FOR THE MRCS
Commissioning Editor: Laurence Hunter
Development Editor: Sheila Black
Project Manager: Frances Affleck
Designer: Stewart Larking
Illustration Manager: Bruce Hogarth
FOR THE MRCS
A revision guide for surgical trainees
Andrew T Raftery BSc MBChB(Hons) MD
Clinical Anatomist. Honorary Teaching Fellow, Hull York Medical School
Formerly Consultant Surgeon, Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust,
Northern General Hospital, Sheffield; Formerly Member (formerly Chairman), Court of Examiners,
Royal College of Surgeons of England; Formerly Member of Panel of Examiners, Intercollegiate Speciality Board
in General Surgery; Formerly Member of Council, Royal College of Surgeons of England; Formerly Honorary
Clinical Senior Lecturer in Surgery, University of Sheffield, UK
Michael S Delbridge MBChB(Hons) MD
Specialist Trainee in Vascular Surgery, Yorkshire and Humber Deanery, UK
Helen E Douglas MBChB MRCS(Eng)
Specialist Trainee in Plastic and Reconstructive Surgery, Yorkshire and Humber Deanery, UK
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2012
© 2012 Elsevier Ltd. All rights reserved.
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be noted herein).
First edition 2006
Second edition 2012
British Library Cataloguing in Publication Data
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A catalog record for this book is available from the Library of Congress
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any
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Printed in China
The authors (ATR and MSD) are grateful to the pub- to the chapter on cellular injury. The section on skin
lishers, Churchill Livingstone, for the invitation to pro- healing has also been extensively rewritten to include
duce a second edition of Basic Science for the MRCS. sections on skin grafting and the anatomy of flaps. As
It was felt that an additional co-author would be help- most examinations are Objective, Structured, Clinical
ful in bringing the book up-to-date. We are pleased Examinations (OSCEs) each chapter now has OSCE
that Helen Douglas, Specialist Trainee in Plastic and scenario questions at the end with sample answers
Reconstructive Surgery, has agreed to fill the role. provided in an appendix at the back of the book. We
have also added some images to the anatomy chap-
The book is a concise revision guide to the core basic ters consisting of MRI and CT scans of the type that are
sciences which comprise the essential knowledge for likely to be encountered in OSCE examinations.
those entering surgical training. It is a basic requirement
that every surgical trainee has a thorough understanding No book of this length could hope to be compre-
of the basic principles of anatomy, physiology and pa- hensive and we have therefore concentrated on the
thology irrespective of which speciality within surgery topics that tend to be recurring examination themes.
they intend to pursue as a career. It is equally important As with the first edition, this book has been written pri-
that they understand the clinical application of the basic marily as a means of rapid revision for the surgical
sciences. This revision guide has been written with this trainee. However, it should also prove useful for those
in mind, using a bullet-point style which we hope will in higher surgical training, as well as for the surgically
make it easier for the reader to revise the essential facts. inclined, well-motivated medical student. We hope
that this second edition will provide a simple and
Much has changed both in the undergraduate cur- straightforward approach to the basic science that
riculum and in the post-graduate examination system underpins surgical training.
since the first edition was published six years ago. In
this second edition, some of the chapters have been Andrew T. Raftery
updated and sections expanded to cover topics which Michael S. Delbridge
are particularly relevant to examinations. The microbi-
ology chapter has been extensively rewritten and a Helen E. Douglas
section on burns, a frequent examination topic, added Sheffield 2012
We are extremely grateful to the publishers, Elsevier Figures 8.1, 8.12B, 8.12C, 10.3, 10.4, 10.5, 10.6,
Limited, and in particular to Laurence Hunter, Commis- 10.7, 11.1, 11.3, 13.1, 13.5A, 13.5B and 13.6 from
sioning Editor, and Sheila Black, Development Editor, McGeown 2002 Physiology, 2nd edn. Churchill Living-
for their support and help with this project. We are also stone, Edinburgh
grateful to the following colleagues at the Sheffield
Teaching Hospitals NHS Foundation Trust who provided Figures 8.3 and 8.4 from Pocock & Richards 2004
help, advice and criticism: Dr Paul Zadik, Consultant Human Physiology: The Basis of Medicine, 2nd edn.
Microbiologist; Dr TC Darton, NIHR Academic Clinical Oxford University Press, Oxford
Research Fellow, Infectious Diseases and Medical
Microbiology; Mr BM Shrestha, Consultant General Figures 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9,
and Transplant Surgeon. We would also like to thank 1.11, 1.13, 1.14, 2.1, 2.2, 2.3, 2.4, 2.7, 2.8, 2.9,
our consultant radiologist colleagues, who provided 2.10, 2.12, 2.13, 2.14, 2.17, 2.18, 2.19, 2.20, 2.21,
images: Dr Matthew Bull, Dr Peter Brown, Dr James 2.22, 2.23, 2.24, 2.25, 2.27, 2.28, 2.29, 2.30, 2.31,
Hampton, Dr Robert Cooper and Dr Rebecca Denor- 2.32, 5.1, 5.2, 5.7, 5.8, 5.16, 5.17, 6.1, 6.2, 6.3,
onha. Mr Raftery would like to thank his secretary, 6.4, 6.7, 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.15, 8.2,
Mrs Denise Smith, for the long hours and hard work 8.6, 8.10, 8.12A, 9.2, 9.4, 9.6, 11.4, 12.1, 12.4,
she has put in typing and re-typing the manuscript, 13.8, 19.2, 20.1, 20.2, 20.3, 21.1, 22.1, 22.2 and
and Anne Raftery for collating and organising the whole 22.3 from Raftery (ed) 2000 Applied Basic Science
manuscript into its final format. The task could not have for Basic Surgical Training. Churchill Livingstone,
been completed without them. Edinburgh
The figures in this book come from a variety of Figure 17.2Q&A from Raftery & Delbridge 2006
sources, and many are reproduced from other publi- Pocketbook of Surgery, 3rd edn. Churchill Livingstone,
cations, with permission, as follows: Edinburgh
Figure 3.9 from the University of Michigan Medical Figures 5.35, 6.14, 22.2Q&A, 22.3Q&A and
School, with kind permission of Thomas R Gest, PhD 22.5Q&A from Raftery, Delbridge & Wagstaff 2011
Pocketbook of Surgery, 4th edn. Churchill Livingstone,
Figures 13.10A, 13.10B and 13.11 from Crossman Edinburgh
& Neary 2000 Neuroanatomy: An Illustrated Colour
Text, 2nd edn. Churchill Livingstone, Edinburgh Figures 1.10, 3.1, 3.2, 3.3, 3.4, 3.8, 3.12, 4.1, 4.2,
4.3, 4.4, 4.6, 4.7, 4.8, 4.9, 4.11, 4.12, 4.13, 4.15,
Figures 3.11 and 4.14, and Tables 6.1 and 6.3 from 4.16, 5.3, 5.4, 5.5, 5.9, 5.10, 5.11, 5.13, 5.14,
Easterbrook 1999 Basic Medical Sciences for MRCP 5.21, 5.22, 5.24, 5.26, 5.27, 5.28, 5.29, 5.30, 5.31
Part 1, 2nd edn. Churchill Livingstone, Edinburgh and 6.16 from Rogers 1992 Textbook of Anatomy.
Churchill Livingstone, Edinburgh
Figure 9.1 from Hoffman & Cranefield 1960 Elec-
trophysiology of the Heart. McGraw-Hill, New York Figure 13.4 from Stevens & Lowe 2000 Pathology,
(now public domain) 2nd edn. Mosby, Edinburgh
Figures 4.20, 4.24, 5.25, 6.5 and 6.6 from Jacob Figures 15.1 and 15.2, and Boxes 15.1 and 15.2
2002 Atlas of Human Anatomy. Churchill Livingstone, from Underwood (ed) 2004 General and Syste-
Edinburgh matic Pathology, 4th edn. Churchill Livingstone,
I ANATOMY 3
1 The thorax 66
2 The abdomen, pelvis and perineum 84
3 The upper limb and breast 112
4 The lower limb 154
5 The head, neck and spine
6 The nervous system 181
II PHYSIOLOGY 215
7 General physiology 245
8 Respiratory system 253
9 Cardiovascular system 272
10 Gastrointestinal system
11 Urinary system 293
12 Endocrine system 311
13 Nervous and locomotor systems 319
III PATHOLOGY 331
14 Cellular injury 355
15 Disorders of growth, morphogenesis and differentiation 373
16 Inflammation 400
17 Thrombosis, embolism and infarction
18 Neoplasia 449
20 Haemopoietic and lymphoreticular system 481
21 Basic microbiology vii
22 System-speciﬁc pathology
OSCE scenario answers
Intentionally left as blank
1 The thorax 3
2 The abdomen, pelvis and perineum 22
3 The upper limb and breast 66
4 The lower limb 84
5 The head, neck and spine 112
6 The nervous system 154
Intentionally left as blank
SECTION ONE ANATOMY
DEVELOPMENT l Boundary tissue between the primitive single atrial
cavity and single ventricle grows out as dorsal and
Heart and great vessels ventral endocardial cushions.
Heart (Fig. 1.1) l The endocardial cushions meet in the midline divid-
ing the common atrioventricular orifice into a right
l Paired endothelial tubes fuse to become the (tricuspid) and left (mitral) orifice.
primitive heart tube.
l An interventricular septum develops from the apex
l Primitive heart tube develops in the pericardial up towards the endocardial cushions.
cavity and divides into five regions:
n sinus venosus l In the atrium, the septum primum grows down to fuse
n atrium with the endocardial cushions but leaves a hole in the
n ventricle upper part which is termed the foramen ovale.
n bulbus cordis
n truncus arteriosus. l A second incomplete membrane known as the
septum secundum develops just to the right of
l Heart tube elongates in pericardial cavity becoming the septum primum and foramen ovale.
U-shaped and then S-shaped.
l The septum secundum acts as a valve-like structure
l Sinus venosus becomes incorporated into the atrium. allowing blood to go straight from the right to the left
l Bulbus cordis becomes incorporated into the side of the heart in the fetus.
ventricle. l At birth, where there is an increased blood flow
through the lungs and a rise in left atrial pressure,
Truncus SVC Aortic
Bulbus veins trunk
Ventricle atrium ventricle
Atrium IVC Right ventricle
Sinus Left atrium
The development of the heart.
4 SECTION ONE ANATOMY
the septum primum is pushed across to close the disappearing on the right, but continuing as the
foramen ovale. ductus arteriosus on the left connecting with the
l The septum primum and septum secundum usually aortic arch.
fuse, obliterating the foramen ovale and leaving a l The above developmental anatomy explains the dif-
small residual dimple (the fossa ovalis). ferent positions of the recurrent laryngeal nerves on
l The sinus venosus joins the atria becoming the two each side. On the right, the fifth and sixth arches
vena cava on the right and the four pulmonary veins disappear to leave the nerve hooked round the
on the left. fourth, i.e. subclavian artery. On the left it remains
hooked round the sixth arch (ligamentum arterio-
Great vessels (Fig. 1.2) sum in the adult).
l Truncus arteriosus gives off six pairs of arches. Fetal circulation (Fig. 1.3)
l These curve round the pharynx to join the dorsal aor-
l Oxygenated blood travels from the placenta along
tae, which fuse distally into the descending aorta. the umbilical vein.
l First and second arches disappear completely.
l Third arch remains as carotid artery. l Most blood bypasses the liver in the ductus venosus
l Fourth arch becomes subclavian artery on the right joining the inferior vena cava (IVC) and then travel-
ling to the right atrium.
and aortic arch on the left (giving off the left subcla-
vian artery). l Most of the blood passes through the foramen ovale
l Fifth arch disappears. into the left atrium so that oxygenated blood can
l Sixth arch (ventral part) becomes right and left pul- enter the aorta.
monary arteries with a connection to dorsal aorta
Vagus Right and left Vagus
nerve recurrent nerve
The development of the aortic arches.
