Anatomy 3.

PART ε: AN ABDOMINAL WALL

PART ε1: GENERAL
1. Superficial fascia:
Camper’s Fascia Scarpa’s Fascia

*Fatty layer *Membranous layer

*Absent in penis *Continues as Colle’s fascia at perineum (prevents passage of extravasated urine)
*Replaced by dartos in *Thickened in median plane to form suspensory & fundiform ligaments of penis/ clitoris
scrotum

*Contents of fascia: fat (variable), cutaneous nerves & vessels, superficial lymphatics

2. Importance of umbilicus:

Anatomical Embryological
Watershed (lymph & venous flow don't Meeting point of 4 folds (2 lateral, head
cross umbilical plane) & tail) of embryonic plate
Supplied by T10 nerve Meeting point of digestive
Portocaval anastomoses (in portal (vitellointestinal duct), excretory
hypertension, caput medusae form) (urachus) & vascular (umbilical vessels)
systems

3. Vessels & nerves: [refer Chaurasia pg 200 – 202]

PART ε2: MUSCLES

4. Muscles of AN abdominal wall:
Muscle Origin Insertion Nerves Others

*Upper & lower 4 slips interdigitate with

serratus AN & latissimus dorsi
 *Xiphoid process respectively
EXTERNAL *(8 slips from) outer *Linea alba *Forms inguinal ligament
OBLIQUE surfaces, middle of shaft *Pubic symphysis & crest T6 – T12 *Forms AN wall of rectus sheath
of lower 8 ribs *Pecten pubis (between linea semilunaris & alba)
*Outer lip of iliac crest *Forms superficial inguinal ring (just
above pubic crest)

*Lower 3/ 4 ribs (&

*(LT 2/3 of) inguinal cartilages)
ligament *7th – 9th costal cartilages
INTERNAL *(AN 2/3,) middle area of *Xiphoid process T6 – L1 *Forms rectus sheath, conjoint tendon
OBLIQUE iliac crest *Linea alba (together with t. abdominis) & cremaster
*Thoracolumbar fascia *Pubic crest
*Pecten pubis

*(LT 1/3 of) inguinal

ligament
*(AN 2/3,) inner lip of iliac *Xiphoid process *Forms rectus sheath (arcuate line)
TRANSVERSUS crest *Linea alba T6 – L1 *Neurovascular plane is located between
ABDOMINIS *Thoracolumbar fascia *Pubic crest t. abdominis & i. oblique muscles
*(Inner surfaces of) lower *Pecten pubis
6 costal cartilages

MD head
AN pubic ligament
RECTUS *Horizontal line passing thru T5/ 6 – *Enclosed by rectus sheath
ABDOMINIS LT head 5th – 7th costal cartilages & T12 *Divided by 3 transverse fibrous bands
LT part of pubic crest xiphoid process

*For pyramidalis, refer Chaurasia pg 207

PART ε3: RECTUS SHEATH

5. Formation:
Level AN Wall PT Wall
 Above costal margin *External oblique (Deficient)

Between costal margin *External oblique *(PT lamina of) internal oblique
& arcuate line *(AN lamina of) internal oblique *Transversus adominis

Below arcuate line (All 3 flat muscles) (Deficient)

*The sheath is formed by aponeuroses of the muscles stated above

**The arcuate line is at the lvl of the midpoint between umbilicus & pubic symphysis

6. Contents:
Pyramidalis
Muscles Rectus abdominis

IF epigastric
Arteries SP epigastric

IF epigastric vena comitantes

Veins SP epigastric vena comitantes

Nerves
(Terminal parts of) T6 - T12

7. Functions:
a) Checks bowing (↑ efficiency) of rectus during contraction
b) Maintains strength of AN abdominal wall

PART ε4: FASCIA TRANSVERSALIS

8. Extent:
 SP AN MD
Continuous with Adheres to linea alba (above Attached to pubic tubercle
diaphragmatic fascia umbilicus) & crest; & pecten pubis

IF
Attached to inner lip of iliac
crest & LT part of inguinal
ligament
Continuous with fascia iliaca
PT
Merges with anterior layer
of thoracolumbar fascia
Continuous with renal fascia

*Part of the fascia forms AN wall of femoral sheath, internal spermatic fascia & deep inguinal ring too

PART ε5: INGUINAL CANAL

9. Boundaries:
Boundary MD Part Whole Extent LT Part

*Skin
AN wall *Superficial fascia *Internal oblique
*External oblique (aponeurosis) (muscle)

*Internal oblique (muscle)

Roof *Transversus abdominis

*Conjoint tendon *Fascia transversalis

PT wall *(Reflected part of) *Extraperitoneal tissue
inguinal ligament *Parietal peritoneum

Floor *Lacunar ligament *Inguinal ligament

10. Structures passing thru:

1. Spermatic cord (♂)/ round ligament of uterus (♀)

2. Ilioinguinal nerve
11. Constituents of spermatic cord:
a) Vas deferens
b) Testicular & cremasteric arteries, artery to vas deferens
c) Pampiniform venous plexus
d) Ilioinguinal, genital branch of genitofemoral & sympathetic nerves
e) Lymph vessels
f) Remains of processus vaginalis

