Lec 40- Posterior Abd Wall And Diaphragm

Front 1

What are the bones of of the posterior abdominal wall?

Back 1

1. Ilium
2. Ribs XI and XII
3. Lumbar verterbrae
4. Sacrum

Front 2

What are the muscles of the posterior abdominal wall?

Back 2

1. Psoas
2. Quadratum lumborum
3. Iliacus
4. Transverse muscles and diaphragm

Front 3

The posterior abdominal region is a conduit to...?

Back 3

1. Vessels: aorta and vena cava
2. Lymphatics
3. Nerves: visceral (autonomic) and somatic

Front 4

Viscera of the posterior abdominal region consist of which 3 organs?

Back 4

1. Kidneys
2. Ureter
3. Adrenal glands

Front 5

What are the bones (and ligament) of the median plane of the posterior abdominal wall? (LV1-LV5)

Back 5

* vertebral bodies
* intervertebral discs
* Transverse processes
* Ligament- anterior longitudinal ligament

Front 6

What plane of the posterior abdominal wall is rarely injured and requires significant force to do so?

Back 6

The median plan
NOTE: LV injury could also involve abdominal visceral fractures

Front 7

What are the bones of the lateral plane of the posterior abdominal wall?

Back 7

11th and 12th ribs superiorly
* Rib 11: posterior to superior part of left kidney
* Rib 12: posterior to superior part of both kidneys
Pelvic brim inferiorly
*Upper margin of sacrum & iliac fossa

Front 8

What are the muscles of the posterior abdominal wall?

Back 8

1. Diaphragm
2. Psoas Major
3. Psoas Minor
4. Quadratus lumborum
5. Transversus abdominis
6. Iliacus

Front 9

The diaphragm is a musculotendinous sheet separating the _____ and ______ cavities

Back 9

* thoracic
* abdominal

Front 10

The diaphragm is dome shaped, and the convexity bulges into the _________

Back 10

Thoracic cavity

Front 11

Where does the musculature of the diaphragm radiate from?

Back 11

* xiphoid process (sternal)
* costal cartilages and lower 6 ribs (costal)
* ant. surfaces of the bodies of lumbar vertebrae, ant. longitudinal ligament., and IV disks (lumbar)

Front 12

The musculature of the diaphragm is _______

Back 12

Peripheral

Front 13

Where is the central tendon of the diaphragm located?

Back 13

It underlies the heart and medial portion of the lungs

Front 14

What is the central tendon of the diaphragm?

Back 14

It is the tenson of insertion of all muscle fibers

Front 15

What attaches the diaphragm to bodies and intervertebral discs of lumbar vertebrae?

Back 15

The crura

Front 16

Tthe right crus attaches the diaphragm to which lumbar vertebrae?

Back 16

L1 to L3

Front 17

Tthe left crus attaches the diaphragm to which lumbar vertebrae?

Back 17

L1 and L2

Front 18

What unites the right and left crura anterior to the aorta?

Back 18

The median arcuate ligament

Front 19

What is a thickening of anterior layer of thoracolumbar fascia over the psoas major muscle?

Back 19

The medial arcuate ligament

Front 20

Describe the course of the medial arcuate ligament

Back 20

It extends from the body of LV1 or LV2 across the psoas to the tip of transverse process of LV1

Front 21

What is a thickening of thoracolumbar fascia over quadratus lumborum?

Back 21

The lateral arcuate ligament

Front 22

Describe the course of the lateral arcuate ligament

Back 22

It extends from the transverse process of LV1 to the tip of the lower margin of 12th rib

Front 23

What traverses through the aortic hiatus?

Back 23

1. Aorta
2. Thoracic duct
3. Azygos vein (sometimes)
4. Lymphatics

Front 24

What traverses through the esophageal hiatus?

Back 24

1. Esophagus
2. Esophageal branches of the left gastric artery and vein
3. Anterior and posterior vagal trunks
4. A few lyphatic vessels

Front 25

Where does the esophageal hiatus lie?

Back 25

At the level of TV10 in the muscular part of the diaphragm

Front 26

Where does the aortic hiatus lie?

