anatomy ii - final exam notes
TRANSCRIPT
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DEC5TH
ANATOMYREVIEWNOTES
SPLANCHNOLOGY I & II
2006
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1 Nasal cavity (bony+soft tissue) & paranasal sinuses
NASAL CAVITY (BONY) Bony nasal cavity is 1st semester material
Inlet:
o Apertura piriformis (pear-shaped aperture). Borders:
Nasal bone, the frontal process of the maxilla, and by the
body of the maxilla.
Outlet:
o Choanae. Borders:
LATERAL: medial plate of pterygoid process.
INFERIOR: horizontal plate of the palatine bone.
MEDIAL: vomer.
SUPERIOR: body of the sphenoid bone (having the ala vomeris
on it).
The nasal cavity has four walls:
o Anterior: nasal bone.
o Superior: nasal part of the 1frontal bone (ant.), 2cribiform plate
(mid.), and 3body of the sphenoid bone (post.).
o Inferior: The hard palate = palatine process of the maxilla (ant) &
horizontal plate of palatine bone (pos).
o Medial: Nasal septum = perpendicular plate of ethmoid & vomer. V-
shaped space in front, filled with cartilage forming the cartilaginous
part of the nasal septum.
o Lateral: Anterior Posterior.
Frontal process of the maxilla.
Lacrimal bone
Ethmoidal bone. (Beneath the middle nasal concha are the
uncinate process and ethmoidal bulla. Between them, we
have the semilunar hiatus)
Inferior nasal concha
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CONNECTIONSOFTHE NASAL CAVITY:
PARANASAL SINUSES (4) are cavities surrounding the nasal cavity, filled by
air, and layered by mucous membrane. They open into the nasal cavity.
a) Frontal sinus: opens into the middle nasal meatus through the anteriorpart of the semilunar hiatus.
b) Maxillary sinus: opens into the middle nasal meatus through the
posterior part of the semilunar hiatus.
c) Ethmoidal sinuses: anterior and middle groups of air cells open into the
middle nasal meatus, and the posterior group opens into the superior
nasal meatus.
d) Sphenoid sinus: open into common nasal meatus via sphenoethmoidal
recess.
Sphenopalatine foramen: Nasal cavity - pterygopalatine fossa.
Incisive canal: Nasal cavity- Oral cavity. It transmits the nasopalatine nerve
and artery.
Cribriform plate: It transmits fibers from olfactory nerve (CNI)
Nasolacrimal canal: Orbital cavity - inferior nasal meatus
NASAL CAVITY (Soft tissue)
nasal vestibule
proper nasal cavity
The borderline between them is the limen nasi.
The mucous membrane of the nasal cavity is divided into two parts:
1. Olfactory region
a. The olfactory mucous membrane covers the superior nasal concha
and the septum (the superior part of the septum and the top of the
nasal cavity).
b. The epithelium of the olfactory region is of a special type which
gives the origin of the fila olfactoria.
c. It is a primary neuroepithelium. The fila olfactoria are running
through the lamina cribrosa and form the olfactory nerve.
2. Respiratory region.
a. Rest of the nasal cavity is the respiratory region
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b. Pseudo-stratified columnar kinociliated epithelium having mucous
glands inside.
BLOOD SUPPLYAND INNERVATION:
This is given from two arteries and two nerves.
o anterior ethmoidal nerve nasociliary nerve Olfactory nerve
( CNI)
o ophthalmic artery internal carotid
Kiesselbach point: the anastomosis between the two arteries.
These structures begin in the orbit; pass through the anterior
ethmoidal foramen to the anterior cranial fossa, then down to
the nasal cavity through the cribriform plate. They innervate
and supply the superior part of the nasal cavity.
o Posterior nasal nerve maxillary nerve
o Sphenopalatine artery maxillary artery.
Innervates and supplies the inferior, main part of the nasal
cavity.
LYMPH DRAINAGE:
Anterior: Submandibular lymphnodes
Deep cervical lymph nodes
Posterior: Retropharyngeal lymph nodes
2 Cartilages and joints of the larynx
CARTILAGES & (BONE):
Hyoid bone
o Lesser and greater horn
o body
Epiglottis
o Elastic cartilage
o Covered by mucous membrane
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o Serves as a diverter over the aditus, during swallowing.
Thyroid
o Left and right palates
o Adams apple in front
o Superior and inferior horns
o Inferior horn forms joint with cricoid
o Thyrohyoid membrane
Cricoid
o Broader posterior than anterior
o Articulates with both thyroid and small arytenoids
o Cricothyroid membrane (conus elasticus)
For relief of respiratory obstruction, it may be pierced
(conicotomy)
Arytenoids (2)
o Pyramidal shaped (apex + base)
JOINTS
Cricothyroid joint
o Articulation:
Inferior horn of thyroid articulating surfaces of cricoid
o Ligament function:
Median cricothyroid ligament; anterior/thickened part of
cricothyroid membrane.
Movement Elevation and depression
o Muscles:
Cricothyroid muscle (only laryngeal muscle supplied by the
external laryngeal nerve (rather than the recurrent laryngeal
nerve)
o Movement:
Tilting the thyroid forward which tenses the vocal cords.
http://en.wikipedia.org/wiki/Larynxhttp://en.wikipedia.org/wiki/External_laryngeal_nervehttp://en.wikipedia.org/wiki/Recurrent_laryngeal_nervehttp://en.wikipedia.org/wiki/Recurrent_laryngeal_nervehttp://en.wikipedia.org/wiki/Vocal_cordshttp://en.wikipedia.org/wiki/Larynxhttp://en.wikipedia.org/wiki/External_laryngeal_nervehttp://en.wikipedia.org/wiki/Recurrent_laryngeal_nervehttp://en.wikipedia.org/wiki/Recurrent_laryngeal_nervehttp://en.wikipedia.org/wiki/Vocal_cords -
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Cricoarytenoid joint
o Articulation:
Articulating surfaces of cricoid base of arytenoids.
o Muscles:
Posterior & Lateral cricoarytenoid muscles
o Movements:
Abduction & Adduction (intramembranous part) of vocal
cords.
Cricotracheal joint
o Cricoid - 1st tracheal ring by the cricotracheal ligament.
3 Cavity and muscles of the larynx
CAVITY
Inlet (Laryngeal Aditus)
o Borders:
Epiglottis
Aryepiglottic folds having cuneiform and corniculate
cartilages
Interarytenoid notch
Vestibule
o 4-5cm
o Vestibular/Ventricular/false vocal -folds
o Laryngeal ventricles
o Vocal fold (Stratified squamos non-keratinized epithelium)
Rima glottidis (Glottis)
o Opening between the two vocal folds
Subglottic cavity
o Found just under the rima glottidis
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o Pseudostratified columnar ciliated epithelium
MUSCLES
Extrinsic muscle innervated by external laryngeal nerve
Intrinsic muscles innervated by the recurrent laryngeal nerve
Extrinsic :
o Cricothyroid:
O&I: Arch of cricoid cartilage lamina of the thyroid
cartilage, having straight fibers and oblique fibers.
Function: Pulls the two cartilages closer by tilting the thyroidforward. This tenses the vocal cord.
Intrinsic:
o Posterior cricoarytenoid:
O&I: Posterior surface of cricoid lamina muscular process of
arytenoids.
Function: Abducts the vocal cord by outward rotation of the
arytenoids.
o Lateral cricoarytenoid:
O&I: Lateral surface of arch of cricoids muscular process of
arytenoids:
Function: Adducts vocal cord (intramembranous part) by
inward rotation of the arytenoids.
o Interarytenoid (Transverse & Oblique)
Transverse adducts vocal cord (intercartilagenous part).
Oblique continue to the epiglottis making aryepiglottic folds
and may narrow the aditus.
o Vocalis
O&I: Posterior surface of thyroid lamina vocal process of
arytenoids.
Function: Relaxes the ligament. (Fine regulators)
o Thyroarytenoid
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O&I: Inner surface of thyroid cartilagemuscular process and
outer surface of arytenoids.
Function: Decreases tension on vocal fold (antagonistic to
extrinsic muscle).
o Thyroarytenoid (thyroepiglottic part)
Function: Widens vestibule and laryngeal aditus.
Other muscles influencing movement of the larynx:
Depression: Infrahyoid muscle
Elevation: Stylopharyngeal, Digastric, Mylohyoid & Geniohyoid muscle
4 The function, innervation and lymphatic drainage of the
larynx
Larynx is an organ of voice production, and the part of the respiratory tract
between the pharynx and trachea
FUNCTION
The intermittent release of expired air between the adducted vocal folds results
in their vibration and the production of sound. The frequency of the voice is
determined by changes in the length and tension of the vocal ligaments. The
quality of the voice depends on the resonators above the larynx; pharynx, mouth
and paranasal sinuses. The frequency is controlled by the intrinsic muscles of
larynx, and the quality is determined by the muscles of the soft palate, tongue,
floor of mouth, cheeks, lips and jaws.
Movement Muscles Function
Abduction pos. cricoarytenoid loudness (increased air)
Adduction lat. cricoarytenoid loudness (decreased air)
Trv. Arytenoid
Shortening/relaxation Thyroarytenoid Degree of vibration
(decreased tension)
Vocalis
Lengthening/tensing Cricothyroid Degree of vibration
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INNERVATION OF THE LARYNX
Sensory
o Above vocal fold: Vagus Sup. Laryngeal nerve int.
laryngeal nerve
o Below vocal fold: Vagus recurrent laryngeal nerve
Motor
o Intrinsic muscles (all but cricothyroid): vagus Recurrent
laryngeal nerve
o Extrinsic muscles (only cricothyroid): vagus sup.
