CLINICAL ANATOMY OF THE

THORAX
Dr. ARIHO SAMUEL BONA
(MBChB, MMED-SURGERY)
KABALE UNIVERSITY SCHOOL OF MEDICINE
MAR,2024
At the end of this session, the student should be able to:
⚫ Discuss briefly anatomical changes in thorax with ageing.
⚫ Describe needle and tube thoracostomy.
⚫ Identify indication of thoracotomy and structures encountered in
performing it.
⚫ Briefly describe the anatomy for intercostal nerve block. Mention its
possible complications.
⚫ Identify clinical application of diaphragm and pleural reflections.
⚫ Classify the congenital anomalies encountered in the ribs and
diaphragm.

2
Introduction: Lines of
orientation

3
Thoracic
wall

4
 VERTEBRAL LEVELS

⚫ Suprasternal notch: T2/3

⚫ Sternal angle (angle of Louis):

T4/5

⚫ Superior angle of scapula: T2

⚫ Inferior angle of scapula: T8

⚫ Xiphisternal joint: T9

⚫ Subcostal plane: lowest part of

costal
margin; L3 5
 Auscultatory sites of
heart
⚫ mitral valve (apex): 5th L ICS; 9cm from
midline; left MCL
⚫ tricuspid valve: 4th LICS; L lower sternal
border
⚫ aortic valve: 2nd RICS; R upper sternal
border
⚫ pulmonary valve: 2ndLICS; L upper
sternal border
⚫ Blood carries sound in the direction of its
flow
⚫ (reverberation due to changes in
direction of blood flow following
6
closure of valves)
 Anatomical changes with
age
⚫ Rib cage becomes more rigid
and inelastic.
⚫ Due to calcification and
ossification.
⚫ Kyphosis: also termed as
stooped appearance.
⚫ Increase in the sagittal
contour of thoracic spine.
⚫ Normal curve is about 20 to
40 degree.
7
⚫ Occurs due to degeneration
 Anatomical changes with
age
⚫ Disuse atrophy of thoracic .
and abdominal muscles.
⚫ Leads to poor respiratory
movements
⚫ Degeneration of elastic tissue in
lungs and bronchi leads to
altered movement in expiration.

8
 The anomalies of the thorax
• Among the most common thoracic
osseous anomalies are:
pectus excavatum
pectus carinatum, sternal
ossification abnormalities, and
deformity of the spine, ribs, clavicle,
or scapula.
Pectus excavatum. More frequent in boys

Pectus excavatum -
sternum the forms
creating a depression
inward, in the
centre of the chest.
Again, this condition may
occur independently or in
association with other
syndromes (can affect normal
organ development and
function).
 Pectus carinatum,

Pectus carinatum is protrusion of the

ribs and sternum anteriorly. This can
occur independently or in
association with other genetic
disorders, including trisomy 18 or 21.
There is little impact in development
of vital organs.
 Thorax emthysematous-
pulmonary emphysemain
which the air sacs of the lungs
are grossly enlarged, causing
breathlessness and wheezing
• All the thorax dimentions a higher:
• The ribs a horisontaly;
• The diaphrag is aplatised
• The heart is verticalised
Kiphosys: refers to the abnormally
excessive convex kyphotic curvature of the
spine as it occurs in the thoracic

Kyphoscoliosis describes an
abnormal curvature of the spine
in both a coronal and sagittal
plane. It is a combination of
kyphosis and scoliosis.
 Near the sternum
are four areas that
are used for
auscultation the
heart

Aortic area: At the 2nd intercostal space to the right of the sternum
Pulmonic area: At the 2nd intercostal space to the left of the
sternum Tricuspid area: Over the lower-left sternal border
Mitral area: At the left 5th intercostal space at the midclavicular line
Puncţia pleural
1.În hidrotorace 2.
În pneumotorace

Blocajul n.
intercostal.
 Needle
thoracostomy
⚫ Indications:
⚫ Tension pneumothorax
⚫ Drain fluid/pus from pleural
cavity.
⚫ To collect sample from pleural
fluid.
⚫ Two approaches of
thoracostomy
✔ Anterior
✔ Lateral

16
 Needle
thoracostomy
⚫ Anterior approach: patient
lie in supine position
⚫ Identify sternal angle
⚫ Identify 2nd rib and insert needle
in 2nd intercostal space in mid
clavicular line.
⚫ Lateral approach
⚫ Mid axillary line is used.

17
 Needle
thoracostomy
⚫ Skin, superficial fascia, serratus
anterior muscle, external
intercostal, internal intercostal,
innermost intercostal, endothoracic
fascia and parietal pleura.
⚫ The needle should always pass
through upper border of 3rd rib to
avoid damage to intercostal nerve
and vessels in sub costal groove
which lies at superior part of
intercostal space.

18
 Tube
thoracostomy
⚫ Preferred site is fourth and
fifth intercostal space.
⚫ Anterior axillary line.
⚫ Incision should be given at
superior border of rib to avoid
neurovascular damage.

19
 Surgical access to
chest
⚫ Thoracotomy
⚫ Indication: penetrating chest injuries
with intrathoracic hemorrhage.
⚫ Incision in 4th intercostal space
from lateral margin of sternum
to anterior axillary line.
⚫ Line of the incision in intercostal
space should be close to the upper
border of rib.
⚫ Right or left side depends on the
site of injury
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 Surgical access to
chest
⚫ Structures to be avoided for
damage in thoracotomy:
⚫ Internal thoracic artery
⚫ Intercostal vessels and nerves
⚫ Medial sternotomy
⚫ Used to access heart, coronary
arteries and valves.

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 Intercostal nerve block
⚫ 7th to 11th intercostal nerve supply skin
and parietal peritoneum covering
outer and inner surface of abdominal
wall
⚫ Indications
✔ Repair of injuries of thoracic and
abdominal
wall.
✔ Relief of pain in rib fractures
⚫ Complications
⚫ Pneumothorax occurs if needle
penetrates
parietal pleura
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⚫ Hemorrhage caused by puncture of
 Intercostal nerve block
⚫ Procedure: to produce analgesia
of anterior and lateral thoracic
wall and abdominal wall
⚫ Perform rib counting from 2 to 12.
⚫ Select the superior part
intercostal space.
⚫ Needle should direct towards the
lower border of rib
⚫ The tip should come close to
subcostal groove to infiltrate
anesthetic agent around nerve.
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 Diaphrag
m of single dome of
⚫ Paralysis
diaphragm by sectioning of
phrenic nerve.
⚫ Performed sometimes in
treatment of chronic
tuberculosis.
⚫ this will give rest to the lower
lobe of the lung.
⚫ Penetrating injuries:
✔ Stab or bullet wound
✔ In any penetrating injury below
the level of nipples, 24
diaphragmatic injury is
 Pleural
reflection
⚫ Cervical dome of pleura and
apex of lungs most commonly
damaged during:
✔ Stab wound in root of neck.
✔ By anesthetist needle during
nerve block of lower trunk of
brachial plexus.

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 Congenital anomalies of
ribs
⚫ Cervical rib:
⚫ Arises from the anterior
tubercle of transverse process
of 7th cervical vertebrae
⚫ Cause compression of
subclavian artery
⚫ Compression of subclavian vein
⚫ Compression of T1 nerve as it
passes above first rib.

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Cervical
rib⚫ On Plain AP radiograph demonstrate small horn like
structure

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 Congenital anomaly of
diaphragm
⚫ Congenital hernia
⚫ Due to incomplete fusion of
septum tranversum, dorsal
mesentery and pleuroperitoneal
membrane.
⚫ Three common sites
✔ Pleuroperitoneal canal
✔ Opening between xiphoid and costal
origin of diaphragm
✔ Esophageal hiatus

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 Pleura
e
•Costodiaphragmatic recess
⚫ Clinical significance: Pleural effusions collect here when in standing
position
⚫ A thoracocentesis (pleural tap) is often performed here while a patient
is in full expiration because of less risk of puncturing the lungs and
thereby causing pneumothorax

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Pleural Diseases & Signs:
Pleural Effusion

Right-sided pleural effusion

•Accumulation of fluid in the pleural space
•Transudative vs. exudative effusion
•Empyema as potential sequelae to exudative
effusion
 Pleural Diseases & Signs: Hemothorax
(Intrathoracic bleeding).

• Numerous sources of potential bleeds

•Large hemothorax: hypovolemic shock,
restricted ipsilateral ventilation
contralateral mediastinal shift
A chylothorax (or chyle leak) is a type of
pleural effusion. It results from lymph called
chyle accumulating in the pleural cavity due to
either disruption or obstruction of the thoracic
 Mediastinal
tumor/cyst
⚫ Usually left lung tumor involve
mediastinal lymph nodes
⚫ Can compress left recurrent
laryngeal nerve
⚫ Compression of superior vena cava
Phrenic nerve, trachea and
Oesophagus may also compressed

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⚫ Clinical anatomy of trachea
and bronchi
⚫ Inhaled foreign bodies
more commonly
enter right bronchus
⚫ Right bronchus is more
wider, shorter and
vertical.
⚫ Pass to middle lobar bronchi

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⚫ Clinical anatomy of lungs
⚫ Apex of the lung can be damaged
by stab wound or bullet injury
above the clavicle.
⚫ A fractured rib can penetrate the
lung causing pneumothorax

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⚫ Clinical anatomy of pericardium and heart

⚫ Cardiac tamponade
Compression of heart
Filling of heart is altered in diastole
⚫ Causes
⚫ pericardial space fills up with fluid faster than the pericardial sac
can stretch

⚫ Pericarditis

⚫ Stab or gun shot wounds

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⚫ Coronary artery bypass graft (CABG)
Great saphenous vein is used as graft
Internal thoracic and radial arteries can
also
be used.

