SURGI-

'--

'--

£l-
1.._. Mind-Mapped 6 Designed by:
\_, Peter Ramez
M.B.B.Ch - Cairo University
'--
__ Michael Safwat
M.B.B.Ch - Ain Shams University

'-'"
\Ni1h Specid
'-- focus on
....._.,
l\pp\ied
f'-NJ,tomy1
'--

\....,

._

...__,,
® Copgl"UJld 201711g Mollanunell EL-Mlllarg

.._/

AU. rillds reserved. No part of this book IIUUJ lie used or

reproduced. in. lllUJ manner wludsoeuer wllhout wrillen
permission, except in. the ease of brief quotallons em.bodied. in.
critical articles or reviews•
..__,

'---'
The pullllshers lulUe nuule eu811J effort to tra.ee the copiyrithl
holders for llorTowed. malerlal. If theg lulUe tnaduertentll
ouertooked. ...,, the will lie pleased. ta make the necessanJ
arTllftlemenls al the first opportunUv.

first edition 2014

second edition 2015
third edition 2017
'-"

-../

..J

'---

'--'

'-../

._,I
'--

'--' Sure/-f OC\1~: Sure·~1 Mi-to~'j

~ ACKNOWLEDGMENT
...._.,
I'd like to thank my Team
........., who have worked to let this
book see the Light

M.B. ,Ch.B. - Cairo University

M.B.,Ch.B. - Ain 9hams University

\.......
Karee• Molulnaell
M.B.,Ch.B. - Ain 9hams University

Dr. Moluuned El M......

.._,

.........
._.,.

....__,,

'-.J

...._,,

'---

-..J

-._,I
'-'

\.....,

\.....,

SURGICAL ANATOMY
..........
Head and Neck: 8

'-- Thorax: 22
'-'

\..... Abdomen: 26
.........
Upper Lirnb 52
..._,,
'-' Lower Limb 66
'--'
Lymphatics: 74
'-'
v
........
..__,,

'-'

v
\,,...,-

._,
.._,,

.__,,

'-"

'--

'----'

......
-...._/

'--'

..._,,

..,_/

...._,

__,,

'--

...__,

_.
\... .,

SURGI-
, -- -- - --- -
I
I

I
I

I
I

I
I
I
I
........

........

---
'----'
' I "'..
 '---

Surty"-fOOvt~: Sure/c:AI A1ttafo~'I W,,f:{b I 8 '--"

THESC _p APPLIED ANATOMY

@J'1$MifiJfJl:itl'"
Comprise the superficial 3
'--'

...__,,

LAYERS layers. They ere turned '--"

downwards & not upwards
9KIN Rich In hair follicles & sebaceous glands : : Nerves & vessels enter the '-J
CONNECTIVE TISSUE Blood vessels are located rimaril in this le er scalp from periphery::
APONEURO919 Flat membrane
\.....,
LOO9E AREOLAR Allows free mobilit\j of the 1st 3 la\jers on the
VERY RICH BLOOD 9UPPL
CONNECTIVE Tl99UE underl ing eriosteum
PER1O9TEUM Loosel\j attached to the bones, but firmly
• Wounds Bleed profusely. .._,,.
• Wounds heal well; minimal
attached to suture lines
debridement is required &
~
wound infection is uncommon
Sken
..___,,

Connective tissue CONNECTIVE Tl99U

..___,,
_ Aponeuros,1 • When Injecting local
/'
anesthetic, the tip of the
loose areolar tissue iSll!!!!!:::!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!~!=!!!!5!!!!!!!!=:a~- Pereosteum
needle should be inserted '-'
in this layer
• NO subcutaneous fat in -..__,I

============.--Dura scalp ➔ no lipoma

EXTENTION MUSCLES '--

@ ANTERIORLY➔ Eye brows 0 OCCIPITALl9:
'-'
0 LATERALY➔Zygometic arcl-i Attached to the skull
THE PERI09TEUM
0 P09TERIORLY➔8uperior nuchal line (At superior nuchal line)
Adheres to the suture lines of ..___,,
@ FRONTALl9: Not
the skull; collections of pus or
attached to the skull
blood beneath this layer,
'-..I
therefore, outline the affected
bone. This is particularly well
BLOOD & 9EN9ORY NERVE SUPPLY seen in birth injuries Involving '-'
the skull (cephalohaematoma)
SENSORY INNERVATION I _ _ARTERIAL BLOOD SUPPLY I '-..,,
By trigeminal (6th) nerve Branches of ophthalmic artery
FRONT 1. 8upra-frochlear n. of the I.C.A:
OF 2. Supra-orbital n. 1. 9upra-trochlear artery. '-...✓
AURICLE 3. Zygomatico- 2. 9upre-orbltal artery.
temporal n. Branches of E.C.A:
4. Auriclo-temporal n. 1. Superficial temporal EMl99ARY VEIN '-"
erter • Don't have valves and open in
BEHIND By cervical plexus Branches of E.C.A: the loose areolar tissue; .J
THE 1. Great auricular n. Posterior auricular artery.
AURICLE therefore, infection can be
2. Lesser occipital n. Occipital artery.
3. Greeter occiritel n. transmitted from the scalp to '-'
4. 3rd occipite n. the cranial cavity. The layer of
loose areolar tissue is known as ._,,
the dangerous area of the scalp

'-'

VENOUS DRAINAGE LYMPHATIC DRAINAGE

0 To the superficial '---
1. 9upratrochlear vein
2. 9upraorbifal vein circle of LNs around
3. 9uperficial temporal vein '-'
lower part of skull ➔
4. Maxillary vein
deep LNs around
6. Occipital vein '--
carotid sheath

"-
'--

.._/
 Surc,1·-100vl~: Surcl~I Avlttoti¼'j 'Pf,.{qf; 1 1

,.____,
THYROID GLAND APPLIED ANATOMY
IPRETRACHEAL FASCIA
Is attached to H\joid bone,
91TE & 9HAPE Oblique line of Th\jroid
• Situated in the Lower part of the APEX:
cartilage
Neck. in Muscular triangle Lies on
thyroid : : During deglutition
• Butterfly in shape ➔ Gland moves up & down : :
cartilage,
• Formed of two lobes connected b\j below • This fascial attachment to t he
an isthmus oblique

~.§ . .
......... gland may result in downward
• Weight: '20 - '26 gms line extension "Plunging Goiter"
• Each lobe is PEAR in shape with:

_., ·
APEX: At level of oblique I9THMU9:
line of thyroid cartilage Ues
- 4cm \ f opposile io
BASE: At the level of 4'hor 2"", 3"', 4 th
5 th Tracheal ring

1
Tracheal
• I9THMU9: Connects the '2 Lobes rings
at the level of '2nd, 3N1 Tracheal '2.5 cm ,. BASE:
rings ,._..,..-►- At the level of
• PYRAMIDAL LOBE: 8 th Tracheal ring
May be present above the isthmus
......., • CAPSULES:
TRUE CAPSULE (From the
stroma of glend)
FALSE CAPSULE (From Pl"e-
...._,. fracheal fascia)
ANTERIOR RELATION9:
• 9kin, 9C tissue •l.fo.a
• Plat\jsma • 1_,.,.
• Investing la\jer of deep STRAP MUSCLES
cervical fascia supplied by ansa cervicalis
• 91ernoma&toid from Below
RELATIONS: • STRAP MU9CLE9 (9ternoh\joid,
9ternoth\jroid, Omoh\jold )
:: During thyroidectomy,
cut the Muscles as
HIGH as possible ::

...._,

..........

P09TERIOR
RELATION9:
• Carotid Sheath
(Carotid artery, IJV,
Vagus N.)'
• Ansa cervicalis
• 9ympathetic chain
MEDIAL RELATION
MEDIAL RELATION9: Dysphagia & Dyspnea may
• UPPER PART: Crlcoid, Thyroid occur with its enlargement
cartilage, Cricothyroid muscle, Due to its relation to
Inferior Constrictor Muscle Trachea & Esophagus
• LOWER PART: Oesophagus,
Trachea, RLN
 '---'

Suro1·-1-00vt~: 5<.,ffb'.t'AI Avt~Jo~'I f J,qf; I \0

BLOOD SUPPLY: APPLIED ANATOMY

1-- - - - tnie,n•I c:.rotfd •n•f"V M!IRi)l)W4'mi
- - - -- E>e1ernat c.tirolld •n• rv
- - - - Super5o.- t hyroi d
•n•rv end vein Is LIGATED WITHIN the gland
to avoid injury of external
- - - - Lett lobe or thyroid
- - - - M ldcHe thyroi d vei n laryngeal N.
. . -. --:-- - tnfe rlo, 1hyro+d •n•rv :: Injury➔ Loss of high
pitched voice & Voice fatigue ::
~ ~ - - ThyrOC4trvlc.1 trunk
Subclavtan •f1•rv

:;;..__ _ _ Thv,-ofd la1hmua

' - - - -- - - Inferior thyroi d vei n

Wli*ij'lif"'n,i
• Should be LIGATED AWAY
FROM THE OLAND to avoid
1-ARTERIEQ injury of RLN.
:: Complete➔ <.:._,.....JI '----'
INFERIOR Partial➔ ~ I
SUPERIOR
THYROID A. • Ligate In continuity, do not
THYROID A.
cut (Slippery of ligature➔
• 1'" Branch of External • Branch of the THYRO-
Stump falls in ohect
Carotid artery CERVICAL TRUNK ➔ Hemothorax)
• Related to EXTERNAL • Its TERMINAL branches
LARYNGEAL N. are related to RLN
THYROID IMA ARTERY
Its cutting during
THYROID IMA A. ACCESSORY
thyroidectomy causes
• Branch of Arch of THYROID A. SEVERE Bleeding
Aorta or innominate • In the Ligament of
artery berry
• Present in 1-3% of • 9upply lower part of
population the gland ACCE99ORY BRANCHES
Supplies the lower part of
the gland, that is preserved
ir, surgery
SUPERIOR THYROID V.
2- VEINQ • Darin's into IJV
MIDDLE THYROID V.
• Drains into UV MIDDLE THYROID VEIN
INFERIOR THYROID V. Is the shortest vein ➔
• Crosses from the Isthmus to drain FIRST vein to be tied & Cut
into the left lnnominate vein
(Brachiocephalic V.)

3- LYMPHATICS
PERIPHERAL PART
'--
DELPHIAN LN9
• Pre-tracheal LNs (DELPHIAN), In papillary thyroid carcinoma,
Delphian LNs may enlarge
Pre-Laryngeal LNs, Deep Cervical LNs
before the gland.

'--'
 5ure/-1"00vt~: Sureiu.l Avt-a-to~'f 'P~~ I \\

RNOMASTOID MUSCLE APPLIED ANATOMY

• 2 ORIGINS:
STERNAL HEAD: Menubrium sterni
CLAVICULAR HEAD: Clavicle
Pl•)mffi~M
A triangle is formed between
• 2 INSERTIONS:
"--' Mastoid process 2 heads; where IJV lies "Can
Superior nuchal line be entered by e needle"
• N. SUPPLY: Spinal accessor1:1 nerve
• ACTION:
2 muscles: Flexes the neck
1 muscle: Bends head to same
side & turns face to opposite
side. STERNOMASTOID
• Must be examined during
examination of thyroid &
parotid glands
• Must be relaxed to Examine
...__,., Deep Cervical L.Ns

.._,,
TRIANGLES OF THE NECK • Divides the neck into anterior &
posterior triangles

POSTERIOR [).
.._, BOUNDARIES:
• ANT.: Post. border of sternomastoid ms.
"-,../ • POST.: Ant. border of trapezius ms.
• BASE: Middle ½ of clavicle .

..........
-
--
'---
- -----
- -
- _, .__

\....,
-- -
ANTERIOR t.
--
BOUNDARIES:
• ANT.: Midline of the neck
• POST.: Ant. border of sternomastoid
..__,.. • BASE: Lower border of the mandible

......_, Anterior Ii is subdivided into:

CAROTID ti DIGA9TRIC /J.
BOUNDARIES: BOUNDARIES:
• ABOVE: Post. belly of digasfric ms. • ABOVE: Body of mandible
• POST.: Sternomastoid ms. • ANT: Ant. bell\l of digastrio ms
• ANT.& INF.: Superior. bell1:1 of • POST: Post. bell11 of digastric
omohyoid ms

9UBMENTAL ti MU9CULAR ti
BOUNDARI ES: BOUNDARIES:
• APEX: S1Jmph1:1sis menti • ABOVE: Superior. bell11 of
• BABE: Body of h1Joid bone omohyoid
• ON EACH SIDE: Ant. belly of • ANT.: Middle line
digastric ms. • POST.: 9ternomastoid ms.

'--"
 Surc/-f00\tt~: Sur0iul Avt~JoM'I 'PW:,.~ I \1.-
APPLIED ANATOMY
,.,,,.,,., Compa,tmon1,

VISCERAL COMPARTMENT
• •
The PARAVERTEBRAL FASCIA divides
Anij swelling wiihin it
\....,,

the neck into: causes pressure

VISCERAL COMPARTMENT (anterior) manifestations e.g .
Larynx, Pharynx, Oesophagus, dysphagia, dyspnea etc.
Trachea & hyoid bone.
MUSCULAR COMPARTMENT (Post.)
Vertebrae & Muscles which
support & move head & neok

VASCULAR COMPARTMENT (lateral)

Common & Internal Carotid arteries,
Internal jugular vein & Vague nerve
'Present in carotid sheath'

SUBMANDIBULAR GLAND
J
SITE➔ In the digastric triangle, partially below &
partially deep to the mandible

Divided into 2 parts

IN RELATION TO MYLOHYOID MS.
SUPERFICIAL PART
✓ WEDGE SHAPE
✓ EXTENTION:
• Posteriorly: Mandible's angle
• Superiorly: Mylohyoid line of
mandible
• Inferiorly: Overlaps the !2
bellies of digastric ms.
✓ RELATIONS:
• lnferolateral surface:
Skin, superficial fascia
& cervical branch of facial n.
• Lateral surface:
Mandible & facial a.
• Medial surface:
Related to 2 muscles
(mylohyoid & hyoglossus
ms) & 2 nerves (lingual &
hypoglossal nerves)
...__,.
My1ohyold muscle an
MANDIBULAR & CERVICA
BRANCHE9 OF FACIAL N.
9kin is incised parallel to lower
border of mandible, 5 cm below
& in front of angle of mandible
as not to injury them
DEEP PART
A small part lying deep to
mylohyoid & superficial i•)Hl®Gi
to hyoglossus - Doesn't ROLL over mandible
- Has intra-oral extension
examined bimanually
. . Differentiate it from
9ubmandibular L.N... '-'

SUBMANDIBULAR DUCT "WARTON'S"

• 5 cm long
rm
Is More liable to
■ Has triple relation with lingual n. OB9TRUCTION &
(lat. then below then medial to the nerve) INFLAMMATION '---"'
• Opens in floor of mouth, close to frenulum of the tongue
...__,_

Sur0i-1DOvt~: Sure/cAI A£,t~JoM'I 1'~~ I l1J

NERVE SUPPLY APPLIED ANATOMY
• SENSORY: lingual nerve
• SYMPATHETIC: Plexus around facial n.
• PARASYMPATHETIC:
• It receives secrefo-motor fibers from submandibular
ganglion
• Passes through chords tympani from facial N .