Back 26

It is bounded at the sides by the crura of the diaphragm at the level of TV12

Front 27

Does the aortic hiatus pierce the diaphragm?

Back 27

NO!

Front 28

Where is the vena caval foramen?

Back 28

It lies at the level of TV8 or at the disk below. It's an opening in the central tendon.

Front 29

What does the vena caval foramen transmit?

Back 29

1. Inferior vena cava
2. Right phrenic nerve
3. Lymphatic vessels

Front 30

What is another name for the sternocostal hiatus?

Back 30

Foramen of Morgagni

Front 31

Where is the sternocostal hiatus located?

Back 31

Interval between the adjacent sternal and costal muscular fasciculi

Front 32

What is transmitted through the sternocostal hiatus?

Back 32

1. Lymphatic channels from the convex surface of the liver to the anterior phrenic nodes
2. Superior epigastric artery (usually)

Front 33

What pierces the cruca of the diaphragm?

Back 33

The greater and lesser thoracic splanchnic nerves

Front 34

What is posterior to the medial arcuate ligaments?

Back 34

Sympathetic trunks
Least splanchnic nerve
Hemiazygos vein (sometimes)

Front 35

What is at the substance of the diaphragm?

Back 35

Hemiazygos vein (sometimes also left crus)
Left phrenic nerve and most branches of both phrenic nerves

Front 36

What accounts for 8% of all major congenital anomalies?

Back 36

Congenital diaphragmatic hernias

Front 37

What is the cause of a congenital diaphragmatic hernia?

Back 37

Failure of pleuroperitoneal membranes to close.

Front 38

What are some symptoms of congenital diaphragmatic hernia?

Back 38

Respiratory distress and cyanosis

Front 39

Congenital diaphragmatic hernias are usually left-sided and involve herniation of which organs?

Back 39

Stomach, spleen, and intestines

Front 40

Which form of congenital diaphragmatic hernia is fatal?

Back 40

Bilateral

Front 41

What is congenital diaphragmatic hernia associated with?

Back 41

Degrees of pulmonary hypoplasia at birth.

Front 42

What is a Bochdalek hernia?

Back 42

posterolateral; left sided; thru pleuroperitoneal hiatus or foramen of Bochdalek (lumbocostal trigone lateral to lateral arcuate ligament); 85% of cases

Front 43

What is a Morgagni hernia?

Back 43

Parasternal hernia. Anterior; right-sided; thru sternocostal hiatus; rare; 2% of cases

Front 44

What is a hiatal hernia?

Back 44

Through esophageal hiatus; usually associated with GERD

Front 45

What are the arteries of the superior surface of the diaphragm?

Back 45

1. pericardiacophrenic &
2. musculophrenic branches (internal thoracic artery)
3. superior phrenic branches (thoracic aorta)

Front 46

What is the artery of the inferior surface of the diaphragm?

Back 46

inferior phrenic branches (abdominal aorta)

Front 47

What are the veins of the superior surface of the diaphragm?

Back 47

Pericardiacophrenic and musculophrenic tributaries to internal thoracic veins

Front 48

What are the veins of the inferior surface of the diaphragm?

Back 48

1. right inferior phrenic veins to inferior vena cava
2. left inferior phrenic veins to left suprarenal vein

Front 49

Describe the lymph drainage of the thoracic surface of the diaphragm.

Back 49

* Anterior diaphragmatic nodes drain in parasternal lymph nodes / also receive lymph from abdominal lymphatic vessels
* Posterior diaphragmatic nodes drain in phrenic & posterior mediastinal nodes
* Parasternal & posterior mediastinal nodes drains into bronchomediastinal trunks & thoracic duct (left) or right lymphatic duct*
NOTE: *Bronchomediastinal trunks may also directly enter venous circulation at venous angles

Front 50

Describe the lymph drainage of the abdominal surface of the diaphragm.

Back 50

* Phrenic nodes
* Superior lumbar (caval/aortic) nodes
* Both drain into thoracic duct

Front 51

What is the motor innervation of the diaphragm?

Back 51

phrenic nerves (C3-C5) are the sole motor nerves

Front 52

What is the sensory innervation of the diaphragm?

