Bernard Gersh, MB, ChB, DPhil

• Professor of Medicine
• Cardiology Diseases
• Mayo Clinic College of Medicine
• Rochester, Minnesota

Because o the consequent pulmonary hypoplasia asymptomatic hiv infection symptoms nemasole 100mg purchase with amex, the mortality rate in these inants is high (approximately 76%) kleenex anti-viral facial tissue 112 count buy nemasole 100mg fast delivery. Surgical access to the sympathetic trunks is commonly through a lateral extraperitoneal approach because the sympathetic trunks lie retroperitoneally in the extraperitoneal atty tissue xylometazolin antiviral buy nemasole on line amex. The surgeon splits the muscles o the anterior abdominal wall and moves the peritoneum medially and anteriorly to expose the medial edge o the psoas major hiv infection personal stories purchase cheap nemasole on-line, along which the sympathetic trunk lies hiv infection rates asia discount 100 mg nemasole with amex. Consequently, the surgeon careully retracts them to expose the sympathetic trunks that usually lie in the groove between the psoas major laterally and the lumbar vertebral bodies medially. Knowing that identication o the sympathetic trunks is not easy, great care is taken not to remove inadvertently part o the genitoemoral nerve, lumbar lymphatics, or ureter. When any o these structures is diseased, movement o the iliopsoas usually causes pain. An acutely infamed appendix, or example, will produce a positive right psoas sign. Because the psoas lies along the vertebral column and the iliacus crosses the sacro-iliac joint, disease o the intervertebral and sacro-iliac joints may cause spasm o the iliopsoas, a protective refex. Adenocarcinoma o the pancreas in advanced stages invades the muscles and nerves o the posterior abdominal wall, producing excruciating pain because o the close relationship o the pancreas to the posterior abdominal wall. Pulsations o Aorta and Abdominal Aortic Aneurysm Because the aorta lies posterior to the pancreas and stomach, a tumor o these organs may transmit pulsations o the aorta that could be mistaken or an abdominal aortic aneurysm, a localized enlargement o the aorta. Deep palpation o the midabdomen can detect an aneurysm, which usually results rom a congenital or acquired weakness o the arterial wall. Acute rupture o an abdominal aortic aneurysm is associated with severe pain in the abdomen or back. I unrecognized, such an aneurysm has a mortality rate o nearly 90% because o heavy blood loss (Swartz, 2014). Surgeons can repair an aneurysm by opening it, inserting a prosthetic grat, and sewing the wall o the aneurysmal aorta over the grat to protect it. Many vascular problems ormerly treated with open repair, including aneurysm repair, are now being treated by means o endovascular catheterization procedures. When the anterior abdominal wall is relaxed, particularly in children and thin adults, the inerior part o the abdominal aorta may be compressed against the body o the L4 vertebra by rm pressure on the anterior abdominal wall, over the umbilicus. Two o these routes (one involving the superior and inerior epigastric veins, and another involving the thoraco-epigastric vein) were discussed earlier in this chapter with the anterior abdominal wall. The third collateral route involves the epidural venous plexus inside the vertebral column (illustrated and discussed in Chapter 2, Back), which communicates with the lumbar veins o the inerior caval system, and the tributaries o the azygos system o veins, which is part o the superior caval system. These anomalies result rom the persistence o embryonic veins on the let side, which normally disappear. The muscular portion arises rom the ring-like inerior thoracic aperture rom which the diaphragm rises steeply, invaginating the thoracic cage and orming a common central tendon. The right dome (higher because o the underlying liver) rises nearly to the level o the nipple, whereas the let dome is slightly lower. The central portion o the diaphragm is slightly depressed by the heart within the pericardium and is used to the mediastinal surace o the central tendon. When stimulated by the phrenic nerves, the domes are pulled downward (descend), compressing the abdominal viscera. When stimulation ceases and the diaphragm relaxes, the diaphragm is pushed upward (ascends) by the combined decompression o the viscera and tonus o the muscles o the anterolateral abdominal wall. The fbers o the right crus o the diaphragm orm a sphincteric hiatus or the esophagus at the T10 vertebral level. The descending aorta and thoracic duct pass posterior to the diaphragm at the T12 vertebral level, in the midline between the crura, overlapped by the median arcuate ligament connecting them. Superior and inerior phrenic arteries and veins supply most o the diaphragm, with additional drainage occurring via the musculophrenic and azygos/hemi-azygos veins. In addition to exclusive motor innervation, the phrenic nerves supply most o the pleura and peritoneum covering the diaphragm. Peripheral parts o the diaphragm receive sensory innervation rom the lower intercostal and subcostal nerves. The let lumbocostal triangle and the esophageal hiatus are potential sites o acquired hernias through the diaphragm. Developmental deects in the let lumbocostal region account or most congenital diaphragmatic hernias. Fascia and muscles: Large, complex aponeurotic