THE LUMBAR PLEXUS

Formed within psoas major from the ANTERIOR rami of L1,2,3&4

Receives grey rami communicantes from the sympathetic trunk

L1&2 give off white rami communicantes to the sympathetic trunk

Branches emerge from the lateral and medial borders and the anterior surface of psoas
major

LATERAL BRANCHES

Iliohypogastric - L1; skin of lower part of anterior abdominal wall

Ilioinguinal - L1; enters inguinal canal and supplies skin of groin, scrotum / labium majus

Lateral cutaneous nerve of the thigh - L2&3; crosses iliac fossa anterior to iliacus, supplies
skin on lateral aspect of thigh

Femoral nerve - L2,3&4; enters thigh behind inguinal ligament lateral to femoral sheath
and canal

MEDIAL BRANCHES

Obturator nerve - L2,3&4; crosses pelvic brim in front of sacro-iliac joint and behind
common iliac vessels

4th lumbar root of the lumbosacral trunk contributes to the sacral plexus

ANTERIOR BRANCH

Genito-femoral nerve - L1&2; genital branch enters spermatic cord and supplies cremaster
muscle; femoral branch supplies skin on medial aspect of thigh

ABDOMINAL SYMPATHETIC TRUNK *****

Enters the abdomen through the medial arcuate ligament and runs downwards along the
medial border of psoas major and enters the pelvis behind the common iliac vessels. The right
trunk lies posterior to the inferior vena cava

Made up of 4 segmentally arranged ganglia; the upper two ganglia receive white ramus
communicans from the 1st and 2nd lumbar nerves

Give off grey rami communicans to the lumbar spinal nerves

Also gives off branches to the aortic sympathetic plexuses andthe hypogastric plexus

CELIAC PLEXUS *****

Two celiac ganglia and a network of fibres surrounding the origin of the celiac artery

Receive sympathetic pre-ganglionic fibres from the greater and lesser splanchnic nerves
and gives off POST-ganglionic fibres to the fore-gut

1
 Receives parasympathetic pre-ganglionic fibres from the vagus and these form synapses
within the wall of the organs supplied

The proximal 2/3 of the transverse colon is mid-gut (superior mesenteric plexus)

ABDOMINAL AORTA *****

Enters the abdomen through the aortic opening of the diaphragm at the level of T12
Bifurcates into the right and left common iliac arteries at L4
The inferior vena cava, cysterna chyli and the beginning of the azygos vein lie to the right
of the aorta

BLOOD SUPPLY TO GI TRACT

Celiac artery - fore-gut (lower 1/3 of oesophagus to proximal half of second part of
duodenum. Gives off left gastric, splenic and hepatic arteries

Superior mesenteric - mid-gut (distal half of second part of duodenum to junction

between proximal 2/3 and distal 1/3 of transverse colon. Gives off inferior pancreatico-duodenal,
middle colic, right colic, ileocolic arteries and 12-15 jejunal and ileal branches

Inferior mesenteric - hind-gut (distal 1/3 of transverse colon to upper half of anal canal).
Gives off left colic and sigmoid branches and continues as superior rectal artery.

CELIAC ARTERY *****

Artery of the fore-gut

Branch of abdominal aorta at T12
Posterior to lesser sac
Three terminal branches: LEFT gastric, splenic and hepatic arteries
The splenic artery has the following branches: Pancreatic branches, left gastro-epiploic
and short gastric arteries

(Common) HEPATIC ARTERY *****

Branch of the celiac artery

Runs within the lesser sac ANTERIOR to the opening into the lesser sac
Lies INFRONT of the portal vein and to the LEFT of the bile duct
Has 4 branches: RIGHT gastric, gastroduodenal and left and right hepatic arteries
The left gastro-epiploic artery is a branch of the splenic artery while the right gastro-
epiploic is a branch of the gastroduodenal artery

PORTAL VEIN *****

5cm long, formed behind the neck of the pancreas from the splenic and superior
mesenteric veins

2
 Posterior to the first part of the duodenum, then enters the lesser omentum, lying anterior
to the epiploic foramen and posterior to the hepatic artery and bile duct
Divides into RIGHT and LEFT terminal branches
Drains blood from the lower third of the oesophagus to the upper half of the anal canal
(the inferior mesenteric vein drains into the splenic vein)

INFERIOR VENA CAVA *****

Formed by the union of the left and right common iliac veins (and median sacral vein)
behind the right common iliac artery at the level of L5 *
Pierces central tendon of the diaphragm at the level of T8 to drain into the right atrium *
Lies to the right of the aorta, cysterna chyli *
Lies to the left (medial) of the right ureter *
Lies posterior to the opening into the lesser sac and the pancreas *
The left suprarenal, testicular / ovarian vein drain initially into the left renal vein then into
the IVC *
Left and right renal veins, hepatic veins, right ovarian / testicular and right suprarenal
vein drain directly into the IVC *

PORTAL-SYSTEMIC ANASTOMOSES *****

Lower third of oesophagus - LEFT gastric vein and azygos vein *

Half way down anal canal - superior rectal vein and middle (internal iliac) and inferior
rectal (internal pudendal) veins *
Umbilicus - veins of anterior abdominal wall and left branch of portal vein, travel within
the falciform ligament *
Veins of the ascending and descending colon, duodenum and pancreas anastomose
with renal, lumbar and phrenic veins *

LYMPHATICS *****

The GI tract drains into pre-aortic (celiac, superior and inferior mesenteric) nodes and the
efferent lymph vessels form the intestinal trunk
The para-aortic nodes drain lymph from the kidneys, suprarenal glands, testes / ovaries,
fallopian tubes, uterine fundus, common iliac nodes and deep lymphatics from the posterior
abdominal wall. Efferent lymphatics form the right and left lumbar trunks
The cisterna chyli is an elongated lymph sac located below the diaphragm anterior to
L1&2 and to the right of the aorta. It receives the intestinal, right and left lumbar trunks and
continues into the thorax as the thoracic duct.

Question 1: With respect to the lumbar plexus

a. The femoral nerve is derived from L1, L1 & L3[f]

True False
b. The femoral nerve enters the thigh anterior to the inguinal ligament [f]p

True False

3
c. The femoral nerve enters the thigh lateral to the femoral sheath [t]

True False
d. The femoral nerve enters the thigh medial to the femoral canal [f]

True False
Question 2: The abdominal aorta
a. Enters the abdomen anterior to the 12th thoracic vertebra [f]

True False
b. Lies to the right of the cisterna chyli [f]

True False
c. Bifurcates into the left and right common iliac arteries at the level of the first lumbar vertebra[f]

True False
d. Lies to the left of the inferior vena cava [t]

True False
Question 3: The portal vein
a. Is formed by the union of the superior and inferior mesenteric veins[f]

True False
b. Lies anterior to the first part of the duodenum [f]

True False
c. Lies within the lesser omentum [t]

True False
d. Lies posterior to the opening into the lesser sac[f]

True False
Question 4: With respect to the lumbar plexus
a. The lumbar plexus is formed from the posterior rami of the upper 4 lumbar nerves[f]

True False
b. The nerves of the lumbar plexus receive grey rami communicantes from the sympathetic trunk[t]

True False
c. The upper 3 lumbar nerves give off white rami communicantes to the sympathetic trunk[f]

True False
d. The lumbar plexus is formed anterior to the psoas and iliacus muscles [f]

True False

Question 5: With respect to the blood supply to the gastro-intestinal tract

a. The inferior pancreatico-duodenal artery is a branch of the celiac artery[f]

True False
b. The middle colic artery is a branch of the inferior mesenteric artery [f]

True False
c. The ileocolic artery is a branch of the superior mesenteric artery [t]

True False
d. The inferior mesenteric artery is the artery to the hind-gut [t]

True False
Question 6: The abdominal part of the sympathetic trunk
a. e) The upper two sympathetic ganglia receive a white ramus communicans from the first and second lumbar nerves[t]

True False
b. f) Gives off grey rami communicantes to the lumbar spinal nerves[t]

True False
c. g) The left sympathetic trunk is posterior to the inferior vena cava[f]

True False
d. h) Enters the abdomen behind the medial arcuate ligament[t]

4
 True False
Question 7: With respect to the blood supply to the gastro-intestinal tract
a. The celiac artery is the artery to the fore-gut[t]

True False
b. The celiac artery supplies the lower third of the oesophagus to the duodeno-jejunal junction (ligament of Treitz)[f]

True False
c.
d. The inferior mesenteric artery is the artery to the mid-gut[f]

True False
e. The superior mesenteric artery supplies the distal half of the second part of the duodenum to the junction between the
proximal 2/3 and distal 1/3 of the transverse colon[t]

True False
Question 8: The (common) hepatic artery
a. Runs within the lesser omentum [f]

True False
b. Lies posterior to the opening into the lesser sac[f]

True False
c. Lies to the right of the bile duct [f]

True False
d. Lies posterior to the portal vein [f]

True False
Question 9: The celiac plexus
a. Gives off pre-ganglionic sympathetic fibres to the fore-gut[f]

True False
b. Receives the greater and lesser splanchnic nerves [t]

True False
c. Receives parasympathetic post-ganglionic fibres from the vagus nerve[f]

True False
d. Supplies the proximal 2/3 of the transverse colon [f]

True False
Question 10: With respect to the blood supply to the gastro-intestinal tract
a. The left colic artery is a branch of the inferior mesenteric artery [t]

True False
b. The superior rectal artery is a continuation of the inferior mesenteric artery[t]

True False
c. The splenic artery is a branch of the celiac artery [t]

True False
d. The short gastric arteries are branches of the splenic artery[t]

True False
Question 11: With respect to the lumbar plexus
a. The genito-femoral nerve is derived from L1 & L2 [t]

True False
b. The genito-femoral nerve emerges from the lumbar plexus on the anterior surface of psoas[t] major

True False
c. The genital bramch of the genito-femoral nerve enters the spermatic cord [t]

True False
d. The femoral branch of the genito-femoral nerve supplies the cremaster muscle[f]

True False
Question 12: The inferior vena cava within the abdomen
a. Lies to the right of the aorta[t]

True False
b. Pierces the central tendon of the diaphragm at the level of T12 [f]

5
 True False
c. Lies medial to the right ureter [t]

True False
d. Is related anteriorly to the opening into the lesser sac[ f]

True False

Question 13: The celiac artery

a. Is the artery of the mid-gut [f]

True False
b. Lies anterior to the lesser sac[f]

True False
c. Is a branch of the abdominal aorta at the level of the 12th thoracic vertebra[t]

True False
d. Has three branches ? the right gastric artery, the splenic artery and the hepatic artery[f]

True False
Question 14: With respect to the lumbar plexus
a. The obturator nerve is derived from L2,L3 & L4[t]

True False
b. The obturator nerve emerges from the lumbar plexus on the medial border of psoas major[t]

True False
c. The obturator nerve crosses the pelvic brim infront of the sacral promontory [f]

True False
d. The obturator nerve crosses the pelvic brim anterior to the common iliac vessels[f]

True False
Question 15: The inferior vena cava
a. Drains into the left atrium [f]

True False
b. Lies to the left of the cysterna chili[f]

True False
c. Is related posteriorly to the pancreas[t]

True False
d. Originates behind the left common iliac vein [f]

True False

LIVER *****

The falciform ligament divides the liver into right and left lobes and splits on the superior
surface of the liver, the right layer forming the upper layer of the coronary ligament while the left
layer forms the upper layer of the left triangular ligament

The peritoneal layers forming the coronary ligaments are widely separated, leaving part of
the liver devoid of peritoneum the - bare - area

The ligamentum teres (remnant of umbilical vein) runs from the umbilicus to the left branch
of the portal vein

The ligamentum venosum (remnant of ductus venosus) runs from the left branch of the
portal vein to the inferior vena cava

6
 The right lobe is further divided into the quadrate lobe (between the ligamentum venosus
and inferior vena cava, superior to the gall bladder) and the caudate lobe (between the
ligamentum teres, porta hepatis and gall bladder

The quadrate and caudate lobes are functionally part of the left lobe and there is very little
overlap in the blood supply of the two sides

The hepatic artery (30%, oxygenated) and the portal vein (70%, de-oxygenated) supply
blood to the liver. Venous drainage (right and left hepatic vein) is into the inferior vena cava.

Although anatomically part of the right lobe, the caudate and quadrate lobes are supplied
by the LEFT hepatic artery

The hepatic lobule contains a central vein (tributary of the hepatic vein) while the spaces
between the lobules (portal canals) contain branches of the hepatic artery, portal vein and a
tributary of a bile duct

Lymphatic drainage of most of the liver is to the celiac nodes but the bare area drains into
posterior mediastinal nodes

The porta hepatis contains the following structures *****

Right and left hepatic arteries

Right and left branches of the portal vein

Right and left hepatic ducts

The upper part of the free edge of the lesser omentum is attached to the liver at this point

Sympathetic and parasympathetic nerves

Lymphatics and nodes draining the gall bladder

BILIARY TREE *****

The bile canniliculi drain into interlobular ducts located at the periphery of the hepatic
lobule. The interlobular ducts join to form larger ducts and eventually form the right and left
hepatic ducts at the porta hepatis

The caudate and quadrate lobes are functionally part of the left lobe of the liver and are
drained by the left hepatic duct

The common hepatic duct is formed from the left and right hepatic ducts

The cystic duct runs from the gall bladder to join the RIGHT side of the common hepatic
duct, forming the common bile duct

The common bile duct is located in the right free edge of the lesser omentum, anterior to
the epiploic foramen, in front of the portal vein and to the right of the hepatic artery

7
 The common bile duct then runs behind the first part of the duodenum (to the right of the
gastro-duodenal artery) then behind the head of the pancreas to open half way down the
second part of the duodenum into the ampulla of Varter

The common bile duct is usually joined by the main pancreatic duct close to its opening
into the duodenum. The opening has a smooth muscle sphincter - the sphincter of Oddi

GALL BLADDER *****

Has a fundus, body and neck which is continuous with the cystic duct

The fundus is at the level of the tip of the 9th right costal cartilage

Related anteriorly to the anterior abdominal wall and the visceral surface of the liver

Related posteriorly to the transverse colon and the first and second parts of the duodenum

Arterial supply - cystic artery, branch of the right hepatic artery

Venous drainage - cystic vein, into the portal vein

Lymphatics - cystic lymph node located near the neck, then to the celiac nodes

Nerves - celiac plexus

THE PANCREAS *****

Exocrine (acini) and endocrine (islets of Langerhans) gland

Head, neck, body and tail. The uncinate process of the head lies posterior to the superior
mesenteric vessels. The neck lies anterior to the origin of the superior mesenteric artery and
portal vein

Related anteriorly to the transverse colon and mesocolon, lesser sac and stomach

Related posteriorly to the bile duct, portal vein, splenic vein, inferior vena cava and aorta,
origin of superior mesenteric artery, left psoas, left suprarenal gland, left kidney and hilus of
spleen

The splenic artery runs along the upper border of the pancreas

Drained by main pancreatic duct, opening half way down the second part of the duodenum.
The accessory pancreatic duct, where present, opens above the opening of the main duct

