THIEME Atlas of Anatomy Necl< and Internal Organs
Michael Schuenke Erik Schulte Udo Schumacher Cons ult ing Editors
Lawrence M. Ross Edward D. Lamperti lllustr.uions by
Markus Voll KarlWesker
~) Thieme
~ Thieme
Neck and Internal Organs
THIEME Atlas of Anatomy Consulting Editors
Lawrence M. Ross, M.D., Ph.D., Department of Neurobiology and Anatomy University ofTexas Medical School at Houston
Edward D. Lamperti, Ph.D., Immune Disease Institute and Harvard Medical School
Authors
Michael Schuenke, M.D., Ph.D., Institute of Anatomy Christian Albrecht University Kiel
Erik Schulte, M.D., Department of Anatomy and Cell Biology johannes Gutenberg University
Udo Schumacher, M.D., FRCPath, CBiol, FIBiol, DSc, Institute of Anatomy II: Experimental Morphology Center for Experimental Medicine University Medical Center Hamburg·Eppendorf
In collaboration with juergen Rude Illustrations by
MarkusVoll Karl Wesker 962 Illustrations 78 Tables
Thieme Stuttgart · New York
Library of Congress Cotologlng-ln-Pub/ICXltkln Data Is available from the publisher.
This book Is an authorized and revised translation of the German edition published and copyrighted 2005 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Schuenke et al.: Hals und lnnere Organe; Prometheus Lematlas der Anatomle.
Illustrators Markus Voll, FDrstenfeldbruck, Germany: Karl Wesker, Berlin, Germany (homepage: www.karlwesker.de) Translator TerryTelger, Fort Worth, Texas, USA
Important note: Medicine Is an ever-changing science undergoing continual development. Research and clinical exper1ence are continually expanding our knowledge, In particular our knowledge of proper treatment and dn.Jg therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the rtate of knowledge at the time of production of the book. Nevertheless, this does not Involve, Imply, or express any guarantee or responsibility on the part of the publishers In respect to any dosage lnstn.Jctlons and forms of applications stated In the book. Every user Is requested to examine cal'l!fully the manufacturers' leaflets accompanying each drug and to check, If necessary In consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contralndlcatlons stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.
C corrected reprint 2010 Georg Thieme Verlag RiidigerstraBe14 D-70469 Stuttgart Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001 , USA http:ffwww.thieme.com
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Softcover ISBN 978-1 -60406-288-5 Hardcover ISBN 978-1 -60406-294-6
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123456
Foreword
Preface
Our errthusiasm for the THIEME Atlas of Anatomy began when each of us, independently, saw preliminary material from this Atlas. Both of us corrtinue to be captivated by the new approach, the conceptual organization, and by the stunning quality and detail of the images ofthe Atlas. We were delighted by the ongoing opportunity provided by the editors at Thieme to cooperate with them in making this outstanding resource available to our students and colleagues in North America.
As it started planning this Atlas, the publisher sought out the opinions
As consulting editors we were asked to review, for accuracy, the English edition of the THIEME Atlas of Anatomy. Our work involved a conversion of nomenclature to tem1s in common usage and some organizational changes to reflect pedagogical approaches in anatomy programs in North America. This task was eased greatly by the dear organization of the original text. In all of this, we have tried diligerrtly to remain faithful to the irrtentions and insights of the original authors. We extend our special thanks to Brian R. MacPherson, Ph. D. for his timely assistance in the role of a Consulting Editor during the emergency illness of one editor (LMR). We would like to thank the team at Thieme Medical Publishers who worked with us: Kelly Wright, Developmental Editor, and Cathrin E. Schulz M.D., Executive Editor, for checking and correcting our work and for their constarrt availability and encouragemerrt. We would also like to extend our heartfelt thanks to Stefanie Langner, Production Manager, for preparing this volume with care and speed. lawrence M. Ross, Edward D. lamperti
and needs of students and lecturers in both the United States and Europe. The goal was to find out what the "ideal" atlas of anatomy should be-ideal for students wanting to learn from the atlas, master the extensive amounts of infom1ation while on a busy dass schedule, and, in the process, acquire sound, up-to-date knowledge. The result of this work is this Atlas. The THIEME Atlas of Anatomy, unlike most other atlases, is a comprehensive educational tool that combines illustrations with explanatory text and summarizing tables, introducing clinical applications throughout, and presenting anatomical concepts in a step-by-step sequence that allows for the integration of both system· by-system and topographical views. Since the THIEME Atlas of Anatomy is based on a fresh approach to the underlying subject matter itself, it was necessary to create for it an errtirely new set of illustrations-a task that took eight years. Our goal was to provide illustrations that would compellingly demonstrate anatomical relations and concepts, revealing the underlying simplicity of the logic and order of human anatomy without sacrifidng detail or aesthetics. With the THIEME Atlas of Anatomy, it was our intention to create an atlas that would guide students in their initial study of anatomy, stimulate their enthusiasm for this irrtriguing and vitally important subject, and provide a reliable reference for experienced students and professionals alike.
"Ifyou want to attuin the possible, you must atrempt the impossible" (Rabindranath Tagore). Michael Schunke, Erik Schulte, Udo Schumacher, Markus Voll, and Karl Wesker
Acknowledgments
Rrst we wish to thank our families. This atlas is dedicated to them. We also thank Prof. Reinhard Gossrau, M.D., for his critical comments and suggestions. We are grateful to several colleagues who rendered valuable help in proofreading: Mrs. Gabriele Schiinke, Jakob Fay, M.D., Ms. Claudia Diicker, Ms. Simin Rassouli, Ms. Heinke Teichmann, and Ms. Sylvia Zilles. We are also grateful to Dr. julia jiims-Kuhnlre for helping with the figure labels. We extend spedal thanks to Stephanie Gay and Bert Sender, who com· posed the layouts. Their ability to arrange the text and illustrations on facing pages for maximum clarity has contributed greatly to the quality of the Atlas. We particularly acknowledge the efforts of those who handled this proj· ect on the publishing side: jiirgen Liithje, M.D., Ph. D., executive editor at Thieme Medical Publish· ers, has "made the impossible possible." He not only reconciled the wishes of the authors and artists with the demands of reality but also managed to keep a team of five people working together for years on a project whose goal was known to us from the beginning but whose full dimensions we came to appreciate only over time. He is deserving of our most sincere and heartfelt thanks. Sabine Bartl, developmental editor, became a touchstone for the au· thors in the best sense of the word. She was able to determine whether a beginning student, and thus one who is not (yet) a professional, could clearly appreciate the logic of the presentation. The authors are in· debted to her.
We are grateful to Antje Biihl, who was there from the beginning as proj· ect assistant, working "behind the scenes" on numerous tasks such as repeated proofreading and helping to arrange the figure labels. We owe a great dept of thanks to Martin Spencker, Managing Director of Educational Publications at Thieme, especially to his ability to make quick and unconventional decisions when dealing with problems and uncertainties. His openness to all the concerns of the authors and art· ists established conditions for a cooperative partnership. Without exception, our collaboration with the entire staff at Thieme Medical Publishers was consistently pleasant and cordial. Unfortunately we do not have room to list everyone who helped in the publication of this atlas, and we must limit our acknowledgments to a few colleagues who made a particularly notable contribution: Rainer Zepf and Martin Wal~ko for support in all technical matters; Susanne Tochtermann· Wenzel and Manfred Lehnert, representing all those who were involved in the production of the book; Almut Leopold for the Index; Marie-Luise Kiirschner and her team for creating the cover design; to Birgit Carlsen and Anne Dobler, representing all those who handled marketing, sales, and promotion. The Authors
Table of Contents
Neck
Overview and Muscles 1.1 1.2 1.3 1.4
The Neck: General Aspects ............................. Overview and Superficial Neck Muscles ................... Suprahyoid and lnfrahyoid Muscles ....................... Prevertebral and Lateral (Deep) Neck Muscles .............
2
Arteries
2.1 2.2 2.3 2.4
Arteries ............................................ Veins .............................................. Lymphatic System ................................... Overview of the Nervous System in the Neck and the Distribution of Spinal Nerve Branches ............ Cranial Nerves and Autonomic Nervous System in the Neck ...........................................
2.5
3
2 4 6 8
4
Topographical Anatomy
4.1 4.2 4.3 4.4
Surface Aniltomy and Triangles of the Neck .............. 42 Posterior Cervical Triangle ............................ 44 Anterior CervicaiTriangle ............................. 46 Deep Lilteral Cervicill Region, Caracotid Triangle, and Thorilcic Inlet ................................... 48 Posterior Cervical and Occipital Regions ................ 50 Cross-sectional Anatomy of the Neck fromtheT1/T2toC6/C7Levels ...................... 52 Cross-sectional Anatomy at the Level oftheC5/ C6Vertebral Bodies ......................... 54
4.5 4.6 10 12 14
4.7
16 18
Cervical VIscera
3.1 3.2 3.3
Embryology ........................................ 20 Thyroid Gland and Parathyroid Glands ...........•....... 22 Larynx: Location, Shape, and Laryngeal Cartilages ............. 24 Internal Features and Neurovasculilr Structures .. .. .. .. . 26 3.4 3.5 Muscles . ... . .. .. .. .. .. . ... . ... . .. .. .. .. .. . ... . .. .. . 28 3.6 Topographical ilnd Clinical Anatomy .. .. .. .. . .. .. .. .. . 30 3.3 Pharynx: Muscles ... . .. .. .. .. .. . ... . ... . .. .. .. .. .. . ... . .. .. . 32 3.8 SurfaceAnatomyofthe Mucosa and its Connections with the Skull . . ... . .. .. .. .. .. . ... . .. .. . 34 3.9 Topographical Anatomy ilnd lnnerviltion. .. .. . .. .. .. .. . 36 3.10 Neurovilscular Structures in the Parapharyngeal Space . . 38 3.11 The Parapharyngeal Space ilnd Its Clinical Significance . . 40
IX
Table ofContents
Thorax
Spaces 1.1 1.2 1.3 1.4 1.5 1.6
Overview of the Thoracic Skeleton and its Landmarks ..... 58 Divisions of the Thoracic Cavity and Mediastinum ......... 60 Overview of the Mediastinum .......................... 62 Contents of the Mediastinum ........................... 64 Pericardium .......................................... 66 Pleural Cavity......................................... 68
2
Organs
2.1
Esophagus: Location, Divisions, and Special Features .............. 70 Location and Wall Structure .......................... 72 Inlet and Outlet, Opening and Closure ................. 74 Trachea: Thoracic Location and Relations ................ 76 Lung: Thoracic Location and Relations ...................... 78 Shape and Structure ................................. 80 Trachea and Bronchial Tree: Shape and Structure ............... • ................... 82 Lung: Segmentation ...................................... 84 Functional Structure ofthe Bronchial Tree ............. 86 Functional Structure ofthe Vascular Tree .............. 88 Diaphragm ........................................... 90 Respiratory Mechanics................................. 92 Prenatal and Postnatal Circulation ...................... 94 Heart: Anterior View....................................... 96 Lateral and Superior Views . . ... . ... . .......... . ...... 98 Shape and Structure ... . ... . .. .. .. .. .. . ... . .. .. .. . .. 100 MuscularStructure(Myocardium) .. .. .. . .. .. .. .. .. . .. 102 Atria and Ventricles ... . ... . .. .. .. .. .. . ... . .. .. .. . .. 104 Overview of the Cardiac Valves; the Atrioventricular Valves . . .. .. .. .. .. . ... . .. .. .. . .. 106 Semilunar Valves and Sites for Auscultating the Cardiac Valves. .. .. . ... . .. .. .. . .. 108 Impulse Formation and Conduction System . . .. .. .. . .. 110 Mechanical Action of the Heart .. .. .. .. .. . ... . ... . .. .. . 112
2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22
X
3
Blood vessel
3.1 3.2 3.3 3.4 3.5 3.6 3.7
Thoracic Aorta ....................................... Vena Cava and Azygos System ........................ Arteries and Veins of the Esophagus .................... Pulmonary Arteries and Veins ......................... Bronchial and Diaphragmatic Arteries and Veins ......... Coronary Vessels (Coronary Arteries and Cardiac Veins): Topography ......................................... Coronary Vessels: Distribution of the Coronary Arteries...
4
Lymphatics System
4.1 4.2 4.3 4.4 4.5
OverviewofThoracic Lymphatic Trunks and Pathways .... Overview of the Lymph Nodes ......................... The Thymus ......................................... Lymphatic Drainage of the Esophagus .................. Lymphatic Drainage of the Trachea, Bronchial Tree, and Lungs ........................................... Lymphatic Drainage of the Diaphragm, Heart, and Pericardium .....................................
4.6
5
Nervous System
5.1 5.2
OverviewofThoracic Innervation ••..••.••.•••..••..••. Innervation of the Esophagus, Trachea, and BronchiaiTree ................................... Innervation of the Heart .............................. Innervation of the Pericardium and Diaphragm ..........
5.3 5.4
114 116 118 120 122 124 126
128 130 132 134 136 138
140 142 144 146
Table of Contents
Abdomen and Pelvis
Spilla!S 1.1
Location of the Abdominal and Pelvic Organs
1.2
Divisions of the Abdominal and Pelvic Cavities ........... 152
1.3
Peritoneal Relationships in the Abdomen and Pelvis:
1.4
Peritoneal Cavity:
2.17 Gallbladder and Bile Ducts: Location and Relationship to Adjacent Organs .•.•.•..... 210 2.18 Gallbladder and Extrahepatic Bile Ducts:
and their Projection onto the Trunk Wall ....•........... 150
Overview and Anterior Abdominal Wall .....•........... 154 Dissections to Display the Abdominal Viscera .......... 156 1.5
Mesenteries and Drainage Spaces ........•........... 158
1.6
Peritoneal Relationships and Recesses on the
Structure and Sphincter System ....................... 212 2.19 Pancreas: Location and Relationship to Adjacent Organs .•.•..... 214 2.20
2.21 Spleen .............................................. 218 2.22 Suprarenal Glands .................................... 220 2.23 Overview of the Urinary Organs........................ 222 2.24 Kidneys:
Posterior Abdominal Wall •.•........................ 160 1.7
The Retroperitoneum and its Contents .....•........... 162
1.8
Omental Bursa ............•.•..............•......... 164
1.9
Transverse Sections through the Abdomen..•........... 166
1.10 Peritoneal Relationships and Pelvic Spaces:
Topographical Anatomy ............................ 224 2.2S
Fasciae and Capsules: Shape and Structure •.•.•.•..... 226
2.26
Architecture and Microstructure ..................... 228
2.27
Renal Pelvis and Urinary Transport ................... 230
2.28 Ureters and Bladder In the Male:
Comparison of Coronal and Parasagittal Sections in the Male and Female •.•.•........................ 168 1.11
Topographical Anatomy .............................. 232 2.29 Ureters and Bladder In the Female:
Peritoneal Relationships and Pelvic Spaces: Comparison of Midsagittal Sections in the Male
Topographical Anatomy .............................. 234 2.30 Bladder and Urethra:
and Female .........•.•.•.•..............•......... 170 1.12 Peritoneal Relationships and Spaces in the Male Pelvis......•.•.•.•..............•......... 172 1.13 Peritoneal Relationships and Spaces in the Female Pelvis ...•.•.•.•........................ 174
Wall Structure and Function ........................... 236 2.31
2.33 EmbryologyoftheGenltaiOrgans ..................... 242 2.34 Female Internal Genitalia: OVerview ......................................... 244 2.35
Topographical Anatomy and
2.36
Wall Structure and Function ......................... 248
and Female •..........•.•.•.•..............•......... 176
2
Organs
2.1
Embryonic Development of the Gastrointestinal Tract: Fonmatlon and Migration of Organs • .. •• . • •.. • •.. •• .. 178
2.2 2.3
Peritoneal Relationships: Shape and Structure .•.•..... 246 2.37
Vagina, Uterine Positions ........................... 250
2.38
OVary and Follicular Maturation . . ........•. •.•. •... . . 252
2.39 Pregnancy and Childbirth . ... . .......... . ... .. .. .. .... 254 2.40 Male Genitalia:
Rotation of the Primary Intestinal Loop •• . • •.. • •.. •• .. 180 Stomach: Location, Peritoneal Relationships,
Urethra: Location and Structure •..........•.•.•.•..... 238
2.32 OvervlewoftheGenltaiTract .......................... 240
1.14 Location and Attachments of the Pelvic Organs: Comparison ofTransverse Sections in the Male
Ductal Anatomy and Histology ...................... 216
Accessory Sex Glands.. . ... . .......... . ... .. .. .. .... 256 2.41
Scrotum, Testis, and Epididymis . .. .. .. .. •. •.•. •... . . 258
2.42
Seminiferous Structures and Ejaculate .. . ... .. .. .. .... 260
and Relationship to Adjacent Organs .. •• . • •.. • •.. •• .. 182 2.4
Shape and Interior . ................. .. ......... .. .. 184
2.5
Wall Structure and Histology .................... .. .. 186
2.6
Small I ntestlne: Duodenum ...... .. ............................ .. .. 188
2.7 2.8
3
Blood Vessels
3.1
Arteries of the Abdomen and Pelvis ... . .. .. .. .. •. •... . . 262
3.2
Branches of the Cellae Trunk:
jejunum and Ileum ................................. 190 Large Intestine:
Arteries Supplying the Stomach, Liver and Gallbladder . 264 3.3
Colon Segments ...... . ... . ........................ 192 2.9
Wall Structure, Cecum and Vermiform Appendix•.. • •. • 194
2.10
Location and Shape of the Rectum • • ..• • . • •.. • •.. • •.. 196
2.11
Wall Structure of the Rectum and Mechanism of Defecation .. .. .. .. .. ......... .. .. 198
2.12
Arteries Supplying the Pancreas, Duodenum, and Spleen •.•. •... . ... . .. . .•. . ... . ... . .. .. •. •.•. • . 266
3.4
Branches of the Superior Mesenteric Artery: Arteries Supplying the Pancreas, Small Intestine, and Large Intestine .......... . .................. .. .... 268
3.5
Innervation of the Rectum and
Branches of the Inferior Mesenteric Artery: Arteries Supplying the Large Intestine . . ... . .. •.•. •... . . 270
Continence Mechanisms ... . . .. .. .. .. .. ......... .. .. 200
3.6
Tributaries of the Inferior Vena Cava ......... .. .. .. .... 272
2.13 Radiography of the Small and Large Intestine ........ .. .. 202
3.7
Tributaries of the Portal Vein .................... .. .... 274
2.14 Liver:
3.8
Position and Relationship to Adjacent Organs .. • •.. •• .. 204 2.15
Peritoneal Relationships and Shape • .. •• . • •.. • •.. •• .. 206
2.16
Segmentation and Histology ......... .. ......... .. .. 208
Portal Vein: Venous Drainage of the Stomach, Duodenum, Pancreas, and Spleen ................ .. .... 276
3.9
Superior and Inferior Mesenteric Vein: Venous Drainage of the Small and Large Intestine .. .. .... 278
XI
Table ofContents
Neurovascular Supply to the Organs 3.10 Arteries and Veins of the Kidneys and Suprarenal Glands: 3.11
1.1
Thymus ............................................. 325
Overview ••••••••••••••••••••••••••••••••••••••••• 280
1.2
Larynx .............................................. 326
Topographical Anatomy and Variants ••••••••••••••••• 282
1.3
Thyroid Gland ....................................... 327
1.4
Pharynx............................................. 328 Esophagus .......................................... 329
3.12 Divisions and Topographical Anatomy of the Internal Iliac Artery ••••••••••••••••••••••••••••• 284
1.5
3.13 Arteries and Veins of the Pelvic Organs ••••••••••••••••• 286
1.6
Heart ............................................... 330
3.14 Arteries and Veins of the Rectum ••••••••••••••••••••••• 288
1.7
Pericardum .......................................... 331
3.15 Arteries and Veins of the Female Genitalia and Urinary Organs............•.•.•.•........•.•.•.•. 290 3.16 Venous Anastomoses in the Abdomen and Pelvis •.•..... 292
1.8
Lung and Trachea .................................... 332
1.9
Diaphragm .......................................... 333
1.10 Liver, Gallbladder, and Spleen.......................... 334 1.11
Stomach ............................................ 335
1.12 Duodenum und Pancreas ............................. 336
4
Lymphatit System
4.1
Overview of Lymphatic Trunks and Lymph Node Groups
4.2
Overview of the Lymphatic Drainage of
1.15 Descending Colon and Sigmoid Colon .•..............•. 339
Abdominal and Pelvic Organs .......................... 296
1.16 Rectum ............................................. 340
Lymphatic Drainage of the Stomach, Spleen,
1.17 Kidney, Ureter, and Suprarenal Gland •.•............•.•. 341
Pancreas, Duodenum, and Liver........................ 298
1.18 Bladder, Prostate, and Seminal Vesicle .•..............•. 342
in the Abdomen and Pelvis ............................ 294
4.3
1.13 jejunum und Ileum ................................... 337 1.14 Cecum, Vermiform Appendix, Ascending and Transverse Colon ................................. 338
4.4
Lymphatic Drainage of the Small and Large Intestine ••••• 300
1.19 Testis, Epididymis, and Vas Deferens •.•..............•. 343
4.5
Lymphatic Drainage of the Kidneys, Suprarenal Glands,
1.20 Uterus, Fallopian Tube, and Vagina •.•.•..............•. 344
Ureter, and Bladder................................... 302
1.21 Fallopian Tube and Ovary ............................. 345
4.6
Lymphatic Drainage of the Male and Female Genitalia •••• 304
5
Autonomit Nervous System
5.1
Organization of the Sympathetic and Parasympathetic Nervous Systems ••••••••••••••••• 306
5.2 5.3
Autonomic Ganglia and Plexuses••••••••••••••••••••••• 308 Autonomic Innervation of the Liver, Gallbladder, Stomach, Duodenum, Pancreas, and Spleen .. ... . . ... . .. 310
5.4
Autonomic Innervation of the Intestine: Distribution of the Superior Mesenteric Plexus.. . ... . .. 312
5.5
Distribution of the Inferior Mesenteric Plexus and Inferior Hypogastric Plexus .. .. .. .. . .. .. .. .. .. . .. 314
5.6
Autonomic Innervation of the Urinary Organs and Suprarenal Glands ... . .. .. .. .. .. .. .. . ... . .. .. .. . .. 316
5.7
Autonomic Innervation of the Male Genitalia . .. .. .. .. . .. 318
5.8
Autonomic Innervation of the Female Genitalia . .. .. .. . .. 320
XII
Table of Contents
Appendix
References .... .
Index ....... .
. .............. 349
. ....... . .•. . . . .•. . . .. 351
XIII
Neck Overview and Muscles •.•.•••••••••••.•.•......... 2
........................ 10
2
Neurovascular Structures
3
Cervical VIscera .•.•....•.•...••.•.•.•....•.•...• 20
4
Topographical Anatomy •••••••••••...•.•.•.•••... 42
Neck - - 1. OwnlfewGnd Nlusdes
The Neck: General Aspects
1.1
The neck is the region of the bodybetweeen the head andtn.tnk.lts sla!l· etal foondiltlon Is the vertdlr.~l column. Its ;urtafor surf.rce aniltOmy Is defined by muscles and vlscer.1 (e.g.. the lal')'llX), and It Is traversed by a number of dosely related neurovascular structures. The muscles, llfs· c:er.a, and neunwascular stJuc:tures are all e!M!Ioped by cervical fasciae (see B), which subdtvlde the neck Into comp;~rtments. In the sections that follow, these fascial spaces (see I and D) wtll pi'OIIIde il basis for dlscus:slng the neck muscles byfunct!onal groups. This wlll be followed by a desaiption of the arteries, wins, lymphatics, and nerves (including
---=-
External oa:lpltal
~ pnllllbo!r.lna: Tip ofmastoid
prooess
the peripheral ;auwnomic nervous ~m) and then the Q!l'Vicalvi5«!r...
The usual order of presentation, In which Ylsara are dlscus.sed before nerves and vessels, has been iltered In order to emphasize the unique importance of the ne..~rov.ascular p.atttways in the neck. Tbe closing sections on lllpogr;aphical and sectional ;anatomy will explore the inte!TC!Ia· tlonshlps of the muscles, neurovascular stn.tctures, and viscera.
Spinous ptOCI!S&
oiC7wrtl!br.a
A Seq111nC11 of t;oplcs In this chilptar Ned:muldes
• Superficial musdes • Nuchal muscles • SUp11hyold muscles • lnfra~ld musdes • Prewrtebralmuscles
• Llte11l (deep) neck musdes
C Supertlctilll ;md lnfeliorbound~rtesoftheneck Left lateralllfew. The following palpable structures define the super1or and inferior bounda(H!S of the neck:
• Superiar boundaries: inferiar bardet' of tbe mandible. b'p of tbe mas·
told process, ~nd ~m.al occipital protuber~nce • Inferior boundaries: supr.~stem.al notch. clivi de. acromion. and splnousprocessoftheC7vertebra
Neu-lltt~n~e~u~e
• Arteries • Veins
• ~phatlc:system • NeNeS
Pretr.u:lletlll)oer muscullrportlon
c.ntcallvtsare
•
Em~logyofthe cervlalllfscel'il
• Thyroid and par;athyrold glands
• ~.arvnx •Pharvnx • Parapharyngul space Topegrwphkalen.eomy • Surface anatomy and regions
• Anterlorcervtal region • Lateral cervical regions • Posterior cervical and oc:c:lpltal regions • Crou-sectlonal•naiiDmy
8 CervfcalhKfil Deep to the slcfn Is the superficial C4!1Yfcal faSCia (subcutaneous tissue) wflich contains the platysma muscle antl!roliltl!rally. Deep tD the super· fldal fasclil are the following laym of deep cerYl cal fasclil: 1. IIM!Sifng ~ enwlops the entire nedc, •nd splits liD endose the
sUnlodeldomastold and tra!)e21us muscles. 2. Pretracheilll•r: the muscular portion encloses the lnf1111~1d muscles. while the llf-al portion surrounds the lhyrold gland, larynx. trachea. pharynx. and esophagus. 3. Prewrtebral.: surrounds the cervtal wrtlbral column, and tlw musclesusodated with 1t. 4. Carotid sheath: end-s tt.common carotid artery, lnUmill
Jugular vern. and wgus nerw.
2
D lelltSoMh._, of tfle deep fucTaln the neck. TraMWrse tedlon attfle I!!WI oftfle cs vertebra The full ~nt «the cerYical f~scl~ b best ilppreclated 11'1 a tr~nsverse sect!on of the neck:
• The musclt fasdo splits Into three layers: - Superflc:Jallamlnil (~low)
- Pre!rilc:he.allamln.a (light gr4!4!1'1) - Prevertebr;allamina (violet)
• There Is also a neurovascular fasclil, called the carotid sllf
Neck - - J. Ow!J'vlftvontllllusdfS
•
Mu!CUiupOrtiOI\ - - - - -f-.:.
p~~~---'.:-7----~
~dleallilyer
E F.JIIdal reftlfonshlp5ln the neck a Antertar view. The cuuneous muscle of the neck, the plilltySma, Is highly v.1riable in its development and is su!Kutanews in location, overlying the superficial anlcal fascia. In the dissection shclwn, the platy5ma has been removed at the level of the Inferior mandibular border on eo~ch side. The CI!Mc.1l fasciae form a fibrous sheet that encloses the muscles, neurwaKIIIar structures, and cen.1cal Ills· ctl'i!l (see B for further deuib). Thae f
li)w
deepest layer of the deep cenllc:al fascia, called the pm'flfJ!brollayfr. Is VIsible postenorly on the left side. These fasc'la·bounded connectivl!·1issue sp;~ces in the
neck al'l! important dinically because they
p~lde
routes for the spmd of lnflammiltOry processes, although the lnftammi!lon may (it Ieist Initially) remiln confined to the af.
fected comp;~rtment. b left llt«al view. This midsagittal sect1on shows that the deepest l;lyer of the deoep cervic.1l fascia, the prevertebri!llayer, directly over· lies the venebril column In the median plane and Is spltt Into two parts. With tuberculous ~ltls of the c:eMcal splr~e, for example. a gmltatlon .ilbscess may develop In the "danger sp;~ce• along the prevertebr.al fatda (retropharyngeal absO!ss). This fascia en· closes muscles laterally and posteriorly (see D). The C.ilrotfd sheath Is located 1\arther later;ally and does not ilppeo!r In the mldsaglttal section.
3
Nedc - - 1. OwnlfewGnd Nlusdes
1.2
Overview and Superficial Neck Muscles
A Scheme used for clllllll'fyt'ng die neck musdes lntograups The next fttw sections follow the outline below, which is based on the topc:~gr~phkal ~natomy of the neck. V~rfous sdlemes may be used. however. While the nuchill muscles are classified as neck muscles from a topographle<~l standpc:~lnt, Uley belor~g functionally to the category of inbin.sic back muscles (which ~re not described here).
~nedrmllld•
~llqlmusd•
• Platysma
(dMP strwpiiiUidll) • longus capltrs o longus mill o Rectus capitis an..nor
• Sternocleidomastoid • 'Trapezius• -~mufdll
• Dlgastllc
• GeniOhyoid • Myloh)'oicl • Stylohyoid
o
Rectus capllls I -ails
t.lenl (deep) ned! IIIUides o
o
Scalenus anterior Scalenus medius Scalenus posmrlor
lnfnll¥*! muldes
o
• • • •
Nudlll musdes (tnlltnsfcbMII
Sternoh)'old Sternothynlld Thyrohyoid Omohyoid
• Not a neck muscle in the strict sense, but lnduded he.owlng ID Its topographical Importance
musdes) o Semispinalis capitis • Semispinalis cervlcls • Splenius capitiS o Splenius cervicis o longissimus capitis o Iliocostalis cervlcls o Suboa::lpltal musdes
Ortetn:
(i) Descending part
Ocdpltal bone (superior nuchal line and ~I oalpltal problberance) • The spinous processes of all ceiVlcal wrtebraevra the nuchal ligament allranswnepart Broad apc:~neurosis at the lewl of the T 1-T4 spinous processes ®Ascending part: Spinous processes of rs-r 12 • LateralthlrdofthedlWlcle(descendlng part) o Acromion (lranswrse part) • Scapular spine (ascending part) o Descending part - Draws the scapula obliquely upward and rvutu It e~Ctemally (<~cling with the l~r part of the o
C!Malar head of sternocleidomastoid
meraan:
8 Schemltkofthe mJnodeldomutold
se~ anterior)
- nits the head to the same side and rvtl~Witto the
Orfllln:
• Sternal heid: manubrium stern!
• Clavicular head: medial third of the dmde l...tf•: Mastoid fi"ICflS and superior nuchal line Adlonl: • Unllaterat - TlllstheheadiDthesameslde - RoQtln the head to the oppos~ side • Bllalltral: - Extends the head - AssiSts In resplratfonwhen the head Is fUced IIIIIBWII•: Accascwy nerw (aanlal nerw )(J (CN XI)) and direct branches hm the cervical plexus (C1-C4)
4
opposlll! side (w1th the shoulder girdle fboed) Transwne part draws the scapula medially o Asandlng part: draws the sapula medially downward (supports the rotating <~cllon afthedescendlng part) • Entl~ muscle: stablllzef the scapula on the thor;~~e Accessory nerw (CN XI) and cervical plexus (C 2-c 4) o
~nerwaon:
Neck - - J. Ow!J'vlftvontllllusdfS
~~-------$~~~~
mmold
D c.ut.neous musdeoftfluedi: (pllltylma} Left lawral view. The platysma Is a bi'OO!d, flat. suba.ttaneous muscular sheet locited superfldal to the IITIH!5tlfl!l lil)'l!r of the deep cervf· c:al fascia. Unll'ke mort musdes,lt ls not enveloped in in own fasci;!l sheath (see ci;Jssific:a· tlor1 scheme lr1 A). but Is Instead directly ass.,. elated with (and In part lfiSefts Into} the sldn. This charactenstfc, wtllch It shartl Mth the musdes of facial exp~ion, malaes the pi;J· tysma dlfflaJit to dissect. It also shares with lho5e aanlofadal muscles Its source of lnnervatfofl: the facial nerve. The platysma Is highly variable in size-;ts fibcn may reach frvm the lowerpartofthef.rcetotheupperthorax.
E SUperfldll nedc mu1des:
stemodeldonwtold arid oentQI ()llrt of t.npezU. llrttarforvllw Torticollis (from L. tortus - "twwstrd" ;md collum- •ned:") Is a contractfor1 or shortening of the neck m~~Sdes c:a~~Sing the he;~d to ll!main tilted to the affected side. and rotited to the other(contralateral) side. The condition Is also c:alled wryneck. It can also be caused by damage to the innetvmon of the sb!rnodeidomastold (see p. 19). Congenital torticollis c:an In· volve degener.rthle sc:arrlng ;md shortening of the stemocleldonnill!itold on one .side (see p.43).
/ 5
Neck - - 1. OwnlfewGnd Nlusdes
1.3
Suprahyoid and lnfrahyoid Muscles
A Ovemew olthe ~pnflrold muscles CD.,.._..mUide Ortgln: • Anterior belly: digastric fo5w of the mandible • Postelfor bdly: medial to the mastoid proctSS (mastoid nOilch) 1_,1111: Body of the f¥1icl bone vii an intennecliate tendon with a fibrous loop Adlonl: • 8.-s tfle hyoid bone (during swallowing) • Assists In opening tfle mandible l-'1111: • Anterior belly: Mylohyoid nerve (from the mandibular nerw, a dMslon of CN V) • Postelfor belly: faSCial neM (CN VIO
lnfer1or mental spine ofthe mandible Body of the hyoid bone
• Draws the f¥11d bone torw.rd (during swallOWing) • Assists in opening the mandible
B Sdu:tnltk olthe lnfnlh)'uld muscle' CD~musde
Ollgfn: neraon: Actl-
~nerwtlan:
Posterior surfa
®~muscle
Ortgln: -.raon: Adlans:
Posterior surfau of the manubrium stemI Thyroid c.arUiage o Draws the larynx and hyoid bone downward (fboes the hyoid bone) o Depresses the larynx and hyoid bone (for phonadon and the tennlnal phase of swallowing) ..nerwtlan: Ansa cervlcalis of the cenric.al plelcus (C 1-Cl)
IIIIIBWif111: 'hntralram•ofC1
®
..,.,..,.,d
®~muKie
IIIUide
Mylof¥11d nne of the mandible Body of the f¥11d bone by a median Oendon of lnserUon (mylohyoid raphe) Adlonl: • Tlghtlensand elevates the oral floor • Draws the hyoid bone torw.rd (dulfng lw.IIIIOWing) • Assists In opening tfle mandible and movtng It from Side to Side (masacatlon) IIIIIBWif111: Mylof¥11d netW (from the mandlbularneM, a division ofCNV)
Ortgln: 1_,1111:
® StJia,uld muscle Orfllln: l...tl111:
Styloid piOGI!SS of the temporal bone Body of the f¥1icl bone by a sprlt Oendon Adlonl: • 8.-s the hyoid bone (during swallowing) • Assists In opening tfle mandible l-'1111: 1'9CialneM(CNVII)
6
Ollgfn: neraon: Actl-
Thyroid carUiage Body of the hyoid bone o Depresses and fbou the hyoid bone o Raises the larynx during swallowing ~nerwtlan: Ventral ramus of C1
® Oma,uld muscle Ortgln: nei'Cion: Adlans:
SUperior border of the scapula Body of the hyoid bone o Deprasa (flxel) the hyoid bone o Draws the larynx and hyoid bone downward (for phonilldon and the tennlnal phase of swallOWing) o Tenses the urvlcal faSCia w1th Its lntennedlate 181don and maintains patau:y of the lntemal Jugular Win ..nerwtlan: Ansa cervlcalis of the cenrical pleaus (C 1-Cl)
;:::;=-- St)loh)ollld ~~~---D~
~bdly
Mylohyoid
tne
C Supr.~· ;md tnfrilhyold musdes.lelt lilll!r.ll 'llfew Mandibular for~~ men
M)lohyold _
_,_,...
Hyoid bone (body)
E Supr.~hyold ITIUR:Iu: the m,fu~td ill!d geniohyoid, posll!rosupelior'llfew
M)lohyold 111phe
H)ocldbone
lhy~d ------l~
Tllyrcldcdlage
--~H......,roJ
D SuJn·•nciTnfnohyold muMies.•nll!rforvl'ew
Part of the sternohyoid musde has bHn remcwed on tfte rtghtslde.
7
Nedc - - 1. OwrW!w tllld Musdes
1.4
Prevertebral and Lateral (Deep) Neck Muscles
A Schcmiltkofthe prcve!Uinw mu~eles
CO Lon.-apltllmuKII
Or1111n:
C~6 wrtltlnt
1-'IM: ~
Seal-mute~•
(!) Scalei'IB ant.rtcr. 1 ntertor tublrdu of the transverw
AIUrlortuberclt$ oft~tr1nsvtr5e prv~ oft~ Orflhl;
Balllr part of the OCICiphl bone • Unilaral: tilts and slightly rotabl!5 the held ID the r.~m•slde
• 9111111,.1: f1a. the held I....WU•: Dl~~ branc~fnlm the oervlcol piDI.II (C 1-C3)
Q) Scalenus poll:l!rlor: poa.r!ar tub..:les Gf thl! t ...nsve'1C!
--.
® t..,..wll-.de
Ol1ik
• v.tlal{lrQr.......) part ..tBtar...r.-aftht C5-C7•ndT1-Tl~bocleo
• Supellat oblqLMI part: .Jr1leflor tubercles of the lriiiSWI'Je PI'O(leSseJ of the CJ-C 5...mebrae • Infllfor oblqiM part: ll1tlr1or surf.as of the T 1-T3 wrtllblllll bodies • Vertical port antlrior surf. .s afthe C2-<:4wrtebra 1-'1•: • Sup1rlar obllqu• part ant.rlor tubercle of the 11:111 • ll'ftrlor oblique port: anllerlor t>Jben:les of the lrii\SIIe'1C! P'-seJ of the CS and Clhtl'1l!br11! • Unllltieral: tilts and I'GtltJK and a:rvlcll splnl! to thO! ~ Simi Side • Bllllllr1l: fleas th• canrical spine 1....,...,.., Dire~ b..nclwsfnlm th..:•rvlcol plaus (C2-<:6)
Lltieralmasofthutlls Balllr part of the OCICiphl bone • Unllaral: laral flaon II: the alllniD-ocdpltiiJolnt • 9111111..1: flulon lit the atllnto-oa:lplbl joint I....WU•: V.ntnolr.1ml ofC1 and C2
® IIKtlllapltia 1-.111. 0r1111n: 1-'1•:
Tran-r11 p-at the atlas llalllr partGfthe oa:lpbl bone (""-ral to the occipital mndylft)
• Unllltieral: l.cer1l fieldon ll:t~ alllniD-ocdpltaiJolnt • ar~~tm~: fieldon a the allnto-oa:lplbl Joint IIMI 'lllf•· Venlrll ramlofCIInd Cl ~
8
~of the C3-Cfi\WtRbnoe
~
pnxzues Gfthe C5-C7 wrteb..e • Sale,_ lil'll:erlcr. saline tubet'Cie on the first rib • ~ medius: first rib (posiBlor liD the gi'OCM far the subdMin lrtllry) • ~ pastllfor: ....surflclt of lhe lltallld r1b • Wtth the rib& mob;lr. inspirlllon (lledlas the upper ribs) • With the ribs~ bends the c:enta I spine to the
11•
(with undlter"lll contractlon) s;ome • Ae.s the neck (With blllttr1l mntr~dlon) ..nerwaon: Direct branches from the carvlcal pleua 1nd brac:hlll plexus(C~I)
Sc.alenw; - - - - - - ,;:. medw Sc.alenw ~ntsfor
-----:-+--
Sc.alems---..FI posb!rior
htencAIIene - ---:;=.-;t'---f -+-~'--------
Scalenus anll!rtor
Flrstr'b
C Pn!vel't.!Mir.JI mdl~ter.ll (dMp) neck mll'ldH, ;mtelionfew The long~JS c.~pltls and scalenus anterior muscles have been p.;~rtlally l'l!!mowd on the left side. Tbe ptiMI"b!br~l muscles stretch between the mvle<~l spine and skull, acting upor1 both. The three OYeriapplng SC3Iene milS des (the K~lenl) are classified as lat:eAI (deep) neck milS·
cles. As they p.iiSS betwe\!11 the cenlfcal spine irld the upper two rlbs, they ilso assist 1r1 r4!$plralfofl. Thescalen~JS antenor indscalen~JS medius are sep.;~ratzd by the intmmll!lle ~ mpographical!y imp~:~rtilnt in· terwl that Is 1r.Mr1ed by the brachial plexus 01nd subclavian a!Ury.
9
2.1
Arteries
8 Brandies tlftfle eld:l!mal arotld artl!ry Antertot bl'llnclles
• Superior thyroid a.ury - lnfr.Jhyold brancll - Supel'lor laryngeal artery - Cricothyroid branch - stunodeldomastold branch - Glandular branches • ungual artery• • Fadal.artery• • Asaend!ng pharynge;~l art2ry Pomerfar brindles
• Occipital a.ury• • I'Ostl:rlor auricular a.ury• Ttrmlnal bl'llnchN
• MU!IIary artery• • Superflclal temporal a112ry• • Notlllslbil'lnthedlssectlon InA
lnbem•l thar..:tc.-tery
• • • •
Medlntlnalbranche.s Thymic branches Pler!cardlliCOphreniC branch Mammary branches • Antl!rlor lntermsbl branches • Musculophrenic artery • Superior 4!pi9Btrlc art2ry 'lllrtl!b111l artlery
• Spinal branches • Meningeal branch • Posterior spinal artl!rles • Antl!rlor spinal art2ry • Posterior inferior cerebellar a.ury • Basilar art2ry
A Common arotsd and o.temlll urottd arteriK and theft br~nches In the neck
Left lawral view. Each side of the neck Is tra· vel'5ed by two major artafes which function as •thoroughfares" to carry blood from the aortk arch tD the he..d and brain: the common carotid artery (and the internal carotid artery arising from It) and the vertebral artefy (see D). The right common carotid ilrtery arises from the brachlocephallc trunk, while the left common carotid artery brantflu directly from the aortl. The common carotid ai'Ufy bl·
10
furcates at approximately the level of the C4 W!rtebr.al body into the inb!!rnal and exb!rnal carotid artl!rles. The lntM!al carotid artefy asCalds directly to the base of the skull and enten the aanlal c.Mt:y, gl\llng off no branches In tile neck. The eJ111!mol carotid artery gives off numm~US brantfln In the hNd <1nd neck (see 8). The cervical part of this ilrtef'y mainly supplies
'nlynlaerwlal tru'* • lnfu1or thyroid artery - 1\s<:endlng oemcal artery • TranM!I'Se cerviCal artery - Supe!fldal branch (superftdal O!I'Ylcal a.ury) - Deep branch (dor.sal scapular artery) • Suprascapular artery ~I trunk
• Deep mi'YICal art2ry • Supreme lntei'C0$~1 artery
D SUbcll'll'l'llll'larteryand Its bnnches Anterior view. The subdavlar1 ;rrtay dlstrl~ utes a number of br;mches to rtructures located at 1he b~e of the neck and about the thoracic inlet. Two br.!nches of special impor· t.lnce are tile thyrocervical trur1k, whkh gives origin to the transwne cemul artery, and 1he costocervlul trunk(see c and E). Nair that the brandies of the subdavian artery may ;rrlse lfl
Sp.ac;!
BracHo· cephatc
lllllk
Ctlmmon
c.nt!d artery
E 11lyrocienlful trunkand autlla!rvfcal trunk and their bnnches Right lab!!ral view. The thyrocerviul trunk arises from the subclavian
artery arid diYldes lr1to the Inferior thyroid
F Collltenl pathways thlt develop In l'l!!lpOI!Se to Tntemal uroad artery ttl!nDIIII Athe!Wderosls ofUie Internal carotid artery Is afrequentcllnlul pro~ lem. NaJTOWlng of the carotid lumen (stenosis) eventually results In decreased blood flow to the brain. If the lumen Is occluded suddellly, the result is a stroke. But if the stenosis di!VI!Iops _.time,. blood can rtfll mch lfle brain til rough the gridual recruitment of collateral chan· nels. As this occurs. the direction of blood flow may become reversed ln anastomotic .ams dose to the brain (see aJTOWS). As long as an ad~ quate collateral drculatlon Is malntollned, the stenosis does not p~uce clinical manifi:!station$. The principal collateral pathways ;rre as foiiOW3!
• Ophtllilmlccollater.!IJ: external Cirotld ;rrtery-f.lclal artery- an· gular artery- ophthalmic .artery-+ carotid siphon • Occipital .an.astomosls: eldernal carotid artery- ocdplt.ll arterysmall meningeal artef.e.s- vertebral artery
11
2.2
Veins
8 PrfncTp;~l wl'rwln the neck. thllr ~b~sandana~
In addition totheveln.s listed below, there;~ne a number of sm.allerveins that drain blood from adjacent structures. Since they are highly v;rrl· able In their development. they are not listed here. The cervical Yl!ins ane intl!rcannecb!d by extenslft anastom0$6 (n~t all of which are shown here. lfl some cases because they are too small). As a result, the ligation of one Yl!ln will not cause a serious impainnent of veno~a newm. A -liS junction is a site wbene two larger veins jolr1 at an approxlm.ately90' angle. The two pr1ndpal venous junctions In the neck ane the )ugulofaclal and the jugulosubclaVIan. The jugulof.lcial V1!nous junction is smaller than the jugulosubclaVIan venO\IS junction. ~Mllch also maries the termlflatlon of the thoracic duct (seep. 48). 'fttbutllrtes of die superior--
• Right brach!Ooephalk vein • Leftbrach~atecwin 'fttbutllrtes Gfthe llrecNoc.phelk win
• Internal jugular vein • Subcl:wlan win - External jugular win • Thyroid venous pltlcus (usually drains to left brachlocephallc win) • vertlebralwln • lntemal thoracic wins
'fttbutllrtes Gfthe ..._Jugularwtn • Dural sinuses
• Ungual win • Superforthyroldvd" • hdalveln - Angular win (anastomosis w1th ophthalmic vein) - Retromancllbular win - Superlldal bmparal veins (anasto~ ses wtth pterygoid plexus) • Postertoraurlcularvdn
Rlghtbntd11o- - - -
cephallcwn
A PrfncTpal wnout trunks In tile neck Left later;ll 1/lew. Three jugular ftlns retum blood to the superior vena C
12
Into !he subcliliVIan Yl!ln and drains super· ficial are
'fttbutllrtes of die extemel Ju.,lerwln • Oc
Oph!Nimlcwln
SuP'!r!or Sll!lltbllslnus
Angl.farwh --~-{ c-mo~ --~---,~~~!!--~~ ..•
f~~-----~~~~---SUP'!~
tl!mpor.JI...ens
sh~
C c:.rwfCill wtns ;nl thttr r.lltlon~htp to the wtrtS of the skull ;mel dur..t sinuses Left tmrllt 111-. The dulllt Yenous sinuses collect Yl!llOUS blood from tne billin ~nd chan· nellt 1» the Internal jugular vein. When the lymph nodes are removed In a neck dissection for ll head and neck malignancy, !he lntl!rnal jugular vein should be ligated on Me side only to awld awing a potl!nt!ally lethil venous stasis In the brain.
Ant2
]ugulnwln
D c:.rwtAI wrns
Superior ~dwin
----,il-+~
Wl+ ----'lt--rntl!mll
)lgularlldn
....Ht- - Anb!rlar
~
)lgularlldn
Anterior 111-. Most veins In the neck are vallll!less "thoroughf.lres• that dlllln blood from tne he;td. They ~re minimally distended and not mdlly vlslble abOYe the plane of the heart In both the standing and sitting posl· tfons. In !he supine position, howeYer, the veins become engorged and are visible IM!n in a healthy lndMdual. VIsible distention ofcervl· al veins. sped!IC311y the jugular vdns. In !he standing position Is .a sign of right-sided hNrt failure. in which blood collects proximal to the right he;art, generally due to Improper functioning of the right ventricle. The Internal jugular vein Is a large and Is frequently used as an access slte for the plaament of a antrilnous catneter In lntmslve care medldne. makIng It possible 1» Infuse gre
""''""=-'------,""'""=-i'~""="'--"""'=i--- Su~r ~~~
13
Lymphatic System
2.3
Lymphlltk system ofthe held and neck A distinction Is milde between reglomllymph nodes, which ~re aJSocl· md w11t1 a ~rtlaJiarorgan or region and constltutethefr primary filter· lng sutrons, and collecUng lymph nodes, which usually recellle lymph from multiple regional lymph node groups. cymph from the head and neck region, gathered In scattered regional nodes. flows through 11:$
MIStold
- - -....:.,__j"G
ttn'4lh nodes DHj) p.II'OIId
ttn'4lh nodes
8 Dell!fHll!rvkill frmph nodes Right lateral view. The deep lymph nodes lfl the neck consist mainly of
collecting nodes. They have major clinical importance as potential sites of metastasis from head and neck tumors (seeD ~nd E). Affected deep cuvlcallymph nodes may be surgically removed (neck dissection) or may be treated ~ reglonallrradlatlofl. For this purpose the Amerlcafl N:ademy of Otclaryngolt~gy, Head and Nedc Surgery has grauped the deep cuvlcallymph nodes lntll six le~~els (Robbins 1991): I Submental and submandibular lymph nodes II-IV Deepcen~tcallymph nodes distributed along the Internal jugular vein (literill jugulir lymph nodes): - II Deep cti'Yicallymph nodes (upper lateral group) - Ill Deep arvic.allymph nodes (middle later.al group) - IV Deep cervical lymph nodes (ICIWer lateral group) V lymph nodes In !he posterior cuvlc;rl triangle VI Anterior cervical lymph nodes (anterior group of CI!I'Ykal nodes)
14
system of deep cervical collecting lymph nodes, inlll the right and left jugular trunks. each dosely ~ssodirted wlth 1U cormpondlng Internal jugular-.-eln. Thejugular trunk on the right side drains lntll the right lym· ph.il11c duct. whkh terminates at the rtght jugulosubdavlan junction. The jugular trunk on the left side terminates at the thoracic duct, wflich empties lntllthe left jugulosubclavlanjunctlon (see D).
A SupertkiiiiJ111ph nodes Ill the neck Right lmril view. It Is extremely lmportint to know the dls!J!butlon of the lymph nodes in the n~dc beause enlarg~d an~iclal lymph nodu are a common flndlng at physlc~l eximlfliltlon. The enlargement of cervkallymph nodes may be caused by lnflammatror1 (usuilly a poill{ul enlargement) or neoplaiia (usu· ally~ po/nlessenlargement) lr1 the area drained by the nodes. The superficial cuvlcal lymph nodes;me prtmarydralnage loc.rtlons for lymph from adjaant areas ororgans.
C Dlreclfons oflymphiltkdr..hJgt In the neck
Right latel'ill lllew. The prinCIPii p.iltb!lfl of lymphatic flow In the nedc is clepictl!d. Understanding tilis p
·r=- - - )lgulosubciM;Jn wnous function
If ooly peripheral no dill groups .are affectl!d, this suggests a localized disease process. If tile centr.ll grvups (e.g., those at the venous june· tlons) are affected. this usually slgnlftes an extensive dlse.1se process. Cern:r;al lymph nodes c.1r1 be obtillned for diagnostic evalllatlon by pre.scalene biopsy.
~b •.
•
D Rel;~ttonshlp of the anful nodes to the systank Jrmphattc draiiiUon Antzriot view. The cerviullymph nodes may be invollll!d by diseases
that are not primary to the head ;md neck region. because lymph from the attire body Is channeled to the left ;md rtghtJugulosubclil\llan junctlons(reddrcles, seep.129). This can leadtorettogr;adeiiTIIOIYementof the cervical nodes. The right lymphatic duct terminates at the right jugu· losubdilllfar1 junction. the thoroc:it" ductitthe leftjugulosubdivlan jufiCtlofl. Besides cr.rnlal ;and cervbl trfbut;ntes. the lymph from thor.rclc lymph nodes (medlastln;al ;and tr;acheobrondllal) ;and from ;abdomln;al and caudilllymph nodes may re;ach the ceNkal nodes by way of the thoracic duct. A:$ a ll!.SUit. dise.1ses in those o~ns m;~y lead to cervical lymph node enlargematt. Nooe: Gastric c;arclnoma may metastasize to the left supr;aclavlcular group of lymph nodes, producing ar1 enlarged senti~ node that sug· gests an abdominal wmor. Systl!mic lymphomas may also spre
~ 4c e
c
E Symmatk p;~lp;llfon ofthe anfullymph nodes The C4!1'11fcallymph nodes are systematlc.ally palp
15
2.4
Overview of the Nervous System In the Neck and the Distribution of Spinal Nerve Branches
A Oftnlewvfdw Mm!luaJY*m In the neck
The following siNctllres of die penph~ral nwus system ill'e present In the neck: spinal nenes, cr~nlill nerves, and nt~WS of the ~u tmnomic nervol.8 syiUm. The table Ml- revlewJ the most lmport1nt slnlctures, followIng the sequenD!! In which they are discussed in the next s~ctions. The spinal neM1.5 th.t supply the nedc arise from the c 1-C4 segments ~ the amcal spinal cord. The spinal-ciMde into dor""' r~ml 1nd ventnll r~ml: • The dorsal rami of the spln1l nerws arisIng from the c 1-C3 spln•l cord segments (su boccipitaI nerw, greaa.r oai pitaI norw, third ocdplbll rww) supply rnotar lnnerwtlon to the Intrinsic nlldlal mutcles ilnd sensOfY Innervation to the C2 •nd C3 clennittama on tlw back of the neck and the ocdput 1). • The ¥mCTII r.ml of the splnll nerves ilrfslng from the c 1-C4spinal c.ord segments supply motor Innervation to the deep neck m-lft (short, direct bra nchesfrom the ¥ei1Cfllram1) 1nd finally unite In the neck t.o form the criocal pleJua (see Q. This plaus oupplla the Jldn 100 ......,... liture of the 111tlerfor and l.ttllll neck (Ill but the nucNI region).
suboalpltal nliW
li-- - - - G r u t
i1Ur1t\llar
""""'
<-
•
G spiMI none. dcnolramus
The ned< CXIIItalns the follawlng m11lil nerwes, whKh arise from the lninstem:
• Glossophlryngeal neM (OIIX) • VIgus nerw (CN X) • Aaessory nerve (C.NXI) • HypogiOSSoll nerve (CN XII)
....:!~--
Ophlh•lmlc l'llf"t (branch dOll V)
L
C2
CJ
These nerves supply motor 1nd sensOI"f 1~ neMiion to the phlrynxand llrynx (011 IX and X) ilnd rnotar lnnervwllon t.o the trapezius ilnd stemocleldom1stold muscles (011 XI). lingual muscles (Oil XII), 1nd floor of the mouth. The .,...,.u.ltlc Plrt of the autonomic nervous syslitm. mns1st1119 of a nerve cord with three g111gli1 thlt extends 1long the vertebral column on Hch .s1.-. The post!lilngllonlc fibers murse with the arotld ilrlit~es to their litmto~es In the head ilnd
a Motor and sensory lnnerv.tton vf the
NoUtheirsubcut:aneouscourse on the lefhide
nudlal region Posl:e!1or view. • Spln~l nerve branches In the nuchal ~ion. b Segmental distribution. The nuchal region receives most of Its mo-
(a). The following ne~ ire deltved from 1'1!11· tral rami ofthe cervfcill spiNI nerves and l!llb!r the nuchal region from the lateral side:
nedc~lon.
tor ~nd sensory Innervation from dorm/ r~ml
'"''*''
,._,...,.tiMac
Another Plrt ~ the 1utonomlc - . s systan, the .,.U111. 1s represenlitd In the nedc b)' thevagus nerw.
16
><:" (4
..
of the cerYICill spinal nel"\\lls artslng from the C 1-C3 cord segments:
• Su bocclpltal nene (Cl) • Gre.;~U!r ac:opital nerw (C2) • Third occ:lpltill nerve (0)
• Lesser occipital nerve • Cireatilurlculilr nerve fllotr. The dorsal nmus of the first cerviCill spinal ncne (the suboccipital nene) is pu~ly motor (stu). ilnd coruequentlythere Is no C1 dlenmiltome.
lnflrlorroot of ansa «rV!cil\!i
•
"
C Motor 01nd sensory tnnerv..UOn of the ill'ltl!ffor 01nd liltl!fill ned:
The an12rolall!ral portion~« the neck, unlike the nuchal region and ocoput, ~resupplied entirely by ~~enrrolrnmi of the C1-C4 arviul spinal nerYe:S. These r.rml distr1bute short branches to the deep neck muscles (see c). They also gllle off branches !hilt form the ce!VIc:al plexus, wttlch consists of a sensory part and a motor p.art supplying the skin and muscles of the neck. Br~ndltng pattern ofthea!Mc.tl plwa (lllt"Wed from the leftstde). The motor fibers from C1-C3 form the ~nsa Q!S'Viulis, which in· nervaru the lnfrahyold muscles (see c). The flbers from C1 courJe briefly with the hypogl~sal nerve, IMthout exchanging flbers with It, before theoy Sl!l)ar.iltl! to form the supt!llor root of the ansa c:eM· ulis, which supplie.s the omohyoid, $1l!mo~ ~nd mmohyoid musdes. Only !he fibers for the thyrohyoid and geniohyoid musclu conlln~~eto course with the hypcglossal nerve. Ottterflber~ from C2 unite with the fib en. from C 3 to fonn the llf(Morrootofthe ansa caYicalis. The bulk of the fibers from C4desand in the phrenic neNeto the diaphragm (see D). b Sensory Tnni!N.IUon of the utertor 01nd liltl!filll neck (viewed from the left side}. £rb's point Is loc.lll!d approximately at the mid-posterior border of the $1l!mDCieidomastoid muscle, and is the sitJ! where the following nerws of the cervical plexus emerge to supply sensory fnnew.rtlon to the an12rlor ;md laterill neck (the srnsory port of the Ceflllcal pleJWs):
a
• • • •
Lesser occipital nenoe Great aurfcular nenoe with Its inll!rtor and p~terror branches Tr.answne cervical nenoe Supraclavicular nerves
fllii-"Tlrw..,__.;....._ 5c.llenus
anterior 5c.llenus
medius c
c
MotorlnfiW'Wtlonofthei!ntarfori!ndl~l neck. Mostofthean· telfor and lall!r.rl neckmusdes ire supplied byvartril r.1ml ofthe spinal nerves. Thefr motor fibers either p.ass directly as short flben from the wntral rami to the deep neck muscles or a:ombine to form the mottx the cen!cal plexus.
root«
D llflrenlc:nl!fft
Anll!rlor lllew. The phrenic nerve arises from the C3, 4, ind 5 ventral roots ("C 3, 4 and 5 keep the dlaphr.1gm a! lYe"). with tile majorcontr1butlon from C4.1t descends thnough the cervical region In front ofthe sulen~K an12rlor, behind the stemodeldomastold, through tile thoradc inlet to the di;lphragm, which it IPI"VI'ides with motor innenlition. AI· though tills Is an unusual anatomical relation between nerve origin and target location lfl tile adult, the embryonk diaphragm deYI!Iops from a precursor (the septum transwrsum) at the ctrvlcallevel, and cames Its innervation with it ~sit migrates. If the C4 segment of the spin~! cord (the main root of the phrenic nerve) sustains bllall!ral Injury lr1 an acddent. the llfctlm will usually die at tile scene from asphyxiation brought on by p.aral~ls of tile diaphragm.
17
2.5
Cranial Nerves and Autonomic Nervous System in the Neck
V.gusnerw
SUperfarcel'lllal ganglion ~ie-----t-'T--
/!Jfl-- -+.l....\_
Sl)4ah)'ald PillryngNI bnond1es
~pathetlclr'Unk
A Glot.sophllryngeel nene left lateral view. The glossopharyngeil nerve (OIIX) urrles the motor flbefs for the stylopharyngeus as well as sensory ftbers for the pharyng~l mucoSil, the mnsils, and the pos· terlor thlrd of the tongue Including the gust<~· tory flbers. It sends small branches to anastomose with bothtltei'JIYlpathetlctrunkandtlte \'igus nerve. It also sends nenlt' fibers (ca!Wd sinus branch) b the blfuncatlon of the com· mon carotid irtefy, which contllns spedal· I'Zed collections of cells that are lmportilnt rn autonamic control af the circulamry system. Mechanoreaptors In the carotid sinus sense blood pressure. ind dlemoreceptors In !he arotkl body monitor bload pH and urbon dl· OXIde ~nd oxygen leYels. This Information Is relayed by the glossopharyngeal nerve w the centers regulating breathing and heart rate In !he bralnstem.
, - - - - - - Vien!r.ll ramus dCl
;.,:........:,.~------
lnfl!rfar roatdai\S.t
amalrs
B ttrPotlo:ss.11 neMI! 01nd 01nsa Cl!l"'lfuns Left lmr~l 'VIew. The llypoglossal nerve (CN XII) supplies motor innel'\'ition wthe tongue. It runsanterfor and Inferiorly In a aJrved course (the ~rc of!he hypoglosSi! nerve), passes
18
c
Ata!uorynerwll'ltMned: Left later.~l view. The aa:essory nerve (CN XI) IJ purely m~tor. Some of 113 flbers arter the sternocleidomastoid muscle from behind while oth· ers conti'nueonmthe traPI!zlus. Adeep(presc;~lene) lymph node biopsy may Injure the accessory nerve In 1t1e neck. D.'! mage tD !he tlbers supplying !he traPI!zius results in lmral ~tation of the $a pula and some shoulder drop. D.'lmilge m the fib en supplying the sternodeldomaJtold le.ilds to we;~kness In tumlng the he.id to the opposite side.
- - SuperlcraMcll
ganglion
Thyroid
stl!llle gangton
GrUiage RJgrt stJbd;M.Jn Mttry
lmrforl1ryngeal nerw
O.rdlac Aortic arch
plemJ Ream!nt
L111)1lgeillnetW
b
D YliV• nerw Tn the neckud the cerwkiiiJIIlPitfu:Uc tru~ a Alltafor view. The v.;rgus nerYe (CN X) conveys the fibers of the cr~nlal portion of the par.uymp.rtltetk nervous system {part af the autDn~:~mic netvDus system) that supply the neck, thorax, and parts of the abdominal cavity. It passes down the neck In the c;~rotfd sheath (sei! topogr.~phlc;~l ;matomy. p.47), gMng off only a few branches In the he.id and neck: • The aurlaJiar branch, a sensory branch that supplies the posll!rior
surface of the ear and the extl!rnal auditory c;~nal • The pharyngeal branch, which supplies m~:~tor innervation to the muKies ofthe pharyn11.and soft palm • The superior laryngeal nerve, a mixed sensory ;md somatomotor nerve that supplies the afcotilyrold muKie and the surrounding mUC0$01
• The re
b Anterior VIew. The pal'iM!!rtebrill chain of sympathetic ganglia tl!rml· nates in the cervical region in the superior cervical ganglion, app_. lrnately 2 em below the base of the skull. deep to the blfurcitlon of the common c;~~tfd artery. Postganglionic tlbers from this gar~gllon follow botil the lntemal and external c;~rotld ~rterles to proY!de sympathetic innervaliarl to the entire cranial vaKulature,ID the iris, and togl;tnds and mucos~ In the he;rd. Thelowestofthecervlcal ganglia In the paravertebr.~l chain Is often fused wtth the flrrt thor.-ack sympathetic ganglfon to form a stellate gang1Jor1.
19
N«k - - 3. C«vvaal V1.5CI!I'D
3.1
Embryology
Trad-lell artillge {artflage rings)
A The bn~nchllll ardlesoftflelllnlll!let
(after lltlmer, Parsons, and frick) Left later;rl Ylew. This simplified schematic ofthe dn:ulatory system of a lanceletftsh lllustr.rtes the bil!lc relatlor1 between Ute vascular tree and tile branchial arches In chord..W. Including Ute venebrates. Oxygendepleted blood (in blue) is pumped rostrally (tow.ard the head) tftrough a ventral
B Det'MIUcln of mu~~a~loslraeletal stnJc:tures from tfle pharyngeal ardlots Tn tfludult (after Sadler) Left latEral view. Besides tfle cartilaginous rudiments of the skelmn (see labels). 1be musdes and their associated nerves can be tr;aced embryologlcallyto specific pharynge;al arches. The first pharyngeal ;anch glvtl rise tD the mastkatory musdes,1be reyloii)'Did muscle, the .interior belly of the digastric muscle. the tensorveU palatlnl. and !he tensor tympani. The second pharynge;rl anch gives origin to Ute mu5eles of f.l. clal expression, the posterfor belly of Ute dlgwtc. tile stylohyoid muscle, .ilnd the st;rpedlus. The stylopharyngeus muscle Is deriVed from the third pharyngeal arm. The fourth and sixth pharyngeal arches give rise to tfle cricothyroid muscle, levator levi palatlr1l, constlictor philryngls, ;and tile Intrinsic muscles of tile larynx. The nerYe supply to Ute musdes can also be explained 1r1 temu ofthefr embryologic orlglru (see D).
Trlgemhal I ganglon - - -------:
Cllrdllc
f
pnxnilencll!
phlryngNIIrdle!
c Ph1rynge.l ardles end phwynge.~~l defU ofa 4-week·old anl11yv (
ryngeal arches irt' shclwn in difl\:!rent colorl. Ub! other ti5SUu of tile pharynge;rl armes,lhey mlgmewllhfurlher development to form varl· ous slrelet;al ;and ligamentous elements In 1be ;adult(see B).
VII
IX
X
\ D lnnerwdon ofthe phlrynge•larme. Left latEral Ylew. Each of tfle pharynge;rl;rrmes Is ;rssodated with a cnnlal nerve (see Thlerne Atlas Vol. I, Genml Anatomy and Musculoskel· etal System): Arst pharyngeal arch
Tr1gemlr~al nerve (CN V)
Second pharyngeal arm Third pharyngeal arch
(mandioolar nerve) Facial nerve (CN VII) Glossopharynge;rl nerve (CNIX)
F«Jrlh and siXth pharynge;rl
;armn
20
Yagm nerve (CN X) (superior and infi:!rior laryngeal nerve)
E lnll!nNIIstrudllreaflhe phllryngul ardis (<~t'tErSidler) Anterior view {plane of section shown In C). The pha~eal arches are covered externally by ectDdenn and lntani lly by endoderm. Eidl phal)ll"lgeal arch contains an arch arteiY, an arch nerve, and a cartilaginous dement. all of which are sunou nded by mesodermal 1nd mUKUIa r tissue. The external fullliWS are c:a lied the pharyngeal defts, and the InterNI furrows are ailed the phliiYngeal poudles. The endodermilllnlng of the ph;11fngeal pouches d-lops Into endocrine glinds of the neck, a pro~s which m
F Mlgrmxy nmwll"ll!nb althe phl..,.alardl lhlul!s
(after Sidler) Anterfor view. Durfng embryonic development, the epithelium from which the thyroid gland Is formed mig ratas from lb sllle of origin on the bisal mldllne of the tongue to the level of the first IJache~l artllage, where the thyroid gland Is located In postnatal life. As the thyroid tissue buds off from the tongue bise, It leaves a w:stlglil depression on the dorsum of the tongue, the funmen cecum. The pi rithyrold g Ia nds ire derived from the fourth phal)ll"lgeal arch (superior pair) or third pharyngeal arm {Inferior pilr), which also glws origin to the thymus (see p.ll2). The ultim~:~branch~l body, wh~;~~e ttlls migrate into the thyroid gland to form the caldtonl1111rocludng C eels or pinfolllc.Jiar cells, Is derived f~~:~m the fifth, vestigial, phllryngul arch. The later arch is the l11t to develop ;md b usually c:oosldered pirt of the fourth philryngeil <~rch. The ~rnal
Fonomen CKUm
UI!Holnock d:=dllal
Hyoid
bono
~-!,old
C.roUd bllun:lllfon
bone
Tlrfrold
Qrtl.,ge flst.!IOUI
tract
Tlll
..
C Lllull11n vii cysts and tlstullll In die neck Median cym, b median fbtulas, c lateral flstulan nd cysts.
1
llell1n qsb ll1d fiiW!n ln the neck (1, b) are remn;onts of the~ glossal duct. Filllure ofthis ductiD r.gness completely m~ lead IDtheformJtlon of a mucu,.tllled e~Ylty ('Y't). which pnescnts cllnlully as a flnn neck mass.
Tnocha
c
l.ltenlcrstJMdftduiBintheneckareanomalous rem nant:softhe ducta I
portions ofthe ceMc:al sinus, which forms au result oftlauc mlgritlons during em bryonlcdewlopment.lfeplthellu m-llned remnants persbt,. neck cysts (rlght) or fistulas (left) may aPI'ear In postnatal life (c). A compl~ ftst1JI<1 opens Into the phirynJI ilnd onto the surface ofthe sldn, whereaun lncomplm- (blind) fistula Is ~:~pen at one end ~:~nly. The ut8n<~l o~ of il literill c:ervlcal fistula Is typically located at the anter\or border d the sternl:ldcldomastold musde.
21
N«k - - 3. C«vvaal V1.5CII!f'D
3.2
Thyroid Gland and Parathyroid Glands
~~-
A Thyroid gland nd pal'lthynlld glands • Thyroid 1Jllnd, anterior view. The thyroid gland com!Jts of two lat·
erally situated lobes ;md a centr.ll naJTOWlng or lsttlm~JS. In place of !he Isthmus there Is oftll!n a pyramldallo!M!, whose apex points cranl· ally to the embi')'DiliC orfgln of the thyroid at the b,ue of the tongue (M!ep.21).
l>.nthyroldglands,
Wi!lforpafr
b Thyroid gland and pal'lthyrold gl1nds, po.sterior view. The p;lrathyrold glands may show considerable y;rrfatfon lr1 thdr number (gener· illy four) and location.
Note: Because the p.1rathyrold gl01nds are WU<~IIy cont
Trachea
Clps\lle afthyroid gland
(exl2m.ll apsule)
Internal Jugl.farwn
1-t=-:'?-il:«r'"'-"!-- Common c.rotrdartl!ly
8
Rll;attorwhlpofthe~dgl;andtothetnc:hN;andneurvw;as.. aj;r struc:tun!s
Tr~n.sverse sect1or1 through the neck at the T 1 lew!, supel'for view. The
thyrvid gl;and partially surrounds tne tr.lchea ~nd is borde.-ed pomro· laterally by the n~roYaKular burldle. When the tilyrold gland Is p;ltttologlcally enlarged (e. g., due to lodlne-defldency goiter), It may gridu· ~lly compress and n~mwt lhe tr~cheallumeo, cauJlng respiratory dls· ln!ss. Now the 01rrangemeot of the fndae: The thyroid gl;and Is JUITOI.Inded by a flbroiiS capsule composed of ar1 lntanal 01nd external l;ryer. The
22
del kate Internal layer (/nwma/ coprulr. not shown here) directly lr1Y1!5ts the thyrokl gland and Is fused with Its glandular parenchyma. VascularIzed ftbrouJ slips extend &om !he Internal capsule Into the substance of the gl;and. subd'n1iding it into lobules. The internal capsule is ~red by the tough extmro/ capsule, which Is p.1rt of the pretradteallayer of the deep cervical fasda. This capsule Invests the thyroid gland and p;lrathyrold glandJ and Is also called the •surgical cap.sule" beca~~Se 1t must be apened to gain surgical acass tD the thyroid gland. Betwl!en tne exb!rnal and Internal capsules In potential spacethatls travened byvaKular branches and Is occupied by the p.1rathyrold glands.
SUportar tlrynlld al'11try
Exll!mol conot!dar11!ry
lhyrai'I'JI'Id mombrone
'conotrd "'""""
thyn>ld""'n
ar1l!ry
S~ar
laryftg""l""'n
~ar
..,.........
lnfaior thyroid .uty Thyn>-
anllal
uunk Rlghtlymphallcduct
Right
"'loryngal ""rront netW
• C Blood 1UppiJ;md lnnlmltlon ofthl th,rold gl;ncl Antelfor view. • AIUftll ....., The thyroid gl~nd deltves most of Its artet1al blood supply from the superior thyroid artery (the flm: branch of the emrnil arotfd il'tsy), which runs forwinl 11nd downwilnl to supply the gland. It issupplied from~ by the infl!riorthyraid artery, which branches from the thyrocentlcal trunk (see p. 48). All of thew arter-
Ies, which course on the right ind left sides of the Ol'giln, must be ligated duringMJrgical remaval of the thyroid gi;Jnd. ~ Oper~tlons on the thyroid gland c.arry i risk of Injury to the recurrent (Inferior) larynge~ ntnll!, which Is closeiJ related to the
posterior sum.~ of the gland. Because it supplies important lolryngeal muscles, unllmnl Injury to the nerve will c.ause postDpemlve hoarseness while bilaberal injury may additionally result in dyspnea (difficulty In breithlng). Prfor tu thyroid surgery, therefore. an lltol;uyngologlst should confirm the lnt.grlty of the nerve supply tu the laryngNI muscles and exd ude any preexisting n - lesion. b Vwna111 dRin1ge: The thyroid gland Is drained antaolnfl!rlorly by i welklewloped l:tiyrold wnous p/mls, whldl usually drilns through the inferior thyroid vein to the left br;~chioc:ephalit win. Blood from the thyroid gl;md illso drains to the Internal jugular ~~~eln vta the superior .and middle th)'rold wins.
rpnhehl call, lqi»'-S
Ill low
wboldol
D Histology of the d!Jrold gllnd The thyrold glilnd ibsorbs Iodide from the blood .and uses It to m;llce the
thyroid hormones, thyroxine {T4,tttr.aladoltcyronlne) and triiodothyronine {T3). These hormones 11re stored iltextracellulilr sites In the gland, bound tu protein, 1ndwhen needed they il re mobilized from the thyroid fDIIIcles and secrmd Into the bloodstnam. A speda Ifeature of the thyroid glind Is the appe11-.rn~ of Its epithelium, which wries depending on whether It Is storing hormones or reluslng them lniD the blood. The epithelial cells are flattened or squamous when in their resting or "sturage stalle" (il), but they are column11rwhen In their active or "secretory sub!" (b). The epithelial morphology thus lndlclltes the current functional state of the ~b. Iodine deflcialc:y causes an enlargement of the colloidal fDIIICllla r lumtn, which ~u;ally results In il gro55 Increase In the size of the thyroid (goimr). With prolonged iodine def!dency there is a reduction In body metilbollsm, and concomlt.llnt lethirgy. t.Jtlgue. and mental depression. CGnwrMiy, hyperactivity of the thyroid, as In GrM!s' disease (an autoimmune disotder), c.auses a generalized metabolic acaleratlon, wtth lrrltiiblllty and Wl!lght loss. In the midst of the thyroid fDIIIdes are pamolllculilr c.lls (COllis), whldl ~ caldtonln. aldtonln Inhibits bone morptlon and redu= the calcium conantratlon In the blood.
E Hlstelogyofthe ,_Rthynlld gllncl
The prlndpal all type In the pa~ttcyrold glilnd Is the ciWf cell, which responds directly to low blood caldum lewis by secreting parathyroid hormone (PTH, parathormone). Parathyroid hormone Increases aldum c:oncentr.ltion In the blood by wrlous means, Including the stimulation of bone resorption by osteodasts and the renal tubular raabSOfl'tlon of c.aklum. Parlthyrold hormone thus acts anugonlstfally ilgalnst c.aldtonln produced by the thyroid's C c.lis. In~wrtl!nt removal af the parathyroid glands during thyroid surgery can ause a d~matic All in serum caldum, with c.austrophk conseq uenc:es. Such 11 ltypocrrlmnlc condition c.auses neuromuscular lmtlblllty and, potentially, gene~ 1ill'd fatal seizum ill'IOiving respiratory musdes. CGI"I'tllersely, pathologic.al hyperactivity of the parathyroid c.an lead to dlronlc hyperorlarnla, often associated with bone lou (osteoporosis) and abnormal calcium deposition In the drculatgry and urinary systems. Chronk hyperpar.tthyroldlsm wtU1 hype11r0phy of chief Clllls and elevilted serum c:aldum is a common comequence of end-sbge renal fa~ute, by a mechanism not cte.rly esublbhed.
23
N«k - - 3. C«vvaal V1.5CI!I'D
3.3
Larynx: Location. Shape. and Laryngeal Cartilages ~ham
Ejllglottls
~ I
Bodyof-hyoldbone
Atlas----
I
~ Thyrohyoid ligament
~ Fo111mMforsuperior lir'yngllill
- -_;:_.;.......,.- - - Aids Hyoid bor.e -----'-~
S~hom
lh)'rold - - ---':-- \
artlage
Crlalld
~ artlage
Cllaltllyrold -
----'::-
llg~ment
Cllc:otr.H:tle. - - . . l . . . -
llpnent
Gener111futu~tofthel.-ynx
A loaltTon aftfu~ llrynx In tfu~ ned:
B
Anterl~rvlew.lnthe~dultmale. whenthehN
Is centered In Ute nedc
Left anterior oblique view. The following urUiaglnous structures of the larynx un be ldent:lfled In tftls view:
• The hyoid bolle lutthe level ofthe C3 vertebra. • The superior borde!' of the thyroid cartilage Is at the C41evel. • The laryngotrache;~l {unction Is at Ute C6-C71evel.
• Epiglottis (see D) • Thyroid carUiage (sed) • Crlcold urtilage (see F)
These structures are loca!l!d appi'OlCimately one-half Yertebra higher In
These cartllages are conllected to one another and to the trachea and hyoid bone by elastic ligaments, which aiiC!w some degree of laryngeal motion during swallowing (see p.37). The af')'Wnold carUiages and corniculate cartilage are not visible In this view (see G).
women .and children. The upper p.art of1he larynx(the thyroid urUiage, see B) is especially prominent in the m;ale. forming the larynge;~l prGmi· nence or •Adam's apple.•
l
fplglotllc
c:artbge
-' - - Foramen for
superlorl~rynQ~I
~lglotilc llg~mtnt
.........~-=+\
- -hF-- - Cricoid crilage
• C L;nyngeal cartl• <~nd ligaments a Saglt:UI section, viewed from Ute left medial aspect. The thyroid car· tllage en doses most of the laryngeal urtllages,lts lnli!rfor partartlc· ulating with the cricoid cartil~ge (eric~ joint). b Posterior view. Arrows Indicate the directions of moverllent In 1he v.ufous joints. The thyroid carUiage un tift re1auve to Ute cricoid ur·
24
b
tllage In Ute afcothyrGld joint. The base of Ute arytenoid urtllage on each side can translate or rot.tte relative to Ute upper edge of Ute cricoid carUlage at1he cricoarytenoid joint. The arytenoid urtllages move during phonation.
IOghtlaml~ Supertcr thyradnctdl
t..ryngeel - promlnoa
~ ObllqueUne
Leftlemltw
llftrtcr / " " tlryft)idnctdl lnfa1orhcm
D Epiglottic c:.r111•ge
Laryngeil,llngual. and left literal views. The 1~1 skeleton ofthe epiglottis IS composed of the elastfc artll~ge shcMn here (the eplglotlk cartflige). This cartdige en1bles the epiglottis to rerum sponti neously to Its lnltlil position It the a1d of swallowing (when musa~lar tnctfon Is lost). If the epiglottis Is remcwed as part of~ tumor resection, the patient must go through an arduous process of le~~rnlng how to swallow effectively without an epiglottis, IVDidlng uplraUon of IngestEd m~ f.al into the lr.lchea.
E Thyroid certil'llt Left oblique view. This hyillne c1rtllage consists of two quad rllmnl
plltes, the right and left l~mrnae. which are Joined In the mldllne ID fonn a kEel-shaped projection. At the upper end of this junction Is the larynge~~l promlna1ce, called the "Adam's ilpple"ln the male. The postl!!rlor ends of the lamlnu ~re prolonged to fonn the superlor and Inferior horns. whkh serw as anchon for ligaments (see 1).
Comlculfoe artilig~
Aperchryllei'IOid artiligo
~~
Lllml,. ----:.:...._-
ofa1
urdl'!le
Plosblfar .........._
•.ma
............
Vocal -
•
~~
Mo.aajar
p........
Conus .._
Vocal --~~-J.I
~0-- Ardcu...-~for
1ry11enold ardlig~
proa$1
Ccllkulus
-4-4----"~
--+-- Artlrularfaatfar thyroid Ulrdlage
c F Cricoid cartl..ge
Posterior view (<1), ;mt:l!rlorvlew (b), left literal vlew(c). This hyaline cartilage Is shaped Ill~ a signet rlng. It consists post:l!rlorly of an expanded cartiliginous pklte, the lamina of the cricoid cartilige. The upper end of the plit:l! bears in irticulu fleet for the iryta"lold artflige, and the lower end bears a facet for the thyroid cartilage. The inli!rior botcler of the a1cold cilrtflage Is connected to the highest lr.lcheiil cartilage by the cr1c:Dtrad'lealllgamtl1t (see I and C).
.. G Arytenoid Ql'fll'llt •nd CIOI'IIIcul•e. c:trtll~ge Right cartilages, viewed from the llttnl (1), medlil (b), posterior (c),
and superior (d) aspects. The function of the arytenoid cartilage ("'Orytenoid" liter;llly means "ladiMhiped") Is to alter the position of the WJcal conls during phonltlon (see p.29). The pyramld-shiped, hyaline arytenoid carblage has three surfaces (anterolateral, medial. and posterior). a bue with two processes (voc1land musa~lar). and an apex. The apex irtla~lat:es with the tfny corniculate urtilage, whld'lls composed of elastic fibrvcartil;1ge.
25
Larynx:
3.4
Internal Features and Neurovascular Structures
B Vesdbulu faldnnd VIKill falds
Ungual to"'Il Eplglcttls
Plrlfonn HyoepiglOttic ligament
rKeiS
Ar}lplglalll< fold
The vestibular folds ("false vocal cords") are clearly displayed in this coronal section. They contain the vestibular ligament. which Is the free lnfer1or end t:A the quadrangular membrane. The flssu re between the watioolarfolds is the rima vatJ"buli. Below the -.atioolar folds are the weal folds ("true vocal cords"), which contain the vocalllg;~ment and !toe vocalls muscle. The ftssure between the vocal folds Is the rima glottidb (glottis), which Is lli~T"CJM~"than the rima vestlbull. NotE: The loose connective tissue of the laryngeal Inlet m~ become markedly swollen in response to an insect bite or inllammatDry prGcess, obstnJC!Ing the rima ~ull. ThiJ liryngHI edema (often Incorrectly ca lied "glottic edema") presents dlnlcally with dyspnlil ind i risk t:A asphyD;Jtion.
CUnetf'onn
tuberde v..tlbul•r
fad
Cllnf
tuberde
Vvcalfdd Median al
.......;~'----
otCIIId arttlage
Su-lotlk JpiiC!
;,aW,::....J,:~-- nansglonlc ll*lt
EJaphlgus
~..:;;.:..-- lo\lbglalllc
ll*lt
Momb,.naus -laflr'ada
A catty of tile larynx: mUCDSIIsurfao ai'IMDmy and cllvlllan lntD lewis
The musa~lu tube of the pharynx and esophagus has been lndsed paster1orty and spreid open (cut edges). Mucous memilr;ne com~ lines the lnt.rlor of !toe larynx and, except at !toeweal folds, b loosely applied tD Its underlying tissue (creating the potential for laryngeal edema, see 1}. The aryepiglottic folds are located on each side of the laryngea IciMty between the arytenoid cartilages and eplglot!ls,and latl!ral to those folds are pear-5haped mucosal fossae, !toe piriform recesses. t«m: These ~have an important role in food tr;msport. The alrw.y andfoodw~ lntl!nect lnltols region, and !toe plrlfonn reCI!5ses channel food past the lai')'IU and into the esaphagus. The epiglottis se.Jis offthe l1ryngeallnlet during sw.~llowtng (see p.l7). b Mlllllllltbil Mellon 1/INIIN frGm the leftside. The cavity ofthe laryrut can be dMded intD th~e IM•ortpaces to aid in describing the p~ loatlon of a li ryngealle5ion (see C).
1 PanlrtQr vlnr.
26
C Levels of the laryn~~ and dlllr baundariiiS Posterior view. The larynx is divided lntD three I~ frGm ab
ltoree levels are also Important In temns of lymphatic drainage. ....,.ofthellrynx
llldlnt
Levell: sup111glotttc: spaa (laryngulwstibult)
From 1M llryngeal Inlet (aditus llryngis) to the -tibullrfolds
Level II: transgloctle SPICI! (intermediate llryng~~al cavity)
from the wstlbul11r folds Kross thellryngeel ventricle (lateral cwglnltlon of muoosa) to die
weal folds l.M N1: sqbglottk spia (lnhglattk:avity)
flom 1Mwal folds to die lr*rlor bon~. of the alaJid artllage
Neck - - l. C811tml VlsanJ
Superior - - -..J,!-11"=Q.'
~~=--+---
Ccmmon
«Jrotkla~
Cl1c:Dttlyrold brand!
tlferforlaryngeal
Supefarlaryll!HI nerw.lmmallnndl
llfYillelllrUry ----+'~\
1/----,;-- - SUpefarlaryngHI nerw. emma! branch
- - --T--7l!-'-\.ll.
---~'-:--~~
artery ~etfar
- - --.:r;
-
old:,-------;-- - - lnfencrlarynge;al
ttfopoldarttry
neM
~Mal
tn.nk
•
D Blood tupply and Tlw!MitSon
- ~~~~~~~----Su~~
lar')'n9fl!IWb Supefar--~~~=---~
ltlyroldwn
tru&--.~G.~::-....,.- r..rdcle ltlyroldwru
lnimar - - --:-:.,....---....., laryngeiJIWb
~--~---,~---~~
)!gular win
• ArterW .,d nerve tupply. Anterior view. The larynx derives Ia blood 5UPP!Y from two major arteries: (1) Ute supertor laryn· geal artery from superior thyroid brllnches of the exlzmal carotid artery and (2} the in· tenor laryngeal artery from the subclavian artery (lila the thyrocei'Ylcal trunk). Thus the artertal supply of the larynx Is anal~ gOU$ w that of the thyroid gland. The lar· yM Is lnnerw!Nbythe superior and lnfafor laryngeal nerves. both of which irtse from the vagus nerve (seep. 19). Nflrz: Owing tD the dose pA:!Ximity of the nerves and arteries. i left·slded aortic aneu· rysm may cause recurrent laryngeal nuve palsy resullfng In hoarseness (the path~ physiology Is explored more fully on p. 31). b Vt~~ollf dr~~I~Mgt.left lateral view. The su· pertor laryngeilvdn drains Into the supertor Utyrold vern. 'Which temllna1Ji!s at the lnter· nal jugular vein. The infi!riar laryngeal vein drains into the thyroid Yell Oil$ plexus, wflith usually drains Into the left brachlocq~hallc vdnllfatftelnfertorthyroldvefn.
27
N«k - - 3. C«vvaal V1.5CI!I'D
Larynx: Muscles
3.5
~{ a left lateral oblique VIew
b Left lateralllfew with the left half ofthe thyroid cartilage removed
T~ry12no1d musde,
~ottlcp;Jrt
tubercle
Oblique ary12nald Tl'll1svene
Comh:ullte tubercle
----';;~~~
lryUMid
Latini
Oblique
ary12nald
_.J,_~~~
crlco-
lryUMkl
d Left lat4!1'allllew. Almost the entire left half of the thyroid ar1flage
c Pl»tenor Y!ew A uryngeel muscles• Extrtllllt l;nyngNI mlllldls. The crfc~d (or anterior crlcothyrold) Is the only laryngeal muscle that attiches to the external sur-
;a
faceofthelarynx.Con!Jactlonofthecrtcothyroldmusdetlltsthecrt· a~id cartilage posteriorly, actiAg with the VOCD/is musclr (see b) tD in· CreaK' tension on the vocal folds. The cricothyroid is the only mu,de lnnerv.rted by the superior laryngeal nerve (external branch). b-d lntJtnslc l1uyngeel miiiCies (the posterior and lmral cr1co.aryte· naids and thethyn:tarytenoid). These muscles insert on the arytenoid c;~rtllage and c;~n alter the position of the vocal folds. Contraction of the postllrlor cdax11ytmold rotates the arytenoid car1flage outward and sllghUy to the side; thll!i It Is the only laryngeal musde that ab· ducts the vocal cords. The /atJ!rol r:r'la>tlrytJ!rrold adducts the cords. Becaun~ this mechanism initiates spe«h production. this intrin,ic Ia· ryngei~l muscle Is alsoc;~lledthe muscltofphoootlon. Be.sldesthevocalls musde, the tnlll.!YI!m' G1)'tl!liOld and thyroorytl!no/d muscles produce com~ do sure of the rlm.a glottldls (see c).
28
has been remCMd to demonstrate the epigl~ttis and the C!Xn!rnal part of the thyroarytenoid musde. NOO!: All of the intrins;c larynge;~l muscles receive their monw in· nerYallon from the Inferior laryngeal nerve. the terminal branch of the recurrent laryngeal nerve. Unilateral loss of the reaurent laryngeal nerve {e.g., on the left side due to nodal metastues from a hi· lar bronchial carcinoma) leads tD ipsilmral palsy of the pi)S!zriof ai· co.arytenold mll!ide. This prevents complete abduction of the vocal folds. resulting In hoarseness. Bilateral loss ofthe reaurent laryngeal nerve{e.g., due to thyroid surgery) leads to dominance of the muscles thatclo:se the tima glottidis, cawing adduction ofthevocal folds
• The muscles descnlled here move the laryngeal cartilages relat:M! to oneanotherandaffectthewnslonand/orpo.!ltlonofthevocalfolds. The muscles that mcwe the larynx os o ..mole (Infra. and suprahyoid mll!ides, constrlctor pharyngls lnfator) are desafbed on p.6.
Neck - - 3. Cervical VJscenr
later.ll cria>Posll!rior
arytenold
Tl'illnsverse arytenoid
cricoarytenoid
b C Indirect laryngoKDpy a MlrTOr I!Xllmlnatlon of the larynx from the perspective of the
B The laryngeal muscles and tflelr actions (arTOWS Indicate directions of pull)
Posterior c~coarytenold muscle
Abduct the vocal folds (open the rima glottldls)
Lateral cricoarytenoid muscle
Adduct tnevocal folds (dose the rima glottlds)
Transverse arytenoid muscle, thyroarytenoid muscle
Adduct tnevocal folds (dose the rima glottldls)
Cricothyroid muscle, wcalls
Tighten the vocal folds
examiner. The larynx Is not accessible to direct Inspection but can be viewed with the aid of a small mirror. The examiner depresses the tongue with one hand while Introducing the laryngeal mirror (or endoscope) with the other hand. b Optical path: The laryngeal mirror is held in front ofltle uvula, directing light from the examiner's head mirror down toward the larynx. The image seen by the examiner is shown in D-
muscle
Median glos50epiglottic
fold
Epiglottis
Vocal fold
Epiglottictubercle
Laryngeal
ventrkle
CUneiform
b
c
d
•
Aryepiglottic fold
Vestibular fold
Piriform sinus
----->;~~
tubercle
Comlcul~
lnt.rarytenold
tubercle
notdl
Trachea
D Appearance of the larynx on indirect laryngoscopy
(after Berghaus, Rettinger, and Biihme) The mirror produces a virtual image of ltle larynx wiltl an anatomically correct portrayal of the right and left sides, i.e., the right vocal fold appears on the right side of the mirror image. Anatomically anterior structures (e. g., the tongue base, valleculae, and epiglottis) appear at ltle top of ltle image, while posterior structures (e. g., the interarytenoid notch) appear at the bottom. The vocal folds appear as smooltl-edged bands that are markedly lighter in color than ltle surrounding mucosa. Reason: There are no blood vessels or submucosa below the stratified, nonkeratinized squamous epithelium of the vocal folds; this contrasts wiltl the adjacent mucosa, which has a rich blood supply. The glottis is evaluated in both the closed (respiratory) and open (phonation) posi-
tions by having the patient alternately inhale and sing "heee. ·The evaluation is based on pathoanatomical changes (e. g., redness, swelling, ulceration) as well as functional changes (e. g., vocal fold position).
a
Deplcdon of the laryngoscopic mirror Image. b-e Indirect laryngoscopic findings. ~splratnry positions: opening of the rima glottldls during normal (b) and vigorous resplradon (c). Pl10natton position with the vocal folds completely adducted (d). During whispered speech, the vocal folds are slightly abducted In their posterior third (e).
29
N«k - - 3. C«vvaal V1.5CI!I'D
3.6
Larynx: Topographical and Clinical Anatomy
s~ larynge;.oln~
-
lnllmall:r.lnch of s~laryngul
s~
llryn51nl vein s~ llrynll4!11lmly
8 Aflproadles to the larynx ilnd tr.ldiN Mldsagltt.al section, left liltl!rill lllew. When
iln acute edeiT\iltous obstnJr:tion of the lar· ynx(e.g., due to~n ~llergic rel!letion}poseHn acute risk of asphyxiation, t:tre following sur· glc.al approildles ilre available for creating an emergency ilitway: Mlddl~thyroldw!n
• DMsfon of the median crfoothyrold IIQil· ment (cricothyrotomy) • lndslon of the trilchea (tracheotomy} at a lewl just below the cricoid c.artilage (high tracheostomy) or just superior to the jugulilrnotd'l (low tracheostomy}.
a
A Topogr.~phlulal'liltllmyofthelarynx:
blood tupp~ and lnneiWUDn Left l~teral view. a Superfici;ll lii)'C!r, b dHP layer. The cricothyroid m111de 01nclleft lamina of the Ulyrold artllage hiM! been ~. .and the pharyngeal mucosa h.as been mob!· lized ;and 11!tr~~. ArteritJ and ~ns enter the larynx 11\ilnlyfrom tile posterior side. Noll!: The motor (external) br;mch of the superfor laryngeal nef\'1! $Upplles the afcothyrold musde. and iU sensory (internal) branch suppiles the laryngeal mucosa down to the level of tile weal folds. By contrast. the Inferior Ia· ryngeal nerve supplies motor Innervation to oil other(intrinsic) laryngeal musdes and sensory Innervation to the larynge;~l mucosa below the vaal folds.
H)'Oidbo~
Superior lll)'l'l!leillne""t
--~~--
Medlao----
Superior la~lwn
Superior
thyrol!yokl llgimelt
la~l;utery
1hyroarytenoid
.ll'laSiomotls
Lalllnl a!colt!yrold
~or
a!~l'j'tenold
Median a!cothyrokl llglment Esoph;tgUS ~ld
Mldcl~
t!Yjrold w'h ll'ache
lnflrior t!Yjro\d Ulery
Tntdlu
lnflrior
" 30
llr,nge~l neM
VDal--~~~~~--~---
lgamont Voalls
_ --=:-=-:c:::..:=-:-::c::--.,.:...,-'-':--
D Structure of the vvAI fold Sdlemiltfc coronal histologic section, posterior view. Exposed to severe medlanical stresses, the voca Ifold (see image inset navigatar for . Information) Is covered by nonlcer.atlnlzed ~~quamous epithelium. Degenerative manges In YOC.ill fold muoos.a m.ay lead to thldlenlng, loss of eli!Sticity, and, potentially, to aquamous cell urcinoma. The adjarent subglottic spare Is covered by dllab!d respiratory epithelium. The mucosa of the vocal folds and subglottic space (Ralnla!'s space) overtres loose connective tissue, and so chronic lrrlbltlon from cigarette smoke In i heiV)'smoker m~ ause chronic edema In the Reinke spare, resultIng In a harsh wlce ("smoker's voice").
• Cmlnl:l ~slans In 1M brcNns1ll!m or ltlgltrr ln\IIOI~ng the nucleus ilmbiguus (e.lj.. caused by a tumor or hemonfMge- an inteml~ilftor paRmedl.an position of the ~~~DC.~ Ifold on the mfected side (seeIt)• • Perlpheralleslom of the vagus nerw haw variable effects, dependIng on the site ofthe lesion:
• Palltlo~ad/tho .......ll'aWs 1. Medllonor phon.Uon pOsition
l. Paramedllon posltlan 3. lnt.medllte pOsition 4. 1..112ral or resplratay position
b
1234
C Eflaas ulc.nlnland p!lrlpher~l YIIIW nerwlulo.. on dl• pcllltlan rii the vaal faIds The vagus nerw provtdu motor lnnerv~on to the pharyngeal and larynge;~l musdes (see .,.ge 37). This Innervation orlglnltes In the numus amblguus In the bnlnst.m, whkh contains motor neurons that contribute .axons to three cranial nerves, arranged in a somatotopic order: the most rostr.al neurons send .axons Into the glonoph.aryngeal nerve: na~ rons In the middle of the group. to the v.agus; the most caudal neurons, to the acxasory ne~ The vagus abo recdves wnK~ry informmon from the larynx, transmitted by primary sensory neurons with cell bodies in the inferior (nodose) ganglion. Lesions affecting the v.gus nt~W an Interrupt rentral control ofthe nucleus amblguus, leaving Its muscle targets In spastic paralysis. ~s that destroy the motDr neurons themlllllves or transect their axons will denervate the musdes. uuslng flaccid paralysb and mrtual muscle arophy. This musde paralysis a~rs the poslllon ofthe voc;al folds.
- Skull boise leslonutthe lew! ofthejugul1rfor•men (e. g., aused by a nasopharyngeal tumor) - an lntennedlllte or paramedian position of the iffected wc.al fold due to a flaa:ld par1lysls of all Intrinsic o~nd extrinsic laryngeal musdes (lftll) -olnabnltyto dose the glottis with - r e hoai'Selle.S$, Sensation is lost in the larynx on the affected side. - SUperior lo~ryngeal nerve In the mldctnltc.al region (e. g., as a complication of carotid surgery) - hypotonicity gf the cricothyroid muscle ... mild hoarseness wtt:h a wuk voice, especially .at hlg her frequencies. Sensation Is lost above theWJcal fold. - Inferior (recu~nt) luynge;~l nerve In the lower neck (e. g., lesion caused by thyroid surgery, bronchlil c1rclnoma, or an aortic ;u"teurysm) ... p.ara lysis of alllniJfnslc laryngeal muscles on the ~d side- a median or param~lan position of the weal fold, mild hoa r:seness, poor tonal control, r1pld voice filtlgue, no dyspnN. Sens.mon is lost below tht vocal fold, Oth~ motor ddicits with high peripher~l re.lons lndude drooping of the soft palate on the ~d side 1nd devlltlon ofthe uvula to the un~ side. Gag 1nd cough l'!ftexes ~be diminished, with sw.llawlng difficulty (dy5phagl<~) and hypemasal speedh due to deficient dosure of the oronas.al avlty. Sensory defects m~ lndude a foreign-body sensation in the throat. Bilateral lesions have more le¥8el!ffeds. Transection of botb recu~nt larynge1l nerves I~ the Wtill cords tuwd In par01medlan position and can ause significant dy5pnea 01nd lnsphtory sbidDt (high-pilthed noise indicating obstruction), necessibting tradheotomy In iiCllte CiiSH.
31
N«k - - 3. C«vvaal V1.5CII!f'D
3.7
Pharynx: Muscles TINCt
whpalatlnl
Tensorw• palatlnl
Ptl!ryvophlryngetl
•
part
r -ff'--";.._- Bucc:opnaryngeal part - - - - - Mylopharynge.l
p.art ----
Clossoplwryn~
p.art
5~ pha~eal
canstrlctar
A Muscles oltfle pt.rynx viewed from the
llftllde a OWrutew of the ph;lryrtQNI muscles, left lm!nl VIew. The pharynx Is a muswlartube whOI!Ie striated musdes are atbched to the base of the skull and are continuous with the e5aphagus at the lew! of!hecricoid C3rtUage (cpposlb! the C6 vertebral body). Although the pharynx loab Ilia! a continuous mus· cular tube emmally. It Is dlvlded Internally Into lflree levels (see p. 36). The pharyngeal musculature consists of the plla1)'1!!1tt11 COI)o .stlict!.v.s (deails in b) and lfle n!bt:ively we.~lc ph~e/M1{ols.
b
32
Tl1tdlea - - -
b SllbdMslcn of the ccnArtd:ors: The muscular wall of !he pharynx Is formed by a trto of ccnstrir:tor musdes en each side: the supc!l'for, middle, ~nd Inferior pllarynge~~l constrfctll~. Eich of these mil!des consists of sewralparts.
N«lc
3. Cmtlml Viscera
~;=t-~~--~
mUIICitbunde ~---~mUIICir.
deep port
4-----mUIICir. s~clllport
:?.!::~-- ~orpharyngeel
~~1--;~----
CDistrlciXIr
lliPhe
1 Philryngeal muscles, poltertor view
As this dissection shOYn, the three philryngeal constr1cton aA! ar· ranged in OYtriOipping layeos. They meet posteriorly illong a vertfal ~nd of connectlw Us.sue, the pha· rynge;~l rilphe.
ObSque l
...llw-,....::"'\.__.1
ao...-....
JMirt
~IJ---f'Undflwm
port
}-~
H\~
Fundlfonn
portofa1a>ph11)!190US
Z..nloor ~m
D Junction ol the phlryngeelend etOphllge~lmuMUietwe lftd the d1M!Iapml!l1t ofZeni!Rr dlvlrtkuli
~~~L--
Mecllll platle ofp«rygold Pn>
Foramen
-~t-==--::IIJ
~~~m
Body of sphonold bone
C PhllryngDIIIBII•faKIIIIIttheblteolthulcull lnfvior vi-. The phiryngeal musc:uiOiture ansa fiom the bi!$<11 of the skull by il thick sheet of a;~nnect!ve tluue, the philryngo!Nsllilr fasda (s'-1 in red). It may be coruidered the tendon of origin for the musculatur...
• Postelfor VIew, b left lm!ral vtew. The a1copharyngeill pirt of the lnft!rlor pha rynge;~l constrictor musc:le Is furthersubdMded Into ;m oblique part and afundlform part. Between these two Jlllrts i$ an a rea of muscu 101 r -~~ness ..._., as tht Killion triang/r. At the lnfutor border of the fundlform part, the musde fibers form a V-shaped area called the 1.11/mertriangle. The weak spot at Killian's triangle may aiiCPN the mucosa of the hypopharynx to bulge outward through thefundlform part of the a1cophilryngeus muscle (b).lhls un result In a Zenbr diYertJcUium, a sad licit protrusion In ~lch food residues may collect ;md gridually expand the 3i!C (with risk of obstructing the esophilgeill lumen by extr1nsk pressure fiom the dlvertkulum). The dlag nosls Is suggemd by the regurglutfon of lr.lpped food residues. Zenker diverticula are most common In middle-aged and elderly lnd 1Yiduals. In older patients who are not optimal surgical Cindldates, treiltment consists vf dMding the fu ndiform part of the inll!rior constrictor endosc:oplally. NotJr: Bec<~use il Zenker dlwrtla~lum Is loc.lltl!d at the junction of the hypo~rynxwith the aophag~.a, it is known also..., a phiryngoaophagul dMrtkulum (the term "esophilgeal dlvertlaJium: while common. is incorrect).
33
N«k - - 3. C«vvaal V1.5CII!f'D
3.8
Pharynx: Surface Anatomy of the Mucosa and its Connections with the Skull Base Sigmoid !linus Mlddl~naal
tumlnatl!
;__..,.:..- - - FliUdal (orapharynge;ll) lst!lmus
- -+- - MedialpUI')'gOid
A ~rfNe MYtllmy of the phlryngclll muCOA Posterior view. ThemuSOJiarposteriorwall oflhepharynxlsclosedposteriorly. In this dissection It hill ~ diVIded and spread open ll'llhe midline to demonstrate iU moonal anatomy. The anb!ricw p;~rt of the muscular tube Is Interrupted by three openings:
• To the nasal C.il1llty (choo!nae) • To !he oral cavity (faucial (oropharyngeal) lsUimus) • To !he laryngeal Inlet (aditus) The pharynx Is dMded accordingly Into a naso-. pharynx{seep. 36}.
8 Po:m!dDrmlnDICOpJ The nasopharynx can be VIsually Inspected by posterior rttlnosccpy. a Technlqueofholdlngthetongue blade and mirror. The angulation of the mirror Is continually adJusted to permit cornpletl! Inspection of the n~ol)h;lrynx (see b). b CompoJlte posterior rhinoscopic Image acquired at various mirror angles. The eustachian tube orffke and pharyngeal tonsil can be Identified (seep. 35).
• 34
~.
and laryngo-
N«lc - - l.
~arl Vlsmnr
Tensarwh pillolfnl
t!-~~-- Stylohyoid ...;_,jFlj~--
s.l!invo-
phoryngeus
hlilll>pharyngeus
Phoryngeol elemxn
Dl!jllb1c
- ---;:;:,roow-- ....;;r-t ' - - - : - - - - lMJ~ muscle
-----'r---""1 -
- f - --
Medial pterygoid
C Ph.iryngal II'UKullture Po512rtor view. This dfssecUon differs from A In that the mucos.a !'las been nemoved to demonstn~ dlr course of the muscle fibcn. The neurwua~lar Jlnlctures In the parlpharyngsl sp.~c:e ire revl.ewed on p. 38.
Pharyngeal
tonsil l..emorwll
--~r-~1
p~lllinl
Slip..,~ pharynge~s
---':".l''r......
Superior _
phJryng .. l mnllrlclllr IJIIUiorrrusde
__:~::='''
D Mulde.ofdlesaftpilllltnnd llllstadlfan blbe Posterior view. The sphenoid bone !'las been sectlaned postertor to die choana! opening In the coronal plane, and the following muscles hive been resected on the right side: levator wn palltlnl, sa lplngoph.aryngeus, p.J latopharyngeus, and supefllll' pharyngeal constrictor. These muscles are p;~rt 11fthe dii'Ollt (sp;~~ ~ tween the soft palate, p.~liiUne arches, ind llnguil dorsum) th.at forms die posterior boundary of the oral cavity. They are ~ here to help explain the muSClllilr founclition of die mucosal features that are seen .at posterior rhinoscopy (51!1! B).
35
N«k - - 3. C«vvaal V1.5CII!f'D
3.9
Pharynx: Topographical Anatomy and Innervation
'1..1tieralband'
Rlghtdl~n•
Alias
Scltp.Matr
DenschlO"s
UVI.fa
~IM!neton:sll
l'ai!OPOSial
ard!
Ungualmnd
~~~~~~~~~~------~d
artill!lf
A Mtdsagltbl sec:Uon
Left lmr~lllfew. The na~l septum. or~l cavity, pharynx. trache
36
11M- - - - - Oro-
pharynx
1\Yr- - t.yngoph;lrynx
8 Leveb ofUte philryiiiNI Gl'lllty
Left lilltefalllfew. The pharyngeal calllty Is divided Into the nasopharynx. aropharynx, and btyngopharynx.. The upper airway and lowerfDadway Intersect In !he o~harynx. The folklw!ng synon)'ITIS for !he lhree pba· ryngeallewls are In common use:
Nasopharynx
EplphaJYnx
Oralpartaf pharynx
Oropharynx
Me:soph;uynx
Laryngeal part ofphaJYnx
Laryngopha· rynx
Hypopharynx
Upper
Na~lpartof
lewI:
pharynx
Middle lewI: I.OWII!f lew!I:
Neck - - 3. Cervical VJscenr
/,L.I-ttt-4---- Epiglottic cartilage
-tt\l\1'= t - - Thyroid
Thyroid
Hyoid bone
cortilage
cortllilge
v· =~~-"-'\--- Oicold
Cricoid
cortllilge
•
cortllage b
C Anatomy of swallowing
As part of the airway, the larynx In the adult Is located at the Inlet to the digestive tract (a). During swallowing (b), therefore, the airway must be briefly occluded to keep food from entering the trachea. The actofswallowlng consists of three phases: 1. Voluntary initiation of swallowing 2. Reflex closure of the airway
3. Reflex transport of the food bolus down the pharynx and esophagus
During the second phase of swallowing, the oral floor muscles (mylohyoid and digastric) and the thyrohyoid muscles elevate the larynx and the epiglottis covers the laryngeal inlet, sealing off the lower airway. Meanwhile the soft palate is tightened, elevated, and apposed to the posterior pharyngeal wall, sealing off the upper airway.
1-----f-';---------- To thalamus and cortex (medlallemnlsC\Is)
Prtnclpal sensory (pontine) - - - + --'r--,f::'\ nucleus of trigeminal nerve Sensilllon (pain, ----'-,="""""'--! temper.Jture, touch)
From the ear
(tympanic nerve)
Sensollon ------11
Taste - - - -tl
.,_,+------,""'====---+-- Stylo-
pharyngeus
.....>.~----------+--
Pharyngeal
constrictor Motor
Somatic sensory Viscer.~l sensory
D Vagus nerve and glossopharyngeal nerve: their peripheral distribution and brainstem nudei (after Duus) Posterior view. Both ltle glossopharyngeal nerve (cranial nerve IX) and the vagus nerve (CN X) originate from nuclei in ltle brainstem. In ltlis simplified schematic, motor pathways are depicted on the right and sensory pathways on the left.
Vocalls (larynx) Note ltlat both nerves contribute to the sensory and motor supply of the
pharynx. Togeltler they form the pharyngeal plexus.
37
Neck -
3.10
J. Cfivlcal Vlsara
Pharynx: Neurovascular Structures In the Parapharyngeal Space
Sl~dolnos
f'lllr-,lgNirapht Ocdpllalartay SUprilr pharyng01l
- ---X!L
--.....;;,;=,~~
conatrldlor
lnf'el1orpharyngml ---H~&,._ CDnsiJictar
__;~.n
A Pll..pllllryngal.-e, pcllt2rtDrvfew The ~rtebral culu mn and all structures posterior to It have been cum· plet:ely removed to display tne posterior outer Willi of tne pharynx from the p0$l:trior aspect. The neu rovas:
c
38
Internal c.-arotld artery, vagus nerw, and sympath~c trunk on the rtght side have been retracb!d medially Into the paraphiryngeal and latero• pharyngeal space. Nib the exposed urotld body, which i$ innt'IVclted by the vagus nerve and sympathetic trunk.
B Ascending phl..,.,.lllrtlry! typiCIIIIIIt:Dmy1nd Vlrllnb (aftermlmann,llppert. and Pabst) Left lmral view. The lllilln arterlil vessel supplying tne upper and middle ~rynx is the a:sanding pharyngeal art.:ry. In 70% of cases (1) it artses fnJm the postervlnfenor surface of the extemil c;arotld artery. In ippraxlmately 20S of c.-aseslt alfses hm the occlpltal illrtery (It). Occasionally (8 S) it originates from the intl!rnal a rvtid ;artery 01" arotid blfuratlon (c), and In 2XGfca.ses 1t alfseshm thefxlal artery(d).
Neck - - l. C81/tml VlsanJ
AbcallllllrtneMe
Oculomotor neMe
nlgemhalnerYe
~V~
~-s----
Vesllxloood!leir ni!M.', lr!telmedlate nenoe. fild1l MrYe
'I;~~~~~L__ CICKSopha~lne~~~r,
vagus nerw. accz=rynenoe ~-1--i----
Faclalnenoe
'""];fr-'"if- - - - Occ\)ltal al'tl!ry ~r-:rt---- S...,enora!Mc.igangllon
~latopharynoeus
HypoglowlneM>
V"!!USnetlle ----~~~
SuperlorlilllfllleillneM ---++~ ~ams----~-~~~~~ S~kt~nk---~~~~~~~~
SuperlorlilllfllleillneM
- - --+- -..-f.H I-
S!4lenctlilryngealartl!ry -----\.--~1-'ft~ Inferior laryngeal win
~lji;;;:::::::::~-- lltlcunm
llryngul nenoe
• - - - - Bntdlloaphlllctrunk
c Pllraphlrynguhplllll! Posterior view. The neurovascular strucllJres in the parapharyngeal space are fully displayed from the posrenor cr~nlal foss;~ to the thoracic Inlet. Al50, the posterior wall of the pharynx hils been longitudinally In· clsed and spread open to demonmare the cavity of the pharynx from the choanae down to the esopllagta.
NOll!: The rna}or neurovascular rtrucllJres In the neck course along the pharynx in a tightly dusten!d a~nfiguration. Stab injuries that perfDra!l! the lumen (frQm accldent~lly Ingested b~nes. for example) mil)' lead to
Inflammation of the paripharynge~l space, causing slgnlfle<~ntdam<~ge
(see p.40}. Even minor Injuries may Incite a punulent bacterlallnflam· matron ti\at spreads rapidly wthln this a~nnectllle-tlssue space (cellu· litis}.
39
N«k - - 3. C«vvaal V1.5CI!I'D
3.11
Pharynx: The Para pharyngeal Space and Its Clinical Significance
lnumal c.;rcad artery lnumaljugulilrw!A
a A
Aetropllaryngeal f1n'9h node.s
P.alm>pharyngeus
Dens
St)4opharynge.;~l
VMI!bral
ofalds
apanwro:sls
a111ery
P
(after Fr!tidl and KOhne!) a Tr.answne section of the neclc at the level of the tonsillar fossa. The pharynx Is surrounded later;rlly ;rnd pomriorly by ;r layer of conr~ec· t!ve tissue (paraphirryngt'i!l space). whkh Is tr;rvened by neurov.ascular structures. It Is further subdivided Into ;r retroplwlryn!lf!GI and latl!topltaryngeol sp;ace.
b The retropharynge;rl space (green) Is only a thin connective-tissue
space directly bordering the deep li!l)'l!r of the cervical fascia (prevertebral lamina, ted). The lab!ropharynge;rl space is subdivided by ;r sh~t of connective tlnue. the rtyloph;rrynge;rl aponeurwls. Into ""anterior part (ydlow) ;rnd a posterlor part(orange). The stylopllaryngNS muscle borders this fibrous sheet. Ylhldl originates from the styloid proce.u of the temporal bone.
• 8 alnkills1gn18canc:ufthe p.;lr.lphilryngNisp.KI!