ormations cover the central parts o the trunk both anteriorly and posteriorly, orming dense sheaths centrally that house vertical muscles and attach laterally to the at muscles o the anterolateral abdominal wall. The anterior layer, part o the endoabdominal ascia, is continuous medially with the psoas ascia (enclosing the psoas) and laterally with the transversalis ascia (lining the transversus abdominis). The tube-like psoas ascia provides a potential pathway or the spread o inections between the vertebral column and hip joint. The endoabdominal ascia covering the anterior aspects o both the quadratus lumborum and psoas is thickened over the superiormost aspects o the muscles, orming the lateral and medial arcuate ligaments, respectively. A highly variable layer o extraperitoneal at intervenes between the endoabdominal ascia and peritoneum. It is especially thick in the paravertebral gutters o the lumbar region, comprising the paranephric at (pararenal at body). The muscles o the posterior abdominal wall are the quadratus lumborum, psoas major, and iliacus. Nerves: the lumbar sympathetic trunks deliver postsynaptic sympathetic fbers to the lumbar plexus or distribution with somatic nerves and presynaptic parasympathetic fbers to the abdominal aortic plexus, the latter ultimately innervating pelvic viscera. With the exception o the subcostal nerve (T12) and lumbosacral trunk (L4­L5), the somatic nerves o the posterior abdominal wall are products o the lumbar plexus, ormed by the anterior rami o L1­L4 deep to the psoas. Only the subcostal nerve and derivatives o the anterior ramus o L1 (iliohypogastric and ilio-inguinal nerves) have an abdominal distribution-to the muscles and skin o the inguinal and pubic regions. Arteries: Except or the subcostal arteries, the arteries supplying the posterior abdominal wall arise rom the abdominal aorta. The abdominal aorta descends rom the aortic hiatus, coursing on the anterior aspects o the T12­L4 vertebra, immediately let o the midline, and biurcates into the common iliac arteries at the level o the supracristal plane. Branches o the aorta arise and course in three vascular planes: anterior (unpaired visceral branches), lateral (paired visceral branches), and posterolateral (paired parietal). The median sacral artery may be considered a diminutive continuation o the aorta, which continues to give rise to paired parietal branches to the lower lumbar vertebrae and sacrum. Lymph vessels and lymph nodes: Lymphatic drainage rom the abdominal viscera courses retrograde along the ramifcations o the three unpaired visceral branches o the abdominal aorta. Lymphatic drainage rom the abdominal wall merges with that rom the lower limbs, both pathways ollowing the arterial supply retrograde rom those parts. Ultimately, all lymphatic drainage rom structures inerior to the diaphragm, plus that draining rom the lower six intercostal spaces via the descending thoracic lymphatic trunks, enters the beginning o the thoracic duct at the T12 level, posterior to the aorta. Board-review questions, case studies, and additional resources are available at thePoint. Anatomically, the pelvis is the part o the body surrounded by the pelvic girdle (bony pelvis), part o the appendicular skeleton o the lower limb. The greater pelvis is occupied by inerior abdominal viscera, aording them protection similar to the way the superior abdominal viscera are protected by the inerior thoracic cage. The lesser pelvis is surrounded by the inerior pelvic girdle, which provides the skeletal ramework or both the pelvic cavity and the perineum-compartments o the trunk separated by the musculoascial pelvic diaphragm. Externally, the pelvis is covered or overlapped by the inerior anterolateral abdominal wall anteriorly, the gluteal region o the lower limb posterolaterally, and the perineum ineriorly. The term perineum1 reers both to the area o the surace o the trunk between the thighs and the buttocks, extending rom the coccyx to the pubis, and to the shallow compartment lying deep (superior) to this area but inerior to the pelvic diaphragm. The perineum includes the anus and external genitalia: the penis and scrotum o the male and the vulva o the emale. The primary unctions o the pelvic girdle are to bear the weight o the upper body when sitting and standing. Consequently, the pelvic girdle is strong and rigid, especially compared to the pectoral (shoulder) girdle. Other unctions o the pelvic girdle are to contain and protect the pelvic viscera (inerior parts o the urinary tracts and the internal reproductive organs) and the inerior abdominal viscera. Bones and Features o Pelvic Girdle In mature people, the pelvic girdle is ormed by three bones. In its most restricted sense, and in obstetrics, it has been used to reer to the area supercial to the perineal body, between the vulva or scrotum and the anus or to the perineal body itsel. In an intermediate sense, it has included only the perineal region, a supercial (surace) area bounded by the thighs laterally, the mons pubis anteriorly, and the coccyx posteriorly. In its widest sense, as used in Terminologia Anatomica (the international anatomical terminology), and in this book, it reers to the region o the body that includes all structures o the anal and urogenital triangles, supercial and deep, extending as ar superiorly as the inerior ascia o the pelvic diaphragm. Right