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  • This was originally an anatomy review for first year medical students. I'm glad to see so many of you guys found it helpful. Interestingly, I'm not the person who posted it on the web. In fact, I had no idea someone did this! I don't mind though and I'm not sure I still have a copy myself. Good luck to everyone!
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Abdomen, Pelvis and Perineum Anatomy - www.jinekolojivegebelik.com Abdomen, Pelvis and Perineum Anatomy - www.jinekolojivegebelik.com Presentation Transcript

  • Abdomen, Pelvis and Perineum Dmitry Goldin [email_address]
  • Know all Terminology, use to navigate in the body
    • Inferior=caudal, superior=cranial, medial, lateral, dorsal=posterior, ventral=anterior
    • Deep vs. Superficial (think ‘onion’ layers of the body)
    • Proximal vs. Distal= further away from attachment point
    • Median plane= mid -sagittal plane ( skull has a sagittal sutur in the middle but sagittal planes move medial & lateral )
    • Transverse=axial= horizontal plane ( move sup./inf.)
    • Frontal=coronal plane (“crown”, can move ant.&post .)
    • Hand has dorsal(dorsum) and Palmar surfaces
    • Foot has dorsal (dorsum) and Plantar (sole) surfaces
    • Extension vs. Flexion ( exception w/ dorsiflexion vs. plantarflexion )
    • Abduction vs. Adduction
    • Opposition, reposition, supination, pronation, retrusion, protrusion, ELEVATION/DEPRESSION, eversion, inversion
  • Abdominal Internal Coverings
    • Visceral and Parietal Peritoneum – define peritoneal cavity
    • Ventral mesogastrium
    • Dorsal mesogastrium
    • Dorsal Common Mesentery
    Transversalis Fascia Extraperitoneal Parietal Peritoneum Intraperitoneal Visceral Peritoneum Gut tube
  • Ventral mesogastrium Dorsal mesogastrium Dorsal Common Mesentery In post-partum age, the ligaments that are the remnants of these membranes still retain their general attachment points (use for IDing in lab). NOTE – The intestines take a 270deg turn counterclockwise and the stomach takes a 90deg turn clockwise
  • Ventral Mesogastrium
    • Lesser omentum (double serosal layer)
        • Peritoneal reflection extends from porta hepatis to duodenum, and all to lesser curvature of stomach
      • Hepatogastric lig.
      • Hepatoduodenal lig.
        • Portal triad is within it in the free margin laterally
    • Ligaments of the liver
      • Falciform lig. – includes:
        • Ligamentum teres hepatis = round lig. of the liver
          • Inferior aspect of falciform lig.
          • Is the obliterated umbilical vein
      • Coronary lig.
        • Makes the right and left triangular lig.s
  • Dorsal Mesogastrium
      • Gastrosplenic lig. (gastrolienal)
      • Gastrophrenic lig.
      • Gastrocolic lig. (to transverse colon)
      • Spleno(lieno-)renal lig.
        • Contains tail of pancreas and splenic A .--> short gastric AA . and left gastroepiploic A . (splenic br.s inside lig.)
      • Phrenicocolic lig.
      • Greater omentum AKA Omental apron (“abdominal policemen”)
        • Hangs down from the greater curvature of the stomach. It adheres to areas of inflammation, preventing diffuse peritonitis. Also transmits R&L gastroepiploic vessels along greater curvature of the stomach.
  • Dorsal Common Mesentery
    • These transmit vasculature from retroperitoneal Aorta to peritonealized structures of the Mid- and Hindgut.
    • Mesentery (proper)
    • Mesoappendix
    • Transverse mesocolon
    • Sigmoid mesocolon
  • Intraperitoneal vs. Retroperitoneal
    • Stomach
    • Part 1 of duodenum
    • Jejunum, Ileum
    • Cecum, Appendix
    • Transverse colon
    • Sigmoid colon
    • Liver, Gallbladder
    • Tail of pancreas
    • Spleen
    • Parts 2,3,4 duodenum
    • Ascending, Descending colon
    • Rectum
    • Head, neck, body of pancreas
    • Kidneys, ureters
    • Suprarenal gland
    • Abdominal Aorta
    • Inferior vena cava
    *** Rule of Thumb : If it has a mesentery or mesogastrium component => Intraperitoneal
  • Primary vs. secondary Retroperitoneal?
    • Primary was always there
    • Secondary became retroperitoneal in development
    • Secondary Retroperitoneal:
      • Pancreas (not tail), most of duodenum (not part 1), ascending & descending colon
  • Omental Bursa (lesser peritoneal sac)
    • Result from stomach taking 90 degree clockwise turn
    • Anterior: liver, stomach, & lesser omentum
    • Posterior: diaphragm
    • Right side: liver
    • Left side: gastrosplenic and splenorenal ligs.
    • Communicates with greater peritoneal sac through the omental foramen (of Winslow) [Omental=Epiploic]
      • Posterior= IVC covered by parietal peritoneum; Anterior= Portal Triad in hepatoduodenal lig .; Inferior= 1st part duodenum ; Superior= caudate lobe in visceral peritoneum
  • Portal Triad - inside free margin of hepatoduodenal lig .
    • Portal V.
    • Proper hepatic A.
    • Common bile duct
      • Descends posterior to 1 st part of duodenum
    posterior anterior Lateral/right Medial/left V A D
  • Greater Peritoneal Sac
    • This is the remainder of peritoneal cavity
    • Greater omentum found here
    • Paracolic gutters are channels along ascending and descending colon
    • CLINICAL: Peritonitis or Ascites cause excess peritoneal fluid that flows downward through paracolic gutters to rectovesical pouch (males) or rectouterine pouch (females) when patient is sitting or standing. When patient is in supine position the fluid runs upwards through gutters to subphrenic and hepatorenal recesses .