(after Bedler, N.aumann, and Pf.lll:z) a The paraphirryngeal sp;ace hillS major clinical importance because bacteria ind lnflamm
40
vagus nerve
b
Med'alt!num
lnflamm
b An
Neck - - l. C811tml VlsanJ
Glauapharyngeal n~ ---':.....r,.,_-=-!r; Asa!ndlng pharyngealamry. ttonslllarbranches
Lingual ttl nsll
Tlr-----1-- - fplgloUicwlltcull
Pllllopharyngeu. SUpo!fforlarynge>~l~rury --~r"l'f.i"'"" SUpo!fforlarynge>~IN!I'Ye
In~
nctdl
c
Neuruvatalllr stnJc:tures af tfu~ ptuaphllryngeal spece (afb!r Pla!ZI!r)
Posterior Ylew ohn en·bloc specimen composed of the tongue. larynx, esophagus. and thyroid gland. as It would be resected at autopsy for pathologic evaluation of the neck. This dissection de.ar1y demonstrates
the branching pattern of the neurovascular structllres that occupy the plane between the pharyngeal muKIH. ~the vascular supply to the palatine wnsll and IU proximity til the neurovascular bundle, which creates a risk of hemormage during tlln· snlectomy.
41
4.1
Surface Anatomy and Triangles of the Neck
~
/ -L._
SIJ!mondbuor lllangle
~ lllangle S~I •
Mumllor tnongle
PoJt.rtor antal regon
A Regions aftlle nedr{arvtaol rea~-) Rlghtliter•lvtew, It leftposterlorobllquevlew.
<11
For deKr1ptiW purposes, the ~nt«1or ~nd l.ltll!r~l neck ~re dMded Into two triangle$ which share the mrnodeidomutDid •s il boundiuy. Each
is further tubdivided into small« triangles (lined in C). The dinician should knowthe boundaries and contents of the cetvlal triangles In order to perfonn ;m orgllntred phys1alexam1Ntlon of structlnes Within each triangle (see D).
Submoncllbulor lllangle -
-
- f ! -..JI[..-- DlgiiS1Jicmusde, p-rior bolly
-+--1---- Stomodeld... INIItxlld
Subm.:~t~l
tnongle
-+---- ..............cal region
- -Sllemacll!ldomostdd
•
LIIIRimmaot regton,
ponorlor cr.1allllangle
42
Tropaluo
B Mutde dltseetlon of tile nedr, wtdt the anTaol regioN outlhed AntErior view wtth the hud slightly emnded. It Left lmnl view. il
Nedc -
4. TopogmphlcGI Ano1Dmy
c llegiDnsofthe n«k(CII!I'IIIc.tlnegiDns) a.leRIIcervlai-..Jon • Omoclavlcular (subdawtan) triangle • Oalpltal triangle
AntertoraMcAII rwglon
• • • •
Submandibular tr1angle Carolld triangle Muscular tr1angle Submental tr1angle
JllaslettDraNial reg""
st.Mdel.,__.d-.g..n • Lesser supraclavicular fossa
D DllltrtbUUDII of -mmlallly lmpartarrtttruc:tlns by Cll!l'lllc.tl
regions (after AnKhirtz) Certain deep siJUct:IJres In the neck have lflelr surface projections In specific cervical regions. Convenely, pathology tf!at Is noted In one region can be reti!m!d m .m underlying anatomlc.ll structure. Clo· mus tumors, for example, are locatl!d in the carotid triangle. All of tf!e regions InC are not listed because some regions ire rarely 01ffected by dlseise.
fmmal oc;q,lt
AIQrt... atVIcal ,.....
• Submandibular triangle
Submandibular lymph nodes, submandlbu· tar gland, hypoglossal nerw, parutld gland (posll!flor)
• Carolld triangle
Qrotld bifurcation, carotid body,
• Muscular tnangle • Submental triangle stemoclet•m..uld
Tbyrold gland,larynx.lrachei. esophigus Submental lymph nodes
hypoglossalnetW
......
b
StemocleidomuiDid musde. anllid artery. ln!BNI Jugular win, Yagus nerw, Jugular lymph nodes
E Pllpable bony promlnotna!S In tile ned! Anterlor'riew, b pomriorvlew. ThesepolnbprOYldeuseful~natom· lc.ll landmarks for physical examination of tile neck. 01nd tf!ey hdp to deflnetf!e boundaries oftf!e cervical regions.
ill
l.a..,._llymph n.-s, accessory nerw, cerYlal pleas, brachial plexus
F l.dt·skled muscul;rtllrtfmllls (aftef AnschOtz) Tortialllis and gDiter (see B) are examples of
cavlc
C Retrostll!m;~l tolb!f (after Hegglln) Agoltl!r.nrt artses from the Inferior poles (see p. 22) of the thyi'Did gland may extend to the lflor~dc Inlet ~rid compreJS lfle cervical veins at .nat le~~el. The result of tf!ls Is venous congestion and dilation In tf!e head .ilnd neck region (see H).
H Asses.slng tfle centr.ll wnous pressure In the nedc In a semHJprtght pDS'Itkln.
Narmally the CA!I'IIical veins atl! collap.sed in the slt1fng po.litlon. But In a patient with rlght· sided heart failure. there Is diminished venous retum to tile right heart. Col Using dlstent· iarl d the jugular veins. The extent of tf!e W:nous congestion Is Indicated by the leYel of pulsations In the external jugular vetn (the •venous pulse." upper end of the blue line). The higher tlle Jewel of jugular pulsation, the gre.1terdle bilckupofblood lntotheveln. This prOYldes a means of assessing the severity of rtght-slded heartfaOure.
43
4.2
Posterior Cervical Triangle
CAnlColllbnndl
P.uotld gland
A Utnlvlewofthe neck, subcutaneous I!IF The po~b!rior ce!'VIC
B Utnl Clenlfc.~~l region (posterior cervk;ll t.rfilrtgle),l\lbt.llcfiiiiOIJIIf Right lateral view. The Inverting layer of the deep arYICil fasda has been removed CM!I'the posteri~rcervical triangletoexpo.sethepl'lM!r· rebrall;ayerofthecervlcalfascla,whlch Is fused to the pretracheallamtna at the lew! of omohyoid muscle (seep. 3). The cutaAeOUS nerYeS from the cel'llicill plexus perforate the i~st· lng layer of the deep ca'\llcil fascia at app_.. lmately the mld-po:sterlor border of the rter· nocleldomastold musde (Erb's point) .ilnd .ilre disttibutl!d in the subcutaneous plane. NOflr the emrnal br.~nc:h of the accessory nerYe, which passes to the trapezius musde. A surgeor1 taking .a lymph node biopsy at may accidentally sewer the extJ!rnal branch. This in· jury mtrlc:ts the mobility of the scapula, and the patient m.ay be unable to elevate !he imn beyond90'.
off.Jd'al neM
ll!tl!lmtdate supra· ciMallarntl'\lltS
S._.tlclal _ _-!.-......!...-'-+.;~"-1. Cl!l'\llal artl!ry Trapezha
Supra-
dr;lt\llar nerves
Pre!racl!ul lamina
44
Nedc -
-6-....,...,,-+---,--+,'---::= ; -\\1~+---':---"--....._~-
4. TopogmphlcGI Ano1Dmy
External
Jugtl~rwl'l
Sllemodeldo· mastoid
'-i---'ll'MIMI'!eullllaland
Trapez\ls ----~---+
(N VII ~na.stllm0$!1
S~dal -----=--=-----..~~iU
Cll!rvlaiYI!fn
•
Sa~n~------~--------~~
pc.ltefiOt
Omohyoid
,.
'
.,~,,
C ~Toroentaol trlllngle i Deeper lil)'er. rtght lilta'al ¥few. In this dissection. the pretrache.11 layefofthe deep ceNfcal f.lsda has iddltfonally been removed to dis· play the omollyold musde, wtlTch rs enwloped byth.rtfasdi.
b Deepm: lii)'C!r with <~ view of tfle brachial plexus. The p~rt!!bral !ayEs has been removed to eJCpose the scalene muscles. Noll! the phrenic nerw, wtllch runs obliquely over the scalenus inte-
rfor muscle to the thor~ de Inlet.
45
4.3
Anterior Cervical Triangle
A The neck. superl'clllllm:t"
Anterlorlliew. The subcutaneous platysma has been removedonlflertghtslde,indthelnvestlnglayeroflfledeepceNkal~da(see p.2for
cervical fascial stJucture) has been split in tile midline ind p;~rt!ally removed. elCPQSing tile sternal head of the rtght sll!modeldornastold mt~~de. The an1l!rlor ce!'lllcal triangle, ~Mllch Is bounded posteriorly by tile sternodeidomastold mt~~de and superiorly by the lower border of!he mandible. Is p;~r1Sa.tlar1ywell dellneited on lfle right side. Tbeintertorj~~gularveln and inch of tile jugulir lll!in can be identified. The Inferior pole of tile p;~~d gland projects Inferior to !he mandible. When lfle p;~notld gland Is Inflamed (mumps), It causes conspicuous facial swelling ind defcnmity in this region (•hamsterchecb" wltll prominent earlobes). NOll! ilso lfle cut.1neous nerves of lfle cervical plexus (great .iiUrlcular, tr.ilnsYerse cervl· cal, supradMc:ular), which radl.iltl! tram £r1l's
l'
lnwstng llyerof ~1\uda
£ldJ!m.il
JugLiarwln
point(~p.-44).
SUpr.ao:l:llllcUar
netW£
Stl!mocleldotn.lstGid nude, stJ!m1l head
hb!m:ll Jugular Yeln SUpe!orllryngNI
ni!M!, exbmal bnlnch Rlghtconvnon
ca nltld art1ry SUpe!or -
B The neck, dHp lm:t"
Anterior Ylew. The pretracheoill lamina (mid· die layer ofcuv!cal fascia) has been removed. The lnfrahyold muscles Inserting on the pretracheal lamina hal/1! been resed:l!d and lfle Yisaral fascia has been removed to expose tile thyroid gland. ~Mllch Is posterior to lhe Infra· hyoid musdes. Tbe superior thyroid <~rtery, lfle flrst branch of lfle exl:l!mal canotld <~rtery, an be identified. The extemill branch of tile supertor laryngeal nave, a br.-anch of lhev.-agus nerw, courses ~h lfle superior thyroid irtefy totileafcctilyroldmt~~de. The Internal branch of tile supefoor laryngeal nerve p;~ss.es til rough tile thyrohyoid membrane with the superior laryngeal artery to supply lfle larynx.
46
llftrdd artlry £xtemal JugularYeln
-+--rf'---t-ti\IVI
An:h of
)lgularwfn
Nedc -
~IYntn~e
4. TopogmphlcGI Ano1Dmy
- - - ---:F-4rt':'"J•
Plu""''-
5uperforlaryngNI - - - --?'-" ntM, emma! branch
Brachial plexus
Internal Jugular vein Inferior ltlyrold al'tl!ry ~ma1--~~~~~m
T~oervlala!Ury
trunk
~or
laryngNI nerve
C Deep;mterforceMc:illl regtanwtthtflethyro'-lgl~nd Antll!rlorvlew. The follOWing neu-ascular struc:turts art oorlyllfslble in tneir co urn thnough tne tn~racic inlet: the comm~n anotid ~IU!ry, subdavlan artery, subd.Man veln,lntll!nnal jugular vein, Inferior thyroid
Cammon a laid a!Ury
~~eln, vagus nerve, phrenic nesve, and Inferior laryngeal nesve. It can be seen that a retrosternal goiter enlarging the Inferior pole of the thynold gland an easily compress ne~Jrovascular stnuCWI'I!!S at tne thoracit inlet (see Ag.G. p.43).
=-""---~or
tlflrdd al'b!IY
Vl!ttl!br.ah!Ury RKumm
laryngml ntM
Sllbcl¥olin ~
D Course ofthe right recurrent larynge~l nerw
(after von Lanzand Wachsmutn) llnterforlltew. The reaJmrn laryngeal nerve Is a somatomotor and sen· sory br.mch of Ute vagus nerve, which lnnew.rtes all Ute muscles of Ute larynx el(C4!pl: the cncothynold musde. Unilateral damage to this ne~Ve supply I'I!!SUfts in hoarseness, while bilateral d~mage l~s to a cl~ed glottis wtlfl severe dyspnea. The reaurent laryngeal nesve may pa~ In fnont of (a), behind (b), or between (c) Ute brandles of the Inferior tfty· nold artery. Its course should be noted during operaUO!U on the thyroid gland.
E VI IfItT-In tfle bnndllng plttem of tile rtght lnf1!rtor thyroid 1!1ery (after Platm'}
The coul'le of tne lnfeltor lhyrold artery Is highly y;rrfable. It may run medially behind Ute vertetmal artery (a), 1t may dMde Immediately if. ter arising &om !he Utynoce!'VIcal trunk (b), or It may arfse as the ffrst br;~nch of tne subci;Man artery (c).
47
4.4
Deep Lateral Cervical Region, Carotid Triangle, and Thoracic Inlet Ccmmon anltfdamry
lntmlll
Jugular'f!ln
A Base of neck ;~nd thor.! de Inlet on 1he
left side Ann!ri~r view.
The sternal end of the clavi de, the anterior end of the first nb. the manubrium sll!ml, and Ule thyroid gland hawoe been n!mcwed to expose the thoroilclc Inlet The subclavian artery and thyroceMc:al trunk c.1n be ldentlfled. NOll! tile coorse of the followlfl!l structures: The Internal thor.-ac:k .-artefy descends par;allel to tile sternum. It is of special clinic.1l interest. In p;atimts with coronary heart disease. the lnternallhoradc artEry can be mobilized and .aflilstomosed to the coronary artery past tile point of tile sb!nosis. The symp;athetic trunk. Y
llr.Jthlill
plexus
Asanctng
O!Mcalartl!ry C6new!Wt
---1----
~r.aloilrtl!ly
--!!.:---..........
Trai'IM!ne
aMc:alartl!ry
~l~~~~~~-s~~~~ artl!ly
SlbdMin oilrtl!ly £mmal
R2cun'ent (lnftrlol)
laryngeal nerve
jugular win
SlbdMin win
lntl!mll
Olgntl1c
a~d artEry
£lmTIII carotid .uty flldalamry Unguala~Ury
Aco!ssory nem.o, oll!mal branch
Marg11'1101lm.11>dlbulilt branch
Sul"!rior CleM a I
offllcllllnen.oe Submanclbtlat gland
ganglon 8 C'arvtld tri'll'lgle Right 1.-ater.-al view. The c.1rotld triangle Is ;a subll!glon of tile .antenor ceNkal triangle. It Is bounded by the mrnodeidomastoid musde. the postenor belly of the digastric musde. and tile superlorbellyofthe omohyoid musde. The submandibular gland an be seen .ilt the lnfe. rfor border of the chin, oilnd the sb!rnodeldDmastoid muscle has been nwarnd posterolat· erally. The follow!r~g SU'Uctures are located In tile arctld triangle: • Internal ;and external arotld artzrtes (the superior thyroid and lingual arterle.s branch from the latter) • Hypoglossal nerw • 'Vagus nerve • Acce$$ory nerve • Sympathetic trunk with associated ganglia
lllb!mill Hypogloual
Juguliir'f!ln
nen.oe
~~----~~H--T-r~l mastoid a1l!l'y
Vagusnem.o {CNX)
Ansaan1Cllils Qrotldboctf EmmaI
Jugular win Sb!moclel~
mastoid Ornchyold
48
Nedc -
4. TopogmphlcGI Ano1Dmy
~~~~4-----s~~ld~ M,\K1r.,.r--...J~;-/,.--- Thyroldgland 1'1~~---fr-+-J.:___ Common~d~rtery
llnrdllal plmu ~~mu~~----~--------------~~~~~~
lnfisforbelly
C Del!ftlmnrlanfulreglon Right lateral VIew. The stemodeldornasmld region ~nd ullltfd !Jfangle hM! been dim!cte
•
Commonul\ltfdarterywlthltsdiVIslonlntothelntem~l~ndextemal
C.11\1tid ~rterie.s Superior and lnfertorthyrold arterles Internal j~~gular vein Deep arvlcallymph nodes ~long the Internal jugular vein Sympathetic trunk inclllding its ganglia
• • • • •
Vagus nerve Hypoglo$$al nerve A\::ce$$ory nerve Brachial plexus Phrenic nerve.
The phll!nlc nerve ortglnams from the C3-C5 segments and therefore Is p.ilrt of the cervlcal pleJWs. The muscular landmark for locating the phrenic nerw is the scalertus anteftOr, along which the neNe descends In the neck. The (posterior) lntm:calene sp.;~ce Is loc.ltlld between the scalenus anterior and medius and the ftrrt rfb and Is tr.wersed by the brachial plexus and ~bclaVIan artery. The ~bclavJan vein passes deeply thi\IUgh the interv.al farmed by the scalenus anterior, the sternocleidl)mastoid muKie (resected), and the first rib (the anterioc- intersalene Sp.ilte).
Ungudadal trunk
Emma! arotld arb!ry ~ilgual
trunk
Thynlfnguolidll trunk
D Yarfable posltfon ofthe otem;rl and lntl!mal arotSd i!rtHTes ndwrflntslntflelfttl!rforbnndlaoftfleotemalaroUd ar1ery (after Faller and PoiHI·Golth) 01, b
~:-e
b
c
d
The Internal carotid artery may artse from the common arotld artery postertolateral (49") or interomedlal (9") to the external arotkl artery, or ~t other lntermedlm sites. The exb!rnal arotid artery may give origin to a thyrolingual trunk (4 ").llnguofaclal trunk(23 "),or !hyrollnguofaclal trunk (O.U).
49
4.5
Posterior Cervical and Occipital Regions
Ocdpl.llwln
()(dplt
lymph nodes
ltllrd O((lpiUI
,_,~---~~
Senllpln•lls
capitis
nenoe ...
~,;;_
A Pom!ftDranful retlon ;md ocdpltal retlon PostenorlltewofUtesubcut.ilneousla)'4!1'onlheleftslde~ndthesubfasclal
layer on Ute tight side. Although theoccipit.ill tegion isp.ut of the head, it bdlscun:ed here beeauK- It borders on the posterlorcervlc
mediallysiwatedgrr.ateroccipit.ill nen~eir.adorsul ramusoflheC 2 spinal
50
_ _ _ Stl!mocll!ldomastdd
nerve. while Ute la!l!i'illy sll:uated lesser ocdpltal ne~Ve Is a~ ramus ofC2thatarlsesfromUtecervlcalplexus(seep.17).Thelymphnodeure located at the .sites where the netvl!s and wins emerge through the cen!ulmda. Note the extl!mal branch of the accessory nerve, which crosses the lateral cervical triangle at a relaUvely superficial level.
~mlspll\llls
!Aipltb Oblqws!Aipllls supaior Redusapllls post8formlnor
I light Mbocdpltal tlitngle
Posterior view. The su boa:lplt1l trl1ngle Is bounded supertoriy by the rectus capitis posterior major, laterally by the obllquus c;~pltls supertor, and lnfalol1y by the obllquus capitis Inferior. This muscular trtang le can be seen only al'b!r the trapezius, splenius capitis, and semispinalis capitis muscles have been re~-A short. free segment of the vertebral i rtery runs through the deep part of the triangle after leaving the transverse foramen and before exiting the triangle by perior.rting the atliln~D-ocdpltal membrane (not visible here). Thrt segment tA the W!Ubral artay gives off br..nches tD the surrounding short nuchal muscles. Both vertebral arteries unitE lntr.Kr.!nrally to form the basilar artery, which Is a m:.jor contrlbutur to cerebr..l blood flow.
G~r------~~~
""~lnerw
Vt~l,roery ---H~
Redusapllls post8for fllil{or
- - -+fi
Obllquus capitis nfmar
Sptlous pnx211 afoJII11 Tblrd ocrlpltol
nerw
Oplttholmk:...,.
Ophthalmic...,..
I
Cl'e3tB'
ocdplto1ln,...,
..
Leser otdplto1ln,...,
b
c
OIN'ullyTmportant S1tft of emerg~NR ollhe oa:tpltal nente~ Posterior view. The sites where the lesser and greater occipital nerves emerge !Tom the fiiSda lntD the subcutilneous connective tissue are dinically important because they are tl!nder to palpation in attain diseases (e. g., meningitis). The eJCollmlner tests the sensation of these nenii!S by pressing lightly on the clrded points with the thumb. If these points (but not their surroundings) all! p;~inf\11, the finding is desoibed. logically, as "tl!ndemm _.the occipital nerves."
·~
D CUtaneau~lnnB'fttlun of the neck Postaior view. The [Nttern of segmental In nervation is illustrated un the left. and the terrllllrlal assignments of spedflc all3nous nerws on the righL The oa:iput and neck deftve most of their segmental innervation from the second and third cavlcal segments. The ophthalmk nerve supplying the o1rea above the C21ewll~ the first br.. nd! of the trlgemin<~l nii!~(OI V}.
Nore that In the perlpherill Innervation pattern, the greeter occipital nerve Is a clorMI spinal nerve r..mu.s whlle the lesser oa:lpltal nerve Is a vmtnJI r;omus (Jell! p.16}.
51
4.6
Cross-sectional Anatomy of the Neck from the T1/T2 to C6/C7 Levels !arnodeklo· IMS!ald
lnllnlal)ugulwwn
Tlwi'ID'I
A Tnintftne -Mdlan of the neck.t1lnel tl'llt)uat 'uta the left planl danw (1-1 afthe T1IT'l V8UIIIilllladles) Inferior view. Due to the curvawre ofthe ne
The section In Alndudes cross-sections of the C6- C8 nerve roots ofthe b111Chlal pii!IWS ilnd a small section of the left pleunl dome. The proximity of the pulmonary apex to the twachial pluus shows why the growth of an aplc.allung tumor rmy darmge the brachial plexus roob. NotJr also the thyroid gland and Its pi'Oidmlty tD the tuchN and neu ro..ascular bundle in the catot:id sheath (a thin fibrous sheet which is not deirly discernible In thesevtews).
safes).
I~ disk
Tlwrtlbn TlsplnaiMrw
1 ll'lln-neaau-Mdlan thi"DDIIh thllawer third of the thyralcl
C6-C8 roots of the br~ehlal pious. Nabl the neuiiiYISCulilr structures
urtlltge 0D11dlan of theT 1/C7 verwll,.llladles) Thls crosHectlon dearly cllspllys the SAien us antedar and medius muscles and the lnten"l between them, which Is trawrsed by the
in the arotid shmth (comlnGil caratid ;~rtery, intern;~! jugular V'll!in,
52
wgus nerve).
.....,.:...;,---- ThyroldGiond
_ _ _ Ellt8niiJU!IUilrWIIn
-~~....,_
C Tninnww croN-siCtlon 1t the 1M rtltheWAIII musdeln tt. lirynx Uunctlon of1M C. I C7 wmbnl IIIMIIes) This ci'OSH«tion panes through the larynx at the level of the vocal folds. The thyroid g lind ap~rs mnsldenbly smaller it this lew! thin In views A and B.
Ary11nold artilagt
Supellcrthyrold Wlln liypopharyJU< /
Convnon co..XId 1mry
Longus coli
II "~ .
C
C5Jplnalnoow~ ~· CGspl'lalneM C&wrttbra
~~
';
'•
Ospl'lalneM
.-sapulle Trapa\ls
__ .,.
-~...,
-..rtlebnl•rch af T1
- --f....,...,.
D Ti'lln- croN-sec:tlon et thelewl althe .-ytmard cartllll1e
(lneloftheCSwe...._l body) This cross-section p.1sses through the bme ofthe .1rytenold cartll.1ge In
Sembplnolb mnlcls
the larynx. The hypophal}llx appHrs as .1 narrow transwne deft be-
hind the lii')'M.
53
4.7
Cross-sectional Anatomy at the Level of the C5/ C6 Vertebral Bodies
l.~-----=----l.alghslmtaaplth ~#:..,....------::--
l..ellatllt .scapulae
~~-+--- T111pe;dus
Spinal con!
v.mbral lll'dloiC7
A Tr.ll\sverse cross-sec:Uon ilttfle 11!111!1 of tfle laryngNI vestibule, demonstratfng tfle eplgiiiUfs (C fi vertll!bral body) The piriform ~$$ an be identified at tnis level, and tne vertebral artefy Is visible In Its coune ;!long the vertebral body. The wgus nerve lies In a postafor angle betwe1!n Ute common arotld artery and Inter· nal j~~gular vein. Tills IIIN shows the prcftle of the phrenk neNe on Ule sc.alenus anterior muscle em the left side.
54
llhombald
minor
Nedc -
Splenlur.
Splr~tofC7
~
4. TopogmphlcGI Ano1Dmy
Semispinalis CA!Mcts
8 TnnliVI!I'V cross-sec:Uclll at the level of the C s vertebnlllody The elollgmd splnoul process of!he c 7 Yel'tl!llra (vertl!bra promrnens) is also visible ;at this level owing w !he l~rdotic curvawre ~f the neck. The !Jfangular shape of the arytenoid e<~rtllage Is clearly demonstr.rted In the laryngeo~l cross-section. The laryngeal veltlbule c;m also belden· tilled. Tilts VIew .illso shows the extern.ill br.ilfiCh of the .ilcxessory nerve medial to the stzm~~Cieid~astoid m1.11de.
55
Thorax Spaces ......................................... 58 2
Organs ......................................... 70
3
Blood Vessels .................................. 114
4
Lymphatic System .............................. 128
5
Nervous system ................................ 140
1.1
Overview of the Thoracic Skeleton and its Landmarks
S!!em~l
B Prqtctfon tit alllf:Dmlul stnJdures ontD tiM thoriiiCk wrtabr.~e
line P.arartl!mal line Ml~k~Mc:&lar
r
•
line
P.ar.M!!'!ebral line
Sapulr line
T1
Superior border of ltle scapula
T2J3
jugular notdl of ltluternum • Medial borderofltluc.apular spine • Posterlorendofltle pulmonary oblique fissure
Po!iterlor mhllne __,/' Sc
spbe
Tll4
---Sc.lpula ---lnfet!Gr 1ngleof
sc.IPI-f•
b
SplriCUS process afT 3
(en die lne connecting
Tl-4
Manubrium of sternum
T4
End of ltle aortic arch
T415
Sternal angle
TS
Thoradcdudcrossesltle midline
T5-8
Sternum
T6
Superior border of ltle IM!r
T7
• lrmenor sapul~r angle • A«essoryhemlaZ)
n
• Gwal hiatus of ltle cllilphragm - Inferior -...ena cav.a - Rlghtph~lcnerve • Left phrenic nerve piera:s ltle diaphragm b)ltie leftofltle central tendon • Hemlazygos win cnJSses ltle midline ID the right and opens lniD the azygos vein
TIJ9
• Xlphostemal synchondrosis • Superior tpi,astric wssels p;ass ltlrough ltle diaphragm • XIphoid proCI!SS
TtO
• Esoph
T12
• Aortlchlalllsofltle diaphragm: -Aorta - Azygos and hemilzyglos veiM - Thorade duct • Orlglnofltlecellactrunk (lnfer1orborderofT12) • SplanchniC nerw:s pass ltinMJgh the aura ofthe diaphragm • Sympathetic trunk passes below ltle medial arruate ligament: tr;rnspylorfc plane (•llnelnabdomen, seep.150)
ltlesapl.farsplles)
b.::::=--':<-:-'-:--:--
SplriCUS process afT 7 (en die lne connecting 1tle lnlerlcunglesof 1tle sapl.fae)
c Spine ~a proc:KS afT12 (sllgrt!y bdow
ltlet'
A Anatom'lallllrndmarb of the tlunck liblaton The thoracic ski!leton presents a number of VIsible .ilfld palpable landmark:!. that are acCI!S· siblew physical and r;rdiographic ex;amin~tion (see 8). These landmarks can be u~ to define referenCI! lines for desaiblng and evaluM· lng the location and eldl!nt of organs based on their ~ationship ID the lines: • longitudinal reference lines (a, b) are defined by viJible or palpable anterior (a} and posterior (b) bony struct\lres .ilnd provide lnformMion on Ule location and extent of specific tltor;rclc organs (e. g., the apical heartbeilt is palpable in the left micf.davitu· larlrne). • Most horfzont.ill reference lines (c) .ilre defined by the position of specll!c tltor;rclc verb!br~e. The selll!!nth D!!rvical vel'll!bra (C 7) is
58
easily Identified by palpating Its very prornl· nent spinaus pr'D(tss. It provides a starting point~ whkh the exo~mtner can locate all12thoraclcvertebrae(T1-T12). The levels of the T 3 .md T 7 vertebrae cortespond l'l!spediwly to the medial end of the .scapu· lar spine and the Inferior angle of Ule scapula. • The ribs as anatomical landmarks (d). The lew!ls of intrathoracic organs ~lso correiM! with speclftc ribs and lntat:oJtal spaces, particularly on the anterior side. The ffrrt rfb Is usually difficult to palp;rte because It Is behind the d.Mcle. The second, however, is ;att.ilched to the palpable sternal an· gle (where the body and manubrium of the sternum joln). Past the second rtb, the examiner should hiM! no dlf!lculty counting d_, the 1'1!maining rib$.
• Tracheal bifurution • IIDotoftheaortlr:arch
Ao111cuch Rlgltpuknonlry ------...11111~ Yl!lns
c
Dllll!nMw af the thoru: a A~rior view. The intertDSt.'!l musdes, fasciae. and abdominal orgafiS have been removed. b Simplified sdlematlc view from the porterlol' side. The scapulae .md several ~b d~:~minall:ll'gilru h;ve been outlined for cl;trity. The tiloradc cavity IJ one of the three main body cavities, along 'With the abdominal and pehlk allltfes. The w~ll surrounding the th~ racic avity c:onsim of:
Superior
wnac.Rlghth.ng _ ...._,_.....,-: Body« st«num
Slldhrlb
•
bone~
12 thoracic Yertebrae. 12 pairs of
ribs, and the rtemum
Boundary of pa~etal pll!tn fnlngthe
Bound.lry ofparietal plwra lirlngtlle rtg~t tlloradt cavtty
leftthoradc~
• connective ti~sue: internal fasciae of the thorax. muscle fasciae • musdes: chiefly the lnten:ost.'!l m111des. lntemal muscles, and diaphragm Thetiloradc cavity IJdtvlded lntothe«ntr.illylocated unpaired mediastinum. wltlchcont
•>·
Narz: The diaphragm is normally in the shape
of a high dome. with a subst
•
De:sandlng won
T12wrtebra
59
1.2
Divisions of the Thoracic Cavity and Mediastinum lhcrliClc:
Inlet
~-~~--Superior
mediastinum
lnfe'lor
-ll!'.i-----"'~--
meclll.stlnum
•
B
Tbor.ldc outlet
-
Daoendlng
Rlghtlung--1-J[...._-
~h.ng
Esophagus -lif-~=--+41D ""'1---t:l-- PoMicr medastlnum
b
Stl!mum
Prtndp;~l neuroviiSClll;r structures1h1tentl!r and leave die medllstlnum
SuJMrfor m~dlastlnum (borders the neck. yellow): • The vagus and phrenic nerves. vans (tributaries of the $Upel'forvena cava), esophagus, and trachea enter the superior medli!ISUnum from tile neck. • Arterial br;mches from the aortic arch and the cervical part of tile sympathetic !JUnk leave the superior mediastinum to enter the neclt. Jrftdgr ITICIIII.trnum (borde~ tne abd~~men and pleural callftles, red): • The thoradc duct and ascending abdomlnallumbilr vans (the azy90$ vein on the rtght side, the hem!azygos vern on the left side) pass through the diaphragm to entl!rthe inferior mediastinum. • The vagus and pllrenic nerves. portigns of the $ympatnetic nervou' system, the aort
(body)
A DM!fons of the tflor.Jdc: avtt:y and medl;utfnum Co~l $ectron, antl!rtorllfew. b Transve~e section, superior view.
C Contents of the mech!ltlnum (for divisions see A)
a
Thetnor;rcic cavity is divided inw tnree &;.rge spa= (see b):
S..rf•_._.lnum
• The medlllltfnum, in the midline. is divided inw an upper, smaller superior mnilartfmHn and a Iowa-. larger ln{eriormnifcmfnum (ll). The Inferior mediastinum Is further subdMded, from front to bKk.lnto the on11!1101; mfddlt, and postl!lior mediastinum. The antl!rlor mediastinum is ar\ exlremely narrow space between tne mmum and peri· cardium, containing only small vaKular components (see table. C). • The p;~lred pleur..l cattfK on the left and rtght sides oftile mediastinum are lined by serosa(- par1et.tl pleura) ;md contain the left and rtght lungs. They are completely separ.rted from each other by the mediastinum. The medi;JJtinum exh!nth further to the left th;an to the rtght owing to the asymmetrical position of the heart and peri· cardium. Because of this, the pleural cavity (and lung) Is $tnaller on the left side !han on the rtght. The pleurlll callftses tennll\312 blindly lit tneir upper end, but the mediastinum is continuous with tne connective tissue of the neck.
• N.lrtk arch • Bt~dlloaphallclrUnk
• Praxlm;tlportlonsofleft a~mmon a~ld artery and
left subclavian a~U~y • SUperlorvenll cava (upper portion)
• Bt~dlloaphallcllelns
• Thymus (In older a..lts: netrosllmal fat pad)
• Vagus._ • ~ recum!llt laryngeal
nerve • C
• Tr.ac!M!II, esophagus.
·l'tnt:lltfor~
- cymphatk ~~Wels and lymph nodes
- Smaller blood vessels ·Middle~:
- Heart ~nd pericardium - Ascending aorta - Terminal segment of superior vtnll cava and azygos win - Pulmonllrylrunkandlts
brandies - Pulmonllryverns - Phrenic nenii!S with pel'kilrdl-
acophrenlc .-es.sell •Pos1:1/ifor~: - E$opht~gUSwlthYilgU$netveS
- Tbaradcaortund Its brandies -Thoracic duct
- Az:yfJos and hemlal)'I)Os \Ieins - Sympattletrctrunkand grellter ~nd les:sersplandlnfc nervK
60
Thorrvc -
1. Spaces
Tnodwobn>nchlollymph nudes --....,:,.-~.,...,..r,-r;.....;..-;..~yr-.....;:
R19:1t pulmon1ry.tery ---f--,...._:.!Y,fi--;i+.;f-'i:R-=---'----iii----iiii
'=::::;;:::::::::....;;;=::::!!--~..J,.-- Sltuhttadlment bftwoen llwr.,d dllplngm (bn~reo)
,
D SuiMIIvlslons afthe medllsttnum
....
MidHgitt
~
"' oa.lled view: simplilifd drawing ofthe perinrdium, hNrt. tr.Khe;~, and esophigus In mldsi11Qitbll section. ThIs latero1l view demonstrates how ltle left ~trfum of the heart narTOWS the postl!!rlor mediastinum ll'o
antcalp;~rt
I ......I,JA.- - Supe!lor medlartinum St2mum
11/otE Single dligranu cannot adequately show the mmponents and mnllgurilllon of ltle medf.utlnum, beuuse of Is iS)Immelly and exten-
Antonor
Jions in all three va. The anatomial relations in this space o1re best appreciated when viewed from multiple directions, at different planes (su pp. 62 and U).
mediMtlnum
medlartinum
Mdcle
" 61
1.3
Overview of the Mediastinum
lnd!IOQ!Ilhlllc ~phnocfH
Rlghtvagus nerve Azygos win
G.lllglon of INilMitebr.JI ~llctnrnk
lA!ft br.M:t!lacl!ph;lllc win
Trachea SUpeiiOr~n~ c:;m
Right phredc nerw
UpperlobN ~nchus
Right pulmonary artery
lhymus (retrommal fat pad) lbrous pelleardum
Common trunk of middle and~ loi>Nbronchl Esophagus
Right pl.fmon;ary veins
PhreniCner\'eo pelleardaalphrenlc arteryand~'b
hr!eul pleu-a
A Uedl;rstii'IUm vSewed from the rfght side
P.arasaglttal section. The enure rfght lung and most of the wall of the pleur~l c.avityhawe been rerTUllll!!d (p.ariebl pleura, see pp. 64 ~oo 63} to display the structures of the pomdor mediastinum adjacent to the vertebrie, mon notiblythe symp.athetlc trunk. and the azygos vein openIng Into the superior vena ava. In the mlddlr! mtdlast.lnum, the (right) phrenic neNe and the (right) peric.ardiamphrenic ~rtl!ry ~nd vein are
62
visible on the perlc.ardlum. The (rtght) vagus nerYe Is dlred:lyvlslble on the lateril wall of the esophagus. The triche<~, wfllch descends In the median plane, is latgt!!ly obsaJred by other structures; p11:1files of the IDbar bronchi of the right lung an be ldentlfted In this view. The thymus. rel;rlfvdy prominent here, Is lirge In early postnatal life (see p.133), but regresses In adulthood, event:uilly replaced In old .ilge by a small retrosb!rnal fat pad (inwluted thymus).
IAitsubdiMan ----=:::----:::7iilr .
<~l'tl!ry<~ndwln
I~IMtery, Ydn~ndneNe
Tllol';l(((~
Aortlcar
LeftV<~tusn~
Left re
Llglmentun
artl!rloum ldtplnnl(
s>pnpaltl etlclru nk
·~ Leftpl.fmonary
~
artl!ry
heml;rzygos wh
Left pulmonary wins
Left main branchls
Flbraut pl!!iard\lm
Tho !';I(((~ (de$andlng ao~)
lolll!r.ll perfc.Ydlal lymph node RmV
Piril!till piei.R
Phn!nlc-. pe!1Girdlaco-
plnnlc
Hem~Ydn
<~l'tl!rr
SUpertar phrmlc lymph node
lnt!ercostal muscles Dlllcllngm
8 Uedl;rsttnum vtewed from the left side P~rasaglttill section. The enure left lung .md most of the parietal pleura of the left pleur~l cavity hal/1! been remtwed, but the pericardium re· mains Intact. The left·slded elements of paired mediaslfBal structures (sympatftetlc trunk, vagus nerve, phrenic nerve, pericanllaco· phrenk vessels) can be lde111:1fled. VIsible unpaired structures Include the hemiazygos vein and the (inconsti!nt) acassory hemiazygos Vl!in. The dominant vessel In this field Is the aort
can be seen anterior ;rnd lal:er.ll to ttre esophiBoth left pulmon<~ry wins hiM! been tr~nsected near their lll!nmf· nations in the left atl'ium of ttre he.~rt. agair1 demonstrating the close topogr;rphkal relationship between the left atrium and esoph
63
1.4
Contents of the Mediastinum
lntemal
Tllyrold gla->d, right lobe
l'l!lfc.ard~aapmnlc
artery andwb,
)lgularwln
---r----7r::;;
phrmlcn~
P;JfleUI pleu~.
cosulpat
----,;...;....-#--/:
Right h.ngv.lth ---r-:+-r---':..:.... \fsanl pleunt
l'l!lfcanlrum (ftbrous)
Dl;phragm
AIUdlrnent betwe.!nftbral.ll perlc.ardlon~ and dtlpiY.11gmatlc t.ooa
A Medl;rstlnum, ;mterionf- wttfl tile illltierfor tflor;ac;kw.~ll remiM!d
CGranal section thrDugh the thorax. All connective tissue has been re· moved from the on!Mol' medlastloom. This dissection displays a prom· lnent thym~JS, ocaJpylng the superior medli1tinum ;md ex:tendlng In· fe!'forty Into the antl!rfor medla~tlnum. VIsible structures that are continued from the superior mediastinum into the neck or upper limb
64
Stomach
Include br;mches of the aortic arch. the superior vena c;rva, and thetr.r· che.a, although !he lattl!r I~ mostly obscured by the vessels surroun~ ing the heart. The middle mediastinum, visible in this mronal section, is domlnmd by the heart and pafcardlum (fused to the diaphragm) and the associated nwrovascular structure~;-the phrenic nerve and perf· cardracophrl!rllc vessels. These wssels descend along the perlc.~rdlum tawand the diaphragm wflile givillg off peticandial branches.
~~ --i Ofcold - - - - - " ' ca!Uiage
IJ!ft man bronttua{seen It!rough
dl~esaphagusand aart.a)
Hart. left allium
~ndlngaorta
8 Contentnfthe medlntfnum, posterfonfew The structures In the po&ttt1or mtdrastfnum are depleted In this VIew. Ncrb! p.1rtirularly the COCJrse of the d~cending aorta, the azygos and
hemlazygos ftlns, and the esophagi!$, which Is pomrlor to the tra· chea and partially obscures lt. (An ;mterfor VIew of the posterior medl· astfnum Is shown on p. 118.) The topogr.ilphkal relatfons of the aorta change sevl!tal timet. along its course. The pAm mal pi!It of the aorta ascends In the middle medlo5tlnum, which Is a subdivision of lfle lnfe· rfor mediastinum. At that level the aorta lies antertorto the trachea and
~-----l..lgilmenttm-~
esophagus. It then ascends Into the superfor mediastinum, where It curve.s posterlorty and to the left to fonm the .ilortlc .ilrch. Thls curve Ires to the left of the esophagusandtrache
65
ThCH"U -
1.5
A
1. Spcrces
Pericardium
LOAIIanafdtepertc.~nlumln
hdtora.ant.ltor.ttw
~Ldl:lung
The chest has been opemd I:D dis-
pliy the pertardlum, which Is tfle
domlnilnt 'tructurw In tfle Inferior mediastinum. It is llltadled inr. oliy to dle dilphr<~grNik f.Jida by mnnectlllll! tissue. Anteriorly, It Is sep~rated
from tfle PQrtl!rigr sur-
ltoflotWdfllpsofftbiUIS peianllum, sh...,.ng ...~obtll.,...ot palcanllum
lllghtlt.ng
l'eflcardlum, exltoiNI
ftb!U1Sf¥r
~~~!,....--
fite Dftlle sternum only by mnnec-
ttw Ussue Df the anb!rlor mediKII-
num (rem~ here. see p.60; see B). The pericardium Is bounded literally by the pleural cavities, from wh h:tt It Is sepil"lted by mediastinal pleun.
Parll!bl ploura, rnediStln;~l f)ilt
l'irlotolploulil, mecllostlnoiP"rt
Hurt
Clrdac sLrlaa!, vlsmnol~r
aherous pertcanllum
nam..
b:oph~.
Cllr.ialpert Left ammon ai'Olld..uty left subd..tln .usy
Aor11c:a'dl
Atatndlng -a
Left INin bren
Second rib
PUimo,.ry
Left puii'I'IONfYwiN
IN'*
lhoradc IOrta llodyofsll!rnum Esoplwgus, lhoradc p.Jrt
"'r1cllrdklm Clophr~gm
Celr.ctrunk Abdoml""l aortl
..,_
1 loA~~an ol tile pertatrdllm 1ftIN tllonx.left alltl!l1or llllllque
This vtew demonstr
66
stomach
sternum. The pericardium is related posteriorly to the esophagus, especially
N'tf:Nllnlr.lnswn:e - - -"----:
pertardlal slru "'=-----...,:,;~--- ~lnobl~
pertaldal sinus
Serous pericardium, partetallayllf Fibrous pella!dum
c Pl!t'Tcardllll aMty and structure of the pertcanllum Antl!riot view of the empty periurdial sac. The pericardium consists of ~ llycrs. one within the other. that enclose and protect the heart
• Parietal layer. The parietal pericardium f\1nn$ a $i!C with ~n outer sur· face, the flbroctS ~. comjX»ed twgh and In distensible connectlvetiSSIJe which Is partially ilttached to thedlaphragm. Its In· ner sumu. f.adng the he.art.ls lined with a serous membrane. • ViKernll;ayer (epioordium). Thi$ is a thin serous membrane which coven. and Is flrmly ;rdherent to, the heart Itself ;rnd the pi'Oidmal parts of the great vessds.
«
The two S«
Openl'lgfor ascending aorta
1r1 the loc.iltlons 'Where the p;~rteallayer Is folded back onto the vrsceral la)'l!r CXM!ring the vessels, two tl'nuses are formed (see am:.ws): • The t:rllnswtse pe!'furdlal sinus loated bei:Wetil the al'tl!rtes and lll!ins • The ob!fquto pericardlal sinus located between the left and right pul· monaryvelns Because the pericardium canriOt expand significantly, bleeding Into the perlcardlal calllty (e. g., from a ruptiJred myot.lrdlal ,;meurysm) will place lncre.aslng pn!.S$Ure on the heart as the blood accumulates within the sac. This condition, called cardi
D OpenlngJ In the pedalrdium ;r Posterior view of the heart with
Openilgfar
ascending aat1
the epicardium. It Anterior view of the •empty" pe!'lcardlal cavity. IV.I ArrvNinlr.lns'O!ne
pertardlal sinus t.;-~~--
Operings lw left
pulmon1rywhs
empty pericardium typically has eight ope~~ings by which vesM!Is en· ter and leave the heart: • One opening for the ascending aorta
• One opening for the pulmonary trunk
• Two openings for the two venae cavae • Up m four openings for the four pulmonaryveins
67
1.6
Pleural Cavity
ltlghtbrachlo· Cl!j)llalcwln
Sul"'ricrwna QY
~ght----==~tJt::!::~~~
pumonarywrru
ltlghth.ng _ _ ____::........:._ ~~~~----Hart
Dlaphragn - - - - "'!·J.~~~y~~--- Bodyofmmum ...1' XlphOklprOaU --------~---+,;;;;liii~~~\ d~~ k-~=---~~--------~ ~~
.
-,._ _ _ _ l'leuralavtt:y Stomadl
a
"'cki;Mc:ular line
Transwrse
Sb!mal line
allen
Am~b
lo!fth.ng
~ghtlung
SGpula
P.arte!al plt
Dflphragn
u.er
Spleen
lo!ftsuprarenal gand
~ghtsuprarenal
gand
T12 wltSira
b
A Prafectton of the ple4ll'ill Cii'WitiH ontD tile thor;~dcskleleton a Antl!rlontew, b postenorVIew. The pleural c.aWies al'l! paired li~ the lungs they enclose. The left pleu· ral cavity Is slightly smaller tNn the right. especially antenorly, due to the asymmetric:<~! position of the heart In the mediastinum. The pleural cnttfes hiM! a gre.rter total extent than the lungs, n!$Uit!ng In the presenae of recesses (see D). Ulo! the pertmneal and perlc:<~rdlal cavities. the pleural cavity is b~unded by ~ ""'us I~ the 1/i:sarol p/e\Jrv ((XII· monary plana), wtllch 1~ attached to the surface of the lung, and the fX!rlr'!tOI pleura, wtlleh lines the thoradc cll\llty and Is attached to the en· dothorlldc fasccla of the chest wall (see D). The parletlll pleura extl!nds
68
SGpular line
Transwrse colon
to the lateral ma~lns of the diaphragm. Bec:<~ll!e of the convex domed conf!guriltlon of the diaphragm, the pllrfetal pleura thus extends down to the s.ame thoracic wrtebral liM! (T 12) as the liwr, spleen, kidneys, and parts of the colon. lntfleselateral recessesthe11baral pleur.ab not In contact with the parletil layer. Over mort of the extent of the lungs, howeW!r, the two pleurae are closely apposed, separli1J!d only by a thin la)'l!l'of dear serous fluid wtllch allows free sliding motion of the luDgs In the pleural c;111ities. This fluid layer also serves to hold the pleural ~ together by Ciplllary action, thus transmitting the force of changes In volume of the thor.adc c:<~ge, caused by the n!$plratory mu~les lncfud· lng the diaphragm, directly to the lungs themselves (see pp. 92-93).
Thorax - - 2. OrgGns
2.1
Esophagus: Location, Divisions, and Special Features
Abdcmlnal p;ll't
A Profectton onto the tflor.ldc: skeletcm Anterlorvrew. The esophag~a Is locattd 51Jghtlym the right of the mid· line. especi~llyin in cou~Wthrough the tho~ where itducencl$ ~long the right side of tile
B DMslanscltfleesophagus
Anterior Ylew with the he.ild tllmed to the rtght. The esophag~a Is a~ J)I'QXimately 23-27cm long, 1-2cm in di;!mmr. and is divided into three parts: •
Cervic~l part: just antl!rior to the Yerteb~l column in tfle neck. extends from C6to T1. • Thoracic part: the longest part. located In the sup error and postl!r1or mediastinum, f!Xtends fn:lm T 1 to the esophageal hiaws of the diaphragm (at approximatelyT11 ). • Abdominal part: the shortest part. located In the perftoneal cavity, extends from the dlaphr.-agm to the cardiac orifice of the stomach.
-
UpperesophagNJ conltlf~on,
esophlgul Inlet
C Constrictlant and CUM!S cl tfle C!:IICiph.lgUI Right lab!ral view (a), antl!ri~:~rview(b).
The esophagus has three normal aflatomlcal constrktlallf. which are profec!td at the lewis of spedflc vertebrae (a). The constJfctlons are caused by .ildjacent structures !Nt Indent the esophagus and by functional dclsure mechanisms (lower constticlian. see p. 75). Tlle.se con· stJfctlons are Ylslble durfng gastroscopy, and the scope must be care· fully maneuYered past them (normal width of the esophagus Is approxl· miltely20mm): • Upper constrfctlor1 (pharyngoesophageo~l constrlc:Uon, 14-16cm from the Jfldsor teeth), corresponds to !he esophageo~l Inlet In the a!Nical part of the esophagus (-'ft p. 74). It ~ located where the esophagus passes behind the cricoid cartilage (C6) and has a milxl· mum width of approodmately 14mm. • Middle constJfctlofl (thorulc constJfctJon, 25-27cm from the Jfld· s~:~rs),locabed where the es~:~phagus p•ses to the tight of the aortic ardlandthor.!dc aorta(atT-4/TS). Ma1dmumwldth Js14mm.
70
Abdom!Oi!p;rt ----'-..'--''"r--
Dlilpllr4151m
b
• l.awl!!r constriction {phrenic constriction, 36-38cm from the incisors), located at tile st.-art of the abdominal part of the esophagus, where It pierces the diaphragm (T 10/T 11). Functional dOSI.Ire of the 4!$0ph.ilgus by muscles .and vernsofthe esophageal wall. The abdomJ. nal part is normally occluded exapt during swallowing (see p. 75). Maximum width Is 14mm. Besides its constrictions. the esoph.ilgus ~!sa present5 ch~r~rnri.s;tic cunR:S (b): an upper curve to the left (lr1 the cerYic.-al part), a mid-level curve to the rtght (In the thor.-adc part, cau5C'!d by !he adjacent thor.-adc .iiOrti), and .illowef curve to the left (In the .ilbdomrnal part). AddJtlo~ ally, the esophagLJS it. slightly mncave antl!riorly in the s.-agittlll plane. follov.ing the curvawre ofthevernbr<~l column (thor<~clc kyphosis, •).
TborGx - - 2. Ol'gtlns
RJglt
Esophagus,
wgusnerw
cemalp;ut
Subdwlon artery Rlghtrec:um!nt -----.:~~~ llryngeelnenoe
. ..-~--------su~n~ ~.::.....~~~:-------
Uftrewrrel'lt
lilrynge~lnenoe
,..---~:::----
Bradlloajlhdt ----~---
Esophagus, -----'~ ltloradtpart
Parlmlplwra, cmlc.llpart
tn.nk
r-''<--:------
AoGrtk .nil
~=~!!lllklo.ft.:...::!J~~--- Tlloradt liOI'Ill. dHamrng part
Plllfeulpleur.-, ---~ aloltllpart
illr--G~~-Eicphagt.ll
pl!lCL5
Ftlrous perlard'um
D lbecsophlguslrnltu Ant2rlor view. The chest has been opened and !he he
directly behind the pericardium (seep. 98 for Its lmport
71
ThoraK - - 2. OrgGns
2.2
Esophagus: Location and Wall Structure
Rlghtalmmon
c.arotkbrtery l.eftlntenal - - - - -+11111 Jugulerveln
Lilli -- - - - Rlghtlnll!mal Jugo.4ar'f!ln Right subc:!Man artay Right subcllvlllnwfn
""'f1..--'!-"___ ~wn -t.i~~+-- RlghtrNln
bronchus
l.dtpulmonary -----.~"""""~:::. .wtle
,.,..-~e----
RJghtpoJmon.;wy
artery
P-"'ll"":--::=--- - Esqlhag~. thcr.xlc:part ,._)~~~--
Rlghtpuhlonilry willS
1.---.,..-.:.:...~-----
Pomrtor'i!tmo.stal
a!Urtes Dlaphr.agn - - - - -
A Topogr.~phlul reY\fons ofthe e~oph;~gus, postlllliontew Th~relatlonsoftheesophillgwototheperfcardrum,gre.rtvessels,andtra
chea are depicted here. Th~ dose prGXimity of the ~ophagus to the left atrium and thora de aorta can be seen (see alsop. 98). Due to the asym· metr1CA1Iposldonofl:ttehe
72
tissue of l:tte medlaslfnum (Important for SWillowtng). It Is st.1blllzed somewhat by tit~ att.1chment of Its .antenor wall to tit~ b.ack of the trach~a. again by numerous slips of conn KIM! tissu~. Note: The tradhe;r develops as an outgrowth from the esophagus during e.arty embryonic development. .at which lime a communication exists betwHn l:tte two structures. Nonmally this communlc.11fon closes, but its pmistence results in a tr.ach~e.sophage.al fisrula, which may allow food to enter the tr
T1tonJx - - 2. OrgGns
~~--
Plw,_lrophe lnM!ar pha1')'119"'11 constJictDr,~
phllyn~~rt
lnfllffarpha1')'119"'11 constJictDr, a1a>phllyngeol ~rt
Tracheol artlllge MuscUar eDit. diWIA-'-"
Pa'lbranchlll
d'-tlalklm Left m1ln ----.~\11 bronch~a
Eplphrenlc dMrtlculum
Dlophragm E>ophaguJ,
•
obd.amlnol part
B Rn11:blre of tile l!lllphilgl!lll-llalllll tile llevelapment rJI IIIWII1IcU• VIewed from the posterior ;md left sides.
a Portions of the pharynx. larynx, and IT.Ichea are also s"-<1. The outermost IIIYI!r (adventitia) has been removed, and the re· ITiilnlng layers of die esophillgeal wall have bees! telescoped to display both IIYI!rs of die muswlar coat (the clrwlar and longitudinal layers). They are connecb!d to the pharyngeal muscles at the esoph· ageallnlet (hidden here by the pN rynl(). The musde of the esoph· aguJ an genente powerful peristaltic fl"'CMMT1ents dlrecb!d towinl the stomillch (illctiVely propel ling a food bolus ID the s!Dmach In s-a semnds), and they can ._.., the direction of u- move· menU during Vl)miting (antiperistalsis). II Esophageal dNM!tulo (abnormil outpouchlngs or silKs) most commonly d..wop it a weak spot like tNt loated above die esophigeal hlibiS of die dli phragm (parahlital or eplphrenlc dlvertlcul um, 1o¥
of cases). These ire "false" puJslon dlmtkulo In which the mucosa and submucosa herniate dlrough weak spots In the muKular aYt due to a rise of pressure in the l!sophagus (e.g., during normal swallowing). A Zenker diverticulum, often described as the most common esophageal diverticulum (70 Xof ases),ls actually a hypop/latyngeol dlwrtla~lum ocamlng it die junction of the pharynx and esophagus (the "Killian b1angle"). This wall proti\ISion, called .also a ~ e~ ~lum. is dist\GSed under the heading of the pharynx (see p.33). The rennalnlng 2U of esophage;~l diverticula do not ocx:ur it typlal WNk .!pots ind are characterized by the protrusion of all-11 ("true• diWrtlcula, tnldtoll dlwrtfcula). They usually result from an inflammmwy proci!SS such as lymphangitis, in which ase dley ocmr it the sitE where the esophillgus do.tely ipproaches die bronchi ;md bronchl~llymph nodes (thoracic or pal'lbronchlal dl· vertlaJium).
•rs
C Func:llanal ;rdlltKt\re rJI tile esophirogeal murdes During the iKt of swalkMing, the esophillgeal outlet it the anllac end of the stomach opens (a) and then immediately doses (b). The longitudinal and clrculir layers of the musc:ul~r wall of the esophillgus (l'ft 81) contain numerous flbers tNt wtnd oblkjuely around the orgin (l'ft the circles In the figure). The muKulablre Is additiona lly "twtsted" due to thl! enbryGnic rotation of the gut (seep. 178). Owing to the presena
of longitudinal, drwlar, and obDque fibers. the esophillgus an be narrowed ;md closed as needed (by die action of the c:lrculuflbers) ~tIts Inlet and outlet (seep. 75), but It an also be simultaneously na~ and shortened by the combined action of the longitudinal, drcular and oblique fibers ID generm peristaltic motion tow;onl the stomach during swallowing,
•
II
73
2.3
Esophagus: Inlet and Outlet, Opening and Closure
Suportor laryngeal artl!ry and •n. suportorl;~e~~l..,.,
QlmlaJiaio
tubado
Oblique •rytmold ~-~--
mUSICie Trlii!WI1e arytmold
mUSICie UopNgNI lntmr _ pharyng•l
__;~"'!·- '11.
EJoplwgul (subm~~~m~l) gllndl
lumen
Cllnstrlcbr
l.eft....,.,nt ----- ~ loryngul """"' L;omortrf•ngl• --E-:'~~·~·:t,
v.nous plows lnsLbmUCDU MuJOJII~s.
longltudiNII loyor MuiQILircmt. longlllldln•IJ¥r
--+-:-'!
A ~llnlet(upper~•lsphlnder}
Post2rfor view. The muscul1r posterfor will of the pharynx has been divided and reflected l~lly,and the uppermost esophagea Isegment has been opened posteriorly. At the postl!rlor Junction of the longltu· dinal esophageal musculalllre with the pharyngeal musc:ulalllre, the longitudinal mwcle.s are thin and do not span the full clrrumference of ti1e esophagus. This aiU of muKulilr -akness (•Lilmer tlfangle") Is a site ofvulnerablllty for ti1e development of dlw!rt1wla (seep. 73). This diagram shOW$ the esophagus with an expanded, stellate lumen near ti1e esophageallnlet.u It would appear during SWllllowtng. While In the resting stm, ti1e esophageal Inlet usu1lly hu the fonn of a transverse slit. The musculalllre of ti1e upper esopmgus Is a continuatiOn of ti1e (sbletal) pharyngeal muscle and consists of striat2d fibers ti1at give w;sy distally to Jmooth muscle (not shown here).
74
B Microscopic strvcblreofthe _.,h,gNI ••• through an esophagus In the contr.lctEd (left) and relaxed stm (right). The Ia~ of ti1e esophagNI wall are typical of a hollow vlsws In the dlgestfw tract:
Tr.~nsverse section
• The muc:osa, which consists of an epltbl!llilll)'l!r,lilmfna propria. and muscular layer. The eplti1ellal layer Is composed of strat!fted, nonkeratini~d squamous epithelium (for mechaninl resistana to food passage). • The submucllfsa, a loose liylr of connective tissue that contains numerous glilnds (esophageal glands) whose secretiOns lu brtcab! ti1e mUCDSa to facilitate fvod p;INIIJ!. ~rticufarly in the 1_.- esoph~ gus, the submucosa contains numerous w:fns ti1ilt partlclpite In ti1e closure ofti1e esophigeal outlet(- Cc). • The IIIIJ«lJJIllfs, mnslstlng of an Inner l.ayer of drculir muscle and an outer layer of longitudinal muKie. Smooth-musde mntr.lctions aid ln the peristaltic prapublon of food. • The odwntltta. 11 lilyer of loose con nectllle tissue thit trthers the esopmgus tD the mediastinal connecuw Ussue and Is firmly ilt· uched to the mn nective tissue of the posterior trachea Iwaf I.
TborGx - - 2. Ol'gtlns
Mwntltla - -
Muswllrit.-longltud'nalllya'
•
Angle of His
Mlllallar'ls.
\
oblique layer
Stomach
b ll'klco:s.11. langlllJdlllllfoldr.
P.-!eal pleur.-. medla\llnal p;~rt
v
M<~Kulllr!s,
longl!lldlnalllyer
Esophlge<;~l ----+!';;..!::!~
hiatus
Junc1fon cfe'Jcphageal --~"""!"-:~"-'--=~ and g;L'Itlfc mucos.ae
~~~-------~~
peritoneum
C E'.soph;ilge;ll outlet ~nd esoph;lge;al closure
Functional dosure of the 4!$0pbageal outlet Is .mlmportant mechanism for prewntir~g the baddlow of gastric mnb!nts, telpeci~lly hydrachla· ric add,lntr>the distil esophagus (gastroesophage;~l ref! we). This mech· anlsm Is essential beGiuse the esophageal mucosa. unlike the girtric mucosa, rs vulner.ilble to corrosl~ Injury by stom<~ch add. As a result, repeabed exposure to hydr«hloric acid an a use esophageal inflam· matlon (reflull esophagitis). Early. rdatl~ly mild forms of this reflux ("heartburn") ire often manifested by a bumlr~g retrostemal piln that Is most pronounced In the supine posltfon (it nlghtl). Effective closure of the esoph.ilgus ~based Ol\ sever<~ If.ldllrs: • NaiTOWing of the esophageal outlet by: - tile circular muscles of tile esophagus (see b) ~nd
submuco~JS venous plexusa. which r01lse longitudinal folds In the esoph.ilgeal mucosa (see c). These prominent veins function as portosystl!!mic collatt!rals in respoi\SI! to ~1\ obstruction of portal vmous blood flow (see p. 119). Together, the esophageal drcul01r musdl!$ and vene~~S plexuses provide "<~nglom~~SaJiar clll:!ure• it the 1!$0pbagogastrlc junction. • Thestructur~llynaJTOW muscul~resophageal hiatus il\ thediaphragm
-
(see c)
• Connect!Ye tissue 01nd fat surTGundlr~g the esophigogastJic junction {c)
• Continuity of the esophageal and gastrtc m~~Sculature (b), and the oblique angle at wflich the esophagus joins the $to mach just below the diaphragm (the angle of His, see a).
75
2.4
Trachea: Thoracic Location and Relations
~&opbfgU.I
ritRightmoln - - - - - - - '-.J
Trad!eo
~=-=-::-:::----:--!Aft main
brwodlus
blflllthus Asandlng
~
PUman.ry
aorta
trunk
Alygolwh Esaph~
Trad!eo
A The tnlchee pro]edl!d onlll tile ned and tlloru. Th~ trachea Is located In the medlutfnum and lies predsely In the median plane. The Initial, cavlcal part of the tnchea begins just below the larynx. and Its thoradc part ends It the lnlcheal bifurcation (see 8). The lnlchea e.pands during Inspiration and mntracb during expira· lion. The projection In the figure shows the appeerance of the trachn It functional residual capacity (~axed end-ellpii'Mlon).
Right pulmcnary irll!ry
Pulmcnary trunk
-=Ht...J.,:.~
A.z)'gaswln
'r-=
Trad!eol allllage
).
~
T~ch•l
blfuratlon
Aa11card!
~main
bronchus
.. 8 Shapeaftlwtnd!H a Anb!!rior view, b superior view of thl! truheal bifurcation.
The trachea Is a flexible aiN:Onductlngtube 10to 12cmlong.Attheap· pradmlte level of the Tl-T4 vertebral bodies, It bifurcates lntxl the left and r1ghtmaln (principal) bronchi, which fo11T1 an angle ofappi'QI('Immly 55-70". Viewed from the anterior sidl!, thl! tracheal bifurcation lies just below the ju nctlon of the m~nubrlu mand body of the sternum. Notl!: The right main bronchus Is more vertical than the left main bron· chus (see p. 82), and therefore It Is more mmmon for aspirated foreign bodies tD enb!!r the right main branch Ill than thl! I!!ft. This also makes it easier lXI view the Interior of the right main bronchus with an endo· smpe. Owing to the nymmetry of the heart and the assodilted asymmetrical position of the lungs. the left milln brondlus Is slightly longer than the right.
76
C Topographical relatl- (al'lzr Agur) Anterior view. With its proximity lXI the base of the heart and surround· lng wssels. the trachea has complex topographlal relations with neigh· boring structures. In the drawings ~~ structures are progressively removed to obtain greilttl'ellposureofthetrachN and brondll. a Wlth all structures Intact. the trachN can be seen anterior to the esophagus. The tracheal blfuratlon Is c-..d by the o~ortlc arch and pulmonary artery (seulso p. 120). b Wlth the superior vena Cil'la and bruhloaphallc veins remDftd, the right maln bronchus Is jushfslble and the azygos vein Is seen "riding" on the right upper lobir bronchus. c The ascending aorta and mum of the aorticardl haw '-1 l'l!mawd, exposing the trache~~l blfurcltlon and puii!IOIIilry artEries. d Wlth the pulmonary trunk remCMd. the aortil "rides" upon the left main brondlus.
TborGx - - 2. Ol'gtlns
Esophages~l --------:----~HH-"--""'-"---";l~lr
-
---'--- - Tlrjrcld
Inlet
cartlage
Origin d left
man bnlnch1.111
r~~n~w----~--~~~-n~~~_,~.r~~
lymph nodes Rlghtpl.fmon;ryartl!r')' ---:,....___,.~f.!i.-!!l~ffi;..-..:.._e---==
\---,-4-,:;,-.:;,-- - l'lerlc:lrchl c;Mty
~...:;:::::::::;:;:::::,~~,_-~-7-- All:ll~ment
-.
D 1be trac:fiH In sttu Midsagitbl section vii!WI!!d from the f'!lht side. The pelicarclium, heart,
trnchea, and esophagus have been transected. In this simplified lmr;ll view, It e<~n be seen that the tr.ufle<~. wttlch Is jll!tanterforto theesoph· a gus, angles posterforly as It descends from the neck through the tho·
betwee'lllver nlcf1phragm
{blU't'atS)
,
..
,.::..-;::----
Xilhold ~
«sternum
rax: After entl!lfng the chest through the thoracic Inlet. It runs beh1lld the Vl!ssels suJTOurlding the heart. The shape and arlai:Dmical relations
ofthe bronchial t:n!e beyond this level are detennlned by the segmental organization oftile lungs(pp. 78-79).
77
Thorax - - 2. OrgGns
2.5
Lung: Thoracic Location and Relations
Pleural dome
IJeft
Right ilrlum
Right
diaphragm lm!let
• A Pm::uulonf!Hdofthelungs Ant2rior view. The air-filled lungs ccnstil:ub! a resonant cavity that produces a sonorous lung sound on percussion of the chest. The sonorouJ lung fleld extends aanlally. wlth iltl:emlitlon. to the iplces of the lungJ at the lhoracfc Inlet. It ilso extends to the front of the chest, <~gain with at:lznl.l3tion, and dosely appto;lches the interior midlirlt' (costomedi· ;uttnal recess wlth antafor lung m..rgln on deep Inspiration. seep. 91 ). The fluid-filled heirt dampens the lung sounds. producing 01n irei of cardiac dullness (seep. 99}. Ashirp transition from lung sound to IIIIer sound Is clearly audible at the Inferior border ofthe lfght lung, srncethe liver is a solid org;~n with less ~nance (medium-pitched, n~n$01l01'0US percussion sound). Nob!: The lung peramton field does not predsely match the aniltomlul extent of the lungs because only welhilerated portions of the lung are s~norous to pertUJsi~n. The anatomiul extent of the lungs iJ gneater thin the percussion field.
b
c
d
c
Radlogn1phlt ~ppe•- afthe norm.tllungl and op~~cltles In dlteaedlur~~~
Rld!CIIJ1Iphlc appeen1nce af the lungs, anterior ~ew. Dlffefent regions of the lungs show dlf!i!rent degrees of lucency In the chest radi~~;~ph. The perihii
1
Right lung uaphagus ~~-=--f".!!IIL--\;-----t,'l;--
Body ofsamum
B PD:Iltion otthe lungs In the thorax: tllpclgraphlcll relationt Traruverse section through the tho~;~x. viewed from above. The lungs completely occupy the left and right pleu~;~l C<~VItles flanking the mediastinum. Anteriorly they appto;ldl eo~ch other In front of the pencardium, ind posteriorly they closely appl\lollch the vertebril column. The left lung is slightly smaller thar1 the right lung owing to the asym· mett1ul position of the heart(see D).
78
TborGx - - 2. Ol'gtlns
Tlftrcld gllnd. left lobe
P
aMt
Superior WNGYa
ltlghtp!.fmanary artery
S~and
rnfu'lor lou brand!!
Rlghtpulmanrary
I.A!ftlJng, ..pperlcbe
WIM Pl.fmaNI')'
lhor.adc:
U'unk
aorta
Parletll ple\lr.t, medliritlrlillpart
IUghtlJfl!l, middle lobe
Parletll ple\lr.t, cost~IPMt
Dllphragm
Partetll pleul'll, diaphragmatic ()Mt
D 1be lunu•lnsltu AntErior view of lfle opened U1orax (depletion simplified). The he
fibrous perfcardh.m
approach the vertebr;rl column pomrlorfy. while crntwiorlythey emnd In front of !he pertcardfum and NITOW lfle antafor mediastinum. Per· cusslor1 of lfle chest yields a •sonorous• lung sound (see A) which Is dulled by the heart and pericardium. The exb!nt of the lung~> depends on tfre pi\;JM! of re:spir.ttion (M!e p. 93), but the ;apices of the lungs always extend Into the thoracic fr1let, which Is dosed by a condensation of loose conrl<lte tfss~the supripfeur~f membrane. The apical lung tis.tue is pictul'l!d her'!! as soft and pliant, corresponding to its nat· ural consistency. It should be IIGted that when the pleural cavities are opened at operation, the lungs tend to collapM! tow.rrd the hilum owIng to their elastic r&Otl; !hey do not rompletelyflll the pleural cavity as shawn here.. (Fordartty,lfle luDgs are portrayed In an expanded rtate.)
79
2.6
Lung:
Shape and Structure
Upper lobe
Anterior
bonier
lnfwlor borolor • Right lung,loto!rol.t-
L.oo.-
lobe
b Left lung. lltlraiYiow
A GrwnnniiiiJvftlw lefhnd rtghtlunga (formicro;anatomysee pp.86-89) a, b l..rtl!r~l view. c:. d Medial VIew. The calor of the healthy Iung r~nges from gray tD bluish11ink. Grayish·
black p;~rtic:les ~~often visible bene.~th the pleur~l surface (as s'-n 11ere) ~nd are found even In nonsmokers. They do not necessarily have pathological slgnlftcance, mnslstlng of dust or carbonaCI!Ous parlfeles tNt have been inhaled and depDSited in the lung. A lung tNt has not been chemically filled has a soft, spongy texture and collapJeS when talcien from the clwst. Theshape shown above Is the In Ylw shape of the dynamlcallyexpinded lung (see p.93). The right lung, with a volume of appr!lld~tely 1500 em, is .slightly larger INn the left lung, which has a volume of app1111Ximately 1-400 em (due to the indination of the heart to the left side.) Elich of the lungs Is divided Into loba by one or more Interlobar trmNG: • The left lung Is dMded Into two lobes (superior and Inferior) by one oblique fissure.
80
• The right lung consists of three lobes (superior, middle, ilnd Inferior) sepamed by one oblique fissure and one horfzonllll fissure. The pul· monaryflssures are completely lined brfvlsceral pleur~. Noll: Owing to the slEep angle ofthe oblique flssure In the left lung, the lingula ofthe upper lobe forms part of the base of the left lung. The smallest morphologically distinct and autonomOUl structural unit of the lung Is the lobuk, which Is amrted by a bronchiole. The pulmonary lobules are separated from one another by (often fnc:omplm) fibrous Interlobular septa, demo~rcatlng numerous polyhedral areo~s that may be visible on the lung surface. Aside from the differences noted abcm, both lungs hi!Ve the same bukparts:
• The apes. which extends Into the thorade In let • The base. which rests on the dfaphrag m
TborGx - - 2. Ol'gtlns
Commonarlgln oflawlerand midclelab;r
brond11 BranchHof right pulmonary
wru
Plllmanary
li9Jment Obi~--,.......;:.....
flssurt'
lnftriarbonler
c Rlghtlung, mtdl1lvfew
llr.lndles
ctleft
pulmonary
wins
Mtd~~~~--~--~~~
surface
Oudac Impression
OudK notd!
lnferfar border
Nmonary ligament d Left lung. mtdlahlew
• Surfaa!lofthelullg: - Con;~l surface: rel~tes l~teri!lly ;rnd posteriorfy to the ribs. The vertebral p~rt of the coml surface faces the vertebral column (see
c,d). - Medlilrtlnal surface: relates medially to the medla~tlnum. - Diaphr
• Borders of the lung: - Anterior border: sharp, thin border located at the junction of the ccltal and mediastinal surt.lces (Inserts Into lhe ccstomedlastlool retest).
- Inferior border: located at the junction of the diaphragmatic and ccstal or mediastinal surfaces, sharp at lhe ccstal surface (Inserts into lhe costodi~phr;rgm
«
Bolh lungs are lnvelted by a serous membrane, the vtscml plt!f.lro (pulmonary pleura), which i$ reflected at the medi
81
Thorax - - 2. OrgGns
2.7
Trachea and Bronchial Tree: Shape and Structure
,., Ola~ld--
C:illtl~e
lllembr.Jnous -
--'.:--::-
pcslJ!rlor Will with
tnldlal glands
? Ill
IJeft
~ Uppe' IV
Rl¢t m16de
Iabar
lobar bronch.ls
- -=--_.., v VIII
brandn.s
IV
•
X main
VIII
brcnctlus
X
A structureoftfletncheaand broncflllltree
a lab!!ral Yii!W, b posterior view with opened postt!riorw.all. The tr.ldtea conslm of 16-20 honnhoe-shaped rings composed of hyillne cartllilge (the tracheal artilages) ind i mernbrinous pos!l!rior wall composed af connectllle tissue and tricheal muscle (not shown here). The tracheal eo~rtilages are lntli!rccnnectl!d lollg'lllldlnally by collolgenous connectivt' tiss~~e (;anulolr lig;aments}. The two parU of the trachea are clearly distinguishable: • Ceflllcal part: extends from the ftrst tracheal cartilage below the cricoid cartil~geofthe larynx ;at the level of the C6/C7vertebrae bl the thoriclc lnlet{see p. 77).
82
•
IX
Thor.~clc PiIt extends from the thoride Inlet m!he tr.ldteil bifurcation, where the trachea diVIdes lnm the right and left main b~chl at the level d the T 4 wrtebra. A cartilaginous spur at the tracheal bifurcation (the carina, not shown here, see p. 76) projects upward
lnm the tricheallumen. The left ind right miln b~chl divide Into two or three lobar bronchi, resrx
{see C).
Thormt - - 2. OlgGns
Hyaline
He!lrt
carthge C
light main
bronchus
Mumsaf
submuCIKO
Olr.ted
•thdala!ll
8 ReconstnldTon of tile brondlllil tree from cross •edfon• lnwgas
Antl!rlorvlew. The bronchial tree can be sunned In a serle$ of sectional lm~ges ~nd reconstructed In three dimensions from the Individual The result is a thru-dlmensional displ
""Rl.
..
lbstmtnt mernbnne
D Will stNdllre afdw lndiN anllllll'lll" llrondll
a Hlstolotlalol'lanlz:iltianaflhe -llofdwtn~ct..: Thetradtea Is C DMtlonsafthe tndiM lftd llrondl181 tree a..lt .............
Right~ lohor lorond!us Apical segiTII!ntal bronchus (I) ,_rtar segmental bronchus (IQ Antertar segmental bronchus OIQ
Aplmpast.lrlar segmental bronch111 (I, II) An!Rrtar segmental bronchus (Ill)
Uft~lobarbronclws
11/ghf ~lobar bronchus
lateral segmental bronchus (IV) M!idlal.segm~nto Ibn~nchus M
Superior lingular bronchus (IV) Inferior hngular bronchus M
11/ghflowtrlobrK bronchus
Uft ,_lobar brondNts Superior segmental bronchus (VI)
(VI)
M!idlal basal segmental bronchus (\Ill) Anll!rtor b&JI segmentol bronchus (\1111) Lateral b&JI segmentol bronchus (IX) Posterior bani segmental bronchus (X)
open end of m. ring is closed by a membranous ~ rlorwall. The entire tube lsllnedbyat~~~~aJ~JU,corulstlngof;meplthe llal layer (It), l'otth an underlying lam Ina propria of loose mnnectlve tissue c:onu lnlng 11 ftbroelislk bind at Its bue. llelow the mucosa Is a submucosa conbining seromuCGus glands that~ a protective mucoU5 film. The membranous wall tNt doses the open end of the tracheal cartilage contains drt:Uiarly-ortentzd smooth musde (tr.l· chealfs) wtth additional longitudinal binds. The outermost comp~ nent is an adventitial layer of connective tissue. Microscopic struc· ture changes substarrtlally at different levels of the brondtlal tree (see pp. 86-89). b T11etncheal epftheiTurn: Facing lhetrac:hul lumen lsa pseudostratified respiratary epithelium with three praminent all types: columnar dffo!Jid cells, which dr~ mucus and particles along the tracheal surface tnward the pharynx. goblet ails, which secrete mutliS, and basal cells, which do not span the full height of the epithelium. Basal cells are mitrltic precursors for other cell types in the epithelium. A thick basement mcmbr;me undmles this epithelium. The tricheal epllhellum conblns sever;ll other Intrinsic cell types, not depleted. as well as lymphocytes ~nd mast cells that hM! migrated from underlying connectlw Ussue. Prolonged exposure to Irritants such ~~ tobacco smo~ inc:ruses the number of goblet cells and decreilses the flow of secn:t!ons, compromising airway cleannet'. til~t-. The
llltht ..... ......,_
Supertor segmental bronchus
a ftbroel~tlc tube supported by spaced C-i~ped rings of hyaline car-
Medial bani segmental bronchus (VII)
AntRrtor basal segmental bronchus (VIII) Lateral ~I segmental bronclu (IX)
Posterior basal segmental bronchus (X)
Notre: The eplthellu m of the carina, unlllae that of the rest of lhe trachea, consists of nonlca11tlnlr:ed sqUilmous cells.
83
Thorax - - 2. OrgGns
2.8
Lung: Segmentation
A Segmental ardlltecture of ttl~ lungs Anterl~r view (a) and pomrior Ylew (b) of the right ~nd left lungs (lat·
eral and medlallltews are shown In C). The segmenul .uchltecture of the lung relates directly 1» !he branch· lng p.ilttl!m of th~ b~chlal tree (seep. 83). The bill!lc structur.al unit of the lung is the lobe, wfl~ bound~ries ~re dedy defined on the surfice of the lung by the lnterlobilr fissures. Each lobe Is further subcllllfded 101» segmenrs-wedge-sha~ functlonal units wtl~ apex points towam tile pulmonary hilum. The pulmonary segments are inmmpletl!ly separ;ted r-. one ~n~tfler by thin connectilll! ti$5Ue and ~re not dis· canlble as separ;te units on 1he lung surface. Passing to the center of each segment ane a Sl!giJ!ellfDI bn:lnchus and a segmen!DI brarn:h of the pulmonary arwy (segmental.a!Ury), constituting the "bronchopulrno-
n~ry segment" or "bronchoarterial $C!gment.• The segments, in turn, consist of sub3egml!l1n deflned by the further br;nchlng p3ttan of the segmental bronchi. E.1ch lung consist> bilslcally of ten segments. Due to the presence of !he cardiac notch In the left lung, however, segment VII of that lung isoftensosmallthat itisnotconsidered~ MFarate segment but part of segment VIII. As n~ted above, the segmental boundaries are not visible on !he surt.lce of the lung. For partial resections ofthe lung (see D). the targeted segments are ldernlfted by damping off the Sl!gmenUI artl!ry. As the devascularized segment blarKhes, It contmts sharply -Mth the surrounding tissues that are still perfuJeel. lntrasegment31 blood flow can also be demonstrated by ultrasound scanning. The pulmonary segments are n.amed and numbered as shown lnubleB.
B Setmentllin:httedureafthelungs lllght ..ng
l.tlPerfobt Apical segment 0) Postelfor segment (II) Anterior segment (Ill)
1.-ftlu.. Upperfobt
Aplcopo&tellar segment (I+ II) Antelfor segment (Ill)
Mrddtflobt
Lateral segment (IV) Medial segment M
84
SUperior llngular segment (IV) lnt.lor llr.gularsegment M
tm.wfobt
tm.wfobt
Superior segment (VI) Medial baM! segment (VII) Antellar basal segment (VIII) Lateral basal segment (IX) Posterior basal segment (X)
SUperior segment (VI) (Medial basal segment (VII)) Antellor basal segment (VIII) Later.al basal segment (IX) Posterior basal segment (X)
TborGx - - 2. Ol'gtlns
• Rlghtlung,medlalvfew
c Rlghtlung,lalleralvfew
d Leftlung,lmf
c Segrnental.-dlltedlre oltfl~ lungs: brondlopcJirnonary
sesmenb l.ata'al;md medlalvlewsoftfle rfght(;a,c) and left lung (&,d).
Right-< I~
a
b
D PartSIIIung nuc:UDnl The ~n;atomicill subdivision ofthe lungJ into lobe:s~nd segments (Hie B)
Is eJq~lolted In putlallung resections:
• Segmenttctomy (wedge resection): removal of or~e or more segments(a) • Lobectomy: removal of ;m entire lobe (b) or the complete resectlon of
a lung (pl'laJmofleCtllmy, c)
85
Thorax - - 2. OrgGns
2.9
Lung: Functional Structure of the Bronchial Tree
Large
subsegmental bra nell us
Small
sulmgnentll brondlus
Tennlnal brondllalt
Re.!plnrtll ry b nx1ttlloles.
flnt·through1fllnl·cnler
llrllnthlolt {artl~ w.~IQ
(IM!tuh'eoll) Resplnrtllry
IRndiolt
• A ConducUng and retplrltDry p1rts of tile brondllll tree The strudllre of the lung is organized m maximize the surfael! area available for gas exchange, ;md the b~chlal tree Is an-anged to de· Itiler the g;sses. In warmed and humldiHed air, to that spedallzed surfice area. The exdlange tolkl!li place mostly In pufroonaryaM!oll, microscopic pouchl!.l apprGXima1zly 201>-250 f'l11 ill diameb!r. The adult lungs ron· to~ln about 300 million atveollwlth a totahurf.tce area of nearly 150m2• From the trachea. the bronchial tree br;mches Into success!Yely finer dMslons (22 "dichotomous• diVlslons, In wtllch each passage divides inmtwo smaller passages). The parts of the bronchialln!e are dassified function;~lly as conducting or respirototy. • Condocting part (blue): main brcmchi,lobar bronchi, segmeBtal and subsegmental bronchi. bronchioles. and temnlnal bronchioles • Respiratory part (red): reiplratory bronchioles. alveolar doct (not VIsible}, and alVeolar sacs
86
b
The bronchial tree presents a uniform structure of a speclalru.d airconduction tube out to the le-..el of the segmeBtal bronchi. The bron· chlal wallis rdnforced by cartilage rings or plates ;md Is lined Inter· nally by a pseudostratllled columnar, dilated eplthdlum (with goblet cells: see p. 83). The walk of the smalfl!r bronchi do not hiM! cal1flage reirrlWcement. The concentric musculature of thest> bronchi atx~uires a li!ttlce-llkl' structure (see 8), and the pseudostratlfled epithelium Is replaced by a single layer of prismatic. ciliated epithelial cells. Goblet cells become less numerous ;md are no longer present past the lewl of the terminal bronchiole. The terminal bronchiole is the fiBal seg· meBt af the air-conducting portion of the bronchialln!e. Each l!!nminal bronchiole aerates ane acinus. Agroup of three to fllle acini whose ter· mlnal bronchioles ;nfse near oDe anothef on the bronchial tn!e forms a lobule, which Is the smallelt morphologkally distinct strudllrlll unrt of the lung.
TborGx - - 2. Ol'gtlns
Acinus
lW!Jl-___;;::,o___ I'Uh!cNry ah'eol
B !itnlc:ture of a n!!ipl'nltllry brandllclle
The respiratory brondliolel, didloi:Dmously divide into first- through third-order respiratory bronchioles, the thinnest of which IJ leu than 0.5 mm In diameter. Alveoli beglr1 to appe;~r on the flrst-orcler respl· ratory brondlfoles. marldng the start of the respiratory por11on of the lung. The alveoli are isolated initially, then berome more numerous and are collected Into sacs. Each sac has a central open space.
Connect!Ye lfssue with .ilbundant elastic fibers Is Interposed between the branches of the bronchial tree and the alveoli.1Mlen these elastic fl. bm are stmched during lnsplr<~tlorl, they store er~ergy and proYide the mechanism for tile elastic recoil of the lung during expiration. In patients with bl"(lriChlal asthma the bronchioles .ilre hypersensitive, and constriction of the smiXIth muscle in the bronchiolar walls can be triggered by allergens (e.g .• pollm) or by stimuli like cold that are tTivlal to non-;~sthrnatlcs. Slr~ce these walls are not car111age-retnfllrced. the bronchioles narrow and remtctthe passage of.illr tothe.illveoll (obstructive venlflatory Impairment). a using dyspnea (respiratory distress).
87
Thorax. - - 2. Organs
2.10
Surfactont
Lung: Functional Structure of the Vascular Tree
C.pillary endothelial tell
C.plllary
lumen
Type II pneumocyte
AM!olar lumen
~
arterial vessel
(deoxygenated blood)
Peripheral------',._ venous R.Ssel
(oxygenated blood)
AM!olar Erythrocyte macrophage
Type I pneumocyte
Elastic flbers In the lnteraM!olar $0ptum
" ' - - - - Sectioned aM!olorsoccule with lnteraiV!!Oiar septa (and sl!l'l!ral $0ctioned vessels)
FU$Ion of the bil!iement
membr3nes
A Epithelial lining of the alw!oll
Alveolar
The alveoli are lined by two types of alveolar epithelial cells (- pneumocytes): • Type I pneumocytes: the more numerous type, Hat and broad, formIng a continuous layer(= cap cells). They are dosely Interconnected by tight junctions. • Type II pneumocytes: markedly larger than the type Icells, frequently isolated (= niche cells). They produce and secrete a protein-phospholipid film called surfactant, which Is distributed over the entire alveolar surface and lowers the surface tension of the alveoli, making It easier for the lung to expand. The Immature lung of a pretenm Infant often falls to produce sufficient surfactant, leading to respiratory problems. There Is a constant turnover of surfactant as the type II cells continuously produce surfactant while the type I cells continuously reabsorb it. At the sites where type I alveolar epithelial cells come into contact with the capillary endothelial cells, their basement membranes are fused together. The anatomical distance from the alveolar lumen to the capillary lumen, over which gaseous diffusion takes place, measures only 0.5 11m at that location. Notr: All diseases which • Increase the diffusion distance between the alveolar lumen and capillary lumen (edematous Hurd collection or Inflammation), • decrease the aeration of the lung (alveolar destruction due to emphysema, for example) or decrease lung perfusion (capillary obliteration), or • cause fluid Infiltration of the alveoli {pneumonia) • will decrease the efficiency of alveolar-<:aplllary gas exchange, leadIng to respiratory compromise.
88
duct ~,...------ Central
arteriilh•essel
(deoxygenated blood)
Peripheral - - -'11 Vl!nOUSYI!.!$01
(oxygenated b
blood)
B Relationship between the alveolar su and pulmonary vessels
In this diagram and inC, the standard convention of coloring all arteries in n!d and veins in blue is not followed, in order to depict more clearly the true physiological changes in pulmonary blood as it travels through the lung. In a, a branch of the pulmonary artery carrying oxygen-depleted blood from the right ventricle is depicted in blue. A corresponding branch of the pulmonary venous system is shown in red, carrying oxygen-i!nriched blood back to the left heart. Pulmonary arterial branches are intimately apposed to, and follow closely the course of, the respiratory bronchiole branches, sending capillaries over the alveolar sacs and invading the alveolar septa. The sectioned alveolar sac (b) clearly shows thatthevessels not only surround the alveoli on the outer surface of the sac but also penetrate the interalveolar septa, enabling the capillaries to undergo gas exchange with multiple adjacent alveoli. Noll!: In most of the circulatory system, small arterial and correspond· ing venous branches tend to follow parallel courses, but this is not true in the pulmonary circulation. While pulmonary arterial branches fol· low the same segmental and lobular branching pattern as the bronchial tree, the pulmonary veins have a more independent course, not closely apposed to the bronchioles, remaining on the periphery of lobules and segments, and often crossing lobular boundaries. This difference in con· fonmation between pulmonary arteries and veins is demonstrated dra· matically in C.
TborGx - - 2. Ol'gtlns
Bronc:Nalartey ---~ Br.anchof ---~~~
puhlonary irtlery (clecixyl)en~
blood)
\\--- - - llr.lnchof
pulmonarywn
(Ck)'!le
blood)
Fbroussep!IJm
--~ll
betwHn
Plofmonary lobule
PUlmonary ------!~....,_.,.__7'111111 alo'eolus - - - - - - Subpleur.al oonnectllletiHU~
c Va~a~llrdrcultlllfai'Mpll'lltorybnlndllllle A resplratJxy brorxhlole ;md associated alveolar sacs of one of Its ter· mlnal brandles. as lllustr.rted on p. 87. Is reproduced here -Mth Ute lo· al vascular tree supertmposed. Note tftat. a sin B. the pulmonary art!!· rial bra riCh is depictl!!d in blue beca~ae of its deoxygenated blood, wflile the corresponding pulmonary venous branch Is shown In red because Its blood has been replenished .tth oxygen. The lung has two separate vascular systems-pulmonary arteries and veins for gas exchange {Vasa publica), arid mud! smaller-diameter bi'Oildlial al'tl!fte.l and Vl!iru (vas.1 privata) for supplying the metabolic needs of the parts d the lung itself ~rorxhl and larger-diameter bronchioles-that do not have direct access to oxygen (seep. 122).
Numerous anastomo.ses between the vasa publica (pulmonary artery and vein) and the vasa prfvat<~ (bronchial artl!ry and vein) help to ensure tftat a pulmonary anbollsm (ocduslon of <1 pulmonary arterial branch by <1 blood dot) W111 not lnmubly destroy Ute deperldent lung tissue arid cause pulmonary infarction. The pcJimonary systzm is selectively vulnerable to such emboli because It Is the first aplllary bed that all the blood triVds tftrough after being collected from Ute body Into Ute right heart; mort pulmonary emboli originate rn stagnant blood rn the wins of the legs. The rollab!!ral circulation cannot compensate for la~e em· boli, which a use massive damage and produce sudden life·th~tening obstructloBS of pcJimonary blood flow.
89
2.11
Diaphragm
lnspi131Jlry paoltlon
IJ.mbotomltliangle (Bododaldc tNngle)
ofdaphragn
A Prafectlan rJ/1 the d..phl'llgm onlll tile trunk Anterior view. The positions of the dliphragm In explriltlon (blue) ;md lnsplriltlon (red) are shown. The rtght hemldlaphr•gm rises as high as
the fourth rlb durtng explratton, and the diaphragm may fall a!most to the level of the sewnth lfb It full Inspiration. ~;
• The l!lelct posilion oftfle diaphragm depends on body type, sex, and a~Je.
• The left diaphragm leilflet Is lower than the right due to the nymmetrtal position ofthe hurt. • Inspiration~ INibd by an overall depression of the diaphr;gm ;and also by a flattening of the diaphragm leiflets. • The diaphragm Is higher In the supine position (pre5$!Jre from the lntri-ibdomlnal organs) than In the standing posiUon. • The degree of diaphragmatic miM!ment during inspiration can be assessed by noting the movement of the h~llic: border, whicn is easily palpated. • The dliphragm In 1 cad-r oc:01ples i higher 11!11111 thin the expiratory position In vtvo due to the loss of muscullor tone.
B Openlnglln tile dl1phragm
Inferior view. This unit deals only with the openings In the diaphragm ind the structures thlt pass between the thonx and abdomen (see C). Detalis on the shape and structure of the dl1phragm may be found In Vol. I, Cifnerol AllotrlmyGIId ~/System. Topogr~phlcally, the diaphr~gm doses the thoruic outlet and funns ib irnrillll' boundary. Openings can develop In the diaphragm beause the spaces ~ the different parts of the dliphragm ire dosed only by connedfve tis. sue 1nd bec:au~e neuravascubr structures pierce the muscle tissue or tendinous ~ of the diaph111Qm. The larger openings are dinically Important beCiluse they create pol:!!ltlal 'ftik spots through which ilb. domlnal GrgiRS may hemtat. lntD the chest. These hemlls are ~ commonly locltl!d at the e-sophageal hlltul. The openings and trans. mittecl stroctura are re'lli~ in Table C.
C Open. . In the dl1plngm 1nd lnn111111tted dnKtura
Vena av.al hiatus (a the r-1 of the TBwrtebr1)
lnfo!riorwniCIIVa Phreni~bdominll br1nch ol right
ph ...,k RIM (tht left phrenlo» abdomln1l br~nch pierces the muscle) EJophigeal hiatus (at the r-1 oflhe T1 0 wrtebra)
E.toph-aus Anmrlor 1nd pllllt.rfor vagal bunks (on the -phlgus)
Aorac hlalus (at the lwei of theT12/L1 ~brie)
DIIKindlng o110rta Thcndcduct
Apertures In the medlil
.Az)ogos win, hemiiZY!IOS -vein,
CRIS
splanchnic nltW!I
Apertures b - n the medial and lotaral crura
Sympathetic trunk
Star.-t.ol trfang!R
90
Int.mlll tfloralc •rtery •nd win,
-r-ror tp1g1s111c artay and ......,
TborGx - - 2. Ol'gtlns
Ant!rlor
Body of
lntl!mallhoradc
medlast\'n.m
Km!LII'l
a1l!l'y and wins
IJ!ft~lc
trunk
D CS.ure ofthethondc oUtlet: dliph~~~gm Superior view. The heart and lung hiM! been removed, ind the p;nfetil pleura h~ been windowed over ala~e area of the dlaphr.agm. OWing to the Juperiorconvexity oftne di~phr;~gnn, a nee!!.$$ is fl:Hmed between the parietal layers of the pleura. This costodkrphmgmatk l1!tm' Is lined by the cost<~ I and dlaphrigm<~!lc pi!rts of the parietal pleura. Allolfler recess, !he -I:Dmed1ostlnol rea!Sf, Is la~ely Independent of Ute dla· phragm CDnvexity.lt is li!M!d by !he cmtil and mediastinal p
mediastinum Is a narrow SPite filled with fat and conne<:tive tissue 11)nted between Ute posterior surface of Ute sternum. Ute per1cardlum, and !11e costomedlas!lnal recess. The phrenic neM and the perlcardl· acophrenic artery and vein de.Kend to tne di;rphragnn by passing between the perimdtum and Ute medlast!n<~l pi!rt of the parietal pleura. Covered byp
91
Thotwc -
2. Organs
Respiratory Mechanics
2.12
Thcndc upilnslon In the langltll.dl,.lao
Dlfphr;~gm
IB ~Upiritory
Thollldc aponslon n the sagittal ads
position b
•
Thollldc mnlnldfon n tile longitudinal lids
T12wrt!bn~
A Baile prlndpln of n!lpfmory mec:hinlcs
The mechanics of emrnalruplratlon (.as opposed tD the Internal resplr<~tion ofails and tissues) are based on a rflythmlt.illncre.ase <~nd decrease In the thorack volume, with an associated expansion and contraction of the lungs. As the lung expands, the pressure within the lung falls and air b dr~Wnlnto the lung (lnsplr~on). As the lung contracts, the pulmONry pressure rises and alrls expelled from the lung (expiration). Thus,
Dllplngm
Tho..,.;,; .ontriildion c
lnthetroruwrw..b
Thorocic
Eplgatrlc
d
angle
B Raplmary lllllldes Adlw411'flll Tnspi!WIIon
Adlft durtngllqlhaon
Solenl
Exlil!rnallntiercosUI muKles
IntemallntertDStll museIts Tl'anwersus thoracls
lnterc.ilrtlloglnous musdes
SubaKtlI mucos;o
Sell'atus post!rtor supe~or ind
lrftrlor Dlilphr~gm
When the upper limb IJ filled (e.g., by bradng the
92
TborGx - - 2. Ol'gtlns
Rlgltlung (elfl)lratlon)
Right lung (hlplratlon)
I
I
:(7
Pleural
I
Spaa!
lnftriar bonlet of h.ng ltiUiecp!nrtlan
±
./:
:::~
~~ ~-=.~ Costodlaphntgm~llc: n!CHS at ful elfl)lnll!an
•
b
Costodlllphf11!1mrtiC re
C Rllpllllltlllrydtilng•ln lurtgwlurne a-c Rl!splnrtury c:on1nd:lon and upenston of the lung. Capillary fora~lntheple\Jr.ill sp.;~cec;auseUie lung to "stlck•tothewall of the pleural c;wity, forting the lung to follow changes in the thoracic vol· ume. This Is particularly evident In lfle ple\lral recesses-sites wflere !he lung does not fully occupy the pleural ciVII:y at functlonill resld· wl eo~p.;~crty(the resting position between rnsp!riltlon .ilnd expiration, seep. 79). As the dome of the di;aphragm flatn!ns during inspirJtion (see p. 90), lfle costodlaphragmatfc recess elq)ands and the lung Is •sucked"lntothe resulting sp.;~ce, though Itdoes notflll It completely.
Airflow wring
Airflow during
elllllllltlon
Inspiration
Lung It full elfl)lnrtlan
Tl'IChel
I
In ferlor bo Rlet of h.n g atiUIInsptrat!on
c
wngatfull Inspiration
d
Durfng expiration, tile lung retr.lcts from lfle recess somewhat. The respiratory changes In the volume of the co~todlaphragmatlc recess lead to considerable displacement ofUie Inferior luAg borders (c). d ltftplni'IDry moveMents of the broru:lllll trM. As the thoracic volume changes during respiration, the entire brvnchlal tree~ within the lung. These structural movements are more pronounced In portion~ of the bronchial tree thilt .ilre more dlst.lnt from the pulmonary hilum.
light
lung
•Empty'"pleural-11.....--11--~
c;Mtyat
atmosphenc prMSUre
Qrdac shlft
• D Olange tft retplratory medlanll:s due tD pneumatflll Nor111111l rctplnrtlory medwlnb; The pleural space is hermetically
seilled on all sides. b Pneumothorax: With InJury to Ule left parletill ple\lra, outside air c;an enter the pleiJril sp.ace. The mechankal effect of the capillary pleural spaa (see C) is IIHI:, and the left lung collapses frDm the in· herent elasticity of Its connective tissue. It no longer partfclpiltes In re:splratlon. The right pleural c.JVIty Is Intact and can function lndependentfy. Air Is sucked Into the opened pleural cavity during In· spiration and is expelled duriAg expiration. Bec.aLIIe normal respi· ratory pressure variations still prevail In the right ple\lral cavity but are absent on the left side due to the pleiJral dek
Collap;sed
Nrflowdl.ffng
Pleural
lung
lnsp'rK!on
defectduring
Inspiration
c
similar to air being pumped Into a bkycle lfre. The mediastinum Is gradually shifted toward the normal 51de (mediastinal shift), wfllch may cause kinking of the vem!ls ~l'lX!nd the heart Withgut tre~~t· ment, tension pneumothorax Is lnvarfably fatal.
93
Thorax. - - 2. Organs
2.13
Prenatal and Postnatal Circulation
Duc!JJs arurtosus - - - (pii!Ent}
&~~,.,._
___
Pulmonarya~rll!s
(""ry little blood How} Left pulmonary veins
(\oery little blood How} Leftatrtum
Ductus venosus
(connects umbilical vein to 1nr..r1or
---~--1ii\:~--:;;;;j~~~~
ve
- - - - Abdominal
aorta - - - - lnfertor..,na cava
A Prelliltal drallatlon (aftEr Fritsch and Kuhnel)
The prenatal circulation is characterized by: • • • •
very little pulmonary blood flow gas exchange In the placenta nutrient delivery to the fetus through the placenta a right-to-left shunt In the heart
The fetal lungs have not yet expanded, are not aerated, and have minimal blood flow. Consequently, the exchange of 0 2 and C02 takes place outside the fetus in the placenta_Oxygen- and nutrient-rich blood from the fetal part of the placenta is delivered to the fetus by the unpaired umbilical vein. Near the liver, the umbilical vein empties into the inferior vena cava through a venovenous anastomosis, the ductus venosus. Oxygen-poor blood in the inferior vena cava mixes with oxygen-rich
94
blood (from the umbilical vein). The umbilical vein has anoltler venovenous anastomosis with the portal vein, which carries nutrient-rich blood into the liver for metabolic processing. Blood flow in ltle heart is characterized by a right-to-left shunt. Blood from both venae cavae flows into the right atrium. Blood from the inferior vena cava is channeled past an endocardial flap (the valve of the inferior vena cava) and through the patent foramen ovale into the left atrium. Blood from the superior vena cava passes through the right ventricle into the pulmonary trunk, but it does not enter the unexpanded fetal lungs. Instead it passes directly into the aorta ltlrough an arterioarterial anastomosis, the ductus arteriosus, and is distributed to the peripheral fetal vessels. Blood returns to the placenta through the paired umbilical arteries (branch of the internal iliac artery). Since very little blood perfuses the lungs, blood is not delivered to the left atrium by the pulmonary veins.
Thorax - - 2. Orgons
Aorticarth
Ligamentum arteriosum - - - - (obliter.I!Ed ductus arteriosus)
Pulmon;~ry arteries
(perfused) Left pulmonary veins (perfused)
Left allium
Ugamentumvenosum ---~---1~~\::---::::tJ.J,.~~~ (obliterated duct
connecting umbilial
vein to Inferior ven;~cava)
Round ligament ----J\-- -...,..£_--f./ of liver (obliterall!d umbilical vein)
- - - - Abdominal aorta - - - - Inferior ~nacava
Obliter.I!Ed umbilical arteries (medial umbilical ligaments)
B Postnat•l circulation (after Fritsch and Kuhnel) At birth, the circulatory system undergoes a radical alteration in terms of gas exchange and hemodynamics. The postnatal circulation is characterized by:
• pulmonary respiration and pulmonary gas exchange • loss of the placental circulation • functional occlusion of the right-to-left shunt and fetal anastomoses When respiration begins, the lungs are expanded and aerated, becoming the essential organs of gas exchange. Vascular resistance falls dramatically in the vessels of the expanded lungs. The pressure in the right atrium plummets, causing an endocardial flap valve in the left atrium to close over the foramen ovale and occlude it (the pressure in the left atrium is now higher than in the right atrium). The contraction of smooth muscle in the ductus arteriosus also functionally occludes that opening. This functional constriction is mediated by oxygen tension and by bradykinin produced by the lungs. The duct eventually involutes to leave a fibrous ligamentum arteriosum. The right ventricle pumps
blood through the pulmonary arteries into the expanded lungs. Blood from the left ventricle is pumped through the aorta and distributed to all body regions before returning through the venae cavae to the right atrium. The right and left sides of the postnatal heart are hemodynamically separate. The umbilical vein is no longer perfused, and the ductus venosus connecting it to the inferior vena cava is occluded (eventually scarring to form the ligamentum venosum). The duct connecting the umbilical vein to the liver is also obliterated, and the umbilical vein usually becomes fibrous over its entire length, forming the round ligament of the liver (ligamentum teres hepatis). Only the proximal portions of the umbilical arteries remain patent while the distal parts are obliterated, fomning a medial umbilical ligament on each side. Nob!: The persistence of a patent ductus arteriosus causes the lung to be "flooded"with blood from the aorta, which is at high pressure, resulting in secondary damage to the pulmonary arteries. Treatment consists of surgical closure of the patent ductus. If the umbilical vein remains patent, a rise of intrahepatic pressure can cause a reversal of blood flow from the liver to the umbilicus (see portosystemic collaterals, p. 293).
95
Thorax - - 2. OrgGns
2.14
Heart: Anterior View
t.eng1hof~rt
t.ong.dtametltr
- - - - -.;.:--
---'o#J
-------~!V~
MDimumv.4dth on l'lghtslde
Short·axls
drammr
•
Anll!flat
Maid mum Width
mldlne
cnleftslcle
Aortlc;m:h ("'ortk lmob•} 1\llmonary
I
~
lnlnk Aocltl,
asandlng pMt
Mulmum'll1dlh c
" A
cnleftslcle
d
cardiac dlmendons and CDnftguretionaln • dlest rad'iogr11ph (after Rauber ~nd Kilpsch) The heart Is located behind ttle stemum lfl ttle middle portion ofthe In· ferior mediastinum. Sea use of ItS asymmetlfcal position, more of Ute heart is at the left of the sternum tban at the right (tfle slructui"I!S that formttleardiat borde<"$ an!~ in B). Virtuallinescan be dr.awn over ttle tardlat silhouette or1 r.adlographs (11) and tafl be used ro ewluilte ttle size ;md conffguriltlofl of the heart. The crlt:le<~l e<~rdlac dimensions .are the long-.rxfs diameter, tranwerse diameter, .arid short..rxh diameter. The long·axis and short-axis di;ameters an be di~ ~sun!d on ttle radlogr.~ph. while the transverse dlametef Is talculated as the sum ofttlemaxlmumc.ardlacwfdtftsmtfterlghtandleftofttlemldllne(me.asured .at dlfti!rer~t lewis). The .ar~gle betweer1 the long,llCfs dlametl!l' and the maximum width to the left of the anterior midline an be ~sured ro assas the mdlac conflgur.~tlon (11-d). which may be dasslfled (left ro right) .as tr;mswrse, oblique, or Wftlcal. The exact conflgur.~tlon of ttle he.art Is dependent upon both Ute patient's body type and the point ofttle n!spiratorycyc:le at the moment ttle image is created.
Right
a!Jfum
position
96
J'
- -+ ----'-
Right wntrtclt
B ltlld!o911phlc eppea~W~Ce of the hiHirt: antertor vl'ew The rlghtatrlum and supaforvena cava form ttle rtghtcomlac border while ttle aorUc arch {e<~lled the "aorUc knob" on radiographs), pcJimonary trunk, left atrium, and left wntrtde form the left anlac bonller. The short intrJthoracic segment of the infi:!riorvena cava can be seen directly above the diaphragm when ttle latt4!1' Is completely depressed .at full lnsplriltlon. The right ventrfde lies behind ttle sternum and Is "lost" In Ute c.ardlac $llhoui!Ul!, but for clarity It has been outlined In ttle dligl'i!m. The $Chem
c
lruplratllry
----,f-- -+--
Retplrltory dwnges Tn the anlllt borders Owing ro the strong fibrous atuc:flment of ttle perltardlum ro the diaphragm. ttle heart must follow the respiratory ITICM!ments of the diaphragm. When ttle dlaphr.agm falls durfr~g lnsplriltlon, the heart desc.ends as well (red). Sina! ttle heart has an oblique orientation in the chest. It appe.ars to assume a more upright position ~nd Ute c.ardlac silhouette becomes nall'OWer. The heart also rot.1t1es sllghtiy clockwise when viewed from above, dlsplayffl!l a greater portion of the left atrtum {1M'IIch,llh Ute left ventricle, helps to form the c.ardlac border). During expiration (pu!JIIe), ttle ardiat apex move$ upw;~rd while the he;~rt assumes a more horlzont.11 orlentiltlon. broadening ttle c:.;rrdlac borders.
TborGx - - 2. Ol'gtlns
llr.Jthlo«Ph;Jik trunk
PI!mcnary
trunk
P
ld't~l
~~
Rlghtii!NI .appendag~
ld't aron.1IY artl!ry
(an!sfor 1-
Right lung, middle~
cularlnndl)
P.lrlml pleura, comlp.vt
ld't \'1!11tllde
Qrdac
R!Qhtlung,
~r~
~pel(
Diaphragm
FltRi.tl
pe
D 1be heart In 11tu. antl!f1'or'Wtl!w
Simplified illustration. The chest has been widely opened, and the pll!!u· rat cavities andflbrous perlcardlum hive been cut open. The oonnect!ve tissue h;ss been removed from the anterfDr medliStlnum to display the heart. Allflough the plellral cavities have been opened, the lungs are not shown in a collapsed state. The heart lies within the periclrdium, which Is flrmly attached tr> the diaphragm (see C) but Is mobile In re· lat:lon to the parfet
while the left ventricle Is only partly Wible. As a result, all of the great ve.uels Ci!nnot be seen ewn when the base of the heart is viewed from the front The short pulmonaryvelm are tovered by lfle cardiac sllhou· ette becall!e they terminate at lfle left atrium. which Is dlrerted posteriorly. It Is easy to ldenttfy the rfght and left atrtal appendages. which partially define the right and left nrdiac borders on radiographs. The cardiac apex points downward and to the left. MOlt oflt Is still covered by pericardium In this dlssectlon. Its movement. called the apical beat. Is palpable as a tine motion In the fifth lnteroostal space on the left mid· clillllcular llne{see p. 109). The thin sen:.~a membrane of the eplcaltllum (see p.67) gives lfle surface of the he;~rt a shiny appearance. Under Illis membrane are clusters of fatty tissue In which the cororlilryvessels are embedded.
97
ThoraK - - 2. OrgGns
2.15
Heart: Lateral and Superior Views
A TopographlcaiM;rdons Left lilteral VIew (stomach not to scale). The heart, enclosedin its pericardium,rtstsbtOadly on the diaphragm In the middle mediastinum and emnds almortto the posterlorsurface of the sternum. The bi5e of the heart. whkh Is occupied by the roots of the great vessels, Is diretted superiorly, posteriorly, and slightly to the right due to the orfent<~tlon of the c<~rdliiC illCls (see p. 96). The left atrium In p
Aortic arch
!At main bnl
- l lr't++-==""11--IAt pulmon1ry wins
E.lcpltagus Diaphragm
ll'act!N
HodiXIntll
flsstnof
Acrtlca'dl Aort.ll.
part
rlg!tklng
CbllqLltlklutl!
Bodyohtemum Antafor medasttnum
Clrdllc apex
..
• B
ltidogr..phk;~ppearanceofthe he;ut: lm!r.IIW!w
The diaphragm leaflets and lungs are faintly visible In this left later.ill view. The radiograph and (OC'I'I!Iati\11! drawing dearly show how naJTOW the anterior mediastinum Is when compared with the relatively btOad
Pulmonary oot!low trnt Rfghtlung
Ascendng acrta
98
olr!ghthllg lletRlC
Lefhnd rlg!t d'aphn~gm IH!Iea
retrocardiac (Holzlcnedlt) sp
c
Appel ranee ofthe heart on MRI Magnetic resonance image of the normal thorax. The cardiac chambers
Tltorrvc -
2. Olgcms
ObiiQJe flau... ar left lung
Dbl""e ft"..-erA
rtghtlung
Thondc dud
Esophagoa
Thcndc (dosaondlng) aorta Azygos vein
Right lung, loworlobl
llh ~us nenoe (•ntoriorwgoltrunkl
D 111e t..rt In sltll, lnfertor vrTri!nswne section through the thor. at the level of T8 vertebra. VIewing the transvsse section demonstrib!sthe uymmelrfc~l position of the heart in the middle mediastinum and its sttght degree of p~ logk countaclockwbe rotation; the left wntrfde faCES downward R tD the left. while the right ventrlcle faCieS forward and ID the rlght. The right ventricle thus lies almost ditedly behind the posterior wall of the stErnum (wtth only the n~rrow antErior medlutlnum Intervening. see 1}. The left mlum Is In very dase relationship ID the esophagus. The c:ostDmedintillll rece~:S is intErposed between the hurt and mmum
on the r1ght lind leftsides (see E). Arel~vely small space Is avallllble between the heart and 'Ntdllv/ o:Jiumn far the passage of neuravasc:uli r structures and organs: thoradc o~ort.l, esophigus, thoro~clc duct. U)'9CS and hemiazygos veins. and portions of the autonomic netWus system. Each lung bellrsoJn Indentation from the heartn Ued the cardiac Impression. This Impression Is larger In the left lung INn In the right lung because of the heart's asymmetfoc po$ition. The potential spaces between the pleur~ll~ o~nd the serous portions ofthe perkllrdlum are consl~ erably smaller INn pictured here.
Kight lung - - - - - ArurA ...IIIM! anfocdull,.,...
~
AmlrA'-llc ---.,....--· d...lnas "'
- - - - . _ ArurAabsol.rte anfocdull,.,... RtlatMardlac dullness
a E C.nllK dulln... on peraaalon efthe chelt
Anmforvlew (11) and tran,_,e section viewed from a~ (b). In contrast tD the sonorous sound tiY1: Is produced by the percussion of o/rfil/ftllung (Rep. 78}, the [IWcl-fillcd heart produces a fbt sound on percussion known au:rmlklcduJ/rrtss. Thedullne~:S mill)'becrbso/utr(atslm where there Is no lung tissue to moderate nrdlllc dullness) or l2lattllr (at sitn wh~ lung tissue CM
Is located between the c:he.st w~ll ~nd heart while the area of relative cardiK dullness Is loated over the right and left costamedlliStlnal recesses, whldl contain small expansions of lung tissue (see b). Notr; CardiK dullnen ghla W"''ID hepatic dullness in the epigastrium and right hypochondrlic region due tD the ani!Dmlcal extent of the llwr(see 11). lhe boundaries of the hartan be roughly esti!Nted from the area ofcardiac dullness because the sound characteristics at the cardiK banllers contrllst wtth the more resonant Iung sounds.
99
Thorax - - 2. OrgGns
2.16 Heart: Shape and Structure
BIIICHo- ---~ aphallctnmk
Right puhlonary ll'h!ry Sl4Mf~Ct
- -+1
Wllilo:
•..,.....,....,.....__ IJ.ft aullde
C..ronary---'lr---::~iBI'I
st.fcus
A HNrt. stemocast;~l S\llfUII!
