Anatomy organs.

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The organs of human body . Anatomy of human body .

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Anatomy organs.

  1. 1. 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- posterior orientation - 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 paries membranaceus - 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
  2. 2. 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 cm - basis pulmonis - the base of the lung wich is concave lying on the diaphragm 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 lung
  3. 3. - 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
  4. 4. 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
  5. 5. - 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 three 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)
  6. 6. 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)
  7. 7. The stomach 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. Walls: -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 function. 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:
  8. 8. -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 ribs. -spatium semilunare Traube- a semilunar space on the left lateral thoracic wall with the top of the arch at the 5th rib. -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.lienalis; -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;
  9. 9. -parasympathetics: belong to the vagus nerves, with a very important role in hydrochloric acid secretion. 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. Duodenum division: -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 inferior; -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 Kerkring. -on the posterior wall of pars descendens a vertical fold is the mark of the choledocus situated posterior; -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 accesor). 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:
  10. 10. -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 retroperitoneal organs: -vena cava inferior; -the right kidney and the suprarenal gland -choledocus; -vena porta. -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 lienalis); -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 cells. 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.
  11. 11. -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; -margo inferior-smooth; 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.
  12. 12. 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 thicker layer - 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 costal cartilage - 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 pericardium - 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)
  13. 13. - 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 thoracic chain - lympha – is drained through a superficial and a deep networks THE HEART (COR)
  14. 14. - 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), situated superiorly - 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 groove - sulcus interventricularis posterior - the posterior inter-ventricular groove - 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 atrium - auricula sinistra – the left auricle represents an appendage of the left atrium 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 interventricularis posterior
  15. 15. - 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 atrium 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 presents: - 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 terminalis - 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 dextra - 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
  16. 16. - 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 and presents: - 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
  17. 17. muscular part of the interventricular septum and the free wall of the right ventricle - 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 “Arantius”) - 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 higher pressure -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
  18. 18. 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- ventricular branch - 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
  19. 19. anterior, than in incisura apicis cordis towards sulcus interventricularis posterior - 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
  20. 20. 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 atrium - nodus atrio-ventricularis of “Aschoff-Tawara” – the atrio-ventricular node situated inferiorly near the orifice of the coronary sinus into the right atrium - 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 inter-ventricular septum - crus sinistrum – the left part situated in the left side of the inter- ventricular septum - 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
  21. 21. 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 pulmonary trunk - tendo of “Todaro” – goes towards the atriums and to the membraneous part of the inter-ventricular septum
  22. 22. - 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 nodes - 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)
  23. 23. The abdominal wall It’s a complex structure composed by muscles, aponeurosis and bones situated around the abdominal cavity. The distribution of the walls: -superior: the diaphragm; -inferior: the pelvic diaphragm-m.levator ani; -anterior and lateral: -m.obliqus externus; -m.obliqus internus; -m.tranversus abdominis; -m.rectus abdominis. -posterior: -m.iliopsoas; -m.quadratus lumborus; -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 to 12th ribs. The origin of obliqus internus intersects the fibres of m.serratus anterior I: crista iliaca; ligamentum inguinale; linea alba. 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; fascia thoracolumbalis; ligamentum inguinale; I : the surface of the 10th to 12th ribs; linea alba; N : nn.intercostales 10-12, n.iliohypogastricum, n.ilioinguinalis.
  24. 24. 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 to 12th ribs; fascia thoracolumbalis; crista iliaca; ligamentum inguinale. 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 to 7th 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 abdominis sheath. 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 mediale -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.
  25. 25. -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; -fascia transversalis. 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: -transversal(horizontal); -longitudinal(verical); The transversal system-the arteries arise from laterally and goes to linea alba. -aa.intercostales posterior 10-11; -a.subcostalis; -aa.lumbales 1-5; 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;
  26. 26. -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 pubica; -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
  27. 27. -provide the motor innervation for the abdomen muscles and the sensitive innervation for the skin and peritoneum. -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 trajectory. -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 genital organs. The topography of the abdominal wall Using three imaginary lines the abdominal wall is divided in nine different regions. The lines -linia bisubcostalis-a horizontal line tangent to the inferior arch of the 10th rib. -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 regions: -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.