  • Quick embryo: Fore-, Mid-, and Hind- Gut
    • These are the divisions of the primitive gut tube, which divide the gut nicely anatomically and functionally
    • Epithelial lining and glands of mucosa= endoderm
    • Lamina propria, muscularis mucosae, submucosa, muscularis externa = mesoderm
    • Foregut = esophagus, stomach, liver, gallbladder, pancreas, duodenum (up to major papilla in the 2 nd part)
    • Midgut = lower duodenum, jejunum, ileum, cecum, appendix, ascending colon, proximal 2/3 of transverse colon
    • Hindgut = distal 1/3 transverse colon, descending and sigmoid colon, rectum, and upper anal canal (above pectinate line )
  • Foregut
    • VAGUS N. provides preganglionic parasympathetic ( posterior vagal trunk passes thru celiac ganglion but does not synapse, the anterior vagal trunk courses on the stomach’s surface)
    • Greater Thoracic Splanchnic Ns . (T5-T9) provides preganglionic sympathetic, which synapse in celiac ganglion
      • Autonomics travel with vasculature from celiac trunk to organs
    • Celiac ganglion found on the crura of diaphragm in the vicinity of celiac trunk, (bulbous and has nerves!)
    • Blood supply : CELIAC TRUNK
      • Upper LV1
    • Splenic A.-largest, tortuous
      • On Sup. Border of pancreas
    • Common hepatic A.
    • Left gastric A.-smallest
  • Celiac trunk branches
    • Left gastric A. ->
    • esophageal br.s
    • Splenic A.:
      • Brs. to pancreas: dorsal pancreatic a ., A. pancreatica magna, caudal pancreatic as.
      • Brs. in splenorenal lig: short gastric as . and left gastroepiploic a .
    • Common hepatic A. -> right gastric a ., gastroduodenal A . (trunk for ant. and post.), and proper hepatic A .=>left hepatic a. + right hepatic a . (right gives off cystic a .)
  • Foregut embryo clinicals
    • Esophageal atresia associated with polyhydramnios and tracheoesophageal fistula.
      • Occurs when esophagus ends in blind tube from malformation of tracheoesophageal septum
    • Hypertrophic pyloric stenosis associated with projectile nonbilious vomiting and small palpable mass at right costal margin
      • Muscularis externa hypertrophies narrowing pyloric lumen
    • Extrahepatic biliary atresia associated with jaundice after birth, pale stool, and dark urine
      • When incomplete recanalization leads to occlusion of biliary ducts
    • Annular pancreas cause obstruction of duodenum when ventral and dorsal pancreatic buds form ring around duodenum
    • Macrosomia (increased birth weight) occurs when fetal islets are exposed to high glucose levels (uncontrolled diabetic) which stimulates insulin secretion causing increased fat and glycogen deposition
  • Midgut
    • Blood supply: SMA at lower LV1
      • SMA starts posterior to neck of pancreas and descends across anterior uncinate process and crosses anterior to 3 rd part of duodenum
    • VAGUS N. provides preganglionic parasympathetic
    • Postganglionic sympathetics from sup. mesenteric ganglion
  • SMA and branches
    • Inferior pancreaticoduo-denal A./trunk (splits into ant. & post. arteries)
    • Middle rectal A.
    • Right colic A.
    • Intestinal brs.
    • Ileocolic A. -> appendicular a.
    • Marginal A.
      • SMA syndrome – SMA is obstructed in some way
      • Nutcracker syndrome - SMA compresses left renal v. (crosses ant. to aorta and inf. to SMA) leading to varicocele in left testis
  • Midgut embryo clinicals
    • Duodenal atresia is associated with polyhydroamnios, bile-containing vomit, and distended stomach
      • Results from failure of recanalization
      • Same process for intestinal atresia or stenosis but Sx are not
    • Omphalocele : a light gray shiny sac protruding form the base of the umbilical cord
      • Results from the midgut loop failing to return to abdominal cavity
    • Ileal (Meckel’s) diverticulum is often asymptomatic but can become inflamed or ulcerated
      • Occurs when a remnant of the vitelline duct persists, forming a blind pouch on the antimesenteric border of the ileum
      • Rule of two’s: 2 in. long, 2 ft. proximal of ileocecal JXN, 2% pop.
    • Vitelline fistula is associated with fecal discharge from umbilicus
      • Occurs when the vitelline duct (connects yolk sac with gut) persists forming a direct connection b/w lumen and outside of body
    • Malrotation of the midgut is associated with volvulus which can compromise blood flow and result in gangrene
      • Result of midgut undergoing only partial rotation
  • Hindgut
    • Blood supply: IMA at LV3
    • Preganglionic parasympathetics from pelvic splanchnic ns. (S2-4)
    • Postganglionic sympathetics from inferior mesenteric ganglion
  • IMA and its branches
    • Left colic A.
    • Sigmoid As.
    • Superior rectal A.
      • Terminal br.
    • Marginal A.
  • Hindgut embryo clinicals
    • Aganglionic megacolon (Hirschsprung’s disease) is associated with the loss of peristalsis, fecal retention, and abdominal distention
      • Results from failure of neural crest cells to form the myenteric plexus in the sigmoid colon and rectum
      • Proximal to this the colon is distended with fecal material and the distal colon is narrow where plexus is missing
    • Anorectal agenesis is when the rectum ends as a blind sac above the puborectalis m. owing to abnormal formation of the urorectal septum
    • Anal agenesis is when the anal canal ends as a blind sac below the puborectalis m.
    • Rectovesical, rectourethral, or rectovaginal fistulas can accompany the above two disorders (fistula = abnormal lumen connections)
  • Referred pain overview Table 4-5. Referred pain pathways (visceral afferents) Left and right flanks and groins, lateral and anterior thighs L1,L2 Lumbar splanchnic nerves Hindgut (organs supplied by inferior mesenteric artery) Flanks (lateral regions) and pubic region T12 Least splanchnic nerve Kidneys and upper ureter Umbilical region T9,T10 (or T10,T11) Lesser splanchnic nerve Midgut (organs supplied by superior mesenteric artery) Lower thorax and epigastric region T5 to T9 (or T10) Greater splanchnic nerve Foregut (organs supplied by celiac trunk) Upper thorax and medial arm T1 to T4 Thoracic splanchnic nerves Heart Referral area Spinal cord level Afferent pathway Organ
  • Portal Venous System
    • Portal V. = Splenic V. + SMV
      • Posterior to neck of pancreas
      • IMV => splenic usually
    • PORTAL HTN (portal-caval anastomoses)
    • 1) Esophageal venous plexus
    • -left gastric v.  esophageal v.