The thorax 1 5
SVC Aortic arch
Foramen ovale Pulmonary
Fig 1.3 arising from
The fetal circulation. the internal
l The remainder goes through the right ventricle with l Ligation of the umbilical cord causes thrombosis of
returning systemic venous blood into the pulmonary the umbilical artery, vein and ductus venosus.
l In the fetus the unexpanded lungs present high re-
sistance to flow so that blood in the pulmonary trunk Malposition
tends to pass down the low-resistance ductus arter-
iosus into the aorta. l Dextrocardia: mirror image of normal anatomy.
l Situs inversus: inversion of all viscera.
l Blood returns to the placenta via the umbilical arter-
ies (branches of the internal iliac arteries). Left-to-right shunt
l At birth, when the baby breathes, the left atrial pres- Atrial septal defect (ASD)
sure rises, pushing the septum primum against the l Fusion between septum primum and septum secun-
septum secundum and closing the foramen ovale.
dum usually takes place about 3 months after birth.
l Blood flow through the pulmonary artery increases l May be incomplete in 10% of population.
and becomes poorly oxygenated as it now receives l If septum secundum is too short to cover foramen
systemic venous blood.
secundum in the septum primum and ASD persists
l Pulmonary vascular resistance is abruptly lowered as after the primum and septum secundum are pressed
lungs inflate and the ductus arteriosus is obliterated together at birth, this results in an ostium secundum
over the next few hours to days.
6 SECTION ONE ANATOMY
defect which allows shunting of blood from left to right n a wide aorta which over-rides the right and left
l ASD may also result if septum primum fails to fuse
with endocardial cushions. n right ventricular hypertrophy.
l This is an ostium primum defect lying immediately l Because there is a right-to-left shunt across the
above the atrioventricular (AV) boundary and may be
associated with a ventricular septal defect. VSD there is usually cyanosis at an early stage.
l Degree of cyanosis depends mainly on the severity
Ventricular septal defect (VSD)
l This is the most common abnormality. of the pulmonary outflow obstruction.
l Small defects occurring in the muscular part of the
Other congenital anomalies
septum may close.
l Larger ones occurring in the membranous part of the Coarctation of the aorta
l Due to abnormality of obliterative process which
septum just below the aortic valves may require repair.
normally occludes ductus arteriosus.
Patent ductus arteriosus (PDA) l Hypertension in upper part of body with weak,
l The ductus may fail to close after birth.
l This should be surgically corrected because it delayed femoral pulses.
l Extensive collaterals develop to try and bring blood
causes increased load on left ventricle and pulmo-
nary hypertension. from upper to lower part of body.
l Enlarged intercostal arteries cause notching of the
l Pulmonary hypertension may cause reversed flow inferior borders of the rib seen on chest X-ray.
(right-to-left shunting). Abnormalities of valves
l This is due to an increased pulmonary flow resulting l Any valve may be imperfectly formed.
l May cause stenosis or complete occlusion.
from either ASD, VSD or PDA. l Pulmonary and aortic valves are more frequently
l When cyanosis occurs as a result of this mechanism
affected than mitral and tricuspid.
it is known as Eisenmenger’s syndrome.
The diaphragm (Fig. 1.4)
Right-to-left shunt (cyanotic)
The diaphragm develops from the fusion of four
Fallot’s tetralogy parts:
l Fallot’s tetralogy consists of: 1. septum transversum (the fibrous central tendon)
2. the mesentery of the foregut (the area adjacent
n stenosed pulmonary outflow track to the vertebral column becomes the crura and
Right Foregut (oesophageal)
Body wall membrane
Oesophagus Septum transversum
The development of the diaphragm.
The thorax 1 7
3. ingrowth from the body wall l Bears a prominent tubercle on the inner border
4. the pleuroperitoneal membrane (a small dorsal part). of its upper surface for insertion of scalenus
These close the primitive communications between
pleura and peritoneal cavities. l In front of the scalene tubercle the subclavian vein
crosses the rib.
l Behind the scalene tubercle is the subclavian
Different types of congenital diaphragmatic hernias groove where the subclavian artery and lowest
occur, depending on which section has failed to close: trunk of the brachial plexus are related to the rib.
l posterolateral hernia through the foramen of Bochda-
l The neck of the first rib is crossed by (medial to lat-
lek (the pleuroperitoneal membrane)—more common eral): sympathetic trunk; superior intercostal artery;
on the left and T1 to the brachial plexus.
l a hernia through a deficiency of the whole central
tendon l First digitation of serratus anterior attaches to outer
l a hernia through the foramen of Morgagni anteriorly edge.
between xiphoid and costal origins
l a hernia through a congenitally large oesophageal l Suprapleural membrane (Sibson’s fascia) is at-
hiatus. tached to inner border.
THORACIC CAGE Second rib
l Less curved than first.
The thoracic cage is formed by: l Twice as long.
l vertebral column behind
l ribs and intercostal spaces on either side Tenth rib
l sternum and costal cartilages in front. l Only one articular facet on head.
Ribs Eleventh and twelfth ribs
l 12 pairs. l No tubercles.
l Ribs 1–7 connect via their costal cartilages with the l Only single facet on head.
l Eleventh rib has shallow subcostal groove.
sternum. These are ‘true’ ribs articulating directly l Twelfth rib has no subcostal groove and no angle.
with the sternum.
l Ribs 8–10 articulate with their costal cartilages, Clinical points
each with the rib above. These are ‘false’ ribs as
they do not articulate directly with the sternum. Rib fractures
l Ribs 11 and 12 are free anteriorly. These are ‘float-
ing ribs’ as they have no anterior articulation. l May damage underlying or related structures.
A typical rib comprises: l Fracture of any rib may lead to trauma to lung and
l a head with two articular facets for articulation with
the corresponding vertebra and the vertebra above development of pneumothorax.
l a neck giving attachment to the costo-transverse l Fracture of left lower ribs (9, 10 and 11) may trau-
l a tubercle with a smooth facet for articulation with matise the spleen.
the transverse process of the corresponding vertebra l Rib fractures may also traumatise related intercostal
l a shaft flattened from side to side possessing an
angle which marks the lateral limit of attachment vessels leading to haemothorax.
of erector spinae. The shaft possesses a groove
on its lower surface, the subcostal groove, in which Coarcation of the aorta
the vessels and nerves lie.
l Collateral vessels develop between vessels above
Atypical ribs and below block.
First rib l Superior intercostal artery, derived from costo-
l Shortest, flattest and most curved. cervical trunk of subclavian artery, supplies blood
l Flattened from above downwards. to intercostal arteries of aorta, bypassing the
l As a consequence, the intercostal vessels dilate
and become more tortuous because of increased
flow eroding the lower border of the ribs, giving
rise to notching which can be seen on X-ray.
8 SECTION ONE ANATOMY
Cervical ribs l Upper part is related to left brachiocephalic vein; left
brachiocephalic artery; left common carotid artery;
l Incidence of 1:200. left subclavian artery.
l May be bilateral in 1:500.
l Rib may be complete, articulating with transverse l Laterally it is related to the lungs and pleura.
process of seventh cervical vertebra behind and first Body
rib in front.
l Occasionally cervical rib may have free distal extrem- l Composed of four pieces (sternebrae).
ity or may be only represented by a fibrous band. l Lateral margins are notched to receive most of the
l Cervical rib may cause vascular or neurological
symptoms. second and third to seventh costal cartilages.
l Vascular consequences include post-stenotic
dilatation of subclavian artery, causing local Relations
turbulence, thrombosis and possibility of distal l On right side of median plane, body is related to
l Subclavian aneurysm may also arise. right pleura and thin anterior border of right lung,
l Pressure on vein may result in subclavian vein which intervenes between it and the pericardium.
thrombosis. l On left side of median plane, the upper two
l Pressure on lower trunk of brachial plexus may re- pieces are related to pleura and left lung; the
sult in paraesthesia of dermatomal distribution of lower two pieces are related directly to the
C8/T1 together with wasting of small muscles of pericardium.
hands (myotome T1).
l Small and cartilaginous well into adult life.
l Upper seven connect ribs to sternum. l May become prominent if patient loses weight.
l 8, 9 and 10 connect ribs to cartilage immediately
l Composed of hyaline cartilage and add resilience to l Sternal puncture is used to obtain bone marrow
from the body of the sternum; one should be aware
thoracic cage, protecting it from more frequent of the posterior relations!
l Calcify with age; irregular areas of calcification l The sternum is split for access to the heart and oc-
seen on chest X-ray. casionally a retrosternal goitre, thymus or ectopic
l The xiphoid may become more prominent when a
The sternum consists of three parts: patient loses weight (naturally or due to disease).
l manubrium The patient may present in clinic because they
l body have noticed a lump, which was previously
l xiphoid. covered in fat.
Manubrium Intercostal spaces (Fig. 1.5)
l Approximately triangular in shape. l A typical intercostal space contains three muscles
l Articulates with medial end of clavicle. comparable to those of the abdominal wall.
l First costal cartilage and upper part of second artic-
l External intercostal muscle: passes downwards and
ulate with manubrium. forwards from the rib above to the rib below; defi-
l Articulates with body of sternum at manubriosternal cient in front where it is replaced by the anterior
joint (angle of Louis).
l Internal intercostal muscle: passes downwards and
Relations backwards; deficient behind where it is replaced by
l Anterior boundary of superior mediastinum. the posterior intercostal membrane.
l Lowest part is related to arch of aorta.
l Innermost intercostal muscle: may cover more than
one intercostal space.
l Neurovascular bundle lies between the internal and
the innermost intercostal.
External Vein The thorax 1 9
intercostal Innermost In the neck
l Anteriorly: isthmus of thyroid gland over second to
fourth tracheal rings, inferior thyroid veins, sterno-
l Laterally: lobes of thyroid gland, carotid sheath.
l Posteriorly: oesophagus, recurrent laryngeal nerves
in the groove between the trachea and oesophagus.
In the thorax
l Anteriorly: brachiocephalic artery and left common
carotid artery, left brachiocephalic vein, thymus.
l Posteriorly: oesophagus, recurrent laryngeal nerves.
l Right side: vagus nerve, azygos vein, pleura.
l Left side: aortic arch, left common carotid artery,
left subclavian vein, left recurrent laryngeal nerve,
Fig 1.5 BRONCHI (Fig. 1.6)
An intercostal space. A needle passed into the
chest immediately above a rib will avoid the The trachea terminates at the level of the sternal angle,
neurovascular bundle. dividing into right and left bronchi.
Right main bronchus:
l Neurovascular bundle consists of (from above down): l wider, shorter and more vertical than left
the vein, artery and nerve; the vein lying directly in the l approximately 2.5 cm long
groove on the undersurface of the corresponding rib. l passes downwards and laterally behind ascending
Clinical points aorta and superior vena cava (SVC) to enter hilum
l Insertion of a chest drain should be close to the up- l azygos vein arches over it from behind to enter SVC
per border of the rib below the intercostal space to l pulmonary artery lies first below and then anterior
avoid the neurovascular bundle. to it
l gives off upper lobe bronchus before entering
l Irritation of the intercostal nerves (anterior primary lung
rami of the thoracic nerves) may give rise to pain l divides into bronchi to middle and inferior lobes
referred to the front of the chest wall or abdomen within the lung.
in the region of the termination of the nerves. Left main bronchus:
l approximately 5 cm long
TRACHEA (Fig. 1.6) l passes downwards and laterally below arch of
aorta, in front of oesophagus and descending aorta
l Extends from lower border of cricoid cartilage (level l gives off no branches until it enters hilum of lung,
of the sixth cervical vertebra) to termination into two where it divides into bronchi to upper and lower
main bronchi (level of fifth thoracic vertebra)— lobes
11 cm long. l pulmonary artery lies at first anterior to, and then
above the bronchus.
l Composed of fibroelastic tissue and is prevented
from collapsing by a series of U-shaped cartilagi- Clinical points
nous rings, open posteriorly, the ends being con-
nected by smooth muscle (trachealis). l The trachea may be displaced or compressed by
pathological enlargement of adjacent structures,
l Lined by columnar ciliated epithelium containing e.g. thyroid, arch of aorta.
numerous goblet cells.
10 SECTION ONE ANATOMY
Right main Left main bronchus
Carina Left upper
lobe bronchus Left lower
Apical segmental bronchus Fig 1.6
of lower lobe The trachea and bronchi.
