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Anatomy_Gray_900 | Anatomy_Gray | to visualize either the bile duct (cholangiogram) or pancreatic duct (pancreatogram) (Fig. 4.119). If a stone is present, it can be removed with a stone basket or an extraction balloon. Usually, a sphincterotomy is performed before stone removal to ease its passage through the distal bile duct. | Anatomy_Gray. to visualize either the bile duct (cholangiogram) or pancreatic duct (pancreatogram) (Fig. 4.119). If a stone is present, it can be removed with a stone basket or an extraction balloon. Usually, a sphincterotomy is performed before stone removal to ease its passage through the distal bile duct. | [
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Anatomy_Gray_901 | Anatomy_Gray | In cases of biliary tree obstruction caused by benign or malignant strictures, a stent can be placed into the common bile duct or into one of the main hepatic ducts to allow opening of the narrowed segment. The patency of the newly inserted stent is confirmed by instillation of more contrast medium to demonstrate free flow of contrast through the stent. In the clinic Jaundice is a yellow discoloration of the skin caused by excess bile pigment (bilirubin) within the plasma. The yellow color is best appreciated by looking at the normally white sclerae of the eyes, which turn yellow. The extent of the elevation of the bile pigments and the duration for which they have been elevated account for the severity of jaundice. Simplified explanation to understanding the types of jaundice and their anatomical causes | Anatomy_Gray. In cases of biliary tree obstruction caused by benign or malignant strictures, a stent can be placed into the common bile duct or into one of the main hepatic ducts to allow opening of the narrowed segment. The patency of the newly inserted stent is confirmed by instillation of more contrast medium to demonstrate free flow of contrast through the stent. In the clinic Jaundice is a yellow discoloration of the skin caused by excess bile pigment (bilirubin) within the plasma. The yellow color is best appreciated by looking at the normally white sclerae of the eyes, which turn yellow. The extent of the elevation of the bile pigments and the duration for which they have been elevated account for the severity of jaundice. Simplified explanation to understanding the types of jaundice and their anatomical causes | [
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Anatomy_Gray_902 | Anatomy_Gray | Simplified explanation to understanding the types of jaundice and their anatomical causes When red blood cells are destroyed by the reticuloendothelial system, the iron from the hemoglobin molecule is recycled, whereas the porphyrin ring (globin) compounds are broken down to form fat-soluble bilirubin. On reaching the liver via the bloodstream, the fat-soluble bilirubin is converted to a water-soluble form of bilirubin. This water-soluble bilirubin is secreted into the biliary tree and then in turn into the bowel, where it forms the dark color of the stool. This type of jaundice is usually produced by conditions where there is an excessive breakdown of red blood cells (e.g., in incompatible blood transfusion and hemolytic anemia). | Anatomy_Gray. Simplified explanation to understanding the types of jaundice and their anatomical causes When red blood cells are destroyed by the reticuloendothelial system, the iron from the hemoglobin molecule is recycled, whereas the porphyrin ring (globin) compounds are broken down to form fat-soluble bilirubin. On reaching the liver via the bloodstream, the fat-soluble bilirubin is converted to a water-soluble form of bilirubin. This water-soluble bilirubin is secreted into the biliary tree and then in turn into the bowel, where it forms the dark color of the stool. This type of jaundice is usually produced by conditions where there is an excessive breakdown of red blood cells (e.g., in incompatible blood transfusion and hemolytic anemia). | [
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Anatomy_Gray_903 | Anatomy_Gray | This type of jaundice is usually produced by conditions where there is an excessive breakdown of red blood cells (e.g., in incompatible blood transfusion and hemolytic anemia). The complex biochemical reactions for converting fat-soluble into water-soluble bilirubin may be affected by inflammatory change within the liver (e.g., from hepatitis or chronic liver disease, such as liver cirrhosis) and poisons (e.g., paracetamol overdose). Any obstruction of the biliary tree can produce jaundice, but the two most common causes are gallstones within the bile duct and an obstructing tumor at the head of the pancreas. In the clinic From a clinical point of view, there are two main categories of spleen disorders: rupture and enlargement. | Anatomy_Gray. This type of jaundice is usually produced by conditions where there is an excessive breakdown of red blood cells (e.g., in incompatible blood transfusion and hemolytic anemia). The complex biochemical reactions for converting fat-soluble into water-soluble bilirubin may be affected by inflammatory change within the liver (e.g., from hepatitis or chronic liver disease, such as liver cirrhosis) and poisons (e.g., paracetamol overdose). Any obstruction of the biliary tree can produce jaundice, but the two most common causes are gallstones within the bile duct and an obstructing tumor at the head of the pancreas. In the clinic From a clinical point of view, there are two main categories of spleen disorders: rupture and enlargement. | [
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Anatomy_Gray_904 | Anatomy_Gray | In the clinic From a clinical point of view, there are two main categories of spleen disorders: rupture and enlargement. This tends to occur when there is localized trauma to the left upper quadrant. It may be associated with left lower rib fractures. Because the spleen has such an extremely thin capsule, it is susceptible to injury even when there is no damage to surrounding structures, and because the spleen is highly vascular, when ruptured, it bleeds profusely into the peritoneal cavity. Splenic rupture should always be suspected with blunt abdominal injury. Current treatments preserve as much of the spleen as possible, but some patients require splenectomy. | Anatomy_Gray. In the clinic From a clinical point of view, there are two main categories of spleen disorders: rupture and enlargement. This tends to occur when there is localized trauma to the left upper quadrant. It may be associated with left lower rib fractures. Because the spleen has such an extremely thin capsule, it is susceptible to injury even when there is no damage to surrounding structures, and because the spleen is highly vascular, when ruptured, it bleeds profusely into the peritoneal cavity. Splenic rupture should always be suspected with blunt abdominal injury. Current treatments preserve as much of the spleen as possible, but some patients require splenectomy. | [
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Anatomy_Gray_905 | Anatomy_Gray | The spleen is an organ of the reticuloendothelial system involved in hematopoiesis and immunological surveillance. Diseases that affect the reticuloendothelial system (e.g., leukemia or lymphoma) may produce generalized lymphadenopathy and enlargement of the spleen (splenomegaly) (Fig. 4.120). The spleen often enlarges when performing its normal physiological functions, such as when clearing microorganisms and particulates from the circulation, producing increased antibodies in the course of sepsis, or removing deficient or destroyed erythrocytes (e.g., in thalassemia and spherocytosis). Splenomegaly may also be a result of increased venous pressure caused by congestive heart failure, splenic vein thrombosis, or portal hypertension. An enlarged spleen is prone to rupture. In the clinic Vascular supply to the gastrointestinal system | Anatomy_Gray. The spleen is an organ of the reticuloendothelial system involved in hematopoiesis and immunological surveillance. Diseases that affect the reticuloendothelial system (e.g., leukemia or lymphoma) may produce generalized lymphadenopathy and enlargement of the spleen (splenomegaly) (Fig. 4.120). The spleen often enlarges when performing its normal physiological functions, such as when clearing microorganisms and particulates from the circulation, producing increased antibodies in the course of sepsis, or removing deficient or destroyed erythrocytes (e.g., in thalassemia and spherocytosis). Splenomegaly may also be a result of increased venous pressure caused by congestive heart failure, splenic vein thrombosis, or portal hypertension. An enlarged spleen is prone to rupture. In the clinic Vascular supply to the gastrointestinal system | [
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Anatomy_Gray_906 | Anatomy_Gray | In the clinic Vascular supply to the gastrointestinal system The abdominal parts of the gastrointestinal system are supplied mainly by the celiac trunk and the superior mesenteric and inferior mesenteric arteries (Fig. 4.129): The celiac trunk supplies the lower esophagus, stomach, superior part of the duodenum, and proximal half of the descending part of the duodenum. The superior mesenteric artery supplies the rest of the duodenum, the jejunum, the ileum, the ascending colon, and the proximal two-thirds of the transverse colon. The inferior mesenteric artery supplies the rest of the transverse colon, the descending colon, the sigmoid colon, and most of the rectum. | Anatomy_Gray. In the clinic Vascular supply to the gastrointestinal system The abdominal parts of the gastrointestinal system are supplied mainly by the celiac trunk and the superior mesenteric and inferior mesenteric arteries (Fig. 4.129): The celiac trunk supplies the lower esophagus, stomach, superior part of the duodenum, and proximal half of the descending part of the duodenum. The superior mesenteric artery supplies the rest of the duodenum, the jejunum, the ileum, the ascending colon, and the proximal two-thirds of the transverse colon. The inferior mesenteric artery supplies the rest of the transverse colon, the descending colon, the sigmoid colon, and most of the rectum. | [
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Anatomy_Gray_907 | Anatomy_Gray | The inferior mesenteric artery supplies the rest of the transverse colon, the descending colon, the sigmoid colon, and most of the rectum. Along the descending part of the duodenum there is a potential watershed area between the celiac trunk blood supply and the superior mesenteric arterial blood supply. It is unusual for this area to become ischemic, whereas the watershed area between the superior mesenteric artery and the inferior mesenteric artery, at the splenic flexure, is extremely vulnerable to ischemia. In certain disease states, the region of the splenic flexure of the colon can become ischemic. When this occurs, the mucosa sloughs off, rendering the patient susceptible to infection and perforation of the large bowel, which then requires urgent surgical attention. | Anatomy_Gray. The inferior mesenteric artery supplies the rest of the transverse colon, the descending colon, the sigmoid colon, and most of the rectum. Along the descending part of the duodenum there is a potential watershed area between the celiac trunk blood supply and the superior mesenteric arterial blood supply. It is unusual for this area to become ischemic, whereas the watershed area between the superior mesenteric artery and the inferior mesenteric artery, at the splenic flexure, is extremely vulnerable to ischemia. In certain disease states, the region of the splenic flexure of the colon can become ischemic. When this occurs, the mucosa sloughs off, rendering the patient susceptible to infection and perforation of the large bowel, which then requires urgent surgical attention. | [
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Anatomy_Gray_908 | Anatomy_Gray | Arteriosclerosis may occur throughout the abdominal aorta and at the openings of the celiac trunk and the superior mesenteric and inferior mesenteric arteries. Not infrequently, the inferior mesenteric artery becomes occluded. Interestingly, many of these patients do not suffer any complications, because anastomoses between the right, middle, and left colic arteries gradually enlarge, forming a continuous marginal artery. The distal large bowel therefore becomes supplied by this enlarged marginal artery (marginal artery of Drummond), which replaces the blood supply of the inferior mesenteric artery (Fig. 4.130). | Anatomy_Gray. Arteriosclerosis may occur throughout the abdominal aorta and at the openings of the celiac trunk and the superior mesenteric and inferior mesenteric arteries. Not infrequently, the inferior mesenteric artery becomes occluded. Interestingly, many of these patients do not suffer any complications, because anastomoses between the right, middle, and left colic arteries gradually enlarge, forming a continuous marginal artery. The distal large bowel therefore becomes supplied by this enlarged marginal artery (marginal artery of Drummond), which replaces the blood supply of the inferior mesenteric artery (Fig. 4.130). | [
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Anatomy_Gray_909 | Anatomy_Gray | If the openings of the celiac trunk and superior mesenteric artery become narrowed, the blood supply to the gut is diminished. After a heavy meal, the oxygen demand of the bowel therefore outstrips the limited supply of blood through the stenosed vessels, resulting in severe pain and discomfort (mesenteric angina). Patients with this condition tend not to eat because of the pain and rapidly lose weight. The diagnosis is determined by aortic angiography, and the stenoses of the celiac trunk and superior mesenteric artery are best appreciated in the lateral view. In the clinic Cirrhosis is a complex disorder of the liver, the diagnosis of which is confirmed histologically. When a diagnosis is suspected, a liver biopsy is necessary. Cirrhosis is characterized by widespread hepatic fibrosis interspersed with areas of nodular regeneration and abnormal reconstruction of preexisting lobular architecture. The presence of cirrhosis implies previous or continuing liver cell damage. | Anatomy_Gray. If the openings of the celiac trunk and superior mesenteric artery become narrowed, the blood supply to the gut is diminished. After a heavy meal, the oxygen demand of the bowel therefore outstrips the limited supply of blood through the stenosed vessels, resulting in severe pain and discomfort (mesenteric angina). Patients with this condition tend not to eat because of the pain and rapidly lose weight. The diagnosis is determined by aortic angiography, and the stenoses of the celiac trunk and superior mesenteric artery are best appreciated in the lateral view. In the clinic Cirrhosis is a complex disorder of the liver, the diagnosis of which is confirmed histologically. When a diagnosis is suspected, a liver biopsy is necessary. Cirrhosis is characterized by widespread hepatic fibrosis interspersed with areas of nodular regeneration and abnormal reconstruction of preexisting lobular architecture. The presence of cirrhosis implies previous or continuing liver cell damage. | [
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Anatomy_Gray_910 | Anatomy_Gray | The etiology of cirrhosis is complex and includes toxins (alcohol), viral inflammation, biliary obstruction, vascular outlet obstruction, nutritional (malnutrition) causes, and inherited anatomical and metabolic disorders. As the cirrhosis progresses, the intrahepatic vasculature is distorted, which in turn leads to increased pressure in the portal vein and its draining tributaries (portal hypertension). Portal hypertension produces increased pressure in the splenic venules, leading to splenic enlargement. At the sites of portosystemic anastomosis (see below), large dilated veins (varices) develop. These veins are susceptible to bleeding and may produce marked blood loss, which in some instances can be fatal. | Anatomy_Gray. The etiology of cirrhosis is complex and includes toxins (alcohol), viral inflammation, biliary obstruction, vascular outlet obstruction, nutritional (malnutrition) causes, and inherited anatomical and metabolic disorders. As the cirrhosis progresses, the intrahepatic vasculature is distorted, which in turn leads to increased pressure in the portal vein and its draining tributaries (portal hypertension). Portal hypertension produces increased pressure in the splenic venules, leading to splenic enlargement. At the sites of portosystemic anastomosis (see below), large dilated veins (varices) develop. These veins are susceptible to bleeding and may produce marked blood loss, which in some instances can be fatal. | [
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Anatomy_Gray_911 | Anatomy_Gray | The liver is responsible for the production of numerous proteins, including those of the clotting cascade. Any disorder of the liver (including infection and cirrhosis) may decrease the production of these proteins and so prevent adequate blood clotting. Patients with severe cirrhosis of the liver have a significant risk of serious bleeding, even from small cuts; in addition, when varices rupture, there is a danger of rapid exsanguination. As the liver progressively fails, the patient develops salt and water retention, which produces skin and subcutaneous edema. Fluid (ascites) is also retained in the peritoneal cavity, which can hold many liters. The poorly functioning liver cells (hepatocytes) are unable to break down blood and blood products, leading to an increase in the serum bilirubin level, which manifests as jaundice. | Anatomy_Gray. The liver is responsible for the production of numerous proteins, including those of the clotting cascade. Any disorder of the liver (including infection and cirrhosis) may decrease the production of these proteins and so prevent adequate blood clotting. Patients with severe cirrhosis of the liver have a significant risk of serious bleeding, even from small cuts; in addition, when varices rupture, there is a danger of rapid exsanguination. As the liver progressively fails, the patient develops salt and water retention, which produces skin and subcutaneous edema. Fluid (ascites) is also retained in the peritoneal cavity, which can hold many liters. The poorly functioning liver cells (hepatocytes) are unable to break down blood and blood products, leading to an increase in the serum bilirubin level, which manifests as jaundice. | [
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Anatomy_Gray_912 | Anatomy_Gray | The poorly functioning liver cells (hepatocytes) are unable to break down blood and blood products, leading to an increase in the serum bilirubin level, which manifests as jaundice. With the failure of normal liver metabolism, toxic metabolic by-products do not convert to nontoxic metabolites. This buildup of noxious compounds is made worse by the numerous portosystemic shunts, which allow the toxic metabolites to bypass the liver. Patients may develop severe neurological features, called hepatic encephalopathy, that can manifest as acute confusion, epileptic fits, or psychotic state. Hepatic encephalopathy is one of the urgent criteria for liver transplantation; if the condition is not reversed, it leads to irreversible neurological damage and death. | Anatomy_Gray. The poorly functioning liver cells (hepatocytes) are unable to break down blood and blood products, leading to an increase in the serum bilirubin level, which manifests as jaundice. With the failure of normal liver metabolism, toxic metabolic by-products do not convert to nontoxic metabolites. This buildup of noxious compounds is made worse by the numerous portosystemic shunts, which allow the toxic metabolites to bypass the liver. Patients may develop severe neurological features, called hepatic encephalopathy, that can manifest as acute confusion, epileptic fits, or psychotic state. Hepatic encephalopathy is one of the urgent criteria for liver transplantation; if the condition is not reversed, it leads to irreversible neurological damage and death. | [