    • 2) Rectal venous plexus
    • -sup. rectal v.  Middle & Inf. Rectal vv. =>internal iliac v.
    • 3) Paraumbilical vv.
    • -paraumbilical v.  supf. & inf. Epigastric vv.
    • 4) colic, testicular vv.
    • Results in:
    • Esophageal varices
    • Hemorrhoids
    • Caput Medusae
    History for portal HTN : vomiting blood, alcoholism, liver cirrhosis, schistosomiasis, ascites, splenomegaly
  • Abdominal Aorta
    • Abdominal Aortic Aneurysms (AAA):
    • Severe, central abdominal pain=> to the back; pulsatile tender mass below ~LV2; if rupture occurs then hypotension and delirium
      • Types: Saccular, Fusiform, Dissection
    • Common site: Below level of renal as. and SMA (IMA is in it)
    • Ruptured AAA most commonly below renal a. in the left posterolateral wall (retroperitoneal)
      • Need to compress above celiac a., in surgery the L. renal V. is in jeopardy
  • Abdominal aortic branches
    • Inf. Phrenic a.
    • Celiac trunk at upper LV1
    • Middle suprarenal A.
    • 1 st lumbar A.
    • SMA at lower LV1
    • Renal A.(right one lower)
      • upper LV2
    • Testicular/ovarian A.
    • 2 nd lumbar A.
    • IMA at LV3
    • 3 rd lumar A.
    • 4 th lumbar A.
    • Middle (median) sacral A. at upper LV4
    • Common Iliacs bifurcate at LV4
      • Right common Iliac A. crosses anterior to lower IVC at LV5
      • The 5 th lumbar As. come off median sacral A.
      • The perivascular plexus has postganglionic sympathetic fibers
  • Abdominal Venous Drainage
    • Azygous V. drains blood from IVC to SVC
    • Hemiazygous V. drains L renal v. to azygous
      • Ascending lumbar vv. => azygous &hemiazy
    • IVC forms at LV5
      • Posterior to aorta, ascends anterior
    • Testicular/ovarian, suprarenal, Inf. Phrenic vv.
      • Right ones into IVC
      • Left ones into left renal v.
  • Occlusion of IVC
    • This is more common than occlusion of SVC
    • Reroutes:
      • Azygous > SVC > right atrium
      • Lumbar vv. > external and internal vertebral venous plexuses > cranial dural sinuses > internal jugular v. > brachiocephalic v. > SVC
      • External iliac v. > Inf. Epigastric v. > sup. Epigastric v. > int. thoracic v. > brachiocephalic v. >SVC
      • Femoral v. > Greater saphenous v. > supf. Epigastric v. > thoracoepigastric v. > lat. Thoracic v. > axillary v. > subclavian v. > brachiocephalic v.
  • Lymph
    • Pre-aortic nodes:
    • Celiac nodes receive from inferior & superior mesenteric nodes
      • Drain GI tract
    • Celiac nodes empty into cisterna chyli (trunk that is the beginning of the thoracic duct)
  • Lymph - lateral aortic or lumbar lymph nodes receive lymphatics from the body wall, the kidneys, the suprarenal glands, and the testes or ovaries. - Pre-aortic nodes receive from GI tract (rectum too), as well as the spleen, pancreas, gallbladder, and liver -Finally, the lateral aortic or lumbar nodes form the right and left lumbar trunks , while the pre-aortic nodes form the intestinal trunk . These trunks come together and form a confluence that, at times, appears as a saccular dilation (the cisterna chyli ). This confluence of lymph trunks is posterior to the right side of the abdominal aorta and anterior to the bodies of vertebrae LI and LII . It marks the beginning of the thoracic duct .
  • Abdominal viscera - Esophagus
    • Enters at TV 10 , passing through sup. & post. Mediastinum
    • Upper esophageal sphincter is skeletal musc.;relaxes upon swallowing ( cricopharyngeus & inf. Pharyngeal constrictor ms. )
    • Lower esophageal sphincter is smooth musc.; prevents reflux
    • Constricted at 3 sites: pharynx-esophagus JXN, bifurcation of trachea, and gastroesophageal JXN
    • Clinicals:
      • Enlarged left atrium can constrict esophagus
      • Sliding hiatal hernia occurs when stomach and GE JXN herniate through diaphragm into thorax (heartburn, reflux, burning retrosternal pain; all of which are worse in supine position)
      • Paraesophageal hiatal hernia is only when stomach herniates (no reflux but can have strangulation)
      • ACHALASIA is failure of the LES to relax during swallowing (dysphagia, “bird’s beak deformity”, Chagas disease)
      • Esophageal reflux is from dysFXN of LES
      • Barrett esophagus - there’s gastric instead of strat. Squamous epithelium in distal esophagus due to reflux (can lead to cancer)
  • Stomach
    • Cardia, fundus (tympanic percussion from air), body, antrum, pylorus and canal
    • Pyloric antrum crosses midline and is most anterior part
    • Transpyloric plane at LV1
    • Stomach bed (rests on in supine position): left leaflet of diaphragm, left kidney, left suprarenal gland, transverse colon and mesocolon, spleen, and pancreas
  • Stomach clinicals
    • Gastric ulcers – presents with epigastric and left hypochondriac pain after a meal. Most common in the body of the stomach along lesser curvature. H. Pylori, say no more…
      • If ulcerates posteriorly then can damage pancreas and splenic a. and potentially cause fatal hemorrhage
    • GERD can cause cancer of esophagus
    • Hypertrophic pyloric stenosis – see earlier
    • Dumping sydrome is rapid emptying of hyperosmotic contents (high carb) into the jejunum and occurs after partial gastrectomy or vagotomy (diarrhea, hypoglycemia, dizziness, borborygmi=rumbling from gas
    • Cancer of the stomach can metastasize to the supraclavicular lymph nodes (Virchow nodes) on the left
  • Duodenum
    • 1 st or superior part – LV1 (AKA duodenal cap)
      • Only part that is peritonealized
      • DUODENAL ULCERS: most common anteriorly but can ulcerate into gastroduodenal A. posteriorly -> severe bleed
      • Common bile duct also crosses posteriorly
    • 2 nd or descending part – LV2/3
      • Plicae circulares begin