Right lower lobe bronchus
l The trachea may be displaced if the mediastinum is l The pretracheal fascia is split longitudinally.
pushed across, e.g. by tension pneumothorax dis- l Bleeding may be encountered from the anterior
placing it to the opposite side.
relations at this point, namely anastomosis be-
l Calcification of tracheal rings may occur in the tween anterior jugular veins across the midline,
elderly and be visible on X-ray. inferior thyroid veins, thyroidea ima artery (when
l Because the right main bronchus is wider and more l In the young child, the brachiocephalic artery, the
vertical, foreign bodies are more likely to be aspi- left brachiocephalic vein and the thymus may be
rated into this bronchus. apparent in the lower part of the wound.
l After splitting the pretracheal fascia and retracting
l Distortion and widening of the carina (angle between the strap muscles, the isthmus of the thyroid will be
the main bronchi), seen at bronchoscopy, usually in- encountered and which may be either retracted
dicates enlargement of the tracheo-bronchial lymph upwards or divided between clamps to expose the
nodes at the bifurcation by carcinoma. cartilages of the trachea.
l An opening is then made in the trachea to admit the
Anatomy of tracheostomy tracheostomy tube.
l Either a vertical or cosmetic transverse skin incision THE LUNGS
may be employed.
l Conical in shape.
l A vertical incision is made downwards from the cricoid l Conform to shape of pleural cavities.
cartilage passing between the anterior jugular veins. l Each has a blunt apex extending above the sternal
l A transverse cosmetic skin crease incision may be end of the first rib.
used placed halfway between the cricoid cartilage
and suprasternal notch.
l The incision goes through the skin and superficial
fascia (in the transverse incision, platysma will be
located in the lateral part of the incision).
The thorax 1 11
l Each has a concave base related to the diaphragm. BRONCHOPULMONARY
l Each has a convex parietal surface related to SEGMENTS (Fig. 1.7)
the ribs. l Each lobar bronchus divides to supply the
l Each has a concave mediastinal surface related to bronchopulmonary segments of the lung.
the pericardium. l There are 10 bronchopulmonary segments for
l Each has a thin anterior border overlapping the peri- each lung.
cardium and deficient on the left at the cardiac l Each is supplied by a segmental bronchus, artery
notch. and vein.
l Each has a hilum where the bronchi and vessels
pass to and from the root. l No communication with adjacent segments.
l Each has a rounded posterior border that occupies l It is possible to remove an individual segment
the groove by the side of the vertebrae.
without interfering with the function of adjacent
Right lung segments.
l There is little bleeding or alveolar air leak from the
l Slightly larger than the left. raw lung surface if excision takes place accurately
l Divided into three lobes—upper, middle and along the boundaries (marked by intersegmental
lower—by the oblique and horizontal fissures. l Each segment is wedge-shaped with the apex at the
hilum and the base at the lung surface.
Left lung l Each segment takes its name from that of the
supplying segmental bronchus.
l Has only an oblique fissure and therefore only two
lobes. Blood supply
l The anterior border has a notch produced by the l Pulmonary trunk arises from the right ventricle.
heart (cardiac notch). l Directed upwards in front of the ascending aorta.
l Passes upwards and backwards on the left of
l The equivalent of the middle lobe of the right lung in
the left lung is the lingula, which lies between the the ascending aorta to reach concavity of aortic
cardiac notch and oblique fissure. arch.
l Divides in front of the left main bronchus into right
Roots of the lungs and left branches.
l Comprise the principle bronchus, the pulmonary Right pulmonary artery
artery, the two pulmonary veins, the bronchial
arteries and veins, pulmonary plexuses of l Passes in front of oesophagus to the root of
nerves, lymph vessels, bronchopulmonary lymph the right lung behind the ascending aorta
nodes. and SVC.
l Chief structures composing root of each lung are ar- l At the root of the lung it lies in front of and
ranged in similar manner from before backwards on between the right main bronchus and its upper
both sides, i.e. the upper of the two pulmonary veins lobe branch.
in front; pulmonary artery in the middle; bronchus
behind. l Divides into three branches, one for each lobe.
l Arrangement differs from above downwards on the Left pulmonary artery
n right side from above downwards: upper lobe l Connected at its origin with the arch of the aorta via
bronchus, pulmonary artery, right principle the ligamentum arteriosum.
bronchus, lower pulmonary vein
n left side: pulmonary artery, bronchus, lower l Runs in front of the left main bronchus and des-
pulmonary vein. cending aorta.
l Visceral and parietal pleura meet as a sleeve l Left recurrent laryngeal nerve loops below the aortic
surrounding the structures passing to and from arch in contact with ligamentum arteriosum.
the lung. This sleeve hangs down inferiorly at the
pulmonary ligament. It allows for expansion of the Bronchial arteries
pulmonary veins with increased blood flow.
l Supply the air passages.
l Branches of the descending aorta.
12 SECTION ONE ANATOMY
2 6 2
3 5 3
6 4 6
10 8 7 10
A Lateral 9
2 3 2
6 5 6
B Lateral 89 10
Bronchi and bronchopulmonary segments for the lungs. Divisions of the main bronchi in the centre, with
corresponding pulmonary segments on the surfaces: A Right lung upper lobe 1 ¼ apical, 2 ¼ posterior,
3 ¼ anterior; middle lobe 4 ¼ lateral, 5 ¼ medial; lower lobe 6 ¼ apical, 7 ¼ medial basal (cardiac),
8 ¼ anterior basal, 9 ¼ lateral basal, 10 ¼ posterior basal. B Left lung upper lobe 1, 2 ¼ apicoposterior,
3 ¼ anterior; lingula (middle lobe) 4 ¼ superior, 5 ¼ inferior; lower lobe 6 ¼ apical, 8 ¼ anterior basal,
9 ¼ lateral basal, 10 ¼ posterior basal.
PLEURA l The two pleural cavities are totally separate from
l Each pleural cavity is composed of a thin serous
membrane invaginated by the lung. Surface anatomy of pleura and lungs
l The visceral pleura is intimately related to the lung Pleura
surface and is continuous with the parietal layer
over the root of the lung. l Cervical pleura extends above the sternal end of the
l The parietal layer is applied to the inner aspect of
the chest wall, diaphragm and mediastinum. l It follows a curved line drawn from the sternoclavi-
cular joint to the junction of inner third and outer
l Below the root of the lung the pleura forms a loose two-thirds of clavicle, the apex arising 2.5 cm
fold known as the pulmonary ligament, which above the clavicle.
allows for distension of the pulmonary vein.
l Line of pleural reflection passes behind the sterno-
l The lungs conform to the shape of the pleural cav- clavicular joint on each side to meet in the midline
ities but do not occupy the full cavity as this would at the angle of Louis (second costal cartilage level).
not allow expansion as in full inspiration.
The thorax 1 13
l The right pleural edge passes vertically down to the l Visceral pleura obtains an autonomic supply from
level of the sixth costal cartilage and crosses: the branches of the vagus nerve supplying the lung
n eighth rib in midclavicular line and is sensitive only to stretching.
n tenth rib in midaxillary line
n twelfth rib at the lateral border of erector l Parietal pleura receives somatic innervation from
spinae. the intercostal nerves.
l Left pleural edge arches laterally at the fourth costal l Diaphragmatic pleura is supplied by phrenic nerve.
cartilage and descends lateral to the border of the l Parietal pleura and diaphragmatic pleura are there-
sternum whence it follows a path similar to the right.
fore sensitive to pain.
l Medial end of the fourth and fifth left intercostal
spaces are therefore not covered by pleura. Clinical points
l The pleura descends below the twelfth rib at its l Pain from the parietal pleura of the chest wall may
medial extremity. be referred via the intercostal nerves to the abdo-
men, e.g. right lower lobar pneumonia may irritate
Lungs the parietal pleura and refer pain to the right lower
abdomen, mimicking acute appendicitis; irritation
l Apex of the lung follows the line of cervical pleura. of the diaphragmatic pleura may refer pain to
l Anterior border of the right lung corresponds to the the tip of the shoulder [irritating the phrenic nerve
(C3, 4, 5) and referring pain to the dermatomal dis-
right mediastinal pleura. tribution of C4 at the shoulder tip].
l Anterior border of the left lung has a distinct notch
THE DIAPHRAGM (Fig. 1.8)
(cardiac notch), which passes behind the fifth and
sixth costal cartilages. l Dome-shaped septum separating the thorax from
l The lower border of the lung (midway between the abdomen.
inspiration and expiration) crosses:
l Composed of a peripheral muscular part and a
n sixth rib in the midclavicular line central tendon.
n eighth rib in the midaxillary line
n tenth rib at the lateral border of erector spinae. l Muscular part arises from crura, arcuate ligaments,
l The oblique fissure is represented by the medial ribs and sternum.
border of the scapula with the arm fully elevated
(abducted), or by a line drawn from 2.5 cm lateral l Right crus arises from the front of the bodies of the
to the fifth thoracic vertebrae to the sixth costal car- first three lumbar vertebrae and the intervening
tilage, about 4 cm from the midline. intervertebral discs.
l The horizontal fissure of the right lung passes hor-
izontally and medially from the oblique fissure at the l Left crus arises from the first and second lumbar
level of the fourth costal cartilage. vertebrae and the intervening disc.
Clinical points l The lateral arcuate ligament is a condensation of
the fascia over quadratus lumborum.
l The pleura rises above the clavicle into the neck. It
may be injured by a stab wound, the surgeon’s l The medial arcuate ligament is a condensation of
knife, or insertion of a subclavian or internal jugular the fascia of psoas major.
l The medial borders of the medial arcuate ligament
l A needle passing through the fourth and fifth inter- join anteriorly over the aorta as the median arcuate
costal spaces immediately lateral to the sternal ligament.
edge will enter the pericardium without traversing
the pleura. l The costal part is attached to the inner aspect of the
lower six ribs.
l The pleura descends below the medial extremity of
the twelfth rib and therefore may be inadvertently l The sternal portion arises as two small slips from
opened in the loin approach to the kidney or adrenal the back of the xiphoid process.
l Central tendon is trefoil in shape and receives inser-
Nerve supply of pleura tion of muscular fibres. Above it fuses with the
l Receives nerve supply from structures to which it is
attached. l Three main openings in the diaphragm:
n aortic (strictly speaking the aortic ‘opening’ is
not in the diaphragm, but lies behind it): lies
at level of T12; transmits abdominal aorta,
thoracic duct and often the azygos vein
14 SECTION ONE ANATOMY Left phrenic
Right phrenic Left crus of
nerve the diaphragm
Right crus of the
Psoas major Quadratus lumborum
The inferior aspect of the diaphragm.
n oesophageal: lies in right crus of diaphragm at chest X-ray. Paradoxical movement of the dia-
level of T10. Transmits oesophagus, vagus phragm occurs on respiration.
nerves, and branches of the left gastric artery
and vein ANATOMY OF RESPIRATION
n IVC opening: lies at T8 level in central tendon of di- l Thoracic breathing: movements of rib cage.
aphragm. Transmits IVC and right phrenic nerve. l Abdominal breathing: contraction of diaphragm.
l Greater and lesser splanchnic nerves pierce the Thoracic breathing
l ‘Pump handle’ action of ribs. Anterior end of ribs
l Sympathetic chain passes behind the medial are raised and as these are below the posterior
arcuate ligament lying on psoas major. end, this increases the anteroposterior diameter
of the thorax.
l ‘Bucket handle’ action of ribs. Ribs 4–7 are raised. As
l Phrenic nerve (C3, 4, 5). The phrenic nerve is the centre of these ribs is normally below the anterior
the sole motor nerve supply to the diaphragm. and posterior ends, the transverse diameter of the
The sensory innervation of the central tendon chest is increased when they move upwards.
of the diaphragm is via the phrenic nerve but the
periphery of the diaphragm is supplied by the lower Abdominal breathing
six intercostal nerves.
l Muscular fibres of diaphragm contract and the
l Irritation of the diaphragm (e.g. in peritonitis or pleu- central tendon descends, increasing the vertical
risy) results in referred pain to the cutaneous area of diameter of the thorax.
supply, i.e. the shoulder tip via C4 dermatome.
l As central tendon descends it is arrested by the liver.
l Damage to the nerve (e.g. in the neck) leads to l Central tendon is now fixed and acts as the origin for
paralysis of the diaphragm. Clinical examination
reveals dullness to percussion at the base on the muscle fibres which now elevate lower six ribs.
affected side and absent breath sounds. This is
due to the diaphragm being elevated as seen on
The thorax 1 15
l Combination of thoracic and abdominal breathing l Consists of four chambers: right and left atria, right
increases all diameters of the thorax. and left ventricles.
l The negative intrapleural pressure is increased and Viewed from the front it has three surfaces and three
the lung expands. borders.
Inspiration Three surfaces:
l anterior: right atrium, right ventricle and narrow
l Quiet inspiration is a combination of thoracic and
abdominal respiration. strip of left ventricle, auricle of left atrium
l posterior (base): left ventricle, left atrium with four
l Forced inspiration (e.g. asthma) brings into action
the accessory muscles of respiration, i.e. sterno- pulmonary veins entering it
cleidomastoid, scalenes, pectoralis major, pectora- l inferior (diaphragmatic surface): right atrium with
lis minor, serratus anterior.