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Anatomy_Gray_913 | Anatomy_Gray | The hepatic portal system drains blood from the visceral organs of the abdomen to the liver. In normal individuals, 100% of the portal venous blood flow can be recovered from the hepatic veins, whereas in patients with elevated portal vein pressure (e.g., from cirrhosis), there is significantly less blood flow to the liver. The rest of the blood enters collateral channels, which drain into the systemic circulation at specific points (Fig. 4.133). The largest of these collaterals occur at: the gastroesophageal junction around the cardia of the stomach—where the left gastric vein and its tributaries form a portosystemic anastomosis with tributaries to the azygos system of veins of the caval system; the anus—the superior rectal vein of the portal system anastomoses with the middle and inferior rectal veins of the systemic venous system; and the anterior abdominal wall around the umbilicus—the para-umbilical veins anastomose with veins on the anterior abdominal wall. | Anatomy_Gray. The hepatic portal system drains blood from the visceral organs of the abdomen to the liver. In normal individuals, 100% of the portal venous blood flow can be recovered from the hepatic veins, whereas in patients with elevated portal vein pressure (e.g., from cirrhosis), there is significantly less blood flow to the liver. The rest of the blood enters collateral channels, which drain into the systemic circulation at specific points (Fig. 4.133). The largest of these collaterals occur at: the gastroesophageal junction around the cardia of the stomach—where the left gastric vein and its tributaries form a portosystemic anastomosis with tributaries to the azygos system of veins of the caval system; the anus—the superior rectal vein of the portal system anastomoses with the middle and inferior rectal veins of the systemic venous system; and the anterior abdominal wall around the umbilicus—the para-umbilical veins anastomose with veins on the anterior abdominal wall. | [
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Anatomy_Gray_914 | Anatomy_Gray | When the pressure in the portal vein is elevated, venous enlargement (varices) tend to occur at and around the sites of portosystemic anastomoses and these enlarged veins are called: varices at the anorectal junction, esophageal varices at the gastroesophageal junction, and caput medusae at the umbilicus. Esophageal varices are susceptible to trauma and, once damaged, may bleed profusely, requiring urgent surgical intervention. In the clinic | Anatomy_Gray. When the pressure in the portal vein is elevated, venous enlargement (varices) tend to occur at and around the sites of portosystemic anastomoses and these enlarged veins are called: varices at the anorectal junction, esophageal varices at the gastroesophageal junction, and caput medusae at the umbilicus. Esophageal varices are susceptible to trauma and, once damaged, may bleed profusely, requiring urgent surgical intervention. In the clinic | [
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Anatomy_Gray_915 | Anatomy_Gray | Esophageal varices are susceptible to trauma and, once damaged, may bleed profusely, requiring urgent surgical intervention. In the clinic Surgery for obesity is also known as weight loss surgery and bariatric surgery. This type of surgery has become increasingly popular over the last few years for patients who are unable to achieve significant weight loss through appropriate diet modification and exercise programs. It is often regarded as a last resort. Importantly, we have to recognize the increasing medical impact that overweight patients pose. With obesity the patient is more likely to develop diabetes and cardiovascular problems and may suffer from increased general health disorders. All of these have a significant impact on health care budgeting and are regarded as serious conditions for the “health of a nation.” | Anatomy_Gray. Esophageal varices are susceptible to trauma and, once damaged, may bleed profusely, requiring urgent surgical intervention. In the clinic Surgery for obesity is also known as weight loss surgery and bariatric surgery. This type of surgery has become increasingly popular over the last few years for patients who are unable to achieve significant weight loss through appropriate diet modification and exercise programs. It is often regarded as a last resort. Importantly, we have to recognize the increasing medical impact that overweight patients pose. With obesity the patient is more likely to develop diabetes and cardiovascular problems and may suffer from increased general health disorders. All of these have a significant impact on health care budgeting and are regarded as serious conditions for the “health of a nation.” | [
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Anatomy_Gray_916 | Anatomy_Gray | There are a number of surgical options to treat obesity. Surgery for patients who are morbidly obese can be categorized into two main groups: malabsorptive procedures and restrictive procedures. There are a variety of bypass procedures that produce a malabsorption state, preventing further weight gain and also producing weight loss. There are complications, which may include anemia, osteoporosis, and diarrhea (e.g., jejunoileal bypass). Restrictive procedures involve placing a band or stapling in or around the stomach to decrease the size of the organ. This reduction produces an earlier feeling of satiety and prevents the patient from overeating. Probably the most popular procedure currently in the United States is gastric bypass surgery. This procedure involves stapling the proximal stomach and joining a loop of small bowel to the small gastric remnant. The procedure is usually performed by fashioning a Roux-en-Y loop with alimentary and pancreaticobiliary limbs. | Anatomy_Gray. There are a number of surgical options to treat obesity. Surgery for patients who are morbidly obese can be categorized into two main groups: malabsorptive procedures and restrictive procedures. There are a variety of bypass procedures that produce a malabsorption state, preventing further weight gain and also producing weight loss. There are complications, which may include anemia, osteoporosis, and diarrhea (e.g., jejunoileal bypass). Restrictive procedures involve placing a band or stapling in or around the stomach to decrease the size of the organ. This reduction produces an earlier feeling of satiety and prevents the patient from overeating. Probably the most popular procedure currently in the United States is gastric bypass surgery. This procedure involves stapling the proximal stomach and joining a loop of small bowel to the small gastric remnant. The procedure is usually performed by fashioning a Roux-en-Y loop with alimentary and pancreaticobiliary limbs. | [
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Anatomy_Gray_917 | Anatomy_Gray | The other type of the procedure, sleeve gastrectomy, is increasing in popularity because it can be used in patients deemed to be at high risk for gastric bypass surgery. It involves reduction of the gastric lumen by removing a large portion of the stomach along the greater curvature. Any overweight patient undergoing surgery faces significant risk and increased morbidity, with mortality rates from 1% to 5%. In the clinic | Anatomy_Gray. The other type of the procedure, sleeve gastrectomy, is increasing in popularity because it can be used in patients deemed to be at high risk for gastric bypass surgery. It involves reduction of the gastric lumen by removing a large portion of the stomach along the greater curvature. Any overweight patient undergoing surgery faces significant risk and increased morbidity, with mortality rates from 1% to 5%. In the clinic | [
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Anatomy_Gray_918 | Anatomy_Gray | Any overweight patient undergoing surgery faces significant risk and increased morbidity, with mortality rates from 1% to 5%. In the clinic At first glance, it is difficult to appreciate why the psoas muscle sheath is of greater importance than any other muscle sheath. The psoas muscle and its sheath arise not only from the lumbar vertebrae but also from the intervertebral discs between each vertebra. This disc origin is of critical importance. In certain types of infection, the intervertebral disc is preferentially affected (e.g., tuberculosis and salmonella discitis). As the infection of the disc develops, the infection spreads anteriorly and anterolaterally. In the anterolateral position, the infection passes into the psoas muscle sheath, and spreads within the muscle and sheath, and may appear below the inguinal ligament as a mass. In the clinic To understand why a hernia occurs through the diaphragm, it is necessary to consider the embryology of the diaphragm. | Anatomy_Gray. Any overweight patient undergoing surgery faces significant risk and increased morbidity, with mortality rates from 1% to 5%. In the clinic At first glance, it is difficult to appreciate why the psoas muscle sheath is of greater importance than any other muscle sheath. The psoas muscle and its sheath arise not only from the lumbar vertebrae but also from the intervertebral discs between each vertebra. This disc origin is of critical importance. In certain types of infection, the intervertebral disc is preferentially affected (e.g., tuberculosis and salmonella discitis). As the infection of the disc develops, the infection spreads anteriorly and anterolaterally. In the anterolateral position, the infection passes into the psoas muscle sheath, and spreads within the muscle and sheath, and may appear below the inguinal ligament as a mass. In the clinic To understand why a hernia occurs through the diaphragm, it is necessary to consider the embryology of the diaphragm. | [
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Anatomy_Gray_919 | Anatomy_Gray | In the clinic To understand why a hernia occurs through the diaphragm, it is necessary to consider the embryology of the diaphragm. The diaphragm is formed from four structures— the septum transversum, the posterior esophageal mesentery, the pleuroperitoneal membrane, and the peripheral rim—which eventually fuse together, separating the abdominal cavity from the thoracic cavity. The septum transversum forms the central tendon, which develops from a mesodermal origin superior to the embryo’s head and then moves to its more adult position during folding of the cephalic portion of the embryo. Fusion of the various components of the diaphragm may fail, and hernias may occur through the failed points of fusion (Fig. 4.146). The commonest sites are: between the xiphoid process and the costal margins on the right (Morgagni’s hernia), and through an opening on the left when the pleuroperitoneal membrane fails to close the pericardioperitoneal canal (Bochdalek’s hernia). | Anatomy_Gray. In the clinic To understand why a hernia occurs through the diaphragm, it is necessary to consider the embryology of the diaphragm. The diaphragm is formed from four structures— the septum transversum, the posterior esophageal mesentery, the pleuroperitoneal membrane, and the peripheral rim—which eventually fuse together, separating the abdominal cavity from the thoracic cavity. The septum transversum forms the central tendon, which develops from a mesodermal origin superior to the embryo’s head and then moves to its more adult position during folding of the cephalic portion of the embryo. Fusion of the various components of the diaphragm may fail, and hernias may occur through the failed points of fusion (Fig. 4.146). The commonest sites are: between the xiphoid process and the costal margins on the right (Morgagni’s hernia), and through an opening on the left when the pleuroperitoneal membrane fails to close the pericardioperitoneal canal (Bochdalek’s hernia). | [
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Anatomy_Gray_920 | Anatomy_Gray | Hernias may also occur through the central tendon and through a congenitally large esophageal hiatus. Morgagni’s and Bochdalek’s hernias tend to appear at or around the time of birth or in early infancy. They allow abdominal bowel to enter the thoracic cavity, which may compress the lungs and reduce respiratory function. Most of these hernias require surgical closure of the diaphragmatic defect. However, large hernias can lead to pulmonary hypoplasia and the long-term outcome depends more on the degree of the hypoplasia rather than on the surgical repair itself. Occasionally, small defects within the diaphragm fail to permit bowel through, but do allow free movement of fluid. Patients with ascites may develop pleural effusions, while patients with pleural effusions may develop ascites when these defects are present. In the clinic | Anatomy_Gray. Hernias may also occur through the central tendon and through a congenitally large esophageal hiatus. Morgagni’s and Bochdalek’s hernias tend to appear at or around the time of birth or in early infancy. They allow abdominal bowel to enter the thoracic cavity, which may compress the lungs and reduce respiratory function. Most of these hernias require surgical closure of the diaphragmatic defect. However, large hernias can lead to pulmonary hypoplasia and the long-term outcome depends more on the degree of the hypoplasia rather than on the surgical repair itself. Occasionally, small defects within the diaphragm fail to permit bowel through, but do allow free movement of fluid. Patients with ascites may develop pleural effusions, while patients with pleural effusions may develop ascites when these defects are present. In the clinic | [
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Anatomy_Gray_921 | Anatomy_Gray | In the clinic At the level of the esophageal hiatus, the diaphragm may be lax, allowing the fundus of the stomach to herniate into the posterior mediastinum (Figs. 4.147 and 4.148). This typically causes symptoms of acid reflux. Ulceration may occur and may produce bleeding and anemia. The diagnosis is usually made by barium studies or endoscopy. Hiatal hernia is often asymptomatic and is frequently found incidentally on CT imaging performed for unrelated complaints. Treatment in the first instance is by medical management, although surgery may be necessary. In the clinic | Anatomy_Gray. In the clinic At the level of the esophageal hiatus, the diaphragm may be lax, allowing the fundus of the stomach to herniate into the posterior mediastinum (Figs. 4.147 and 4.148). This typically causes symptoms of acid reflux. Ulceration may occur and may produce bleeding and anemia. The diagnosis is usually made by barium studies or endoscopy. Hiatal hernia is often asymptomatic and is frequently found incidentally on CT imaging performed for unrelated complaints. Treatment in the first instance is by medical management, although surgery may be necessary. In the clinic | [
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Anatomy_Gray_922 | Anatomy_Gray | In the clinic Urinary tract stones (calculi) occur more frequently in men than in women, are most common in people aged between 20 and 60 years, and are usually associated with sedentary lifestyles. The stones are polycrystalline aggregates of calcium, phosphate, oxalate, urate, and other soluble salts within an organic matrix. The urine becomes saturated with these salts, and small variations in the pH cause the salts to precipitate. Typically the patient has pain that radiates from the infrascapular region (loin) into the groin, and even into the scrotum or labia majora. Blood in the urine (hematuria) may also be noticed. Infection must be excluded because certain species of bacteria are commonly associated with urinary tract stones. The complications of urinary tract stones include infection, urinary obstruction, and renal failure. Stones may also develop within the bladder and produce marked irritation, causing pain and discomfort. | Anatomy_Gray. In the clinic Urinary tract stones (calculi) occur more frequently in men than in women, are most common in people aged between 20 and 60 years, and are usually associated with sedentary lifestyles. The stones are polycrystalline aggregates of calcium, phosphate, oxalate, urate, and other soluble salts within an organic matrix. The urine becomes saturated with these salts, and small variations in the pH cause the salts to precipitate. Typically the patient has pain that radiates from the infrascapular region (loin) into the groin, and even into the scrotum or labia majora. Blood in the urine (hematuria) may also be noticed. Infection must be excluded because certain species of bacteria are commonly associated with urinary tract stones. The complications of urinary tract stones include infection, urinary obstruction, and renal failure. Stones may also develop within the bladder and produce marked irritation, causing pain and discomfort. | [
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Anatomy_Gray_923 | Anatomy_Gray | The diagnosis of urinary tract stones is based upon history and examination. Stones are often visible on abdominal radiographs. Special investigations include: ultrasound scanning, which may demonstrate the dilated renal pelvis and calices when the urinary system is obstructed. This is the preferred way of imaging in pregnant women or when clinical suspicion is low. low-dose CT of the urinary tract (CT KUB), which allows the detection of even smaller stones, shows the exact level of obstruction and, based on the size, density, and location of the stone, can help the urologist plan a procedure to remove the stone if necessary (extracorporeal shock wave lithotripsy versus ureteroscopy, percutaneous nephrolithotomy, or, extremely rare these days, open surgery) (Fig. 4.156). an intravenous urogram, which will demonstrate the obstruction, pinpoint the exact level of the stone is currently less often used because access to low-dose CT KUB has increased. In the clinic | Anatomy_Gray. The diagnosis of urinary tract stones is based upon history and examination. Stones are often visible on abdominal radiographs. Special investigations include: ultrasound scanning, which may demonstrate the dilated renal pelvis and calices when the urinary system is obstructed. This is the preferred way of imaging in pregnant women or when clinical suspicion is low. low-dose CT of the urinary tract (CT KUB), which allows the detection of even smaller stones, shows the exact level of obstruction and, based on the size, density, and location of the stone, can help the urologist plan a procedure to remove the stone if necessary (extracorporeal shock wave lithotripsy versus ureteroscopy, percutaneous nephrolithotomy, or, extremely rare these days, open surgery) (Fig. 4.156). an intravenous urogram, which will demonstrate the obstruction, pinpoint the exact level of the stone is currently less often used because access to low-dose CT KUB has increased. In the clinic | [
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Anatomy_Gray_924 | Anatomy_Gray | an intravenous urogram, which will demonstrate the obstruction, pinpoint the exact level of the stone is currently less often used because access to low-dose CT KUB has increased. In the clinic Most tumors that arise in the kidney are renal cell carcinomas. These tumors develop from the proximal tubular epithelium. Approximately 5% of tumors within the kidney are transitional cell tumors, which arise from the urothelium of the renal pelvis. Most patients typically have blood in the urine (hematuria), pain in the infrascapular region (loin), and a mass. | Anatomy_Gray. an intravenous urogram, which will demonstrate the obstruction, pinpoint the exact level of the stone is currently less often used because access to low-dose CT KUB has increased. In the clinic Most tumors that arise in the kidney are renal cell carcinomas. These tumors develop from the proximal tubular epithelium. Approximately 5% of tumors within the kidney are transitional cell tumors, which arise from the urothelium of the renal pelvis. Most patients typically have blood in the urine (hematuria), pain in the infrascapular region (loin), and a mass. | [
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Anatomy_Gray_925 | Anatomy_Gray | Renal cell tumors (Figs. 4.157 and 4.158) are unusual because not only do they grow outward from the kidney, invading the fat and fascia, but they also spread into the renal vein. This venous extension is rare for any other type of tumor, so, when seen, renal cell carcinoma should be suspected. In addition, the tumor may spread along the renal vein and into the inferior vena cava, and in rare cases can grow into the right atrium across the tricuspid valve and into the pulmonary artery. Treatment for most renal cancers is surgical removal, even when metastatic spread is present, because some patients show regression of metastases. | Anatomy_Gray. Renal cell tumors (Figs. 4.157 and 4.158) are unusual because not only do they grow outward from the kidney, invading the fat and fascia, but they also spread into the renal vein. This venous extension is rare for any other type of tumor, so, when seen, renal cell carcinoma should be suspected. In addition, the tumor may spread along the renal vein and into the inferior vena cava, and in rare cases can grow into the right atrium across the tricuspid valve and into the pulmonary artery. Treatment for most renal cancers is surgical removal, even when metastatic spread is present, because some patients show regression of metastases. | [
