Anatomy 100 Concepts Most Important General Anatomy

General Anatomy 100 concepts

1. Dr. Mavrych, MD, PhD, DSc [email protected]
100 must important
GA conceptions
Dr. Mavrych, MD, PhD, DSc
Dr. Bolgova, MD, PhD
Understand first, then memorize and apply

2. Dr. Mavrych, MD, PhD, DSc [email protected]
zDear students, you can use this presentation like a guide during your
preparing for GA exams.
zIt does NOT cover all material of the Gross Anatomy course.
zTo complete GA material you should work with ALL professor’s
presentations.
zGood Luck and All the best!
Dr. Mavrych

3. Dr. Mavrych, MD, PhD, DSc [email protected]
1. Lumbar puncture (tap) and
Epidural anesthesia
zWhen lumbar puncture is
performed, the needle
enters the subarachnoid
space to extract
cerebrospinal fluid (CSF)
or to inject anestheticto
epiduralspace.
zThe needle is usually
inserted between L3/L4or
L4/L5. Level of horizontal
line through upper points
of iliac crests.
zRemember, the spinal cord
may ends as low as L2in
adults and does end at L3
in children and dural sac
extends caudally to level of
S2.

4. Dr. Mavrych, MD, PhD, DSc [email protected]

5. Dr. Mavrych, MD, PhD, DSc [email protected]
zPatients typically have history
of back pain that may radiate
down to the lower limb.
zHerniation of disc usually
occurs in lumbar (L4/L5or
L5/S1) or cervical regions
(C5/C6orC6/C7) of
individuals younger than age
50.
zHerniated lumbar disc usually
compreses the nerve root one
number below: traversing root
(e.g., the herniation L4/L5 will
compress L5 root).
zThe pain begins soonafter
patient lifted some heavy thing.
zLower limb reflexesare
decreasedon the affected
side
2. Herniated IV disc

6. Dr. Mavrych, MD, PhD, DSc [email protected]
3. Abnormal curvatures of the
spine
zKyphosis is an exaggeration of
the thoracic curvature that may
occur in elderly persons as a result
of osteoporosis(multiply
compression fracture of vertebral
bodies) or disk degeneration.
zLordosis is an exaggeration of the
lumbar curvature that may be
temporary and occurs as a result
of pregnancy, spondylolisthesis
or potbelly.
zScoliosis is a complex lateral
deviation, or torsion, that is
caused by poliomyelitis, a leg-
length discrepancy, or hip disease.

7. Dr. Mavrych, MD, PhD, DSc [email protected]
4. Upper limb fractures:
Humerus fractures
Sites of potential injuryto major
nerves in fractures of the humerus:
1.Axillary nerveand posterior
humeral circumflex arteryat the
surgical neck.
2.Radial nerveand profundabrachii
artery at midshaft. Midshaft
fracture affect origin of brachialis
muscle.
3.Brachial artery and median nerve
at the supracondylarregion.
4.Ulnar nerveat the medial
epicondyle.

8. Dr. Mavrych, MD, PhD, DSc [email protected]
Fracture of distal radius:
zTransverse fracture within the distal 2 cmof
the radius. Most commonfracture of the
forearm (after 50).
zSmith's fracture results from a fall or a blow
on the dorsal aspectof the flexed wrist
and produces a ventral angulation of the
wrist. The distal fragment of the radius is
ANTERIORLYdisplaced.
zColles' fracture results from forced
extensionof the hand, usually as a result of
trying to easea fall by outstretching the
upper limb. Distal fragment is displaced
DORSALLY-“dinner fork deformity”.
Often the ulnar styloidprocess is avulced
(broken off)

9. Dr. Mavrych, MD, PhD, DSc [email protected]
Scaphoid fracture
zOccurs as a result of a fall onto
the palmwhen the hand is
abducted
zPain occurs primarily on the
lateral sideof the wrist,
especially during wrist extension
and abduction
zScaphoid fracture may not show
on X-ray films for 2 to 3 weeks,
but a deep tendernesswill be
present in the anatomical
snuffbox.
zThe proximal fragment may
undergo avascular necrosis
because the blood supply is
interrupted.

10. Dr. Mavrych, MD, PhD, DSc [email protected]
Boxer’s fracture
zNecks of the metacarpal
bones are frequently
fractured during fistfights.
zTypically, fractures of 2
d
and
3
d
metacarpals are seen in
professionalboxers, and
fractures of 5
th
and sometimes
4
th
metacarpals are seen in
unskilledfighters.

11. Dr. Mavrych, MD, PhD, DSc [email protected]
Mallet or Baseball Finger
zThis deformity results from the DIP joint suddenly
being forced into extreme flexion (hyperflexion)
when, for example, a baseball is miscaught or a
finger is jammed into the base pad.
zThese actions avulsethe attachment of the
extensor digitorum tendon to the base of the
distal phalanx. As a result, the person cannot
extend the DIP joint. The resultant deformity bears
some resemblance to a mallet.

12. Dr. Mavrych, MD, PhD, DSc [email protected]
5. Rotator cuff muscles –SITS
zSupportthe shoulder joint by
forming a musculotendinous
rotator cuff around it
zReinforces joint on all sides
except inferiorly, where
dislocation is most likely
Rotator cuff muscles are:
zSupraspinatus
zInfraspinatus
zTeres minor
zSubscapularisRight humerus
Abducts
these two externally rotate
internally rotate and adduct.

13. Dr. Mavrych, MD, PhD, DSc [email protected]
6. Abduction of the upper limb
z(0°-15°) Abduction of the
upper extremity is initiated
by the supraspinatus
muscle (suprascapular
nerve).
z(15°-110º) Further abduction
to the horizontal position is a
function of the deltoid
muscle(axillarynerve).
z(110°-180°)Raising the
extremity above the
horizontal position requires
scapular rotation by action
of the trapezius(accessory
nerve CNXI) and serratus
anterior (long thoracic
nerve).

14. Dr. Mavrych, MD, PhD, DSc [email protected]
Subacromial bursitis &
Tearing of supraspinatus tendon
zSubacromial bursitis (inflammation of
the subacromial bursa)is often due to
calcific supraspinatus tendinitis,
causing a painful arc of abduction.
zThe same symptoms will be in case of
inflammation or trauma of the
supraspinatus tendon (MRI→ torn
tendon)

15. Dr. Mavrych, MD, PhD, DSc [email protected]
7. Three Elbows: Student's elbow
(Subcutaneous olecranon bursitis)
zThe olecranon,to which the triceps
tendon attaches distally, is easily
palpated. It is separated from the
skin by only the olecranon bursa,
which allow the mobility of the
overlying skin.
zRepeated excessive pressure and
friction may cause this bursa to
become inflamed, producing a
friction subcutaneous olecranon
bursitis.

16. Dr. Mavrych, MD, PhD, DSc [email protected]
Tennis elbow
(Lateral epicondylitis)
zLateral epicondylitis: repeated
forceful flexion and extension of the
wrist resultingstrain attachment of
common extensortendon and
inflammation of periosteumof
lateral epicondyle. Pain felt over
lateral epicondyle and radiates
downposterior aspect of forearm.
Pain often felt when opening a
dooror lifting a glass
zOrigins of following muscles may
be affected:
1.Extensor Carpi Radialis
Longus & Brevis
2.Extensor Digitorum
3.Extensor Digiti Minimi
4.Extensor Carpi Ulnaris

17. Dr. Mavrych, MD, PhD, DSc [email protected]
Golfer’s elbow
(Medial epicondylitis)
zMedial epicondylitis is
inflammation of the common
flexortendon of the wrist
where it originates on the
medial epicondyleof the
humerus.
zOrigins of following muscles
may be affected:
1.Pronator Teres
2.Flexor Carpi Radialis
3.Palmaris Longus
4.Flexor Carpi Ulnaris

18. Dr. Mavrych, MD, PhD, DSc [email protected]
8. Arterial anastomoses
around the scapula
zBlockage of the
Subclavian or Axillary
artery can be bypassed
by anastomoses
between branches of
the Thyrocervicaland
Subscapulararteries:
zTransverse cervical
zSuprascapular
zSubscapular
zCircumflex scapular

19. Dr. Mavrych, MD, PhD, DSc [email protected]
9. Cubital fossa
zContents from lateral to medial:
1.Biceps brachii tendon
2.Brachial artery
3.Median nerve
zSubcutaneosstructuresfrom lateral to
medial:
1.Cephalic vein
2.Median cubital vein: joins cephalic
and basilic veins
3.Basilic vein
zSites of venipunctureis usually median
cubital veinbecause:
zOverlies bicipitalaponeurosis, sodeep
structures protected
zNot accompanied by nerves

20. Dr. Mavrych, MD, PhD, DSc [email protected]
10. Carpal Tunnel Syndrome
zResults from a lesion that
reducesthe size of the carpal
tunnel (fluid retention, infection,
dislocation of lunate bone)
zMediannerve –most sensitive
structure in the carpal tunnel
and is the most affected
zClinical manifestations:
zPins and needles or anesthesia
of the lateral 3.5 digits
zpalmsensation is not affected
because superficial palmar
cutaneous branch passes
superficially to carpal tunnel
zApehanddeformity -absent
of OPPOSITION

21. Dr. Mavrych, MD, PhD, DSc [email protected]
11. Test of the proximal and
distal interphalangeal joints
zPIP –FDS
zDID -FDP

22. Dr. Mavrych, MD, PhD, DSc [email protected]
12. Lesion of UL nerves
Upper Brachial Palsy
zInjury of upper roots and trunk
zUsually results from excessive
increase in the anglebetween the
neck and the shoulder stretching or
tearing of the superior parts of the
brachial plexus (C5and C6roots or
superiortrunk)
zMay occur as birth injury from
forceful pulling on infant's head
during difficult delivery

23. Dr. Mavrych, MD, PhD, DSc [email protected]
Upper Brachial Palsy
(Erb-Duchenne palsy)
xInallcases,paralysisofthemusclesofthe
shoulderandarmsuppliedbyC5andC6spinal
nerves(roots)oftheuppertrunk.
xCombinationlesionsofaxillary,suprascapular
andmusculocutaneousnerveswithlossofthe
shouldermmandanteriorarm.
xAsresultpatienthas“waiter’stip”hand:
xadductedshoulder
xmediallyrotatedarm
xextendedelbow
xlossofsensationinthelateralaspectofthe
upperlimb

24. Dr. Mavrych, MD, PhD, DSc [email protected]
Lower Brachial Palsy
(Klumpke paralysis)
zInjury of lower roots and
trunk
zMay occur when the upper
limb is suddenly pulled
superiorly:stretching or
tearing of the inferior parts
of the brachial plexus (C8
and T1 roots or inferior
trunk)
zE.g., grabbing support
during falling from height
or as a birth injury, or
TOS –thoracic outlet
syndrome

25. Dr. Mavrych, MD, PhD, DSc [email protected]
Lower Brachial Palsy
(Klumpke paralysis)
zAll intrinsic muscles of the hand
supplied by the C8and T1roots of
the lower trunkaffected.
zCombination lesions of ulnar
nerve (“claw hand”) and median
nerve (“ape hand”)
zLoss of sensation in the medial
aspect of the upper limb and
medial 1,5 fingers.
zMay include a Hornersyndrome

26. Dr. Mavrych, MD, PhD, DSc [email protected]
Injury to musculocutaneous
nerve
zUsually results from lesions
of lateral cord
zGreatly weakens flexionof
elbow (biceps and brachialis
muscles) and supinationof
forearm(biceps muscle)
zMay be accompanied by
anesthesia over lateral
aspect of forearm

27. Dr. Mavrych, MD, PhD, DSc [email protected]
Cutaneous innervation
of the hand
Dorsum: 1,5-U and 3,5 R Palm: 1,5-U and 3,5 M
In reality, in case of superficial branch of
radial nerve lesion it will be skin deficit
between 1 & 2 digits onthedorsum of the
hand ONLY because of nerve overlapping

28. Dr. Mavrych, MD, PhD, DSc [email protected]
13. Cardiac catheterization
zThe femoral artery is
used for cardiac
catheterization
zIt can be cannulated
for left cardiac
angiography & also
for visualizing the
coronary arteries –a
long, slender catheter
is inserted
percutaneously and
passed up the
external iliac artery,
common iliac artery,
aorta, to the left
ventricleof the heart

29. Dr. Mavrych, MD, PhD, DSc [email protected]
14. Injury of the gluteal region
Fractures of Femoral Neck
zA common fracture in
elderly women with
osteoporosisis fracture of
the femoral neck.
zFractures of the femoral
neck cause shortness and
lateral rotation of the lower
limb.
zFractures of the femoral
neck often disrupt the blood
supply to the head of the
femur.
zAt present time the best way
in case of femoral neck
fracture is hip replacement.

30. Dr. Mavrych, MD, PhD, DSc [email protected]
Avascular necrosis
of femoral head
zTranscervicalfracture
disrupts blood supplyto
the head of the femur via
retinaculararteries(from
medial circumflex femoral
artery) and may cause
avascular necrosisof the
femoral headif blood
supply through the ligament
to the head is inadequate.