Laryngealext. laryngeal
LYMPHATIC DRAINAGE
The laryngeal lymph nodes are situated on the cricothyroid ligament; some are
found in front of the thyrohyoid membrane. They receive lymph from adjacent
structures, including the thyroid gland.
Draining into deep cervical lymph nodes jugular trunk thoracic duct/right
lymph duct.
5 The oral cavity (except the teeth). The palate and the floor of
the oral cavity
THE ORAL CAVITY
Inlet: Rima Oris
o Surrounded by upper and lower lips
o The lips are connected to the gums by frenulum of upper and lower
lips.
Vestibule:
o Anterior Lips
o Posterior Teeth and gums
o Lateral Cheek, + buccinator muscle
Oral cavity proper
o Superior Hard and soft palate
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o Inferior Tongue & Mylohoid muscle
o Lateral Teeth
Outlet: Oropharyngeal isthmus
o Lateral Palatoglossal and palatopharyngeal arches
o Superior Uvula, soft palate
o Inferior Root of tongue, terminal sulcus
HARD PALATE
Anterior bony part of the palate, consisting of:
Horizontal plate of palatine bone
Palatine process of maxilla
It is covered by mucous membrane
Canals:
Greater palatine foramen
o Maxillary nerve pterygopalatine ganglion greater palatine
nerve
Supplies the mucosa and glands of the hard palate and
anterior part of soft palate
Lesser palatine foramen
o Maxillary nerve pterygopalatine ganglion lesser palatine
nerve
Supplies the mucosa and glands of the soft palate and uvula
Contain postsynaptic parasympathetic and sensory fibers of
the maxilla
Incisive canal
o Pterygopalatine ganglion nasopalatine nerve
SOFT PALATE
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Posterior muscular part of the palate; forming an incomplete septum between
the mouth and oropharynx & between the oropharynx and nasopharynx
Muscles inserting into it:
Levator veli palatini muscle
o Origin
cartilage of auditory tube
o Function
Elevates the soft palate during swallowing and yawning
o Nerve supply
Vagus nerve
Tensor veli palatini muscle
o Origin
Medial pterygoid plate
o Function
Tenses the soft palate during swallowing and yawning.
Equalize pressure of middle ear.
o Nerve supply
Mandibular nerve
Muscles originating from soft palate:
Palatoglossal muscle: Forms anterior arch of the tonsillar fossa
Palatopharyngeal muscle: Forms the posterior arch of tonsillar fossa
FLOOR OF THE ORAL CAVITY
Diaphragm oris
Genioglossus
o O&I: Superior part of mental spine Dorsum of tongue
o Hypoglossal nerve (CXII)
o Protrude & depress the tongue
Geniohyoid:
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o O&I: Mental spine body of hyoid bone
o Hypoglossal nerve (CXII)
o Draws hyoid forward or depresses jaw when hyoid is fixed
Mylohyoid
o O&I: Mylohyoid line of mandible converge and unite, attaches to a
median fibrous raphe and inserts into hyoid
o Mylohyoid branch from mandibular nerve
o Elevates floor of mouth and the tongue
Digastric
o O&I: Anterior belly from the digastrics fossa of mandible & Posteriorbelly from mastoid notch of the temporal bone Greater horn of
hyoid bone
o Posterior belly facial nerve & anterior belly mylohyoid branch of
mandibular nerve
o Elevates the hyoid bone, helps the lateral pterygoid muscle to open
mouth
6 The Tongue
The tongue is a muscular organ with muscle fibers in three directions, horizontal,
longitudinal and vertical, covered by mucous membrane: Root (1/3), Body (2/3)
and an apex.
It is an organ oftaste. Most of the tongue is covered in taste buds. The tongue
assists in forming the sounds ofspeech. It is sensitive and kept moist by saliva,
richly supplied with nerves and blood vessels to help it be moved.
Papillae and taste buds
Four types of papillae:o filiform (thread-shape)
o fungiform (mushroom-shape)
o foliate (leaf-shape)
o Circumvallate (ringed-circle).
All papillae except the filiform have taste buds on their surface. Thecircumvallate are the largest of the papillae. There are 8 to 14
http://en.wikipedia.org/wiki/Tastehttp://en.wikipedia.org/wiki/Taste_budhttp://en.wikipedia.org/wiki/Speechhttp://en.wikipedia.org/wiki/Salivahttp://en.wikipedia.org/wiki/Taste_budhttp://en.wikipedia.org/wiki/Tastehttp://en.wikipedia.org/wiki/Taste_budhttp://en.wikipedia.org/wiki/Speechhttp://en.wikipedia.org/wiki/Salivahttp://en.wikipedia.org/wiki/Taste_bud -
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circumvallate papillae arranged in a V-shape in front of the sulcusterminalis, creating a border between the oral and pharyngeal parts of thetongue.
The upper side of the posterior tongue (pharyngeal part) has no visible taste
buds, but it is bumpy because of the lymphatic nodules lying underneath. Thesefollicles are known as the lingual tonsil.
The human tongue can detect four basic taste components, sweet, sour, saltyand bitter.
The tongue is the strongest muscle in the human body proportional to size.
NERVE INNERVATIONS
Motor
o Hypoglossal nerve for both extrinsic and intrinsic muscles
General sensory
o Anterior 2/3: lingual nerve
o Posterior 1/3: Glossopharyngeal nerve
Taste
o Anterior 2/3: Chorda tympani from facial nerve (VII)
o Posterior 1/3: Glossopharyngeal nerve
MUSCLES
Intrinsic
o Superior & Inferior longitudinal: Rolls tongue up and down
o Transverse: Makes the tongue
more narrow and thick
o Vertical: Flattens and widens tongue
Extrinsic
o Genioglossus
From mandible to the lingual fascia
It depresses and protrudes the tongue
o Hyoglossus
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From body and greater horn of hyoid bone to the side of the
tongue
Depresses and retracts tongue to the floor of the mouth
o
Styloglossus
From styloid process to the tongue
Retracts and draws it upwards during swallowing
o Palatoglossus
From oral surface of soft palate to the tongue
Forms anterior arch of tonsillar fossa
It draw tongue backwards and upwards
Innervated by Accessory nerve (IX) via the Vagus (X)
BLOOD SUPPLY
Greater palatine artery maxillary artery
o Supplies gum and mucous membrane of the hard palate
Lingual artery external carotid artery
o Floor of mouth and extrinsic muscles of tongue
Descending palatine artery maxillary artery
o Soft palate, gums, bones and mucous membrane of hard palate
Facial artery
o Ascending palatine, tonsillar branch, inferior & superior labial
Tonsils and soft palate
7 Description of the teeth, their types, blood supply and
innervations
GENERAL DESCRIPTION
The teeth posses a:
Crown covered by enamel
Neck, where the gingival connects to it
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Root
They have four surfaces:
Masticatory
Buccal
Lingual
Contact, mesial and distal
When describing the teeth, we consider them in four quadrants
MILK TEETH
20 total. 5 teeth in each quadrant
2 incisors
1 canine
2 molar
The teeth erupt in average 6-8 months, starting with the medial incisors. The
exchange for permanent teeth starts in average 6 years.
PERMANENT TEETH
32 total. 8 teeth in each quadrant
2 incisors
o Upper ones has a wider crown
o Labial and lingual surfaces are flattened
o Lingual surface is excavated
o Have a single root, the upper is more rounded
1 canine
o Longest root of all teeth
o Its crown is columnar shaped
2 premolar
o Its crown has two tubercles, 1 large buccal and 1 lingual
o It has one root, except, upper first which is divided to two roots
3 molar
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o Lower: 2 roots; 1 mesial & 1 distal
o Upper: 3 roots; 2 buccal & 1 lingual
o Lower: 1st has 5 tubercles, the others usually have 4, 2-3 buccal and
2 lingual
o Upper: 2 first have 4 tubercles, 2 buccal & 2 lingual. 3 rd molar
(wisdom) has 3 tubercles
BLOOD SUPPLY
Upper teeth Maxillary artery Superior alveolar artery
Anterior/
Middle/
Posterior alveolar branches
Lower teeth Maxillary artery Inferior alveolar artery
NERVE SUPPLY
Upper teeth Maxillary nerve (V2) infraorbital nerve alveolar
branches
o In individual nerve canals
Anterior branch from infraorbital
Middle branch from infraorbital
Posterior sup. Alveolar branch comes directly from maxillary
nerve
Lower teeth Mandibular nerve (V3) inferior alveolar nerve
o In a common canal
CLINICAL IMPORTANCE
When giving anesthetics the upper teeth may be individual affected, but the
lower teeth must be anesthetized together, the needle is set at the opening of
the mandibular foramen.