Anterior view. The heart ~ a muscular hollow organ shaped ~pproxl· m~tely like a flatb!ned cone.lt consim topogr;~phic;~lly of~ ba5e. ~pex. and tilree surf.lces: • The base of the heart. which Is occupied by e~rlng and emerging vessels, Is dlrerted superfolfy. posteriorly, and to the right. • The apex 1s directed inti!rforfy, a~lto!iy, and to the left. • The surfaces are described ar. anb!rior (stl!rnocostal), postl!riot, and inferior (diaphragmatic) (see B). The stl!mDCOstal surface of the heart is fDm1ed chiefly by the right lll!n· trlcle, whose boundary with tile left ventricle Is marked by tile ante· rfor l~rventrlcular sulcus. The left ventricle (occupying the Inferior .and postenor c;~rdlac surfaces) forms the left border .and .ilpex of the
heart. The ontl!dGr ll'lti!M!II!Ifcular sulats contains the a~rlor l~rven· tlfcular branch of the left co~ry ~rtery (seep. 124) and the ~ntelfor inte111C!ntricular (great cardiac) win. Both Ye$$Cis are embedded In fat and almost completely occupy tile grocwe, so that the ante1101' surface of the heart appears nearly smooth. The left and rtght atria are separated &om the ventrfcles by the COI'Mill)' mlcus, wtlich also tr.lnsmiU coronary vessels (the intrinsic vessels of the heart. see pp. 124-127). The right atrial appa1dage lies at tile root of tile ascending aort
m-
c.dlacdlamlan thlltfann lhe..rt.e (wllh -lsJ
5lriKe
Anterior (sternocostal) surface
Directed antel1orlytowarcl the posterior surflla of the sllmum andtherlbs
• • • •
Right atrfum w1th right atrial appendag. Right wntride Small partoflefhentrlclewlth cardiac apex Leftarlal appendage • Asandlng <101U, superior vel\il ava, pulmonary trunk
Posterior surbm
Directed posteriorly IDwarcl the posterior mecllaltlnum
• Left arlum with termination of four pulmonary veins • Left wntllde • Part of right altum wtthtennrnatlon of superior ~ncll~r ~~enae
avae Inferior (cllaphr~matlc) surface (dlnlcaily: the posterior wall)
100
Directed Inferiorly toward the dl~phragm
• Left wntllde with arcllac:apo • Right llentrlde • Part rA lfght atrlumwtth tmnlnatlon of l~rwna ava
TborGx - - 2. Ol'gtlns
Left common arotld art2ry
C He.rt.poJterfor.u~
)-,•
-
Rlslhtpulman1ry veins
Rlghtitrium
Posterior view. This dissection shows how the aortic .ilrdl crosses over the pulmonary trunk at the point where the trunk divides into tbe left and right pulmonary artl:!ries. At that sin! the aorta gllles oft the three major arteries to the upper limbs. neck, and skull: the bra· chioCl!phalic trunk, left common carotid artery, and left subclavian artery. Thls view abo deirly shom the tamlnatloru of the pulm~ nary veins (usually four In number) lr1 the ltft atrium and the terminations of the I.'M) venae cavae in the right ;atrium. N~te also the corvnary sin liS In !he posterior ptumed from the heart by the ardlac velru.
Coronary sinus
rr;r----Rlslht
pulmonary
veins
Rldlt
itrlum D Hetrt. di•JIIn!lm•tTttllrhce
Posterolnferforvlew. The heirt lsttlted forw.~rd to glwoe a better view of Its diaphragmatic surface, which Is formed by bolb ventrfdes and the right atrium with thetenminalion of the in· fenorvma cw.~.lftheheolrtwerellfewed from below. from the perspectiwoe of the diaphragm (not shCiwn here), It would be obvious that bolb vmae C.iiYae art> in alignment: Looking into the Inferior vena cava. one can see thrwgh the ter· mlnal p
Coronary
--~,.....-:::':=::=-'!""!:::L'III
slnw
E Stnlcture ot the cardiJc: Willi CilmpaiiiiDn
Endocardium
lnnenmost layl!r.llnes the cavities of the hNrt
Single layer of flat epllbellum. cooanuous with YiiSCularendotflellum 111 blood lleSSels
Myocardium
Mlddlt ~rand thki!Ht Pilt of the he<~rt mil; motor for the pumping action of the heart (see pp. 102. 103)
Complex urangement of muscle ftben
Epicardium
Outenmosti<~YtrofththNrtwalk part of the
Serous membrane
pe(lcilrolum (see p. 67). fonmlng ItS ~saralla)oef
101
Thorax - - 2. OrgGns
2.17
Heart: Muscular Structure (Myocardium) Aortlcan:h
ntl!Nermfcular --fT--TSI!plllm
A Myoc.trdlal 1rdlltMtllre ;a. b External muKulature of the heart. slmplt6ed ~nt:erolnferfor view.
The mu5eular walls of tile rtght ind left ventricles hive been win· dowed to display the deeper fib en. NeZ Theepic.al1lium has been~ in a and b along with the subepitardi;ll fat. The coronary veSiel$ are not sh~Jim in order to
102
lnterwntrlallar ---J~
.sep111m
Jtria and is common to both. wh~s each atrium hils its own deep layer. looped and annular m111de fibers extend down to the atr1oven1rfcular boundary and ilso endrcle the venous ortflce.s. The IH!fttlfc.Un mLIKUmlre has a complex .ilrnngement, consisting basically of a superficial (subepicardial), middle, and deep (suben· doc.ardlal) layer. The supaildall;syer jolm apically with the deeper layers to form a whorled amiDgement of muscle flben arocJnd the cardiac ilpex (vortex cordis). The right ventrtcle, which Is a lowprtSiUre systtm (see c), k leu muscular than the left and almost compleb!ly lades~ middle layer. The subendOCi!rdial layer forms the trab«ulae cameae and papillary muscles (seed and p.107).
Mrtlcordl
Left pulmonory ------,.==.. lrUry
Loft pulmorary
..,.....
Left11rium, ,..ardlum
Coronory sinus
llghlpulmol'lll)' veins
IUghtllrlllll, myoardlum
ondrdng or1ftco err Wer1or_,• cavo
Wer1orwrw Cl¥l
Llft~~-~-~
mlddell)orcrf "¥X'!rdum
The histological unit of the myocal'lllum Is the c.arlllac myocyte, a spedal ized form of tal'lliac muscle cell. Unli~ their electronically isolill:ed counterparts In skeletal muscle, ca!lilac myocytes form .1 .!}'IIC}" awn ln which membrane depolarllatlon and contraction spread In a
-·
c:, cl Myocardial crvu-secUons perpendlculu to the long ads of the he;Jrt,. viewed from allow. cSchematic representation: The leftheart Is In an eJqHnded state (dlutole), the rtghthmrt Ina contracted state (systole). d Transwrse section through a spedmen during diastole.
All the sections dNrly demonstrate the difference In thickness between the left and right ventricular myocardia: The left wntride Is part of the hlgll-pressure systlm, and therefore Its myocardium must generate aslgnlflcantlyhlgher pressure (120-14DmmHg durfng ventricular contraction) than the right vartrlde (approximately 25-30 mmHg). The difference In thickness Is most pronounced during ventricularmntraction (see c). Section cl shows IMPN the coronary vessels and subeplcardllll fit fill the suld In the heart.
103
ThoraK - - 2. OrgGns
2.18
Heart: Atria and Ventricles
ltlghtpulmanary artery
llft atrium
llft plllmcnary Wins Tnlbe
larsej)blm
USIIITN!ntum .uriosum
Clio nile
tl!ndhW~~e
Pl:mltl'lor p.lpllarymusd~
:rmor.Jry arh!ry ~"a---Lefts~
ptllllOOir')'wln va~of
for.amen owle
A Ou11mbers of tfu~ left helrt l.o!ft lateral view. a Venbide,. b ventricle and atrium. The lll!!nbiwlar and atrial walb have been opened. The left MI'Un I~ smaller Ulan U!e right (see 8.1). Itt. muscular wall I~ thin (low-pressure ~ystem) and Is smooth In area~ derfved embryologl· cally fi-Dm the orifas of tne pc.lmonary veins. The rest of the atrium is lined by pect!Bate muscles. The pulmonary veins. usually four In num· ber. terminate In the left atrium. Occasionally a narrowtl~uefold (valve of the foramen cwale) Is focJnd on the Interatrial septum, formed by a protrusion of the fossa cwalis into the left atrium. It marks tne site of fusion between the embryonic septum pdmum and septum seam· dum. The leftwntrtde has an Inflow tract and outflow tract. The Inflow 110ct begins at !he left atrlcwentrklllar orlfk2, which Is guarded by the left atrioventricul~r valve (see p. 106). The muscul~r ridges of the trabec-
104
ulae arneae project lntD the lumen of !he ventrlaJiar lntlclilt tract. Specialized eJCn!nsions of the tril*ulae, tne p~pill~ry muscln. are attached to the cusps of the left atrioYmtrlcular Y
TborGx - - 2. Ol'gtlns
Superlcr WNCOMI
Right pulmonary
al'tlery Crimi b!m/n.~ls
Rlghtatlfum
RJg!tpulmoNry w~s
lnterab'lal Sl!ptllm
'--.....1--- RJg!tlllriiMntrlcularor!ftcewllh
Limbus of
atlf~lr
fo.uaov.alls
YaM
\fahoed or!ftceof coronary sinus
Right pulmlltlary lrb!\'y
Rlghtatlfum
Coronary nfcus lntem!ntrlalln
RJ¢t zafOYen!JJQJiarvallle,
sepbm
anter!oraJsp Trabeculae cam151e
b
B Olambers of tfu~ rfght heart
a Right lab!r<~lview of the atrium. b Anterior view of the wnlricle. The vmtrlcular and atrial walb have been opened widely, and the heart wall has be\!!\ cut open to dlspl;aythe Jntemal chamben. The rtght lltrbn (see a) consists of a postl!r1or and anterior segmem. The~ segment with the smooth-walled sinU$ wnarum (not vis· lble here) bears the orlftces of the superior and Inferior venae cavae. A smallva!Ye at the orifice of the lnfafor vena cava (Valve of the Inferior wna cava) directs blood In the prenatx:ll circulation through the foramen ovale in the interatrial septum.lleclusetheforamen ov.1le is sealed shut postnmlly, becoming the h»sa ovalls (sunrounded by a rounded mar· gin, the limb liS), this valve atrophies after birth. The orifice of the coronary sinus also bears a small crescatt-shaped valve (valve of the coronary sinus}. The onl1!dor segment. which comprfsel the actual atrium with the atri;ll appendage (au ride), is separated frvm the posterior M!!l·
Po:Nrlar
lM!ptomanjnal
papllarymusde
trabecula
ment by a ridge, the afsta ttrmlnalls. Small m~~Swlar trabeculae. the pectinatt muscles, arise from the crista tenninali$, giving this segment an Irregular wall texture. The wall of the right atrium Is thin (low-preJsure system). The right ventricle Is dMded Into !:\WI segments by two muscular ridges, the supr;M!ntrirular crest and septomarginal trabecula: the in· flow tract posterolnferlorly (wtth the heart posltloned In situ) and the outflowtr.rct;mtefOsuperlorfy(see also p.113). As In the lefl:vmtrlde, the wall of the right ventricular JltfkJw tn:1ct Is studded with trabeculae carneae. and papillary mU5Cie.s are attached by chordae tendineae to the right atrkwmtrlcular valve. The cxttf1ow 1r0ct Is colle'shaped and consists mainly of the conus irteriosus, which has a smooth wall. The 11ght ventricular outflow tract expels blood Into the pcJimonary trunk, whose orifice Is guarded by the pulmonary valve. The wall of the right lll!ntride i$ relatiYI!!Iy thin o-pressure symm).
105
ThoraK - - 2. OrgGns
2.19
Heart: Overview of the Cardiac Valves; the Atrioventricular Valves Pulmanaryw!Ye
Right cusp
Antl!rfar
cusp
Right coronary Ntl!ly Rl~ht
• Mil!liar
cusp l.
Rlgh!NrOnary ~rtey
Right
Anti!rio< cusp
lltlloo;entll· Wla'VI!Ye
Pcml!rlor
Pomrior
cusp
W5P
b
A
Oventewoftflec.rcl~tnlvet
Plane of ttle e<~rdlac valves 1ltewed from above. The atria have been re· moved, ;md the great arterfes hiM! been transected at their roots. The e<~rdlac valves are dasslfled Into two typer.atl1oventl1cular and semi· lur\ar. A.trf0'1181!trtc~ilf wlws.l.ocated between ttle atria and ventrfcles, ttle left ind right atrlcwentrlaJiar v.allles ire composed of thin, ava5aJiar connec:t!Yetlssue cowred by endocardium. They are dasslfted me chan· ically as sail wft.oes (see B) bee<~use the chordae b!ndoneae (see B) con· strain the movement of each aJ5P like thetutherlng ropes on i SOln.The funcdon of these valves Is to prevent the reflux of blood from the Yen· !Jfcles Into the at11a. • The leftotrlOIII!lltrfcularwlile has twoOJsps (blanpldwhle): an inll!!1or cusp (anteromedlaO and a postl!rfor cusp (postl!rolateral). The ante· riorClllp is continuous with the wall ofthe<1t1rta. The aftzon<~te tenm mltrol vohle Is dertved from the two nn<~}or cusps. which are similar In shape to a bishop's mll:ef. SubdMslons lr1 the lal:efal margins of the otht!'Wfse smooth v.atve have led some anatomists to describe small acusSCII')' cusps e<~lled the mmmissural cusps (usually two). These
106
Lefhtri
Corm~ry
s'rlus
are not true cusps, heM-ever, .and are not connected to the flbrous ar~ulus of the cardiac.le!J:In (see C). The QJ!ps areb!thell!d by papIllary muscles (see B). • The rly!Jta!J1oill!nrriatlari'Oftlr has three cusps (tncuspld voh!r): arnertor. posterfor. and septal. One or two small ~sory cusps may also be filurld;they do not extend to the flbn:lus anulus. Semltun~rvalws.Thesevalves have three crescent-shaped cwps of ap-
praxlmab!lyl!llual size pi .aced .at theorlfk2lof the pulmonarytrunk(pul· monary Yillle) and aorta (;IOI'tic v.allle). lila! the atrioventriaJiar val-. they are mmpD.Ied of thin cor~ne<:tive tissue COYered by a1doe<~rdlum. The semllurl.ilr v.a!ves are dassHled medlanle<~lly as poclret IIUM:s because their cusps pouch Into theventdcle like bc.ilglr~g pockets. The wall of the aarta and pulmonary trunk show slight dilations just abcwe the valve (the pulmonary and aortic sinuses). The aortic sinuses t'lq)and the cross-section of the a ona, forming the <~ortlc bc.ilb. The rtght and left coronary anl!lfes br.mch
TborGx - - 2. Ol'gtlns
Lelt
atttum
Right~~
Rlght~Mntri
~ntertorcusp
~ltiiSP
Rlght~owotrl
wllrwllle.
posttrior
lntl!rwnlrlallll'~(ltllm,
mtmbranous p;ut
l'o.ltlerlof
p;aplllary m~aele
• 8 Atrtvventrkul1r wha end pepllllfY IIIUSdr:s AntErior view of the left (ll) ;md rtght (b) atrtoventrtcular Vilw:s. The dr.ii'Win!JS represent a Vf!tY e;~rty phase of ventricular contr<~CUon In which the abiOVI!!nbicular valves haYe just cla:ted. The p;apillary mill· cle.s a~ ch~11rly dispbyecl. There a~ tft~W p;lpillary musdes for the thtW cuspJ of the rtght atrloventrkular Vilve (antertor. posterior. and sept;rl papnlary muscle~) ind two papillary mil!des for the two cusp~ of the left atrioventricular valve (anterior and posterfor papillary muscles). The p;lpn!ary muscles (speci;ali.zed extl:!nsions of the trabeculae carneae) are attached to the free nn.1rgln.s of the valve cuspJ by tendinous cords (the chordae telldlneae). When the papillary muscles contract (valve do·
sure), the chordaewndln~S~e .1re shortmed w rertrfct the mo1ion of the valve cusps. Thlskeepthecusps fromopenlngtntotheatrtadurlngventrtcular contrilctlon {syrtole), thereby p~nti'ng the regurgltiiUon of blood bitck into the abia. NOO!: Lilcil! other myocardial regions, the myocandium of the p;lpillary m~~Seles may suffer neaosls due to a myocandlal Infarction, leaving the comespondlng cusp prone to prolapse Into the atrium. Conversely, pathologkal shorteniDg of the chordae mil)' also p~ntthev.alve frcm cl011ing completely. This also -uld allow blood to regurgiti!te into the atrium during ventricular systole, produdng an audible heart murmur (see p. 113).
C Slcil!letonoftMhe..t
V;alve plane VIewed from <1bove.. Tbe skeleton of the he;~rt Is a layer of cartnective tissue (of!:J!n with contiderable fat) that complewly separ.1tes the rnygundlum from the candlac ventrldes and atria. The components of the cardiac skeletor1ln a norTOW senst ire as follows: TMdonof - - - - - - - - lr/trulbuum - - - Flbrousrlng
)_,.
l
cfaortlcwlllle
Right-::' ----
lbrous
trigone
)
I
Leftflbrous
arn.ius
Opening forlhe bundleoflfs
\
RJdttflbrous ~nulus
• The rtght and left flbrous a null and Intervening fibrous trtgones • The fibrous rtng of the aortic valve, which Is connected to both fibrous ~nuli • The membranous part of the Interventricular septum (not shown here) In a broodSftlse, the fibrous rtDg ofthe pulmonary valve also contributes to the cardiac skeleton. It Is connected by a collagenous band (12ndon of lnfundlbulum)totheflbrousrl'ngoftheaorUcvalve. Thea!Jfoven!Jfcul.ar valves are andhored to the fibrous ~nuli, while the semilunar valves a~ e;~ch attilched by connteUve tissue to their valvular fibrous rings. Thill, the cardiac skeleton In the broad sense prwldes a mechanical framework for all the cardiac valves. Besides mecltankDI/ystflbJitz!ngthe heart, the fibrous skeleton ~lso functions ;15 an ~~ inwlator between the atria and ventrtdes. The electrical Impulses thit stimulate cardiac contrictlons (see pp. 110 and 111) can pa~ from the atrfum to the ventrtcles only through the bundle of His. and there Is only one opening rn the fibrous skeleton (in the right fibrous trigone) which tr~nsmits that bundle.
107
2.20 Heart: Semilunar Valves and Sites for Auscultating the Cardiac Valves
A !iemllwwrVIIIws Dfthe outnawtr.u (..ttc ond pulmonory
""'ve)
Theaortlcval~~e (a) and pulmonary valve (b) have been displayed by cutling open ltle asO!IIdlng aorta and pulmonary trunk and opening them up lib a book. The aortic valve and pulmonary valve dose the ventlfcular autflaw tracts during diastole:
• The a.ortk:valve closes the 111ft wmtrlcular outflow trac:t • The pulmonary valve closa the right Yl!ntricul;ar outflowtrac:t. These vaiW!I almost c.amplittely prevent tile regurgitation of blood expelled by the ventricles. The origins of the left and right coronary u· teries nn be clearly Identified In ltle aortic sinuses past the semilunar cusps (1), and the ortgln ofthe right pu lmon.uy artl!ry can be ldenUfled in the pulmonary trunk (b). The frl!e margin of each semilunar cusp is thickened centrally I» form a wlvular nodule, and on each side of the nodule Is a fine rim called the lunule. The nodule and lunule ensure that ltle margins of the cusps appose lightly and complmfy during Yiillve closure. lloltl the ati'IIMntrlallu v.~lves (see p. 106) and the semllunarv;dW!I ""Y unde.rgo pathol~ical changes, usually due to inftamma·
108
tlon (endocardltls). lnlbmnnatlon m~ result In secondary ~~a~Scularlza tion of the initially avaKular valves, causing them to undergo fibrotic changes that stiffen the valll'eS and compromise lhelr function. There are two main abnonnallttes of valvuln mer:N nics, whldl may coexist In the same v.Jive: • Villvular stenosis: ()pl!fllng of the valwls Impaired, causing a reduction of blood flow iKI'Ol1 the valve. Usually ltlls cteill2s a pressure CM!fioad on the dla mber pruxlmal to the obstruction. • Valvular lnsufRclency: ~of the wive Is Impaired, ;IIlowing blood to regu rgltiiltl! lntD the chamber proximal to the v.Jive. Such a pathological reflux cteill2s a volume DYII!rload on the affected ca rdliK ffgmenu. When the load exceeds a certain magnitude, surgical replacement of the wive may be necessary to prevent further damage to the hllilrt. • Stenosis and lnsuffldency may coexist: Avalve may become stuck In an intermediate position, unable tD open Dlt dose c.amplebely.
TborGx - - 2. Ol'gtlns
•
Mu~u~----------~~--~
- - - - : , . . . - - - -....:,.- - IIIUITIIUIS
tr.lnsmll:b!dfram
tr.lnsmll:b!dfram
pumonaryva~~.te
IIIUITIIU~ ----~~~~~
tr.ansmllb!d from
--....:,;:...._____.;__ Murmurs transmitted from
right-·
'ularw!Ye
left
B AlllalltiiUon of tflec.trdlac wlw1 In the he~fttry he.'!rt, blood don not gener.~te a ~tible sound as It flows ~ross the card I~ valves. But If the valves are functionally lm· paired as a result of disease (stenosis. lnsufftdency), the blood flow .at the card I~ valltel becomel tl.lrbc.ilent. This type of flow prodUCI!s audible sounds th~t are transmitted vi;! the bloodWl!;lm.ln most casu these sounds (murmurs) are not heard best over the anatomlc
Dliii!Jram • shows the anatz~rnlcal projections of the valves or1 the chest wall in re~tion to the sites where tfle valves ~re auscult.ated. and b s'-s tfle areas OYer which transmitted valvl.llar murmurs car1 be auscultated on physlc.1l examination. The iuscultatlon sites ire located approxlnn<~tely .at the centll!r of the areas for auscultating transmitted valvular mumnurs. Table C compares the a~tomic.1l projections of the valves wlth their iuscultatlon sires. Noll!: As a reiult or sound transmission, the aortic vall/e. while part of the kft heart, Is auscult.ated Ofl the r1ght side of tfle chest. The pulm~ nary valve, whi1e part of the right heart, is auSCIIftated or1 the I~ side. Normal heart sounds are described on p. 112.
Fourth Jflfth lllltal cartilage on the left side
Fifth lntera~stal space on the mlddmcular line
Rloht atrlcMntrtOJiar wllle
stemum at the lewl of the fifth cwtal cartilage
Right fifth lnteltOSbl spaoe dose to the Sllemum
Aortic v.alve
laft stamal borcler at the lew! of the third rtb
Right second lntemmal sp;a close to the sternum
Pulmonary valve
laft stemlll borcler at the levd of the third toStal artllage
Left second lntm:ost.al spaoe dose to the stemum
109
Thorax - - 2. OrgGns
2.21
Heart: Impulse Formation and Conduction System
Rlghtburde branch
~~H'--+--In-lar
.sepQim
_ _.;;;_......Or---- l'\llmonary trunk
Left bunde branch IUght atrf..m
Antl!rfo rpapll lary musde
b
A Ovemew ofardlu lmJNjlte fvnnltlon nd amdudlon Anteriorvlew(;a), right lmral view (b),left liltl!fil vlew(c). Even when !he extnnsrc nerwus cootrol of !he heart IS c:cmpletl!ly dJs. rupted, it mntinues to beilt. When supplied with axygen and nutrtents, It can even keep bNtlng ifter It has been remowd from the cheJt. This Is milde possible by an lntrfnslc:.lndependent system ttl at gener.rtes and ron ducts excitatory Impulses In !he heart. This system consists ofspecial· izl!d myoc.arclial cells and has four m..in p;~rts: • • • •
srno.rtrtal node (SA node, sinus node) Abioventticular node (AV node) Atrioventricular bcJndle (AV bcJndle, bundle of His) Right ind left bundle brindles
110
~node (the •pacemaker" ofttle heart. appi'OlCIITiitely 1 em long). The cardiac Impulse begins In Ule SA node, i subepkardlal node located on the posterior side of the right atrium near ttle orifice of the superior vena cava. The SA node generam salvos of lmpuiJes which stimulate the iltrlal myocardium ita resting rate of60-70 bem/mln. The mlal Impulses spread rapidly toward !he wntrlcles (p;~rtleular1y In ttle a1sta temninalis and internodal bundii!.S between the SA and AV nodes, iS shcMn by electrophyslologlc studies). The lmpuiJes travel from the AV node to the bundle of His, 'l'otllch dlstrfbum brinches to the ventrfc· ular myocardium. (Dir&t Impulse conduction from Ule atrium to ttle ventrfcles rs norm..lly prevented by the Insulating efti!ct of ttle tlbrous slcl!leton.)
TborGx - - 2. Ol'gtlns
B llftordlng tfle electrtul adMty ofthe
han
,_
Wd'IIKIJX's
ltw;we
T-
In Eln1hoo.-en's trtancje
The cardiac Impulse that travels aaoss the heart c.;m be detected With electrodes and recorded over Ume as an electrocardlogrllm (ECG). a ECG using three electrodes th
record electr1cal heart activity along three axes or •vectors" (Ein1hown limb leads). b lnclng lllustrille:5 the ECC components of one ardiac: cytle (one "heartbeJt"). The cyde consists of ;r definite sequence o f - . segmEilts, and lnti!!'Yals. The shape of the tradng Is useful In detennlnfng whether the conductian of the ardiac impulse is normal or abnormal (e.g .. due to 111)'0Cardlallnfarc· tion).
~llg
eledrode.s
b
Q~
Sw.M!
STsegment
A standard ECG elC
Plllmonary - - - - - trunk
~~~r----~~~
septum
A.Y nllde (appraximmly 5 mm long): h:Kated in the intz!rab'ial teprum near the orlftce of the coron;rrysln~JS. Thb node delayllmpulse ccmductlon to the ventricles. allowing both ab'la to depolarize before ventricular contraction begins. Itcan also generate Impulses spontaneously, but at a c.oruiderably low!!r rate than the SA node (appraximmly 40-50 de· polartz;rUonsf min). Because of 1U siCIWer rate, the AV node an not act as a pacem<~ leer for the heart when the SA node Is Intact. A!JtovenbtcU1r bundle {of His) (appruxlmately 2cm long). The atrfo· wntrirular bundle (af His) is subendocardial while st11 in the atrium. It then passes through the right flbroos trigone (see p. 107) to entl!r the ventricular septum. where It dMdes (In the mernbr.;rnous part of the seprum) Into the right and left bundle branches. The AV bundle conducts impulses from theAV nDdetD thelll!!ntrides.
1St bLIIUIIe br1ndl: branches to !he left from the bundle of Hlsand dl· vides intD three main faKicle.s (antz!rior, middle. and po.sterior). Right blmcle bnnch: Initially continues In the ventricular septum toward the ardlac apex and Is then distributed tD the ventrla.tlar wall. The main trunk of the rtght bundle brand! enters tile septomarginal trabecula, known alto as the "moderator band." Finally the impulse is distributed througtlout the ventricular mygardium by tile Purlcinje fiber$. Norr.Tbe Purlcln]eflben stimulate tlteventrlcularwalls In a retrograded!· rectlon, proceeding from tile cardlacapextoward the ab'la. Thus tile apl· cal myoClrdium contracts first. pumng the apex of the he.;~rt tow.ard the plane ofthe wives. The papillary m~~Sdes. wltlch are stimulated by dlr«t flbenfrom the bundle br.rndles. contractbeforetheventrfcularwallstD ensure that the AV wives remain closed during vent11cular sys1llle.
111
2.22 Mechanical Action of the Heart
Pllua filth!! he.tbut
The he.artbeilt amslsts of two main ph;ases: contraction (systole) ind relautlon (dlasmle). A mul of four ph;ases are distinguished In the contnctlon and eqNnslon of the --.trldes: YlntrtMar SJ~lale: • lsollolu m~c contradkln phase: The wntrtcu lu m)'IIQnflu m conlnlc:ts and tightens argund the blood culumn within the wntridl!. All valves are closed,l.e.. the AVvalveJ are crlm!dydosed (ventrtcular pressure UD!eds ltle ltrlal pre~sure), and ltle aortk ;md pulmonary valves are still doJed (wnb1cular pmsure Is still lower than the lnbartl!rial pressure). IIJCMllumetJic contraction of the myocardium arvund the blogcj culum n produces a mechanlca I vlbr'iltlon that is audible as the first heart sound. • EJection ph;ase: The AV valves rem11n closed ind prevent the reflux of -nriwLar blogcj inmltle atf&a. /U the intraventncular pressure tx· ceeds the pressure In the artl!rles. the aortic and pulmonary valves open. ilnd blood ftowsln1XI the 1orta i nd pulmonary trunk.
VwntrtcYar dlatalr. • R.elaxalfon phase: The venb1cular myotirdlum reliiXeS. All valves are dosed durtng this phase: The AV valves are Sill/ closed, and
b
112
the aortic and put monary valves are tJ/tmdy closed (to prevent the reflux of ejected blood back lnm ltle venb1cles). Closure of the aortk ind pulmollilry valves ("slamming doors") Is audible as the second heart sound. Occasionally ltle arterial valves dose at slightly different times, produting a divided second heart sound. • Riling phase: The lntrawntrlculu pressure Is very and the arter1al valves remain clased. The AV valves open. and blood flows lnm the wntrtcles. Ventricular filling results more from the movement of the wive plane than from atrial contraction: The valve plane rnc:NeS tow;rd the cardiac ape.x. during systl)le, and it returns_,. quiddy to Its Initial position during dlilstole. "tttrowing Itself" over the blood column. Note: Dunng both the isovolumetric contraction phase and the reluillfon phase, there are perlgcjs In which all the valves are closed. By con· trast, there Is no point In the ca rdiK cyde when all valves are open I Heart sounds are normill ilaJustfcal phenomena prod uc:ed by the heart. Abnormal valvular heart sounds (murmurs) ane described on p. 109. AJ. though the first heart SGund is g~nerated by ~tricular contraction it· self, that flrJt sound Is cllnltilly nsoclated with closure of the ab1oven· trlcu larvalves.
1-.
A Ultrasound Imaging of the hMrt (after Flachskampf) The •four-chamber view.• • PIKement of the ultrasound probe relative tu the heart. b Position ofthe heart In the ultrasound beam. c Uitrasoundlmageofthe heart. The probe Is angll!d from ltle ardrac apex to the lfght ventrtde, directIng the main beam along the approximate anatDmkal axis of ltle heart. Scanning in this pian~ demonmtes ell fvur chamben of the heert (th~ ventrtcles are displayed above the atria). The left cardiK chambers appear on the rtght side of the Image, the right chambers on the left side. The left and right atrioventria.lar valves, the interventrtw Lar septum, and the in~tri
Tltorrvc -
2. Olgcms
....-- - - - Bloodftaw
tothelungJ
ltightlllrlum
• ......,..~--
Amriollluw IDthesysmmlc
d10.11atlon
__.....__ _ ArteNI Inflow thooudl pU1110111ry..,ns
.. I BIDDd 11-ln the Mlrt The sept;! between the iltr~ and wntrldes funclionilly divide the heart Into two main parts: tile right heart and left heart. The cardiac valves define tile direction of blood flc:lw through both sides of the heilrt, en,. bllng the right and left he
dosed here) and conus i rteriosus intxl the pulmonary ti\Jnk. From there It flows through the pulmonary 1rterfes Into the lungs, where It Is oxygenated. The right heart pumps blood 'With a low oxygen tl!nslon. Blood ftow In the left helrt (b): Left anterior view. All of the cardiac cham ben have been cut open anteriorly. Oxygenated blood from the Iungs flows aaoss the open left atrfoventrlcu lar valw and through the left atrioventricu Ia r Grificu long the Inflow tract into the left wntridle. There It Is rerouted Into the outftowtnlct and flows aaoss the open ilortlc wlw (shown closed here) through the aortlc orifice Into the ascendIng aorta for distribution throughoutthe systemlcdrculiltlon l•rflrst perfusing tile coronary arteries). The left hurt pumps blood w1th il hlg h oxygtn t8lsion.
113
Thon:ut: - - 3. Blood Vessels
3.1
Thoracic Aorta
Right Olmmon c<~rocld ~l'tlery~nd right
Ld'tcommona~ ~ l1!ery ~ nd left
lntm~aljugul~rw~
lntJem~l jugullr~n
c f\l~tonel grwps d arteries tNt supply dM tho fliCk Of'9lll'l These are ma!nlyvessels th.ilt supplythe organs and tnfl!mtll stnJctuii!S of the thorax. The In~ thoracic br.~nche.s of the aorta can be divided Into four main functlon.ill groups: Artale to the heed •nd nedt (seepp.lO,ll)ortothe ..perl~: • Bnldllocephallc trunk wllh: - Right common carotid .ilrtery - Right subclavian a!Ufy • Thyroid lmaartlry(presentlnonly10Sof Ule population) • Left common arotld a!Wy • Left subd;wtan artery
l*«taortk IINnct.lhlt-.ply l~cllniCIUrw:
A ProJectfan of the hNrt~nd lolll!foldr.ontothe cMrtWII Anterior view. The two great artelfal vessels In the thorax .are the aor!rl
The asanding aorta is •;n the shad-· of the mmum on the PAchest radiograph, wfllle the aortic arch (".ilortlc knob•) forms the supafor left portion of the left heart border. The desant!ng aorta Is hlddeen by the heart ltl4!lf.
• VIsceral branches to thoradc organs (heart. nchea. bronchi, and esoph.ilgus): - Right and left coronary arteries - Tracheal branches - Pericardia! branches - Bronchial branches - Esophageal branches • Parietal branches 111 the intemaf (mainly posbl!rO!amral) chest wall and diaphragm: - Post«lor lntler
ldecl prtmallytoUie heed end Me~~ but giW riff brllllches, _ . , siMIII,Ih.t ent. thechlltancl-.ply~....r.:k...-:
• lmrior thyroid artery (from lhe thyroot1111al trunk- branch of subclavian artery) with: - Esophageal branches - TtachNI branches lndlrectptln!d flnlnchawhtchtu""lhe chat-I(IMS!Iy..a.tw,same.rertlll'), lhe r.rm of !*let.al branches,
.~;::,...-~--
Ligamentum artl!nosum
IJ!ftmaln --1-~.f.--C\ broncllus
8 P
cle.ls dilated near the he.ilrtto form the aortic bulb(notWible here). • Aortic arch: the .arched portion of the .iiOrta bl!twl!en ttle atcending and deKC!Ilding
114
"*--+-- artl!l'y IJ!ftpl.fmonary
paru, runs posteriorly and to ttle left. A mnstrfctlon nn;ry pm\st as an embryonic remnant In this part or the aorta (the .ilortlc isthmus, nat sh!Mn hen!). • Dftcending aorta: consists of the thoracic and abdominal portlonsoflbeaorta(seeD).
-•rr•n end1111J81W•IIIIwlnnchetolntn· lhoAdc orgens (War-.1 sub-lnnche):
• lntem.af thoradc .a!Ufy (fnlm the subda· vran artery) with: - Thymic branches - Mediastinal branches - Anterior Intercostal branches - PericardiKOphrenic a!Ufy (with br~nches to the pericardium and diaphragm) - M~~~a~fophrwnlc a~ (with a branch to Ule diaphragm)
ThorGx - - 3. Blood Vt'SSI!Is
Rlghtmatn brondl~a £soph~lbrolnth
Left main brondl~a
!'om!rio< l~larltrles
Cdactrunk Lumbaraltl!ly
D Posttllln of tfluort.J tn the tfloru Antll!rlor view. The pleura, lntll!rnal fasciae, and most tflorlldc organs hM! been 11!moved, ~nd tne di;lphragm has been windowed to displiJY moreoftfletfloraclc c.Mty. The branches oftfle aorti (see Cand p. 263) supply blood to all tfle organs. delivering almost 5 llten of blood per mrnuteUucughout the body. The tfloradc acrt.il rs tftlck-w.alled, p.ilrtk· ularly in its aSCI!!nding segmentand arch, but thelew.alls are also elastic. During the systolic w.~ve of pressure as the leftvmtrldecontracu, these segments of Ute aorta dilate rapidly and !hen recoil. This serves to abSCib .and dlsslp.ilte tfle pressure w.ave to produce a steadier, more even n- of blood in tne arteries farther away from the heart_ Becallle tne aortic arth runs postaforly ;rnd to tne left. tne relationship of the aort;r to tfle trachei and esophagus changes as the vessel p.;~sses Inferiorly tflrc~~ghthechest(seealso Bind p.118). The mortantll!rklrp.;~rtoftfte aorta is the asandjng cwto. The oarDc on:h ttl en passes to tne left side
of!he trilchea, ;arching over tfle left main brcnchus.lt passes Initially to tfle left oftfte esophagus buttften descends pcstm'crto Ute esophagus and antll!rior to the vertebral column. Because of this 11!1;Jtiomhip, an abnor!Tiill 01.11;10uchlng of the aortic Willi (aneurysm) may na,._ the esophagus and cause swallowing difficulties (dysphagia). The tflor;adc ;aorta pierces the dlaphr.agm it the aortic hiatus Ounctlon of the Tllf T12111!rtebrae), becoming tne abdominal aorta (seep. 263). ~In r;rre cases the aortic arch Is constricted behind the ligamentum ;arterfosum (see 8). This constrtctlon Is normal In Ute embryonic circulation, but Its persistence after blrtn may prcduce the clinical manifestations ofa coo:~n tl{thttiiJI'to. This includes hyperten.sion ir1 the head, neck. and upper limbs. Insufficient blood flow lr1 the lower mremltles, ;and left ventricular hypenrophy(dueto chrcnlcexcesslveworldoad and pre.ssure).
115
Thon:ut: - - 3. Blood Vessels
3.2
Vena Cava and Azygos System c Right~
IUSitl•rwn ~ subc:lwliln win
Rlgltbr.u:tllc>- __.-
~
l
oephallcw!n ____-·
ails-- --;--
~pl.fmoNrYWins
~f--------"7------ lnfuforwna c.wa
Right pulmonary
M
wins
A Profec:tlon of tile venae ovae onto tile
liblaton AnteriorW!w. Thesuperlorwna cava lies to the light of the midline .and appears .at the light stzmal bon!er on r.adiographs. Formed by the confl- of the two brachloaphallc vans, thesuperforven.auvaenterstherfght.iltrfumof the he.art from above. forming Its border lrl the
M.chestracl"oogl'i!ph (see p.96}. The in{erior!lfnQ CUIII7nuns a very short dlmncewlthlr~thethorax (approoclmately 1 em, not shown here}.lmmeciJ. .ii1Jely .after ple!"clng the diaphragm (at the vena uval hiatus}, it passes through the pericardium and endsbyopenlng Into the rlghtmlum ofthe heart from below. It has no trfbut
...
~·~--,...._
0>5t.1l wl ns
Hepatlewrns ---=:+J~r
f\Jrldl'onalgroups of wins tflat dralrt the thondeorg1ns These are mainly vessels th.at drain the organs ond lnrRmal siTuctiH1!s of the thorax. All of them drain ultlmiltl!ly to the supenor vena uva, whosl! tribut.lries in the dlest can be divided Into four maln functional groups: VIII• IMtdr.~lnthe held •nd nedr(see
pp.12and 13)ertheupperlmb: • Left and right lnchlocephallc:veln with: - Rl!lht and left subdmanwlns - Right and left lntemaiJugular wins - Right and left e~rtemal Jugular veins - SUpreme lnllercostal veins - Perlcardlal veins - Left superior lntertOStal vein ¥1118 dMitdNin ~Ndc iltnlclurM
(open lntD theaccasOfY hem~ vein or hemlazyp vern on the left Side. Into the ~ Yeln on the nght Side}. Blood from both wriiDrles Is calledalln the azygos vein. whkh efnptles Into the superior Yen.a cava. The tribul3ries can be grouped as follows: • VISceral branches that drain the trachea. bronchi, and esophagus: - ltachHI veins - Bronchlalwns - Esophageal veins • Panetal brancheslhatdralnthelnner chest wall and dlaph111gm: - Posterior lntlemlstill veins - Right and left superior phrenic vein - Right superior lnten:osUI vein Indirect paired tr1llutaltes of the supettar
- - t h a tdescend from the head and ned< but rec2ive smaller veins that drain thoraCic organs: • lnfwior thyroid vein (•tributaries of the brachiOoephalrc vern) with: - Esophageal veins - Tracheal veins
RJghttal:lalar/---~
owrlanwrn
lndlrect.,_rrecl tr1llutaltes of the supettar
~axnmon ---~
llllcwln
B The azygos systl!m Ana!rior'lliew. The venous drainage of the tho-
rax is h;!ndled mainly by the long i2Y5IOS SY$" tem, whkh runs vertically through the chest. The ~ 11'1!111 nuns to the rfght of the Yertebral CDiumrl, the ltemiczygos win to the left. The hemlazygos vein empties Into the azygos vdn, which lr1 tum empties Into the superior wna uva. An occessGry hem/oZ)'gos 1'1!111 Is fre. quently present In the upper left lhorax; It may open independently into the <~zygos vein or by wq of the heml;szygos vein. The azygos system receives trfbutirfes from the medlomlnum
116
and from portions of the chest w.all, predoml· nantly in the antral and low!!r thorax. Nob/!: The ;~zygos vein empties into the supeo rfor Yena uva, while the ascending lumbir wins on both sides open 1r1to the lnferfor vena cava via the lumbir Vl!ins and the CDmmon il· lac veins. In this way the azygos system crmes a shunt between the superior arid Inferior ven.ae avile, called the •cavocawl <~n.astomosls.• If dralr~age from the lnfenor Yena uv.a Is oDroucted, W!nOU$ blood an sb11 mch the su· perlor vena cava and enter the right he
- - t h a t mainly drain theantltrlor chest wall as (Mrietal branches but may also receive bfbutarles (lllsmral sub~ndles) from organs: • Internal thoradc vein (opens lniD the brachiOcephalk vein) with: - lhymlc:velns - Mediastinal tr1butar1es - Anterior lntertOStalwlns - Perlcardlacophrenlc: vein (with tributaries from the pericardium and diaphragm) - Muteulophrenlcwn(wlthatrlbuury from the diaphragm) Nolr. Slructura of the superior medlntl·
num may also dr<~ln directly to the brachl~ cephalic wins (e.g.. VIa the tracheal veins. esophageal,..lns, and medlullnal wins).
ThorGx - - 3. Blood Vt'SSI!Is
Right lramalthoraclcw'b
I.St lntmlalthoraclc win
left bnttlloaphillcwln Right '-Ilk>-
SUpellorYeN CMa
Ul)h~lrcwn
A:.!)'9os w'n Postl!flot lntl!l'·
Jla:Hsory hemla:eygoswn
a>~U~wrns
Hemlll)'lloswln
DlaphntiJTI, O!ntlll II!nlien
Venac:av.al hiatus
DlaphntiJTI, tmllll*t
£s0j)Ngeal hiatus
Right al
I.A!I'tasa!ndng
Aortic hiatus
l~n~b.vwln
1nfl!lforwnac.11r.1 wmbilrwiM
D SUpelior~cav~•nd uygossystem In the thorax Anterior view. The tho~ hn bec!n cut open and the org~ns. internal fasclile. and serous membranes have bec!n removed. The Inferior vena c:av.;a has been removed atthelevelofthe L1/L2vertebraetodlsplaythe rtght ascending lumb.ilr veln. The tupl!f'lar W!M cav~ls formed by the conflue11ce of the two br.~chiocephalic veins at the approxim~te level of the T2/Tl junction. to the right of the median plane. Each brachlo· cephalic veln Is formed In tum by the union of the Internal jugular vein
and subclillllan vern. The azygos vern ascends on the rfght sldeofthe vertebral a~lumn and opens inw the posterior right ;~spect of the superior vena cava just below the union of the brachlocephalk veins. The right ind left ascending lumb.ilr veins pass upward through the dlaphr.~gm to form the uygos wlft on the rfght side .and the heml:uygos win on the left side. At the level of the T 7 vertebra, the hemiazygos vein CI'O$$C!$ ovefthe vertebral column from the left side and opens lnw !he azygos ~~eln.ln this dissection Ute <1ccessory heml;azygos vein drains separately Into the .azygos vern .after cR)SS!'ng over the vertebral column from left to right. Not infrequently, hCIWeVI!!r, the hemiaeygos win and accessory hemlazygos ~~eln are Interconnected by anastomoses.
Right subdawn Win
Right brxHo-
aephallcwln
E Rl!latklrt5 of the t111cbN, supedorwn;1 cor.r.~, 01nd illY!IOS symm The supenor vena C211/a lies to the rfght of the trachea. The left brachlocephalicveinpauesanteriortothet:rachea&omtheleftsidetounitewilh the right brachlocephallcveln. The azygos vein <~sands posterior to !he rtght main bronchus ind turns anteriorly to arterthe supel'for vena caw from behind {the azygos vein "11des" upon Ute rlghtm<~ln bronchus). The accessory hemrazygos vein ascends behind the left m.arn bronchus and may open independently inw the ;~zygoslll!in or may join the hemiazygos vein to form a a~mmon trunk that OPC!IlS Into the azygos vein.
117
Thon:ut: - - 3. Blood Vessels
3.3
Arteries and Veins of the Esophagus
Esophagus. amalpart
Left common anllld artery
A Blood vessels oftfl~ esophllfllll
a Arteries, b veins. Posterior wall of the
tflor.~:~~. ~nd
upper abdomen. viewed from the ant2rlor aspect. All of ttt~ thoracic organ~
~
have been n!rnowd I!:JCa!l)t
thoi1Kk -__,.....:;;z..,
12ft sibd;Manart21'y
lltfty
for the esophag~JS and part of ttl~ tt~chea. The pi'Oldmal portion of ttl~ sto~ch has been left In the ab· domen. NoW: The e$0phag~JS is supplied by thn!e groups of arteries, comlsttnt wtlh Its dMslon lntD three parts ($ee p. 70), and It Is lllaewlse drlllned by three venous groups.
Bradl'lo· ----=~
Ve!1o!bral artery
lli!Phllictn.nk
Arstrib
Trachel 11-i~~J'---
L..;;;_..:..:..:;~:.:....-
Aortic Me~~
Left main
bronctna
Esophegt.tS.
-.....;:,,.-.~...:.;_.:....;::;;.;.:__;;,;.
thonlclc part Dflphr.I!JTI
CIStric fundUJ E$0j)Ngt.IS,
.....
...,~.._--~r-- EsophaQe.~lbra'lch
abdomhliii!Nrt
Right lnti!tlot
l.eftlnh!rlor phn!nk: ll1l!ry
phr~:nlc ;~rury
CdactnJnk Common hepatic artay
--~:;;;::~....:Jl-~:J
,-----Left!ji!Sttlcartay
- -""'F-+
Splenlcl111>!1y
Abdom'nlll-'3
•
PartofiiGPheg•
Arllltllsupply
v-usdrwM~e(seeAII)
• CeNial part
• Esophageal b12nches - usually from the lMlrfor thyroid artlefy or - Direct branches (rare, not shown here) from the thyroceNICal trunk or common arotld
• Esophageal wins - DralntoiMlrlorthyrQid\ld'n or - Left brachlocephallc vein
• Thor~ part
• Esophageal branches from the thoradc aorta, distributed to ttteantarior and posllefior siclel of the esophagus
• EsaphagtQI veins - Drain at upper left intrl the accessory hemiazygc» vein or left brachlocephallc win - Drain at lower left lntrl the hemlazygc» win - Drain lntrl the ZZ)'9CS vein on the right side
• Abdominal part(smallutarterlu and vdns scntng the esophagU$)
• Esophageal branchoftheleftgastrlcartBy
• Esophageal wins draining Into the left gnlrlc win
arUry
118
ThorGx - - 3. Blood Vt'SSI!Is
Esophagus Fhtrfb--"'""'""" Rlghtbradlb-
aphallcwh
~ ~~
Subclavian win I.A!ftlncHo~IItwin
Superior-~=~ wnacava
....
,
- - - Stomldl Aa::i:uory
hemlal)'gOS w'h
a
Vl!lnstn sa.madlwal
Pam!rtor htl!f·
CGitii'Wins
Hem!IZ)'!Io:swln
Olaptuagn Dtaudwtns
Gastric: fundus
b ~I
In stomach wall
'Wins
b
b Veins of the esophag.a(legendofl prellfous p.age)
C Submuco111 wnou5 pluuses ~nd VlfiOUS collatenls a, b SubmLICIKB venOIIS plex.ulet and Vlrioes In the esophegut (af· tt!r Stelzner): The smalle.st b'ibutaries of the esophageal wins pass thro~~gh ~II laym of the esophage-al wall. <~ccomp.anled by arte· rial brindtes, to the lamina propria of the muCil.l
c EsophagNI venous collltil!l'lls (after Strohmeyer and Dillie). Venous anastomoses provide two n:.utes for draining tbe 111!in.s at the june· tton of the thor<~ck and ibdomlr~al parts ofthe esoph;lgus: 1. Via the azygos or herniazygos win tD the superior vena cav.a (thD-
rackroute) 2. VIa the left:gas!Jfc velr1 to the poml Yeln (<~bdomlnal route) Thus. when poml venous flow b«omes obstructed In the IIva' (clr· mosls), blood may be dlllerted Ulrough tbe esophageal veins to the supel'for vena cav.a (portosystemlc col laterals, seep. 293).
119
Thon:ut: - - 3. Blood Vessels
3.4
Pulmonary Arteries and Veins
Rlghth.llg
"toor''-;..;::o.__ _ _'!-- - SUpertorleft lnfenctl1¢t --r--------~~~ pulmonaryw!n __ __::;=~~~~
j _____
SUperior
ptlmor.JI')IYdA
~~~---~~ lnfenctleft pl.fmor.JI')IYdA
wnaava
PUimonarytnJnk
Ascending aorta
Mlddlt~
lnfmorlabe
lnfl!rfor wnac.1111a
A Topogriphlul al'liltllmy of the pulmon;uyvessefs Antl!rlor lllew of a "heart-lung prepar.atfor~.• The wnae c.111.11e haw been cut doK' to the he.1rt. ~nd a segment h;Js ~ rem!Wed from the ascending aorta and arch to display the dllllslor1 of the pulmonary trunk. .tllch Is Inferior to ttre aortic arch, and ttre origin of !he right pulmonary artery. The lungs and he.1rt are shown p.utlally transp.uent. The arteries and wins ttrat pass to the lung are divided intD twD gi1XIps:
• Plslmonoryartr:nesond ~ns, which arry blood to the lungs and b;rck
for gas e.>irlrcrngf (O:z, CO:J • Brondllal altl!r#es and 'lll!lns (nat shown here), which supply blood to
partsofthelungs ttremsehles (see p.122). The dtvlllont of the jdmo111ry 11'b!ftes b
120
called lob
ThorGx - - 3. Blood Vt'SSI!Is
ltlght
pulrncnary artery
L'T" ' - - - - - - : - - PulmOI'IiiiY tMk
b
a Projedlon of the pulmoNry.uneunclvefr\f onto the dlethV1111 llnwrlontew. 1
Projectlanofthe pulmanlry~ontothedlest-11. The pul·
monary trunk arises from the right vartrlde, whkh Is
Middle lobe artery
llghtl~mg
b Prafedlonofthepulmonary'W!Insontothechi!Stwlll. Normally, a pair of pulmaooryveinsopen into the leftabiumaAeaduide. Talcen together, the rtght and left pulmonary velnJ <~nd both ftnae cavae fonn an asymmetrle<~l crudfonn pattern on the chelt radiograph.
Left pulmonary artery
c The pulmon1ry artl!ttes and tfletr brandies Right Jllllmenary.eery
Noo:: The pulmon;arytJUnk lie$ to the left of the midline in the chest. /1$ a reJult. the rtght pulmonary artefy (lenglfl appl'lliClmately 23an) Is longer than Ute left pulmonary artery.
a.ltlung a.ltpulmenary lriiiY
D The pulmDnarywfM and thtlr trtbuuriK
IUghllung
Rl!lht !Umonarywn
SUplftor/obf ~
ScQl«1or,. Grtr1fU
J!1911ts~pcdmoncHy-.
Uft SIJf)flforpublloooryWitl
CD Apklll segmental artery CD Posterior segmental artay
CD Apical win CD Posterior Win
Gt Aplcoposlltrtor
®Anterior Jegmental artery
tl Apical segmental artery ~ Posll!rtor segmental artery @ Anterior segmental artery
~Anterior win
Mlddlt 11/kcmry
18 ungular artery
®Anterior win ®Middle lobe win
® Lateral segmental artery ® Medial Jegmental artery 111/edoflobf Ma1es
ln(wlorlobe Clttfl1es
® SUperior segmental artl!l'y CD Anterior basal segmental artery ® Lateral basal segmental artery ® Posterior basal segmental artery ~Medial basal segmental artl!l'y
@ Superior segmental artery
win
0 Ungular win
Right *'(triorpu/montHYwllt
Uft flr(flfor pubollaryWin
® SUperior win
~Superior win
®Common basal win
® Inferior basal win @SUperior bawl Win ®Anterior bawl win
e Common basal win $Inferior basal win 8 Superior bawl~~eln ~Anterior basal win
artery
Gil Medial bawl segmental artery
121
Thon:ut: - - 3. Blood Vessels
3.5
Bronchial and Diaphragmatic Arteries and Veins
A Brorldllal arb!d'es and verns Ant2rior view. The tr~chea and bronchi shown part!allytramp;~rent.
~te
a AJterW supplr of tile lu~nchl: The b~chi derive their blood supply from the thoradc ~orb Ilia bronchial ~rterlill br~nches th~ follow the dMslons of 1he main bronchi. It is not uncommon for one of the bronchial arteries to arhe from a postafor lnterantal
Bl'lOdllill b111nche5 from
~rtery(usuallyonthertghtslde),ra'lher!Nn
directly from the aorta. Chien the relationship of the bA:IIlChitDthethor~cicaorta, the bronchial arteries usually enter the b~l from the posterior side. Nofr. Tbe truhea Is supplied with <~rtenal
thelhollldc~
l.d'tmaln bl'lOdll.IS
SUpuforlobe -~~-~ bronchLtS
$--.;;~-
bloodbysmalltr.achl!lllbr~nches(notshown
SUper!orlobe bl'lOdlus
here)th~IN)'arist'fromthethoradcaorta,
the Internal thor<~clc artery. or the thyrocertrunk. depending on the level of the trachl!ll that Is supplied. b Yen Gus dnll1111ge Gftfle lnvrldll; The bron· chi are drained by bronchial veins. whlth usually open Into the <~ccesory hemlazvgos win on the left side. On 1he rfght side, the veins may drain via cvllaterals into the JZ!f' gos vein, but may ;llso empty Into the pulmonary veins. e<~uslng a snn<~ll amount of deoxygenated bronchial blood tD be miXed with the much la~er outfb¥ of pulmonary blood on Its way to the left atrium. Snn<~ll tracheal veins (not shown here) empty Into the supertorvena cava, left brachlocephalfc vein, « intern~! thoracic vein at different leftIs ofthe trachea. vle<~l
~-~~~~-~~
lnleralstal arttrles
nferiorlobe bt1>nchus
lnfenar ---'~~~..all~ thyroid win RJg!tbnd11o- ----l!~~ O!phallcwln
B!Widllal wins opening Into
lflex
hem~azygos wn
SUperior lobe ----''=:A.:bt1>nchLtS Bl1>nchlilwlns - - - < . OJM!nlng ln!D the azygos win Mlddltlobe bnllld1L5
Inferior lobe _ _ bt1>nchus
122
~--- SUperior!~
bl1lnchlli
...i!!i~--
_.,_,.Ff
lnfenarlobe bl1l0d1US
ThorGx - - 3. Blood Vt'SSI!Is
Hemlaz)'gos win
~~t\~~~"__:~~~-~~-- 1\artetalpleura, medlasthal part
"!1!""=-',.,..-'-P.....~..:....---
l'!ln!llk 01!\'Vl', perit.ftiaolpl'nnk art«y«~dwln
Esoph~
hlm.ts
Rlghtphre!'ic ntM
Cdactrunk
RJgtt Inferior phreric ;~l'll!ry
l.l!ftlnfetfcr phre!'ical'll!ry
RJgtt Illperior supra~artJery
l.l!ftlllperior supran!nalal'll!ry
Common
hepatiC artJery
•
SplmcartJery
Quadr.ma
Abdominal
lumbon.m
aorta
8 Artmesofthedl1plngm a SUperklr surfaa! of the claphraam IM'Md from abow.. The pari· et.ll ple1na {diaphragmatic pan) hotS been removed
b lnfetiorsurt.lc:e of the dlaph~ llfawed from bel_.. The parietal perlt:Dneum his be\!11 completEly removed. The lnferlor surf.lce of the diaphragm Is supplied by tile paired lnfenor phrenic arteries, tile highest branches of the abdaminal aorta. The dllplngrn.ttk vtlna {nat shown here) mainly accompany the ar-
teries: • Inferior phrenic wins: open into tile inti!tiorvena Cllr.l. • ~perior phrenic veins: usuallyOSJen inwthe azygos vein on the right side and Into the hemlazygos vein an the left side.
123
1'horaK - - 3. Blood Vessels
3.6
Coronary Vessels (Coronary Arteries and Cardiac Veins): Topography
Pulmonll'y trunk
ltlghtm!alappendage
Superior lrft
pukmnlryw!n
---~
Smallc.vdllocw'h ---~
Lom!ralbranch
• A Coro111ry al'tiHTes aM cardJ'ac: wfns a Ant!!rioc'view oftne mmocwtal $Urfac:e of the he;~rt. b Posterolnfenor view of the dliphragmirtlc surf.lce ofthe he..rt.
Note: The ccronary irtel'les ane functional end·irtel'les bec.luse they f1xm anastomotl!S that are not adequate for recipnx:al blotld n- (see ibo p. 127).The coronaryal'tl!ries musteffldeotlydelrver blood to an or·
Bee01use tne hNrt f\Jnctions continuously w JXJmp blood. it h
gan wttfl constant hlgh metabolic demand that Is Itself atelev;ated preJsure. especially durtng systole. This dlf!lcult requirement Is achieved In part by the anatomical telirtion between the aortic valve and the origin of the col\ll\ary al'tl!rfes. just superior to the valve leaflets. As the left ventr1de completes Its contraction ind the dlstaldecl aorta begins to recon. Ute iortlcvilve Isforced dosed by the bacldlowind a local surge In pressune {a pressure homme') deYelops. This pressune hammer driVes blood into tne coron~ry ~rteries. The hearti$ thus efficientlype~ at the maximum pressure that tile cardlw.sscular system can reich. The ard:ru Vl!fns usually cour5e with Ute coronary arteries ind consist of tile great, middle and small cardiac veins. These veins open on the posterior heart wall into the txlfDti(Jry sittus, which empties into lfle right atr1um. Additional smaller veins (smallest c01rdlac veins, not sh~ here. Utebes&an veins) open directly Into the cardiac ch
• C1rcumflex brinch: runs In tne coronary $UlCUS (boundary between tile atr1um ind ventricle) around the ll!ftsldeoftile hearttotneposterfor heirtwall. • Ant!!rior int!!rventricular branch: runs in the anterior intem!ntricular sulcus (boundary betwHn theventr1cles) to the cardiac apex. Each of Ulesevessels gives off smaller branclles (seep. 126). The rtght cwonary artery, usually smaller than the left, runs In tne coron<~ry sulcm around the l1ght side of the heart to the posterfor Will, whene it forms tne pomrior inte.,.,tricular branch. It also gives oft' nu· merous br;mdtes (seep. 126).
124
ThorGx - - 3. Blood Vt'SSI!Is
Alrlll branch
Superior- aw
- - - - Branch!D sinoatrial node
Postsforleft wrbfcularbranch
---"""":i~
b
b Po.stenllnftrlor view of !he diaphragmatic surface of!he heart (legend on previou• p;roge).
taft GIM'IIftiiY.-y • Ora~mftex b110nch • Atrial branch • Left marginal b111nch • Anterior interwntricular branch • Conus brand! • Late111l brand! • Posterior ldhentlfcular branch • lntetwnb'kular septal
branches
• .... CIII'OniiY arill!ry • Brandl to slnoatlfal node • 1¢11al brand! • Right marginal brand! o
l'olllrior int.wntricular
o
Conus b111ndl
brand! o rtlghtposterolateralbrandl • Brandl to atr1oYentlfcular node o lnterwntrlcular sepbl
G..tanhc-. • Left marginal vein • Anterior lnterwntrlcular win • Posterior win Ill left wntrlcle
MIIIWiec.ardiK vein SIMianhcwM • Anterlorwlnofrlghtwntrlde • Right marglnallldn
"-*"""' ""n of left .......
brandies NotJ!; Blood from !he cardiac veins passes through the coronary sinus Into the right atll'um.
AAlti!: The left and right coron~ry arterin arise from the aortic sinu• ju•t superior to the aortic valve CUifl$.
125
Thon:ut: - - 3. Blood Vessels
3.7
Coronary Vessels: Distribution of the Coronary Arteries
V
Clrwmflexb111nth
AntB!or lntlerwntlitulllr
bnndl
'\~"'~..0.:--
t.eftrnargtn.al
brand!
l-----"H - - t..atml brand! Antl!r!or lilt«· wnttlwlll' br.ano:h
•
tntii!Mnllfwlar
Sl!p!OIIbranthes
A Dktltbutt:onlllfthe left and right CDronllfY MtertK The drawings Illustrate a "bo!larKed" type of coronary dmJiirtlon (see C). See 8 for details.
8 Dhtrtbutlon of the lcfhnd right con~111ry el'tll:rles
Left atr1um
Alr1al branches and an lntennecllate 11111al branch of the dr
ltlghtatrtum l.eltwntride • Anterior wall • Uteralwall • Posterior Willi Right wntrtde • Anterior Wllll
• Anllerlor ln12M!ntrlaJiar branch and Ia lateral branch • left marginal branch of the c:lra.~mftex bn.nch • • Partly by the posllef1or left ~~entr1cular br<~ndl ~the drcumflex branch • Strip netr the septum by the a.nus bn~nch and small twigs fnlm the anterior lnterwntJfaJiar branch
• Uteralwall • Posterior Willi lnterwntJfcular septum
• Partlybythertghtposlleror.tleral bn~nch
• Conus branch with smaller twigs and the right marginal branch • Right marginal branch • Posterior tntenlentrlaJI;Ir branch
ln!Bwntr1cularseptal branches (supply the larger antmor part of the sEPtUm)
lnten~antrlaJiar septal bn.nches (supply the smaller posterior part of the septum)
Slnolllr1al node (sinus node)
Branch to the sinoatrial node
All'lowntrtcular node (AV node)
Branch to the atrtowntr1cular node
• The left marginal bnlnch has a variable origin. It typically arises hm the dra.~mftex bn~nch. but often 1t springs from the anterior lnterwntJfcular branch (as shGWnln A).
126
LeftOI"'"'IY
..
lrtl!ry
leftauonary .tfty
c
l'o5tl!rlorlnter""lllrlculor bnondl
C Typu of C:VI'VIIII'J •rt4II'J d!Mlbutlon Anterior and posterior views of the heart and cross-sections through the wntrides viewed from above. The left coronary artery end its di$tributlon are shown In r~: the right coronary irtery and Its dlstrfbutlon ueshown In green. Note Because the pDrterior interventricuIa r coroniry branch is variable In Its orfgln and dewlopment, there Is considerable variation In the blood supplyto thel.rtand rfght wntrldes and lntei'VI!ntrtcularseptum by the left and right coronary il rterles.ln cases with ltft or rfghtc:wonoty domlnana, the heart recelws Its blood supply predomlmmtly from the left or right coronary arte.y, respectively. This contrasts with the btJS. onml di5trltMfon (see 8), In which there Is only o;ery slight functional domina nee by the left coronilry artery. As this Is the most frequent pattem, it~ ibo called the "normal distribution."
il
•
D DfllturiMncH ufc:ul'lllai'J biDodfl(~fter Hl!lneclmr) Anteriur view. AlthDugh the coronary ~Iter res are IntErlinked by anastDmoses. the Interconnections arelnsuflfclent tD compensate for sudda~ disruptions of blood flDWin a part!a~ Ia r brand!. Atherosclerosis Is the most common cause of a na~ng ofthe cotonary arteriall~r men (stenosis) with plaques that enhance the formltlon and lodging of thromboses (dots). S~osis of an arterial brandl, and the con• quent dlronlc compromise of blood flow (/sch111110), will c.~use dlest pain (crngllla pedrlrls). lnitAIIy the pain is induced by physial effwt, but prog~lw: s~osls and Increasing lsc»emla -ntually lead to perslstenat of the pain litrat. and the pain begins tD racDite In typ1al patterns (left arm, left stde of nedc and head). Sudden lou of blood now in a (stenotic) co.-. Dnary arterial bnnch, as from ocd uslon by a dot. causes a myocardlol lll(arctlon, necrosis of tissue that was dependent upon the occluded brilndl. The loe~tlon and extEnt of lnbrctfon Is detennlned by which vessel Is 11Mllved: a Apical anterior inf.lrction, b sup~apic:al anterior lnflrctton: c anterior lilteral lnbrctton, d posterior lateral Infarction; e postzrlor lnbrctfon.
Wit m1111INIIY domlllilnce (appi'Qidmately 15 1): The postmor lntwomrtr1allorbranch arises from the dramlflex brondl of!heleft coronal)' lfl'h'ly, and the right coronary artery Is WN ldy developed on the pos-
terior heart wall. The left coronary artery su pplle:s everything but the litera Iwall (;md small portions of theanteffor and posterior walls) of the right wntride. II llllllaiiCI!d dlllrlllutlon (approximately 701): The polttdor lt!RrwntJfcular Mind! arises from the rlgllt COI'OIICIJ)' o11rty. The l.rt corONry artery often hu a small posterior branch for the left wntrlde. The rfght colllllilry artery .supplies the posterior wall of the rtghtwntrlde. ~ stl'ip along the posl2ficw wall of lhe left ventricle, and the posl2rior pirtofthe lnterventlfculir septum. c llgllt mnMJY dorniM- (ipproxlmiltely 151): This type Is characterized by a W8Y l•n·ge pomrio<" ~biallclr broncfr from !heright CIIRIIIOI)' artety. The drcumflell brilnch of the left coronary artery Is wealcly dewlopecl. The r1ght coronary artery supplies everything but the interior wall ofthe left wntricle and il small strip illong the antrrforwaU of the right Yl!llb1cle.
127
Thon:ut: -
4.1
4. lymphGtlc System
Overview of Thoracic Lymphatic Trunks and Pathways
Rlghtlympha!lcduct atfunctfon cl r!ghtstbdoMan and rmernaljugtlarwbs
Brondlomediastlllill trunk
- - -+-.::
Diaphragm
A ~hiltk:trunkslntflelhoru Antl!rlor view of the opened tflorax with the pl~ra, lntanal fasdae, arid «gan.s temOVI!!d. Tbe diaplu~gm has been wirldo-Ned, ~nd tne up· per part of the abdomen CAn be seen. The prfndpal trunks ~t con· vey lymph from ill body regions to the \lalous system ire the thoracic duct and right lymphatiC duct. Tbe tfMndc: duct begins rn the ibdo· men at the upper end of a large sac, tile cisb!mi d!yli. It transverses tne diaphragm Ill rough the aortic: hiatus, passing behind tne aorta and In front of the vertebril column. irld usually iscends just to the right of the midline. Just below the aortic irth It shifts to the left and temAinomediostinPitrunlc./dtjugulor tnJnk. ind 11!/t subclavian tnJnk. A number of smill. unn01med lym· phatrc trunks ~t collect lymph from smaller groups of lymph nodes convey lymph from the mediastinum and lntercosbl spaces to the tho·
128
ride duct (lymph from the posterior portions of the lower right Inter· costal spiKI!l usually drains Into the thoracic duct rather than the short right brondtomed~stinil trunk). The rfght frmphltk: duct is i short duct that receives the right bronchomedlortinal tnJnk. rightjugular !TUnic. ind rlgllt subdavtan tnJnlc just before 1t opens Into the Junction of the rlghtsubclillllan and Internal )ugularveln.s.. ~All major lymphatic trunk$ p.ass through the thora de CAVIty. The In· trathor.rcic prw.sure undergoes rhythmic v;ariations with breathing, and these pressure d!ar~ges are transmitted to the lymphatic trunks. These changes act mainly on the relathtely large-caliber thoracic duct irld have a slgnrtlCAnt Impact on lymphatic return: the fall of lntrathoradc pressure during inspiration CAUSe.J a passive, traruient $welling of tne Ill~ ride duct. which IDCreises the flow of lymph tflrough tflat vessel. This prfndplean be applied theripeutfCAIIy rn lymphedema patients by h
Had and neck - - - Arsdralned by !tie right lymphatic duct
;\l "1\_
•
Arsdralnedby the thor.adc dLICt
c
l.ymflhlltkdl'llnage by quacln~nts
Lymphiltlc drainage follows the •quadr;mt principle." wllh three quadrllnts drlllnlng Into tile lfloI;IICit duct and one quadrant dl'i!in· lng Into the right lymphatic duct (see 8 for details).
\
Paramammary
1--\
Antwior med'-ttlum
~phnodes
llta:hlaa!phalc ~ -
SUpertormed'-ttlum
Prt-pelbldallymph nodes Pertardlum
Hart
Bronchi l'oltertor dlutwall
-
Pams11!1nllymph nods
wng
--- i' _/
SUpertorphranlc
~Abdomen, pelvls.lawer limb
8 Ovenf- of frmphattc p;ltflwaysln lfle thorax The lymph frcm.illl body regions lsrellJmedtotileVI!Ilousdrculiltlon at the junctions of the tight and left subdavian and internal jugular wins (sometimn called the tight and left "lll!nous angle$"). The tflOIIIIC!c duct conveys lymph from !he .ilbdomen, pelvis, lower limb, left half of tfle lhorax, left uppef limb, and left half of lfle he.ad and neck to lfle juncti:ln of the leftsubd.Man .ilnd internal jugularVI!ins (mrresponding to three ofthefourq~aadrantuhown In C). The rtght lymphatlc;duc:t is .il short duct (only about 1 em long) !flat conveys lymph from the right half of lfle lhorax, portions of lfle liver, tfle right uppef limb, and tile right half of the head .ilnd neck to lfle junction of lfle lfg/lt subdilllfan and internal jugularwins (mrresponding to one afthe four quadrants}.
Lymph from the posterior portions of tile lower lnt:m:ortal spaces on both 5ldes usually dr.alns Into !he thor.ildc duct (see A). Bolfl of tfle m.arn
trunks recei~ thoracic lymph from the left and rfght branc:homedl· illlltlnill tnmb and from smaller, unnamed trunks. The lymph nodes (see p. 130) may be located dose to the dlest wall (e.g., tfle p.armernal, par.ilmammary .ilfld prevertebrallymph nodes), In the mediastinum (known clinically as the •mediastinal" lymph node.s), or may be closely i!ssociilted with the bronchial tn!e .ilnd named for their location.
129
Thoi'Q}( - - 4. Lymphatlc System
4.2
Overview of the Lymph Nodes
A Overview of the thoradc lymph nodes Transverse section at the level of the tracheal bifurcation (at approximately T4), viewed from above. Topographically, the thoracic lymph nodes can be divided Into three broad groups:
• lymph nodes in the chest wall (shown here in purple), which drain the chest wall. • lymph nodes in the lung and at the divisions of the bronchial tree (intrapulmonary and bronchopulmonary lymph nodes, shown here in blue). This group drains the lung and bronchial tree and conveys its lymph to the next group (see C and p. 129). • lymphnodesassociatedwiththecentralstructuresofthemediastinum (trachea, esophagus, and pericardium, shown here in green). Chest
wall group
Centr.ll (mediastinal) group
lntr.lpulmo~ry
and bronchopulmonary group
Esophagus
~.r:=.-----
Right brodlloCI!phalicVI!in
Thoracicductatjunction of left subclilvfan and lnt.mal jugulilrvelns
Brachloceph;lllc - - - - +-="'i.... lymph nodes
Tracheobronchial ---,...,'--r'--...CO::::.;IIIL· lymph nodes
pericardium Abrous i
Dlilphragm
n...rl~"---"'"'\t--
Superiorph,..,nlc lymph nodes
t;p?'~~ ~ml~l---r-~t-./
aorta
B Thoracic lymph nodes Schematic, left anterior view (the stomach and brachiocephalic vein are not shown to scale). Part of the diaphragm has been cut away, and the brachiocephalic vein has been retracted posterosuperiorly to display the lymph nodes and the junction of the left subdavian and internal jugular veins. There is no significant functional distinction between parietal and visceral lymph nodes in the thorax (in sharp contrast with the segregated visceral lymphatic flow in the abdomen and pelvis (see
130
pp. 296-297). The thoracic lymph nodes are grouped in the mediasti· num ("mediastinal" lymph nodes) around the pericardium, trachea, esophagus, and bronchi and collect the lymph from these organs. Nob!: There may be a transdiaphragmatic connection, varying in differ· ent individuals, by which the thoracic lymph nodes communicate di· rectly with abdominal lymph nodes. This connection may allow a direct lymphatic metastasis of malignant tumors (e.g., gastric carcinoma) to the thoracic lymph nodes.
c lbondc lymph nodes, pclltl!fforv'lll!w The numerous lymph nad61oc.a!H at the divisions of the main bron· chllnto lobolr brorKhl are o!Un e<~lled the "hll01r" lymph nodn beciUJe !heyire locatedlnthereglon ofthepulmorlilryhllum(notshown here). Frequenttytheyarettteflrrtgroupoflymphnodestobealfectl!dbypul· monary dlseaJe {tuberculosis, mallgrlilnttumors).
131
Thon:ut: -
4. lymphGtlc System
The Thymus
4.3
Proji!Ctlcn of ~he right pleun~l CMI!ty
_l
re=
Ptojtdlancfthetf!ymus ("'t!ymmc triangle')
- - - Ptojtdloncf the left pleu nil CI'A1;y
A Pro)Ktkln ottfle thymus orltD tfle chert wall !'«clarity, the pleural cavities have also been pr1:1;e.cted onto the chest wall. The thymus lies In the supa!or medlilrtlnum ~nd extends down Into the antafor mediastinum, where It Is anterior to the h~rt ~nd great 'VeSsels and posterior to the sternum. The area In wttlch the thym~ pro}ects onto the chest wallis sometlml!l called !he "thymic !Jf· angle.• On the chest r.ldlograph of a very sm~ll cillld, the large thymus may appear to broaden the sllhouetm of the cardiac base.
Fibrous
trabeculae
•
Macrcphage
Remr111113 of thymic mtdul1
b
Hlstologtc:~l stn.Jc.'bR of the tf~Jna structure of tfle tflymLB In adolesa!llce (1~) .nd old age (be·
8
IDW). The thym~a Is a primary lymphatic (lymphoepllflellal) organ ~t hasa predominantlyendgcfennal origin (third pharyngeal pouch) but also cont31ns ectodermal elements. It play3 a central role In the maturation ofT (thymll!i) lymphocytes and Ulelr differentiation Into Immunologically competent cells. Addltlonally,lmmun~modulatlng ht1tmt1nes (thymDSin, thymopoielin, thymulin) are produced in the thymus. Congenital absenreofthethymus results In severe Immune· deficiency. The thymus conslm of a cortex and medulla. The cortex appears much darla!r·rt.llnlng due to the predominance of thymocylz.l (pn!aJrsors to T-lymphrxytes). The inner medullary l'l!!gian ap· pears llghter·stalnlng as a multoffewerthymocytes and an lnc~se In the numbefof epithelial cells. Fine. v.J5allaltzed trabeaJiae extald fromUiedellcatl!tlbrouscapsuleofthethymll!ilntotheparenchyma. subdMding the r:~rgan into numerDus ltlbules. b f\lndltln•larchltledure(as described by L.UIImann·R
132
Thymk(H&'Ual's) COiplllde
lflellal cells form a densely packed. subcapsular layer that creates a boundary between the Interior of lfle thymus ind the cortical caplllarles In the tlbrous tribeculae (the •blogcf-thymll!i b.'lrrfer: not shc:lwn h~). Epitheli;!l (epithel~l reticul~r) cells with long pi'Oa$ses join together In the cortex <~nd medulla to fonn a three-dimensional network that encloses the thymocytes. (Thymocytes ire not shown here In ollie!' to display olfler C4!11 types clearly.) Epllflellal cells In lfle medulla aggregate to fDrm the thymic (Hassall's) corpusdes. The in· nermost allsln large thymic corpuscll!l often degenerate Into~ homogelleous mass. The function of the thymic corpusdes Is not yet fully understood. The thymus cont31ns sewral othef cell typl!l as well:
• Macrophages{phagtlcytoslsof~) • Dendritic cells (~ntigen presentation) • Myoid cells (function undeolr) Maturation of 1he thymocyte$ ocaJrs during their migration from lfle corte11.totbe medulla. Amature T-lymphocytecan recognlzeforelgn in!Sgens and dtffen!ntlate Ill em from endoge11ous cells (•autotolerance").
lntt~NI
)lgularYdn
lnfellorttl)ToldYdn ------:::::z:~;.o:;..""l Bradllo-
---...,;:~,---
apllallc trunk ~~----
Plnnkn!!M!, perit:M'dllalplnnlc a1l!ry lrldYdn
Rlghtbr.IICH~
a.philtclldn
Rlghtlung - - - --
lnlphragm
-----I l'llrlet.llpleura, d:aphragmllllc:palt
c
Slzund shape ofthe tflymus Ant!!rior view inw the superior medi;JJtinum of a 2-ye~r-old cflild. The lflymus Is still well developed at tills age. consisting of two prominent lobes (right and left) Ulilt are subdlvlded by ffbrous septa Into numerous lobules. Usually the thynnas ls apposed to tile anterior surface of
Fbrous perioudum
the perfcardlum and lies anterior to lfle supertor vena CJNill, brxhl~ ceph;!lit veins, ~nd ;1011;1. In a sm;~ll cflild, tne thymus may ~nd up Into the nedcalmosttolhe level oftiletflyrold gland. lying posterior to the pretr.u:heallamlna of tile arYIC
133
Thoi'Q}( - - 4. Lymphatlc System
4.4
Lymphatic Drainage of the Esophagus
Paraesophageallymph nodes
Drained by )ugulortrunks
•
----- -------} :~~r:;rt
Internal jugular vein
'-------;l-
Draln•d by broncho· mediastinal trunks
Esophagus, thoracic part cymph drains - - - - - < 1
lnlerioriy
···········==:~·-··?····
6':J
b
A Lymphatic drainage of the esophagus il lymphatic drainage of the esophageal wall, b lymphatic drainage at different levels of the esophagus.
lymph from the esophagus flows from inside to outside through the var· ious wall layers (a), draining initially to the lymph nodes that are distributed along the esophageal wall (paraesophageallymph nodes, see B). There are three principal directions of lymphatic drainage, which correspond roughly to the three divisions of the esophagus (b): • The cervical partof the esophagus drains cranially, mainly to the deep cervical lymph nodes and then to the jugular trunk. • The thoradc part of the esophagus drains In two principal directions: - Cranially to the bronchomedlastlnal trunks (upper half). - Inferiorly (partly via the superior phrenic lymph nodes) to the bronchomedlastlnal trunks (lower half). Fine lymphatic vessels may
134
-------------i;._~---------
}
Esophagus. abdominal part
convey a small amount of lymph through the esophageal hiatus into the upper abdomen to the abdominal part of the esophagus (lymph maydraintotheinferiorphreniclymph nodes as well as the celiac nodes). The "watershed" area for these two flow directions lies at the approximate midpoint of the thoracic esophagus, whose upper part may also drain to tracheal lymph nodes. • The abdominal part of the esophagus, like the stomach, drains to the cellae lymph nodes (not shown here). Thus, when the flow direction In these lowest esophageal lymph nodes Is reversed (a simple change of body posture or Intracavitary pressure change due to breathing or bearing down can alter the direction of lymph How), lymph from the stomach (which may bear malignant cells from gastric carcinoma) can reflux across the diaphragm and enter the thoracic nodes.
~·
lymph nodes
lnferiortr.lcheo- _ _.;.......,""""'"""== bronc:tlillllymph nodes
li..L~--=-=-~~'7'-- IJ!ftmaln
bronchus
Glrdlaclympha11c ring (lnawutant)
8 ~nodesoftheesophilgus Antzrlontew of the opened thor.IX. All thoracic organs. with the eJU:eptlofl of a portion of the trachea, the main bronchi, and the esophagus haw been remOVI!d. P~rt of the abdomen is shown. and the st&lmach h
etOI)hageallymph nodes.l:ymph fi'Dm the par.aesophageal nodes drains to collecting nodes or directly Into the jugulartrunkorthe right and left bronchomedlast!nal trunks (see A). Esophageallymphalks ne
cheal blfurt.1tlon also communicate wlth the (lnferfor) tracheob11)11chlal lymph nodes. Lymphatic vessds descend with the esophagus through the esophageal hiatus.
135
Thoi'Q}( - - 4. Lymphatlc System
4.5
Lymphatic Drainage of the Trachea, Bronchial Tree, and Lungs
Parasternal lymph nodes
Sternum
Bronchopulmonary lymph nodes
Intrapulmonary lymph nodes
Tracheobronchial lymph node•
Lymphatics lnthetnmk
wall Peribronchial--+---\-'\\-:-'~~
networlc
Subpleural networlc
Trachea
Intercostal lymph nod.. Trachea Drained by------.. right bronchomediastinal trunk
Paratradheal lymph nodes
~----Drained by
left brondhomediastlnal trunk
---fl!----"''::-"~-=lliA
AE"<:-"¥.-i;-----¥,;-- Inferior tracheobronchial lymph nodes Drained by Inferior --Ti----':._% -,-\i--':._-"'Y tradheobronchlal lymph node•
J>-------¥.''---- Drainage through •.n --r
_,~..,.,
b
A cymphatic drainage of the lungs, bronchial tree, and trachea il, b Transverse and coronal sections viewed from above (a) and from the front (b). The lymphatic drainage of the lungs and bronchi is handled by two separate networks of delicate lymphatic vessels (see b):
• The peribronchial network follows the branching pattern of the bronchial tree (seep. 82) and collects lymph from the bronchi and most of the lungs. • The subpleurol networlc (smaller) bonderlng the lungs collects lymph from peripheral lung areas and from the vlscerol pleura. The parietal pleura (part of the chestwalll) Is drained by the Intercostal and parasternal lymph nodes of the chest wall. These two networks communicate at the pulmonary hilum and convey lymph cranially, ultimately to the tracheobronchial lymph nodes (deep tissue areas may drain to the intrapulmonary or bronchopulmonary nodes, but the lung as a whole is drained by the tracheobronchial
136
diaphragm to inferior phrenic lymph nodes
lnfenor phrenic lymph nodes
nodes). Lymph flows from the tracheobronchial lymph nodes to the paratracheal nodes and bronchomediastinal trunks, which terminate at the junction of the subclavian and internal jugular veins independently or after joining the thoracic duct or right lymphatic duct. Nob!: Lymph from the left lower lobe may also drain to the right bronchomediastinal trunk via (inferior) tracheobronchial lymph nodes. The lower lobes of both lungs may drain cranially, but they may also drain inferiorly to the superior phrenic lymph nodes or may drain through the diaphragm to the inferior phrenic nodes. The trad!u drains to the paratracheallymph nodes, which may empty directly into the jugular trunk or indirectly via the bnonchomediastinal lymph nodes. Note: Tracheobronchial lymph nodes that lie very close to the pulmonary hilum are known in clinical parlance as the "hilar lymph nodes.· Their enlargement in response to pathological processes may be detectable by imaging studies.
Rlghtln!Jemal Jugl.farwil
IJ!ft Jugularii'Unk
Rldlt
Jugularii'Unk
J!-'';1---- .:,...-....:.;_--:-....,....::...,...- - - IJ!ftbrooo:ho-
mecfastfnal trunk
}::,.,...--..:,..,.....;.;.;:::....'":-- - lnlnlpulmonary lymphnodu iJ!.-~J:,!i!5;--....,.,--___;,.,.....,~--
8 ~nodes ofthetnchel, bronchl,llld lungs AntErior view. The following lymph nodes CAn be distinguished Inside ~nd outside the lungs,llstl!d In order from deep to superficial (see A):
-
lhondc
• OuUidethelung: lnfaforandsuperfortrach"'bronchli!llymph nodes at the tracheal bifurCAtion and on both main bronchi; paratriche
• Inside the lung: Intrapulmonary lymph nodes In Ule lung tissue and illt the dl\llslons of Ule segmental broncht bronchopulmon~ry lymph nodes at the division d the lobar b!Uldli.
137
Thon:ut: -
4.6
4. lymphGtlc System
Lymphatic Drainage of the Diaphragm, Heart, and Pericardium
Vena
awlhllml
A lF!phnodls;and lymplmf,d1111n1geofthedllpfn11gm Superior view. The lymph nodes of tile dlaphrigm are divided Into two groups bised on tilelr loc.ittfor1: • Superior phrenic lymph nodes or1 the superior surfilce of the dla· phr.ilgm • Inferior phrenic lymph nodes on tne inferit:orsurface ofthe diaphragm (not shown here, see pp. 297 01nd 302) The superior phrenk:frmph nodes, then, arethorociclymph nodes tnat collect lymph fromthedlaphragm,loweresophilgus (see p.134),1ung, and ilso from the liver (by a trinsdfiphragmatlc route, seep. 129). The supenorlymph nodes on the rfght side .ilre Involved rn hepatic dr.illnage. The superior lymph nodes drain to tne bronchomedianinal trunk. The Inferior phranlc lymph nodes are abdominal lymph nodes; they collect lymph from the diaphragm and usually convey It to ilumbirtrunk(see p. 297). They may also collect lymph from tile lower lobes of the lungs (seep. 136). Dl;Jphr.~gm,
Dlaphiii!Jm,
oentral b!nCion
Supertotphrcnlc lymph nodes
costal part
lnll!rtor~
- - +-2!ill
brcndllal
lymph nodes
•
io!ftwntrfc:lt
8 ~hl\kdl\llnlfloftM Mirt (ilfta'F61dl and Kubik)
The heart viewed from the in!l!rior 01spect (a. b) ind porterlor iiSj)ect (c).
The lymphlltl,d!11ln"!Jeofthevcntlfdc.(~d pilrtofthe .trt.) c:an be roughly divided Into two regions (see a 01nd b): • The /qt., («)encompasses the left ventricle, a small strip of the right ventrlde. and portions of the left atrlum. It conveys Its lymph throiJ!Ih ,. •left coron01ry trunk" to the Inferior tracheobronchial lymph nocle.s, which dralfl to the junction of the right subd.Mar1 and intl!rn01l jii!Jular veins (directly or via the right brondtomed~stin;~l trunk). • The rlgllt region (b) mainly encompasses the right wrnrlde and portfofiS of the rfght atrfum.lt conveoys ItS lymph through 01 "rtght coroni!rytrunk" along tnuscending aart;t and ttl en totne junction oftne left subclavian ;md lntemiljugularvelns.
Broncllapulmanary lymph nodes
This 01rrangement aNtes two •aossed" pathwilyl for lymphatic dr01ln· ilge: • Right region- "right coron;rry trunk"-junction of the left: subdavlafl and Internal jugular veins • Left region- "leftcoronarytrunlt"-junction of the rfghtsubcliiiVIin and internal jugularVI!ifiS Lymphatic dratn1ge of tile rut of tht atria: Portions of the 01tr1a that are outside tne 01bove reglor1 drain to the Inferior tr.lcheobronchlal lymph nodes or to the Ipsilateral bronchopulmonary lymph nodes and thence to the bronchomedfistlnal trunks.
138
Right atrium ~"""""""";--- Rlghlt<1111n1rytnmk
c
8111dllcn:l!!)hlllc: lymph nodes
---.......,='11'-''-T''-:-'"'---~
~+--- IF9hnodtof
ligamentum
a~U~toa~m (lnccn~tant}
"T-ii-'-- - Left ILng hrfeul pie~~" --""'!""rr-f!-- -"":""'--
mediMtln.alpart
l.
"""'*'
--~~~~-====-
Diaphragm
c
Lymph nodes nd lymphltfc dr.IM!Je of the ptffcard'um Antl!rlor 11tew of the opened thorax. The pleur.al cavities hiM! been ope11ed. ;~nd the lungs ;~nd pleur.~ have been re~ lmrally. f.¥mph node groups of wrying size (preperlc3rdlal and later;ll pertcardlal lymph nodes) lie .an!l!rtor .and adjacent to the peric.mllum and are lntefton· nected by a network of ftne lymphatic ve.ssels. These pertcardlal lymph
Endocardium Eptc,ftlum
{¥150!1'11llilyoerof ~IOUJ~rdlum}
Cllpllllllych coronarylll'tl!fy
--+'~._...,.t.\
nodes may drain lnfenorly (to the supertor phrenic lymph nodes) orcr.~ nlally (usually tD the brachlocephallc lymph nodes). ~¥nph &om the pericardi;!l lymph nodes is ultimmly co~ tD tne bronchomedin· tlnal trunks (see p.129), ~lch open at the junc:tlon of the rtght or left subclavian and lntemal Jugular veins.
D ~F~phltfcdr.'hlgeofthe hHrt-1 (a!Urfiildl and Kubik) Section through the heo~rt wall. There ane three networks of densely lntl!rconnected lymphaUc Yessels, correspondif19 to the thnee layen of the heartw.all: • Epicardium (•VIsceral layer of the serous pertcardium): Asubepicardial netwark collects lymph &om the epicardium and from tne other two networks. The subeplc
139
Thotwc -
5.1
5. NttvousS,mtn
Overview of Thoracic Innervation
__.,.....
"" J I 'h4't
e .-
->,,..-- S1!lllle
ganglo11
Plwyngeal plliiQS
-
lntomol
I I
I
Grulerandles~er
splan
---I 1
tt A O. .nlutlon oldie sylllplthttlc and plnsympadletk: Rl!nllllll systems In die thorax With the prominent eJCtepttons of the phrenic nerw (pp. 146-147) and Intercostal nerws (B), thoracic Innervation Is largely autonomic, arisIng from eSther the par.we!Ubr~l sympathetic trunks or tile parasympathetic wgus nerves. Sympllhetk orpnlutlon: The perlpheril sympathetic system consists of a two-neuron rllay, with pi'H)'naptic (preg;mglionic) fibers arisIng from neurons In the spinal cord. These axons syn;~pse onto neurons In the paired par.we!Ubral sympatilettc !PngIIa, which send axons to innerwte the thoracic YiJCitl"'l and blood ¥eSSeIs. The cell bodies of tile snsynapttc motor neurons ire loCited In the later~• horns of the thor~columbarspin~l Cllrd (T1 to l 2); tile neurons ;,., wived In sympathetic lnnervltlon ofthe thoru are concentrated In uppel thoradc lewis. Alcons from the paralll!rtebral gmgllon cells (postsynaptic (postaanglionic) fibers) follow sewwal counes: some fibers followlnterc:.ostiJI nerves to Innervate blood vessels ind gllnds In the chest wall; oChers accompany arteries to \'15CIIral targets; other groups of pvstgo~ngllonlc - sgather In the grutrr and lesser splinchnlc nerws
140
and enter tile abdomen 1- p. 306). Pll.-..ym~etk org.,.TUtlon: The perfpheral parasympathetic ner¥OUS sy51em has a slmiS..rtwoofleuron relay, but Its presyno~ptlc neurons are In the bralnstem and the !Pngllon cells ire scattered In microscopic grDUps rn their brget orgins, The vagus nerve (CN X) carltes presyn;~p tlc parasympathetic motor axons from bniNtem neurons Into the thom: and gives off tile following branches:
• ca rdlac branmes to the Cirdlic plexus (hurt, .see pp. 144 and 145) •
Esophage~~l
brandies to the
esophageo~l
plexus (esophagus, see
p.143)
• TrachNI branches (trachea, see p. 142); bronchl~l branches to the pulmon11ry plexus (brvndll, pulmoBaryvessels see p.142) The vagm nerws continue. , dthese branches,following the esophilgus Into the ilbclomen p,307), Noll!: The v:agus nllr'lll also a!Ties viso~l sensory aons (mostly pressure sensation) for thoracic organs. The sensory neunJn cell bodies are In tlhe Inferior vagill gilngllon (nodose) ( - p. 19); the first synapse In this HSnory pattwAy Is In the brains~.
<-
Common
a~aury
\..-;r';-'~----
Bflldoial plexus
••":--r----
!JeftsubciMina!Wy
~-~~--- Rrst~b
~---- I.A!ftrea.urtnt laryngeal n~ ....-~-- Aortic arch
,_.--- - - l.eftmaln bnindlur.
Amltrlar .....I
trunk\Mth
e:sophageal pltlCI.5 Cil'l5ltl!f
splanchnic:
nenoe
8 Ovl!ntew of tile nerves In tile thorax Antl!rlor lllew. All organs have been remowd exupt fertile esophagus and part of the trachea m display the sympathetic trunk, intermstal nerves. and esophageal pl~us. The symp;dfletktnlnk runs alongside the venebral column In the tho· rax. Postsynaptic branches of the synnpathetk trunk usually ucompany the intrathoracic arteries to their target orgarl in the chest. where they enter the plexus associated with that orgar1 (seep. 306). The ln18~W~> tal nei'III!S ire all pos!l!rior. They arise from spinal cord segments 112 (the paired nerws arising from segment 12 are ailed the subcos· IDit!tM!S because they run below the twelfth rib:; not shown here) and they emerge bei!M the T 1 through T 12 vertebra. They Initially course with the lntl!rcostal venels along the Inferior border of the assodated rib. They supply motor Innervation to tile lntl!rcostal mil!des and glYe sensory Innervation m the Tl-T12 dermammes. E
two main bronchi while gMng off branches, and !hen desc:end on !he esophagus, passing With It through the esophageal hiatus Into the abdomen. No~: The left and right vagi!! naves are C~ganlzed around the esoph· a gus to form the anterior and pcmerfor vagal trunks. Topographkally, these !JUnks .ilre a continuation of the esophageal pl~us. Botti trunks contain fibers from both vagus nerves: the onb!tior!JUnk mntains mare flbm from tile leftwgus nerve. while the p~ortnunk mntalns more flbus from the rlgllt wgus nerve. The left wgus nerve glYes off the left ncul7l!llt /aryngtalnervt at the .ilortlc irch, whlle the right wgus nerve giws off the rightn!'CUMJttlal)'ngeal ne1'11rat the right subclavian <~rtery. E.'lchofthesenaveslsanecurrentbranchofthewgusnervethataKends ln!D the neck. It Is not uncommon for the rea~rrent laryngeal nerves to nun more posteriorly lr11he neck than shown here, occul'jlng the groove between the trachea and esophagus ~ere !hey are vulnerable during oper.~tions on !he nearby tlryroid gi;!nd. Fclr clarity, the rea~rrent laryn· geal nerves have been rdr.ICIEd slightly forward In this dissection. NOIJ!; The perkardlum and diaphragm do not have iln <1utonomlc nerve supply{exceptthelrbloodwss4!h),seepp.146and 147.
141
Thorax. - - 5. Nervous System
5.2
Innervation of the Esophagus, Trachea, and Bronchial Tree
A Aulllnomlc Innervation of the esophagus Parasympathetic flben arise from the dorsal
Vagus nerve
Dorsalnudeus ofVilQUS nerve
Recurrent laryngeal nerve T2 spinal cord segment
T6splnalcord segment
B Aulllnomlc Innervation of the trad!ea nd bronchlill tree Parasympathetic Branches from both vagus nerves are distributed to the cervical part of
Vagus nerve
Doi'Sillnudeus ofvagus nerve
Middle
Cervicothoradc ganglion
laryngeal nerve Recurrent laryngeal nerve
Tl spinal cord segment
l.aryngopharyngeal branch (sympathetic br.lnch to larynx and pharynx)
Second through flfth thoracic ganglia
Autonomic br.lnchesto b"achea
Pulmonary pll!XIIS
Bronchial branches in pulmonary plexus
I Right main bronchus
142
vagal nuclei and enter the vagus nerves. The vagus gives off parasympathetic motor Hbers Ill the cervical part of the esophagus via the recurrent laryngeal nerve. Other vagal axons form an extensive esophageal plexus, which extends to abdominal levels of the esophagus. These presynaptic fibers synapse on scattered parasympathetic ganglion cells (not depleted here) In the esophageal wall. The embedded ganglion cells In turn Innervate esophageal smooth muscle and glands. Notl!: The vagus nerve also conveys direct molllr Innervation, without an Intervening local synapse, from the nucleus ambiguus in the brainstem (not shown here) to striated muscle in the cervical esophagus via the recurrent Iaryngeal nerve. Sympathetlcflben are contributed mostly by the second through sixth thoracic paravertebral ganglia. These postsynaptic axons enter the esophageal plexus but directly innervate the esophagus. The middle cervical sympathetic ganglion contributes innervation to the cervical part of the esophagus. On the whole, sympathetic innervation is much less extensive than the parasympathetic supply to the esophagus.
Left main
bronchi.IS
the trachea, mostly via the recurrent laryngeal nerves. At the thoracic level they form tracheal branches that enter the pulmonary plexus, which is heavily branched at the pulmonary hilum. sympathetic Few postsynaptic fibers are distributed to the trachea; numerous thoracic pulmonary branches (postsynaptic branches of the thoracic ganglia) pass into the pulmGnary plexus. The pulmonary plexus regulates the caliber and secretory activity of the bronchi and influences the caliber of the pulmonary vessels. Activation of the parasympathetic nervous system causes the bronchi to constrict (as in bronchial asthma), while activation of the sympathetic nervous system causes bronchial dilation. Thus, drugs that activate the sympathetic nervous system cause bronchial dilation and may be useful in the treatment of acute bronchial asthma. The autonomic effects on the pulmonary vessels provide a means of varying the perfusion to different areas of the lung by controlling vascular calibers. For exampie, the autonomic system can greatly reduce the blood flow to poorly ventilated lung areas during shallow respiration.
SubmuCQSi
f}l""tl;;u- Slb-
-~M-·\~f'(
mucmal piOOOJS
MIACular -~fi~~~~ coat. drcular lajller
I I M!ACUIIrCOit.
longitudinal lay!f
c Foi!NI1ior\ oftfle esoplwlgul plexn The esophilgus and part of the stoiTiilch, viewed from tfte anterior slde (;a) ;md posterior slde(b). Initially the v.agus netves de sand a short dist.lna on the left and right sides of the e50ph· a gus as the left ;md right vagus nerves. but then they turn interiorly ind posteriorly owIng to tfte 90" clockwfse n:~t.ltlon of the e50ph· agus (viewed from above) that occurs during embryonic development. The left vagus nerve now becomes Ute ;mterfor vagal trunk. and the rtght vagus ni!M! becomes the posterfor Yil!fal trunk. Both trunk$ exdl.ange a consider· able number offlbers, however. so that tile antl!rior vagal trunk (actually a derlvatfwoe of the
left vagus nerve) ilso contains fibets from the right ~r.~gus nerve, and vice versa. Both vagus nerves and both vagal trunks dlsiJfbute numerous ftben to tile esophagus, which form the anterior and postertor esophageal plex· uses. The esophageal plexus iJcontinuous inferiorly with the gastlic plel~US. The cervical part of Ute esophagus Is supplied by Ute recurrent laryngeal nerwoes, which arfse from Ute vagus nerves. The postganglionic symp;rthetic liben enter tfte esophageal plexus, which thus cont.llns both parasymp;rthetfc and symp;rthetfc flben. On Ute whole, howewr, the parasympathetic innecwtion of the esophagus is gruter than 113 sympathetic Innervation.
D Autonomic nerve plexunt II\ the
aophi!Vell-11 Oblique view of the esophagus. dissected to show the different wall layers. Lllce all hollow organs in the gastrointestinal tr.act, the esoph· agus has Its own autonomous lntnmural ner· vous sy3tem. This sy3tem consists mainly of two plexuses, 'Which are locatl!d In Ute submu· cma (submucosal plexus) and in the muscular coat (myentl!ric plexus). These plexuses are composed of lntr.1mural ganglion cells tftat .1re Interconnected by an exl:l!nstve netwollc and aontrol the musculir furw:lioru of the esoph· ~gus (e.g.,peristalsi$). The activity of this au· tonomous netwollc Is modulated by tfte sympathetic and parasympathetic nervous systems (see A).
Hurt
MyacaNIIum
lnaeeses tlw slrength of myocardial contractions
Slightly Increases contractility
Coronaryvasels
Causes mronary dilation
Causes minor mronary
Sinoatrial node
lnaetses thedischa19e ~
~the discha19e rail! (mainly by the right vagus nerw)
l\tlfoventr1cular node
Ac
Slows Impulse conduction (mainly by the left vagus nerw)
lrondllaltne
• Bronchial dl'*n • Deaetses lnnchial glar\dular secretions
• Bn:lnchlal constrlctlon • Increases bnlt'lchial glar\dular
• Deaetses peristalsis • Deaetses esophageal gland secretions
• lncreasesperistalsis • lncreasesesophagalgland
constrlct1on
seaetlons
seaet!Ons
F Refem:d peln from tile aophllgu• Anteltor 1/tew. As with olher vl~«r.~l structures, pain In the esophagus may not be local· !Zed to the organ Itself, but may Instead seem to originate elsewhere. Esophage-al pain may be referred to cut.lMOUS areas OYef the ster· num(Headzoneoftheesophagus, seep.146). The phenomenon Is ailed •referred pall\.•
143
5.3
Innervation of the Heart
Dcrsalnuc:leus _ afvagusnerw
_Jlf--t)'l-- -,-- - - - - - - -
t.Uddl~
aervbl gansjron CSspln.al ---1::::::::r~--.L_...: card segment
..----,H - -
S~and
lnf8'1or aervbl
ardlac br.~nd!es
T1spin.al cord~
S)mp;lthetlc trunk
-+=~:t"-:::;~'\-!+1-H-----+-- lhor.lclc:
cardiac br.~nd!H
T6spln.al au\! segment
,-~--
!!!!ll:~~l!-\-+--
lhor.ldc ardlac br.~nd!es
Allfo...entrlalar nade(AVnode)
A AlltllnomlclnnervaUonoftheheart Parasympathetic Vagus netvefibers from the dorsal va!Jal nucleus give off the superior and Inferior ceme<~l cardiac branches In the neck and the thoracic cardiac branches In the thorax. The cardiac branch~!! pass to the cardiac plexus. Symp;l\tMUc:: The three arvlc31 sympathetic ganglia give off the superior, middle and lnfertor ceNkal cardiac nerves, and the thoradc gan51lia givt' off the thoracic cardiac branches. 1111 of the cardiac branchn radiate to the cor· dlac p/e.laJs, which distributes tlbers to the SA node. AV node, myocardium, and coronary vessels. The $YfT!pathetic: axons, all postsynaptic, Innervate ;rll these t.argea directly, while the parasympathetic ;ucons from the vagus synapse to the SA node, AV node, myocardium, and coronary vessels. The sympometic symm Increases the rate and fo~e of myoc:ar· dial contractions and dilates the coronary vessels, while the parosympathetlc S)W!m acts Plf· martlyto slow the heart rate. Dn.rgs !Nt acton both systems are ~~5ed In the tteatment of nu· mero~~5 diseases lncllldlng hypertension. myocardial Infarction, and cardiac aiTbythmliS. Ncrz: Since the heart has its own pacemaker (see IPP· 110 ;and 1 11 ), the autonomic nerwus system don not gener;rte the he;rrtbm, bc.rt Instead acts on the SA node to regulate heart rate, and on othl!f areas of the heart to modu· I~ its function under different phy$iol~ical loads.
$11mpatht(lc trunk. t'*"or
~ulll~nsJIIon
Qn:fiiCbt.arw:hes --~ tourdliiCpii!IWS .((3~--
1\llmonary-ryand p IJIT*'IIr)' wins v.4th piJIT*'IIr)' plexus
%.---':-- C.rdlacpll!!luulong thtax'Onlr'Y a!Urfes
8 Au'IDnomlc plex111enbout the he;nt Extensllle autonomic nerve plexuses ue formed on the heart and surrounding vesseh. These plexuses receive tlbers from the sympathetic and parasympathetic nerw~~5 symms (not shown here): • Cardiac pi~ located em the heart, eJpeciallypraminentatthe base of the heart and along the coronaryvellSels (cardiac Innervation). • Thoradcaortfc plexus: located about the thora de aoltl (flbentothe heart .and other plexuses: pulmonary plexus, e.sophillgeal plexus). • Pulmonary pi9:W: surrounding the pulmonary arteries (and W!ins) and the bronchi. The pulmonary plexus Is conslstartly paired. the two parts being connected to each other and to the cardiac plexus (supply the bronchial tree and Intrapulmonary YI!.SSels).
144
C R.efem!d pain and autonomk 1'4!ictlolll ~wltfl he;rrt
dlseit!se 11'1 patients Mth heart disease, especially coronary occl~~5lve disease (angi~
or inf~rction). the p;rln radiates to characteristic body regions (Head zones [see p.146)): • Left shoulder ;rnd left arm (particularly the Inside of the left;rrm) • Lefthalfoftheneck;rndhe
Alltllnomlc neactlona may be noted In the dermatornes over the heart ;and in more dist;ant dermatornes: ;a ch~nge in cut
Common urotld artsy
""'7.""':-----~
lnl'llr, t!loradc
ganglion
Superior wniCMI
-
Asandii'Q
Posts! or In!a'· cmt.1l
Pulmonary plom~S
Pulmonary tJmlc
Cionllac
pii!IWS Ht.lrt
nenoe Plftnlcn~ cnth~
Diaphragm
drapmgm
D AutDnomlc neMI!S of tile heart Antll!rlor lllew of the opened thor
nal fasciae removed. The pericardium has been broadly apened anM· rlorly. The vessels suJTOurldlng the heitrt are lnt<1ct excqrt for a partlon at the ascending aorta. wtlkh has been rernoved to display the right pulmorl.ilry artl!ry. Part of the upptf abdomen Is also shown. The cardiac plexus, pulmonary plexus, and thoracic aortic plexus can be dsrly Identified on the heart and SIJrroundlng vessels. These plexuses receive flben from the vagus nerves and sympathetic trunk. The rteht;md 11ft l/llliUS net¥tS lntually run In the anterior part of the superior medlastl·
num. After gMng affbrandtes to !he plexuses. !hey enter the pastafor medlasUnum (see A). SympltheCfc ftben pass to the eo~tdlac plexus In the form of the cervical cardiac nerves (from the thtM cervical ganglia) and thoradc cardiac branches (from the thoracic ganglia) (see A). Noll!: Most at the autonomic flben In the plexuses are extremdy fine, butlnthlsdlssectlontheyareshown largerfordartty. The phrenic nerve doe.s not innervaM the heart but does gilll! oll'somamsens«y branches to the pericardium (pericand'~;~l branches. nouhQwn here) in the middle mediastinum on Its w.l)'to the diaphragm (seep. 146).
145
5.4
Innervation of the Pericardium and Diaphragm
-
-
llghtpltmk An!Rrtor .oa~ne mLIICie
Leftphi'WIIc
Pltu111
- - lntei'CI:>SUI
mLIICie
Qlllty
lnnernllon af por1cu~lum by por1c1RIIal bnrlc:hes
SlbdiVIon win
Pllrietal ploul'il, medlloUnol .,.rt Ptllardlum
•
lnnernllon af di
Parietal plwl'il, dlophrilgmollcporl
Ilia-
phrogm
...Parietal
.
~
•
Ill
-
A lnnernllon fllthe 1111phngm 1nll pB'Ianlkrm The diaphragm ;rnd pericardium are supplied by the phrenic nerve, a somalllmolllr ;rnd somlltDsensory spln;rl nerve that irises from the cerviCill plexus, .spedftCillly from the C1-C4 .spiNI mrd segments (millnly C4, see 1). The phrenk niiW d!KCI!nds to the diaphragm while giVing off b1"i0nches to the mecf101stinal pleul"iO and periCllrdium (pericardia! branches). It contains both effi!m~t (molllr) il nd afferent (sensory) fl. bers, the litb!r being reponslble for piln mnductlon from the serous membranes 11\rt COW!' the diaphragm. A phreniCDibdamlnal brindl p11sa through the diaphreg m tD the peritoneum on its inferior surfilce. S..10ry llldltliutllln:
• Fibrous per1Ci1rdlu m and the pi r1etalliyer of the serous pericardium • Lilrge portions ofthe dlaphragmatk pirt of the pirletal pleuril • Portions of the mediastinal pirt ofthe pafoeta I pleura
~ftbe's
DllphfW!Im
-
lnnernllon af d•ph111gmby lniB'coltll nerws
Alfmntf'bers
• The pirletill perltDneum on the Inferior surface of the diaphragm • The pef.taneum mverf ng the inferior dlaph rag matic surface. Mater lllstltllutlon: diaphragm. Areas of the diaphragm near the ribs also reaive somatosensory inner-
vation from the tEnth ;md el.~h IntErcostal nerves (see b) and from the subcostal nen~e (T 12. not lltslble). An accessory phrenic nerve (not shown here) Is occasionally obserwd as fibers from C5 (C6} join with the phrenic nerve vii the subdman nerve. The blood W$51!/s of tile cbphr
Note: Bilateral dluuptton of lfle phrenic nlfW (e.g., due to 1 high trillsection of the cervical spiNI cord) leads to bilateral pirilysis of the diaphrigm. BeCiluse the dlaphrigm l11fle doml111nt muscle of respiration. bllatera Idiaphragmatic pirllysls Is usually fm I.
8 ReferTed paTn from the dlaphl'8film As with other thoracic viscera, pain e~used by trauma ar pathology of the diaphragm mil)' not be IOCi!llzed In tne site of Injury but mil)' seem to be originating at different loatlons, 1 phenomenon nlled "referred pain.• This Is easily understood for the diaphragm, whose sensory In· nervation from the phrenic nerw is associated with mid-arvicalll!lll!ls of the spln101l mrd, where the phrmlc nerve originates from branches of the cervtcal plelCUS. Dl;rphragmatk piln Is ttl us referred ID cublneous areas at those cervical levels, spedftcally to the a ntErtor 15pect of lfle shoulder glrdi!K. These lreoiiS. and othen associated with 1'8en'ed piln from different visaral organs, ;rre known as Hm 20nes 01" lines (from Henry He.! (1860-1941 ). Br1tlsh neurologist). BeCiluse the phrenic nerve pravkiiK sensory Innervation to the pi r1etal peritoneum under the diaphragm, and because of lfle pl'lllllmtty of the gall bladder to the diaphragm on the right lide, gallbl.!der infbommation rroay thus Ciluse pain that seems tD came from the r1ght shoulder girdle.
146
~wgus ne'W
lnb!malthcndt arlllryar.dwh
llnu:t•ioaphlllc trunk
IJ!ftbr.Khlouphatcwfn
Rlg1t bt.adlloQ!Phallcwln
Aartll:an:h
~
I.A!ftvagusni!!'W
SUpj!r!Gr wnaava
I.A!ftpulmon~ry
artery
Perlc:;mfaco· P,renlc:arll!ry
Parietal plalra, mediMtln.alpart
.andvttn. phrenlc:nerve
IJ!ftlung Rlglrtlung Fbrous perlcrrdum Phrenic neNeonthe
dapil!'a!JI'l Diaphragm
Phrenic neNe, pj!r'lc:lrdal brandlH
C Course of the phrenic nerw tn the tfiORX
Antl!rlorllfew. Thepleur.al cilllttleshavebeenopened andlhelur~gsha'lle been retracted laterally. When the chert is opened from the front, lhe right ~nd left phrenic nerves c.an be seen
cheit by !he per1c:ardlacophrenlc artery and vern from the Internal lhor.adc artery .md vern. This neuroYascular bundle runs dose to the superior vena uv.a on the right side and close to the aortic an:h on lhe left side before passing directly to the surf~ce of the flbrvus perlc.ardlum, where It gives off perlc.ardlal branches. It th~JS descends In the poten· !Sal space between the perfcardlurn and medl;sstlnal pleura. As a spinal nerve, the phrenic neNe contains bolh sensory and momrfibers.
147
Abdomen and Pelvis Spaces ........................................ 150 2
Organs ........................................ 178
3
Blood Vessels .................................. 262
4
Lym phatir: System .............................. 294
5
Autonomic Nervous System ..................... 306
Location of the Abdominal and Pelvic Organs and their Projection onto the Trunk Wall
1.1
(jllg;Jstric !!!i~lon
ltlght hypocllor>-
Unbilio:
drlacf1!91on
IJ!fthypochondrtacneg'on
Rlgltklmhar f1!9kln
IJ!ftlumhar regan
Right Inguinal
IJ!ftlngulnal neg'on
n!glon Pllblcn!91on
Unbillals L5wrtl!br.l
1..\'ogenltll reglcn
A Regions ofthunteliortrunkwall
B Qu;ldr.mtsofthnnterfortrunkW~II
Three levels an be ldentlfled Ofl the abdominal wall fi'om iboile downwam: the epigasbium, mesogasbium, and hypogastrium. Each lew! oomlsts of three regions:
The quadrants of the anterlortrunkwall are centered on the umbnlcus, which lies at the level of the L3-4 vertebr;l body and are n~med right ;rnd left upper and lower quadrant (RUQ. WQ. RLQ. u.Q).
• The median region of the epigasbium is the fpigosf1ic ~ion. It is flanked laterally by the right and left hypochondrfiiC regloru. • The median region oftile mesogastrium Is the uml:l/1/col region, which Is bounded latl!rally by the rfght .and left lumbar regions. • The median region of the hypogastrium is the pubic n!gl'M, which Is flanked by the right and left Inguinal regions. The pubic region Is bounded Inferiorly by tile urogfnltul region. The lewis of the ;rbdomen are deflned by horlzont
C H1nilon~l {tnrwvene) pl1nes In the .-rtor trunk-11 The ar1tertor trur1k w;rllls dlvlded transvendy by the following IITiilgl· Nry planes of section:
• .q,hostemal plillle: p;rsses through the synchondrosis between the xJpho1d process ;rnd body ofthe S!l!mLtm. • Trallilll¥ortc pllne plane midway bl!l:wl!en the jugular notch of the sternum ;rnd the superior bomeroftile pubic symphysis. Louted at the level ofthel1 wrtebr;r,ltdtvldesthe;rntertortrunkwalllnto upper and lower halves. The pylorus ofthe smmiiCh Is genmlly louted slrghtly belowthls plane. • Subc:lomll p&.ne: pam!$ ttnnugh the/~poi'nts oftheoostrtl ordt of the tenth rfb at the lew! of the L3 vertebral body. It marks the bound· ary between the eplgastr1um ;rnd mesogastrium (see A). • Supracriltal plane: p;rS$eS through the junction of the L4 vertebra, oonnectir~g the highert poiniSQn the iliocCli/Sts. • lntertuberallarplanr.coonects the1/foctlbm:lesand passesthrough the L5vertebril body. The lnte11:1Jberculilr plar~e marks the boundary bl!l:wl!en the mesogast11um .and hypogastrium. • ln'llefSplr~~l pllne oonnecu the two Gntetior wperiorifiocspines.
150
Subccstal
--~--.,....-:--~
plane ---,,...---:-:':""'~---::--:---
1~!. ----,:--7--::::=~----':-:
pl1ne
Supraalltal plane
_.:,,.--;,.-.....:.;:.,---.,.:....;,...-- hbenplnal plane
Noll!: The three upper plar~es are variable In their location, which de. pends ootheposltlor~.md shapeofthethoraclccage. The key variables
are respiratory po:tition, age,~ and coostiWiianal type.