12. Hesselbach’s triangle:

PART ζ: ABDOMINAL CAVITY & PERITONEUM

PART ζ1: PERITONEUM
1. Parietal & visceral peritoneum:
Parietal Peritoneum Visceral Peritoneum

General Fibrous Mesothelial cells which secrete serous fluid

Development Somatic mesoderm Splanchnic mesoderm

Blood & Nerve *(Same as body wall – somatic innervation) *(Same as the viscera – autonomic innervation)
Supply *Pain-sensitive *Pain when viscera is stretched/ ischemic/ distended
PART ζ2: PERITONEAL FOLDS
2. Ventral mesogastrium:

1. Divided by (developing) liver into ventral & dorsal part

2. Development of ventral mesogastrium:

Ventral Part Dorsal Part

Falciform lig Lesser omentum
Triangular lig (right & left)
Coronary lig (SP & IF)

3. Fate of dorsal mesogastrium:

Part Develops into…
Cranial Gastrophrenic ligament
Caudal/ Greater Greater omentum
Ventral Gastrosplenic ligament
Dorsal Lienorenal ligament

*Spleen divides dorsal mesogastrium into ventral & dorsal parts

PART ζ3: GREATER OMENTUM

4. Attachments:

1. AN 2 layers descend from greater curvature of stomach & fold to form PT 2 layers which
ascend to (AN surface of head & AN border of body of) pancreas

2. Upper part of 4th layer is partially fused with AN surfaces of transverse colon & mesocolon

3. Lesser sac between 2nd & 3rd layers degenerates [except for ≈2.5 cm below greater curvature
(of stomach)]
5. Contents:
a) Gastroepiploic vessels (left & right)
b) Fat

6. Functions:
Function Description

Fat storage

Protects peritoneal cavity from infections Marcophages form small, dense patches

Limits spread of infection Moves to site of infection & seals it from surrounding areas

Partition between supra- & infra-colic

compartments of greater sac

PART ζ4: LESSER OMENTUM

7. About:

1. Is the peritoneal fold which extends from lesser curvature of stomach & 1st part of duodenum
to liver

2. Comprises hepatogastric & hepatoduodenal ligaments

3. (A part of) lesser sac lies behind it

4. Has a free right margin with epiploic foramen (allows communication between greater &
lesser sacs)
8. Attachments:

Margins of porta hepatis (of liver)

SP Bottom of fissure for ligamentum venosum (of liver)

1st part of duodenum

IF Lesser curvature of stomach

9. Contents:

Lesser Curvature of Stomach –

Right Free Margin
Duodenum

Proper hepatic artery Gastric vessels (left & right)

Portal vein (Branches of) gastric nerves
Hepatic nerve plexus (enclosed by Gastric lymph nodes & lymphatics
perivascular fibrous sheath)
Lymph nodes & lymphatics
Bile duct

PART ζ5: MESENTRY

10. Borders:
Border Description

*Directed obliquely downwards to the right

*Extends from duodenojejunal flexure (on left side of L2 vertebra) to (upper part of) right
sacroiliac joint
*Passes thru…
Attached @ root of i) 3rd part of duodenum (site of entry of SP mesenteric vessles)
mesentry ii) Abdominal aorta
 iii) IF vena cava
iv) (Right) psoas major
v) (Right) genitofemoral nerve
vi) (Right) ureter
vii) (Right) iliosacral joint

*Folded into pleats

Free @ intestinal *Attached to gut, forming its visceral peritoneum

11. Contents:
a) Jejunal & ileal branches of SP mesenteric artery
b) Accompanying veins
c) Autonomic nerve plexuses
d) Lacteals & lymph nodes
e) Connective tissue (with fat)

PART ζ6: MESOAPPENDIX, TRANSVERSE MESOCOLON & SIGMOID MESOCOLON

12. Attachments & contents:
Attachments Contents

*Vessels, nerves, lymph nodes &

Mesoappendix lymphatics of appendix

*(AN surface of) head & (AN border of) body of *Middle colic vessels
Transverse pancreas *Nerves, lymph nodes & lymphatics of
Mesocolon transverse colon

*Left limb of V: Upper part of external iliac artery

*Apex of V: Left ureter (at termination of external iliac *Sigmoid vessels (at left limb)
Sigmoid artery) *SP rectal vessels (at right limb)
Mesocolon *Right limb of V: PT pelvic wall (extends down & MDly *Nerves, lymph nodes & lymphatics (at
from apex  median plane at lvl of S3 vertebra) right limb)
PART η: ABDOMINAL VISCERA & MACRO-STRUCTURES
PART η1: STOMACH
1. Blood supply:
Region Artery Veins

Lesser *Left gastric (br. of celiac trunk)

Curvature *Right gastric (br. of proper hepatic)
*Right & left gastric  Portal
Greater *Left gastroepiploic (br. of splenic) *Left gastroepiploic & short gastric  Splenic
Curvature *Right gastroepiploic (br. of gastroduodenal) *Right gastroepiploic  SP mesenteric

Fundus *Short gastric (br. of splenic)

2. Nerve supply:
Sympathetic Parasympathetic

Nerve T6 – T10 Vagus

*Greater splanchnic *AN (mainly for left vagus) & PT (mainly for right vagus) gastric
Via… *Celiac & hepatic plexuses *Esophageal plexus

