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A etus at 28 weeks (7th month) reveals the processus vaginalis and testis passing by way of the inguinal canal. In a new child inant, obliteration o the stalk o the processus vaginalis has occurred. The stays o the processus vaginalis have ormed the tunica vaginalis o the testis. At 2 months, the undierentiated gonads (primordial ovaries) are situated on the dorsal belly wall. The processus vaginalis (not shown) passes through the stomach wall, orming the inguinal canal on each side as within the male etus. The spherical ligament passes through the canal and attaches to the subcutaneous tissue o the labium majus. In the mature emale, the processus vaginalis has degenerated, but the round ligament persists and passes via the inguinal canal. Consequently, increases in intra-abdominal pressure act on the inguinal canal, orcing the posterior wall o the canal against the anterior wall and strengthening this wall, thereby reducing the likelihood o herniation till the pressures overcome the resistant eect o this mechanism. Simultaneously, contraction o the external indirect approximates the anterior wall o the canal to the posterior wall. It additionally will increase rigidity on the medial and lateral crura, resisting enlargement (dilation) o the supercial inguinal ring. Contraction o the musculature that orms the lateral half o the arcades o the inner oblique and transversus abdominis muscle tissue makes the roo o the canal descend, constricting the canal. The spermatic twine begins on the deep inguinal ring lateral to the inerior epigastric vessels, passes by way of the inguinal canal, exits on the supercial inguinal ring, and ends within the scrotum on the posterior border o the testis. Fascial coverings derived rom the anterolateral abdominal wall throughout prenatal growth encompass the spermatic wire. The coverings o the spermatic wire embody the ollowing: Internal spermatic ascia: derived rom the transversalis ascia. Anterolateral Abdominal Wall 429 Cremasteric ascia: derived rom the investing ascia o both the supercial and deep suraces o the interior oblique muscle. External spermatic ascia: derived rom the external indirect aponeurosis and its investing ascia. The cremasteric ascia accommodates loops o cremaster muscle, which is ormed by the lowermost ascicles o the interior oblique muscle arising rom the inguinal ligament. The cremaster muscle refexively attracts the testis superiorly in the scrotum, particularly in response to chilly. In a heat surroundings, such as a sizzling bath, the cremaster relaxes and the testis descends deeply within the scrotum. Both responses occur in an try to regulate the temperature o the testis or spermatogenesis (ormation o sperms), which requires a constant temperature approximately one diploma cooler than core temperature, or during sexual activity as a protecting response. The cremaster typically acts coincidentally with the dartos muscle, easy muscle o the at-ree subcutaneous tissue o the scrotum (dartos ascia), which inserts into the skin, helping testicular elevation because it produces contraction o the skin o the scrotum in response to the identical stimuli. The cremaster muscle is innervated by the genital department o the genitoemoral nerve (L1, L2), a derivative o the lumbar plexus. The cremaster is striated muscle receiving somatic innervation, whereas the dartos is smooth muscle receiving autonomic innervation. Coverings corresponding to those o the spermatic wire are indistinct along the spherical ligament. Pampiniorm venous plexus: a community ormed by as much as 12 veins that converge superiorly as right or let testicular veins. Arterial supply and lymphatic drainage o the testis and scrotum; innervation o the scrotum. The lumbar plexus provides innervation to the anterolateral aspect o the scrotum; the sacral plexus offers innervation to the postero-inerior aspect. Vestige o processus vaginalis: could additionally be seen as a brous thread in the anterior half o the spermatic twine extending between the abdominal peritoneum and the tunica vaginalis; it is most likely not detectable. It includes solely vestiges o the decrease part o the ovarian gubernaculum paralleled by remnants, i any, o the obliterated processus vaginalis.