31. Dr. Mavrych, MD, PhD, DSc [email protected]
Injury to sciatic nerve
zWeakened hip
extension and knee
flexion
zFootdrop(lack of
dorsiflexion)
zFlail foot (lack of
both dorsiflexion and
plantar flexion)
zCause of injury:
caused by
improperly placed
gluteal injections
but may result from
posterior hip
dislocation

32. Dr. Mavrych, MD, PhD, DSc [email protected]
Posterior hip dislocations
zThey are most common. A head-on
collision that causes the knee to
strike the dashboard may dislocate
the hip when the femoral head is
forced out of the acetabulum.
zThe joint capsule ruptures inferiorly
and posteriorly (fracture of ishium),
allowing the femoral head to pass
through the tear in the capsule
(tearing of ishiofemoral lig.) and
over the posterior margin of the
acetabulum onto the lateral surface
of the ilium, shortening and
medial rotatingthe limb.

33. Dr. Mavrych, MD, PhD, DSc [email protected]
Superior gluteal
nerve injury
zThe superior gluteal nerve
may be injured during surgery,
posterior dislocationof the
hip or poliomyelitis.
zParalysisof the gluteus
mediusand gluteus minimus
muscles occurs so that the
abilityto pull the pelvis up
and abduction of the thigh
are lost.
Trendelenburgsign:
zIf the superior glutealnerve on
the right side is injured, the left
pelvisfalls downwardwhen the
patient raises the left foot off the
ground.
zNote that side is contralateralto
the nerve injury.
Right
superior
gluteal nerve
injury
Normal

34. Dr. Mavrych, MD, PhD, DSc [email protected]
Injury to inferior gluteal nerve
zWeakened hip extension
(gluteus maximus), most
noticeable when climbing
stairs or standing from a
seated position
zCause of injury:posterior
hip dislocation, surgery in
this region

35. Dr. Mavrych, MD, PhD, DSc [email protected]
Injury of obturator
nerve
zDifficulty adducting thigh
(e.g., crossing legs while
sitting)
zDecreased sensation
over upper medial thigh
zCause of injury: anterior
hip dislocation, radical
retropubic prostatectomia

36. Dr. Mavrych, MD, PhD, DSc [email protected]
zAvulsion fractures occur
wheremusclesare
attached -ischial
tuberosities
Hamstrings muscles:
1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
zAction: extensionof hip
joint and flexion of knee
joint
zNerve supply –Tibial
nerve(short head of
biceps femoris is supplied
by the common fibular
nerve)
15. Avulsion fractures
of the hip bone and
hamstrings muscles

37. Dr. Mavrych, MD, PhD, DSc [email protected]
16. Structures under inguinal
ligament:
zFrom lateral to
medial side:
zIliopsoas muscle
zFemoral nerve
zFemoral artery
zFemoral vein
zFemoral canal

38. Dr. Mavrych, MD, PhD, DSc [email protected]
Femoral hernia
zA femoral hernia passes below
inguinal ligamentthrough the femoral
ring into the femoral canal to form a
swelling in the upper thigh inferior and
lateral to the pubic tubercle
zThe hernial sac may protrude through
the saphenous hiatusinto the
superficial fascia
zA femoral hernia occurs more
frequently in femalesand is dangerous
because the hernial sac may become
strangulated
zAn aberrant obturator artery is
vulnerable during surgical repair
Inguinal lig.

39. Dr. Mavrych, MD, PhD, DSc [email protected]
17. Knee joint injuries:
Unhappy triad
zBecause the lateral side of the
knee is struck more often
(e.g., in a football tackle), the
tibial collateral ligament is
the most frequently torn
ligament at the knee.
zThe unhappy triad of athletic
knee injuries involves:
1.Tibial collateral ligament
2.Medial meniscus
3.Anterior cruciate ligament

40. Dr. Mavrych, MD, PhD, DSc [email protected]
Tibial collateral ligament
(medial collateral ligament)
zBroad flat band
extending from medial
epicondyle of femur to
medial condyle and
shaft of tibia
zBlends with capsule and
firmly attaches to
medial meniscus
zLimits extension and
abduction of leg at
knee

41. Dr. Mavrych, MD, PhD, DSc [email protected]
Fibular collateral ligament
(lateral collateral ligament)
zRounded cord between
lateral epicondyle of femur
and head of fibula
zDoes NOTblend with joint
capsule and does NOT
attach to lateral meniscus
zLimitsextensionand
adduction of leg at knee

42. Dr. Mavrych, MD, PhD, DSc [email protected]
Rupture of the
cruciate ligaments
zWith rupture of the anterior
cruciate ligament, the tibia
can be pulled forward
excessively on the femur,
exhibiting anterior drawer
sign.
zIn the less common rupture of
the posterior cruciate
ligament, the tibia can be
pushed backward excessively
on the femur, exhibiting
posterior drawer sign.

43. Dr. Mavrych, MD, PhD, DSc [email protected]
Prepatellar bursa
Suprapatellar bursa
zPrepatellar bursa: between
superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis).
zSuprapatellar bursa: superior
extension of synovial cavity
between distal end of femur
and quadricepsmuscle and
tendon. Usualplace for intra-
articular injections.May
become inflamed and swollen
(suprapatellar bursitis).

44. Dr. Mavrych, MD, PhD, DSc [email protected]
Knee jerk reflex
zThe patellar reflex
is tested by tapping
the patellar
ligament with a
reflex hammer to
elicit extension at
the knee joint. Both
afferent and
efferent limbs of
the reflex arch are
in the femoral
nerve(L2-L4).
zKnee jerk reflex:
testsspinal nerves
L2-L4.

45. Dr. Mavrych, MD, PhD, DSc [email protected]
18. Ankle joint injuries:
Ankle sprains
zSprains are the most common
ankle injuries
zA sprained ankle is nearly
always an inversion injury,
involving twisting of the weight-
bearing plantarflexed foot.
zThe lateral ligament(anterior
talofibular ligament)is injured
because it is much weaker than
the medial ligament.
zIn severe sprains, the lateral
malleolusof the fibula may be
fractured.

46. Dr. Mavrych, MD, PhD, DSc [email protected]
Pott’s fracture
zIt is fracture-dislocations of
the ankle joint
zReason -forced eversion
(abduction) of the foot
zThe Deltoid ligament
avulses the medial
malleolusand after that
fibula fracturesat a
higher level
Pott's fracture

47. Dr. Mavrych, MD, PhD, DSc [email protected]
Ankle jerk reflex
zAchilles tendon reflex is
tested by tappingthe
calcaneal tendonto elicit
plantar flexion at the ankle
joint.
zBoth afferent and efferent
limbs of the reflex arc are
carried in the tibial nerve
(S1, S2).
zAnkle jerk reflex: tests
spinal nerves S1-S2.

48. Dr. Mavrych, MD, PhD, DSc [email protected]
19. Injures of the leg and foot:
Fracture of the fibular neck
zMay cause an injury to the common
peroneal nerve, which winds
laterally around the neck of the
fibula.
zThis injury results in paralysisof all
muscles in the anteriorand lateral
compartmentsof the leg
(dorsiflexors and evertors of the
foot) and loosing sensation on the
dorsum of the foot.
zCausing foot drop.

49. Dr. Mavrych, MD, PhD, DSc [email protected]
Rupture of the Achilles tendon
and Triceps surae muscle
zAvulsion or rupture of the calcaneal
(Achilles) tendon disables the triceps
sure muscle (gastrocnemius & soleus)
so that the patient cannot plantar flex
the foot.
Triceps surae muscle:
z2 Heads of Gastrocnemiusm.
z1 Head -Soleusmuscle
zPlantaris
zsmall fusiform belly with long thin
tendon;
zsometimes may become
hypertrophy

50. Dr. Mavrych, MD, PhD, DSc [email protected]
Plantar Fasciitis(calcaneal spur)
zPlantar fasciitis is the
most common hindfoot
problem in runners. It
causes pain on the
plantar surface of the
foot and heel.
zPoint tenderness is
located at the proximal
attachment of the plantar
aponeurosis to the
medial tubercle of the
calcaneusand on the
medial surface of this
bone.

51. Dr. Mavrych, MD, PhD, DSc [email protected]
20. Injury of tibial nerve
zIn popliteal fossa:loss of
plantar flexion of foot (mainly
gastrocnernius and soleus
muscles) and weakened
inversion (tibialis posterior
muscle), causing
calcaneovalgus.
zInability to stand on toes
zLoss of sensation and
paralysisof intrinsic muscles
of the sole of the foot
zPopliteal fossa from superficial to
deep, contains:
zTibial nerve
zPopliteal vein
zPopliteal artery

52. Dr. Mavrych, MD, PhD, DSc [email protected]
On soil of the foot there are two terminal
branches of tibial n:
zMedial plantar nerve supplies:
1.Abductor hallucis,
2.Flexor hallucis brevis
3.Flexor digitorum brevis
4.1st lumbrical muscles
zskin of medial 3.5 digits
zLateral plantar nerve supplies:
zAll intrinsic plantar muscles which
are not innervated by medial plantar
nerve
zskin of lateral 1.5 digits

53. Dr. Mavrych, MD, PhD, DSc [email protected]
21. Breast:
Carcinoma of the Breast
zCarcinomas of the
breast are malignant
tumors, usually
adenocarcinomas
arising from the
epithelial cells of the
lactiferous ducts in the
mammary gland
lobules
z1. It enlarges, attaches
to suspensory
(Cooper‘s)ligaments,
and produces
shortening of the
ligaments, causing
depression or dimpling
of the overlying skin.

54. Dr. Mavrych, MD, PhD, DSc [email protected]
Lymphatic drainage
of the breast
zItis important because
of its role in the
metastasis of cancer
cells.
zMost lymph (> 75%),
especially from the
lateral breast
quadrants, drains to
the axillary lymph
nodes, initially to the
anterior (pectoral)
nodesfor the most
part.
zMost of the remaining
lymph, particularly from
the medial breast
quadrants, drains to the
parasternal lymph
nodesor to the
opposite breast.
75% 25%

55. Dr. Mavrych, MD, PhD, DSc [email protected]
Mastectomy
zRadical mastectomy, a more extensive surgical
procedure, involves removal of the breast, pectoral
muscles, fat, fascia, and as many lymph nodes as
possible in the axilla and pectoral region.
1.During a radical mastectomy, thelong thoracic
nervemay be lesioned during ligation of the lateral
thoracic artery. A few weeks after surgery, the
female may present with a winged scapulaand
weakness in abductionof the arm above 90°
because serratus anterior m. paralysis.
2.Theintercostobrachial nervemay also be
damaged during mastectomy, resulting in skin
deficit of the medial arm.

56. Dr. Mavrych, MD, PhD, DSc [email protected]
Breast infection
zMastitisis an infection of the tissue
of the breast that occurs most
frequently during the time of
breastfeeding(1 to 3months after the
delivery of a baby).
zThis infection causes pain, swelling,
redness, and increasedtemperature
of the breast.
zIt can occur when bacteria, often from
the baby's mouth, enter a milk duct
through a crack in the nipple.
zIt can occur in women who have not
recently delivered as well as in women
after menopause.

57. Dr. Mavrych, MD, PhD, DSc [email protected]
22. Thoracic wall & Diaphragm:
Intercostal spaces
Intercostal blood vessels
and nerves:
zrun betweenthe
internal intercostaland
innermostintercostal
muscles in the costal
groove
zarranged from superior
to inferior as vein,
artery, nerve
zMost vulnerable
structures –intercostal
nerveand posterior
intercostal artery
because they are not
covering by ribs.

58. Dr. Mavrych, MD, PhD, DSc [email protected]
Diaphragm:
Paralysis of half and ruptures
zParalysis of the half
of the Diaphragm
may result from injury
or operative division of
the phrenic nerveof
same side
zIt can be detected
radiologically.
zParadoxical
movement:dome of
diaphragm of injured
side pushed superiorly
by abdominal viscera
during inspiration
instead of descending

59. Dr. Mavrych, MD, PhD, DSc [email protected]
Phrenic nerve
zArises from the anterior
branches C3-C5nervesand
lies in front of the anterior
scalene muscle.
zRuns anterior to the root of
the lung, whereas the vagus
nerve runs posterior to the
root of the lung.
zInnervates the fibrous
pericardium, the
mediastinaland
diaphragmatic pleurae
(sensory innervation), and
the diaphragmfor motor
and its central tendon for
sensory.

60. Dr. Mavrych, MD, PhD, DSc [email protected]
Diaphragmatic ruptures
zDiaphragmatic injuries are
relatively rare and result from
either blunt trauma or
penetratingtrauma.
zPresently, 80-90% of blunt
diaphragmatic ruptures result
from motor vehiclecrashes.
zThe majority (80-90%) of blunt
diaphragmatic ruptures have
occurred on the left side.
zBlunt trauma typically produces
large radial tears measuring 5-15
cm, most often at the
posterolateral aspectof the
diaphragm.

