1- ANATOMY OF THE THORACIC WALL

Bones of thoracic cage

- Sternum
- 12 pairs of ribs, costal cartilages
- 12 thoracic vertebrae

RIBS

Classification according to their attachments to sternum:

- Total number of Ribs: 12 pairs
A: True ribs: Upper 7 ribs (Directly attached to the sternum).
B: False ribs: Lower 5 ribs (Indirectly attached to sternum).
- The lower 2 ribs (11th & 12th) are called Floating ribs because they are
free anteriorly.
Classification of ribs according to their structure:
A: Typical: 3rd - 9th ribs.
B: non typical:1st, 2nd, 10th, 11th, and 12th ribs. (first two and last 3) ribs.

STERNUM
- 3 Parts, Manubrium, Body , Xiphoid process.
- Manubrium: Lies opposite T3,4. - Body: T5 toT8 - Xiphoid T9

Thoracic vertebra
- There are 12 thoracic vertebra, classified into Typical and
non typical thoracic vertebra

JOINTS OF THE THORAX

A- Sternal joints:
1- manibriosternal joints: secondary cartilages.
2- xiphisternal joints: functionally classified as primary cartil. ossify in
old age(but structurally classified as secondary).
B- joints of the rib:
1- Sternochondral joints: (1st one is
primary cartil. but others from 2nd to 7th
are synovial.
2-Chondrocostal joints: primary cartil.
3- Interchondral joints: between costal
cartilages 5,6,7,8,and 9 are synovial.
4- Costovertebral joints: between head
of ribs and vert. column by plane synovial.
5- Costotransverse: between tubercle of ribs and tip of corresponding
vertebra. It is a plane synovial. It is strengthen by , sup, lat and inf.
costotransverse lig.

THORACIC CAGE
Shape: Conical
Boundaries:
- Sternum & costal cartilages: anteriorly
- 12th pairs of ribs: laterally
- 12th thoracic vertebrae: posteriorly
Has 2 apertures (openings):
- Superior (thoracic outlet): narrow, open, continuous with neck
- Inferior: wide, closed by diaphragm
Thoracic inlet
Boundaries:
a. Anterior: Supra-sternal notch of the manubrium sterni.
b. On each side: First rib.
c. Posterior: First thoracic vertebra.
Contents of thoracic inlet:
1- Arteries: common carotid artery, subclavian and brachiocephalic
arteries
2- Nerves: vagus n., phrenic n. and recurrent laryngeal n.
3- Tubes: tachea, oesophagus and thoracic duct.
4- Apex of lung.
5- On either sides, it is closed by a dense suprapleural membrane
Suprapleural Membrane
- Tent shaped dense fascial sheet that covers the apex of each lung. It is an
extension of the endothoracic fascia
- Extends approximately an inch superior to the superior thoracic aperture
- It is attached:
# Laterally to the internal border of the first rib & costal cartilage
#At its apex to the transverse process of C7 vertebra.
# Medially to the fascia covering the structures passing through the
superior thoracic aperture
Thoracic outlet
Boundaries:
a. Anterior: xiphoid
process.
b. On each side: lower 6
costal cartilages & Last 2
ribs.
c. Posterior: last thoracic
vertebra.
- It is closed by the
diaphragm which
separates it from the abdominal cavity.
 The Intercostal Space
Definition: the space between 2 successive ribs.
Number: 11 intercostal spaces and a subcostal space(on each side).
Contents:
1- Intercostal muscles.
2- Intercostal nerves.
3- Intercostal arteries.
4- Intercostal veins.
Intercostal muscles
Intercostal muscles arranged in 3 layers:
I. Outer layer → External intercostal muscle
II. Intermediate layer → Internal intercostal muscle
III. Inner layer → Transversus thoracis group, subdivided into:
1. Innermost intercostals 2. Sterno-costalis 3. Sub-costalis

External Intercostal Muscle (most superficial) - Origin: from lower

border of the rib above
- Fibers directed downward & forward
- Insertion: upper border of rib below
- Extends from the rib tubercle behind to the costo-chondral junction in
front, deficient anteriorly & replaced by external (anterior) intercostal
membrane
Internal Intercostal Muscle (intermediate layer)
- Origin &Insertion: as external intercostal muscle.
- Extends from the sternum in front to the angle of the rib behind,
deficient posteriorly & replaced by internal (posterior) intercostal
membrane
Transversus thoracis muscle (deepest layer)
A- Innermost intercostal Muscle
B- Sternocostalis
- 4 to 5 slips which arise from inner surface of lower part of body of
sternum and costal cartilages
- Inserted into inner surface of costal cartilages from 2 to 6.
C- Subcostalis:
- thin bands of muscle fibers, mainly in lower 6 spaces, only in post. part
of the spaces.
Origin: Inner surface & lower border of rib above.
Insertion: Upper border of 2nd or 3rd rib below.

Nerve supply of intercostal musces: Supplied by corresponding

intercostal nerves and its collateral.
Action of intercostal musces: (respiration)
-Tend to pull the ribs nearer to each other - Strengthen the tissue of the
space
Endothoracic Fascia
- It is the extrapleural fascia that lines the wall of the chest
- It is located between the muscles and bones of the thoracic wall and the
parietal pleura, extends over the apex (cupola) of the pleura as the
suprapleural membrane, and forms a thin layer between the diaphragm
and the pleura.

DIAPHRAGM
Shape and position: dome-shaped fibro- muscular structure between
thorax and abdomen, consists of a peripheral muscular part and a central
tendon
Origin
1- Sternal part: back of xiphoid process
2- Costal part: inner aspect of lower six ribs and costal cartilages
3- vertebral origin: arises by;
- 2 crura and 5 ligaments(median, 2 medial and 2 lateral arcuate
ligaments)
Insertion: central tendon
Nerve supply: by phrenic nerve(C3,4,5) and lower 6 intercostal n.
Action:
- its contraction→ increases the volume of thoracic cavity → inspiration
- its contraction→↑ intra-abdominal pressure→ defecation, vomiting or
labour.
- its relaxation→ reduces the volume of the thoracic cavity→ expiration.
Openings of the diaphragm
1- Aortic opening: at level of T12, between the crura. It transmits the
aorta, thoracic duct and azygos vein.
2- Esophageal opening: at level of T10, for esophagus and vagus nerves
3- Vena cava opening: at level of T8, through central tendon for IVC.
 Respiratory Movement
1- In inspiration
A- Quite inspiration:
During inspiration, movements of thoracic wall and diaphragm result in
an increase in all diameters of the thorax:
1- Vertical diameter: increased by contraction (descent) of the
diaphragm
2- Transverse diameter: increased by bucket-handle movements
3- Anteroposterior diameter: increased by pump- handle movements
B- Forced inspiration:
muscles of head and neck and upper limb aid in increase in thoracic and
lung volumes.
-The scalenes. - sternomastoid muscles. - pectoralis minor.

2- In expiration
A- Quite expiration: elastic recoil of diaphragm and intercostal muscles.
B- Forced expiration: forcible contraction of muscles of anterior
abdominal wall, abdominus rectus and abdominal obliques: internal
obliques, external obliques.

Intercostal Nerves
Number: 11 intercostal nerves in the upper 11 intercostal spaces and a
subcostal nerve below the last rib (on each side).
They are classified into:
I. Typical Intercostal Nerves: 3-6 intercostal nerves .
II. Atypical Intercostal Nerves: which are the 1st, 2nd and lower 5
intercostal nerves .
Typical Intercostal Nerves:
Beginning: as a continuation of ventral rami of thoracic spinal nerves.
Course:
- run in the intercostal space between internal and innermost intercostal
muscles.
- in the space, it lies below intercostal vein and artery (VAN).
End: as anterior cutaneous nerve.
Branches:
1. ganglionic branches to the sympathetic ganglion.
2. Collateral branch which runs over the upper border of the rib below.
3. Anterior cutaneous branch .
4. Lateral cutaneous branch which divides into anterior and posterior
branches.
5. Muscular branches to the intercostal muscles.
6. Sensory branches to the pleura.

