Understand first, then memorize and apply

You¤can¤use¤this¤presentation¤like¤a¤guide¤during¤your¤
preparing¤for¤final¤GA¤exam.
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100 must important course.
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professor’s¤presentations.
Dr. Mavrych, MD, PhD, DSc Good¤Luck¤and¤All¤the¤best!¤
Professor of Gross anatomy, SMU
Dr.¤Mavrych

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1. Lumbar puncture (tap) and

Epidural anesthesia
When a lumbar puncture is
performed, the needle enters the
subarachnoid space to extract
cerebrospinal fluid (spinal tap) or to
inject anesthetic (spinal block) or
contrast material.
The needle is usually inserted
between L3/L4 or L4/L5. Level of
horizontal line through upper points
of iliac crests.
Remember, the spinal cord may
end as low as L2 in adults and
does end at L3 in young children
and dural sac extends caudally to
level of S2.
Before the procedure, the patient
should be examined for signs of
increased intracranial pressure
because cerebellar tonsils may
herniate through the foramen
magnum.
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 3. Abnormal curvatures of the
2. Herniated IV disc spine
Herniated discs usually Kyphosis is an exaggeration of
occur in lumbar (L4/L5 or the thoracic curvature that may
L5/S1) or cervical regions
(C5/C6 or C6/C7) of occur in elderly persons as a result
individuals younger than of osteoporosis (multiply
age 50. compression fracture of vertebral
Herniations may follow bodies) or disk degeneration.
degenerative changes in
the anulus fibrosus and be Lordosis is an exaggeration of the
caused by sudden lumbar curvature that may be
compression of the nucleus temporary and occurs as a result
pulposus. of pregnancy, spondylolisthesis
Herniated lumbar discs or potbelly.
usually involve the nerve
root one number below - Scoliosis is a complex lateral
traversing root (e.g., the deviation, or torsion, that is
herniation L4/L5 will caused by poliomyelitis, a leg-
compress L5 root).
length discrepancy, or hip disease.

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4. Upper limb fractures:

Humerus fractures Fracture of distal radius:
Sites of potential injury to major Transverse fracture within the distal 2 cm of
nerves in fractures of the the radius. Most common fracture of the
humerus: forearm (after 50).
1. Axillary nerve and posterior Smith's fracture results from a fall or a blow
humeral circumflex artery at on the dorsal aspect of the flexed wrist
the surgical neck. and produces a ventral angulation of the
2. Radial nerve and profunda wrist. The distal fragment of the radius is
brachii artery at midshaft. ANTERIORLY displaced.
3. Brachial artery and median Colles' fracture results from forced
nerve at the supracondylar extension of the hand, usually as a result of
region. trying to ease a fall by outstretching the
4. Ulnar nerve at the medial upper limb. Distal fragment is displaced
epicondyle. DORSALLY - “dinner fork deformity”.
Often the ulnar styloid process is avulced
(broken off)

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 Scaphoid fracture Boxer’s fracture
Occurs as a result of a fall onto Necks of the metacarpal
the palm when the hand is bones are frequently
abducted fractured during fistfights.
Pain occurs primarily on the Typically, fractured 2d and 3d
lateral side of the wrist,
especially during wrist extension metacarpals are seen in
and abduction professional boxers, and
Scaphoid fracture may not show fractured 5th and sometimes
on X-ray films for 2 to 3 weeks, 4th metacarpals are seen in
but a deep tenderness will be unskilled fighters.
present in the anatomical
snuffbox.
The proximal fragment may
undergo avascular necrosis
because the blood supply is
interrupted.

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5 Rotator cuff muscles – SITS 6. Abduction of the upper limb

Support the shoulder joint by
(0°-15°) Abduction of the
forming a musculotendinous upper extremity is initiated
rotator cuff around it by the supraspinatus
Reinforces joint on all sides muscle (suprascapular
except inferiorly, where nerve).
dislocation is most likely (15°-110º) Further abduction
Rotator cuff muscles are to the horizontal position is a
Supraspinatus, Infraspinatus, function of the deltoid
muscle (axillary nerve).
Teres minor, Subscapularis:
SITS. (110°-180°) Raising the
extremity above the
horizontal position requires
Right humerus
scapular rotation by action
of the trapezius (accessory
nerve CNXI) and serratus
anterior (long thoracic
nerve).
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 7. Medial (golfer’s elbow) and
Subacromial bursitis lateral (tennis elbow) epicondylitis
Subacromial bursitis Medial epicondylitis is inflammation of
(influmution of the subacromial the common flexor tendon of the wrist
bursa) is often due to calcific where it originates on the medial
supraspinatus tendinitis, epicondyle of the humerus.
causing a painful arc of of
abduction.
Lateral epicondylitis: repeated forceful
flexion and extension of the wrist resulting
strain attachment of common extensor
tendon and inflammation of periosteum
of lateral epicondyle. Pain felt over
lateral epicondyle and radiates down
posterior aspect of forearm. Pain often felt
when opening a door or lifting a glass

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8. Arterial anastomoses
around the scapula 9. Cubital fossa
Contents from lateral to medial:
Blockage of the 1. Biceps brachii tendon
Subclavian or Axillary 2. Brachial artery
artery can be bypassed
by anastomoses 3. Median nerve
between branches of Subcutaneos structures from lateral to
the Thyrocervical and medial:
Subscapular arteries: 1. Cephalic vein
Transverse cervical 2. Median cubital vein: joins cephalic
Suprascapular and basilic veins
Subscapular 3. Basilic vein
Circumflex scapular
Sites of venipuncture is usually median
cubital vein because:
Overlies bicipital aponeurosis, so deep
structure protected
Not accompanied by nerves

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 11. Test of the proximal and
10. Carpal Tunnel Syndrome distal interphalangeal joints
Results from a lesion that
reduces the size of the carpal
tunnel (fluid retention, infection,
dislocation of lunate bone) PIP – FDS
Median nerve – most sensitive
structure in the carpal tunnel
and is the most affected
Clinical manifestations:
Pins and needles or anesthesia
of the lateral 3.5 digits
palm sensation is not affected
because superficial palmar
cutaneous branch passes
superficially to carpal tunnel DID - FDP
Apehand deformity - absent
of OPPOSITION

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12. Lesion of UL nerves Upper Brachial Palsy

Upper Brachial Palsy (Erb-Duchenne palsy)
Injury of upper roots and trunk • In all cases, paralysis of the muscles of the
Usually results from excessive shoulder and arm supplied by C5 and C6 spinal
increase in the angle between the nerves (roots) of the upper trunk.
neck and the shoulder stretching or • Combination lesions of axillary, suprascapular
tearing of the superior parts of the
brachial plexus (C5 and C6 roots or and musculocutaneous nerves with loss of the
superior trunk) shoulder mm and anterior arm.
May occur as birth injury from • As result patient have “waiter’s tip” hand:
forceful pulling on infant's head • adducted shoulder
during difficult delivery • medially rotated arm
• extended elbow
• loss of sensation in the lateral aspect of the
upper limb

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 Lower Brachial Palsy Lower Brachial Palsy
(Klumpke paralysis) (Klumpke paralysis)
Injury of lower roots and
trunk All intrinsic muscles of the hand
supplied by the C8 and T1 roots of
May occur when the upper the lower trunk affected.
limb is suddenly pulled Combination lesions of ulnar
superiorly: stretching or nerve (“claw hand”) and median
tearing of the inferior parts nerve (“ape hand”)
of the brachial plexus (C8 Loss of sensation in the medial
and T1 roots or inferior aspect of the upper limb and
trunk) medial 1,5 fingers.
E.g., grabbing support May include a Horner syndrome
during fall from height or
as a birth injury, or TOS –
thoracic outlet syndrome

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Cutaneous innervation
Injury to musculocutaneous nerve of the hand
Usually results from lesions
of lateral cord

Greatly weakens flexion of

elbow (biceps and brachialis
muscles) and supination of
forearm (biceps muscle)

May be accompanied by
anesthesia over lateral
aspect of forearm

Dorsum: 1,5-U and 3,5 R Palm: 1,5-U and 3,5 M

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 13. Avascular necrosis 14. Knee joint injury:
of femoral head Unhappy triad
Because the lateral side of the
knee is struck more often
(e.g., in a football tackle), the
tibial collateral ligament is
A common fracture in the most frequently torn
elderly women with ligament at the knee.
osteoporosis is fracture of
the femoral neck. The unhappy triad of athletic
knee injuries involves:
Transcervical fracture
disrupts blood supply to 1. Tibial collateral ligament
the head of the femur via 2. Medial meniscus
retinacular arteries (from 3. Anterior cruciate ligament
medial circumflex femoral
artery) and may cause
avascular necrosis of the
femoral head if blood
supply through the ligament
to the head is inadequate.