..........
LYMPHATIC DRAINAGE
• To submandibular & upper deep cervical L.Ns

......... 91:ROW~ FLUID

- The nature of fluid secreted

decrease the incidence
of stones compared with
submandibular gland

SITE & SHAPE

00 Below the auricle, between the angle of the mandible
& the sternomasfoid
00 Inverted pyramidal in shape

Made of 2 parts
Part of the face
MAIN PART
It's divided info
infront of the ear and
'--' superficial & deep below zygomatic arch
parts by facial nerve Masseter

ACCE990RY
PART
9emi-detached part
of the gland, which
..........
lies just above the
parotid duct
\.-,

...._,,

PAROTID OUC
PAROTID DUCT Can be seen
• 5cm long, emerges from the anterior border. radiographically
• Runs superficial to masseter ms. then pierces the buccinator. by injecting
• Opens in vestibule of mouth, opposite upper 2nd molar tooth radiopaque contrast
(Parotid 9ialogram)
.........
 St.,ffcJ'-,OOvt~: St.,ff0 ii:ALI .Avt~:roW\'I f~E; I \4-

8URFACE8 & RELATIONS APPLIED ANATOMY

OF THE MAIN PART 1#StJla
POSTERO-MEDIAL SURFACE: Must be examined in
,,__,
• 9ternomastoid process ANTERO-MEOIAL Parotid cases to exclude
• Mastoid process SURFACE malignant infiltration
•
•
Posterior belly of digastrics
9tyloid process & muscles •
BONE BETWEEN 2 MUSCLES
Massater muscle
"'
attached to it. • Mandible ( ramus )
• Carotid sheath & it's contents • Medial pterygoid muscle

1
fiJJAlltll11 ·wwi~;ni1iUl:J'
~Li-J~¥M,fflll
9kin and 9uperficial fascia
containing Parotid L.Ns, Great
auricular n. & platysma
•
•
•
•
•
Temporal branch of facial nerve
Zygomatic branch of facial nerve
Transverse facial Artery
Bucoal branch of facial nerve
Accessory part of the gland
-·~
STRUCTURES WITHIN
THE GLAND {superficial
to deep FRE)
• Parotid Ouot
• Mandibular Branch of facial nerve • Facial nerve
• Retro-mandibular vein
• External carotid •
• Cervical branch of facial • External carotid artery
ill
• Superficial temporal vessels
• Auriculo-temporal nerve

lntamal carotid
• Temporal branch of facial N. ~-Jlil!(MIJ-10:IM
artery Parotid abscess should
lntemal jugular vain, •
vagu.s end sympathatic O Superior constrictor be drained by Hilton
chain r-r--.._......,,.--~ of pharynx ....,.,
.
technique to avoid
Posterior belly - ~ - -
digastric injury of facial N.
Mao1oid

Sternocteidoma.atoid _
'""7:::::::;:::::::::::i&-VII (lying
superficially to
external carotid
■rtory end
retromandibular
vein)

NERVE 9UPPLY
• PARAQYMPATHATIC: 8ecretomotor fibers are originally
supplied by glossopharyngeal n. & reach the gland
through the auriculotemporal branch of trigeminal N.

m• 1 tlMl■ 4n
• 9YMPATHATIC: Plexus around E.C.A
• 8EN90RY: Auriculotemporal nerve
This explains parotid
enlargement in
LYMPHATIC DRAINAGE chronic endemic
Superficial & deep parotid L.Ns (within the gland) ...__,
then to upper deep cervical
parotitis
.........,

...._,

BLOOD 9UPPLY
ARTERIAL ➔External carotid arterij inside the gland
VENOUS ➔Retro-mandibular vein above

CAPSULE DEFECT IN CAPSULE

Fibrous capsule (Parotld fascia) derived from investing This explains elevation of
deep fascia of the neck, with a defect from above LOBULE of ear during
examination of ENLARGED
Parotid gland

Condylo o f mondlble
....._, ~ - - ,- T ragus o f enr

~.,.
~
-- \,~
~~JIC}
._.J.
,r- - L Anterior ""''ll'" o l
mas toid procoss
Contef' of masse1er

"-Lk...---1~ - Postoroinfcnor to
angte of mandible

.......
SURFACE ANATOMY
......... PAROTID GLAND PAROTID DUCT
a. Head of the mandible Corresponds to the middle 1/3
b. Middle of masseter ms. of a horizontal line drawn from
c. 2 cm below & behind the the tragus of the ear to a point
angle of mandible on the upper lip midway
between the a la of the nose &
d. Middle of mastoid process the angle of t he mouth
'--

\. . . PARATHYROID GLAND
\..... • 9 uperlor parathyroid Is
® 91ZE: Each gland is about 0.5 cm more constant In position
® COLOR: Yellowish brown (posterior to thyroid &
® POSITION: They are embedded in the back of the false above inferior thyroid a.)
capsule of thyroid (rarely in substance of the gland) • Inferior parathyroid may
® BLOOD SUPPLY: Main supply is from Inferior thyroid a rtery rarely be looeted in
superior mediastinum

...__,
~ - - - •nfenor c:on s 1nctor muscle

~
PARATHYROID
........ Thyroid gland During s ubtotal
Superior thyroidectomy we preserve
'- and
u •~ - lnferior thyroid artery ~ the postero-medial part as
pa rathyroid gland is related
... i nferior
par11thyroid
t o that part
glands
,__,..

'---
 5urf/UI Mi-f-oti\-'\'J 'PN:{i I \b
APPLIED ANATOMY
ARTERIES OF
HEAD AND NECK lliillRltl=
These are 8ites of A-V fistula
INTERNAL CAROTID A. Styloid p10C8$S bet. ICA & cavernous sinus
BEGINS FROM C.C.A Superficial 11mpo,1I leading to throbbing pain &
artery pulsating proptosis
COURSE: Inside carotid
Mexill•ry arte,y _ _
sheefh
U END In crenlel cavity by
dividing into ANTERIOR &
MIDDLE CEREBRAL IX EXTERNAL CAROTID A.
ARTERIES Pheryng..lX ■ Pulsation of ECA is felt
iuperior l1ryng11I X by compression against
EXTERNAL CAROTID A. carotid tubercle of
1 , BEGINS From C.C.A Facial arte,y -transverse process of CS
I COURSE Passes outside • This is used for detection
carotid sheath XII of Berry's sign
r END At the level of the Lingual ane,y
neck of mandible inside
parotid gland by dividing perionhyroid 1rte,y 9UPERFICIAL TEMPORAL A.
int o 8UPERFICIAL ■ Called "Anesthetist's a."
icanden1 hypogloni
TEMPORAL & as it's used to count
MAXILLARY ARTERIE8 pulse
■ In malignant goiter,
obstruction or
COMMON CAROTID A. { CCA) displacment of carotid
I BEGINS Rt. from lnnominat e A., Lt.
can occur leading to
from Aortic erch
r COURSE Enters neck in Carotid sheath weakening of pulsation of
[. END At level of upper border of thyroid superficial temporal a.
..J
cartilage (bet. C3 & C4) By dividing into
INTERNAL & EXTERNAL C.As
BIFURCATION OF C.C.A.
• 9ite of BARORECEPTOR9
➔ hypersensHivity ➔
"Cerotid 9inus $"
• 9ite of CHEMORECEPTOR9
➔ Origin of Carotid Body
FROM MEDIAL ASPECT Tumour '-
■ Ascending pharyngeal artery
FROM ANTERIOR ASPECT LINGUAL ARTER
■ Superior thyroid artery: First branch Dur ing tongue bleeding pull
■ lingual artery: At level of greater horn of hyoid -the tongue outward to
bone compress it against the Hyoid
• Facial artery: Deep & tortuous bone
FROM POSTERIOR ASPECT
• Occipital artery
.___,,
• Posterior auricular artery
MIDDLE MENINGEAL A.
TWO TERMINAL BRANCHES Is t he most common
■ Superficial temporal artery cause of extradural Hge.
■ Maxillary artery: Gives Middle meningeal artery

___,,.
 Sure/-f OC¼~: Sure·<'.AI kt~JoM~ f~f; I \1

I RNAL JUGULAR VEIN APPLIED ANATOMY

......... BEGINS INTERNAL JUGU LAR VEI~
At the jugular foramen as a continuation of the is the Vein of central
sigmoid sinus venous catheterization

ENDS
By uniting with subclavian vein to form innominate vein
behind the sternal end of the clavicle

RELATIONS
• It lies inside the carotid sheath lateral to the internal
...._,, & common carotid with vagus nerve in between.
• Passes in front of the thoracic duct on the left side.
.__. • Runs alongside the chain of deep cervical LNs•
• Passes anterior to the phrenic nerve

........, TRIBUTIRIE9
• Inferior petrosal sinus.
• Jugular lymph trunk•
......... • Common facial vein.
Lingual vein •
..........
• Superior thyroid vein.
• Middle thyroid vein

Superfic. lemporol v. Supra-orbital v.

\_.,

.........

.........

U--4-----Anl. jugular v.
,.__ _ Jugular arch
 ¼t"c/ul Wttfo~'I ff,/qf; I \8

APPLIED ANATOMY

It is a muscular organ covered by mucus membrane,

lying in the floor of mouth & oropharynx

PART9
A. ROOT:
Through which muscles connect tongue to mandible & hyoid bone.
B. TIP & MARGINS:
• Lie opposite gum & teeth.
c. LOWER SURFACE:
• Facing the noor of mouth & shows:
Frenulum; Raised fold of mucosa in the midline.
Deep lingual veins: On either sides of the frenulum.
Fimbriated fold: Raised mucosa! fold.
D. OOR8UM OF THE TONGUE:
Divided by sulcus ferminalis info 2 parts:
IEI Anterior ¾: contains papillae without lymphoid follicles ___,
!Bl Posterior 1/,: contains lymphoid follicles without papillae

MU8CLE8 OF THE TONGUE

A.EXTRINSIC MU9CLE9
□ snLOGLOSSUS
Origin lnaertlon N. Qupply Action
9tyloid 9ide & inferior Hypoglossal Retract & elevate
process aspect of the nerve the tongue
ton1!.ue
□ HYOGLOSSUS
Orlglr, Insertion N. Supply Action
Body & 9ide & inferior Hypoglossal Depress &
greater horn aspect of the nerve retract the
of hyoid bone ton1!.ue ton1!.ue
□ GENIOGLOSSUS .._,,
Orlglr, Insertion N. Supply Action
Genial tubercle Inferior aspect of Hypoglossal Protrudes &
of the mandible the tongue& body nerve depress the
of h!loid bone tongue

□ PAlATOGlOSSUS
Origin Insertion N. Supply Action
Palatine 9ide of Cranial root of accessory Elevate
aponeurosls tongue nerve via pharyngeal posterior
of soft palate branch of vagus & part of the
ha n eal lexus ton ue '--

B. INTRIN9IC MU9CLE9
They have no bony attachments. They change the shape of the tongue:
Superior & inferior longitudinal.
- Transverse & vertical muscles.
\..._..,
5urtji-fOC¼~: 5ure·u.1 AVttto~'f 1'MJ~ I \1
'- I NERVE 9UPPLY APPLIED ANATOMY
.___,, ➔ MOTOR: ONGUE SENSATION
All muscles supplied by hypoglossal n. EXCEPT Ulcer on tongue with
palatoglossus supplied by spinal accessory n. involvement of lingual
➔ 9EN90RY: nerve can give rise to
1. Anterior. ½: referred pain in the ear
- V cranial nerve ➔ general sensation. through auriculo-
- VII cranial n. ➔ taste sensation. temporal nerve (both
are branches of
2. Posterior 1/3 and circurnvallate papillae:
posterior division of
- IX cranial n. ➔general sensation & taste
mandibular nerve)
...._,,,
BLOOD 9UPPLY LINGUAL ARTER
During tongue bleeding, we
1. Lingual artery (frorn external carotid)
should pull tongue
2. Lingual vein (to IJV) outwards as this causes
compression on the lingual
a. against the greater horn
of hyoid bone.
.......... LYMPHATIC DRAINAGE
(9ee lymphatic system)

L1nguol branch
ofV
'--' Stylohyoid and
styloglossus
XII ~-#--1---Sublingual
gland
'--'
_,__ _ _ Gen,oglossus
.._,, Submandibular
duct
Lingual artery Gen,ohyoid
'-'

'- Hyo,d

"--
,____, Hyoglossus

'---"

\._.

"---

.........

'-

,._
 ?UYf/-fOOvt~: 'Sure/~! N'ti'fOM~ f~~ I w
NERVE SUPPLY OF THE FACE APPLIED ANATOMY
SENSOlff INNERVATION~ 9EN90RY INNERVATION
• Trigeminal neuralgia may
effect any one or more of
This is via Trigeminal nerve (V) through the 3 terminal branches the three divisions, giving
rise to acute, episodic pain
Nerve over the corresponding area
Supplies • Lower eye lid • Skin over mandible
Upper pert of • Lower part of check • Pain is frequently referred
check • Pert of temple between branches, thus a
nooo • Upper lip • Pert of ear patient with tongue
• Ala of nose • Lower teeth carcinoma has ear ache.
• Part of temporal • Ginglvel mucosa
region (Auriculotemporal nerve).
• Lower lip
• Maxillary teeth Giving the classical picture
• Nasal cavity of an old gentlemen sitting
in the outpatients
department spitting blood
and with a piece of cotton
wool In his ear
....._,,

GREAT AURICULAR NERVE

It ls derived from t he
anterior raml of 2'"' & 3..i
cervical nerves. It supplies
the skin over the angle of
Maxillary nerve the mandible

MOTOR FIBERS OF
...__,
MANDIBULAR NERVE
SUPPLY
• Muscles of mastication
• Mylohyoid ms.
'---
• Ant. belly of digastrlc ms.

MOTOR INNERVATION FACIAL NERV

• Mandibular & cervical branches of
➔ This is through branches of the FACIAL NERVE end they are: facial nerve ere prone to Injury in
3. Nerve to stylohyoid procedures in submandlbular region
4. Nerve to posterior belly of digastric • It Is Important to differentiate
6. 5 terminal branches: between UMNL & LMNL of facial
Temporal: nerve
It leaves superior border of the parotid gland
It supplies the frontalis muscle
Zygomatic:
There are 3 branches:
3. UPPER branch supplies the frontalis & orbicularis occuli
4. MIDDLE branch supplies the superomediel part of orbicularis occuli
6. LOWER branch supplies the lip elevator & lower orbicularis occuli
Buccal:
Runs above the parotid duct a~er leaving the parotid gland
It supplies buccinator muscle of upper lip & nose
Mandibular:
It exits the lower part of parotid gland
It supplies lip depressors
Cervical:
It supplies the platysma

.........
~ SURGl-
00

I
I
I,._.,

M1c.CltA-t:-1e l &d/wt:1t f
Bil:11118 IIIIIVl'fB¢1
.A,;,
MBB
 Surgi-T00ns: Surgical Anatomy PAGE 122

THORACIC DUCT
• 46 cm long.
APPLIED ANATOMY
THORACIC DUC
May be damaged during
• UPWARD CONTINUATION of the cisterns chyli. block dissection of the neck,
if noticed during operation
• ENTER9 the thorax through the aortic opening of the diaphragm
ihe duct should oe ligated &
between the azygos vein medially & aorta laterally lymph finds its way into
• l:ND9 at the confluence of Lt. subclavian vein & Lt. internal jugular venous system by
vein anastomosing channels.
• DRAIN9 lymph from the body except Rt. upper limb, Rt. side of (If missed ➔ chijlous fistula
chest & Rt. half of head & neck in the neck)

COURSE
• Ascends behind esophagus in the posterior mediastinum
Jugular l tvmph
Ouophaou• Subolavia'!J trunk
and crosses midline at T6.
• Lies superflcial (anterior) to the posterior intercostal - - - L•ft
brach,ocoph1ilic
arteries, crossing azygos system, the dome of pleura, vein
Superior
Lt. vertebral & Lt. subclavian artery. vona cave _ _ ___,,~
• At the level of C7, it crosses laterally behind the carotid ._,,
sheath & anterior to the vertebral vessels

Ciatarn1
chyli

THEAZYGOSVEIN
ORIGIN
• It is formed by the union of the ASCENDING LUMBAR VEIN with the
9UBC09TAL VEIN on the RIGHT 91DE at the level of the 12th thoracic
vertebra
COURSE • Consists of veins on each side
• Goes through the aortic opening of the diaphragm and passes upwards of vertebral column
lying on the sides of vertebral bodies, Posterior to the oesophagus
• These veins drain back,
• AT level of T4 it arches FORWARD9 over the right lung & ends in
thoracic 8r abdominal well 8r
9uperior vena cave. they ere:
TRIBUTARIES Azygos vein
• Lower 8 posterior intercostal veins Hemi-ezygos veins
• 9uperior intercostel vein of the RIGHT 91DE AoC0SSOry Heml-ezygos
• Bronchial veins of the RIGHT LUNG vein
• Veins from the MIDDLE THIRD OF THE OE90PHAGU9
• The two HEMIAZYG09 veins JOIN if et the level of T7 & T8
 Surgi-T00ns: Surgical Anatomy PAGE 123

APPLIED ANATOMY
'---'
THE DIAPHRAGM
jORIGIN
STERNAL ➔ Back of xiphoid process
.........., COSTAL ➔ Lower 6 costal cartilages
VERTEBRAL➔
0 !2 crura:
'-" Rt. crus from front of upper 3 lumbar vertebrae.
Lt. crus from front of upper !2 lumbar vertebrae.
0 5 arcuate ligaments:
!2 Lateral ➔ bridges over quadrates lumborum muscle
.....__, 2 Medial ➔ bridges over psoas major muscle
I Median
IIN9ERTION Central Tendon
DIAPHRAGMATIC OPENINGS
0Due to: perelstent pleu,a-
9TRUCTURE9 perlfoneal canal.
OPENING LEVEL
TRAVERSING
Cavel opening
T 8, I inch to the
Rt. inside central
,.2.
IVC
Rt. phrenic n
li!l'Oife: It is a triangular gap
between the Lateral rib & the
diaphragm.
tendon 3. Lymph vessels @Posterior diaphragmatic hernia
Esophageal
T 10, 1 inch to 4. Esophagus may develop through H
opening
the Lt. inside Rt. 5. !2 va~ nerves
crus 6. Esop ageal vessels
....__, From Lt. to Rt.
T 12, Midline 7. Abd. Aorta
Aortic opening behind median
arcuate ligament 8. Azygos vein
9. Thoracic duct Ri#IJM•OOM
This explains referred pain
NERVE 9UPPLY from diaphragm to the
2. MOTOR: Phrenic nerve (C4) shoulder
3. SENSORY:
4. - Central region ➔ Phrenic nerve
5. - Peripheral region ➔ lower six or seven intercostal nerves

ACTION
• It is the chief muscle of inspiration (Involuntary)
• It can also be used voluntarily to increase pressure in the abdomen.
• Contraction of diaphragm assists in venous return to the heart.
• Contraction of Rt. crus helps in preventing regurgitation of food
....___,
from stomach into the esophagus (pinch- cock mechanism)

jRELATION9
RELATION9 OF THE UPPER SURFACE:
• Pleura & lung on both sides.
• Base of pericardium in the middle.
RELATIONS OF THE LOWER SURFACE:
Liver, kidney & suprarenal gland
_...______ ~
v-
( on both sides)
• Spleen & stomach (on the left)
'--

----

..,,
..__,
SURGI-
-

'----'

'--"'

