THE TRACHEA (TRACHEA)
- it is a membraneous pipe wich connects the larynx with the lungs, having its
posterior surface flattened and being situated in front of esophagus and
deviated slighty to its right side
- it starts at the level of C6 vertebra (liggamentum crico-trachealis) and it ends
at Th4 vertebra (bifurcatio tracheae) and thus presents a cervical part and a
thoracic one, having a supero-inferior direction and a slighty oblique antero-
- at the level of Th4 it divides at approximately 80 degrees angle into the main
right and left bronchus (bronchus principalis dexter et sinister)
I. The COMPONENTS of the trachea are:
- cartilagines tracheales - the tracheal cartilages are incomplete arches
(in the posterior part of the trachea) in number of 18-20
- carina tracheae – it represents the last tracheal cartilage wich has
a “V” shape
- liggamenta trachealis (annularia) - the ligaments of the trachea wich
are situated in between the cartilages
- paries membranaceus - the membranous part of trachea is situated
posteriorly in between of the ends of the incomplete tracheal cartilages
- musculus trachealis - the tracheal (smooth) muscle wich is part of the
- the lumen of the trahea - the interior of the trachea is coated with
tunica mucosa wich incorporates glandulae tracheales
II. The TOPOGRAPHICAL RELATIONSHIPS of the trachea are:
- anterior - with arcus aortae, to the antero-right side with truncus
brachicephalicus and to the antero-left side with arteria carotis
communis sinistra and vena brachiocephalica sinistra
- posterior - with the oesopagus wich is situated slighty to the left side
of the trachea
- right - with vena cava superior, arcus venae azygos, nervus phrenicus
dexter and pleura medistinalis
- left - with arcus aortae, arteria carotis communis sinistra and nervus
laryngeus recurrens sinister
THE LUNGS (PULMOS)
- the lungs are pair organs situated in the pleural cavity
I. The lung presents:
- apex pulmonis - the tip of the lung wich exceeds the first rib with 2-3
- basis pulmonis - the base of the lung wich is concave lying on the
II. The SURFACES OF THE LUNG are:
- facies costalis – the costal surface is the lateral one and presents the
imprints of the ribs (impressio costales)
- facies diaphragmatica – the diaphragmatic surface is the inferior one
- facies medialis – the medial surface it is split into:
- pars vertebralis - the posterior smaller part
- pars medistinalis - the anterior bigger part wich presents:
- hilus pulmonis - the hilum of the lung wich is situated in
its upper third
- it presents imprints given by other anatominal structures
situated in direct contact with this surface:
- impressio cardiaca – the imprint of the heart wich is
present on both lungs and it is more accentuated on the left
lung and they are situated antero-inferior to the hilum
- sulcus arteriae subclaviae – the groove of the subclavian
artery wich is present on both lungs and it is situated antero-
superior to the hilum
- impressio venae cava superioris – the imprint of the
superior caval vein wich is situated anterior to the right hilum
- impressio arcus venae azygos – the imprint of the arch of
the azygos vein (wich comes from posterior to anterior) wich
is situated above of the right hilum
- impressio oesophageus – the imprint of esophagus wich is
situated in the inferior part of facies mediastinalis of the right
- impressio aorta descendens – the imprint of the
descending aorta wich is situated posterior to the left hilum
- impressio arcus aortae – the imprint of the arch of the
aorta (wich comes from anterior to posterior) wich is situated
above of the left hilum
- facies interlobaris – the surface situated in between the lobes
III. The MARGINS OF THE LUNG are:
- margo anterior – the anterior margin wich is situated in between the
costal and medial surfaces
- incisura cardiaca pulmonis sinistri - the cardiac notch of the left
lung is situated on the left anterior margin
- lingula pulmonis sinistri - the “lingula” of the left lung
represents the “process” of pulmonar tissue situated under the
lingula and oriented towards anteriorly
- margo inferior - the inferior margin wich is situated circumferentially
around the inferior surface
IV. The FISSURES OF THE LUNG are:
- fissura obliqua – the oblique fissure wich is present on both lungs and
it is situated on the costal surface; it starts posteriorly 6-7 cm under the
tip of the lung (at Th3 level) and goes towards antero-inferior part of the
lung along the costal surface, reaching the inferior margin near the
meeting point with the anterior margin; it will split each the lung into
lobus superior and lobus inferior
- fissura horizontalis pulmoni dextri – the horizontal fissure wich is
present only on the right lung and it is situated also on the costal surface;
it starts where the fissure oblique meets the 4th
rib (in the middle axillary
line) goes towards anterior margin along the 4th
rib; it will generate
(from the right superior lobe) the lobus medius pulmoni dextri
- each of the lung will contain 10 segments (the components of the lobes)
– each of them is considered a small lung, having a prismatic shape with
the tip oriented towards the hilum of the lung (and receving through this
tip a segmental bronchus and an artery) and the base of the segment being
oriented towards the surfaces of the lung (along the surfaces of the
segment are situated the segmental veins of it):
-the right lung presents 3 segments in the superior lobe
(segmentum apicale, anterius, posterius), 2 segments in the
medial lobe (segmentum mediale, laterale) and 5 segments
in the inferior lobe (segmentum superius, basale anterius,
basale posterius, basale mediale, basale laterale)
-the left lung presents 5 segments in the superior lobe
(segmentum apicale, anterius, posterius, lingulare
superius, lingulare inferius) and 5 segments in the inferior
lobe (segmentum superius, basale anterius, basale
posterius, basale mediale, basale laterale)
V. The HILUM OF THE LUNG:
- is situated in the upper third of the pars mediastinalis of the medial
surface and it is surrounded by the ligamentum pulmonare of
“Zenker” (the reflection of pleura medistinalis in pleura visceralis)
- anterior to the hilum lies the phrenic nerve
- posterior to the hilum lies the vagus nerve
- it represent the zone through the components of the pedicle of the lung
(radix pulmonis) enter/exit into/from the lung; the pedicle consists in:
- venae pulmonales - two pulmonary veins (superior et inferior)
for each lung, wich are going to be drained into the left atrium; they
contain the oxygenated blood coming from the peri-lobular
network, than from the segmental veins wich in the end are forming
the lobar veins and from here the pulmonal veins
- arteria pulmonalis dextra / sinistra (=vasa publica) - the main
right / left pulmonary artery wich are the two division branches of
the pulmonary trunk and they contain un-oxygenated blood wich
goes towards the lungs in order to be oxygenated
- bronchus principalis dexter / sinister - the main right / left
bronchus are the two division branches of trachea
- in the both hilums the order of these three components in
antero-posterior direction is V-A-B
- in the right hilum the order of these three components in
supero-inferior direction is B-A-V
- in the left hilum the order of these three components in
supero-inferior direction is A-B-V
- arteria bronchialis dextra / sinistra (=vasa privata) - the right /
left bronchial arteries wich are destined to vascularise the lung as
organ; they are situated on the posterior surface of the bronchus,
being branches of the thoracic aorta
- venae bronchiales dextrae / sinistrae - the right / left bronchial
veins wich are destined to drain the lung as organ – situated also on
the posterior surface of the bronchus and they are drained into the
azygos / hemiazygos system
- lymphatic vessels – they are draining the limpha from the two
networks of the lung: the superficial (under the pleura visceralis)
and the deep one (intrapulmonar)
- vegetative nervous networks – branches from the vagus nerve
(plexus anterior) and from the sympatic thoracic chain (plexus
posterior) wich are going into the lung along with the bronchial
a. The main bronchi:
- they are the result of the bifurcation of the trachea at approximately 80
degrees angle at the level of Th4
- the two main bronchus are united inferiorly under the bifurcation by the
“inter-bronchial ligament of Lushka”
- the main right bronchus (bronchus principalis dexter) it is shorter and
larger, being almost vertical in the axis of the trachea; it will be split into
the lung in three lobar bronchi corresponding to each lobe: bronchus
lobaris superior, medius et inferior dexter
- the main left bronchus (bronchus principalis sinister) it is longer and
thinner, being deviated to the left from the axis of the trachea; it will be
split into the lung in two lobar bronchi corresponding to each lobe:
bronchus lobaris superior et inferior sinister
- the lobar bronchi will split in 10 segmentar bronchi (bronchus
segmentalis) corresponding to each segment
- the segmentar bronchi will split in lobular bronchi (bronchus lobularis)
corresponding to each lobuli
- into the lobuli the lobular bronchi will split in bronchioli respiratorii,
wich will split at their turn in 2-3 ductuli alveolares wich will end with
sacculi alveolares wich are made from alveoli pulmonis (where the gas
exchange take place)
b. The main pulmonary arteries:
- they are the result of the bifurcation of the truncus pulmonalis
- the main right pulmonary artery (arteria pulmonalis dextra) it is longer
and larger, going almost transversally under the aortic arch towards the
right pulmonar hilum; it will split into the lung in two lobar arteries
(arteria lobaris superior et inferior dexter), the inferior one giving the
branch for lobus medius (arteria lobaris media)
- the main left pulmonary artery (arteria pulmonalis sinistra) it is shorter
and thinner, going above the right main bronchus towards the left
pulmonar hilum; in between the aortic arch and the initial portion of the
artery there is the “ligament arteriosum of Botallo”; it will split into the
lung in two lobar arteries (arteria lobaris superior et inferior)
It’s the most dilatated segment of the digestive tract, situated in the left hypocondrum, about 1300 ml
capacity, between the oesophagus and duodenum. The two major parts, the horizontal one and the
vertical one give the J shape aspect.
-paries anterior- is pointing to anterior and superior ;
-paries posterior- is pointing to posterior and inferior.
They are joint in two margins:
-curvatura ventriculi minor-the superior fusion of the two walls. On the inferior part a sudden
change of curve’s direction from vertically to horizontally is called incisura angularis
-curvatura ventriculi major-the inferior joint of the walls.
The entering in the stomach is bordered by the cardia – a sphincter muscle with one way valve
The exit from the stomach is delimited by the pylor with the same function.
The constitutive parts of the stomach: a bisecting line through the incisura angularis split the stomach
in two parts:
-pars verticalis (pars dygestoria): above
-pars cardiaca – a small part situated around the cardia with mucous glands in submucosa;
-fundus ventriculi – the part situated above the horizontal line through the cardia, rich in
hydrochloric acid secretory glands. Usually this part is full of air. The angle between the curvatura
ventricului major and fundus ventricului is called Incisura cardiaca or His angle.
-corpus ventriculi – the largest vertical part under the horizontal line through the cardia, with
hydrochloric acid secretory glands and pepsinogen secretory glands.
-pars horisontalis (pars egestoria): under
-antrum pyloricum – the last dilatated part of the stomach , where the ingested aliments are
prepared and waiting to be evacuated ( antrum means waiting room) ;
-canalis pyloricus- it’s a 1 cm length channel at the end of the stomach which contains the
pyloric muscle-the circular muscle layer development.
The interior aspect of the stomach:
-the folds of mucosa are called plicae villosae and delimit between them ariae gastricae.
-on the small curve, two developed longitudinal folds goes downwards and parallel from cardia to
pylor and bound a groove for the liquids flow – Waldayer highway.
-a wide thin fold – Gubarov’s valve - situated on the cardial region has an one way valve function.
The stomach layers:
-mucosa-the glandular epithelium lies on the thin muscular layer-muscularis mucosa. Also here are
developed the secretory glands, producing hydrochloric acid, pepsinogen, mucous and gastrin.
-submucosa – contain collagen fibres, vessels and autonomic nerves (plexus Meissner).
-the muscular layer:
-the inner one- oblique fibres, surrounding the stomach
-the middle one – the circular muscle layer which is more developed at the sphincter regions.
-the outer one-the longitudinal muscle layer, more developed at the curves regions;
-serosa-the peritoneum which cover the stomach.
The topography of the stomach:
-the anterior wall is pointing to the abdominal wall.
-Labbe’s triangle – bordered by the inferior margin of the liver, the inferior left margin of the
thoracic wall and a horizontal line through the 9th
-spatium semilunare Traube- a semilunar space on the left lateral thoracic wall with the top of
the arch at the 5th
-the posterior wall is pointing to bursa omentalis.
The arteries of the stomach are organised along the two curves as two anasomotic arches. They are
directly or indirectly branches of the truncus celiacus.
-a.gastrica sinistra – the most important branch, arises from truncus celiacus and is situated on the
superior part of the small curve;
-a.gastrica dextra – branches from a.gastroduodenalis (from a.hepatica communis) and lies on the
inferior part of the small curve;
-a.gastroepiploica sinistra – is situated on the superior part of the large curve. Is a small branch of
-a.gastroepiploica dextra – branches from a.gastroduodenalis and is situated on the inferior (right)
part of the large curve.
-aa.gastricae breves – a few branches from arteria lienalis to fundus ventriculi.
The veins of the stomach have the same disposition and drain in the portal system:
-v.gastrica sinistra and dextra drains in vena porta;
-v.gastroepiploica sinistra-drains in v.lienalis;
-v.gastroepiploica dextra – drains in v.mesenterica superior;
-vv.gastricae breves-drains in vena lienalis
A small branch of v.gastrica sinistra is connected with the caval system (v.azygos) in the lower part of
the oesophagus ( here is the site of the oesophageal varix in liver chirossis)
The lymph is drained in:
-nodi lymphatici gastrici dextri et sinistri;
-nodi lymphatici gastroepiploici dextri;
-nodi lymphatici pylorici;
-nodi lymphatici pancreaticolienalis;
-nodi lymphatici celiaci.
The autonomic nerves are:
-sympathetics: enter in the stomach layers around the arteries;
-parasympathetics: belong to the vagus nerves, with a very important role in hydrochloric acid
The two autonomic systems are organised into the stomach layers in:
-plexus submucosus Meissner;
-plexus myentericus Auerbach.
1. The duodenum
It’s a horseshoe shape organ, about 25-30 cm length, situated in continuation of the stomach.
-pars superior-bulbus duodenalis-is between the duodenopyloric groove (where vena pylorica is
situated) and superior duodenum’s knee-flexura duodenalis superior;
-pars descendens-the second part, between flexura duodenalis superior and flexura duodenalis
-pars horisontalis-intersect the spine at L4 level and cross in the left side;
-pars ascendens – the last part, until the duodenojejunal flexure
-flexura duodenojejunalis or the Treitz angle , the starting point of the jejunum.
The flexure is sustained by a small muscle-musculus Treitz, which arises from the left pillar of
diaphragm and aorta abdominalis.
The layers of duodenum:
-mucosa-the inner layer , made by glandular epithelium and under it, muscularis mucosae.
-submucosa-contains glands specific to duodenum-glandulae duodenales with mucous secretion. Also
here are the nerves of plexus submucosus Meissner;
-tunica muscularis: circular and longitudinal fibres. Also contain the plexus myentericus Auerbach.
-serosa (adventitia): only the first part of duodenum is situated inside the peritoneal cavity and is
covered by peritoneum. The rest of it is in retroperitoneum. A peritoneal fold, situated behind of the
Treitz’ angle, split the space between the last part of duodenum and the posterior peritoneum in two
parts: recessus retroduodenalis superior et inferior.
The internal aspect of duodenum;
Due to muscularis mucosae, the inner layer appear life circular folds, named Plicae circulare
-on the posterior wall of pars descendens a vertical fold is the mark of the choledocus situated
-also in pars descendens on the medial wall, there are two little perforated mucosal projections:
-papilla duodeni major-the opening of the choledocus and Wirsung channel in duodenum;
-papilla duodeni minor-the opening in duodenum of ductus Santorini (canalis pancreatis
The blood supply will be presented at the pancreas.
The autonomic nerves arise from plexus celiacus (sympathetic part) and from vagus nerves
(parasympathetic part), forming the two inner layer plexus:
-plexus submucosus Meissner;
-plexus mientericus Auerbach.
2. The pancreas
It’s a double function gland: endocrine and exocrine situated profound, behind the stomach.
The parts of pancreas:
-Head – caput pancreatis - is situated in the duodenal frame and presents two surfaces:
-facies anterior-points to bursa omentalis and through it, to the posterior wall of the stomach. It is
split by the mesocolon insertion in a supramesocolic and inframesocolic parts. A small pancreatic
tissue called processus uncinatus, borders with the inferior part of the head the pancreatic notch
(incisura pancreatica). Inside of it lies artera and vena mesenterica superior.
-facies posterior-points to the retroperitoneum. Behind the pancreas and duodenum is stretching
the fascia retroduodenopancreatica Treitz. Through it, the pancreas borders with the following
-vena cava inferior;
-the right kidney and the suprarenal gland
-Neck - Collum pancreatis– is a small narrowing part between the head and corpus
-Body - Corpus pancreatis– presents three margins:
-margo superior – is bordering by the splenic artery ;
-margo anterior-represents the insertion of the transverse mesocolonum;
-margo inferior (posterior)
-and three surfaces:
-facies anterior-points to bursa omentalis;
-facies posterior-points to retroperotoneum(aorta abdominalis, vena renalis sinistra, vena
-facies inferior-points to the inframesocolic region.
- Tail - Cauda pancreatis- is situated on the left in front of the kidney and suprarenal gland and is
continued by the pancreaticolienalis ligament which is the spleen’s vascular pedicle.
The endocrine function consists of insulin and glucagon secretion by the alpha and beta pancreatic
The exocrine function consists in enzymes secretion in two collecting channels:
-Wirsung duct-canalis pancreatis principalis – cross the entire gland and is opened with
choledocus in papilla duodeni major;
-Santorini duct-canalis pancreatis accesorius-crosses only the superior part of the pancreatic
head and is opened in papilla duodeni minor. The connection with the Wirsung duct is variable.
Arteries of the pancreas:
-Head – has the same vascularisation with the duodenum. The two anastomotic arches situated in front
and behind the head (arcada pancreatis anterior et posterior ), have the following sources:
-a.pancreaticoduodenalis superior-branches from a.gastroduodenalis;
-a.pancreaticoduodenalis inferior-branches from a.mesenterica superior.
-Body and tail: due to a large variability, is almost individual. The most frequent pattern contain three
arteries: a.pancreatica magna, a.pancreatica dorsalis and a.pancreatica inferior. All of these are
anastomosis between a.mesenterica superior and a.lienalis.
The veins of the pancreas have the same distribution and drain in vena porta.
The lymph is drained in:
-nodi lymphatici hepatici-the head;
-nodi lymphatici celiaci-the body;
-nodi lymphatici pancreaticolienalis-the tail.
The nerves arise from plexus celiacus (sympathetic part ) and vagus (parasympathetic part).
3. The spleen (Lien)
It’s an ovoid shape organ, situated in the left hypocondrum. The dimensions are 12/8/4 cm.