II. Atypical Intercostal Nerves

1. First intercostal nerve: share in formation of brachial plexus.
2. Second intercostal nerve
- Its lateral cutaneous branch does not divide into anterior and posterior
branches and called the intercosto-brachial nerve which supplies the
base of the axilla and upper part of the medial side of arm.
3. Lower five intercostal nerves
- They reach the anterior abdominal wall at the anterior ends of the spaces
and supply its structures in addition to the diaphragm.
 Intercostal Arteries
Each intercostal space contains:
1- Anterior Intercostal Arteries.
2- Posterior Intercostal Arteries.
Anterior Intercostal Arteries
Beginning:
- In the upper 6 spaces, arise from the internal thoracic artery
- In the lower 3 spaces arise from the musculophrenic artery (one of the
terminal branch of internal thoracic)
End: by anastomosis with the posterior intercostal arteries
Internal thoracic (mammary) artery
Beginning: From 1st part of the subclavian artery.
End: opposite the 6th intercostal space by dividing into superior
epigastric and musculo-phrenic arteries.
Course:
- descends in the thorax 1.2cm lateral to edge of sternum in accompany
with Internal thoracic (mammary) vein.
- it ends at the sixth costal cartilage by dividing musculophrenic and
superior epigastric arteries.
Branches:
1. Anterior intercostal arteries (upper 6 spaces).
2. Perforating branches for the mammary gland.
3. Mediastinal branches.
4. Sternal branches.
5. Pericardiaco-phrenic artery.
6. Pericardial branches.
7. Superior epigastric artery.
8. Musculo-phrenic artery.
 Posterior Intercostal Arteries
Beginning:
- In the upper 2 spaces, arise from the superior intercostal artery (a branch
of costocervical trunk of the subclavian artery)
- in 3-12 spaces, arise from the branches of descending thoracic aorta
Course: follow the same course of intercostal nerves
- Each posterior intercostal space, contains one posterior intercostal
artery which runs in the costal groove
- Each artery gives a collateral branch, which runs over the upper border
of the rib below.
End: by anastomosing with anterior intercostals arteries.

Intercostal Veins
I. Anterior intercostal veins II. Posterior Intercostal Veins
I. Anterior intercostal veins:
- They are 9 correspond to the anterior intercostal arteries.
They drain into
- the 9th, 8th and 7th veins drain into venae comitantes of musculophrenic
art.
- the 6th, 5th and veins drain into venae comitantes of internal thoracic
artery.
- the 3rd, 2nd and 1st veins drain into internal thoracic vein.

II. Posterior Intercostal Veins

On Right side:
- 1st post. intercostal vein→ right innominate vein.
- 2nd + 3rd +4th post. intercostal veins unite to form the right superior
intercostal vein → azygos vein.
-5th - 11th post. intercostal veins+ Subcostal vein → azygos vein.
On Left side:
- 1stpost. intercostal vein→ left innominate vein.
- 2nd + 3rd + 4th post. intercostal veins unite to form the left superior
intercostal vein → left innominate vein.
- 5th – 8th post. intercostal veins→ superior hemiazygos.
- 9th – 11th post. intercostal vein +Subcostal vein → inferior hemiazygos
vein.

AZYGOS VEIN
Beginning: - as continuation of right ascending lumbar vein
- back of IVC.
- as continuation of right subcostal vein
Course:
- It enters the thorax through aortic opening of diaphragm.
- Ascend in post. Then sup. mediastinum.
End: in SVC by aching above right lung root at level of 2nd Rt costal cart.
Relations
- Anteriorly: root of RT lung, pericardium
and esophagus
- Posterior: RT posterior intercostal arteries
and lower 8 thoracic verteb.
- Left: descending thoracic aorta and
thoracic duct.
- Right: RT lung and pleura
Tributaries
- right subcostal vein.
- right posterior intercostal veins(5-11).
- right superior intercostal vein.
- right ascending lumbar vein.
- superior hemiazygos v.
- Inferior hemiazygos v.
- left bronchial veins.
- esophageal veins.
- pericardial veins.
- diaphragmatic veins.

2- Anatomy of the Upper Respiratory Tract

NOSE
Functions of the nose:
- It provides an airway for respiration
- It filters and cleans inspired air
- It moistens and warms (cools) the entering air
- It serves as a resonating chamber for speech
- It houses the olfactory (smell) receptors
External nose:
- The nasal root: is the top of the nose that
attaches the nose to the forehead.
- The nasal root is above the bridge and below
the glabella.
-The dorsum of nose: border between the root
and the tip of the nose.
- The apex: lower end of the dorsum of nose.
- Philtrum: Just inferior to the apex
-The ala of the nose: (ala nasi, "wing of the nose") is the lower lateral
surface of the external nose, it flare out to form a rounded eminence
around the nostril.
 NASAL CAVITY
is divided into the right and left halves by nasal septum, each half has 4
walls; medial, lateral, roof and floor.
Medial (Nasal Septum): formed by;
(a) Perpendicular plate of ethmoid bone.
(b) Nasal septal cartilage.
(c) Vomer.
Inferior wall(Floor): the hard palate.
Superior wall(Roof)
(a) anterior sloping part: by nasal bone.
(b) middle horizontal part: by cribriform plate of ethmoid.
(c) posterior sloping part: by body of sphenoid and ala of vomer.
Lateral wall:
(a) Vestibule: small dilation above nostril.
(b) Atrium: shallow depression above and behind the vestibule.
(c) Nasal conchae (turbinate): 3 shelf- like elevations separated by spaces
called meatuses. The 3 conchae are superior, middle and inferior.
(d) nasal meatuses: below the
corresponding conchae
1- Superior meatus: receive the opening
of posterior ethmoidal sinus.
2- Middle meatus: show the following;
- bulla ethmoidalis: rounded elevation at
which middle ethmoidal sinus opens
- hiatus semilunaris: a crecentic groove receive the openings of; anterior
ethmoidal sinus, frontal air sinus and maxillary air sinus.
3- Inferior meatus: receive the opening of nasolacrimal duct.
NB: Spheno-ethmoidal recess: at the roof of the nose and receive the
opening of sphenoidal air sinus
Arterial supply of the nose:
The upper part of the nasal cavity receives its arterial supply from
branches of ophthalmic artery, a branch of ICA. While the lower part of
the cavity from branches of the maxillary artery, from the ECA.
1- Branches of the ophthalmic artery: the anterior and posterior
ethmoidal arteries supply the roof, upper bony septum,
2- Branches of the maxillary artery include:
a- greater palatine artery.
b- sphenopalatine artery and its branches
c- infraorbital artery and its branches.
3- A branch of the facial artery (the superior labial artery)

NB:
Kesselbach’s Plexus/Little’s Area: This
area lies in the vestibule of the nose, on the
anteroinferior part of the septum, in which
90% of nose-bleeds occur, arteries form it:
- Anterior Ethmoid (Opth)
- Superior Labial A (Facial)
- Sphenopalatine A (MAX)
- Greater Palatine (MAX)
Woodruff’s Plexus: lies in the back of nasal cavity, arteries form it are:
- Pharyngeal and Posterior nasal branches of Sphenopalatine A
(MAX).
- A nosebleed, also known as epistaxis, is bleeding from the nose. Blood
can also flow down into the stomach, In more severe cases, blood may
come out of both nostrils. Blood may also come up the nasolacrimal duct
and out from the eye.
 - There are two types: anterior, which is more common; and posterior,
which is less common but more serious. Anterior nosebleeds generally
occur from Kiesselbach's plexus while posterior bleeds generally occur
from the sphenopalatine artery

Nerve supply of the nose:

- Special sensation: by Olfactory nerves.
- General sensation: comes from 2 branches of the trigeminal nerve;
)the ophthalmic nerve and the maxillary nerve).
In the nasal cavity, the nasal mucosa is divided in terms of nerve
supply into a posteroinferior, and a anterosuperior parts.
The posteroinferior part is supplied by a branchs of maxillary nerve
1- the nasopalatine nerve which reaches the septum.
2- Lateral nasal branches of the greater palatine nerve
The anterosuperior part is supplied from a branch of the ophthalmic
nerve
- the nasociliary nerve, and its branches (anterior and posterior
ethmoidal nerves).
Most of the external nose, the dorsum, and the apex are supplied by:
1- infratrochlear nerve, (a branch of the nasociliary nerve).
2- The external branch of the anterior ethmoidal nerve.
3- the infraorbital nerve

PARANASAL SINUSES
- These are air-filled cavities, which develop in facial and cranial bones.
- The paranasal sinuses are paired and are named for the bone in which
they are located:
1- Frontal sinuses.
2- Sphenoid air sinuses.
3- Ethmoidal sinuses (anterior , middle and posterior).
4- Maxillary sinuses.
- paranasal sinuses drain into nasal cavity: see the nasal cavity.
Nerve supply of paranasal sinuses:
- The maxillary sinus → by superior alveolar and infraorbital nerves
from the maxillary nerve.
- The frontal sinus is supplied by branches of the supraorbital nerve.
- The ethmoid sinuses are supplied by anterior and posterior ethmoid
branches of the nasociliary nerve.
- The sphenoid sinus is supplied by the posterior ethmoidal nerves.