8 Lymphatic drainage of the oral and nasal cavities
Waldeyer's tonsillar ring is an anatomical term describing the lymphoid tissue
ring located in the nasopharynx
http://en.wikipedia.org/wiki/Lymphatic_systemhttp://en.wikipedia.org/wiki/Nasopharynxhttp://en.wikipedia.org/wiki/Lymphatic_systemhttp://en.wikipedia.org/wiki/Nasopharynx -
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The ring consists of (superior to inferior):
Pharyngeal tonsil (adenoids)
o Roof of nasopharynx
o Function and size decrease with age
o Hypertrophy may obstruct airways
Tubal tonsils
o Pharyngeal recess behind opening of auditory tube
Palatine tonsils
o In tonsillar fossa between Palatoglossal & palatopharyngeal arch
o Drain to upper deep cervical lymph nodes
Lingual tonsils
o Dorsal surface at the base of the tongue in posterior region
LYMPHATIC DRAINAGE OF THE ORAL AND NASAL CAVITIES
(According to paper given by Professor Kovacs which was copied and distributed
within 2nd grp)
1. Submental lymph nodes. Primary lymph nodes for:
i. Lower lip
ii. Lower incisor
iii. Tip of the tongue
iv. Anterior part of the sublingual region
2. Submandibular lymph nodes. Primary lymph nodes for:
i. Middle part of tongue and sublingual region
ii. Soft & hard palate
iii. Upper & lower teeth
a. Except lower incisor & lower wisdom teeth
iv. Nasal vestibule
3. Deep cervical lymph nodes. Primary lymph nodes for:
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i. Root of tongue
ii. Palatine tonsils
iii. Lower wisdom teeth
iv. Nasal cavity proper
v. Also secondary lymph nodes for submental & submandibular
lymph nodes
Lymph filtered by deep cervical lymph nodes is collected by the right/left jugular
trunk right/left venous angle.
9 Cavity and parts of the pharynx
Pharynx is a common tube for food and air, 7-7.5cm long. It is lined by mucous
membrane, and it has posterior and lateral walls. It has no anterior wall because,
it communicates with the nasal, oral cavity, and larynx.
The muscles forming the lateral and the posterior wall arise from the pterygoid
process of the sphenoidal bone.
Part of the pharynx (sup inf)
Pharyngobasilar fascia
O&I: Basilar part of the occipital bone & superior constrictor
muscle.
Superior pharyngeal constrictor muscle.
It has four origins: 1 pterygopharyngeal part (pterygoid
process); 2 buccopharyngeal part (pterygomandibular
raphe ); 3 mylopharyngeal part (mylohyoid line); 4
glossopharyngeal part (root of the tongue).
Middle pharyngeal constrictor muscle which overlaps the superior.
It arises from the greater and lesser horns of the hyoid bone.
The borderline between the superior and the middle
pharyngeal constrictor muscle is marked by the
stylopharyngeus muscle (entering the pharynx between
them). The glossopharyngeal nerve runs along the
stylopharyngeus muscle.
Inferior pharyngeal constrictor muscle (two parts):
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thyropharyngeal and cricopharyngeal parts (according to
their origins, thyroid and cricoid cartilages). The inferior
constrictor overlaps the middle constrictor muscle.
All three constrictors are inserted to the PHARYNGEALRAPHE, a connective
tissue septum on the posterior wall of the pharynx.
CAVITY
The cavity of the pharynx has three parts: Nasopharynx (epipharynx),
Oropharynx (mesopharynx), and Laryngopharynx (hypopharynx).
NASOPHARYNX (EPIPHARYNX) Upper 1/3
It starts from the roof of the pharynx, which is formed by the basilar part of
the occipital bone, until the soft palate.
Anteriorly, it communicates with the nasal cavity through the choanae.
Inferiorely, it communicates with the oropharynx.
Superiorly, it communicates with the roof of the pharynx,
Laterally with the tympanic cavity through the auditory tube.
Structures:
o Opening for auditory tube
o Torus tubarius, formed by the cartilaginous part of the auditory
tube.
o Behind and a little above this tubal elevation, the pharyngeal recess
is where the tubal tonsils are located. The fornix of the pharynx is
between the superior and posterior walls of the pharynx, and in the
fornix, we have the pharyngeal tonsils (adenoids).
If enlarged, it can obstruct airway.
OROPHARYNX (MESOPHARYNX) Middle 1/3
From the soft palate to superior part of the epiglottis.
It communicates with the oral cavity through the oropharyngeal
isthmus/isthmus faucium.
o Its borders are the palatoglossal and palatopharyngeal arches
(laterally), Root of tongue (inferior); and Uvula (superior).
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Tonsilar fossa, where the palatine tonsils are located. Supratonsillar fossa
where fish bone may get stuck.
Epiglottic vallecula: between the root of the tongue and the epiglottis. It is
bordered by the median glossoepiglottic fold and the lateral
glossoepiglottic folds.
o Another fish bone site
LARYNGOPHARYNX (HYPOPHARYNX) Lower 1/3
From the epiglottis until the esophagus.
Communicates with larynx via laryngeal aditus (inlet of the larynx)
o Bordered by: 1 epiglottis (in front), 2 aryepiglottic fold (laterally), 3
interarytenoid notch, 4 tuberculum cuneiforme + corniculatum (not
important).
The food from the oral cavity passes through the piriform recess which is
in the two sides of the epiglottis, then it goes to the esophagus.
10 Muscles and wall of the pharynxPharynx is a common tube for food and air, 7-7.5cm long. It is lined by mucous
membrane.
Layers:
Mucous and submucous layers
Fibrous layer
Muscular layer
MUSCLES
Constrictor muscles:
Superior pharyngeal constrictor muscle.
It has four origins: 1 pterygopharyngeal part (pterygoid
process); 2 buccopharyngeal part (pterygomandibular
raphe ); 3 mylopharyngeal part (mylohyoid line); 4
glossopharyngeal part (root of the tongue).
Middle pharyngeal constrictor muscle which overlaps the superior.
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From greater and lesser horns of hyoid bone.
The borderline between the superior and the middle
pharyngeal constrictor muscle is marked by the
stylopharyngeus muscle (entering the pharynx between
them).
The glossopharyngeal nerve runs along the stylopharyngeus
muscle.
Inferior pharyngeal constrictor muscle (two parts):
thyropharyngeal and cricopharyngeal parts (according to
their origins, thyroid and cricoid cartilages).
The inferior constrictor overlaps the middle constrictor
muscle.
All three constrictors are inserted to the PHARYNGEALRAPHE, a connective
tissue septum on the posterior wall of the pharynx.
Levator muscles of pharynx:
Stylopharyngeal muscle (IX)
o From styloid process to sup. & inf. Pharyngeal constrictor muscles.
o Elevates pharynx towards base of skull.
Salpingopharyngeal muscle (IX+X)
o From cartilage of auditory tube, soft palate and pterygoid hamulus.
o Opens auditory tube during swallowing and yawning
o inside the salpingopharyngeal fold
Palatopharyngeal muscle (X)
o Pulls pharynx upward and lowers soft palate
o Palatopharyngeal arch, which is posterior to the palatine tonsils
INNERVATION:
The muscles of the pharynx and the mucous membrane are innervated by
the glossopharyngeal nerve (upper part) and the vagus nerve (lower part).
The pharyngeal plexus is formed by the two nerves and by some
sympathetic fibers of the sympathetic trunk (cervical part).
BLOOD SUPPLY:
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The main artery that supplies the pharynx is the ascending pharyngealartery (from the external carotid).
11 Para & retropharyngeal spaces
PARAPHARYNGEAL SPACE
Lateral to the pharynx, we have the parapharyngeal spaces. Its also called the
peritonsilar space because only the pharyngeal wall separates it from palatine
tonsils, and the lymphatic vessels of the palatine tonsils going through this space
into the deep cervical lymph nodes.
Internal carotid artery sometimes forms a loop which is close to the pharyngeal
wall. If you operate on the palatine tonsil, be careful not to cut too deep because
we may cut the pharyngeal wall and the internal carotid artery.
Borders:
Medial wall: pharynx
Lateral wall: medial pterygoid muscle, ramus mandibulae, and masseter
muscle,
Anterior: Bichat's fat pad; encapsulated mass of fat in the cheek.
Especially marked in infants
Posterior: styloid muscles, digastric, and sternocleidomastoid muscles
Inferior: submandibular triangle.
Structures:
Glossopharyngeal nerve (CN IX)
Most anterior structure
Vagus nerve (CN X)
Lying behind the carotid arteries and next to CNIX
Accessory nerve (CN XI)
Most posterior nerve, attached to sternocleidomastoid muscle
Hypoglossal nerve (CN XII)
Turns anterior and lies superior to mylohyoid muscle
Internal jugular vein
Formed as a continuation of the sigmoid sinus
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Superior cervical ganglion of the sympathetic trunk,
Internal carotid artery.
RETROPHARYNGEAL SPACE
It is located behind the pharynx; Any infection on the posterior wall of thepharynx could be spread to the retropharyngeal space. From this space,the
thoracic cavity (posterior mediastinum) is accessible.
Borders:
Anterior Pos. wall of pharynx; buccopharyngeal fascia
Posterior prevertebral fascia
Lateral Carotid sheath and muscles of the styloid process
Inferiorly Posterior mediastinum
Superior Base of skull
There are no structures in the retropharyngeal space, but it is rich in lymphatic
vessels.
12 Surface projections of the pleura, lungs & the heart.cardiac
dullnesses. Points of auscultation of the valves of the heart
The lungs are surrounded by two membranes of the pleurae. Parietal pleura &Visceral pleura. Between the two is a thin space, pleural cavity. It is filled withpleural fluid, a serous fluid produced by the pleura.