and let hip bones (coxal or pelvic bones): large, irregularly shaped bones, each o which develops rom the usion o three bones (ilium, ischium, and pubis). The internal (medial or pelvic) aspects o the hip bones bound the pelvis, orming its lateral walls; these aspects o the bones are emphasized here. The pelvis (green) is the space within the pelvic girdle, overlapped externally by the abdominal and gluteal regions, perineum, and lower back. The greater pelvis (light green) is pelvic by virtue o its bony boundaries but is abdominal in terms o its contents. The lesser pelvis (dark green) provides the bony ramework (skeleton) or the pelvic cavity and deep perineum. As part o the vertebral column, the sacrum and coccyx are discussed in detail in Chapter 2, Back. In inants and children, each hip bone consists o three separate bones united by a triradiate cartilage at the acetabulum, the cup-like depression in the lateral surace o the hip bone that articulates with the head o the emur. The right and let hip bones are joined anteriorly at the pubic symphysis, a secondary cartilaginous joint. The hip bones articulate posteriorly with the sacrum at the sacro-iliac joints to orm the pelvic girdle. The ala (wing) o the ilium represents the spread o the an, and the body o the ilium, the handle o the an. The iliac crest, the rim o the an, has a curve that ollows the contour o the ala between the anterior and posterior superior iliac spines. Posteriorly, the sacropelvic surace o the ilium eatures an auricular surace and an iliac tuberosity, or synovial and syndesmotic articulation with the sacrum, respectively. The body o the ischium helps orm the acetabulum and the ramus o the ischium orms part o the obturator oramen. The small pointed posteromedial projection near the junction o the ramus and body is the ischial spine. The concavity between the ischial spine and the ischial tuberosity is the lesser sciatic notch. The larger concavity, the greater sciatic notch, is superior to the ischial spine and is ormed in part by the ilium. The pubis is an angulated bone with a superior ramus, which helps orm the acetabulum, and an inerior ramus, which contributes to the bony borders o the obturator oramen. A thickening on the anterior part o the body o the pubis is the pubic crest, which ends laterally as a prominent swelling, the pubic tubercle. The lateral part o the superior pubic ramus has an oblique ridge, the pecten pubis (pectineal line o the pubis). The pelvis is divided into greater (alse) and lesser (true) pelves by the oblique plane o the pelvic inlet (superior pelvic aperture). The bony edge (rim) surrounding and dening the pelvic inlet is the pelvic brim, ormed by the promontory and ala o the sacrum (superior surace o its lateral part, adjacent to the body o the sacrum). The pubic arch is ormed by the right and let ischiopubic rami (conjoined inerior rami o the pubis and ischium;. These rami meet at the pubic symphysis, their inerior borders dening the subpubic angle. The width o the subpubic angle is determined by the distance between the right and the let ischial tuberosities. This can be measured with the gloved ngers in the vagina during a pelvic examination. Features o the pelvic girdle demonstrated anatomically (A) and radiographically (B). The pelvic girdle is ormed by the two hip bones (o the inerior axial skeleton) anteriorly and laterally and the sacrum (o the axial skeleton) posteriorly. The preadolescent hip bone is composed o three bones-ilium, ischium, and pubis-that meet in the cup-shaped acetabulum. Prior to their usion, the bones are united by a triradiate cartilage along a Y-shaped line (blue). Pubic arches or subpubic angles typical or each gender (male = red; emale = green) can be approximated by spreading the index and middle fnger (demonstrating narrow subpubic angle o male pelvis) or thumb and index fnger (demonstrating wider subpubic angle o emale pelvis). The concave superior surace o the musculoascial pelvic diaphragm orms the foor o the true pelvic cavity, which is thus deepest centrally. The convex inerior surace o the pelvic diaphragm orms the roo o the perineum, which is thereore shallow centrally and deep peripherally. The terms pelvis, lesser pelvis, and pelvic cavity are commonly used incorrectly, as i they were synonymous terms. The lumbosacral and sacrococcygeal joints, although joints o the axial skeleton, are directly related to the pelvic girdle. The auricular suraces o the synovial joint have irregular but congruent elevations and depressions that interlock. The sacro-iliac joints dier rom most synovial joints in that limited mobility is allowed, a consequence o their role in transmitting the weight o most o the body to the hip bones. Consequently, the curved axis o the pelvis intersects the axis o the abdominal cavity at an oblique angle. These sexual dierences are related mainly to the heavier build and larger muscles o most men and to the adaptation o the pelvis (particularly the lesser pelvis) in women or parturition (childbearing). Greater dimensions o the girdle in male but greater volume o the pelvic cavity appear during inancy, with the greatest distinctions developing ollowing puberty. The sacro-iliac joints link the axial skeleton (skeleton o the trunk, composed o the vertebral column at this level) and the inerior appendicular skeleton (skeleton o the lower limb).