Maxillary air sinus

Site: in maxilla. One sinus located in each side of the face.
Shape: It is pyramidal in shape has;
- base: forming the lateral wall of the nose.
- apex: in the zygomatic process of the maxilla.
- inferiorly: tooth-bearing area of maxilla.
- roof: formed by the floor of the orbit.
- floor: formed by the alveolar process of maxilla.
Opening of the sinus: into hiatus semilunaris of middle meatus of nose.
Nerves related to maxillary sinus
a- superior alveolar nerves: anterior, middle and posterior.
b- infraorbital nerve.

NB: sinsusitis: Sinuses frequently become infected due to obstruction of

normal drainage, results in reduction of ventilation and negative pressure
in a sinus, it can cause headaches.
 PHARYNX
- a musculomembranous tube, 12 – 14 cm long
- located behind nasal cavities, mouth &
larynx
- Extends from base of skull to level of C6
vertebra
- Common passage for food and air
- Its cavity divided into:
– Nasopharynx: behind nose, From base of skull in front of C1 & C2
– Oropharynx: behind the mouth, in front of C3
– Laryngopharynx: behind the larynx, in front of C4, C5, C6
Nasopharynx
- Location: Posterior to nasal cavity& superior to level of soft palate
- Communicate with oropharynx through pharyngeal isthmus.
- ONLY an air passageway
- Closed off during swallowing by the soft palate ( uvula)
- Contents of Nasopharynx
A- Opening of Eustachian tube: communicates nasopharynx with
middle ear, opening and closing of the auditory tubes equalize the
barometric pressure in the middle ear with that of the ambient atmosphere.
B- Adenoid (pharyngeal tonsils) : collection of lymphoid tissue at the
roof of nasopharynx.
C- Tubal elevation: Upper and posterior margins of orifice of eustachian
tube are elevated due to collection
of lymphoid tissue.
D- Salpingopharyngeal fold: a
vertical fold of mucous membrane
extending from the inferior part of
the opening and containing the salpingopharyngeus muscle.
E- pharyngeal recess (fossa of Rosenmüller): a deep recess behind tubal
opening, common site of nasopharyngeal cancer
F- Salpingopalatine fold: A mucous fold which extends downwards and
forwards to the soft palate from tubal elevation. It contains levator Palati
muscle
3- Anatomy of the lower Respiratory Tract
Larynx
- It is the part of respiratory tract containing the vocal cords.
- A tube-shaped organ, 2-inch-long
- It opens into the laryngeal part of the pharynx above.
- It is continuous below with the trachea.
- It is functioning in:
1- Deglutition (swallowing).
2- Respiration (breathing).
3- Phonation (phonation).
Structure: The larynx consists of four
basic components:
1- A cartilaginous skeleton.
2- Membranes and ligaments.
3- Muscles (intrinsic and extrinsic).
4- Mucosal lining.
Cartilages: The cartilaginous skeleton
is comprised of :
1- Single: as Thyroid, Epiglottis and cricoid
2- Paired: as Arytenoid, Corniculate and Cuneiform.
- All the cartilages are hyaline, except the epiglottis (elastic cartilage).
- The cartilages are Connected by joints, ligaments & membranes and
moved by muscles.
Membranes & Ligaments
1- Thyrohyoid membrane, (one median & two lateral thyrohyoid
ligaments).
2- Median cricothyroid ligament.
3- Cricotracheal membrane.
4- Hyoepiglottic ligament.
5- Thyroepiglottic ligament.
6- Quadrangular membrane:
- Extends between the epiglottis
and the arytenoid cartilages.
- Its lower free margin forms the vestibular ligament that lies within the
vestibular fold.
7- Cricothyroid membrane (conus elasticus):
- Attached to upper border of the cricoid cartilage.
- Its upper free margin forms vocal ligament.
Laryngeal Cavity: Extends from laryngeal inlet to the lower border of the
cricoid cartilage.
- Narrow in the region of the vestibular folds (rima vestibuli).
- Narrowest in the region of the vocal folds (rima glottidis).
- Divided into three parts:
1- Supraglottic part, the part above the vestibular folds, is called the
vestibule.
2- Ventricle: The part between the vestibular & the vocal folds.
3- Infraglottic part, the part below the vocal folds.
Mucous Membrane
- The cavity is lined with ciliated columnar epithelium
- The surface of vocal folds, is covered with stratified squamous
epithelium because of exposure to continuous trauma during phonation,
 - Contains many mucous glands, more numerous in the saccule (for
lubrication of vocal folds)
Muscles of the larynx: divided into;
Extrinsic muscles: Intrinsic muscles:
divided into two groups divided into two groups
A- Elevators of the larynx A- Muscles controlling the laryngeal inlet
1- The Suprahyoid Muscles: 1- Oblique arytenoid
- Digastric. 2- Aryepiglottic muscle
- Stylohyoid. B- Muscles controlling the movements of
- Mylohyoid. the vocal cords
- Geniohyoid. 1- Muscle relax Vocal Cords
2- The Longitudinal - Thyroarytenoid (vocalis)
Muscles of the Pharynx: 2- Muscle stretch Vocal Cords
- Stylopharyngeus. - Cricothyroid
- Salpingo-pharyngeus. 3- Adductors of Vocal Cords
- Palatopharyngeus. - Lateral cricoarytenoid
B- Depressors of the larynx - Transverse arytenoid
The Infrahyoid Muscles: 4- Abductor of Vocal Cords
- Sternohyoid. Posterior cricoarytenoid.
- Sternothyroid. NB: Cricothyroid is the only intrinsic
- Omohyoid. muscle that present in the outer surface of
the larynx.

Laryngeal Inlet
- It is the upper opening of the larynx.
- It is directed upward and backward
and opens into the laryngeal part of the
pharynx.
- Bounded by:
@ Anteriorly: by the upper margin of epiglottis.
@ Posteriorly & below by arytenoid cartilages
@ Laterally by aryepiglottic folds
NB: Piriform fossa: The area of the pharynx that surrounds the inlet of
larynx.

Blood Supply and lymphatic drainage:

Arteries:
- Upper half: Superior laryngeal artery, branch of superior thyroid artery.
- Lower half: Inferior laryngeal artery, branch of inferior thyroid artery.
Veins: Accompany the corresponding arteries.
Lymphatics: The lymph vessels drain into the deep cervical lymph
nodes.
Nerve Supply
- Sensory
- Above the vocal cords: Internal laryngeal nerve, branch of the superior
laryngeal of vagus.
- Below the vocal cords: Recurrent laryngeal, of vagus.
- Motor
All intrinsic muscles of the larynx are supplied by the recurrent laryngeal
except cricothyroid, which is supplied by the external laryngeal of
superior laryngeal of vagus.
Trachea (windpipe)
- Mobile, fibrocartilginous tube, 5 inches long, 1 inch
in diameter.
- Begins: In the neck below the cricoid cartilage of the
larynx (at the level of C6).
- Ends: below in the thorax at the level of sternal angle (lower border of
T4), by dividing into right and left principal (main, primary) bronchi.
- Structure: 15-20 C-shaped cartilages, completed posteriory by tachealis
muscle.
- The ridge at the bifurcation is called carina. It is the most sensitive part
of the tract and is associated with the cough reflex.
Relations of trachea:
Anterior Posterior Right side Left side
- Sternum. - Esophagus. - Azygos vein. - Arch of aorta.
- Thymus. - Left recurrent - Right vagus nerve. - Left common
- Lt brachiocephalic laryngeal nerve. - Pleura. carotid artery.
vein. - Left subclavian a.
- brachiocephalic artery. - Left vagus & left -
- Left common carotid a. phrenic nerves.
- Arch of aorta. - Pleura.

