Lab I Vertebrae & Muscles of the back

Body Planes:
Sagittal/Lateral
Coronal/Frontal
Transverse/Axial/Horizon
tal

Positional terminology:
Medial vs. lateral
Distal vs. Proximal
Superior/Cranial/Cephalad vs. Inferior
Caudal

Vertebrae: (33 Total)

7 cervical (Atlas/C1,
Axis/C2, & C3-C7)
12 thoracic (T1-T12)
5 lumbar (L1-L5)
5 sacral (S1-S5)
4 coccygeal

Skeleton:
Axial skull, vertebral column,
sternum, ribs
Appendicular pectoral girdle, pelvic
girdle, appendages

Spine has 2 Sets of Curvatures:

Primary Concave; Thoracic & Sacral
Secondary Convex; Cervical & Lumbar; (form later, thus secondary)
Common parts of vertebrae:
Sketch all vertebrae
Spinous processes attachment points for
parts and be able to
interspinous ligaments and muscles (trapezius)
distinguish between
the different types
Transverse processes can hold facet for tubercle
of vertebrae: Atlas,
of rib
Axis, Cervical,
Veretebral foramen house the spinal cord
Thoracic, Lumbar,
Pedicles
Sacrum, and Coccyx
Lamina
Body (Centrum) support weight of body
Vertebral notches - 2 combine to form intervertebral foramen
Articular facets
Cervical Vertebra (7)
Distinguishing Characteristics: traverse foramen in C1-C6; C1-C6 transverse
foramen carry vertebral arteries ( L&R Subclavians) and veins to back of
brain; C7 also carries vertebral veins, but no transverse foramen; C2-C6 have
bifid spinous processes
C1: the Atlas - articulates with the occipital chondyles, has no body, no
spinous process, no rotation; transverse ligament, anterior tubercle,
foramen for dens
C2: the Axis - skull rotates on it, has the Dens and facet for atlas
C7 is vertebra prominens (identifiable spinous process is clinical landmark)
Thoracic Vertebrae (12)
Distinguishing Characteristics: demifacets for articulation with head of ribs;
transverse facet for articulation with tubercle of rib in T1-T10;
posteroinferiorly-sloping spinous processes
T10-T12: no inferior demi facet
Lumbar Vertebrae (5)
Distinguishing Characteristics: massive bodies

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Spinal cord extends down to L2; therefore, spinal taps performed between L3
& L4 (third lumbar interspace)

Sacral Vertebrae (5)

Distinguishing Characteristics: fused
Fusion completes by 23rd year of maturity
Coccygeal Vertebrae (4)
Distinguishing Characteristics: transverse process of coccyx, fused
Intervertebral Discs:
Purpose: separate and cushion vertebra
Contents: nucleus pulposus inside and annulus fibrosus outside
Compose 1/5 of the length of the spine
Symphysis joint (since uses fibrocartilaginous disc)
Ligaments
Anterior Longitudinal Ligament: Anterior to bodies
Posterior Longitudinal Ligament: Posterior to bodies in
spinal canal
Ligamentum Flavum: Anterior to Lamina in spinal canal
- connects adjacent laminae; 2x (right and left)
Supraspinous - covers spinal processes
Interspinous - between spinous processes

Sketch the
ligamentum flavum
(yellow),
supraspinous, and
intraspinous
ligaments

Joints of the Spine (Review Appendix I)

Synarthrosis: Intervertebral Disc (Symphysis fibrocartilaginous disc)
Diarthrosis (Synovial): Atlanto-occipital, Atlanto-axial, Zygapophyseal,
Costovertebral, Costotransverse
Disorders of the Column:
Kyphosis: slumping forward; convexity of thoracic region, dowagers hump
Scoliosis: lateral curvature, could be caused by hemivertebra
Lordosis: slumping back; concavity in lumbar
Herniation of IV discs: annulus fibrosis pushes into vertebral canal
Rupture of Transverse Ligament Dislocated Dens Cervical region damage
Quadriplegia
Parts of the Scapula:
Spine of Scapula attachment point for muscles
Acromion attachment point for muscles and clavicle
Coracoid Process beak-like projecting anterolaterally; attaches to
pectoralis minor
Superior and inferior angles
Costal Surface and Subscapular fossa
Draw the
Posterior Surface, Supraspinous fossa, and Infraspinous
scapula and
label its parts
process
Medial/vertebral border
Body of Scapula, Glenohumoral (shoulder) joint
Back Muscles

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Two types
Extrinsic: superficial and intermediate; innervated by ventral rami (since
migrated from the front embryologically)
Intrinsic: deep muscles, innervated by dorsal rami (since there all along)
SUPERFICIAL MUSCLES OF THE BACK
Purpose: connect back to the upper limbs
Trapezius squares shoulders; fibers run towards acromion, diamond
shaped
o Attachments: Ligamentum nuchae (over C1-C7), spinous process of C7T12 (via aponeuroses), acromion, spine of the scapula, medial 1/3 of
clavicle
o Innervation: Spinal accessory nerve CN XI and Ventral Rami of
C2-C4
Latissimus dorsi erects back; widest of back; fibers run toward humerus
o Attachments: T6-T12, iliac crest, thoracolumbar fascia, humerus
Major and Minor Rhomboids pull shoulders down; fibers run
inferolaterally from spine to scapula. Major is inferior to minor.
o Attachments: Medial border of scapula to spine
Levator scapula raises scapula
o Attachments: Superior part of medial border to transverse processes of
C1-C4
INTERMEDIATE MUSCLES OF THE BACK
Purpose: aid in respiration
Look like aponeurosis; Serratus because rib attachments like serrations on a
knife
Serratus Posterior Superior
o Attachments: Spinous processes of C7-T3 to Ribs 3-5, fibers running
inferolaterally
o Function: Elevate ribs
Serratus Posterior Inferior
o Attachments: Ribs 8-12 to spinous processes of T11 to L2; fibers
running inferomedially
o Function: Depress ribs
DEEP MUSCLES OF THE BACK
Erector Spinae (sacrospinalis)
o Mnemonic: I Love Singing (lateral to medial)
o Iliocostalis Cervical transverse processes and lower ribs to
lumborum/iliac
o Longissimus Ribs and mastoid process to lumborum/iliac crest
o Spinalis Spinous processes of upper thorax to lower spinous
processes
Transversospinalis - between transverse and spin. Processes
o Mnemonic: Slow Motown Rhymes" (superficial to deep)
o Attachments: transverse process to spinous process of superior
vertebrae
o Semispinalis spans 4-6 segments
o Multifidius spans 2-4 segments
o Rotatores spans 1-2 segments
ILLIAC CREST

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Posterior Superior Iliac Spine source of dimples on lower back

Boundary for Triangle of Auscultation Inferior portion of trapezius (Medially),

Vertebral border of scapula (laterally), Superior border of Latissimus dorsi (Inferiorly)

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Appendix I: Joints
Two Classes
DIARTHROSIS (synovial) - most movable
o Requirements
Has an articular capsule, also called capsular ligament
Inner layer -- synovial membrane, which secretes synovial
fluid
Hyaline cartilage on bone surfaces
o Common Examples
Zygapophyseal joint - between articular processes of vertebrae
Atlanto-occipital joint
Atlantoaxial joint
Costovertebral joint - between head of rib and bodies of
vertebrae
Costotransverse - between tubercle of rib and transverse
process
Sternocostal joints of Ribs 2-7
Interchondral (Ribs 6&7, 7&8, 8&9)
Acromionclavicular
Sternoclavicular
SYNARTHROSIS
o Sutures - fibrous connection
Examples: cranial plates
o Synchondrosis cartilage connection
Examples: Sternocostal Rib 1, Xiphoidsternal, Costochondral,
Interchondral 9 & 10, Sacrococcygeal
o Syndesmosis ligaments connection
Examples: Interspinous, Intertraverse
o Symphysis - ligaments w/ a fibrocartilaginous disc in-between
Examples: Intervertebral discs, Pubic Symphysis,
Manubriosternal
TYPES OF DISLOCATIONS:
Subluxation partial dislocation of articular surfaces in above joints
Luxation complete dislocation of articular surfaces in above joints

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Appendix II: Cardiovascular System

Arterial System:

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Venous System:

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ARTERIAL ANASTOMOSES:
Coarctation of the Aorta Distal to Subclavian: Subclavian Internal
Thoracic Artery Superior Epigastric Artery <==> Inferior Epigastric Artery
External Iliac Common Iliac Abdominal Aorta
Coarctation of Aortic Arch: Right Subclavian ITA Anterior Intercostals
<==> Posterior Intercostals Thoracic Aorta
Common Hepatic Occlusion: Celiac Trunk L. Gastric <==> R. Gastric
Hepatic Artery Proper
Celiac Trunk Common Hepatic Gastroduodenal Anterior/Posterior
Superior Pancreaticoduodenal <==> Anterior/Posterior Inferior
Pancreaticoduodenal SMA
SMA Middle Colic <==> Left Colic IMA
PORTAL-CAVAL ANASTOMOSES:
Normally: Portal Vein Liver Hepatic Vein IVC (No valves)
Types - (All result in portal hypertension)
o Prehepatic blockage - thrombus or aneurysm of portal vein
o Intrahepatic blockage within liver; common in cirrhosis
o Extra-hepatic blockage - stenosis of hepatic veins or IVC
Esophageal Anastomoses - most dangerous
o Portal Vein Left Gastric Esophageal (portal) <==> Esophageal
(systemic) Azygous/Hemiazygous SVC
o Results in Esophageal Varices (ballooning bleeding)
Rectal Anastomoses