*Sympathetic nerves are…

a) Vasomotor
b) Motor to pyloric sphincter, inhibitory to rest of stomach
c) Chief pathway for pain (from stomach)

3. Lymphatics: [refer Chaurasia pg 252]

 PART η2: DUODENUM
4. Pertoneal relations:
a) Mostly retroperitoneal & fixed
b) Its 2 ends are suspended by peritoneal folds & are mobile
c) AN part is partly covered by peritoneum

5. Visceral relations:
1st Part 2nd Part 3rd Part 4th Part

*Head & uncinate process (of

SP *Epiploic foramen pancreas) *Body of pancreas

IF *Head & neck of pancreas *Coils of small intestine

*Right lobe (of liver) *Transverse colon &

*Quadrate lobe (of liver) *Transverse colon *SP mesenteric vessels mesocolon
AN *Gall bladder *Transverse mesocolon root *Root of mesentery *Lesser sac
*Small intestine *Stomach

*Right ureter
*AN surface of kidney (near *Right psoas major *Left sympathetic chain
*Gastroduodenal artery hilum) *Right gonadal vessels *Left renal & gonadal artery
PT *Bile duct *Right renal vessels *IVC *IF mesenteric vein
*Portal vein *IVC *Abdominal aorta (with origin of
*Right psoas major IF mesenteric artery)

*Head of pancreas *Left kidney

Left *Bile duct *Left ureter

Right *Right colic flexure *Root of mesentery

6. Features of interior of 2nd part of duodenum:

 Contains opening for hepatopancreatic ampulla
Major Duodenal Papilla Located 8 - 10 cm distal to pylorus

May contain opening for accessory pancreatic duct

Minor Duodenal Papilla Located 6 - 8 cm distal to pylorus

Located below major duodenal papilla

Plica Longitudinalis

7. Arterial supply: SP & IF pancreaticoduodenal

*1st part of duodenum receives additional supply from…

a) Right gastric
b) Supraduodenal artery of Wilkie (branch of common hepatic)
c) Retroduodenal branches (of gastroduodenal)
d) Branches of right gastroepiploic

8. Venous drainage: splenic, SP mesenteric, portal

9. Nerve supply:
Sympathetic T9 & T10
Parasympathetic Vagus

10. Lymphatic drainage:

PART η3: JEJUNUM & ILEUM
11. Comparison between jejunum & ileum:
Jejunum Ileum

Location Upper & left parts (of intestinal area) Lower & right parts (of intestinal area)

*Wider *Narrower
Lumen *Usually empty *Usually loaded

Wall Thicker, more vascular Thinner, less vascular

*Long, rectangular windows *Short, squarish windows

*Less fat *More fat
Mesentery *1/ 2 generations of arterial arcades *3 – 6 generations of arterial arcades
*Less & longer vasa recta *More & shorter vasa recta

Lymphoid nodules M (microfold) cells Peyer’s patches

12. Blood & nerve supply:

Blood Supply Nerve Supply

Branches/ tributaries of SP mesenteric Sympathetic: T9 - T11
Parasympathetic: vagus
PART η4: CECUM
13. Relations:
AN PT

*Gonadal (testicular/ ovarian) vessels

*Intestinal coils *(Right) genitofemoral, femoral & LT cutaneous nerve of thigh
*AN abdominal wall *(Right) iliacus & psoas major

14. Blood & nerve supply:

Arteries
Cecal (branches of ileocolic)

Veins
SP mesenteric

Parasympathetic: Vagus
Nerves Sympathetic: T11 - L1

15. Ileocecal valve: [refer Chaurasia pg 268 – 269]

PART η5: VERMIFORM APPENDIX

16. Appendicular orifice:

1. Location:

External 2 cm below junction of transtubercular & right LT lines

Internal PosteroMD part of cecum, 2cm below ileocecal orifice

2. Is sometimes guarded by valve of Gerlach

3. McBurney’s point is the site of maximum tenderness during appendicitis

17. Blood supply:

Arteries Veins
Appendicular (brnch of lower division of Appendicular --> ileocolic --> superior
ileocecal) mesenteric --> portal

18. Nerve supply:

a) Sympathetic: T9 – T10 (via celiac plexus)
b) Parasympathetic: Vagus

19. Lymphatic drainage: appendicular, ileocolic

PART η6: COLON

[Refer Chaurasia pg 265 – 267]

20. Nerve supply:

Midgut Region Hindgut Region

Sympathetic *Celiac & SP mesenteric ganglia (T11 – L1) *Lumbar sympathetic chain (L1 & L2)

Parasympathetic *Vagus *Pelvic splanchnic (nervi erigentes)

*SP hypogastric
Plexus Involved *SP mesenteric *IF mesenteric

*Sympathetic nerves are vasomotor, motor to internal anal sphincter & inhibitory to colon
**Parasympathetic nerves are motor to colon & inhibitory to internal anal sphincter

PART η7: EXTRAHEPATIC BILIARY APPARATUS

21. Parts of bladder:
Part Description Relations

*Projects beyond IF border of liver (in angle between LT border of right

Fundus rectus abdominis & 9th costal cartilage) *AN: AN abdominal wall
*Surrounded by peritoneum *PT: Transverse colon