The ovoid has two extremities and two margins:
-extremitas anterior-points to anterior and inferior;
-extremitas posterior – points to posterior and superior;
-margo superior-easy to recognized due to irregular shape;
The surfaces of the spleen:
-facies diaphragmatica-convex, points to diaphragm;
-facies visceralis-points to the abdominal cavity and internal organs:
-facies gastrica – superior;
-facies colica – inferior and anterior;
-facies renalis-inferior and posterior;
-hillus lienis – is situated between the three surfaces contains artera and vena lienalis.
The spleen’s ligaments
-ligamentum gastrolienale-is the left lateral part of omentum majus. Arteriae et venae gastricae
breves cross the ligament and provides the blood supply for the fundus ventriculi.
-ligamentum phrenicolienalis-maintain the spleen stick to the diaphragm;
-ligamentum pancreaticolienalis-contain the spleen vessels
-ligamentum phrenicocolicum sinistrum- the spleen lies on this ligament –this is the reason why
it is called sustentaculum lienalis.
The blood supply is provided by the artera lienalis, a branch of truncus celiacus, it is situated first
on the superior margin of the pancreas body and enter in ligamentum pancreaticolienalis;
Vena splenica drains in vena porta;
The lymph is drained in nodi lymphatici pancreaticolienalis;
The nerves arise from plexus celiacus and vagus.
THE PERICARD (PERICARDIUM)
- it is a membranous sac wich contains in interior the heart and the main
vessels from the base of the heart
I. The COMPONENTS of the pericardium are:
- pericardium fibrosum – the fibrotic pericardium wich is the external
- pericardium serosum – the seros pericardium wich is the internal thinner
layer wich is made by two components:
-lamina parietalis – the parietal part wich is coating the internal
side of the fibrotic pericardium
-lamina visceralis (=epicardium) – the visceral part wich is
coating the external side of the muscle of the heart (=myocardium)
- so this layer is called epicardium
- cavum pericardii – the cavity of the pericardium (virtual) wich is situated
in between the two components of the pericardium serosum
- liquor pericardii – the liquid of the pericardium, in cuantity of
approximately 20g wich has the role of lubrifiyng the surfaces wich are
coming in contact durig the movements of the heart
II. The TOPOGRAPHICAL RELATIONSHIPS of the pericardium are:
- anterior - with the thymus (superiorly), the sternum (inferiorly) -here
presenting ligg. sterno-pericardica - and with the 4-6th
- posterior - with the oesophagus
- right and left - with pleura mediastinalis on each side and through it
with the medistinal surface of each lung
III. The CONTENT of the pericardium is made by:
- cor – the heart wich is completely included into the cavity of the
- aorta ascendens – the ascending aorta on wich pericardium extents until
the limit with the aortic arch (approximately 1,5 cm below the origin of
the brachio-cephalic truncus)
- truncus pulmonalis – the pulmonary trunk wich is completely included
- vena cava superior – the superior caval vein wich is almost completely
included (under the level of confluence of the azygos vein)
- vena cava inferior – the inferior caval vein wich has its entire supero-
diaphragmatic portion included
- venae pulmonales – the four pulmonal veins (two from right and two
from the left lung) wich have their distal portion included
- due to this inclusion/encircling of these vessels the pericardium presents
dorsally a reflection line (from lamina visceralis into lamina parietalis)
wich has a horizontalized “T” shape with its vertical part starting from
vena cava inferior, going up to the right pulmonary veins and from here to
vena cava superior, and the horizontal part starting from the right
pulmonary veins and going towards the left side to the left pulmonal veins
-in between the reflection line situated in between vena cava
inferior and the right pulmonal veins on one side, continued to the
left pulmonal veins on the other side, there will be a “closed” part
of the cavity of the pericardium called sinus obliquus of “Haller”
-in between the reflection line situated in between vena cava
superior and the right and left pulmonal veins on one side, and the
aorta acendens and truncus pulmonalis on the other side, there will
be a “open” part of the cavity of the pericardium called sinus
transversus of “Theile”
IV. The A-V-N package of the pericardium is made by:
- arteries – a. pericardio-phrenica (branch from a. mamaria interna)
- smaller branches from different sources: aorta descendens, a.
phrenicae superiores, a. eophageales, a. bronchiales
- veins – they are drained into the internal mammary veins and into the
superior phrennic veins
- nerves – branches from n. phrenicus, n. vagus and from the symphatic
- lympha – is drained through a superficial and a deep networks
THE HEART (COR)
- the heart is an organ situated in the pericardial cavity cavity, having a
asymmetrical position related to the medio-sagital plane of the body with two
thirds situated to the left and one third situated on the right side of it
I. The EXTERNAL CONFIGURATION of the heart:
- atrium cordis - the atria of the heart, in numbers of two (right and left),
- ventriculus cordis - the ventricle of the heart, in numbers of two (right
and left), situated inferiorly
- sulcus coronarius – the coronar groove is situated in between the atrias
and the ventricles
- sulcus interventricularis anterior - the anterior inter-ventricular
- sulcus interventricularis posterior - the posterior inter-ventricular
- incisura apicis cordis – the notch of the tip of the heart wich results
from the antero-inferior meeting of the two interventricular grooves
- apex cordis – the tip of the heart situated antero-inferiorly on the left
side of the incisura apicis cordis (belongs to the left ventricle)
- basis cordis - the base of the heart wich is situated supero-posteriorly
and it is made from the atrias and the proximal part of the big vessels
- auricula dextra – the right auricle represents an appendage of the right
- auricula sinistra – the left auricle represents an appendage of the left
II. The SURFACES OF THE HEART are:
- facies sterno-costalis – the sterno-costal surface is the anterior one
being made almost entirely from the right ventricle and right atrium
(3/4) and the left ventricle with the apex (1/4), the limit in between them
being sulcus interventricularis anterior
- on this surface we find the right auricle, truncus pulmonalis, aorta
ascendens, the distal portion of the left auricle
- facies diaphragmatica – the diaphragmatic surface is the inferior one
being made by the right ventricle and a small part of the right atrium
(2/5) and the left ventricle (3/5), the limit in between them being sulcus
- facies pulmonalis (dextra et sinistra) – the lateral surfaces being made
on the right side by the right atrium and the right auricle, and on the left
side by the left ventricle, the left auricle and a small part of the left
III. The MARGINS OF THE HEART are:
- margo obtusa – the obtuse margin wich is rounded and situated in
between the sterno-costal surface and the left pulmonal surface
- margo acuta - the margin wich is situated sharper and situated in
between the sterno-costal surface and the right pulmonal surface
IV. The CHAMBERS OF THE HEART – are coated on their inner surface by
a thin layer of cells called endocardium:
- ATRIUM DEXTRUM – the right atrium has a cuboidal shape and
- sinus venarum cavarum – the posterior part wich receives the
blood from the two caval veins
- atrium primitivum – the anterior part
- crista terminalis – the terminal crest wich is situated endo-
atrially and represents the border in between these two parts
- sulcus terminalis – the terminal groove wich is situated exo-
atrially and represents the external correspondence of crista
- auricula dextra – the right auricle wich is a anterior-oriented
appendage of the atrium primitivum, being larger and blunter than
the left auricle
- musculi pectinati – the “comb” muscles are oriented from crista
terminalis towards the right atrio-ventricular orifice and auricular
- ostium venae cavae superioris – the orifice of the superior caval
vein is situated superiorly
- ostium venae cavae inferioris – the orifice of the inferior caval
vein is situated inferiorly and presents a embrionar reminiscence:
valvula venae cavae inferioris of “Eustachio”
- tuberculum inter-venosum of “Lower” – the inter-venous
tubercle wich is situated posteriorly in between these two orifices
- ostium sinus coronarii - the orifice of the coronary sinus is
situated on the inferior wall and presents a embrionar reminiscence:
valvula sinus coronarii of “Thebesius”
- fossa ovalis – the oval fossa is situated on the medial wall (= the
common wall of the two atrias = inter-atrial septum) and presents a
border: limbus fossae ovalis
- foramina venarum minimarum – the orifices of the small veins
of “Thebesius” wich are situated near the inter-atrial septum
- ATRIUM SINISTRUM – the left atrium has a more rounded shape
- ostia venarum pulmonalium – the orifices (4) of the pulmonar
veins wich are situated in two groups of two (superior and inferior)
on the right and on the left side of the atrium
- auricula sinistra – the left auricle wich is a anterior-oriented
appendage of the atrium primitivum, being thinner and sharper than
the right auricle
- valvula foraminis ovalis (= falx septi) – the valvula of the oval
fossa is situated on the medial wall (= the common wall of the two
atrias = inter-atrial septum) in the corresponding area of fossa ovalis
- VENTRICULUS DEXTER – the right ventricle has thin wall being
situated like a pocket attached to the left ventricle and presents:
- “the filling chamber” – represents the main part of the right
ventricle being situated inferiorly and towards the right side under
the right atrio-ventricular orifice; presents on the interior surface
muscular trabeculas (trabeculae carnae) of myocardium
-the “evacuation chamber” (= conus arteriosus = infundibulum)
– the infundibulum is situated superiorly and towards the left side
and presents on the interior surface muscular trabeculas less
accentuated than those from the filling chamber
- crista supraventricularis – the supraventricular crest is a bigger
muscular trabecula and represents the border in between these two
parts of the right ventricle
- trabecula septo-marginalis – the septo-marginal crest is an other
muscular trabecula situated into the filling chamber in between the
muscular part of the interventricular septum and the free wall of the
- ostium atrio-ventricularis dextrum – the right atrio-ventricular
orifice wich is situated in between the right atrium and ventricle
- valva atrio-ventricularis dextra (= valva tricuspidalis) – the
right atrio-ventricular valve wich is situated into the corresponding
orifice, being made from three parts (= cuspsis anterior, posterior
et septalis); each of these cusps will be connected by tendineous
chords (chordae tendineae) to the corresponding papillar muscles
(m. papillaris anterior, posterior et septalis) of the right ventricle
- ostium trunci pulmonalis – the orifice of truncus pulmonalis
wich is situated at the end (superior) of the infundibulum
- valva trunci pulmonalis – the valve of truncus pulmonalis wich
is situated into the corresponding orifice, being made from three
“pocket-like” parts with a semilunar shape (valvula semilunaris
anterior, dextra et sinistra); each of these valvula presents a free
margin called lunula (lunulae valvulae semilunaris) wich has in the
middle point a fibrotic nodule (nodulus valvulae semilunaris of
- VENTRICULUS SINISTER – the left ventricle has thick wall having
a conic shape and presents:
- “the filling chamber” – represents the part of the left ventricle
wich is situated inferiorly and to the left side under the left atrio-
ventricular orifice and presenting on the interior surface muscular
trabeculas wich are smoother than those of the right ventricle the
-the “evacuation chamber” – represents the part of the left
ventricle wich is situated superiorly and to the right side and
presents the interior surface smoother compare with that one from
the filling chamber
- ostium atrio-ventricularis sinistrum – the left atrio-ventricular
orifice wich is situated in between the left atrium and ventricle
- valva atrio-ventricularis sinistra (= valva bicuspidalis = valva
mitralis) – the left atrio-ventricular valve wich is situated into the
corresponding orifice, being made from two parts (cuspsis anterior
et posterior); each of these cusps will be connected by tendineous
chords (chordae tendineae) to the corresponding papillar muscles
(m. papillaris anterior et posterior) of the left ventricle
- ostium aortae – the orifice of aorta wich is situated at the end
(superior) of the evacuation chamber
- valva aortae – the valve of aorta wich is situated into the
corresponding orifice, being made from three “pocket-like” parts
with a semilunar shape (valvula semilunaris dextra, sinistra et
posterior); each of these valvula presents a free margin called lunula
(lunulae valvulae semilunaris) wich has in the middle point a
fibrotic nodule (nodulus valvulae semilunaris of “Arantius”); in
between each of these valvulas and the aortic wall there is a space
called sinus of “Valsalva”
V. The ARTERIES OF THE HEART – named coronary arteries and they are
situated under the epycardium, having a sinuous course and giving branches that
will go profound into the myocardium:
- Arteria Coronaria Dextra – the right coronary artery
-originates from the right sinus of Valsalva of the aortic valve and
goes towards the right side into the coronary groove under the right
auricle, than around the base of the right ventricle reaching sulcus
interventricularis posterior where it gives its terminal branch:
- ramus interventricularis posterior – the posterior inter-
- it vascularises the right atrium, the inferior 1/2 part of the inter-
atrial septum, Keith-Flack nodule (rami nodus sino-atrialis), the
right ventricle, the posterior 1/3 of inter-ventricular septum, the
para-septal area of the left ventricle, the posterior papillar muscle of
the mitral valve
- Arteria Coronaria Sinistra – the left (main) coronary artery
-originates from the left sinus of Valsalva of the aortic valve and
goes towards the left side into the coronary groove in between the
left auricle and truncus pulmonalis, and after a short (main)
segment it divides in two branches:
- ramus interventricularis anterior – the anterior inter-
ventricular branch wich goes in sulcus inter-ventricularis
anterior, than in incisura apicis cordis towards sulcus
- ramus circumflexus – the circumflex branch wich goes
towards the left side into the coronary groove under the left
auricle, than around the base of the left ventricle giving
branches on the postero-lateral surface of it
- it vascularises the left atrium, the superior 1/2 part of the inter-
atrial septum, the left ventricle, the anterior 2/3 of inter-ventricular
septum, the para-septal area of the right ventricle, the anterior
papillar muscle of the mitral valve
VI. The VEINS OF THE HEART:
- approximately 60% of the blood of the heart is drained towards the
coronary sinus (sinus coronarius) wich is situated on the diaphragmatic
surface of the heart and has a “funnel” shape (starting at the meeting point
in between the big cardiac vein and the vena of “Marshall”); it is drained
at its turn into the right atrium
- vena cordis magna – the big cardiac vein comes from the apical
area being situated into the anterior inter-ventricular groove and
goes upwards into the coronary groove under left auricle around the
base of the left ventricle; it will be drain into the left extremity of
the coronary sinus
- vena cordis media – the middle cardiac vein comes from the
apical area being situated into the posterior inter-ventricular
groove; it will be drain into the coronary sinus
- vena cordis parva – the small cardiac vein comes from the righr
side being situated into the coronary groove and goes under right
auricle and around the base of the right ventricle; it will be drain
into the right extremity of the coronary sinus
- vena posterior ventriculi sinistri – the posterior vein of the left
ventricle comes from the postero-lateral area of the left ventricle; it
will be drain into the coronary sinus
- vena obliqua atrii sinistri of “Marshall” – the posterior vein of
the left atrium comes from the posterior area of the left atrium; it
will be drain into the the left extremity of the coronary sinus (at the
meeting point of this vein with the big cardiac vein it will starts the
coronary sinus wich presents here an embrionar reminiscence:
“valvula of Vieussens”
- the rest of 40% of the blood of the heart is drained directly into the
cardiac chambers through:
- venae cordis anteriores – the anterior cardiac veins wich are
situated on the anterior surface of the right ventricle and they are
going to be drained into the right atrium
- venae cordis minimaes – the minimal cardiac veins wich are
situated on the surface of the atriums and they are going to be
drained into the right (mainly) or left atrium
VII. The CONDUCTING SYSTEM OF THE HEART – is made by special
cells situated in groups (wich are connected in between them by specific
pathways); these cells can generate and conduct electrical impulses wich are
going to give the contraction stimulus to the heart:
- nodus sino-atrialis of “Keith-Flack” – the sino-atrial node situated
anteriorly at the confluence in between the vena cava superior and right
- nodus atrio-ventricularis of “Aschoff-Tawara” – the atrio-ventricular
node situated inferiorly near the orifice of the coronary sinus into the right
- fasciculus atrio-ventricularis of “His” – the atrio-ventricular bundle
goes inferiorly through the right fibrous triangle near the membraneous
part of the inter-ventricular septum, being split in:
- crus dextrum – the right part situated in the right side of the
- crus sinistrum – the left part situated in the left side of the inter-
- rete of “Purkinje” – the network wich derives from the right and the
left parts and it will be distributed into the myocardium of the ventricles
VIII. The SEPTUMS OF THE HEART – are the walls that are separating the
chambers of the heart:
- septum atrio-ventricularis – the atrio-ventricular septum is the wall
situated in between the two atrias on one side and the two ventricles on
the other side; it contains the ostiums of the two atrio-ventricular valves
and it is placed in the transversal plane
- septum interatriale – the inter-atrial septum is the common wall (the
medial one) of the atrias, being placed in the sagital plane
- septum interventriculare – the inter-ventricular septum is the common
wall (the medial one) of the ventricles, being placed also in the sagital
plane and having two parts:
- pars membranacea – the membraneous part wich is the superior
one; due to the different levels of insertion of the atrio-ventricular
valves (the tricuspid valve being placed more distally), this
membraneous part will present two components:
- the atrio-ventricular component of the membraneous part
(wich is the superior component, being placed above the
level of insertion of the tricuspid valve) wich is situated in
between the right atrium and the left ventricle
- the inter-ventricular component of the membraneous part
(wich is the inferior component, being placed under the level
of insertion of the tricuspid valve) wich is situated in
between the right ventricle and the left ventricle
- pars muscularis – the muscular part wich is the inferior one and
being situated under pars membranacea, in between the right
ventricle and the left ventricle
IX. The FIBROUS SKELETON OF THE HEART – has the role of support
for different components of the heart structure:
- annuli fibrosi – the fibrotic annuluses wich have the role of “ring” for
the insertion for the cusps of the atrio-ventricular and semilunar valves
- trigonum fibrosum dextrum – the right fibrotic triangle wich is
situated posteriorly in between the mitral valve (anterior cusp), the
tricuspid valve (septal cusp) and the aortic valve (posterior semilunar
valvula); it is perforated by the “His” bundle and presents two expansions:
- tendo coni arteriosi – goes on the posterior surface of the
- tendo of “Todaro” – goes towards the atriums and to the
membraneous part of the inter-ventricular septum
- trigonum fibrosum sinistrum – the left fibrotic triangle wich is situated
anteriorly in between the mitral valve (anterior cusp) and the aortic valve
(left semilunar valvula)
X. The LYMPHATIC DRAINAGE AND INERVATION OF THE HEART:
- lymphatic vessels – they are draining the limpha from the three
networks of the heart: the under-epicardic, myocardic and under-
endocardic; in the end small leyphatic vessels deriving from these
networks are going along the coronary vessels to the anterior medistinal
- vegetative nervous networks – branches from the vagus nerve and
from the sympatic thoracic chain wich are going into the lung along with
the coronary vessels (plexus coronarius)
The abdominal wall
It’s a complex structure composed by muscles, aponeurosis and bones situated around the abdominal
The distribution of the walls:
-superior: the diaphragm;
-inferior: the pelvic diaphragm-m.levator ani;
-anterior and lateral:
-the paravertebral muscles;
The posterior wall will be studied in “The back muscles”
The abdominal wall muscles
1. M obliqus externus-the outer muscle. Its fibres go downwards and forwards .The muscular part is
situated only laterally and is continued medially by the aponeurosis musculi obliqus externus.
