Liver: largest gland (4 lobes; 1.5-1.

.7kg) in R Hypochondriac, Epigastric, and some L Hypochondriac (receives everything absorbed from gut except lipids)
- Borders: Superior (ICS 4) and Inferior (711)
- Glissons Capsule: thick (thickest @ hilum) protective CT around liver/portal (surrounded by serous visceral peritoneumdynamic); gives off trabeculae lobes/lobules (incomplete in male)
- Porta Hepatis: accepts portal triad (HPV, HA, BD) which branches together down to sinusoids
- Lesser Omentum: hepatogastric + hepatoduodenal (Ant. border of Winslow : Portal Triad in R free margin)
o Epiploic Foramen (of Winslow): greater <-> lesser sac (bursa);
o Pringle Maneuver: pinch off hepatoduodenal ligament rapidly stems blood loss/bile leakage (may affect hepatocyte metabolism)
Aberrant R/L Hepatic Artery: from L Gastric or SMA (does not pass through hepatoduodenal ligament) ineffective Pringle
From L Gastric: careful in stomach cancer resection (liver dysfunction / bleeding)
o Posterior Gastic/Duodenal Perforation: compromises bursa structures
- Crush Trauma: fractured ribs or xiphoid perforation
- Falciform Ligament: suspends from ant. wall & diaphtragm (divides left lobe into M/L)
o Round Ligament (of Teres): remnant of L umbilical vein (obliterated fetal liver bypass for 02 bood to IVC as Ductus Venosum posteriorly) Ligamentum Venosum posteriorly
o Subphrenic Recess: divided L/R by falciform; continuous w/Morrisson anteriorly
- Bare Area: direct diaphragmatic (capsule but no peritoneum); bound by ant/post coronary ligaments and L/R triangular ligaments (hold liver in place)
o Metastatic Portal: (to thorax) via small lymphatics/veins bronchomediastinal trunk neck root (enlargement of supraclavicular/pre-scalene nodes)
- IVC trough (GB ant.): L/R lobes
- Caudate Lobe: (posterior) independent filtration/blood supply; contains both L/R HA and HV and bile to both L/R BD (caution not to tear bleed out); btw IVC and Lig. Venosum
- Quadrate Lobe: (anterior) functionally tied to L lobe; btw GB and Teres / ant. margin and porta hepatis; bile L/R ducts
- Hepatorenal Recess (Pouch of Morrison): most inferior when supine fluid accumulation
- Segmentation: based on triad distribution; allows partial resection (down to 1/3 still fxns)
o Hepatic Plexus: largest celiac plexus derivative
- Innervation: via arterial hwy; Vagal and Symp Trunk Celiac Plexus follow celiac branches liver/gullbladder/pancreas
- Central Celiac Nodes (+ proper hepatic/cystic): metastatic traffic indicators (enlargement) btw liver capsule and pancreatic head (virulent)
- Portal HTN: cirrhosis/blockage esophageal/rectal (hemorrhoid)/abdominal (caput medusa) varices
o Portal/Caval Graft: (direct s-s / e-e or central splenorenal) temporary life extension for transplant wait questionable bloodrenal filtrates
- Hepatitis: inflammation (usually viral)
- Cirrhosis: chronic inflammation (from chronic hepatitis or alcoholism)
- Microanatomy: hepatocytes in hexagon w/central vein that receives percolation from triads in sinusoids (macrophages); bilecanaliculie
Gallbladder: bile storage + dehydrationconcentration; neck (2duo)/fundus/body (fossa btw lobes @ TC / sup. Duodenum)
- Bile: alkaline solution of bile salts (from chol)/pigments (bilirubin from heme), cholesterol, neutral fats, phospholipids, and electrolytes
- Wall: mucosa / Fibromuscular (enteroendocrine-cholecystokinin responsive smooth + ACT) / perimuscular CT (BV/N/L) / thick CT + serosa
- Hepatocystic Triangle (of Calot): contains Mascagnis Lymph Node (enlarged due to cholecystitis)
o Borders: common hepatic duct (med.), cystic duct (inf.), and cystic artery (sup.)
