Anatomy - Abdomen

Front 1

Label these parts

Back 1

Front 2

What are the lower ribs and if a trauma patient comes in w/injury to the lower ribs what injury must you the Urologist think of?

Back 2

The lower ribs are the 10th-12th ribs, and the concern is injury to the kidneys and adrenals.

Front 3

What are the limits of the pleura, and why is this significant to the urologist?

Back 3

The limits of the pleural space are the 8th rib anteriorly, the 10th rib in the mid-axillary line, and the 12th rib posteriorly. This is significant because flank incisions at or above the 11th or 12th rib risk pleural violation.

Front 4

Where do the sympathetic and parasympathetic nervous systems originate from?

Back 4

The sympathetic nervous system originates from the thoracic and lumbar paravertebral chain ganglia and the parasympathetic nervous system originates from the cranial and sacral spinal segments.

Front 5

What are the major autonomic nerve plexuses we care about as Urologists and what organs are they associated with?

Back 5

The celiac, superior hypogastric and inferior hypogastric plexuses. The celiac is the largest and controls autonomic input to the kidneys, adrenals, renal pelvis, ureter, and some of the testis. The superior and inferior hypogastric plexuses control the autonomic input to the pelvic urinary organs and genital tract.

Front 6

What plexus provides somatic sensory and motor innervation to the abdomen and lower extremities? Name the 6 branches.

Back 6

The lumbosacral plexus which originates in the retroperitoneum. Branches include the iliohypogastric (L1), ilioinguinal (L1), lateral femoral cutaneous (L1-L3), genitofemoral (L1-L3), femoral (L2-L4), obturator (L3-L4), and sciatic (L4-S3).

Front 7

Why must a urologist be cautious with retraction with respect to the femoral nerve?

Back 7

If a retractor is placed inferolaterally against the inguinal ligament in lower abdominal incisions, it may cause a femoral nerve palsy manifested in inability to provide knee extension.

Front 8

What is the body’s single largest nerve?

Back 8

The sciatic nerve.

Front 9

What are the layers of the adrenal cortex and what are their functions? What is the adrenal medulla composed of and what is its origin?

Back 9

From outside to inside, the layers of the adrenal cortex are GFR: zona glomerulosa (produces mineralocorticoids), zona fasciculata (produces glucocorticoids), zona reticularis (produces androgens) [SALT, SUGAR, SEXY-TIME]. The adrenal medulla is composed of chromaffin cells and it is of neural crest cell origin.

Front 10

Describe the vascular supply to the adrenal glands.

Back 10

ARTERIAL: The superior portion of the adrenals are supplied by the inferior phrenic artery. The middle adrenal artery is a direct branch from the aorta, and the inferior adrenal from the ipsilateral renal artery. VENOUS: Both are drained by a single large vein that exits anteromedially. The left adrenal vein join the inferior phrenic and enter the cranial aspect of the left renal vein. The right adrenal vein drains directly into the IVC on its posterolateral aspect.

Front 11

Name the functions of the kidney.

Back 11

The kidneys are the primary organ for maintaining fluid and electrolyte balance and play a large role in maintaining acid-base balance as well as the production of renin and erythropoietin, and conversion of vitamin D.

Front 12

What are the dimensions and weight of an adult kidney?

Back 12

The typical male adult kidney weighs 150 g, female weighs 135 g. They usually measure 10 to 12 cm vertically, 5 to 7cm transversely, and 3 cm in AP dimension. The right kidney tends to be shorter and wider because of compression by the liver.

Front 13

What is a Dromedary? What is a Dromedary hump? What do you call a camel with no hump?

Back 13

The dromedary or Arabian camel (Camelus dromedarius) is a large even-toed ungulate (Ungulates (meaning roughly "being hoofed" or "hoofed animal") are several groups of mammals, most of which use the tips of their toes, usually hoofed, to sustain their whole body weight while moving.) with one hump on its back. A Dromedary hump is a renal parenchymal bulge along the kidney’s lateral contour that is non-pathologic and more common on the left than right, presumably from downward compression by the spleen. A camel with no hump is called Humphrey.

Front 14

What is a column of Bertin and why are they significant?

