorius

V. iliaca interna

V. iliaca externa

V. glutea inferior

V. obturatoria V. pudenda interna

M. obturatorius internus

V. rectalis m edia M. levator ani Rectum Plexus venosus rectalis Vv. rectales inferiores M. sphincter ani externus

Fig. 7.1 0 1

R e c ta l v e in s , V v . rec ta le s ; d o rs a l v ie w .

C o rre s p o n d in g to th e re c ta l a rte rie s , th e v e n o u s b lo o d fr o m th e R ec A. rectalis superior V. iliaca communis V. cava inferior V. sigmoidea

tu m a nd th e anal canal d ra in s via th r e e v e in s : V. re c ta lis s u p e rio r (u np a ired ): a c c e s s to th e p o rta l v e in (V. p o rta e h e p a tis ) via th e V. m e s e n te ric a in fe rio r V. re c ta lis m e d ia (paired): a c c e s s to th e V. cava in fe rio r via th e V. iliaca in te rn a V. re c ta lis in fe rio r (paired): a c c e s s to th e V. cava in fe rio r via th e V. p u d e n d a in te rn a a nd th e V. iliaca in te rn a

V. sacralis mediana

T h e w a te rs h e d b e tw e e n th e v e n o u s d ra in a g e to th e V. p o rta e h e p a tis a n d th e V. cava in fe rio r is in th e area o f th e Linea p e c tin a ta . T h e re are

V. rectalis sup erior V. iliaca externa

n u m e ro u s a n a s to m o s e s .

V. iliaca interna

Ampulla recti

Fig. 7 .1 0 2

V e n o u s d r a in a g e o f r e c tu m . R e c tu m , a n d a n a l c an a l,

C a n a lis a n a lis ; v e n tra l v ie w . T rib u ta rie s to th e V. p o rta e h e p a tis Plexus venosus rectalis

Vv. rectales m ediae

M. levator ani A.pudenda interna

Columnae anales M. sphincter ani internus M. ani externus

Vv. rectales inferiores

(p urp le ) a n d t o th e V. cava in fe rio r (blue). T h is illu s tra tio n d e m o n s tra te s th a t th e v e n o u s d ra in a g e p a th w a y s to th e p o rta l v e in a nd to th e in fe rio r v e n a cava have n u m e ro u s a n a s to m o s e s . W ith in c re a s e d b lo o d p re s s u re in th e p o rta l s y s te m (p o rta l h y p e r te n s io n ), e.g. in liv e r c irrh o s is , th e s e a n a s to m o s e s are u tilis e d fo r th e d ra in a g e o f b lo o d to th e V. cava in fe rio r (p o rto c a v a l a n a s to m o s e s ). S in c e th e y d o n o t re s u lt in h a e m o rrh o id s , th e a n a s to m o s e s have no c lin ic a l re le v a n c e .

Anus

225

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d

Innervation o f th e re ctu m and anal canal

Plexus coeliacus; Ganglia coeliaca Truncus coeliacus

Ganglia trunci sympathici

Pars abdominalis aortae m it Plexus aorticus abdominalis

Ganglion mesentericum inferius Nn. splanchnici lumbales

A. mesenterica inferior

Plexus hypogastricus superior

A. iliaca communis Radices anteriores (S 2 -S 4 )

N. hypogastricus dexter V

/ Plexus hypogastricu s inferior

Plexus rectalis G anglia pelvica, Radix parasym pathica [Nn. splanchnici pelvici]

Plexus sacralis

M. levator ani N . pudendus Nn. anales

Anus

Fig. 7 .1 0 3

In n e rv a tio n o f th e r e c tu m , R e c tu m , a n d a n a l c a n a l,

C a n a lis a n a lis ; v e n tra l v ie w ; s c h e m a tic illu s tra tio n . T h e P le x u s re c ta lis c o n ta in s s y m p a th e tic (g ree n ) a n d p a ra s y m p a th e tic (p urp le ) n e rv e

226

M. sphincter ani externus

P re g a n g lio n ic p a r a s y m p a th e tic fib re s d e riv e fr o m th e sa cral d iv is io n o f th e p a ra s y m p a th e tic n e rv o u s s y s te m (S 2 -S 4 ) via th e N n. s p la n c h n ic i

fib re s . T h e P lexu s re c ta lis is a c o n tin u a tio n o f th e P le xu s h y p o g a s tric u s in fe ri-

p e lv ic i t o th e g a n g lia o f th e P le x u s h y p o g a s tric u s in fe rio r. T h e y are s y n a p s e d to p o s tg a n g lio n ic fib re s e ith e r h e re o r in th e v ic in ity o f th e in te s tin e s fo r th e s tim u la tio n o f th e p e ris ta ls is a nd th e in h ib itio n o f th e in te r

T h e p re g a n g lio n ic s y m p a th e tic fib re s (T 1 0 -L 2 ) d e s c e n d fr o m th e Ple

nal anal s p h in c te r m u s c le s (M . s p h in c te r ani in te rn u s ) to fa c ilita te d e fa e c a tio n .

x u s a o rtic u s a b d o m in a lis via th e P le xu s h y p o g a s tric u s s u p e rio r a nd fr o m th e sa cral g a n g lia o f th e s y m p a th e tic tru n k (T ru n cu s s y m p a th ic u s )

T h e a u to n o m ic in n e rv a tio n e n d s a p p ro x im a te ly in th e area o f th e Linea p e c tin a ta . T h e in fe rio r p o rtio n o f th e anal canal is in n e rv a te d b y th e s o

via th e N n. s p la n c h n ic i s a cra le s. T h e y are p re d o m in a n tly s y n a p s e d to p o s tg a n g lio n ic s y m p a th e tic n e u ro n s in th e P le xu s h y p o g a s tric u s in fe ri

m a tic N . p u d e n d u s to c o n v e y s e n s o ry in n e rv a tio n to th e s k in in fe rio r to th e p e c tin a te lin e . T h u s , anal c a rc in o m a s in fe rio r to th e p e c tin a te lin e

or. T h e s e p o s tg a n g lio n ic fib re s re ach th e R e c tu m a n d anal canal via th e P le xu s re c ta lis . S y m p a th e tic fib re s a c tiv a te th e s p h in c te r m u s c le s (M .

are e x tr e m e ly p a in fu l, w h e re a s anal c a rc in o m a s lo c a te d a b o v e th is d e m a rc a tio n lin e are n o t. In a d d itio n , th e N. p u d e n d u s c o n v e y s m o to r

s p h in c te r a n i in te rn u s ).

fib re s to th e M . s p h in c te r ani e x te rn u s a n d to th e M . p u b o re c ta lis and, th u s , fa c ilita te s v o lu n ta ry c lo s u re o f th e A n u s .

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

H aem orrhoids

Columna analis

Canalis analis

Sinus analis

Fig. 7 .1 0 4

A n a l c a n a l, C a n a lis a n a lis ; re c to s c o p y ; cra nia l v ie w .

c o lo s c o p e

C le a rly, s ix s u b s ta n tia lly e n la rg e d k n o ts o f th e C o rp u s c a v e rn o s u m re c ti are v is ib le (h a e m o rrh o id s ).

th re e h a e m o rrh o id a l k n o ts

Accessory node at 1 o'clock Major node

7 o'clock 3 o'clock

Fig. 7 .1 0 5

H a e m o r r h o id s g ra d e IV; ca ud a l v ie w w it h th e p a tie n t in

s u p in e p o s itio n a nd th e e x a m in e r fa c in g th e P e rin e u m . [4] T h e p o s itio n o f h a e m o rrh o id a l k n o ts is d o c u m e n te d a c c o rd in g t o th e

o r in th e C o rp u s c a v e rn o s u m re c ti, m a jo r h a e m o rrh o id a l k n o ts ty p ic a lly a p p e a r a t 3, 7 a nd 11 o 'c lo c k . M in o r k n o ts m a y d e riv e fr o m th e s m a lle r a rte ria l b ra n c h e s . A s m a lle r k n o t is v is ib le h e re a t 1 o 'c lo c k .

c lo c k -fa c e . D u e to th e m a jo r b ra n c h in g p a tte rn o f th e A . re c ta lis s u p e ri

i- Clinical R em arks-------------------------------------H a e m o r r h o id s are fre q u e n tly o c c u rin g p a th o lo g ic a l d ila tio n s o f th e C o rp u s c a v e rn o s u m re c ti. T h e c a u s e s are n o t fu lly u n d e rs to o d b u t

• •

th e n u tritio n in in d u s tria lis e d c o u n trie s (rich in fa t, p o o r in fib re s ) m a y be a c o n trib u tin g fa c to r. H a e m o rrh o id s are c a te g o ris e d in d iffe r e n t gra d e s :

B e g in n in g a t g ra d e II, th e ra p e u tic in te rv e n tio n is re c o m m e n d e d e ith e r b y s c le ro th e ra p y , ru b b e r b a n d lig a tio n , o r s u rg ic a l e x c is io n (h a e m o rrh o id e c to m y ; g ra d e III a n d IV).

•

g ra d e I: o n ly v is ib le e n d o s c o p ic a lly

•

g ra d e II: p ro tru d e d u rin g b e a rin g d o w n fo r b o w e l m o v e m e n ts ; a fte rw a rd s re tra c t in to th e anal canal

g ra d e III: p ro tru d e s p o n ta n e o u s ly , can be re p o s ite d m a n u a lly g ra d e IV: c a n n o t be re p o s ite d

227

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Blood vessels o f th e re trope rito neal space A.; V. phrenica inferior

Vv. hepaticae

A.; V. phrenica inferior

Glandula suprarenalis

A. suprarenalis media; V. suprarenalis sinistra

Truncus coeliacus A. m esen terica superior

Glandula suprarenalis

A. suprarenalis inferior; V. suprarenalis dextra Ren

A.; V. renalis

V. cava inferior

Ureter

A.; V. renalis

A.; V. testicu laris Pars abdom inalis aortae A.; V. lumbalis I

Ureter

A. m esen terica inferior

V.; A. testicularis

A.; V. sacralis mediana

Aa.; Vv. iliacae com m unes

Colon sigmoideum

Fig. 7 .1 0 6

B lo o d v es s e ls in th e r e tr o p e r ito n e a l s pace; v e n tra l

B ra n c h e s o f t h e P ars a b d o m in a lis a o rta e

v ie w . A ft e r its p a ssa g e th ro u g h th e d ia p h ra g m , th e A o rta c o n tin u e s as Pars a b d o m in a lis a nd is lo c a te d in th e re tro p e rito n e a l s p a ce a t th e le ft s id e o f th e V. cava in fe rio r a nd a n te rio r to th e v e rte b ra l c o lu m n . T h e b ra n c h e s o f th e P ars a b d o m in a lis a o r ta e are lis te d in th e ta b le .

P a rie ta l b ra n c h e s to th e b o d y w a ll

•

A . p h re n ic a in fe rio r: a t th e in fe rio r s id e o f th e

•

d ia p h ra g m , g iv e s ris e to th e A . s u p ra re n a lis s u p e rio r to th e a d re n a l g la n d A a. lu m b a le s : fo u r pairs d ire c tly b ra n c h in g o ff th e A o rta , th e fift h p a ir d e riv e s fr o m th e A . sa cralis m e d ia n a

T h e V. c a v a in fe r io r o rig in a te s fr o m th e m e rg in g o f th e t w o Vv. iliacae c o m m u n e s a nd is lo c a te d a t th e rig h t s id e o f th e A o rta .

T rib u ta rie s o f th e V. c a v a in fe rio r • •

Vv. ilia cae c o m m u n e s V. sa cra lis m e d ia n a

• • • • •

Vv. lu m b a le s V. p h re n ic a in fe rio r d e x tra , e n te rs th e V. re n a lis on th e le ft s id e V. te s tic u la ris /o v a ric a d e x tra , e n te rs th e V. re n a lis on th e le ft s id e V. su p ra re n a lis d e x tra , e n te rs th e V. re n a lis on th e le ft side V v. re n a le s d e x tra a n d s in is tra

•

th re e Vv. h e p a tic a e (Vv. h e p a tic a e d e x tra , in te rm e d ia and s in istra )

V is c e ra l • T ru n c u s c o e lia c u s : u n p a ire d , o rig in a te s d ire c tly b ra n c h e s b e n e a th th e H ia tu s a o rtic u s a nd s u p p lie s th e to th e v is c e ra o f th e E p ig a s triu m (-» Fig. 6 .1 1 3 ) v is c e ra •

•

T e rm in a l b ra n c h e s

228 — ♦

dissection link

A . s u p ra re n a lis m e d ia : s u p p lie s th e a dre n a l g la n d • A . re n a lis : to th e k id n e y , a ls o g iv e s ris e to th e A . s u p ra re n a lis in fe rio r to th e a d re n a l g la n d A . m e s e n te ric a s u p e rio r: u n p a ire d , s u p p lie s p a rts o f th e P a n cre a s, th e e n tire s m a ll in te s tin e s and th e C olo n up t o th e le ft c o lic fle x u re {-» Fig. 6 .1 1 5) A . te s tic u la ris /o v a ric a : s u p p lie s T e s tis a nd E p id id y m is in m e n a nd th e o v a ry in w o m e n

•

A . m e s e n te ric a in fe rio r: u n p a ire d , s u p p lie s th e C olo n d e s c e n d e n s a n d u p p e r R e c tu m (-» Fig. 6 .1 1 8 )

•

A . iliaca c o m m u n is : to th e p e lv is a n d th e lo w e r e x tr e m ity A . s a c ra lis m e d ia n a : d e s c e n d s on th e s a c ru m

•

Efferent urinary system -► Genitalia -► Rectum and anal canal

Topography -> Sections

Lym ph vessels o f th e re tro p e rito n e a l space

V. cava inferior

Nodi lymphoidei gastrici sinistri

Nodi lymphoidei phrenici inferiores

Truncus intestinalis

C istern a chyli

Nodi lym phoidei lum bales dextri Pars abdominalis aortae

Truncus lum balis dexter

Nodi lym phoidei lum bales interm edii

Nodi lym phoidei lum bales sinistri

V. cava inferior A. iliaca communis Ureter Nodi lymphoidei iliaci communes

V. iliaca communis Nodi lym phoidei iliaci interni

N odi lym phoidei iliaci externi

Colon sigmoideum

Nodi lymphoidei inguinales superficiales, Nodi superolaterales

Nodi lymphoidei inguinales superficiales, Nodi superomediales et inferiores Nodi lymphoidei inguinales, (Nodi profundi)

Fig. 7 .1 0 7

L y m p h v es s e ls a n d ly m p h n o d e s o f th e r e tr o p e r ito n e

al s pace; v e n tra l v ie w . T h e ly m p h fr o m th e p e lv is d ra in s via th e N o d i ly m p h o id e i iliaci c o m m u n es in to th e p a rie ta l ly m p h n o d e s o f th e re tro p e rito n e a l s p a c e w h ic h are c o lle c tiv e ly re fe rre d to as N o d i ly m p h o id e i lu m b a le s . T h e s e are p o s itio n e d in th re e ch a in s as N o d i ly m p h o id e i lu m b a le s s in is tri a ro u n d th e A o rta , as N o d i ly m p h o id e i lu m b a le s d e x tri t o b o th s id e s o f th e V. cava in fe rio r, a n d as N o d i ly m p h o id e i lu m b a le s in te rm e d ii in b e tw e e n b o th b lo o d v e s s e ls . T h e lu m b a r ly m p h n o d e s n o t o n ly c o lle c t th e ly m p h

fr o m th e lo w e r e x tre m itie s , p e lv ic v is c e ra , a n d th e C olo n d e s c e n d e n s , b u t th e y a ls o s e rv e as re g io n a l ly m p h n o d e s ta tio n s fo r th e k id n e y , th e a d re n a l g la n d , a nd th e te s tis /o v a ry . T h e e ffe r e n t ly m p h v e s s e ls fro m th e lu m b a r ly m p h n o d e s fo r m th e bi la te ra l T ru n c i lu m b a le s . B o th T ru n c i lu m b a le s m e rg e w ith th e T ru n c u s in te r s tin a lis (c o lle c ts ly m p h fr o m th e v is c e ra l ly m p h n o d e s o f th e a b d o m in a l c a v ity ) in th e C is te rn a c h y li a n d c o n tin u e as D u c tu s th o ra c icus. T h u s , th e D u c tu s th o ra c ic u s b e lo w th e d ia p h ra g m d ra in s th e ly m p h fr o m th e e n tire lo w e r h a lf o f th e body.

dissection link

229

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

S o m atic nerves o f th e re trope rito neal space

M. quadratus lumborum

N. splanchnicus major

N. subcostalis V. cava inferior Truncus sympathicus

N. subcostalis Pars abdominalis aortae N. iliohypogastricus

N. iliohypogastricus

N. genitofem oralis Truncus lum bosacralis

N. ilioinguinalis N. obturatorius

M. psoas major Rr. musculares

N. ilioinguinalis N. fem oralis M. transversus abdominis

N. cutaneus fem o ris lateralis N. genitofemoralis, R. femoralis N. genitofemoralis, R. genitalis

Rectum

Fig. 7 .1 0 8

S o m a tic n e rv e s o f th e r e tr o p e r ito n e a l s pace; v e n tra l

m o to r b ra n c h e s t o th e M . ilio p s o a s a nd M . q u a d ra tu s lu m b o ru m

p e c t o f th e th ig h are a lso lo c a te d in th e re tro p e rito n e a l s p a c e (-» p. 3 30 ,

• •

N. ilio in g u in a lis (T12, L1) N. g e n ito fe m o ra lis ( L I , L2)

• •

N. c u ta n e u s fe m o r is la te ra lis (L2, L3) N. fe m o ra lis (L2, L4)

•

N. o b tu ra to riu s (L2, L4)

V o l. 1). T h e T ru n c u s lu m b o s a c ra lis is th e c o n n e c tio n to th e P lexu s sa cra lis in th e le s s e r p e lvis. T h u s , th e P le xu s lu m b o s a c ra lis c o n s titu te s a c o n tin u o u s n e rv e p le x u s .

230

B ra n c h e s o f t h e P le x u s lu m b a lis (T 1 2 -L 4 ):

v ie w . In a d d itio n to th e b lo o d a nd ly m p h v e s s e ls , th e n e rv e s o f th e P le x u s lu m b a lis fo r th e in n e rv a tio n o f th e in g u in a l re g io n a nd th e a n te rio r as

dissection link

(T 1 2 -L 4 ) • N. ilio h y p o g a s tric u s (T12, L1)

Efferent urinary system -► Genitalia -► Rectum and anal canal -► Topography -► Sections

A u to n o m ic nerves o f th e re tro p e rito n e a l space

vagus [X], Plexus oesophageus Oesophagus N. splanchnicus m ajo r

Plexus coeliacus, G anglia coeliaca

N. thoracicus [T11], N. intercostalis Costa XII Truncus coeliacus

N. subcostalis

Plexus m esen tericus superior, G anglion m esen tericum superius

M. quadratus lumborum

N. iliohypogastricus

Plexus in term esentericus Plexus m esen tericus inferior, G anglion m esen tericum inferius Truncus sympathicus

N. ilioinguinalis

Crista iliaca

N. cutaneus femoris lateralis

Plexus hypogastricu s sup erior

N. genitofemoralis

N. femoralis

N. obturatorius M. iliacus Truncus lumbosacralis

Plexus sacralis

Ganglion impar Rectum

A u to n o m ic n e rv e s o f th e r e tr o p e r ito n e a l s pace; v e n tra l

ic n e u ro n s . T h e ir a x o n s re ach th e ta rg e t o rg a n s a lo n g s id e a rte ria l

v ie w ; a fte r re m o v a l o f th e visce ra . T h e a u to n o m ic n e rv e s o f th e s y m p a th e tic a nd th e p a ra s y m p a th e tic s y s te m fo r m a p le x u s o f n e rv e fib re s on th e a n te rio r a s p e c t o f th e A o r

Fig. 7 .1 0 9

b ra n c h e s . T h e p re g a n g lio n ic p a r a s y m p a th e tic n e u ro n s o f th e N n . v a g i [X ]

ta (P le x u s a o rtic u s a b d o m in a lis ). It c o n trib u te s to a d d itio n a l n e rv e p le x u s e s a t th e o rig in s o f th e b ra n c h e s o f th e A o rta . T h e n e rv e fib re s th e r e o f a c c o m p a n y th e a rte rie s to th e ir ta rg e t o rg a n s . T h e s e p le x u s e s in c lu d e th o s e a t th e th re e u n p a ire d b ra n c h e s o f th e A o rta : th e P le x u s c o e lia c u s , th e P le x u s m e s e n te ric i s u p e rio r a nd in fe r io r a nd th e P le x u s in te r m e s e n te r ic u s (-► Fig. 6 .5 1 ). F a rth e r ca u d a l, th e p le x u s e s c o n tin u e via th e P lexu s h y p o g a s tric u s s u p e rio r to th e P le xu s h y p o g a s tric u s in fe rio r in th e le s s e r p e lv is fo r th e in n e rv a tio n o f th e p e lv ic visce ra . T h e p re g a n g lio n ic s y m p a th e tic n e u ro n s are lo c a te d in th e la te ra l c o

(-» p. 3 1 6 , V o l. 3) d e s c e n d a lo n g th e O e s o p h a g u s a s T ru n c i va ga le s a n te rio r a nd p o s te rio r, tra v e rs e th e d ia p h ra g m a nd tra v e l w ith in th e a u to n o m ic n e rv e p le x u s e s a ro u n d th e A o rta w it h o u t s y n a p s in g to reach th e ir ta r g e t o rg a n s . T h e p o s tg a n g lio n ic p a ra s y m p a th e tic n e u ro n s are lo c a te d in th e v ic in ity o r w ith in th e w a ll o f th e ta rg e t o rga n s. T h e v is c e r al in n e rv a tio n o f th e N n. v a g i [X] e n d s in th e P le x u s m e s e n te ric u s s u p e rio r a nd th u s , in th e area o f th e le ft c o lic fle x u re (C A N N O N B O E H M 's p oin t). T h e C o lo n d e s c e n d e n s is in n e rv a te d b y th e sac ra l d iv is io n o f th e

lu m n o f th e th o ra c ic a nd u p p e r lu m b a r sp in a l c o rd . T h e y p ass th ro u g h

p a r a s y m p a th e tic n e rv o u s s y s te m . T h e p re g a n g lio n ic n e u ro n s are lo c a te d in th e sa cral sp in a l c o rd (S 2 -S 4 ), e x it th e v e rte b ra l c o lu m n to

th e s y m p a th e tic tru n k (T ru n cu s s y m p a th ic u s ) w it h o u t b e in g s y n a p s e d a n d c o n tin u e as N n. s p la n c h n ic i m a jo r a n d m in o r to th e a o rtic p le x u s e s .

g e th e r w it h th e sp in a l n e rv e s a nd tra v e l as N n. s p la n c h n ic i p e lv ic i to th e P le x u s h y p o g a s tric u s in fe rio r in th e v ic in ity o f th e R e c tu m . A ft e r b e in g

H e re th e y s y n a p s e in d iffe r e n t gan g lia (Ganglia coeliaca, Ganglia m e s e n te ric a s u p e riu s a nd in feriu s, Ganglia aorticorenalia) o n to p o stg a n g lio n

syn ap se d , th e postg an g lio n ic nerve fib re s ascend to th e Colon d e s c e n d e n s a n d C olo n s ig m o id e u m .

231

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d -►

A. iliaca interna Pars abdominalis aortae

A. mesenterica inferior Plexus sacralis, Truncus lumbosacralis A. iliaca communis sinistra V. iliaca communis sinistra

A. sacralis lateralis

A. sacralis mediana A. iliaca communis dextra A. iliaca interna A. iliolum balis

A. glutea superior

A. obturatoria

A. glutea inferior

N. obturatorius N. genitofemoralis, R. genitalis

Anulus inguinalis profundus Plexus sacralis A. cremasterica A. epigastrica inferior

M. ischiococcygeus [coccygeus] R. pubicus

R. obturatorius Lig. sacrospinale A. pudenda interna

Symphysis pubica

A. obturatoria, R. pubicus

N. pudendus

M. obturatorius internus A. rectalis m edia

A. vesicalis inferior

Fig. 7 .1 1 0

A . ilia ca in te rn a ; v ie w fro m th e le f t side .

In m o s t c a se s (6 0 % ), th e A . iliaca in te rn a d iv id e s in to an a n te rio r a n d a p o s te rio r m a in b ra n c h . T h e s e q u e n c e fo r th e c o n s e c u tiv e b ra n c h in g is

h ig h ly va ria b le . T h u s , th e a rte ria l b ra n c h e s are c a te g o ris e d a c c o rd in g to th e ir p e rfu s io n area in p a r ie ta l b ra n c h e s fo r th e p e lv ic w a ll a n d th e e x te rn a l g e n ita lia a n d v is c e ra l b ra n c h e s fo r th e p e lv ic v isce ra .

A. iliaca interna

A. iliaca communis

Fig. 7.1 1 1

A. iliolum balis

P a rie ta l b ra n c h e s o f th e A . ilia ca in te rn a .

• •

A . ilio lu m b a lis : s u p p lie s th e Fossa iliaca a nd th e lu m b a r re gio n A a. s a cra le s la te ra le s: to th e sa cral canal

• •

A . o b tu ra to ria : tra v e rs e s th e C analis o b tu ra to riu s A . g lu te a s u p e rio r: e x its th ro u g h th e F o ra m e n s u p ra p irifo rm e to th e

•

g lu te a l re gio n A . g lu te a in fe rio r: e x its th ro u g h th e F o ra m e n in fra p irifo rm e t o th e

A. sacralis lateralis

A. glutea superior

M. piriformis

g lu te a l re gio n F o r th e v is c e ra l b ra n c h e s (d iffe re n t in m e n a n d w o m e n ) - * Figs. 7 .1 1 2

A. glutea inferior

a nd 7 .1 1 3 . Lig. sacrospinale A. iliaca externa A. pudenda interna A. obturatoria

Lig. sacrotuberale A. rectalis media

A. umbilicalis

A. vesicalis superior

232

A. uterina

Efferent urinary system -» Genitalia -► Rectum and anal canal -> Topography -*■ Sections

Blood vessels o f th e m ale pelvis

Pars abdominalis aortae

A. um bilicalis

A. sacralis mediana A.; V. vesicalis superior A. iliaca interna

A.; V. rectalis superior

Ureter dexter A.; V. obturatoria V. iliaca externa

V. iliaca interna

A. iliaca externa A.; V. vesicalis inferior

Ductus deferens dexter

A. ductus deferentis

M. piriformis Plica umbilicalis lateralis; A.; V. epigastrica inferior

M. ischiococcygeus [coccygeus]

Plica umbilicalis medialis Plexus venosus rectalis

Vesica urinaria A.; V. rectalis m edia

Ductus deferens sinister

Ureter sinister Glandula vesiculosa A. vesicalis superior A.; V. rectalis m edia V. dorsalis profunda penis

A. dorsalis penis

Plexus venosus vesicalis A. profunda penis

Fig. 7 .1 1 2

B lo o d s u p p ly o f th e p e lv ic v is c era in m e n ; v ie w fro m

th e le ft side .