36
⚫ The sternum is a common site for
bone marrow biopsy because it
possesses hematopoietic marrow
throughout life and because of its
breadth and subcutaneous position
⚫ It may be split in the median plane
(median sternotomy) to allow the
surgeon to gain easy access to the
lungs, heart, and great vessels.

37
⚫ Flail chest is a loss of stability of the
thoracic cage that occurs when a
segment of the anterior or lateral
thoracic wall moves freely because of
multiple
⚫ rib fractures, allowing the loose
segment to move inward on
inspiration and outward on expiration.
⚫ Flail chest is an extremely painful
injury and impairs ventilation, thereby
affecting oxygenation of the blood and
causing respiratory failure

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⚫ Rib fractures: Fracture of the first rib
may injure the brachial plexus and
subclavian vessels.
⚫ The middle ribs are most
commonly fractured and usually
result from direct blows or
crushing injuries.
⚫ The broken ends of ribs may cause
pneumothorax and lung or spleen
injury. Lower rib fractures may tear the
diaphragm, resulting in a
diaphragmatic hernia.

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⚫ Pulmonary embolism (pulmonary
thromboembolism) is an
obstruction of the pulmonary
artery or one of its branches by
an embolus (air, blood clot, fat,
tumor cells, or other foreign
material), which arises in the
deep veins of the lower limbs or
in the pelvic veins or occurs
following an operation or after a
fracture of a long bone with fatty
marrow.

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⚫ Angina pectoris is characterized by
attacks of chest pain originating in
the heart and felt beneath the
sternum, in many cases radiating to
the left shoulder and down the arm.
⚫ It is caused by an insufficient supply
of oxygen to the heart muscle
because of coronary artery disease
or exertion (e.g., exercise,
excitement) or emotion (e.g., stress,
anger, frustration)

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 Central Venous Catheterization — Subclavian
Vein
IndIcatIons - administration of caustic and critical
medications as well as allowing sampling of blood
and measurement of central
venous pressure.
ContraIndIcatIons
1.infection of the area overlying the target vein and
thrombosis of the target vein.
2.fracture of the ipsilateral clavicle or anterior
proximal ribs, which can distort the anatomy and
make placement difficult.
3.Caution when placing a central venous catheter
For men the mammary glands has
1,5x0,5cm.
Anomalies
-gynaecomastiy-
amastia
- polymastia
 Mastitis
Mastitis is an infection of the
breast tissue that results
breast in pain, swelling,
and redness of the breast.
warmth
Mastitis most commonly affects
women who are breast-feeding
(lactation mastitis), although
sometimes this condition can
occur in women who aren't
breast-feeding.
Mastitis
• Typs:
• 1 — retromamaris;
• 2 — interstitialis;
• 3 — subareolaris;
• 4 — retromammaris;
• 5 — parenhimatic;
• Radial incizion, submamarincision)
 Department of Anatomy KABSOM

COURSE CODE: SOM 1202

COURSE NAME: GROSS ANATOMY OF THORAX AND ABDOMEN
2
 The lungs are the vital organs of respiration situated in the
thoracic cavity.

 The right and left lungs are separated from each other by the
mediastinum.

 Cadaveric lungs may be shrunken, firm or hard to the touch,

and discolored in appearance.

 Healthy lungs in living people are normally light, soft, and

spongy, and fully occupy the pulmonary cavities

3
 Each lung is conical,
 Covered with visceral pleura,
 Attached to the mediastinum only by its root

4
5
6
 APEX OF THE LUNGS
 Blunt and lies at the level of the anterior end of first rib
 Reaches 1-2 cm above medial 1/3rd of clavicle
 Covered by the cervical pleura & suprapleural membrane
 Grooved by subclavian artery and vein

 BASE OF THE LUNGS

 Rests on the dome of the diaphragm
 Semilunar and concave in shape
 The right sided dome is higher than left

7
Anterior Border
 Corresponds to the anterior (costomediastinal) line of pleural
reflection
 Deeply notched in the left lung posterior to 5th costal cartilage
by the pericardium
 Extends vertically downwards to form lingular. This is the
cardiac notch

Inferior Border
 Thin and sharp
 Separates the base of the lung from the costal surfaces and
extends into phrenicocostal sinus.
8
Posterior Border
 Thick/blunt and ill defined
 Fits into deep paravertebral gutter
 Extends from C7 to T10

9
 Costal Surface: is large, smooth and convex and in contact
with costal pleura and overlying thoracic wall

 Mediastinal surface: is concave because it is related to the

middle mediastinum, which contains the pericardium and
heart.

 Diaphragmatic surface: is also concave, forms the base of

the lung, which rests on the dome of the diaphragm
11
RIGHT SIDE
 Right atrium
 Right ventricle (small part)
 Superior vena cava
 Azygous vein
 Right brachiocephalic vein
(lower part)
 Inferior vena cava
 Esophagus
 Trachea
 Right phrenic nerve
 Right vagus nerve
LEFT SIDE
 Left ventricle
 Pulmonary trunk
 Arch of Aorta
 Left Subclavian artery
 Left brachiocephalic vein
 Descending thoracic aorta
 Thoracic duct
 Left phrenic nerve
 Left vagus nerve
 Left recurrent laryngeal
nerve
 Vertebral bones
 Intervertebral Discs
 Posterior Intercostal Vessels
 Splanchnic Nerves.
HILUM:
 is a large depressed area that lies near the centre of the medial
surfaces.
 Various structures enter and leave the lung through its root

ROOT OF THE LUNG:

 is enclosed in a short tubular sheet of pleura that joins the
pulmonary and mediastinal parts of peura.
 It extends inferiorly as a narrow fold – the pulmonary
ligament
 It lies opposite of the bodies of 5th, 6th and 7th thoracic
vertebra
 Principal bronchus on the left side
 Eparterial and Hyparterial bronchi on the right side
 One pulmonary artery
 Two pulmonary veins (Superior & Inferior)
 Bronchial arteries (One on the right and two on the left sides)
 Bronchial veins
 Anterior & posterior plexus of nerves
 Lymphatics
 Bronchopulmonary Lymphnodes
 Areolar tissue
Assignment
 Critically study the arrangement of structures
in the root of the right and left lungs.
1. Above Downwards
2. Before Backwards
19
 Well defined areas of the
lungs, each of which is
aerated by a
segmental/tertiary bronchus.

 They are the anatomic,

functional, and surgical units
of the lungs
21
 Trachea

Right & Left Principal Bronchus

Lobar Bronchi (Secondary)

Segmental Bronchi (Tertiary)

Terminal Bronchioles

Respiratory Bronchioles

Alveolar ducts

Alveolar Sacs

Alveoli
22
23
24
 It is a subdivision of a lung lobe.
 It is pyramid shaped, with its apex toward the lung root.
 It is surrounded by connective tissue.
 It has a segmental bronchus, a segmental artery, lymph
vessels, and autonomic nerves.
 The segmental vein lies in the connective tissue between
adjacent bronchopulmonary segments.
 Because it is a structural unit, a diseased segment can be
removed surgically

Note: A bronchopulmonary segment is not a broncovascular

segment as it does not have its own vein.
 The bronchi, the connective tissue of the lung, and the visceral
pleura receive their blood supply from the bronchial arteries,
which are branches of the descending aorta.
 Bronchial veins (which communicate with the pulmonary veins)
drain into the azygos and hemiazygos veins
 Alveoli receive deoxygenated blood from the terminal branches
of the pulmonary arteries.
 Oxygenated blood leaving the alveolar capillaries drains into the
tributaries of the pulmonary veins, which follow the
intersegmental connective tissue septa to the lung root.
 Two pulmonary veins leave each lung root to empty into the left
atrium of the heart.
 The lymph vessels originate in superficial and deep plexuses; they
are not present in the alveolar walls.
 Superficial (subpleural) plexus lies beneath the visceral pleura and
drains over the surface of the lung toward the hilum, where the
lymph vessels enter the bronchopulmonary nodes.
 Deep plexus travels along the bronchi and pulmonary vessels
toward the hilum of the lung, passing through pulmonary nodes
located within the lung substance; the lymph then enters the
bronchopulmonary nodes in the hilum of the lung.
 All the lymph from the lung leaves the hilum and drains into the
tracheobronchial nodes and then into the bronchomediastinal
lymph trunks.
 At the root of each lung is a pulmonary plexus composed of
efferent and afferent autonomic nerve fibers. The plexus is formed
from branches of the sympathetic trunk and receives
parasympathetic fibers from the vagus nerve.
 Sympathetic efferent fibers produce bronchodilatation and
vasoconstriction. Parasympathetic efferent fibers produce
bronchoconstriction, vasodilatation, and increased glandular
secretion.
 Afferent impulses derived from the bronchial mucous membrane
and from stretch receptors in the alveolar walls pass to the central
nervous system in both sympathetic and parasympathetic nerves
 The alveoli are thin-walled pouches which provide the respiratory
surface for gaseous exchange.
 Their walls contain two types of epithelial cell (pneumocytes),
which cover a delicate connective tissue within which a network
of capillaries ramify.
 Since the walls are extremely thin, they present a minimal barrier
to gaseous exchange between the atmosphere and the blood in the
capillaries.
 Adjacent alveoli are frequently in close contact and then the
intervening connective tissue forms the central part of an
interalveolar septum.
 Alveolar macrophages are present within the alveolar lumen, and
migrate over the epithelial surface.
31
32
 Variations in the Lobes of the Lung
 Appearance of the Lungs and Inhalation of Carbon Particles
and Irritants
 Auscultation of the Lungs: listening to their sounds with a
stethoscope
 Percussion of the Thorax: tapping the thorax over the lungs
with the fingers to detect sounds in the lungs
 Lung Resection
 Segmental Atelectasis
 Lung Cancer and Mediastinal Nerves
 Pleural Effusion
 Emphysema
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35
OSTEOLOGY OF THE THORAX
AND ABDOMEN
Year 1 semester 2 Anatomy
KABSOM 2021
By
Echoru Isaac