8 e fw t1Bt~~'I
M1cltt1Atelit 8N /lf 8 IIIINW
M B l3CJ, -
 5tAr6r-fOC¼~: 5tAr6rul Avttto~'f 'P~~ 1 u,
ANTERIORAIDOMINAL WALL APPLIED ANATOMY
SUPERFICIAL
LAYER9: 9u erficial fatt la er
PERINEAL FASCIA
• Called camper's fascia
-Called colle's fascia
1- 9KIN • Continuous with superficial fascia of adjoining parts -continuation of scarpa's fascia
of the body below superficial inguinal ring
l!li§•iui4,MWill•Uit6Ut4 -Forms envelope like around
• Called scarpa's fascia "Condensation of superficial penis & scrotum
fascia"
2- SUPERFICIAL • Midway bet. umbilicus & symphysls pubis
FAQCIA • Attached to fascia late finger breadth below ing. lig.
l•)Uli414t4
No Deep fascia to allow
3- MU9CLE9 ramlifijMM#E'U'i1EEMrn:i'ffliTil l'iffl'Tfw@ 1-Free resp. movement
2- Pregnancy
1. External oblique muscle
2. Internal oblique muscle 3- Gastric fullness
3. Transversus abdominls muscle
Rectus a ominis muse e
FASCIA TRANSVERSAL!
4- FASCIA • This is a thin strong fascia! layer which lines Has a small opening
TRAN9VER9All9 the inner surface of the transversus abdominis forming the Internal
muscle. ring, lies about 1/2
• Ues In front of peritoneum inch above midpoint of
• lower part thickened to form illo-pubic tract
inguinal ligament
• Extends as the anterior layer of femoral sheath
• Prolonged medially as Internal spermatic fascia Inferior epigastric
vessels run medial to
5- PERITONEUM it. Covered anteriorly
by lower border of
6- PRE- PERITONEAL SPACE internal oblique

FlAT ANTERO-lATERAL EXTERNAL OBLIQU

ABDOMINAL MUSCLES Has an opening
forming the
Muscle
external rin~
Origin
Lower 8 ribs fascia lower 6 costal
ILIOINGUINAL: cartilages INTERNAL OBLIQU
lat. 'l/3 of reflected LUMBAR: lumbar
Arches horizontally
surface of inguinal fascia
lig. & iliac crest ILIOINGUINAL:
above the cord &
lat. 1/3 of reflected fuses with
surface of inguinal lig. Transversus
& iliac crest abdominis ms. to
Direction Downwards, forwards & upwards, forwards Transversely forward form Conjoint tendon
mediall & medial!
Insertion • Iliac crest • lower 6 costal • Xiphoid process
._/
• Unea alba from xiphoid cartilages • Linea alba

ii•·,■,·,e~m•
process to symphysis • Xiphoid process • Pubic crest
pubis • Linea alba • Pecttneal line
• Folded upwards & • Pubic crest Has different
backwards upon Itself to • Pectineal line directions that
form the inguinal ligament
strengthen the
from AQl9 to pubic
anterior abdominal
tubercle
Lower 6 thoraoio and first lumbar nerves
wall
N. supply
 St.,ffc/-fOOw,: 5t,n·•c'f°c.All AVtifoM~ 'P~f; I 2--1
'-' RECTUS AIDOMINIS MUSCLE APPLIED ANATOMY
RECTU9 ABOOMINl9
Origin I) Pubic crest
2) 9ymphysis pubis
• MUST be divided
:: IN KOCHER INCISION ::
..__,, I) Xiphoid process
lnsetlion • Is displaced laterally
2) 6th, 8th & 7th Costa! :: IN PARA-MEDIAN
cartila es INCISION ::
Aofion Flexion of the trunk as it receives it's nerve
Nerve
supply from the lateral side
Lower 8 thoracic nerves
suppl\j • Hematoma of rectus
..._,,, Imp. abdominis is localized
• It Is divided Into segments
Features by 3-4 tendinous because of tendinous
intersections which are intersections
adherent to anterior rectus
sheath
• Each rectus muscle is
enveloped in e fibrous sheath
called "Rectus sheath"
• It's lateral border Is called
linea semilunaris

CONJOINT TENDON
• Formed by fusion of both internal oblique
• It's weakness predisposes
& transversus abdominis muscles to direct inguinal hernia
• It is attached to pubic crest & medial • It prevents direct inguinal
part of pectineal line hernia from descending to
• It forms & strengthen the medial part of the scrotum, So it's defect
the posterior wall of inguinal canal causes descent of direct
• Nerve supply: llio-inguinal nerve inguinal hernia to the
..._,,, scrotum (Funicular type)
• Injury of ilia-inguinal n.
during appendectomy in grid
'--'
iron incision with Rutherford
extension causes paralysis
of conj oint tendon resulting
in Direct inguinal hernia
(Paralytic type)

• Formed by the lower border of external

oblique aponeurosis between pubic INGUINAL LIGAMENT
tubercle & A819 being folded backward • Mid-inguinal point:
➔ Surface anatomy of
upon itself.
external iliac a.
• Points on inguinal ligament: • Mid-point of inguinal ligament:
• Mid inguinal point: Point midway ➔ Landmark to reach
between A818 & symphysis pubis, It's internal ring
............ the surface anatomy of external iliac a .
• Mid-point of inguinal ligament: Point
midway between A818 & pubic
tubercle. Internal ring 1/2 inch above it.

~
 f;.,ff; I i8
APPLIED ANATOMY
• DEFINITION: Envelope-likesheath for rectus muscle
• 9ITE: Between linea alba (medially) & lines semilunaris (laterally)
• FORMATION
ANTERIOR WALL POSTERIOR WALL
Above oostal - Ext. oblique - 6th, 6th.& 7th costal
margin cartila es
Fl'<>m oostal - Ext. oblique. - Post. layer of Int. oblique
margin to midway - Ant. layer of Internal · Transversus abd. (Its
bet. umbilious & oblique. lower border is the
9P arcuate line
Below the level External oblique. Absent & is replaced by
midway between - Internal oblique. fascia transversalis
urnbilious & 8P • Transversus abd. l:S,V.mtWf,1t.•I
fr?--.!:2h1Art
You must bend the legs
CONTENTS during abdominal
examination to relax the
fascia late & therefore relax
2 MU9CLE9 I 4 VE99El9 I 6 NERVE9
the abdominal muscles
- Recfus · 9up. Epigastric vessels - Lower 6 intercostal ns.
abdomlnls - Inf. Epigastric vessels - 9ubcostal nerve (TI!2)
- P ramldalis PROTECTIVE MECHANISM
OF THE INGUINAL CANAL

INGUINAL CANAL I. Obliquity of the Inguinal canal,

The attachment of the deep
Inguinal ring to the posterior

"DEEP INGUINAL POUCH'' surface of the transversus

muscle. 80, the contraction
of the muscle pulls the ring
DEVELOPMENT upwards & laterally thus
Develops by the passage Increasing the obliquity of
of the testis from the the canal.
abdomen to the scrotum !2. 8trong fascia t ransveraalis
DEFINITION supporting the posterior
An oblique intermuscular wall.
in the lower anterior 3. 9uperflcial Inguinal ring
abdominal well transmitting supported by conjoint
spermatic cord (in Male) tendon posteriorly.
or round ligament (in 4. Deep inguinal ring supported
Females) by fascia transversalis &
91TE, LENOTH & DIRECTION Internal oblique muscle In
In the lower & lateral part of anterior abdominal wall. 4 cm in adults. front of it.
Oblique downwards, forwards & medial 6. Shutter mechanism: In which
contraction of the arohing
flbera of the transversus
ebdomlnls cover a part of
a. External oblique. a. Fascia transversalis the lnterh81 ring with cough.
b. Fibers of the internal oblique. b. Conjoint tendon 6. Cremastarlc mechanism;
c. Transversus abdominis. (In fts medial Y2 only) contraction of spermatic
•••
a. Arching fibers of the Int. oblique
ms. plugs the superficial
inguinal ring.
a. Inguinal ligament (its medial Y2)
b. Transversus ebdominis muscle 7. Valwlar mechanism;
Contraction of external
oblique tightens Its
aponeurosis & narrows
CONTENTS superficial inguinal ring
 TRIANGLEOFHALStrrED APPLIED ANATOMY
"HASSELIACH'STRIANGLE" RIANGLE OF HALSHTED
• Weakness in it predisposes
If is a part of the posterior wall of the inguinal canal to direct inguinal hernia
It is divided btJ lateral umbilical ligament into medial
and lateral parts
'-.,/
BOUNDARIES
LATERAL: Inferior epigastric vessels
MEDIAL: Lateral border of rectus sheath
INFERIOR: Inguinal ligament (onltJ medial 1/2)

ABDOMINAL AORT~ ABDOMINAL AORT

Is most common site of
blood vessels aneurysm
ORIGIN
.. specially infra-renal
• At the eortic 't>pening in the
diaphragm opposite the lower
border of TI2 in the median POSTERIOR:
TERMINATION SIT
plane behind the median • It lies directl~ anterior to L1-L4
arcuate ligament & between
Is the site of
the Rt. & Lt. crura. "LERICHE 9YNDROME"
ON IT'S LEFT SIDE:
TERMINTATION 9ympathetic chain Is
• At L4 vertebra slightly to the Closely related.
left by dividing into 2 terminal
branches (2 common iliac ON IT'S RIGHT SIDE
arteries) IVC & cisterns chyll

L - --
RELATIONS
~~-

'---
Hepalic veins
'--'
BRANCHES Phrenlc artery

3 PAIRED BRANCHES
'-....; TO GLANDS Coeliac axis Leh suprarenal

-
I. Middle suprarenal a. Righi suprarena1 artery end vein
2. Renal artery a. (L2). vein
3. Gonadal lower border of Superior mesenteric Leh renal

-
'--
L2.

3 SINGLE BRANCHES
TO GIT VISCERA
artery

Righi gonadal vein

ertary and vein

- - - +- Leh testlcular
(or ovarian)
artery end vein

-- 1. Celiac trunk
At upper border of L1
2. 9UP. mesenteric a.
At lower border of LI.
lumbar artery
and vein Inferior
mesenteric
artery
'--
3. INF. mesenteric A. Atl3
\..._,.
Median sacral
3 TERMINAL artery Common}
'--' BRANCHES Internal Iliac artery
and vein
I. Rt. common iliac a. External
2. Lt. common iliac a.
'-- 3. Median sacral a.

'-
......
 5urt:,t-fOC\1~: 5urt/t-111, AvttfoM'I 'PP-k117 I 1)()

APPLIED ANATOMY
THE ESOPHAGUS
COURSE & RELATIONS
MEOIA9TINAL RELATION
Behind PERICARDIAL 8AC 80
used in:
• It's a muscular tube (!25 cm) • Trans-esophageal ECHO
• Extending from the pharynx at the level of the 6th cervical vertebra to • Assessment of severity of
the stomach Left atrial enlargement
• IN NECK: Lies behind the frachea
• IN MEDIA9TINUM: Passes behind left bronchus then behind
pericardia! sac.
• REACHES THE ABDOMEN:
I. Through the esophageal hiatus
!2. One inch to the le~ of the middle line ABDOMINAL PAR
3. At the level of the body of the tenth thoracic vertebra 8ite of Columnar
• IN ABDOMEN: metaplasia ➔ BARRET'S
1. It's of variable length E80PHAOU8
!2. Ends at the gastro-esophageal junction
3. Covered by peritoneum anterior only.

BLOOD SUPPLY:
1- ARTERIES
INFERIOR ESOPHAGEAL ESOPHAGEAL
THYROID ARTERY BRANCHES FROM BRANCHES OF Are small vessels which
THE AORTA THE LEFT GASTRIC can easily be dissected
• Upper part ARTERY
• Middle part in trans-hiatal
• Lower part
esophagectomy
2- VEIN9
UPPER PART MIDDLE PART LOWER PART
• To braohio- • To azygous (Rt. side) To le~ gastric
share in portosystemic
oeohalio veins • Hemiazygos (Lt. side) vein then
anastomosis resulting
portal vein
in varices in portal
hypertension
3- LYMPHATIC9
CERVICAL PART THORACIC PART ABDOMINAL
• Deep cervical Mediastinal LNs PART
L.Ns • Celiao L.Ns

4- NERVE 9UPPLY
CERVICAL PART THORACIC PART ABDOMINAL
Recurrent • Vagus n. PART
laryngeal n. Autonomic
supphJ

5- CON9TRICTION9
From the incisor teeth: CONSTRICTION9
• 15 cm ➔ Crioopharyngeus sphincter Are sites of foreign body
• 22.5 - 25 om ➔ Aortic arch impaction
• 27cm ➔ Left main bronchus
• 40 om ➔ Opening in diaphragm
 ?lM'"c/-f OOw): Svo'"t/c/41 Avt-1-roWt'I 'PU,,~ I 17\

THESTOMACH
If lies in the left hypochondrium, epigastric & umbilical regions.
LIED ANATOMY
IAil•ldl-1
Identified at operation by:
1. Pte-pyloric vein of Mayo
It's completely covered by peritoneum between Rt. gastric and Rt.
gasfro-epiploic veins.
'-' ORIFICES 2.Feeling its thickness.

'--
CARDIAC ORIFICE PYLORIC ORIFICE
• At the level of TIO, 1inch fo the POSTERIOR RELATION
At the level of Ll, ½ inch
left of the midline. Posterior gesiric ulcer or
'--" to the right of the midline cancer ➔ Erodes pancreas
• At 40-45 cm from incisors in
endoscopy Ulceration info splenic a.
.... (Direct posterior relation)
➔ Hoe.
.__,, 9URFACE9
...___, POSTERIOR ANTERIOR
1. lf. Crus of diaphragm Related to the liver, diaphragm,
2. Lt. Kidney. & ant abdominal wall
3. 9pleen (separated by greater sac)
4. 9plenic artery
► .._
6 . Lt. 9uprarenal gland. • Angle of Hlas: Acute ➔ valwlar
6. Body of pancreas. effect between leA side of
7. Transverse mesocolon. \ ,,_,.,--........, esophagus & fundua.
8. Transverse colon SplHn • l ower part of esophagus (6
Diaphragm -1114~ , Supraranal cm) la intra- abdominal ➔

~-~~~~ii~~r~~- Splenlc
closed on rise of abdominal
11 Loft kidney pr888ure.
:: army
/1>'-'-ff-"-f+- p.,,.,... • Roaeffe-ahaped mucosal folds
of lower end ➔ bulging In the
lumen.
• Pinch-cook effect of Rt. orus
_ _ _ __,_____..,.__ T, ·a ntvorM colon
of diaphragm.
and mHOCOlon • Phrenlco►eaophageal ligament:
PART9 Keeping the Intra-abdominal
part in place.
1. CARDIA 2. FUNDUS • Continuous release of aoetyl
lies immediately below choline ➔ lower end relaxes
Above the level of cardia
the entrance of the only on swallowing.
esophagus • Pteaaure at lower 6 om of
3. PYLORIC PORTION esophagus la 8 - 26 mmHg
4. BODY while the Infra-gastric pte88ure

-
'-
Between the fundus & the
pyloric portion
narrow
art
is 7 mmHg, thus, no reflux
occurs

FUNCTIONAL DIVISION
The Important division Ilea
between the anfrum & the
Cardia Fundus body:
...___,
fncisura angufaris • THE BODY:
Qeoretea HCL, pepalnogen,
'--- Pyloric sphincter Body mucus & lnfrlnslo factor
_ _ _ _ _ __,,'--_ Pyloric anrrum (Aoldlo)
• THE ANTRUM:
Qecretea gaafrln hormone &
mucus (Alkaline)

.....
 Sure/~ Ntt~:f-oM'j 'Pf,./q~ I "Jt-
BLOOD 9UPPLY: APPLIED ANATOMY
n 8uppliecl by branches of
_ _ _ _I_
1- ARTER Eo_ celiac trunk (foregut)
ALONG THE LESSER ALONG THE GREATER
CURVATURE CURVATURE
• Rt. gastric ➔ From hepatic a • Rt. gasfro-epiploic ➔ from gastro-
• Lt. gasfric ➔ From celiac duodenal a.
trunk • Lt. gastro-epiploic ➔ from splenic a.

Lell gNtnc artery _ _ _,

AT THE Coehac •~•'- - - - . . . : :
FUNDUS Cystic anery
8hort gastric Hepatic artery _ _ _ _,..,.
arteries ➔ From
Right gastm: artery _ ______ __ -.1
,,ll■.
splenic a. &
passing through Gasvoduodenal artery
gastrosplenic lig.
Supenor
pancrea11coduodenal_ "'-'-illll
artery

2- VEIN9
!2. Rt. gastro-epiploic vein
3. Lt. gastro-epiploic vein
I
(Portal + anastomosis wtth esophageal veins)

1. Rf. & Lt. gastric

•
•
Portal vein
8uperior mesenteric vein
8plenic vein
& short ~astrlc veins

3- LYMPHATICS

The above groups

converge proximally
to end in the celiac
L.Ns or Superior
mesenteric L.Ns

4- NERVE 9UPPLY
9YMPATHETIC PARA9YMPATHETIC
From greater splanchnic (9ECRETOMOTOR)
nerves then to celiac
ganglion. Afferent fibres
carry visceral pain

8ife in
chest
ranc es in epatic eiac
abdomen
Continues Ant. nerve o Post. Nerve o
as •. Laterjet Laferjet

En s \l Crow's oof No crow's oof

1
 5urt:i-f ro-t~: 5urc/~I k'ttfoW\'j 'PN::{i I 1fJ

'--
THE LIVER
It's the largest solid organ in the body, It weighs 1200- 1800 gms in
adults.
APPLIED ANATOMY
lnfifttofwn.tav• Mo,phologlal left -

81TE & 8HAPE ■ wedge shaped

■ In right hypochondrium & epigestrium
(On visceral surface) Extends to Right lumber & pert of left
hypochondrium
Mo<p>,ologlul ,1¢,1 · -

'--'

"--'
LOBES OF THE LIVER::.::::-_~
=
ANATOMICAL LOBES
Divided into large right & small left lobes by:
• Anterior & Superiorly ➔ Falciform
ligament (On parietal surface)
'--" • Inferiorly ➔ ligementum tares
• Posteriorly ➔ ligementum venosum
l<I
SURGICAL LOBES

-
'----
•!• The liver is divided into almost two equal lobes
by middle hepatic vein. [plane of division lies to
the right of felclform ligament & passes from
gall bladder fosse to inferior vena ceva]
SURGICAL LOBES
Each segment has its own
•!• Each lobe of the two lobes is supplied by a artery, vein & duct ➔ can

--
'--
separate branch of hepatic a., portal v. &
separate bile duct.
•!• There ere three hepatic veins:
be removed separately
:: 81:GMENTECTOMY ::
• Rt. hepatic v. drains from Rt. lobe
• Lt. hepatic v. drains from Lt. lobe
-._..,
• Middle hepatic vein drains from both
lobes
❖ Hepatic vein & ifs tributaries divide the lobe into
4 sectors & sectors into 8 segments.
'--- ❖ Segments ere numbered from 1-8

9URFACE9 & RELATION9

Formed of PARIETAL surface & V19CERAL surface
separated from below by sharp lower border
• Thia is segment one
PARIETAL SURFACE VISCERAL SURFACE • Lies just behind the ports
• Related to the diaphragm • LEFT PART: hepetla.
separating it from lungs, Related to abdominal esophagus & • Hee a special status as it's
pleural cavities, heart & anterior surface of the stomach supplied by hepatic a. &
'---- lower tight ribs. • FURTHER TO THE RIGHT: portal v. branches from both
• Related to the anterior Related to gall bladder sides, and ie drained directly
abdominal wall. (adherent to undersurface by multiple small veins Into
• IVC indents into its of the liver "gall bladder fossa") the inferior vane cave
posterior aspect. Gall bladder & quedrate lobe related
'---- to lsi & 2nd part of duodenum QUADRATE LOBE
& Hepatic flexure of colon • Part of liver between the
• RIGHT PART: round ligament & gall bladder
Bears the renal impression which fosse
is caused by rt. kidney & suprarenel
gland.