T h e v e n o u s b lo o d d ra in s in to th e V. ilia ca in te r n a . Its trib u ta rie s fo rm c o m m u n ic a tin g v e n o u s p le x u s e s (P lexu s v e n o s i) a ro u n d th e p e lv ic v is

T h e p e lv ic v is c e ra are s u p p lie d b y th e v is c e ra l b ra n c h e s o f th e A . iliaca in te rn a . T h e p a r ie ta l b ra n c h e s fo r th e p e lv ic w a ll are id e n tic a l in m e n a nd w o m e n (-* Fig. 7 .1 1 1 ).

c e ra . T h e s e have to be re m o v e d d u rin g d is s e c tio n to d is p la y th e a rte rie s a n d n e rv e s o f th e p e lv is : • P le x u s v e n o s u s rec ta lis: c o n n e c te d via th e V. re c ta lis s u p e rio r to

V is c e ra l b ra n c h e s o f th e A . ilia c a in te r n a in m e n : • A . u m b ilic a lis : g iv e s rise to th e A . v e s ic a lis s u p e rio r to th e u rin a

th e p o rta l v e n o u s s y s te m a nd via th e V v. re c ta le s m e d ia a n d in fe rio r to th e d ra in a g e s y s te m o f th e V. cava in fe rio r (p o rto c a v a l a n a s to m o

ry b la d d e r a nd o fte n (h e re n o t s h o w n ) th e A . d u c tu s d e fe re n tis to th e va s d e fe re n s b e fo re its o b lite ra te d p a rt (Lig. u m b ilic a le m e d ia le )

•

sis) P le x u s v e n o s u s ves ica lis: a t th e base o f th e u rin a ry b la d d e r, a lso

•

c re a te s th e Plica u m b ilic a lis m e d ia lis . A . v e s ic a lis in fe rio r: to th e u rin a ry b la d d e r, p ro s ta te g la n d , a n d s e m i

•

c o lle c ts th e v e n o u s b lo o d fr o m th e a c c e s s o ry s e x g la n d s P le x u s v e n o s u s p ro s ta tic u s : d ra in s n o t o n ly th e v e n o u s b lo o d

•

nal v e s ic le , o c c a s io n a lly (as s h o w n h ere ) g iv e s rise to th e A . d u c tu s d e fe re n tis A . re c ta lis m e d ia : a b o v e th e p e lv ic flo o r t o th e R e c tu m

fr o m th e p ro s ta te g la n d , b u t a ls o th e b lo o d fr o m th e C orp o ra c a v e rn o s a p e n is (V. d o rs a lis p ro fu n d a p en is). C o n n e c tio n s to th e v e n o u s p le x u s e s a round th e v e rte b ra l c o lu m n explain th e fre q u e n tly o c c u rrin g

A . p u d e n d a in te rn a : p a sse s th ro u g h th e F o ra m e n in fra p irifo rm e and s u c c e s s iv e ly th e F o ra m e n is c h ia d ic u m m in u s to th e la te ra l w a ll o f

v e rte b ra l m e ta s ta s e s in p a tie n ts w it h p ro s ta tic c a rc in o m a .

•

th e Fossa is c h io a n a lis (C analis p u d e n d a lis , A L C O C K 's canal). H ere th e A . re c ta lis in fe rio r b ra n c h e s o f f to th e in fe rio r anal canal. The A . p u d e n d a in te rn a th e n d iv id e s in to th e s u p e rfic ia l a n d d e e p te r m in a l b ra n c h e s to s u p p ly th e e x te rn a l g e n ita lia . T h e s u p e rfic ia l A . p e rin e a lis s u p p lie s th e P e rin e u m a nd p ro v id e s Rr. s c ro ta le s p o s te rio re s to th e S c ro tu m . T h e d e e p b ra n c h e s p ro v id e a rte ria l b lo o d to th e c a v e rn o u s b o d ie s o f th e P e n is (A. b u lb i p e n is , A . d o rs a lis p en is, A . p ro fu n d a p en is).

dissection link

233

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

Blood vessels o f th e fe m a le pelvis

V. iliaca interna A. sacralis mediana A. iliaca interna A.; V. rectalis superior

A. um bilicalis

A.; V. ovarica

A.; V. rectalis m edia Ureter

Ovarium dextrum Plexus venosus rectalis

Tuba uterina Lig. teres uteri; A. ligamenti teretis uteri

A.; V. uterina

A.; V. iliaca externa

Uterus A.; V. rectalis m edia

Vesica urinaria

A. vaginalis

Ovarium sinistrum A. vesicalis inferior

M. levator ani

V. rectalis inferior

Bulbus vestibuli

Plexus venosus vaginalis

A.; V. p ud enda interna Plexus venosus uterinus

Fig. 7 .1 1 3

B lo o d s u p p ly o f th e p e lv ic v is c e ra in w o m e n ; v ie w

p u d e n d a in te rn a th e n d iv id e s in to th e s u p e rfic ia l a nd d e e p te rm in a l

fro m th e le f t side . T h e p e lv ic v is c e ra are s u p p lie d b y th e v is c e ra l b ra n c h e s o f th e A . iliaca

b ra n c h e s to s u p p ly th e e x te rn a l g e n ita lia . T h e s u p e rfic ia l A . p e rin e a lis s u p p lie s th e p e rin e u m a nd p ro v id e s Rr. la b ia le s p o s te rio re s to

in te rn a . T h e p a r ie ta l b ra n c h e s fo r th e p e lv ic w a ll are id e n tic a l in m e n a nd w o m e n (-» Fig. 7 .1 1 1 ). V is c e ra l b ra n c h e s o f th e A . ilia ca in te r n a in w o m e n :

th e labia. T h e d e e p b ra n c h e s s u p p ly t o th e c a v e rn o u s b o d ie s o f th e C lito ris a n d v e s tib u le (A. b u lb i v e s tib u li, A . d o rs a lis c lito rid is , A . p ro

•

234

Plexus venosus vesicalis

A . u m b ilic a lis : g iv e s rise to th e A . v e s ic a lis s u p e rio r fo r th e u rin a ry b la d d e r a nd th e A . u te rin a b e fo re its o b lite ra te d p a rt (Lig. u m b ilic a le

•

m e d ia le ) c re a te s th e Plica u m b ilic a lis m e d ia lis. A . v e s ic a lis in fe rio r: to th e u rin a ry b la d d e r a n d V a g in a , m a y n o t be

•

p re s e n t a n d is th e n s u b s titu te d b y th e A . va g in a lis A . u te rin a : s u p p lie s th e U te ru s a nd h as b ra n c h e s to th e T u b a u te rin a ,

•

O v a riu m , a nd V agina A . va g in a lis : o c c a s io n a lly s u b s titu te s th e A . v e s ic a lis in fe rio r

• •

A . re c ta lis m e d ia : a b o v e th e p e lv ic flo o r to th e R e c tu m A . p u d e n d a in te rn a : p a s s e s th ro u g h th e F o ra m e n in fra p irifo rm e a nd

fu n d a c lito rid is ). T h e v e n o u s b lo o d d ra in s in to th e V . ilia c a in te r n a . Its tr ib u ta rie s fo rm c o m m u n ic a tin g v e n o u s p le x u s e s (P le x u s v e n o s i) a ro u n d th e p e lv ic v is ce ra. T h e s e h a v e to be re m o v e d d u rin g d is s e c tio n to d is p la y th e ar te rie s a n d n e rv e s o f th e p e lv is : P le x u s v e n o s u s re c ta lis : c o n n e c te d via th e V. re c ta lis s u p e rio r to th e p o rta l v e n o u s s y s te m a n d via th e Vv. re c ta le s m e d ia a n d in fe rio r

•

to th e d ra in a g e s y s te m o f th e V. cava in fe rio r (p o rto c a v a l a n a s to m o sis) P le x u s v e n o s u s v es ica lis: a t th e b a s e o f th e u rin a ry b la d d e r, a lso c o lle c ts th e v e n o u s b lo o d fr o m

th e C o rp o ra ca v e rn o s a c lito rid is

s u c c e s s iv e ly th e F o ra m e n is c h ia d ic u m m in u s to th e la te ra l w a ll o f th e Fossa isc h io a n a lis (C analis p u d e n d a lis , A L C O C K 's canal). H ere,

(V. d o rs a lis p ro fu n d a c lito rid is ) P le x u s v e n o s i u te rin u s a n d v ag in a lis : d ra in s th e b lo o d fr o m U te

th e A . re c ta lis in fe rio r b ra n c h e s o ff to th e in fe rio r anal canal. T h e A.

ru s a n d V a gina

dissection link

Efferent urinary system -► Genitalia -► Rectum and anal canal

Topography -> Sections

Lym ph vessels o f th e pelvis

Pars abdominalis aortae lym phoidei iliaci co m m unes Nodi lymphoidei preaortici aortici laterales et retroaortici Nodi lym phoidei lum bales Nodus lymphoideus precavalis

Nodi lym phoidei iliaci interni

Rectum

Nodus lymphoideus rectalis superior N odi lym phoidei iliaci externi

Lig. sacrospinale Nodi lymphoidei pararectales

Nodi lym phoidei iliaci externi M. levator ani Uterus Ureter

Fig. 7 .1 1 4

L y m p h n o d e s a n d ly m p h v es s e ls o f th e p e lv is (s h o w n

re c te d in to th e N o d i ly m p h o id e i in g u in a le s s u p e rfic ia le s . T h is e x p la in s

h e re in a w o m a n ) ; v ie w fr o m th e le f t side . T h e p e lv is c o n ta in s th e N o d i ly m p h o id e i ilia ci in te rn i a n d e x te rn i a lo n g

w h y ly m p h n o d e m e ta s ta s e s fr o m p ro x im a l re c ta l c a rc in o m a s are fo u n d in th e re tro p e rito n e a l s p a c e a nd in th e p e lv is , b u t th o s e fr o m d is

th e re s p e c tiv e b lo o d v e s s e ls a n d th e N o d i ly m p h o id e i s a cra le s a t th e v e n tra l s id e o f th e s a c ru m . D u e to th e ir c lo s e p ro x im ity a s tr ic t se p a ra

ta l re c ta l c a rc in o m a s are fo u n d in th e in g u in a l re g io n . T h e re g io n a l ly m p h n o d e s o f th e u rin a ry b la d d e r are p re d o m in a n tly

tio n b e tw e e n p a rie ta l ly m p h n o d e s a t th e p e lv ic w a ll a nd v is c e ra l ly m p h n o d e s a ro u n d th e p e lv ic v is c e ra is n o t p o s s ib le . T h u s, th e p e lv ic v is c e ra

th e N o d i ly m p h o id e i ilia ci in te rn i. T h e ly m p h a tic d ra in a g e p a th w a y s fo r th e fe m a le g e n ita lia (-» p. 213 )

(R e c tu m , u rin a ry b la d d e r, in te rn a l g e n ita lia ) d ra in in to all g ro u p s o f ly m p h n o d e s.

a n d th e m a le g e n ita lia (-* p .195) are d e s c rib e d in d e ta il w it h th e re s p e c tiv e o rg a n s .

T h e ly m p h fr o m th e u p p e r R e c tu m flo w s via th e N o d i ly m p h o id e i re c ta le s s u p e rio re s to th e N o d i ly m p h o id e i m e s e n te ric i in fe rio re s in th e

A t last, th e ly m p h p a s s e s th ro u g h th e N o d i ly m p h o id e i ilia ci c o m m u n e s a n d re a c h e s th e p a rie ta l ly m p h n o d e s o f th e re tro p e rito n e a l sp ace

re tro p e rito n e a l s p a ce a n d to th e N o d i ly m p h o id e i ilia ci in te rn i in th e p e lv is . H o w e v e r, th e ly m p h a tic d ra in a g e fro m th e lo w e r R e c tu m is d i

w h ic h are c o lle c tiv e ly re fe rre d to as N o d i ly m p h o id e i lu m b a le s on b o th s id e s o f th e A o rta a nd th e V. cava in fe rio r.

dissection link

235

Pelvis and Retroperitoneal Space

Kidney and adrenal gland

M ale pelvis, m edian section

Colon sigmoideum

Mesenterium Ostium urethrae internum Intestinum tenue Omentum majus

Ostium ureteris

Plexus venosus prostaticus Plica umbilicalis mediana (Lig. umbilicale medianum)

Plica transversa recti

Sp atium retro p u b icu m * Excavatio rectovesicalis

Linea alba

Symphysis pubica

Ampulla recti

Lig. fundiforme penis

Fascia re c to p ro s ta tic a ** Prostata

V. dorsalis profunda penis

Fascia pelvis visceralis V. dorsalis superficialis penis Lig. anococcygeum Urethra, Pars spongiosa

M. sphincter ani externus

Ductus deferens M. sphincter ani internus

Caput epididymidis Tunica albuginea corporum cavernosorum Corpus cavernosum penis

M. sphincter ani externus Corpus spongiosum penis

M. transversus perinei profundus Membrana perinei

Corona glandis

Urethra, Pars membranacea

Gians penis Fossa navicularis urethrae

Lig. pub oprostaticu m

Preputium penis Bulbus penis, Corpus spongiosum penis

Ostium urethrae externum M. cremaster; Fascia cremasterica

Fig. 7 .1 1 5

Scrotum, Tunica dartos

P e lv is , P e lv is , o f a m a n ; m e d ia n s e c tio n ; v ie w fro m th e

le ft side . T h e m o s t in fe rio r p o u c h o f th e m a le p e rito n e a l c a v ity is th e E x c a v a tio re c to v e s ic a lis . It is la te ra lly c o n fin e d b y th e P lica re c to v e s ic a lis c o n ta in in g th e P le x u s h y p o g a s tric u s in fe rio r. C audal to th is p o u c h , th e Fascia r e c to p ro s ta tic a (’ clin ic a l te rm : D E N O N V IL L IE R 's fa scia ) in th e s u b p e rito n e a l s p a c e s e p a ra te s th e R e c tu m fr o m th e p ro s ta te gla n d .

236

dissection link

T h e c o n n e c tiv e tis s u e s p a c e b e h in d th e p u b ic s y m p h y s is , th e S p a tiu m r e tr o p u b ic u m ( * * c lin ic a l te r m : R E T Z IU S ' sp a ce ), c o n ta in s th e Lig. p u b o p ro s ta tic u m w h ic h a tta c h e s th e p ro s ta te g la n d a n d u rin a ry b la d d e r to th e p e lv ic b o n e . In th e in fe rio r p a rt o f th e S p a tiu m re tro p u b ic u m , th e V. d o rs a lis p r o fu n d a p e n is d ra in s th e b lo o d fr o m th e C orp o ra ca v e rn o s a p e n is in to th e P le x u s v e n o s u s p ro s ta tic u s a nd fu r th e r in to th e V. iliaca in te rn a .

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

Female pelvis, median section

Infundibulum tubae uterinae

Uterus Cavitas uteri; Canalis cervicis uteri

Ureter Lig. suspensorium ovarii; A.; V. ovarica Colon sigmoideum

A.; V. iliaca externa Am pulla tubae uterinae Ovarium Isthmus tubae uterinae Fundus uteri

Plica rectouterina

Lig. teres uteri A.; V. epigastrica Plica umbilicalis medialis

Ampulla recti

Peritoneum parietale Plica umbilicalis mediana (Lig. umbilicale medianum)

Excavatio re c to u te rin a **

Fascia pelvis parietalis

Fornix vaginae, Pars posterior

Spatium retropubicum

Ostium uteri

Portio vaginalis cervicis

Excavatio vesicouterina Glomus coccygeum

Lig. pubovesicale

Fascia rectovaginalis

Ostium urethrae internum

Corpus clitoridis, Corpus cavernosum clitoridis Ostium ureteris

V. dorsalis profunda clitoridis

Plexus venosus vesicalis

Labium minus pudendi

Ostium urethrae externum

Labium majus pudendi

Fig. 7 .1 1 6

P e lv is , P e lv is , o f a w o m a n ; m e d ia n s e c tio n ; v ie w fro m

th e le ft side . B e c a u se th e U te ru s is p o s itio n e d b e tw e e n th e R e c tu m a n d th e u rin a ry b la d d e r th e fe m a le p e rito n e a l c a v ity h as t w o ca ud a l p o u c h e s . T h e m o s t c a ud a l p o u c h is th e E x c a v a tio re c to u te r in a ( * * c lin ica l te rm : p o u c h o f

th e s u b p e rito n e a l S e p tu m v e s ic o v a g in a le . T h e c o n n e c tiv e tis s u e sp ace b e h in d th e p u b ic s y m p h y s is , th e S p a tiu m r e tr o p u b ic u m , c o n ta in s th e th in Lig. p u b o v e s ic a le w h ic h a tta c h e s th e u rin a ry b la d d e r to th e p e lv ic b o n e . In th e in fe rio r p a rt o f th e S p a tiu m re tro p u b ic u m , th e V . d o rs a lis p ro fu n d a c lito rid is d ra in s th e b lo o d fro m th e C o rp o ra c a v e rn o s a c lito rid is in to th e P le x u s v e n o s u s v e s ic a lis a nd fu r th e r in to th e V. iliaca in

D O U G L A S ). T h is s p a ce is a d ja c e n t to th e p o s te rio r F o rn ix v a g in a e a nd is c o n fin e d la te ra lly b y th e Plica re c to u te r in a a nd th e a s s o c ia te d Ple

te rn a .

x u s h y p o g a s tric u s in fe rio r. C au d a lly, th e s u b p e rito n e a l Fascia r e c to v a g in a lis s e p a ra te s th e R e c tu m a n d th e V agina. T h e E x c a v a tio v e s ic o

c lin ic a l te r m : S e p tu m v e s ic o v a g in a le

u te rin a b e tw e e n u rin a ry b la d d e r a nd U te ru s is n o t a s d e e p a nd c o v e rs

r- Clinical R em arks----------------------------------------------------------------------------------------------------------W ith in fla m m a tio n s in th e lo w e r a b d o m e n , p u s a nd flu id s m a y a c c u m u la te in th e p o u c h o f D O U G L A S . T h e c lo s e v ic in ity to th e p o s -

te r io r fo r n ix o f th e V a gina e n a b le s th e s a m p lin g o f e x u d a te s th ro u g h th e V agina.

dissection link

237

Pelvis and Retroperitoneal Space

K id n e y a nd a d re n a l g la n d

Male pelvis, transverse sections

Symphysis pubica

Lig. pubicum superius M. rectus abdominis Vesica urinaria I Os pubis /

A. testicularis Ductus deferens N. genitofemoralis, R. genitalis

Funiculus spermaticus M. pectineus Nodus lymphoideus inguinalis superficialis

N. obturatorius Acetabulum, Limbus A. femoralis

Bursa subtendinea iliaca M. sartorius

N. femoralis

M. iliopsoas M. rectus femoris A.; V. obturatoria

A. profunda femoris

Lig. capitis femoris M. Femur, Caput femoris Zona orbicularis

Bursa subtendinea iliaca

M. tensor fasciae latae M . obturatoriu s internus

Femur, Trochanter major

Plexus venosus vesicalis

Bursa trochanterica musculi glutei medii

M. gluteus maximus A. glutea inferior

M. gluteus medius A. circumflexa femoris medialis

V. glutea inferior

M . levator a n i,' / M . pub orectalis d eferens

Ductus

Os ischii

Bursa subtendinea musculi obturatorii interni

Os coccygis

V. circumflexa femoris medialis

A.; V. pudenda interna

Rectum

Acetabulum, Limbus

N. ischiadicus

G landula vesiculosa

7 .1 1 7

M. rectus abdominis

Funiculus spermaticus M. iliopsoas

Symphysis pubica M. pectineus

M. sartorius M. rectus femoris

M . o b turatoriu s internus

M. tensor fasciae latae

Fossa acetabuli

Caput femoris

Vesica urinaria

Mm. glutei medius et minimus G landula vesiculosa Femur, Trochanter major M. obturatorius externus

M. gluteus maximus

N. ischiadicus

7 .1 1 8 Spina ischiadica M . levator ani Rectum

Fig. 7 .1 1 7 a n d Fig. 7 .1 1 8

P e lv is , P e lv is , o f a m a n ; tra n s v e rs e

Fossa ischioanalis M. ischiococcygeus

s e c tio n a t th e level o f th e le s s e r p e lvis (-» Fig. 7 .1 1 7 ) a nd c o rre s p o n d

p u b o re c ta lis o f th e M . le v a to r ani is s h o w n , w h ic h fo r m s a lo o p b e h in d th e R e c tu m a nd s u p p o rts th e p e rin e a l fle x u re . T h is m e c h a n is m c o n

ing c o m p u te d to m o g ra p h ic s e c tio n (CT; -» Fig. 7 .1 1 8 ); c a ud a l v ie w . A c c o rd in g to g e n e ra l c o n v e n tio n , CT im a g e s are a lw a y s v ie w e d fro m

tr ib u te s to th e c lo s u re o f th e R e c tu m a nd is im p o rta n t fo r fa e c a l c o n ti n e n c e . In a d d itio n , th e c o m p lic a te d c o u rs e o f th e M . o b tu ra to riu s in te r-

c a u d a l. T h e fo llo w in g p e lv ic v is c e ra are re c o g n iz a b le : u rin a ry b la d d e r (V esica urinaria), R e c tu m , a n d p a rts o f th e in te rn a l g e n ita lia (vas d e fe

n u s is v is ib le : th e m u s c le o rig in a te s a n te rio rly fr o m th e in n e r a s p e c t o f th e b o n y p e lv is a nd c o u rs e s d o rs a lly u n til it b e n d s a ro u n d th e is c h iu m

re n s [D u c tu s d e fe re n s ] a nd s e m in a l v e s ic le [G la n d u la v e s ic u lo s a ]). T h e tra n s v e rs e s e c tio n is b e s t s u ite d to tra c e d is tin c t m u s c le s . H ere , th e M .

w h ic h s e rv e s as h y p o m o c h lio n fo r th e m u s c le . F in a lly th e M . o b tu ra to riu s in te rn u s in s e rts a t th e in n e r a s p e c t o f th e T ro c h a n te r m a jo r.

Efferent urinary system -► Genitalia -► Rectum and anal canal

- *

Topography -► Sections

Female pelvis, transverse sections

Lig. pubicum superius

Symphysis pubica

M. iliacus

Vesica urinaria

Spatium retropubicum M. sartorius \

. Dectineus

M. rectus femoris

V. femoralis V.; A. obturatoria; N. obturatorius <A. femoralis ■A. profunda femoris N. femoralis

M. psoas major, Tendo

M. tensor fasciae latae

Femur, Collum femoris M . obturatoriu s externus

N. ischiadicus N. cutaneus femoris posterior

Bursa subtendinea musculi obturatorii interni; Tuber ischiadicum

A. glutea inferior N. gluteus inferior

M. gluteus maximus

V.; A. pudenda interna; N. pudendus

M . o b turatoriu s internus

7 .1 1 9

Excavatio rectouterin a

V. saphena magna

M. pectineus

A. femoralis A. profunda femoris

Os pubis Symphysis pubica

M. sartorius M. rectus femoris V. femoralis M. iliopsoas

Vesica urinaria

M. tensor fasciae latae Vagina M. vastus lateralis R ectu m , A m pu lla recti

Femur, Collum femoris

Fossa ischioanalis

M . obturatoriu s externus Ramus ossis ischii; Tuber ischiadicum N. ischiadicus Os coccygis

7 .1 2 0 M . o b turatoriu s internus

Fig. 7 .1 1 9 a n d Fig. 7 .1 2 0

P e lv is , P e lv is , o f a w o m a n ; tra n s v e rs e

s e c tio n a t th e le ve l o f th e le sse r p e lvis (-» Fig. 7.119) and c o rre sp o n d in g c o m p u te d to m o g ra p h ic s e c tio n (CT; -» Fig. 7 .1 2 0 ); caudal v ie w . T h e fo llo w in g p e lv ic v is c e ra are v is ib le : u rin a ry b la d d e r (V esica urinaria), R e c tu m , a n d th e V a gina in b e tw e e n th e R e c tu m a n d b la d d e r. T h e s e c

M. gluteus maximus

tio n a ls o s h o w s th e E x c a v a tio re c to u te rin a (p o u c h o f D O U G L A S ) as th e m o s t c a ud a l p a rt o f th e p e rito n e a l c a v ity . C o m p a re d to th e s e c tio n o f th e m a le p e lv is (-* Fig. 7 .1 1 7 ), th e tra n s v e rs e s e c tio n h e re is fu r th e r ca ud a l. T h e re fo re , in a d d itio n to th e M . o b tu ra to riu s in te rn u s , th e M . o b tu ra to riu s e x te rn u s a t th e o p p o s ite s id e o f th e p e lv ic b o n e is s h o w n .

Pelvis and Retroperitoneal Space

Kidney

Sections

Male pelvis, frontal section

Aa. sigmoideae Peritoneum parietale

V. iliaca interna

Os ilium

Appendices omentales [epiploicae]

Colon sigmoideum

Ureter

Ductus G landula vesiculosa

M . o b turatoriu s internus Ampulla M. levator ani

Fossa

V.; A. pudenda interna

Columnae anales

Tuber ischiadicum

M. biceps femoris; M. semitendinosus; M. semimembranosus

M . levator ani, M . pub orectalis M. sphincter ani internus

Fig. 7.121

P e lv is , P e lv is , o f a m a n ; o b liq u e fr o n ta l s e c tio n th ro u g h

th e le s s e r p e lvis.