1
Objectives
• By the end of this topic you should be able to;
1. Describe osteology of the sternum, its constituent parts,
articulations, and clinical correlations.
2. Describe osteology and bony landmarks and clinical correlations of
the ribs
3. Describe the osteology of the thoracic vertebrae, examining
their characteristic features and clinical correlations.
4. Describe the osteology of the lumbar vertebrae, examining their
characteristic features and their clinical correlations

2
BONES OF THE THORAX
• The bones of the thorax form the major part of the thoracic cage and
provide support and protection to viscera (e.g., heart and lungs)
present within the thoracic cavity.
• The thoracic cage is not static in nature, but dynamic as it keeps on
moving at its various joints.
• The bones of the thorax are:
• 1. Sternum.
• 2. Twelve pairs of ribs.
• 3. Twelve thoracic vertebrae

3
STERNUM
• The sternum (breast bone is an
elongated flat bone, which lies in
the anterior median part of the
chest wall.
• It is about 7 cm long
• 3 Parts
• The xiphisternal joint lies
opposite the body of the ninth
thoracic vertebra
• Sternal angle

4
Sternal angle • Anatomical happenings:
• Second costal cartilage articulates, on either side, with
the sternum at this level, hence this level is used for
counting the ribs.
• It lies at the level of intervertebral disc between T4 and
T5 vertebrae
• Horizontal plane passing through this level separates
superior mediastinum from inferior mediastinum.
• Ascending aorta ends at this level.
• Arch of aorta begins and ends at this level.
• Descending aorta begins at this level.
• Trachea bifurcates into right and left principal bronchi at
this level.
• Pulmonary trunk divides into right and left pulmonary
arteries at this level.
• Upper border of heart lies at this level.
• Azygos vein arches over the root of right lung to end in
the superior vena cava
5
Attachments on the sternum

6
Applied anatomy
• Sternum and Marrow Biopsy
• Since the sternum possesses red hematopoietic marrow throughout
life, it is a common site for marrow biopsy.
• Under a local anesthetic, a wide-bore needle is introduced into the
marrow cavity through the anterior surface of the bone.
• The sternum may also be split at operation to allow the surgeon to
gain easy access to the heart, great vessels, and thymus.

7
CLASSIFICATION OF RIBS
• True (vertebrocostal) ribs (1st
to 7th ribs):
• False (vertebrochondral) ribs
(8th, 9th, and usually 10th
ribs):
• Floating (vertebral, free) ribs
(11th, 12th, and sometimes
10th ribs):

8
CLASSIFICATION OF RIBS
According to features
• 1. Typical ribs: 3rd–9th.
• 2. Atypical ribs: 1st, 2nd, 10th, 11th, and 12th.
• The typical ribs have same general features, whereas the atypical ribs
have special features and therefore can be differentiated from the
remaining ribs.

9
TYPICAL RIBS
• A typical rib is a long, twisted, flat
bone having a rounded, smooth
superior border and a sharp, thin
inferior border
• The inferior border overhangs and
forms the costal groove, which
accommodates the intercostal
vessels and nerve.
• The anterior end of each rib is
attached to the corresponding
costal cartilage
• Has a head, neck, tubercle, shaft,
and angle
10
 ATYPICAL RIBS
• First rib
• Shortest, broadest and
most acutely curved
• Its shaft flattened above
downwards
• Its head has single facet
• Its angle and tubercle
are coincided
• Has no costal groove
• Its neck is rounded and
elongated
• Anterior end is larger
and thicker

11
Applied anatomy
• Cervical Rib
• Cause pressure on the lower
trunk of the brachial plexus in
some patients.
• It can also exert pressure on the
overlying subclavian artery and
interfere with the circulation of
the upper limb.

12
 ATYPICAL RIBS
• Second Rib
• The 2nd rib is more typical; its body is thinner,
less curved, and substantially longer than the 1st
rib, and its head has two facets for articulation
with the bodies of the T1 and T2 vertebrae;
• Its main atypical feature is a rough area on its
upper surface, the tuberosity for serratus
anterior, from which part of that muscle
originates

13
 ATYPICAL RIBS
• Tenth Rib
• It has single articular facet on its head,
which articulates with the body of
corresponding thoracic vertebra.
• 11th and 12th Rib
• Single large, articular facet on the head.
• No neck and no tubercle.
• Its anterior end is pointed and tipped
with cartilage.

14
THORACIC VERTEBRAE
• There are 12 thoracic vertebrae. They are identified by the presence
of costal facet/facets on the sides of their bodies for articulation with
the heads of the ribs
• CLASSIFICATION
• According to the features, the thoracic vertebrae are classified into
two types:
• 1. Typical: second to eighth.
• 2. Atypical: first and ninth to twelfth.

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TYPICAL THORACIC VERTEBRAE
• Characteristic Features
• 1. Presence of articular facets on each side of the body and on front
of transverse processes for articulation with the ribs.
• 2. Body is heart shaped, particularly in the midthoracic region when
viewed from above.
• 3. Vertebral foramen is circular.
• 4. Spinous process is long, slender, and directed downwards.
• 5. Pedicle is attached to the upper part of the body, thus making the
inferior vertebral notch deeper.

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TYPICAL THORACIC VERTEBRAE

17
ATYPICAL THORACIC VERTEBRAE

18
Joints
• The joints of the thoracic spine can be divided into two groups –
those that are present throughout the vertebral column, and those
unique to the thoracic spine
• Present throughout Vertebral Column
• There are two types of joints present throughout the vertebral column:
• Between vertebral bodies – adjacent vertebral bodies are joined by
intervertebral discs, made of fibrocartilage. This is a type of
cartilaginous joint known as a symphysis.
• Between vertebral arches – formed by the articulation of superior and
inferior articular processes from adjacent vertebrae. It is a synovial type
joint.

19
Joints
• Unique to Thoracic Spine
• The articulations between the vertebrae and the ribs are unique
to the thoracic spine.
• For each rib, there are two separate articulations – costovertebral and
costotransverse

20
Ligaments
• The thoracic spine is strengthened by the presence of numerous ligaments.
• Present Throughout Vertebral Column
• Anterior and posterior longitudinal ligaments: Long ligaments that run
the length of the vertebral column, covering the vertebral bodies and
intervertebral discs.
• Ligamentum flavum: Connects the laminae of adjacent vertebrae.
• Interspinous ligament: Connects the spinous processes of adjacent
vertebrae.
• Supraspinous ligament: Connects the tips of adjacent spinous processes.

21
Ligaments
• Unique to Thoracic Spine
• A number of small ligaments also support the costovertebral joints:
• Anterior and posterior longitudinal ligaments: Long ligaments that run the length of the
vertebral column, covering the vertebral bodies and intervertebral discs.
• Ligamentum flavum: Connects the laminae of adjacent vertebrae.
• Interspinous ligament: Connects the spinous processes of adjacent vertebrae.
• Supraspinous ligament: Connects the tips of adjacent spinous processes.
• Radiate ligament of head of rib – Fans outwards from the head of the rib to the bodies of the two
vertebrae and intervertebral disc.
• Costotransverse ligament – Connects the neck of the rib and the transverse process.
• Lateral costotransverse ligament – Extends from the transverse process to the tubercle of the rib.
• Superior costotransverse ligament – Passes from the upper border of the neck of the rib to the
transverse process of the vertebra superior to it

22
JOINTS OF THE THORAX

23
Applied anatomy
• Rib fractures

24
Osteology of the Abdomen
• The osteology of abdomen deals with the bones of the abdomen and
pelvis.
• The bones of the abdomen and pelvis are as follows
• 1. Lower ribs and costal cartilages.
• 2. Lumbar vertebrae.
• 3. Sacrum.
• 4. Coccyx.
• 5. Hip or innominate bone

25
Osteology of the Abdomen

26
LUMBAR VERTEBRAE
• The lumbar vertebrae consist of the same elements as the thoracic
vertebrae but are more massive in keeping with the greater load,
which they have to transmit.
• There are five lumbar vertebrae out of which first four (L1 to L4) are
typical and fifth (L5) is atypical

27
 FEATURES OF TYPICAL LUMBAR VERTEBRAE
(L1, L2, L3, L4)
Part Characteristics
Body Massive and kidney shaped
Vertebral foramen Triangular and relatively smaller than in cervical vertebrae
Transverse process Long and slender with accessory process on the posterior
surface of base of each process

Articular processes • Superior articular facets directed posteromedially

• Inferior articular facets directed anterolaterally

Spinous process Short, thick, broad, and hatchet shaped

28
LUMBAR VERTEBRAE

29
FEATURES OF ATYPICAL FIFTH LUMBAR
VERTEBRA (L5)
• 1. The transverse processes are thick, short, and pyramidal in shape. They
seem to be turned upward.
• 2. The spine is small, short, least substantial, and rounded at the tip.
• 3. The body is largest of all lumbar vertebrae. The vertical height of the
anterior surface of the body is more than that of the posterior surface. This
difference is responsible for sharp/prominent lumbosacral angle (120°).
• 4. The superior articular facets look more backward than medially and
inferior articular facets look more forward than laterally as compared to
typical lumbar vertebrae.
• 5. The distance between the inferior articular processes is equal or more
than that between the superior articular processes

30
FEATURES OF ATYPICAL FIFTH LUMBAR
VERTEBRA (L5)

31
Attachments of the lumber vertebra

32
Joints
• There are two types of joint in the lumbar spine. Both of these
articulations are not unique to the lumbar vertebrae, and are
present throughout the vertebral column.
• Between vertebral bodies – adjacent vertebral bodies are joined
by intervertebral discs, made of fibrocartilage. This is a type of
cartilaginous joint, known as a symphysis.
• Between vertebral arches – formed by the articulation of superior
and inferior articular processes from adjacent vertebrae. It is a
synovial type joint.