IVC entering it and lower part of ventricles.
Expiration Three borders:
l right: right atrium with IVC and SVC
l Elastic recoil of lung tissue and chest wall. l inferior: right ventricle and apex of left ventricle
l Forced expiration (e.g. coughing and trumpet play- l left: left ventricle, auricle of left atrium.
ing) requires use of muscles, i.e. rectus abdominis, Chambers of heart
external and internal obliques, transversus abdomi-
nis, latissimus dorsi. Right atrium
THE HEART (Fig. 1.9) l Receives blood from IVC, SVC, coronary sinus,
anterior cardiac vein.
l Roughly conical in shape, lying obliquely in the
middle mediastinum. l Crista terminalis runs between cavae—muscular
ridge separating smooth-walled posterior part of
l Attached at its base to the great vessels, otherwise atrium (derived from sinus venosus) from rougher
lies free in pericardial sac. area (due to pectinate muscles) derived from true
l Base directed upwards, backwards, to the right.
l Apex directed downwards, forwards, to the left. l The fossa ovalis (the site of the fetal foramen
ovale) is an oval depression on the interatrial
Arch of aorta Pulmonary trunk septum.
Superior vena cava
Right coronary Left pulmonary artery Right
artery Left auricle pulmonary
Right atrium Left ventricle
Small cardiac Coronary
Right ventricle Anterior descending Posterior Middle cardiac vein
(interventricular) branch interventricular
of left coronary artery
A and great cardiac vein B
The heart and great vessels in A anterior and B posterior view.
16 SECTION ONE ANATOMY
Right ventricle l The mouths of the right and left coronary arteries
are seen opening into the anterior and left posterior
l Thicker-walled than atrium. aortic sinuses respectively.
l Communicates with atrium via tricuspid valve.
l Connects with pulmonary artery via pulmonary Fibrous skeleton of the heart
valve. l AV orifice is bound together by figure-of-eight con-
l Tricuspid valve has three cusps: septal, anterior, joined fibrous ring.
posterior. l Acts as fibrous skeleton for attachment of valves
l Atrial surface of valve is smooth but ventricular and muscles of atria and ventricles.
surfaces have fibrous cords, the chordae tendinae, l Helps to maintain shape and position of heart.
which attach them to papillary muscles on the ven-
tricular wall. They prevent eversion of the cusps in Conducting system
the atrium during ventricular contraction.
l Moderator band is a muscle bundle crossing from l Sinoatrial (SA) node situated in right atrial wall at up-
the interventricular septum to the anterior wall of per end of crista terminalis (SA node ¼ pacemaker
the heart. of heart).
l Moderator band may prevent overdistension of
ventricle. Conducts right branch of the AV bundle l From SA node, cardiac impulse spreads to reach
to anterior wall of ventricle. AV node.
l Infundibulum is the outflow tract of the ventricle.
Directed upwards and to the right towards the l AV node lies in interatrial septum immediately
pulmonary trunk. above opening of coronary sinus.
l Pulmonary orifices guarded by the pulmonary valve
consisting of three semilunar cusps. l Cardiac impulse is conducted to ventricles via
AV bundle (of His).
l AV bundle passes through fibrous skeleton of heart
l Smaller than the right. to membranous part of interventricular septum
l Consists of principal cavity and auricle. where it divides into right and left branch.
l Auricle extends forwards and to the right, over-
l Left AV bundle is larger and both run under endocar-
lapping the commencement of the pulmonary dium to activate all parts of the ventricular muscle.
l Four pulmonary veins open into the cavity (two from l Papillary muscles contract first and then wall and
each lung: superior and inferior). septum in rapid sequence from apex towards out-
l Shallow depression on septal surface corresponds flow tract, both ventricles contracting together.
to fossa ovalis of right atrium.
l Largely smooth-walled, except for ridges in the l AV bundle is normally only pathway through which
auricle due to underlying pectinate muscles. impulse can reach ventricles.
Left ventricle Blood supply of heart (see Fig. 1.9)
l Longer and more conical than right with thicker wall Right coronary artery
(three times thicker).
l Arises from anterior aortic sinus.
l Communicates with atrium via mitral valve. l Passes to the right of the pulmonary trunk between
l Connects with aorta via aortic valve.
l Mitral valve has two cusps: anterior (larger) and it and the auricle.
l Runs along the AV groove around the inferior
l Chordae tendinae run from the ventricular surfaces border of the heart and anastomoses with the left
coronary artery at the posterior interventricular
of cusps to papillary muscles. groove.
l Aortic valve is stronger than pulmonary valve. Has l Branches include:
three cusps—anterior, right and left posterior— n marginal branch along the lower border of the
each having a central nodule in its free edge and heart
a sinus or dilatation in the aortic wall alongside
each cusp. n posterior interventricular (posterior descend-
ing) branch which runs forward in the inferior
interventricular groove to anastomose near
the apex with the corresponding branch of
the left coronary artery.
The thorax 1 17
Left coronary artery l Tributaries of coronary sinus:
n great cardiac vein: ascends in anterior inter-
l Arises from the left posterior aortic sinus. ventricular groove next to anterior interventri-
l Larger than the right coronary artery. cular artery
l Main stem varies in length (4–10 mm). n middle cardiac vein: drains posterior and
l Passes behind and then to the left of the pulmonary inferior surfaces of heart and lies next to the
posterior interventricular artery
trunk. n small cardiac vein: accompanies marginal artery
l Reaches the left part of the AV groove. and drains into termination of coronary sinus.
l Initially lies under cover of the left auricle where it
Nerve supply of heart
divides into two equally sized branches.
l Branches: l Sympathetic (cardio-accelerator).
l Vagus (cardio-inhibitor).
n anterior interventricular (left anterior descend-
ing): runs down to the apex in the anterior inter- Clinical point
ventricular groove supplying the wall of the
ventricles, to anastomose with the posterior l Cardiac pain is experienced not only in the chest but
interventricular artery is referred down the inner side of the left arm and up
to the neck and jaw. Cardiac pain is referred to
n circumflex: continues round the left side of the areas of the body surface which send sensory im-
heart in the AV groove to anastomose with the ter- pulses to the same level of the spinal cord that re-
minal branches of the right coronary artery. ceives cardiac sensation. The sensory fibres from
the heart travel through the cardiac plexus, sympa-
l Occlusion of the left coronary artery will lead to thetic chain and up to the dorsal root ganglia of
rapid demise. T1–4. Excitation of spinothalamic tract cells in the
upper thoracic segments contribute to the anginal
Variations pain experienced in the chest and inner aspect of
the arm via dermatomes T1–4. Cardiac vagal affer-
l Left coronary and circumflex arteries may be larger ent fibres synapse in the nucleus of the tractus soli-
and longer than usual and give off the posterior tarius of the medulla and then descend to excite
intraventricular artery before anastomosing with upper cervical spinothalamic tract cells. This inner-
right coronary artery, which is smaller than usual vation contributes to the angina pain experienced in
(known as ‘left dominance’, occurs in 10% of the area of the neck and jaw.
l Right and left coronary arteries may have equal
contribution to posterior interventricular artery Fibrous
(known as codominance, occurs in 10% of
population). Heart and roots of the great vessels are contained
within the conical fibrous pericardium.
l Left main stem may divide into three branches. The l Apex: fuses with adventitia of great vessels about
third lies between the anterior interventricular and
circumflex arteries and may be large, supplying 5 cm from the heart.
the lateral wall of the left ventricle. l Base: fuses with central tendon of the diaphragm.
l In just under 60% of the population the SA node is Relations
supplied by the right coronary artery, while in just
under 40% it is supplied by the circumflex artery. l Anterior sternum: third to sixth costal cartilages,
In 3% it has a dual supply. thymus, anterior edges of lungs and pleura.
l AV node supplied by right coronary artery in 90% l Posterior: oesophagus, descending aorta, T5–8
and circumflex in 10%. vertebrae.
Venous drainage (see Fig. 1.9) l Lateral: roots of lung, phrenic nerves, mediastinal
l Venae cordis minimae: tiny veins draining directly
into the chambers of the heart.
l Anterior cardiac veins: small, open directly into the
l Coronary sinus:
n main venous drainage
n lies in posterior AV groove
n opens into the right atrium just to the left of the
mouth of the IVC.
18 SECTION ONE ANATOMY
Serous l Inferior: line from the sixth right costal cartilage
1.2 cm from sternal edge to fifth left intercostal
l The fibrous pericardium is lined by parietal layer of space, 9 cm from midline (i.e. position of apex beat).
l Left border: curved line joining second left costal
l Parietal layer is reflected to cover the heart and cartilage 1.2 cm from sternal edge to fifth left inter-
roots of great vessels to become continuous with costal space, 9 cm from midline.
visceral layer of serous pericardium.
l Right border: curved line joining third right costal
Oblique and transverse sinuses cartilage 1.2 cm from sternal edge to sixth right
costal cartilage, 1.2 cm from sternal edge.
MEDIASTINUM (Fig. 1.11)
At the pericardial reflections, veins are surrounded by
one sleeve of pericardium and arteries by another. The space between the two pleural cavities is called
the mediastinum. It is divided into:
Transverse sinus l superior mediastinum
l anterior mediastinum
l Lies between the aorta and pulmonary trunk in l middle mediastinum
front, and the SVC and left atrium behind. l posterior mediastinum.
Oblique sinus Superior mediastinum
l Bounded by the pulmonary veins. The boundaries are:
l Forms a recess between pericardium and left atrium. l anterior: manubrium sterni
l posterior: first four thoracic vertebrae
Clinical points l above: continues up to root of neck
l below: continues with inferior mediastinum at level
l Fibrous pericardium can stretch gradually if there is
gradual enlargement of the heart. of horizontal line drawn through angle of Louis.
l Sudden increase in pericardial contents as in sudden l lower end of trachea
bleeds: stretching does not occur and cardiac func- l oesophagus
tion is embarrassed (cardiac tamponade). l thoracic duct
l aortic arch
Surface anatomy of heart l innominate artery
l part of carotid and subclavian arteries
l Superior: line from second left costal cartilage
1.2 cm from sternal edge to third right costal carti-
lage, 1.2 m from sternal edge.
Superior vena cava Aorta
Right Pulmonary trunk
pulmonary Tranverse sinus
veins Left pulmonary
Inferior vena cava Oblique sinus Fig 1.10
The posterior surface of the pericardial
cavity after removal of the heart. The
reflection of the pericardium around the
great vessels is shown.
The thorax 1 19
Angle of 1 Superior
Louis 2 mediastinum
Anterior 4 Posterior
mediastinum 5 mediastinum
Middle Diaphragm 7 Fig 1.11
mediastinum 8 The divisions of the mediastinum.
l innominate veins l above: horizontal plane drawn through the angle of
l upper part of SVC Louis
l phrenic and vagus nerves
l left recurrent laryngeal nerves l below: diaphragm.
l cardiac nerves Contents:
l lymph nodes l descending thoracic aorta
l remnants of thymus gland. l oesophagus
l vagus and splanchnic nerves
Anterior mediastinum l azygos vein
l hemiazygos vein
Boundaries are: l thoracic duct
l anterior: sternum l mediastinal lymph nodes.
l posterior: pericardium. Fig 1.12 shows some of the structures in the anterior,
Contents: middle and posterior mediastinum.
l part of the thymus gland in children
l anterior mediastinal lymph nodes. The mediastinal surfaces
Middle mediastinum (Figs 1.13 and 1.14)
Boundaries are: Because of the arrangements of structures in the
l anterior: anterior mediastinum mediastinum, it appears differently when viewed
l posterior: posterior mediastinum. from right- and left-hand sides.
l heart The angle of Louis
l great vessels
l phrenic nerves The angle of Louis (manubriosternal junction) is an
l pericardiophrenic vessels. important anatomical landmark. It corresponds to
the plane of T4 which is an important landmark. The
Posterior mediastinum following occur at T4:
l commencement and termination of aortic arch
Boundaries are: l bifurcation of trachea
l anterior: pericardium, roots of lungs, diaphragm l junction of superior and inferior mediastinum
l second costo-sternal joint
below l confluence of azygos vein with superior vena cava
l posterior: vertebral column from lower border of l thoracic duct runs from right to left
l ligamentum arteriosum lies on this plane.
fourth to twelfth vertebrae
20 SECTION ONE ANATOMY Body of sternum
Thymic residue Pulmonary trunk
mediastinal fat artery
Ascending aorta Descending aorta
Superior vena cava
Oesophagus Body of T5 vertebra Trachea
Contrast CT at the level of the fifth thoracic vertebra showing some of the structures in the anterior, middle and
Left common carotid artery
Left subclavian artery
Left vagus nerve
Arch of aorta
Left phrenic nerve
The mediastinum seen from the left
The thorax 1 21
Right vagus nerve
Azygos vein Fig 1.14
The mediastinum seen from the right side.