Abdoma~ and Pf!Ms
~supra.W ---::~~:;;
""""~-- flldltsup~~nNI
glond
tJin4 Alancfng eel on Claim wtth wrmllonn
- - -+
- - J, Sp«n
U!ft lildrwy ---.~~~~~~~
i""'- -- RJg1t llldrwy
---4,, _~
oppendlx
Rectum
..
•
\
D l'rllfedton af theliWomlnillanlll pllvl' IJI'PRI oniD the lnlnk -II a Anll!ttor trunk wall, II posterior trunk watt. The surfue projection of organs on the trunk Will dC~~ends on body
posture, ~ge, mnstltutlollill type, sex. nutritional state, and resplritory position. No!21he owrlap of the abdomlniland thoradc cavities: Perfo. ntlng lll]urfes of the abdominal cavtty tholt lnYOiw the IIW!r, for exam· pie, miiY aIso invdll!! the pleural cavity ("multie
E l'rllfedlon afilrulllm1AIIItnactu1'81ln tlw o~INiamm ;and pelvis ontD the wrliellral [QII.mn The spinal noutlon refers to wrtehral bodies. T7
SUpellor border at tht IMr
T1~
Aortic hlitus
L1
• Till nspytor1c plane (generally the pylorus II at or bii
thll plone) •
su':!:~~ 'hdslon Uppermldllne , I1----i-.;--....:..- Llpon>tomy ($11lmtd\ fi'I'C'-)
"'""mbllal - - - - - - - - .} I midline laporo!Dmy
(wrmlfarm appondlx)
• llilnalhdum • Superior part of the duodenum
1--- --';-1
I \
Mdklrrwy - - ---. lndllan
1--:--- Plrallldallndslon (....,.dcolon)
ngulrwllndslon 0191lnol canaO
~
mlcllne
l•po~
Pflln,.,sUellndolon (peMc«gans)
• Pancreas (nee(()
• Origin of the celiac trunk • Origin of the superior mesen12rlc artery • Attachment at the transwrse mesocolon • Spleen (hilum) L3
Origin of lhe ..nala rteries Duodena;ejunaI flc>wre
LJ
Ollgln of lhe Inferior mesenliellc ill1llly
L1/L.Z
LJ I L4
lJrT1biDs
L4
AorUc bifurcation Origin of the lnfertor vena CiVi from the mm mon lAic
L5
F Plac:emll1t olsu111ullldn lndslons In theanl:ll!rtor ilbclomhll
-n
NtX2: The perium bn ic.al midline incision passes around the k{l: side of
the umbdlcus to Mild cutting the remnant of the umblllulve!n on the right side (the llgamartum teres of the liver, see p. 155). This umblllc;al win rem n;ant Is gen.-.lly but not ilfways obllterilted, ;and Injury to the vssel, if it is .still patent. may cause significant bl-ting. The McBurney Incision Is ;~ho caDecl the grldiron Incision because It changes direction In different planes of the trunk Will. The muscles of the tnankwall can be dMded less trau moltlcally by blllorlng the dlrectlon of the cuttD the prevailing fiber direction of the various muscle layers.
..Ins 51
Upper (aania ~ bonier of the rectl.lm
151
1.2
Divisions of the Abdominal and Pelvic Cavities
Th~o~ans oflfle abdomen and pelvis c.m be dasslfled according to various tgpographit
• By layers in lfle ~nteroposterior direction (A) • By levels in lfle c:raniouuclal direction (8)
• As lntT
Right
~upr.~A!nal gland
~~--
.~·---- IJ!ftklct!r!'f
StGmach
'/- =;.:....<--'*- - , - - Right iddMY l r- - - - Abdominal
.,..-.....-7'::..._--ll'ai'IM!r:se
allan
•
Smllllntatile
(lejl.f!Lnund Oeun)
flO rill
Asandlng cdonv.4lh CII!CJm
..
A auslflc
B aaNifl~onofthubdomlnal•nd p411vfc org;ms by lawlll In this classlffcatlon !he organs ilre roughly .assigned to cr~nlocaudallevels based on their l'l!lationship to Ill~ tran!M!rse me.wcolon (upper arid lower abdominal org<~ns. see p. 1S9) ilrld l~ser pelvis (pdllfc organs). Bee<~ll!e lfle lc!dneys and .ildrenal glilrlds .ilre retroperltone;~l, IIley are not lined in the table. When lfle kidney Is projecll!d onto the abdominal wall, Its lnferlor pole extends Into lfle lower abdomen.
Bladder
andwnnlfonnl!PP81dk
c
Anterior layer: liver. trilnsverse colon, jejunum, Ileum. and bladder (for clarity not shown here, but shown Mth lfle olfler Urfn.ilry organs inc) b Middle I;Jyer. liver. duodenum, P41ncrst, spleen. ascending and descending colon, and uterus (not shown for clarity, extends Into lfle .ilnterlor layer) c Posterfor layer: great YeSsels,lcldneys, ureters, and supnrenal gl.arlds (for clanty, the bladder i$ shown in its nelation.ship to lfle olfler uri· Nry organs). ;a
l.-1
Upper abdomen (above the transwrse metOCOion)
• Stomach • Duodenum • Liver
• Gallbladder •nd biliary tract • Spleen • Pancras a.-rabdomen (between the tr<~nswrsemesocolon
and pelvlclnktplane) Las.. pelvis
• Small intestine (l!lldudlng the duodenum) • I.Jrge lntesUne (exdudlng the rectum) Noll!: The t1111nMrSe colon, while loated In the upper abdomen, Is
dasslfted fvnrtlon.illly as part of the lower •bdomen. • Blaclcler •Rectum • uteNs. f.illloplan tube, CMiry, and vagina • PortiOns of thews deferens. prostate. ilnd semlnaloland (the testis and epididymis
152
AbdomMfBttiFf!Ms - - l. Sptlcu
Ewphagus
Ollphi'I!JTI
Llwr
Stomldl l'lrlml pe!itaneun
TranswM mesocolon 'll
omemum
Oment.llburJa P.anc:re.as Abdom'nll D'bl
Duodenum Me54!11tery
l'lrtetal
per11D'H!um
b
,..,um a
lnt-'toneal Cfllll'l
le~Jm
b The mesentery consim of a band of connective tiPUe ("s111pensory ligament") covered by two layen of perltone\Jm. The mesenrery at· uchment to Ute orgar~ls continuous -with the vlsceral peritoneum•
C CSmlflmfgn of the ~bdclml111l ~nd pchk 11191• by their rela1fonshlp to tile pllfit.o1H!41m ~nd meHn1llry a Mldsagll:til section (kidneys outsldethesectlonal plane)llfewedfrom the left side. The pedt.oneum (shown lfl red) dMdes Ute abdomen
and pelvis intJ:t a ~us avity, tne perin:lneal cavity. and a con nee:· live-lissue space, tne extraperitoneal ~pace (forfunher subdivisions. see below; tne ilntl!rolilter;al porliofiS ofthe ex:traperttone;al space be· tween the partet:al and Vlsctral peritoneum conuln no orgons and are disregarded here). Nort.!: Cllnlally. the m:tum Is sometimes subdMded lntl:l an extraperitoneal fbred rectum and ;an lntr;aperltoneal mobile rectum (which may have a small mesentery). Surglc.-.1 procedures or1 the fixed rectum are less hazardous, as tney can be performed without opening the peritoneal cavity.
•md tne al:tichment to the body wall Is continuous With the parf· etal peritol'leum. The mesentery tr.lnsmits the neurcwaSCIIIar struc· tum that supply tile lnttaperltoneal organs •suspended• from It The presence of tne mesenll!fy causes tne fn!Tapl!rltoneof organs to hiM! greater mobility than ex:traperttoneal organs without a mesentery. N-rthelm, the intraperitoneal organs still m~intain a rei· at!vely constant position beause they are a!:tiched to the wall of the peritoneal c;Mty. &rmpf!dtDIIHI organs• are either embedded prtmarlly In tne connecUI/e tissue of Ute extraperitoneal space (prf· marily reb'operitrmeal) or they become att.lched secondan1y to the wall of tne peritoneal aYity by peritoneal fusion (secondarily rem.perltoneal). It Is only the fleldbnlty of tne ex:traperttone;rl conriKUve tissue that allows Utese organs (e.g.• tne rectum and bladder) to unde~o necessary chaDges In sW! and shape. ~ Altnough tne intraperin:lnealliver possesses a mesentery in the fonn of anterior arid postErlor peritoneal folds (ventral and dorsal mesenterle.s), Ute part of the IIYef !hat ls al:tiched to the diaphragm lacks a pelitone
• "£xtraperltonear occasionally refers to an o~an !hat Is not In contact with tne peritoneum when formed.
D Extr• and lntr8perttDneal org-
Exl. . and~'IPIItiOIIIIIOI'IIIIII lftftpa.-.....1
• In the abdominal perilionul cavity
• In the pelvic perltDneal cawlty
These org;~ns are completely OMred bv perttona~m and are attached bv a mesenllefyto lhe posterior wall ofthe perlblneal av1ty (lhe llwr and sblmach are also .ttached ID lhe anterior wall). • Stomach. small intestine (some of the superior part of the duodenum plus the jejunum and lltum). spleen,lrwr. and gallbladder; cecum With lhe wrmlform appendix (the oecum has a variable perttoneal cowling, and portions ofwnable size mav be retroper1tonea9; and lhe large Intestine (tr11nswrse colon and sigmOid colon) • Fundus and body ttl the uterus. the owrfes, and the fallopian tubes Tllae organs either lade a peritoneal CIMring (e.g., the lddn.,s) or are pi~rtlally CCM.-1
bv peritoneum (e.g.. the duodenum. plncnttS. and bladder). usually on theiranll!rior or superior surface; they do not have a .,_ntery. ~perlto.-1 (behind the peritoneal cavity) - Primarily rwvoperlto.-1 (al,_dy relnlperltoneal when fvrmed) - Secondarily retroperitoneal (enter the retroperftoneum during embryonic dewlopment) • lnfraperttoneal/ subperltoneal (below the pellloneal cawlty /bel-the peMc pentoneal c.wlty)
•
• ICidni!Y'> suprarenal glands (not lllslble here.lall!ral to this mldsagttt
• Duodenum (descending, horimntal and ascending (partial)); panaeas; ascending and descending mlon; NCtum up 10 the sacn~l flexure • Bladder and distal ureters. prosute, semlnalwslcle, uterine cervbl. wglna. and ..aum post the saaal flelcure
153
1.3
Peritoneal Relationships in the Abdomen and Pelvis: Overview and Anterior Abdominal Wall St!mum 1..11/o!r
E.sophagur.
B.n area of twr
Omentalfon~men H~strfc
ligament Omentalbl.nll
P
Stanacll
"'ddeccllcart8')' Transwrse mesoaion
l>.lrletal ~m
TlliMM!I'lle allon Cre;r~J!romentum
Co!llactrunk Spll!nk~andwin
I.A!ftn!Nial'llery SUpErior mesemtrlc .:111!ery I.A!ft~lven
Ptncreas (uncilm!pnxDJ}
Abclamlnalaoctt Duodenum. horiiOITUIIPirl Mesentl!ly
l>.lrleal perlta1eun Jejunum and Ileum
Rectui Mxiomh!s musde
Bladder
Va:sdefmn5 (ampulla}
LSvertellra I.A!ftcommonlllic
arteryandven
~c.JI
pouch 11«11Jm ~
Deep lr.lnmne P'!rilll!5ill
llulbosponglosus ml!lde S
A Dvl!nlttw of pmtoneal relatTomhlps In ttl~ abdomen and mal~ pelllfl•
Here The lowest part of the pel1toneal caVIty In the ftmale Is the~
Mldsagltt~l section (kidneys outs!~ the plane of section), viewed from
peritoneal ta1llty In the male Is the m:1:11!1esk:ol pouch. Blood. pus. ortu· mor cells may collect at ~t site as a result of lntr.Hbdomlnallnfla~ matton or neoplasia. In females, a fluid sample can be obtained fordragnD<'Itic analysi$ by passing ;a needle into the cuJ.c!H;Ic through the po$· teriorwgrnal fomlx. The female pelvis conto~lns in iddltlonal perlt:oneal fossa toea~ between the bladder and uterus: the narrowves!coutertne pouch (seep. 174).
thelelhlde. Thepa!toneo~lcavltylsbasle<~lly~dosedcavlty~tlsltned by p
154
W'rin~ pouch (known clinically as the cui-de-roc). The lowest part ol the
• Th~ following Illustrations present a sertes of dissections ~t progness!lll!ly trace the perttoneal1'1!1attonshlps through the perttoneal c:Mty to its PD<'Iteriorwall and into the ~erimneum.
AbdomMfBttiFf!Ms - - l. Sptlcu
Dllplngm
P
ll!lilmentofllwr ligamentum tl!m of llwr (v.1th pa-&~mbllul ~ns)
Tr.answrse
mea
ll'answ~se abdomlnus, ln!lemal,.;andexumal oblque muscles
lknblllcul
A~Wat~elrne
Redus abdomlnls mulde ~oreplg;Wtc arb!ryand~n
rltattrat llo~mt~~de
Deep lnglln.ll ring
~'
Obt1Jrator n~
Obtur.ltlr arteryandw'b
Bladder
8 Ptdtonell rel1ttorwhlpson tfu: postaionu~ofthe ;~bclomlnal wal Postenor surfaceoftheantl!rtor abdominal wall, VIewed from the poste· rioratpect. The peritDneum on the left side hat been remcwed to display the contellts of the peritone;~l fold$ (umbilical folds}. They al'l:! 1\:Hmed by ttle peritoneum that covers structures on the posterior surface of !he antl!riortrunkwall. The p;u1etoll peritoneum lying between !he folds raised by these sbrucbures fonms shallow deprrssions called fossae. PerltDneel folds (umblllr:al folds):
• One median umbilical fold: This is wflere the parietal peritoneum covers ttle median umblllc;rlllg;rment. which Is ttle oblltemed ura· chus (remnant of the allentols that Is obliteratEd during embi}'Oillc development). • /tlotr: Incomplete obliteration of the ur.achus may lead to umbilical fubulae In postnmlllfe. • Two medial umbllfcal folds: sites where the parfetoll peritoneum ON· ers !he umbilical artery (the portion of the artery 1Nt bealmes occluded at birth).
SUprli\Ge<~l
fo:aa
• Two lateral umbilical folds: sitl!s when! the parietal pefomneum usvcn the Inferior epigastric artery and vein. f.olch of the poiml umbi1'Jall o!U'ries consists of a proxim;~l patent part (wfllch gives rfse to the supertorveslcal artery and,lrl males. tile branch to the v.as deferens) and a distal ocduded part The UfiiXIlred umblllcol M!Tn ~usuallyoblll:er.rttdtofonmthellgamentum teres of the liver. PHttoneal fotule:
• ~supri1111!51calfossae • Two me
Note: The dHp Inguinal rfng (lntanallngulnal rlng) Is a structuralweork point In the abdominal wall which forms the enttance to the Inguinal canal. This canal ptovides a path for a path for the descer~t of the testis during normal development. but also creates a potential route for ttle herniation of abdominal viscera (Indirect lr~gulnal hernia).
155
1.4
Peritoneal Cavity: Dissections to Display the Abdominal Viscera
Ftldfo!m
IJ!ftbbe
ofiM!r
IIQiment ofiMI' llgamentum
uresollrwr Right lobe
Sllmldl
ofiMI'
IJ!ftcolc
&aft
Gallbladder
Tr.answne colon
'*'"---- TraruYenuubclomk115. ln~emiland~
obiiQuemwdu
i>-----,----,=="'=~------::-!----- Litf!r.ll umbltc;olfald
(w!l!llnfu'lar eplgastJ!c artJeryand~n)
~--~~------~~~~~~
Mxlon'tllls MUII:Ie
Araia121ine
Medlin umblliGII fdd (w!l!lcbllll!rated uractua)
A The gr&t.il!t' omenblm lnslb.r Antl!rlor llfew. The layers of the abdominal wall haYe been opened and mradl!!d tD display the gneatA!r omentum in its normal anatomical pt> sltlon. The greater omentum Is draped -the loops of small lntes· line, whldlire visible only it the Inferior border of the omentum. The greilter omentum Is an apron-like fold of per!tantllm suspended from lfle greaber curvature of the stDmadl and caveting lfle anterior surface of the trilmwrse colon. It develops from the embryonic dorsal meso· gi1U'Um, whlcfl becomes greatly enlarged to form 01 perll:ooe;rl SiC suspended from the greater cuMture (see p. 165). The gl'eilter omenl:\lm ~ relat!Wiy mlbne. ind ~subject to consldmble varlatfon. Not lnfre·
156
quently. adhesions form between the gre
AbdomMfBttiFf!Ms - - l. Sptscu
Tr..nSio'ei'Se ----';--:r-~
lne$OCOion
v.ith mlckleQllit
Aland\'lg -----+-~W' a~lon
.~----
ll$n$111!1'$U$ abdomtnus, illll!mal and ert.emal oblique mUides
~s-~:-----~~==~~~
abdomtris
mulde
.;....+,f-- .,...;.;.::__ _--::.....,...:,....- --4- - Medtal~.mblitalfald (Mth obltmtat ~.mblital artery)
Alwite line
Median umblik
(!Mth obi~ ur
8 Dtssedton wtth the gi'Ntlt!roml!fltum reftected 1upl!ftorty;md the smalllnteltfne lrt t1tu Antl!tiotview. The gtNteromentum has been reflected supefoorly, car· ryfng with It the tr.msverse colon. to demomtrate how the lntr~perlto· ne.;rl p;~rt of the small Intestine Is framed by the color1 segments. The 11lrn.M!IWmesocolon dMdes the perttor~eal cil\llty Into .a supraccllc p;1rt and an infr.acolic part (see 8, p.152). The large epithelial surface a~ of the perin:lneum is important clini· cally: • With bacterial inll!ttion (ca~ by external tr.luma or the seepage of septic material from ;m Inflamed appl!fldtx), pathogl!fllc micro-
organisms carl easily spread ~thlr1 the peritoneal cavity, wflere bacterial toldns are readily absorbed and canfed Into the bloodstream. As a result. bacterial peritonitis (lnfl.ammatlofl of the peritoneum) generally constlllltes a WI')' sel'fous and llfi!·threaU!nlng condition. • Localized inflammations ~ result in peritoneal adhesions and scar-tissue bands (see A). • The large surface area can be ulfllzed for pei11:onnl dkllysts In patients Mth renal failure: A dlaly$1s solut1or1 lnsillled Into the perttoneal c;Nitycan absorb waste products from the blood through the perin:lneum, allowing them to be remcwed from the body.
157
1.5
Peritoneal Cavity: Mesenteries and Drainage Spaces
~~~~~~~--~~--f---T~~
tolcn
Eil~t
_
__;:__,"4r-~ .;
mesocolon
~---- TIII'IMnUS~bdcmnU'I,
lnltmlll ~nd extern~~ obllquemuscles
f--~-¥.:,.......~.--~--=:!---1..1Ural umbllc.al fold
(wiiUlfer!or l!jl'lgastrlc artwyandwn)
Median -~-----'---=---..:,--:._;,~--,..;;:<---~.,.....j
umb11c.alfdd (,.,.th abl'b!nb!d ur.ldlus)
,....-H....,--+.-,----l.l:--~----;i--
Medal umbilical fold (wlthcblllltrated
umbilical artlery)
A OVI!nlttw cltfle metenteriel wttfl the greatrtr omentum
n:flected supcrforfy nd the smlllfr*ltlne n=mCM:d Anterior view. The tr;msvene color! ;md grull!f omentum have be\!!\ reflected superiorly ;md the lntrape!'ltoneal small Intestine hillS be\!!\ removed, leaving short stumps of jejunum and ileum. Three principal mesentl!rfes are distinguishable In relation to the small ~nd large lntes· line (the structure of the mesentery Is described or1 p.153): • The me:senlefyof the small Intestine (the mesenlefy proper) • The tr~nsverse me.socolor1 • The sigmoid mesocolor1 (called ~lso the mesosigmoid, seeD, p. 163) The origins of the me.sentenes are shown In B. Smaller mesemrrtes are found Ofl the vermiform append be (-ppenr6Jr) and rarely the upper part of the rectum(~. $ee(). B Pro)KUar1 cltfle rne54!ntl!t1t roots onto the skeletor1
158
AbdomMfBttiFf!Ms - - l. Sptscu
Right lobe
H~rtric
oiiM!r
llgameat
IJ!ftlobe of I !Yet
Spl~
~JI!l!IH''---- 91Str!csurface
l.essefomemun, heJ)ItOduodl!nll
"!E~~~:ir.rtf--- GMW!pll!!'icllgament
l~ment
Omo!ntllforamen - - -1-1!
~.----.--~!Jt-,..:..,~.-1.!+---- l>.lnc-(body)
Duodenum, - - -.......\' superior p;rt
Stamach,PV!orlcpart - - ---'!i'ti CA1rtl!romentum - - --'-\'" RJ~hlc<~licbre
-----;r;-
~-rsecolon
.~---- ~MWRusabdomlnus, ~IMICIClCtlem~l
oblique musdes
R.ect111abdomln!J mUlde
i----'==="c:i':~:-----:::!i-- Lmfal~.mbiiiGII fold (Y.1thlnferfor~2lt!lc
- -:-- - - - --+--..,---;.-
art2ry and vein)
M~an-~---------~~-~--~~
c
:7--f-,1----i,.,...,--:-"'--:-------~- Medllll~.mbllicllfold
~.mblllalfold
(I'Aih oblttnted
(YAth obllb!r.lttd urac:llw)
umbllicllarttry)
OVI!nltew oltfle ll'llelll!!nt:ll!ries• Wltfl the grelter omentum
rcmCM:d Ant2rlor view. The mesenteries hawoe been exposed by removing the stomKh, Jefunum, .ilnd Ileum, leillllng short stumps of small lnt251fne. The liwr has been l'l!fledl!d superiorly to display ane p.1rt of the lwer omentum: the hepatodutldenalllgament, whkh connects the liver to the pylorus and duodenum. The other p.1rt of the lesser omentum, the hep.atogastrlc II!J.ilment (perltolleal fold between the liVer .ilnd lesser curvature af the stomKh), has been removed with the stomach. apen· ing the anteri~r wall of ttle omenti!l burs.il. M05t of the tr.lnsverw colon and sigmoid colon have been removed to display the 1'0013 oftile trans· verse mesocolon ;md sigmoid mesooolon. NotJ!: The ascendrng and desandlng aJon be
CDJon became fused to the po.sterior wall af the peritoneal C.iiVity. The froll.l'lm'e' mesocolon crosses over ttle duodenum, whose mesentery ilso fuses to the posterior Will of the per1toneo~l cavity during embryonic development (seep. 179). The trinsverse mesocolon necessarily passe.soverthis •retroperitoneal porticm• of the duodenum because of IU ittachment to the poJtmor w.~ll of the peritoneal c.Mt:y (see also J, p. 161 ). Dew!opmentilly. almost all of the mesent2ries ire dorsol mesenteries. Only upper abdominal organs II lei! the stom<~ch .ilnd lr~r have 'III!JittfJ/ mesenterie.s.
• "Mesentefy"' In tile broad sense refers to any of the peritoneal folds ittolched to the small ind large lnte5tlne. "Mesentery" rn Ute s!Jfct sense refen speclffcally to the me.sentery of the jejunum and Ileum, ~nd COrl'le
159
1.6
Peritoneal Cavity: Peritoneal Relationships and Recesses on the Posterior Abdominal Wall Pa~d:ll p~1111
Hepatic surnte ofdliph111!1m
Hej);jtlc veins
l'lfellor \'II!Oi(;MJ
Cudlile
Rlghtsupr.~n!NI
I.Aoftsupnrenalgland
gland ~enlc
Hep;Jt!)Wodeniil lg;ment (!Mlh portal win, proper hep;lllc: .:lltl!ly, and Olmmon
lg;ment ~--l!lfJl!---- Splenic arteryindwn
bUewrt) ---~-::ITT"----
Rl!Jhtldctley _ __,
Pancrus (boctf.andtaiO
~~*---ll'answn;emesocolan
(root) .::J~=~i'-.,--- I.Aoftalllcartery<~ndwln
Duodenum, - --.."-' dl'Sandlngpart
>f-....U...:-----steof.atlactlmentof dtsa!ndng colan
Pa~(h~--....J...
~~~~'----;~~.------SUperior~
.:lltl!l'y.andwln
Duodenum, asanclingpart
- ---:- +.-
o:r.l:!!!!:l!:::--=--!!:::;---;:!::::-+......;.- - lnfu!armesen11erlc .:lltJ!I'y
v-'--ll'answrsusabdomlnus.
AbdomlnalliO!tl - -----:d
\rtemil indextemal
oblique mU5Cies ll.T-~-
Rlghtcommonlhc - --:--.:lltl!ly.andwln Slteofattao:hrnent ohsandlng .:dan Ml'Soappf!llclllt
....:::.;..
Par.lalicgultl!r
,. .__:~=---....l..~t---..£1-'--___;,....---
Parlrtil peritoneum
- ---+- - - -
---T------4~=-----...;;;s;;
~b--""""'-;E-~;-----+-- I.Aoftun!l;!t
Rlghtureller - -+-- - - - - -....;:......,:mil
~~:.._-~=----+--
Elr:tlemalllac irtely
f-- ....,.-:::::-:-- --3::--- --+ltedusabdamlnls muscle
~lumbllial
fold {I'Alh lnfetlor ~pl;&'ltlfc artery
- -+- - - - -+-- -:----
~ndwln)
M~lio-~----~~~~-~~-~~~-1
umbilt.ll fold (wllhobOta'illl'd unu:tua)
A Pmtor~eal rellt'lanlhlps on tfle posterior wall ofthe perftonell c.ntty Anterior view of the opened thorax and abdomen. All oftfle lntraperltoneil organs have been rem DYed mdisplay the retroperltoneum {retroperltone<~l space). The posterior wall of the peritoneal cavity ilso forms the antl!rlorwall of the retroperltDneum. Unlllaethe antl!rlorwall of1be peritl:lneal «Vity, which consim largely of muKin and fi'ciae, much of the postertorwallls formed by1beorgans In the rettoperltoneum, which irevlslblethrough the p;u1etal peritoneum In this dlssec:tfon. For clarity, the l'l!treperttoneal conD«ttlle tissue and fat have been thinned out m dispi;Jy the coulle of ttle retroperitoneal ve~els and the ureter (where It crosses In front of the llli1Cvessds; see A. p. 162). The hepatic surfice
160
d the diaphragm rs devoid of perftolll!um and ccrresponds to the b.ane area of the liver. The ascending and descending colon (remiM!d hen! fordarlty}areattadted byconnedlvetbsuetothe posterior mil of the peritoneal avtty, so they ire also located In the netroperitoneum {see C. p. 159).1n this spedman, the area of attachment of the ascending colon extends further inh!rioriy m the pelvis than usLJal. The transverse mesocolon, like 1be transverse colon, Is located antenor to the duodenum (I.e., Is lntr.-aperttooo.1l). The mlgr.-atlor1 of these organs during embryonic development Is described Ofl p. 181. The sigmoid mesocolon crosses anterior to the left lilac vessels and left ureCJ!r.
Hopoloduodn -~,..+. llgomentwllh pc>ralwn. praperhepollc>rt2fy,
.,d commGR bdf d.lct
Anllllmitll pOSition
ahlgmalda:olon
I l'l!rtblneill mnrlngs of the cbldenum ilnd pnc:rt!lll!l Anttrior view. This d~gram shows how the root of the tran~e mesocolon crosses CMI' the desC21'1dlng part of the duodenum and the pane""' (both ofwhich are secondarily retroperitonN 1).
HopotOduoclenil l111mont IUghtlcld"fV D~l'llm
C Pasldon afthe iilgmakl metOCDion ilndiiiDnlllmold remss
The sigmoid colon has been ~Nrtlally removed (left) or reflected superiorly w1tf1 the sigmoid mesocolon (right). The left ureter descends through the inttrsigmoid receu in the retroperitoneum.
----l·-4-- Sploon
, .---+----.-!-- Lift ldmfV Suporlor
ducldl!nll ,._., Sill! of atbdlmentaf ...andlng cdon
-.J/t.~d~~-;t-- lnieftGr
duadenalre<2U
- -
Subhepollc
~bph11nk
-+H'+-- S~dlttadmlent of..._nding..., Pirot:olk,.,U.
SI!Jnald
me:SGa~lc>n
(root)
IUght ~lc gu~r
Right tlframlc space
D RIKwHIIn lh• pwtMtor-11 ofthl perftoiiNI uvtty ~rior view ot a malr abdomtn and pelvis.
The perttDneum forms remssesor sukl at some sites between the organs (see also land C). In a sense, the omental bursa may be considered the largest reass In the perttDneal cavity (see p. l64). Noa>: The individwl ~~- ~~ loca~ between organs or between an orgiln and the Willi of the peritonul cavity. Freely mobile
bowel loops may become entrilpped In these recesses {"Internal hernia"), hampering the passage of materlill through the small Intestine and potll!!ntlally causing allfe-threatelllng bowel obstruction ("mechaniCilllleus").
Lift lnfrocalk: space
E DrilllagclspKB with~ the pelttDnYI cnlty
Anl:el1or view. The 1m1ngement of the mesent.rtc roots ind sltas of Gf!P n attachment create partlilly bounded spa~ (receues onulcl) wlthln the per1tonHI callfty. PerltonHI fluid rele
161
1.7
The Retroperitoneum and Its Contents
Right
kidney
Spleen
Ascending
Transwn:e
colon
colon
A Tnnsperftllneal'llfew of tfle reCJ'opefftoneum Ann!ri~rview. The intraperitoneal org~ns hiM!
been ranoved excqrt for the spleen and a small part of the tr.msverse colon. The retroperi!ZMleal descending colon has .also been remiM!d. The connective ti$$ue ~nd f.lt in the retroperlt:ooeum are of normal volume In this dissection. The kidneys form In the retroperf· toneum durlr~g l!mbryonlc development and are embedded in the netropetitoneal fat and conne<:ttve tiJSue. Thus the kidneys, like the gre.rtveJSels, are obscuned bytheanterlorwall of the retroperltoneum and are VIsible only as
bulges behind the parietal peritoneum. Add!· tionally, the prerenallayer of the renal fascia is Interposed ~the kidneys arid the pari· et.11 paltone\lm (seep. 226). Beca~~Se the pan· cre.as Is secondarily retroperitoneal, It Is not fully integratl!d into the retroperitoneal fat and connective tissue. Being atUched to the po~ terlor w.~ll ofthe peritoneal CJII!ty "only" byfu. slon of the peritoneal layers, the pancreas can be seen with much greatef' darity. Although Its anterior surface Is ccr.-ered by peritoneum. ~t layer Is more translucent than the retroperitoneal connec:Uve tissue and f.tt.
Plimor!ly~l
S«om:laliJy~ • P\ancreas
• Duodenum: descending and horiZ~~ntal parts. some of the ascmdlng part • As«ndlng and descending colon • 'hrlable: portions of the aecum
• Rectum to the ~era! flexure
162
Zone 1: centr.ill netroperttoneum wtth the duodenum arid greatwssels Zone 2: left ;and right fl;ank ll!gioru with the kldneys,urders.ascendlngcolon,arlddescen~
lng colon (omitted here to give a dearer VIew of the other org.ans) Zone 3: pelvic ll!gion (corruponding to the hypogilrtrlum) with the bladder, dlst.11 uretErs, rectum, and Internal genitalia
CJI1InS (or e:xtr.~peritonul): • Right and left kidneys • Right ;and leftsupruenalglands • Right and leftu11!11!n
C ZoiiK of tfle n!tnlperftDneum (after von Lmz .ilrld W.achsmuth) The retrvperitoneum, like other body cavi· ties, can be divided Into zones based on dlnlcal crtll!rla. This type of classlffcatlon Is useful for evaluating what org.aM m.ay be jointly af· fected by dise~e or injury due to their p-· lmlty t» each other, even If they belong to en· tlrely different functional systems. The retroperiiZIIleum Is dMded Into three zones:
• Aorta (abdominal part) and Its branches • lnfertorveRa~and Its tributaries • Asandlng lum~r-..elns
• P
• Branc:hesofthe lumbar plexus (IIIOhypog;lrtrfc,
Ilioinguinal, genltlm!maral,lateral femoral cutaneous. femoral. and abiiJratori'M!n'I!S)
• Sympathetlctrunk • Autllnomicgangr~~t and plelcuses
AbdomMfBttiFf!Ms - - l. Sptlcu
S~3UPr.ln!nll
Cellae
trunk
Esophlgus
~rtl!ryandwln
Left!j~L!ttfc
-l)'anclveln LeftSI,JHllrenllglllld Splenic ~rtely
Common bllecllct
hnasl~
Submstal ni!M!
Left~
S~me54!1'Mrit
-IY<~nclveln
artery and win Left lcktw!y Duotlenum
Left ureter
lliohypogil!ilricllt!M Left ovarian -l)'anclveln
lfalngl.fn.al ni!M!
Abdomln~l
Aartft blluratlon
Right ovarian arteryandw'h
tlferfarm-r!c -ryanclveln
Rlghtcommonlrac artl!ly.andYI!In
Genllmmoral n~!~'¥~!
lier.ll femor.al
cutaneousSigmoid
l'
me'JOallan
perltone\lm
Slgmoldmlon
Rlghtextltmallllac
UIJ!M
(fundus)
Femonll.-
Bladder
D Ovenff!Woftfleretropern-um Antzriot view of a female abdomen aoo pehlis. The mesenteries and fntt~perltooe<~l organJ have been re!TICIVed except for the sigmoid co·
ron and Internal genitalia. Most of the pal1et11 peritoneum hilS been removed, aoo the retroperitone;~f fat ilnd connective tlssue have been af· mostcompfetefyremoved. Thestumpoftheesophagushasbeendrawn
slightly Inferiorly to ptoYide an anatomkallandmark. Norr. Some of tile retroperitoneal organs ilre fully Integrated In that space, h.Mng fonmed In the retroperl!Oneum: the kidneys. suprarenal
glands, great vesSI!Is, and ne!VI!S. Other structiJres form In the peritoneal c.111ity and migrate to the retroperitoneum secondarily (the pan· CttiiJ and duodenum, see 1). Thefr vfscer~l per!tone\lm becomes fused to the parfetilf peritoneum of the posterior w.rll. and !hey retain a peri· tone.ilf cOWifng on tnelr antzrfor surt.lce. The prtmary retroperitoneal organs do not have a peritoneal cowring because they are fully integrated Into the retroperftone.il
163
1.8
Omental Bursa
Glllbllddor
omental bu..a Gelnlc:Dik: llgonwd:
A Slwpeand lacalfan afhomental buruln ugntai!IIKtlan Left lmnl vlew. The oment.ll bursa Is the largest potential spa~ In the perllxlneal Cilvlty. It Is loCilred behind the lesser omentllm ilnd stom· idl. N~: AJ the IIDmach rotatzs during embryonic di!VI!!Iopment, the omental burA comes to lie posterior to the stomKh. The pancJ'Ns, which mlgrms Into the retropaftoneum secondarily, thus forms part ofthe posrerlorwall ofthe bursa, which plllllldiH il roure for gaining surgicaliaeu to that organ. AJ the stomach rDbb!s in the dodwiJe di· ~ction (vi~ from the front), itlla- curvatul'l! points to the right and ilso superiorly, simultaneously dlspladng the ll¥er superiorly
•
Bodyof
Cutedg~fA
~""',_
gi$1J'O(OIIc ligament
c..-r
Transwne
GITW1tum
mHOCIIIon
51*nlc rKaa of
Vesllbue d Diaphragm
omental bu..a
am~l buna
I lound.tu ofh oment411 IKIIH Ante1or
lesser omentum, gastrocolic llg:ament
l'llstariar
Pancreas, aorta (abdominal part), miJ.c trunk, splenic artery and vein, gasti'OjNncreatlc fold, left sup11renal gland, superior pole fA ll!ft kid...,
Superior
I..IW!r (With audare lobe), suptrior reass of omental bursa
lrArlor
Tran_,. rnaocolon, lrArlor,.... of .......tal bursa
'--ft:
Spleen. gasb'OSplenic ligament . .splenic rla!SS m ornenCII buna
Right
I..IW!r, duodenal bulb
C SUrtkill ipproadles to the omenul b&ni (see A}
• Through the omental foramen (nalllrool ope11lng, see E)
m
• lletwMn !he gruter curvature the stomach and !he lnlnsverse ClOIDn lh IVugh the gasbvcollc ligament • T1vDugh the tranftlel1e ITieiiDClDian . . .elool.atlng the tr----
colon (lnfenor :approK/1) • 11etween !he lesser curvalllrl of the stomach and the IMr (through !he lesMr omentum) • fnlm the greatJer cuMillreof!he stomach .,._clivision fA the grealleromentum
164
b
lnf
Hepatoliloclenal
omental bu..a
tgament
D Omental burs~, •nterforllfew
a Boundirtes of the omental bursa, also the shipe ind IOCiltfon mthe gmJkbed. b structu r. of the post2rfor VQJI of the omenbl bursa.
AbdomMfBttiFf!Ms - - l. Sptlcu
GMtro.!p!eric ligament Galblld6er IJ!ftQ&rtlic:~rtl!ry
IJ!ftsuprlll'l!l'llllglllnd
VesUIHJecf om~lburu
AITowlflwgh omo!nt!l lOra me> C4mmon h~lcartl!ry
I.M!r, rlg1t lobe
Duodenul'\
d~ngp;Jrt
Rlghtlddney
Right a~lc llexun!
~ndklgo:olon
IJ!ftlddney, superior pole Splericartl!ly Spleel\ Cehctrunk Plnnklxllllc llg1m1!11t
llocttof p.ana'SI T!111'1WeM mesoa>~on
MlcldeOlUc 1rt«y lind vein Galb'oclollc: ligament 'n\lnwe1'14!o:olon Daaendlng colcn
G1'9t!er omentlm
E Omermrl burs;a In die upper ;~bdamen Antl!rlor llfew. The gastrocolrc ligament hillS been dllllded, !he smmach h
r.al orlftce of the omentill bursa {opens posterior to the hepatoduodenal ligament). The WS!fbule of!he omental bursa lies just past the foramen and forms the initi;llportion of the burs;a c;aYity.
F TnniiVI!I'V SKU on through the omentlll bursa Sdlematic section through !he abdomen at the T 12/ L1 lew!, vii!WI!d from;rbove. NorJ! the walls ;rnd nec6ses thilt nesultfrom the formation of !he bursa durfngUie embryonic rot;rtton ofthe stomach. Bec;awe the Initial upper right portion of the embryonic body cavity moves po.steriorly as part of !he 90' rot;rtton of!he stoma ell, structures that were formaly posterfor (spleen) move to the left side wfllle structures that were formerly ante· rfor (IIIIer) mOYe to the rfght side. Rece.sses In the omernal bursa extend close to these OI'!J'IRl (see B).
165
1.9
Transverse Sections through the Abdomen
S91edt artery
Falctfonn ll§ilment ofllwr
Common ht!p;rtft artay
I.M!r,
I.M!r.
left lobe
r'Jghtlobe Glllblldder
Olaptmagn, CQStalpMt
FOotUIWin Stom~eh
lnfu!or
wnaewa
Left supra11!11al gland
Right supnnn~l
gland
Wtc:otic: flwl~
Dllphn~gm,
aiSUI part
Spleen
WI: kidney
t.unbilr ~node (p~l
Vertebr.JI tan II
wltlupbii
A Tnrwvenesedfontlnughth~lbdomcnlttheleftlofth~T1Z vertebral body VIewed from .ilbOYe. Not~! the anatomiul extent of the liwt'. The single heaviest organ in the body, the liwr oc:tupiu most of the right upper .ilbdomen .ilnd also ex· tends Into the left upper ibdomen it this level. The hepatoduoden;ll ligament COirt.illns the portal vein, bile docts. and hepatic ;uterles. The hepaticVI!ins(notvisible in the S«tion) leave the IM!rin the •b.ireal'l!a,• wfllch lsout5fdrthe surface covered by peritoneum. The dose prolllmlty ofthestomachandspleen reiultsfromthedevelopmentofthelrverand stomach: Embryologically, !he spleen forms postelfor to the rtomi!dl In the dol'$al mesogastrium. As the stomach rot.rtl!s, the spleen moves into the left upper abdomen. the quadrant toward which the fundus ;md greater curv.rture of the rotated stomach ire directed. In the sec-
166
T 12 vertebrl
Abdominal aorta
tton shown abc~Ye. the left colic flexure ocaJpies an unusually pomrior location (normal anatomical wrtatlon). Because the section through the flexure Is slightly oblique, the ascending part (from the tr.an.svel'$e colon) and the descendirlg part (m the descending colon) are inCXlm· pletely $4!J).ilrated, creating the appe;~rance of .il unifoi1Tl wbe. The fal· clform lrgament of the llvef Is derived from the ventral mesentery. The levelthatmortorgansoccupylntheboclylsdependentonage. poswre. constitutional type. nutrttlonal rtate. .ilnd position of the diaphragm In the breathing cyde. Thus. a transverse section it a cemtn lem Is apt to s"- consldl!rabk I'OrlcrtSon, espedally In the organs that just border the sectional plane. The section above p.i!Sses through the left lddney (and left iuprarenal gland). The right kidney, which Is lower because of the IM!r, lin below the plane of wction. Its po$ition can be infen'ed, however. from the location ofthe right suprarenal gland. wfltch Is cut by the section.
AbdomMfBttiFf!Ms - - l. Sptlcu
lntlemal thor~IC
artery
mwin DLIIlderu.m
lt.lnswne Gllan
Greaur
cnv:rnum
Gall bll ddl!r
Stomach
LM!f,
11ghtlobe lnti!nct
Postl!rfor
wall
WNGMI
lnten:ost.11 a~Uy,w'h,
Omer1tll burn
andne~W I~ lite
Splet'icwln
h.mbar lymph ..odes
Pancnz
Rl¢t suprannal gland
Spleen
KldM)I
(wll!lr1ght renalartl!r)l)
Tn1nswne } Left Gllon Ollie fluure Daaendlng colcn
Llltl!rllllumbar lymph node
8 TnnJVCne section tfnvugh thnbdomcn •the level oftfu: L1 vertebnl body VIewed from below. Noflt the position of the omental bcJrsa. It extznlh tD the left to the g;~5Wsp1C!Ilic ligament. which fWms the left bounci;lry of the omen· tal burs;r. During embryonic rot
the splenk recess. The omental burw runs along the full length of the posterior stom ce~lon r'e$Uits from the level of the sec· tlon: the CCiflnectlng part lies outside the sectional plane. Both kidneys ire ttinsected itthis lew!.
167
1.10
Peritoneal Relationships and Pelvic Spaces: Comparison
of Coronal and Parasaglttal Sections In the Male and Female Subdlvlllan fllthal-r pelvis br lp.ICIIIm!d fiKM s,_,:The le_. peMs mnslsts of two SJN~:the peMcpelftDneDJCJNIty and the peMc ~rvl~The extnperftone;~l SJN~ Is further divided by the leYator ani musdelnto an upper and 1_. JNrt (defining the three levels of the lesser pelvis, see 1}. It Is oa:upled by mnnedlve tissue ofvar1able dtnslty and c.an be.wbdMded topographically (based on Its relitionshlp to the pl!ritoneum and pelvk w.~ll) Into three smaller SJNC21: • Relrolngulnalspact: below the periiDneum and behind the Inguinal region • Retropubic SJNce: b~n the bbdder and pubic symphysis • RelroperftonealspKt: between the peritoneum and sacrum (contfnu.atlon of the retroper1toneum of the abdomen) F~r. The pdvlc (osdo consists of pal'iehll fascia (covering the structures of the pelvic w.ll) and vlscenl fascli (covering the pelvic organs).
Bladder
The amMdiw tlssw of the Ylscmll {osdo Is thklaened at sites between and around the organs and Is condnuous with the adwntft~ orca psull!! of the pelvic org;ms: • Rectoprost3tlc fascli: reac-sk<~l septum (m.llle pelvis, located t. ~the rectvm and bladder) • R«tovaglnill t.cll: rectDYigll'llll septum (famle pelvis, loc.ated t. tween the rectvm and vagil'lll) The a~~~nectM !#ssw around the CJ190ns Is also thlclaened i nd generally transmits the neurovasa.llar bundles 1Nt supply the organs. • Lateral rect.o~lligament
• l..ateri lllgilment of the bladder • PUbaveslallar llgamem:
• Tromsverse cervical ligament
Per1tonei.IT1, pa'imllayer
I
---~dmrms
.
___... Supertorbor::la
• •• ~
ctpelvlc
d•phrogm
LPimr•nl - - -
~0~~~ memlnn~
a
Bulb of peols OVs of peris pi.Oic ramus 1 The th'ee le¥elt of the pelvis Anterior vi- of 1 posterior coron1l section tNt passes through the lower part of the rectvm. Notl!: The periiDneum 1nd le'llltor1nl muscle divide the pelvis Into three lewis (see C). The rectum subdivides level$ II and Ill into left and right hillves. The uretErs are retroperitoneal.
.
...
,..._~
~~~;~ ,_~~-
/I
Superlorfadlof -
pelvlcdlophrogm
--
lnfertarladaof pelvic daphrogm
muscle
umhr•
lsd!loanal
PeriiDneal
~::1
\
---
Spl'lne11et'
"
~--- l..ovlrtDnnl
../
~
• Coils of ileum • Vennlfonn ippendiX • Sigmoid calon
ml
mombrane
Suporfldal perineol fadl
II SubperttonHiml
• Distal ureters •
lntlmlllllaurtl!ry<~ndwln
wllh vlsaril and JNrleb I
ani muscle
.-CIS"'
A l'w!rttm.1l relltlonlhlpl, fad8-. md tile pelvis • Male pelvis, antfrior ~ ah caronal Hdian tilted slightly forward. This section displays the peritoneum, fasciae, and connective-tissue spacts around the bladder and prust.ate. b Female pelvis, anterior llfew of a corONI section tilted slightly badcWllrd. This section displays the peritoneum, ~iae. and connectitls.we spaces around the ulilNiand vagina.
Extr1perttonnl, allcMihel.wtur
br~ndles
• Obtur.llllr 1rtay and win • Obturator nerw
• s..:..lplooua
-
• lnlw1or hypogastric plelws II
Pellneum
•
~
pudendal.-ry and
• Plldendillnerw ind Its brandies
168
AbdomMfBttiFf!Ms - - l. Sptscu
D
Perftc~ne;~l rel~ttonshlps In the m~le
peMs
section, Yii!Wl!d from the right side. The pl~ne of section Is slightly later~! to tile medl;m plane so that midline structures are also displayed. For clarity, most of the connecUve tissue In tile peMc ex.traperttoneal space has been remiM!d. This ac:counU for the apparattly •empty• spaces bei.Weal the organs. NcltJ! the relationship of the rectum to tile pelP~rasagittal
vitflo~:~r ;and bl;oclder: Bei.Weallhe bi;!C!der and
rectum Is the generally shallow rectove:slc~l pouch,¥>ilosespedflcshapeanddepthdepend on the degree of dlstl!ntfon of tile bladder and rectum. The lower portions of the rectum and tile connective tissue around the rectiJm (not shown here) are supported by the pelvic dla· phragm (chiefly the levator ani m111de). The bladder is shown here ill a distznded state so that the supmymphyleal part of the bladder not COIII!red by peritoneum c~n be seen (this part of the bladder Is tilrgeted In a suprapubic bladder aspiration, which is performed with a full bladder to iVOid perito!le.ll InJury; see ~bo ~mahnal
~lundon
sphlneu<
ofpe~tne~.~m
flldtt
Recto· p10$M!ctaosda
p.234).
51Qmold meiOCdon
R.otlld
ligament of
uterus
Ve!lcoUIBt!e pouch
PeriiXI neal
ofn!Cilm
E Perttonelll'l!latTonshlps 11'1 tflefem1le
IJ!Witor
ani mulde
£xbmil anal sphlncta'
Peinul
\lagllli
pehlf1 Parasaglttal section, viewed from the rtght side. For clartty, most of the connecttYe tissue has again been removed from the pelvic extra· peritor~NI space. The em
body
169
1.11
Peritoneal Relationships and Pelvic Spaces: Comparison of Midsagittal Sections in the Male and Female A Vlla!t1llfuc:Tae Tn the m1le pii!Ma ~-...,-'~..:..:>;;.---
Mkbiigltt
Slgmcld me:soa.lon Slgmold allan
~----'-----''----'-7--- lle
pouch
Rl!lroperitonal
-,-_...,-=--::--
C.ntr.lltltndan ____
of p«rtlet.rn
AKILm
mage.
~ul
pouch
R.ect\Jm
Ptblc~
ll!tropublc space lle
Suspensay II~ of penis Pl!nle fa5da
Corpus c:;wemo.sum of penis
Sphincter
sepblm Ampulla of -defen!ns
pBiJbourethral gland
lftlhrn
C;xpur.spongloSim of penis
Bulbcupanglccus muscle
Scrotal Sl!j)t1m
8 Pftflllneal n!liltklnsHps In tile male pelwts Mldsilglttalsectlon, VIewed from the left side. The bulbourethral gland has been displaced slightly medially to show JU position In !he sphlnc· ter u~rae musde. The peritoneum is reftected from the ~nteri~r wall ofthe peritoneal CiiYltyonto the upper surf.-ace of the bl.-adder. The bladder In ttlIs section Is shown In a distended state. Wilen ttle bladder Is empty, 1t Is CDnslderably smaller and lies behind ttle pubic symphysis.
170
The surf.rce of the empty bladder .-also bears a nnsvene crease, the tr.ilnswne ve.skal fold. Postl!l1orty, ttle pe!'ltoneum Is reflected from ttle bladder surf.rce onm ttle anterior wall of ttle redl.lm, forming a small reocess termed the ~ctOYe$ital pouch. The peritoneum d~ not extl!nd to the prostrte. The rectoveJical pouch Is the lowest part of the male peritoneal CiMty.
AbdomMfBttiFf!Ms - - l. Sptscu
C 'VIK:Ier~llfud~e Tn the fan~lle pclvb Mldsagll:t11 section. viewed from the left side. As In the male peMs, tile pelvic ex:trapern:oneal space conbins fasciae and ~ that deta'mlne the boundarfn of faKial sp;~ce. The spedllc spatial relationships are altered relattlle to the male. howeftr by the presence of the utenJS, which is inb!tposed between the blildder and rectum (see D). The f.lllcial spa= are greatly distorted durlng labor and dellmy as the connective &sues surrounding the organs are compressed by the piSsage of the f~ tus through the birth canal.
.--...,......_.;.....,.......,..;.,+-.;-- - Ldtcommonlllac lll'tlt
Right~
Miac:al'tl!ryandw!n Rec:lllsabdamln\1 musde ~r!nefundUi
Round= ~ne
Plr!eul
pouch (aJ-
pu1llanwm \'ie.s~nepouch
- - - -+ -¥----;;=-;:-,..,..-;o;,--=-'?''-·
B~~---------~~~ ~~c----~--~-
l)'mphy$1S
vag1na
---~-:------::-#'::......:--+--;:v
~Md~s----~~--~pj·~~ ~~.£.=------...,~--
D P'llrttone.JirelatTorwhlps In the nmale peMJ Midsagittal section, viewed from the left side. The small and large lntes· Une have been rern011ed el(Uptforthe sigmoid colon and rectum. NofJI: In the female. the uterus and its ligaments are interposed be· !:Weal the bladder and rectum. This alters the peritoneal relationships In a dlaractertstfc way compared with tile male pelvfs. The periton~m Is reflected from the anb!rlorwall ofthe peritoneal Glllfty onto the blad· der surface as in the male, but from then! it is reffecb!d antothe anterior wall of the uterus. Because the uteM typically occupies an antdlexed andinteverted posltlonontheblildcler(seep.251). the perll:olleum be·
£lttJ!mal anal sphincter
tween the bladder and uteM forms a deep but narTOW recess. the wnThe reflection of the peritoneum from the posterior wall of the utenJs onto the anb!rtor wall of tile rectum f'ornu a second recess. the ~ne pouch (lcnc:lwn dinically as the cuf-de-liClC). This pouch Is tile lowest p;1rt of tile female perltone
171
1.12
Peritoneal Relationships and Spaces in the Male Pelvis
llwm
T111MMIW
w.slalfokl
l>.lrtetJI ----=.-~
perttones.m
Medlal~.mbilia.a fold ltedus (!Mth undeey!ngOOI~ llbdon'inl5 mUJde umblllalartey}
A PIN1'tone~l n!llt'lanlhlps In tile mile lesser peMs Ann!rosuperiorview.loop.$ of sm;all ini!!Stine and p~rti~ns ~f the colon hive been retr;u:ted li!terally ~nd pcmerlorly to demonstJ~te the blild· der ;md rectum. No!Je: The p.artetal peritoneum on the antl!rtor abdominal w.~ll Is ...,_ fleeted onto the surfaa of the bla&:ler. It forms a lranslll!rse aeate in
172
the empty bladder, the transvene veslc:al fold, which Is eff.aced wben the bladder is full. The vn deferens, which p.a$$1!$ through tne ;ant!!rior wall via the Inguinal canal, Is also COYered by parietal peritoneum In this ireill. The peritoneum between !he bladder and rectum Is deepened Into a cavity, the rectcveslc-.1 pouch.
AbdomMfBttiFf!Ms - - l. 5pac:u
ulilnlaMI lymph nodes
-
Abdamln~l
lltedlll'l s.t~CRialtl!ry
Superior rectlliltl!ry ,.-,-----Sigmoid .:llt!f!K
llailgulnal ni!M!
Middle rertal al't!ly
Medlll'l umbllc.ll fold (with ui'Kieriytlg
obltlilnted untdlus)
B P~Httone~l relatTonshlps 11'1 tile male lesser pelwll Ant!!rosuperior view. The sigmoid colon hn been netracted lmrally. In contrast tD A. the peritoneum over the sigmoid mesocolon, rectum, bladder. and the !)05t2rfor ;md lateral peMc walls his been partially removed to expose the uflderlylng structures. Lymph nodes and .iluto· nomic neNe plexuses are shown schematically for clarity.
I~
l..atelalumblrc.llfold (\01111 unclef¥ng ln~rlot
ej)f~Mteryand\'Cin}
Medial umbllcus fdd
Rectus (with underiyfng Zldomtlls muscle oblltermd umbllc.ll Mtery)
Noll!theslte'Wheretheureten pass lnfrontofthe llr.ilcvesseh. Thlscre-
Jtes a constricted a neil in 'Which rem I stones m;y become lodged while passll'lg down the uretl!r. This crossing site Is one of three anat!Xnlcal cons!Jfctfons of the uretl!r (seep. 233).
173
1.13
Peritoneal Relationships and Spaces in the Female Pelvis
r.llopiln tl.lbe
Sigmoid colon
Rlound
lig!ment of uterus
Mecllan umblical fcld (\111111 cblltltrated uradua)
A PH1'tone1l rellt'lanlhlps In tile fiemal~ IKset' pelwll Ann!rosuperior view. Th~ p;~rieto~l peritoneum of tnt- ~ntl!rior ~bdomin;~l wall Is reflected onto tfte bladder and ttl en Is continued onto the uterus ;md the interior wall oftfle rectum. The per!tontllm on the bladder coven the bladder apex. The peritoneum cown all of the uterus except for part oftbe arvix (notYisible here), and it C4M!n mcmof tne p;~r.amettial oonnectlve tissue (parametrium). The peritoneum on the rectum coven the anterior and lateral wall oftile upper rectum. The perttontllm Is recessed between tile bladder and Ull!IUS to fonm the narrow -reo-
174
Ull!rlne pouch. The perrtooeum between the uterus and rectum forms
the broad rectouterine pouch (cuJ.dH~). which is the lowest p;~rt of the female peritoneal «VVty. The ovaries and fallopian tubes are I~ peritoneal organs, and so they ire completely covered by perlt:oneum. The peritoneal t.il\llty In tfle male Is a completely dosed t.il\llty. In the fl!male,"--, tneabdomin
cre.rtes a genm·proofseal on the Ull!rus tflatprotecu the peritoneal c:.wltyfrom ascending Infections.
AbdomMfBttiFf!Ms - - l. 5pac:u
SUperior Bladder
Faloplan
pubic ramus
£mm.llllac liiU!yoand win
tube M~
~~~~~~-~e
salphx
lll't2ly ~~~~+-Umbilical ~ruty.~nt
part fF-.,.:.;.--Infmorw.slcal aruty
fll'·§-- - - - 0\r.alfon aruty andwln
B Pll!rftonell relatTonshlps 11'1 tflefem1le lessl!f'pelwlt
Poste
Vde«
pouch
- "~· -~- Posttr!orvaglnal fomllo:
:........,>rr->;>-- Rled:GU1ltrtl~
~c~~~
pouch(rukl~
verted and antl!flexed position (seep. 251) and It CM!I'I'fdl!ltile bladder, which pushes tfle uterus upward as it fills witfl urine. A:s the ureter descends toward the bladder, It passes through the parametrfum (removed here on the right side) ;md lnfer1or to tile utel'fne .ilrtefy. This proximity of Ule ureter to the .ilrtely should be t.lki!n Into acc~MJnt during operations c:m the uten.ts and paraml!b'ium.
C NI!Mie;asptmfonofthe red:outerfnepoclch Mlds.aglttal section of Ule pe!Yis, v~ fi'om tile left side. A needle can be passed thraugh the po.steriorvaginal fomixintD!he rectouterine pouch (known dlnkally as the cul-de-sac) to obtain 01 fluid sample for diagnostic analysis. The fluid may a~nslst of blood or pus, for example, that has gravitated to this deepest point In the female perftoneal Ci'lllty. In the ase lllustrated, the cul-de-s.ac has been marktdly expaooed by blood, effacing the posteriorlli!ginal fornix
175
1.14
Location and Attachments of the Pelvic Organs: Comparison of Transverse Sections In the Male and Female llecbls abdorrlnls
musde
Obturatl:lra!Ury.
lltln,arodn~
Semlnol vesld~ ll«
Bladder
hflr!orwslala!Ury
=
Vellcop!O>tilllc wnous plelC1a
hflr!or
aptum
~stlfcpleous
IIKtum
Obbnt« tntemus rmsde
Sdatlc:nlfW
lsdllalsplnt
Cilutaamaxmaa
s.crotpll\il
musde
11Qii1M!nt
Coocyx.
A l.oatlon atdte m11le pelvic argiNin t n l n - sedfGn
Section thR~ugh the mtle pelvis ~ the level of the hlp joints. viewed from below. The bli.sc!K lies 1nttf!oriy and hu been sectioned 1t lite l~ of the ureteral orificu. Just behind the bladder are lite smionl!d seminal 'o'eSides. The postertor orlfke Is the rectum. whldlls separated from the bladder by the connecUYe tissue of the rect:owslal septum. The con nec:tille tissue around tile bladder and rectum allOW$ them to
change their shape and volume u they bKome dlst~tn~. The CGnnectlve tissue lollllvltothe blidder (the lateral ftSic:ulir ligament) c:ontalns multiple sec:tioJU of an utens!Ye wnous networtr. the vestal venous plexus, which drains venous blood from tile bla.sderand Pf0$tatl! (as the 'o'eSicoprostiltlc'Valous p.lelWs) to tile vestal wins (notvlslble here) and tlten to lite lntel'l'llllll~e vein.
llladd~
Rlghtull!tl!r T"'"....-seanfcal llpnent
Obtu""""'
lniBnuo mUlde
Rec!Dutafnollgomont (farru th~ lounciltlon oflite redllull!~nefald)
Rsmvaglnal septum
~ctum
1 cannectlw! tlaue&lumlllndlng the pelvic arg~ns
Superior view. a Male pelvis, b female pelvis. Most of the connective tissue In the extraperltonulsp.;~ce of the male and fem~e pelvis consists of loose connective tissull!. IU fundion is to lmp.;~rt a czrtaln mobility to the pelvic organs. Another function of this connective tissue, however. Is to glw attachment and stability to lite pdvk ~ns. Thb pu~pose Is seMCI by two large supporting columns
116
SacnJm
of con nec:tille tis,ue that IL'lltend from the pelitic wall to the rectum and to the blidder. These columns not only provide structural support but also transmit neurovuc:ular bundles to the organs. The connective tissue is aiJo condtnsed to farm ~ coronally-oriented con necti~-tiuue plate th~ Is ailed tile rrclll¥alall sqtum In the male (see p. 170) and the~Rptum In lite female.
AbdomMfBttiFf!Ms - - l. Sptlcu
Obtu-al\ll (Inlet) --++;.-.:..,.........:;.--Ll!jamenturntJe~ ~~u~ --~c-~~~~~~--~~~
(Clltablrquely)
of femoral head ,~~~~~~~~---OMu~r lnllemus m~Aele
"~-\'--...;;,..;....:;:;..;:.:,.*~=--=---
Ut«ovvghal \'eMOUS plexus
c loaltfon oftflefem•lepeMc0f91nllntnnlllll!ii'SesecUon Section through tne fl!male pelvis ;at the superi~r border d the pubic symphysis. The section OJts the blildder juJt below the ureter.~! orifices. Po~tenor to the blildder Is a section d the uterfne ceNfx. and behind !hat 1~ tne rectum (sep;arated fn:Mn the ceNfx by the base of tne rectouterine pouch).IU in the male pelllis, connective tinue is distrilxm!d around the bladdef and rectum. Additional connective tissue Is found around the cerYlx. representing a downward prolonga!Son of tne transverse ceNfcal ligament. A venous network. the uten:waglnal Vl!llous plexus, is embedded in the connective tissue and is cut at numerous
sites In the section abaile. This plexus p.,._,ldes venous drainage for the ub!ruJ and vagina. Note: Peritoneal pouchu eldrtln front of and behind the utmJs: theveJIcouterlne pouch ;mtenorly and the rectouterine pouch porterlorty. The sectlonshawn()erecutsthepeMsatthelewlofthertctouterinepouch (cul-
177
Abdomen and Pelvis - - 2. Organs
2.1
Embryonic Development of the Gastrointestinal Tract: Formation and Migration of Organs
A Embryonic development of the gastrointestinal canal Right kidney
The gastroiniEstillill can.ill and its associated organs (liver and J>illlCrNS} d
Vertebral column
Left kidney
Pancreotlc bud
Abdominal aorta Splenic bud Pa~l!tal
Stomach
•
• Rotation oftf1e stomach and formation of the liver and J>ilncreas (see C. D,and E) • Development of tf1e pancreas and Its migration to the dorsal wall of tf1e peritoneal cavity behind the peritoneum ("retroperltoneallz.a· lion," see E and G) • Fonmation of the omental bursa (see F) • Rotation of the intestillill loop and the disposition of the small and large intestine (seep. 180) • Development of the cecum and vermiform appendix (seep. 180) • Migration of the ascending and descending colon to the dorsal body wall and attachment of the mesocolon (retroperltoneallz.atlon, see p.181) • Fonmatlonofthegre.ateromentum (see p.181).
pe~IDneum
liver
b
P.anc~s
Splenorenal ligament Spleen
lntraperitonNI organ
(e.g., jejunum) Paril!tal
VIsceral peritoneum
peritoneum
Lesseromentum --1i\---i''dl (hepatDgost~c
Perttoneal cavity
Retroperitoneal
Retroperitoneal spaoe aorta
Longltudln.ill axis
spine
178
Donoventr.~l
Lesser
axls
curvature
Esophagus
V~lJ
Lumbar
B Peritoneal rei.Uons of the organs In the abdomen and pelvis Transverse section through the embryonic abdomen at the level of the lumbar spine, viewed from above. A knowledge ofthe embryonic development of the alimentary tract can yield important topographical and functional insights. All organs can be classified based on their relationship to the peritoneal cavity. lntn~perttoneal organs lie within tf1e peritoneal cavity and are covered by visarol peritoneum. This allows them to glide relative to one another and relative to the wall of the peritoneal cavity. Neurovascular structures are distributed to tf1ese organs through a mesentery, which passes from the wall of the peritoneal cavity to the organ and is also covered by peritoneum on both sides (examples: jejunum and ileum). Extraperltonal organs are located in a connective-tissue space that is behind or below the peritoneal cavity (retro- or subperitoneal). Organs tf1at are primarily extraperitoneal from tf1e outset do not have a peritoneal covering. Organs that are secondarily extraperitoneal (become extra peritoneal during the course of embryonic development) are covered by peritoneum anteriorly, while their posterior surface is fused to the parietal peritoneum. The neurovascular structures that supply the extra peritoneal organs course within the (retroperitoneal) connectivetissue space and do not require a mesentery (example: the kidneys).
(gastrosplenic ligament) Faldform ligament of liver
organ(e.g., ascending colon)
Extr.!periiDneal orpr1mary retroperiton...r organ (e.g.. kidney)
'"""'"----"'--- Greateromentum
ligament)
Mesentery
d
Pylorus
Pylorus
Greater CJrvature
C Rotation of the stom•ch (after Sadler) a-c Abdomen In transverH section, viewed from above. a At the end of the 5tf1weekofdevelopment,c in the 11tf1weekofdevelopment (the pancreas is already retroperitoneal). a Liver, stomach, spleen, and pancreas displayed on one axis. b,c As the stomach rotates (details In d), the llver gradually moves to the rlghtwhilethe spleen and pancreas are carried to the left. The stomach, liver, and spleen remain Intraperitoneal, while the pancreas becomes retroperitoneal. d Stomach viewed from the anterior side. The stomach rotates around Its longitudinal axis (by approximately 90') and also around a dorsoventral axis (see arrows). As a result, the ventral wall of the stomach moves to the right while the dorsal wall moves to the left. The dorsal wall grows faster tf1an the ventral wall, fonmlng the greo!l!r curvature on the left side of tf1e stomach and tf1e ksser curvoture on tf1e right side.
Abdomen and Pelvis - - 2. Organs
Porletal perltoneum
Dor
Stomach
(-part of ventral mesogastrium) Hepatic bud Ventr.~l
mesentery (faldfonn ligamentofliver)
Hepatic duct
Uver Splenic bud ltetroperltoneal -~[l~~~~~t9-- space Dorsal
Ventral bodywall
mesogastrium
Ugamentum teres of llvl!r
Dorsal pancreatic bud
b
Gallbladder
Ventral pancreatic bud
Duodenum
Pancreatic duct
Common bllo duct
pancreatic bud Stomach Uver Hepmogastr1c and hepatoduodenal ligaments (lesser omentum)
Acc:e.550ry pancreatic duct:. duodenal orfflce
('::f~t~~t:~ Spleen
~~~:;;,:::~- Fuslonofbath
C.strosplenic ligament
Ugamentum teres of liver
Stomach Duodenum
a Fifth week of development: By this stage the liver, gallbladder, and ventral pancreatic bud have developed in the ventral mesogastrium. The spleen and dorsal pancreatic bud have developed in the dorsal mesogastrium. b Eleventh week of development: With the rotation ofthe stomach, the ventral mesogastrium becomes the lesser omentum while the dorsal mesogastrium becomes the greater omentum. The ventral mesentery develops into the faldform ligament with the ligamentum teres of the liver In the free margin. The mesenterlc expansions ventral and dorsal to the spleen become the gastrosplenic and splenorenalllgaments. ltetroperitoneal space Dorsal mesogastrium
pancreatic buds
d
Main pancreatic duct, opens lntD duodenum with common bile duct
Duodenum
Greater omentum
D Formation oftt.e Vt!ntral and donal mesogastrtum and migration of the organs In the upper abdomen Transverse section ofthe abdomen. left superior view.
E Donal and wntral pancreatic buds (after Sadler) Embryonic gut viewed from the left side. The two pancreatic buds fomn as endodermal outgrowths from the duodenum in the ventral and dor· sal mesentery. The ventral bud develops in close association with the common bile duct. It migrates around the duodenum and assumes a position slightly caudal to the dorsal bud (c). The two buds fuse, and a communication is established between their ducts (d). The duct of the ventral bud generally opens jointly with the common bile duct into the duodenum at the major duodenal papilla (of Vater). while the duct of the dorsal bud may open higher at the minor duodenal papilla (the pa· pillae are inside the duodenum, hence they are not visible here).
ltetroperitoneal space Omental for.~ men
-=·~j
b
Stomach
Cystic duct
Splenorenal ligament
Falcifonn ligament of liver
b
Hepmlc duct
Parietal peritoneum
Ventr.!l
Greater
mesogastrium
omenb.Jm
~
Omentll burso
Right kidney -u"C~~7t-- Left kidney Parietal
Lt---1-- Pancrea5 (still intn~peritoneal)
peritoneum
Duodenum
(stlll peritoneal)
~t%~ -~r.:;;;;=:::lt~~... Abdominal ---lf,....i...,.:-f') ~art~
'-....>..----fl-- Duodenum and pancreas after retroperlto· nealization
F Devl!lopment of the omental burH (after Sadler) a-c Transverse sections through the abdomen, viewed from above. d, e Sagittal sections, viewed from the left side. b
Between the fourth and fifth weeks of embryonic development, Isolated clefts or spaces develop In the dorsal mesogastrlum at the same time the stomach Is undergoing rotation. As the stomach rotates and displaces the dorsal mesogastrium, these clefts coalesce Into a large open space behind the rotated stomach: the omental bursa. This bursa temnlnates blindly on Its cranial, caudal, and left sides. A single physiological open· lng, the omental foramen, remains on the right side (see arrow In d; the lower arrow In e shows the deepening pouch formed by the greater omentum).
C Retroperitonealization of the pancras and duodenum (after Sadler) Superiorview, simplified schematic. The liver, stomach, and spleen in the dorsal mesogastrium are not shown. As a result of gastric rotation, the pancreas migrates dorsally while the duodenum swings dorsally toward the rightside. Both organs fuse to the dorsal wall of the peritoneal cavity, becoming secondarily retroperitoneal.
179
Embryonic Development of the Gastrointestinal Trad: Rotation of the Primary Intestinal Loop
2.2
Cranlal~ot Duodenum tm!'ltlnalloop
Stlmllch
s~
mew!lrtertc: " a~ey Omphlloe1tl!tk C.Udal PI~ of clJct
tm!stfnalloop Duadl!num
Slllmach
Asund'ng
c:don
A RoUUart of the prtmary lrrtesttnalloop
Ptojectz.d onto the anb!riorb'unk w.all and skelet:Dn. NO!J!: The primary Intestinal loop to1:iiWs c:oontm:loc!Misewhen viewed ftom the front. contrasting with Ute cloclaM~ rotation of Ute stx~mi!dl (see p. 178). This Is Important In undemanding how the organs reach their final positions. The frame-like shape of the colon and the loation of the juncdon be· tween the small Intestine ind cecum In the right Iowa- abdomen (Ute Ileocecal junction} result from Ute normal rota!Son oftfte Intestinal loop. lnccmplete rotation of the Intestinal loop (less tftan 270") or rotation In the dot:1cwistt direction result$ in an abnormal position of the colon $C!g· menu. This condition may remain asymptomatic or may cause twisting ind ocduslon oflntestlnal segments.
Bud
Vlb!lline duct ~pmentofthe oecum •nd 1101:nmlfonm •ppendm
(after Sadler) Anterior vlew.
a In ipproxlrnatl!ly the 6th week of development. the rudiment of Ute cecum appears attftejunctlon of tile small Intestine and large lntes· tine. b In the 7tft to 8th week. Ute nudlment ofthe venmlform appendl11.ap· pears on the cecum. c The Ileum, cecum, and vermlfomn appendix shown In tftelr normal relationship ;at tile conclusion of embryllnic development. The ce· aJm at tftls stage forms a blind sac at the commencement of Ute large Intestine. The lle1Jm opens Into the cecum from Ute left side. The vermiform appendiX extends lnferomedlally from the ceaJm.
180
c Yermlfonn
appendiX
c Development of the embryo nit lntl!stb! •nd Its nltatlan .,und thelrl1e$tinlllloop (after Sadler) Gastrointestinal canal viewed from the left side. The rotation of the prt. mary Intestinal (midgut) loop Is an extremely oomple11. process lasting approximately from Ute Stft to 11th week of embryonic development.
;a, b VIewed from Ute left tile Intestinal loop goes through a total rotatfon of 270' In the counten:lockwlse drrecaon (Ute axis of rotatian is the supetiar mesenteric attzty). Aftzr an initial rotnian of 180'. the transvene colon lies In anterior to the duodenum. c The cecum Is locatEd In Ute rlght upper quadrant. The srnalllnte~· tlnealre.adysllowsdeffnttecolllng,andthebowelloops hiM! reached their final position. d When the rotation of the rtomach and Intestinal loop Is complete. the organs hive 01ssumecl tftelrtyplcal adult positions:
otoecum
B
DeKendng allen
Cec:um
• The liver Is In the rlght eplgastrlum (attached to the duodenum ind stomach bytfte lesser omentum). • The le.sser aJrvature of the rtomach Is directed upward to the right. the greater curvature downward to the left. • The pancre<~s and most of the duodenum are retroperltooeal. • The cecum. vermiform appendix. and Ileocecal junctlon are In the rfght lower quadrant. and Ute \lltelllne duct Is obliterated. • The colon farms a frame around the jejunum and ileum, the trans· ftrse colon lying anterior to the duodenum. At this Jtage the a'lcending and descending colon become HCondarily retroperitoneal (see D). NoiJe: Due to space llmlt.ttlons. the rotatfon of the Intestinal loop occurs partly outslclt! the embryonic body cavity (elCtraccrporeal). The rotated midgut then retrilets bade into the abdomen. F;ailure of this retraction may lead to an omphalocele. In whkh part of tile small Intestine protrudes tftrough the abdominal wall attfte umbilicus.
Abdomen and Pelvis - - 2. Organs
Retroperitoneal
Ascending mesocolon
Descending mesOCDion
Parietal
Gastrocolic
Omental bursa
ligament
Parie!ill
peritoneum
peritoneum
Ascending
-Hlf-¥r-+-- Descending
mlon
-
spa~
1
colon
•
Retroperitoneal
Pancreas Duodenum
--
Greater
omentum
Transverse colon
jejunum Mesentel)' and Ileum D Retnlperrtoneallzatlon of the ascending and descending colon and fusion of the greater omentum (after Moore and Persaud) a, b TranSVi!rse sections, viewed from abiM!. Following rotation of the intestinal loop, the colon segments have assumed their definitM! positions with their mesenteries on the posterior wall of the peritoneal cavity. The ascending and descending mesocolon fuse completely to the parietal peritoneum, allowing the ascending and descending colon to become secondarily retroperitoneal.
Vl!ntral
Meckel
bodywall
diverticulum
Umblllc:alftstula through persistent vitelline duct
~'")f cus
Obliterated vitelline duct
C}l'tln b
vitelline duct
E Remnants of the vitelline duct (after Sadler)
Generally the vitelline duct, initially patent in the embryo, is completely obliterated and is lost as a connection between the ileum and trunk wall. Occasionally, however, the obliteration is incomplete or leaves an intact cord of connective tissue that tethers the ileum to the anterior trunk wall. This can have various manifestations: a The wall of the Ileum Is outpouched at the fibrous cord, forming a Meckel diverticulum (usually located 40-60 em cranial to the Ileocecal valve). This protrusion Is subject to Inflammatory changes and often contains ectopic gastric or pancreatic tissue. b A cyst remains within the fibrous cord. This cyst may cause complaints and requires differentiation from a tumor. c The vitelline duct remains patent over Its entire length, resulting In an umblllcal fistula. In extreme cases, portions of the small Intestine may herniate at the umbilicus and become Inflamed. If a remnant of the vitelline duct persists as a fibrous cord between the Ileum and umbilicus, mobile loops of small Intestine may wrap around It and become strangulated (intestinal paralysis or "Ileus; which often has a fatal outcome If untreated).
TranS\Ierse d
mesocolon
c, d Sagittal sections, viewed from the left side. The greater omentum Is draped over the tranSVi!rse colon, which remains Intraperitoneal. As the two layers of the greater omentum fuse together, the Inferior recess of the omental bursa becomes smaller. When the greater omentum also fuses secondarily to the mesentery of the transverse colon, it assumes its final conformation and creates the definitM! tranSVi!rse mesocolon.
F Developmental anomalies of the gastrointestinal canal The anomalies listed here, some quite rare except for Meckel diverticula, vary considerably in their pathological significance: Acomplete or nearcomplete occlusion in the gastrointestinal tract is usually fatal without treatment, whereas mild degrees of narrowing may remain asymptomatic. The twisting of bowel segments often causes strangulation and obstruction leading to a life-threatening condition.
Duodenal atresia
Solid duodenum without a lumen
Duodenal stenosis
Narrowing of the duodenall..-nen (e.g., by an anular pancreas)
Blllary atresia
Congenital or aa]Uired obstruction of some or al of the extrahepatic bile ducts
Anular pancreas
Duodenalstl!nosls (see above) caused by a ring of pancreatic tissue (seep. 214)
Omphaloa!le
Extracorpo!NI protrusion of small intestine • the umbilicus, caused by a failure of the rotab!d Intestinal loop to retract (see C)
Malrotation
Abnormal or failed rotation of the intestinal loop (see A and C)
Volvulus
Twisting of ...,.11 intestine on its mesentery, with risk of bowel obstruction or necrosis N~rrowing
lntestinalstl!nosis Intestinal atresia Meckel diverticulum
of the intestinal lumen
Complete occlusion of the intestinal lumen, usually Incompatible with life Failure of negresslon of the vitelline duct with an assoclatl!d Ileal diverticulum (see E)
181
2.3
Stomach: location, Peritoneal Relationships, and Relationship to Adjacent Organs
~n
Uwr
IJ!3:ser
Splenic -of omenul
omentum ~ giS!Jic
Stomach
Panc:rt!ll!O
L4wrtl!bra
txna
ligament)
A Pra{edTanontDthetrunk
Ant2riorview. NOll: the posltlon of the tr~mpylortc plane (h~lfway between the supe· rforborderofthepublcsymphyslsandthesuperlorborderofthe manu· brtum sternl, seep. 150).1t provides an Important landmark In physical examinations, for exo~mple, as the pylon.ts is located at or tlightly below the transpylorlc plane. hence Its name. Unlike other pam of the swm· ad!, the pylorus malntilns a con stint position because It Is coonected to the duodenum, which Is retropelltoneal and therefore relatfllely lm· mobile.
B TopographTcal relllt'lonshlps Tr.ansverse section at apprmimab!ly the T12/ L 1 lewl, viewed from above. Noll! the relationship of the stomach to the spleen, pancreas, liver, and omentil bursa: The greater aJrvature of the stomach otends to the spleen. The left labe of the liwf'exll!nds in frontafthe stamach and inta the left upper quadrant (WQ). Thus -Mlen the abdomen Is opened, very little of the stomach Is visible, most of It Is obsaJred by the mass of the liVer. The omental burn Is a namow pefltaneal space located directly behind the stomach. The pancreas forms most of the po.stenor wall or the bursa. With iU peritoneal covering, the mmadl is very mobile l'l:!lative to the surrounding organs, and this Is an lmportintf.lctor In fadlltatlng Its lntrfnslc pelfstaltlc movements. The stomadl has direct perttoneal attidlmerns to the spleen and liVer owing to Its embryonk placement in thedorwl and ventral me.sogastrium (see p.179).
Panc:rstlc _ ___:::---- - S\1~
Colomesoc:Dic _ _ _.:....__
Jumae
• C Areas of mntilctwtth adfiiOI!nt organs a. b Ant2rlor and po.stel'for VIews of the swmach walls. Because the mmi!Ch is intraperitoneal, it i$ very mobile l'l:!lati~ to ~djacent organs. But since the stomach Is In close cOiltictwtth other organs,IHionsthat
182
-He!)lt(c
Jumae b
penetrate the stomach wall (ulcers, malignant tumors) may spread ta nearby organs or may cause adhe.sla1u ta deYelop between the stom· ach and adjacent o~ns.
Abdomen GndPelvis - - 2. Organs
folld'fcnn ligament ofiM!f
fiJndus
Galblldder
cardia H~
~IIUI ligament
l.ellsct
cml!rlbJm,
til'=
Bod)' of stDITIIICII
~~~
Spleen
om.mal ~men
._..
LHHr CUMtlft
onv:ntt.m, ~
ligament
cre.;m,r
Right lddM)'
curw11.ft
RJghtailt
limn Desandlng colon ~dhg
Trlii\M!I'SUS abdomlnls,
a:olon
lntmlal~nd
-mal oblkJH! muscles
Duodenum
Pylolft canal
D lhutomach In situ Antzriot Yii!W of the opened upper abdomen. lhe lilll!r has been re· trncted superolirterally, and the esophag~JS has bea'l pulled slightly downward for better exposure. The arrow points to the omartal foramen, the openlfl!l In the omental bursa behind the lesser omeni:IJm. Peritone.-al adhe.!ions are visible between the lilll!r and the descendir~g part of the duodenum. The lesser omeni:IJm Is Ylslbly subdMded Into a relatively thick hepai:Dduodenal ligament (transmitting neuroYascutar
P)!orlc
antnm
Ciatl!r omentum
rtructures to the porta hepatls) and a thinner hep;lt.Ogit!trfc ligament. which is att.'!ched tD the lesser curv.awre of the smmach. A he~ sophageaiii!Ji!ment can also be Identified. 1he g111ater CIJMI:IJre of the stomach Is ciDSely related to !he spleen In the left upper quadrant (WQ). Thegreatefomeni:IJm Is a dupllcattonofperlt:olleumthatmvers the tr.anM!rse colon and drapes_. the loops of small intzstine (not visible here).
183
2.4
Stomach: Shape and Interior
r-----I
I
'
I
., / ' ,
Duoderu.m
A hpeandanltOmkaldMdon& Anterior view of the anterior mil. The body (corpus)« the stomach Is the largest part of the stomach. It tErminates blindly at the gastric fun· dus. wltlch 111 the st.mdrng patient Is the highest part of the 5tllmi11Ch and it. usually filled with air (visible on r.adiogr.aphs as the •gastric bcJbble"). No~: The cardia Is the area of the gastric Inlet where the esophagus opau Into the stomach (at the cardli!C or!llce). WhOe the esophagus Is Invested by ac:tventltlal connective lfssue. the stomach has a vlscer.ill pefrtzlneal aM!!ting or serma. The transiticm fram advl!nlitia tD serosa is
184
sharply defined, and oa:asianally the SenMa mnlinues a short dist.ilna onto the IOWErendoftheesophagu~ The part of the stllmach that OpalS Into the duodenum. the pyloric part,. mnslsts of a bnoad pylolfc antrum, .il narrow pytortc canal, .ilnd the P'fiOtuS itself (pyloric orifice). The circular musde layer of the stomach Is markedly thlck2ned at the end of the pytortc canal tDform the P'flork sphincter {not visible here). which produces a visible external co liStric· tlonofthe~ccanal.
Abdomen Gnd Pelvis - - 2. Organs
: ---l!adyv.nh
lcnglludnal
folds
Duodenum
B lntl!rior of thutlllniiCh Anwrlor view of the stomach with the anwrior w..ll removed. For clar· lty, small portion~ of !he esophagus and duodenum are 01lso shown. The gastric mucosa fonns promlnl!llt folds (rugal folds) tttat 5erve to inc~Nte its surface area. These folds are directed larlgitudinally toward !he pylorus. forming •gastric e<~Bals.• The rugal foldJ ire most prom!·
nent in the body of the stomach and along the greall!r curvature and diminish lfl size toward the pyloric end. The muc:osa lmpi!rts a glossy sheer~ to !he stomach llr~lng. NO!J!; The pyloric ortflce Is quite large In this dissection. Normally, !he cuifa usually apens ma luminal diametl!r of anly 2-3 mm.
185
2.5
Stomach: Wall Structure and Histology
IIIUICU;Irc:oat _ _.:.._c_·
ofesophagus,
longltudln;JIIayer
Duodenum. JUpetlar part
lnnerobllquefben ofmusalartsotema
A Muscular &a,.ers Anterior view of the anterior stomach wall with the serwa and subse· rosa removed. The muscular coat of the stomiiCh has been windowed at sewral slb!s. Tbe entJrt stom«h wall ranges from 3 mm to approxl· mately 10 mm in thickness (see 8 fDr individual layers). Mo.st of its mur.· cular coat corubts not of two layers (as In other holklw organs of the giMG!nteUlnal tr.rct) but of thn!f muscular layer$: • An outer longitudinal layer. whkh Is most pronounced along the gre.rter curvature (gre.rtelt longii:IJdlnal expansion) • A middle circular layer, whkh Is well developed In the body of the stomach arid most strongly diMioped in the pyloric canal (anular sphincter, seep. 184)
186
• An innemnost layer of oblique fibcn, which is denll1!d from the circu·
larmuKie layer and Is deariyvlslblelnthebodyofthestomach The three-layered structure of iU muKUiar wall embles the stomach to urldergo powerful churning ITIOYeiTients. The mu5eles can forcefully propel solid food components against the stomach wall In the addle gastric Juice, breaking the m.rterlal up Into partldes approximately 1 mm in size that can pass easily thrvugh the pylonus. The longitudi· nal~rlented rugal fDids (reserve folds that disappear when the stom· ach Is distended) form dlanr~ets. called gastJfc canals, that rapidly convey liquids from the gas!Jfc Inlet to the pylorus.
c.trlc mumsal surfa<2
Sufall! epithelium
Wrtrlc pit
catrtcplt
Slo!mCI!II
--{ ..,.,..,.
See•
Ml.lli
·=! ~~j
Hock all
ParlmiCI!II CNela!l
dgllnd (shorUtled)
Noiii'CIOI>daatl~
all - - MUJaJiarls
m"""""'
•
SeAlSa
SUbsErosa
I strucblre of the nom*Ch .....land gelltriC glench il The dnKtuN of the noiiiiCh -'1 lllustrate:s die layered wall structure that Is typical of the hollow OI'!Pns throughout the gastrointestinal tract. The sto~T~Kh is unique, h~. in that itl muscular co;rt: mnslsts ofthree rithef thin two li)'ers (see A). Notc. The serosa (vtsctr.~llayer of the perttoneum) and subserosa (connectlw-tlssue l~r giving attachment to the serosa and transmitting neurovascular structures for the musculilr coat) are present only In altis where the organ In question Is c.over-ed by visceral peritoneum. In wall aren d!at lack a perlt!Jneal clMI!ng (e.g., large portions of the duodenum and colon), the serosa and sub5er0Sa ilre replaced bya fibrous adwntitia, which connecb die wall oftheorgan tD the mnnectiYetlssue of sumJUndlng structures. The llliiCDSQ mntalns spedallzed cens thitilre aggregmd Into glands (visible microK9piCillly}. The glandular orifias open it die base of the gastric pits (see b). In die body ilnd pylorus of the stDmiKh these glinds. nl:2nd down to the muscular layer of the mucasa, the m~ a~larls muanae (deeper glands • more celb • higher seaetory ou~ piii:J. The rubmucoso (l~r of connective tissue transmitting neurovasculir structures for the muscular coat) contall\5 the subtnuccus
b
SUbmuceu
plexus for viscerumotDr and viscerosenSGf)' control of the hollow O~' gans In the gastrointestinal tract. This plexus, Ill«! the myenmricplexus (loCill!d In the musculi r mit for visceromotor control of the visceral musde. not shown here), Is part of die entrrlc nerwus system, which mntalns, In tota I, millions of satll!red gang lion cells. b stnodure of the gutrtc g..ndt (after LDIImann-Riluch) (51mpllfled schematic of a gland from the body of the stomach). Several types of cells are distinguished In the fund us and body al the stomach: • Surface epithelial ctfls: mver the surface of the muca'la and secrete il mumus film • Nec:X ails: produce mucln tD strengthen the mucous film (mab It more anionit) • Parietal cells: produce HO ilnd lntrlraslc futor, which Is necesary forvitamin Bu absollrtlon In the Ileum • Chief cells: produce pepsinogen, which Is mrMrted to pepJin (for protein breakdown) In the stDmilch • Neuroendocrine ctfls: different subtypes producing gastrin (G CElls), somatostatin (D cells), or other filctors mnt:rolllng motility and secretion. • ~m cells: reservoir for replenishing tile surfac:e epithelial ctfls and gland cells
Gii5!Jic
ulal!r
• c EndOICIIIplc•ppul'lnce of the g1strtc muma •.b Healthy gastric mumsawidl a glistening surfilc:e c Gastric ulc:er. il VIew Into the body of the stomach, which Ius been moderately distended by air InsufflatiOn. The mucasals raised Into prominent, tortuous rugal folds that form the gntric anaIs. b Inspection of die pyloric antrum shows less prominent folds than In the body althe stomach.
c
c Flbltn-cawred gastlfc: ulcer 'Afth hematin spots. Agastric ulcer Is defined as a tissue defect dlit extends it IHSt lntD the muscularis mucosae, but lllilny ulcers extend mum deeper Into the stomach wall. Most gastric ulcer$ are cauMCI by infection with~ pylori. a barte· rtum that Is resistant tD stomach acid (from Block. Schichschal and Schmidt: 11le GclstroscDpyTIVIner. Stuttgart Thleme,2004).
187
2.6
Smalllntestine: Duodenum lnfmar
!\bdcn1nal
Duodenal wna c:ava
aorta
bulb
Duodenum.
~pertorpart "'-...
~
Superiorf s
duodenalflelan
~
Duodenum - - -,
L4ve
Duodenum,
- - - DuodenoJtjun.ll flexure
Suspenswyllgament
desandlng Ptrt
ofduodenum
lnfenor
duodenalflelue
Duodenum,-
Duodenum, ascending pMt
horfzant.ll part A Pra{ected onto tflnertl!b111l CD!umn The duodenum is a C~haped loop of small in· testlne lying predomlnantlyon the right side of the vertebral column In the right upper quad· rant (RUQ) ind encompassing the L1 through L3vert:ebraeandoccasionallyextendingtol4. The conc;Mty of the duodenum normally en· closes the heid of the pancreas it the L21evel
B Pllrtsoftheduodenum AnU!rioc' view. The ~n~tomic;~l parU of the duodenum (Silpafor, descending, horizontal, ind ascending parU with Intervening flexures) have .a total length of .applllldmmly 12 fingerwidths (L. duod<:ni • •twe~ve it a time•). Nof:ll! the sll!pmsory ligament of tile duod~ num (called also the ligament ofTreltz), which
often conulns smooth·mll!de flbers. Mobile laops of small intutine may wrap around this ligament and become artrapped between lfle ligament and the vessels behind It (mott not~ blythe ibdomlnal aoru). This •rre112 hemIa• m~ cause mechanical abstnuction of the ;~f· fect:ed bowel loop and strangulate Its blood supply.
(seeD).
Duodenum,
--~,..;
s~p.;rt
OI'C\IIIrfolds ----,F--' (wM!ofKefdcrfng)
. , . , . . - - - - - Bodyof
pancrear.
Du aden u"" desand'ng part
- -4 ....---- DuodenoieJun.ll ftel(!,lre
M~lnpa~
duct
·=! C W..lllltnlcture ilrtd duc.t orfliCIII!I Anterior view. Most of the duodenum has been opened. The ~or1c orIfice (here greaUy dll.atl!d) opens m .a luminal diameter of only .abcut 2-3 mm for the pauage of chyme. The duodenum has basically the same wall structure as the other hollow organs of the gastrointestinal tract (see B. p. 187). The structure of the mucosa Is shown In F. The de·
188
scendlng part of the duodenum has two small elevitlons along Its lnnl!f curve: the minor duodenal p
Hepolic win•
Common hopltk ortory
Phmd~plenlc
EsGpNg.Js
llgoment
Left !l"'lrlc artory
Hq>OIIc "'rfaot
Leftwpro,..,... g...d
llvomont
1U!f1t"'prarenal g"'.nd
~~!j~~~~~~'~tt--- Splenlcartery
Body
Ll..£' - - - - T•l
Right kkroey
Duodenum,
ouporiorp11r1
---.. 1
:;.._+--
- Leftlddnoy
~:.-!---
SUporlarduodenal ,_,.
JefuNJm SUporlar muentmc artoryandwln
Desoendlng cdon
Ex11tmaland _ _ _..c;..
lnfellor duodenal
Internal oblique. lrill>'m>U5
reo!55
abdomlnb Duodenum, desandlng part
Right mlk:ortl!ry
af mesenl2ry
D Tlle m..lenumIn sltll
Anterior view. The stomach, liver, small intestine, and large portions of the tmuvene mlon have been rem0111ed. The retroperitoneal fat ;md mnnedl'll! tissue, lndudlng the perfrtNI fat capsule, haw been sulr $tllntiillly thinn~. The heed or the po~ncnas lies in the conc
•• - -F'--:iF:iii
a~
f'olck
Plplillry
~"'"
- +-=:.. . . .,-
E EndDKDplc:vlew The endosc.ope Is pointing down Into the de· scendlng part of the duodenum. The papillary region where the bile duct and po~ncre atic duct open into the duodenum Is visible on the left side ofthe Image at appradmmly the 10 o'dock position. The clradar folds (wl\ti of !Wckrin.g ) are typical of those found in the small Intestine. dlmlnbhlng In sl~ In the pi"'OCC· nultodl!.ul direCtion (from Bloclc.Schadlschal ilnd Sdlmldt: Endomlpy of tilt~ GI Troct. Stutl:girt: Thl~me, 2004).
Duodenum. hcllmnUI part
Duodenum, liKm
Lift mlk: ar!By aNI win
neiil. Owtng largely to the pr01Cimlty ofthe duodenum and the he.id of the pancreas, lesions ofthe pancreas (tumol$) ormalronnatiCNU (anular
pancreas. xe p.214) may a111e du.odeNI obstruction. The peritoneum atthe duodeno-fe]una Ijunctionforms the superfor ~nd lnr«for duode-
rNim:esse. Mobile 11101» ofsmall i~stine may en~ thew peritoneal recesses and become entrapped ltlere(lnlft'nal hrmlll), a111lng a potentially l~ltlrelltfnlng ~ obs1rucUon.
OLJDdeNI gland> ---"""'~ --~!:r-- Ormorfold
(BrunnK gland>)
lnt.st!nal --'*"'M'i'~
g!Md(aypt)
F tlstoi.Ciil dnldure Lllngltlldlnal seCtion lh111Ugh the duodenal Will. The duodenum his basic.;rlly the $ame hlstolog leal structure as the other hollow atg:~ns or the gastrointestinal tract (see I. p.187), with some notable differences such as the presence of duodeNI (Brunner) glands (sc~te m udns 01nd bitarbo!Ntf to nll!utrali~ the addle gastrlcjula) and valw:s of Kerdalng (spedallzed CII'OIIarfolds). Olherfeatui'I!S!hilt dlstlngulsh the duodenum from the jejunum
;md lieu m are Its mOll! prom lnent mucosal folds, whldl diminish In sill!! tDWard the end of thesnulllntestlne. NotE The musculilr1s emrna of all portions of the intestine, unlike that of the stonuch, CMJbtl of only aw ~)'!11: an Inner layer of clrmlar musde flberu nd an outs" layer of longllll-
dinal musde fibers.
189
Smalllntestine: jejunum and Ileum
2.7
DesO!tldlng colon
Vennlfrlnn -----'lft-"1'--"J-/ ~ppendbt
• 8 W..llstrvcturufthejl)urNmud Ilium The walll;tyers of the smalllnte.s!lne are displayed In a "teeescoped" crosNectlon. The mUCO$al layer has be.!n fndsed longitudinally and opened. The jejunum and ileum h
Aslzndl'lg colon
Jejunum
llwm
b
A P
l~·~·-~*7--
foldJ
i~
!lne like a frame. Be<:iuse the small bowel loops are lntnperltxlneil and therefore very mobile, It Is not possible to define their loc.ttfon by refer. enc2 to slctleUIIandrnarks. If the lntestiBalloop rotates nonnally during embryonic cievel~pment (see p.180), th~ duodenum liH behind the transvene colon. If tile lntest!Balloop roUtes In the wrong direction, the duodenum wlll come to lie In (Tonto{the tt;ms~~erse colon. Nolle the following normal anatomical constrktfons: • junctlonofthepylorus;mdduodenum(lumlnaldlametl!rofthepylolfc ortfla Is only ~bout 2-3 mm) • DuodenojejuBal flexure • Ileocecal orlf!ce Sw.lllowed foreign bodies may become lodged at these sites. obstruct· lng Intestinal tr.lnslt and causing mtchanlc:al Intestinal paralysis (mecltanla11 11c!us,allfe.Chreatenlng condition that Is an absolute lndlc.ttfon forsurgiul tre11tment).
D EndoscopTc: 'Wtll!w llf the jejunum View in the distill direction reve;lls tile numerous circul;tr folds along tile jejunum (from Block. Meier ;md Mann~ Lthrutlos dfr Gostmsknplt. Thl· eme,1997).
190
On:ulllr
• c
Dlffen!noes rn the Will st111cture ofthe je)lnum and neum MilcroKopic vi~ of th~ jejunum (a) and ileum (b), which hOM be.!n opened longitudinally to display their muCOSill surface anatomy. NotE: The transversely oriented drcularfolds In the Je{unum (see D) are spaced much close!' together INn In tile Ileum. Lymphatic follkiH .are particularly abundant in the wall of the ileum (from the lamir\a propria to the submucoSi) for mounting an Immune response to antigens In the Intestinal contents ("aggregated lymph nodules." Peyer's patches).
Abdomen GndPelvis - - 2. Organs
Eplplclc .1ppl!n dices
Tr.JI'IS'f!ne _
Taenia coh
Tr.anS'olllne colen
___::------::::-.-~
mtsacdanv.41tl mlddltcohc arteryandw\'1
1\saendtlg ----:----:~ colon
+---- TranM1ft.US~bdamlnls, lntemal~nd eldl!moll
abl~tmusdts
lteclul abdam\'111
- -+--------''------"---'-':----
musclt
Mtdlan umbl11cal fcld (wtlllobllt!r.ated ur.adu.s)
E
lbe.Jepun•ndlem~l'nsltll
Anll!!tiotYii!W. The abdomiool w.1ll has been opened arld the transverse colon has been reflected upw;~rd. Colis of jejunum and ll~m com· plet:ely fill the four quadr;mts of the peritoneal C3111ty below tile trans-
Yerse mesocolon ;md are framed by the colon segments. In this diS$eC· tion the laops of small intestine hM! been displaced slightly to the left In front of the desandlng colon, hiding It from view. The asandlng colonirld cecum are\llslble along the rtghtflankofthe abdomen.
191
2.8
Large Intestine: Colon Segments B Dlstlndhe morphoiOglaol rettures of the " • Intestine There are four morpholcJ91u Ifeatures -three visible extErnally ind one Internally- ttut: distinguish lhe large Intestine from the srNIIlntestlne. It should be nllt2d thrt these features do not occur equally In all parts of' the large intestineand ane absent in the cecum, vermiform appe11dix, and rectum.
Ta.,laR mil
In mast pllltlons of the large lnta•llne, lhelon-
gltudlnil musclt trtoers do not fonn a contln~t ous
r.r II'OII1d the lnlestlnll Will lila are
Olllafill-.1 llofonnthreelongbdlnal binds. not preMnt in C). the taenile
c-
riMiliae ...
the rt!dum or wrmlfurm appendix. Th• three taenia -rge to fonn the mUICullrls ,... tem1 of the appendiX. E'piplok appendices
Aectum
A PrafKtlon of the I.Jrge lnlillltlne oniDU. libletDn BeauseoftheembryonlcrotatlonoftheprlrNrylntesUnal(mldgut)loop, the large inb!stine typically forms a frame encompass;ng the smaII inbe$tlne. The position and length of the colon segments mayviry, however, depending on the c:ou rse of Intestinal rotation. For example. when the lnte1t1nalloop l'1ltltes normally, !heascending colon acquires a"nonnal" length (as shown here)- lfintesti~ rotation is incomplete. the ascending colon b shortened. The lninsvene colon b p;~rtlcularly m.oblle owing to Its mesomlon, while the asandlng ind desczndlng colon ue less mobile beause they ilre ftMd to the postl!r1or wall of the peritoneal c.l'ifty. The left colic flexure usually occup1e1 a somNhat higher level than the right colic flexure due to the sp;~ce occupied by the large right lobe of the liver. Also, lhe descending colon Is USUilly more postl'l1or than the a~ndlng colon.
Fat>fllled pralruslons of the ....,..., oatt.wd over the surface of the large lntmtlne ._.,c: on the cecum (lbsent or sp;orse) •nd rectum
(absent). Haustra (haustratlons) SICCUiilr Will probUSions between the nnJ~rse folds of the la~ge Intestine (see p. 195), ibsent In the nectum Semllun~rfolds
VIsible only~. In contrast to the emr· 1'111 fubns .,_, They
Ire
Nnrt1onll ,..
!Ins caused by contradlon of the IIIIIKlUr ~ The int8nal folds CllrTeSpCifld to Mtamal mnstrtctlons that ~~~p~rall! the h..tn.
The la~ge lnllestlntconslsts ofthe follOWing diviSions In the pi'CIIIIII!III-to-dlstal dlnectlon: • Cecum wlttl tht ""'"ll'onn ~ • Colon. ~ alfuur [Nrts: Iii"'----
-'--+-- Mesocdlc taonla
- AtandlnG C30ion
- Tl'an-rsa CDion - D...,..,dlng calon
- Slgmald calon • lt2d1Jm
C The three tMniM of the Qllon Sigi!DII section, viewed from the left side. The three taenlie are named for their po11t1on on the colon: • Free txnla (Taenia IIbera) • Omental taenlo1 (!he taenia £ the Etachment of !he gmter omen-
tum) • Mesocollctaenla (the taenia
192
Abdomen GndPelvis - - 2. Organs
IUght---ll. all It ftelelft
rree ---!l..~~r:11•
tat!'i;a
Asa!ndlng <>Oion
Ileum. tl!m'lnal p;lrt
Cecum
Vermiform appendiX
Slgmaid col an
E urge tntetttM: segments, shl~. and dlltfM!M fi!atures view, large Intestine. The te1111lnal part of the Ileum ~nd portions of the transvene ~nd sigmoid mesocolon are shown. The ascending and dHCI!ndlng colon have been rot.rted to dlspliiiYtflelr tae· niae. No~: Colorec:tll cancw. which has become one of the most common cancers In Industrialized countlfes. has a spedal predllectlon fortfle rectosigmoid junction and Ute rectum ltself(l.e.• sltle.sdlstal !»the left colic fll!lrure). The lli!r'icxa colon segments po~us all the morphological characteris· tics of!he large Intestine (haustra. t~enlae.. epiploic appendices. see B). Typically tflese features disappear past !he rec!D51gmold junction. As
A~rlor
the taeniae dis.appear, they are replaa!d or1 the rectum by a mntinuous layer of longitudinal musde flbers. Instead of haustra. the rectum has three penn;rnent constrictions !hat are produced by lntemal transvuse folds (see p. 198). The pe!'ltoneall'l!flectlon on the anterior rectal wall represent$ the site wnere the peritoneum isl'l!flected onto the posterior wall ofthe uterus (In the female)orollW the upper surface of the bladder (In the male). NO!J!; The ascending and dHCI!ndlng colon are (secondarily) retroperitOneal arid therefl:we, unlike the .sigmoid and transwne colon, Iiley do not have a mesocolon and are cC~VCRd only anteriorly by peritoneum. The rectum Is extraperitonealln the lesser pelvis. lacks a •suspensory ligament." ind be<~rs olher unique features (seep. 196).
193
2.9
Large Intestine: Wall Structure, Cecum, and Venniform Appendix
lleoc:olc labrum (superior lip}
lleoaeallabrum
(Wtrforllp}
A Cecum•ndtenntn•lll~m Antafor11few. The cecum Is unlq~~e lr1lts end-to-side con fleCtion with the terminal p.art oflfte smalllnte.sl1ne (lleum) andtlte presence oflhevenml· formappendrx.Asaresult,tlterearel:\WiopenlngslfltltewalloflfteQ!Qim: the ileoacol orifio! on a small p.apilla (i'le.al p.apilla) and, bel-lftat, the t:ll'lf1a of thr Vllmll[onm appendbc. The Ileocecal orifice Is appl1llldmately round In lfte IMng tndMdual but Is often slit-like In lfte pcstmortem condltlon.ltls bounded by superior andlnferforflaps or"llps:lfte Ileocolic labrum (• superior lip) and the ileocecal labrum (• inferior lip). Both ane
B Ileocecal orltk:e Anterior VIew of a longitUdinal coronal section of the cecum and 11eum. The 11eocecal orfflc:e connects the tamlnallleum and the cecum (struc· tlnal constriction. see A. p. 190). The Ileocecal Yillve Is Incompetent and .allows reflux Into the terminal Ileum Yilhle. The end of the lle!Jm evagl· nates thecircularmusdelaye.-of the large intestine into the c:ecallumen. Alllayersofthel1e.alwallexaptthelongltudlnalmusdeandpaltone1Jm cor~tlibute to the structure of the 11eocecal orifice. The combined drcular mil!de layers of the lleum ind ceaJm function iS a sphllxter which periodically operu lfte ortftc:e, alklwl'ng the contents of the smalllntes· tine to enterlfte large intestine while effectively preventing reflux. The funcdon of lftls sphincter Is similar to !hat of the pylorus.
194
com!nued iS a namlW ridge of mucosa, the frenulum qf the lleoc«al ortf!ce. Nolle: lflflamrnrtlon oflfteW!Tillfomuppendrx(appendlcltls) Is one of lfte most common surgically b'eated dise
Asandlng colon
- + --
Healp;~plla. -+----.r.{<~\.
lleocdlc labrum Is~ !ill ~~~~ lfe.;~lpaplla,
lleou.:allabrum Qnfl!flcrlp)
Abdomen Gnd Pelvis - - 2. Organs
l:rmPhl1kfallcles
C lnterlorofthec:olon The Interior of the colon Is ITiill'ked by transvendy oriented folds ailed semllunar folds. They are formed by the shortness of lfle muscular tile· nia of the colon wall and are visible tOOem.ally as anular consbictions. The S<~cculatlom between the folds are lfle colonic haustra. The Hmnunar folds are Inconstant fe<1tures that depmd on lfle musCIJiar tension In lfle tilenla. The folds and haustr<~ mcwe slowly down lfle colon wllfl waves of pertstilltk activity.
D ~II structure of the colon nd CJKUm Longitudinal section til rough lfle bowel wall. All the typical wall layers ofthe gastrointestinal e<~nal are present the muCO.Iil, submucosa, muscularis extl!IN, and seroS<~ {or adventitia lfl the retroperii:Dileal parts of the colon, see a. p. 187, and D, p. 153). There are several features, however. that distinguish the wall structure of the colon and cecum from that of the roxnach and small Intestine:
• The muCOS
McBurney
pont
Rlghtanttr!ar ----'l~~::eir---'-:"-;---.e--- ldt anterior supe!ar
llllcspile
wpo!tforlllac spine
!Anrpolnt
E Yllrlln'bln the position of the ftrmlf'vnn •ppendlx Dlsturbinces In lfle rotiltlon of the embryonic gut an result In numerous positional variants or the cecum <~nd vennlform appendiX. The appendix may tM!n rome tD lie in tne left side of tne abdomen. The lnflamiTiiltiOfl of an appendix In the typkul position Is characterized by tenderness at two points: • McBurney paint: Position an a line connecting the umbilicus and the right anterior superior lilac spine. The McBurney point Is on~thlrd or the distance alor~g lflls line from the lilac spine. • Lomz point Position on a lir~e aonnecting the the anterior superior Iliac spines. The lanl point Is one third of the distance along this line from the right spine.
F Wlllltructune ofh wnntfonn appendix Thevenniform appendix has tne typie<~l wall sb'uCU.re of an intr.aperitDneallntest!nal tube. One strfldng feature b lfle abundance of lymphatic follldes In the submucosa (also present In lfle color! and cecum, but In much smaller numbers). Wllflrts high degree of lmmunotoglc.~l actiVIty, the appendiX has been characterized as ttle •rntz!Sifnal tonsil.• The mucos~ has numerou5 deep crypU that ~rein intimm cont
lllttlough very useful,lflese are not deflnttlve dlnkal signs. Tenderness may be felt at oCher abdominal sites, especially If lfle appendix Is lr1 ;m atypical posltlofl.
195
2.10
Large Intestine: Location and Shape of the Rectum
}-· A Prqectton of the r.ctum onto the bony peM1 Anterior view. Therectumextelldsipproxlmatelyfromthesuperlorbor· der of the third s.1cr.al veiUbra to the perlnl!llm and~ 15-16 em long. It is "str;ight" only in the ~tal proj~ction (as shown h~re); it pl'ft~nU ~flexures In the sagittal projection (see 8).
B ~rveJ of the r.ctum
Left interior view. Two curves Ciln be Identified: the s;~crill flexure (ret· roperftone.al) and the peri'ne.al flexure (ex.traperltDne.aQ, which represents the start of the anal canal. The socrol (kxure is anteriorly conCilve, foiJO'Mng tile curvature of the siiCrum. The more dlst
D DTstTncUIIe morphoiDglall futiJI'H of the rectum Alltlough ltle rectum Is mnsldered part of the colon. It d~ from the large Intestine by the ollRIIa of stWral coloniC cha11ctells-
Tr.wper!lonml
aa:
-~--1--n-
~pcwdl
• f.J)ngltudlnal muscle bands (taeniae). The rectum has a continuous longltudl· nal muscle layer. • Fatty epiploic appendages • Hauslra • Semilunar muODUI folck. The rectum has deep.llrve trai\MI'se folds (see p.198). In addlllan, ltle rectum hal a comPDund em~lc or1gln. Abwe the anorectal line,
It Is deriW>d,lllre the colon, from embfY(Ink
endodenn. The anal canal, '-er. cleveJ.. ops from edlxlenn.
c SIJrglallappro.lldles to the rectln Sagittal section through a male pelVIs, left lat· ec;alview. Noi:J!: With a posterior or Ciludal approildh,lt Is unneceSS<~ryto open the perftoneo~l cavity be-
196
Ciluse the rectum Is retro- or extrape!'ltone.al. The ma)or advantage of these 01pproaches is tfl
Abdomen Gnd Pelvis - - 2. Organs
Fm!
£xbmll
I lee win
Obblr.ator - --:-:-;.-'-r
lntmi~Amusd~
Rectum
tunla
Sigmoid mesocolon
''
t.ewtoranl ----'-+~i.---~lli....
llil.~~---•ntemalpudend.il.arll!ly
musde
~f.--":c---lntemalpudend.i!Win
Eid:emll ~nel ---..;...,..:,..~---.-----:,.-1.,:.:-.. sphlnctl!r
E
lntl!mal.;nal
Anal
Transwr.se
sphlnctl!f
anal
rt
lbe~mlnslbl
Coronal se<:tlon of lfle feiTiille pelvis. antErior view, with the rectum opened from about the lew! of the middle tr;msverse rect.11 fold. The t.1enlae of the sigmoid cnlon are not cnntlnued onm the rectum. The constrictions in the outer Will of the rectum corTeSpond to the trans· vene folds on lfle Inner Will. The rectum (which would appe;rr In this form only Ifthe ampulla W8e full) Is shown In a slightly raised position. Below the lev.~tor ani muscle Is the powerful external analsphlnetl!r, the
muscu13r component of the reoct;~l continC!Ilte o~an. The pararectal connecUYe tissue below the peritoneal c:.Mty contains numerous vessels that supply the rectum. This dr.awrng was made from the dissection of a female cadaver. Thus, the peritoneum would be refletted frvm the 3nteri~rWill of the 11!ctum onto the posterior Will of the ul:ef'Us. Although both the antErior rectal wall and uterus are not 'lllslble here (antErfor to this plane of se<:tlon). parts ofthe rectouterl'ne folds are stlll 1/lslble.
197
2.11
Large Intestine:
Wall Structure of the Rectum and Mechanism of Defecation
l'er!blnealcow
ofreciiJm
=:;;;;,...;:...:~,;..;....---
Supe'lortnlnwaw
rectal fold
lllllKlllarts )
ext!tma
,.............==:::.,.._.;.:...;:;_,;.:____ lnfet!crtr.lnswne rectllfcld
SubcutiiOI!OIIi
- - - ----l:,.
p;rt
A Redum and a111l a nil: lntltrior and Will structure Anterior view of the rectum In coronal section with the <1ntafor wall rernorml.ln~re<~d «semilunar folds, the rectum cont31ns three penn;~· nent tr.msverse folds. The tennln<~l part of the gastrolnte.stfnaltr.ict Is divided inm two segments based on its murosal surface anatomy (all!> rectal line)*: • RecUI ampulla: the lowest portion of the recwm between the mid· die transvene rect<~lfold (Ktlhlrauschfold) and the anorectal junction. The ampulla Is tile most dl~tmslble part of tile rectum. The middle transvene fold, which projects rom tile n!Ct\lm from Its right posterior wall, is <~pproximately 6-7 an from the anus and can just be mched with the palpating finger. Rectal tumors located below tile Kohlrausch fold may therefore be p;~lpable.
198
• Anal canal: di!YI!Iopment3lly, a pelvic floor derivative located below the ano11!1Ctal junction and tamlnatlng at the anus. The anal canal Is suiT'Ounded by tile Internal and external anal sphlncten and the levator <~nl musde. The hemorrhoidal plexus Is a network of caMTIOIIS tissue with an arterial blood supply. The muscles and hemorrhoidal plexus combine with other structures to form the continence organ (see C), whldl pi'OIIfdes for fecal continence and flatu~ control. The pe!'lllaneum COYers tile n!Ct\lm liltl!r<~lly .ind antertorly to .approldmatelythe lew! of the middle tranMne l'l!!ctal fold. • The .anal canal may be considered tbe lowest segment of the rectum based on functional cllnlc.1l corukleratlons as well as functional .ar.<~tomkal a!te!'fa {neurovaswlar supply, lymphatic dr.ilnage). In this interpretation the anorectal junction HFaraw two rectal segmenb: the (upper) rectal ampulla and tile (lower) anal anal.
C 5trudllre af the mnlfnenm organ and 111edlanllll'lllfdefealtlan The~ Ofllll1 prawlda far~ clolr.n ~ t~ reoctum and OJnSIIts d ~ clsterdlll holow Ol'9lllo vascular and rnuspp..lOO, 201) Clll1llrwna! ....n. nlsms, lnd thdr neural
......
)Indian Dent.telln~
----...:::....,.........:.::......__-.11-..
• Dhanslbleholl-o111•n: - Rectum wtth Its strtkh reaptors.
