practical surgery

Anatomy of Anterior Abdominal Wall and Groin hernia

Anterior Abdominal WallLayer of anterior abdominal

wall:

A- Lateral:1- Skin.2- Subcutaneous tissue.3- External oblique muscle.4- Internal oblique muscle.5- Transversus abdominis muscle.6- Fascia transversalis.7- Peritoneum.

Anterior Abdominal Wall

B- Medial:1- Skin.

2- Superficial

fascia.

3- Anterior wall of

rectus sheath.

4- Rectus muscle.

5- Posterior wall

of rectus sheath.

6- Peritoneum.

1- Skin

A- Lateral

2- Subcutaneous tissue

A- Lateral

The external oblique which runs infero-medially, originating on the

external posterior surface of ribs 5-12 (the lower 8 ribs, where its

originating fleshy digitations interlock with the digitations of the serratus

anterior and lattisimus dorsi

3- External Oblique m.

A- Lateral

The internal oblique which runs supero-medially (at right angles to the

external oblique). It originates in the thoracolumbar fascia of the lower

back, the anterior 2/3 of the iliac crest and the lateral 2/3 of the inguinal

ligament. Its insertions are on the inferior borders of the 10th-12th ribs

and the linea alba

4- Internal Oblique m.

A- Lateral

The transversus abdominus runs medially (horizontally) from the inner aspect of

the costal margin (just medial to the line formed by ribs 7-12), the lumbar fascia,

the anterior 2/3 of the iliac crest and the lateral third of the inguinal ligament. Its

insertion blends into the linea alba, with the lowest fibres inserted on the pubic

crest and the pectineal line (pelvic floor) along with the inferior part of the internal

oblique muscle

5- Transversus abdominis m.

A- Lateral

6- Fascia Transversalis m

A- Lateral

7- Peritoneum

A- Lateral

Anterior Abdominal WallLayer of anterior abdominal wall:

B- Medial:1- Skin.

2- Superficial fascia.

3- Anterior wall of rectus sheath.

4- Rectus muscle.

5- Posterior wall of rectus sheath.

6- Peritoneum.

1- Skin

B- Medial

2- Subcutaneous tissue

B- Medial

3- Ant. Wall of Rectus

sheath

B- Medial

The rectus abdominus and the rectus sheath

The rectus abdominus is a long paired vertically running muscle that

extends the entire length of the abdominal wall (narrowing as they

descend), originating at the pubic crest + pubic symphysis and inserting

on the cartilages of ribs 5-7 and the xiphoid process of the sternum

The anterior surface of the muscle is interrupted by 3 transverse fibrous

bands of tissue called transverse tendinuous intersections (the linea alba also

bisects the muscle vertically - this divides the muscle into 6 segments – think

six pack)

Has a special role as powerful flexors of the lumbar spine

The aponeuroses of the 3 sheet-like muscles form the rectus sheaths,

which enclose the rectus abdominus and meet at the middle to form the

linea alba (a tough fibrous band that extends from the xiphoid process to

the pubic symphysis)

o The arrangement of the rectus sheath is different superiorly and inferiorly to

the arcuate line (line ½ way between the umbilicus + pubic symphysis)

4- Rectus Muscle

B- Medial

B- Medial

5- Post. Wall of Rectus sheath

B- Medial

6- Peritoneum

Rectus Abdominis

Muscle

The muscle is divided into segments by tendinous intersections, Which indicate that the muscle arises from a number of myotomes, fused together

1- Segmental nerve supply.

2- Hematoma of rectus m. is localized

2- In paramedian incision displace m.

laterally (n. supply comes from lateral)

Surgical Importance

Pyramidalis

Muscle

It is a landmark of linea alba intraoperative

Actions of Anterior Abdominal

Wall Muscles

They assist in raising the intra-bdominal pressure (so,

they help in vomiting, cough, delivery, etc….)

Keep the abdominal viscera in position.

Rectus abdominis flexes the trunk, while the 2 oblique

muscles bend the trunk laterally.

Act as accessory expiratory muscles.

Lower midline & paramedian incisions.

The aponeuroses of the 3 sheet-like muscles form the rectus sheaths, which

enclose the rectus abdominus and meet at the middle to form the linea

alba (a tough fibrous band that extends from the xiphoid process to the

symphysis pubis)

o The arrangement of the rectus sheath is different superiorly and inferiorly to

the arcuate line (line ½ way between the umbilicus + pubic symphysis)

Superior to the arcuate line, the internal oblique aponeurosis splits to envelope the

rectus abdominus

o Inferior to the arcuate line, all 3 aponeuroses lie anterior to the rectus abdominus,

therefore the muscle lies purely on the transversalis fascia

At the lateral margin of the rectus abdominus, the aponeuroses also fuse to form the

linea semilunaris

Medially

Laterally

Rectus Sheath

Linea Alba

Linea Semilunaris

Arcuate Line

Rectus Sheath

Falciform Ligament

External Oblique

Internal Oblique

Transversus Abdominis

Ant. Layer of Rectus Sheath

Post. Layer of Rectus Sheath

Rectus Abdominis

Above Arcuate Line

SKIN

PeritoneumTransverslais Fascia

Rectus Sheath

External Oblique

Internal Oblique

Transversus Abdominis

Ant. Layer of Rectus Sheath

Rectus Abdominis

Below Arcuate Line

Urachus in Median Umbilical Fold

Medial Umbilical Ligament

Transverslais Fascia

SKIN

Peritoneum

Vessels and nerves

The rectus sheath contains arteries and veins lying posterior to

the muscle. These are the epigastric vessels

There is an anastomosis between the superior epigastric

arteries coming from the internal thoracic (branch of the

subclavian) and the inferior epigastric arteries that ascend

from the external iliac (by-pass of the abdominal aorta)