O : the surface of the 5th
ribs. The origin of obliqus internus intersects the fibres of m.serratus
I: crista iliaca;
N: nn.intercostales 6-12 , n.iliohypogastricum , n.ilioinguinalis.
A: rotates the thorax to the opposite side;
lateroflexion of columna vertebrae.
2. M.obliqus internus – the middle one with the direction of the fibres upwards and forwards. Like
the previous one, the muscular part is situated only laterally and is continued medially by the
aponeurosis musculi obliqus internus. The inferior margin free of any insertions is called Arcus
tendineus muscului obliqus internus, part of tendo conjuctivus.
O : crista iliaca;
I : the surface of the 10th
N : nn.intercostales 10-12, n.iliohypogastricum, n.ilioinguinalis.
A : rotates the thorax to the same side;
lateroflexion of columna vertebrae.
respiration muscle (the exhale phase)
3. M.transversus abdominis- the inner muscle of the abdominal wall with horizontal direction of the
fibres. The limit between the muscular part (laterally) and the aponeurotic part (medially) is a vertical
line – linea semilunaris Spiegel. The inferior free margin is the other part of tendo conjuctivus – Arcus
tendineus musculi transversus abdominis.
O : the inner surface of the 7th
I : linea alba
N : nn.intercostales 6-12 , n.iliohypogastrum , n.ilioinguinalis.
A : respiration muscle (the most important in the exhale phase).
4. M.rectus abdominis – situated medially, with 4-5 intermediate tendons between the origin and
insertion – intersectiones tendinea. They are situated into a sheath – vagina musculi rectus abdominis.
O : the external surface of the 5th
ribs and processus xiphoideus;
I : simphysa pubica
N : nn intercostales 6-12;
A : respiration muscle (the exhale phase)
increase the abdominal pressure.
5. M.Pyramidalis-a small inconstant triangle shape muscles situated in the lower part of the rectus
O : simphysa pubica;
I : linea alba;
N: n.intercostales 12;
The abdominal wall conjunctive structures
1. Ligamentum inguinale – represents the inferior part and also insertion of m.obliqus externus
stretched between spina iliaca anterior superior and tuberculum pubis.
-The medial insertion on pubis is complex, composed of three pillars:
-crus laterale - between this two pillars are connecting fibres -Fibres intercrurales
-crus posterior-ligamentum reflexum Colles – the fibres from the two sides are intersected on
the superior surface of symphisa pubica.
-The three pillars delimit the superficial ring of the inguinal channel.
- In the angle between ligamentum inguinale and ramus superior osis pubis the arched fibres are called
Ligamentum lacunare Gimbernat.
-The pectineal muscle’s fascia which lies on the pecten osis pubis with ligamentum Gimbernat and
Thomson’s ligament fuse in ligamentum pectineale Cooper.
2. Linea alba-an aponeurotic raphe between processus xiphoideus and symphisa pubica and
represents the fusion of all aponeuroses on the median line. The inferior insertion is wide –
adminiculum lineae albae. In the middle is perforated by the anulus umbilicalis. Up to it, linea alba is
thinner than under it.
3. Vagina musculi rectus abdominis-is an aponeurotic sheath of rectus abdominis muscles with two
laminas (anterior et posterior).
In the upper part of the abdomen (2/3 superior) the disposition of the aponeurosis is:
-lamina anterior-aponeurosis musculi obliqus externus;
-the anterior splitting of obliqus internus aponeurosis;
-lamina posterior-the posterior splitting of obliqus internus aponeurosis;
-aponeurosis musculi transversus abdominis;
Lower (1/3 inferior) the disposition is changed:
-lamina anterior: - aponeurosis musculi obliqus externus;
- aponeurosis musculi obliqus internus;
- aponeurosis musculi transversus abdominis;
-lamina posterior : -fascia transversalis.
The two types of disposition are separated by an arcuate line-Linea arcuata Douglas.
On the lamina anterior are inserted the Intersectiones tendinea of m.rectus abdominis.
The arteries of the abdominal wall
There are two systems of arteries for the abdominal wall blood supply:
The transversal system-the arteries arise from laterally and goes to linea alba.
-aa.intercostales posterior 10-11;
The longitudinal system
-a.epigastrica superior: branch of a.thoracica interna, perforates the diaphragm through the Larrey’s
hiatus, then enters into the rectus abdominis sheath and lies on the lamina posterior;
-a.epigastrica inferior: branch of a.iliaca externa, is situated first in the preperitoneal space –
ligamentum ombilicale laterale and then perforates the lamina posterior of rectus abdominis sheath.
Inside of it conect the ending part of a.epigastrica superior, resulting the epigastric anastomosis.
Branches of a.epigastrica inferior:
-ramus obturatoria-with the homonim branche from a.obturatoria (a.iliaca interna) form an
important anastomosis under the ramus superior osis pubis called corona mortis (the death’s arch) due
to severe bleedings in the past during the surgical interventions for femoral hernia repair;
-a.cremasterica – enter into the spermatic cord;
-a.circumflexa iliaca profunda – upwards and laterally.
The veins of the abdominal wall
The veins of the abdominal wall represent a wide anastomotic system between the major venous
systems: vena cava superior, vena cava inferior and vena porta.
The superior caval system tributary veins:
-vv intercostales 10-11 – drains in vena azygos and hemiazygos;
-v.subcostales - drains in vena azygos and hemiazygos;
-vv.lumbales 1-2 : - drains in vena azygos and hemiazygos;
-v.epigastrica superior – drains in vena subclavia.
The inferior caval system tributary veins:
-vv.lumbales 3-5 – drains directly in vena cava inferior;
-v.epigastrica inferior-drains in vena iliaca externa;
The portal system tributary veins:
-vv.periombilicales-are spiraling around the ligamentum teres hepatis.
Between the three systems result anastomosis which are very important in some conditions:
-the cavo-caval anastomosis;
-the porto-caval anastomosis (the jellyfish head sign).
The lymphatic drainage of the abdominal wall
-The superior part of the wall drains in the axillary and mediastinal lymph nodes;
-The inferior part of the wall drains in the inguinal lymph nodes and iliacus externus.
The nerves of the abdominal wall
-provide the motor innervation for the abdomen muscles and the sensitive innervation for the skin and
-Nn.intercostales 6-8: for the superior part of the abdominal wall, goes medially, forwards and
upwards, resulting three curves with a superior concavity.
-N.intercostalis 9: for the medial part of the abdominal wall, goes forwards keeping its horizontal
-Nn.intercostales 10-12: for the inferior part of the abdominal wall, goes forwards and downwards,
resulting in three curves with inferior concavity.
-N.iliohypogastricus-branch of plexus lumbalis, lies on the m.obliqus internus. Gives motor branches
for the abdominal muscles and sensitive branches for the inferior part, the hypogastric region, after it
perforates the aponeurosis of m.obliqus externus.
-N.ilioinguinalis – arises from the same plexus, is situated between m.obliqus internus and
m.transversus abdominis. In canalis inguinalis, it is attached to the spermatic cord .Gives motor and
sensitive branches: Nn scrotales anteriores or Nn labiales anteriores
-N.genitofemuralis:the genital branch is attached to the spinal cord and gives sensitive branches for the
The topography of the abdominal wall
Using three imaginary lines the abdominal wall is divided in nine different regions.
-linia bisubcostalis-a horizontal line tangent to the inferior arch of the 10th
-linia supracristalis-a horizontal line tangent to the highest points of the crista iliaca;
-linia pararectalis-a vertical line tangent to the lateral margin of m.rectus abdominis.
-the horizontal lines divide the abdominal wall in three compartments (superior, median, inferior) and
the two vertical lines split every compartment in three regions.
The superior compartment:
1. Regio hypocondrica dextra;
2. Regio epigastrica;
3. Regio hypocondrica sinistra;
The median compartment:
4. Regio lateralis dextra;
5. Regio umbilicalis;
6. Regio lateralis sinistra;
The inferior compartment:
7. Regio inguinalis dextra;
8. Regio hypogastrica;
9. Regio inguinalis sinistra.
The interior aspect of the abdominal wall
-covered by the peritoneum, the inside view of the abdominal wall presents folds and ligaments, most
of them embryonic rests. The center of all the folds is anulus umbilicalis.
The downwards folds:
-Plica umbilicalis mediana – a fold which contains ligamentum umbilicalis medius – the fibrotic
transformation of urachus.
-Plica umbilicalis medialis – laterally, contains ligamentum umbilicalis medialis – the fibrotic
transformation of the aa.umbilicales.
-Plica umbilicalis lateralis – more laterally, contains the inferior epigastric vessels, covered by the
The upward fold:
-Ligamentum teres hepatis-betweeen the anulus umbilicalis and incisura hepatica, represents the
fibrotic transformation of the vena umbilicalis.
-situated on each sides above the ligamentum inguinalis is a 4-5 cm length channel.
The direction is parallel with the inguinal ligament.
The channel has two rings, four walls and the content.
-Anulus inguinalis profundus-is situated at 2 cm above to the middle point of ligamentum inguinalis ,
bordered medially by the inferior epigastric vessels and ligamentum Hasselbach.
-Anulus inguinalis superficialis-situated at 2 cm above and laterally to the tuberculum pubicum is
bordered by the pillars of ligamentum inguinalis : crus mediale , crus laterale , fibres intercrurales and
posterior – ligamentum reflexum Colles.
Anterior- Aponeurosis musculi obliqus externus.
Inferior- Ligamentum inguinalis;
Superior- the two inferiors margins of the m.obliqus internus and transversus abdominis-arcus
tendineus musculi obliqus internus, arcus tendineus musculi transversus abdominis. Sometimes these
margins are fused into a tendon called tendo conjunctivus or falx inguinalis.
Posterior-fascia transversalis enforced by three ligaments:
-ligamentum interfoveolare Hasselbach-the insertion on the ligamentum inguinalis of
linia arcuata Douglas, is situated on the lateral border of anulus inguinalis profundus.
-ligamentum Henle-the tangent part of fascia transversalis to the tendo conjuctivus. Some
authors include ligamentum Henle in tendo conjuctivus or falx inguinalis;
-ligamentum Thomson-the fusion of the fascia transversalis with fascia iliopsoica , is
situated behind to ligamentum inguinalis and parallel to it.
Trigonum Hasselbach – a triangle on fascia transversalis, bordered by ligamentum Hasselbach,
ligamentum Henle and ligamentun inguinalis. It is considered the weakest part of the posterior wall,
the place of inguinals hernias.
The content of canalis inguinalis is different in men and women:
-the spermatic cord-funiculus spermaticus-contains the arteries, veins, nerves for the testes, ductus
deferens and the cremaster muscle.
-ligamentum teres uteri-a ligament that keeps the uterus in a normal position.
-is situated behind the vertical plane traced through the posterior wall of the trachea and pericardium;
-anterior: trachea and pericardium;
-posterior: columna vertebralis and the joints between the ribs and the vertebral bodies;
-lateral: the left and right pleura mediastinalis;
-superior: wide communication with the regions of the neck.
2. Aorta thoracica
3. Ductus thoracicus
4. Vena azygos et hemiazygos
5. Truncus sympathicus
A muscular tube by 25 cm length, part of the digestive tract, between the pharynx and the stomach.
-the cervical part: 5 cm length, from the pharynx (C4) to apertura thoracica superior (Th1) with a
slight disposition to the left.
-the thoracic part: 17 cm length, from apertura thoracica superior to the hiatus oesophageus of
diaphragma (Th9).The aortic arch and the left bronchus subdivide it in a retrotracheal part
(suprabronchus part) and a retropericardium part (infrabronchus part).The last one is fixed by two
muscles : m.bronchooesophageus and m.pleurooesophageus);
-the abdominal part:3 cm length , from the hiatus oesophageus to the cardia (the junction between with
Constrictions:-represent the mark of some structures situated nearby the oesophagus.
-cricoidian constriction-behind the cricoid cartilage of the larynx;
-bronchoaortic constriction-due to aortic arch and left bronchus;
-diaphragmatic constriction- the mark of the diaphragma piercing.
-in the frontal plane the oesophagus is situated first, on the cervical region, to the left, then in the
thorax it is pushed to the right by the aortic arch and finally, the last part, return on the left side, so
results three curves.
-in the sagittal plane the aspect is from posterior to anterior with one single curve anteriorly concave.
-like all the digestive tract, the oesophagus has four layers:
-Mucosa-the inner layer is composed of stratified squamous epithelium which lies on the muscularis
-Submucosa-contains small blood vessels, collagen and elastin fibres, mucous glands and the
-Tunica muscularis-a longitudinal outer part and a circular inner part. The last one, at the end of the
oesophagus, participates to the cardiac sphincter muscle.
-Adventitia: the outer layer, by the collagen and elastin fibres connects the oesophagus to the
-rami oesophagei from:
-directly from aorta;
-a.gastrica sinistra (a small branch which penetrates the hiatus oesophageus.
-the veins, organised in plexus perioesophageus, drains in v.thyroidiana inferior, vv.bronchiales ,
v.azygos , v.hemiazygos and v.gastrica sinistra. The last one is a part of the portal system and the rest
of the veins belong to the caval system. Therefore, the inferior veins of the oesophagus connect the
two major venous systems- portocaval anastomosis (shunt).This is the site of oesophageal varix in
-lymph is drained in nodi lymfatici cervicales profundae, tracheales, mediastinales and
-the sympathetic innervation -postganglionary fibres from truncus sympaticus.
-the parasympathetic innervations-nervus vagus.
-situated posteriorly to the oesophagus and also to the left side, from Th4 in continuation of aortic
arch, to the hiatus aorticus (Th10).
-Rr bronchiales-for nutritive vascularisation of the lungs;
-Rr mediastinales-for the mediastinal soft tissue.
-Aa. Intercostales posterior (3-11)-situated in the homolog intercostal spaces. The first two intercostal
arteries arise from truncus costocervicalis (from a.subclavia).
-each one gives the following branches:
-Rr dorsales-for the back muscles;
-Rr spinalis-for the transverse vascularisation of the spinal cord;
-Rr cutaneus lateralis et medialis-for the thoracic superficial layers;
-R.comunicans-with aa.intercostales anterior (from a.thoracica interna)
-A.subcostalis-for the inferior part of the thorax and the upper abdominal part.
-Aa phrenicae superiores-situated superior and posterior on the diaphragm (unlike the
a.pericardophrenica which is situated superior and anterior).
-a 30-35 cm length and 4 mm diameter vein-like tube;
-the lumbalis lymphatic trunks convey the lymph in an elongated lymph sac-Cisterna Chyli (Pecquet)
at L2 level.
-ductus thoracicus arises from cisterna chyli, at L2 level, goes upwards on the median line, perforates
the diaphragm through the hiatus aorticus and enters in the posterior mediastinum. Here, it first lies
between the aorta and azygos vein, then up the aortic arch, changes its direction to the left, behind the
oesophagus and finally enters into the left junction between the internal jugular vein and subclavian
vein (The Pirogov angle).
-collects the lymph from the inferior limbs, pelvis, abdomen, the left side of the thorax, the left
superior limb and head and neck.
-the right hemithorax and superior limb drains the lymph in the right lymph duct which enters in the
venous system in the same way as ductus thoracicus, but on the right side.
Venae azygos et hemiazygos
The azygos vein arises in the retroperitoneum, from the lumbalis veins, goes upwards piercing the
crus mediale of diaphragma, ascends on the right side of the aorta and enters in the superior vena cava
up to the right pulmonary pedicle (Th4).
-the azygos vein collects the intercostalis posterior veins 4-11, vena subcostalis, vena intercostalis
superior dextra(the common vein for the first three intercostales posteriores) , venae bronchiales and
The hemiazygos has the same trajectory like the azygos on the left side of the aorta, until the Th6-Th8
level where the hemiazygos vein crosses the median line and enters in vena azygos.
-the hemiazygos vein collects the intercostalis veins from 6-8 to 11 and the left subcostalis vein. The
intercostales posteriores 4-6 are collected by the hemiazygos accesoria. The first three intercostales
veins drain in vena intercostalis superior sinistra with two possibilities to convey: in vena hemiazygos
accesoria or in vena brachiocephalica sinistra.
-the trunk consists of 11-12 ganglia joined by longitudinal preganglionary and postganglionary fibres.
It lies on the posterior wall of the thorax, on each side.
-the last cervical ganglion and the first thoracic one are frequently fused to form the cervicothoracic
-the ganglions are connected with the spinal nerves (in our case the intercostal nerves) by white or
grey rami. The white rami (preganglionary fibres-covered by the myelin sheath) connects the
intercostal nerve with the trunk (the ganglion neurons) and by the grey rami (postganglionary fibers-
without myelin sheath) the fibres may return to the intercostal nerve following its trajectory.
Sometimes the postganglionary fibers remain individual forming autonomic nerves or plexus.
-from the first five ganglions, the postganglionary fibers provide the sympathetic innervation of the
oesophagus and lungs.
-from 6-9 ganglions arise nervus splanchnicus major wich contains postganglionary fibers for plexus
celiacus (the nervous system of the supramesocolic organs).
-from 10-11 ganglions arise nervus splanchnicus minor with postganglionary fibres for plexus
mesentericus superior et inferior (the nervous system of the small and large bowell)
-from the last ganglion result nervus splanchnicus minimus for the aorticorenalis plexus (the
The first part of the digestive tract.
It is divided by the teeth and gums in two parts:
- vestibulum- the outer part
- cavum oris propria- the inner part
Walls - is a slit- like space, bounded externally by the lips and cheeks; internally by the gums and
It communicates with - the surface of the body by the rima or orifice of the mouth.
- cavum oris propria- through the space between the teeth of the open mouth;
- cavum oris propria- through the retromolar space .