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Portal Vein Splenic IMV Superior rectal (via Rectal plexus)

either
Middle rectal Internal iliac vein Common iliac vein IVC
(or)
Inferior rectal (systemic) Internal pudendal Internal iliac
Common iliac IVC
o Results in Hemorrhoids (varices in rectal veins) and Melena (bloody
stool)
Umbilical Anastomoses
o Left Portal Vein Paraumbilical vein (via Ligamentum teres)
Superficial epigastric vein either
Great saphenous vein Femoral External iliac Common
iliac IVC (or)
Thoracoepigastric Lateral Thoracic Axillary Subclavian
Brachiocephalic SVC
o Results in Caput Medusae (Medusas head): a spidery network of
veins on abdomen
o

VENOUS ANASTOMOSES:
Inferior Phrenic <==> Suprarenal
Hemiazygous <==> Accessory Hemiazygous
Accessory Hemiazygous <==> Superior Intercostals
General:
Portal Vein Splenic, SMV, and IMV
Azygous drains the thorax
Mnemonics
Major Branches of the Aorta: (note, coronary arteries are first, minor branch)
"Know your ABC'S":
Aortic arch gives rise to:
Brachiocephalic trunk
Left Common Carotid
Left Subclavian
Branches of Brachiocephalic Trunk:
"Clearly Very Tired Individuals Sip Strong Coffee Served Daily"
Common Carotid (Right)
Vertebral artery
Thyrocervical trunk
- Inferior thyroid
- Superficial cervical
- Suprascapular
Costocervical
- Superior intercostal
- Deep cervical
Branches of Abdominal Aorta:
Please Call Someone So Returning Today Is Less Intrusive, Sarah

Phrenic
Celiac
Suprarenal Artery (middle)
Superior Mesenteric

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Renal Artery
Testicular/Ovarian Artery
Inferior Mesenteric
Lumbars 1-4
Iliac, common
Sacral, median
Branches of Internal Iliac Artery:
"I Love Going Places In My Very Own Underwear"
Ileolumbar
Lateral sacral
Gluteal (superior and inferior)
Pudendal (internal)
Inferior vesicle (uterine in females)
Middle rectal
Vaginal
Obturator
Umbilical
Branches of Thoracoacromial Artery
"CAlifornia Police Department"
Clavicular
Acromial
Pectoral
Deltoid

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Lab II: The Spinal Cord

Meninges Coverings - SPINAL-PAD (from inside-out)
SPINAL cord
o Cord is enlarged at C3-T2 for upper limbs
and T9-12 for lower limbs
Pia Mater
o Tender mother; intimate with cord
o Forms denticulate ligaments pierce
arachnoid and link w/ dura to suspend cord
o After L2, continues as filum terminale
(coccygeal ligament); anchored on coccyx
Arachnoid Mater
o Spiderlike mother; filamentous layer
Dura Mater
o Hard mother; fibrous sack; continues
outside canal to cover nerves
o Also continues after L2, so spinal taps can
be performed at L3-L4 level (3rd lumbar
interspace)
Intermeningeal Spaces
Epidural Space: above dura and below canal
Subdural space: above arachnoid and under dura
o Contains thin film of fluid
Subarachnoid Space: above pia and under arachnoid
o Actual space containing CSF
Conus medularis - narrowing at end of cord at L1-L2
Cauda equina horses tail; ventral and dorsal roots caudal to end of cord
Filum terminale - continuation of pia; anchors spinal cord to coccyx

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Appendix III: The Nervous System

Human Nervous System
CENTRAL NERVOUS SYSTEM
o Brain and Spinal Cord
o Characterized by Interneurones
PERIPHERAL NERVOUS SYSTEM
o Somatic Nervous System
Afferent (Input): Skin sensations
Efferent (Output): Skeletal Muscle
o Autonomic Nervous System
Afferent (Input): Gut
Efferent (Output): Smooth Muscle, Cardiac Muscle, Glands
Sympathetic System
Fight or flight; Noradrenaline neurotransmitter
Parasympathetic System
Rest and digest; Acetylcholine neurotransmitter
Axons: Tract in CNS, Nerve in PNS
Nerve coverings: endoneurum, perineurum, & epineurum
Bodies: Nucleus in CNS, Ganglion in PNS
General Nerve Fibers
Somatic
o AFFERENT (GSA) Skin (sensory)
Synapse at Dorsal Horn of spinal cord
o EFFERENT (GSE) Skeletal Muscle (motor)
Arise from Ventral Horn of spinal cord
Visceral (Autonomic)
o AFFERENT (GVA) (sensory)
Synapse at Dorsal Horn of spinal cord
o EFFERENT (GVE) Autonomic Nervous System; Smooth Muscle, Cardiac
Muscle, Glands (motor)
Sympathetic (Thoracolumbar)
Parasympathetic (Craniosacral)
Arise from Lateral Horn (Intermediolateral Horn) of spinal
cord, but exit at Ventral Horn
Dorsal Root (Pure AFFERENT) + Ventral Root (Pure EFFERENT) =
Spinal Nerve (MIXED joins & exits at intervertebral foramen)
Dorsal Root Ganglion (DRG) - cell bodies of dorsal root; no synapses here!
31 spinal nerves:
8 Cervical (C1-C7 exit above vertebrae; C8 & rest below)
12 Thoracic
5 Lumbar
5 Sacral
1 Coccygeal
Spinal Nerve: splits into
Dorsal Ramus (branch)

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o Deep muscles of back and skin of back

Ventral Ramus (branch)
o Extrinsic muscles of the back & everything else

General Course of Nerves:

White ramus communicans

Contains GVA and GVE (preganglionic sympathetic axons)
Only present at T1-L2, because only preganglionic sympathetic axons present
here
Gray ramus communicans
Contains postganglionic sympathetic axons (where synapse occurs in
sympathetic chain)
Present throughout vertebral column, allowing GVE to enter at one root value
and exit at another vertebral level
GSA & GVA: (Skin sensory neuron shown here)

GSE (Motor Neuron):

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GVE Autonomic Motor Neuron: 2 cell bodies

Postganglionic

Preganglionic

Sympathetic

Intermediolateral Horn
Preganglionic

Postganglionic

Parasympathetic

GVE Autonomic System:

Preganglionic Cell Bodies
Characteristics of
Preganglionic Fibers
Postganglionic Cell
Bodies
Characteristics of
Postganglionic Fibers
Function

SYMPATHETIC
Thoracolumbar (T1-L2);
intermediolateral nucleus
Short; White Ramus

PARASYMPATHETIC
Craniosacral; Cranial nerves III,
VII, IX, X; pelvic splanchnics (S2S4)
Long

Paravertebral ganglia
(Sympathetic chain) or
prevertebral ganglia (celiac, sup.
mesenteric, or inf. mesenteric)
Long; Gray Ramus

At effector structure

Fight or Flight;
vasoconstriction, heart
(excitatory), gut (inhibitory),
papillary dilation, ejaculation,
piloerection

Rest and Digest; vasodilation,

heart (inhibitory), gut
(excitatory), papillary
constriction, penile erection

Short

Plexus - a group of nerves, often w/ branching

Dermatomes - areas of skin innervated by a nerve
(see illustration)
Pain:
Somatic - direct, with pinpoint localization
Visceral - extremely diffuse, poorly localized pain
from stretch receptors
Referred Pain
Cause: irritation of a viscous (organ) is
perceived somatically
Examples:
o Appendix: Innervation from T10, so
pain felt in midgut (where GSAs
originate)
o Heart: Innervation from T1-T5, so
pain felt in upper arm and shoulder.
Heart also has cervical ganglia @ C4
(called cervical nerves), interacting
with GSAs of the jaw
o Transverse colon: Innervation below
T10, so early pain felt hypogastric
(midgut)
Root Values for Organs:
THORAX
o Heart: T1-5, C4
o Lungs: T2-4

Esophagus: T5-6

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ABDOMEN
o Stomach: T6-10
o Pancreas: T6-10
o Spleen: T6-10
o Gall bladder: T7-T9
o Liver: T7-T9
o Small Intestine: T9-10
o Cecum: T10
o Appendix: T10
Root Values
CN VII
CN X
CN XI
C3-C5
C6-C8
C5-C7
C5-C7
C8-T1

T12
L1
L1
L1-L2
L2-L3
L2-L4
L2-L4
L4-L5
L4-S1
L5-S2
S1-S2
L4-S1
L5-S2
L4-S3
S2-S3
S2-S4
S2-S4

Testicle: T10
So testicular pain
felt on back near
kidneys
Kidney: T10-L1
So kidney pain is
felt in somatic of
scrotum
Ureter: T11-L2