The nerve supply to all the antero-lateral muscles comes from

T6-L1

The intercostal nerves T6-T12 enter the abdominal wall at the

anterior ends of the intercostal spaces, passing deep to the costal

cartilages where these close the spaces

The main trunks of the nerves lie between the internal oblique

and transversus layers

Superior epigastric a.

Subcostal a.

Inferior epigastric a.

Deep circumflex iliac a.

- I -Internal Mammary a.

- III -External Iliac a.

- II -Descending Aorta

10th, 11th intercostal a.

Anatomy of inguinal hernia

Important definitions

The inguinal region

The inguinal ligament is formed by the inferior folding-under of the external oblique,

and runs straight from the anterior superior iliac spine to the pubic tubercle .

The deep inguinal ring (internal) is an opening in the back wall of the inguinal canal,

which lies just superior and medial to the inguinal ligament. It marks the mid-point of the

length of the inguinal ligament, and provides an entry through which the canal’s contents

enter.

The superficial inguinal ring is a V-shaped slit in the external oblique aponeurosis

that allows the content of the canal to exit e.g. into the scrotum

E.g. the testicles develop from the back of the abdomen at the level of the kidneys,

and then descend through the deep ring into the inguinal canal and into the scrotum

The inguinal canal contains the ilioinguinal nerve in both males + females

In males it also contains the spermatic cord, which is covered in cremester muscle

(cremester reflex raises the testicles when cold) and 2 associated nerves

The borders of the inguinal canal:

o Floor – inguinal ligament

o Anterior – external oblique aponeurosis + internal oblique

o Roof – internal oblique arching over

o Posterior – transversalis fascia and the conjoint tendon medially

The inguinal region is an area of weakness in the abdominal wall, thus is often the site

of an inguinal hernia

The inguinal canal :-

The inguinal canal is approximately 4 cm long and is directed

obliquely inferomedially through the inferior part of the

anterolateral abdominal wall. The canal lies parallel and 2- 4 cm

superior to the medial half of the inguinal ligament .

The inguinal canal has openings at either end : –

The deep (internal) inguinal ring is the entrance to the inguinal

canal. It is the site of an outpouching of the transversalis fascia.

This is approximately 1.25 cm superior to the middle of the

inguinal ligament .

The superficial, or external inguinal ring is the exit from the

inguinal canal. It is a slit like opening between the diagonal fibres

of the aponeurosis of the external oblique

Inguinal canal

walls of The inguinal canal :-

The anterior wall is formed mainly by the aponeurosis of the external

Oblique along its whole length + internal oblique muscle along its

lateral 1/2

. The posterior wall is formed mainly by transversalis fascia along its

whole length + conjoint tendon along its medial 1/2

The roof is formed by the arching fibres of the internal oblique and

transverse abdominal muscles.

The floor is formed by the inguinal ligament. It is reinforced in its most

medial part by the lacunar ligament.

Contents of inguinal canal :-

1. Spermatic cord ( round ligament of the uterus in

female )

The Cord Itself.—The contents of the spermatic cord are

(a) the ductus (vas) deferens and its artery .

(b) the testicular artery and venous (pampiniform)

plexus.

(c) the genital branch of the genitofemoral nerve.

(d) lymphatic vessels and sympathetic nerve fibers.

(e) fat and connective tissue surrounding the cord and

its coverings in various amounts

2. Ilioinguinal nerve .

3. Ilioinguinal lymph node .

• Obliterated processusvaginalis

• Parietal layer of tunica vaginalis

• Visceral layer of tunica vaginalis

• Internal spermatic fascia

• Cremasteric fascia and muscle

• External spermatic fascia

• Dartos fascia and muscle• Superficial fascia • Membranous

layer(Scarpa's)• Fatty layer (Camper's)• Skin

Peritoneum

Transversalis fascia

Transversus abdominism.Internal oblique m.

External oblique m.

skin

Covering

The Hesselbach triangle

The inferior epigastricvessels serve as itssuperolateral border, therectus sheath as medialborder, and the inguinalligament as the inferiorborder. Direct hernias occurwithin the Hesselbachtriangle, whereas indirectinguinal hernias arise lateralto the triangle

• Indirect Hernia

• Direct Inguinal Hernia

Femoral Canal

The major feature of the femoral canal is the femoral sheath. This sheath is a

condensation of the deep fascia (fascia lata) of the thigh and contains, from

lateral to medial, the femoral artery, femoral vein, and femoral canal. The

femoral canal is a space medial to the vein that allows for venous expansion

and contains a lymph node (node of Cloquet). Other features of the femoral

triangle include the femoral nerve, which lies lateral to the sheath,

Wall of The Femoral canal

anterior is the inguinal ligament

posterior is the iliopsoas, pectineal, and long adductor muscles (floor).

