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Bony areas of abdominal cavity
1. 5 lumbar vertebrae
2. iliac crest
3. sacrum and ala
4. lower costal angle
Muscles of abdominal cavity
1. Diaphragm
2. Quadratus Lumborum
3. Psoas major
4. Psoas minor
5. Iliacus
6. Iliopsoas (compound muscle of PM w/ iliacus)
Quadratus Lumborum (QL)
-rectangular muscle
-cephalad attachment to 12th rib
-caudal attachments to iliac crests
-continuous w/ in same plane as transversus abdominis muscle
-helps extend back
-innvervated by ventral rami of lowest thoracic and upper 3 lumbar nerves (T12-L3)
-lies adjacent to transverse processes of lumbar vertebrae and lateral to superior part of psoas major
Psoas Major
-strongest flexor of hip (bringing knee up to hip)
-innervated by L1-L3 ventral rami
-very deeply placed muscle--some therapists try to massage this muscle
-combines w/ iliacus to attach to lesser trochanter of femur as ileopsoas muscle
-extends somewhat inferiorly at oblique trajectory (lateral) from lumbar spine and inserts on lesser trochanter
Ileopsoas Muscle
-combination of Psoas Major and Iliacus
-attaches directly to lesser trochanter of femur for powerful flexion of hip
-helps form part of femoral triangle (lateral 1/2 of floor)
Psoas minor
-seen in about 50% of people with ethnic differences
-atavistic muscle like palmaris longus (not found in everyone)
-innervated by L1
-arises primarily from transverse processes of lumbar vertebrae
-runs superficial to psoas major
-attaches to iliopubic eminence
Where does the abdominal aorta bifurcate?
What does the abdominal aorta bifurcate into?
-right and left common iliac arteries
What do the right and left common iliac arteries branch into?
-right and left external and interal iliac arteries
Iliacus muscle
-other half of iliopsoas
-fills iliac fossa
-corresponding muscle to infraspinatus in lower extremity
-innervated by femoral nerve
-acts w/ psoas major to flex thigh and stabalize hip joint
-IVC pierces central tendon of diaphragm
-esophageal hiatus
-right crufa
sternocostal foramen
-underside supplied by inferior phrenic arteries
-innervated by phrenic nerves
Central tendon of diaphragm
-IVC pierces this
-central tendon does not compress IVC but opens up and holds IVC taught acting as a siphon to bring venous return from lower torso to right atrium of heart
-IVC pierces diaphragm at T8
Esophageal hiatus
-contributed to primarily by right crura
-2-3 inches to left of midline
-carries anterior and posterior vagal trunks and esophageal branch of left gastric artery
Aortic hiatus
-opening posterior to diaphragm
-transmits aorta, azygos vein, and thoracic duct
-aorta passes between crura of diaphragm posterior to the median acruate ligament
Crura of diaphragm
-the little lets on the midline anterior to the vertebral bodies in lumbar region
-get pierced by different structures
Left crus of diaphragm
-gets pierced by hemiazygos
-arises from only the first two or three lumbar vertebrae
Right crus of diaphragm
-attached to Treitz ligament
-larger and longer than left crus
-arises from first three or four lumbar vertebrae
Arcuate Ligaments
-thickenings of fascia near the posterior inferior attachment of the diaphragm
-laterial, medial, and median arcuate ligaments
Median Arcuate Ligament
-unites left and right crura
-passes over the anterior surface of aorta
Medial arcuate ligaments
-thickening of fascia covering psoas muscles
Lateral arcuate ligaments
-thickenings of fascia covering quadratus lumborum muscles
Sternocostal foramen
-anterior, just lateral to xiphoid process
-point where internal thoracic a. sends off superior epigastric that then gains access to anterior abdominal wall
-site of Morgagni herniation
-between sternal and costal attachments of diaphragm
Vertebrocostal trigone
-site of Bochdalek herniations
What does the right phrenic nerve travel with through the diaphragm?
Left phrenic nerve
-directly pierces diaphragm wher eit aborizes on inferior surface
-supplies the entire diaphragm with motor fibers
-supplies central portion of diaphragm w/ sensory fibers
Inferior phrenic arteries
-usually the first branches of descending abdominal aorta
-occasionally branches of celiac trunk
-run off to form a tentacular vessel to supply underside of diaphragm
Dunbar's syndrome
-inadequate distribution of bloodflow, especially to celiac trunk
-can be caused by compression of aorta by median arcuate ligament
Does the aorta pierce the diaphragm?
-no, it runs behind it
What are the unpaired vessels of the abdominal region?
