FUNDAMENTALS

*Anatomical Position – refers to the body position as if the person were standing upright with the:
• head, gaze (eyes) and toes directed anteriorly
• arms adjacent to the sides with palms facing anteriorly, and
• lower libs close together with the feet parallel

*Anatomical Planes
• Median plane (median sagittal) – divides into right and left
• Sagittal plane – parallel to median plane (paramedian- parallel & near median plane)
• Frontal plane (coronal) – at right angles to median plane; divides into anterior and posterior
• Transverse plane – at right angles to median and frontal planes; divides into superior and inferior

*Sections
• Longitudinal – lengthwise
• Transverse – cross sections
• Oblique

*Terms
• Superior – near vertex
• Cranial – near head

• Inferior – near sole/foot

• Caudal - near tail or hind part

• Posterior (dorsal) – back

• Anterior (ventral) – front
• Rostral – anterior (brain)

• Medial – middle/center
• Lateral – side

• Dorsum – superior aspect of any part that protrudes anteriorly from body (e.g., tongue, nose)

• Dorsal surface
• Palmar surface
• Plantar surface

• Inferomedial
• Superolateral

• Superficial, Intermediate, Deep

• External, Internal
• Proximal, Distal

*Terms of Laterality
• Bilateral – occurring both sides/ present on right and left (e.g. kidneys)
• Unilateral – occurring on one side only (e.g. spleen)
1|Anatomy Study hard. Pray harder. -jeshrlys
 • Ipsilateral – occurring on same side of the body
• Contralateral – occurring on opposite side of the body

*Movements
• Flexion – bending/decreasing angle
• Extension – straightening/ increasing angle

• Dorsiflexion – lifting foot/ toes off the ground

• Plantarflexion – bends foot toward ground
• Hyperextension – overextension, cause “whiplash”

• Abduction – moving away from median plane

• Adduction – moving toward median plane

• Circumduction – circular movement involving sequential flexion, abduction, extension and adduction
• Rotation – turning/ revolving around longitudinal axis
Medial rotation – internal
Lateral rotation – external

• Pronation – rotates radius; dorsum of hand

• Supination – uncrossing radius from ulna (anatomical position); palmar

• Eversion – moves sole with foot away from median plane; laterally
• Inversion – moves toward median plane; medially

• Opposition – pad of thumb (1st digit) brought to another digit pad

• Reposition – movement of thumb from opposition back to anatomical position

• Protrusion and Retrusion – movement anteriorly (forward) and posteriorly (backward) - jaw
• Protraction and Retraction – anterior-posterior movements of the scapula or mandible

• Elevation – moves superiorly

• Depression – lowers/ moves part inferiorly

*Landmarks (thorax and abdomen)

Note: Xiphoid process (sternum) – inferior part, T10 vertebra
-important landmark in median plane
• Inferior limit of central part of thoracic cavity
• Midline marker for superior limit of liver, the central tendon of diaphragm, and inferior border of heart

2|Anatomy Study hard. Pray harder. -jeshrlys

RESPIRATORY SYSTEM
*Retropharyngeal space (neck) – largest and most important interfascial space; potential space consists of loose connective tissue
between visceral part of prevertebral layer of deep cervical fascia and buccopharyngeal fascia surrounding pharynx superficially
(inferiorly, buccopharyngeal fascia is continuous with pretracheal layer of deep cervical fascia)

SKELETON
Sternum
1. Manubrium – T3-T4 vertebrae level – widest, thickest
-jugular (suprasternal) notch at T2 vertebra level
-clavicular notches (2- latera)
-manubriosternal joint/sternal angle of Louis – T4-T5 vertebrae level/ 2nd pair of costal cartilage level
2. Body of sternum – long, narrow at T5-T9 vertebrae level
-costal notches
-transverse ridges (lines of fusion- synostosis)
3. Xiphoid process – smallest, T10 level
Landmarks:
• Xiphisternal joint – inferior limit of the thoracic cavity
• Infrasternal angle (subcostal angle) – inferior thoracic aperture

-12 pairs (or 24) ribs & costal cartilages

-12 thoracic vertebrae & intervertebral disc (interposed between them)

Note: clavicles & scapulae form pectoral girdle (not part of thoracic cage)

THORAX- primary organs of the respiratory & cardiovascular system

True thoracic wall: skin, subcutaneous tissue, muscles, fascia, & cage

Thoracic cavity:
1. Central compartment (Mediastinum) – conducting structures of the thoracic viscera
2. Lateral compartment (Pulmonary cavities) – housing the lungs

RIBS- costal cartilages & intercostal spaces

1. True (vertebrocostal) ribs – 1st-7th ribs – attached directly to sternum
2. False (vertebrochondral) ribs – 8th, 9th & usually 10th ribs – their cartilages are connected to the cartilage of the rib above them
3. Floating (vertebral, free) ribs – 11th-12th, may include 10th ribs

Typical ribs: 3rd to 9th ribs

1. Head – 2 facets separated by crest of the head
2. Neck – connects head of the rib with the body at the level of the tubercle
3. Tubercle – junction of neck & body
-articular part:
• Smooth articular part – articulates with corresponding transverse process of vertebra
• Rough articular part – attachment for costotransverse ligament
4. Body (shaft) – thin, flat & curved at costal angle
-costal groove – provides some protection for intercostal nerve & vessels
Atypical ribs: 1st, 2nd, 10th 11th 12th ribs
1. 1st ribs – broadest, shortest, most sharply curved of 7 true ribs
-single facet on head (articulation with T1 vertebra only)
-2 transverse grooves for subclavian vessels (vein & artery)
3|Anatomy Study hard. Pray harder. -jeshrlys
 -scalene tubercle – separates 2 grooves
2. 2nd ribs – thinner, less curved body, substantially longer than 1st rib
-2 facets (articulation with T1 & T2 vertebrae)
-with tuberosity for serratus anterior muscle (atypical feature)
3. 10th-12th – one facet articulates with single vertebra
4. 11th-12th – short, no neck or tubercle

THORACIC APERTURES
1. Superior thoracic inlet (kidney-shaped)
• Posterior: T1 vertebra
• Lateral: 1st pair of ribs
• Anterior: superior border of manubrium
-6.5cm A-P / 11cm transverse
2. Inferior thoracic outlet
• Posterior: T12 vertebra
• Posterolateral: 11th & 12th pair of ribs (floating ribs)
• Anterolateral: 7th-10th ribs & costal cartilages
• Anterior: xiphisternal joint

THORACIC WALL JOINTS (and types of joints)

1. Vertebrae – intervertebral joint – symphysis (secondary cartilaginous)
2. Ribs & vertebrae – costovertebral joint (synovial plane joint)
3. Ribs & costal cartilage – costochondral joint (primary (hyaline) cartilaginous joint)
4. Costal cartilage – interchondral joint (synovial plane joint)
5. Sternum & costal cartilage – sternocostal joint
(1st – primarily cartilaginous joint - synchondrosis; 2nd-7th – synovial plane joint)
• 1st pair of cartilage – manubrium only
• 2nd pair of cartilage – manubrium & body of sternum
• 3rd-6th pair of cartilages – body of sternum
• 7th pair of cartilage – body pf sternum & the xiphoid process
6. Sternum & Clavicle – sternoclavicular joint (saddle type of synovial joint)
7. Parts of the sternum – manubriosternal joint (secondary cartilaginous joint – symphysis) & xiphisternal joint (primary
cartilaginous joint – synchondrosis

THORACIC WALL MUSCLES (S-LIST)

1. Serratus posterior muscle
2. Levatores costarum muscle
3. Intercostal muscle
4. Subcostal muscle
5. Transverse thoracic muscle

4|Anatomy Study hard. Pray harder. -jeshrlys

FASCIA OF THORACIC WALL
1. Pectoral or pectoralis fascia – in association with pectoralis major
2. Clavipectoral fascia – from clavicle – invest the pectoralis minor muscle
3. Endothoracic fascia – thin fibro-areolar layer lining the lung cavities (costal parietal pleura) to the thoracic wall
-apex of the lung: suprapleural membrane (more fibrous)

NERVES OF THORACIC WALL

-supplied by 12 pairs of thoracic spinal nerves
-as soon as they leave intervertebral (IV) foramina -> divide into anterior rami & posterior rami
• Anterior rami of nerves T1-T11 – form intercostal nerves which run along extent of intercostal spaces
• Anterior ramus of T12 – subcostal nerve coursing inferior to 12th rib
• Posterior rami of thoracic spinal nerves – pass posteriorly immediately lateral to articular processes of the vertebrae supplying
the ff. in thoracic region:
-joints
-deep back muscles
-skin of the back

*Typical intercostal nerves

3rd to 6th intercostal nerves: enter medial-most parts of posterior intercostal spaces
- between parietal pleura (lateral & anterior cutaneous branches) & intercostal membrane
• Lateral cutaneous branches – between internal & innermost intercostal muscles
• Anterior cutaneous branches – passing between costal cartilages

*Dermatome – supplied by thoracic spinal nerves T2-T12

*Myotome – group pf muscles supplied by posterior ramus & anterior ramus of thoracic spinal nerves T2-T12, include LISTS muscles:
• Levatores costarum
• Intercostal

5|Anatomy Study hard. Pray harder. -jeshrlys

 • Subcostal
• Transversus thoracis
• Serratus posterior

*Branches of typical intercostal nerves: R-CLAM

1. Rami communicantes (communicating branches)
-connect each intercostal nerve to ipsilateral sympathetic trunk
2. Collateral branches – arise near the angle of the ribs & descend to course along the superior margin of the lower rib – helping
supply the intestinal muscles & parietal pleura
3. Lateral cutaneous branches – arise near MAL (midaxillary line)
-pierce internal & external intercostal muscles dividing them into anterior & posterior branches
-terminal branches – supply the skin on the lateral aspect of the thorax & abdomen
4. Anterior cutaneous branches – pierce the muscles & membranes of intercostal space in parasternal line dividing into medial &
lateral branches
-terminal branches – supply the skin on the anterior aspect of thorax
5. Muscular branches - supply LISTS muscles

*Atypical intercostal nerves

1st, 2nd, 7th-11th intercostal nerves
• Anterior ramus of T1 divides into
1. Large superior part = brachial plexus
2. Small inferior part = 1st intercostal nerve
• 1st & 2nd intercostal nerves – course on internal surface of 1st & 2nd ribs instead of along the inferior margin in costal grooves
• 1st intercostal nerve – no anterior cutaneous branch; often no lateral cutaneous branch
• 2nd & sometimes 3rd intercostal nerve – give rise to large lateral internal branch (intercostobrachial nerve) – penetrates serratus
anterior & enters axilla & arm
• Lateral cutaneous branch of 3rd intercostal nerve – gives rise to 2nd intercostobrachial nerve
• 7th-11th intercostal nerves – no longer being between the ribs (intercostal) become thoraco-abdominal nerves of the abdominal
wall.