61. Dr. Mavrych, MD, PhD, DSc [email protected]
23. Cardiac hypertrophy
zLeft atrialenlargement
(hypertrophy) secondary to
mitral valve failure may
compresson the
esophagusand manifest
as dysphagia (difficulty in
swallowing).
zIt may be observed as a
filling defect in the
esophagus bybarium
swallow on the lateral
thoracic X-Ray

62. Dr. Mavrych, MD, PhD, DSc [email protected]
Cardiac Shadow
Right borderis formed by:
1.SVC,
2.Right atrium
Leftborderis formed by:
1.Aortic arch
2.Pulmonary trunk
3.Left auricle
4.Left ventricle
P-A projection

63. Dr. Mavrych, MD, PhD, DSc [email protected]
24. Auscultation of Heart
Valves
Right 2 ICS
PSL
Left 5 ICS
MCL
Left 4 ICS
PSL
Left 2 ICS
PSL

64. Dr. Mavrych, MD, PhD, DSc [email protected]
Auscultation sites for
mitral and aortic murmurs
A heart murmur is heard downstream from the valve:
zstenosisis orthogradedirection from valve
zinsufficiencyis retrogradedirection from valve

65. Dr. Mavrych, MD, PhD, DSc [email protected]
25. Conducting System
of the Heart
zSinoatrial (SA) node
zsite where contraction of heart muscle is
initiated (pacemakerof the heart)
zsituated in the upper part of the sulcus
terminalis just near to the opening of
the SVC
zAtrioventricular (AV) node
zthe AV node receives impulses from the
SA node; situated in the lower part of
the atrial septum near coronary sinus
zAtrioventricular bundle of His
zdescends from the AV node to the
membranous portion of the ventricular
septum where it divides into the left and
right bundle branches
zRight bundle branch–passes down to
reach the moderator band-right
ventricle
zleft bundle branch–passes down left
side of ventricular septum

66. Dr. Mavrych, MD, PhD, DSc [email protected]
26. Blood supply of the Heart:
Right coronary artery (RCA)
zIt supplies major parts of the right
atriumand the right ventricle.
zIt anastomoses with the marginal
branch of the left coronary artery
posteriorly
Branches:
1.Anterior cardiac branches –
supplies the right atrium
2.Nodal branch –supplies the (1) SA
node, (2) AVnode
3.Marginal artery–supplies the right
ventricle
4.Posterior interventricular artery–
supplies (1) diafragmatic (inferior)
surface of both ventricles and (2)
posterior 1/3 of the IV septum

67. Dr. Mavrych, MD, PhD, DSc [email protected]
Left coronary artery
(LCA)
Branches:
1.Anterior (descending)
interventricular artery –most
common place of MI descends in the
anterior interventricular sulcus and
provides branches to the (1) anterior
heard wall, (2) anterior 2/3 of IV
septum, (3) bundle of His, and (4)
apex of the heart.
2.Circumflex artery–winds around the
left margin of the heart in the
atrioventricular groove to anastomose
with the right coronary artery
posteriorly; supplies the left atrium
and left ventricle

68. Dr. Mavrych, MD, PhD, DSc [email protected]
Blood supply of the conducting
system
zSA node–RCA
zAV node –RCA
zAV bundle (and
moderator band)-LCA

69. Dr. Mavrych, MD, PhD, DSc [email protected]
27. Congenital cardiac defects:
Atrial Septal Defect (ASD)
zIt is less frequentthan
VSD
zIt results from failure to
close of the foramen
ovale after birth (failure of
the septum primum and
septum secundum to
fuse)
zPostnatally, ASDs result
in left-to-rightshunting
(between right and left
atrium) and are non-
cyanotic conditions.
zIf it is small, has no
clinical significance & if
large -necessarysurgical
repair

70. Dr. Mavrych, MD, PhD, DSc [email protected]
Ventricular Septal
Defect (VSD)
zVentricular septal defect
(VSD) is the most common
of the congenital heart defects
zIt may be found in the
membranous part of the
ventricular septum and
results from failure to fuse of
the membranous portion with
the muscular portion of the
ventricular septum
zIn this case, present left–to-
right shunt(right ventricular
hypertrophy(RVH)) and
again non-cyanotic.
zNecessary surgery for large
defects

71. Dr. Mavrych, MD, PhD, DSc [email protected]
Patent Ductus Arteriosus (PDA)
zIt results from failure of the ductus
arteriosus(a connection between the
pulmonary trunk and aorta) to constrict and
close after birth.
zProstaglandin E and low O
2tension sustain
patency of the ductus arteriosus in the fetal
period.
zPDA is common in premature infants and in
cases of maternal rubellainfection.
zLeft –to-right shunt increased pressure in
pulmonary circulation (pulmonary
hypertension)and is non-cyanotic
zTreatment: surgical division and ligation
imperative. In great danger is left recurrent
nerve (wrapping aorta arch). Injure of this
nerve results in hoarseness.

72. Dr. Mavrych, MD, PhD, DSc [email protected]
Aneurysm of the aorta
zAneurysm of the aortic arch:
compresses the left recurrent
laryngeal nerve, leading to
coughing, hoarseness, and
paralys is of the ipsilateral vocal
cord. It may cause dysphagia
(difficulty in swallowing), resulting
from pressure on the esophagus,
and dyspnea (difficulty in
breathing), resulting from
pressure on the trachea, root of
the lung, or phrenic nerve
zAneurysm of the thoracic aorta
may compress and tug on the
trachea with each cardiac systole
so that the aneurysm can be felt
by palpatingthe trachea at the
sternal notch (T2).

73. Dr. Mavrych, MD, PhD, DSc [email protected]
Abdominal aortic aneurysm
zIt is a localized dilatationof the
aorta. It is typically happened
just above of the bifurcationat
level of L4and crossed by 3
rd
part of duodenum.
zPulsations of a large aneurysm
can be detected to the left of
the midlineat the umbilical
region.
zAcute rupture of an abdominal
aortic aneurysm is associated
with severe pain in the
abdomen or back (mortality rate
is nearly 90%).
zSurgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.

74. Dr. Mavrych, MD, PhD, DSc [email protected]
Coarctation of the Aorta
zIt results from congenital
narrowingof the aorta distal to the
offshoot of the left subclavian
artery.
zCardinal clinical sign: higher blood
pressure in the upper limbs
compared to the lower limbs.
zCoarctation of the aorta results in
the intercostalarteries providing
collateral circulation between the
internal thoracic artery and the
thoracic aorta to provide blood
supply to the lower parts of the
body
zCoarctation of the Aorta
characteristic X-ray picture:
serrated appearance of inferior
borders of ribs (rib notching)

75. Dr. Mavrych, MD, PhD, DSc [email protected]
28. Aspiration of Foreign
Bodies & Bronchopulmonary
segments
Aspiration of Foreign Bodies:
zInhalation of FB’s (e.g. pins,
parts of teeth, screws, nuts,
bolts, toys) into the lower
respiratory tract is common,
especially in children
zMore likely to enter the right
primary bronchus and pass into
the middleor lowerlobe
bronchi
zIf the vertical position of the
body, the foreign body usually
falls into the posterior basal
segment of the right inferior
lobe.

76. Dr. Mavrych, MD, PhD, DSc [email protected]
Right lung:
10 bronchopulmonary segments
Superior lobe:
1.Apical
2.Anterior
3.Posterior
Middle lobe:
4.Lateral
5.Medial
Inferior lobe:
6.Superior
7.Anterior basal
8.Posterior basal
9.Lateral basal
10.Medial basal
1
8
9
7
6
4
5
2
3
10

77. Dr. Mavrych, MD, PhD, DSc [email protected]
Left lung:
9 bronchopulmonary segments
Superior lobe:
1.Apicoposterior
2.Anterior
3.Superior lingular
4.Inferior lingular
Inferior lobe:
5.Superior
6.Anterior basal
7.Posterior basal
8.Lateral basal
9.Medial basal
1
3
5
7
8
9
6
2
4

78. Dr. Mavrych, MD, PhD, DSc [email protected]
29. Lung diseases:
Pneumonia
zPneumonia is an inflammation
of the lung, caused by an
infection or chemical injury to the
lungs.
zThree common causes are
bacteria, virusesand fungi.
zSymptoms: cough, chest pain,
fever, and difficulty in breathing.
zChest x-rays: areas of opacity
(seen as white) of the lung
parenchyma and enlargementof
bronchomediastinal lymph
nodes(mediastinal widening).

79. Dr. Mavrych, MD, PhD, DSc [email protected]
Bronchogenic Carcinoma
zArises in the mucosa of the
large bronchi
zProduces as persistent,
productive coughor
hemoptysis
zEarly metastasis to thoracic
(bronchomediatinal) lymph
nodes
zHematogenous spread to the
brain, bones, lungs,
suprarenal glands
zA tumor at the apex of the
lung (Pancoasttumor) may
result in thoracic outlet
syndrome

80. Dr. Mavrych, MD, PhD, DSc [email protected]
Bronchogenic carcinoma
may lead to:
1. Thoracic outlet syndrome (TOS)
zIt can cause pressure on the lower
trunkof the brachial plexus C8-T1
and subclavian artery by cervical
rib orpancoast tumor. It results in
paindown the medial side of the
forearm and hand and atrophy of
the intrinsic hand muscles)
2. Horner syndrome:
zmiosis-constriction of the pupil
due to paralysis of the dilator
pupillae muscle
zptosis-drooping of the eyelid due
to paralysis of the superior tarsal
muscle
zhemianhydrosis-loss of sweating
on one side
11
22

81. Dr. Mavrych, MD, PhD, DSc [email protected]
Bronchogenic carcinoma
may lead to:
3. Superior vena cava
syndrome, which causes
dilationof the head and
neck veins, facial swelling,
and cyanosis
4. Dysphagiaas a result of
esophageal obstruction
5. Hoarsenessas a result of
recurrent laryngeal nerve
involvement
6. Paralysis of the
diaphragmas a result of
phrenicnerve involvement
33

82. Dr. Mavrych, MD, PhD, DSc [email protected]
Qs about Auscultation
and penetrated wounds
zTo listen to breath sounds of the
superior lobes of the right and left
lungs, the stethoscope is placed on
the superior area of the anterior
chest wall (above the 4
th
ribfor the
rightlung & above 6
th
for the left
one).
zFor breath sounds from the
middle lobeof the right lung, the
stethoscope is placed on the
anterior chest wall between the 4
th
and 6
th
ribs
zFor theinferior lobes of both
lungs, breath sounds are primarily
heard on the posterior chest wall.
4
6

83. Dr. Mavrych, MD, PhD, DSc [email protected]
30. Open pneumothorax &
pleura
zIt is entry of airinto a pleural
cavitycausing lung collapse.
zOpen pneumothorax–due to stab
wounds of the thoracic wall which
pierce the parietal pleura so that
the pleural cavity is open to the
outsideair via the lung or through
the chest wall.
zAir moves freely through the
wound during inspiration and
expiration. During inspiration, air
enters the chest wall and the
mediastinum will shift toward other
side and compress the opposite
lung. During expiration, air exits
the wound and the mediastinum
moves back toward the affected
side.

84. Dr. Mavrych, MD, PhD, DSc [email protected]
Pleura & Pleural Cavity
z1. Cervical pleura may be affected in
case of improper subclavian
venipuncture.
z2. Costodiaphragmatic Recess is
deepest place in pleural cavity, around
the chest wall, there are two rib
interspaces separating the inferior
limit of parietal pleural reflections from
the inferior border of the lungs and
visceral pleura:
1.Midclavicular line -between ribs 6-8
2.Midaxillary line -between ribs 8-10
3.Paravertebral line between ribs 10-12
2

85. Dr. Mavrych, MD, PhD, DSc [email protected]
Nerve supply of the pleura
Parietal Pleura–sensitive to general
sensibilities (pain, temperature, touch,
and pressure)-somatic sensory
innervation:
zcostal pleura –intercostal nerves
block may be used to decrease
thoracic pain
zmediastinal pleura –phrenic nerve
zdiaphragmatic pleura –phrenic nerve
over the domes and lower 6 intercostal
nerves around the periphery
Visceral Pleura–sensitive to stretch but
insensitive to general sensibilities;
autonomicnerve supply from the
pulmonary plexus

86. Dr. Mavrych, MD, PhD, DSc [email protected]
31. Mediastinum
Superior mediastinum
zImproperly done
sternal puncture
may affect
structures related
to the posterior
surface of the
manubrium
sternum:
zIn upper part –
Left
brachiocephalic
vein
zIn lower part –
Aortic arch

87. Dr. Mavrych, MD, PhD, DSc [email protected]
Thoracic duct
zFunction–conveys to the
blood all lymph from the
lower limbs, pelvic cavity,
abdominal cavity, left side
of the thorax, left side of
the head & neck, and left
upper limb(3/4 of the
body)
Tributaries–at the root of the
neck
zLeft jugularlymph trunk
zLeft subclavian lymph
trunk
zLeft bronchomediastinal
lymph trunk

88. Dr. Mavrych, MD, PhD, DSc [email protected]
Constrictions of the esophagus
There are sites where ingested
foreignbodies can lodge or
where stricturesmay develop
following ingestion of caustic
fluids, common sites of
esophageal carcinoma
1.C6 -where the pharynxjoins
the upper end (6" from the
upper incisors)
2.T4-T5 -where the aortic arch
and left main bronchus cross
its anterior surface (10" from the
upper incisors)
3.T10-where it passes through
the diaphragminto the
stomach (16" from the upper
incisors)
1
2
3

89. Dr. Mavrych, MD, PhD, DSc [email protected]
32. Anterior abdominal wall
zThe liverand gallbladder
are in the right upper
quadrant;
zThe stomachand spleen
are in the left upper
quadrant;
zThe cecumand appendix
are in the right lower
quadrant;
zThe end of the descending
colon and sigmoid colon
are in the left lower
quadrant.