-celiac trunk
Artery of Adamkiewicz
-left side, uper lumbar artery region
-very important in supplying distal spinal cord
-**if you have an abdominal aortic aneurism, you should make sure that the patient can move lower extremities after operation
Paired visceral branches of abdominal arteries
-Suprarenal aa.
-Renal aa.
-Gonadal aa. (ovarian or testicular)
Paired somatic/parietal branches of abdominal arteries
-Lumbar aa. (pass around the sides of superior 4 lumbar vertebrae to supply posterior abdominal wall)
-Inferior phrenic arteries (supply inferior surface of diaphragm and suprarenal glands)
Unpaired parietal branch of abdominal arteries
-Median sacral artery
Median sacral artery
-arises from aorta at its bifurcation and descends into lesser pelvis
Ascending lumbar vein
-connects common iliac veins to lumbar veins
-has connections to left renal vein
-communicates perpendicularly w/ subcostal vein to form azygos on right and hemiazygos on left
Cisterna chyli
-dilated proximal portion of thoracic duct as it ascends through aortic hiatus
-located just deep to right crus of diaphragm
Lumbar plexus
-collection of ventral rami L1-L4
-located w/in psoas major anterior to lumbar transverse processes
-largest branch is femoral nerve
-Consists of:
1. Obtruator nerve (L2-L4)
2. Femoral nerve (L2-L4)
3. Lumbrosacral trunk (L4-L5)
4. Ilioinguinal and Iliohypogastric nerves (L1)
5. Genitofemoral nerve (L1-L2)
6. Lateral cutaneous nerve of thigh (L2,L3)
Intercostal/Subcostal nerve
-may or may not be considered part of lumbar plexus
-called subcostal nerve (T12) because it doesn't have a rib underneath it
-ventral ramus of T12
-runs over surface of quadratus lumborum
-arise in thorax and pass posterior to lateral arcuate ligaments into abdomen
-run inferolaterally
-pass through transverse abdominal and interal oblique muscles
-supply external oblique and skin of anterolateral abdominal wall
Iliohypogastric and Ilioinguinal nerves
-arise from anterior ramus of L1
-enter abdomen posterior to medial arcuate ligaments
-pass inerolaterally, anterior to quadratus lumborum
-pierce transverse abdominal muscles near anterior superior iliac spines
-pass through internal and external oblique muscles
-supply abdominal muscles and skin of pubic and inguinal regions
Ilioinguinal nerve
-often thought to be a component of iliohypogastric nerve
-innervates patch of skin on anterior thigh
-travels out with spermatic cord
-superficial to spermatic cord or round ligament of uterus
Iliohypogastric nerve
-innervates the muscles it traverses
-ends and supplies skin over pubic bone
-innervates pyramidalis
Lateral femoral cutaneous nerve
-travels over iliacus muscle
-exits medial to ASIS
-innervates a patch of skin down lateral thigh
-entrapment of this nerve can lead to neuralgia parastetica
-L2, L3
Neuralgia parastetica
-results from entrapment of lateral femoral cutaneous nerve
-most commonly seen in new army recruits due to long days of marching
Femoral nerve
-largest nerve of lumbar plexus
-emerges from lateral border or psoas major
-innervates iliacus
-passes deep to inguinal ligament to anterior thigh
-supplies flexors of hip and extensors of knee
-innervates most muscles of anterior thigh
-has cutaneous branches that supply skin over anterior thigh and medial thigh and leg regions
-comes out of lumbar plexus just lateral to psoas major
Opterator nerve
-emerges from medial border of psoas major
-passes through pelvis to medial thigh
-supplies adductor muscles
-travels medial to psoas major through obturator foamen
-supplies medial thigh muscles and skin
Obturator foramen
-large hole through pelvic bone through which obturator nerve passes
Lumbrosacral trunk
-passes over ala of sacrum
-descends into peovis
-participates in formation of sacral plexus along w/ anterior rami of S1-S4
T10 cutaneous branch of ilioinguinal nerve
-travels down spermatic cord or round ligament
-changes name to anterior scrotal or anterior labial nerve
-supplies 1/3 skin to scrotum or labia
Does the ilioinguinal have a lateral cutaneous branch?
Genitofemoral nerve
-pierces anterior surface of psoas major
-runs inferiorly on psoas major deep to psoas fascia
-divides laterally to common and external iliac arteries into femoral and genital branches
Genital branch of genitofemoral nerve
-enters ilioinguinal canl through deep ring and leaves through superficial ring
-runs out to supply cremaster muscle and sking of scrotum/labia
-motor arm of cremaster reflex (ilioinguinal nerve is sensory arm)
Femoral branch of genitofemoral nerve
-runs out to skin over femoral triangle
What does the cremaster reflex test for?