*Lies in fossa for gall bladder

Body *Continues with neck at right end of porta hepatis *1st & 2nd parts of duodenum
*SP surface is non-peritoneal while IF surface is peritoneal *Transverse colon

*Located near right end of porta hepatis

*Curves AN-SP and then PT-IF to continue as cystic duct (with a
Neck constriction) *SP: Areolar tissue of liver
*Mucous membrane is folded spirally to prevent obstruction to bile flow (with cystic vessels)
*PT-MD wall forms Hartmann’s pouch (which may harbour gallstones) *IF: 1st part of duodenum

22. Ducts: [Refer Chaurasia pg 287 – 289]

23. Arteries & the regions they supply:

Cystic, hepatic & upper part of bile duct
Cystic Gall bladder

Middle part of bile duct

Right Hepatic

Branches of SP Lower part of bile duct

Pancreaticoduodenal

24. Venous drainage:

Region Drainage
 SP surface of gall bladder “Veins which enter liver via fossa for gall bladder & join with tributaries of hepatic veins”

Rest of gall bladder Cystic (tributary of right branch of portal)

Lower part of bile duct Portal

25. Nerve supply: [Refer Chaurasia pg 290 – 291]

26. Lymphatics:
Region Nodes

*Cystic
Other than lower part of bile duct *Node of AN border of epiploic foramen

*Lower hepatic
Lower part of bile duct *Upper pancreaticosplenic

27. Calot’s triangle: [Refer Chaurasia pg 289]

PART η8: SPLEEN

[Refer Chaurasia pg 294 – 297]

PART η9: PANCREAS

[Refer Chaurasia pg 299 – 302]

PART η10: LIVER

[Refer Chaurasia pg 304 – 307]

28. Arterial supply: hepatic artery (20% of blood supply to liver)

29. Venous drainage:

 Portal Interlobular Sublobular

Right & left Hepatic

Hepatic sinusoids
branches

Segmental Interlobular IVC

*Blood from hepatic artery merges with that of sinusoids & drain into interlobular veins
*No anastomoses between adjoining hepatic arterial territories

30. Nerve supply: Hepatic plexus [contains sympathetic & parasympathetic (vagus) fibres]

31. Lymphatics:
Superficial Caval, hepatic, pericardial & celiac nodes

Deep Nodes around end of IVC, (partly) hepatic nodes

*Some vessels from coronary ligament may directly join thoracic duct

PART η11: KIDNEY

[Refer Chaurasia pg 312 – 314 & 316]

32. Coverings of kidney:

a) Fibrous capsule:

1. Closely invests kidney & renal sinus

2. Can normally be stripped off, but in certain diseases, adheres to kidney

b) Perirenal fat:

1. Surrounds capsule

2. Thickest at borders of kidney

3. Fills extra space in renal sinus

 c) Renal fascia:

d) Pararenal fascia:

1. Lies outside renal fascia

2. More abundant at PT surface & lower pole

3. Fills paravertebral gutter & forms cushion (for kidney)

PART η12: SUPRARENAL GLAND

[Refer Chaurasia pg 326 – 328]
 PART η13: DIAPHRAGM
33. Origins:
Part Details

Sternal *(2 slips from) PT part of xiphoid process

*Inner surface of lower 6 costal cartilages (& adjacent ribs)

Costal *Interdigitates with transverses abdominis

Attached LT to (front of) transverse process of L1

MD Lumbocostal Attached MD to sides of L1 & continuous with LT margin of each crus
Arch Tendinous arch in fascia covering upper part of p. major

Attached LT to lower border of 12th rib

LT Lumbocostal Attached MD to transverse process of L1
Lumbar Arch Tendinous arch in fascia covering upper part of q. lumborum

Arises from (AN-LT) surfaces of L1 - L2

Left Crus

Arises from (AN-LT) surfaces of) L1 - L3 (& intervertebral discs)

Right Crus Larger & stronger than left crus

34. Insertion (central tendon):

1. Lies below & is fused to pericardium

2. Trilobar in shape, with 3 leaflets:

Middle Left Right

*Triangular *Tongue-shaped
*Apex directed to xiphoid process *Curved LT & PT

3. Has 4 diagonal bonds located AN to opening for esophagus

35. Openings:
a) Large/ Main:
Name Location Structures

*IVC
Vena Caval *Central tendon *(Branches of) right phrenic nerve
*At lvl of T8 *Lymphatics of liver

*Esophagus
Esophagea *Muscular part (of diaphragm) *Esophageal branches of left gastric artery (& accompanying veins)
l *At lvl of T10 *Vagus

*Aorta
Aortic *Osseoaponeurotic *Azygos vein
*At lvl of T12 *Thoracic duct

b) Small:
Hemiazygos vein (for left crus only)
Crus Greater & lesser splanchnic nerves

Sympathetic chain
Behind MD arcuate ligament

Subcostal vessels & nerve

Behind LT arcuate ligament
Lymphatics
Larry's space @ foramen of Morgagni SP epigastric vessels

Musculophrenic vessels
(At lvl of 9th costal cartilage)

*Larry’s space is the part between origins of diaphragm from xiphoid process & 7th costal cartilage