-
 Sure·-fOC\1~: Sure·ut Avttfo~'i f~~ I 1)4-

LYMPHATIC9 _ _ _ _ eo..._. r_ APPLIED ANATOMY

• liver drains into L.Ns at ports
hepatis which drains into ,_ _ _ __ Fakiform Hgamt
celiac L.Ns
• Some lymphatic vessels pierce
,......,~~ :;,,-'' ---r.::~:~
G•II~
the diaphragm io reach the
_ _ __ Galltuddof
thoracic duct Pc><to
hopolho , - - -- Ouodroto lobo
Right
lobe
BLOOD 9UPPLY: _ Fissure for
Common-1-J,\--- _,,.,_~ i;'\I trn.':::um te,H
1- ARTERIE9 hopotic
duct
-+11➔------.,-C.udo,. lobo
I1-- - - - , -flM-u,e tor
liga.tl'\4mtum

PORTAL VEIN HEPATIC ARTERY .., Yefl09\Jffl

• Supplies 70 % of liver blood • Supplies 30 % Inferior vena uv•

• Formed by union of superior • Branch from celiac trunk
mesenteric vein & splenic vein
behind neck of pancreas '-"
2- VEINQ • 3 hepatic veins draining into inferior vena cava llVC).
• The right drains directly into IVC while left & middle
unite to form short trunk before draining to IVC.

PERrTONEAL
-._..,

COVERING & FOLDS

Formed of PARIETAL surface & VISCERAL surface
separated from below by sharp lower border
....__..,
PERITONEAL PERITONEAL FOLD9
COVERING • FALCIFORM LIGAMENT:
The parietal surface is Related to abdominal
coverecl by peritoneum esophagus & anterior surface
except: of the stomach
• 9mall bare area lying • RT. & LT. TRIANGULAR
between superior & LIGAMENTS
inferior layers of • UPPER & LOWER CORONARY
Coronary ligaments LIGAMENTS '--
• Fossa of gall bladder • LE89ER OMENTUM:
• IVC groove Connects the lesser curvature of the
• Porta hepatis stomach to visceral surface of the
liver. Has a free right border which
contains:
1. CBD➔Anterior & to the right
2. Hepatic a. ➔Anterior & to the
le~
3 . Portal v. ➔ Posterior
As they reach the liver they all divide into
right & left branches & enter the hilum
of the liver [Known as ports hepatis]
..,_,.
S<Ar0ie/4' Avttto~'f 'f,6..4~ I 1£

GALLBLADDER APPLIED ANATOMY

81TE & 8HAPE & CAPACITY

• Pyriform in shape
• 30 -50 ml.
BLOOD SUPPL
• Lies in fossa of gall bladder on the visceral surface of the liver at
the plane dividing it into 2 surgical lobes Gangrene is RARE d.t .
2'1! rich blood supply
'---
PART8 coming from liver bed

•i!N!'I!l-1 ■m,H■ ■ :r,u)W INFUNDIBULUM

• Is the angulated
• Covered by • Forms an 9 • In contact
peritoneum shaped with 1st post. Portion of
'---' all around. curve. part of the body of gall CYSTIC ARTER
• At angle of • Connected duodenum bladder. Maybe very short when
9th costal to cystic • Occupies • When dilated Rt. hepatic or common
margin. duct the OB celled "Hartman's hepatic artery take a
fossa. Pouch". tortuous course
"CATERPILLAR" ➔ In
BLOOD 8UPPLY: such cases, clamping the
cystic a. during gall
1- ARTERIES bladder surgery is
difficult & the Rt. hepatic
CYSTIC A. ACCE99ORY CY9TIC A. a. may be mistaken as
A branch of Rt. hepatic artery If present cystic a. and ligated
passing In the triangle of Callot (from Rt. or Lt. hepatic A. or
common hepatic A.)
'---'
2- VEIN8
Cystic artery
• 9mall veins ➔ directly enter the liver bed.
• cystic veins ➔ Info right branch of portal vein.
. -- - -Common he patic
a rtory
3- LYMPHATIC8
..._,,.
Cystic LN of Lund et the junction of cystic duct & CHO ➔ to celiac LN

4-NERVE
AUTONOMIC 9EN9ORY
• SYMPATHETIC ➔ By the Rt. phrenic C3.4,6
From T7-9 (The same segments es the
(Pain is referred to inferior supra-cleviculer nerves ➔
'--' angle of Rt. scapula) 9o pain In gall bladder is
• PARASYMPATHETIC ➔ referred to Rt. shoulder)
Hepatic branch of anterior
vagus
'-' (Pein referred to stomach)

'-'
 EXTRA-HEPATiC~" APPLIED ANATOMY ...._,

BILIARY PASSAGES
RT. HEPATIC DUCT LT. HEPATIC DUCT
• Length ➔ 2-3 om
' coMMONil' . CYSTIC • Diameter ➔ 2-3 mm
• J-!EPAT_ICi!QUCT; , DUCT • Its mucosa is thrown int o

\.._..__ _-I COMMON

BILE DUCT
___ ,/
oresenterlo folds called
spiral valve of Heister
'--

COMMON BILE DUCT

• Lengt h ➔ 8-10 om "3-4
inches"
Hopot,C duct•
• Diameter:
Cy11k: duct _ _ _..,....:,-----..._ - 8mmbyU/9
·H•nmann'• pouch - 8 mm by cholangiography
Goll bladder Body
Common bile
dUCI
• Parts ➔
9upra duodenal pert
Fundua Intra pancreatic part
Retro duodenal part
Intra duodenal part
Main panc,•11k:
• Either unites with the
Duodenal papUI.I duel pancreatic duct to end
Atnpull• of V•tor
together or each opens
separately
• Ends at the ampulla of veter
in the 2nd part of the '-..,-
duodenum
• Opening is surrounded by

FORAMEN OF WINSLOW sphincter of Oddi

.,___,

'----'
(OPENING TO THE LESSER SAC)
FORAMEN OF WINSLO
. . eritoneal sao • During cholecystectomy,
control of bleeding from '--'
cystic artery is achieved
INFERIOR ➔ 1st part of duodenum
POSTERIOR ➔ IVC by Pringles maneuver ➔
Put the index finger of the
Falciform ligament
Lt. hand in the foramen of
Winslow & compress the
Liver Stomach free border of lesser
omentum aga:nst the
thumb ➔ compression of .__,
Ponal triad hepatic artery.
(portal vein. Greater sac
hepat ic artery • Site of exposure of supra- .._,
and common
bile duct> duodenal portion of CBD
Foramen of for removal of stones.
Winslow • A site for internal hernia
~'7Tr-r-- Spleen wilh ita
llenorenal and {epiplocele) where the
gastrosplenic
llgaments foremen represents the
defect
Lesur sac
 5t,u·e/<=AI .AvttfoWt'I 'ff,./qf; I ~1
APPLIED ANATOMY
.._,,, NTERIOR NOTCH
It weights 80 - 300 gms.
Lies in the left hypocfiondrium deep to the 9th, IOth & 11th ribs Differentiates it from the
'--" It's long axis is patallel to the 10th rib left kidney
• Has a notch on it's anterior border
'--
8URFACE8 PARIETAL RELATIONS
l'njury of spleen may lead
PARIETAL to injury of Vital structures
• Convex
• In contact wHh the (e.g . Diaphragm, Pleura,
diaphragm
• Througll the diaphragm lunng) due to close
Sph,,.cn
'--' It's related to pleura relations
& thin inferior border Tallofp;ancreH
of left lung

VISCERAL RELATIONS
~ Special care should be
~ addressed when clamping it
• 8tomach PERITONEAL COVERING in order to preserve tail of
• Colon
• It's completely covered by peritoneum
..__, •
•
Left kidney
Tall of P.ancreas at "lntraperltoneal organ" pancreas during "
hilum of the spleen • Is fixed firmly to tFie splenlc capsule
• Two peritoneal folds hang the spleen
'-..,I at it's hilum:
1-Gasto-splenic ligament
!2-lieno-renal ligament
\...I

LIGAMENT8
GA9TR0- UENO-
9PLENIC RENAL
LIGAMENT
• Attached to the
hilum of the
LIGAMENT
• Attached to the
hilum of the
• From splenic exure
of the colon to the
jQm~l'!J;"tE
'--' spleen spleen diaphragm Pushes the spleen to Rt.
■ Transmits short ■ Transmits the • Lower pole of the iliac fossa when enlarged
gastric vessels blood vessels to spleen is in contact
which are the spleen & tail with it, which is one
branches of of pancreas of Its main supports
splenic or gastro-
epiploic vessels

BLOOD 8UPPLY:
Runs a ong posterior s u ace o
pancreas below the level of SPLENIC ARTER
mesenteric artery splenic artery It's tortuous course
'--' Hes a tortuous course a e Receives e in erlor mesenteric
upper border of pancreas vein allows contraction of
Oivi es into superior in erior oins t e superior mesenteric spleen & respiratory
terminal branches that enter the vein behind neck of pancreas to movement
splenic hilum form portal vein
...__,,

LYMPHATIC8 lymphatic vessels that

drain to l.Ns of the hilum
'--
 5urc/t4.I Avttto~w-, 'PA4~ I 1JS

PANC
During development, the fwo segments may completely
surround the 2 00 part of the duodenum ➔ ANNULAR PANCREA9
LIED ANATOMY
........,

PART9 & RELATIONQ DUCTQ ........,

A retroperitoneal organ formed of the MAIN PANCREATIC
following parts Head, neck. body & Tall DUCT
HEAD "Duct of wirsun " RETROPERITONEAL
■ Lies within the concavity of the duodenum • Joins the CBD at The onlt-1 organ that never ........,
11011
ampulla of vater becomes content in the
■ Has a hook like process called unclnate • Opens in the middle of sac of a hernia
process where superior mesenteric the medial surface of
vessels lies infront of it & emerges at the 2nd part of the
-.......,
lower border of the pancreas • Duodenum on major iA•mi§;U•etlU-M•G➔
• Posterior to it duodenal papilla :t
1. Common bile duct (CBD) • The common opening 90 in cancer heed of
!2. Inferior vena cava Is surrounded by pancreas ➔ CBD
NECK sphincter of oddl obstruction➔ obstructive
• Posterior to it: junction between superior
jaundice
mesenteric vein & splenic v to form portal ACCE990RY ..__,,
v.
BODY
• Anterior to it: Lesser sac "separating it
from posterior surface of the stomach
PANCREAllC DUCT
"Duct of santorini"
• May join main duct or
opens separately
4miiOMBf
:
1M~••); ..
Perforation of P08TERIOR
• Posterior to it: 8plenio vein & aorta above it on minor GASTRIC ULCER may lead to
• 8plenic artery runs to the left just above duodenal papilla PANCREATIC P8EUDOCY8T
'-....,
the body
TAIL
Related to splenic hilum & splenic vessels PANCREATIC DUCT
Joins CBD, that's why
stones are a cause of
Main pancreatic
duct !Wirsung) acute pancreatitis
...__,,
Aorta giving olf coehoc aXtt
left gastric artory
Acceuory • ertery
pancreatic:
duct
Inferior vena eav• --.~'-4,~
ISantorini) Portal vein ~
Common bile duet - -,'---,,;:
Duodonal pepilf■
Right kidnoy
"-"
Pancreq
Hepatic flt.xur•

>Superior moHnto,ic
v.nel1

1- ARTERIES 2- VEIN8
9uperior & inferior Drains to SUPERIOR & SUPERIOR
ancreatico-duodenal arteries INFERIOR PANCREATICO-
corresponding
• Forms an arcade that lies In DUODENAL ARTERIE9
concavity of duodenum "C" veins ending in
9upplies also the ........,
• 8u~~ies the head & duodenum portal vein
duodenum so it's
■~ib A,I4i•lfflMl11iii4tfflt4W
• 8upplies the rest of pancreas removed in Whipple's
operation
'----"

'----" 5ure/-f C>CM~: 5ure/c:AI Anafo~'I 1'A4~ I 1fJ

'---' APPENDIX
91TE, QIZE & 8HAPE
LIED ANATOMY
[tllil■l'h
Used as a guide to
appendix in appendectomy
• Blind ended hollow muscular tube
• Arises at caecum at convergence of taeniae coli
• Measures between 7.5 -10 om
.iihl¼iU~rjl•iti
• gives some 1f erenoe
81TE, QIZE & 9HAPE in the clinical picture
of acute appendicitis
• The base of appendix is toced • In appendectomy we
• The relation of the tip to open over the surface
caecum is variable: anatomy of the base.
1. Retro-caecal (74%)
MORE VARIABILITY
2. Pelvic (21%)
The location of caecum Is not
3. Para-caecal (2%)
always in right iliac fossa
4. 9ub-oaeoal (1.5%)
because the ascending colon
5. Pre-ileal (1%) may be:
8. Post-ileal (0.6%) I. Too short making the caecum
9ub-hepatio
2. Too long making the caecum
jPERITONEAL COVERINGS in the Pelvis
'--' The appendix is completely covered by peritoneum & has a
mesoappendix which stops shortly at tip of appendix
NERVE SUPPL
NERVE SUPPLY That's why pain in acute
appendicitis starts around
T tO supplies the peritoneal covering of the appendix
the umbilicus "Visceral pain"

BLOOD One or two appen icu ar

arteries PPENDICULAR ARTER
Run In t e meso- It's the ONLY blood supply
SUPPLY appendix, closely applied
to the wall distally ➔ RAPID development of
gangrene & perforation

'--' @m,,a:tarna
HISTOLOGY LYMPHOID Tl99UE
90 Acute appendicitis
1. MUC09A
in old age ➔ must
Similar to colonic mucosa
suspect cancer
formed of columnar
epithelium with goblet cells.
crypts are present but
'--"' fewer & shorter
2. 8UBMUC09A
Rich in lymphoid tissue which becomes afrophied with age.
The base of the appendix lies
3.MU9CUL09A
et McBurney's point
Thin & formed of two complete layers, circular & It's a point at junction of
longitudinal muscles. lateral 1/3 & medial 2/3 of a
'---
4.9ER09A llne extending from AQIQ to
Completely covered by peritoneum the Umbilicus
 Sure/u.l N-ttfo~'I f f,-4~ I 4-0
APPLIED ANATOMY
BEGIN9 Opposite to 93 at reotosegmoid junction
END At snoreotal junction st the level of the pelvic floor
LENGTH 12-16 om
9HAPE:
•.!li'U ...,1 ■ 1 t W'tl
Concave
~
·-· . "' ·-· '
Bladd.. - '1-';J'<---fF
Svmphyett
pub<t
S.,.,inal w•lca.
RKtum
Concave 1st to the The distal pert of the Fncuo of
anteriorl\j bec. right, then to the left O.nonvilll•r•
It follows the rectum, which sots es
conoavity of the then to right again. s reservoir because of
88crum Opposite to the Its characteristic
bending the mucosa distenssbility
forms muco881 folds
which ere called
Valves of Houston
PERITONEUM LOWER THIRD
Partially covered by peritoneum "Refroperitoneal structure"
➔ Upper third --> Front & sides
Not covered by peritoneum ➔
➔ Middle third - • Front No trsnscelomic implantation
➔ Lower third --. Not covered

I FASCIA AROUND THE RECTUM

- Gives - Posterior to t e • Anterior to the
attachment rectum rectum
between the • It loosely bound • It's a tough fascia
rectum & side the rectum to 88orum
wells of the elvls
• Contains the • Pelvic p exua o • 9aJ>!lrstes it rom the
middle rectal autonomic nerves lies baok of urinary bladder
vessels behind the fascia & roatate In maI98

BLOOD SUPPLY:
systemic circulation
• Direct continuation
of Inferior mesenteric leading to varices
arter & vein
• Gives reno es at • Runs me lay • Crossest e
3,7,12 In the lateral lschloreotal fossa to
rectal Ii ament reach the anal canal SUPERIOR RECTAL VEIN
Its branches are site of
LYMPHATICS mother piles
• Usually in upwards direction
• To L.Ns along the superior rectal vessels then to Inferior LYMPHATIC SPREAD IN
mesenterio L.Ns UPWARD DIRECTION
• To a minor extent, some lymphatics pass along the 90
middle rectal vessels to internal iliac L.Ns Removal of 2 cm BELOW
the tumor is enough in
cancer rectum
 ?UY-cf·-,DCM~: 5urtjiu.1 Av-t~:rotiv\'f 'PAfJ~ I 4-\
APPLIED ANATOMY
\....,I