Medial is lacunar ligament

Lateral is femoral vessle

A femoral hernia occurs through this space and is medial to the femoral

vessels

Femoral Canal

Testis

Spermatic cord

Ductus deferens

Testicular artery

Testicular vein (pampiniform plexus)

Epididymis:Head,Body,Tail

Efferent ductules

Rete testis

Seminiferous tubule

Septum

Lobules

Visceral layer of tunica vaginalis

Cavity of tunica vaginalis

Parietal layer of tunica vaginalis

Tunica albuginea

www.themegallery.comHernia Lecture


SCARPA’S FASCIA


EXTERNAL RING

EXTERNAL SPERMATIC FASCIA

EXTERNAL OBLIQUE APONEUROSES


ILIOHYPOGASTRICILIOINGUINAL

INTERNAL OBLIQUE APONEUROSES

CREMASTIC MUSCLE

INTERNAL OBLIQUE MUSCLE


RECTUS MS

TRANSVERSUS ABDOMINUS MS

TRANSVERSUS ABDOMINUS APPONEUROSES


INFERIOR EPIGASTRIC A. &V.


FASCIA TRANSVERSALIS

INFERIOR EPIGASTRIC Vs.

INTERNAL RING

CREMASTRIC Vs


PERITONEUM

CONTENTS OF CORD

TSETICULAR VEIN

PAMPINEFORM PLEXUS


ARTERY OF VAS


VAS

www.themegallery.com

FEMORAL TRIANGLE

SARTORIUS

ADDUCTOR LONGUS

INGUINAL LIGAMENTS


FEMORAL NERVE

FEMORAL SHEATH


CONTENTS OF THE FEMORAL SHEATH

LYMPH NODE

FEMORAL ARTERYFEMORAL VEIN

FEMORAL NERVE

FEMORAL BRANCH OF GENITO FEMORAL NERVE

Liver

The liver is the largest gland in the body and has a wide variety offunctionsWeight: 1/50 of body weight in adult & 1/20 of body weight in infantIt is exocrine(bile) & endocrine organ(Albumen , prothrombin &fibrinogen)

Function of the liver

Secretion of bile & bile saltMetabolism of carbohydrate, fat and proteinFormation of heparin & anticoagulant substancesDetoxicationStorage of glycogen and vitaminsActivation of vita .D

Location …

•Occupies righthypochondrium +epigastrium &extends toleft hypochondrium

Apex of the heart Xiphisternum. 5th rib MCL

7th rib MAL

9th rib

Upper Border

Lower Border

5th intercostal space

8th costal cartilage

Rt 9th costal cartilage

Midway between xiphisternum & umbilicus

Rt. Border

Surface anatomy of the liver

-The greater part of the liver is situated under cover of the right costal margin

- Diaphragm separates it from the pleura, lungs, pericardium, and heart.

Surfaces of the liver, their relations &

impressions

Postero - inferior surface= visceral surfaceSuperior surface = Diaphragmatic surfaceAnterior surfacePosterior surfaceRight surface

Ant. View of the liver

Right lobe

Cut edge of the Falciform ligament

left lobe

Diverging cut edges of the superior

part of the coronary ligament

Fundus of the gall bladder

Relations of the liver Anteriorly

Diaphragm

Rt & Lt pleura and lung

Costal cartilage

Xiphoid process

Ant. abdominal wall

Postero- infero surface= visceral surface

RelationsI.V.Cthe esophagusthe stomachthe duodenumthe right colic flexurethe right kidneyRt. Suprarenal glandthe gallbladder.Porta hepatic( bile duct,H.a.H.V)Fissure for lig. Venoosum & lesser omentumLig.teres

Postero-inferior surface of the liver

Sup. Surface of the liver

Right & left lobes Cut edge of the Falciform ligament The cut edges of the superior and inferior parts of the coronary ligament The left triangular ligament The right triangular ligament Bare area of the liver (where there is no peritoneum covering the liver Groove for the inferior vena cava and the hepatic veins Caudate lobe of the liver more or less wrapping around the groove of the inferior vena cava Lig.teres

Relations of Sup. surface of liver

Diaphragm

Pleura & lung

Pericardium & heart

Posterior relation of the liver

DiaphragmRt. KidneySupra renal glandT.colon(hepatic flexureDuodenumGall bladderI.V.CEsophagusFundus of stomach

Lobes of the liver

Rt. Lobe

Lt .lobe

Quadrate lobe

Caudate lobe

Rt. Lobe-Largest lobe - Occupies the right hypochondrium

Left Lobe

Varied in size

Lies in the epigastric and left

hypochondrial regions

Divided into lateral and

medial segments by the left

hepatic vein

Lobes of the liver…..cont

Rt. & Lt lobe separated by

Falciform ligament

Ligamentum Venosum

Ligamentum teres

Caudate Lobe

-present in the posterior surface

from the Rt. Lobe

Relations of caudate lobe

- Inf. the porta hepatis

- The right the fossa for

the inferior vena cava

- The left the fossa for

the lig.venosum.