      • Receives CBD and main pancreatic duct posteriorly or medially at hepatopancreatic ampulla (of Vater)
        • CBD is narrowest here -> gallstone obstruction -> obstructive jaundice
        • Spincter of oddi
        • In the lumen major duodenal papilla marks this
    • 3 rd or horizontal part – crosses LV3 at midline
      • SMA crosses anterior and IVC and aorta posteriorly
      • Abdominal injury can crush this part against vertebra
    • 4 th or ascending part – up to LV2
      • Suspensory lig. (of Trietz) = cranial end of the dorsal mesentery
        • Supports duodenojejunal flexure
  • Jejunum
    • Villi long
    • larger crypts (glands)
    • Many large plicae circulares
    • Initial 2/5 small intestine
    • Long vasa recta
    • Main absorbtion site
    • Often empty
    • Thicker, more vascular, and redder than ileum
    • Located in umbilical region on the left
    • Villi short
    • smaller crypts
    • Small and few plicae circulares that diappear distally
    • Terminal 3/5 small intestine
    • Short vasa recta
    • Site of VIT B12 absorbtion
    • Prominent peyer patches
    • Ends at cecum
    • Located in hypogastric and inguinal region on right
    • More arcades
  • Large intestine
    • No villi
    • Largest crypts
    • No plicae circulares
    • Teniae coli (3 bands of smooth musc. that used to be longitudinal musc. layer before)
    • Epiploic appendages (fatty tags, fat is in extraperitoneal space )
    • Haustra (sacculations of the wall, separated by plicae semilunaris)
  • Small and large intestine– clinicals
    • Ileus – obstruction of small intestine
    • Celiac disease – hypersensitivity to gluten and gliadin protein found in wheat; causes immunologic damage to mucosa
    • Crohn disease – chronic inflammatory bowel disease, mostly in ileum (mass in right lower quadrant, strictures, & fistulas)
    • Appendicitis – caused by obstruction of lumen by fecal concretion and lymphoid hyperplasia.
      • INITIALLY referred pain is paraumbilical (T9-10)
      • LATER (after appendix touches parietal peritoneum) pain is at MCBURNEY’S POINT = 1/3 the way from ASIS going to umbilicus
  • Sigmoid colon
    • Intraperitoneal
    • Begins at SV1 (sacral promontory) & ends at SV3
    • Stores feces
    • Left ureter & left common iliac lie at apex of sigmoid mesocolon
    • At rectosigmoid JXN sigmoid colon bends anterior & to left
    • Clinicals
      • Diverticulosis  Diverticulitis
      • Often used in colostomy (it is diverted out through rectus abdominis m.)
      • Colonic Adenocarcinoma – accounts for 98% of all cancers in the large intestine; metastasis most common to liver
        • Right sided – iron def. anemia
        • Left sided – obstruction, bloody stools
    • Extraperitoneal
    • Begins at SV3
    • Ends at tip of coccyx
    • Puborectalis m. forms u-shaped sling and cause a 90deg perineal flexure
    • 3 transverse rectal folds (folds of Houston)
    • Clinicals
      • Polyps (FAP)
      • Ulcerative colitis – idiopathic inflammatory bowel disease (always in rectum & extends proximally)
      • Rectal prolapse – protrusion of the full thickness of rectum through anus
  • Anal Canal
    • Sup. Rectal A. (IMA)
    • Sup. Rectal v. > IMA > portal system
    • Deep nodes drain lymph
    • Autonomic motor innervation & stretch sensation (no pain)
    • Endoderm (hindgut)
    • Simple columnar
    • Int. hemorrhoids (sup. Rectal vs., no pain)
    • Has anal columns (of Morgagni) that at the base have anal sinuses (*anal fistula)
    • Inf. Rectal A. (int. pudendal A.)
    • Inf. Rectal v. > int. pudendal v. > int. iliac v. > IVC
    • Supf. Inguinal nodes drain
    • Somatic innervation (pudendal n. to ext. sphincter)
    • Ectoderm (proctodeum)
    • Stratified squamous
    • Ext. hemorrhoids (inf. Rectal vs., with pain)
    Lower Upper -divided by pectinate line -Surrounded by int. & ext. anal sphincter
  • Gallbladder and biliary ducts
    • Fundus, body, neck (posterior part)
    • Common hepatic duct + cystic duct (spiral valve of Heister) = common bile duct
    • Cystic A. off of right hepatic a.
    • Ampulla of Vatar (CBD is narrowest here and gallstones commonly get stuck  obstr. Jaundice & pancreatitis)
      • Spincter of oddi
    • Cholecystitis – pain in right flank (fundus is at 9 th costal cartilage) and radiates to right shoulder
      • Pain first along T5-T9 before touch parietal peritoneum
      • Could be from gallstone in cystic duct (Mirizzi syndrome when also blocks hepatic duct)
  • Liver
    • Understand the H
      • Left side formed by line through gallbladder and IVC (anatomical division of R + L lobes)
      • Right side formed by ligamentum teres & ligamentum venosum
      • Horizontal line formed by porta hepatis (hilum, no visc. Peritoneum)
    • FXNally (quadrate is left lobe & caudate is in R+L lobes)
      • Anatomically they are in left lobe
    • Ligamentum venosum (=obliterated ductus venosus)
    • Subphrenic & hepatorenal recesses
    • Bare area of liver = gap in coronory lig. (nothing b/w diaphragm & liver)
    • If hepatic A. comes off SMA then it passes post. To portal v.
  • Liver clinicals
    • Liver biopsy – at 10th intercostal space with patient exhaled
    • Resection of liver – hepatic vs. are landmarks that mark periphery in liver segment resection
    • Congenital biliary atresia – present within weeks after birth, jaundice doesn’t start immediately (bile duct proliferation, with dilation of bile canaliculi and bile plugs)
    • Alcoholism and Cirrhosis –cause Portal HTN
  • Pancreas
    • Retroperitoneal (except tail)
    • Receives dorsal pancreatic A. (sometime off celiac trunk), great pancreatic A., and caudal pancreatic as. From splenic A.