The abdominal aorta may be represented on the anterior abdominal wall by a band (approximately 2 cm wide) extending rom a median point new antiviral drugs purchase 100mg nemasole with mastercard, approximately 2 hiv infection rate in sierra leone generic nemasole 100mg on-line. In children and lean adults how the hiv infection cycle works discount 100mg nemasole mastercard, the lower abdominal aorta is suciently close to the anterior abdominal wall that its pulsations may be detected or apparent when the wall is relaxed (see the Clinical Box "Pulsations o Aorta and Abdominal Aortic Aneurysm how hiv infection is diagnosed buy 100mg nemasole overnight delivery," p hiv infection blood nemasole 100 mg sale. The common iliac arteries diverge and run inerolaterally, ollowing the medial border o the psoas muscles to the pelvic brim. Just beore leaving the abdomen, the external iliac artery gives rise to the inerior epigastric and deep circumex iliac arteries, which supply the anterolateral abdominal wall. From superior to inerior, the important anterior relations o the abdominal aorta are as ollows: Celiac plexus and ganglion. Paired parietal branches o the aorta serve the diaphragm and posterior abdominal wall. The median sacral artery, an unpaired parietal branch, may be said to occupy a ourth (posterior) plane because it arises rom the posterior aspect o the aorta just proximal to its biurcation. Although markedly smaller, it could also be considered a midline "continuation" o the aorta, in which case its lateral branches, the small lumbar arteries and lateral sacral branches, would also be included as part o the paired parietal branches. Right Intermediate Hepatic veins (middle) Left Hemi-azygos vein Left inferior phrenic vein Posterior intercostal veins Left suprarenal vein Left renal vein Left gonadal vein (testicular or ovarian) Right gonadal vein (testicular or ovarian) Ascending lumbar vein Left common iliac vein Left external iliac vein Left internal iliac vein Median sacral vein Right common iliac vein Azygos vein Right inferior phrenic vein Inferior vena cava Right suprarenal vein Right renal vein 1st 2nd Lumbar 3rd veins 4th the abdominal aorta descends anterior to the bodies o the T12­L4 vertebrae. On the right, the aorta is related to the azygos vein, cisterna chyli, thoracic duct, right crus o the diaphragm, and right celiac ganglion. On the let, the aorta is related to the let crus o the diaphragm and the let celiac ganglion. The veins that correspond to the unpaired visceral branches o the aorta are instead tributaries o the hepatic portal vein. The branches corresponding to the paired visceral branches o the abdominal aorta include the right suprarenal vein, the right and let renal veins, and the right gonadal (testicular or ovarian) vein. Lymphatic vessels and lymph nodes o the posterior abdominal wall and lymphatic trunks o the abdomen. All lymphatic drainage rom the lower hal o the body converges in the abdomen to enter the beginning o the thoracic duct. Lymph rom the common iliac lymph nodes passes to the right and let lumbar lymph nodes. Lymph rom the alimentary tract, liver, spleen, and pancreas passes along the celiac and superior and inerior mesenteric arteries to the pre-aortic lymph nodes (celiac and superior and inerior mesenteric nodes) scattered around the origins o these arteries rom the aorta. Eerent vessels rom these nodes orm the intestinal lymphatic trunks, which may be single or multiple, and participate in the confuence o lymphatic trunks that gives rise to the thoracic duct. These nodes receive lymph directly rom the posterior abdominal wall, kidneys, ureters, testes or ovaries, uterus, and uterine tubes. They also receive lymph rom the descending colon, pelvis, and lower limbs through the inerior mesenteric and common iliac lymph nodes. Eerent lymphatic vessels rom the large lumbar lymph nodes orm the right and let lumbar lymphatic trunks. The inerior end o the thoracic duct lies anterior to the bodies o the L1 and L2 vertebrae between the right crus o the diaphragm and the aorta. The thoracic duct begins with the convergence o the main lymphatic ducts o the abdomen, which in only a small proportion o individuals takes the orm o the commonly depicted, thin-walled sac or dilation, the cisterna chyli (chyle cistern). More oten, there is merely a simple or plexiorm convergence at this level o the right and let lumbar lymphatic trunks, the intestinal lymph trunk(s), and a pair o descending thoracic lymphatic trunks, which carry lymph rom the lower six intercostal spaces on each side. Consequently, essentially all the lymphatic drainage rom the lower hal o the body (deep lymphatic drainage inerior to the level o the diaphragm and all supercial drainage inerior to the level o the umbilicus) converges in the abdomen to enter the beginning o the thoracic duct. The thoracic duct ascends through the aortic hiatus in the diaphragm into the posterior mediastinum, where it collects more parietal and visceral drainage, particularly rom the let upper quadrant o the body. The duct ultimately ends by entering the venous system at the junction o the let subclavian and internal jugular veins (the let venous angle). Hiccups result rom irritation o aerent or eerent nerve endings, or o medullary centers in the brainstem that control the muscles o respiration, particularly the diaphragm. Hiccups have many causes, such as indigestion, diaphragm irritation, alcoholism, cerebral lesions, and