ARTERIAL SUPPLY OF THORACIC WALL

-arteries of thoracic wall are derived from the (TSA)
1. Thoracic aorta -> give rise to posterior intercostal artery (pICA) & subcostal artery (subCA)
2. Subclavian artery -> give rise to internal thoracic artery (ITA) & supreme/superior intercostal artery (SICA)
3. Axillary artery -> give rise to superior & lateral thoracic arteries

• Intercostal arteries -> course through thoracic wall between ribs

-each intercostal space (except 10th & 11th) is supplied by 3 arteries:
o large posterior intercostal artery (& its collateral branches)
o a small pair of anterior intercostal arteries

Posterior Intercostal arteries (PIA)

• of 1st & 2nd intercostal space (ICS) – from SICA (a branch of costocervical trunk of subclavian artery)
• 3rd-11th ICS (and subcostal arteries of the subcostal space) – arise posteriorly from thoracic aorta
• all give off posterior branch – accompanies posterior ramus of spinal nerve
• small collateral branch – crosses ICS along superior border of rib
• accompany intercostal nerves through ICS
• have terminal & collateral branches which anastomose anteriorly with anterior intercostal arteries

6|Anatomy Study hard. Pray harder. -jeshrlys

Internal Thoracic arteries (ITA)
• arise in root of neck from inferior surfaces of 1st parts of subclavian arteries
• descend into thorax posterior to the clavicle
• crossed near origins by ipsilateral phrenic nerves
• descend internal surface of thorax lateral to sternum
• terminate in 6th ICS- dividing into
o Superior epigastric artery
o Musculophrenic arteries
• directly give rise to anterior intercostal artery (AIA) supplying superior 6 ICS

Anterior Intercostal arteries (AIA)

• supply anterior parts of upper 9 intercostal spaces
• pass lateral in intercostal space
• first 2 ICS -> endothoracic fascja – between parietal pleura & internal intercostal muscle
• 3rd-6th ICS – separated from pleura by slips of transversus thoracis muscle
• 7th-9th ICS – derived from musculophrenic arteries & also branches of internal thoracic artery
• supply intercostal muscles
• absent from inferior 2 ICS
o 10th & 11th CS – only contain posterior intercostal artery

VENOUS DRAINAGE OF THORACIC WALL

Intercostal veins – accompany intercostal arteries & nerves: lie most superior in the costal grooves
• 11 posterior intercostal veins – anastomose with anterior intercostal veins
• 1 subcostal vein on each side
• most posterior intercostal veins (PIV) (4-11) – end in azygos/hemi-azygos venous system
-conveys venous blood to SVC (superior vena cava)
• PIV of 1st intercostal space – enter directly into the right & left brachiocephalic veins
• PIV of 2nd & 3rd (occasionally 4th) ICS – unite to form superior intercostal vein
o Right superior intercostal vein – final tributary of azygos vein before it enters SVC
o Left superior intercostal vein – empties into left brachiocephalic vein
• Internal thoracic veins – companion veins of internal thoracic arteries

TRACHEA
-internal diameter: 1.5-2.0cm
-length: 10-11cm
-begins at level of C6 vertebra
-at level of T5 – carina
-15-20 rings
-bifurcates at the level of the transverse thoracic plane (sternal angle) into main bronchi

LUNGS
-Root of the lung – medial to hilum; enclosed within the area of continuity between parietal & visceral layers of pleura
-Pleural sleeve or mesopneumonium – mesentery of the lung
-Hilum of lung – wedge-shaped area of the mediastinal surface of each lung
-Horizontal & oblique fissures – divides the lungs into lobes

7|Anatomy Study hard. Pray harder. -jeshrlys

 Note: Right lung is larger & heavier than the left lung, but it is
Right lung has three lobes shorter & wider because the right dome of the diaphragm
Left lung has two lobes is higher & the heart & pericardium bulge more to the
left.
Right lung: superior, middle & inferior lobes
• Superior & middle lobes separated by horizontal fissure
• Middle & lower lobes separated by oblique fissure
Left lung: superior & inferior lobes
• Separated by oblique fissure

Surfaces of the lungs (CMD)

1. Costal – smooth & convex; related to the costal pleura
2. Mediastinal – concave; related to the middle mediastinum (containing the pericardium & heart)
-include the hilum & receives the root of the lung which the pleura forms the pleural sleeve
-pulmonary ligament hangs inferiorly from the sleeve among the root
3. Diaphragmatic – concave; forms the base of the lung – rests on the dome of the diaphragm
-concavity is deeper in the right lung because of the higher position of the right diaphragmatic dome
Borders of the lungs (AIP)
1. Anterior – sharp border
2. Inferior – rounded border
3. Posterior – concave

Bronchi
Primary:
1. Right main bronchus – wider, shorter, more vertical; passes directly to hilum
2. Left main bronchus – passes inferiorly – inferior to the arch of the aorta & anterior to esophagus & thoracic aorta to reach
hilum
Secondary (lobar) bronchi: 2 on left, 3 on right

8|Anatomy Study hard. Pray harder. -jeshrlys

Tertiary (segmental) bronchi: each supplies a bronchopulmonary segment (10 on right; 8 on left)
Bronchioles
• Segmental bronchi – 20-25 generations which end in terminal bronchioles
• Each bronchiole gives rise to several generations of respiratory bronchioles
• Each respiratory bronchiole provides 2-11 alveolar ducts
• Each alveolar duct gives rise to 5-6 alveolar sacs
Alveoli – the basic unit of gas exchange in the lung
-new alveoli continue to develop until 8 years old (at this time, there are 300 million alveoli)

Broncho-pulmonary segments
• Pyramidal-shaped, with apices facing the lung root & bases at pleural surface
• Largest subdivision of a lobe
• Separated from adjacent segments by septa
• Supplied independently by a segmental bronchus and a tertiary branch of the pulmonary artery
• Named according to the segmental bronchi supplying them
• Drained by intersegmental parts of the pulmonary veins
• Surgically resectable
• Usually 18-20 in number (10 in right; 8-10 in left)

In the left lung, the first and second segments are often fused and the seventh segment is usually absent. It is, therefore,
possible that the left lung only has a total of eight segments.

Mnemonics for bronchopulmonary segments:

Right lung – A PALM Seed Makes Another Little Palm
Left lung – ASIA ALPS

9|Anatomy Study hard. Pray harder. -jeshrlys

VASCULATURE OF THE LUNGS & PLEURA
• Each lung has a large pulmonary artery supplying blood & 2 pulmonary veins draining blood
Pulmonary artery (right & left) – arise from pulmonary trunk at sternal angle level
-carries poorly oxygenated/venous blood to lungs for oxygenation
• Arteries & bronchi are paired in the lung
Pulmonary veins – 2 in each side
-carry well-oxygenated/arterial blood from lungs to left atrium of the heart
o Veins from visceral pleura -> drain into pulmonary veins
o Veins from parietal pleura -> joins systemic veins (in adjacent parts of thoracic wall)

Note:
Pulmonary arteries – carry deoxygenated blood from heart
Pulmonary veins – carry oxygenated blood to heart

Y
Bronchial arteries – carry oxygenated blood (part of systemic circulation)
-supply blood to
o Root of lungs
o Supporting tissues of lungs
o Visceral pleura
• 2 left bronchial arteries – from thoracic aorta
• 1 right bronchial artery – may arise directly from aorta or indirectly from proximal part of one of upper posterior intercostal
arteries (right 3rd Intercostal artery) or common trunk with left superior bronchial artery
Small bronchial arteries – provide branches to upper esophagus & typically pass along the posterior aspects of the main bronchi
-distal most branches of bronchial arteries anastomose with branches of pulmonary arteries in walls of bronchioles in visceral pleura
-the parietal pleura is supplied by the arteries that supply the thoracic wall
Bronchial veins – drain only part of the blood supplied to lungs by bronchial arteries
1. Right bronchial vein -> drain to azygos vein
2. Left bronchial vein -> drain to hemiazygos vein or the left superior intercostal vein

Lymphatics
Pulmonary lymphatic plexus
1. Superficial subpleural lymphatic plexus -> drain into bronchopulmonary lymph nodes (hilar lymph nodes) -> into superior
tracheobranchial lymph node
2. Deep lymphatic plexus (drain structures that form root of lung) -> initially drain into pulmonary lymph nodes along lobar
bronchi -> bronchopulmonary lymph nodes -> inferior tracheobronchial lymph nodes

-the right lung drains primarily through the respective sets of nodes on right side
-superior lobe of the left lung drains primarily through nodes of the left side
-many lymphatics from lower lobe of left lung drain to right superior tracheobronchial nodes -> follow right-side pathway

-lymph from tracheobronchial lymph nodes passes to

• Right bronchomediastinal lymph trunk -> emerge with other lymphatic trunks forming short right lymphatic trunk
• Left bronchomediastinal lymph trunk -> may terminate in thoracic duct

-lymph from parietal pleura drains into lymph node of thoracic wall (intercostal, parasternal, mediastinal & phrenic)