o Caution: may sever structures ( or aberrant R hepatic) bleeding/bile leakage
o Aberrance: cystic + ant/post branches may arise from SMA or Left Hepatic
- Gallstones: 80% cholesterol / 20% bilirubin (pigments)
o 4Fs: Fat, Female, Fertile, Forty
o Hartmans Pouch: outpouching @ neck (may block GB); may ulcerate into TC or duodenum (Ileocecal
o Cholecystitis: right shoulder referred pain (C5) + upper R quadrant (T5/6 in greater splanchnic)
o Palpation: @ right hypochondriac at jxn of linea semilunaris and costal margin
- Innervation: (along arterial hwy) splanchnic (symp) and vagus (para)
- Duodenal Relationships: neck (1
st
), body (2
nd
), fundus (TC)
o Duct System: hepatic + cystic (spiral)common bile duct >>> + Duct of Wirsung (insulin + amylase)Ampulla of VaterMajor Duodenal Ampulla (@ sphincter of Oddi)
o Biliary Blockage: Liver dysfxn, Jaundice (Bilirubenemia), Steatorrhea (no ADEK uptake), Bilirubin Urea (Bilirubinemiakidney filter), and Pruritus (itching)
Pancreas: endo/exocrine; dorsal/ventral developmentallyduodenal rotationmerger; thin CT capsule w/septa (interlobular ducts)lobules
- Head/Uncinate: nestled in duodenum curve (dual BS); uncinate is behind SMA
- Neck/Body/Tail: fed via anastomosing dorsal and greater pancreatic arteries (from inf. pancreatic via splenic)
- Lymphatics: SMN, Cel N, Pyloric Nod Metastatic Variance
- Tumors: @ head HPV + SMA + BD + duod : @ neck SMV/SV jxn to HPV : @ body/tail Splenic Vessels
- Splenic Artery/Vein: post/sup spleen; convoluted artery / straight distensible vein (occlusion)
- Hilum: highly vascular (important in splenectomy)
- Annular Pancreas: split ventral bud (head/unc.)wraps/constricts duodenumabsence or obstruction (vomiting)
o Polyhydramnios: baby cant swallow amniotic fluidtoo much amniotic fluid
- Islets of Langerhans: B-insulin, glucagon, somatostatin (more in tail)
- Acinar Cells: enzyme secretion (storage in granules as proenzymes); activation acute pancreatitis
- Ducts of Wirsung (mainmaj ampulla mp of 2nd) + Santorini (accessorymin ampulla 2cm above)
- PP Cells: pancreatic polypeptide
Spleen: r>w; fed by splenic artery (4 branches @ hilum); w/weak capsule (ribperforationsplenectomy)
- 1 x 3 x 5 in 7oz. ribs 9-11
- Ligaments: (@ pedicle btw spleen and pancreatic tail) must be ligated during splenectomy
o Gastrosplenic: (greater omentum)GC of stomach; contains short gastric and gastroepiploic arteries
o Colosplenic:
o Splenorenal: (greater omentum) kidney; splenic vessels
o Phrenocolic:
- Splenomegaly: due to lymph diseases (palpable at left hypochondria)
- Terminal End Arteries: divide into segments (partial splenectomy)
Kidney: retroperitoneal blood ultrafiltration and metabolic control (12 fetal lobules fuse by adulthood)
- L Kidney (ICS 11) [slightly longer/narrower] v. R Kidney (12
th
rib-L3)
- Cortex: (outer) nephrons [glomerulus, bowmans capsule, PCT/DCT) renal columns
- Medulla: (inner) drainage [henle] renal sinuses (slits)
o Pyramids: 10-18; apexcollecting duct opening
- Calyces: minor (8-9)major (3) pelvis (expanded ureter @ hilum)
- Sinus: fat-filled concavity at medial hilum border
- Renal Vessels: hilumterminal/segmental branches (Ant./Pos./Sup./Inf. - to pelvis)
o Interlobar Arcuate Interlobular aff arterioles glomerulus caps eff arteriole peritubular caps/vasa rectainterlobular varcuate vinterlobar vrenal veinIVC
o Capsular
o Pelvic
o Ureteric
- Nutcracker: SMA distention L Renal Vein impingement throbbing pain, haematuria (rupture of congested renal veins) , pampiniform varicocoele
- SMA Syndrome: impingement of duodenum
- Suprarenal Arteries: inf. (renal), middle (aorta), sup. (inf. phrenic)
- Ureter: ( ID via squeeze contraction) opportunistic blood supply (kidneys, gonadal, aorta, common Iliac, Internal Iliac)
o Right: medial to IVC (crosses over R Colic and Ileocolic aa)