An0<11b"""'us ____...,::::.::...::---:....._--!~ lin~
.........,
E'pllhellln
Colon-tyr- epithelium with crypts and goblet otlls Anarwctal Junction (formerly: ano~c aolline)
• Column.r zone
Slr.UIIed, nonlltratlnlzed squa rnous tplthehum
mMt nume10us In the rectal ampulla (111om......,soryln...,.tlon) - Anus with di*nslble skin In the an~l canal (somatosensory innervation) • Mu!lalllr oonlinenar. - lnt.r111lanal sphincter (visceromotor lnnenlltlon) - £xter111hnal$phlndl!f' (somltomotor lnneMtlon) - t.vaiDr ani com plu, eopedally the pub~lls muscle (sornaiDmotor Innervation) • Ya!lallar oontlnenrz - HlmCIIThoklll piiiXIIS (permanently distendad ~us tluue that subsides only durtng defeatlon) • Neural mntrol: - Vl...alond sorMtlt neM>LB ~12m (mainly from sz- 54) with the peMc lplancMic -
redalplaus
• Olbneous-
.........
~
(pigmented)
I Epithelial regbw afthnlllll ~IHII (after l.OIImann-Rauch) The anal canal Is the terminal part of the allment.tryunal.ltcan be divided into three levels bas.:d on the chal'ilcteristia Gf its epithelium. These levels reflect a trillnsltlon frvm the rectal epithelium i~ the 1nal anil tD the exll!mal perine..l skin bel- the anal unal. The three levels of the IIlii aNI are sepa1111ted by two Indistinct lines thit mark the ep~lal Junctions. Hoi!!: The anal pec1:81 hau whiiWl appearance ("whe zone") beCiuse the mu=;a at that
Slr.UIIed, loerltlnlzed ~~ eplthell\lm with s.ebaceous glands !tratllled, laer.Unlzed squamoos epithelium With s.ebaceous glands, hairs, and sweat glands
levellslntlmmly attached to the Intern~ Ianal sphincter by connective Ussue. The pectl!fl Is e~~dowed with numerous stretch and pain receptors (rella zone fDr continer~ce and defec
lneatment
· pudendal-. and
The ...... Cll'gll\ a.ntnno. mecNniJms, and neur.r oonlrol (see ~) Interact n w-durlng cWk.laon: - Fillingofthe..aalampulla - Stlmulotlon rtllocal slretl:h rea~plln In t~ ampullaryMII
- u.,. ""
clef.cmt
_, Contr.ctlon oft~ recnllongltudlnol musd.. short.nlng the rectum - 101-..tlon of th• anolsphlnctars (lrtcreues blood draln~~~tfrom the ~or rhoiclal piiiXIIS, which dttumesc.!) and the pubol'lldllls muscle _, Wld.-.lngofthean~lanal plusmlght.,,ng of thei'IICium
Defeadon is also assislled by straining. which ralsu the lntn-.bclomlnol pressure. The oontrol Cllltlr for cllfec.atlon hes In the SZ- 54 Mgnwnt:l of the sacral splnol oond. Nter a r1y child hood (when hygltnlc habits are ICAIUINd), d.r.catlon and fecallnconUnen~ .,. also •bject ID volunbory central neM>us oontrol.
199
2.12
Large Intestine: Innervation of the Rectum and Continence Mechanisms
tlfufor~
ntetllfald
l.evltlx'anlmusde: --..:........;,.....," I'Won!Cblfs
~~~~~~~-----H~~
plexur.
Exb!rnalanal sphiu:b!r
SLCOerfkiiiiPtrt --....,..:~:,....o!;
sphll'dl!r
Subcut.lneous --~~:-':::::0~ Ptrt
A Contl'nen«:2 111f911n: structure ofthe miiiCIIInmntfnence mcchlnllln Ant:erlorvlewof!he rectum In coronal section wllh the anterior wall removed. Tile continence organ consists of four functional compooents: • A structurally narTOW segment (chiefly !he Internal anal sphlnctl!f) • The •.anortctal angle• creatl!d by !he puborectalls mwde (• com!)!> nentof the levamr ani mill de,. see B) • The constricting function ohne extunal;mal sphlncur
B Contl'nen«:2 0f911n: closure bytfle pubon!ctlllll musde The pubon!ctalis mill de it. a component of the lev.ator ani complex. It arises from the posterior surface of the pubic bone and loops around !he rectum to fonn an anteriorly open sling. By drawing the rectum anterosuperlorly, It Increases the angle of the rectal "kink" (part or the perineal f!l!lWre) above the anal canal and helps to pnMnt fecal expcJislon. Nobi!:Thepuborectallslsthemostlmportantmusdeformalnt.11nlngfe· cal conl1nence; Injury to that muscle (e.g .• during an operation) r4!$Uits In more severe Incontinence U\an Injury to both of !he sphincter muscles.
200
.,_.,.;:;,;;,.....,......l.:..:;..~---lnb!miiiMII
'-=-'~~---'"=:.:..;._--Corrug~ cutis ~nl muscle
• Theexp;ansil'l!and constricting properties of the hemO!Thoidal plexus (lo~d beneath ttle mucosa In ttle rectal w.rll. see D) Noh!: Fi~ from the internal anal sphincter pil$$ through the exter· nal anal sphincter and blend with the subartaneous tissue of the perla· nat skin: thus. a visceral smoolh muscle projects Into ttle subcutaneous connect!l'l! tissue. This exp;~nslon of the lntemal sphlnctl!r, wllosetonus tightl!ns and wrinkles the skin around the anus, bears the specific name of•corrugamr artls ant• muscle.
S)mpothotlc
trunc
1---l'--"'i,...........li~-- l.urlll»r op!Jnchnlc-
:Mcllll pii!IWs Bnonch.. fn>mS2-S4
T"'litll-- - SUpllforh)opo-
- ---.::<---+
gastr1tplous
--+--f
Pudendol
_.....""-- - S.cllll !!Utchric nerws
lnfellcr recbll
-~,..,.,/,:.~H~~_Jc.J._ PelvlcspLinchrlc
........
nerwo
nerws
"
Oltlneous
lramal anal
zone
ophlndu"
~~--
lntamala,.l sphlndu"
b
C lnnerwtlanafth!!CIIIIItlneMRarw-n (ollfterstelzner) Somammotor ;md JOmitosensory Innervation, b v!sc:e!111Tlotor ;md viKerosauorylnnervitl.on.
il
• Somatumotor. pudendill n~ for the emrn~ ilnill sphlnc:tl!r. levator nerves fclr the leviltDr ani musde (espedilly the puborect:alls). They provide acUve, partially lduntary lnnervitlon of the extemill anal sphincter and levator ani. • Somatusen-r-lrnri~Jr ~I nerves for the ilnuJ ilnd perianal skin. Arising from the pudendal nen
• VIsceromotor: pelvic spl;;mchnlc nerws (52 - 54) fur the Internal ~ nal sphincter. The resting tone of the internal sphincter helps to ma intllin closu ~ of the anal C
D ConUnenm org~~n: ll'tl!rfllsupplytD theW~CDIIIr mntTN!MR medllnllll\ (hemorrhaldll pii!IIUI)
External and Ciludal view of the perineum (supine patient In the litho· tomy position). The hemorrfloldal plexus Is a pei'TI'Iinently distended Cilwmous body at the a norectal Junction. It Is supplied by thii! superior recta Iartery, and sustained mnt:taction of ttle muKlJ lar sphincter appantuJ In a mntlnent lndlvld uallnhlblts wru1us d ralnage from ttle hemorrhoidal plexus, which nemalru full and ensures giiS-tlg ht dosure of the rectum. The hemorrhoidal pii!IWs Is supplied by arter1al branches at ttl~! 3, 7 and 11 o'dodc positions (no~rttly for ligation of the superior rectal ;utay). When the sphincter ipparatus relaxes during deletiltfon, It removes tension from the hemorrfloldal plexus ;md illows blood to drain from the cavernous !Issue. Nom: The condition known colloqIaiiy as hemonftalds results from a b· normal, excessive dilitlon and consequent abruion gf the hemorrhoidal plexus.
rtectum
Nutrllnt .nory at3 o'dodc Nub1entart2fy
- -..3!:;i!!
at7o'dodc
201
2.13
Radiography of the Small and Large Intestine
Ileum
A Do11ble-annrt ndO!l111Ph ofthurNIIIntertfne Double-con!Rrt radiograph of the srmlllnteJtlne In the antef'Oposrerfor profectlorl (x-ray source lr1 front of the portfent, fllrn-screer1 combl· nation behind tile patient). Antefforvlew.ln a doubiKOrltnst study, alr i$ instilled into the bowel thi'OII!lh a wbe ;and a radiopaque liquid con·
202
trast medium i:s administered to provide an exceptionally high·contTist lm<~ge. This technique guarantees hlgh morphologlc.;ll resolution and Is senslttlle In detecting mucosal dlanges. The Image above Illustrates a normal double-contrast study. The transversely orlen!l!d drcular folds of the small intestine are defined with great clarity.
Abdomen GndPelvis - - 2. Organs
Right colic
llelcure
~lng
colon
Sgmold Ollon
8 Doub!Mioll'lnl$t ndlognph of the 11111~ Intestine Double-colll:r.lrt radlogr.~ph of a nonnallarge Intestine In Ute anteroposterior proJection, anterior llfN. The tllm clearly demonstrates Ute diffetl!nt p.arts of the large intestine and their haLIItra. Tbe radiap.aque contrast medium is notCM!nlydistribute
~ the variability In Ute shape <1nd position of the colon segments comp.ared with the diagrams In A. p. 192. and In E. p.193. The Image abcwe shows considerable ugglng ofthe tran.swne colon 1r1 the stand· ing patient. but this finding is well within the normal r~nge of varia· tlon. Bee<~ use the transvene colon Is Intraperitoneal, It has a mesentery (transverse mesocolon) that gives It considerable mobnlt)'.
203
2.14
Uver: Position and Relationship to Adjacent Organs
Spleen
c
Costalmargh Left supra~ gand
l..lvEr ~i---
Ldtkldlt!f - -----\=
b
PrcfedTon of tfle liver onto the trunk •nd 41dj11CII!nt organs; palpation of du~ Iher ;a llnt1!rlorview, b posterior view, c; palp;U!ofl ofthe liver. The liver Is situated mainly lr1 the right upper qu;!drant but extends .across the eplgas!Jfum Into the left upper qu;!drant,lylng antertortothe stDmach. The right lobe or the lilll!t is closely related to the right kidney and right col it flexure. Owing to the dome of the hemidiapllr~grn. the ple\lril cavity overlaps the .1r1terior and posterior surfaces of the liver. Bec.ause the IIYef Is attached to the lnfenor surface of the dlapt,r;~gm. A
ltlghtwpran!NI gland
Rectum
ItS position Is slgnlftc.antly affected by resplr.rtllry excursions. ltalso depends on posture and age: The liver de.KC!Ilds in the mnding position, and It Is aiJO affected by the gradual settllr~g of organs that ocaJrs with aging. The liver Is palpated (c) most e;~slly by having 1he patient lie su·
pine with the abdominal wall relaxed (legs drawn up) .and exhale fully (the lil'l!t rises with the diaphragm), followed by a full inhalortion. This
causes the !rver to fall. and lU sharp lr1fafor border (see D) can be pal· pated at the margin of the rfbs. If the IIva' Is abnormally enlarged (hepatomeg.iily),lt may oc;c.aslonallyextend to the pelvic brtm.
'""""'-::----:':--
S"""'ren~l
Imp radon
Spit«~
~.-::'"::t!it--1:::+-- Omo!nbll
bun a, splenic
n!Oe!l,$
smmach
8 Posltklr1 of the liver Tr.an.swrse section through the ibdomefl at .ilpproxlmatelythe T12 Ill IIM!I, view!!d ftorn a~. The IM!r is inlr.lperitone
204
Gntric
CtJUc
fm-slon
mprm~on
C Arusofcorttolctwfthother01'9ins
VIew of the visceral surface of the liver. Noa: Impressions from organs that are in dil'l!!ct contact with the IM!r ~re visible only on a liver that has bftn hardened In plate by a cheml· cal preserv.rtlve {"llxatlon"). An unflllied lrverfrom a c.adilva-that has not beenchemkallypreieNedlssosoftthatgenerallyltwlll not show organ lmpreS$IOns. Diseases ofthe lll'l!r may easily spread to other organs. and vice lll!rsa, ~t aneas of contact with ~djacent organs (extensilll! owing to the size and topography of the liver).
Abdomen GndPelvis - - 2. Organs
-
Abdomlnral
Rl¢t g;atro. omentalartl!ry
Duodenum
ClJtedgeof lesHr amentlm
Splencaotery
Mttrlot superior pancreatlco-
duoden.ll
D The llvertnslbl Antll!rlor view of lfle opened upper <1bdomen. Retr.iel'llrs hiM! been plaa!d on the liver arid spleen to imprwe lfle exposure. The lwer omentum has been opmed. allowing a direct '¥lew Into lfle oment
the hepiltOduodenalllgament. transmits the blood vessels of the ltwf (prcper hep.ilt:fc artery .ind portal vein) and lfle commor1 bile duct. The contour d the right kidney an be ~n on the inferior surface of lfle right lobe of the liver. Noa: The opening of the hep.ilt:fc veins Into the Inferior vena C3lr.l Is loc
205
2.15
Uver: Peritoneal Relationships and Shape I.A!fttlilllgular ligament
Abra us appendiX cf IM!f
RlghtlcMcfiM!f,
\lsmalwrf.aat QudmpRighthep;ltfccllct
RlghUrfangulu IIQament BrMI
G.lllblildder
A Pefftonealcowrfng of the ltftr Postenor vff!Wof lhe upper part oftftedraphragmatfc surface of the IIIIer. The liver is sum:MJnded by a fibrDus capsule with ~sions that pass lnw the liver and transmit n~roYaKularstructures. Most of the svrfoa of lhe liver Is covered by glistening viKeril peritoneum. which Is exter· nal to Ule fibrous capsule. Only the bare area, whkh Is highly v.ulable in exlznt, locks a pM!Dneol aM!ring; it has a rough appe
which hive mesenteric structures for transmltllng !heir veins ;md arter· les. In Ute case of the IIIIer, only the C/fri!rl!nt artery, a{frretlt portal Yeln, and common bile duct course ill the hepatoduodenalligament (seeCb), while theelli:!rentveir!i$do not. At$iteswhene theviKeral pc!riton~m is reflected Into the parietal pertto~m on the Inferior surface of the dlipluigm, Ute delicate peritoneal epithelium Is oftEn bacted by connectllle tl$$ue to form a llgamen1llus b.'lnd (coronary ligament, see ca). This connective tissue is dr;swn out into a taPC!"!d band at the ext:remity of the left lobe (the fibrous appendix oftile lim').
PMI'eul peritoneum
r~or Yellil avi
Abdom'holl <~Orta
\
•
b
B 8Ift area of the IIIIer and tfle hepatk surf~C~t of the diaphragm Posterior lllf!W of Ute diaphragmatic surface of Ute IIIIer (a) and Ute In·
ferior surface of the di;lphragm (b). The linn of periWneal reflection on the liver and dlaphr;rgm demonstrate the mirror-Image correspon-
206
dence of the b.'lre area with Ule hepatic surface of lhe diaphragm. The b.ilre area Is firmly attached to Ute lnli!rtor surface of lhe dlaphrigm by peritoneal reflection (coronary ligamenU), rendering the liverimmobile despite IU lntr;rperftonealloc
Abdomen Gnd Pelvis - - 2. Organs
Right lobed IM!r, dlaptuagnatlc
turfaae
r~cr
L\Qame.~tof
B
Flbrws
llj)pj!ndbcofllwr
Right lobe of lilottr,
Ga'ltrfc lmpn!'1Slon
Vlllcl!falsumce
Prl)l)efh~c ,rtery.
right bnll'dl
Right hepatic duct
Com man b
C ll'ller: cfllphl'lgll'lollk and 'lll:&eel'lltUrfM21
Arnerklr'lll:-ofthedl;rrphr..giiM'Iksurf.lce. Twolobnarevlslble In !his view: the larger rtght lobe and the smaller left lobe. Between !he two lobes Is!hefalciform ligament ofthe !rver, a •ventral mesentery• !hat extends mthe anterior abdominal wall. b lnfctigr 'lll:ew of tile vltcel'll.urfJCit'. Two more d the fl:lur hepatic lobes are visible In lhlsvlew: !he caudate lobe and quadriltl! lobe. The vlsceril surfice .1lso contains !he port;1 hep;rtls where neui'OIIa1aJiar structures enter and leave the IM!r (common hepaUc duct, p~er hepatic artery, portal vein). Topographically, the hepatoduodenallig· ament Is,. component of!he lesser omentum. The extent of the he·
;rr
c.ystlc duct
Gal bladder
bile duct
patoduodenalligament can be appreciated by noting !he cut edge of visceral perito~m surrounding !he portal triad. Along with !he hep;rt»gl!trfc ligament, It creites a "dorsal mesentery• for the IlYe!'. The numerous Impressions from adjacent organs .ilre seen !his pl;rr!nly anly in a liver that has been memically preserved. The gallbladder is closely aPFiied to the visceral sur-faa! of the liver. Its fundus extends slightly past the InfErior hepatic border, and Its neck Is directed toWird !he porti hep.itls, ¥>flere It comes Into cont.1ct wllh !he eidra· hep;rtlc bile ducts.
207
2.16
Liver:
Segmentation and Histology Lcftmtda,l roegment(4) ~rglclill',uppor
subsegmtnt.C.)
/;f
Right
pomramedld segment(l) Rlght-pooll!rollllnl segment(7)
-
Brindle> of h..,.UC VI!!no llrlndle>ofportlllwfn llrlndle> of proper hej811c •r11ery llrlndle> of hop;rlk duct
A Segmentation JJIIIIe llwr Anterior view. The proper hepltlc artery, portal vein, and common heJNUc duct enb!r/ ~dle llwr ll:dle porta hepitls u dle "portalllfad." Th~ ~r~l branch fir~t divides into two i;lrger branches, function~lly subdividing dle I~ Into left parts (yellow) and right parts (purple). The boundary b~ IN left and light parts of dle I~ Is an Imaginary line tNt roughly connects the 5J1IIbladder bed to the Inferior wnil cava (ci11Vai1Jitllblidder line, see 0.). Thus It Is not Identical to tile externally visible boundary formed by tile falcifonn ligament (see p.207). The portal triad continue to ram lfy within the liver, fonmlng a tutal of eight se!Jo ments thll: are more or less functfonally Independent of one another. Th;, allows the surgeon to nesect one or more hepalit segments without danaglng the liver as • whole. Additionally, the remillining hepatic segments haW! a high regener~ potential. In the diagram above, tile llverhu been "el!Pioded" at Its vlrtu1l segmental bound1rlestD demonstme dle position and shape of Its segmtrlt:l (numerical designations are shown In a and C).
Rlght -.b!rollllnl seament(6J
lAttmedlll Right ~nll!ramedlll oegment(S)
Mgment(4)
(1.-glally. loMr subsegment 4b)
Fbrous
C.udalobe
IIJpondK
(past211or p.-t of llwr).
oegmentl
\
I
lnfmor WlliaYO
Right onterollllnl segment($)
l.!ft----
~nllrdno~
...gmtnt(l)
Right anl2n>onedlll oegment(5)
~m-.n/ I llo..soflwr
l.eftmedalsegmtnt(4)
C:.llbladder
(W'l!lully, bootr wbroegment4b)
Left ..lltfll
thellftr
• Post8rlor p1 rt. audltllobe • Lll'l: literal dMsiDn
• S.gment1 • Lift posterolmral segment
(• segment 2) • Lift anterolallnl.segment
(· segment 3) • Left mecn.l
• Lift medlill oegment
divlsian
llghtpn ofdleiW
• Right mMIIII division
• •
• Rlghtlllllral division
• •
(• segment 4). subdivided Into suboegment"" ~~~) and 4b (below) Right •nll!ramedl•l segment (• oegment5) Right pasteromecllool segment (· oegment •> Right anterolateral segment (• segment 6) Right posteroliteral segment (• segment 7)
208
C Pro)edton Dlsesmenul baundilrle DIIID the surfilm althelwr Views of th~ dillphrag!Ntic surface (•) and vfscmll surface of th~ liver (II). • The seg mtrltS defined by the divisions of the portal ViiScular trlild (see A) are projected onto th~ surface of dle llwr with dlelr lotrtual boundaries. In this way the pattern of hepatic segmentation. which Is based on vascul.ar dlsllfbutlon, can be directly Cllmpared with dle tndltiona Idivision of the liver intD four lobes based on extemal morpholog i~1 crlll!sfil. For surgl~l purposes, It Is useful to group the segments by parts and divisions (see B) because dle por1lon of the liver selected for surgical resection may encom pass notjustone segment but two neighboring segments or the enlf~ right or left p1rt ofthe liver. Surgeons can positively Identify the hepatic segments by ligating the feeding vesse until the segment or segments beeom~ discolored due to lo" of blood supply.
• Blue line In b: caVi111)allbladder line
~4:-....;......,....-------
lr.,chofablle duct (lnbliobular b1e ct.Jct)
D HIIIDiaglml ilpp&l'illa! ol 11 porlill iii'H
anhosls al the IJwr Is chiraclertzed by 1 prollfemlon of connective
Hemalmytin and easin oin, magniraution appn:mirNUiy 540:~. The pornl trlad of the liver, while grossly visible it the porn hepitis, rimlftes Into o1 network of microscopic bnonches embedded In connectiVe tissue: the port
tissue In the llwr tNt Is most conspicuous In the portal am and about the central wins. Necrvtic htpiltocytes are permanently replaced by sc;ar tissue. The sinuses- the caplllilry bed of the 1'-"-are obliterated In the scarred ams, progresslWiy diminishing the blood ftow through the llwr. The afferent blood vessels are still carrying the same amount of blood to the llwr, howewr. This c;auses obstruction of pornl wnous now and an abnormill pressure increoase (portil hyper"Wnsion).ln m;any cases the blood Is returned tDthe right heart by an altmlilte route (portosystemlc colla.rals, SN p. 293).
• Interlobular artery: thid wall, squamous er~dathelium, SINHlumen • lnterlobul•r vein: thin wall, squ•mous epithelium, large lumen • Interlobular bile duct: a1boldal epithelium o1nd vay smo1ll lumen
H~
llruch
E Sbucture afil mntnlwnour;lollllle (h..Uc lollule) This is " tlrree-dimmsiona/ stn/ttUn1l mode of a hep;~tic lobule based on studies of numerous hlltologlc;al sections (see D). It shows tNt uch poi)tledr;al hepiltlc lobule Is composed of htpiltocyll!s that are arr~ around a central vein (hence the term "central wnous lobulej. Ultimately the centrill veins reblm their blood to the hepiltlcvelns. The portal areo. (see D) In this model rs located bftwHn ~djacent lobules at the points where the lobules Interconnect (hence the term "lnterlobular" for the artery, win and bile duct). While the interlobular artery and vein convey their blood into sinusolds that have 01 mble wall (see D), the billa ry CiiNIIaJII thit tnmsfer bile to the lntl!rlooolar bile duct do nat ~ their own walls. They also course benften the hepatocytes. but on the oppositE side from the slnusolds. If biliary slllsh develops between ad)acent hep;~txr cyb!s (e.g., due tD hepatitis), the hepatocytas mo~y sepilrall! and lose their lntermlular conticts. Abnormilly large lnta'spilces miY form. alkMtng the bile to escape from the bftl.iry canillkllll ind seep tD the opposite side of the cells, where it can enter the sinusoids and bloodstrei m, causing a yellowish dlscolorltlon al the sldn and mucous membranes (Jaundice).
209
AbdomM and l'eMs - - 2. Organs
2.17
Gallbladder and Bile Duds: Location and Relationship to Adjacent Organs
A Praflldlan fll the elltnlihepdc bile ducts gntg the lbllton
VIewed from the front, the gallblitdder Is project.d It a point where the mlcklavlaJiar line lnt2rsects the lnfel'lar border of the ninth l'lb. The orilitz of the cgmmon bile duct (which generally opens jointly with the pilncmitlc duct on the major duodenal p;~pma) Ires appi'Diimltely at the level of the L2 vertebral body. The g~ll~dde- ernerge5 benelth the right cgstal arch at appi'Qidmately the L1/ L2 level. In certain diseases (e.g., cholecystitis), tenderness to pressure may be noted at this location.
a Prafedlan fll the lntr• and extno-,.tlc WI• ducts ontD th•IUit.lal fll th•llwr Antl!rlor lllew. Bile flows through the biliary ca nallcull (microscopic) Into the sm<~lllnterlob ular bile ducts in the portal are;~ (see p. 209). Thne ducts Olillesce to form lncl'llilslngly larger unlb thlt drain i hq~atk segment. The bile from all the segments ultimately drains into twD large mllecting ws.sels, the left: and right hepatic ducts, whkh rece~ the small left and right ducts of the caudate lobe, respectlwly, while still Inside the llwr. The right arvlleft: hepatic ducts unitz to fonTI the common hepatk duct. Almost Immediately the excretory duct of the gallbladder, the cyJtk duct. enters the side of the common hepatic duct. which then becomes the common bile duct.
RJgrt
"'''"'"" ~ (fsdc duct
left hepatic cb:t Common hepotlc du.c t
Cilllbllldder Common blleduct
L4-bra
Rlg1t duct af
Left duct af taldlte labe
CIU~ia
Common ~duct
4'stkduct -----.~'"77<---......:::i'\
Left~
duct
----Bin!IIU
l.eft--
--
hopatlcw\'1
\ --------U~M
afwnoavo
Caudltelobe - - - - -
L.eltlcbe---
- - - - - - - - Portlllltln Right hepotlc duct
c
PMIlion til the g..lllladdl!l' et the part. he~ lnfeior ll1ew with the common bile duct di-
VIded. The perltoneil COW!rlng of the I~ Is reflected onto the gall bladder, which therefore is intra perilune<~ I.
210
Abdomen Gnd Pelvis - - 2. Organs
Rlghtlabe ofltwr LA!ftSJpra11!11al gland
I.A!fthl!patlc
duct RJ~ht hepatic
Cellae trunk
duct Common
Splenic
hepatic duct
artay Common hllp.ltlc lii1By
cystic duel
l'l'apj!r htjl.Kic artBy
"t.lllof p.1l')Q'SI
Gall bla ddl!r
LA!fta.tc flexlre
Common bile duct
Bodyd p.1l')Q'SS
~aUc
limn
LA!ftllldney
Common bile duct.openng
JejunLm
oomajor duoclen11 p;Jplll
Desaodlng o:
P.anae:rtlc
DLIOdenum,
SUpmorme:ll!lltlerlc
diet
asoendngp.vt
ar11eryandw!n
D RelatTonshlpllfthe blllarytnr:ttltldjiCII!ntorgAntl!rior view of the opened ~bd~men. The SWn~ach. small intestine, transven:e colon. and large portions of the liver have been removed, ~nd the peritoneum has been divided lr1Uie area ofthe hepatoduodenal llg~ment. The gallbladder Is partlallyccnt.arned In a fossa on !he v~saral
$Urface ofthe liver. The common bile duct pas.ses behind the duodenum
towird the he.'!d of the pancreas. After passing throii!Jh the head of the pancl'ea$, the bile duct frequently unites with the pancreatic duct, as $hown here. BoCh ducts then open togelher at the maJor duodenal pa· pnlalnthedescendlng part of the duodenum (seep. 188).
211
2.18
Gallbladder and Extrahepatic Bile Ducts: Structure and Sphincter System
c.llblulder, lnfundbuhrn
---,..r,.,to~. \
-------Duodenum, superior P'l rt
Galbladder, - -....,,..,.. fundus
----Duodenum. hartzantll p;ut
A Dh!llonnftheutnheJN'Iftblledudl Anterior view. The gallbladder has been opened, and the doodenum has been opened .and windowed. The web-lllae pattern of folds In the gall· bladder mucos-1 is plainly seen. The mua:~:~a between the folds may be deepened to form crypts that can tr~p b
212
doodenal ~pllla (of vatu). Ashon distance superior to the major p;apllla Is the minor duodenal papma, whose associated duct (accessory ~ncreat:fc duct) crosses In front of the common bile duct. Tbe dlagr.am illustrates a normal pattJ!rn of development in wflich the common hepatic ~nd panaeatlc ducts unite to form an ~mpiJIIa (variants are shown InC). Notr: The combined termination of the common bile duct .and ~ncre alic duct has two important implications: A tumor in the head of the ~ncre<~s may obstruct the common bile duct (causing biliary reflux Into the liver wtth jaundice), ;~nd a g;~llstone that his migrated from the gallbladder Into the common bile duct may obstruct the termiNI ~rt of the pancreatic duct. The obstructlon of pancreatic secreuons may lnclt2 .;~ llfe..thre
Abdomen Gnd Pelvis - - 2. Organs
Sphncl:2f
ofoommon bll~duct
:s=;=--- Sphncl:2f
ofp.wnc!UIIc
Hep.atll- -+-+..::.!'~
Wet
pancrutlc ~h
B Fundlon nd stnldu~ ofdte bll1ry sphlndlr:t' system ;a Sphlnctarnf the common blladuct;and p;ancrNUcduct. Each duct hiS Its own sphlnctef system. Typically both of the ducts unite to form .a large ampulla, the hepatopancreatSc .ilmpulla, which .illso has iUown spllincter. The sphinctet"mechanism iuupporUd by adjacent venous p;lds (not shown here) In the w.rlls ofthe ducts. b lntl!tl'lltlon oftttesphlnctersystern In the duodenal wall. The muscles of both ducts blend with the sphlncttrmusde of the hepatopan· crutic ampul!;!, which passes through the duodenal wall.
Duodenum, musalaremma
Noll!: Thumpullary sphlnctersysttm works lndej)l!ndenUy of the di'DJo
~------ sUpsolduodenal IAX'I9t\ldNI mladeon ammon bile
Sphnct~er
duct
afhepatopanc!UIIc
l;lr muscle l~r oftheduodenal wall, ;ll~ngthe sphinct~ to function even during f.ilstlng when the duodenum Is relil:l!.ed.ln this state the duetil sphlnctl!rs .ilre contracted and bile Is stored. When food Is Ingested, the sphlndtr systtm opens and allows bl1e tD flow Into the duoclellum. The sphincter system fomru a ~I anatomical constriction where a gallstone may become lodged, obstructing !he outflow of bile and paDaeatfc Juice (pancre.rtftls, see A). The function of the sphlnctl!rs, the discharge of bile by the gallbladdet", and the production of bile by the IIWI' ;recontrolled partially by the ;utanomic nC!fVCIUS system (especially !he par.ilsympathetlc system) .ilnd partially by gastrolnt.5Unal hormones {e.g., cholecystokinin and seaelln).
a~h
Walof G!odenum
•
Common bile Wet
~~·
b
c
Extrahepltfc bite ducts: typl'c.tllllltllmy and varlllnts Yarian13 in the termination of the aommon bile duct and pancreatic duct.
a Typlallani'IIIITty: Both ducts open at the major duodenal papilla by W1¥Yof a common ampulla (the most common form).
c
d
b-d Vlrtlnts: b Varying degrees of Sl!!ptation of the mmmon ampcJIIa. c Complew sept.iltfon of the ampulla, with a separ<~te opening fore<~ch duct. d The ducts unite Mthoutformlng .il true .ilmpulla.
213
2.19
Pancreas: Location and Relationship to Adjacent Organs ~or
Abdomln.al
wnae~W
<101t1
Left kldnty
Spit«~
PallaNS
--l-fi~------"~•
~~r-m- Omalt
Omemal
s=mach
IM.n.a.
Wit! buill:
A
Pra{edTanoftflepanc~U~~antothewrtl!bralcoklmn
bursa,spll!nlc reau
B LocaUon oftfle panaeas
The p.ancreas is an elongated organ that is orientzd transversely in the rlght and left upper quadrants,lylng rNlnly In the Epigastric region. The body of the p.anaeis crosses the midline at the L1/l2 level. The heo~d of the p.anaeis Is directed to the r1ght ind extends to the L2/ L31evel. The tail of the p.ancreas may closely approach the spleen in the WQ. The pain associated with diseases of the p.ancreas Is often a "girdling pain" tllilt encircles the upper ibdomen ind even the lower thora (see
Tr.ansverse sectian through the abdomen .atapproximately the T 12/l1 level, viewed from abclve. The p.anaeas Is a secondilrily retroperitoneal orgiln located on the posterior Will of the omental bursa. It extends ill· most to the spleen on the left side. ~The p.anaeas appears shortened at this level because i13 head is below the plane ohectlon.
p.310}.
Dorsal parxreltlc bud
Common blledJct
~1111'al ~
Pl~a11cbocl
..
)~~
~
t.fg~ofYCMr..l PI~ bud
C AnomlllouJ development of the p~nCR~J (1rwlu PIIKRU) Embryologkally. the pancreas develops from il donal and venll'ill bud thilt grow Into the dorsal and venll'ill mesoduodenum. Thewrnrill pancreatic bud cansist.s of a left and right part. Normally only the ri9ht part of the ventral bud migratl:!S bade around the duodenum to the fu· tiJre convex right side of that organ. coming to lie brhlrld the duodenum when Its development Is completed (seep. 179). The fUtiJre com-
214
Cam man blledutt
DJodenum
AIYJiolr PI net$$
mon bile duct mlgram In the wme direction, also coming to lie behind the duodenum. The lfft p.art of tile venll'ill bud genmlly regrases at iln early stage. But If It persists, both the anteriOr ind posterior sides of the duodenum will be encirded by a ring of p.ancreatic tissue: an Qnulor PQnaws. Thi' fire anomaly may cau.se olntruction of the duodenum (doodenal stalosls) lmmedlarely after blrtil, but It can also be ilsympto!Ntlc.
Abdomen GndPelvis - - 2. Organs
Common
~lac
hepa!lcar!Jery
II'Unk
Leftsupr;J~
H~csurfaoe
ofdaph111gm RJgrt supnrenal
gland
gland
Splenic HepaloduodeNI l!lilllll!nt
Oll'tl!l'y
Til of Plno::n!IB
Rlgrtkldney
Left colic
Body of
fii!IW~
p.lnCft.a.s
!loot of tranMne
Duodsn.m, S~Pirt
~on
HNC!of p;ll1a11l15
Duodenum. clesa!ndlng p.wt Elm!nlaland lnmal obiiQul\ tr.lllS'm'l4!
abdomlnls
Duodenum, horizontal p;~rt
llootof mi!S
D lhepenauslnsftu Antl!rior view. The liver, stomach. sm;~ll intt'stinc!. and ~rge intmine have been remcwed pi'Oldmal to the left colic flexure. The retroperitoneal fat and conneclive tissue and Ule perirenal fat capsule ha~ been greatlythlnned to betttrdem01utrate the rtrudllres In the n!l:reperttoneum. Surgical accm to the pan ere;~$ is difficult due to ~lfyingorgaru andthepi'Oidmltyoflargevessds. The head of the pancreas Is enclosed
~odenum.
asaodng p;Jrt
Supeiarmel81b!lic
within the C·shaped loop of the duodenum. The lrne of .attachment of the transverw mesocol~n run$ along the anterior $Urface of the pan· creas. Malignant tumors of the pancreas may spre;~d to nearby blood Ye.SSels (mort notiblythe superior mesenteric artery and vein) and rmy surround and conrtrlct them, reducing blood flow tD dependent organ$. Simi~riy, inflammations and tumor.s of the head of the pancreas may constJfct the common bile duct.le
215
2.20 Pancreas: Ductal Anatomy and Histology
Duodenum, supertorpart
1\lilof
DuodenLm, desandlng part
p.anae:IS
Unclnatepol~·(-
A loaltTonand-..rseaftfu~p•ncmdkduct Ann!ri~r view. The anterior side of the pancre<~s h;Js been p~rti~lly dis· sected. This dr.tWlng Illustrates the most common form: The ducts from the former ventril and dorsil pancreatic buds h;ave unlll!d to fonnn a common duct. The ma1r1 p.ancreatfc duct~ formed frcm the distal portion of the d~rs~l pancre.'ltic d~~et. The proximal portion of the m~in duct Is dertved from the ventral p;maeitlc duct. The m~lfl pancreatic duct opens Into the descendlllg p.art of the duodenum (usually sbir· lng .1n ortftce wtth the common bile duct) on the mo}orduodenal papilla (seep. 188). The remainillg small segiTII!ntof the former dorsal pi!nae·
216
DuodtnUI\\
~~ng~rt
atfc duct. now called the GCC!.ISOJY po110'1!11tk: duct,~ found only In the he~ Ill the p~ncreas .1nd opens inw the duodenum on its own papilla, the minor duodenal PiPillii. which Is slightly mnlal to the major papilla {seep. 188). Sewralv.1rlants of ductal anatomy nn.1y be encountered: • Both ducts rem.1ln separ.rte .1rld open on two separite PiPIIIiie. • Both ducts are united, forming .1 single d~~et that opens on only one papilla. • In both cases (though rarely). the commor1 bile duct may open Into the duodenum by a separate orlflce.
Alphaall(gklc.agon
-....;;:~-.;;.~-2:~.i
production)
P\anaeatlclsllt - - - -.....
(of 1..1rlgerllans)
I Hlllllllogtc.JIIIInrdure of the p;IIID'HA Histologically, the p.~ncms consists of two functloNIIy distinct types of gLandular tissue:
• The ~11e ,...,._ (911 S af tfte 0rg3 n mass, light pink In tfte upPill' part of the figur1!) consists of myriad beTy-shaped glands ((ltini, see C), which secrele an enzyme-rim fluid lhrough lhe pancreatic duct Into the duodenum. Produced it i nte of 1pprODCimmly 2 JJ. ters1day, this fluid contains enzymes thx ISslst numerous dlgesttw procesHS in the bowel. Insufficiency af the PUcrlne p;~ncre<~sle
IJimonDf
proximal dudl.lle Eplthelll all of
pnlldm•l dudl.lle
-......~:.<--;--
Ctntnlodnar ul Ad...., I• longlbldlral
Spediltml stilnlng methods (u depleted here) can be used ID distinguish two types of Islet ails-the much more numerous beti (B) cells, whl.ch produce Insulin, and a mlnorlty populitlon of ails somewhat more concenttamd on the islet periphery, alpha (A) cells.•whidl produce gluc:~gon. Olhe7lslet c:en types, distinguishable only by lm· munohlstochemlnl methods, Include delti (D) ails, whkh produce somatDstMin, and otiws tftat make pancreaUc polypepUde or lddltioN Ineuroendocrine factors. Pancreatic islets are _.l.....asculanzed, prvviding direct, efficient release ofthen submntft intD lhe blood· stream. Glucagon mobRizes hep.iiUc store5 of glyrogen and raises blood glucose lewis; Insulin promotes glucose utilization and lowers blood gluCOH levels. Destruction of pancreatic Bcells is the hallmark of (type I) di;o betu mellitus.
C HlltDIDglmllltnKtW'e fA the p;IIICI'MI: the ldftUI These dniWings represent hlghtl"mag nlflcat:lon views of an Klnus from tfte e110crine pancniS shown In aoss-sec:Uon and In longlllldlnal sectson (detail from B). The ulnar cells, whkh produce tfte enzyme-rtdl secretion (numerous proteins), stain intensely with conwwrtional techniques, causing them tD appe;u dirk In the hlstDiogkal sec:Uon. Noll: It Is dlaractertstlc of the pancreas thattfte pi'Oidm;JI ductule- tfte Initial part of the system that transports secretions -Is Invaginated Into the center of the acinl4. The ductule cells stain less intensely than tfte ulnar cells. BeCiuse of this, lhe cells thx lie morphologlc<~lly lit the a.n· ter of tfte iclnus, and are mnsplcuous In histological sections as the relaUvely light-mining ant1Dadllarr:tils. The panaeas Is theonlyi!JIOcr1ne glind tftx contains cen~clnircells.
~on.
glondul•r all
217
2.21
Spleen lnlerlor
Abdcm'nll
IJ!ft
wn.la\'ll
IOrta
ijdney
Spleen
e:::::...
Splenorenal ligament
TentMb
Omentll
SpleM
bu~.splenk
l'l!
Gastnlosplenlc
ligament Sllmacll
A Profecttonoftflespleen ontothe5ke4eton
Postenor VIew (a) and left liltel'alllfew (b). The spleen Is located In Ute left upper quadr~nt. Its position v.aries CDnsiderably with respiration bec.1111e It lies jlllt below Ute dlapluagm and Is directly affected by Its movemerns. ewn though (unlike Ute liver) It Is not att.1ched to Ute dla· phr.1gm. At functlonil residual api!dty (Ute resting position between inspiration and expiration), the hilum ofthespleen crosses the tenth rib on the left side. Generally a healthy. unenlarged spleen Is not pi!lpable on phy31al examlnitlon.
Uti lobe ofllvef Phrenlcosplenlt I!Qament
B I.AicaUDn of tfle spleen Tr.msverse secUon through the abdomen. VIewed from ibCM!. This sectian demonstrates the relationship of the spleen to neighboring organs. The lntnperttoneal spleen linin Its own compartment and Is at· tached by folds of peritoneum mUte posterior trunk wall (splenorenal llgiment) and to !he stomach (gistrosplenlc ligament). Arecess of Ute omenbl bursa (splenic recess) extends to the spleen.
Dliphr.~gm
P.-!eul Pl!fl=ne~Jm
Escpltagus
Spleen faldfonm ll~ment ofiM!r
SplenltYdn
IJ!ft gl5tllc lr'tely lt!ftsu~
gland
SplenkW!Iy
Ta1ofp.ll'la&S
Splenocolc ligament IJ!fttollcfle~UJ~
Middle toile artJeryandYdn
l:le:k:endllgallon
ll'answRe allon
C Thupleen In sftu: pa1tllneal relatSoMhl>s Anterlorllfew Into the WQ'Wfth Ute stomach removed. When the spleen is abnonn;dly enlarged, it may press hemly upon the stomach and co· lon. c.1uslng pain. The driWlng lllustr.ttes the cl05e proximity of tfle spleen mUte ull of the PinaeiiS ;md left colic flexure. wfllch Is .1lso c.1lled the splenic flexure. Noll! the peritoneal attachment bl!l:wl!en the spleen and lr.lnsverse colon (splenOCDIIc ligament, part of the greater omentum). Embryologl·
218
cally, Ule greater omentum Is a dorsal mesenl:e!'y!nwhlchtfte spleen develops. During rotaUol'l of!he stomach In the embryo, the spleen~ from it$ origil'lal position posterior to the gut into the WQ. A "side stitch" (plerdng sensation fdt below the rib c.1ge during exercise) Is believed to be caused by stretching oftfte perttoneal CDYerfng ind splenocollc ligament due to sWI!IIIng of the spleen during phy$1c.ll exercise.
Abdomen Gnd Pelvis - - 2. Organs
Splelic ll'll!ry
Scoll!!llcwln
•
b
D Splcen:npeudsurhceulltomy VIews ofthe costal surface (;a) and 1/tsar.ll surface (b) of the organ. The spleen Is highly va11able In Its confonnatlon rn different people,. but be· c;ause this wry soft organ is COVI!red by a finn fibrous capsule, it main· tarns a relatively comtant emrnal shape ("coffee bean"). Since It Is very
difficult to suture the soft splenic tissue. It Is not uncommon to treat splenic Injuries by splenectomy. which eliminates a potential source of severe lntr.ilperltOileal bleeding. The blood ves:sels tNt enter .ilnd IeiWe the organ at the splenic hilum are usually tortuous and form multiple colb.
Qpsulecfsplee> Tenn'halartmal apllarles Pelldllar a1:2f!de
Fibrous trabe
Lymphatlcfr.ollde Pufarterfallymphatlc shealh {PAlS)
MqlnaiZOM
Shea1tl apllarles Pilip win O!ntral artsy
l'dllcuaraplllarfes
Trawlrartsy Splenk:ll'nus 'lt.lbuulllrwln
E Stnu:ture oftfluplcen The spleen b the single largest lymphoid organ and the only lymphatic organ that Is Incorporated directly Into the bloodstream (to screen out abnormal cells, see below). Strands of connectiVe tissue c.1lled trabecu· laeextendfnlmtheflnntlbrousCllpsuletowardthe hRumofthespleen, subdividing the splenic tissue into small cb;!mbers. The b~nthu of the tlbrous trabeculae and the YeSsels they transmit (ITObtculor <1rttrll!s atld lll!ltls} detennrne the architecture of the spleen. Between the flbrous trabeculae is a meshwork of fine netirular connective tissue, the splenic pulp. On entering ttle pulp, ttle blood vessels become kn!1im as ttlep~tlp ari:Wtfs and pulp wins. The tennlnalarterfal brandles have the appear· ance of the mycelia of bread mold (penldlfl11tn), ind ire thll!i named •penlclllar" arterioles. Tlw types of splenic pulp are distinguished: red pulp and white pulp.
• The tfJ pulp consists of c.avities (splenic sinuses) that are engDrged with blood in the living org;rnism (aggl'l!gation oflarge masses of red
blood cells), accounting for Its red color and Its name (In the sect1on shown here. the pulp is dewid of blood and is col~:~riess}. The func· tion ofthe red pulp Is to screen out aging and defective erytflrocytes frGm tile bloodstream. The numerous sinuses within the reticular meshwork give the spleen Its soft, spongy consistency. • The wfl/11! pulp consists of spleniC nodules (malplghlan bodies) ~r.~r'i
219
2.22 Suprarenal Glands
filer!I'I!OII
---zf?~,_
lirtapsule
Meehl--/ border
·- - - - - ,f-- - Anterior surf.n:e
Rlghtul'l!tl!r
• A I.AaltTonandlhape
a Location of the suprarenal gland on the right kidney. b Isolated left suprarenal gland, anterlor'Wew. The renal surf.rce ofeo~c:h suprarenal gland lies upon the superior pole of lfle assocliltl!d kidney. Alflln layer of fat sep.;~rates the suprarenal gland from the n!IIDifibrous capsule (making iteo~sytD dissect the gland from
b
the kidney). The pt!drerlol fat capsule, howewr, encompass~ bolhlfle kidDey and the suprarenal gland. Noce; The entire suprarenal gland cannot be seen wfllle In situ. and Its true size Is not ippreclated until It his been deac:hed from the kidney. POI1Sons descend on the posterior surface of lfle kidney .ilnd ire not visible in situ.
Zon;~
glomerulosa
B
~rucblreofthuupn~reNigla"CC
Right suprarenal gland, cut open. b Histological section from a su· prarenal gland. The supr.arenal gland consists of an outer cortl!x and ,;m Inner medulla (see a). The c«tex is COVI!!red by a thin fibrDus capsule arld consists of three morphologtc;rlly distinct zones (see b) In which adrenocortl· al hormones are produced ;rnd secreted Into the bloodstream. These zones.ilre, frcmoutsldetD Inside:
;a
• Zon.il glomeruiOS.il: mainly seaetes miDeralocortlcolds (ildosterone) • Zon.il fasclculata: mainly secretes glucocortlcollh (hydrocorUsone) • Zon.il retiaJiaris: RX hormones (~ens ~nd ~ndrogecu) No/:1:: Loss or dl!f~~:iency of both suprarenal corticrs leads to Addiscm disease. while hyperfunctfon of the suprarenal cortex(or adrenocortlal tiJmors) leads tD Cushing syndrome. The supr.~renal medull;a Is ~sentially a completely different endocrine gland, of different origin, lflilt happens to be .ilnatomlcally (but ~lso functionally) anotiilted with the suprarenal cortn. The cortex is derived embryonically from mesoderm lining the posterior ;rbdomlnal wall. The supr.arenal medulla Is, by contrast. a neiJril crest derivattlle, arld thus has an edodennal orfgfn. The caU!c:holamln~ epinephrine
220
;rnd norepinephrine are produced In the suprarenal medulla and are released Into the bloodstream. From <1 (Deuro)functfonal st.1rldpolnt, the $Uprarenal medulla rs less a gland than .il S)'II!.P011letlc gangiJon: pre.syn· ~ptic $ympathetic neurons Pin from the greater and I~ splanchnic nerves Into the suprarenal medulla. Beause the suprarenal glands are endoafne glands arld sympathetic g<~nglla In one, lfley can secrete both epinephrine .and glucocortlcolds {cortisone) In response to stress.
Abdomen GndPelvis - - 2. Organs
Diaphragm -....,...-lnfetlcrphrenlc:
----'-....;&~
Suprarenalw'b
arteryandw'b
Superior -~.,.:..:t• SIJprarenal artetes
Middle suprarenal artery Cellaclnlnk
Rlght-....;.,.--i>'t supr
lnll!rlor Sllprarenalartery
Rlghtklclney. ll.pet!cr pole
RlghtreNI~
Rlghturttl!f --""*"'~
RlghtreNI.-e!n
llohypOg:;J stric
- - - - TedlculmuuryJ
new
~OVidan artery
' ~'-----,'1~---
llolngl.fn.al nti'W - ---"--:-
Supo!f!or E!ophag~
supr.~reOIIarteries
IA!ftsupr
Tedlcularw'bJ l1glt Ol'irlanwtn
Inferior pmnkwkl Diaphragm Anammostsbmo!en
!nfetforphrenlc:wh andsupr.~renalwfn
Porlllwln
Leftklalc.y, SIJpcrforpde
Left gMII!c artery
MlddleSIJpr.arenal ;rtery
"-h1!91t!cartery
Left supra~ wkl
Qxnmon hejl&fc artery
Subai!UI ner.oe
Common bile duct
TalofPIIltn!IS
Splenic win
hfetfor suprarenal ;rtery
Spll!llltlrtery
Left renal ft!ly
Neclc of pancreas
Left renal \'tin
Supmor~Yeln
Leftklalc.y Tranwenus ibdomln\i, fllll!miil ind exlen!ll oblque Lefttestlalar/ b
G~~artanwfn
Gedtafemoral nerw
l.dt Ureb!r
Ulatngl.fnal
nerve
lrohypogai1Jfc nti'W
c Right and left -.raren.tl glands tn IIIII AllU!rlor view of the right (;a) and left (b) kidney and suprarenal gland with the pafrenal fit capsule removed. To demonslr.ltethevessels be· hind the suprarenal gland, the vena cava has been retraetl!d medially In a and the pancreas has been retracted lnferforly In b. The principal dlf· ferences between the two suprarenal glands are a$ follOW$:
• The right suprarenal gland is normally ir1 contact with the ir~li!rior vena C
• The right supr.arenal gland is often so~hat smaller thar1 the left supr;renal gland, which frequently exb!nd$ inferiorly to the ren~l hi· lum. • The right suprarenal gland Is pyramid-shaped while the large left suprarenal gland is more oblang.
Ntlll!.: The.supr.arenal glands are rich!yvasa.Jiarized because. as endocrine
organs. they release their hormones drrectlyln1» the bloodstrum.
221
2.23 Overview of the Urinary Organs
Rlght SI.CJI1Iren!l liftrio< §and ven.tCMI
···-··· ~ gland
Right lddley
l.efhupnu'l!l111 gland l.l!ftlddney l.l!fturetl!f
L4wrtdl~
De5andlng colon
As«nd:ngo:olon
AKI!Jm
Bladder
A Prclfectlon of the llfdne,s ll!d other urtrwy 0191"' on'lll the gl<~flds
IJ!ftl:ldney
Right lddley
Rlght~t
·~-·-----{ sbleton Antl!rlor 1/few. The supr•renal
Left SUPillreNI gland
.ilre .illso shown to illd orienta·
lion. The kidneys .ilre loated next to the vertebral column .ilfld .ilre high
enough that they overlap the eleYCnth and twelfth nbs. The renal hilum lssltuatedatthel1/l21eYel.llsu•llyther1ghtlddneylssom~tlower
thin the left kidney due to the spue occupied by the flYer (see p.204). The bladder is shown fully distended in the diagram. When empty, it is oomlderably smaller and Is hidden behind thesymphylls pubis. The ure· ters descend In the retroperitoneum and open Into the bladderfromthe posterior side.
01'91"'
B Pnljec:tlon of the urhlry org~n• on'lll the ofthe ilbdomen ind ptlvts Antenorvlew. OWing to ItS large srze. the !rver displaces the 11ghtlc!dney
slightlyinferiorty. The bladder is shown in a fully distended st.ilte.lt is .ilrr taior to the rectum In the male and antaior to the uterus (not shown here) In the female. 8ee<~use of this relationship, mart.ed distention of the rect.ill ilmpullil or enlargement of the utl!rus due to pregnancy exerts greab!r pre.uure on the bladder, creating .ill\ urge to urinate ewn when the bladder Is not full. Urinary lnoontlnence may deYelop due to pathologlc31 Pf'OCUSU of longer duration. such as m~~SaJiar tumors of the utl!rus (flbrolds), or due to weakening of the bladder do sure media· nlsm .iiS a result of pl'l!lllous vaginal dellverll!l (descent of the muscular pelvic floor).
C Ccmmon slb!s of OCGJm!flce of urtray stDnes When the solubility limit of ctrtlllr\ cornpocmds In the urine (e.g., urk <~tid) is ~ed. theoompounds do not rem;~in in solution but are precipitated to form crystalllzitlon nuclei. These e<~lcuh ("stones") may develop anywhere In the upper urtNry tract and may migrate to Yilrfous sites In ilny of the urlnilry orgaru (renal and reNI pellllc stones, ureteral $tones, bladder stones. urethr;l stones). la~er stones ire particularly apt to become lodged In the ureter. ofUn stimulating powerful waves of muscular contrilctfons to expel the stone arid e<~uslng exauclatlng pain {renal colic, ureteral mile).
222
Abdomen GndPelvis - - 2. Organs
Rlghtl'nfetfcrphrenlc: .wt!ly.M>dw!n
lnfafor WNGM
Esophagus
IJ!ftl'nfetfcrphrenlc: artl!ryandveln
Lefts~
RlghtsuP'Irior
!iUpr.Jr8\ill.wt!ly
S141fil~lartery
Abdominal
LeftS141filreNI gland
.aorta IUghtSUPilln!r!ll gland
CdiOICtMk Leftmldde !iUpr.Jr8\illlll'tl!l'y
Right supr.nnal Win
Left Inferior suprar8\ill a1!ly
SUpetfor mes.tnter'lc a r1l!ry
LeftS141filreNI
Rlgrtlnferior SUpnln!lllllrtery
\ttl'!
Left renal artl!ry
Right ~nal artery
Left renalwn
R~grt-..lw!n
l.eftCMrioi1Wil
Rlght lcktley
Leftureur
FatCilpsule
Leftaso!ndlnu lumbar Win
Right ~nter Right
lllohypOgiStllc !!eM!
GYI rill n¥t:ISels
lnfeflor
Ilioinguinal neM
me~entericartery
Left ovarian artl!ryandveln
RJgrt ccrnmon 1rac.wt!ly
Lllter.llfemoral
Psolsm~)or
Cllt.lneousnen~t
P.arle!al per!lllneum
Genflmmorlll !!eM
Rlghtotlnlal lilac artery
Inferior mesl!llt2rlc Win
Bladder
D lbeurt1111ryorg-lntltll Antl!riot view of an opened female abdomen. The tpleen and gastro-
Intestinal organs hive been re!TICIVed to the sigmoid oolon. ;rnd the esophagus has been pulled slightly Inferiorly. The fat apsule remains partially Intact on Ute rtght side, removed on the left side. The lddneys ~nd suprarenal glands ~re lncnrpor.atl!d Into Ute retnopenmneum by the structur~l fat of this apsule. The moder.atl!ly distended bl~dder is juJt vlslble above the symphysis pubis In front of the uterus. The pa· rtetal perftollellm has been re!TICIVed to pi'OIIfde a clear 11tew Into Ute l'l!ti'Cperltoneum.
Sigmoid
sqncld
~on
calon
NOII!:Theuretenpassbeh!nd theov~l1anvesselsand!nfrontoftftelllac ve.uels as they detcend in the retnoperitone.Jm. These sites represent clrnlcally lmport
223
2.24 Kidneys: Topographical Anatomy
1\lolelftMb
Subcostal none Right kidney 1ro~c
naw
llo~c -........J MM
...........
____1::. ) >---------7neM
lliclngulnal
•
ll'flemrlled sk~HrN
b
A l'rGld'ml'tV of the lddneys tD the nlohypogiiiiJtc and llolngulnal nl!ii'VI!S
When alllayeB of the trunk w..ll h;we been d111ided ;md the fat capsule removed (see p. 223). It an be $Hn how close !he kidneys are to Ute Iliohypogastric and Ilioinguinal nerves (branches of Ute lumbar plexus from T12 and especially L1). These nerves supply me~tor inner-
;a
vatlon to !he muscles of the trunkw.all and sensory Innervation to skfn areas on the later;tl and anterior abde~minal w.all. Thus, when an abnor· mally mlarged kidney ex.ats prnsure on the iliohypogastric and nlolngulnal naves. pain may be referred to the skin area shown In b. The subcostal nerve (also from T12) usually lies far enough from Ute kidneys that it is ne~t compn!.Ued by renal enlargement.
Right ~ ~ left
~U
ldcney
lddntY
1
b
8 l.ocltton oftfn: lddne,s. norm II n. pll'lhologlc.~hnobftlty ;a Postlt!r'lor vrew. The pleural c.avltles overlap the kidneys posteriorly 0Wif19 to Ute convexity of Ute dtaphr<~gm. Notrthat the right lcidneyis lower than the left kidney and is closer to the palpablellliiCcrest(seeC. p.1SO). b, c; Antllrforvtew. The kldney3 are loeited In the retroperltoneum just below the dlaphr.agm. Henc:eUteymOYe passlvelyw!tll the dlaphr.ilgm durl'ng resplr.iltory e~U:urstons, ~lng rnferlorl'y and slightly latl!rally during inspiration beause of their oblique position (their inferior poles point away from !he spine. see oblique red lines In ;a). These
224
c
passlvemovemmumayause resplr.iltlor~-dependent paln In patients with renal dlse<~se. Apot11otoglmllncre<~se In renal mobility ("ffoating kidney." see c) results from <~trophy or Ute fat apsule Utat nonmally surrounds the kidneys and ~s them in a stable position. Awast· lng Illness (e.g .. met.ilstrtlctumoBofvarylng orlgln) maya use such sewre fatty <~trophy Utat the kidneys descend to a lower level In !he .ilbdomen. As Utey are still tethered by Ute ureter and vasc:ular stalk, this descent m1ty kink the renal vessels or urettr and Interfere With ren;~l blood flow or urin~ry outflow.
Abdomen Gnd Pelvis - - 2. Organs
Hl!l)lllcsurfiCII!ofdaph~
(notaM!n!dbo/per!IIX1eom)
Pcrtal wil
Inferior vei'IIOMI
l'l'oper Esophagus
Splenic
Mpwticlr'b!fy
fo.sw
Dl;Jphragm
HepatOCfuodenal
lgament
l..l!ftgastnc ~l'llry
ltlghtt~.pr.Jrenal
gand
l..l!fttupr;nnal
gand ,_.-~ff"'r- Splenlc~rb!ry
Duoclentm. S~p;Jrt
P
_....,_,f.:.;.. ----,-~
l..l!ftl:ldnty Duodenum, desa!ndilg p;Jrt
--,~=-=*ml---
Alt.ldlment otdesandlng
Superior
colon
~ric
al'llryandwln
1!1~~\----'lr.l~
abdcmnls, I~ .;and
Altachment otuandlng
exllemalobllqu~
colon
Duoden~~m,
c Topogrwphtc:al l'll!tltfonsofthe llfdneoys In ttl~ retroperttoneum Ant!!rior view. All of the intr.lperitone~l organs and $C
Left t~.pr.Jrenal gland
I
~ofOIIItilct
with duodenum
lng cclon on th~ posterior wall of the ~toneal cavity and by !he root ofth~tr.lnJVerst' me:socoh:on. Because the pancreas. parts ofth~ duodenum.andth~leftandrfghtcollcflexuresare~retro~toneal,
they are In cl~ proximity to th~ pdmorfly retroperftor~eallddneys but are stillsepara~from them bythefitand connective tissue of the fit capsule (see D).
D .Are. ol rel'lll Cllln'Rict with ~bdgmln1l and pt!Mc 0111ans Amrtor 'Yiew. The suprarenal glands (also shown for clafoty) aM very close tD the kidneys but do not touch them. bdng separ.1~ from !he ta'lal surf
225
2.25 Kidneys: Fasciae and Capsules; Shape and Structure
A I'Wltlonoftfleldch!'ptnthe renal bed Right renal bed. a Sagll:t'll secUor1 at approximab!ly the level d the renal hilum, viewed from the right side. b Tl'1lnsvecw section through the 01bdomen at appi'Oldmately the L1/L21evel,llfewedfrom above. The renal bed Is loca!2d on each side of !he spine ifl !he l'l!b'operimneum. It ccntains the kidneys. which ire Invested by a thlr1 orsan capsule (renal fibrous capsule), and the sup"" renal glands, wtllch are sum~unded by the perlreMI fJt c:~psule that also endo$eS the kid· neys. The fat capsule Is thicker poS12rtorlythan ;mteriorly. Nob!: SWelling of !he kfdr~ey (usually due to inflammation) may c.luse ~ pain due to stmchlngoftheflbrouscapsule. The fat capsule Is sum~unded by the renal fiLs. eTa, which separates It from Its surroundings by two layers: • The anl2rlor layer behind the parietal perf· toneum (tow+tith it is fused at some sites) • The posterior layer, whlc:h Is p;~rtlally at· tolched to the tranSVI!fSillls f.lsda and muscular f.lsdae on the postl!rtortrur~kwall The renal fasda, and thus the renal bed, Is open lnfertoliy and medially to allow p;~ss;age of the ure12r and renal vessels. It is dosed lat· erally and superiorly by fusion of the fisclal layers. Because of this arrilngement. lflflammatory proC!sses that are adjaC!nt to Ute kid· ney but within the renal f.lscia !2nd to sp~d to the contralateral side or Inferiorly ind may spread Into Ute pelvis. Nob!: The enure renal bed mOYeS downward during inspiratory depl't'$$ion of the diol· phragm. llllilTI/dly Ciluslng the kfdr~ey and suprarenal gland to move as wen. This dlffm from the liver. wttkh Is attached to Ute dla· phragm (bare area) and is dftl!cdy moved by diaphrigm excursions.
Abdcmnal
lrhrlor
.110rta
wnaGNa
Parietal
pmmneum
B Rsll bed: f.udaund capsuleufthelifdneoys
226
Renal flbnlus c.apsu!.
Thin, firm canne~tlssue capsule that closely lnwsl:s uch kidney
l'l!rirenal fat capsule
Mass of fat that surn!Unds the kidneyund supraNnal glands and completaly occupies the renal bed; It Is thlc..st lateral and IMI*flor tD ltle kidneys
Renal fascia
Conne~lssue fascial sac that encloses ltle perirenal bt, pCNtlons « ltle abdamlnala-and lnf81onena ava dale tD the lddney (see Alt), and the proldmal urel2r; subdMded Into a thin anUrlor l•r and a thick PQSIItrlor l~r (see Ae)
Abdomen GndPelvis - - 2. Organs
l'erfn!nalfat
capsule
Rlghtsupr.an!nal gland
Supt!r!or pOle !i
Mlddlesupr.nnal
Po5terlor
MU
surflce
Rlghtsupr.an!nal Win
Medial border
Atm!rior
striiCII!
Rlghtn!RII
army
Renal hilum
Ren.1l pelvis
Medial border
Antl!!1or surt.u:e
R\ghtn!RII
Right renal artery l..at!l'al border
velA
Right renoll win
Renal hilum
Right ureblr
RemlpeMs
lnfi!tlcr pole
lnfe1ar pOle
c Strueblrea,..wpeofthdldney
lnfetlcr supr.an!nal artery
A~rlor vlew (a),
posterior ¥few (b), and medlaiYiew (c) of the right kkfney. The suprarenal gland Is left lnt:lct In a ~nd b, ~nd !he ureter hifiS bffn cut ;at tne level of tne infi:!rior renal pole. The fibrous e<~psule thilt directly In· YeSts the kidney Is lnt.1ct In a ;md c ;md has been p.ar!Sally opened II\ b to display tile underlying renal parenchyma. The renal sinus (tne deep space Into whldl tile hilum opens) gener.ally contains a certain amount of structural fat.
• two poles (superior ;md lnferfor}, • two surfaces (anterior al\d posterfor}, ~nd • two bo"'~ (lateral and medial). The medial border be.ars the renal hi1um, where vascular structures al\d the ureter en· ter and leave the kidney. The shallow surface grooves result from tile embryonic lobulation of !he kidney. The hllar structures are usually arr;anged ;as foi!Qws from anterior to posterior (ifiS shown In c): right renal vdn, right renal artery, and right uretef.
Rlg!t n!nalartery --4iiii::::~
RemI hilum
Rl!lht!Ww!n _ __..,.
Posterior surflce
Right tre1Jer
b
Nott!:Tberenalarterylsusuallyposterlortotile renal vein becausetile right renal artery passes tD the r1ght kkll\ey bl!h1M tne Inferior vena cava (where the renal veins tennin;rte), while the left renal veil\ pa~es to tile left kidney 111 {rGntofthe abdominal aoltl (which gives or1·
lnfedorpde gin to the renal arteries). The left renal artery may also loop around the left renal vein from above to OCUIPV an antl!rlor posltfol\. The ureter leaves tne renal pelvi$ (see p.230) below tile vessels and Is usually somewhat posterior In relation to the blood vessels.
227
2.26 Kidneys: Architecture and Microstructure
Mlnaralyx
illaJ;rtr.li1J!I'y
andwln
A MIICroscoptc~~ofthelddney Posterior view of a right kidney ~th tile upper half of the kidney P'!rtlally removed. The rt!nll p~rendlyma consists of
Macula clens.1l
]UIItlglarrwrularcels ---l."'"l.!llt~~~~:!::::...._
(madlfted sm~of!lusclt Cl!lls l'uf!'efent amrfale)
V..SGJiar pale of glamenliU"J
Meunglal
aells
• B Renal caopusde • With the carnull! opened, b in .H
228
b
glomerulus through the rfll!rentglomerular arteriole. The primary urine Is formed ~thin the renal corp~~Jde and drains through a tubular sys· tern at the urinary pole of the glomerulus. The Initial portion of this tu· bularsystemthatlsconDeCtedtotheglomerularcapsulelstileproxfmal convoluted tubule (see C). Noh!: S~~lized cell$ at the lla'IC\IIar pole of the renal corpuscle regu· late the blood pressure that Is necessary for ultraflltratfon.
11'111111abular
amry
lntatobular win
Af!innt
c Archltedllre of the ren1l wuelund
..ut1ole
il
glome!Uar jummedulory nephron
IIINI- - - - - -
'fir'+ - - - Glomerulus Etr.nnt
glomen.iar A"t!llde
-+-!.-- - - Tubuloroymm 1-'-- - - - str>lghtar1111ole
lnwrtoblr - - --:II lr11ry
l--- - - - Str>lght_,Lie
lnlatoblrlll!ln - - - . . . ; H
- - - llenalp)'I'IITfd
• Renalpopllla
-"""~---1Pl'allmaltubule, stnolght part
Efrtrtnt
glomorulw
(lhldo:sogment
orllrlole
afHonlel""!')
\."1Y~II,\--- Maa.io denso Dlslaltubulo. -+-4HI Jtnlghtport
OWrmedulll. oUII!r.stJipe OIIWmedulll. nrw.stl'lpe ln!W medulla
,.......-r
Cdloctlng tubule
- -+- -
CDiodlng duct
.,
1'11n ugment ctHonleloop
lntn1W111 coledl~ IJillam llil!nal vessels: S«Uomrl view of a medullary pyramid with adjacent corUcal areiiS. The intrarenal vascular and collecting systems are dosdy Interrelated spltlllly and functionally. An ul!rlflltrate from the blood (primary urine) drains Into a mlcroscoplally small symm of renal tubules. Blood flow Ill ~ iidnrr(•) is suppli~ by interlobar a.Urles thit pass along the sides of the medullary pyramlch from the reN I hDum. Eolctllnterlob;ar artery supplies two ad)ocent me6ullary pyramids and the ;associatEd cortical mnes (these branches ire not shown). At the base of the pyrimld, the lnterfobar artery giVes 1tse to the araute ;artery, flom which the interlobular arteries are distributed Into the cortex n far as the fibrous renal capsule. The qffemlt glomerular a rterioles thlt arise from an lntlllobular artely I!QCh supply one glomeru Ius. The efferwtt glomeruli! r 01rter1oles that emerge from the glomerulus are stlll carrying blood ati high oxygen tension; they JUpplythe ren.JI cortD or medulla. II lnlnnnll coi1Ktfn.1 syst~m; The smaOest functional unit of the kidney Is the nephron, whlctl consists of the renal corpusde (see B), renal tubules, ;and collecting ducts. There ire approximately one to two mdllon nephrons In eiiCh kidney. They process approximately 1700 liters of blood dally, v.tllctl Is fllll!red by the counterall'rent mech~nism tDform appllalimately 170 llters of prlmoty urine. This primary filtrate enters the tubular system It the urinary pole of the renal corpusde and reiiChes the renal papilla as the {indl ~. whiCh draint lntD the cal)oce;ll system (app~mately 1.7 liters I day). The tllbulor system CGM!sts of the proxfm;al and distal tubules (Net! With a convoluted and straight portion) and an lntenmedlate tubule (with de~andlng and ascending limbs). The Intermediate tubule and the adjacent stralg ht portions of the proximal and distal tubules comptise the loop ofHen~. Whde passlngthroughthetubular system, substances contained In the fllmte (mainly water) are reabsorbed while other substances (e.g., Ions) are secreted into the filtrate. This proc:as yields the firul urine, which passes through a collectIng tubule Into ill collecting duct and drains through the renal papilla lntD the mflad S)ISI!!m. It is ~ from the n lica and renal pelvis tD the ull!M by perfsbilsls.
01brlfomurea of renal pepllla
229
2.27 Kidneys: Renal Pelvis and Urinary Transport
j;;-:uhry "'""""' !z
ReNI P'J!IImld -
Renllflbnlus Gpsule lieNI cdumn
Rlghturet!er
A Sln.K:tu... lind shilpe and ... nil peMs Mid-longitudinal sectlor1 through a right kid· ney, posterlorvlew. The ren;al pelllls lies posterior to the ren;al Ye$Sels and is continuous inferiorly wlth !he ureter. It may present a variable shape (see 8). It Is usually divided Into two or three larger (major) alytes, 'Which dMde further into smaller (min~r) calycn. The minor alyces mcompass the tips of the renal papillae lfl such a way that urine drains from the papillae Into the calyx 'Without esaplng Into the renal p;~renchyma. Smooth-muscle fibers in the calyas, renal pelvis and ureter (w.rll structure lr1 D) mable lhe.se structures to undergo peristaltic contractions (see C). No~: Stones (see C. p. 222) that fonn in tile alyce$ or renal pelvis may become so large !hat they fill the cavity lumen and assume Its shape (caliceal stone, staghorr1 calculus).
lnflnlrpolt
8
V.nhUonslntfleshipeoftfleren;~l
pel Ill's Ann!ri~r view of the left ren;al peNis. The ren~l pelvis and ureter develop from ~n outgrowth
of the mesonephric doct. This •ureteral bud" grows superiorly frcm the peMs IIWr.lrd the embryonic renal bud and unites with it. The
alytes subsequently form by branching frcm the ren;al pelvis. This branching occurs lr~var lous p;rtl:l!rns 'With .ilpproxlmately equ..l frequency, and mila!d farms are also seen: • Unear pattern (a} • Dendritic (ramified) J)Jtb!rn (b) • Ampullary pattern (c)
230
Mlnareo~lyx
Abdomen and Pelvis - - 2. Organs
Renal pyramid
Sphincter fomicis
-----\~
+++--+-- ureter Right
Sphincter
allcls
• C Closurt! mechanisms of the rt!nal calices and rt!nal pelvis; urinary b'ansport (after Rauber and Kopsch) Schematic representation of a kidney (b) with magnified sections of a calix (a) and renal pelvis(~) and a dynamic functional diagram of the calix and pelvis during urinary transport (d). Urine is transported by an active mechanism. The smooth musculature of the sphincter fornicis and calicis (a) and the sphincter pelvids (c) (the functional sphincter system) enables the wall of the renal calices and pelvis to contract in segments. These contractions are continuous with the peristaltic waves of the ureter, with the result that the urinary tract is never patent over its entire length but is patent in some portions and closed in others (d). This
maintains a distal flow of urine from the tip of the renal papilla Into the calix, through the renal pelvis, Into the ureter, and on toward the bladder while preventing the reflux of urine Into the kidneys. Note: If this actlvetransportprocessls Impaired (e.g., by renal stones or drugs that Inhibit the ureteral muscles), urine may reflux Into the kidney and Incite an Inflammatory process In the renal pelvis. The papillae, calices and pelvis are often affected jointly by disease (e.g., Inflammation) because of their close proximIty to one another. One of the most common diseases Is suppurative bacterial pyelonephritis (pyt!lo-, referring to the (renal] pelvis, from Gr. pyt!los-trough, tub, or vat).
Sphincter
allcls, closed
Sphincter
d
peMcls, closed
Mucosa
Submucma Muscular1s coat,
longitudinal layer Muscularis coat,
drcularl¥r
Adventitia
D Will structure of the ureter Transverse section through a ureter. A characteristic feature is the stellate lumen that appears in cross-section due to the longitudinal mucosal folds. As in the urethra and bladder, the ureteral mucosa consists of a transitional epithelium of varying height (seep. 237). The smooth muscle consists basically of a longitudinal and a circular layer. It is powerfully developed and shows a functionally spiral architecture (see E). When a renal stone enters the ureter, the smooth muscle in the uterine wall undergoes powerful contractions in an effort to expel the stone, causing very severe pain (renal or ureteral colic). The colic may be relieved by drugs that suppress the activity of the parasympathetic nervous system, though this will also inhibit normal urinary transport to the bladder. The renal pelvis is structurally analogous to the ureter, including the stellate shape of its lumen.
E Arrangement of th11 ureteral musculature (after Graumann, von Keyserlingk, and Sasse) Schematic cross-sections at various levels of the ureter. The longitudinal and circular muscle layers of the ureter wall have a slightly oblique arrangement, forming a kind of spiral that propels urine toward the bladder by peristaltic contractions. Although the ureters are richly innervated (see pp. 316-317), the peristaltic contractions are instigated by spontaneously depolarizing smooth-muscle cells in the walls of the renal pelvis. Peristaltic waves of contraction (with a speed of 2-3 emf s) are propagated through direct electrical connections (gap junctions) between adjacent smooth-muscle cells. Autonomic motor innervation and local sensory reflexes serve to modulate this intrinsic activity. This mechanism may thus have some superficial similarities to the system that controls heartbeat.
231
Abdomen and~ - - 2. Of'gons
2.28
Ureters and Bladder in the Male:
Topographical Anatomy Left mldcle S~Rllill i1J1Jiry
Left Inferior phrtnlc ilrWry ind win
RJght~rtNI
Left lnl'et1cr aJP"'"""I ilrtay
win
ltlghtlddnoy
Left renal ilrtay
SUpaior
Left renal will
mesonll!rlc .mry
Left1lS1!alar
Rltapa~Je
will
Asa!ndlng lJmbarwln
Leftlddnl!'f Lefturmr. Dlamlnal part
lnfer!Gr mosentorfc artery
Left 1151Ja.jar
__..
wssels
Rlght-cu!;,r
l'solsiTIIjcr ltlght~~~mmcn
IIICUS
nlilcaiUfy
Leftlnll!m•l
Mecf•nucnl
llilcomry
1rtory •nd .,.,n
J.eftsuportor
light literal sacnhiUfy
!J)utul ll12fy
Saclllplt~<~~s
Medl;!n umb11ul llgaml!lll
A Coun;eaflhe ureter In dlubdametund pelvf1 Anterlorvlew.rmle ~bdomen.AII organs hilll! been removed except the urinary organs. suprarenal gl~nds. and a rectal rbJmp. The esophagus has been pulled slightly downwilrd. and the fat capsule of the rfght kfd· ney has been partially preserved. A prolongation of the renal pelvis. the ureter passes lnfe!1orly and slightly antl!rlor In the retrope!1toneum for a length tJI appi"Qllimab!ly 26-29 em. It opens intD the p~f10t aspect of the blidder. Anatumlwlly, the ureter consists of three parts:
• Abdominal part (franl the renal pelvi! Ill the line.a terminalis of the bony pelvis) • Pelvic p;1rt (fram the linea termlnalls to the bl;;~elder wall) • Intramural p;1rt (passes through the bladcler wall)
232
The ureter Is also divided lntD three dtnlcal segments. based more on the presence of a free segment and t';W)Oig.IA-bound segments than on the analllmical boundary between th abdominal and pelvic parts: • Rl!nal segment (connected to the lddn~ • lumbar segment (between the kidney and blidder) • Vesical segment (In the bladder w~ll. corresponds analiomlcally to the Intramural p;1rt) The most common CJlllffllltD/ anomalies of the ureter are duplkatlon anomalies ;;md defts. They rNY allaw urine to bade up to the lddney (e..l)., a cleft may al~ reflux due to defldent veslmuretl!ral closure), producing an i~ction that asancb from the blidder to the renal pelvis (biiCtertal ~phrltls).
Abdomen Gnd Pelvis - - 2. Organs
~bk~p~~-------+-~~~~
Dec~>c~otsa1 ---~=--- iPir'iillla:-....:;r~~-~,....---- Tr.lnMnepe11MOII penll~wh ligament Bladde<, body
----:-=-- -.::::::
Bladder. apex
Mechn un'blllc:al IIQ;Iment
RJghturmr
•
~Mcectr.Jperftoneal ------....=.~....-
SPICll!wtthvenous plex~~s ofbladller
~nt. pra:sllr!lcpart, with sernilllla~llc:ulus
•
lsdlbc:awmosus
SUperildal
Bulb
pefneill f.asda «penis
8 Loatfon of the bl;!ddl!t'rnthe pelwlund on the peMcfl_.
a SUperklr vfew with the bladder pulled slightly postel1orty ;md the urcgenlt:ll perttoneurn rtrnoved. When the bladder Is dlstl!nded (;.s shown hert). it hols an almost spheriul shaJ)t'.lt is louted in the lessa- peMs on the mll!aJiar sheet of the pelvlc dlaphr;rgm. lying prlnclp;rlly upon the levator anlind Its f01scla (superior fascia of the pelllk diaphragm}. This area of cont:lct Is smaller In the male than in the female (seep. 23S) Ilea use the lesser pelvis alloCI cont:lins the prost
Bulbo-
spongiCIIUI
tkethra,
spongy part
tbsue space, which has ;r wdl-
c AnltDmTc.tl an~tlfctrons of the uretH There are three narmal onoiDmiml consttSc!icns where a stcne from the renal peMs Is apt to become lodged: • Origin of the ureterfram the renal pelllir. (ureteropelvic juncti~:~n) • Slit' where the ureter crosses OYer the external or oommon Iliac vessels • Passage of the ureter through the bladdtf wall (uret.oo.'eslcular ]UriC· tion) Occasionally a fourdl awfl1dloll eo~n be ldentllled where the testlaJiar or ovarian arb!ry and vein pi!$$ in front of the ureter.
233
2.29 Ureters and Bladder in the Female: Topographical Anatomy l'llbls
l'llblc symphysis
Median un'bllblllgament
Partetal pe!ltaneum
ltDI.fldllgament ofull!rw
Properovartan
-::Si
Superior YMk:al ar111!1y
:lJ~!I:..::;:>'!~
_,~. ,- ~.
Median umbiiColll fold (umbllk:al.ii!Ury, ocdwed p;ut}
----'~
ligament Broad ligament--......., ofuti!Ns Fallopian tube
Pel'flc: chphr.Jpn ,___ _ Emmalllac
<111:2\'yandwln Vllglnal branch of
~arl/eSIColllarury
Ullmearll!ry ~CMII'IInarury - - - -
andvdn In cw.llfan
sus~lgarnent
Ub!fo:s.xral fold
1tectout81'ne
pouch
Rectum
Middle
rec:t.11<111:2\'y
Common liac
A Couneof the ureter In the fefnille peMs SUpenorVIew. Most of the perttoneum hillS been removed or~ !he rfght side. and the large intl!.Stine has been removed down to a rectal stump. NOflr: The uretEr t.1kes !he following course In the female abdomen and pelvis:
• P.ilsses behind the ovarlar1 vessels. • CroS$eS lnfi'ont ofthe Iliac vessl!h (usuallytheextemallllac ve.ssels on the right side, also the common iliac~s on tile left side). • Passes lnferfortotheuterfne artesy(seep.291).
B loaltTonandpeitllntllll mverfflgoftheti!tnllle{a)and m~le(b)
tovesiC.ill pouch. Most of the bladder Is loosely embedded In pelvic con· nectivt> tissue. Note: A well-distended bladder pushes the vlscer;il peritoneum superiorly, creating an area that Is devoid of pel1toneum an1l!lfor to the bla~ der.Thls prollfdes .iln .ilcce.ss route for percut;meous puncture of the dis· tended bladdera~thuymphysiswithouthaving to enter the peritDneal cavity with the needle.
bl•dder Midsagittal section, viewed from the left side. The bli!dder Is shown slightly distended, ralslr~g !he uterus to a slightly higher position. The perltolleum extends fi'om the posterforSIJrface of the ar~tenor .ilbdoml· nal wall to !he superior surface of tile bladder arid is reflected onto the organ posterior to the bladder, forming a peritoneal pouch. In the fe. male, It fomns the vesicouterine pouch; In the male, It forms !he rec-
234
Abdomen Gnd Pelvis - - 2. Organs
Pubis
\ P.arlelal per!!Dneum
.1 --lj,.JI"---IIiotlldi!Q;Iment
Pa!s.1ge oflelt ll'eter
ofuttrus
t!V'Gugh brnad
.....::---..41--- - - lltl!rus,pclrtl!rlot
ligament of uterus
IUrfate
Left broad _ _ _.....,;
ligament of uterus
Pa!s.1geofrlght
ll'etertllroug.~
Leftl'alaplan
IIQ;Iment ofuterus
111~
Leftov.ary
/
Left ov.a rta n~ rt!ry anciYeln n
•
ltectum
Saa.ll pramantary
=--~~-....!..,,......._..J...
___ Fl.fldusandtrlgane of bladder
\~~~~~~~~~---NKkdb~
,.,.thwula
ubklmmtnar
ubl~.mma)or
b
c Locilion of the blldderrn the pclwtnrld on the pchkfloor ;a
SUpcrklr 'lltew. The uteru~ I~ shown upright for darlty. Mort of the large Intestine hilS been removed, leaving the urogenlt.ll perlton~m intact. The tr.mM!tse vesiul fald, a peritonl!>ll fold on the surface of the bladder, Is effaced when the bladder Is full (ilS shclwn here). In the female. the bladder lies Inferior to the utetuS and elevates It when diS!J!nded. When the slniC!IJresof the pelvic floor (levator ani and Its
fasdae) are weotkened due to Injuries sustained In a vaginal delivery, for example. they may allow the bladder to descend, resulting In In· continence.
b CGranal section tlb!d slightly posteriorly, antltrklr'lltew. The blad· der and umnra h;we been opened. The att;tchment5 of the bladder to the connective tissue and muscular structures of the pelvic floor ire desafbed on p. 168
235
Abdomen and Pelvis - - 2. Organs
2.30
Bladder and Urethra: Wall Structure and Function
Blidder, body
Blodderfunduswlth bladder-wall muscle to uvula
Deep b"ansve:rse perf neal
External urethral sphincter
A Muscular mechanisms for opening and closing the bladder: mlcturttlon and mntlnence The muscular apparatus of the bladder and urethra performs three functions: • Empties the bladder completely during micturition • Protects the ureteral orifices from reflux • Maintains urinary continence with a full bladder. Involuntary (autonomic) and voluntary(somatlc, by the pudendal nerve) muscle control interact as follows in opening and closing the bladder: • Involuntary mechanism for opening the bladder (controlling micturition). The sequence of events Is as follows: The sacral micturition center Is activated by a center In the brainstem (pontine micturition center) - The detrusor vesicae muscle contracts, raising the pressure wtthln the bladder- The bladder trigone Is raised, and a groove forms at the bladder outlet- The uvula of the bladder retracts from the internal urethral orifice, and the ureteral orifice narrows (to prevent reflux) - The pubovesicalis and rectovesicalis smooth muscles contract, dilating the urethra (fibers to the anterior and posterior urethral walls). and blood drains from the venous plexus beneath the uvular mucosa- The sphincters relax- Voiding occurs.
B Attachments of th11 bladder Most of the bladder is loosely attached to the connective tissue of the pelvis via the visceral pelvic fasda. Only its superior surface is covered by visceral peritoneum. The "lateral vesicular ligament• refers to the connective tissue located mainly around the bladder(seeA. p. 168). The ligaments listed here are basically condensations of connective tissue that surround tile entire bladder. Individual strands of connective tissue may contain smooth muscle.
• Muscular mechanisms for closing tfle bladder (maintaining continence): - Involuntary closure mechanism: Loops of muscle fibers in the bladder wall encircle the urethral orifice. They are supported by the looped fibers of the pubovesicalis. - Voluntary closure mechanism: Descending fibers from the pelvic floor muscle (deep transverse perineal) encircle the urethra (external urethral sphincter). With a structural weakness of tile pelvic floor, which may develop after multiple vaginal deliveries, this closure mechanism may fail. When combined with descent of the pelvic floor and bladder, this failure may lead to urinary incontinence. The maximum bladder capacity Is approximately 700 ml In the female and 500ml In the male (It may exceed 4000 ml In patients with abnormal urinary retention). Urgency may be felt, however, when the bladder contains as little as 150-200 ml of urine, and even smaller volumes may cause urgency during pregnancy due to pressure from the gravid uterus. A normal bladder contains no residual urine after voiding.
llntMIDr Mgarnents
Puboveslcalllgament Puboprostatic ligaments Posterior surface ofsymphysis- bladder, prostate PostBfor llgilments
Rectovesical ligaments Rectoprostatlc ligaments Rectum- bladder, prostate Cranllll ilgllment
236
Median umbilical fold with uracnus
Abdomen Gnd Pelvis - - 2. Organs
Blad6er, body
Right ureur,
IJ!ftuti!Ns,
IIV.amural p;ut
Intramural p;rt
Un!l:enll aifloe
• t-o.,.:;,- - - u-ethra(mucouwtlll langltlldln.lll folds)
lke!hnt, O!lflc:eJ;of--~'a
lft!hral glonds
C W..llstructu ... <~nd tntertor of the bl;ufder;md u...dll'ill Anterior view. Cont:rGIIed by autonomk lnnefYildon, the smootil mus-
cle ofthe bladder wall consists mainly of the three layers ofthe detrusor -icae: the inAer longitlldinallayerand the outzr circularand longitudi· nallayers(the lndlvld~~allil)'ers are not shown here). The outmnost layer sends longitudinal slips poster1orlyto the veslcoprost.iltlcus or w::slcovaglnalls and antll!rlodyto the pubove.slcalls (see A). The dettusor vesicae consists of one layer In the bladder tngone. Its elliptical sllpl forming a functional smooth-musde sphincter that su~nds the intll!rnal ure·
SlbmUCIOSI
•, - - - lkethra, mUIC\IIarl's
thral orlflce (the •fntEmill urethral sphincter.• see A; more pronounced In the male). Abers of deep tr.ansverJe perineal profundus (see A) form a loop of stnated m~~Sde (wth wluntary, somatic lnnerv.atlon) th.at encindes the external urethral orifice: the external urethral sphincter. Noce the slit-like ureter
E lnnel'llil\lonofdlebladder
..
Autlanomk ~lll!lwlloft {ltlsClerom- and VlsatnMeMOry) Paraympathetlc ~hilc spr.nchnrc -(S2-s4) lila the Inferior ~s system
peMc plexus
s,.tlpathetic
Lumber splanchnic nerws via the inferior
~~system
mesenteric ganglion and lnfwrlor hypogastric plexus, and sacnl splanchnic neNBS
D E'flltllelumoftheblilddermuCOA
a Bladder empty: tall epltheUum. b Bladder full: flattened epithelium. Lila! almost all portions of the urinary tr.act (exapt the distal un!thra), the bladder Is lined bytransldonal epithelium wltoJe height and str.atlfl· c;rdon depend on the degree ofdls!l!n!lon of the urfnarytract segmem. Thetr.anst!lonal epithelium bislc..lly consists of multiple cell layers. The con.splcuo~ cells In the surfaa! layer are called "transitional cells• be· cause they chilnge shape. NofJ!: The total thickness of the bladder wall (muscle plus mucosa) ranges from 2 to 5mm In the full bladder and from 8 to 15mm In the empty bladder.
~omlc lnneNlltlon lndudes the motDr lnneMtlon ofthe bladder smooth muscle for controlling contrnenoe and mlcturtllon (both systems) and the perception ofVIsceral pain due to - • dlste~ lion (chiefty the parasympathetic system).
Sem.aclni*WIIon PUdendal nerw (S2-S4) This consists mainly d Innervation to the wluntary extemal urethral sphlnct.r but also Includes the sensory lnneMI!Ion to por11onsof the urethra.
237
2.31 Urethra: Location and Structure B walsegrnents. col'liltrfc:tSons, and exp~nslanl oftfle 1n1le un!thra Mechn un'bllkal ligament
......... <-~!soD)
l'llblc symphysis
IUghtJtmlnal
..........
CondrfcUon51nd
Internal urettoral
IA!.IIclt l'mS.CillllUS
GMmosum
ar1flce
Intramural part
umhral sphincter
sphlncll!f Uretln,
Ureth~
spangypart
piUSta1lc p;l rt
Right bulbo-
I'm~
urethral gland
Glarupenll
Bulb« penls(CGIJ)US
Urettn.
spanglosum)
nmcular"-a
nm
a~~~strtction:lntemal
Ex1emah.1'eltlral
~----T~.u lljaali!Ory duct
Prostat1c part
nrst expansion
Membranous part
Second constncaon: ex11tmal urethral sphlnmr
Spongy part
SeCDnd expaMion:
ampul'Third expansion: 1\lMcularfoMa Extemal urettor.al
Tlllld constJiction
ar1flce Saolllm
Rlghttl!stfs
A Plrts of the maleuretflra Male urogenital system in the pelvis, viewed from the right side. Un· lllcethefemale urethra. the m~le urethra furKtiofiHS a Olmmon urinary aile# genltil passii!Je. It has ilflaverage length of 20cm and consists of four p.;~rts with tflree constrictions ilnd three exp.;~nslons (see B). The In· IJ'ilmural partoftfle ureehrilln Ule bladder wallis not shown here. Willie the female urethra is eQenti~lly 5traight (see E). the male urethri pres· ents two curves: ilfl fn(nJpublc curw ilnd a Pf'Pllb1c curvt. These curves .are lmport.ant In trilnsurethral bladder c.tthetertz.atlon (see F).
Sejltllm
of penis Deep penile artery Coll)US
c.wemo:sum
Tunlculbuglnee cfCOIJ)US
avemosum ~nllefascla
(de.!!') Tunica
C Locatlonoftfle.,.leumln lr~tfle penis
Tr;msverse sectlor1 through the penile shaft. The spongy part ofthe uretflril Is contained lr1 tfle corpus sponglo5um of tfle penis. The corpus sponglosum does not become compll!tl!ly hard t'YI!fl at miiXImum erection, ensuring that the urethra l'l!!mains patent during ejaculation. The umhr.lllumen often presents i flattened rither than circular shape In cross-section. with tfle upper and lowe!' walls touching.
238
D Mill uni!thl'llln longR\Idtnalll8dfon
The whole length oftfle uretflra has been cut open and displayed with· ollt curves, and ill of the pelvic floor muscles have been rtmoved. The fwr parts of the male urtthra c:an be identified. The male urethra extends distally In the corpus sponglosum to Its external orifice on the glans penis. The piQStlltlc partofUie urethra miiY be greatly narTOWed In patients Vl!th benlgfl prostatic enlargement (prcstat:tc ~Ia). This condition is often mirla!d by incompll!lz voiding a nod the dribbling of ur1ne after micturition. The residual urine left In the blildder may Incite in{often bi!Cterialln nature) lnflammatlonofUie bladder{cysUtfs).
Abdomen Gnd Pelvis - - 2. Organs
Iliad de<, mucosa Sllldder, ......__ muKI.IIIrfs ~
l\ledtaf bliddtr\Mih IMIIa lit lntmlal ureth~l orifice
I
Bliddt<, adwoentllli _ _ ____.. ... llld~sar.JI ~ttasdi
..~~~~.
u~~-----~~~--
mulalllrf'
Extlemil ure1!r.ol spN'nclltr ---.,...;:.-:-.=:.--..;;....-.,-+• u~~.--~-~~~-~~~~ !.J.f-7----:="""~'"""==---------
menbnii'IO
\
Ublumma)or
E Female uretflra Tn longitudinal sec:Uon Coronal section tilted slightly ptiSIJ!f«, anb!riclt view. Unlike the male uretlu<~.
the female urethr<1 Is str<~lght
<~nd
only <~bout 3-S em long.
•
• .qu\J
ublum minor
Thus It Is much e..slerto catheterfze than tn the male. At the same time, the short length of the female unethra inc-susaptiMity to urinary tract Infections.
fJo---c-- Anus Extemal ortl'lce of the female uretflra Viewed frcm below. The pubic bone (pubis) is shtiWI'I in shadow to aid
Ci
Pel'ls. pendulous p;Jrt
Prl:publc OJM (S1r.IIQhttned .,.,cumber)
F Tnnwretlln~l bladder utlletertatkln tn tile m.tle The two curves of the m<~le urethr<~ (ln1\-apcJbic <1nd prepubic) and lU three constrfctlons m;ry pose an obstacle to transurethril c<~!heterlu· tlon. The prepubic curve can be straightened out somewh.ttbystralght· ening the penile shaft.
ortent<~tlon.
The elCtaNI urethral orlfloe Is IO«ted between the l<~bla anterior to the vagina. Despite 1t3 pi'Oldmlty to the femille external genitalia, the female urethra timc:tlons exclusiVely as a urtrl.ilry passage. The close topographical 11!1atioruhip of the urethra arid external genitalia Is lmportlnt during embryonic development. however. both the urethra .1nd the vagln.. lnltlilly have,. common opening at the urogenital sinus .and become sep.arated only afteffurther development. Fanure of this sep.aration results in an abnormal fistulousconnec:lion be~en thewgirl.il and urethra, a ~t~Whrowgirnzl [lstulo. E~n!n with nonmal anbryonlc development. the pi'Oldmlty of the urethra (which Is physlologleilly gann-free) to the vagina (which Is not a rterlle zone) predisposes to bactenal lnflamm<~tlol'l of the urethra (IH'ti:Mtts}. Gillen the short length of the fem<~le urethra, the infection c~n e<~Jily ;.,cend to the bladder (cystitis). minor<~.
239
Abdomen and Pelvis - - 2. Organs
2.32 Overview of the Genital Tract
aauiHcatlon of the genital organs
A Male and female Tntemal and external genitalia •
The genital organs of the male and female can be classified In various ways: • Topographically (A) as: - internal genital organs (internal genitalia) or - external genital organs (external genitalia) • Functionally (B, C) as: - organs for germ-cell and hormone production (gonads) or - organs of transport. incubation and copulation, plus accessory sex glands • Ontogenically (see pp. 242, 243) as: - the undifferentiated gonad primordium (develops into the gonads) - two undiffi!rentiated duct systems (develop into the male and female transport organs, the female uterus, a portion of the female copulatory organ, and one of the accessory sex glands in the male) - the urogenital sinus and its derivatives (giving rise to the external genitalia of both sexes, the accessory sex glands, and portions of the copulatory organs)
B Functions ofthl! mal• genital organs
lntemal genltllla
Testis Epididymis Vas deferens Prostate Semi nil Ivesicle Bulbourethr;~l gland
OVary Uterus Fallopian tube Vagina (upper portion)
External genital..
Penis and urethra Scrotum ilnd coverings of the testis
Vagina (vestibule only) Lilbla majora and minora Mons pubis Greater and lesser vestibular glands Clitoris
• Tile {mlak external genitalia (pudlenda) are kna.vn clinically as the vulw.
C Functions of the fl!male g•nltal organs Function
Testis
~m-cell
production Hormone production
OVary
Germ-<:~~11 production Hormone production
Epididymis
Reservoir for spenm (sperm maturation)
Fallopian tube
Site of conception and transport organ for zygote
Vas deferens
Transport organ for spenm
Uterus
Urethra
Tromsportorg;m for spenm ;md urinary organ
Organ of incubation and parturition
Vagina
Organ of copulation and parturition
Labia majora and mlnon
Copulatory organ
Greater and lesser vestlbulilr glands
Production of secretions
Accessory sex glands (prostate, seminal vesicles, and bulbourettval glands)
Production of secretions (semen)
Penis
Copuliltory ;md urinary organ
240
Abdomen and Pelvis - - 2. Organs
Rlghtlddney
Righturet1!r
OVartan suspensory llgament
----H
Penis, corpus avemosum
Median -----."-- -.. umbilical ,.------~~~..,..... , llgament
Glans penis
Bladder
-----'<-'
Uterine cervix
J.IIFT- -
Vagina
~~f---- Ureter.~!
orfflce
Scrotum
Testis
Epididymis
\.L.T----
Urethr.1
U.blum major
Greater vestibular gland
U.blum minor
b
D Overview of the urogenital system Schematic representation of the urogenital apparatus in the male and female, viewed from the left side. Unpaired pelvic organs and the external genitalia are shown in midsagittal section. a In the male, the urinary and genital organs are closely Interrelated functionally and topographically. The urethra passes through the prostate, which Is derived embryologically from the urethral epithelium. All of the accessory sex glands (prostate, seminal vesicles, and bulbourethral glands) ultimately discharge their secretions Into the urethra
b In the female, the urinary and genital tracts are functionally separate
from each other. Topographicul/y, however, the anterior wall of the uterus is closely related to the urinary bladder. In the external genital region as well, the urethra is embedded in the anterior wall of the vagina. For these reasons, the collective term urogenitD/ sys~m is generally used.
241
Abdomen and Pelvis - - 2. Organs
2.33
Embryology of the Genital Organs
A Development of embryonic rudiments In the male and female Although the gonad primordium (future ovary or testis) Is genetically determined, It Is "colonized" only secondarily by primordial germ cells. Once this has taken place, the primordial gonad begins Its sex-specltlc honmone production, laying the foundation for further development
lucltment
Undifferentiated gonad with o
cortex
o
medulli
Definitive strudun! In the
The uretero/ bud develops from the perivesical portions of the mesonephric ducts In both sexes, doing so Independently of sex and hormones. Embryonic remnants of the duct systems are often still present In the mature male and female. They have no functional Importance, but in rare cases they may lead to disease (e.g., cysts or malignant tumors).
ll1olle
Definitive structure In the fen1llle
Testlswlth • Seminiferous tubules o Rete testis
OVary with • follicle • ovarian stroma
Mesonephric ductule
Efferent ductules of testis
Mesonephric (wolffian) duct
o o o o
Epididymal duct Vas deferens Ejaculitory duct Seminal vesicle
·U~
• 1/eno/ pelvis and caHces, coll«tlng dum Para mesonephric (mUIIerian) duct
Nonfunctlonlng remnanb In the ll1llle
Nonfunctlontng remnants In the fenuole
Paradidymis
Epo- and paroophoron
Appendix of epididymis
Vesiculir appendix. Gartner duct
Appendix of testis
Morgagni hydatids
·~ • lienal pelvis and oollces, coll«tfng dum • Fallopian tube
• Uterus • Superior portion of vagina
Urogenital sinus
o o
Philllus (genital tubercle) Genital folds
Lal>loscrotal swellings Gubemaculum
Genital tuben:le (of MUller)
242
Prostate Bulbouretkral gland
• Inferior portion of vagina • Greater and lesser ..estibular glinds • Blodder
• lllodtkr • Makumhra
• frmale urethra
Corpus CJVemosum of penis
Oitoris, glins of clitoris
o
Glans of penis
Scrotum
• Labia minora • Vestibular bulb
Prostatic utricle
Penile raphe
Labia majora • Proper ovarian ligament • Round ligament of uterus
Gubernaculum of testis
Seminal mlliculus
Hymen
Abdomen Gnd Pelvis - - 2. Organs
Wolflllnduct
Gonad prima !dum
MDIIerlan duct
Cludal ganadal
fg;ment (gu!MmaaJklm)
1\ UII!I'IJS
Flllleplio tllbt!
'*=..------- Epoophoron
Yasdeflnns
O'ilrllln SIJIIM!I151XY
fgarnent 0\l;lry
Pl'clstat2 ------~~*-lr
Bulbalftlllral
-------nr~~-'
Prapercwarllln f!J!ment
~ir.d
G.lr'tnerduct
~ecoid
{embryonlc remnant
cfwolfll;m duct)
Raund fQiment cfutena
Epididymis
Vagln~
B Devdopmentofthelntem•lgenlblll• GeiMtkillly male lllll~wtthtlls\kularprfmordlum; Under !he lnflu· ence of tertorterolle produced In the testis, the wolffkm ducts develop
ln1ZI the v~ deftre1u ~nd epldldymls. The mOIIeffan ducts regress ln respomebl anti-mulleri;an hormone. which 'i$ also p~uced in the ruw.
Gendh31~fern~~le embryo wl'th ov.rT•n prlmonlum: Unties- the influ· enceofowrfar~hormones. themOikrlanductsdevelopln1Zithefalloplan
tube.s{Utl!rfne 1:\ibes) and 01lso fuse to form the uterus 01nd part of the vagina. The 'M:IIfflan ducts, 'Which c:m develop only In respon.ie to testos· terone, regress almost completely.
C Dl!VI!fDpmeflt ofthe atemal genitalia
The elCtemal genltSage. In both sexes, however. the urinary ind genital organs ire so dosely related topogriphlcallythatthey ~re ofu!n referred to collectiVely as the urogenital Ol!ans.
243
2.34 Female Internal Genitalia: Overview
l4WI'tebra
lntmlal Mlac Mtl!l'y
Aortleblfu!Udon
(
Commonrracart8'y
I
Ov.llry
\.l
-
'
£xll!mallliilc artery Ub!Ns
F.allcplan tube
~No
Prcfedlonaftflefl!m•l~lntl!mllgenltllllloni:Dtfl~pehll:t Anterl~rvlew. Th~ bifurcation ofthe abd~mlnal aort.11nto the common
A
llli1Cartafes 1~ also ~hown to aid orfernatlon. The uteru~.llke the wglna, Is located In the pelvk m!dlln~wh!leth~ovarfes are superior, lateral, and
postl!rlor to th~ uterus In the RLQ and LLQ. E.'lch ovary occupies a fossa
located just inferior tD the dMsicm of the common iliac artery. The fallopian tubes do not pau to the ovalfes by the sh~rtest route but drcle around them from the later.rl side, bec3use both of tile milllerfan ducts (whldl dewlap lntD the fallopian tubes) run later.! Ito the gonadal ridge In -whldl the ovartes develop.
·.<:T--if--~~~--~--~------~. p!!f!!Dne
~sat11l antl!rior
ll!ctilwal
ub!rus ~~~----~--~,
po!t!tl:lnl!ilman the bladder
'hglni
Blildcler
B Ute rut end~''* ~'-tlon•htp to tfl~ peMc orpns
Midsagittal section through a female peMs. viewed from the left: side. The peritoneum hiS been outlined In color. The uterus directly overlies the bladder (see alsop. 169), and the rectum Is posterior to the utenJs. ThefunduHnd COI'JI'l$ (body) of the uteru.nre covered byvi~l peri· tone\Jm, whkh Is reflected onto the bladder and rectum to form the YeSicouterfne pouch and rectoutelfne pouch. The peritoneum extends
244
fartner down the posterior wall ol the utenJs than its anterior wall, with the result that the pllStelfor part of the utafne cavil! and upper v;rglna Is COYered by peritoneum -while the anterior part Is not. The vagina Is surrounded on all sides by pelvic connective tissue. This tissue Is thick· ened anteriorly and posteriorly to form the vesicovaginal and rectcMginalsept
Abdomen GndPelvis - - 2. Organs
R.edum
Sigmoid
colon
llum Rlghtl!llttl!mal - - -....:.::.., 11M:Ntl!l'y Rlghtl!llttl!mal _ _ _
....;:;..;....._""""::'~
n~acwn
"'I.. .;,---;r~7::-"-:-::-:-:------ llound llg;unert ofut«US
..J.:--+;_,;.~-:--- lltMtutra-
~~---~~~~~~~~~
perftonal sp.~C~e
uteine orlfh::~
VieillbularbulbWI1tl
Ublumma}Or
bulbaspang~ur.
c 1he ti!mlle genital organs rn sttu Slightly angled coron;~l $C!1Ciion, ;ant!!rior view. The bi;ldder, which lin anterior to the wglna and Inferior to the uterine fundu~ (see 1). Is not shown. This Illustration represents a compilation of muiUple sections to provide a single lntl!grated llfew. The uterine fundus. 'Which Is dlrectl!d anteriorly DWing tD its ant.ewrted and antefl~ position (see p.2S1).
pro}ectsautofthedeeperplaneofsectlontowardtheobsei'Yei'.Around the Yi!li~ is a connective·ti$Sue !IPKe containing ;an elaborate venous ple1!.Us. This loose connecdve tissue allows for a~nsldmble ap;~n~lon of the vagina during childbirth. The sections of irl:erial vessds are il'terfal br.ilnches ta the vagina as well as sections of the Inferior veslt.ll ar· teries.
245
2.35
Female Internal Genitalia: Topographical Anatomy and Peritoneal Relationships; Shape and Structure
Tlbal brand!H
Planeaf
Pl'oper~~~~<~IW>
S«ttan In I
ll91ment
l.lb!!fne fund~&
F.lllcplan lllbe, lllflm~a
Rlghtfalopi'an lllbe
of uterfnew:mds
Fln!Hfaeat
lnmeosa~M
abdominal a:stlum offillloplllntube
vesicular~ppendlcH (1!11'b!)o nlc rem 1'1101 nt)
""ll~ll..:~- Falop!antube. • lnfuldbllum 1\aloplantube, abdomiAal a:stlum
CMrllln~slnD't'llrllln ---""'f~
SUipen!Oryl191ment
A Utenls n Mlll!llil: tDpography and perft:orleal rNUonshlps Postel'o$upenor llfew of the uterus, <~dnexa, and !he postl!lfor surf~ce of the u1zrine broad ligament. The u1zrine adnele;l (ovary and f.allopiarl tube) are att
the ov.Jr1an suspensory ligament (these .Jnd olher ligaments are reVIewed InC). lit*: The ureten descend in the retroperi1lll'leum ID the base of the broad ligament and run forward between Its layen to the bladder. pan· lng Inferior ID Ute uterine irtefy (not visible here. see p.17S). This rela· tlonshlp must be duly noted In operations on Ute uterus and broid llga· ment (risk of ureteril Injury).
c llgiiiiMnts and perttur~e~l structures ofthe femlle genltlll organs
......
IIINd lgamentof
Bnlad fold af perltiJntum extending from lhe latual peMc 'Mill to the ul!erus (transmitS vasaJiar structurM tolhe Inte-l geniUI o~gans). The ligament has thlft main parts 11\at extand to specific o~gans: • Maometrium • to the uterus • Mesosalpirot •to the fllllopilln tube • Mesovarium ·to the ovary Theoon~ussuespace~nlhe
two ()U110neal flyers of the b!NCI llgammt Is 1coown dlnlcally as the parametrium
Tranwerse bands af mnnectfw Uaue betwemlhe uiBine cervix and peMc wall (paraaerM)
8 Folck of perftorwum on dlenm;lleganltill org;ms (after Graumann, von Keyserilnkg, and Sasse) s.agn:tal sectfofl through !he broad ligament of Ute uterul. The ovary, fal· Joplantube, and much of!he uterus(seeA)areCOYered by peritoneum. The f.rlloplar1 tube Is attached mUte superior margin of tile broad llga· ment by the mesosalpinx. The ovary Is attadled w1he posterosupenor surface of the bnoad ligament by its own pefo!Dneal struchJre,. themes· ovarium. These peritoneu~ bands of connectivt' tissue per· form the same functions for the genital organs as the mesenteries do for Ute bowel ;md are named accordingly (see C): Ute mesovarium for !he ovary. Ute me.so.salprnxfor the fallopian tube (salpinx), and the mesometrium for the uterus. Collectively they form the broad ligament.
lllound ...mentof
'*"''
Pl!rltoneum-red fold of connectiW ussue betwem the u11en1s and rectum: often contalM smootto muscle (-rtne mutcle) Prodmal remnant of gubernaculum passing
from the uterine pole of the e~~~ary to the angl. oflhe uterus With the fallopian tube OWitln...,._., lle•ment
246
Distal remnant !If the gubemaGJium (• embryonk COR! In both-. guides the descent of the testis or ovary). ExUnds from !he lateral angle ofthe llllfrus thoough the Inguinal c.anal Into the subcutaneous connedift tissue of the labium-jus
Fold of pertloneum stretdllng from the peMc 'Mill wthe cwary: tnonsmlts theova,_n ~s
Abdomen Gnd Pelvis - - 2. Organs
Propeumrlan ~~~
Ampulla of fallopian tube
Me:sowltal ma111n
l'pooplloroo
~lallilrap~
lnfundbtlum'W!III
~mlostlum
(embi)'Onle rannan1)
vascular pole _ _ _.....;:.._ ••
offlllopiantube
...-oc.....-
D Uten1s ~nd t.lllopl~n tla!s: sh;pe ~nd stn.Jc:twe Po~ll!nor
lllew of a ccronal section with the utll!rus mlghtened and
the mesometrium removed. The uterus CDnsist.s basiully of the ccrpus (with the fundus) ~nd ccrvl~ the corpus being joined to the cervix by a narrow Isthmus appi'Oldmarely 1 em long. MacroKoplcally. the uterine Isthmus Is dasslfled as p;ut of the c:ervlx but hlstologk:ally It Is lined by endometrtum. The junctSon of the body of the utl!rus .and ceMll k lo· cated at the lntMJal os of the uterus. The lumm of the uterus, called the uterine calllty. communicates with the v;rglnallumen through the Isthmus ind cervical canal. It has a totillength ("probe length") of7-8
utmn!al'lltlc Is subdMded Into a suprav;rglnal part and vaginal part. The emmal GS of the uteru~ Is the opening In the vaginal part of the cervtx that is directed tcw.ard the vagina. The vaginal part of the cervix prcj·
ects Into the v~gln~. forming recesses called thev;rglnal fornices. The fulloplon tube (uterine tube, toGIIength approximately 10-18 an) I~ subdivided from lateral to medial Into the Infundibulum, .ampcJIIa, Isthmus. and uterine part. The abdominal ostium of the tube at the In· fundi""lum is surrounded by fimbriae (the •fimbriated end") and opens Into the perltone;rl cavity. The o~tlum at the utafne end of the lllbe opens Into the uterine cavity.
em. TheuOMneOl'llftypresmuatrlangularshapelnccronal section. The
E F•lloplan llDe Tn crou-sectSon:: -n stn1c1llre Cross-sectional view ol the ampullary portion of a right fallopian tube.
The meso:silplnx extends lnfertorfy. The three wall layers are clearly dis· tlngulsbable (wall thickness= 0.4-1.5 em): • The miKIIAis raised Into a great many folds th.at occupy most of the tubal lumen. These folds are of key lmport;ance In transporting the zyglltl! to the uterus. Postlnflammatory adhesions between the mu· cosal folds may hamper or even prevent transport of the h!rtilized ovum(see p.254). • The musaJIIrts consists of severil thin layers of smooth muscle that proVIde the fallopian tiJbe w1t1t Its motll!ty (see 8, p. 252) and propel the zygote W!Nard the utll!rus by a ciliated epithelium. • The Hrosa (perltone;il ccverfng) flf the fallo~n tube Is continuo liS wltlt the mesosalpinx.
247
2.36 Female Internal Genitalia: Wall Structure and Function
The ut.ine wall also a~~~slsts Gf three layers from Inside tD outside: • M-or-.lemelltum(seeC): Single layer Gf columnar eplthehum (eplthellalleyer) on a a~~~ne~tlssue base (lamina Jl")prla) • M~~~a~. . a.tor...,........m (see A): Sfteral siMOth-muscle layers with amul thickness Gf apprad· mately 1.5 em • Serous ClNt or parfm8btum: Serosa cowrlng the anterior and posterior sides Gf the uterine COIPIII and the posterior wall
adjacent to the myometrium becomes adwntltla In areas where the ut.us lades a peritoneal CCMrlng (e.g.,llt the lllbdlment of the ut.ine braad ligament).
l'plthellal aUs
Endomelrklm (mUCDSoJ). fllnctlaNI
layer
A ._.... (a) and functSonal pr11ql!e (b) ofdie myometrtum
Spongy layer
Stroma
(after Rauber ~nd Kop.Kh) The myometrium (musaJiar mit) of tile uterus conslsts of three layen fromoutsldetolnslde: SUpmt;ua~l;r layer: thin outermost layer with crts:s
•
The myometrium pedorms two se\!mlngly contridlctory functions: It must keep the uterus dosed durfng pregnancy, but It must ope~~ tile cervix during childbirth. To fulfill the.se functions, the individual m111de ~ (see ~bc:we) are equipped with longitudinal, oblique. and tr~ns· verse or drt~.~lar fibers. The circular musde fibers ue most ibundint In the cemeil region and serve to maintain closure of the cervix durfng pregnancy. The longitudinal and oblique muscle tlben are most abundant in tfle uterine body ~nd fundu.J; they shorten tfle uterus ~nd IC~~~~~er the fundus durfng childbirth. The myometrium bleslds with !he drt~.~lar fibers of the fallopian tube muscles it the uterine fundus ne01r the tu· bal ostium. Myome!Jfal con!J'ilctlolls ire stlmulmd most eff&ttlle!y by tfle pituit.lry hormone oxyblcin. These con!J'ilctions ocaJr not only dur· lng labor and delivery but also during menstruation. when tiley aid In expcJislon of the uterine mucosa. Belllgn tumors of the myometrium (flbnolds, myomiiiS) may Ciluse abnormalities of menstrual bleeding.