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The subperitoneal space between the parietal and visceral pelvic ascias is occupied with atty endopelvic ascia. This ascial matrix has loose areolar portions, occupying potential spaces, and condensed fbrous tissue, surrounding neurovascular buildings in transit to the viscera while also tethering (supporting) the viscera. The two portions o endopelvic ascia are indistinct in appearance but have distinctly dierent textures. The main ascial condensations orm the hypogastric sheaths alongside the posterolateral pelvic partitions. As these ascial sheaths extend toward the viscera, three laminae are ormed, including the lateral ligament o the bladder anteriorly and the lateral rectal ligaments posteriorly. In emales, the middle lamina is the cardinal ligament that passively supports the vagina and uterine cervix, while conveying their neurovasculature. The somatic nerves lie laterally (adjacent to the walls), with the vascular buildings medial to them. Pelvic lymph nodes are largely clustered around the pelvic veins, the lymphatic drainage oten paralleling venous fow. In dissecting rom the pelvic cavity towards the pelvic walls, the pelvic arteries are encountered rst, ollowed by the associated pelvic veins, and then the somatic nerves o the pelvis. Six major arteries enter the lesser pelvis o emales: the paired inner iliac and ovarian arteries and the unpaired median sacral and superior rectal arteries. Each inside iliac artery, approximately 4 cm long, begins as the frequent iliac artery and biurcates into the inner (continued on p. Generally, the pelvic veins lie between the pelvic arteries (which lie medially or internally) and the somatic nerves (which lie laterally or externally). The origins, courses, and distribution o the arteries and the arterial anastomoses ormed are described in Table 6. The ureter crosses the common iliac artery or its terminal branches at or immediately distal to the biurcation. The inner iliac artery is separated rom the sacro-iliac joint by the inner iliac vein and the lumbosacral trunk. It descends posteromedially into the lesser pelvis, medial to the exterior iliac vein and obturator nerve and lateral to the peritoneum. Although variations are common, the inner iliac artery often ends on the superior edge o the greater sciatic oramen by dividing into anterior and posterior divisions (trunks). The branches o the anterior division o the interior iliac artery are mainly visceral. Beore birth, the umbilical arteries are the main continuation o the internal iliac arteries, passing alongside the lateral pelvic wall and then ascending the anterior belly wall to and thru the umbilical ring into the umbilical twine. Prenatally, the umbilical arteries conduct oxygen- and nutrient-decient blood to the placenta or replenishment. When the umbilical twine is minimize, the distal parts o these vessels no longer unction and turn out to be occluded distal to branches that cross to the bladder. The ligaments increase olds o peritoneum (medial umbilical olds) on the deep surace o the anterior belly wall (see Chapter 2, Back). Postnatally, the patent elements o the umbilical arteries run antero-ineriorly between the urinary bladder and the lateral wall o the pelvis. It runs anteroineriorly on the obturator ascia on the lateral wall o the pelvis and passes between the obturator nerve and vein. Within the pelvis, the obturator artery gives o muscular branches, a nutrient artery to the ilium, and a pubic branch. Anterior divisions o the inner iliac arteries usually provide most o the blood to pelvic buildings. In a standard variation (20%), an aberrant or accent obturator artery arises rom the inerior epigastric artery and descends into the pelvis alongside the standard route o the pubic branch. The extrapelvic distribution o the obturator artery is described with the decrease limb (Chapter 7). In emales, it may occur-with nearly equal requency-as a separate department o the inner iliac artery or as a department o the uterine artery.