o Left: lateral to Aorta (crosses over L Colic and Sigmoid Colon)
o 90 Drop: @ linea terminalis bladder
o Trigone: post. entrance to blatter
- Surfaces: rests on QL, Psoas, Diaphragm, Trans Colon
- Non-metabolic Fat: capsule / perirenal fat / renal fascia (of Gerota) / pararenal fat
o Bulimia/Dietary Disorders: sunken eyes and lower back depressions
- Renal Plexus: Aorticorenal ganglia mix of symp/para fibers renal plexus (mostly symp)
- Kidney Stones: crystalized (Ca, oxalate, P03, urea, cysteine) masses irritation, bleeding (haemeturia), and obstruction vomiting/nausea, urinary frequency/urgency, pain
o Common Locations: @ Pelvis (kidney-ureter), 90 bend, and Tragone region of bladder
o Hydronephrosis: fluid-filled enlargement of renal pelvis/calyces
o Stag Horn: filling pelvis + calyces (requires ultrasound)
- Renal Agenesis: renal bud fails to attach to ureters and develop (bilateral = life threatening)
o Potters Sequence: urine oligohydramnios (<400mL) compression (club foot, facial disfigurement) + pulmonary hypoplasia
Anhydramniosis: total lack
- Berry Aneurysms: intima breakdown due to polycystic kidney (or liver/pancreas) disease growing thrombosis (usually In circle of willis ant. comm)berry aneurysm
- Cysts: everyone has some; many = pathology (improper DCT collecting tubule linkage)
- Horseshoe Kidney: Kidneys fuse @ sup/inf poleIMA-blocked ascensionpelvic kidney
Posterior Abdominal Wall:
- Retroperitoneal Viscera: (properitoneal = ant.) btw peritoneum and transveralis, which lines QL and Psoas
- Psoas Major: (L1-4) + Iliacus lesser trochanter
o Psoas Abcess: lumbar tuberculosispsoas sheath (abcess)pusinferiorlyLinea terminalis
o Post. Abdominal Pain upon movement: indicates kidney, cecum, ureter, pancreas, or appendix inflammation
- Quadratus Lumborum: 12 rib + Lumbar TPs Iliac Crest (lateral spine flexion)
- Lumbar Plexus:
o Subcostal: T12 ant. rami
o Obturator: medial thigh adductors
o Femoral: Iliacus + thigh flexors + knee extensors
o Lumbosacral: (L4/5)ala + S1-4 = sacral plexus
o Iliohypogastric: Ant Rami L1 (post to medial arcuate)
o Ilioinguinal: Ant Rami L1 (post to medial arcuate)
o Genitofemoral: (L1/L2) ant. psoas (deep to psoas fascia)divides (lat to common/ex. Iliac aa)femoral / genital branches
o Lateral Cutaneous: (L2/3) inferolateral on Iliacusanterolateral thigh
o Lumbar Symp Trunks: receive L1-3 (found in psoas major groove
o Gray Rami communicantes: post-gang synapticsant. rami
Inguinal Region:
- Gubernaculum: ligamentous structure btw gonad pole and labial/scrotal fold; pulls retroperitoneal developing testes through canal (just round ligament in females)
o Ovaries: Pelvis by 3
rd
month (considered Definite @ deep pelvis trailing vessels/nerves)
o Testis:
Processus Vaginalis: peritoneal pouch evaginates into developing scrotum ahead of testes (DIR @ 7mo; canal @8mo; scrotum by birth)
Obliteration: @ birthtunica vaginalis (parietal and visceral); if patentcongenital indirect inguinal hernias
Spermatic Cord:
Ext Spermatic Fascia: (from EO fascia)
Cremaster: (from IO/fascia)
Int. Spermatic Fascia: (from transversalis)
Components:
o Ductus Deferens
o Testicular Artery
o Artery of Ductus Deferens
o Pampiniform Venous Plexus
o Autonomic nerves (para/symp)
o Lymphatics
o Genital branch of genitofemoral
Inguinal Canal: spermatic cord/round ligament + Ilioinguinal
Boundaries:
o SIR: in EO
o DIR: in transversalis fascia (Indirect Hernias)
o Ant. Wall: IO (lat) + EO apo (med)
o Roof: falx inguinalis (arches of IO)
o Floor: Inguinal Lig + Lacunar Lig (med)
o Post. Wall: transveralis (lat) and conjoint tendon (medially)
Inguinal Triangle (of Hesselbach): d
Border: DIRECT Inguinal Hernias
o Medial: linea semilunaris
o Laterally: inf epigastric
o Inferiorly: inguinal lig
- Femoral Hernia: below I-lig
- Obturator Hernia:
- Other: umbilical, lumbar, incisional, hiatal????

