Nerve
Targets
Cranial Nerves (observed thus far):
Facial Nerve
Platysma muscle
Vagus Nerve
Various Targets
Accessory Nerve
Trapezius, Larynx, Pharynx
Muscles and Innervation of Thorax and Abdomen:
Phrenic Nerve
Diaphragm
Thoracodorsal
Latissimus Dorsi
Long Thoracic
Serratus Anterior
Lateral Pectoral
Pectoralis Major & Minor
Medial Pectoral
Pectoralis Major & Minor
Thoracic Splanchnic Nerves (See Table Below)
Nerves of Pelvis and Peritoneum: (Lumbar Nerves)
Subcostal
Iliohypogastric
Skin of groin
Ilioinguinal
Skin of thigh
Genitofemoral (Cremaster)
Cremaster muscle
Lateral Femoral Cutaneous
Femoral
Obturator
Lumbosacral Trunk
Nerves of Pelvis and Peritoneums: (Sacral Nerves)
Superior Gluteal
Gluteus maximus and minimus
Inferior Gluteal
Gluteus maximus
Nerve to Piriformis
Piriformis muscle
Nerve to quadratus femoris
Quadratus femoris & inferior
gamellus
Nerve to Obturator Internus
Obturator internus & superior
gamellus
Sciatic Nerve
Hip joint, flexors of knee, leg,
foot
Posterior Femoral Cutaneous
Buttock and uppermost medial
part of thigh
Pudendal (Shameful)
Perinneul structures, sensory to
genitalia, sphincter urethrae
and anal sphincter
Pelvic Splanchnics
Parasympathetic innervation of
bladder and everything after
left colic flexure

SPLANCHNIC NERVES
Splanchnic Nerves
Cardiopulmonary

System
Sympathetic

Greater Thoracic

Sympathetic

Root Levels
Cervical & Upper
thoracic sympathetic
trunk
T5-T9

Lesser Thoracic

Sympathetic

T10-T11

Least Thoracic

Sympathetic

T12

Destination
Viscera above the level
of the diaphragm
Celiac Ganglia Viscera
supplied by celiac trunk
Superior mesenteric
Ganglia Viscera
supplied by SMA
Inferior mesenteric

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Lumbar

Sympathetic

Abdominal sympathetic
trunk

Pelvic

Parasympathetic

S2-S4

Ganglia Viscera
supplied by IMA
Inferior mesenteric
Ganglia & Hypogastric
plexuses Desc. Colon
and Sigmoid
Intrinsic ganglia of
descending and sigmoid
colon, rectum, and
pelvic viscera

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Lab III: Thoracic Body Wall

Rib parts:
Head
o Demifacets
Rib 1 articulates w/ T1
Ribs 2-10 (x) articulate
with T(x) and T(x-1)
o Interarticular crest
Neck
o Articular part of tubercle
articulates with transverse
process of T(x) (Ribs 1-10 only)
Angle (curve)
Costal groove
o Covers VAN (Vein, Artery, Nerve), in order of top to bottom
o RIB-VAN (Sup. to Inf.); Rib, Vein, Artery, Nerve
Until rib angle, btw. parietal pleura and internal intercostal
membrane
After rib angle, btw. internal and innermost muscles
Intercostal Space region between two adjacent ribs
o Rule of thumb: ICS X = vertebral level X+2 (Ex. ICS 4 = T6)
Rib Types:
True ribs (1 through 7) cartilage attaches directly to sternum
False ribs (8 through 10) fuse to Rib 7
Floating ribs (11 and 12) do not come in contact with sternum
Sternum parts:
Manubrium Upper part @ T3-T4
o Jugular notch, articulates with clavicle
Manubriosternal Joint (Symphysis
Fibrocartilaginous)
o Sternal angle (angle of Louis)
Body Middle part @ T5-T9
Xiphoidsternal Joint (Synchondrosis Cartilaginous)
Xiphoid process - Lower part @ T10
Layers of thorax:
Skin - epidermis and dermis which has glands and
vessels
Superficial fascia - adipose tissue, loose layer
Deep fascia - dense, intimate with muscles
Breasts: (ICS 4)
Mammary glands - sweat glands in superficial fascia
Lactiferous ducts run from glands to sinuses
Lactiferous sinuses dilated portion of ducts before nipple
Areola circular pigmented area surrounding nipple
Suspensory (Coopers) ligaments attaches mammary glands firmly to skin
Retromammary space between superficial and deep fascia; no tethering
of breasts, so mobile
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Innervation: anterior and lateral cutaneous branches of 4th-6th intercostals

Vasculature: (from ICS 2,3,4)
o Medial mammary branches Anterior Intercostals Internal Thoracic
Artery Subclavian Aorta
o Lateral Thoracic and Thoracoacromial arteries Axillary Artery BCT
Aorta
o Posterior Intercostal Arteries Thoracic Aorta

Muscles:
Platysma - grimace muscle; runs inferomedially to
clavicle
o Attachments: Superior portion at lower
mandible; Inferior portion at fascia of pectoralis
minor
o Innervation: CN VII (facial nerve)
Pectoralis Major moves the humerus
o Two Parts: Clavicular Head (Clavicle to Crest of
Greater Tubercle of Humerus) & Sternocostal
Head (Manubrium and Body of sternum to Crest
of Greater Tubercle of Humerus)
o Innervation: Lateral & Medial Pectoral Nerves; C5-T1
o Deltapectoral Triangle
Boundaries: Pectoralis Major, Deltoid, &
Clavicle
Cephalic Vein runs here; joins axillary
vein
Pectoralis Minor stabilizes the scapula
o Attachments: 3rd to 5th ribs (Inferior), Coracoid
process of Scapula (Superior)
o Innervation: Lateral & Medial Pectoral Nerves;
C5-T1
Subclavius protects subclavian artery
o Attachments: Ribs 1-8; Anterior surface of
medial border of scapula
o Innervation: C5 & C6
Serratus anterior anchors scapula; interdigitates w/ external oblique
o Attachments: Ribs 1-8; Anterior surface of medial border of scapula
o Innervation: C5, C6, & C7
Endothoracic Fascia Separates innermost intercostal muscles and pleural
membrane
Nerves:
Mnemonic: Medial more, Lateral less
Medial pectoral nerve - pierces pectoralis minor & major (actually lateral)
Lateral pectoral nerve pierces only pectoralis minor (actually medial)
Positional information relative to brachial plexus; thus opposite of actual
positions
Both nerves innervate the pectoralis minor and major
Muscles:
External Intercostal Elevate ribs
o Direction: hands in pockets; become membrane anteriorly
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Internal Intercostal Depress ribs

o Direction: at right angle to externals
[Intercostal VAN travels here between Internal and Innermost]
Innermost Intercostal Probably elevate
o Direction: Transversus same as external; Subcostalis same as internal
o Consists of: Transversus thoracus (depress) and Subcostalis
(elevate)

INTERCOSTAL ARTERIAL SUPPLY

ANTERIOR
o Top 6 Internal Thoracic Artery
o 7-9 Musculophrenic Internal thoracic
o 10-12 (None)
POSTERIOR
o Top 2 Superior Intercostal Costocervical Subclavian
o 3-12 Aorta (directly)
Nerves:
Ventral rami of T1-11 Intercostal nerves 1-11
Ventral rami of T12 Subcostal nerve

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Lab IV: Abdominal Body Wall

Abdominal Wall Layers:
Skin
Superficial fascia (superior to inguinal ligament)
o Campers fascia fatty, superficial tissue
o Scarpas fascia - fibrous tissue, continuous with fascia lata of thigh
Deep fascia - intimate with the superior muscle
Muscles:
External oblique
o Direction: hands into pockets
o Anterior becomes aponeurosis over rectus abdominus
o Folds back upon itself to form inguinal ligament
Internal oblique
o Direction: at right angles to external oblique
Transversus Abdominus
o Direction: horizontally
o Transversalis fascia - between transversus and peritoneum (or
peritoneal fat)
Rectus abdominus - 2 muscle bundles
o Direction: vertical fibers, from pubic symphysis to Xiphoid process
o Innervation: Ventral Rami of T7-T12
o Linea Alba
Medial fibrous band separating both bundles
Jessica Alba has sweet abs!
Formed from pyramidal muscle
Sheath of rectus abdominus:
ABOVE the arcuate line (line btw. crests of Iliacs)
Rectus
o Anteriorly: aponeurosis of external oblique
Abdomin
us
and anterior lamina of internal oblique
o Posteriorly: posterior lamina of internal
oblique and aponeurosis of transversus
Thinning Occurs Here
abdominus
Rectus
BELOW the arcuate line
Abdomin
o Anteriorly: aponeurosis of external, internal,
us
and transversus; however, major thinning of
aponeurosis occurs Weakening of abdominal wall
o Posteriorly: Only transversalis fascia
Nerves: (run between Internal oblique and Transversus abdominus)
T7-T9: skin and muscle above the umbilicus
T10: Umbilicus
T11-L1: skin inferior to umbilicus
o L1 also branches into 2 nerves:
Iliohypogastric - skin of groin
Ilioinguinal - skin of thigh, exits @ superficial ring of inguinal
canal
Vessels:
ARTERIES

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o
o

Deep Circumflex Iliac External iliac

Inferior Epigastric External iliac
Runs superiorly in transversalis fascia until enters rectus sheath
@ arcuate line and anastomosizes with superior epigastric near
umbillicus
Superior epigastric Internal thoracic
Anastomosizes with inferior epigastric near umbillicus