OSCE SCENARIOS OSCE scenario 1.2
OSCE scenario 1.1 A 35-year-old male sustains a crushing upper ab-
dominal injury in an RTA. On admission to A&E he
A 19-year-old male is admitted with a right-sided has a tachycardia of 120 and a systolic blood pres-
spontaneous pneumothorax. He has a past history sure of 90 mmHg. He is complaining of abdominal
of a treated coarctation of the aorta. He requires a and bilateral shoulder tip pain. Urgent CT scan re-
chest drain. veals liver and splenic trauma as well as a ruptured
1. Describe the anatomy of a typical intercostal left hemidiaphragm.
1. Describe the three origins of the muscular part
2. Why is this knowledge important in your of the diaphragm.
2. At what vertebral levels do the oesophagus and
technique of insertion of an intercostal drain?
3. What is the ‘triangle of safety’ when inserting a the IVC pass through the diaphragm?
3. What is the nerve supply of the diaphragm?
chest drain? 4. Explain why in some cases irritation of the
4. Explain the anatomical basis for notching of the
diaphragm may result in referred pain to the
lower border of a rib seen on a chest X-ray of a shoulder while in others it may result in referred
patient with coarctation of the aorta. pain to the abdomen.
Answers in Appendix page 449
SECTION ONE ANATOMY
The abdomen, pelvis
DEVELOPMENT l The apex of the herniated bowel is continuous with
the vitellointestinal duct into the yolk sac.
Development of the gut
l While the midgut is within the cord it rotates 90
The gut develops from a primitive endodermal tube. It counterclockwise around the axis of the superior
is divided into three parts: mesenteric artery, bringing the third and fourth
l foregut: extends to the entry of the bile duct into the parts of the duodenum across to the left of the mid-
line behind the superior mesenteric artery; this part
duodenum (supplied by the coeliac axis) of the duodenum is now fixed retroperitoneally.
l midgut: extends to distal transverse colon (supplied
l The midgut returns to the abdomen at the 10th
by superior mesenteric artery) week and during this time it continues to rotate
l hindgut: extends to ectodermal part of anal canal counterclockwise through a further 180 , bringing
the ascending colon to the right side of the abdo-
(supplied by inferior mesenteric artery). men with the caecum lying immediately below
l The caecum descends into its definitive position in
l Starts to divide into the oesophagus and the the right iliac fossa, pulling the colon with it.
laryngotracheal tube during the 4th week.
l If it fails to do so correctly, there may be pure oeso- Fig 2.1
phageal atresia (8% of cases), or atresia associated Types of oesophageal atresia. A Oesophageal atresia
with tracheo-oesophageal fistula (the commonest, with distal tracheo-oesophageal fistula—most
80% of cases), the fistula being between the lower common type, with an incidence of 80%. B Isolated
end of the trachea and the distal oesophagus oesophageal atresia—second commonest, with an
(Fig. 2.1). incidence of about 8%.
l Distal to the oesophagus the foregut dilates to form
l Rotates so that the right wall of the stomach now
becomes its posterior surface, forming the lesser
l Vagus nerves rotate with the stomach so that the right
vagus nerve becomes posterior and the left anterior.
l As the stomach rotates to the left, so the duodenum
swings to the right, its mesentery fusing with the
peritoneum of the posterior abdominal wall, leaving
all but the first inch retroperitoneal.
Midgut (Fig. 2.2)
l Enlarges rapidly in early fetal life, becoming too big
for the developing abdominal cavity, and herniates
into the umbilical cord.
Ventral mesentery The abdomen, pelvis and perineum 2 23
Liver (in the
ventral mesentery) Stomach developing from foregut
Caecum Spleen developing
in the dorsal mesentery
cord Coeliac trunk
The developing gut and mesentery seen from the left. The midgut is in the umbilical cord. The arrows
show the direction of rotation for the foregut and midgut.
l The mesenteries of the ascending and descending is not fixed at either end, and the whole of the midgut
colon blend with the posterior abdominal wall, may twist around its own blood supply, i.e. volvulus
except for the sigmoid colon, which retains a neonatorum.
mesentery. l Persistence of midgut herniation at the umbilicus
may occur after birth, i.e. exomphalos.
l In early fetal life, growth obliterates the lumen of the
developing gut. It then recanalises. If recanalisation l Rectum, anus and genitourinary tracts develop at
is incomplete, areas of atresia or stenosis may the end of the 9th week by separation of these
result. structures within the cloaca (Fig. 2.3).
l The communication between the primitive l Urorectal septum divides the cloaca into bladder
midgut and yolk sac may persist as a Meckel’s anteriorly and rectum (hindgut) posteriorly.
diverticulum. This may occasionally be attached
to the back of the umbilicus by a fibrous cord, a l Anal canal develops from the end of the hindgut
remnant of the vitellointestinal duct (this may (endoderm) and an invagination of ectoderm, the
act as fixed point for small bowel volvulus). proctodeum.
l Rarely, the Meckel’s diverticulum may open onto l At its caudal end, the urorectal septum reaches the
the skin at the umbilicus. cloacal membrane and divides it into anal and
l Malrotation occurs when the sequence described
above fails to occur or is incomplete. The duodeno- l The anal membrane separates the hindgut from the
jejunal flexure may not become fixed retroperitone- proctodeum (anal pit).
ally and hangs freely from the foregut lying to the
right of the abdomen. The caecum may also be free l Eventually the anal membrane breaks down and
and may obstruct the second part of the duodenum continuity is established between the anal pit and
because of peritoneal bands (of Ladd) passing across the hindgut.
it. The base of the mesentery is then very narrow as it
l Failure of the anal membrane to rupture or anal pit
to develop results in imperforate anus.
24 SECTION ONE ANATOMY
Allantois l Metanephros develops at the 5th week in the pelvis.
Metanephric duct arises as a diverticulum from the
Urorectal lower end of the mesonephric duct.
l Metanephric duct (ureteric bud) invaginates the
Cloaca metanephros, undergoing repeated branching to
develop into the ureter, pelvis, calyces and collect-
Common Mesonephric ing tubules.
excretory duct duct
l Collecting tubules fuse with the proximal part of the
Metanephric tubular system and glomeruli which are developing
duct from the metanephros.
Hind gut l The mesonephric duct loses its connection with the
l The kidney develops in the pelvis, eventually migrat-
The connections between cloaca (rudimentary ing upwards, its blood supply moving cranially with it,
bladder) and allantois. The urachus is the embryonic initially being from the iliac arteries and eventually
remnant of this connection. from the aorta.
The kidneys and ureter (Fig. 2.4) Development anomalies
l Pronephros develops at 3rd week; it is transient and l Failure of fusion of the derivatives of the ureteric bud
never functions. with the derivatives of the metanephros may give rise
to autosomal recessive form of polycystic kidney.
l Mesonephros develops at 4th week; this also
degenerates but its duct persists in the male to l The kidney may fail to migrate cranially, resulting in
form the epididymis and vas deferens. pelvic kidney.
Pronephros l One or more of the distal arteries may persist giving
rise to aberrant renal arteries (occasionally one may
Urogenital persist from the common iliac artery).
l The two metanephric masses may fuse in the mid-
Cloaca line, resulting in a horseshoe kidney.
Mesonephros l The ureteric bud may branch early, giving rise to
double ureter. Rarely, the extra ureter may open
Common Mesonephric ectopically into the vagina or urethra, resulting in
excretory duct urinary incontinence.
duct Metanephros l The metanephros may fail to develop on one side,
resulting in congenital absence of the kidney.
duct Bladder and urethra
Fig 2.4 Bladder
l Urinary bladder is formed partly from the cloaca and
Development of the pronephros, mesonephros,
metanephros and their ducts. partly from the ends of the mesonephric ducts.
l The anterior part of the cloaca is divided into three
n cephalic: vesicourethral
n middle: pelvic portion
n caudal: phallic portion.
l The latter two constitute the urogenital sinus.
l The ureter and mesonephric duct come to open
separately into the vesicourethral portion.
l The mesonephric duct participates in the formation
of the trigone and dorsal wall of the prostatic
l The remainder of the vesicourethral portion forms
the body of the bladder and part of the prostatic
The abdomen, pelvis and perineum 2 25
l The apex of the bladder is prolonged to the umbili- l The terminal part of the urethra develops within the
cus as the urachus (where the primitive bladder glans, which in turn develops from the genital
joins the allantois). tubercle.
Urethra Clinical points
l In the female, the whole of the urethra is derived
l Failure of fusion of the genital folds results in per-
from the vesicourethral portion of the cloaca. sistence of the urethral groove. This is known
l In the male, the prostatic part of the urethra cranial as hypospadias and occurs in varying degrees,
e.g. complete groove open or just a narrow ure-
to the prostatic utricle is derived from the vesico- thral orifice on the undersurface of the penile
urethral part of the cloaca and the incorporated shaft.
caudal ends of the mesonephric duct.
l The remainder of the prostatic urethra and the l Epispadias occurs where the dorsal wall of the
membranous urethra are derived from the urogen- urethra is partially or completely absent and is
ital sinus. due to failure of infraumbilical mesodermal de-
l The succeeding portion as far as the glans is velopment. In extensive cases this results in ecto-
formed by fusion of the genital (urethral) folds pia vesica where the trigone of the bladder and
enclosing the phallic portion of the urogenital sinus ureteric orifices are exposed on the abdominal
(Fig. 2.5). wall associated with cleft pelvis, e.g. no symphy-
folds l Develops as a mesodermal ridge on the posterior
abdominal wall medial to the mesonephros (uro-
Cloacal membrane genital ridges).
Labio-scrotal l Links with mesonephric duct which forms the epi-
swelling didymis, vas deferens and ejaculatory ducts.
A Tail l Undergoes descent from the posterior abdominal
wall to the scrotum.
Epithelial tag at
site of definitive l In the 3rd intrauterine month it lies in the pelvis.
meatus l In the 7th intrauterine month it passes down the
Glans penis inguinal canal.
l Reaches the scrotum by the end of the 8th month.
Urethral groove l Guided into scrotum by the gubernaculum, a
– hypospadias results mesenchymatous column which extends from the
if failure to close lower pole of the developing testis to the scrotal
Scrotal swelling l ‘Slides’ down into the scrotum behind a prolonga-
tion of peritoneum, i.e. the processus vaginalis.
B Anus l The processus vaginalis obliterates at birth leaving
Fig 2.5 its distal portion to cover the testis as the tunica
Development of the penis and urethra. vaginalis.
A Undifferentiated stage of development of
external genitalia. B Fusion of the urethral folds and Clinical points
penis development. The glans develops from the
genital tubercle. l Testis develops on posterior abdominal wall and
its blood supply, lymphatic drainage and nerve sup-
ply remain associated with the posterior abdominal
l The testis may descend into an ectopic position and
may be found at the root of the penis, in the peri-
neum or in the upper thigh.
26 SECTION ONE ANATOMY
Peritoneal cavity Peritoneal cavity Peritoneal cavity
Spermatic Hydrocele of
cord the cord
Testis Testes Epididymis
Types of hydrocele: A congenital, B vaginal, C hydrocele of the cord (a similar lesion exists in
the female—a hydrocele of the canal of Nuck).
l The testis may fail to descend and may be found any- Abdominal wall muscles (Fig. 2.7)
where along its course either intra-abdominally,
within the inguinal canal or at the external ring. l Abdominal wall consists of three sheets of muscle.
l Fleshy laterally and aponeurotic in front and behind.
l Processus vaginalis may fail to obliterate or may be- l As aponeuroses pass forward they ensheath the
come partially obliterated, resulting in a variety of
hydroceles (Fig. 2.6). rectus abdominis muscle.