Quadrate lobe

Present on the inferior surface

from the Rt. Lobe

Relation- Ant. anterior margin of the

liver

- Sup. porta hepatis

- Rt. fossa for the gallbladder

- Lt by the fossa for lig.teres

Falciform ligament

Fissure of ligamentum teres

Fissure of Ligamentum venosum

Ligamentum teres

Rt. lobe Lt. lobe

Superior surface: Related to the diaphragm

Anterior surface

Xiphoid process

Diaphragm

Ant. abdominal wall

Right lateral surface

Rt. Lung &pleura

6 -11 ribs

Diaphragm

Inferior surface:

Esophagus

StomachDuodenum

Lesser omentum

Transverse colon

Gall bladder

Rt. colic flexureRt. kidney

Peritoneal Coverings:

Bare area of the liver

Fossa for gall bladder

Groove for IVC

Porta hepatis

Peritoneum of the liver

The liver is covered by

peritoneum

(intraperitoneal organ)

except at bare area.

Inferior surface covered

with peritoneum of greater

sac except porta hepatis,

G.B & Lig.teres fissure

Rt. Lateral surface

covered by peritoneum,

related to diaphragm

which separate it from Rt.

Pleura , lung and the Rt

Ribs (6-11)

Falciform lig.

Coronary ligaments

Rt. triangular lig.

Lesser omentum

Lt. triangular lig.

1- The Falciform ligament of liver

2- The Ligamentum teres hepatis

3- The coronary ligament

4- The right triangular ligament

5- The left triangular ligament

6- The Hepatogastric ligament

7- The hepatoduonedenal ligament

8- The Ligamentum Venoosum

1. The ligaments of the liver

Falciform ligament of liver Consists of double peritoneal layer Sickle shapeExtends from anterior abdominal wall (umbilicus) to liverFree border of the ligament contains Ligamentum teres (obliterated umbilical vein)

Hepatogastric ligamentHepatoduodenal ligament

Liver anatomy

Historically, the liver was divided into right and left lobes by the external marking of the falciform ligament.

Segmental anatomy of the liver

Rt .& Lt. lobes anatomically no morphological significance. Separation by ligaments (Falciform, lig. Venoosum & Lig.teres)True morphological and physiological division by a line extend from fossa of GB to fossa of I.V.C each has its own arterial blood supply, venous drainage and biliary drainageNo anastomosis between divisions 3 major hepatic veins Rt, Lt & central8 segments based on hepatic and portal venous segments

Cantlie’s lineRt Lobe Lt Lobe

Segmental anatomy of the liver

Liver segments are based on the portal and hepatic venous segments

Schematic diagram of the segmental anatomy of the liver.

Each segment receives its own portal pedicle (triad of portal vein, hepatic artery, and bile duct).

The Right Lobe The Left Lobe

VIII

V

IV

IV

III

II

VII

VI

I

Blood supply of the liver

Blood supply of the liver

Proper hepatic artery

The right and left hepatic

arteries enter the porta

hepatis.

The right hepatic artery

usually gives off the cystic

artery, which runs to the

neck of the gallbladder.

http://upload.wikimedia.org/wikipedia/commons/4/4c/Common_and_proper_hepatic_artery.png

http://upload.wikimedia.org/wikipedia/commons/4/4c/Common_and_proper_hepatic_artery.png

Blood Circulation through the Liver

The blood vessels conveying bloodto the liver are the hepatic artery(30%) and portal vein (70%).The hepatic artery brings

oxygenated blood to the liver, and theportal vein brings venous blood richin the products of digestion, whichhave been absorbed from thegastrointestinal tract.The arterial and venous blood isconducted to the central vein of eachliver lobule by the liver sinusoids.The central veins drain into the rightand left hepatic veins, and theseleave the posterior surface of the liverand open directly into the inferiorvena cava.

Vein drainage of the liver

The portal vein divides

into right and left

terminal branches that

enter the porta hepatis

behind the arteries.

The hepatic veins (three

or more) emerge from

the posterior surface of

the liver and drain into

the inferior vena cava.

Portal v. 70%

Hepatic a. 30%

Hepatic veins

IVC

The anatomy of the portal vein

Lymphatic drainage of the liver

Liver produce large amount of lymph~ one third – one half of total body lymphLymph leave the liver and enters several lymph nod in porta hepatis efferent vessels pass to celiac nodsA few vessels pass from the bare area of the liver through the diaphragm to the posterior Mediastinal lymph nodes.

Nerve supply

Sympathetic hepatic plexus>>> celiac plexuses thoracic ganglion chain T1-T12Parasympathetic vagous nerve( anterior part)

Sympathetic and parasympathetic nerves form the celiac plexus.The anterior vagal trunk gives rise to a large hepatic branch, which passes

directly to the liver

Porta hepatis

-It is the hilum of the liver-It is found on the posteroinferior surface - lies between the caudate and quadrate lobes-Lesser omentum attach to its margin

Contents- Hepatic ducts ant.- Hepatic. Art + nerve+ lymphatic node middle.- Portal vein post.