36. Nerve supply:

Sensory Motor

*Phrenic (supplies central part)

 *T6 – T12 (supplies periphery) *Phrenic (ventral rami of C3 – C5)

PART θ: PT ABDOMINAL WALL

PART θ1: MUSCLES
1. Muscles:
Origins Insertions Nerves

*(AN surface), transverse process of L1 – L5

*(5 slips) bodies of T12 – L5 (1st slip arises from T12 &
L1)
*4 tendinous arches (from IF border of T12  SP
border of L5) *(Passes behind inguinal ligament)
PSOAS *(Joins with iliacus) Branches from L2 &
MAJOR *(MD part,) AN surface of lesser L3 (sometimes L4)
trochanter

PSOAS *Pecten pubis

MINOR *(Sides of) bodies of T12 & L1 (& the disc between) *Iliopubic eminence Branches from L1

*Upper 2/3 of iliac fossa

ILIACUS *Inner lip of iliac crest *(LT part,) AN surface of lesser Branches of femoral
*(SP surface,) LT part of sacrum trochanter (L2, L3)

*Transverse process of L5
QUADRATUS *Iliolumbar ligament *Transverse process of L1 – L4 Ventral rami of T12
LUMBORUM *Inner lip of iliac crest *(MD part,) IF border of 12th rib – L4

PART θ2: VESSELS

[Refer Chaurasia pg 337 – 340]

PART θ3: LUMBAR PLEXUS

2. Nerves:

*Iliohypogastric & ilioinguinal are of neither divisions

**The red circle denotes deep inguinal ring

PART θ4: LYMPHATICS

[Refer Chaurasia pg 341]
PART ι: PERINEUM
PART ι1: BOUNDARIES
[Refer Chaurasia pg 350 – 351]

PART ι2: ANAL REGION

1. Cutaneous innervations:
Nerve Region of Skin Supplied

IF Rectal (S2 – S4) Around anus & over ischioanal fossa

Perineal branch of S4 PT to anus

2. Fascia:

Superficial Deep
Copious fat Formed by anal & obturator fascia
Fills ischioanal fossa

*Anal fascia = IF fascia of pelvic diaphragm

3. Ischioanal fossa:
a) Boundaries:
*Apex is formed by line where obturator & anal fascia meet
**Base is formed by skin

b) Recesses:
Recess AN PT Horseshoe

*(Forwards)
*Above perineal membrane *(Smaller than AN) *(Connects ischioanal fossae)
Extent *Almost up to PT surface of body *Deep to sacrotuberous ligament *Behind anal canal
of pubis

c) Spaces & Canals: [Refer Chaurasia pg 353 – 354]

d) Contents:
1. Ischioanal fat

2. IF rectal vessels & nerve (supply mucous membrane, external sphincter & skin around anus)

3. PT scrotal/ labial vessels & nerve

4. Pudendal canal [refer Chaurasia pg 364]

5. Perforating cutaneous branches of S2, S3

6. Perineal branch of S4
4. Perineal body:
Aspect Description

*Median plane
Location *1.25 cm AN to anal margin
*Close to bulb of penis

Paired Unpaired
Bulbospongiosus Ex. anal sphincter
Muscles
Transversus perinei (superficial Longitudinal muscle of anal
Converging & deep) canal (striped & unstriped)
Levator ani

*Support for ♀ pelvic organs

*Attachment of sphincter urethrovaginalis
Functions *(Damage may cause bladder/ uterus/ ovary/ rectum prolapse)

PART ι3: POUCHES

5. [Refer Power Point slides]

PART ι4: PUDENDAL NERVE

6. Originates from sacral plexus in pelvis with root values S2 – S4

7. Course:
 Originates in pelvis

Enters gluteal region (thru greater sciatic notch)

Enters pudendal canal in lateral wall of anal fossa (after leaving lesser
sciatic notch)

Branches

8. Branches:
Branch Description

*Pierces MD wall of pudendal canal  crosses ischioanal fossa from LT to MD

*Supplies…
IF Rectal a) External anal sphincter
b) Skin around anus
c) Lining of anal canal below pectinate line

*Larger terminal branch of pudendal nerve

*Runs forwards under internal pudendal vessels
*Branches:
Perineal a) MD & LT PT scrotal/ labial
b) Muscular (supplies urogenital muscles, AN part of external anal sphincter & levator ani)
c) Nerve to bulbospongiosus (gives nerve to bulb which supplies corpus spongiosum, penis & urethra)

*Course:

Dorsal Nerve
of Penis/
Clitoris
 Runs forwards in pudendal canal above internal
pudendal vessels

Deep perineal space between internal pudendal vessels

& pubic arch

Lateral part of oval gap between apex of perineal

membrane & arcuate pubic ligament

Dorsum of penis/ clitoris

Ends in glans penis/ clitoris

*Supplies skin of glans & body of penis/ clitoris

PART κ: PELVIS & NON-GENITAL STRUCTURES

PART κ1: OSTEOLOGY OF PELVIS
1. Sex differences in pelvis
♂ ♀

False pelvis Deeper

Pelvic Inlet Shape ♥ (due to forward jutting of promontory)

