The nose

External configuration - The external nose is pyramidal in shape , the tip of the pyramid points anteriorlly and the base points posteriorlly. -The root is the most superior part and it lies on the naso facial suture.The most posteriorlly point situated in the middle of the root , between the two eyes is called nasion and it helps in cranium measurements. It has an anterior border called dorsum nasi wich is ending with the tip of the nose-apex nasi and two lateral sides called alla nasi. - The opening of the nose to air is called nostrils - nares which are openings through which air enters into the nasal cavity. The layers -The skin is thick and reach in seborrheic glands. -The subcutaneous tissue is thin and even absent on the inferior parts, were the skin is fix. -According with the elements witch are making the skelet of the nose it can be divided in a superior part made by muscles and the two nasal bones joints in the middle in sutura nasalis and an inferior part made by muscles and cartilages.The limit between the two parts is visible on the mucosa like a grove called limen nasi. -The muscles: -M.Procerus runs from the root of the nose to the alar parts.Its a constrictor of the nostrils; -M.Nasalis situated on the alar parts. Its a dilatator of the nostrils; -M.Levator labii superioris alaque nasi- also on the alar sides with the same function as previous one; -The cartilages-are maintained together by a fibrotic membrane. -Cartilago septi nasi-is situated on the median sagital plan and is inserted on the bonie septum(processus posterior) made by laminas perpendicularis of ethmoidal bone and vomer bone both articulated with crista nasalis.From the median line runs laterally two parts of this cartilage processus lateralis situated on the superior alar region. -Cartilago alaris major-are making the borders of the nostrils.Presents a horse shoe shape with a medial pillar (crus mediale) and a lateral pillar (crus laterale).The two medial pillars with pars membranacea of the septum nasale are fused on the septal inferior border called columela. -Cartilagines alares minores and Cartilagines nasales accesoriae files the rest of the walls of the nasal pyramid. Vessels and nerves -A.dorsalis nasi arise from arteria oftalmica and supplies the superior regions; -A.angularis-is the ending part of arteria facialis for the lateral and inferior regions;

-The veins drains in vena facialis; -The lymph nodes drains in nodi lymphatici parotidei and nodi lymphatici submandibulares. -The sensitive nerves arise from nervus infraorbitalis; -The motor nerves for the muscles , arise from nervus facialis.

The nasal cavity

Description: -The walls of the nasal pit were presented at the bones. -A special epithelium covers the entire nasal cavity and also the sinuses.Presents glands witch generate mucus. -The superior part near to lamina cribrosa is called region olfactoria due to its sensorial (smelling) function; -The inferior part near to the conchas is called regio respiratoria. -Septum nasalis presents three parts: -pars ossea-made by bones(ethmoidal and vomer-laminas perpendicularis); -pars cartilaginea-the septal cartilage , the median part; -pars membranaceea-the most inferiorly , in between the two nostrils(crus mediale of the greater alar cartilage) Comunications of the nasal cavity : -Apertura piriformis-the anterior opening; -Choane-the posterior opening to the pharynx; -Lamina cribrosa- on the superior wall - with fossa cranii anterior; -Foramen sphenopalatina-on the lateral wall - with fossa pterygopalatina; -Canalis incisivus-on the inferior wall - with the oral cavity; In meatus nasalis superior: - the posterior ethmoidal cells; - recessus sphenoethmoidalis the opening of the sphenoidal sinus; In meatus nasalis medius: - the anterior ethmoidal cells; - hiatus semilunaris(made by bula ethmoidalis , processus uncinatus , processus ethmoidalis and processus maxillaries of concha nasalis inferior-presents the opening of the maxillary sinus (hiatus maxillaris) ; - infundibulum the opening of the frontal sinuses; In meatus nasalis inferior: - canalis nasolacrimalis.

Arteries: A.ethmoidalis anterior and posterior , arise from arteria oftalmica.They supplies the anterior and superior areas; A.sphenopalatina-the ending part of arteria maxillaris presents: -Aa.nasales posteriores laterales; -Rami septales posteriores; The veins -are collected in vena facialis , vena sphenopalatina and venae ethmoidales. The lymph nodes drains in : -nodi lymphatici parotidei ; -nodi lymphatici submandibulares ; -nodi lymphatici faciales ; -nodi lymphatici retropharyngeales ; The nerves : -Nn.olfactori-sensorial nerves for smelling perforates lamina cribrosa ; -N.ethmoidalis anterior (or posterior depending through witch foramen enters)-ending branch of n.nasociliaris presents: -Rr.nasales interni: -laterales -mediales; -R.nasalis externus ; -Rr.nasales posteriores superiores laterales-arise from the pterygopalatine ganglion and enters through foramen sphenopalatina ; -Rr.nasales posteriores superiores mediales-arise also from the pterygopalatine ganglion and runs on the superior wall and the posterior part of septum nasales; -N.Nasopalatinus-enters through the foramen sphenopalatina and exits through the canalis incisivus.In the nasal cavity arise : -N.nasopalatinus longus-for the septum; -Nn nasopalatini breves-for the lateral wall and maxillary sinus; -The autonomic fibers (sympathetic and parasympathetic) runs in the same nerves to the nasal glands.

The mouth (Cavum oris)

The first part of the digestive tract. It is divided by the teeth and gums in two parts: - vestibulum- the outer part - cavum oris propria- the inner part

Vestibulum
Walls - is a slit- like space, bounded externally by the lips and cheeks; internally by the gums and teeth. Communications: It communicates with - the surface of the body by the rima or orifice of the mouth. - cavum oris propria- through the space between the teeth of the open mouth; - cavum oris propria- through the retromolar space . Divisions: The groove between the two lips (sulcus interlabialis) divides the vestibulum in - pars maxilaris(superior) - pars mandibularis(inferior) A vertical line traced on the angle of the lips delimits: - regio gingivolabialis(medial) - regio gingivobucalis(lateral) Description: - sulcus vestibularis superior- a groove between the superior external wall and processus alveolaris maxillae; - sulcus vestibularis inferior- a groove between the inferior external wall and processus alveolaris mandibulae; - frenulum labii superioris - a mucosal crest on the median line of the superior groove; - frenulum labii inferioris - a mucosal crest on the median line of the inferior groove; - papilla ductus parotidei- the opening of the parotid gland duct near the second superior molar; - Foramen infraorbitale- situated in the superior vestibular groove on a vertical line traced between the two premolars; - Foramen mentale- situated in the inferior vestibular groove , on the same vertical line; Arteries - For the superior part (maxillaris) - a. infraorbitalis; - a. labialis superior(from a. Facialis);

- For the inferior part (mandibularis) - a. mentalis - a. submentalis - a. labialis inferior - For the lateral region - a. bucalis The veins drain in vena facialis and plexus pterygoideus Nerves - rami labiales superiores - from n. infraorbitalis - rr. gingivales superiores - from plexus dentalis superior - ramus labiales inferiores - from n. mentalis - rr gingivales inferiores - from plexus dentalis inferior - n. bucalis- For the cheek

Cavum oris propria

Walls: - anterior and lateral: processus alveolaris (maxillaris and mandibularis) and the teeth - superior: the hard palate (palatum durum); - inferior: the floor of the oral cavity (M. mylohyoideus) Comunications: - vestibulum - pharynx - isthmus facium Divisions: - Regio palatina; - Regio sublingualis; - Regio retromolaris - Regio tonsillaris

Regio palatina - the superior wall with two parts: - hard palate (palatum durum); - processus palatinus os maxillae - lamina horisontalis os palatinum - soft palate (palatum molle) ;

Description: - Torus palatinus - a bony crest situated on the median line - Raphe palati - the median joint of the mucosa and periosteum with poor vascularisation - Papilla incisiva - 1 cm posterior to the incisive teeth, covers the opening of the canalis incisivum - Plicae palatinae transversae - 2- 6 anterior transversal lines of the mucosa - Hamulus processus pterygoidei - on the lateral part of the soft palate - Foramen palatinum majus - in the posterior and lateral angle of the hard palate - A line the limit between the hard and the soft palate - Isthmus facium - delimited by uvula palatina, radix linguae and the pillars of the soft palate Arteries - A. palatina major - For the posterior part of hard palate - Aa. palatinae minores For the soft palate - A. nasopalatina - For the anterior part of hard palate - A. palatina ascendens - For the soft palate The veins drain in - V. lingualis - V. Facialis - Plexus pterygoideus Nerves - N. nasopalatinus - the sensitive innervations of the anterior part of the hard palate - N. palatinus major - For the posterior part - Nn. palatini minors - For the soft palate, uvula and the tonsils - N. glossopharyngeus and N. vagus give branches For the posterior part of the region Regio sublingualis

The inferior wall of the mouth. There are two symmetric triangular shape regions

Limits: - anterior and lateral: processus alveolaris mandibulae; - posterior :the root of the tongue; - medial: frenulum linguae; Description: - pelvis salivalis - the deeper part of the triangle always full with saliva; - frenulum linguae - a mucosal insertion of the top of the tongue;

- caruncula sublingualis - a little projection (tuberculum) situated on the anterior margin of the frenulum lingualis and is perForated by the openings of the ductus submandibularis and ductus sublingualis major. - eminentia salivaris - the external shape of glandula sublingualis with a mucosal crest in the middle plica sublingualis- perForated by little channels- ductus sublinguales minores. The arteries are from a. sublingualis, the veins drain in vena sublingualis and the sensitive innervations is from nervus sublingualis. Under the mucosa of the region and the inferior wall muscles we find a space called spatium sublingualis. Walls: Superior: The mucosa of the regio sublingualis; Inferior: musculus mylohyoideus; Medial: musculus genioglossus and musculus hyoglossus Lateral: fovea sublingualis (on the mandibula) The contents of the space: the vessels and nerves penetrate into the region through the lateral groove of the tongue. - glandula sublingualis; - ductus submandibularis (Wharton) - oblique trajectory from the lateral groove of the tongue to the caruncula lingualis; - nervus lingualis - spins around the Wharton duct; - nervus hypoglossus - For the tongue muscles, is situated medial to the sublingual gland; - artera sublingualis - from a. lingualis; - vena sublingualis - drains in vena lingualis. Regio retromolaris The postero-lateral wall of the mouth situated between the last molars (superior and inferior) and arcus palatoglossus. Description: - Fossa retromolaris superior(inferior): a little space behind the last superior (inferior) molar , covered by a little projection of the gum papilla retromolaris superior (inferior); - plica pterigomandibularis- a fold between hamulus processus pterygoidei and fossa retromolaris inferior. The mucosa of the region covers the pterygomandibular space- the anterior part of regio infratemporalis. The contents of the pterygomandibular space: - ramus mandibulae- with its elements- Foramen mandibulae , lingula , antilingula and sulcus mylohyoideus. - N. alveolaris inferior;

- N. buccalis; - N. mylohyoideus; - N. lingualis; - A. alveolaris inferior. Regio tonsillaris

Situated on the limit between mouth and pharynx (isthmus faucium) Walls: - anterior: arcus palatoglossus; - posterior: arcus palatopharyngeus; - inferior: plica triangularis - lateral: pharyngeal wall. Contents: - Tonsilla palatina covered by capsula tonsillaris; - The tonsillar vascular pedicle from a. pharyngealis ascendens and a. facialis; - Fossa supratonsillaris - a space situated superior between the tonsil, the lateral wall and the two arches.

THE LARYNX (LARYNX)

- the larynx represents the segment of the respiratory tract placed in between farynx and trachea and being situated at the cervical level in the antero-median part of the neck, corresponding to the 3-6 cervical vertebras - it is the principal organ of fonation, but it has also respiratory and sphincterian functions I. The CARTILAGES of the larynx are in number of 9 (3 pair and 3 odd) and they are making the cartilaginous skeleton of the larynx: a. CARTILAGO THYROIDEA the thyroid cartilage is an odd one and presents: - lamina dextra et sinistra - the right and left lamella, wich are united anteriorly, in between them finding an angle openeds towards posterior - proeminentia laryngea - the laryngeal proeminency represents the angle situated anteriorly and given by the anterior unification of the anterior margin of the two lamellas - incisura thyroidea superior the superior thyroid notch is situated on the superior end of the angle - incisura thyroidea inferior the superior thyroid notch is situated on the inferior end of the angle - linea obliqua - the oblique line wich is situated on the external surface of each lamella - tuberculum thyroideum superius the superior thyroid tubercle is situated on the superior end of the oblique line - tuberculum thyroideum inferius the inferior thyroid tubercle is situated on the inferior end of the oblique line - cornu superius - the superior horn is situated in the postero-superior angle of each lamella, being oriented superiorly - cornu inferius - the inferior horn wich is shorter and it is situated in the postero-inferior angle of each lamella, being oriented inferiorly b. CARTILAGO CRICOIDEA the cricoids cartilage is an odd one, situated under the thyroid cartilage and presents: - arcus cartilaginis cricoidea - the arch of the cricoid cartilage is situated antero-laterally

- lamina cartilaginis cricoidea - the lamella of the cricoid cartilage is situated posteriorly and presents: - facies articularis thyroidea the thyroid articular surface (pair) is situated infero-laterally on each side of the lamella and it is destined for the articulation with the inferior horn of the thyroid cartilage - facies articularis arytenoidea the arytenoid articular surface (pair) is situated supero-laterally on each side of the lamella and it is destined for the articulation with the the arytenoid cartilage c. CARTILAGO EPIGLOTTICA the epiglottic cartilage is an odd one, situated above the thyroid cartilage having an oval shape; the space situated in between the thyroid and the epiglottic cartilages is filled by corpus adiposum pre-epiglotticum; it presents: - epiglottis - the epiglotta has as skeleton the epiglottic cartilage - petiolus epiglottidis - the petiol of the epiglottic cartilage is situated inferiorly being united with the superior thyroid notch by the liggamentum thyro-epiglotticum d. CARTILAGO ARYTENOIDEA the cricoids cartilage is an pair one, situated on the superior margin of the lamella of the cricoid cartilage and presents: - basis cartilaginis arytenoidea - the base of the arytenoid cartilage wich presents: - facies articularis the articular surface for the articulation with the cricoid cartilage - facies antero-lateralis - the antero-lateral surface with a triangular shape, presents: - crista arcuata the arched crest is situated obliqually on this surface and presents on each end a small tubercle (colliculus) - fovea triangularis the triangular fovea is situated above the arched crest - fovea oblonga the oblonga fovea is situated under the arched crest - processus vocalis the vocal projection is situated in the antero-inferior angle of this surface and serving for the insertion of the vocal ligament - facies medialis - the medial surface is orientd towards the other arytenoid cartilage

- facies posterior - the posterior surface presents: - apex cartilaginis arytenoidea the tip of the arytenoids cartilage is situated in the superior angle of this surface and it will be articulated with the corniculate cartilage - processus muscularis the muscular projection is situated in the postero-inferior angle of this surface and serving for the insertion of crico-arytenoid muscle e. CARTILAGO CORNICULATA Santorini the corniculate cartilage is small and pair, being situated on the superior tip of the arytenoid cartilage and presents: - tuberculum corniculatum - the corniculate tubercle wich lifts up the mucosa of the laryngeal opening e. CARTILAGO CUNEIFORME Wrisberg the cuneiform cartilage is small and pair, being situated supero-latyerally to the corniculate cartilage and presents: - tuberculum cuneiforme - the cuneiform tubercle wich lifts up the mucosa of the laryngeal opening f. CARTILAGO TRITICEA the triticeal cartilage is small, pair and inconstant, being situated on the posterior margin of the thyro-hyoidian ligament g. CARTILAGO SESAMOIDEA the sesamoid cartilage is small, pair and inconstant, being situated into the vocal muscle II. The ARTICULATIONS of the LARYNX are: a. articulatio crico-thyroidea the crico-thyroid articulation is situated in between the inferior articular surfaces of the lamella of the cricoid cartilage and the inferior horns of the thyroid cartilage, and presents: - capsula articularis crico-thyroidea - the crico-thyroid articular capsule presents interiorly a synovial membrane and a ligament: - liggamentum crico-thyroideum medianum the median crico-thyroid liggament is situated in between the inferior margin of the lamellas of the thyroid cartilage and the superior margin of the cricoids cartilage b. articulatio crico-arytenoidea the crico-arytenoid articulation is situated in between the superior articular surfaces of the lamella of the

cricoids cartilage and the articular surfaces of the basis of the arytenoid cartilage, and presents: - capsula articularis crico-arytenoidea - the crico-arytenoid articular capsule presents interiorly a synovial membrane and a ligament: - liggamentum crico-arytenoideum the crico-thyroid liggament is strengthening the capsule III. The LIGGAMENTS of the LARYNX are: a. membrana thyro-hyoidea the thyro-hyoid membrane is fibroelastic and situated in between the inferior margin of the hyoid bone and the superior margin of the thyroid cartilage; it is strengthened by: - liggamentum thyro-hyoideum medianum the median thyro-hyoid liggament is situated on the median line of the membrane - liggamentum thyro-hyoideum laterale the lateral thyrohyoid liggament is situated posteriorly in between the big horns of the hyoid bone and the superior horns of the thyroid cartilage - foramen thyro-hyoideum the thyro-hyoid orifice is situated on the lateral part of the membrane being destined for the superior laryngeal vasculo-nervous package b. liggamentum thyro-epiglotticum the thyro-epiglottic liggament is situated anteriorly in between the petiolus of the epiglottic cartilage and the superior part of the inner angle of the thyroid cartilage c. liggamentum hyo-epiglotticum the hyo-epiglottic liggament is situated anteriorly in between the epiglottic cartilage and the inferior part of the hyoid bone d. liggamentum crico-thyroideum the crico-thyroid liggament is situated anteriorly in between the inferior margin of the thyroid cartilage and the superior margin of the cricoid cartilage e. liggamentum crico-tracheale the crico-tracheal liggament is situated inferiorly in between the inferior margin of the cricoid cartilage and the superior margin of the first cartilage of the trachea f. liggamentum crico-pharyngeum the crico-pharyngeal liggament is situated in between the posterior surfaceof the lamella of the cricoid cartilage and the mucosa of the pharynx that covers this lamella

g. membrana fibro-elastica laryngis the fibro-elastic membrane of the larynx is coated interiorly by the mucosa of the larynx; it covers the spaces situated in between the components of the cartilaginous skeleton of the larynx and it is made by: - membrana quadrangularis the quadrangular membrane represents the superior part of membrane fibro-elastica and it borders laterally the superior (vestibular) part of the larynx (being situated in between the inferio-lateral margin of the epiglotta, the almost entire inner part of the angle of the thyroid cartilage and the anterior margin of the arytenoid cartilage); it presents: - liggamentum vestibulare the vestibular ligament wich is the inferior free margin of the quadrangular membrane, being situated in between the the inferior part of the angle of the thyroid cartilage and the fovea triangularis of the arytenoid cartilage - conus elasticus the elastic conus represents the inferior part of membrane fibro-elastica and it borders laterally the inferior (infra-glottic) part of the larynx (being situated in between the inferior part of the inner part of the angle of the thyroid cartilage, the vocal process of the arytenoid cartilage and the superior margin of the cricoid cartilage); it presents: - liggamentum vocale the vocal ligament wich is the superior free margin of the elastic cone, being situated under the vestibular ligament, in between the inferior part of the angle of the thyroid cartilage and the processus vocalis of the arytenoid cartilage IV. The MUSCLES of the LARYNX are: a. musculus crico-thyroideus the crico-thyroid muscle is situated on the external antero-lateral surface of the larynx and presents two parts: - pars recta the straight part situated medially and presenting almost vertical fibers - pars obliqua the oblique part situated laterally and presenting almost horizontal fibers b. musculus crico-arytenoideus posterior the posterior cricoarytenoid muscle is the only abductor of the vocal chords and it is

situated on the external posterior surface of the larynx and presents oblique fibers oriented in supero-anterior direction c. musculus crico-arytenoideus lateralis the lateral crico-arytenoid muscle is situated on the external lateral surface of the larynx and presents oblique fibers oriented in supero-posterior direction d. musculus arytenoideus obliquus the oblique arytenoid muscle is situated on the external posterior surface of the larynx and presents oblique fibers crossed in between them - pars ary-epiglottica the ary-epiglottic part continues antero-superiorly along the lateral margins of the epiglottic cartilage e. musculus arytenoideus transversus the transvers arytenoid muscle is situated on the external posterior surface of the larynx, under the oblique arytenoid muscle, and presents horizontal fibers f. musculus thyro-arytenoideus the thyro-arytenoid muscle is situated on the internal surface of the larynx, with the fibers oriented antero-posteriorly in between the inner part of the angle of thyroid cartilage and the anterior part of the arytenoids cartilages; it presents: - pars thyro-epiglottica the thyro-epiglottic part wich is the lateral one and continues towards the lateral margins of the epiglottic cartilage - musculus vocalis the vocal muscle wich is the medial part being situated in between the inner part of the angle of the thyroid cartilage and the fovea oblonga of the arytenoid cartilage (along the vocal ligament) V. The CAVITY of the LARYNX is covered by mucosa (wich is coated on the components of the fibro-elastic membrane of the larynx) and contains laryngeal glands and lymphatic follicles; it presents three parts (with a sand-watch shape) and an opening: a. aditus laryngis the opening of the larynx is situated superiorly into a oblique plane oriented postero-inferiorly; the borders of the opening are made in antero-posterior direction by: - epiglottis the epiglottic cartilage (wich closes / opens the aditus) with its superior margin; it is connected with the base of the tongue by plica glosso-epiglottica mediana and lateralis