M. sphincter ani externus

T h e A . a nd V. p u d e n d a in te rn a c o u rs e to g e th e r w ith th e N. p u d e n d u s w ith in a d u p lic a tu re o f th e M . o b tu ra to riu s in te rn u s fa s c ia (clin ical te rm : A L C O C K 's canal) t o th e Fossa is c h io a n a lis .

240

Appendix P icture C redits ..................................... 243 A b b re v ia tio n s , Term s, e tc .................. 245 Index ...................................................... 247

Picture Credits T h e e d ito rs s in c e re ly th a n k all c lin ica l c o lle a g u e s th a t m a de u ltra s o u n d , c o m p u te d to m o g ra p h ic a nd m a g n e tic re s o n a n c e im a g e s as w e ll as e n d o s c o p ic a nd in tra o p e ra tiv e p ic tu re s available: P rof. A lta ra s , C e n te r fo r R a d io lo g y, U n iv e rs ity o f G ie sse n (Figs. 2 .1 8 ; 2 .3 9 ; 2.40) P rof. B rü c k m a n n a nd Dr. Linn, N e u ro ra d io lo g y , In s titu te fo r D ia g n o s tic R a d io lo g y, U n iv e rs ity o f M u n ic h (Fig. 4 .1 4 8) P rof. D an ie l, D e p a rtm e n t o f C a rd io lo g y, U n iv e rs ity o f E rlan g e n (Fig. 10.39) P rof. G alanski a n d Dr. S ch a fe r, D e p a rtm e n t o f D ia g n o s tic R adiology, H a n n o v e r M e d ic a l S ch o o l (Figs. 2 .9 7 ; 5 .3 ; 5 .1 0 3 ; 6 .3 1 ; 6 .1 2 9) P rof. G e b e l, D e p a rtm e n t o f G a s tro e n te ro lo g y a nd H e p a to lo g y , H a n n o v e r M e d ic a l S ch o o l (Figs. 6 .7 3 ; 6 .7 5 ; 6 .7 6 ; 6 .9 4 ; 6 .9 5 ; 7.25) D r. G re e ve n , St. E lisa b e th H o sp ita l, N e u w ie d (Figs. 4 .9 6 ; 8.96) P rof. H o ffm a n n a nd Dr. B e kta s, C lin ic fo r A b d o m in a l a nd T ra n p la n ta tion S u rg e ry, H a n n o v e r M e d ic a l S ch o o l (Fig. 4.41) P rof. H o h lfe ld , C lin ic fo r P n e u m o lo g y , H a n n o v e r M e d ic a l S ch o o l (Fig. 5.71) P rof. Jo n a s, U ro lo g y , H a n n o v e r M e d ic a l S ch o o l (Fig. 7.33) P rof. K a m p ik a nd P ro f. M ü lle r, O p h th a lm o lo g y , U n iv e rs ity o f M u n ic h (Fig. 9.66) D r. K irc h h o ff a nd D r. W e id e m a n n , D e p a rtm e n t o f D ia g n o s tic R a d io lo g y, H a n n o v e r M e d ic a l S ch o o l (Figs. 6 .1 3 1 ; 6 .1 3 3 ; 7.26) P rof. K le in sa sse r, C lin ic a nd P o ly c lin ic o f O to -R h in o -L a ry n g o lo g y , P la stic a nd A e s th e tic S u rg e ry, U n iv e rs ity H o s p ita l W u e rz b u rg (Figs. 1 1 .4 1 ; 1 1.4 2; 11.43) PD Dr. K u tta , C lin ic a nd P o lyclin ic fo r O to -R h in o -L a ry n g o lo g y , U n iv e rs ity H o sp ita l H a m b u rg -E p p e n d o rf (Figs. 8 .1 0 1 ; 1 0.1 6; 11.16) D r. M e y e r, D e p a rtm e n t o f G a s tro e n te ro lo g y a nd H e p a to lo g y, H a n n o v e r M e d ic a l S ch o o l (Figs. 6 .2 2 ; 6 .3 2 ; 7 .1 0 4) P rof. P fe ife r, R a d io lo g y In n e n s ta d t, In s titu te fo r D ia g n o s tic R ad io lo g y, U n iv e rs ity o f M u n ic h (Figs. 2 .6 3 -2 .6 5 ; 2 .6 7 -2 .7 0 ; 3 .5 2 ; 3 .5 4 ; 3 .5 5 ; 4 .9 7 ; 4 .9 9 ; 4 .1 0 0 ; 4 .1 0 5 ; 4 .1 0 6) P rof. P o s s in g e r a nd P rof. B ick, M e d ic a l C lin ic a nd P o lyclin ic II, D ivision o f H e m a to lo g y a nd O n c o lo g y , C h a rité C a m p u s M itte , B e rlin (Fig. 2 .1 4 1) P rof. R avelli t , fo rm e rly In s titu te o f A n a to m y , U n iv e rs ity o f In n s b ru c k (Fig. 2.62) P rof. R eich, O ro fa cia l S u rg e ry, U n iv e rs ity o f B o n n (Figs. 8 .6 0 ; 8.61) P rof. R e is e r a nd Dr. W a g n e r, In s titu te fo r D ia g n o s tic R ad io lo g y, U n iv e rs ity o f M u n ic h (Figs. 2 .7 1 ; 1 2 .1 0 5 ; 1 2 .1 0 6 ; 1 2 .1 1 0 ; 1 2.1 11 ) D r. S ch e ib e , D e p a rtm e n t o f S u rg e ry, R osm a n H o sp ita l, B re isa ch (Fig. 4 .7 9 ) P rof. S c h e u m a n n , C lin ic fo r A b d o m in a l a nd T ra n p la n ta tio n S u rge ry, H a n n o v e r M e d ic a l S ch o o l (Fig. 11.58) P rof. S c h illin g e r, D e p a rtm e n t o f G yn a e co lo g y, U n iv e rs ity o f F re ibu rg (Fig. 1.49) P rof. S ch lie p h a ke , O ro fa c ia l S u rg e ry, U n iv e rs ity o f G o e ttin g e n (Figs. 8 .1 5 6 ; 8 .1 5 7) P rof. S c h lo e s s e r, C e n te r fo r G yn a e co lo g y, H a n n o v e r M e d ic a l S ch o ol (Fig. 7.79) ca nd . m e d . C a rste n S ch ro e d e r, K ro nsh a g en (Fig. 9.27) P rof. S c h u m a c h e r, N e u ro ra d io lo g y , D e p a rtm e n t o f R ad io lo g y, U n iv e rs ity o f F re ib u rg (Fig. 12.5)

A d d itio n a l illu s tra tio n s w e r e o b ta in e d fr o m t h e fo llo w in g te x tb o o k s : 1 B e n n in g h o ff-D re n c k h a h n : e d ito r), 17. A u fl., U rba n & 2 B e n n in g h o ff-D re n c k h a h n : e d ito r), 16. A u fl., U rba n &

A n a to m ie , B a n d 1 (D re n c k h a h n D., F is c h e r 2 0 0 8 A n a to m ie , B a n d 2 (D re n c k h a h n D., F is c h e r 2 0 0 4

3 B e n n in g h o ff-D re n c k h a h n : T a s c h e n b u c h A n a to m ie (D re n c k h a h n D., W a s c h k e , J., e d ito rs ), U rban & F is c h e r 2 0 0 7 4 B e rc h to ld , R., B ru c h , H.-P., T re n tz , O . (e d ito rs ): C h iru rg ie , 6. A u fl., U rban & F is c h e r 2 0 0 8 5 B ö c k e r, W ., D en k, H., H eitz, P. U., M o c h , H. (e d ito rs ): P a th o lo g ie , 4. A u fl., U rban & F is c h e r 2 0 0 8 6 C la sse n , M ., D ie h l, V., K o ch sie k, K., B e rde l, W . E., B ö h m , M ., S c h m ie g e l, W . (e d ito rs ): In n e re M e d iz in , 5. A u fl., U rba n & F is c h e r 2003 7 C la sse n , M ., D ie h l, V., K o ch sie k, K., H allek, M ., B ö h m , M . (e d ito rs ): In n e re M e d iz in , 6. A u fl., U rban & F is c h e r 2 0 0 9 8 D rake, R. L., V o g l, A . W ., M itc h e ll, A ., P aulsen, F. (e d ito rs ): G ra y's A n a to m ie fü r S tu d e n te n , 1. A u fl., U rba n & F is c h e r 2 0 0 7 9 D rake, R. L., V o g l, A . W ., M itc h e ll, A .: G ra y 's A n a to m y fo r S tu d e n ts , 2 nd ed., C h u rc h ill L iv in g s to n e 2 0 1 0 10 D rake , R. L., V o g l, A . W ., M itc h e ll, A .: G ra y 's A tla s d e r A n a to m ie , U rba n & F is c h e r 2 0 0 9 11 F le c k e n s te in , P., T ra n u m -J e n s e n , J .: R ö n tg e n a n a to m ie , U rba n & F is c h e r 2 0 0 4 12 F o rb es, A ., M is ie w ic z , J ., C o m p to n , C., Q u ra is h y , M ., R u b e s in , S., T h u lu v a th , P.: A tla s o f C linical G a s tro e n te ro lo g y , 3 rd ed., M o s b y 2004 13 Franzen, A .: K u rz le h rb u c h H a ls -N a s e n -O h re n -H e ilk u n d e , 3. A u fl., U rba n & F is c h e r 2 0 0 7 14 G arzorz, N.: B A S IC S N e u ro a n a to m ie , U rban & F is c h e r 2 0 0 8 15 K anski, J. J .: K lin is c h e O p h th a lm o lo g ie , 5. A u fl., U rba n & F isch e r 2003 16 K anski, J. J .: K lin is c h e O p h th a lm o lo g ie , 6. A u fl., U rba n & F isch e r 2008 17 K a u ffm a n n , G. W ., M o s e r, E., S a u er, R. (e d ito rs ): R ad io lo g ie , 3. A u fl., U rba n & F is c h e r 2 0 0 6 18 L ip p e rt, H.: L e h rb u c h A n a to m ie , 7. A u fl., U rba n & F is c h e r 2 0 0 6 19 M e ttle r , F. A . (e d ito r): K lin is c h e R ad io lo g ie , U rba n & F is c h e r 2 0 0 5 20 M o o re , K., P ersau d , T. V. N., V ie b a h n , C. (e d ito rs ): E m b ry o lo g ie , 5. A u fl., U rba n & F is c h e r 2 0 0 7 21 S ch u lze , S.: K u rz le h rb u c h E m b ry o lo g ie , U rban & F is c h e r 2 0 0 6 22 S p e c k m a n n , E .-J., H e s c h e le r, J ., K ö h lin g , R. (e d ito rs ): P h y s io lo g ie , 5. A u fl., U rba n & F is c h e r 2 0 0 8 23 T re p e l, M .: N e u ro a n a to m ie , 4 . A u fl., U rba n & F is c h e r 2 0 0 8 2 4 W e ls c h , U.: S o b o tta L e h rb u c h H is to lo g ie , 2. A u fl., U rban & F isch e r 2005 25 W e ls c h , U., D e lle r, T.: S o b o tta L e h rb u c h H is to lo g ie , 3. A u fl., U rban & F is c h e r 2 0 1 0 26 W e ls c h , U.: A tla s H is to lo g ie , 7. A u fl., U rba n & F isch e r 2 0 0 5 27 W ic k e , L.: A tla s d e r R ö n tg e n a n a to m ie , 7. A u fl., U rba n & F is c h e r 2005 2 8 R en g ier, F.: B A S IC S L e itu n g s b a h n e n , U rba n & F is c h e r 2 0 0 9 T h e f o llo w in g illu s tra to rs h a v e d e v e lo p e d th e n e w illu s tra tio n s :

D r. Sel, U n iv e rs ity H o s p ita l a nd P o ly c lin ic fo r O p h th a lm o lo g y , U n iv e rs ity H o s p ita l H alle (Saale) (Fig. 9.64) D r. S o m m e r a nd PD Dr. B a u er, R a d io lo g ists, M u n ic h (Figs. 4 .1 0 1 ; 4 .1 0 2 )

Dr. Katja D a lk o w s k i: Figs. 5.2, 5.5, 5.6, 5.7, 5 .1 0 , 5 .2 0 , 5.26, 5.28, 5 .4 0 , 5.41, 6 .1 , 6 .2 , 6.6, 6 .6 4 , 6 .6 5 , 6 .6 6 , 6 .6 7 , 6 .9 2 , 6 .1 1 4, 7.6, 7.7, 7.8, 7 .1 8 , 7 .1 9 , 7 .4 2 , 7 .4 3 , 7 .5 3 , 7 .7 2 , 7 .7 3

PD Dr. V o g l, R a d io lo g y, U n iv e rs ity o f M u n ic h (Figs. 9 .6 9 ; 9.70) P rof. W itt, D e p a rtm e n t o f N e u ro s u rg e ry , U n iv e rs ity o f M u n ic h (Fig. 3 .1 1 6 ) P rof. Z ie rz a nd Dr. J o rd a n , U n iv e rs ity H o sp ita l a n d P o ly c lin ic fo r N e u ro lo g y , U n iv e rs ity H o s p ita l H alle (Saale) (Figs. 8 .8 2 , 12.151)

S onja K lebe: Figs. 5 .6 2 , 5 .6 4 , 5 .7 9 , 5 .9 5 , 5 .9 6 , 5 .9 7 , 6 .1 2 , 6 .1 3 , 6.18, 6 .1 9 , 6 .2 0 , 6 .2 8 , 6 .4 6 , 6 .4 7 , 6 .4 8 , 6 .5 0 , 6 .5 1 , 6 .7 1 , 6 .7 9 , 6 .8 0 , 6 .9 3 , 6 .1 1 5 , 6 .1 1 8 , 7 .6 1 , 7 .6 2 , 7 .8 5 , 7 .8 6 , 7 .9 0 , 7 .9 9

1. List of abbreviations S ingular: = A. = Lig. = M. N. P roc. R. V. Var.

= = = = =

Plural: A rte ria L ig a m e n tu m M u s c u lu s N e rvu s P ro ce ssu s R am us V ena V a ria tio n

Aa.

= = Ligg. Mm. = = Nn. Procc. = = Rr. = Vv.

A rte ria e L ig a m e n ta M u s c u li N ervi P ro ce ssu s Ram i

Â§

fe m a le

m a le

P e rc e n ta g e s : In th e lig h t o f th e large va ria tio n in in d iv id u a l b o d y m e a s u re m e n ts , th e p e rc e n ta g e s in d ic a tin g size s h o u ld o n ly be ta k e n as a p p ro x im a te v a lu e s.

V e n ae

2. General term s of direction and position T h e fo llo w in g te rm s in d ic a te th e p o s itio n o f o rg a n s a nd p a rts o f th e

longitudinalis = para lle l to th e lo n g itu d in a l a x is (e .g . M u s c u lu s

b o d y in re la tio n to each o th e r, irre s p e c tiv e o f th e p o s itio n o f th e b o d y (e.g. su p in e o r u p rig h t) o r d ire c tio n a nd p o s itio n o f th e lim b s . T h e s e te rm s are re le v a n t n o t o n ly fo r h u m a n a n a to m y b u t a lso fo r clin ical m e d ic in e a nd c o m p a ra tiv e a n a to m y.

sagittalis = lo c a te d in a s a g itta l plane transversalis = lo c a te d in a tra n s v e rs e plane transversus = tra n s v e rs e d ire c tio n (e .g . P ro c e s s u s tra n s v e rs u s o f a

lo n g itu d in a lis s u p e rio r o f th e to n g u e )

th o ra c ic v e rte b ra ) G e n e ra l te rm s

an terior - p o s te rio r = in fr o n t - b e h in d (e.g. A rte ria e tib ia le s a n te rio r e t

T e rm s o f d ire c tio n a n d p o s itio n fo r th e lim b s

p o s te rio r) ventralis - dorsalis = to w a rd s th e b e lly - to w a rd s th e b ack sup erior - infe rior = abo ve - b e lo w (e.g. C o n ch a e n asa le s s u p e rio r e t inferio r)

proxim alis - distalis = lo c a te d to w a rd s o r a w a y fro m th e a tta c h e d e n d

cranialis - caudalis = to w a rd s th e h ead - to w a rd s th e tail d e xte r - s in is te r = rig h t - le ft (e .g . A rte ria e iliacae c o m m u n e s d e x tra e t

fo r th e u p p e r lim b :

s in istra )

internus - externus = in te rn a l - e x te rn a l superficialis - profun dus = s u p e rfic ia l - d e e p (e.g. M u s c u li fle x o re s d ig ito ru m s u p e rfic ia lis e t p ro fu n d u s ) medius, interm edius = lo c a te d b e tw e e n tw o o th e r s tru c tu re s (e.g. th e C oncha n asalis m e d ia is lo c a te d b e tw e e n th e C on ch a e n asa le s s u p e rio r a nd in fe rio r)

o f a lim b o r th e o rig in o f a s tru c tu re (e.g. A rtic u la tio n e s ra d io u ln a re s p ro x im a lis e t d is ta lis )

radialis - ulnaris = on th e radial s id e - on th e u ln a r s id e (e.g. A rte ria e radialis e t ulnaris) fo r th e hand: palm aris - dorsalis = to w a rd s th e p a lm o f th e h and - to w a rd s th e back o f th e h and (e .g . A p o n e u ro s is p a lm a ris , M u s c u lu s in te ro s s e u s dorsa lis)

m edianus = lo c a te d in th e m id lin e (Fissura m e d ia n a a n te rio r o f th e

fo r th e lo w e r lim b :

sp in a l c o rd ).T h e m e d ia n p la n e is a s a g itta l p la n e w h ic h d iv id e s th e b o d y in to rig h t a nd le ft halves. m edialis - lateralis = lo c a te d n e a r to th e m id lin e - lo c a te d a w a y fro m

tibialis - fibularis = on th e tib ia l s id e - on th e fib u la r s id e (e.g. A rte ria

th e m id lin e o f th e b o d y (e.g. Fossae in g u in a le s m e d ia lis e t lateralis)

frontalis = lo c a te d in a fr o n ta l pla n e , b u t a lso to w a rd s th e fr o n t (e.g. P ro c e s s u s fro n ta lis o f th e m axilla)

tib ia lis a n te rio r) fo r th e fo o t: plantaris - dorsalis = to w a rd s th e s o le o f th e fo o t - to w a rd s th e back o f th e fo o t (e.g. A rte ria e p la n ta re s la te ra lis e t m e d ia lis , A rte ria d o rs a Â lis ped is)

3. Use of brackets [ ]: Latin te r m s in sq u a re b ra c k e ts re fe r to a lte rn a tiv e te r m s as g iv e n in th e T e rm in o lo g ia A n a to m ic a (1998), e .g . R en [N e p h ro s ], To k e e p th e le g e n d s s h o rt, o n ly th o s e a lte rn a tiv e te r m s have b e e n a d d e d th a t d iffe r in th e ro o t o f th e w o rd a nd are n e c e s s a ry to u n d e rs ta n d clin ical

( ) : R o u n d b ra c k e ts are u s e d in d iffe r e n t w a y s : - fo r te r m s a lso lis te d in ro u n d b ra c k e ts in th e T e rm in o lo g ia A n a to m iÂ ca, e .g . (M . p soa s m in o r) - fo r te r m s n o t in c lu d e d in th e o ffic ia l n o m e n c la tu re b u t w h ic h th e

te rm s , e .g . n e p h ro lo g y. T h e y are p rim a rily u se d in fig u re s in w h ic h th e p a rtic u la r o rg a n o r s tru c tu re p la ys a c e n tra l role.

e d ito rs c o n s id e r im p o rta n t a n d c lin ic a lly re le v a n t, e.g. (C rista z y g o m a tic o a lv e o la ris ) - to in d ic a te th e o rig in o f a g iv e n s tru c tu re , e .g . R. s p in a lis (A. v e rte b ra lis ).

Index

A A b d o m e n 1 4 8 -1 5 3 A b d o m in a l ca v ity 70, 151 - tra n sve rse s e c tio n 1 5 4 -1 5 6 - - c o m p u te d to m o g ra p h y 1 5 4 -1 5 6 A b d o m in a l viscera 6 9 -1 5 6 - a na sto m o se s o f a rte rie s 140 - a rte rie s 140 - d e v e lo p m e n t 70 - p ro je ctio n o n to th e b o d y su rfa ce 86 - to p o g ra p h y 70 A b s c e ss, Fossa ischioanalis 2 00 A b s o lu te cardiac d u lln e ss 4 A c c e s s o ry sex g lands 1 8 3 ,1 9 0 A c e ta b u lu m 2 38 Acinus(-i) - pan cre a tici 123 - p u lm o n a lis 38 - p u lm o n is 32 A c ro m io n 68 A D D IS O N 's disease 170 A drenal gland 122, 166, 170 - in th e re tro p e rito n e a l space 164 A d re n o co rtica l in s u ffic ie n c y 170 - h y p o g lyca e m ic sh ock 170 A ir c o n d u ctin g part, lo w e r re sp ira to ry tra c t 32 A LC O C K 's canal (Canalis p u d e n d a lisj 1 9 9 -2 0 0 , 2 1 7 -2 1 8 , 2 34 , 240 A m p ulla - d u c tu s d e fe re n tis 178, 186, 190, 201 - d uo d e ni 77, 8 8 - 9 0 - hepato p a ncre a tica 127 - re cti 148, 180, 222, 225, 2 3 6 -2 3 7 , 2 3 9 -2 4 0 - tu b a e ute rin a e 93, 2 0 6 -2 0 8 , 237 Anal canal 92, 2 2 2 -2 2 3 - in n e rva tio n 2 26 - p ro je ctio n o n to th e b o d y su rfa ce 220 - re c to sco p y 227 - s p h in c te r m u scle s 2 23 - ve in s 2 25 Anal c a nce r 223 Anal fis tu la 223 Anal p rolapse 2 23 A n a s to m o se s, a rte rie s o f th e a bd o m ina l v is cera 47, 81, 106, 112, 140, 2 25 A n a to m ica l dead-space, re su scita tio n 32 A n d ro g e n s, adrenal g lands 170 A n gina p e cto ris 27 - co ro n a ry a rte ry s te n o sis 23 A n g le o f HIS 75 A n g u stia (O esophagus) 45 - a ortica 45 - cricoid ea 45 - diap h rag m a tica 45 A n n ula r pancreas 121 A nsa subclavia 5 8 , 61 A n te fle xio n , u te ru s 2 08 A n te v e rsio n , u te ru s 2 08 A n ti-M Ü L L E R IA N h o rm o n e 1 6 3 ,2 0 5 - d iffe re n tia tio n o f th e M Ü L L E R IA N d u c ts 185 A n tru m p ylo ricu m 42, 75, 77, 85, 89, 153 A n u lu s - fib ro su s ------d e x te r 16 ------s in is te r 16, 18 - inguinalis - - p ro fu n d u s 232 ------s u p e rficia lis 187, 1 91-192 - u m bilica lis 93, 148 A n u s 163, 199, 202, 217, 222, 2 2 4 -2 2 6 - p ro je ctio n o n to th e b o d y su rfa ce 86 A o rta 4, 15, 20, 24, 6 6 , 6 8 , 72, 103, 148, 155, 162 - a b d o m in a lis/th o ra cica See Pars a b d o m in a lis/ th oracica aortae - a sce n d e n s/d e sce n d e n s See Pars ascend e n s/d e sce n d e n s aortae - branches 56 - o v errid in g aorta 7 A o rtic arch 6, 55 - bran ch ing va ria tio n s o f th e g re a t ve ssels 55 A o rtic co a rcta tio n 7, 9

A o rtic ring 16 A o rtic valve 16, 19 - in s u ffic ie n c y 5 - p ro je ctio n o n to th e ve ntra l th o ra cic w all 4 A o rtic valve s te n o s is 5, 7, 9 - h y p e rtro p h y o f th e cardiac m u s c le 15 Apex - co rdis 4 - 5 , 10, 12-13, 15, 17-18 - p u lm o n is 3 4 - 3 5 , 4 0 , 63 - vesicae 1 77-178 A p p e n d ic itis 73, 9 3 , 95 - p e rfo ra tio n , p e rito n itis 95 - pouch o f D O U G L A S 2 37 A p p en d ix(-ce s) - e p id id y m id is 188, 191 - e pip loica e [o m e n ta le s] 9 4 , 134, 240 - fib rosa h e p a tis 1 0 4 -1 0 5 - proje ctio n ------o n to th e b o d y su rfa c e 86 ------o n to th e ve ntra l th o ra c ic w all 93 - te s tis 183, 188, 191 - v e rm ifo rm is 74, 86, 9 2 - 9 3 , 9 5 -9 7 , 101-102, 120, 128, 1 3 5 -1 3 8 , 143, 1 4 5 -1 4 6 , 161, 187, 2 08 , 220 - vesicu lo sa 203 A rcu s - a orta e 5 - 6 , 8 - 9 , 11-13, 2 4 -2 5 , 3 8 , 41, 4 3 4 4 , 4 8 , 5 4 - 5 6 , 62, 6 4 , 68 - c o sta lis 210 - te n d in e u s m u s c u li leva to ris ani 1 9 6 ,2 1 4 215 Area(-ae) - cribrosa 167 - g astrica e 7 7 -7 8 - nuda 1 0 4 -1 0 6 , 148 A rrh y th m ia , ECG 22 A rteria(-ae) - app e n dicu la ris 9 6 - 9 8 , 140, 143, 146 - arcuata (Ren) 167, 169 - axillaris 6 0 - 6 1 , 6 4 , 6 8 - bulbi ------p enis 197, 2 0 0 ------ve s tib u li 216 - caecalis a n te rio r 9 6 -9 7 , 146 - ca rotis ------co m m u n is 6, 12-13, 3 8 , 4 3 - 4 4 , 4 6 , 48, 51, 5 3 - 5 5 , 58, 6 0 - 6 1 , 6 3 - 6 4 , 68 - - e xte rn a 55 - - intern a 55 - caudae p an cre a tis 140 - ce rvica lis - - a sce n d e n s 6 0 -6 1 - - profu nd a 56 - circum fle xa - - fe m o ris m e dia lis 2 38 h u m e ri p o s te rio r 68 - - scapulae 68 - colica - - dextra 9 6 - 9 7 , 140, 143, 1 4 5 -1 4 6 - - m e dia 9 6 -9 7 , 140, 143, 1 4 5 -1 4 7 - - sinistra 97, 140, 1 4 5 -1 4 7 - coronaria(-ae), 24 - - balanced o r c o d o m in a n t p e rfu sio n ty p e 2 6 - 2 7 - - dextra 12-13, 17, 19, 2 4 -2 7 , 62, 67 - - - branches 24 ------in fa rctio n p a tte rn in th e case o f o c c lu s i on 27 - - le ft-d o m in a n t p e rfu s io n ty p e 2 6 - 2 7 p e rfu sio n areas 27 - - rig h t-d o m in a n t p e rfu sio n ty p e 2 6 -2 7 sinistra 13, 19, 2 4 -2 7 , 62, 67 - — branches 24 - co rtica lis radiata 169 - cre m asterica 1 9 1 -1 9 3 , 232 - cystica 8 0 , 104, 110, 116, 118, 140, 142 - dorsalis ------c lito rid is 216, 218 - - p enis 192, 197, 2 00 , 2 33 - d u ctu s d e fe re n tis 1 9 1 ,1 9 3 ,2 3 3 - epig a strica in fe rio r 2 3 2 -2 3 3 , 237 - fe m o ra lis 2 3 8 -2 3 9