Back 14

Columns of Bertin are the extensions of cortex between the renal medulla or pyramids. These columns contain renal vessels, therefore renal access for a PUL is given through a renal pyramid not through a column of Bertin.

Front 15

Does Gerota’s fascia envelope the kidney on all sides?

Back 15

No, the fascia is not closed inferiorly and opens to a potential space, therefore perinephric fluid collections can track inferiorly into the pelvis without violating Gerota’s fascia.

Front 16

T/F Gerota’s fascia is connected across midline to the contralateral side.

Back 16

True.

Front 17

What is the anatomic relationship at the hilum?

Back 17

The vein is most anterior, then the artery. The renal pelvis and ureter are posterior to the vascular structures

Front 18

What is the progression of the arterial supply to the kidney?

Back 18

Renal artery, segmental artery, lobar artery, interlobar artery, arcuate artery, interlobular artery, and then afferent arteries which feed the glomeruli

Front 19

How many segmental arteries does the renal artery usually split into and are there good collaterals for these segmental arteries and why do we care?

Back 19

The renal artery usually splits into 5 segmental arteries, the first branch being the posterior segmental artery, which separates from the renal artery before it enters the hilum. The other four anterior segmental branches are the apical, upper, middle and lower branches. There are not good collaterals for these arterie, and we care because they each supply a distinct portion of the kidney, and thus occlusion or injury will cause segmental renal infarction.

Front 20

What is a possible cause of a UPJ obstruction?

Back 20

Usually, the posterior segmental artery passes posteriorly to the renal pelvis whereas the anterior segmental arteries pass anteriorly. A posterior segmental artery which crosses anteriorly may cause a UPJ obstruction.

Front 21

What is surgically important regarding the division between the posterior and anterior segmental arteries? How could you, the Urologist, delineate this plane before incision?

Back 21

Between these circulations is an avascular plane lying just posterior to the lateral aspect of the kidney. This plane or line is known as Brodel's line. Incision within this plan results in much less blood loss. Because the location of this plane can vary, it can be delineated preoperatively with angiography or intraoperative segmental arterial injection of a dye such as methylene blue.

Front 22

If a segmental vein is occluded in the kidney, will this cause alteration in the venous drainage of the kidney?

Back 22

No this will not cause alteration because the venous drainage system of the kidney has good collateral flow.

Front 23

How often do anatomic variations of the renal vasculature occur?

Back 23

They occur in 25-40% of kidneys. The most common variation is more than one renal artery. This occurs more often on the left and is more common with ectopic kidneys. Supernumerary renal arteries may cause UPJ obstruction.

Front 24

When performing a psoas hitch how should you throw your stitch?

Back 24

he stitch should be thrown in parallel with the psoas muscle fibers and in parallel with the genital branch of the genitofemoral nerve as well as in parallel with the femoral nerve so as not to injure the nerves. Retractors should not rest on the psoas muscle to avoid compression injury to the femoral nerve (weakening of knee EXTENSION).

Front 25

What are the muscle layers of the bladder and does this vary by location?

Back 25

In the upper aspect of the bladder, muscle fibers consist of interlacing bundles or loosely arranged inner longitudinal, middle circular and outer longitudinal muscle. However, at the bladder neck, it becomes more organized with distinct inner longitudinal, middle circular, and outer longitudinal muscles- and the muscle fibers are much finer.

Front 26

What segments of the spinal cord constitute the sympathetic presynaptic cell bodies of the pelvic autonomic plexus?

Back 26

T10 to L2

Front 27

What are the two pathways by which the sympathetic cell bodies reach the pelvic plexus?

Back 27

--Superior hypogastric plexus (from fibers of the celiac plexus and first 4 lumbar splanchnic nerves)

--Pelvic continuations of sympathetic trunks send branches anterolaterally to the pelvic plexus

Front 28

What segments of the spinal cord constitute the parasympathetic portion of the pelvic plexus?

Back 28

S2 through S4 (emerge as pelvic splanchnic nerves (nervi erigentes)

Front 29

What does the most caudal portion of the pelvic plexus provide innervation to?