Back 52

* phrenic nerves are sensory from most of central portions (origin> septum transversum)
* ower six intercostal and subcostal nerves (T5-T12) are sensory from peripheral portions of diaphragm (origin> mesoderm from body wall)

Front 53

Inflammation of ________ of the diaphragm produces pain in the shoulder

Back 53

Parietal peritoneum

Front 54

Describe referred pain (in terms of nerve fibers)

Back 54

referred pain happens when nerve fibers from regions of high sensory input (such as the skin) and nerve fibers from regions of normally low sensory input (such as the internal organs) happen to converge on the same levels of the spinal cord

Front 55

Referred pain to the right shoulder pain may be due to?

Back 55

1. Inflammed gallbladder
2. Liver abscess
3. Abscess in hepatorenal recess

Front 56

Referred pain to the left shoulder pain may be due to?

Back 56

1. Pancreatitis
2. Splenic rupture

Front 57

Referred pain to any side of the shoulder pain may be due to?

Back 57

1. internal bleeding due to ectopic pregnancy or perforated gastric ulcer
2. appendicitis (usually right, left if malrotation of colon during development)

Front 58

What is the origin of Psoas major?

Back 58

TV12-LV5

Front 59

What is the insertion of the psoas major?

Back 59

Lesser trochanter of the femur

Front 60

The psoas major muscle is related superiorly to the _______?

Back 60

medial arcuate ligament

Front 61

What is the nerve supply of the psoas major muscle?

Back 61

Lumbar plexus L1-L3

Front 62

What is the action of he psoas major muscle?

Back 62

Flexes thigh; Flexes trunk laterally; flexes trunk to the thigh in sitting position;

Front 63

What is the nerve supply of Psoas minor?

Back 63

Lumbar plexus L1

Front 64

The tendon of Psoas minor may be mistaken for _____________?

Back 64

Genitofermoral nerve "Student's nerve"
Note: it is absent in 40-50% of cases

Front 65

Lumbar back pain and a mass in groin area may be indicitative of what?

Back 65

Psoas abscess

Front 66

What is common in tuberculosis of the vertebral column?

Back 66

Psoas abscess

Front 67

In a psoas abscess where does the infection spread and where does pus accumulate?

Back 67

Infection spreads from intervertebral discs to psoas sheath, pus accumulate beneath inguinal ligament

Front 68

What is the origin of the quadratus lumborum?

Back 68

*iliolumbar lig
*iliac crest
*tip of LV5

Front 69

What is the insertion of quadratus lumborum?

Back 69

12th ribs
tip of LV1-LV4

Front 70

What is the quadratus lumborum related to superiorly?

Back 70

The lateral arcuate ligament

Front 71

What is the function of the quadratus lumboum muscle?

Back 71

Fixes/depresses 12th ribs during respiration; extend & flexes trunk laterally;

Front 72

What is the nerve supply of the quadratus lumboum muscle?

Back 72

lumbar plexus (T12 & L1 to L4)

Front 73

What is the nerve supply of transversus abdominis?

Back 73

lower 6 thoracic nerves, branches of iliohypogastric, ilioinguinal nn

Front 74

What compresses abdominal contents?

Back 74

Transversus abdominis

Front 75

What is the origin of the Iliacus?

Back 75

Iliac fossa

Front 76

What is the insertion of the iliacus?

Back 76

lesser trochanter of femur

Front 77

What is the function of the iliacus?

Back 77

Stabilizes hip joint; flexes thigh (act with psoas major)

Front 78

What is the nerve supply of the iliacus?

Back 78

lumbar plexus: branches from femoral n, (L2 to L4)

Front 79

What is the location of the abdominal aorta?

Back 79

Anterior to vertebral bodies TXII and LIV

Front 80

What are the visceral unpaired arteries and what do they supply?

Back 80

1. Celiac artery (L1)- supply foregut
2. Superior mesenteric artery (L1)-supply midgut
3. Inferior mesenteric artery (L3)- supply hindgut

Front 81

What are the visceral paired arteries and what do they supply?

Back 81

1. Middle suprarenal arteries- supple adrenal glands
2. Renal arteries- supply kidneys
3. Testicular or ovarian arteries- supply testes or ovaries

Front 82

What are the posterior arteries of the abdominal wall and what do they supply?