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Because the unsupported facet o the hip tends to drop in the course of the swing phase (which would negate the eect o limb shortening), abductor muscular tissues on the supported aspect contract strongly during the single assist half o the stance section. The same muscle tissue additionally rotate (advance) the contralateral facet o the pelvis orward, concurrent with the swing o its ree limb. Primarily, the hip is passively prolonged by momentum during stance, besides when accelerating or strolling ast, and becomes increasingly energetic with improve in slope (steepness) throughout walking uphill or upstairs. The invertors and evertors o the oot are principal stabilizers o the oot during the stance section. Their long tendons, plus those o the fexors o the digits, additionally help support the arches o the oot during the stance phase, assisting the intrinsic muscles o the only. Modication o the form o the emur essential or bipedal walking and operating (specically the "bending" o the bone, creating the angle o inclination and the trochanters) permits the superior placement o the abductors o the thigh into the gluteal region. The remaining thigh muscles are organized into three compartments by intermuscular septa that pass deeply between the muscle teams rom the inner surace o the ascia lata to the linea aspera o the emur. The compartments are anterior or extensor, medial or adductor, and posterior or fexor, so named on the basis o their location or action at the knee joint. Generally, the 704 Chapter 7 Lower Limb anterior group is innervated by the emoral nerve, the medial group by the obturator nerve, and the posterior group by the tibial portion o the sciatic nerve. Although the compartments range in absolute and relative dimension relying on the extent, the anterior compartment is the most important general and contains the emur. To acilitate continuity and ollow an method commonly used in dissection courses, the anterior and medial compartments o the thigh are addressed initially, ollowed by steady examination o the posterior aspect o the proximal limb: gluteal area and posterior thigh. Anterior Thigh Muscles the massive anterior compartment o the thigh contains the anterior thigh muscles, the fexors o the hip. Damage to one or more o the listed spinal twine segments, or to the motor nerve roots arising rom them, ends in paralysis o the muscular tissues concerned. Femoral nerve (L2, L3, L4) Extend leg at knee joint; rectus emoris additionally steadies hip joint and helps iliopsoas ex thigh. It oten seems to be composed 1 Because o its anterior position, the tensor asciae latae is oten studied with the anterior thigh muscle tissue or comfort. The iliopsoas, the chie fexor o the thigh, is the most powerul o the hip fexors with the longest range. Its broad lateral half, the iliacus, and its long medial part, the psoas main, come up rom the iliac ossa and lumbar vertebrae, respectively. It is in a novel position not 706 Chapter 7 Lower Limb only to produce movement but to stabilize (xate). Concentric contraction o the iliopsoas typically moves the ree limb, producing fexion on the hip to lit the limb and provoke its orward swing during strolling. Bilateral contraction o the iliopsoas muscles initiates fexion o the trunk at the hip on the xed thigh-as when (incorrectly) doing sit-ups-and decreases the lumbar lordosis (curvature) o the vertebral column. The iliopsoas is also a postural muscle, active throughout standing in maintaining normal lumbar lordosis (and indirectly the compensatory thoracic kyphosis; see Chapter 2, Back) and resisting hyperextension o the hip joint. The sartorius lies supercially within the anterior compartment, within its personal relatively distinct ascial sheath. The actions o both sartorius muscular tissues deliver the decrease limbs into the cross-legged sitting position. The quadriceps emoris (usually shortened to quadriceps) consists o our elements: (1) rectus emoris, (2) vastus lateralis, (3) vastus intermedius, and (4) vastus medialis. Collectively, the quadriceps is a two-joint muscle capable o producing motion at both the hip and knee. In degree strolling, the quadriceps muscle tissue turn out to be lively during the termination o the swing section, preparing the knee to settle for weight. The quadriceps is primarily responsible or absorbing the jarring shock o heel strike, and its activity continues as the burden is assumed during the early stance section (loading response). It additionally unctions as a xator during bent-knee sports, corresponding to skiing and tennis, and contracts eccentrically throughout downhill strolling and descending stairs. The tendons o the our parts o the quadriceps unite in the distal portion o the thigh to orm a single, sturdy, broad quadriceps tendon. The medial and lateral vasti muscular tissues also connect independently to the patella and orm aponeuroses, the medial and lateral patellar retinacula, which reinorce the joint capsule o the knee joint on each side o the patella en route to attachment to the anterior border o the tibial plateau.