Nerve Supply
- Branches of vagus and the recurrent laryngeal nerves. (from vagus)
supply sensory fibers to the mucous membrane.
- Branches from the sympathetic trunks supply the trachealis muscle and
the blood vessels.
Blood Supply
Arteries: Branches from the inferior thyroid and bronchial arteries.
Veins: Drain to inferior thyroid veins.
Lymphatic Drainage: Into the pre- & paratracheal lymph nodes.
 Principal Bronchi
Right Principal Bronchus
- About one inch long
- Wider, shorter and more vertical
than the left ( foreign bodies).
- Gives superior lobar bronchus
before entering the hilum of the
right lung
- On entering the hilum it divides
into middle and inferior lobar
bronchi.
Left Principal Bronchus
- About two inches long
- Narrower, longer and more
horizontal than the right
- Passes to the left below the arch of
aorta and in front of esophagus
- On entering the hilum of the left
lung it divides into superior and
inferior lobar bronchi

Bronchial Divisions
- Within the lung each bronchus
divides into number of branches
that can be divided into two
groups:

Conduction zone branches Respiratory zone branches

- Primary (main) bronchi - Respiratory bronchioles
- Secondary (lobar) bronchi - Alveolar ducts
- Tertiary (segmental) bronchi (supply - Alveolar sacs
the bronchopulmonary segment) - Alveoli
- Smaller bronchi
- Bronchioles
- Terminal bronchioles
 4- ANATOMY OF LUNG AND PLEURA
pleura
- It is a closed serous sac which surrounds the lung and invaginated from
its medial side by the root of lung.
- Its components are:
1- Parietal pleura which lines the thoracic cavity.
2- Visceral pleura which surrounds the lung.
3- Pleural cavity: contains 5-10 ml of serous fluid which lubricates both
surfaces and allows the lungs to move free during respiration.

Divisions of parietal pleura

1- Cervical pleura: part of parietal pleura which protrudes into the root of
neck.
2-Costal pleura: it lines inner surface of ribs, costal cartilages, intercostal
muscles and back of the sternum.
3-Diaphragmatic pleura: it covers upper surface of the diaphragm.
4-Mediastinal pleura: it covers mediastinal surface of the lung.

Visceral Pleura
- Firmly covers outer surfaces of the lung and extends into its fissures.
- The 2 layers (mediastinal parietal pleura & visceral pleura) are
continuous with each other to form a tubular sheath (pleural cuff) that
surrounding root of lung (vessels, nerves & bronchi) in the hilum of the
lung.
- On the lower surface of root of the lung, pleural cuff hangs down as a
fold called pulmonary ligament.
Pleural Recesses
Definition: potential spaces in the pleura, the lung reaches these recesses
only in deep inspiration.
Types:
1- Costodiaphragmatic recess: lies between costal & diaphragmatic
parietal pleura along the inferior border.
2- Costomediastinal recess: lies between costal & mediastinal parietal
pleura along the anterior border.
Nerve Supply of Pleura
Parietal pleura:
- Costal: by intercostal nerves. - Mediastinal: by phrenic nerve.
- Diaphragmatic: by phrenic nerve and lower 6 intercostal nerves.
Visceral pleura: by autonomic nerves from pulmonary plexus.
Blood supply of Pleura
- Parietal pleura… by intercostal, internal thoracic & musculophrenic
vessels.
- Visceral pleura ….by bronchial vessels.
Lymphatic Drainage:
- Parietal pleura: into intercostal, mediastinal & diaphragmatic LN.
- Visceral pleura: into broncho-pulmonary LN.

LUNGS
Each lung has the following features:
- It is conical in shape.
- It has an apex, a base, 2 surfaces and 2 borders.
Apex: projects into root of the neck (one inch above the medial 1/3 of the
clavicle). It is covered by cervical pleura. It is grooved anteriorly by
subclavian artery.
Base: (inferior= diaphragmatic surface) is concave and sits on the
diaphragm.
Borders: Anterior & Posterior
- Anterior border: sharp, thin and overlaps the heart.
- Anterior border of left lung presents a cardiac notch at its lower end +
thin projection called the lingula below the cardiac notch.
- Posterior border: is rounded, thick and lies beside the vertebral column.
Surfaces: costal & mediastinal
- Costal surface: convex, covered by costal pleura which separates lung
from ribs, costal cartilages & intercostal muscles.
- Medial surface: divided into 2 parts:
# Anterior (mediastinal) part: contains a hilum in the middle (it is a
depression in which bronchi, vessels, & nerves forming the root of lung).
# Posterior (vertebral) part: it is related to; bodies of thoracic vertebrae,
IVDs, post. intercostal vessels & sympathetic trunk.

Comparison between the 2 lungs:

Right lung
- Larger & shorter than left lung.
- Divided by 2 fissures (oblique &
horizontal) into 3 lobes (upper,
middle and lower lobes).
RIGHT LUNG ROOT(hilum)
- 2 bronchi lie posterior.
# main bronchus(hypartrial)
# accessory bronchus(epartrial)
- Pulmonary artery is superior
- 2 Pulmonary veins are inferior and - 2 Pulmonary veins are inferior and
anterior.
Left Lung
- thinner & longer than left lung.
- Divided by one oblique fissure into 2
lobes, Upper and lower.
- There is No horizontal fissure.
- It has a cardiac notch at lower part of
its anterior border.
LEFT LUNG ROOT(hilum)
-One bronchus lies posterior
- Pulmonary artery is superior
anterior.
Mediastinal surface of the lungs:
Mediastinal surface of right lung Mediastinal surface of left lung
Above the hilum: Above the hilum:
1- Azygos vein and its arch. 1- arch of aorta.
2- Vertical impressions above azygos 2- vertical impressions above
arch for: aortic arch for:
- RT brachiocephalic V. - LT common carotid artery.
- Trachea. - LT subclavian artery.
- Esophagus. - Esophagus.
Behind the hilum: Behind the hilum:
- Esophagus. - Azygos arch. - Impression of descending aorta.
Infront of the hilum: Infront of the hilum:
- Cardiac impression: for Rt atrium. - Cardiac impression: for LT
- Impression of ascending aorta. ventricle.
Below the hilum: Below the hilum:
- Groove for I.V.C. - Impression of Esophagus
- Impression of descending aorta.
Blood supply of lung
- Bronchial arteries (branches of descending thoracic aorta): supply
oxygenated blood to bronchi, lung tissue & visceral pleura.
- Bronchial veins: drain into azygos & hemiazygos veins.
- Pulmonary artery: carries non-oxygenated blood from RT ventricle to
lungs.
- 2 pulmonary veins: carry oxygenated blood from lung to the left atrium.
Nerve Supply of the lung:
from Pulmonary plexus at the root of lung which formed of autonomic
Nerves from sympathetic & parasympathetic fibres.
Lymph drainage of the lungs:There are 2 lymphatic plexuses;
- Superficial plexus (subpleural): lies under the visceral pleura and drain
to bronchopulmonary nodes in the hilum of lung.
- Deep plexus: lies along the bronchial tree & pulmonary blood vessels
and drain into the pulmonary nodes within the lung substance. Then into
bronchopulmonary nodes in the hilum of lung.