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Anatomy_Gray_926 | Anatomy_Gray | Treatment for most renal cancers is surgical removal, even when metastatic spread is present, because some patients show regression of metastases. Transitional cell carcinoma arises from the urothelium. The urothelium is present from the calices to the urethra and behaves as a “single unit.” Therefore, when patients develop transitional carcinomas within the bladder, similar tumors may also be present within upper parts of the urinary tract. In patients with bladder cancer, the whole of the urinary tract must always be investigated to exclude the possibility of other tumors (Fig. 4.159). This is currently achieved by performing a dual-phase CT urogram that allows visualization of the renal parenchyma and the collecting system at the same time. In the clinic | Anatomy_Gray. Treatment for most renal cancers is surgical removal, even when metastatic spread is present, because some patients show regression of metastases. Transitional cell carcinoma arises from the urothelium. The urothelium is present from the calices to the urethra and behaves as a “single unit.” Therefore, when patients develop transitional carcinomas within the bladder, similar tumors may also be present within upper parts of the urinary tract. In patients with bladder cancer, the whole of the urinary tract must always be investigated to exclude the possibility of other tumors (Fig. 4.159). This is currently achieved by performing a dual-phase CT urogram that allows visualization of the renal parenchyma and the collecting system at the same time. In the clinic | [
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Anatomy_Gray_927 | Anatomy_Gray | In the clinic A nephrostomy is a procedure where a tube is placed through the lateral or posterior abdominal wall into the renal cortex to lie within the renal pelvis. The function of this tube is to allow drainage of urine from the renal pelvis through the tube externally (Fig. 4.160). The kidneys are situated on the posterior abdominal wall, and in thin healthy subjects may be only up to 2 to 3 cm from the skin. Access to the kidney is relatively straightforward, because the kidney can be easily visualized under ultrasound guidance. Using local anesthetic, a needle can be placed, under ultrasound direction, through the skin into the renal cortex and into the renal pelvis. A series of wires and tubes can be passed through the needle to position the drainage catheter. | Anatomy_Gray. In the clinic A nephrostomy is a procedure where a tube is placed through the lateral or posterior abdominal wall into the renal cortex to lie within the renal pelvis. The function of this tube is to allow drainage of urine from the renal pelvis through the tube externally (Fig. 4.160). The kidneys are situated on the posterior abdominal wall, and in thin healthy subjects may be only up to 2 to 3 cm from the skin. Access to the kidney is relatively straightforward, because the kidney can be easily visualized under ultrasound guidance. Using local anesthetic, a needle can be placed, under ultrasound direction, through the skin into the renal cortex and into the renal pelvis. A series of wires and tubes can be passed through the needle to position the drainage catheter. | [
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Anatomy_Gray_928 | Anatomy_Gray | The indications for such a procedure are many. In patients with distal ureteric obstruction the back pressure of urine within the ureters and the kidney significantly impairs the function of the kidney. This will produce renal failure and ultimately death. Furthermore, a dilated obstructed system is also susceptible to infection. In many cases, there is not only obstruction producing renal failure but also infected urine within the system. In the clinic Renal transplantation is now a common procedure undertaken in patients with end-stage renal failure. Transplant kidneys are obtained from either living or deceased donors. The living donors are carefully assessed, because harvesting a kidney from a normal healthy individual, even with modern-day medicine, carries a small risk. Deceased kidney donors are brain dead or have suffered cardiac death. The donor kidney is harvested with a small cuff of aortic and venous tissue. The ureter is also harvested. | Anatomy_Gray. The indications for such a procedure are many. In patients with distal ureteric obstruction the back pressure of urine within the ureters and the kidney significantly impairs the function of the kidney. This will produce renal failure and ultimately death. Furthermore, a dilated obstructed system is also susceptible to infection. In many cases, there is not only obstruction producing renal failure but also infected urine within the system. In the clinic Renal transplantation is now a common procedure undertaken in patients with end-stage renal failure. Transplant kidneys are obtained from either living or deceased donors. The living donors are carefully assessed, because harvesting a kidney from a normal healthy individual, even with modern-day medicine, carries a small risk. Deceased kidney donors are brain dead or have suffered cardiac death. The donor kidney is harvested with a small cuff of aortic and venous tissue. The ureter is also harvested. | [
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] |
Anatomy_Gray_929 | Anatomy_Gray | An ideal place to situate the transplant kidney is in the left or the right iliac fossa (Fig. 4.161). A curvilinear incision is made paralleling the iliac crest and pubic symphysis. The external oblique muscle, internal oblique muscle, transversus abdominis muscle, and transversalis fascia are divided. The surgeon identifies the parietal peritoneum but does not enter the peritoneal cavity. The parietal peritoneum is medially retracted to reveal the external iliac artery, external iliac vein, and bladder. In some instances the internal iliac artery of the recipient is mobilized and anastomosed directly as an end-to-end procedure onto the renal artery of the donor kidney. Similarly the internal iliac vein is anastomosed to the donor vein. In the presence of a small aortic cuff of tissue the donor artery is anastomosed to the recipient external iliac artery and similarly for the venous anastomosis. The ureter is easily tunneled obliquely through the bladder wall with a straightforward | Anatomy_Gray. An ideal place to situate the transplant kidney is in the left or the right iliac fossa (Fig. 4.161). A curvilinear incision is made paralleling the iliac crest and pubic symphysis. The external oblique muscle, internal oblique muscle, transversus abdominis muscle, and transversalis fascia are divided. The surgeon identifies the parietal peritoneum but does not enter the peritoneal cavity. The parietal peritoneum is medially retracted to reveal the external iliac artery, external iliac vein, and bladder. In some instances the internal iliac artery of the recipient is mobilized and anastomosed directly as an end-to-end procedure onto the renal artery of the donor kidney. Similarly the internal iliac vein is anastomosed to the donor vein. In the presence of a small aortic cuff of tissue the donor artery is anastomosed to the recipient external iliac artery and similarly for the venous anastomosis. The ureter is easily tunneled obliquely through the bladder wall with a straightforward | [
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Anatomy_Gray_930 | Anatomy_Gray | donor artery is anastomosed to the recipient external iliac artery and similarly for the venous anastomosis. The ureter is easily tunneled obliquely through the bladder wall with a straightforward anastomosis. | Anatomy_Gray. donor artery is anastomosed to the recipient external iliac artery and similarly for the venous anastomosis. The ureter is easily tunneled obliquely through the bladder wall with a straightforward anastomosis. | [
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Anatomy_Gray_931 | Anatomy_Gray | The left and right iliac fossae are ideal locations for the transplant kidney because a new space can be created without compromise to other structures. The great advantage of this procedure is the proximity to the anterior abdominal wall, which permits easy ultrasound visualization of the kidney and Doppler vascular assessment. Furthermore, in this position biopsies are easily obtained. The extraperitoneal approach enables patients to make a swift recovery. In the clinic Investigation of the urinary tract After an appropriate history and examination of the patient, including a digital rectal examination to assess the prostate in men, special investigations are required. | Anatomy_Gray. The left and right iliac fossae are ideal locations for the transplant kidney because a new space can be created without compromise to other structures. The great advantage of this procedure is the proximity to the anterior abdominal wall, which permits easy ultrasound visualization of the kidney and Doppler vascular assessment. Furthermore, in this position biopsies are easily obtained. The extraperitoneal approach enables patients to make a swift recovery. In the clinic Investigation of the urinary tract After an appropriate history and examination of the patient, including a digital rectal examination to assess the prostate in men, special investigations are required. | [
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Anatomy_Gray_932 | Anatomy_Gray | After an appropriate history and examination of the patient, including a digital rectal examination to assess the prostate in men, special investigations are required. Cystoscopy is a technique that allows visualization of the urinary bladder and urethra using an optical system attached to a flexible or rigid tube (cystoscope). Images are displayed on a monitor, as done in other endoscopic studies. Biopsies, bladder stone removal, removal of foreign bodies from the bladder, and bleeding cauterization can be performed during cystoscopy. Cystoscopy is helpful in establishing the causes of macroscopic and microscopic hematuria, assessing bladder and urethral diverticula and fistulas, as well as serving as a tool to investigate patients with voiding problems. | Anatomy_Gray. After an appropriate history and examination of the patient, including a digital rectal examination to assess the prostate in men, special investigations are required. Cystoscopy is a technique that allows visualization of the urinary bladder and urethra using an optical system attached to a flexible or rigid tube (cystoscope). Images are displayed on a monitor, as done in other endoscopic studies. Biopsies, bladder stone removal, removal of foreign bodies from the bladder, and bleeding cauterization can be performed during cystoscopy. Cystoscopy is helpful in establishing the causes of macroscopic and microscopic hematuria, assessing bladder and urethral diverticula and fistulas, as well as serving as a tool to investigate patients with voiding problems. | [
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Anatomy_Gray_933 | Anatomy_Gray | An IVU is one of the most important and commonly carried out radiological investigations (Fig. 4.162). The patient is injected with iodinated contrast medium. Most contrast media contain three iodine atoms spaced around a benzene ring. The relatively high atomic number of iodine compared to the atomic number of carbon, hydrogen, and oxygen attenuates the radiation beam. After intravenous injection, contrast media are excreted predominantly by glomerular filtration, although some are secreted by the renal tubules. This allows visualization of the collecting system as well as the ureters and bladder. Ultrasound can be used to assess kidney size and the size of the calices, which may be dilated when obstructed. Although the ureters are poorly visualized using ultrasound, the bladder can be easily seen when full. Ultrasound measurements of bladder volume can be obtained before and after micturition. | Anatomy_Gray. An IVU is one of the most important and commonly carried out radiological investigations (Fig. 4.162). The patient is injected with iodinated contrast medium. Most contrast media contain three iodine atoms spaced around a benzene ring. The relatively high atomic number of iodine compared to the atomic number of carbon, hydrogen, and oxygen attenuates the radiation beam. After intravenous injection, contrast media are excreted predominantly by glomerular filtration, although some are secreted by the renal tubules. This allows visualization of the collecting system as well as the ureters and bladder. Ultrasound can be used to assess kidney size and the size of the calices, which may be dilated when obstructed. Although the ureters are poorly visualized using ultrasound, the bladder can be easily seen when full. Ultrasound measurements of bladder volume can be obtained before and after micturition. | [
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Anatomy_Gray_934 | Anatomy_Gray | Nuclear medicine is an extremely useful tool for investigating the urinary tract because radioisotope compounds can be used to estimate renal cell mass and function and assess the parenchyma for renal scarring. These tests are often very useful in children when renal scarring and reflux disease is suspected. In the clinic An abdominal aortic aneurysm is a dilation of the aorta and generally tends to occur in the infrarenal region (the region at or below the renal arteries). As the aorta expands, the risk of rupture increases, and it is now generally accepted that when an aneurysm reaches 5.5 cm or greater an operation will significantly benefit the patient. With the aging population, the number of abdominal aortic aneurysms is increasing. Moreover, with the increasing use of imaging techniques, a number of abdominal aortic aneurysms are identified in asymptomatic patients. | Anatomy_Gray. Nuclear medicine is an extremely useful tool for investigating the urinary tract because radioisotope compounds can be used to estimate renal cell mass and function and assess the parenchyma for renal scarring. These tests are often very useful in children when renal scarring and reflux disease is suspected. In the clinic An abdominal aortic aneurysm is a dilation of the aorta and generally tends to occur in the infrarenal region (the region at or below the renal arteries). As the aorta expands, the risk of rupture increases, and it is now generally accepted that when an aneurysm reaches 5.5 cm or greater an operation will significantly benefit the patient. With the aging population, the number of abdominal aortic aneurysms is increasing. Moreover, with the increasing use of imaging techniques, a number of abdominal aortic aneurysms are identified in asymptomatic patients. | [
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Anatomy_Gray_935 | Anatomy_Gray | For many years the standard treatment for repair was an open operative technique, which involved a large incision from the xiphoid process of the sternum to the symphysis pubis and dissection of the aneurysm. The aneurysm was excised and a tubular woven graft was sewn into place. Recovery may take a number of days, even weeks, and most patients would be placed in the intensive care unit after the operation. Further developments and techniques have led to a new type of procedure being performed to treat abdominal aortic aneurysms—the endovascular graft (Fig. 4.165). | Anatomy_Gray. For many years the standard treatment for repair was an open operative technique, which involved a large incision from the xiphoid process of the sternum to the symphysis pubis and dissection of the aneurysm. The aneurysm was excised and a tubular woven graft was sewn into place. Recovery may take a number of days, even weeks, and most patients would be placed in the intensive care unit after the operation. Further developments and techniques have led to a new type of procedure being performed to treat abdominal aortic aneurysms—the endovascular graft (Fig. 4.165). | [
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Anatomy_Gray_936 | Anatomy_Gray | Further developments and techniques have led to a new type of procedure being performed to treat abdominal aortic aneurysms—the endovascular graft (Fig. 4.165). The technique involves surgically dissecting the femoral artery below the inguinal ligament. A small incision is made in the femoral artery and the preloaded compressed graft with metal support struts is passed on a large catheter into the abdominal aorta through the femoral artery. Using X-ray for guidance the graft is opened, lining the inside of the aorta. Limb attachments are made to the graft that extend into the common iliac vessels. This bifurcated tube device effectively excludes the abdominal aortic aneurysm. This type of device is not suitable for all patients. Patients who receive this device do not need to go to the intensive care unit. Many patients leave the hospital within 24 to 48 hours. Importantly, this device can be used for patients who were deemed unfit for open surgical repair. In the clinic | Anatomy_Gray. Further developments and techniques have led to a new type of procedure being performed to treat abdominal aortic aneurysms—the endovascular graft (Fig. 4.165). The technique involves surgically dissecting the femoral artery below the inguinal ligament. A small incision is made in the femoral artery and the preloaded compressed graft with metal support struts is passed on a large catheter into the abdominal aorta through the femoral artery. Using X-ray for guidance the graft is opened, lining the inside of the aorta. Limb attachments are made to the graft that extend into the common iliac vessels. This bifurcated tube device effectively excludes the abdominal aortic aneurysm. This type of device is not suitable for all patients. Patients who receive this device do not need to go to the intensive care unit. Many patients leave the hospital within 24 to 48 hours. Importantly, this device can be used for patients who were deemed unfit for open surgical repair. In the clinic | [
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Anatomy_Gray_937 | Anatomy_Gray | In the clinic Deep vein thrombosis is a potentially fatal condition where a clot (thrombus) is formed in the deep venous system of the legs and the veins of the pelvis. Virchow described the reasons for thrombus formation as decreased blood flow, abnormality of the constituents of blood, and abnormalities of the vessel wall. Common predisposing factors include hospitalization and surgery, the oral contraceptive pill, smoking, and air travel. Other factors include clotting abnormalities (e.g., protein S and protein C deficiency). The diagnosis of deep vein thrombosis may be difficult to establish, with symptoms including leg swelling and pain and discomfort in the calf. It may also be an incidental finding. In practice, patients with suspected deep vein thrombosis undergo a D-dimer blood test, which measures levels of a fibrin degradation product. If this is positive there is a high association with deep vein thrombosis. | Anatomy_Gray. In the clinic Deep vein thrombosis is a potentially fatal condition where a clot (thrombus) is formed in the deep venous system of the legs and the veins of the pelvis. Virchow described the reasons for thrombus formation as decreased blood flow, abnormality of the constituents of blood, and abnormalities of the vessel wall. Common predisposing factors include hospitalization and surgery, the oral contraceptive pill, smoking, and air travel. Other factors include clotting abnormalities (e.g., protein S and protein C deficiency). The diagnosis of deep vein thrombosis may be difficult to establish, with symptoms including leg swelling and pain and discomfort in the calf. It may also be an incidental finding. In practice, patients with suspected deep vein thrombosis undergo a D-dimer blood test, which measures levels of a fibrin degradation product. If this is positive there is a high association with deep vein thrombosis. | [
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Anatomy_Gray_938 | Anatomy_Gray | The consequences of deep vein thrombosis are twofold. Occasionally the clot may dislodge and pass into the venous system through the right side of the heart and into the main pulmonary arteries. If the clots are of significant size they obstruct blood flow to the lung and may produce instantaneous death. Secondary complications include destruction of the normal valvular system in the legs, which may lead to venous incompetency and chronic leg swelling with ulceration. The treatment for deep vein thrombosis is prevention. In order to prevent deep vein thrombosis, patients are optimized by removing all potential risk factors. Subcutaneous heparin may be injected and the patient wears compression stockings to prevent venous stasis while in the hospital. | Anatomy_Gray. The consequences of deep vein thrombosis are twofold. Occasionally the clot may dislodge and pass into the venous system through the right side of the heart and into the main pulmonary arteries. If the clots are of significant size they obstruct blood flow to the lung and may produce instantaneous death. Secondary complications include destruction of the normal valvular system in the legs, which may lead to venous incompetency and chronic leg swelling with ulceration. The treatment for deep vein thrombosis is prevention. In order to prevent deep vein thrombosis, patients are optimized by removing all potential risk factors. Subcutaneous heparin may be injected and the patient wears compression stockings to prevent venous stasis while in the hospital. | [