  28. 28. 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 peritoneum. The upward fold: -Ligamentum teres hepatis-betweeen the anulus umbilicalis and incisura hepatica, represents the fibrotic transformation of the vena umbilicalis. Canalis inguinalis -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. The rings: -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. The walls: 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;
  29. 29. -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.
  30. 30. Mediastinum posterior -is situated behind the vertical plane traced through the posterior wall of the trachea and pericardium; Walls: -anterior: trachea and pericardium; -posterior: columna vertebralis and the joints between the ribs and the vertebral bodies; -lateral: the left and right pleura mediastinalis; -inferior: diaphragma; -superior: wide communication with the regions of the neck. Contents: 1. Oesophagus 2. Aorta thoracica 3. Ductus thoracicus 4. Vena azygos et hemiazygos 5. Truncus sympathicus Oesophagus A muscular tube by 25 cm length, part of the digestive tract, between the pharynx and the stomach. Divisions: -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 the stomach). 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. Curves:
  31. 31. -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. Structure: -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 mucosae; -Submucosa-contains small blood vessels, collagen and elastin fibres, mucous glands and the autonomic nerve; -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 surrounding tissues. Blood suplie: -a.thyroidiana inferior; -rami oesophagei from: -directly from aorta; -aa.bronchiales; -a.phrenica superior; -aa.intercostales posterior; -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 liver cirrhosis. -lymph is drained in nodi lymfatici cervicales profundae, tracheales, mediastinales and juxtaoesophageles. Nerves: -the sympathetic innervation -postganglionary fibres from truncus sympaticus. -the parasympathetic innervations-nervus vagus. Aorta thoracica
  32. 32. -situated posteriorly to the oesophagus and also to the left side, from Th4 in continuation of aortic arch, to the hiatus aorticus (Th10). Rami viscerales: -Rr bronchiales-for nutritive vascularisation of the lungs; -Rr oesophagei; -Rr pericardici; -Rr mediastinales-for the mediastinal soft tissue. Rami parietales: -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). Ductus thoracicus -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
  33. 33. 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 venae oesophageales. 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. Truncus sympathicus -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 (stellate) ganglion. -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 retroperitoneal organs)
  34. 34. The mouth (Cavum oris) 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 Vestibulum Walls - is a slit- like space, bounded externally by the lips and cheeks; internally by the gums and teeth. Communications: 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 . Divisions: 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) Description: - sulcus vestibularis superior- a groove between the superior external wall and processus alveolaris maxillae; - sulcus vestibularis inferior- a groove between the inferior external wall and processus alveolaris mandibulae; - 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; Arteries - for the superior part (maxillaris) - a. infraorbitalis; - a. labialis superior(from a. Facialis);
  35. 35. - 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 Nerves - 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 Walls: - 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) Comunications: - vestibulum - pharynx - isthmus facium Divisions: - Regio palatina; - Regio sublingualis; - Regio retromolaris - Regio tonsillaris Regio palatina - the superior wall with two parts: - hard palate (palatum durum); - processus palatinus os maxillae - lamina horisontalis os palatinum - soft palate (palatum molle) ;
  36. 36. Description: - 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 Arteries - 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 Nerves - 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 Regio sublingualis The inferior wall of the mouth. There are two symmetric triangular shape regions Limits: - anterior and lateral: processus alveolaris mandibulae; - posterior :the root of the tongue; - medial: frenulum linguae; Description: - pelvis salivalis - the deeper part of the triangle always full with saliva; - frenulum linguae - a mucosal insertion of the top of the tongue;
  37. 37. - 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 sublingualis major. - 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 sublingualis. Walls: 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 caruncula lingualis; - 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. Regio retromolaris The postero-lateral wall of the mouth situated between the last molars (superior and inferior) and arcus palatoglossus. Description: - 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 retromolaris inferior. The mucosa of the region covers the pterygomandibular space- the anterior part of regio infratemporalis. The contents of the pterygomandibular space: - ramus mandibulae- with its elements- foramen mandibulae , lingula , antilingula and sulcus mylohyoideus. - N. alveolaris inferior; - N. buccalis; - N. mylohyoideus;
  38. 38. - N. lingualis; - A. alveolaris inferior. Regio tonsillaris Situated on the limit between mouth and pharynx (isthmus faucium) Walls: - anterior: arcus palatoglossus; - posterior: arcus palatopharyngeus; - inferior: plica triangularis - lateral: pharyngeal wall. Contents: - 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 arches.