Arterial supply - splenic, superior and inferior pancreatico-duodenal arteries

Lymphatics - celiac nodes

8
 Nerves - parasympathetic (vagus) and sympathetic from the celiac plexus

SPLEEN *****

Lies in the left hypochondrium under the 9th, 10th and 11th ribs with its long axis along the
shaft of the 10th rib. Extends to the mid-axillary line and the normal spleen is not palpable. It is
intra-peritoneal *

Has a notched anterior border *

Anterior relations: stomach, tail of pancreas and left colic flexure *

Medial relation: left kidney *

Posterior relations: diaphragm, left costo-diaphragmatic recess, left lung, 9th,10th and 11th
ribs *

Blood supply - splenic artery, branch of celiac artery

Lymphatics - celiac nodes *

Nerves - celiac plexus *

STOMACH *****

Lies in the left HYPOCHONDRIUM extending onto the epigastric and umbilical regions

Has a fundus, body, antrum and pylorus

Body extends from the level of the cardiac orifice to the incisura angularis on the lesser
curvature

Connected to the liver by the lesser omentum

Three muscle layers - outer longitudinal, inner circular and innermost oblique. Intra-
peritoneal (has peritoneum on all surfaces)

The pyloric sphincter is an anatomical sphincter but a physiological sphincter only exists at
the cardiac orifice

RELATIONS OF THE STOMACH

Anterior

Anterior abdominal wall, left costal margin, diaphragm, left lung and pleura, left lobe of
liver

Posterior

Lesser sac, diaphragm, spleen, splenic artery, pancreas, left suprarenal gland and upper
part of left kidney, transverse colon and transverse mesocolon

9
BLOOD SUPPLY *****

Left gastric artery - branch of celiac artery - lower third of oesophagus and upper RIGHT
part of stomach

Right gastric artery - branch of hepatic artery - lower right part of stomach

Short gastric arteries - branches of splenic artery - fundus

Left gastro-epiploic - branch of splenic artery - runs along GREATER curvature

Right gastro-epiploic - branch of gastroduodenal artery - lower part of greater curvature

Left / right gastric veins - drain into portal vein directly

Short gastric and left gastro-epiploic veins - drain into the splenic vein

Right gastro-epiploic vein - drains into the superior mesenteric vein

NERVES AND LYMPHATICS *****

Lymphatics follow arteries, all drain into celiac nodes. Those from the fundus of the
stomach initially drain into nodes in the hilus of the spleen then to the celiac nodes

Nerves: Anterior vagal trunk - Left vagus nerve mainly; has hepatic branch to the liver from
which the pyloric branch arises

Posterior vagal trunk - Right vagus mainly; has branch to celiac and superior mesenteric
plexuses which supply foregut and mid-gut (splenic flexure)

Vagal impulses are secretomotor to the glands and motor to the muscle (but inhibitory to
the pyloric sphincter)

Sympathetic supply - from celiac plexus - motor to the pyloric sphincter

DUODENUM *****

25cm long, first 2.5cm are intra-peritoneal. Divided into 4 parts

First part - 5 cm long on transpyloric plane

Anterior: quadrate lobe of liver and gall bladder

Posterior: Lesser sac, gastroduodenal artery, bile duct, portal vein, inferior vena cava

Superior: Epiploic foramen

Inferior: Head of pancreas

Second part - 8cm long

Anterior: gallbladder, right lobe of liver, transverse colon and small intestine

10
 Posterior: Hilus of right kidney and right ureter *

Lateral: Ascending colon, right colic flexure, right lobe of liver

Medial: Head of pancreas

Pancreatic and bile ducts open into second part of duodenum

Third part - 8cm long

Anterior: Superior mesenteric vessels, root of mesentery of small intestine and jejunum

Posterior: Right ureter, right psoas, inferior vena cava and aorta*

Superior: Head of pancreas

Inferior: Jejunum

Fourth part - 5cm long

Anterior: Jejunum

Posterior: Aorta and left psoas

Ligament of Trietz attaches the duodeno-jejunal junction to the right crus of the
diaphragm

SMALL INTESTINE *****

Jejunum and Ileum, 6m long

Attached to the posterior abdominal wall by a mesentery

Mucosa has CIRCULAR folds called plicae circularis which are more prominent in the
jejunum

Aggregations of lymphoid tissue are present in the mucous membrane of the lower ileum
along the antimesenteric border (Payers patches)

Blood - Superior mesenteric vessels

Lymphatics - superior mesenteric nodes

Nerve - sympathetic and parasympathetic (vagus) from the superior mesenteric plexus

THE RIGHT KIDNEY *****

Lower level than the left due to the bulk of the right lobe of the liver

11
 Anterior relations: suprarenal gland, liver, second part of duodenum, right colic flexure

Posterior relations: Diaphragm, costo-diaphragmatic recess

12th rib. Psoas, quadratus lumborum and transversus abdominis
Sub-costal (T12), iliohypogastric and ilioinguinal nerves

LEFT KIDNEY *****

Descends 2.5cm on INSPIRATION

Anterior relations: LEFT suprarenal gland, spleen, stomach, left colic flexure and coils of
jejunum

Posterior relations: 11th and 12th ribs, diaphragm and costo-diaphragmatic recess.
Psoas, quadratus lumborum and transversus abdominis
Sub-costal, iliohypogastric and ilioinguinal nerves

KIDNEY - BLOOD SUPPLY *****

Renal artery - branch of abdominal aorta. Enters the hilus of the kidney behind the renal
vein; has 5 segmental branches at the hilus, four in front and one behind the renal pelvis

Subsequent branches are as follows: segmental - lobar - interlobar - arcuate - interlobular

arteries - afferent glomerular arterioles

Renal vein drains y into the inferior vena cava directly

THE URETER *****

25cm long, leaves renal pelvis behind the renal vein and descends on psoas major which
separates it from the tips of the transverse processes of the lumbar vertebrae *

Adherent to parietal peritoneum *

Enters the pelvis in front of the sacro-iliac joint and the bifurcation of the common iliac
artery *

Supplied by the renal, testicular / ovarian and superior vesical arteries *

Lymphatic drainage is to the para-aortic and iliac nodes *

Nerve - renal, testicular / ovarian and hypogastric plexuses. Afferent (sensory) fibres travel
with the sympathetic nerves and enter the spinal cord at L1&2 *

Within the pelvis, the ureter runs at first downward on the lateral wall of the pelvic cavity,
along the anterior border of the greater sciatic notch and under cover of the peritoneum. *

12
 It lies in front of the internal iliac artery and medial to the obturator nerve obturator, inferior
vesical, and middle rectal arteries *

In the female, the ureter forms the posterior boundary of the ovarian fossa,in which the
ovary is situated and is separated from the ovary by pelvic peritoneum *

In the region of the ischial spine, it runs medially and forward beneath the base of the
broad ligament on the lateral aspect of the cervix and upper part of the vagina to reach the
bladder. *

It is crossed by the uterine artery ~2cm lateral to the supra-vaginal cervix and the lateral
vaginal fornices *

At the bladder base, the ureters are ~5 cm apart in the full bladder and 2.5cm apart when
the bladder is empty. The ureter lies anterior to the anterior vaginal fornix as it reaches the
bladder *

Finally, the ureters run obliquely for about 2 cm. through the wall of the bladder and open
by slit-like apertures into the cavity of the viscus at the lateral angles of the trigone. *

The ureter is narrowed at the pelvi-ureteric junction, where it bends into the pelvis at the
pelvic brim and where it passes into the bladder wall - renal calculi are likely to lodge at these
points *

During pelvic surgery, the ureters can be injured at the following points:*****

The ureteric tunnel where it is crossed by the uterine artery during clamping & ligation of
the uterine artery pedicle *

At the bladder base during vaginal surgery - anterior colporrhaphy / vaginal hysterectomy
or during colpo-suspension *

Anterior to the vagina as it courses forward to enter the bladder and can be injured while
excising the upper vagina during radical hysterectomy *

At the ovarian fossa where it may be involved in an ovarian mass *

At the pelvic brim where it may be confused with the infundibulo-pelvic ligament *

RIGHT URETER *

Anterior relations include: second part of duodenum, terminal ileum, right colic and ileocolic
vessels, right testicular / ovarian vessels and the root of the mesentery of the small intestine.

LEFT URETER *

Anterior relations: sigmoid colon, sigmoid mesocolon, left testicular / ovarian vessels, left
colic vessels

13
 Medial relation: inferior mesenteric vessels

Structure *****

Three coats - fibrous, muscular and mucosa

The fibrous coat is continuous with the renal capsule and the fibrous structure of the
bladder

Muscular coat arranged in two layers- outer longitudinal and inner circular *

The mucosa is smooth lined by transitional epithelium *

SUPRARENAL GLANDS *****

Right - pyramidal, Left - crescenteric in shape *

Right related anteriorly to: right lobe of liver and lateral border of inferior vena cava *

Left related anteriorly to: pancreas, lesser sac and stomach *

Both glands rest posteriorly on the diaphragm *

Blood - suprarenal branches of aorta, inferior phrenic and renal arteries

Single suprarenal vein drains into renal vein on the left or inferior vena cava on the right *

Lymphatics - para-aortic nodes *

Nerves - predominantly sympathetic pre-ganglionic fibres derived from the splanchnic nerves *

CECUM *****

6cm long, intra-peritoneal

Has 3 bands of outer longitudinal muscles (Tenia coli) which converge on the base of the
appendix

Appendix arises from its postero-medial aspect and its lumen is in direct communication
with the cavity of the cecum

Related anteriorly to coils of small intestine, greater omentum and anterior abdominal wall

Related posteriorly to the psoas, iliacus, femoral nerve and lateral cutaneous nerve of the
thigh (and usually the appendix)

Blood supply - anterior and posterior cecal arteries - branches of the ileocolic artery which
arises from the superior mesenteric artery

Nerves- sympathetic and parasympathetic (vagus) from the superior mesenteric plexus

Lymphatics - superior mesenteric nodes

14
APPENDIX *****

8-13cm long

Arises from the postero-medial aspect of the cecum

Lies in RIF with its base located 1/3 of the way up the line joining the anterior superior iliac
spine to the umbilicus (McBurneys point)

Identified within the abdomen by followint the Tenia coli of the caecum to its base

Arterial supply - appendicular artery, branch of posterior cecal artery

Lymphatics - superior mesenteric nodes

Nerve - parasympathetic (vagus) and sympathetic from superior mesenteric plexus

Fibres transmitting visceral pain signals enter the spinal cord at T10 (dermatome is in the
region of the umbilicus, the site of referred pain during acute appendicitis)

ASCENDING COLON *****

13cm long, from the cecum to the inferior surface of the right lobe of the liver

retro-peritoneal

Related anteriorly to coils of small intestine, the greater omentum and the anterior
abdominal wall

Related posteriorly to the psoas, iliacus, quadratus lumborum, origin of the right
transversus abdominis muscle; iliohypogastric and ilioinguinal nerves; lower pole of RIGHT
kidney

Blood supply - right colic and iliocolic branches of theSUPERIOR mesenteric artery

Lymphatics - superior mesenteric nodes

Nerves - parasympathetic (vagus) and sympathetic from the superior mesenteric plexus

TRANSVERSE COLON *****

38cm long, from the right colic flexure to the left colic flexure, which is attached to the
diaphragm by the phrenico-colic ligament

Intra-peritoneal - transverse mesocolon is attached to its SUPERIORborder

The POSTERIOR layer of the greater omentum is attached to its inferior border

Typically hangs down into the pelvis

Related posteriorly to the second part of the duodenum, head of pancreas, coils of
jejunum and ileum

Blood - proximal 2/3 - middle colic artery (superior mesenteric); distal 1/3 - left colic
(inferior mesenteric)
15
 Lymphatics - proximal 2/3 - superior mesenteric nodes; distal 1/3 - inferior mesenteric
nodes

Nerves - proximal 2/3 - superior mesenteric plexus (vagus - parasympathetic); distal 1/3 -
inferior mesenteric plexus (sympathetic) and pelvic splanchnic nerves (parasympathetic)

NOTE that the junction between the proximal 2/3 and distal 1/3 of the transverse colon is
the junction between the mid-gut and the hind-gut, hence the arrangement of blood, nerve
supply and lymphatics.

DESCENDING COLON *****

25cm long, retroperitoneal, extends from left colic flexure to pelvic brim
Related anteriorly to greater omentum, coils of small intestine and the anterior abdominal
wall
Related posteriorly to the lateral border of the left kidney, LEFT psoas, iliacus, iliac crest,
quadratus lumborum and origin of the left transversus abdominis; iliohypogastric, ilioinguinal
and femoral nerves and lateral cutaneous nerve of the thigh
Blood - left colic artery and sigmoid arteries (inferior mesenteric)
Lymphatics - inferior mesenteric nodes
Nerves - sympathetic - inferior mesenteric plexus; parasympathetic - pelvic splanchnic
nerves

DIFFERENCES BETWEEN SMALL AND LARGE BOWEL *****

Longitudinal smooth muscle - continuous in small bowel, 3 bands (teniae coli) in large
bowel
Fatty tags - appendices epiploicae - present in large bowel, absent in small bowel
Payers patches - lymphoid tissue within mucosa - present in small bowel, absent in large
bowel
Plicae circularis - folds of mucous membrane - present in small bowel, absent in large
bowel

Muscle wall - smooth in small bowel, sacculated in large bowel

PERITONEUM *****
The central part of the diaphragmatic peritoneum is supplied by the phrenic nerve
while the peripheral parts are supplied by the lower intercostals nerves*

The parietal peritoneum of the anterior and lateral abdominal wall is supplied
segmentally by the lower six thoracic and first lumbar nerve. It is sensitive to pain, temperature,
touch and pressure while the visceral peritoneum is supplied by autonomic nerves and is
sensitive to streatch*
The pelvic parietal peritoneum is supplied by the obturator nerve. *
The ureters are retro-peritoneal throughout their course

PERITONEAL LIGAMENTS *****

Falciform ligament - anterior surface of liver to anterior abdominal wall and
diaphragm *
Ligamentum Teres - free border of falciform ligament, contains obliterated umbilical
VEIN *
Median umbilical ligament - urachus (remnant of the allantois), apex of bladder to
umbilicus *

16
 Lateral umbilical ligament - INTERNAL iliac artery to umbilicus, obliterated umbilical
ARTERY *
Gastrosplenic ligament - greater curvature of stomach to spleen

GREATER OMENTUM *****

Anterior layer attached to the greater curvature of the stomach

Posterior layer attached to the inferior border of the transverse colon
The lower part of the lesser sac lies within it
The right gastro-epiploic artery runs along the greater curvature of the stomach in the
upper border of the greater omentum

LESSER OMENTUM
Runs from the lesser curvature of the stomach to the porta hepatis
Its right free border forms the ANTERIOR margin of the opening into the lesser sac
(epiploic foramen) and contains the RIGHT gastric artery

Boundaries of the epiploic foramen *****

Anterior - right free border of LESSER omentum (containing bile duct to the right and
in front, hepatic artery to the left and in front and portal vein posteriorly)

