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Block 3: Thorax and Abdomen

Lecture 20: Thorax 1 and 2


• Bone Thorax: Anatomy of Chest Cavity
o Thoracic inlet borders= manubrium, T1, rib and cartilage
o Physical characteristics of thorax
 Sternal angle: attachment of costal cartilage of 2nd rib
 Sternum: manubrium, body, xiphoid process
 First 7 ribs: TRUE ribs, costal cartilage btwn sternum and rib (synovial joint)
 Ribs 8-10: cartilages fuse to undersurface (FALSE ribs)
 Ribs 11/12: FLOATING ribs, no attachment to sternum anteriorly, function to protect kidneys
 Nipple: 4th intercostal space
 Intercostal spaces named for rib ABOVE it
• Basic dermatomes
o Nipple: T4
o NO C1!
o Umbilicus: T10
o C2-C8 and T1-T12 have pain fibers which are segmentally innervated and consistently located in the upper
limbs and posterior chest wall
• Muscles of respiration
o Inspiration: Intercostals, diaphragm (Scalene muscles may assist  hypertrophy)
o Expiration: PASSIVE PROCESS (intercostals and abdominals may assist)
o Needles inserted directly above ribs to avoid intercostals nerves/arteries
• Coverings of the lung
o Thin, serous, water-secreting membrane which allows diaphragm to slide over lung and lung to glide freely
over surface of chest cavity
o Costal pleura  Internal intercostal muscle  External intercostals muscle  skin
o Pleural potential space: between visceral and parietal pleura, can become REAL space (filled with blood, air,
pus, etc.)
o Diaphragmatic portion, costal portion, copular portion, mediastinal portion
• General circulation
o R side: pulmonary source  low pressure
o L side: systemic circulation  high pressure
• Lungs
o Blood supply: bronchial artery, pulmonary artery, pulmonary vein
o Right vs. left lung (lobes, fissures, etc.)
 Horizontal fissure on R lung: 3rd intercostal space
 Oblique fissure on both lungs: 5th/6th intercostal space
 Lingula on L lung: 4th/5th intercostal space
o Trachea: series of C-shaped cartilaginous rings
o Lymphatics: ultra filtrate of blood that is drawn up in the lymph system and put back into the blood system by
the main thoracic duct
 Main thoracic duct on LEFT side
o Innervation of the lungs
 Parasympathetic innervation from VAGUS nerve
 VERY FEW afferent visceral pain fibers  lung tumors go unnoticed

Lecture 21: Heart 1, 2, and 3; Posterior Mediastinum


• Pericardium
o Phrenic nerve and paricardiophrenic artery run along the pericardium (between fibrous pericardium and
mediastinal pleura of lungs)
o Fibrous layer- gives rigidity, strength to heart covering
o Serous layer- folds over and becomes epicardium (coronary arteries just deep to epicardium)
 Between serous layer and epicardium lies the pericardial sac
 Epicardium= visceral pericardium
 Serous layer= parietal pericardium
o Heart layers: epicardium, myocardium, endocardium
• Heart sinuses
o Oblique pericardial sinus
 Between R and L pulmonary veins on posterior wall of pericardial cavity.
 Clinical importance: infection, tumors
o Transverse pericardial sinus
 Superior to pulmonary veins and inferior to pulmonary trunk
 Clinical importance: heart surgeons put their thumb on the aorta and their fingers in this sinus
• General location of the heart in the thorax
o Retrosternal
o Base of heart: 2nd intercostal space
o Apex of heart: 5th intercostal space (PMI= medial to mid-clavicular line; can be displaced down and laterally
during congestive heart failure)
• Heart chambers
o Right atrium
 Thin walled, on top of R ventricle
 Major structures: vena cavae, coronary sinus (main vein that drains blood from heart), tricuscpid
valve to R ventricle, R auricle (extra bulge of contractile muscle), pectinate muscles in lateral
wall, fossa ovalis that separates R and L atria
o Right ventricle
 Thick, below R atrium
 Major structures: chordae tendonae, papillary muscles, moderator band (conduction system of
heart), trabeculae carnae (clinical relevance: pacemaker)
o Left atrium
 4 pulmonary veins enter bringing oxygenated blood from lungs
o Left ventricle
 VERY high pressure (THICK wall)
 Pumps blood systemically
 Major structures: papillary muscles, chordae tendinae, mitral/bicuspid valve
• Heart valves
o Diastole: rest, ventricles are filling and AV valves are open
o Systole: pump, blood exits thru outflow valves
o AV valves: tricuspid, bicuspid (open/close via papillary muscle contraction)
o Outflow track valves allow blood to flow passively from the ventricles (pulmonary and aortic); close as a
result of elastic recoil
o Stenosis: smaller opening (may cause hypertrophy)  murmur during systole
o Murmur of regurgitation/insufficiency: valve doesn’t close all the way and blood flows backwards  murmur
during diastole
• Coronary circulation
o R coronary artery: blood supply to the back of the heart, major blood supply for the conduction system of the
heart (disease  atrial fibrillation)
o L coronary artery: left interventricular descending artery (coronary artery disease)
o Veins: coronary sinus drains into R atrium (main venous return)
• Innervation of the heart
o Sympathetic: T1 to L2
o Parasympathetic: R/L vagus nerves
o Referred pain: visceral pain interpreted as somatic pain, heart pain is referred to intercostals nerves (T1-T4
dermatomes)
• Mediastinum (median portion of thoracic cavity)
o Superior and inferior separated by arch of the aorta
o Inferior: anterior, middle and posterior mediastinum
o Fascial layers
 Infection anterior to pretracheal fascia can travel to superior mediastinum and anterior
mediastinum
 Retropharyngeal fascia is behind pharynx (infection in neck)
 Fascial planes serve as routes for infection spread from neck into chest cavity
 Infection can NEVER spread to middle medastinum because it is completely closed off by fusing
with the antitia of the major blood vessels
• Posterior mediastinum