10 | A n a t o m y Study hard. Pray harder. -jeshrlys

INNERVATION OF LUNGS & PLEURA
• Parasympathetic fibers – from vagus nerve
• Sympathetic fibers – from sympathetic trunks
Parasympathetic Sympathetic
Smooth muscle Bronchoconstrictor (motor) Bronchodilator (inhibitor)
Pulmonary vessels Vasodilator (inhibitor) Vasoconstrictor
Glands of bronchial trees (type II) Secretory/secretomotor (motor) Inhibitory to secretion

11 | A n a t o m y Study hard. Pray harder. -jeshrlys

CARDIOVASCULAR SYSTEM

*CARDIAC CYCLE
• starts with DIASTOLE – ventricular elongation and filling; D-F (filling)
• ends with SYSTOLE – ventricular shortening and emptying; S-S (shortening)

• “lub” closure of AV valves (atria -> ventricles)

• “dub” closure of semilunar valves (ventricles expels blood)

*FIBROUS SKELETON
• 4 fibrous rings= annuli fibrosis
• fibrous trigone (connection between rings)
• membranous part of interatrial and interventricular septa= septum membranaceum

*HEART
• apex= LV (left ventricle) at posterior left of 5th ICS (Intercostal space)
• base= LA (left atrium) at bodies of T6-T9 vertebrae

surfaces: S= A – D – R – L
• Anterior (sternocostal)= RV (right ventricle)
• Diaphragmatic (inferior)= LV (left ventricle- related to central tendon of diaphragm)
• Right pulmonary= RA (right atrium- note: near right lung! see its orientation)
• Left pulmonary= LV (left ventricle- note: near left lung w/c has cardiac impression)

borders: B= R – I – L – S
• Right= RA
• Inferior= RV
• Left= LV
• Superior= RA & LA, ascending aorta & pulmonary trunk

*Right Atrium (RA)

-receive venous blood from SVC, IVC and coronary sinus
• Right auricle (muscular pouch)
• Sinus venarum – posterior part which is smooth; thin-walled
• Pectinate muscles/ musculi pectinati – rough, muscular anterior part
• Sulcus terminalis (terminal groove) – separates smooth and rough parts (externally)
• Crista terminalis (terminal crest) – vertical ridge separates smooth and rough parts (internally)
• Superior Vena Cava (SVC) at the level of 3rd costal cartilage
• Inferior Vena Cava (IVC) at the level of 5th costal cartilage
• Interatrial septum (separating atria)
• Oval fossa – depression; remnant of foramen ovale

*Right Ventricle (RV)

• Conus arteriosus (infundibulum) – superior, leads to pulmonary trunk
• Trabeculae carnae – interior, irregular muscular elevations
• Supraventricular crest – thick, internal muscular ridge; demarcating the inflow & outflow tracts
• Tricuspid valve with anterior, posterior and septal cusps
12 | A n a t o m y Study hard. Pray harder. -jeshrlys
 • 3 papillary muscles
Key: (muscle- cusps)
Anterior papillary muscle (largest)- cords attached to Anterior & Posterior cusps
Ant- A & P
Posterior papillary muscle- cords attached to Posterior & Septal cusps
Post- P & S
Septal papillary muscle- cords attached to Anterior & Septal cusps Sept- S & A

• Interventricular septum (separates ventricles) Note: APS-PSA

• Septomarginal trabeculae (moderator band)

*Left atrium (LA)

• Left auricle
• Pectinate muscle
• larger than RA, smooth walled
• 4 pulmonary veins (2 inferior, 2 superior)
• slightly thicker than right (wall)
• Interatrial septum
• Left AV orifice

*Left ventricle (LV)

• walls thicker
• mostly covered with trabeculae carnae (finer & more numerous than RV)
• conical cavity & longer
• Bicuspid/ Mitral valve: with anterior & posterior papillary muscles onlu
• Aortic orifice

• Mitral valve (2 cusps: anterior & posterior) – at level of 4th costal cartilage
Posterior of sternum
• Aortic valve – at level of 3rd intercostal space (ICS), left

note:
Key:
P= A- R- L
Semilunar valves:
A= P- R- L
• Pulmonary valve- 3 cusps (Anterior, Right & Left)
if P/A, the letter should only appear once
• Aortic valve – 3 cusps (Posterior, Right & Left)

Sinus – dilated portion

• Right aortic – mouth of right coronary artery
• Left aortic – mouth left coronary artery
• Posterior aortic (non-coronary) – no artery arises

*Coronary circulation

arteries:
RCA= S60%- R- A80%- P67%- T

LCA= S- A- L- C + L (left marginal) + Posterior IV (determines dominance: RCA67% > LCA

note: percentage= occurrence/presence of artery among population

veins:
G- M- S- O- A- S

13 | A n a t o m y Study hard. Pray harder. -jeshrlys

Right Coronary Artery (RCA)
1. Sinoatrial nodal branch – supplies SA node
2. Right marginal branch – supplies right border of heart (RA)
3. Atrioventricular nodal branch – supplies AV node
4. Posterior Interventricular (IV) branch – supplies both ventricles
-with perforating IV septal branches supplying 1/3 of Interventricular septum/IVS (posterior)
5. Terminal (Left ventricular) branch – supplies diaphragmatic surface of heart (LV)

Left Coronary Artery (LCA)

1. SA nodal branch – from circumflex branch
2. Anterior IV branch/ left anterior descending branch – supplying part of both ventricles via IV septal branches & anterior 2/3
of IVS
3. Lateral (diagonal branch) – from anterior IV branch
4. Circumflex branch with left marginal artery supplying left ventricle

note:
Circumflex artery gives rise to 2 arteries: SA nodal artery & Left marginal artery

Anterior IV artery has 2 branches: Lateral (diagonal) branch & IV septal branch

RCA LCA

- RA - LA
- most of RV - most of LV
- part of LV (diaphragmatic surface) - part of RV
- part of IV septum (posterior 1/3) - most of IVS (anterior 2/3)
- SA node (~40%)
- SA node (60%)
- AV node (80%)
key: S for= Sixty (60%)
AV= 8tri0ventricular (80%)

note:
Right dominant pattern = 67%
Left dominant pattern = ~15% hearts (LCA is dominant wherein Posterior IV
branch arises from circumflex artery)
Codominance= ~18% hearts (branches of both right & left coronary arteries
reach apex of heart

Cardiac Veins
Coronary sinus – main vein of the heart; wide venous channel; runs from left to right

note: G- M- S- O- A- S
• main vessels drain into coronary sinus -> RA
• anterior cardiac vein- drain directly to right auricle

1. Great cardiac vein – main tributary of coronary sinus

- 1st part (Anterior IV vein)
- drains areas supplied by LCA
2. Middle cardiac vein – accompanies posterior IV artery
3. Small cardiac vein – accompanies right marginal branch of RCA

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note: Middle & small cardiac veins drain most areas supplied by RCA
4. Oblique vein of left atrium – remnant of embryonic left SVC; descends over posterior half of LA
- merges with great cardiac vein – forming coronary sinus

the ff. do not drain via coronary sinus:

5. Anterior cardiac vein – drain anterior surface of RV -> coronary sulcus -> RA
6. Smallest cardiac vein – opens directly into chambers of heart

Lymphatics

vessels from myocardium and subendocardial connective tissue -> subendocardial lymphatic plexus -> follows coronary arteries ->
inferior tracheobronchial arteries

*SA node= “pacemaker of the heart”

-impulse: 70 times/minute
-spreads marginally to both atria
-supplied by SA nodal artery (RCA= 60%; LCA= 40%)

*Cardiac plexus – formed by both sympathetic & parasympathetic fibers

Sympathetic supply:
• presynaptic fibers with cell bodies in intermedial lateral cell columns of superior 5 or 6 thoracic segments of spinal cord
• postsynaptic fibers with cell bodies in cervical & superior thoracic paravertebral ganglion of sympathetic trunk
- end in SA & AV nodes
↑ heart rate
↑ impulse conduction
↑ force of contraction
↑ blood flow through coronary vessels

Adrenergic stimulation of SA nodes & conducting tissue (most adrenergic receptors: β2 receptors)
↑ rate of depolarization of pacemaker cells
↑ AV conduction

Parasympathetic supply
• presynaptic fibers of vagus nerve
• postsynaptic cell bodies (intrinsic ganglion) are located in atrial wall and interatrial (IA) septum near SA & AV nodes
- release acetylcholine- binds with muscarinic receptors (to slow the rates of depolarization of pacemaker cells and AV
conduction; decrease atrial contractility)
↓ slows heart rate
↓ force of contraction
constricts coronary arteries- saving energy

15 | A n a t o m y Study hard. Pray harder. -jeshrlys

RENAL/ GENITOURINARY SYSTEM

*Kidney (10cm length, 5cm width, 2.5cm thickness)

• right is lower than left
• level of T12-L3 vertebrae

@ renal hilum – arrangement: V- A- P (renal vein (anterior)- artery- pelvis)

each kidney has

surfaces
• anterior
• posterior
margins
• medial (concave)
• lateral (convex)
poles
• superior
• inferior

-renal sinus – space within kidney

-renal pelvis – tunnel-shaped, flattened expansion of superior end of ureter
-2 to 3 major calices – each divides into 3-5 minor calices (each indented by renal papilla, the apex of renal pyramid)
note: renal pelvis and major calices are collapsed in living person

-renal lobes – formed by pyramids + associated apex

*Renal arteries - @ level of IV disc between L1 and L2 vertebrae

- longer right renal artery, passes posterior to IVC
- each divides close to hilum into 5 segmental arteries which are end arteries

5 segmental arteries (and renal segments which they supply):

1. Superior (apical) artery – supplies superior (apical) segment
2. Anterosuperior artery – supplies anterior superior segment
3. Anteroinferior artery – supplies anterior inferior segment
4. Inferior artery – supplies inferior segment
5. Posterior artery – supplies posterior segment

note:
arteries from #1 to #4 arise from anterior branch of renal artery
posterior artery, #5, arises from posterior branch of renal artery

main branches of renal artery:

anterior –> 4 segmental arteries
posterior -> 1 segmental artery

• anterior view – 4 segments (excluding posterior renal segment)

• lateral view – 5 segments
• posterior view – 5 segments

16 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Renal veins – several unite forming right and left renal veins note: v- a- p orientation
longer left renal vein – receives: renal vein is anterior to renal artery
• left suprarenal vein
• left gonadal (testicular/ovarian) vein
• & a communication with the ascending lumbar vein
- then traverses acute angle between superior mesenteric artery (SMA) anteriorly and aorta posteriorly

note: why?
longer RIGHT RENAL ARTERY – IVC is on the right!
longer LEFT RENAL VEIN – aorta is on the left !