Posterior - inferior vena cava

Superior - caudate lobe of liver

Inferior - first part of duodenum

PARACOLIC GUTTERS

There are 4 paracolic gutters - left and right medial / lateral

The right lateral extends from the pelvis to the right posterior sub-phrenic space *

The right medial is closed off from the pelvis by the mesentry of the small intestine *

The left lateral is separated from the spleen by the phrenicocolic ligament extending
from the left colic flexure to the diaphragm

Question 1: The ascending colon

a. Is related posteriorly to the right ureter

True False
b. Is related superiorly to the right lobe of the liver

True False
c. Is related anteriorly to the greater omentum

True False
d. Has parasympathetic supply from the vagus nerve via the inferior mesenteric plexus

True False

17
Question 2: With respect to the biliary tree
a. The bile canaliculi drain into the interlobular ducts

True False
b. The interlobular ducts are located at the centre of the hepatic lobule

True False
c. The right hepatic duct drains bile from the caudate lobe of the liver

True False
d. The left hepatic duct drains bile from the quadrate lobe of the liver

True False
Question 3: The cecum
a. Is in direct communication with the lumen of the appendix

True False
b. Is related posteriorly to the psoas and iliacus muscles

True False
c. Is related posteriorly to the femoral nerve

True False
d. Is related posteriorly to the lateral cutaneous nerve of the thigh

True False
Question 4: The ureter
a. Lies 5cm lateral to the lateral vaginal fornix

True False
b. Crosses superior to the uterine artery in the broad ligament

True False
c. Is supplied by the uterine artery within the pelvis

True False
d. Lies more than 5cm lateral to the supra-vaginal cervix

True False

Question 5: The duodenum

a. Is 25cm long

True False
b. Is retro-peritoneal throughout its length

True False
c. The first part is 5cm long and lies on the intercristal plane

True False
d. The first part is related anteriorly to the quadrate lobe of the liver and the gall bladder

True False
Question 6: The pancreas
a. Is related anteriorly to the transverse colon and the transverse mesocolon

True False
b. Lies anterior to the lesser sac

True False
c. Is posterior to the stomach

True False
d. Is related posteriorly to the splenic vein

True False
Question 7: The cecum
a. Is related posteriorly to the right ureter

True False
b. Receives its blood supply from the inferior mesenteric artery

True False
c. Receives its blood supply from branches of the ileocolic artery

18
 True False
d. Is supplied by the left and right caecal arteries

True False
Question 8: The ureter
a. Enters the pelvis posterior to the bifurcation of the common iliac artery

True False
b. Enters the pelvis in front of the sacro-iliac joint

True False
c. Is supplied by the renal artery

True False
d. Is supplied by the testicular / ovarian artery

True False

Question 9: With respect to the blood supply to the kidneys

a. The lobar arteries supply the renal pyramids

True False
b. The interlobular arteries arise from the lobar arteries

True False
c. The efferent glomerular arteriols arise from the interlobular arteries

True False
d. The renal vein drains directly into the inferior vena cava

True False
Question 10: The ureter
a. Is 35cm long

True False
b. Leaves the renal pelvis anterior to the renal vein

True False
c. Is adherent to visceral peritoneum

True False
d. Is separated from the tips of the transverse processes of the lumbar vertebrae by psoas major

True False
Question 11: With respect to the transverse colon
a. Parasympathetic supply to the proximal 2/3 is from the vagus via the inferior mesenteric plexus

True False
b. Parasympathetic supply to the distal 1/3 is from pelvic splanchnic nerves

True False
c. Sympathetic supply to the proximal 2/3 is from the superior mesenteric plexus

True False
d. Sympathetic supply to the distal 1/3 is from the inferior mesenteric plexus

True False
Question 12: The descending colon
a. Is supplied by the left colic artery, a branch of the inferior mesenteric artery

True False
b. Lymphatic drainage is to the inferior mesenteric nodes

True False
c. Receives sympathetic supply from the pelvic splanchnic nerves

True False
d. Receives parasympathetic supply from the pelvic splanchnic nerves

True False

19
 Question 13: With respect to the nerve supply and lymphatic drainage of the stomach
a. The lymphatics drain into the superior mesenteric nodes

True False
b. The anterior vagal trunk is derived mainly from the left vagus nerve

True False
c. The posterior vagal trunk supplies the pancreas

True False
d. The posterior vagal trunk supplies the intestine as far as the splenic flexure

True False
Question 14: The transverse colon
a. In the standing subject, lies along the transpyloric plane

True False
b. Is intra-peritoneal

True False
c. Has the transverse mesocolon attached to its inferior border

True False
d. Has the anterior layer of the greater omentum attached to its inferior border

True False
Question 15: The following structures are present at the porta hepatis
a. Right and left hepatic ducts

True False
b. Right and left branches of the hepatic artery

True False
c. Right and left branches of the hepatic vein

True False
d. The upper part of the free edge of the lesser omentum

True False

INGUINAL LIGAMENT *****

FORMED BY THE APONEUROSIS OF THE EXTERNAL OBLIQUE MUSCLE

ATTACHED MEDIALLY TO THE PUBIC TUBERCLE

FORMS THE INFERIOR WALL OR FLOOR OF THE INGUINAL CANAL

INGUINAL CANAL *****

4CM LONG IN ADULTS

DEEP RING: - OVAL SHAPED HOLE IN TRANSVERSALIS FASCIA, 1.3CM ABOVE

INGUINAL LIGAMENT, MID-WAY BETWEEN ANTERIOR SUPERIOR ILIAC SPINE AND
SYMPHYSIS PUBIS. MEDIAL RELATION - INFERIOR EPIGASTRIC VESSELS. GIVES
RISE TO THE INTERNAL SPERMATIC FASCIA OR THE INTERNAL COVERING OF THE
ROUND LIGAMENT OF THE UTERUS *

SUPERFICIAL RING:- TRIANGULAR IN SHAPE, DEFECT IN EXTERNAL OBLIQUE

20
APONEUROSIS, BASE FORMED BY PUBIC CREST, GIVES RISE TO EXTERNAL
SPERMATIC FASCIA *

THE FOLLOWING PASS THROUGH THE SUPERFICIAL RING: ROUND LIGAMENT,

ILIOINGUINAL NERVE, GENITAL BRANCH OF THE GENITOFEMORAL NERVE,
LYMPHATICS AND SYMPATHETIC PLEXUS *

ANTERIOR WALL - APONEUROSIS OF EXTERNAL OBLIQUE, REINFORCED

LATERALLY BY ORIGIN OF INTERNAL OBLIQUE *

POSTERIOR WALL - TRANSVERSALIS FASCIA, REINFORCED MEDIALLY BY

CONJOINT TENDON - COMMON INSERTION OF INTERNAL OBLIQUE AND
TRANSVERSUS TO THE PUBIC CREST AND PECTINEAL LINE *

FLOOR - INGUINAL LIGAMENT *

ROOF - INTERNAL OBLIQUE AND TRANSVERSUS ABDOMINIS *

THE FEMORAL NEUROVASCULAR BUNDLE AND LATERAL CUTANEOUS NERVE

OF THE THIGH PASS BENEATH THE INGUINAL LIGAMENT. *

THE FEMORAL BRANCH OF THE GENITOFEMORAL NERVE ENTERS THE THIGH

BEHIND THE MIDDLE OF THE INGUINAL LIGAMENT. *

THE ILIOINGUINAL NERVE ENTERS THE THIGH THROUGH THE SUPERFICIAL

INGUINAL RING. *

THE SUPERFICIAL EPIGASTRIC VESSELS CROSS THE INGUINAL LIGAMENT *

INGUINAL CANAL IN MALE CONTAINS: *

VAS DEFERENS

TESTICULAR VESSELS

LYMPHATICS

SYMPATHETIC FIBRES FROM THE RENAL OR AORTIC SYMPATHETIC

PLEXUSES

REMAINS OF THE PROCESUS VAGINALIS

CREMASTERIC ARTERY - BRANCH OF THE INFERIOR EPIGASTRIC ARTERY

ARTERY TO THE VAS - BRANCH OF INFERIOR VESICAL ARTERY

GENITAL BRANCH OF GENITOR-FEMORAL NERVE - SUPPLIES CREMASTER

MUSCLE

INGUINAL CANAL IN THE FEMALE CONTAINS: *

ROUND LIGAMENT OF THE UTERUS

LYMPHATICS

21
 REMAINS OF THE PROCESSUS VAGINALIS

GENITAL BRANCH OF THE GENITOFEMORAL NERVE

CREMASTER MUSCLE / CREMASTERIC REFLEX

DERIVED FROM INTERNAL OBLIQUE

SUPPLIED BY CREMASTERIC ARTERY - BRANCH OF INFERIOR EPIGASTRIC

SUPPLIED BY GENITAL BRANCH OF GENITOR-FEMORAL NERVE

CREMASTERIC REFLEX - CREMASTER MUSCLE CONTRACTS WHEN SKIN ON

MEDIAL ASPECT OF THIGH IS STROKED. AFFERENT - FEMORAL BRANCH;
EFFERENT - GENITAL BRANCH OF GENITOR-FEMORAL NERVE

SCROTUM *****
MADE UP OF FOLLOWING LAYERS (SUPERFICIAL - DEEP):
SKIN
DARTOS MUSCLE - SMOOTH MUSCLE, CONTINUOUS WITH FATTY /
MEMBRANEOUS LAYER OF SUPERFICIAL FASCIA OF ANTERIOR ABDOMINAL WALL;
INNERVATED BY SYMPATHETIC FIBRES AND RESPONSIBLE FOR WRINKLING OF
OVERLYING SKIN

COLLES- FASCIA CONTINUOUS WITH SCARPAS FASCIA

EXTERNAL SPERMATIC FASCIA - EXTERNAL OBLIQUE

CREMASTERIC FASCIA - INTERNAL OBLIQUE

INTERNAL SPERMATIC FASCIA - TRANSVERSALIS FASCIA

TUNICA VAGINALIS - PROCESUS VAGINALIS - COVERS ANTERIOR AND

LATERAL BUT NOT POSTERIOR ASPECT OF TESTIS

TUNICA ALBUGINEA - FIBROUS CAPSULE OF TESTIS - COVERS ENTIRE TESTIS

BOTH DARTOS MUSCLE AND COLLES - FASCIA CONTRIBUTE TO MEDIAN

PARTITION OF SCROTUM.

LYMPHATIC DRAINAGE: *****

SKIN AND SUPERFICIAL FASCIA (INCLUDING TUNICA VAGINALIS) -

SUPERFICIAL INGUINAL NODES

TESTIS / EPIDIDYMIS - PARA-AORTIC NODES (L1)

FOR SUCCESSFUL SPERMATOGENESIS, THE TEMPERATURE OF THE TESTIS IS

MAINTAINED AT 3C BELOW BODY TEMPERATURE BY VARIOUS MECHANISMS
INCLUDING A COUNTER-CURRENT HEAT EXCHANGE SYSTEM FORMED BY THE
PAMPINIFORM PLEXUS (TESTICULAR VEIN).

BLOOD SUPPLY TO TESTIS *****

TESTICULAR ARTERY - LEAVES AORTA AT L1

22
 RIGHT TESTICULAR VEIN - DRAINS INTO IVC

LEFT TESTICULAR VEIN - DRAINS INTO LEFT RENAL VEIN

EPIDIDYMIS - TESTICULAR ARTERY

ABDOMINAL WALL MUSCLES

ANTERIOR ABDOMINAL WALL

External oblique *
ORIGIN: Outer surface of lower 8 ribs
INSERTION: Xiphoid process, linea alba, pubic crest and pubic tubercle and the anterior
half of the iliac crest

Internal oblique *

ORIGIN: Lumbar fascia, anterior 2/3 of iliac crest and lateral 2/3 of inguinal ligament

INSERTION: Lower border of lower 3 ribs and costal cartilages, xiphoid process, linea
alba and symphysis pubis

Lower free border gives rise to cremasteric fascia

Transversus abdominis *

ORIGIN: Deep surface of lower 6 costal cartilages, lumbar fascia, anterior 2/3 of iliac crest
and lateral 1/3 of inguinal ligament

INSERTION: Xiphoid process, linea alba and symphysis pubis

Conjoint tendon formed by insertion of internal oblique and transversus abdominis onto
pubic crest and pectineal line

Rectus abdominis *

ORIGIN: Symphysis pubis and pubic crest

INSERTION: 5th,6th and 7th costal cartilages and xiphoid process

Lateral margins form the Linea semilunaris

Pyramidalis *
ORIGIN: Anterior surface of pubis
INSERTION: Linea alba

NERVES
External oblique, internal oblique and transversus: Lower 6 thoracic nerves and L1
(ileoinguinal and ileohypogastric nerves)

Rectus abdominis: Lower 6 thoracic nerves

23
 Pyramidalis: T12 *

FUNCTION

External / internal oblique / transversus - laterally flex and rotate the trunk, relax during
inspiration to accommodate abdominal viscera, contract during micturiction, defecation and
vomiting.

Rectus abdominis - flexes the trunk and stabilises the pelvis

RECTUS SHEATH *****

Above costal margin

Anterior wall: Aponeurosis of external oblique *
Posterior wall: thoracic wall. *

Between costal margin and anterior superior iliac spine *

Anterior wall: Aponeurosis of external and internal oblique

Posterior wall: Aponeurosis of internal oblique and transversus abdominis

Note that the aponeurosis of the internal oblique splits to enclose the rectus abdominis

Between anterior superior iliac spine and pubis *

Anterior wall: Aponeuroses of external, internal oblique and transversus

Posterior wall: Transversalis fascia

Arcuate line *: Site where the aponeuroses of the posterior wall pass anterior to the rectus
at the level of the anterior superior iliac spine. The inferior epigastric artery enters the rectus
sheath at this point and lies posterior to the rectus abdominis. Pyramidalis lies within the rectus
sheath.

POSTERIOR ABDOMINAL WALL

PSOAS MAJOR *****

Origin: Roots of transverse processes, sides of vertebral bodies and inter-vertebral discs
T12 - L5
Insertion: Lesser trochanter of the femur
Nerve: Lumbar plexus

Action: Flexes thigh on trunk. If thigh if flexed, flexes trunk on thigh.

ILIACUS

Origin: Iliac fossa

Insertion: Lesser trochanter of the femur

Nerve: Femoral nerve

24
 Action: Flexes thigh on trunk. If thigh is flexed, flexes trunk on thigh

QUADRATUS LUMBORUM

Origin: Iliolumbar ligament, iliac crest and tip of transverse processes of lower lumbar
vertebrae

Insertion: Lower border of 12th rib and transverse processes of upper 4 lumbar vertebrae

Nerve: Lumbar plexus

Action: Laterally flexes spine to same side, fixes or depresses 12th rib during respiration

The Pfannestiel incision cuts through *****

Skin and superficial fascia including Scarpas fascia

The rectus sheath which is formed at this level by the aponeuroses of the external, internal
oblique and transversus abdominis

The linea alba is split to separate the recti abdominis which are NOT cut

The transversalis fascia

The parietal peritoneum

Incisions should be made along Langers lines which run horizontally in the lower
abdomen *

SURFACE ANATOMY - ABDOMEN *****

The abdomen is divided into 9 regions:

Right hypochondrium, Epigastrium, left hypochondrium

Right lumbar, umbilical, left lumber
Right iliac, hypogastrium, left iliac; by:

1) Two vertical planes through the mid-point between the anterior superior iliac spine and the
symphysis pubis and

2) Two horizontal planes:

I )The sub-costal plane - joins lowest points of costal margin on both sides (inferior margin of
10th costal cartilage; level L3)

ii) The inter-tubercular plane - joins tubercles of iliac crests (level L5)

Trans-pyloric plane:

Through tips of 9th costal cartilages (point where linea semilunaris intersects with costal
margin). Passes through the pylorus, nexk of pancreas, hili of kidneys and duodeno-jejunal
25
junction.