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Anatomy_Gray_939 | Anatomy_Gray | In certain situations it is not possible to optimize the patient with prophylactic treatment, and it may be necessary to insert a filter into the inferior vena cava that traps any large clots. It may be removed after the risk period has ended. In the clinic From a clinical perspective, retroperitoneal lymph nodes are arranged in two groups. The pre-aortic lymph node group drains lymph from the embryological midline structures, such as the liver, bowel, and pancreas. The para-aortic lymph node group (the lateral aortic or lumbar nodes), on either side of the aorta, drain lymph from bilateral structures, such as the kidneys and adrenal glands. Organs embryologically derived from the posterior abdominal wall also drain lymph to these nodes. These organs include the ovaries and the testes (importantly, the testes do not drain lymph to the inguinal regions). | Anatomy_Gray. In certain situations it is not possible to optimize the patient with prophylactic treatment, and it may be necessary to insert a filter into the inferior vena cava that traps any large clots. It may be removed after the risk period has ended. In the clinic From a clinical perspective, retroperitoneal lymph nodes are arranged in two groups. The pre-aortic lymph node group drains lymph from the embryological midline structures, such as the liver, bowel, and pancreas. The para-aortic lymph node group (the lateral aortic or lumbar nodes), on either side of the aorta, drain lymph from bilateral structures, such as the kidneys and adrenal glands. Organs embryologically derived from the posterior abdominal wall also drain lymph to these nodes. These organs include the ovaries and the testes (importantly, the testes do not drain lymph to the inguinal regions). | [
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Anatomy_Gray_940 | Anatomy_Gray | In general, lymphatic drainage follows standard predictable routes; however, in the presence of disease, alternate routes of lymphatic drainage will occur. There are a number of causes for enlarged retroperitoneal lymph nodes. In the adult, massively enlarged lymph nodes are a feature of lymphoma, and smaller lymph node enlargement is observed in the presence of infection and metastatic malignant spread of disease (e.g., colon cancer). The treatment for malignant lymph node disease is based upon a number of factors, including the site of the primary tumor (e.g., bowel) and its histological cell type. Normally, the primary tumor is surgically removed and the lymph node spread and metastatic organ spread (e.g., to the liver and the lungs) are often treated with chemotherapy and radiotherapy. In certain instances it may be considered appropriate to resect the lymph nodes in the retroperitoneum (e.g., for testicular cancer). | Anatomy_Gray. In general, lymphatic drainage follows standard predictable routes; however, in the presence of disease, alternate routes of lymphatic drainage will occur. There are a number of causes for enlarged retroperitoneal lymph nodes. In the adult, massively enlarged lymph nodes are a feature of lymphoma, and smaller lymph node enlargement is observed in the presence of infection and metastatic malignant spread of disease (e.g., colon cancer). The treatment for malignant lymph node disease is based upon a number of factors, including the site of the primary tumor (e.g., bowel) and its histological cell type. Normally, the primary tumor is surgically removed and the lymph node spread and metastatic organ spread (e.g., to the liver and the lungs) are often treated with chemotherapy and radiotherapy. In certain instances it may be considered appropriate to resect the lymph nodes in the retroperitoneum (e.g., for testicular cancer). | [
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Anatomy_Gray_941 | Anatomy_Gray | The surgical approach to retroperitoneal lymph node resection involves a lateral paramedian incision in the midclavicular line. The three layers of the anterolateral abdominal wall (external oblique, internal oblique, and transversus abdominis) are opened and the transversalis fascia is divided. The next structure the surgeon sees is the parietal peritoneum. Instead of entering the parietal peritoneum, which is standard procedure for most intraabdominal operations, the surgeon gently pushes the parietal peritoneum toward the midline, which moves the intraabdominal contents and allows a clear view of the retroperitoneal structures. On the left, the para-aortic lymph node group is easily demonstrated, with a clear view of the abdominal aorta and kidney. On the right the inferior vena cava is demonstrated and has to be retracted to access the right para-aortic lymph node chain. | Anatomy_Gray. The surgical approach to retroperitoneal lymph node resection involves a lateral paramedian incision in the midclavicular line. The three layers of the anterolateral abdominal wall (external oblique, internal oblique, and transversus abdominis) are opened and the transversalis fascia is divided. The next structure the surgeon sees is the parietal peritoneum. Instead of entering the parietal peritoneum, which is standard procedure for most intraabdominal operations, the surgeon gently pushes the parietal peritoneum toward the midline, which moves the intraabdominal contents and allows a clear view of the retroperitoneal structures. On the left, the para-aortic lymph node group is easily demonstrated, with a clear view of the abdominal aorta and kidney. On the right the inferior vena cava is demonstrated and has to be retracted to access the right para-aortic lymph node chain. | [
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Anatomy_Gray_942 | Anatomy_Gray | The procedure of retroperitoneal lymph node dissection is extremely well tolerated and lacks the problems of entering the peritoneal cavity (e.g., paralytic ileus). Unfortunately, a complication of a vertical incision in the midclavicular line is division of the segmental nerve supply to the rectus abdominis muscle. This produces muscle atrophy and asymmetrical proportions of the anterior abdominal wall. A 45-year-old man had mild epigastric pain, and a diagnosis of esophageal reflux was made. He was given appropriate medication, which worked well. However, at the time of the initial consultation, the family practitioner requested a chest radiograph, which demonstrated a prominent hump on the left side of the diaphragm and old rib fractures. The patient was recalled for further questioning. | Anatomy_Gray. The procedure of retroperitoneal lymph node dissection is extremely well tolerated and lacks the problems of entering the peritoneal cavity (e.g., paralytic ileus). Unfortunately, a complication of a vertical incision in the midclavicular line is division of the segmental nerve supply to the rectus abdominis muscle. This produces muscle atrophy and asymmetrical proportions of the anterior abdominal wall. A 45-year-old man had mild epigastric pain, and a diagnosis of esophageal reflux was made. He was given appropriate medication, which worked well. However, at the time of the initial consultation, the family practitioner requested a chest radiograph, which demonstrated a prominent hump on the left side of the diaphragm and old rib fractures. The patient was recalled for further questioning. | [
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Anatomy_Gray_943 | Anatomy_Gray | The patient was recalled for further questioning. He was extremely pleased with the treatment he had been given for his gastroesophageal reflux, but was concerned about being recalled for further history and examination. During the interview, he revealed that he had previously been involved in a motorcycle accident and had undergone a laparotomy for a “rupture.” The patient did not recall what operation was performed, but was assured at the time that the operation was a great success. The patient is likely to have undergone a splenectomy. In any patient who has had severe blunt abdominal trauma (such as that caused by a motorcycle accident), lower left-sided rib fractures are an extremely important sign of appreciable trauma. | Anatomy_Gray. The patient was recalled for further questioning. He was extremely pleased with the treatment he had been given for his gastroesophageal reflux, but was concerned about being recalled for further history and examination. During the interview, he revealed that he had previously been involved in a motorcycle accident and had undergone a laparotomy for a “rupture.” The patient did not recall what operation was performed, but was assured at the time that the operation was a great success. The patient is likely to have undergone a splenectomy. In any patient who has had severe blunt abdominal trauma (such as that caused by a motorcycle accident), lower left-sided rib fractures are an extremely important sign of appreciable trauma. | [
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Anatomy_Gray_944 | Anatomy_Gray | In any patient who has had severe blunt abdominal trauma (such as that caused by a motorcycle accident), lower left-sided rib fractures are an extremely important sign of appreciable trauma. A review of the patient’s old notes revealed that at the time of the injury the spleen was removed surgically, but it was not appreciated that there was a small rupture of the dome of the left hemidiaphragm. The patient gradually developed a hernia through which bowel could enter, producing the “hump” on the diaphragm seen on the chest radiograph. Because this injury occurred many years ago and the patient has been asymptomatic, it is unlikely that the patient will come to any harm and was discharged. | Anatomy_Gray. In any patient who has had severe blunt abdominal trauma (such as that caused by a motorcycle accident), lower left-sided rib fractures are an extremely important sign of appreciable trauma. A review of the patient’s old notes revealed that at the time of the injury the spleen was removed surgically, but it was not appreciated that there was a small rupture of the dome of the left hemidiaphragm. The patient gradually developed a hernia through which bowel could enter, producing the “hump” on the diaphragm seen on the chest radiograph. Because this injury occurred many years ago and the patient has been asymptomatic, it is unlikely that the patient will come to any harm and was discharged. | [
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Anatomy_Gray_945 | Anatomy_Gray | Because this injury occurred many years ago and the patient has been asymptomatic, it is unlikely that the patient will come to any harm and was discharged. A medical student was asked to inspect the abdomen of two patients. On the first patient he noted irregular veins radiating from the umbilicus. On the second patient he noted irregular veins, coursing in a caudal to cranial direction, over the anterior abdominal wall from the groin to the chest. He was asked to explain his findings and determine the significance of these features. | Anatomy_Gray. Because this injury occurred many years ago and the patient has been asymptomatic, it is unlikely that the patient will come to any harm and was discharged. A medical student was asked to inspect the abdomen of two patients. On the first patient he noted irregular veins radiating from the umbilicus. On the second patient he noted irregular veins, coursing in a caudal to cranial direction, over the anterior abdominal wall from the groin to the chest. He was asked to explain his findings and determine the significance of these features. | [
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Anatomy_Gray_946 | Anatomy_Gray | In the first patient the veins were draining radially away from the periumbilical region. In normal individuals, enlarged veins do not radiate from the umbilicus. In patients with portal hypertension the portal venous pressure is increased as a result of hepatic disease. Small collateral veins develop at and around the obliterated umbilical vein. These veins pass through the umbilicus and drain onto the anterior abdominal wall, forming a portosystemic anastomosis. The eventual diagnosis for this patient was cirrhosis of the liver. | Anatomy_Gray. In the first patient the veins were draining radially away from the periumbilical region. In normal individuals, enlarged veins do not radiate from the umbilicus. In patients with portal hypertension the portal venous pressure is increased as a result of hepatic disease. Small collateral veins develop at and around the obliterated umbilical vein. These veins pass through the umbilicus and drain onto the anterior abdominal wall, forming a portosystemic anastomosis. The eventual diagnosis for this patient was cirrhosis of the liver. | [
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Anatomy_Gray_947 | Anatomy_Gray | The finding of veins draining in a caudocranial direction on the anterior abdominal wall in the second patient is not typical for veins on the anterior abdominal wall. When veins are so prominent, it usually implies that there is an obstruction to the normal route of venous drainage and an alternative route has been taken. Typically, blood from the lower limbs and the retroperitoneal organs drains into the inferior vena cava and from here to the right atrium of the heart. This patient had a chronic thrombosis of the inferior vena cava, preventing blood from returning to the heart by the “usual” route. | Anatomy_Gray. The finding of veins draining in a caudocranial direction on the anterior abdominal wall in the second patient is not typical for veins on the anterior abdominal wall. When veins are so prominent, it usually implies that there is an obstruction to the normal route of venous drainage and an alternative route has been taken. Typically, blood from the lower limbs and the retroperitoneal organs drains into the inferior vena cava and from here to the right atrium of the heart. This patient had a chronic thrombosis of the inferior vena cava, preventing blood from returning to the heart by the “usual” route. | [
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Anatomy_Gray_948 | Anatomy_Gray | Blood from the lower limbs and the pelvis may drain via a series of collateral vessels, some of which include the superficial inferior epigastric veins, which run in the superficial fascia. These anastomose with the superior, superficial, and deep epigastric venous systems to drain into the internal thoracic veins, which in turn drain into the brachiocephalic veins and the superior vena cava. After the initial inferior vena cava thrombosis, the veins of the anterior abdominal wall and other collateral pathways hypertrophy to accommodate the increase in blood flow. A 52-year-old woman visited her family physician with complaints of increasing lethargy and vomiting. The physician examined her and noted that compared to previous visits she had lost significant weight. She was also jaundiced, and on examination of the abdomen a well-defined 10-cm rounded mass was palpable below the liver edge in the right upper quadrant (Fig. 4.185). | Anatomy_Gray. Blood from the lower limbs and the pelvis may drain via a series of collateral vessels, some of which include the superficial inferior epigastric veins, which run in the superficial fascia. These anastomose with the superior, superficial, and deep epigastric venous systems to drain into the internal thoracic veins, which in turn drain into the brachiocephalic veins and the superior vena cava. After the initial inferior vena cava thrombosis, the veins of the anterior abdominal wall and other collateral pathways hypertrophy to accommodate the increase in blood flow. A 52-year-old woman visited her family physician with complaints of increasing lethargy and vomiting. The physician examined her and noted that compared to previous visits she had lost significant weight. She was also jaundiced, and on examination of the abdomen a well-defined 10-cm rounded mass was palpable below the liver edge in the right upper quadrant (Fig. 4.185). | [
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Anatomy_Gray_949 | Anatomy_Gray | The clinical diagnosis was carcinoma of the head of the pancreas. It is difficult to appreciate how such a precise diagnosis can be made clinically when only three clinical signs have been described. The patient’s obstruction was in the distal bile duct. When a patient has jaundice, the causes are excessive breakdown of red blood cells (prehepatic), hepatic failure (hepatic jaundice), and posthepatic causes, which include obstruction along the length of the biliary tree. The patient had a mass in her right upper quadrant that was palpable below the liver; this was the gallbladder. In healthy individuals, the gallbladder is not palpable. An expanded gallbladder indicates obstruction either within the cystic duct or below the level of the cystic duct insertion (i.e., the bile duct). The patient’s vomiting was related to the position of the tumor. | Anatomy_Gray. The clinical diagnosis was carcinoma of the head of the pancreas. It is difficult to appreciate how such a precise diagnosis can be made clinically when only three clinical signs have been described. The patient’s obstruction was in the distal bile duct. When a patient has jaundice, the causes are excessive breakdown of red blood cells (prehepatic), hepatic failure (hepatic jaundice), and posthepatic causes, which include obstruction along the length of the biliary tree. The patient had a mass in her right upper quadrant that was palpable below the liver; this was the gallbladder. In healthy individuals, the gallbladder is not palpable. An expanded gallbladder indicates obstruction either within the cystic duct or below the level of the cystic duct insertion (i.e., the bile duct). The patient’s vomiting was related to the position of the tumor. | [
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Anatomy_Gray_950 | Anatomy_Gray | The patient’s vomiting was related to the position of the tumor. It is not uncommon for vomiting and weight loss (cachexia) to occur in patients with a malignant disease. The head of the pancreas lies within the curve of the duodenum, primarily adjacent to the descending part of the duodenum. Any tumor mass in the region of the head of the pancreas is likely to expand and may encase and invade the duodenum. Unfortunately, in this patient’s case, this happened, producing almost complete obstruction. Further discussion with the patient revealed that she was vomiting relatively undigested food soon after each meal. A CT scan demonstrated further complications. | Anatomy_Gray. The patient’s vomiting was related to the position of the tumor. It is not uncommon for vomiting and weight loss (cachexia) to occur in patients with a malignant disease. The head of the pancreas lies within the curve of the duodenum, primarily adjacent to the descending part of the duodenum. Any tumor mass in the region of the head of the pancreas is likely to expand and may encase and invade the duodenum. Unfortunately, in this patient’s case, this happened, producing almost complete obstruction. Further discussion with the patient revealed that she was vomiting relatively undigested food soon after each meal. A CT scan demonstrated further complications. | [
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Anatomy_Gray_951 | Anatomy_Gray | A CT scan demonstrated further complications. In the region of the head and neck of the pancreas are complex anatomical structures, which may be involved with a malignant process. The CT scan confirmed a mass in the region of the head of the pancreas, which invaded the descending part of the duodenum. The mass extended into the neck of the pancreas and had blocked the distal part of the bile duct and the pancreatic duct. Posteriorly the mass had directly invaded the portal venous confluence of the splenic and superior mesenteric veins, producing a series of gastric, splenic, and small bowel varices. This patient underwent palliative chemotherapy, but died 7 months later. A 44-year-old woman had been recently diagnosed with melanoma on the toe and underwent a series of investigations. | Anatomy_Gray. A CT scan demonstrated further complications. In the region of the head and neck of the pancreas are complex anatomical structures, which may be involved with a malignant process. The CT scan confirmed a mass in the region of the head of the pancreas, which invaded the descending part of the duodenum. The mass extended into the neck of the pancreas and had blocked the distal part of the bile duct and the pancreatic duct. Posteriorly the mass had directly invaded the portal venous confluence of the splenic and superior mesenteric veins, producing a series of gastric, splenic, and small bowel varices. This patient underwent palliative chemotherapy, but died 7 months later. A 44-year-old woman had been recently diagnosed with melanoma on the toe and underwent a series of investigations. | [