VEINS
o Superficial epigastric vein and Lateral Thoracic also
anastomose

Inguinal Region:
Inguinal canal - superior and parallel to medial portion of inguinal ligament
o OPENINGS (2)
Deep (internal) ring - entrance
Superior to midpoint of inguinal ligament
Lateral to Inferior Epigastric Artery
Outpouching of transversalis fascia
Superficial (external) inguinal ring - exit
Triangular opening in the aponeurosis of external oblique
o WALLS (2)
Anterior: aponeurosis of external oblique
Posterior: transversalis fascia
Conjoint tendon - formed by merging of internal
oblique and transversus abdominus aponeuroses;
strengthens posterior wall
o ROOF
TIE arch (Transversus abdominus, Internal Oblique, External
Oblique)
o FLOOR
Inguinal Ligament - runs from anterior superior portion of iliac
crest to pubic symphysis (formed by folding over of external
oblique)
Descent of the Testes:
Testes develop between peritoneum and transversalis fascia (in lumbar
region)
Processus vaginalis, outpouching of peritoneum, migrates through fascia &
3 muscle layers into the scrotum; becomes tunica vaginalis after separation
of pouch
Tunica vaginalis covers only the testis (has visceral and parietal layers w/ fluid
in-between to allow for smooth movements of the testis)
No obliquity to canal during infancy & descent
Cremaster Muscle formed by pouching of internal and transverse
abdominal muscle
Scrotal sac consists of testes, processus vaginalis, internal spermatic
fascia, cremaster muscle and fascia, and external spermatic fascia
Spermatic Cord:
Ductus Deferens duct between epididymis and ejaculatory duct
Arteries
o Testicular Artery Aorta (supplies testes)
o Cremasteric Artery Inferior Epigastric (supplies cremaster muscle)
21 of 53

Veins
o Pampiniform plexus venous network around testis; maintains
cooler temperature; drain into testicular vein
Nerves
o INSIDE SPERMATIC CORD:
Genitofemoral nerve innervates cremaster muscle; lumbar
plexus (L1, L2)
Genital branch of genitofemoral nerve innervates
scrotum
o OUTSIDE OF SPERMATIC CORD:
Testes Autonomic Nerves Sympathetic (on arteries) &
Parasympathetic (on ductus deferens)
Sympathetic: T10
Parasympathetic: Vagal (CN X)
Scrotum Innervation
Ilioinguinal - branch of L1
Pudendal - S2-S4
Posterior femoral cutaneous S1-S3
Lymph nodes
Fascial Coverings
o Internal spermatic fascia - from transversalis fascia
o Cremaster fascia and muscle - from internal oblique; innervated by
Ilioinguinal nerve (L1)
o External spermatic fascia - from external oblique

Hesselbachs triangle
Bordered by inguinal ligament, inferior
epigastric, rectus abdominus
Only transversalis fascia posteriorly and thin
aponeuroses anteriorly, thus weakening of
abdominal wall
Passage of sperm:
Testes [Seminiferous Tubules Rete Testes Efferent
Ductule] Epididymis Vas Deferens (Joins
seminal vesicles) Ejaculatory ducts Prostate
[Prostatic urethra] Membranous Urethra Bulb of
penis (Joins Bulbourethral glands) Spongy urethra

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23 of 53

Appendix IV: Hernias

Definition: Protrusion of viscous thru an abnormal opening
Main reasons for hernias:
1. Weak Areas: protected only by fascia
a. Direct bulging in weak area (Acquired); Medial to Inferior Epigastric
b. Fluid pressure throughout abdomen further weakens walls
c. Gravity pulls organs down, putting weight on hernia-prone region
d. Hasselbachs Triangle - only transversalis fascia is posterior to
rectus abdominus, thus weak walls
2. Improper Development: Improper closing Openings
a. Indirect needs to follow oblique path of canal to outpouch
(Congenital); Lateral to Inferior Epigastric
i. Other example: processus vaginalis does not fuse completely
after descent of testes
b. Umbilical hernia - hernia through patent umbilicus
Mnemonic: MDs Love Insurance
Medial Direct; Lateral Indirect
ORCHOS is root for testes.
Hasselbachs Triangle:

24 of 53

Lab V: Thorax: Pleura and Lungs

Types of Pleura:
VISCERAL PLEURA no nerve fibers; no pain
o Adheres to all surfaces of lung; reflects at root of lung to become
parietal pleura
PARIETAL PLEURA intercostal and phrenic nerves; therefore, local and
referred pain
o Costal pleura internal surface of thoracic wall
Endothoracic fascia separates ribs and costal pleura
o Mediastinal pleura lateral aspects of mediastinum
o Diaphragmatic pleura covers superior (thoracic) surface of
diaphragm
o Cervical pleura - extends through superior thoracic aperture to root
of neck
Pleura meets behind esophagus to form the mesoesophagus
Pleural Recesses:
Costodiaphragmatic recesses where costal parietal meets diaphragmatic
parietal
o During inspiration, lungs descend into here; during expiration, ascend
o Pleural tap occurs here midaxially at intercostal space 6, 7, or 8
(above rib)
o Recess extends inferiorly as far as T12 posteriorly
Costomediastinal recesses where costal parietal meets mediastinal
parietal
o During inspiration, lungs enter recesses; during expiration, exit
recesses
o Left is larger because cardiac notch, therefore less lung in recess
The Lungs:
Bifurcation of Trachea occurs @ T6 (near ICS 4)
Hilus point where root of the lung enter and leave the lung (only
attachment point)
o Mnemonic: Are Brides Vain? Right, Brides Are Vain!
LEFT LUNG
o Two lobes: upper and lower
To help identify
o Fissures: oblique fissure
each: bronchi have
o Bronchi: two secondary bronchi
cartilaginous rings,
o Other: cardiac notch, lingula toungelike process of
pulmonary arteries
superior lobe
have thick walls,
o Hilus (superior to inferior): Artery, Bronchiole, Vein
and pulmonary
veins have flexible,
o Defining Grooves: Aortic arch, cardiac notch, desc.
thin walls
aorta
RIGHT LUNG
o Three lobes: upper, middle, and lower
o Fissures: oblique fissure and horizontal fissure
o Bronchi: three secondary bronchi
o Other: cardiac notch (smaller)
o Hilus (superior to inferior): Bronchiole, Artery, Vein
o Defining Grooves: Esophagus and superior vena cava
Lungs Bronchial arteries Aorta

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Carina - ridge running anteroposteriorly between the orifices of the two main
bronchi

Innervation:
Know the paths of
PARASYMPATHETIC EFFERENT
the vagus nerve
o Pulmonary plexus cell bodies of postsynaptic PS
(left and right are
different), phrenic
neurons
nerves, and where
o Vagus Nerve
the left recurrent
Source: CN X
laryngeal branches
Targets: Bronchi smooth muscle
off the left vagus
(bronchoconstrictor), pulmonary vessels
nerve.
(vasodilator), glands of the bronchial tree
(secretomotor)
LEFT VAGUS
Gives rise to left recurrent laryngeal nerve; hooks
beneath the ligamentum arteriosum and travels
superiorly between trachea and esophagus to innervate
the larynx
Crosses (anteriorly) aortic arch posterior to hilus
anterior to esophagus
RIGHT VAGUS
Arch of azygous posterior to hilus posterior to
esophagus
Mnemonic: Left Anterior, Right Posterior
SYMPATHETIC EFFERENT
o Paravertebral Sympathetic Ganglia cell bodies of postsynaptic S
neurons
MOTOR
o Phrenic nerve - innervates diaphragm
C3-C5; anterior (phrenic, front) to the root of each lung
Fibers are General Somatic Efferent (GSE)
Piercing the diaphragm: Right travels w/ IVC, so enters @ T8;
Left travels along superior diaphragm and pierces lateral to
pericardium @ ~T10

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Lab VI: Mediastinum

Mediastinum:
SUPERIOR MEDIASTINUM
o Contents: SVC, arch of aorta, trachea,
esophagus, thymus, left recurrent laryngeal
nerve, and phrenic nerve
[Sternal Angle @ T4/T5 splits Superior and
Inferiors]
MIDDLE MEDIASTINUM
o Contents: pericardium, roots of the great
vessels, arch of the azygos, and main
bronchus
ANTERIOR MEDIASTINUM
o Contents: remnants of the thymus, lymph
nodes, fat, connective tissue
POSTERIOR MEDIASTINUM
o Contents: esophagus, thoracic aorta, azygos and hemiazygos veins,
vagus nerves, sympathetic trunks, and splachnic nerves
Ligamentum Arteriosum - connects aortic arch to pulmonary artery; remnant of
fetal ductus arteriosus
Left Recurrent Laryngeal Nerve - branch of the left vagus, hooks around
ligamentum arteriosum and travels up to innervate larynx
Thoracic Duct
Function: drain lymph from entire body except right
upper quadrant
Position Mnemonic: The duck is between two gooses thoracic duct lies between the esophagoose and
azygoose.
Drains into junction of Left Internal Jugular and Left
Subclavian Vein

Thoracic Duct is a
guaranteed
practical exam
question! (It is left
of the azygos and
much thinner)