The groove between the two lips (sulcus interlabialis) divides the vestibulum in
- pars maxilaris(superior)
- pars mandibularis(inferior)
A vertical line traced on the angle of the lips delimits:
- regio gingivolabialis(medial)
- regio gingivobucalis(lateral)
- sulcus vestibularis superior- a groove between the superior external wall and processus alveolaris
- sulcus vestibularis inferior- a groove between the inferior external wall and processus alveolaris
- frenulum labii superioris - a mucosal crest on the median line of the superior groove;
- frenulum labii inferioris - a mucosal crest on the median line of the inferior groove;
- papilla ductus parotidei- the opening of the parotid gland duct near the second superior molar;
- foramen infraorbitale- situated in the superior vestibular groove on a vertical line traced between
the two premolars;
- foramen mentale- situated in the inferior vestibular groove , on the same vertical line;
- for the superior part (maxillaris)
- a. infraorbitalis;
- a. labialis superior(from a. Facialis);
- for the inferior part (mandibularis)
- a. mentalis
- a. submentalis
- a. labialis inferior
- for the lateral region
- a. bucalis
The veins drain in vena facialis and plexus pterygoideus
- rami labiales superiores - from n. infraorbitalis
- rr. gingivales superiores - from plexus dentalis superior
- ramus labiales inferiores - from n. mentalis
- rr gingivales inferiores - from plexus dentalis inferior
- n. bucalis- for the cheek
Cavum oris propria
- anterior and lateral: processus alveolaris (maxillaris and mandibularis) and the teeth
- superior: the hard palate (palatum durum);
- inferior: the floor of the oral cavity (M. mylohyoideus)
- pharynx - isthmus facium
- Regio palatina;
- Regio sublingualis;
- Regio retromolaris
- Regio tonsillaris
- the superior wall with two parts:
- hard palate (palatum durum);
- processus palatinus os maxillae
- lamina horisontalis os palatinum
- soft palate (palatum molle) ;
- Torus palatinus - a bony crest situated on the median line
- Raphe palati - the median joint of the mucosa and periosteum with poor vascularisation
- Papilla incisiva - 1 cm posterior to the incisive teeth, covers the opening of the canalis incisivum
- Plicae palatinae transversae - 2- 6 anterior transversal lines of the mucosa
- Hamulus processus pterygoidei - on the lateral part of the soft palate
- Foramen palatinum majus - in the posterior and lateral angle of the hard palate
- “A” line – the limit between the hard and the soft palate
- Isthmus facium - delimited by uvula palatina, radix linguae and the pillars of the soft palate
- A. palatina major - for the posterior part of hard palate
- Aa. palatinae minores – for the soft palate
- A. nasopalatina - for the anterior part of hard palate
- A. palatina ascendens - for the soft palate
The veins drain in
- V. lingualis
- V. Facialis
- Plexus pterygoideus
- N. nasopalatinus - the sensitive innervations of the anterior part of the hard palate
- N. palatinus major - for the posterior part
- Nn. palatini minors - for the soft palate, uvula and the tonsils
- N. glossopharyngeus and N. vagus give branches for the posterior part of the region
The inferior wall of the mouth.
There are two symmetric triangular shape regions
- anterior and lateral: processus alveolaris mandibulae;
- posterior :the root of the tongue;
- medial: frenulum linguae;
- pelvis salivalis - the deeper part of the triangle always full with saliva;
- frenulum linguae - a mucosal insertion of the top of the tongue;
- caruncula sublingualis - a little projection (tuberculum) situated on the anterior margin of the
frenulum lingualis and is perforated by the openings of the ductus submandibularis and ductus
- eminentia salivaris - the external shape of glandula sublingualis with a mucosal crest in the middle
– plica sublingualis- perforated by little channels- ductus sublinguales minores.
The arteries are from a. sublingualis, the veins drain in vena sublingualis and the sensitive
innervations is from nervus sublingualis.
Under the mucosa of the region and the inferior wall muscles we find a space called spatium
Superior: The mucosa of the regio sublingualis;
Inferior: musculus mylohyoideus;
Medial: musculus genioglossus and musculus hyoglossus
Lateral: fovea sublingualis (on the mandibula)
The contents of the space: the vessels and nerves penetrate into the region through the lateral groove
of the tongue.
- glandula sublingualis;
- ductus submandibularis (Wharton) - oblique trajectory from the lateral groove of the tongue to the
- nervus lingualis - spins around the Wharton duct;
- nervus hypoglossus - for the tongue muscles, is situated medial to the sublingual gland;
- artera sublingualis - from a. lingualis;
- vena sublingualis - drains in vena lingualis.
The postero-lateral wall of the mouth situated between the last molars (superior and inferior) and arcus
- Fossa retromolaris superior(inferior): a little space behind the last superior (inferior) molar ,
covered by a little projection of the gum – papilla retromolaris superior (inferior);
- plica pterigomandibularis- a fold between hamulus processus pterygoidei and fossa
The mucosa of the region covers the pterygomandibular space- the anterior part of regio
The contents of the pterygomandibular space:
- ramus mandibulae- with its elements- foramen mandibulae , lingula , antilingula and sulcus
- N. alveolaris inferior;
- N. buccalis;
- N. mylohyoideus;
- N. lingualis;
- A. alveolaris inferior.
Situated on the limit between mouth and pharynx (isthmus faucium)
- anterior: arcus palatoglossus;
- posterior: arcus palatopharyngeus;
- inferior: plica triangularis
- lateral: pharyngeal wall.
- Tonsilla palatina covered by capsula tonsillaris;
- The tonsillar vascular pedicle from a. pharyngealis ascendens and a. facialis;
- Fossa supratonsillaris - a space situated superior between the tonsil, the lateral wall and the two
THE LARYNX (LARYNX)
- the larynx represents the segment of the respiratory tract placed in between
farynx and trachea and being situated at the cervical level in the antero-
median part of the neck, corresponding to the 3-6 cervical vertebras
- it is the principal organ of fonation, but it has also respiratory and
I. The CARTILAGES of the larynx are in number of 9 (3 pair and 3 odd) and
they are making the cartilaginous skeleton of the larynx:
a. CARTILAGO THYROIDEA – the thyroid cartilage is an odd one and
- lamina dextra et sinistra - the right and left lamella, wich are united
anteriorly, in between them finding an angle openeds towards posterior
- proeminentia laryngea - the laryngeal proeminency represents the
angle situated anteriorly and given by the anterior unification of the
anterior margin of the two lamellas
- incisura thyroidea superior – the superior thyroid notch is situated on
the superior end of the angle
- incisura thyroidea inferior – the superior thyroid notch is situated on
the inferior end of the angle
- linea obliqua - the oblique line wich is situated on the external surface
of each lamella
- tuberculum thyroideum superius – the superior thyroid tubercle is
situated on the superior end of the oblique line
- tuberculum thyroideum inferius – the inferior thyroid tubercle is
situated on the inferior end of the oblique line
- cornu superius - the superior horn is situated in the postero-superior
angle of each lamella, being oriented superiorly
- cornu inferius - the inferior horn wich is shorter and it is situated in the
postero-inferior angle of each lamella, being oriented inferiorly
b. CARTILAGO CRICOIDEA – the cricoids cartilage is an odd one,
situated under the thyroid cartilage and presents:
- arcus cartilaginis cricoidea - the arch of the cricoid cartilage is situated
- lamina cartilaginis cricoidea - the lamella of the cricoid cartilage is
situated posteriorly and presents:
- facies articularis thyroidea – the thyroid articular surface (pair)
is situated infero-laterally on each side of the lamella and it is
destined for the articulation with the inferior horn of the thyroid
- facies articularis arytenoidea – the arytenoid articular surface
(pair) is situated supero-laterally on each side of the lamella and it
is destined for the articulation with the the arytenoid cartilage
c. CARTILAGO EPIGLOTTICA – the epiglottic cartilage is an odd one,
situated above the thyroid cartilage having an oval shape; the space situated
in between the thyroid and the epiglottic cartilages is filled by corpus
adiposum pre-epiglotticum; it presents:
- epiglottis - the epiglotta has as skeleton the epiglottic cartilage
- petiolus epiglottidis - the petiol of the epiglottic cartilage is situated
inferiorly being united with the superior thyroid notch by the
d. CARTILAGO ARYTENOIDEA – the cricoids cartilage is an pair one,
situated on the superior margin of the lamella of the cricoid cartilage and
- basis cartilaginis arytenoidea - the base of the arytenoid cartilage wich
- facies articularis – the articular surface for the articulation with
the cricoid cartilage
- facies antero-lateralis - the antero-lateral surface with a triangular
- crista arcuata – the arched crest is situated obliqually on this
surface and presents on each end a small tubercle (colliculus)
- fovea triangularis – the triangular fovea is situated above the
- fovea oblonga – the oblonga fovea is situated under the arched
- processus vocalis – the vocal projection is situated in the antero-
inferior angle of this surface and serving for the insertion of the
- facies medialis - the medial surface is orientd towards the other
- facies posterior - the posterior surface presents:
- apex cartilaginis arytenoidea – the tip of the arytenoids cartilage
is situated in the superior angle of this surface and it will be
articulated with the corniculate cartilage
- processus muscularis – the muscular projection is situated in the
postero-inferior angle of this surface and serving for the insertion of
e. CARTILAGO CORNICULATA “Santorini” – the corniculate cartilage
is small and pair, being situated on the superior tip of the arytenoid cartilage
- tuberculum corniculatum - the corniculate tubercle wich lifts up the
mucosa of the laryngeal opening
e. CARTILAGO CUNEIFORME “Wrisberg” – the cuneiform cartilage is
small and pair, being situated supero-latyerally to the corniculate cartilage
- tuberculum cuneiforme - the cuneiform tubercle wich lifts up the
mucosa of the laryngeal opening
f. CARTILAGO TRITICEA – the triticeal cartilage is small, pair and
inconstant, being situated on the posterior margin of the thyro-hyoidian
g. CARTILAGO SESAMOIDEA – the sesamoid cartilage is small, pair and
inconstant, being situated into the vocal muscle
II. The ARTICULATIONS of the LARYNX are:
a. articulatio crico-thyroidea – the crico-thyroid articulation is situated in
between the inferior articular surfaces of the lamella of the cricoid cartilage
and the inferior horns of the thyroid cartilage, and presents:
- capsula articularis crico-thyroidea - the crico-thyroid articular capsule
presents interiorly a synovial membrane and a ligament:
- liggamentum crico-thyroideum medianum – the median crico-
thyroid liggament is situated in between the inferior margin of the
lamellas of the thyroid cartilage and the superior margin of the
b. articulatio crico-arytenoidea – the crico-arytenoid articulation is situated
in between the superior articular surfaces of the lamella of the cricoids
cartilage and the articular surfaces of the basis of the arytenoid cartilage, and
- capsula articularis crico-arytenoidea - the crico-arytenoid articular
capsule presents interiorly a synovial membrane and a ligament:
- liggamentum crico-arytenoideum – the crico-thyroid liggament
is strengthening the capsule
III. The LIGGAMENTS of the LARYNX are:
a. membrana thyro-hyoidea – the thyro-hyoid membrane is fibro-elastic
and situated in between the inferior margin of the hyoid bone and the
superior margin of the thyroid cartilage; it is strengthened by:
- liggamentum thyro-hyoideum medianum – the median thyro-
hyoid liggament is situated on the median line of the membrane
- liggamentum thyro-hyoideum laterale – the lateral thyro-hyoid
liggament is situated posteriorly in between the big horns of the
hyoid bone and the superior horns of the thyroid cartilage
- foramen thyro-hyoideum – the thyro-hyoid orifice is situated on
the lateral part of the membrane being destined for the superior
laryngeal vasculo-nervous package
b. liggamentum thyro-epiglotticum – the thyro-epiglottic liggament is
situated anteriorly in between the petiolus of the epiglottic cartilage and the
superior part of the inner angle of the thyroid cartilage
c. liggamentum hyo-epiglotticum – the hyo-epiglottic liggament is
situated anteriorly in between the epiglottic cartilage and the inferior part of
the hyoid bone
d. liggamentum crico-thyroideum – the crico-thyroid liggament is
situated anteriorly in between the inferior margin of the thyroid cartilage and
the superior margin of the cricoid cartilage
e. liggamentum crico-tracheale – the crico-tracheal liggament is situated
inferiorly in between the inferior margin of the cricoid cartilage and the
superior margin of the first cartilage of the trachea
f. liggamentum crico-pharyngeum – the crico-pharyngeal liggament is
situated in between the posterior surfaceof the lamella of the cricoid
cartilage and the mucosa of the pharynx that covers this lamella
g. membrana fibro-elastica laryngis – the fibro-elastic membrane of the
larynx is coated interiorly by the mucosa of the larynx; it covers the spaces
situated in between the components of the cartilaginous skeleton of the
larynx and it is made by:
- membrana quadrangularis – the quadrangular membrane
represents the superior part of membrane fibro-elastica and it
borders laterally the superior (vestibular) part of the larynx (being
situated in between the inferio-lateral margin of the epiglotta, the
almost entire inner part of the angle of the thyroid cartilage and the
anterior margin of the arytenoid cartilage); it presents:
- liggamentum vestibulare – the vestibular ligament wich is
the inferior free margin of the quadrangular membrane, being
situated in between the the inferior part of the angle of the
thyroid cartilage and the fovea triangularis of the arytenoid
- conus elasticus – the elastic conus represents the inferior part of
membrane fibro-elastica and it borders laterally the inferior (infra-
glottic) part of the larynx (being situated in between the inferior
part of the inner part of the angle of the thyroid cartilage, the vocal
process of the arytenoid cartilage and the superior margin of the
cricoid cartilage); it presents:
- liggamentum vocale – the vocal ligament wich is the
superior free margin of the elastic cone, being situated under
the vestibular ligament, in between the inferior part of the
angle of the thyroid cartilage and the processus vocalis of the
IV. The MUSCLES of the LARYNX are:
a. musculus crico-thyroideus – the crico-thyroid muscle is situated on the
external antero-lateral surface of the larynx and presents two parts:
- pars recta – the straight part situated medially and presenting
almost vertical fibers
- pars obliqua – the oblique part situated laterally and presenting
almost horizontal fibers
b. musculus crico-arytenoideus posterior – the posterior crico-arytenoid
muscle is the only abductor of the vocal chords and it is situated on the
external posterior surface of the larynx and presents oblique fibers
oriented in supero-anterior direction
c. musculus crico-arytenoideus lateralis – the lateral crico-arytenoid
muscle is situated on the external lateral surface of the larynx and presents
oblique fibers oriented in supero-posterior direction
d. musculus arytenoideus obliquus – the oblique arytenoid muscle is
situated on the external posterior surface of the larynx and presents
oblique fibers crossed in between them
- pars ary-epiglottica – the ary-epiglottic part continues antero-
superiorly along the lateral margins of the epiglottic cartilage
e. musculus arytenoideus transversus – the transvers arytenoid muscle is
situated on the external posterior surface of the larynx, under the oblique
arytenoid muscle, and presents horizontal fibers
f. musculus thyro-arytenoideus – the thyro-arytenoid muscle is situated on
the internal surface of the larynx, with the fibers oriented antero-
posteriorly in between the inner part of the angle of thyroid cartilage and
the anterior part of the arytenoids cartilages; it presents:
- pars thyro-epiglottica – the thyro-epiglottic part wich is the
lateral one and continues towards the lateral margins of the
- musculus vocalis – the vocal muscle wich is the medial part
being situated in between the inner part of the angle of the thyroid
cartilage and the fovea oblonga of the arytenoid cartilage (along the
V. The CAVITY of the LARYNX is covered by mucosa (wich is coated on the
components of the fibro-elastic membrane of the larynx) and contains laryngeal
glands and lymphatic follicles; it presents three parts (with a “sand-watch”
shape) and an opening:
a. aditus laryngis – the opening of the larynx is situated superiorly into a
oblique plane oriented postero-inferiorly; the borders of the opening are
made in antero-posterior direction by:
- epiglottis – the epiglottic cartilage (wich closes / opens the aditus)
with its superior margin; it is connected with the base of the tongue
by plica glosso-epiglottica mediana and lateralis
- plica ary-epiglottica – the ary-epiglottic plica is situated on the
lateral side of the aditus and it is given by the mucosa over the
- tuberculum cuneiforme – the mucosa over the cuneiform
cartilage’s relief, being situated in the posterior part of plica ary-
- tuberculum corniculata – the mucosa over the corniculate
cartilage’s relief , being situated in even more posterior part of plica
- incisura inter-arytenoidea – the inter-arytenoid notch is situated
posteriorly in between the arytenoids cartilages
b. cavum supra-glotticum (vestibulum laryngis) – the vestibule of the
larynx is the superior part (being larger superiorly and narrower inferiorly
and placed in between the aditus of the larynx and the vestibular plica)
corresponding to the space situated under the aditus in between the two
membrana quadrangularis; it presents:
- plica vestibularis – the vestibular plica represents the inferior
border of the vestibulum, being placed horizontally and having a
antero-posterior direction; it is given by the mucosa over the
vestibular liggament (the vestibular plica + the vestibular liggament
are making togheter “the false” vocal chords)
- rima vestibularis – the vestibular slot represents the space
situated in between the two vestibular plicas
c. cavum intermedium (glotta laryngis) – the glotta of the larynx is the
narrow middle part being situated in between the superior and inferior
parts of the larynx - more accurate in between the plica vestibularis
(superior) and plica vocalis (inferior); it presents:
- plica vocalis – the vocal plica represents the inferior border of the
intermediate cavity, being placed horizontally under the vestibular
plica and having also a antero-posterior direction; it is given by the
mucosa over the vocal ligament; the vocal plica + the vocal
liggament + the vocal muscle are making togheter the (“true”)
- rima glottidis – the glottic slot represents the space situated in
between the two vocal plicas and presents:
- pars intermembranacea – the inter-membranous (anterior)
part wich is situated in between the two vocal plicas
- pars intercartilaginea – the inter-cartilagenous (posterior)
part wich is situated in between the medial surfaces of the
- ventriculus laryngis “Morgagni” – the laryngeal ventricles are
two diverticles of the glotta oriented laterally and presenting:
- sacculus laryngis – the laryngeal sacc represents the
superior extension of the laryngeal ventricle
d. cavum infra-glotticum – the infra-glottic part of the larynx is the large
inferior part (being narrower superiorly and larger inferiorly and placed in
between the vocal plica and the superior margin of the first cartilage of
the trachea), corresponding to the space situated in between the two conus
elasticus and the inner space of the cricoid cartilage until the first cartilage
of the traches
VI. The VASCULO-NERVOUS PACKAGES of the LARYNX are:
a. arteries – are given by two sources:
- arteria laryngea superior – it vascularises the external antero-
lateral muscles and by perforating the thyro-hyoid membrane
(through foramen thyro-hyoideum) is giving branches for the
interior of the larynx (supra-glottic and glottic parts)
- arteria laryngea inferior – it vascularises the external posterior
muscles and by perforating the crico-thyoid membrane is given
branches for the interior of the larynx (infra-glottic part)
b. veins – are drained in two directions:
- vena laryngea superior – it collects almost the entire venous
drainage of the larynx (going through foramen thyro-hyoideum)
- vena laryngea inferior
c. nerves – are given by one main source (nervus vagus):
- nervus laryngeus superior wich presents:
- an external motor branch (for the crico-thyroideus muscle)
- an internal branch (going through foramen thyro-hyoideum)
destined for sensitive and vegetative innervation of the supra-
glottic and the glottic part of the larynx
- nervus laryngeus inferior (from nervus laryngeus reccurens)
- an external motor branch (for all the other muscles of the
- an internal branch destined for sensitive and vegetative
innervation of the infra-glottic part of the larynx
d. lymphatics – are drained in corresponding regional nodules:
- cavum supra-glotticum – the limpha from this part is drained
towards nodi lymphatici jugulares interni
- glotta – the limpha from this part is drained towards nodi
lymphatici cervicales anteriores profundi pre-laryngeales and then
to nodi lymphatici jugulares interni
- cavum infra-glotticum – the limpha from this part is drained
towards nodi lymphatici cervicales anteriores profundi pre- and
para-tracheales and then to nodi lymphatici jugulares interni or
The liver (Hepar)
It is the greatest gland attached to the digestive tract , situated in the upper floor of the
abdominal cavity : right hipocondrum , epigastrium and partially in left hypocondrum.