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I a peptic duodenal ulcer ruptures, a alse passage may orm between the pouch and the superior half o the duodenum, permitting gallstones to enter the duodenum. Infammation o the gallbladder may trigger ache in the posterior thoracic wall, or right shoulder owing to irritation o the diaphragm. Cholecystectomy People with extreme biliary colic often have their gallbladders removed. The cystic artery mostly arises rom the best hepatic artery within the cystohepatic triangle (Calot triangle). In current clinical use, the cystohepatic triangle is dened ineriorly by the cystic duct, medially by the frequent hepatic duct, and superiorly by the inerior surace o the liver. Careul dissection o the cystohepatic triangle early during cholecystectomy saeguards these important constructions ought to there be anatomical variations. Errors during gallbladder surgery commonly result rom ailure to recognize the widespread variations in the anatomy o the biliary system, particularly its blood provide. Beore dividing any structure and eradicating the gallbladder, surgeons identiy all three biliary ducts, as well as the cystic and hepatic arteries. Continued infammation could break down (ulcerate) the tissue boundaries between the gallbladder and a component o the gastrointestinal tract adherent to it, resulting in a cholecysto-enteric stula. Because o their proximity to the gallbladder, the superior half o the duodenum and the transverse colon are more than likely to develop a stula o this kind. The stula would enable a big gallstone, incapable o passing although the cystic duct, to enter the gastrointestinal tract. A cholecysto-enteric stula also permits gasoline rom the gastrointestinal tract to enter the gallbladder, providing a diagnostic radiographic signal. Portal Hypertension When scarring and brosis rom cirrhosis hinder the hepatic portal vein within the liver, pressure rises in the vein and its tributaries, producing portal hypertension. The large volume o blood fowing rom the portal system to the systemic system on the websites o portal�systemic anastomoses may produce varicose veins, particularly within the lower esophagus. The veins might turn into so dilated that their partitions rupture, resulting in hemorrhage. Bleeding rom esophageal varices (abnormally dilated veins) on the distal finish o the esophagus is oten severe and could additionally be atal. In severe cases o portal obstruction, the veins o the anterior abdominal wall (normally caval tributaries) that anastomose with the para-umbilical veins (normally portal tributaries) may turn out to be varicose and look considerably like small snakes radiating beneath the skin across the umbilicus. This condition is reerred to as caput medusae because o its resemblance to the serpents on the top o Medusa, a personality in Greek mythology. Initially, portocaval anastomoses or portosystemic shunts were laparotomy procedures in which the two veins had been surgically connected, usually where they lie near each other posterior to the liver. Another means o decreasing portal strain was to join the splenic vein to the let renal vein, ater splenectomy (splenorenal anastomosis or shunt). Once in the hepatic vein, the unopened stent is pushed through the parenchyma o the liver into the portal vein. The spleen is completely lined by peritoneum, except on the splenic hilum, where the splenorenal ligament (conveying splenic vessels to the spleen) and gastrosplenic ligament (conveying the short gastric and let gastro-omental vessels to the stomach) attach. Although it receives safety rom the overlying let 9th�11th ribs, the comparatively delicate spleen is the abdominal organ most susceptible to indirect trauma. Strong blows to the stomach could cause a sudden increase in intra-abdominal pressure that will rupture the spleen, leading to prouse intraperitoneal hemorrhage. The splenic vein runs parallel and posterior to the tail and body o the pancreas as it runs rom the spleen to the hepatic portal vein. The major pancreatic duct runs an identical course within the pancreas, continuing transversely via the head to merge with the bile duct to orm the hepatopancreatic ampulla, which enters the descending half o the duodenum. As an endocrine gland, the pancreas receives an plentiful blood supply rom the pancreaticoduodenal and splenic arteries. Although it receives vasomotor sympathetic and secretomotor parasympathetic nerve fbers, regulation o pancreatic secretion is primarily hormonal. The exocrine pancreas is seldom the trigger o clinical issues, though diabetes, involving the endocrine pancreas, has turn out to be increasingly widespread. It is our major metabolic organ, initially receiving all absorbed oodstus, besides ats.