- plica ary-epiglottica the ary-epiglottic plica is situated on the lateral side of the aditus and it is given by the mucosa over the musculus ary-epiglotticus - tuberculum cuneiforme the mucosa over the cuneiform cartilages relief, being situated in the posterior part of plica ary-epiglottica - tuberculum corniculata the mucosa over the corniculate cartilages relief , being situated in even more posterior part of plica ary-epiglottica - incisura inter-arytenoidea the inter-arytenoid notch is situated posteriorly in between the arytenoids cartilages b. cavum supra-glotticum (vestibulum laryngis) the vestibule of the larynx is the superior part (being larger superiorly and narrower inferiorly and placed in between the aditus of the larynx and the vestibular plica) corresponding to the space situated under the aditus in between the two membrana quadrangularis; it presents: - plica vestibularis the vestibular plica represents the inferior border of the vestibulum, being placed horizontally and having a antero-posterior direction; it is given by the mucosa over the vestibular liggament (the vestibular plica + the vestibular liggament are making togheter the false vocal chords) - rima vestibularis the vestibular slot represents the space situated in between the two vestibular plicas c. cavum intermedium (glotta laryngis) the glotta of the larynx is the narrow middle part being situated in between the superior and inferior parts of the larynx - more accurate in between the plica vestibularis (superior) and plica vocalis (inferior); it presents: - plica vocalis the vocal plica represents the inferior border of the intermediate cavity, being placed horizontally under the vestibular plica and having also a antero-posterior direction; it is given by the mucosa over the vocal ligament; the vocal plica + the vocal liggament + the vocal muscle are making togheter the (true) vocal chords - rima glottidis the glottic slot represents the space situated in between the two vocal plicas and presents: - pars intermembranacea the inter-membranous (anterior) part wich is situated in between the two vocal plicas

- pars intercartilaginea the inter-cartilagenous (posterior) part wich is situated in between the medial surfaces of the arytenoids cartilages - ventriculus laryngis Morgagni the laryngeal ventricles are two diverticles of the glotta oriented laterally and presenting: - sacculus laryngis the laryngeal sacc represents the superior extension of the laryngeal ventricle d. cavum infra-glotticum the infra-glottic part of the larynx is the large inferior part (being narrower superiorly and larger inferiorly and placed in between the vocal plica and the superior margin of the first cartilage of the trachea), corresponding to the space situated in between the two conus elasticus and the inner space of the cricoid cartilage until the first cartilage of the traches

VI. The VASCULO-NERVOUS PACKAGES of the LARYNX are: a. arteries are given by two sources: - arteria laryngea superior it vascularises the external antero-lateral muscles and by perforating the thyro-hyoid membrane (through foramen thyro-hyoideum) is giving branches for the interior of the larynx (supra-glottic and glottic parts) - arteria laryngea inferior it vascularises the external posterior muscles and by perforating the crico-thyoid membrane is given branches for the interior of the larynx (infraglottic part) b. veins are drained in two directions: - vena laryngea superior it collects almost the entire venous drainage of the larynx (going through foramen thyro-hyoideum) - vena laryngea inferior c. nerves are given by one main source (nervus vagus): - nervus laryngeus superior wich presents: - an external motor branch (for the crico-thyroideus muscle) - an internal branch (going through foramen thyrohyoideum) destined for sensitive and vegetative

innervation of the supra-glottic and the glottic part of the larynx - nervus laryngeus inferior (from nervus laryngeus reccurens) wich presents: - an external motor branch (for all the other muscles of the larynx) - an internal branch destined for sensitive and vegetative innervation of the infra-glottic part of the larynx d. lymphatics are drained in corresponding regional nodules: - cavum supra-glotticum the limpha from this part is drained towards nodi lymphatici jugulares interni - glotta the limpha from this part is drained towards nodi lymphatici cervicales anteriores profundi pre-laryngeales and then to nodi lymphatici jugulares interni - cavum infra-glotticum the limpha from this part is drained towards nodi lymphatici cervicales anteriores profundi pre- and para-tracheales and then to nodi lymphatici jugulares interni or mediastinales

THE TRACHEA (TRACHEA)

- it is a membraneous pipe wich connects the larynx with the lungs, having its posterior surface flattened and being situated in front of esophagus and deviated slighty to its right side - it starts at the level of C6 vertebra (liggamentum crico-trachealis) and it ends at Th4 vertebra (bifurcatio tracheae) and thus presents a cervical part and a thoracic one, having a supero-inferior direction and a slighty oblique antero-posterior orientation - at the level of Th4 it divides at approximately 80 degrees angle into the main right and left bronchus (bronchus principalis dexter et sinister) I. The COMPONENTS of the trachea are: - cartilagines tracheales - the tracheal cartilages are incomplete arches (in the posterior part of the trachea) in number of 18-20 - carina tracheae it represents the last tracheal cartilage wich has a V shape - liggamenta trachealis (annularia) - the ligaments of the trachea wich are situated in between the cartilages - paries membranaceus - the membranous part of trachea is situated posteriorly in between of the ends of the incomplete tracheal cartilages - musculus trachealis - the tracheal (smooth) muscle wich is part of the paries membranaceus - the lumen of the trahea - the interior of the trachea is coated with tunica mucosa wich incorporates glandulae tracheales II. The TOPOGRAPHICAL RELATIONSHIPS of the trachea are: - anterior - with arcus aortae, to the antero-right side with truncus brachicephalicus and to the antero-left side with arteria carotis communis sinistra and vena brachiocephalica sinistra - posterior - with the oesopagus wich is situated slighty to the left side of the trachea - right - with vena cava superior, arcus venae azygos, nervus phrenicus dexter and pleura medistinalis - left - with arcus aortae, arteria carotis communis sinistra and nervus laryngeus recurrens sinister

THE LUNGS (PULMOS)

- the lungs are pair organs situated in the pleural cavity I. The lung presents: - apex pulmonis - the tip of the lung wich exceeds the first rib with 2-3 cm - basis pulmonis - the base of the lung wich is concave lying on the diaphragm II. The SURFACES OF THE LUNG are: - facies costalis the costal surface is the lateral one and presents the imprints of the ribs (impressio costales) - facies diaphragmatica the diaphragmatic surface is the inferior one - facies medialis the medial surface it is split into: - pars vertebralis - the posterior smaller part - pars medistinalis - the anterior bigger part wich presents: - hilus pulmonis - the hilum of the lung wich is situated in its upper third - it presents imprints given by other anatominal structures situated in direct contact with this surface: - impressio cardiaca the imprint of the heart wich is present on both lungs and it is more accentuated on the left lung and they are situated antero-inferior to the hilum - sulcus arteriae subclaviae the groove of the subclavian artery wich is present on both lungs and it is situated antero-superior to the hilum - impressio venae cava superioris the imprint of the superior caval vein wich is situated anterior to the right hilum - impressio arcus venae azygos the imprint of the arch of the azygos vein (wich comes from posterior to anterior) wich is situated above of the right hilum - impressio oesophageus the imprint of esophagus wich is situated in the inferior part of facies mediastinalis of the right lung

- impressio aorta descendens the imprint of the descending aorta wich is situated posterior to the left hilum - impressio arcus aortae the imprint of the arch of the aorta (wich comes from anterior to posterior) wich is situated above of the left hilum - facies interlobaris the surface situated in between the lobes III. The MARGINS OF THE LUNG are: - margo anterior the anterior margin wich is situated in between the costal and medial surfaces - incisura cardiaca pulmonis sinistri - the cardiac notch of the left lung is situated on the left anterior margin - lingula pulmonis sinistri - the lingula of the left lung represents the process of pulmonar tissue situated under the lingula and oriented towards anteriorly - margo inferior - the inferior margin wich is situated circumferentially around the inferior surface IV. The FISSURES OF THE LUNG are: - fissura obliqua the oblique fissure wich is present on both lungs and it is situated on the costal surface; it starts posteriorly 6-7 cm under the tip of the lung (at Th3 level) and goes towards anteroinferior part of the lung along the costal surface, reaching the inferior margin near the meeting point with the anterior margin; it will split each the lung into lobus superior and lobus inferior - fissura horizontalis pulmoni dextri the horizontal fissure wich is present only on the right lung and it is situated also on the costal surface; it starts where the fissure oblique meets the 4th rib (in the middle axillary line) goes towards anterior margin along the 4th rib; it will generate (from the right superior lobe) the lobus medius pulmoni dextri - each of the lung will contain 10 segments (the components of the lobes) each of them is considered a small lung, having a prismatic shape with the tip oriented towards the hilum of the lung (and receving through this tip a segmental bronchus and an artery) and the base of the segment being oriented towards the surfaces of the lung

(along the surfaces of the segment are situated the segmental veins of it): -the right lung presents 3 segments in the superior lobe (segmentum apicale, anterius, posterius), 2 segments in the medial lobe (segmentum mediale, laterale) and 5 segments in the inferior lobe (segmentum superius, basale anterius, basale posterius, basale mediale, basale laterale) -the left lung presents 5 segments in the superior lobe (segmentum apicale, anterius, posterius, lingulare superius, lingulare inferius) and 5 segments in the inferior lobe (segmentum superius, basale anterius, basale posterius, basale mediale, basale laterale)

V. The HILUM OF THE LUNG: - is situated in the upper third of the pars mediastinalis of the medial surface and it is surrounded by the ligamentum pulmonare of Zenker (the reflection of pleura medistinalis in pleura visceralis) - anterior to the hilum lies the phrenic nerve - posterior to the hilum lies the vagus nerve - it represent the zone through the components of the pedicle of the lung (radix pulmonis) enter/exit into/from the lung; the pedicle consists in: - venae pulmonales - two pulmonary veins (superior et inferior) for each lung, wich are going to be drained into the left atrium; they contain the oxygenated blood coming from the peri-lobular network, than from the segmental veins wich in the end are forming the lobar veins and from here the pulmonal veins - arteria pulmonalis dextra / sinistra (=vasa publica) - the main right / left pulmonary artery wich are the two division branches of the pulmonary trunk and they contain unoxygenated blood wich goes towards the lungs in order to be oxygenated - bronchus principalis dexter / sinister - the main right / left bronchus are the two division branches of trachea - in the both hilums the order of these three components in antero-posterior direction is V-A-B

- in the right hilum the order of these three components in supero-inferior direction is B-A-V - in the left hilum the order of these three components in supero-inferior direction is A-B-V - arteria bronchialis dextra / sinistra (=vasa privata) - the right / left bronchial arteries wich are destined to vascularise the lung as organ; they are situated on the posterior surface of the bronchus, being branches of the thoracic aorta - venae bronchiales dextrae / sinistrae - the right / left bronchial veins wich are destined to drain the lung as organ situated also on the posterior surface of the bronchus and they are drained into the azygos / hemiazygos system - lymphatic vessels they are draining the limpha from the two networks of the lung: the superficial (under the pleura visceralis) and the deep one (intrapulmonar) - vegetative nervous networks branches from the vagus nerve (plexus anterior) and from the sympatic thoracic chain (plexus posterior) wich are going into the lung along with the bronchial three a. The main bronchi: - they are the result of the bifurcation of the trachea at approximately 80 degrees angle at the level of Th4 - the two main bronchus are united inferiorly under the bifurcation by the inter-bronchial ligament of Lushka - the main right bronchus (bronchus principalis dexter) it is shorter and larger, being almost vertical in the axis of the trachea; it will be split into the lung in three lobar bronchi corresponding to each lobe: bronchus lobaris superior, medius et inferior dexter - the main left bronchus (bronchus principalis sinister) it is longer and thinner, being deviated to the left from the axis of the trachea; it will be split into the lung in two lobar bronchi corresponding to each lobe: bronchus lobaris superior et inferior sinister - the lobar bronchi will split in 10 segmentar bronchi (bronchus segmentalis) corresponding to each segment - the segmentar bronchi will split in lobular bronchi (bronchus lobularis) corresponding to each lobuli - into the lobuli the lobular bronchi will split in bronchioli respiratorii, wich will split at their turn in 2-3 ductuli alveolares

wich will end with sacculi alveolares wich are made from alveoli pulmonis (where the gas exchange take place) b. The main pulmonary arteries: - they are the result of the bifurcation of the truncus pulmonalis - the main right pulmonary artery (arteria pulmonalis dextra) it is longer and larger, going almost transversally under the aortic arch towards the right pulmonar hilum; it will split into the lung in two lobar arteries (arteria lobaris superior et inferior dexter), the inferior one giving the branch for lobus medius (arteria lobaris media) - the main left pulmonary artery (arteria pulmonalis sinistra) it is shorter and thinner, going above the right main bronchus towards the left pulmonar hilum; in between the aortic arch and the initial portion of the artery there is the ligament arteriosum of Botallo; it will split into the lung in two lobar arteries (arteria lobaris superior et inferior)

THE PLEURA (PLEURA)

- it represents a thin layer of cells wich are making togheter a thin membrane ( a serosa) wich is placed on the inner part of the thoracic cavity and on the lungs I. The COMPONENTS of the pleura are: - pleura parietalis the parietal pleura wich is coating the internal side of the thoracic cavity (on the fascia endo-thoracica); it presents several parts: -pleura costalis is coating the inner side of the ribs, intercostal spaces and a small part of the sternum; its upper part is situated above the aperthura thoracica superior with 3-4 cm and it is named cupola pleurae - pleura diaphragmatica is coating the superior part of the diaphragm (except centrum tendineum) - pleura medistinalis situated into the sagital plane in between the sternum and the thoracic vertebrae, being in contact with the organ of the mediastinum; around the hilum of the lungs pleura medistinalis is continued with pleura visceralis; this transition line has a stronger constitution wich gives liggamentum pulmonale of Zenker - pleura visceralis the visceral pleura wich is coating the lungs - cavum pleurae the pleural cavity (virtual) is situated in between the two components of the pleura; the two pleural cavities (the right from the left one) are completely separated - liquor pleuralis the liquid of the pleural cavities, in cuantity of several milliliters wich has the role of lubrifiyng the surfaces wich are coming in contact durig the ventilatory movements of the lungs II. The TOPOGRAPHICAL RELATIONSHIPS of the pericardium are: - anterior - with the thymus (superiorly), the sternum (inferiorly) -here presenting ligg. sterno-pericardica - and with the 4-6th costal cartilage - posterior - with the oesophagus - right and left - with pleura mediastinalis on each side and through it with the medistinal surface of each lung

III. The CONTENT of the pleural cavity is made by:

- pulmon the lung on each side is completely included into the pleural cavity (wich is completely separated from the opposite one) - recessus pleuralis the recessuses of the pleural cavities are complementary spaces of the pleural cavity wich are destined to accommodate the lung in forced inspiration: -recessus costo-diapragmaticus it is the biggest and most important recessus (being the lowest point of the pleural cavity in ortostatism); it is situated in between the costal and diaphragmatic parts of pleura parietalis along the base of the lungs, in the middle axillary line the depth of the recessus being approximately 5-6 cm -recessus phrenico-mediastinalis it is situated in between the diaphragmatic and mediastinal parts of pleura parietalis, near the vertebrae thoracicae -recessus costo-mediastinalis it is situated in between the costal and mediastinal parts of pleura parietalis near the sternum, being more evident of the left side

IV. The A-V-N package of the pleura parietalis is made by: - arteries - branches from the sources that are vascularising the thoracic wall and the diaphragm - veins they are drained into the intercostal veins and into the superior phrenic veins - nerves branches from n. phrenicus, n. vagus , n. intercostales and from the symphatic thoracic chain - lympha is drained towards the intercostals and diaphragmatic lymph nodes - the A-V-N package of the pleura visceralis is given by the corresponding branches of the lung V. The TOPHOGRAPHY of the pleural cavity: - the reflection line of the recessus costo-mediastinalis from the right side starts at the level of the right sterno-clavicular articulation, from here goes inferiorly and towards the left side of the body reaching the middle line of the sternum at the level of the 2nd costo-sternal articulation; from here goes downward vertically on the middle line of the sternum until the level of the 4th sterno-costal articulation, here being deviated slighty towards the right side of the body reaching the 7th sterno-costal articulation - the reflection line of the recessus costo-mediastinalis from the left side starts at the level of the left sterno-clavicular articulation, from here goes inferiorly

and slighty towards the right side of the body reaching the 2nd costo-sternal articulation; from here goes downwards vertically along the left margin of the sternum resching the 4th sterno-costal articulation, here being deviated towards the left side of the body reaching the 7th costal cartilage at a point situated approximately 3-4 cm laterally to the left margin of the sternum -due to the convergent disposition of the two pleural reflection lines situated superiorly in the back of the manubrium sterni, at this level they will delineate a triangular area (with the base up) uncovered by the pleura and named aria interpleuralis superior = the timic triangle -due to the divergent disposition of the two pleural reflection lines situated inferiorly in the back of the corpus sterni, at this level they will delineate a triangular area (with the base down) uncovered by the pleura and named aria interpleuralis inferior = the pericardic triangle - the reflection line of the recessus costo-diaphragmaticus from both sides starts at the level of the 7th sterno-costal articulation, from here goes inferiorly and laterally intersecting the 8th costa in the medio-clavicular line, the 10th costa in the middle axillary line and from here goes horizontally towards the level of the 12th vertebra VI. CUPOLA PLEURALIS: - the pleural domes are the parts of the pleura parietalis that are situated above the level of the first rib, being placed simetrically into the apertura thoracica superior, posteriorly raching the level of the Th1 vertebra - here pleura parietalis is separated to the profound structures of the neck by fascia endothoracica who has at this level a fibrotic constitution (being named fascia of Sibson) - the pleura parietalis plus fascia of Sibson are suspended by the nearby bony structures by fibrotic structures wich are named the pleural suspension apparatus of Sebileau-Zuckerkandl: -ligamentum costo-cupularis situated in between the neck and the internal margin of the first rib -ligamentum transverso-cupularis situated in between the transverse apophisis of the C7 vertebra and the internal margin of the first rib -ligamentum vertebro-pleuralis situated in between the bodies of the C7, Th1 and Th2 vertebras and the fascia of Sibson - ligaments situated in between the fascia of Sibson and the other structures and organs of the neck

- the tophographical relationships of the cupola pleuralis are: - anterior - with artera subclavia (its retro-scalenic part) and the branches deriving from this level (truncus costo-cervicalis, arteria mamaria interna), nervus phrenicus also with the anterior part of the first rib and with the clavicle - posterior - with the head and neck of the first rib, inferior trunk of plexus brachialis, thoracic symphatic chain and the first intercostals artery - right - with vena brachiocephalica dextra and nervus vagus dexter, truncus lymphaticus - left - with the bifurcation of vena brachiocephalica sinistra and nervus vagus sinister, ductus thoracicus

THE PERICARD (PERICARDIUM)

- it is a membranous sac wich contains in interior the heart and the main vessels from the base of the heart I. The COMPONENTS of the pericardium are: - pericardium fibrosum the fibrotic pericardium wich is the external thicker layer - pericardium serosum the seros pericardium wich is the internal thinner layer wich is made by two components: -lamina parietalis the parietal part wich is coating the internal side of the fibrotic pericardium -lamina visceralis (=epicardium) the visceral part wich is coating the external side of the muscle of the heart (=myocardium) - so this layer is called epicardium - cavum pericardii the cavity of the pericardium (virtual) wich is situated in between the two components of the pericardium serosum - liquor pericardii the liquid of the pericardium, in cuantity of approximately 20g wich has the role of lubrifiyng the surfaces wich are coming in contact durig the movements of the heart II. The TOPOGRAPHICAL RELATIONSHIPS of the pericardium are: - anterior - with the thymus (superiorly), the sternum (inferiorly) here presenting ligg. sterno-pericardica - and with the 4-6th costal cartilage - posterior - with the oesophagus - right and left - with pleura mediastinalis on each side and through it with the medistinal surface of each lung

III. The CONTENT of the pericardium is made by: - cor the heart wich is completely included into the cavity of the pericardium - aorta ascendens the ascending aorta on wich pericardium extents until the limit with the aortic arch (approximately 1,5 cm below the origin of the brachio-cephalic truncus) - truncus pulmonalis the pulmonary trunk wich is completely included

- vena cava superior the superior caval vein wich is almost completely included (under the level of confluence of the azygos vein) - vena cava inferior the inferior caval vein wich has its entire superodiaphragmatic portion included - venae pulmonales the four pulmonal veins (two from right and two from the left lung) wich have their distal portion included - due to this inclusion/encircling of these vessels the pericardium presents dorsally a reflection line (from lamina visceralis into lamina parietalis) wich has a horizontalized T shape with its vertical part starting from vena cava inferior, going up to the right pulmonary veins and from here to vena cava superior, and the horizontal part starting from the right pulmonary veins and going towards the left side to the left pulmonal veins -in between the reflection line situated in between vena cava inferior and the right pulmonal veins on one side, continued to the left pulmonal veins on the other side, there will be a closed part of the cavity of the pericardium called sinus obliquus of Haller -in between the reflection line situated in between vena cava superior and the right and left pulmonal veins on one side, and the aorta acendens and truncus pulmonalis on the other side, there will be a open part of the cavity of the pericardium called sinus transversus of Theile IV. The A-V-N package of the pericardium is made by: - arteries a. pericardio-phrenica (branch from a. mamaria interna) - smaller branches from different sources: aorta descendens, a. phrenicae superiores, a. eophageales, a. bronchiales - veins they are drained into the internal mammary veins and into the superior phrennic veins - nerves branches from n. phrenicus, n. vagus and from the symphatic thoracic chain - lympha is drained through a superficial and a deep networks

THE HEART (COR)