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Labs VII & VIII: The Heart

Pericardium:
Fibrous pericardium tough external fibrous layer; actual space
Serous pericardium single layer of flattened cells; potential space
(meaning can form a space filled w/ blood, but naturally does not)
o Parietal pericardium
PERICARDIAL CAVITY between parietal and visceral; filled with
frictionless fluid
o Visceral pericardium forms the epicardium
o Serous pericardium fuses with central tendon of diaphragm
o Cardiac Tamponade blood fills between layers of serous
pericardium, pushing against the heart and obstructing hearts ability
to distend
Sinuses
o Transverse Sinus posterior to aorta and pulmonary trunk, anterior
to SVC
o Oblique sinus posterior to SVC, IVC, and pulmonary veins
Layers of the Heart:
Epicardium thin external layer formed by visceral layer of serous
pericardium
Myocardium - muscle of the heart
Endocardium - lines the lumen on the heart
Innervation:
Sympathetic: T1-T5; exits sympathetic trunk @ C4, so referred pain felt in jaw,
and upper left arm
Parasympathetic: Vagus Nerve (CN X)
Surfaces of the Heart:
Apex: blunt inferior point formed by LV
Surfaces:
o Anterior-Sternocostal: RV
o Diaphragmatic: 2/3 of LV, 1/3 RV
o Pulmonary: Left & Right borders (LV, RA)
o Base-vertebral (the posterior portion
against the vertebral column): mostly LA,
some RA
Borders:
o Right border: RA
o Left border: LV
o Superior: RA & LA
o Inferior: RV, some LV
Sulcus Lines:
Purpose: fat and vessels run here; marker separating
the chambers of the heart
Coronary Sulcus - encircles the heart, separates atria
from the ventricles
Anterior and Posterior Interventricular Sulcus separates the ventricles. Starts anteriorly at pulmonary
trunk, wraps around to posterior up to coronary sulcus

(No Brainer) Know

the hearts
partitions, great
vessels, coronary
vessels,
anastomoses,
surfaces, and
conduction

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Pericardial Sinuses: (allow heart room to beat)

Transverse Pericardial Sinus post. to aorta and pulmonary trunk; anterior
to SVC
Oblique Pericardial Sinus bounded by SVC, IVC, and pulmonary veins
RIGHT ATRIUM collects bodys deoxygenated blood
Venous Sources
o Superior Vena Cava - drains above diaphragm
o Inferior Vena Cava - drains below diaphragm
IVC has a valve w/ function only in fetus
o Coronary Sinus drains hearts deoxygenated blood
Two Walls
o Posterior: sinus venarum smooth
o Anterior: pectinate muscles; rough
o Separated by vertical ridge crista terminalis
Notable structures
o Fossa Ovalis remnant of foramen ovale; thumb print sized area,
slight discoloration; interatrial side
o Limbus Fossae Ovalis superior margin of the fossa ovalis
o Right Auricle leaf/appendage; rough from pectinate muscles
TRICUSPID VALVE between RA and RV
Three cusps: septal, anterior, posterior
Cusp Structure: Nodule (midpoint of free edge), Lunule (thin connective
tissue flanking nodules)
Attached to three papillary muscles via chordae tendinae in RV
Each muscle is linked to two cusps; S SA, A AP; P PS
RIGHT VENTRICLE pumps deoxygenated blood into lungs for oxygenation
Notable structures
o Conus Arteriosis (infundibulum) smooth region right below
pulmonary valve
o Trabeculae carneae - elevated muscles in ventricle
o Moderator Band (Septomarginal trabeculae) - a trabeculae carneae
between septum to ventricular wall; carries conductive impulses
LEFT ATRIUM receives oxygenated blood from lungs
Receives blood from 4 pulmonary veins
Smooth, except for auricle, which is rough from pectinate muscles
MITRAL VALVE between LA and LV
Two Cusps: anterior, posterior
Cusp Structure: Nodule (midpoint of free edge), Lunule (thin connective
tissue flanking nodules)
Attached to two papillary muscles (anterior and posterior) via chordae
tendinae
Each muscle is linked to both cusps; A AP, P AP
LEFT VENTRICLE
Most muscular (3x RV) strongest contraction
IV septum curves to right (so more volume)
Forces blood into ascending aorta
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PULMONIC VALVE between RV and pulmonary trunk

Three cusps: anterior, left, and right
Attached to three papillary muscles via chordae tendinae in RV
Each muscle is linked to two cusps; A AL, L LR; R RA
TERATOLOGY OF FALLOT:
Stenosis of Pulmonary Artery
RV Hypertrophy
Ventricular Septal Defect
Above 3 defects Overriding Aorta, because need patent Ductus Arteriosus
to survive!
HEART CONDUCTION SYSTEM:
Conducting Fibers in heart are NOT nervous tissue; instead, modified cardiac
muscle!
Sinoatrial (SA) Node pacemaker of the heart; initiates impulses at 70/min
o Causes atria to contract
Atrioventricular (AV) Node located in posteroinferior region of interatrial
septum
o Receives SA node impulse, then pauses for ~ .1 seconds
o Initiates signal through atrioventricular bundle (Bundle of His)
right and left bundle branches Purkinje fibers
o Causes ventricles to contract from apex upwards
o Stimulates anterior papillary muscle through septomarginal
trabeculae (moderator band); these contract slightly before ventricles
to keep cusps firmly in place
Systole contraction of ventricles; Diastole relaxation phase when
ventricles fill
Clinical Correlates
o Blockage of L/R Purkinje Asynchronous contractions of Ventricles
o Damage to AV Node Simultaneous contraction of Atria and Ventricles
Auscultation Sites
o Aortic area:
Right second intercostal space close to the sternum
The site where the ascending aorta is nearest to the thoracic
cage
o Pulmonary area:
Left second intercostal space close to the sternum
The site where the infundibulum is closest to the thoracic cage
o Mitral area:
At position of apex beat; slightly inferiomedial of left nipple
Left ventricle is closest to thoracic cage at this point
o Tricuspid area:
Inferior left sternal margin
Point closest to valve in which auscultation is possible
o General - lub-dub
lub Tricuspid & Mitral valves closing
dub Semilunars closing
HEART VESSELS
Coronary Arteries
o Branches begin at proximal part of ascending aorta
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Fill during diastole (when aortic valves are closed)

Right Coronary Artery (RCA) - runs in the coronary groove (sulcus)
Sinoatrial (SA) nodal branch branch from RCA; supplies SA
node
Right Marginal supplies right border of heart
AV nodal branch supplies AV node; branch at crux (cross) of
heart
Posterior Interventricular (IV) supplies ventricles and IV
septum
Near apex, RCA anastomoses with the Circumflex and
Anterior IV branches of LCA
o Left Coronary Artery (LCA) passes between coronary groove and
pulmonary trunk
Anterior IV / Left Anterior Descending branch supplies
ventricles and IV septum
Circumflex branch supplies left atrium and left ventricle
Left Marginal Artery supplies left ventricle
Anastomoses with Posterior IV branch at posterior of
heart
Major Anastomoses
o All are non-functional anastomoses / functional end-arteries;
do not allow for sufficient collateral circulation; therefore, coronary
occlusion ischemia necrosis / Myocardial Infarction
o Right Coronary Artery L. Circumflex Artery Branch
o Posterior IV Branch Left Anterior Descending Artery
Coronary Veins
o Coronary sinus - posterior part of coronary sulcus, drains into the
right atrium
Great Cardiac Vein - drains anterior IV sulcus into coronary
sinus
Middle cardiac vein - runs in posterior IV sulcus into coronary
sinus
Small cardiac vein - runs with marginal artery into coronary
sinus
Oblique vein drains tissue of left atrium into coronary sinus
o Anterior Cardiac Veins drains right ventricle directly into right
atrium
o Venae cordis minimae drain myocardium directly into atria
o
o

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32 of 53

Lab X: Unpaired Aortic Vessels

Unpaired Aortic Vessels of the Abdomen
Celiac Trunk
Superior Mesenteric Artery (SMA)
Inferior Mesenteric Artery (IMA)
Celiac Trunk
Common Hepatic supplies liver
o Location: left of the bile duct
o Path: celiac trunk (branches into inferior gastroduodenal and right
gastric superior) becomes hepatic proper
o Gastroduodenal - splits into the right gastro-epiploic artery as
well as the superior pancreaticoduodenal
Anastomoses with inferior pancreaticoduodenal off SMA
Splenic Artery supplies spleen
o Has short gastric branches, pancreatic arteries, and left
gastroepiploic
Left Gastric Artery supplies stomach
o Anastomoses with right gastric, also gives off esophageal branch
Superior Mesenteric Artery
Supplies: Parts 2-4 of duodenum to 1st Half of Transverse Colon
Position: Anterior to third part of duodenum (can occlude opening fullness &
vomiting)
Branches:
o Inferior Pancreaticoduodenal Artery pancreas and duodenum
o Middle Colic Artery - of transverse
o Jejunal Artery - jejunum
o Ileal artery - ileum
o Right colic Artery - Ascending colon
Anastomoses with left colic at marginal
o Ileocolic Artery - cecum and appendix
Superior Mesenteric Vein - drains what the artery supplies
Inferior mesenteric artery
Supplies: 2nd Half of transverse colon to Superior part of Rectum
Position: 3 cm superior to aortic bifurcation
Branches:
o Left Colic - transverse and descending colons
Anastomoses with right colic at marginal
o Sigmoid Artery - sigmoid colon
o Superior Rectal - top part of rectum
Porta Triad enters through the opening of liver (Porta Hepatic)
Mnemonic: Portal Posterior, Bile Duct Dexter, so Hepatic Left!
Portal Vein
o Origin: Where Superior Mesenteric Vein meets Splenic Vein
o Inferior Mesenteric Vein empties into Splenic (just prior)
o Left gastric empties directly into Portal Vein
Hepatic Artery
Bile Duct
33 of 53

o
o

Connects to gall bladder via cystic duct

Continues as the common hepatic duct, until splits into Left and
Right hepatic ducts in the liver