33
Ligaments
• Present throughout Vertebral Column
• Anterior and posterior longitudinal ligaments: Long ligaments that
run the length of the vertebral column, covering the vertebral
bodies and intervertebral discs.
• Ligamentum flavum: Connects the laminae of adjacent vertebrae.
• Interspinous ligament: Connects the spinous processes of adjacent
vertebrae.
• Supraspinous ligament: Connects the tips of adjacent spinous
processes

34
Ligaments
• Unique to Lumbar Spine
• The lumbosacral joint (between L5 and S1 vertebrae) is
strengthened by the iliolumbar ligaments. These are fan-like
ligaments radiating from the transverse processes of the L5 vertebra
to the ilia of the pelvis

35
Anatomical Relationships
• Throughout the vertebral column, the spinal cord travels through the
vertebral canal (made up by the foramina of all vertebrae). At around
the level of L1, the spinal cord terminates and the cauda equina
begins. This is a bundle of lumbar , sacral and coccygeal nerve roots.
• Spinal nerves exit the vertebral canal through the intervertebral
foramina

36
Clinical anatomy
• Read about the following clinical condition
• Kyphosis and lordosis
• Spondylolysis
• Spondylolisthesis
• Sacralization of the fifth lumbar vertebra:
• Spina bifida
• Cauda equina syndrome

37
References
• Clinically anatomy by regions, Snells
• Clinically oriented anatomy, Moore
• Grays anatomy for students

38
Thoracic Duct and
Azygos vein
Gross Anatomy
Thoracic duct
• It functions to transport lymph back to the circulatory system.

• It is the largest lymphatic channel in the body.

• Commences at the upper end of the cisterna chyli

• on a level with the body of T12 vertebra
• between the aorta and the azygos vein.

• It passes upwards, with these structures, between the crura of

the diaphragm

• It comes to lie against the right side of the oesophagus.

Figure 1. Azygos system of veins and thoracic duct on the posterior wall of
the thorax.
Thoracic duct
• At the level of T5 vertebra
• it inclines to the left
• passes behind the oesophagus.

• In the superior mediastinum

• it lies to the left of the oesophagus on a posterior plane.

• As the duct ascends in the thorax it lies anterior to

• the right aortic intercostal arteries
• the terminal parts of the hemiazygos vein
• accessory hemiazygos veins.
Thoracic duct
• Passing vertically upwards in the superior mediastinum.

• it lies posterior to
• the arch of the aorta
• the left subclavian artery.

• At the root of the neck

• it arches forwards and to the left,
• lies behind the carotid sheath and its contents
• crosses over the dome of the pleura and the left subclavian
artery to enter the point of confluence of the left internal
jugular and subclavian veins.
Fig. 2 The thoracic aorta has been pulled slightly to the left and the azygos vein
slightly to the right to expose the thoracic duct.
Thoracic duct
• At its termination:
• It may divide into two or three separate branches, all of
which open at the angle between these two veins.

• The thoracic duct has several valves carrying all the

lymph from the lower half of the body

• the duct receives in its course through the thorax

lymph from
• the posterior mediastinal
• left intercostal nodes
• left bronchomediastinal trunk.
Thoracic duct
• In the neck it receives
• the left jugular
• subclavian lymph trunks

• thus finally comes to drain all the lymph of the body

except that from
• the right upper limb
• the right halves of the thorax
• and the head and neck.
The right lymphatic duct
• It is much smaller than the thoracic duct

• drains
• the right intercostal nodes
• the right broncho-mediastinal trunk.

• It may receive
• the right jugular and subclavian lymph trunks before it opens into
the commencement of the right brachiocephalic vein

• or they may remain separate and open independently into the

jugulo-subclavian junction
Azygos system of veins
• The thoracic wall and upper lumbar region are drained by
• the posterior intercostal
• and lumbar veins into the azygos system of veins.

• Azygos vein
• is usually formed by the union of the ascending lumbar vein with the
subcostal vein of the right side.
• Its lower end is connected to the IVC

• goes through the aortic opening of the diaphragm under shelter of the
right crus

• lateral to the thoracic duct

• passes upwards lying on the sides of the vertebral bodies, on a plane

posterior to that of the oesophagus.
Azygos vein
• At the level of T4 vertebra
• the azygos vein arches forwards over the hilum of the right lung
• ends in the superior vena cava.

• Tributaries:
• It receives the lower eight posterior intercostal veins
• at its convexity the superior intercostal vein of the right side.
• receives the bronchial veins from the right lung,
• pericardial veins
• and some veins from the middle third of the oesophagus.

• The two hemiazygos veins

• usually join it at the levels of T7 and 8 vertebrae
Hemiazygos veins
• arises on the left side by the junction of the left subcostal
and ascending lumbar veins.

• It ascends on the left side of the vertebral column, posterior

to the thoracic aorta as far as the T9 vertebra.

• At the level T9 it crosses to the right, posterior to

• the aorta,
• thoracic duct
• esophagus
• and joins the azygos vein.
Hemiazygos veins
• The hemi-azygos vein receives
• the inferior three posterior intercostal veins
• the inferior esophageal veins
• and several small mediastinal veins.
Accessory hemiazygos vein
• The superior vein is the accessory hemiazygos vein

• The accessory hemi-azygos vein

• begins at the medial end of the 4th or 5th intercostal space
• descends on the left side of the vertebral column
• from T5 through T8.

• It receives tributaries from veins

• in the 4th–8th intercostal spaces
• sometimes from the left bronchial veins.
Accessory hemiazygos vein
• It crosses over the T7 or T8 vertebra, posterior to
• the thoracic aorta
• thoracic duct
• where it joins the azygos vein.

• Sometimes the accessory hemi-azygos vein joins the

hemi-azygos vein and opens with it into the azygos
vein.

• The accessory hemi-azygos is frequently connected to

the left superior intercostal vein
Accessory hemiazygos vein
• The left superior intercostal vein
• drains the 1st–3rd intercostal spaces,
• may communicate with the accessory hemi azygos vein
• it drains primarily into the left brachiocephalic vein.
Superior Intercostal Vein

• Is formed by a union of the second, third, and fourth

posterior intercostal veins

• drains into the azygos vein on the right

• the brachiocephalic vein on the left.

Duodenum, jejunum
and ileum
Gross anatomy
Duodenum
• The duodenum is a C-shaped tube
• It lies in front of, and to the right of the inferior vena cava
and aorta.

• It is divided into four parts, superior, descending,

horizontal and ascending,
• or more simply first, second, third and fourth.

• The total length is 25 cm (10 in)

• the lengths of the parts being easily remembered in inches as
2, 3, 4 and 1
• or in centimetres (5, 7.5, 10 and 2.5).

• The first 2.5 cm are contained between the peritoneum

of the lesser and greater omenta
• but the remainder is retroperitoneal.
Duodenum
• The duodenum makes its C-shaped loop round the
head of the pancreas
• This is opposite the body of L2 vertebra

• so the
• first part may be said to lie at the level of L1,
• the second on the right side of L2,
• the third crosses in front of L3,
• the fourth is on the left of L2 vertebrae.
1st part of Duodenum
• The first part of the duodenum runs to
• the right
• upwards
• and backwards from the pylorus
• a foreshortened view is consequently obtained in
anteroposterior radio graphs.

• It lies in front of
• the gastroduodenal artery
• bile duct
• portal vein
• and behind these structures lies the inferior vena cava.
• The gallbladder is anterior to the duodenal cap.
1st part of duodenum
• The next 2.5 cm
• passes backwards and upwards on the upper part of
the head of the pancreas to the medial border of the
right kidney.
• It is covered in front with peritoneum
• and the inferior surface of the right lobe of the
liver lies over this peritoneum.
• Its posterior surface is bare of peritoneum.
2nd part of Duodenum
• The second part of the duodenum
• curves downwards over the hilum of the right kidney.

• Anteriorly:
• It is covered with peritoneum
• crossed by the attachment of the transverse
mesocolon
• so that its upper half lies in the supracolic
compartment
• to the left of the hepatorenal pouch (in contact with the
liver)
• and its lower half lies in the right infracolic
compartment
2nd part duodenum
• It lies alongside
• the head of the pancreas
• approximately at the level of L2 vertebra.

• Its posteromedial wall receives

• the common opening of the bile duct
• main pancreatic duct at the hepatopancreatic ampulla (of
Vater)
• this opens on the summit of the major duodenal papilla
• halfway along the second part, 10 cm from the pylorus.

• It is overlapped by
• a semilunar flap of mucous membrane.
• Two centimetres proximal is the small opening of the accessory
pancreatic duct (on the minor duodenal papilla).
3rd part of duodenum
• The third part of the duodenum
• curves forwards from the right paravertebral gutter
• over the slope of the right psoas muscle (gonadal
vessels and ureter intervening)
• passes over the forwardly projecting inferior vena
cava and aorta
• to reach the left psoas muscle.

• As its inferior border crosses the aorta it lies

• on the commencement of the inferior mesenteric artery.
• Its upper border hugs the lower border of the pancreas.
3rd Part of duodenum
• It is covered by
• the peritoneum of the posterior abdominal wall
• just below the transverse mesocolon.
• It is crossed by the superior mesenteric vessels
• and by the leaves of the commencement of the
mesentery of the small intestine sloping down from
the duodenojejunal flexure.

• It lies, therefore, in both right (mainly) and left

infracolic compartments.
• Its anterior surface is in contact with coils of
jejunum.
4th part of duodenum
• ascends to the left of the aorta,
• lies on the left psoas muscle
• left lumbar sympathetic trunk,
• to reach the lower border of the body of the pancreas.

• It is covered
• in front by the peritoneal floor of the left infracolic
compartment

• and by coils of jejunum.

