Anatomy II - Final Exam Notes

8/22/2019 Anatomy II - Final Exam Notes

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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

Documents

Anatomy II - Final Exam Notes