Back 82

1. Inferior phrenic arteries: supply diaphragm
2. Lumbar arteries (4 pairs): posterior abdominal wall (muscles minus diaphragm & bones) & spinal cord
3. Median sacral artery

Front 83

What are the terminal arteries of the posterior abdominal wall?

Back 83

Common iliac arteries

Front 84

What are the common locations of abdominal aortic aneurysm (AAA)?

Back 84

~90% of AAAs are located below the level of the renal arteries.
~66% of AAAs extend from the aorta into one or both of the iliac arteries.

Front 85

What is the major cause of AAA?

Back 85

At least 80% of aortic aneurysms are from arteriosclerosis. Runs in family.

Front 86

What demographic is mostly affected by AAA?

Back 86

~ 5% of men (1% women) over age 60 develop AAA. Often asymptomatic.

Front 87

Most __________ are fusiform with widening all around the circumference of the aorta.

Back 87

Abdominal aortic aneurysms

Front 88

How would one repair an AAA rupture?

Back 88

Must be repaired by surgery or endovascular stenting.

Front 89

When is rupture of an AAA most common?

Back 89

Rupture is far more common in aneurysms that are over 5.5 cm wide and are expanding rapidly (>0.5 cm/year).

Front 90

What are the consequences of a threatened rupture of an AAA?

Back 90

Threatened rupture is a surgical emergency. >80% of ruptured AAA result in death. The operative risk for a ruptured aneurysm is about 50%.

Front 91

The _____ is responsible for the return blood from structures below diaphragm to right atrium

Back 91

Inferior vena cava

Front 92

What are the tributaries of the Inferior vena cava?

Back 92

KNOW THESE!!!
1. Common iliacs
2. 5 Lumbar veins
3. Right testicular/ovarian vein
4. Renal veins
5. Right suprarenal vein
6. Inferior phrenic veins
7. Hepatic

Front 93

What do the common iliacs drain?

Back 93

Pelvis and lower limbs

Front 94

Where do the lumbar veins drain?

Back 94

KNOW THESE!
*1 & 2 drain in azygos & hemi-azygos via ascending lumbar vein
* 5 drains in IVC via iliolumbar vein
* 3 & 4 drain directly in IVC

Front 95

What does the left renal vein drain?

Back 95

* left testicular/ovarian vein
* left suprarenal vein

Front 96

What are the lymph nodes and vessels associated with aorta, IVC, & iliac vessels?
Also describe their drainage

Back 96

1. Para-aortic nodes (lumbar)
drain body wall, kidneys, adrenal glands & testes or ovaries, uterus and uterine tubes / efferent vessels form lumbar lymphatic trunks

2. Pre-aortic nodes (celiac, superior mesenteric, inferior mesenteric)
drain GI tract & accessory organs & pass to lumbar nodes

3. Common iliac nodes:
drain descending colon, pelvis & lower limbs / efferent vessels form intestinal lymphatic trunks

4. Descending thoracic lymphatic trunks:
drain lower six intercostal space

Front 97

Where do the lymph nodes od the posterior abdominal wall drain?

Back 97

All drain in thoracic duct (inferior end is cisterna chyli)

Front 98

Where does the thoracic duct drain in the venous system?

Back 98

Thoracic duct drains in venous system at junction of left subclavian & internal jugular veins

Front 99

What are the inferior phrenic nerves (C3-5) responsible for?

Back 99

Motor and sensory innervation of the diaphragm

Front 100

What are the subcostal nerves (T12) responsible for?

Back 100

*motor & sensory innervation of quadratum lumborum, transversus abdominis & anterolateral wall
* sensory afferents to diaphragm

Front 101

What are somatic motor efferents responsible for?

Back 101

Contracion of skeletal muscles

Front 102

What are somatic afferents responsible for?

Back 102

* pain & proprioception of skeletal muscles
* pain, temperature, touch & pressure of skin

Front 103

What is the lumbar plexus ( anterior rai of L1-L5 spinal nerves) responsible for?