• It frees from the peritoneum that has plastered it down to the

posterior abdominal wall
• and curves forwards and to the right as the duodenojejunal flexure.
• It pulls up a double sheet of peritoneum from the posterior abdominal
wall, the mesentery of the small intestine
• this slopes down to the right across the third part of the duodenum
and posterior abdominal wall.
4th part of duodenum
• The duodenojejunal flexure
• is fixed to the left psoas fascia
• by fibrous tissue
• it may be further supported
• by the suspensory muscle of the duodenum (muscle or ligament of
Treitz).
• This is a thin band of connective tissue
• may contain muscle—skeletal muscle fibres
• that run from the right crus of the diaphragm to connective tissue
around the coeliac trunk
• and smooth muscle fibres that run from there, behind the pancreas and
in front of the left renal vein, to the muscle coat of the flexure.

• Internally
• the mucous membrane of most of the duodenum, like the rest of
the small intestine, is thrown into numerous circular folds
• this is called plicae circulares or valvulae conniventes
• The first 2.5cm lacks circulares but smooth
Vessels of the duodenum
• Blood supply
• is supplied by
• the superior and inferior pancreaticoduodenal arteries

• but the first 2 cm, the usual site of ulceration receives blood from
• the hepatic
• gastro duodenal
• Supraduodenal
• right gastric
• right gastro epiploic arteries.

• Venous drainage
• is to tributaries of the superior mesenteric and portal veins.

• Lymph drainage
• drains by channels that accompany the superior and inferior
pancreaticoduodenal vessels
• to coeliac and superior mesenteric nodes
Jejunum and ileum
• The jejunum
• is wider-bored and thicker-walled than the ileum.

• The thick wall of the jejunum feels double (the

mucous membrane can be felt through the muscle wall,
‘a shirt sleeve felt through a coat sleeve’)
• the thin wall of the ileum feels single.

• The lower reaches of the ileum are distinguished by

the presence of aggregated lymphoid follicles
(Peyer’s patches).
• these are located on the antimesenteric border of elongated
whitish plaques in the mucous membrane, usually but not
always visible through the muscle wall.
Jejunum and ileum
• The jejunum lies coiled up in the upper part of
the infracolic compartment

• the ileum in the lower part thereof and in the

pelvis.

• The jejunum and ileum together lie in the free

margin of the mesentery.

• Total length varies greatly, from about 4 to 6

metres.

• The jejunum constitutes two-fifths, while ileum

constitute the rest of the three-fifths
Ileal (Meckel’s) diverticulum
• is present in 2% of individuals

• It is 60 cm (2 ft) from the caecum, and is 5 cm (2 in) long

• but the length of the diverticulum is variable and its site may be
more proximal.

• Its blind end may contain gastric mucosa or liver or pancreatic

tissue
• ulceration and perforation of the tip can occur.

• It represents the intestinal end of the vitellointestinal duct

• its apex may be adherent to the umbilicus or connected to it by a

fibrous cord, a further remnant of the duct
Vessels of jejunum and ileum
• Blood supply
• Numerous jejunal and ileal branches arise from the
left side of the superior mesenteric artery
• and enter the mesentery by passing between the two layers of
the root.

• The jejunal branches join each other in a series of

anastomosing loops to form arterial arcades
• single for the upper jejunum and double lower down.

• From the arcades

• straight arteries pass to the mesenteric border of the gut.
• These vessels are long and close together forming high narrow
‘windows’ in the intestinal border of the mesentery, visible
because of the scantiness of mesenteric fat here
Blood supply
• The straight vessels pass to one or other side
of the jejunum and sink into its wall.

• Occlusion of a straight artery may lead to

infarction of the segment supplied because
these are end arteries

• but occlusion of arcade vessels is usually

without effect due to their numerous
anastomotic connections.
Blood supply
• The ileal arteries are similar but form a larger series of
arcades—three to five,
• the most distal lying near the ileal wall so that the straight
vessels branching off the arcades are shorter.

• There is more fat in this part of the mesentery, so the

windows characteristic of the jejunal part are not seen in
ileum
• this is a useful feature in identifying loops of the bowel.

• The end of the superior mesenteric artery itself supplies

the region of the ileal diverticulum (if present),
• and anastomoses with the arcades and with the ileocolic branch to
supply the terminal ileum.

• The veins all correspond to the arteries and thus drain to

the superior mesenteric vein
Vessels and innervation
• Lymph drainage
• Jejunal and ileal lymph drains to superior mesenteric
nodes via mural and intermediate nodes in the mesentery.

• Nerve supply
• Autonomic nerves reach the wall of the small intestine
with its blood vessels.
• The parasympathetic vagal supply augments peristaltic
activity and intestinal secretion.
• There are many afferent fibres whose function is
uncertain.
• The sympathetic supply, which is vasoconstrictor and
normally inhibits peristalsis, is from the lateral horn
cells of spinal segments T9 and 10.
• Pain impulses use sympathetic pathways mainly and small
intestinal pain is usually felt in the umbilical region
of the abdomen.
Large
intestine

Gross anatomy
The large intestine
• consists of
• the caecum with the (vermiform) appendix,
• the ascending colon
• the transverse colon
• the descending colon
• the sigmoid parts of the colon
• the rectum
• the anal canal.
Caecum and appendix Caecum
• This blind pouch of the large intestine projects down
wards from the commencement of the ascending colon,
below the ileocaecal junction

• Peritoneum
• It is completely covered by peritoneum
• the peritoneum is reflected downwards to the floor of the right
iliac fossa
• and the retrocecal peritoneal space may be shallow or deep,
according to the distance of this reflection from the lower end
of the caecum.
• Often there are two peritoneal folds from either side of the
posterior wall of the caecum, forming between them the
retrocaecal recess in which the appendix may lie.

• Muscular wall
• the longitudinal muscle of the caecum is concentrated into
three flat bands, the taeniae coli,
Caecum and appendix Caecum
• The taeniae lie
• one anterior
• one posteromedial
• and one posterolateral.
• All three converge on the base of the appendix,
• to which they are a useful guide.

• Internally the ileocaecal junction is guarded by

the ileocaecal valve
• whose almost transverse lips may help to prevent some
reflux into the ileum, but any possible sphincteric
action is poor.

• In the infant the caecum is conical and the

appendix extends downwards from its apex.
Caecum and appendix Caecum
• The lateral wall out grows the medial wall and
bulges down below the base of the appendix in the
adult
• the base of the appendix thus comes to lie in the
posteromedial wall of the caecum above its lower end and
the three taeniae coverage to this point.

• The caecum lies on the peritoneal floor of the

right iliac fossa
• over the iliacus and psoas fasciae and the femoral and
lateral femoral cutaneous nerves.
• Its lower end lies at the pelvic brim.

• When distended its anterior surface touches the

parietal peritoneum of the anterior abdominal wall
• when collapsed coils of ileum lie between the two.
Caecum and appendix Caecum
• Vessels.
• Branches of the anterior and posterior caecal
arteries (branches of the ileocolic artery) fan out
over the respective surfaces of the caecum.

• The posterior caecal artery is larger and gives a

branch to the base of the appendix

• There are corresponding veins

• Lymph drainage.
• Lymph passes to nodes associated with the ileocolic
artery.
Caecum and appendix Caecum
• Appendix
• The vermiform (worm-shaped) appendix is a blind ending
tube varying in length (commonly about 6–9 cm),
• which opens into the posteromedial wall of the caecum 2cm below
the ileocaecal valve.

• On the surface of the abdomen this point (McBurney’s)

lies one-third of the way up the oblique line that
joins the right anterior superior iliac spine to the
umbilicus.

• While the position of its base is constant in relation

to the caecum, the appendix itself may lie in a variety
of positions.
• The most common, as found at operation, is the
retrocaecal position, with the pelvic position next in
order of frequency
Appendix
• The three taeniae of the caecum merge into a
complete longitudinal muscle layer for the
appendix.

• The submucosa contains many lymphoid masses and

the lumen is thereby irregularly narrowed.
• This lumen is wider in the young child and may be
obliterated in old age.

• The appendix has its own short mesentery, the

mesoappendix, which is a triangular fold of
peritoneum from the left (inferior) layer of
Appendix
• A small fold of peritoneum extends from the terminal
ileum to the front of the mesoappendix.

• This is the ileocaecal fold (or ‘bloodless fold of

Treves’, although it sometimes contains blood vessels)
and the space between it and the mesoappendix is the
inferior ileocaecal recess.

• Another fold lies in front of the terminal ileum,

between the base of the mesentery and the anterior wall
of the caecum.
• This fold is raised up by the contained anterior caecal artery
and is called the vascular fold of the caecum.

• The space behind it is the superior ileocaecal recess.

Vessels
• Blood supply.
• The appendicular artery
• is normally a branch of the inferior division of the
ileocolic artery,
• which runs behind the terminal ileum to enter the mesoappendix.
• it gives off a recurrent branch which anastomoses with a
branch of the posterior caecal artery
• this may replace the appendicular artery.

• The appendicular artery

• runs first in the free margin of the mesoappendix
• then close to the appendicular wall,
• where it may be thrombosed in appendicitis
• leading to ischaemic necrosis and perhaps rupture of the
appendix
• there is no collateral circulation because appendicular
artery is an end artery
Vessels
• Veins
• There are corresponding veins.

• Lymph drainage.
• from the caecum, lymph passes to nodes associated with
the ileocolic artery.

• Appendicectomy.
• Exposure of the appendix during appendicectomy is through
a McBurney or transverse muscle-splitting incision.
• If it is not immediately obvious, tracing any of the
taeniae down over the caecal wall will lead to the base
of the appendix
Colon
• It is divided into four parts

• Of the four parts, the transverse and sigmoid

parts are suspended in mesenteries
• By the transverse mesocolon and sigmoid mesocolon
respectively

• ascending and descending colon are plastered on to

the posterior abdominal wall so that they have
posterior ‘bare areas’ devoid of peritoneum.
Ascending colon
• This first part of the colon
• It is about 15 cm in length

• extends upwards from the ileocaecal junction to the right

colic (hepatic) flexure.