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35 of 53

Lab XI: Abdomen in Situ

Peritoneum
Parietal Peritoneum
o Somatic nerves
o Blood vessels and lymph drainage from abdominopelvic wall
Visceral Peritoneum
o Visceral afferent (autonomic) nerves
o Blood and lymph drainage from viscera (organs)
Closed sac, except in females, where uterine tubes pass through
DORSAL MESENTERY
Greater Omentum 4 Major Subdivisions
o Omental Apron derived from dorsal mesogastrium and formed by
rotation of stomach (4 layers); transverse mesocolon often fuses 6
layers
o Gastrophrenic ligament (2 layers) Connects fundus of stomach to
left diaphragm
o Gastrosplenic ligament connects greater curvature of stomach to
hilum of spleen; also called gastrolienal ligament
o Gastrocolic ligament connects greater curvature of stomach to
transverse colon
Lienorenal ligament attaches spleen to posterior abdominal wall above
left kidney
VENTRAL MESENTERY
Lesser Omentum nomenclature separates into two parts (but actually
continuous)
o Gastrohepatic and Gastroduodenal ligaments - attach lesser
curvature of stomach and 1st part of duodenum to liver
Hepatoduodenal ligament edge of lesser omentum; conducts the portal
triad
Falciform ligament connects liver to anterior abdominal wall
o Ligament teres intrahepatic extension of Falciform ligament;
remnant of umbilical vein
Coronary ligament peritoneal reflections around the bare area
Right and Left Triangular - flexures of liver
No ventral mesentery for intestines due to outpouching of yolk sac
OTHER MESENTERIES
Transverse Mesocolon - mesentery of transverse colon
o
Divides greater sac into supracolic and infracolic compartments
The Mesentery of the Small Intestine attaches the jejunum and ileum
to the posterior abdominal wall
o Ligament of Treitz connects duodenojejunal junction to the caecum
Sigmoid mesocolon connects sigmoid colon to posterior abdominal wall
Mesoappendix connects vermiform appendix to mesentery of terminal
ileum
Ascending colon, descending colon, and cecum do not have mesenteries
Abdominal sacs
Greater Sac also called abdominal sac

36 of 53

Lesser Sac also called omental bursa (fat skinned purse)

o Boundaries: lesser omentum (anteriorly), peritoneum (posteriorly),
greater omentum (inferiorly), and gastrorenal and lienorenal ligaments
(left)
o Openings: the epiploic (omental) foramen (right)
Boundaries: portal triad (anteriorly), IVC (posteriorly), Caudate
lobe of liver (superiorly), 1st part of duodenum and portal triad
(inferiorly)

Peritoneal Recesses
Subphrenic Recess space between diaphragm and liver
Omental Recesses
o Superior Recess superior to coronary ligament, inferior to
diaphragm
o Inferior recess inferior portion of omental bursa; usually closed off
due to merging of greater omentum
Hepatorenal Recess/Pouch (potential space)
o Position: behind the liver, in front of the kidney;
o Most dorsal point when supine.
Rectouterine/Rectovesical Pouch (actual space)
o Position: behind the uterus or bladder (in men);
o Most inferior point when standing
The Gutters
Right Paracolic
o Position: lateral, right of the ascending colon
o Path: Transfer fluids from hepatorenal recess and lesser sac to pelvic
portion
Left Paracolic
o Position: lateral, left of the descending colon
o Closed cranially by Phrenicocolic ligament
Gutter to the Right of the Mesentery - closed cranially and caudally
Gutter to the Left of the Mesentery - opens into the pelvis
PARIETAL PERITONEAL FOLDS
Ligament of Treitz - suspensory ligament of
duodenum/jejunum juncture from diaphragm; consists of
striated muscle from diaphragm and smooth from duodenum
Phrenicocolic ligament connects left colic flexure to
diaphragm; shelf for spleen
Broad ligament of uterus - consists of mesometrium,
mesosalpinx, mesoovarium, ligamentum teres uteri
Suspensory ligament of ovary - not the round ligament
Round ligament of Uterus - analogous to gubernaculum of
men
Tunica vaginalis - surrounds the testes

Guaranteed
questions on
ligaments and
position relative to
peritoneum (Intra,
Primary, Secondary,
or Retro, or Extra),
so memorize all of
them! Remember,
anything w/ a
mesentery is
Intraperitoneal

INTRAPERITONEAL ORGANS - completely enclosed in visceral peritoneum

Liver
Jejunum
Gall bladder
Ileum
Spleen
Vermiform appendix
Stomach
Transverse colon
1st part of duodenum
Sigmoid colon
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Infundibulum and fimbriae of

ovary

PRIMARY RETROPERITONEAL ORGANS - anterior surface covered by parietal

mesentery
Kidney
Aorta
Adrenal glands
Testes (due to tunica vaginalis)
IVC
SECONDARY RETROPERITONEAL ORGANS - adherent to posterior parietal wall;
anterior surface is covered by visceral peritoneum
Rest of duodenum
Descending colon
Cecum
Rectum
Ascending colon
Pancreas
EXTRAPERITONEAL - outside but not posterior to peritoneum
Urinary bladder
Uterus
Prostate
Ovaries (though appear intra,
covered by fold of peritoneum)
Seminal vesicles
CLINICAL NOTES
Since parietal peritoneum has no somatic afferents, pain is only felt from GSAs
of overlying muscle
o Appendicitis: variable positioning can, so even be in pelvis against
obdurater muscle. Having patient flex thigh can thus produce pain.
Pain referred to T10 midumbilical region
Upon parietal peritoneum involvement, position will locate
exactly (around L1 & L2) called McBirneys point
o Inflamed Diaphragm: Has parietal pleura and peritoneum, so patient
will take shallow respirations
Pain referred to C3-C5 shoulder
Colic: pain produced by spasm, distention, or obstruction of hollow organs
o Hepatic colic gallstones obstruct bile duct
o Intestinal colic caused by gas
o Renal colic passage of calculus from kidney through ureter
o Biliary colic gallstones obstruct cystic duct
Pain referred to T8 @ tip of scapula

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Lab XI: GI Tract and Glands

Liver hepato
Split into 4 lobes, resembling an H
o Left lobe, Right lobe (large), Caudate lobe, & Quadrate lobe
Right side: IVC and bed for gall bladder
Left side: Ligamentum teres
ligamentum venosum
Middle-Center: Porta hepatis
enters here (Portal Vein,
Hepatic Proper, and Bile Duct)
Hepatic Vein Exits from
Caudate Lobe IVC
Bare area posterior
triangular area; direct contact
w/ diaphragm (no
peritoneum)
Coronary ligaments
surround bare area
Liver cirrhosis (Greek for
tawny/orange) portal
hypertension
Vasculature: portal vein (70%)
and hepatic artery (30%)
Gall bladder cystic
Stores bile; has cystic duct communicating with bile duct.
Spleen lien
Hilus - where vessels enter
From Anterior to Posterior @ ICS 9: Pleura, Diaphragm, and then spleen
Gastrolienal ligament connects dorsal mesogastrium to spleen
Lienorenal/Splenorenal ligament attaches spleen to left kidney
Pancreas GR, sweetbread
Position: Retroperitoneal; Posterior to the stomach
Head and Neck of the pancreas expanded part of gland; visualize as a
fist punching 2nd part of duodenum, holding the SMA and SMV in its palm
Tail of the pancreas passes between splenorenal ligament and splenic
vessels; in contact with superior part of left kidney and left colic flexure
Pancreatic duct runs through parenchyma (substance) of gland to head;
combines with bile duct to form short, dilated hepatopancreatic ampulla
Sphincters: sphincter of the pancreatic duct, sphincter of the bile duct,
and surrounding hepatopancreatic sphincter (Sphincter of Oddi / Major
duodenal papilla)
Accessory pancreatic duct empties the uncinate process (inferior
extension of pancreatic head) and drains into Minor duodenal papilla of
duodenum
Vasculature: Celiac Trunk Common Hepatic A Gastroduodenal
Superior Pancreaticoduodenal Arteries; Superior Mesenteric A Inferior
Pancreaticoduodenal Arteries

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Innervation: vagus, thoracic splanchnic nerves (from celiac plexus and

superior mesenteric plexuses)