248
fndomet~m (mLlallii}, - { bas.lllayer
$
<""""'
Myame!Jfum ,...-
ll&il blood VKSelr.
c Structure ofthe W!fTN! miKDII (endor'III!M.Im) Stn.rctumlly, the endometrium consists of a simple columnar epithelial cell layer and a lamin~ proprli!. The epithelial layer lines the uterine sur· f.rce and encloses the tubular. coiled endometrial uterine glands. The lamina propria, 'Which surrounds and supports the lltl!rfne gkmds, Is made up of connectllle tissue (stroma) and the vessels embedded In lt. The endometrium Is (unctfonally subdMded Into a basal layer (stmum bas.1le) ;md a functional layer (Sirill:\lm functfonale). The b
Abdomen and Pelvis - - 2. Organs
Folllcularphase
Ovulation
~op
®
~
eo Functlonalloyerln the secretory phose
Prollfl!r.ltlon of functional Ioyer
Menstruation
7
28
Luteal phase
Blood....._of •terlarpllllbry hormones
14
21
7 Days
28
Z1
a.... ._.,.~,..
--_Lfo .._.s_·c_----:-___J/ D
Menstrual phase
D
\..___ _ Proliferative phase
D
D Cyclical manges In the endometrium The ovary secretes estrogens (e.g., estradiol) and progestlns (e.g., progesterone) on a cyclical basis. Estrogens stimulate proliferation of the endometrium, while progestins induce its secretory transformation. The release of both hormones Is controlled chiefly by the hormones FSH (=follicle stimulating hormone) and LH (= luteinizing hormone), which are secreted cyclically by the pituitary gland. While estrogens are produced by the ovarian follicle, progestins are produced in significant amounts only by the m~pus luteum. If conception does not take place, the co~pusluteum regresses and stops producing hormones. As a result of this, the functional layer of the endometrium breaks down and Is expelled during menstruation. Estrogen production by a new, pituitary-stimulated ovarian follicle Initiates a new cycle, which lasts an average of 28 days (= 1 lunar month). Ovulation usually occurs on day 14 of the cycle. Note: For practical reasons, the first day of the menstrual period (which lasts about 4 days) is considered day 1 of the cycle, despite the fact that the cycle ends with menstruation. This is because the sudden onset of menstrual bleeding is easier to detect than its more gradual cessation. From the standpoint of the endometrium, however, the last day of the menstrual period (difficult to detect) marks the end of the cycle.
Secretory phase
Suprwaginal
part of cervix Vaginal part ofO!rvlx
Vaginal part _
___j~.-
ofceNIK
E Cervlaleplthellum and Its changes (after liillmann-Rauch) Simplified schematic representation of the cervix and vagina in coronal section, anterior view. The arrows indicate the location of intemal os, and the dashed lines mark the boundaries of the cervical epithelium. The cervical canal bears a single layer of columnar epithelium (cervical epithelium), while the vagina is lined by stratified, nonkeratinized squamous epithelium (vaginal epithelium). The boundary between the two epithelia varies in location according to the woman's hormonal status. Before puberty (a): The vaginal part of the cervix is covered by vaginal epithelium, and the boundary with the cervical epithelium is not visible from the vagina (endocervical above the external os). Rl!produdlve age (b): In response to hormonal stimuli, the cervical epithelium is everted out of the cervical canal (ectropion), and so its boundary with the vaginal epithelium is visible from the vagina. After menopause (epithelial relations same as before puberty, see a): The cervical epithelium has retracted, and its boundary with the vaginal
epithelium is again endocervicaL Metaplastic tnlnsfol"'l''lllion: In women of reproductive age, the single layer of everted cervical epithelium may undergo a transformation (metaplasia) to stratified, nonkeratinized squamous epithelium. If this squamous epithelium overgrows the orifices of the mucus-producing cervical glands, it may occlude them and incite the formation of mucus retention cysts (nabothian follicles). Nob!: The squamous epithelium may also undergo malignant transformation, forming precancerous lesions that progress to cervical carcinoma. The precancerous changes can be detected early by a test in which smears of epithelial cells are taken from the vaginal part of the cervix and examined microscopically to assess their degree of differentiation (Papanicolaou or "Pap" smear). An iodine test can also be used to detect areas of greaterorlesserdilh!rentiation on the vaginal part of the cervix: Normally dilh!rentiated surface epithelium is stained by the iodine solution owing to its glycogen content, whereas less dilh!rentiated (glycogen-deficient) epithelium remains unstained.
249
Abdomen and~ - - 2. Olgans
2.37 Female Internal Genitalia: Vagina, Uterine Positions
-==-l--- llb!rlnec..w,part ~Ina!
Alltslorllp ofllllt1neCB
TranMFW
porinMIIIgomont
Anllto1ar wglnal cohmn
l'lblc ~Is
DorHid~t~;~ral o!Ufy~dnerw
Femole
...
U~rl
~· anta1orwall
£xtomol u~ralartllao
Vagina
A v.g1.. POsterior 'llew. Tht~ Qglna has been cut open along a mronal plane angled slightly posteriorly to display ib anterior w;~ll. The vaginal lumen presentun H-shaped cross section (see 1). but the lumen In this dissec-
lsd'lo~rnosus
I I..DcUionvfthl nglm1ln tiM pelvic: floor
This drawing lllustr.Jtes the dose pnliiCJmlty of the vag Ina and urethra. Muscular fiben from the deep tr•nsverse perineal profundus ~ncirde the vagina (see G, p. 239).
tion hils been stretched open to a mor~~ drculilr shape (In slru the pos~rio;~r and anterior waiiJ <1re dosely appoJed). The Qginal muCGSi hu numerous trann
UIB1necervll<,
C Locdan Gfthn..IMin th• ,.Ma Midsagittal Hctlon through a !'email! pelvis, viewed from the lefhide. The longitudinal axi$ of the Qglna Is directed ~rosuperlorly. The vagina Is ilttadled to the pelvic connK· ti\1' tissue antef10rly (\lt:SICIMIQinal seprum), ~rlolly (rKtovaglnal septum), and laterally (not .shown here). The vaginal fornix surrvunds the vaginal p;1rt of the ceMx. which it· self Is directed superiorly and anteriorly. As 1 result, the .anterior fornix Is considerably IOWI!r than the posterior fornllL The 11!~1 peritoneum extl!nds far dawn the posterior utertn11 Willi, bringing the posterior p;~rt ~;~f the wginal fornix Into dose prOI!Imltyto the redioutertne pouch (cul-de-sac, the IOMSt p;~rt of the fermle peritoneal c<~vity).
250
suprnaglllll part \-...-~-- Vlgnalfomlr..
pador1ar part ~E-...,!11!!~-
Vl9na.--~~~~--~~ • . . -...11 U~ra
VesiiXMigln•l sepbm (dlnlcill~)
Vlglllill ortfloe ----T--:: Vld...toestlbue -...::::lllii;\io~.,... ,..th llblum minor
Vl"nalfomlr.. lnlilrlorpn llectum
Abdomen and Pelvis - - 2. Organs
Uterine cavity with Endometrium
D O.uvature and position of the ute111s
Mldsaglttal51!ctlon of the uterus and uppervaglna, viewed from the left side. Nob! the two angles that determine the normal anteversion and anteflexion of the uterus (see r:;). Posterior angulation and curvature of the uterus (retroflexion, retroversion) are considered abnormal. A retroverted uterus Is more susceptible to descent because It Is more closely aligned with the longitudinal axis of the vagina. Moreover, a retroverted uterus that enlarges during pregnancy may become Immobile below the sacral promontory(L5/S1 junction) and jeopardize the further course of the pregnancy by constraining uterine expansion.
longlwdlnal uterine axis
Uterine Isthmus CI!Nical canal with
Flexion
Perimetrium
longlllldlnal ceNical axis
(5elll5il)
Uterlnefundus Uter1nebody
---<
~
~
Vesicouterine
pouch
uterine cervix, vaginal part
Version
Angle between
the cervical axis
and longitudinal body axis• (Rotatfon)
Pelvic peritoneal cavity
Vaginal fornix,
V.glnawfth
Longitudinal
anterior part
longitudinal axis
body axis
Pelvic bone
;---!-,1--- Vaginal part
of uterus
•
F Physiological changes In uterine posldon Midsagittal section of the pelvis, viewed from the left side. Uterine position Is directly affected by the varying degrees of bladder and rectal
distention. 1 Bladder and rectum empty; 2 bladder and rectum full; 3 bladder full, rectum empty.
E Position and level of the ute1111 In the pelvis
r:; Describing the position of d!e ute111s in d!e pelvis
Coronal section of the pelvis, anterior view. The uterus has been slightly straightened for clarity. Normally the uterus is located approximately in the median plane (a) with its vaginal part level with a line connecting the two ischial spines. The uterus may be displaced from this position to the left or right (sinistroposition or dextroposition, b and c) or may lie above or below the plane of the ischial spines (elevation or descent, see d and e). Anterior and posterior displacement (anteposition, retroposition) may also occur but ane not illustrated here. Descent of the uterus usually results from a structural weakness ofthe pelvic floor (chiefly the levator ani, often after numerous vaginal deliveries). Displacement of the uterus may cause complaints and functional disturbances due to pressure on adjacent organs (bladder, rectum). Descent of the uterus may even cause the vaginal part of the uterus to protrude from the vagina (cervical prolapse).
The position of the uterus in the pelvis can be described in terms of rotation, flexion, and position (angles are described in D). Rotation
Inclination of the cervix In the pelvic cavity: deft ned by the angle between the cervical axis and the vagina; the nonmal condition Is crnmerslon
Flexion
Inclination of the uterine corpus relative to the cervix; defined by the angle between the longitudinal axes of the cervix and uterine body; the normal condition Is ante[lexlon
Position
Position of the vaginal part of the uterus in the pelvic cavity; physiologically, the vaginal part of the uterus Is at the level of the Interspinous line at the center of the pelvis
• The angle between the cervical axis and the longitudinal body axlsls clinically relevant by certain conventions (see D).
251
2.38 Female Internal Genitalia: Ovary and Follicular Maturation Faloplan~
I UtMa.---
postlerlor surf.u:e
~-"'---:;=.----lt.noularpole
--:z~---
Onrllln-ryii!IIIITWnt
MesomeU!um - - - - - - - - -
A OVIry
C) arid Is surrounded by a tough collagenous ~psule (tunica .albuginea).
Posterior view of a right ovary, showing the peritoneelligamenU th~t transmit vessels to the ov.~ry (ovarian suspauory ligament with the ovilrlan ilrtl!ry and velr1, proper owriar~llgament with the ovarlar1 brilrldl of the uttrfr~e ~!Ury, ~rid portions of the utl!rl'ne venous plexus) along with part of the uterus, ~llopian tube, ~nd blwd lig;~ment. The ovary is positioned such that It lies lr1 the lilac fossa of the l6ser pelvis. NOll!: Glllen the dual Yiscular supply to the ovary from the upper ab· domen (the vessels .accomp.my the ovary durtng Its developmenul de· stl!!nt) and the blood supplytD the ub!rus (dose to the ov.1ry), both vascular systems should be ligated durfr~g a hysterectomy. In a woman of reproductllle age, the ov.~ry Is 3-5 em long and has the slzeindshipeofaplum.ltconslruoficortlcalandmedullaryzone(see
The a~rti~l zone conuins follicles ~t varying suge.s of devel~pment. The folllcl6 cont31n an oocyte surrounded by follicular epithelium and a connectlve-tlssue mantle. Female hormones ane not produced by the ooc:yteltselfbut by the cells th~ surroundlt. Although .ilrllntraperftDneal organ, tt1e ov.~ry is covered externally bygemnin.al epittlelium (on iU tu· nlca albuglne<~) and h;ss ;uhlnysurface. NOO!: The visceral peritoneal covering of the owry, i slngle-layened cuboid~! epithelium that surrounds the tur11c.11 albuginea, has been refl!ITI!d tD traditionally as •gemniBalepittlelium: but it does not partici· pate at all In the principal. reproductive function of the ov.~ry--egg production-nor Is It lrtVOIYed In replenishment of cdls In the owry Itself. HoweYef,ltls •gemnlnal"ln another, unfortur\ate way-9DZ of all malignant ov.1riarl tlJmon are thought to originate in thif. aU layer.
8 Ovum colledfon medlantsm
Postel'forlltewofa right ovary arid f.lllop&antube. Both thefalloplan I:IJbe .arid the ovary are motlle. The tube deriVes Its motility from Its muscular wall. Rotiltional and longitudin.al movemenU of tt1e tube make it ell$· ler for the fimbriated end of the tube to conuct the entire ov.~ry. The movements stop when the abdomln.al orlffce ofthe tube has cupped the mourld formed by a graafl~r1 folllde.
252
Abdomen andPelvis - - 2. OrgGns
~uow
FQIIcu~r
Gl'ilnulosi
aiiJ
antnm
ails
1'1loa
tll2ml
OIKytlo
Zo111 pellucid!
Thea
Cumulus oophonis
b
Zone polucldl
c Prtmryfolllde
Prfmord~l follcle
«
c1 Se
1\Jnla
T/
~
Utzrtne pole -----;.
CDrpusalllarns
- ---=:=--D,..r.:7---:
C>- O!Kytlo~ corona radloto ~-lotion
Cumukls oophona wlthoocyt.
GranuiOillab Theca lntBna
Blood wssels
SurfKedCMiry (dCDedagaln)
Thoca eciMia
---...c...,....,_,..
FQIIcullr antnm e GrNIIIn follde
1 CDrpus lub!um Folllall~rmmrratlon1n the GAry The sequence a1 falllcul.llr maturation Is lllustnted In a clockwise direction around the ovary. The folliOJIJr stages ~re not d111Wn tD sale. • Ovlory: Section through the ovary alan adult woman, demonstrating itJ structure and foil iOJIJr staoes. The ~trill medu II~ is surrounded by a curtlcalfe9lon ClJntlllnlng fallldes atwrlous stages of development At the lower edge of the ovary, an oocyte Is being released from .ll ruplllred follrcle (owla!Son). After OYUiatlon has talaen place, the !ll"lllfliln follicle initially developa intD a hoi'TI'IOnl lly a~ corpus Iuteum and later regresses tD form a wh Ire fibrous Kar (corpus alblcans) (see~). • Prtmordlll ralllde: Oocyte surrounded by .ll single Ia)'III' of flat epithelial cells (ne b). • 1'1t1111ry folldE When the single layer of epithelium around the oocyte bemmes multllamlnar but without an alrium. the folllde Is called a prli!Wiry Mlllcle (see c). • Sealftolllry folldr. The epithelium (composed al granulosa cellt) beClJmes stratified with an antrum present. and the epithelium
C
Tunica •lbugnu 1nd epithol•l t
fluid. The connectM tissue surrounding the follicular epithelium Is org;mlzed Into a thea ub!ma and thecalntl!rnil (hormone productkln), which are separated from the epithelium by a basement membrane.
• Cnallin folnd~K PreowlitDry follkle with a large follicular cavity. The oocyte Is locmd on an eccenb1c hillock, the cumulus oophorus, together with a large aggregation of epithelial cells, the mrona radlatil (see e). Nate: The grnflan follkle Is appraxlmately 2 em In diameter -large enough to create a distinct bulge on the ovartan surface. • Ovulatlan: The follide ruptures, and the oocyte is upelled with the cumu Ius oaphorus cells Into the perftDneal cavity. Gener111ly the oocyte Is caught by the fimbriated end of the fallopian rube. Same spontaneous bleeding occurs lntD lhe falllcular cavity (see f). • Carpu~luteum: lhls Is a )'l!flll'Msh strucllJre al ~ry high hormonal activity formed by transformation of the !lraaf~an follicle. If tile Cilium 15 not fertdlzed. the COfl'US luteum Involutes and degenerms during the menstrual cyde (becoming the corpus luteum of menstruation). lffertlllz.liUon tabs place, the corpus luteum persists (as the curpus luteum of pregnancy) during the first trimetb!r in response to hormonal stimulation from the zygote, lasting until Its hormONI func!Son has been replaced by the placenta (see Q).
253
2.39 Pregnancy and Childbirth
lf1'91antltlon rn
thefalloplantube
/J•~"'tl~--7'1:----
ln'CIIIntltlon onltle0111ry lf1'91antltlon 'h the per!tllneiiiGMty ~l!jllthelklm)
f.llloplan tube
30 HOLn
ln'CIIIntltlon In the
7Z
rectoultrine pouch
Hours
l~on
of IN: blamx:yst
Coraptfon nltlellbal ampulla
•
~-
mdtfum
Endc>mdtfum
A Ph1ses In tfle mfgrattDn ofthe fer1fllrl!d IIIMim 1nd sites of
edopl' presnnc;y ;a Ph.JI:es In the mltl'llllon oftfle fertllzeciiiiiWm: Norm;~llythe zygote mlgr.ttes to the uterus. The ovum Is fertlllzed In Ute fallopian tllbe, us wily in its ampullaty portion. SpermatDma reach that site by a fla· gellatlng t.ln action that enables them to swim •upstream• agalnn theflowoftheclliatedeplthellum(posiUvemeOt.llds)-thesamecur· rentUtat propels Ute zygote toward the uterine c;avlty. As It migrates lhrcugh the faiiDplan tllbe, Ute zygotl! undergoes vartllus stages of development. On approxim;ately the sixth day after ovulation, the blastocY5t lmplanu In the endometrium. wfllch has been prepared by secretorytr.msfonnatlon (see close-up In e).
•
cavity.
• at sites dose to the uterus (tubal pregnancy) or • within the peritA:Jneal avity (abdominal pregnancy). In a tllbal pregnancy(e.g., c.~ used by postlnl!ammatory aodheslo!u of the tubal mucos~thrt h~mper zygote migration), there is a risk of tubal wall ruptllredue totfte doseconflnes ofthetllballumen, possibly causing a llfe·threatenlng hemocmage Into the peritoneal cavity.
8 a.-:b of the wrw dumg pn:gnii!C)' AntErior view, b left lateral view.
254
'll'aphoblm
b-e show !he two- and four-ceU st.lges of development (30 hours}. a morula with 16 ~Is (3 days), and the zygote after implantation (e). :RtlK of KblpTc pn!fnancy. Under abnonnal conditions. a fertlllzed ovum may become ImplantEd at vartous sites outside the uterine
;a
The uterine fundus Is palpable at dlfli!rent levels durfngUtevarfous lunar months of )lftgnancy (lunar monlh • a 28-day period). N~; At. the st.lrt of the 1Oth lunar month. the uterine fundus tllrns anteriorly and drops to a leYel that Is slightly lower !han In the 9th lunar monlh. lu term approaches, tile greatly enlarged uterus presses against almost all tile organs In the abdomen ;and peiYis.ln tile supine position the uterus may even compress Ute lnfafor vena cava. comprcmlslng venous return to the heart In emergencysltllatlons, therefore. a pregnant patient should always be placed rn the ltft latfral di!Citbltus position to avoid lli!ISCular compn!$Sion.
Endo-
mettfum
•
Abdomen Gnd Pelvis - - 2. Organs
Diys2-J
"--S ., -··
-=5)
-lllaccrest - - Antertotsuperlor
"'Y
Dlys9-10
liiiCiplnt
•"•=--....,...-:--- PUbic symphysis
c Pllltpll1ln l'lwolutlon of the utl!nll Anterior view. With normal postpartum Involution of the uterus. the uterine fundus c;m be palp;ated and physically examined at various levels. Three palp;able bony landmarks (1be lilac ae.st, ;mtenor superior llracsplr~e, and pubic symphysis) car1 be helpful In evaluating the II!YI!I of the uterine fundus.
Une.a
DllgonaiiXIn]ugm
-+-~,.,.-----
UIT!IInalls
LS-bnl
Jl:i::::,....-'n'-1--- Saaal pi'OmOilD'y ~=~rt'o:-Unea
~nails
b
D llllfiiCINnt olmetlft peMt clmcl'llllollll: peMt pl-=s ;a Mldsagll:t11 section of the female pelvis, viewed from the left side b Superior view of a female pelvis.
During p;arturftlofl, the fetus p;asses through vartous planes of the ma· temal pelvis. The pelvic dimensi~ns of g~n dinical impoltlnce are Silglttal (smallm anteropcmerlor diameter). The pelvis has Its smallest
PUbic symphysis
sagittal diametEr at the •true conjugate." whkh Is the shormt distance from the pcmerlor surfice of1be pubic symphysis to the silaal prom· ontory. That distance should be at least 11 em: If not. a normal vaginal dellllerymaybedlftlc:ultorlmposslble. Themostlmportantfetaldlmensian:s ~re crani;!l, particularly the greaten S
E lntem;ll dlm1111k11'111 of1M famii•INhll Dellglllllon
ConJugate diameter (tNe conjugate)
Diagonal conjugall!
Distance between the sacral prvmonbKy •nd the posterior border ~the pubic symphysis
lltm
Distance between the sacral prvmonbKy •nd ttle lnfellor border of the pubic
12.S-
~;t.::;..._---t'-+-1+-
Guldelllll! through blrtll anal
13cm
symp~s
1# diameter of pelvic
Dislllnce between the Inferior border of the pubic symphysis and the Up of thecaccyx
9(+2)cm
TranlWt'le dlamela-of peMc Inlet plane
~ngest cllsUnce between the llneee tennlnates
13cm
lnll!rsplnous diameter
Distance between the Ischial spines
llcm
Right (I) and left (I~ oblique diameter
Distance between the sacroiliac JOint at tt1e lelld of the linee terminalis and the lllopectfneel eminence on the opposlll! side
12cm
outlet plane
F lll'rttu:.tllll Tn the apulslon phase of l1bor (~fter R.'!uber ~nd k'opsch) The utafne cervix. vagina, and peMc floor have been stretched open to fonn a "soft·tlssue tube.• The fetal head, which always rotates Its great· est (S
255
2.40 Male Genitalia: Accessory Sex Glands A Aim:POIJSCX911ncb {prostnt<, scmln1l ft"des. 1nd bulboumhl'lll91illndl) Posll!nor llfew of the bladder, prostate, semlnalvesldes, ;md bulbouretlu~l glands. The perilzlneum and viscer.al pelvic fascia hall!! been Olin· pleUiy remlro'led; Jtumps of both u~t~ ~nd vasa dmrentia h;ve been left In place to aid orientation. Each of the Hmlnal wsklls consists of ~tube ilppi'Oldmately 15cm long that Is coiled upon Itself to~ length of .about Scm. The secretion from the semlniiiVI!$Icle.s malaes up approxl· mately 702: of the volume of !he ejaculate, is slightly ~llc;aline (pH 7.4), and Is very high In fiuctose (energy source for !he spennatozoa). The term "seminal veslde• Is mlsleildlng In !hat the glilnd does not contalr1 spemnatocyll!s. The excretory duct of the seminal vesicle Uflllles With the v;as def~ns to form the ejaculatoryd~~et. which pa$Ses through the prostate. The seminal veJiclu de'Velop from the epithelium of the wolfflan d~~et ilnd are situated liltefill to the vas deferens. which illso devel· ops from thewolflliln duct. The bulbourethnlgllluts are embedded In the deep ttar\M!r'Se periAe.'ll, and their appi'CIXimately 2· tD 4-cm-le~ng ducts open Into the posll!nor <1spect of the urethra. The secrete a de~u. watayfluld that prepares the urethra for the pa!.Si!Qe of the sperm. The prostate Is desa1bed In II.
Vls«ni perltont!um
IU¢tv.u deflnns ~.;,..L--
IUght sanhll '111!5icle
Bladcler, ne
SUperilclal abdominal 1\asda{dtj!j)laye\')
llecta.lesbl pouch
Bladcler, fiJnd.a
Plblc~ls
Retrapublc !piCe
SUperflc:laldarJal penfeveln
T':tt----:;~::SIP-- ljawliltOryduct l'enllefal
Prost.ite
Urethra. 590"9Yp;lrt
Scrotum
8 The p~lnsltu Sagittal section through a male pelvis, llfewed from the left side. With the blildder and rectum opened. This drawing Is~ composite from many planes 1ZI demofiStrilte the peritoneal relationships and the .attachment of the seminal vesicle lzl !he pros~ and u~thra. The p;~ramedian am· pulla of the vas deferens has beal straightened somewhat and projected Into the sectional plane wl!h tile ejaculatory duct ;md left bul·
256
be urethral gland. The prost<1te Is located at the bladder outlet and en· clrdes the urethra (see C). It borders posll!norly on the anterior wall of the rectum. separated from It by connective-tissue fasda. The prost.tte has no contact with the periiZI!leum and lies enti'rt!y In !he pelvic elttra· perilzlneal sp;~ce. By contrast. the tips of the 5eminal vesides a~ frequentlycwered by visceral peritoneum.
...
U'e!hn, -+~~ p~pilrtwtth
: •II i~,...-,--:f--- Seml.-..t cdlkulu>
lftllnl
wllh arfflcos af ejoah!Dry dud: -li~-;;._- Um!l~
momn....... part um~~,.,
•
•pongypilrt
C ~OiliHpafltleprclltiRIDthe Umfll'il • CDronal section (anlielfor viiW), b sagittal section (ltft lab!ral view). and c tnm.vene section (superior view) through the prostm ind ure-
ttml. The pl'llllbtl! is a chestnut-srzed gland consisting of two lateral lobes (right <~nd left) that are joined posta1orfy by the median lobe and anteriorly by the prostllk Isthmus. The enttre gland Is surrounded by a firm connect~tiuue capsule (pi"DDbltic capsule). The p~'!l~Sbb! is a derlvatlve of the urethral epithelium. appearlng Initially as a poste-
.. rlor epltheflil bud INt liter grows to encircle the urethr1 (prostatic Histologically, the prosute Is composed of 30-50 tlJ bu loalveolar glands that open lnW the promtic part of the ureth1111 via ~ppn~~~l mab!ly 20 e.:retory ducts. The prostiUc secretion makes up ilpprollimately 3D :1: of the volume of the ejaculate. It contains compounds that are lm portant for active sperm motility. The seaetlon Is colorless, watery, and slightly addle (pH 6.4). It also contilns a prob!ln (prostlt2spec:ific antigen, PSA) whose serum levels are frequt!ntty eii!Vab!d in patients with a prostatic millgnancy. p1 rt).
Um!lr.~,
piDSUtlc pilrt
D
c.ntnlzoroe (lnnenone)
D
Ptllo.rethr.~l
""""
D CllniAI•nd hllbll~~t~lall dlviiiDn vftM ~lilllntD 11111• Sc:hemattc repreHilbltlon of the prostate viewed In three sections: • coronal (antlll1or111ew), b sagittal (left lateral view), and c lr.lnsverse (anterosuperior view). The ejaculatory duct Is also shown for darfty. To ild In desafblng the loutlon of certain dfsease processes, the prostate is divided dlniQIIy into three zones; • Periu~r<~l zone (the :smallmZOI"Ie) • Central zone (Inner zone!. approxlmlltely 25 X of prost:lltlc weight) • Peripheral zone (outer:ldne, approximately 701 of prostatic \Wight) HlltlllagiCIIIy, It Is not uncommon to add a lr.lnsltloNI zone from ilglindularw...wy glandular tissue (lateral to the ptuldmil urethral segment) .;md .;manterior ilglindulir zone. These zones shaw dllf~Rnt predilections for disease: B«nlgn pttiShltic en/cHvfment (benign prostilti( hyperplasli, BPH) most commonly lnwlvesthe perlurethril zone ortransitional zone ofthe prostib!, causing obstruction of urfnary outflow. PmJtGtic arrtinomo, on the other hind, !lends to dMop in the peripheral zone (see E).
E 1Jpkill lite viDcaarrB~C~e of pndlltk c.~hom• Sagittal section through 1 male pelvis, viewed from the left side. Prostiltic: carcinoma is one of the mort common malignant t umors in older males. Itoften grows it a subcapsular IOCillon In the pertpher;ll zone of the prostatl!. Unlike BPH, which begins In ltle centrr11 p1rt of the gland, prostatic: Ul'(inoma thus does not a use urinary outflow obstruction in Its early sages. Being In the pertphend ZOOC!. '-ever. the tumor Is p~l pible as a firm mass through the anterior ~II of the rectum. A digitally guided biopsy needle Cin be p.used Into the prostm through the rectal wall to obtain i tissue biopsy fvr hlstologlal eumlnitlon.
F Nolmill Yilhlft fvrdlelnille accaaxyiiUglinds l'foRitll Saglttll dlimeb!r
Width Thlckne:u Cia!Ids
Ductsyam ~~n
a.Z-lcm a .4cm a .l - Zcm Ci.40
lobules a .ZOducb pH f... ~11ch
Wlight
a . :ZOg
Semml Wilde Llngth a.l-Sa-n -CIMI•d a.15an - Una~lled Secr.tlon pH7.4: fNctose-rich lu!Nunth.-ltiiM 5'PeHizled DuctJ.ngth a.4cm
257
2.41
Male Genitalia: Scrotum, Testis, and Epididymis
Cremaster musdeandfaKia
P.ar!e!allor,
oftullca~nalll
-.::.~~~---
Ttltl$\olth1S«
l.,ott\lrlcav~tnalls
A The SCHtum <~nd ~ oftfl~ttestls In situ Left lilter.alvlewMththescrotum opened lfllayefs. The testis Is .a p;~lred organ having the apprcximate sill! .and shape or a plum (see D). It is di· Y!ded by fibrous sept.'! 1m ~pp!'Qldmatdy 350 lobules. The layers of the saotum andmverir~gsofthet:estls areformed bythelayers ofthe;mterfor .ilbdomlr~al wall dur1ng the developmental de:scent of the testis (see E). As the tl!$tls de.st:ellds, It c:arrfes With It a flnger-wped process af peritoneum (vagin~l prvcess) tluvugh the ir~guinal Gln~l; no~lly this process becomes obllter.lted and separated from the perltoneal c
the fntl!rnal {deep) lngulr~al rlng. Thus the perltofiC!Um forms a dosed sac within the saoi:IJm (tunlc:a vagfnalts) composed of a lllscer.al la)l!r and a p;~rietallii)'C!I'. An abnormal collettion of $C!I'OI1S fluid in the sp;~ce between the twv peritoneal layers (hydro«le) may ewrt pressure on the testis. c:auslr~g dlnlc:al complaints. Occasionally. however. the peritoneal process rem.ilfns patent ;md giYes rise to a Q)llgenltallrldfrect Inguinal hernia.
Testtcularmedla'ltfnum with
me-
Te:stfcularartl!ry
8 Scrotl.tm <1rtd Cl!IWrfngs of the testis In aoss-sec:tron Trlln.sverse sectSon through the rtght testis, lltewed from above. The
magnified view shOW$ the ~~;~rio us~ thrt m~Jcto up the coverings of the testis. The testis Is ~rrounded by,. firm fibrous capsule. the tunlci albuginea. Ane connective-tissue septa radfm Inward from !he tunica
258
ilbuglnea to the testicular mediastinum. ~bdlvldlng the tertrslnto approxtmattly 350-370 lobules ti\at contain the seminiferous tubules (see C). The seminiferous tubules are the sw wh~ the spemnatocym dewlop (spermatogenesis). Groups of cells embedded In the Interstitial connectlve 11s5ue produce testosterone.
Abdomen Gnd Pelvis - - 2. Organs
TUnica -----albugbea
I
•
lobule with CXInvoluled
b
c !itnH:ture ot tfle WUs and epllfldrmls Left lab!r~l view of the left wtis and epididymis. The tzstis has been sectloned In the silgltt!matdy 12 efferent ductules. which open Into the epididymis. Att.1ched to tile postenor aspect of the testis, the epTdkfrmTs Is tile organ« storage
Slmi!lferous l\lbules
Ell!dklymal duct In tlllolepkl~ls
maturation for Ute spenn.iltom.'l. The head «the epididymis consists mostly of the eff'e~nt ductulu. while its body ~nd ti!il cvnsist of the highly convol~d epldldym;rl duct (;rppi'Oldmirtdy 6 m long when un· raveled}. In the head of the epididymis. the efferent ductules open Into the epldldym;rl duct, which Is continuous at Its Col tidal end with the vas deferens. Note: The testis ~nd epididymis lie Inside the scrotum and ol.ltSfdr tile abdominal Cll'llltybec:ausethetempemurewtthlntftebodyc:avltylstoo high for nonmal spermatogenesis. Thus, failure of Ute testis 1» descend normally into the scrotum (i.e., an iAguinal testis) is frequently associ·
D Nonnal Vlllues fDrthe tutfs end epdkfrmls
Weight
Length Width
.......
~,
T.as ca. 20g a. 4cm ca.2cm
Length of epididymal duct - Uncoiled ca. 6 m -Coiled ca.6cm
350-370tlestlcular lobules
Appradm.ately 12 e"-nt cluctules
E ~oftfletestlosandl~oftheabdomlnaiWilll The Inguinal Cllnalls .an eYaglnatlon of tile abdominal wall. As .a result, the anatomical layers of the abdominal wall have their cvunterp;lrt.s in !he layers of the scrotum and testicular o:wafngs.
F Utrntructure of a mature spermatmoon c-tnpdthe tMif Abdominal sl:ln
Saotalsldn
Superftclal fascta
ll.lnladar1DS
Eldena! oblique muscle
Ex18nal spennalic Wcia
Internal oblique muscle
Cremaster muscle • and Its fascia
TranlWt'lusabclclmlnls
(No counterpart)
Tran-.salls faKia
11112rnal speiiNtlc fascia
Ptnloneum
ll.lnla vaglnalls
•No~Jt: the cn!lllaster.lllot the lntll!rnal oblique. Is slrlated and rea!Ms
It takes approximately 80 days for a spennatlc stem cell (spermatog~
nium) to di!Y!!Iop into a mature spennatozoon. The spennatogonia a~ fonned In the cvnvoluted seminiferous tubules. whlle final maturation t.1kes place In Ute epididymis. The ultrastructural re.ttures «Ute spermatozoon, which Is approximately 60 p.m long ('Mtft t.11Q, Include Ute fair-ing: • The ltt!adVI!tft the acrosome and nude.a • The lllil (flagellum), which contains tne axonenna (axial filament) and consists of sever~! parts: -Neck - 11.41dplece - Principal piece - End piece (not shown hel't')
som.atic mamr lnneMitlon, but Is usually nat under wluntary control.
259
Abdomen and Pelvis - - 2. Organs
2.42
Male Genitalia: Seminiferous Structures and Ejaculate
Inguinal canal
v••
Uretor Bladder
Musculor1s, outer longitudinal fiben
dl!feren<
lnb!rmedlate circular fibers
-.~:~~ Mucosa
Qaculotory duct
'I· ' .
. . ·~ l!,Ji·. ..···. .... .:. II ,. .·.. )
., i'
\.::.:.;~-'
---'f,,----f-~,J
Musmlar1s, lnner
a
longitudinal fibers
b
B wall strudure and musculature of the vas deferens a wall structure of the vas deferens. cross-section through the lumen. The vas deferens (ductus deferens) is approximately 40 em long and
A Overview of the !ll!mlnlferous structures Anterior view of the male reproductive tract. The bladder is also shown
to aid orientation. NotE: The male urethra serves as a common urinary and genital pas-
sage. The vas deferens and the duct of the seminal vesicle join to form the ejaculatory duct, which opens into the urethra (see C).
3 mm in diameter. It arises in continuity with the epididymal duct at the caudal end of the epididymis. Its function is to transport the sperm suspension rapidly toward the urethra during ejaculation. It is equipped for this task with powerful smooth muscle fibers that •I>' pear to be arranged in three layers (longitudinal, circular, and longitudinal; see b). Facing the lumen of the vas deferens is a simple columnar epithelium. Close to the epididymis the epithelium becomes pseudo stratified, and many cells bear stereocilia (nonmotile cellular projections). b Musculature of the vas deferens, three-dimensional representation of the muscle fiber pattern (after Rauber and Kopsch). The smooth muscle of the vas deferens appears to have a three-layered arrangement when viewed in cross-section. Actually, however, the muscle fibers are arranged in a continuous pattern that spirals around the duct lumen in turns of varying obliquity. The smooth-muscle fibers of the vas deferens have an extremely rich sympathetic innervation, as ejaculation is triggered by the sympathetic nervous system.
C Slm ofspermatogenesis nd pathw.y of sperm tr.nsport
The seminiferous structures in the strict sense consist of the efferent ductules, epididymal duct, and vas deferens. Tatl•
Epididymis: • Head 0
Body
• Tail
• Convoluted seminiferous tubules (spenmatogenesls) • Straight seminiferous tubules • Rete testis • Efferent ductules • Efferent ductules (open Into epldklym;~l duct) • Epididymal duct • Epididymal duct(opens into vas deferens) o
Vas dleferens
• Ejaculatory duct (union of vas defm!ns and duct of seminal veskle) "--vk: floor and pelvis
(mrpuuponglosum)
260
o
D The ejaa.rlall! (normal values and terminology)
The ejaculate consists of spermatozoa and seminal fluid, which comes mainly from the seminal vesicles (approximately 70 %) and prostate (approximately 30 %). Quantity pH
2-6ml 7.0-7.8
Sp~mcourrt
Ca.40 millionspermatoma/ml(40-SO~ of which show vigorous motility; ~t least 60% are structuraly nonmal)
Length of spermatoma
Ca.60Jlm
Normozoospermia Aspermia Hypospenmla
Normal ejaculate No ejaculate < 2 mlofe]aculate
Normozoospermla Azoospermiil
Normal sperm count (see above) No sp~iltozoil <20 milion s~atozoa/ ml
Oligozoosp~mia
Urethra Necrozoosp~ia T~~tozoosperml~
All sp~matoma all!! motionless > 60% of sperrnatozo~ ~re structur~lly abnormal
Abdomen Gnd Pelvis - - 2. Organs
Testlalar~s
£xtl!mal I lac
S
Umblle<~larmy
lngulrtalllgament ~oreplg;lstrtc:
ltie:dllm
artayandwn Saphenous hlatlls
Bladder
&.temal pudendal artltryandwln 11!mor.ll ar18y and wn
Pen!~~ suspensory
ligament
Pa"'fllnllcnn plexus (tle.ltlallarwln)
~ v;u deferens
Rlghtv.asdeforens
Dorsumofp.!ds Dorsal penlearmy lind deo!pdorsal penile Win
ln18nal sP'!ITI\&Ic flacll
Testis Cilanspenls
!illdlclymls
E 1he spermatk coni In situ Antl!rior view. The inguinal canal has bftn opened on both $ides, ~nd the coverings of the spamatlc cord have been opmed antertoriy to show the course of the vas deferens. The Inguinal canal Is markedly la"er In the male than In the female due to the presence of the spermatit cord. Thisl;n'gl!l' can;~l ~nd the larger inguinal ring fP~isp~e the
Motcrt>Ompcnent dgerlt.llbnlndl
1>.111'41!nlfonn -ii-ii-d!m"'cV plellus (testfcullr
vein)
N!!t'-H-i:+-lr- Testlalar
male to tile herniation of abdominal Vlsce!'a through the Inguinal canal hemia). Note: The vas deferau passes later.~ Ito the lnfafor efPigamlc al'tlery and ~~eln. This relationship should be noted In operations on the Inguinal ring to aWIId vascular Injury. (inguin;~l
F Contenbohhespcmmlccord Transverse section lhrough the spermatic cord to display the wall layers of the cord and the arrangement of Its contents. Even a normally dew!· aped venous networic (pampiniform plexus) may be affi!cted by abnor· mal varicose dilation about tile testis (varicocele, due for eMmple to a ~~enous outflow obmuctlon) and may raise the temperature of the testis, leading to decreased ferUIIty. ~The pampiniform plm~S dl'ilins into the testicular 111!in. The right testicular ~~etn opens Into the Inferior vena Civa. while the left testlcu· larveln runs close to the Inferior pole of!he kidney ;md enters the renal ~~eln at almost a 90" angle. Thus, It Is more common for varlcoceles to develop on the left side than on the rtghtslde ln nesponsetD a condition that obstrucu testicui;lrvenous flow (mass on the lower ren;~l pole, vein artafng at a hemoczynamlcally unf.lvorable angle).
261
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.1
Arteries of the Abdomen and Pelvis
E.ccpltagus
left superior
~~-~ erterf~
left nferfor phrenltarttry left middle
~l.li.\!1!-!'ff-'t--- supraren;~I
left klferior SUpnln!MI.-tlry
Superior - --+-ctt
'~"liii"i7-ii---leftrenalaltl!ly
~ntl!!ltlltl!ly
..,...=...,..:!1;.!+;\-- - - leftovartan artuy
---;~+::-'::---- Medans.aaal
artery Rlghtl~ ---:~Til_;!,..;._,;
----r....,.:.....;:..,.:....;,-- IJ!ftsuper!or
ifiUitl!ly
ltlghtemmal
ltaultl!ly
- --:--
gluteal
"'":-'-----dl--"'
Mtl!l'y
RJghtumbiiC
;...__~'-------"--
5.Jmll plo;us
altl!ly Rlghtoblu~Wlr
lltl!ly Right lnierior Yl'!llt<~llltl!ly
Right deep drcumflex lfacaltl!ly ltlght Inferior ~altl!ly
Uterine lltl!ly
Right middle rt<:I
Obblrata' lnndl of l1glt
l'nfetloreplg;tlb'lc a rttry
A Dvl!nlttw of tfle lbdomlrlll aorta and peMc: arti!I'IH (abdominal orgln11'1!1'110111!d) Anterior view (female pelvis). The esophagus hu been pulled slightly in· ferlorty. and !he peritoneum has been completely removed. The abdominal aorta Is the distil c:onUnuatfon of the thorildc aorta. It descends slightly to the left d !he midline to approximately the level of
262
Right lrbmal pudendal altl!ly
the L4 wnebra, as shown rn B (or possibly to the L5 wrtebra rn older individuals). There it divides into the p.aired common iliac arteries (aortic bifurcation). The common Iliac artates divide further Into the Inter· nal and extemallllac arterfes. The abdominal aortil (see C) and Its major branches give origin to wrlous •subbranches" that supply!he ilbdomen and pelvis (see D).
Abdomen and Pelvis -
- 3. Blood Veaels
D Fundf-lta,_..of.-rlelthat•pplytfle lbclomen •d peM$
The br.mches of the 1bdomlnal iiiOIU and pelv'rc 111Erles an be divided Into five bro1d functioN! groups(- • give rtse to)
_......_.......,tMt....,tM ................. ............................................. . . . . . . . . . . . . . . . (laC)
• Right-' left: ..... plnnlc.mria
-light-' left JUpeflar sup<_,.
middle...,.....,..---.
SUpertorll'eMI1Ill~ - - - -
1 -ry(l )
---:----- - lllnolortwta (l1/L2) lnftllorm.....wtc - - - - - - lP. Left cenvncn .m.y (L3)
niM: ortery
Aatlc blfuatlan (1.4)
irtlllles • Right and left • IU9ht I nd left !'CRill rtertes -Right and l.tt lnNrior supriNRII art.rles • 1U9ht 1nd left tesUGIIilr (-rlln)artlrtes • Right and !.ft lumbar artl!rtes (tlrstthrough fourth) • Median SICJ111artrry (with lowat lumbt r arteries)
.,.....lllnedl,..
On••PIINdtrunlca.tiUppl•tleiMr,glllw.Ner,,.--. d-...t-m(seeCindp.~51
••ts
m~Jor brtndlet onto 8 Proledfon ofthe abclomlnlll loot. the wi'IIIIIRI colamn and p41lvtl Antll!!rlor vtew of tile five m1jor arterial trunks. The major brancf1e.s of the abdominal aorta un be ldenllfteclln Imaging sllldles based on their l'l!lationship Ill the ~!Ubrn.
• Celiac trunk with - Left gastric artrry - Splenic artery
...., Esophagal b"nches -IAI't fjlltro-omentallrtlly - Pancrutlr: brondlu -+ Gmt pancmllc•rtety - Dor11l pana.etlc artl!ry - Pmlleriorgamfc orwy - Common heplllc1rt.y ..... Proper hi!plllc 1ra.y - Cyslfc lrWy
light llftrlrlr ph...,lc artery
~lac
tJU'*
Left lrftrtor ph....,lc artery
Right supolfor ...........-Jir1ltry
Lefts...,erlor supronnol..uty
Carman h~artery
Left gaQJ!c ar11ry
light gastrtc 1r11try
--;;:;!"'~II!;
..................clllk"-w(AIC, p.lfil) -+ llft!tor PIIICIUCialiluodenlllrtely
suproi'INI.Jrtffy
rastroGrodONIIrtery
-Jejunal lrtl!ries
~=--- ll!ftlrlerlcr
-llulortertes -ll•oc:ollc lrtltry - Right callr: lrtl!ry
suproi'INI.Jrtffy
~mesl!llllrlc
ortery
artery
!'plonlc artery
Pl~ll1ierles
Olle . . . .u.lnllit. . . . .thl ....................
ll!ftrnldde
Praper hl!potlc .m.y
lrftrtor m...,ntalc
...., Right g1$111C artery .... Gistrod uocllnalartery - Supracluodenol branch (lnconsbnt branch of gastroduodenal artery) - Right gi~Dmltntlllrtl!ry - Duorl4tMI branchB - Reeroduodenlllltlf1K - Anlllrtot and postertar...,.tar
LeftreNI artery ll!ftftrst lumbar artery
- - -...::=Jt-
Left testicular/ cwarlan.Jrtffy
..... Mlddlc colic ertery One unPIINdtnllllcthltiUPall•the p.l71) mlktl...,.
<-C.
-.e ........... .._ the left
• lnfertarmesentl!ricartery -left: mile artery .... Sigmoid artltl'lls -superior rwcbllort.y
Onei'IIIIN&t(Aiw-)pellwdtrunlrlhiiiUP. . .Ihiii'I*(-A) • Internal lilac art.y (from the common 111M: 111111y, not dlrectlyf10m the acxu, hera an "lrdrect palnod lnlnk") with lnndla tNt supply: -+ Umblllal1rtery
- Superior wslcllar111ry -Inferior11Klcll1111ery ..... Ut.1ne 1rt1try(or artltly of vu d.r.rens) - Middle rectolertery
-lnlllrftll pudendlllrtery
The pehllc -us (parlm Ibro nclws)
- llolurnb¥ ntry - . _.. 5lallartery - ObbntDr lrtltry -+ SUperior and 1nlitrtor gfl*lllr1lr1es
263
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.2
Branches of the Cellae Trunk: Arteries Supplying the Stomach, Uver, and Gallbladder Prop« hepatic artery,
left branch
~au
!'nlper
IM!pa1ic -ry Portai~A _,_~
Antler!orsupl!llor panc:reatlalduodenal arllery
A Cell1c trunhnd ~rtll:fles to the ttomildl, nver,lnd g1llbllddft" Ant:erlorlltew. Thelesseromenl:\lm(see p.183)has beenopenedtodls· pliiiYthe cellae trunk. Tbe greater omentum (see pp.156
264
Greater
cn-.m Note tf!attite proper hepatic .ilrtefy, port.ill vein, and common bile duct reach the liver fl:y passing through the hep;atoduodenalllgament, 'Which ISp;artofthe lesser omentum. Theseve.sselsmustbeprotectedlnsurgl· cal operations on the gallbladder and bile duct.
AbdomenantiPeMs - - 3. BlootlVeaels
Leftgamfc
Common ------=;~~t!'i:.i+-:r---- hepal!c
artl!ry
L4
Splenii: artBy
-
~~1f ~ j
t.-------Abdomlnal -----,-"-----,A
Wl1:2bra
artBy
• B
tf
c
PraledfonlllftheG!IIIttftlnkontDtMVI!ttl!bn~ICDiumn (T12)
c
1nd lb relltfgn~~hlp to tM IM:r 1nd ltomlch
• The common hcp;rtic artay,left gastrlc amry, and splenic ~rmy have~ common origin (
&.:9-.~::P~..,_
Spll!nlc 1112ry
Varfantsoftflecdactrunk (afterUppett~nd Pabst)
Rl¢t branch
lo!ft Prep« lnrH:tt hepatic artBy
Rl!lht91$111c - - -Aiill" ~11By
Gasln>-
dLIOdenal artl!ry
SUJ~j!ffar
Right gadrocm1!11tal artl!ry
D Ara:rfes of tile .wm.ch NorJ! that the pomrlor wo/1 of the stxlmi!Ch Is supplied by the posterior
gastric artery, 'Which irises from the splenic irtery In 60S of cases. Vilrl· ants of the gas!Jfc ~rtelfes do 0«11r, but for simplicity they are not lllus· lr.!tedhere.
a me:co!1111erlc.artl!l'y
SUJ~j!ffar
b me:co!1111erlc.artl!l'y
SUJ~j!ffor
c me:co!1111erlc.artl!l'y
E V.rlllnb II\ the arU:dlol supply to the liver (after Lippert and Pabst) Typlcil dMslon of the proper hepatic artery Into a right ind left branch (ipproxlm;ately75X of cases). b The right branch ~rfses from the superior me.senterfc artery (approxl· mately 10 S). c Both branches arise separately from the cellae !JUnk (less than 5X). ;a
265
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.3
Branches of the Cellae Trunk: Arteries Supplying the Pancreas, Duodenum, and Spleen l'l'operhl!p;ltlc.ur,.. Ptoperhep.wtlcutl!ry. Common IJ!ftQIIStllc light branch left branch hepatic .ur,. utBy
Celllc trunk Abdomnal
cysttc~rtsy --~~!='
Proper - -4----., hep;ltlcarmy lnl!riorwn~ava
- --;;;=
Right--- ;-. 911tr1c a rtsy CiaslnlWodi!NI artl!ry
- - - -11'
Portllwln
lnftrfo r pan creatlcoduodenal.ury, antl!rforbranch
lnferforp;ll'l(fl5ltfcoduodenal
A O!llu trunk n ;utelies to tile p;mcrss. duodenum, and spleen Anterlorllfewwlth the body of the rtomach .md Ute lesw omeni:IJm remOIII!!d. The I'DOt of the tranM!f'H! mesomh:1n extends anterior ta the
duodenum. p;~ncreas, ~rid the superior me5mtafc ~rtery and vetn. As ;a result. tumoB oftfte he;rd of the pancre;rs may Impinge upon tile superior mesenteric artery or vein ;md restr1ctthelr blood flow (see C).
266
An;utcmosll~n
S\IJlj!ffor mesentl!rlc
and Wet! or panCftlltlc artery
Abdomen and Pelvis - - 3. Blood Vessels
Common
Abdominal
hepatic artery
aorta
Celiac trunk
Antl!nor/postl!riorsuperior pancreoticoduodenalart.!ry
- - ---::;o'-'.._..._
Duod.,.,.l brandies
B Sdlematlc overview of the distribution of the cellae bunk Note: The pancreas is additionally supplied by branches from the supe-
rior mesenteric artery.
Abdominal aorto
Splenlcarterywlth
pancreatic branches
Splonlc art..ry
Cellae trunk
Celiac trunk
Common hep;rtlcart..ry Gastroduodenal artery Gastroduodenal artery Posterior superior pancreaticoduodenal artery
-----JJH r -
- +-_,.el:.!.
Anterior supenor pancreoticoduod.,.,.lartery
a
Postertor superior pancreotic<> duodenalart..ry Dorsal pancreatic artery
Inferior pancreatia>Superior duodenalartery, mesenteric artery anterior branch
c Arterial supply to the pancreas a Anterior view, b posterior view. In b, the abdominal aorta has been removed to show the origins of the celiac trunk and superior mesenteric artery. Note that the pancreas is supplied by branches from the celiac trunk as well as branches from the superior mesenteric artery. The superior and
Anterior superior pancreotfce>duodenalartery
b
lnfl!rior panaeotiroduodenalartery, antl!rior branch
lnfl!rior panaeotiroduodenalartery. postl!rior branch
inferior arteries that supply the pancreas are arranged in an anastomosing system called the "pancreatic arcade.• The largest ofthe anastomoses between the splenic artery and inferior pancreatic artery is called the great pancreatic artery.
267
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.4
Branches of the Superior Mesenteric Artery: Arteries Supplying the Pancreas, Small Intestine, and Large Intestine
Ccmmon hepatic~
Splen\cal'tlery I! lz!.-i.l-- -
-
Abdominal
rnc:.....r--- lt!ftrenal artcry
s~
mesenteric
artcry Middle calc ilrtcry
lleocollcauty, - ----:-- -h,.lll cdi
lleooolicaufY, --..2...---'-'-'r~~ llealbr.andl
A DlltrtbuUon ofthuupet'Tormesentertc.UIY Antl!rior view. For clarity, the sb:lmach and peritDneum have been p;~r tially removed or wtndtlwed.INV!ng lntict mort of the retroper!Wne..l oonnect!Ye tissue below the transvene colon. The superfor mesenteric artery ilrfses from lfle front of the ibdomln..l iiOrta .rt the level of lfle ffrrt lumbar (L 1) ve!Ubra. It p;IS$tS antelforly and infi:!riorly, dirtributing most iU numerow br.!nches to lfle tight side. Thus. It Is cle..rly i1CC6slble to Inspection ilnd dlssecdon only when lfle loops of smalllnwtfne are reflected to the left side. as lllustr.rted here. Th~ view illso dlspl.ays the serfes of arcades formed by the lntes·
268
tlnill branch6 of lfle superklr meS4!1'rterk artery {only one set of arches is pteH!nt along the jejunum, but the arches in create disti!lly and form multiple sets along the Ileum). Straight artelfes (ViiS a rect
AbdomenantiPeMs - - 3. BlootlVeaels
._...,..f----++1-.f- Mlddlecollc
--~~--- aorta Abdoml'lal
arury
Right colic -t--+1-:iT-~ art2ly lleoalllc -+--4+~1-,_ artl!ry
.?"..._---¥"rr-".- Jejunal and llul.-tl!f!H
Appendicular art21y
8 Prvjlctlon of the superior m. .l'l18rtc <1118ry onto the wit4blllll mklmn 01nd tts ref~ttonshlp to the lqelntesttne 01rtd p;~naeu Thesupertormesenttrlcarttryarlsesattheleveloftheftrrtlumbarwrtebr;~.
C Sequcncc of bnnc.:hH from the supcdor mc•entertc .-tcry (seeilso E) Relilltlonshlp of the superior mesenteric artery ta speciBc organs. The territory of the superior mesenteric artery ends just J)I'Dllimal to the left colic flexure. illt which point the supply by the fnferlor mesenteric artery begins (see pp. 270 ind 271).1t Is common formultlpleinirtomoses to exist be'-"'-' the two mesenteric systems (see Eand F, p. 271).
Superior
E Brindles ol the supeliar mesentl!f'lc: artery, listed In the
mt.~entl!rfcartl!ly
l.eftrmaiWIA
-----,=
Smllllnlel!ne
sequcncc of the orpns they supply • lnfwior pancreilltlcaduodenal artery • JejuMIInd lleal1rterles (apprGI(Imltl!ly 14-20) • Ileocolic arterywilh anterior and r-terior aal arteries and appe~ dlaJiar artery • Right colic artery • Mlddt. mile arU~y
D Rcl1ttorwhlp of the supcdormesentertc .-tcryto the dugdenum ~nd left ren~l Yl!fn
left tattralllfew. Nflrz: The superior mescnttricart.ery desands in front of the duodenum and left ren;~l vein. The left renal vein lies within the aorticomesenteric angle, where It may become entrapped and compressed (seep. 272).
Tt. arteries to lhe small and large Intestine form numerous aracles from whkh small straight arteries (vasa recta) pass lhrough lhe mesentery to supply lhe various parts af lhe Intestine.
269
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.5
Branches of the Inferior Mesenteric Artery: Arteries Supplying the Large Intestine
~~~~-~---G~~
omenttJm
T111MWM --:---=:.......::+.':~~~':-':::--T:?-'-~
Left cclic tlexift
Middle colk:lll'tl!ty
Supetlor
mesentl!r!camry Duodenum
Abdominal aorta
Rlg!t ccllc a~Ury
infoliar wna c;wa
De.sa!nding allon
A$anding cclon
lnh!rlor mesentl!r!carttry
Rlghto:ommon
Aortic tifuratlon
I.A!ftcclica~Ury
illlc;~rtay
Slgmoldilrtl!f!K
lleoccl lc a~Ury
leoc:ollc:arb!ry, colic branch
Supetlor
n!ctllarttry
leocollc:arb!ry, Ileal branch Sigmoid colon
l'ostl!!lor cealalt8)' Anterior cealalt8)'
A Artl!rlllsupplytD the large lntl!st'lne from tfle superior and lnfl!riDI' mesentl!ric: lltl!riel
Anterior Ylew. The jejunum and most of lfle Ileum have been removed, and !he tr;msvme colon (see p.193) has been reflected superiorly. The peritoneum has beenwfndowed or removed at sewral slb!s,IUYing part ofthe retroperitoneal connective lhsue In place. The inferior mesentl!ric artery arises from the abdominal aorta at the 3 level (see I) and desca1ds tow.rrd the left: side. Thus, It Is dearly
270
.iiCCe.ssible tD Inspection and dissection only 'When the loops of Sm.illl intestine are reflected to lfle right side (boMIIooj)s ~been removed here). This view also displays the numerous sets of arc<~ des formed by the branches of the Inferior mesenteric artery. This artery supplies the distal portions of the large Intestine. starting approl(lmately at the left
colic flexure. Note; The rectum Is supplied by three uterfes (see D). only one ofwhich,
the superior rect:alartefy,ls visible In lflls dissection.
AbdomenantiPeMs - - 3. BlootlVeaels
~or ~.nry
t.eftOltc
t.eftcdrc
utery
ftexure
lnfenct mesentlerfc arury
SIJJ)e!1or
n!CI.IIartery Hr~---
lntl!mal rtac..wy
.?----"---- I!Umll pudlndlll
arury
Slgmokl.u.!es
t.eftaUcarury
B Prqedfonlllfthe lnfl!rior mesentrKTc 1rteryontothe~la~lumnudlb
1'4!1a1fonshlp to tile lufll! tntaUne The lnfenor me.sl!lltenc al'tZ!ry branches from the abdominal aorta at the level of the L311l!r· tebrae.
u-
Spleln
c Sequence of br-.nches from tile lnfll!rtor macntaic;~ntrefY
(see also D. p.263)
Left colic ;rl'tZ!ry. sigmoid ;rl'tZ!rfes(~orthree). superior rectill ;rl'tZ!ry. Nelli! that the left cclic flexure marks the approximate boundary between the blood ~p ply by the supel'for and Inferior me:senterfc arteries.
Cd~ctt\lnk
;rrttrh!.s supply the smaller, kliNer portions of the rectum.
Stomach
l'llltltliiS
Duodenum jl!junum leum CeaJm Asa!ndngand tnnso;ene colcn Tl';l~~nd
6esal\dlng colon Sigmoid colon Re
• The lnfertor me:senterfc al'tZ!ry (or Its branch, tile ~penor rectal artery) • The middle rectal artefy (directly) • The Internal pudenclal
Duodenum Glllbllddl!f l'lllCINI
D Contribution ofdie tniiNTor rnesentertc 1rtay Ito the rec.:tll blood supply The rectum Is supplied by three dlfftrent
Superior me~enurtc ~rtey
M:dcleaUc ~rtey
Left cole flDin
t.eftcdrcarury lrmrlor mHenurlc arury Superior n!Cbllarury M:dcleJ!nferior n!Cbllarury
Mqlr.~lartery
(ofDn.mmond)
Middle colic
el-~:-7!-::/-- Nc: of Rlolan
.nry
Superior mesent«
artery
~--~-~"+-+-- lnfenct
~r'lc..Ury
~'±-:-~-
t.eftcolcartery
-rnUm.ll lrac.n.y
E Afldgmlnlllrtmll..t.omDIH 1 Between the cdlirc trunk ;rnd supertor me.senter1c ;rl'tZ!ry via the panaeatfcoduodenal ;rl'tZ!rle:s 2 Between the superior and inferior mesenteric al'tZ!ries (middle and left colic al'tZ!rln; Rlolan and Drummond aBastomosn. see F); 3 Between the Inferior mesenteric artery;rnd Internal lilac al'tZ!ry(supertor rectal artery and middle or Inferior rectill artefy) These anastomoses are lmport;rnt In that they Cifl functlor1 as collate!'· als, dellllerlng blood to Intestinal areas that halll! be4!n depr!Yed of !heir ntwrn.1l blood supply.
F AnutolliCISa ~the middle 01nd left colic ;~rteries The aBastomoses between these two vessels are loc;rted near the left cclic flexure and should be noted during operations in this region (vas· cular ligations). One of these vessels can compensate for dec1'91ed blood f'-lr1 the other.
271
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.6
Tributaries of the Inferior Vena Cava
,....----,;.......;,...;.;....- - ld'tlnftrior
H~wns----~~~--~
phn!nk:wn
Right lnfufar - - - -.;...;;.,.
phrenkw'h
Rl~ht ren..l win
Right
lnftrfar maenll!rlc:
rugrtamman ~~~n
~
Right lnti!INI llac~n
Medlansaa.al
Rights~
gki!Hiveln
IJ!ftemmat
Ill!#
nlllcwn
cbtunrtor~n
rugrtmlddle r..:tallll!ln
ltect1Jm
rugrtlnfedar eplgMtr!c artery llld'lfin Right lnttmal pudend1lveln
Redilwnaw pious Utertnewnaus plems
Rlghtlnffiiar g~lvetn
Veslalwnaus pious
Rlghtub!ffn~~n
RJgrt W'er!ar -kallll!ln
Urethra
A Tribut.Jrii!S ofthe lnfertDrwna Cilllilln the postedor 01bdomen
andpellll's Antl!ri~:~rview of an opened female abdomen. All organs but tile left kid· ney and supr;rrenal gland have been removed, and the esoph;rg~JS hu been pulled slightly Inferiorly. The lnferlorven;r Ulli receives numerous tributaries tNt retum ~~enous blood from tile abdomen ;rnd pelllll (and, of course. from the law!!r limb$}, an;rloo.;roul to the diltribvtion of the paired abdominal aortic br.rnches In this region. The fnferlorven;r c.111a Is formed by the union of tile two common fllacvefns at the appi'OlCimate few! of the L5 Yertebra (see C). behind ;rnd slightly Inferior to the aort1c bifurcation.
272
Noll! the spedalloatfon of tile left renal vein and Its rfskofcompresslon by the superior me.sentenc ;rrtery(see p. 269): The left renal Yeln passes
in fTDnt of the abdaminal a~:~rt
utaries of the Internal lilac vern .ilre frequently multiple (unllki! tilose
st-n abave) but un~ to fonm a single trunk before entering the mac vein (see alsop. 287).
AbdomenantiPeMs - - 3. BlootlVeaels
\ - - - - Hl!mla:lygc4wn _
__.._ _ _ Hep;IUCWins
RJg!tW'tt!or ----::~~~'-~:;--- l.l!ftlnferlcr phre!'icwtn
phre!'icwln
lrhrlor'f!!ll - - - - " l ' c : : _....._~ CMI
RJgtt~~ng--......lo~--:lM
\li-~-~---l.l!fttestlcU~r/
l~barveln
1\---11-- - - Leftasandlng lumb.1rwtn
Rl¢tccmmon ----IP-f1racwn
8 TrfbutartH ofdte tnferlarwnu.;rr.a The difference In the venous draiDage ofthe rlght~nd left kidneys Is dis· playedmorecle~rfyhet1!thaninA. Thecx:~nt!nultyoftherfght~cendlng
lumbirvdn with !he ~zygos vdn lulso shown. Dlr«:ttrlbut;nt• retum venous blood directly to the lnferforftna a¥<~ without pa~lng through ;m Intervening aplllary bed. Direct tributaries drain the following o~ans: • The diaphragm, abdominal w.all,lddneys. suprarenal glands, te.sti!S I ov.arle.s, and liftr • For the p
c
Pro)Ktlan of the lnferklr vena cava onto the wrtl!flnl mklmn The inferior vena av~ ascends on the right side of the ~bdomiDal aortl ~nd pla'CI!5 the diaphragm ~t the vena aval hiatus located ~t the T8 level. The common lilac vdns unite~ the L5 levd to form the Inferior vena cava (see .illso A).
D Direct trfbutartes of1M Tnll!tfarwna ClMI
• • • • • • • •
Rightand left inferior phrenic winl Hepatic wins Right supn~renal win Right ;~nd left rereal11elns at the L1/L21ewl (the left testkulilrI ovarian win ;~nd left suprarenal win terminate In the ltft renal win) lllmb.ilrvelns RlghttesUOJiar/ovarlanwln Common lllilcwlns (l5 leleQ Median Yeral win (ofan termlnatelln tr.lelt CDmmon Iliac win)
Noll!: Venous blood from !he lnfenor vena ava may dr~ln through the
ascending lumb.'lrwfns Into the ~zygos or hemlazygos vein and thence to the superior vena ava. Thus a cx:~nnection between the two venae cay;re exists on the posterior w.~ll of the abdomen and thorax: a CJVO· a¥<~1 or lnten:aval anastomosis. The locatSon and slgnlffcance of CJVO· ca¥<~1 anastomoses are dlsc:u~ed on p.292. Frequently an anastomosis exists bet\veen the supr;reDal vein and inferior phrenic vein (not shown here. see A) on tile leftsldeoftile body.
273
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.7
Tributaries of the Portal Vein
A 1M pDrtll Vll!ftOUt lystl!m l'nthe abdDrnen
The arterial blood supply ~nd venous draiNge of the abdominal and peMc organs dlffa' In their functional organization: While they derive their artenaf blood supply 4!11tlre!y ti'om the abdominal aorta or one of 1ts ma)or branches, VI!IIOIJ$ drofrlage Is .accomplished by one of I:M dtf/i!f'
ent lo'l!r!OIB' symms: 1. Orgarl veins tbat drain directly or indirectly (via the iliac veins) into
the Inferior vena cw.~. which then returns the blood to the light heart (see01fso p.272) 2. Orgar1 veins that ftrrt drain directly or lndlrectiy (Yia the mesenteric veins or spfenkwfn)fnmtlteporllrllll!lll-and thtaS totheflvef-~ fore the blood enters the Inferior vena cava and retiJms to the right heart. The first potlrway saves the urfNry organs. suprara~al glands, genital organs. and the walls of the abdomeJ'I and pelvis. The S«::O!d pottrwoy mvesU!e organs of the dlgtsave system (holloYtorgans oftheg~ intestinal tract, p;ancre.as, gallbladder} and the spleen (see D). Only the lower portlons of the rectum are exempt from this pathway and drain directly through the lllac vdns to the Inferior vena ca>r.~. This (re)l'tlut· lng of venous blood through the hepatic portal systl!m ensures that the «gallS of the digestivetr.lctdeliver their nutril!llt-rich blc!od to the liver for mmbolrc processing before It Is retllmed to the heart. It also provides a route by which elements of degenerated reel blood oells an be conveyed ti'om the spleeJ'I to the IIIIer. Thus, the portia! vein funcaons to deliver blood to the liver to support metabolism. This contrasts with the proper hepatic artery, wflich supplies the lill1!r with oxygen and other nutlients. Anastomoses may develop between the port;al venous system and ~~ena caval system {portacaral anastomosis) and function as collateral pathways 11'1 certain diseases (seep. 293) •
• su,..torm--luwln (seep.278)wlth ltstr1butar1es: - Pancreaticoduodenal wins - Pancreatic wins - Right~menllll vein -jejunal wins -Ileal wins -lleocollc:wln - Right tolk win - Middle tollc win • Wedor..-takvMI (seep.279)wtthltstr1butalfes: -Left: colic vein
B ProJection of the portal Vl!fn and lb nw mejortl'llutll'les onto
the vertll:lnl column The portal vdn ofthe lrver Is formed by the union ofthe 5llptrlor mesentl!ricveln andsplenfcvelntothe rlghtofUiemfdllneatthe L1 revet. The f/l(Mor mesenteric vein typh:affy operu Into the splenic vein, also conveying its blood to the p~rtaf vein vi~ this route. Now the relationship of the portal vdn to the lrver. stomiiCh, and pan· creas.
274
-Sigmoid wins - Supelfor recbll win • _..,k 118ln (seep. 277)wlth Its tributaries: - Left oastro-omental win - Pancreatic wins -Short gastric veins • Dhctlltbulllrta (seepp.276-279)
-C¥Jikwln - Leftptlfcwin with esophageal wiM - Right oastrtcwln - Pos11!rtor superior pancreatlcoduodeNI win - Ptepylolfc will Pan~umbilial VliM
-
Abdomen and Pelvis - - 3. Blood Vessels
l.l!ftgastrtclll!ln wlth
Right gastric vein
esophogealveins
Short gastric~ins
1 - - - - - Left gastroomental,.,ln Postet1orsuper1or-----------:::.~,...
pancreaticoduodenal vein
i"---~~~f------------ Rightgastro~entalveln
lnren~---~~~~~~~~~ pancre;~tlcoduodenal
""In
~-~~c-~~~~.---lnreoor
mesenterk:: ..,In
Leftcollcveln
lleolveins
jejunal V1!ins
D Dlstrtbutlon of the portal win (see also C) The portal vein of the liver is a short vessel (total length 6-12 em) with a large caliber. On entering the liver, it divides into two main branches, one fur each of the hepatic lobes. The region drained of the portal vein corresponds to the region supplied by the celiac trunk and the superior and inferior mesenteric arteries. The portal vein receives venous blood
Supenorrectalvein
from the hollow organs of the gastrointestinal tract (excluding the lower rectum) and from the pancreas, gallbladder, and spleen. Some of this blood Hows directly to the portal vein through the corresponding organ veins, and the rest reaches the portal vein indirectly byway of the mesenteric veins or splenic vein.
275
Abdomen Grtd Pelvis - - 3. Blood Vessels
Portal Vein: Venous Drainage of the Stomach, Duodenum, Pancreas, and Spleen
3.8
lnfetfor
l'llltheln
Splenic \lll!h Gehac
Posterfor superior
trunk
pan~co-
duodenalw'b R!gltl!dney
Stomach
R!glt gll5tllc'f!ln
CI'Mntll
!Jdtgastl1>-
win
~olic...eln
Duoderu.m Qab!r
oment11m
P.ancrea11c:oduadenalw!n
Middle
SUperior
a.tcwfn
m~terlcwfn
A Venous chtnage of tile stDmildl lind duodenum Antl!rlor VIew. The IIIIer and leS$er omentum have been removed, and the greatel" omentum h;Js been opened ~nd rev..cted w the left. The stomach has been pulled slightly Inferiorly, and the palton~rn h;Js been removed or w!fldowed it sever.~! sites w display the tamlna!lor1 oftile hepatic veins In tile lnfedorvena c.iiYa <~rid the communication of tile gastl'ic Vl!ins with the pcrtal Wl'!ous systl!m. Blood from the lesm curwture of tM stomadl gener.rlly flom directly low the portal vein, while blood from the gT1!0ttr CllJ'VIIture re<~ches Ute portal vein byway oftile splenk vefn and supenor mesenteric vein. The low!!r pcrtions of the duodenum drain chiefty to the superior mesen· terfc vein, while the upper pordons usually drain directly to the portal vein. V.ufar1ts are commor1, howew:r. NDtx! how the esophageal vefns drain tow the pcrtal vein by way of Ute left gastfoc wins. This is impcrtant in the pol'tilcav.al mllatzral cir
splenic velr1 behind the stomach.
276
AbdommantiPeMs - - 3. BlootlVeaels
Hlplltlc veins
Celli t trunk
Partalvtln
~~~ ---=~--~~~~~~~
GlodeNI wins
Mlddleallltwln
Superior ~wln
Rlghtgastroornent.llwln
C Venaus dr..lnage of1M p;mcreas and spleen Antll!rlor VIew. The stDmiiCh has been partially removed and pulled slightly inferiorly fW better exposure, ~nd most of the peritoneum has
been removed. Thl~dlssectlon deartyshaws how !he portil wfn Is fonned byttle junction of ttle supenor mesentll!rk vein and splenic vern near the IIIIer. In 70X of cases !he splenic vein reaives ttle inferior mesentl!ric vein, as shawn here, before unltlng with the superior mesenteric VEin (see al50 8). \otonous Dlood from the 5pfeen Is camed by ttle splenic vein dJ.rtoctlyto ttle portal vein, Vlhlle blood from ttle po~ tilki!:s varfous routes: Mo~t
lnffi1cr
I.A!ftwt~cular/
mtsentertc:wb
owl1an win
of the pancreatic veins (mainly from the tilt! and body of ttle pancreas) open into ttle splenic W!in. A few (mainly from the head of the pancreas)
open into the superior mesenteric vein or drain directly into the portal vein. Noll! ttle W!nous arcade along ttle pancreas (which Is rtchlyvast111ar~) and !he close relationship of!he he
7:17
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.9
Superior and Inferior Mesenteric Vein: Venous Drainage of the Small and large Intestine
cysuclldn
~~-ava
Portallldn
Left DASttfclldn
Right g;utrfc lldn s~
mes
Splenic Win
Left colic flelCln~
·~
ltlghtgR'Oomentlllldn
mo!:S1!1111erlc:wln
Pancre.atm. duodeNI Wins
Mkldlecotlcwln
Rlghtalilclldn Asand'ngcolan
Jejunal and lle.IIWIM lleoaUc lldn
A Trtblltllrtes ofthuuperformesentertcvern Antl!rior view. Most of the sttlmach has been l'l!!mOVI!d, and the pefotoneum has bea'l re~ or windowed ;rt multiple sites. leaving some of the retroperttoneo~l connectiYetlnue In pl;rce. The mesentery ;rfld tr;rnsYerse colon have been partially removed, and the loops of smalllnteslfne have been displaced ttl the left. ThesuperiormesentericYein unimwith the SFienicvein at the L11evel to fonn the poml Yeln (see •· p.274). The small fntl!stlne drains exdusM!Iy Into br;rnches of the superior mesenteric vern. The superfor mesenterfc Yeln also collects blood from the
278
cecum, .append[X, ascending, .and two-thirds of the transYerse colon .al· mo.sttotheltftcolic flexure. From thatpointthecalcmisdrairled by the ln[frior mes,entertc vein. As wtth the mesentl!rk arteries. multiple anas· IOITlO$es are present between these two large veins. The superfor mesenterfc win drains a much larger ten'ltory than the Inferior mesenteric. Thus, the Yenous drainage of the small arid large lnwlfne foiiOM the pattern of their arterial SUPSJiy. Note: The ;rscendlr~g colon. which Is secondarily retroperttoneo~l. may also be dr;rlned by wins In the retroperfttln~m (lumbar Yelns) that empty Into the Inferior wna cava. This Is another ex.1mple of a porta· ca~r.~l collateral pathw;Jy (seep. 293).
AbdommantiPeMs - - 3. BlootlVeaels
lnti!flor wna c:ava lt!ftgutJfcWin Portalwn Rlg1t gastric win
Superior ~wn
~giStro-
ornertll win
Splenic win
lt!ft
Mkldlet>Oik:wn
P.lnc:r9tlco-
duodenal Wins
lt!ftOik:wln lnti!flor mesenll!rlcwn
De'landr>g
COlen llt«dlcw!n SlgnoldWins
CeaiWins
SUperior I'Ktll wn
Awendlwt. wiA Slgnold a.lcn
B TrtblltlriH ofh Tnfetfor mesenteric vern Anterior vii!W. Most of the stomach, p;mO'I!as, and small intestine haw been ~mDVed. The peritoneum has been ~mOiled or windowed at sever.;rl slt:es. leaving sDme of the retroperltone
place. The lnferformesentertc veil\ Is fonmed byibe union of the leftcolkveln, sigmoid veiru, and .wperior re«al vein. Unlike the SIJperior mesenteric vein. the Inferior mesenteric veil\ runs separite from tfte artery and gener.allyopenslntottresplenlcvefn behll\dttrestomKh and pancreas (see p. 277). Thus the tn{r!OOr mesenteric vein returru blood on(y from t1te ltzrpeirlte$titll:. The boul\dary betwl!en the territorii!$ of the superior ~nd Inferior mesenteric vell\5 Is usually loc
The descending colon, which Is secoodarfly retropentoneal, may
279
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.10
Arteries and Veins of the Kidneys and Suprarenal Glands: Overview
Left lnfe11ar ph re nlc wh (anastomo:srs 'With left supr.areNI wh)
Right lnfmar phi'E!llc:Wh hferiorYI!Oi c.Mt
Left~cr
suprarenal
Right lnfulorplllullc a rttry (ru II$ posttrlot tolnfl!rlotYellilava}
Left lnfe11ar phrmlc a1!ly
Rl¢t suplrfar suprarenal artery
CA!IIaciNik
Rlghtlqmrenalwn
Left niclde supnln!l'llllll'tl!l'y
(gener;~llyOJ)O!fl$
dft>ct~tn11> hfulo•
WOa(
Left sqmrm.~l wn
Right middle S\IPillrmal artery (runs pOsll!rlot to
ln11>1eftn!Niwln)
(lleM'1llly~
Left lnlerlot supnln!l'llllll'tl!l'y
lnNnorWOila¥i)
Rlghtlnftr1a r supran!NI.arb!
Left nNI al't!ly Leftn!Niwh
Right nNI artery (runs postafar to lnll!r'lorwnaaw)
Suplrfar l'lleSI!I1b!llc
Rluht~t\1'-1
Left b!stlcula r/ owr!1nwln
1Muliln artery ltlghtb!stlcularJ cw.~r!anw'h
Left best!culi r/ mrian artery
Right Inlier
Abdominal -"1
UM«~Iblllnd1es
(1\wn testicular/
w.ulan 1rteryar axnman Olac:ll't!ly)
A Dvl!nlttw oftfle aurtennd wins of the llfdneyund supnn!NI gl1ndt Anterior view. The esophag~JS has been pulled slightly Inferiorly, ~nd the right kidney and supr.-arenal gland h;we been pulled '6Wiii'J from the In· fel'forwna cava to show the vascular anatomy of the suprarenal gland. The other abdominal organs have been removed. lten;!l ;rrrtary. The renal aruries branch from the sides ofthe abdomlrNI .-aoltl at tile lew.l of tile L1/L2 vembr.-ae (see C). TherlgiJtreNI artery
runs post1!11orto the lnfenorven.-a GiiVi (shown trinsp.;~rent In the dr.iiWing), and tile left renal artJ!ry run.sposWiortothe ll!ftl'l!!nallll!in. Each 1'1!!· ml artery divides Into ~n .-anteriorand postaiorbr~nch. The reBa! artery gives off the Inferior supr.-arenal .-arteries to tile suprarenal gland: apsular (perirenal) branclles to tissues surrounding !he lddr~ey and to thereNI capsule (tlbrous apsule and perirenal fat apsule,remc:wed here for clarity); and ureter;al br;anches to supply the proximil ureter and di.Jtal renal peMs. Possible varlan13 .-are lllumatEd In E, p. 283.
lnfular ITM!SII!I1II!fl
SUJII'Iftlllllrtl!~ Superior, middle .-and Inferior suprirenal .ilrtel'fes {from the infl!riar phrenic artery, abdamiNI aorta, and l'l!!nal artJ!ry, see
~bOft).
Rl!nill win: The renal vein an each side Is generally formed by tile union oftwo or three venous branches(V.ilrfanture shown In F, p.283). While the left l'ftiQI ~receives the left supr;~ren;~l vein ~nd left testicular or OYO!rlan vein, the rlgllt renal vein opens directly Into tile Inferior vcm cava wltttout receiYing these trlbut.ilries (see alsa D). The reNI vein alsa receiYes apsular branches from !he renal fibrous capsule In .-addition to .small branches fram the renal pelvis and proximal ureter (nat shown here). SUprinllill wins: NotE: The three main .ilrtel'fes of tile supr•renal glands (see above) ;are generally accompanied llyonlyOMwl'n (r•relytwo), tile suprall!llof win.
While the left suprarenal vein opens into the left reNI vein, ~uently amstomoslng with the left Inferior phrenic vein (as shown here), the rlgllt supr•renal vein empties directly Into !he Inferior vena CiVa (see also D).
280
AbdomenantiPeMs - - 3. BlootlVeaels
Right lnftrlar
phrmc al'llry
IJ!ftlnferlct
phrenic: Win
Rlghtwpoerfor
Anastomosis~
leftsupr.nnalw!n
S14111iA!nal artery
IA!ftsupedor SLJHllrenil-ry
CelilctNnk
IUghtsupr.nnalw!n
Lel'tmldde S14111irenil.llttry
~middle
s LJH11 n! naI artery IUcjrt Infer! ar S14111iA!nal artery
-,!'----~---
Left supran!NI gland
J"{l,j"'"'"-----'l--l.d'tlnfeior
$f.V
S~me5e<"aric artay --+-----::~:::11~__;
LeftsuprareNI~~tn
Right A!nal artery
Left renal al'b!ry
~nmiWin
Left renalw'b
LeltlddM)'
Abdomll\llao~ ---~--+.~t.....-
lt.--"!!k-- - - - - - nferforme:sentertc:
8 Artlftes ;md wtr. of tile lcldneyl ;md supraren;~t glands
Antl!rtorvlew. The rtght kidney and supr.uenal gland have been slightly l'l!b'actzd frDm the inferior vena cava to displ;ty their blood vessels more cleariy. It I~ evident In ttlls dlagr.-.m and In A !hat ttle supr.uenal glands have a more complex vaSOJlar anatomy than the kidneys: More ttlan 50 small
~-----
Lefttl!stlcullllj
owl1an
branches may piSs from ttle ilrtel'fal trunks ofttle suprilrenal glands (su· perror, middle ilnd lnli!rforsuprarenal ilrttrll!l) Into the glands. Noti: ttlat ttle thnee m;~in arteril!l Ill the supr;renal glands are generally ilccomp.;rnled by onlyonevdn, the suprara~<~l vdn. This vessel opens 1#m:lfy Into ttle lnferlor\lellil Cil\la on ttle right side and Into the renal vein on !he left side (see D).
RJcjlt rntft!or phn!nkwln
Left rntertor phrenlcWin
Milito mash bmoeenleft lnh!rior phn!nlc Ylfnandleft 'LJHllren~l....,n
IJ!It supraA!naiWin Lel'tn!nal'l'lfn
RJcjlt llestlc:Ua r[
l.dt tl!itlcularf
CMI1an Win
0Voll1anw!n
C Prafedloo of the ren.1l arterfes and vel:ns orrtDU!e wrtlebral
D nibutarfesoftheleftrellillwlfl
column The renalarteryarises fram ttleabdominal aortaatttlel1/L2 level. NofJI: The renal veins lie anterior to the arteries.
The renal ve1r1 hu more trfbutilrtes on the left skle than on ttle right. The left renal veirlrea!M!s the left suprarenal win (oftl!n arlilslzlmD:Singwilh the left tnfenor phrenic vein, see A) and ttle left testicularI ovarian vein, whereas the corresponding veins on the rlgftt side open dll1!dlylnto the Inferior vena cava. Beause ofthis ilrrilngement. varicose dilations ofttle veins In ttle spermatic cord (\larfcoceles) are more common Ofl ttle left side ttlan on !he foght.
281
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.11
Arteries and Veins of the Kidneys and Suprarenal Glands: Topographical Anatomy and Variants
AnterforMJper!or segmentll al'llery
FlbrousapsJie
lnfl!rforsegmentllal'llely
A DMifon of the rer~o~~l.teryTM1> segmenul ar1erfl:$ Anterior vlew oftile left kidney. The main trunk ofttre renal artery dMdes Into an anterior and posterior branch. The anterior branch dMdes further Into four segmenul artl!l'· ies:
• • • •
Superior segmenul artefy Antl!rionuperior .Hgmental art!!ry Antertor Inferiorsegmental artery Inferior segmentihrtefy
"Av<~Kular"
zone
Pos!:er!o r side
The postafor branch gives rise to only one segmentil Ye:S.sel, the posrerforsegrnental artery.
Renal artery
B "Av.cul1n" .zonern the lddncy lnfaforllfew of the right kidney. Between the postafor segment and interior segments Is a relatively avaSClllar zone ofttre kkfney, wtlfch oeherwlse Is vel)' hetMtywlSculorfztd. Thi$ zgne provides an important line of acass for intra renal surgery.
282
Abdomen and Pelvis - - 3. Blood Vessels
Superior Inferior suprarenal artery phrenic arury
Abdominal aorta Posterior brand!
Middle suprarenal artery
{gives off posterior
segmental artery)
Inferior supra11!nal artery
An~rior superior
segmentalarury
Right renal artery
Anterior branch Anterior Inferior segmentalarury Inferior segmental
p
A
L
C Vllscular segmentation of the kidney
Left kidney viewed from the anterior (A), posterior (P) and lateral (L) sides. The renal artery and its branches divide the kidney into five segments: 1 Superior segment 2 Anterior superior segment 3 Anterior inferior segment 4 Inferior segment 5 Posterior segment
Abdominal aorta
AberTant nghtl1!nal artery
Uretl!ral branches
artery
D RelatloiL'Ihlp of the renal arterial brandies to the renal segments Anterior view of the nght kidney, demonstrating the origins of the renal artery, middle suprarenal artery, and Inferior phrenic artery from the abdominal aorta. Note the division of the renal artery into an anterior branch (anterior segments, superior and inferior segment) and a posterior branch (for the posterior segment, see also A). The upper part of the ureter is supplied by ureteral branches from the renal artery.
Abdominal aortil
Aa:essory
"'nalarury behind Inferior vena cava
-~=of-
Aca!5SOry renal vein
Aa:essory
renalaruryin front of Inferior vena cava Inferiorvena cava
b
lnfertorvena cava
lnfertorvena cava
b
E Vllrillnts of the renal arteries
F Vllrlants of the renal veins
Anterior view of the right kidney.
Anterior view.
a Two accessory renal arteries (one crossing In front of the Inferior vena
a Accessory (supernumerary) renal veins. b A left vena cava (persistent lower part of the supracardlnal vein) as-
cava): Accessory renal arteries are elCtra arteries that pass from the abdominal aorta to the renal hilum. As a common variant with accessory renal arteries, the Inferior suprarenal artery does not arise from the renal artery. b An aberrant renal artery Is one that does not enter the kidney at the renal hilum.
cends to the level of the left renal vein and opens Into it.
283
Abdamen and Pc!lvls - - 3. Blood Vessels
3.12
Divisions and Topographical Anatomy of the Internal Iliac Artery
um~~~. --------~~
pmntpart lnlllnlalllllc arllery. ----.;-"N an1211ortrunk Obturator new
A ll'llnd!IS oflhe r1tlht Intimal II.: artery In 1M male pelvk Left lite~l view with the peMc organs rM~IM!d. This lllustRtlon Is ~n id~lizd compos!U of a series of sa~:~Qital sections that ind ude the midline and more literal slnlei!.Jres. The lnb!mil DIM: ilrl2ry arises from the common lillie utery. In 60% of cases it diVides anterior to the piriformis (see C} into an anterior and posterior trunk. The anterior trunk gllll!s off Vlsanl branches and also
parietal branches to the pelvic wall, while the posterior trunk gives off b~ndtes only to tile peMc Will. The sequence of the branches Is shown
in D. ~the ndatlonshlp of the lnl:emiiiiiiK ilrtesy il nd Its branches to the siiCSil plexus. S~l branches of the lnl:emill IIIK irlery "disappear" behind this n~ plexus. The rel.rirtfonship of the intemill iliaurtery to the bony pehlk walland pelvk apll'tures Is shown In c.
Dorsol diiDralar!Ery - - - - - /"""----"7~/--
1-i!-~!:;'--
RJghtlramal fllac:o1111ery
Deep dllrnl ~r!Ery -----......,••, Ml!ryof
Mlddlerectal
wstbulllbulb Posarlcr labial - - --fl'_,
a!Wry
brancha
Pertnoal army
-~~~':
1nf8tarrectal•rtory ------...Cif"
• 1 Coui"Mind bnndlel ofthil rfllht lnll!mal pudendalai'Uryen the
pehlclloor
The lntemil pudendil artery Is only partially visible In A. This diagram Illustrates lbfurthll' coune.
284
b
lntmlal pudendlll
army
Course ofthurtery In the mille (same perspective iiS In A). b Courw of the a.Ury in the f8nale. lbe cou~e of the inb!mill puder>dil ilrtery Is analogous to Its course In the mille pelvis. An Inferior view Is shown to supplement the lmr~l view In a, ~nd beause this view Is tmpgmnt In surgtnl proc:edum on the female pelvkfloor.
il
.AbdonN!n Gltd1'8vfs - - 1 Blood\feuels
Rl!trt a~mmon 1111< c Seque..e of lll'llndle of die rtght lntB111IIIK ertB'y .nd dlllr prajectlan ant~~ the11111le pelvll
Compilred with A, tills dllgram ilddltlonillly shows tile superior vesrc:ai
light lrmrnal 11ac:.ury
Median S~a~la.-ry
Right
aii!Jral
llldumbarartery
lllc illtay
SUporlar -'<:II
..-ry
D Sequence of llrendle of the II*I"MI die~ eltely
Enh Internal llilc ilrtlfl)' suppiiH the Willis and organs of the pelvis with ft\11! p;~rlebl branches 1nd ftWl or Slit vlsanl br1nr:hes (""' • "gives olf"). Obtura!Drbran
llalum._.tay liD the llterill pelvic WJII
LltwiiNaal....., tD the pMtlrior peMc wall
irb!rytoilllBICm051s with obi>Jra!Dr a.-ry
- Splllol brandies
Lacuna musculonJm
Olotu- •.t.ry liD the medlill thigh and
-l'ublc branch -Ac~CD&u~w bnmdl
la!B'alpeMc-11
- ltlatfof bnmdJ
Plrifurmls
hgulllll
ligament
-Paw~or&ranch
SUperior glulllll1rt1ry
- SUp«f/ccrrl brondl
tD the gluiHI ~ion
- Dftpbtondl
...,....., .......I'Wy tD 11M! glu...l'"'!lion
-~armycfmalicnorw
- MIIycf-lllflr- s..,.riorllftiarl Gttay(ID!he ~
. . . . . . . . . eottry liD the ,..... tilndus
.........,
- Pnlltallc""-11es
tD the UlleNs, bllopl1n
Obbntor membrane
E Arbrtel ........ Tntlwpelvfc -11 Vinr of a right hemipelvi$ lh-ing the pelvic apertu- that transmit tl1e arteries and mmespondlng veins. There ilre ii iDtil of sbc pilhWilyS. whme bnd mirb ill'll! tile piriformis, SIC:rosplnous llgilment. Silcrotuber-ous llgiment, lngulnal llg•ment. and ob«uriltllr membrane (see also F)• F lllleu..-sU•tndl 011 die peMI:...I There are six lllilljor neurovaJCullr tracts on the pelvic Willis, four~ wlhlch (") contain lnnches from the lntemlllllic artery.
tubes. vagina, ilnd 11111r1a
M.._.nNMaW.-.~bb. . . S~-4~ .
V.81111111rtllry
MiiY i111$e as il MP~rlte br-.nch from tile hum1l Rile: ilrtery (as sr-. here) or. more commonly. from thelnflriorwslal 1rteryor ulilrlne artery ("v;ogln1l..,.ot 1rter(')
Mld.ei'ICCIIer1!1ry to the rectiIa mpull1 and levator ani
-~~
Greallersclitk fora~. sup111plrtfurm p.~rt"
Superior glutula.t.ry 1nd win.
supet1or gluteal-
(abcM the plrtrurmls) Gmllersclitk foramen,
lmrfor glutttlartery and win, Inferior
infra pirifonn pe rt• (below the plrtrurmls)
glutal nerw,lldltic nerw. in11en111 pu-
dend1l1rtery1nd ~n. pudend11lnerve. p-riorfwnontolc:ut.l.-.-
liniBnljf pudondlla.t.ry
-lrl(frlorrrdt/1 Cllffty (to 1M tfnnlrrcrl
(Included with thevtsceral branches because it giws flff the Inferior reml1 rtay)
- PerlrtMIINU!ry
f'IC!IIm, de.)
On pelvlclloar
PUdendil anal•
lntllmll pudendal arblry •nd will, pudendal nerw
.....
Obtllrator1rtery andwln, obtu l'iltllr
...., _ . ,SCJ'DtDI bnlncha (m), ,_,.,./oblolllnwlla (f}
-lhthral «fllly
-Attrtof.......bulll (lJ. artlryo{ ,..bulb(m) - DotsaldiiDIDI art.}'(f), dotrtJI
'*'*.n.y(mj
-o..p di!DtalwtBy(f}, ....,,_~ Gf111y(m) _,.,.,..., _ _of,.,.
LacuM muscularum (PG*-
rior to lngulllllllgo.....,t. literil to lllopedlra arch) l.xunlwsorum (pGIIB1ot
nFemor~l nerw,lmral femorill cutilneousnerw
femonllrtery ilnd wln,lympholk
to lngl*lalllgament. me.bl ¥ISSiis (thefwnorallrt.l'yIsI brilllch to~l;oa:h)
d the ntemllllllc ~rt.ry). fanonl branchdfllo~IIOI.t-
285
Abdamen and Pelvis - - 3. Blood Vessels
3.13
Arteries and Veins of the Pelvic Organs
Supaforglululwln Oblu131Dr•rtay•nd Yell\ obturll:or nerw
Supaior glllllul•rtay •nd win S~orre::t>l.mty
IIJghtllltllolllll
and wn (fram/11> lnfB1ar
I lac.tsy•nd win
mes«~torlc~
Right lUpl!rlor veslal .tsy•ndwn
•ndwln) -~.t-1--- ltlghtlrM!Ior....rcal
artay ond vein
~wsd~~--~~-+~~~ and llnrll!ry
r.;:..-
Left:~r----~~~~~~~~
4 - - lllghtmlddlorm.l •rtay ond vein
~-----'+- SemlnoiWIIIdo
Left:superlorWIIal - - - - -':"!!;;---.:!!!!!!
:.-- - - - il-- Left:mlddlorecbl•rtorv
..uryandwn
andwn(cut)
Dorsal penile~. - - - - - . t _
deopdorHI~IIewln
~
Spemwtlc cord
--~(-;:.--:::!t~-
Left:l~or~lcal
artay ond win
i;r~~~~~------'="=-+
Left lnfaiorrecbl artory ond vein lnt.n'lll pudBICW~ andwln l'llsttllorsacoblln~
posllrfor ta"Obllwln
A Arbrl•l lllppl:r ud -ous dralnate of the pelwk organs tn the male(ovemew) Right hemlpelvls (Olmplled hom multlple sagittal sections) Wewed from the leftslde.ldNIImd. The pelvic organs derive their IIUII!IItupplyfrom the visceral brandies ofthe internal iliac arh'ry (see p. 285). Their-• drab• Is by corresponding veins (often running parallel tu the arterIes), whldl driln ID the lni'A!malllrac win. The Wins, unlllle lfle irtel1es, are fm!uattly multiple on e~~th side Gfthe pelvis and ire Gften expanded nar the org<~ns tu fonn lirge pii!ICUSI!S. The m<~ln differences In the ar12rlal supply ind venous drainage of the pehrlc organs In lfle male and ~ nn<~le are based on tile copious blood supply tu the uterus and vagina In the fanale (see p. 290): The uterus and vagina are supplied by their DWII nnajorvutels.lnthe male, h~. theaccessorysexgland$are supplied by smaller branches arising from the vessels Gf neiirby organs (bliidder, rectum).
lnllrnollllocwln Vslalwns
Prosblk:
...........
=-~~~f'§~J
dorsiI ~lie
win
Doop
Veins of
penlewlns
~llobulb
C Venou5 dl'ii!Jyge llf the bliddl!r 1nd ITiillle tt!niUIIil
I Araflai1Uppl:r of tlw pi"CIItiW Coronal section, anb!fior vtew. Most prosbtlc branches arise from the inferior vesical artery, and a smaller number arise from the middle rectal ~rtay (not shown here). The prosbtlc branches ramify Into a grm many bra ndlltts outside the organ capsule of the prostm.
286
Large venous pii!XUses around the bliidder (lllt.llcal venous ple!Ws) and prortate (prostatic venous pltxUs) drain through the vesica Iveins to the lntl!mal lilac vein. An ~nasiDmotfc connection betwMn the prostatic venous plelWs (not shown i~ids 111!· nous draln<~ge of the vembril column and spl nal una~ crems <1 route by whldl tumor cells from~ prostatic arcfnorna may metastasize ID dle spine (whidl may fi"t came tu clinical attention as back p;~in).
h-.
Abdomen Gild l'r!Ms - - 1 BloodVeuels
Right umblltalarterv lllghtu~
Right superior ft'llcii..U.,
IUght CMI'Y
Supertorii!C'tll
---..,.--.,.:;r
artl!ryandwln
RightfJIIaplln tube ----.~
IUght vaglnahrtlory
IO'ghtobtundDr artloryandw'h RJdlteJitell'lll11ac artery and w'h RJght round llglment d ui2IUS
::!111......!.- 4-- - Right middle re
L8t supet1
---.--~-- Vllgmlwnous
artlory ond vein
~i-:-a-- Uteme\'tiiOUS
pleows r:r""-:-~,__- Left uttllne
aroeryandvdn
plexw
LAft mlddle II!C'tll arlluyandwfn
D Arll!rTalsupply ilnd wnouscll'il~ oftil~ pehllc OIJilnlln tlw fe-.le(awn1Jew) Right hemlpelvlJ (e«nplled from multiple Ngltul sections) Ylewed Abdomlrwl•orta
lloh.mbor artery
IlK artery
Obbntr:r-ry Rlghtottmol II!Kal'ttly Superior ....talartlory Welfor
....talirtlory
lnforlorw"" C3lll ltlghtrnt.mol llilcwln
~IRIBnll
Umbllal-ry, pmntp.-t
from the left slde.,ldellllzed. The supply ofthe lntem1l genital orgms, which represent 1 slgnlftcant fr~ctlon of the mtal vasa.~br demand In the female pe!Yis,ls desa1bed on p. 290.
Ulslneartlory 11111!11'111 pudendil
artlory Inlet!or gluteal artlory YagNil11'11ry (here
;.:'to:= llac artory) Middle II!C'tll ;rt1ry
UIIRiewlns
lnforlor glutNwlll> 11111!11'111
a.b.lndDrwfns
pudendal win
Right e~~tem•l lllocwfn
Middle II!C'tll we!M(from reml..,ous
Vesical wins
Yaglnol branch
"'"""''
of~aroery
E SequeiKII! of lll'ilndles ot die lntemiiiiiiK ll'tery n tile &mille pelvis
Left l~ral Ylew. The ves:sels to the utErus and vagina mark the principal difference from the YiiKUiature of the male pelvis (see iilso E, p. 285). 1he utau. receives a large vessel, the uterine al'lll!ry, whido usually arises separately from the InterNI lilac artery (the analogous vessel In the mile. the iifttry of the v.s de&rens, usu.ally brandies from the umbilical artery). The uterine al'lll!ry mgy also arne from the middle reml artEry. which Is lirger In those cases. The arterial supply to the Vil!lfnals alsosubject to valtlaon. The vagina may be supplied bya separatz vaginal arrery branching from tile lnterNIIIIac arreryorbyavaglnal br.ndo ilrlslng from ettherthe uteltne irtl!ryorthelnfl!riorwslcal iirtl!ry.
F Venous dlilfnage of the o~ns ofthe female pelvis Left l~tera I view showing the rtght InterN I lilac win. The female pelvl'
organs are genenlly driilned by four plexuses (seealso E. p. 291): • VesiYrl venous plexus (vesical wins) • Vllglnil ~ous plexus (wslal wins) • Utertne wonous plelals (utertne vein) • ltectil venous plelWS (rectal wins) The mlcldle ;;rnd Inferior rectal veins drain to the InterN! lilac vein. The supertor rectal win drains Into the Inferior mestntllffc win. (The superior and lnmfor~l veins 1renot shown h-.)
287
Abdomen Grtd Pelvis - - 3. Blood Vessels
3.14
Arteries and Veins of the Rectum
Abdamlrtal aart.l
SUpellotrect~l
artBy (from lnflrlor ~r!c-ry)
nleurb!ry l.eftfnU!nlil
------: , ----"T---
Left mkldlt re
l.eftlnU!mal pudencbl artery
A .Arb!rial supply of the rec:.tum Postenor lllew. For clarity, portions of the Ilium are shown transi~Kent. No/:1:: The unpaired superior redal artery (frDm the unpaired inferior mese~rk: a!Ury) divides Into two branches on reaching the rectum. By contrast. the mlddk rectal arteries (from the Internal lilac artery) and Inferior rectal arteries (from the l~rnal pudendal artery) are paired owir~g to their origin from p.1ired parent vessels.ln the female, it is not unusual for the middle rectal atUryto arise frDm the uterine a JUry. The tnfMor rectal artery leiwoes the l~mil pudendal artery In the pudendal canal (Air:Ddc's mnaQ. The superior rectal artery approaches the
288
rectum from abOYe and posteriorly. also coming In cont.1ct with the pefltoneal COWI1Ag ofthe rectum (for clarity, not shown here}. The ml~ die and inferior rect.11 arteries approach the rectum from the sides, the levator ani forming a welJ.deflned p.1rtltlon between them: The middle rectal arterlu pass to the rectum above that muscle, the Inferior rectal artenes below tt Because tile lev.ttor ani forms an esent!al part of the •pelvic diaphragm• (see p. 168), the course of the middle and infl!!tior rectalirteneslsalsodescribedassuprod/ophrvgmalfrandln{mllaphrogmatlc, res~J«Iively. The recti I arteries frequently accomp.1nythe rectal veins for a considerable distance.
AbdommantiPeMs - - 3. BlootlVeaels
!Jeftc:rxnmon lllc'f!ln Sigmoid veins
!Jeftmldde rect
l.t!ftlnti!
!Jeftlnfi!rlct rectal win
8 Venous chlllilge of the n!Cium Po~tenor lllew. Portions of the Ilium are shown transiOO!ntfor darlty. Nfltl:: The unpaired $4J{If!rior l'l!ctal win (to lfle unp.1ired inferior mesen· terfc vein) divides lntJ) two branches Ofl reachl11g lfle rectum. By con· trast. the mlddlf rectal veins (to the lntani!l llli!Cveln) and ln{morrectal Yelns (ID the Internal pudendal vein) are paired O'Mng to their tennlnation in paired venous trunks.. Because the rectal Yelns accompany the corresponding artaies for some dlstafiCe, their course Is analogous tD that preYiou~ly desaibed for the arteries (see A): The superklr rectal ve1r1 follows an abdomlr~al
roure, while the middle arid Inferior rectal vein~ take supra- arid lnfrildla· phragmatrc roures. The superior rectal vein dralru tD the hepatic portal !Yltem by WiJ'f of lfle inferior mesenteric vein (see pp. 275 arid 279). Nom: Tumors In the region drained bythe superlorrectalvdn can metaJtaslze through the port<~ Ivenous system tD Ule capillary bed ofthe llvef (hepatic metastases), whereas tumors 1r1 the reglor1 drained by tile~ dk and in[enor rectal Yein$ metil'lta,izelflrough lfle infi:!riorYena cava to the capillary bed ofthe lu11g (pulmonary meta5tases). Note also the lm· porta nee ofthese velfiS as port;acaval collaterals (see p.293).
289
Abdomen Grtd Pelvis - - 3. Blood Vessels
Arteries and Veins of the Female Genitalia and Urinary Organs
3.15
ovary
Umbllt.ll
t.'l6den!Cilll
PllltntPirt
amry
Obalramra~
Round
alldwn
r~ment 0~
Utl!f!""' art8)'
lnfetlor
VagtnalartJery
andwn
lllt.lll:31art8')'
S!.pelfo rYe:llt.ll artety,-kal
MeiOmettl~
Win
Umbltt.ll
Blll6di!r
A 'Valall;!r supply ofthefw!m;~l~t ln1lt!rn.11 genltitll;tt
AnUrlorVIew. All of Ute pe!'ltoneum has been removed on Ute left side, and most has been re~ on the right side. The utenJS has been stralghtl!ned and tilted to the right. The Onternal) female genital organs are supplied by two large <~lUI" les that
p.246). The ureter cro~es just Inferior to the artery, and this rdatlon· ship should be noted In operations on lhe uterus (see G). The uterlne .arte!y enters the uterus at the )unctfon of the body of the uterus and the cervix. At that point it often givu off a vagiNI branch w the vagina and then runs a very tortuous course to the uterine fundus. This tort:u· oslty pi'OIItdes redundant vessel length that allows the artery to stretch when Ute uterus enlarges during pregnancy. The WI10UI dr11h"'9t of the uterus is to the utl!rine plexus. which is dr;ined on eeth side by the uterine ~~eln. The uterine vdn empties Into the Internal lilac vein, ruDnlng a course analogous to Utat of the uterine arte!y. The rtght ovar· Jan vefn dr.alns blood from the lfght ov.ary directly Into !he Inferior vena cava, wflile blood from the left ov.lry drain$ to the left renal vein be~ reachlngtheWI1a cava.
Abdomtl\al aorQ
~*~nil ..
art8')'
RJghtonrJan/
Left Clll'arlan/
testlaJiar
te:dla.far
al'tlery
al'tlely
B Vlrtlnts In tfle OlfgJn of the ovarfan and teltSallar arterfes
(after Lippert and P.abst) 011 Typical case: The ovari;ln or testicular arteries ariR from the abdomi· Nl aorta (approxlmately70,; of cam). b Accessory vessels are present (approximatEly 15 %). c The arteries arise from the renal .artery (.approxl~tely 15 X).
290
c
bnge ofv.IIIUon tr1 the locatTon of tfle CMrTirlarterfes (after von Lllnz and Wachsmuth)
Anterlorvlewshowlngthe relatlomhlpofthe
Abdomen and Pelvis - - 3. Blood Vessels
Left renal Common lllacVI!In
Left ovarian win
utertneartl!ry (from intemal lll;lcartl!ry)
uterine ...nous -----',----: plexus
D Arterial supply of the female lntemill genitalia Anterior view. Note: Two arteries supply the ovary In the "ovarian arcade": the ovarIan artery from the abdominal aorta (courses In the ovarian suspensory ligament) and the ovarian branch of the uterine artery (runs along the fallopian tube). Attention must be given to both vessels during adnexal surgery. With a tumor or cyst of the ovary, •ovarian torsion" may occur, causing a dangerous reduction In the ovarian blood supply. Reason: The plum-sized ovary Is suspended on a vascular cord, the suspensory ligament (consisting of the ovarian artery and vein and surrounding peritoneum, not shown here). An ovarian cyst or tumor leads to eccentr1c enlargement of the ovary. When the human body spins or rotates (e.g., during sports), the affected ovary may become twisted about the axis of this vascular pedicle, strangulating the vessels and constricting or totally occluding the ovarian blood supply.
E Venous drainage of the female Internal genitalia Anterior view. The uterine vein (often multiple on both sides, but shown here as a single vessel for clarity) collects venous blood from the uterIne plexus and also drains a portion of the vaginal plexus. The ovarian venous plexus creates an anastomosis between the ovarian vein and uterine vein (It Is drained by both veins). Note the different modes of termination of the left and right ovarian veins.
Superior gluteal artery
Left uterus
ureter
pudendalartl!ry
lnlenorrectalartl!fy utertneartery
Vaglnalortery
F Arteriillsupply of the uterus, vagina, and blildder View into the pelvis from the left side. The uterine broad ligament has been cut open to display the branches of the left internal iliac artery. NoD!: The serpentine course ofthe uterine artery along the uterine body is particularly well demonstrated in this lateral view (see also A). The origins of the uterine artery and vaginal artery are subject to consider· able variation.
Bladder
Vaginal branch
Left uterine artEry
G Relationship of the uterine artery and ureter Left lateral view of the left uterine artery and left ureter. The ureter crosses inferior to the uterine artery in the base of the broad ligament (see also A) and is therefore susceptible to injury in operations on the uterus.
291
Abdomen and Pelvis - - 3. Blood Vessels
3.16
Venous Anastomoses in the Abdomen and Pelvis
-rfortrunkal
Sulxlavianvein Axlllaryvein
~
~~
--•m*~---1 Latl!r.~l thoradc'll!in
- - - - Accessory hemiazygos vein
-+---,..._-
- - -+ - --1
<....,. ~--'---
~
Superlorepigastrlcvein
I
Umbilicus ~
Superftdal epigasbtcvein
Hemiazygos ..,;n Right ascending lumbar vein
- - -+ - -+- --l
Pertumbilicalveins ~
Superftdal drcumflox lllacvein
Superlor'll!na cava
--+--+----:--- Azygos'll!ln
___j
_I
- - - - Left ascending lumbarYI!in
>---
Abdominal wall
Lumbarveins
....,
- - -+ - -l
Femoral vein
A Clvoc:nal (lnb!rcaval) anutomoses Large venous anastomoses are present between the inferior and superior vena cava on the anterior and posterior trunk walls. Known as Clliii>CllVCJI or intwaJWJI anas!Dmoses, they provide collateral pathways for returning venous blood to the superior vena cava and right heart in patients with outflow obstructions affecting the inferior vena cava in the abdomen or the common iliac veins in the pelvis. Veins crfthe chest wall form the cranial portion of this collateral network. The veins crf the antr!rior abdominal wall provide both a superficial pathway (anterior to the rectus abdominis) and a deep pathway (posterior to the rectus abdominis). (In the chest. these pathways lie outside or inside the thoracic skeleton.) Notr!: On the ontr!riortrunkwall, the paraumbilical veins (see B) establish a collateral pathway between the portal vein and drainage to the venae cavae. This portosystemic (portacaval) pathway is important in patients with obstructed portal venous flow and may affect the superficial and deep anterior pathways. • Anastomoses on the posrertor wall of the abdomen. They utilize the connection between the ascending lumbar vein and the azygos/ hem Iazygos vern. Two pathways are available: 1. A dirrct pathway between the ascending lumbar vein and azygos/ hemiazygos vein: Inferior vena cava- (possibly via the common iliac vein) ascending lumbar vein - azygos f hemiazygos vein - superior vena caw.
292
2. An indiR!ct pathway between the ascending lumbar vein and azygos/ hemiazygos vein by way crf horizontal trunk wall veins (intercostal and lumbar veins, mediated by venous plexuses on the spinal column; for clarity, not shown here): Inferior vena cava- (possibly via the common iliac vein) ascending lumbar vein -lumbar veins -vertebral venous plexus- posterior intercostal veins - azygos/ hemiazygos vein - superior vena c.~va.
• Anastomoses on the anterior wall of the abdomen. They utilize superHclal and deep cutaneous veins, which may exchange blood between them. Two pathways are available: 1. Deep pathway (posterior to the rectus abdominis): Inferior vena cava-common iliac vein-external iliac vein- inferior epigastric vein- superior epigastric vein- internal thoracic vein - subclavian vein - brachiocephalic vein - superior vena cava. 2. Superficial pathway (anterior to the rectus abdominis): Inferior vena ciiVa - common iliac vein - external iliac vein femoral vein -superficial epigastric vein/ superficial circumflex iliac vein- thoracoepigastric vein /lateral thoracic vein- axillary vein - subclavian vein - brachiocephalic vein - superior vena cava.
Abdomen and Pelvis - - 3. Blood Vessels
llfiiiA---~,.,....-- Azygos/ hemiaz:ygos vein
Right gastric
lll!ln
~-----!lf----
lnfl!r1orvena cava
Superiormesenteric - -H-- -+ vein
Ascending lumbor "'In
Superior
Middle/infl!nor
"'wlveln
...ctalveln
B Schematic uf collateral pat~ for the port~ I vein (porto-sys· temlc col laterals) Venous collateral pathways are also available between the portal venous system and the inferior and superior venae cavae. These portosysh!mic collaterals are physiological pathways that can develop in response to (1) overlapping venous territories in organs (venous plexuses in the esophagus, colon, rectum) or (2) the persistence of patent blood vessels that are normally obliterated after birth (umbilical vein, paraumbilical veins). These collateral pathways become clinically signif· icant when the portal system is compromised (as in hepatic cirrhosis, for example). As venous pressure increases, the portal vein can divert blood away from the liver and return it to the supplying vessels. Thus, veins that are nonmally a~tvessels for the liver undergo a flow reversal (see red arrows) and transport blood back through the inferior or su· periorvena cava and and back to the heart. Portosystemicshunts can be life-saving, but nevertheless cause significant additional problems, be· cause some of the vessels in the shunt pathways (in the esophagus and rectum, specifically) are barely capable of handling the significant redi· rected blood How, with consequent rise of pressure in the system, and are thus liable to rupture. The following four collater•l pathw~~ys are of key importance:
Portal Vl!ln - gastric veins - esophageal!ll!ins- azygos I hemiazygos vein -superior ven• CIIVII. ® Through veins of the anterior abdominal wall: Portal vein - umbilical vein (patent part) - paroumbiliml veins superior epigastric vein- internal thoracic vein- subclavian veinsuperior ven• CIIVII or Portal Vl!ln- umbilical vein (patent part)-paroumbiliml veins- inferior epigastric vein- external iliac vein -Inferior ven• CIIVII. Drainage from paraumbilical veins into the superficial veins (rare) of the anterior abdominal wall (thoracoepigastric vein, lateral thoracic vein, superficial epigastric vein, see A) leads to dilation of these tortuous veins (Medusa head, caput medusae). ® Through veins of the posterior abdominal wall: Portal vein - superior and inferior mesenteric vein -colic veinsascending lumbar veins- azygos I hemiazygos vein -superior vena CiiVil. The ascending lumbar veins may also divert blood to the inferior vena cava. ® Through the rectal venous plexus (with dilation): Portal vein - inferior mesenteric vein- superior rectal vein- mid· d/efin{l?rior recto/veins- internal iliac vein -lnfertorvena cava.
CD Through veins of the stomach and distal esophagus (dilation of these veins may lead to esophageal varices, with risk of life-threatening hemorrhage):
293
AbdomMGrtdPelvls - - 4. l.ymphGtkSy.rtem
4.1
Overview of Lymphatic Trunks and Lymph Node Groups in the Abdomen and Pelvis
lil!ral c.wal lymph node Ccmmon llac
Sacral lymph nodes
--+--!,..._"": ~---'-:"-"f:-7---
---:-~~
lnll!mlllllac lymph nodes
!:,-,:~--:::~---l,....-- Ext!mlllllac
lymph nodes
- --:-- -.,. . :.,.- -.:...,.w
-.gulrtal lf91ment tnb!nnedm - -.;-----,.- -....,.,.,,. laa.nar l)'mph node
A Ovlnf- of p;nfmllymph nodes In the 01bdomen 01nd pehts Antl!rlor llfew of .an opened female abdomen. Allllfsceral structlJres hawe been remOIII!d exa!pt far majarveuels, and the lymphatic Vl!ssels
are shown larger for clarity. Size disparities between the lymph nodes (1 mm to ows 1 em) and actlJal numbers {several hundred} are Ignored. Regional lymph nodes (see C) may be .m.mgecl so densely that lndl· vidual gn:~ups an scata!ly be identified. Lymph nodes in the abdomen and peMs are claS51fled by their location as parlml or ~I. Parietal lymph nodes are located near the trunk woU (often distributed along blood vessels). whllevlscerallymph nodes are located ntarOI!IOns In the conneethle tissue of the emaperltoneal space or In the mesentery at· tached to an organ. A large percentage of parietal lymph nodes are Ia· cated on the posterior wall of the abdomen and pdllfs: they are clustefed ,afi)Und the large vessels that course on the postl!lfor ibdomlnal
294
ind peMc walls, such as the abdominal aorta ind Inferior vena ava rn the abdomen and the lilac arttrlel and veins and their branches In the pelvis. Only a ft:W lymph nodes are located on the anterior Will, such as the lr~gulnallymph nodes and the nodes around the external lilac ir1efy (ntac lymph nodes). The lymph nodes and lymphatic vessels ire .ilrranged In in lntriCite network In the ibdomen .ilnd pelVIs, as they gen· er.ally are elsewhere in the body. As a result. lymphatic drainage tends to follow multiple regional patterns of flow rathc:rthan a slnglewell·deflned pathway (see p. 296). Potential drainage n:~utes ire particularly numerous for the o~ans of the peMs, where sever.al organs may share lymphatic pathways. F« ex:ample. certain lymph nodes are utlllzed (with varying degrees of preferen"') by the blildder. genital org;ans. and
rectlJm.