ANTERIOR ABDOMINAL WALL Rectus abdominis
Superficial fascia of abdominal wall l Origin: 5th, 6th, 7th costal cartilages.
l Insertion: pubic crest.
l Only superficial fascia on abdominal wall. l Three tendinous intersections:
l Two layers in lower abdomen:
n level of xiphoid
n superficial fatty layer (Camper’s fascia) n level of umbilicus
n deep fibrous layer (Scarpa’s fascia). n halfway between the two.
l Superficial fascia extends onto penis and scrotum. l Tendinous intersections adhere to the anterior
l Scarpa’s fascia is attached to the deep fascia of sheath but not the posterior sheath.
thigh 2.5 cm below the inguinal ligament.
l Extends into perineum as Colles’ fascia. External oblique
l Colles’ fascia is attached to the perineal body, per-
ineal membrane, and laterally to the rami of the l Origin: outer surface of lower eight ribs.
pubis and ischium. l Insertion: linea alba, pubic crest, pubic tubercle,
Clinical points anterior half of iliac crest.
l Between anterior superior and iliac spine and pubic
l In rupture of the bulbous urethra, urine tracks into the
scrotum, perineum and penis and into abdominal tubercle, its recurved lower border forms the
wall deep to Scarpa’s fascia. It does not track into inguinal ligament.
the thigh because of the attachment of Scarpa’s l Fibres run downwards and medially.
fascia to the deep fascia of the thigh.
l An ectopic testis in the groin cannot descend any
lower into thigh because of the attachment of l Origin: lumbar fascia, anterior two-thirds of iliac
Scarpa’s fascia to the deep fascia of the thigh. crest and lateral two-thirds of inguinal ligament.
l Insertion: linea alba and pubic crest via conjoint
l Fibres run upwards and medially at right angles to
The abdomen, pelvis and perineum 2 27
Rectus abdominis muscle
External oblique Xiphisternum 6th and 7th costal cartilage
A Linea alba
External oblique Transversalis
Internal oblique fascia
The formation of the rectus sheath: A above the costal margin, B above the arcuate line, C below the arcuate line.
Transversus abdominis l The rectus sheath fuses in the midline to form the
linea alba which runs from the xiphisternum to
l Origin: deep surface of lower 6th costal cartilages pubic symphysis.
(interdigitating with diaphragm), lumbar fascia,
anterior two-thirds of iliac crest, lateral third of Clinical points
l A Spigelian hernia emerges at the lateral part of the
l Insertion: linea alba and pubic crest via the conjoint rectus sheath at the level of the arcuate line of
Nerve supply of abdominal muscles l The epigastric vessels (superior and inferior) are ap-
plied to the posterior surface of the rectus muscle.
l Rectus and external oblique supplied by lower 6th Rupture of these with violent contraction of the rec-
thoracic nerves. tus muscle leads to a rectus sheath haematoma.
l Internal oblique and transversus supplied by lower THE ANATOMY OF ABDOMINAL
6th thoracic nerves and iliohypogastric and ilio- INCISIONS
Rectus sheath (see Fig. 2.7)
l Through linea alba skirting the umbilicus.
l The lower border of the posterior aponeurotic l Excellent for routine and rapid access.
part of the sheath is marked by a crescentic line, l Linea alba virtually bloodless.
the arcuate line of Douglas (halfway between umbi-
licus and pubic symphysis).
l At this point the inferior epigastric vessels enter the
28 SECTION ONE ANATOMY
l Structures encountered: l anterior rectus sheath and tendinous inter-
n skin sections (segmental vessels enter here
n subcutaneous fat and bleeding will be encountered)
n superficial fascia (two layers in lower abdomen)
n linea alba l rectus muscle (which is retracted laterally)
n extraperitoneal fat l posterior rectus sheath
n peritoneum. l extraperitoneal fat
Subcostal (Kocher’s) n below arcuate line posterior rectus sheath con-
sists of transversalis fascia alone.
l Right side (cholecystectomy), left side (elective
splenectomy), both sides connected (kidneys: ante- Pararectus incision (Battle incision)
l Used occasionally for appendicectomy; more often
l Incision 2.5 cm below and parallel to costal margin for open insertion of peritoneal dialysis catheters
extending laterally to lateral border of rectus or (Tenckhoff catheter for continuous ambulatory peri-
further. toneal dialysis).
l Structures encountered: l Incision at lateral border of rectus below umbilical
n skin level.
n subcutaneous fat
n superficial fascia l Structures encountered:
n anterior rectus sheath n skin
n rectus abdominis n Camper’s fascia
n posterior rectus sheath n Scarpa’s fascia
n extraperitoneal fat n anterior rectus sheath
n peritoneum. n rectus muscle (retracted medially)
n posterior rectus sheath
l Ninth intercostal nerve is present in lateral part of n extraperitoneal fat
wound. Damage to it may result in weakness and n peritoneum.
atrophy of upper rectus with predisposition to inci-
sional hernia. l Extending the incision may damage nerves
entering sheath to supply rectus, with consequent
Gridiron incision (muscle-splitting) weakening of muscle.
l Used for appendicectomy. INGUINAL CANAL
l Centred on McBurney’s point (two-thirds of the way
l Oblique passage in lower abdominal wall.
along a line drawn from the umbilicus to the anterior l Passes from deep to superficial inguinal rings.
superior iliac spine). l About 4 cm long.
l Structures encountered: l Transmits the spermatic cord and ilioinguinal nerve
n skin in the male and the round ligament of the uterus and
n Camper’s fascia ilioinguinal nerve in the female.
n Scarpa’s fascia at lower end of incision
n external oblique aponeurosis Relations
n internal oblique muscle
n transversus muscle l Anteriorly:
n extraperitoneal fat n skin
n peritoneum. n Camper’s fascia
n Scarpa’s fascia
Paramedian incision n external oblique aponeurosis
n internal oblique in lateral third of canal.
l Use is declining.
l 2.5 cm lateral to and parallel to midline. l Posteriorly:
l Structures encountered: n medially: conjoint tendon
n laterally: transversalis fascia.
n above the arcuate line (of Douglas):
l skin l Above:
l superficial fascia n lower arching fibres of internal oblique and
The abdomen, pelvis and perineum 2 29
l Below: n medially: lacunar ligament (of Gimbernat); oc-
n lower recurved edge of external oblique, i.e. casionally an abnormal obturator artery runs
inguinal ligament. in close relationship to the lacunar ligament
and is in danger during surgery for femoral
Deep inguinal ring hernia.
l Defect in transversalis fascia. l Contents of femoral canal:
l Lies 1 cm above midpoint of inguinal ligament. n fat
l Immediately lateral to inferior epigastric vessels. n lymphatics
n lymph node (Cloquet’s node).
Superficial inguinal ring
l V-shaped defect in inguinal ligament. n dead space for expansion of femoral vein
l Lies above and medial to pubic tubercle. n pathway for lymphatics of lower limb to exter-
nal iliac nodes.
Surgical anatomy of hernias
l Three layers of fascia: l An indirect inguinal hernia passes through the deep
inguinal ring along the inguinal canal and into the
n external spermatic fascia from the external scrotum (if large).
l An indirect hernia is covered by the layers of the
n cremasteric fascia and cremaster from the cord.
internal oblique aponeurosis
l A direct hernia bulges through the posterior wall of
n internal spermatic fascia from the transversalis the canal medial to the inferior epigastric artery
fascia. through Hasselbach’s triangle.
l Three arteries: l Boundaries of Hasselbach’s triangle are:
n testicular artery n laterally: inferior epigastric artery
n cremasteric artery n inferiorly: inguinal ligament
n the artery to the vas. n medially: lateral border of rectus abdominis.
l Three nerves: l Distinction between direct and indirect inguinal her-
n genital branch of the genitofemoral to nia at operation depends on relationship of sac to
cremaster the inferior epigastric vessels: direct hernia is
n sympathetic nerves medial, indirect lies lateral to the artery.
n ilioinguinal nerve (actually lies on the cord and
not within it). l Clinical distinction between inguinal and femoral
hernias depends on the relationship to the pubic
l Three other structures: tubercle: inguinal hernias lie above and medially,
n vas deferens femoral hernias lie below and laterally.
n pampiniform plexus of veins
n lymphatics. l Clinical distinction between direct and indirect her-
nias can be made by reducing the hernia and apply-
FEMORAL CANAL ing pressure over the deep inguinal ring (1 cm
above the midpoint of the inguinal ligament). Pres-
l Medial compartment of the femoral sheath. sure over the deep ring should control an indirect
l Femoral sheath is prolongation of transversalis hernia when the patient coughs. If a bulge appears
medial to the point of finger pressure, then it is a
fascia anteriorly and iliacus fascia posteriorly pro- direct hernia.
longed over the femoral artery, vein and canal
(but not the nerve). l The femoral ring is narrow and the lacunar ligament
l Upper opening of femoral canal is the femoral forms a ‘sharp’ medial border. Therefore, irreduc-
ring which will just admit the tip of the little finger. ibility and strangulation are more common in a fem-
l Boundaries of the femoral ring are: oral hernia (also femoral hernias are more likely to
be of the Richter type).
n anterior: inguinal ligament (of Poupart)
n posteriorly: pectineal ligament (of Astley l In the female, the pelvis is wider and the canal
therefore larger. Femoral hernias are consequently
Cooper) more common in the female.
n laterally: femoral vein
30 SECTION ONE ANATOMY
PERITONEAL CAVITY l Peritoneal reflexions of the liver are described fur-
ther in the section on the liver (see p. 51).
l The peritoneum is the serous membrane of the
peritoneal cavity. l After enclosing the liver the peritoneum descends
from the porta hepatis as a double layer, i.e. the
l Consists of a parietal layer and visceral layer. lesser omentum.
l Visceral layer covers contained organs.
l Parietal layer lines abdominal and pelvic wall. l This then separates to enclose the stomach,
l Lined by mesothelium (simple squamous reforming again on the greater curvature, and then
loops downwards again, turning upwards and
epithelium). attaching to the length of the transverse colon,
l Divided into two cavities: a main cavity, i.e. the forming the greater omentum (Fig. 2.8).
greater sac, and a smaller cavity, the lesser sac l The lower leaf of the greater omentum continues
(omental bursa). upwards, enclosing the transverse colon as the
Greater sac of peritoneum
l At the base of the transverse mesocolon the double
l Below the umbilicus the peritoneum contains three layer divides again.
n median umbilical fold (due to obliterated l The upper leaf passes over the abdominal wall and
urachus) upwards to reflect onto the liver.
n medial umbilical fold (obliterated umbilical
artery) l The lower leaf passes downwards to cover the
n lateral umbilical fold (inferior epigastric artery). pelvic viscera and join with the peritoneum of
the anterior abdominal wall.
l Peritoneum of pelvis is continuous with that of
abdominal cavity. l The peritoneum of the posterior abdominal wall is
interrupted as it is reflected along the small bowel
l It completely encloses sigmoid colon forming from the duodenojejunal flexure to the ileocaecal
sigmoid mesocolon. junction, forming the mesentery of the small
l Applied to front and sides of upper third of
rectum. l The lines of peritoneal reflexion are shown in
l Applied to the front of the middle third of the
rectum. Liver Bare area of
l In male, reflected onto base and upper part of Stomach
bladder. Lesser sac
l In female, reflected onto upper part of posterior omentum Pancreas
vaginal wall and over posterior, upper and anterior Transverse
surface of uterus onto bladder. Greater sac mesocolon
l Between uterus and rectum is rectouterine pouch mesentery
l Peritoneum passes off lateral margins of uterus to
pelvic wall, forming broad ligaments with fallopian A longitudinal section of the peritoneal cavity,
tubes in upper border. showing the lesser and greater sacs and peritoneal
l Falciform ligament passes upwards from umbilicus
and slightly to right of midline to liver (containing the
ligamentum teres in its free edge).
l Passes into groove between quadrate lobe and left
lobe of liver.
l Traced superiorly, the two layers of the falciform lig-
ament separate: the right limb joins the upper layer
of the coronary ligament, the left forms the anterior
layer of the left triangular ligament.
l Above the umbilicus the peritoneum sweeps up-
wards and over the diaphragm to be reflected onto
the liver and the right side of the abdominal
Superior layer of the The abdomen, pelvis and perineum 2 31
Left triangular ligament
Inferior layer of the
coronary ligament Oesophagus
Cut free edge of Root of transverse mesocolon
lesser omentum Root of mesentery
Second part of duodenum Sigmoid mesocolon
Fourth part of duodenum Rectum
The posterior abdominal wall. The lines of reflexion of the peritoneum are shown. The liver, stomach,
spleen and intestines have been removed.