Innervation:
- Intrinsic: CNS visceral aff/eff GI, spleen, pancreas, gallbladder & liver
o Sympathetic Trunks: // cords of pre/post-synaptic symp. + viscera aff in neck (c-sheath), thorax (rib necks/lat. to VB), lumbar (VB ant/lat), pelvic (ant. to sacrum)
Paravertebral Symp. Ganglia: raised clumps of soma outside CNS
3 cervical
11-12 thoracic
4 lumbar
4-5 sacral
Ganglion Impar: trunks unite ant. to coccyx
Gray Rami Communicantes: (full length) connect ganglia to spinal nerves
White Rami Communicantes: (T1-L2) connect ganglia to spinal nerves
o Splanchnic Nerves: (trunk/gangliaprevertebral Plexuses/ganglia)
Preganglionic Symp + VA: Trunk/ganglia ant. aortic plexuses
Thoracic Splanchnics:
o Greater Splanchnic: (TG 5-9/10 Celiac Ganglion)
o Lesser Splanchnic: (TG 9/10/11 Aorticorenal Ganglion)
o Least Splanchnic: (TG 12 Renal Plexus)
Lumbar Splanchnics: (2-4) lumbar plexus
Sacral Splanchnics: Inf. Hypogastric Plexus (extansion into plexus)
Preganglionic Para: S2-4 Ant. Rami pelvic prevertebral plexus (Inf. Hypogastric)
Pelvic Splanchnics: Inf. Hypogastric Plexus
o Ascending Fibers: (to abd. Plexus) hindgut
o Abdominal Prevertebral Plexuses: surrounds abdominal aorta
Celiac: @ celiac trunk/SMA 2 SM, Renal, other branches of celiac
2 Celiac Ganglia:
SM Ganglion:
2 Aorticorenal Ganglia:
Aortic: (SMA rootAortic bifurcation) 2 IM, Spermatic, Ext. Iliac
IM Ganglion:
Sup. Hypogastric: transition to pelvic; several small ganglia
Hypogastric Nerves: pelvis Inf. Hypogastric/Pelvic Plexus
Receives:
Vagus: pregang para + VA
Thoracic/Lumbar Splanchnic: pregang symp + VA
Pelvic Splanchnic: pregang para
o Parasympathetic:
Ant/Post Vagus: along esophagus/thru diaphragm pregang para + VA abdominal pervert. Plexus foregut + midgut
Pelvic Splanchnic: hindgut
- Enteric (Extrinsic): self-sufficient motor/sensory in walls of G gastric secretion, blood flow, and peristalsis
o Myenteric Plexus: (btw long/circ)
o Submucosal Plexus: (btw circ/sumbucosa)
o Receives: postgagng symp + pregang para
- Sympathetic Innervation of the Stomach:
o T6 pregang ant. root spinal nerve white ramus communicante symp trunk greater splanchnic celiac ganglion (SYNAPSE) postgang celiac plexus 2 plex
stomach
- Lumbar Plexus: (from ant. rami of T12-L3/4)


Subcostal: (T12) [P] lat. LS arch (arcuate lig) / [A] QL thru TA {IO/EO/TA/RA/pyramidalis}
Iliohypogastric: (L1) lat psoas [A] QL thru TA thru IO {IO/TA} ant. cut. (suprapubic) + lat. cut.(gluteal)
Ilioinguinal: (L1) [A] QL thru {TA/IO} fem. cut. (med. thigh) + ant. scrotal/labial (follows spermatic cord/round ligament)
Genitofemoral: (L1/2) ant. psoas fem. cut. (fem. ) + genital (DIRIcan {cremaster} + scrotum/labium majora
Lat. Fem. Cut: (L2/3) lat. psoas [A] Iliacus /[P] I-lig skin of ant./lat. thigh
Femoral: (L2-4) lat. psoas psoas/Iliacus groove [P] I-lig / [L] fem. V/A fem. (outside sheath)branches:
- Ant. Fem. Cut. + Saphenous (medial) + {quads, pectineus, sartorius} + hip/knee joints
Obturator: (L2-4) [M] psoas along lat. pelvic wallthru obturator foramen ant./post. branches{adductors, pectineus} + hip/knee joints + med. thigh
Acc. Obturator: (L3/4) (only 9% pop.) [M] psoasover sup. Pubic ramus {pectineus} + hip join
Lumbosacral Trunk: (L4 +L5)sacral plexus

Autonomic Ganglia:
- Sympathetic Chain (Paravertebral) Ganglia: ascending/descending preganglionic symp. GVE+GVA (soma in DRG)
- Collateral (Prevertebral) Ganglia: (soma of postganglionic symp.) Celia, SM, aorticorenal, IM ganglia (@ origin of resp. arteries)
o Receive preganglionic symp. From greater, lesser, & least splanchic nerves
- Paraaortic Bodies: (a.k.a. aortic bodies, Zuckerlands bodies, organs of Zuckerkandl, or aortic glomerula) chromaffin cells near symp. Chain ganglia
o Chemoreceptors (O2 lack, C02 excess, [H+])control reception
Splanchnic Nerves:
- Thoracic: preganglionic symp. GVE (soma in lat. horn) + GVA (some in DRG)
- Lumbar: (from lumbar symp. Trunks)celiac, mesenteric, aortic, and sup. Hypogastric plexuses (preganglionic symp. GVE + GVA)
Autonomic Plexuses:
- Celiac: (splanchnic + vagus) + ganglia (from splanchnic) [A]crura + AA @ CT, SMA, RA trunks
o Subsidiary Plexuses: along branches of CTgastric, splenic, hepatic, suprarenal, and renal
- Aortic: (from Celiac plexus) [A] aorta; branches along arteries SM, gonadal (T/O), and IM
- Sup./Inf. Hypogastric: (from Aortic [A] aorta) just below aortic bifurcation
Enteric Division: pre/postganglionic parasymp., postganglionic symp., GVA, and soma of postganglionic para
- Symp. Nerves (inhibit GI motility/secretion + constrict sphincters)
- Para Nerves (stimulate GI motility/secretion + relax sphincters)
- Myenteric (Auerbachs) Plexus: (btw long./circ.)