-intergrity of L1
Preaortic plexus
-rich plexus network on anterior aorta
-nerves strand down midline, extended from thorax down into abdomen
-various ganglia associated w/ this plexus
-reinforced by sympathetic trunk in lumbar region
-plexus leaves association w/ anterior aorta and runs down into pelvis
Splanchnic nerves
-pierce crura of diaphragm
-presynaptic fibers extending off thoracic sympathetic trunk
-pierce diaphragm and run out and synapse in ganglia associated w/ major vessels of proximal aorta (celiac trunk, SMA, aorticorenal ganglia)
-postganglionic fibers continue down anterior aorta, some passing out to various structures such as ureter
Superior hypogastric plexus
-plexus inferior to bifurcation of aorta at L4
-primarily sympathetic plexus
-carries motor and sensory fibers, which are not by definition included in autonomic nervous system
-in the pelvis, S2-S4 merge w/ descending superior hypogastric plexus
Inferior Hypogastric plexus
-occurs once S2-S4 parasympathetic fibers merge w/ descending superior hypogastric plexus and disseminate to viscera of pelvis
Lumbar sympathectomy
-cutting the lumbar sympathetic trunk
-done for different reasons
-used to be done for hypertension to create more of a reservoir for blood of body to reduce BP but not done much now b/c we have good drugs for this
-also done for lower extremity disease
-interferes w/ ejaculation in men
Vagus nerve
-anterior and posterior vagal trunks supply parasympathetic innervation of abdominopelvic region up to splenic flexure
-after splenic flexure, parasympathetics brought by S2-S4
What is the primary contributor to celiac plexus?
-posterior vagal trunk
Presacral neurectomy
-cut superior hypogastric plexus near promontory of sacrum
-done for intractable pain coming from a pelvic organ
-cuts inflow into spinal cord
-problem is that not all viscera of pelvis have pain fibers that travel in sympathetic system, but most do
Parts of Kidney
-inner medula
-renal pelvis
-major calices
-minor calices
-renal pyramid
Major calices
-1-3 per kidney
-large tributaries into renal pelvis
-formed by merging of 2-3 minor calices
Minor calices
-7-14 per kidney
-one drop of urine enters per heart beat
-merge to empty into major calices
Where are the kidneys located?
-posterior abdominal wall at level of T12-L3 vertebrae
-right kidney lies slightly lower than left due to relationship to liver
-11th and 12th rib associated w/ left kidney
-only 12th rib associated w/ right kidney
-enveloped by renal fascia
Renal pyramid/renal papilla
-indents each minor calyx
What has an anterior relationship to right kidney?
-ascending colon
What has an anterior relationship to left kidney?
-descending colon
Renal pelvis
-funnel shaped end of ureter that lies w/ in renal sinus
Renal sinus
-space within kidney that is occupied by renal pelvis, calices, vessels, nerves, and fat
Renal capsule
-fibrous capsule that can be stripped off surface of kidney
Renal cortex
-outer zone of kidney
-approx. 1/3 of depth
Renal medulla
-inner zone of kidney
-consists of renal pyramids and renal columns
-approx. 2/3 of depth
Renal papilla
-apex of renal pyramid that projects into minor calyx
Minor calyx
-cup like chamber that is beginning of extrarenal duct system
-several combine to form a major calyx
Gerota's (renal) fascia
-Anterior part = Tolt's fascia
-Posterior part = Zuckerkandt layer
Left renal vein
-receives adrenal vein, inferior phrenic vein, left gonadal vein, ascending lumbar vein
Right renal vein
-receives just adrenal vein
What should you look for if someone presents w/ huge swollen left testicle?
-compression of renal vein
5 branches of renal artery
1. apical
2. inferior
3. posterior
4. anterior superior
5. anterior inferior
Are the branches of the renal artery terminal or do they anastamose?
-if you were to clip a branch, that part of the kidney would necrose
Brodel's white line
-watershed area of kidney
-located between anterior superior and posterior branches or renal artery
-avascular area
-25 cm long
-blood supply mainly from renal artery
-innervated by splanchnic nerves
-3 common areas of constriction
1. pelvic rim whre ureter joins bladder
2. beginning of ureter
3. where ureters cross bring of pelvic inlet
Common places for kidney stone to become trapped
1. junction of ureters w/ renal pelves
2. where ureters cross brim of pelvic inlet
3. during passage of ureters through wall of urinary bladder
Right Adrenal Gland
-pyramidal shaped
-lies anterior to the diaphragm
-makes contact w/ IVC anteromedially and liver anterolaterally
Left Adrenal Gland
-semilunar shaped
-related to spleen, stomach, pancreas, and left crus of diaphragm

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