- the heart is an organ situated in the pericardial cavity cavity, having a asymmetrical position related to the medio-sagital plane of the body with two thirds situated to the left and one third situated on the right side of it I. The EXTERNAL CONFIGURATION of the heart: - atrium cordis - the atria of the heart, in numbers of two (right and left), situated superiorly - ventriculus cordis - the ventricle of the heart, in numbers of two (right and left), situated inferiorly - sulcus coronarius the coronar groove is situated in between the atrias and the ventricles - sulcus interventricularis anterior - the anterior inter-ventricular groove - sulcus interventricularis posterior - the posterior inter-ventricular groove - incisura apicis cordis the notch of the tip of the heart wich results from the antero-inferior meeting of the two interventricular grooves - apex cordis the tip of the heart situated antero-inferiorly on the left side of the incisura apicis cordis (belongs to the left ventricle) - basis cordis - the base of the heart wich is situated superoposteriorly and it is made from the atrias and the proximal part of the big vessels - auricula dextra the right auricle represents an appendage of the right atrium - auricula sinistra the left auricle represents an appendage of the left atrium II. The SURFACES OF THE HEART are: - facies sterno-costalis the sterno-costal surface is the anterior one being made almost entirely from the right ventricle and right atrium (3/4) and the left ventricle with the apex (1/4), the limit in between them being sulcus interventricularis anterior - on this surface we find the right auricle, truncus pulmonalis, aorta ascendens, the distal portion of the left auricle - facies diaphragmatica the diaphragmatic surface is the inferior one being made by the right ventricle and a small part of the right

atrium (2/5) and the left ventricle (3/5), the limit in between them being sulcus interventricularis posterior - facies pulmonalis (dextra et sinistra) the lateral surfaces being made on the right side by the right atrium and the right auricle, and on the left side by the left ventricle, the left auricle and a small part of the left atrium III. The MARGINS OF THE HEART are: - margo obtusa the obtuse margin wich is rounded and situated in between the sterno-costal surface and the left pulmonal surface - margo acuta - the margin wich is situated sharper and situated in between the sterno-costal surface and the right pulmonal surface IV. The CHAMBERS OF THE HEART are coated on their inner surface by a thin layer of cells called endocardium: - ATRIUM DEXTRUM the right atrium has a cuboidal shape and presents: - sinus venarum cavarum the posterior part wich receives the blood from the two caval veins - atrium primitivum the anterior part - crista terminalis the terminal crest wich is situated endoatrially and represents the border in between these two parts - sulcus terminalis the terminal groove wich is situated exoatrially and represents the external correspondence of crista terminalis - auricula dextra the right auricle wich is a anterior-oriented appendage of the atrium primitivum, being larger and blunter than the left auricle - musculi pectinati the comb muscles are oriented from crista terminalis towards the right atrio-ventricular orifice and auricular dextra - ostium venae cavae superioris the orifice of the superior caval vein is situated superiorly - ostium venae cavae inferioris the orifice of the inferior caval vein is situated inferiorly and presents a embrionar reminiscence: valvula venae cavae inferioris of Eustachio - tuberculum inter-venosum of Lower the inter-venous tubercle wich is situated posteriorly in between these two orifices

- ostium sinus coronarii - the orifice of the coronary sinus is situated on the inferior wall and presents a embrionar reminiscence: valvula sinus coronarii of Thebesius - fossa ovalis the oval fossa is situated on the medial wall (= the common wall of the two atrias = inter-atrial septum) and presents a border: limbus fossae ovalis - foramina venarum minimarum the orifices of the small veins of Thebesius wich are situated near the inter-atrial septum - ATRIUM SINISTRUM the left atrium has a more rounded shape and presents: - ostia venarum pulmonalium the orifices (4) of the pulmonar veins wich are situated in two groups of two (superior and inferior) on the right and on the left side of the atrium - auricula sinistra the left auricle wich is a anterior-oriented appendage of the atrium primitivum, being thinner and sharper than the right auricle - valvula foraminis ovalis (= falx septi) the valvula of the oval fossa is situated on the medial wall (= the common wall of the two atrias = inter-atrial septum) in the corresponding area of fossa ovalis - VENTRICULUS DEXTER the right ventricle has thin wall being situated like a pocket attached to the left ventricle and presents: - the filling chamber represents the main part of the right ventricle being situated inferiorly and towards the right side under the right atrio-ventricular orifice; presents on the interior surface muscular trabeculas (trabeculae carnae) of myocardium -the evacuation chamber (= conus arteriosus = infundibulum) the infundibulum is situated superiorly and towards the left side and presents on the interior surface muscular trabeculas less accentuated than those from the filling chamber - crista supraventricularis the supraventricular crest is a bigger muscular trabecula and represents the border in between these two parts of the right ventricle

- trabecula septo-marginalis the septo-marginal crest is an other muscular trabecula situated into the filling chamber in between the muscular part of the interventricular septum and the free wall of the right ventricle - ostium atrio-ventricularis dextrum the right atrioventricular orifice wich is situated in between the right atrium and ventricle - valva atrio-ventricularis dextra (= valva tricuspidalis) the right atrio-ventricular valve wich is situated into the corresponding orifice, being made from three parts (= cuspsis anterior, posterior et septalis); each of these cusps will be connected by tendineous chords (chordae tendineae) to the corresponding papillar muscles (m. papillaris anterior, posterior et septalis) of the right ventricle - ostium trunci pulmonalis the orifice of truncus pulmonalis wich is situated at the end (superior) of the infundibulum - valva trunci pulmonalis the valve of truncus pulmonalis wich is situated into the corresponding orifice, being made from three pocket-like parts with a semilunar shape (valvula semilunaris anterior, dextra et sinistra); each of these valvula presents a free margin called lunula (lunulae valvulae semilunaris) wich has in the middle point a fibrotic nodule (nodulus valvulae semilunaris of Arantius) - VENTRICULUS SINISTER the left ventricle has thick wall having a conic shape and presents: - the filling chamber represents the part of the left ventricle wich is situated inferiorly and to the left side under the left atrio-ventricular orifice and presenting on the interior surface muscular trabeculas wich are smoother than those of the right ventricle the higher pressure -the evacuation chamber represents the part of the left ventricle wich is situated superiorly and to the right side and presents the interior surface smoother compare with that one from the filling chamber - ostium atrio-ventricularis sinistrum the left atrioventricular orifice wich is situated in between the left atrium and ventricle - valva atrio-ventricularis sinistra (= valva bicuspidalis = valva mitralis) the left atrio-ventricular valve wich is situated

into the corresponding orifice, being made from two parts (cuspsis anterior et posterior); each of these cusps will be connected by tendineous chords (chordae tendineae) to the corresponding papillar muscles (m. papillaris anterior et posterior) of the left ventricle - ostium aortae the orifice of aorta wich is situated at the end (superior) of the evacuation chamber - valva aortae the valve of aorta wich is situated into the corresponding orifice, being made from three pocket-like parts with a semilunar shape (valvula semilunaris dextra, sinistra et posterior); each of these valvula presents a free margin called lunula (lunulae valvulae semilunaris) wich has in the middle point a fibrotic nodule (nodulus valvulae semilunaris of Arantius); in between each of these valvulas and the aortic wall there is a space called sinus of Valsalva V. The ARTERIES OF THE HEART named coronary arteries and they are situated under the epycardium, having a sinuous course and giving branches that will go profound into the myocardium: - Arteria Coronaria Dextra the right coronary artery -originates from the right sinus of Valsalva of the aortic valve and goes towards the right side into the coronary groove under the right auricle, than around the base of the right ventricle reaching sulcus interventricularis posterior where it gives its terminal branch: - ramus interventricularis posterior the posterior inter-ventricular branch - it vascularises the right atrium, the inferior 1/2 part of the inter-atrial septum, Keith-Flack nodule (rami nodus sinoatrialis), the right ventricle, the posterior 1/3 of interventricular septum, the para-septal area of the left ventricle, the posterior papillar muscle of the mitral valve - Arteria Coronaria Sinistra the left (main) coronary artery -originates from the left sinus of Valsalva of the aortic valve and goes towards the left side into the coronary groove in between the left auricle and truncus pulmonalis, and after a short (main) segment it divides in two branches: - ramus interventricularis anterior the anterior interventricular branch wich goes in sulcus inter-ventricularis

anterior, than in incisura apicis cordis towards sulcus interventricularis posterior - ramus circumflexus the circumflex branch wich goes towards the left side into the coronary groove under the left auricle, than around the base of the left ventricle giving branches on the postero-lateral surface of it - it vascularises the left atrium, the superior 1/2 part of the interatrial septum, the left ventricle, the anterior 2/3 of interventricular septum, the para-septal area of the right ventricle, the anterior papillar muscle of the mitral valve VI. The VEINS OF THE HEART: - approximately 60% of the blood of the heart is drained towards the coronary sinus (sinus coronarius) wich is situated on the diaphragmatic surface of the heart and has a funnel shape (starting at the meeting point in between the big cardiac vein and the vena of Marshall); it is drained at its turn into the right atrium - vena cordis magna the big cardiac vein comes from the apical area being situated into the anterior inter-ventricular groove and goes upwards into the coronary groove under left auricle around the base of the left ventricle; it will be drain into the left extremity of the coronary sinus - vena cordis media the middle cardiac vein comes from the apical area being situated into the posterior inter-ventricular groove; it will be drain into the coronary sinus - vena cordis parva the small cardiac vein comes from the righr side being situated into the coronary groove and goes under right auricle and around the base of the right ventricle; it will be drain into the right extremity of the coronary sinus - vena posterior ventriculi sinistri the posterior vein of the left ventricle comes from the postero-lateral area of the left ventricle; it will be drain into the coronary sinus - vena obliqua atrii sinistri of Marshall the posterior vein of the left atrium comes from the posterior area of the left atrium; it will be drain into the the left extremity of the coronary sinus (at the meeting point of this vein with the big cardiac vein it will starts the coronary sinus wich presents here an embrionar reminiscence: valvula of Vieussens

- the rest of 40% of the blood of the heart is drained directly into the cardiac chambers through: - venae cordis anteriores the anterior cardiac veins wich are situated on the anterior surface of the right ventricle and they are going to be drained into the right atrium - venae cordis minimaes the minimal cardiac veins wich are situated on the surface of the atriums and they are going to be drained into the right (mainly) or left atrium VII. The CONDUCTING SYSTEM OF THE HEART is made by special cells situated in groups (wich are connected in between them by specific pathways); these cells can generate and conduct electrical impulses wich are going to give the contraction stimulus to the heart: - nodus sino-atrialis of Keith-Flack the sino-atrial node situated anteriorly at the confluence in between the vena cava superior and right atrium - nodus atrio-ventricularis of Aschoff-Tawara the atrioventricular node situated inferiorly near the orifice of the coronary sinus into the right atrium - fasciculus atrio-ventricularis of His the atrio-ventricular bundle goes inferiorly through the right fibrous triangle near the membraneous part of the inter-ventricular septum, being split in: - crus dextrum the right part situated in the right side of the inter-ventricular septum - crus sinistrum the left part situated in the left side of the inter-ventricular septum - rete of Purkinje the network wich derives from the right and the left parts and it will be distributed into the myocardium of the ventricles VIII. The SEPTUMS OF THE HEART are the walls that are separating the chambers of the heart: - septum atrio-ventricularis the atrio-ventricular septum is the wall situated in between the two atrias on one side and the two ventricles on the other side; it contains the ostiums of the two atrioventricular valves and it is placed in the transversal plane - septum interatriale the inter-atrial septum is the common wall (the medial one) of the atrias, being placed in the sagital plane

- septum interventriculare the inter-ventricular septum is the common wall (the medial one) of the ventricles, being placed also in the sagital plane and having two parts: - pars membranacea the membraneous part wich is the superior one; due to the different levels of insertion of the atrioventricular valves (the tricuspid valve being placed more distally), this membraneous part will present two components: - the atrio-ventricular component of the membraneous part (wich is the superior component, being placed above the level of insertion of the tricuspid valve) wich is situated in between the right atrium and the left ventricle - the inter-ventricular component of the membraneous part (wich is the inferior component, being placed under the level of insertion of the tricuspid valve) wich is situated in between the right ventricle and the left ventricle - pars muscularis the muscular part wich is the inferior one and being situated under pars membranacea, in between the right ventricle and the left ventricle IX. The FIBROUS SKELETON OF THE HEART has the role of support for different components of the heart structure: - annuli fibrosi the fibrotic annuluses wich have the role of ring for the insertion for the cusps of the atrio-ventricular and semilunar valves - trigonum fibrosum dextrum the right fibrotic triangle wich is situated posteriorly in between the mitral valve (anterior cusp), the tricuspid valve (septal cusp) and the aortic valve (posterior semilunar valvula); it is perforated by the His bundle and presents two expansions: - tendo coni arteriosi goes on the posterior surface of the pulmonary trunk - tendo of Todaro goes towards the atriums and to the membraneous part of the inter-ventricular septum - trigonum fibrosum sinistrum the left fibrotic triangle wich is situated anteriorly in between the mitral valve (anterior cusp) and the aortic valve (left semilunar valvula) X. The LYMPHATIC DRAINAGE AND INERVATION OF THE HEART:

- lymphatic vessels they are draining the limpha from the three networks of the heart: the under-epicardic, myocardic and underendocardic; in the end small leyphatic vessels deriving from these networks are going along the coronary vessels to the anterior medistinal nodes - vegetative nervous networks branches from the vagus nerve and from the sympatic thoracic chain wich are going into the lung along with the coronary vessels (plexus coronarius)

THE DIAPHRAGMATIC REGION (REGIO DIAPHRAGMATICA)

- the diaphragmatic region represents the inferior wall of the thoracic cavity wich is separating it from the peritoneal cavity - the main component of the region is the diaphragm muscle (diaphragma) wich is covered on the superior surface by fascia endothoracica (and indirectly through this by pleura parietalis) and on the inferior surface by fascia endo-abdominalis (and and indirectly through this by peritoneum parietalis) I. The DIAPHRAGM muscle is developing at the neck level, from where is going distally towards the border in between thorax and abdomen; it presents: a. CENTRUM TENDINEUM the tendinous center is situated in the middle, having a stronger platform-like constitution and being made by three parts: anterior (the smallest), sinister et dexter (the biggest); it presents: - ostium venae cavae inferioris - the orifice of the inferior vena cava wich has a tendineous constitution (inextensible) and it is situated at the meeting point in between the right and the anterior part; it serves for the passage of the inferior vena cava and a branch of the right phrenic nerve b. PARS MUSCULARIS the muscular part is situated at the periphery around the tendineous center, being made by three parts: - pars lumbaris - the lumbar part is made at its turn by three components (principal, secundar and intermediary columns): - the principal (or medial) columns wich are: - crux mediale dextrum the right medial/principal column, the longer one, inserted on the anterior surface of the of L1-4 vertebras - crux mediale sinistrum the left medial/principal column, the shorter one, inserted on the anterior surface of the of L1-3 vertebras - hiatus aorticus the aortic orifice (situated at the level of the Th12 vertebra) is situated posteriorly on the middle line and it is made by crossed muscular fibres from the

two columns; it presents also fibrotic fibers (so it is inextensible) and it serves for the passage of the aorta and the thoracic duct - hiatus oesophageus the esophagian orifice (situated at the level of the Th10-11vertebra) is situated posteriorly on the middle line but in front and above to the aortic orifice; it is made also by crossed muscular fibres from the two columns; it serves for the passage of the esophagus and the vagus nerves - the secundar (or lateral) columns are situated laterally to the principal columns, and they present: - liggamentum arcuatum mediale the first lateral/secundar column (= medial arched ligament = the psoas arch), wich is situated medially over the psoas muscle, in between the body of Th1 and the tip of the transverse aphophysis of the same Th1 -liggamentum arcuatum laterale the second lateral/secundar column (= lateral arched ligament = the quadratus lumborum arch), wich is situated laterally over the quadratus lumborum muscle, in between the tip of the transverse aphophysis of the Th1 and the tip of the 12th rib - the intermediary columns are situated in between the principal and the secundar columns, being thinner and inserted on the body of the L2 - pars costalis - the costal part starts from the medial surface of the 712 ribs - pars sternalis - the sternal part starts from the medial surface of the sternum and it is made by two (right and left) parts, in between them being a thin space through wich the anterior mediastinum communicates with the pre-peritoneal space - trigonum lumbo-costalis Bochdalek represents is a triangular space whithout muscular fibers situated in between pars lumbaris and pars costalis (with the base at the 12 rib and the tip oriented towards the meeting point in between the muscular fibers of the lumbar and costal parts) - hiatus costo-sternalis Larrey represents a smaller triangular space whithout muscular fibers situated in between pars costalis and pars

sternalis (through this space the internal mammary artery passes from thorax towards the abdomen becoming the superior epigastric artery) - in between the principal columns and the intermediary columns there is a small space wich serves for the passage of the azygos veins and the splachnic nerves - in between the secundar columns and the intermediary columns there is a small space wich serves for the passage of the symphatic trunk II. The VASCULO-NERVOUS PACKAGES of the DIAPHRAGMA are: a. arteries are given by two main sources: - arteria phrenica superior direct branch from aorta thoracica (pars descendeds), it vascularises the superior surface of the diapragma - arteria phrenica inferior direct branch from aorta abdominalis, it vascularises the inferior surface of the diaphragma - indirect branches from internal mammary artery and intercostals arteries b. veins are drained in two directions: - venae phrenicae superiores drained mainly in the azygos system (and from here in vena cava superior) - venae phrenicae inferiores drained mainly in vena cava inferior c. nerves are given by one source - the phrenic nerve - with comes from the cervical plexus C3-5 (with the fibers originating from C3-4 being destined for the anterior part and the fibers originating from C5 - the phrenic accesor nerve - being destined for the posterior part): - nervus phrenicus sinister wich presents: - an anterior branch - an posterior branch (wich gives an inferior branch wich goes through hiatus oesophageus towards the left inferior surface of the diaphragma) - an lateral branch - nervus phrenicus dexter wich presents: - an anterior branch

- an posterior branch (wich gives an inferior branch wich goes through hiatus venae cavae inferioris towards the right inferior surface of the diaphragma) d. lymphatics are drained in corresponding regional nodules: - the antero-superior part the limpha from this part is drained towards nodi lymphatici sternales - the postero-superior part the limpha from this part is drained towards nodi lymphatici medistinales posteriores - the lateral part the limpha from this part is drained towards nodi lymphatici costales - the inferior part the limpha from this part is drained towards nodi lymphatici caeliaci III. Topographical relationships of the DIAPHRAGM are: a. superiorly the tendinous center is in direct contact with pericardium and the heart; the lateral muscular parts are in contact through pleura parietalis with the pleural cavities and the lungs b. inferiorly the tendinous center and the lateral muscular parts are in indirect contact through peritoneum parietalis with the peritoneal cavities (so with the liver, stomach, spleen); through the retroperitoneal space in direct contact with the suprarenal glands and the kidneys c. - the right hemidiaphragm reaches the 4th inter-costal space - the left hemidiaphragm reaches the 5th inter-costal space - hiatus venae cavae inferioris reaches the Th9 level - hiatus oesophageus reaches the Th10 level - hiatus aorticus reaches the Th11 level

MEDIASTINUM ANTERIOR superior part

- the mediastinum is split into a anterior and posterior part by a frontal plane wich is tangent to the posterior surface of the trachea and pericardium - further on the anterior mediastinum is split in other two levels: the inferior one (containing the pericardium and the heart) and the superior one (= the thymovascular medistinum) - the thymo-vascular mediastinum is situated above the hilum of the lungs, having as anterior border the sternum and as posterior border the posterior surface of trachea - the thymo-vascular mediastinum contains several planes in antero-posterior direction: I. The THYMIC plane: - represents the most anterior plane and contains the thymus wich is made by two lobes (lobus dexter and sinister), wich are made at their turn by smaller lobuli (lobuli thymi) - the surface of the thymus is coverd by a capsula fibrosa wich sends inside septa interlobularia - cortex thymi represents the peripheric part of the thymus - medulla thymi represents the central part of the thymus wich presentsthe characteristic corpusculi thymi Hassal - corpus adiposum thymi - in the adult life the thymus becomes fat tissue - topographically the thymus presents two parts: the cervical and thoracic: - pars cervicalis thymi is covered by the pretracheal lamella of fascia cervicalis and by the under-hyioidien muscles; it comes in contact superiorly with the thyroid gland, posteriorly with trachea and the recurrent laryngeal nerves and laterally with the brachiocephalic trunk (right side) and with left common carotid artery (left side) - pars thoracica thymi is situated in the back of the sternum, starting from the sterno-clavicular articulation until the 4th intercostals spaces; it comes in contact anteriorly with the posterior surface of the sternum, posteriorly with the venous plane (mainly with vena brachiocephalica sinistra) and laterally with pleura medistinalis and the internal mammary artery and veins - arteries - branches from the internal mammary artery - veins they are drained into the left brachio-cephalic vein - nerves branches from n. vagus and nervus laryngeus recurrens - lympha is drained towards the anterior medistinal lymph nodes