Pelvic Cavity Smaller & deeper

*Larger
Pelvic Outlet *Everted

Sacrum Longer & narrower

Subpubic Angle (°) 50 – 60 80 – 85

Greater Sciatic Notch (°) 50 75

*Larger
Acetabulum *Diameter ≈ distance from AN margin  pubic
 symphysis

Preauricular sulcus More prominent

PART κ2: VESSELS OF PELVIS

[Refer Chaurasia pg 419 – 422]

PART κ3: NERVES & PLEXUSES OF PELVIS

2. Lumbosacral plexus:
a) Formation:

1. Descending branch, ventral ramus of L4

2. Ventral rami of L5 – S3

3. (Part of) S4

*Lumbosacral trunk (part of the plexus) is formed by #1 & #2 (L5 only)

b) Branches:
Nerve Root Value
L4 L5 S1 S2 S3 S4
Nerve to q. femoris
SP gluteal
 Nerve to o. internus
IF gluteal

Pudendal
Pelvic splanchnic
Muscular (supplies levator ani & external anal sphincter)

Nerve to piriformis
Perforating cutaneous

Tibial
Common peroneal
PT cutaneous nerve of thigh

*Red = ventral division, blue = dorsal, purple = both

3. Coccygeal plexus:

1. Formation:
a) Descending branch, ventral ramus of S4
b) S5
c) Coccygeal nerve

2. Gives anococcygeal nerves (which supply skin around coccyx)

4. Pelvic sympathetic chain:

 *Glomus coccygeum is a gland at tip of coccyx

5. IF hypogastric plexus:
Formation Branches to…

*Prostatic plexus
*SP hypogastric plexus (via hypogastric nerve) *Rectal plexus
*Branches from upper ganglia of sacral sympathetic chain *Uterovesical plexus
*Pelvic splanchnic nerves *Vaginal plexus

PART κ4: MUSCLES OF PELVIS (LEVATOR ANI)

6. Origin, insertion & nerve supply:
Origins Insertions Nerves

AN fibres (levator prostatae/ sphincter vaginae) AN fibres

*(Pelvic surface,) MD part, body of pubis *Perineal body

Middle fibres (puborectalis) Middle fibres

PUBOCOC- *(Pelvic surface,) LT part, body of pubis *(Loops around anorectal junction)
CYGEUS Branch of S4
PT fibres (pubococcygeus proper) PT fibres
*(AN part, white line of) obturator fascia *Tip of coccyx
 *Anococcygeal ligament

ILIOCOC- *(PT part, white line of) obturator fascia *Last 2 pieces of coccyx
CYGEUS *(Pelvic surface of) ischial spine *Anococcygeal ligament Branch of IF rectal

ISCHIO- *(Pelvic surface of) ischial spine *S5

COCCYGEUS *Sacrospinous ligament *Side of coccyx Branch of S4 & S5

PART κ5: URINARY BLADDER

[Refer Power Point slides]

PART κ6: MALE URETHRA

7. Parts:
*Passage of urine thru different shapes causes it to flow in a continuous stream under pressure

8. Arterial supply:
a) Urethral (branch of internal pudendal)
b) Dorsal penile (via circumflex branches)

9. Venous drainage:
Part of Penis Veins

AN Dorsal penile  Internal pudendal  Prostatic plexus  Internal iliac

PT Prostatic & vesical plexus  Internal iliac

10. Nerve supply:

Supplies smooth muscle of prostate & prosthetic urethra

Prostatic Plexus
Sympathetic to preprostatic sphincter during ejaculation
Greater Cavernous
Parasympathetic
S2 - S4

*Supply to rhabdosphincter (?) is by neurones of Onuf’s nucleus in S2 which pass via perineal branch of pudendal

11. Lymphatics:

12. Extravasation of urine: [Refer Chaurasia pg 357]

PART κ7: RECTUM

13. Curvatures: [refer Chaurasia pg 408]

14. Relations:
 a) Peritoneal:

Part Description

Upper 1/3 Peritoneal in front & on sides

Mid 1/3 Peritoneal in front

*Peritoneum-free
Lower 1/3 *Lies below rectovesical/ rectouterine pouch

b) Visceral:

AN PT
♂ ♀
*Rectovesical pouch *Rectouterine pouch *Median sacral, LT sacral, SP rectal vessels
*Prostate & seminal vesicles *Uterus *Sympathetic chain, ganglion impar, pelvic
*(Terminal parts of) ureters & vas deferens *(IF part of) vagina splanchnic nerves
*Lymphatics
*Coils of intestine & sigmoid colon
*Piriformis, coccygeus, levator ani
*(Base of) bladder
*S3 – S5, coccyx & anococcygeal ligament
*Fat

*Both innervations pass thru SP rectal or IF mesenteric & IF hypogastric plexuses

15. Transverse folds:

 (Sometimes) encircles & partially constricts lumen

1st
Projects from left wall
Present near SP end (of rectum), 7.5 cm above anus

Projects from AN & right walls

2nd
Lies at SP end of (anal) ampulla
Largest & most constant

Projects from left wall

3rd
Lies 2.5 cm IF to 3nd fold
Inconsistent

*Longitudinal folds are temporary & are obliterated upon distention

16. Arterial supply:

Artery Region of Rectum Supplied

SP Rectal Muscular coats, (anal canal & valves)