thoracic and abdominal lesions, all which disturb the phrenic nerves. Reerred Pain rom Diaphragm Pain rom the diaphragm radiates to two dierent areas because o the dierence in the sensory nerve supply o the diaphragm (Table 5. Pain resulting rom irritation o the diaphragmatic pleura or the diaphragmatic peritoneum is reerred to the shoulder region, the area o skin supplied by the C3­C5 segments o the spinal cord (see the Clinical Box "Visceral Reerred Pain" earlier in this chapter). Irritation o peripheral regions o the diaphragm, innervated by the inerior intercostal nerves, is more localized, being reerred to the skin over the costal margins o the anterolateral abdominal wall. Rupture o Diaphragm and Herniation o Viscera Rupture o the diaphragm and herniation o viscera can result rom a sudden large increase in either the intrathoracic or intra-abdominal pressure. The common cause o this injury is severe trauma to the thorax or abdomen during a motor vehicle accident. Most diaphragmatic ruptures are on the let side (95%) because the substantial mass o the liver, intimately associated with the diaphragm on the right side, provides a physical barrier. Posterior Abdominal Wall 545 A nonmuscular area o variable size called the lumbocostal triangle usually occurs between the costal and lumbar parts o the diaphragm. This part o the diaphragm is normally ormed only by usion o the superior and inerior ascias o the diaphragm. When a traumatic diaphragmatic hernia occurs, the stomach, small intestine and mesentery, transverse colon, and spleen may herniate through this area into the thorax. Hiatal (hiatus) hernia, a protrusion o part o the stomach into the thorax through the esophageal hiatus, was discussed earlier in this chapter. The structures that pass through the esophageal hiatus (vagal trunks, let inerior phrenic vessels, esophageal branches o the let gastric vessels) may be injured in surgical procedures on the esophageal hiatus. An inection may spread through the blood to the vertebrae (hematogenous spread), particularly during childhood. An abscess resulting rom tuberculosis in the lumbar region tends to spread rom the vertebrae into the psoas ascia (sheath), where it produces a psoas abscess. Pus rom the psoas abscess passes ineriorly along the psoas muscle within this ascial tube over the pelvic brim and deep to the inguinal ligament. Pus can also reach the psoas ascia by passing rom the posterior mediastinum when the thoracic vertebrae are diseased. The inerior part o the iliac ascia is oten tense and raises a old that passes to the internal aspect o the iliac crest. The superior part o this ascia is loose and may orm a pocket, the iliacosubascial ossa, posterior to the above-mentioned old. Part o the large intestine, such as the cecum and/or appendix on the right side and the sigmoid colon on the let side, may become trapped in this ossa, causing considerable pain. Herniation almost always occurs on the let owing to the presence o the liver on the right. Posterolateral deect o the diaphragm is the only relatively common congenital anomaly o the diaphragm, occurring approximately once in 2,200 newborn inants (Moore, Persaud, and Torchia, 2016). With abdominal viscera in the limited space o the prenatal pulmonary cavity, one lung (usually the let lung) does not have room to develop normally or to infate ater birth. The lumbosacral and sacrococcygeal joints are joints o the axial skeleton directly related to the pelvic girdle. The auricular suraces and tuberosities o the ilium and sacrum are demonstrated in an "opened book" view. The weight o the body is transmitted to the sacrum anterior to the axis o rotation at the sacro-iliac joint. The tendency or increased weight or orce to rotate the upper sacrum anteriorly and ineriorly is resisted by the strong sacrotuberous and sacrospinous ligaments anchoring the inerior sacrum and coccyx to the ischium. Weight is transerred rom the axial skeleton to the ilia (plural o ilium) via sacro-iliac ligaments. As long as tight apposition is maintained between the articular suraces, the sacro-iliac joints remain stable. Unlike a keystone at the top o an arch, the sacrum is actually suspended between the iliac bones and is rmly attached to them by posterior and interosseous sacro-iliac ligaments. The thin anterior sacro-iliac ligaments are merely the anterior part o the brous capsule o the synovial part o the joint. The abundant interosseous sacroiliac ligaments (lying deep between the tuberosities o the sacrum and ilium and occupying an area o approximately 10 cm2) are the primary structures involved in transerring the weight o the upper body rom the axial skeleton to the two ilia o the appendicular skeleton. The posterior sacro-iliac ligaments are the posterior external continuation o the same mass o brous tissue. Because the bers o the interosseous and posterior sacro-iliac ligaments run obliquely upward and outward rom the sacrum, the axial weight pushing down on the sacrum actually pulls the ilia inward (medially) so that they compress the sacrum between them, locking the irregular but congruent suraces o the sacro-iliac joints together. Ineriorly, the posterior sacro-iliac ligaments are joined by bers extending rom the posterior margin o the ilium (between the posterior superior and posterior inerior iliac spines) and the base o the coccyx to orm the massive sacrotuberous ligament. The ligaments o hip joint (shown but not labeled) are identifed in Chapter 