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Fibular collateral ligament Rupture of the

(lateral collateral ligament) cruciate ligaments

Rounded cord between With rupture of the

lateral epicondyle of femur anterior cruciate ligament,
the tibia can be pulled
and head of fibula forward excessively on the
Does NOT blend with joint femur, exhibiting anterior
capsule and does NOT drawer sign.
attach to lateral meniscus
In the less common rupture
Limits extension and of the posterior cruciate
adduction of leg at knee ligament, the tibia can be
pulled backward excessively
on the femur, exhibiting
posterior drawer sign.

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 Prepatellar bursa
Suprapatellar bursa Knee jerk reflex
Prepatellar bursa: between
superficial surface of patella The patellar reflex
and skin. May become is tested by tapping
the patellar
inflamed and swollen ligament with a
(prepatellar bursitis) reflex hammer to
elicit extension at
the knee joint. Both
Suprapatellar bursa: superior afferent and
extension of synovial cavity efferent limbs of
between distal end of femur the reflex arch are
in the femoral
and quadriceps muscle and nerve (L2-L4).
tendon. Usual place for intra-
articular injections Knee jerk reflex:
tests spinal nerves
L2-L4.

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15. Ankle joint injury:

Ankle sprains Pott’s fracture
Fracture-dislocations of
Sprains are the most the ankle (Pott's
common ankle injuries fracture):
A sprained ankle is nearly Forced eversion
always an inversion injury, (abduction) of the foot
involving twisting of the
weight-bearing plantarflexed The medial ligament
foot. avulses the medial
malleolus or the
The lateral ligament (anterior medial ligament
talofibular ligament) is tears, and fibula
injured because it is much fractures at a higher
weaker than the medial level
ligament.
Forced inversion
In severe sprains, the lateral (adduction) avulses the
malleolus of the fibula may be lateral malleolus of fibula
fractured. or tears the lateral
ligament
Pott's fracture

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 16. Injury of the gluteal region:
Ankle jerk reflex Piriformis syndrome

Achilles tendon reflex is Inflammation or spasm of

tested by tapping the the piriformis muscle may
produce pain similar to that
calcaneal tendon to elicit caused by sciatica
plantar flexion at the ankle ("piriformis syndrome").
joint.
Both afferent and efferent Piriformis “Landmark” of
limbs of the reflex arc are the gluteal region: provides
key to understanding
carried in the tibial nerve relationships in the gluteal
(S1, S2). region; determines names
of blood vessels and nerves
action: supination of hip
Ankle jerk reflex: tests joint
spinal nerves S1-S2.

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Superior gluteal
Injury to sciatic nerve nerve injury
The superior gluteal nerve may
be injured during surgery,
Weakened hip posterior dislocation of the
extension and knee hip or poliomyelitis.
flexion
Paralysis of the gluteus
Footdrop (lack of medius and gluteus minimus
dorsiflexion) muscles occurs so that the
Flail foot (lack of ability to pull the pelvis up
both dorsiflexion and and abduction of the thigh
plantar flexion) are lost.

Cause of injury: If the superior gluteal nerve on

caused by the left side is injured, the right
improperly placed pelvis falls downward when the
gluteal injections Superior gluteal
patient raises the right foot off the
but may result from nerve injury
ground.
posterior hip Note that it is the side
dislocation contralateral to the nerve injury
that is affected.

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 17. Avulsion fractures
of the hip bone and
Injury to inferior gluteal nerve
hamstrings muscles
Weakened hip extension Avulsion fractures occur
(gluteus maximus), most where muscles are
attached - ischial
noticeable when climbing tuberosities
stairs or standing from a
seated position
Hamstrings muscles:
Cause of injury: posterior
1. Biceps femoris
hip dislocation, surgery in
this region 2. Semitendinosus
3. Semimembranosus
Action: extension of hip
joint and flexion of knee
joint
Nerve supply – Tibial
nerve (short head of
biceps femoris is supplied
by the common fibular
nerve)

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18. Femoral sheath & femoral

hernia Femoral hernia
Inguinal lig.
Extension of
transversalis fascia A femoral hernia passes through the
and iliacus fascia femoral ring into the femoral canal to
that enters thigh form a swelling in the upper thigh
deep to inguinal inferior and lateral to the pubic tubercle
ligament
The hernial sac may protrude through
Divided into three
compartments from the saphenous hiatus into the
lateral to medial superficial fascia
enclosing: A femoral hernia occurs more
Femoral artery frequently in females and is dangerous
Femoral vein because the hernial sac may become
Femoral canal strangulated
An aberrant obturator artery is
vulnerable during surgical repair

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 19. Rupture of the Achilles
tendon and Triceps surae muscle Injury to tibial nerve

Avulsion or rupture of the calcaneal In popliteal fossa: loss of

(Achilles) tendon disables the triceps plantar flexion of foot (mainly
gastrocnernius and soleus
sure muscle (gastrocnemius & soleus) muscles) and weakened
so that the patient cannot plantar flex inversion (tibialis posterior
the foot. muscle), causing
Triceps surae muscle: calcaneovalgus.
2 Heads of Gastrocnemius m. Inability to stand on toes
1 Head - Soleus muscle
Plantaris
small fusiform belly with long thin
tendon; may be absent
sometimes may become
hypertrophy

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21. Breast:
20. Fracture of the fibular neck Carcinoma of the Breast
May cause an injury to the
common peroneal nerve, Carcinomas of the
which winds laterally around breast are malignant
the neck of the fibula. tumors, usually
This injury results in adenocarcinomas
paralysis of all muscles in arising from the
the anterior and lateral epithelial cells of the
compartments of the leg lactiferous ducts in the
(dorsiflexors and evertors of mammary gland
the foot) lobules
Causing foot drop. 1. It enlarges, attaches
to suspensory
(Cooper‘s) ligaments,
and produces
shortening of the
ligaments, causing
depression or dimpling
of the overlying skin.

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 Lymphatic drainage
of the breast Mastectomy

It is important because Radical mastectomy, a more extensive surgical

of its role in the procedure, involves removal of the breast, pectoral
metastasis of cancer muscles, fat, fascia, and as many lymph nodes as
cells. possible in the axilla and pectoral region.
Most lymph (> 75%),
especially from the During a radical mastectomy, the long thoracic
lateral breast nerve may be lesioned during ligation of the lateral
quadrants, drains to thoracic artery. A few weeks after surgery, the
the axillary lymph
nodes, initially to the female may present with a winged scapula and
anterior (pectoral) weakness in abduction of the arm above 90°
nodes for the most
part. because serratus anterior m. paralysis.
Most of the remaining The intercostobrachial nerve may also be
lymph, particularly from damaged during mastectomy, resulting in
the medial breast
quadrants, drains to the numbness of the skin of the medial arm.
parasternal lymph
75% 25% nodes or to the
opposite breast.

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22. Diaphragm:
Breast infection Paralysis of Half and ruptures
Mastitis is an infection of the tissue
Paralysis of the half
of the breast that occurs most of the Diaphragm
frequently during the time of may result from injury
breastfeeding (1 to 3months after the or operative division of
delivery of a baby). the phrenic nerve of
same side
This infection causes pain, swelling, It can be detected
redness, and increased temperature radiologically.
of the breast.
It can occur when bacteria, often from Paradoxical
the baby's mouth, enter a milk duct movement: dome of
diaphragm of injured
through a crack in the nipple. side pushed superiorly
It can occur in women who have not by abdominal viscera
recently delivered as well as in women during inspiration
instead of descending
after menopause.

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 Diaphragmatic ruptures
Diaphragmatic injuries are
23. Cardiac hypertrophy
relatively rare and result from
either blunt trauma or Left atrial enlargement
penetrating trauma. (hypertrophy) secondary to
Presently, 80-90% of blunt mitral valve failure may
diaphragmatic ruptures result compress on the
from motor vehicle crashes. esophagus and manifest
The majority (80-90%) of blunt as dysphagia (difficulty in
diaphragmatic ruptures have swallowing).
occurred on the left side. It may be observed as a
Blunt trauma typically produces filling defect in the
large radial tears measuring 5-15 esophagus by barium
cm, most often at the swallow on the lateral
posterolateral aspect of the thoracic X-Ray
diaphragm.