SUFACE ANATOMY OF PLEURA

- Apex of both lungs: lies one inch above the medial 1/3 of the clavicle.
Left pleura:
- The anterior margin extends from sternoclavicular joint to the level of
4th costal cartilage, then deviates for about
1 inch to left at 6th costal cartilage to form
cardiac notch.
Right pleura:
- The anterior margin: extends vertically
from sternoclavicular joint to 6th costal
cartilage.
- Inferior margin: passes round chest wall, on the 8th rib in midclavicular
line, 10th rib in mid-axillary line and finally reaching the 12th thoracic
spine.
- Posterior margin: along the vertebral column from the apex to the
inferior margin.

SURFACE ANATOMY OF LUNG

- Apex, anterior border and posterior border: correspond nearly to the
lines of pleura but are slightly away from the median plane.
- Inferior margin:
passes round chest wall, on the 6th rib in midclavicular line, 8th rib in mid-
axillary line and finally reaching the 10th thoracic spine.
- Oblique fissure:
represented by a line extending from 3rd thoracic spine, obliquely ending
at 6th costal cartilage.
- Transverse fissure only in right lung: represented by a line extending
from 4th right costal cartilage to meet the oblique fissure.

Bronchopulmonary segments
Definition: they are the anatomic, functional, and surgical units of the
lungs.
Characters:
- It is a subdivision of a lung lobe.
- It is pyramidal in shaped, its apex lies toward the root, while its base
lies on the lung surface.
- It has a segmental bronchus, a segmental artery, lymph vessels, and
autonomic nerves.
- A diseased segment can be removed surgically, without affection of
other segments.
- the right lung has 10 segments but the left has 8-10 segments
Bronchopulmonary segments of both lungs.

5- Embryology of Respiratory System

Development of the nose

- At the end of 4th week, mesodermal facial processes(prominences) are

formed mainly by the 1st pair of pharyngeal arches, these prominences
are:

1- The Frontonasal process, formed by proliferation of mesoderm

ventral to the brain vesicles

- On both sides of the frontonasal prominence, local thickenings of the

surface ectoderm, the nasal (olfactory) placodes→ the nasal placodes
invaginate to form nasal pits (nostril) and create a ridge of tissue that
surrounds each pit and forms the nasal prominences.

- The nasal prominences on the outer edge of the pits are the lateral nasal
prominences; those on the inner edge are the medial nasal prominences

2- The maxillary process continue to increase in size and grow medially,

compressing the medial nasal prominences toward the midline and fuse
them to form the intermaxillary process, which is the primordia of the
septum and bridge of the nose
- Olfactory pit forms the nostril and then becomes deeper to form a blind
sac ( the vestibule).

- So, the nose is formed from 5 facial prominences

- The frontal process gives rise to the bridge and nasal septum

- The intermaxillary process provide the crest and tip

- The lateral nasal prominences form the sides (alae)

Paranasal air sinuses development:

- Paranasal air sinuses develop as diverticula of the lateral nasal wall

and extend into the maxilla, ethmoid, frontal, and sphenoid bones.They
reach their maximum size during puberty.

Respiratory diverticulum

Sources of development:

1- The epithelium of the internal lining

of the larynx, trachea, and bronchi, as
well as that of the lungs→ of endodermal
origin.
- The cartilaginous, muscular, and connective tissue components of the
trachea and lungs→ from splanchnic mesoderm surrounding the
foregut.

Steps of development:

- When the embryo is approximately 4 weeks old, the respiratory

diverticulum (lung bud) appears as an outgrowth from the ventral wall
of the foregut

- When the diverticulum expands caudally, two longitudinal ridges, the

tracheoesophageal ridges, separate it from the foregut→ when these
ridges fuse to form the tracheoesophageal septum, the foregut is divided
into a dorsal portion, the esophagus, and a ventral portion, the trachea
and lung buds

- Initially the lung bud is in open communication with the foregut, later
on respiratory primordium maintains its communication with the
pharynx through the laryngeal orifice.

Development of Larynx

- The internal lining of the larynx originates from endoderm, but the
cartilages and muscles originate from mes oderm of the 4th and 6th
pharyngeal arches

- the laryngeal epithelium proliferates rapidly resulting in a temporary

occlusion of the lumen, then vacuolization and recanalization produce a
pair of lateral recesses, the laryngeal ventricles

- These recesses are bounded by folds of tissue that differentiate into the
false and true vocal cords.
- Since musculature of the larynx is derived from mesoderm of the 4th and
6th pharyngeal arches, all laryngeal muscles are innervated by branches of
the vagus nerve

- The superior laryngeal nerve innervates derivatives of the 4th

pharyngeal arch, and the recurrent laryngeal nerve innervates
derivatives of the 6th pharyngeal arch

Lungs and Bronchial tree development

- During its separation from the foregut, the lung bud forms the trachea
and two lateral outpocketings, the bronchial buds → each bud enlarges
to form right and left main bronchithen forms secondary bronchi (3 in
RT and 2 in LT), So there are three lobes on the right side and two on the
left

- With subsequent growth in caudal and lateral directions, the lung buds
expand into the pericardioperitoneal canals and form the primitive
pleural cavities

- During further development, secondary bronchi divide repeatedly in a

dichotomous fashion, forming 10 tertiary (segmental) bronchi in the
right lung and 8 in the left, creating the bronchopulmonary segments of
the adult lung.

- By the end of the 6th month, approximately 17 generations of

subdivisions have formed and an additional 6 divisions form during the
first 10 years of postnatal life.

Stages of lungs maturation:

1- Psudoglandular 5-16 week Branching has continued to form

terminal bronchioles, no respiratory
bronchioles or alveoli present.
2- Canalicular 16 -26week Each terminal bronchioles divide
phase into 2 or more respiratory
bronchioles which in turn divide
into 3-6 alveolar ducts
3- Terminal sac 26 week - Terminal sacs (primitive
birth alveoli)form and capillaries
establish close contact
4- alveolar period 8 month- Mature alveoli have well developed
childhood epithelial endothelial(capillary)
contact

NB: Cells of terminal sacs are:

1- Type I alveolar epithelial cells, become thinner, so that surrounding

capillaries protrude into the alveolar sacs→ makes up the blood-air
barrier.

2- Type II alveolar epithelial cells, produce surfactant.

A- Congenital anomalies of larynx:

1- Laryngeal atresia: a rare anomaly and cause obstruction of the upper

fetal airway, also known as congenital high airway obstruction
syndrome (chaos)

2- Laryngeomalacia: Softness, or lack of consistency of laryngeal

tissues.

3- Laryngeal or saccular cyst: out pouching called saccule or laryngeal

appendix.

4- Laryngocele: air filled dilatation of laryngeal wall, may be external or

internal.

5- Laryngeal webs: failure of complete canalization of the larynx

6- Congenital vocal cord paralysis: Second most common congenital

anomaly of larynx

B- Trachea and bronchia Congenital

anomalies:

1- Tracheoesaphageal fistula (TEF):

Abnormalities in separation of the
esophagus and trachea by the
tracheoesaphageal septum result in
esophageal atresia with or without
tracheoesaphageal fistulas, its types are:

type A: isolated esophageal atresia (8%)

type B: proximal fistula with distal atresia (1%)

type C: proximal atresia with distal fistula (85%)

type D: double fistula with intervening atresia (1%)

type E: isolated fistula (H-type) (4%)

2- Tracheal agenesis: rare, failure of trachea formation.

3- Tracheal stenosis: due to complete cartinogenous rings

4- Tracheomalacia: Softening of the tracheal wall, due to cartilaginous

abnormalities.

5- Tracheal bronchus ( Pig bronchus): Right upper lobe bronchus

arises directly from the trachea

6- Bronchial atresia: The upper lobe bronchi are more frequently

affected by congenital atresia of lobar or segmental bronchi

C- Congenital anomalies of lung:

1- Respiratory distress syndrome (RDS): also called hyaline

membrane disease, (30% of all neonatal diseases), due to defect in
surfactant formation.

2- Agenesis of lung: blind-ending trachea with absence of lungs

3- Lung hypoplasia: reduced lung volume in congenital diaphragmatic

hernia→ lung fail to develop normally

4- Ectopic lung lobes: due to additional respiratory buds of the foregut

that develop independently of the main respiratory system.

5- Congenital cysts of the lung: due to dilation of terminal bronchi,

giving the lung a honeycomb appearance on radiograph and cause chronic
infections.