*Renal lymphatic vessels -> follow renal veins -> drain into right (caval) and left (aortic) lumbar lymph nodes
*Suprarenal lymphatic vessels from plexus deep to capsule -> lumbar lymph nodes

– both sympathetic and parasympathetic fibers

• renal nerve plexus - from abdominopelvic fibers and (least) splanchnic nerves
• nerves of abdominal part of ureter- from the ff plexuses:
-renal
-abdominal R- A- A- Sh plexuses
-aortic
-superior hypogastric
• visceral afferent fibers – pain sensation; follows sympathetic fibers retrograde to spinal ganglion & T11-L2 spinal cord
segments

*Kidney surface anatomy

• hilum of left kidney- transpyloric plane from median plane
• right kidney, superior pole – 2.5 cm lower than left kidney

17 | A n a t o m y Study hard. Pray harder. -jeshrlys

 • posteriorly, superior part of kidney – lie deep to the 11th & 12th ribs
• each kidney moves 2-3 cm vertical during movement of diaphragm
• inferior pole of right kidney- finger breadth superior to iliac crest

*Ureter
• muscular, 25-30cm long (narrow lumen)
• constrictions in 3 places:
1. junction of ureters & renal pelves
2. where ureters cross brim of pelvis inlet
3. during passage through wall of urinary bladder
• surface marking from the back: 5cm lateral to L1 spinous process

*Ureter Blood Supply

1. renal arteries – supplies abdominal portion of ureter
2. small branches from G- A- C
- gonadal artery
- abdominal aorta
- common iliac artery

*Ureter venous drainage:

abdominal part drains into renal & gonadal veins

*Ureter lymphatic drainage:

• superior part -> may either (1) join those from kidney or (2) pass directly to lumbar lymph nodes
• middle part -> common iliac lymph nodes
• inferior part -> common/ external/ internal iliac lymph nodes

*Urinary bladder – tetrahedral when contracted @ lesser pelvis

-4 surfaces: superior, 2 inferolateral, posterior
-borders:
• anterior (S- P- R)
- symphysis pubis
- pubic bones
- retropubic space (of Retzius)
• posterior (P- R- C)
- pelvic floor
- rectovesical fascia, rectum (male)
- cervix, vagina (female)
• superior (P- U)
- peritoneum
- uterus (female)
• inferior
- prostate gland (male)
• lateral (P- S)
- pubic bones
- seminal vesicle (male)

-parts of UB:
• apex • detrusor muscle
• fundus • rugae
• body • trigone

18 | A n a t o m y Study hard. Pray harder. -jeshrlys

 • internal urethral sphincter • uvula
• ureteric orifice

Blood supply of UB:

1. Superior vesical artery – from Internal iliac artery
- supplies anterior & posterior parts of UB (in both male and female)
2. Inferior vesical artery – from Internal iliac artery
- supplies fundus & neck of UB (in male only)
3. Vaginal artery – from Internal iliac artery
- supplies fundus & neck of UB (in female only)
4. Inferior gluteal artery – minor supply
5. Obturator artery – minor supply

-venous drainage of UB
Male Female

Vesical venous plexus – mostly Vesical venous plexus

associated w/ bladder; continuous with
prostatic venous plexus
Surrounds: F- P- S- D- D
1. fundus of UB
2. prostate gland
3. seminal glands
4. ductus deferens
5. distal ends of ureter
(inferior ends)
-> drains into inferior vesical vein ->
internal iliac vein
Surrounds: F- P- D
1. fundus of UB
2. proximal urethra &
bladder neck
3. distal ends of ureters
-> drains to internal iliac vein
-> may also drain/ communicate with
vaginal/ uterovaginal venous plexus
-> receives drainage from dorsal vein of
clitoris

-> may also drain to sacral veins ->

internal vertebral venous

-> receive deep dorsal vein of penis via

prostatic plexus

Lymphatic drainage of UB
1. External iliac lymph node – drains superolateral part of UB
2. Internal iliac lymph node – drains fundus & UB neck
3. Sacral or common iliac lymph node – some, from UB neck

Innervation of UB
1. Parasympathetic fibers
- motor to: detrusor muscle
- inhibitory to: internal urethral sphincter (in male)
Sacral spinal cord -> pelvic splanchnic nerves & inferior hypogastric plexus
Visceral afferent fibers – stimulated by stretching

motor- stretching of UB= micturition

sensory- overdistention-> pain

2. Sympathetic fibers
- inferior thoracic & upper lumbar spinal cord -> hypogastric plexus & nerves -> vesical plexus

19 | A n a t o m y Study hard. Pray harder. -jeshrlys

 - ejaculation
- prevents retrograde ejaculation
- prevents “accidental urine leak”

*Urethra
- male: 18-22cm long
- female: 4cm long
- 0.6 cm (/ 6mm) diameter

-male urethra
1. Intramural/ Prostatic – shortest (0.5-1.5cm)
filling= small & high (UB contracted)
emptying= wide & low (UB relaxed)

2. Prostatic – widest, most distensible

- where reproductive & urinary tract merges (ejaculatory duct)
ft:
• urethral crest
• prostatic sinuses
• seminal colliculus/ verumontanum (rounded eminence)
• utricle (slit orifice)
• ejaculatory duct
3. Intermediate/ Membranous – narrowest, least distensible
- penetrates perineal membrane
4. Spongy/Penile Urethra – longest, most distensible
- within corpus spongiosum of penis
ft:
• bulb of penis
• opening of bulbourethral glands/ Cowper’s glands
• urethral glands of Lithe (mucus)
• navicular fossa
• external urethral opening

-female urethra
• ~4cm long, 6mm in diameter
• shorter course

ft.

• external urethral orifice

• paraurethral glands/ Skene’s gland

Female Genitalia
Internal organs: External organs:
1. vagina 1. mons pubis
2. uterus 2. labia majora
3. fallopian tubes 3. labia minora
4. ovaries 4. clitoris (root: 2 crura; body: 2 corpora cavernosa;
glans clitoris with prepuce; frenulum)
5. vestibule of the vagina
6. bulbs of the vestibule
7. vestibular gland

20 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Ovaries
- mesovarium of broad ligament
- suspensory ligament of ovary (carries ovarian vessels, lymphatics & nerves)
-ovarian ligament (remnant of ovarian gubernaculum)
Arterial supply of ovaries:
Abdominal aorta -> Ovarian arteries -> (1) ovarian branch & (2) tubal branch (anastomose with branches of uterine artery)

Venous drainage of ovaries:

Pampiniform plexus of veins -> ovarian vein
- Right ovarian vein -> inferior vena cava (IVC) >> note: IVC is on the right
- Left ovarian vein -> left renal vein -> IVC

Lymphatic drainage of ovaries:

- Ovarian lymph nodes -> lumbar lymph nodes

Innervation of ovaries:
- Ovarian plexus
- Uterine plexus

• visceral afferent pain: T11-L1

• visceral afferent reflex: S2-S4

*Uterus
- 7.5cm long x 5cm wide x 2cm thick Note:
- ~90g Uterus is supported by
- anteverted, anteflexed - dynamic/active: pelvic diaphragm
- passive: by its anteverted & anteflexed position
Parts:
• Body – upper 2/3rd
- fundus
- isthmus
• Cervix – lower 1/3rd
-
2.5cm long; supravaginal & vaginal
- openings: (1) internal os (uterine cavity); (2) external os (vagina)
• Uterine cornu

Layers:
1. Perimetrium (outermost)
2. Myometrium
3. Endometrium (innermost)

Ligaments:
1. Broad ligament- double layer of peritoneum (mesentery)
- Ligament of ovary’(posterosuperiorly)
- Round ligament of uterus (anteroinferior)
- Mesosalpinx (uterine tube)
- Mesometrium – largest part (uterus)
2. Transverse cervical (Cardinal) / Lateral cervical (Mackenrodt’s ligaments) – from supravaginal cervix & lateral vaginal fornix to
lateral pelvic walls (uterine arteries run on its superior part)
3. Uterosacral ligament (posterior) – from cervix to middle part of sacrum
4. Round ligament – originate @ uterine horns in parametrium -> inguinal canal -> ends in labia majora

21 | A n a t o m y Study hard. Pray harder. -jeshrlys

Arterial supply of uterus:
Uterine arteries – originate from Internal Iliac artery

Venous drainage of uterus:

Uterine venous plexus -> Internal iliac veins

Lymphatics of uterus:
• Fundus -> Lumbar nodes, External iliac nodes, Superficial inguinal nodes (L- E- S)
• Body -> External iliac nodes
• Cervix -> Internal iliac nodes & Sacral nodes

Innervation of the Uterus

Uterovaginal nerve plexus – from inferior hypogastric plexus
• Sympathetic – inferior thoracic spinal segment (lumbar splanchnic)
• Parasympathetic – S2-S4 (pelvic splanchnic)
Visceral afferent
• Pain from fundus & body: follow sympathetic retrograde -> inferior thoracic & superior lumbar spinal ganglia (T11-L1)
• Pain in uterine cervix & vagina – follow parasympathetic fibers through pelvic splanchnic (S2-S4)

*Uterine/ Fallopian tube- ~10cm in length

Parts:
• Infundibulum
• Fimbriae
• Ampulla
• Isthmus
• Intrauterine segment

*Vagina – 7-9 cm
Vaginal fornices:
• Anterior fornix
• Posterior fornix
• Lateral fornix

Muscles compressing vagina: P- E- U- B (epub)

1. Pubovaginalis
2. External urethral sphincter
3. Urethrovaginal sphincter
4. Bulbospongiosus

Arterial supply of vagina: from Internal iliac artery

1. Uterine artery U- superior
2. Vaginal artery V- middle
3. Internal pudendal artery I- inferior

Venous drainage of vagina:

Vaginal venous plexus -> Uterine venous plexus -> Internal iliac veins

Lymphatics of vagina:
• Superior – Internal & External Iliac Nodes
• Middle – Internal Iliac Nodes
• Inferior – Sacral & Common Iliac Nodes

22 | A n a t o m y Study hard. Pray harder. -jeshrlys

 – Superficial Inguinal Nodes

Innervation of vagina:
• Superior ¾ visceral (uterovaginal plexus)
contains :
-sympathetic fibers – from lumbar splanchnic nerves (T11-L1)
-parasympathetic fibers – from pelvic splanchnic nerves (S2-S4)
-visceral afferent fibers – from S2, S3, & S4

• Lower ¼ somatic – deep perineal branch of pudendal nerve (sensitive to touch & temperature)

*Vulva = pudendum (external genitalia)

Arterial supply of vulva:
• External pudendal artery
• Internal pudendal artery
-Labial artery
-Artery to clitoris

Venous drainage of vulva: Internal pudendal veins

Lymphatic drainage of vulva: Superficial inguinal nodes

Innervation of vulva:
• Anterior labial nerves – from Ilioinguinal nerves A- Ii
• Genital branch of Genitofemoral nerve G- Gf
• Posterior labial nerves – from Perineal nerve P- P

Homologous structures
FEMALE MALE
Round ligament Gubernaculum testis
Skene’s glands Prostate gland
Bartholin’s glands Cowper’s gland
Labia majora Scrotum
Labia minora Penile skin
Gartner’s duct Epididymis
Canal of nuck Processus vaginalis

*Perineum
- shallow compartment (perineal compartment) bounded by pelvic outlet & separated from pelvic cavity by the fascia covering the
inferior aspect of pelvic diaphragm
Formed by Levator ani = Pubococcygeus + Iliococcygeus
• Levator ani
• Coccygeus m. Pelvic diaphragm = Pubococcygeus + Iliococcygeus + Coccygeus

Perineal fascia – consists of superficial & deep layers

-like that of inferior anterior abdominal wall, consists of
• Superficial fatty layer
• Deep membranous layer (Superficial Perineal fascia/ Colle’s fascia)

23 | A n a t o m y Study hard. Pray harder. -jeshrlys

Male Genitalia

*Scrotum
External fts.:
• Perineal raphe
• Scrotal raphe
• Penile raphe

Layers of scrotum:
• Skin
• Subcutaneous tissue (dartos fascia) & dartos muscle
• External spermatic fascia – from external oblique (EO) muscle
• Cremaster muscle – from internal oblique (IO) muscle
• Cremasteric fascia – from internal oblique (IO) fascia
• Internal spermatic fascia – from transversalis fascia
• Tunica vaginalis (visceral & parietal layers) – covers AML (anterior-medial-lateral) surfaces of testis

Blood supply of scrotum:

1. Femoral artery -> External Pudendal artery -> Anterior Scrotal artery
2. Internal iliac artery -> Internal Pudendal artery-superior perineal branch-> Posterior Scrotal artery
3. Inferior epigastric artery -> Cremasteric artery
Key (arterial supply)
Venous drainage of scrotum: External Pudendal Artery (promotes heat loss) 1. FA -> EPA -> ASA
2. IIA -> IPA-spb -> PSA
Lymphatic drainage of scrotum: Superficial Inguinal lymph nodes 3. IEA -> CA

Nerve supply of scrotum: 4.

1. Genital branch of Genitofemoral nerve (lumbar plexus) Key (nerve supply)
2. Anterior scrotal nerves from Ilioinguinal nerve G – G: anterolateral
3. Posterior scrotal nerves from branches of superficial Perineal branches of Pudendal nerve A – I: anterior
4. Perineal branch of Posterior femoral cutaneous nerve (sacral plexus) P– sP of Pud: posterior
Per – P: posteroinferior
*Penis
Consists of:
• Root
a. Bulb of penis – covered by bulbospongiosus
b. Right & left crura of penis – covered by ischiocavernosus
• Body (no muscles)
a. Corpus spongiosum – contains spongy urethra; expanded ends= glans penis
b. Corpora cavernosa – has outer covering= tunica albuginea
• Glans
a. Corona
b. Neck
c. External urethral opening
• Skin
a. Prepuce/ foreskin – double layer skin
b. Frenulum – median fold…
• Preputial sac – between glans & prepuce where smegma accumulates
• Suspensory ligament of the penis
• Fundiform ligament of the penis

24 | A n a t o m y Study hard. Pray harder. -jeshrlys

Blood supply of penis:
- from Internal Pudendal artery:
• Dorsal artery – supplies fibrous tissue around corpora, spongy urethra & skin
• Deep artery – supplies corpora cavernosa
• Arteries of bulb of penis – supplies posterior (bulbous) part of corpus spongiosum & urethra, bulbourethral gland
- from External Pudendal artery: supplies penile skin
• Superficial branches
• Deep branches

Venous drainage of penis:

- from cavernous space:
Penile venous plexus -> deep dorsal vein of penis -> prostatic venous plexus -> internal iliac vein
- from superficial:
Superficial dorsal vein of penis -> superficial external pudendal vein

Key
-pvp -> ddvp -> prvp -> iiv (from cavernous space)
- sdvp -> sepv (from superficial)

Lymphatic drainage of penis:

• SI – Superficial inguinal lymph nodes – drains skin of penis
• DI – Deep inguinal lymph nodes – drains glans & distal spongy urethra
• EI – External iliac lymph nodes – drains glans & distal spongy urethra
• II – Internal iliac lymph nodes – drains cavernous bodies & proximal spongy urethra

Nerve supply of penis:

• S2-S4 spinal cord segments -> pelvic splanchnic nerves (parasympathetic)
-cavernous nerves (helicine artery of penis)

• From spinal ganglia -> pudendal nerve (somatic)

a. Dorsal nerve of penis – sensory + sympathetic – skin of glans
b. Ilioinguinal nerve (L1) – skin of the root of penis

*Seminal glands = Seminal vesicles: 2in (5cm) long

- joins ductus deferens to form ejaculatory duct

Blood supply of SG:

- from Internal iliac artery
1. Inferior vesical artery (IVA)
2. Middle rectal artery (MRA)

Venous drainage of SG: drains to Internal iliac veins

Lymphatic drainage of SG:

• External iliac nodes – superior part
• Internal iliac nodes – inferior part

*Ejaculatory duct: <1in. (2.5 cm) long

Blood supply of ED: artery to ductus deferens from Superior Vesical/Inferior Vesical branches

Venous drainage of ED:

• Prostatic venous plexus (PVP)
25 | A n a t o m y Study hard. Pray harder. -jeshrlys
 • Vesical venous plexus (VVP)

Lymphatic drainage of ED: External iliac lymph nodes

*Prostate Gland: 3x4x2cm

Parts:
• Glandular 2/3
• Fibromuscular 1/3

Blood supply for PG:

- from Internal iliac artery
1. Inferior vesical artery (IVA)
2. Internal pudendal artery (IPA)
3. Middle rectal artery (MRA)

Venous drainage for PG:

Prostatic venous plexus -> inferior vesical vein -> internal pudendal veins -> internal iliac veins
(pvp -> ivv -> ipv -> iiv)

Note:
• PVP also receives venous blood from deep dorsal vein of penis
• PVP communicates superiorly with vesical venous plexus
• PVP communicates posteriorly with internal vertebral venous plexus

Lymphatic drainage of PG:

• Internal iliac lymph nodes (usually)
• Sacral nodes

Nerve supply of PG:

• Inferior hypogastric plexuses
• Sympathetic nerves

*TESTES (left is more inferior than right)

Blood supply of testes: Testicular arteries from abdominal aorta

Venous drainage of testes:

Pampiniform venous plexus (8-12 veins) – converge superiorly as right & left testicular veins
• Right testicular vein -> drains to Inferior vena cana (IVC) (note: IVC is on the right)
• Left testicular vein -> drains to left renal vein -> IVC

Nerve supply of testes:

- testicular plexus of nerves, contains:
• Vagal parasympathetic fibers
• Visceral afferent fibers
• Sympathetic fibers from T7 segment

*Epididymis
Parts:
• Head
• Body
• Tail

26 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Ductus Deferentes (18in/ 45cm long)
Blood supply of DD: artery to the ductus deferens – from superior/inferior vesical artery

Venous drainage of DD:

• Testicular vein
• Distal pampiniform plexus
• Vesicular/ Prostatic venous plexus

Lymphatic drainage of DD: External iliac lymph nodes

*Bulbourethral glands = Cowper glands

Blood supply: Internal Pudendal artery (IPA) -> Artery to bulb of penis

ALIMENTARY SYSTEM
*Abdominal cavity:
-With 9 regions
Right Epigastric Left
hypochondriac region hypochondriac
region region
Right Lumbar Umbilical Left Lumbar
(flank) region region (flank) region

Right iliac Hypogastric Left iliac

(inguinal) region (inguinal)
region region
-4 quadrants
• right upper and lower quadrants
• left upper and lower quadrants
-4 planes
• 2 sagittal (vertical) -> midclavicular planes (9cm from midline)
• 2 transverse (horizontal)
-transverse planes – subcostal plane; pass inferior of 10th costal cartilage
-transtubercular plane – pass through iliac tubercle (5cm posterior to ASIS & body of L5 vertebra)
-transpyloric plane – L1 vertebral level
-interspinous plane – pass through ASIS on each side (L1)
-transtubercular plane – L5 vertebral level

*Layers:
• Skin
• Subcutaneous tissue
-Superficial fatty layer= Camper fascia
Investing fascias:
-Deep membranous layer= Scarpa fascia
1. Superficial investing fascia
• Superficial investing fascia
2. Intermediate investing fascia
• External oblique (EO) muscle 3. Deep investing fascia
• Intermediate investing fascia
• Internal oblique (IO) muscle 3 flat muscles:
• Deep investing fascia 1. EO muscle
• Transversus abdominis (TA) muscle 2. IO muscle
• Endoabdominal (transversalis) fascia 3. TA muscle
• Extraperitoneal fat (variable amount)
• Parietal peritoneum (glistening lining)