Lesser sac (omental bursa) T12
Relations IVC Aorta
Foramen of Winslow
l Anteriorly: lesser omentum and stomach.
l Superiorly: superior recess whose anterior border is Portal vein
the caudate lobe of the liver.
l Inferiorly: projects downwards to transverse
l To the left: spleen, gastrosplenic and lienorenal
l To the right: opens into the greater sac via the
Epiploic foramen (Foramen Common bile Hepatic artery
of Winslow; Fig. 2.10) duct
l Anteriorly: free edge of lesser omentum containing Free edge of
bile duct to the right, hepatic artery to the left and lesser omentum
portal vein behind.
l Posteriorly: IVC.
l Inferiorly: first part of duodenum. A transverse section through the foramen of
l Superiorly: caudate process of the liver. Winslow (epiploic foramen).
Clinical points SUBPHRENIC SPACES
l The hepatic artery can be compressed between fin- l Potential spaces below liver in relation to diaphragm,
ger and thumb in the free edge of the lesser omentum which may be site of collections or abscesses (sub-
(Pringle’s manoeuvre). Useful if cystic artery is torn phrenic abscesses).
during cholecystectomy or if there is gross haemor-
rhage following liver trauma. l Two spaces are directly subphrenic, the other two
spaces are subhepatic.
32 SECTION ONE ANATOMY
l Right and left subphrenic spaces lie between the Psoas major
diaphragm and liver and are separated by the
falciform ligament. Psoas major is a massive fusiform muscle extending
from the lumbar region of the vertebral column across
l Right subhepatic space (renal well of Rutherford the pelvic brim and under the inguinal ligament to the
Morrison) is bounded by: thigh.
n above: liver with attached gall bladder l Origin: transverse processes of all lumbar vertebrae
n behind: posterior abdominal wall and kidney
n below: duodenum. and the sides of the bodies and intervening discs
from T12– L5 vertebrae.
l The left subhepatic space is the lesser sac. l Insertion: into the tip of the lesser trochanter of the
Clinical points l Nerve supply: L2, L3.
l Action: flexion and medial rotation of extended
l Subphrenic abscesses may result from perforated thigh.
peptic ulcers, perforated appendicitis, perforated l Important relations of psoas include:
n psoas sheath enclosing muscle and extending
l On the right side, infected fluid tracks along the right beneath inguinal ligament
paracolic gutter into the right subhepatic space
when the patient is recumbent. n lumbar nerves forming lumbar plexus in sub-
stance of muscle
l The left subhepatic space (lesser sac) may dis-
tend with fluid with perforated posterior gastric n important structures lie on it, such as ureter,
ulcer or acute pancreatitis (pseudocyst of the gonadal vessels, IVC
n tendon lies in front of hip joint with bursa inter-
l Most subphrenic abscesses are drained percutane- vening and lies directly behind femoral artery
ously nowadays under ultrasound or computerised
tomography (CT) control. n a retrocaecal or retrocolic appendix lying
l If surgery is required, posterior abscesses can be
accessed by an incision below or through the bed Quadratus lumborum
of the 12th rib; anterior abscesses can be accessed
by an incision below and parallel to the costal l Origin: iliolumbar ligament and adjacent portion of
margin. iliac crest.
POSTERIOR ABDOMINAL WALL l Insertion: medial half of lower border of 12th rib and
by four small tendons into the transverse processes
The posterior abdominal wall is made up of bony and of the upper four lumbar vertebrae.
muscular structures. The bones are:
l bodies of the lumbar vertebrae l Anterior relations of quadratus lumborum include:
l the sacrum n colon
l the wings of the ilium. n kidney
The muscles are: n subcostal, iliohypogastric, ilioinguinal nerve lie
l the posterior part of the diaphragm in front of the fascia covering it.
l psoas major
l quadratus lumborum Iliacus
Important structures on the posterior abdominal wall l Origin: greater part of iliac fossa extending onto
l abdominal aorta
l inferior vena cava (IVC) l Insertion: lateral aspect of tendon of psoas major
l kidneys onto lesser trochanter of femur.
l suprarenal glands
l lumbar sympathetic chain. l Nerve supply: branch of femoral nerve (L2, L3).
The diaphragm has been described in the section on
the thorax, and the kidneys and suprarenal glands are Clinical points
dealt with elsewhere in this chapter.
l Femoral artery lies on psoas tendon and can be pal-
pated and compressed against it at this point.
l Psoas sheath is attached around origin of psoas
major. Pus from tuberculous infection of the lumbar
vertebra may track down the sheath and present as
a swelling below the inguinal ligament (psoas
The abdomen, pelvis and perineum 2 33
l An inflamed retrocaecal or retrocolic appendix lies n renal artery
in contact with psoas—the resulting spasm in the n gonadal artery.
muscle leads to persistent flexion of the hip, and l Paired branches to the parietes:
pain on attempted extension (psoas test). n inferior phrenic arteries
n four lumbar arteries.
ABDOMINAL AORTA (Fig. 2.11) l Terminal branches:
n common iliac arteries
l Extends from 12th thoracic vertebra to left side of n median sacral artery.
front of body of fourth lumbar vertebra where it
divides into the common iliac arteries. Common iliac artery
l Enters abdomen between crura of diaphragm lying l Arises at bifurcation of aorta at level of body of
throughout its course against the vertebral bodies. fourth lumbar vertebra.
l Relations: l Bifurcates at level of sacroiliac joint into internal and
n anterior from above down: lesser omentum, external iliac artery.
stomach, coeliac plexus, pancreas, splenic
vein, left renal vein, third part of duodenum, l Anterior relations:
root of mesentery, coils of small intestine, n peritoneum
aortic plexus, peritoneum n small intestine
n posterior: bodies of upper four lumbar vertebra, n ureters
left lumbar veins, cisterna chyli n sympathetic nerves.
n right side: IVC, thoracic duct, azygos vein, right
sympathetic trunk l Differences between right and left common iliac
n left side: left sympathetic trunk. arteries:
n right common iliac artery is the longer, the
The branches of the aorta are: aorta being on the left side of the spine
l Anterior unpaired branches passing to the viscera: n on the right side lie the IVC and right psoas
n right common iliac vein is at first behind but to
n coeliac axis: giving off the hepatic artery, the right at upper part
splenic artery, left gastric artery n left common iliac vein crosses behind right
common iliac artery
n superior mesenteric artery n left common iliac artery is crossed anteriorly by
n inferior mesenteric artery. inferior mesenteric artery
l Lateral paired branches: n left common iliac vein is below and medial to
n suprarenal artery left common iliac artery.
Aorta Splenic artery
Coeliac axis Spleen
Common hepatic artery
Right renal artery Left common iliac artery
Superior mesenteric artery
Right external iliac artery
Right internal iliac artery
Left femoral artery
MRA showing the main branches of the abdominal aorta.
34 SECTION ONE ANATOMY
External iliac artery l right renal vein
l left renal vein
l Runs along brim of pelvis on medial side of psoas l right suprarenal vein
major. l phrenic vein
l hepatic vein.
l Passes below the inguinal ligament to form the
femoral artery. Lumbar sympathetic chain
l Gives off inferior epigastric artery immediately l Commences deep to the medial arcuate ligament of
before passing below the inguinal ligament. the diaphragm as a continuation of the thoracic
Internal iliac artery
l Lies against the bodies of the lumbar vertebrae
l Passes backwards and downwards into the pelvis overlapped on the right side by the inferior vena
between ureter anteriorly and internal iliac vein cava and on the left side by the aorta.
l The lumbar arteries lie deep to the chain but the
l At upper border of greater sciatic notch divides into lumbar veins may cross superficial to it.
anterior and posterior branch.
l Below the chain passes deep to the iliac vessels
l Branches supply: to continue as the sacral trunk in front of the
n pelvic organs sacrum.
n buttock l Inferiorly the right and left chain converge and unite
n anal canal. in front of the coccyx to end in the ganglion impar.
Inferior vena cava l Branches from the sympathetic chain pass as
l Formed by junction of two common iliac veins n to the plexuses around the abdominal aorta
behind the right common iliac artery at the level n to the hypogastric plexus (presacral nerves) to
of the fifth lumbar vertebra. supply the pelvic viscera via plexuses of nerves
distributed along the internal iliac artery and its
l Lies to the right of the aorta as it ascends. branches.
l Separated from aorta by right crus of diaphragm
when aorta passes behind the diaphragm.
l IVC passes through diaphragm at level T8, traverses l Resection of abdominal aortic aneurysm and
extensive pelvic dissection may remove aortic
the pericardium and drains into the right atrium. and hypogastric plexuses and hence compromise
l Anterior relations include: ejaculation.
n mesentery l Lumbar sympathectomy may be carried out for
n third part of duodenum plantar hyperhidrosis or vasospastic conditions of
n pancreas the lower limb. Usually the 2nd, 3rd and 4th ganglia
n first part of duodenum are excised with the intermediate chain.
n portal vein
n posterior surface of liver PELVIC FLOOR AND WALL
n from above down the following arteries: hepatic, The muscles of the pelvic floor and wall comprise:
right testicular, right colic, right common iliac.
l Posterior relations include: n levator ani
n vertebral column l Pelvic wall:
n right crus of diaphragm and psoas major n piriformis (on the front of the sacrum)
n right sympathetic trunk n obturator internus (on the lateral wall of the true
n right renal artery
n right lumbar arteries pelvis).
n right suprarenal arteries Piriformis and obturator internus act on the
n right inferior phrenic artery femur and are described with the muscles of
n right suprarenal gland the lower limb.
n to the left: the aorta.
The IVC receives the following tributaries:
l lumbar branches
l right gonadal vein
The abdomen, pelvis and perineum 2 35
External anal sphincter
Median fibrous raphe Coccygeus
Fig 2.12 Actions
Levator ani viewed from below. l Acts as principal support of pelvic floor.
l Supports pelvic viscera and resists downwards
pressure of abdominal muscles.
The levator ani muscles arise from the side wall of l Has a sphincter action on the rectum and vagina.
the pelvis and are thin sheets of muscle which meet l Assists in increasing intra-abdominal pressure dur-
in the midline and close the greater part of the outlet
of the pelvis (posterior part of the pelvic diaphragm) ing defecation, micturition and parturition.
l Back of body of pubis. l Small triangular muscle behind and in the same
l Spine of ischium. plane as levator ani.
l Between these from the fascia covering obturator
internus along a thickening between the above l Spine of ischium.
Insertion l Side of coccyx and lowest part of sacrum.
l Forms a sling around the prostate (levator prosta- l Muscle has same attachments as sacrospinous
tae) or vagina (sphincter vaginae) inserting into ligament.
the perineal body.
l Forms a sling around the rectum and anus inserting Nerve supply
into and reinforcing the deep part of the anal l Perineal branch of S4.
sphincter at the anorectal ring (puborectalis).
l Into the sides of the coccyx and to a median fibrous Action
raphe stretching between the apex of the coccyx l Holds the coccyx in its natural forwards position.
and the anorectal junction.
l Perineal branch of S4 on pelvic surface, and branch l Parietal pelvic fascia is a strong membrane covering
the muscles of pelvic wall and is attached to bones
of the inferior rectal and perineal division of the at margins of muscles.
pudendal on the perineal surface.
36 SECTION ONE ANATOMY
l Visceral pelvic fascia is loose and cellular over mov- l The deep perineal pouch encloses the external
able structures, e.g. levator ani, bladder, rectum. urethral sphincter.
l It is strong and membranous over fixed or non- l Below the external urethral sphincter is the peri-
distensible structures, e.g. prostate. neal membrane, while above is an indefinite layer
of fascia, i.e. the superior fascia of the urogenital
The perineum comprises: l In the male, the deep perineal pouch contains the
l The anterior (urogenital) perineum. bulbourethral glands (of Cowper) whose ducts
l The posterior (anal) perineum. pierce the perineal membrane to open into the
Urogenital triangle (the anterior
perineum) l The pouch also contains the deep transverse peri-
l Triangle formed by the ischiopubic inferior rami and
a line joining the ischial tuberosities which passes l Superficial to the perineal membrane is the super-
just in front of the anus (Fig. 2.13). ficial perineal pouch.
l The perineal membrane (the inferior fascia of the Superficial perineal pouch
urogenital diaphragm) is a strong fascial sheath
attached to the sides of this triangle. In the male, this contains:
l The bulb of the penis which is attached to
l The perineal membrane is pierced by:
n urethra in the male the undersurface of the perineal membrane;
n urethra and vagina in the female. bulbospongiosus muscle covers the corpus
l Deep to the perineal membrane is the external ure- l The crura of the penis which are attached at
thral sphincter composed of striated muscle fibres the angle between the insertion of the perineal
which surrounds the membranous urethra. membrane and ischiopubic rami; each crus is
surrounded by an ischiocavernous muscle.