5- Supernumerary lobules: abnormal divisions of the bronchial tree →

have little functional significance except during bronchoscopies.
DEVELOPMENT OF DIAPHRAGM

-Time: between the 4th and 8th weeks of gestation.

Sources: it is a musculotendinous structure. It develops from:

1- the Septum Transversum.

2- the Mesoesophogus.

3- pleuroperitoneal membranes.

4- somatic mesoderm of the body wall.

1- The septum transversum

- it is the primary structure forming the central tendon.
- It is a thick layer of mesoderm formed in the neck by fusion of 3 rd, 4th
and 5th cervical myotomes.
- during folding, it migrate downward (bringing phrenic nerves with
them) to separate the thoracic and abdominal cavities but not completely
due to presence of cardialperitoneal canals.

2- Somatic mesoderm of the body wall

It form the peripheral margins of the diaphragm. and is responsible for

the dome-shaped appearance of the diaphragm.

3- The mesoesphagus: form the cura of the diaphragm.

4- The pleuralperitoneal membranes: form the dorsal/lateral posterior

wings of the diaphragm

Congenital Anomalies of diaphragm

1- Congenital Diaphragmatic hernia of Bockdalek:

pleuroperitoneal membranes fail to fuse with the other components→ a

Posteriolateral defect of the diaphragm → movement of abdominal
contents into the thoracic cavity.

2- Retrosternal hernia (Morgagni’s hernia): defect between the sternal

and costal muscular portions of the diaphragm. Intestines can pass into
the thoracic cavity.
3- Epigastric hernia: uncommon, occurs between xiphoid process &
umbilicus due to incomplete fusion of lateral body folds (wall)

4- Hiatal hernia: stomach or part of intestines may herniate through

defect around esophagus.

5- Eventration of Diaphragm: Failure of myoblast to migrate to

diaphragm→ no muscles of diaphragm so the non contractile tissue of the
diaphragm balloons into thoracic cavity.

6- ANATOMY THE KIDNEY AND URETER

KIDNEYS

Size: 12cm long, 6cm wide and 3cm thick.

Site: it is a retroperitoneal organ, in posterior abdominal wall opposite

T12- L3.

- The right kidney lies slightly lower than the left kidney because of
the large size of the right lobe of the liver.

- during respiration, both kidneys move downward in a vertical direction

by as much as 1 inch (2.5 cm)

Shape: bean-shaped has:

- 2 ends (poles): - 2 borders: - 2 surfaces:

#upper end: broad. #lateral border: convex. # anterior surface: irregular.

#lower end: rounded, #medial border: concave # Posterior surface: flat.

located 5 cm from the and show hilum.
iliac crests.

Hilum of the kidney: Structures that enter or exit from the kidney:

- Renal vein (anterior).

- Renal artery (intermediate).

- Pelvis of the kidney (posterior).

- The renal sinus contains the upper expanded part of the ureter called the
Renal pelvis

- Perirenal fat continues into the hilum and sinus and surrounds all
structures.

Coverings of the kidney:

1. Fibrous capsule: Surrounds the kidney and is closely applied to the

outer surface.
2. Perirenal fat: covers the fibrous capsule
3. Renal (Perirenal) fascia: Condensation of connective tissue that
lies outside the perirenal fat and encloses the kidney and the
suprarenal gland
4. Pararenal fat: Lies external to the renal fascia, is part of the
retroperitoneal fat
- Structures 2,3 & 4 support the kidneys and hold them in position on
the posterior abdominal wall.

RELATIONS OF THE KIDNEY:

Anterior Relations:

Of the RT kidney Of the LT kidney

1- Right suprarenal gland: 1- Left suprarenal gland: A small

A small medial area of the medial area of the superior pole.
superior pole.
2- spleen: at lateral upper ½ of anterior
2- Right lobe of liver: large surface.
area below suprarenal area.
3- pancreas: central quadrilateral area.
nd
3- 2 part of duodenum: A
4-stomach: triangular region, between
narrow medial area.
the suprarenal and splenic areas.
4- Right colic flexure:
5- Lt colic flexure and beginning of
lateral medial area at lower
descending colon, lateral area at lower
part of anterior surface.
part of anterior surf.
5- Loops of jejunum: An
6-loops of jejunum: lower medial area at
extensive lower medial area.
lower part of anterior surface.
Posterior Relations: the same in both kidneys:

1- Superiorly are the diaphragm and the medial and lateral arcuate
ligaments.

2- More inferiorly, moving in a medial to lateral direction, are

- Psoas major - quadrates lumborum - transverses abdominis.

3- The subcostal vessels and the subcostal, iliohypogastric, and

ilioinguinal nerves.

NB:

Renal angle: The angle between the last rib and the lateral border of
erector spinae muscle, is occupied by kidney

Vertebrocostal angle: The angle between the last rib and the lateral
border of vertebral column , is occupied by lower part of the pleural
sac.

Internal structure of the kidney

- Each kidney consists of an outer renal cortex and an inner renal

medulla.

- The renal cortex is a continuous band

of pale tissue that completely
surrounds the renal medulla.
Extensions of the renal cortex, the
renal columns project into the inner aspect of the kidney, dividing the
renal medulla into discontinuous aggregations of triangular-shaped
tissue, the renal pyramids.

- The bases of the renal pyramids are directed outward, toward the
renal cortex, while the apex (called the Renal papilla) of each renal
pyramid projects inward, toward the renal sinus.

- The renal papilla is surrounded by a cup shaped minor calyx, in the

renal sinus, several minor calices unite to form a major calyx, and
two or three major calices unite to form the renal pelvis, which is the
funnel-shaped superior end of the ureters.

Arterial supply of the kidney:

- The renal artery arises from the aorta at the level of the 2nd lumbar
vertebra. Each renal artery divides into 5 segmental arteries that
enter the hilum of the kidney, 4 in front of and one behind the renal
pelvis, they are distributed to the different
segments of the kidney.

- Each segmental artery gives rise to

number of lobar arteries, each supplies a
renal pyramid. Before entering the renal
substance, each lobar artery gives off two
or three interlobar arteries which run
toward the cortex on each side of the renal
pyramid.

- At the junction of the cortex and the

medulla, the interlobar arteries give off the
arcuate arteries, which arch over the bases of the pyramids and give off
several interlobular arteries that ascend in the cortex and give off the
afferent glomerular arterioles.
Abdominal aorta→ renal artery→segmental arteries→ lobar arteries→
interlobar arteries→ arcuate arteries→ interlobular→ afferent glomerular
arterioles→ glomerulus → afferent glomerular arterioles→ peritubular
capillary plexus→ interlobular veins→ arcuate veins → interlobar veins →
renal vein→ IVC.
Segments of the kidney:

Each kidney has 5 segmental branches and thus is divided into 5

vascular segments named as:

1- Apical

2- Caudal

3- Anterior Superior

4- Anterior Inferior

5- Posterior

Vascular supply and lymphatic

drainage:

Arteries Veins Lymphatics

Renal artery: RT and LT renal arteries Renal vein: RT End in paraortic
arise from abdominal aorta. and LT renal LN at level of
Accessory renal artery: in 30% of veins: end in L2
people, enter kidney either at hilum or IVC.
one of 2 poles.

NB:

left renal vein Is 3 times longer than the right (7.5 cm and 2.5 cm). So, for
this reason the left kidney is the preferred side for live donor
nephrectomy.

Surface anatomy of the kidney:

On the back of the patient, draw the

following lines:

- 2 vertical lines, 1inch and 3 inches from

the median plane.

- 2 horizontal planes: at level of T12-L3

spines.
 - Hilum: opposite L1 spines, 2 inches from median plane.

URETER

Shape and Size: retroperitoneal muscular tubes, about 25–30 cm in

length and 3 mm in diameter

Beginning: in front of L1 by adilatation called the renal pelvis.

End: by opening into posterosuperior angle of the urinary bladder.

Course: divided into 3 parts:

1- Abdominal part.2- pelvic part. 3– Intramural part.