II. The VENOUS plane: - represents the second plane (being situated posterior to the thymic plane and anterior to the arterial plane) and contains the major veins that are draining the superior limb, the neck and the head: - vena brachiocephalica dextra the right brachiocephalic vein derives from the confluence of vena subclavia and vena jugularis interna from the right side; it has a length of 2,5-3 cm and goes downwards vertically towards the confluence with its omonim part from the left side; receives on its way vena thoracica interna dextra - vena brachiocephalica sinistra the left brachiocephalic vein derives from the same confluence of vena subclavia and vena jugularis interna but from the left side; it has a bigger length of 6-7 cm and goes downwards obliqually towards the right side of the body crossing by anterior the arterial plane (mainly the left common carotid artery and the brachiocephalic trunk); receives on its way the thymic veins, the impar thyroid venous plexus and vena thoracica interna sinistra - vena cava superior the superior caval vein derives from confluence of vena brachiocephalica dextra and sinistra; it has a length of 6-7 cm and goes downwards vertically towards the right atrium; receives before entering into the pericardium the azygos vein; it comes in contact posteriorly with the right pulmonary artery and the right-superior pulmonal vein and laterally with pleura mediastinalis and the right phrenic nerve (to the right) and with aorta ascendens (to the left) III. The ARTERIAL plane: - represents the third plane (being situated posterior to the venous plane and anterior to the trachea) and contains the major arteries emerging from the base of the heart: - truncus pulmonalis the plumonary trunk has the origin into the right ventricle, being situated completely in the pericardium, initially situated in the front of aorta ascendens, than going superiorly slighty towards the left side of the body under the aortic arch where it bifurcates in arteria pulmonalis dextra and sinistra - aorta ascendens the ascending aorta has 5-6 cm in length and the origin in the left ventricle, being situated initially situated in the back of the pulmonary trunk, than going superiorly slighty towards the right side of the body; at its origin presents a dilated part named bulbus aortae (in the lumen of aorta this zone corresponds with the sinuses aortae of Valsalva); it is situated completely into the pericardium and comes in

contact posteriorly with the bifurcatio trachealis and arteria pulmonalis dextra, laterally on the right with vena cava superior and auricula dextra; laterally on the left side with truncus pulmonalis - arcus aorticus the aortic arch continues aorta ascendens as it exits the pericardium (at the level of the 2nd sterno-costal articulation from the right side), connecting the distal end of aorta ascendens with the proximal end of aorta descendens (situated at the level of the left margin of Th4); the transition zone in between the arcus aortae and aorta descendens presents a slighty smaller diameter being named isthmus aorticus; it has approximately 6cm in length with his highest point being situated at the middle of manubrium sterni; it comes in contact anteriorly with the thymus and vena brachiocephalica sinistra, posteriorly with the left side of the trachea, inferiorly with bifurcatio trunci pulmonalis and pediculus pulmonalis sinister; arteria pulmonalis sinistra is connected with arcus aortae by liggamentum arteriosum Botallo; from the convexity of the aortic arch are emerging (in right to left order): - truncus brachiocephalicus the brachicephalic trunk goes upwards and slighty to the right (corresponding to a line situated in between the sternal extremity of the 2nd right rib and the sternoclavicular articulation from the same right side); at the level of the right sternoclavicular articulation it will bifurcate into arteria carotis communis dextra and arteria subclavia dextra; it comes in contact anteriorly with the vena brachiocephalica sinistra, posteriorly with the right side of the trachea, laterally to the right with pleura mediastinalis and with the upper part of facies mediastinalis pulmonis dextri - arteria carotis communis sinistra the left common carotid artery emerges to the left and posterior to the brachiocephalic trunk (corresponding to a line situated in between the middle point of manubrium sterni and the sternoclavicular articulation from left side); it comes in contact anteriorly with the vena brachiocephalica sinistra, posteriorly with the left side of the trachea, laterally to the left with the left subclavian artery - arteria subclavia sinistra the left subclavian artery emerges to the left and posterior to the left common carotid artery (corresponding to a line situated in between the middle point of the left margin of manubrium sterni and the sternoclavicular articulation from left side); it comes in contact anteriorly with the vena brachiocephalica sinistra, posteriorly with the left side of the trachea, laterally to the left with the pleura mediastinalis,

nervus vagus sinister and with the upper part of facies mediastinalis pulmonis sinistri

IV. The TRACHEAL plane: - represents the forth plane (being situated posterior to the arterial plane and anterior to the medistinum posterior) and contains the trachea

The abdominal wall

Its a complex structure composed by muscles, aponeurosis and bones situated around the abdominal cavity. The distribution of the walls: -superior: the diaphragm; -inferior: the pelvic diaphragm-m.levator ani; -anterior and lateral: -m.obliqus externus; -m.obliqus internus; -m.tranversus abdominis; -m.rectus abdominis. -posterior: -m.iliopsoas; -m.quadratus lumborus; -the paravertebral muscles; The posterior wall will be studied in The back muscles

The abdominal wall muscles

1. M obliqus externus-the outer muscle. Its fibres go downwards and forwards .The muscular part is situated only laterally and is continued medially by the aponeurosis musculi obliqus externus. O : the surface of the 5th to 12th ribs. The origin of obliqus internus intersects the fibres of m.serratus anterior I: crista iliaca; ligamentum inguinale; linea alba. N: nn.intercostales 6-12 , n.iliohypogastricum , n.ilioinguinalis. A: rotates the thorax to the opposite side; lateroflexion of columna vertebrae.

2. M.obliqus internus the middle one with the direction of the fibres upwards and forwards. Like the previous one, the muscular part is situated only laterally and is continued medially by the aponeurosis musculi obliqus internus. The inferior margin free of any insertions is called Arcus tendineus muscului obliqus internus, part of tendo conjuctivus. O : crista iliaca; fascia thoracolumbalis; ligamentum inguinale; I : the surface of the 10th to 12th ribs;

linea alba; N : nn.intercostales 10-12, n.iliohypogastricum, n.ilioinguinalis. A : rotates the thorax to the same side; lateroflexion of columna vertebrae. respiration muscle (the exhale phase) 3. M.transversus abdominis- the inner muscle of the abdominal wall with horizontal direction of the fibres. The limit between the muscular part (laterally) and the aponeurotic part (medially) is a vertical line linea semilunaris Spiegel. The inferior free margin is the other part of tendo conjuctivus Arcus tendineus musculi transversus abdominis. O : the inner surface of the 7th to 12th ribs; fascia thoracolumbalis; crista iliaca; ligamentum inguinale. I : linea alba N : nn.intercostales 6-12 , n.iliohypogastrum , n.ilioinguinalis. A : respiration muscle (the most important in the exhale phase). 4. M.rectus abdominis situated medially, with 4-5 intermediate tendons between the origin and insertion intersectiones tendinea. They are situated into a sheath vagina musculi rectus abdominis. O : the external surface of the 5th to 7th ribs and processus xiphoideus; I : simphysa pubica N : nn intercostales 6-12; A : respiration muscle (the exhale phase) increase the abdominal pressure. 5. M.Pyramidalis-a small inconstant triangle shape muscles situated in the lower part of the rectus abdominis sheath. O : simphysa pubica; I : linea alba; N: n.intercostales 12;

The abdominal wall conjunctive structures

1. Ligamentum inguinale represents the inferior part and also insertion of m.obliqus externus stretched between spina iliaca anterior superior and tuberculum pubis. -The medial insertion on pubis is complex, composed of three pillars: -crus mediale -crus laterale - between this two pillars are connecting fibres -Fibres intercrurales

-crus posterior-ligamentum reflexum Colles the fibres from the two sides are intersected on the superior surface of symphisa pubica. -The three pillars delimit the superficial ring of the inguinal channel. - In the angle between ligamentum inguinale and ramus superior osis pubis the arched fibres are called Ligamentum lacunare Gimbernat. -The pectineal muscles fascia which lies on the pecten osis pubis with ligamentum Gimbernat and Thomsons ligament fuse in ligamentum pectineale Cooper. 2. Linea alba-an aponeurotic raphe between processus xiphoideus and symphisa pubica and represents the fusion of all aponeuroses on the median line. The inferior insertion is wide adminiculum lineae albae. In the middle is perforated by the anulus umbilicalis. Up to it, linea alba is thinner than under it. 3. Vagina musculi rectus abdominis-is an aponeurotic sheath of rectus abdominis muscles with two laminas (anterior et posterior). In the upper part of the abdomen (2/3 superior) the disposition of the aponeurosis is: -lamina anterior-aponeurosis musculi obliqus externus; -the anterior splitting of obliqus internus aponeurosis; -lamina posterior-the posterior splitting of obliqus internus aponeurosis; -aponeurosis musculi transversus abdominis; -fascia transversalis. Lower (1/3 inferior) the disposition is changed: -lamina anterior: - aponeurosis musculi obliqus externus; - aponeurosis musculi obliqus internus; - aponeurosis musculi transversus abdominis; -lamina posterior : -fascia transversalis. The two types of disposition are separated by an arcuate line-Linea arcuata Douglas. On the lamina anterior are inserted the Intersectiones tendinea of m.rectus abdominis.

The arteries of the abdominal wall

There are two systems of arteries for the abdominal wall blood supply: -transversal(horizontal); -longitudinal(verical); The transversal system-the arteries arise from laterally and goes to linea alba. -aa.intercostales posterior 10-11; -a.subcostalis; -aa.lumbales 1-5;

The longitudinal system -a.epigastrica superior: branch of a.thoracica interna, perforates the diaphragm through the Larreys hiatus, then enters into the rectus abdominis sheath and lies on the lamina posterior; -a.epigastrica inferior: branch of a.iliaca externa, is situated first in the preperitoneal space ligamentum ombilicale laterale and then perforates the lamina posterior of rectus abdominis sheath. Inside of it conect the ending part of a.epigastrica superior, resulting the epigastric anastomosis. Branches of a.epigastrica inferior: -ramus pubica; -ramus obturatoria-with the homonim branche from a.obturatoria (a.iliaca interna) form an important anastomosis under the ramus superior osis pubis called corona mortis (the deaths arch) due to severe bleedings in the past during the surgical interventions for femoral hernia repair; -a.cremasterica enter into the spermatic cord; -a.circumflexa iliaca profunda upwards and laterally.

The veins of the abdominal wall

The veins of the abdominal wall represent a wide anastomotic system between the major venous systems: vena cava superior, vena cava inferior and vena porta. The superior caval system tributary veins: -vv intercostales 10-11 drains in vena azygos and hemiazygos; -v.subcostales - drains in vena azygos and hemiazygos; -vv.lumbales 1-2 : - drains in vena azygos and hemiazygos; -v.epigastrica superior drains in vena subclavia. The inferior caval system tributary veins: -vv.lumbales 3-5 drains directly in vena cava inferior; -v.epigastrica inferior-drains in vena iliaca externa; The portal system tributary veins: -vv.periombilicales-are spiraling around the ligamentum teres hepatis. Between the three systems result anastomosis which are very important in some conditions: -the cavo-caval anastomosis; -the porto-caval anastomosis (the jellyfish head sign).

The lymphatic drainage of the abdominal wall

-The superior part of the wall drains in the axillary and mediastinal lymph nodes; -The inferior part of the wall drains in the inguinal lymph nodes and iliacus externus.

The nerves of the abdominal wall

-provide the motor innervation for the abdomen muscles and the sensitive innervation for the skin and peritoneum. -Nn.intercostales 6-8: for the superior part of the abdominal wall, goes medially, forwards and upwards, resulting three curves with a superior concavity. -N.intercostalis 9: for the medial part of the abdominal wall, goes forwards keeping its horizontal trajectory. -Nn.intercostales 10-12: for the inferior part of the abdominal wall, goes forwards and downwards, resulting in three curves with inferior concavity. -N.iliohypogastricus-branch of plexus lumbalis, lies on the m.obliqus internus. Gives motor branches for the abdominal muscles and sensitive branches for the inferior part, the hypogastric region, after it perforates the aponeurosis of m.obliqus externus. -N.ilioinguinalis arises from the same plexus, is situated between m.obliqus internus and m.transversus abdominis. In canalis inguinalis, it is attached to the spermatic cord .Gives motor and sensitive branches: Nn scrotales anteriores or Nn labiales anteriores -N.genitofemuralis:the genital branch is attached to the spinal cord and gives sensitive branches for the genital organs.

The topography of the abdominal wall

Using three imaginary lines the abdominal wall is divided in nine different regions. The lines -linia bisubcostalis-a horizontal line tangent to the inferior arch of the 10th rib. -linia supracristalis-a horizontal line tangent to the highest points of the crista iliaca; -linia pararectalis-a vertical line tangent to the lateral margin of m.rectus abdominis. The regions: -the horizontal lines divide the abdominal wall in three compartments (superior, median, inferior) and the two vertical lines split every compartment in three regions. The superior compartment: 1. Regio hypocondrica dextra; 2. Regio epigastrica; 3. Regio hypocondrica sinistra;

The median compartment: 4. Regio lateralis dextra; 5. Regio umbilicalis; 6. Regio lateralis sinistra; The inferior compartment: 7. Regio inguinalis dextra; 8. Regio hypogastrica; 9. Regio inguinalis sinistra.

The interior aspect of the abdominal wall

-covered by the peritoneum, the inside view of the abdominal wall presents folds and ligaments, most of them embryonic rests. The center of all the folds is anulus umbilicalis. The downwards folds: -Plica umbilicalis mediana a fold which contains ligamentum umbilicalis medius the fibrotic transformation of urachus. -Plica umbilicalis medialis laterally, contains ligamentum umbilicalis medialis the fibrotic transformation of the aa.umbilicales. -Plica umbilicalis lateralis more laterally, contains the inferior epigastric vessels, covered by the peritoneum. The upward fold: -Ligamentum teres hepatis-betweeen the anulus umbilicalis and incisura hepatica, represents the fibrotic transformation of the vena umbilicalis.

Canalis inguinalis
-situated on each sides above the ligamentum inguinalis is a 4-5 cm length channel. The direction is parallel with the inguinal ligament. The channel has two rings, four walls and the content. The rings: -Anulus inguinalis profundus-is situated at 2 cm above to the middle point of ligamentum inguinalis , bordered medially by the inferior epigastric vessels and ligamentum Hasselbach. -Anulus inguinalis superficialis-situated at 2 cm above and laterally to the tuberculum pubicum is bordered by the pillars of ligamentum inguinalis : crus mediale , crus laterale , fibres intercrurales and posterior ligamentum reflexum Colles.

The walls: Anterior- Aponeurosis musculi obliqus externus. Inferior- Ligamentum inguinalis; Superior- the two inferiors margins of the m.obliqus internus and transversus abdominisarcus tendineus musculi obliqus internus, arcus tendineus musculi transversus abdominis. Sometimes these margins are fused into a tendon called tendo conjunctivus or falx inguinalis. Posterior-fascia transversalis enforced by three ligaments: -ligamentum interfoveolare Hasselbach-the insertion on the ligamentum inguinalis of linia arcuata Douglas, is situated on the lateral border of anulus inguinalis profundus. -ligamentum Henle-the tangent part of fascia transversalis to the tendo conjuctivus. Some authors include ligamentum Henle in tendo conjuctivus or falx inguinalis; -ligamentum Thomson-the fusion of the fascia transversalis with fascia iliopsoica , is situated behind to ligamentum inguinalis and parallel to it. Trigonum Hasselbach a triangle on fascia transversalis, bordered by ligamentum Hasselbach, ligamentum Henle and ligamentun inguinalis. It is considered the weakest part of the posterior wall, the place of inguinals hernias. The content of canalis inguinalis is different in men and women: -the spermatic cord-funiculus spermaticus-contains the arteries, veins, nerves for the testes, ductus deferens and the cremaster muscle. -ligamentum teres uteri-a ligament that keeps the uterus in a normal position.

1. The stomach
Its the most dilatated segment of the digestive tract, situated in the left hypocondrum, about 1300 ml capacity, between the oesophagus and duodenum. The two major parts, the horizontal one and the vertical one give the J shape aspect. Walls: -paries anterior- is pointing to anterior and superior ; -paries posterior- is pointing to posterior and inferior. They are joint in two margins: -curvatura ventriculi minor-the superior fusion of the two walls. On the inferior part a sudden change of curves direction from vertically to horizontally is called incisura angularis -curvatura ventriculi major-the inferior joint of the walls. The entering in the stomach is bordered by the cardia a sphincter muscle with one way valve function. The exit from the stomach is delimited by the pylor with the same function. The constitutive parts of the stomach: a bisecting line through the incisura angularis split the stomach in two parts: -pars verticalis (pars dygestoria): above -pars cardiaca a small part situated around the cardia with mucous glands in submucosa; -fundus ventriculi the part situated above the horizontal line through the cardia, rich in hydrochloric acid secretory glands. Usually this part is full of air. The angle between the curvatura ventricului major and fundus ventricului is called Incisura cardiaca or His angle. -corpus ventriculi the largest vertical part under the horizontal line through the cardia, with hydrochloric acid secretory glands and pepsinogen secretory glands. -pars horisontalis (pars egestoria): under -antrum pyloricum the last dilatated part of the stomach , where the ingested aliments are prepared and waiting to be evacuated ( antrum means waiting room) ; -canalis pyloricus- its a 1 cm length channel at the end of the stomach which contains the pyloric muscle-the circular muscle layer development. The interior aspect of the stomach: -the folds of mucosa are called plicae villosae and delimit between them ariae gastricae. -on the small curve, two developed longitudinal folds goes downwards and parallel from cardia to pylor and bound a groove for the liquids flow Waldayer highway. -a wide thin fold Gubarovs valve - situated on the cardial region has an one way valve function.

The stomach layers: -mucosa-the glandular epithelium lies on the thin muscular layer-muscularis mucosa. Also here are developed the secretory glands, producing hydrochloric acid, pepsinogen, mucous and gastrin. -submucosa contain collagen fibres, vessels and autonomic nerves (plexus Meissner). -the muscular layer: -the inner one- oblique fibres, surrounding the stomach -the middle one the circular muscle layer which is more developed at the sphincter regions. -the outer one-the longitudinal muscle layer, more developed at the curves regions; -serosa-the peritoneum which cover the stomach. The topography of the stomach: -the anterior wall is pointing to the abdominal wall. -Labbes triangle bordered by the inferior margin of the liver, the inferior left margin of the thoracic wall and a horizontal line through the 9th ribs. -spatium semilunare Traube- a semilunar space on the left lateral thoracic wall with the top of the arch at the 5th rib. -the posterior wall is pointing to bursa omentalis. The arteries of the stomach are organised along the two curves as two anasomotic arches. They are directly or indirectly branches of the truncus celiacus. -a.gastrica sinistra the most important branch, arises from truncus celiacus and is situated on the superior part of the small curve; -a.gastrica dextra branches from a.gastroduodenalis (from a.hepatica communis) and lies on the inferior part of the small curve; -a.gastroepiploica sinistra is situated on the superior part of the large curve. Is a small branch of a.lienalis; -a.gastroepiploica dextra branches from a.gastroduodenalis and is situated on the inferior (right) part of the large curve. -aa.gastricae breves a few branches from arteria lienalis to fundus ventriculi. The veins of the stomach have the same disposition and drain in the portal system: -v.gastrica sinistra and dextra drains in vena porta; -v.gastroepiploica sinistra-drains in v.lienalis; -v.gastroepiploica dextra drains in v.mesenterica superior; -vv.gastricae breves-drains in vena lienalis A small branch of v.gastrica sinistra is connected with the caval system (v.azygos) in the lower part of the oesophagus ( here is the site of the oesophageal varix in liver chirossis)

The lymph is drained in: -nodi lymphatici gastrici dextri et sinistri; -nodi lymphatici gastroepiploici dextri; -nodi lymphatici pylorici; -nodi lymphatici pancreaticolienalis; -nodi lymphatici celiaci. The autonomic nerves are: -sympathetics: enter in the stomach layers around the arteries; -parasympathetics: belong to the vagus nerves, with a very important role in hydrochloric acid secretion. The two autonomic systems are organised into the stomach layers in: -plexus submucosus Meissner; -plexus myentericus Auerbach.

2. The duodenum
Its a horseshoe shape organ, about 25-30 cm length, situated in continuation of the stomach. Duodenum division: -pars superior-bulbus duodenalis-is between the duodenopyloric groove (where vena pylorica is situated) and superior duodenums knee-flexura duodenalis superior; -pars descendens-the second part, between flexura duodenalis superior and flexura duodenalis inferior; -pars horisontalis-intersect the spine at L4 level and cross in the left side; -pars ascendens the last part, until the duodenojejunal flexure -flexura duodenojejunalis or the Treitz angle , the starting point of the jejunum. The flexure is sustained by a small muscle-musculus Treitz, which arises from the left pillar of diaphragm and aorta abdominalis. The layers of duodenum: -mucosa-the inner layer , made by glandular epithelium and under it, muscularis mucosae. -submucosa-contains glands specific to duodenum-glandulae duodenales with mucous secretion. Also here are the nerves of plexus submucosus Meissner; -tunica muscularis: circular and longitudinal fibres. Also contain the plexus myentericus Auerbach. -serosa (adventitia): only the first part of duodenum is situated inside the peritoneal cavity and is covered by peritoneum. The rest of it is in retroperitoneum. A peritoneal fold, situated behind of the Treitz angle, split the space between the last part of duodenum and the posterior peritoneum in two parts: recessus retroduodenalis superior et inferior.

The internal aspect of duodenum; Due to muscularis mucosae, the inner layer appear life circular folds, named Plicae circulare Kerkring. -on the posterior wall of pars descendens a vertical fold is the mark of the choledocus situated posterior; -also in pars descendens on the medial wall, there are two little perforated mucosal projections: -papilla duodeni major-the opening of the choledocus and Wirsung channel in duodenum; -papilla duodeni minor-the opening in duodenum of ductus Santorini (canalis pancreatis accesor). The blood supply will be presented at the pancreas. The autonomic nerves arise from plexus celiacus (sympathetic part) and from vagus nerves (parasympathetic part), forming the two inner layer plexus: -plexus submucosus Meissner; -plexus mientericus Auerbach.