BEOIN9 At the level of the pelvic floor, As the rectum passes

through pelvic floor it ends by turning backwards at right
angle forming the anal canal ~
END At the anal opening ~
LENGTH 3-4 cm the anal crypts join
COUR9E Continues downwards & backwards, surrounded by three each other, anal
concentric cylinders of muscles these are the fwo internal glands open on the
& external sphincters & a thin longitudinal ms. layer anal crypts that are
.......... circumferentially
between them
RELATION9 It's cushioned on either sides by fat-filled ischiorectal arranged
'---' fossa
MUC09A OF THE ANAL CANAL
Dentate line "which Is en Important surgical land mark" divides the anal
canal into 2 arts:

Development Hlndgut Prootodeum =

Eotoderm
Cubical epithelium which Modified skin lacking
lining changes gl'8dually hair follicles & sweat
upwards to columnar glands. Called
......__,, e ithellum at rectum anoderm
Nerve auppl\j Vlscel'81, noi sensitive 9omatlc, sensitive Is caused by
to aln to ain
'-..,,
Blood suppl\j
oorrugators outls anl
9uperlor rectal vessels Middle & Inferior
{portel) rectal vessels
ms. "Lowest fibres of
9 m the longitudinal muscle"
Lymphafio 9uperior reotel L.Ns 8upel'flclal Inguinal
........... drainage L.Na then to Deep
L.Ns
Columns of Present Absent
Morgagnl
(Elevated
mucosa
Color Pink Parchment-like

ANAL 9PHINCTER9
-
INTERNAL SPHINCTER
- --~-- -
EXTERNAL
- --
SPHINCTER
- --

Involuntary muscle Voluntary muscle

Thickened continuation of the Forms the outer moat
clrouler muscle coat of the muscular cylinder ~-.;:,...i--- Internal
sphincter
rectum
......,,. 9urrounds the anal canal for a Innervated by pudenda! n. ..
.,..~g~~~;. sphincter
External
distance about 2.6 om (92,3.4)
2 .6 mm In thickness & white Pink in color - - - Pectinate
line
in color
8paam In It plays a major role In Attached post. to coccyx &
pathology of anal fissure & ant. to mldperineal point In
perlanal s uppuration males & fuses with the NORECTAL RING
sphincter of vaR.lnae In females
It's injury leads to faecal
ANORECTAL • 9urrounds anorectal junction
• Composed of joining of :
incontinence

RING - Puborectalis part of levator eni

- Upper part of internal & external sphincter
 SlM"cl-fOCM~: Surt/~I N'tifOM'J 'PMi~ I +i.
SUPRARENAL GLAND APPLIED ANATOMY
RIGHT LEFT
SITE Higher, upper pole of lower, reaching hilum of
kidne kidne
SHAPE Trian ular 9emi-lunar
ANT. Rt. lobe of the liver lesser sac of stomach
RELATION
POST. Rt. crus of diaphragm Lt. crus of diaphragm
RELATION
V. DRAINAGE Rt. suprarenal vein to Lt. suprarenal v. to It. renal .__,
IVC v.
• Arteries don't enter through the hilum
• 3 arteries to each gland
ARTERIAL 1. Superior suprarenal a.-+from inferior phrenic
SUPPLY
a.
2. Middle suprarenal a. -+from the abdominal
aorta (main supply) Pronoph,'ot

3. Inferior suprarenal a. -+from renal a.

V1lefhne duc:1-1iiF==--
Allln1011 ~:::;:,:S:,_
_ _ _ MG,.neph<os

,,__ _ Metanephnc duct

-+Arises from meaonephric duct.
-+Grows upwards retroperttoneally.
- •Forma ureter, pelvis, oalyoea & collecting tubules. ..._,,
-+Will be capped by metanephron which forms glomerull & nephrlo
tubules which establish oontlnuHy with oolleotlng tubules. KIDNEY DEVELOPMENT
ASCENT & ROTATION: • Failure of fusion of
-+ 9tarta developing In the pelvis mesonephric with
-+later aaoend to the loin metanephric duct ➔
-+ Aa It ascends It rotates: first the pelvla la ant. & oalycea la
leads to CONGENITAL
post. THEN peMa la medial & oalyoes la lateral
POLYCY8TIC KIDNEY

THE KIDNEY • In ,NJ™~•l'f!lf1ei&'1

we open the
P08TERIOR surface.
91ZE POSITION • In HYPERNEPHROM ___.,.,
12 x 8 x 3 cm Retroperitoneal organ, in paravertebral we open the ANTERIOR
PEOICLE gutter surface
lies on the uprer part of posterior
In the hllum we have (VAP) abdominal wal
• Renal Vein-• Anterior • The right kidney is lower than the left
• Renal Artery- • Middle by 0.5 inch because of the pressure
• Pelvis of ureter-+ Posterior of the liver

RT. KIDNEY LT. KIDNEY

Upper lower border Upper border
pole of T12 ofTI2
lower lower border Upper border
pole ofl3 ofl3 ._,,

-..J
..___,

5t,o,..c/-1DCM,: 5t,u-6i~I N-'tifOW\'/ 1'~~ I ~

BLOOD SUPPLY
A. Arterial supply: Renal artery (branch of abdominal aorta at Ll/2)
APPLIED ANATOMY
8. V. drainage: Renal vein (drains into IVC) RENAL ARTERY 9TEN091
CAPSULE leads to 2'119Y9TEMIC
From within outwards: _:::, HYPERTEN910N
I) Fibrous capsule (True capsule)
2) Fatty capsule: Peri-nephric fat
3) Fascia of Zuker- candle or In closed trauma ➔ !l1m
..___,,
Oerota or peri-renal capsule i#Mat+i ➔ TAMPONAOE ➔
(False capsule) CONTROL BLEEDING
4) Paranephric fat 1
w.,.., _ _

RELATIONS
\.....,

Anterior .9uprarena
relations 2. 9econd pert of tomach
duodenum estlne 4.
3. Rt. colic flexure re 6. 8pleen • un y Ines on
4.9mall lnteatlne 6. Rt. vessels & of the patient:
lobe of llver ➔ 2 vertical lines: 3 & 9 cm
Posterior usces rovascu ar from median plane
I. Diaphragm siruotures ➔ 2 horizontal lines: at level of
relations T11 & L3
2. Quadratus lumborum 1. 9ubcostal vessels
3 . Psoas major 2. 9ubcostal nerve • The centre of the hllum Ilea
\......, 4. Transveraus abdomlnls 3. lhohypogastrlc opposite to the lower bordr of L1
nerve s Ina, 8 cm from median ane.
4. llloin,gulnal nerve •
I-It's position In t para-vetf re
gutter
2-lt's mscial & fatty capsules

....._,
THEUkEIER
BEOIN8 At pelvi-ureteric junction. in front of the tip of transverse
3-Renal vessele connectln,g kidney
to Aorta & IVC

Process of L1
12lhrib Ou.dt• tua.
END Opening Into posterosuperior angle of the urinary bladder lumborum
Subcotul n•IV9
9ITE9 OF URETERIC CON9TRICTION9 lllohypoguuic n.,v•
1) Pelvi-ureteric junction (L2) lho-lnguJru;I MNe

2) Inlet of pelvis (Bifurcation of common iliac)

3) lschial spine
COUR8E It's divided into 3 parts A) Abdominal B) Pelvic C) Intramural
Abdominal art: It's 12.5 cm long

Course • Each ureter descends vertically behind peritoneum of

the posterior abdominal wall
• Opposite the tips of transverse processes of lower 4
...__, lumber vertebrae
• The same course In both & & Q
Post. • Medial border of psoas major
relation • Genito-femoral nerve on it.
• Tips of transverse processes of the lower 4 lumbar
vertebrae
Ant. • 3rd art of the duodenum
relation • 3 arteries: Rt. gone e. Rt. • 3 arteries: Lt.
colic & ileo-colic. gonadal, upper & lower
Lt. Colle
to It passes in e
mesentry: fossa intersigmoidae.
• Its root • 91gmold mesocolon
• 9up. mesentrlc vessels • Coils of sigmoid
• coils of ileum colon
 Sure/u.l Mi-1-otM'I 'P~ I ff
A. PELVICPARI': It's 12.6 cm long
• It enters the pelvis by crossing in front of the bifurcation of APPLIED ANATOMY
common iliac artery lat the sacroiliac joint}.
It runs downwards & backwards on ttie side of pelvic wall till it The course differs
reaches ischial spine between males & females
• At the level of lschial spine, it curves antero-medially opening
in urinary bladder
B. INTRAMURALPARI':
It is 2 cm long. runs on oblique course in the bladder wall

BLOOD 9UPPLY "9egmental"

- UPPER ½ ➔ renal artery.
- MIDDLE½ ➔ gonadal, aorta & common iliac arteries
- LOWER ½ ➔ vesical artery in male & uterine artery in female • t appears as t 1c
muecurar tube with
longitudinal blood vessel
along it's wall
!Z. It shows peristalsis &
gives urine on aspiration
3. It cro888s in front of the
bifurcation of the common
Iliac a.

PSOASMAJOR
ORIGIN
I. Front of the transverse processes of all lumbar P90A9 MAJOR
vertebrae.
2. By 6 digitations, each of which arises from the sides of ll. P90A9 9 1GN:
the bodies of each 2 adjacent lumbar vertebrae and
• In acute appendicitis, there ls ..._,,
the inter-vertebral discs in between.
3. From tendinous arches attached to sides of the lumbar spasm of psoas major ms. ➔
vertebrae. These arches bridge over the lumbar arteries flexion deformity.
• Hyperextension of the limb leads
INSERTION
to abdominal pain lpsoas sign)
• The muscle descends medial to iliacus muscle &
b. P90A9 AB9CE99:
continues downwards to enter the front of the thigh
behind inguinal ligament above superior pubic ramus. • Produces cross fluctuation
Ifs tendon receives fibers of the iliacus muscle and is lDD: mass in the Rt. iliac fossa &
inserted into the lesser frochanter of femur. mass in the femoral triangle)
NERVE SUPPLY c. OBLITERATED P90A9 9HAOOW IN
Branches from the X-RAY FILM:
lumbar plexus lL 1, 2, 3) • Rupture spleen.
ACTION r-nw,o,~-='- • Peri-nephric abscess.
Ouodro111, ii. IN FRACTURE NECK OF THE
1. It flexes the thigh and l.ml;,or...., "'-
rotates it medially FEMUR
2. Acting from below, the Tile muscle rotates the thigh
muscle bends the trunk laterally lnot medially)
forwards
.....__,,
....__,, $1.,u-c)'°-fOl\1~: s1.,u-c/u.t Avtt-toM'/ -r~~ , 4-6"

'--'
COELIAC TRUNK
It is the artery of foregut, 9upplies the gut above the level of ampulla of Vate
AP'PLIED ANATOMY
COELIAC TRUNK

..........
BRANCHE9 May cause fatal bleeding
in perforated DU•

-
"--"'

'---

'--'
• ts
include:
• Esophageal
branches
• Gastric
branches
• Its ranc es inc u e
• PANCREA9
: : Pancreatic branches
for body & tell ::
• 9TOMACH
:: 9hort gastric es., Lt.
gastro-eplploic a.::
• TERMINAL BRANCHES
Its ranc es inc u e ➔
• Right Gastric artery
• 9upra-duodenel
artery
• Left hepatic artery
• Right hepatic artery
• Oastro-duodenel
artery

- SUPERIOR MESENTERIC ARTERY

to the spleen

➔ Arises from the front of abdominal aorta et the level of lower border of LI
.._., ➔ It supplies the mldgut from the level of ampulle of Vater till the Rt. 1/, of
the transverse colon
BRANCHE9 BRANCHES OF 9.M.

...__,, During colectomy, we ligate

1.
2. arteries arising from Rt. side
....__,, 3. •ranc• es inc u e ➔
of 9MA: which are the
middle colic, Rt. colic &

-
a. lleal branches.
b. Appendiculer branches (Continuation of the lleo-colic a.).
c. Anterior caecal & posterior caecal branches to the caecum. ileocolic, while those arising
d. Ascending branches enastomose with the descending from Lt. side: which are
a e Rt. colic
•
ranc es inc u e
jejunal & ileal branches are
• Descending branches anastomose with ascending branch of kept: to avoid ischemia of
ileocolic. jejunum & ileum
• Ascen_ding bra~ches enastomose with the Rt. branches of
I fe I 8.
5.
renc es inc u e
• Rt. branch anastomoses with ascending branches of Rt.
colic.
• Lt. Branch anastomoses with ascending branches of
'--" superior Lt. Colic artery.

INFERIOR MESENTERIC ARTERY

➔ Arise from the front of abdominal aorta at the level of lower border of L3.
➔ It supplies the hindgut from lateral ½ of the transverse colon to the
upper 1/2 of the anal canal

..__,
BRANCHE9
I. LER COLIC ARTERY
.._., Its branches include ➔
a- Ascending branches anastomose with the Lt. Branches of the
middle colic.
....___,. b- Oescendin!l branches anastomose with sigmoid branches
2. 91GMOID 8RANCHE9
3. SUPERIOR RECTAL ARTERY
It supplies the rectum & upper 1/!2 of anal canal.
it is a continuation of the inferior mesenteric artery &
anastomoses with the middle & inferior rectal arteries
..__...
 Sure/-fro-t,: Sur0i~I k-11-ro~'I 'Pp../q~ I 4-b

INFERIOR VENA CAVA APPLIED ANATOMY

BEOIN9
• At the lower border of L5 by union of the 2 common iliac veins behind
the Rt. common iliac artery
COURQE
If ascends on the right side of the abdominal aorta.
If is closely related to the Rf. sympathetic trunk
END
If pierces the central tendon of the diaphragm to open info the right
atrium.
TRIBUTARIEQ
The 3 tributaries of origin are The 2 common iliac veins & Median sacral vein
➔ Others:
1. Phrenic vein.
2. Hepatic veins.
3. Rf. suprarenal vein.
4. Renal vein.
5. Rt. gonadal vein. (Testicular or ovarian)
8. Pairs of lumbar veins

PORTAL VEIN
➔ Formed by union of 9UPERIOR ME9ENTERIC VEIN & 9PLENIC VEIN
Normall'J pressure in
SIJstemic veins is
lower than portal vein
behind neck of pancreas
jCOUR9E
It begins in front of the IVC. PORTAL PRE99UR
It ascends behind 1st part of the duodenum. If increases it leads to
....__,,
It ascends in the free margin of the hepato- PORTAL HTN.
duodenal ligament (lesser omentum) behind CBD to
the right & the proper hepatic artery to the left.
• It ends at the Porte hepatis
Right ■ nd leh hopalic voina
draining into inferior vena cava
LENGTH
3 Inches
DIAMETER
0.8 -1.2 cm
PRE99URE
• 10 - 20 cm H~O
• (7 - 11 mmHg)

Splenic vein

Superior metenleric vein .,,/ Inferior mnenteric vein

DIRECT TRIBUTARIE9
• Lt. and Rt. gastric veins.
• 9mall pancreatic & duodenal veins.
• Para-umbilical veins into le~ branch of portal vein.
• 9plenic v.
■ 9MV.
• Cystic vein
'--'
'--

Surc/-fOOn~: Sur0iual N,t-afo~'f 'P/>,/qf; I 4-1

THE SCROTUM
• Pouch in which lie the testes and their coverings •
APPLIED ANATOMY
• Common
THE 9CROTUM
site for
• The skin of the scrotum is thin, pigmented and sebaceous cysts
marked by a longitudinal median raphe. • NOT site of lipoma
• It is rich with sebaceous glands • The lax tissues of the
• The subcutaneous tissue contains no fat but does scrotum and its
contain the involuntary dartos muscle dependent position cause
it to fill readily with
oedema fluid in cardiac or
renal failure. Such a
condition must be
carefully differentiated

'-'

'-'
1s1z1:
THETESTIS from extravasation or
from a scrotal swelling

Testis is an ovoid structure 4 - 6 cm in length & !2.6 - 3.6

cm in width
j9HAPE
It is oval in shape, having !2 borders (anterior & posterior),
...._, !2 ends (upper & lower) & 2 surfaces (lateral & medial).
IRELATION9
Its posterior border Is related to
Epididymis: laterally
- Vas deferens: medially
ICOVERING8 OF THE Tl:9Tl9
1. 9kin
2. Dartos muscle
3. Colle's fascia
4. External spermaflc fascia
6. Cremasteric muscle & fascia
6. Infernal spermatic fascia
7. Tunica vaginalis (parietal & visceral layers)
8. Tunica albuginea (fibrous capsule)

o.,, tos. tl''luscfe •n

Sc, OIJI !tl..1n
!»UPerf,cuJI hl~C.HJ
e .. 1crnttl <.,pormollc
Crcn,.i,.tor mu>,CI(• ,n f J~CU.1
crcrnnstcrec fa-s.c,d
P,HIQli)I lntcrnJI sporma toc
l,1m111a of tho ta :.,.c,o
....,,. tun,ca vog,nah~ V,scoral lam,na of
1he """ca vug,nat,i,.
Tun,c-t albu9,noo
Lobule-. of thP.
S01>h.1la tC5'llb IOS IIS

Ep1d1dy1nu;

.__, To-.1,culJr anerv

Areerv o f the v,,..,
doforcnt-
 ?l,U'""e/-fOCM~: St,u-ef~"I Antfo~'i 'PN:,f; I '1-8
STRUCTURE APPLIED ANATOMY
The testis is covered by thick fibrous layer
(tunica albuginea), which is thickened
posteriorly to form the medlastlnum testis.
• It sends septa that divide the testis into 400
spaces. each contains 2-4 semineforous tubules
which are 80 cm in length.
The semine½'erous tubules open into rete testis
in the mediastinum testis.
• The refe testis forms the vasa eff'erentia (16-
20). '--
• The semine½'erous tubules are surrounded by
vascular connective tissue contains leydig cells
that secrete testosterone

Testicular ARTERY OF VA9

artery - --1--#Jl. .fl.. It may be efficient to
maintain the testicular
viability when the
testicular artery is divided.