• The latter lies on the inferolateral part of the anterior

surface of the right kidney, in contact with the inferior
surface of the liver.

• The ascending colon lies on the iliac fascia and the

anterior layer of the lumbar fascia.

• Its front and both sides possess a serous coat, which

runs laterally into the paracolic gutter and medially
into the right infracolic compartment.
Ascending colon
• The original embryonic mesentery is retained in
about 10% of adults.

• The taeniae coli lie, in line with those of the

caecum, anteriorly, posterolaterally and
posteromedially.

• These consist of longitudinal muscle fibres and

the circular muscle coat is exposed between them.

• The ascending colon is sacculated, due to the

three taeniae being ‘too short’ for the bowel.
Ascending colon
• If the taeniae are divided between the
sacculations the latter can be drawn apart and the
bowel wall flattened.

• Small pouches of peritoneum, distended with fat,

the appendices epiploicae, project in places from
the serous coat.

• The blood vessels supplying them from the mucosa

perforate the muscle wall.
• Mucous membrane may herniate through these vascular
perforations, a condition known as diverticulosis.

• Diverticulitis is inflammation of these mucosal

herniae.
Transverse colon

• This part of the colon is about 50 cm long

• It extends from the hepatic to the splenic flexure
in a loop which hangs down to a variable degree
between these two fixed points
• anterior to coils of jejunum and ileum.

• The convexity of the greater curvature of the

stomach lies in its concavity, the two being
connected by the gastrocolic omentum.

• Because of the fusion between the greater omentum

and the transverse colon, the rest of the greater
omentum appears to hang down from its lower
convexity.
Transverse colon
• The transverse colon is completely invested in
peritoneum
• it hangs free on the transverse mesocolon, which is
attached from the inferior pole of the right kidney
across the descending (second) part of the duodenum
and the pancreas to the inferior pole of the left
kidney.

• The splenic flexure lies, at a higher level

than the hepatic flexure, well up under cover
of the left costal margin.
Transverse colon
• Due to the looping downwards and forwards of
the transverse colon from the flexures
• the anterior taenia of ascending and descending
colons lies posteriorly,
• while the other two lie anteriorly, above and below.

• The appendices epiploicae are larger and more

numerous than on the ascending colon
Descending colon
• Approximately 25 cm long

• this extends from the splenic flexure to the

pelvic brim

• in the whole of its course is plastered to the

posterior abdominal wall by peritoneum
• though a mesentery is present in about 20% of
adults.

• The splenic flexure lies on the lateral surface

of the left kidney, below and in contact with
the tail of the pancreas and the spleen.
Descending colon
• A fold of peritoneum, the phrenico-colic
ligament attaches the splenic flexure to the
diaphragm at the level of the tenth and
eleventh ribs.

• Surgical mobilization of the splenic flexure

requires division of this ligament.

• During this manoeuvre the spleen needs to be

safeguarded as it lies in contact with the
upper surface of the ligament.
Descending colon
• The descending colon lies on the lumbar fascia and
the iliac fascia.

• It ends at the pelvic brim about 5 cm above the

inguinal ligament.
• Mobilization of the descending colon is conveniently
carried out by dividing the peritoneum along the white
line of Toldt.

• The three taeniae coli, in continuity with those

of the transverse colon, lie one anterior and two
posterior (medial and lateral).
Sigmoid colon
• The sigmoid colon extends from the descending colon at
the pelvic brim to the commencement of the rectum in
front of the third piece of the sacrum.

• It is usually about 40 cm long, though great variations

in length are common.

• It is completely invested in peritoneum and hangs free

on a mesentery, the sigmoid mesocolon.
• this is attached pelvic mesocolon to the pelvic brim and the
sacrum.

• Congenital peritoneal adhesions are frequently found

between the lateral aspect of the pelvic mesocolon and
the parietal peritoneum of the floor of the left iliac
fossa
• they need to be divided during surgical mobilization of the
Sigmoid colon
• Like the rest of the large intestine,
• the commencement of the sigmoid colon is sacculated by
three taeniae coli,
• but these muscular bands are wider than elsewhere in the
large gut,
• meet at the terminal part of the sigmoid to complete the
longitudinal coat.

• The sigmoid colon possesses

• well-developed appendices epiploicae
• and diverticulosis.

• It lies, usually, in the pelvic cavity,

• coiled in front of the rectum,
• lies on the peritoneal surface of the bladder (and
Blood supply of the colon
• The ascending colon and the proximal two-thirds of
the transverse colon are supplied by
• the ileocolic,
• the right colic
• and the middle colic branches of the superior mesenteric
artery

• the remainder of the colon by

• the left colic and sigmoid branches of the inferior
mesenteric.

• The anastomotic branches near the inner margin of

the whole colon form
• the marginal artery (of Drummond) from which short
vessels run into the gut wall.
Blood supply of the colon
• The weakest link in this marginal chain of vessels is
near the left colic flexure,
• between the middle and left colic branches,
• i.e. between midgut and hindgut vessels.

• An inner arterial arc (of Riolan) is formed

• between the ascending branch of the left colic artery
• and the trunk of the middle colic artery
• may supplement the blood supply to the colon in this region.

• The veins
• correspond to the arteries
• and thus reach the portal vein via the superior or inferior
mesenteric veins.
• There is some anastomosis between portal and systemic venous
drainage
• where the ascending and descending colon are in contact with the
posterior abdominal wall
Blood supply of the colon
• Lymph drainage
• the lymph channels follow the arteries, so that drainage
is to superior or inferior mesenteric nodes.

• Nerve supply
• Being derived from the midgut and the hindgut,
• the large intestine receives its parasympathetic supply
partly from the vagi and partly from the pelvic
splanchnic nerves.
• The sympathetic supply is derived from spinal cord
segments T10–L2.
• The pain fibres that accompany these vasoconstrictor nerves
give rise to periumbilical pain if from midgut derivatives
(e.g. the appendix) but to hypogastric pain if from the
hindgut.
• As from the rectum, some pain fibres from the descending and
sigmoid colon appear to run with the parasympathetic nerves
ANATOMY OF THE
ESOPHAGUS AND STOMACH
Dr. ARIHO SAMUEL BONA
(MBChB, M.MED-SURGERY)
KABALE UNIVERSITY SCHOOL OF MEDICINE
MAR,2024
 OBJECTIVES
• By the end of this lecture the student
should be able to:
• Describe the anatomy of the esophagus;
extent, length, parts, strictures, relations, blood
& nerve supply and lymphatic.
• Describe the anatomy of the stomach;
location, shape, parts, relations, blood & nerve
supply and lymphatic.
• Describe the anatomical clinical application
for esophagus and stomach.
 INTROUCTION
The abdominal cavity
is divided into 9
compartments: by:
2 vertical and 2
horizontal planes.
Vertical planes:
Right and left vertical
lines (from
midclavicular to
midinguinal points).

Horizontal plane:
Subcostal plane (L3)
and intertubercular
lines (L5).
 ESOPHAGUS
• It is a tubular structure about
10 inches, (25 cm) long.
Cervical
• It begins as the continuation
of the pharynx at the level
of the 6th cervical vertebra.
• It pierces the diaphragm at
the level of the 10th thoracic
vertebra to join the
stomach.
thoracic • It is formed of 3 parts:
• 1- Cervical.
• 2- Thoracic.
Abdominal
• 3- Abdominal.
RELATIONS OF CERVICAL PART

• Anteriorly:
• Trachea.
• Recurrent
laryngeal nerves.
• Posteriorly:
• Cervical
Vertebrae.
• Laterally:
• Lobes of thyroid
gland.
 THORACIC PART

• In the thorax, it passes

downward and to the
left through superior and
then the posterior
mediastinum.
• At the level of the sternal
angle, the aortic arch
pushes the esophagus
again to the midline.
 Thoracic
part

ANTERIOR
RELATIONS

1. Trachea.
2. Left recurrent
laryngeal
nerve.
3. Left principal
bronchus.
4. Pericardium.
5. Left atrium.
Thoracic part
POSTERIOR
RELATIONS

1. Bodies of the
thoracic
vertebrae.
2. Thoracic duct.
3. Azygos vein.
4. Right posterior
intercostal
arteries.
5. Descending
thoracic aorta
(at the lower
end).
LATERAL RELATIONS

• On the Right side:

1. Mediastinal pleura.
2. Terminal part of the
azygos vein.
• On the Left side:
1. Mediastinal pleura.
2. Left subclavian
artery.
3. Aortic arch.
4. Thoracic duct.
 CLINICAL IMPORTANCE
ESOPHAGUS AND LEFT ATRIUM OF THE HEART

• There is a close
relationship between
the left atrium of the
heart and the
esophagus.
• What is the clinical
application?
• A barium swallow in
the esophagus will help
the physician to assess
the size of the left
atrium (dilation) as in
case of a heart failure.
 RELATIONS IN THE ABDOMEN

• Fibers from the right crus of the

• In the abdomen, the esophagus
descends for 1.3 cm and joins the
stomach.
• Anteriorly, it is related to the left
lobe of the liver.
• Posteriorly, it is related to the left
crus of the diaphragm. Prof. Makarem – Lymphatic vessels.
diaphragm form a sling around the
esophagus.
• At the opening of the diaphragm,
the esophagus is accompanied by:
– The two vagi
– Branches of the left gastric
vessels
 ESOPHAGEAL
CONSTRICTIONS

• The esophagus has 3 anatomic

constrictions.
• The first is at the junction with the
pharynx.
• The second is at the crossing with
the aortic arch and the left main
bronchus.
• The third is at the junction with
the stomach.
• They have a considerable clinical
importance.
• Why?
 ESOPHAGEAL
STRICTURES

1. They may cause difficulties in

passing an esophagoscope.
2. In case of swallowing of caustic
liquids (mostly in children), this
is where the burning is the worst
and strictures develop.
3. The esophageal strictures are a
common place of the
development of esophageal
carcinoma.
4. In this picture what is the
importance of the scale?
 ARTERIAL SUPPLY

• Upper third is
supplied by the
inferior thyroid
artery.
• The middle third
by the
descending
thoracic aorta.
• The lower third
by the left
gastric artery.
 VENOUS
DRAINAGE

• The upper third

drains in into the
inferior thyroid
veins.
• The middle third
into the azygos
veins.
• The lower third
into the left
gastric vein.
• The left gastric
vein is a tributary
of the portal vein.
 LYMPH
DRAINAGE

• The upper third

is drained in the
deep cervical
nodes.
• The middle third
is drained into
the superior
and inferior
mediastinal
nodes.
• The lower third is
drained in the
celiac lymph
nodes in the
abdomen.
Prof. Makarem
 NERVE SUPPLY

• It is supplied by
sympathetic fibers
from the sympathetic
trunks.
• The parasympathetic
supply comes form
the vagus nerves.
• Inferior to the roots of
the lungs, the vagus
nerves join the
sympathetic nerves
to form the
esophageal plexus.
• The left vagus lies
anterior to the
esophagus.
• The right vagus lies
posterior to it.