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Stomach gaster
Four parts
o Cardiac orifice opening of esophagus via cardiac sphincter
o Fundus superior part of stomach; often dilated by gas, fluid, and/or
food
o Body between fundus and pyloric antrum
o Pyloric part pyloric
antrum (wide part), pyloric
canal (narrow part),
pyloric sphincter
(controls discharge of
stomach), and pyloric
orifice (opening to
duodenum)
Two curvatures:
o Greater Curve
o Lesser Curve
Interior of Stomach
o Longitudinal gastric
folds canals for
saliva/food to travel to
pylorus
o Ruggae stomach folds
which allow expansion
Arterial supply:
o Left Gastric - from celiac
trunk
o Right gastric and right
gastroepiploic - from
common hepatic and
gastroduodenal (branch of
common hepatic), respectively
o Left gastro-epiploic and short gastrics - from splenic
Duodenum - Latin for 12, since it is 12 fingerbreadths long
Has 4 parts Parts 1-3 form a C, Part 4 is junction to jejunum.
o 1st Part - Intraperitoneal; supplied by celiac artery
o 2nd Part - Bile and pancreatic ducts enter here; covered by hood-like
plica
Ampulla of Vater - slightly dilated distal part of the common
bile duct
Sphincter of Oddi one-way valve opening bile duct into
duodenum
Major Duodenal Papilla bile duct entrance into duodenum
Minor Duodenal Papilla accessory pancreatic duct entrance
into duodenum
o 3rd Part - Crossed anteriorly by SMA and SMV (thus distension here
vomiting)
o 4th part - Suspended by Ligament of Treitz, attached to diaphragm
Plica circulares folds in submucosa to increase internal surface area of
intestine
Jejunum & Ileum

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Although no specific boundary between jejunum and ileum, some

distinguishing characteristics:
o Jejunum: longer vasa recta; longer arcades; more plica circulares
o Ileum: shorter vasa recta; shorter arcades; fewer plica circulares
Plica circulares folds in submucosa to increase internal surface area of
intestine
Vasculature: Superior Mesenteric Artery Various branches Arterial
Arcades (highly-branched vascular networks) Vasa Recta (straight
arteries)
Innervation: [Sympathetic vasoconstrictor; reduces motility] Greater
splanchnic nerve (T5-T9) Celiac and Superior Mesenteric ganglia;
[Parasympathetic increases motility and secretions] CN X Posterior Vagal
trunk

Cecum blind; also spelled caecum

Has no mesenteryso freely moves
Ileocecal orifice invagination of ileum into cecum, forms Ileocecal valve
Appendix Vermiform (wormlike) diverticulum of intestine; has
mesoappendix (short, triangular mesentery from ileum); position varies
Retrocecal recess space behind the cecum
Colon
Four parts:
o Ascending Colon
Secondarily Retroperitoneal
Vasculature: supply from ileocolic and right colic branches of
SMA
Innervation: [Sympathetic] Superior mesenteric plexus
o Transverse Colon
Intraperitoneal
Has transverse mesocolon which often fuses with greater
omentum
Crosses abdomen from right colic flexure to left colic
flexure
Bound to diaphragm through phrenicocolic ligament
Embryologically begins in hypogastrium, yet moves to
epigastrium
Vasculature: supply from middle colic branch of SMA
Innervation: [Sympathetic] Superior mesenteric plexus
o Descending Colon
Secondary retroperitoneal
Vasculature: supply from left colic branch of IMA
Innervation: [Sympathetic] Inferior mesenteric plexus
o Sigmoid Colon
S-shaped
Has mesentery attaching it to posterior wall
Rectosigmoid junction indicated by termination of teniae
coli
Vasculature: sigmoid branch of IMA
Innervation: [Sympathetic] Superior hypogastric plexus;
[Parasympathetic] Pelvic splanchnic nerves
Distinguishing features of large intestine:
o Plica semilunares semilunar folds of large intestine wall
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Teniae coli three bands of longitudinal muscle fibers; equally spaced

around colon
o Haustra pouches of the colon formed by contraction of teniae
o Omental appendices (appendices epiploicae) fatty sacs attached to
colon
Marginal Artery formed by the anastomoses of the ileocolic (left, middle,
right) and sigmoid arteries
o

Rectum
Position: S3-level
Partially covered by peritoneum Secondarily Retroperitoneal

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Lecture 8: Venous and Lymphatics of

Thorax/Abdomen
Four Main Systems:
Systemic circulation blood to bodys tissues and back
Pulmonary circulation circulation to lungs for oxygenation
Hepatoportal - 2 capillary bed system; brings products of digestion to liver
Lymphatic system Drains lymph fluid into Venous system
Abdominal Vessels of the Aorta: (4 Categories)
Ventral - Celiac, SMA, IMA
Lateral - Inferior phrenics, suprarenals, renals, gonadal
Dorsal - Lumbars and median sacral
Terminal - Common Iliacs
HEPATOPORTAL VENOUS SYSTEM
25% of cardiac output in portal system at any given time
Inferior Mesenteric Vein (IMV) drains into Splenic Vein
Superior Mesenteric Vein (SMV) & Splenic Vein Portal Vein
Left Gastric and Paraumbilical drain into Portal Vein
Youll need to draw
LYMPHATIC SYSTEM
out the full paths of
Function: Immunity and defense
the lymphatics to
Two Parts: Superficial lymphatic vessels (like Campers fascia)
get a good grasp of
and Deep Lymphatic Vessels (skeletal muscles and organs)
it!
Organs/Tissues: Thymus, Lymph nodes, Spleen, Tonsils, and
Lymphatic Nodules
Conduits: Right: Capillaries Vessels Trunks Right Lymphatic Duct R.
Subclavian Vein SVC RA; Left: Capillaries Vessels Trunks Cisterna
Chyli Thoracic Duct L. Subclavian Vein SVC RA
Lymph plasma proteins, antigens, antibodies, fat, and lymphocytes
Lymph Nodes
o Dark stain (outer) lymphocytes, macrophages, fibrous tissue
o Light stain (inner) medullary sinuses
o Afferent Lymphatics lymph entering
o Efferent Lymphatics lymph exiting
o Unidirectional Valves exist in afferent and efferent lymphatics
o Major nodal sites:
Superficial inguinal nodes
Lumbar nodes posterior abdominal wall, kidneys, ureters,
testes or ovaries, uterus, and uterine tubes
Preaortic nodes
Parasternal nodes
Axillary Nodes - 75% of breast lymph, arms
Iliac nodes descending colon, pelvis, and lower limbs; drain
into lumbar nodes
Cervical nodes head
o Important Drainage Paths: (Organs Nodes)
Testis/Ovaries Preaortic and Paraortic Nodules
Vagina/Penis & Scrotum Inguinal Nodes
Superficial Drainage Superior to Umbillicus Axillary

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Superficial Drainage Inferior to Umbillicus Inguinal

Breast Axillary (75%) and Clavicular/Parasternal/Abdominal
(25%)
Cisterna Chyli milky, creamy lymph
o Fat (through Lacteal capillaries) Chylomicrons Cisterna Chyli
o Sac that collects fat/lymph from small intestine
o Drains into Thoracic duct
Thoracic Duct
o Superiorly along right vertebral column Wraps behind the great
vessels Merges at branching of L. Subclavian Vein and L. Internal
Jugular Vein
Right Lymphatic Duct
o Drains right part of body from arcuate line upwards Drains into
junction of R. Subclavian Vein and R. Internal Jugular Vein

SYSTEMIC CIRCULATION
Venous System
o Superior Vena Cava
Tributaries: R. Internal jugular vein, R. Subclavian vein, R.
Brachiocephalic vein (and same on left)
o Inferior Vena Cava
Source: Drains everything below diaphragm, except GI Tract
Common Iliacs IVC
Lumbars (L1-L4) IVC
R. Testicular Vein IVC
L. Testicular Vein L. Renal Vein IVC
R. Renal Vein Azygous Vein (which goes to SVC) and IVC
(anastomoses site)
R. & L. Suprarenals, phrenics, hepatic veins (R, L, & middle)
IVC
o Azygous System
Source: Thoracic and abdominal walls, Vertebral venous plexus,
Esophagus (via esophageal veins), Lungs (via bronchial veins)
Azygous SVC
Right Side: Ascending Lumbar Vein joins Subcostal Vein
Azygous
Left Side: Ascending Lumbar Vein joins Subcostal
Hemiazygous
Bronchial veins on right side Azygous
Branches between Azygous and Hemiazygous @ IC7 & IC8
o Hepatic Portal System
Source: blood from digestive tract, gall bladder, pancreas, and
spleen
Portal & SVC do not have valves (lymphatic and systemic do)
Venous Path: Artery Capillaries Vein (Portal)
Capillaries/Sinusoids (in liver) Vein Heart
CLINICAL CORRELATES - DISEASE
Elephantitus - a parasitic worm can lay eggs in lymph nodes, causing gross
edema
Metastasis - cancer likes to spread through lymph vessels

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CLINICAL CORRELATES LYMPHOGRAPHY

Lymphangiogram - shows lymph vessels
Lymphadenogram - shows nodes

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Lab XII: Posterior Abdominal Wall

Vessels:
Male
o
o
o

Aorta Left and Right Testicular arteries (exit at superficial ring)