1-ABDOMINAL PART

Relations of abdominal part:

RT ureter LT ureter

Course - Each ureter descends posterior to the peritoneum of posterior abdominal wall,
opposite tips of transverse processes of the lower 4 lumbar vertebrae.

Posterior - Medial border of psoas major muscle.

relations: - Tips of transverse processes of the lower 4 lumbar vertebrae

Anterior - 3rd part of the duodenum. - Sigmoid colon and its mesentery.

relations: - 3 arteries (RT gonadal, right colic and - 3 arteries: LT gonadal and upper
ileocolic) and lower left colic vessels.

Medial The inferior vena cava. Aorta and inferior mesenteric

relations: artery.

2- PELVIC PART

- It enters the pelvis by crossing in front of bifurcation of common iliac

artery (opposite sacroiliac joint)

- it descends posterolaterally along the anterior border of the greater

sciatic notch→ opposite the ischial spine it turns anteromedially to reach
the base of the bladder.

- On the pelvic side-wall it is related to:

Anteriory: internal iliac artery and the beginning of its anterior trunk.

Posteriorly: internal iliac vein, lumbosacral nerve and sacroiliac joint.

Laterally: it lies on the fascia of obturator internus.

3- INTRAMURAL PART

It pierce the posterior aspect of the bladder and run obliquely through its
wall for a distance of 1.5–2.0 cm before terminating at the ureteric
orifices .This arrangement is believed to assist in prevention of reflux of
urine into the ureter

Constrictions of the ureter:

- At the pelvi-ureteric.

- At the inlet of the lesser pelvis.

- At intramural part.

Vascular supply of the ureter:

- Arteries: the ureter is supplied by branches

from the renal, gonadal, common iliac,
internal iliac, inferior vesical and uterine
arteries, and the abdominal aorta.

- Veins: the venous drainage of the ureters

generally follows the arterial supply.

Surface anatomy of the ureter:

A line drowns between 2 points:

- A point on the transpyloric plane, 2inches from median plane.

- A point on the pubic tubercle.

Surface anatomy of ureter

Anteriory: is represented by a line from 5cm from the midline at level of

L1 to a down to pubic tubercle.

Posteriory: is represented by a line from spine of L1 to posterior inferior

iliac spine
 8- ANATOMY OF URINARY BLADDER AND URETHRA

Urinary bladder

Site:

- at birth: in abdomen.

- in children: pelvi-abdominal organ.

- in adults: lies in the pelvis, but as it distends it expands into the

abdominal cavity.

Shape: An empty bladder resemble cut anterior part of a ship and has a
base (posterior surface), neck, apex, a superior and two inferolateral
surfaces.

Relations:

-Apex: median umbilical ligament (urachus) ascends from the apex to

the umbilicus, covered by peritoneum to form the median umbilical fold

- Neck:

- in both sexes, it faces towards the upper part of the symphysis pubis.

- In males: it rests on, and is in direct continuity with, the base of prostate.

- In females it is related to the pelvic fascia, which surrounds the upper

urethra, and gives attachment to pubovesical ligament.

- Inferolateral surface: not covered by peritoneum and related to:

- pubis and puboprostatic ligaments.

- obturator internus muscle.

- levator ani muscle.

- Posterior surface:

- In females: it is closely related to the anterior vaginal wall.

 - In males: it is related to the rectum although it is separated from it
above by the rectovesical pouch, and below by the seminal vesicle and
vas deferens on each side.

- Anterior border: related to the retropubic space (of Retzius) separating

it from the symphysis pubis.

- Superior surface:

- In males: completely covered by peritoneum, it is in contact with the

sigmoid colon and the terminal coils of the ileum.

- In females: covered by peritoneum, which is reflected posteriorly

onto the uterus to form the vesicouterine pouch.

LIGAMENTS OF THE BLADDER

A- True ligaments: condensations of pelvic fascia which attach the

bladder to the pubis, lateral pelvic side-walls, and rectum.

1- Median umbilical ligament( urachus): from the apex of the bladder

to the umbilicus.

2- Pubovesical ligaments: from the bladder neck to the inferior aspect of

the pubic bones. In males, it's called the puboprostatic ligaments.

3- Lateral vesical ligaments: from bladder to the tendinous arch covering

obturator internus muscle.

4- Posterior vesical ligaments: from bladder to the front of sacrum.

B- False ligaments: these are peritoneal folds;

1- Median umbilical fold: over the median umbilical ligament.

2- 2 Medial umbilical folds: over the obliterated umbilical arteries.

3- Lateral false ligaments: reflection of peritoneum from side of bladder

to side wall of the pelvis.

4- Posterior false ligament: peritoneal fold from side of the bladder to

the front of the sacrum.
BLADDER INTERIOR : the bladder mucosa show folds (rugae) except
in trigone.

Trigone:

- it is a triangular area in the inner aspect of posterior wall of the bladder.

- it is bounded by 3 lines connecting the 2 ureteric orifices and internal

urethral orifice. It shows:

- smooth mucosa rich in nerves and vessels and firmly adherent to the
underlying muscle coat .

- interureteric ridge: transverse ridge between openings of the ureters.

- uvula vesicae: median lobe of prostate protrude inside bladder behind the

internal urethral orifice.

- internal urethral orifice: at the apex of trigone.

VASCULAR SUPPLY AND LYMPHATIC DRAINAGE

Arteries

1- Superior vesical artery: from the proximal, patent part of fetal

umbilical artery.

2- Inferior vesical artery: from internal iliac artery.

3- Additional branches: from the obturator and inferior gluteal arteries.

Veins

The veins which drain the bladder form a complicated plexus on its
inferolateral surfaces and pass backwards to end in the internal iliac
veins.

Lymphatic's: to the external iliac nodes (some may go to the internal or

common iliac group).
 MALE URETHRA

Length: 18–20 cm long.

Beginning and End: extends from the internal urethral orifice in the
urinary bladder to the external urethral opening, or meatus, at the end of
the penis.

PARTS OF URETHRA:

Preprostatic urethra

- approximately 1 cm in length, and

extends from the base of the bladder
to the prostate.

- it surrounded with internal urethral

sphincters.

Prostatic urethra

- about 3–4 cm in length and tunnels through the prostate.

- in its posterior wall, it shows:

- Urethral crest: a midline ridge, which projects into the lumen causing
it to appear crescentic in transverse section.

- Prostatic sinus: a shallow depression on each side of the crest, it is

perforated in its floor by the orifices of 15–20 prostatic ducts.

- Seminal colliculus: an elevation in the middle of the length of the

urethral crest, it receive the opening of prostatic utricle in its middle.
On both sides the two small openings of the ejaculatory ducts.

Membranous urethra

- the shortest (2–2.5 cm), least dilatable(with the exception of the external
orifice).

- it pierces 2 membranes(pelvic fascia and perineal membrane).

- it surrounds by external urethral sphincters.

Spongy(penile)urethra.

- lies within the corpus spongiosum of the penis.

- it is about 15 cm long and extends from the end of the membranous

urethra to the external urethral orifice on the glans penis.

URETHRAL SPHINCTERS:

Internal urethral sphincters external urethral sphincters

- Surrounds the bladder neck. - Surrounds the membranous urethra in

deep perineal pouch.
- Smooth muscle fibers,
supplied by sympathetic fibers - Striated muscle fibers, supplied by
n. pudendal n.

- Prevent retrograde - Responsible for voluntary control of

ejaculation. urine.

FEMALE URETHRA

- Approximately 4 cm long and 6 mm in diameter.

- It begins at the internal urethral orifice of the bladder, approximately

opposite the middle of the symphysis pubis, and runs anteroinferiorly
behind the symphysis pubis, embedded in the anterior wall of the vagina.

- It has an external urethral sphincter.

 8- Development & anomalies of the Kidneys and Ureters

Development of the upper Urinary System

1- Stages of kidney Development

development of pronephros

Development of mesonephros

Development of metanephros
2- Development of Ureter

Site of Urinary System development

- Urinary and genital systems are closely associated

- Both develop from intermediate mesoderm(7th- 28th) somite level.

- Its upper part is segmented called nephrotomes but its lower part is
unsegmented (nephrogenic cord).