The weight is about 1,5 Kg at the cadaver and 2.0 Kg at living human , due to the inner blood.
The liver has an ovoidal shape with two faces and two margins:
-margo anterior-the sharp one , is divited in two parts by incisura hepatica;
-margo posterior-more rounded ;
-facies superior-facies diaphragmatica-is situated under the right and left diaphragmatic
domes.Between the two structures there is a virtual space – spatium interhepatophrenicum.
-facies inferior-facies visceralis-point to the intraperitoneal organs.
-through the diaphragmatic dome the superioe face is related with :
-the right anterior and lateral arch of the 7th
-the heart apex-impressio cardiaca;
-the posterior part of this face is partially uncoverred by the peritoneum-aria nuda-where the
liver is attached to the posterior abdominal wall and vena cava inferior.
-the inferior limit of facies superior ussualy follow a line that joint the tip of the 10th
rib from the right
with the tip of 8th
rib from the left.
-on the superior face the liver presents two external lobes:lobus dexter et lobus sinister separeted by
the ligamentum falciforme.This lobes are not the correspondents of the portobilliary division of the
liver , as we will see.
Is divided in four lobes by a H shape grooves:
-sulcus longitudinalis sinister:
-pars anterior-is represented by the Fissura(Incisura) ligamenti teretis , where is the entrance
of ligamentum teres hepatis (the fibrotic transformation of vena umbilicalis)
-pars posterior-Fissura ligamenti venosi , where is situated the Ligamentum venosus Arantzius-
embriologycal rest of the umbilicalo-caval shunt;
-sulcus longitudinalis dexter:
-pars anterior-Fossa vesicae fellae-the site of the gallbladder;
-pars posterior-sulcus venae cave inferior-in the upper part of it is the confluence between the
suprahepatic veins and vena cava inferior.
-sulcus transversalis-joint the middle points of the two longitudinal lines and is occupied by the
hepatic pedicle (hillus hepaticus)
The visceralis face external lobes:
Lobus dexter:the greater lobe , situated in the right hypocondrum , on the right side of the falciform
ligament and the right side of sulcus longitudinalis dexter.
The organs related with this inferior lobe face are:
-impressio colica-situated anterior;
-impresio duodenalis-posteriorlly to the first one;
-impressio renalis and suprarenalis-more posteriorlly and inferiorlly to the others.
Medium size situated partially in epigastrium and left hypocondrium , on the left side of ligamentum
teres hepatis and sulcus longitudinalis sinister , presents a projection near to the hepatic pedicle-tuber
omentale.I.s releated with the abdominal oesophagus-impressio oesophagei
Lobus quadratus-situated anteriorlly to the hepatic pedicle presents the following limits:
-sulcus longitudinalis dexter-pars anterior-on the right side;
-sulcus longitudinalis sinister-pars anterior-on the left side;
-sulcus transversalis(hillus hepaticus)-inferiorlly;
It’s releated with the pylor.
Lobus caudatus (The Spiegel’s lobe) -situated posteriorlly to the hepatic pedicle is bordered by:
-sulcus longitudinalis dexter–pars posterior;
-sulcus longitudinalis sinister-pars posterior;
Presents two projections that points to bursa omentalis:
-processus papillaris-border inferiorlly the hepatic pedicle;
-processus mamillaris-border latterally on the left side vena cava inferior.
The ligaments of the liver
The entire organ , excepting the hepatic pedicle and aria nuda , is covered by the peritoneum with two
layers (tunica subserosa-the inner one and tunica fibrosa – Glisson)
-Ligamentum falciforme: two paralelly and adherent peritoneal folds between the diaphragm dome
and facies superior.The anterior part is continuated by the ligamentum teres hepatis.
-Ligamentum coronarium:is the posterior continuation of the falciforme ligament wich is splited in
two folds bordering superiorlly aria nuda.
-Ligamentum triangulare-two ligaments on the each side wich are joint with the coronar ligament
and border the lateral limit of aria nuda.
-Omentus minus :
-Ligamentum hepatoduodenale-between the first part of the duodenum and hillus hepaticus.
-Ligamentum hepatogastricum-between the inferior face of the liver and the lesser curvature.
The hepatic pedicle (porta hepatis):
-is situated on sulcus transversalis
The elements of the hepatic pedicle:
-ductus hepaticus comunis-is situated anteriorlly and to the right , represents the fusion of the canalis
hepaticus dexter et sinister.Transport the bile through it and then choledocus into the duodenum.
-artera hepatica propria-arise from artera hepatica communis , branch of truncus celiacus , is
situated anteriorlly and to the left.Represnts the nutritive blood suplie , transporting the oxygen and the
nutritive substances to the cells (hepathocites).After a short way into the hepatoduodenal ligament
divides in the right branche and in the left branche.The right one gives two segmentary arteries:
A.segmenti anterior and A.segmenti posterior.The left branche gives another two segmentary
arteries:A.segmenti medialis and A.segmenti lateralis.The caudat lobe receive blood suplie from the
-vena porta-represents the joint of vena lienalis and vena mesenterica superior-is the functional blood
suplie of the liver by providing the absorbed nutriens from the small bowell to the hepatic cells.Is the
most posterior element of the hepatic pedicle.The intrahepatic divisions are the same like the arterie
-lymph nodes:nodi lymphatici hepatici;
-nervs:symphatetic fibers:from plexus hepaticus;
parasymphatetic fibers:from n.vagus.
-capsula fibrosa perivascularis-the continuation of the Glison membrane , on the hepatoduodenal
-Venae porte accesoria-small veins wich belongs to the portal system
The suprahepatic pedicle:
Drains the liver blood in vena cava inferior:
-Vena hepatica intermedia-principalis-the most important one;
-Vena hepatica dextra;
-Vena hepatica sinistra;
The three veins can drain into the inferior caval vein one by one , ore they are first joint into a single
The segments of the liver:
The anatomic segments-are the consequence of the vasculobiliary divisions inside the hepatic
tissue.The real limit between the right lobe and the left one from vascularisation point of view is an
imaginary line – scizura hepatica principalis – Rex Cantle line and is situated between the
gallbladder(anterior) and the left border of the inferior caval vein (posterior).Guiding by the arteria
hepatica division(or vena porta) results the following anatomical segments:
-Segmentum anterius of the right lobe;
-Segmentum posterius of the right lobe;
-Segmentum mediale of the left lobe;
-Segmentum laterale of the left lobe.
The surgical segments:is different to the anatomical division and has clinical and surgical importance
in hepatic resections.Through each suprahepatic veins thrre imaginary lines will split the liver in four
parts (four primary segments) , two situated on the left and two on the right.Then an horisontal plane
through the midle of the liver will divide each primary segment in two , resulting eight segments.An
easier way to evaluate the surgical segments is counting them on clockwise sense.
1. Segmentum paramedianum sinister superior-lobus caudatus;
2. Segmentum lateral superior sinister;
3. Segmentum lateral inferior sinister;
4. Segmentum paramedianus inferior sinister-lobus quadratus;
5. Segmentum paramedianus inferior dexter;
6. Segmentum lateral inferior dexter;
7. Segmentum lateral superior dexter;
8. Segmentum paramedianus superior dexter
The extrahepatic billiary system
1. Ductus hepaticus communis – arise from the confluence of canalis hepaticus dexter et
sinister.It’s about 3-4 cm lenght , situated on the right side of the hepatic pedicle crossing
anteriorlly the right branches of arteria and vena porta.The distal part will collect the cystic
2. Ductus choledocus-results from the confluence of ductus hepaticus and ductus
cysticus.Presents three parts:retroduodenal , retropancreatic and intraparietalis. Transports the
bile from the liver to the duodenum.Before the opening in ampulla duodeni major will fuse
with the Wirsung duct.
Quenu quadratum-is bordered by the first three duodenal parts and vena mesenterica superior.The
diagonal of this quadrilateral , from superior to inferior and from the left to the right is ductus
3. The gall bladder(Vesica fellea) -a piriform storage chamber for the bile between the meals.It
has three parts:
-Fundus vesicae fellae-point to the abdominal wall;
-Corpus vesicae fellae-is attached to the liver and lies on the duodenum and transversal
-Collum vesicae fellae-ampular shape , presents a mucosal fold-plica spiralis or Heister
-Ductus cysticus:between the gallbladder and ductus hepaticus comunis.The Budde triangle
is bordered by the cystic duct , hepatic duct and the inferior face of the liver and is cossed by
arteria cystica-branche of a.hepatica dextra.
The sphincters muscles of the extrahepatic billiary system:
-Mirrizi sphincter muscle-on the ductus hepaticus communis;
-Lutkens sphincter muscle-on the cystic duct;
-The sphincter of the Wirsung duct;
-Oddi sphincter muscle-the common sphincter muscle for ductus choledocus and Wirsung duct.
The vessels, nervs and lymphatic system of the gallbladder
-arteria cystica arise from artera hepatica dextra;
-the veins drains into the portal system;
The lymph is drained in hepatic pedicle lymph nodes.Near to ductus cysticus is situated the
Mascagni lymph node considered particular for the gallbladder.
The nervs arise from plexus celiacus and the vagus nervs.
ORGANA GENITALIA MASCULINA
These consist of the testicles, genital ducts, accessory glands and copulating organ.
The testicle - Testis
The testis is responsible for producing the spermatozoa and male sex hormones. It has an oval shape,
slightly flattened from lateral, with a weight of 10-14 g, a greater length of 4-5 cm, a width of 2.5 cm
and an antero-posterior thickness of 3 cm.
Extermitas superior et inferior - the former oriented antero-laterally, while the latter towards
postero-medial. Thus, the testicle suspended in the scrotum by the spermatic cord, has an oblique
Facies medialis et lateralis
Margo anterior - anterior, convex margin
Margo posterior - posterior, more straight margin
The extremities, surfaces and anterior margin are free, smooth, covered by the visceral layer of the
tunica vaginalis. The posterior margin has attached to it the spermatic cord and epididymis.
Tunica albuginea - a thick, fibrous, whitish surface layer
Tunica vasculosa - a thin layer of loose connective tissue, with a fine vascular network
Mediastinum testis - the thickening of the tunica albuginea (called the “Body of Heighmore”), where
the vessels penetrate the testis
Septula testis - incomplete septa of connective tissue, positioned in a radial manner, dividing the
parenchyma of the testis in
Lobuli testis - 250-400 lobules of conical shape, with their bases toward the exterior and their apexes
toward the Heighmore body
Parenchyma testis - the proper tissue of the testis
Tubuli seminiferi contorti - 1-3 coiled seminiferous tubules, beginning blindly, with several
anastomoses between them and the tubules of the neighboring lobules
Tubuli seminferi recti - these are formed by the union of the previous tubules, and penetrate the
Rete testis - the multiple anastomoses between the straight tubules form the “network of Haller”,
located in the Heighmore body
One testicle contains approximately 840 such seminiferous tubules, of 60-70 cm length, and 0.3 mm
Interstitium testis - the spaces between seminiferous tubules, containing vessels and interstitial cell
islets (“Leydig cells”), which secrete androgens
It is the beginning of the genital tract.
Caput epididymidis - a club like upper part, turning anteriorly and attached to the superior pole of the
Corpus epidydimis - its intermediary part, following the posterior margin of the testicle
Cauda epidydimis - the thinner inferior segment, attached to the inferior pole of the testis
Ductuli efferentes testis - the head is made up of 12-15 efferent tubules, coming from the network of
Lobuli seu Coni epididymidis - after a short straight path, they coil up, and form a cone-shaped
lobule, making up together the head of epidydimis
Ductus epididymidis - the efferent tubules open into a single, coiled tube, having 6 meters in length,
and 0.5 mm diameter. The tightly packed convolutions of this tube are held together by loose
connective tissue, and it makes up the body and tail of the epidydimis
There are a series of vestigial structures contacting the head of the epidydimis:
Ductuli aberrantes - they represent the caudal portion of the persisting mesonephric tubules
(“aberrant vessel of Haller”)
Appendix epididymis - remnant of the Wolff duct
Paradidymis - atrophic remnant of the paragenital tubes of the mesonephros
The vascular supply and innervation of the testis-epidydimis complex is common: the arteria
testicularis, and plexus pampiniformis draining into the vena testicularis (right - VCI, left vena
It is a round duct of 50-60 cm length and 3 cm thickness, with a 0.5 mm narrow lumen.
It continues the ductus epidydimis, from the tail of this organ, where it turns upwards along this organ,
with an initial tortuous path and a subsequent straight portion.
In the spermatic cord it is located posterior to the vessels, with whom it courses through the canalis
inguinalis, and reaches the pelvis through the internal inguinal opening. It arches then under the
peritoneum covering the lateral surface of the urinary bladder, reaching its base, where the two
deferent ducts cross the ureters and converge toward the prostate.
It has three segments: epidydimal, funicular and abdomino-pelvic.
Ampulla ductus deferentis - its terminal portion, placed on the bladder, with a larger lumen , and
mucosal depressions (Diverticula ampullae).
Vascular and nervous supply
The arteries of the ductus deferens come from the arteria vesicalis superior, and near the testicle form
anastomoses with the branches of the arteria testicularis.
It is like a membranous, lobular pouch, located on the fundus of the bladder, lateral to the ampulla
ductus deferentis. It is not a storage place for sperm cells, but a gland actively contributing to the
production of seminal liquid.
It is about 8 cm in length, but its dimensions can vary even compared to the opposing vesicle. In
reality, it is a tube with zigzag curves that generates blind ending portions, connected by connective
Ductus excretorius - its inferior portion narrows gradually, and is continued by an excretory duct,
which unites with the ductus deferens to form the ductus ejaculatorius.
Vascular and nervous supply
The arteries of the ductus deferens come from the arteria vesicalis superior, and near the testicle form
anastomoses with the branches of the arteria testicularis. The ampulla ductus deferentis and vesicular
seminalis also receive arterial supply from the arteria vesicalis inferior and the arteria rectalis media.
The veins drain in the plexus pampiniformis, venae vesicales and plexus venosus prostaticus.
The lymphatic vessels drain towards the nodi lymphatici iliaci externi and interni.
The nerves come from the plexus hypogastricus inferior, along the above named arteries.
It is formed by the junction of ductus deferens and ductus excretorius vesiculae seminalis. It travels
obliquely downward and anterior the prostate, up to its opening into the urethra. It is 2 cm in length
and it narrows gradually (down to 0.2 mm) until its opening on the lateral side of colliculus seminalis.
It is a cord like structure containing vascular, lymphatic and nervous structures, accompanying the
ductus deferens from the epidydimis to the abdominal cavity, and traveling through the canalis
Arteria testicularis - branch of the abdominal aorta, supplying the testiculo-epidydimal complex
Arteria cremasterica - from the arteria epigastrica inferior, supplying the layers of the spermatic cord
Arteria ductus deferentis - form the arteria iliaca interna, supplying the ductus deferens and forming
anatomoses with the above named arteries
Plexus pampiniformis - collects all blood from the territory of the above arteries It makes up around
the ductus deferens and complex venous plexus, which fuses into 2-3 common trunks at the superficial
inguinal opening. After passing through the canalis inguinalis, these veins will form the vena
testicularis on each side.
In addition, the cord comprises lymphatic vessels and autonomic plexus, accompanying the ductus
deferens and its artery.
The ductus deferens in located in the posterior part of the spermatic cord, and can be easily identified
by palpation, due to its rough consistency.
Tunicae funiculi spermatici et testis - the protective coating layers derived from the abdominal wall
(fascia exoabdominalis, musculus obliquus externus et internus, musculus transverses abdominis,
fascia transversalis and peritoneum - the canalis peritoneo-vaginalis of the fetus).
Tunica vaginalis testis - makes up a closed serous pouch around the testiculo-epidydimal complex,
closed by the obliteration of the canalis peritoneo-vaginalis.
It comprises a visceral layer (Lamina visceralis), covering these organs, and turning into the parietal
layer (Lamina parietalis) along the posterior margin of the testicle. Sinus epididymidis - a deeper
pouch of the line of reflection, located in the angle between the testicle and the corpus epidydimis
The prostate encircles the neck of the bladder and the first portion of the urethra, located behind
symphysis pubica, anterior to the rectum and above the urogenital diaphragm. Its weight is about 20 g;
its widest transversal diameter is 4 cm, antero-posterior 2 cm, and vertical 3 cm.
Basis prostatae - a large bases, on the inferior surface of the bladder
Apex prostatae - a thinned inferior portion, sustained by the urogenital diaphragm
Lobus dexter et sinister - the two lateral lobes
Lobus medius or Isthmus prostatae - a middle lobe, underdeveloped, linking the two lateral lobes
behind the urethra There are no clear boundaries between the parts of the prostate.
Facies anterior - short and convex, it is posterior to the symphysis pubica (by 1.5 -2.0 cm), and
between them there is a connective tissue with an abundant venous plexus It is attached to the prostate
by ligaments and musculus pubo-prostaticus. The urethra passes through the prostate near this surface.
Facies posterior - flatter and wider, slightly convex on its lateral sides. It is oriented towards the
rectum, and it is accessible to examination through rectal digital exam. Close to its superior border
there is a depressed area where the canales ejaculatorii enter the gland. Inferior to this depression
there is a shallow median groove, representing the boundary between the right and left lobes.
Facies inferolateralis - covered by connective tissue and the periprostatic venous plexus, sustained by
the anterior part of the musculus levator ani, termed musculus levator prostatae.
The prostate is traversed by the urethra and the ejaculatory ducts. The former is places obliquely,
along the junction between its anterior and middle thirds, the latter reach the organ on its posterior
surface, near the bladder. Between these structures there is the middle lobe, visible only on the
Vascular and nervous supply
The prostatic arteries are branches of the arteria pudenda interna, arteria vesicalis inferior and arteria
The veins are collected by the plexus venosus prostaticus, which empties into the vena iliaca interna.