B J..¥mphlltk: trunb In thubdomen and
pelvis Lymph from the abdomina I and pelvic organs drains to the lumbar and Intestinal trunks (see p. 296) after first passing through one or more lymph node groups (see C). An expansion, the dstema chytl, Is frequently present at the union ofthese trunks. Lymph from the dsb!ma chytl drains through the thoracic duct to the junction of the left subclavian and internal Jugular veins. The thoracic duct Is the principal lymphatic trunk tilat returns lympll to the venous system.
C
Rlghtlu...,.r
-----4~~"------,..
lymphnocJ.,.
~.¥mph node groups In the abdomen and
pelvis Before lymph from the organs of the abdomen and peNis enters the lymphatic tl\lnk$, It is filtered by lymph nodes that collect the lymph from a particular organ (or region). After leavIng the regional nodes, the lymph drains to mlledlng lymph nodes. These are the nodes that collect lymph from several lymph node groups and carry It to the lym phatlc trunks. In the abdomen and pelvis, these are the lumbar and Intestinal trunks. AAll:e: One lymph node may function as a reg/olltll lymph noM for wrfous organs, but at the same time 1t may collect lymph from sever.~l regional nodes, functioning also as a collecting ~ noM. This prlndple Is Illustrated In the abdomen and pelvis by the lumbar lymph nodes: They function as regional lymph nodes for the kidneys, supr..renal glands. gonads. and adnex.a (see pp. 302-305) and as collecUng lymph nodes for the iliac nodes.
D Lymph nDCIRgroups mdll1but;111y n~glons Locllllon (see C)
C..llac lymph nodes
Around the cellae trunk
Distal third af esophagus, s!Dmodl, gi'I!Oib!r omentum, duodenum (superior and descending parts). pancreas, spleen, llwr. and gallbladder
Superior mesenb!~c lymph nodes
N. the or1gln of the su per1or
mesen!Bic a.Ury
Second through fourth parts of duodenum, JeJunum and lleum, ceaJ mwith vennlform appendix, asCI!ndlng mlan, transverse ex>lon (prmimol tMHhhds)
I nfl!rtor mesenterfc
N. the ortgln of the lnferfor
Tl'ai'IM!rse cnlan (dlsbl third). descending colon. sigmoid colon. rectum (prmimol pa~
lymph nodes
mesen!Bic artery
Lumbar lymph nodes (rfght. lntennecllate.left)
Around the abdominal aorta and lnferfor vena cava
Diaphragm (abdominal side), kidneys. suprarenal glands, testis and epididymis, ov:ary, fallopian tube. uterine fundus. ureters. retroperltoneum
Iliac lymph nodes
Around the lllu -.Is
~«tum (anal end), bladdennd urethra, utErus (body and cervix), vas deferens, seminal w.lcle. prostate, external genitalia (via Inguinal lymph nodes)
295
4.2
Overview of the Lymphatic Drainage of
Abdominal and Pelvic Organs
t t
-·
...........
L. .J
--
Left..... • :raottlct,nlph
• "'-''lc.,....,n nodo<~
........ ~¥Mill'-
-----f
Spleoft
·~lllllllbl~nodos
lllpllk........... • Qlsdclymph rood•
•I'Nwcll.,....,llnocllls
• ~lnallymph
........ lympllnode
• llmcalclymph noda
• Appendo:ullr lympll noclos
--
llltiCII"'...... .,....".,...
~
ptlaotc .....hNIII• ~.end l'ltn>p,lortc lymph noda
.s.,.....
·--... ..... llltiCII"'~
,.,
_./
Slomoch
,...._ .....
"""".....
...._,.""',.,
·~clymph
.......,._,.....,..hnllll• • Slgrnoldlymphnocllls
... 1 1 1 1 - - - - - - - - - -......
L
• Supdorrtct.lllyr!oc)ll nodll
A P11ncfJMIIymphdc path.wys ll...rnlng the lllgesllve arg1ns ..t spleen l.¥mph !Tom the spleen and most of the digestive organs drains directly !Tom regional lymph nodes or through lnteiWI'IIng mlledlng lymph nodes to the in~ol lnlllb. Ulteptions are the descending colon, sigmoid c:olon, and the upper part of the rectum, whkh are dn~lned by thelefllumbortrunlr. The organs and visceral lymph nodes intheabOVI!! sche'Tlatlc ue served rTMinly by three large collecting stations (Individual lymph nodes are c:owred later In the dlilpter):
• Cellllc lymph nodes: collect lymph from the stDm~. duodenum, pancmos, spln!n, and IM!r. Topographically and
296
are often lndlstfngulshable from the regional lymph nodes ot'nealby upper abdominal organs. • SUpelfor mesente11c lymph nodes: collect lymph from the jejunum, ileum, iiSC\'Ilding colon, and tra nM!I'le colon. • Inferior mesenteric lymph nodes: collect lymph from the descending collllf'l, sigmoid colon, and rectum. These collecting lymph nodes drain pritl
-
Abclomlnol-1
t ................... <•..und lnr.tcr... QOII)
• ~-.~ ..... ¥-ph ....... • " - - llrmph nodto ·-IIJ!n~h-
CDMIIIGII...,.,.,.,• Suboorlldrmphnaol., • Promonb>ryiJmph nodes • Lotmil, rn•dlil, ..d ,...,._ onedi.U.1:11111rnanlnoc: ~hn.m.
l!lghtlii'*'"Y
Rlg>tvwory
Right tall
•nd tupn~W<~I glond
ond fllloplln tube
nhplcldymls
_....ll.........h ......
/
• Obt..-¥-phnodes • L.ltlnl, mediiL lnd l....,...lle . . . .ldllc"hnaol.. • IIUI1IIIc¥'nPhnodes
t
t t
1 PrtndpallympMtlc ~ dnlnlng the arg-1:/dle retropelttoneum 1ndpelvis (1nd lower limb) Lvm ph !Tom these OIJjil ns dnlns prtndpally to the rfght; nd left lumbar trunks. The fDIIow1ng are Important lymph node groups for the organs vf the mroperitclneum and peNis (and ICMV limb):
• Common lllic lymph nodes; collect lymph from the pelvic organs and IDWI!I' limb. • Right and left lumbar lymph nodes: c.GIIecting lymph nodes for the common lilac nodes, ;~lso regiON I lymph nodes for the org;Jns of the retroperltaneum and the gonids, although the I~ are loe~ted In
Llll-ry •ndfllloplln
tAft ldclnoy ond supnnnol
tube
~-
lntlemolln.ciJmph...... • Slcnllymph nodes • S~c>ortorond lnfortor~IIIUI lymph node
1 .... _..,......., •--'lymph .....
·1'1-~phnoda
• P•~lnolll'mph noda • Lotzrol-ac.IIJ!nphnodos • ...,..,nd ...-aollymph
.......
the pelvis or scrotum. ~ the gonads undergo their developmental descent. they rNintiin their lymphatic connection to the lumbar lymph nodes (analogous to their blood supply, see p. 290). As a result, v.t.en tumon vf llle taUs (or DVilr,'), for wmple, undergo lymphogenous spmtd, they tend to m~stuize directly to the abdomen rather than to the pelvis. Both the lilac lymph nodes and the Iumba r lymph nodes are classified il5 pgrietDI nodes.
a c01tegory Cholt includes the phrenic and epigastric nodes. Lymph nodes such is the pa,rectal and parauterlne lymph nodes are classllled as vlsarvl nodes.
297
AbdomMGrtdPelvls - - 4. l.ymphGtkSy.rtem
4.3
Lymphatic Drainage of the Stomach, Spleen, Pancreas, Duodenum, and Liver
Left gastric lymph
nodes "!T-; --Spltnlc:
~ IT+r+--I.A!ftg~
Panaeatlc: lymph
- - r':M-
Su)X11A'Ior1c lymph nodl!s
---:-:tr.
node
omental lymph
nodes
--~~=-------'f'~=-~~7---- Rlghtga~
omenlll lymph node
A lymphftkdraTNtgeofthestom•ch Anterior view. The lessa- omentum has been removed, the greater
omentum has been p.;~rtlally opened along ttle greater OJrv.tture ofttle stDmach, andttle lr~r has b~n retracted slightly superf011y. The flllklilting lymphatic p~t~ .tn! important in this n!gion: • Drainage l:aw.lrd the grut2r and lesser NI'Witllr1!S cf the ltllmlch.lnltfal drainage Is to the regional lymph nodes: the right and left gastric lymph nodes (tllWilrd ttle lessa- curval:\lre) or !he right ind
298
left gastro-omentallymph nodes (l:aw.lrd the greater OJrvature. see white lines ind ilrrow!o). These regional lymph nodes convey lymph either directly or Indirectly to !he cellae lymph nodes (Indirectly by way of the pyla ric and splenic nodes). Fram there the lymph drains to the Intestinal trunk. • Dr.il!nagefrom the fundus and cardia: Initially to !he lnconst.ilnt (not always present) lymphatic ring ofthegastlfc cardia. then to the lnU!s· tina! trunk,
AIHiomen and PeMs - - 4. lfmphatlc Symm
Leftll"''ri<:
q.sttc lymph
lymphnacle
""*
Splenic lymphnodos
H.Uc l)mph nodos Celilc l)mph nodes
S'4"0J¥o11c l)mphnodos Reln>pyforlc lymph nodes
l'lntlftlk: J,mph noda(s...,etlor)
SlbJ¥orlc lymph nodes l'lrlasllc l)mph nodes (lnfmor)
Superior mesenllr1c
l)mphnodes
P¥1creiCicoduoclenil lymphnodos
B Lymplwlk dniMge ofh lpl•n, .-n~n~~.. lftd duodenum A~rior view.
MIISt of the stomKh has bern """oved, the colon has been detilched, and the lllo'er hu been retrilcted up¥Nrd. The following lymph nocles and groups of nodes llr.lmportilnt In thl.s region; • 5p1Hn: dralru lnltiilly tD the spiWc ¥nPh nodu. then directly or Indirectly to the ltl~st1ntll trunk (the Indirect route IN)' be through the
•
superior pilncrealic lymph nodes alotw or through the superior pi! ncreiltlc nodes ilnd the cellae nodes). ~ncr&S: dr.~lns lnltYily tD the~ ond ln{lrfor panaeatk ~ nodu, then directly or Indirectly (VIa the cellae nodes) tD the lntestl· nal trunk; ordr.~ins initially to theslljll!riorellld ill{triot ponCI'I!Idicoduo-
denollymph nodu (mainly on the posterior side of the pi! ncreas). then
directly or lndlredfyvii the superior mesesrtelfc nodes tD the lntesU· naltnlnk. • Duodenum: The upprrportfon of the duodenum drillnslnllfilltyto the pykJrlc lymph nodes (see C). then to the superior pi!ncre3tl.coduodenal lymph noda ;~nd from there tD the hepatic lymph noda. or di· reedy to the celiic nodes In someases. before entering the Intestinal trunk. The loww portliln of the duodenum 11m drillns tD the supet1of ond ll1(e1or poncnatkoduodmol /ympll no~. then directly to the lntl!.Jtinil trunk.
C lfmpiMtlc plltlrlny. far the llwr lftd bll..ry lrKt Anterior 'lfew. The following fymphitlc pithwilys are lmpllltilnt In this
regron:
lJvet' and lntn1he~k bile dum (three drainage pathways):
Llwler
Hepatic
lymph
nodes Stxunxh
lnfertor --1-!-JI---~=-~rl-J loltllle¥oli
ConmonblltWct
Duodenum Pyloric l)mph nodos
• Mllrt lymph drillns Inferiorly through the hepiltfc lymph nodes tD the
celiK lymph nodes and then tD the Intestinal trunk;md dstrrna chyli, or It mq drain dlredfy from the hepatic lymph nodes tD the lntestl· nal trunk and dsterna chyll. • ASmilll ilmount of lymph dr.alns cranially through the Inferior phrenic lymph nod~s to the lum b~r 11\Jnk. • In some cases lymph drains through the dlilphrag m (partly through the lo'enil Cil'lil hliltus and partly through musculir openings In the diaphragm) to the suptffor phrt~~lc lymph nodes and then tD the branchornediartinaI trunk. Calillllldtler: Lymph from the gallblad.W drains ln112ally to the cyslk lymph node. then follows the pathway described above. Common bile duct: Lymph from the bile duct drains through the pyll)11c lymph nodes (supril-, sub-, and retropylor1c nolies) and the fo.rilmlnill lymph nodetDthectllic nodes, tt1111 tDttletntestlnaltrunk.
299
4.4
Lymphatic Drainage of the Small and Large Intestine
n.o..dc diJCt'OIII'h --...;::l!!==='!!P~!!.:k'"'fll dst8111 dlyl
111!!!!!!!'~-......:o,!~~--
Intermediate
m"""""'rlc l)mphnodes lymph nodes '~""'
A ..,.,.... nad. and !rmpNtk di'IIIDIIe oldleJe}uum and dum An!B1or llfew. The slorNch,llller, pancrMS, and mast ol th~ colon h;M! '-'e ~moved. The lymph nodes of the small inttJtine a~ the largest group of lymph nodes In die hum~ n body, numbering ilppniiiCimmly 100 150 nodes of gready varying siZe. For c~lfty. the • ' - drawing shows only a few lymph nodes dllt ~~ ~resentld~~e of larger groups. Lymph !Tom both thejejunum and Ileum drains lnltlilly to regional lymph nodes QLilltalntesUnal lymph nodes), then to the superior mesenteric lymph nodes, ind finally to die Intestinal trunk. The lymph nodes and vessels In the mesemq biiSially follow the dlstrfbutSon of the arteries ilnd veins.
Musa.lir
SUbmUCOAI
pluuo
pluuo
They are Cillled "lntermedlilte" beause they are situated ~ vlscenol and collecting lymph nodes (die .wpenor and lnfer1or mesenteric lymph nodes). In palierts with a malignant tumor, it is desirable toremCM: ;~s INA)' lymph nodes iiS poJSible along il drillnage pilthway to ensure die remiMII of any mlcrometasus.es (metastases not grossly visible) lflilt may be present In the nodes. In the CISe of the duodenum, dlls meansthilt the re5Ktlon should Indud~ not only the ilffected part ofthe duodenum but also th~ attached portion of the mesentery and the (lntermedlilte) lymph nodes dlilt It contains. Ocuslonally even the superior and Inferior mesenteric lymph nodes are also ~moved.
B lfmphltlc draln1ge ofthe lntettlne bJ~~~gmenb (after Fllldl and Kubik)
Lymph Is collected In several plexuses (nn-rtcs of lymphatic vessels and lymph collectors) In the lnteJtinal w;~ll. The lymphiltlcs accompany the mesenteric artl!rles ind wins through th~ mesentery, ;md In principle they drain th~ intestinal segment that is supplied bythose"""sels. 'VaM5 In the sul»aous collectors detennlne the dl~ of flow and define the bound;11fes ofth~ lndMdual driiNg~ segments In the Intestinal w"ll.llecause of these segmental boundaries, it is~ for a tumor to spread emnslvely ilong the Intestine bJthe lymphatic route. Arrows: prtndpil dlrecUon of lymphatic dr~lnage.
300
i:pla>llc lymph node.s
Wdclecolc
Sl.pel1or m..enlorlc lymph nod..
l1rtl>h node.s light cole lymph node.s
LL'ftcolc lymph nod.. Parac:ollc: lymph nod ..
lnflrlor IT'IIS8!btr1c lymph nodes
Ileocolic lymph nodes
Mesocollc lymphnodos
Sigmoid lymph nodes
l'l"l!!aot.lllymph nodes
c Lympfwtlc: dnlnage of the lq~ lnt2tt1M (modified from FOidi ~nd Kubik) Antlerlor view. The transvene colon lind gre.lber omentum h~ been reflected supertorty. The foiiO'Mng lymph~c pathwlys 1 re lmportil nt In this region: • ~lldhll Cllllon, CII!CUI\, and tnn-ne colon: lymph from these struc:tu res drains initially tD the right ond middle aJic l)mp/t nad!s, then to the .suptrior mmnterlt' ~)mph noda, and finally to the lnmtlna/tnmt.
• DelciB!dlng calon: Lymph from the descending colon drollns lnltlilly to reg lonallymph nodes, the left ro1tc lymph natlti, then tD the In{trior meHnl!'rir lymph nocks, il nd then drains 1lia the left hlmbor lymph
nocks (not visible here) Into the left lumbar tnmk (not visible here).
• Sigmoid mlon: lymph from the sigmoid colon draIns lnllfilly tD the sigmoid lymph nodes, then follows the ~way dw:rlbed for the des«nding mlon (~'-e).
5L4'«10r rectiI lymph nod..
• Upper rectum (see also D): Lymph from the upper rectum drains lnltilllly to the S4lpf1ior l'fdol lymph nodes, then follows the p;~thw;iy de-
scrfbed for the sigmoid colon (<~bove). Thus, il mallgna nt tumor undergoing lymphogenous spread must neg()tlate sever.JIIymph node groups (a II of which should be removed In tumor resections) before the malignant cells can reach the inl2stfnal trunk and thoradc duct and finally enter the bloodstrnm. This longi'OIIt2 of lymphogenous sprelld lmprcMS the prospects for a Cl/re. The lymph nodes of the large Intestine can be clisslfted cllnlaJI/y and function oily inm more groups than by anammical critef.a alone: lymph nodes of the Intestinal wall (epimllc group), lymph nodes neer the In· testfne (p;~racollc group),lymph nodes at the ortglns of the three large Intestinal arteries (central group), and lymph nodes at the ortglns of the mesenteric arterfes (collecting lymph nodes). In standard anatDmical nomendature, the eplcollc nodes are not dlstfngulshed as a seperille group, ;md the paramllc and central groups are considered collectively
~IIIIK
lymph nod .. lni2INI lilac artery Supotfldll.,guhwl lymphnodos
-""""""'"="
--41~-~',./
• Upper lewl: through superlorrectallymph nodes (not shown here) to infwi'or mesenteric lymph nodes (- intertina I trunk and left lumbar trunk). • Mldd le lewt: lntJernal lilac lymph nodes (..... rtght and left lumbar trunks). • I.Dwer level: - Columnar zone: to Internal dlac lymph nodes. - Cutaneous mne: through superficial Inguinal lymph nodes m external lilac lymph nodes (-lumbartnmks).
301
AbdomMGrtdPelvls - - 4. l.ymphGtkSy.rtem
4.5
Lymphatic Drainage of the Kidneys, Suprarenal Glands, Ureter, and Bladder
:::-=:!=~-- lnfaiorphmtic
lymph node ~~--
l..ll«aa..Ortlc lymph nodes
lnunned~ lJmbar
lymph node.s
A Lymphiltk dr.1tnage oftfle lddnii!Y, supraren<~l gi.Jrtd, .1rtd ureter (abdominal p;u1; the peiYIC p.ut rs shown In C) AnUrlor view. The follOWing lymphatic p.Jthways are Important In this region (see alsop. 297):
• lA!ft lddney and supr;nn<~ltland: dr;lln to the 111(1: lumbar lymph nodf!s (lateral aortic, pre<~ortlc <~rid mroaonsc lymph nodes. see 1),
then to the lt!ft. /umbor t7'tH!k.
• um.r (ibclomlnal p.iit): follows the Pithw.rY for the right and left lddfleyS <~nd suprarenal glands (see <~lso C).
• Right lddney artd supr1renal gllnd: drain to the right lumbor lym9h
nodes (•lateral c.lV.tl, prec.1V.tl and mrocavcav;rllymph nodes, see 1). !hen to the rlglrt lum&or tnmlr.
B aasllflcaUon of the krnbar ¥nPh nodes TraniM!!u.e section, 'lliewl!d frcm above. The lumb.'!r lymph nodes are distributed around the abdominal aorta and Inferior vena c.lVa. They are dl\llded Into three groups bi5ed on their relationship to these vessels:
• Left lumbar lymph nodes (around the aorta) • lnte!Tnedlate lumbar lymph nodes (between the aorta and Inferior vena cava} • Right lymph nodn (around the inll!riorvena cava) These groups ane further divided into subgroup.s (see legend of A).
The lumb.'!r lymph nodes additionally function as collecting lymph nodes for the common lilac nodes.
c
~phnodesoftheuneter
Anterior view of the right ureter. The lymphatic draln<~ge of the ureter b roughly divided Into two levels: • Abdominal part of tfle ureter: lumb.'!r lymph nodes - Right lateral avallymph nodes (• right lumbar lymph nodes) - Left: laterill aortic lymph nodes(= left: lumbar lymph nodes) • Pel\lk p
302
Abdomen God Pelvis - - 4. l.ympllallc System
...1!-'--:'----::------:---- Superior ml!'l1!ntl!rlt lrtl!r)> ¥A1tl super! ar mHents!tlymphnodH
w ,....--.-.,!-,-- - - l.l!ftlumbllrtrunk
'\""~~r--.~--- Ovarian art~erywttl\ JympNttclleSSCis Pnlaartlc: lymph nodes
Common I lac ---+~~ lymph nodes
r-~t&--ih:---- Commontllaclymphnodes - - - - - - Leftcommonlllacveln
Sacnllymph nodes
.,_."-;1-t-~-- Left ln~emilllitc~
lnguln.alltganvm ----~
107'":<7'=s-+- - - !Xtmlaltlac Jo.ln'4lh nodes
Rlght~nUr ------~~.!!!! ~pllajfc1II!S1els
~7''-sj'--~-- Deep lnguln.allymph nodes
_ __;;..._ _ _.,.
F""""':"--T::-::--i-- - Supetfldill.,guln.allymph
cfd!e blad6er
nodes(horlziontiltnctl
~~"--4~~+---+---
D OVen/few of the peMc lymph nodes 01nd the frmph;dk dr.lllllllgl! of the blldder A~riorview of ;an opened female abdomen ;and pelvis. All orgaru h;we been retooYed except for the bladder and a small rectal stump. and !he per!tonaJm has been removed. The bladder Is distended, ITiilklng It VIsible aboYe the pubic symphysis. This dr.ii'WI'ng dearly shows the numerous parietal lymph nodes that are distri~ arDUnd the iliac vessds In tfle pelvb (see E). Lymph from the bladder usually drains first
Supetfldilll'lgutn.allymph nodes (mt~altr.act}
to grDUps of visceral lymph node.s: the late!'al ve.slc:allymph nodes and the pre- and retrDIIe51callymph nodes (known collectively as the p.ar.t· ~cal nodi!$). 'fhesto nodes ~rt' embedded in the pelvic COIInectiYe tis· sue suiTOUndlr~g the bladder and lie so deep wltttln the peMs that they are not visible here. Lymph from these l/lsca"al nodes drains directly or Indirectly .iiiOflll 1:\W nnajor pathways, reaching lymph nodes lmral to the abdominal.iloltl.ilnd inferior vena cava (lumbar lymph nodes) and finally enteffr~g the lumbartruniG. These pathways are Illustrated In F.
l'ltl!m.1ll n1ac ----"~---::l:il.l\1 lymphnodH
Oel!ptngutnallymph nodH Sacral lymph nodes
SUperflclaltngutnallymph nodK (dnlca~ wrtfo:altnrt)
E Oventew of the peMc lymph nodes The pelvic lymph nodes are distributed a lang ITiiljor blood veuels and in front of the sacrum. The blood vessels are not Ylsualrzed by lymphogra· phy (contrast radiography of the lymph nodes), howevef. and so the I~ catlor1 ofUie pelllk lymph nodes must be detetmlned byothefmeans. Otle meCbod Is to use four rtferena lrnes based Ol'l slaeletallandmark.s: A Iliolumbar line: hor!Mirtalltne tangent to the superior borders of the iliac cn:~.sts I lllosaaalllne: hortzont
Superfldalllld --.~Mo..~ delplngulnal lyn'Cih nodes
F Lymphltfc dralrlol§e of the blttddennd urethra The blttdder is drained by two prii'ICipal pathways:
• Cr.ilnlally alol'lg 1he Vlsctrallllacvessels (see D), • To the internal and external iliac lymph nodes (ITiitinly at the base of the bladder) Portlolu of the bladder near tfle lntanal urethral orifice are drained by the superildal and deep Inguinal lymph nodes. The untflra drains
chiefly to the deep and superffclallngulnal lymph nodes (the lattef mainly dr.tll'llng areas near the external uretltr.tl orlftce). The proxliTiill portions ofthe Urt'thra ~redrained by the ~i;lc lymph nodes. particularly the lntanallllac nodes. Note: The penis, like the urethra, Is drained by the supertldal and deep Inguinal lymph nodes.
303
AbdomMGrtdPelvls - - 4. l.ymphGtkSy.rtem
4.6
Lymphatic Drainage of the Male and Female Genitalia ~lumb.lr
~nodt
Rlglt~mb~r
~node
"'-11C
~nodes
lntamt!dlm-~mbn
r,mphnodes
Cllmmon Iliac ~nodes
Abdominal
aorta Sacral r,mpll nod~
l'nlrncn1%1ry r,mphnodes
Dl:tlm1l I lac ~nodes
£mm.1l
1racart>!ry lted!Jm S~allngl.fnal
r,mph nodes, hartmntaltract Bladder
Decj)lngtll\ll f)lmph node$
SUperftd'allngl.f!\11 lymphnodH, wrtlo:.itract
Epididymis Testis
Penis Sci'CCIJm
A LY1111h noel• i!rtd lymph.nlc piltfrw..,. of the malel~~taTi;~l i!nd extl!nl;llgenlbllla Anterior lltew. All portlcllu of the gutrolntest!Dal tract have been nemCM!d exapt for a rectal $lump. The peritoneum hilS been removed. and the bladder has been pulled slightly to the left. The emma/ gmltal/o consist of the penis and scrotum. while the testis ;md epididymis (despllle their location) are lnduded With the lllfl!r'IKll {lf!flltlll/a because of their embryo nit ongin, along with the prostJbe and semin;~l ve.sides. (The lymphatic drainage of the prD$t.1te, testis, and epididymis Is de· sa1bedln8.)
8 Lymphi\lc dri~tnaga of the tllltb, epldkf,ml1. and iiCC81101'f su glands All lymph from the male genit.'!lia if. ultimately channeled by various groups of parfmllymph nodes to lumbar nodes distributed around the abdomiDal aortil and Inferior vena cava (see pp.297 and 302). Thefol· lowing speclfk draln;~ge pathways are available: Testitartd et~lclcfrmll: long, direct drainage patilw.ay along the testfcul
Prostlte (multlple pathways}: external lilac lymph nodes: along the ve·
slcularvessels to the Internal lilac lymph nodes; sacral lymph nodes (and on to the lumb.ar nodes)
304
Nore: The lumbarlymph nodes that drain the tmts ond f9/dldymls ue lc.cated farther from these organs than most "vvsceral lymph nodes.• A:s w1th the Ciliary, this ll!sults In a long drainage pathway from the testis and t!Fididymis to the lumbar nodes. Mmost.'!sesfroma testicularrn;~lig nancy are mostfrequen!lymcountered In the lumbar lymph nodes. The f1lll:l!ltlal genltoNa are drained by !he superildal and d~ Inguinal lymph nodes. The lymphatic ve.ssels on the dorsum ofthe penis all! connected by anastomoses that allow for bilateral lymphatic drainiJI!Ie. Bec:i!use of this bilateral arr;mgement. a rn;~llgnant tumor on the right side of the penis may metistaslze to tile rtght ond left Inguinal lymph nodes.
lntc!mallltac _ ...;;;::"<-- M lymph nodes
Abdomen God Pelvis - - 4. l.ympllallc System
~edlatel~bar
PteaorUclymph nodes
lymph nodes
Sacral lymph node'! Fallopian tube
lntml.ll11ac lymph nodes
awry
DIUmii11K lymph nodes
\Mus Obtunrtw lymph nodH
Mesomtafum
Superilcfallngllnlll lymphnadH, hcxb:orm.ltract
lntem1edlete lla.nlr lyn'C'hnocle Ilia elder
Superilcfallngllnal lymphnadK, wrtlc.al tr.act
DHplngul'lal lymph nodes
c
~nodesnlymp!Mtkp~t~ofthefemlle lntl=fn~l ~nd ex.tll!rn.11genltlll;rr
Antll!rlor llfew. The uterus Is ret~cted to the right. The broilld ligament (seep. 246) has been temtwed em the left side and partially Ol)ened on
the right side to display the numerous lymphatic ~ssels th~t travecw the lfg~mem. For clarlty. the drawing shows only Isolated lymph nodes 'Within certain groups of nodes. f¥mpll from 1M Intmalgf!flltDikl In the female pelvis drains principally to the iliac and lumbar lymph nodes, while ~~~ from the eJCtemal 9ftlltullo drains mainly w the lnguiBal
lymph nodu. The lnguiBallymph nodes are dMded by dinleal alter1a Into a horizontal tract and vertical tract. It Is believed that the emmal genitalia .ue dr.alned mainly by the Yertleo~l tract. Hole:The ov.ary. though located in thepelvis. drains to the lumbarlymph nodes. A large portion of the lymph;ltic vessels of the uterus course within the broad ligament. Consequemly the lymphogenous spread of maiJgBant uterine tumors takl!s pl.ace along that ligament. proceeding laterally tow.lrd the pelvic wall.
D Lymphatfcdrall'lolfeofthefemalegl!flltill;a All of the genitalia .ue dr.alned by varfous gnoups of parfetill lymph nodes, wflich ultimrtely drain to lumbar nodes distributed ~round the light common rllic;~rury
ln!J!mal
IJac~
nodes
abdominal aoltl and Inferior vena ava (see pp. 297 and 302). Eltl!malgenltll&;a (and lowest portions of the vagiBa): supef1lclal and deep Inguinal lymph nodes, plus an accessory route (not shown} df· tectly to the iliac lymph nodes. lntarl'lillil91n1'tilll;rr: • Ovary. uterine fundus. and (mainly distal} portions of the fallopian tube: long dr.illnage p;lthwaytothe lumbar lymph nodes.ilround the abdominal aort.il and inferior vena U!.l/a • Uter1r1e fundus and body and (mainly proximal) portions of the fal· loplan tube: sam! lymph nodes. Internal and external ntx lymph nodes • Uterus (cervix) and middle and upper portions of vagina: deep ingui· nallymph nodes Note: Small vlscer;allymph no del for the wnus and vagina (parauter· lne and paravaginal lymph nodes, not shown here) are embedded In regional peMc cnnnecu~ tissue close tD the organs they serve.
305
5.1
Organization of the Sympathetic and Parasympathetic Nervous Systems
_
8 Eflectl oftfle qmpalhetfc lllnOUI r,stem on arg- In the alldonten •ndpelvtJ
........... Orgill,
....
Ill ,_.,... I
• Gutrolntlrstlnll tract
- Longlllldltlol ottd ctrculllf rrtllld«
flies
- ~lncUrlllllfdls - Qands
Decremed motility
Contnlctlon Decremed ~~emions
• Splolnleapsule • Liver
Contnlctlon lncremed
glymgenolysll/ gluCllfleogenesis • P1nc:reu - Emloalne
DecnoaMICI lnwlln
panaws -Elllla1M JICIIIC1""
Decr-.cl
MCnetilln se
• Bhodd•r - DlfrWI)t wslcllt
blilutlon
- FUndloiiGI biGdrJtr Contnlc:tlon
Jflhlnmr
Inter-
•
~Miwslde
pl.....
• V•cldlnns
mefenl!l1c g•f'Oion
• Ut.Ns
......
depending an
hormonill stilbJs
·~
abdomen •nd peiVll The first. or presyru pile, na~rons of the sympithe1fc system that sup-
ply the orpn• of the lbdomen are lrxmd in the !aUral horns of spiI cord segments T5 -T12. Their presynilptlc uons piSS without .synapsing through the ganglia IX the sympathetic trunk and f01111 the thorKk: splilnchnlc nerws (• greater ilnd lesser thorilclc splanchnic nerves, and occulonally alent thoracic spl.mchnlc nerve from 112). The .syn~ witlt the S«ond. orpostsysncrplic. ntun:~~~ is louted in the celiac ga ngllon, the superior (or Inferior) mesenteric gilngllon, or the aortlcorena I gilnglion (see p. 308). The first, or pnesyruptfc, neurons ofthe sympithetlc syst.n thatsupply tfle ora.,, of tt. p~~IW ue located In the literal horns of spinal cord segments L1 and L2. Thtlr preS)flaptlc .illltlns pass through the lumbilr ga ngllil of the sym pithetlc trunk ilnd form the lumbar splinchnlc n.:rva. The ~ witlt lhe smmcl. or poroynaptit', MVIIJfl may ~ loCilted In the lumbargilnglbi, lnfer1or mesenteric: gilngllon, or lmerlor hyN
306
Conlrilc:tlon
orm.utlon,
spllnclwllc
A Org111Tutlon of tfle sympethetlc nervous r,stem In the
Conlrilc:tlon
(.pwlation)
llftnar ~[~~--~--~~~~~
Conlrilc:tlon
($alliltlon)
moesenl!l1c
Vlsooonst~ctfon
pc~gubic plexus. Beyond thil: point the pc~stsynaptfc flben of the pGstsyna pUc neuron generally p;ISS ID the b rget organ wtth Its artery, usually accompi nled by pirnym pathetic fibers of the autonom lc nervous
symm. Nta: The pertpher.~l gil ngllil of the sympilthetlc nervous system are dis-
tributed along the sides ofthe wrtebrtl column (parilvertebrtl). Peripheral ganglia In the abdomen and pelvis are aka pia~ anterior to the vertebral column (prever1Ebral) and saaum. The paravertebral ganglia are interconnected by interganglionit connections ID form the sympil:hetlc trunk - two lang pil:hwiys extending along each side of the wrtebral column. The gilngliolare nilmed for the corresponding lewis of the spine (thoracic gilngllil, lumiNr ga ngllil, etc.) •nd are variable In num~r. The preverUI!r.ol ganglia are loCilted at the ollglns of the major arteries from the abdominal illlrta and ;ore named accordingly (ceii
........ _,_
~
D
Etl'vcbofthepii~Cn.,_
syd2m on 0191ns In the abdomen and
pelvis Organ,
....,niJIII!m
"~ _,_.,_.. etreds
• Gastrointestinal !Tact - Longlrud!nul and
Increased motlllty
dmJiar muscle
fibers - SphincterllliiSdes - Clcmds
Re~n
Increased
secretions • Splenic apsule
·~ • Pancreas - fiutoafne ponqeiJ$
- EJoDcrine ponerem
Incmsed secretion
• Bladder - DelniSor ~
CAintr;~ctlon
- Func:tiotlall>lrJdder !phmrnr
• Seminal veslde • Vas defe
c
Of9I!Uitl'on of the piii'1ISJII'IpathetiC n - qstem In the abdomen and pelvis Contrasting with the thoramlumbar organization of the sympathetic
nervous $}'$tem, the parasympathetic nervous system in the abdomen and pelvis mnslsts of 1'Ml lrlpogrophla!lly distinct sysRills: a cranial part and a s.acral part. This system also differs from the sympathetic nei'\IOus system In that the synapse of the first. or presynaptic, neuron with the second or postsynaptk neuron Is located In the Intramural ganglia of the organ walls. • Cnnlill p;11rt Gf th• paraiiJIIIp;lltfletk n~n~~~• syslllm In tha abdomen and pelviE The presynaptic neuron is located in the dorsal nucleus ofthe vag us nerve (I.e., the nudeus of crania Inerve XIn the me-
dulla oblongata). The iXDns (presynaptic nerve fibers) course with the vagus nerve ID visceral or Intra mural ganglia, where they synapse with the postsym1ptic neuron. The dJstribultoo of the aanlal part In-
Viisodllatron of the arteries In the penis or clitoris (erection)
dudes the stolllilch, liver, gallbladder, pancreas, duodenum, kidney, suprarenal gland, small Intestine, and the large lnt:l!!stlne fitlm the ascending colon to near the left colic flexure. • Sacral pert of the peniiJIIIplltheUc nervous sysmm In the llbclomen and pelvis: Its origin Is located In the late1"211 horns of spinal mrd segments S2 -54 (sacral Intermediolateral nudeus). The amns {synaptic nerve fibers) run a very short distance with spinal nerves S2- S4, then ~pa~ from them and course as the ~ splanchnk nerves to ganglion cells In the Inferior hypogastrk plexus or organ wall, where they synapse with the postsynaptic neuron. The distributiM af the satral part of the parasymp;iithellc nervous system In the abdomen and pelvis lndudes left mile flexure, the descending and sigmoid colon, rectum, <~nus, bladder, urethra, and the intennal<~nd extemal genltalla.
307
5.2
Autonomic Ganglia and Plexuses
Cellae br.ruh af
Post!flcr
pastl!rlor vagal tn.nk
vagal trunk
RJgrt lesaer splancmlcni!M! Cdac91"!111Dn Su~l
plexuJ ~1\ilplflWI
LeftlesMr 'lllancl1nlcneM Superior ml!'l1!ntl!rfcgll'l!jlan
Acrt!C:Ort!NJI ganglia ~pa1fletlctn.nk.
~r'lc:
lJmbargangha
plel!JJS Uretl!r.al pltlll.5 Inferior mesentl!rfc ganglion
~pa1fletlctn.nk. ~"!lllanlctrunk
Te'JtfOJIIr {cwnn) plelaa Right}left hypagastJICNrVe:S
~or hypog;Jstr!C plexui
5)mpa1fletlc tn.nk. s.11Cr11lgll~la
G~r.aml
(l)mmuniCMttes PeMc splanchnic MI!NK
Flrits.11a111Yl!lllr
Left h)'pogamlc
·~ Sacral plelaa
Coc:c)ogeal ganglion
A Overuttw of autDnomTc g~nghlar~d pll!ll.IIS8lrl the abdomen andpehll:t Anterior view of an opened male abdomen and peMs with all of the perlt:olleum remOYed. Almortill of the rtDmich his been rtrnOYed. 01nd
the gas!Jfc s!IJmp ;md esophagus hive been pulled slightly lnferfor. The pel\llc organs hive been removed except for 01 rect:al S!lJmp. The auto· nomic nerv~~us JYStem forms extensive~ and a number of gemgila around the abdominal aort<~ and wllftln the pelvis. the ganglia maltIng the sites where the flrst presynaptic neuron synapses with the second postsynaptic neuron. All of the aumnomk plexuses In front of and alongside tne abdominal aorta are a~llectively termed tne obdomimll aortlcphiws. This structure also Includes the lndlvld~~al plexuses located
308
at the origins d the paired and unpaired branches of the abdominal aorta (see B). As a general rule, sympathetic and parasympathetic nervi! fibers come togetfler In tne plexuses on thelrw.aywthe t
I
9Jmpatllet!c - trunk With lumbar ganglia
CtiiKpllas wltfl Alllcpnllll • Hepatic pltxus - I..M!t, gallbladder • Gulltc plelcus -Stomach • Splenic plelcus -Spleen • Pancrettk pleJCUs
-+
Pancrees, duodenum
Suplllorm-.te~tcplaa
with supellarmesenterk ganglion • No subplelcuses
- PancreM (head only). duodenum. jejul'llm, Ileum, cecum, colon tD left colk ftexure. -ry
Sup,...l~r~d nnal pluu5 with aorllcoiW'Ial ganglion
• Uretnl plexus
- Suprarenal glar.d.lcldney,
pnlldmalu,....
lnfettor-nta'lcplelcul • Superior ~I pltlCUs - Ltft colic flexure. descending and sigmoid mlon, upper rectum
• Branches to uretJer and genital CNgans Sacral
gangh
- u-.
epididymis, tHis, wary
- --¥--m<.....:; lnfertarhypogallrtc plaus with pelvic ganglia
• Middle and Inferior ~lpltlCUs
• Prostatic plexus
The ganglia and plexuses of the autonomic nervous system are named for !he 0111:eries that they 01ccomp;my or 01round which !hey are dlslrlb· uted (e.g., lhe cellae ganglion ind mesenteric plexus). In the sympaltlefk system, the presynapUc neuron synapses with the postl'jnaptlc neuron in gangli;l dirtont from the organs (or ganglion ~Us in a plexus distant from the organs): In the porasympath!lk systEm. this synapse occurs In g01nglla MGrtheorgilns (or ganglion cells In 01 plexus ne..rthe
Prollate. seminal wsi~. bulbourethral
• Pefermtlal pleliiiS
-+
gland, ejaallmlry duct, penis, urahr.~ vas deferens. epididymiS
• Ute.-ginal plexus
-
Utl!r~ fallopian lube, wgina, -ry
• Velal plexus
-Bladder - lhOI!r, ascending from peMs
• Uretnl plexus
B Organli.Uon of autDnomlc gangllland plexuses In the abdomen and peMs
-+ Mldd~ ind towrer rectum
-
organs). ThiiS, the parasynnp;rtftetlc ganglia are usually loCiltll!d on the target organ or in its wall, where they receive branches from the v.1gal trunb or pelvic splanchnic nerws. NolA!: Even plexuses may contain aggregations of ganglion cells. sometimes very small. An ex.1mple Is tile renal plexus. wltlch contains the renal ganglia {too smarr to be shown rn the drawtng). The autonomic plexuses contain efferent (viK1:!1'Dmon:w) fiber.s as well as numerous afferent (viscerosensory) flbm for both their sympathetic ind parisynnp;rtfteUc components.
309
5.3
Autonomic Innervation of the Liver, Gallbladder, Stomach, Duodenum, Pancreas, and Spleen
~-1
l'llstl!rfor--~
w~tn.nk
vagallnlnk
~brtndl
of;mll!lior viQII tnJnk Pylolfcbr.~no:h
Hep.atlcbranchof an1ltr!orvagal trunk
afpclrtl!rlor vagaltnJnk
A Auton omit rnnervltlon of the lim', g~llblldder, ..t sto1111ch These organs receive their !IYIIIp;lthetksupplyfrom the cellae gangll~. The postsynoptlc ftben course witt! the bra fiChes of the ceiiK trunk. wflile the pre.~ynaplic fibers fonn the splandlnic nervu (mainly the g!Wier splanchnic nerve) ;md synapse with the postsynaptic neuron In the g~ngllon. They receive their ~etTc supply from the vagal trunks (presynaptic fibers). The onb!Jfo( vagal trunk (preponderance of left v.agus nerve fibers) termin~ at the stomach, while the postrrlor va!Ji!l trunk goes on to supply large portions of the Intestine. The anterior ~nd posterior gastric plexuses are distributed to the anterior and posterior walls of the stomadl. The synapse with the postsynaptic parasynnpathetlc neuron occurs In small ganglia located dlrectiy on the Jtomadlwall. Symp;l'lh.Ut ind p;muympathetk t1b4H's p;m along the proper he· p~ artefy to the porta hepalis as the hepMic plexus. After dMdlng at the liver. this plexus also dlstnbutes ftbers to the gallbladder and the intra· and extrahepatic Me dLJCts.
Br~~ndlei afwpeiiOt muen1ltr!c
lllelM to Pi1Kf61S <~ndWocii!I'Aim
B Autonomk fnncrwtfgn of the p~ncRn, duodaun, ~nd spleen These org~ns receive thEir !IYIIIpathetk: supply from the ceiiK gangll~ and supenor mesenterk !Ji!ngllon. The postsynapttc: tlbers pass along the branches oltbe celiac trunk and superior mesenteric artery. Thepne.~ynaptic fibers form the greater and lesser splanchnic nerves. They receive thEir p;1ra!IYIIIp;lthetk suppt, from the vagal trunks (mainly the posterior trunk). Sympethetk 1nd plrii!IYIIIjlltfletk ftben course With the splenic artery to the spl~~n il'l tht- spJenic ~. ;~nd they course with branchH of the splenic artery ~nd superior mesenteric ~rtay to the p~ncreas il'l the ponaeotfc ~- The flbers to the duodenum reach thM organ via the gastrcduodenal artay, pancreaticoduodenal artl!ry, and duodenal branches as part d the supmor mesentrric plexus. The synapse with the second parasympathetic neuron oa:urs In small ganglia located near the organs.
Galbladder - -
C Refem!d patnfrom the llwr,gallbl;tddl!t', ..nd stu mild!
D ldem!d p;llll tram of the pai'ICHiiS
The Head l'Dnes (see p. 146) of the IIIIer, gallbladder, and stomach extend from the right and left hypochondrii!IC 11!!1iocu to the epigil'ltric region. Gallbladder pain may also radiate to the right shoulder. (There are no Heild l'Dnes il'ISOClated with the doodenum and spital.)
The Head l'Dne of the p;~ncreas glrdlel the abdomen. Pain due to p;~n ~c dise;~se rmybe perceived not justin the upper abdomen but also In the back. The ~ntafor Ht-ad zone overlaps with the zones of the liver and stom~dl.
310
Hep.lltlc:brancll of .ilnUrlcr vagal trunk
lo!ftgastllc: artery v.41h
gutlfc plexJJs Hep;ltlc:branc:ll ofpo:stl!rlcr vagal trunk
Spll!ricpll!wJ
!Jeftgrei!l!f splanchnlcnerw
J>,!orlc:br.Jndl of
Llftel1!r splanchnlc:nerw
Ma~nof
hl!j)oii:OdlodeNI
~~~
Oellac91n91a
Hep;ltlc pluus
llrlr!c:llesof g~sttlcplexus
P.anccutlc: piwls on PI nc:reatic:oGlodenllll'tl!ries
on llllltn>-
cment
Sul"!ffcr mes.enllerlc: piwls (on5ul"!ffcr
me5enleric artery)
E lnnl!llllltlan ottfl~ ltwr, gallbl1dder, stD!n.ldl, duodenum, f)llncreat, and spleen ll~rlor view. The less:« omentum has been broadly reiTIOYed, and the greater omen!IJm has been opened. The ascending colon and p;1rt of !he tranMrse colon have been removed. The retroperitoneal fat and connectivt' ti$$ue hi!IS been partially removed to improve the expcnure. The vlsca'al plexuses <~rising from the celiac ganglion mainly iltcom· p;1ny !he irteries iS they pass to their target organs. NotJ!: The Jl!l'lona Is generallysupplled by separatl! ~orfc branches that arise frDm the vagal trunks (p;~rarympathl!l:ic supply) and often nm ini· tlallywlth the hep;~lk branches. Because of this 01rrangement. the function of tile ~orus Is not lmp;~lred when the vagal trunks are dtvlded
distal to the ortgln ofthe~ortcbranches, .ultl~ by ut!ltdll!tprOidmo/ ~(see F). Thus It Is possible to red~~ee acid production by the p;~rlet:al cells In the body and fundus of tile stomach without affecting necessary gastrtn productlon In the antrum and ~oru~ or comproml~· ing the motor function of the Jl!l'lotus. The her and bile dud$ receive their autonomit supply from poras)'mpathftlc hepatic branches that join the sympothetk flbers In !he hep;~lk plexus. The hepatkp/elaJs accompanies the proper hepatic artery to the IIWI and gliii!S off branches that supply the gallbladder and biliary tract. The spleen and pa~ receive autonomidiber5 frDm the splenic and p;~ncre.rtlc plexuse5. The duodenum derives p;1rt oflts supply fNm the superior mese~rk ganglion and superior mese~rtc plexus.
Heprtfcbn~nc:ll
cf posterior w;altTunk Hep;ltltblllnch
ohntcrlor ~~;~l}lltTunk
Pylolfc bran ell ofposterlor vagaltTunk
11-.::.....-+--
Anlerfor gamic plexJJI
F Se!Kttw pi'OIIdmal YiiQDtclmy
lmpulse5 from the vagus nerve stlmulatl! the p~uctfon ofHCI (hydrochloric adic). Th~JS, a selective proximal vagotomy may be o;onsidered for the treatment of ga51Jfc hype!'addity that Is A!{rc!ctory to m~l tn!otmel!t. This Is an operation In which the vag liS flbers that stimulate the acld·produdng p;1rletal cells (mainly In the gastric body and fundus) ~re transected on the stomach w;rll, at a sin! which is p;~st the origin of the pyloric branche5 from the vagal trunks. The pylork branches are left Into~ ct. ensuring the maintenance of nom1al pyloric function.
311
Abdomen and Nris - - 5. Aulunomlc Nfnous Symm
5.4
Autonomic Innervation of the Intestine: Distribution of the Superior Mesenteric Plexus
____ s...• ~
tll2fllne ---Lollje tll2fllne
wl!'blr splonchnlc --l==::t---t-;'O.J norws(fromthlrd
lhJIIU!IIIIfth
lumb.r "'"'IIIa) S..cnl splonchnlc -~;::::::i"'="~~ ..... (from tlrst thrau~thlrd
...,.1 "'"'IIIa)
a Ret.ted Pill" from the sm•ll nd l.,e lntntlne In milny cases the paln usodited with Intestinal diseases Is not locatR~ed pre
P
A Autonomic dlltrtbutton of lfle .,pertor mesenteric plexw While 1 cle1r dlst!rKifon lJ d1111wn ~n the smillllnd l1rge Intestine topogriphkally and hlstologlally, iutDnonnlc lnnerwlfon Is based on the supply of a partlcu Ia r ln!Mtlnal ill!g ment by a partlcu lar plexus, regardleSJ of whether that segment is p;~rt of the small orlarge i~tine. The main distinction to be millie Is whether the lnteslfnal segment Is supplied by the supcrfor or Jn[Mor mesenteric plexus. This plfndple Is Illustrated In the above diagram (see alsop. 314): SympatlleCic lnl'll!rwtfon: • The ]f}lmum, tlf!llm, mum. osandlhg mlon, and the prtlll}mol twDthirdso{thr troRS~~WWcolott ~~supplied bypo.rtsynaptic brancbe:J of the sup6for mesenteric ganglion Y11 the superior mesenteric plexus, whldl Is distributed to the w rfous Intestinal segments along the
brandles of th1t supertor mesentltrlc artery. • Similarly, the disriJI third of rM fi'IIII.IVfiV mlon, thlt dtsanding mlon, sigmoid colon, and uppl!l' rM:um are lnnerwted by postsynap· lfc brilnches of the /ri(trlof melll!nterk gil ngllon i nd the assodated plexus, whkh Is dlstrlbut»d along the brandlesofthe lnfeltor mesenteric artery (MJe p.l15). • The mldd~ and kNm' rM:um are supplied by the lumbar and Rml s~ndlnlc nerves Ylil the Inferior hypogistrk plexus (the wpply to the three lewis of the redum lsshown on p.314).
312
The superior mesenterit g;~nglion, thtn, provides sym,.dleCic innerw· tlon to the enlfre smillllntest!ne and part of the lilrge Intestine, supplyIng by far the grHter pori!on of the enUre bowel. The p;IRsym,.theCic lnl'll!rwtlan of the small ind large lnteslfne Is ana logous to their synnpathetk lnneMtlon. • The smoU inii!SiiM, mum. ascendittg colon, and pi'DIIimtrl two-thirds of rM trvnswrw colon are supplied by the wgcrllnmlc: and Its br~ndles. • The remillnlng colon and IMitm are lnnerwted by the pelvic splonchn/c ntnti from segments S2-S4 (see p.l14). Some of these nerves have their synapses In ganglion cells within the Inferior hypogastltc plexus and some in ganglion cells an the organ wall. Thus, the vagi I trunk (i.e., el~tmenb of the aanial part of the p;~rasym pathelfc nervous system) pi'DYides p;~r.ymp;llhlllc lnnerwtlon to the enlfre small Intestine ilnd part of the large Intestine, supplying the grHter portion of the enUre bovMI. A sltl! on the transverse colon called the Olnnon-116/Jm point marla thit boundary between the proximal and distal territories of the autonomic neNOUS system.
Anllrlar Vl!lllll'llnk
light~
spl;mcmk n~
~lie bn~nch of postl!!1o ry;agal tnlnk
IJ!ftgemr
splancmknenoe H~cp~
~llcgll'lgll
Splenic plems P)iorlcb~ndl
ohn!Jerlor vagaltnlnk Aorllcmnal !}angton
IJ!ftless«
splancmlc nenoe llenll plex~~s
Supj!rlor muen·
uncgangllcn
Te:stlcular (cwartan) plelw!;
SUpl!t!cr Me$Cnterlcp~
::::::;;...._-~"'----~~~-- Jej..nalandllul
arterfe:s IMth Rljjrt ollie artay -.....;...,--~-+r
wftllalltllnomlc
autcnamlc
plelc!.5es
plellus lies:MX~tc artery -....;..-.......,~
'With ;~utonomlc plellts
C Autxlnomlc dlstrlbutlon of the ~rfor maentelic plelals to the
artefy In the mesentery as the superior ml!lentl!ric plexus. being dis-
lntl!st'lne Anll!!tiorYii!W. The liver has bftn retracted superiorly. and the st&lmach
tributed to the JeJunum, Ileum, cewm (and wnmlfomn .appendix), and the colon as far as the junction of the middle and distil thinds of the transverse colon. Past that point tile bCIWel receives Its sympatlletlc In· nervation from the lnfeltor mesent:erkgangllon (not visible here). PilrJ• ~t«Tc lnnei"'//Uon from lfle jejunum to lfle distal third of the tr~nswne colon Is supplied by the vagal trunk and Its branches. The In· nervation of the remaining colon and rectum i$ deKribed on p. 314.
and pancreaJ hive been part!allyre!MVed. Most of the distal part ofthe transvene colon has~ removed, and ill loops ofsmall Intestine have been reflected toward lfle left side. The post:synaptlc branchl!l of lfle superior mesenterfc ganglion (symP'thdlc 'IUJl~Pir) pass along the branches of lfle superior rna enteric
313
Abdomen and Pelvis - - 5. Autonomic Nervous Systll'm
5.5
Autonomic Innervation of the Intestine: Distribution of the Inferior Mesenteric Plexus and Inferior Hypogastric Plexus
I__ Symj>i!!hetic trunk
I
Po!ll!rior - 1
vogal trunk Greatersplam:hnlc
--+-----!'=~+-,
nerve{T5-T9)
l.essersplilndmlc
-----f-_,~.-..'-.
nerve {TlO-Tll)
Middle rect.l
-
Sympothotlc fibers
-
Pa~padletfcflber-.
Inferior
A Autunomlc distribution of the Inferior mesenteric plexus ~nd Inferior hypogutrtc plexus Nob!: The autonomic innervation of the bowel is not divided anatom-
ically between the small and large intestine. It is best understood in terms of the particular bowel segment that is supplied by a particular plexus (supenor or inferior mesenteric plexus, inferior hypogastric Muscularis ext:erna, longitudinal layer
Serosa
plexus
plexus). Because this unit is concerned mainly with the distribution of the infenor mesenteric plexus and inferior hypogastric plexus (see also C), the regions supplied by these plexuses are highlighted in the above diagram. Further details on the innervation pattern are given on p. 309.
MuSOJiarls externa, circular layer
:·1·
Subserosa!
plelWS
rectal plexus
-~-+'!~ ~H?\b--
SubmUCDSal plelWS
B Organization of the enteric plexus The enteric plexus is the portion of the autonomic nervous system that specifically serves all the organs of the gastrointl?rtinal troct. Located within the wall of the digestive tube (intramural nervous system), it is subject to both sympathetic and parasympathetic influences. Congeni· tal absence of the entenc plexus leads to severe disturbances of gastro· intestinal transit (e.g., Hirschsprung disease). The enteric plexus has ba· sically the same organization throughout the gastrointestinal tract, al· though there is an area in the wall of the lower rectum that is devoid of ganglion cells (see p. 201). Three subsystems are distinguished in the entenc plexus: • Submucosal plexus (Meissner plexus) • Myenteric plexus (Auerbach plexus) • Subserosa! plexus
314
Transw~ ---t-----"""'::-~-=:-..::-~~'T::~::~~
calcn
r.tdde<~ndrl¢t
oollc:-wtth aumncmlc: pluuses hb!nn~
pleJWS
LA!ftcolcal'llry wtthautonomlc plexi4
Descendng oolcn
1nrenor mes
lleoalllc a l1lry v.4th autonomic plexus
lnti!riormes
Asa!ndlng colcn S~lrfpo-
gutllc plellls
Slgnold arteries wtthautonomk: plexi4
Right lrfpo-
gastrlcnenoe Leftlrfpo-
gastric nenoe Supaior n!Cbll plexl4
Brandies of Inferior hypogRfcplexi4 to~lng
calcnarld slgnold calon
C Autxlnomlc distribution ofthe lnleftor mi!St!flterfc pii!XI1'I ;md lnferfor hypogllltrfc pltx'lll to the llclwe4 Antl!tiot view. The jejunum and i1eum hiM! been remOIII!d, le.Mng a short Ileal stump on the cecum. The transverse colon hilS been reflectl!d superlor1y. and the sigmoid colon has been retracted Inferiorly.
Inferior mesenterfc ganglion, 'Which follow the branches of the lnf~ rfor mesenteric arttry .u the Inferior mesenteric plexus. • The middlt ond ~ ~· are supplied by the lumbar and sacr;l splanthnk nerves via the Inferior hypogastric plexus (which follows the visceral branches ofthe Internal lilac artefy).
SymPitflltlc lnnllv.ltlon: • The Cf!Wm, wnnl(onn oppf!Sidbc, asandlng Cl:llon, and prold~MI twol:tlfnds oftlte t:ran.M!I'SI! CDion (pi~ all of the smalllnwti'ne, not Wible here) are .wpplied by po$tfynaptic branches of the .wperior mesen· terre ganglion. • The dfsml third of thf transwne co/oil, desatndlng colon, slgmokl txJ!on, and uppertl!dllm are .wpplled by post:synaplk branches ofthe
P
315
5.6
Autonomic Innervation of the Urinary Organs and Suprarenal Glands
RJuht~
5Piillldlnk nln'l' Rlghtlemer splil lldl nlc nI!Nt' Right suprarenal gland
Aartlcorenal gangh Suprarenal plexus
Renal plexur.
SuP'!r!or~n·
tl!r!cganglion
~
terlc:plexus S)mpa1fleUc trunk.
lumbargangllil
lnfl!lforrnt:lll!nte11tgangllon
Uretl!nl plexus
Te'Jtfoullrplelaa lnfl!lforrnt:lll!ntl!r!cpll!lQIS
lllacplelaa
SUpt!rlor hypo-
9UtJ1e pleaus ~IMk.
Left~
gastrlcn~
s~mlganulla
ltlght~
First U1C1111 neNe.
ven~J~~Iramt~~
9Utrftni!Nt'
R.ectum
-
lnfl!lfor~
gastric plexus
PeMc splandlnk Vetkal plelaa
"'clde rectal plexus (from Inferior hypo!Jistr!C plelaa)
Pnm&fc plelaa
A Dvl!nltf!W of tfle autonomk lniM!f'VItTon of1M Urfnllf'/ 0f91M and ~&~pnren.tl!#andt
Anterior view Into an opened male abdomen and pelvis. The stomach has been largely remO'IIed and pulled slightly lnferlor Yo1th Ute esopha· gus for better exposure. The right lddney has been displaced slightly lat· erally, and the bladder has been straightened ;md retracted to the left The peMs has been sec:tlorled In a coronal plane passing approximately through Ute center of Ute acetilbula. The 01utonomlc lnnew.~tton oftfte urinary organs and suprarenal glands varies according to the location of the spedllc organ: • The lddneys Tn the 11ttr0ptdtoneum aDd porUoru of the upper urt· n01ry tract (prciDIIIIWII ureten) reailll! sympo!ho!lic: fibers initially from the lena-.le
316
• The supl'lrtn~l cortex.,d medullin the retroperttoneum l'eC4!IIIe ~fibers from the greater aDd lessa-splariChnic nen.w. They recdve ~~fibers from the posterior vagal trunk. which pass wiUI Ute tenil plexus to the supratenil glands as the supr01renal plexus. Tbe sympotjlf!tk: autonomk 1nnervatfor1 of the suprarenal medulla is Da!ptional in tilat the supranmal medulla is supplied only by presynaptic S)'IT!patfletlc flben from the suprarenal plexus. These <~X ons directly lnnervilte Ute suprarenal medullary cells (see p.220). At. present. there Is no convincing eW!ence tftat the suprarenal medulla reed- parasympotlldJc Innervation. • Thebl"fllcr,mostofthnbdomlf!llll,.-tandpefwt!;Pilrtoftheureter (ioo the uNthrJ, not shown here) 111 the peMs (see D) l'eC4!IIIe .sympotllettcflbers from !he lumbar and sacral splanchnic nerves, and they fi!CI!ive ~fibers fn:lm tile pelvic splanchnic nervH (S2 -S4). The plexuses are s'-n In D. and tile autonomic innerv.~· ttonoftherec:tumls desa1bed on p.312.
I Autonomic lnnii!IYoltlon of tile lddrtey 1ncl upper uretu
r --::: :==IF'!--
Wrlt~nthnlc net~~t(T12)
Arrtklmbllr 'l'llllr:tuicl'lli'W
The sympathetic fibers from the ~otticorenal ganglia ~nd renal ganglia combine with the parasymp;lt:ttetlc flbers from the posterior Yi· galtrunktoform thermrlpll!lws. which passes to the kldney. Branches from that plexus form the ummrl pl~s. which supplies the ~bdoml· nal (upper) part ofthe ureter. Presynaptic sympathetic tlben form the thoracic splanchnic nerves (not shown here).
S)mp;l1tletlc: trunk
c Refl!md p1tn from tile left lddnty and bllldder Pain associated wlth dlsNses of the kidney and bladder (Inflammation, calculi) may be percellled In these skin areas. Occasionally the pain radiates iniD the groin ("lair\ ID groir\ pain").
Pelvic splilldlnlc nenoes (S2-S4}
Inferior hypo·
9Utlft pltlWS Veslt.ll plsus
D Autonomic lnnerntlon of tile bl1dder 1nd tile 1bdomlrMI1nd pt!Mc p;1rts of tfle ureter
Sympilthetfc flbers from the lumbar ;md sacril splanchnk nerves piSs with the p.arasympathetfc ftben from the peiYic splanchnic nerves to the inll!rior hypoo;jilStric plexus. Branches from that p~exu, are distrib· uted to fomn additional plexuses.lncludlngthevesleilind ureter;ll plex· uses !hit supply the bladder ;md ureter(lts ibdomlnal and pelvic parts). 11lrthe pG'fO.I.YI!lpa!Ml1cftben, the synapse with the postsynaptic neuron is loated entirely in the inferior lrypogastric plexus (or organ w;~ll).
The sympothetlc tlben synapse partly In the Inferior mesenteric gan· gllon ind partly In the lnfer1or hypogilStrfc plexus (see the fibers !hilt continue from the sup«lor hypogistrk plexus ID the Inferior hypogastrk plexus). Non!: With a complete tran,ection of the $pinal cond, the effect of higher CNS centers on the central parasympathetic neurons of S2-S4 (-pellife splanchnic nerves) Is ibollshed. Beciuse the pelvic splanchnic nerves Initiate irMI control micturition, a complete cond leslor1 also Ciuses problem' of bladder control.
317
5.7
Autonomic Innervation of the Male Genitalia
lnfmltmf54!nttric plt."wr.
-~111• ••
lumbar ----llfMI
}-4~::;.....
splanchnic neNei
_ _ _ _ Symp.1thetlctrurir_ ltmbarta"'llla
'F-~~--
lumbirnerws, wntnlraml
~~~~~~--lum~~
trunk
'I. .
Ho=---~"::?:~....:::...~-- lefthypog115!11c:
ni!M!
=---~w=--- fleMcSIIIilldlnlc OI!!VeS
Deferent~~~
plexus
Semlnalwslcle
-----.,~~~~~~i
~...,.-----:rl---- .ne~~or~
nenou
A Overuttw of the autonomk lniM!f'VIItTon of tfle mille genitalII
Opened male pelvis Yii!Wl!!d fnlm the left side. This drawing is a mm· posllt' from many planes of section to st-the three-
318
;nfses predominantly from the pellllc splariChnlc nerves (see B). Sym· pathetic and parasympathetic fibers join to form the in[riicr hY1KJ901if1Tc pkxus. whkh also receives the hypogastric nerves (arise from the dlvl· slon of the superior hypogastric plex.us). The paired Inferior hypogastrk plexuses, wl!ldh giYe origin to the plexuses that supply the urinary organs (see p. 309), then diVIde IJltl) mullfple plexuses !hat lnnervm the genital organs (see C). The innervation of the rectum is described on pp.312;md 314.
Abdomen and Pelvis -
- ~
-
- 5. AutonomicNervous Symm
......
l'lnljmpdwacftbon
C Autanamlc !Merwtlon of the 11111le genital!•
...,......_
,..........., ..._.'111." (IJIIIpllhlllclnd
R.-•uran
l!!lrKt
SVm!ldidc TIO-T11 (leuer•nd
VII IWIII ganglia Ill
• Testis
mtla.ollr pious
• Epididymis
1111 suporlar~
." ' -
• Vlsamnlb1ctlon
18st splinchnlc -) L1-L2(1umb;lrandMcr•l
_,
splanchnic
!liStric ple,.uund Inferior lwogulllc p'-cus ... prostltlc p'-cus lnd toe
• !itlmul. JeCJ'ftlons
• Bulbourethral glands and sen'lnal wslde • Penis (~rtly) • flla.olltlon
Dmmlllll plecus SemiNI vesldt V3l deftrer6 with dofwtntlal piOIAII
Bllddor wl1ll -calpii!,IIS -with pi'IIIUIIc plaus
• vas dertrem
• Conlrlctlon
• Penis, 8'Klllo tiliues
• Eiwdlon
...,...,....,_.netic SZ-S4 (peMc spland1nlc -)
'hw..tur~
jpilrlcplaalll pnllt.lllc plrJua, continuing ID the
awmous na"WS ofth•~nls
B Debills oftr. eutanDmlc llw!I'Uiicln of the l'llllle genlbll1
• The 1 - . y 11a alandt (prclstate. llftllnel Wilde, end b~bo umhral glands) l'eCI!ivl! their aumnomic innervation from the prostalk pleJ~US. whkh br.mches from the lnferlar hypog.utrlc plexus (iilm believed to carry pain flben). • The penis ii lm recelws 1ts autonomic Innervation from br;mches of the prostiitlc ple!Ws and from the cawrnous nerws of the penis (see A).l n both cases the syNpse with the postsym1ptlc neuron occurs In the ganglion cells of the Inferior hypogastrlc plexus. • The VII defl!ftns Is supplied mainly by the deferenllil plaus, whkh iilso branches fi'om the Inferior hypogastrlc pltx~~s and tD .a lesser degift from the ~sticu Ia r plexut th
D Refened pillft from the male gonllds The pain auociated with diseases ofthe testis (e.g., inflammatfon) may
be referred tD thIs skin area. Gonadal pain, like l~stlnal pain, b not perceived at the 1natomlal lociltfon of the organ (referred pain (see p. 146)).
319
5.8
Autonomic Innervation of the Female Genitalia
wmbar---wFi splancmlc nen't'
Rami
---+-."!~
(()mnY,Jnl~~
Lumbosacnl trur*
~~f---...,...-7--
-
PeMcsplandlniC
"------!:=-- - Right middle n!
A OVI!nlttwcltfleau1Dnomltlnnl!f'VIItTonaftflefil!melegenrtaiTa An opened fl!male pehlis vii!M:d fn:lm the left side, with the rectum and wrus reflected. This drawing was composited from multiple planes of section to show the three-dimensional rdat:fonshlps more dearly. The sympot1tet1c fibers for the utenJs, f.alloplan tubes, .and ov.arles arise predomin~ntly from the lem!r, le;!!St. and lumb~r splanchnic nerves. The parosympotftetic flbm arise from the pelvic splanchnic nerves. Nobl!: The fibers that are dl51r1buted to the cw.~ry synapse mainly lr1 Ute renal ganglia because as Ute OYary undergoes Its development.ill de· sa!nt., it carril!.l its autonomic supply fn:lm the abdomen with it. The fi. bers then continue Ofl to the ovarian plexus, wfllch abo recdves flbm from the superior mesenteric plexus. This Is analogous to the lnnerva!Sonoftftetestlsvfatfte renalgangllaandtftesuperfor arid lnferlormesenteri'c plexus arid testicular plex.a In Ute male.
B Rl!faTed p;~tn from the hmille gonilds The palr1 assodated with ovarian diseases {e.g., Inflammation) may pro}ect to tftese slcfn areas and may not be percellled within the organ
itself(see p. 146).
320
Abdomen and Pelvis - - 5. Autonomic Nervous System
Sympathetic trunk
-
Sympathoticfibors Poruympathotlcflbe"
l.essersplandmlc nerve(TlO- Tll)
D Autonomic lnnenllltlon of the female genitalia l'el1phll'81 mune
lsYmi*Mtlc•nd
Tlrget
.,....,..p!lthetlc)
0'11..
Effect
T10-T12
VIa renal ganglia and
• Oval)'
(lesser and least splanchnic nen-es)
superior mesenteric ganglion ID avarian
• Vasoc:onstrlc· lion
• Ull!rus • Faloplan tube • Vagina
• Contraction On uterus, depends on hormone status)
Flntneuron
Cellae ganglia Renal ganglion
Sympathetic
plexus
Superior mesente~c
ganglion lntermesenterfc plexus
L1-L2
VIa superior
(lumbar splanchnic nen-es)
hypogastJfc plexus, hypogastJfc nei'YI!s, and Inferior hypogastnc plexus to uteravaginal plexus
Inferior mesenteric:
• Vagina
• Vasoc:onstric;:-
ganglion Superior hypogastric plexus
lion P•ruymp~theUc:
S2-S4 (pelvic spl;mchnlc nen-es
Inferior hypogastric
• l.Jtl!.rus,
plexus to uteroYaQI-
fallopian tube • Vagina • Clitxxis
nal plexus, continuing to cavernous
nerves of clitoris
Abdominal
tends a considerable distance along the OVo!rian artery in the ovarian suspensory ligament (the ovarian plexus, which arises from the abdominal aortic plexus via the renal ganglia- analogous to the innervation of the testis via the testicular plexus). The uterus, fallopian tube, and vagina receive their autonomic innervation from the inferior hypogastric plexus. The sympathetic portion is derived from the lesser, least. and lumbar splanchnic nerves, which synapse partly in the mesenteric ganglia and partly in the ganglion cells of the inferior hypogastric plexus. The parusympathetic fibers are derived from the pelvic splanchnic nerves (S2-S4), which synapse in the inferior hypogastric plexus or in I on the organ wall. Branches from the inferior hypogastric plexus fonm the prominent uterovaginal plexus (of Frankenhauser) located on both sides of the uterus. The OVo!ry may receive additional autonomic innervation along the fallopian tube from the inferior hypogastric plexus.
• Vasodilation
• Transudation • Erection
Inferior me5en-
aortic plexus
C Autonomic lnnerv.tlon of the female genlblla Because of the developmental descent of the ovary, its nerve supply ex-
)
terlcplexus
lilac plexus Right -t-------:.im~ hype>-
H~k----+- Left
hypogastric
gastrlc
nerve
ni!M!
Right lnferlorhypo-
Llterov;~glnal
gas~cpl"""s
pl"""s
Left Inferior hypogastric plexus
E Overview of the autonomic plexuses In the female pelvis Anterior view. Note the division of the of the superior hypogastric plexus into two hypogastric nerves, which are continuous with bath in(Mor hypogastric pi~ U!if!S. The latter then give off individual visceral plexuses to the rectum, uterus, vagina, and bladder (see p.318 for the vesical plexus). The ovary is supplied chiefly by the OVo!rian plexus, which nuns along the ovarian artery in the ovarian suspensory ligament. Thus, the autonomic supply of the female pelvis corresponds to that in the male, although the plexuses in the female pelvis are more strongly developed due to the very rich nerve supply ofthe uterus.
321
Neurovascular Supply to the Organs: A Schematic Approach Thymus ........................................... 325 Larynx ............................................ 326 Thyroid Gland ..................................... 327 Pharynx ........................................... 328 Esophagus ........................................ 329 Heart ............................................ 330 Pericardium ........................................ 331 Lung and Trachea .................................. 332 Diaphragm ........................................ 333 Liver, Gallbladder, and Spleen ....................... 334 Stomach .......................................... 335 Duodenum and Pancreas ........ .... ....... ... ..... 336 Jejunum and Ileum .. ............ ..... ........ .. ..... 337 Cecum, Vermiform Appendix, Ascending and Transverse Colon ••••......•••••• •••• 338 Descending Colon and Sigmoid Colon ................ 339 Rectum ........................................... 340 Kidney, Ureter, and Adrenal Gland ................... 341 Bladder, Prostate, and Seminal Vesicle ............... 342 Testis, Epididymis, and Vas Deferens ................. 343 Uterus, Fallopian Tube, and Vagina ................... 344 Fallopian Tube and Ovary ........................... 345
NeuroWJSCUiar Supply to the Organs - - How to Use this Chapter
How to Use this Chapter
Each of the sections In this chapter reviews the neurovascular supply to an organ or group of organs In a schematlzed form. The following subgroups are distinguished In the diagrams: • • • •
Arterial supply (red) Venous drainage (blue) lymphatic drainage (green) Innervation (yellow)
The sc:hem.tlcs can be used In various ways:
• Reviewing for a test: The student can quickly obtain a basic grasp of neurovascular structures and pathways. • Looking up a specific structure: The diagrams make It easy to locate and Identify a particular neurovascular supply. • Understanding compii!X anatomy by appreciating the basic neurovascular supply to an organ in the diagrams and then referring back to the more compii!X anatomical relationships shown in earlier chapters. Points to keep in mind when using the schematics: • They reflect a simplified, idealized view. • Topographical anatomy is ignored, and the structures are not drawn to scale. • Organs that are in close proximity to each other but are supplied by different groups of neurovascular structures are shown In separate diagrams. • By and large, variants are disregarded. • In cases where the neurovascular supply is bilaterally symmetrical, only one side is shown.
324
1.1
Thymus
1
Right brac:Ho-
lntlelll;ll tllontdt art«y
upltallcw!n
1
~cbranches
)
\
Lymph nodes
Junction of right slbd;Man
Juncacn oflefhubcl;nllan
and lnll!n1al Jugl.far veins
and lntmi;IIJugLfarwns
lf.lgusnei'WS
t
t
ltlghtbroncho-
lo!ftbroncho-
Superior, Inferior,
medlaltlnal trunk
mlddlecervk:al
medlaltlnal tn.nk
y
Br.acllloc:l!jlhatcl)lmph nodes
ganglia
l
\ 325
Larynx
1.2
Ydns
SUperiOr l~ryngeal ~rury
\ S~U!yn)ld
ull!ry
\
i
lnfmar laryngml arb!ry
t
Ellt«nalarotld
ar«ry
t
f
~
ln!l!r!or thjirdd
an>lld~
Left a.mmon
t
a.mmon
~·~l-. arb!ry
J
lnlnk
cymphnodes
tnJnk
t Left slbd;Man arb!ry
Brattlloaeph.lllc
t_
t.eft~l
Aaltlc: ardl
_]
allltid<~rb!ry
l ·--=ry lnneMitTon
Sympalhetrc trunk
Donalwgal
Nucleus ;mblguus
nucleus
AleGiment
larynge.al rw:rve
t \._.
326
-· -· -· -·-
Thyroid Gland
1.3
£mmill (ill'ltld
.w.y
t
t ~
t.elt lnfa!or
lllmmcn
thyn)ld ar18y
CNGtkl artuy
t Left~C
trunk
t
l
Aortic ln:ll
Lymph nodes
lnneiWUan
!
Junctfoncfslbd;Man and 'i!ttmal Jugular wins
327
Nftlrot1Q«t~ltJr SUpply
1.4
mtiM! OfJGns - -
Plu:nymc
Pharynx•
Tonsillar
artery
I Facial artery
l t
Right e~~mmon
anltfdartery
Right lnti!INI JLI!JIIA'Win
t
l
Left subdoMan
Rlghtbrac:h~
artl!ry
a.phaUcw!n
t_
Lymph node$
lnncrwtlon
l
SUper!orJinfmor
dflep lmtal c:
Jugu~A"tnlnk
l Junction ofJubdiMin and lnb!mal)ugularwlns
• Po.!;terior view
328
1.5
Esophagus
-
lh)'ro~ul
tt\Jnk
l
~{
£$0phageal
branchei
lnffi1cr~lcl
~or
arttry
~ldveln
._1
~{
t -.......... E$opllageal / veins
~---Azygos win
'---•
l
Hem~UygMwln
- - - - • £$0phagtQivefns
~
~{
Lymph nodi!$
lnneMUon Junction of11ghtsubc:I;Man junction oflelt subdMan .and lntmlaljugularwfns and~ )lglllariii!IM
f
/<
I
Thoradc ganglia
2-4
L
329
lftui"GWSCUiorSupply to the Orgons - - Heart
1.6
Heart
tiJght
mlum
Cn:umfle><
Portorlor lnteMntrtcullr bnnch
brond!
1.J
.............. lrond~nol
trunk
f llrac:Hoaplgllc lymph nod.., tr.Jdleobronchlall)'mph nodes
51,_.•1
node
330
AtrlcMntrlculor node
Neui'OWSCUiar SUpplyfD the Organs - - PMcGrdlum
1.7
Pericardium
Subc:lwlil'laI'll!ry
l
t
Inti!mal
lntl!mal
tllaradc arury
tlloradclldn
t
l
1'8fc.;njlaa)-
phrenlcwln
Inn l!f'\IIIUan
Lymph nodes
Spnala:u~ ~((3)-4-(Sl
~~as~n..r
lnllk
t
t
hr.ammallymph nades
Ctn!CAII pltlWS
t
t
Pn!per!c.;nl lal lymph nodes
!..1tl!nl pencardlal
( ~~·~M )
l)mphnodK
)
331
1.8
Lung and Trachea
Right llrtUft'l
~
t
t
Pulmo111ry tnmk
PLI.._y
Supettor~~
t!Wik
~
~ IUghtJiolt pum onory 1rte1y
t
Azygoswnl
llrond'liol brindle>
\·9-llrondllal ......
, _.... ~
...,•••, . . . -
j111ctlcn ofnahulbdi~Un Junction ofleftsubclillllln and~ugLiarwlns
and-...l)lgubrwns
t
lnnen.6on
I'
RlghtJirftb!'lnchomedleUMIINnk
t t
light vagusnerw
Plmndwlllymph nodes
t t
~
SUpe~/lnfwiorl!'ldwobronchloll)mph nodes
y
Thorode !JIII!il113- 4
\"'
Pulmonary br.-.dlel
LumbriNnk lharOidc
O..rt
332
1.9
Diaphragm
Brachloaphallcw!n
Mrtlc+
..
t
_______ ..,.
,. Thontdt ,.· IOI'Ill
SUpufor ph~nlcwfns
lnferiorwnat
In nef'\liltkln
Lymph nodes )unc:tfonofrlght subd!MIIn a'ld lntl!mll )lgullrwfns
)unc:tfonofleft nbdiManand ln1:1mal]ugl.farwils
t
t
lllght
~
br
bronchomed;~.Sttn~l
trunk
trunk
'\/
SUpuforphrenlc lymph nod~
Scllnalc:ord segmentsC(l)-4-(5)
il H
1
Ql'lllalplexus
Right/left
ph~niCM'I/e
SUbc!Min-
-
1
~
phren'lc:neM!
Spl~loonl
st9""tnts no-n2 wmb.utrunk
+
lntlrcostlll nerws 10-11. subccstalnerve
-·· Sensoryln-on
333
1.1 0
Liver, Gallbladder, and Spleen
Arlllrtet
veins
Abcklm.-.il •orta
I
ILftgamlc
~
,.,--
-.y
Celllc lnlnk
l ........_
i
Sploric•IUfy
Comrnon
Hopotlcwlns
htplllcirtfty
C,Ucwln
dMct
t
Modi1111Unol
lymphnodu
Olll:tml
d!yl
\
~~ndleuer
~
v.t•ltnonlls
1
1-....ltrulic
,dJ.i r•""'
334
l
nodor
Celloc lymph nodes
~llwough
~-
•planc:Mic n,_ Spllnk lyrrc)h _ _ ,
\
I
----
..... ,...._
'» 11t'lllllc
'lllcncX
1
lnfwior ~win
lnn.wll811
Lymph--
/
Supedor
rnaentlltc wn
· ------- ~
f-
Golac
gangIa
\
Hepftkbra~
/
\
Splenic
plexus
1.11
Stomach
-
Abdominal
- - - - + Splenkarury
Cammon
/
I
!llortgastric
Right~
omeltilwln
Lymph nodes
Inn l!f'\IIIUan
GJUter and lesser spllnctlnlc neNeS
Cellae ganglla
335
1.12
Duodenum and Pancreas
Abdomlul ao~
Splenic 1rllry - - -
SL.pel1or
_.1.._____
___
Splonlc....tn
_j
meoenlllfcWfn Pai'IO'eatlcw'hs
5uponar
m....m.rtc.mry
/ ...___ _ _ _ _ __
lnftrtor~.-b-
Gioo!Oflll•rtsy
Thcnclcdua
. . .. , , , . tk
t
-rlor
vogoltrunk
J
S~or
l
'--
3l6
m-*rkplews s..,enorJlnfertar -• ponciUIIalduodenol ~ph nodes
t
NeurowscularSUpplyfD the Organs - - }f1unum and Ileum
1.13
jejunum and Ileum
Abdamlrtal aorta
Lymph nodes
lnnef'\IIIUan "--;ii. .IIOitk
l f l
Clltl!ma dl)4t
c:.remr m
~ser
splanchnkne~"<~U
lnb!stl nal trunks
Supo!ffar maentltrtc:
lymph nodes
l
337
1.14
Cecum, Vermifonn Appendix, Ascending and Transverse Colon
Lymph nodes 1111J!!tfnal IN!b
t
338
-
Inn l!f'\IIIUan Thontdt duct
......
~
Neurot~t~sculGr Supply to rite Ol'gtlns
1.15
- - Descmd'ng Colon anti Sigmoid CIJion
Descending Colon and Sigmoid Colon
-
Abdamlrtal
":'
-~- Splenlcw!n
1 ' '
Lymph nodes
lniH!f'\IIIUan 051J!ma
lnte!tlnal ,...,.-
tnlnb
d!)il
-
Thoradcduct
-.........
....____....... Gremr~ndleuer
splarlehnlc nonH
~ Superior me"Hrarft ganglion
lll~r
splarlehnlt-..__ _ _ _ _ _ _ PtMcsplariChnlc Mei'YK
339
Neui'Oti'Qscultlr Supply to tlu! OrgQns - - R«tvm
1.16
Rectum
/
\
lnferiorm~teric Ullery
l'ortll\'eln
I SpiMlc\'eln
/
Commanllac
I
rnferfa r mesent!!rlc vein
-ry
\
I I /I
Common
/
Supencrrectllwtn
Ollcwh
lnlanllllacwln
flU dele rect.1l\'elns
lnlli!I"Viitron Thor11dc duct
t.eft/lntmnedlalle/ _ 11ght lumb.lr lymph node.s
t Commonllac lymph nodes
t
omem.a chyt
-
Left lumbar lymph nodes
t rnferfcrmesenterlc lymph nodes
t
t
lntm!alllac lyn'Cih nodes
Superior m:l31 lymph nodes
IJJmbar
splandlnlcN!r\'rS
'\ rnferfor me:sen12r1c 91ngllcn
~ ~~~~+-------------~ plour.
\ :>--r
l 340
NturotltiSGIIGr Supply to the Ol'gtlns - - Kidney. C/J"eM; GndSUprtll'f!IHII Cltlnd
1.17
Kidney, Ureter, and Suprarenal Gland
-
Abdominal
_ _ _ _ lnftrfarplnnlc ~ltl!ly
1
SUpef!CI'sUPI
artelles
·--~~·\
j
lnferlarsupn~~nal lll'tl!l'y
t Uretl!nl
br.1111d!es
Lymph nodes
lnnerwtklll "'........lk Cl!;temad\)41
f
Left lumbar trunk
t
l
)
Aartmm ganglia
\
Renalplelu
' - - - - - " " " ' - - PeMcsplanchnlc NrVKS2-S4
341
Neui'Oti'Qscultlr Supply to tlu! OrgQns - - Bllldftr. Prostcrb!, ondSeminal Veflde
1.18
Bladder, Prostate, and Seminal Vesicle
Ylelns S~wnaava
rnfemr~~enaarn
I
Common lhc: .mry
\
Azygos/
Common
hemi'D)'!IOS win
lilac win
I
\
Asaendtlg lumbar wins
rntemallrK\'tln
\
'
Vertl!br.ll wnousplexus
VMblwfn.s
t
Inferior -ialar18'y
)
~¥mph nodes
lnr~ei'Witl'on
lhorulc duct
s,mptlhtlk
t
Pl.....~
ammu:!lyll UJ~r
I \ Rlglt .and left
~ ~~.
h.mbartrunk
t
t
tlfertor
splanc!lnlc- -~g;Jr'!JIOn
hypog;Jstrfc plexus
Rlghtllnttrmedlte/ left lumbw lyn'Cih node
l
\ Common lilac lymph nodK
'
l:mrnai/Tntlemlllllac lymph nodes
~ral-lal
~node
·~
(-~·Ve$ial _./ plel
......--"
--........ -
Prt<~eJ;tcaf
retn:l\ole$lcallyn'flh nodei
342
~
plexus
Pmllc: splllndl nrc neM:SS2-S4
1.19
Testis, Epididymis, and Vas Deferens
lnftrforwna c.w.a
Abdominal aorta
/
Common tllaca!Ury
1
ln!lem.ll1 lac lll1>!l'y
1
Te:stlc:Uarartl!ry
Umbilical artery
Right
tl!slfcularwln
l
l
l>.lmplnlfonn pltiUIS
1
left
~nodes
llnnerVIUon Thontdt duel
i i
IA!It h.mbartn.nk
i
....,.,.pdwtk
"'.......lie Cell;lc~la
\
eel lac plelcus
(/
\
lntl!mlesenle'lc:
plexur.
Testlwlilr piellus
""-I~ ~stttcplexui
IJJmbar!landlnlc nerwsTU-ll/2
~
Pdlllcsplandlnlc -s2-S4
343
Neui'Oti'Qscultlr Supply to tlu! OrgQns - -
tnwvs. Fallopian 'lllbto, t1nd VcrgiM
1.20 Uterus, Fallopian Tube, and Vagina
-
Abdominal
I
\
Comnan tltacwt'n
\
tnumal tltac artery
I
tntemal1tacveln
- - - - VollglnalbranchH
~nodes
In r~el'WIII'on
Thar.adc duct
Rlghtklmbllr
tn.nk
t Rlghtlumbar lyn'9h nodes
-
t Clltl!ma
clftlt
t
-
tnurmedtateklmbar lymph no6es
'-...._
t
/
IJ!ftlumN' trunk
t IJ!ftlumb;r lymph nodes
+=====::---...
Commontlllc lymph no6es •
tnumaltllac lymph nodH
\I
-Pllr.I!Ub!t!nelymph node'! / Exb!millllac lymph nodes
t
'-~~:t.~ltngllna
r 344
lymph nodes
'
tnfl!rla r ITW!HI1b!lfc pltlW s
1.21
Fallopian Tube and Ovary
Olmmon lllacal1ery
Or.lrtan al1ery
l
ln11!mal Iliac al1ery
Right owrtanwln
IJ!ft ov.v!an\'eln
\
'
Or.lrtan
0\lartan
wnausplems
\lmOUSplela.s
rfght
TUbal bra nell
~nodes
lrii'II!I"'//Uon Tllal'lldc duct
I O'stl!ma~l
I wmb.lrtrunk
I wmbolrno6e.s
«h
.........
c-·--.... ~llldlemr
lslt
_/"
splanctlnlc nerve
l
lten;llplexus
~or
SUpefor
w;altrunk
ml!54!nteric
ganglion
!
SUperior metj!ntl!rft pi~
0\larta!plexus /
~~ NY!c:splllncllnlc nen'e'SS2-S4
345
Appendix List of References ••••••••....••••••••.....••••••••• 349
Subjec;t Index .•••••••••••••••••••••••.....••••••••• 351
List of References
Agur, A.M. R.: Grant's Anatomle. Atlas und Lehrbuch. Enke, Stuttgart
Moore, K., T. Persaud: Embryologle, 4.Aufl. Schattauer, Stuttgart 1996
1999
Anschutz, F.: Die korperllche Untersuchung, 3. Aufl. Springer, Heidelberg 1!178 Bahr, M., M. Frotscher: Duus' Neurologisch-topische Diagnostik, 8.Auf1. Thieme, Stuttgart 2003 Becker, W., H. H. Naumann, C. R. pfaltz: Hals-Nasen-Ohren-Hellkunde, 2. Aufl. Thieme, Stuttgart 1983 Berghaus, A., G. Rettinger, G. Bohme: Hals-Nasen-Ohren-Hellkunde, Hlppokrates, Stuttgart 1996 Block, B., P. N. Meier, M.P. Manns: L.ehratlas der Gastroskopie. Thieme, Stuttgart 1997 Block, B., G. Schachschal, H. Schmidt: Der Gastroskople-Trainer. Thieme, Stuttgart 2003 Dauber, W.: Feneis' Bild-L.exikon derAnatomie, 9.Aufl. Thieme, Stuttgart2005 Feneis, H., W. Dauber: Anatomisches Bildwiirterbuch, 8. Aufl. Thieme, Stuttgart 1999 F1achskamp, F.: Kursbuch Echokardiographie, 2.Aufl. Thieme, Stuttgart2004 Fiildi, M., S. Kubik: L.ehrbuch der Lymphologie fiir Mediziner und Physiotherapeuten. G. Fischer, Stuttgart 1989 Frick, H., H. Leonhardt, D. Starck: Allgemeine und spezielle Anatomie. Taschenlehrbuch der gesamten Anatomie, Bd.1 und 2, 4. Aufl. Thieme, Stuttgart 1992 Fritsch, H., W. KOhnel: Taschenatlas der Anatomie, Bd. 2, 7. Aufl. Thieme, Stuttgart 2001 Graumann, W., D. v. Keyserlingk, D. Sasse: Taschenbuch der Anatomie. G. Fischer, Stuttgart 19!}4 Hegglin, ].: Chinurgische Untersuchung. Thieme, Stuttgart 1976 Heinecker, R.: EKG in Klinik und Praxis. Thieme, Stuttgart 1!175 Kahle, W., M. Frotscher: Taschenatlas der Anatomie, Bd.1, Thieme, Stuttgart 2001 Klinke, R., S. Silbemagl: Lehrbuch der Physiologie, 3.Aufl. Thieme, Stuttgart 2001 Lippert, H., R. Pabst: Arterial Variations in Man. Bergmann, Miinchen 1985 Loeweneck, H.: Diagnostische Anatomie. Springer, Berlin 1981 LOIImann-Rauch, R. : Histologie. Thieme, Stuttgart 2003
Netter, F. H.: Farbatlanten der Medlzin. Thieme, Stuttgart 1983-1 !1!15 Platzer, W.: Tasch enatlas der Anatomie, Bd. 1, Thieme, Stuttgart 1999 Platzer, W.: Atlas der topographischen Anatomie. Thieme, Stuttgart 1982 Probst, R., G.Grevers, H. fro: Hals-Nasen-Ohren-Hellkunde. Thieme, Stuttgart 2000 Rauber/Kopsch: Anatomie des Mensch en, Bd. 1-4, Thieme, Stuttgart. Bd. 1.,2.Auf1.: 1997, Bd.2 u.3: 1987, Bd.4: 1988 Rohen, j. W.: Topographische Anatomle, 10. Aufl. Schattauer, Stuttgart 2000 Romer, A. S., T.S. Parson: Vergleichende Anatomie der Wirbettiere, 5. Aufl. Paul Parey, Hamburg und Berlin 1983 Sadler, T. W.: Medizinische Embryologie, 10. Aufl. Thieme, Stuttgart 2003 Schiinke, M.: Funktionelle Anatomie - Topographie und Funktion des Bewegungssystems. Thieme, Stuttgart 2000 Schumacher, G.-H., G. Aumiiller: Topographische Anatomie des Menschen, 6. Aufl. G. Fischer 1994 Schumpelick, V., N. Bleese, U. Mommsen: Chirurgie, 4. Aufl. Enke, Stuttgart1999 Silbemagl, S., A. Despopoulos: Taschenatlas der Physiologie, 6.Aufl. Thieme, Stuttgart 2003 Stelzner, F.: Chirurgie an viszeralen Abschlul!systemen. Thieme, Stuttgart1998 Stelzner, F.: Der Verschlug der term ina len Speiseriihre. Deutsch. Med. Wochensch. 93 (1 968), 1679-1 685 Strohmeyer, G., W. Dolle: Osophagusvarizen: Bedeutung, Ursa chen und Behandlung. Med. Klein. 58 (1 963), 1649-1653 Tiedemann, K.: Anatomy of the head and neck. Verlag Chemie, Weinheim 1993 Tillmann, B.: Farbatlas der Anatomie Zahnmedizin- Humanmedizin. Thieme, Stuttgart 1997 Thurn, P., E. BOcheler: Einfiihrung in die Rontgendiagnostik, 6. Aufl. Thieme, Stuttgart 1979 von Lanz, T., W. Wachsmuth: Praktische Anatomie, Bd. 2, 6. Teil (hrsg. von Loeweneck u. Feifel), Springer, Berlin 1993 von Lanz, T., W. Wachsmuth: Praktische Anatomie, Bd. 1/2: Hals, Springer, Berlin 1955
Masuhr, K. F., M. Neumann: Neurologie, 5. Aufl. Thieme, Stuttgart 2005 Moiler, T. B., E. Reif: Tasch enatlas der Riintgenanatomie, 2.Aufl. Thieme, Stuttgart 1998
349
Subject Index
Anatomical terms not Included In the current T~nnino/ogia Ana!Dmicu are marked with an asterisk(").