- Each cord produces a bulge into the coelom called the urogenital
ridge, which form the urinary and genital structures.

Pronephros:

- Simplest & most primitive.

- From intermediate mesoderm of cranial 12-13 somites.

- 7-10 solid or tubular arranged cell groups in the cervical region (head
kidney).

- Formed of pronephric duct and tubules.

Fate:

- Rudimentary, disappears by the end of 4th week.

- The pronephric duct persist as mesonephric duct (Wolffian duct).

Mesonephros:
- Intermediate-more advanced stage.

- Appear during regression of pronephros

- Located in midsection of embryo, thoracolumbar region.

- Formed of mesonephric tubules and the mesonephric duct (Wolffian

duct).

- These tubules carry out some kidney function at first, but then many
of the tubules regress. However, the mesonephric duct persists and
opens into the cloaca at the tail of the embryo.

Fate of mesonephros:

Male Female
Mesonephric tubules - Efferent ductules of - Epoöphoron
testis - paroöphoron
- Head of the
epididymis
- Paradidymis
Mesonephric duct - Body of epididymis Aberrant duct called
- Head of epididymis. Gartner duct.
- vas deferens.
- Seminal vesicle.
- ejaculatory duct
In both sexes Ureteric bud.

Metanephros:

- Develop in 5th week, functions by 11th week

- Its site: in lumbosacral region(adult kidney).

- Has 2 sources:

1- Ureteric bud: an outgrowth of the distal end of mesonephric duct.

- Penetrates metanephric mesoderm(metanephric cap) and form the

nephron.

- As the kidney grows the ureteric bud forms finger-like projections and
divide into 1-3 million branches.
- It forms the Collecting system (collecting ducts, minor calyces, major
calyces, renal pelvis and ureter).

2- Metanephric cap (blastema): condensation of nearby renogenic

intermediate mesoderm. it give the following derivatives:

- Epithelial cells lining Bowman’s capsule

- Proximal convoluted tubules

- limbs of the loops of Henle

- Distal convoluted tubules

Changes occurring in the kidney during development:

1- Renal Ascent: at 6-9 week kidney ascend to lumbar site below

adrenals.

2- Renal lobulation: early the metanephric tubules are lobulated and

remain this way until after birth and diappear during infancy

3- Change of renal blood supply: At 1st receive blood supply from

median sacral and common iliac arteries→ then from transient aortic
branches → then final pair of renal arteries.

4- Rotation of the kidneys: early the kidneys lie in the pelvis with their
hila pointed anteriorly → By the 7th week, the hilum points medially and
the kidneys are located in the abdomen.

Congenital Malformations of the kidneys.

1- Renal agenesis→lack of development.

2- Dysplasia→abnormal development of nephrons and collecting

3- Hypoplasia→small sized kidney and agenesis of ureter→

hydronephrosis.

4- Ectopic kidneys and ureters: at any site along the course of renal
ascent (mostly pelvic).

5- Polycystic kidneys→failure of nephrons to join collecting ducts.

6- Horseshoe (fused) kidneys

Anomalies of the ureter

1- Duplication of the ureter: due to early splitting of the ureteric bud.

2- Ectopic ureter: one ureter opens into bladder and other into vagina,
urethra, or vestibule.

3- Bifid ureter (double pelvis of the ureter).

4- Absence of the ureter.

NB:

Congenital multi cystic kidneys

- due to failure of comunication between derivatives of metanephric cap

and ureteric bud.

-2 Types:

- Autosomal recessive: (1/5,000) progressive, cysts form from

collecting ducts. (RF in infancy or childhood).

- Autosomal dominant: (1/500) cysts form from all segments of

nephron. (RF in adulthood).

Horseshoe (fused) kidney

- Fusion of two kidneys at their lower end., 1:400

- Common with trisomy 13-15; 18, 21, and Turner syndromes.

- Result in ectopic kidney below inferior mesentric artey

9- Development of the urinary bladder and urthra

Sources of bladder development

1- Bladder body: endoderm of vesicourethral canal.

2- Trigone(mesoderm): right and left mesonephric fuse in midline to

form this triangular area.

3- Part of apex of bladder: from allantois.

Development of the urinary bladder

- Cloaca is the caudal dilated end of the

hindgut

- Cloaca ends blindly at the cloacal

membrane

- Allantois and mesonephric ducts open

into cloaca.

During 4th to 7th week cloaca

subdivided into:

- Posterior part→ anorectal canal

- Anterior part → primitive urogenital sinus.

- primitive urogenital sinus further divided into:

1- Vesicourethral part: form urinary bladder and upper ½ of proststic

urethra.

2- Definitive urogenital sinus: divide into;

# pelvic part: form lower ½ of prostatic urethra , membraous urethra

and bulbo urethral glands in the male and the membranous urethra
and part of the vagina in females.

# phallic urethra: form spongy urethra in males and the vestibule in

females:

- Most of bladder is formed from primitive urogenital sinus.

- Initially bladder is continuous with allantois, over time, the allantois

degenerates to form a cord-like structure, the urachus.

- The urachus extend from umbilicus to apex of the bladder and forms
the median umbilical ligament which can be seen in adults.

Development of trigone

- Terminal ends of mesonephric ducts become part of bladder wall

- Ureter is outgrowth of mesonephric duct, later on ureter obtains separate
entrance into bladder.

Congenital Anomalies of the bladder

A- Anomalies of bladder itself B- Anomalies of the urachus

A- Anomalies of bladder itself

- Extrophy of bladder(ectopia vesicae): failure of formation of muscles

of anterior abdominal wall below umbilicus with absent anterior wall of
urinary bladder, anterior wall of bladder covered by mucosa only, it is
accompanied mostly with epispadias

B- Anomalities of the urachus

1- urachal sinus: unobliterated distal part

of urachus.

2- urachal fistula: persistence of urachus

3- urachal cyst: a cyst anywhere along the

course of urachus

Development of the urethra

- In the 3th week, mesodermal cells originating in the region of the

primitive streak migrate around the cloacal membrane to make a pair of
slightly elevated cloacal folds.

- Cranial to the cloacal membrane, the folds

unite to form the genital tubercle

- Caudally the folds are subdivided into

urethral folds anteriorly and anal folds
posteriorly

- Another pair of elevations (geniatl

swellings) becomes visible on each side of
the urethral folds, later these swellings form the scrotal swellings in
male, labia majora in female
- Under the influence of androgens from the fetal testes→ rapid
elongation of the genital tubercle (phallus or penis) → the phallus pulls
the urethral folds forward so that they form the lateral walls of the
urethral groove.

- The urethral groove does not reach the most distal part of penis (glans)

- The epithelial lining of the groove which originates in the endoderm,

forms the urethral plate

Development of urethra in male

- At the end of 3rd month the two urethral folds close over the urethral
plate; forming the penile urethra, this canal does not extend to the tip of
the phallus

- This most distal urethra(in the glans) is formed during 4th month when
ectodermal cells from the tip of the glans penetrate inward and form an
epithelial cord. This cord obtains a lumen and forms the external urethral
meatus

- The genital/scrotal swellings arise in the inguinal region; move caudally

and each one makes up half of the scrotum, separated by scrotal septum.

Anomalies of urethra development

1- Hypospadias: most common anomaly of urethra. The external

urethral orifice is on the ventral surface of the penis. It cause is
inadequate production of androgens by the fetal testes/or
inadequate receptor sites for the hormone, its types are:

- Glandular and Penile (80%)

- Penoscotal and perineal (20%)

2- Epispadias:the urethra opens on the dorsal surface of the penis; often

associated with extrophy of the bladder; resulting from inadequate
ectodermal-mesodermal interactions during development of genital
tubercle.
Development of urethra in female

- Stimulated by estrogens, genital tubercle elongates only slightly forming

the clitoris

- Urethral folds do not fuse; develop into labia

minora

- Genital swellings enlarge and form the labia

majora

- Urogenital groove is open and forms the vestibule

NB: Although the genital tubercle does not elongate extensively in

female, its larger than in male during the early stages; resulting in
mistakes in identification of the sex by sonar examination.

Done by: assistant professor dr. Medhat Atta Salah