90. Dr. Mavrych, MD, PhD, DSc [email protected]
Referred abdominal pain
zPainarising out of the
foregutderived structures
is referred to the
epigastric region.
zPainarising out of the
midgutderived structures
is referred to the
umbilical region.
zPainarising out of the
hindgutderived
structures is referred to
the hypogastric region.

91. Dr. Mavrych, MD, PhD, DSc [email protected]
Nerve supply of the
anterior abdominal wall
zTherefore totally 7 nerves:
lower 5intercostals, 1
subcostal and L1
(iliphypogastricand
ilioinguinal) nerves supply
the anterior abdominal wall.
zL1 can be anaesthetized by
injecting 1 inch (2.5 cm)
superiorto the anterior
superior iliac spine.
zAll nerves and deep blood
vessels lie in the
neurovascular plane:
between internal oblique
and transversusmuscles

92. Dr. Mavrych, MD, PhD, DSc [email protected]
Arterial supply of the anterior
abdominal wall:
Important SUPERFICIAL
ARTERIES(supply skin) are:
1.Superficial epigastric
2.Superficial circumflex iliac
Important DEEP ARTERIESlie in
the neurovascular plane:
1.Superior epigastric
2.Posterior intercostals arteries
3.Lumbar arteries
4.Deep circumflex iliac artery
5.Inferior epigastric

93. Dr. Mavrych, MD, PhD, DSc [email protected]
33. Herniations
Hernia consist of 3 parts:
zHernial sacis a pouch
(diverticulum) of peritoneumand
has a neck and a body
zHernial contentsmay consist of
any structure found in the
abdominal cavity (more offen –
loops of smallintestineand
piece of omentum major)
zHernial coveringsare formed
from the layers of the abdominal
wall through which the hernial
sac passes

94. Dr. Mavrych, MD, PhD, DSc [email protected]
Transversalis fasciais the FIRST
STRUCTURE which is crossed by
anyabdominal hernia

95. Dr. Mavrych, MD, PhD, DSc [email protected]
Indirect Inguinal Hernia
zIndirectinguinal hernia is the most
common formof hernia and is believed
to be congenitalin origin (boys 0-3
years).
zIt passes through the deep inguinal ring
lateral to the inferior epigastric
vessels, inguinal canal, superficial
inguinal ring and descend into the
scrotum.
zAn indirect inguinal hernia is about 20
times morecommon in males than in
females, and nearly 1/3 are bilateral.
zIt is more common on the right
(normally, the right processus vaginalis
becomes obliterated after the left; the
right testis descends later than the left).

96. Dr. Mavrych, MD, PhD, DSc [email protected]
Direct Inguinal Hernia
zDirectinguinal hernia composes
about 15%of all inguinal hernias.
zDuring a direct inguinal hernia,
the abdominal contents will
protrude through the weak area of
the posterior wall of the inguinal
canal medial to the inferior
epigastric vesselsin the inguinal
[Hesselbach's] triangle and after
that through superficial inguinal
ring.It never descendsinto the
scrotum.
zIt is a disease of old men with
weak abdominal muscles. Direct
inguinal hernias are rare in women,
and most are bilateral.

97. Dr. Mavrych, MD, PhD, DSc [email protected]
34. Peritoneal structures:
Lesser omentum
Consist of 2 ligaments:
zhepatogastric
zhepatoduodenal
Contents :
zRight & Left gastric
vessels
zConnective and fatty
tissue
and Portal triad:
zBileduct
zPortal vein
zProper hepaticartery

98. Dr. Mavrych, MD, PhD, DSc [email protected]
Epiploic (winslow’s) foramen
zAnteriorly:The free
border of the
hepatoduodenal
ligament, containing
portal triad (DVA).
zPosteriorly:IVC
zSuperiorly:Caudate
lobe of the liver.
zInferiorly:The 1
st
part of the
duodenum.

99. Dr. Mavrych, MD, PhD, DSc [email protected]
Douglas (rectouterine) pouch
zRectouterine pouch
(pouch of Douglas):
deeper point of
peritoneal spacein
verticalposition of the
female body between the
rectumand the cervixof
uterus.
zIt is space of the pelvic
abscess location.

100. Dr. Mavrych, MD, PhD, DSc [email protected]
Culdocentesis
zCuldocentesis is
aspiration of fluid from
the cul-de-sac of
Douglas (rectouterine
pouch) by a needle
puncture of the
posterior vaginal
fornix near the midline
between the uterosacral
ligaments
zBecause the
rectouterine pouch is
the lowest portion of
the female peritoneal
cavity, it can collect
inflammatory fluid
(pelvic abscess).

101. Dr. Mavrych, MD, PhD, DSc [email protected]
35. Smart Table
FOREGUT MIDGUT HINDGUT
Esophagus
Stomach
Duodenum(1
st
and
2
nd
parts)
Liver
Pancreas
Biliary apparatus
Gallbladder
Duodenum(2
nd
, 3
rd
,
4
th
parts)
Jejunum
Ileum
Cecum(with
Appendix)
Ascending colon
Transverse colon
(proximal 2/3)
Transverse colon
(distal 1/3)
Descending colon
Sigmoid colon
Rectum(anal canal
above pectinate line)

102. Dr. Mavrych, MD, PhD, DSc [email protected]
FOREGUT MIDGUT HINDGUT
Artery: CA Artery:SMA Artery: IMA
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: pelvic
splanchnic nerves, S2-S4
Sympathetic
innervation:
•Preganglionics: greater
splanchnic nerves, T5-T9
•Postganglionics:
celiac ganglion
Sympathetic
innervation:
•Preganglionics: lesser
splanchnic nerves, T10-
T11
•Postganglionics:
superior mesenteric
ganglion
Sympathetic
innervation:
•Preganglionics: lumbar
splanchnic nerves, L1-L2
•Postganglionics: inferior
mesenteric ganglion
Sensory Innervation:
DRG T5-T9
Sensory Innervation:
DRG T10-T11
Sensory Innervation:
DRG L1-L2
Referred Pain:
Epigastrium
Referred Pain:
Umbilical
Referred Pain:
Hypogastrium

103. Dr. Mavrych, MD, PhD, DSc [email protected]
36. Posterior gastric ulcer
1.Posterior gastric ulcermay
erode through the posterior
wall of the stomach into the
Omental bursa (Lesser
peritoneal sac) and affect
pancreasresulting in
referred pain to the back.
2.Erosion of splenic arteryis
very common in posterior
gastric ulcers as well
because of the proximity of
the artery to this wall.

104. Dr. Mavrych, MD, PhD, DSc [email protected]
37. Congenital diaphragmatic
hernia
zHernia of stomach or
intestine through a
posterolateral defect
in diaphragm
(foramen of
Bochadalek).
zIt is seen in infants
and the mortality rate is
high because of left
lung hypoplasia.

105. Dr. Mavrych, MD, PhD, DSc [email protected]
38. Sliding hiatal hernia
zA sliding hiatal hernia which
occurs in individuals past
middle age is caused by
the hernia of cardia of the
stomachinto the thorax
through the esophageal
hiatusof the diaphragm.
zThis can damage the vagal
trunksas they pass through
the hiatus and resulting in
hyposecretion of gastric
juice.

106. Dr. Mavrych, MD, PhD, DSc [email protected]
39. Meckel's diverticulum
zMeckel's diverticulum is a congenital
anomaly representing a persistent portion of
the vitellointestinal duct.
zThis condition is often asymptomatic but
occasionally becomes inflamed if it contains
ectopicgastric, pancreatic, or endometrial
tissue, which may produce ulceration.
zMeckel's diverticulum is located on the
Ileum about 2 feet (61 cm) beforethe
ileocecal junction and SMA supply it. It
occurs in 2%of patients and is about 2 inches
(5 cm) long.
zThe diverticulum is clinically important
because diverticulitis, liberation, bleeding,
perforation, and obstruction are complications
requiring surgical intervention and frequently
mimicking the symptoms of acute
appendicitis.

107. Dr. Mavrych, MD, PhD, DSc [email protected]
40. Features of the large
intestine
Features of the large intestine:
1.Appendices epiploic
2.Sacculations
(haustrations)
3.Taeniae coli
zThe taeniae coli meet
together at the base of
the appendixwhere they
form a complete
longitudinal muscle coat
for the appendix.

108. Dr. Mavrych, MD, PhD, DSc [email protected]
Colon
zThe ascending colon lies
retroperitoneallyand lacks a
mesentery.
zIt is continuous with the
transverse colon at the right
(hepatic) flexure (1)of colon.
zThe transverse colon (3) has
its own mesentery called the
transverse mesocolon
(intraperitoneal position).
zIt becomes continuous with the
descending colon at the left
(splenic) flexure (2)of colon.
zThe sigmoid colon (4) is
suspended by the sigmoid
mesocolon (intraperitoneal
position).
1
3
4

109. Dr. Mavrych, MD, PhD, DSc [email protected]
41. Pain of Appendicitis
zIn appendicitis, first painis
referred around the umbilicus.
Visceral painin the appendix is
produced by distention of its
lumen or spasm of its muscle.
zThe afferent pain fibers enter
the spinal cord at the level of
T10 segment, and a vague
referred pain is felt in the region
of the umbilicus.
zLater if parietal peritoneum
gets involved, and then the pain
is shifted laterally to the Mc
Burney’s point. Here the pain
is precise, severe, and localized
(second pain)

110. Dr. Mavrych, MD, PhD, DSc [email protected]
Mc Burney's point
zThis point indicates
the surface marking
of the base of the
appendix.
zIt is a point at the
junction between the
lateral 1/3 and
medial 2/3 of a line
joining the right
anterior superior iliac
spine with the
umbilicus.

111. Dr. Mavrych, MD, PhD, DSc [email protected]
42. Volvulus
zBecause of its extreme mobility,
the Jejunum, Ileumand
Sigmoidcolonsometimes
rotates around its mesentery.
It results in avascular necrosis
corresponding part of interstine.
zThis may correct itself
spontaneously, or the rotation
may continue until the blood
supply of the gut is cut off
completely.

112. Dr. Mavrych, MD, PhD, DSc [email protected]
43. Hirschsprung's Disease
zIt is a rare congenital abnormality that
results in obstruction because the
intestines do not work normally.
zIt is commonly found in Down Syndrome
children.
zThe inadequate motility is a result of an
aganglionic section(congenital absents
of postganglionic parasympathetic
neurons inside of the intestinal wall) of the
intestines resulting in megacolon.
zIn a newborn, the main signs and
symptoms are failure to pass a
meconium stoolwithin 1-2 days after
birth, reluctance to eat, bile-stained
(green) vomiting, and abdominal
distension.
zTreatment is removalof the aganglionic
portion of the colon.

113. Dr. Mavrych, MD, PhD, DSc [email protected]
44. Branches of Abdominal aorta
and Mesenteric ischemia
zCeliac trunk(CA) originates
from the aorta at the lower
border of T12vertebra
zSuperior mesenteric artery
originates at the lower
border of L1vertebra
zRenal arteriesoriginate at
approximately L2vertebra
zInferior mesenteric artery
originates at L3vertebra
zTwo terminal branches are
common iliac arteries at
the level of L4vertebra

114. Dr. Mavrych, MD, PhD, DSc [email protected]
CELIAC ARTERY (TRUNK)
zOrigin:T12, just below the
aortic opening of the
diaphragm.
zThe CA passes above the
superior border of the
pancreas and then divides
into three retroperitoneal
branches:
zLeft gastric artery (1)
zCommon hepatic artery (2)
zSplenic artery (3)
2
3
1

115. Dr. Mavrych, MD, PhD, DSc [email protected]
Left gastric artery
zThe left gastric artery (1)
courses upward to the left to
reach the lesser curvature of
the stomach and may be
subject to erosion by a
penetrating ulcer of the
lesser curvature of the
stomach.
Branches:
zEsophageal branches (2) -to
the abdominal part of the
esophagus
zGastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosiswith right
gastric artery.
2
3
1

116. Dr. Mavrych, MD, PhD, DSc [email protected]
Common hepatic artery
zThe common hepatic artery
(1) passes to the right to
reach the superior surface of
the first part of the duodenum,
where it divides into its two
terminal branches:
zProper hepatic artery (2)
zGastroduodenal artery (3)
1
2
3

117. Dr. Mavrych, MD, PhD, DSc [email protected]
Proper hepatic artery
zProper hepatic artery (1) gives
offright gastric artery (2) and
thenascends within the
hepatoduodenalligament of the
lesser omentum to reach the
porta hepatis, where it divides
into the right(4) andleft (3)
hepatic arteries.
zThe right and left arteries enter the
two lobes of the liver, right
hepatic artery gives cystic artery
(5) to the gallbladder.
zRight gastric artery (2)supplies
the right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery.
5
4
3
2
1

118. Dr. Mavrych, MD, PhD, DSc [email protected]
Gastroduodenal artery
zGastroduodenal artery (1)
descends posteriorto the first
partof the duodenum(may be
subject to erosionby a
penetrating ulcer in this place)
and divides into two branches:
zRight gastroepiploic artery (2)
(supplies the right side of the
greater curvatureof the
stomach where it anastomoses
the left gastroepiploic)
zSuperior pancreaticoduodenal
arteries (3) (supply the headof
the pancreas, where they
anastomosesthe inferior
pancreaticoduodenal arteries
from the SMA).
1
2
3

119. Dr. Mavrych, MD, PhD, DSc [email protected]
Ligature of the hepatic artery:
zThe hepatic artery may be
ligated proximal to the origin
of its gastroduodenal branch,
a collateral circulation to the
liver is established through
the left and right gastric
arteries, left and right
gastroepiploicand
gastroduodenal arteries.
zThe right hepatic artery
may be mistakenly ligated
during holecystectomyin
Calottriangle together with
the cystic artery, right lobe
hepatic necrosiscommonly
occurs.