Lecture 22: Anterior Abdominal Wall


• Rectus sheath above arcuate line
o Anterior layer: external oblique and ½ internal oblique
o Posterior layer: ½ internal oblique and transverses abdominus
o Above arcuate line/semicircular line of Douglas: much stronger than lower 1/3 of abdomen
• Rectus sheath below arcuate line
o NO posterior rectus sheath!
o All muscle tendons/fascia comes in front of rectus abdominus
o ONLY endoabdominal fascia: weaker than upper 2/3 of abdomen
• Hernias
o Hasselback’s Triangle
 Borders: rectus abdominus, inferior epigastric artery and inguinal ligament
 Floor: transversalis fascia
 Protrusion thru is a direct hernia
o Indirect hernia (congenital)
 Processus vaginalis typically closes off at 7-8 months of development and becomes a ligament
 No closure (remains patent)  indirect hernia into scrotum

Lecture 23: Abdomen 1, 2 and 3


• Quadrant system
• Intra vs. retroperitoneal organs
o Intraperitoneal: totally wrapped in visceral peritoneum, “within”, attach via mesentery to body wall (blood
vessels, nerves enter/exit via mesentery)
 Stomach, liver, small intestines, transverse colon
o Retroperitoneal: behind, organ is fused to posterior body wall, NO mesentery
 Kidneys, pancreas, duodenum, ascending colon, descending colon, rectum
• Arterial blood supply
o Visceral branches off the aorta: celiac trunk, superior mesenteric artery, inferior mesenteric artery
• Stomach
o Left upper quadrant
o Parts of the stomach: fundus, body, cardiac part, greater and lesser curvatures, pyloric part, pyloric canal,
pyloric sphincter
o Disease in cardiac part feels like cardiac problem (heart burn)
o Blood supply (celiac trunk)
 Left gastric artery  lesser curvature
 Short gastric arteries (branch of splenic artery)  greater curvature
 L. gastroepiploic artery  greater curvature
 R gastroepiploic artery (branch of gastroduodenal artery)  greater curvature
 R gastric artery (branch of proper hepatic artery)  lesser curvature
o Innervation
 Sympathetic: celiac ganglion (controls blood supply by controlling smooth muscle of the arteries)
 VASOCONSTRICTION
 Parasympathetic: Vagus nerve (LARP)
 Visceral pain: POORLY localized, pain referred to T5-T9; afferent fibers in vagus nerve and
splanchnic nerve
• Liver
o R upper quadrant, intraperitoneal, well-protected by ribs
o Undersurface: H
o Referred pain: greater splanchnic nerve (T5-T9 on R side), R phrenic nerve (C3-C5 on R side)  pain
localized to R upper quadrant and R shoulder
• Pancreas
o “wrapped in the arms of the duodenum”, posterior abdominal wall
o endocrine and exocrine functions
o Intraperitoneal
o Parts of the pancreas: uncinate process, head, neck, body, tail
o Blood supply
 Superior mesenteric artery
 Gastroduodenal artery
 Splenic artery
o Innervation
 Sympathetic: greater and lesser splanchnic nerves
 Referred pain: T5-T9 (mid/lower back above belly button)
 Inflamed pancreas  direct stimulation of intercostals nerves  back pain
o Duct work (between liver, gallbladder, pancreas and stomach)
• Duodenum (1st part of small intestine)
o Retroperitoneal except parts 1 and 4
o Four parts: bulb, descending, transverse, ascending
o Ulcer in the bulb can affect the gastroduodenal artery
o Anterior to transverse portion is the superior mesenteric artery and vein
o Blood supply: gastroduodenal artery and superior mesenteric artery