Middle Rectal Muscular coats of IF part

Median Sacral PT wall (of anorectal junction)

17. Venous drainage:

*Median sacral drains into LEFT common iliac

18. Nerve supply:
Sympathetic Parasympathetic

Root value L1 & L2 S2 – S4

*Inhibitory to musculature
*Motor to internal sphincter *Motor to musculature
Actions *Vasoconstriction *Inhibitory to internal sphincter

*Pain
Sensations detected *Pain *Distention

19. Lymphatics: IF mesenteric & internal iliac nodes

20. Supports:

PART λ: ♂ REPRODUCTIVE ORGANS & EXTERNAL GENITALIA

PART λ1: SCROTUM
1. Layers:
 Skin Dartos (prolonged into median
(continuation of vertical septum between 2
abdominal skin) halves of scrotum)

Internal spermatic Cremaster & External spermatic

fascia (from fascia fascia from fascia (from external
transversalis) internal oblique oblique)

2. Blood supply (arteries):

a) Superficial & deep external pudendal
b) Scrotal branches of internal pudendal
c) Cremasteric branch of IF epigastric

3. Nerve supply: [refer Chaurasia pg 222]

PART λ2: TESTIS

4. External features:
a) Poles:
1. Upper & lower poles are smooth & convex

2. Upper pole…
a) Gives attachment to spermatic cord
b) Contains appendix of testis (remnant of paramesonephric duct)

b) Borders:

AN PT

1. Fully covered by tunica 1. Partially covered by tunica vaginalis

vaginalis 2. Epididymis lies on its LT part
3. Contains sinus of epididymis (which separates LT part of
epididymis from testis)
 c) Surfaces: MD & LT

5. Coverings (from outside  inside):

Covering Description

*Represents lower persistent portion of processus vaginalis

*Has parietal & visceral layers (& a cavity in between)
Tunica vaginalis *Covers whole testis (except PT border)

*Covered by visceral layer of tunica vaginalis (except PT where testicular vessels & nerves
enter gland)
*PT border is thickened to form mediastinum testis (incomplete vertical septum)
Tunica albuginea *Many septa extend from mediastinum into inner surface of tunica albuginea, dividing testis
into 200 – 300 lobules

Tunica vasculosa *Vascular coat which lines lobules

6. Blood supply: [refer Chaurasia pg 225]

7. Nerve supply:

Sympathetic nerves:

1. T10 (via renal & aortic plexuses)

2. Sensory & vasomotor

8. Lymphatics: pre- & para-aortic nodes

PART λ3: BODY OF PENIS

9. Free portion of penis is continuous with the root in front of pubic symphysis.

10. Comprises 3 elongated muscles:

 a) Called right & left corpora cavernosa & corpus spongiosum (at median):
Corpora Cavernosa Corpus Spongiosum

*Terminate under cover of glans penis in a blunt conical

extremity
*Surrounded by tunica albuginea (strong fibrous envelope)
*The tunica has…
a) Inner circular fibres (which enclose each corpus
separately & form median septum)
b) Outer longitudinal fibres (which enclose both corpora)
*Forward continuation of bulb of penis
*Terminal part is expanded (conically) to form glans penis
*Traversed by urethra throughout its whole length
*Surrounded by fibrous sheath

b) During erection, they are engorged with blood, leading to considerable enlargement

11. Glans penis:

a) Its base has a projecting margin (corona glandis) which overhangs neck of penis
b) Urethra dilates in its roof to form navicular fossa

12. Skin of penis:

1. Loosely connected with fascial sheath (of penis)

2. Is folded at the neck of penis to form prepuce @ foreskin which covers the glans

3. On the undersurface of glans is a median fold of skin called frenulum

4. Preputial sac is the potential space between glans & prepuce

5. On the corona glandis & neck of penis, there are numerous small preputial glands that
secrete smegma (sebaceous material), which collects in preputial sac

13. Superficial fascia of penis:

a) Consists of very loose areolar tissue & completely fat-less
b) May contain a few muscle fibres
 c) Is continuous with membranous layer of abdominal superficial fascia above & that of perineum below
d) Contains superficial dorsal vein (of penis)

14. Deep fascia of penis @ Buck’s fascia:

1. Surrounds all 3 masses of erectile tissue

2. Doesn’t extend into glans

3. Deep to it are dorsal arteries, deep dorsal vein & dorsal nerves of penis

4. Is continuous proximally with dartos & fascia of urogenital triangle

15. Supports of body of penis:

*Extends downwards from linea alba & splits to enclose penis
Fundiform Ligament *Superficial to suspensory ligament

Suspensory Ligament *Extends from pubic symphysis & blends with fascia on either side of penis

PART λ4: EPIDIDYMIS

[Refer Chaurasia pg 226]

PART λ5: VAS DEFERENS

[Refer Chaurasia pg 399 – 400]

PART λ6: PROSTATE

16. Gross features:
a) Apex & base:
 Apex Base
Directed downwards Directed upwards
Surrounds junction of prostatic & Contains circular groove (which
membranous urethra contains venules of vesical & prostatic
Separated from anal canal via perineal plexuses) at lvl of neck of bladder
body

b) Surfaces:
Surface Description

*Lies 2 cm behind pubic symphysis (separated by retropubic fat)