3. The pancreas
Its a double function gland: endocrine and exocrine situated profound, behind the stomach. The parts of pancreas: -Head caput pancreatis - is situated in the duodenal frame and presents two surfaces: -facies anterior-points to bursa omentalis and through it, to the posterior wall of the stomach. It is split by the mesocolon insertion in a supramesocolic and inframesocolic parts. A small pancreatic tissue called processus uncinatus, borders with the inferior part of the head the pancreatic notch (incisura pancreatica). Inside of it lies artera and vena mesenterica superior. -facies posterior-points to the retroperitoneum. Behind the pancreas and duodenum is stretching the fascia retroduodenopancreatica Treitz. Through it, the pancreas borders with the following retroperitoneal organs: -vena cava inferior; -the right kidney and the suprarenal gland -choledocus; -vena porta. -Neck - Collum pancreatis is a small narrowing part between the head and corpus -Body - Corpus pancreatis presents three margins: -margo superior is bordering by the splenic artery ; -margo anterior-represents the insertion of the transverse mesocolonum; -margo inferior (posterior) -and three surfaces: -facies anterior-points to bursa omentalis;

-facies posterior-points to retroperotoneum(aorta abdominalis, vena renalis sinistra, vena lienalis); -facies inferior-points to the inframesocolic region. - Tail - Cauda pancreatis- is situated on the left in front of the kidney and suprarenal gland and is continued by the pancreaticolienalis ligament which is the spleens vascular pedicle. The endocrine function consists of insulin and glucagon secretion by the alpha and beta pancreatic cells. The exocrine function consists in enzymes secretion in two collecting channels: -Wirsung duct-canalis pancreatis principalis cross the entire gland and is opened with choledocus in papilla duodeni major; -Santorini duct-canalis pancreatis accesorius-crosses only the superior part of the pancreatic head and is opened in papilla duodeni minor. The connection with the Wirsung duct is variable. Arteries of the pancreas: -Head has the same vascularisation with the duodenum. The two anastomotic arches situated in front and behind the head (arcada pancreatis anterior et posterior ), have the following sources: -a.pancreaticoduodenalis superior-branches from a.gastroduodenalis; -a.pancreaticoduodenalis inferior-branches from a.mesenterica superior. -Body and tail: due to a large variability, is almost individual. The most frequent pattern contain three arteries: a.pancreatica magna, a.pancreatica dorsalis and a.pancreatica inferior. All of these are anastomosis between a.mesenterica superior and a.lienalis. The veins of the pancreas have the same distribution and drain in vena porta. The lymph is drained in: -nodi lymphatici hepatici-the head; -nodi lymphatici celiaci-the body; -nodi lymphatici pancreaticolienalis-the tail. The nerves arise from plexus celiacus (sympathetic part ) and vagus (parasympathetic part).

4. The spleen (Lien)

Its an ovoid shape organ, situated in the left hypocondrum. The dimensions are 12/8/4 cm. The ovoid has two extremities and two margins: -extremitas anterior-points to anterior and inferior; -extremitas posterior points to posterior and superior; -margo superior-easy to recognized due to irregular shape; -margo inferior-smooth;

The surfaces of the spleen: -facies diaphragmatica-convex, points to diaphragm; -facies visceralis-points to the abdominal cavity and internal organs: -facies gastrica superior; -facies colica inferior and anterior; -facies renalis-inferior and posterior; -hillus lienis is situated between the three surfaces contains artera and vena lienalis. The spleens ligaments -ligamentum gastrolienale-is the left lateral part of omentum majus. Arteriae et venae gastricae breves cross the ligament and provides the blood supply for the fundus ventriculi. -ligamentum phrenicolienalis-maintain the spleen stick to the diaphragm; -ligamentum pancreaticolienalis-contain the spleen vessels -ligamentum phrenicocolicum sinistrum- the spleen lies on this ligament this is the reason why it is called sustentaculum lienalis. The blood supply is provided by the artera lienalis, a branch of truncus celiacus, it is situated first on the superior margin of the pancreas body and enter in ligamentum pancreaticolienalis; Vena splenica drains in vena porta; The lymph is drained in nodi lymphatici pancreaticolienalis; The nerves arise from plexus celiacus and vagus.

The Liver
The liver is the largest gland of our body, its mean weight is about 1500 g, which can vary between 1000 and 2000 g in the living person, depending on the quantity of blood it contains. External features It is malleable, so it follows the shape of the surrounding organs. It has two surfaces, and four lobes. Facies diaphragmatica - its superior surface. It is attached to the right dome of the diaphragm, and it is made up mainly by the right lobe, and with a small part belonging to the left one. The latter has a shallow groove formed by the heart sitting on it, with the diaphragm in between them. (Impressio cardiaca). Facies visceralis - its inferior surface. It contacts the abdominal viscera, it is essentially flat, uneven, and it is oriented posterior and inferior. It is crossed by two longitudinal, antero-posterior grooves, that are linked by a transversal groove, the porta hepatis. The left longitudinal groove is narrow, and it is embedded in the parenchyma of the liver, and compared to the porta it has two - one anterior, and one posterior - portions. Its anterior part (Fissura ligamenti teretis) contains the remnant of the umbilical vein, the round hepatic ligament, while in the posterior portion (Fissura ligamenti venosi) there is the ligamentum venosum, the obliterated vestigium of the ductus venosus (Arantius). The right longitudinal groove is wider than the left, and also has two portions (anterior and posterior). The anterior portion is the groove of the gallbladder (Fossa vesicae felleae), the posterior, deeper one contains the inferior vena cava (Sulcus venae cavae). The two portions of the right longitudinal groove are separated by the processus caudatus of the caudate (Spiegel) lobe of the liver. The transversal groove is essentially the Porta hepatis, linking the longitudinal grooves. It has an oblique orientation, it is 6-7 cm long, and 1.5 cm wide. The structures of the hepatic pedicle enter and exit the porta. The above grooves divide the visceral surface of the liver into four lobes. Lobus hepatis sinister - the left lobe, located to the left of the left longitudinal groove, following the anterior surface of the stomach (Impressio gastrica). It ends to the left in a pyramid shaped fibrous appendage (Appendix fibrosa hepatis). Lobus hepatis dexter - the right lobe, located to the right of the right longitudinal groove, contacting several organs, that produce impressions on it: anterior - the right colic flexure (Impressio colica) posterior - the right kidney (Impressio renalis) in the middle - the duodenum (Impressio duodenalis) Lobus quadratus - the quadrate lobe, located anterior to the porta hepatis, between the anterior portions of the longitudinal grooves, contacting the pylorus. Lobus caudatus - the Spiegel lobe is located posterior to the porta hepatis, between the posterior portions of the longitudinal grooves. It has a left papillary process (Processus papillaris), and a right caudate process (Processus caudatus), which separates the groove of the gallbladder from the groove of the inferior vena cava. The posterior surface is essentially a posterior linking portion (Pars posterior) between the diaphragmatic and visceral surfaces; it is almost vertical, contacting the spine. The groove of the inferior vena cava continues to this surface, and it turns into a channel buried into the hepatic parenchyma. The hepatic veins drain into the inferior vena cava by passing the walls of this channel. The right, convex portion of this posterior surface attaches directly to the diaphragm, and it is not covered by peritoneum (Area nuda). It bears the mark of the suprarenal gland (Impressio suprarenalis). The middle portion of the posterior surface corresponds to the Spiegel lobe, contacting the right column of the diaphragm and the aorta; the left portion is on the left lobe, bearing the mark of the esophagus (Impressio oesophagea). The anterior (inferior) border (Margo inferior) of the liver separates the diaphragmatic and visceral surfaces. It has two notches, corresponding to the anterior ends of the longitudinal grooves; the left one is deeper (Incisura ligamenti teretis).

The peritoneal relations of the liver are complicated. The duplications formed by the transition of the visceral peritoneum into the parietal peritoneum will be the peritoneal ligaments of the liver. Lig. falciforme hepatis - it rises from the umbilicus towards the liver, linking the anterior surface of the liver to the anterior abdominal wall and the diaphragm. Its thickened anterior margin contains the obliterated, fibrous vestigium of the umbilical vein (Lig. teres hepatis). On the convexity of the liver it separates into a left and a right lamina, and passes into the coronary ligament of the liver (Lig. coronarium hepatis). Lig. coronarium hepatis - it is oriented in the frontal plane along the posterior-superior margin of the liver, attaching it to the diaphragm (the anterior transition of the liver peritoneum). Along the right and left edges of the coronary ligament the anterior lamina continues in the posterior lamina of the ligament, which also transitions from the convexity of the liver to the concavity of the diaphragm, along the posterior-inferior margin. To the right the posterior lamina diverges from the anterior one, forming a fairly large area (Area nuda). Here, the transition of the peritoneum crosses over the anterior surface of the vena cava inferior, goes along the Spiegel lobe, and duplicates along the groove of the ligamentum venosum, entering the lesser omentum. Lig. triangulare dextrum et sinistrum - as they close on each other, the laminae of the right and left edges of the coronary ligament end in two triangular ligaments. The inferior surface (the porta hepatis) is linked to the duodenum, the lesser curvature of the stomach and the abdominal part of the esophagus by the lesser omentum.

EXTRAHEPATIC BILE DUCTS

The common hepatic duct - Ductus hepaticus communis It is formed in the porta hepatis by the right (shorter) and left (longer) hepatic ducts. These are located anterior to the branches of the portal vein. The 3-4 cm long, 0.5 cm wide common hepatic duct travels obliquely to the left and posterior in the free edge of the lesser omentum. It unites with the cystic duct to form the Ductus choledochus. The 5-7 cm long, 0.5 cm wide common bile duct continues to travel along a path concave to the right and anterior. Along its path it crosses several structures, thus it has 4 segments: supraduodenalis (not constant) retroduodenalis retropancreaticus and intraparietalis. The latter is in the wall of the duodenum, and has a 2-3 mm diameter. The inner surface of these ducts is smooth, with 0.5 mm diameter grooves (crypts). The gallbladder - Vesica biliaris, Vesica felleae, Cholecysta It is 8-10 cm long, stores bile, and it is located in its own groove (Fossa vesicae felleae). Parts: Fundus vezicae felleae - rounded bottom Corpus vezicae felleae - slightly flattened body, continued towards left and posterior into the Collum vesicae felleaeben - the neck of the gallbladder. The wider, ampullar part of the neck has an anteriorly open angle with the body, with a lymph node in the angle. The part of the body continuing into the neck is clinically called infundibulum. Ductus cysticus - the cystic duct continues the neck, and uniting with the common hepatic duct forms the common bile duct. It has an average length of 3 cm, with a 2.5 mm upper, and a 3-4 mm lower diameter. On its inner surface there are 5-12 spiral plicae (Plica spiralis). These may play a role in the filling of the gallbladder under low bile pressure conditions, and emptying of the bladder under higher pressure conditions. The last plica is clinically called the sphincter of Ltkens.

The liver (Hepar)

It is the greatest gland attached to the digestive tract , situated in the upper floor of the abdominal cavity : right hipocondrum , epigastrium and partially in left hypocondrum. The weight is about 1,5 Kg at the cadaver and 2.0 Kg at living human , due to the inner blood.

External configuration:
The liver has an ovoidal shape with two faces and two margins: -margo anterior-the sharp one , is divited in two parts by incisura hepatica; -margo posterior-more rounded ; -facies superior-facies diaphragmatica-is situated under the right and left diaphragmatic domes.Between the two structures there is a virtual space spatium interhepatophrenicum. -facies inferior-facies visceralis-point to the intraperitoneal organs. Facies diaphragmatica. -through the diaphragmatic dome the superioe face is related with : -the right anterior and lateral arch of the 7th to 10th ribbs-impressio costalis; -the heart apex-impressio cardiaca; -the posterior part of this face is partially uncoverred by the peritoneum-aria nudawhere the liver is attached to the posterior abdominal wall and vena cava inferior. -the inferior limit of facies superior ussualy follow a line that joint the tip of the 10th rib from the right with the tip of 8th rib from the left. -on the superior face the liver presents two external lobes:lobus dexter et lobus sinister separeted by the ligamentum falciforme.This lobes are not the correspondents of the portobilliary division of the liver , as we will see. Facies visceralis: Is divided in four lobes by a H shape grooves: -sulcus longitudinalis sinister: -pars anterior-is represented by the Fissura(Incisura) ligamenti teretis , where is the entrance of ligamentum teres hepatis (the fibrotic transformation of vena umbilicalis) -pars posterior-Fissura ligamenti venosi , where is situated the Ligamentum venosus Arantzius-embriologycal rest of the umbilicalo-caval shunt; -sulcus longitudinalis dexter: -pars anterior-Fossa vesicae fellae-the site of the gallbladder; -pars posterior-sulcus venae cave inferior-in the upper part of it is the confluence between the suprahepatic veins and vena cava inferior. -sulcus transversalis-joint the middle points of the two longitudinal lines and is occupied by the hepatic pedicle (hillus hepaticus)

The visceralis face external lobes: Lobus dexter:the greater lobe , situated in the right hypocondrum , on the right side of the falciform ligament and the right side of sulcus longitudinalis dexter. The organs related with this inferior lobe face are: -impressio colica-situated anterior; -impresio duodenalis-posteriorlly to the first one; -impressio renalis and suprarenalis-more posteriorlly and inferiorlly to the others. Lobus sinister Medium size situated partially in epigastrium and left hypocondrium , on the left side of ligamentum teres hepatis and sulcus longitudinalis sinister , presents a projection near to the hepatic pedicle-tuber omentale.I.s releated with the abdominal oesophagusimpressio oesophagei Lobus quadratus-situated anteriorlly to the hepatic pedicle presents the following limits: -sulcus longitudinalis dexter-pars anterior-on the right side; -sulcus longitudinalis sinister-pars anterior-on the left side; -sulcus transversalis(hillus hepaticus)-inferiorlly; -margo anterior Its releated with the pylor. Lobus caudatus (The Spiegels lobe) -situated posteriorlly to the hepatic pedicle is bordered by: -sulcus longitudinalis dexterpars posterior; -sulcus longitudinalis sinister-pars posterior; -sulcus transversalis; -margo posterior. Presents two projections that points to bursa omentalis: -processus papillaris-border inferiorlly the hepatic pedicle; -processus mamillaris-border latterally on the left side vena cava inferior.

The ligaments of the liver The entire organ , excepting the hepatic pedicle and aria nuda , is covered by the peritoneum with two layers (tunica subserosa-the inner one and tunica fibrosa Glisson) -Ligamentum falciforme: two paralelly and adherent peritoneal folds between the diaphragm dome and facies superior.The anterior part is continuated by the ligamentum teres hepatis. -Ligamentum coronarium:is the posterior continuation of the falciforme ligament wich is splited in two folds bordering superiorlly aria nuda. -Ligamentum triangulare-two ligaments on the each side wich are joint with the coronar ligament and border the lateral limit of aria nuda. -Omentus minus : -Ligamentum hepatoduodenale-between the first part of the duodenum and hillus hepaticus. -Ligamentum hepatogastricum-between the inferior face of the liver and the lesser curvature.

The hepatic pedicle (porta hepatis): -is situated on sulcus transversalis The elements of the hepatic pedicle: -ductus hepaticus comunis-is situated anteriorlly and to the right , represents the fusion of the canalis hepaticus dexter et sinister.Transport the bile through it and then choledocus into the duodenum. -artera hepatica propria-arise from artera hepatica communis , branch of truncus celiacus , is situated anteriorlly and to the left.Represnts the nutritive blood suplie , transporting the oxygen and the nutritive substances to the cells (hepathocites).After a short way into the hepatoduodenal ligament divides in the right branche and in the left branche.The right one gives two segmentary arteries: A.segmenti anterior and A.segmenti posterior.The left branche gives another two segmentary arteries:A.segmenti medialis and A.segmenti lateralis.The caudat lobe receive blood suplie from the booth branches -vena porta-represents the joint of vena lienalis and vena mesenterica superior-is the functional blood suplie of the liver by providing the absorbed nutriens from the small bowell to the hepatic cells.Is the most posterior element of the hepatic pedicle.The intrahepatic divisions are the same like the arterie system. -lymph nodes:nodi lymphatici hepatici; -nervs:symphatetic fibers:from plexus hepaticus; parasymphatetic fibers:from n.vagus. -capsula fibrosa perivascularis-the continuation of the Glison membrane , on the hepatoduodenal ligament. -Venae porte accesoria-small veins wich belongs to the portal system The suprahepatic pedicle: Drains the liver blood in vena cava inferior: -Vena hepatica intermedia-principalis-the most important one; -Vena hepatica dextra; -Vena hepatica sinistra; The three veins can drain into the inferior caval vein one by one , ore they are first joint into a single big trunk.

The segments of the liver:

The anatomic segments-are the consequence of the vasculobiliary divisions inside the hepatic tissue.The real limit between the right lobe and the left one from vascularisation point of view is an imaginary line scizura hepatica principalis Rex Cantle line and is situated between the gallbladder(anterior) and the left border of the inferior caval vein (posterior).Guiding by the arteria hepatica division(or vena porta) results the following anatomical segments: -Segmentum anterius of the right lobe; -Segmentum posterius of the right lobe; -Segmentum mediale of the left lobe; -Segmentum laterale of the left lobe.

The surgical segments:is different to the anatomical division and has clinical and surgical importance in hepatic resections.Through each suprahepatic veins thrre imaginary lines will split the liver in four parts (four primary segments) , two situated on the left and two on the right.Then an horisontal plane through the midle of the liver will divide each primary segment in two , resulting eight segments.An easier way to evaluate the surgical segments is counting them on clockwise sense. 1. 2. 3. 4. 5. 6. 7. 8. Segmentum paramedianum sinister superior-lobus caudatus; Segmentum lateral superior sinister; Segmentum lateral inferior sinister; Segmentum paramedianus inferior sinister-lobus quadratus; Segmentum paramedianus inferior dexter; Segmentum lateral inferior dexter; Segmentum lateral superior dexter; Segmentum paramedianus superior dexter

The extrahepatic billiary system

1. Ductus hepaticus communis arise from the confluence of canalis hepaticus dexter et sinister.Its about 3-4 cm lenght , situated on the right side of the hepatic pedicle crossing anteriorlly the right branches of arteria and vena porta.The distal part will collect the cystic duct. 2. Ductus choledocus-results from the confluence of ductus hepaticus and ductus cysticus.Presents three parts:retroduodenal , retropancreatic and intraparietalis. Transports the bile from the liver to the duodenum.Before the opening in ampulla duodeni major will fuse with the Wirsung duct. Quenu quadratum-is bordered by the first three duodenal parts and vena mesenterica superior.The diagonal of this quadrilateral , from superior to inferior and from the left to the right is ductus choledocus 3. The gall bladder(Vesica fellea) -a piriform storage chamber for the bile between the meals.It has three parts: -Fundus vesicae fellae-point to the abdominal wall; -Corpus vesicae fellae-is attached to the liver and lies on the duodenum and transversal colon; -Collum vesicae fellae-ampular shape , presents a mucosal fold-plica spiralis or Heister valve. -Ductus cysticus:between the gallbladder and ductus hepaticus comunis.The Budde triangle is bordered by the cystic duct , hepatic duct and the inferior face of the liver and is cossed by arteria cystica-branche of a.hepatica dextra. The sphincters muscles of the extrahepatic billiary system: -Mirrizi sphincter muscle-on the ductus hepaticus communis; -Lutkens sphincter muscle-on the cystic duct; -The sphincter of the Wirsung duct;

-Oddi sphincter muscle-the common sphincter muscle for ductus choledocus and Wirsung duct. The vessels, nervs and lymphatic system of the gallbladder -arteria cystica arise from artera hepatica dextra; -the veins drains into the portal system; The lymph is drained in hepatic pedicle lymph nodes.Near to ductus cysticus is situated the Mascagni lymph node considered particular for the gallbladder. The nervs arise from plexus celiacus and the vagus nervs.

The small intestine

The two parts of the small intestine are the longest parts of the digestive tract, measuring about 5-6 m (1/4 jejunum and 3/4 ileum). External aspect: -both parts have the same external aspect: a round shape covered by visceral peritoneum except a thin line where the mesenterium is inserted. They are organised in 15-16 intestinal loops which lie all over the inframesocolic compartment. -sometimes at 50-70 cm to ileocecal joint there may be situated the Meckel diverticulum an embryological rest of omfaloenteric duct. -the mesenterium -represents the root of the jejunum and ileum. Its composed by vessels, nerves, lymph vessels and fat tissue situated between two peritoneal walls. The insertion of mesenterium is oblique, on the peritoneum parietale posterior (radix mesenterii) and crosses from left to right: left ureterus, vena mesenterica inferior, aorta abdominalis, vena cava inferior, right ureterus and the right genital vessels. With the colic frame, the inframesocolic space splits into trigonum mesentericocolicum dextrum et sinistrum. Internal aspect: Due to the muscularis mucosa contractions, the internal aspect appears with a lot of mucosal folds (plicae circulares Kerkring). These folds are more developed into the superior part (jejunum) and less at the end of ileonum. By folding the mucosa, the intestines increase the absorption surface by 400%. Vilii intestinales (about 5-10 million) represent rounded projections of the mucosa 0.51.5 mm high, increasing the intestinal surface by 600%. Each one contains the epithelium which covers the pedicle- arteries, vein, a thin muscle and lymph vessel. The intestinal layers: -mucosa: -epithelium made by columnar cells. Each cell again increases the absorption surface by folding the cell membrane. Between the villus intestinales the cells are organised into the intestinal glands(Glandulae intestinales Lieberkuhn) with mucous secretion -soft tissue- contains a rich network of lymph vessels and nodes organised in two structures: Folliculi lymphatici solitari and Folliculi lymphatici agregati- Peyer. The last ones are present only in the ileonum terminale ; -muscularis mucosa- gives by its contraction plicae circulares. -submucosa: consists in areolar tissue with blood and lymph vessels and plexus submucosus Meissner; -tunica muscularis-contains a longitudinal outer layer and a circular inner layer. Between them is situated the Plexus mientericus Auerbach; -serosa- the peritoneum covering the intestinal outer surface, except the insertion of mesenterium.