120. Dr. Mavrych, MD, PhD, DSc [email protected]
Splenic artery
zSplenic artery (1) runs a
tortuoushorizontal course to
the left along the upper border
of the pancreas,behind the
peritoneumof the posterior
wall of the lesser sac, forming a
part of the stomach bed.
zThe splenic artery may be
subject to erosionby a
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac.
zN.B. The splenic vein runs a
more straightcourse below the
artery and behind of the
pancreas.
1

121. Dr. Mavrych, MD, PhD, DSc [email protected]
Splenic artery
zSplenic(1) a. is retroperitoneal
until it reaches the tailof the
pancreas, where it enters the
splenorenal ligament to enter
the hilum of the spleen.
Branches:
zBranches to the spleen (2)
zBranches to the neck, body, and
tailof pancreas (3)
zLeft gastroepiploic (4) artery that
supplies the left side of the
greatercurvature of the stomach
where it anastomosesthe right
gastroepiploic
zShort gastric (5) branches that
supply fundusof the stomach
5
43
1
2

122. Dr. Mavrych, MD, PhD, DSc [email protected]
SMA Branches:
z(1) Inferior
pancreaticoduodenal
arteries
z(2)Jejunaland (3)
Ilealbranches
z(4) Ileocolicartery
zAscending branch
zAnterior cecal artery
zPosterior cecal artery
z(5) Appendicular
artery
z(6) Right colic artery
z(7) Middle colic artery
1
7
6
5
4
3
2

123. Dr. Mavrych, MD, PhD, DSc [email protected]
IMA Branches:
z(1) Left colic artery
z(2) Sigmoidarteries
z(3) Superior rectal artery
3
2
1

124. Dr. Mavrych, MD, PhD, DSc [email protected]
Mesenteric ischemia
zAtherosclerosis, which slows the
amount blood flowing through arteries, is
a frequent cause of chronic mesenteric
ischemia.
zIschemia occurs when blood cannot flow
through arteries as well as it should, and
intestines do not receive the necessary
oxygen to perform normally. Mesenteric
ischemia usually involves SMA andsmall
intestine.
zMesenteric ischemia primarily affects
organs which locate far away from
anastomoses with CA & IMA. Usually
blood supply of the Jejunumand Ileumis
most compromised.
zMesenteric ischemia typically occurs in
people older than age 60 with history of
smokingand high cholesterollevel.

125. Dr. Mavrych, MD, PhD, DSc [email protected]
45. Biliary system & gallstones
zBile is secreted by the livercells,
stored, and concentrated in the
gallbladder and later it is
delivered to the duodenum.
zThe gallbladderlies in it’s fossa
on the visceral surface of the
liver right side of quadrate lobe.
zIt stores and concentrates bile,
which enters and leaves it
through the cystic duct.
zThe cystic duct joins the
common hepatic (from left
andright hepatic) due to form
the common bile duct.

126. Dr. Mavrych, MD, PhD, DSc [email protected]
Biliary system
zThe common bile duct descends in
the hepatoduodenal ligament,
then passes posteriorto the first
part of the duodenum
zIt penetrates the head of the
pancreaswhere it joins the main
pancreatic ductand they form the
hepatopancreatic ampulla
(sphincter of Oddi), which drains
into posteromedial wall the
second partof the duodenum at the
major duodenal papilla

127. Dr. Mavrych, MD, PhD, DSc [email protected]
Cholelithiasis (gallstones)
zThe distal end of the hepato-
pancreatic ampulla (Bile duct)is the
narrowest part of the biliary passages
and is the common site for impaction
of gallstones.
zAs result of common hepatic (1), bile
duct(2), or hepatopancreatic
ampulla (3) obstruction patient will
have yellow eyesand jaundice
zGallstones may also lodge in the
cystic duct. A stone lodged in the
cystic duct (4) causes biliary colic
(intense, spasmodic pain in the
gallbladder) but doesn't produce
jaundice.
1
2
3
4

128. Dr. Mavrych, MD, PhD, DSc [email protected]
Gallstones
zThe fundus[1]of the gallbladderis
in contact with the transverse colon
and thus gallstones erode through the
posterior wall of the gallbladder and
enter the transverse colon. They are
passed naturally to the rectum
through the descending colon and
sigmoid colon.
zGallstones lodged in the body[2]of
the gallbladdermay ulcerate through
the posterior wall of the body of the
gallbladder into the duodenum
(because the gallbladder body is in
contact with the duodenum) and may
be held up at the ileocecal junction,
producing an intestinal obstruction.
2
1

129. Dr. Mavrych, MD, PhD, DSc [email protected]
46. Nerve supply of the liver
and gallbladder
zSensory innervation of the liver: by the right
phrenic nerve (C3-C5). Pain may radiate to the
right shoulder.
zThe liverreceives parasympathetic innervation
from the vagi nerves(CNX), reaching it through
the celiac plexuses around the supplying arteries.
The preganglionic fibers synapse on the cells of
the uxtramuralplexuses in hilum of the liverand
shot postganglionic fibers supply organs.
zSympathetic fibers of preganglionic neurons
T5-T9segments (IML) come through the
sympathetic trunk and form greater splanchnic
nerves. They contribute to the celiac plexus,
where postganglionic neurons are located.
Branches of celiac plexus reach the liver wrapping
around the branches of the celiac artery.

130. Dr. Mavrych, MD, PhD, DSc [email protected]
47. Portal Hypertension &
Portocaval shunts
zPortal hypertensionis a
common clinical condition, and
for this reason portal-systemic
anastomoses should be
remembered.
z[1] Extrahepatic portocaval
shunt for the treatment of
portal hypertension: the
splenic veinmay be
anastomoses to the left renal
veinafter removing the
spleen.
z[2] Intrahepatic portocaval
shunt : betweenportal vein
and hepatic veins

131. Dr. Mavrych, MD, PhD, DSc [email protected]
Large intestine metastases &
Portocaval anastomosis
zMetastasesof the Large intestine
cancertypically rich the Livervia
portal venous system: Rectum -
IMV -splenic vein -portal vein -
Liver
zIf there is an obstruction to flow
through the portal system (portal
hypertension), blood can flow in a
retrograde direction and pass
through anastomosesto reach the
cavalsystem. Sites for these
anastomoses include:
z(1) esophageal veins
z(2) paraumbilical veins
z(3) rectal veins

132. Dr. Mavrych, MD, PhD, DSc [email protected]
Esophageal anastomosis
zAnastomosisbetween the
tributaries of the left gastric
vein (portal vein) and the
tributaries of the azygous
vein (SVC) in the wall of the
lower end of the esophagus.
zIn portal hypertension these
veins enlarge in the wall of the
esophagusand later burst
into the lumen of the
esophagus (esophageal
varices)resulting in
hematemesis (vomiting red
blood).

133. Dr. Mavrych, MD, PhD, DSc [email protected]
Umbilical anastomosis
zAnastomosis between the
paraumbilical veins (portal
vein)and the superiorand
inferior epigastric veins
(SVCand IVC) in anterior
abdominal wall around the
umbilicus.
zIn portal hypertension, this
anastomosis gets enlarged
and dilated veins form “caput
Medussae”around the
umbilicus.

134. Dr. Mavrych, MD, PhD, DSc [email protected]
Rectal anastomosis
zAnastomosis between the
superior rectal vein
(inferior mesenteric vein
and then portal vein) and
inferior rectal vein which
drains into the internal iliac
vein (from IVC system).
zIn portal hypertension
(chronic alcoholics) this
anastomosis gets dilated
resulting in internal
hemorrhoids and bleeding
per anus from superior
rectal vein.

135. Dr. Mavrych, MD, PhD, DSc [email protected]
48. Pancreas:
Head and uncinate process
zThe head of the pancreas
rests within the C-shaped
area formed by the
duodenum and is
traversed by the common
bile duct.
zIt includes the uncinate
process which is crossed
by the superior
mesenteric vessels.

136. Dr. Mavrych, MD, PhD, DSc [email protected]
Cancer of the head
of the pancreas
xCancerof the head of the
pancreascompresses the bile
ductand results in
OBSTRUCTIVE TYPE OF
JAUNDICE.
xPainwill be conveyed to sensory
neurons T5-T9 dorsal root
gangliavia celiac plexus and
greater splanchnic nerve.
xThis type of jaundice is NOT
usually associatedwithfever.
xHepatitisalso causes jaundice
but is associated with the
fever.

137. Dr. Mavrych, MD, PhD, DSc [email protected]
Neck of the pancreas
zPosteriorto the
neckof the
pancreas is the site
of formation of the
PORTAL VEIN.
z(1)Splenic vein
joins with (2)
superior
mesenteric vein to
form (3) portal vein.
3
2
1

138. Dr. Mavrych, MD, PhD, DSc [email protected]
Body of the pancreas
zThe bodypasses to the
left and anteriorto the (1)
aortaand the (2)left
kidney.
zThe (3) splenic artery
undulates along the
superior border of the
body of the pancreas with
the splenic vein coursing
posteriorto the body.
3
2
1

139. Dr. Mavrych, MD, PhD, DSc [email protected]
Tail of the pancreas
zThe tailof the pancreas
enters the splenorenal
ligamentto reach the
hilum of the spleen.
zIt is the only part of the
pancreas that is
intraperitoneal.
zTail of the pancreas may
be mistakenly removed
during spleenectomy
(ligation of splenic artery
and vein)and resulting in
sugardiabetesbecause it
contains a lot endocrine
cells.

140. Dr. Mavrych, MD, PhD, DSc [email protected]
Arterial supply of the
pancreas
HeadandDuodenum:
z(1) Superior
pancreaticoduodenalarteries -
branches of gastroduodenal
artery.
z(2) Inferior pancreaticoduodenal
arteries-branches of SMA
zThis region is important for
collateral circulation because
there are anastomoses between
these branches of the CAand
SMA.
Neck, Body, and Tailof the
pancreas:
zPancreatic branches of the (3)
Splenic artery.
1
2
3

141. Dr. Mavrych, MD, PhD, DSc [email protected]
Annular Pancreas
zAnnular pancreas is caused by
malformation during the
development of the pancreas,
before birth.
zOccurs when the ventral and dorsal
pancreatic buds form a ring around
the duodenum, thereby causing an
obstruction of the duodenum and
polyhydramnios
zSymptoms:
1.Feeding intolerance in newborns
2.Fullness after eating
3.Nausea and bile-stained vomiting
zHalf of cases are not diagnosed
until symptoms occur in adulthood.

142. Dr. Mavrych, MD, PhD, DSc [email protected]
49. Spleen:
Rapture of the Spleen
zRapture of the spleen may be
result of the left 9
th
and 10
th
ribs
fracture or blunt trauma of the
left upper abdomen.
zThe spleen is a peritonealorgan
in the upper left quadrantthat is
deep to the left 9
th
, 10
th
, and 11
th
ribs.
zThe spleen follows the contour of
rib 10 (axis of the spleen).
zWhen blood collected deep to the
diaphragm phrenic nerve
irritates and pain may irradiate to
left shoulder.
zWhen spleen is ruptured, it
cannot be sutured therefore
removingis required.

143. Dr. Mavrych, MD, PhD, DSc [email protected]
Relations of the Spleen and
Left Kidney
zThe spleen follows
the contour of 10
th
rib
and extends from the
superior pole of the
left kidney to just
posterior to the
midaxillary line.
zThe border between
spleenandupper
pole of the left kidney
is 11
th
rib.

144. Dr. Mavrych, MD, PhD, DSc [email protected]
50. Kidney:
Dimensions and position
zDuring life, kidneys are
reddish brown and measure
approximately 11-12 cm in
length, 5-6 cm in width, and
2.5-3cmin thickness.
zThey are extending from the
level of T12to the level of L3,
the rightkidneylying about
2-3 cm lowerthan the left
one.
zThe lateral border of the
kidney is convex. Its medial
border is convex at both ends
but concave in the middle
where there is the hilumof
the kidney (L1).