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P-A projection
24. Auscultation of Heart
Valves
Right 2 ICS Left 2 ICS
PSL PSL
Cardiac Shadow
Right border is formed by:
1. SVC,
2. Right atrium

Left border is formed by:

1. Aortic arch
Left 4 ICS Left 5 ICS
2. Pulmonary trunk PSL MCL
3. Left auricle
4. Left ventricle

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 Auscultation sites for 25. Blood supply of the Heart:
mitral and aortic murmurs Right coronary artery (RCA)
It supplies major parts of the right
atrium and the right ventricle.
It anastomoses with the marginal
branch of the left coronary artery
posteriorly
Branches:
1. Anterior cardiac branches –
supplies the right atrium
2. Nodal branch – supplies the (1) SA
node, (2) AV node
3. Marginal artery – supplies the right
ventricle
4. Posterior interventricular artery –
supplies (1) diafragmatic (inferior)
surface of both ventricles and (2)
posterior 1/3 of the IV septum
A heart murmur is heard downstream from the valve:
stenosis is orthograde direction from valve
insufficiency is retrograde direction from valve
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Left coronary artery Blood supply of the conducting

(LCA) system
Branches: SA node – RCA
1. Anterior interventricular artery
descends in the anterior
interventricular sulcus and provides AV node – RCA
branches to the (1) anterior heard
wall, (2) anterior 2/3 of IV septum,
(3) bundle of His, and (4) apex of the AV bundle (and
heart. moderator band)- LCA
2. Circumflex artery – winds around the
left margin of the heart in the
atrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left atrium
and left ventricle

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 26. Aspiration of Foreign Right lung:
Bodies & Bronchopulmonary 10 bronchopulmonary segments
segments
Aspiration of Foreign Bodies:
Superior lobe:
Inhalation of FB’s (e.g. pins,
parts of teeth, screws, nuts,
1. Apical
bolts, toys) into the lower 2. Anterior
1
respiratory tract is common, 3. Posterior
especially in children Middle lobe:
3
More likely to enter the right 4. Lateral
2
primary bronchus and pass into 5. Medial
the middle or lower lobe Inferior lobe: 6 4
bronchi 6. Superior
8 5
If the vertical position of the 7. Anterior basal
body, the foreign body usually 8. Posterior basal 10
falls into the posterior basal 9. Lateral basal 9
segment of the right inferior 7
10. Medial basal
lobe.

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Left lung: 27. Lung diseases:

9 bronchopulmonary segments Pneumonia
Pneumonia is an inflammation
Superior lobe: of the lung, caused by an
1. Apicoposterior infection or chemical injury to the
2. Anterior lungs.
1
3. Superior lingular Three common causes are
4. Inferior lingular bacteria, viruses and fungi.
2
Inferior lobe: Symptoms: cough, chest pain,
5. Superior fever, and difficulty in breathing.
6. Anterior basal 3 5
Chest x-rays: areas of opacity
7. Posterior basal
7 (seen as white) of the lung
8. Lateral basal 4
parenchyma and enlargement of
9. Medial basal 9 8
bronchomediastinal lymph
nodes (mediastinal widening).
6

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 Bronchogenic Carcinoma Qs about Auscultation
and penetrated wounds
To listen to breath sounds of the
Arises in the mucosa of the
large bronchi superior lobes of the right and left
Produces as persistent, lungs, the stethoscope is placed on
productive cough or the superior area of the anterior
hemoptysis chest wall (above the 4th rib for the
Early metastasis to thoracic right lung & above 6th for the left
(bronchomediatinal) lymph one).
nodes For breath sounds from the
Hematogenous spread to the middle lobe of the right lung, the
brain, bones, lungs,
suprarenal glands stethoscope is placed on the
4
A tumor at the apex of the anterior chest wall between the 4th
lung (Pancoast tumor) may and 6th ribs
result in thoracic outlet 6 For the inferior lobes of both
syndrome lungs, breath sounds are primarily
heard on the posterior chest wall.

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28. Open pneumothorax Nerve supply of the pleura

It is entry of air into a pleural cavity Parietal Pleura – sensitive to general
causing lung collapse. sensibilities (pain, temperature,
Open pneumothorax – due to stab touch, and pressure) - somatic
wounds of the thoracic wall which sensory innervation:
pierce the parietal pleura so that costal pleura – intercostal nerves
the pleural cavity is open to the mediastinal pleura – phrenic
outside air via the lung or through nerve
the chest wall. diaphragmatic pleura – phrenic
Air moves freely through the nerve over the domes and lower 6
wound during inspiration and intercostal nerves around the
expiration. During inspiration, air periphery
enters the chest wall and the
mediastinum will shift toward other
side and compress the opposite Visceral Pleura – sensitive to stretch
lung. During expiration, air exits but insensitive to general
the wound and the mediastinum sensibilities; autonomic nerve
moves back toward the affected supply from the pulmonary plexus
side.

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 Referred abdominal pain
29. Anterior abdominal wall
The liver and gallbladder
are in the right upper
quadrant; Pain arising out of the
foregut derived structures
The stomach and spleen is referred to the
are in the left upper epigastric region.
quadrant;
Pain arising out of the
The cecum and appendix midgut derived structures
are in the right lower is referred to the
quadrant; umbilical region.

The end of the descending

colon and sigmoid colon Pain arising out of the
are in the left lower hindgut derived
quadrant. structures is referred to
the hypogastric region.

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Transversalis fascia is the FIRST

STRUCTURE which is crossed by
any abdominal hernia Indirect Inguinal Hernia
Indirect inguinal hernia is the most
common form of hernia and is believed
to be congenital in origin (boys 0-3
years).
It passes through the deep inguinal ring
lateral to the inferior epigastric
vessels, inguinal canal, superficial
inguinal ring and descend into the
scrotum.
An indirect inguinal hernia is about 20
times more common in males than in
females, and nearly 1/3 are bilateral.
It is more common on the right
(normally, the right processus vaginalis
becomes obliterated after the left; the
right testis descends later than the left).

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 30. Peritoneal structure:
Direct Inguinal Hernia Lesser omentum
Direct inguinal hernia composes Consist of 2 ligaments:
about 15% of all inguinal hernias.
hepatogastric
During a direct inguinal hernia,
the abdominal contents will hepatoduodenal
protrude through the weak area of
the posterior wall of the inguinal Contents :
canal medial to the inferior Right & Left gastric
epigastric vessels in the inguinal vessels
[Hesselbach's] triangle and after
that through superficial inguinal Connective and fatty
ring. It never descends into the tissue
scrotum. and Portal triad:
It is a disease of old men with Bile duct
weak abdominal muscles. Direct Portal vein
inguinal hernias are rare in women, Proper hepatic artery
and most are bilateral.

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Epiploic (winslow’s) foramen Douglas (rectouterine) pouch

Anteriorly: The free

border of the Rectouterine pouch
hepatoduodenal (pouch of Douglas):
ligament, containing deeper point of
portal triad (DVA). peritoneal space in
vertical position of the
female body between the
Posteriorly: IVC rectum and the uterus. It
is space of the pelvic
Superiorly: Caudate abscess location.
lobe of the liver.
Vesicouterine pouch: it is
Inferiorly: The 1st deepness between the
part of the uterus and the urinary
duodenum. bladder.

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 31. Everything about Foregut, Midgut
Culdocentesis & Hindgut

Culdocentesis is FOREGUT MIDGUT HINDGUT

aspiration of fluid from
the cul-de-sac of Esophagus Duodenum (2nd, 3rd, Transverse colon
Douglas (rectouterine Stomach 4th (distal 1/3)
pouch) by a needle Duodenum (1st and parts) Descending colon
puncture of the
posterior vaginal 2nd parts) Jejunum Sigmoid colon
fornix near the midline Liver Ileum Rectum (anal canal
between the uterosacral Pancreas Cecum (with above pectinate line)
ligaments Biliary apparatus Appendix)
Because the Gallbladder Ascending colon
rectouterine pouch is
the lowest portion of Transverse colon
the female peritoneal (proximal 2/3)
cavity, it can collect
inflammatory fluid
(pelvic abscess).

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FOREGUT MIDGUT HINDGUT

Artery: CA Artery: SMA Artery: IMA

32. Posterior gastric ulcer
Parasympathetic Parasympathetic Parasympathetic
innervation: vagus innervation: vagus innervation: pelvic
nerves, CNX nerves, CNX splanchnic nerves, S2-S4
1. Posterior gastric ulcer may
Sympathetic Sympathetic Sympathetic erode through the posterior
innervation: innervation: innervation: wall of the stomach into the
•Preganglionics: greater •Preganglionics: lesser •Preganglionics: lumbar pancreas resulting in
splanchnic nerves, T5-T9 splanchnic nerves, T10- splanchnic nerves, L1-L2 referred pain to the back.
•Postganglionics: T11 •Postganglionics: inferior
celiac ganglion •Postganglionics: mesenteric ganglion
2. Erosion of splenic artery is
superior mesenteric
very common in posterior
ganglion
gastric ulcers because of
Sensory Innervation: Sensory Innervation: Sensory Innervation: the proximity of the artery to
DRG T5-T9 DRG T10-T11 DRG L1-L2 this wall.
Referred Pain: Referred Pain: Referred Pain:
Epigastrium Umbilical Hypogastrium

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 33. Congenital diaphragmatic
hernia 34. Sliding hiatal hernia

A sliding hiatal hernia which

Hernia of stomach or occurs in individuals past
intestines through a middle age is caused by
posterolateral defect
in diaphragm the hernia of cardia of the
(foramen of stomach into the thorax
Bochadalek). through the esophageal
hiatus of the diaphragm.
It is seen in infants
and the mortality rate is
high because of left This can damage the vagal
lung hypoplasia. trunks as they pass through
the hiatus and resulting in
hyposecretion of gastric
juice.