The lymphatic vessels drain towards the nodi lymphatici iliaci interni and sacrales, and in a lesser
extent towards the nodi lymphatici iliaci externi.
The nerves come from the plexus hypogastricus inferior.
Glandula bulbourethralis - Cowper
These are paired lobular, yellowish glands, the size of a pea; they are located in the diaphragma
urogenitalis, postero-lateral to the membranous urethra.
Ductus glandulae bulbouretnralis - the relatively long excretory duct, opening into the spongy
urethra, at about 2.5 cm inferior to the urogenital diaphragm.
The male copulating organ, positioned anterior to the pubic arch; it changes its size and consistency
based on its functional state.
Radix penis - the root, attached to the pubis and ischium
Corpus penis - the body narrows towards its distal end
Collum glandis - a circular separation groove between the corpus and glans
Glans penis - the wider distal end of the penis
Collum glandis - the larger, rounded perimeter of the glans
Dorsum penis - the surface that continues the surface of the pubic region
Facies urethralis - the inferior surface, containing the urethra
Raphe penis - the thin, pigmented and mobile skin of the urethral surface shows a darker line that
continues on the scrotum and perineum
Preputium - a fold of extra skin at the distal end, which covers the glans of the relaxed penis, and is
retracted during erection
Frenulum preputii - surrounds the external opening of the urethra, and forms a divergent plica under
Fascia penis superficialis et profunda - the two fascial layers of the penis
Corpus cavernosum penis - make up the anterior ¾ of the corpus penis, and are fused together; they
have a rounded anterior end, covered by the glans
Crus penis - the radix penis contains these divergent posterior extremities of the corpora cavernosa,
attached to the rami ossis pubis and ischium
Tunica albuginea corporum cavernosorum - the external, fibrous, resistant covering of the
Septum penis - a fibrous extension that incompletely separates the corpora cavernosa in the sagittal
Corpus spongiosum penis - a single spongy body, containing the urethra
Bulbus penis - the conical, dilated segment, adherent to the inferior surface of the urogenital
It also makes up the glans. This structure extends transversally beyond the diameter of the corpus
penis, forming the corona glandis and its collum.
Tunica albuginea corpori spongiosi - the external, fibrous covering of the spongy body, much
thinner than that of the corpora cavernosa
Vascular and nervous supply
The arteries come from the arteria pudenda interna, and comprise the arteria profunda penis (in each
cavernous body) and arteria dorsalis penis.
The veins drain into the plexus venosus prostaticus, through the venae profundae penis and vena
The lymphatic vessels of the gland drain into the nodi lymphatici inguinales profundi and iliaci
externi. The rest of the organ is drained into the nodi lymphatici inguinales superficiales.
The nerves come from the nervus pudendus and the plexus hypogastricus inferior.
It is a skin pouch continuing the skin of the penis and perineum, and contains the testicles, epidydimes
and the initial part of the funicula spermatica, with their coverings.
Raphe scroti - it forms a midline ridge
Septum scroti - a sagittal connective tissue septum, dividing the cavity of the scrotum into two
Tunica dartos - a layer of connective tissue, containing smooth muscle fascicles and bands of elastic
The vascular supply of the scrotum is from the arteria pudenda interna and externae, through rami
scrotales anteriores and posteriores. The venae scrotales anteriores drain towards the vena femoralis or
vena safena magna, and the venae scrotales posteriores towards the vena pudenda interna.
The lymphatic vessels have similar drainage as the penis.
The nerves are branches of nervus ilioinguinalis or genitofemoralis (nervi scrotales anteriores), and
nervus pudendus (nervi scrotales posteriores).
ORGANA GENITALIA FEMININA
The female gonad, it weighs about 3.5 g and it is located in the angle of bifurcation of the common
iliac artery. Its surface is smooth in children and becomes uneven in mature women.
It has extremities, faces and margins. Its long axis is oriented almost vertically in a standing woman.
Extremitas tubaria/tubalis - its external extremity is attached to a long fimbria of the tuba uterine
and it is suspended by a peritoneal ligament (Ligamentum suspensorium ovarii) to the lateral wall of
the abdomen. This ligament also contains the vessels and nerves of the ovary.
Extremitas uterina - its internal extremity faces downwards and medial towards the uterus, to which
it is attached by a fibrous structure located between the layers of the broad ligament of the uterus.
Facies lateralis - it contacts the peritoneal fossa located in the bifurcation angle of the common iliac
Facies medialis - it is almost completely covered by the fimbria of the fallopian tube.
Margo liber - the free border of the ovary.
Margo mesovaricus - the mesovarium attaches to it.
The external surface of the ovary is covered by peritoneum up to the insertion of the mesovarium.
Tunica albuginea - a fibrous, thin, whitish coat
Stroma ovarii - divided into a peripheral (Cortex ovarii), and a central (Medulla ovarii) part. The
former contains the ovarian follicles in different stages of development, the latter contains mostly the
vessels and nerves of the ovary.
Vascular and nervous supply
Arteria ovarica - located within the ligamentum suspensorium ovarii, it anastomoses with the Ramus
ovaricus of the uterine artery, and these two make up the "ovarian arch" comprised between the layers
of the mesovarium.
The veins drain in the plexus ovaricus, corresponding to the plexus pampiniformis of the male, and
subsequently form the venae ovaricae.
The lymphatic vessels drain into the nodi lymphatici lumbales.
The mixed autonomic nerves concentrate in a superior group, derived from the plexus mesentericus
superior and plexus renalis, and an inferior group coming from the plexus rectalis along the arteries.
It is a tortuous duct, of 10-15 cm length, and receives the ovum expelled by the ovary guiding it
towards the uterus.
It has three main parts: the infundibulum, the ampulla and the isthmus.
Infundibulum tubae uterinae - it is the funnel-shaped lateral part of the fallopian tube
Ostium abdominale tubae uterinae - the opening in the center of the infundibulum
Fimbriae tubae - radial extensions starting from the edge of the infundibulum towards the medial
surface of the ovary
Fimbria ovarica - a longer extension, directly attached to the ovary
Ampulla tubae uterinae - the next slightly dilated segment, 5-10 mm long, arching over the ovary,
comprising almost 2/3 of the length of the tube
Isthmus tubae uterinae - the third very narrow and short segment It is essentially in the uterine wall
Ostium uterinum tubae - the small opening into the superior angle of the uterine cavity.
Mesosalpinx - a peritoneal doubling, attached posteriorly to the mesovarium, and continued by the
mesometrium connected directly to the uterus.
Vascular and nervous supply
Arteries: the most important arterial source is the Ramus tubarius of the uterine artery. This follows
the tube, and gives out a series of collaterals up to the level of the fimbria, where it anastomoses with
the ovarian artery.
The veins drain into the plexus venosus uteri.
The lymphatic vessels drain partly into the nodi lymphatici lumbales, and partly towards the uterine
The nerves come from the plexus hypogastricus inferior and the sacral parasympathetic system.
It is an unpaired, pear shaped, antero-posteriorly slightly flattened organ, with very thick walls, located
in the middle of the pelvis, between the bladder and rectum.
In nuliparous women its length is about 8 cm, its width about 5 cm in its superior widest area, and it
has a 3 cm thickness. In multiparous women these dimensions are larger, and increase largely during
The uterus is divided into two major parts: the corpus and the cervix, connected through a narrow
segment, that is distinguishable only from the uterine cavity.
Corpus uteri - comprises the superior 2/3 of the uterus, starting with a free, wide and rounded
extremity (Fundus uteri), which receives bilaterally the fallopian tubes.
Facies vesicalis - the anterior surface; it is slightly concave, and it is oriented towards the vesica
urinaria. It is covered by peritoneum up to the level of the cervix.
Facies intestinalis - the posterior surface; it is convex, and it is oriented towards the rectum and the
small intestinal loops. Its whole surface is covered by peritoneum.
Margo uteri dexter et sinister - the two surfaces meet in the margins of the uterus; this has
symmetrically attached to it the fallopian tubes, the round and ovarii proprium ligaments, and also the
broad ligament of the uterus.
Cervix uteri - approximately 2 cm in length, it continues the body, and its inferior end enters the
vagina. The insertion of the vagina on the uterus divides the latter into a supravaginal and an
Portio supravaginalis cervicis - anteriorly it is below the reflection line of the peritoneum,
surrounded by connective tissue that contains the intersection of the arteria uterine with the ureter,
located 2 cm lateral from the margin of the uterus. Dorsally it is completely covered by peritoneum,
which reflects here onto the rectum and form the “Douglas pouch”.
Portio vaginalis cervicis - rounded, it protrudes into the vagina, and in nuliparous women has a small
opening in the middle (Ostium uteri). After the first delivery this transforms into an oval shaped
fissure, with two lips - Labium anterius et posterius.
Cavum uteri - a narrow, triangular space, with two infundibular extensions towards the ostia of the
Canalis cervicis uteri - the fusiform channel of the cervix opens into the vagina through the ostium
Isthmus uteri - located between the body and cervix uteri, about 1 cm long.
These maintain the relatively stable median position of the uterus, and allow for size and position
changes during pregnancy, and returning to the original position after delivery. The failure of the
anchoring structures results in position changes of the uterus (lateral deviation, lateroflexion or
prolapse). The cervix and insthmus are more strongly anchored.
Ligamentum latum uteri - it is a peritoneal doubling, extending between the lateral borders of the
uterus and the wall of the pelvis.
Ligamentum teres uteri - approximately 15 cm long, departs from the supero-lateral portion of the
corpus, passes through the broad ligament, turns anterior, passes through the canalis inguinalis and
ends up in the connective-adipose tissue of the labia major. Maintains anteversion of the uterus.
Parametrium - it is the connective tissue around the isthmus and cervix uteri, comprising the vesico-
uterine and sacro-uterine ligaments, parts of the sacro-recto-pubic retinaculum.
Ligamentum cardinale - connective tissue extending between the cervix uteri and the lateral wall of
Vascular and nervous supply
The arteries are branches of arteria uterina, which anastomoses with the other uterine artery.
The venae uterinae drain into the plexus venosus uterinus et vaginalis, located in the parametrium, and
subsequently into the vena iliaca interna.
The lymphatic vessels of the fundus and corpus drain towards the nodi lymphatici lumbales et aortici.
A small part is directed along the round ligament towards the nodi lymphatici inguinales. The
lymphatic vessels of the cervix drain towards the nodi lymphatici iliaci communes and interni.
The nerves come from the ganglion mesentericum inferius and make up the plexus uterovaginalis. In
this sympathetic plexus enter parasympathetic fibers from the S3-4 spinal nerves.
The copulating organ of the female, located between the bladder and rectum. From the cervix up to the
opening into the vulva, it measures about 7 cm anterior and 9 cm posterior.
Paries anterior et posterior - the two walls of the vagina are touching each other, with an “H” shaped
narrow space between them.
Fornix vaginae - the superior portion, inserted around the intravaginal segment of the cervix.
Rugae vaginales - transversal folds on the internal surface of the vagina.
Columna rugarum anterior et posterior - two median columns of the folds.
Carina urethralis vaginae - a small tubercle oriented towards the external urethral orifice.
Vascular and nervous supply
The arteries are branches of arteria uterina, which gives out the arteria vaginalis at the level of the
cervix uteri. This descends and anastomoses with the branches of the arteria vesicalis inferior and
arteria rectalis media. The veins have similar disposition.
The lymphatic vessels of the superior part of the vagina drain into the nodi lymphatici iliaci communes
and interni. The inferior part is drained into the nodi lymphatici inguinales. Some lymphatic vessels of
the posterior wall bypass the rectum and drain into the nodi lymphatici sacrales.
The nerves are identical to the uterine ones; some branches stem from the nervus pudendus.
Vulva - Pudendum femininum
Labium majus pudendi - two rounded skin folds
Mons pubis - a triangular prominence oriented downwards, located antero-superior to the symphysis.
Commissura labiorum anterior et posterior - the anterior and posterior joining points of these
Rima pudendi - the interlabial space, narrow slit-like in nulliparous women, wider in older and
Labium minus pudendi - two, about 4 cm long diverging folds on the internal surface of the labia
Frenulum labiorum pudendi - posterior joining fold of the above, which is ruptured at the time of
the first delivery.
Vestibulum vaginae - the labia minora delineate the vestibule.
Fossa vestibuli vaginae - a groove between the posterior commissure and the opening of the vagina.
Glandula vestibularis major (Bartholin) - a paired, bean sized vestibular gland, located
symmetrically at the base of the labia minora, on the musculus tranversus perinei profundus. Their
excretory ducts open on the posterior third of the labia minora. They correspond to the Cowper glands
of the male.
Bulbus vestibuli - an erectile tissue at the base of the labia minora, on both sides of the vestibule,
homologous to the male bulbus penis. The two narrowing vestibular bulbs unite into the glans clitoris
above the external urethra orifice.
Clitoris - above the labia minora, it is homologous to the male penis. It is attached to the inferior
border of the symphysis pubica through the ligamentum suspensorium clitoridis.
Crus clitoridis - the roots of the clitoris, attached to the pubis and ischium
Corpus clitoridis - anterior to the symphysis
Preputium clitoridis - a skin fold on the anterior end of the clitoris.
Frenulum clitoridis - two folds starting from the labia minora and joining below the clitoris.
Glans clitoridis - the glans of the clitoris.
Corpus cavernosum clitoridis - two, incompletely separated cavernous bodies.
Septum corporum cavernosorum - a comb-like septum between the corpora cavernosa.
Fascia clitoridis - the fascial layer of the clitoris.
Ostium urethrae externum - located below the clitoris.
Ductus paraurethrales (Skene ducts) - homologous to the excretory ducts of the prostate.
Ostium vaginae - between the inferior, convergent parts of the labia minora.
Hymen - a thin membrane blocking the ostium, its integrity denotes virginity.
Vascular and nervous supply
The arteries of the vulva are mainly from the arteria pudenda interna: ramii labiales posteriores, arteria
bulbus vestibuli, arteria profunda et dorsalis clitoridis. The labia majora are also supplied by the
arteriae pudendae externae through ramii labiales anteriores.
The veins drain in the plexus venosus uterinus and vaginalis. The blood of the labia majora is drained
by the vena pudenda interna and vena femoralis.
The lymphatic vessels drain towards the nodi lymphatici inguinales superficiales and iliaci externi.
The sensory nerves stem from the nervus ilioinguinalis and nervus pudendus; the autonomic fibers
come from the plexus uterovaginalis.