5 (Lower Limb). The sacrospinous ligament, passing rom the lateral sacrum and coccyx to the ischial spine, urther subdivides this oramen into greater and lesser sciatic oramina. Usually, movement at the sacro-iliac joint is limited by interlocking o the articulating bones and the sacroiliac ligaments to slight gliding and rotary movements. When landing ater a high jump or when weight liting in the standing position, exceptional orce is transmitted through the bodies o the lumbar vertebrae to the superior end o the sacrum. Because this transer o weight occurs anterior to the axis o the sacro-iliac joints, the superior end o the sacrum is pushed ineriorly and anteriorly. However, rotation o the superior sacrum is counterbalanced by the strong sacrotuberous and sacrospinous ligaments, which anchor the inerior end o the sacrum to the ischium, preventing its superior and posterior rotation. By allowing only slight upward movement o the inerior end o the sacrum relative to the hip bones, resilience is provided to the sacroiliac region when the vertebral column sustains sudden increases in orce or weight. The decussating bers o the tendinous attachments o the rectus abdominis and external oblique muscles also strengthen the pubic symphysis anteriorly (see Chapter 5, Abdomen). The ligaments joining the bones are thickened at the superior and inerior margins o the symphysis, orming superior and inerior pubic ligaments. The superior pubic ligament connects the superior aspects o the pubic bodies and interpubic disc, extending as ar laterally as the pubic tubercles. The pubic symphysis is a secondary cartilaginous joint between the bodies o the pubic bones. The bodies o the pubic bones are nearly horizontal, and the joint appears oreshortened in this position. The acets on the S1 vertebra ace posteromedially, interlocking with the anterolaterally acing inerior articular acets o the L5 vertebra, preventing the lumbar vertebra rom sliding anteriorly down the incline o the sacrum. These joints are urther strengthened by an-like iliolumbar ligaments radiating rom the transverse processes o the L5 vertebra to the ilia. The anterior and posterior sacrococcygeal ligaments are long strands that reinorce the joint. In orensic medicine (the application o medical and anatomical knowledge or the purposes o law), identication o human skeletal remains usually involves the diagnosis o sex. A prime ocus o attention is the pelvic girdle, because sexual dierences usually are clearly visible. Pelvic Diameters (Conjugates) the size o the lesser pelvis is particularly important in obstetrics because it is the bony canal through which the etus passes during normal childbirth. To determine the capacity o the emale pelvis or childbearing, the diameters o the lesser pelvis are noted radiographically or manually during a pelvic examination. However, this distance cannot be measured directly during a pelvic examination because o the presence o the bladder. During a pelvic examination, i the ischial tuberosities are ar enough apart to permit three ngers to enter the vagina side by side, the subpubic angle is considered suciently wide to permit passage o an average etal head at ull term. Obstetric conjugate, >11 cm Diagonal conjugate Pelvic Fractures Anteroposterior compression o the pelvis occurs during crush accidents. Fractures o the bony pelvic ring are almost always multiple ractures or a racture combined with a joint dislocation. Some pelvic ractures result rom the tearing away o bone by the strong ligaments associated with the sacro-iliac joints. They may also be caused by orces transmitted to the pelvic bones rom the lower limbs during alls on the eet. Weak areas o the pelvis, where ractures oten occur, are the pubic rami, the acetabula (or the area immediately surrounding them), the region o the sacro-iliac joints, and the alae o the ilium. Pelvic ractures may cause injury to pelvic sot tissues, blood vessels, nerves, and organs. Fractures in the puboobturator area are relatively common and are oten complicated because o their relationship to the urinary bladder and urethra, which may be ruptured or torn. Falls on the eet or buttocks rom a high ladder may drive the head o the emur through the acetabulum into the pelvic cavity, injuring pelvic viscera, nerves, and vessels. In persons younger than 17 years o age, the acetabulum may racture through the triradiate cartilage into its three developmental parts. Sacral promontory Anatomical conjugate Pubic symphysis Plane of least pelvic dimension (B) Medial view (from left) 11. Ater the examining hand is withdrawn, the distance between the tip o the index nger (1. Relaxation o Pelvic Ligaments and Increased Joint Mobility in Late Pregnancy the larger cavity o the interpubic disc in emales. This change increases Pelvic Girdle 563 (A) Superior views Double break in continuity of anterior pelvic ring causes instability but usually little displacement. Fracture of acetabulum (femoral head is driven through acetabulum into lesser pelvis) the circumerence o the lesser pelvis and contributes to increased fexibility o the pubic symphysis. Increased levels o sex hormones and the presence o the hormone relaxin cause the pelvic ligaments to relax during the latter hal o pregnancy, allowing increased movement at the pelvic joints. Relaxation o the sacro-iliac joints and pubic symphysis permits as much as a 10­15% increase in diameters (mostly transverse, including the interspinous distance;.