Back 29

Prostate and cavernosal nerves

Front 30

What is the relationship between the location of the ureter and ovary?

Back 30

The ureter lies directly posterior to the ovary.

Front 31

What are the three main pelvic muscle & fasciae which help prevent prolapse of the female urogenital organs?

Back 31

--Pubovisceral and perineal muscles (forms sphincter around urogenital hiatus)

--Levator plate

--Cardinal and uterosacral ligaments

Front 32

Back 32

Front 33

What is the structure being identified?

Back 33

This is the falciform ligament which the free end of is the ligament teres hepatis or the round ligament of the liver. This continues down to the umbilicus and used to be an umbilical vein.

Front 34

What is this a picture of?

Back 34

This shows the mesenteric fat of the small bowel picked away and you see the superior mesenteric artery as it comes off of the aorta supplying the small bowel with all of its branches, you should be able to name.

Front 35

What is the examiner showing you?

Back 35

He is showing the duodenum as it terminates marked by the ligament of treitz and it becomes the jejunum, you also see the recess made behind it and to the right there is a fat pad area that represents the inferior mesenteric vein as it joins back with the splenic vein to become the hepatic portal vein.

Front 36

What is the examiner showing?

Back 36

This is the terminal ileum as it ends at the cecum of the ascending colon.

Front 37

What is this?

Back 37

This is another picture showing the duodenum as it terminates and the fat pad to the right of it is the inferior mesenteric vein as it goes back up to join the splenic vein and become the hepatic portal vein.

Front 38

What is shown here? Is it on small bowel and large bowel or just one?

Back 38

These are the epiploic appendages that are extension of the mesentery that you see only on the large bowel, you will not see this on the small bowel

Front 39

What is this an image of?

Back 39

This is a picture of the superficial circumflex vein as it emerges through the fat below campers fascia and above scarpas fascia. You also see the supervicial epigastric branches.

Front 40

What is this?

Back 40

Again you see the superficial epigastric vein.

Front 41

What is being shown by how the dissector can take the skin off of the muscle like so?

Back 41

You see the fact that Scarpa's fascia is really a true layer and that it directly overlies the muscle.

Front 42

What are the boundaries of the retroperitoneum?

Back 42

Lateral: transversus abdominus muscles. Cranial: the diaphragm. Caudal: the extraperitoneal pelvic structures. Anterior: peritoneum. Posterior: the abdominal wall (lumbodorsal fascia and sacrospinalis & quadratus lumborum muscles)

Front 43

What is a dorsal lumbotomy incision and why is it clinically important?

Back 43

It is a vertical incision lateral to the quadratus and sacrospinalis muscles, following the lateral border of the paraspinous muscles from the 12th rib superiorly and the iliac crest. It allows entrance to the retroperitoneum without violation of the musculature, and in properly selected thin patients allows for relatively atraumatic access to the UPJ.

Front 44

Which is anterior, the renal artery or the vein? Is there a similar relationship between the common iliac arteries/veins?

Back 44

The renal vein is anterior but this is reversed when the aorta & IVC divide into the common iliacs and the iliac artery is anterior.

Front 45

What are the lateral flank muscles from superficial to deep?

Back 45

The lateral flank muscles from superficial to deep are the external oblique, the internal oblique, and the transversus abdominus followed by the transversalis fascia.

Front 46

Where does the psoas major originate, what does it do, and does everyone have a psoas minor muscle?

Back 46

The psoas major originates at T12 to L5 and it functions in hip flexion. About 50% of people have a psoas minor muscle that is just medial to the psoas major.

Front 47

What are the branches of the abdominal aorta in order, what significant vessels come off of these branches, and what significant structures are supplied by these vessels? At what spinal level does the abdominal aorta bifurcate into the common iliacs?

Back 47

The aorta enters the abdomen via the aortic hiatus at T12. The paired inferior phrenic arteries are the first to branch. They supply the inferior diaphragm and the superior portion of the adrenal gland. Next to branch is the celiac trunk which is the origin for the common hepatic, left gastric, and splenic arteries (liver, stomach, spleen). The adrenal arteries branch next followed by the SMA which DRAPES OVER the left renal vein supplies the entire small intestine and the majority of the large intestine. The renal arteries branch off next overlying L2, followed by the paired gonadal arteries. The IMA is next to branch off the aorta. The IMA provides vascular supply to the left third of the transverse colon, descending colon, sigmoid colon, and rectum. The aorta then bifurcates into the common iliac vessels at L4.