THE KIDNEY (REN)
- the kidneys are situated in the retroperitoneal space, having a asymmetrical
position related to the medio-sagital plane of the body
- capsula fibrosa – the fibrotic capsule covers the surface of the kidney
- capsula adiposa (corpus adiposum peri-renalis) – represents the fat tissue
situated around the fibrotic capsule of the kidneys
- fascia renalis – represents the fascia situated around corpus adiposum
perirenalis; it is made by two lamellas:
- lamella anterior – wich is thinn and un-interrupted in between the
right and the left side of the body
- lamella posterior (or fascia retro-renalis “Zuckerkandl”) – wich
is thicker and interrupted in between the right and the left side of the
- corpus adiposum para-renalis “Gerota” – represents the fat tissue situated
posteriorly in between lamella posterior (or fascia retro-renalis “Zuckerkandl”)
and the musculus quadratum lumborum
II. The EXTERNAL CONFIGURATION of the kidney:
- extremitas superior - the superior extremity wich is larger and
rounded, being situated under the diaphragm; the superior extremities
are more closed to the medio-sagital plane than the inferior ones
- extremitas inferior - the inferior extremity wich is thinner and sharper,
being situated on musculus quadratus lumborum and iliopsoas
II. The SURFACES of the kidney are:
- facies anterior – the anterior surface wich it is crossed on the right side
by the insertion line of mesocolon transversum
- facies posterior – the posterior surface wich is split by the 12th
a “thoracic” part and an “abdominal” part
III. The MARGINS of the kidney are:
- margo medialis – the medial margin wich is concave and presents in
the middle a opening (hilum renalis) wich is continued with a fossa
- margo lateralis - the lateral margin wich is convex
IV. The INTERNAL CONFIGURATION of the kidney:
- cortex renis represents the peripheric part of the kidney, wich is made
from pars radiata (with the urtinifer tubes - the pyramis “Ferrein”) and
pars convoluta (with the convolute tubes); from this level start the renal
columns (columnae renales “Bertin”) that are going to be situated in
between the renal pyramids
- medulla renis represents the central part of the kidney wich presents the
characteristic renal pyramids (pyramis renales) with the base oriented
towards the periphery of the kidney and the tip (papilla renalis) oriented
towards the sinus renalis
V. The urine-conducting system of the kidney is made by:
- calyces renales minores – they are in number of 8-9, being the first part
of the urinary drainage system; they start at the tip of the papilla renalis
and are drained into the major calyces
- calyces renales majores – they are in number of 3 (superior, medius,
inferior), being the second part of the urinary drainage system; they are
drained into the renal pelvis
- pelvis renalis – represents the larger sac wich collects the urine as the
third part of the urinary drainage system; it presents an intra-renal part and
a extra-renal part
- ureter – represents the pipe wich conducts the urine from the renal
pelvis to vesica urinaria
VI. The ARTERIES of the kidney – Arteria Renalis (dextra et sinistra):
- they emerge as visceral direct branches from aorta abdominalis at the
level of L1, having have a different length: the left one is shorter and the
right one being longer and passing under vena cava inferior
- before reaching the hilum renis they are giving a branch – arteria
- close to the hilum the renbal arteries are dividing in:
- ramus anterior – the anterior branch wich is going to give 4
-arteria segmenti superioris – for the superior extremity of
-arteria segmenti anterioris-superioris – for the antero-
superior pre-hilar zone of the kidney
-arteria segmenti anterioris-inferioris – for the antero-
inferior pre-hilar zone of the kidney
-arteria segmenti inferioris – for the inferior extremity of
- ramus posterior – the posterior branch wich is going to give 1
-arteria segmenti posterioris – for the posterior retro-hilar
zone of the kidney
VII. The VEINS OF the kidney - Vena Renalis (dextra et sinistra):
- they are drained as visceral direct branches in vena cava inferior at the
level of L1, having have a different length: the right one is shorter and the
left one being longer and passing over aorta abdominalis
- the left renal vein receveis directly the venous drainage from vena supra-
renalis inferior sinistra and vena testicularis/ovarica sinistra
VIII. The LYMPHATIC DRAINAGE AND INERVATION of the kidney:
- the lymphatic drainage of the limpha derives from three networks (and
it will be drain further on in the nodi lymphatici lombares):
- perirenal network – situated into the capsula adiposa renis and
having connections with the lymphatic system of the colon
- under-capsular network – situated superficially under the
capsula fibrosa renis
- profound network – situated deep into the tissue of the kidney
- the nervous branches from the ganglia caeliaca, ganglion mesentericus
superior and ganglia aorticorenalia, also with branches from nervus
- they are going into the kidney along with the renal vessels (plexus
IX. TOPOGRAPHICAL RELATIONSHIPS the kidney:
- the right kidney:
- anterior with: duodenum - DII (on the medial side of the surface
parahilar), hepar - lobus dexter (on the lateral side of the surface),
flexura colica dextra (at the insertion line of mesocolon
transversum), small intestin (under the insertion line of mesocolon
- posterior with musculus quadrates lumborum and musculus
iliopsoas (Trigonum “Petit”, Quadrulaterum ”Grynfelt”), through
corpus adiposum retro-renalis with nervus ilio-hipogastricus, ilio-
- superior with glandula suprarenalis dextra and indirectly through
the right hemi- diaphragm with the right pleural cavity and pulmo
- inferior with the small intestine
- the left kidney:
- anterior with: glandula suprarenalis sinistra (on the medial side of
the surface suprahilar), stomach (on the medial side of the surface
suprahilar under the suprarenal gland), cauda pancreatis (on the
medial side of the surface parahilar), small intestin (on the medial
side of the surface infrahilar), spleen (on the lateral side of the
surface), flexura colica sinistra (on the lateral side of the surface,
inferior to the spleen)
- posterior with musculus quadrates lumborum and musculus
iliopsoas (Trigonum “Petit”, Quadrulaterum “Grynfelt”) ), through
corpus adiposum retro-renalis with nervus ilio-hipogastricus, ilio-
- superior with glandula suprarenalis sinistra and indirectly through
the left hemi- diaphragm with the left pleural cavity and pulmo
- inferior with the small intestin
- the ureter is a musculo-membranous conduct wich connects pelvis renalis with
vesica urinaria, going downwards 1 cm medial to the tip of the costiform
aphophisis of the L3,4,5; on its course in presents two parts (abdominal and
pelvic) and three narrower zones (pielo-ureteralis – at the confluence of the
pelvis renalis with the ureter, marginalis – at the crossing point with linea
terminalis of the pelvis, vesicalis – at the entering point in vesica urinaria)
- pars abdominalis presents two segments:
- segmentum lombaris (from pelvis renalis untill ala ossis sacri); it is
longer than the iliac one and has topographical relationships with:
- anterior: crossed by the testicular / ovarian vessels (at the
level of L3), crossed by the colic vessels
- posterior: musculus ilio-psoas, nervus genito-femoralis and
nervus cutaneus femoris lateralis
- lateral – the medial margin of the kidney and the colon
(ascending on the right and descending on the left)
- medial – vena cava inferior (on the right side) and aorta
abdominalis (on the left side)
- segmentum iliacus (from ala ossis sacri until linea terminalis); it is
shorter than the lombar one and has topographical relationships with:
- anterior: crossed by radix mesenterii (on the right side) and
by radix mesocolon transversum (on the left side)
- posterior: a. iliaca externa (on the right side) and a. iliaca
communis (on the left side)
- pars pelvina presents three segments:
- segmentum parietalis (fixed, situated on the internal iliac vessels)
medially having topographical relationships with the ovarium (on female)
- segmentum visceralis (mobile, situated in between the walls of the
pelvis and the vesica urinaria), having different topographical
- in male situated in between the vesica urinaria and rectum,
crossing the ductus defferens by posterior and inferior
- in female situated in the base of ligamentum latum uteri, crossing
the arteria uterina by posterior and inferior
- segmentum intramuralis (situated into the wall of vesica urinaria and
being opened into the posterior angles of trigonum “Lieutaud”)
I. The ARTERIES of the ureter:
- they emerge as branches from different sources:
- from a. renalis – for the upper third
- from a. testicularis/ovarica – for the middle third
- from a. ducti deferens / a. uterina, a. vesicalis inferior – for the
II. The VEINS of the ureter:
- they are drained corresponding with the venous drainage of the arterial
VII. The LYMPHATIC DRAINAGE AND INERVATION of the ureter:
- the lympha is drained in the nodi lymphatici lombares (from pars
abdominalis) and in nodi lymphatici iliaci intyerni (from pars pelvic)
- the nervous branches are coming from plexus renalis for the upper
third, plexus aorticus abdominalis for the middle third, plexus iliacus
(for the inferior third)
- the suprarenal gland are situated in the retroperitoneal space, being situated on
the superior extremity of the kidneys
III. The EXTERNAL CONFIGURATION of the suprarenal gland:
- the suprarenal gland has the shape of a pyramid, the right one being
situated on the top of the right kidney and the left one being situated
mainly on the medial margin of the left kidney; due to this different
disposition the complex kindey-suprarennal glad has the same height on
the right and left side (despite the fact that the right kidney is situated on
a lower level compere with the left one)
II. The SURFACES of the suprarenal gland are:
- facies anterior – the anterior surface wich presents the hilum
- facies posterior – the posterior surface wich is oriented towards the
- facies inferior (renalis) – the posterior surface wich is oriented towards
the superior extremity of the kidney
III. The MARGINS of the suprarenal gland are:
- margo medialis – the medial margin
- margo superior - the lateral margin
IV. The INTERNAL CONFIGURATION of the suprarenal gland:
- cortex suprarenalis represents the peripheric part of the suprarenal
gland, wich is made from zona glomerulosa (small round cells arranged
in groups), zona fasciculata (thicker, with large clear cells) and zona
reticularis (thinner, situated around the medulla and presenting lines of
cells and in between them blood capillaries)
- medulla suprarenalis represents the central part of the suprarenal gland
wich presents cells that are secreting the specific hormons of the
V. The ARTERIES of the suprarenal gland:
- they emerge as visceral branches from different sources:
- arteria suprarenalis superior – branch from a. phrenica inferior
- arteria suprarenalis media – direct branch from aorta abdominalis
- arteria suprarenalis inferior – branch from a. renalis
VI. The VEINS of the suprarenal gland:
- they are collected into a singke vein (vena centralis) drained differently:
- on the right side as visceral branch direct branches in vena cava
- on the left side as visceral branch in vena renalis sinistra
VII. The LYMPHATIC DRAINAGE AND INERVATION of the
- the lympha is drained in the nodi lymphatici lombares
- the nervous branches from mainly from nervi sphlahnici
- they are going into the kidney along with the renal vessels (plexus
IX. TOPOGRAPHICAL RELATIONSHIPS the suprarenal gland:
- the right suprarenal gland:
- anterior with the hepar - lobus dexter (at the level of area nuda)
- posterior with the muscles of the posterior abdominal wall
- superior indirectly through the right hemi- diaphragm with the
right pleural cavity and pulmo dexter
- inferior with the superior extremity of the right kidney
- medial with vena cava inferior and ganglion caeliacum dextrum
- the left suprarenal gland:
- anterior with the cauda pancreatis
- posterior with the muscles of the posterior abdominal wall
- superior indirectly through the right hemi- diaphragm with the left
pleural cavity and pulmo sinister
- inferior with the medial margin (the supra hilar part) and with the
superior extremity of the left kidney
- medial with aorta abdominalis and ganglion caeliacum sinistrum
The muscles of the perineum(Musculi perinei)-are disposed in three layers and they fuse into a
common tendon situated in the middle part of perineum called centrum tendinei perinei. All are
innervated by the pudendal nerve.
1.M.levator ani-the most profound muscle of the perineum, is situated between the lateral walls of the
lesser pelvis, rectum and coccyx.
-the superior part of ramus pubicus;
-the inferior part of ilium bone;
-a thickness of fascia obturatoria-Arcus tendineus Rouget;
The fibers are organised in three major parts:
-M.pubococcygeus-in the middle;
-M.iliococcygeus-the outer part.
On the median line the fibers delimits a space for the anus, genitals organs in women and urethra.
The levator ani muscle with its fascias is called diaphragma pelvis and represents the inferior wall of
the abdominal cavity.
2.M.ischiococcygeus-belongs to the profound plane, between spina ischiadica and coccyx. It is
situated lateral and posterior to the levator ani.
3.M.sphincter ani externus-is situated around the canalis analis and presents three parts:
-Pars subcutanea-by its contraction makes cutaneus folds in the perianal region. It’s also called
M.corrugator cutis ani;
-Pars superficialis-is the most important part, contains fibres which start from ligamentum
anococcygeus and end on centrum tendineum surrounding the anus.
-Pars profunda-is thin and is attached to the internal sphincter muscles-is situated on the Pecten level.
The contraction of each part closes the canalis analis.
4.M.transversus perinei profundus
The origin is on the ramus pubis inferior and ischium and is inserted on the centrum tendineum. It
belongs to the perineum anterior. With its fascias it is called diaphragma urogenitalis.
5.M.transversus perinei superficialis-a small muscle with transversal disposition between tuber
ischiadicum and centrum tendineum.
6.M.sphincter urethrae-the Wilson’s muscle-consist in circular fibers detached from diaphragma
7.M.ischiocavernosus-starts from the inferior part of the ischium and ends by surrounding corpus
8.M.bulbospongiosus-starts from centrum tendineum and ends on radix penis.
The fascias of perineum
Fascia pelvis -is situated superior to the muscles of the lesser pelvis. It presents the following parts:
-fascia obturatoria superior-cover m.obturatorus internus. Presents a horizontal thickness – arcus
tendineus Rouget, which represents a part of the origin of levator ani muscle.
-fascia piriformis-cover the piriform muscle;
-fascia diaphragmatis pelvis superior – cover the levator ani muscle and ischiococcygeus muscle;
Fascia visceralis:-the adventitia of the pelvic organs.
Fascia obturatoria inferior-situated under the Rouget arch, inside of fossa ischioanalis;
A vertical thickness of it is called Canalis pudendalis Alcock which contains the pudendal artery and
Fascia diaphragmatis pelvis inferior- covers the inferior surface of m.levator ani.
Fascia diaphragmatis urogenitalis superior: covers the superior surface of the m.transversus perinei
Fascia diaphragmatis urogenitalis inferior:is thick and resistant-called also the ligament of
The two fascias are fused anterior to the muscle transversus perinei profundus, resulting in
Ligamentum perinei profundus and posterior in centrum tendinei.
Fascia perinei superficialis-is situated under the skin and cover the superficial muscles
(ischiocavernosus and bulbospongiosus).
A rhomboid shape bordered by symphisa pubica, ramus ischiopubicus, tuber ischiadicum and coccyx.
A horizontal line divide the perineum in perineum anterior (Regio urogenitalis) et posterior (Regio
The posterior perineum presents the same elements at both genders, the anterior perineum present
Represents the posterior triangle, perforated by the anus.
The skin is mobile, with hair and seborrheic glands.
The subcutis consist in arteries branched from a.pudenda externa, veins and nerves. Fascia perinealis
superficialis is missing in this region.
M.sphincter ani externus with its three parts.
Diaphragma pelvis-consist in musculus levator ani with fascia diaphragmatis pelvis superior et inferior
Fossa ischioanalis-two paired cavities situated arround the canalis analis. It is bordered :
-inferior-the covering plan of the region;
The content of the fossa ischioanalis is fat tissue: corpus adiposum fossae ischiorectalis and Canalis
The rapports of Canalis analis in the perineal region:
-posterior-the posterior fibers of levator ani muscle and ligamentum anococcygeum;
-anterior- in men-the prostate and Cowper glands;
- in women-the posterior wall of the vagina;
Canalis analis with external and internal aspects was presented in another chapter (rectum)
The anterior perineum in men
In this region are situated the masculine genital organs and the urogenital diaphragm is perforated by
The skin of the region is mobile and presents on the median line a thickness which is continued
anteriorly by the raphe scroti.
The subcutis is thin with vessels and nerves (the pudendal pedicle).
Spatium perinei superficiale-is situated between the fascia perinei superficialis and diaphragma
urogenitalis. The content of this space is:
-corpus cavernosus, covered by m.ischiocavernosus;
-the Cowper glands canal;
-vessels and nerves for the penis;
Spatium perinei profundum-is situated between the fascia diaphragmatis urogenitalis superficialis and
profunda. The content of this space:
-m.transversus perinei profundus;
-the Cowper glands;
-the pudendal pedicle.
The anterior perineum in women
Is the region of the external genitals organs (vulva with its elements).The urogenital diaphragm is
perforated by the urethra and vagina.
Spatium perineale superficiale
-m.bulbospongiosus and ischiocavernosus;
Spatium perineale profundum
- it represents a thin layer of cells wich are making togheter a thin
membrane ( a serosa) wich is placed on the inner part of the thoracic cavity
and on the lungs
I. The COMPONENTS of the pleura are:
- pleura parietalis – the parietal pleura wich is coating the internal side of
the thoracic cavity (on the fascia endo-thoracica); it presents several parts:
-pleura costalis – is coating the inner side of the ribs, intercostal
spaces and a small part of the sternum; its upper part is situated
above the aperthura thoracica superior with 3-4 cm and it is named
- pleura diaphragmatica – is coating the superior part of the
diaphragm (except centrum tendineum)
- pleura medistinalis – situated into the sagital plane in between
the sternum and the thoracic vertebrae, being in contact with the
organ of the mediastinum; around the hilum of the lungs pleura
medistinalis is continued with pleura visceralis; this transition line
has a stronger constitution wich gives liggamentum pulmonale of
- pleura visceralis – the visceral pleura wich is coating the lungs
- cavum pleurae – the pleural cavity (virtual) is situated in between the two
components of the pleura; the two pleural cavities (the right from the left
one) are completely separated
- liquor pleuralis – the liquid of the pleural cavities, in cuantity of several
milliliters wich has the role of lubrifiyng the surfaces wich are coming in
contact durig the ventilatory movements of the lungs
II. The TOPOGRAPHICAL RELATIONSHIPS of the pericardium are:
- anterior - with the thymus (superiorly), the sternum (inferiorly) -here
presenting ligg. sterno-pericardica - and with the 4-6th
- posterior - with the oesophagus
- right and left - with pleura mediastinalis on each side and through it
with the medistinal surface of each lung
III. The CONTENT of the pleural cavity is made by:
- pulmon – the lung on each side is completely included into the pleural
cavity (wich is completely separated from the opposite one)
- recessus pleuralis – the recessuses of the pleural cavities are
complementary spaces of the pleural cavity wich are destined to
accommodate the lung in forced inspiration:
-recessus costo-diapragmaticus – it is the biggest and most
important recessus (being the lowest point of the pleural cavity in
ortostatism); it is situated in between the costal and diaphragmatic
parts of pleura parietalis along the base of the lungs, in the middle
axillary line the depth of the recessus being approximately 5-6 cm
-recessus phrenico-mediastinalis – it is situated in between the
diaphragmatic and mediastinal parts of pleura parietalis, near the
-recessus costo-mediastinalis – it is situated in between the costal
and mediastinal parts of pleura parietalis near the sternum, being
more evident of the left side
IV. The A-V-N package of the pleura parietalis is made by:
- arteries - branches from the sources that are vascularising the thoracic
wall and the diaphragm
- veins – they are drained into the intercostal veins and into the superior
- nerves – branches from n. phrenicus, n. vagus , n. intercostales and from
the symphatic thoracic chain
- lympha – is drained towards the intercostals and diaphragmatic lymph
- the A-V-N package of the pleura visceralis is given by the corresponding
branches of the lung
V. The TOPHOGRAPHY of the pleural cavity:
- the reflection line of the recessus costo-mediastinalis from the right side
starts at the level of the right sterno-clavicular articulation, from here goes
inferiorly and towards the left side of the body reaching the middle line of
the sternum at the level of the 2nd
costo-sternal articulation; from here
goes downward vertically on the middle line of the sternum until the level
of the 4th
sterno-costal articulation, here being deviated slighty towards
the right side of the body reaching the 7th
- the reflection line of the recessus costo-mediastinalis from the left side
starts at the level of the left sterno-clavicular articulation, from here goes
inferiorly and slighty towards the right side of the body reaching the 2nd
costo-sternal articulation; from here goes downwards vertically along the
left margin of the sternum resching the 4th
sterno-costal articulation, here
being deviated towards the left side of the body reaching the 7th
cartilage at a point situated approximately 3-4 cm laterally to the left
margin of the sternum
-due to the convergent disposition of the two pleural reflection lines
situated superiorly in the back of the manubrium sterni, at this level
they will delineate a triangular area (with the base up) uncovered by
the pleura and named aria interpleuralis superior = the timic
-due to the divergent disposition of the two pleural reflection lines
situated inferiorly in the back of the corpus sterni, at this level they