  39. 39. 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 sphincterian functions 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 presents: - 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 antero-laterally
  40. 40. - 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 cartilage - 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 liggamentum thyro-epiglotticum d. CARTILAGO ARYTENOIDEA – the cricoids cartilage is an pair one, situated on the superior margin of the lamella of the cricoid cartilage and presents: - basis cartilaginis arytenoidea - the base of the arytenoid cartilage wich presents: - facies articularis – the articular surface for the articulation with the cricoid cartilage - facies antero-lateralis - the antero-lateral surface with a triangular shape, presents: - 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 arched crest - fovea oblonga – the oblonga fovea is situated under the arched crest - processus vocalis – the vocal projection is situated in the antero- inferior angle of this surface and serving for the insertion of the vocal ligament
  41. 41. - facies medialis - the medial surface is orientd towards the other arytenoid cartilage - 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 crico-arytenoid muscle e. CARTILAGO CORNICULATA “Santorini” – the corniculate cartilage is small and pair, being situated on the superior tip of the arytenoid cartilage and presents: - 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 and presents: - 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 ligament 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
  42. 42. lamellas of the thyroid cartilage and the superior margin of the cricoids cartilage 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 presents: - 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
  43. 43. 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 cartilage - 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 arytenoid cartilage IV. The MUSCLES of the LARYNX are:
  44. 44. 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 epiglottic cartilage - 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 vocal ligament) 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:
  45. 45. 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 musculus ary-epiglotticus - tuberculum cuneiforme – the mucosa over the cuneiform cartilage’s relief, being situated in the posterior part of plica ary- epiglottica - tuberculum corniculata – the mucosa over the corniculate cartilage’s relief , being situated in even more posterior part of plica ary-epiglottica - 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”) vocal chords - rima glottidis – the glottic slot represents the space situated in between the two vocal plicas and presents:
  46. 46. - 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 arytenoids cartilages - 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) wich presents:
  47. 47. - an external motor branch (for all the other muscles of the larynx) - 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 mediastinales
  48. 48. 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. External configuration: 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. Facies diaphragmatica. -through the diaphragmatic dome the superioe face is related with : -the right anterior and lateral arch of the 7th to 10th ribbs-impressio costalis; -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. Facies visceralis: 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:
  49. 49. -impressio colica-situated anterior; -impresio duodenalis-posteriorlly to the first one; -impressio renalis and suprarenalis-more posteriorlly and inferiorlly to the others. Lobus sinister 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; -margo anterior 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; -sulcus transversalis; -margo 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
  50. 50. arteries:A.segmenti medialis and A.segmenti lateralis.The caudat lobe receive blood suplie from the booth branches -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 system. -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 ligament. -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 big trunk. 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
  51. 51. 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 duct. 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 choledocus 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 colon; -Collum vesicae fellae-ampular shape , presents a mucosal fold-plica spiralis or Heister valve. -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.
  52. 52. 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. External configuration 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 position. 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. Internal structure 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 Heighmore body 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 diameter each Interstitium testis - the spaces between seminiferous tubules, containing vessels and interstitial cell islets (“Leydig cells”), which secrete androgens Epididymis 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 testicle 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 Haller 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

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