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When the spleen is diseased, resulting rom, or example, granulocytic leukemia (high leukocyte and white blood cell count), it might enlarge to 10 or extra instances its regular measurement and weight (splenomegaly). Generally, i its decrease edge may be detected when palpating under the let costal margin at the finish o inspiration. Accessory Spleen(s) and Splenosis One or more small accessory spleens could develop prenatally close to the splenic hilum. They may be e embedded partly or wholly within the tail o the pancreas, between the layers o the gastrosplenic ligament, in n the inracolic compartment, within the mesentery, or in shut proximity to an ovary or testis. Accessory spleens are relatively common, are often small (approximately 1 cm in diameter, and range rom zero. Awareness o the potential presence o an adjunct spleen is necessary as a result of i not eliminated during a splenectomy, the signs that indicated elimination o the spleen. Splenosis-generalized autoimplantation o ectopic splenic tissue into the peritoneum, omentum, or mesenteries- typically ollows splenic rupture. This potential area descends to the extent o the tenth rib in the midaxillary line. Its existence have to be kept in mind when doing a splenic needle biopsy, or when injecting radiopaque material into the spleen or visualization o the hepatic portal vein (splenoportography). Blockage o Hepatopancreatic Ampulla and Pancreatitis Because the main pancreatic duct joins the bile duct to orm the hepatopancreatic ampulla and pierces the duodenal wall, a gallstone passing along the extrahepatic bile passages may lodge in the constricted distal finish o the ampulla, the place it opens at the summit o the most important duodenal papilla. In this case, each the biliary and pancreatic duct systems are blocked and neither bile nor pancreatic juice can enter the duodenum. However, bile might again up and enter the pancreatic duct, usually resulting in pancreatitis (infammation o the pancreas). A similar refux o bile sometimes outcomes rom spasms o the hepatopancreatic sphincter. Normally, the sphincter o the pancreatic duct prevents refux o bile into the pancreatic duct; however, i the hepatopancreatic ampulla is obstructed, the weak pancreatic duct sphincter could be unable to face up to the excessive strain o the bile within the hepatopancreatic ampulla. I an adjunct pancreatic duct connects with the principle pancreatic duct and opens into the duodenum, it could compensate or an obstructed major pancreatic duct or spasm o the hepatopancreatic sphincter. Utilizing the fuoroscopic visualization provided by the contrast medium, devices operated via the endoscope are then utilized or the intervention. The accent pancreatic tissue might comprise pancreatic islet cells that produce glucagon and insulin. This method produces detailed photographs o the hepatobiliary and pancreatic methods, including the liver, gallbladder, bile ducts, pancreas, and pancreatic duct. Then the duodenum is entered and a cannula is inserted into the most important duodenal papilla and advanced under fuoroscopic management into the duct o selection (bile duct or pancreatic duct) or injection o radiographic distinction Rupture o Pancreas the pancreas is centrally located within the physique. Pancreatic harm may finish up rom sudden, severe, orceul compression o the abdomen, such as the orce o impalement on a steering wheel in an automobile accident. Because the pancreas lies transversely, the vertebral column acts as an anvil, and the traumatic orce could rupture the riable pancreas. Rupture o the pancreas requently tears its duct system, permitting pancreatic juice to enter the parenchyma o the gland and to invade adjacent tissues. Abdominal Viscera 507 Subtotal Pancreatectomy Pancreatectomy, partial or complete surgical elimination o the pancreas, is mostly perormed when pancreatic tumors are detected (see "Pancreatic Cancer" below). However, subtotal or partial pancreatectomy is utilized to take away ruptured parts o the pancreas and or the remedy o continual pancreatitis ater nonsurgical choices have ailed. Subtotal pancreatectomy reduces pancreatic secretion by reducing the scale o the pancreas. While surgical removal o the physique and tail is less dicult, the anatomical relationships and blood provide o the pinnacle o the pancreas, bile duct, and duodenum make it inconceivable to take away the complete head o the pancreas with out eradicating the duodenum and terminal bile duct (Skandalakis et al. Usually, a rim o the pancreas is retained along the medial border o the duodenum to preserve the duodenal blood provide. Pancreatic Cancer Cancer involving the pancreatic head accounts or most circumstances o extrahepatic obstruction o the biliary ducts. Because o the posterior relationships o the pancreas, cancer o the top oten compresses and obstructs the bile duct and/or the hepatopancreatic ampulla. Obstruction o the biliary tract, often the common bile duct or ampulla, ends in the retention o bile pigments, enlargement o the gallbladder, and obstructive jaundice.