- Submucosal (Meissners) Plexus: (submucosa)


Sacral Plexus: (lumbosacral trunk + VR S1-4) internal surface of piriformis muscle
-




Pudendal Nerve: (S2-4) Greater Sciatic Foramen btw piriformis/coccygeusIschial spinelesser Sciatic foramen (w/pud artery)pudendal canal
- Inferior Rectal: branchesischiorectal fossa (comm. w/perineal from post. femoral cutaneous) {sphincter ani externus} + anal skin
- Perineal: deep branch {perineal muscles} + superficial scrotal/labial branch
- Dorsal Nerve of Penis/Clitoris: thru perineumbtw suspensory ligs (deep to deep fascia)skin, prepuce, glands
-


Sympathetic Nervous Supply:
- Greater Splanchnic (T5-9)
- Lesser Splanchnic (T9-10)
- Lowest/Least Splanchnic (T12)
- Lumbar Splanchnic (L1-3)
- Sacral Splanchnic
Parasympathetic Nervous Supply:
- Vagus
- Pelvic Splanchnic (S2-4)
Coeliac Plexus: @ T12-L1 (surrounds Coeliac Trunk and SMA)
- Aorticorenal Plexus: bottom half of Coeliac plexus (partially detached)
- Secondary Plexuses:
o Phrenic: accompanies Inf. Phrenic Artery diaphragm + suprarenal gland
o Splenic: coeliac + left coeliac ganglion + right vagus BV + smooth of splenic capsule and trabeculae
o LG: lesser curvature of the stomach
o Intermesenteric (abdominal): supplies IVC + testicular plexuses (comm. w/IM and SM)
o Suprarenal: medulla of suprarenal gland
o Renal: coeliac + aorticorenal + lowest/least splanchnic + 1
st
lumbar splanchnic + aortic plexus
Gonadal (ovarian/testicular): follows gonadal artery
Ureter: follows ureter
o SM: downward extension of Coeliac along SMApancreas, SI, colon (R 2/3 trans)
o IM: from aortic plexus + 2/3 lumbar splanchnics (rest of colon)
o Hepatic Plexus: coeliac + L/R vagus + phrenic follow hepatic artery/portal vein
Cystic Plexus: gallbladder
Branches: pylorus, GC, lower bile duct, head of pancreas, duodenum
Superior Hypogastric Plexus: (aortic plexus + 3/4 lumbar splanchnic) ant. to aortic bifurcation (L5/sacral promontory)
- L/R hypogastric nerves2 inferior hypogastric plexuses (ant. to sacrum)
o Inf. Hypogastric Plexus: (pelvic splanchnic + sacral splanchnic)
Middle Rectal Plexus
Vesical Plexus
Prostatic Plexus
Uterovaginal Plexus
Segmental Sympathetic Supplies/Referred Pain
- Esophagus (T5-6): epigastric/retrosternal
- Stomach (T6-10):


















Pelvic Neurovasculature: retroperitoneal; Lat- N/V/A Med (lymph // veins)
- Arteries True Pelvis:
o Paired Internal Iliac:
Internal Iliac: medially over linea terminalis
Anterior Division: along lat. pelvic wall
o Umbilical superior vesicle (superior bladder)
Medial Umbilical Ligament (obliterated artery
o Obturatorobturator canal Pelvic muscles, Ilium, Femoral Head, Medial Thigh Muscles
Aberrant Obturator Pubic Branch Inf Epigastric
o Uterine/Ductus Deferens
Ascending (uterine) and Superior Vaginal in Females: runs through roots of broad lig
o Vaginal/Inf. Vesicle:
Females: middle/inferior vagina
Inf. Vesicle is a branch
Males: fundus of bladder
Prostatic branch Prostate + prostatic urethra
SeminalSeminal Vesicles
o Middle Rectal: (anastomoses with sup. Rectal) seminal glands and inf rectum
o Inferior Gluteal: exits via infrapiriform part of greater sciatic pelvic diaphragm (coccygeus and levator ani), piriformis, QG, hamstrinkgs, gluteus
maximus, sciatic nerve
Ant: anastomoses w/ circumflex femoral
Post: muscle and skin of posterior thigh and buttocks
o Internal Pudendal: Greater Sciatic (exit) Lesser Sciatic (reenter)pudendal canalUrogenital Triangle
Perineal Artery
Dorsal Artery of Clitoris or Penis