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36. Features of the large

35. Meckel's diverticulum intestine
Meckel's diverticulum is a congenital Features of the large intestine:
anomaly representing a persistent portion of
the vitellointestinal duct.
This condition is often asymptomatic but 1. Appendices epiploic
occasionally becomes inflamed if it contains 2. Sacculations
ectopic gastric, pancreatic, or endometrial (haustrations)
tissue, which may produce ulceration. 3. Taeniae coli
It occurs in 2% of patients, is located about 2 The taeniae coli meet
feet (61 cm) before the ileocecal junction, together at the base of
and is about 2 inches (5 cm) long. the appendix where they
form a complete
The diverticulum is clinically important longitudinal muscle coat
because diverticulitis, liberation, bleeding, for the appendix.
perforation, and obstruction are
complications requiring surgical intervention
and frequently mimicking the symptoms of
acute appendicitis.

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 37. Pain of Appendicitis Mc Burney's point
In appendicitis, first pain is This point indicates
the surface marking
referred around the umbilicus. of the base of the
Visceral pain in the appendix is appendix.
produced by distention of its
lumen or spasm of its muscle.
It is a point at the
The afferent pain fibers enter junction between the
the spinal cord at the level of lateral 1/3 and
T10 segment, and a vague medial 2/3 of a line
referred pain is felt in the region joining the right
of the umbilicus. anterior superior iliac
spine with the
umbilicus.
Later if parietal peritoneum
gets involved, and then the pain
is shifted laterally to the Mc
Burney’s point. Here the pain
is precise, severe, and localized
(second pain)

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38. Volvulus 39. Hirschsprung's Disease

It is a rare congenital abnormality that
results in obstruction because the
intestines do not work normally.
Because of its extreme It is commonly found in Down Syndrome
mobility, the small intestine children.
and sigmoid colon The inadequate motility is a result of an
sometimes rotates around aganglionic section (congenital absents
its mesentery. of postganglionic parasympathetic
neurons inside of the intestinal wall) of the
This may correct itself intestines resulting in megacolon.
spontaneously, or the rotation In a newborn, the main signs and
may continue until the blood symptoms are failure to pass a
supply of the gut is cut off meconium stool within 1-2 days after
completely. birth, reluctance to eat, bile-stained
(green) vomiting, and abdominal
distension.
Treatment is removal of the aganglionic
portion of the colon.

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 40. Branches of Abdominal aorta
CELIAC ARTERY (TRUNK)

Celiac trunk (CA) originates Origin: T12-L1, just below

from the aorta at the lower the aortic opening of the
border of T12 vertebra
Superior mesenteric artery 1 diaphragm.
originates at the lower The CA passes above the
border of L1 vertebra superior border of the
Renal arteries originate at pancreas and then divides
approximately L2 vertebra 3 into three retroperitoneal
Inferior mesenteric artery branches:
originates at L3 vertebra 2
Two terminal branches are Left gastric artery (1)
common iliac arteries at Common hepatic artery (2)
the level of L4 vertebra
Splenic artery (3)

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Left gastric artery Common hepatic artery

2 The left gastric artery (1)
The common hepatic artery
courses upward to the left to
(1) passes to the right to
reach the lesser curvature of
reach the superior surface of
the stomach and may be 2
3 the first part of the duodenum,
subject to erosion by a
1 where it divides into its two
penetrating ulcer of the
terminal branches:
lesser curvature of the
1 stomach. Proper hepatic artery (2)
Branches: Gastroduodenal artery (3)
Esophageal branches (2) - to
the abdominal part of the 3
esophagus
Gastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.

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 Proper hepatic artery Gastroduodenal artery
Proper hepatic artery (1) gives Gastroduodenal artery (1)
off right gastric artery (2) and descends posterior to the first
5 then ascends within the part of the duodenum (may be
4
hepatoduodenal ligament of the subject to erosion by a
lesser omentum to reach the penetrating ulcer in this place)
3
porta hepatis, where it divides and divides into two branches:
into the right (4) and left (3) 1 Right gastroepiploic artery (2)
hepatic arteries.
(supplies the right side of the
The right and left arteries enter the greater curvature of the
two lobes of the liver, with the stomach where it anastomoses
1 2
2 right hepatic artery first giving rise the left gastroepiploic)
to the cystic artery (5) to the
Superior pancreaticoduodenal
gallbladder.
arteries (3) (supplies the head
Right gastric artery (2) supplies of the pancreas, where it
the right side of the lesser 3 anastomoses the inferior
curvature of the stomach where it pancreaticoduodenal
anastomoses the left gastric branches of the SMA).
artery.

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Ligature of the hepatic artery: Splenic artery

The hepatic artery may be Splenic artery (1) runs a
ligated proximal to the origin tortuous horizontal course to
of its gastroduodenal branch,
a collateral circulation to the the left along the upper border
liver is established through of the pancreas, behind the
the left and right gastric peritoneum of the posterior
arteries, left and right wall of the lesser sac, forming a
gastroepiploic and part of the stomach bed.
gastroduodenal arteries. 1 The splenic artery may be
subject to erosion by a
The right hepatic artery
may be mistakenly ligated penetrating ulcer of the
during holecystectomy in posterior wall of the stomach
Calot triangle together with into the lesser sac.
the cystic artery, right lobe
hepatic necrosis commonly N.B. The splenic vein runs a
occurs. more straight course below the
artery and behind of the
pancreas.

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 Splenic artery 7
1

Splenic (1) a. is retroperitoneal

5 until it reaches the tail of the 6 SMA Branches:
pancreas, where it enters the (1) Inferior
1 2 splenorenal ligament to enter pancreaticoduodenal
the hilum of the spleen. 2 arteries
Branches: (2)Jejunal and (3)
3 4 Ileal branches
Branches to the spleen (2) 4
(4) Ileocolic artery
Branches to the neck, body, and
Ascending branch
tail of pancreas (3)
Anterior cecal artery
Left gastroepiploic (4) artery that
Posterior cecal artery
supplies the left side of the
greater curvature of the stomach (5) Appendicular
artery
where it anastomoses the right
gastroepiploic (6) Right colic artery
3 (7) Middle colic artery
Short gastric (5) branches that
supply to the fundus of the
5
stomach
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41. Mesenteric ischemia

Ischemia occurs when your blood cannot
1 IMA Branches: flow through arteries as well as it should,
and intestines do not receive the
(1) Left colic artery necessary oxygen to perform normally.
(2) Sigmoid arteries Mesenteric ischemia usually involves the
small intestine.
(3) Superior rectal artery Mesenteric ischemia usually occurs in
people older than age 60. You may be
more likely to experience mesenteric
ischemia if you are a smoker or have a
3 high cholesterol level.
Atherosclerosis, which slows the
amount blood flowing through arteries, is
a frequent cause of chronic mesenteric
ischemia.

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 42. Abdominal aortic aneurysm 43. Biliary system
It is a localized dilatation of the Bile is secreted by the liver cells,
aorta. It is typically happened stored, and concentrated in the
just above of the bifurcation at gallbladder and later it is
level of L4 and crossed by 3rd delivered to the duodenum.
part of duodenum. The gallbladder lies in a fossa
Pulsations of a large aneurysm on the visceral surface of the
can be detected to the left of liver to the right of the quadrate
the midline at the umbilical lobe.
region. It stores and concentrates bile,
Acute rupture of an abdominal which enters and leaves
aortic aneurysm is associated through the cystic duct.
with severe pain in the The cystic duct joins the
abdomen or back (mortality rate common hepatic (from left
is nearly 90%). and right hepatic)due to form
Surgeons can repair an the common bile duct.
aneurysm by opening it and
inserting a prosthetic graft.