Vessels and nerves: -Arteries arise from A.mesenterica superior and there are 10-16 Aa.jejunales and ilei. These arteries are organised in anastomotic arches (usually three levels and from the last level the small arteries perforate the intestinal wall). -Veins- with the same disposition, drain in Vena mesenterica superior; -The lymph is drained through Folliculi lymphatici solitari and Folliculi lymphatici agregati-Peyer in Trunci intestinales and then in Cysterna Pecquet. -The sympathetic nerves arise from plexus celiacus and with parasympathetic branches from nervus vagus enter into the two plexus: submucosus Meissner and mientericus Auerbach.

The large intestine (Intestinum crassum)

The last part of the digestive tract begins at the ileocecal junction and ends with the anus. It measures about 1,5 m, consisting of six different segments: caecum, colon ascendens, colon transversum colon descendens, colon sigmoideum and rectum. External aspect of the colon The particular external configuration of the colon is due to the disposition of the muscular layer. The longitudinal one is organised in three taenias: -Tenia libera-visible on the entire anterior surface. -Tenia mesocolica-represents the insertion of the mesocolons; -Tenia omentalis-consists in insertion of omentum majus on the transversal colon. The three taenias are joined proximally at the insertion of appendix in caecum and distally in the outer longitudinal muscular layer of the rectum. On the surfaces of the taenias are inserted Appendices epiploicae-fat tissue covered by peritoneum The circular layer by its contraction will give to the colon a particular aspect with dilatated parts (Haustra coli) separated by circular contracted muscular layer. The colon layers -mucosa: is flat with no circular folds or villus. The collumnar cells are organised in Glandulae intestinales Lieberkuhn with a rich mucous secretion. The muscularis mucosa is very thin with just a few lymph nodes. -submucosa: consists in blood and lymph vessels and nerves. -tunica muscularis: the longitudinal layer is organised in taenias and the circular layer separates the haustra coli; -serosa: the peritoneum covering the colon surface, except the mesocolon insertions and the posterior surface of colon ascendens and descendens.

1. Caecum et appendix vermiformis. a.Caecum, a blind end of the colon, is the first part, situated in regio inguinalis dextra or fossa iliaca dextra by 5-7 cm length. It lies on the iliopsoas muscle and femoral nerve. Anteriorly it is in direct contact with the abdominal wall. Medially it is bordered by intestinal loops and ileocecal junction. Laterally it is bordered by the iliac muscle and iliac crest. Its continued superiorly by the colon ascendens and inferiorly may be related with the urinary bladder, uterus and ovarium dextrum. Usually the caecum is fixed to the posterior wall and the posterior surface is not covered by the peritoneum. Sometimes due to a real mesocecum the organ is very mobile. Between the caecum and the posterior peritoneum there are some blind cavities Recessus ileocecalis superior et inferior, separated by plica cecalia vascularis (a.iliocecalis) and plica ileocecalis. Recessus retrocecalis is situated posterior. Internal aspect -the opening of the ileonum is covered by a one way valve-valvula ileocecalis Bauhin. This valve consists in two folds, superior and inferior. -the opening of appendix is bordered also by a fold-valvula Gerlach. b.Appendix vermiformis-is inserted in caecum at 2-3 cm distance to the ileocecal junction where the three taenias are joined. The position of appendix is variable due to its mesoapendix. Usually the normal position is the descending one to the pelvis presented in 30-40 % of the cases. The other position are: appendix retrocecalis (behind the cecum), appendix mezoceliacus (with a medial direction to the umbilical region between the intestinal loops), apendix pelvicus (the top of the appendix is in the lesser pelvis), appendix subhepaticus (anterior or lateral to the caecum but the top of the appendix is near the gall bladder). These positions may be described by numbers using the Gerota clock, where the root of the appendix is in the middle and the top show on this clock shape different hours depending on its position. The normal one its on 5 oclock. In clinical practice some points and triangles are described to indicate appendicular pain: -Mac Burney point-situated between the lateral third and medial two-thirds of the right spinoumbilical line; -Lanz point- situated between the lateral third and medial two-thirds of the bispinosus line; -Iacobovici triangle-bordered by the following right lines: spinoumbilicalis, bispinosus and pararectalis. The walls of the appendix are the same as the colon but in mucosa there are a lots of lymph follicles and for these reason the appendix was called Tonsilla intestinalis. 2.Colon ascendens-situated in the right lateral region of the abdomen , in continuation of caecum until the flexura colica dextra. Its covered by the peritoneum only on the anterior surface. It is bordered by:

-anteriorly- the anterior abdominal wall and the inferior face of the liver (impressio colica); -posteriorly: iliac muscle, quadratus lumborus muscle and the inferior part of the right kidney. Between these elements and the ascending colon is situated the Told I fascia -medially: the second part of duodenum, right ureterus and the genital vessels. -laterally: the abdominal wall and the diaphragm (ligamentum phrenicocolicum dextrum); Between the colon ascendens and the lateral abdominal wall there is a space: sulcus (spatium) parietocolicus dexter. Through this space the supramesocolic region communicates with the pelvis. 3.Colon transversum-the most mobile part of the colon due to its wide rootmesocolonum transversum. The right part of it is situated lower, at 10th rib level that the left angle-flexura colica sinistra, situated at 8th rib level. The position is variable, related with the greater curvature of the stomach. Flexura colica sinistra is bordered by: anteriorly: the greater curvature and the diaphragm (ligamentum phrenicocolicum sinistrum or Sustentaculum lienalis), laterally and superiorly with the spleen and posteriorly with the left kidney. The mesocolonum transversum splits the abdominal cavity into an supramesocolic space and an inframesocolic space. It is inserted on tenia mesocolica of the colon. The root of mesocolonum transversum is inserted on the posterior wall and intersects from left to right the left kidney, duodenujejunal angle, the anterior margin of the pancreatic body, the head of the pancreas, the descending part of duodenum, vena cava inferior and the right kidney. 4.Colon descendens-is situated deeper in the left lateral region of the body. It lies on the posterior muscles and the left kidney, the iliohypogastric and ilioinguinalis nerves. Between these elements and the descending colon is situated the Told II fascia. Sulcus paracolicus sinister is bordered by the left colon and the left abdominal wall. 5.Colon sigmoideum-presents two parts: a. Pars iliaca-is fixed and lies on the iliopsoas muscle, artera et vena iliaca externa sinistra, the left genital vessels and nervus genitofemoralis. b.Pars pelvina-is mobile and presents the mesocolonum sigmoidei. It is bordered by the intestinal loops. 6.The rectum-the last part of the digestive tract, measuring 12 cm length, is situated in the lesser pelvis. The limit between rectum and colon sigmoideum is considered at the S3 level, where the mesocolon sigmoidei ends. External aspect: The rectum presents two parts: ampulla recti (8-9 cm) and canalis analis(3-4 cm). In the sagittal plan the rectum describes two curves: Flexura sacralis-with anterior concavity corresponding to ampulla recti and Flexura perinealis-with posterior concavitycorresponding to canalis analis.

Only a small part of the ampulla recti is covered by the peritoneum, the rest of it being situated in the pelvisubperitoneal space. Internal aspect: -In the superior part the mucosa presents three or four transversal folds called Plicae transversales Houston. These folds are made by the muscular circular layer contraction. The most developed (usually the third) is called plica Kohlrausch. -In the inferior part at the limit between the ampulla and canalis analis there are 8-10 longitudinal (vertical) folds Columna anales Morgagni. These folds delimit 8-10 grooves Sinus anales with the inferior part called Valvula anales. -Linea pectinata-linia anorectalis anatomica-is traced by the inferior limits of Columna anales Morgagni. It represents also the limit between a.rectalis media and inferior, the portal and caval system, the autonomic and somatic innervation of the rectum. -Linea alba Hilton-between the m.sphincter ani internus and m.sphincter ani externuspars superficialis. -Linea anocutanea-the limit between the anal mucosa and the perineal skin. -Pecten-the narrow segment of canalis analis, between linia alba and linia pectinata.At this level the canalis analis wall presents the both sphincter muscles (internus et externuspars profunda). The vessels and nerves of the colon: Arteries. The colon and rectum receive blood supply from three major sources: -A.mesenterica superior: -A.ileocolica-the ended part of a.mesenterica superior, gives branches for ileonum terminale, caecum (a.cecalis anterior and posterior) and appendix(a.appendicularis). -A.colica dextra-is situated in the right angle of the colon and irrigates the colon ascendens and the flexura colica dextra; -A.colica media-is oriented upwards and is divided in two branches: the right one is anastomosed with the ascending branch of colica dextra; the left one is anastomosed with the ascending branch of colica sinistra resulting the Riolan Haller arch in the left angle of the colon; -A.mesenterica inferior: -A.colica sinistra-presents an ascending branch for the Riolan Haller arch and an descending branch for the colon descendens; -Aa sigmoideae-2-5 arteries for the sigmoid colon. The last one is anastomosed with a.rectalis superior-the Sudeck anastomosis; -A.rectalis superior-the last branch of a.mesenterica inferior irrigates the ampulla rectalis and is anastomosed with the other rectal arteries; -A.iliaca interna: -A.rectalis media-branches directly from a.iliaca interna; -A.rectalis inferior-branches from a.pudenda interna , also from a.iliaca interna.

Veins: The blood of the colon and rectum is drained by veins with the same names as the arteries in vena mesenterica superior (vena ileocolica , vena colica dextra and vena colica media) , vena mesenterica inferior (vena colica sinistra, venaae sigmoidaeae and vena rectalis superior) and vena iliaca interna (vena rectalis media and inferior). Between the vena rectalis media and superior results an portocaval anastomosis. The lymph is drained in: -Nodi lymphatici ileocolici; -Nodi lymphatici colici dextri et colicii medii; -Nodi lymphatici mesenterici superior; -Nodi lymphaticii colici sinistri; -Nodi lymphatici sacrales; -Nodi lymphatici iliaci interni. The nerves: -The sympathetic innervation arises from plexus mesentericus superior and inferior for the colon and plexus aorticus for the rectum. -The parasympathetic innervation arise from nervus vagus for the caecum, colon ascendens and the right two-thirds of colon transversum; for the left third of transversal colon, colon descendens, colon sigmoidei and rectum the parasympathetic innervation arises from Nn splachnicii pelvini (S2-S4). The limit between the two parasympathetic sources, situated on the transversal colon is called the Canon-Boem point. It is also the vascular limit between artera mesenterica superior et inferior and the embryological limit between mesenetron and metenteron.

The perineum The muscles of the perineum(Musculi perinei)-are disposed in three layers and they fuse into a common tendon situated in the middle part of perineum called centrum tendinei perinei. All are innervated by the pudendal nerve. 1.M.levator ani-the most profound muscle of the perineum, is situated between the lateral walls of the lesser pelvis, rectum and coccyx. Origin: -the superior part of ramus pubicus; -the inferior part of ilium bone; -a thickness of fascia obturatoria-Arcus tendineus Rouget; Insertion: -rectum wall; -coccyx; -ligamentum anococcygeus; -prostate; The fibers are organised in three major parts: -M.puborectalis-medial; -M.pubococcygeus-in the middle; -M.iliococcygeus-the outer part. On the median line the fibers delimits a space for the anus, genitals organs in women and urethra. The levator ani muscle with its fascias is called diaphragma pelvis and represents the inferior wall of the abdominal cavity. 2.M.ischiococcygeus-belongs to the profound plane, between spina ischiadica and coccyx. It is situated lateral and posterior to the levator ani. 3.M.sphincter ani externus-is situated around the canalis analis and presents three parts: -Pars subcutanea-by its contraction makes cutaneus folds in the perianal region. Its also called M.corrugator cutis ani; -Pars superficialis-is the most important part, contains fibres which start from ligamentum anococcygeus and end on centrum tendineum surrounding the anus. -Pars profunda-is thin and is attached to the internal sphincter muscles-is situated on the Pecten level. The contraction of each part closes the canalis analis. 4.M.transversus perinei profundus The origin is on the ramus pubis inferior and ischium and is inserted on the centrum tendineum. It belongs to the perineum anterior. With its fascias it is called diaphragma urogenitalis. 5.M.transversus perinei superficialis-a small muscle with transversal disposition between tuber ischiadicum and centrum tendineum.

6.M.sphincter urethrae-the Wilsons muscle-consist in circular fibers detached from diaphragma urogenitalis. 7.M.ischiocavernosus-starts from the inferior part of the ischium and ends by surrounding corpus cavernosus 8.M.bulbospongiosus-starts from centrum tendineum and ends on radix penis. The fascias of perineum Fascia pelvis -is situated superior to the muscles of the lesser pelvis. It presents the following parts: Fascia parietalis: -fascia obturatoria superior-cover m.obturatorus internus. Presents a horizontal thickness arcus tendineus Rouget, which represents a part of the origin of levator ani muscle. -fascia piriformis-cover the piriform muscle; -fascia diaphragmatis pelvis superior cover the levator ani muscle and ischiococcygeus muscle; Fascia visceralis:-the adventitia of the pelvic organs. Fascia obturatoria inferior-situated under the Rouget arch, inside of fossa ischioanalis; A vertical thickness of it is called Canalis pudendalis Alcock which contains the pudendal artery and nerve. Fascia diaphragmatis pelvis inferior- covers the inferior surface of m.levator ani. Fascia diaphragmatis urogenitalis superior: covers the superior surface of the m.transversus perinei profundus; Fascia diaphragmatis urogenitalis inferior:is thick and resistant-called also the ligament of Carcassone The two fascias are fused anterior to the muscle transversus perinei profundus, resulting in Ligamentum perinei profundus and posterior in centrum tendinei. Fascia perinei superficialis-is situated under the skin and cover the superficial muscles (ischiocavernosus and bulbospongiosus). Regio perinealis A rhomboid shape bordered by symphisa pubica, ramus ischiopubicus, tuber ischiadicum and coccyx. A horizontal line divide the perineum in perineum anterior (Regio urogenitalis) et posterior (Regio analis). The posterior perineum presents the same elements at both genders, the anterior perineum present different elements.

Regio analis Represents the posterior triangle, perforated by the anus. The skin is mobile, with hair and seborrheic glands. The subcutis consist in arteries branched from a.pudenda externa, veins and nerves. Fascia perinealis superficialis is missing in this region. M.sphincter ani externus with its three parts. Diaphragma pelvis-consist in musculus levator ani with fascia diaphragmatis pelvis superior et inferior and m.ischiococcygeus. Fossa ischioanalis-two paired cavities situated arround the canalis analis. It is bordered : -medially-canalis analis; -superiorly-m.levator ani; -lateral-m.obturatorus internus; -inferior-the covering plan of the region; The content of the fossa ischioanalis is fat tissue: corpus adiposum fossae ischiorectalis and Canalis pudendalis Alcock. The rapports of Canalis analis in the perineal region: -posterior-the posterior fibers of levator ani muscle and ligamentum anococcygeum; -lateral-fossa ischiorectalis; -anterior- in men-the prostate and Cowper glands; - in women-the posterior wall of the vagina; Canalis analis with external and internal aspects was presented in another chapter (rectum) The anterior perineum in men In this region are situated the masculine genital organs and the urogenital diaphragm is perforated by the urethra. The skin of the region is mobile and presents on the median line a thickness which is continued anteriorly by the raphe scroti. The subcutis is thin with vessels and nerves (the pudendal pedicle). Spatium perinei superficiale-is situated between the fascia perinei superficialis and diaphragma urogenitalis. The content of this space is: -bulbus penis; -m.bulbospongiosus; -corpus cavernosus, covered by m.ischiocavernosus; -the Cowper glands canal; -vessels and nerves for the penis; Spatium perinei profundum-is situated between the fascia diaphragmatis urogenitalis superficialis and profunda. The content of this space: -m.transversus perinei profundus; -m.sphincter urethrae; -urethra membranosa -the Cowper glands; -the pudendal pedicle.

The anterior perineum in women Is the region of the external genitals organs (vulva with its elements).The urogenital diaphragm is perforated by the urethra and vagina. Spatium perineale superficiale -bulbus vestibuli; -m.bulbospongiosus and ischiocavernosus; -Bartholin glands; Spatium perineale profundum -urethra membranosa; -m.sphincter urethrae; -vagina; -the pudendal pedicle.

THE KIDNEY (REN)

- the kidneys are situated in the retroperitoneal space, having a asymmetrical position related to the medio-sagital plane of the body - capsula fibrosa the fibrotic capsule covers the surface of the kidney - capsula adiposa (corpus adiposum peri-renalis) represents the fat tissue situated around the fibrotic capsule of the kidneys - fascia renalis represents the fascia situated around corpus adiposum perirenalis; it is made by two lamellas: - lamella anterior wich is thinn and un-interrupted in between the right and the left side of the body - lamella posterior (or fascia retro-renalis Zuckerkandl) wich is thicker and interrupted in between the right and the left side of the body - corpus adiposum para-renalis Gerota represents the fat tissue situated posteriorly in between lamella posterior (or fascia retro-renalis Zuckerkandl) and the musculus quadratum lumborum I. The EXTERNAL CONFIGURATION of the kidney: - extremitas superior - the superior extremity wich is larger and rounded, being situated under the diaphragm; the superior extremities are more closed to the medio-sagital plane than the inferior ones - extremitas inferior - the inferior extremity wich is thinner and sharper, being situated on musculus quadratus lumborum and iliopsoas II. The SURFACES of the kidney are: - facies anterior the anterior surface wich it is crossed on the right side by the insertion line of mesocolon transversum - facies posterior the posterior surface wich is split by the 12th rib into a thoracic part and an abdominal part III. The MARGINS of the kidney are: - margo medialis the medial margin wich is concave and presents in the middle a opening (hilum renalis) wich is continued with a fossa (sinus renalis) - margo lateralis - the lateral margin wich is convex

IV. The INTERNAL CONFIGURATION of the kidney: - cortex renis represents the peripheric part of the kidney, wich is made from pars radiata (with the urtinifer tubes - the pyramis Ferrein) and pars convoluta (with the convolute tubes); from this level start the renal columns (columnae renales Bertin) that are going to be situated in between the renal pyramids - medulla renis represents the central part of the kidney wich presents the characteristic renal pyramids (pyramis renales) with the base oriented towards the periphery of the kidney and the tip (papilla renalis) oriented towards the sinus renalis V. The urine-conducting system of the kidney is made by: - calyces renales minores they are in number of 8-9, being the first part of the urinary drainage system; they start at the tip of the papilla renalis and are drained into the major calyces - calyces renales majores they are in number of 3 (superior, medius, inferior), being the second part of the urinary drainage system; they are drained into the renal pelvis - pelvis renalis represents the larger sac wich collects the urine as the third part of the urinary drainage system; it presents an intra-renal part and a extra-renal part - ureter represents the pipe wich conducts the urine from the renal pelvis to vesica urinaria VI. The ARTERIES of the kidney Arteria Renalis (dextra et sinistra): - they emerge as visceral direct branches from aorta abdominalis at the level of L1, having have a different length: the left one is shorter and the right one being longer and passing under vena cava inferior - before reaching the hilum renis they are giving a branch arteria suprarenalis inferior - close to the hilum the renbal arteries are dividing in: - ramus anterior the anterior branch wich is going to give 4 segmental branches: -arteria segmenti superioris for the superior extremity of the kidney -arteria segmenti anterioris-superioris for the anterosuperior pre-hilar zone of the kidney -arteria segmenti anterioris-inferioris for the anteroinferior pre-hilar zone of the kidney

-arteria segmenti inferioris for the inferior extremity of the kidney - ramus posterior the posterior branch wich is going to give 1 segmental branches: -arteria segmenti posterioris for the posterior retrohilar zone of the kidney VII. The VEINS OF the kidney - Vena Renalis (dextra et sinistra): - they are drained as visceral direct branches in vena cava inferior at the level of L1, having have a different length: the right one is shorter and the left one being longer and passing over aorta abdominalis - the left renal vein receveis directly the venous drainage from vena supra-renalis inferior sinistra and vena testicularis/ovarica sinistra

VIII. The LYMPHATIC DRAINAGE AND INERVATION of the kidney: - the lymphatic drainage of the limpha derives from three networks (and it will be drain further on in the nodi lymphatici lombares): - perirenal network situated into the capsula adiposa renis and having connections with the lymphatic system of the colon - under-capsular network situated superficially under the capsula fibrosa renis - profound network situated deep into the tissue of the kidney - the nervous branches from the ganglia caeliaca, ganglion mesentericus superior and ganglia aorticorenalia, also with branches from nervus sphlahnicus minor - they are going into the kidney along with the renal vessels (plexus renalis) IX. TOPOGRAPHICAL RELATIONSHIPS the kidney: - the right kidney: - anterior with: duodenum - DII (on the medial side of the surface parahilar), hepar - lobus dexter (on the lateral side of the surface), flexura colica dextra (at the insertion line of mesocolon transversum), small intestin (under the insertion line of mesocolon transversum)