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The medial suraces o these muscles are covered by obturator ascia hiv infection rate nigeria nemasole 100mg with amex, thickened centrally as a tendinous arch that provides attachment or the pelvic diaphragm infection cycle of hiv virus buy generic nemasole pills. These sections o the trunk show the relationship o the thoracic and abdominopelvic cavities anti virus protection order 100mg nemasole fast delivery. Although the greater pelvis and pelvic cavity are actually continuous hiv infection origin cheap nemasole 100mg otc, they are demarcated by the plane o the pelvic inlet (defned by the pelvic brim) hiv infection of the brain order discount nemasole on line. The pelvic diaphragm is a dynamic barrier separating the lesser pelvis and the perineum, orming the oor o the ormer and roo o the latter. The ligaments include the anterior sacro-iliac, sacrospinous, and sacrotuberous ligaments. The piriormis muscles arise rom the superior sacrum, lateral to its pelvic oramina. The muscles pass laterally, leaving the lesser pelvis through the greater sciatic oramen to attach to the superior border o the greater trochanter o the emur. The piriormis muscles occupy much o the greater sciatic oramen, orming the posterolateral walls o the pelvic cavity. Immediately deep (anteromedial) to these muscles (oten embedded in the feshy bers) are the nerves o the sacral plexus. A gap at the inerior border o each piriormis muscle allows passage o neurovascular structures between the pelvis and the perineum and lower limb (gluteal region). The pelvic foor is ormed by the bowl- or unnel-shaped pelvic diaphragm, which consists o the coccygeus and levator ani muscles and the ascias (L. The pelvic diaphragm lies within the lesser pelvis, separating the pelvic cavity rom the perineum, or which it orms the roo. The attachment o the diaphragm to the overlying obturator ascia divides the obturator internus muscles into a superior pelvic portion and an inerior perineal portion. Medial to the pelvic portions o the obturator internus muscles are the obturator nerves and vessels and other branches o the internal iliac vessels. The coccygeus muscles arise rom the lateral aspects o the inerior sacrum and coccyx, their feshy bers lying on and attaching to the deep surace o the sacrospinous ligament. The levator ani (a broad muscular sheet) is the larger and more important part o the pelvic foor. It is attached to the bodies o the pubic bones anteriorly, the ischial spines posteriorly, and a thickening in the obturator (continued on p. The oor o the pelvis is ormed by the pelvic diaphragm, encircled by and suspended in part rom the pubic symphysis and pubic bones anteriorly, the ilia laterally, and the sacrum and coccyx posteriorly. Parts (B) through (D) show the staged reconstruction o the parietal structures o the right hemipelvis. Posterolaterally, the coccyx and inerior part o the sacrum are attached to the ischial tuberosity by the sacrotuberous ligament and to the ischial spine by the sacrospinous ligament. The obturator membrane, composed o strong interlacing fbers, flls the obturator oramen. The obturator internus pads the lateral wall o the pelvis, its fbers converging to escape posteriorly through the lesser sciatic oramen (see part B). The levator ani is added, suspended rom a thickening in the obturator ascia (the tendinous arch), which extends rom the pubic body to the ischial spine. The obturator internus and piriormis are muscles that act on the lower limb but are also components o the pelvic walls. The muscles o the levator ani and the coccygeus comprise the pelvic diaphragm that orms the oor o the pelvic cavity. The ascia covering the inerior surace o the pelvic diaphragm orms the "roo" o the perineum. An anterior gap between the medial borders o the levator ani muscles o each side-the urogenital hiatus-gives passage to the urethra and, in emales, the vagina. The levator ani consists o three parts, oten poorly demarcated but designated according to attachments and ber course. The components o the pelvic diaphragm (levator ani and coccygeus muscles) orm the oor o the pelvic cavity and the roo o the perineum. The basin-like nature or which the pelvis was named is evident in this coronal section. The atflled ischio-anal ossae o the perineum also lie within the bony ring o the lesser pelvis. Pubococcygeus: the wider but thinner intermediate part o the levator ani, which arises lateral to the puborectalis rom the posterior aspect o the body o the pubis and anterior tendinous arch. It passes posteriorly in a nearly horizontal plane; its lateral bers attach to the coccyx and its medial bers merge with those o the contralateral muscle to orm a brous raphe or tendinous plate, part o the anococcygeal body or ligament between the anus and coccyx (oten reerred to clinically as