Right Testicular Vein drains into IVC
Left Testicular Vein drains into Left Renal drains into IVC
Left Renal crosses between SMA and aorta (like a nut in a
nutcracker)
Female
o Ovarian vessels cross External Iliacs (same otherwise)

Kidneys
Perirenal capsule surrounds kidney; enclosed in renal fascia w/ fat; not
rigidly attached to abdominal wall; Retroperitoneal
Differences between left and right kidney:
o Position: Top of Left @ T11, Top of Right @ T12 (because of liver)
o Venous return: Left renal vein is longer and it drains L.
testicular/ovarian and inferior suprarenal vein
o Contacts: [Left] L. Colic flexure, tail of pancreas; [Right] R. Colic flexure,
liver, descending portion of duodenum
Parts of the Kidney:
o Renal Fascia - fibrous tissue surrounding kidney; separated from
fibrous capsule by perirenal fat
o Renal Hilum vertical cleft, marks entrance to Renal Sinus
o Renal Cortex - outer 1/3 of kidney
o Renal Medulla - consists of renal columns and pyramids
Renal Columns - straight, support cortex
Renal Pyramids triangular consisting of medullary rays;
drain into papillae
o Renal Filtrate Drainage: Pyramids Papillae Minor Calices Major
Calices Renal Pelvis Ureter
Renal papillae - small cups under pyramids drain into
Minor calices - under each pyramid ad papilla (branch from
majors)
Major calices - only 2 or 3, the minor drain into them
Renal pelvis - the major calices drain into here and then on to
ureter
Retroperitoneal position of kidney (from Posterior to Anterior)
o Mnemonic: U Are Very Pretty Ureter, Artery, Vein, Peritoneum
Neighboring surfaces: diaphragm, psoas major, quadratus lumborum,
posterior transversus abdominus
Pyelogram used to detect urine
Adrenal Glands
Position: Above the kidneys
Shape: Right is triangular R, and Left is Semilunar L (like shape of letters)
Vascular supply:
o Superior: superior suprarenals inferior phrenics aorta
o Middle: middle suprarenals aorta
o Inferior: inferior suprarenals renal arteries aorta
Venous return:
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o Left Suprarenal Vein L. Renal Vein IVC

o Right Suprarenal Vein IVC
Innervation: thoracic splanchnics renal plexus kidneys & ureters; thoracic
splanchnics celiac plexus suprarenal glands

Muscles of Posterior Abdominal Wall:

Psoas Major (loin muscle) flexes vertebral column
o Attachments: (Superiorly) Transverse process & Intervertebral discs of
T12-L5; (Inferiorly) Lesser trochanter of femur
o Vasculature: Iliolumbar artery lumbar arteries
o Innervation: L1-L3 Lumbar plexus
Quadratus lumborum flexes vertebral column
o Attachments: (Superiorly) Tips of lumbar transverse process & Inferior
border of 12th Rib; (Inferiorly) Iliolumbar ligament & Iliac crest
o Vasculature: Iliolumbar artery lumbar arteries
o Innervation: T12, L1-L4
Iliacus flexes thigh and stabilizes hip joint
o Attachments: (Superiorly) Iliac fossa; (Inferiorly) Lesser trochanter of
femur
o Vasculature: Iliolumbar artery lumbar arteries
o Innervation: Femoral Nerve (L2 & L3)
o Often referred to as iliopsoas because flexes together w/ psoas
Nerves:
Subcostal (T12)
o Path: Inferior to 12th rib; Anterior to quadratus lumborum
Iliohypogastric (L1) supply skin of suprapubic and inguinal regions
o Path: Emerges from lateral border of psoas anterior to quadratus
lumborum
Ilioinguinal (L1) supply skin of suprapubic and inguinal regions
o Path: Shares trunk with Iliohypogastric, but splits off inferiorly
Lateral femoral cutaneous (L2,3) supplies lateral aspect of thigh
o Path: lateral of psoas and anterior to Iliacus
Genitofemoral (L1,2) supplies cremaster and medial portion of thigh
o Path: Pierces and emerges from ventral surface of psoas;
Femoral nerve (L2,3,4) supplies iliacus muscle and extensors of knee (big
nerve)
o Path: Descends in lateral groove of psoas and iliacus
Obdurater (L2,3,4) adductor muscles of the thigh
o Path: Medial border of psoas into obdurater foramen; most posterior
THORACIC DIAPHRAGM:
Parts:
o Sternal two muscular slips that attach to Xiphoid process
o Costal interdigitates with costal cartilages of Ribs 7-12
o Lumbar Left and Right Crura
Crura: musculotendinous bundles that extend down to L1-L3
Right crura is longer than left
Median arcuate ligament unites crura; forms aortic hiatus;
thickened fascia of psoas
Lateral Arcuate Ligament thickened fascia of quadratus
lumborum
o Central Tendon aponeurotic insertion of the muscle
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Openings:
o Caval foramen - T8; IVC and right phrenic; Most anterior and lateral
right
o Esophageal hiatus - T10; esophagus and 2 Vagal trunks; Middle
o Aortic hiatus - T12; Aorta, thoracic duct, azygous vein; Most posterior
and left
Aortic hiatus not actually in diaphragm, but in arcuate ligament;
therefore, not affected by respiration
o Mnemonic: I Eight Ten Eggs At Twelve
Innervation:
o Motor: Phrenic Nerves (C3-C5); Sensory: Phrenic Nerves (C3-C5) and
peripherally by intercostal nerves (T5-T11) and subcostal nerve (T12)

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Lab XIII: Pelvis and Perineum

Pelvis
Major Divisions divided by pelvic brim
o Greater Pelvis - pelvis major; false pelvis
o Lesser Pelvis - pelvis minor; true pelvis
Pelvic Openings
o Pelvic Inlet opening to abdomen
o Pelvic Outlet closed by pelvic diaphragm
Bony Pelvis 4 Parts:
o Hip Bones
Three parts that meet at the acetabulum
Ilium superior part
Ischium posterior part
Pubis anterior part
o Sacrum
o Coccyx
Important parts:
o Iliac crest
o Iliac fossa
o Ischial tuberosity
o Ischial spine
o Sacral foramen exit points for nerves S1-S5
o Sciatic Foramen formed by sacrotuberous and sacrospinous
ligaments
Greater Sciatic Foramen
Piriformis muscle and Sciatic nerve exit here
Lesser Sciatic Foramen
Pudendal nerve and internal pudendal vessels enter here
and continue into Ischioanal/ischiorectal fossa of anal
triangle
o Obturator Foramen
Joints of the Pelvis
o Lumbosacral Joints
Zygapophysial joints (between L5 and S1)
Iliolumbar Ligaments joins L5 and Ilium
o Sacroiliac joint Synovial
Sacroiliac ligaments join sacrum and ilium
Sacrotuberous ligament join Ischial tuberosity and sacrum
Sacrospinous ligament join Ischial spine and sacrum
o Pubic symphysis - Symphysis
Pubic Arch greater angle in females than males
Superior pubic ligament thickening of superior symphysis
ligament
Inferior (arcurate) pubic ligament - thickening of inferior
symphysis ligament
MUSCLES OF PELVIC WALLS
Obturator Internus rotates thigh laterally
o Attachments: pelvic surface of ilium and ischium to greater trochanter
of femur
o Innervation: Nerve to Obturator internus (L5-S2)

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Piriformis rotates thigh laterally; adducts thigh

o Attachments: sacrum to greater trochanter
o Innervation: S1-S2
Muscles of the Pelvic Diaphragm
o Levator Ani support pelvic viscera; relaxes during urination and
defecation; by reflex, contracts when abdominal muscles contract
sneezing/coughing leads to increased support for pelvic viscera
Attachments: Body of pubis and Ischial spine to Coccyx and
walls of vagina, rectum and anal canal
Innervation: S4, Anal nerve, and Coccygeal plexus
Parts:
Pubococcygeus
Puboprostaticus/Pubovaginalis
Puborectalis
Iliococcygeus
o Coccygeus support pelvic viscera

PELVIC NERVES:
Refer to Appendix III for complete listing
Anococcygel nerves arise from coccygeal plexus; pierce sacrotuberous
ligament to supply small cutaneous region
Hypogastric plexus autonomic plexus for synapsing of pelvic splanchnics
(S2-S4)
PELVIC ARTERIES AND VEINS:

To be continued some other time this is the lab from hell.

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Appendix V: Embryological Remnants

Embryological Part
Ductus Arteriosus
Foramen Ovale
Ductus Venosus
Left Umbilical Vein
Umbilical Arteries
Urachus
Right Umbilical Vein

Remnant
Ligamentum Arteriosum
Fossa ovalis
Ligamentum Venosum
Ligamentum Teres Hepatis
Medial Umbilical Ligament
Median Umbilical Ligament
Involutes in Fetus
Truncus Arteriosus

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Appendix VI: Tips for the Practical Exam

1. Be sure to specify Left or Right / Superior or Inferior / Medial or Lateral
2. When talking about nerve fibers, specify preganglionic or postganglionic
3. Stuck on one? Note down a few things about it and wait till you get an easy
station/rest stop to spend some more time thinking about it.
4. If necessary, use the L/R markings on X-Rays to get your bearings
5. More to come from your friendly TAs

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