Inferior Rectal
Posterior Division:
o Iliolumbar: Iliac Branch (Iliacus Muscle/Ilium) along anteromedial piriformispelvic sacral foraminapiriformis, erector spinae, overlying skin
o Lateral Sacral:
Parietal Branches: (Spinal Meninges, Roots of Sacral Nerves, Erector Spinae, Skin)
Visceral Branches:
Superior Rectal
Middle Rectaln
o Superior Glueteal: (Largest) supplies gluteal muscles
o Unpaired Median Sacral: (post AA) descends medially over L4/5 and tailbone inf. lumbar vertebrae, sacrum, and coccyx
Anastomoses: lateral sacral artery (via medial sacral artery)
o Unpaired Superior Rectal: (from IMA) crosses L common and descends in sigmoid mesocolondivides (to each side of rectum) Internal Anal Sphincter
Anastomoses: middle rectal and inferior rectal
o (Females Only) Paired Ovarian Arteries: (from AA) descends in suspensory ligament of oary abdominal/pelvic ureter, ovary, ampulla of uterine tube
Anastomoses: uterine arter (via tubal/ovarian branches)
- Testicular Arteries: (lat AA) inguinal canal abdominal ureter, testis, and epididymis
o Anastomoses: cremasteric, ductus deferens artery
- External Iliac: deep circumflex artery, femoral artery, inferior epigastric artery
- Pelvic Venous Plexus: drains mainly into Internal Iliac Vein (some to superior rectalportal system) [few drainlateral sacral (to internal vertebral plexus), parietal sacral, ovarian veins)
- Lymph Node Groups: Common Iliac Nodes Aortic Nodes
o External Iliac: above linea terminalis along artery (does not // venous) Common Iliac Nodes
Inguinal, Sup/Middle Pelvic Viscera
o Internal Iliac: clustered at ant/post divisions and gluteal arteries Common Iliac Nodes
Inferior Pelvic Viscera, Deep Perineum, Gluteal
o Sacral: in concavity near medial sacral vessels Common Iliac Nodes
Posterio/Inferior Pelvic Viscera
- Nerves: sacral and coccygeal spinal nerves + pelvic ANS
o Obturator: (Ant. Rami L2-4) extraperitoneal fatobturator canal/foramenmid thigh
o Lumbosacral Trunk: (L4 + L5 @ brim trunk + lumbosacral plexus @ ala
o Sacral Plexus:
Sciatic: (L4-S3) largest in body foot, leg, and post. thigh (flexors)
Pudendal: (S2-4) Main perineal nerve; chief sensory nerve of external genitalia
Superior Gluteal: (L4-S1) Gluteus Medius/Minimus
Inferior Gluteal: (L5-S2) Superior gluteal muscle
o Coccygeal Plexus: small network @ S4-S5 coccygeal muscle, part of levator ani, sacrococcygeal joint, skin
- Autonomic Nerves:



























Urinary Organs:
- Ureters: 25-30cm muscular tubes w/opportunistic BS and VD; (over CIA bif) (obliquely) bladder wall
o Lymphatics Common and Internal Iliac Nodes
o Innervation: adjacent autonomic plexuses (opportunistic): inf. hypogastric/pelvic plexus and pelvic splanchnic nerves
Afferent Pain Fibers: T11-L1/2 (ureteric calculi)
o BS: renal, gonadal, aorta, common iliac (all abdominal) + internal iliac, superior vesical, uterine, middle rectal, vaginal/inf. vesical (pelvis)
o Calculi: renal pelvis, ureteric bend (@LT), bladder tragone
- Urinary Bladder: hollow distensible viscus
o Dynamic: only median and two lateral ligaments @ neck movement
Lat: puboprostatic (M) / pubovesical (F)
o Retropubic (Retzius) Space: btw bladder / pubis
o Detrussor Muscle: walls + internal urethral sphincter (contraction during ejaculation)
o Trigone: ureteric orifices
o Arterial Supply: Superior / Inferior Vesical, Obturator, Inferior Gluteal Arteries
o Innervation:
Somatic: pelvic splanchnic
Symp: Inf. Thoracic + Upper Lumbar Hypogastric Plexus/Nerves