145. Dr. Mavrych, MD, PhD, DSc [email protected]
Anterior relations
of the rightkidney
1.Right suprarenal gland
2.2
nd
part of the
duodenum
3.Rightlobe of the liver
4.Rightcolic flexure
5.Small intestine

146. Dr. Mavrych, MD, PhD, DSc [email protected]
Anterior relations
of the leftkidney
1.Left suprarenal gland
2.Stomach
3.Spleen
4.Body of pancreasand
splenic vessels
5.Descending colon
6.Small intestine

147. Dr. Mavrych, MD, PhD, DSc [email protected]
Renal (Gerota) fascia
zEnclosing the perinephric fat is
a membranous condensation
of the extraperitoneal fascia -
the renal fascia (3).
zThe suprarenal glands (4) are
also enclosed in this fascial
compartment, usually
separated from the kidneys by
a thin septum.
zN.B. The renal fascia must
be incisedin any surgical
approach to this organ.
3
4

148. Dr. Mavrych, MD, PhD, DSc [email protected]
Perinephric abscess
zMost infections of the perinephric
space occur as a result of extension
of an ascending urinary tract
infection, commonly in association
with nephrolithiasis or tuberculosis.
zPerinephric abscess typically
descends down between 2 sheetsof
the renal fascia along the psoas
major muscle.
zIn case if abscess locates behindof
the psoas major muscle it descends
downand may affect hip joint.
zIf abscess spreads up it’ll reach the
diaphragmand irritate phrenic
nerve. As result patient will feel pain
in shoulder region.

149. Dr. Mavrych, MD, PhD, DSc [email protected]
51. Nephrolithiasis
zRenal calculi are solid concretions
(crystal aggregations) formed in the
kidneys from dissolved urinary minerals.
zThere are several types of kidney
stones. The majority are calcium
oxalate stones, followed by calcium
phosphatestones.
zKidney stones typically leave the body
by passage in the urine stream, and
many stones are formed and passed
without causing symptoms.
zIf stones grow to sufficient size before
passage (at least 2-3 mm), they can
cause obstruction of the ureter (renal
colic).

150. Dr. Mavrych, MD, PhD, DSc [email protected]
3 constrictions of ureter:
zUreter located on the anterior
surface of the Psoas major
muscleand has 3 constrictions:
z1stconstriction is at the
pelviureteric junction (level of L1)
z2dconstriction lies at the level of
pelvic brim (level of the sacroiliac
joint)
z3dconstriction appears where
ureter lies obliquely in the wall of
urinary bladder (level of ischial
spine)
1
2

151. Dr. Mavrych, MD, PhD, DSc [email protected]
Staghorn calculi
zRenal stone that develops in the
renal pelvis and greater calices,
and in advanced cases has a
branching configuration which
resembles the antlers of a stag.
zStaghorn calculi are composed of
magnesium ammonium
phosphate, which forms in urine
that has an abnormally high pH
(above 7.2).
zThis high pH usually develops
because of recurrent urinary tract
infection with microorganisms
such as Proteus mirabilis.

152. Dr. Mavrych, MD, PhD, DSc [email protected]
52. Suprarenal glands
zThey are endocrineglands
having cortex and medulla.
zThe adrenalcortex [1]
secretes aldosterone,
corticosteroidsand
genital hormones.
1
2
zThe chromaffin cells of the adrenal medulla [2]
secrete two catecholamines: epinephrineand
norepinephrine, which affect smooth muscle, cardiac
muscle, and glands in the same way as sympathetic
stimulation.
zSympathetic stimulation orhypersecretion of
catecholamines(tumor of adrenal medullaor
sympathetic chainganglia) resulting in: episodes of
tachycardia, sweatingand high blood pressure.

153. Dr. Mavrych, MD, PhD, DSc [email protected]
Unpaired tributaries of IVC
zThe right renal (1) vein is
much shorterthan the left.
Both veins lie anterior to the
corresponding artery in
hilum of kidneys.
zThe long left renal vein (2)
is joined by theleft
suprarenal (3) andleft
gonadal (4)(testicular or
ovarian)veins before it
reached IVC.
zRightsuprarenal vein and
rightgonadal vein drain
directly to IVC (unpaired
IVC tributaries).
1
2
3
4

154. Dr. Mavrych, MD, PhD, DSc [email protected]
53. Varicocele
zIt is enlargementof the
pampiniform plexusthat
produces a wormlike scrotal
mass and enlargement of the
spermatic cord. Varicocele
may be reason of low sperm
count.
zVaricocele formation is usually
on the leftsideand may
disappear in supine position
of the body.
zVaricocele may indicate
kidney diseaseor may signal
a retro peritoneal malignancy
obstructing the testicular
vein.

155. Dr. Mavrych, MD, PhD, DSc [email protected]
Pampiniform plexus
zEach testicular or ovarian vein is
formed by coalescence of a
pampiniform plexus: the
testicular at the deep inguinal
ring, the ovarian at the margin of
the superior aperture of the
pelvis.
zThe veins run accompanied by
the corresponding arteries. The
leftpampiniform plexus enters
the left renal vein; the right one
enters directly the IVCinferior
to the renal vein.
zThat is why varicocely
(engorgement of the pampiniform
plexus that produces a scrotal
mass)is more often located on
the left.

156. Dr. Mavrych, MD, PhD, DSc [email protected]
54. Hydrocele
zThe tunica vaginalis testis or
other remnants of the processus
vaginalis may form a hydrocele
or hematocele.
zIn spermatic cord it is smooth
sausage-shaped structure that
persists under gentle
compression and isn’t disappear
in supine position.
zIn the scrotum with
transillumination, a hydrocele
produces a reddish glow,
whereas light will not penetrate
other scrotal masses such as a
hematocele, solid tumor, or
herniated bowel.

157. Dr. Mavrych, MD, PhD, DSc [email protected]
55. Hemorrhoids:
Venous drainage from rectum
zAbovepectinate line: superior
rectal vein [1] into portal
system [2].
zBelowpectinate line: inferior
rectal vein [3] into inferior
vena cava [4].
1
2
3
4

158. Dr. Mavrych, MD, PhD, DSc [email protected]
External hemorrhoids
zHemorrhoidsare masses that
typically protrude from anus
during defecation.
zHemorrhoids are commonly
associated with constipation,
extended sittingand straining at
the toilet, pregnancy, and
disorders that hinder venous return.
z1. External hemorrhoids are
dilated tributaries of the inferior
rectal veins (IRV) BELOW THE
PECTINATE LINEand are painful
because the mucosa is supplied by
somatic afferent fibers of the
inferior rectal nerves (from
pudendal).
1
1

159. Dr. Mavrych, MD, PhD, DSc [email protected]
Internal hemorrhoids
z2. Internal hemorrhoids
are dilated tributaries of the
superior rectal veins
(SRV) ABOVE THE
PECTINATE LINEand are
not painfulbecause the
mucosa is supplied by
visceral afferent fibers.
zInternal hemorrhoids
frequently develop in
chronic alcoholics
because of liver cirrhosis
and portal hypertension
syndrome.
2
2
2

160. Dr. Mavrych, MD, PhD, DSc [email protected]
56. Perineal pouches:
Deep perineal pouch
The deep perineal pouch is
formed by the fasciae and
muscles of the urogenital
diaphragm.
It contains:
1.Sphincter urethrae
muscle
2.Deep transverse
perineal muscle
3.Bulbourethral
(Cowper) glands (in
the male only) -ducts
perforate perineal
membrane and enters
bulbar urethra.

161. Dr. Mavrych, MD, PhD, DSc [email protected]
Superficial perineal pouch
1.Ischiocavernosusmuscle –related to the Crus of the
penis(Male) & Crus of the clitoris (Female)
2.Bulbospongiosusmuscle –related to the Bulb of
vestibule (Female) & Bulb of the penis (Male)
3.Superficial transverse perineal muscle –related to the
Perineal body(both genders)
1
2
3

162. Dr. Mavrych, MD, PhD, DSc [email protected]
Urine leaks
zAfter a crushing blow or a
penetrating injury, the spongy
urethracommonly ruptures
within the bulb of the penis, and
urine leaksinto the superficial
perineal pouch.
zThe superficial perineal fascia
keeps urinefrom passing into the
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubisinto
the anterior abdominal wall deep
to the deep layer of superficial
abdominal fascia.

163. Dr. Mavrych, MD, PhD, DSc [email protected]
57. Ischiorectal abscess
2
3
zIschiorectal abscess [1]is an important
surgical condition which usually results
from spread of an infectionthrough the
external sphincter ani into the
ischiorectal fossa [2].
zIschiorectal abscess is a surgical
emergency which should be
immediately drained by a wide cruciate
incision through the skin of the base of
the fossa to avoid fistula formation.
zA surgeon should avoid lateral wall of
ischiorectal fossa because here located
Pudendal (Alcock's) canal [3] with
pudendal nerve and internal pudendal
artery.
1

164. Dr. Mavrych, MD, PhD, DSc [email protected]
58. Cystocele
(hernia of bladder)
zLoss of bladder support in
femalesby damage to the
pelvic floor during childbirth
(e.g., laceration of perineal
muscles or a lesion of the
nerves supply).
zIt can result in protrusionof
the bladderonto the
anteriorvaginal wall and
loss of urine when a women
strains or coughs.

165. Dr. Mavrych, MD, PhD, DSc [email protected]
59. Paracentesis of Urinary
Bladder
Suprapubic aspiration:
zUrine can be removedfrom
the bladder without penetrating
the peritoneum by inserting a
needle JUST ABOVE the
pubic symphysis.
zThe needle passes
successively through skin,
superficial and deep layers of
superficial fascia, linea alba,
transversalis fascia,
extraperitoneal connective
tissue, and wall of the bladder.

166. Dr. Mavrych, MD, PhD, DSc [email protected]
60. Prostate tumors:
Prostate cancer
zIt usually begins in the posterior
lobeof the gland, and early
stages are often asymptomatic,
may be found during digital
rectal examination.
zProstatic malignancies tend to
metastasize tovertebraeand
the brainbecause the prostatic
venous plexus has numerous
connections with the vertebral
venous plexus via sacral veins.
A
P
M

167. Dr. Mavrych, MD, PhD, DSc [email protected]
Benign hypertrophy of the
prostate (BHP)
zBHPis common in men after
middle age.
zProstate adenoma(benign
hypertrophy) usually involves
median lobe.
zBHPis a common cause of
urethral obstruction, leading
to nocturia(need to void
during the night), dysuria
(difficulty and/or pain during
urination), and urgency
(sudden desire to void).
zThe prostate is examined for
enlargement and tumors by
DIGITAL RECTAL
examination.

168. Dr. Mavrych, MD, PhD, DSc [email protected]
Prostatectomy
zA prostatectomy may be performed
through a suprapubic [1]or
perineal [2] incision or
transurethrally [3].
zBecause of damage to nerves in
the capsule of the prostate and
around the urethra (cavernosus
nerves) can cause impotence
(erectaile dysfunction) and/or
urinary incontinence.
zPelvic splanchnic nerves may be
injured in case of intensive
dissection of pelvic lymph nodes
(prostatic cancer ectomy) and as
result autonomic innervation of
derivate of hindgutmay be
affected.
1
2
3
Transurethral
resection of the
prostate = TURP

169. Dr. Mavrych, MD, PhD, DSc [email protected]
61. Male urethra
Prostatic 1
st
part
zIt is the widestand the most
dilatable part.
zIt is spindleshaped (middle part is
dilated)
zIts posterior wall presents the
following features:
1.Seminal colliculus
2.Openings of the 2 ejaculatory
ductsare seen on each side on
the seminal colliculus.
3.Ducts of the prostate gland open
into the male urethra

170. Dr. Mavrych, MD, PhD, DSc [email protected]
Membranous 2
nd
part
zPasses through the
urogenital
diaphragm to enter
the bulb of the penis
zIt is the shortest,
NARROWEST and
the least dilatable part
zIt is surrounded by the
external sphincter
urethra
zBulbourethral
glands lie
posterolateral to this
part inside of
urogenital diaphragm
(deep perineal
pouch)

171. Dr. Mavrych, MD, PhD, DSc [email protected]
Spongy 3
rd
part
zLongestpart: average 15
cm in length.
zPasses through the bulb
and corpus spongiosum
of the penis to open at the
external urethral orifice on
the tip of the glanspenis.
zThere are two dilatations
–bulbar fossa(in the
beginning) and navicular
fossa(in the glans penis)
zDucts of the
bulbourethral glands
open into the floor of the
spongy part in its
beginning

172. Dr. Mavrych, MD, PhD, DSc [email protected]
2 sphincters of the urethra
1.Internal urethral
sphincter is made of
smooth muscles in the
neck of the bladder
and has sympathetic
innervation
2.Externalurethral
sphincter has skeletal
muscle fibers and
surrounds the
membranouspart of
urethra, supplied by
the perineal branch of
the pudendal nerve
1
2

173. Dr. Mavrych, MD, PhD, DSc [email protected]
62. Ejaculatory duct
zIt is a very narrow duct
2 cm long
zFormed by union of
ductus deferens and
duct of seminal vesicle
zIt serve to passage of
seminal fluid from
ductus deferens to
prostatic urethra.