Corpus cavernosum Ischiocavernosus
Corpus spongiosum Bulbospongiosus
Crus of penis
Bulb of penis
Superficial transverse Levator ani
perineal muscle External anal sphincter
The male perineum viewed from below. On the right side the muscles have been removed to display
the crus and bulb of the penis.
Crus of the clitoris The abdomen, pelvis and perineum 2 37
Bartholin’s gland Urethra
Superficial transverse External anal sphincter
perineal muscle Levator ani
The female perineum. On the right side the muscles have been removed to display the bulb of the
vestibule and Bartholin’s glands.
l Superficial transverse perineal muscle running Ischiorectal fossa
transversely from the perineal body to the ischial
ramus. This is a space between the anal canal and side wall of
l The same muscles are present in the female but are l Its boundaries are:
less well developed (Fig. 2.14).
n medially: fascia over levator ani and the exter-
Perineal body nal anal sphincter
l Fibromuscular nodule lying in the midline between n laterally: fascia over obturator internus
anterior and posterior perineum. n anteriorly: extends forwards as a prolongation
l Attached to it are: deep to the urogenital diaphragm
n anal sphincter n posteriorly: limited by the sacrotuberous liga-
n levator ani
n bulbospongiosus ments and the origin of gluteus maximus from
n transverse perineal muscles. this ligament.
l Floor is formed from skin and subcutaneous fat.
l Important site of insertion of levator ani; tearing of l Contains mainly fat and is crossed by the inferior rec-
perineal body during childbirth will considerably tal vessels and nerves from lateral to medial side.
weaken the pelvic floor. l The internal pudendal vessel and pudendal nerve lie
on the lateral wall of the fossa in the pudendal canal
The posterior (anal) perineum (of Alcock), a tunnel of fascia which is continuous
with the fascia overlying obturator internus.
l Triangular area lying between the ischial tuberosi-
ties on each side and the coccyx. Clinical points
l It contains the following: l Infection of the ischiorectal space may occur from boils
n anus and its sphincters or abscesses on the perianal skin, from lesions within
n levator ani the rectum and anal canal, from pelvic collections
n ischiorectal fossa. bursting through levator ani.
38 SECTION ONE ANATOMY
l The fossae communicate with one another behind Corpus spongiosum
the anus, allowing infection to pass readily from l Commences at the perineal membrane by an
one fossa to another.
enlargement, i.e. the bulb.
l The pudendal nerves can be blocked in Alcock’s l Runs forward in the groove on the under surface
canal on either side, giving regional anaesthesia
in forceps delivery. of the corpora cavernosa, expanding over their
extremities to form the glans.
Penis l The bulb lies below the perineal membrane and is
surrounded by the bulbospongiosus muscle.
The penis is divided into: l The urethra pierces the bulb on its upper surface
l Root. and runs forwards in the middle of the corpus
l Body. spongiosum.
l The root is attached at:
n perineal membrane The male urethra is 20 cm long and is divided into:
n the pubic rami by two strong processes, the crura l prostatic urethra
n the symphysis pubis by the suspensory ligament. l membranous urethra
l spongy urethra.
l Forms the extremity of the penis.
l At its summit is the opening of the urethra—the l Passes through the prostate gland from base to
l Passing from the lower margin of the glans is a fold l 3 cm long.
l Bears the urethral crest on the posterior wall on each
of mucous membrane continuous with the prepuce
called the frenulum. side of which is the shallow depression, the prostatic
l At the base of the glans is a projecting edge or sinus, into which 15–20 prostatic ducts empty.
corona, behind which is a constriction. l In the centre of the urethral crest is a prominence
l The skin of the penis is attached to the neck of the (verumontanum) into which opens the prostatic
glans and doubles up on itself forming the prepuce utricle.
or foreskin. l The ejaculatory ducts formed by the union of the
duct of the seminal vesicle and the terminal part
Body of the vas deferens open on either side of the
l Part of the penis between the root and glans. The
body comprises: Membranous urethra
n corpora cavernosa
n corpus spongiosum. l 2 cm in length.
l Contained between perineal membrane and pelvic
l Placed dorsally. fascia.
l Connected together in anterior three-quarters with l Surrounded by and pierces the external sphincter
septum of penis intervening. urethrae.
l Separated behind to form the two crura which are
attached along the medial margins of the ischial
and pubic rami. l 15 cm long.
l Anteriorly, the corpora cavernosa fit into the base of l Traverses corpus spongiosum of penis.
the glans. l Passes upwards and forwards to lie below pubic
l There is a groove on the upper surface for the dorsal
vein of the penis and another groove on the lower symphysis and then in flaccid state, bends down-
surface for the corpus spongiosum. wards and forwards.
l Corpora cavernosa are attached to the pubic l The ducts of the bulbourethral glands open on its floor.
symphysis by the suspensory ligament. l The urethral canal enlarges just behind the external
meatus, i.e. the fossa navicularis.
The abdomen, pelvis and perineum 2 39
l The lumen of this part of the urethra is transverse n free extremity or glans is formed by the corpus
except at its meatus (narrowest part) where it is spongiosum.
vertical, hence the spiral stream of urine.
l The greater vestibular glands (Bartholin’s glands):
Clinical points n analogous to bulbourethral glands in male
n pea-sized mucus-secreting glands lying deep
l Where the urethra passes beneath the pubis, it may to the posterior part of the labia majora
be ruptured by a fall astride a sharp object which n ducts open on the labia minora external to the
crushes it against the edges of the symphysis. hymen
n impalpable when healthy but obvious and pal-
Female urethra pable when inflamed or distended
n each gland is overlapped by the bulb of the
l 4 cm long. vestibule, a mass of erectile tissue equivalent
l Traverses the sphincter urethrae and lies immedi- to bulbospongiosus of the male
n this erectile tissue passes forward under cover
ately in front of the vagina. of bulbospongiosus around the sides of the
l Its external meatus opens 2.5 cm behind the clitoris vagina to the root of the clitoris.
and between the labia minora.
THE VULVA SCROTUM
The vulva is the term applied to the female external l Contains the testicles suspended by the spermatic
l The mons pubis is the eminence in front of the pubis
l The skin shows a median raphe.
covered in hair. l A fibrous septum divides the scrotum into two
l The labia majora:
n two prominent folds extending from the mons l The left cavity is longer than the right, the left testicle
to the perineum
n externally covered with hair and skin, internally l Skin is thin, pigmented, rugose and contains
with mucous membrane
numerous sebaceous glands.
n they are the equivalent of the male scrotum. l The subcutaneous tissue is devoid of fat but
l The labia minora:
contains the dartos muscle.
n lie between the labia majora as lips of soft skin
which meet posteriorly in a sharp fold at the Clinical points
l Scrotal subcutaneous tissue is continuous with the
n surround the clitoris, the upper fold forming the fascia of the abdominal wall and perineum; extra-
prepuce of the clitoris, the lower ones attached vasation of urine or blood deep to this plane
to the glans, being the frenulum of the clitoris. gravitates into the scrotum, hence frequent
bruising of scrotum following hernia repair.
n area enclosed by the labia minora l Tissues of scrotum are extremely lax and because
n contains the urethral orifice which lies immedi- of its dependent position it fills with oedema fluid in
ately behind the clitoris cardiac or renal failure.
n contains the vaginal orifice.
TESTIS AND EPIDIDYMIS
l Vaginal orifice:
n guarded in the virgin by a thin mucosal fold— l Each testis is ovoid, measuring 4 cm from upper to
the hymen lower pole, 3 cm anteroposteriorly and 2.5 cm from
n hymen is perforated to allow menstruation medial to lateral surface.
n following childbirth, the only remnants of the
hymen are a few tags named the carunculae l Left testis lies at a lower level than the right within
myrtiformes. the scrotum.
l Clitoris: l Covered by a fibrous white capsule, the tunica
n corresponds somewhat in structure to the penis albuginea.
n contains two corpa cavernosa attached to the
40 SECTION ONE ANATOMY
l Covering this is a double serous membrane into Coverings of the testis
which the testis became invaginated in fetal life,
i.e. the tunica vaginalis testis. In the surgical approach to the testis via the scrotum
the following structures are encountered:
l Septae pass from the tunica albuginea dividing the l scrotal skin
testis into lobules, each lobule containing one to l dartos muscle
three tightly coiled tubules, i.e. the seminiferous l external spermatic fascia
tubules, in which sperm is produced. l cremaster muscle in cremasteric fascia
l internal spermatic fascia
l Testes lie outside the body because spermatogene- l parietal layer of tunica vaginalis
sis requires a temperature below that of the body. l once the parietal layer of the tunica vaginalis has been
Failure of the testes to descend properly leads to a
malfunction in spermatogenesis and relative incised, the visceral layer of the tunica vaginalis is
infertility. seen covering the white tunica albuginea.
l At the hilum of the testis, the seminiferous tubules Clinical points
drain into an irregular series of ducts called the
rete testis from which afferent tubules arise, transport- l The testis arises at the level of L2/3 on the posterior
ing the sperm into the head of the epididymis. abdominal wall. In its development it takes its vas-
cular supply, lymphatic supply and nerve supply
l Epididymis lies along posterior border of testis to its from this region; hence lymphatic drainage is to
lateral side. the para-aortic nodes and pain from the kidney
may radiate down to the scrotum and conversely
l Epididymis divided into head, body and tail testicular pain may radiate to the loin.
l A rapidly developing varicocele may be a presenting
l Medially, there is a distinct groove, the sinus epidid- sign of tumour of the left kidney; tumour invades the
ymis, between it and the testis. left renal vein and blocks the drainage of the left
testicular vein into the left renal vein.
l The epididymis is covered by the tunica vaginalis
except at its posterior margin which is free. l Congenital anomalies of descent of the testis are
explained under embryology at the beginning of this
l Sperm passes from the epididymis through the vasa chapter.
which join with the seminal vesicles prior to forming
the common ejaculatory ducts. VAS DEFERENS (DUCTUS
l Testis and epididymis each may bear, at their upper
extremities, a small stalked body named respec- l Commences at the inferior pole of the testis as the
tively the appendix testis and the appendix epidid- continuation of the epididymis.
ymis (hydatid of Morgagni).
l Approximately 45 cm long.
Blood supply l Thick muscular tube, which transports sperm from
l Testicular artery arising from the aorta at the level of the epididymis to the ejaculatory ducts within the
the renal vessels. prostate gland.
l Passes through the scrotum and inguinal canal, and
l Testicular artery anastomoses with artery to vas comes to lie on the lateral wall of the pelvis.
(which supplies the vas deferens and epididymis) l At this point, lies immediately below the peritoneum
which arises from the inferior vesical branch of of the lateral wall of the pelvis.
the internal iliac artery. l Then runs towards tip of ischial spine.
l Turns medially to base of bladder.
l Anastomosis between these two arteries means l Vas ends by uniting with the ducts of the seminal
that ligation of the testicular artery is not necessarily vesicles to become the common ejaculatory duct.
followed by testicular atrophy. l This occurs at the most superior and posterior
aspect of the prostate gland.
l Venous drainage is via the pampiniform plexus of l The common ejaculatory duct traverses the
veins which usually becomes a single vessel, the prostate to open into the prostatic urethra at the
testicular vein, at the deep inguinal ring. verumontanum on either side of the utricle.
l Right testicular vein drains into the IVC; the left into
the left renal vein.
l Accompany testicular veins to drain into para-aortic
The abdomen, pelvis and perineum 2 41
ABDOMINAL VISCERA cricoid cartilage to the cardiac orifice of the stomach. It
is about 25 cm long. It has three parts:
The relationships of abdominal viscera to one another l cervical
in the upper abdomen are shown in Figures 2.15 l thoracic
and 2.16. l abdominal.
Although only a small part of this is contained within the l Passes downwards and slightly to left.
abdominal cavity, it will be dealt with here in its entirety. l Anterior relations:
The oesophagus extends from the lower border of the
n thyroid gland.
Duodenum Transverse colon
Hepatic artery Superior
Portal vein artery
Inferior vena cava Aorta
Right suprarenal Diaphragm
Right crus of vein
diaphragm Superior mesenteric
Fig 2.15 Jejunum
CT scan passing through the body of the 11th thoracic vertebra.
Left renal vein
Head of pancreas
Body of L2 vertebra
Right renal vein
Inferior vena cava
CT scan passing through the body of the second lumbar vertebra.