Arteria (-ae) - gastrica(-ae) -

- breves 80, 140, 142, 144 - d e xtra 80, 8 3 , 110, 140, 142 p o s te rio r 80, 142 - - s inistra 4 6 , 80, 8 3 , 9 6 , 110, 125, 140, 142, 144, 150, 155 - — branches 142 - g astro du o de n a lis 80, 83, 96, 110, 118, 122, 125, 140, 142, 144, 150 - g a s tro o m e n ta lis - - d e xtra 8 0 , 8 3 , 110, 125, 140, 142, 144 - - s inistra 8 0 , 8 3 , 110, 140, 142, 144 - glutea - - in fe rio r 224, 2 32 , 2 3 8 - 2 3 9 s u p e rio r 2 24 , 2 32 - helicinae 186 - hepatica - - c o m m u n is 80, 9 6 , 110, 118, 122, 125, 140, 142, 144, 155 - — branches 142 - - propria 80, 83, 9 6 , 104, 108, 110, 118, 122, 125, 140, 142, 1 4 9 -1 5 0 , 155 - ileales 96, 140, 143, 145 - ile o co lica 9 6 -9 7 , 140, 143, 1 4 5 -1 4 6 - iliaca - - co m m u n is 8, 1 4 8 -1 4 9 , 175, 215, 226, 228, 232 - - externa 8, 2 24 , 2 3 2 -2 3 4 , 237 - - interna 8, 224, 2 3 2 -2 3 4 - — parietal branches 232 - - - viscera l branches 232 -------------------- in m an 2 3 3 in w o m a n 2 3 4 - ilio lu m b a lis 232 - in te rc o s ta lis 3 8 , 67 - - p o s te rio r 5 2 -5 3 , 5 6 - 5 7 - - suprem a 56, 6 0 -6 1 - in terlo b aris (Ren) 1 6 7 -1 6 9 - inte rlo b u la ris 106 - jeju n ale s 96, 140, 143, 145, 147, 150 - lig a m e n ti te re tis u te ri 2 3 4 - lob a ris s u p e rio r 65 - lobi caudati 104 - lum b a le s 2 28 - m e sen terica - - in fe rio r 97, 140, 1 46 -1 4 7, 156, 162, 224, 2 26 , 228, 232 - - - branches 146 - - - c o urse 147 - - s u p e rio r 8 0 , 9 6 -9 7 , 110, 1 22 -1 2 3, 125, 127, 140, 1 4 2 -1 5 0 , 156, 165, 2 28 - — branches 9 8 , 143 c o urse 145 ----------o rig in 144 - o btu ra to ria 1 9 6 , 2 1 5 ,2 2 4 , 2 3 2 - 2 3 3 ,2 3 8 239 - ovarica 1 7 5 ,2 0 6 - 2 0 8 ,2 1 1 -2 1 2 ,2 2 8 ,2 3 4 , 2 37 - pancreatica - - dorsa lis 125, 140 in fe rio r 125 - - m agna 140 - pan cre a ticod u o de n a lis - - in fe rio r 9 6 , 125, 140, 1 4 3 -1 4 4 , 147 s u p e rio r 125 - - - a n te rio r 9 6 , 125, 144 p o s te rio r 96, 125, 140 - perica rd ia co ph re n ica 11, 5 2 - 5 4 - perinealis 197, 2 00 , 218 - phrenica in fe rio r 171-172, 2 28 - profunda c e rv ic is 6 0 -6 1 - - fe m o ris 2 3 8 -2 3 9 - - p e n is 186, 192, 198, 2 33 - pudenda - - e xte rn a profu nd a 192 - - interna 1 9 7 ,2 0 0 - 2 0 1 ,2 1 8 -2 1 9 ,2 2 4 - 2 2 5 , 2 3 2 -2 3 4 , 2 3 8 -2 4 0 - p ulm onalis(-es) 8 - 9 , 3 8 , 52 - - d e xtra 1 0 -1 3 , 15, 25, 35, 4 4 , 62, 65 - - s inistra 6, 1 0 -1 3 , 25, 35, 4 4 , 53

Index

Arteria(-ae)

Basis rectalis - p ro sta ta e 190 - in fe rio r 140, 2 00 , 218, 224, 2 3 3 -2 3 4 - p u lm o n is 3 4 - 3 5 - m e dia 1 9 3 ,2 2 4 ,2 3 2 - 2 3 4 B A U H IN 's valve (Valva ileocaecalis) 86, 95 - su p e rio r 97, 140, 1 46 -1 4 7, 2 2 4 -2 2 5 , 2 3 4 B enign p ro s ta tic h yp e rtro p h y (BPH) 159, 190 renalis 1 4 8 -1 4 9 , 156, 162, 1 6 4 -1 6 7 , 1 7 1 - d ig ita l re cta l exam in a tion (DRE) 221 172, 175, 193, 2 28 B ifu rcatio - - a ccessoria 164, 171 - a orta e 147 c o u rse 171 - tracheae 3 2 - 3 3 , 41, 4 3 - 4 4 , 62 - - polaris - tru n c i p u lm o n a lis 11 in fe rio r 172 Bile c o n c re m e n t, p a n c re a titis 124 - — su p e rio r 172 Bile d u c ts sinistra 165 - ERCP 127 - sacralis - e xtra h e p a tic d u c ts 117 - - lateralis 2 32 ra dio g rap h y 119 ------m ediana 2 28 , 2 3 2 -2 3 4 - in tra h e p a tic d u c ts , ra dio g rap h y 119 - sig m o id e a e 97, 140, 1 46 -1 4 7, 224, 2 40 - lym ph v e ssels and ly m p h nod e s 113 - sp lenica [lienalis] 8 0 , 8 3 , 9 6 , 110, 122, 125, - m a lig na n t tu m o rs 119 127, 129, 140, 142, 144, 1 50 -1 5 1, 1 5 4 -1 5 5- va ria tio n s 118 - - branches 142 B iopsies, C T -co ntrolled p u n c tu re s 65 - subclavia 6, 1 2-1 3 , 3 8 , 4 3 - 4 4 , 4 6 , 4 8 , 51, B orders o f th e rig h t and le ft lungs 5 4 - 5 6 , 58, 6 0 -6 1 , 6 3 - 6 4 - m ida xilla ry line 29 - s u b co sta lis 57 - m idcla vicu la r line 29 - subsca p u la ris 64 - p aravertebral line 29 - su p ra d u od e n alis 140 - p ro je ctio n - suprarenalis(-es) 172 ------o n to th e a n te rio r th o ra c ic w a ll 29 - - in fe rio r 164, 166, 171-172, 228 o n to th e back 29 - - m edia 166, 171-172, 2 28 ------o n to th e p o s te rio r th o ra c ic w all 29 su pe rio res 166, 172 sca pu la r line 29 - su prascapularis 6 0 -6 1 - ste rn a l line 29 - te sticu la ris 171, 187, 189, 1 9 1 -1 9 4 , 2 28 , 2 38 BPH (benign p ro s ta tic h ype rtro p h y), d ig ita l co urse 193 rectal exam in a tion (DRE) 221 Bradycardia, ECG 22 - th o ra cica interna 52, 54, 56, 6 0 -6 1 , 6 4 , 66 Bronchial buds 31 - th o ra co d o rsa lis 64 - th yro id e a B ronchial ca rcin o m a 41 - - ima 55 B ronchial tru n k 31 ------in fe rio r 4 6 , 6 0 -6 1 B ro nch io li 32 - re spira to rii 38 - tra n sve rsa ce rv ic is 6 0 -6 1 - u m bilicalis(-es) 8, 210, 2 3 2 -2 3 4 - te rm in a le s 32, 38 - ureth ra lis 192 B ro n c h o p u lm o n a ry s e g m e n ts 3 6 - 3 7 - uterina 211, 2 32 , 2 3 4 B ro n c h o s c o p y 37 - vaginalis 211, 2 34 B ronchus(-i) 3 2 - 3 3 , 41 - b ro n c h o s c o p y 37 - ve rte b ra lis 4 6 , 55, 6 0 -6 1 - vesicalis - lingularis - - in fe rio r 193, 2 3 2 -2 3 4 - - in fe rio r 32, 37 su p e rio r 32, 37 - - su p e rio r 2 3 2 -2 3 3 A rticu la tio (-n e s) - lobaris - a crom io cla vicu la ris 68 ------in fe rio r 66 - coxae 2 3 9 ---------d e x te r 28, 3 2 - 3 3 , 35 - h u m e ri 68 ----------s in is te r 28, 3 2 - 3 3 - sacroco ccyg e a 198 - - m e d iu s 28, 3 2 - 3 3 , 35, 66 A sce n d in g co lo n 101 su pe rio r A S C H O FF-T A W A R A n ode (AV node, N odus ----------d e x te r 28, 3 2 - 3 3 , 35, 4 3 , 65 a triove n tricu la ris) 2 0 -2 1 ----------s in is te r 28, 3 2 - 3 3 , 37 A sp ira tio n 28 - principalis - fo re ig n b o d ie s 28 - - d e x te r 28, 3 2 - 3 3 , 35, 3 8 , 41, 4 3 - 4 5 , 52, A s th m a b ronchiale, le ft ve n tricu la r h y p e rtro 56, 58, 65 phy 15 - - s in is te r 28, 3 2 - 3 3 , 35, 3 8 , 41, 4 3 - 4 4 , 53, A trio v e n tric u la r b un d le (Fasciculus a trio v e n tri 56, 58, 65 cularis, b un d le o f HIS) 16, 2 0 -2 1 , 24 - se g m e n ta lis A trio v e n tric u la r va lve s 16 ------a n te rio r 32, 37, 68 - s te n o sis 16 ------a picalis 32 A triu m co rdis 6 ------a p ic o p o s te rio r 32, 37 - d e x tru m 4 -1 0 , 1 2-1 3 , 15, 17, 21, 2 4 -2 5 , 41, ------basalis 55, 62, 67, 1 4 9 -1 5 0 ----------a n te rio r 32, 37 - sin is tru m 6 - 9 , 13, 15, 18, 2 4 -2 5 , 55, 62, ---------lateralis 32, 37, 67 6 6 -6 7 ----------m e dia lis 32 A uricula ----------p o s te rio r 32, 37 - d e xtra 12, 17, 19 - - lateralis 32 - sinistra 5, 1 2-1 3 , 15, 18, 2 4 -2 5 , 41, 55, 66 - - m e dia lis 32 A u scu lta tio n , cardiac so u n d s 4 p o s te rio r 32 AV n ode (N od u s a trio ve n tricu la ris, n ode o f TA- - s u p e rio r 32 W A R A ) 2 0 -2 1 B R U N N E R 's g lands (Gil. duodenales) 89 Bulbus A xilla 68 A x illa ry fossa 68 - a orta e 19 A zyg o s syste m , v e in s 57 - p enis 186, 201, 2 36 - v e s tib u li 2 0 2 ,2 1 8 -2 1 9 , 2 34 B undle o f HIS (a trio ve n tricu la r bundle, Fascicu lus a triove n tricu la ris) 16, 2 0 -2 1 , 24 B Bursa - o m e n ta lis 72, 1 3 2 -1 3 3 , 139, 148, 1 5 3 -1 5 5 B A R TH O LIN 'S g lands (Gil. v e stib u lä re s m a jo - - d e v e lo p m e n t 72 res) 202, 2 04 , 217, 219 -

Bursa - s u bte nd ine a iliaca 2 38 - - m u s c u li o b tu ra to rii intern i 2 3 8 -2 3 9 - tro c h a n te ric a m u s c u li g lu te i m e d ii 2 38

c C aecum 9 2 - 9 3 , 9 5 -9 7 , 101, 130, 1 3 4 -1 3 8 , 143, 1 4 5 -1 4 6 , 2 08 - p ro je c tio n o nto th e ve ntra l a bdom inal w a ll 86 C alices renales 169 - m a jo re s 167, 174, 176 - m in o re s 156, 1 6 7 -1 6 8 , 174, 176 C A LO T's tria n g le (Trigonum c h o le c y s to h e p a ticum ) 118 Canalis - analis 92, 2 20 , 2 2 2 -2 2 3 , 2 2 5 -2 2 7 - - p ro je c tio n o n to th e b o d y su rfa ce 86 - a trio v e n tric u la ris 6 - c e rv ic is u te ri 207, 2 37 - inguinalis 187 - o b tu ra to riu s 196, 214, 2 2 4 -2 2 5 - pud e n da lis (A LC O C K 's canal) 1 9 9 -2 0 0 , 2 1 7 -2 1 8 , 2 3 4 , 2 40 - p ylo ric u s 75, 77, 89, 124 Capsula - adiposa (Ren) 151, 155, 164, 166, 171, 173 - fib ro s a (Ren) 164, 1 6 6 -1 6 8 C aput 187 - e p id id y m id is 1 8 8 -1 8 9 , 191, 193, 2 36 - fe m o ris 2 38 - h u m e ri 63, 68 - lon g u m (M . b ic e p s brachii) 68 - m e du sa e 112 - p ancreatis 93, 1 2 0 -1 2 4 , 127, 144, 1 4 9 -1 5 0 p ro je ctio n o n to th e ve ntra l a bdom inal w all 86 Cardia (Pars cardiaca) 7 4 -7 5 , 77, 8 0 , 131, 148, 153 Cardiac a rrh yth m ia s, ECG 22 Cardiac m u s c le 15 - d ila tio n 13 - h y p e rtro p h y 5, 13, 15 Cardiac ve in s 25 Cardiac w a ll, s tru c tu re 14 Carina tra ch e ae 62 C artilago(-ines) - bron ch iale s 32 - c o s ta lis 6 5 , 67 - cricoid ea 3 2 - 3 3 - th yro id e a 3 2 - 3 3 - tra ch e ale s 3 2 - 3 3 , 62 C arunculae hym en a les 202 C atech o lam in es, adrenal gland 170 Cauda - e p id id y m id is 183, 1 8 8 -1 8 9 , 193, 2 36 - equina 148, 156 - p ancreatis 1 2 0 -1 2 2 , 124, 127, 1 3 8 -1 3 9 , 150, 155 ------p ro je c tio n o n to th e ventral a bdom inal w a ll 86 C avernae c o rp o ru m ca ve rn o s o ru m 186 Cavitas - a bd o m ina lis 70, 151, 1 5 4 -1 5 6 - e x tra p e rito n e a lis p e lv is 2 0 1 ,2 1 9 - g le n o id a lis 68 - nasi 28 - o ris propria 42 - pericardiaca 62, 65 - p erito n e alis 70, 139, 1 4 8 -1 5 0 , 1 5 3 -1 5 6 - - a b d o m in is 158 - - p e lv is 158, 201, 219 - p leuralis 4 0 , 50, 5 2 - 5 3 , 6 6 , 1 5 4 -1 5 5 - serosa s cro ti 189 - th o ra c is 62, 6 4 - 6 8 , 151 - u te ri 2 0 7 -2 0 8 , 219, 237 C entral ve n o u s c a th e te r (CVC) 35, 63 - p n e u m o th o ra x 35 C en tru m - perinei 215 - te n d in e u m (D iaphragm a) 4 3 , 52, 148, 152

Index

C ervical ca rcin o m a 2 09 - lym ph n ode m e ta sta se s 213 C ervical c o n s tric tio n , o e so p h ag u s 45 C ervix u te ri 2 06 , 2 0 8 -2 0 9 , 211, 219 C h o le c y s titis 71 - re fe rred pain in th e rig h t s h o u ld e r 54 C ho le sta sis 118-119 C hordae te n d in e a e 17-19 C hro n ic o b s tru c tiv e p u lm o n a ry disease (COPD), h yp e rtro p h y o f th e rig h t v e n tricle 15 C isterna chyli 57, 99, 2 29 C lavicula 5, 54, 63, 68 C lito ris 2 02 , 2 04 , 212 Cloaca 162 C ollectin g d u c t 169 C olliculus se m in a lis 1 77-178 C ollum - fe m o ris 2 39 - ve sica e b iliaris 88, 116-117, 119 C olon 74, 102, 120, 128, 161, 173, 220 - ascen d e ns 81, 9 2 -9 3 , 9 5 - 9 8 , 101, 111, 130, 134, 1 3 7 -1 3 8 , 146, 150, 176 - - p ro je ctio n o n to th e b o d y su rfa ce 86 - d e s ce n d e n s 81, 9 2 -9 3 , 9 7 -9 8 , 101, 111, 134, 1 3 7 -1 3 8 , 1 46 -1 4 7, 150, 1 5 5 -1 5 6 , 176 ------p ro je ctio n o n to th e b o d y su rfa ce 86 - s ig m o id e u m 9 2 -9 3 , 97, 101, 130, 134, 136â&#x20AC;&#x201D; 139, 1 4 5 -1 4 8 , 150, 221, 2 2 4 -2 2 5 , 228, 2 3 6 -2 3 7 , 240 ------p ro je ctio n o n to th e b o d y su rfa ce 86 - tra n sve rsu m 72, 9 2 -9 3 , 97, 101, 116, IS O 131, 1 3 3 -1 3 4 , 1 3 6 -1 3 8 , 1 4 5 -1 4 6 , 1 4 8 -1 5 0 , 1 5 2 -1 5 3 , 1 5 5 -1 5 6 ------p o sitio n a l va ria tio n s 101 ------p ro je ctio n o n to th e b o d y su rfa ce 86 C olo n ic ca rcin o m a s 101 - ly m p h a tic drainage 99 C olum nae - anales 2 2 2 -2 2 3 , 225, 227, 2 40 - renales 167, 174 C om m issu ra - lab io ru m a n te rio r 202 p o s te rio r 202 C om p lexu s stim u la n s e t c o n d u ce n te co rdis 2 0 -2 1 C o m p u te d to m o g ra p h y (CT) 65, 154 - abdom inal cavity, transverse section 1 54-156 - kidn e y 173 - p elvis - - o f a m an, tra n sve rse s e ctio n 2 3 8 o f a w o m a n , tra n sve rse s e ctio n 2 39 - th o ra c ic cavity, tra n sve rse s e ctio n 65 - th o ra x 3 C o n d u cting syste m o f th e h e a rt 2 0 -2 1 C ongenital cardial d e fe c ts 7 C ongenital inguinal hernia 185 C o n tin e nce organ 2 23 C onus a rte rio su s 6, 12, 24 C or 2, 12-13, 55, 6 6 , 74, 102, 120, 128, 1 6 0 161 - b o vin u m 13 - p o s itio n w ith in th e th o ra x 10 Corona g landis 1 8 6 -1 8 7 ,2 3 6 C oronary a rte rie s 19 - See also A rte ria coronaria d e xtra /sin istra C oronary a rte ry dise a se (CAD) 27 C oronary a rte ry s te n o sis 23 C orpus(-ora) - a dip o sum pararenale 173 - a n o co ccyg e u m 198, 221 - ca vern o su m - - c lito rid is 202, 237 - - p enis 1 7 8 -1 7 9 , 184, 186, 1 91 -1 9 2, 194, 2 04 , 2 3 6 - - re cti 2 2 3 -2 2 4 - c lito rid is 237 - e p id id y m id is 1 8 8 -1 8 9 - g a s tricu m 7 4 -7 5 , 77, 8 5 , 1 3 0 -1 3 2 , 151 - luteu m 207 - o ssis p u b is 149, 214 - p an cre a tis 1 2 0 -1 2 4 , 127, 133, 138, 144 - - p ro je ctio n o n to th e ve ntra l abdom inal w a ll 86

Corpus (-ora) -

p enis 182 pineale 160 sp o n g io su m p enis 1 7 8 -1 7 9 , 184, 186, 191 â&#x20AC;&#x201D; 192, 194, 199, 2 23 , 2 36 - ste rn i 6 4 - 6 6 - u te ri 2 0 6 -2 0 8 , 211, 219 - ve rte b ra e 65, 155, 173 - vesicae 1 7 7 -1 7 8 - - b iliaris 8 8 , 116-117, 119 C orp u scu lu m renale 168 C o rte x 170 - (Gl. suprarenalis) 170 - renalis 156, 1 6 7 -1 6 8 , 1 73-174 C osta 6 4 - 6 8 C O W P E R 's g lands (Gil. bulb o ure th ra le s) 160, 178, 183, 186, 190, 194, 1 97 -1 9 9, 201, 221 C rista - iliaca 29, 161, 231 - te rm in a lis 17, 21 - u rethralis 1 7 7 -1 7 8 C R O H N 's disease 95 C rus - c lito rid is 2 02 , 219 - d e xtru m ------(D iaphragm a) 155 ------(Fasciculus a triove n tricu la ris) 2 0 -2 1 - - (Pars lum b a lis d ia phragm atis) 57 - p enis 186, 198, 201 - s in istru m ------(Fasciculus a triove n tricu la ris) 2 0 -2 1 - - (Pars lum b a lis d ia phragm atis) 57, 154 C ryp to rch id ism 185 C upula p leurae 29, 4 0 -4 1 , 63, 68 C urvatura - m a jo r 75, 77, 1 3 0 -1 3 2 - m in o r 7 5 -7 7 , 9 0 , 1 31-132 C u rva tu re s o f th e s to m a ch , a rte rie s 80 C uspis - a nte rio r - - (Valva a trio v e n tric u la ris d extra) 1 6 -1 7 - - (Valva a trio v e n tric u la ris sinistra) 16, 1 9 ,6 6 - c o m m issu ra lis - - d e xtra 16 sinistra 16 - p o ste rio r ------(Valva a trio v e n tric u la ris d extra) 1 6 -1 7 ------(Valva a trio v e n tric u la ris sinistra) 16, 1 8 ,6 6 - se p ta lis (Valva a trio v e n tric u la ris d extra) 1 6 17 C utis 187, 191 CVC (central ve n o u s ca th e te r) 3 5 , 63 - p n e u m o th o ra x 35 C ys titis 180 C ysto ce le 214 C ysto scop y, u re te ric o rific e 177

D D E N O N V ILL IE R 's fascia (Fascia re c to p ro s ta tica) 1 9 0 ,2 2 1 ,2 3 6 D escensus - te s tis 185 - U te rus/V a gin a 214 D iabetes m e llitu s 123 - fa tty live r 102 D iaphragm a 5, 41, 4 3 - 4 6 , 4 8 , 52, 54, 58, 74, 79, 102, 104, 115-116, 120, 122, 128, 131, 148, 151, 155, 161, 173 - p e lvis 158, 196, 198, 2 1 4 -2 1 5 - u ro g e n ita le 158 D ia p h ra g m a tic c o n s tric tio n , o e so p h ag u s 45 D iastole 16 D ig e stive tra c t, o v e rv ie w 42 D igital rectal e xam in a tion (DRE), p rosta ta 221 D iscus in te rp u b ic u s 210 D ive rticu lu m (-a ) - a m pu lla e 178 - ilei 91 - o f th e o e so p h ag u s 45 D orsal p an cre a tic b ud 103, 121 D orsum p enis 182

D R U M M O N D 's a n a stom o sis 9 7 ,1 4 5 -1 4 7 D uctuli - e ffe re n te s te s tis 1 8 5 ,1 8 9 - p ro s ta tic i 1 77-178 D uctus - a rte rio s u s 6, 8 p e rs is tin g 7, 9 - b ilife r inte rlo b u la ris 106 - ch o le d o c h u s (biliaris) 8 8 , 1 0 3 -1 0 4 , 108, 110, 117-119, 121, 1 2 3 -1 2 4 , 127, 142, 149, 155 - - varia tio n o f th e ju n c tio n 124 - c y s tic u s 8 8 , 108, 110, 117-119, 122-123, 127, 155 - d e fe re n s 149, 160, 178, 183, 185, 187, 1 8 9 192, 194, 198, 2 33 , 2 3 6 , 2 38 , 240 - e ja cu latoriu s 1 7 7 -1 7 8 , 183 - e x c reto riu s (pancreas) 123 - glandulae b ulb o ure th ra lis 1 7 8 ,1 8 3 ,1 9 7 - hepaticus - - co m m u n is 8 8 , 108, 110, 117-119, 1 2 2 123, 127 - - d e x te r 117, 119 s in is te r 117, 119 - ly m p h a tic u s 39, 60 - m e s o n e p h ric u s (W O LF F IA N d u ct) 1 6 2 -1 6 3 , 185, 2 05 - p an cre a ticus a ccesso riu s (SAN TO R IN I'S duct) 8 8 , 117, 121, 124 - p an cre a ticus (d u c t o f W IR S U N G ) 8 8 - 8 9 , 117, 121, 1 2 3 -1 2 4 , 127, 1 4 8 -1 4 9 - - va ria tio n s o f th e ju n c tio n 124 - p ara m e so n e p h ricu s (M Ă&#x153; LL E R IA N d u ct) 163, 185 - th o ra c ic u s 2, 39, 53, 5 6 -5 7 , 59, 61, 6 4 -6 7 , 99, 151, 1 5 4 -1 5 5 , 2 29 - - ju n c tio n 39 - ve n o s u s 8 - v ite llin u s 73 D uodenal u lce rs 78 - d u o d e n o s c o p y 90 D u o d e n o sco p y 90 D u o d e nu m 42, 58, 72, 7 4 -7 7 , 8 0 - 8 1 , 8 5 , 8 8 90, 93, 9 8 , 1 0 2 -1 0 3 , 110-111, 1 16 -1 2 4, 1 2 7 128, 135, 1 3 7 -1 3 9 , 142, 1 4 9 -1 5 0 , 161 - a rte rie s 96 - d ivision s 88 - e n d o s c o p y 90 - in n e r re lie f 89 - p ro je c tio n o n to th e ventral a bdom inal w a ll 86, 120 - radiograph 90 - w a ll s tru c tu re 89 D ysphagia lusoria 55