//upload.wikimedia.org/wikipedia/commons/3/33/Gray591.png

//upload.wikimedia.org/wikipedia/commons/3/33/Gray591.png

GALLBLADDER

Anatomical position of

GB

- Epigastric - Right hypochondrium

region

- At the tip of the 9th RT . C.C

- Green muscular organ

- Pear-shaped, hollow structure

- On inferior surface of liver

- Between quadrate and right lobes

- Has a short mesentery

- Capacity 40- 60 cc

- Body and neck

Directed toward porta hepatis

Structure of GB

Fundus

-Ant:ant.abdominal wall

- Post.inf: transverscolon

Body

sup: liver

post.inf: Tr.colon. End of 1st part of

doudenum , begins of 2nd part of doudenum

Neck

- Form the cystic duct, 4cm

Hartmann’s Pouch1. Lies between body and neck of gallbladder

2. A normal variation

3. May obscure cystic duct

4. If very large, may see cystic duct arising from

pouch

Cystic

duct

- It joins common hepatic

duct

Arterial Supply to the Gallbladder

Cystic artery

Right hepatic arteryProper hepatic arteryCommon hepatic artery

Blood supply of GB:

- Cystic artery branch of Rt. Hepatic artery

- Cystic vein end in portalvein

- Small branches ( arteries and veins run between liver and gall bladder

Common Hepatic Artery

Proper Hepatic Artery

Gastroduodenal Artery

Lymphatic drainage of GB

1. Terminate @ celiac nodes

2. Cystic node at neck of GB

a. Actually a hepatic nodeb. Lies at junction of cystic & common hepatic ducts

3. Other lymph vessels also drain into hepatic

nodes

Nerve supply

Sympathetic and parasympathetic from celiac plexus

Parasympathetic ---- vagous nerve

Extra hepatic biliary system

Rt. hepatic duct+Lt hepatic duct↓Common hepatic duct+Cystic duct↓Common bile duct

- 4cm- Descend in free edge of lesser omentum- Supra duodenal part

Retro duodenal partRetro pancreatic part

Common bile duct

Bile duct……. parts

and relations

-3 inc long

-1st part-Located in right free margin of lesser omentum

- in front of the opening into the lesser sac

(Epiploic opening)

-Rt to hepatic artery and portal vein

- 2nd part-Behind the 1st part of the duodenum

-Rt to the gastroduodenal artery

-3 rd part

-Posterior surface of the head of the pancreas

-Contact with main pancreatic duct

-Related with IVC, gastroduodenal artery, portal

vein

-End in the half second part of duodenum at

ampulla of Vater

Ampulla of Vater with CBD and Pancreatic Duct

Ampulla of Vater

Hepaticopancreatic ampulla

(Ampulla of Vater)

Pyriform in shape

30-50 ml

8x12x3cm

Cut section

Fundus

Body

Neck

Cystic artery

Rt. hepatic artery

cystic vein

Portal vein

cystic LNs

Rt. hepatic duct Lt. hepatic duct

Common hepatic duct Cystic duct

Common bile duct

Extra-hepatic biliary tract

The common bile duct is about 7.5 cm long and is

formed by the junction of the cystic and common

hepatic ducts. It is divided into four parts:

•the supraduodenal portion, about 2.5 cm long, running

in the free edge of the lesser omentum;

• the retroduodenal portion;

• the infraduodenal portion, which lies in a groove, but

at times in a tunnel, on the posterior surface of the

pancreas;

• the intraduodenal portion, which passes obliquely

through the wall of the second part of the duodenum,

where it is surrounded by the sphincter of Oddi, and

terminates by opening on the summit of the ampulla of

Vater.

Anterior:Free border of lesser omentum

Caudate process

1st part of duodenum

IVC

Caudate process

1st part of duodenum

IVC

PV

CBD

Hepatic artery

Variations in the anatomy of the cystic artery, duct , and Variations in the

anatomy of the hepatic duct.

[email protected]

Ext. 308

Office 308

Dr. AMR EL HEFNI

Ass. Prof. of General Surgery

mailto:[email protected]

Breast and axilla anatomy

Anatomy of the breast

Shape : hemispherical with its base applied to the anterior chest wall and its

apex at the nipple.

Extent of the breast :

2nd rib

6th rib

4th rib

The axillary tail of the breast is of surgicalimportance. In some normal subjects it ispalpable and, in a few, it can be seenpremenstrually or during lactation. Itpierces the deep facsia to enter the axilla

Areas of the breast

upper medial,lower medial,upper lateral, lowerlateral, nipple andarola and theaxillary tail of thebreast it is ofsurgicalimportance.

Deep relation of the breast

It lies on

Pectoralis major m. with its deep fascia

Serratus anterior m.

External abd. Oblique m.

The upper most part of rectus abd. And sheath

Pectoralis major m.&

fascia

The breast lies over


External oblique m.

Rectus sheath

Pectoralis major m.