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44. Cholelithiasis (gallstones)

Biliary system
The distal end of the hepatopancreatic
ampulla is the narrowest part of the
biliary passages and is the common
site for impaction of gallstones. As
result of common hepatic (1), bile
The common bile duct duct (2), or hepatopancreatic ampulla
4 1
descends in the (3) obstruction patient will have yellow
hepatoduodenal ligament, eyes and jaundice
then passes posterior to the
first part of the duodenum
It penetrates the head of the 2 Gallstones may also lodge in the cystic
pancreas where it joins the duct. A stone lodged in the cystic duct
main pancreatic duct and (4) causes biliary colic (intense,
3
forms the hepatopancreatic spasmodic pain in the gallbladder ) but
ampulla (sphincter of Oddi), doesn't produce jaundice.
which drains into the second
part of the duodenum at the
major duodenal papilla.
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 45. Nerve supply of the liver
Gallstones and gallbladder
The fundus (1) of the gallbladder is
in contact with the transverse colon Sensory innervation of the liver is done by the
and thus gallstones erode through the right phrenic nerve (C3-C5). Pain may radiate to
posterior wall of the gallbladder and the right shoulder.
enter the transverse colon. They are
passed naturally to the rectum 2 The liver receives parasympathetic innervation
through the descending colon and from the vagi nerves (CNX), reaching it through
sigmoid colon. the celiac plexuses around the supplying arteries.
The preganglionic fibers synapse on the cells of
the uxtaramural plexuses in hilum of the liver and
Gallstones lodged in the body (2) of shot postganglionic fibers supply organs.
the gallbladder may ulcerate through 1
the posterior wall of the body of the
gallbladder into the duodenum Sympathetic fibers of preganglionic neurons
(because the gallbladder body is in T5-T9 segments (IML) come through the
contact with the duodenum) and may sympathetic trunk and form greater splanchnic
be held up at the ileocecal junction, nerves. They contribute to the celiac plexus,
where postganglionic neurons are located.
producing an intestinal obstruction. Branches of celiac plexus reach the liver wrapping
around the branches of the celiac artery.

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Portocaval anastomosis
46. Portal Hypertension
If there is an obstruction to flow
Portal hypertension is a through the portal system (portal
common clinical condition, hypertension), blood can flow in
and for this reason the list of 1
portal-systemic anastomoses a retrograde direction (because
should be remembered. of the absence of valves in the
Enlargement of the portal- portal system) and pass through
systemic connections is anastomoses to reach the caval
frequently accompanied by system.
2
congestive enlargement of the Sites for these anastomoses
spleen.
include the (1) esophageal
veins, (2) thoracoepigastric
Portacaval shunt for the veins, and (3) rectal veins.
treatment of portal
hypertension: the splenic Enlargement of these veins may
vein may be anastomoses to result in (1) esophageal varices,
the left renal vein after 3 (2) a caput medusae and (3)
removing the spleen. internal hemorrhoids.

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 Esophageal anastomosis Umbilical anastomosis
Anastomosis between the
Anastomosis between the paraumbilical vein (portal
tributaries of the left gastric vein) and the superior and
vein (portal vein) and the inferior epigastric veins
tributaries of the azygous (SVC and IVC) of the anterior
vein (SVC) in the wall of the abdominal wall around the
lower end of the esophagus. umbilicus.
In portal hypertension, this
In portal hypertension these anastomosis gets enlarged
anastomoses veins enlarge in
the wall of the esophagus and and dilated veins form “caput
later burst into the lumen of Medussae” around the
the esophagus (esophageal umbilicus.
varices) resulting in
hematemesis (vomiting red
blood).

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47. Pancreas:
Rectal anastomosis Head and uncinate process
Anastomosis between the
superior rectal vein (inferior The head of the pancreas
mesenteric vein and then into rests within the C-shaped
portal vein) and inferior area formed by the
rectal vein which drains into duodenum and is
the internal iliac vein (from traversed by the common
IVC system). bile duct.
In portal hypertension this
anastomoses gets dilated
resulting in internal It includes the uncinate
hemorrhoids and bleeding process which is crossed
per anus. by the superior
mesenteric vessels.

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 Cancer of the head
of the pancreas Neck of the pancreas
• Cancer of the head of the
pancreas compresses the
bile duct and it results in
OBSTRUCTIVE TYPE OF
JAUNDICE. Posterior to the
• This type of jaundice is NOT neck of the
3
usually associated with pain 1 pancreas is the site
or fever. of formation of the
PORTAL VEIN.
• Hepatitis also causes jaundice
but is associated with the 2
(1)Splenic vein
fever. joins with (2)
superior
mesenteric vein to
form (3) portal vein.

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Body of the pancreas Tail of the pancreas

The tail of the pancreas
The body passes to the enters the splenorenal
left and passes anterior to ligament to reach the
the (1) aorta and the (2) hilum of the spleen.
1 left kidney. It is the only part of the
3 pancreas that is
The (3) splenic artery intraperitoneal.
undulates along the Tail of the pancreas may
superior border of the be mistakenly removed
2 body of the pancreas with during spleenectomy and
the splenic vein coursing resulting in sugar
posterior to the body. diabetes because it
contains a lot endocrine
cells.

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 Ducts of the pancreas Annular Pancreas
Annular pancreas is caused by
malformation during the development of
the pancreas, before birth.
Occurs when the ventral and dorsal
Main pancreatic duct pancreatic buds form a ring around the
runs along the long axis of duodenum, thereby causing an
the pancreas from the tail obstruction of the duodenum and
to the head. polyhydramnios
Accessory pancreatic Symptoms:
duct which is runs 1. Feeding intolerance in newborns
horizontally opens onto
the top of the minor 2. Fullness after eating
duodenal papilla which is 3. Nausea and vomiting
about 2 cm proximal to
the major duodenal
papilla on the Half of cases are not diagnosed until
posteromedial wall of the symptoms occur in adulthood.
duodenum.

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48. Spleen:
spleen comes from -dorsal mesogastrium
and liver comes from vental mesogastrium
Relations of the Spleen and
Two borders Left Kidney
The spleen is a peritoneal The spleen follows
organ in the upper left the contour of 10th rib
quadrant that is deep to the and extends from the
left 9th, 10th, and 11th ribs. superior pole of the
left kidney to just
The spleen follows the contour
posterior to the
of rib 10 (axis of the spleen).
midaxillary line.

Because the spleen lies

The border between
above the costal margin, a
spleen and upper
normal-sized spleen is not
pole of the left kidney
palpable.
is 11th rib.
The spleen may be lacerated
with a fracture of the 9th and
10th ribs.

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 49. Kidney:
Peritoneal connections Dimensions and position
Gastrosplenic ligament (1) During life, the kidneys
connects the spleen with the are reddish brown and
upper end of the greater measure approximately
curvature of the stomach. It 11-12 cm in length, 5-6
contains the short gastric cm in width, and 2.5-3
vessels, left gastroepiploic cm in thickness.
(gastroomental) vessels and
1 accompanying lymph vessels They are extending from
the level of T12 to the
level of L3, the right
Splenorenal (lienorenal) kidney lying about 2-3 cm
ligament (2) connects the lower than the left one.
spleen with the left kidney. It The lateral border of the
contains the tail of the kidney is convex. Its
pancreas, splenic vessels, medial border is convex at
accompanying lymph vessels both ends but concave in
2 and nerves. the middle where there is
the hilum of the kidney.

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Anterior relations
Position of the kidneys of the right kidney
The upper end of the left kidney
(XI rib) is a little higher than the
right one (XII rib). 1. Right suprarenal gland
The lower ends of the kidneys 2. 2nd part of the
occur around the level of the IV duodenum
disc L3/L4. 3. Right lobe of the liver
N.B. The border between left
kidney and spleen is XI rib 4. Right colic flexure
5. Small intestine
The hila of the kidneys and the
beginnings of the ureters are at
approximately the L1 vertebra.

The ureters descend vertically

anterior to the tips of the
transverse processes of the
lower lumbar vertebrae and enter
the pelvis and lies on the psoas
major muscle.

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 Anterior relations
of the left kidney Renal (Gerota) fascia
Enclosing the perinephric fat is
a membranous condensation
1. Left suprarenal gland of the extraperitoneal fascia -
2. Stomach the renal fascia (3).
3. Spleen The suprarenal glands (4) are
4. Body of pancreas and 4 also enclosed in this fascial
splenic vessels compartment, usually
5. Descending colon separated from the kidneys by
6. Small intestine a thin septum.
3
N.B. The renal fascia must
be incised in any surgical
approach to this organ.

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50. Nephrolithiasis Staghorn calculi

Renal calculi are solid concretions Renal stone that develops in the
(crystal aggregations) formed in the pelvicaliceal system, and in
kidneys from dissolved urinary minerals. advanced cases has a branching
There are several types of kidney configuration which resembles the
stones. The majority are calcium antlers of a stag.
oxalate stones, followed by calcium Staghorn calculi are composed of
phosphate stones. magnesium ammonium
Kidney stones typically leave the body phosphate, which forms in urine
by passage in the urine stream, and that has an abnormally high pH
many stones are formed and passed (above 7.2).
without causing symptoms. This high pH usually develops
If stones grow to sufficient size before because of recurrent urinary tract
passage (at least 2-3 mm), they can infection with microorganisms
cause obstruction of the ureter (renal such as Proteus mirabilis.
colic).