E E ch o card iog ra p hy 3 - tra n so eso p ha g e al 62 E jaculation, N. p u d e n d u s 194 E lectroca rd iog ra m (ECG) 3 - ana tom ica l p rin ciple s 22 - P w a v e 22 - Q w a v e 22 - R w a v e 22 - S w a v e 22 - T w a v e 22 E m ission 194 - S y m p a th ic u s 194 E n d ocardium 14 E ndocrine orga n s 160 E n d om e tria l ca rcinom a 207 - lym ph nod e s m e ta sta sis 213 E n d o m e triu m 207 E ndoscopy - d u o d e n u m 90 - d uodenal u lce rs 78, 90 - g a stric u lce rs 78 E picardium 11-12, 14, 17-18, 62 E p id id ym is 160, 183, 1 8 7 -1 8 9 , 191, 194 - b lo o d v e s s e ls 189 E pigastrium - a bdom inal s u rg e ry 133

Epigastrium - p o sitio n o f th e viscera 1 3 0 -1 3 2 - re tro p e rito n e a l organs 122 E piorchium 187 E piphrenic d ive rticu la 45 E p isio to m y 217 Epispadias 184 E pithelium - (Gaster) 78 - (In te stin u m te n u e) 87, 94 ERCP (e nd o sco pic re tro gra d e C holangiopancreatico g ra ph y) 122 - bile d u c ts 127 - pancreas 127 Erection 194 - in h ib ito rs o f th e e n zym e p ho sp h o d ie ste ra Â se 192 - p a ra sym p a th e tic syste m 194 Excavatio - re cto u te rin a (pouch o f D O U G LA S ) 1 3 8 -1 3 9 , 2 0 8 -2 1 0 , 237, 2 3 9 - - a p p e n d icitis 237 - - s a lp in g itis 237 - re cto ve sica lis 138, 149, 181, 2 2 1 -2 2 2 , 2 36 - v e sico u te rin a 139, 2 0 8 -2 1 0 , 219, 237 E xternal fe m a le g en ita lia 202 - d e v e lo p m e n t 2 0 4 - lym p h v e sse ls and lym ph nod e s 213 - lym p h a tic d rainage p a th w a y 213 E xternal m ale g en ita lia 1 8 2 -1 8 3 - d e v e lo p m e n t 184 - lym p h v e sse ls and lym ph nod e s 195 - n eurovascular stru c tu re s 192 E xtre m ita s - a crom ia lis (Clavicula) 68 - a n te rio r - - (Splen) 129 - in fe rio r - - (Ren) 173, 176 (Testis) 188 - p o s te rio r (Splen) 129 - su pe rio r - - (Ren) 173 (Testis) 188 - tu b a ria (O varium ) 2 06 - ute rin a 2 0 6

F Facies - a n te rio r - - (Gl. suprarenalis) 170 - - (Ren) 173 - co lica (Splen) 129 - costalis - - (P ulm o d exter) 34 - - (P ulm o sinister) 3 4 - 3 5 - d iaphragm atica - - (Cor) 10 ------(Hepar) 1 0 4 -1 0 6 , 1 31-132 - - (Pulm o) 35 - - (Splen) 129 - g a strica (Splen) 129 - m e dia lis (O varium ) 2 06 , 2 08 - m e d ia stin a lis (Pulm o sinister) 35 - p o ste rio r ------(Prostata) 178 - - (Ren) 173 - p ulm o n alis (Cor) 10 - renalis (Splen) 129 - ste rn o co sta lis (Cor) 10 - vesica lis 2 08 - visceralis - - (Hepar) 1 0 5 -1 0 6 , 131 - - (Splen) 129 FALLO T's te tra lo g y 7 Fascia - cre m a ste rica 1 8 7 -1 8 9 , 191, 2 36 - o btu ra to ria 199, 217 - pelvis - - parie ta lis 2 37 - - viscera lis 219, 2 36

250

Fascia - p enis 192

Frenulum - lab io ru m p ud e n di 202

- o s tii ilealis 95 - p re p u tii 187 Fundus - g astricu s lb -1 1 , 116, 131 - u te ri 1 3 9 ,2 0 6 - 2 0 8 ,2 1 0 -2 1 1 ,2 3 7 p ositio n during p reg n a ncy 210 - ve sica e 139, 177 - - b iliaris 8 8 , 116-117, 130, 135, 138 Funiculus - sp e rm a tic u s 183, 188, 1 9 1 -1 9 2 , 198, 221, 2 38 - - co verin g s o f th e s p e rm a tic co rd 187,191

- profu nd a 187, 191 - s u p e rfic ia lis 187, 192 re c to p ro s ta tic a (D E N O N V ILL IE R 's fascia) 1 9 0 ,2 2 1 ,2 3 6 - recto va gin alis 237 - renalis (GEROTA's fascia) 1 5 2 -1 5 3 ,1 6 1 , 164, 173 - sp erm a tica ------externa 187, 189, 191 - - interna 1 8 7 -1 8 9 , 191 Fasciculus - a trio v e n tric u la ris (a triove n tricu la r bundle, b un d le o f HIS) 2 0 - 2 1 ,2 4 - lateralis (Plexus brachialis) 68 - m e dia lis (Plexus brachialis) 68 - p o s te rio r (Plexus brachialis) 68 F a tty liver - a lcohol a bu se /d iab e te s m e llitu s 102 Fecal in c o n tin e n c e 214 Fem ale g e n ita l s y s te m 203 Fem ale genita lia , in n e rv a tio n 212 Fem ale p e lv is 180 Fem ale urin a ry organs 2 03 Fem ale urin a ry s y s te m 160 Fe m u r 2 3 8 -2 3 9 Fetal c ircula tion 8 Fibrae obliq ua e (Tunica m usula ris, G aster) 76 Fim bria(-ae) - ovarica 2 0 6 -2 0 7 - tu b a e ute rin a e 2 0 6 -2 0 8 Fine n ee d le aspira tio n b io p s y (FN AB) 173 Fissura - horizo n ta lis (Pulm o d exter) 29, 3 4 - 3 5 - lig a m e n ti te re tis hep a tis 1 0 4 -1 0 5 - obliqua (Pulm o) 29, 3 4 - 3 5 , 6 4 - 6 7 - u m b ilic a lis 107 Flexura - a n o re cta lis 198 - coli - - dextra 92, 101, 116, 134 - - s inistra 92, 101, 134 - d u o d e no je ju n alis 8 9 - 9 0 , 120, 124, 136, 139, 150 - - p ro je c tio n o n to th e ve ntra l abdom inal w a ll 86 - perin e alis 2 2 0 -2 2 2 - sacralis 2 2 0 -2 2 2 Floating lung te s t 30 Folliculi ovarici 207 Foram en(-ina) - in fra p irifo rm e 196 - ischia d icu m - - m ajus 214 - - m inu s 196 - o m e n ta le 131-132 - ovale 6 - 9 - papillaria 167 - su p ra p irifo rm e 196 - venae cavae 43 - ve na ru m m in im a ru m 17 - ve rte b ra le 65 Fo re gu t 30 Foreign b odies in th e o e so p h ag u s 45 Fornix - g astricu s 77, 148, 153 - vaginae 207, 2 09 , 2 37 Fossa - aceta bu li 2 3 8 - ischioanalis 1 9 9 -2 0 1 ,2 1 7 - 2 1 9 ,2 3 8 - 2 4 0 - - a b sce sse s 2 0 0 ,2 1 8 - - b o rd e rs 199, 217 c o n te n ts 2 00 , 218 - ju g u la ris 74 - navicularis urethrae 1 7 8 -1 7 9 ,2 3 6 - ovalis 17 Foveolae gastrica(-ae) 78 FR A N K E N H Ă&#x201E; U S E R 's plexus (Plexus u te ro vag inalis) 212 Frenulum - c lito rid is 202

G G allbladder 117 - a rte rie s 110 - d e ve lo p m e n ta l s ta g e s 103 - laparo scop ic im ag e 116 - p ro je c tio n o nto th e ve ntra l a bdom inal w a ll 115 - radiograph 119 - - a fte r intrave n o us a pp licatio n o f co n tra s t m e d iu m 119 - su rgica l rem oval, C A LO T 's tria n g le 118 - ve in s 111 G anglion(-ia) - a ortic o re n a le 100 - cardiacum 23 - cervica le ------m e d iu m 23, 58 ------su p e riu s 23 - c e rv ic o th o ra c ic u m (stellatum ) 23, 58, 6 0 -6 1 - coeliaca 8 4 , 100, 155, 2 26 , 231 - im pa r 231 - m e s e n te ric u m - - inferiu s 100, 226, 231 su p e riu s 100, 231 - pelvica 194, 212, 2 26 - s te lla tu m See G anglion c e rv ic o th o ra c ic u m - th o ra cica 5 2 - 5 3 , 58 - tru n c i s y m p a th ic i 5 6 -5 7 , 194, 212, 226 G aster 4 2 - 4 3 , 4 6 , 58, 72, 7 4 -7 8 , 8 0 - 8 5 , 88, 90, 9 3 , 9 8 , 1 0 2 -1 0 3 , 110-111, 120, 128, 1 3 0 -1 3 2 , 138, 142, 1 4 8 -1 5 0 , 1 5 2 -1 5 6 , 1 6 0 161 - See also S tom ach G astric canal 77 G astric c a rcin o m a s 71 - ly m p h v e ssels and ly m p h nod e s 82 - ly m p h a tic drainage 4 8 , 82 - p erfo ra tio n into a d ja c e n t organs 79 G astric ulce r 78 - e n d o s c o p y 78 - p erfo ra tio n 79 - s e le c tiv e v a g o to m y 84 - to ta l v a g o to m y 8 4 G a stritis 71 G astro-(o)esophageal re flu x disease (GERD) 4 2 , 75 G a stro sco p y 85 - b io p sies 85 G enital tu b e rc le s 161, 1 6 3 -1 6 4 , 1 8 4 ,2 0 4 - n e p h re c to m y 164 GEROTA's fascia (Fascia renalis) 1 5 2 -1 5 3 , 161, 164, 173 - n e p h re c to m y 164 Glandula(-ae) - analis (p roktod e a l gland) 2 23 - b ulb o u re th ra le s (C O W P E R 's glands) 160, 178, 183, 186, 190, 194, 1 97 -1 9 9, 201, 221 - duo d e na le s (B R U N N E R 's glands) 89 - g astrica e 78 - in te stin a le s 87, 94 - m a m m aria 6 5 - 6 6 - oeso p h ag e a e 4 4 - p arathyroideae 160 - p inealis 160 - pituita ria 160

Index

Glandula(-ae) - suprarenalis 79, 122, 139, 151, 155, 1 6 0 —

Hiatus - o eso p h a g e u s 4 3 - 4 4 , 48

161, 164, 166, 1 70 -1 7 1, 2 28 - c o n ta c t area on th e p o ste rio r w all o f th e sto m a ch 79 - th y ro id e a 4 8 , 51, 54, 62, 160-161 - tra ch e a le s 33 - vesiculosa 1 4 8 -1 4 9 , 160, 178, 183, 1 85— 186, 190, 194, 198, 201, 221, 2 3 3 , 2 38 , 240 - ve stib u lä re s ------m ajores (B A R TH O LIN 'S glands) 2 0 2 ,2 0 4 , 217, 219 - - m in o re s 202 Gians - c lito rid is 202 - p enis 178, 182, 184, 1 8 6 -1 8 7 , 194, 2 36 G L IS S O N 's tria d 106 G lo m us co ccyg e u m 237 G lu c o co rtico id s, adrenal gland 170 G reater o m e n tu m 130 G u b e rna cu lu m te s tis 185

- u ro g e n ita lis 196, 214 H ilar lym ph nod e s 3 9 , 41 H ilu m 166 - p u lm o n is 35 - renale 156, 166 - s p le n icu m 129, 155 H in d g u t 30 Hip, m u scle s 196 HIS, b un d le o f (a triove n tricu la r bundle, Fascicu lus a triove n tricu la ris) 16, 2 0 -2 1 , 24 H orse sh o e kidn e ys 162 H u m e ru s 64 H ydro ce le te s tis 185 H ym en 202 H ype rte n sion - increased s y m p a th e tic to n u s 23 - in s u ffic ie n c y o r s te n o s is o f th e m itra l valve 5 - p u lm o n a ry h yp e rte n s io n 5 ,1 5 - s te n o sis o f th e a o rtic valve 5 H yp o g a striu m - in fla m m a tio n s 237 - p o s itio n s o f th e viscera 1 3 4 -1 3 6 H yp o p h ysis 160 H ypo sp a dia s 184 H ypo th a lam u s 160 H yste re cto m ie s , lig a tio n o f th e u rete r during s u rg e ry 175

H H ae m o rrho id al kn o ts 2 22 , 2 27 H a e m o rrh o id s 223, 227 H austra coli 9 4 - 9 5 , 101 H E AD'S zones 42 H e a rt 2, 12-13, 55 - a uscu lta tio n 4 - c o n d u ctin g s y s te m 2 0 -2 1 - c o n g e n ita l cardial d e fe c ts 7 - c ritica l w e ig h t 13 - d e v e lo p m e n t sta g e s 6 - fib ro u s ske le to n 16 - in n e rva tion 23 - p ercu ssio n 4 - p o s itio n w ith in th e th o ra x 10 - p ro je ctio n o n to th e th o ra x 4 - radiograph o f th e rig h t and le ft b o rd e r 5 - s ta g e s o f d e v e lo p m e n t 6 - ultraso u n d im age 66 H ea rt c o n to u rs - p o s te ro -a n te rio r radiograph 5 - p ro je ctio n o n to th e ventral th o ra cic w all 4 H e a rt m u rm u rs 4, 16 H ea rt so u n d s 4, 16 - a uscu lta tio n 4 H e a rt valves 16 - a uscu lta tio n areas 4 - p ro je ctio n o n to th e ve ntra l th o ra cic w all 4 H e lic o b a cte r p ylori bacteria, p ro d u ctio n o f g a s tric acid 84 H ep a r 8 - 9 , 4 2 , 62, 72, 74, 81, 98, 102-107, 109-111, 114-116, 120-121, 1 27 -1 2 8, 1 4 8 150, 1 5 2 -1 5 6 , 161, 173 - a rte rie s 110 - c o n ta c t areas 79 - d e v e lo p m e n t 72, 103 - laparoscopy 116 - lym ph ve ssels and lym p h nod e s 82, 113 - o f a fe tu s 8 - p ro je ctio n - - o n to th e b o d y su rfa ce 86 ------o n to th e ve ntra l a bdom inal w all 8 6 , 115 - s a g itta l s e ctio n 106 - s e g m e n ts 1 0 7 -1 0 9 - size, m e a s u re m e n t 102 - so no g ra ph y 114 - s tru c tu re 106 - va ria tio n s o f th e b lo o d su p p ly 110 - v e in s 111 H ep a tic d iv e rtic u lu m 103 H ep a tic lob u les 106 H e p a titis 102 - so no g ra ph y 114 - s u spicio us tu m o u rs 115 H e p a to cyte s 106 H iatus - analis 196, 214 - a o rticu s 43 - levatorius 214

I lleocaecal valve (Valva ileocaecalis, B A U H IN 's valve) 95 Ileum 74, 9 1 -9 3 , 9 5 - 9 6 , 102, 120, 128, 130, 1 3 4 -1 3 5 , 138, 143, 145, 1 4 8 -1 5 0 , 161, 220 - a rte rie s 96 - p ro je ctio n o nto th e b o d y su rfa ce 86 Ileus, m a lro ta tio n 73 Im p o te n tia - c o e u n d i 194 - g en e ra nd i 194 Im p re ssio - cardiaca ------(P ulm o d exter) 35 - - (P ulm o sinister) 35 - co lica (Hepar) 104 - d uo d e n a lis 104 - g a strica (Hepar) 104 - o eso phagea 3 5 ,1 0 4 - renalis 104 - supra re n alis 104 Incisura - a ngularis 75, 77, 90 - cardiaca (P ulm o sinister) 29, 3 4 - 3 5 , 4 0 , 50 - cardialis 75, 77 - lig a m e n ti te re tis 104 In fu n d ib u lu m tu b a e ute rin a e 2 03 , 2 0 6 -2 0 8 , 2 37 Inguinal hernia 185 Inner fe m a le genitalia 2 03 - arte ria l su p p ly 211 - d e v e lo p m e n t 2 05 - lym p h a tic drainage p a th w a y s 213 - lym ph ve ssels and lym ph nod e s 213 Inner m a le genitalia 183 - b lo o d v e s s e ls 193 - d e v e lo p m e n t 185 - lym ph ve ssels and lym ph nod e s 195 Insulae p ancreaticae 1 2 3 ,1 6 0 In te rm e d ia te tu b u lu s 169 Internal hernias 133 Internal organs, p ro je ctio n o n to th e b o d y sur fa ce 74, 102, 120, 128, 161 Inte stin a l ro ta tio n 73 - m a lro ta tio n s 73 In te stin u m 160 - cra ssum 42, 92, 94, 9 7 -1 0 1 , 137 See also C olon - te n u e 42, 72, 87, 9 8 -1 0 0 , 128, 136, 220, 2 36 - - See also S m all in te s tin e

Intracardiac in je c tio n 4 In tra p e riton e a l organs 70 Isle ts o f L A N G E R H A N S 123 Isthm u s - bursae o m e n ta lis 132 - tu b a e ute rin a e 2 0 6 -2 0 8 , 2 37 - u te ri 2 0 6 -2 0 7

J Je ju n u m 74, 8 8 -9 1 , 96, 102, 120, 122, 1 2 7 128, 1 3 4 -1 3 5 , 137, 143, 145, 148, 150, 153, 1 5 5 -1 5 6 , 161 - a rte rie s 96 - p ro je c tio n o n to th e b o d y su rfa c e 86 J u n c tio (Linea) ano re cta lis 222

K K E ITH -FLAC K, n ode o f (sinu-atrial node, N odus sinuatrialis) 2 0 -2 1 KER CKR IN G 's fo ld s (Plicae circulares) 77, 8 9 91, 124 K idney 122, 164, 1 6 6 -1 6 7 - See also Ren - a rterial supply, va ria tio n s 172 - a scensus 162 - c o m p u te d to m o g ra p h y 173 - c o n ta c t areas 165 - - on th e p o s te rio r w all o f th e sto m a ch 79 - c o urse o f renal a rte rie s 169 - d e v e lo p m e n t 162 - physical e xam in a tion , pain s e n s itiv ity 161 - p o s itio n in th e re tro pe rito n ea l space 164 - p ro je c tio n o n to th e dorsal b o d y w all 161 - tra n s v e rs e s e c tio n 168 - ultraso u n d im ag e 173 K idney lobes 167 K IL L IA N 's tria n g le 45 KO C H 's tria n g le 1 7 ,2 0 KR ISTE LLE R 's m u c o u s plug 210

L Lab io scrotal fo ld s 184, 202, 2 04 Labium - a nte riu s (O stiu m uteri) 2 09 - m ajus p ud e n di 202, 2 0 4 , 237 - m in u s p ud e n di 2 0 2 ,2 0 4 ,2 1 2 ,2 1 7 - 2 1 9 ,2 3 7 - p o s te riu s (O stiu m uteri) 2 0 9 Lacunae u reth ra le s 178 Lam ina - m u s c u la ris m u cosa e (In te s tin u m te n u e) 78, 87, 94 - parietalis ------(P ericardium serosu m ) 1 2-1 3 , 62 - - (Tunica vaginalis te s tis ) 187, 189, 191 - propria m u c o s a e 78, 87, 94 - vis c e ra lis 18 ------(P ericardium serosu m ) 12-13, 1 7 ,6 2 ------(Tunica vaginalis te s tis ) 187, 189, 191 LA N G E R H A N S , is e le ts o f 123 L A N Z 's p o in t 93 Lapa ro scop ic im ag e 116 - gallb la d de r 116 - live r 116 Large in te s tin e 137 - See also In te s tin u m crassum - a rte rie s 97 - a u to n o m ic in n e rv a tio n 100 - c o nve n tio na l radiograph 101 - d ivision s 92 - ly m p h v e s s e ls and regional lym ph nod e s 99 - p ro je ctio n - - o nto th e b o d y su rfa ce 86 - - o nto th e ve ntra l a bd o m ina l w all 8 6 , 92 - regional ly m p h nod e s and lym ph v e ssels 99 - s tru c tu re o f th e w a ll 94 - ve in s 98 Laryn g o tra che a l p rim o rd iu m 31

Index

L aryn x 28, 3 2 -3 3 , 45 L e ft v e n tricle 17-19 L e ft ve n tricu la r h y p e rtro p h y 15 L e ft-to -rig h t s h u n t 7 L igam entum (-a) - a n o co ccyg e u m 1 9 8 -2 0 0 ,2 1 7 -2 1 8 ,2 2 1 , 2 36 , 2 3 9 - anularia 3 2 - 3 3 - a rte rio su m 9 -1 0 , 12-13, 53, 55 - ca pitis fe m o ris 2 38 - cardinale (Lig. tra n sve rsu m ce rvicis) 2 06 - co ron a rium 72, 1 0 4 -1 0 6 , 131, 139 - - d e v e lo p m e n t 72 - e p id id ym id is ------in fe riu s 188 ------su p e riu s 188 - fa lc ifo rm e hepatis 1 0 3 -1 0 5 , 1 0 7 -1 0 8 , 118, 1 3 0 -1 3 1 , 138, 149, 1 5 4 -1 5 5 - - d e v e lo p m e n t 72 - fu n d ifo rm e p enis 1 9 2 ,2 3 6 - g a stro co licu m 1 3 0 -1 3 3 , 144, 149, 153 - g a stro p h re n icu m 139 - g a stro sp le n icu m 72, 129, 131, 133, 139, 151, 153 - - d e v e lo p m e n t 72 - h e p a to d u od e na le 108, 118, 1 31 -1 3 2, 138â&#x20AC;&#x201D; 139, 155 - h e p a to g a stricu m 8 0 , 1 31 -1 3 2, 155 - inguinale 182 - latum u te ri 2 0 6 -2 0 8 - lo n g itu d in a le a n te riu s 57, 64 - ovarii p ro p riu m 203, 2 0 5 -2 0 8 ,2 1 1 - p h re n ico co licu m 131 - p hre n ico sp le n icu m 153 - pub icu m ------in fe riu s 197, 216 - - su p e riu s 2 3 8 -2 3 9 - p u b o p ro sta ticu m 177, 179, 198, 221, 2 36 - pub o ve sica le 2 37 - p ulm o n ale 35 - re c to u te rin u m (Lig. sa crou terin um ) 2 06 , 2 09 - sacrosp in ale 2 00 , 2 32 , 2 35 - sa crotu be ra le 1 9 9 - 2 0 0 ,2 1 4 ,2 1 7 ,2 3 2 - sp le n o ren a le 72, 129, 151 - - d e v e lo p m e n t 72 - su spe n so riu m ------c lito rid is 202 ------d u o d e n i 89 - - ovarii (Lig. in fu n d ib u lo p e lvicu m ) 2 0 5 -2 0 6 , 2 08 , 211, 237 ------p enis 187, 192 - teres - - hep a tis 9, 104, 1 0 7 -1 0 8 , 110, 115, 127, 1 3 0 -1 3 2 , 138, 142, 1 5 5 -1 5 6 - - - d e v e lo p m e n t 72 ------u te ri (Lig. ro tu n du m ) 2 0 3 , 2 0 5 -2 0 6 , 208, 211, 2 34 , 2 37 - tra n sve rsu m perinei 1 97 ,21 6 - tria ng u lare d e x tru m 104 ------sin is tru m 104, 139, 150-151 - um bilica le m e dia n um 9, 1 77 -1 7 8, 2 3 6 -2 3 7 - ve na e cavae 1 0 4 -1 0 5 - ve n o su m 8 - 9 , 104, 107 Lim bus - aceta bu li 2 38 - fo ssa e ovalis 17 Linea - alba 1 5 4 -1 5 5 , 2 3 6 - a nocutanea 2 2 2 -2 2 3 - d en tata (Linea p ectin a ta , C analis analis) 2 2 2 -2 2 3 - te rm in a lis 214 Lingula p u lm o n is (Pulm o sinister) 3 4 - 3 5 , 40, 50 Live r See H epar L ive r cirrh o sis 102, 106, 112 - p o rta l h yp e rte n sio n 98 - so no g ra ph y 114 - s u sp icio u s tu m o u rs 115 Live r p un cture - p o sitio n o f th e n ee d le 115 - referred pain in th e rig h t s h o u ld e r 54