    • Main pancreatic duct (of Wirsung); Accessory (of Santorini)
    • 5 parts
      • Uncinate process (ventral pancreatic bud)
      • Head (ventral pancreatic bud & dorsal pancreatic bud) – in duodenal C-loop
      • Neck (dorsal pancreatic bud) – anterior to joining of SMV with splenic  portal v.
      • Body (dorsal pancreatic bud)
      • Tail (dorsal pancreatic bud) – toward spleen
    • Clinical
      • Acute pancreatitis – epigastric pain that radiates to back (biliary tract disease or alcoholism)
      • Pancreatic adenocarcinoma (very aggressive)– same pain + blocks common bile duct (obstructive jaundice)
        • Treatment – pancreaticoduodenectomy (Whipple procedure), which removes head of pancreas, duodenum, distal CBD, gallbladder, and distal stomach.
  • Spleen
    • Left hypochondriac region, anterior to ribs 9, 10, and 11
    • Does not extend below costal margin normally; palpable only in spenomegaly
    • Attached to stomach by gastrosplenic lig.
    • Attached to left kidney by splenorenal lig. (  left gastroepiploic vessels & short gastric as.)
      • Tail of the pancreas
    • Clinicals:
      • Splenic vein thrombosis associated w/ pancreatitis (gastric varices & upper GI bleed)
      • Splenectomy – removal of spleen can damage pancreas or left kidney depending on what lig.s and their respective as. That are damaged. Most commonly, atelectasis occurs (collapse) of the left lower lobe of lung.
      • Splenic A. aneurysm – particularly likely to rupture in pregnant women (resected from when present in women of childbearing age)
  • Urinary System - Kidneys
    • 5 segmental arteries (limited collateral circulation)
      • Ligation of one will cause necrosis of whole segment
      • Accessory (supernumerary) segmental as., if ligated cause necrosis of whole segment
        • Hilar if arise off renal a. and polar if directly from aorta
    • Segmental a.> interlobar a.> arcuate a.(base of pyramid, corticomedullary JXN) > interlobular a.> afferent arteriole
    • Surrounded by true renal capsule, perirenal fat, renal fascia (=false renal capsule), pararenal fat, then parietal peritoneum anteriorly and transversalis fascia posteriorly
      • Perirenal fat packs in structures in the hilus
    • Renal papilla > minor calyx > major calyx > renal pelvis
    • Superior poles are closer together
    • Left – 11 th + 12 th rib, right at 12 th rib
      • 12 th rib can get removed in kidney surgery
      • Left kidney transplanted more common because of longer renal v.
  • ANTERIOR POSTERIOR Renal pelvis Vein then artery
  • * Clinical * -Abscess internal to renal fascia in one kidney CAN NOT spread to other kidney b/c although renal fascia is continuous across midline, it wraps around central vessels very tightly
  • Kidney clinicals
    • Renal agenesis –when the ureteric bud fails to develop
      • Unilateral type is relatively common and asymptomatic
      • Bilateral (relatively uncommon, incompatible w/ life) causes oligohydramnios during pregnancy, which allows uterine wall to compress the fetus  Potter’s Syndrome
    • Horseshoe kidney – inferior poles fuse and kidney gets trapped at IMA
    • Urachal fistula – allantois persists forming direct connection b/w bladder lumen and outside at umbilicus
      • Urine drainage from the umbilicus!
    • Wilm’s tumor – most common primary renal tumor of childhood (displays 3 areas of embryological development: stromal, blastemal, and tubular areas)
    • Polycystic disease of kidneys – loops of Henle dilate forming large cysts
  • Ureters
    • Begin at ureteropelvic JXN, then descend retroperitoneally and anterior to psoas musc.. Then cross pelvic inlet into minor (true) pelvis where they are still retroperitoneal and cross anterior to common iliac bifurcation and follow internal iliac a.
      • Could be compromised by aneurysm of common iliac
    • End at ureterovesical JXN and open into bladder and define upper border of urinary bladder trigone.
    • “ Water under the bridge!”
      • Males – pass posterior to ductus deferens
      • Females – pass posterior & inferior to uterine A.
        • ***During hysterectomy ureter can be ligated with uterine A. (it is posterior to artery near cervix)
    • Pass posterior to testicular/ovarian vessels
    • 3 normal constrictions (kidney stones get stuck):
      • (1) at ureteropelvic JXN (2) where ureters cross pelvic inlet (3) and at ureterovesical JXN (intramural)
  • Ureter clinicals -Ureteric caliculi – obstruction of flow most often occurs at 2 nd and 3 rd constrictions causing unilateral hydronephrosis -Passing of kidney stones is an excruciating pain -ectopic openings (urine leakage)
    • Posterior surface (fundus/base)
      • In males related to rectovesical pouch, rectum, seminal vesicles, and ampulla of ductus deferens
      • In females related to anterior wall of vagina
    • Anterior surface
      • Related to pubic symphysis and retropubic space of Retzius
    • Superior surface
      • In males - peritoneal cavity
      • In females – vesicouterine pouch (peritoneal cavity)
    • Apex – related to median umbilical lig. or urachus
    Urinary bladder
    • Neck – in males related to prostatic urethra and prostate while in females related to urogenital diaphragm
    • Trigone of the bladder – on posterior surface of bladder and defined superiorly by ureters and inferiorly by urethra (internal urethral meatus)
  • Bladder clinicals
    • In infants, empty bladder lies within abdominal cavity
    • In adults, empty bladder is within minor pelvis, but when full can rise above pelvic inlet.
      • Suprapubic cystostomy (drain in acute retention)
        • Needle is passed through the ant ab wall [skin, supf. Fascia (camper + scarpa), linea alba, transversalis fascia, extraperitoneal fat, bladder wall)
        • Avoids entering peritoneal cavity
      • Incontinence (total, stress, urge, overflow types)
  • Urethra (male)
    • Males (3 parts)
      • Prostatic – post. wall has urethral crest that contains 2 openings of ejaculatory ducts. Prostatic ducts are lateral to urethral crest.
      • Membranous – crosses urogenital diaphragm and surrounded by deep tranverse perineal m. and sphincter urethrae m. (external sphincter)
        • Both musc. by pudendal n.