174. Dr. Mavrych, MD, PhD, DSc [email protected]
63. Pudendal nerve (S2-S4)
zIt is PRINCIPALSOMATIC(motorand
sensory) nerveto supply perineum.
zLies against ischial spine as it passes
through lesser sciatic foramen to
traverse pudendal canal on lateral
wall of ischiorectal fossa.
Branches:
z1. Inferior rectal nerve
zSupplies external anal sphincter
muscle and skin around anus
z2. Perineal nerve
zDeep branch is motor nerve to muscles
of urogenital triangle.
zSuperficial branch gives cutaneous
posterior scrotal/labial branches.
z3. Dorsal nerve of penis or clitoris
zSupplies body, prepuce, and glans of
penis or clitoris
1
2
3

175. Dr. Mavrych, MD, PhD, DSc [email protected]
Pudendal nerve block
zTo relieve painfor the mother and
prepare for an episiotomy, a
pudendal nerve block may be
administered during early labor.
The nerve may be blocked in 2 ways
either:
1.by piercing the vaginal wall
posterolaterally near the ischial
spine or
2.percutaneouslyalong the medial
side of the ischial tuberosity.
zNote: Pain from uterine contractions is
unaffected because pelvic visceral
pain is carried by afferent fibers
accompanying autonomic nerve fibers.

176. Dr. Mavrych, MD, PhD, DSc [email protected]
64. Nerve supply of pelvic
viscera
Parasympathetic innervation:
zPreganglionicneurons are located in sacral parasympathetic n.
(S2-S4)in the spinal cord.
zTheir processes run into pelvicsplanchnic nerves and relay with
postganglionic neurons located inside of pelvic organs in the
intramural plexus.
Sympathetic innervation:
zSympathetic fibers of preganglionic neurons T12-L2segments (IML)
come through the sympathetic trunk and form sacral splanchnic
nerves.
zThey contribute to the inferior hypogastric plexus, where
postganglionicneurons are located. Branches of inferior hypogastric
plexus reach organs wrapping around the branches of the internal iliac
artery.
Sensory innervation:
zThe sensory fibers from S2-S4 dorsal root gangliamove together
with parasympathetic and carry painsensations from the organs.

177. Dr. Mavrych, MD, PhD, DSc [email protected]
Micturition reflex
Facilitating emptying:
zParasympatheticfibers (pelvic
splanchnic nn.) stimulate
DETRUSORMUSCLE[1]
contraction and involuntary relax
internal sphincter [2].
zSomatic motorfibers (pudendal
nerve) cause voluntary
relaxationof external[3] urethral
sphincter.
Inhibiting emptying:
zSympathetic fibers (sacral
splanchnic nn.) inhibit detrusor
muscle [1] and stimulate
internalsphincter [2].
1
2
3

178. Dr. Mavrych, MD, PhD, DSc [email protected]
65. Erection and ejaculation
zAfferent fibrous: Dorsal nerve of penis or clitoris from
Pudendal nerve (DRG S2-S4)
zEfferent fibrous:
zErection:Parasympathetic fibers(S2-S4) from the
Pelvic splanchnic nerves dilate arteriessupplying
erectile bodies of the penis, allowing them to fill with
blood. Somatic motor (S2-S4) fibrous from the
pudendal nerves cause contraction of
ischiocavernosusand bulbospongiosusmuscles to
press the root of the penis and relax external urethral
sphincter.
zEjaculation:Sympathetic fibers(L1-L2)from the
Inferior hypogastric plexus (Sacral splanchnic
nerves) cause contraction of smooth muscle of
epididymis, ductus deferens, seminal vesicles, and
prostate; sympathetic nerve fibers stimulate internal
urethral sphincter to prevent semen from entering
bladder or urine entering prostatic urethra.

179. Dr. Mavrych, MD, PhD, DSc [email protected]
66. Cryptorchism
zUndescended testes
(cryptorchism) when the testes
fail to descend into the scrotum.
This normally occurs within 3
months after birth.
zThe undescended testes may be
found in the abdominal cavity or
in the inguinal canal.
zIf neglected, malignant
transformationmay occur in the
undescended testis.
zN.B. In case of cryptorchism,
spermatogenesis is arrested
and the spermatogenic tissue is
damaged leading to permanent
sterility in bilateral cases.

180. Dr. Mavrych, MD, PhD, DSc [email protected]
67. Torsion of the spermatic
cord
Main components of the spermatic cord:
zDuctus deferens
zTesticular artery –direct branch of
Aorta
zPampiniform plexusto become
single testicular vein (right → IVC, left
→ Left renal vein)
zTorsionof the spermatic cord
produces acute pain with swelling
because of twisting of testicular
artery that can result in testicular
avascular necrosis.
zRepair requires a high scrotal incision
to untwist the cord, and the testis is
sutured to the scrotal septum to
prevent recurrence.

181. Dr. Mavrych, MD, PhD, DSc [email protected]
68. Lymphatic drainage of the
male viscera
?Testis& epididymis–lumbar
lymph nodes
?Scrotum–superficial inguinal
nodes
?Penis:
?skin -superficial inguinalnodes
?glans –deep inguinal nodes
?body and roots –internal iliac
nodes
?Prostategland & bladder-internal
iliacnodes
?Anal canal:
?above pectinate line -internal iliac
?below pectinate line -superficial
inguinalnodes

182. Dr. Mavrych, MD, PhD, DSc [email protected]
Lymphatic drainage from the
female viscera
?Ovary anduterine tubes –to Lumbar
lymph nodes
?Uterus:
?lateral angle and teres ligament –
Superficial inguinal lymph nodes
?fundusand upperpart of the body
-Lumbarlymph nodes
?lowerpart of the body-External
iliaclymph nodes
?cervix-External& Internal iliac
?Vagina:
?Superior to hymen -to External&
internaliliac
?Inferior to hymen -to Superficial
inguinalnodes
?All external genitalia (with exception -
glans clitoris) -Superficial inguinal
lymph nodes
?Glans clitoris –Deep inguinal

183. Dr. Mavrych, MD, PhD, DSc [email protected]
69. Arterial supply of the uterus
and Hysterectomy
The uterusis almost exclusively
supplied by the uterine arteries
[1] (from internal iliac artery):
zUterine a. crosses pelvic floor in
cardinal ligament [2]
zUreter passes superior and
anterior to uterine artery[3]
zAscending branch[4] of uterine
artery comes along lateral wall of
uterus within broad ligament.
2
1
3
4
Note: During hysterectomyureterin the
greatest risk because of close relations
with uterinearteryand cervixof the
uterus.

184. Dr. Mavrych, MD, PhD, DSc [email protected]
Hysterectomy
zHysterectomy is surgical removing of the
uterusand may include removing of the cervix
(total) and the vagina (radical).
zBlood supply to the ovaries is saved in case of
partial hysterectomy ovarian suspensory
ligament should be left intact because contain
ovarian artery (direct branch of abdominal
aorta) and vein.
zIn case of total hysterectomy (with cervix)
pelvic splanchnic nervesmay be affected.
That’s resulting in bladder dysfunction
because of detrusor urine muscle loose
parasympathetic innervation.

185. Dr. Mavrych, MD, PhD, DSc [email protected]
70. Parts of the uterine tube
zUterine part
zPierces uterine wall to
open into uterine cavity
zIsthmus
zNarrowestpart of tube
just lateral to uterus
zAmpulla
zMedial continuation of
infundibulum comprising
about half of uterine tube
zUsual site of fertilization
zInfundibulum
zFunnel-shaped expansion
of lateral end, fringed with
fimbriae
zOverlies ovary and
receives oocyte at
ovulation

186. Dr. Mavrych, MD, PhD, DSc [email protected]
Hysterosalpingography
zThe instillation of
viscous iodine
throughthe
external os [1] of
the uterine cervix
allows the lumen of
the cervical canal
[2], the uterine
cavity[3], and the
different parts of
the uterine tubes
[4] to be visualized
on X-ray.
1
2
3
4

187. Dr. Mavrych, MD, PhD, DSc [email protected]
71. Branches of the Internal
iliac artery
Anterior Division Posterior Division
1. Obturator 1. Iliolumbar
2. Umbilical 2. Lateral sacral
3 Inferior gluteal 3. Superior gluteal
4. Internal pudendal
5. Inferior vesical (males)
or
Vaginal (females)
6. Middle rectal
7. Uterine(females)

188. Dr. Mavrych, MD, PhD, DSc [email protected]
Internal iliac artery

189. Dr. Mavrych, MD, PhD, DSc [email protected]
72. Fracture of the
anterior cranial fossa
zFracture of the anterior cranial
fossa(Cribriform plate of the
Ethmoid bone) is suggested by
anosmia, periorbital bruising
(raccoon eyes), and CSF leakage
from the nose(rhinorrhea).

190. Dr. Mavrych, MD, PhD, DSc [email protected]
73. Cranial Malformations
z[A] Scaphocephaly: premature
closure of the sagittal suture, in
which the anterior fontanelle is small
or absent, results in a long, narrow,
wedge-shapedcranium.
z[C] Oxycephaly: premature closure
of the coronal suture results in a
high, tower-likecranium.
zWhen premature closure of the
coronal or the lambdoid suture occurs
on one side only, the cranium is
twisted and asymmetrical, a condition
known as plagiocephaly [B].

191. Dr. Mavrych, MD, PhD, DSc [email protected]
74. Epidural hematoma
zSkull fracture near pterionoften
causes epidural hematoma from
torn middle meningeal artery
(foramen spinosum).
zUnconsciousness and deathare
rapidbecause the bleeding
dissects a wide spaceas it strips
the dura from the inner surface of
the skull, which puts pressure on
the brain.
zAn epidural hematoma forms a
characteristic biconvex pattern
on computed tomography
images.

192. Dr. Mavrych, MD, PhD, DSc [email protected]
76. Infection of the Cavernous
sinus
Structures which may be affected by
cavernous sinus thrombosis:
1.Structures that pass through
sinusdirectly:
?Internal carotid artery(in case
of laceration -arteriovenous
fistula)
?Abducens nerveCN VI (in case
of lesion -internal squint)
2.Structures onlateral wall of
sinus:
?Oculomotor nerve (CN III)
?Trochlear nerve (CN IV)
?V1
?V2

193. Dr. Mavrych, MD, PhD, DSc [email protected]
Dangerous triangle of the face
zThe middle third of the face
is a "danger area“ because
infectionthere may produce
thrombophlebitisof the facial
vein that can spread to the
cavernous sinusvia
ophthalmic veinsor
pterygoid venousplexus.
zSepticemia leads to
meningitis and cavernous
sinus thrombosis, both of
which can cause neurological
damage and are life-
threatening.

194. Dr. Mavrych, MD, PhD, DSc [email protected]
77. Pituitary gland tumors and
transsphenoidal operation
zPituitary tumors [1] may extend
superiorly through opening in the
diaphragma sella, producing
disturbancesin endocrine system.
zSuperior extension of a tumor may
cause visual deficit owing to pressure
on the optic chiasm[2], the place
where the optic nerve fibers cross.
zThe transsphenoidal operation is the
most common operation for a pituitary
tumor. The surgical approach for it is
through the nose, nasal cavity and
sphenoidal sinus[3]. This surgical
approach provides the best exposure
of the tumor at the lowest risk.
12
3

195. Dr. Mavrych, MD, PhD, DSc [email protected]
Hormones of the pituitary
gland
zReleasing and inhibiting factors
from neurosecretory cells of the
hypothalamusreach pituitary
gland thought special capillary
network –hypophyseal portal
systemand control the production
of adenohypophysealhormones
(ACTH, FSH, LH, TSH, prolactin
andsomatotropin).
zHormones of neurohypophysis
(ADHand Oxytocin) are secreted
in hypothalamusand transported
through axons to pituitary gland.

196. Dr. Mavrych, MD, PhD, DSc [email protected]
78. Trigeminal nerve
zSkin of face supplied
by branches of the
three divisions of the
[1] TRIGEMINAL
NERVE(CN V)
zExceptfor a small
area over the angle
of the mandible
which is supplied by
the [2] great
auricular nerve
(C2-C3) –cervical
plexus
2
1
Infraorbital
foramen

197. Dr. Mavrych, MD, PhD, DSc [email protected]
79. Bell's palsy
zIt is idiopathic unilateral facial
paralysis.
zTerminal branches of CN VII
may be injured by parotid
canceror inflammation
(parotitis) by surgeryto
remove a parotid tumor
(stylomastois foramen).
zManifestations:
zunable to closelips and eyelids on affected side
zeye on affected side is not lubricated(dry eye)
zunable to whistle, blow a wind instrument, or chew effectively
zfacial distortion due to contractions of unopposedcontralateralfacial
muscles

198. Dr. Mavrych, MD, PhD, DSc [email protected]
80. Epistaxis
zEpistaxis(nosebleed)
most often occurs from
the anterior nasal septum
(Kiesselbach's area),
where branches of the
sphenopalatine,
anterior ethmoidal,
greater palatine, and
superior labial (from
facial) arteries converge.