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Anatomy_Gray_952 | Anatomy_Gray | This patient underwent palliative chemotherapy, but died 7 months later. A 44-year-old woman had been recently diagnosed with melanoma on the toe and underwent a series of investigations. Melanoma (properly called malignant melanoma) can be an aggressive form of skin cancer that spreads to lymph nodes and multiple other organs throughout the body. The malignant potential is dependent upon its cellular configuration and also the depth of its penetration through the skin. The patient developed malignant melanoma in the foot, which spread to the lymph nodes of the groin. The inguinal lymph nodes were resected; however, it was noted on follow-up imaging that the patient had developed two metastatic lesions within the right lobe of the liver. Surgeons and physicians considered the possibility of removing these lesions. A CT scan was performed that demonstrated the lesions within segments V and VI of the liver (Fig. 4.186). | Anatomy_Gray. This patient underwent palliative chemotherapy, but died 7 months later. A 44-year-old woman had been recently diagnosed with melanoma on the toe and underwent a series of investigations. Melanoma (properly called malignant melanoma) can be an aggressive form of skin cancer that spreads to lymph nodes and multiple other organs throughout the body. The malignant potential is dependent upon its cellular configuration and also the depth of its penetration through the skin. The patient developed malignant melanoma in the foot, which spread to the lymph nodes of the groin. The inguinal lymph nodes were resected; however, it was noted on follow-up imaging that the patient had developed two metastatic lesions within the right lobe of the liver. Surgeons and physicians considered the possibility of removing these lesions. A CT scan was performed that demonstrated the lesions within segments V and VI of the liver (Fig. 4.186). | [
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Anatomy_Gray_953 | Anatomy_Gray | Surgeons and physicians considered the possibility of removing these lesions. A CT scan was performed that demonstrated the lesions within segments V and VI of the liver (Fig. 4.186). The segmental anatomy of the liver is important because it enables the surgical planning for resection. The surgery was undertaken and involved identifying the portal vein and the confluence of the right and left hepatic ducts. The liver was divided in the imaginary principal plane of the middle hepatic vein. The main hepatic duct and biliary radicals were ligated and the right liver was successfully resected. The segments remaining included the left lobe of the liver. | Anatomy_Gray. Surgeons and physicians considered the possibility of removing these lesions. A CT scan was performed that demonstrated the lesions within segments V and VI of the liver (Fig. 4.186). The segmental anatomy of the liver is important because it enables the surgical planning for resection. The surgery was undertaken and involved identifying the portal vein and the confluence of the right and left hepatic ducts. The liver was divided in the imaginary principal plane of the middle hepatic vein. The main hepatic duct and biliary radicals were ligated and the right liver was successfully resected. The segments remaining included the left lobe of the liver. | [
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Anatomy_Gray_954 | Anatomy_Gray | The segments remaining included the left lobe of the liver. The patient underwent a surgical resection of segments V, VI, VII, and VIII. The remaining segments included IVa, IVb, I, II, and III. It is important to remember that the lobes of the liver do not correlate with the hepatic volume. The left lobe of the liver contains only segments II and III. The right lobe of the liver contains segments IV, V, VI, VII, and VIII. Hence, cross-sectional imaging is important when planning surgical segmental resection. A 55-year-old man developed severe jaundice and a massively distended abdomen. A diagnosis of cirrhosis of the liver was made, and further confirmatory tests demonstrated that the patient had significant ascites (free fluid within the peritoneal cavity). A liver biopsy was necessary to confirm the cirrhosis, but there was some debate about how this biopsy should be obtained (eFig. 4.187). | Anatomy_Gray. The segments remaining included the left lobe of the liver. The patient underwent a surgical resection of segments V, VI, VII, and VIII. The remaining segments included IVa, IVb, I, II, and III. It is important to remember that the lobes of the liver do not correlate with the hepatic volume. The left lobe of the liver contains only segments II and III. The right lobe of the liver contains segments IV, V, VI, VII, and VIII. Hence, cross-sectional imaging is important when planning surgical segmental resection. A 55-year-old man developed severe jaundice and a massively distended abdomen. A diagnosis of cirrhosis of the liver was made, and further confirmatory tests demonstrated that the patient had significant ascites (free fluid within the peritoneal cavity). A liver biopsy was necessary to confirm the cirrhosis, but there was some debate about how this biopsy should be obtained (eFig. 4.187). | [
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Anatomy_Gray_955 | Anatomy_Gray | In patients with cirrhosis it is important to determine the extent of the cirrhosis and the etiology. History, examination, and blood tests are useful and are supported by complex radiological investigations. To begin treatment and determine the prognosis, a sample of liver tissue must be obtained. However, there are important issues to consider when taking a liver biopsy from a patient with suspected cirrhosis. One issue is liver function. The liver function of patients with suspected liver disease is poor, as demonstrated by the patient’s jaundice—an inability to conjugate bilirubin. Importantly, because some liver products are blood-clotting factors involved in the clotting cascade, the blood-clotting ability of patients with severe liver disease is significantly impaired. These patients therefore have a high risk of bleeding. Another issue is the presence of ascites. | Anatomy_Gray. In patients with cirrhosis it is important to determine the extent of the cirrhosis and the etiology. History, examination, and blood tests are useful and are supported by complex radiological investigations. To begin treatment and determine the prognosis, a sample of liver tissue must be obtained. However, there are important issues to consider when taking a liver biopsy from a patient with suspected cirrhosis. One issue is liver function. The liver function of patients with suspected liver disease is poor, as demonstrated by the patient’s jaundice—an inability to conjugate bilirubin. Importantly, because some liver products are blood-clotting factors involved in the clotting cascade, the blood-clotting ability of patients with severe liver disease is significantly impaired. These patients therefore have a high risk of bleeding. Another issue is the presence of ascites. | [
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Anatomy_Gray_956 | Anatomy_Gray | Another issue is the presence of ascites. Normally the liver rests against the lateral and anterior abdominal walls. This direct contact can be useful for care after a liver biopsy has been obtained. After the procedure, the patient lies over the region where the biopsy has been obtained and the weight of the liver stems any localized bleeding. When patients have significant ascites, the liver cannot be compressed against the walls of the abdomen and blood may pour freely into the ascitic fluid. The patient has ascites, so another approach for a liver biopsy must be considered. The patient was referred to the radiology department for a transjugular liver biopsy. | Anatomy_Gray. Another issue is the presence of ascites. Normally the liver rests against the lateral and anterior abdominal walls. This direct contact can be useful for care after a liver biopsy has been obtained. After the procedure, the patient lies over the region where the biopsy has been obtained and the weight of the liver stems any localized bleeding. When patients have significant ascites, the liver cannot be compressed against the walls of the abdomen and blood may pour freely into the ascitic fluid. The patient has ascites, so another approach for a liver biopsy must be considered. The patient was referred to the radiology department for a transjugular liver biopsy. | [
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Anatomy_Gray_957 | Anatomy_Gray | The patient has ascites, so another approach for a liver biopsy must be considered. The patient was referred to the radiology department for a transjugular liver biopsy. The skin around the jugular vein in the neck was anesthetized. Access was obtained through insertion of a needle and a guidewire. The guidewire was advanced through the right internal jugular vein and into the right brachiocephalic vein. It entered the superior vena cava, was passed along the posterior wall of the atrium, and entered the superior aspect of the inferior vena cava. A catheter was inserted over the wire and directed into the right hepatic vein. Using a series of dilators, the hole was enlarged and a biopsy needle was placed over the wire and into the right hepatic vein. The liver was biopsied through the right hepatic vein and the biopsy sample was removed. A simple suture was used to close the internal jugular vein in the neck, and minor compression stemmed any blood flow. | Anatomy_Gray. The patient has ascites, so another approach for a liver biopsy must be considered. The patient was referred to the radiology department for a transjugular liver biopsy. The skin around the jugular vein in the neck was anesthetized. Access was obtained through insertion of a needle and a guidewire. The guidewire was advanced through the right internal jugular vein and into the right brachiocephalic vein. It entered the superior vena cava, was passed along the posterior wall of the atrium, and entered the superior aspect of the inferior vena cava. A catheter was inserted over the wire and directed into the right hepatic vein. Using a series of dilators, the hole was enlarged and a biopsy needle was placed over the wire and into the right hepatic vein. The liver was biopsied through the right hepatic vein and the biopsy sample was removed. A simple suture was used to close the internal jugular vein in the neck, and minor compression stemmed any blood flow. | [
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Anatomy_Gray_958 | Anatomy_Gray | Assuming that the biopsy needle does not penetrate the liver capsule, it is not important how much the patient bleeds from the liver, because this bleeding will enter the hepatic vein and is immediately returned to the circulation. A 30-year-old man had a diffuse and poorly defined epigastric mass. Further examination revealed asymmetrical scrotal enlargement. As part of her differential diagnosis, the resident considered the possibility that the man had testicular cancer with regional abdominal para-aortic nodal involvement (the lateral aortic, or lumbar, nodes). A primary testicular neoplasm is the most common tumor in men between the ages of 25 and 34 and accounts for between 1% and 2% of all malignancies in men. A family history of testicular cancer and maldescent of the testis are strong predisposing factors. Spread of the tumor is typically to the lymph node chains that drain the testes. | Anatomy_Gray. Assuming that the biopsy needle does not penetrate the liver capsule, it is not important how much the patient bleeds from the liver, because this bleeding will enter the hepatic vein and is immediately returned to the circulation. A 30-year-old man had a diffuse and poorly defined epigastric mass. Further examination revealed asymmetrical scrotal enlargement. As part of her differential diagnosis, the resident considered the possibility that the man had testicular cancer with regional abdominal para-aortic nodal involvement (the lateral aortic, or lumbar, nodes). A primary testicular neoplasm is the most common tumor in men between the ages of 25 and 34 and accounts for between 1% and 2% of all malignancies in men. A family history of testicular cancer and maldescent of the testis are strong predisposing factors. Spread of the tumor is typically to the lymph node chains that drain the testes. | [
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Anatomy_Gray_959 | Anatomy_Gray | Spread of the tumor is typically to the lymph node chains that drain the testes. The testes develop from structures adjacent to the renal vessels in the upper abdomen, between the transversalis fascia and the peritoneum. They normally migrate through the inguinal canals into the scrotum just before birth. The testes take with them their arterial supply, their venous drainage, their nerve supply, and their lymphatics. A computed tomography scan revealed a para-aortic lymph node mass in the upper abdomen and enlarged lymph nodes throughout the internal and common iliac lymph node chains. Assuming the scrotal mass was a carcinoma of the testes, which would normally drain into the lateral aortic (lumbar) nodes in the upper abdomen, it would be very unusual for iliac lymphadenopathy to be present. Further examination of the scrotal mass was required. | Anatomy_Gray. Spread of the tumor is typically to the lymph node chains that drain the testes. The testes develop from structures adjacent to the renal vessels in the upper abdomen, between the transversalis fascia and the peritoneum. They normally migrate through the inguinal canals into the scrotum just before birth. The testes take with them their arterial supply, their venous drainage, their nerve supply, and their lymphatics. A computed tomography scan revealed a para-aortic lymph node mass in the upper abdomen and enlarged lymph nodes throughout the internal and common iliac lymph node chains. Assuming the scrotal mass was a carcinoma of the testes, which would normally drain into the lateral aortic (lumbar) nodes in the upper abdomen, it would be very unusual for iliac lymphadenopathy to be present. Further examination of the scrotal mass was required. | [
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Anatomy_Gray_960 | Anatomy_Gray | Further examination of the scrotal mass was required. A transillumination test of the scrotum on the affected side was positive. An ultrasound scan revealed normal right and left testes and a large fluid collection around the right testis. A diagnosis of a right-sided hydrocele was made. Scrotal masses are common in young males, and determining the exact anatomical site of the scrotal mass is of utmost clinical importance. Any mass that arises from the testis should be investigated to exclude testicular cancer. Masses that arise from the epididymis and scrotal lesions, such as fluid (hydrocele) or hernias, are also clinically important but are not malignant. The ultrasound scan revealed fluid surrounding the testis, which is diagnostic of a hydrocele. Simple cysts arising from and around the epididymis (epididymal cysts) can be easily defined. A diagnosis of lymphoma was suspected. | Anatomy_Gray. Further examination of the scrotal mass was required. A transillumination test of the scrotum on the affected side was positive. An ultrasound scan revealed normal right and left testes and a large fluid collection around the right testis. A diagnosis of a right-sided hydrocele was made. Scrotal masses are common in young males, and determining the exact anatomical site of the scrotal mass is of utmost clinical importance. Any mass that arises from the testis should be investigated to exclude testicular cancer. Masses that arise from the epididymis and scrotal lesions, such as fluid (hydrocele) or hernias, are also clinically important but are not malignant. The ultrasound scan revealed fluid surrounding the testis, which is diagnostic of a hydrocele. Simple cysts arising from and around the epididymis (epididymal cysts) can be easily defined. A diagnosis of lymphoma was suspected. | [
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Anatomy_Gray_961 | Anatomy_Gray | A diagnosis of lymphoma was suspected. Lymphoma is a malignant disease of lymph nodes. Most lymphomas are divided into two specific types, namely Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. If caught early the prognosis following radical chemotherapy is excellent. | Anatomy_Gray. A diagnosis of lymphoma was suspected. Lymphoma is a malignant disease of lymph nodes. Most lymphomas are divided into two specific types, namely Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. If caught early the prognosis following radical chemotherapy is excellent. | [
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Anatomy_Gray_962 | Anatomy_Gray | The patient underwent a biopsy, which was performed from the posterior approach. He was placed in the prone position in the computed tomography (CT) scanner. A fine needle with a special cutting device was used to obtain a lymph node sample. A left-sided approach was used because the inferior vena cava is on the right side and the nodes were in the para-aortic regions (i.e., the biopsy needle would have to pass between the inferior vena cava and the aorta from a posterior approach, which is difficult). The skin was anesthetized using local anesthetic at the lateral border of the quadratus lumborum muscle. The needle was angled at approximately 45° within the quadratus lumborum muscle and entered the retroperitoneum to lie beside the left-sided para-aortic lymph nodes. Because this procedure is performed using CT guidance, the operator can advance the needle slowly, taking care not to “hit” other retroperitoneal structures. | Anatomy_Gray. The patient underwent a biopsy, which was performed from the posterior approach. He was placed in the prone position in the computed tomography (CT) scanner. A fine needle with a special cutting device was used to obtain a lymph node sample. A left-sided approach was used because the inferior vena cava is on the right side and the nodes were in the para-aortic regions (i.e., the biopsy needle would have to pass between the inferior vena cava and the aorta from a posterior approach, which is difficult). The skin was anesthetized using local anesthetic at the lateral border of the quadratus lumborum muscle. The needle was angled at approximately 45° within the quadratus lumborum muscle and entered the retroperitoneum to lie beside the left-sided para-aortic lymph nodes. Because this procedure is performed using CT guidance, the operator can advance the needle slowly, taking care not to “hit” other retroperitoneal structures. | [
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Anatomy_Gray_963 | Anatomy_Gray | A good biopsy was obtained and the diagnosis was Hodgkin’s lymphoma. The patient underwent chemotherapy and 2 years later is in full remission and leads an active life. A 35-year-old man had a soft mass approximately 3 cm in diameter in the right scrotum. The diagnosis was a right indirect inguinal hernia. What were the examination findings? The mass was not tender and the physician was not able to “get above it.” The testes were felt separate from the mass, and a transillumination test (in which a bright light is placed behind the scrotum and the scrotal sac is viewed from the front) was negative. (A positive test occurs when the light penetrates through the scrotum.) When the patient stood up, a positive cough “impulse” was felt within the mass. After careful and delicate maneuvering, the mass could be massaged into the inguinal canal, so emptying from the scrotum. When the massaging hand was removed, the mass recurred in the scrotum. | Anatomy_Gray. A good biopsy was obtained and the diagnosis was Hodgkin’s lymphoma. The patient underwent chemotherapy and 2 years later is in full remission and leads an active life. A 35-year-old man had a soft mass approximately 3 cm in diameter in the right scrotum. The diagnosis was a right indirect inguinal hernia. What were the examination findings? The mass was not tender and the physician was not able to “get above it.” The testes were felt separate from the mass, and a transillumination test (in which a bright light is placed behind the scrotum and the scrotal sac is viewed from the front) was negative. (A positive test occurs when the light penetrates through the scrotum.) When the patient stood up, a positive cough “impulse” was felt within the mass. After careful and delicate maneuvering, the mass could be massaged into the inguinal canal, so emptying from the scrotum. When the massaging hand was removed, the mass recurred in the scrotum. | [