      • Penile (spongy/cavernous) – surrounded by corpus spongiosum, enlarges into fossa navicularis, and ends as external urethral meatus. Openings of bulbourethral glands just below urogenital diaphragm. (vulnerable to catheter penetration)
    • Females
      • Courses through urogenital diaphragm and is surrounded by deep transverse perineal m. and sphincter urethrae m. (latter musc. doesn’t completely surround urethra and is the reason for high incidence of stress incontinence in women)
      • Posterior surf. fuses with ant. wall of vagina
      • External urethral orifice opens into vestibule of vagina b/w labia minora
    Urethra (female)
  • Urine extravasation (from trauma)
    • Rupture of superior bladder wall (compression of full bladder) – INTRAPERITONEAL urine!
    • Rupture of anterior wall (from fractured pelvis, car accident) – EXTRAPERITONEAL in retropubic space of Retzius
    • Rupture of urethra above urogenital diaphragm (from fractured pelvis or catheter complication) – same as above
    • Rupture below urogenital diaphragm
      • Most common, happens in STRADDLE INJURY
      • Extraperitoneal, urine in supf. Perineal space  scrotal, penile, and ant. Ab wall areas (not thigh and anal triangle)
      • Internal to : colles fascia & dartos m. in scrotum, supf. Fascia (camper and scarpa) in ab wall, and supf. Fascia of penis
      • External to : external spermatic fascia in scrotum, external oblique m. in ab wall, and Buck’s fascia in penis
    • Rupture of penile urethra – urine is in penis only, beneath deep fascia (Buck’s) unless it is also torn then urine goes throughout supf. Perineal space
  • Suprarenal glands
    • Covered by renal fascia
    • Right is pyramid shaped, left is half-moon
    • Cortex
      • makes steroids (mineral-, gluco-, sex)
      • gets postganglionic sympathetic (vasomotor)
    • Medulla (NorE, 90% Epi)
      • has chromaffin cells=modified postganglionic sympathetic neurons (from neural crest cells)
      • Gets preganglionic sympathetics from splanchnic nn.
    • Blood supply:
      • (1) sup. suprarenal a. (from inf. Phrenic a.)
      • (2) middle suprarenal a. (off aorta)
      • (3) inf. suprarenal a. (off renal a.)
  • Posterior abdominal wall
    • Diaphragm
      • Retroperitoneum
      • Inf. Fascia = transversalis fascia
      • Inf. Phrenic aa.
    • Right crus: LV1-3 origin
      • Spincteric to esophagus, if enlarged  stomach can herniate
    • Left crus: LV1-2 origin
    • Central GSA pain (C3,4,5 dermatomes) refers to neck & shoulder
    • lateral arcuate lig. (quadratus)
    • medial arcuate lig. (over psoas & sympathetic trunk)
    • Quadratus lumborum m.
    • Psoas m. (Psoas Sign – flex thigh and psoas m. should irritate inflamed appendix)
    • Iliacus m.
  • Lumbar plexus (somatic, ventral primary rami) Table 4-6. Branches of the lumbar plexus Skin on anterior thigh and medial surface of leg Iliacus, pectineus, and muscles in anterior compartment of thigh L2 to L4 Femoral Skin on medial aspect of the thigh Obturator externus, pectineus, and muscles in medial compartment of thigh L2 to L4 Obturator Skin on anterior and lateral thigh to the knee   L2,L3 Lateral cutaneous nerve of thigh Genital branch-skin of anterior scrotum or skin of mons pubis and labium majus; femoral branch-skin of upper anterior thigh Genital branch-male cremasteric muscle L1,L2 Genitofemoral Skin in the upper medial thigh , and either the skin over the root of the penis and anterior scrotum or the mons pubis and labium majus Internal oblique and transversus abdominis L1 Ilio-inguinal Posterolateral gluteal skin and skin in pubic region Internal oblique and transversus abdominis L1 Iliohypogastric Function: sensory Function: motor Spinal segments Branch
  • Lumbar plexus cont.
    • Subcostal n. not part of plexus (T12)
    • Plexus forms posterior to psoas
    • Lumbosacral trunk (part of L4, all of L5) crosses ala of sacrum
    • Cremasteric Reflex (genitofemoral n.)
    -Know how nerves are in relation to psoas for lab IDing
  • Pelvis – men and women
    • Female : male
      • Inlet oval : heart shaped
      • Outlet larger in female b/c of everted ischial tuberosities
      • Cavity is wider and shallower in female
      • Subpubic angle larger and greater sciatic notch is wider in female
      • Female sacrum is shorter and wider
      • Obturator foramen is oval/triangular in female : round in male
  • Pelvic musc. Lateral rotation of the extended hip joint; abduction of flexed hip Branches from L5, S1, and S2 Medial side of superior border of greater trochanter of femur Anterior surface of sacrum between anterior sacral foramina Piriformis Lateral rotation of the extended hip joint; abduction of flexed hip Nerve to obturator internus L5, S1 Medial surface of greater trochanter of femur Anterolateral wall of true pelvis (deep surface of obturator membrane and surrounding bone) Obturator internus Function Innervation Insertion Origin Muscles of pelvic wall
  • Pelvic Diaphragm ***Childbirth can injure perineum, levator ani, & pelvic fascia. Usually pubococcygeus is torn. -Get urinary stress incontinence - sacrospinous lig . Is immediately external (posterolateral) of coccygeus m.