- posterior with musculus quadrates lumborum and musculus iliopsoas (Trigonum Petit, Quadrulaterum Grynfelt), through corpus adiposum retro-renalis with nervus iliohipogastricus, ilio-inguinalis - superior with glandula suprarenalis dextra and indirectly through the right hemi- diaphragm with the right pleural cavity and pulmo dexter - inferior with the small intestine - the left kidney: - anterior with: glandula suprarenalis sinistra (on the medial side of the surface suprahilar), stomach (on the medial side of the surface suprahilar under the suprarenal gland), cauda pancreatis (on the medial side of the surface parahilar), small intestin (on the medial side of the surface infrahilar), spleen (on the lateral side of the surface), flexura colica sinistra (on the lateral side of the surface, inferior to the spleen) - posterior with musculus quadrates lumborum and musculus iliopsoas (Trigonum Petit, Quadrulaterum Grynfelt) ), through corpus adiposum retro-renalis with nervus iliohipogastricus, ilio-inguinalis - superior with glandula suprarenalis sinistra and indirectly through the left hemi- diaphragm with the left pleural cavity and pulmo sinistri - inferior with the small intestin

THE URETER (URETER)

- the ureter is a musculo-membranous conduct wich connects pelvis renalis with vesica urinaria, going downwards 1 cm medial to the tip of the costiform aphophisis of the L3,4,5; on its course in presents two parts (abdominal and pelvic) and three narrower zones (pielo-ureteralis at the confluence of the pelvis renalis with the ureter, marginalis at the crossing point with linea terminalis of the pelvis, vesicalis at the entering point in vesica urinaria) - pars abdominalis presents two segments: - segmentum lombaris (from pelvis renalis untill ala ossis sacri); it is longer than the iliac one and has topographical relationships with: - anterior: crossed by the testicular / ovarian vessels (at the level of L3), crossed by the colic vessels - posterior: musculus ilio-psoas, nervus genito-femoralis and nervus cutaneus femoris lateralis - lateral the medial margin of the kidney and the colon (ascending on the right and descending on the left) - medial vena cava inferior (on the right side) and aorta abdominalis (on the left side) - segmentum iliacus (from ala ossis sacri until linea terminalis); it is shorter than the lombar one and has topographical relationships with: - anterior: crossed by radix mesenterii (on the right side) and by radix mesocolon transversum (on the left side) - posterior: a. iliaca externa (on the right side) and a. iliaca communis (on the left side) - pars pelvina presents three segments: - segmentum parietalis (fixed, situated on the internal iliac vessels) medially having topographical relationships with the ovarium (on female) - segmentum visceralis (mobile, situated in between the walls of the pelvis and the vesica urinaria), having different topographical relationships: - in male situated in between the vesica urinaria and rectum, crossing the ductus defferens by posterior and inferior - in female situated in the base of ligamentum latum uteri, crossing the arteria uterina by posterior and inferior

- segmentum intramuralis (situated into the wall of vesica urinaria and being opened into the posterior angles of trigonum Lieutaud) I. The ARTERIES of the ureter: - they emerge as branches from different sources: - from a. renalis for the upper third - from a. testicularis/ovarica for the middle third - from a. ducti deferens / a. uterina, a. vesicalis inferior for the inferior third

II. The VEINS of the ureter: - they are drained corresponding with the venous drainage of the arterial supply VII. The LYMPHATIC DRAINAGE AND INERVATION of the ureter: - the lympha is drained in the nodi lymphatici lombares (from pars abdominalis) and in nodi lymphatici iliaci intyerni (from pars pelvic) - the nervous branches are coming from plexus renalis for the upper third, plexus aorticus abdominalis for the middle third, plexus iliacus (for the inferior third)

THE SUPRARENAL GLAND (GLANDULA SUPRARENALIS)

- the suprarenal gland are situated in the retroperitoneal space, being situated on the superior extremity of the kidneys II. The EXTERNAL CONFIGURATION of the suprarenal gland: - the suprarenal gland has the shape of a pyramid, the right one being situated on the top of the right kidney and the left one being situated mainly on the medial margin of the left kidney; due to this different disposition the complex kindey-suprarennal glad has the same height on the right and left side (despite the fact that the right kidney is situated on a lower level compere with the left one) II. The SURFACES of the suprarenal gland are: - facies anterior the anterior surface wich presents the hilum - facies posterior the posterior surface wich is oriented towards the diaphragm - facies inferior (renalis) the posterior surface wich is oriented towards the superior extremity of the kidney III. The MARGINS of the suprarenal gland are: - margo medialis the medial margin - margo superior - the lateral margin IV. The INTERNAL CONFIGURATION of the suprarenal gland: - cortex suprarenalis represents the peripheric part of the suprarenal gland, wich is made from zona glomerulosa (small round cells arranged in groups), zona fasciculata (thicker, with large clear cells) and zona reticularis (thinner, situated around the medulla and presenting lines of cells and in between them blood capillaries) - medulla suprarenalis represents the central part of the suprarenal gland wich presents cells that are secreting the specific hormons of the suprarenal gland V. The ARTERIES of the suprarenal gland: - they emerge as visceral branches from different sources: - arteria suprarenalis superior branch from a. phrenica inferior

- arteria suprarenalis media direct branch from aorta abdominalis - arteria suprarenalis inferior branch from a. renalis VI. The VEINS of the suprarenal gland: - they are collected into a singke vein (vena centralis) drained differently: - on the right side as visceral branch direct branches in vena cava inferior - on the left side as visceral branch in vena renalis sinistra

VII. The LYMPHATIC DRAINAGE AND INERVATION of the suprarenal gland: - the lympha is drained in the nodi lymphatici lombares - the nervous branches from mainly from nervi sphlahnici - they are going into the kidney along with the renal vessels (plexus suprarenalis) IX. TOPOGRAPHICAL RELATIONSHIPS the suprarenal gland: - the right suprarenal gland: - anterior with the hepar - lobus dexter (at the level of area nuda) - posterior with the muscles of the posterior abdominal wall - superior indirectly through the right hemi- diaphragm with the right pleural cavity and pulmo dexter - inferior with the superior extremity of the right kidney - medial with vena cava inferior and ganglion caeliacum dextrum - the left suprarenal gland: - anterior with the cauda pancreatis - posterior with the muscles of the posterior abdominal wall - superior indirectly through the right hemi- diaphragm with the left pleural cavity and pulmo sinister - inferior with the medial margin (the supra hilar part) and with the superior extremity of the left kidney - medial with aorta abdominalis and ganglion caeliacum sinistrum

ORGANA GENITALIA MASCULINA

These consist of the testicles, genital ducts, accessory glands and copulating organ.

The testicle - Testis

The testis is responsible for producing the spermatozoa and male sex hormones. It has an oval shape, slightly flattened from lateral, with a weight of 10-14 g, a greater length of 4-5 cm, a width of 2.5 cm and an antero-posterior thickness of 3 cm. External configuration Extermitas superior et inferior - the former oriented antero-laterally, while the latter towards postero-medial. Thus, the testicle suspended in the scrotum by the spermatic cord, has an oblique position. Facies medialis et lateralis Margo anterior - anterior, convex margin Margo posterior - posterior, more straight margin The extremities, surfaces and anterior margin are free, smooth, covered by the visceral layer of the tunica vaginalis. The posterior margin has attached to it the spermatic cord and epididymis. Internal structure Tunica albuginea - a thick, fibrous, whitish surface layer Tunica vasculosa - a thin layer of loose connective tissue, with a fine vascular network Mediastinum testis - the thickening of the tunica albuginea (called the Body of Heighmore), where the vessels penetrate the testis Septula testis - incomplete septa of connective tissue, positioned in a radial manner, dividing the parenchyma of the testis in Lobuli testis - 250-400 lobules of conical shape, with their bases toward the exterior and their apexes toward the Heighmore body Parenchyma testis - the proper tissue of the testis Tubuli seminiferi contorti - 1-3 coiled seminiferous tubules, beginning blindly, with several anastomoses between them and the tubules of the neighboring lobules Tubuli seminferi recti - these are formed by the union of the previous tubules, and penetrate the Heighmore body Rete testis - the multiple anastomoses between the straight tubules form the network of Haller, located in the Heighmore body One testicle contains approximately 840 such seminiferous tubules, of 60-70 cm length, and 0.3 mm diameter each Interstitium testis - the spaces between seminiferous tubules, containing vessels and interstitial cell islets (Leydig cells), which secrete androgens

Epididymis
It is the beginning of the genital tract. Caput epididymidis - a club like upper part, turning anteriorly and attached to the superior pole of the testicle Corpus epidydimis - its intermediary part, following the posterior margin of the testicle Cauda epidydimis - the thinner inferior segment, attached to the inferior pole of the testis Ductuli efferentes testis - the head is made up of 12-15 efferent tubules, coming from the network of Haller Lobuli seu Coni epididymidis - after a short straight path, they coil up, and form a coneshaped lobule, making up together the head of epidydimis

Ductus epididymidis - the efferent tubules open into a single, coiled tube, having 6 meters in length, and 0.5 mm diameter. The tightly packed convolutions of this tube are held together by loose connective tissue, and it makes up the body and tail of the epidydimis There are a series of vestigial structures contacting the head of the epidydimis: Ductuli aberrantes - they represent the caudal portion of the persisting mesonephric tubules (aberrant vessel of Haller) Appendix epididymis - remnant of the Wolff duct Paradidymis - atrophic remnant of the paragenital tubes of the mesonephros The vascular supply and innervation of the testis-epidydimis complex is common: the arteria testicularis, and plexus pampiniformis draining into the vena testicularis (right - VCI, left vena renalis)

Ductus deferens
It is a round duct of 50-60 cm length and 3 cm thickness, with a 0.5 mm narrow lumen. It continues the ductus epidydimis, from the tail of this organ, where it turns upwards along this organ, with an initial tortuous path and a subsequent straight portion. In the spermatic cord it is located posterior to the vessels, with whom it courses through the canalis inguinalis, and reaches the pelvis through the internal inguinal opening. It arches then under the peritoneum covering the lateral surface of the urinary bladder, reaching its base, where the two deferent ducts cross the ureters and converge toward the prostate. It has three segments: epidydimal, funicular and abdomino-pelvic. Ampulla ductus deferentis - its terminal portion, placed on the bladder, with a larger lumen , and mucosal depressions (Diverticula ampullae). Vascular and nervous supply The arteries of the ductus deferens come from the arteria vesicalis superior, and near the testicle form anastomoses with the branches of the arteria testicularis.

Vesicula seminalis
It is like a membranous, lobular pouch, located on the fundus of the bladder, lateral to the ampulla ductus deferentis. It is not a storage place for sperm cells, but a gland actively contributing to the production of seminal liquid. It is about 8 cm in length, but its dimensions can vary even compared to the opposing vesicle. In reality, it is a tube with zigzag curves that generates blind ending portions, connected by connective tissue. Ductus excretorius - its inferior portion narrows gradually, and is continued by an excretory duct, which unites with the ductus deferens to form the ductus ejaculatorius. Vascular and nervous supply The arteries of the ductus deferens come from the arteria vesicalis superior, and near the testicle form anastomoses with the branches of the arteria testicularis. The ampulla ductus deferentis and vesicular seminalis also receive arterial supply from the arteria vesicalis inferior and the arteria rectalis media. The veins drain in the plexus pampiniformis, venae vesicales and plexus venosus prostaticus. The lymphatic vessels drain towards the nodi lymphatici iliaci externi and interni. The nerves come from the plexus hypogastricus inferior, along the above named arteries.

Ductus ejaculatorius
It is formed by the junction of ductus deferens and ductus excretorius vesiculae seminalis. It travels obliquely downward and anterior the prostate, up to its opening into the urethra. It is 2 cm in length and it narrows gradually (down to 0.2 mm) until its opening on the lateral side of colliculus seminalis.

Funiculus spermaticus
It is a cord like structure containing vascular, lymphatic and nervous structures, accompanying the ductus deferens from the epidydimis to the abdominal cavity, and traveling through the canalis inguinalis. Arteria testicularis - branch of the abdominal aorta, supplying the testiculo-epidydimal complex Arteria cremasterica - from the arteria epigastrica inferior, supplying the layers of the spermatic cord Arteria ductus deferentis - form the arteria iliaca interna, supplying the ductus deferens and forming anatomoses with the above named arteries Plexus pampiniformis - collects all blood from the territory of the above arteries It makes up around the ductus deferens and complex venous plexus, which fuses into 2-3 common trunks at the superficial inguinal opening. After passing through the canalis inguinalis, these veins will form the vena testicularis on each side. In addition, the cord comprises lymphatic vessels and autonomic plexus, accompanying the ductus deferens and its artery. The ductus deferens in located in the posterior part of the spermatic cord, and can be easily identified by palpation, due to its rough consistency. Tunicae funiculi spermatici et testis - the protective coating layers derived from the abdominal wall (fascia exoabdominalis, musculus obliquus externus et internus, musculus transverses abdominis, fascia transversalis and peritoneum - the canalis peritoneo-vaginalis of the fetus). Tunica vaginalis testis - makes up a closed serous pouch around the testiculo-epidydimal complex, closed by the obliteration of the canalis peritoneo-vaginalis. It comprises a visceral layer (Lamina visceralis), covering these organs, and turning into the parietal layer (Lamina parietalis) along the posterior margin of the testicle. Sinus epididymidis - a deeper pouch of the line of reflection, located in the angle between the testicle and the corpus epidydimis

Prostata
The prostate encircles the neck of the bladder and the first portion of the urethra, located behind symphysis pubica, anterior to the rectum and above the urogenital diaphragm. Its weight is about 20 g; its widest transversal diameter is 4 cm, antero-posterior 2 cm, and vertical 3 cm. External configuration Basis prostatae - a large bases, on the inferior surface of the bladder Apex prostatae - a thinned inferior portion, sustained by the urogenital diaphragm Lobus dexter et sinister - the two lateral lobes Lobus medius or Isthmus prostatae - a middle lobe, underdeveloped, linking the two lateral lobes behind the urethra There are no clear boundaries between the parts of the prostate. Facies anterior - short and convex, it is posterior to the symphysis pubica (by 1.5 -2.0 cm), and between them there is a connective tissue with an abundant venous plexus It is attached to

the prostate by ligaments and musculus pubo-prostaticus. The urethra passes through the prostate near this surface. Facies posterior - flatter and wider, slightly convex on its lateral sides. It is oriented towards the rectum, and it is accessible to examination through rectal digital exam. Close to its superior border there is a depressed area where the canales ejaculatorii enter the gland. Inferior to this depression there is a shallow median groove, representing the boundary between the right and left lobes. Facies inferolateralis - covered by connective tissue and the periprostatic venous plexus, sustained by the anterior part of the musculus levator ani, termed musculus levator prostatae. The prostate is traversed by the urethra and the ejaculatory ducts. The former is places obliquely, along the junction between its anterior and middle thirds, the latter reach the organ on its posterior surface, near the bladder. Between these structures there is the middle lobe, visible only on the posterior surface. Vascular and nervous supply The prostatic arteries are branches of the arteria pudenda interna, arteria vesicalis inferior and arteria rectalis media. The veins are collected by the plexus venosus prostaticus, which empties into the vena iliaca interna. The lymphatic vessels drain towards the nodi lymphatici iliaci interni and sacrales, and in a lesser extent towards the nodi lymphatici iliaci externi. The nerves come from the plexus hypogastricus inferior.

Glandula bulbourethralis - Cowper

These are paired lobular, yellowish glands, the size of a pea; they are located in the diaphragma urogenitalis, postero-lateral to the membranous urethra. Ductus glandulae bulbouretnralis - the relatively long excretory duct, opening into the spongy urethra, at about 2.5 cm inferior to the urogenital diaphragm.

Penis
The male copulating organ, positioned anterior to the pubic arch; it changes its size and consistency based on its functional state. External configuration Radix penis - the root, attached to the pubis and ischium Corpus penis - the body narrows towards its distal end Collum glandis - a circular separation groove between the corpus and glans Glans penis - the wider distal end of the penis Collum glandis - the larger, rounded perimeter of the glans Dorsum penis - the surface that continues the surface of the pubic region Facies urethralis - the inferior surface, containing the urethra Raphe penis - the thin, pigmented and mobile skin of the urethral surface shows a darker line that continues on the scrotum and perineum Preputium - a fold of extra skin at the distal end, which covers the glans of the relaxed penis, and is retracted during erection Frenulum preputii - surrounds the external opening of the urethra, and forms a divergent plica under it

Internal structure Fascia penis superficialis et profunda - the two fascial layers of the penis Corpus cavernosum penis - make up the anterior of the corpus penis, and are fused together; they have a rounded anterior end, covered by the glans Crus penis - the radix penis contains these divergent posterior extremities of the corpora cavernosa, attached to the rami ossis pubis and ischium Tunica albuginea corporum cavernosorum - the external, fibrous, resistant covering of the cavernous bodies Septum penis - a fibrous extension that incompletely separates the corpora cavernosa in the sagittal plane Corpus spongiosum penis - a single spongy body, containing the urethra Bulbus penis - the conical, dilated segment, adherent to the inferior surface of the urogenital diaphragm It also makes up the glans. This structure extends transversally beyond the diameter of the corpus penis, forming the corona glandis and its collum. Tunica albuginea corpori spongiosi - the external, fibrous covering of the spongy body, much thinner than that of the corpora cavernosa Vascular and nervous supply The arteries come from the arteria pudenda interna, and comprise the arteria profunda penis (in each cavernous body) and arteria dorsalis penis. The veins drain into the plexus venosus prostaticus, through the venae profundae penis and vena dorsalis penis. The lymphatic vessels of the gland drain into the nodi lymphatici inguinales profundi and iliaci externi. The rest of the organ is drained into the nodi lymphatici inguinales superficiales. The nerves come from the nervus pudendus and the plexus hypogastricus inferior.

Scrotum
It is a skin pouch continuing the skin of the penis and perineum, and contains the testicles, epidydimes and the initial part of the funicula spermatica, with their coverings. Raphe scroti - it forms a midline ridge Septum scroti - a sagittal connective tissue septum, dividing the cavity of the scrotum into two symmetrical halves Tunica dartos - a layer of connective tissue, containing smooth muscle fascicles and bands of elastic tissue The vascular supply of the scrotum is from the arteria pudenda interna and externae, through rami scrotales anteriores and posteriores. The venae scrotales anteriores drain towards the vena femoralis or vena safena magna, and the venae scrotales posteriores towards the vena pudenda interna. The lymphatic vessels have similar drainage as the penis. The nerves are branches of nervus ilioinguinalis or genitofemoralis (nervi scrotales anteriores), and nervus pudendus (nervi scrotales posteriores).

ORGANA GENITALIA FEMININA Ovarium

The female gonad, it weighs about 3.5 g and it is located in the angle of bifurcation of the common iliac artery. Its surface is smooth in children and becomes uneven in mature women. External configuration It has extremities, faces and margins. Its long axis is oriented almost vertically in a standing woman. Extremitas tubaria/tubalis - its external extremity is attached to a long fimbria of the tuba uterine and it is suspended by a peritoneal ligament (Ligamentum suspensorium ovarii) to the lateral wall of the abdomen. This ligament also contains the vessels and nerves of the ovary. Extremitas uterina - its internal extremity faces downwards and medial towards the uterus, to which it is attached by a fibrous structure located between the layers of the broad ligament of the uterus. Facies lateralis - it contacts the peritoneal fossa located in the bifurcation angle of the common iliac artery. Facies medialis - it is almost completely covered by the fimbria of the fallopian tube. Internal structure Margo liber - the free border of the ovary. Margo mesovaricus - the mesovarium attaches to it. The external surface of the ovary is covered by peritoneum up to the insertion of the mesovarium. Tunica albuginea - a fibrous, thin, whitish coat Stroma ovarii - divided into a peripheral (Cortex ovarii), and a central (Medulla ovarii) part. The former contains the ovarian follicles in different stages of development, the latter contains mostly the vessels and nerves of the ovary. Vascular and nervous supply Arteria ovarica - located within the ligamentum suspensorium ovarii, it anastomoses with the Ramus ovaricus of the uterine artery, and these two make up the "ovarian arch" comprised between the layers of the mesovarium. The veins drain in the plexus ovaricus, corresponding to the plexus pampiniformis of the male, and subsequently form the venae ovaricae. The lymphatic vessels drain into the nodi lymphatici lumbales. The mixed autonomic nerves concentrate in a superior group, derived from the plexus mesentericus superior and plexus renalis, and an inferior group coming from the plexus rectalis along the arteries.

Tuba uterina
It is a tortuous duct, of 10-15 cm length, and receives the ovum expelled by the ovary guiding it towards the uterus. External configuration It has three main parts: the infundibulum, the ampulla and the isthmus. Infundibulum tubae uterinae - it is the funnel-shaped lateral part of the fallopian tube Ostium abdominale tubae uterinae - the opening in the center of the infundibulum Fimbriae tubae - radial extensions starting from the edge of the infundibulum towards the medial surface of the ovary Fimbria ovarica - a longer extension, directly attached to the ovary

Ampulla tubae uterinae - the next slightly dilated segment, 5-10 mm long, arching over the ovary, comprising almost 2/3 of the length of the tube Isthmus tubae uterinae - the third very narrow and short segment It is essentially in the uterine wall (Pars uterina). Ostium uterinum tubae - the small opening into the superior angle of the uterine cavity. Mesosalpinx - a peritoneal doubling, attached posteriorly to the mesovarium, and continued by the mesometrium connected directly to the uterus. Vascular and nervous supply Arteries: the most important arterial source is the Ramus tubarius of the uterine artery. This follows the tube, and gives out a series of collaterals up to the level of the fimbria, where it anastomoses with the ovarian artery. The veins drain into the plexus venosus uteri. The lymphatic vessels drain partly into the nodi lymphatici lumbales, and partly towards the uterine vessels. The nerves come from the plexus hypogastricus inferior and the sacral parasympathetic system.