Prof. Makarem
 LOCATION
STOMACH • The stomach is the
dilated part of the
alimentary canal.
• It is located in the
upper part of the
abdomen.
• It extends from
behind the left
costal region to
the epigastric and
umbilical regions.
• Much of the
stomach is
protected by the
lower ribs.
• It is roughly J-
shaped.
 2 Orifices:
PARTS • Cardiac orifice
• Pyloric orifice
2 Borders:
• Greater curvature
• Lesser curvature
2 Surfaces:
• Anterior surface
• Posterior surface
3 Parts:
• Fundus
• Body
• Pylorus:
The pylorus is formed
of 3 parts
• Pyloric antrum
• Pyloric canal
• Pyloric sphincter
CARDIAC ORIFICE • It is the site of the
gastro- esophageal
sphincter.
• It is a physiological
but not an
anatomical,
sphincter.
• Consists of circular
layer of smooth
muscle (under
vagal and
hormonal control).
• Function:
• Prevents
regurgitation (reflux)
 FUNDUS

• Dome-shaped
• Located to the left
of the cardiac
orifice
• Usually full of gazes.
 BODY
• Extends from:
– The level of the
fundus to
– The level of
Incisura
angularis
• Incisura
angularis:
• a constant
notch on the
lesser curvature
LESSER CURVATURE

• Forms the right

border of the
stomach.
• Extends from
the cardiac
orifice to the
pylorus.
• Attached to
the liver by the
lesser
omentum.
GREATER CURVATURE • Forms the left
border of the
stomach.
• Extends from
the cardiac
orifice to the
pylorus.
• Its upper part is
attached to
the spleen by
gastrosplenic
ligament
• Its lower part is
attached to
the transverse
colon by the
greater
omentum.
PYLORIC ANTRUM AND PYLORUS

• The pyloric antrum

extends from Incisura
angularis to the pylorus
• The pylorus is a tubular
part of the stomach
• It lies in the transpyloric
plane
• It has a thick muscular
end called pyloric
sphincter.
• The cavity of the pylorus
is the pyloric canal.
 ANTERIOR
RELATIONS

1. Anterior
abdominal wall.
2. Left costal
margin.
3. Left pleura &
lung.
4. Diaphragm.
5. Left lobe of the
liver.
POSTERIOR RELATIONS
1. Lesser sac,
(omental bursa).
2. Left crus of the
diaphragm.
3. Left suprarenal
gland.
4. Part of left kidney.
5. Spleen.
6. Splenic artery.
7. Pancreas.
8. Transverse
mesocolon.
9. Transverse colon.
• All these structures
form the stomach
bed.
ARTERIES

• Left gastric
artery:
• It is a branch of
celiac artery.
– Ascends along
the lesser
curvature.
• Right gastric
artery:
From the hepatic
artery of the
celiac trunk.
– Runs to the left
along the lesser
curvature.
 • Short gastric arteries
ARTERIES – arise from the
splenic artery.
– Pass in the
gastrosplenic
ligament.
• Left gastroepiploic
artery:
from splenic artery
– Pass in the
gastrosplenic
ligament.
• Right gastroepiploic
artery:
• from the
gastroduodenal
artery of hepatic .
– Passes to the left
along the
greater
curvature.
 VEINS

• All of them drain into the portal circulation.

• The right and left gastric veins drain directly into the portal vein.
• The short gastric veins and the left gastroepiploic vein join the
splenic vein.
• The right gastroepiploic vein drain in the superior mesenteric vein.
LYMPH DRAINAGE
• The lymph vessels
follow the arteries.
• They first drain to
the:
– Left and right
gastric nodes
– Left and right
gastroepiploic
nodes and the
– Short gastric
nodes
• Ultimately, all the
lymph from the
stomach is
collected at the
celiac nodes.
 NERVE
SUPPLY

• Sympathetic fibers are derived from the celiac plexus.

• Parasympathetic fibers from both vagi.
• Anterior vagal trunk:
– Formed from both vagi mainly from the left vagus
– Supply the anterior surface of the stomach
– Gives a hepatic branch, from which a branch to the pylorus.
• Posterior vagal trunk:
– Formed from both vagi mainly from the right vagus
– Supply the posterior surface of the stomach
– Gives off a large branch to the celiac and the superior
mesenteric plexuses.
Applied anatomy

• Eseophageal Cancer
• Foreign Bodies in the Esophagus
• Esophagitis
• Esesophageal Varices
• Gastroeseophageal Reflux Disease
Applied anatomy
• Ulcers, helico bacter pylori and
vagotomy
• Gastrectomy
• Feeding Tube Gastrostomy
• Gastritis
• Barium meal x ray, gastroscope

Prof. Makarem
Applied anatomy

• Displacement of stomach
• Hiatus hernia
• Congenital diaphramatic hernia
• Pyloro spasm
• Congenital hypertrophic pyloric stenosis
• Stomach Cancer
• Gastrectomy
ANATOMY OF THE
SUPERIOR AND
POSTERIOR
MEDIASTINUM
DR. ARIHO SAMUEL BONA
(MBCHB, MMED SURGERY)
KABALE UNIVERSITY SCHOOL OF MEDICINE
FEB. 2024
DEFINITION OF
MEDIASTINUM

► It is a partition between the

right & left pleural sacs. It
includes all the structures
which lie in the intermediate
compartments of the thoracic
cavity
DIVISIONS OF MEDIASTINUM
DIVISIONS OF MEDIASTINUM

► It is divided by a horizontal plane extending from

sternal angle to lower border of 4th thoracic
vertebra into:
1. Superior mediastinum: above the plane
2. Inferior mediastinum: below the plane, it is
subdivided into:
► Anterior mediastinum: in front of pericardium
► Middle mediastinum: contains heart &
pericardium
► Posterior mediastinum: behind pericardium
SUPERIOR MEDIASTINUM

BOUNDARIES:
► Anterior: manubrium sterni
► Posterior: Upper 4 thoracic vertebrae
► Superior: Plane of thoracic inlet
► Inferior: Horizontal plane
► On each side: Pleura
SUPERIOR MEDIASTINUM
SUPERIOR MEDIASTINUM
SUPERIOR MEDIASTINUM
SUPERIOR MEDIASTINUM

CONTENTS:
► FROM BEHIND FORWARD:
1. Esophagus
2. Trachea
3. Arch of aorta & its 3 branches: brachiocephalic, left
common carotid & left subclavian arteries
4. Right & left brachiocephalic veins & superior vena
cava
5. Thymus gland
SUPERIOR MEDIASTINUM

OTHER CONTENTS:
► Nerves:
1. Right & left vagus
2. Right & left phrenic
3. Right & left sympathetic trunks
4. Left recurrent laryngeal
► Lymphatic structures:
1. Thoracic duct
2. Lymph nodes
POSTERIOR MEDIASTINUM

BOUNDARIES:
► Anterior: Pericardium & diaphragm
► Posterior: Lower 8 thoracic vertebrae
► Superior: Horizontal plane
► Inferior: Diaphragm
► On each side: Pleura
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM
POSTERIOR MEDIASTINUM

► CONTENTS:
1. Esophagus (most anterior structure)
2. Thoracic duct
3. Right & left vagus
4. Descending aorta
5. Azygos & hemiazygos veins
6. Right & left sympathetic trunks & their branches
(splanchnic nerves)
7. Lymph nodes
MIDDLE MEDIASTINUM

► CONTENTS:
1. Pericardium & heart
2. Arteries: ascending aorta, pulmonary trunk
3. Veins: lower half of superior vena cava,
terminations of inferior vena cava & pulmonary
veins
4. Nerves: phrenic
5. Lymph nodes
MEDIASTINUM
VEINS

BRACHIOCEPHALIC: (Superior mediastinum)

► FORMATION: by union of internal jugular & subclavian
vein (behind medial end of clavicle)
► END: Both veins unite to form S.V.C.
► RIGHT VEIN: shorter & has a vertical course, related
laterally to right phrenic nerve & right pleura & lung, its
tributaries in thorax: right 1st posterior intercostal vein,
right internal thoracic vein, right lymphatic duct
► LEFT VEIN: longer & has an oblique course, related
anteriorly to manubrium & thymus gland, & posteriorly
to branches of arch of aorta, its tributaries in thorax: left
1st posterior intercostal vein, left superior intercostal
vein, left internal thoracic vein, thoracic duct
VEINS

SUPERIOR VENA CAVA: (Superior

& middle mediastinum)
► FORMATION: by union of brachiocephalic veins,
behind lower border of right 1st costal cartilage
► END: opens into right atrium behind right 3rd costal
cartilage
► TRIBUTARIES: azygos vein
AZYGOS & HEMIAZYGOS
VEINS
VEINS