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This fastened arm retractor is placed in order to retract both the sternum and the skin incision in a cephalad direction. This permits glorious publicity of the aorta while maintaining the unique incision in a really low beauty location. The retractor blade of the Bookwalter retractor system is inserted throughout the pericardium and aids within the creation of a pericardial cradle, as nicely as retracting the thymus, sternum and pores and skin. The venous cannulation sutures can be placed approximately 2 cm apart in the proper atrial appendage and the best atrial free wall. The aortic cannulation suture is positioned on the anterior floor of the aorta at roughly its midpoint. Arterial cannulation may be carried out in the usual style using a aspect biting clamp which pulls the aorta down into higher view. Alternatively, a Seldinger-type method can be used introducing a guide wire into the lumen of the aorta and then threading an introducer and Biomedicus cannula. The straight venous cannulas are inserted instantly into the superior vena cava and inferior vena cava. Cardiopulmonary Bypass and Cardioplegia Standard cardiopulmonary bypass is begun and the affected person is cooled to a mild degree of hypothermia similar to 32�C. During this time, tourniquets are positioned across the superior vena cava and inferior vena cava and a cardioplegia stitch is inserted into the aortic root. The aortic cross-clamp is applied, cardioplegia is infused in the traditional trend and the caval tourniquets are tightened. Care should be taken to avoid dividing any arteries visible in the atrial free wall which may in part supply the sinus node. It is mostly an advantage to use a Castro Viejo-type needle holder which is extra ergonomically acceptable for a limited incision. The defect is closed with two layers of steady 5/0 polypropylene using a single double-ended polypropylene suture. By inserting a number of throws after the initial sew, two independent suture lines are created. The inset illustrates that the incision is begun at in regards to the stage of the nipples and is carried down for three. The aorta is cross-clamped in the usual trend and cardioplegia solution is infused into the root of the aorta. The suture line must be begun at the decrease, most dependent end of the incision, typically adjacent to the inferior vena caval proper atrial junction. Right Atrial Closure and Weaning from Bypass During warming, the best atriotomy is closed with two layers of fine prolene suture. Wide spacing of sutures ends in the suture line pursestringing itself collectively so that the resulting scar is shorter than is seen if multiple fine sutures are placed within the atrium. When the kid has been rewarmed to a rectal temperature of 35�C, weaning bypass is discontinued. It is generally not necessary to monitor central venous stress with a proper atrial catheter and no pacing wires are positioned. Creation of a Pleuro-Pericardial Window In order to cut back the chance of late pericardial tamponade a pleuro-pericardial window should be created. The rightsided pleura is opened and the pericardium is opened posteriorly to inside approximately 1 cm of the phrenic nerve. Incision Closure Although a heavy absorbable suture, similar to polydioxanone, can be used for sternal closure, the massive knots which end result can be palpable for many weeks or even months and can be bothersome to mother and father and children. We due to this fact use mild gauge stainless-steel wire to approximate the decrease end of the sternum. The the rest of the closure is routine with continuous Vicryl to the presternal fascia and linea alba with steady Vicryl to the subcutaneous fat and subcuticular Vicryl finishing wound closure. It is important that a light gauge Vicryl be employed to reduce the risk of a response to the suture materials. The whole thoracic cavity is retracted cephalad bettering exposure for aortic cannulation in particular. Care ought to be taken to keep away from suctioning within the left atrium which should stay nearly full all through the procedure. The left atrium ought to remain full of blood always and no air should be launched. The echocardiographer ought to have made a note of their report concerning the usual connection of a superior and inferior proper pulmonary vein coming into the left atrium.

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Diverticula are subject to inection and rupture, leading to diverticulitis, which can distort and erode the nutrient arteries, leading to hemorrhage. Descending colon Volvulus o Sigmoid Colon Rotation and twisting o the cellular loop o the sigmoid colon and mesocolon-volvulus o the sigmoid colon. Obstipation (inability o the stool or fatus to pass) and ischemia (absence o blood fow) o the looped half o the sigmoid colon end result. Volvulus is an acute emergency, and until it resolves spontaneously, necrosis (tissue death) o the concerned segment could happen i untreated. The esophagus penetrates the diaphragm on the T10 vertebral degree, passing by way of its right crus, which decussates around it to orm the physiological inerior esophageal sphincter. The trumpet-shaped stomach part, composed entirely o easy muscle innervated by the esophageal nerve plexus, enters the cardial part o the abdomen. The abdominal part o the