Lobuli te s tis 1 7 9 ,1 8 8 -1 8 9 Lobus - a n te rio r (Pulm o sinister) 64 - ca udatus 1 0 4 -1 0 5 , 1 0 8 -1 0 9 , 132, 150, 155 - d e x te r ------(Gl. thyroidea) 48 ------(Thym us) 51 - hepatis - - d e x te r 82, 9 3 , 1 0 4 -1 0 5 , 109, 115-116, 118, 1 3 0 -1 3 2 , 135, 138, 142, 1 5 0 -1 5 2 , 1 5 4 -1 5 6 , 173 - - s in is te r 80, 82, 1 0 4 -1 0 5 , 1 0 9 -1 1 0 , 1 1 5 116, 118, 127, 1 3 0 -1 3 2 , 138, 142, 1 4 8 149, 151, 1 5 3 -1 5 6 - in fe rio r - - (P ulm o d exter) 2 8 - 2 9 , 3 4 - 3 6 , 40, 50, 54, 6 5 - 6 7 , 149, 151-152 - - (P ulm o sinister) 2 8 - 2 9 , 3 4 - 3 6 , 40, 50, 67, 151, 153 - m e d iu s (P ulm o d exter) 2 8 -2 9 , 3 4 - 3 6 , 40, 50, 6 6 - 6 7 , 151 - prosta ta e ------d e x te r 190 ------m e d iu s 190 ------s in is te r 190 - q ua d ra tu s 104, 109, 155 - renalis 167 - s in is te r (Thym us) 51 - su pe rio r - - (Pulm o d exter) 2 8 - 2 9 , 3 4 - 3 6 , 4 0 , 5 0 -5 1 , 54, 6 4 - 6 5 ------(Pulm o sinister) 2 8 - 2 9 , 3 4 , 36, 4 0 , 50, 54, 6 4 , 6 6 - 6 7 , 151 L o w e r in te stin a l tra c t - hae m o rrh ag e 89 L o w e r re s p ira to ry tra c t - air c o n d u c tin g p a rt 32 Lung b ud 30 Lung d e ve lo p m e n t - a lveolar period 31 - canalicular period 31 - p se u d o gla n du lar period 31 - sta g e s 31 Lungs 2, 28, 4 0 , 74, 102, 115, 120, 128, 161 - See also Pulm o - acinus 38 - a lve o les 38 - flo a tin g lung te s t 30 - lym ph nod e s 39 - lym ph v e ssels 39 - m o b ility during respiration 29 - size 29 - Vasa ------privata 38 - - p ublica 38 Lunula valvulae s e m ilu na ris 19 Lym ph n ode m e ta sta sis - ce rvica l ca rcin o m a 213 - e n d o m e tria l ca rcinom a 213 - p an cre a tic ca rcin o m a 126 - penile ca rcinom a 1 9 5 ,2 1 3 - vu lva r ca rcin o m a 213 Lym ph vessels - bile s y s te m 113 - co lon 99 - e xte rn al and internal fe m a le genitalia 213 - e xte rn al and internal m ale genitalia 195 - lungs 39 - p erib ro nch ial s y s te m 39 - re c tu m 2 3 5 - re tro p e rito n e a l space 2 29 - se pta l ly m p h s y s te m 39 - sm a ll in te s tin e 99 - subpleural lym ph s y s te m 39 L ym p h a tic drainage, c a rcin o m a s in th e c o Â lon 99

M M a g n e tic reson a n ce im aging (M R I) 65 - th o ra x 3

M ain b ronchi, p ro je c tio n o n to th e a n te rio r c h e s t w a ll 28 M a le g e n ita l s y s te m , in n e rva tion 194 M a le p e lv is 179 M a le urin a ry organs 183 M a le urin a ry s y s te m 160 M a lro ta tio n 73 - ileus 73 M a m m a 67 M a n u b riu m s te rn i 64 M argo - a nte rio r ------(Pulm o d exte r) 3 4 - 3 5 , 40 - - (P ulm o sinister) 3 4 - 3 5 , 40 (Testis) 188 - in fe rio r - - (H epar) 104, 106 (Pulm o d exter) 3 4 - 3 5 - - (Pulm o sinister) 3 4 - 3 5 , 40 - - (Splen) 129 - lateralis (Ren) 166 - lib e r 2 06 - m edialis - - (Gl. suprarenalis) 170 - - (Ren) 166 - m e sova ricu s 2 06 , 2 08 - p o s te rio r - - (P ulm o d exte r) 3 4 - - (Pulm o s iniste r) 34 - - (Testis) 188 - su pe rio r - - (Gl. suprarenalis) 170 - - (Ren) 166 - - (Splen) 129, 1 3 2 -1 3 3 M c B U R N E Y 's p o in t 93 M EC KE L's d iv e rtic u lu m 73, 91 M e d ia s tin u m 2, 50, 5 2 -5 3 - a nte riu s 5 2 - 5 3 - inferiu s 5 2 - 5 3 - lym ph nod e s 59 - lym ph v e ssels 59 - m e d iu m 5 2 - 5 4 - p o s te riu s 5 2 -5 3 ------lym ph nod e s 48 ------ n e rv e s 58 - su p e riu s 5 2 -5 3 - te s tis 1 8 8 -1 8 9 ,2 3 6 M e du lla - (Gl. suprarenalis) 170 - renalis 29, 152, 156, 1 6 7 -1 6 8 , 1 73-174 - sp inalis 6 2 - 6 3 , 1 5 4 -1 5 5 , 194, 212 M e m b ra n a p erin e i 197, 199, 202, 2 16 -2 1 7, 2 36 M e s e n te rie s 137 M e s e n te riu m 70, 87, 91, 1 3 6 -1 3 8 , 2 36 - d iv e rtic u li 91 - dorsa le 103, 121 - ve ntra le 103 M e s o a p p e n d ix 1 3 5 -1 3 9 M e s o c o lo n - sig m o id e u m 139 - tra n s v e rs u m 94, 1 3 2 -1 3 3 , 135, 137, 139, 1 4 4 -1 4 5 , 147 ------c o n ta c t areas on th e p o s te rio r w a ll o f th e sto m a ch 79 M e s o g a s triu m dorsa le 72, 103 M e s o n e p h ro s 1 6 2 -1 6 3 M e s o s a lp in x 2 0 6 -2 0 8 M e s o th e liu m epicardiale 14 M e s o v a riu m 2 06 , 2 0 8 M e ta n e p h ro s 162 M E Y E R -W E IG E R T 's rule, cro ssin g o f both urete rs 176 M id a x illa ry line 29 - b o rd e rs o f th e lungs 29 M id c la v ic u la r line 29 - b o rd e rs o f th e lungs 29 M in e ra lo c o rtic o id s , adrenal gland 170 M itra l va lve (Valva a trio v e n tric u la ris sinistra) 4, 6, 16, 1 8 -1 9 , 6 6 - 6 7 - p ro je c tio n o n to th e ventral th o ra c ic w all 4 - s te n o s is o r in s u ffic ie n c y 5 M o d e ra to r band 17

Index

M o n s p u b is 202 M Ü L L E R IA N d u c t (D u ctu s para m e so ne p h ricus) 163, 185 - d iffe re n tia tio n , a n ti-M Ü L L E R IA N h o rm o ne 185 M usculu s(-i) - biceps - - brachii 68 fe m o ris 240 - b u lb o sp o n g io su s 1 9 8 -2 0 2 ,2 1 7 -2 1 9 ,2 2 3 - coraco b ra chia lis 68 - c o rru g a to r ani 223 - c re m a s te r 1 8 7 -1 8 9 , 191, 198, 2 36 - d a rto s 187, 191 - d e lto id e u s 6 3 , 68 - e re c to r sp inae 6 5 , 6 8 , 149, 1 5 2 -1 5 6 , 173 - glu te u s - - m a xim u s 149, 196, 1 9 9 -2 0 0 , 2 1 7 -2 1 8 , 2 3 8 -2 3 9 ------m e diu s 2 38 ------m in im u s 2 38 - gracilis 199, 217 - iliacus 196, 231, 2 39 - ilio c o ccyg e u s 1 4 9 ,1 9 6 ,2 1 4 - ilio co sta lis th o ra cis 155 - iliopsoas 2 3 8 -2 3 9 - infra sp in a tu s 6 3 - 6 5 - inte rco sta le s - - e xte rn i 56, 64, 6 6 -6 7 , 115, 1 5 4 -1 5 5 - - in te rn i 5 6 -5 7 , 6 8 , 115, 1 5 4 -1 5 5 - ischio ca vern o sus 1 9 8 -2 0 2 ,2 1 7 -2 1 9 - is c h io co ccyg e u s (coccygeus) 1 9 6 ,2 1 4 -2 1 5 , 2 3 2 -2 3 3 , 2 38 - la tissim u s dorsi 6 6 -6 7 ,1 5 4 - 1 5 6 - levator ani 1 4 8 -1 4 9 , 196, 1 9 8 -2 0 1 , 2 1 4 215, 2 1 7 -2 1 9 , 2 2 1 -2 2 6 , 2 3 3 -2 3 5 , 2 3 8 -2 4 0 - lo n g issim u s th o ra cis 155 - m u ltifid i 155 - o b liq u u s e xte rn u s a b d o m in is 154 - o btu ra to riu s - - e xte rn u s 2 3 8 -2 3 9 - - in te rn u s 2 0 1 ,2 1 4 - 2 1 5 ,2 1 9 ,2 2 4 -2 2 5 , 232, 2 3 8 -2 4 0 - o m o h yo id e u s 63 - papillaris ------a n te rio r 17-19, 21 ------p o s te rio r 17-19 ------se p ta lis 17 - p e c tin a ti 17 - p e c tin e u s 2 3 8 -2 3 9 - pecto ralis ------m a jo r 6 3 - 6 7 - - m in o r 64 - p ha ryn g is 45 - p irifo rm is 149, 196, 215, 2 3 2 -2 3 3 - psoas m a jo r 153, 164, 173, 176, 196, 230, 2 39 - p u b o co ccyg e u s 1 4 8 -1 4 9 , 196, 214, 2 23 - p u b o re cta lis 2 23 , 2 38 , 2 40 - q uadratus lu m b o ru m 1 5 2 - 1 5 3 ,1 6 4 ,2 3 0 231 - re ctu s - - a b d o m in is 130, 1 5 3 -1 5 6 ,2 3 8 fe m o ris 2 3 8 -2 3 9 - s a rto riu s 2 3 8 -2 3 9 - scalenus - - a n te rio r 54, 6 0 - 6 1 , 63 - - m e d iu s 68 - s e m im e m b ra n o su s 2 40 - s e m ite n d in o s u s 2 40 - serratus ------a n te rio r 6 3 - 6 8 - - p o ste rio r in fe rio r 155 - s p h in cte r - - a m pu lla e (O D D I) 117 - - ani ----------e x te rn u s 148, 1 9 8 -2 0 0 , 2 02 , 2 17 -2 1 8, 2 2 1 -2 2 6 , 2 36 , 2 40 ----------in te rn u s 148, 2 2 2 -2 2 3 , 2 25 , 2 36 , 240 - - p ylo ricu s 77, 89, 124 urethrae 221 - - - e x te rn u s 181, 1 9 7 -1 9 8 , 216 ureth ro va g in a lis 216

M usculus (-i) - sp le n ius c a p itis 68

Nervus (-i) - th o ra c o d o rs a lis 68

ste rn o c le id o m a s to id e u s 63 s te rn o h yo id e u s 63 s te rn o th y ro id e u s 64 subcla vius 6 3 , 68 subsca p u la ris 6 4 , 68 su pra sp ina tu s 63, 68 su spe n so riu s d uo d e ni (m uscle o f TREITZ) 89 - te n s o r fa sciae latae 2 3 8 -2 3 9 - te re s m a jo r 6 4 - 6 5 , 68 - tra ch e a lis 33 - tra n sve rsu s - - a b d o m in is 1 5 5 ,2 3 0 perinei ----------pro fu n d u s 148, 181, 190, 1 97 -1 9 9, 201, 216, 221, 2 23 , 2 36 ----------su p e rfic ia lis 197, 1 9 9 -2 0 0 ,2 1 7 -2 1 8 ------th o ra cis 67 tra p e ziu s 6 3 - 6 6 , 68 - va stu s lateralis 2 3 9 M yo card ia l in fa rc tio n 27 - co ro n a ry a rte ry s te n o s is 23 M yo ca rd iu m 1 4 -1 5 , 17-19 M y o m e triu m 207

INI N ep h re cto m y, GEROTA's fascia 164 N ep h ro lith iasis, radiating pain 164 N ephron 169 N ervus(-i) - anales 2 26 - a no co ccyg ei 2 00 , 218 - axillaris 68 - cardiacus ce rv ic a lis ------in fe rio r 2 3 , 6 0 -6 1 ------m e d iu s 23 - - su p e rio r 23 - ca vern o si 194 - clun iu m in fe rio re s 2 00 , 218 - cu ta n e u s fe m o ris lateralis 2 3 0 -2 3 1 ------p o ste rio r 2 00 , 218, 2 39 - dorsalis ------c lito rid is 218 - - p enis 192, 197, 2 00 - fe m o ra lis 2 3 0 - 2 3 1 ,2 3 8 - 2 3 9 - g e n ito fe m o ra lis 1 6 4 ,1 9 1 - 1 9 2 ,2 3 0 -2 3 2 ,2 3 8 - g lu te u s in fe rio r 2 3 9 - h y p o g a stricu s 100, 194, 212, 226 - ilio h yp o g a stric u s 164, 2 3 0 -2 3 1 - ilio in g u in a lis 1 6 4 ,1 9 1 -1 9 2 ,2 3 0 -2 3 1 - inte rco sta lis 5 2 - 5 3 , 5 6 - 5 8 , 6 0 - 6 1 , 6 4 , 6 7 , 154, 231 - ischia d icu s 2 3 8 -2 3 9 - labiales p o ste rio re s 2 1 2 ,2 1 8 - laryn g e us re curre n s 10-11, 23, 5 1 -5 4 , 56, 58, 6 0 -6 1 - o b tu ra to riu s 1 9 6 ,2 1 5 ,2 3 0 - 2 3 2 ,2 3 8 - 2 3 9 - pelvici 100 - p erineales 2 00 , 218 - phre n icus 2, 11, 5 1 -5 4 , 56, 6 0 - 6 1 , 6 4 - 6 7 co urse 54 - p u d e n du s 1 9 7 ,2 0 0 - 2 0 1 ,2 1 2 ,2 1 8 - 2 1 9 ,2 2 6 , 2 32 , 2 39 - - e ja culation 194 - re cta le s in fe rio re s 2 0 0 ,2 1 8 - sacralis 212 - scro ta le s p o s te rio re s 2 00 - sp la nchnicus(-i) 8 4 , 2 39 lum b a le s 2 26 - - m a jo r 5 2 - 5 3 , 5 6 - 5 8 , 100, 151, 155, 2 3 0 231 - - m in o r 53, 56, 58, 100, 151, 155 - - p elvici 194, 212, 2 26 - su bco sta lis 164, 2 3 0 -2 3 1 - su prascapularis 63 - th o ra cicu s(-i) 52, 5 6 - 5 8 , 155, 231 longus 6 4 - 6 6 , 68

vaginalis 212 vagus [X] 2, 10-11, 2 3 , 5 1 -5 4 , 56, 58, 6 0 61, 6 3 - 6 7 , 231 - - preg a n glion ic p ara s y m p a th e tic n e u rons 100 N IS S E N 's fu n d o p lic a tio n 75 N odulus(-i) - lym p h o id e i - - agg re g ati (PEYER's plaques) 9 1 ,9 5 so lita rii 78, 87, 91, 94, 222 - valvulae s e m ilu na ris 19 N odus(-i) - a trio v e n tric u la ris (AV node, n ode of TA W A R A ) 2 0 -2 1 - lym ph o id e u s(-i) - - a o rtic i 21 - — laterales 2 35 - - axillaris, 64, 68 - — apicalis 64 - - b ron c h o p u lm o n a le s 3 9 , 4 1 , 6 5 - 6 7 ce rv ic a le s p rofu nd i 48 - - coeliaci 8 3 , 113, 126 colici ----------d e x tri 99 ----------m e d ii 99 ----------s in is tri 99 ------c y s tic i 113 ------g astrici 8 2 - 8 3 ----------d e x tri 82 ----------s in is tri 82 ------g a s tro o m e n ta le s 83, 155 ----------d e x tri 82 ----------s in is tri 82 - - hep a tici 82, 113, 126 ile o co lici 99 - - iliaci ----------co m m u n e s 1 9 5 ,2 1 3 ,2 2 9 ,2 3 5 ----------e x te rn i 195, 213, 2 29 , 2 35 ---------in te rn i 99, 195, 213, 2 35 - - ing u ina les 9 9 ,1 1 3 ,2 1 3 - — in fe rio re s 2 29 ----------p rofu nd i 195, 213, 2 29 ----------s u p e rfic ia le s 1 9 5 ,2 1 3 ,2 3 8 ------------ s u p e ro m e d ia le s 2 29 ------in te rc o s ta le s 59 - - intra p u lm o n a le s 39 - - ju x ta in te s tin a le s 99 - - ju xta o e so p h a g e a le s 4 8 , 59, 67 - - lum b a le s 59, 99, 195, 213, 2 35 - - - in te rm e d ii 2 29 m e d ia s tin a le s 67 ----------an te rio re s 10, 51, 59, 61 - — p o s te rio re s 4 8 , 151 - - m e s e n te ric i - - - in fe rio re s 99 s u p e rio re s 99, 126 - - m e s o c o lic i 99 - - pancreatici 156 - - - in fe rio re s 126 s u p e rio re s 126 - - p a n c re a ticod u o de n a le s 126 - - paracolici 99 - - pararectales 2 35 - - para stern a le s 59 - - paratracheales 3 9 , 5 9 - 6 0 , 64, 68 - - pericardiaci 59 - - phrenici - — in fe rio re s 59, 1 1 3 ,2 2 9 - — su pe rio res 10, 59, 113 - - p re a o rtici 2 35 - - precavalis 235 p ylorici 8 2 - 8 3 - - re cta lis 83 ----------s u p e rio r 2 35 ------re tro a o rtic i 2 35 ------sacrales 195, 213 - - sp le n ici 8 2 - 8 3 , 126, 151, 155 su praclaviculares 59 - - tra c h e o b ro n c h ia le s 35, 53, 59, 68 - - - in fe rio re s 35, 39, 4 8 , 62, 67 su pe rio res 39, 4 8 , 62

Index

Nodus (-i) - sinu a tria lis (sinu-atrial node, n ode o f KEITHFLACK) 2 0 -2 1

o O esophageal atresia 30 O esophageal carcin o m a , lym ph drainage 48 O esophageal varices 47, 81, 112 - b le e d in g 4 9 , 71 - - live r cirrh o sis 112 - - p orto cava l a na sto m o sis 112 - p o rta l h yp e rte n sio n 49 O e so p h a g o sco p y 4 9 , 85 - o esophageal va rice s 49 O e so p ha g u s 2, 30, 4 2 - 4 6 , 4 8 , 5 2 -5 3 , 5 6 -5 8 , 6 2 -6 7 , 7 4 -7 7 , 81, 85, 9 8 , 111, 148, 151, 161, 231 - a rte rie s 4 6 - ce rvica l c o n s tric tio n 45 - d ia p h rag m a tic c o n s tric tio n 45 - d ive rticu la 45 - fo re ig n b o d ie s 45 - lym p h drainage 48 - o e so p h a g o sco p y 49 - p ro je ctio n - - o n to th e b o d y su rfa ce 86 ------o n to th e ve ntra l th o ra cic w a ll 42 - s tru c tu re o f th e w a ll 4 4 - th o ra c ic c o n s tric tio n 45 - ve in s 4 6 - 4 7 O m e n tu m - m a ju s 72, 80, 82, 9 3 - 9 4 , 116, 1 3 0 -1 3 8 , 142, 1 4 8 -1 4 9 , 1 5 2 -1 5 3 , 155, 2 36 - - d e v e lo p m e n t 72 - - p e rito n e al d up licature s 130 - m in u s 72, 80, 103, 121, 1 31 -1 3 2, 138, 155 O m p h a lo ce le 73 O rch is See Testis Organa - genitalia fe m in in a - - e xte rn a 2 02 , 2 04 - - interna 160 - g en ita lia m asculina ------e xte rn a 182, 184, 192 ------interna 160, 183, 185 - urinaria 160 - urogenitalia - - fe m in in a 2 03 - - m asculina 183 O ris 42 Os - c o ccyg is 148, 199, 217, 2 3 8 -2 3 9 - ilium 1 5 0 ,2 1 4 ,2 4 0 - ischii 201, 2 38 - p ubis 148, 150, 186, 198, 216, 221, 2 3 8 2 39 - sacrum 1 4 8 -1 4 9 , 214 O stiu m - a bd o m ina le tu b a e uterinae 2 06 - a p p e n d icis v e rm ifo rm is 95 - a triove n tricu la re - - d e x tru m 17 ------sin is tru m 1 8 -1 9 , 66 - ca rdia cu m 77, 1 3 8 -1 3 9 , 1 50 -1 5 1, 153 - ileale 95 - p rim u m 7 - p ylo ricu m 89 - se cu n d u m 7 - sinu s coronarii 1 7 ,2 4 - u rete ris 177, 1 7 9 -1 8 0 , 2 3 6 -2 3 7 - urethrae 2 05 - - e x te rn u m 1 7 8 -1 8 0 , 1 8 6 -1 8 7 ,2 0 2 -2 0 3 , 2 1 7 -2 1 9 , 2 3 6 -2 3 7 - - in te rn u m 1 7 7 -1 8 0 , 1 8 6 ,2 0 9 ,2 3 6 - 2 3 7 - u te ri 207, 2 0 9 -2 1 0 , 237 - u te rin u m tu b a e ute rin a e 207 - vaginae 2 0 2 -2 0 3 ,2 1 9 - venae cavae in fe rio ris 21 O va ry (O varium ) 93, 139, 160, 2 03 , 2 0 5 -2 0 8 , 2 11 -2 1 2, 2 34 , 2 37

Ovary (Ovarium) - in fla m m a to ry p roce ss 159

Pars - convoluta

------(Tubulus distalis) 169 ------(Tubulus proxim alis) 169 - costalis - - d ia p h rag m a tis 114, 1 5 2 -1 5 6 - - (Pleura parietalis) 4 0 , 5 2 -5 3 , 6 4 , 1 5 2 -1 5 6 - d esce n d en s - - a o rta e (A o rta d escendens) 13, 4 5 , 4 8 , 55, 6 5 -6 7 - - d uo d e ni 75, 77, 8 8 - 9 0 , 93, 117, 120, 1 2 2 124, 127 - — p ro je ctio n ------------ o n to th e b o d y su rfa ce 86 ------------ o n to th e ve ntra l a bd o m ina l w a ll 86 - diap h rag m a tica (Pleura parietalis) 1 1 ,4 0 ,5 4 , 151, 1 5 4 -1 5 6 - horizo n ta lis (D uodenum ) 8 8 - 9 0 , 117, 120, 1 22 -1 2 4, 135, 137, 139 ------p ro je ctio n - — o n to th e b o d y su rfa ce 86 - — o n to th e ve ntra l a bd o m ina l w a ll 86 - in tra m u ra lis (U rethra m asculina) 1 7 8 -1 7 9 - in tra s e g m e n ta lis 68 - laryngea p ha ryn g is 28, 42 - lum b a lis d ia p h rag m a tis 4 3 , 5 6 -5 7 , 62, 114, 142, 1 4 8 -1 4 9 , 151, 1 5 4 -1 5 6 - m e d ia s tin a lis (Pleura parietalis) 11, 35, S I 52, 65 - m e m bra n a cea - - (S e ptu m interve n tricu la re ) 6 -7 , 19 - - (Urethra) 1 7 8 -1 7 9 , 186, 2 36 - m u s c u la ris (S eptum interve n tricu la re ) 6 -7 , 17-18 - nasalis p ha ryn g is 28 - oralis pha ryn g is 28, 42 - p o s te rio r (Fornix vaginae) 2 0 9 ,2 3 7 - profu nd a (M . s p h in c te r ani exte rn us) 2 23 - p ro sta tica (Urethra) 1 77 -1 7 9, 190 - pylorica (Pylorus) 58, 7 4 -7 7 , 8 0 , 85, 8 8 - 9 0 , 130, 133, 138, 153 - recta ------(Tubulus distalis) 169 - - (Tubulus proxim alis) 169 - sp on g iosa (U rethra) 1 7 8 - 1 7 9 ,1 9 2 ,2 3 6 - s te m a lis d ia p h rag m a tis 62 - su bcutanea (M . s p h in c te r ani exte rn us) 202, 223 - s u p e rfic ia lis (M . s p h in c te r ani exte rn us) 223 - s u p e rio r (D uodenum ) 75, 77, 8 8 - 9 0 , 1 1 6 117, 120, 123, 1 3 8 -1 3 9 , 150 - - p ro je ctio n ----------o n to th e b o d y su rfa c e 86 - — o n to th e v e n tra l a bd o m ina l w a ll 86 - te rm in a lis ilei 95, 135 - th oracica - - a orta e (A o rta thoracica) 7, 38, 4 3 - 4 6 , 53, 5 5 - 5 6 , 58, 6 4 , 122, 154 - — bran ch e s 56 ------(D u ctu s th o ra cicu s) 53, 5 6 - 5 7 - - (O esophagus) 4 3 - 4 6 , 4 8 , 53, 5 6 - 5 8 , 62, 151 - uterina 2 07 P ecten analis (Canalis analis) 2 2 2 -2 2 3 P elvic flo o r - fu n c tio n 196 - in m an 198 - m u s c le s 196 - in w o m a n 2 1 4 -2 1 5 Pelvic flo o r in s u ffic ie n c y 214 P elvic kidneys 162 P elvic viscera - in m an, blood s u p p ly 2 3 3 - in w o m a n , blood s u p p ly 2 34 Pelvis 1 4 8 - 1 5 0 ,1 7 9 - 1 8 0 ,2 3 5 - 2 3 9 - fe m a le 1 8 0 ,2 3 7 - - lym ph nod e s and ly m p h v e s s e ls 2 35 - - tra n sve rse s e c tio n 2 39 c o m p u te d to m o g ra p h y 2 39 - m ale 1 4 8 -1 5 0 , 179, 2 36 - - o b liq u e fro n ta l s e c tio n 2 40 tra n sve rse s e c tio n 2 38

p e rito n e al d u p lic a tu re s 2 06 , 2 08

P Pancreas 42, 72, 74, 82, 102, 1 2 0 -1 2 4 , 1 2 6 128, 132, 1 3 5 -1 3 6 , 142, 1 4 7 -1 4 8 , 151, 1 5 5 156, 161 - anulare 121 - a rte rie s 125 - c o n ta c t area o n to th e p o s te rio r w a ll o f s to m ach 79 - d e v e lo p m e n t 121 - d iv is u m 121 - ERCP 127 - e xc re to ry d u c t s y s te m 124 - h is to lo g y 123 - in fla m m a tio n 120 - lym p h a tic drainage 126 - p ro je ctio n ------o n to th e su rfa ce o f th e b o d y 86 - - o n to th e ve ntra l a bdom inal w all 8 6 , 120 - ultraso u n d im age 127, 155 P ancreatic bud s 103,121 - fu s io n 121 P ancreatic ca rcin o m a 119 - lym ph n ode m e ta s ta s e s 126 P ancreatic dise a se s 124 P an cre a titis 71, 120, 123 - bile c o n c re m e n ts 124 - ultraso u n d im ag e 155 Papilla - d uodeni - - m a jo r (am pulla o f VATER) 8 8 - 8 9 , 117118, 124 ---------- e n d o s c o p y 122 ------m in o r 88, 117, 124 - m a m m aria 67 - renalis 1 6 7 -1 6 8 , 174, 176 Papillary m u s c le s 17, 19 Paracystium 2 09 P aradidym is 183 P aram etrium 2 09 P araproctium 2 0 9 P a rasym p a th e tic n ervo u s s yste m - e ffe c t on th e h e a rt 23 - e re c tio n 194 - p e rfu s io n o f th e in te s tin e s 100 - sacral d ivision 1 00 ,23 1 Paravertebral line 29 - b o rd e rs o f th e lungs 29 Paries - a n te rio r (Gaster) 8 5 , 131-132 - m e m b ra n a ce u s (Trachea) 33, 62 - p o s te rio r (Gaster) 85 Pars - abd o m ina lis ------a o rta e (A o rta abd o m ina lis) 9, 4 3 , 56, 58, 114, 127, 140, 1 47 -1 4 8, 151, 156, 165, 1 72 -1 7 3, 193, 2 26 , 2 28 , 2 30 , 2 3 2 -2 3 3 , 2 35 ----------branches 2 28 ------oeso p h ag e a e 4 5 - 4 6 , 58, 75, 77 ----------a rte rie s 4 6 ------(O esophagus) 43 - a n te rio r ------(Facies d ia p h rag m a tica, Hepar) 106 ------(Fornix vaginae) 2 09 - ascen d e ns ------a orta e (A o rta ascendens) 10, 13, 17, 21, 2 4 -2 5 , 5 5 - 5 6 , 58, 62, 6 5 - 6 6 - - d uo d e ni 8 8 - 9 0 , 9 3 , 117, 120, 124, 137 p ro je c tio n 86 ------------- o n to th e bod y su rfa c e 86 ------------ o n to th e ve ntra l a bd o m ina l w a ll 86 - cardiaca 4 3 , 75 - ce rv ic a lis (O esophagus) 4 3 - 4 4 , 4 6 , 4 8 , 62 - - a rte rie s 46 - - ve in s 46