Para: Pelvic Splanchnic + inferior hypogastric plexus (detrusor)
Sensory: visceral; above pain line
- Urethra:
o Male:
Proximal: prostatic branches of inf. vesical / middle rectal prostatic venous plexus [prostatic plexus symp/para/visceral eff]
Intramural: (1cm) vert @ bladder neck within internal urethral sphincter
Prostatic: (3.5cm) through ant. prostate; trough of external urethral sphincter anteriorly (seminal coliculus)
Intermediate (membranous): (1cm) through deep perineal pouch within cicular ext. urethral sphincter (penetrates perineum)
Spongy: (15cm) through corpus spongiosum (widens @ bulb and navicular fossa glans of penis) accepts bulbourethral glands @ bulb
o Femal: (4cm) poor internal sphincter w/vestibular external sphincter (ant to vagina)
Paraurethral (Skenes) Glands: (prostate equivalent)
Vestibular (Bartholin) Glands: in perineum
BS: internal pudendal / vaginal arteries (VD = same)
Innervation: pudendal nerve + vesicle nerve plexus
Rectum:
- Peritoneal Covering: ant / lat of sup 1/3 AND ant of middle 1/3
- Rectovesical Pouch (M)
- Vesicouterine Pouch + Rectovesical Pouch (F)
- BS: sup. Rectal / middle rectal (2/3) / inf. rectal (anorectal jxn and anal canal)
- VD: sup Rectal (portal) + mid/inf.
- Portal / Caval: Internal Rectal anal venous plexus (deep to anorectal jxn mucosa) + External Rectal anal Venous Plexus (ext to muscular rectal wall)
- Innervation:
o Symp: lumbar hypogastric/pelvic plexus + IMA/SMA plexuses
o Para: pelvic splanchnic + L/R hypogastric plexuses
o Visceral Aff: below pain line (para fibers to S2-4)
Testes: (germinal cells and testosterone) surrounded by tunica albuginea and cupped ant. by tunica vaginalis
- Tubules: SeminiferousStraightRete TestisEfferent Ductules
- BS: testicular artery (anast w/ductus deferens)
- VD: pampiniform testicular vein
- Lymph: right/left aortic + preaortic nodes
- Nerves: testicular plexus (vagal para/VA) + T7 (symp)
Epidydimis: long convoluted on post. testis that transports sperm (headbodytail Vas Def)
Vas Deferens: (main part of spermatic cord) thick muscular walls w/narrow lumen seminal ducts (forms ejaculatory ducts)
- BS: superior vesicle
- VD: pampiniform
- LD: external Iliac
- Vasectomy: cut and separated (highly regenerated)
Seminal Glands: elongated (rectovesical pouch & peritoneum superiorly, oblique over prostate) alkaline w/fructose + anticoag ductus deferens (forms ejaculatory duct)
- AS: inf. vesical + middle rectal
- VD: inf. vesical + middle rectal
- LD: External Iliac (sup) + Internal Iliac (inf)
- Palpation: rectal exam massage detects gonococci infection
Ejaculatory Ducts: @ bladder neckprostatic urethra
- AS: sup. Vesical
- VD: prostatic/vesical plexus
- LD: external Iliac
Prostate: largest accessory (2/3 glandular, 1/3 fibromuscular) in FECT w/dense neurovascular all in visceral prostatic sheath (cont with puboprostatic ligs)
- Ducts: milky/thinsinuses 20% semen
- Lobules/Zones: Peripheral, Central, Transitional, Periurethral
- AS: Internal Iliac (Inf Vesical, Int Pudendal, Middle Rectal)
- VD: prostate and vesical plexuses and internal Iliac vein
- LD: internal iliac and sacral nodes
Bulbourethral (Cowpers) Glands: posterolateral to intermediate urethra
- Ducts: cross perineum w/spongy urethra (penis) mucus secretion during arousal
Ovaries: (~testis) produce ova
- Suspensory (Infundibulopelvic) Ligament of Ovary: direct uterus
- Broad Ligament of Uterus: Mesosalpinx (@ uterine tube), Mesovarium (mesosalpinxovary), and Mesometrium (ovaryuterus)