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 51. Renal veins
52. Varicocele
The right renal (1) vein is It is engorgement of the
3 much shorter than the left. pampiniform plexus that
Both veins lie anterior to the produces a wormlike
2 corresponding artery in scrotal mass and
hilum of kidneys. enlargement of the
The long left renal vein (2) spermatic cord.
1 Formation is usually on
4 is joined by the left
suprarenal (3) and left the left side.
gonadal (4) (testicular or Varicocele on either side
ovarian) veins before it may indicate kidney
reached IVC. disease or may signal a
retro peritoneal
The left renal vein crosses malignancy obstructing
anterior to the aorta, just the testicular vein.
inferior to the origin of the
SMA.

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Pampiniform plexus 53. Hemorrhoids:

Venous drainage from rectum
Each testicular or ovarian vein is Above pectinate line: superior
formed by coalescence of a rectal vein [1] into portal
pampiniform plexus: the 2 system [2].
testicular at the deep inguinal 4
ring, the ovarian at the margin of
the superior aperture of the Below pectinate line: inferior
pelvis.
rectal vein [3] into inferior
The veins run accompany the
corresponding arteries. The left vena cava [4].
pampiniform plexus enters the
left renal vein; the right one
enters directly the IVC inferior 1
to the renal vein.
That is why varicocely
(engorgement of the pampiniform
plexus that produces a scrotal
mass) is more often located on
the left. 3

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 External hemorrhoids Internal hemorrhoids
Hemorrhoids are masses that 2. Internal hemorrhoids
typically protrude from anus are dilated tributaries of the
during defecation. superior rectal veins
Hemorrhoids are commonly (SRV) above the pectinate
associated with constipation, line and are not painful
extended sitting and straining at because the mucosa is
the toilet, pregnancy, and supplied by visceral afferent
disorders that hinder venous return. fibers.
1. External hemorrhoids are
1 dilated tributaries of the inferior Internal hemorrhoids
2
rectal veins (IRV) below the frequently develop during
pectinate line and are painful pregnancy because of
because the mucosa is supplied by 2 pressure on the superior
somatic afferent fibers of the 2 rectal veins.
1 inferior rectal nerves.

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54. Perineal pouches:

Contents of the deep pouch
55. Superficial perineal pouch
The deep perineal pouch is 1. Ischiocavernosus muscle
formed by the fasciae and 2. Bulbospongiosus muscle
muscles of the urogenital 3. Superficial transverse perineal
diaphragm. muscle
1
It contains:
1. Sphincter urethrae
muscle 2
2. Deep transverse
perineal muscle 3
3. Bulbourethral
(Cowper) glands (in
the male only) - ducts
perforate perineal
membrane and enters
bulbar urethra.

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 56. Cystocele
Urine leaks (hernia of bladder)
After a crushing blow or a Loss of bladder support in
penetrating injury, the spongy females by damage to the
urethra commonly ruptures pelvic floor during childbirth
within the bulb of the penis, and (e.g., laceration of perineal
urine leaks into the superficial muscles or a lesion of the
perineal pouch. nerves supply) can result in
protrusion of the bladder onto
The superficial perineal fascia the anterior vaginal wall.
keeps urine from passing into the When intrabdominal pressure
thigh or the anal triangle, but after increases (as when “bearing
distending the scrotum and penis, down” during defecation), the
urine can pass over the pubis into anterior wall of the vagina may
the anterior abdominal wall deep protrude through the vaginal
to the deep layer of superficial orifice into the vestibule
abdominal fascia.

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1 58. Nerve supply of pelvic

57. Ureter
2 viscera
Ureter [1] crosses pelvic brim Parasympathetic innervation:
near bifurcation of common iliac Preganglionic neurons are located in sacral parasympathetic n.
artery (S2-S4) in the spinal cord.
In male, crossed superiorly by Their processes run into pelvic splanchnic nerves and relay with
ductus deferens [2] near postganglionic neurons located inside of pelvic organs in the
bladder intramural plexus.
In female, crossed anteriorly Sympathetic innervation:
and superiorly by uterine artery Sympathetic fibers of preganglionic neurons T12-L2 segments (IML)
[3] in base of broad ligament come through the sympathetic trunk and form sacral splanchnic
3 nerves.
They contribute to the inferior hypogastric plexus, where
N.B. The ureter can be postganglionic neurons are located. Branches of inferior hypogastric
damaged during a 1 plexus reach organs wrapping around the branches of the internal iliac
hysterectomy or surgical repair artery.
of a prolapsed uterus because it Sensory innervation:
lies posterior and inferior to the The sensory fibers from S2-S4 dorsal root ganglions comes together
uterine artery. with parasympathetic and carry pain sensations from the organs.

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 59. Paracentesis of urinary
Micturition reflex
bladder
Facilitating emptying:
Parasympathetic fibers (pelvic Suprapubic aspiration:
1 splanchnic nn.) stimulate
detrusor muscle [1] contraction Urine can be removed from
and involuntary relax internal the bladder without penetrating
sphincter [2]. the peritoneum by inserting a
2 needle JUST ABOVE the
Somatic motor fibers (pudendal pubic symphysis.
nerve) cause voluntary
relaxation of external [3] urethral The needle passes
sphincter. successively through skin,
superficial and deep layers of
3 superficial fascia, linea alba,
Inhibiting emptying: transversalis fascia,
Sympathetic fibers (sacral extraperitoneal connective
splanchnic nn.) inhibit detrusor tissue, and wall of the bladder.
muscle [1] and stimulate
internal sphincter [2].

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60. Prostate tumors

Benign hypertrophy of the
Prostate cancer
prostate (BHP)
It usually begins in the
posterior lobe of the gland, and BHP is common in men after
early stages are often middle age.
asymptomatic. Prostate adenoma (benign
Later malignant enlargement of hypertrophy) usually involves
the prostate can narrow or median lobe.
occlude the prostatic urethra. BHP is a common cause of
urethral obstruction, leading
N.B. Prostatic malignancies to nocturia (need to void
tend to metastasize to during the night), dysuria
vertebrae and the brain (difficulty and/or pain during
because the prostatic venous urination), and urgency
plexus has numerous (sudden desire to void).
connections with the vertebral The prostate is examined for
venous plexus via sacral enlargement and tumors by
veins. DIGITAL RECTAL
examination.

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 61. Male urethra
Prostatectomy Prostatic part
A prostatectomy may It is the widest and the most
be performed through a dilatable part.
suprapubic [1] or It is spindle shaped (middle part is
perineal [2] incision or dilated)
transurethrally.
1 Its posterior wall presents the
following features:
2 Because damage to Urethral crest - vertical ridge in the
nerves in the capsule midline
of the prostate and
around the urethra Seminal colliculus- a spherical
(cavernous nerves) swelling in the middle of the
can cause impotence urethral crest
and/or urinary Openings of the 2 ejaculatory
3 incontinence. ducts are seen on each side on
the seminal colliculus
transurethral resection of the Ducts of the prostate gland open
prostate = TURP into the male urethra

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Spongy part
Membranous part
Passes through the Average 15 cm in length.
urogenital Passes through the bulb
diaphragm to enter and corpus spongiosum
the bulb of the penis of the penis to open at the
It is the shortest, external urethral orifice on
narrowest and the the tip of the glans penis.
least dilatable part There are two dilatations
It is surrounded by the – bulbar fossa (in the
external sphincter beginning) and navicular
urethra fossa (in the glans penis)
Bulbourethral Ducts of the bulbourethral
glands lie glands open into the floor
posterolateral to this of the spongy part in its
part inside of beginning
urogenital diaphragm
(deep perineal
pouch)

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 62. Hydrocele &
Sphincters of the urethra hematocele
1. Internal urethral The tunica vaginalis testis
sphincter is made of or other remnants of the
smooth muscles in the processus vaginalis may
neck of the bladder form a hydrocele or
and has sympathetic hematocele.
innervation
1
With transillumination, a
2. External urethral hydrocele produces a
2 sphincter has skeletal reddish glow, whereas
muscle fibers and light will not penetrate
surrounds the other scrotal masses such
membranous part of as a hematocele, solid
urethra, supplied by tumor, or herniated bowel.
the perineal branch of
the pudendal nerve

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64. Lymphatic drainage of the

63. Cryptorchism male viscera
Testis & epididymis – lumbar
lymph nodes
Undescended testes
Scrotum – superficial inguinal
(cryptorchism) occurs when the
nodes
testes fail to descend into the
scrotum. This normally occurs Penis:
within 3 months after birth. skin - superficial inguinal nodes
The undescended testes may be glans – deep inguinal nodes
found in the abdominal cavity or body and roots – internal iliac
in the inguinal canal. nodes
If neglected, malignant Prostate gland & bladder - internal
transformation may occur in the
undescended testis. iliac nodes
N.B. In case of cryptorchism, Anal canal:
spermatogenesis is arrested above pectinate line - internal iliac
and the spermatogenic tissue is
damaged leading to permanent below pectinate line - superficial
sterility in bilateral cases. inguinal nodes