Parietal pleura has three main parts: a) Costal (or sternocostal), b)Diaphragmatic, and c) Mediastinal
Phrenicocostal recess: between the diaphragmatic and costal layers of the
parietal pleura.
Phrenicomediastinal recess: between the diaphragmatic and mediastinal
layers.
Costomediastinal recess: between the costal and mediastinal layers.
The phrenicocostal recess is the most important because:
CLINICAL: It is the lowest point of the pleural cavity, so the fluid inside the cavity
is collected there. We can drain this fluid and examine the quality (serous, blood,
etc.)
PHYSIOLOGICAL: The lower margin of the lung descends into this sinus during
inspiration. The inferior border of the lung descends into this sinus.
http://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Membranehttp://en.wikipedia.org/wiki/Serous_fluidhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Membranehttp://en.wikipedia.org/wiki/Serous_fluid -
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SURFACE PROJECTIONS OF THE PLEURA
Superior: Pleural dome, 3cm above the first rib
Middle: The two runs toward each other, the closest at the level
of the 2nd rib
Parasternal: 6th rib
Medioclavicular line: 7th rib
Ant. Axillary line:8th rib
Mid. Axillary line: 9th rib
Pos. Axillary line:10th rib
Scapular line: 11
th
rib
Paravertebral line: 12th rib
Cardiac notch: left 4-6th rib, into the medioclavicular line
SURFACE PROJECTIONS OF THE LUNGS
The lungs cover the heart except at one part, where the insisura cardiaca
of the left lung is.
The apex of the lung is above the clavicle, approximately 1-3 cm above
the 1st rib.
The medial borders of the lungs run toward each other.
o The closest point is at the level of the 2nd ribs. At this point, the
border of the right lung is in the midline of the sternum, and the
medial border of the left lung is at the left margin of the sternum.
Left lung. From the 2nd rib, the medial border descends until the 4 th rib,
where the left lung makes a notch between the 4th and 6thribs, called the
cardiac notch.
The medial border of the right lung descends straight down until the 6thrib.
So, a part of the heart is not covered by lung (between the 4th and 6thribs,
left side).
The inferior border of the lung starts from the 6thrib (upper border) and
descends a little.
Medioclavicular line, it crosses the inferior border of the 6 thrib.
Anterior axillary line, level = 7th rib. At the middle axillary line, it is at the
level of the 8th
rib. At the posterior axillary line, it is at the level of the 9th
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rib. At the scapular line, it is at the level of the 10th rib. At the vertebral
column, it is at the level of the 11th rib (10th vertebra).
SURFACE PROJECTIONS OF THE HEART
Superior border roots of great vessels
o 2nd left costal cartilage, 1,3cm from the sternum
Right superior - entrance of the superior vena cava
o 2nd intercostal space, 1cm to the right
Right inferior Right inferior end of coronary sulcus
o 1cm right to 6th sternocostal joint
Right border - right atrium
o From sternal junction of 3rd rib to sterna junction of 6th in parallel to
the sternum
Left superior left superior end of coronary sulcus
o 2nd intercostals space, 3cm left of sternum
Left inferior Apex of heart
o 5th intercostals space, left 9cm
Left border left ventricle
o A straight line from a point 3cm left of 3 rd sternocostal joint and
down to the apex
Inferior border right ventricle & apical part of left ventricle
o A line from 6th sternocostal joint to apex
ABSOLUTEAND RELATIVE DULLNESSOFTHE HEART:
Percussion of the chest above the lungs produces a sound, resulting from
resonance within the air-filled lung (1st and 2nd intercostal spaces).
Third intercostal space
o Dull resonance due to fluid-filled heart being behind the lung.
o Sound changes to relative dullness.
Fourth intercostal space (near the sternum),
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o More dull because the lung does not cover the heart. The sound
reaches only the blood-filled heart, and therefore no resonance.
This sound is called absolute dullness.
o The region of absolute dullness is at the level of the 4th -5th
intercostal spaces (left side).
o The size of the absolute dullness area gives the size of the cardiac
notch.
Relative dullness marks the upper border of the heart. If you hear the
relative dullness at the 2nd intercostal space instead of the 3rd, it means
that the heart is enlarged superiorly.
For the right border, place your finger parallel to the expected border, and you
will hear the dullness at the right side of the sternum. If you hear the dullness
farther from the right side of the sternum, it means that the heart is enlarged tothe right.
For the left border, place your finger parallel to the expected border. Normally,
you can find it left of the medioclavicular line. If the heart is enlarged, it will
exceed the medioclavicular line to the left.
PROJECTIONSOF OSTIAONTHE CHEST WALL & Points of Auscultation
Ostium of the Pulmonary Trunk:
o Left side, at the level of the third sternocostal joint.
Auscultation: right 2nd intercostal space next to sternum
Ostium of the Aorta:
o Right below the third rib, behind the sternum.
Auscultation: Left 2nd intercostal space next to sternum
Ostium Bicuspid/Mitral:
o Level of the 4th sternocostal joint, left side.
Auscultation: Left 5th intercostal space 9cm left of sternum
Ostium Tricuspid:
o Level of the 5th sternocostal joint, right side
Auscultation: Sternal junction of right 5th rib
Ostium of the pulmonary trunk (most superficial)
The deepest is the left venous ostium.
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Aortic valve will be auscultated at 2nd intercostal space, 2 cm right to the
sternum.
o The aorta comes from the left ventricle, but we hear it on the right
side because it crosses the pulmonary trunk (embryology).
13 The mediastinum. Anterior mediastinum. Intercostal
topography
The mediastinum is the middle part of the thoracic cavity which is bordered
laterally by the mediastinal pleura, anteriorly by the sternum, and posteriorly by
the vertebral column (thoracic part).
Separated into anterior and the posterior mediastinum, and the borderline
between these two is the hilus and the pulmonary ligament. The anterior
mediastinum is also divided into two parts: the cardiac, and the supracardiac
mediastinum, which contain the heart, thymus, the great vessels of the heart,
trachea, and lymph nodes of the central chest.
o Anterior to the hilus & pulmonary ligament, the anteriormediastinum;
o Posterior to the hilus, the posterior mediastinum.
SUPRACARDIAC MEDIASTINUM
The supracardiac mediastinum has four layers:
Adipose thymus (just behind the sternum)
Layer of main veins (tributaries of the superior vena cava)
o left brachiocephalic vein (oblique and long) approx. 10-12 cm.
o right brachiocephalic vein (straight and short) approx. 2-3 cm.
these drain into the superior vena cava
Into the left brachiocephalic vein, drains the inferior thyroid vein (from the
thyroid gland).
Main arteries (branches of the aortic arch):
o brachiocephalic trunk
right common carotid & right subclavian
o left common carotid artery
o left subclavian artery
http://en.wikipedia.org/wiki/Anterior_mediastinumhttp://en.wikipedia.org/wiki/Anterior_mediastinumhttp://en.wikipedia.org/wiki/Posterior_mediastinumhttp://en.wikipedia.org/wiki/Anterior_mediastinumhttp://en.wikipedia.org/wiki/Anterior_mediastinumhttp://en.wikipedia.org/wiki/Posterior_mediastinum -
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Between the layers of the main arteries and main veins, the vagus nerve and
phrenic nerve enter the thoracic cavity
14 The pleura and the pericardiumTHE PLEURA
Serous membrane enveloping the lungs and lining the walls of the pleural cavity
Visceral pleura
Parietal pleura
The two parts of the pleura meets at the roots of the lungs where the pulmonary
arteries and veins, and the bronchi enter the lungs. An inferior elongation forms
the pulmonary ligament. The cavity between the two pleura is filled with serousfluid. The lungs and the cavity are not a perfect match and recesses are found.
Phrenicocostal/costodiaphragmatic
o If fluid enters the cavity, it can be drained from this recess
Phrenicomediastinal
Costomediastinal
THE PERICARDIUM
Fibrous membrane, covering the heart and beginning of the great vessels. It is a
closed sac having two layers; Visceral layer & Parietal layer.
Reflections of the parietal layer onto the visceral layer:
Arterious reflection
o At the division of the pulmonary trunk
o The ascending aorta and pulmonary trunk remains inside
Venous reflection
o Superior vena cava, below the entrance of zygomatic vein.
o Inferior vena cava, phrenic entrance, therefore, entire inferior vena
cava is inside
o Pulmonary veins (ca 1-2cm are inside the pericardiac cavity). These
reflections form a letter "T" which is called Sappey's T.
Transverse sinus
o Formed during heart tube folding
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venous end migrates upward and behind the arterious end,
and if forms a "U" shaped tube
o Separates the ascending aorta and the pulmonary trunk from the
superior vena cava
Oblique sinus
o A blind recess posterior to the base of the heart
o Between left and right pulmonary veins
15 Atria of the Heart
The portion of the blood that receives blood from the systemic & pulmonary
circulation
RIGHT ATRIUM
Right atrium (having right border), forms the anterior surface of the heart.
Two main parts: Auricle & Atrium proper
Separated by sulcus terminalis (outside) and crista terminalis (inside). The
crista terminalis develops from the septum spurium (see embryology).
Pectinate muscles only inside the auricle.
The atrium proper, has smooth inner surface (no pectinate muscles)
The main part of the atrium proper is the sinus venarum cavarum
(receives the superior and inferior venae cavae).
Openings of right atrium
Superior vena cava
o No valves
Inferior vena cava
o Eustachian valve (non-functional).