A Abdomen - anastomoses, venous 292 - lymphatic trunks 295 - transverse section 166 Abdominal aorta see Aorta. abdominal Abdominal cavity - divisions 152 -layers -- anterior 152 -- middle 152 -- posterior 152 - peritoneal relationships 153, 154 Abdominal layers, organ locations 152 Abdominal levels, organ locations 152 Abdominal pregnancy 254 Abdominal wall, anterior, skin incisions, surgical 151 Abdominal wall, peritoneal relationships 155 Accessory phrenic nerve 146 Acini 217 Acromion 2, 4, 43 Acrosome 259 Action of heart, mechanical 112 Adam'sapple 24 Addison's disease 220 Adituslaryngis (laryngeal inlet) 26,34 Adventitia - of bladder 239 - of esophagus 72, 74 - of trachea 83 - of ureteral wall 231 - of vas deferens 260 Alcock's canal 288 Allergic reaction, bronchial asthma 117 Alpha (A) cells 217 Alveolar epithelial cells -type I 88 - typell118 Alveolus, pulmonary• 86 -lining 88 Ampulla - hepatopancreatic 21 3 - - septated 213 - of duodenum 188 - of fallopian tube 246 -of rectum 198 - of urethra 238 - of vas deferens 256 Anal canal 197, 198 - epithelial regions 1 99
-levels 199 Anastomoses - arterloarterlal, fetal 94 - cavocaval 116, 273, 292 - portosystemic collaterals 75, 95, 11 9, 274, 278, 289, 292 - portocaval collaterals see Anastomes, portosystemlc collaterals - venovenous, fetal 94 -venous - - abdomen 292 - - pelvis 292 Anastomoses, arterial, abdominal 271 Anatomical constrictions of the ureter 173, 222, 233 Androgen production 259 Angina pectoris (chest tightness) 127 - radiating pain 144 Angle of His 75 Angle(s) - inferior scapular, line connecting 58 - of mandible 35 - of sternum 58 Angle, epigastric 92 Anulus/Ring - [anulus] fibrous -- left 107 -- right 107 - [ring) inguinal - - deep 155, 174 - - superficial 155 - [ring) lymphatic, of gastric cardia 135, 298 Ansa - cervicalis 411 -- deep• 48 --- root - - - - Inferior 17, 18 - - - - superior 17, 18 - -- thyroid branch 1II --superficial" 17,44, 49 - of hypoglossal nerve 111 Anteflexion, of the uterus 171, 175,251 Anterior cricothyroid muscle see Muscle, cricothyroid Anterior myocardial Infarction, supra-apical 127 Anterior subcostal incision 151 Anterior surface of heart 100 Anteversion, of the uterus 171, 175,251 Antrum - follicular 253 - gastric, endoscopic appearance 187 - pyloric 183, 184 Anus 198 Aorta - abdominal 162 ff, 114, 173, 1811, 205, 21 1' 221, 223, 232,
262, 264, 266 ff, 270, 272, 284, 286 -- In abdominal transverse section 166 -- location 152 -- projection onto skeleton 263 -- sequence of branches 263 - ascending 10, 61, 65, 77, 1 00, 114 -- projectionontochestwall 114 -branches -- bronchial 114 -- esophageal114 -- pericardiaI 114 -- tracheal 114 - descending 10, 60, 63, 65, 114 - location 115 -- relationship to esophagus 114 -- relationship to trachea 114 - "riding" on left main bronchus 76 -thoracic 63, 79, 114 -- branches bronchial 122 --- esophageal 1111 --- tracheal 122 -- descending part 71 -- hiatus in diaphragm 91 -- relationship to esophagus 72 -ventral 20 Aortic aneurysm 115 - left-sided 27 Aortic arch see Arch, aortic Aortic bifurcation 262 Aortic constriction of esophagus 70 Aortic knob 96 Aortic valve see \t.Jive, aortic Apex - cardiac, see Cardiac apex - of arytenoid cartilage 25 - of bladder 256 - prostatic 257 - pulmonary 59, 79, 80 Apical anterior myocardial Infarction 127 Aponeurosis, stylopharyngeal 40 Appendicitis 194 Appendix (-ces) - epiploic 158, 1 91 - fibrous, of liver 206 - of bladder 242, 246 - of epididymis 242 - of testis 242 - omental 192 -vermiform 172,1110,193, 194 -- Innervation, sympathetic 315 -- position 152 -- - variants 1 95 -- projection onto trunk wall 151 -- wall structure 1 95 Approach - Ischiorectal 1 96
- perineal 196 -sacral 196 - transanal 196 - transperitoneal, to the rectum 196 Arcades 268 Arch - costal see costal margin - iliopectineal 285 - charta (aortic arch) 10, 27, 59, 63, 65, 66, 70, 72, 95, 98, 1 00, 114 --fetal 94 -- radiographic appearance 96, 911 -- relationship to esophagus 70, 72 - of C7 vertebra 54 - of cricoid cartilage 25 -- viewed with laryngeal mirror 29 -of jugular vein 13,46 - palatoglossal 36 - palatopharyngeal 34 Arterioles - glomerular -- afferent 228 -- efferent 228 - penicillar 21 9 - straight 229 Artery (arteries) - abdominal 262 - accompanying the sciatic nerve 2115 -angular 11 -appendicular 194,269 - arcuate 228 -- of kidney 282 - ascending pharyngeal 10, 38 -- tonsillar branches 41 -- variants 38 -azygos, of vagina 285 - basilar 10. 51 - bronchial 120, 1 22 -bulbar -- of pelvis 284 -- of vestibule 245, 284 -carotid --common 10,27,39,46,48, 52, 59,100,114 --- esophageal branches 118 -- external 10, 23, 38, 48 --- branches 10 --- - antErior. variants 4g --- variable position 49 -- Internal 10, 23,38 collateral pathways 11 origin of ascending pharyngeal artery 38 stenosis 11 variable position 49 -cecal -- anterior 194,268.270 -- posterior 268, 270 -cervical
351
A Artery (arteries)
Amry(a~ries),
cetVical --ascending 10,47,48 --deep 10 -- superficial 44 --superior 10 --transverse 10,47,48 occluded 95, 155, 158, 160, 172, 174, 234, 290 patent 95, 155, 175, 232, 284,290 -clitoral --deep 284 -- dorsal 250, 284 -colic --left 162,189.215,225,263. 270 -- middle 1 65, 263, 268, 270 --- anastomoses with left colic artery 271 --right 189,263,268,270,313 - coronary 124 -- balanced distribution 127 -- cardiac plexus 144 -- left 106,108,114 --- branch anterior intervl!ntricular 97, 98,124,126 atrial 124, 126 circumflex 124, 126 intervl!ntricular septal 125,126 lateral 1 24, 126 left marginal 124, 1 26 posterior left ventricular 125,126 --- branches 125 --- distribution 126 -- left coronary dominance 127 -- right 106,108,114,124 --- branch(es) atrial 124 conus 124,126 Interventricular septal 126 nodal ----- atrioventricular 125 ----- sinoatrial 124, 126 posterior Interventricular 126 right marginal 124, 126 right posterolateral 126 --- branches 125 --- distribution 126 -- right coronary dominance 127 -- sympathetic effects 143 - cremasteric 261 - cystic 205, 206, 263, 264, 266, 268 - deep circumflex iliac 262, 272 - diaphragmatic 123 -dorsal -epigastric -- Inferior 160, 172, 232, 261, 262, 272, 284 --- obturator branch 262, 284 --- peritoneal covering 155 --superior 10 - esophageal 1 18 - facial 1 0, 38, 48 -- origin of ascending pharyngeal artery 38
352
- femoral 261, 262 - first lumbar 262 - fourth lumbar 263 -gastric -- left 163. 189. 205. 221. 225, 263,264,266,267,311 --- esophageal branches 118 --- origin from abdominal aorta 265 -- posterior 263. 265, 266 -- right 205, 263, 264 - gastroduodenal 205, 263, 264 -- duodenal branches 263, 266 - gastro-omental 31 1 -- left 205. 263. 264, 266. 268 -- right 205, 263, 265, 267, 268 -gluteal -- Inferior 262, 284 ff, 288 -- superior 232, 262, 284, 288 --- branch ---- deep 285 ---- superficial 285 -hepatic --common 165,205,211,221, 263.264 --- in abdominal transverse section 166 -- proper 161,163,206,208, 211, 221' 263 ff, 268, 274 --- branch left 205, 264, 266, 268 ---- right 205, 206, 265, 266, 268 - Ileal 263, 268, 313 - ileocolic 263. 268, 270, 31 3 -- branch --- colic 268, 270 --- Ileal 268,270 -Iliac -- common 163, 171, 173, 175, 223, 232, 262, 270, 272, 284, 286, 288, 290 --- ureteral branches 280 -- external 1 63, 171, 173, 175, 1 97, 223, 232, 234, 244, 262, 284,286 -- Internal 173, 175, 232, 234, 262, 284, 286, 288, 290 --- anterior trunk 284 --- branches ---- parietal 285 ---- visceral 285 posterior trunk 284 projection onto male pelvis 285 sequence of branches 284 ---- female pelvis 287 --- topographical anatomy 284 - Iliolumbar 262, 284, 286 -- branch iliac 285 --- lumbar 285 --- spinal 285 - Intercostal 62 - - posterior 114 --- bronchial branch 114 - - supreme 10 - Interlobar 228 -- ren;ll 282 - interlobular -- of kidney 228,282 - - of liver 209
- internal thoracic 1 0, 48, 64, 114 -- branches anterior Intercostal 10 mammary 10 mediastinal 1 0 thymic 10 tracheal 122 -- diaphragmatic branches 123 -- passage through diaphragm 91 - jejunal 268, 313 -laryngeal -- Inferior 27 -- superior 1 0, 27. 30, 39, 41, 46 --- passage through thyrohyoid membrane 24 - lingual 10, 48 - llngular 121 -lobar 120 -- inferior pulmonary 121 -- middle 121 -- superior pulmonary 121 - maxillary 1 0 - mesenteric -- inferior 1 63, 173, 223. 232, 262, 270, 272, 280, 286, 288, 290 branches 263, 270 origin 271 projection onto vertebral column 271 supply to rectum 271 --superior 163,180,188,211, 215,221,223, 225,232,262, 268.270, 272, 280.311' 313 anastomosis with inferior pancreatic artery 266 branches 263, 268 location relationship to duodenum 269 relationship to pancreas 269 relationship to renal vein 269 --- origin 269 --- - projection onto vertebral column 151 --- projection onto vertebral column 269 -musculophrenic 10,114,123 - obturator 175, 176, 234, 262, 284, 286, 288, 290 -- branch acetabular 285 anterior 285 posterior 285 pubic 285 - occipital 1 0, 38, SO -- origin of ascending pharyngeal artery 38 -of pancreatic tall 266 - of uterine round ligament 291 -of vas deferens 155, 261, 263, 285,286 - ophthalmic 11 - ovarian 175, 221, 223, 234, 252,262, 272, 280,287, 290 -- branch(es) --- tubal 291 --- ureteral 280 -- left 163
-- right 163 - - variable location 290 - - variants In origin 290 - pancreatic - - dorsal 263. 266 - - great 263, 266 - - inferior 266 - -- anastomosis with superior mesenteric artery 266 - pancreaticoduodenal 311 - - inferior 263, 266 --- branch - --- anterior 266, 268 - --- posterior 266, 268 -- superior
anterior 205, 263, 264, 266, 268 posterior 205, 263, 264, 266,268 - p~rasympathetic effects 307 -penile - - deep 238, 284 -- dorsal 238, 261, 284, 286 - perforating, of pelvis 285 - pericardiacophrenic 1D. 62. 64, 114,123,147 -- course 91 - perineal 284 - phrenic - - inferior 1 15. 123, 221. 262 --- left232, 280 --- right 280 -- superior 114,123,263 - posterior auricular 1 0 - posterior inferior cerebellar 10 - pudendal - - external 261 - - Internal 197, 262, 271, 284, 288 - -- branches - --- in the female 284 ---- In the male 284 - -- branches - --- posterior labial 284 - --- scrotal 284 - --- - posterior 285 - pulmonary 95 - - branches 81 - - division 120 -- fetal 94 -- left 63, 64, 79, 100, 120 - -- projection onto the thorax 121 - - projection onto the thorax 121 -- right 61, 62, 77, 79, 100, 120 - -- projection onto the thorax 121 - - segmental branch 84 -rectal - - inferior 271, 285, 286, 288 -- middle 173, 175,262,271, 284ft, 288 - -- branches - --- prostatic 295 - --- vaginal 285 - - superior 201, 263, 270, 286, 288 - renal 223, 225, 227. 228, 230, 232, 262, 268, 280, 282, 290 - - aberrant 283 - - accessory 283
Bronchial tree B
-- branch -- - anterior 280, 282 -- - posterior 280, 282 -- branches 280 -- - correlation with renal segments 283 -- course 227 -- left 163, 221 -- origin, projection onto vertebral column 151 -- projection onto vertebral column 281 -- right 220 -- ureteral branches 282 -- variants 283 - retroduodenal 263 - sacral -- lateral 232, 262, 284, 287 -- - spinal branches 285 -- median 173, 232, 262, 272, 284, 286, 288, 290 - scapular, dorsal 10 - segmental (pulmonary artery segmental branch) 84, 120 -segmental -- anterior -- - inferior renal 282 -- - superior renal 282 -- Inferior renal 282 -- posterior renal 282 -- renal 230 -- superior renal 282 -- - capsular branches 282 - short gastric 265, 266 - sigmoid 173, 263, 270, 288 - small, meningeal 11 -spinal -- anterior 10 -- posterior 10 -spiral 248 - splenic 163 ff, 189,205,211, 218,221,263,264 -- In abdominal transverse section 166 -- pancreatic branches 266 - sternocleidomastoid 48 - straight 268, 269 -subclavian 10, 27, 39, 47, 48, 59,62,65 -- branches 10 --left114 -- - projection onto chest wall 114 --right 100,114 -- - projection onto chest wall 114 - superficial temporal 10 - supraduodenal 263, 266 - suprarenal -- inferior 220, 223, 227, 232, 262, 280, 283 -- middle 220, 223, 227, 232, 262, 280, 283 -- superior 163, 221, 223, 227, 232, 262, 280 - suprascapular 10, 45, 47, 48 - sympathetic effects 306 - testicular 173,221,258, 261, 263,280 -- ureteral branches 280 -- variants in origin 290 -thyroid
-- ima 10,114 - - inferior 10, 22, 27, 30, 39, 41, 47ff, 114 - -- branches, variations 47 - -- esophageal branches 118 -- superior 10, 22, 27, 38, 46,49 - -- branch(es) - - - - cricothyroid 10, 27 - -- - glandular 1 0 - -- - infrahyoid 10 - -- sternocleidomastoid 10 - umbllrcal 94, 262, 285, 286 - urethral 238, 285 - uterine 245, 262, 287, 290 - - branch(es) helicine 285, 291 ovarian 252, 285, 291 tubal 285, 290 vaginal 285, 287, 290 - - relationship to ureter 291 - - relationship to ureters 246 - vaginal 285, 287, 290 -vertebral 10, 40,48, 54,114 - - branch(es) - -- meningeal 10 --- spinal 10 -- course 11 -vesical -- Inferior 175, 176,234,239, 262, 284 ff, 290 - -- branch(es) - -- - prostatic 285, 286 - -- - vaginal 234 - - superior 155, 175, 234, 263, 285, 286. 290 Arytenoid cartilage see Cartilage, arytenoid Aschoff-Tawara nodes see Node, atrioventricular Ascites277 Aspermia 260 Asthma, bronchial 87, 142 Atlas 24,36 -processes -- spinous 51 -- transverse 51 Atrial appendage -left 97,100,124 - - on radiographs 96 -right 97,100,124 Atrial musculature 102 Atrial septum 104, 107 Atrioventricular bundle 110 Atrioventricular node see Node, atrioventricular Atrioventricularvalve 105,106 - left see Valve, left atrioventricular - rlghtsee Valve, right atrloventricular Atrioventricular valves 106 Atrium -left 61, 65, 72, 77, 95, 99,101, 104 - - arterial supply 126 -- blood flow 113 -- fetal 94 - - myocardium 103 - - on radiographs 96 - - relationship to esophagus 72 - right 65, 95, 99, 101, 1 OS - - arterial supply 126
-- bloodflow 113 -- fetal 94 -- myocardium 103 -- on radiographs 96 Auditory canal, external, development 21 Auerbach plexus 143,314 Auscultation sites for cardiac valves 109 Autotolerance 132 Auxiliary respiratory muscles 92 AV node see Node, atrioventricular Axis 24 Azoospennla 260 Azygos system 116 - relationship to trachea 117
B Back muscles, intrinsic 4 Basal body temperature 249 Basement membrane 83 Beta (B) cells 217 Bicuspid valve see Valve, left atrioventricular Bifurcation - aortic 163,244,262, 270 -- projection onto vertebral column 151 -carotid 49 - tracheal 65, 76, 82 -- projection onto vertebral column 76 Bile duct see Duct, bile, common Blllaryatresla 181 Birth canal 255 Bladder 163, 168, 170, 173, 223, 241,250 - adventitia 237, 239 -apex 233 - arterial supply 291 - attachments 236 - autonomic innervation 316 - body 233, 235, 237 - closure mechanism -- Involuntary 236 -- voluntary 236 - development 242 -female 290 -- location 235 -- peritoneal covering 234 -- relationship to pelvic organs 244 -- topographical anatomy 234 - fundus 233, 235, 237 - gallbladder see Gallbladder - Head zone 317 - innervation 237 -- autonomic 237 -- somatic 237 - Internal structure 237 - location 152 - lymphatic drainage 297, 303 - male 256, 261 -- location 233 -- peritoneal covering 234 -- topographical anatomy 232 - mucosal epithelium 237 - muscular apparatus 236 - muscular coat 237, 239
- muSOIIar dosing mechanism 236 - muscular opening mechanism 236 - opening, Involuntary 236 - parasympathetic effects 307 - peritoneal covering 154, 169, 175,244, 256 - sympathetic effects 306 - venous drainage 286 Bladder aspiration, suprapubic 169,234 Bladder capacity, maximum 236 Bladder catheterization, transurethral, in the male 239 Bladder stone 222 Blastocyst, implantation of 254 Bleeding into pericardia I cavity 67 Blood-thymus barrier 132 Bochdalek triangle 90 Body, carotid 38, 48 Bone resorption by osteoclasts 23 Bone(s) -coccyx 176,200 -hyoid 7, 24, 26,36,42 -- greater horn 20, 24, 33 - ileum, radiographic appearance 203 [sic: should be /llumJ -Ilium 245 - occipital 4 -- basilar part 8 - pelvic 233, 235 -pubis 200 -- Ischiopubic ramus 233, 235, 244,250 - sacrum, radiographic appearanee 203 Border - anterior, of lung 80 - free, of ovary 247, 252 -inferior - - of liver 207 --of lung 80,81 -- ofspleen 219 - lateral, of kidney 227 -medial --of kidney 227 -- of suprarenal gland 220 - mesovarlan, of ovary 247, 252, -.superior -- of scapula, projection onto vertebral column 58 -- ofspleen 219 -- of suprarenal gland 220 Bowman's capsule 228 Bri!linstem lesion, vagus nerve lesion 31 Branchial arches, of lanceletflsh 20 Broad ligament of uterus 246 Bronchi -caliber, regulation of 142 - lymphatic drainage 129, 130, 136 Bronchial arteries 120, 122 Bronchial carcinoma - recurrent laryngeal nerve lesion 31 - sectional Images 83 Bronchial tree 82 - divisions 83 - Innervation, autonomic 142
353
B Bronchial tree
Bronchial tree - lymphatic drainage 12g, 130, 136 -- network, peribronchial 136 - movements. respiratory 93 - parasympathetic effects 143 -parts -- conducting 86 -- respiratory 86 - reconstruction from sectional images 83 - sympathetic effects 143 Bronchial veins 120, 122 Bronchiolus - respiratory 86 -- structure 87 -- vascular tree 89 - terminal 86 Bronchus (bronchi) -lobar 82 -- inferior 79, 122 left 82 --- right 82 --- trunk 82 -- middle 82, 122 --- trunk 62 -- superior 62, 79, 122 --- left 82 --- right 82 -main 60 -- left 61, 63, 65, 66, 70, 72, 76, 82, 114, 120 --- angle at bifurcation 76 --- lymph nodes 131 --- origin 77 -- right 65, 70, 76, 82, 120 --- angle at bifurcation 76 -- wall structure 83 - segmental 65, 84, 86 Brunner glands 189 Bulb -aortic 106, 114 -Inferior, of jugular vein 23 - of penis 238,241 - vestibular 235, 239, 244 Bundle branches, right and left 110 BundleofHis 110 - opening for, In fibrous cardiac skeleton 107 - fascicles 111 Bundle, atrioventricular 11 0 Bursa, omental 154, 164, 182, 204 -access 164 - boundaries 164 - development 179 - In abdominal transverse section 167 - location 164
c Ccells 23 - embryonic origin 21 C loop, duodenal 189 C-ring, tracheal cartilage 83 Calcitonin 21, 23 Canal - anal see Anal canal
354
- cervical 247 - gastric 186 - Inguinal 155 - obturator 285 - pudendal 285 - pyloric 183, 184 - vertebral 166 Canaliculus, biliary 209 Cannon's point 312 Cap cells 88 Capsule - external, of thyroid gland 22 - fat, perirenal 167, 220, 223, 226 - - atrophy 224 - fibrous. renal 226 If, 230. 282 - glomerular --wall -- - Inner 228 -- - outer 228 - Internal, of thyroid gland 22 - prostatic 257 Capsule of thyroid gland, surgical 22 Cardia, gastric 75 Cardia, gastric, lymphatic drainage 298 Cardiac apex 97,100,104,111 - on chest radiograph 96, 98 - projection onto chest wall 114 Cardiac atrium see Atrium Cardiac base see Heart, base Cardiac borders - during expiration 96 - during Inspiration 96 -left 96 -right 96 Cardiac dullness - absolute 99 - on chest percussion 78, 99 - relative 99 Cardiac musculature 67, 101, 102 Cardiac pacemaker, natural see Node, sinoatrial cardiac prominence, embryonic 20 Cardiac tamponade 67 Cardiac valves 106 - auscultation sites 109 - Insufficiency 108 - stenosis 108 -- plus valvular insufficiency 108 Cardiac ventricle see Ventricle, cardiac carina - tracheal 76 -- - epithelium 83 - urethral 250 Carotid bifurcation, ortgln of ascending pharyngeal artery 38 Carotid sheath 2, 10. 12, 19 Carotid siphon 11 Carotid surgery, lesion of superior laryngeal nerve 31 carotid triangle 42, 48 - structures 48 Cartilage rings, tracheal, embryc>nrc origin 20 Cartllage(s) - arytenoid 24, 55, 82 - - pro[es.s
-- - muscular 25, 28 -- - vocal 24, 28
--- - viewed with laryngeal mirror 29 - corniculate 24 - cricoid 24, 26, 36, 82 -- embryonic origin 20 -- relationship to esophagus 70, 73,74 - epiglottic 25, 26, 37, 55 -hyaline 83 -Meckel 20 - of hyoid bone -- greater horn 20, 24, 33 -- lesser horn 20, 24 - thyroid 7, 24, 26, 37, 46, 48, 82 -- embryonic origin 20 -- inferior horn 24 - - superior horn 24 - tracheal 26, 76, 82 -- embryonic origin 20 -- hyaline see cartilage, hyaline Catecholamines 220 Caval-gallbladder line 208 Cavity - extraperltoneal 154 - lnfraglottlc (subglottic space) 26 - laryngeal 26 --- Intermediate (transglottlc space) 26 - pericardia I 61, 67, 77 - peritoneal 153, 154 -- abdominal 153 -- drainage spaces 161 -- part --- infracolic 157 --- supracolic 157 --pelvic 153,168,244 - - posterior wall 160 -- scrotal 258 - pleural 60. 68 - uterine 247 Cecum 172,180,191,192,194 - formation 180 - Innervation, sympathetic 315 - location 152 - lymphatic drainage 296, 301 - on radiographs 203 - projection onto trunk wall 151 - wall structure 195 Cells - centroacinar 217 - dendritic, thymus 132 - myoid, thymus 132 - neuroendocrine, stomach 187 - parafollicular 21, 23 Cellulitis, parapharyngeal 39 Central tendon - of diaphragm 90 - of perineum 169, 170 Central venous lobule 209 Centriole 259 Cerebral blood flow 51 Cervical carcinoma 249 Cervical epithelium 249 - everted 249 Cervical fascia 2 Cervical fistula 21 - complete 21 - incomplete 21 - lateral 21 -median 21 Cervical lymph nodes
-deep 14 - enlarged 14 - palpation 15 - superftclal 14 Cervical region - lateral 42, 49 -- innervation 17 - posterior 42, 50 Cervical sympathetic trunk 19 - interganglionic branches 19 Cervical triangle(s) 42 -lateral 42 - posterior 44, 45 Cervix/Neck -(neck]ofbladder 233.235,237, 256 -uterine 171,177,244,246 -- lymphatic drainage 305 -- part -- - supravaginal 247, 249, 250 -- - vaginal 241, 245, 247, 250 -- -- epithelial changes 249 Chest percussion - cardiac dullness 78, 99 - hepatic dullness 99 - lung sounds 78 Chest tightness see Angina pectoris Chest wall - arterial supply 1 14 - innervation. autDnomic 140 - lymphatic drainage 129, 130 Chief cells 187 Choana 34, 36, 39 Cilia 83 Ciliated epithelium, respiratory 31 Circle of Willis 11 Circulation - high-pressure system 104 - low-pressure system 105 - postnatal 95 - prenatal 94 Cisterna chyll 128, 294, 296, 299, 300 Clavicle 2, 4, 42, 44, 58. 62 Clitoris 241, 243, 250 - autonomic Innervation 321 - function 240 Closure of uterus during pregnancy 248 Coarctation of aorta 115 Collecting lymph nodes 14, 295, 301 Collecting system, lntrarenal, architecture 229 Collecting tubule 229 Colliculus - of arytenoid cartilage 25 - seminal 233, 238, 242, 257 Colloid 23 Colon -ascending 162,180,191,192 -- connection to retroperitoneal veins 278 -- location 1 52 -- lymphatic drainage 301 -- projection onto trunk wall 151 -- radiography 203 -- retroperitonealization 181 - descending 189, 192 -- Innervation, sympathetic 315
DuctjDuctusfVas D
-- location 152 -- lymphatic drainage 301 -- projection onto trunk wall 151 - - radiography 203 -- retroperitonealization 181 - innervation, autonomic 312 - Interior 195 - lymphatic drainage 296 - sigmoid 1 63. 173. 192, 196, 223,245 -- Innervation, sympathetic 315 -- lymphatic drainage 296, 301 -- projection onto trunkwall 151 - Taeniae 192 - tranSVI!rse 162,191,192 -- formation 1 80 -- Innervation, sympathetic 315 -- location 1 52 -- lymphatic drainage 301 -- projection onto trunk wall 151 - - radiography 203 - wall structure 1 95 Colon segments 1 92 Column(s) -anal 198 - renal 228, 230 - vaginal 250 Columnar epitllelium, of colon 195 Complementary spaces, thoracic 91 Conception 254 Congenital anomalies of tile ureter 232 Conjugate - AP diameter of pelvic outlet 255 - diagonal 255 -true 255 -- obstetric 255 Connectl~tlssue
- pararectal 200 - pelvic 168 - in pelvis, columns 176 Constriction - diaphragmatic (laweresophageal constriction) 70 - of thoracic esophagus (middle esophageal constriction) 70 - pharyngoesophageal (upper esophageal constriction) 70 Continence organ 199 - continence -- muscular 199.200 -- vascular 199 -- - arterial supply 201 - effMtors 199 - functional components 200 - hollow organ 199 - innervation 201 - neural control 1 99 - receptors 199 Conus - arteriosus 113
- elasticus 25, 26, 28, 31 Cord(s)/Chorda(e) - [chordae[ tendlnae 104, 107 -umbilical 95 Cord, spermatic 261, 286 - contents 261 - venous dilatation 281
Corniculate cartilage 26, 28, 34, 39,41 Corona radiate 253 Coronary blood flow, disturbances of 127 Coronary sulcus 100,102, 124 Coronary vessels see Arteries, coronary Corpusluteum 249, 253 Corpus/Body - [body] of bladder 256 - [body] of epididymis 259 - [body] of hyoid bone 24 - - embryonic origin 20 - [body] of pancreas 160. 163 ff, 188, 211,214 ff, 218, 225 - [body] of sternum 59, 61 - [body] of stomach 75, 183, 184 - [body] of tongue 36 - [corpus] albicans 253 - [corpus] cavemosum -- of penis 238, 241, 256 --- arterial supply 201 - -- development 242 - [corpus] luteum 249, 253 - [corpus]ofuterus 171,244 - - lymphatic drainage -- surface - -- anterior 250 - - - posterior 246 - [corpus]spongiosum 238,241, 256 - - development 242 Corpuscle, renal 228 Cortex - of ovary 253 - ofsuprarenal gland 220 - renal 227, 228, 230 Costal margin 150, 204 Coverings of testis 258 Cranial nerve IX see Glossopharyngeal nerve Cranial nerve X see Vagus nerve Cranial nerve XI see Accessory nerve Cranial nerve XII see Hypogi0$531 nerve Cranial nerves 18 - association with pharyngeal arches 20 -in the neck 16 Crest/Crista - [ crest]lllac 150 - [crest] urethral 257 - [crista] terminalis 105. 110 Cricoarytenoid and thyroarytenoid muscles 28 Cricoid cartilage see Cartilage, cricoid Cricothyrotomy 30 Cruciform pattern, formed on chest radiograph by pulmonary veins and venae cavae 121 Crus/Branch - [branch]left, of His bundle 110 - - fasicles 111 - [branch] right, of His bundle 110 - [crus]lateral. of diaphragm. aperature 90 - [crus] medial, of diaphragm, aperatures 90
- [crus] of clitoris 239,244 - [crus] of penis 233, 238 Crypts 189,195 Cumulus oophorus 253 Curvatures of stomach - greater 75, 165, 183, 184 - lesser 75, 164, 1113, 184 Curve/Curvature - [curvature] greater, of stomach 75, 165.183.184 - [curvature]lesser, of stomach 75, 164,183,184 - [curve]lnfrapublc, ofuretllra 239 - [curve] prepubic. of urethra 239 Cushing's syndrome 220 Cusp(s) - anterior, of atrioventricular valve -- left 106 -- right 106 - commissural, of left atrioventricular valve 1 07 - posterior, of atrioventricular valve -- left 106 -- right 106 -semilunar -- anterior, of pulmonary valve 106,108 -- left of aortic valve 106. 108 --- of pulmonary valve 106, 108 -- posterior, ofaortlcvalve 106, 108 -- right of aortic valve 106, 108 --- of pulmonary valve 106, 108 - septal, of right atrioventricular valve 106 Cycle, ovarian 249 Cyst -neck 21 -vitelline duct 181 Cystitis 238
D Dcells 187 Danger space 40 Defecation, mechanism of 199 -- control center 199 Dens ohxis 36, 40 Dermatome 16 Descent of testis 258 - Incomplete 259 Development, of gastrointestinal canal 178 Diameter - conjugate 255 - diagonal 255 -oblique -- left 255 -- right 255 - sagittal, of pelvic Inlet plane 255 - transverse -- Interspinous diameter 255 -- of pelvic inlet plane 255 Diaphragm 59, 62, 64, 70, 77, 90, 138,211
- central tendon 91, 138 - costal part 91, 138 - degree of movement 90 - Head zones 146 -hernia 90 - in abdominal transverse section 166 -Innervation 17, 146 - lymphatic drainage 138 - pelvic 233, 234 - position in expiration 90, 92 - position in inspiration 90, 92 - projection -- onto the trunk 90, 114 -site of attachment to liver 61. 77 Diaphragmatic paralysis 146 Diastole 1 03, 108, 112 Diffusion distance, alveolocaplllary 88 Digestive tract. lymphatic drainage 296 Diverticulum - eplphrenlc 73 - parabronchlal 73 - parahiatal 73 - tlloracic 73 Drummond anastomosis 271 Duct/Ductus/Vas - [duct] alveolar 87, 88 - [ducts] bile --common 161,163,179,188, 205,206,212, 221,264 --extrahepatic 210,212,213 -- Intrahepatic 21 0 -- lymphatic drainage 299 -- relationship to adjacent organs 211 -- sphincter 213 - [duct] cystic 206. 212 - [duct] ejaculatory 238, 241, 256,260 -- development 242 -- termination 238, 257 - [duct] epididymal 259 -- development 242 - [duct] excretory 260 - [duct] hepatic 179,208,225 -- common 211 , 21 2 --left 207,211,212 -- right 206,211,212 - [duct] interlobular bile 209 - [duct] MDIIerlan 242 - [duct] pancreatic 179, 211. 216 -- accessory 179, 188. 21 2, 216 -- major --- course 216 --- termination 179 -- sphincter 213 --variants 216 - [duct] paraurethral 243 - [duct] parotid 40 - [duct] right lymphatic 14, 23, 129 - [duct] thoracic 14, 23, 48, 63, 99, 129, 130, 295, 296,300 -- passage through diaphragm 91 - [duct] thyroglossal 21 Duct{DuctJJsfVas - [duct] vitelline 180 -- formlngaflbrouscord 181
355
D DuctfDuctusjVas
-- obliterated 180 -- remnants 181 - [ ductlJs] arteriosus 94 -- obliterated 95 -- occlusion --- artificial 95 - -- functional 95 -- patent 95 - [ductlJs] venosus 94 -- obliterated 95 - [vas] deferens 172, 176, 232, 2311,241.256, 258, 260,286, 319 -- autonomic Innervation 319 -- development 242 -- function 240 -- lymphatic drainage 304 -- musculature 260 -- relationship to vessels 261 -- right Hi9, 1 73 -- wall structlJre 260 Ductules/Tubules - [ductlJies] efferent, of testis 259 -- development 242 - [ductlJies] of p=tate 238 - [tubules] seminifl!rous -- convoluted 259 -- straight 259 Duodenalatresla 181 Duodenal stenosis 181 Duodenal villi 189 Duodenum 163, 164, 1 83, 1114, 1811,205,212, 216, 264 - arterial supply 266 - (·shaped curve 215 - development 179 - duct orifices 188 - endoscopic view 189 -lnsltu 189 - innervation, autonomic 31 0 - location 152 - lymphatic drainage 296, 299 -part --ascending 188.211,215,225 -- descending 160, 165, 188, 211, 21 5, 225, 226 --- projection onto vertebral column 151 -- horlzontill 1 60, 225 -- inferior 188,215 --superior 160,188,215,225 -parts 1118 - peritoneal relationships 161 - projection -- onto trunk wall 151 -- onto vertebral column 188 - relationship to superior mesenterlc artery 269 - retroperltoneallzatlon 1 79 - venous drainage 276 - wall structure 188 -- histological 189 Dyspnea (respiratory distress) 87 - after thyroid surgery 23
E ECG (electrocardiography) 11 1 Echocardiography, transesophageal 98
356
Ectoderm 21 Eindhoven triangle 1 11 Ejaculate 260 Ejaculation 260 Electrocardiography 111 - esophageal 98 End arteries 124 End of aortic arch, projection onto vertebral mlumn 58 Endocarditis 108 Endocardium 101 - lymphatic drainage 139 Endometrium 247, 248 - blastocyst Implantation 254 - cyclical changes 249 -layer -- basal 2411 -- compact 248 -- functional 248 - - spongy 2411 Epicardium 67, 97, 101 - lymphatic drainage 139 Epididymis 238,241,258, 261, 319 - autonomic Innervation 319 - dimensions 259 - function 240 - left, lymphatic drainage 297 - lymphatic drainage 304 - right, lymphatic drainage 297 - structlJre 259 Epigastrium 150 Epiglottic cartilage see Cartilage, epiglottic Epiglottis 24, 26, 30. 34, 36. 39. 41 - removal, operative 25 - viewed with laryngeal mirror 29 Epinephrine 220 Epithelium - bronchial 83 - peritoneal 1 57 - tracheal 83 Epithelium of thyroid gland 23 - secretory state 23 - storage state 23 Epoophoron 242, 246 Erb's point 17,44 Esophageal closure 75 - ilnglomusculilr 75 Esophageal constriction -lower 70 -middle 70 -upper 70 Esophageal curves 70 Esophageal diverticulum 73 Esophageal inlet 70, 74 Esophageal mucosa 74 - Inflammation 75 Esophageal musculature 73 - functional arrangement 73 Esophageal narrowing due to atrial enlargement 98 Esophageal outlet 75 Esophageal peristalsis 73 Esophageal varices 11 9, 293 Esophageal wall. plexus. autonomlc 143 Esophagitis 75 Esophagogastric junction 75 Esophagus 26, 30, 62, 65, 70, 163, 183,211,262
- aortic mnstriction 70 -arteries 118 - circular muscle ftbers 35, 73, 74 -divisions 70 - Heild zone 143 - hiatus, in diaphragm 70, 75 -in situ 71 - Innervation, autonomic 142 - location 70, 72 -- relationship to aorta 1 14 - lymphatic drainage 129, 130, 134 --caudad 134 -- cephalad 134 -- plexus --- mucosal 134 --- muscular 134 - parasympathetic eff1!cts 143 -part -- abdominal 70, 73 --- arterial supply 118 --- lymphatic drainage 134 --- venousdralnage 118 -- cervical 61, 70, 72, 77 --- arterial supply 1111 --- lymphatic drainage 134 --- venousdrainage 118 -- thoracic 61, 66, 70, 72, 77, 79 --- arterial supply 1111 --- lymphatic drainage 134 --- venousdrainage 118 - plexus, fonmation of autonomic 143 - projection onto thoracic skeleton 70 - sympathetic effects 143 -veins 118 - wall structure 73 -- histological 74 Estrogens 249 Expiration 92 - active respiratory muscles 92 - change In cardiac borders 96 Extl!mal occipital protuberance 2, 4,43
F Falx, inguinal 155 Fascia -cervical 2 -- layer 61 investing. of cervical fascia 2, 22, 40, 44, 46 pretracheal, of cervical fascia 2, 22, 44, 46, 61 prevertebral, of cervical fascia 2, 22, 40. 44 - cremasteric 258, 261 - deep penile 238 - diaphragmatic, fusion with fibrous pericardium 64, 67 - inferior diaphragmatic. of pelvis 168,198 - obturator 245 -pelvic 168 -- parletal168, 233, 235 -- visceral 168,233, 235,237, 239 -penile
-- deep256 - - superficial 256 - perineal 235, 239 - - superficial 245 - pharyngobasilar 33, 38 - rectoprostiltic 168, 256 - rectovaginal 1 68 -renal 226 -spermatic - - external 258, 261 - - internal 258, 261 - superficial abdominal 256 - superficial penile 238 - superior diaphragmatic, of pelvis 168. 1 98. 233 - transversalis 1 55 Fat pad, retrosternal 61, 62 Fat, subepicardial 102 Fecal continence 1 99 Flbromusculocartilaglnous layer
83 Fifth pharyngeal arch 21 Fimbriae, of fallopian tube 246, 252 Fimbriated end, of fallopian tube 246,252 Final urine 229 First pharyngeal arch 20 First pharyngeal cleft 20 Fissure - horizontal, of right lung 80, 98 -oblique -- of left lung 80,99 - - of right lung 80, 98 - -- posterior end, projection onto vertebral mlumn 58 Flank region 162 Flexion, uterine 251 Flexure -colic --left 189,192 in abdominal transverse section 166 radiography 203 -- right 165.189,192 - -- radiography 203 -duodenal - - lnfl!rlor 188 - - superior 188 - duodeno]e]unal 188, 190 - - projection onto vertebral column 151 -left colic 218 - perineal 196, 199, 200 - sacral, of rectum 1 96 Floating kidney 224 Fold(s) - aryepiglottic 26, 28, 34, 41 - - viewed with laryngeal mirror 29 - circular - - duodenum 188 - - radiographic appearance 202 - - small Intestine 190 -epigastric 155.159.172 - gastric 75, 185, 186 -- endoscopic view 187 - gastropancreatlc 164 - glossoeplglottlc. median 29 - interuretl!ral 237 - rectouterine 174, 1 97, 234, 246 - salpingopharyngeal 34
Heart H
- semilunar, of colon 192, 195 - transverse vesical 174, 235 - transverse, of rectum 193, 197 -- Inferior 198 -- middle 198 -- superior 198 - umbilical 155 -- lateral 155, 156, 158, 160, 172,174 -- medial 155. 156. 158. HiO, 172, 174, 234 --median 155,156,158,160, 172,191,236 - uterosacral 234 - vestibular 26, 31, 36 -- viewed with laryngeal mirror 29 - vocal see Vocal fold Follicles, lymphatic -ofileum 190 - of vermiform appendix 195 Follicular maturation 253 Follicular stigma 252 Follltropln 249 Foramen/Hiatus - [foramen] cecum 21 - [foramen] greater sciatic -- part -- - Infrapiriform 285 -- - suprapiriform 285 - [foramen] jugular, vagus nerve lesion 31 - [foramen] omental 154, 159, 164,179,183 - [foramen] ovale, of heart 94 -- closed 95 - [hiatus] vena caval 90, 116, 138, 299 -- projection onto vertebral column 58 -- transmitted structures 90 Foregut, development of 178 Foreign body aspiration 76 Foreign body, swallowed 190 Fornix,. vaginal
-- anterior part 171 - posterior part 171, 175, 250 Fossa -Inguinal -- lateral 155. 172, 174 -- medial 155 - ischioanal 168, 197 - navicular 256 - - of urethra 238 - ovalis 105 - paravesical 174 - supraclavicular -- greater 42 -- lesser 42 - supravesical 155. 174 Fourth pharyngeal arch 20 Frankenhluser plexus 321 Frenulum, oflleocecalorlflce 194 FSH (follicle stimulating hormone) 249
c Gcells 187 Gag reflex 37
Galen's anastomosis 30 Gallbladder 165, 183, 205, 206, 210,264 -body 212 - development 179 -fundus 151,207,212 -Head zones 310 - In abdominal transverse section 166 - Infundibulum 21 2 - innervation, autonomic 31 0 - location 152, 210 -neck 212 Gallbladder disease, projection of pain due to 146 Ganglia - autonomic 3011 - parasympathetic 307, 309 - - Intramural 307 - sympathetic 220, 306, 309 -- interganglionic branches 140 - - paravertebral 140, 306 - - peripheral 306 - - prevertebral 306 Ganglion (·Ia) - aorticorenal 306,308,313,316 - celiac 306, 308, 31 0, 316 - cervical -- middle 39, 48, 140, 142 -- superior 18, 38, 48, 140 - cervicothoracic 19,48, 140,142 - impar, coccygeal 3011 -Inferior - - of glossopharyngeal nerve 18 -- ofvagus nerve 19, 31, 37 - lumbar 306, 308, 31 6, 31 8, 320 -mesenteric - - Inferior 237, 306, 308, 312, 314,316,321 --superior 306.308.310,312, 314,316,321 -renal 321 - sacral 3011, 31 6 -stellate 19,39,48, 140,142 -superior - - of glossopharyngeal nerve 18 -- of vagus nerve 19, 31, 37 - of sympathetic trunk, paravertebral 62 -thoracic 143,306 - - branch(es) - -- esophageal 142 - -- laryngopharyngeal 142 --- pulmonary thoracic 142 Gartner duct 242 Gas exchange - alveolocapillary 811 - placental 94 - pulmonary 95 Gastric arteries 264 Gastric canal 185, 186 Gastric carcinoma - lymph node mmstases, supraclavicular 15 - mwst.lsis,lymphogenous. transdiaphragmatic 130, 134 Gastric glands 187 Gastric mucosa, endoscopic view 187 Gastric rotation 178 Gastrin 187 Gastrointestinal canal
- development.ll anomalies 181 - normal development 178 Gastrointestinal tract - parasympathetic effects 307 - sympathetic effects 306 Genital folds 242 Genital organs - embryology 242 - female, In situ 245 Genital swellings 242 Genital system 240 Genital tubercle 242 Genital tubercle (of MOiler) 242 Genitalia - external, development 243 -female 240 -- arterial supply 290 -- autonomic innervation 320 -- external 240 -- Internal 240, 244 function 248 -- - peritoneal folds 246 -- - peritoneal relationships 246 -- - topographical anatomy 246 -- - wall structure 248 -- lymphatic drainage 295, 297. 305 -- venous drainage 291 -male 240 -- autonomic Innervation 318 -- external 240 -- glands, accessory 256 -- Internal 240 -- lymphatic drainage 295, 297, 304 -- venous drainage 286 Germinal epithelium, of ovary 246,252 Gland(s) - bulbourethral 233. 238. 241, 256,260 -- autonomic innervation 319 -- development 242 - duodenal 189 - esophageal 74 - greater vestibular 241 - Intestinal 189, 195 - parathyroid, see Parathyroid gland - parotid 3, 46 - prostatic see Prostate - seminal vesicle 176, 2311, 241, 256,286 -- autonomic Innervation 319 -- development 242 -- lymphatic drainage 297, 304 - submandibular 48 - suprarenal 59, 211, 218,220, 223, 225, 227' 232 -- in situ 221 -- left 151,152,162,164,189 -- right 151,152, 162,189 - thyroid see Thyroid gland - tracheal 83 - urethral, orifices 237. 239 - uterine 248 - vestibular -- development 242 -- function 240 -- greater 242 -- lesser 242 Glans
- of clitoris, development 243 -of penis 238,241, 242, 256,261 -- development 242 Glisson triad 209 Glomerulus 228 - urin;ny pole 228 - vascular pole 228 Glomus tumor 43 Glottic aperture 29 Glottic aperture see Rima glottldls Glottic closure 29 Glottis - phonation 29 - respiratory 29 Glucagon production 217 Goblet cell 83 Goiter 23 - retrostemal 43, 47 Gonad primordium 243 Gonad(s) - female, Head zone 320 - male, Head zane 319 - undlfh!rendated 242 Gonadal ligament, caudal 243 Graafian follicle 253 Granulosa cells 253 Graves' disease 23 Gravlt.~tlon abscess 3, 40 Gridiron Incision 151 Gubernaculum 242 - of prost.lte 242 Gutter, paracardiac 160, 161
H Hamulus, pterygoid 35 Hassall corpuscles 132 Haustra. colonic 192, 195 - radiography 203 Head - arterial supply 114 - Innervation, parasympathetic 307 - lymphatic system 14 Head -Medusa 293 - of epididymis 258 - of femur 176 - of pancreas 1811, 21 1, 214 ff, 221,225 Head zones 143,146,310,312, 317,319 Hearing loss 36 Heart 59, 65, 96 -base 97,98 -- cardiac plexus 114 - chambers 104 - configurations 96 - coronary artery distribution, types of 122 -- balanced 127 - diameter, longitudinal 96 -fetal 94 - Head zones 144 - lm pulse conduction system 11 0 -lmpulseformadonsystem 110 -in situ 97,99 - innervation 144
- left coronary dominance 126
357
H Heart
Heart
- left, blood flow 1 13 - lymphatic drainage 1 29, 138 -- territories 138 - magnetic resonance imaging 98 - mechanical stabilization 1 07 - parasympathetic effects 143, 144 - projection onto chest wall 96, 114 - radiographic appearance 96 - relationship to lung 120 - right coronary dominance 1 26 - right, blood flow 11 3 -shape 100 - strudiJre 1 00 -sympathetic effects 143,144 - topographlc.al relationships 98 - ultrasound Imaging 1 12 - valve plane 1 1 1 -vascular valves 106, 108 - wall structure 101 - width, maximum 96 Heart disease, autonomic reactions associated with 144 Heart sounds 112 Heart wall - blood flow 139 - lymph flow 139 - lymphatic drainage 1 39 Heart, posterior surface 1 00 Heartbeat, apical 58, 97 Heartburn 75 Hemorrhoidal plexus see plexus, hemorrhoidal Hemorrhoids 201 Hepatic border, superior, projectlon onto vertebral column 58, 151 Hepatic bud 179 Hepatic cirrhosis 119, 209 Hepatic enlargement - In right-sided heart failure 65 - palpable 205 Hepatic mebstases 289 Hepatic surface of diaphragm 1 60, 164,189,207,215,225 Hepatocytes 209 Hepatoduodenalllgament see ligament. hepatoduodenal Hernia - diaphragm 90 - Internal 161, 189 Hernia, Inguinal 155, 261 - congenital 258 HiallJs - aortic 90, 115, 1 17 -- projection onto vertebral column 58 -- transmitted structures 90 - esophageal 72, 75, 90, 138 -- projection onto vertebral column 58 -- transmitted structures 90 - saphenous 261 Hilar lymph nodes 131, 136 Hilum - pulmonary 81 - renill 222, 227. 230 -- projection onto vertebral column 151 Hlrschsprung disease 314
358
Hoarseness 27, 28 - after thyroid surgery 23 Holzknecht space see space, retrocardlal - on chest radiograph 98 Hormone, follicle-stimulating 249 Hyaline cartilage see cartilage, hyaline Hydrocele 258 Hymen 242 Hyoid arch (second pharyngeal arch) 20 Hyoid bone see Bone, hyoid Hyoid muscles see Muscles, hyoid Hyperfunctional thyroid gland 23 Hypertension, portal 209 Hypofunctional thyroid gland 23 Hypogastrium 150, 1 62 Hypopharyngeal diverticulum 33, 73 Hypospermia 260
Ileum 190 - anatomlc.al constrictions 190 -lnslru 191 - innervation, autonomic 312 -loc.ation 152 - lymphatic drainage 296, 300 - projection onto trunk wall 151 - termini!I part 194 - wall structure 1 90 Ileus, mechanic.al 161, 190 Immunodeficiency, due to thymic aplasia 132 Impression -cardiac 81 - colic 204, 207 - duodenal 204 - gastric 204, 207 - renal 204, 207 - suprarenal 204 Impulse conduction bundle - Interatrial 1 1 0 - Internodal 1 1 0 Impulse conduction system of heart 110 Impulse formation system of heart 110 Incus, embryonic origin 20 Indirect (mirror) laryngoscopy 29 -findings 29 Inflow tract - left ventricular 104 - right ventricular 105 Infundibulum, of fallopian tube 246 Inguinal hernia 155, 261 - congenital 258 lngulnilllnclslon 151 Inguinal testis 259 Inspiration 92 - change In cardiac borders 96 - lymphatic return In thoracic duct 128 - respiratory muscles active
during 92 Insulin production 217
lntercosbl spaces, lymphatic drainage 1 29 lntercosbl vessels, lymphatic 128 Interior of larynx 26 Interlobular septa 80 Internodal bundle 1 10 lntersc.alene space 9, 11 - anterior 49 - posterior 49 Interspinous plane 150 Interstitial Leydig cells 259 Intertubercular plane 1 50 Intestinal atresia 181 Intestinal loop rotation 190, 192 Intestinal stenosis 1 81 "Intestinal tonsil" 1 95 Intestine - autonomic innervation 314 -embryonic -- development 180 -- robtion about umbilical cord 180 - large see Large intestine - small see Small Intestine Intestine, lymphiltlc drainage 300 lntrilmural nervous system, of intestine 314 Iodine deficiency 23 Iodine test 249 Islet. pancreatic 217 Islets of Langerhans 217 Isthmus -aortic 114 -faucial 34 - of fallopian tube 246 - oropharyngeal, see isthmus faucial - of prostate 257 - of thyroid gland 22 - of uterus 247, 251
jejunum 189, 1 90 - endoscopic view 190 - lnslru 191 - Innervation, autonomic 31 2 - loc.ation 152 - lymphatic drainage 296, 300 - projection onto trunk wall 151 - wall structure 190 joint - cricoarytenoid 24 - cricothyroid 24 junction of esophageal and gastric mucosae 75 junction, anorectal 198 junction. duodenojejunal 189 junction, uteropelvic 233 junction, uteroveslcular 233 juxuglomerular apparatus 228
K Keith-Flack node see Sinoatriill node Kerckring, valves of 188, 1 89 Kidney 162,221,241
- architediJre 228 - areas of contact with other organs 225 - autonomic Innervation 31 6 - ;wascular zone 282 - collecting duct 229 - development 1 78 - Head zones 317 - In abdominal transverse section 166 - in sillJ 223, 232 -left 59,162,189,211,215,221, 222 - - loc.atlon 152 - - lymphatic drainage 297 -- projection onto trunk wall 151 - loc.atlon 224 - lymphatic drainage 302 - moblllty 224 - neurovascular strudiJres 227 -pole - - Inferior 227 - - superior 221, 227 - projection onto skeleton 222 -right 59,162,165, 189,215, 221,222 - - loc.atlon 152, 226 - - lymphatic drainage 297 -- projection onto trunk wall 151 -shape 227 - sphincter system, functional 231 - topographical anatomy 224 Kidney 162,221,241 -left 59,162,189,211,215,221, 222 -right 59,162,165, 189,215, 221,222 Killian triangle 33, 73 Klnocllla 83 Kohlrausch fold 198
L Labium/Lip - (labium( rnajus. of pudendum 235, 239,241,245 - - development 242 - (labium( minus, of pudendum 235, 239,241.245, 250 - - development 242 - (lip( anterior, of uterine os 250 - (lip( posterior, of uterine os 250 Labrum - lleocec.al, of Ileal papilla 194 - ileocolic, of ileal papilla 194 Lacuna - musculorum 285 - vasorum 285 Laimer's triangle 33, 74 Lamina of cricoid cartilage 25, 53 Lamina/Layer - (lamlna(left, of thyroid cartilage 24 - (lamina] mediill, of pterygoid process 35 - (lamina( muscularis mucosae, of colon wall 1 95
Lung l
- [lamina] of cricoid cartilage 25, 53 - [lamina] propria, of colonic mucosa 195 - [lamina] right, of thyroid cartilage 25 - [layer] epitllelial, of colonic mucosa 195 - [layer) Investing, of cervical fascia 2, 22, 40. 44, 46 - [layer] parietal -- of serous pericardium 66 -- of tunica Yo~glnalls 258 - [layer) pretracheal, of cervical fascia 2, 22, 44, 46. 61 - [layer] prevertebral, of cervical fascia 2, 22, 40, 44 - [layer] visceral -- of serous pericardium 66 -- of tunica Yo!ginalis 258 Lancelet fish, branchial arches 20 L.anz point 195 Laparotomy, midline -lower 151 - periumbilical 151 -upper 151 Large intestine 192 - arterial supply 268, 270 - framing of smillllntestlne 190 - Head zones 31 2 - innerviltion. autonomic 312 - lymphatic drainage 296, 300 - radiography 203 - venous drainage 278 - wall structure 194 Larney cleft 90 - transmitted structures 90 Laryngeal cartilages 24 L.aryngeilllnlet 24 Laryngeal ligaments 24 Laryngeal mucosa, innervation 30 Laryngeal muscles see Muscles, laryngeal L.aryngeill prominence (Adilm's apple) 24 Laryngopharynx 34, 36 Laryngoscopy, Indirect 29 Larynx 24, 26, 54 - ilrterlal supply 27, 30 -location 24 - mucosal surface anatomy 26 - nerve supply 27, 30 - neurovascular structures 27 -shape 24 - surgical approaches 30 - topographical anatomy 30 - venous drainage 27 Lateral Infarction, of myocardium - ilnterlor 127 - posterior 127 Lateral pharyngeal band 36 Layer -circular -- detrusorveslcile 237 -- gastric musculature 186 -- wall of colon 195 -- wallofduodenum 188,213 -- wallofrectum 198 -- wall of small intestine 190 -- wall of vermiform appendix 195 - longitudinal
-- -- - - - --- --
external, detrusor vesicae 237 gastric musculature 186 Internal, detrusor vesicae 237 subvascular• 248 supravascular• 248 Yo~scular• 248 wall of colon 195 wall of duodenum 188,213 wall of rectum 198 wall of small intestine 190 wall of vermiform appendix 195 Lemniscus, medial 37 Length of aorta 96 Levels of larynx (I-III) 26 Levels of the rectum - lower, venous drainage 279 - upper, venous drainage 279 Levels of uterus, during pregnancy 254 LH (luteinizing hormone) 249 Ligament(s) - [ligamentum] arterlosum 63, 67, 79, 95,100,114 - [ligamentum] teres. of femoral head 177 - [ligamentum] venosum 95,206 - anular 82 - broad, of uterus 174, 234, 246, 290 - - lymphatic vessels 305 - - peritoneal covering 246 - cardinal 245, 246 - cervical, tranSVI!rse 168, 176 - coronary of liver 206. 207 - cricoarytenoid 24 - cricothyroid 24 -- Incision 30 - - median 22, 24, 26, 30, 82 - cricotracheal 24 - falciform, of liver 155, 156, 178, 183,207 - - In abdominal transverse section 166 - gastrocolic 164 - gastrosplenic 159, 160, 164, 178,218 - hepatic 154 - hepatoduodenill 153, 159, 160, 164.179.183.189.205.215, 225,311 -- contents 161,264 - hepatoesophageal 183 - hepatogastrlc 153, 159, 178, 179.183.218 - hyoepiglottic 26 - Inguinal 175, 234, 285 - lnterfoveolar 155 - medlill ilfCUilte, reliltlon to sympathetic trunk 58 - median umbilical 95, 155, 232 ff, 238, 241 - middle cricoarytenoid 28 -nuchal 3,4 - of Botalli (ligamentum arteriasum) 63,67, 79,95,100,114 - of vena cava 65, 207 - phrenlcocollc 165 - phrenicosplenic 189, 21 8 - properovarian 169,171,174, 234,252 - - development 242
- puboprostatic 236 - pubovesicular 174, 236, 239 - pulmonary 81 - rectal, lateral 168, 176 - rectoprostatic 236 - rectouterine 176 - rectovesical 236 - sacrospinous 176, 285 - sacrotuberous 285 - sacrouterine 246 - splenocolic 218 - splenorenal 178 - stylohyoid, embryonic origin 20 - suspensory -- ofduodenum 188 -- of OVilry 174,234,241, 243, 246, 252, 287. 291 -- of penis 170 -teres -- of liver 95.151,155. 156. 179, 183, 206 -- of uterus 171,174,234,241, 245, 246, 287' 290 -- - ilttachment 239 -- - development 242 - thyrohyoid 24, 26 -- median 30, 46, 48 -thyroid 36 - transverse -- cervical HiS. 176, 246 -- perineal 233, 250 - triangular -- left 206 -- right 206 -vesicular. lateral of the bladder 168, 176, 236 - vestibular 24, 26 -vocal 24, 26, 31 Limb, lower, lymphatic drillnage 297 Limbus of fossa OVillis 1OS Line - anocutaneous 198 - ilrCUilte 155, 156, 191 - median anterior 58, 96 - midaxillary -- lung boundaries 69 -- pleural boundaries 69 - mldclavicular 58, 68 -- lung boundaries 69 -- pleural boundaries 69 - mylohyoid 6 - oblique, of thyroid cartilage 25 - parilsternill 58 - paravertebral 68 -- lung boundaries 69 -- pleural boundaries 69 - pectinate 199 - scapulilr 68 -- lung boundaries 69 -- pleural boundaries 69 - sternal 58, 68 -- lung boundaries 69 -- pleurill boundaries 69 - superior nuchal 4 - [linea] terminalis, of pelvis 255 Lingual muscles, Innervation 18 Lingual tonsil 26, 36, 40 f Lingulil of left lung 80 Liver 59, 61, 77, 165, 204, 226, 264 - arterial supply 264
-- variants 265 -attachment to diaphragm 61, 77. 153, 154, 206, 226 - bare area 61, 77, 153, 154, 206, 226 - development 178 - Head zones 310 -histology 209 - In abdominal tranSVI!rse section 166 -in situ 205 - Innervation, autonomic 310 - location 152,204 - lymphatic drainage 296, 299 - palpation 204 - peritoneal relationships 206 - projection onto trunk wall 151, 204 - relationship to adjacent organs 204 - segments 208 -shape 206 Liver see Liver Lobilr bronchus 82 Lobe - caudate, of liver 164, 206 - lower, of lung 120 -- left 80, 84 -- right 80, 84 - middle, of right lung 80, 84, 120 -of liver -- left 65, 218 In abdominal tranSVI!rse section 166 surface --- - diaphragmatic 207 --- - visceral 206 -- right 65, 165, 183, 206 --- diaphragmatic surface 207 --- in abdominal transverse section 166 - of prostate -- left 257 -- right 257 - ofthymus 133 - ofthyroid gland 22, 64 - pyramidal, of thyroid gland 22 - quadrate, of liver 206 -upper --of left lung 80. 84,120 -- of right lung 80, 84, 120 Lobectomy 85 Lobule(s) - hepatic 209 - of testis 258 - ofthymus 133 - pulmonary 80, 86 Long axis of heart 97, 98 Loop of Henle - thick segment 229 - tllin segment 229 Lower abdominal organs 152 Lung 59, 60, 78 - arteries 120 -base 80 -fetal 94 -In situ 79 -left 59 -- border - - - anterior 80 --- inferior 80 -- lobe
359
l.
Lung
--- lower 80 Lung. artorin, lobe -- - upper 79, 80 -- surface --- =till 80 -- - - ~l ~rt 81 --- diaphragmatic 81 - location 78 - lymphatic drainage 129, 130, 136 -- subpleural network 136 - percussion field 78 - radiographic appearance 78 -right 59 -- border -- - anterior 80 -- - inferior 80 -- costal surface 80 -- lobe --- lower 80 -- - middle 79, 80 --- upper 80 -shape 80 - structure 80 -veins 120 Lung boundaries, projection onto thoracic s~ton 69 Lung ex~nslo n, resplratoly 93 Lung sound. sonorous 78 Lung volume, I'C$plratory changes 93 L.unuleofsemllunar valve 108 L.utelnlzlng hormone 249 L.utopln 249 Lymph circulation. systemic 15 Lymph collectors, small intestine 300 Lymph follicle 195 -spleen 219 Lymph node enlargement, painless 14 Lymph node metastases, supraclavicular 15 Lymph node stations. tributary regions 295 Lymph node(s) 139 - anterior superficial 14 - appendicular 296 - brachloceph~lc 62, 77, 129, 130,139 -bronchopulmonary 129, 131, 136,138 - cellae 130, 294 ff, 298, 300 -- flow reveml 134 - central129. 130 - cervical -- anterior 14 - -deep 14 -- superflclill 44 - chest-wall group 130 -colic -- left 296, 301 -- middle 296, 301 -- right 296, 301 - cystic 296, 299 - epiploic 301 - foramina! 296, 299 -gastric -- left 296. 298 -- right 296 - gastro-omental -- left 296, 298
360
- - right 296, 298 - gluteal - - Inferior 297 - - superior 297 - he~tlc 296. 298 -- ileocor~e 296, 300 - hilar 131, 136 - Mlac - -common 294,297,302, 304 --- intermediate 297 - - - lateral 297 - -- medial 297 -- external 173,294, 297, 302, 304 --- intermediate 297 --- lateral 297 - -- medial 297 -- Internal 294,297, 301, 302, 304 - Inferior epigastric 297 - infraclavicular 14 - inguinal -- deep 294, 297, 303, 304 - - superflcl<~l 294. 297, 301 --- tract - - - - horizontal 294, 303, 304 - - - - vertical 294, 303, 304 - Intercostal 136 - lnteriiiOlc 297 - intemne
- lacunar -- intermediate 294. 297 -- lateral 297 - - medial 297 - lateral aortic 294, 296, 302, 304 - lateral cOJVal 173, 294, 297, 302, 305 - lateral pericardiaI 63, 129, 139 - lateralsuperflcial 14 - lateral vesical 297 - lumb01r 166, 167 - - intermediate 294, 297, 302, 304 - - lateral 167 -- left 295 ff, 302,304 - - right 295, 297, 302, 304 - mOJstoid 14 - mediastinal 129, 130 - mgenteric - - Inferior 295, 296, 301 , 303 -- intermedlilte 300 -- superior 294 ff, 299. 300 - mesocolic 296,301 - obturator 297 - occipital 14, 50 - ofposterlorcervkal tmngle 14 - ~ncreOJtic - - inferior 296, 299 - - superior 296, 299 - ~ncreatlcoduodenal - - Inferior 296, 299 - - superior 296, 299 - para-aortic 166 - paracolic 301 - paramammary 129 - ~rarectal 297 - parasternal 129, 136 - paratracheal 129, 130, 136 - parauterlne 297
- paravaginal 297 - p.1r1etal 297 --abdomen 294 -- pelvis 294 - ~rotld --deep 14 -- superfoclal 14 - perkardal 139 - phrenic -- Inferior 135. 136. 138. 294, 297, 299, 302 -- superior 61,63, 77,129,130, 138, 299 - preaortlc 294, 296, 302, 304 - preaval 297, 302 - prececal 296, 301 - prepericardlal 129, 139 - prevertebral 129, 130 - prevesical 297 - promontory 297. 302, 304 - pyloric 296, 299 - regional 14, 295 - retroaortfc 294, 297, 302 - retrocav<~l 294, 297, 302 - retroceca l 296 - retropharyngeal 40 - retropyloric 299 - reti"'YY!Sical 297 - sacr01l 294, 297, 303, 304 - sigmoid 296. 301 - sinoatrial (sinus node, KrithFiack node) 110 -- artei'IOII supply 126 - - Innervation 144 - - sym~thetlc effects 143 - splenic 296, 298 - subaortlc 297 -submandibular 14 - submental 14 - subpytorlc 298 - superior rectal 296, 301 - suprapylorlc 298 -thoracic 130 - tracheobronchial 61, 77, 129, 130, 136 -- inferior 136, 138 - - superior 137 -wall of vermiform .1ppendlx 195 LymphOJtlc drainage -axillary 15 -facial 15 - laryngotracheot nyroidlll 15 - oochal 15 - occlpltill 1 - ~rotld~rlcular 15 - submenta~submandibular 15 Lymphatic drainage -by quadrants 129 - tr;msd~phr<~gmatic 130, 134 Lymphatic dralnOJge, overl01pping patterns 129 Lymphatic pathways, Intersection ln theneck 15 LymphOJtlc pathways, thoracic 129 Lymphatic return, respiratory effects on 128 Lymphatic trunks - abdomen 295 -pelvis 295 - thoracic 128 Lymphedema 128
s
M Macrophages, t hymus 132 Macula densOl 229 Magnetic J1!5001;1Mce imaging, of heart 98 Malplghlan bodies 219 Malrot ation 181 Mammary bland, lymphatic drainage 129 Mandible 3, 42, 46 - Inferior border 2 Mandible, opening 6 Mandibular arch (first pharynge01l arch) 20 Manubrium of the sternum 4, 43, 59,61 - projection onto vertebral column 58 Masticatory muscles, embryonic o rigin 20 McBurney (gridiron) Incision 151 McBurney poi nt 195 Meckel cartilage 20 Meckel diverticulum 181 Mediastinitis 40 Mediastinum 60, 62 - anterior 60, 64, 91 - - contents 60 - - lymphatic drai nage 129 -- radiographic appearance 98 - classification 60 - Inferior 60 -- contents 60 -- neurovascular structures 60 - middle 60, 62 - - contents 60 - - structures 64 -of testis 258 - posterior 60, 62 - - contents 60 -- structures 65 - superior 60. 113 - - content s 60 - - lymphat ic d rainage 129 - - neurovascular struct ures 60 -- structures 64 Medulla -ovarian 253 -renal 228 - spinal 52 - of suprarenal gland 220 Medul~ry ray 228 Medusa head 293 Meissner plexus 314 Membrane - attanto-occlpl~ 51 - obturator 285 - perineal 168,235, 250 - quadrangular 26 - thyrohyoid 23, 24, 30, 46 Membranous part of trach ea 26, 76.82 Meningitis 40 Menstruation 248 Mesanglal cells 228 - extraglomerul<~ r 228 Mesenchyme 21 Mesenteric root 160, 189, 215, 225 - projection onto skeleton 158 Mesentery 153, 154, 158
Muscle(s) M
- anterior 159 Mesoappendix 158, 160, 193, 194 Mesocolon 192 -sigmoid 158,160,163,169, 193.197,223 - tranSVI!rse 154,157,158,164, 193 -- attachment, projection onto vertebral column 151 -- course 160 -- root 160,225, 266 Mesogastrium 150 - development 179 - dorsal 156, 179 Mesometrium 246, 252, 290 Mesonephric ductule 242 Mesorectum 153, 158 Mesosalpinx 175, 246 Mesosigmoid (sigmoid mesocolon) 158.160 Mesovarium 246, 252 Mesovary 246 Metastasis, lymphogenous, transdlaphragmatlc 130, 134 Micturition center - pontine 236 -sacral 236 Micturition, control 236 Mldclavlculilr line see Line, midclavicular Mitral valve see Valve, left atri<>ventrlcular Morgagnl hydatlds 242 Morgagnl sp01ce 26, 31 Morula 254 Mucin production 187 Mucosa -layers -- llilmlna] propria 74, 83 -- epithelial 74, 83 -- muscular 74 - of bronchus 83 - of duodenum 188 - of esophilgus 74, 143 - of fallopian tube 247 - of small intestine 190 - of stomach wall187 - of trachea 82 -of uterine wall 231 -of uterus 247,248 - of vas deferens 260 - ofvermifonm appendix 195 Mucosa, subglottic 31 Mucosal fossile,lilryngeill 26 Mullerian duct 242 Multicavity injury 151 Muscle(s) - anterior cricothyroid see Muscle, cricothyroid -arytenoid -- oblique 28, 35, 39, 74 -- posterior 74 -- transverse 28, 39, 74 -- - ilctlon 29 - buccinamr 32 - bulbospongiosus 170, 233, 235, 239, 244, 256 - coccygeus 284 - corrugator cutis ani" 198 - cremaster 258, 261 - cricoarytenoid -- lateral 28, 30
- -- action 29 -- posterior 28, 30, 39, 41 action 29 - -- lnnerviltlon 47 --- palsy 28 - - transverse 35 - cricothyroid 22, 27, 29, 46, 48 -- action 29 - - embryonic origin 20 - - innervation 19, 28, 30 -- part - -- oblique 28, 30, 32 - -- straight 28, 30, 32 - detrusor vesicae 236 -- IOI)fers 237 - digastric 4, 6, 35, 48 -- action 6 -- belly - -- anterior 6, 32, 42 - -- - embryonic origin 20 - -- posterior 6, 32, 34, 42 - -- - embryonic origin 20 - - Innervation 6 - - Insertion 6 --origin 6 - of facial expression 5 - - embryonic origin 20 - genioglossus 18 - geniohyoid 4, 6, 18, 36 -- action 6 - - innervation 6, 17, 18 - - Insertion 6 --origin 6 - gluteus maxim us 176 - hyoglossus 18, 32 -hyoid - - lnfrahyold 4, 6 - -- Innervation 17 - - suprahyoid 4, 6 - iliacus 232, 244 - iliocostalis cervicis 4 - Iliopsoas 176 - lnfrahyold 4, 6 - intercostals 62 - intertransversarius cervical
posterior 51 - Ischiocavernosus 233, 235, 239, 244,250 - laryngeal 28, 29 - - function 20 - - innervation 19, 28, 30 - - paralysis 31 - lateral cricoarytenoid 29 - levilmr(s) --ani 168,171,197,198,233. 235, 236, 239, 245, 288 - - embryonic origin 20 - - pharyngeal 32, 35 - - scapulae 54 - - veli palatini 32, 35 --- loss 31 - lingual, Innervation 18 - longissimus capitis 4, 51, 54 -longus - - capitis 4, 8 action 8 Innervation 8 Insertion 8 origin 8 --calli 4, 8 action 8 - -- Innervation 8
-- - insertion 8 -- - oblique part -- -- Inferior 9 -- -- superior 9 --- origin 8 -- - straight part 9 - masseter 34 -- part --- deep 33 -- - superficial 33 - medial pterygoid 33 ff, 40 - mylohyoid 4, 6, 32 -- action 6 -- embryonic origin 20 - - innervation
6
-- insertion 6 -- origin 6 - obllquus capitis -- Inferior 51 -- superior 51 - obturator internus 168, 176, 197. 245, 284 - omohyoid 4, 6, 18, 45, 46, 48 -- action 6 -- belly --- inferior 7, 49 -- - superior 7 -- Innervation 6, 17 -- Insertion 6 -- intermediate tendon 7 -- origin 6, 21 - palatoglossus 41 - palatopharyngeus 35, 39, 40 - paplllilry 103, 107 -- anterior 104,107 -- posterior 104, 107 -- septal 105 - pectinate 104 - pharyngeal 32, 35 - pharyngeal constrictor -- inferior 18, 30,38 --- part -- -- crlcopharyngeal 32, 73 -- --- fundiform part 33 - - - - - oblique part 33 -- -- thyropharyngeal 32, 73 -- Innervation 37 -- middle 35, 38 --- part -- -- ceratopharyngeal 32 -- -- chondropharyngeal 32 -- superior 35, 37, 38 --- part buccopharyngeal 32 -- -- glossopharyngeal 32 -- -- mylopharyngeal 32 -- -- pterygopharyngeal 32 - posterior cricoarytenoid 28, 30, 39,41 - prevertebral 4, 8 - psoas major 223, 232 - pubococcygeus 200 - puborectalls 199, 200, 236 - puboveslcalls 235, 236, 239 - recmuterine 235 - rectovesicalis 236 - rectus abdomlnls 169 - rectus capitis -- anterior 4, 8 action
8
innervation 8 Insertion 8
--- origin 8 -- lateral is 4, 8 action 8 Innervation 8 insertion 8 origin 8 -- posterior --- major 51 --- minor 51 - rhomboideus minor 54 - salpingopharyngeus 35 -scalenus 8 --action 8 -- anterior 4, 8, 17, 45, 48, 52, 54,64 --- insertion 8 --- origin 8 -- Innervation 8 -- medius 4, 8, 17, 45, 49, 52, 54 --- insertion 8 --- origin 8 -- posterior 4, 8, 45, 52, 54 --- Insertion 8 --- origin 8 - semispinalis -- capitis 4, SO -- cervlcls 4, 52, 54 -serratus -- anterior, inferior part 4 -- inferior 92 -- posterior superior 54, g2 -sphincter --anal --- external 168,171,197,200 - - - - part - - - - - deep 198,201 --- -- subcutaneous 198, 201 - - - - - superficial 198, 201 --- internal 198, 200 -- calicis 231 -- fornlcls 231 -- of hepatopancreatlc ampulla
213 -- pelvicis 231 -- pyloric 185, 188 -- urethral 170 --- external 230, 233, 235, 236, 238, 239 --- - innervation 237 --- internal 237 -splenius -- capitis 4, 50 -- cervlcls 4, 52, 54 - stapedius. embryonic origin 20 -sternocleidomastoid 3, 4, 19, 38, 42, 44, 50 --action 4 -- head --- clavicular 4 --- sternal 4, 46 -- Innervation 4 -- Insertion 4 -- orifice of cervical flstulil 21
--origin 4 Muscle(s) - sternohyoid 3, 4, 6, 18, 32, 42, 46,49, 52 --action 6
-- innervation 6. 17 -- insertion 6 --origin 6
361
M Musde(s)
- >ll!motllyroid 4, 6, 18, 46, 48, 52 --action 6 -- Innervation 6, 17 -- Insertion 6 --origin 6 - styloglossus 18, 32, 40 - stylohyoid 4, 6, 18, 32, 34 --action 6 -- embryonic origin 20 - - innervation 6
-- insertion 6 --origin 6 - stylopharyngeus 32, 35, 38, 40 -- embryonic origin 20 -- innervation 18, 37 - suboccipital 4 - suprahyoid 4, 6 - suspensory, of duodenum 188 -tensor -- tympani, embryonic origin 20 -- veli palatini 32, 35 - -- embryonic origin 20 - thyroarytenoid 26, 28, 30 --action 29 -- thyroepiglottic part 28 -thyrohyoid 4, 6, 18, 30, 32, 37, 46,48 --action 6 -- Innervation 6, 17,18 -- insertion 6 --origin 6 - tracheal 82 - transverse arytenoid 28, 39, 74 -- deep transve~ perineal 1 68, 171, 236. 245, 250. 256 -transversus abdominis 169 -trapezius 3,4, 19,42,44,47, 50,54 --action 4 - - innervation
4. 44
-- insertion 4 -- part --- ascending 4 --- descending 4 - - - tranwerse 4
- uvula 34, 35, 36, 39 - veslcoprostatlcus 237 - veslcovaglnalls 237 - vocalls 26, 28, 31 --action 29 Muscular coat -layers -- circular 73, 74, 143 -- longitudinal, of esophagus 73, 74,143 - of bladder 239 - of colon wall 1 95 - of duodenum 190 - of esophagus 73 - of fallopian tube 247 - of pharynx 32 - of rectum 198 - of small Intestine 190 -of stomach wall 187 - of urethra 237 - of uterine corpus 247 -of uterine wall 231 - of uterus 248 - of vas deferens 260 - of vermiform appendix 195 Muscularis extema see Muscular coat
362
Mydriasis in heart di5eilse 144 Myocardial infarction 127 - pain patterns 144 Myocardium 67,101,102 - deep IOI)fer 1 02 - lymphatic drainage 139 - middle layer 102 - myocyte 103 - superflciallayer 102 - sympathetic effects 143 Myoepithelial cells 228 Myometrium 248
N Nabothian follicles 249 Nasopharyngeal tumor, vagus nerve lesion 31 Nasopharynx 34, 36 Neck 2 - anterior view 12 - anterior, Innervation 1 7 -arteries 10. 114 -base 48 - bony prominences, palpable 43 - boundaries 2 - carotid sheath 2 - congestion 43, 47 - cranial nerves 16 - cutaneous muscle see Platysma - directions of lymphatic drainage 15 - fascial relationships 2 - innervation -- parasympathetic 307 -- segmental 51 - lymphatic pathways, lntersectionsof 15 - lymphatic system 14 -- deep lymph nodes 14 - muscle fascia 2 - nervous system 16 - neurovascular bundle 52 -regions 42 -- association with anatomical structures 43 - sectional anatomy 52 - spinal nerve branches 1 6 - surface anatomy 42 -veins 12 -- anastomoses 12 - visceral fascia 2 Neck cells. in gastric glands 187 Neck cyst 21 -lateral 21 -median 21 Neck dissection 13, 14 Neck muscles -deep -- Innervation, motor 1 6 -- lateral 4, 8 -- strap 4 - superficial 4 Necrozoospermia 260 Nephron - juxtamedullary 229 - subcapsular 229 Nerve fibers - parasympathetic -- flrst efferent neuron 307
-- presynaptic 307 -- second efferent neuron 307 - sympathetic -- flrst efferent neuron 306 -- postsynaptic 140 -- second efferent neuron 306 Nerve(s) - abducent 39 - accessory 4, 16, 19,47 -- external branch 19, 38, 44, 48,50,55 - auricular, great 16, 44, 46, 50 -- root --- anterior 17 --- posterior 17 - cervical cardiac 1 40 -- inferior 144 -- middle 144 -- superior 144 - cavernous, of penis 318 - cervical, dorsal rami 50 - cutaneous, lateral femoral 163, 223 -dorsal -- clitoral 197, 250 -- penile 238,318 - facial 5, 6, 39 -- association with pharyngeal arches 20 -- cervical branch 46. 48 --- anastomosis with trilnsverse cervical nerve 17, 44 - femoral 163, 176 - first sacral 308 -- ventral ramus 31 6. 320 - genitofemoral 163, 221, 223 -- genital branch 261 -glossopharyngeal 16, 18,31, 38,41 -- association with pharyngeal arches 20 -- bralnstem nuclei 37 -- branch(es) --- carotid sinus 18 --- pharyngeal 18 -- pharyngeal innervation 37 - hypogastric 173,308,315, 316, 318,320 -- left 173 - hypoglossal 16 ff, 38. 46. 48 -- thyrohyoid branch 46, 48 - iliohypogastric 163, 221 -- Innervated skin area 224 -- relationship to kidney 224 - ilioinguinal 163. 173. 221, 223 -- innervated skin area 224 -- relationship to kidney 224 - Intercostal 62, 141 - Intermediate 39 - laryngeal -- inferior 19, 23, 27, 28, 30, 39, 47 --- distribution 30 --- lesion 31 bilateral 31 --- tracheal branches 30 -- recurrent 19, 27,39 ---- esophageal 142 ---- tracheal 142 left 23, 411, 63, 64, 71, 74, 140,141 loss 27
----
----
bilateral 28,31 unilateral 28 ---right 23,71,74,141,143 ---- course 47 -- superior 30, 38, 41, 140 --- branch external 19, 27. 28, 30, 46,48 Internal 19, 27,30,46,48 distribution 30 lesion 31 passage through thyrohyoid muscle 24 - lingual 18 - lumbar, ventral rami 318, 320 - mandibular, association with pharyngeal arches 20 - mylohyoid 6 - obturator 176, 284, 286, 31 8, 320 -occipital - - lesser 16, 44, 50 - - greater 16, 50 - - third 16, 50 - oculomotor 39 -ophthalmic 16, 51 -phrenic 17,47,49, 54,64,146 -- accessory 146 - - branch(es) --- pericardia! 17,145,146 - -- phrenicoabdominal 146 -- cou~ 91, 146 --- lnthethorax 147 - - distribution ---motor 146 - - - sensory 146 -- left 63, 147 passage through diaphragm 123 projection onto vertebral column 58 -- lesion, bilateral 17, 146 - - muscular landmark In the neck 49 -- right 62, 97, 147 - -- passage through diaphragm 123 - po>ll!rtorscrotal 318 - pudendal 197. 201, 236, 284, 318.320 - rectal, inferior 201, 318 - retroperitoneal 162 - sciatic 176 -spinal -- C6 52 -- C7 52 --C852 -- T1 52 - splanchnic -- first lumbar 317 - - greater 62, 140, 142, 308, 310ff, 314,316 --least 312,314,317,321 -- lesser 140,308, 311 ff, 316, 321 - - lumbar 201, 237, 306, 312, 314,318,320 - - pelvic 201, 237, 307. 308, 312,314, 316ff, 320 - - projection onto vertebral column 58
----
Parasympathetic nervous system P
--sacral 237,306,312,314, 317 -- thoracic -- - greater 306 - - - lesser 306 - - - lowest 306 - subcostal 163, 221 - suboccipital 16, 51 - supraclavicular 44, 46, 51 - - intermediate 44 -- lateral 44 -- medial 44 - suprascapular 47 - transverse cervical 17, 44, 46 -- anastomosis with cervical branch of facial nerve 17, 44 - trigeminal 39 - tympanic 37 - vagus 16, 19, 23, 27, 38, 47, 48, 62, 140, 143,307,308 -- ossociation with ph•ryngeal arches 20 -- brainstem nuclei 37 -- branch(es) -- - auricular 19 -- - cardiac 140 ---- cervical ----- Inferior 144 ----- superior 144 - - - - thoracic 144 - - - esophageal 140 -- - pharyngeal 19 - - - tracheal 140 -- cardiac Innervation 144 -- esophageal innervation 142 -- left 63, 64, 71,97 -- lesion - - - high peripheral 31 -- - vocal fold position 31 - - - central 31 -- motor fibers 31 -- pharyngeal Innervation 37 --rlght71 -- roots 31 -- tracheal innervation 142 - vestibulocochlear 39 Nervous system - autonomic, In the neck 18 - lntramurill 314 - thoracic 140 Network of lymphatic vessels - myocardial 1 39 - peribronchial 136 - subendocardial 139 - subepiCilrdial 139 - subpleural 136 Neurovascular bundle, cervical 52 Neurovascular structures, uterine 246 Neurovascular tracts, on pelvic wall 285 Niche cells 88 Node(s) - atrioventricular (Aschoff-Tawara node) 110 -- arterial supply 126 -- Innervation 144 -- sympilthetic effects 143 Nodule, of semilunar valve 1 08 Norepinephrine 220 Normozoospermla 260
Notx:h - angular 184 - cardiac, of left lung 81 - interarytenold 41 - - viewed with laryngeal mirror 29 - jugular, of sternum, projection onto vertebral column 58 -mastoid 6 -thyroid - - inferior 25 - - superior 25 Nuchal muscles 4 - Intrinsic, Innervation, motor 16 Nuchal region, innervation -motor 16 -sensory 16 Nucleus - ambiguus 31. 37 - dors•l, of vagus nerve 142, 144, 307 - Intermediolateral, sacral 307 - main sensory, of trigeminal nerve 37 - mesencephalic. of trigeminal nerve 37 - of reticular formation 37 -solitary 37 - spinal, of trigeminal nerve 37
0 Oblique muscle fibers, of stomach wall186 Obstruction of pancreatic duct 212 Occipital anastomosis 11 Occipital nerves, sites of emergence 51 Occipital region 50 Occiput - innervation, segmental 51
- nerves, sites of emergence 51 Oesophagus see Esophagus Oligozoospermia 260 Omentum -greater 154, 156,158.164, 178,183,191,192,205 -- development 218 --fusion 181 - lesser 154, 159, 164, 178, 183, 204,218 Omphalocele 181 Oocyte 253 Opening of the cervix during childbirth 248 Openings in diaphragm 90 - transmitted structures 90 Ophthalmic collaterals 11 Oral floor 37 Orgiln(s) - extraperitoneal 153, 178 - intraperitoneal 153, 1 78 - Intraperitoneal 153 - lymph node stiltlons 295 - lymphatic drainage 296 - lymphoepithelial 132 - migration In upper abdomen 179
- porasympothetic efh!cts 307 - primarily retroperitoneal 153, 162 - retroperitoneal 153, 162 -- lymphatic drainage 297 - secondarily retroperitoneal 153, 162 - sympathetic effects 306 Oropharynx 34, 36 Osteoclast stimulation 23 Ostium/Orifice/Os - lorltlce] atrioventricular -- left 113 -- right 105,113 -lorifice]ileocecal 190,194 -lorifice]ofcoronarysinus 105 -lorifice]ofinferiorvenacava 105 - lorltlce] of vermiform appendix 194 - !orifice] pharynge•l, of eustachian tube 34, 36 - lorltlce] pyloric 185, 188, 190 - lorltlce] ureteral 233,235, 237, 241 -- closure, functional 237 -- narrowing 236 - lorltlce] urethral -- external 235, 238, 250 -- - location in the female 239 -- internal 236, 238 - !orifice] vaginal 245,250 - los]intemal, of uterus 247 - los] uterine 245,250 -- external 247 - !ostium] abdominal, of fallopian tube 246 - !ostium] uterine, offalloplan tube 247 Outflow tract -leftventricular 104,113,108 - right ventricular 105, 108, 113 -- on MRI 98 Ovarian honmones 249 Ovary 163, 174,223,234, 241, 244, 252, 287' 290 - autonomic Innervation 321 - cortical zone 253 - development 242 - extremity, wbal 246, 252 - function 240 - left, lymphatic drainage 297 - lymphatic drainage 305 - medullary zone 253 - ovum collection mechanism
252 - peritoneal covering 246, 252 - right, lymphatic drainage 297 -surface -- medial 252 -- posterior 252 - uterine pole 246, 247 - vasculilr pole 246, 247 - vasculilr supply, duili 252 Oviduct see Tube, fallopian Ovulation 249, 253 Ovum collection mechanism, on OVilry 252 Ovum, fertilized, philses in migration 254
p Pain, referred - bladder 317 - diaphragm 146 - esophagus 143 - gallbladder 310 -gonad -- male 319 -- female 320 -heart 144 - Intestine 310 -Kidney 317 - poncreas 310 -stomach 310 Pain, burning, retrosternal 75 Pancreas 160, 162 ff, 205, 214, 21 8, 225, 264 - •nnular 181,214 - anomalous development 214 - arterialsupply 266, 268 - development 178 -- dorsal bud 179 --ventral bud 179,214 --- migration 214 - endocrine 217 - exocrine 217 - head of 189, 211,214, 215, 221,225 -- tumor 167,212,277 - Head zones 31 o -histology 217 -in situ 215 - innervation, autonomic 31 0 -Islet 217 - location 152, 214 - lymphatic drainage 296, 299 - porasympathetic efh!cts 307 - peritoneal relationships 161 - projection 1 64 -- onto trunk wall 151 -- onto vertebral column 151 - retroperitonealization 179 - sympathetic efh!cts 306 - venous drainage 277 Pancreas see Pancreas Pancreatic duct see Duct. poncreatic Pancre.Jtic tumor. malignant 215 Pancreatitis 21 3 Pap smear 249 Paplllil -duodenal -- major 188,211,212 --minor 188,212 -foliate 41 - Ileal, frenulum 194 - renal 228, 230 -- cribriform area 229 - Villlate 41 -Vater see Papilla, major duodenal Paplllilry muscle 107 Paracrdiac gutter 160, 161 Paracervix 177 Paradidymis 242 Paramesonephrlc duct 242 Parapharyngeal space see Space, porapharyngeal Pararectal incision 151 Parasympathetic nervous system 307 - bladder innervation 237
363
P Parasympathetic nervous system
Parosympathetic nMI!lus sys!l!m - cranial part 307, 31 5 -In the neck 16 -sacral part 307,315 -thoracic. organization 140 Parathormone 23 - deficiency 23 Parathyroid gland(s) 22 - enlargement 23 - hirtology 23 - inferior pair 22 - migration, embryonic 21 - superior pair 22 Paravertebral line see Line, paravertebral Parietal cells 187 Paroophoron 242 Part - ascending, of aorta see Ascending aorta - costal, of diaphragm 166 -- in abdominal transverse section 166 - descending -- of aorta see Aorta. descending -- ofduodenum 160 --- projection onto vertebral column 151 - horizontal, of duodenum 160 - of liver -- left 208 - - porterior 208 -- right 208 - superior, of duodenum 160 - supravaginal, of cervix 247, 249. 250 - vaginal, of cervix 241, 245, 247, 250 -- epithelium 249 Partial lung resection 85 Parts of colon, intraperitoneal 195 Parturition 255 - cervical dilation 248 Passavant ridge 37 Pecten, anal 198 Pelvic arteries 262 Pelvic cavity - divisions 152 -layers --anterior 152 -- middle 152 -- porterior 152 - peritoneal relationships 153 Pelvic connective tissue 168 Pelvic dimensions 255 - internal 255 Pelvlcfasclae 1 68 Pelvic floor, structural weakness of 236 Pelvic inlet plane 255 Pelvic layers, organ locations 152 Pelvic levels 168 - organ locations 152 - peritoneal 168 - subfascial 168 - subperitoneal 168 Pelvic lymph nodes 303 - visceral 297 Pelvic organs 1 52 - attachments 176 -female -- arterial supply 287
364
- - loGJtion 177 - - venous drainage 287 -male - - arterial supply 286 - - loGJtion 176 - - venous drainage 286 Pelvic outlet plane 255 Pelvic region 162 Pelvic wall - arterial pathways 285 - neurovascular tracts 285 Pelvis - anastomoses, venous 292 -female - - autonomic plexuses 321 - - internal iliac artery, sequence of branches 287 - - peritoneal relationships 169, 171,174 - - visceral fasciae 171 -lesser - - fasciae 168 - - levels 168 - - organs 1 52 - - spaces 168 - lymphatic trunks 295 -male - - peritoneal relationships 154, 169,170,172 - - visceral fasciae 170 Pelvis, renal 227, 228, 230, 282 - ampullary 230 -closure 231 - dendritic 230 - embryonic development 242 -linear 230 - rtructure 230 - variants In shape of 230 Penis 238, 240 - autonomic innerviltion 31 g -dorsum 261 - glans 238,241, 242, 256,261 - lymphatic drainage 304 - pendulous part 239 Pepsinogen 187 Percussion, chest 99 PericardiaI cavity 61, 67, 77 - bleeding Into 67 PeriGirdltls 67 PeriGirdium 61. 64. 97 - fibrous 62, 64, 66, 72, 79, 91, 97,99 - - fusion with diaphragmatic fascia 64, 67 - innervation 146 - location 66 - lymphatic drainage 129, 130, 139 - openings 67
-serous - - parietallayer 67 - - visceral layer 97,101 - rtructure 67 Perimetrium 234, 244, 248, 250 Portal area 209 Perirenal fat capsule 167, 220, 223,226 - atrophy 224 Peritoneal adhesions 156 Peritoneal cavity see Cavity, peritoneal Peritoneal dialysis 157
Peritoneal fold see Fold, umbiliGII Peritoneal folds, genitalia, female 246 Peritoneal fossa 155 Peritoneum 1 53 -layer -- parietal 153, 169 --visceral 153 - parietal 154, 163, 233, 244 -- in abdominal transverse section 166 - visceral 166, 234, 244, 250, 256 Peritonitis 157, 194 - bacterial 157 Phallus 242 Pharyngeal arches 20 - arch nerve 21 - Innervation 20 - Internal structure 21 - tissue migration 21 Pharyngeal clefts 20 Pharyngeal constrictors 32, 35 - embryonic origin 20 - Inferior 18, 30, 38 - innervation 1 8 - superior 35, 37, 38 -- contracted 37 Pharyngeal mucosa, Innervation, sensory 18 Pharyngeal muscles 32. 35 Pharyngeal muscles, paralysis of 31 Pharyngeal pouch 21 Pharyngeal tonsil 34, 36 - enlargement 36 Pharyngoesophageal diverticulum 33 Pharynx 32, 40 - connections with skull base 34 - division into levels 34, 36 - innervation 37 - mucosal surface anatomy 34 - muscle bundle, accessory 33 -part -- laryngeal (laryngopharynx) 34,36 -- nasal (nasopharynx) 34, 36 -- oral (oropharynx) 34, 36 - topographical anatomy 34 Phonation 28 - muscle of 28 - position of glottis 29 Phrenic constriction of esophagus 70 Piloerection In heart disease 144 Pits, gastric 187 Placenta 94 Plane - Interspinal 150 - intertubercular 150 - subcostal 150 - transpyloric 58, 150 - xlphosternal 150 Plane, transpylorlc 150 Platysma 3. 4, 46, 55 Pleura - lymphatic drainage 129, 136 - parietal 59, 60, 62, 68 -- boundaries 59 -- part costal 69, 79 diaphragmatic 64, 69, 75, 79
- -- mediartinal 64, 66, 75, 79 - - recesses 5g - pulmonary 64, 68, 81 - visceral 64, 68, 69, 81 Pleural cavity 60. 68 - projection onto chest wall 132 Plexus -aortic - - abdominal 308, 321 - - thoracic 140. 144 - autonomic 140, 308 - - nerve fibers - -- visceromotor 309 - -- viscerosensory 309 -Auerbach 143,314 - autonomic. esophageal wall 143 - brachial 45, 47 ff, 62, 64 -cardiac 140, 144 -carotid - - common 140 - - external 140 - - internal 140 -cellae 309 - - branches to duodenum 31 0 - cervical 4, 16 - - branching pattern 117 - - cutaneous nerves, sensory 44 - - part - - - motor 17 - - - sensory 17 - deferential 309, 318 - enteric. organization 314 - esophageal 71, 140, 142 - gastric 309, 311 - - anterior 143,310 - - posterior 143,310 - hemorrhoidal 198, 200 -hepatic 309,311,313 - hypogastric - - inferior 201, 237, 306, 308, 314,316,319,320 - - - autonomic distribution 315 - - superior 173, 201, 308, 312, 314,316,318,320 -iliac 316,318,321 - intermesenteric 306, 308, 314, 316, 318,320 - mesenteric --Inferior 309,314,316,318, 320 - - superior 309,311,312 - -- branches - - - - toduodenum 310 - - - - to pancreas 310 - - - dirtribution 312 - - autonomic distribution 31 5 - muscular 300 - myenteric (Auerbach plexus) 143,314 -ovarian 308,313,321 - pampiniform 258, 261 - pancreatic 309,310 - pharyngeal• 37, 38, 140 - piriform 285 - prostatic 309, 316, 318 - pterygoid 12 - pulmonary 60, 140, 142, 144 - - bronchial branches 142 - rectal 201 - - inferior 309,314, 318 --middle 309,314,316,318, 320
Renal pyramid R
--superior 309,314 - renal 308,313, 316 - sacral 201, 232, 261, 262, 284, 308,320 -splenic 309.311,313 - subclavian 140 - submucosal 300 -submucous -- esophagus 143 -- gastric wall 187 -- intestine (Meissner plexus) 314 - subserous 314 - suprarenal 308, 316 - testicular 308.313.316, 319 -ureteral 308,316,318,320 - uterovaginal 309, 320 -venous -- prostatic 286 -- rectal 272, 287 -- subcutaneous 1 98 -- submucous, esophagus 74 -- testicular 258 -- thyroid 12, 23, 27,47 -- uterine 245, 272, 287. 290 -- vaginal 244, 287 -- vesical 233, 235, 239, 272, 286 -- vesicoprostatic 176 -vertebral 8. 140 -vesical 309,316,318 Pneumocytes (alveolar epithelial cells) -type I 88 -type II 88 Pneumonectomy 85 Pneumonia 88 - radiographic findings 78 - recurrent 72 Pneumothorax, respiratory
mechanics 93 Podocytes 228 Polyps In children 36 Porta hepatis 207 Portal area 209 Portal vein see Vein, portal Portal venous system 274 Portocaval collateral circulation 274, 276, 278, 293 Position of uterus 251 Posterior cricoarytenoid muscle see Muscle, posterior criooarytenord Posterior-wall Infarction 127 Pouch - rectouterine (cul-de-gc) 154, 169,171,174,177, 234,244, 250 -- needle aspiration 175 -rectovesical 154,161,169.170, 234 -vesicouterine 154,169,171, 174, 177' 234, 244, 250 Pregnancy 254 - closure of uterus 248 - ectopic 254 - levels of uterus 254 Prepuce 238, 256 Primary intestinal loop, rotation 180 Primary urine 228 Primordial follicle 253
Process - caudate 206 -coronoid 7 - mastoid 2, 4, 43 - muscular. of arytenoid cartilage 25,28 -spinous -- of atlas 51 -- ofC7vertebra 2, 58 - - ofT12 vertebra 58 - - ofT3 vertebra 58 - - of T7 vertebra 58 -styloid 40 - - embryonic origin 20 - - of temporal bone 35 - transverse, of atlas 51 - uncinate 215 - vaginal, of peritoneum 258 - vocal, of arytenoid cartilage 24, 28 - - viewed with laryngeal mirror 29 - xiphoid, of sternum 59, 61 Progestlns 249 Projection of organs - ontoanteriortrunkwall 151 - onto posterior trunk wall 151 -onto vertebral column 151 Promontory, sacral 235, 255 Prostate 168. 169.233. 238. 241, 256,260 - arterlalsupply 286 - autonomic Innervation 319 -base 257 - development 242 - division into zones, clinical and histological 256 - location, periurethral 257 - lymphatic drainage 297, 304 Prostati[ carcinoma 257 Prostatic hyperplasia 238, 257 Prostatic secretion 257 Pulmonary acinus 86 Pulmonary apex 59, 79, 80 Pulmonary arteries 120 - projection onto chest wall 121 Pulmonary blood flow 142 Pulmonary edema 88 Pulmonary emphysemil 88 Pulmonary lobectomy 85 Pulmonary lobules 80, 86 Pulmonary metastases 289 Pulmonary opacities on radiographs 78 Pulmonary segments 84 Pulmonary trunk. on chest radiograph 96, 121 Pulmonary valve see Valve, pulmonary Pulmonary vascular tree 88 Pulmonary veins 120 - projection onto chest wall 121 Pulmonary vessels, topographical anatomy 120 Pulp artery 219 Pulp of spleen 219 -red 219 -white 219 Pulp vein 219 Pulsion diverticulum 73 Pumping of blood into aorta, rhythmical 115
Punctum nervosum (Erb's point) 17,44 Pupillary dilatation, on left side, In heart disease 144 Purkinje fibers 111 Pyl!lonephritis, suppurative, bacterial 231 Pylorus - Innervation, autonomic 311 - projection onto vertebral column 151
R Rami/Branches - lbranches]lntergangllonlc of cervical sympathetic trunk 19 - !branches] posterior cutaneous 50 - !rami] communicantes 308, 318,320 -- gray 308 Raphe - mylohyoid 6 -penile 242 - pharyngeal 33, 38 Recess - costodiaphragmatic 69. 79, 81, 91,225 - costomedlastlnal 69, 81, 91, 99 -duodenal -- Inferior 161,189 -- superior 161, 189 -ileocecal -- Inferior 161 -- superior 161 - Inferior, of omental bursa 164 - intersigmoid 161 - piriform 26, 34, 41, 54 - retrocecal 161 -splenic 167,204 -- of omental bursa 164 - subhepatic 161 - subphrenic 161 - superior, of omental bursa 164 Rectal tumor, milllgnant, lymphil· tic drainage 301 Rectouterine pouch (cul-de-sac) 154, 169, 171, 174, 177' 234, 244,250 - needle aspiration 175 Rectum 163, 170, 176, 192, 196, 232. 234, 244, 250. 256. 261 - arterial supply 288 -- lnfradlaphragmatlc route 288 -- peritoneal route 288 -- supradiaphragmatic route 288 - curvature 196 - embryonic development 196 - flxed 153 -In situ 197 - innei'Villtion -- autonomic 312 -- sympathetic 315 - Interior 198 - location 169 - lymphatic drainage 296, 301 -mobile 153 - peritoneal covering 198
- projection -- onto the pelvis 1 96 -- ontothetrunkwall 151 - start. projection onto vertebral column 151 - surgical approach 1 96 - venous drainage 289 - wall segment devoid of ganglion cells 196 - wall structure 198
-zone -- cutaneous, lymphatic drainage 301 Recurrent laryngeal neiVe palsy 27 - bilateral 28, 31 Referred pain see pain referred Refluxesophagltls 75 Refluxofunne 231 Reflux. gastroesophageal 75 Reflux. vesicoureteral, protection against 236 Region -abdominal -- lateral --- left 150 --- right 150 -cervical -- anterior 42, 44 -- lateral 42, 49 -- posterior 42, 50 - epigastric 150 - hypochondriac -- left 150 -- right 150 -inguinal -- left 150 -- right 150 - occipital 42, 50 - parietal 42 - posterior cervical see Region, posterior cervical -pubic 150 - sternocleidomastoid 42, 44 - urogenital 150 Regurgitation 33 Reichert cartilage 20 Reinke space 31 Renal ilrtery see Artery, renal Renal bed 226 Renal calyces 230 -closure 231 - stone 222, 230 -system 229 Renal calyx - major 228, 230, 282 - minor 228, 230 - superior 228, 230 Renal colic 222,231 Renal corpuscle 228 Renal cortex 228 Renal fascia 226 Renal hilum 222, 227, 230 - projection onto vertebral column 151 Renal medulla 228 -Inner 229 -outer 229 Renal parenchyma 228 Renal pelvicstone 222, 230 Renal pelvis see Pelvis, renal Renal pyramid 228, 230, 282
365
R. Renal segments
Renal segments 283 Renal vein see Vein, renal Renal vessels - architecture 229 -course 227 Residual urine 238 Respiratory distress - after thyroid surgery 23 Respiratory mechanics 92 Respiratory mechanics in pneuma· thorax 93 Respiratory muscles - active during expiration 92 - active during Inspiration 92 Respiratory position of glottis 29 Rete testis 258 Retrocardial space 61, 63 - radiographic appearance 98 Retroflexion, of uterus 251 Retroperitoneum see Retroperi· toneum Retroperitoneum, central 162 Retroperltoneum, surgically exposed 162 Retropharyngeal abscess 3 Retroversion, of uterus 251 Retrovesicular pouch 153, 239 Rhinoscopy, posterior 34 Rib 59 -first 59.62 -second 58 -third 52 -twelfth 58 Right-sided heart failure 43, 65, 205 Right-tr>-left shunt, intracardiac, prenatal 94 Rima - glottldls (glottis) 26, 53 -- closure 28 -- opening 28 -- part --- Intercartilaginous 28 --- intermembranous 28 - vestibuli 26 Ring see anulus Rlolan anastomosis 271 Root - C8 48 -of lung 81 - of mesentery (mesenteric root) 160, 189, 215, 225 -- projection onto skeleton 158 -of tongue 34 - of transverse mesocolon 225 - Tl 48 Rootoflung 81
5 Sac - alveolar 86 -- structure 88 - laryngeal 26 Salpinx see Fallopian tube Scapula 59 Scapular line see Line, scapular Scrotum 238, 241, 256, 258 - development 242 Second pharyngeal arch 20
366
Secondary follicle 253 Secretion, bronchial, regulation 142 Segment -anterior -- inferior, of kidney 283 -- superior, of kidney 283 - bronchopulmonary 85 - Inferior renal 283 - posterior rem1l 283 - superior renal 283 Segment, bronchoarterial 120 Segmental bronchus 65, 84, 86 Segmentectomy 85 Semilunar valves 1 06 Seminal vesicle see Glands, Vesicle, seminal
Seminiferous structures 260 Seminiferous tubules 259 Sentlm1l node 15 Sepsis 40 Septulum testis 258 Septum - lnteralveolar, elastic fibers 88 - Interatrial 104, 1 07 - interlobular 87 - interventrio.Jiar 99, 102, 1 05, 110 -- arterial supply 126 -- part -- - membranous 1 07 ---muscular 107 -nasal 34 - of penis 238 - of scrotum 256, 258 - of testis 258 - rectovaginal168, 171,176,250 - rectovesical 168 ff, 176 -vesicovaginal" 250 Serosa -of colon wall 195 - of duodenum 189 - of fallopian tube 247 - of small Intestine 190 -of stomach wall 187 - of testis 258 - of uterus 248, 250 Serosa, of vermiform appendix 195 Sex glands, ilccessory 240 - autonomic innervation 31 9 - lymphatic drainage 304 Shedding, of functional layer of myometrium 248 Short-axis diameter of heart 96 "Side stitch" 21 8 Sigmoid colon see Colon, sigmoid Sinus -anal 198 -aortic 124 -carotid 10 - cavernous 13 - cervical 21 -coronary 101,103,104, 106, 124 -dural 12 - oblique, perlcardlal 67 - piriform, viewed with laryngeal mirror 29 - sigmoid 34, 38 - superiorsagittal 13 - transverse, perlcardlal 67
- urogenital 242 - vena rum 1 1J Sinus node see Node, sinoatrial Sixth pharyngeal arch 20 Skin Incisions, surgical abdominal 151 Skin of penis 238 Skin, perianal 198 Skull base tumor, vagus nerve lesion 31 Skull base, pharyngobasilar fascia 33 Small Intestine 157,184,190 -anatomical constrictions 190 - arterialsupply 268 - Head zones 312 - innervation
-- autonomic 312 --sympathetic 315 - location 152 -loops 190 - lymphatic drainage 296, 300 - radiography 202 - venous drainage 278 Soft palate 34, 36 Soft palate. muscles 35 Somatostatin 187 Space - "danger• 3 - extraperltoneal 153, 154 -- pelvic 1 68, 233, 235, 239, 244 - lnfracollc -- left 161 -- right 161 - lateropharyngeal 40 -- part --- anterior 40 --- posterior 40 - parapharyngeal 40 -- clinical significance 40 -- neurovascularstructures 38, 41 - parletocollc -- left 161 -- right 161 - retrocardial 61, 63 -- radiographic appearance 98 - retrolngulnal 168 - retroperitoneal (retroperlto· neum) 154, 162. 170, 176, 179, 215,226 -- pelvis 168 -- renal bed 225 --vessels 160 --zones 162 - retropharyngeal 40 - retropubic 168, 170, 176, 256 - subglottic 26 - supraglottic 26, 55 - transglottic 26 Speech, hypemasal 31 Sperm 259 Sperm count 260 Spermatic cord see Cord. spermatic Spermatogenesis 259, 260 Spermatozoon 259 - maturation 259 Spinal nerve branches, cervical 16 Spinal neiVes, cervical 1 6
Spine(s) - anterior superior iliac 150 -- left 195 -- right 195 - Ischial 176 -scapular 4 -- line connecting scapular spines 58 Spiral arteries 248 Spleen 59, 162, 164, 189, 205, 211, 218 ff, 264 - arterial supply 266 - development 1 78 -extremity -- anterior 21 9 - - posterior 219 - histological structure 219 - in abdominal transverse section 166 -In situ 218 - innervation, autonomic 310 - location 218 - lymphatic drainage 296, 299 - peritoneal relationships 218 - projection -- ontotrunkwall 151 -- onto skeleton 218 -shape 219 - venous drainage 277 Splenlcfossa 225 Splenic nodules 219 Splenicsinus 21 9 Spread of Infection, perlpharyngeal 40 Squamous epithelium, nonkerati· nized, stratified, vocal fold 31 Staghorn calculus 222 Stalk of epiglottis 25 Stapes, embryonic origin 20 Stem cells, of stomadl 187 Sternal line see Line, sternal Sternum 98 Stomach 64, 75, 79, 165, 1 82, 205,264 - areas of contact with adjacent organs 182 - cardia see cardiac part -cardiac part 183, 184, 185 - circular muscle layer 186 - development 1 78 - fundus 75. 183, 1 84 -- lymphatic drainage 298 - Head zones 310 - In abdominal transverse section 166 -in situ 183 - innervation, autonomic 310 - Interior 185 - location 1 52 - longitudinal folds 185 - longitudinal muscle layer 186 - lymphatic drainage 296, 298 -mucosa 185 - muscular coat, oblique, Inner 186 - projection onto trunk wall 151, 182 -shape 184 - topographical relationships 182 - venous drainage 276 - wall structure 1 86 Stroke 11
Triangle T
Subcostal plane 1SO Submucosa - of colon wall 195 - of duodenum 189 - of esophagus 73. 74, 143 - of small intestine 190 - of urethra 237 -of uterine wall 231 Subsegmental bronchus - large 86 -small 86 Subserosa - of colon wall 195 - of small Intestine 190 - of stomach wall 187 - of vermiform appendix 195 Subserosa, of duodenum 189 Sulcus (sulci)/Groove(s) - [groove] for Inferior vena cava 206 - [groove] for subclavian artery 9 - [sulci] paracolic 160 -[sulcus] coronary 100,102,124 - [sulcus]lnterventrlculilr 124 -- anterior 100, 1 07 --posterior 101,103 Superficial epithelial cells, stomach 187 Supracrlstal plane 150 Suprarenal artery see Artery, suprarenal Suprarenal cortex 220 Suprarenal gland 59, 211, 218, 220, 223, 225, 227. 232 - autonomic innervation 316 - differences between right and left suprarenal glands 221 - In abdominal transverse section 166 -left 151,152, 162,164,189 -- location 1 52 -- projection onto trunk wall 151 - location 220 - lymphatic drilinage 302 -right 151,152,162,189 -- location 1 52 -- projection onto trunk wall 151 -shape 220 - structure 220 Suprarenal medulla 220 Suprarenal vein see Vein, suprarenal Suprasternal notch 2 Surface
-anterior -- of kidney 227 -- of suprarenal gland 220 - anterolateral, of arytenoid cartilage 25 -articular -- arytenoid, of cricoid cartilage 25 -- of arytenoid cartilage 25 - - thyroid 28 -- - of cricoid cartilage 25 - colic. of spleen 219 - colomesocolic" 182 - costal, of lung 80 - diaphragmatic -- of heart (inferior cardiac surface) 1 01, 125
--of lung 81 -- ofspleen 219 - diaphragmatic, of heart 125 - epigastric" 182 - gastric, of spleen 219 - hepatic" 182 - interlobar 81 - mediastinal, of lung 81 - pancreatic" 182 - phrenic" 182 -posterior - - of heart• 101 - - of kidney 227 - - of uterus 234 - pulmonary 81
- renal• -- of spleen 219 --of stomach 182 - - of suprarenal gland 220 - sternC>COstal (anterior cardiac surface) 100 - suprarenal" 182 Surface of liver 206 Surfilces of lung 81 Surfactant 88 Swallowing 26 -anatomy 37 - difficult, with an aortic aneurysm 115 - esophageill peristalsis 73 - muscular actions 6 -phases 37 -reflux 37 Swelling of laryngeill muCD!ia 26 Sympathetic nervous system 306 - bladder innervation 237 - effects 306 -thoracic, organization 140 Symphysis pubis 250, 256 Systole 103,112
T Taenia - free see Taenia, Iibera - Iibera 192,194,197 - mesC>COilc 192 -of colon 156.158,191,192, 195 - omental 192 Tall - of epididymis 258 - ofpancreils 160.189.211,214, 216,218,221,225 Tawara node 11 0 Tendon of Infundibulum 107 Tension pneumothorax, resplra· tory mechanics 93 Teratozompermia 260 Termination of hepatic veins 205 Tertiary follicle 253 Testicle see Testis Testis 238,241, 258, 261,319 -autonomic innervation 319 - development 242 - dimensions 259 - function 240 - Head mnes 319 - lymphatic drainage 297, 304 - strudl.Jre 259
Tetraiodothyronine 23 Theca - externa 253 - lnterna 253 Theca cells 253 Third of tongue, pmterior, sensory innervation 18 Third pharyngeal arch 20 Thoracic aperture - inferior 59, 60 -- closure 91 - superior 59, 60, 77 -- neurovascular structures 47, 48 Thoracic cavity 59 - complementary spaces 91 - divisions 60 Thoracic contraction - In longitudinal axis 92 - In sagittal axis 92 - in transverse axis 92 Thoracic expansion - In longitudinal axis 92 - In sagittal axis 92 - In trilnsverse ilxls 92 Thoracic orgilns, ilrterial supply 114 Thoracic spine, projection of anatomical structures 58 Thorax 58 -bony -- projection of lung boundaries 69 -- projection of pleural boundaries 69 - lymphatic pathways 129 - lymphatic trunks 128 - nervous system 140 - reference lines -- horizontal 58 -- longitudinal 58 - venous drainage 116 Throat see Pharynx Thymocytes 132 Thymus Thymus 61, 62, 64, 132 -cortex 132 - embryonic development 132 - functional ilrthltecture 132 - histology 132 - involution 62, 132 -lobe -- left 133 -- right 133 -medulla 132 - migration, embryonic 21 - projection onto chest wall 132 -shape 133 -size 133 - triangle 132 Thyroid cartilage see Cartilage, thyroid Thyroid follicles 23 Thyroid gland 22, 30, 34, 36, 47, 48,52 - embryonic migration 21 - histology 23 -location -- relationship to neurovascular structures 22 -- relationship to trachea 22 Thyroid hormones 23
Thyroid region - blood supply 23 - Innervation 23 - venous drainage 23 Thyroid surgery 47 - removal of parathyroid glands 22 - recurrent laryngeal nerve lesion 23, 28,31 Thyroid surgery, recurrent laryn· geal nerve lesion 31 Thyroxine 23 Tight )unctions 88 T·lymphocytes, maturation of 132 Tonsil see Tonsil, palatine Tonsil(s) - [tonsilla[ tubaria 36 - lingual 26, 36, 40 - palatine 36, 40 -- embryonic origin 21 -- sensory innervation 18 -- vascular supply 41 - pharyngeal 34, 36 Tonsillectomy, risk of bleeding 41 Torticollis - congenital 5 - muscular 43 Torus tubarlus 36 Trabecula(e) - carneae 103,104 -septomarginal 105, 107 Trabecular artery, of spleen 219 Trabecular vein, of spleen 219 Trachea 30, 61, 62, 65, 70, 76, 82 -course 77 - divisions 83 - insib.J 77 - Innervation, autonomic 142 - lymphatic drillnage 129, 130, 136 -part -- cervical 76 -- thoracic 76 - projection onto chest wall 76 - relationship to aorta 114 - relationship to esophagus 70, 72 - relationship to thyroid gland 22 - shilpe 76 - strudl.Jre 82 - surgical approaches 30 - topographical relations 76 - viewed with laryngeal mirror 29 - Willi structure 83 Tracheoesophageal fistula 72 Tracheotomy 30 Tract - cortlconuclear 37 - horizontal 294 - vertical 294 Traction diverticulum 73 Transitional cells, domed 237 Transportofurlne 231 Tree, bronchial see Bronchial tree Treitz hernia 188 Triad -portal 208 Triangle - anterior cervical 46, 48 - [trigone] bladder 233,237 - [trigone] fibrous -- left 107
367
T Triangle
Triangk, {trigone] fibrous -- right 107 - carotid 42. 48 - cervical, anterior 40, 48 - lateral cervical 42, 44 - lumbocostal (of Bochdalek) 90 - muscular 42 - occipital 42, 43 - omocli!vlculilr 42 - posterior cervical 42, 44, 45 - sternocostal (of Larrey) 90 -- transmitted structures 90 - subclavian see omoclavlcular - submilndibular 42 - submental 42 - suboccipital 51 Tricuspid valve see Valve, right atrioventricular Triiodothyronine 23 Trunk wall - i!lnterior -- horizontal (transverse) planes 150 -- quadrants 150 -- regions 1 50 - projection of organs onto 151 Trunk(s) - brachlocephalic 10, 27, 39, 100, 114,128 - celiac 163 ff, 1 88. 205. 211, 221' 232, 262, 266, 272 -- branches 263, 264 --- esophageal 263 --- pancreatic 263 -- origin, projection onto vertebral column 58, 151 -- projection onto vertebral column 265 -- variants 265 - costocervical 1 0 -jugular 14 - linguofaclal 49 -lumbar 128 --- left 294 ff, 302 --- right 294, 297, 302 -- subclavian 128 - lumbosacral 318, 320 -lymphatic -- bronchomediastlnal 128, 130, 136. 139. 299 -- coronary --- left 138 --- right 138 -- Intestinal 294, 296, 298 --jugular 128,130.134 - pulmonary 59, 66, 79, 95, 97, 98,100,120,124 -- blood flow 113 -- fetal 94 -- projection onto chest wall 1 14 -- radiographic appearanll! 96 - sympathetic 16, 18, 38, 48, 62, 140,142,306,310,312,314, 316,318,320 --ganglia lumbar 306,308,316, 318, 320 sacral 308, 316 --in the neck 16 -- interganglionic branches 306 -- passage through diaphragm 91
368
- thyrocervical 10, 23, 27, 47, 52 -- branches --- esophageal 118 --- tracheal 122 - thyrolingual 49 - thyrolinguofacial 49 -vagal 142 --anterior 71,140,143,308, 310,316 --- branch celiac 310 - - - - hepatic 310,313 - - - - pyloric 310,313 -- posterior 140,143,308,310, 312.314,316 --- branch celiac 308,311,313 - - - - hepatic 310 - - - - pylorlc310 Tubal pregnancy 254 Tubal wall rupture 254 Tube - eustachian 36 -- cartilaginous part 35 -- closure 36 -- dysfunction 36 -- embryonic development 21 -- eustachian tube see Tube, eustachian -- muscles 35 -- opening 34, 36 - fallopian (uterine) 163, 169, 174,223, 234,241, 244,246, 287,290 -- ampulla 246 -- autonomic innervation 321 -- cross section 247 -- development 242 -- function 240 -- infundibulum 240 -- isthmus 246 -- lymphatic drainage 297 -- peritoneal covering 240 -- right, lymphatic drainage 297 Tubercle - corniculate 26, 28, 34, 39, 41 -- viewed with laryngeal mirror 29 - cuneiform 26, 28, 34, 39, 41 -- viewed with laryngeal mirror 29 - epiglottic, viewed with laryngeal mirror 29 -Iliac 150 -scalene g -thyroid -- Inferior 25 -- superior 25 Tubular system, renal 228 Tubule(s) -distal -- part -- - convoluted 229 -- - straight 229 - proximal 228 -- part -- - convoluted 228 -- - straight 229 - renal collecting 22g - seminiferous
-- contorted 259 -- straight 259
Tunica albugineil - of corpus spongiosum 238 - of ovary 252 - of testis 258 Tunica dartos 258 Turbinate, nasal - inferior 34, 39 - middle 34, 39 Tympilnic cavity, embryonic development 21
u Ulcer, gastric. endosmpic view 187 Ultlmobranchlal body 21 Umbilical cord 95 Umbilical fistula 181 Umbilicus 150 - projection onto vertebral column 151 Upper abdomen, opened 165, 211 Upper abdominal organs 1 52 Upper esophageal sphincter 61, 70, 74,77 Urachus - Incomplete obliteration of 155 - obliterated 155. 156. 1 58. 160. 172,191 Ureter 160, 227, 228, 230, 241, 245, 282, 286 - arrangement of muscle layers 231 -autonomic innervation 316 -course 223 -- In the female 234 -- in the mille 232 - crossing vessels 160, 173, 233 - development 242 -In situ 223 - left 163, 221, 223 -- location 152 - lymphatic drainage 302 -part -- abdominal 232 -- Intramural 232, 237 - - pelvic 232 - passage below uterine artery 246 - relationship to uterine artery 291 - right 173, 220, 223 -- location 152 - termination 176 -wall structure 231 Ureteral colic 222,231 Ureterill orifice see Orifice, ureteral Ureteral peristalsis 231 Ureteral segment -lumbar 232 -renal 232 - vesicill 232 Ureteral stone 222 Ureteropelvic junction 233 Uteroveslcular junction 233 Urethril - femille 241, 250 -- development 242 -- external orifice 239 -- location 239
- - membranous part 239 - function 240 - lymphatic drainage 303 - male 241, 260 - - development 242 - - location 238 -- part Intramural 238 membromous 233, 238, 257 - -- prostatic 233. 238. 257 - -- spongy 233, 238, 256 -mucosa 237 - muscular apparatus 236 - muscular coat 237 - submucosa 237 Urethral stone 222 Urethritis 239 Urethrovaginal fistula 239 Urge to defecate 199 Urinary bladder see Bladder Urinarycontinence 236 Urinary incontinence 222, 236 Urlnilry organs 222 - autonomic Innervation 316 - in situ 223 - in the female 234 - In the male 232 - projection - - onto the organs 222 - - onto the skeleton 222 - topographical anatomy 224, 232,234 Urinary retention, abnormal 236 Urinary space, In renal corpuscle 228 Urinary stone 222 Urinary urgency 236 Urogenital system - in the femille 241 - in the male 241 Urothelial cell 237 Uterine cavity 247 Uterine tumor, malignilnt, lymphogenous spread 305 Uterus 163,169,174,234,241, 244,290 -adnexa 246 - arterial supply 287 - autonomic Innervation 321 - changes in position, physiologi· cal 251 - curvature 251 - development 242 - flexion 251 - function 240 - fundus 163, 171, 234, 244, 290 - - lymphatic drainage 305 - junction of corpus and cervix 247 - location 251 - lymphatic drainage 297, 305 - peritoneal covering 175, 244 - position In pelvis 251 - regression, postpartum 255 - relationship to pelvic organs 244 -shape 247 - structure 247 - venous drainage 290 -version 251 - wall structure 248 Uterus and Its ligaments 171
Vein(s)
Utricle, prostatic 242 Uvula - of bladder 233, 235, 237 -- retraction of, during micturition 236 - palatine 34, 35, 36, 39
v Vagina 169,171,241,244,250 - arterial supply 287, 291 - autonomic Innervation 321 - development 242 - fornix 171, 175, 250 - function 240 - location 250 - lymphatic drainage 297 - relationship to pelvic organs 244 -wall -- anterior 250 -- posterior 244, 246, 250 Vaginal epithelium 249 - development 242 Vaginal rugae 244, 250 Vagotomy, proximal, selective 311 Vagus roots 31 Vallecula of epiglottis 29. 41 Valve (tension) pneumothorax, respiratory mechanics 93 Valve(s) -aortic 61,104,108,113 -- auscultation site 1 09 -- fibrous ring 107 -- projection onto thoracic skeleton 109 -- sound transmission 1 09 - atrioventricular 105, 106 -- left (mitral valve) 104, 106 --- auscultation site 109 ---cusp anterior 106 - - - - commissural 1 D7
-- -- posterior 107 -- - projection onto thoracic skeleton 1 09 -- - sound transmission 1 09 -- right(tricuspidvalve) 105.106 --- auscultation site 109 ---cusp anterior 105, 106 -- -- posterior 106 ---- septal106 -- - projection onto thoracic skeleton 1 09 -- - sound transmission 1 09 - cardlac(heartvalves) 106 - of foramen ovale 104 - ofKerckring 188,189 -pulmonary 105,106, 108,113 -- auscultation site 1 09 -- tibrousring 107 - - projection onto thoracic
skeleton 109 -- sound transmission 1 09 Valved orlflce of coronary sinus 105 Vatved orifice of inferior vena cava 94,105 Valves, anal 198
Varicocele 261,281 Vasa recta see Arteries, straight Vascular valves, cardiac 106 Veln(s) -angular 12 - anterior interventricular 124 - anterior, of right ventricle 124 - appendicular 275, 279 - arcuate 228 - axillary 292 - azygos 62, 65, 72, 99, 1 16, 11 8, 273,292 - - opening Into superior vena cava 65 - - passage through diaphragm 91 - - "riding" on right upper lobar bronchus 76 - - termination of bronchial veins 122 - brachiocephalic 1 2, 23, 27, 59, 61. 62, 7g, 11 8, 128, 292 - - tributaries 12 - bronchial 120, 1 22 - bronchial, termination - - at accessory hemiazygos vein 122 --at azygos vein 122 - cardiac 1 24 - - divisions 125 - - great see vein, anterior Interventricular - - middle 124 --short 124 - - smallest 1 24 - [vena] cava - - Inferior 65, 72, 91, 94, 1 DO, 116, 162, 188,205,207,211, 221. 232, 262, 264, 268, 270, 274, 276, 278, 288, 292 blood flow 1 13 fetal 94 In abdominal transverse section 166 origin from common iliac
veins, projection onto vertebral column 151 outflow obstruction 116 projection onto vertebral column 273 tributaries 272 - -- - direct 273 - -- - Indirect 273 - - left, persistent 283 - - superior 23, 59, 62, 65, 66, 98,100,116,292 blood flow 1 13 projection onto chest wall 114 relationship to trachea 1 17 tributaries 1 2 -cecal 278 - central, of suprarenal gland 220 - cervical --deep 13 - - superficial 44 -colic 293 --left 162,189,215,225, 275, 279 - - middle 165, 275, 276, 278 - - right 275, 278 - cystic 275, 278
- deep circumflex iliac 272, 292 - diaphragmatic 1 23 -dorsal -- deep -- - clitoral 250 -- - penile 233, 238, 261, 286 -- superficial penile 238, 256 - epigastric -- Inferior 160, 172, 232, 272, 292 -- - peritoneal covering 155 -- superftclal 292 -- superior 292 - esophageal 11 8, 275, 276, 293 -- anastomoses 199 - facial 12, 27 --common 48 - femoral 261, 272, 292 -gastric -- left 1 18. 163. 275. 276. 278. 293 -- right 276, 278, 293 -- short 275, 276 - gastro-omental -- left 276 -- right 275, 276, 278 -gluteal -- Inferior 272, 286, 289 -- superior 272, 286, 289 - hemiazygos 63. 65. 99. 1 16. 118,273,292 -- accessory 63, 65, 116, 1 18, 292 projection onto vertebral column 58 termination of bronchial veins 122 -- passage through diaphragm 91 -- projection onto vertebral column 58 - hepatic 95, 189, 208, 211, 273, 276 -- fetal 94 -- intermediate 206 -- left 206 -- right 206 - Ileal 275, 278 - Ileocolic 275, 278 -iliac -- common 272, 289, 292 --- right 163 -- external 175, 197, 234, 245, 272, 286, 292 --- right 163 -- internal 232, 234, 272, 286 - Intercostal 62 -- left superior 63 -- posterior 1 16 - interlobular -- of kidney 228, 229 -- of liver 209 -jejunal 275, 278 - jugulilr -- external 12, 44, 46, 52 --- tributaries 12 -- anterior 12,46, 52 -- Internal 12, 23, 27, 38, 46, 52, 59, 64,128 -- - tributaries 12 -laryngeal -- Inferior 27, 39
V
-- superior 23, 27, 30 -lingual 12 - lumbar 278, 292 -- ascending 1 16, 232, 272, 292 --- left 223 -marginal -- left 124 -- right 124 -maxillary 13 -mesenteric
-- inferior 163, 173, 223, 274, 278, 286, 289, 293 --- tributaries 279 --superior 163,188,211,215, 225,274, 276, 278,293 --- tributaries 278 - obturator 176, 272, 286, 289, 290 - occipital 1 2, 50 - of penile bulb 286 - ophthalmic 1 2 -ovarian 163, 175, 221, 223, 234, 252, 272, 277. 280, 287' 290 - pancreatic 275 - pancreaticoduodenal 275, 276 -- posterior superior 275, 276 - paraumbilical 155, 293 - pericardlacophrenlc 62, 1 23, 147 --course 91 -phrenic -- Inferior 123, 221, 272 anastomosis with suprilrenal vein 221, 281 left 232, 280 right 280 --superior 123,221 - portill 95, 161, 163,205, 206, 208, 221. 264, 266, 268, 276, 278,289 --fetal 95 -- In abdominal trilnsverse section 166 -- obstruction 1 19 -- portosystemic collaterals 293 -- portocaval see Veins, portal, portosystemlc collaterals -- projection onto vertebral column 274 -- territory 275 -- tributaries 274 - posterior auricular 12 - posterior scrotol 286 - posterior, of left ventride 1 25 - prepyloric 276 -pudendal --external 261 --Internal 197,272,286,289 -pulmonary -- blood How 113 -- branches 81 -- divisions 120 -- left 59, 63, 66, 95, 100 fetal 94 --- inferior 65,120 --- superior 65, 104, 120 -- projection onto chest wall 114,121 -- relationship to esophagus 72 -- right 59, 62, 65, 79, 1 Dl, 1OS --- Inferior 120
369
V Vein(s)
Vein(s), right --- projection onto chest wall 114 --- superior 120 - rectal -- inferior 2116, 289 --- tumor In territory 289 -- middle 272, 286, 2119, 293 - -- tumor In territory 2119 -- superior 275, 279, 286, 289, 293 --- tumor In territory 289 - renal 223, 225, 227, 228, 230, 232, 272, 280 -- accessory 283 -- course 227 --left 163,11111,221,268 --- relationship to superior mesenteric artery 269 --- tributaries 280 -- projection onto vertebral column 281 -- right 220 -- variants 283 - retromandibular 40 - sacral -- lateral 272 -- median 232, 272, 288, 290 - second lumbilr 272 - segmental. of kidney 230 - sigmoid 173, 275, 289 -splenic 164,218,221,274,276, 278 -- In i!bdomlnill transverse section 167 -subclavian 12, 23, 27, 45,47, 59, 62, 65, 79, 128, 292 -- left, projection onto chest wall 114 -- right, projection onto chest wall 114 - superficial temporal 12, 13 - suprarenal 280 -- left 220, 223, 232. 272, 277' 2110 --- anastomosis with inferior phrenic vein 273 -- right 220, 223, 227, 232, 272, 280 --superior 163 -testicular 221,232, 261,273, 277,280 -- right 173
370
- thebesian 124 - third lumbar 272 -thoracic -- Internal 12, 64, 293 -- - passage through diaphragm 91 -- lateral 292 - thoracoeplgastnc 292 -thyroid -- superior 12, 23. 27 -- middle 13, 23, 27, 30 -- Inferior 13, 23, 27, 41, 64, 118 - trilnsverse cervical 13 - umbilical 94 -- obliterated 95 -- patent 95 -- remnant 151 - uterine 272, 287, 290 - vertebral 12 - vesical 173, 272, 290 -- inferior 2116 -- superior 286 Veins In esophageal wall 1 19 - dilated 1 19 Veins in stomach wall, dilated 11 9 Veins, penumbllical 292 Venous catheter, central 13 Venous junction - jugulofacial 1 2, 1 5 - jugulosubclavian 12, 1 5 - of left subclavian and Internal jugulilrvelns 14, 128, 130 - of right subclavian and Internal jugular veins 14, 128 Venous plexus, submucous, esophageal 75, 11 9 Venous pressure, central, assessmentor 43 Venous pulse 43 Ventilatory impairment, obstructlve 87 Ventricle -cardiac -- left 65, 95, 97' 99, , 00 -- - arterial supply 126 --- blood flow 113 --- fetal 94 -- - Inflow tract 104 - - - outflow tract 1 04 -- right 95, 97, 99, 100, 105 arterlalsupply 126 --- blood flow 113
fetal 94 inflow tract 105 on chest radiograph 96 outflow tract 105 - laryngeal (Morgagni space) 26, 31 -- viewed with laryngeal mirror 29 Ventricular contrilctlon 103 Ventricular diastole 11 2 -filling phase 112 - relaxation phase 112 Ventricular musculature 102 Ventricular systole 112 - ejection phase 1 1 2 - isovolumetric contraction phase 112 Venule, straight 229 Vermiform appendix see Appendix, vermifonn
Version, of uterus 251 Vertebra - C7 (vertebra promlnens) 55, 58 - L4 192,195,196 - LS 150.284 - prominens, spinous process 55, 58 - T1 59 - T12 59 -- spinous process 58 - T3, spinous process 58 - T7, spinous process 58 Vertebral column, projection of organs onto 1 51 Vessel(s) -iliac 160 - lymphatic 302 - ovar1iln 223, 246 - "private" -- ofliver 274 -- oflung 120 - "public" 274 - Superior epigastric, projection onto vertebral column 58 - testicular 232 - uterine, tubal branches 246 Vessel, retroperitoneal 162 Vestlbulilr fold 24, 26 Vestibular fold see Fold, vestibular Vestibule - laryngeal (supraglottic space) 26,55 - of omental bursa 164
- of vagina 245, 250 Villi, intestinal 1119 Vocal cord 24, 26, 31 - cricoarytenoid and thyroarytenoid muscles 28 - cricothyroid and vocalis muscles 28 - false see Fold, vestibular Vocal fold(s) 26, 36 - abduction 29 - adduction 29 - Intermediate position 31 - paramedian position 31 - phoniltion position 31 - position 28, 31 - respiratory position 31 -structure 31 - viewed with laryngeal mlnror 29 Vocalls muscle 26, 28, 31 Volvulus 181 Vortex cordis 1 02
w Waldeyer's ring 36 Wolffian duct 242 Wryneck see tortocollls
X Xiphosternal plane 150
z Zenker diverticulum 33, 73 Z1lnefl1Jna - (zona( fasclculilta 220 - (zona( glomerulosa 220 - (zona( pellucida 253 - (zona( reticularis 220 - (zone( columnar 199 - (zone( cutaneous 199, 201 - (zone( white 198
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