Abdominal wall

Dermatomes *****

Xiphoid process - T7
Umbilicus - T10
Pubis - L1

Blood supply: *****

Medial aspects - Superior epigastric artery (above umbilicus - continuation of the internal
thoracic artery, branch of the first part of the subclavian artery. Enters the rectus sheath
between the sternal and costal origins of the diaphragm and descends behind rectus muscle)*

Inferior epigastric artery (below umbilicus - branch of external iliac artery just above
inguinal ligament. It pierces the transversalis fascia to enter the rectus sheath anterior to the
arcuate line; runs behind rectus muscle). There is no anastomosis between the arteries of the
left and right side *
Lateral aspects - intercostals, lumbar arteries and deep circumflex iliac artery (branch of
external iliac artery above the inguinal ligament). *

Venous drainage: *****

Above umbilicus - axillary vein via lateral thoracic vein *

Below umbilicus - femoral vein via superficial epigastric and great saphenous vein *

Few para-umbilical veins drain into the portal vein via the ligamentun teres, forming a
portal-systemic anastomosis. Distended veins may indicate portal hypertension *

Deep veins follow the arteries with the posterior intercostals veins draining into the
azygous vein and the lumbar veins into the inferior vena cava

Lymphatics: *****

Above umbilicus - anterior axillary nodes

Below umbilicus - superficial inguinal nodes

Deep lymphatics follow the arteries into the internal thoracic, external iliac, posterior
mediastinal and para-aortic nodes

HERNIAS

INGUINAL

Indirect commoner than direct

Indirect more common in males and on the right side (right testis descends later than the
left)

Direct hernias commoner in (old) males

26
 Indirect: Enters inguinal canal through deep inguinal ring, lateral to inferior epigastric
vessels. Can descent into the scrotum or labia majora. Sac is formed by the remains of the
processus vaginalis

The sac of all inguinal hernias lies above and medial to the pubic tubercle

FEMORAL

Commoner in females protrudes through the femoral canal medial to the femoral vein,
below and lateral to the pubic tubercle.

UMBILICAL

Congenital - exomphalos

Acquired infantile - weakness in scar of umbilicus

Acquired adult - para-umbilical, weakness in linea alba above or below umbilicus,

commoner in females

EPIGASTRIC

Weakness in linea alba above umbilicus

RICHCTERS

A knuckle of the side-wall of the bowel is incarcerated in the sac but the continuity of the
bowel is maintained and there is no obstruction.

Question 1: With respect to the scrotum and its contents

a. Colles? fascia is a continuation of Scarpa?s fascia
True False
b. Dartos muscle does not contribute to the median partition of the scrotum
True False
c. Dartos muscle is innervated by the genital branch of the genitor-femoral nerve
True False
d. The tunica albuginea does not cover the posterior surface of the testis
True False
Question 2: The iliac crest
a. Ends anteriorly at the anterior superior iliac spine
True False
b. Ends posteriorly at the sacral promontory
True False
c. Has its highest point at the level of the second lumbar vertebral body
True False
d. Has a tubercle which lies at the level of the body of L5
True False
27
Question 3: With respect to abdominal hernias
a. Umbilical hernias are always congenital
True False
b. Para-umbilical hernias are more common in males
True False
c. The neck of a femoral hernia lies medial to the femoral vein
True False
d. A Richter?s hernia occurs through the arcuate line
True False

Question 4: Prolactin
a. Is not produced by the fetal membranes
True False
b. Concentration in amniotic fluid decreases with gestation from 20 weeks
True False
c. Is important in the regulation of amniotic fluid electrolyte balance
True False
d. Production by the decidua is inhibited by dopamine agonists
True False
Question 5: Concerning the abdominal wall
a. The umbilicus is located in the L1 dermatome
True False
b. The left and right epigastric arteries anastomose
True False
c. Distended veins radiating from the umbilicus are indicative of portal hypertension
True False
d. Langer?s lines run vertically in the lower abdomen
True False
Question 6: With respect to the blood supply to the testis
a. The testicular artery is a branch of the aorta at the level of L5
True False
b. The left testicular vein drains into the left renal vein
True False
c. The right testicular vein drains into the inferior vena cava
True False
d. The epididymis is supplied by the artery to the vas, a branch of the inferior epigastric
artery
True False

28
Question 7: With respect to the scrotum and its contents
a. Dartos muscle is smooth muscle
True False
b. The external spermatic fascia lies superficial to Dartos muscle
True False
c. Cremasteric fascia lies deep to the external spermatic fascia
True False
d. The tunica vaginalis covers the anterior, posterior and lateral aspects of the testis
True False
Question 8: When making a low transverse (Pfannestiel) incision, the following
structures are divided
a. The aponeurosis of the internal oblique
True False
b. The rectus abdominis muscle
True False
c. The visceral peritoneum
True False
d. Linea alba
True False
Question 9: With respect to the muscles of the anterior abdominal wall
a. The rectus abdominis originates from symphysis pubis and the pubic crest
True False
b. The rectus abdominis inserts onto the 5th, 6th and 7th costal cartilages and the xiphoid
process (T)pyramidalis lies deep to rectus abdominis
True False
c. The external oblique, internal oblique and transversus abdominis are supplied by the
lower 6 thoracic nerves and the ileoinguinal and ileohypogastric nerves
True False
d. Pyramidalis is supplied by L1
True False

Question 10: The inguinal ligament

a. Is formed by the aponeurosis of the internal oblique muscle
True False
b. Is attached laterally to the anterior superior iliac spine
True False
c. Is attached medially to the posterior superior iliac spine
True False
d. Forms the posterior wall of the inguinal canal

29
 True False
Question 11: The following structures pass beneath the inguinal ligament
a. Ilioingiunal nerve
True False
b. Femoral artery
True False
c. Femoral branch of the genitor-femoral nerve
True False
d. Lateral cutaneous nerve of the thigh
True False
Question 12: A normal distribution
a. Is symmetrical about the mode
True False
b. Has a median which is always less than the mean
True False
c. Has 75% of its values above the upper quartile
True False
d. Cannot contain negative values
True False

Question 13: With respect to the blood supply and lymphatic drainage of the skin of the
anterior abdominal wall
a. The superior epigastric artery is a branch of the aorta
True False
b. The inferior epigastric artery is a branch of the external iliac artery
True False
c. The lateral aspects of the abdominal wall are supplied by the lumbar arteries and the
deep circumflex iliac artery
True False
d. There is no connection between the veins of the anterior abdominal wall and the portal
vein
True False
Question 14: The following structures are present within the inguinal canal in the male
a. Testicular artery
True False
b. Vas derefens
True False
c. Inguinal nerve
True False
d. Genital branch of the genitor-femoral nerve
True False
Question 15: With respect to the inguinal canal
a. The pubic crest forms the base of the superficial inguinal ring
True False
30
b. The margins of the superficial inguinal ring form the external spermatic fascia
True False
c. The anterior wall is formed by the aponeurosis of the external oblique muscle
True False
d. The anterior wall is reinforced laterally by the origin of the internal oblique muscle
True False

THE URINARY BLADDER *****

Lined by transitional epithelium - the upper part is derived from the yolk sac and is
continuous with the urachus *

The trogone is derived from the mesonephric duct and is lined by cells of mesodermal
origin. It is believed that these are later replecad by cells of endodermal origin *

The bladder wall is made up of a syncytium of smooth muscle fibres called the detrusor -
contraction results in simultaneous reduction in all dimensions of the bladder *

The female urethra has an intrinsic and an extrinsic component: the intrinsic component is
made up of epithelial, vascular and connective tissue and the rhabdosphincter which is a
circular ring of striated muscle with slow twitch fibres. The ring is well developed anteriorly, thins
laterally and is virtually absent posteriorly *

The extrinsic sphincter mechanism is made up of the striated muscles of the levator ani -
mainly fast twitch fibres *

Main nerve supply to the detrusor is parasympathetic - causes contraction (S2,3 4) *

Beta-sympathetic innervation causes relaxation (L 1&2) *

The urethral smooth muscle has alpha sympathetic innervation which causes contraction -
there is however, significant overlap *

The rhabdosphincter is supplied by somatic nerves (S2,3,4) via the pelvic splanchnic
nerves *

Levator ani supplied by S2,3,4 through the perineal branch of the pudendal nerve *

Sensory innervation (stretch) is via both sympathetic and parasympathetic pathways *

PHARMACOLOGY *****

INHIBIT DETRUSOR CONTRACTILITY - Anti-cholinergic agents, calcium channel

blockers, beta-agonists, CNS depressants like chlorpromazine cause voiding dysfunction *

STIMULATE DETRUSOR CONTRACTILITY - Cholinergic agonists *

INCREASE URETHRAL RESISTANCE - alpha agonists *

URODYNAMIC PARAMETERS *****

31
 MAXIMUM FLOW RATE - measured with a full bladder - at least 15ml/s. Reduced with
hypotonic detrusor, outflow obstruction or an inadequate voided volume *

A graph of flow rate against time is bell-shaped

BLADDER CAPACITY - 400 - 600ml *

First sensation to void occurs at 150 - 250ml - decreased in sensory urgency and detrusor
instability; increased in overflow incontinence *

Detrusor pressure rise should be less than 15cm H2O during filling - increased pressure
occurs in low compliance bladder and detrusor instability *

Leakage occurs if detrusor pressure exceeds urethral pressure. If there is no abnormal

pressure rise on filling and the woman leaks because of a rise in intra-abdominal pressure
without a rise in detrusor pressure then a diagnosis of GENUINE STRESS INCONTINENCE is
made. Leakage with a rise in detrusor pressure occurs in detrusor instability and fistulas

Cystometry is required for a diagnosis of detrusor instability - detrusor contraction

associated with symptoms during bladder filling when the individual is trying to inhibit
micturiction

High urethral pressure profile occurs in outflow obstruction. Low pressure in GSI.

SIGMOID COLON *****

Continuous with the descending colon in front of the LEFT external iliac artery, and with
the rectum at the level of S3

Intra-peritoneal with an inverted V-shaped mesentery - one limb running on the medial
side of the left external iliac artery and the other from the bifurcation of the left common iliac
artery to S3. The recess of the pelvic mesocolon is located at the apex of the V and the left
ureter lies beneath it *

Related anteriorly to the bladder in the MALE and the uterus and upper part of the vagina
in the female *

Related posteriorly to the sacrum and rectum

Blood supply - inferior mesenteric artery

Venous drainage - inferior mesenteric vein - to portal vein

Lymphatics - inferior mesenteric plexus

Nerve - inferior hypogastric plexuses

THE RECTUM *****

~13cm long

32
 Upper third - covered by peritoneum on its anterior and lateral surfaces, middle third
covered by peritoneum on the anterior surface only and lower third devoid of peritoneum *

The three teniae coli of sigmoid colon come together to form a broad band of longitudinal
smooth muscle on its anterior and posterior surfaces *

Three transverse folds, two on the left and one on the right *

Anterior relations: sigmoid colon and small intestine within pouch of Douglas (upper third);
Posterior surface of vagina (lower third) *

Posterior relations: sacrum, coccyx, piriformis and coccygeus muscles, lavatory ani, sacral
plexus and pelvic sympathetic trunk *

Blood supply: *****

1) Superior rectal artery - continuation of inferior mesenteric artery - main blood supply to
mucosa

2) Middle rectal artery - branch of internal iliac artery - muscular coat mainly

3) Inferior rectal artery - branch of internal pudendal artery

Veins correspond to arteries and form an important portal-systemic anastomosis

Lymphatic drainage: Upper two thirds - inferior mesenteric nodes; lower third - internal iliac
nodes *

Nerve supply - inferior hypogastric plexus *

THE OVARY *****

4x2 cm, attached to the posterior aspect of the broad ligament by a mesentery - the
mesovarium *

Attached to the lateral pelvic wall by the suspensory ligament of the ovary (infundibulo-
pelvic ligament) *

Attached to the upper part of the lateral uterine wall by the round ligament of the ovary
(remnant of upper part of the gubenaculum) *

Position variable, but usually lies within ovarian fossa in lateral pelvic wall. The ovarian
fossa is bounded superiorly by the external iliac vessels, inferiorly by the ureter and internal iliac
vessels and its floor is crossed by the obturator nerve *

33
 The ovary is surrounded by a thin fibrous capsule - the tunica albuginae *

Blood supply - ovarian artery - branch of abdominal aorta at L1 *

Venous drainage - LEFT -left ovarian vein drains into left renal artery; RIGHT - right
ovarian vein drains into inferior vena cava *

Lymphatics - para-aortic nodes *

Nerve - aortic plexus

FALLOPIAN TUBES *****

~10cm long, 4 parts

Infundibulum - funnel-shaped lateral end, projects beyond the broad ligament with fimbriae
at its free end

Ampulla - widest and longest part, site of fertilisation *

Isthmus - narrowest part, just lateral to the uterus

Intra-mural part - pierces uterine wall

Three coats: serous, muscular, and mucous.

The external or serous coat is peritoneal. The middle or muscular coat consists of an
external longitudinal and an internal circular layer of smooth muscle fibers continuous with those
of the uterus*

The mucosa is thrown into longitudinal folds, which in the ampulla are much more
extensive than in the isthmus. Lined by ciliated columnar epithelium *

Blood - ovarian and uterine arteries

34
 Lymphatics - aortic and internal iliac nodes (follow arteries)

Nerves - inferior hypogastric plexus

THE UTERUS *****

8cm long x 5cm wide x 2.5cm thick

Covered by peritoneum except anteriorly below the reflection of the utero-vesical fold of
peritoneum and laterally between the layers of the broad ligament *

Fundus - that part of the uterus above the entrance of the uterine tubes

Cavity - triangular in coronal section, cleft in saggital section

Anteverted uterus - long axis of uterine body at 90degrees to long axis of vagina

Ante-flexed uterus - long axis of the body of the uterus bent forward at the level of the
internal os

Retroverted uterus - body and fundus bent backwards on the vagina to lie within the pouch
of Douglas

Anterior relations: utero-vesical pouch and superior surface of bladder *

Posterior: Pouch of Douglas, sigmoid colon and coils of ileum *

Laterally: uterine vessels, ureter *

Nerve - inferior hypogastric plexuses (Parasympathetic via the pelvic splanchnic nerves,
sympathetic via the lumbar splanchnic nerves). Pain sensation is transmitted via the
sympathetic nerves and the lumbar splanchnic nerves *

Lymph: *
1)Fundus - accompany ovarian artery to para-aortic nodes at the level of L1

2) Body and cervix - internal and external iliac nodes

THE UTERINE ARTERY *****

Branch of the anterior division of the internal iliac artery *

Runs medially in the base of the broad ligament

Reaches the cervix at the level of the internal os *

Crosses the ureter *

35
 Ascends within the broad ligament on the lateral aspect of the uterus
Gives off descending branch to the cervix and vagina *

Supplies uterus and fallopian tube *

LIGAMENTS *****

Transverse cervical ligament: fibro-muscular condensations of pelvic fascia pass from the
cervix and upper end of the vagina to the lateral pelvic wall

Utero-sacral ligament: cervix and upper end of vagina to the lower end of the sacrum -
form two ridges on either side of the pouch ofDouglas

Pubo-cervical ligament: cervix to posterior surface of pubis

Round ligament: Of the ovary - from medial margin of ovary to upper part of lateral wall of
uterus. Of the uterus - from upper part of lateral uterine wall to deep inguinal ring

The uterus is supported mainly by the tone of the pelvic floor muscles (levator ani) which are
partly inserted onto the perineal body and condensations of pelvic fascia forming the transverse
cervical, pubo-cervical and utero-sacral ligaments.