27 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Abdominal muscles:
- 3 flat: EO, IO, TA muscles
- 2 vertical: Rectus abdominis, Pyramidalis

- between midclavicular line & midline, 3 flat muscles form tough, aponeurotic tendinous rectus sheath –midline raphe- Linea alba
(from xiphoid to pubic symphysis)

1. EO muscle – orientation: \ \ \ \ ; most at superior- almost horizonntal

supplied by:
• thoracoabdominal nerve (T7-T11)
• subcostal nerve (T12)

2. IO muscle – orientation: / / / /
supplied by:
• thoracoabdominal nerve (anterior rami of T6-T12)
• 1st lumbar nerve

3. TA muscle – orientation: = horizontal

supplied by:
• thoracoabdominal nerve (anterior rami of T6-T12)
• 1st lumbar nerve
(IO and TA muscles have the same nerve supply)

4. Rectus abdominis muscle – orientation: |||| vertical

supplied by:
• thoracoabdominal nerve (anterior rami of T6-T12)

5. Pyramidalis– absent in 20%

-Rectus sheath – strong, incomplete fibrous compartment of 2 vertical muscles

-superior 2/3 IO splits
• IO + EO aponeuroses – anterior layer
• IO + TA aponeuroses – posterior layer
-from umbilicus to pubic crest (inferior)
• 3 flat muscles pass anterior to RA – anterior layer
• transversalis fascia – posterior layer

-Arcuate line – crescentic line; demarcates transition between aponeurotic posterior wall of sheath covering ¾ of rectus and
transversalis fascia covering inferior ¼

*Innervation: L- I- S- T (/T- L- S- I)
1. Thoracoabdominal -> inferior thoracic spinal nerve T7-T12 -> innervates muscles of anterolateral abdominal wall & skin
2. Lateral (thoracic) cutaneous branch -> thoracic spinal nerves T7-T9 or T10 -> skin of right & left hypochondriac region
3. Subcostal -> large anterior ramus of T12 spinal nerve
4. Iliohypogastric (superior) terminal branch of anterior ramus
Ilioinguinal (inferior) of L1 spinal nerve

Anterior cutaneous branches of thoracoabdominal nerves:

1. T7-T9 – skin superior to umbilicus
2. T10 – skin around umbilicus
3. T11 + T12 + L1 – skin inferior to umbilicus

28 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Veins
1. Subcutaneous venous plexus
• Superiorly
- medially: Internal thoracic vein -> Subclavian vein
- laterally: Lateral thoracic vein -> Axillary vein
• Inferiorly
- Inferior epigastric vein -> External iliac vein
- Superficial epigastric vein -> Femoral vein

2. Cutaneous veins – around umbilicus -> anastomose with paraumbilical veins

3. Thoracoepigastric vein

*Arteries and Origins

1. Musculophrenic artery ITA
2. Superior epigastric artery (Internal thoracic artery)
Arteries:
3. 10th & 11th Posterior intercostal arteries Ao MS- PS- ID- SS
4. Subcostal artery (Aorta)
Mnemonic for arteries’ origins:
5. Inferior epigastric artery EIA I- A- E- F
6. Deep circumflex iliac artery (External iliac artery) I Ate Egg Frequently

7. Superficial circumflex iliac artery FA

8. Superficial epigastric (Femoral artery)

*Lymphatics
1. Superficial lymphatic vessels
-superior to transumbilical plane -> mainly drain to axillary nodes; few to parasternal nodes
-inferior to transumbilical plane -> mainly drain to superficial inguinal node
2. Deep lymphatic vessels – accompany deep veins of abdominal wall:
- External iliac node
- Common iliac node
- Right & left lumbar (caval & aortic) nodes

*Infraumbilical part – peritoneal folds

1. Median umbilical fold – raised by median umbilical ligament from urachus
2. Medial umbilical folds – raised by obliterated umbilical artery
3. Lateral umbilical folds – raised by inferior epigastric vessels

*Peritoneum – continuous glistening; slippery transparent serous membrane

- 2 continuous layers:
• Parietal – internal surface of abdominopelvic cavity (pain is well-localized)
• Visceral – invest viscera (pain poorly localized)

- Intraperitoneal organs – almost completely covered with visceral peritoneum (e.g., stomach & spleen)
- Extraperitoneal organs
- Retroperitoneal (parietal peritoneum on anterior surfaces) such as kidney
- Subperitoneal (parietal peritoneum only on its superior surface) such as urinary bladder

- with peritoneal cavity containing peritoneal fluid

29 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Peritoneal formations:
1. Mesentery – double layer which forms a continuity of visceral & parietal peritoneum
- occurs as result of invagination of peritoneum by an organ
- provides means for neurovascular communications between organs & body walls
2. Omentum – double-layered extension/ peritoneal fold; passes from stomach & proximal duodenum to adjacent organs
3. Greater omentum – prominent, four-layered peritoneal fold
- greater curvature of stomach to proximal duodenum
4. Lesser omentum – lesser curvature of stomach to proximal part of duodenum to the liver
• Hepatogastric ligament
• Hepatoduodenal ligament- thickened free edge which conducts portal triad: vad: portal vein, portal artery & bile
duct
5. Peritoneal ligament – double-layer peritoneum; connects an organ with another organ or to abdominal wall

LIVER – connected to LESSER OMENTUM (L- L)

- to anterior abdo. wall by falciform ligament
- to stomach by hepatogastric ligament continuous
- to duodenum by hepatoduodenal ligament

STOMACH – connected to GREATER OMENTUM (S- G)

- to inferior segment of diaphragm by gastrophrenic ligament
- to spleen (reflects to hilum of spleen) by gastrosplenic ligament continuous attachment
- to transverse colon by gastrocolic ligament along greater curve

*Subdivision of peritoneal cavity:

1. Greater peritoneal sac – main & large part of peritoneal cavity

2. Lesser peritoneal sac – (omental bursa) posterior to stomach & lesser omentum

- Transverse mesocolon – mesentery of transverse colon

- divides abdominal cavity into
1. Supracolic compartment – stomach, liver & spleen
2. Infracolic compartment – small intestine, ascending & descending colon (right & left infracolic)

- Paracolic gutters – free communications between supracolic & infracolic compartments

- Omental bursa – extensive sac-like cavity that lies posterior to stomach, lesser omentum and adjacent structures, it has
• Superior recess – limited superiorly by diaphragm & posterior layer of coronary ligament of the liver
• Inferior recess – between superior parts of the layers of greater omentum

- Greater peritoneal sac – connects through omental foramen

- Omental foramen (epiploic foramen) – opening posterior to free edge of the lesser omentum; boundaries:
• Anteriorly: hepatoduodenal ligament
• Posteriorly: the IVC & muscular band- right crux of diaphragm
• Superiorly: the liver- covered by visceral peritoneum
• Inferiorly: the superior/ first part of duodenum

30 | A n a t o m y Study hard. Pray harder. -jeshrlys

 FOREGUT – esophagus; stomach; pancreas; duodenum; liver & biliary ducts
Blood supply: CELIAC TRUNK
Pain: localized at epigastric area

MIDGUT – small intestine; distal to bile duct; cecum; appendix; ascending colon; proximal
transverse colon
Blood supply: SUPERIOR MESENTERIC ARTERY
Pain: localized at periumbilical area (umbilical area)

HINDGUT – distal part of transverse colon; descending colon; sigmoid colon; & rectum
Blood supply: INFERIOR MESENTERIC ARTERY
Pain: localized at hypogastric area

*Esophagus - ~10in/ 25cm (pharynx-stomach)

- with 3 constrictions:
1. Cervical/ pharyngoesophageal – cricoid cartilage (C6 vertebra) due to cricopharyngeus muscle
- superior esophageal sphincter
2. Thoracic/ bronchoaortic – due to aortic arch & left main bronchus
3. Diaphragmatic – due to esophageal hiatus (T10 vertebra)
- inferior esophageal sphincter/ gastroesophageal sphincter (left inferior phrenic artery)

Blood supply of esophagus:

• Upper third: Inferior thyroid artery (ITA)
• Middle third: branches from Descending thoracic aorta: (1) bronchial arteries & (2) esophageal arteries
• Lower third: branches from Left gastric artery (branch of Celiac trunk) & Left inferior phrenic artery

Venous drainage of esophagus

• Upper third: Inferior thyroid veins

• Middle third: Azygous veins
• Lower third: Left gastric veins (tributary to hepatic portal vein)

Lymphatics of esophagus

• Upper third: Deep cervical lymph nodes

• Middle third: Superior & inferior tracheobronchial lymph nodes
• Lower third: Nodes along left gastric artery & Celiac nodes

Nerve supply of esophagus

• Parasympathetic- vagus nerve – motor innervation: peristalsis; gross sensation

• Cervical & thoracic sympathetic trunk – blood vessel constriction & esophageal sphincter contractions; increase glandular &
peristaltic activity

*STOMACH – (2-3 L)
Chime= food + gastric juice

Parts:
• Cardia (posterior to 6th left intercostal cartilage)
- Cardiac notch
- Cardiac orifice (posterior to 6th left costal cartilage; @ T11 vertebral level, 2-4cm from median plane)
• Fundus
• Body
31 | A n a t o m y Study hard. Pray harder. -jeshrlys
 • Pylorus (R, between L2-L4 vertebra)
- Pyloric antrum
- Pyloric canal
- Pyloric sphincter
- Pyloric orifice
Interior:

• Gastric folds/ rugae

• Gastric canal

Curvatures:

• Lesser curvature (concave)

-angular incisure/ notch: between proximal 2/3rd & distal 1/3rd
• Greater curvature (convex)

Blood supply of stomach:

1. Right gastric artery -> branch of hepatic artery supplies lesser curvature
2. Left gastric artery -> branch of celiac trunk
3. Right gastro-omental (/gastroepiploic) artery -> branch of hepatic artery which also gives rise to gastroduodenal artery
-between layers of greater omentum & curvature
4. Left gastro-omental artery -> branch of splenic artery
-between layers of gastrosplenic ligament to stomach
5. Posterior gastric artery -> branch of splenic artery
-supplies posterior wall & fundus of stomach
6. Short gastric artery -> branch of splenic artery
-supplies fundus of stomach

Venous drainage of stomach:

1. Left gastric vein-> portal vein
-drains lesser curvature; receives some esophageal veins
(LGV & Azygos vein – collaterals between portal & systemic venous system)
2. Right gastric vein -> portal vein
-drains lesser curvature
3. Right gastro-omental vein -> superior splenic vein
-drains greater curvature & body
4. Left gastro-omental vein -> splenic vein
- drains greater curvature
5. Prepyloric vein-> right gastric vein

Lymphatics of stomach:
1. Gastric lymph nodes – superior 2/3rd; drains along right &left gastric vessels
2. Pancreotico-splenic lymph nodes – fundus & superior part of the body; drains along short gastric arteries & left gastro-
omental vessels

Nerve Supply of stomach:

• Parasympathetic- Vagal trunk
-left -> hepatic & duodenal (pyloric) branches @hepatoduodenal ligament -> anterior gastric branch
-right -> celiac branch to celiac plexus -> posterior gastric branch

-seromotor
-inhibitory to pyloric sphincter

32 | A n a t o m y Study hard. Pray harder. -jeshrlys

 • Sympathetic- T6-T9 segments of spinal cord -> greater splanchnic nerve -> celiac plexus
-pain-transmitting fibers
-motor to pyloric sphincter

*DUODENUM (1st part of Small Intestine)

- widest, shortest (25cm)
- fixed, L2 vertebra, 2-3cm to left of midline
-partially retroperitoneal

1st part – superior, short (5cm)

• Duodenal ampulla- 1st 2cm
• Mobile, with mesentery
• Superiorly, attached to hepatoduodenal ligament (lesser omentum)
• Inferiorly, attached to greater omentum
nd
2 part – descending duodenum, 10cm, right of L1-L3 vertebrae
• Hepatopancreatic ampulla (ampulla of vater) (distal common bile duct + main pancreatic duct)
- opens at major duodenal papilla
rd
3 part – horizontal part, 8cm to left
4th part – ascending part, short, 5cm right of L3 to superior L2 vertebra

Blood supply of duodenum:

1. Superior pancreaticoduodenal artery
-supplies duodenum proximal to hepatopancreatic ampulla
-branch of Gastroduodenal artery (which arises from Celiac trunk)
2. Inferior pancreaticoduodenal artery
-supplies duodenum distal to hepatopancreatic ampulla
-branch of Superior mesenteric artery

Venous drainage of duodenum:

1. Hepatic Portal vein – most drainage
2. Superior mesenteric vein
3. Splenic vein

Lymphatics of duodenum:
*anterior
• Pancreaticoduodenal lymph nodes – along superior & inferior pancreaticoduodenal arteries
• Pyloric lymph nodes – along gastroduodenal artery
*posterior
• Superior mesenteric lymph nodes – posterior to head of pancreas
-> all drains to Celiac lymph nodes

Nerve supply of duodenum:

• Sympathetic fibers: from T6-T9 spinal cord
• Parasympathetic fivers from:
-Vagus nerve – via Celiac & Mesenteric plexuses
- Periarterial plexus

33 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Arterial supply to Intestines

Artery Origin Distribution

Superior mesentiric artery (SMA) Abdominal aorta Part of GI- midgut
Intestinal (jejunal & ileal; n= 15-18) a. SMA Jejunum & ileum
Middle colic a. SMA Transverse colon
Right colic a. SMA Ascending colon
Ileocolic a. Terminal branch of SMA Ileum, Cecum & Ascending colon
Appendicular a. Ileocolic artery Vermiform appendix
Inferior mesenteric artery (IMA) Abdominal aorta Part of GI- hindgut
Left colic a. IMA Descending colon
Sigmoid a. IMA Descending & Sigmoid colon
Superior rectal a. Terminal branch of IMA Proximal part of rectum
Middle rectal a. Internal iliac artery Midpart of rectum
Inferior rectal a. Internal pudendal artery Distal part of rectum & anal canal

MIDGUT
- from duodenum-jejunal flexure to ileo-cecal junction
*JEJUNUM – 2nd part of small intestine; 2/5th (of 6-7m); LUQ (left upper quadrant) mostly
*ILEUM – 3rd part of small intestine; 3/5th (of 6-7m); RLQ
- intraperitoneal- mesentery (attached both to PAW- posterior abdominal wall) ~20cm from root; root of which runs obliquely,
inferiorly & right

Blood supply of Jejunum and Ileum:

• Abdominal aorta -> SMA @ level of L1 vertebra (~1cm below celiac trunk) -> between layer of mesentery, sending 15-18
branches to jejunum & ileum (Jejunal & Ileal arteries)
• Arteries unite to form loops/arches= Arterial arcades that give rise to straight arteries= Vasa recta

Venous drainage of Jejunum and Ileum:

• Superior mesenteric vein – anterior & to right of SMA in root of mesentery

SMV + Splenic vein -> Hepatic Portal vein

Lymphatic vessels of Jejunum & Ileum:

• Lacteals – specialized to absorb fat; within mesentery, lymph passes sequentially through
1. Juxta-intestinal lymph nodes – close to intestinal wall
2. Mesenteric lymph nodes – scattered among arterial arcades
3. Superior central lymph nodes – located along proximal part of SMA

• Efferent lymphatics from mesenteric lymph nodes -> Superior mesenteric lymph nodes
• Those from terminal ileum -> follow ileal branches of ileocolic artery -> ileocolic lymph nodes

Innervation of Jejunum & Ileum: Sympa functions:

• SMA & branches - surrounded by periarterial nerve plexus ↓ motility & secretion
• Sympathetic fibers - T8-T10 segments of spinal cord – reach Superior mesenteric nerve Vasoconstriction
plexus through sympathetic trunks & thoracic & abdominopelvic (greater, lesser & least) Reduces/ stops digestion
splanchnic nerves
34 | A n a t o m y Study hard. Pray harder. -jeshrlys
 -Presynapic sympathetic neurons in celiac & superior mesenteric (paravertebral) ganglia
• Parasympathetic fibers –from posterior vagal trunks
-Presynaptic parasympathetic fibers – synapse with postsynaptic Parasympa functions:
parasympathetic neurons in myenteric & submucosal plexuses in intestinal ↑ motility & secretion
wall Sensory (visceral afferent) fibers insensitive
to most pain
Sensitive to distention (colic-spasmodic
abdominal pain)

*LARGE INTESTINE
Distinguishing characteristics from SI:
1. Omental appendices- small, fatty omentum-like projection
2. Tenia coli – thickened bands of smooth muscle; 3 distinct longitudinal folds:
a. Mesocolic tenia – to which transverse & sigmoid mesocolons attach
b. Omental tenia – to which omental appendices attach
c. Free tenia – neither the mesocolons and omental appendices are attached
3. Haustra –sacculations of wall between teniae
4. Much greater caliber
5. Shorter than SI
a. CECUM (blind intestinal pouch) 7.5cm l&w, RLQ (right lower quadrant)
-2.5 within inguinal ligament
- almost entirely enveloped with peritoneum (no mesentery)
- Ileocolic lips (superior & inferior)
- Ileal orifice – Ileal papilla - Frenula of valve (ridges)s

b. VERMIFORM APPENDIX (blind intestinal diverticulum) 6-10cm l

- with masses of lymphoid tissue
- posterior medial aspect of cecum
- mesoappendix: short, triangular; from posterior side of mesentery of terminal ileum
- usually retrocecal (64%)

Arterial blood supply of Cecum & Appendix:

• Ileocolic artery – terminal branch of SMA supplying cecum
• Appendicular artery – branch of ileocolic artery supplying the vermiform appendix

35 | A n a t o m y Study hard. Pray harder. -jeshrlys

Venous drainage of Cecum & Appendix:
• Ileocolic vein – tributary of SMV (drains both cecum & vermiform appendix)

Lymphatic drainage of Cecum & Appendix:

• Passes to lymph nodes in meso-appendix -> ileocolic lymph nodes that lie along ileocolic artery
• Efferent lymphatic vessels -> superior mesenteric lymph nodes

Nerve supply of Cecum & Appendix:

• From sympathetic & parasympathetic fibers from superior mesenteric plexus
• Sympathetic nerve fibers- originate in lower thoracic part of spinal cord
• Parasympathetic fibers- derive from vagus nerve

• Afferent nerve fibers from the appendix accompany sympathetic nerves to T10 segment of spinal cord

c. ASCENDING COLON -2nd part

-turns left (right lobe of liver) @ right colic (hepatic) flexure
-narrower than cecum
-secondarily retroperitoneal (peritoneum anteriorly; on sides-25% short mesentery)
-right paracolic gutter- deep vertical groove lined with parietal peritoneum

Arterial supply of ascending colon (see arterial supply table)

• Ileocolic + Right colic arteries + Right branches of middle colic artery = anastomose
• Marginal artery (juxtacolic artery)- close to mesenteric border

Venous drainage of ascending colon:

• Ileocolic & right colic veins -> SMV

Lymphatics of ascending colon:

• Epicolic -> Paracolic -> Ileocolic -> Intermediate right colic -> superior mesenteric lymph nodes

Innervation of ascending colon:

• Superior mesenteric nerve plexus

d. TRANSVERSE COLON- 3rd part; 45cm, longest & most mobile

-runs from right colic (hepatic) flexure to left colic (splenic) flexure

Note: left colic flexure is more mobile, more acute, less mobile than the right ; it lies anterior to inferior part of left kidney &
attached to diaphragm through the phrenicocolic ligament

Arterial supply of transverse colon (see arterial supply table)

• May receive arterial blood supply from right & left colic arteries via anastomoses

Venous drainage of transverse colon:

• Superior mesenteric vein

Lymphatics of transverse colon:

• Middle colic lymph nodes -> superior mesenteric lymph nodes

Nerve supply of transverse colon:

• Superior mesenteric plexus via plexuses of right & middle colic artery

36 | A n a t o m y Study hard. Pray harder. -jeshrlys

 -transmit sympathetic, parasympathetic (vagus) & visceral afferent nerve fibers

HINDGUT
e. DESCENDING COLON- secondarily retroperitoneal position
-peritoneum covers it anteriorly
-@iliac fossa has short mesentery in 33%
-left paracolic gutter

Arterial supply of descending colon (see arterial supply table)

• IMA -> left colic artery & sigmoid artery

Venous drainage of descending colon:

• Inferior mesenteric vein (IMV)

f. SIGMOID- S-shaped loop of variable length (40cm)

-from iliac fossa -> S3 vertebra – where it joins rectum
-rectosigmoid junction – termination if tenia coli (~15cm from the anus)
-has long mesentery, sigmoid mesocolon (freedom of movement)
-root of sigmoid mesocolon – inverted V-shaped attachment which extends medially & superiorly along external iliac vessel ->
medially & inferiorly at bifurcation of common iliac vessels

-@left colic flexure – occurs a 2nd transition of blood supply

SMA orad (proximal) to flexure – supplying midgut
IMA aborad (distal) to flexure – supplying hindgut

Arterial supply of sigmoid colon:

• Sigmoid arteries -> descend obliquely to left -> dividing into ascending and descending branches
• Superior branch of most superior sigmoid artery anastomose with descending branch of left colic artery = marginal artery

Venous drainage of sigmoid colon:

• Inferior mesenteric vein (IMV) -> flowing usually into splenic vein -> hepatic portal vein -> liver

Lymphatics of sigmoid colon:

• Descending colon & sigmoid colon -> epicolic lymph nodes -> paracolic lymph nodes -> intermediate colic lymph nodes ->
inferior mesenteric lymph nodes -> lymph nodes around IMA

Innervation of sigmoid colon:

• Orad to left colic flexure, sympathetic & parasympathetic fibers travel together from abdominal aortic plexus via periarterial
plexus -> reach abdominal part of alimentary tract
• Aborad to flexure, they follow separate routes
-Sympathetic nerve supply (descending colon & sigmoid colon): from lumbar part of sympathetic trunk -> via lumbar
(abdominopelvic) splanchnic nerves -> superior mesenteric plexus & periarterial plexuses -> following inferior
mesenteric arteries & its branches

-Parasympathetic nerve supply: from pelvic splanchnic nerves via inferior hypogastric plexus & nerves
• Orad to middle of sigmoid – visceral afferents conveying pain sensation pass retrogradely with sympathetic fibers to
thoracolumbar spinal sensory ganglia
• Fibers carrying reflex information – travel with parasympathetic fibers retrogradely to vagal sensory ganglia
• Aborad to middle pf sigmoid – all visceral afferents follow parasympathetic fibers retrogradely to the sensory ganglia of spinal
nerves S2-S4.

37 | A n a t o m y Study hard. Pray harder. -jeshrlys

 g. RECTUM -fixed, primary retroperitoneal & subperitoneal
-continuous with sigmoid colon at S3 vertebra
-rectosigmoid junction – anterior to S3 vertebra
-sacral flexure of rectum – follows the curve of sacrum & coccyx
-anorectal flexure of anal canal – sharp postero-inferior angle where the rectum ends (roughly 80 degrees

3 sharp lateral flexures of rectum: superior, intermediate & inferior (viewed anteriorly) related to 3 internal foldings (transverse rectal
folds: 2 on left, 1 on right)
-ampulla of rectum -> dilated terminal part of rectum – superior to & supported by pelvic diaphragm (levator ani) &
anococcygeal ligament; receives & holds accumulating fecal mass until it is expelled during defecation

-peritoneum covers anterior & lateral surfaces of superior 3rd of rectum, only anterior surface of middle 3rd & no surface is
covered on its inferior 3rd (subperitoneal)

Arterial supply of rectum:

1. Superior rectal artery – continuation of IMA, supplying proximal part
2. Middle rectal artery – from Inferior vesical artery (anterior divisions of internal iliac arteries) -> supply middle & inferior part
of rectum
3. Inferior rectal artery – from Internal pudendal artery -> supply anorectal junction & anal canal; anastomoses between these
arteries provide collateral circulation

Venous drainage & lymphatics of rectum:

1. Superior rectal vein -> drain into portal venous system
2. Middle rectal vein -> drain into systemic system
3. Inferior rectal vein -> drain into systemic system

• Submucosal rectal venous plexus -> surrounds the rectum & communicates with vesical venous plexus in males &
uterovaginal venous plexus in females
-2 parts:
1. Internal rectal venous plexus -> deep to the mucosa of anorectal junction
2. External rectal venous plexus -> subcutaneous, external to muscular wall of rectum

Lymphatics of rectum:
1. Superior half of rectum -> Pararectal lymph nodes (directly on muscle layer of rectum) -> Inferior mesenteric lymph nodes ->
either via Sacral lymph nodes or directly through nodes along superior rectal vessels -> Lumbar (Caval/Aortic) lymph nodes
2. Inferior half of rectum -> direct to Sacral lymph nodes or from distal ampulla follow middle rectal vessels -> Internal iliac
lymph nodes

Innervations of rectum:
• Sympathetic supply – from lumbar spinal cord -> conveyed via lumbar splanchnic nerves & the hypogastric/pelvic plexuses
and through -> peri-arterial plexus of inferior mesenteric & superior rectal arteries
• Parasympathetic supply – from S2-S4 spinal cord level -> via pelvic splanchnic nerves & the left & right inferior hypogastric
plexuses -> to rectal (pelvic) plexus
-because rectum is inferior (distal) to pelvic pain line – all visceral afferent fibers follow parasympathetic fibers retrogradely to S2-S4
sensory spinal ganglia

h. ANAL CANAL (2.5-3.5cm long)

-begins where the rectal ampulla narrows at the level of the U-shaped sling formed by the puborectalis muscle
-anal canal ends at the anus, the external outlet of the alimentary tract
• Internal anal sphincter – involuntary, superior 2/3; thickening of the circular muscle layer
- contraction (tonus) stimulated and maintained by sympathetic fibers from the superior rectal (peri-arterial) and hypogastric
plexuses

38 | A n a t o m y Study hard. Pray harder. -jeshrlys

 - contraction inhibited by parasympathetic fibers stimulation, both intrinsically in relation to peristalsis, and extrinsically by
fibers conveyed by the pelvic splanchnic nerves
• External anal sphincter – large, voluntary, inferior 1/3
- attached anteriorly to the perineal body & posteriorly to the coccyx via the anococcygeal ligament
- blends superiorly with the puborectalis muscle

- anal columns – series of longitudinal ridges (internal superior half of mucous membrane); contain the terminal branches of the
superior rectal artery and vein
- anorectal junction – where the rectum joins the anal canal
- inferior ends of the anal columns are joined by anal valves
- superior to the valves are small recesses called anal sinuses (exude mucus when compressed by feces which aids in evacuation of
feces from anal canal)
- inferior comb-shaped limit of the anal valves forms an irregular line, the pectinate line, that indicates the junction of the superior
part of the anal canal (visceral), and the inferior part (somatic)

Arterial supply of anal canal:

1. Superior rectal artery -> canal superior to pectinate lime
2. Inferior rectal artery -> inferior to pectinate line & surrounding muscle & perianal skin
3. Middle rectal artery -> assists, anastomoses with both

Venous drainage of anal canal:

• Internal rectal venous plexus – drains in both directions from level of pectinate line
-superior to pectinate line -> internal rectal venous plexus drains chiefly to -> superior rectal vein -> IMV -> portal system
-inferior to pectinate line -> internal rectal venous plexus drains to -> inferior rectal vein -> caval venous system
-middle rectal vein -> internal iliac veins (drain muscularis externa – form anastomoses with superior & inferior rectal veins)

Internal rectal venous plexus receives multiple arteriovenous anastomoses (AVAs) from superior & middle rectal arteries

Lymphatics of anal canal:

1. Superior to pectinate line -> internal iliac lymph nodes -> common iliac & lumbar lymph nodes
2. Inferior to pectinate line -> superficial inguinal lymph nodes

summary:
arteries
upper ½ - SRA (branch of IMA)
lower ½ - IRA (branch of Internal Pudendal Artery)

veins
upper ½ - SRV -> Inferior mesenteric vein
lower ½ - IRV -> Caval venous system

lymphatics
upper ½ - Internal iliac lymph nodes -> Common iliac & Lumbar lymph nodes
lower ½ - Superfical inguinal lymph nodes

Innervation of anal canal:

• Superior to pectinate line – visceral innervation (sensitive to stretching) – from Inferior hypogastric plexus (with sympa,
parasympa & visceral afferent fibers)
• Inferior to pectinate line – somatic innervation (sensitive to pain, touch & temperature) – from Inferior anal (rectal) nerves
branches of pudendal nerve
- somatic efferent fibers – stimulate contraction of voluntary external anal sphincter
- all visceral efferent fibers – travel with parasympathetic fibers -> spinal sensory ganglia S2-24

39 | A n a t o m y Study hard. Pray harder. -jeshrlys

*Inguinal region
• Inguinal ligament – fibrous thickened folded margin
-inferiormost part of external oblique (EO) aponeuroses

+ Iliopubic tract -> extend from ASIS (anterior superior iliac spine) to pubic tubercle
- constitute a bilaminar anterior (flexor) retinaculum to hip joint
- retinaculum – spans subinguinal space through which pass flexors of the hoop
- these fibrous bands are thickened inferolateral-most portions of EO and aponeuroses and the inferior margin of
transversalis fascia

• Lacunar ligament (of Gimbernat) – posteriorly attach to superior ramus, lateral to tubercle
• Pectineal ligament (of Cooper) – run along pectin pubis (lateral)

Inguinal canal
• Deep Internal Inguinal ring (entrance)
• Superficial External Inguinal ring (exit)

40 | A n a t o m y Study hard. Pray harder. -jeshrlys