Epididymis

11
,■1a~c,
Tunica
vaginalis

Testis One of the theories

explaining occurrence
of varicocele much
more on the left side
BLOOD 9UPPLY
0 ARTERIAL 9UPPLY
1- Testicular artery
(From the Aorta) LYMPH DRAINAGE
2- Artery to vas - No radical
(From inferior vesical artery) orchiectomy because
0 VENOU8 DRAINAGE Para-aortic L.Ns ..._,
1- Testicular veins "From removal has high
pampiniform plexus" morbidity & mortality
- Rt. testicular vein ➔ directly to IVC. - In cancer we do high
- Lt. testicular vein ➔ left renal vein inguinal simple
2- Cremasteric veins orchiectomy to avoid
3- Vein of vas ends in the internal iliac vein. spread of malignant
4- Vein of the gubernaculum cells to inguinal L.Ns
via scrotal incision
LYMPH DRAINAGE - 9eminoma may
0 Testis ➔ Para-aortic LNs infiltrate the inguinal
0 The scrotum ➔ inguinal LNs LNs in case of scrotal
infiltration

'----"
 Sur6i-fOOn~: Sure1·u.t Avttfo~'f 'PA/qf; I 41
APPLIED
SPERMATIC CORD
CONTENT9
llro-inguinal nerve is a
3 ARTERIE9 3 NERVE9 3 9TRUCTURE9
content of the inguinal
\....., 1. Testicular 1. Genital branch of I. Pampinlform plexus.
canal and NOT the
2. Cremasterlc Genito-femoral n. 2. Vas deferens.
3. Artery of 2. 9ympathetlc ne. 3. Obliterated processus spermatic cord
'-- vae. around testicular a. vaginalis (Vestige)
3. 9ympathetlc ns.
'-- around artaru of vas.

\......, COVERING9
• External spermatlc fascia ➔ from external oblique.
'--'
• Cremasteric muscles ➔ from internal oblique & transversus abdomlnls.
• Internal spermatic fascia ➔ from fascia transversalis

Testicular artery.
pamp,niform plexus
and sympathetics _ _
'-

......,
llto-ingu,nal nerve _ 0

Cremastenc nerve
and vessels ___ _ External spermatic fascia

9ITE
URINARY BLADDER
0 AT BIRTH: It lies In the abdominal cavity (Pelviabdominal organ)
0 IN ADULT: It occupies the anterior part of the pelvis (Pelvic organ),
when it is full it expand upward Into the abdominal cavity

4 ANOLE9
0 APEX ➔ Attached to median umbilical
ligament.
0 NECK ➔ Lying on prostate (d') or
pelvic fascia ( ~ ). it gives the urethra,
9urrounded by smooth muscle fibers
'- constituting the sphincter vesioae
0 2 P09TER0-9UPERIOR ANGLE9 ➔
Receiving the 2 ureters

PERITONEAL COVERING
0Male ➔ 9uperior surface & upper of base
0Female ➔ 9uperior surface ONLY

.....

.._
 ?l,ffe·-,00n~: 5ure·cA.1 Avt-AfoW''I 'PN:,f; I 6"0 .._

RELATIONS APPLIED
0 ANTERIOR
• Male: puboprostatic ligament.
• Female: pubovesical ligament.
0 INFEROLATERAL 9URFACE
• Pubis, retropubic fat, obturator internus & levator ani
muscles
0 9UPERIOR 9URFACE
• Male: Coils of ileum & pelvic colon.
• Female: The uterus & retrovesical pouch
0 PO9TERIOR SURFACE
'--
• Male: 2 seminal vesicles, 2 vase defferentia & rectum.
• Female: Cervix & vagina

RIGONE CHARACTER
CAVITY OF THE BLADDER - Rich in blood supply ➔
0 TRIGONE 90 stone ➔ Hematuria
.........
• Triangular part of the base between the 2 openings of the - No submucosa ➔ No
ureter & the opening of the urethra bilharziasis ➔ No
• Characters:
Egyptian cancer
I. No rugae
2. Pink (rich blood supply)
3. No submucosa
4. It is richly supplied by nerves
0 URETERIC ORIFICE9
• They lie at the posterolateral angles of the trigone
• The 2 orifices are ,;eps r..;.:id from each other by a transverse
ridge called the interureteric crest
0 UVULA OF THE BLADDER UVULA OF THE BLADDE
• It is produced by the median lobe of the prostate In old age, the uvula
0 INTERNAL URETHRAL ORIFICE enlarges leading to
• It is placed at the lowest pert of the bladder. difficulty to pass urine
• It is surrounded by en involuntary non-striated muscle
forming the sphincter vesicae ·
0 INTRAMURAL PART OF THE URETER
• The lowermost part of the ureter pas.s es obliquely through the INTRAMURAL PART
wall of the bladder: this part is called the intramural part Its oblique course is a
factor in preventing
regurgitation of urine
BLOOD 9UPPLY into ureter when the
0 VE9ICAL ARTRIE9 ➔ From internal iliac a. bladder is distended
0 VE9ICAL VEIN9 ➔ Internal iliac vein

LYMPH DRAINAGE
0 Perivesical LN ➔ Internal & External iliac LNs ➔
Common iliac LNs ➔ para-aortic LNs

NERVE 8UPPLY
0 SYMPATHETIC: Til, 12 & Ll, 2 (inhibitory to the wall &
motor to the sphincter) .
0 PARASYMPATHETIC: 92,3,4 (motor to the wall &
inhibitory to the sphincter). '--'

..___,,
 URGl-
0
I I
I
I
I

M1cflttt1 el $11t t?fwMrt1 t

- Atit alta a IIII Bitlf
MBB.C

-
 Surc/-fOOvt~: Sure,iull Avttfo~'I 'f'Nq~ I 5"2-
,.._,,
MIJSCLES OF THE SHOULDER APPLIED ANATOMY
PECTOR.ltL)_S MAJOR

• ORIGIN:
PECTORALIS MAJOR • Is absent In Poland $.
• In radical mastectomy (RM)
.J

- Clavicular head: medial 1/2 of front of the clavicle we remove the sterno-costel
'--
- 9ternocostal head: heed but we preserve the
Ant. 9urface of the sternum, Upper 6 costo-.condral junction, clevicular heed (to protect the
-...J
External oblique aponeurosis. cephalic v. & prevent
• IN9ERTION: Lateral lip of the bicipital groove of the humerus lnfrecleviculer hollowness)
• NERVE 9UPPLY: Medial and lateral pectoral nerves • In modified RM only the
• ACTION: pectoral fascia is removed
- Whole muscle: Adducts and rotates the arm medially. while the ms. Is preserved.
- Cleviculer head: Flexes the extended arm.
- 9ternocostal head: Extends the flexed arm.
'-'
PECTORALl9 MINOR

PECTORALIS MINOR • It divides the axillary artery Into ...__,,

3 perts.
• It divides the axillary lymph
• ORIGIN: 3rd.4th & 6th ribs nodes to 3 groups
• IN9ERTION: Coracolds process of scapula • It is removed in RM to open the
• NERVE 9UPPLY: Medial pectoral nerves e:xille (The door to the axille)
• ACTION: Protraction (Draws the scapula forwards) • It is retracted or cut for
clearance of the e:xille in '-.../

modified RM

• ORIGIN:
DELTOID 1•H•Ml•1
Injury of axillary nerve
I-Ant. border of let. 1/2 of clavicle, causes paralysis of deltoid
2-Lat. border of acromion ms. (Manifested by: flat
3- Crest of the spine of the scapula. shoulder deformity &
• INSERTION: Deltoid tuberosity of the humerus. failure of abduction from
• NERVE 9UPPLY: Axillary n. (circumflex n.) 15 -90) & loss of
• ACTION: sensation over lower 1/2 of
• Ant. fibers: Flex. & med. rotation of srm deltoid ms.
• Post. fibers: Ext. end let. rotation of arm.
• Middle fibres: Abduction of arm from 16° to 90".

'-.../

• ORIGIN:
IATISSIMUS DORSI ''1■®
1-Lower 8 thoracic spines. During mastectomy we
2- Lumbar fascia preserve nerve to
3-Post. pert of iliac crest. letissmus dorsi to use
the ms. es a
4-Lower 3-4 ribs.
myocutaneous flap
4-lnf. Angle of scapula
• INOERTION: Acor of bicipital groove of the humerus.
• NERVE OUPPLY: N. to latissmus dcrsi (Thoraco-dorsal nerve)
• ACTION: ,.._,,
- Extension, adduction & medial rotation of the arm.
- Used in climbing and swimming

..._,,.
...__.,

\......,
?l,ffe/-IOC\lt':>: s<.,w-e/ual A1'1t-rot,,.,\'I v~~ 1 517
MUSCLESOFTHEFOREMM APPLIED ANATOMY

-
A.SUPERFICIAL GROUP
Pronator teres
- Flexor carpi radialls
- Palmaris longus
- Flexor digit. Superficialis
- Flexot carpi ulnaris
Arise by a common tendon from the front
of medial epicondyle of humerus
(common flexor origin CFO)
They are flexots of the elbow + the name
Supplied by median n. except f1exor carpi
ulnaris by ulnar n. PRONATOR TERE
Median nerve may be
compressed bet. the iwo
heads of Pronator Tares

\....,
PRONATOR TERES: FO
(By post-traumatic
fibrosis I

• onoid process
ulnar
ator tu erosity o t e Mtd,11 cuteneouo
8 n&rve or forearm
\...., n n. passes eiween it's
Sup1nato,
Superf,cial radio! Common flC'!>cOt ongin
nerve
Extensor carpi

FLEXOR CARPI RADIALIS: radial11 longus

Pron.ator to_ro1 deep
ond ouperf,c11I heads
UlnarnON6
Ulnar ortttV
Anterior intorMSOOu•
branch of
~di•n nerve Flexor d1gi1orum
profundus
'--'
Flexor carp. ufn1n•

PAI.MARIS LONGUS : (MAYIEABSEHT) Flexorpolllcislongua

Doraal branch of
ulnar nerve
CF

......,.

'---' FLEXOR DIGrr. SUPERFICIALIS:

l)Humero-u nar ea : CFO & coronoi

......,.

FLEXOR CARPI ULNARIS: FO

'-' one.
 Sur-0i-1DCtt~: Sure/cAI Al,1~:roWt'I 'Pf,.b,f; I 5"4-

I.DEEP GROUP
- Flexor pollicis longus
APPLl£D ANATOMY
- Flexor digitorum profundus s.../

- Pronator quadratus

FLEXOR POLLICIS
LONGUS:
Origin
--:-:---::--,::---:---:---,----,------~---=---:---:---,
Upper '1./3 of the anterior surface of the radius
Insertion Base of the terminal phalanx of the thumb
Nerve Supply Anterior lnteroeeeus nerve
Action (1) Flexion of ell joints of the thumb
!2 flexion of wrist

__,/

FLEXOR DIGrrORUM .J

PROFUNDUS: Upper '1./3 of the ent. & medial surface of the ulna
4 tendons into terminal phalanges of med. 4 fingers

Medial V!2 by ulnar N. & lateral 1/!2 by median n.

1-Flexion of elbow !2-flexion & abduction of wrist

PRONATOR QUADRATUS:
Origin Lower 1/4 of anterior surface of the ulna
Insertion Lower 1/4 of anterior surface of the radius
~~ve Supply Median n.
Action Pronetion
._,,

-su,g- fOC¼~: Surc/u.1 M~foM'f 1'~17 I 6l3"

MUSCLES OF THE BACK OF REARM APPLIED ANATOMY
\..../

\....., A.SUPERFICIAL GROUP ARRANGED FROM

LATERAL TO MEDIAL AQ
.._,.. FOLLOW9:
- Brachioradialis
racond lar rid e of Hum. - Ext. carpi radialis longus
ess of the radius - Extensor carpi radialis brevis
- Extensor digitorum
1-lnltiates pronation & suplnatlon - Extensor digiti minimi
!Z-Rexes mid rone forarm - Extensor carpi ulnaris
\.....I - Anconeus

\._,,

\.....,,
Extension & radial deviation of the wrist
\.....,,
EXTENSOR CARPI RADIALIS
------ BREVIS,---
: ----,---- - ---, Front of the let. epicondyle (common extensor
orl in C.O.E)}
Base of the3rd metaoar al bone
Posterior interosseous n.
Extension & radial deviation of the wrist

EXTENSOR DIGR'ORUM:
Origin C.E.O
_.::-_I nse_rtion 4 tendons into extensor exnansion of med. 4 fingers
_ _Nei:.v_e__ !}_uppJy _ Posterior interosseous n.
Action I-Extension of wrist
--- -- --··-- - · - - !Z-Extension of medial 4 flngera

EXTENSOR DIGR'I MINIMI:

- - C>_!igi_ri__ __ C.E.O
__Insertion Extensor exnansion of the little finii.er
~ply Posterior intero88eous n.
'--' ,_ ..!'ct.~on Extension of the little finger

.
EXTENSOR CARPI ULNARIS:
Or_igil'l___ . __ C.E.O l!Z) Posterior border of the ulna
lnserf~!:_l_.__ ase of the 6th metacarpal bone
Nerve 9__upp.!y~ osterlor interosseous n.
- ~ct ion ___ Extension & ulnar deviation of the wrist

ANCONEUS: --
Ba
-...,
ck =---
of-::-:
th:-e-:-
la-te_r_e:-
1e_ i_
co_n_d-:-:--le- of
-=--=
th:-e- h
=-u- m
- eru
- s'
r 1/4 of the ost. border of the ulna

Extension of the elbow

 Sur0i-f00vt~: Sure/e,al AvttfoM'J -P,¾~ I 61?
...../

I. DEEP GROUP
6 muscles all supplied by Posterior lnterosseous nerve
APPLIED ANATOMY
- 1.9upinator
- !2.Abductor pollicis longus
- 3. Extensor pollicis brevis
- 4.Extensor pollicis longus
- 6.Extensor indicis

SUPINATOR: 9u inator fossa of the ulna.

Posterior surface of the radius.
9u ination of extended forearm

ABDUCTOR POLLICIS LONGUS:

Posterior surface of radius, ulna & lnterosseous membrane
Lateral base of the 1st metacar al bone
Abduction of the thumb

EXTENSOR POLLICIS BREVIS:

Posterior surface of radius & lnterosseous membrane
Base of the roximal halanx of the thumb.

EXTENSOR POLLICIS LONGUS:

-
£.c.teiNOr °'9-tOfUffl

Posterior surface of ..:~~a & interosseous membrane

Base of the terminal halanx of the thumb.
.......,._
Extension of ell ·olnte of the thumb

EXTENSOR INDICIS:
~~.--
&ttMo,.,........, ~
.,__,,
a.wn..-ol,liiopcta\UIIOI,_ tbl o....l ~ • -

MUSCLES OFTIIE HAND

~1 ~~!cl~ [
1
Origin I .l11serti
L on -~ - -
l . _- :,Actio!)
-
, These include:
.
tl!-_~-::r.. - "'-- - _____
' .
flexor
.
proximal Extends IPJ
I
Lateral group (4 muscles):
3 Tihenar muscles (Abduotor pollicis
digItorum phalanx brevis, Flexor pollicis brevis, &
profundus Opponens pollicis)
Extensor + I muscle deep to them (Adductor
lnterossei Metacarpa 1 Extension IPJ
bones expans on Palmer ➔ adduction of polllci&).
IPJ (Ped) Medial group 14 mu&clea):
Dorsal ➔ abduction of 3 hypothenar mu&cle& (Abductor
IPF Dab digiti minimi, flexor digHl minimi
um r1ca s + nterossei Writing osition & opponens digiti minimi)
Aexion In MP Joint + Extension Of IP Joint + 1 muscle superficial to them
Nerve Supply: .... (Palmarls brevis).
The Ulnar nerve supplies all the intrinsic muscles of the hand Central:
except the 3 muscles of thenar eminence + lumbrioals 1 & 2 4 lumbrioals
(Supplied by median nerve). 4 palmer interossei
4 dor&al interossei .....,,
..__,.