THE BROAD LIGAMENT *****

Two layered fold of peritoneum extending from the lateral uterine wall to the lateral pelvic
wall
Has an upper free edge which contains the fallopian tube

The layers of peritoneum separate inferiorly to cover the pelvic floor

Has ovary attached to its posterior surface by the mesovarium

Uterine artery crosses the ureter at the base (lower attached border)

Round ligament of the uterus forms a ridge an the anterior surface

Contains vestigial structures: epoophron and paroophron (remnant of the mesonephric
system)

Uterine and ovarian blood vessels and lymphatics run within it

CERVIX *****
Lower, narrow portion of the uterus, connected to the uterine fundus by the uterine isthmus -
upper limit is the internal os. Made up mainly of fibrous tissue with very little smooth muscle *

Protrudes through the upper anterior vaginal wall

Approximately half its length is visible in the vagina (vaginal cervix), the rest being above
the vagina (supra-vaginal cervix) *

The vaginal cervix ~3 cm long and 2.5 cm wide. Size and shape varies widely with age,
hormonal state, and parity - bulkier and the external with a wider and more slit-like external os in
multiparous women.
36
 Ectocervix - portion of the cervis beyond the external os - lined by stratified squamous
non-keratinising epithelium. *

Endocervical canal - links external and internal os - lined by columnar epithelium

The squamo-columnar junction - variable location - high up the endocervical canal

before puberty and in the post-menopausal women. Site of origin of squamous cell carcinoma of
the cervix *

The external os is bounded by two lips, an anterior and a posterior, of which the anterior
is the shorter and thicker, although due to the slope of the cervix, it projects lower than the
posterior. Both lips are in contact with the posterior vaginal wall

The supravaginal cervix is separated in front from the bladder by fibrous tissue
(parametrium), which extends also on to its sides and laterally between the layers of the broad
ligaments. Not covered by peritoneum on the anterior aspect *

The uterine arteries reach the margins of the cervix within the parametrium *

The ureter runs downward and forward 2 cm lateral to the supravaginal cervix *

Posteriorly, the supravaginal cervix is covered by peritoneum, which extends on to the

posterior vaginal wall, when it is reflected on to the rectum, forming the Pouch of Douglas which
may contain coils of small intestine.*

The vaginal cervix projects free into the anterior wall of the vagina between the anterior
and posterior fornices.

Blood supply *****

Uterine artery, branch of internal iliac

Cervical and vaginal branches supply the cervix and upper vagina.

The cervical branches of the uterine arteries descend on the lateral aspects of the cervix
at 3 and 9 o'clock. Venous drainage parallels the arterial supply, eventually emptying into
the hypogastric venous plexus.

Lymphatics *****

Regional lymph nodes for the cervix include: paracervical, parametrial, presacral, sacral, external iliac,
common iliac, hypogastric (obturator), internal iliac..

Support and innervation

Mainly the cardinal (transverse cervical) and uterosacral ligaments.

These attach to the lateral and posterior aspects of the supra-vaginal cervix and extend
laterally and posteriorly bony pelvis.

37
 The uterosacral ligaments are the conduits of the main nerve supplying to the cervix,
derived from the hypogastric plexus.

Sensory, sympathetic, and parasympathetic fibers are present in the cervix *

Sensory fibres travel via the parasympathetic nerves (S2,3,4 - pelvic splanchnic nerves) *

Dilatation of the cervix using dilators may result in a vasovagal attack with reflex
bradycardia

The endocervix has a plentiful supply of sensory nerve endings, while the ectocervix is
relatively lacking in these. Small cervical biopsies and cryotherapy can be performed in most
patients without the use of anaesthesia *

THE VAGINA *****

~8cm long, axis directed upwards and backwards from the vulva. Posterior wall longer
than anterior wall *

Lined by stratified squamous epithelium which undergoes changes during the menstrual
cycle. Does not secrete mucus *

Has anterior and posterior walls which are normally in apposition, and four fornices
(anterior, posterior, left and right lateral)

Upper half lies above the level of the pelvic floor

Relations *****

Anterior: bladder, urethra *

Posterior: upper third - pouch of Douglas; middle third - ampulla of the rectum; lower third -
perineal body *

Lateral: upper part - ureter, middle part - anterior fibres of levator ani; lower part - uro-
genital diaphragm and the bulb of the vestibule*

Blood: vaginal artery, branch of internal iliac artery

Lymphatics: upper third - internal and external iliac nodes; middle third - internal iliac
nodes; lower third - superficial inguinal nodes *

Nerve:Upper two thirds - inferior hypogastric plexuses. Parasympathetic from pelvic

splanchnic nerves, sympathetic from lumbar splanchnic nerves (L1 & 2) *

Autonomic innervation to the lower third - pudendal nerve *

Somatic sensation is present mainly in the lower thirs and is carried by the pudendal
nerve *

38
VAGINAL SUPPORT *****

The vagina is supported by

1) Levator ani muscles, transverse cervical, pubo-cervical and utero-sacral ligaments in its
upper part

2) The uro-genital diaphragm in its middle part

3) The perineal body in its lower part

Question 1: With respect to the bladder and urodynamic studies

a. Cystometry is not always necessary to make a diagnosis of detrusor instability
True False
b. Urinary leakage occurring without a rise in detrusor pressure is consistent with genuine
stress incontinence
True False
c. During bladder filling, the detrusor pressure rise should be < 15mmHg
True False
d. High urethral pressure profile occurs in detrusor instability
True False
Question 2: With respect to the bladder and urodynamic studies
a. High urethral pressure profile occurs in genuine stress incontinence
True False
b. A peak urinary flow rate of <15ml/s may occur if only a small volume of urine is passed
True False
c. A peak urinary flow rate of <15ml/s may occur with a hypotonic bladder
True False
d. A first sensation to void at 50ml is consistent with sensory urgency
True False
Question 3: With respect to the blood supply to the rectum
a. The superior rectal artery is a branch of the internal iliac artery
True False
b. The middle rectal artery is a branch of the internal iliac artery
True False
c. The inferior rectal artery is a branch of the superior vesical artery
True False
d. The lower third of the rectum is supplied by a branch of the internal pudendal artery
True False

39
Question 4: With respect to the uterus
a. In an anteverted uterus, the long axis of the uterus is typically at 45degrees to the long
axis of the vagina
True False
b. In an ante-flexed uterus, the long axis of the body of the uterus is bent forward at the
level of the external os
True False
c. The body of a retroverted uterus lies within the utero-vesical pouch
True False
d. The body of an anteverted uterus lies within the pouch of Douglas
True False
Question 5: The broad ligament
a. Has the ovary attached to its posterior surface by the mesovarium
True False
b. Is a two layered fold of peritoneum
True False
c. Has the ureter crossing the uterine artery at its base
True False
d. Contains the epoophron
True False
Question 6: With respect to the bladder and urodynamic studies
a. A first sensation to void at 200ml is consistent with detrusor instability
True False
b. Urinary leakage with a rise in detrusor pressure during bladder filling is consistent with
genuine stress incontinence
True False
c. A first sensation to void ar 500ml is consistent with overflow incontinence
True False
d. Cystometry is required to measure peak urinary flow rate
True False

Question 7: The sigmoid colon

a. Is retro-peritoneal
True False
b. Is continuous with the rectum at the level of S3
True False
c. Is continuous with the descending colon in front of the right external iliac artery
True False
d. Is related anteriorly to the uterus
True False
Question 8: The ovary
a. Lies on the obturator nerve within the ovarian fossa
True False
b. Is surrounded by a fibrous capsule, the tunica albuginae
True False
40
c. Is supplied by the ovarian artery, a branch of the abdominal aorta at L1
True False
d. Lymphatic drainage of the ovary is to the internal iliac nodes
True False
Question 9: The uterus
a. Is completely covered by peritoneum
True False
b. Is related anteriorly to the bladder
True False
c. Is anterior to the pouch of Douglas
True False
d. Is related posteriorly to the sigmoid colon
True False

Question 10: With respect to the uterus

a. The fundus is that part of the uterus above the entrance of the fallopian tubes
True False
b. The uterus is 8cm long x 2cm wide by 5cm thick
True False
c. In saggital section, the cavity of the uterus is triangular in shape
True False
d. In coronal section, the cavity of the uterus is represented by a cleft
True False
Question 11: The following structures provide support to the uterus
a. Perineal body
True False
b. Transverse cervical ligament
True False
c. Utero-sacral ligament
True False
d. Pubo-cervical ligament
True False
Question 12: The following normal structures can be palpated through the vagina
a. The cervix
True False
b. The bladder
True False
c. The appendix
True False
d. The perineal body
True False

41
Question 13: The ovary
a. Is attached to the anterior surface of the broad ligament
True False
b. Is retro-peritoneal
True False
c. Is attached to the pelvic side wall by the round ligament of the ovary
True False
d. Is attached to the upper end of the lateral wall of the uterus by the suspensory ligament
of the ovary
True False
Question 14: The cervix
a. Communicates with the cavity of the uterus through the internal os
True False
b. Has a spindle-shaped cervical canal
True False
c. Communicates with the vagina through the external os
True False
d. Is divided into a supra-vaginal and a vaginal part
True False
Question 15: The broad ligament
a. Contains the paroophron
True False
b. Has the fallopian tube in its upper free border
True False
c. Has the ovarian artery in its lower attached border
True False
d. Has the round ligament forming a ridge on its posterior surface
True False

PYRIFORMIS

Origin: Lateral mass of sacrum

Leaves pelvis through greater sciatic foramen

Insertion: Upper border of greater trochanter

Action: Laterally rotates femur at hip joint

Nerve: Sacral plexus

OBTURATOR INTERNUS *****

Origin: Pelvic surface of obturator membrane and adjoining part of the hip bone

42
 Leaves pelvis through Lesser sciatic foramen *

Covered by the obturator fascia which gives rise to the origin of the levator ani muscle *

Forms the lateral wall of the roof of the ischio-rectal fossa (medial wall of the roof formed
by the levator ani) *

Insertion: Greater trochanter of femur *

Action: Laterally rotates femur at hip joint

Nerve: nerve to obturator internus from sacral plexus *

LEVATOR ANI MUSCLE *****

Origin: Back of body of pubis, obturator fascia and ischial spine

Insertion: Anterior fibres (sphincter vaginae) - perineal body

Intermediate fibres (puborectalis) - median raphe and anococcygeal body

Posterior fibres (iliococcygeus) - anococcygeal body and coccyx
Action: Support pelvic viscera and resist rise in intra-pelvic pressure during straining;
sphincter action at anorectal junction and vagina

Nerve: Perineal branch of S4 and perineal branch of the pudendal nerve

COCCYGEUS

Origin: ischial spine

Insertion: lower end of sacrum and upper part of coccyx

Action: supports pelvic viscera, flexes coccyx

Nerve: branch of S4 and S5

TRUE PELVIS

That part of the pelvis between the pelvic inlet and the pelvic outlet

The pelvic inlet is oval in shape in the Gynaecoid pelvis and has the following borders:

1) Posterior: Sacral promontory *

2) Lateral: Iliopectineal lines *
3) Anterior: Symphysis pubis *

The pelvic outlet is diamond shaped with the following borders:

1) Posterior: Coccyx *
2) Lateral: Ischial tuberosities *
43
3) Anterior: Pubic arch formed by the simphysis pubis and the ischio-pubic rami *
Part of the lateral border is formed by the sacro-spinous and sacro-tuberous ligaments
which convert the greater and lesser sciatic notches into the greater and lesser sciatic
foramina *
The pelvic cavity has a shallow anterior wall and a deeper posterior wall. The ischial
spines are at the level of the mid-cavity
The acetabulum is formed from the ilium, ischium and pubic bones *

THE SACRUM *****

5 rudimentary vertebrae
The anterior and upper margin of the first sacral vertebra bulges forward as the
posterior margin of the pelvic inlet and forms the sacral promontory *
Articulates with innominate bone at the sacro-iliac joint, with the 5th lumbar vertebra
superiorly (where it is tilted forwards at the lumbo-sacral angle) and with the coccyx inferiorly
The laminae of S5 and occasionally S4 fail to fuse in the mid-line, forming the sacral
hiatus

The vertebral foramina form the sacral canal which contains the cauda equine, filum
terminale and meninges as far as the lower border of S2 while the rest of the canal contains the
filum terminale and lower sacral and coccygeal nerves *
The anterior / posterior surfaces contain 4 foramina for the anterior and posterior rami of
the upper 4 sacral nerves respectively *
The piriformis muscle arises from the front of the lateral mass of the sacrum and leaves
the pelvis through the greater sciatic foramen to insert onto the greater trochanter *

THE SACRO-ILIAC JOINT

Synovial joint - the irregular articular surfaces of the joint make a contribution to joint
stability but this is mainly maintained by the very strong posterior and inter-osseous sacro-iliac
ligaments.
The sacro-spinous and sacro-tuberous ligaments also contribute to joint stability
Supplied by branches of the sacral plexus and POSTERIOR rami of S1
Differences between the Male and Female Pelvis *****
The female pelvis:
Less massive
The anterior iliac spines more widely separated - greater lateral prominence of the hips.
Wider pelvic inlet - both antero-posterior and transverse diameters
Pelvic inlet more circular
More shallow
The sacrum is shorter wider, and its upper part is less curved
The obturator foramina are triangular in shape and smaller in size
The outlet is larger and the coccyx more movable.
The sciatic notches are wider and shallower
The ischial spines are less prominient.
The pubic symphysis is less deep, and the pubic arch is wider and more rounded than in
the male

SACRAL PLEXUS *****

44
 Formed from anterior rami of L4&5 (lumbosacral trunk) and anterior rami of S1,2,3&4

Related anteriorly to internal iliac vessels + branches and the rectum

Related posteriorly to the piriformis muscle

Branches

To lower limb - leave the pelvis through GREATER sciatic foramen

Sciatic nerve - L4,5, S1,2&3; largest nerve in the body

Superior gluteal nerve - gluteus medius, minimus and tensor fascia lata

Inferior gluteal nerve - gluteus maximus

Nerve to obturator internus - also supplies superior gamellus muscle

Nerve to quadratus femoris - also supplies inferior gamellus muscle

Posterior cutaneous nerve of the thigh

Branches to pelvic organs

Pudendal nerve - S2,3&4 - leaves the pelvis through the greater sciatic foramen and
enters the perineum through the lesser sciatic foramen *