Pectoralis minor m. & fascia

Suspensory lig. of axilla

Clavipectoral fascia

Architecture of the breast

The breast consists of :1- the covering skin including the nipple and areola2- the superficial fascia 3- the mammary gland ( modified sweat glandectodermal in origin).The lobule is the basic structural unit of themammary gland (ducts and alveoli).The number and size of the lobules varyenormously: they are most numerous in youngwomen.From 10 to over 100 lobules empty via ductules intoa lactiferous duct, of which there are 15–20converging towards the nipple.The lobules of the breast are separated by fibrous septa ( coopers ligaments)

The ligaments of Cooper are hollow conical projectionsof fibrous tissue filled with breast tissue; the apices of thecones are attached firmly to the superficial fascia andthereby to the skin overlying the breast to the deepfascia . These ligaments account for the dimpling of theskin overlying a carcinoma.

The areola contains involuntary muscle arranged inconcentric rings as well as radially in the subcutaneoustissue. The areolar epithelium contains numerous sweatglands and sebaceous glands, the latter of which enlargeduring pregnancy and serve to lubricate the nipple duringlactation (Montgomery’s tubercles).

The male breast differs from the female breast in beingrudimentary and its glandular tissue consists only ofducts with no alveoli.

Lobe of mammary gland(breast fat)

Suspensory lig. of breast

Lobe of mammary gland

Suspensory lig. of breast

Blood supply of the breast

Arterial supply:

1- pectoral branch of thoraco acromial artery supply the

upper part (axillary)

2- Perforating branches of internal thoracic artery: 2nd,

3rd, 4th, supplying the medial part of the breast.( 1st part

of subclavian ar.)

3- Branches of the lateral thoracic artery supplying the

lateral part (axillary)

4- Lateral branches of posterior intercostals arteries

supply the lower and lateral parts.

Venous drainage :

1- axillary vein. 2-Intarnal thoracic vein. 3-Intercostal

veins

Axillary a.

Internal mammary a.

Superior thoracic a.

Lateral thoracic a.

Thoracodorsal a.

Axillary v.

Brachial plexus

Internal mammary artery

Medial perforators(artery, vein, nerve & lymph)

Axillary a.

Lateral thoracic a.

Aorta

3rd intercostal a.

Intercostal arteries

Accessory hemiazygos v.

Intercostal v.

Hemiazygos v.

Azygos v.

Azygos v.

S.V.C

Sympatheticchain

Nerve supply of the breast

By the anterior and lateral branches of the 4th, 5th and 6th intercostals nerves

which supply

A- sensory fibers to the breast.

B- autonomic fibers to the smooth muscles and blood vessels.

Lymphatic drainage of the breast

The lymphatic vessels arranged in four plexuses:

1- subcutaneous plexus

2- subareoral plexus of sappy

3- interlobular plexus

4- submammary plexus

The regional lymph nodes draining the breast:

1- axillary lymph nodes

2- internal mammry lymph nodes

3- posterior intercostal subscapular and supraclavicular .

Lymphatic drainage of the breast

The lymphatics of the breast drain predominantly into the axillary and internal mammary lymph nodes.

The axillary nodes receive approximately 85% of the drainage and are arranged in the following groups:

• lateral, ,,,,,,along the axillary vein;

• anterior,,,,,,, along the lateral thoracic vessels;

• posterior,,,,,,,,, along the subscapular vessels;

• central,,,,,,,,,,, embedded in fat in the centre of the axilla;

• interpectoral, The apical nodes are also in continua few nodes lying between the pectoralis

major and minor muscles;

• apical, which lie above the level of the pectoralis minor tendon in continuity with the lateral nodes

and which receive the efferents of all the other groups.

The internal mammary nodes are fewer in number. They lie along the internal mammary vessels deep to

the plane of the costal cartilages, drain the posterior third of the breast and are not routinely dissected.

Lymphatic drainage of different parts of the breast:A- nipple and areola: drained by the subareolar plexus to pectoral and apical

groups

B- skin and subcutaneous tissue and parenchyma :

1- upper lat. Quadrant + upper ½ of breast : pectoral lymph nodes

2- lower lat. Quadrant : subscapular // //

3- upper medial // : internal mammary (both sides)

4- lower medial // : mediastinal L.ns then pass through the rectus sheath

to the falciform lig. Then spread to the liver , umbilicus and peritoneum.

Recently the axillary Lns are classified into 3 levels:

1- lymph nodes above the level of pectoralis minor ( medial) : apical

infraclavicular

2- lymph nodes deep to pectoralis minor: central

3- lymph nodes below the level of pectoralis minor ( lateral ) : the ant and post

and lateral

Pectoral node II

Pectoral node I

Pectoral node III

Major nervous structures in the axilla is required

to avoid their sacrifice during surgery

Coursing close to the chest wall on the medial sideof the axilla is the long thoracic nerve, or theexternal respiratory nerve of Bell, which innervatesthe serratus anterior muscle. Division may result inthe winging scapula deformity.

The second major nerve trunk encountered duringaxillary dissection is the thoracodorsal nerve to thelatissimus dorsi muscle at the lateral border of theaxilla. Enters the axillary space under the axillaryvein, close to the entrance of the long thoracicnerve. Its sacrifice leads to loss of latissimusfunction and atrophy of the muscle.