Uterus
It is an unpaired, pear shaped, antero-posteriorly slightly flattened organ, with very thick walls, located in the middle of the pelvis, between the bladder and rectum. In nuliparous women its length is about 8 cm, its width about 5 cm in its superior widest area, and it has a 3 cm thickness. In multiparous women these dimensions are larger, and increase largely during pregnancy. External configuration The uterus is divided into two major parts: the corpus and the cervix, connected through a narrow segment, that is distinguishable only from the uterine cavity. Corpus uteri - comprises the superior 2/3 of the uterus, starting with a free, wide and rounded extremity (Fundus uteri), which receives bilaterally the fallopian tubes. Facies vesicalis - the anterior surface; it is slightly concave, and it is oriented towards the vesica urinaria. It is covered by peritoneum up to the level of the cervix. Facies intestinalis - the posterior surface; it is convex, and it is oriented towards the rectum and the small intestinal loops. Its whole surface is covered by peritoneum. Margo uteri dexter et sinister - the two surfaces meet in the margins of the uterus; this has symmetrically attached to it the fallopian tubes, the round and ovarii proprium ligaments, and also the broad ligament of the uterus. Cervix uteri - approximately 2 cm in length, it continues the body, and its inferior end enters the vagina. The insertion of the vagina on the uterus divides the latter into a supravaginal and an intravaginal segment. Portio supravaginalis cervicis - anteriorly it is below the reflection line of the peritoneum, surrounded by connective tissue that contains the intersection of the arteria uterine with the ureter, located 2 cm lateral from the margin of the uterus. Dorsally it is completely covered by peritoneum, which reflects here onto the rectum and form the Douglas pouch. Portio vaginalis cervicis - rounded, it protrudes into the vagina, and in nuliparous women has a small opening in the middle (Ostium uteri). After the first delivery this transforms into an oval shaped fissure, with two lips - Labium anterius et posterius. Cavum uteri - a narrow, triangular space, with two infundibular extensions towards the ostia of the fallopian tubes.

Canalis cervicis uteri - the fusiform channel of the cervix opens into the vagina through the ostium uteri. Isthmus uteri - located between the body and cervix uteri, about 1 cm long. Anchoring structures These maintain the relatively stable median position of the uterus, and allow for size and position changes during pregnancy, and returning to the original position after delivery. The failure of the anchoring structures results in position changes of the uterus (lateral deviation, lateroflexion or prolapse). The cervix and insthmus are more strongly anchored. Ligamentum latum uteri - it is a peritoneal doubling, extending between the lateral borders of the uterus and the wall of the pelvis. Ligamentum teres uteri - approximately 15 cm long, departs from the supero-lateral portion of the corpus, passes through the broad ligament, turns anterior, passes through the canalis inguinalis and ends up in the connective-adipose tissue of the labia major. Maintains anteversion of the uterus. Parametrium - it is the connective tissue around the isthmus and cervix uteri, comprising the vesico-uterine and sacro-uterine ligaments, parts of the sacro-recto-pubic retinaculum. Ligamentum cardinale - connective tissue extending between the cervix uteri and the lateral wall of the pelvis. Vascular and nervous supply The arteries are branches of arteria uterina, which anastomoses with the other uterine artery. The venae uterinae drain into the plexus venosus uterinus et vaginalis, located in the parametrium, and subsequently into the vena iliaca interna. The lymphatic vessels of the fundus and corpus drain towards the nodi lymphatici lumbales et aortici. A small part is directed along the round ligament towards the nodi lymphatici inguinales. The lymphatic vessels of the cervix drain towards the nodi lymphatici iliaci communes and interni. The nerves come from the ganglion mesentericum inferius and make up the plexus uterovaginalis. In this sympathetic plexus enter parasympathetic fibers from the S3-4 spinal nerves.

Vagina
The copulating organ of the female, located between the bladder and rectum. From the cervix up to the opening into the vulva, it measures about 7 cm anterior and 9 cm posterior. Internal configuration Paries anterior et posterior - the two walls of the vagina are touching each other, with an H shaped narrow space between them. Fornix vaginae - the superior portion, inserted around the intravaginal segment of the cervix. Rugae vaginales - transversal folds on the internal surface of the vagina. Columna rugarum anterior et posterior - two median columns of the folds. Carina urethralis vaginae - a small tubercle oriented towards the external urethral orifice. Vascular and nervous supply The arteries are branches of arteria uterina, which gives out the arteria vaginalis at the level of the cervix uteri. This descends and anastomoses with the branches of the arteria vesicalis inferior and arteria rectalis media. The veins have similar disposition. The lymphatic vessels of the superior part of the vagina drain into the nodi lymphatici iliaci communes and interni. The inferior part is drained into the nodi lymphatici inguinales. Some lymphatic vessels of the posterior wall bypass the rectum and drain into the nodi lymphatici sacrales. The nerves are identical to the uterine ones; some branches stem from the nervus pudendus.

Vulva - Pudendum femininum

Labium majus pudendi - two rounded skin folds Mons pubis - a triangular prominence oriented downwards, located antero-superior to the symphysis. Commissura labiorum anterior et posterior - the anterior and posterior joining points of these structures. Rima pudendi - the interlabial space, narrow slit-like in nulliparous women, wider in older and multiparous women. Labium minus pudendi - two, about 4 cm long diverging folds on the internal surface of the labia major. Frenulum labiorum pudendi - posterior joining fold of the above, which is ruptured at the time of the first delivery. Vestibulum vaginae - the labia minora delineate the vestibule. Fossa vestibuli vaginae - a groove between the posterior commissure and the opening of the vagina. Glandula vestibularis major (Bartholin) - a paired, bean sized vestibular gland, located symmetrically at the base of the labia minora, on the musculus tranversus perinei profundus. Their excretory ducts open on the posterior third of the labia minora. They correspond to the Cowper glands of the male. Bulbus vestibuli - an erectile tissue at the base of the labia minora, on both sides of the vestibule, homologous to the male bulbus penis. The two narrowing vestibular bulbs unite into the glans clitoris above the external urethra orifice. Clitoris - above the labia minora, it is homologous to the male penis. It is attached to the inferior border of the symphysis pubica through the ligamentum suspensorium clitoridis. Crus clitoridis - the roots of the clitoris, attached to the pubis and ischium Corpus clitoridis - anterior to the symphysis Preputium clitoridis - a skin fold on the anterior end of the clitoris. Frenulum clitoridis - two folds starting from the labia minora and joining below the clitoris. Glans clitoridis - the glans of the clitoris. Corpus cavernosum clitoridis - two, incompletely separated cavernous bodies. Septum corporum cavernosorum - a comb-like septum between the corpora cavernosa. Fascia clitoridis - the fascial layer of the clitoris. Ostium urethrae externum - located below the clitoris. Ductus paraurethrales (Skene ducts) - homologous to the excretory ducts of the prostate. Ostium vaginae - between the inferior, convergent parts of the labia minora. Hymen - a thin membrane blocking the ostium, its integrity denotes virginity. Vascular and nervous supply The arteries of the vulva are mainly from the arteria pudenda interna: ramii labiales posteriores, arteria bulbus vestibuli, arteria profunda et dorsalis clitoridis. The labia majora are also supplied by the arteriae pudendae externae through ramii labiales anteriores. The veins drain in the plexus venosus uterinus and vaginalis. The blood of the labia majora is drained by the vena pudenda interna and vena femoralis. The lymphatic vessels drain towards the nodi lymphatici inguinales superficiales and iliaci externi. The sensory nerves stem from the nervus ilioinguinalis and nervus pudendus; the autonomic fibers come from the plexus uterovaginalis.

The lesser pelvis organs

The rectum The rectum is the last part of the digestive tract, measuring 12 cm length, it is situated in the lesser pelvis. The limit between rectum and colon sigmoideum is considered the S3 level, where the mesocolon sigmoidei is ended. External aspect: The rectum presents two parts: ampulla recti (8-9 cm) and canalis analis(3-4 cm).In the sagittal plan the rectum describes two curves: Flexura sacralis-with anterior concavity corresponding to ampulla recti and Flexura perinealis-with posterior concavitycorresponding to canalis analis. Only a small part of the ampulla recti is covered by the peritoneum, the rest of it being situated in the pelvis subperitoneal space. Internal aspect: -In the superior part the mucosa presents three or four transversal folds called Plicae transversales Houston. These folds are made by the muscular circular layer contraction. The most developed (usually the third) is called plica Kohlrausch. -In the inferior part at the limit between the ampulla and canalis analis there are 8-10 longitudinal (vertical) folds Columna anales Morgagni. These folds delimit 8-10 grooves Sinus anales with the inferior part called Valvula anales. -Linea pectinata-linea anorectalis anatomica-is traced by the inferior limits of Columna anales Morgagni. It also represents the limit between a.rectalis media and inferior, the portal and caval system, the autonomic and somatic innerveation of rectum. -Linea alba Hilton-between the m.sphincter ani internus and m.sphincter ani externuspars superficialis. -Linea anocutanea-the limit between the anal mucosa and the perineal skin. -Pecten-the narrow segment of canalis analis, between linea alba and linea pectinata. At this level the canalis analis wall presents both of the sphincter muscles (internus et externus-pars profunda). The vessels and nerves of the rectum: Arteries. -A.mesenterica inferior: -A.rectalis superior-the last branch of a.mesenterica inferior irrigates the ampulla rectalis and is anastomosed with the other rectal arteries; -A.iliaca interna: -A.rectalis media-branches directly from a.iliaca interna; -A.rectalis inferior-branches from a.pudenda interna, also from a.iliaca interna. Veins: The blood of rectum is drained by veins with the same names as the arteries in vena mesenterica inferior (vena rectalis superior) and vena iliaca interna (vena rectalis media and inferior).Between the vena rectalis media and superior results a portocaval anastomosis.

The lymph is drained in: -Nodi lymphatici sacrales; -Nodi lymphatici iliaci interni. The nerves: -The sympathetic innervation arises from aorticus. The fibres situated around the a.iliaca interna will form plexus hypogastricus superior et inferior -The parasympathetic innervation arises from nn splachnicii pelvini (S2-S4); -Both types of fibres are organised in three plexuses: -Plexus rectalis superior; -Plexus rectalis medius; -Plexus rectalis inferior; The perianal region is innervated by somatic fibres- Nn.rectales inferiores-from N.pudendus internus. The urinary bladder The urinary bladder, when it is empty or with a small quantity of urine (less then 200 ml), has the shape of three-sided pyramid. External aspect: The borders are: -Apex vesicae-is situated anteriorly and is continued by the ligamentum umbilicale medianus (the rest of urachus); -Corpus vesicae-is the bigger part of it situated in the middle. It presents a superior face covered by the peritoneum and two lateral faces, bordered by the pubic rami. -Fundus vesicae-points posteriorly to the rectum (or uterus in women); -Collum or Cervix vesicae-points inferiorly and represents the narrowing part to the urethra. When the quantity of urine is over then 300-400 ml the urinary bladder becomes oval and the rounded, most part of the body being situated over the horizontal plane traced through the symphisa pubica. The antero-lateral corners of the body are continued by the ligamentum umbilicale mediale (the rest of arteria umbilicalis after the vesicals vessels branched from it). Internal aspect. The entire internal surface of the urinary bladder is covered by folds of mucosa, except a small area situated posteriorly-trigonum vesicae Lieutaud. The corners of this trigonum are: -Ostium ureterius dextrum; -Ostium ureterius sinistrum; -Ostium urethrae internus. The superior margin of the triangle is a fold between the two uretheric openings, called plicae interureterica.

In the inferior corner, the triangle presents another fold, near to the urethral opening Uvula vesicae. The layers of the urinary bladder. -mucosa-consists in transitional epithelium and foliculi limphatici solitari. Underneath is a soft tissue with elastine fibres. -tunica muscularis-has three layers: -stratum longitudinale externum-Musculus pubovesicalis; -Musculus puboprostaticus; -Musculus pubovaginalis; -stratum circulare-its more developed at the collum level; -stratum longitudinale internum-arises from the previous one. -M.sphincter vesicae-consists in circular fibers which are surrounding the first part of urethra. -serosa-is situated only superiorly (the peritoneum), the rest of urinary bladder surface is covered by adventitia. The vessels and nerves. Arteries arise from: -a.vesicales superiores; -a.vesicales inferiores; -a.obturatoria; -a.glutealis inferior; -a.uterina and a.vaginalis in women. The veins are organised in plexus venosus vesicae, which is drained in vena iliaca interna; The lymph is drained in nodi limphatici iliaci interni; The nerves are organised in plexus vesicalis. The sympathetic part arises from plexus hypogatricus superior et inferior and the parasympathetic part arises from S3-S4 the pelvic nerves. The genital organs of the lesser pelvis was presented in another chapter The ligaments and fascias of the lesser pelvis Fascia pelvis -is situated superior to the muscles of the lesser pelvis. Presents the following parts: Fascia parietalis: -fascia obturatoria superior-covers m.obturatorus internus. It presents a horizontal thickness arcus tendineus Rouget, which represents a part of the origin of levator ani muscle. -fascia piriformis-cover the piriform muscle; -fascia diaphragmatis pelvis superior covers the levator ani muscle and ischiococcygeus muscle; Fascia visceralis:-the adventitia of the pelvic organs.

The ligaments are organised around the hypogastric artery (a.iliaca interna)-which is surrounded by a fibrotic tissue-the hypogastric sheath or ligamentum sacro-recto-genito pubianum. These two ligaments (left and right) are situated in a sagittal plane from posterior to anterior. They consist in: -lig. Pubovesicalis; -lig puboprostaticus; -lig rectovezicalis; -lig sacrouterinus; The retinaculus, or the winds of the visceras are situated in frontal plane and surround the major branch of a.iliaca interna: -paracystium; -parametrium; -pararectum; The intervisceral septum (Septum interviscerale) is a fibrotic tissue between the lesser pelvis organs or the organs and the lesser pelvis walls which consists in: -Fascia umbilicoprevezicalis Testut-situated anteriorly to the urinary bladder posterior to sypmphisa pubica. -Septum rectovesicale-with its inferior part in men fascia rectoprostatica Denonvilliers. -Septum rectovaginale; -Fascia retrorectalis Ionescu-between the rectum and sacrum bone.

The topography of the lesser pelvis in men 1.Spatium rectale; Borders: -anterior-septum rectovesicale and fascia Denonvilliers; -lateral-m.levator ani; -posterior-sacrum and coccyx covered by fascia retrorectalis; -inferior-diaphragma pelvis fused with the rectum walls; Content: rectum; The superior part of it, covered by the peritoneum is bordered anteriorly by excavatio rectovesicalis Douglas. The inferior part (extraperitoneal part) is bordered by: -anterior: prostate, vesicules seminales, ductus deferens and the inferior part of the urethra. Between the two ductus deferens results a triangle-trigonum interdeferentialewhere the urinary bladder is in directly contact with the rectum; -posterior: fascia retrorectalis, a.sacrales laterales and sacralis media, nodi lymphatici retrorectales Gerota, sacrum and coccyx. -lateral: the ureterus and ligamentum sacrorectogenitopubianum.

2.Spatium vesico-genitales Borders: -anterior: symphisa pubica; -posterior: septum rectovesicalis and fascia Denonvelliers; -lateral: M.levator ani , M.obturatorius internus. -inferior-diaphragma urogenitalis. Content: Urinary bladder; Inferior part of urethra; Prostate; The seminal vesicles; Ductus deferens; The topography of the lesser pelvis in women 1.Spatium rectale-has the same limits as at man, excepting the anterior: -superior-excavatio rectouterina Douglas; -inferior-septum rectovaginalis; The borders of the rectum are the same, except the anterior one: the posterior wall of the vagina. 2.Spatium vesicale: the same limits, except the posterior one: septum vesico-vaginalis and ligamentum latum uteri. Content: The urinary bladder; The pelvic ureterus. 3.Spatium genitale. Borders: -anterior-septum vezicovaginalis; -posterior-septum rectovaginalis; -lateral-m.levator ani; -inferior-diaphragma urogenitalis. Content: The uterus; The Ovary; The uterine tube; The vagina.

The perineum The muscles of the perineum(Musculi perinei)-are disposed in three layers and they fuse into a common tendon situated in the middle part of perineum called centrum tendinei perinei. All are innervated by the pudendal nerve. 1.M.levator ani-the most profound muscle of the perineum, is situated between the lateral walls of the lesser pelvis, rectum and coccyx. Origin: -the superior part of ramus pubicus; -the inferior part of ilium bone; -a thickness of fascia obturatoria-Arcus tendineus Rouget; Insertion: -rectum wall; -coccyx; -ligamentum anococcygeus; -prostate; The fibers are organised in three major parts: -M.puborectalis-medial; -M.pubococcygeus-in the middle; -M.iliococcygeus-the outer part. On the median line the fibers delimits a space for the anus, genitals organs in women and urethra. The levator ani muscle with its fascias is called diaphragma pelvis and represents the inferior wall of the abdominal cavity. 2.M.ischiococcygeus-belongs to the profound plane, between spina ischiadica and coccyx. It is situated lateral and posterior to the levator ani. 3.M.sphincter ani externus-is situated around the canalis analis and presents three parts: -Pars subcutanea-by its contraction makes cutaneus folds in the perianal region. Its also called M.corrugator cutis ani; -Pars superficialis-is the most important part, contains fibres which start from ligamentum anococcygeus and end on centrum tendineum surrounding the anus. -Pars profunda-is thin and is attached to the internal sphincter muscles-is situated on the Pecten level. The contraction of each part closes the canalis analis. 4.M.transversus perinei profundus The origin is on the ramus pubis inferior and ischium and is inserted on the centrum tendineum. It belongs to the perineum anterior. With its fascias it is called diaphragma urogenitalis. 5.M.transversus perinei superficialis-a small muscle with transversal disposition between tuber ischiadicum and centrum tendineum.

6.M.sphincter urethrae-the Wilsons muscle-consist in circular fibers detached from diaphragma urogenitalis. 7.M.ischiocavernosus-starts from the inferior part of the ischium and ends by surrounding corpus cavernosus 8.M.bulbospongiosus-starts from centrum tendineum and ends on radix penis. The fascias of perineum Fascia pelvis -is situated superior to the muscles of the lesser pelvis. It presents the following parts: Fascia parietalis: -fascia obturatoria superior-cover m.obturatorus internus. Presents a horizontal thickness arcus tendineus Rouget, which represents a part of the origin of levator ani muscle. -fascia piriformis-cover the piriform muscle; -fascia diaphragmatis pelvis superior cover the levator ani muscle and ischiococcygeus muscle; Fascia visceralis:-the adventitia of the pelvic organs. Fascia obturatoria inferior-situated under the Rouget arch, inside of fossa ischioanalis; A vertical thickness of it is called Canalis pudendalis Alcock which contains the pudendal artery and nerve. Fascia diaphragmatis pelvis inferior- covers the inferior surface of m.levator ani. Fascia diaphragmatis urogenitalis superior: covers the superior surface of the m.transversus perinei profundus; Fascia diaphragmatis urogenitalis inferior:is thick and resistant-called also the ligament of Carcassone The two fascias are fused anterior to the muscle transversus perinei profundus, resulting in Ligamentum perinei profundus and posterior in centrum tendinei. Fascia perinei superficialis-is situated under the skin and cover the superficial muscles (ischiocavernosus and bulbospongiosus). Regio perinealis A rhomboid shape bordered by symphisa pubica, ramus ischiopubicus, tuber ischiadicum and coccyx. A horizontal line divide the perineum in perineum anterior (Regio urogenitalis) et posterior (Regio analis). The posterior perineum presents the same elements at both genders, the anterior perineum present different elements.

Regio analis Represents the posterior triangle, perforated by the anus. The skin is mobile, with hair and seborrheic glands. The subcutis consist in arteries branched from a.pudenda externa, veins and nerves. Fascia perinealis superficialis is missing in this region. M.sphincter ani externus with its three parts. Diaphragma pelvis-consist in musculus levator ani with fascia diaphragmatis pelvis superior et inferior and m.ischiococcygeus. Fossa ischioanalis-two paired cavities situated arround the canalis analis. It is bordered : -medially-canalis analis; -superiorly-m.levator ani; -lateral-m.obturatorus internus; -inferior-the covering plan of the region; The content of the fossa ischioanalis is fat tissue: corpus adiposum fossae ischiorectalis and Canalis pudendalis Alcock. The rapports of Canalis analis in the perineal region: -posterior-the posterior fibers of levator ani muscle and ligamentum anococcygeum; -lateral-fossa ischiorectalis; -anterior- in men-the prostate and Cowper glands; - in women-the posterior wall of the vagina; Canalis analis with external and internal aspects was presented in another chapter (rectum) The anterior perineum in men In this region are situated the masculine genital organs and the urogenital diaphragm is perforated by the urethra. The skin of the region is mobile and presents on the median line a thickness which is continued anteriorly by the raphe scroti. The subcutis is thin with vessels and nerves (the pudendal pedicle). Spatium perinei superficiale-is situated between the fascia perinei superficialis and diaphragma urogenitalis. The content of this space is: -bulbus penis; -m.bulbospongiosus; -corpus cavernosus, covered by m.ischiocavernosus; -the Cowper glands canal; -vessels and nerves for the penis; Spatium perinei profundum-is situated between the fascia diaphragmatis urogenitalis superficialis and profunda. The content of this space: -m.transversus perinei profundus; -m.sphincter urethrae; -urethra membranosa -the Cowper glands; -the pudendal pedicle.

The anterior perineum in women Is the region of the external genitals organs (vulva with its elements).The urogenital diaphragm is perforated by the urethra and vagina. Spatium perineale superficiale -bulbus vestibuli; -m.bulbospongiosus and ischiocavernosus; -Bartholin glands; Spatium perineale profundum -urethra membranosa; -m.sphincter urethrae; -vagina; -the pudendal pedicle.