Front 48

Describe the course of the gonadal arteries in the male & female. Why can the gonadal arteries be ligated during surgery and what are the collaterals in men and women?

Back 48

The artery moves caudally and laterally from the aorta. In men, it then crosses the ureter and exits the retroperitoneum at the internal inguinal ring. In females, it crosses medially back over the external iliac vessels and enters the pelvis where it advances toward the ovary via the suspensory ligament. The gonadal arteries may be ligated during surgery because of good collateral blood flow to the ovaries from the uterine artery in females and to the testes from the deferential and cremasteric arteries males.

Front 49

Can the IMA be sacrificed during surgery if necessary?

Back 49

Yes, collaterals from the SMA, middle hemorrhoidal, and inferior hemorrhoidal arteries are sufficient in patients without significant vascular disease if the IMA is sacrificed.

Front 50

What posterior branches off of the aorta may be encountered during surgery and what may happen if ligated?

Back 50

Lumbar arterial branches (usually 4 pairs) come off of the posterior aorta. If these branches are ligated at multiple levels there is a risk of spinal ischemia and paralysis, but this is very rare.

Front 51

At what spinal level does the IVC begin?

Back 51

The IVC generally begins at L5 where the confluence of the common iliac veins is present.

Front 52

Into what do the left and right gonadal veins drain?

Back 52

Left gonadal vein drains into left renal vein & right gonadal vein drains into the IVC (although in a small minority of freaks the right gonadal drains into the right renal vein)

Front 53

What drains into the left renal vein and where?

Back 53

After leaving the hilum, the left renal vein receives a lumbar vein posteriorly, the left gonadal inferiorly, and the adrenal vein superiorly (typically also the left inferior phrenic)

Front 54

Is it typical for a lumbar vein to drain into the right renal vein?

Back 54

No, because the right renal vein is shorter, but it can occur.

Front 55

Where does the right adrenal vein drain into and why is this important for Urologists?

Back 55

It drains directly into the posterior aspect of the IVC, and this is important because it is a short vein that is challenging to mobilize in right adrenal or renal surgery

Front 56

How does lymphatic drainage flow in the retroperitoneum, and why is this important to the Urologist?

Back 56

The lymphatic drainage flows cranially and from right to left. This is important because in cancers, such as testicular cancers, the lymphatic spread in the retroperitoneum will proceed in this fashion.

Front 57

Where do retroperitoneal lymphatics meet?

Back 57

They meet posterior to the aorta at the level of L1 or L2 to form the thoracic duct. This coalescence is usually marked by a local dilation called the cisterna chyli.

Front 58

How are retroperitoneal lymphatics divided for an RPLND?

Back 58

They are divided into a system of three major nodal areas: right paracaval extending from the midline of the IVC to the right ureter, interaortal caval region extending from the midline of the IVC to the midline of the aorta, and the left para-aortic region extending from the midline of the aorta to the left ureter.

Front 59

What provides lymphatic drainage for the kidneys and testicles? To where do metastatic cells from the right testis drain? How about from the left?

Back 59

The lumbar lymphatics. Right: primarily into the interaortal caval nodes with significant drainage to the right paracaval nodes, and a small amount to the left para-aortic nodes. Left: primarily to the left para-aortic nodes with significant drainage to the interaortal caval nodes, with essentially NO drainage to the right paracaval nodes.

Front 60

During an RPLND what may occur if the superior and inferior hypogastric autonomic nervous system plexuses are disrupted?

Back 60

Disruption of these plexuses may result in failure of seminal vesicle emission and/or failure of bladder neck closure resulting in retrograde ejaculation.

Front 61

Where does the genital branch of the genitofemoral nerve lie and what is its function?

Back 61

The genital branch of the genitofemoral nerve lies directly on top of the psoas and runs parallel with it. It provides sensation to upper thigh and genitalia and it provides innervation for the dartos and cremaster muscles.