  • Pouches
    • Recto-uterine pouch (pouch of douglas)
      • lowest point in peritoneal cavity
      • collects fluid in supine position (can palpate/ access with digital exam)
    • Recto-vesical (same as above but in males)
    • Vesico-uterine pouch
    • Retropubic space of Retzius
  • Pelvic nerves From sacral plexus: -sciatic n. (infrapiriform) -pudendal n. (infrapiriform) -obturator n. -pelvic splanchnic ns. -Sup. & inf. Gluteal ns. (supra & infrapiriform) -lumbosacral trunk (part L4 and all L5) -Hypogastric N . (connects sup. & inf. Hypogastric plexuses) -Sympathetic trunk (grey rami here only) *** Caudal Epidural block : anesthesia given in sacral canal (S2-S4) [entire birth canal, pelvic floor, & perineum is anesthetized]
  • Posterior trunk of Int. Iliac A. -iliolumbar A. -Lateral sacral As. (anastomose with median sacral a.) -sup. Gluteal A. (suprapiriform)
  • Anterior trunk of Int. Iliac a. -umbilical A.  sup. Vesical A. -obturator A. -Inf. Vesical A. -middle rectal A. -Int. Pudendal A. (infrapiriform) -Inf. Gluteal A. (infrapiriform)
  • Lymph from pelvis
    • Lymphatics from most pelvic viscera drain mainly into lymph nodes distributed along the internal iliac and external iliac arteries and their associated branches, which drain into nodes associated with the common iliac arteries and then into nodes associated with the lateral surfaces of the abdominal aorta. In turn, these lateral aortic nodes drain into the lumbar trunks , which continue to the origin of the thoracic duct at approximately vertebral level T12.
    • Lymphatics from the testes , ovaries and related parts of the uterus and uterine tubes leave the pelvic cavity superiorly and drain, via vessels that accompany the ovarian/testicular arteries, directly into lateral aortic nodes and, in some cases, into the pre-aortic nodes on the anterior surface of the aorta.
    • In addition to draining pelvic viscera, nodes along the internal iliac artery also receive drainage from the gluteal region of the lower limb and from deep areas of the perineum .
  • Lymph from perineum -Lymphatic vessels from deep parts of the perineum accompany the internal pudendal blood vessels and drain mainly into internal iliac nodes in the pelvis. -Lymphatic channels from superficial tissues of the penis or the clitoris accompany the superficial external pudendal blood vessels and drain mainly into superficial inguinal nodes , as do lymphatic channels from the scrotum or labia majora. -The glans penis, the glans clitoris, labia minora, and the terminal inferior end of the vagina drain into deep inguinal nodes and external iliac nodes .
  • Perineum
    • Part of pelvic outlet inferior to pelvic diaphragm
    • Diamond shaped divided into anal and urogenital triangles by line b/w ischial tuberosities
    • Deep perineal space
      • Bounded by sup. fascia of the urogenital diaphragm and perineal membrane (inf. fascia)
    • Supf. Perineal space
      • Bounded by perineal membrane and supf. Perineal fascia (continuous w/ colles fascia)
    • Ischioanal fossa and recesses, know if probe is in it
    • *Clinical* - Episiotomy = incision in perineum to enlarge vaginal opening during childbirth
      • Median episiotomy : starts at frenulum of labia minora and cuts down through skin, vaginal wall, perineal body, and supf. Transverse perineal musc. (may cut ext. anal sphincter inadvertently)
      • Mediolateral episiotomy : starts at frenulum and cuts at 45deg angle through skin, vaginal wall, and bulbospongiosus m.
        • Creates more room than median type
  • *** Pelvic relaxation is the weakening or loss of support of pelvic organs; caused by damage to: -perineal body (vaginal prolapse) -pelvic/ UG diaphragm -Transverse cervical, uterosacral, & pubocervical lig. -CAUSES: cystocele, rectocele, uterine/vaginal prolapse
  • Arteries in perineum
    • Internal Pudendal A., V. ( they exit pelvis into gluteal region via greater sciatic foramen [infrapiriform] and reenter perineum via lesser sciatic foramen within the fascia of the obturator internus m. [passes through Pudendal or Alcock’s canal with pudendal n.; ] )
      • Inf. Rectal a.
      • Perineal a. (clitoral or labial brs. in women)
        • Post. Scrotal a.
        • Dorsal a. of penis
        • Deep a. of penis
        • A. to & of bulb?
  • Nerves in perineum -out of Alcock’s canal w/ Int. pudendal A. &V. *** Pudendal block (forceps delivery in childbirth) – landmark is ischial spine, needle through sacrospinous lig. (for complete perineal block need to get ilioinguinal and genitofemoral ns.) ***
  • Deep perineal space structures
    • Male
      • Membranous urethra
      • Urogenital diaphragm
        • Deep transverse perineal m.
        • Sphincter urethrae m.
      • Br. Of int. Pudendal A.
        • A. of the penis
      • Br. Of Pudendal N.
        • Dorsal N. of the penis
      • Bulbourethral glands (Cowper glands)
    • Female
      • Urethra
      • Vagina
      • Urogenital diaphragm
        • Same as male
      • Br. Of Int. Pudendal A.
        • A. of the clitoris
      • Br. Of Pudendal N.
        • Dorsal N. of the clitoris
      • NO GLANDS
  • Deep pouch musc. Man Woman
  • Superficial perineal space structures
    • Male
      • Penile urethra
      • Bulbospongiosus m.
      • Ischiocavernosus m.
      • Supf. Transverse perineal m.
      • Brs. Of int. pudendal A.
        • Perineal a.  post. Scrotal as.
        • Dorsal a. of penis
        • Deep a. of penis
      • Brs. Of pudendal N.
        • Perineal n.  post. Scrotal n.
        • Dorsal n. of penis
      • Bulb of penis
      • Crura of penis
      • Perineal body
    • Female
      • Urethra
      • Vestibule of the vagina
      • Bulbospongiosus m.
      • Ischiocavernosus m.
      • Supf. Transverse perineal m.
      • Brs. Of int. pudendal A.
        • Perineal a.  post. Labial as.
        • Dorsal a. of the clitoris
        • Deep a. of the clitoris
      • Brs. Of pudendal N.
        • Perineal n.  post. Labial ns.
        • Dorsal n. of the clitoris
      • Vestibular bulb
      • Crura of the clitoris
      • Perineal body
      • GREATER VESTIBULAR GLANDS (Bartholin glands)
  • Supf. Perineal space musc.s
  • Female reproductive system
    • Ovaries
      • Posterior to broad lig .
      • Attached to lateral pelvic wall by suspensory lig. of the ovary (contains ovarian a., v., n.)