Nerve to piriformis

Pelvic splanchnic nerves - S2,3&4 - sacral part of parasympathetic system *

Perforating cutaneous nerve - skin of lower medial part of buttock *

PELVIC SYMPATHETIC TRUNK *****

Continuous with the abdominal part behind the common iliac vessels

Lies posterior to the rectum *

Lies anterior to the sacrum *

Lies medial to the anterior sacral foramina *

Has 4-5 segmentally arranged ganglia *

Gives off grey rami communicantes to the sacral and coccygeal spinal nerves

Gives off fibres to the pelvic (hypogastric) plexuses *

No white rami communicantes join this part of the sympathetic trunk

HYPOGASTRIC PLEXUSES
45
Superior hypogastric plexus

Retroperitoneal, between common iliac arteries and in front of the sacral promontory

Formed from aortic sympathetic plexus and branches from the lumbar sympathetic ganglia

Parasympathetic fibres from the pelvic splanchinc nerves join the inferior hypogastric
plexus and ascend to the superior hypogastric and eventually inferior mesenteric plexus to
supply the hind gut
Right and left inferior hypogastric plexuses
Branches of superior hypogastric plexus

Descend medial to internal iliac artery

Descend lateral to rectum

Receive parasympathetic fibres from the pelvic splanchnic nerves

The descending colon (hindgut) is supplied by the inferior mesenteric plexus

PELVIC SPLANCHNIC NERVES *****

Formed from the ventral (anterior) primary rami of S2 throughS4. *
These are the ways in which parasympathetic neurons reach the hypogastric plexus,
and therefore the pelvic viscera and distal colon. *
The parasympathetic part of the autonomic nervous system is the "craniosacral" part.
Parasympathetic innervation to most of the gut comes from the "cranio-" half of that, i.e., the
vagus nerve. The rest, to colon distal to the splenic flexure and to pelvic viscera, is from the "-
sacral" half, via the pelvic splanchnic nerves
There are thoracic, lumbar, sacral, and pelvic splanchnic nerves.
"Splanchnic" refers to nerves that supply viscera.
Thoracic, lumbar and sacral splanchnic nerves emerge from sympathetic ganglia and
carry sympathetic fibers
Pelvic splanchnic nerves are parasympathetic *
Contain pre-ganglionic fibres *
Join inferior hypogastric plexus *

Some fibres ascend to the superior hypogastric and eventually inferior mesenteric plexus
and supply the hind-gut *

Provide parasympathetic supply to the pelvic viscera

Afferent impulses from the pelvic viscera are transmitted mainly by the sympathetic
pathway *

Parasympathetic nerves innervate detrusor and internal sphincter via the pelvic splanchnic
nerves (S2,3,4) and also innervate the external sphincter via the pudendal nerve ? initiate
micturiction by inhibiting internal sphincter activity and stimulating detrusor contraction *

Parasympathetic supply to the ovary is from the vagus nerve. Sympathetic innervation is
from the L1/2 segment *

Pain from uterine contractions goes back to T10-L1. This means that uterine contraction
pain is sympathetic. But for the lower portion of the uterus and upper vagina (the cervix) - it is
parasympathetic back to the pelvic splanchnic nerves *

46
OBTURATOR NERVE *****

Branch of lumbar plexus - L2,3,4 - anterior divisions *

Descends through psoas major and emerges on its medial border to enter the pelvis
anterior to the sacro-iliac joint *

Passes behind the common iliac vessels and on the lateral side of the internal iliac vessels
and the ureter. Separated from the ureter by the internal iliac vessels *

Runs on the lateral wall of the pelvis above and infront of the obturator vessels

Separated from the ovary within the ovarian fossa by parietal peritoneum only

Leaves pelvis to enter the thigh through the obturator foramen, accompanied by the
obturator artery and vein *

Supplies parietal peritoneum on lateral pelvic wall *

Splits into anterior and posterior divisions *

Anterior division supplies gracilis, adductor brevis, adductor longus, the hip joint and
occasionally pectineus. Also supplies skin on medial aspect of thigh *

Posterior division supplies obturator externus, adductor part of the adductor magnus, the
knee joint and occasionally adductor brevis *

Question 1: The pelvic splanchnic nerves

a. Contain afferent fibres for the ovary
True False
b. Conduct pain from the body of the uterus
True False
c. Originate from L 2,3,4 spinal segments
True False
d. Are adrenergic
True False
Question 2: With respect to the levator ani muscle
a. Anterior fibres are inserted into the perineal body
True False
b. The posterior fibres (iliococcygeus) are inserted into the anococcygeal body and the
coccyx
True False
c. Intermediate fibres (puburectalis) are inserted into the anococcygeal body and the
median raphe
True False
d. Form a smooth muscle sphincter at the ano-rectal junction
True False

47
Question 3: The pyriformis muscle
a. Originates from the sacral promontory
True False
b. Leaves the pelvis through the lesser sciatic foramen
True False
c. Is inserted onto the lesser trochanter of the femur
True False
d. Medially rotated the femur at the hip joint
True False
Question 4: The levator ani muscle
a. Originates from the back of the pubic bone anteriorly
True False
b. Originates from the obturator fascia laterally
True False
c. Originates from the ischial spine
True False
d. The anterior fibres are inserted onto the symphysis pubis
True False
Question 5: The obturator internus muscle
a. Forms the roof of the ischio-rectal fossa
True False
b. Is innervated by the femoral nerve
True False
c. Has fascia on its pelvic surface which gives rise to the levator ani muscle
True False
d. Is a medial rotator of the thigh
True False
Question 6: The obturator nerve
a. Passes through the greater sciatic foramen
True False
b. Arises from the sacral plexus
True False
c. Descends through psoas major
True False
d. Mainly supplies the abductor muscles of the thigh
True False

Question 7: The obturator nerve

a. Emerges from the lateral border of the psoas muscle
True False
b. Is formed from the posterior division of L 2,3 4
True False
c. Passes lateral to the internal iliac vessels
True False
d. Lies below the obturator artery in the obturator foramen

48
 True False
Question 8: The pelvic part of the sympathetic trunk
a. Receives white rami communicantes from the sacral nerves
True False
b. Is continuous with the abdominal part of the sympathetic trunk anterior to the common
iliac vessels
True False
c. Supplies the descending colon
True False
d. Is part of the sacral plexus
True False
Question 9: The obturator internus muscle
a. Originates from the pelvic surface of the obturator membrane
True False
b. Leaves the pelvis through the greater sciatic foramen
True False
c. Is inserted onto the greater trochanter of the femur
True False
d. Laterally rotates the femur at the hip joint
True False
Question 10: The levator ani muscle
a. Is supplied by the perineal branch of S4
True False
b. Is supplied by the nerve to obturator internus
True False
c. Is supplied by the perineal branch of the pudendal nerve
True False
d. Support the pelvic viscera and resist the rise in intra-pelvic pressure during straining
True False
Question 11: The pelvic surface of the sacrum
a. Gives origin to the piriformis muscle
True False
b. Gives origin to the levator ani muscle
True False
c. Is broader in the male than in the female
True False
d. Transmits the dorsal rami of the spinal nerves
True False
Question 12: With respect to the hypogastric plexuses
a. The inferior hypogastric plexuses lie medial to the rectum
True False
b. The inferior hypogastric plexuses lie lateral to the internal iliac artery
True False
c. The inferior hypogastric plexuses contain both sympathetic and parasympathetic fibres
True False
49
d. The superior hypogastric plexus supplies the descending colon
True False
Question 13: The pelvic splanchnic nerves
a. Join the inferior hypogastric plexus directly
True False
b. Join the superior hypogastric plexus directly
True False
c. Provide parasympathetic supply to the hind-gut
True False
d. Provide sympathetic supply to the bladder
True False
Question 14: The pelvic splanchnic nerves
a. Supply afferent fibres
True False
b. Intermingle with branches of the sympathetic pelvic plexus
True False
c. Are pre-ganglionic fibres
True False
d. Supply the bladder sphincter with motor fibres
True False
Question 15: With respect to the true pelvis
a. The inlet is bounded posteriorly by the sacral promontory
True False
b. The lateral border of the inlet is formed by the lacunar ligament
True False
c. The anterior border of the inlet is formed by the symphysis pubis
True False
d. The posterior border of the outlet is formed by the sacro-spinous ligament
True False

PUDENDAL NERVE *****

Branch of sacral plexus (S2,3,4) *

Leaves pelvic cavity through greater sciatic foramen *

Enters perineum through lesser sciatic foramen *

Enters perineum below and medial to the ischial spine *

Lies medial to the internal pudendal artery as it exits from the pelvis into the perineum *

Branches
Inferior rectal nerve - supplies external anal sphincter and mucous membrane of the
lower half of the anal canal *

50
 Dorsal nerve of the clitoris (penis) *

Perineal nerve - supplies muscles of the urogenital triangle and the skin on the posterior
surface of the labia majora

Internal pudendal artery *****

Leaves the pelvis through the greater sciatic foramen, and emerges between the
Piriformis and Coccygeus *

Crosses the ischial spine, and enters the perineum through the lesser sciatic foramen. *

Then crosses the Obturator internus, along the lateral wall of the ischiorectal fossa, ~ 4
cm above the lower margin of the ischial tuberosity. *

Passes forward between the two layers of the fascia of the urogenital diaphragm

Runs forward along the medial margin of the inferior ramus of the pubis behind the pubic
arcuate ligament *

Pierces the inferior fascia of the urogenital diaphragm *

Branches include the inferior rectal artery (supplies lower half of anal canal) and
branches to the penis or labia and clitoris *

SUPERFICIAL PERINEAL POUCH

Bounded inferiorly by the membranous layer of the superficial fascia

Bounded above by the urogenital diaphragm

Closed posteriorly by the fusion of its upper and lower walls

Communicates anteriorly with the potential space between the superficial fascia of the
anterior abdominal wall and the abdominal wall muscles

Contains the structures forming the root of the clitoris: the bulb of the vestibule,
bulbospongiosus and ischiocavernosus muscles; superficial transverse perineal muscle with
their nerve supply (perineal branch of the pudendal nerve), blood supply (branches of the
internal pudendal artery) and the perineal body

SUPERFICIAL TRANSVERSE PERINEAL MUSCLE

Located in the posterior part of the superficial perineal pouch

Origin: ischial ramus

Insertion: perineal body

Action: fixes perineal body in the centre of the perineum

Nerve: perineal branch of the pudendal nerve

BULBOSPONGIOSUS MUSCLE *

51
 Surrounds vaginal orifice and covers the bulb of the vestibule

Origin - perineal body

Inserted onto the corpus spongiosus of the clitoris

Compresses dorsal vein of the clitoris and assists in erection

ISCHIOCAVERNOSUS MUSCLE *

Origin - ischial tuberosity

Insertion - fascia covering corpus cavernosus

Nerve - perineal branch of the pudendal nerve

Action - assists in erection of the clitoris

UROGENITAL DIAPHRAGM *****

Musculo-fascial diaphragm with a superior and inferior fascial layer containing the deep
transverse perineal muscle and the sphincter urethrae

The two layers fuse anteriorly, leaving a gap beneath the simphysis pubis

The two layers fuse posteriorly with the perineal body

The two layers are attached laterally to the pubic arch

The enclosed space between the two fascial is the deep perineal pouch

DEEP PERINEAL POUCH

Enclosed space between superior and inferior fascial layers of the urogenital diaphragm

Contains:

1) The sphincter urethrae and the deep transverse perineal muscle

2) Part of the vagina
3) Part of the urethra

4) Internal pudendal vessels

5) Dorsal nerve of the clitoris

MUSCLES OF THE DEEP PERINEAL POUCH

Deep transverse perineal muscle

Origin - ischial ramus

Insertion - perineal body

52
 Nerve - perineal branch of pudendal nerve

Action - fixes perineal body

Sphincter urethrae *****

Origin - pubic arch

Insertion - surrounds urethra

Nerve - perineal branch of pudendal nerve

Action - voluntary control of micturiction

THE CLITORIS *****

Located at the apex of the vestibule anterior to the opening of the urethra

Has a root made up of three masses of erectile tissue ? the bulb of the vestibule (divided
into two by the vaginal orifice) and the left and right crura

The bulb is covered by the bulbospongiosus muscle and becomes the corpus spongiosus
and the glans clitoris anteriorly

The crura are covered by the ischiocavernosus muscles and form the corpora cavernosa
anteriorly

EXTERNAL GENITALIA

Labia majora: prominent hair-bearing folds of skin extending from the mons pubis to
fuse posteriorly in the mid-line

Labia minora: hairless folds of skin within the labia majora; unite posteriorly to form
the fourchette; split anteriorly to enclose the clitoris, forming an anterior prepuce and a posterior
frenulum

Vestibule: triangular area bounded laterally by the labia minora with the clitoris at its
apex and the fourchette at its base

The urethra opens within the vestibule posterior to the clitoris

THE ANAL TRIANGLE

Bounded posteriorly by the tip of the coccyx and laterally by the ischial tuberosities
Skin supplied by inferior rectal nerve
Lymphatic drainage is to the medial group of superficial inguinal nodes

THE ANAL CANAL *****

~4cm long, extends downwards and backwards from the rectal ampulla to the anus
LATERAL walls kept in apposition by the levator ani and anal sphincter except
during defecation
Anterior relations: perineal body, urogenital diaphragm and perineal body *

Posterior relations: anococcygeal body and the coccyx *

53
UPPER HALF

Derived from hind-gut endoderm *

Lined by columnar epithelium *
Thrown into vertical folds called anal columns *
Autonomic supply from the inferior hypogastric plexus, sensitive to stretch only *

Blood - superior rectal branch of inferior mesenteric artery *

Lymphatics - inferior mesenteric nodes *
Dentate line - boundary between endodermal and ectodermal origin of anal canal

LOWER HALF

Derived from the ectoderm of the proctodeum *

Lined by stratified squamous epithelium
No anal columns
Blood - inferior rectal artery, branch of internal pudendal artery *
Lymphatics - medial group of superficial inguinal nodes *
Nerve - inferior rectal nerve - sensitive to temperature, pain, touch and pressure *

ANAL SPHINCTER *****

Internal

Thickening of the inner circular layer of smooth muscle in the upper half of the anal canal
Lies deep to the outer layer of longitudinal smooth muscle

External
Skeletal muscle *
Sub-cutaneous part - lower half of anal canal, no bony attachments *
Superficial part - attached to the perineal body anteriorly and the anococcygeal body
posteriorly *
Deep part - no bony attachments, blends with puborectalis *

ISCHIO-RECTAL FOSSA *****

Wedge shaped space filled with dense fat
Base formed by skin
Medial wall formed by anal canal and levator ani muscles
Lateral wall formed by lower part of obturator internus muscle
Contains the pudendal nerve and internal pudendal vessels within the pudendal canal on
the lateral wall