Remember that you can see it when doing RPLND dissection.

Front 62

What GI structure is immediately anterior to the right renal hilum? What is the Kocher maneuver?

Back 62

The second portion of the duodenum is immediately anterior to the right renal hilum. The Kocher maneuver refers to mobilizing this portion of the duodenum to expose the right kidney, renal pelvis or additional upper abdominal structures.

Front 63

What GI structures must we be careful of when doing a left nephrectomy?

Back 63

The pancreas as the body and tail overly the left adrenal and upper pole. Also be careful not to injure the splenic vessels which course along the posterior aspect of the pancreas.

Front 64

Which parts of the colon are retroperitoneal and why is this important?

Back 64

ascending colon, about 15 cm in length, runs upward toward the liver on the right side; like the descending colon, the posterior surface is fixed against the retroperitoneum, whereas the lateral and anterior surfaces are true intraperitoneal structures. The white line of Toldt represents the fusion of the mesentery with the posterior peritoneum.

The rectum is 12 to 15 cm in length and lacks taeniae coli or appendices epiploicae. It occupies the curve of the sacrum in the true pelvis, and the posterior surface is almost completely extraperitoneal in that it is adherent to presacral soft tissues and thus is outside of the peritoneal cavity. The anterior surface of the proximal third of the rectum is covered by visceral peritoneum.

Front 65

Are the adrenals within Gerota’s fascia and what is their general appearance? Does having a renal embryologic abnormality mean that you will have an adrenal abnormality?

Back 65

The adrenals are within Gerota’s and they appear yellow orange with a mustard-like appearance. They are 3 to 5 cm. in greatest dimension and weigh approx. 5 g. The right is pyramidal and the left is crescentic in shape.

No, Embryologically, they develop independently.

Front 66

Where do the lymphatics from the right and left kidneys drain?

Back 66

The right kidney drains into the paracaval and interaortocaval lymphatic systems with occasional right to left drainage into the paraaortic system. The left kidney drains mostly into the paraaortic system.

Front 67

Describe the inner anatomy of the renal collecting system, moving inward from the medullary pyramid to the renal pelvis.

Back 67

Each pyramid tapers to the renal papilla which is then cupped by a minor calyx. Each minor calyx narrows to an infundibulum. Infundibuli then combine to form two or three major calcyces, frequently termed upper, middle and lower calyces. These in turn combine to form the renal pelvis.

Front 68

What is the typical length of a ureter and what are its four layers?

Back 68

The typical length is 22 to 30 cm. Layers from inner to outer are the transitional epithelium, lamina propria, smooth muscle (divided into an inner longitudinal and outer circular muscular layer providing the peristaltic wave), and adventitial layer containing blood supply and lymphatic vessels.

Front 69

Where can the ureters classically become narrowed?

Back 69

The UPJ, the crossing of the iliacs, and the UVJ. These are areas where calculi may become lodged.

Front 70

How can the ureter be divided anatomically for description?

Back 70

By an Ob-GYN! Ha ha ha. But seriously, the ureter can be divided into an upper segment (renal pelvis to the upper border of the sacrum), middle segment (upper to lower borders of the sacrum), and lower segment (lower border of the sacrum to the bladder). Alternatively, it can be divided into abdominal ureter (kidney to iliac vessels) and pelvic ureter (iliac vessels to bladder).

Front 71

What is the blood supply to the ureter and how does the blood supply approach the ureter by location?

Back 71

Blood supply to the abdominal ureter approaches in a medial fashion from the the renal artery, gonadal artery, aorta, and common iliac arteries. The pelvic ureter is supplied in a lateral fashion from the internal iliac artery and its branches especially the vesical and uterine arteries, as well as the rectal and vaginal arteries. It is important not to strip the adventitia of the ureters so as to not compromise its blood supply.

Front 72

T/F: Normal ureteral peristalsis requires autonomic input.

Back 72

False- peristalsis originates and is propagated from intrinsic smooth muscle pacemaker sites located in the minor calyces of the renal collecting system.

Front 73

To minimize scarring of the anterior abdominal wall and flank, what should the Urologist do when making an incision?