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Anatomy_Gray_964 | Anatomy_Gray | After careful and delicate maneuvering, the mass could be massaged into the inguinal canal, so emptying from the scrotum. When the massaging hand was removed, the mass recurred in the scrotum. An indirect inguinal hernia enters the inguinal canal through the deep inguinal ring. It passes through the inguinal canal to exit through the superficial inguinal ring in the aponeurosis of the external oblique muscle. The hernia sac lies superior and medial to the pubic tubercle and enters into the scrotum within the spermatic cord. A direct inguinal hernia passes directly through the posterior wall of the inguinal canal. It does not pass down the inguinal canal. If large enough, it may pass through the superficial inguinal ring and into the scrotum. | Anatomy_Gray. After careful and delicate maneuvering, the mass could be massaged into the inguinal canal, so emptying from the scrotum. When the massaging hand was removed, the mass recurred in the scrotum. An indirect inguinal hernia enters the inguinal canal through the deep inguinal ring. It passes through the inguinal canal to exit through the superficial inguinal ring in the aponeurosis of the external oblique muscle. The hernia sac lies superior and medial to the pubic tubercle and enters into the scrotum within the spermatic cord. A direct inguinal hernia passes directly through the posterior wall of the inguinal canal. It does not pass down the inguinal canal. If large enough, it may pass through the superficial inguinal ring and into the scrotum. | [
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Anatomy_Gray_965 | Anatomy_Gray | A 25-year-old man developed severe pain in the left lower quadrant of his abdomen. The pain was diffuse and relatively constant but did ease for short periods of time. On direct questioning the patient indicated that the pain was in the inguinal region and radiated posteriorly into his left infrascapular region (loin). A urine dipstick was positive for blood (hematuria). A diagnosis of a ureteric stone (calculus) was made. The patient’s initial infrascapular pain, which later radiated to the left groin, relates to passage of the ureteric stone along the ureter. The origin of the pain relates to ureteral distention. A series of peristaltic waves along the ureter transport urine along the length of the ureter from the kidney to the bladder. As the ureteric stone obstructs the kidney, the ureter becomes distended, resulting in an exacerbation of the pain. The peristaltic waves are superimposed upon the distention, resulting in periods of exacerbation and periods of relief. | Anatomy_Gray. A 25-year-old man developed severe pain in the left lower quadrant of his abdomen. The pain was diffuse and relatively constant but did ease for short periods of time. On direct questioning the patient indicated that the pain was in the inguinal region and radiated posteriorly into his left infrascapular region (loin). A urine dipstick was positive for blood (hematuria). A diagnosis of a ureteric stone (calculus) was made. The patient’s initial infrascapular pain, which later radiated to the left groin, relates to passage of the ureteric stone along the ureter. The origin of the pain relates to ureteral distention. A series of peristaltic waves along the ureter transport urine along the length of the ureter from the kidney to the bladder. As the ureteric stone obstructs the kidney, the ureter becomes distended, resulting in an exacerbation of the pain. The peristaltic waves are superimposed upon the distention, resulting in periods of exacerbation and periods of relief. | [
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Anatomy_Gray_966 | Anatomy_Gray | The pain is referred. The visceral afferent (sensory) nerve fibers from the ureter pass into the spinal cord, entering the first and second lumbar segments of the spinal cord. Pain is thus referred to cutaneous regions innervated by somatic sensory nerves from the same spinal cord levels. The patient was investigated by a CT scan. Traditionally, a plain radiograph was used to look for the radiopaque stone (90% of renal stones are radiopaque) and this often proceeded to intravenous urography to determine precise location of renal stones. Currently, low-dose CT of the collecting system is used to visualize the renal stones and pinpoint the level of obstruction, using low radiation dose and no intravenous contrast. | Anatomy_Gray. The pain is referred. The visceral afferent (sensory) nerve fibers from the ureter pass into the spinal cord, entering the first and second lumbar segments of the spinal cord. Pain is thus referred to cutaneous regions innervated by somatic sensory nerves from the same spinal cord levels. The patient was investigated by a CT scan. Traditionally, a plain radiograph was used to look for the radiopaque stone (90% of renal stones are radiopaque) and this often proceeded to intravenous urography to determine precise location of renal stones. Currently, low-dose CT of the collecting system is used to visualize the renal stones and pinpoint the level of obstruction, using low radiation dose and no intravenous contrast. | [
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Anatomy_Gray_967 | Anatomy_Gray | An ultrasound scan may also be useful to assess for pelvicaliceal dilation and may reveal stones at the pelviureteral junction or the vesicoureteric junction. Ultrasound is also valuable for assessing other causes of obstruction (e.g., tumors at and around the ureteric orifices in the bladder) and is particularly useful in pregnant women when imaging with the use of radiation is a concern. Usually an intravenous urogram would be carried out to enable assessment of the upper urinary tracts and precise location of the stone. Not infrequently, CT scans of the abdomen are also obtained. These scans not only give information about the kidneys, ureters, and bladder but also show the position of the stone and other associated pathology. If this patient’s infrascapular pain was on the right and predominantly within the right lower abdomen, appendicitis would also have to be excluded. A CT scan would enable differentiation of appendicitis and urinary colic. | Anatomy_Gray. An ultrasound scan may also be useful to assess for pelvicaliceal dilation and may reveal stones at the pelviureteral junction or the vesicoureteric junction. Ultrasound is also valuable for assessing other causes of obstruction (e.g., tumors at and around the ureteric orifices in the bladder) and is particularly useful in pregnant women when imaging with the use of radiation is a concern. Usually an intravenous urogram would be carried out to enable assessment of the upper urinary tracts and precise location of the stone. Not infrequently, CT scans of the abdomen are also obtained. These scans not only give information about the kidneys, ureters, and bladder but also show the position of the stone and other associated pathology. If this patient’s infrascapular pain was on the right and predominantly within the right lower abdomen, appendicitis would also have to be excluded. A CT scan would enable differentiation of appendicitis and urinary colic. | [
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Anatomy_Gray_968 | Anatomy_Gray | A 27-year-old woman was admitted to the surgical ward with appendicitis. She underwent an appendectomy. It was noted at operation that the appendix had perforated and there was pus within the abdominal cavity. The appendix was removed and the stump tied. The abdomen was washed out with warm saline solution. The patient initially made an uneventful recovery, but by day 7 she had become unwell, with pain over her right shoulder and spiking temperatures. This patient had developed an intraabdominal abscess. Any operation on the bowel may involve peritoneal contamination with fecal contents and fecal flora. This may not be appreciated at the time of the operation. Over the postoperative period an inflammatory reaction ensued and an abscess cavity developed, filling with pus. Typically, the observation chart revealed a “swinging” pyrexia (fever). The most common sites for abscess to develop are the pelvis and the hepatorenal recess. | Anatomy_Gray. A 27-year-old woman was admitted to the surgical ward with appendicitis. She underwent an appendectomy. It was noted at operation that the appendix had perforated and there was pus within the abdominal cavity. The appendix was removed and the stump tied. The abdomen was washed out with warm saline solution. The patient initially made an uneventful recovery, but by day 7 she had become unwell, with pain over her right shoulder and spiking temperatures. This patient had developed an intraabdominal abscess. Any operation on the bowel may involve peritoneal contamination with fecal contents and fecal flora. This may not be appreciated at the time of the operation. Over the postoperative period an inflammatory reaction ensued and an abscess cavity developed, filling with pus. Typically, the observation chart revealed a “swinging” pyrexia (fever). The most common sites for abscess to develop are the pelvis and the hepatorenal recess. | [
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Anatomy_Gray_969 | Anatomy_Gray | The most common sites for abscess to develop are the pelvis and the hepatorenal recess. When a patient is in the supine position, the lowest points in the abdominal and pelvic cavities are the posterior superior aspect of the peritoneal cavity (the hepatorenal recess) and, in women, the recto-uterine pouch (pouch of Douglas). The shoulder pain suggested that the abscess was in the hepatorenal recess and that the pain was referred from the diaphragm. The motor and sensory innervation of the diaphragm is from nerves C3 to C5. The somatic pain sensation from the parietal peritoneum covering the undersurface of the diaphragm is carried into the spinal cord by the phrenic nerve (C3 to C5) and is interpreted by the brain as coming from skin over the shoulder—a region supplied by other somatic sensory nerves entering the same levels of the spinal cord as those from the diaphragm. A chest radiograph demonstrated elevation of the right hemidiaphragm. | Anatomy_Gray. The most common sites for abscess to develop are the pelvis and the hepatorenal recess. When a patient is in the supine position, the lowest points in the abdominal and pelvic cavities are the posterior superior aspect of the peritoneal cavity (the hepatorenal recess) and, in women, the recto-uterine pouch (pouch of Douglas). The shoulder pain suggested that the abscess was in the hepatorenal recess and that the pain was referred from the diaphragm. The motor and sensory innervation of the diaphragm is from nerves C3 to C5. The somatic pain sensation from the parietal peritoneum covering the undersurface of the diaphragm is carried into the spinal cord by the phrenic nerve (C3 to C5) and is interpreted by the brain as coming from skin over the shoulder—a region supplied by other somatic sensory nerves entering the same levels of the spinal cord as those from the diaphragm. A chest radiograph demonstrated elevation of the right hemidiaphragm. | [
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Anatomy_Gray_970 | Anatomy_Gray | A chest radiograph demonstrated elevation of the right hemidiaphragm. This elevation of the right hemidiaphragm was due to the pus tracking from the hepatorenal space around the lateral and anterior aspect of the liver to sit on top of the liver in a subphrenic position. An ultrasound scan demonstrated this collection of fluid. The abscess cavity could be clearly seen by placing the ultrasound probe between ribs XI and XII. The inferior border of the right lower lobe lies at rib X in the midaxillary line. When the probe is placed between ribs XI and XII the ultrasound waves pass between the intercostal muscles and the parietal pleura laterally on the chest wall, and continue through the parietal pleura overlying the diaphragm into the cavity of the abscess, which lies below the diaphragm. | Anatomy_Gray. A chest radiograph demonstrated elevation of the right hemidiaphragm. This elevation of the right hemidiaphragm was due to the pus tracking from the hepatorenal space around the lateral and anterior aspect of the liver to sit on top of the liver in a subphrenic position. An ultrasound scan demonstrated this collection of fluid. The abscess cavity could be clearly seen by placing the ultrasound probe between ribs XI and XII. The inferior border of the right lower lobe lies at rib X in the midaxillary line. When the probe is placed between ribs XI and XII the ultrasound waves pass between the intercostal muscles and the parietal pleura laterally on the chest wall, and continue through the parietal pleura overlying the diaphragm into the cavity of the abscess, which lies below the diaphragm. | [
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Anatomy_Gray_971 | Anatomy_Gray | Drainage was not done by an intercostal route. Instead, using CT guidance and local anesthesia, a subcostal drain was established and 1 liter of pus was removed (eFig. 4.188). It is important to bear in mind that placing a drain through the pleural cavity into the abdominal cavity effectively allows intraabdominal pus to pass into the thoracic cavity, and that this may produce an empyema (pus in the pleural space). The patient made a slow and uneventful recovery. | Anatomy_Gray. Drainage was not done by an intercostal route. Instead, using CT guidance and local anesthesia, a subcostal drain was established and 1 liter of pus was removed (eFig. 4.188). It is important to bear in mind that placing a drain through the pleural cavity into the abdominal cavity effectively allows intraabdominal pus to pass into the thoracic cavity, and that this may produce an empyema (pus in the pleural space). The patient made a slow and uneventful recovery. | [
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Anatomy_Gray_972 | Anatomy_Gray | The patient made a slow and uneventful recovery. A 45-year-old man developed a low-grade rectal carcinoma just above the anorectal margin. He underwent an abdominoperineal resection of the tumor and was left with a left lower abdominal colostomy (see below). Unfortunately, the man’s wife left him for a number of reasons, including lack of sexual desire. He “turned to drink” and over the ensuing years developed cirrhosis. He was brought into the emergency room with severe bleeding from enlarged veins around his colostomy. An emergency transjugular intrahepatic portosystemic shunt was created, which stopped all bleeding (eFigs. 4.189 and 4.190). He is now doing well in a rehabilitation program. A colostomy was necessary because of the low site of the tumor. | Anatomy_Gray. The patient made a slow and uneventful recovery. A 45-year-old man developed a low-grade rectal carcinoma just above the anorectal margin. He underwent an abdominoperineal resection of the tumor and was left with a left lower abdominal colostomy (see below). Unfortunately, the man’s wife left him for a number of reasons, including lack of sexual desire. He “turned to drink” and over the ensuing years developed cirrhosis. He was brought into the emergency room with severe bleeding from enlarged veins around his colostomy. An emergency transjugular intrahepatic portosystemic shunt was created, which stopped all bleeding (eFigs. 4.189 and 4.190). He is now doing well in a rehabilitation program. A colostomy was necessary because of the low site of the tumor. | [
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Anatomy_Gray_973 | Anatomy_Gray | A colostomy was necessary because of the low site of the tumor. Carcinoma of the colon and rectum usually develops in older patients, but some people do get tumors early in life. Most tumors develop from benign polyps, which undergo malignant change. As the malignancy develops it invades through the wall of the bowel and then metastasizes to local lymphatics. The tumor extends within the wall for a few centimeters above and below its origin. Lymphatic spread is to local and regional lymph nodes and then to the pre-aortic lymph node chain. These drain eventually into the thoracic duct. | Anatomy_Gray. A colostomy was necessary because of the low site of the tumor. Carcinoma of the colon and rectum usually develops in older patients, but some people do get tumors early in life. Most tumors develop from benign polyps, which undergo malignant change. As the malignancy develops it invades through the wall of the bowel and then metastasizes to local lymphatics. The tumor extends within the wall for a few centimeters above and below its origin. Lymphatic spread is to local and regional lymph nodes and then to the pre-aortic lymph node chain. These drain eventually into the thoracic duct. | [
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Anatomy_Gray_974 | Anatomy_Gray | When this man was assessed for surgery, the tumor was so close to the anal margin that resection of the sphincters was necessary to be certain that the tumor margins were clear. The bowel cannot be joined to the anus without sphincters because the patient would be fecally incontinent. At surgery the tumor was excised, including the locoregional lymph node chains and the peritumoral fat around the rectum. The free end of the sigmoid colon was brought through a hole in the anterior abdominal wall. The bowel was then carefully sutured to the anterior abdominal wall to allow placement of a bag to collect the feces. This is a colostomy. Contrary to their usual immediate negative reaction to having a bag on the anterior abdominal wall, most patients cope extremely well, especially if they have been cured of cancer. | Anatomy_Gray. When this man was assessed for surgery, the tumor was so close to the anal margin that resection of the sphincters was necessary to be certain that the tumor margins were clear. The bowel cannot be joined to the anus without sphincters because the patient would be fecally incontinent. At surgery the tumor was excised, including the locoregional lymph node chains and the peritumoral fat around the rectum. The free end of the sigmoid colon was brought through a hole in the anterior abdominal wall. The bowel was then carefully sutured to the anterior abdominal wall to allow placement of a bag to collect the feces. This is a colostomy. Contrary to their usual immediate negative reaction to having a bag on the anterior abdominal wall, most patients cope extremely well, especially if they have been cured of cancer. | [
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Anatomy_Gray_975 | Anatomy_Gray | Contrary to their usual immediate negative reaction to having a bag on the anterior abdominal wall, most patients cope extremely well, especially if they have been cured of cancer. This patient’s pelvic nerves were damaged. The radical pelvic surgical dissection damaged the pelvic parasympathetic nerve supply necessary for erection of the penis. Unfortunately, this was not well explained to the patient, which in some part led to the failure of his relationship. With any radical surgery in the pelvis, the nerves that supply the penis or clitoris may be damaged, so interfering with sexual function. This patient was bleeding from stomal varices. As he developed a serious drinking problem, his liver became cirrhotic and this damaged the normal liver architecture. This in turn increased the blood pressure in the portal vein (portal hypertension). | Anatomy_Gray. Contrary to their usual immediate negative reaction to having a bag on the anterior abdominal wall, most patients cope extremely well, especially if they have been cured of cancer. This patient’s pelvic nerves were damaged. The radical pelvic surgical dissection damaged the pelvic parasympathetic nerve supply necessary for erection of the penis. Unfortunately, this was not well explained to the patient, which in some part led to the failure of his relationship. With any radical surgery in the pelvis, the nerves that supply the penis or clitoris may be damaged, so interfering with sexual function. This patient was bleeding from stomal varices. As he developed a serious drinking problem, his liver became cirrhotic and this damaged the normal liver architecture. This in turn increased the blood pressure in the portal vein (portal hypertension). | [
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Anatomy_Gray_976 | Anatomy_Gray | In patients with portal hypertension small anastomoses develop between the veins of the portal system and the veins of the systemic circulation. These portosystemic anastomoses are usually of little consequence; however, at the gastroesophageal junction, they lie in a submucosal and mucosal position and are subject to trauma. Torrential hemorrhage may occur from even minor trauma, and death may ensue following blood loss. These varices require urgent treatment, which includes injecting sclerosant substances, banding, and even surgical ligation. | Anatomy_Gray. In patients with portal hypertension small anastomoses develop between the veins of the portal system and the veins of the systemic circulation. These portosystemic anastomoses are usually of little consequence; however, at the gastroesophageal junction, they lie in a submucosal and mucosal position and are subject to trauma. Torrential hemorrhage may occur from even minor trauma, and death may ensue following blood loss. These varices require urgent treatment, which includes injecting sclerosant substances, banding, and even surgical ligation. | [