AZYGOS VEIN: (Posterior mediastinum)

► ORIGIN: by union of right ascending lumbar & subcostal veins (passes through
aortic opening of diaphragm)
► END: forms an arch above the root of right lung & ends in S.V.C. opposite lower
border of T4
► RELATIONS:
1. Anterior: esophagus
2. Posterior: thoracic vertebra
3. Right: right pleura & lung
4. Left: thoracic duct
► TRIBUTARIES: superior & inferior hemiazygos veins, right superior intercostal vein,
right posterior intercostal veins (from 4th to 11th), right bronchial veins,
esophageal & pericardial veins
VEINS

INFERIOR HEMIAZYGOS: (Posterior

mediastinum)
► ORIGIN: by union of left ascending
lumbar & subcostal veins (passes
through left crus of diaphragm)
► END: into azygos vein, opposite T8
► TRIBUTARIES: left posterior intercostal
veins (9th to 11th), esophageal veins
VEINS

SUPERIOR HEMIAZYGOS: (Posterior mediastinum)

► ORIGIN: by left posterior intercostal veins
(4th to 8th)
► END: into azygos vein, opposite T7
► TRIBUTARIES: left bronchial veins
INFERIOR VENA CAVA: (Posterior mediastinum)
► END: passes through vena caval opening
of diaphragm & opens into right atrium
behind right 6th costal cartilage
ARTERIES

AORTA:
► ASCENDING AORTA: (Middle mediastinum)
1. ORIGIN: at the base of left ventricle opposite
lower border of left 3rd costal cartilage
2. END: ascends upward, forward & to the right &
continues as arch of aorta
3. BRANCHES: right & left coronary arteries
 ARTERIES

► ARCH OF AORTA: (Superior mediastinum)

1. ORIGIN: continuation of ascending aorta, opposite upper border of
right 2nd costal cartilage

2. COURSE & RELATIONS: ascends upward backward & to the left

(behind manubrium & in front of trachea) then curves backward (to
the left of trachea) then finally curves downward
3. TERMINATION: continues as descending aorta, opposite lower
border of T4
 ARTERIES

► BRANCHES OF ARCH OF AORTA: (Superior mediastinum)

1. BRACHIOCEPHALIC: ascends upward & to the right
(behind left brachiocephalic vein & in front of trachea)
& divides into right common carotid & right subclavian
arteries (behind right sternoclavicular joint)
2. LEFT COMMON CAROTID: ascends upward & to the left
(to the left side of brachiocephalic artery) & enters the
neck (behind left sternoclavicular joint)
3. LEFT SUBCLAVIAN: ascends upward (behind left
common carotid artery, in front of esophagus, to the
left side of trachea), arches over apex of left lung to
enter neck
 ARTERIES

DESCENDING AORTA: (Posterior mediastinum)

► ORIGIN: continuation of arch of aorta
► TERMINATION: passes through aortic opening of diaphragm
(opposite T12) & continues as abdominal aorta
► RELATIONS:
1. Anterior: esophagus
2. Posterior: thoracic vertebrae
3. Right: thoracic duct
4. Left: left pleura & lung
► BRANCHES: posterior intercostal (from 3rd to 11th), subcostal,
bronchial, esophageal, pericardial arteries
TRACHEA

► BEGINNING: continuation of larynx, opposite C6

► TERMINATION: bifurcates into 2 bronchi, opposite lower border of T4
► RELATIONS: (in superior mediastinum)
1. Anterior: arch of aorta, brachiocephalic & left common carotid
arteries
2. Posterior: left recurrent laryngeal nerve, esophagus
3. Right: right vagus nerve
4. Left: arch of aorta, left subclavian artery
► NERVE SUPPLY: sympathetic trunks & vagus
► BLOOD SUPPLY: inferior thyroid vessels
► LYMPHATIC DRAINAGE: pretracheal & paratracheal
ESOPHAGUS

► BEGINNING: continuation of pharynx, opposite C6

► TERMINATION: passes through esophageal opening
of diaphragm (opposite T10) & joins stomach
► RELATIONS: (in superior mediastinum)
1. Anterior: left recurrent laryngeal nerve, trachea, left
subclavian artery
2. Posterior: thoracic vertebrae
3. Right: right pleura & lung
4. Left: thoracic duct, left pleura & lung
 ESOPHAGUS

► RELATIONS: (in posterior mediastinum)

1. Anterior: pericardium, separating it from left atrium
2. Posterior: thoracic duct, descending aorta, azygos vein
3. Right: right pleura & lung
4. Left: descending aorta, left pleura & lung
► NERVE SUPPLY: as trachea
► ARTERIAL SUPPLY: descending aorta
► VENOUS DRAINAGE: azygos & hemiazygos
► LYMPHATIC DRAINAGE: posterior mediastinal lymph
nodes
THORACIC DUCT

► ORIGIN: from upper end of cysterna chyli (opposite L1 & L2)

► COURSE: passes through aortic opening of diaphragm,
ascends in posterior mediastinum (behind esophagus) & in
superior mediastinum (to the left of esophagus) to enter root
of neck
► END: in left brachiocephalic vein
► RELATIONS: ( in posterior mediastinum)
1. Anterior: esophagus
2. Posterior: thoracic vertebrae
3. Right: azygos vein
4. Left: descending aorta
THORACIC DUCT

TRIBUTARIES:
► It drains lymph from both sides of the body below
the diaphragm through cysterna chyli
► It drains lymph from left half of the body above
diaphragm through:
1. Left jugular lymph trunk: drains left side of head &
neck
2. Left subclavian lymph trunk: drains left upper limb
3. Left bronchomediastinal lymph trunk: drains left
side of thorax
RIGHT LYMPHATIC DUCT

► ORIGIN: formed by union of:

1. Right jugular lymph trunk: drains right
side of head & neck
2. Right subclavian lymph trunk: drains
right upper limb
3. Right bronchomediastinal lymph trunk:
drains right side of thorax
► END: in right brachiocephalic vein
 NERVES

PHRENIC NERVES: (Superior & middle mediastinum)

► ORIGIN: anterior rami of C3,4,5
► COURSE & RELATIONS IN THORAX:
1. RIGHT: descends to the right side of: right brachiocephalic vein, S.V.C.,
pericardium, I.V.C.
2. LEFT: descends to the left side of: arch aorta, pericardium
► BRANCHES:
1. Motor branches to: diaphragm
2. Sensory branches from:
► Mediastinal & central part of diaphragmatic pleura
► Fibrous pericardium & parietal layer of serous pericardium
► Peritoneum covering central part of undersurface of diaphragm
 NERVES

► VAGUS NERVES: (Superior & posterior mediastinum)

► ORIGIN: 10th cranial nerve
► COURSE & RELATIONS IN THORAX:
1. RIGHT: descends to the right side of: trachea, behind root of right lung
(pulmonary plexus), behind esophagus (esophageal plexus), passes
through esophageal opening of diaphragm to reach posterior surface
of stomach
2. LEFT: descends to the left side of: arch aorta, behind root of left lung
(pulmonary plexus), in front of esophagus (esophageal plexus), passes
through esophageal opening of diaphragm to reach anterior surface of
stomach
 NERVES

BRANCHES IN THORAX:

► BOTH VAGI: to lungs & esophagus

► RIGHT VAGUS: to heart

► LEFT VAGUS: left recurrent laryngeal nerve: curves below arch of

aorta, behind ligamentum arteriosum, ascends in groove between
trachea & esophagus to reach the neck. It supplies: heart, trachea,
esophagus (in thorax) & larynx (in neck)
NERVES

THORACIC PART OF SYMPATHETIC TRUNKS: (Superior & posterior

mediastinum)
► BEGINNING: the cervical part continues as thoracic part by passing in
front of neck of first rib
► TERMINATION: the thoracic part continues as lumbar part by passing
behind medial arcuate ligament
► COURSE:
1. In upper part of thorax: descend in front of heads of ribs
2. In lower part of thorax: descend on the sides of bodies of vertebrae
► GANGLIA: usually 11 (1st thoracic ganglion fuses with inferior cervical
ganglion forming stellate ganglion)
NERVES

► BRANCHES:
1. Rami communicantes: each ganglion receives a white ramus
(preganglionic) & gives a grey ramus (postganglionic) to
corresponding thoracic spinal nerve
2. Visceral branches (postganglionic) to thoracic organs (from upper 5
ganglia): to heart, lungs, esophagus, descending aorta
3. Visceral branches (preganglionic) to abdominal organs:
► Greater splanchnic nerve (from 5th to 9th ganglia)
► Lesser splanchnic nerve (from 10th 7 11th ganglia)
► Lowest splanchnic nerve (from 12th ganglion)
 THE DIAPHRAGM AND
CONGENITALS ANOMALIES

Professor Dr. Mario Edgar Fernández.

 Summary:
Diaphragm.
⚫ Situation.
⚫ Portions: sternal part, costal part, lumbar part.
⚫ Diaphragmatic apertures: Caval opening, Esophageal
hiatus, Aortic hiatus, small openings in diaphragm.
⚫ Vessels and nerves of Diaphragm.
⚫ Functions.
THE DIAPHRAGM
 DIAPHRAGM
Muscular
Central
Part. Tendon
 Sternal
Costal part
par

Lumbar
part
 Costal Crura or
pillars
part

Porción
lumbar
Right Left Crura
Crura

Median
Arcuata
Ligament
 Caval
opening
Esophageal
hiatus
Aortic
hiatus
 Aorta

Esophagus

IVC
FUNCTION
 Bibliography.
⚫ Grays anatomy: the anatomical basis of clinical
practice.
⚫ Grays anatomy; anatomy descriptive and surgical.
⚫ Clinically oriented anatomy: Keith L. Moore.