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 65. Lymphatic drainage from
the female viscera
Ovary and uterine tubes – to lumbar
66. Arterial supply of the uterus
lymph nodes
Uterus: The uterus is almost exclusively
lateral angle and teres ligament – supplied by the uterine
superficial inguinal lymph nodes arteries [1] (from internal
fundus and upper part of the body iliac artery):
- lumbar lymph nodes Crosses pelvic floor in
lower part of the body - external 6 transverse cervical
iliac lymph nodes ligament on the base of
cervix - external & internal iliac broad ligament [2]
Near uterus, passes superior
Vagina: 3 and anterior to ureter [3]
Superior to hymen - to external & Ascends along lateral wall
internal iliac 4 [4] of uterus within broad
1 ligament
Inferior to hymen - to superficial
inguinal nodes Vaginal branch anastomoses
All external genitalia (with exception - with vaginal artery [5]
5 Ovarian branch anastomoses
glans clitoris) - superficial inguinal 2
lymph nodes with ovarian artery [6]
Glans clitoris – deep inguinal

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67. Parts of the uterine tube

Hysterosalpingography
Uterine part The instillation of
Pierces uterine wall to viscous iodine
open into uterine cavity
through the
Isthmus
Narrowest part of tube external os of the
just lateral to uterus uterine cervix
Ampulla allows the lumen of
Medial continuation of the cervical canal,
infundibulum comprising the uterine cavity,
about half of uterine tube
Usual site of fertilization and the different
Infundibulum parts of the
Funnel-shaped expansion uterine tubes to
of lateral end, fringed with be visualized on X-
fimbriae ray.
Overlies ovary and
receives oocyte at
ovulation

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 68. Foramina of the base
of the skull Exit of cranial nerves

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69. Fracture of the 70. Development of skull

anterior cranial fossa Sutures of neurocranium
Fracture of the anterior cranial Coronal suture: lies
fossa (cribriform plate of the between the frontal bone
Ethmoid bone) is suggested by
and the two parietal
anosmia, periorbital bruising
(raccoon eyes), and CSF leakage
bones.
from the nose (rhinorrhea). Sagittal suture: lies
between the two parietal
bones.
Squamous suture: lies
between the parietal bone
and the squamous part of
the temporal bone.
Lambdoid suture: lies
between the two parietal
bones and the occipital
bone.

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 Cranial Malformations Fontanelles
[A] Scaphocephaly: premature Anterior fontanelle
closure of the sagittal suture, in present at birth; closes
which the anterior fontanelle is small at age 9 to 18 months
or absent, results in a long, narrow, diminished size or
wedge-shaped cranium. absence at birth may
[C] Oxycephaly: premature closure indicate
of the coronal suture results in a craniosynostosis or
high, tower-like cranium. microcephaly.
Posterior fontanelle
When premature closure of the
coronal or the lambdoid suture occurs present at birth; usually
closes by age 2 months
on one side only, the cranium is
twisted and asymmetrical, a condition Persistence suggests
underlying
known as plagiocephaly [B].
hydrocephalus or
congenital
hypothyroidism.

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75. Infection of the Cavernous

74. Epidural hematoma sinus
Skull fracture near pterion often
causes epidural hematoma from Lateral to body of
torn middle meningeal artery. sphenoid bone and sella
Unconsciousness and death are turcica, forming lateral
wall of hypophyseal fossa
rapid because the bleeding
Related structures:
dissects a wide space as it strips
Structures that pass
the dura from the inner surface of through sinus:
the skull, which puts pressure on 1. Internal carotid artery and
the brain. internal carotid plexus
An epidural hematoma forms a 2. Abducens nerve (CN VI)
characteristic biconvex pattern on
computed tomography images. Structures on lateral wall of
sinus:
1. Oculomotor nerve (CN III)
2. Trochlear nerve (CN IV)

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 76. Layers of the scalp
Ophthalmic Veins
Superior ophthalmic vein – 1. Skin - contains numerous sweat
communicates anteriorly with glands, sebaceous glands, and
hair follicles
the facial (angular) vein
2. Connective tissue- Dense
Inferior ophthalmic vein – superficial fascia containing nerves
communicates through the and blood vessels
3. Aponeurosis (Epicranial) -Fibrous
inferior orbital fissure with the epicranial aponeurosis connecting
pterygoid plexus of veins frontalis and occipitalis parts of
occipitofrontalis muscle
4. Loose areolar tissue -Allows 3
Both veins pass posteriorly more superficial layers to move
through the superior orbital over skull surface; somewhat like a
sponge because it contains
fissure and drain into the innumerable potential spaces
Cavernous sinus capable of being distended with
fluid resulting from injury or
infection
5. Pericranium -periosteum covering
the outer surface of the skull bones

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77. Innervation skin of the face

78. Facial nerve (CN VII)
FACIAL NERVE (CN VII) -
sole motor supply to the
Skin of face supplied muscles of facial
by branches of the expression and certain
three divisions of the other muscles derived
[1] TRIGEMINAL from the embryonic 2nd
NERVE (CN V) pharyngeal arch
Sensory to the taste buds
1 Except for a small in anterior 2/3 of the
area over the angle tongue through the
of the mandible chorda tympani
which is supplied by Secretomotor
the [2] great (parasympathetic) to the
auricular nerve submandibular,
(C2-C3) – cervical sublingual, palatine
plexus salivary glands, glands of
2 nasal cavity and lacrimal
gland

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 Bell's palsy Lesions of CN VII
It is idiopathic unilateral facial Symptoms associated with lesions of CN VII are determined by the
paralysis (constitutes 75% of location of the lesion in the nerve.
all facial nerve lesions) Bels Manifestations:
Terminal branches of CN VII unable to close lips and eyelids on affected side
may be injured by parotid eye on affected side is not lubricated (dry eye)
cancer or by surgery to unable to whistle, blow a wind instrument, or chew effectively
remove a parotid tumor. facial distortion due to contractions of unopposed contralateral facial
An infant's facial nerve may be muscles
injured during a forceps A lesion within the facial canal will also affect taste from the anterior 2/3
delivery because the mastoid of the tongue carried by the chorda tympani and loss of secretion
process has not yet developed from submandibular and sublingual glands ipsilateral to the lesion
and the stylomastoid foramen is
relatively superficial.

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79. Communication of the

paranasal sinuses 80. Epistaxis
Sphenoethmoidal recess
Epistaxis (nosebleed)
receives the opening of the most often occurs from
sphenoidal air sinus the anterior nasal septum
Superior meatus (Kiesselbach's area),
Receives opening of where branches of the
posterior ethmoidal air cells sphenopalatine,
Middle meatus anterior ethmoidal,
greater palatine, and
Infundibulum, ethmoidal bulla
superior labial (from
and semilunar hiatus
facial) arteries converge.
Receives openings of frontal
and maxillary sinuses and
anterior and middle
ethmoidal air cells
Inferior meatus
Receives opening of
nasolacrimal duct

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 81. Sphenoiditis 82. Cheeks
Relationships of the Form the lateral, movable
sphenoidal sinus are clinically walls of the oral cavity and
important ; because of potential the zygomatic prominences
injury during pituitary of the cheeks over the
surgery and the possible zygomatic bones
spread of infection. Buccinator – principal
Infection can reach the sinuses muscle of the cheek
through their ostia from the Buccal pad of fat –
nasal cavity or through their encapsulated collection of fat
floor from the nasopharynx. superficial to buccinator
Infection may erode the walls to Parotid duct opens in inner
reach the cavernous sinuses, surface of the cheek right
pituitary gland, optic nerves, opposite 2nd upper molar
or optic chiasma tooth

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83. Movements at the TMJs 84. Lesion of CN XII

A lesion of CN XII allows the
contralateral, unparalyzed
genioglossus muscle to pull
the protruded tongue toward
the paralyzed side (deviation of
the tongue).

All 4 muscles of mastication are innervated by V3:

1. Temporalis – elevation & retraction
2. Masseter - elevation
3. Medial pterygoid - elevation
4. Lateral pterygoid - protrusion

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 83. Gag reflex 84. Tonsillitis
Touching the posterior part of
the pharynx results in muscular During palatine tonsillectomy, the
contraction of each side of the peritonsillar space facilitates tonsil
pharynx - gag reflex: removal, except after capsular
Afferent limb: CN IX adhesion to the superior constrictor.
Efferent limb: CN X If the glossopharyngeal nerve is
injured, taste and general
Injury to the glossopharyngeal
sensation from the posterior 1/3 of
nerve (CN IX) will result in a
the tongue are lost.
negative gag reflex
Hemorrhage may occur, usually
from the tonsillar branch of the
facial artery; if the superior
constrictor is penetrated, a high
facial artery or tortuous internal
carotid artery may be injured.