Back 103

* motor & sensory innervations of quadratum lumborum, transversus abdominis, Iliacus, psoas major & minor, muscles of thigh and pelvis, and muscles of anterolateral wall by L1

* sensory innervation of skin of thigh, gluteal and pubic area & articulation of hip and knee and skin of anterolateral wall and peritoneum by L1

Front 104

What are the nerves of the lumar plexus?

Back 104

L1: Iliohypogastric & ilioinguinal nerves
L1-2: Genitofemoral nerve
L2-L3: Lateral cutaneous nerve of thigh
L2-L4: Obturator nerve
L2-L4: Femoral nerve
L4-L5: lumbosacral trunk

Front 105

The ________ nerve pierces the psoas major muscle

Back 105

Genitofemoral nerve

Front 106

The ______ nerve passes medial to the psoas major muscle

Back 106

Obturator nerve

Front 107

Which nerves of the lumbar plexus innervate structures of the posterior abdominal region (i.e. they are not mixed nerves)?

Back 107

* Iliohypogastric nerve
* Ilioinguinal nerve
* Femoral nerve

Front 108

What are the visceral motor efferents (GVE) responsible for?

Back 108

Innervation of smooth muscles of viscera, vessels, and glands

Front 109

Sympathetic visceral nerves of the posterior abdominal wall are located at which spinal levels?

Back 109

Spinal levels T5-L2

Front 110

Parasympathetic visceral nerves of the posterior abdominal wall are located at which spinal levels?

Back 110

cranial n. X and spinal level S2 to S4

Front 111

What is the parasympathetic innervation of the vagus nerve?

Back 111

Most of GI tract & associated glands, kidneys, ureters

Front 112

What is the parasympathetic innervation of the plevic splanchnic nerves?

Back 112

descending colon & pelvic viscera

Front 113

What are the visceral sensory afferents responsible for?

Back 113

Pain or subconscious reflex from viscera

Front 114

What do sensory (visceral) fibers (anterior rami T5-S4) travel with?

Back 114

Autonomic fibers in splanchnic nerves

Front 115

Fibers carrying pain travel mostly with (a)_________ except at S2-S4 level where they travel with (b) _______ fibers

Back 115

a. Sympathetic (T5-L2)
b. Parasympthetic fibers

Front 116

For sympathetic innervation of viscera, glands, and vessels, fibers travel in _______ nerves

Back 116

Splanchnic nerves

Front 117

For sympathetic innervation of skin and vessels of skeletal muscles, fibers travel in ______ nerves

Back 117

Spinal

Front 118

Where do parasympathetic nerves synapse?

Back 118

On intrinsic parasympathetic ganglia or within viscera

Front 119

What are three characteristics of the sympathetic trunk/ paravertebral ganglia?

Back 119

1. Connected to spinal verves via grey and white rami communicantes
2. Conduit for pre & postganglionic sympathetic fibers and, visceral afferent fibers
3. Ganglia contain postganglionic soma of fibers going to skin & skeletal muscles

Front 120

What fibers do thoracic and lumbar splanchnic nerves carry?

Back 120

*Preganglionic sympathetic fibers
* Visceral afferent fibers

Front 121

What fibers fo the pelvic splanchnic and vagus nerves carry?

Back 121

* Preganglionic parasympathetic fibers
* Visceral afferent fibers

Front 122

What are the periarterial plexuses?

Back 122

Extension of the pre-vertebral plexuses- named after an artery.

Front 123

What are the pre-vertebral plexuses and where are they located?

Back 123

1. Celiac (solar)- around celiac trunk and SMA
2. Intermesenteric (aortic)-between SMA to aortic bifurcation
3. Superior hypogastric-at bifurcation of aorta

Front 124

What does the celiac plexus consist of and what does it receive?

Back 124

* Celiac , aorticorenal & superior mesenteric ganglia (contain sympathetic postganglionic soma)
* Receive thoracic splanchnic n. & vagus n.

Front 125

What does the intermesenteric plexus consist of and what does it receive?

Back 125

* Inferior mesenteric ganglia (contain sympathetic postganglionic soma)
* Receive lumbar splanchnic n. & vagus n.

Front 126

What does the superior hypogastric plexus receive?

Back 126

Receives pelvic splanchnic n. via inferior hypogastric plexus