In fetal life this valve guided the blood from the inferior vena
cava through the oval foramen to the left atrium. When
pointing, note the direction
Coronary Sinus
o Thebesian valve
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o Drains the blood from the heart wall. When pointing, note the
direction
Fetal remnant:
Oval fossa (from oval foramen)
o Surrounded by limbus fossae ovalis
o Patent foramen ovale (Atrial septal defect)
When the foramen doesnt entirely close
Pacemaker of the heart, called the sinoatrial node or the sinus node. This node is
located in the upper end of the terminal sulcus at the inlet of the superior vena
cava
LEFT ATRIUM
The left atrium is located on the posterior surface (or mediastinal) of the
heart, and has a close relation with the esophagus.
o During esophagoscopy (or gastroscopy) it is possible to accidently
pierce the wall of the esophagus, risking injuring the left atrium of
the heart.
Two parts: the AURICLE and the ATRIUMPROPER.
o
The auricle has the pectinate muscles.
Only part of the left atrium which is visible at the left margin
of the heart.
o The smooth part is the atrium proper.
The atrium proper receives oxygenated blood from the 4
pulmonary veins (no valves) on the posterior surface
16 Orifices of the heart. The valves and their function
Atrioventricular orifices:
Right
o Tricuspid valve (ant, pos & septal cusps)
Attached to chorda tendinae and further papillary muscle
Regulates flow from atrium to ventricle
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Closed during systole & Opened during diastole
Left
o Bicuspid/Mitral valve (ant & pos cusps)
See above
Venous openings:
Superior vena cava
o No valves
Inferior vena cava
o Eustachian valve, located anterior inferior
Coronary orifice
o Thebesian valve
Pulmonary orifice:
Pulmonary veins (4)
o Open into left atrium, draining oxygenated blood from lungs
Pulmonary trunk
o Divide into right/left pulmonary artery and run from right ventricle
to lungs.
o Semilunar valve with 3 semilunar shaped cusps (ant, right pos & left
pos)
Aortic orifice
From left ventricle into the aorta
Aortic semilunar valve with posterior, anterior right & anterior left cusps
VALVES
There are cuspid and semilunar valves
Cuspid valves are composed of mesothelium on both surfaces.
o Between the mesothelium layers, we have fibrous cutaneous tissue.
o These valves arise from the annulus fibrosus, the skeleton of the
heart.
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Semilunar valves
o Function of the nodules is to close the orifice.
o There are 6 lunulae and 3 nodules in one valve.
o Dense part &flexid part.
The dense part is the peripheral part (arising from the fibrous
ring), and the flexid part is the central part (loose).
Above the valve of the aorta, there is a dilated part which is called the aortic
sinus. This aortic sinus has the orifice of the coronary arteries (right and left).
FIBROUS RINGS:
The muscles of the atria and ventricles arise from this fibrous ring, and it has the
orifices. Between the left and right venous ostia and the aorta there is a rightfibrous trigone. The left one is between the aorta and the left venous ostium.
Through the right fibrous trigone, we have the His bundle. From the atrium, the
impulse goes through the fibrous ring into the ventricle.
17 Ventricles of the heart. Radiogram of the heart
Generally, the ventricles have three muscular layers and the atria have two
muscular layers; therefore, the ventricles are thicker than the atria. The papillary
muscles form the inner layer of the ventricle together with the bridges and ridges
or the trabeculae carneae (Rathke's bundles).
The border between atrium and ventricle is the coronary sulcus.
The border between the ventricles are the anterior interventricular groove.
RIGHT VENTRICLE
V-shaped
In flowing part
o The portion from which blood flows from the atrium to the ventricle
via tricuspid.
The out flowing part forms a cone on the outer surface which is called the
conus arteriosus. From the conus, the pulmonary trunk starts.
Crista supraventricularis separates the inflowing and out flowing parts of theventricles from each other.
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The largest papillary muscle has a muscular cord from the interventricular
septum. This cord is called Moderator band of septomarginal trabecula
LEFT VENTRICLE
Forms the left surface, diaphragmatic surface and apex of the heart.
Bicuspid valve attached to the anterior and posterior papillary muscle by
chorda tendinae.
Thicker wall than that of the right ventricle (about 1-1.5cm), and the
interventricular septum is also formed by this thick wall of the ventricle.
o In cross section, the left ventricle is round.
Aortic orifice (the origin of the aorta).
RADIOGRAM
The X-ray of the heart has two arches on the right side and four arches on the
left side.
The superior arch on the right side is formed by the superior vena cava
and the ascending aorta.
The inferior arch on the right side is formed by the right atrium.
On the left side, the arches are formed by 1 aortic arch, 2 pulmonary trunk, 3
left auricle, and4
left ventricle.
Inferior border is not visible because below, we have the liver, and the
density of the heart and liver is the same.
(Netter plate 209)
18 Blood supply of the heart
ARTERIES:
The coronary arteries arise from the sinus (ascending) aorta, which is the first
dilated portion of the aorta just above the valves. The coronary arteries and their
major branches are distributed over the surface of the heart, lying within
subepicardial connective tissue
Right coronary artery:
Runs forward between the pulmonary trunk and the right auricle
It descends in the posterior interventricular groove
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It anastomose with the left one coronary artery
Branches supplies the right atrium, 1cm into the right ventricle and
posterior part of interventricular septum (by posterior septal artery)
Branches:
o Right conus artery
o Anterior ventricular branch
o Posterior ventricular branch
o Atrial branch
o S-A nodal branch
Left coronary artery:
It runs forward between the pulmonary trunk and the left auricle
It divides into circumflex branch and anterior interventricular branch
o Anterior interventricular branch descends in anterior interventricular
groove
Supplies major part of the heart:
Left atrium and left ventricle
Anterior part of Interventricular septum
1cm or the right ventricular wall
VENOUS DRAINAGE OF THE HEART
Great cardiac vein
o Begins at apex and ascends in the anterior interventricular groove
o Runs with the anterior interventricular branch of the left coronary
artery, then with circumflex branch of the left coronary artery, and it
enters the coronary sinus from the left side
o Oblique/Marshal vein of left atrium joins great cardiac vein
Middle Cardiac vein
o Begins at apex and ascends in the posterior interventricular groove
o
Runs together with the posterior interventricular branch of the rightcoronary artery
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o Joins small cardiac vein before draining to coronary sinus on the
right side
Small cardiac vein
o Right ventricle
o Runs with Right coronary artery
o Joins middle cardiac vein before draining to the coronary sinus.
Between the right and left ends, the coronary sinus opens into the right atrium of
the heart.
In addition to these three veins, there are also tiny veins on the right ventricle
(anterior surface) called venae cordis anterioris. They cross the coronary sulcus
to enter the right atrium directly. There are also the tiny veins called venae
cordis minimae (thebesian veins) from the atria which also directly drain to the
atria.
19The structure of cardiac wall. The conducting system and
innervation of the heart
LAYERSOFTHE HEART:
3 main layers:
A serous layer: epicardium (visceral layer is the pericardium).
A muscular layer: myocardium.
An inner layer: endocardium.
Epicardium
o Layered by mesothelium
o Connected to the muscle by a fibrous connective tissue which has
fat
o The coronary artery and cardiac veins lie beneath this epicardium.
Myocardium
VENTRICLE
o The external oblique
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Starts from the right end of the coronary sulcus on the
anterior surface and descends toward the apex from right and
superior to left and inferior.
On the posterior surface, it starts from the left side to the
right side.
At the apex, these fibers meet each other and form a turn
which is called vortex cordis.
o The middle circular layer
Parallel to the coronary sulcus.
This layer is missing on the apex, where there is only the
vortex cordis.
o The internal longitudinal layer
The fibers turning inward and upward continue into the inner
muscular layer of the heart forming papillary muscle and
trabeculae carneae.
ATRIUM
The muscle of the atrium is not so regular and it is thin (just two layers). The
outer is longitudinal and the inner is circular.
Around the inlet of the veins (sup & inf vena cava) the muscle fibers are regulararranged in circles around the inlet of them.
Endocardium has 2 layers:
Fibrous layer & epithelial (endothelial layer)
Fibrous layer connects the endothelium
(innermost layer) to the myocardium
The valves are also layered by endocardium,
both inferior and superior surfaces, and between
these endothelial layers, there is the fibrous
layer.
CONDUCTING SYSTEM:
Sinoatrial node
o Natural pacemaker
o Situated at upper end of terminal sulcus, near the anterior margin of
inlet superior vena cava
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o Impulses travel by intermodal pathways in right atrium towards
Atrioventricular node.
Atrioventricular node
o In interatrial septum below oval fossa and left to the orifice of
coronary sinus
His bundle
o Pierces right fibrous trigone (entering ventricle)
o Divide into left and right tawara bundles moving in the interseptal
surface.
Right bundle is located inside the moderator
band/septomarginal trabeculae
Purkinje Fibers
o Fibers from tawara bundles from interventricular septum runs
upwards again along inner ventricular wall.
INNERVATIONOFTHEHEART:
The heart is supplied by both sympathetic and parasympathetic fibers. These
fibers reach the heart in three plexuses called superior, middle, and inferior
cardiac plexuses.
Sympathetic innervation:
Postganglionic fibers from the cervical and upper thoracic portions of the
sympathetic trunk
The fibers reach the heart through superior, middle and inferior cardiac
branches.