- Uterine Tubes (10cm) conduct oocytes + fert. ; in mesosalpinx of broad ligament
o Infundibulum: fimbriae
o Ampulla
o Isthmus
o Cornua (uterine part)
- BS: ovarian
- VD: pampiniform plexus, uterine plexus/vein, ovarian vein
- LD: lumbar preaortic nodes
- Innervation:
o Ovarian Plexus
o Uterine Plexus: visceral afferent (symp), Lumbar splanchnic (T11-S2), visceral afferent (para S2-4)
Uterus: thick, dynamic walls; usually anteverted/anteflexed and resting on bladder (full bladderstraight uterus)
- Body: w/fundus
- Isthmus: @ uterine tube
- Cervix: supravaginal and vaginal
- Layers: perimetrium, myometrium, endometrium
- Ligaments:
o Ovarian Gubernaculums: ovarian and round ligaments
o Broad Ligament
o Suspensory Ligament
- Principal Support:
o Pelvic Diaphragm: levator ani + coccygeus
Active: sitting, standing, sneezing, or coughin
o Ligaments: pubocervical, cardinal, uterosacral
o Pouches: vesicouterine, rectouterine
- BS: uterine + ovarian
- VD: uterine plexus + internal Iliac veins
- Uterine Triad???
Vagina: distensible musculomembranous tube vestibule btw labia minora (copulation/birth/menstruation); ant. to rectum/post to bladder
- Fornices:
- Sphincters: pubovaginalis, external urethral, urethrovaginal, bulbospongiosus
- BS: vaginal branch of uterine, vaginal, internal pudendal
- VD: vaginal, vesical, and rectal plexuses + Internal Iliac
Innervation of Uterus and Vagina:
- Somatic: (lower vagina) pudendal nerve
- Visceral: (upper vagina + uterus): uterovaginal plexus (symp, para, visceral aff)
Male External Reproductive Organs:
- Urogenital Triangle: ant. perineal triangle (pubic sypmh ischia tuberosities)
- External Genitalia:
o Scrotum:
Pigmented Skin
Dartos Fascia: covers dartos muscle (T control) *continuous w/scarpas + colles+ from labioscrotal folds
BS: post. scrotal (from int. pudendal), ant. scrotal (deep ext. pudendal), and cremasteric (inf. epigastric)
VD: same
LD: superficial inguinal
Nerves:
Genital (of genitofemoral)
Ant. Scrotal (ilioinguinal)
Post. Scrotal (pudendal)
Perineal
Post. Cutaneous of Thigh
o Distal Urethra:
BS: dorsal artery of penis (from internal pudendal)
VD: same
LD: Intermediate Internal Iliac Spongy Deep Inguinal
Innervation:
Prostatic Plexus: symp/para/VA
Dorsal nerve branch of pudendal: somatic
o Penis: male copulation (root / body / glands)
Three Cylindrical Bodies
Corpus Cavernosa (2): surrounded by tunica albuginea
Spongy Corpus: around urethra
Foreskin: frenulum (circumcision)
Bucks Fascia
BV
Lymph nodes
Glands: corona and neck
Erectile Muscles: ischiovacernosus (in crus restricts venous flow maintain erection) + bulbospongiosus (in bulb support/enlargement/turgidity) + sup. Transverse
perineum (same as bulbospongiosus)
Suspensory Ligament: condensation of deep fascia anchors to pubic symph
BS: internal pudenda (dorsal, deep (helicine), and bulbar arteries of penis) + external pudendal (from femoral)
VD: deep (perineal memprostatic plexus) + superficial (ext. pudendal)
LD: superficial and deep inguinal nodes + preaortic nodes
Innervation: dorsal nerve, ilioinguinal, and cavernous nerves
- Perineal Muscles
- Anal Canal:
o External and Internal Anal Sphincter: inf. rectal nerve (from pudendal)
- Spermatic Cord: DIRICSIRpost. testes
o Deferent Duct
o Testicular Artery
o Deferent Duct Artery (from sup. Vesical)
o Cremasteric Artery (inf epigastric)
o Pampiniform Plexus
o Sympathetic Fibers
o Genital Branch of Genitofemoral Nerve
o Lymphatics
o Vaginal Process Remnants (~ round lig)
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