Question 1: The external anal sphincter

a. Is made up of skeletal muscle
True False
b. Has a sub-cutaneous component
True False

54
c. Has a deep component which is attached to the perineal body
True False
d. Has a superficial component which is attached to the anococcygeal body
True False
Question 2: The deep transverse perineal muscle
a. Lies anterior to the sphincter urethrae
True False
b. Originates from the ischial ramus
True False
c. Is inserted onto the perineal body
True False
d. Is supplied by the perineal branch of the pudendal nerve
True False
Question 3: The superficial perineal pouch in the female
a. Communicates anteriorly with the potential space between the superficial fascia of the
anterior abdominal wall and the anterior abdominal wall muscles
True False
b. Contains the bulbospongiosus muscle
True False
c. Contains the ischiocavernosus muscle
True False
d. Contains the superficial transverse perineal muscle
True False

Question 4: The superficial perineal pouch in the female

a. Is bounded inferiorly by the upper surface of the urogenital diaphragm
True False
b. Is closed posteriorly by the fusion of its upper and lower walls
True False
c. Communicates with the cavity of the pelvis laterally
True False
d. Is closed laterally by the attachment of the membraneous layer of superficial fascia to the
pubic arch
True False
Question 5: The internal anal sphincter
a. Is superficial to the longitudinal muscle fibres of the anal canal
True False
b. Is made up of smooth muscle
True False
c. Has a deep, superficial and sub-cutaneous component

55
 True False
d. Is attached to the perineal body
True False
Question 6: The bulbospongiosus muscle
a. Surrounds the orifice of the urethra
True False
b. Surrounds the orifice of the vagina
True False
c. Covers the bulb of the vestibule
True False
d. Is attached to the crus of the clitoris
True False

Question 7: The superficial perineal pouch in the female

a. Contains the bulb of the vestibule
True False
b. Lies between the two layers of the urogenital diaphragm
True False
c. Contains the perineal branch of the pudendal nerve
True False
d. Contains branches of the internal pudendal artery
True False
Question 8: The urogenital diaphragm
a. Is attached anteriorly to the symphysis pubis
True False
b. Is attached posteriorly to the perineal body
True False
c. Is attached laterally to the pubic arch
True False
d. Contains the deep perineal pouch
True False
Question 9: The anal canal
a. Is 2cm long
True False
b. Has its axis directed downwards and forwards from the rectal ampulla
True False
c. Has its anterior and posterior walls in apposition by the tone of the levator ani muscles
True False
d. Is related posteriorly to the anococcygeal body
True False
Question 10: The ischiocavernosus muscle
a. Originates from the ischial spine
True False
b. Is inserted onto the corpus cavernosus
True False
56
c. Is supplied by the dorsal nerve of the clitoris
True False
d. Assists in erection of the clitoris
True False
Question 11: The sphincter urethrae
a. Is made of skeletal muscle
True False
b. Originates from the pubic arch
True False
c. Surrounds the membranous part of the urethra
True False
d. Is supplied by the perineal branch of the pudendal nerve
True False
Question 12: The superficial transverse perineal muscle
a. Lies in the anterior part of the superficial perineal pouch
True False
b. Originates from the ischial tuberosity
True False
c. Is inserted onto the perineal body
True False
d. Is supplied by the perineal branch of the pudendal nerve
True False

Question 13: The ischio-rectal fossa

a. Is bounded inferiorly by the ischial tuberosities
True False
b. Contains the pudendal nerve
True False
c. Contains the internal pudendal artery
True False
d. Is bounded laterally by the obturator internus muscle
True False
Question 14: The deep perineal pouch in the female
a. Contains part of the vagina
True False
b. Contains the deep transverse perineal muscle
True False
c. Contains the superficial transverse perineal muscle
True False
d. Contains the branches of the internal pudendal artery
True False
Question 15: The pudendal nerve
a. Enters the perineum lateral to the ischial spine
True False
b. Supplies the internal anal sphincter

57
 True False
c. Gives off the inferior rectal nerve
True False
d. Gives off the dorsal nerve of the clitoris
True False

THE RIGHT ATRIUM

Has a main cavity and an auricle

The superior and inferior vena cava and coronary sinus open into the right atrium

Drains into right ventricle via the tricuspid valve

Fetal remnants include the fossa ovalis (on the atrial septum, remnant of foramen ovale);
annulus ovalis (upper margin of fossa ovalis, lower edge of septum secundum)

THE RIGHT VENTRICLE

Communicates with the right atrium (tricuspid valve) and the pulmonary artery (pulmonary
valve with three semilunar cusps). Pumps de-oxygenated blood to the lungs

Cavity contains muscular projections called trabeculae carneae:

1) Papillary muscles - connected by chordae tendinae to the cusps of

the tricuspid valve

2) Muscular projections, one of which traverses the cavity and transmits the right
branch of the atrio- ventricular bundle (moderator band)

THE LEFT ATRIUM

Has a main cavity which is smooth and an auricle with muscular ridges

Lies posterior to the right atrium and forms the base of the heart. Separated from the
oesophagus by the pericardium

Receives 4 pulmonary veins and opens into the left ventricle via the mitral (bicuspid) valve

THE LEFT VENTRICLE

Communicates with the left atrium (mitral valve, two cusps) and with the aorta through the
aortic valve (three cusps)
Myocardium is three times thicker than that of the right ventricle
Has trabeculae carneae and two large papillary muscles

There is no moderator band (right ventricle only)

CONDUCTING SYSTEM OF THE HEART *****

58
Sino-atrial node *

Specialised cardiac muscle of the right atrium to the right of the opening of the superior
vena cava

Pacemaker

Supplied by the left and right coronary arteries

Atrio-ventricular node *

Situated in the lower part of the atrial septum

Supplied by the right coronary artery

Atrio-ventricular bundle

Conducts impulses from the atrio-ventricular node to the ventricles

Only muscular connection between atrial and ventricular myocardium

Descends to reach the inferior border of the membranous part of the inter-ventricular
septum

Supplied by the right coronary artery

Right and left atrio-ventricular bundles *

Formed from the atrio-ventricular bundle in the upper border of the muscular part of the
ventricular septum

Right branch enters the moderator band

Continuous with the Purkinje plexus

Right branch is supplied by the right coronary artery, left branch by the left and right
coronary arteries

BLOOD SUPPLY TO THE HEART *****

Right coronary artery

From anterior aortic sinus

Descends in the atrio-ventricular groove, supplying right atrium and ventricle

Gives off marginal branch at the inferior border of the heart and a posterior interventricular
branch

Left coronary artery

From the left posterior aortic sinus

Gives off anterior interventricular and circumflex branches

59
 Anterior interventricular branch supplies right and left ventricles and interventricular
septum

Circumflex branch supplies left atrium and ventricle

Venous drainage

Coronary sinus, a continuation of the great cardiac vein. Drains into the right atrium

Small cardiac and middle cardiac veins drain into the coronary sinus

The anterior cardiac vein drains directly into the right atrium

THE PLEURA

Parietal - lines the thoracic wall, thoracic surface of the diaphragm and lateral aspect of
mediastinum

The cervical pleura extends ~3cm above the medial third of the clavicle to line the under
surface of the suprapleural membrane

Supplied by the intercostal nerves (costal pleura and peripheral part of diaphragmatic
pleura); phrenic nerve (mediastinal pleura and diaphragmatic pleura over dome of diaphragm)

Visceral - surrounds the lungs and receives autonomic supply

THE LUNGS

Right - three lobes with a horizontal and an oblique fissure

Left - two lobes only, with an oblique but no horizontal fissure. Has a cardiac notch

Blood supply to the bronchi and connective tissue of the lung is from the bronchial
arteries, branches of the descending aorta

Alveoli receive de-oxygenated blood from the pulmonary arteries and oxygenated blood
leaves via the pulmonary veins

Lymphatic drainage is to the pulmonary nodes close to the hilum and then into the
bronchomediastinal lymph trunks. These two trunks ascend on either side of the trachea and
drain into the brachiocephalic vein (left) or the thoracic or right lymphatic duct

Parasympathetic supply is from the vagus nerve - produce bronchoconstriction,

vasodilation and increased glandular secretion

Sympathetic supply is from the thoracic sympathetic trunk, cause bronchodilation,

vasoconstriction and decreased glandular secretion

THE OESOPHAGUS

25cm long, continuous with the laryngeal part of the pharynx opposite C6

60
Relations in the neck

Posterior: vertebral column

Anterior: trachea and recurrent laryngeal nerves

Lateral: lobes of thyroid gland

Relations in the thorax

Anterior: trachea, left recurrent laryngeal nerve, left main bronchus, left atrium separated by
pericardium

Posterior: thoracic vertebral bodies, thoracic duct, azygos vein, descending thoracic aorta

Right side: terminal part of azygos vein and mediastinal pleura

Left side: left subclavian artery, aortic arch, thoracic duct and mediastinal pleura

Blood supply

Upper third: inferior thyroid artery / vein

Middle third: descending thoracic aorta / azygos vein

Lower third: left gastric artery / vein (portal vein)

Lymphatic drainage

Upper third: deep cervical nodes

Middle third: posterior mediastinal nodes

Lower third: celiac nodes

Oesophageal opening of the diaphragm

Level T10

Left vagus (anterior), right vagus (posterior)

Transmits left gastric vessels and lymphatics

AORTIC ARCH
Runs upwards, backwards and to the left, initially anterior then to the left of the trachea
Branches
Brachiocephalic artery which divides into the right common carotid and right subclavian
arteries
Left common carotid artery
Left subclavian artery

DESCENDING THORACIC AORTA

61
 Begins on the left side of the lower border of T4
Descends in the posterior mediastinum and ends at the aortic opening of the diaphragm
at the level of T12 where it continues as the abdominal aorta

Branches
Posterior intercostal arteries
Subcostal artery
Pericardial, oesophageal and bronchial arteries

THE PULMONARY TRUNK

5cm long begins at the pulmonary valve, runs upwards, backwards and to the left,
terminating in the concavity of the aortic arch by dividing into the left and right pulmonary
arteries. Lies anterior to the trachea
Connected to the aortic arch by the ligamentum arteriosum (remnant of the ductus
arteriosus)
The left recurrent laryngeal nerve hooks around the ligamentun arteriosum

INTERNAL THORACIC ARTERY *****

Branch of the first part of the subclavian artery

Supplies the anterior wall of the body from the clavicle to the umbilicus
Descends on the pleura deep to the costal cartilages
Ends at the 6th intercostal space dividing into the superior epigastric and
musculophrenic arteries

Gives off two anterior intercostal arteries to the upper 6 intercostal spaces
Pericardiophrenic artery to the pericardium
Mediastinal arteries to the anterior mediastinum including the thymus
Perforating arteries to thoracic and anterior abdominal wall
The internal thoracic vein drains into the brachiocephalic vein

SUPERIOR VENA CAVA *****

Formed from the left and right brachioceplalic veins (which are formed from the
subclavian and internal jugular veins)
Receives the azygos vein just before piercing the pericardium
Lies anterior to the trachea and aorta in the superior mediastinum

THORACIC DUCT *****

Begins in the abdomen as the cysterna chyli

Enters thorax through aortic opening of the diaphragm on the right side of the
descending aorta
Crosses the mid-line posterior to the oesophagus
Ascends on the left side of the oesophagus within the superior mediastinum
Drains into the left brachiocephalic vein
Receives the LEFT bronchomediastinal, jugular and subclavian lymph trunks
Conveys lymph from the lower limbs, pelvis, abdomen, left side of the thorax, left side of
the head and neck and left upper limb into the blood stream

Lymph from the right side of the head and neck, right upper limb and right side of the thorax is drained
by the right jugular, subclavian and bronchomediastinal trunks respectively. These may unite to form the
right thoracic duct which drains into the right brachiocephalic vein or drain independently in to the vain.

62
THE VAGUS NERVES *****

Right

Enters the thorax posterior-lateral to the brachiocephalic artery

Descends lateral to the trachea and medial to the terminal part of the azygos vein

Passes posterior to the root of the right lung

Descends onto the posterior surface of the oesophagus to enter the abdomen and
posterior surface of the stomach

Left
Enters the thorax between the left common carotid and left subclavian arteries

Crosses the left side of the aortic arch

Is crossed by the left phrenic nerve

Descends posterior to the root of the left lung

Then passes onto the anterior surface of the oesophagus to enter the abdomen

Branches

Both nerves contribute to their respective pulmonary and oesophageal plexuses

The right vagus gives off a cardiac branch

The left vagus gives off the left recurrent laryngeal nerve at the level of the ligamentum
arteriosum. The nerve hooks around the ligament to ascend between the trachea and the
oesophagus on the left side and supplies all the muscles of the left vocal cord except the
cricothyroid muscle (external laryngeal branch of the vagus)

THE PHRENIC NERVES *****

Right

Arises in the neck from the anterior rami of C3,4,5

Enters the thorax on the right side of the right brachiocephalic vein and inferior vena cava

Descends anterior to the root of the right lung

Is separated by the pericardium from the right atrium

Leaves the thorax through the caval opening of the diaphragm on the right side of the
inferior vena cava

Left

Enters the thorax on the left side of the left subclavian artery

Crosses the left side of the aortic arch and the left vagus nerve
63
 Descends anterior to the root of the left lung

Is separated from the left ventricle by the pericardium

Terminal branches pierce the muscle of the diaphragm and supply the central part of the
peritoneum on its under surface

Provide motor supply to the diaphragm and sensory supply to the pericardium, mediastinal
pleura, the central part of the diaphragmatic pleura and peritoneum. *

THORACIC SYMPATHETIC TRUNK *****

Continuation of the cervical sympathetic trunk, descends on the head of the ribs

Arranged in 11/12 segmental ganglia

Enters the abdomen on the side of the body of T12 by passing behind the medial arcuate
ligament

First ganglion often fused with the inferior cervical ganglion to form the stellate ganglion

Gives grey rami communicantes to the thoracic spinal nerves

Receives white rami communicantes from the thoracic spinal nerves

Upper five ganglia give POST-ganglionic fibres to the heart, lungs, oesophagus and aorta

Lower eight ganglia give PRE-ganglionic fibres which form the greater (5th-9th), lesser
(10th & 11th) and lowest (12th) splanchnic nerves

THE MEDIASTINUM

Divided into superior and inferior mediastinum by a plane passing from the sternal angle to
the lower border of T4

Inferior mediastinum divided into middle mediastinum containing the heart, posterior and
anterior mediastinum posterior and anterior to the heart respectively

Superior mediastimun has the following structures from front to back: thymus, large veins,
large arteries, trachea, oesophagus + thoracic duct, sympathetic trunk

Inferior mediastinum has the following structures from front to back: thymus, heart +
phrenic nerves, oesophagus + thoracic duct, descending aorta, sympathetic trunk

TRACHEA

13cm tube with a fibro-elastic wall within which are embedded U-shaped bars of hyaline
cartilage

64
 Commences in the neck below the cricoid cartilage of the larynx (C6) and ends at the level
of the angle of Louis (lower border of T4)

Anterior relations: sternum, thymus, left brachiocephalic vein, arch of the aorta and the
origins of the brachiocephalic and left common carotid arteries

Posterior relations: oesophagus, left recurrent laryngeal nerve

Right side: azygos vein, right vagus nerve

Left side: arch of the aorta with left common carotid and subclavian arteries, left vagus
and left phrenic nerves.