esophagus receives blood rom esophageal branches o the let gastric artery (rom the celiac trunk). Submucosal veins drain to each the systemic and portal venous methods and thus represent portocaval anastomoses that will turn out to be varicose in the presence o portal hypertension. Internally, in residing individuals, the esophagus is demarcated rom the stomach by an abrupt mucosal transition, the Z-line. Stomach: the stomach is the dilated portion o the alimentary tract between the esophagus and the duodenum, continued on subsequent web page 486 Chapter 5 Abdomen the Bottom Line (continued) specialized to accumulate ingested ood and put together it chemically and mechanically or digestion. The stomach lies asymmetrically within the abdominal cavity, to the let o the midline and normally in the upper let quadrant. However, the place o the abdomen can range markedly in individuals o dierent physique types. The belly portion o the esophagus enters its cardial portion, and its pyloric half results in the exit to the duodenum. In lie, the interior surace o the stomach is covered with a protecting layer o mucus, overlying gastric olds that disappear with distension. The stomach is intraperitoneal, with the lesser omentum (enclosing the anastomoses between right and let gastric vessels) attached to its lesser curvature and the greater omentum (enclosing the anastomoses between proper and let gastro-omental vessels) connected to its higher curvature. The trilaminar clean muscle o the abdomen and gastric glands receives parasympathetic innervation rom the vagus; sympathetic innervation to the abdomen is vasoconstrictive and antiperistaltic. The duodenum ollows a principally secondarily retroperitoneal, C-shaped course around the head o the pancreas. The descending part o the duodenum receives both the bile and the pancreatic ducts. At or just distal to this degree, a transition occurs within the blood provide o the abdominal part o the digestive tract. The jejunum and ileum make up the convolutions o the small intestine occupying most o the inracolic division o the larger sac o the peritoneal cavity. The diameter o the small gut turns into more and more smaller as the semiuid chyme progresses by way of it. Its blood vessels also become smaller, but the number o tiers o arcades will increase whereas the size o the vasa recta decreases. The at by which the vessels are embedded inside the mesentery will increase, making these eatures more difcult to see. The ileum is characterized by an abundance o lymphoid tissue, aggregated into lymphoid nodules (Peyer patches). The intraperitoneal portion o the small intestine (jejunum and ileum) is suspended by the mesentery, the foundation o which extends rom the duodenojejunal junction to the let o the midline on the L2 degree to the ileocecal junction in the best iliac ossa. It is 3�6 cm in size and is typically positioned 50 cm rom the ileocecal junction in adults. Large gut: the large gut consists o the cecum; appendix; ascending, transverse, descending, and sigmoid colon; rectum; and anal canal. The giant gut is characterised by teniae coli, haustra, omental appendices, and a big caliber. The large gut begins on the ileocecal valve; but its frst half, the cecum, is a pocket that hangs inerior to the valve. The ileocecal valve is a combination valve and weak sphincter, actively opening periodically to permit entry o ileal contents and orming a largely passive one-way valve between the ileum and the cecum, stopping reux. The appendix is an intestinal diverticulum, rich in lymphoid tissue, that enters the medial side o the cecum, often deep to the junction o the lateral third and medial two thirds o the spino-umbilical line. Most commonly, the appendix is retrocecal in position, but 32% o the time, it descends into the lesser pelvis.

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The emale recto-uterine pouch is often deeper (extends arther caudally) than the male rectovesical pouch (7 in Table 6. In males, a mild peritoneal old or ridge, the ureteric old, is ormed as the peritoneum passes up and over the ureter and ductus (vas) deerens (secretory duct o the testis) on all sides o the posterior bladder, separating the paravesical and pararectal ossae. Posterior to the ureteric olds and lateral to the central rectovesical pouch, the peritoneum oten descends ar enough caudally to cowl the superior ends or superior posterior suraces o the seminal glands (vesicles) and ampullae o the ductus deerens. In both sexes, the inerior third o the rectum is below the inerior limits o the peritoneum. The posteriormost half o the band runs as the sacrogenital ligaments rom the sacrum across the side o the rectum to attach to the prostate in the male or the vagina in the emale. In emales, the lateral connection o the visceral ascia o the vagina with the tendinous arch o the pelvic ascia is the paracolpium. The paracolpia droop the vagina between the tendinous arches, helping the vagina in bearing the weight o the undus o the bladder. This "layer" is a continuation o the comparatively skinny (except around kidneys) endoabdominal ascia that lies between the muscular belly partitions and the peritoneum superiorly. Traditionally, the pelvic ascia has been described as having parietal and visceral components. The visceral pelvic ascia consists of the membranous ascia that instantly