Sure·-,O<:M~: Sure"u.l .Altt~:totM'/ f,¼~ I 51

THE cu1rrAL FOSSA APPLIED ANATOMY

Boundaries: Floor:
@.!l:@li•t-·W·!
One of its contents is
Base "Above": an im&Jlinary line
1. Brachiafis ms. Median cubital vein, this
passing bet. the 2 epicondyles of
2 . 9upinator ms. vein Used for I.V injection
the humerus.
- Laterally: the brachioradialis muscle
- Medially: the pronator teres muscle.
- Apex : Meeting of lat. & med.
Borders. Ulnar nerve
\._,
Brachia! anery

Median nerve
Radial nerve
Biceps tendon Common flexor
origin

Bicipital
aponeurosis

Brachioradialis Pronator teres

\.._.,,
Ulnar anery
Radial artery

FLEXOR RETINACULUM A1xor rehnlCUlum

lroofl11gc:.rptl 1unneO
Ulnar 1nery
end nerve
9ite: Thick fibrous band stretches distal to wrist joint
Then,r muacles Hypolhtner
Attachments: muaclH
'- - Medially: Attached to pisiform bone & hook of hamate f ltxor cirpl,_,,,._~:'.;:S~~:::;':::~::.>-::'-. "'..:""
::;-.ll,_:
,-.,.:.-\--r-+
-:_ - M1di1n nerve
r,d11h1
- Laterally: Tubercle of scaphoid bone & crest of trapezium _l..J,;i,'l'.'Q~~K~"'C)('5;~!-).£.\L~L F1uor dlgilorum
\.._.., Flexor pollicis 1uperflcialls end
8uperficial to it: " 2 ulnar & 2 palmar" longus profundu1
I. Ulnar n. 2.Ulnar vs. 3. tendon of Palmaris longus ms. Trapei,um H1m11e
4.Palmar cutaneous branch of ulnar & median nerves Trepezo,d _ _ _ _T"
Deep to it: " The carpal tunnel containing" Cap,1111 _ _ _ _ _ _ _..,.
- Flexor digiterum superflcialis
- Flexor digitorum profundus tendon
-
-
Flexor pollicis longus tendon
Flexor carpi radielis tendon & it's synovial sheath
(special canal)
- Median n.
j:··~•rw.1·1e
In carpal tunnel
syndrome sensation in is
- Ulnar bursa (Encloses tendons of superflcialis & profundus) preserved over palm as
- Radial bursa (Encloses tendon of flexor pollicis longus)
palmar cutaneous branch
._,- of median 11. passes
Flexor carpi radialis Palmaris longus superficial to flexor
Rad,al anery Aexor d ,gitorum retinaculum
superficialis
Median nerve Flexor carpi ulnaris

Ulnar anery
and nerve
Aexor retinaculum
\.....,-
Thenar muscles

Hypo1henar muscles
Recunent motor
branch of
median nerve

........
 'Surc/-f<XM~: Sure·t'.AI MifoW\'I 'PN,~ I 6"8

SPACES OF THE HAND APPLIED ANATOMY -.../

- Incision should be deepened

PULP SPACE
- It is a subcutaneous compartment related to palmer
to divlde all septa
- Osteomyelitis affects distal
phalanx except epiphysis
'--'
surface of distal phalanx giving parrot peak deformity
- Divided Into locull filled with fat by fibrous septa
extending from the skin to perioste um (content)
- Contains also digltal artery which gives epiphyseal
branch before entering the space.
I •
_.__ I ._
-.../
8,1nc.h to base 1 .......___,,,__ BranehH 10 •hall
of diSIBI phalan•- ::;=:::;;;~~ - - - ; -, of doltal phalan•
tr1verijng the
01g11at •rtery pulp •~ce

DEEP MID- PAI.MAR SPACE '--'

- ANTERIOR: ....._,,,
Flexor tendon of the medial 3 fingers & ulnar bursa.
- POSTERIOR:
Fascia covering the lnterosael & 3rd, 4th & 6th metacarpals.
- LATERAL:
Fibrous band from palmer aponeuroais to 3rd metacarpal.
- DISTALLY:
3 lumbrical canals to the medial 3 webs.
- MEDIALLY:
Separated from hypothenar muscles by medial palmer septum. ®#:i1:t4Hs
When infected,
infection spread to
WEBSPACE THENAR the mid-palmer &
thenar spaces.
'-"

- Triangular region bet. Dorsal & SPACE

ventral skin present at bases of
- ANTERIOR: thenar
fingers
muscle, radial bursa,
- Communicate with mid-palmer &
end flexor pollicis
thenar spaces.
longus.
- POOTERIOR: adductor
pollicis & 2nd & 3rd
metacarpals.
- MEDIALLY: deep mid
palmer space
- DISTALLY: extends to
web of the thumb. ..__,

Mid-palmor
spoce '-'
._,
5urt:;"-f00vl~: 5urci~1 Altttfo~'j 'PN:f; I rscJ

SYNOVIAL SHEATH APPLIEDANATOMY

"DILATED CUL-DE-9AC"
SYNOVIAL SHEATII OF MIDDLE 3 FINGERS: Is the Bite of Incision in
- Each frnget of these has a sepatate synovial sheath infection
- Proximal end: At level of metacatpo-phalangeal joint "dilated cul-de-sac"
- Distal end: At base of distal phalanx
- Encloses the flexot tendons

\....,
RADIAL BURSA
- 9mallet
- DISTALLY connected with synovial
sheath of the thumb
- PROXIMALLY ruM below the flexor
tetinaculum; extends 1" in foreatm
- ENVELOP8 the tendon of flexot
pollicis longus
- CONTINUE with synovial sheath of
the thumb
\.._,,
ULNARBURSA
- Latget
- 019TALLY connected with synovial sheath of the litt e frn e
- PROXIMALLY tuns below the flexot tetinaculum; extends 1"
in foreatm
- ENVELOP8 flexor tendons of medial 4 fingers
- CONTINUE with synovial sheath of the little finget

ANA8TOM081:8
AROUND SCAPULA
19T PART OF THE 9UBCLAVIAN ARTERY:
Both arise from thyro-cervical trunk.
- Supra-scapular artery.
- Deep branches of transverse cervical artery.
3RD PART OF THE AXILLARY ARTERY:
- Sub-scapular artery.
- Circumflex scapular arter'd
........ (branch from sub-scapular artery) .

.,_,.

...._,.
 Surc;/~I Ntti-roM'/ 'PA(q~ I foO

APPLIED ANATOMY
BRACHIAL PLEXUS BRACHIAL PLEXUS
-.....,I

ROOTS: DIVISIONS Injury (see neurosurgery

Each trunk divides into book. P. 150)
cs, cs, anterior & posterior divisions
C7, C8, Tl

TRUNKS CORDS
~ Union of Lateral: Union of anterior divisions of
C5&C8 upper & middle trunks (C5, CS, C7)
Middle: C7 ONLY Medial: Anterior division of lower trunk
Lower: Union of Posterior: Union of posterior divisions of -.....,
ca &Tt the 3 trunks.
'-./

BRANCHESOF "-.../

BRACHIAL PLEXUS:
A. Roots: C6
1) N. to rhomboids (C5)
2) N. to serratus ant. (C5,C8,C7)
cs Mu"uloc.utanoou,
8. Upper trunk branches: nerve
~ ~- - La1oral root of
1) 9uprascapular n. (C5,C8) median norv•
C7 ,-\--\-_ _ Ax11l,11ry norva
2) N. to subclavius (C5,C8) _ _ _,. Radial n<1rvo
C.Branches of lateral cord: Meehan norve
C8
I) Lat. pectoral n.
-.....,
2) Musculocutaneous n.
Tl
3) Lat. root of median n.
O. Branches of medial cord:
1) Med. pectoral n. Roo11

2) Med. cutaneous n. of arm Upper1;;:~:~u~~ Lateral, PC>$14rior and

modlal cord!I
3) Med. cutaneous n. of forearm Antorior and
ooator·ior d1v11iona
4) Ulnar n.
5) Med. root of median n. Norvo to cs
rhomboids
E. Branches of posterior cord: (ULN
1) Upper subscapular n. Supraacepulor Phrenic norvo
oorvo
2) Lower subscapular n.
3) N. to latissimus dorsi
' -- - - J!W'-- - Nerve to subclevius ___.,.
Norvo to serrnrus
anterior
.__,,

Muaculocuton&0us
norve -.....,

C8 ..___,,
Redial norvo - -- - i4---,.r Nerve to loticsimus
dorsi hhornc;odorsal
Axillary ~ .;,...._,,."-4- - - -- norvo) botwoon 2 ......,
nerve subscopular norvos

Mod,ar, Mrva Tl
1st intorcostal
Modial poctoral
norvo
Modinl cutenoous
nerve of arm
' - - - - - - - - Medial cutaneous
nerve ol forearm
 5urtji-fOCM~: 5ureiu1 k'\tfo~'f 'P~~ I bl
I RADIAL NERVE I APPLIED ANATOMY
COURSE &RELATIONS
- In Axilla: Arisea from poaierior cord (C6,6,7,8,T1 ) behind 3rd part of
axillary a .
- In Arm: It pierces the lateral inter-muscu lar septum to enter the anterior
compartmen t on lateral side of arm
........ - In Forearm: It plercea aupinator ms. through Posterior interosseou s n .
- At wrist: The nerve winds around lateral side of radius to reach the back
of the hand crossing over the anatomical snuff box & superficial to
extensor retineculum

I ULNAR NERVEI
\.....,

.._,,
COURSE &RELATIONS
- In Axllle: Arlaes from medial cord of brachia! plexus (C7,8,T1)
between 3rd pert of axillary a. & axillary v. It deacends
medial to exilleNJ a.
- In Arm: Till the Insertion of corecobrach ialis where it deviates
medially & downwards to pierce the medial infer-muscu lar
septum, to reach posterior compartmen t of the arm
- In Forearm: It passes between 2 heads of flexor carpi ulnaris
& flexor digitorum profundus.
- At wrist: Continues downwards superficial to flexor
retineculum. ,(
,j' - - - - - - Radial nerve
,,
•1?
I MEDIAN NERVE! I
,

COURSE &RELATIONS
- In Axilla: Arises from medial & lateral cord of brachia(
._ plexus (C5,8,7,8,TI). It passes lateral to axillary a .
- In Arm: It crosses in front of braohial a. from lateral to
medial. It lies medial to biceps, anterior to brachialis &
triceps.
I
- In Forearm: It leaves the cubital fossa by passing 1 - - - - - - - Ulnar nerve
between 2 heads of pronator tares.
- At wrist: The nerve enters the carpal t unnel immediately
under flexor retinaculum.

MOTOR&
.........
SENSORY SUPPLY Median nerve

See neurosurgery book

Surgical importance:
Nerve injury Ulnar nerve
::8ee neurosurgery book::
P. 140 "Radial nerve injury "
P. 144 "Ulnar & Median n. injury"
'-"

THEB
DEVELOPMENT
• A modified swest glsnd
• It arices from the milk
linea, which extends from
• Micromastla: abnormally small breast
the axillae to the groins.
• Macromastia: abnormally large breast
Only the middle part of the
• Polymastia: presence of accessory
upper third persists to form
the breast while the rest
breast(s) anywhere along the mammary
line
dissapears.
• Polyihelia: presence of aoce88ory
nlpple(s) anywhere
along the mammary line
SHAPE
► Hemispherical with its base
applied to the ant. chest wall
& it's apex at the nipple
► The nipple is directed
downwerd, forward and
lateral ,et the level of the
4th rib & devoid of fat
ARCHITEaURE
Of THE BREAST
A. EpHhellal element:
I.These are responsible for
milk secretion and transport.
2 .Each breast consists of
16-20 radially arranged lobes
separated by fibrous septa
3.Each lobe consists of 20-
40 lobule & each lobule
consists of 10-100 alveoli.
4.Each lobe ls drained by a
lactiferous duct, where ducts
converge at the nipple
B. Conneotlve tlaaue:
1. Rbrous tissue:
This Is celled cooper's
ligaments extending from the
pectoral fascia to the skin
2. Fatty tissue:
It's present between the
fibrous septa that gives the
female breast it's shape.
\..._,
Sure/~I AntfoM'j 'PNq~ I tot-
\.....,
APPLIED ANATOMY
NIPPLE DIRECTION
This direction is changed when
there is e pathological condition
CONGENfl'AL in the breast
ANOMALIES
l•l=WIJUl•lli4i
Not a site of lipoma
\.....,
RELATION TO MU9CLE
Must examine these muscles
........,
in determining the mobility of
breast swelling.
INTERC09TAL VEIN9
Drain into azygous (rt. side) and
EXTENT
• lies between the skin end the
hemi-ezygous (It. side) end
communicate with valveless
vertebral venous plexus, this
-..__/
pectoral fascia. explains axial skeleton deposits
• Apparently en adult female breast in cancer breast.
extends from the 2nd to the 8th rib
& from the lateral border of the
sternum to the anterior axillary line RADIAL LOBE9 ARRANGMEN ....
• It lies over the pectoralis major, 9o incision of draining a breast
serretua anterior and eponeurosis of abscess is made redial Incision _,,
external abdominal oblique muscle to avoid Injury of multiple ducts
• The actual extension of the breast Is
► Upwards: to the clavicle
► Downwards: to below the
DUCTS CONVERGANCE AT AREOLA
9o Incision must not reach the areola ..._,.
costal margin
► Medially: to the middle line
► Laterally: to the posterior COOPER'9 LIGAMENTS '--"
axillary line Any fibrosis affecting these
• The axillary tail (of spence): ligaments results in dimpling to '--
► Is a prolongation of the fhA Akin nf fhA hl'AAAf
parenchyma.
► It pleroas the deep fascia of
the exilla through e defect known
as foremen of longer at the level
of the third r,h
_,,
BLOOD SUPPLY OF THE BREAST
rA. Arierial supply:
1-The pectoral branch of the acromiothoraoic al"fery
2-Perforating branches from internal mammary a., ...._,
( Medial perforators) the 2nd, 3rd and 4th branches are
especially large to supply the medial side of the breast.
3-The lateral thoracic artery
4-Lateral branches from the posterior intercostal
.._./
al"feries (Lateral perforators)
B. Venous drainage:
The veins of the breast drains into
1. axillary v. 2.internal thoracic v.
3.intercostal v.
 St,.ffe/-f OOn,: Sl,ffe/t-41 AvtfJoM'f 'PN:,f; I b1J
\.J LYMPHATIC DRAINAGE APPLIED ANATOMY
• AXILLARY NODES:
These receives about 76% of breast lymph. They are average 35
ltU@Ul•1•1@
■ Its affection is used to
nodes.
I,...,
1-Anterior2-Posterior determine the prognosis
3 -Lateral 4-Central 5-
Aplcal GROUPS after mastectomy.
The posterior and lateral groups don't drain the breast ditecfly, ■ The first node to receive the
however they are potential alfes of breast cancer spread as they lymph intra-operative is
have alot of connections with the anterior group called "SENTINEL LYMPH
• INTERNAL MAMMARY NODES: NODE" and is excised and
They ate 3 or 4 lymph nodes. They receive part of the lymph s&nt to the pathologist to
from the medial aide of the breast. determine lymph node
• LYMPH NODEQ OF ROTTER: infiltration.
............ Few lymphatics pierce the pectoralis major ms. to teach lymph
nodes of Rotter then reaches the posterior intercostal veins.
• LYMPHATIC SPREAD:
✓ After lymph reaches either the Internal mammary or the
axillary nodes, If teaches the jugulosubclavian venous (if
obstruoted, lymph will pass retrograde to the
supraclavicular nodes)
✓ Lymph channels cross the diaphragm reaching the liver
lymphatics.
'--' ✓ Lymphatics from the lower inner quadrant pierce the
reotus sheath to reach peritoneal lymphatic plexus
❖ The axillary Lymph nodes may be classified into 3 levels:
L.Ns above the level of pecforalis minor: apical L.Ns
L.Ns deep to pecforalia minor: central L.Ns
L.Ns below the level of pecforalis minor: ant., post. and lateral L.Ns

'--'
..__,

'--' ,.. ;..\

I \
'-'-.._, J
........
____e' \ .,,,,
~ I
I 2
..._, -----
_____ _.
Internal
r mammary
,
- ,•,--
\,....,
3
'--- .,•.,
I nodes
I
.......,.
, .,
~

,.
'-./ I 4 , ..... ,
'\ _, .,. / I
I
, ,, "
'-'
I
'-'

'--"'

.......
'--

._,,

-----
 -

SURGI-
S -

......,. I
v
v I
I
I
'--'"
I
~

'- '
>--J~,
V -J I\

--
 Surgi-T00ns: Surgical Anatomy PAGE 166

FEMORAL ARTERY APPLIED ANATOMY

FEMORAL ARTER
....__

BEGINNING • Pulsation is felt at Midinguinal

• Continuation of external iliac artery point
- Weak FEMORAL pulse
• At midinguinal point
with normal RADIAL pulse ➔
• Behind the inguinal ligament Coarctation of Aorta
Midlin•
- Atherosclerosis➔
Weak or Abscent pulse
• Upper 1/2: 9uperficial in • Artery of DYE injection since
femoral 6. it's 9upetAciel in position
• lower 1/'l.: Deep in
subsartorial canal

\,------ - - Adductor hia1u1 in

END .ttdd uet or magnus

• By becoming popllteal artery Popliloal anerv

..J
• By passing through the opening
of adductor megnus ms.
• Between the upper 2/3 end
lower 1/3 of the thigh

BRANCHES •8uperfioiel external • Deep external pudendaI a. \.....,

pudenda! a. •Deep femoral a.
•8uperf1oial epigastric e. (profunda femoris e.) .......,
• 8uperf1oial circumflex •Descending genioular a.
iliac a.

POPLrrEAL ARTERY POPLITEAL ARTER

Is COMMONE8T site for
...._,,

Posterior Begins at the lower Anterior peripheral aneurysm -../

tibial A. border of popliteus ms. tibial A.