The fibers pass through and terminate on the sinoatrial and
atrioventricular nodes
Stimulate increased heart rhythm, increased contraction force and dilation
of the coronary arteries.
Parasympathetic innervation:
Vagus nerve
Terminate by synapsing on neurons in the cardiac plexus.
Postganglionic fibers terminate on the sinoatrial, atrioventricular nodes
and on the coronary arteries.
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Stimulate decreased heart rate, force and constriction of the coronary
vessels.
20 The lungs, pulmonary roots, bronchopulmonary segmentsTHE LUNGS
Paired visceral organs occupying the pulmonary cavities of the thorax. They are
the organs in which respiration, gas exchange of blood happens. They are
covered by pleura.
Right lung:
3 lobes (superior, middle & inferior)
impressions for the azygos vein (below and above the hilus) and also the
superior vena cava. Because the azygos vein drains into the superior vena
cava, we also have the impressio cardiaca pulmonis (impression for the
heart).
Horizontal and oblique fissure
Inferior lobe is mainly behind the superior and inferior lobes
Left lung:
2 lobes (superior & inferior)
It has a wide impression called the aortic sulcus. It is made by the
descending thoracic aorta and the aortic arch. It also has the sulcus of the
subclavian artery that is next to the apex.
Oblique fissure
Surface projections
The horizontal fissure follows the fourth rib.
The oblique starts from the horizontal fissure in the axillary line and
crosses the 5th rib, terminating at the 6th rib (at the 6th sternocostal joint).
PULMONARY ROOT
The site where the visceral and parietal pleura meet. A fold descends and forms
the pulmonary ligament. The pulmonary root consist of the structures passing
through the hilum of the lung.
Structures:
Pulmonary artery
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2 Pulmonary veins
Main/Principal bronci
Lymphnodes
Nerves
Structures in the lung:
From superior to inferior:
o Left lung (artery, bronchus, vein) - ABV
o Right lung (Bronchus, artery, vein) - BAV
From anterior to posterior:
o Vein, artery, bronchus (in both lungs)
BRONCOPULMONARY SEGMENTS
The segments are the morphological, functional, pathological, and surgical units
of the lung. We can remove one segment surgically if there is a disease or tumor
10 segments in each lung
o Right: three in the superior lobe, two in the middle, and five in theinferior lobe.
o Left: five in the superior lobe and five in the inferior
Pyramidal shaped
The apex of the pyramid is facing toward the hilus
At the apex of this pyramid, the segmental bronchus enters the segment
together with the segmental branch of the pulmonary artery.
Center of the segment is the bronchus tree and the pulmonary artery (nextto each other).
Segments separated by connective tissue septa.
o Inside this septa are the pulmonary veins and lymph vessels running
toward the hilus.
Segment is composed of smaller units called lobules.
Pyramidal shape
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One lobule belongs to one terminal bronchus which is branching inside the
lobule forming bronchioli.
The difference between bronchi and bronchioli-- no cartilage, no glands,
but there is smooth muscle.
On the surface of the lung, you can see small, approximately 1-2cm areas
bordered by black color (surrounded) that are the lobules. We can only see the
base because the base is facing toward the surface. The black area is pollution
inside the connective tissue that separates the lobules from each other.
Double circulation (functional and nutritive)
21 Posterior mediastinum
The mediastinum is the middle part of the thoracic cavity which is bordered by:
Laterally: mediastinal pleura
Anteriorly: sternum
Posteriorly: vertebral column (thoracic part).
Superiorly: Thoracic outlet & root of the neck
Inferiorly: The diaphragm
Anterior and the posterior mediastinum
Borderline = hilus & pulmonary ligament.
Structures:
o esophagus
25cm
3 parts: Cervical, thoracic & small abdominal part (T11)
o vagus nerve
Right: vagus behind the esophagus. Left: vagus in front of
the esophagus.
o Descending aorta (thoracic part)
o Thoracic duct
Between azygos vein and thoracic aorta, in right pos.
mediastinum.
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At the level of 4th thoracic vertebra, it turns left behind
esophagus in front of the vertebral column, to the left venous
angle
Before entering, it collects: left jugular trunk (left
side, head and neck), left subclavian trunk (drains theleft upper limb), and left bronchomediastinal trunk
(drains the lung and the thoracic cavity mediastinum,
so the left part of the whole thoracic cavity).
Arises from the CISTERNACHYLI (in abdominal cavity behind
aorta ,L1)
Collects lymph from right/left lumbar trunks &
intestinal trunk
Drains 3/4 of the body
Last of the body is drained by right lymphatic trunk
having the same 3 trunks (right)
Runs through diaphragm behind aorta
o Azygos & hemiazygos vein
Azygos vein originate in abdominal cavity as ascending
lumbar vein
Collects segmental lumbar vein (drain posterior abdominal
wall).
Via diaphragm with greater & lesser splanchnic nerves
between medial and intermediate crus.
Collects intercostals vein in posterior mediastinum
Drain thoracic wall), the bronchial veins from the lungs, the
esophageal veins, and the external vertebral venous plexus
Only the intercostal veins are visible and dissectible
Azygos vein receives the hemiazygos vein from the left side
which collects the same veins from the left side plus the
accessory hemiazygos
o Sympathetic trunk
composed of 12 paravertebral ganglia
interganglionic fibers
1st thoracic 3rd lumbar: Autonomic nervous system:
Sympathetic neuron cell bodies
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Sacral part contains parasympathetic neuron cell bodies
White rami communicants:
Preganglionic fibers with myelin sheath
Originate from lateral horns of grey matter
Contain synapses to neuron cell bodies within the
ganglion that further sends axon fibers to the periphery
Grey rami communicants:
Postganglionic fibers without myelin sheath
Innervate glands & smooth muscles of vessels and
skin(Arrestor pile)
Ventral root contains sympathetic motor and
somatomotor fibers
Dorsal root (sensory): Only sensory ganglions that has
pseudounipolar neuron cell bodies.
Splanchnic nerves are formed by sympathetic fibers
that run through ganglia without synapsing.
6-9th ganglia greater splanchnic
10-11th ganglia lesser splanchnic
Preganglionic fibers terminate in celiac ganglion
where they synapse: Their postganglionic fibers
innervate:
Blood vessels of viscera
Smooth muscles of abdominal viscera
22 Lymphatic drainage of the thoracic wall and thoracic viscera
Thoracic duct
o Between azygos vein and thoracic aorta, in right pos. mediastinum.
o At the level of 4th thoracic vertebra, it turns left behind esophagus in
front of the vertebral column, to the left venous angle
Before entering, it collects: left jugular trunk (left side, head
and neck),
left subclavian trunk (drains the left upper limb),and left bronchomediastinal trunk (drains the lung and the
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thoracic cavity mediastinum, so the left part of the whole
thoracic cavity).
o Arises from the CISTERNACHYLI (in abdominal cavity behind aorta ,L1)
Collects lymph from right/left lumbar trunks & intestinal
trunk
o Drains 3/4 of the body
o Last of the body is drained by right lymphatic trunk having the
same 3 trunks (right):
Right bronchomediastinal trunk (drains the lung and the
thoracic cavity mediastinum, so the right part of the whole
thoracic cavity).
Primary lymph nodes?
Axillary lymph nodes?
o Drains lateral half of breast
o Investigated regularly as a part of the clinical investigation of breast
cancer
23 The lymphatic system and lymphatic circulation. The main
lymphatic trunks
LYMPHATIC SYSTEM (See topic 22 for Main lymphatic trunks)
Network of lymphoid organs, lymph nodes, lymph ducts, and lymph vessels thatproduce and transport lymph fluid from tissues to the circulatory system. Thelymphatic system is a major component of the immune system.
The lymphatic system has 3 functions:o Removal of excess fluids from body tissues
o Absorption of fatty acids and subsequent transport of fat, chyle, tothe circulatory system
o Production of immune cells (such as lymphocytes, monocytes, andantibody producing cells called plasma cells).
Lymph originates as blood plasma that leaks from the capillaries of thecirculatory system, becoming interstitial fluid, and filling the space between
individual cells of tissue.
http://en.wikipedia.org/wiki/Lymph_nodehttp://en.wikipedia.org/wiki/Thoracic_ducthttp://en.wikipedia.org/wiki/Lymph_vesselhttp://en.wikipedia.org/wiki/Biological_tissuehttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Immune_systemhttp://en.wikipedia.org/wiki/Chylehttp://en.wikipedia.org/wiki/Lymphocytehttp://en.wikipedia.org/wiki/Monocytehttp://en.wikipedia.org/wiki/Plasma_cellhttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Interstitial_fluidhttp://en.wikipedia.org/wiki/Lymph_nodehttp://en.wikipedia.org/wiki/Thoracic_ducthttp://en.wikipedia.org/wiki/Lymph_vesselhttp://en.wikipedia.org/wiki/Biological_tissuehttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Immune_systemhttp://en.wikipedia.org/wiki/Chylehttp://en.wikipedia.org/wiki/Lymphocytehttp://en.wikipedia.org/wiki/Monocytehttp://en.wikipedia.org/wiki/Plasma_cellhttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Circulatory_systemhttp://en.wikipedia.org/wiki/Interstitial_fluid -
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Plasma is forced out of the capillaries by oncotic pressure gradients, and as itmixes with the interstitial fluid, the volume of fluid accumulates slowly. Theproportion of interstitial fluid that is returned to the circulatory system byosmosis is about 90% of the former plasma; with about 10% accumulating asoverfill.