o No defined pattern of referred pain
o Ligaments
 Hepatoduodenal ligament (does NOT contain inferior vena cava)
 Hepatogastric ligament
• Spleen
o Intraperitoneal organ
o L upper quadrant
o Injury to the ribs can injure spleen, disease can cause expansion or contraction of the spleen
• Small intestines
o Upper portion= jejunum, lower portion= ileum
o Ligament of Treitz: R crus of diaphragm, marks the end of the duodenum and the beginning of the jejunum
(important surgical landmark)
o Blood supply: branches of the superior mesenteric artery
 Jejunum: simple blood supply, very convoluted mucosa
 Ileum: more complicated blood supply, smooth mucosa, Peyer’s patches
o Parasympathetic innervation: vagus nerve
o VERY FEW visceral pain fibers
• Ileocecal region (junction of ileum and cecum)
o APPENDIX: may not be where it’s supposed to be
 Appendicitis: vague visceral pain near belly button, abdominal pain, appendix then becomes
swollen and large  contact with body wall  sharp, parietal pain in R lower quadrant
• Large intestine
o Water absorption (products of digestion  solid)
o Retroperitoneal (transverse colon is intraperitoneal)
o Blood supply
 Superior mesenteric artery and inferior mesenteric artery connected by marginal artery
o Innervation
 Lesser/least splanchnic nerves
 Vagus nerve
 S2, S3, S4  parasympathetic to hindgut
• Portal circulation (specialized venous system that drains alimentary system)
o LOTS of disease
o Main portal vein  LIVER
 Major tributaries include superior mesenteric vein, splenic vein and gastric veins
o Anastomoses provide potential for mixing of blood (normally insignificant in healthy people)
 Esophagus
 Rectovault
 Umbilical area
o Liver disease (damage)  increased portal vein pressure due to scarring  hypertension  engorged
tributaries (porta cava anastomoses)

Lecture 24: Posterior Abdominal Wall


• Kidney
o Retroperitoneal
o Kidney is a little lower in position due to the liver (both are described as located between T11 and L3)
o Collecting system: medullary rays  medullary pyramids  renal column  renal papilla  Minor calices
 major calices  pelvis of ureter  ureter
o Innervation: renal/aortic plexus
 T10-T12: pain
o Blood vessels
 Renal vein: IVC on L side of the aorta  L testicular vein and L renal vein are a little longer than
R side
 Renal vein runs under superior mesenteric artery
 Vein – Artery – Ureter (ureter deep to testicular vessels)
 Increased pressure in L testicular vein  testicle varicoele  infertility
• Ureters
o Runs DEEP to testicular/ovarian vessels
o Runs superficial to bifurcation of iliac artery
o Runs along psoas muscle and joins bladder on posterior surface
o Poor blood supply  lacerations take a LONG time to heal
o Kidney stones= PAIN (T12-L2)
• Adrenal Gland
o Upper pole of each kidney
o R: triangular shaped, L: semilunar shape
• Muscles
o Psoas major
 Flexes hip
o Psoas minor
 “do nothing”
o Iliacus
 Flexes hip
o Quadratus lumborum
 Bends trunk from side to side
• Lumbar Plexus
o Subcostal nerve
o Iliohypogastric nerve
o Ilioinguinal nerve
o Genitofemoral nerve
 Cremaster reflex
o Lateral cutaneous nerve of the thigh
 Sensory ONLY
o Femoral nerve
 Innervates quadriceps muscles (flexes hip, extends leg)
o Obturator nerve
 Innervates ADDuctors of leg
o Lumbosacral trunk