.___,.,
BEGINNING POSTERIOR ANTERIOR
TIBIAL A. TIBIAL
- A.
Continuation of femoral e. at . - -
- - ~

-~M
adductor hiatus g
terminal branches of
popliteal e.
COURSE
Descends as the deepest - ► Course: It escen sin ► Course: It eecen
structure in the popliteel magnu1
the poet.compartment
of leg, accompanied
fos&a over It's floor with poet. tibial n.,
between superficial &
END deep calf muscles
At the lower border of
popliteus ms. by dividing Into ; ,:;!~~::i.:.- Medial llllll lalernl p to exor
two terminal branches
1- Posterior tibial a.
.,_
-gerllOllaf um midway
medial
2- Anterior tibial a. & calcaneus
into lateral
lantar A.
ranc es:
BRANCHES 1. Muscular branches
• Muscular branches &nutrient artery of
tibia 2.
• 6 genicular branches 2. Circumflex fibular & 3.
peroneal arteries
3. Calcanean &medial 4.
malleolar arteries
6.
two terminal
branches of popliteal '--
a.
~
ant.compartment of
the leg, accompanied
with ant. tibial n.,
then on ant. surface
of the lower end of
tibia
e
een the 2
leoli by becoming ......,.
dorsalis pedis A.
ranc es:
Poet. And ant. tibial
recurrent arteries
Muscular branches
Ant. medial
melleolar artery
Ant. lateral
malleolar artery
Circumflex fibular
arter
 Surgi-T00n s: Surgical Anatomy PAGE 167

DORSALIS PEDIS ARTERY APPLIED ANATOMY

BEGINNING Perorwu.1• b,o..,.. DOR9ALl9 PED19 A.
As a direct continuation of Is absent in 16 % of people
anterior Tibial e. In front and the arterial supply of the
of ankle joint P•tior■tong branch dorsum of the foot is carried
of ptHon.•• •r1•rv .
COUR8E out by perforating br. of
• Runs on the dorsum of peroneal a.
the foot between the
tendon of ext. hellucls
\,,..., longus medially & ext.
dlgltorum longus laterally.
• Pierces the 1st dorsal
interosseous ms. to reach
.........., sole of foot
PitfCM"Mut term,a
BRANCHE8
• Medial & lateral tarsal
arteries.
• 1st dorsal metatarsal
artery.
• Arcuete artery (gives the
2nd, 3rd & 4th This anastomosis Is placed on the
metatarsal A.) back of the thigh a short distance
END below the gteater trochanter and
• In the sole by completing looks like a CN>88.
the planter arterial arch

-- ARTERIES OF THE SOLE

Jlr;Ua;@•R'4N~U141
• It's the larger brenc of the 2
terminal branches of the
posterior tibial e.
• Ends by forming the planter
arch
which ends by joining dorsalfs
pedis A.
At the 1st interosseous space.
• Branches ere muscular,
ol laleral planar
planter
metatarsal arteries & Med.
calcaneel a.
2-MEDIAL PLANTER A:
• It's the smaller of the 2
lfitthl
terminal branches of the
posterior tibial a.
• If runs along the
medial side of the sole.
It haa !2 hmbs: horizontal & vertical
o Upper deeoendlng limb ➔
Ouperior & Inferior gluteal
arteries.
o Lower ascending limb ➔ I"'
perforating artery.
o Medial horizontal limb ➔
transverae branches of
medial circumflex femoral
Plana,, artery.
melalarsal
arteries o Lateral horizontal limb ➔
franev81'88 branches of leterel
01<ectbtatldl olrcumflex femoral artery.
arta,y
i?iihfiiFIHd
....,11111rm•7
It connects internal iliac a.
Fig. 99.10: Plantar artenes and plantar 811enal arch with femoral a. 80, if
external iliac a. is
obstructed, internal iliac a.
can supply the thigh.

It's a relatively poor anastomosis between the following

arteries:
- Descending genlcular branch of femoral artery.
- Descending branch of the lateral circumflex femoral
artery.
- 6 genioular branches from poplitaal artery.
Anterior and posterior tlblal recurrent branches

- from the anterior tibial artery.

 Surgi-T00ns: Surt?ical Anatomv PAGE I 68
VENOUS SYSTEM OF THE LOWER LIMB APPLIED ANATOMY
f!ISt4i61Ni;W;
• Companion artery of Sciatic
•
Perforates the deep Nerve Should be ligated In
fascia muscular veins above knee amputation to
• Valves allows blood • Accompany the avoid bleeding
Long Short to pass from corresponding • All branches emerge from
saphenous saphenous superflcial to deep artery
med. side except nerve to
system • Often run es
paired venee short head of biceps so
• Perforators on the .___.
medial side of the commitants incision is done on the lat.
leg are 6,12, 18 cm below the knee side
above the sole of the "--'"
foot

Long saphenous I! 9hort saphenous

From medial part of the venous
arch
In front of the medial malleolus
In the medial side of the leg
Runs behind the medial border
of the tibia towards the knee,
lying a hand breadth behind the
medial border of the oatelle
It accompanies the saphenous
nerve In the leg
Joins the femoral vein at the
saphenous opening 4 cm below
& lateral to the oubic tubercle
From lateral part of the venous
arch
LONG 9APHENOU9 VEIN
Behind the lateral malleolus
- Used in CABG Operation
In the lateral side of the leg (as CORONARY GRAFT)
Pesses upwards In the - Most common site for
subcutaneous fat along the mldline venous cut-down
of the calf - Might be injured during
"Stripping Operation"
It accompanies the aural nerve ....,,.
Joins the popllteal vein In the .....,,,
middle of popliteal fossa

FACTOR9 THAT HELP VENOU9

I

RETURN FROM THE LOWER LIMB9

1. The muscle pump which needs strong muscles
and intact deep fascia
2.. Transmitted arterial pulsations to the venae
commitents
3. The unidirectional valves
4. The negative intrethoraolo pressure

THE 8KIN OF THE LOWER PART OF.THE Ankle

perfora1ors
LEO 18 DRAINED BY SPECIAL
PERFORATORQ WHICH ARE EITHER:
A. Indirect perforators
B. Direot perforators Medial plantar
~em

FEMORAL VEIN
■ Acoompanies femoral artery through opening in adductor magnus.
■ In the adduotor canal: saphenous nerve passes from latel'81 to
medial superficial to it.
■ PaBSes anterior to the upper attachment of the pectlneus musole APPLIED ANATOMY
'---'
ORIGIN
largest branch of sacral plexus
'--'

Surgi-T00ns: Surgical Anatomy PAGE I 69

........

S\lSMftOf Ql.lltHI nMt•

.,___,, COURSE GIVl~fflll\l!'TIUti

P1.t,to,m.1
Leaves the pelvis
...__ through greater sciatic ,~ ,.._ """"''
Otm,ret.ot lnt.,nu\

foremen below the

..._, piriformis & descends
in the gluteal region
IW1!f!:l~il:-ll'tf-- =tc:..~~,!....
'lhOrt 10 blC~ hHd
'-../
81(:U)t.femo,"

...___,,
END
By dividing into
- Lateral popliteal n.
-
Common.,.,.,,...1

- Medial popliteal n.

"$iii~). ~ \NI gful«I► m,1,,hu, h..b ~ rnTW-"" «I

«1111p.....,;y hkklm glutru,. ffllf\lrn~
to..,.,,
Otw,,ctkln o( th..t ltl.lllt non't: '" thtt •hlsh .anJ popht~l ffloiU (rtght
1hw ~ ! ' 4 t

~-----------~
Blood 8upply Branches
• Companion artery of • Museuler bl'Snches to:
sciatic nerve 1-Biceps femoris
IBr. Of inf. Gluteal a.I !2-8emimembreoosus
3-Bemlfeodlnosus
4-lsohiel pert of adductor megnus
• !2 termioal divisions

MUSCLES OF 11tE FRONT OF THE 11tlGH

- t,t•L' •J ,1 t3 ½iii W!t•j ,1 ~i!t1t1, ~ J
ORIGIN INSERTION
lf's formed of 4 heads: reotus Ba a common tendon into t he patella
---- femorls and 3 vasii:
1. RECTU9 FEMORl9: WWhJ1'1RRh
Femoral nerve
'---" • 9ttalght head: Anterior
Inferior iliac spine
ACTION
...__. • Renected head: Groove • The whole muscle ls !he main extensor
of the koee
above acetabulum
• The reotus femoris is also a powerful
..__,. 2. VA9TU9 LATERALl9: flexor of !he hip
• Lateral lip of the linea
aspra Rec1ua fomoria
.___. Vaatua medialia Vootua lat oroli•
3. VA9TU9 INTERMEDIU9: Serto,iue
• Upper 'l./3 of the Vaatua intormodiua
Saph onoua norvo
.._,. anterior and lateral Fomorol artery ond
vein and norvo
surface of the femur 10 vaatua modialis .....,,__~_.
...__, 4. VA9TU9 MEDIALl9: a.ophonou• voin
Groot

• Medial lip of the linea Adductor longua

Profunda fomoria
Grocili•
._, aspra
Short hood of
Adductor magnua bicopa fomoria
Scia t,c nervo
Somimombrttnoau• Long hoed of
bicep• femoria
Somilondinoaua
 FEMORAL TRIANGLETOOnsAPPLIEDANATOMYO '---
It is a sub-fascia! space occupying the front of the upper 1/3 of
the thigh just below the inguinal ligament
I. BOUNDARIES:
l..lta,tt w 11neou,
1-Base: Inguinal ligament n,ef'\ft o f l heOh
2 -Lateral:Medial border of sartorius FefflOtal ne,ve
3-Medial:Medial border of adductor longus At10,v
Vonl
4-Apex:Meefing of Sartorius & adductor longus c....,
Swmthc C04'd
II. FLOOR: =~~~,;?:r,,no
Composed of four muscles arranged from medial to lateral
1-Adductor longus S.,t O,tUS
2-Pectineus
3-Psoas major
4-lliacus
Ill. ROOF: FORMED OF:

Skin Deep fascia '-'

9upe1oial fascia
..._
containing Containing
,r-------1'-------...
Superficial
the
saphenous
--..,

Great Superficial .,__

Inguinal opening
saphenous inguinal
arteries

IV. CONTENTS:
vein L.Ns
-
-......,
I-Femoral Vein 2-Femoral artery 3-Femoral nerve
4-Femoral sheath 6-099p Inguinal L.Ns
..._,,

'-/

FEMORAL SHEATH DEFENITION

'--

_,
Funnel shaped fascia enclosing the
lnguinol lig:,mont
upper 4 om of femoral vessels '-
Antoroor 1uperior
iliacsp,no
FUNCTION l.a1orol cutoneou• ..._
nor,• or 1h,gh
Allows smooth gliding of the vessels
Faecio
lran5VOtHhl - -->t-......:>.,.w..:. "-
Femoral norvo
COMPARTMENTS Artory ' -.-J
LATERAL ➔ Femoral a. and Femoral P10Qatttndon
branch of genito-femoral nerve Pec1inou1
El<tnrnol ring '--
MIDDLE ➔ Femoral vein with 0mo1g1ng
,permotla cori.t
MEDIAL ➔ Femoral canal '--"

91ZE lAounM ltgomont '-./

4 cm Lateral & Pua1,noue
1 cm Medial '-'

-./

..__,
 Surgi-T00ns: Surgical Anatomy PAGE 171

APPLIED ANATOMY
POPLrrEAL FOSSA
BOUNDARIE9
POPLITEAL ARTER
COMMONEST site of
peripheral arterial
UPPER LATERAL Bice s femotis aneurysm
UPPER MEDIAL Qemitendinosus & 8emimembranosus muscles
LOWER LATERAL Lateral head of Gasfrocnemius & Plantaris muscles
LOWER MEDIAL Medial head of Gastrocnemius

ROOF FLOOR
• Qkin • Popliteal surface of femur
• Qupetficial fascia • Back of the capsule of the knee joint
• Popliteal fascia • Fascia covering the popliteus muscle
(Deep fascia of the roof)
• OKIN & QOFT TIQQUE ➔
Lipoma, Qebaceous cyst
CONTENTQ • VEIN ➔ Varicosities of short
.._, l• Lateral popliteal nerve saphenous vein
2. Medial popllteal nerve • ARTERY ➔ Poplfteal
..../ 3 . Popliteal artery aneur1ism
4. Popliteal vein • LYMPH NOOE ➔ ~ to foot
6. Termination of the posterior infection
"---
cutaneous nerve of the thigh • KNEE JOINT ➔ Qemi-
8. Popliteal l1imph nodes membrenousus, Baker's cyst
'--" • BONEQ➔ Tumor of lower
femur or upper tibia
SUPEROMEDIAL SUPEROLATERAL
Short head of
biceps femoris

Long head of
Semimembranosus biceps femoris
...__,, Semltendinosus

Medial head of Lateral head of

gastrocnemius gastrocnemius

INFEROMEDIAL INFEROLATERAL

Fig. 96.1: Boundaries of right popliteal fossa

...__,
Surgi-T00ns: Surgical Anatomy PAGE 172
M1cltt:1 el 8efw t:1t
- Atit SNlfts lllfiim-stt-r
M .8B a
 Surgi-T00ns: Surgical Anatomy PAGE 174
-..../

LYMPH NODES OF HEAD & NECK

1- Pharyngeal
(Adenoid)
1-9ubmental
2 -9ubmandibular
3-Preaurioular
• 9upetfioial to the
deep fascia
UPPER
.....
\>--_ __,,.......__ _...,.,

• Deep to the deep fascia

LOWER
.._,,

..,,
'\.....)
• Runs with external
2-Tubal tonsils 4-Postaurioular jugular vein. • Runs with internal jugular
3- Palatine tonsils 5-Ocoipital • Draining the parotid vein
4-Lingual tonsils and lower part of ear • Separated from each others
PhJr-vn.a~.tl by superior belly of
1on~H
omohyoid muscle

APPLIED ANATOMY

.__,
!)Middle part of lower lip
!2)Tip of the tongue
3 Floor of the mouth
9ubmandibuler region l)Upper lip
!2)Angle of the mouth
3)0uter pert of lower lip
4 8ide of the ton ue • Total lymph nodes of the
In fl'Ont of the tregus l)Outer surface of the pinna body are about 800 L.Ns,
!2 Side of the seal 300 of them are In the
l)Back of the pinna NECK.
!2 Tern oral re Ion of the seal • Most common cause of
l)Back of the scalp cervical L.N enlargement is
& occlput !2)Back of the neck T.B.
► THE DEEP CERVICAL GROUP HAQ !2 NAMED L.NQ: • The left supraclavicular L.N is
1. Jugulo-digastric➔drains the tonsil called "Virchow's Node"
!2. Jugulo-omohyoid- >dreins the tip of the fongue
'----
► THE EFFERENT FROM THE DEEP CERVICAL GOEQ TO:
I. Rt. side- >left jugular lymph
duct ➔ right lymph trunk.
1f1-1 1R;HBh1'4 1f;1;l
1 1

!2. Lt. side- >right jugular lymph Is of great surgical

duct ➔thoracic duct. importance as it enlarges
in visceral malignancy
"Troisier's sign"

AXILLARY LYMPH NODES

• The axilla is a pyramid with 4 walls, apex and a base.
• This pyramid is oblique so that the apex is directed upwards
and medially and is continuous with the cervicoaxillary canal. r..,_.,,....:..,.;~__.- AntanOf O,OUP .,,
'-'--"---'"-- Pect0t11h.1, mtnor
• The lymph nodes are arranged on the walls in 5 groups:
~ f-!l..,...:,"<..~~--c:;--- Po.tonor group
1.Anterior (pectoral) 2.Posterior (subscapular) '-1---1-- ~ ~'--- >.--~-- lateral group
3.Medial (central) 4.Lateral (humeral)
5.Apical (infraclavicular)
 Surgi-T0 0ns: Surgical Anatomy PAGE I 75
THE AXILLARY LYMPH NODEO MAY BE CLASSIFI ED INTO 3 LEVELO:
► LEVEL I ➔LNQ BELOW THE LEVEL OF PECTORAL19 MINOR: ANT. POQT. AND
LATERAL L.NQ
► LEVEL II ➔LN9 DEEP TO PECTORALIQ MINOR: CENTRAL L.NQ
► LEVEL Ill ➔L.NQ ABOVE THE LEVEL OF PECTORALIQ MINOR: APICAL
'\....., L.NQ

~ ::. . . GUINAL LYMPH NO

9uperficio l lo the
deep fascia of
lhe thigh

· · FIC rJ~ 1nr1•]1~r;, ! !~S1

SUPER I •J 33ii 1~r;, ! !~Sil
VERTICAL GROUP Around the upper part of the femoral vein
8ide of the upper Below and parallel io
part of saphenou s v. the inguinal ligament

LYMPH NODES OF TH_E ABDOMEN & PELVIS

1-JJ~11 ~ , J •
• lijing behind peritoneum and in
a,J ~~ ~ ~,J •
• lijing along the aide of
relation to large blood vessels visceral vessels.
• These are divided info: • These ere man\:l groups e.g:
1. External iliac nodes coeliao, gasttic, hepatic,
2. Infernal iliac nodes inferior meaenteric etc.
3. Common iliac nodes
4. 8aoral nodes
• V.para-aor tic nodes

.......
LYMPHNODESOFTHETHORAX
'-' • lijing in relation to the thoracic walls. • lijing in relation to thoracic viscera.
• These are divided info 4 groups: • The\j include:
1. Anterior (Infernal mammal'\! nodes) 1. 9uperior mediaatinal nodes
2. Posterior (Posterior mediasfinal nodes) 2. Peri-tracheo-bronchial nodes
3. lateral (lnterooatal nodes)
4 . Inferior (Diaphragmatic nodes)
.........

LYMPHNODESOFTHETONGUE
W!,,'Ii~ ~1 [•1 ~f,..J:W
APPLIED ANATOMY
llfiii
Submental
liiii
lpsilateral
-•PG .
submandibular 8ubmand1bular
il•Md•IIIM
lymphati cs pierce the floor
of the mouth fo reach
on both sides aubmental & submandibular
L.Ns BUT it's NOT affected
....., b\:l lijmphatic spread in
malignancy
......... (L.Ns are Involved by

• 0
• embolizetlon NOT permeation)
 Surgi-T00ns: Surgical Anatomy PAGE\ 76
.._/

LYMPHATIC DRAINAGE OF THE LIPS

_;
-
.._,,

Submandibular
Submental Submandibular

Watershed Lines:
► These are three lines
• 0 •
1. At the level of the clavicle
2. At the level of the umbilicus
3. Midline
APPLIED ANATOMY
ATERSHED LINE
• ABOVE THE CLAVICLE DRAIN9 IN CERVICAL L.N9
used surgically to assess
• BELOW THE UMBILICU9 DRAIN9 IN INGUINAL L.N9
, • IN BETWEEN DRAIN9 IN AXILLARY L.N9 the exposure area in
clinical examination : :we
expose till wateshed line
of L.Ns group examined

'-

'-

l nl8<01nory
Anaatomo...
- - - +--..a...--
'---'

A>llllO •
Inguinal
AnD■tomos•
SurQ1toons
Textbook of General surgery
Textbook of GIT surgery
-
Textbook of Special surgery
Surg1cal operat1ons
Surg1cal instruments
Surg1cal Rad1ology
-

..........