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Anatomy_Gray_977 | Anatomy_Gray | Fortunately, most of the other portosystemic anastomoses are of relatively little consequence. In patients with colostomies, small veins may develop between the veins of the large bowel (portal system drainage) and cutaneous veins on the anterior abdominal wall (systemic veins). If these veins become enlarged because of portal hypertension, they are subject to trauma as feces are passed through the colostomy. Torrential hemorrhage may ensue if they are damaged. A procedure was carried out to lower the portal pressure. To reduce the pressure in the portal vein in this patient, several surgical procedures were considered. These included sewing the side of the portal vein onto the inferior vena cava (portacaval shunt) and sewing the splenic vein onto the renal vein (a splenorenal shunt). These procedures, however, require a large abdominal incision and are extremely complex. As an alternative, it was decided to create a transjugular intrahepatic portosystemic shunt. | Anatomy_Gray. Fortunately, most of the other portosystemic anastomoses are of relatively little consequence. In patients with colostomies, small veins may develop between the veins of the large bowel (portal system drainage) and cutaneous veins on the anterior abdominal wall (systemic veins). If these veins become enlarged because of portal hypertension, they are subject to trauma as feces are passed through the colostomy. Torrential hemorrhage may ensue if they are damaged. A procedure was carried out to lower the portal pressure. To reduce the pressure in the portal vein in this patient, several surgical procedures were considered. These included sewing the side of the portal vein onto the inferior vena cava (portacaval shunt) and sewing the splenic vein onto the renal vein (a splenorenal shunt). These procedures, however, require a large abdominal incision and are extremely complex. As an alternative, it was decided to create a transjugular intrahepatic portosystemic shunt. | [
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Anatomy_Gray_978 | Anatomy_Gray | Creating a transjugular intrahepatic portosystemic shunt is a relatively new technique that may be carried out under local anesthesia. Using a right internal jugular approach, a long needle is placed through the internal jugular vein, the superior vena cava, and the right atrium, into the inferior vena cava. The right hepatic vein is cannulated and, with special steering wires, a needle is passed through the hepatic substance directly into the right branch of the portal vein. A small balloon is passed over the wire and through the hepatic substance and is inflated. After the balloon has been removed, a metallic stent (a flexible wire tube) is placed across this tract in the liver to keep it open. Blood now freely flows from the portal vein into the right hepatic vein, creating a portosystemic shunt. | Anatomy_Gray. Creating a transjugular intrahepatic portosystemic shunt is a relatively new technique that may be carried out under local anesthesia. Using a right internal jugular approach, a long needle is placed through the internal jugular vein, the superior vena cava, and the right atrium, into the inferior vena cava. The right hepatic vein is cannulated and, with special steering wires, a needle is passed through the hepatic substance directly into the right branch of the portal vein. A small balloon is passed over the wire and through the hepatic substance and is inflated. After the balloon has been removed, a metallic stent (a flexible wire tube) is placed across this tract in the liver to keep it open. Blood now freely flows from the portal vein into the right hepatic vein, creating a portosystemic shunt. | [
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Anatomy_Gray_979 | Anatomy_Gray | As a result of this procedure, the pressure in this patient’s portal system is lower and similar to that of the systemic venous system, so reducing the potential for bleeding at the portosystemic anastomoses (i.e., the colostomy). A 62-year-old man came to the emergency department with swelling of both legs and a large left varicocele (enlarged and engorged varicose veins around the left testis and within the left pampiniform plexus of veins). The patient was known to have a left renal cell carcinoma and was due to have this operated on the following week. Anatomically it is possible to link all of the findings with the renal cell carcinoma by knowing the biology of the tumor. Renal cell carcinoma tends to grow steadily and predictably. Typically, when the tumor is less than 3 to 4 cm, it remains confined to the kidney. Large tumors have the propensity to grow into the renal vein, the inferior vena cava and the right atrium and through the heart into the pulmonary artery. | Anatomy_Gray. As a result of this procedure, the pressure in this patient’s portal system is lower and similar to that of the systemic venous system, so reducing the potential for bleeding at the portosystemic anastomoses (i.e., the colostomy). A 62-year-old man came to the emergency department with swelling of both legs and a large left varicocele (enlarged and engorged varicose veins around the left testis and within the left pampiniform plexus of veins). The patient was known to have a left renal cell carcinoma and was due to have this operated on the following week. Anatomically it is possible to link all of the findings with the renal cell carcinoma by knowing the biology of the tumor. Renal cell carcinoma tends to grow steadily and predictably. Typically, when the tumor is less than 3 to 4 cm, it remains confined to the kidney. Large tumors have the propensity to grow into the renal vein, the inferior vena cava and the right atrium and through the heart into the pulmonary artery. | [
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Anatomy_Gray_980 | Anatomy_Gray | The tumor grew into the renal vein. As the tumor grew into the renal vein it blocked off all tributaries draining into the vein, the largest of which is the left testicular vein. This blockage of the left testicular vein caused a dilation of the veins around the left testis (a varicocele occurred). The swollen legs were accounted for by caval obstruction. The tumor grew along the renal vein and into the inferior vena cava toward the heart. Renal tumors can grow rapidly; in this case the tumor grew rapidly into the inferior vena cava, occluding it. This increased the pressure in the leg veins, resulting in swelling and pitting edema of the ankles. The patient unfortunately died on the operating table. | Anatomy_Gray. The tumor grew into the renal vein. As the tumor grew into the renal vein it blocked off all tributaries draining into the vein, the largest of which is the left testicular vein. This blockage of the left testicular vein caused a dilation of the veins around the left testis (a varicocele occurred). The swollen legs were accounted for by caval obstruction. The tumor grew along the renal vein and into the inferior vena cava toward the heart. Renal tumors can grow rapidly; in this case the tumor grew rapidly into the inferior vena cava, occluding it. This increased the pressure in the leg veins, resulting in swelling and pitting edema of the ankles. The patient unfortunately died on the operating table. | [
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Anatomy_Gray_981 | Anatomy_Gray | The patient unfortunately died on the operating table. In this patient’s case, a “tongue” of tumor grew into the inferior vena cava. At the time of surgery, the initial dissection mobilized the kidney on its vascular pedicle; however, a large portion of tumor became detached in the inferior vena cava. The tumor embolus passed through the right atrium and right ventricle and occluded the pulmonary artery. This could not be cleared at the time of surgery, and the patient succumbed. A 65-year-old businessman came to the emergency department with severe lower abdominal pain that was predominantly central and left sided. He had pain radiating into the left loin, and he also noticed he was passing gas and fecal debris as he urinated. A CT scan of his abdomen and pelvis was performed (eFig. 4.191). | Anatomy_Gray. The patient unfortunately died on the operating table. In this patient’s case, a “tongue” of tumor grew into the inferior vena cava. At the time of surgery, the initial dissection mobilized the kidney on its vascular pedicle; however, a large portion of tumor became detached in the inferior vena cava. The tumor embolus passed through the right atrium and right ventricle and occluded the pulmonary artery. This could not be cleared at the time of surgery, and the patient succumbed. A 65-year-old businessman came to the emergency department with severe lower abdominal pain that was predominantly central and left sided. He had pain radiating into the left loin, and he also noticed he was passing gas and fecal debris as he urinated. A CT scan of his abdomen and pelvis was performed (eFig. 4.191). | [
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Anatomy_Gray_982 | Anatomy_Gray | A CT scan of his abdomen and pelvis was performed (eFig. 4.191). The CT scan demonstrated a collection of fluid (likely a pelvic abscess) in the left iliac fossa. Associated with this collection of fluid was significant bowel wall thickening of the sigmoid colon and multiple small diverticula arising throughout the sigmoid colon. Gas was present in the bladder. An obstruction was noted in the left ureter and the left pelvicalyceal system. The patient underwent an urgent operation. | Anatomy_Gray. A CT scan of his abdomen and pelvis was performed (eFig. 4.191). The CT scan demonstrated a collection of fluid (likely a pelvic abscess) in the left iliac fossa. Associated with this collection of fluid was significant bowel wall thickening of the sigmoid colon and multiple small diverticula arising throughout the sigmoid colon. Gas was present in the bladder. An obstruction was noted in the left ureter and the left pelvicalyceal system. The patient underwent an urgent operation. | [
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Anatomy_Gray_983 | Anatomy_Gray | The patient underwent an urgent operation. As the surgeons entered into the abdominal cavity through a midline incision, the tissues in the left iliac fossa were significantly inflamed. The surgeon used his hand to mobilize the sigmoid colon and entered a cavity from which there was a “whoosh” of pus as indicated on the CT scan. The pus was washed out and drained. The sigmoid colon was remarkably thickened and inflamed and stuck to the dome of the bladder. Careful finger dissection revealed a small perforation in the dome of the bladder, allowing the passage of fecal material and gas into the bladder and producing the patient’s symptoms of pneumaturia and fecaluria. The sigmoid colon was resected. The rectal stump was oversewn and the descending colon was passed through the anterior abdominal wall to form a colostomy. The bladder was catheterized and the small hole in the dome of the bladder was oversewn. | Anatomy_Gray. The patient underwent an urgent operation. As the surgeons entered into the abdominal cavity through a midline incision, the tissues in the left iliac fossa were significantly inflamed. The surgeon used his hand to mobilize the sigmoid colon and entered a cavity from which there was a “whoosh” of pus as indicated on the CT scan. The pus was washed out and drained. The sigmoid colon was remarkably thickened and inflamed and stuck to the dome of the bladder. Careful finger dissection revealed a small perforation in the dome of the bladder, allowing the passage of fecal material and gas into the bladder and producing the patient’s symptoms of pneumaturia and fecaluria. The sigmoid colon was resected. The rectal stump was oversewn and the descending colon was passed through the anterior abdominal wall to form a colostomy. The bladder was catheterized and the small hole in the dome of the bladder was oversewn. | [
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Anatomy_Gray_984 | Anatomy_Gray | The patient had a difficult postoperative period in the intensive care unit where he remained pyrexial and septic. The colostomy began to function well. An ultrasound was performed and demonstrated the continued dilation in the left kidney, and the patient underwent a nephrostomy. Under ultrasound guidance a drainage catheter was placed into the renal pelvis through the renal cortex on the left. A significant amount of pus was drained from the renal tract initially; however, after 24 hours urine passed freely. The likely cause for the obstruction was the inflammation around the distal ureter on the left. It is also possible that a small ureteric perforation occurred, allowing bacteria to enter the urinary tract. The patient made a further uneventful recovery with resumption of normal renal function and left the hospital. | Anatomy_Gray. The patient had a difficult postoperative period in the intensive care unit where he remained pyrexial and septic. The colostomy began to function well. An ultrasound was performed and demonstrated the continued dilation in the left kidney, and the patient underwent a nephrostomy. Under ultrasound guidance a drainage catheter was placed into the renal pelvis through the renal cortex on the left. A significant amount of pus was drained from the renal tract initially; however, after 24 hours urine passed freely. The likely cause for the obstruction was the inflammation around the distal ureter on the left. It is also possible that a small ureteric perforation occurred, allowing bacteria to enter the urinary tract. The patient made a further uneventful recovery with resumption of normal renal function and left the hospital. | [
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Anatomy_Gray_985 | Anatomy_Gray | The patient made a further uneventful recovery with resumption of normal renal function and left the hospital. On return to the surgeon in the outpatient clinic some weeks later, the patient did not wish to continue with his colostomy and bag. Further to discussion, surgery was planned to “rejoin” the patient. At operation the colostomy was “taken down” and the rectal stump was identified. There was, however, a significant gap between the bowel ends. To enable the bowel to be sutured, the descending colon was mobilized from the posterior abdominal wall. An anastomosis was performed and the patient left the hospital 1 week later and currently remains well. A 72-year-old man was brought to the emergency department with an abdominal aortic aneurysm (an expansion of the infrarenal abdominal aorta). The aneurysm measured 10 cm, and after discussion with the patient it was scheduled for repair. The surgical and endovascular treatment options were explained to the patient. | Anatomy_Gray. The patient made a further uneventful recovery with resumption of normal renal function and left the hospital. On return to the surgeon in the outpatient clinic some weeks later, the patient did not wish to continue with his colostomy and bag. Further to discussion, surgery was planned to “rejoin” the patient. At operation the colostomy was “taken down” and the rectal stump was identified. There was, however, a significant gap between the bowel ends. To enable the bowel to be sutured, the descending colon was mobilized from the posterior abdominal wall. An anastomosis was performed and the patient left the hospital 1 week later and currently remains well. A 72-year-old man was brought to the emergency department with an abdominal aortic aneurysm (an expansion of the infrarenal abdominal aorta). The aneurysm measured 10 cm, and after discussion with the patient it was scheduled for repair. The surgical and endovascular treatment options were explained to the patient. | [
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Anatomy_Gray_986 | Anatomy_Gray | The surgical and endovascular treatment options were explained to the patient. Treatment of abdominal aortic aneurysms has been, for many years, an operative procedure where the dilation (ballooning) of the aorta is resected and a graft is sewn into position. A modern option is to place a graft to line the aneurysm from within the artery (endovascular aneurysm repair). In this technique the surgeon dissects the femoral artery and makes a small hole in it. The graft is compressed within a catheter and the catheter is passed through the femoral artery and the iliac arterial system into the distal abdominal aorta. The graft can then be released inside the aorta, effectively relining it to prevent further expansion of the aneurysm. Occasionally the relined aneurysm may continue to enlarge after the endovascular graft has been placed and a cause needs to be identified. | Anatomy_Gray. The surgical and endovascular treatment options were explained to the patient. Treatment of abdominal aortic aneurysms has been, for many years, an operative procedure where the dilation (ballooning) of the aorta is resected and a graft is sewn into position. A modern option is to place a graft to line the aneurysm from within the artery (endovascular aneurysm repair). In this technique the surgeon dissects the femoral artery and makes a small hole in it. The graft is compressed within a catheter and the catheter is passed through the femoral artery and the iliac arterial system into the distal abdominal aorta. The graft can then be released inside the aorta, effectively relining it to prevent further expansion of the aneurysm. Occasionally the relined aneurysm may continue to enlarge after the endovascular graft has been placed and a cause needs to be identified. | [
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Anatomy_Gray_987 | Anatomy_Gray | Occasionally the relined aneurysm may continue to enlarge after the endovascular graft has been placed and a cause needs to be identified. A Doppler ultrasound investigation of the abdomen and a CT scan revealed there was flow between the endovascular lining and the wall of the aneurysm. The likely sources for this bleeding were assessed. The graft usually begins below the level of the renal arteries and divides into two limbs that end in the common iliac arteries. The aneurysm may continue to be fed from any vessels between the graft and the aneurysm wall. These vessels can include the lumbar arteries and the inferior mesenteric artery. Interestingly, blood usually flows from the abdominal aorta into the inferior mesenteric artery and the lumbar arteries; however, with the changes in flow dynamics with the graft in place, blood may flow in the opposite direction through these branches, thereby leading to enlargement of the aneurysm. | Anatomy_Gray. Occasionally the relined aneurysm may continue to enlarge after the endovascular graft has been placed and a cause needs to be identified. A Doppler ultrasound investigation of the abdomen and a CT scan revealed there was flow between the endovascular lining and the wall of the aneurysm. The likely sources for this bleeding were assessed. The graft usually begins below the level of the renal arteries and divides into two limbs that end in the common iliac arteries. The aneurysm may continue to be fed from any vessels between the graft and the aneurysm wall. These vessels can include the lumbar arteries and the inferior mesenteric artery. Interestingly, blood usually flows from the abdominal aorta into the inferior mesenteric artery and the lumbar arteries; however, with the changes in flow dynamics with the graft in place, blood may flow in the opposite direction through these branches, thereby leading to enlargement of the aneurysm. | [
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Anatomy_Gray_988 | Anatomy_Gray | Blood flow was from the superior mesenteric artery into the aneurysm sac. Above the level of the graft the superior mesenteric artery arises normally. From the right colic and middle colic branches a marginal branch around the colon anastomoses, in the region of the splenic flexure, with marginal branches from the inferior mesenteric artery (this can become a hypertrophied vessel known as the marginal artery of Drummond). In this situation, blood passed retrogradely into the inferior mesenteric artery, filling the aneurysm and allowing it to remain pressurized and expand. The inferior mesenteric artery was ligated laparoscopically and the aneurysm failed to expand further. Over the ensuing 6 months the aneurysm contracted. The patient remains fit and healthy, with two small scars in the groin. 412.e1 412.e2 Fig. 4.1, cont’d Conceptual Overview • Relationship to Other Regions Fig. 4.13, cont’d Fig. 4.15, cont’d Fig. 4.47, cont’d. Fig. 4.50, cont’d In the clinic—cont’d | Anatomy_Gray. Blood flow was from the superior mesenteric artery into the aneurysm sac. Above the level of the graft the superior mesenteric artery arises normally. From the right colic and middle colic branches a marginal branch around the colon anastomoses, in the region of the splenic flexure, with marginal branches from the inferior mesenteric artery (this can become a hypertrophied vessel known as the marginal artery of Drummond). In this situation, blood passed retrogradely into the inferior mesenteric artery, filling the aneurysm and allowing it to remain pressurized and expand. The inferior mesenteric artery was ligated laparoscopically and the aneurysm failed to expand further. Over the ensuing 6 months the aneurysm contracted. The patient remains fit and healthy, with two small scars in the groin. 412.e1 412.e2 Fig. 4.1, cont’d Conceptual Overview • Relationship to Other Regions Fig. 4.13, cont’d Fig. 4.15, cont’d Fig. 4.47, cont’d. Fig. 4.50, cont’d In the clinic—cont’d | [