Index

Pelvis male - - c o m p u te d to m o g ra p h y 2 3 8

Plexus - o eso p h ag e u s 52, 58, 231

Processus - p apillaris 155

- ovaricus 212 - p a m p in ifo rm is 187, 189, 1 9 1 -1 9 3 - p ro s ta tic u s 194 - p u lm o n a lis 5 2 -5 3 - rectalis 2 26 - renalis 100 - sacralis 212, 226, 2 3 1 -2 3 2 - sp le n icus 100 - te s tic u la ris 191, 194 - u rete ricu s 100 - uterovaginalis (FR A N K E N H À U S E R 's p le xus) 212 - ve no su s ------p ro sta ticu s 193, 201, 2 3 3 , 2 36 - - re cta lis 225, 2 3 3 -2 3 4 - - su b m u co s u s 47, 112 u te rin u s 2 3 4 - - vaginalis 2 3 4 - - ve rte b ra lis in te rn u s (p oste rio r) 6 2 - 6 3 - - vesica lis 201, 219, 2 3 3 -2 3 4 , 2 3 7 -2 3 8 Plica(-ae) - caecalis va scularis 135 - circulares (KER CKR IN G's fo lds) 7 7 ,8 9 - 9 1 , 124 - duo d e na lis in fe rio r 137, 139 - g astrica e 77, 85 - gastro pa n crea tica 1 3 2 -1 3 3 , 139 - hepato p a ncre a tica 1 3 2 -1 3 3 , 139 - ile ocaecalis 135, 139 - inte ru re te rica 177 - lo n g itu din alis d uo d e ni 124 - m u cosa e (Vesica biliaris) 117 - re cto u te rin a 2 06 , 237 - re cto ve sica lis 2 3 6 - se m ilu na re s coli 9 4 - 9 5 , 101 - spiralis (HEISTER) 88, 117, 119 - tra n sve rsa recti 148, 180, 2 2 2 -2 2 3 , 2 36 - u m bilica lis - - lateralis 2 33 ------m e dia lis 2 08 , 2 33 , 237 ------m ediana 2 3 6 -2 3 7 P n e u m o th o ra x 29 - central ve no u s c a th e te r (CVC) 3 5 , 63 Porta hep a tis 104 Portal h ype rten sion 47, 81, 106, 2 25 - live r cirrh o sis 98 - o esophageal v a rice s 49 - p orto cava le a na s to m o s e s 49 Portal syste m , h y p e rte n s io n 98 Portal tra c ts 106 Portal ve in 81, 141 - increased b lo o d p ressu re 81 - trib u ta rie s 141 - u ltraso u n d im ag e 114 P ortio - supravaginalis c e rv ic is 207 - vaginalis ce rv ic is 207, 2 0 9 -2 1 0 , 237 P ortocaval a n a stom o se s 4 6 - 4 7 , 81, 9 8 , 106, 112, 225 - b le e d in g s o f e sophageal v a rice s 112 - p o rta l h yp e rte n s io n 49 P o ste rio r m yocardial in fa rc tio n (P M I) 10, 27 P ostnatal circula tion 9 Pouch o f D O U G L A S (Excavatio re c to u te ri na) 1 3 8 -1 3 9 ,2 0 8 - 2 1 0 ,2 3 7 ,2 3 9 - a p p e n d icitis 237 - s a lp in g itis 2 37 P reganglionic p ara s y m p a th e tic neu ro n s 100 P reganglionic s y m p a th e tic neu ro n s 100 Prenatal circula tion 8 P re pu tiu m - clito rid is 202 - p enis 182, 1 8 6 -1 8 7 , 2 3 6 P rim ary intestin a l loop 73 P rim itive laryngeal in le t 31 Prim ordial g u t, d e v e lo p m e n t 72 Prim ordial o vary 163 Prim ordial te s tis 163 P rocessus - a rticu la ris su p e rio r 154 - co raco id eu s 68

- sp in o su s 6 3 - 6 4 , 67, 173 - tra n s v e rs u s 65 - uncin a tu s 1 2 3 -1 2 4 , 144, 149 - xip h o id e u s 62, 67, 74, 154, 210 P roctodeal glands (Gil. anales) 2 23 P ro m o n to riu m 148 P ronephros 162 P rostate (Prostata) 1 4 8 -1 4 9 , 160, 177-178, 181, 183, 1 8 5 -1 8 6 , 190, 194, 198, 201, 221, 2 23 , 2 33 , 2 36 - d ig ita l rectal e xam in a tion (DRE) 221 - zones 190 P ro sta tic ca rcin o m a 1 5 9 ,1 9 0 - d ig ita l rectal e xam in a tion (DRE) 221 Pubes 182 P ulm o 2, 4 0 , 74, 102, 115, 120, 128, 161 - d e x te r 11, 28, 3 4 - 3 6 , 4 0 , 5 0 -5 1 , 5 4 , 6 3 -6 7 , 149, 151-152 - s in is te r 11, 28, 3 4 - 3 6 , 4 0 , 51, 54, 6 3 - 6 4 , 6 6 - 6 8 , 151, 153 P u lm o n a ry c ircula tion 2 P u lm o n a ry e m b o li, rig h t v e n tric u la r h y p e rtro p hy 15 P u lm o n a ry h y p e rte n s io n 5 - righ t v e n tric u la r h y p e rtro p h y 15 P u lm o n a ry ring 16 P u lm o n a ry va lve 16 - p ro je c tio n o n to th e ventral th o ra c ic w all 4 P u lm o n a ry va lve s te n o s is 7 - rig h t v e n tric u la r h y p e rtro p h y 15 P u lm o n a ry v e in s 18 Pulpa splenica 129 P ye lo n e ph ritis, re fe rred pain 164 P ylorus (Pars pylorica) 58, 7 4 -7 7 , 8 0 , 85, 8 8 90, 130, 133, 138, 153 P yra m id e s renales 1 6 7 -1 6 8 ,1 7 3 -1 7 4

renalis 160, 1 6 6 -1 6 8 , 1 73 -1 7 4, 176, 183, 2 03 P enis 1 8 2 -1 8 3 , 1 8 5 -1 8 7 , 192 - ca vern o u s b odies 186 P e rfu sio n o f th e in te stin e s - p ara sym p a th e tic in flu e n ce 100 - s y m p a th e tic in flu e n ce 100 Pericardial ca v ity 30, 72 Pericardial e ffu s io n 11 Pericardial ta m p o n a d e 11 P erica rd itis 11 P ericardium 2, 11, 13, 4 0 , 4 4 , 50, 5 4 , 153 - fib ro s u m 11, 4 8 , 5 1 -5 3 - se rosu m 2, 11-13, 17-18, 62 P e rim e triu m 207 Perineal m u scle s - in man 1 9 7 -1 9 8 - in w o m a n 216 Perineal region - in man 199 - - v e sse ls and n erve s 2 0 0 - in w o m a n 217 ------v e sse ls and n erve s 218 Perineal space - d e e p 197, 199, 201, 217, 219 - in m an 201 - s u p e rfic ia l 197, 199, 217, 219 - in w o m a n 219 Perineal tears 217 P erineum 199, 2 02 , 217 P e rio rch iu m 187 P eritoneal ca rcin o sis 133 P eritoneal c a v ity 70, 72, 148, 158 - dorsal w a ll 139 - recesse s 139 P e riton e u m 105 - p arietale 70, 116, 130, 148, 1 5 4 -1 5 6 , 181, 201, 219, 2 2 1 -2 2 2 , 237, 2 40 - visce ra le 70, 87, 148, 152, 1 5 4 -1 5 5 P e rito n itis 133 - a pp e n dicitis, p erfo ra tio n 95 PEYER's p la ques (N oduli ly m p h o id e i a g g re g a te 91, 95 P h a ryn x 28, 42, 85 P him osis 186 - c irc u m cisio n 186 P hosph o die ste ra se, e nzym e in h ib ito rs, e rec tio n 192 P hysiological um bilical hernia 73 Placenta 8, 210 Pleura - parie ta lis 1 1 , 3 5 , 4 0 ,5 1 - 5 4 , 6 3 - 6 5 ,1 5 1 - 1 5 6 - vis c e ra lis (pulm onalis) 4 0 , 6 3 - 6 4 , 68, 152— 153 Pleura bord e rs, p ro je ctio n - o n to th e a n te rio r th o ra cic w a ll 29 - o n to th e p o s te rio r th o ra cic w all 29 Pleural ca v ita ty 2, 4 0 , 50, 5 2 -5 3 Pleural cupula, tra n sve rse s e c tio n s a t th e level o f th e s h o u ld e r jo in t 63 Pleural e ffu s io n s 29, 40 Plexus - a o rticu s ------a b d o m in a lis 226, 231 ------th o ra cicu s 11, 5 3 , 58 - brachialis 51, 6 0 -6 1 , 6 3 - 6 4 , 68 - cardiacus 23, 5 3 - 5 4 , 58 - coelia cus 100, 2 26 , 231 - d e fe re n tia lis 191, 194 - h e p a ticu s 100 - h ypo g a stricu s - - in fe rio r 100, 194, 212, 226 - - s u p e rio r 100, 194, 212, 2 26 , 231 - in te rm e s e n te ric u s 100, 231 - lum b a lis 164, 2 30 branches 2 30 - m e se n te ricu s - - in fe rio r 100, 231 s u p e rio r 100, 231

R Radiograph(s) - a fte r intravenous a pp licatio n o f c o n tra s t m e diu m 119 - co lon 101 - d uodenal u lce rs 90 - d u o d e n u m 90 - e xtra h e p a tic bile d u c ts 119 - gallb la d de r 119 - h ea rt c o n to u rs 5 - in tra h e p a tic bile d u c ts 119 - le ft b o rd e r o f th e h ea rt 5 - renal p elvis 176 - rig h t b o rd e r o f th e h ea rt 5 - th o ra c ic cage 5, 41 - th o ra c ic v iscera 5, 41 - th o ra x 3, 5 - u rete r 176 - - va ria tio n s 176 Radix - m e s e n te rii 139 - parasym p a th ica 1 9 4 ,2 1 2 ,2 2 6 Ram us(-i) - a nte rio r - - (A. p a n c re a ticod u o de n a lis inferior) 96, 125 - - (A. renalis) 166 ------(V. p o rta e h epatis) 114 - atriales (A. coronaria d extra) 26 (A. coronaria sinistra) 26 - a triove n tricu la re s - (A. coronaria d extra) 26 - (A. coronaria sinistra) 26 - bronchiales - - (A orta) 38, 52, 56 (N. vagus) 56, 58 - cardiacus(-i) ------c e rv ic a lis in fe rio r (N. vagus) 23 ------th o ra c ic i ----------(N. vagus) 23, 5 2 - 5 4 ----------(Truncus sym p ath icu s) 53

Index

Ramus(-i) - c irc u m fle x u s (A. coronaria sinistra) 13, 2 4 26 - coelia cus (Truncus vagalis) 84 - co licu s (A. ileocolica) 9 6 -9 7 , 143, 146 - co m m u n ica n te s (Truncus sym p ath icu s) 52, 58, 194, 212 - coni a rte rio si - - - (A. coronaria d extra) 24, 26 - - - (A. coronaria sinistra) 24 - d e xte r - - (A. hep a tica propria) 155 ------(V. p o rta e hepatis) 114, 141, 150, 1 5 4 -1 5 5 - fe m o ra lis (N. g e n ito fe m o ra lis) 2 30 - g astrici a n te rio re s (Truncus vagalis a n te ri or) 58, 84 - g e n ita lis (N. g e n ito fe m o ra lis) 1 9 1 -1 9 2 ,2 3 0 , 232, 2 3 8 - helicin i (A. uterina) 211 - hep a tici (Truncus vagalis) 84 - ilealis (A. ileocolica) 9 6 , 143 - in fe rio r o ssis p ubis 1 8 6 ,2 1 6 - in te rg a n glion a ris (Truncus sym p ath icu s) 212 - in te rve n tricu la ris(-es) - - a n te rio r (A. coronaria sinistra) 12, 19, 2 4 27, 67 ------p o ste rio r (A. coronaria dextra) 13, 24, 2 6 27 - - se pta le s - — (A. coronaria dextra) 26 - — (A. coronaria sinistra) 24, 26 - labiales p o ste rio re s (A. pudenda interna) 218 - lateralis (R. diagonalis, A . coronaria sinistra) 24, 2 6 -2 7 - m arginalis - - d e x te r (A. coronaria dextra) 24, 26 - - s in is te r (A. coronaria sinistra) 24, 26 - nodi - - a trio ve n tricu la ris (A. coronaria dextra) 20, 24, 26 - - sinuatrialis ----------(A. coronaria dextra) 20, 24, 26 ----------(A. coronaria sinistra) 24 - o b tu ra to riu s (A. e pig a strica inferior) 232 - oeso p h ag e a le s - - (A. g astrica sinistra) 4 6 , 140 (A. th yro id e a inferior) 4 6 ------(N. laryn g e us recurrens) 56, 80 ------(Pars th o ra cica aortae) 4 6 , 56 - - (V. cava inferior) 47 (V. p o rta e hepatis) 47 - o m e n ta le s ------(A. g a s tro o m e n ta lis dextra) 80 - - (A. g a s tro o m e n ta lis sinistra) 8 0 , 142 - o ssis ischii 1 9 7 ,2 1 6 ,2 3 9 - ovaricus (A. uterina) 211 - pan cre a tici (A. splenica) 125 - perica rd ia cu s (N. p hrenicus) 54 - p erin e ale s (N. cu ta n e u s fe m o ris p o s te ri or) 2 00 , 218 - p hre n icoa b d om in ale s (N. phrenicus) 54 - p o ste rio r - - (A. p a n cre a ticod u o de n a lis inferio r) 96, 125 ------(A. renalis) 166 ------(V. p o rta e hepatis) 114, 154 - - v e n tricu li s in istri (A. coronaria sinistra) 24, 26 - p o ste ro la te ra lis d e x te r (A. coronaria dextra) 24, 26 - p ub icu s ------(A. e pig a strica inferio r) 232 ------(A. obtu ratoria ) 2 32 - scro ta le s ------a nte rio re s (V. dorsa lis profunda penis) 192 ------p oste rio re s ----------(A. perinealis) 2 0 0 ----------(A. pudenda interna) 2 33 ----------(V. p udenda interna) 233 - s in is te r (V. p o rta e hepatis) 114, 127 - sp le n ici (A. splenica) 144 - su be n d oca rd iale s 20 - su p e rio r o ssis p ubis 1 9 6 ,2 1 6

Ram us (-i) - tu b a riu s (A. uterina) 211 - vaginales (A. uterina) 211 Raphe - perinei 199, 202, 217 - sc ro ti 187, 189, 191 R ecessus - axillaris 68 - co s to d ia p h ra g m a tic u s 5 ,2 9 , 4 0 - 4 1 , 5 0 , 5 4 , 1 5 2 -1 5 4 , 156 - co s to m e d ia s tin a lis 4, 4 0 , 50, 64, 67 - duo d e na lis - - in fe rio r 136, 139 su p e rio r 136, 139 - ile ocaecalis ------in fe rio r 1 3 5 -1 3 7 , 139 ------su p e rio r 135, 137, 139 - in fe rio r (Bursa o m en talis) 1 3 2 -1 3 3 - in te rs ig m o id e u s 136, 139 - p h re n ic o m e d ia s tin a lis 4 0 - p n e u m a to e n te ric u s 72 - sig m o id e u s 139 - splenicus (Bursa om entalis) 1 3 2 -1 3 3 ,1 3 9 ,1 5 5 - su p e rio r (Bursa o m en talis) 1 3 2 ,1 3 9 ,1 5 5 - ve rte b ro m e d ia s tin a lis 4 0 , 6 4 , 66 R ectal p rolapse 2 23 R ectoce le 214 R ectoscopy, anal canal 227 R ectum 74, 81, 92, 9 7 -9 8 , 101, 111, 120, 1 3 7 138, 1 46 -1 4 7, 149, 161, 181, 196, 198, 2 0 8 2 09 , 215, 2 1 9 -2 2 6 , 230, 2 35 , 2 3 8 -2 3 9 - a rte rie s 2 24 - in n e rv a tio n 2 26 - lym ph nod e s and ly m p h v e s s e ls in a w o man 2 35 - in th e m ale p e lv is 221 - p ro je c tio n o n to th e b o d y su rfa c e 8 6 , 2 20 - v e in s 2 25 Red pulp, sp leen 129 R eferred pain 115 - in th e rig h t sh ou ld er - - c h o le c y s titis 54 ------live r b io p sies 54 Regio - analis 158, 199, 217 - perin e alis 1 5 8 ,1 9 9 ,2 0 1 ,2 1 7 - 2 1 9 in m an 1 9 9 -2 0 0 - u rog e n italis 158, 199, 217 R elative cardiac d u lln ess 4 Ren (N ephros) 74, 1 0 2 -1 0 3 , 120, 122, 1 2 7 128, 131, 136, 1 3 8 -1 3 9 , 147, 1 51 -1 5 3, 1 5 5 156, 1 6 0 -1 6 8 , 171, 173, 1 7 5 -1 7 6 , 183, 185, 193, 2 03 , 205, 2 28 - See also Kidney Renal b io p s y 173 Renal calices 167 Renal cell ca rcin o m a 171 Renal c o n c re m e n ts 175 Renal co rp u scle 169 Renal c o rte x 167 - m ic ro s c o p y 168 Renal in fa rc tio n 165 Renal m e dulla 167 Renal p elvis 167, 174 - radiograph 176 Renal p yram id s 167 Renal s e g m e n ts 165 Renal tu m o u rs , o b s tru c tio n o f th e ve no u s drainage 193 Renal ve in s 169 R esp irato ry d is tre s s s y n d ro m e (RDS) 30 R esu scita tio n, anatom ical dea d -sp ace 32 Rete te s tis 163 R etrofle xio n o f th e u te ru s 2 08 R e trop e rito ne a l organs 70, 138 R e trop e rito ne a l space 70, 158, 2 28 - a u to n o m ic n ervo u s s y s te m 231 - lym ph nod e s 2 29 - lym ph v e ssels 2 29 - so m a tic n erve s 2 30 R etrove rsio n o f th e u te ru s 2 08 R ETZIU S ' space (S patium re tro p u b ic u m ) 2 0 9 210, 2 3 6 -2 3 7 , 2 39

R ight and le ft branches o f th e a rtio v e n tric u la r bundle (Crus d e x tru m and sin is tru m , bundle o fT A W A R A ) 1 7 ,2 0 R ight v e n tric le 17 R ight v e n tric u la r h y p e rtro p h y 7, 15 R ig h t-to -le ft s h u n t 7 Rima o ris 42 R IO L A N 's a na s to m o s is 97, 140, 143, 1 4 5 -1 4 7 Rugae vaginales 207, 2 09

s Saccus a o rtic u s 6 S alpingitis, pou ch o f D O U G LA S 237 S alpinx (Tuba uterina) 139, 160, 2 03 , 2 0 5 -2 0 8 , 2 11 -2 1 2, 2 34 S A N T O R IN I's d u c t (D u ctu s p an cre a ticus a cces sorius) 88, 117, 121, 124 Scalene gap 60 Scapula 5, 6 3 - 6 5 , 68 S capular 29 - b ord e rs o f th e lungs 29 S cro tu m 182, 184, 187, 2 36 S e g m e n ta l b ron ch i 36 - b ro n c h o s c o p y 37 S egm e n tu m (-a ) - anterius - - (Hepar) 107 inferiu s - — (Hepar) 108 - — (Ren) 165 ------(P ulm o d exter) 36 ------(P ulm o sinister) 36 ------supe riu s ----------(Hepar) 108 - — (Ren) 165 - apicale (P ulm o d exte r) 36 - a p ic o p o s te riu s (Pulm o sinister) 36 - basale anterius ----------(Pulm o d exte r) 36 ----------(Pulm o sinister) 36 laterale ----------(P ulm o d exte r) 36 ----------(P ulm o s iniste r) 36 - ----- m e diale (cardiacum ) (P ulm o d exter) 36 ------p o s te riu s ----------(Pulm o d exte r) 36 ----------(P ulm o s iniste r) 36 - b ron ch o pu lm on a lia 3 6 - 3 7 - in fe riu s (Ren) 165 - laterale ------in fe riu s (Hepar) 1 0 7 -1 0 8 - - (P ulm o d exte r) 36 ------su p e riu s (Hepar) 1 0 7 -1 0 8 - lingulare ------in fe riu s (P ulm o sinister) 36 ------su p e riu s (Pulm o sinister) 36 - m e diale ------in fe riu s (Hepar) 1 0 7 -1 0 8 ------(P ulm o d exte r) 36 ------su p e riu s (Hepar) 1 0 7 -1 0 8 - p o s te riu s ------in fe riu s (Hepar) 1 0 7 -1 0 8 ------(P ulm o d exte r) 36 - - (Ren) 165 ------su p e riu s (Hepar) 1 0 7 -1 0 8 - renalia 165 - supe riu s ------(P ulm o d exte r) 36 ------(P ulm o s iniste r) 36 ------(Ren) 165 Sem inal ve s ic le (Gl. ve siculosa) 178, 183, 190 S e m in ife ro u s tu b u le s 188 S eptula te s tis 1 8 8 -1 8 9 S e p tu m - a trio v e n tric u la re (Pars m em branacea) 7 - intera tria le 17-18 - in te rv e n tric u la re 6 - 8 , 1 7 -2 0 , 66 - - (Pars m e m bra n a cea ) 7 - - (Pars m u scula ris) 7

Index

Septum - o e s o p h ag o tra ch ea le 31

Stomach - d e v e lo p m e n t 72

Tela - subserosa

- - d e v e lo p m e n t 31 - p enis 192 - p rim u m 7 - s cro ti 187, 189, 191 - se cu n d u m 7 - s p u riu m 7 - tra n sve rsu m 72 - ve sico va g in a le 2 37 S e p tu m fo rm a tio n , d e ve lo p m e n ta l ste p s 7 S ho uld er jo in t 68 S inu-atrial n ode (N odus sinuatrialis, node o f KE ITH -FLAC K) 2 0 -2 1 Sinus - anales (anal cry p ts ) 2 2 2 -2 2 3 , 227 - a orta e 19, 67 - co ron a rius 13, 15, 25 - e p id id y m id is 188 - o b liq u u s p erica rd ii 11,1 3 - paranasales 28 - p ro s ta tic u s 177 - renalis(-es) 1 5 6 ,1 6 7 -1 6 8 ,1 7 3 -1 7 4 - tra n sve rsu s p ericardii 11, 13, 62, 66 - tru n c i p u lm o n a lis 15 - u rog e n italis 163 - v e n a ru m cavarum 25 S inus se p tu m 7 S inus valves 7 Situs - co rdis 10 - inve rsu s 73 - v is c e ru m 1 3 0 -1 3 6 Sm all in te stin e - See also In te stin u m te n u e - a u to n o m ic in n e rva tion 100 - c ro ss-se ctio n 87 - m e s e n te rie s 137 - p ro je ctio n o n to th e ventral a bdom inal w a ll 86 - regional lym p h nod e s and lym ph ve ssels 99 - tu m o rs 71 - v e in s 98 - w a ll s tru c tu re 87 S o nography See u ltraso u n d im age(s) S patium - epid u rale 154 - e x tra p e rito n e a le 70, 158 p e lvis 70, 158 - p ro fu n d u m perinei 1 9 7 ,1 9 9 ,2 0 1 ,2 1 7 ,2 1 9 - re tro p e rito n e a le 70, 158 - re tro p u b icu m (space o f RETZIUS) 2 0 9 -2 1 0 , 2 3 6 -2 3 7 , 2 39 - re tro re cta le 2 09 - s u ba ra ch no id eu m 63 - s u p e rficia le perinei 1 9 7 ,1 9 9 ,2 0 1 ,2 1 7 ,2 1 9 S p e rm a tic cord See Funiculus sp e rm a ticu s Spina - iliaca ------a n te rio r su p e rio r 74, 9 3 , 182, 210 ------p o s te rio r su p e rio r 161 - ischiadica 2 38 - scapulae 29, 63 Spinal cord injuries 54 S pleen (Splen, Lien) 72, 74, 8 0 -8 1 , 93, 98, 1 0 2 -1 0 3 , 110-111, 120-121, 1 2 8 -1 2 9 , 1 3 1 133, 139, 142, 151, 1 5 3 -1 5 5 , 161 - c o n ta c t area on th e p o ste rio r w a ll o f th e sto m a ch 79 - in fa rctio n 129 - p e rito n e al d u p lica tu re s 129 - ru ptu re 71, 129 S p o ntan e o us b re a thin g 30 Sternal line, b ord e rs o f th e lungs 29 S te rn u m 51, 62, 6 5 , 67, 74, 210 S teroid h o rm o n e s, adrenal gland 170 S tom ach 30, 75, 77, 85 - See also G aster - a rte rie s 80 - a u to n o m ic in n e rva tio n 84 - c o n ta c t areas 79 - - o f th e a n te rio r w a ll 79 o f th e p o s te rio r w a ll 79