The excess interstitial fluid is collected by the lymphatic system by diffusion intolymph capillaries, and is processed by lymph nodes prior to being returned to thecirculatory system. Once within the lymphatic system the fluid is called lymph,and has almost the same composition as the original interstitial fluid.
LYMPHATIC CIRCULATION
Acts as a secondary circulatory system, except that it collaborates withwhite blood cells in lymph nodes.
Unlike the circulatory system, the lymphatic system is not closed and hasno central pump;
o The lymph moves slowly and under low pressure due to peristalsis,the operation ofsemilunar valves in the lymph vessels, and themilking action of skeletal muscles. Lymph vessels have one-way,semilunar valves and depend mainly on the movement of skeletalmuscles to squeeze fluid through them.
This fluid is then transported to progressively larger lymphatic vesselsculminating in the right lymphatic trunk (1/4 th right upper body) and thethoracic duct (3/4th); these ducts drain into the circulatory system at the
right and left venous angles.
The lymph goes through minimum 1 lymph node before it enters the bloodcirculation
SPLANCHNOLOGY II
24 Regions of the abdomen. Projections and
peritoneal relations of the abdominal viscera
REGIONS OF THE ABDOMEN
11 regions by two longitudinal lines (right and left
midclavicular lines) and two transverse planes (subcostal
http://en.wikipedia.org/wiki/Oncotic_pressurehttp://en.wikipedia.org/wiki/Capillarieshttp://en.wikipedia.org/wiki/Peristalsishttp://en.wikipedia.org/wiki/Semilunar_valveshttp://en.wikipedia.org/wiki/Thoracic_ducthttp://en.wikipedia.org/wiki/Oncotic_pressurehttp://en.wikipedia.org/wiki/Capillarieshttp://en.wikipedia.org/wiki/Peristalsishttp://en.wikipedia.org/wiki/Semilunar_valveshttp://en.wikipedia.org/wiki/Thoracic_duct -
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and interspinous planes). +2 regions, lateroposterior to each of the
hypochondriac regions called renal regions (not seen in picture).
PROJECTIONS AND PERITONEAL RELATIONS OF THE ABDOMINAL VISCERA
Viscera: An organ of the digestive, respiratory, urogenital, and endocrine systems
as well as the spleen, heart and great vessels; Hollow multilayered walled
organs.
Right hypochondrium
o Liver
Highest of the level of upper 5th
rib behind costal arch
If felt below right costal arch, it is enlarged
Intra
o Gallbladder
Crossing midclavicular line and right costal arch
Painful during palpation if infected
Intra
o Right colic flexure
Intra
Epigastric region
o Stomache
Cardia (T11, right), Pylorus (L1, left)
When full of food, it can reach down to umbilicus
Intra
o Left lobe of liver
Intra
o Pancreas
Head (L1,L2), Body runs in front of L1 & tail reach T12
Head & Body (Retro), Tail (Intra)
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o Duodenum
Sup. Hor. (L1), Descending (L1-L3), Inf. Hor. (L3), Ascending
(L3-L2)
Sup. Horizontal (intra), The rest is retroperitoneal
o Abdominal aorta & Inferior vena cava
Left Hypochondrium
o Spleen
9th-11th Rib
If felt below left costal arch, it is enlarged
Intra
o Fundus of stomach
Intra
o Left colic flexure
Related to the spleen
Intra
Umbilical region
o Small intestine
Retro
o Transverse colon
Related to the spleen on left side, and liver on right side
Intra
o Abdominal aorta & Inferior vena cava
Right lumbar region
o Ascending colon
Intra/retro
Left lumbar region
o Descending colon
Intra/retro
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o Small intestine (jejunum)
Right iliac region
o Cecum
Intra/Retro
o Appendix
McBurneys point: Line between umbilicus & ant. Sup. Iliac
spine. The point is 1/3rd from ant. Sup. Iliac spine
Intra
o Terminal part of Ileum
Intra
Left Iliac region
o Sigmoid colon
Intra/retro
o Small intestine
Pubic region
o Urinary bladder
Infraperitoneal
o Uterus after 12 weeks of pregnancy
o Part of small intestine
Kidneys and suprarenal glands are found in the left/right renal region, right/left
hypochondriac or right/left lumbar region depending on textbook.
25 The peritoneum and the peritoneal cavity
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The serous sac, consisting of mesothelium and a thin
layer of irregular connective tissue, that lines the
abdominal cavity and covers most viscera contained
therein. It forms the greater & lesser sac, connected by
the epiploic foramen.
PERITONEAL RELATIONS OF VISCERA
Stomache Intra
Duodenum
o Superior horizontal intra
o Descending retro
o
Inferior horizontal retro
o Ascending retro
Colon
o Cecum intra/retro
o Ascending intra/retro
o Transverse intra
o Descending intra/retro
Small intestine intra
Liver intra (except bare area)
Spleen intra
Kidney retro
Pancreas
o Head & body retro
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o Tail intra
Uterus infra
Urinary bladder infra
Rectum
o upper 1/3 intra
o middle 1/3 retro
o lower 1/3 infra
LIGAMENTS (Taken from Kovacs notes)
Diaphragm is layered by parietal peritoneum which reflects onto the liver,
forming the posterior layer of the coronary ligaments (left and right)
Another reflection of the parietal peritoneum onto the liver is the falciform
ligament (double layer.
o The left layer of the falciform ligament continues into the anterior
layer of the left coronary ligament, and the right layer of the
falciform ligament continues in the right coronary ligament.
The posterior layer of the coronary ligament comes from the parietal
peritoneum from the diaphragm above. This way, the two layers are next
to each other, forming a double layer at the left coronary ligament. The
right ligament remains as separate layers.
The peritoneum reflecting to the liver covers both surfaces of the liver, and the
two layers meet each other again at the porta hepatis along side the fissura
ligamenti venosi.
This double layer descends in the stomach and duodenum forming the
hepatogastric and hepatoduodenal ligaments that are together called the lesser
omentum. The hepatogastric ligament, reaching the lesser curvature of thestomach, divides into two layers that cover the stomach and meet each other
again at the greater curvature.
The new double layer descends into the lesser pelvis and turns back, forming
four layers which is the greater omentum. These four layers go up until the
transverse colon. Here, the third layer of the four runs back to the posterior
abdominal wall and continues with the parietal peritoneum covering the pancreas
(posterior wall of the lesser sac). The fourth layer also turns back to the posterior
abdominal wall, but it comes forward again, forming the visceral layer of the
transverse colon, then turns back again. These four layers then form the
transverse mesocolon. Comes forward again to form the mesenterium (layeringthe small intestine). After this, it reflects onto the posterior abdominal wall.
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BURSA OMENTALIS (lesser sac):
Superior wall: liver and superior recess of the lesser sac,
Anterior wall has three parts: 1 lesser omentum, 2 stomach, 3 gastrocolic ligament.
Posterior wall: parietal peritoneum (covering the pancreas)
Splenic recess: the left recess of the lesser sac (at the hilus of the spleen
between the gastrolienal and phrenicolienal ligaments.
Epiploic (Winslow's) foramen:
o Right side of the hepatoduodenal ligament, behind the ligament
o Hepatoduodenal ligament (front)
o
Liver (above)
o Hepatorenal ligament (behind)
o Duodenorenal ligament (below)
26 Parts, topography and peritoneal relations of the stomach
Fragments of food are chemically broken down in the stomach by the gastric
juice to produce chyme. Stomach controls the rate of delivery of chyme to the
small intestine. Capacity: 1200-1600ml.
PARTS OF STOMACH
Cardiac orifice: Continuation of the esophageal orifice
Cardia: Transition between esophagus and stomach
Fundus: Arises on the left superior part of stomach
Pylorus
SURFACE PROJECTIONS
Upper part of abdomen in epigastric region
Extend from beneath left costal margin into the umbilical region
Majority lies under the cover of lower ribs
J shaped organ
SKELETOPY
Cardia: T11, left (fixed point)
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Fundus: 7th rib, 2cm left of the midline
Pylorus: L1, right (fixed point)
Lesser and greater curvature runs between cardia and pylorus
PERITONEAL RELATIONS
Stomach is intraperitoneal, and the peritoneum forms several ligaments
connecting it to the viscera:
Along the lesser curvature: Hepatogastric ligament
Along the greater curvature:
o Gastrosplenic ligament
o
Gastrophrenic ligament
o Gastrocolic ligament
o Greater omentum
RELATIONS OF STOMACH
Superior
o Liver
o Diaphragm
Inferior
o Transverse colon
o Mesocolon
Anterior
o Abdominal wall
o Left costal arch
o Diaphragm
o Left lobe of liver
Posterior
o Omental bursa
o Diaphragm
o Left adrenal gland
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o Left kidney
Left lateral
o Spleen
27 Blood supply of the stomach
Left gastric artery:
Abdominal aorta-celiac trunk-left gastric artery
Extend left to esophagus, then descend along lesser curvature
Supplies upper right part of stomach
Supplies lower third of esophagus
Right gastric artery:
Abdominal aorta-celiac trunk-common hepatic-hepatic artery proper-right
gastric artery
Runs along lesser curvature
Supplies lower right part of stomach
Anastomose with left gastric artery
Short gastric artery:
Abdominal aorta-celiac trunk-Splenic-short gastric artery
Arise at splenic hilum and run in gastrosplenic ligament
Supply fundus of stomach
Left gastroomental artery
Abdominal aorta-celiac trunk-splenic-left gastroomental artery
Arise at splenic hilum and runs along greater curvature
Supply stomach along the upper part of greater curvature
Right gastroomental artery
Abdominal aorta-celiac trunk-common hepatic-gastroduodenal-right
gastroomental artery
Ascends along greater curvature
Anastomose with left gastroomental artery
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Supply lower part of the greater curvature
Veins
From lesser curvature:
o Right and left gastric veins-portal vein
From Greater curvature
o Right and left gastroomental-sup. Mesenteric-splenic-portal vein
The left gastric vein anastomose with the esophageal venous plexus that drain
into the azygos vein which drains to the superior vena cava. This anastomoses is
also an anastomoses between the portal and cava venous systems.