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Anatomy_Gray_989 | Anatomy_Gray | 412.e1 412.e2 Fig. 4.1, cont’d Conceptual Overview • Relationship to Other Regions Fig. 4.13, cont’d Fig. 4.15, cont’d Fig. 4.47, cont’d. Fig. 4.50, cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d Surface Anatomy • How to Find the Superficial Inguinal Ring Surface Anatomy • Visualizing Structures at the LI Vertebral Level Surface Anatomy • Using Abdominal Quadrants to Locate Major Viscera Surface Anatomy • Where to Find the Spleen The pelvis and perineum are interrelated regions associated with the pelvic bones and terminal parts of the vertebral column. The pelvis is divided into two regions: The superior region related to upper parts of the pelvic bones and lower lumbar vertebrae is the false pelvis (greater pelvis) and is generally considered part of the abdominal cavity (Fig. 5.1). | Anatomy_Gray. 412.e1 412.e2 Fig. 4.1, cont’d Conceptual Overview • Relationship to Other Regions Fig. 4.13, cont’d Fig. 4.15, cont’d Fig. 4.47, cont’d. Fig. 4.50, cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d In the clinic—cont’d Surface Anatomy • How to Find the Superficial Inguinal Ring Surface Anatomy • Visualizing Structures at the LI Vertebral Level Surface Anatomy • Using Abdominal Quadrants to Locate Major Viscera Surface Anatomy • Where to Find the Spleen The pelvis and perineum are interrelated regions associated with the pelvic bones and terminal parts of the vertebral column. The pelvis is divided into two regions: The superior region related to upper parts of the pelvic bones and lower lumbar vertebrae is the false pelvis (greater pelvis) and is generally considered part of the abdominal cavity (Fig. 5.1). | [
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Anatomy_Gray_990 | Anatomy_Gray | The superior region related to upper parts of the pelvic bones and lower lumbar vertebrae is the false pelvis (greater pelvis) and is generally considered part of the abdominal cavity (Fig. 5.1). The true pelvis (lesser pelvis) is related to the inferior parts of the pelvic bones, sacrum, and coccyx, and has an inlet and an outlet. The bowl-shaped pelvic cavity enclosed by the true pelvis consists of the pelvic inlet, walls, and floor. This cavity is continuous superiorly with the abdominal cavity and contains elements of the urinary, gastrointestinal, and reproductive systems. The perineum (Fig. 5.1) is inferior to the floor of the pelvic cavity; its boundaries form the pelvic outlet. The perineum contains the external genitalia and external openings of the genitourinary and gastrointestinal systems. Contains and supports the bladder, rectum, anal canal, and reproductive tracts | Anatomy_Gray. The superior region related to upper parts of the pelvic bones and lower lumbar vertebrae is the false pelvis (greater pelvis) and is generally considered part of the abdominal cavity (Fig. 5.1). The true pelvis (lesser pelvis) is related to the inferior parts of the pelvic bones, sacrum, and coccyx, and has an inlet and an outlet. The bowl-shaped pelvic cavity enclosed by the true pelvis consists of the pelvic inlet, walls, and floor. This cavity is continuous superiorly with the abdominal cavity and contains elements of the urinary, gastrointestinal, and reproductive systems. The perineum (Fig. 5.1) is inferior to the floor of the pelvic cavity; its boundaries form the pelvic outlet. The perineum contains the external genitalia and external openings of the genitourinary and gastrointestinal systems. Contains and supports the bladder, rectum, anal canal, and reproductive tracts | [
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Anatomy_Gray_991 | Anatomy_Gray | Contains and supports the bladder, rectum, anal canal, and reproductive tracts Within the pelvic cavity, the bladder is positioned anteriorly and the rectum posteriorly in the midline. As it fills, the bladder expands superiorly into the abdomen. It is supported by adjacent elements of the pelvic bone and by the pelvic floor. The urethra passes through the pelvic floor to the perineum, where, in women, it opens externally (Fig. 5.2A) and in men it enters the base of the penis (Fig. 5.2B). Continuous with the sigmoid colon at the level of vertebra SIII, the rectum terminates at the anal canal, which penetrates the pelvic floor to open into the perineum. The anal canal is angled posteriorly on the rectum. This flexure is maintained by muscles of the pelvic floor and is relaxed during defecation. A skeletal muscle sphincter is associated with the anal canal and the urethra as each passes through the pelvic floor. | Anatomy_Gray. Contains and supports the bladder, rectum, anal canal, and reproductive tracts Within the pelvic cavity, the bladder is positioned anteriorly and the rectum posteriorly in the midline. As it fills, the bladder expands superiorly into the abdomen. It is supported by adjacent elements of the pelvic bone and by the pelvic floor. The urethra passes through the pelvic floor to the perineum, where, in women, it opens externally (Fig. 5.2A) and in men it enters the base of the penis (Fig. 5.2B). Continuous with the sigmoid colon at the level of vertebra SIII, the rectum terminates at the anal canal, which penetrates the pelvic floor to open into the perineum. The anal canal is angled posteriorly on the rectum. This flexure is maintained by muscles of the pelvic floor and is relaxed during defecation. A skeletal muscle sphincter is associated with the anal canal and the urethra as each passes through the pelvic floor. | [
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Anatomy_Gray_992 | Anatomy_Gray | The pelvic cavity contains most of the reproductive tract in women and part of the reproductive tract in men. In women, the vagina penetrates the pelvic floor and connects with the uterus in the pelvic cavity. The uterus is positioned between the rectum and the bladder. A uterine (fallopian) tube extends laterally on each side toward the pelvic wall to open near the ovary. In men, the pelvic cavity contains the site of connection between the urinary and reproductive tracts. It also contains major glands associated with the reproductive system—the prostate and two seminal vesicles. Anchors the roots of the external genitalia In both genders, the roots of the external genitalia, the clitoris and the penis, are firmly anchored to: the bony margin of the anterior half of the pelvic outlet, and a thick, fibrous, perineal membrane, which fills the area (Fig. 5.3). The roots of the external genitalia consist of erectile (vascular) tissues and associated skeletal muscles. | Anatomy_Gray. The pelvic cavity contains most of the reproductive tract in women and part of the reproductive tract in men. In women, the vagina penetrates the pelvic floor and connects with the uterus in the pelvic cavity. The uterus is positioned between the rectum and the bladder. A uterine (fallopian) tube extends laterally on each side toward the pelvic wall to open near the ovary. In men, the pelvic cavity contains the site of connection between the urinary and reproductive tracts. It also contains major glands associated with the reproductive system—the prostate and two seminal vesicles. Anchors the roots of the external genitalia In both genders, the roots of the external genitalia, the clitoris and the penis, are firmly anchored to: the bony margin of the anterior half of the pelvic outlet, and a thick, fibrous, perineal membrane, which fills the area (Fig. 5.3). The roots of the external genitalia consist of erectile (vascular) tissues and associated skeletal muscles. | [
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Anatomy_Gray_993 | Anatomy_Gray | The roots of the external genitalia consist of erectile (vascular) tissues and associated skeletal muscles. The pelvic inlet is somewhat heart shaped and completely ringed by bone (Fig. 5.4). Posteriorly, the inlet is bordered by the body of vertebra SI, which projects into the inlet as the sacral promontory. On each side of this vertebra, wing-like transverse processes called the alae (wings) contribute to the margin of the pelvic inlet. Laterally, a prominent rim on the pelvic bone continues the boundary of the inlet forward to the pubic symphysis, where the two pelvic bones are joined in the midline. Structures pass between the pelvic cavity and the abdomen through the pelvic inlet. During childbirth, the fetus passes through the pelvic inlet from the abdomen, into which the uterus has expanded during pregnancy, and then passes through the pelvic outlet. | Anatomy_Gray. The roots of the external genitalia consist of erectile (vascular) tissues and associated skeletal muscles. The pelvic inlet is somewhat heart shaped and completely ringed by bone (Fig. 5.4). Posteriorly, the inlet is bordered by the body of vertebra SI, which projects into the inlet as the sacral promontory. On each side of this vertebra, wing-like transverse processes called the alae (wings) contribute to the margin of the pelvic inlet. Laterally, a prominent rim on the pelvic bone continues the boundary of the inlet forward to the pubic symphysis, where the two pelvic bones are joined in the midline. Structures pass between the pelvic cavity and the abdomen through the pelvic inlet. During childbirth, the fetus passes through the pelvic inlet from the abdomen, into which the uterus has expanded during pregnancy, and then passes through the pelvic outlet. | [
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Anatomy_Gray_994 | Anatomy_Gray | During childbirth, the fetus passes through the pelvic inlet from the abdomen, into which the uterus has expanded during pregnancy, and then passes through the pelvic outlet. The walls of the true pelvis consist predominantly of bone, muscle, and ligaments, with the sacrum, coccyx, and inferior half of the pelvic bones forming much of them. Two ligaments—the sacrospinous and the sacrotuberous ligaments—are important architectural elements of the walls because they link each pelvic bone to the sacrum and coccyx (Fig. 5.5A). These ligaments also convert two notches on the pelvic bones—the greater and lesser sciatic notches—into foramina on the lateral pelvic walls. Completing the walls are the obturator internus and piriformis muscles (Fig. 5.5B), which arise in the pelvis and exit through the sciatic foramina to act on the hip joint. The diamond-shaped pelvic outlet is formed by both bone and ligaments (Fig. 5.6). It is limited anteriorly in the midline by the pubic symphysis. | Anatomy_Gray. During childbirth, the fetus passes through the pelvic inlet from the abdomen, into which the uterus has expanded during pregnancy, and then passes through the pelvic outlet. The walls of the true pelvis consist predominantly of bone, muscle, and ligaments, with the sacrum, coccyx, and inferior half of the pelvic bones forming much of them. Two ligaments—the sacrospinous and the sacrotuberous ligaments—are important architectural elements of the walls because they link each pelvic bone to the sacrum and coccyx (Fig. 5.5A). These ligaments also convert two notches on the pelvic bones—the greater and lesser sciatic notches—into foramina on the lateral pelvic walls. Completing the walls are the obturator internus and piriformis muscles (Fig. 5.5B), which arise in the pelvis and exit through the sciatic foramina to act on the hip joint. The diamond-shaped pelvic outlet is formed by both bone and ligaments (Fig. 5.6). It is limited anteriorly in the midline by the pubic symphysis. | [
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Anatomy_Gray_995 | Anatomy_Gray | The diamond-shaped pelvic outlet is formed by both bone and ligaments (Fig. 5.6). It is limited anteriorly in the midline by the pubic symphysis. On each side, the inferior margin of the pelvic bone projects posteriorly and laterally from the pubic symphysis to end in a prominent tuberosity, the ischial tuberosity. Together, these elements construct the pubic arch, which forms the margin of the anterior half of the pelvic outlet. The sacrotuberous ligament continues this margin posteriorly from the ischial tuberosity to the coccyx and sacrum. The pubic symphysis, ischial tuberosities, and coccyx can all be palpated. The pelvic floor, which separates the pelvic cavity from the perineum, is formed by muscles and fascia (Fig. 5.7). | Anatomy_Gray. The diamond-shaped pelvic outlet is formed by both bone and ligaments (Fig. 5.6). It is limited anteriorly in the midline by the pubic symphysis. On each side, the inferior margin of the pelvic bone projects posteriorly and laterally from the pubic symphysis to end in a prominent tuberosity, the ischial tuberosity. Together, these elements construct the pubic arch, which forms the margin of the anterior half of the pelvic outlet. The sacrotuberous ligament continues this margin posteriorly from the ischial tuberosity to the coccyx and sacrum. The pubic symphysis, ischial tuberosities, and coccyx can all be palpated. The pelvic floor, which separates the pelvic cavity from the perineum, is formed by muscles and fascia (Fig. 5.7). | [
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Anatomy_Gray_996 | Anatomy_Gray | The pelvic floor, which separates the pelvic cavity from the perineum, is formed by muscles and fascia (Fig. 5.7). Two levator ani muscles attach peripherally to the pelvic walls and join each other at the midline by a connective tissue raphe. Together they are the largest components of the bowlor funnel-shaped structure known as the pelvic diaphragm, which is completed posteriorly by the coccygeus muscles. These latter muscles overlie the sacrospinous ligaments and pass between the margins of the sacrum and the coccyx and a prominent spine on the pelvic bone, the ischial spine. The pelvic diaphragm forms most of the pelvic floor and in its anterior regions contains a U-shaped defect, which is associated with elements of the urogenital system. The anal canal passes from the pelvis to the perineum through a posterior circular orifice in the pelvic diaphragm. The pelvic floor is supported anteriorly by: the perineal membrane, and muscles in the deep perineal pouch. | Anatomy_Gray. The pelvic floor, which separates the pelvic cavity from the perineum, is formed by muscles and fascia (Fig. 5.7). Two levator ani muscles attach peripherally to the pelvic walls and join each other at the midline by a connective tissue raphe. Together they are the largest components of the bowlor funnel-shaped structure known as the pelvic diaphragm, which is completed posteriorly by the coccygeus muscles. These latter muscles overlie the sacrospinous ligaments and pass between the margins of the sacrum and the coccyx and a prominent spine on the pelvic bone, the ischial spine. The pelvic diaphragm forms most of the pelvic floor and in its anterior regions contains a U-shaped defect, which is associated with elements of the urogenital system. The anal canal passes from the pelvis to the perineum through a posterior circular orifice in the pelvic diaphragm. The pelvic floor is supported anteriorly by: the perineal membrane, and muscles in the deep perineal pouch. | [
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Anatomy_Gray_997 | Anatomy_Gray | The pelvic floor is supported anteriorly by: the perineal membrane, and muscles in the deep perineal pouch. The perineal membrane is a thick, triangular fascial sheet that fills the space between the arms of the pubic arch, and has a free posterior border (Fig. 5.7). The deep perineal pouch is a narrow region superior to the perineal membrane. The margins of the U-shaped defect in the pelvic diaphragm merge into the walls of the associated viscera and with muscles in the deep perineal pouch below. The vagina and the urethra penetrate the pelvic floor to pass from the pelvic cavity to the perineum. The pelvic cavity is lined by peritoneum continuous with the peritoneum of the abdominal cavity that drapes over the superior aspects of the pelvic viscera, but in most regions, does not reach the pelvic floor (Fig. 5.8A). | Anatomy_Gray. The pelvic floor is supported anteriorly by: the perineal membrane, and muscles in the deep perineal pouch. The perineal membrane is a thick, triangular fascial sheet that fills the space between the arms of the pubic arch, and has a free posterior border (Fig. 5.7). The deep perineal pouch is a narrow region superior to the perineal membrane. The margins of the U-shaped defect in the pelvic diaphragm merge into the walls of the associated viscera and with muscles in the deep perineal pouch below. The vagina and the urethra penetrate the pelvic floor to pass from the pelvic cavity to the perineum. The pelvic cavity is lined by peritoneum continuous with the peritoneum of the abdominal cavity that drapes over the superior aspects of the pelvic viscera, but in most regions, does not reach the pelvic floor (Fig. 5.8A). | [
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Anatomy_Gray_998 | Anatomy_Gray | The pelvic viscera are located in the midline of the pelvic cavity. The bladder is anterior and the rectum is posterior. In women, the uterus lies between the bladder and rectum (Fig. 5.8B). Other structures, such as vessels and nerves, lie deep to the peritoneum in association with the pelvic walls and on either side of the pelvic viscera. The perineum lies inferior to the pelvic floor between the lower limbs (Fig. 5.9). Its margin is formed by the pelvic outlet. An imaginary line between the ischial tuberosities divides the perineum into two triangular regions. Anteriorly, the urogenital triangle contains the roots of the external genitalia and, in women, the openings of the urethra and the vagina (Fig. 5.9A). In men, the distal part of the urethra is enclosed by erectile tissues and opens at the end of the penis (Fig. 5.9B). Posteriorly, the anal triangle contains the anal aperture. | Anatomy_Gray. The pelvic viscera are located in the midline of the pelvic cavity. The bladder is anterior and the rectum is posterior. In women, the uterus lies between the bladder and rectum (Fig. 5.8B). Other structures, such as vessels and nerves, lie deep to the peritoneum in association with the pelvic walls and on either side of the pelvic viscera. The perineum lies inferior to the pelvic floor between the lower limbs (Fig. 5.9). Its margin is formed by the pelvic outlet. An imaginary line between the ischial tuberosities divides the perineum into two triangular regions. Anteriorly, the urogenital triangle contains the roots of the external genitalia and, in women, the openings of the urethra and the vagina (Fig. 5.9A). In men, the distal part of the urethra is enclosed by erectile tissues and opens at the end of the penis (Fig. 5.9B). Posteriorly, the anal triangle contains the anal aperture. | [
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Anatomy_Gray_999 | Anatomy_Gray | Posteriorly, the anal triangle contains the anal aperture. The cavity of the true pelvis is continuous with the abdominal cavity at the pelvic inlet (Fig. 5.10A). All structures passing between the pelvic cavity and abdomen, including major vessels, nerves, and lymphatics, as well as the sigmoid colon and ureters, pass via the inlet. In men, the ductus deferens on each side passes through the anterior abdominal wall and over the inlet to enter the pelvic cavity. In women, ovarian vessels, nerves, and lymphatics pass through the inlet to reach the ovaries, which lie on each side just inferior to the pelvic inlet. Three apertures in the pelvic wall communicate with the lower limb (Fig. 5.10A): the obturator canal, the greater sciatic foramen, and the lesser sciatic foramen. | Anatomy_Gray. Posteriorly, the anal triangle contains the anal aperture. The cavity of the true pelvis is continuous with the abdominal cavity at the pelvic inlet (Fig. 5.10A). All structures passing between the pelvic cavity and abdomen, including major vessels, nerves, and lymphatics, as well as the sigmoid colon and ureters, pass via the inlet. In men, the ductus deferens on each side passes through the anterior abdominal wall and over the inlet to enter the pelvic cavity. In women, ovarian vessels, nerves, and lymphatics pass through the inlet to reach the ovaries, which lie on each side just inferior to the pelvic inlet. Three apertures in the pelvic wall communicate with the lower limb (Fig. 5.10A): the obturator canal, the greater sciatic foramen, and the lesser sciatic foramen. | [
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