will delineate a triangular area (with the base down) uncovered by
the pleura and named aria interpleuralis inferior = the pericardic
- the reflection line of the recessus costo-diaphragmaticus from both sides
starts at the level of the 7th
sterno-costal articulation, from here goes
inferiorly and laterally intersecting the 8th
costa in the medio-clavicular
line, the 10th
costa in the middle axillary line and from here goes
horizontally towards the level of the 12th
VI. CUPOLA PLEURALIS:
- the pleural domes are the parts of the pleura parietalis that are situated
above the level of the first rib, being placed simetrically into the apertura
thoracica superior, posteriorly raching the level of the Th1 vertebra
- here pleura parietalis is separated to the profound structures of the neck by
fascia endothoracica who has at this level a fibrotic constitution (being
named fascia of “Sibson”)
- the pleura parietalis plus fascia of “Sibson” are suspended by the nearby
bony structures by fibrotic structures wich are named the pleural
suspension apparatus of “Sebileau-Zuckerkandl”:
-ligamentum costo-cupularis – situated in between the neck and
the internal margin of the first rib
-ligamentum transverso-cupularis – situated in between the
transverse apophisis of the C7 vertebra and the internal margin of
the first rib
-ligamentum vertebro-pleuralis – situated in between the bodies
of the C7, Th1 and Th2 vertebras and the fascia of Sibson
- ligaments situated in between the fascia of Sibson and the other
structures and organs of the neck
- the tophographical relationships of the cupola pleuralis are:
- anterior - with artera subclavia (its retro-scalenic part) and the
branches deriving from this level (truncus costo-cervicalis, arteria
mamaria interna), nervus phrenicus’ also with the anterior part of
the first rib and with the clavicle
- posterior - with the head and neck of the first rib, inferior trunk
of plexus brachialis, thoracic symphatic chain and the first
- right - with vena brachiocephalica dextra and nervus vagus
dexter, truncus lymphaticus
- left - with the bifurcation of vena brachiocephalica sinistra and
nervus vagus sinister, ductus thoracicus
THE DIAPHRAGMATIC REGION
- the diaphragmatic region represents the inferior wall of the thoracic cavity
wich is separating it from the peritoneal cavity
- the main component of the region is the diaphragm muscle (diaphragma)
wich is covered on the superior surface by fascia endothoracica (and
indirectly through this by pleura parietalis) and on the inferior surface by
fascia endo-abdominalis (and and indirectly through this by peritoneum
I. The DIAPHRAGM muscle is developing at the neck level, from where is
going distally towards the border in between thorax and abdomen; it presents:
a. CENTRUM TENDINEUM – the tendinous center is situated in the
middle, having a stronger platform-like constitution and being made by three
parts: anterior (the smallest), sinister et dexter (the biggest); it presents:
- ostium venae cavae inferioris - the orifice of the inferior vena cava
wich has a tendineous constitution (inextensible) and it is situated at the
meeting point in between the right and the anterior part; it serves for the
passage of the inferior vena cava and a branch of the right phrenic nerve
b. PARS MUSCULARIS – the muscular part is situated at the periphery
around the tendineous center, being made by three parts:
- pars lumbaris - the lumbar part is made at its turn by three components
(principal, secundar and intermediary columns):
- the principal (or medial) columns wich are:
- crux mediale dextrum – the right medial/principal column, the
longer one, inserted on the anterior surface of the of L1-4 vertebras
- crux mediale sinistrum – the left medial/principal column, the
shorter one, inserted on the anterior surface of the of L1-3 vertebras
- hiatus aorticus – the aortic orifice (situated at the level of
the Th12 vertebra) is situated posteriorly on the middle line
and it is made by crossed muscular fibres from the two
columns; it presents also fibrotic fibers (so it is inextensible)
and it serves for the passage of the aorta and the thoracic duct
- hiatus oesophageus – the esophagian orifice (situated at
the level of the Th10-11vertebra) is situated posteriorly on
the middle line but in front and above to the aortic orifice; it
is made also by crossed muscular fibres from the two
columns; it serves for the passage of the esophagus and the
- the secundar (or lateral) columns are situated laterally to the principal
columns, and they present:
- liggamentum arcuatum mediale – the first lateral/secundar
column (= medial arched ligament = the psoas arch), wich is
situated medially over the psoas muscle, in between the body of
Th1 and the tip of the transverse aphophysis of the same Th1
-liggamentum arcuatum laterale – the second lateral/secundar
column (= lateral arched ligament = the quadratus lumborum arch),
wich is situated laterally over the quadratus lumborum muscle, in
between the tip of the transverse aphophysis of the Th1 and the tip
of the 12th
- the intermediary columns are situated in between the principal and the
secundar columns, being thinner and inserted on the body of the L2
- pars costalis - the costal part starts from the medial surface of the 7-12
- pars sternalis - the sternal part starts from the medial surface of the
sternum and it is made by two (right and left) parts, in between them
being a thin space through wich the anterior mediastinum communicates
with the pre-peritoneal space
- trigonum lumbo-costalis “Bochdalek” represents is a triangular space
whithout muscular fibers situated in between pars lumbaris and pars
costalis (with the base at the 12 rib and the tip oriented towards the
meeting point in between the muscular fibers of the lumbar and costal
- hiatus costo-sternalis “Larrey” represents a smaller triangular space
whithout muscular fibers situated in between pars costalis and pars
sternalis (through this space the internal mammary artery passes from
thorax towards the abdomen becoming the superior epigastric artery)
- in between the principal columns and the intermediary columns there is a
small space wich serves for the passage of the azygos veins and the
- in between the secundar columns and the intermediary columns there is a
small space wich serves for the passage of the symphatic trunk
II. The VASCULO-NERVOUS PACKAGES of the DIAPHRAGMA are:
e. arteries – are given by two main sources:
- arteria phrenica superior – direct branch from aorta thoracica
(pars descendeds), it vascularises the superior surface of the
- arteria phrenica inferior – direct branch from aorta abdominalis,
it vascularises the inferior surface of the diaphragma
- indirect branches from internal mammary artery and intercostals
f. veins – are drained in two directions:
- venae phrenicae superiores – drained mainly in the azygos
system (and from here in vena cava superior)
- venae phrenicae inferiores – drained mainly in vena cava
g. nerves – are given by one source - the phrenic nerve - with comes from
the cervical plexus C3-5 (with the fibers originating from C3-4 being
destined for the anterior part and the fibers originating from C5 - the
phrenic accesor nerve - being destined for the posterior part):
- nervus phrenicus sinister wich presents:
- an anterior branch
- an posterior branch (wich gives an inferior branch wich
goes through hiatus oesophageus towards the left inferior
surface of the diaphragma)
- an lateral branch
- nervus phrenicus dexter wich presents:
- an anterior branch
- an posterior branch (wich gives an inferior branch wich
goes through hiatus venae cavae inferioris towards the right
inferior surface of the diaphragma)
h. lymphatics – are drained in corresponding regional nodules:
- the antero-superior part – the limpha from this part is drained
towards nodi lymphatici sternales
- the postero-superior part – the limpha from this part is drained
towards nodi lymphatici medistinales posteriores
- the lateral part – the limpha from this part is drained towards
nodi lymphatici costales
- the inferior part – the limpha from this part is drained towards
nodi lymphatici caeliaci
III. Topographical relationships of the DIAPHRAGM are:
a. superiorly – the tendinous center is in direct contact with pericardium
and the heart; the lateral muscular parts are in contact through pleura
parietalis with the pleural cavities and the lungs
b. inferiorly – the tendinous center and the lateral muscular parts are in
indirect contact through peritoneum parietalis with the peritoneal cavities
(so with the liver, stomach, spleen); through the retro-peritoneal space in
direct contact with the suprarenal glands and the kidneys
c. - the right hemidiaphragm reaches the 4th
- the left hemidiaphragm reaches the 5th
- hiatus venae cavae inferioris reaches the Th9 level
- hiatus oesophageus reaches the Th10 level
- hiatus aorticus reaches the Th11 level
The small intestine
The two parts of the small intestine are the longest parts of the digestive tract, measuring about 5-6 m
(1/4 jejunum and 3/4 ileum).
-both parts have the same external aspect: a round shape covered by visceral peritoneum except a thin
line where the mesenterium is inserted. They are organised in 15-16 intestinal loops which lie all over
the inframesocolic compartment.
-sometimes at 50-70 cm to ileocecal joint there may be situated the Meckel diverticulum – an
embryological rest of omfaloenteric duct.
-the mesenterium -represents the root of the jejunum and ileum. It’s composed by vessels, nerves,
lymph vessels and fat tissue situated between two peritoneal walls. The insertion of mesenterium is
oblique, on the peritoneum parietale posterior (radix mesenterii) and crosses from left to right: left
ureterus, vena mesenterica inferior, aorta abdominalis, vena cava inferior, right ureterus and the right
genital vessels. With the colic frame, the inframesocolic space splits into trigonum
mesentericocolicum dextrum et sinistrum.
Due to the muscularis mucosa contractions, the internal aspect appears with a lot of mucosal folds
(plicae circulares Kerkring). These folds are more developed into the superior part (jejunum) and less
at the end of ileonum. By folding the mucosa, the intestines increase the absorption surface by 400%.
Vilii intestinales (about 5-10 million) – represent rounded projections of the mucosa 0.5-1.5 mm high,
increasing the intestinal surface by 600%. Each one contains the epithelium which covers the pedicle-
arteries, vein, a thin muscle and lymph vessel.
The intestinal layers:
-epithelium made by columnar cells. Each cell again increases the absorption
surface by folding the cell membrane. Between the villus intestinales the cells are
organised into the intestinal glands(Glandulae intestinales Lieberkuhn) with
-soft tissue- contains a rich network of lymph vessels and nodes organised in two structures:
Folliculi lymphatici solitari and Folliculi lymphatici agregati- Peyer. The last ones are present only in
the ileonum terminale ;
-muscularis mucosa- gives by its contraction plicae circulares.
-submucosa: consists in areolar tissue with blood and lymph vessels and plexus
-tunica muscularis-contains a longitudinal outer layer and a circular inner layer. Between
them is situated the Plexus mientericus Auerbach;
-serosa- the peritoneum covering the intestinal outer surface, except the insertion of mesenterium.
Vessels and nerves:
-Arteries – arise from A.mesenterica superior and there are 10-16 Aa.jejunales and ilei. These arteries
are organised in anastomotic arches (usually three levels and from the last level the small arteries
perforate the intestinal wall).
-Veins- with the same disposition, drain in Vena mesenterica superior;
-The lymph is drained through Folliculi lymphatici solitari and Folliculi lymphatici agregati-Peyer in
Trunci intestinales and then in Cysterna Pecquet.
-The sympathetic nerves arise from plexus celiacus and with parasympathetic branches from nervus
vagus enter into the two plexus: submucosus Meissner and mientericus Auerbach.
The large intestine (Intestinum crassum)
The last part of the digestive tract begins at the ileocecal junction and ends with the anus. It measures
about 1,5 m, consisting of six different segments: caecum, colon ascendens, colon transversum colon
descendens, colon sigmoideum and rectum.
External aspect of the colon
The particular external configuration of the colon is due to the disposition of the muscular layer.
The longitudinal one is organised in three taenias:
-Tenia libera-visible on the entire anterior surface.
-Tenia mesocolica-represents the insertion of the mesocolons;
-Tenia omentalis-consists in insertion of omentum majus on the transversal colon.
The three taenias are joined proximally at the insertion of appendix in caecum and distally in the outer
longitudinal muscular layer of the rectum. On the surfaces of the taenias are inserted Appendices
epiploicae-fat tissue covered by peritoneum
The circular layer by its contraction will give to the colon a particular aspect with dilatated parts
(Haustra coli) separated by circular contracted muscular layer.
The colon layers
-mucosa: is flat with no circular folds or villus. The collumnar cells are organised in Glandulae
intestinales Lieberkuhn with a rich mucous secretion. The muscularis mucosa is very thin with just a
few lymph nodes.
-submucosa: consists in blood and lymph vessels and nerves.
-tunica muscularis: the longitudinal layer is organised in taenias and the circular layer separates the
-serosa: the peritoneum covering the colon surface, except the mesocolon insertions and the posterior
surface of colon ascendens and descendens.
1. Caecum et appendix vermiformis.
a.Caecum, a blind end of the colon, is the first part, situated in regio inguinalis dextra or fossa iliaca
dextra by 5-7 cm length. It lies on the iliopsoas muscle and femoral nerve. Anteriorly it is in direct
contact with the abdominal wall. Medially it is bordered by intestinal loops and ileocecal junction.
Laterally it is bordered by the iliac muscle and iliac crest. It’s continued superiorly by the colon
ascendens and inferiorly may be related with the urinary bladder, uterus and ovarium dextrum.
Usually the caecum is fixed to the posterior wall and the posterior surface is not covered by the
peritoneum. Sometimes due to a real mesocecum the organ is very mobile.
Between the caecum and the posterior peritoneum there are some blind cavities – Recessus ileocecalis
superior et inferior, separated by plica cecalia vascularis (a.iliocecalis) and plica ileocecalis. Recessus
retrocecalis is situated posterior.
-the opening of the ileonum is covered by a one way valve-valvula ileocecalis Bauhin. This valve
consists in two folds, superior and inferior.
-the opening of appendix is bordered also by a fold-valvula Gerlach.
b.Appendix vermiformis-is inserted in caecum at 2-3 cm distance to the ileocecal junction where the
three taenias are joined. The position of appendix is variable due to its mesoapendix. Usually the
normal position is the descending one to the pelvis presented in 30-40 % of the cases. The other
position are: appendix retrocecalis (behind the cecum), appendix mezoceliacus (with a medial
direction to the umbilical region between the intestinal loops), apendix pelvicus (the top of the
appendix is in the lesser pelvis), appendix subhepaticus (anterior or lateral to the caecum but the top of
the appendix is near the gall bladder). These positions may be described by numbers using the Gerota
clock, where the root of the appendix is in the middle and the top show on this clock shape different
hours depending on its position. The normal one it’s on 5 o’clock.
In clinical practice some points and triangles are described to indicate appendicular pain:
-Mac Burney point-situated between the lateral third and medial two-thirds of the right spinoumbilical
-Lanz point- situated between the lateral third and medial two-thirds of the bispinosus line;
-Iacobovici triangle-bordered by the following right lines: spinoumbilicalis, bispinosus and
The walls of the appendix are the same as the colon but in mucosa there are a lots of lymph follicles
and for these reason the appendix was called Tonsilla intestinalis.
2.Colon ascendens-situated in the right lateral region of the abdomen , in continuation of caecum until
the flexura colica dextra. It’s covered by the peritoneum only on the anterior surface. It is bordered by:
-anteriorly- the anterior abdominal wall and the inferior face of the liver (impressio colica);
-posteriorly: iliac muscle, quadratus lumborus muscle and the inferior part of the right kidney.
Between these elements and the ascending colon is situated the Told I fascia
-medially: the second part of duodenum, right ureterus and the genital vessels.
-laterally: the abdominal wall and the diaphragm (ligamentum phrenicocolicum dextrum);
Between the colon ascendens and the lateral abdominal wall there is a space: sulcus (spatium)
parietocolicus dexter. Through this space the supramesocolic region communicates with the pelvis.
3.Colon transversum-the most mobile part of the colon due to it’s wide root-mesocolonum
The right part of it is situated lower, at 10th
rib level that the left angle-flexura colica sinistra, situated
rib level. The position is variable, related with the greater curvature of the stomach. Flexura
colica sinistra is bordered by: anteriorly: the greater curvature and the diaphragm (ligamentum
phrenicocolicum sinistrum or Sustentaculum lienalis), laterally and superiorly with the spleen and
posteriorly with the left kidney. The mesocolonum transversum splits the abdominal cavity into an
supramesocolic space and an inframesocolic space. It is inserted on tenia mesocolica of the colon. The
root of mesocolonum transversum is inserted on the posterior wall and intersects from left to right the
left kidney, duodenujejunal angle, the anterior margin of the pancreatic body, the head of the pancreas,
the descending part of duodenum, vena cava inferior and the right kidney.
4.Colon descendens-is situated deeper in the left lateral region of the body. It lies on the posterior
muscles and the left kidney, the iliohypogastric and ilioinguinalis nerves. Between these elements and
the descending colon is situated the Told II fascia. Sulcus paracolicus sinister is bordered by the left
colon and the left abdominal wall.
5.Colon sigmoideum-presents two parts:
a. Pars iliaca-is fixed and lies on the iliopsoas muscle, artera et vena iliaca externa sinistra, the left
genital vessels and nervus genitofemoralis.
b.Pars pelvina-is mobile and presents the mesocolonum sigmoidei. It is bordered by the intestinal
6.The rectum-the last part of the digestive tract, measuring 12 cm length, is situated in the lesser
pelvis. The limit between rectum and colon sigmoideum is considered at the S3 level, where the
mesocolon sigmoidei ends.
The rectum presents two parts: ampulla recti (8-9 cm) and canalis analis(3-4 cm). In the sagittal plan
the rectum describes two curves: Flexura sacralis-with anterior concavity - corresponding to ampulla
recti and Flexura perinealis-with posterior concavity-corresponding to canalis analis.
Only a small part of the ampulla recti is covered by the peritoneum, the rest of it being situated in the
-In the superior part the mucosa presents three or four transversal folds called Plicae transversales
Houston. These folds are made by the muscular circular layer contraction. The most developed
(usually the third) is called plica Kohlrausch.
-In the inferior part at the limit between the ampulla and canalis analis there are 8-10 longitudinal
(vertical) folds Columna anales Morgagni. These folds delimit 8-10 grooves – Sinus anales with the
inferior part called Valvula anales.
-Linea pectinata-linia anorectalis anatomica-is traced by the inferior limits of Columna anales
Morgagni. It represents also the limit between a.rectalis media and inferior, the portal and caval
system, the autonomic and somatic innervation of the rectum.
-Linea alba Hilton-between the m.sphincter ani internus and m.sphincter ani externus-pars
-Linea anocutanea-the limit between the anal mucosa and the perineal skin.
-Pecten-the narrow segment of canalis analis, between linia alba and linia pectinata.At this level the
canalis analis wall presents the both sphincter muscles (internus et externus-pars profunda).
The vessels and nerves of the colon:
The colon and rectum receive blood supply from three major sources:
-A.ileocolica-the ended part of a.mesenterica superior, gives branches for ileonum
terminale, caecum (a.cecalis anterior and posterior) and appendix(a.appendicularis).
-A.colica dextra-is situated in the right angle of the colon and irrigates the colon
ascendens and the flexura colica dextra;
-A.colica media-is oriented upwards and is divided in two branches: the right one is
anastomosed with the ascending branch of colica dextra; the left one is
anastomosed with the ascending branch of colica sinistra resulting the Riolan
Haller arch in the left angle of the colon;
-A.colica sinistra-presents an ascending branch for the Riolan Haller arch and an
descending branch for the colon descendens;
-Aa sigmoideae-2-5 arteries for the sigmoid colon. The last one is anastomosed with
a.rectalis superior-the Sudeck anastomosis;
-A.rectalis superior-the last branch of a.mesenterica inferior irrigates the ampulla
rectalis and is anastomosed with the other rectal arteries;
-A.rectalis media-branches directly from a.iliaca interna;
-A.rectalis inferior-branches from a.pudenda interna , also from a.iliaca interna.
The blood of the colon and rectum is drained by veins with the same names as the arteries in vena
mesenterica superior (vena ileocolica , vena colica dextra and vena colica media) , vena mesenterica
inferior (vena colica sinistra, venaae sigmoidaeae and vena rectalis superior) and vena iliaca interna
(vena rectalis media and inferior). Between the vena rectalis media and superior results an portocaval
The lymph is drained in:
-Nodi lymphatici ileocolici;
-Nodi lymphatici colici dextri et colicii medii;
-Nodi lymphatici mesenterici superior;
-Nodi lymphaticii colici sinistri;
-Nodi lymphatici sacrales;
-Nodi lymphatici iliaci interni.
-The sympathetic innervation arises from plexus mesentericus superior and inferior for the colon and
plexus aorticus for the rectum.
-The parasympathetic innervation arise from nervus vagus for the caecum, colon ascendens and the
right two-thirds of colon transversum; for the left third of transversal colon, colon descendens, colon
sigmoidei and rectum the parasympathetic innervation arises from Nn splachnicii pelvini (S2-S4). The
limit between the two parasympathetic sources, situated on the transversal colon is called the Canon-
Boem point. It is also the vascular limit between artera mesenterica superior et inferior and the
embryological limit between mesenetron and metenteron.