199. Dr. Mavrych, MD, PhD, DSc [email protected]
81. Sinusitis
Sphenoiditis
zRelationships of the
sphenoidal sinus are clinically
important ; because of potential
injury during pituitary
surgery and the possible
spread of infection.
zInfection can reach the sinuses
through their ostia from the
nasal cavity or through their
floor from the nasopharynx.
zInfection may erode the walls to
reach the cavernous sinuses,
pituitary gland, optic nerves,
or opticchiasma

200. Dr. Mavrych, MD, PhD, DSc [email protected]
Ethmoiditis
zInfection in the ethmoidal
sinuses can erode the medial
wall of the orbit, resulting in
orbital cellulitesthat can
spread to the cranial cavity.
zIn orbital cavity infection may
erode structures related to the
medial orbital wall:
zMedial rectus muscle
zSuperior oblique muscle
zNasociliary nerve

201. Dr. Mavrych, MD, PhD, DSc [email protected]
83. Cheeks
zForm the lateral, movable walls of
the oral cavity and the zygomatic
prominences of the cheeks over the
zygomaticbones.
zBuccinator[1]–principalmuscle
of the cheek.
zBuccal pad of fat–encapsulated
collection of fat superficial to
buccinator.
zParotid duct[2]from Parotid gland
[3] perforate buccinator and opens in
inner surface of the cheek right
opposite2
nd
upper molartooth
2
1
3

202. Dr. Mavrych, MD, PhD, DSc [email protected]
84. Movements at the TMJs
All 4 muscles of
mastication are
innervated by V3:
1.Temporalis–
elevation &
retraction
2.Masseter -
elevation
3.Medial
pterygoid -
elevation
4.Lateral
pterygoid -
protrusion
Note: In case of mandibular nerve
damage mandible (when it is
protruded) deviate towardthe side of
lesion because of Lateral pterygoid
weakness.

203. Dr. Mavrych, MD, PhD, DSc [email protected]
85. Innervation of the tongue
1.Sensory anterior 2/3: general –lingual n. (V3),
taste –chorda tympani (CNVII)
2.Sensory posterior 1/3: general and taste –
glossopharyngeal (CNIX)
3.Motor–hypoglossal (CNXII)
?A lesion of the chorda tympani –lose of the taste
sensation anterior 2/3 of the tongue
?A lesion of the lingual nerve –lose of both
general and taste sensation anterior 2/3 of the
tongue
?A lesion of CN XII (hypoglossal canal) allows the
contralateral, unparalyzedgenioglossusmuscle to
pull the protruded tongue towardthe paralyzed side
(deviation and atrophy of the tongue).

204. Dr. Mavrych, MD, PhD, DSc [email protected]
86. Gag reflex
zTouching the posterior part of the
pharynx results in muscular
contraction of each side of the
pharynx -gag reflex:
zAfferent limb: CN IX
zEfferent limb: CN X
zInjury to the
GLOSSOPHARYNGEAL NERVE
(CN IX) will result in a negative
gag reflex

205. Dr. Mavrych, MD, PhD, DSc [email protected]
87. Palatine tonsils
zReceives main blood supply
from tonsillar branch of
facial artery
zDrained by lymph vessels
mainly to jugulodigastric
lymph node, which is body's
mostfrequently enlarged
lymph node
zNerve supply:tonsillar
plexus of nerves formed by
branches of CN IX and CN X

206. Dr. Mavrych, MD, PhD, DSc [email protected]
Tonsillitis
zDuring palatine tonsillectomy, the
peritonsillar space facilitates tonsil
removal, except after capsular
adhesion to the superior constrictor.
zIf the glossopharyngeal nerve
CNIX is injured, taste and general
sensation from the posterior 1/3 of
the tongue are lost.
zHemorrhagemay occur, usually
from the tonsillar branch of the
facial artery; if the superior
constrictor is penetrated, a high
facial artery or tortuous internal
carotidartery may be injured.

207. Dr. Mavrych, MD, PhD, DSc [email protected]
88. Muscles of Soft Palate
1.Tensor veli palatini and
2.Levator veli palatini –elevates
the soft palate during swallowing
to prevent food entering to the
nasopharynx
3.Palatoglossus and
4.Palatopharyngeus –depress
soft palateand pulls walls of
pharynx superiorly
5.Uvular muscle –shortens uvula
and pulls it superiorly

208. Dr. Mavrych, MD, PhD, DSc [email protected]
89. Lymph drainage from face
structures
1. Preauricular(parotid) (on front
of auricle)receive lymph from
anteriolateral part of scalp
(including eyelids)
2. Submandibular(in digastric or
submandibular Δ) –from all air
sinuses, noseand adjacent
cheek, upper lip and lateral
parts of lower lip.
3. Submental (in submental Δ) –
from the chin, tip of the tongue
and central part of the lower
lip.
1
2
3

209. Dr. Mavrych, MD, PhD, DSc [email protected]
90. Blow-out fracture
zA blow-out fracture of the
orbital floortypically is not
involve the orbital rim and is
caused by blunt trauma to the
orbital contents (e.g., by a
handball). Content of orbital
cavity blow-out in maxillary
sinus.
zBlow-out fractures may damage:
1.Inferior rectus muscle
2.Infraorbital nerve (from
maxillary V2)
3.Infraorbitalartery
(hemorrhaging).

210. Dr. Mavrych, MD, PhD, DSc [email protected]
91. Muscles of the orbit
Muscle Action Innerva-
tion
Superior rectus Elevates and adducts
pupil
CN III
Inferior rectus Depresses and adducts
pupil
CN III
Medial rectus Adducts pupil CN III
Lateral rectus Abducts pupil CN VI
Superior oblique Depresses and abducts
pupil
CN IV
Inferior oblique Elevates and abducts
pupil
CN III
Levator pulpebra superiorElevates upper eyelidCN III

211. Dr. Mavrych, MD, PhD, DSc [email protected]
92. Strabismus
Oculomotor Nerve Palsy (CNIII)
zOculomotor Nerve Palsy
(external squint) affects mostof the
extraocularmuscles
zManifestations:
zptosis,
zfully dilated pupil,
zand eye is fully depressed and
abducted (“down and out”) due to
unopposed actions of superior
oblique and lateral rectus,
respectively.

212. Dr. Mavrych, MD, PhD, DSc [email protected]
Trochlear Nerve Palsy (CNIV)
zLesions of this nerve or its nucleus
cause paralysis of the superior
oblique and impair the ability to turn
the affected eyeball infero-medially
(pupil look superio-laterally)
zThe characteristic sign of trochlear
nerve injury is diplopia(double
vision) when looking down (e.g.,
when going down stairs)
zThe person can compensate for the
diplopiaby inclining the head
anteriorlyand laterally toward the side
of the normal eye.

213. Dr. Mavrych, MD, PhD, DSc [email protected]
Abducens Nerve Palsy (CNVI)
zAbducens Nerve Palsy
(internal squint). Injury to abducens
nerve oparalysis of lateral rectus
oinability to abduct the affected
eye
zAffected eye is fully adductedby
the unopposed action of the medial
rectus that is supplied by CN III

214. Dr. Mavrych, MD, PhD, DSc [email protected]
93. Horner syndrome
zPenetratinginjury to the neck,
Pancoast tumor, or thyroid carcinoma
may cause Horner syndrome by
interrupting ascending preganglionic
sympathetic fibersanywhere between
their origin in the T1 segment (IML) of
spinal cord and their synapse in the
Superior cervical ganglion.
zIt includes the following signs:
zConstriction of the pupil (miosis)
zDrooping of the superior eyelid
(ptosis),
zRedness and increased temperature
of the skin (vasodilation)
zAbsence of sweating (anhydrosis)

215. Dr. Mavrych, MD, PhD, DSc [email protected]
94. Otitis Media
zHearingis diminishedbecause of
pressure on the eardrum and
reduced movement of the ossicles.
zTaste may be altered because the
chorda tympani is affected.
zInfection spreading posteriorly
cause mastoiditis.
zInfection that spreads to the
middle cranial fossa can cause
meningitis or temporal lobe
abscess, and infection moving
through the floor may produce
sigmoid sinus thrombosis.

216. Dr. Mavrych, MD, PhD, DSc [email protected]
Perforation of the
Tympanic Membrane
zMay result from otitis mediaand is
one of several causes of middle ear
(conduction) deafness
zCauses: foreign bodiesin external
acoustic meatus, excessive pressure
(as in diving), trauma
zBecause chorda tympani directly
relates to the posterior surface of the
tympanic membrane it may be
damagedand resulting in loss of
taste over anterior 2/3 of the tongue
and secretion of the sublingualand
submandibular glands
zMinor perforation heal spontaneously;
large ones require surgical repair

217. Dr. Mavrych, MD, PhD, DSc [email protected]
95. Thyroid and parathyroid
glands
Hormones:
zThe thyroid gland is the body's largest endocrine
gland. It produces thyroid hormone (T3 & T4),
which controls the rate of metabolism (increase
the temperatureof the body), and calcitonin, a
hormone controlling calcium metabolism (reduce
blood calcium Ca2+).
zAfter total thyroidectomy may develop lower
temperatureof the body and hypercalcemia.
zThe hormone produced by the parathyroid
glands, parathormone (PTH), controls the
metabolism of phosphorus and calcium in the
blood (increase Ca2+ level).

218. Dr. Mavrych, MD, PhD, DSc [email protected]
Anatomical relations
of the thyroid gland
zAnterolateral–
infrahyoidmuscles
zPosterolateral–
COMMON CAROTID
ARTERY [1]
zMedial–larynx,
TRACHEA [2],
pharynx, esophagus,
cricothyroid muscle,
recurrent laryngeal
nerve [3]
zPosterior–
parathyroid glands
[4]
1
3
1
1

219. Dr. Mavrych, MD, PhD, DSc [email protected]
CS of the neck

220. Dr. Mavrych, MD, PhD, DSc [email protected]
Median cervical cyst
zUsually presents as a painless
midlinemasson the anterior aspect
of the neck just below of the hyoid
boneand moves during
swallowing together with thyroid
gland because of relation with
pretracheal layer of cervical fascia
and infrahyoid muscles of the neck.
zRemanent of the thyroglossal canal
(thyroid gland originally from
epithelium of the tongue).
zTreatment: surgical excision

221. Dr. Mavrych, MD, PhD, DSc [email protected]
Variation of parathyroid
glands position
zThe superior parathyroid
glands, more constant in
position than the inferior ones.
zThe inferior parathyroid
glands are usually near the
inferior poles of the thyroid
gland, but they may lie in
various positions
zIn 1-5% of people, an inferior
parathyroidgland is deep in
the superior mediastinum
inside the thymusbecause of
common embryonic origin.

222. Dr. Mavrych, MD, PhD, DSc [email protected]
96. Larynx
Cavity of the Larynx -2 Folds:
zVestibular folds [1] (false vocal
cords)
zVocal folds[2] (true vocal cords)
?Rima vestibuli–gap between the
vestibular folds
?Rima glottidis [3] –gap between
the vocal folds anteriorly and
vocal processes of the arytenoid
cartilages posteriorly is most
narrowplacein the larynx (it
limits size of intubation tube
during endotrachial anaesthesia)
3
1
2
1
2

223. Dr. Mavrych, MD, PhD, DSc [email protected]
Muscles of the Larynx
Abductors
zPosterior cricoarytenoid –
abducts vocal folds (the only
abductors of the vocal folds)
zIt is innervated by recurrent
laryngealnerve (CNX
vagus).
?Interruption of recurrent
laryngeal nerve results in
hoarsenessbecause the
corresponding vocal fold
does not abduct and deviate
toward the midline.

224. Dr. Mavrych, MD, PhD, DSc [email protected]
Cricothyrotomy
zA cricothyrotomyis an emergency
procedure that relieves an airway
obstruction(e.g. swallowed foreign
bodies or abnormal tissue growths).
zA hollow needle is inserted into the
midline of the neck, just below the
thyroid cartilage (needle
cricothyrotomy).
zMore frequently, a small incision is made
in the skin over the Cricothyroid
membrane, and another one is made
through the membrane between the
cricoid and thyroid cartilage. A tube
that enables breathing is inserted through
the incision.

225. Dr. Mavrych, MD, PhD, DSc [email protected]
98. Retropharyngeal space
zIt is interval between pharynx
(Bucco-pharyngeal fascia)
and prevertebralfascia
zMay provide a passageway of
infection from pharynx to
posterior mediastinum
(mediastinitis≈ 90% mortality
rate).

226. Dr. Mavrych, MD, PhD, DSc [email protected]
99. Axillary sheath
zDerived from the prevertebral
fascia
zEncloses the subclavian artery
and brachial plexusas they
emerge in the interval between the
scalenus anteriorand medius
muscles (Interscalenus space)
zExtends into the axilla

227. Dr. Mavrych, MD, PhD, DSc [email protected]
100. Posterior Triangle of the
Neck
zVeins–external jugular vein,
subclavian vein.
zArteries –occipital artery.
zNerves–Accessory nerve (XI),
trunks of the brachial plexus, branches
of cervical plexus, phrenic nerve.
zLymph nodes –superficial cervical
nodes along external jugular vein.
CN XI (accessory nerve) supply:
zSternocleidomastoidmuscle -face
looks upward to the opposite side
zTrapezius-superior fibers elevate,
middle fibers retract, and inferior fibers
depress scapula.
CN XI

228. Dr. Mavrych, MD, PhD, DSc [email protected]
Good Luck!