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85. Lymph drainage from

Palatine tonsils face structures
Submandibular lymph nodes
Receives main blood supply receive lymph from:
from tonsillar branch of front of scalp
facial artery nose and adjacent cheek
Drained by lymph vessels upper lip and lower lip (except
mainly to jugulodigastric central part*)
lymph node, which is body's frontal, maxillary, and ethmoid
most frequently enlarged air sinuses
lymph node
upper and lower teeth (except
Nerve supply: tonsillar lower incisors*)
plexus of nerves formed by
anterior 2/3 of tongue (except
branches of CN IX and CN X
tip*)
After submandibular & submental → floor of mouth ,gums and
drain lymph to Deep cervical vestibule
*to Submental lymph nodes
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 87. Muscles of the orbit
86. Blow-out fracture
A blow-out fracture of the
orbital floor typically is not
involve the orbital rim and is
caused by blunt trauma to the
orbital contents (e.g., by a
handball). Muscle Action Innerva-
Blow-out fractures may tion
Superior rectus Elevates and adducts CN III
damage: inferior rectus pupil
muscle, infraorbital nerve Inferior rectus Depresses and adducts CN III
and artery (hemorrhaging). pupil
Medial rectus Adducts pupil CN III
Blow-out fractures are rare in Lateral rectus Abducts pupil CN VI
Superior oblique Depresses and abducts CN IV
young children because the pupil
maxillary sinus is small and Inferior oblique Elevates and abducts CN III
the orbital floor is not a weak pupil
Levator pulpebra superior Elevates upper eyelid CN III
point.

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Clinical Testing Actions 88. Oculomotor Nerve Palsy

of Extraocular Muscles (external squint)
Medial rectus – ask the patient It affects most of the
to look directly medially extraocular muscles
Lateral rectus – ask the patient Manifestations:
to look directly laterally ptosis,
Superior rectus – ask the
fully dilated pupil,
patient to look laterally, then
superiorly and eye is fully
Inferior rectus – ask the patient depressed and
to look laterally, then inferiorly abducted (“down and
Superior oblique – ask the out”) due to unopposed
patient to look medially, then actions of superior
inferiorly oblique and lateral
Inferior oblique – ask the rectus, respectively.
patient to look medially, then
superiorly
testing for eye movements where the single action of each muscle predominates

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 90. Abducens Nerve Palsy
89. Trochlear Nerve Palsy (internal squint)
Lesions of this nerve or its
nucleus cause paralysis of the Injury to abducens nerve →
superior oblique and impair paralysis of lateral rectus →
the ability to turn the affected inability to abduct the affected
eyeball infero-medially (pupil eye
look superio-laterally) Affected eye is fully adducted
The characteristic sign of by the unopposed action of the
trochlear nerve injury is medial rectus that is supplied
diplopia (double vision) when by CN III
looking down (e.g., when going
down stairs)
The person can compensate for
the diplopia by inclining the
head anteriorly and laterally
toward the side of the normal
eye.

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91. Corneal reflex 92. Horner syndrome

Corneal reflex (blinking) in Penetrating injury to the neck,
response to touching the Pancoast tumor, or thyroid carcinoma
cornea may cause Horner syndrome by
interrupting ascending preganglionic
It involves reflex connections sympathetic fibers anywhere between
between sensory afferent their origin in the upper thoracic spinal
fibers in the ophthalmic nerve cord and their synapse in the superior
(CN V1) that make synaptic cervical ganglion.
connections with motor fibers It includes the following signs:
of facial nerve (CN VII) which Constriction of the pupil (miosis)
supply orbicularis oculis Drooping of the superior eyelid
muscle. (ptosis),
Redness and increased temperature
of the skin (vasodilation)
Absence of sweating (anhydrosis)

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 Perforation of the
93. Otitis Media
Tympanic Membrane
Hearing is diminished because of May result from otitis media and is
pressure on the eardrum and one of several causes of middle ear
reduced movement of the ossicles. (conduction) deafness
Taste may be altered because the
Causes: foreign bodies in external
chorda tympani is affected.
acoustic meatus, excessive pressure
Infection spreading posteriorly
(as in diving), trauma
cause mastoiditis.
Infection that spreads to the Because chorda tympani directly
middle cranial fossa can cause relates to the posterior surface of the
meningitis or temporal lobe tympanic membrane it may be
abscess, and infection moving damaged and resulting in loss of taste
through the floor may produce over anterior 2/3 of the tongue and
sigmoid sinus thrombosis. secretion of the sublingual and
submandibular glands
Minor perforation heal spontaneously;
large ones require surgical repair

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94. Thyroid and parathyroid Anatomical relations

glands of the thyroid gland
Hormones:
The thyroid gland is the body's largest
Anterolateral –
endocrine gland. It produces thyroid infrahyoid muscles
hormone, which controls the rate of
1 Posterolateral –
metabolism (increase the temperature of common carotid
the body), and calcitonin, a hormone artery [1]
controlling calcium metabolism (reduce Medial – larynx,
blood calcium Ca2+). The thyroid gland trachea [2], pharynx,
affects all areas of the body except itself and esophagus,
the spleen, testes, and uterus. cricothyroid muscle,
The hormone produced by the parathyroid recurrent laryngeal
glands, parathormone (PTH), controls the 1 nerve [3]
metabolism of phosphorus and calcium in the Posterior –
parathyroid glands
blood (increase Ca2+ level). The parathyroid
1 [4]
glands target the skeleton, kidneys, and
3
intestine.

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 Variation of parathyroid
Median cervical cyst glands position
Usually presents as a painless The superior parathyroid
midline mass on the anterior glands, more constant in
aspect of the neck at the level position than the inferior ones.
of the hyoid bone and moves The inferior parathyroid
during swallowing. glands are usually near the
Remanent of the thyroglossal inferior poles of the thyroid
canal (thyroid gland originally gland, but they may lie in
from epithelium of the tongue). various positions
Must be differentiated from a In 1-5% of people, an inferior
thyroid mass parathyroid gland is deep in
the superior mediastinum
Treatment: surgical excision
within the thymus because of
common embryonic origin.

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95. Larynx:
Muscles of the Larynx
Cavity of the Larynx - 2 Folds: Abductors
Vestibular folds (false vocal Posterior cricoarytenoid –
cords) abducts vocal folds (the only
Vocal folds (true vocal cords) abductors of the vocal folds)

Rima vestibuli – gap

between the vestibular folds
Rima glottidis – gap between
the vocal folds anteriorly and
vocal processes of the
arytenoid cartilages
posteriorly

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 Vagus Nerve (CN X) Vagus Nerve (CN X)
Superior laryngeal nerve: Recurrent laryngeal nerve:
divides into internal and external supplies all muscles of larynx,
laryngeal nerves except cricothyroid; mucous
Internal laryngeal nerve – membrane of larynx below
sensory; supplies floor of vocal fold; mucous membrane
piriform recess and mucous of upper trachea
membrane of larynx above of right recurrent laryngeal
the vocal folds nerve → hooks around the right
subclavian artery
External laryngeal nerve –
left recurrent laryngeal nerve
motor; supplies the
→ hooks around the arch of the
cricothyroid muscle aorta posterior to the
ligamentum arteriosum
ascends in the neck in a
groove between the trachea
and esophagus

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96. Cricothyrotomy 97. Retropharyngeal space

A cricothyrotomy is an emergency procedure It is interval
that relieves an airway obstruction . between pharynx
In case of swallowed foreign bodies or (Buccopharyngeal
abnormal tissue growths. fascia) and
A hollow needle is inserted into the midline of prevertebral fascia
the neck, just below the thyroid cartilage
(needle cricothyrotomy).
More frequently, a small incision is made in
the skin over the cricothyroid membrane,
and another one is made through the
membrane between the cricoid and thyroid
cartilage. A tube that enables breathing is
inserted through the incision.
Cricothyrotomy is generally followed by a
surgical tracheosotomy, if there is need for a
prolonged use of a breathing tube.

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 above thyroid, it is only
internal carotid, and
below is common carotid

98. Carotid sheath 99. Axillary sheath

Derived from all 3 Derived from the
layers. prevertebral fascia
Encloses : Encloses the axillary
1. Common and vessels and brachial
internal carotid plexus as they emerge in
arteries, the interval between the
2. Internal jugular scalenus anterior and
vein medius muscles –
3. Vagus nerve Interscalenus space
some deep cervical Extends into the axilla
lymph nodes, carotid
sinus nerve,
sympathetic nerve
fibers (carotid
periarterial plexuses)
internal larygeal accompany superior larygenal artery

Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

external larygeial nerve accompaniyes superior thyroid artery
Dr. Mavrych, MD, PhD, DSc prof.mavrych@gmail.com

100. Posterior Triangle of the

Good Luck!
Neck
Summary:
Scalene muscles
Veins – external jugular vein,
subclavian vein
Arteries –occipital artery
Nerves – accessory nerve (XI),
trunks of the brachial plexus,
branches of cervical plexus,
phrenic nerve
Lymph nodes – superficial
cervical nodes along external
jugular vein

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