*SP part is connected to pubis via puboprostatic ligaments
AN *IF part is pierced by urethra
*Comprises fibrous tissue

*Separated from rectum via Denonvillier’s fascia

PT *Lies 4 cm from anus
*Is pierced by ejaculatory ducts near its SP border

*AN fibres of levator ani enclose prostate in pubourethral sling

2 IF-LT *Separated from levator ani by venous plexus in its sheath

17. Zones: [refer Chaurasia pg 402]

18. Lobes:
a) Surgical: AN, PT, Median & 2 LT
b) Anatomical: Median * 2 LT

19. Capsules & ligaments:

20. Blood supply:
Arteries Veins

Branches of… Prostatic plexus:

*IF vesical Communicates with… Vesical & Batson’s plexus, internal pudendal
*Middle rectal Drains into… Vesical & internal iliac

*Internal pudendal

21. Nerve supply: prostatic plexus

22. Lymphatics: sacral, internal & external iliac nodes

PART μ: ♀ REPRODUCTIVE ORGANS & EXTERNAL GENITALIA

PART μ1: UTERUS
1. Angulation: [refer Chaurasia pg 387 – 388]

2. Parts:
a) Fundus:

1. Forms free upper end of uterus & lies above openings for Fallopian tubes

2. Convex (dome-shaped)

3. Covered with peritoneum

4. Directed AN when bladder is empty

5. Implantation occurs at its PT wall

b) Body:
AN/ Vesical Surface PT/ Intestinal Surface

Appearance Flat Convex

*Coils of small intestine

Relation *Bladder *Sigmoid colon

*Covered with peritoneum *Covered with peritoneum

Peritoneum *Forms SP/ PT wall of uterovesical pouch *Forms AN wall of rectouterine pouch

1. Rounded & convex

2. Provide attachment to…

a) Broad ligament
b) Round ligament (at end of borders)
c)c) LTOvarian
borders: ligament (PT-IF to Fallopian tubes)

3. Fallopian tubes open at their SP end

4. Uterine artery ascends between 2 layers of broad ligament

3. Cervix:
Part Description

*Relations:

AN: bladder
Supravaginal
PT: rectouterine pouch &
rectum
Sides: Ureter & uterine
artery (embedded in
parametrium)

Vaginal *Projects into AN wall of vagina (& forms AN, PT & 2 LT fornices)

*Fusiform-shaped
*Has AN & PT walls (contain interlocking arbor vitae uteri which close the canal)
(Canal) *Communcates with…
a) Body of uterus via internal os
b) Vagina via external os

4. Ligaments:
Type Name Description

AN *Comprises uterovesical fold

PT *Comprises rectovaginal fold

*Attach uterus to LT pelvic wall

*AN & PT peritoneal layers become continuous at its free upper border
*MD border attached to LT margin of uterus
*PT & IF borders attached to corresponding parts of pelvic wall
*Contents:

Fallopian tube
P
E Round & ovarian
Broad
R ligament
I
T
Uterine & ovarian vessels
O
N
Uterovaginal & ovarian
E
A
nerve plexuses
L
Epo- & para-ophoron

Lymphatics

Parametrium (dense
connective tissue)

Ovarian *Passes from lower pole of ovary  LT wall of uterus

Mesovarium *Attaches ovary to PT layer of broad ligament

Mesosalpinx *Is the part of broad ligament between Fallopian tube & ovarian ligament

Mesometrium *Is the part of broad ligament below ovarian ligament

Suspensory *Is the part of broad ligament stretching from upper pole of ovary  LT pelvic wall
*For fibromuscular ligaments, refer Chaurasia pg 389 – 392]

5. Arterial supply:
a) 2 uterine arteries
b) Ovarian artery

6. Venous drainage:

7. Nerve supply:
a) Sympathetic: T12 – L1
b) Parasympathetic: S2 – S4

8. Lymphatic drainage:
Part Drainage
Upper Superficial inguinal nodes
Middle External iliac nodes
Lower External & internal iliac, sacral nodes
*Lymphatics of uterus begin from 3 intercommunicating networks (endo- & myo-metrial, subperitoneal)

PART μ2: VAGINA

[Refer Chaurasia pg 393 - 394]

9. Arterial supply:

Main Additional
Vaginal branch (of internal iliac) Cervicovaginal branch (of uterine)
Internal pudendal
Middle rectal

10. Venous drainage: vaginal plexus  vaginal veins  internal iliac veins

11. Nerve supply:

Upper 2/3 Lower 1/3

*IF hypogastric & uterovaginal plexuses

*Sympathetic: L1 – L2 *Pudendal (via IF rectal & PT labial branches of perineal)
*Parasympathetic: S2 – S4 *(Pain-sensitive)
*(Pain-insensitive)

12. Lymphatic drainage:

a) Upper 1/3: external iliac nodes
b) Middle 1/3: internal iliac nodes
c) Lower 1/3: superficial inguinal nodes

PART μ3: OVARY

[Refer Power Point slides]

PART μ4: FALLOPIAN TUBE

[Refer Chaurasia pg 385 – 386]