Back 73

Follow Langer’s lines of cleavage. These lines parallel dermal collagen fibers and are oriented along line of stress. They correspond to the segmental thoracic and lumbar nerves.

Front 74

What is the arcuate line?

Back 74

It is the location two thirds the distance from the pubis to the umbilicus in which all aponeurotic layers abruptly pass anterior to the rectus, leaving the rectus clothed posteriorly only by transversalis fascia and peritoneum posteriorly.

Front 75

What is a paramedian incision and why is it risky?

Back 75

A paramedian incision is made laterally to the rectus muscles. It may result in injury to the thoracic segmental nerves supplying the rectus and can lead to possible atrophy and can predispose to ventral hernia.

Front 76

Definition of direct versus indirect inguinal hernia

Back 76

Direct: hernia occurs medial to the inferior epigastric vessels. Indirect: lateral to vessels

Front 77

What are the three elevations of peritoneum located on the anterior abdominal wall and what do they contain?

Back 77

Median umbilical ligament (urachus), medial umbilical fold (obliterated umbilical artery), lateral umbilical fold (inferior epigastric vessels as they ascend to the rectus)

Front 78

What is the anatomic importance of the obliterated umbilical artery for the urologic surgeon?

Back 78

It is an important landmark because you can trace its origin from the internal iliac artery to locate the ureter (which lies on its medial side). Also, during a lap pelvic LN dissection, the obturator packet is accessed by incising the peritoneum lateral to the obliterated umbilical artery.

Front 79

The hernia sac will be located where in a inguinal hernia in relation to the vessels and the vas?

Back 79

*If you think about the structures of the inguinal canal in a male they are retroperitoneal or extraperitoneal and so the hernia sac through an outpouching of the peritoneum will be anterior and medial...makes sense right....

Front 80

What are the different regions of the stomach?

Back 80

Front 81

What is this?

Back 81

An omphalocele, where the abdominal contents herniate into the hernia sac, this can even include the liver.

Front 82

What is this?

Back 82

This is another picture of an omphalocele. This is where the abdominal contents can herniate out into a defect in the anterior abdominal wall.

Front 83

What are hindgut structures and what is the blood supply to the hindgut?

Back 83

The distal one third of the transverse colon, descending colon, and rectum evolve from the hindgut fold and are supplied by the inferior mesenteric artery. – Sabiston’s

Front 84

How long is the colon and rectum?

Back 84

The colon and rectum constitute a tube of variable diameter about 150 cm in length. – Sabiston’s

Front 85

How much is too much dilation of the cecum?

Back 85

Although it is distensible, acute dilation of the cecum to a diameter of greater than 12 cm, an event that can be measured by a plain abdominal radiograph, can result in ischemic necrosis and perforation of the bowel wall. Surgical intervention may be required when this degree of cecal distention is caused by obstruction or pseudo-obstruction. – Sabiston’s

Front 86

What are the typical locations of the appendix in relation to the cecum and terminal ileum?

Back 86

The appendix extends from the cecum about 3 cm below the ileocecal valve as a blind-ending elongated tube 8 to 10 cm in length. The proximal appendix is fairly constant in location, whereas the end can be located in a wide variety of positions relative to the cecum and terminal ileum. Most commonly, it is retrocecal (65%), followed by pelvic (31%), subcecal (2.3%), preileal (1.0%), and retroileal (0.4%). Clinically, the appendix is found at the convergence of the taeniae coli. – Sabiston’s

Front 87

How can you easily locate the terminal ileum?

Back 87

Another clinical aid useful in detecting the location of the terminal ileum through a small abdominal incision is the identification of the fold of Treves, the only antimesenteric epiploic appendage normally found on the small intestine, marking the junction of the ileum and cecum. - Sabiston’s

Front 88

What does the term Bloomer’s shelf refer to?

Back 88

This anterior peritonealized space is called the pouch of Douglas or the pelvic cul-de-sac and may serve as the site of so-called drop metastases from visceral tumors. These peritoneal metastases can form a mass in the cul-de-sac (called Bloomer's shelf) that can be detected by a digital rectal examination.