LYMPHATIC DRAINAGE
The lymph vessels follow the arteries into the left and right gastric node,
gastroomental nodes and the short gastric nodes. All lymph from the stomach
eventually passes to the celiac nodes.
NERVE SUPPLY
Sympathetic Celiac ganglion
Parasympathetic Vagus nerve
28 The hepatoduodenal ligament and its content. The lesser sac
THE HEPATODUODENAL LIGAMENT
The portion of the lesser omentum which connects the liver and duodenum. The
hepatoduodenal ligament have 3 structures:
Bile duct
o Formed by the union of common hepatic duct and cystic duct. It
discharges bile at the major duodenal (vaters) papilla.
o Bile: Secretum for fat digestion
Hepatic artery proper
o Celiac trunk-common hepatic artery-hepatic artery proper
Portal vein
o Drains the unpaired viscera of the abdomen
LESSER SAC
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The lesser sac or omental bursa is found behind the lesser omentum and is
connected to the greater sac via the epiploic (Winslows) foramen, which is found
behind the hepatoduodenal ligament and in front of the inferior vena cava. The
lesser sac is developed as the stomach, duodenum and lesser omentum turns 90
degrees.
Superior
o Liver & superior recess of lesser sac
Anterior
o Lesser omentum
o Stomach
o Gastrocolic ligament
Posterior
o Parietal peritoneum
Lateral right
o Open space (epiploic foramen)
Lateral left
o Splenic recess
29 Topography and peritoneal connections of the liver
Skeletopy
Superior level: Upper & lower border of 5 th rib depending on right or left
lobe or liver
Inferior level: Right costal arch
PERITONEAL RELATION (Kovacs notes)
Diaphragm is layered by parietal peritoneum which reflects onto the liver,
forming the posterior layer of the coronary ligaments (left and right)
Another reflection of the parietal peritoneum onto the liver is the falciform
ligament (double layer.
o The left layer of the falciform ligament continues into the anterior
layer of the left coronary ligament, and the right layer of the
falciform ligament continues in the right coronary ligament.
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The posterior layer of the coronary ligament comes from the parietal
peritoneum from the diaphragm above. This way, the two layers are next
to each other, forming a double layer at the left coronary ligament. The
right ligament remains as separate layers.
The peritoneum reflecting to the liver covers both surfaces of the liver, and thetwo layers meet each other again at the porta hepatis along side the fissura
ligamenti venosi.
This double layer descends in the stomach and duodenum forming the
hepatogastric and hepatoduodenal ligaments that are together called the lesser
omentum. The hepatogastric ligament, reaching the lesser curvature of the
stomach, divides into two layers that cover the stomach and meet each other
again at the greater curvature.
The new double layer descends into the lesser pelvis and turns back, forming
four layers which is the greater omentum. These four layers go up until thetransverse colon. Here, the third layer of the four runs back to the posterior
abdominal wall and continues with the parietal peritoneum covering the pancreas
(posterior wall of the lesser sac). The fourth layer also turns back to the posterior
abdominal wall, but it comes forward again, forming the visceral layer of the
transverse colon, then turns back again. These four layers then form the
transverse mesocolon. Comes forward again to form the mesenterium (layering
the small intestine). After this, it reflects onto the posterior abdominal wall.
30 Parts and surfaces of the liver
The liver has a diaphragmatic & a visceral surface
The visceral surface has a right and left lobe, separated by the falciform
ligament. Between the right left lobes, the caudate and quadrate lobes are found.
Superior
o Diaphragm via bare area
Right lobe
o Costal arch
o Colic impression
o Renal impression
o Suprarenal impression
o Duodenal impression
Quadrate lobe
o Gallbladder
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o Pylorus
o Groove for inferior vena cava
Left lobe
o Esophageal impression
o Gastric impression, lesser curvature and anterior surface
o Diaphragm through the bare area
Caudate lobe
o Inferior vena cava
LIGAMENTS OF LIVER
Falciform ligament
o Inferior part of falciform Round ligament of the liver
(remnant of left umbilical vein)
Right layer of falciform continues to right coronary ligament, and the left
layer to left coronary ligament.
o The coronary ligaments on each side form the right and left
triangular ligaments.
Ligamentum venosum
Hepatoduodenal ligament
Between the 4 lobes of the liver, the H-fissure is found
Longitudinal part
o Left
Superior: Ligamentum venosum (fissure for venous ligament)
Inferior: Round ligament (fissure for round ligament
o Right
Superior: Fissure for inferior vena cava
Inferior: Fissure for gallbladder
o Horizontal part
Hepatoduodenal ligament + portal triad (Portal fissure)
Ligaments connecting the liver to other viscera
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Hepatoduodenal
Hepatorenal
Hepatogastric
31 The spleen
A large vascular lymphatic organ lying in the upper left part of the abdominal
cavity, between the stomach, pancreas and kidney medially and the diaphragm
posterolaterally.
SKELETOPY
Level of 9th-11th rib
SURFACES
Diaphragmatic surface (convex)
Anterior visceral surface
o Superiorly: Gastric impression
o Inferiorly: Colic impression
Posterior visceral surface
o Renal impression
RELATIONS OF SPLEEN
Anterior: Stomache. Posteromedial: Kidney. Posterolateral: Diaphragm. Inferior:
Left colic flexure. Hilus: Tail of pancreas
HILUS
Splenic artery
Splenic vein
LIGAMENTS
Splenorenal (lienorenal)
o Contain splenic vessels
Gastrosplenic
o Contain short gastric vessels
Phrenicocolic
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o It forms a nest for the spleen that prevent it from descending
NERVE INNERVATION
Splenic plexus branches ofceliac plexus the left celiac ganglion
Vagus nerve (right)
32 The duodenum and the pancreas
DUODENUM
It is the first division of the small intestine, connected to the pylorus of the
stomach superiorly (proximal end) and the jejunum inferiorly (distal end).
Superior horizontal part
Intraperitoneal
L1
Descending part
Retroperitoneal
L1-L3
Inferior horizontal part
Retroperitoneal
L3
Ascending part
Gradually becomes intraperitoneal at the duodenaljejunal flexure
L3-L2
BLOOD SUPPLY
Arterial
o Gastroduodenal artery
o Superior pancreaticoduodenal artery
o Inferior pancreaticoduodenal artery
Venous
o Superior and Inferior Pancreaticoduodenal veins
Nerve
http://en.wikipedia.org/wiki/Celiac_plexushttp://en.wikipedia.org/wiki/Celiac_ganglionhttp://en.wikipedia.org/wiki/Vagus_nervehttp://en.wikipedia.org/wiki/Celiac_plexushttp://en.wikipedia.org/wiki/Celiac_ganglionhttp://en.wikipedia.org/wiki/Vagus_nerve -
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o Celiac ganglia & Vagus
PANCREAS
It is an elongated, lobulated and retroperitoneal gland. Devoid of capsule.
Extending from concavity of duodenum to spleen. The gland secretes part of
the pancreatic juice that is discharged into the intestine, and from its endocrine
part, insulin, glucagons, etc.
The pancreas posses a head, body, tail
SKELETOPY
Head: L3-L2
Body: L1
Tail: L1-T12
Main pancreatic duct
The duct unites with the common bile duct in the hepatopancreatic
ampulla
Opens into the major duodenal (Vaters) Papilla
Accessory pancreatic ducts opens into the minor duodenal papilla
Blood supply
Arterial:
o Superior & Inferior pancreaticoduodenal arteries
o Pancreatic arteries (from splenic artery)
Venous:
o Pancreaticoduodenal veins
Nerve supply
Pancreatic plexus
Celiac ganglia
Vagus
33 The intestines (except the duodenum and rectum)
THE INTESTINES
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The intestines start with the duodenum, which is connected to the pylorus of
stomach. It then continues as jejunum, ileum and colon. The greater omentum
covers the intestines.
Jejunum:
o Located in the upper left part of the abdomen
o The coils runs horizontally
o 6m long together with Ileum
Ileum
o Located in the lower part of the abdomen, umbilical region and
sometimes the right and left lumbar regions.
o The coils runs vertically
o Iliocecal (iliocolic) junction in right iliac region
The small intestines have a long mesenterium carrying the blood vessels
supplying it
Colon: To differentiate between the small and large intestine, look for the tenia,
epiploic appendices.
Cecum
o Iliocecal junction (in right iliac fossa)
o Appendix is found below this junction
Tonsil of intestine
Ascending colon
o Right lumbar region
o Retr