Axillary v.

Axillary a.

Nerve to serratus anterior

Serratus anterior

AxillaIt is a 4 sided pyramidal shaped space

between the upper part of arm and the

upper part of the side of the thorax

Boundaries : it has apex, base, 4 wall

and content

Base : formed by the skin of the arm ,

superficial and deep fascia

What is axilla?Medial side of the arm

Lateral side of chest wall

ApexConnects the axilla with the posterior triangle of the neck

Bounded by :

Medial : outer border of the 1st rib

Posterior: upper border of the scapula

Anterior: middle 1/3 of clavicle

Neurovascular bundle

Clavicle

1st ribAcromion

Anterior wall of axilla

3ms + fascia

Superficial layer : pectoralis major ms

Deep layer : pectoralis minor and subclaivus ms

Claveipectoral fascia.

Pectoralis major m.

Pectoralis minor m. & fascia

Suspensory lig. of axilla

Clavipectoral fascia

Subclavius m. & fascia

Posterior & medial wall of axilla

Posterior : subscapularis , teres major and latissmus dorsi

Medial :

1- upper 4 or 5 ribs and intercostal ms

2- serratus anteroir ms

Subscapularis m.

Teres major m.

Serratus anterior m.(medial wall)

Posterior wall

Lateral wall of axilla

Upper part of humerus

Coracobrachialis ms

Short head of biceps

Coracobrachialis m.

Short head of biceps brachii m.

Contents of axilla

Axillary artery

Axillary vein

Cords and branches of the brachial plexus

Axillary lymph nodes , fat and axillary tail of the breast.

Axillary artery

Axillary vein

Brachial plexus

Lymphatics

THYROID EMBRYOLOGY AND ANATOMY

Company Logo

Triangles of the neck

Company Logo

STERNO MASTOID

POSTERIOR BELLY OF DIGASTRIC

ANTERIOR BELLY OF DIGASTRIC

CLAVICLE

MANDIBLE

MID LINE

TRAPEZIUS

Posterior triangle Superior belly of omohyoid

Company Logo


MANDIBLE

POSTERIOR BELLY OF DIGASTRIC


HYOID BONE


STERNOMASTOID

SUPERIOR BELLY OF OMOHYOID

MID LINE

STERNOMASTOID

SUPERIOR BELLY OF OMOHYOID

THYROID EMBRYOLOGY AND ANATOMY

The tissue bud that ultimately becomes the

thyroid gland arises initially as a midline

diverticulum in the floor of the pharynx.

The original attachment in the pharynx is in

the buccal cavity at the foramen cecum, and

this becomes the thyroglossal duct, which

after 6 weeks of age is usually absorbed. The

very distal end of this remnant may

occasionally be retained and mature as a

pyramidal lobe in the adult thyroid.(50%)

Congenital malformations

A-These include the thyroglossal cyst, which

result from retained tissue along the thyroglossal

duct. These cysts are almost in the midline. They

usually occur as a cyst found in the midline on

physical examination moving up and down with

swallowing and protrusion of the tongue .B- lingual thyroid .In most of these cases, this may be the only thyroid tissue that

remains.

Anatomic Considerations

The normally developed thyroid is a bilobed structure

that lies immediately next to the thyroid cartilage in a

position .

The two lateral lobes are joined at the midline by an

isthmus. The pyramidal lobe represents the most distal

portion of the thyroglossal duct and in the adult may be a

prominent structure.

A thin layer of connective tissue surrounds the thyroid is

part of the fascial layer, which invests the trachea. This

fascia is different from the thyroid capsule. This is why

thyroid gland moves up and down with digulitaion

This fascia coalesces with the thyroid capsule posteriorly

and laterally to form a suspensory ligament, known as

the ligament of Berry. The ligament of Berry is closely

attached to the cricoid cartilage and has important

surgical implications because of its relation to the

recurrent laryngeal nerve.

Right & left lobes connected by an isthmus • Occasional pyramidal lobe • Levator glandulaethyroideae• Slightly larger in women; may enlarge during menstruation & pregnancy • Extends from oblique line on thyroid cartilage down to 4th or 5th tracheal ring • Attaches to cricoidcartilage via suspensoryligament

thyroid lobes

isthmus

thyroid cartilage

common carotid a.

skin

fat

Platysma

deep fascia

Deep Fascia &

Spaces

prevertebral fascia

pretracheal fascia

carotid sheath

investing fascia

The arterial supply to the thyroid gland is supplied by

four main arteries, two superior and two inferior. And

additional thyroid ema

Three pairs of venous systems drain the thyroid.

Superior venous drainage is immediately adjacent to

the superior arteries and joins the internal jugular vein

at the level of the carotid bifurcation.

The middle thyroid veins exist in more than half of

patients and course immediately laterally into the

internal jugular vein.

The inferior thyroid veins are usually two or three in

number and descend directly from the lower pole of

the gland into the innominate and brachiocephalic

veins.