MAIN BRONCHI

RIGHT

Shorter, wider and more vertical than the left

Gives off the superior lobar bronchus before entering the hilum of the lung where it divides
into the middle and inferior lobe bronchus

LEFT

Passes to the left below the aortic arch, anterior to the oesophagus

At the hilum of the left lung divides into superior and inferior lobe bronchi

=============================
Question 1: The pulmonary trunk
a. Lies posterior to the trachea
True False
b. Lies superior to the aortic arch
True False
c. Conveys de-oxygenated blood from the heart
True False
d. Divides into right and left pulmonary veins
True False
Question 2: With respect to the conducting system of the heart
a. The atrio-ventricular bundle is the only muscular connection between the myocardium of
the atria and the ventricular myocardium
True False
b. Cardiac impulses are relayed from the atrio-ventricular node to the ventricles by the atrio-
ventricular bundle
True False
c. The sino-atrial node is supplied by the left and right coronary arteries
True False
d. The atrio-ventricular node is supplied by the left coronary artery
True False
Question 3: The superior vena cava
65
a. Is formed from the right brachiocephalic and left internal jugular veins
True False
b. Receives blood from the azygos vein
True False
c. Lies anterior to the aorta in the superior mediastinum
True False
d. Lies posterior to the trachea in the superior mediastinum
True False
Question 4: The trachea
a. Lies anterior to the thymus in the superior mediastinum
True False
b. Is posterior to the arch of the aorta
True False
c. Lies anterior to the origin of the left common carotid artery
True False
d. Is related anteriorly to the oesophagus
True False
Question 5: The right ventricle
a. Has a pulmonary out-flow tract (pulmonary valve) with two semilunar cusps
True False
b. Contracts during ventricular diastole
True False
c. Communicates directly with the inferior vena cava
True False
d. Pumps oxygenated blood into the pulmonary artery
True False
Question 6: The left ventricle
a. Has trabeculae carneae
True False
b. Has a moderator band
True False
c. Has three papillary muscles
True False
d. Has a thicker wall than that of the right ventricle
True False
Question 7: The arch of the aorta has the following branches
a. The left common carotid artery
True False
b. The left subclavian artery
True False
c. The internal thoracic artery
True False
d. Oesophageal artery
True False
Question 8: The right vagus nerve
66
a. Enters the thorax medial to the brachiocephalic artery
True False
b. Lies medial to the trachea in the superior mediastinum
True False
c. Lies medial to the azygos vein in the superior mediastinum
True False
d. Descends anterior to the root of the right lung
True False
Question 9: The arch of the aorta has the following branches
a. The right brachiocephalic artery
True False
b. The left brachiocephalic artery
True False
c. The right subclavian artery
True False
d. The right common carotid artery
True False
Question 10: Within the mediastinum
a. The heart is anterior to the oesophagus
True False
b. The thymus is anterior to the heart
True False
c. The thoracic duct lies anterior to the heart
True False
d. The oesophagus lies posterior to the descending aorta
True False
Question 11: The left lung
a. Receives de-oxygenated blood from the left pulmonary artery
True False
b. Has Lymphatic drainage to the para-aortic nodes
True False
c. Receives parasympathetic supply from the vagus nerve
True False
d. Sympathetic stimulation results in bronchodilation and vasoconstriction
True False
Question 12: The right vagus nerve
a. Enters the abdomen on the anterior surface of the oesophagus
True False
b. Contributes to the right pulmonary plexus
True False
c. Gives off the right recurrent laryngeal nerve within the thorax
True False
d. Stimulation results in vasodilation of the bronchial vessels
True False

67
Question 13: The right ventricle
a. Communicates with the pulmonary vein
True False
b. Has papillary muscles
True False
c. Is traversed by the moderator band
True False
d. Has papillary muscles which are connected to the cusps of the tricuapid valve by the
chordae tendinae
True False
Question 14: The left atrium
a. Communicates with the left ventricle via the tricuspid valve
True False
b. Receives blood from two pulmonary arteries
True False
c. Forms the base of the heart
True False
d. Has an auricle
True False
Question 15: The right atrium
a. Has a main cavity and an auricle
True False
b. Opens into the right ventricle via the mitral valve
True False
c. Has the fossa ovalis located on the atrial septum
True False
d. The fossa ovalis is the remnant of the septum secundum
True False

THE DIAPHRAGM *****

Has a peripheral muscular part and a central tendon

Three origins:
Sternal - from the posterior surface of the xiphoid process *
Costal - from the deep surfaces of the lower 6 ribs and their costal cartilages *
Vertebral - right crus from the sides of the bodies and inter-vertebral discs of the upper 3
lumbar vertebrae; left crus from the sides of the bodies and intervertebral disc of the first 2
lumbar vertebrae. Also has an origin from the medial and lateral arcuate ligaments. The median
arcuate ligament joins the crura *
Insertion - central tendon

Action
Contracts during inspiration - most important muscle for inspiration *
Contraction raises intra-abdominal pressure during micturiction, defecation or
parturition *

68
 Thoraco-abdominal pump - contraction lowers intra-thoracic and raises intra-abdominal
pressure, aiding venous return from the inferior vena cava to the right atrium *
Nerve supply - motor : phrenic nerve. Sensory supply to parietal pleura and peritoneum
covering the central tendon is from the phrenic nerve. Sensory supply to the peripheral part is
from the lower 5 intercostal nerves

OPENINGS *****

Aortic - anterior to T12 between the crura, transmit the aorta, thoracic duct and azygos
vein *
Oesophageal - level of T10, also transmits right and left vagi, oesophageal branch of
the left gastric vessels and lymphatics from the lower third of the oesophagus *
Caval - level of T8 in the central tendon, also transmits terminal branch of the right
phrenic nerve *
The superior epigastric vessels pass between the sternal and costal origins ; the left
phrenic nerve pierces the left dome; the greater, lesser and lowest splanchnic nerves pierce the
crura and the sympathetic trunk lies posterior to the medial arcuate ligament. *

THORAX - SURFACE ANATOMY

Supra-sternal notch: Upper margin of manubrium sterni, palpable in mid-line

between medial ends of clavicles

Sternal angle (angle of Louis): angle between manubrium and body of sternum; lies
at the level of the second costal cartilage opposite the intervertebral disc between the 4th
and 5th thoracic vertebrae

Xiphisternal joint: lies opposite the body of the 9th thoracic vertebra

Costal margin: formed from costal cartilages of 7th ? 10th ribs and the ends of the
11th and 12th cartilages. Lowest point formed by the 10th rib and lies at the level of L3

The first rib is not palpable

The apex beat of the heart is located in the 5th left intercostal space 9cm from the
mid-line

The first spinous process that is palpable is that of the 7th cervical vertebra
(vertebra prominens)

The superior angle of the scapula lies at the level of the spine of the 2nd thoracic
vertebra while the inferior angle lies at the level of the spine of the 7th thoracic vertebra.
The root of the spine of the scapula lies at the level of the spine of the 3rd thoracic
vertebra

THE RIB

A typical rib has a head which articulates with the body of the corresponding
vertebra and the vertebra immediately above; a neck between the head and the tubercle;

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a tubercle which articulates with the transverse process of the corresponding vertebra; a
shaft or body and an angle where the shaft turns sharply forwards.

The costal groove is located on the inferior border of the shaft

FIRST RIB

Has the scalene tubercle on its medial border for the attachment of the scalenus
anterior muscle

The subclavian vein crosses the rib anterior to the scalene tubercle

The subclavian artery and brachial plexus lie posterior to the scalene tubercle

Has a head which articulates with the body of the 1st thoracic vertebra. Unlike other
ribs, the first rib does not articulate with the body of the vertebra above it (7th cervical)

Has a tubercle which articulates with the transverse process of the 1st thoracic
vertebra

Is not palpable - lies deep to the clavicle

INTERCOSTAL MUSCLES

EXTERNAL - fibres directed downwards and forwards from the inferior border of the
rib above to the inferior border of the rib below; extends from the tubercle to the
costochondral junction where it is replaced by the anterior intercostal membrane

INTERNAL - fibres directed downwards and backwards, extends from the sternum
to the angle of the rib posteriorly where it is replaced by the posterior intercostal
membrane

TRANSVERSUS THORACIS - extends over more than one intercostal space

INTERCOSTAL NEUROVASCULAR BUNDLE

Runs within the costal groove between the internal thoracic and transversus
thoracis muscles

Arranged from above downwards: Vein, Artery and Nerve (VAN)

INTERCOSTAL VESSELS

Each intercostal space has two anterior and one posterior arteries

1st and 2nd posterior intercostal arteries are branches of the superior intercostal
artery, a branch of the costocervical trunk of the subclavian artery

Lower 9 posterior intercostal arteries - branches of the thoracic aorta

Upper 6 anterior intercostal arteries - branches of the internal thoracic artery

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 Lower 5 anterior intercostal arteries - branches of the musculophrenic artery
(terminal branch of the internal thoracic artery)

Intercostal arteries supply parietal pleura, intercostal muscles and skin of thoracic
wall

Posterior intercostal veins drain into azygos or hemiazygos veins

Anterior intercostal veins brain into musculophrenic and internal thoracic veins

INTERCOSTAL NERVES *****

Anterior rami of upper 11 thoracic spinal nerves

Enter intercostal space between the parietal pleura and the posterior intercostal
membrane

Run in the subcostal groove between the internal intercostal and transversus
thoracis muscles and inferior to the intercostal vein and artery (VAN)

Upper 6 supply intercostal spaces

Lower 5 also supply anterior abdominal wall

Branches *****

Rami communicantes - give white rami and receive grey rami from the sympathetic
trunk

Lateral cutaneous branch - divides into anterior and posterior branches and
supplies the skin

Anterior cutaneous branch - divides into medial and lateral branches

Collateral branch - runs forward below the main nerve

Muscular, pleural and peritoneal branches

First intercostal nerve - the equivalent of the lateral cutaneous branch joins the
brachial plexus. There is no anterior cutaneous branch

Second intercostal nerve - the equivalent of the lateral cutaneous branch forms the
intercostobrachial nerve which joins the medial cutaneous nerve of the arm to supply the
skin of the armpit and medial side of the arm

Question 1: The diaphragm

a. Has a left crus originating from the lateral arcuate ligament
True False
b. Has the median arcuate ligament between the medial and the lateral arcuate ligaments

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 True False
c. Contracts during expiration
True False
d. Contracts during micturiction and defecation
True False
Question 2: The following statements about the intercostal arteries are true
a. The anterior intercostal arteries of the lower 5 spaces are branches if the superior
epigastric artery
True False
b. The intercostal arteries supply the parietal pleura
True False
c. The intercostal arteries supply the visceral pleura
True False
d. The intercostal arteries supply the intercostal muscles and skin of the thoracic wall
True False
Question 3: A needle inserted in the mid-axillary line over the 8th intercostal space into
the pleural space would traverse the following structures
a. Serratus anterior muscle
True False
b. External intercostal muscle
True False
c. External oblique muscle
True False
d. Internal intercostal muscle
True False
Question 4: The internal thoracic artery
a. Supplies the pericardium
True False
b. Supplies the thymus gland
True False
c. Gives off one anterior intercostal artery to the upper 6 intercostal spaces
True False
d. Gives off perforating branches
True False
Question 5: The first rib
a. Articulates with the first thoracic vertebral body
True False
b. Articulates with the body of the 7th cervical vertebra
True False
c. Is crossed by the subclavian vein anterior to the scalene tubercle
True False
d. Is crossed by the subclavian artery posterior to the scalene tubercle
True False
Question 6: The diaphragm
a. Causes a reduction in venous return during contraction

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 True False
b. Has the right and left vagus nerves entering the abdomen through the oesophageal
opening
True False
c. Has a caval opening at the level of the 8th thoracic vertebra
True False
d. Has the peritoneum on its inferior surface supplied by the phrenic nerve
True False

Question 7: The diaphragm

a. Is covered by visceral pleura on its superior surface
True False
b. Receives motor nerve supply from the phrenic nerve
True False
c. Receives sensory supply from the phrenic nerve
True False
d. Receives sensory supply from the lower 5 intercostal nerves
True False
Question 8: With respect to the intercostals muscles
a. The fibres of the external intercostal muscles are directed downwards and forwards
True False
b. The external intercostal muscles extend from the tubercle of the ribs to the sternum
True False
c. The internal intercostal muscles extend from the sternum to the tubercle of the rib
posteriorly
True False
d. The transversus thoracis muscle extends over more than one intercostal space
True False
Question 9: A needle inserted in the mid-axillary line over the 8th intercostal space into
the pleural space would traverse the following structures
a. Transversus thoracis muscle
True False
b. The costal origin of the diaphragm
True False
c. Visceral pleura
True False
d. The posterior intercostal membrane
True False
Question 10: With respect to the lymphatic drainage of the thoracic wall
a. Lymphatic drainage of the skin of the anterior chest wall is to the anterior axillary nodes
True False
b. Lymphatic drainage of the skin of the posterior chest wall is to the posterior axillary
nodes
True False
c. Lymphatic drainage of the anterior part of the intercostal spaces is to the internal thoracic
nodes
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 True False
d. Lymphatic drainage of the posterior part of the intercostal spaces is to the para-aortic
nodes
True False
Question 11: The first rib
a. Has the scalenus anterior muscle inserted onto the scalene tubercle
True False
b. Is crossed by the brachial plexus anterior to the scalenus anterior muscle
True False
c. Articulates with the transverse process of the 7th cervical vertebra
True False
d. Is palpable throughout its length
True False
Question 12: With respect to the lymphatic drainage of the breast
a. Lymphatic vessels cross the mid-line
True False
b. Lymphatic drainage of the lateral part of the gland is to the anterior axillary nodes
True False
c. Lymphatic drainage of the superior part of the gland is to the supra-clavicular nodes
True False
d. Lymphatic drainage of the medial part of the gland is to the internal thoracic nodes
True False

Question 13: The diaphragm

a. Has a central muscular part and a peripheral tendinous part
True False
b. Has a sternal origin from the posterior surface of the body of the sternum
True False
c. Has a costal origin from the deep surfaces of the lower 4 ribs and their costal cartilages
True False
d. Has a right crus originating from the medial arcuate ligament
True False
Question 14: The intercostal nerves
a. Are the posterior rami of the first 11 thoracic spinal nerves
True False
b. Enter the intercostal space between the internal intercostal muscle and the transversus
thoracis
True False
c. Run superior to the intercostal vein
True False
d. Give off grey rami communicantes to the sympathetic trunk
True False
Question 15: With respect to the surface anatomy of the thorax
a. The xiphisternal joint lies opposite the body of the 9th thoracic vertebra

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 True False
b. The lowest part of the costal margin is formed by the 12th rib
True False
c. The lowest part of the costal margin lies at the level of the 3rd lumbar vertebra
True False
d. The first rib is palpable throughout its length
True False

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