      • To uterus by ovarian lig . (below fallopian tube)
      • Not covered by peritoneum, but germinal epithelium
      • Malignancy  deep para-aortic nodes by renal a. (lumbar lymph nodes)
    • Fallopian (uterine) tubes , divisions:
      • Infundibulum (fimbriae)– the only opening into peritoneal cavity
      • Ampulla – site of fertilization
      • Isthmus
      • Intramural – opens into uterine cavity
  • Uterus (peritonealized)
    • Regions: fundus, cornu, body, isthmus, cervix (internal os, cervical canal, external os  round in nulliparous, transverse in parous women)
    • Support:
      • pelvic & urogenital diaphragms, bladder
      • round lig. of the uterus (remnant of gubernaculum, supplied by inf. Epigastric vessels, ends in labium majus)
      • transverse cervical lig . AKA cardinal lig. Of Mackenrodt (from cervix to pelvic wall laterally at base of broad lig., contains uterine a.)
      • Uterosacral lig . (from cervix posteriorly to sacrum, holds anteverted postion)
      • Pubocervical lig . (from cervix anteriorly to pubic symphysis, helps prevent cystocele= herniation of bladder into vagina)
      • Broad lig . (double fold of parietal peritoneum, laterally to pelvis)
        • Mesosalpinx – supports uterine tubes
        • Mesovarium – supports ovary
        • Mesometrium
        • Suspensory lig. Of ovary
    • Broad lig.: uterine a., v., & n. lie at the base w/in transverse cervical lig. and ureter is inferior to these
      • Ovarian lig. Of uterus & round lig. Of the uterus are both remnants of the gubernaculum in embryo
    • Uterus is anteflexed – anterior bend b/w cervix & body
    • Uterus is anteverted – anterior bend b/w cervix & vagina
  • Vagina
    • Longest part of birth canal
    • Degree to which it can distend during childbirth is limited by ischial spines and sacrospinous lig.s
    • Fornix = recess around cervix
      • Anterior fornix – can palpate bladder here
      • Lateral fornices
      • Posterior fornix – can palpate rectum, sacral promontory, & coccyx here (site for culdocentesis = needle is passed through into pouch of douglas (rectouterine) for fluid sample or oocytes)
    • Cystocele, rectocele (organs herniate into ant./post. walls vagina)
  • External female genitalia
    • Body of clitoris (by 2 corpora cavernosa)
    • Glans of clitoris (fusion of the vestibular bulbs)
    • Vestibule of vagina:
      • Urethral orifice
      • Greater vestibular glands of bartholin
      • Paraurethal glands of skene
      • Vaginal introitus
  • Female clinicals
    • Salpingitis (bact. Infection of uterine tube leads to scarring) – most common cause of female infertility and predisposes to ectopic tubal pregnancy
    • Ectopic tubal pregnancy – most often in ampulla, intraperitoneal blood seen on culdocentesis ( sudden onset of abdominal pain confused for appendicitis)
    • Cervical carcinoma – may spread to side wall of pelvis (ureters become obstructed  hydronephrosis)
      • Most common lymph node spread = obturator lymph nodes
    • Uterine fibrinoid (leiomyoma) – benign smooth musc. proliferation that becomes calcified ( can be palpated in ant. Ab wall)
  • Male reproductive system -Epididymis (head, body, tail) sperm maturation and storage in head and body -Ductus deferens – begins at inf. Pole of testes, eventually joined by seminal vesicles to form 2 ejaculatory ducts, which open into prostate on urethral crest *** Vasectomy – cuts layers: 1)skin, 2)colles fascia, 3)dartos m., 4)ext. spermatic fascia, 5)cremasteric fascia & m., 6)int. spermatic fascia, 7)extraperitoneal fat (tunica vaginalis is NOT cut)
  • Prostate -Clinical- -BPH is found in transition zone and may compress urethra slowing or stopping urine flow -PC (carcinoma) commonly found in peripheral zone (post. Lobes) and can be palpated on DRE (PSA lvls)
    • -Inf. Vesical A. supplies
    • b/w bladder & UG diaphragm
    • prostatic fluid has citric acid, acid phosphatase, prostaglandins, fibrinogen, PSA
    • 5 lobes: R+L lateral and post., 1 middle (3 zones=peripheral, cental, transitional/periurethral)
    • Venous drainage (prostatic venous plexus) *cancer follows paths below *  to heart & lungs or brain
      • 1)to int. iliac  IVC
      • 2)to vertebral venous plexus
  • Testes
    • Surrounded by tunica albuginea (thick CT layer)
    • Next is tunica vaginalis (not posteriorly)
    • Collateral circ. Allows ligation of testicular A.
      • A. of ductus def.
      • Cremasteric a.
      • Ext. pudendal. A.
    • Pampiniform plexus forms testicular vs.
    • Drain to deep lumbar nodes by renal a.
    CLINICALS -left kidney tumor, SMA, sigmoid colon – can give left varicocele ( bag of worms ) –caused by pampiniform plexus - cryptorchidism (uni/bilateral) – testes don’t descend completely along normal path ( ectopic – abnormal path) - hydrocele (processus vaginalis patency), torsion
  • External male genitalia
    • Scrotum – see ant. abdominal wall
    • Penis
      • 1 corpus spongiosum (begins as bulb of penis) and 2 corpora cavernosa (begin as crura , bound together by tunica albuginea )
        • See associated musc. on next slide
      • Supported by suspensory lig . (from linea alba to Buck’s fascia)
      • Deep a. of penis (involved in erections), dorsal a. of penis
      • Deep dorsal v .  prostatic venous plexus  int. iliac v.  IVC
      • Supf. Dorsal v .  ext. pudendal v.  great saphenous v.  femoral v.  ext. iliac v.  IVC
      • Dorsal n. of penis (pudendal n.)
      • CLINICAL: urethral folds do not fuse completely
        • Hypospadias – external urethral meatus/orifice is ventral
        • Epispadias – external urethral meatus/orifice is dorsal
      • Erection / Emission (“point and shoot”):
        • Parasymphathetic: cavernous spaces dilate, bulbospongiosus & ischiocavernosus compress venous plexus
        • Sympathetic: close urethral sphincter (L1-2), contract prostatic and urethral ms. (parasym S2-4), contract bulbospongiosus m. (pudendal n.)
    • You made it!
    • Remember, you know your stuff just keep your cool on the test