- e x it 77 - inner m u scle layers 76 - lym ph nod e s and ly m p h v e s s e ls 82 - lym p h a tic drainage sta tio n s 83 - p ara sym p a th e tic fib re s 84 - p ro je ctio n ------o n to th e b o d y su rfa ce 86 - - o n to th e ve ntra l a bd o m ina l w a ll 74 - regional lym p h nod e s 83 - s y m p a th e tic fib re s 84 - ve in s 81 - w all 78 S tratum - circulare re cti 223 - - (Tunica m uscula ris, D uo d e nu m ) 89 - - (Tunica m uscula ris, G aster) 76, 78 (Tunica m uscula ris, In te s tin u m cras sum ) 87, 94 - - (Tunica m uscula ris, In te s tin u m te n u e) 87 (Tunica m uscula ris, O esophagus) 4 4 - longitu din ale - - re cti 2 2 2 -2 2 3 ------(Tunica m uscula ris. D uo d e nu m ) 89 ------(Tunica m uscula ris, Gaster) 78 - - (Tunica m uscula ris, In te s tin u m cras sum ) 87, 94 ------(Tunica m uscula ris, In te s tin u m te n u e) 87 ------(Tunica m uscula ris. O esophagus) 4 4 S U D EC K's p o in t 224 Sulcus - a o rticu s 35 - a rte ria e subclaviae 35 - co ron a rius 1 2-1 3 , 15, 25 - in te rve n tricu la ris - - a n te rio r 12, 15 - - p o s te rio r 12-13, 15, 25 - te rm in a lis 13 - ve na e brach io cep h a lica e 35 S u p e rio r th o ra c ic a pe rture , n eurovascular s tru c tu re s 6 0 -6 1 Suprarenal a rte rie s 172 - va ria tio n s 172 Suprarenal g lands 122, 166, 170 - in th e re tro p e rito n e a l space 164 Suprarenal v e in s 172 - va ria tio n s 172 S u rfa cta n t 30 S y m p a th e tic inne rva tion - e m issio n 194 - p e rfu s io n s o f th e in te s tin e s 100 S y m p a th e tic to n u s , increased - h e a rt rate 23 - h yp e rte n sio n 23 - ta ch yca rdia 23 S y m p a th e tic tru n k 2, 58 S ym p h ysis pubica 74, 150, 181, 1 96 -1 9 7, 202, 2 0 9 -2 1 0 , 214, 216, 2 32 , 2 3 6 , 2 3 8 -2 3 9 S yste m ic c ircu la tio n 2 S ysto le 16

- - (Gaster) 78 - - (Ileum ) 91 - - (In te s tin u m crassum ) 94 - - (In te s tin u m te n u e) 87 - - (Jejunum ) 91 - - (P e riton e u m viscerale) 87 Term inal ileum 95 Testicu la r c a nce r 1 8 5 ,1 9 4 - ly m p h n ode m e ta s ta s e s 195 - tra n s s c ro ta l te s tic u la r b io p s y 195 T e stis (O rchis) 160, 183, 185, 1 8 8 -1 8 9 , 191, 194 - co verin g s 187, 191 - lob u les (Lobuli te s tis ) 188 - p rim o rd ia l 163 T e sto ste ro n 183 - W O L F F IA N d u c ts , d iffe re n tia tio n 185 T high, m u scle s 196 T h o racic a orta 4 3 - 4 4 T h o racic cage - in fe rio r 151 - p o s te ro -a n te rio r radiograph 5 - radiograph 41 T h o racic c a v ity 6 2 , 68 - radiograph 5, 41 - tra n sve rse s e c tio n 6 4 - 6 7 - - c o m p u te d to m o g ra p h y 65 T h o racic c o n s tric tio n , o e so p h ag u s 45 T h o racic viscera 1 -6 8 - radiograph 5, 41 T h o racic w a ll, layers 115 Thorax - co m p u te d to m o g ra p h y 3 - c o nve n tio na l radiograph 5 - MRI 3 T h y m u s 4 0 , 5 0 - 5 3 , 160 - o f an a d o le s c e n t 51 - in a n e w o rn 51 T O D A R O 's te n d o n 1 6 -1 7 ,2 0 Trabecula(-ae) - carneae 18 - se p to m a rg in a lis 17, 21 - sp lenicae 129 Trachea 2, 5, 28, 3 0 - 3 3 , 3 8 , 4 3 , 4 5 - 4 6 , 48, 51, 54, 5 6 - 5 8 , 60, 6 2 - 6 4 , 161 - p ro je c tio n o n to th e ve ntra l th o ra c ic w a ll 28 T ra ch eo-oesophageal fis tu la 30 Traction d ive rticu la 45 Transoesophageal e cho ca rd io g rap h y 66 Tra n spo sitio n o f th e g re a t v e s s e ls 7 Transscrotal te s tic u la r b io p s y 195 Transurethral c a th e te r, p o s itio n in g 180 Transverse co lon See C olon tra n sve rsu m TREITZ hernias 136 TREITZ, m u s c le o f (M . su spe n so riu s) 89 T ricuspid valve (Valva a trio v e n tric u la ris d e x t ra) 4, 6, 16-17, 62, 67 - p ro je c tio n o n to th e ve ntra l th o ra c ic w a ll 4 Trigone o f th e b la d d er (Trigonum vesicae) 177 Trigonum - ch o le c y s to h e p a tic u m (C A LO T's tria ng le ) 118 - fib ro s u m - - d e x tru m 16 s in is tru m 16 - perica rd ia cu m 4, 40 - th y m ic u m 4 0 , 50 - ve sica e 177 Truncus(-i) - a rte rio s u s 6 - brach io cep h a licu s 1 2 - 1 3 ,4 3 - 4 5 , 4 8 ,5 1 , 5 4 - 5 6 , 62, 64 - b ro n c h o m e d ia s tin a lis 39, 4 8 , 6 0 -6 1 - c o elia cus 4 6 , 8 0 , 9 6 , 103, 110, 122, 125, 140, 142, 144, 165, 2 26 , 2 28 , 231 - - branches 142 - - o rig in s 144 - c o s to c e rv ic a lis 56, 6 0 -6 1 - in fe rio r 6 0 -6 1 - in te s tin a lis 4 8 , 9 9 , 2 29 - ju g u la ris 4 8 , 60

T Tachycardia - ECG 22 - increased s y m p a th e tic to n u s 23 Taenia - libera 9 4 - 9 5 , 130, 134 - m e so co lica 9 4 - 9 5 - o m e n ta lis 9 4 - 9 5 , 130 T A W A R A , n ode o f (N odus a trio v e n tric u la ris) 2 0 -2 1 Tela - su bm u co sa ------(D uo d e nu m ) 89 ------(Gaster) 78 - - (In te stin u m crassum ) 94 ------(In te stin u m te n u e) 87 ------(O esophagus) 4 4 ------(P e riton e u m viscerale) 87

Index

Truncus (-i) -

lum balis(-es) 99, 2 29 - d e xte r 2 29 lu m b o sa cralis 2 3 0 -2 3 2 p u lm o n a lis 5 - 6 , 8 -1 0 , 12-13, 15, 19, 2 4 -2 5 , 41, 55, 6 5 - 6 6 - subcla vius s in is te r 61 - sym p a th icu s 2, 5 2 -5 3 , 5 6 - 5 8 , 6 0 -6 1 , 6 4 65, 67, 100, 151, 154, 156, 194, 2 3 0 -2 3 1 - th yro ce rvica lis 6 0 -6 1 - vagalis - - a n te rio r 58, 8 4 , 100, 231 - - p o s te rio r 8 4 , 100, 231 Tuba ute rin a (Salpinx) 139, 160, 203, 2 0 5 -2 0 8 , 2 11 -2 1 2, 2 3 4 - p e rito n e al d up licature s 2 06 , 2 08 Tuber ischia d icu m 199, 202, 217, 2 3 9 -2 4 0 Tub e rcu lu m pub icu m 202 Tubulus - distalis 1 6 8 -1 6 9 - proxim a lis 1 6 8 -1 6 9 Tunica - adve n titia ------(In te stin u m crassum ) 94 ------(O esophagus) 4 4 ------(Trachea) 33 - albuginea - - co rp o ru m ca ve rn o so ru m 186, 191-192, 236 - - (Testis) 1 8 8 -1 8 9 - d a rto s 187, 189, 191, 2 36 - fib ro sa (Splen) 129 - m ucosa ------(Gaster) 78 - - (In te stin u m crassum ) 94 (In te stin u m te n u e) 87 - - (O esophagus) 4 4 (Trachea) 33 - - (U terus) 2 07 - - (Vesica biliaris) 117 - - (Vesica urinaria) 177 - m u scula ris ------(D uodenum ) 89 ------(Gaster) 76, 78 - - (In te stin u m cra ssum ) 94 - - (In te stin u m te n u e) 87 (Jejunum ) 91 ------(O esophagus) 4 4 , 76 ------(R ectum ) 2 22 - - (U terus) 207 ------(Vesica urinaria) 1 77-178 - serosa ------(Gaster) 78 ------(Ileum ) 91 - - (In te stin u m crassum ) 94 ------(In te stin u m te n u e) 87 ------(Jejunum ) 91 ------(Lobus hep a tis d exte r) 105 - - (Lobus hep a tis siniste r) 105 (O esophagus) 4 4 ------(P e rim e triu m ) 2 06 ------(Splen) 129 ------(U terus) 207 ------(Vesica biliaris) 117 - vaginalis te s tis 1 8 7 -1 8 9 ,1 9 1

u U lcus - d uo d e ni 90 - - e n d o sco p y (d uo denoscopy) 90 - - radiograph w ith c o n tra s t im ag ing 90 - v e n tricu li 71, 78 U ltraso u n d im age(s) - kid n e y 173 - live r 114 - live r ve in s 114 - pancreas 127 - p a n cre a titis 155 - p o rta l ve in 114 - Vv. hep a tica e 114 U m bilical co rd 9

U m bilica l hernia 73 U m b ilic u s 182 U pp e r a bd o m ina l situs - a bd o m ina l s u rg e ry 133 - d e v e lo p m e n t 72 - p o s itio n o f th e viscera 1 3 0 -1 3 2 - re tro p e rito n e a l organs 122 U p p e r in te stin a l tra c t, hae m o rrh ag e 89 U p p e r re s p ira to ry tra c t 28, 3 2 - 3 3 - d e v e lo p m e n t 30 U reter 139, 160, 162-167, 171, 174-176, 178, 180, 183, 185, 194, 198, 2 03 , 2 0 5 -2 0 6 , 2 0 8 -2 0 9 , 221, 2 28 , 2 3 3 -2 3 5 , 237, 2 40 - c o m m o n v a ria tio n s, radiographs 176 - c o n s tric tio n s 175 - co urse 175 - crossin g , M E Y E R -W E IG E R T 's rule 176 - d u p le x 176 - fis s u s 176 - irreve rsible dam age, h y s te re c to m y 175 - p a rts 175 - radiograph 176 U reteric b ud 162 U reteric co lic, renal c o n c re m e n ts 175 U reteric o rific e 163 - cy s to s c o p y 177 U rethra 179, 186, 190, 204, 216, 2 36 - ben d s 179 - fe m in in a 1 6 0 ,1 8 0 - 1 8 1 ,2 0 3 ,2 1 0 ,2 1 6 ,2 1 9 - m asculina 160, 1 77 -1 7 8, 181, 190, 192, 194, 197 U rethral fo ld s 1 8 4 ,2 0 4 - in c o m p le te fu s io n 184 U rethral groo ve 184 U rin a ry b la d d er S ee V esica urinaria U rin a ry in c o n tin e n c e 214 U rin a ry organs - d e v e lo p m e n t 163 - in m an 183 - in w o m a n 183 U rin a ry pole 168 U rin a ry s y s te m 160 U rog e n ital fo ld s 184 U te rin e n eck 2 09 U te ru s 9 3 , 160, 2 03 , 2 0 5 -2 1 0 , 216, 2 3 4 -2 3 5 , 237 - a nte flexio n 2 0 8 - ante versio n 2 08 - co n n e c tiv e tis s u e spaces 2 09 - d e sce n su s 214 - d u p le x 2 05 - w ith fo e tu s 210 - lig a m e n ts 2 09 - p e rito n e al d u p lic a tu re s 2 06 , 2 08 - p o s itio n 2 08 - p rolapse 214 - re tro fle x io n 2 0 8 - re tro v e rs io n 2 08 - se p tu s 2 05 - su b s e p tu s 2 05 U tricu lu s p ro s ta tic u s 177 Uvula ve sica e 177

V Vagina 160, 180, 2 0 3 -2 0 5 , 2 0 7 -2 0 8 , 2 10 -2 1 1, 2 1 5 -2 1 6 , 219, 2 34 , 2 39 - d e sce n su s 214 - m u sculi re cti a b d o m in is 155 - p o s itio n 2 08 - p rolapse 214 V a g otom y, s e le c tiv e proxim a l o r to ta l, g a stric ulce r 84 Valva(-ae) - a orta e 4, 6, 16, 19, 62, 6 6 - 6 7 - a triove n tricu la ris - - d e xtra (Valva tricu spid a lis) 4, 6, 16-17, 62, 67 ------sinistra (Valva m itralis) 4, 6, 16, 1 8-1 9 , 6 6 -6 7 - co rdis 16

Valva (-ae) -

ile ocaecalis (ileocaecal valve, B A U H IN 's val ve) 86, 95 - tru n c i p u lm o n a lis 4, 6, 16 Valvula(-ae) - anales 2 2 2 -2 2 3 - fo ra m in is ovalis 7, 18 - s e m ilu na ris - - a n te rio r 16 - - dextra - — (Valva aortae) 1 6 ,6 6 ----------(Valva tru n c i pulm o n alis) 16, 19 ------p o s te rio r (Valva aortae) 16, 19, 62, 66 - - sinistra ----------(Valva aortae) 16, 19, 66 - — (Valva tru n c i pulm o n alis) 16 - sinu s coronarii 7, 17, 21 - venae cavae infe rio ris 7, 17, 21 V arico ce le 171, 193 Vas(-sa) - lym ph a tica 87, 191 - privata (Pulm o) 38 - publica (Pulm o) 38 - recta 169 Vena(-ae) - app e n dicu la ris 111, 141 - arcuata (Ren) 169 - atriales 25 - axillaris 6 0 - 6 1 , 64, 68 - azygos 4 6 - 4 8 , 52, 5 6 -5 7 , 6 4 - 6 7 , 112, 155 - brach io cep h a lica 4 0 , 50, 5 2 - 5 3 , 60 - - d e xtra 13, 51, 54, 57 - - s inistra 13, 4 6 , 51, 54, 57, 6 1 -6 2 - b ron ch iale s 52, 57 - bulbi - - p enis 197 v e s tib u li 218 - cardiaca(-ae) (cordis) ------m agna 1 2-1 3 , 18, 25, 67 - - m e dia (V. in te rv e n tric u la ris p o ste rio r) 13, 25, 62 - - m in im a e (Vasa TH EBESII) 25 - - parva 12, 25 - cava ------in fe rio r 5 - 6 , 8 - 9 , 11, 13, 15, 17, 20, 25, 4 6 - 4 7 , 55, 57, 72, 81, 9 8 , 1 0 4 -1 0 5 , 1 0 7 108, 111-112, 114, 122, 127, 141, 144, 1 4 9 -1 5 0 , 1 5 4 -1 5 6 , 1 6 4 -1 6 5 , 171-173, 193, 2 25 , 2 2 8 -2 3 0 ----------trib u ta rie s 2 28 - - s u p e rio r 4 - 6 , 8 -1 3 , 15, 17, 21, 25, 4 4 , 46, 4 8 , 5 1 -5 2 , 5 4 - 5 5 , 57, 6 4 - 6 6 - centralis ------(Gl. suprarenalis) 170 - - (H epar) 106 - cephalica 68 - circ u m fle x a fe m o ris m e dia lis 2 3 8 - colica - - dextra 9 8 , 111, 141, 145 - - m e dia 9 8 , 111, 141, 145, 147 - - sinistra 9 8 , 111-112, 141, 145, 147 - co rdis 25 - c o rtic a le s radiatae 169 - cre m asterica 1 9 1 -1 9 2 - cystica 9 8 , 111, 116, 141-142 - dorsalis profunda ----------c lito rid is 216, 237 ----------penis 192, 197, 2 33 , 2 36 - - s u p e rfic ia lis p e n is 1 9 2 ,2 3 6 - epigastrica - - in fe rio r 112, 2 33 , 2 37 s u p e rfic ia lis 112 - fe m o ra lis 2 3 8 -2 3 9 - gastrica(-ae) - breves 8 0 - 8 1 , 98, 111, 141 - d e xtra 8 0 - 8 1 , 98, 111, 141 - - s inistra 4 6 - 4 7 , 8 0 - 8 1 , 98, 111-112, 141 142, 150, 155 - g a s tro o m e n ta lis 80 - d e xtra 8 0 - 8 1 , 9 8 , 111, 141-142, 144 - s inistra 4 6 , 8 0 - 8 1 , 9 8 , 111,141-142, 144

Index

Vena (-ae) - glutea ------in fe rio r 2 25 , 2 38 ------s u p e rio r 225 - h em ia zyg os 4 6 -4 7 , 53, 57, 62, 112, 155 - - accessoria 4 6 , 53, 57 - hepatica(-ae) 8 - 9 , 9 8 , 1 0 5 -1 0 6 , 111-112, 141, 2 28 - - d e xtra 108, 149, 154 - - in te rm e d ia 108 ------s inistra 108, 1 4 9 -1 5 0 - - ultraso u n d im ag e 114 - ileales 98, 111, 141, 145 - ile o co lica 9 8 , 111, 141 - iliaca - - c o m m u n is 112, 1 4 8 -1 4 9 , 175, 215, 225, 2 28 , 232 - - e xte rn a 225, 2 3 3 -2 3 4 , 237 - - intern a 112, 2 25 , 2 3 4 , 2 40 - inte rco sta le s p oste rio re s 4 6 , 5 2 -5 3 , 5 6 -5 7 , 6 6 -6 7 - in te rlo b a ris (Ren) 169 - inte rlo b u la ris 106 - in te rve n tricu la ris a n te rio r 12, 25 ------p o s te rio r (V. cardiaca [cordis] m edia) 13, 25 - jeju n ale s 9 8 , 111, 141, 145, 147 - jug u laris intern a 3 9 , 4 4 , 4 6 , 54, 6 0 - 6 1 , 68 - lum balis(-es) 2 28 a sce n d e n s 57 - m arginalis - - dextra 25 sinistra 25 - m e d ia stin a le s 57 - m e sen terica - - in fe rio r 81, 9 8 , 111-112, 141, 147, 225 branches 98, 111 ----------co u rse in th e re tro p e rito n e a l space 147 - - s u p e rio r 81, 9 6 , 9 8 , 111-112, 1 22 -1 2 3, 141, 1 4 4 -1 4 5 , 1 4 7 -1 5 0 ----------branches 111 ----------co u rse 145 - obliqua atrii s in istri 25 - o btu ratoria 1 9 6 , 2 1 5 ,2 2 5 ,2 3 3 ,2 3 8 - 2 3 9 - o eso p h ag e a e/oe so p ha g e ale s 4 6 -4 7 , 5 7,8 1, 98, 111-112, 141 - ovarica(-ae) 112, 175, 2 0 6 -2 0 8 , 228, 234, 237 - - dextra 165 - - s inistra 1 6 5 -1 6 6 , 171 - p ancreaticae 98, 111, 141 - pancre a ticod u o de n a lis(-e s) 9 8 , 111 s u p e rio r p o s te rio r 141 - para u m b ilicale s 111-112 - pericardiacae 57

Vena (-ae) - perica rd ia co ph re n ica 1 1 ,5 1 -5 4 -

perin e alis 197 phrenica in fe rio r 4 6 -4 7 , 112, 171, 2 28 p o rta e hep a tis 8 - 9 , 47, 8 0 - 8 1 , 98, 104, 108, 110-112, 114, 118, 1 2 2 -1 2 3 , 127, 141-142, 144, 1 4 9 -1 5 0 , 1 5 4 -1 5 6 - pudenda(-ae) - - e xte rn a 191 - â&#x20AC;&#x201D; profu nd a 192 ------interna 1 9 7 ,2 0 0 - 2 0 1 ,2 1 8 ,2 2 5 ,2 3 3 - 2 3 4 , 2 3 8 -2 4 0 - pulm o n alis(-es) 3 8 , 41, 52 - - dextra(-ae) 10, 13, 15, 18, 25, 35, 4 4 - â&#x20AC;&#x201D; in fe rio r 11, 66 - â&#x20AC;&#x201D; su p e rio r 11, 66 - - sinistra(-ae) 9, 13, 15, 25, 4 4 , 53, 62 ----------in fe rio r 1 0 -1 1 ,1 8 , 35, 62, 6 6 - 6 7 ---------su p e rio r 10-11, 18, 3 5 , 62, 65 - re ctalis(-es) - - in fe rio re s 112, 141, 225, 2 3 3 -2 3 4 - - m e dia e 1 4 1 ,2 2 5 ,2 3 3 - 2 3 4 - - su p e rio r 9 8 , 111-112, 141, 147, 225, 2 34 - renalis(-es) 156, 1 6 4 -1 6 8 , 171, 175, 193, 228 - - co urse 171 - - dextra 1 4 8 -1 4 9 , 165, 1 72-173 - - sinistra 112, 127, 165, 172 - sacralis m ediana 225, 2 28 - saphena m agna 2 39 - sig m o id e a e 98, 111-112, 141, 147, 225 - sp lenica (lienalis) 81, 9 8 , 111-112, 1 22 -1 2 3, 127, 129, 141, 144, 147, 151, 1 5 4 -1 5 6 - - branches 111 - stellata (Ren) 169 - subclavia 4 4 , 51, 54, 57, 63 - - d e xtra 39, 4 6 , 54, 60 - - sinistra 39, 61 - su bco sta lis 57 - suprarenalis(-es) 166, 172 - - d e xtra 164, 171-172, 228 - - m e dia 164 - - sinistra 1 6 4 -1 6 5 , 1 7 1 -1 7 2 ,2 2 8 - te sticu la ris 112, 1 6 5 -1 6 6 , 171, 1 9 2 -1 9 3 ,2 2 8 c o u rse 193 - th o ra cica intern a 4 0 , 5 0 -5 1 , 64 - th yro id e a in fe rio r 4 6 , 51 - u m b ilica lis 8, 103, 210 - uterina 2 3 4 - ve n tricu li - - d e xtri a n te rio re s 25 - - s in is tri p oste rio re s 25 - ve rte b ra lis 46 - vesica lis in fe rio r 233 Ventral p an cre a tic b ud 103, 121 V e n tricu la r se pta l d e fe c t 7

V e n tricu lu s - d e x te r 4, 6, 8 -1 0 , 12-13, 15, 17, 25, 55, 6 6 67, 150 - s in is te r 4 -1 0 , 1 2-1 3 , 15, 17-19, 25, 41, 44, 55, 6 6 -6 7 V ertebra - lum b a lis 1 5 5 -1 5 6 - th o ra cica 6 3 - 6 8 , 154 Vesica - b iliaris (fellea) 8, 42, 8 0 - 8 1 , 93, 98, 1 0 2 104, 1 0 7 -1 0 8 , 110-111, 115-119, 121, 127, 1 31 -1 3 2, 142, 156 - - p ro je c tio n o nto th e b o d y su rfa ce 86 - urinaria 8, 9 3 , 1 37 -1 3 9, 1 4 8 -1 4 9 , 160, 162, 1 77 -1 7 8, 181, 183, 1 8 5 -1 8 6 , 190, 194, 203, 2 05 , 2 0 8 -2 1 0 , 216, 219, 221, 2 23 , 2 3 3 -2 3 5 , 2 3 8 -2 3 9 ------ly m p h n o d e s 2 35 ------in m an 181 - - in w o m a n 181 V e stib u le (V e stibu lu m vaginae) 202 V e stib ulu m - bursae o m e n ta lis 1 3 2 -1 3 3 - nasi 28 - o ris 42 - vaginae 180, 2 02 V illi in te s tin a le s 87 V isceral surgery, live r s e g m e n ts 108 V o rte x co rdis 15 V ulvar carcin o m a , ly m p h n ode m e ta s ta s e s 213

w W h ite pulp, sp leen 129 W IR S U N G 's d u c t (D u ctu s pancreaticus) 8 8 89, 117, 121, 1 2 3 -1 2 4 , 127, 1 4 8 -1 4 9 - va ria tio n s o f th e ju n c tio n 124 W O L F F IA N d u c t (D u ctu s m e s o n e p h ricus) 1 6 2 -1 6 3 ,2 0 5 - d iffe re n tia tio n , te s to s te ro n 185 W O LF F -P A R K IN S O N -W H IT E syn dro m e , ECG 22

z ZEN KE R 's d iv e rtic u la 45 Zona - alba (Canalis analis) 222 - co lu m n a ris (Canalis analis) 2 2 2 -2 2 3 - cutanea (Canalis analis) 2 2 2 -2 2 3 - o rbicu la ris 2 3 8