Recurrent Laryngeal Nerve

The recurrent laryngeal nerves ascend on

either side of the trachea, and each lies

just lateral to the ligament of Berry as they

enter the larynx. There are a number of

important variations. Then disappearing

beneath the inferior border of the

cricothyroid muscle. The nerve can

usually be found immediately anterior or

posterior to a main arterial trunk of the

inferior thyroid artery at this level.

The motor function of the recurrent

laryngeal nerve is abduction of the vocal

cords from the midline.

Damage to a recurrent laryngeal nerve

results in paralysis of the vocal cord on the

side affected. Such damage might result in a

cord that remains in a medial position or just

lateral to the midline.

If the vocal cord remains paralyzed in an

abducted position and closure cannot occur,

a severely impaired voice and ineffective

cough can be the result.

If recurrent laryngeal nerves are damaged

bilaterally partialy , complete loss of voice

and airway obstruction requiring emergency

intubation and tracheostomy may be

necessary.

Superior Laryngeal Nerve

Parathyroid Glands

Lymphatic drainage of thyroid gland

Anatomical

position - Epigastric

- left upper

hypochondrium region

Right lobe of liver

Falciform ligament

Gallbladder

Pancreas

Duodenum

L-3

Common relation

Anterior

-Transverse colon

-Transvers mesocolon

-Lesser sac

-Stomach

-Posterior

--Bile duct

-Portalvein

-Splenic vein

-IVC

-Aorta

- origin of Sup.mesentric.a

-Lt.Psoas muscle

-Lt.Suuprarenal gland

-Left kidney

-Hilum of the spleen

PANCREAS

Parts of the pancreas

Parts

Head

Neck

body

Tail

The head

-It is disc shaped

- lies within the

concavity of the

duodenum

- A part of the head

extends to the left

behind the superior

mesenteric vessels

and is called the

Uncinate process.

The neck

- It is the

constricted portion

of the pancreas

- connects the

head to the body.

- It lies in front of

the

beginning of the

portal vein the

origin of the

superior

mesenteric artery

The body

-Runs upward

and to the left

across the

midline

- It is

somewhat

triangular in

cross section.

Body of pancreas…cont

-Three surfaces: anterior, posterior,

and inferior.

-Three borders: ant ,post & inf

The anterior surface

1- Covered by peritoneum of post. Wall

of lesser sac

2- Tuber omental :

where the ant. surface of pancreas join

the neck

Body of

pancreas…cont

The posterior surface

- devoid of peritoneum

- in contact with

1- the aorta

2- the splenic vein

3- the left kidney and its

vessels

4- the left suprarenal

gland

5- the origin of the

superior mesenteric

artery

6- and the crura of the

diaphragm.


The inferior surface

- Narrow on the right but broader on the left

-Covered by peritoneum of greater omentum

- lies upon the duodenojejunal flexure

- Some coils of the jejunum

- its left extremity rests on the left colic

flexure

The superior border

-Blunt and flat to the right;

- Narrow and sharp to the left near the tail

It commences on the right in the omental

tuberosity

In relation with

1- The celiac artery

2- Hepatic artery

3- The splenic artery runs toward

the left in a groove along this border.


The anterior border

separates the anterior surface from the inferior surface

along this border the two layers of the transverse mesocolon diverge from one

another; one passing upward over the anterior surface, the other backward

over the inferior surface.

Body of pancreas

The inferior border

separates the posterior from the inferior surface

the superior mesenteric vessels emerge under its

right extremity.

The Tail

- Passes forward in

the splenicorenal

ligament and

comes in contact

with the hilum of

the spleen

Pancreatic ducts

The main duct-Begins in the tail and runs the lengthof the gland-Receiving numerous tributaries on theway .- It opens into the second part of theduodenum at about its middle with thebile duct on the major duodenal papilla

Accessory duct- When present, drains the upper part of

the head-Then opens into the duodenum a shortdistance above the main duct on the minorduodenal papilla .- The accessory duct frequentlycommunicates with the main duct

Blood Supply of pancreas

ArteriesThe splenic.a The superior pancreaticoduodenal .aInferior pancreaticoduodenal arteries.a

VeinsThe corresponding veins drain into the portal system.

Lymphatic drainage of pancreas

Lymph nodes are situated along the arteries that supply the gland. The efferent vessels ultimately drain into the celiac and superior mesenteric lymph nodes.

Nerve supply

Sympathetic and parasympathetic chain

Parasympathetic = vagus nerve

Congenital defects of

pancreas

Annular Pancreas (pancreas

encircles duodenum) (rare)

Ectopic Pancreas (very common)=

Outside the gastrointestinal tract

Clinical notes

Cancer head of pancreas Obstruction jaundices

Cancer body of pancreas pressure I.V.C & portal vein

Acute pancreatitis= inflammation of pancreas

Colon

Posterior

CBD

IVC

Head

Anterior

Neck

Pyloroduodenal junction

Anterior

Neck

Posterior

SMV

Splenic v.

Posterior

Splenic artery

Splenic vein

CBD

Main pancreatic duct Accessory pancreatic duct

Superior pancreaticoduodenal artery

Inferior pancreaticoduodenal artery

Splenic a.

Superior mesenteric a.

Celiac LNs

Superior mesenteric LNs