ensheathes the pelvic organs, orming the adventitial layer o every. The membranous parietal and visceral layers turn out to be steady the place the organs penetrate the pelvic foor. Here, the parietal ascia is thickened, orming the tendinous arch o pelvic ascia, a steady bilateral band operating rom the pubis to the sacrum alongside the pelvic foor adjoining to the viscera. It is probably extra sensible to think about this remaining ascia merely as extraperitoneal or subperitoneal endopelvic ascia. This ascia orms a connective tissue matrix or packing materials or the pelvic viscera. During dissection or surgical procedure, the ngers could be pushed into this free tissue with ease, creating precise areas by blunt dissection, or instance, between the pubis and bladder anteriorly and between the sacrum and rectum posteriorly. The presence o unfastened connective tissue here accommodates the growth o the urinary bladder and rectal ampulla as they ll. They encounter the so-called hypogastric sheath, a thick band o condensed pelvic ascia. It provides passage to essentially all the vessels and nerves passing rom the lateral wall o the pelvis to the pelvic viscera, together with the ureters and, within the male, the ductus deerens. As it extends medially rom the lateral wall, the hypogastric sheath divides into three laminae (layers) that pass to or between the pelvic organs, conveying neurovascular constructions and providing support. The anteriormost lamina, the lateral ligament o the bladder, passes to the bladder, conveying the superior vesical arteries and veins. Coronal and transverse sections o emale (A, B) and male (C, D) pelves demonstrating the parietal and visceral pelvic ascia and the endopelvic ascia between them, with its ligamentous and free areolar components. The posteriormost lamina (lateral rectal ligament) passes to the rectum, conveying the center rectal artery and vein. In the male, the center lamina orms a comparatively skinny ascial partition, the rectovesical septum. In the emale, the middle lamina is markedly extra substantial than the opposite two, passing medially to the uterine cervix and vagina as the cardinal ligament (transverse cervical ligament). In its superiormost portion, on the base o the peritoneal broad ligament, the uterine artery runs medially towards the cervix whereas the ureters cross instantly inerior to them. This relationship ("water passing beneath the bridge") is an especially necessary one or surgeons (see the Clinical Box "Iatrogenic Injury o Ureters"). The cardinal ligament, and the way in which the uterus normally "rests" on top o the bladder, supplies the main passive support or the uterus. The perineal muscular tissues present dynamic assist or the uterus by contracting during moments o increased intra-abdominal stress (sneezing, coughing, etc. Passive and dynamic supports together resist the tendency or the uterus to all or be pushed by way of the hole tube ormed by the vagina (uterine prolapse). The cardinal ligament has sufficient brous content to anchor extensive loops o suture throughout surgical repairs. Peritoneum and unfastened areolar endopelvic ascia have been eliminated to reveal the pelvic ascial ligaments positioned inerior to the peritoneum however superior to the emale pelvic oor (pelvic diaphragm).

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Rocko, 42 years: Here, it anastomoses with the posterior ulnar recurrent and inerior ulnar collateral arteries, taking part within the peri-articular arterial anastomoses o the elbow. Epiphysial arteries grow into the developing cavities with associated osteogenic cells. Trauma to muscular tissues and/or vessels within the compartments rom burns, sustained intense use o muscles, or blunt trauma could produce hemorrhage, edema, and infammation o the muscular tissues.

Kasim, 43 years: Eerent ductules o the testis transport newly developed sperms to the epididymis rom the rete testis. Consideration should be given to using Prolene sutures pledgetted with pericardium to buttress this suture line. The lung buds as they arise from the primitive foregut carry the arteries and veins which make investments the foregut and which are derived from the systemic arterial and systemic venous circulations.

Norris, 64 years: Pleuritis (Pleurisy) During inspiration and expiration, the sliding o usually clean, moist pleurae makes no detectable sound throughout auscultation o the lungs (listening to breath sounds); however, infammation o the pleura, pleuritis (pleurisy), makes the lung suraces tough. The coronary arteries are excised with a button composed of nearly all of the adjoining sinus of Valsalva. Because the sacral hiatus is positioned between the sacral cornua and inerior to the S4 spinous course of or median sacral crest, these palpable bony landmarks are essential or finding the hiatus.

Sancho, 41 years: The iliopsoas can be a postural muscle, energetic throughout standing in maintaining regular lumbar lordosis (and indirectly the compensatory thoracic kyphosis; see Chapter 2, Back) and resisting hyperextension o the hip joint. The swing section occupies roughly 40% o the walking cycle and the stance section, 60%. The interosseous border o the tibia is sharp the place it gives attachment to the interosseous membrane that unites the 2 leg bones.

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