the "levator plate"). Shorter muscular slips o pubococcygeus extend medially and blend with the ascia around midline structures and are named or the structure near their termination: pubovaginalis (emales), puboprostaticus (males), puboperinealis, and pubo-analis. Iliococcygeus: the posterolateral part o the levator ani, which arises rom the posterior tendinous arch and ischial spine. It is thin and oten poorly developed (appearing more aponeurotic than muscular) and also blends with the anococcygeal body posteriorly. Most o the let hip bone has been removed to demonstrate that this part o the levator ani is ormed by continuous muscle fbers ollowing a U-shaped course around the anorectal junction. The puborectalis thus orms a puborectal sling, the tonus o which is responsible or maintaining the anorectal angle (perineal exure). Puborectalis (forming puborectal sling) contracted most o the time to support the abdominopelvic viscera and to assist in maintaining urinary and ecal continence. It is actively contracted during activities such as orced expiration, coughing, sneezing, vomiting, and xation o the trunk during strong movements o the upper limbs. Penetrated centrally by the anal canal, the levator ani is unnel shaped, with the U-shaped puborectalis looping around the "unnel spout"; its tonic contraction bends the anorectum anteriorly. Active contraction o the (voluntary) puborectalis portion is important in maintaining ecal continence immediately ater rectal lling or during peristalsis when the rectum is ull and the involuntary sphincter muscle is inhibited (relaxed). The increased intra-abdominal pressure or deecation is provided by contraction o the (thoracic) diaphragm and muscles o the anterolateral abdominal wall. Acting together, the parts o the levator ani elevate the pelvic foor ater their relaxation and the consequent descent o the pelvic diaphragm that occurs during urination and deecation. Peritoneum and Peritoneal Cavity o Pelvis the parietal peritoneum lining the abdominal cavity continues ineriorly into the pelvic cavity but does not reach the pelvic foor. Instead, it refects onto the pelvic viscera, remaining separated rom the pelvic foor by the pelvic viscera and surrounding pelvic ascia (Table 6. The pelvic viscera are not completely ensheathed by peritoneum, lying inerior to it or the main part. Only the uterine tubes (except or their ostia, which are open) are intraperitoneal and suspended by a mesentery. The ovaries, although suspended in the peritoneal cavity by a mesentery, are not covered with glistening peritoneum; instead, a special, relatively dull epithelium o cuboidal cells (germinal epithelium) covers them. A loose areolar (atty) layer between the transversalis ascia and the parietal peritoneum o the inerior part o the anterior abdominal wall allows the bladder to expand between these layers as it becomes distended with urine. Consequently, the level at which the peritoneum refects onto the superior surace o the bladder, creating the supravesical ossa (2 in Table 6. When the peritoneum refects rom the abdominopelvic wall onto the pelvic viscera and ascia, a series o olds and ossae is created (2­7 in Table 6. In emales, as the peritoneum at or near the midline reaches the posterior border o the roo o the bladder, it refects onto the anterior aspect o the uterus at the isthmus o the uterus (see "Female Internal Genital Organs"); thus, it is not related to the anterior vaginal ornix, which is subperitoneal in location. The peritoneum passes over the undus o the uterus and descends the entire posterior aspect o the uterus onto the posterior vaginal wall beore refecting superiorly onto the anterior wall o the inerior rectum (rectal ampulla). The "pocket" thus ormed between the uterus and the rectum is the recto-uterine pouch (cul-de-sac o Douglas) (6 in Table 6. The median recto-uterine pouch is oten described as being the ineriormost extent o the peritoneal cavity in the emale, but oten, its lateral extensions on each side o the rectum, the pararectal ossae, are deeper. Prominent peritoneal ridges, the recto-uterine olds, ormed by underlying ascial ligaments demarcate the lateral boundaries o the pararectal ossae (Table 6. As the peritoneum passes up and over the uterus in the middle o the pelvic cavity, a double peritoneal old, the broad ligament o the uterus, extends between the uterus and the lateral pelvic wall on each side, orming a partition that separates the paravesical ossae and pararectal ossae o each side. The uterine tubes, ovaries, ligaments o the ovaries, and round ligaments o the uterus are enclosed within the broad ligaments. Subdivisions o the broad ligament related to these structures are discussed with the uterus later in this chapter. Recall that in emales, the pelvic peritoneal cavity communicates with the external environment via the uterine tubes, uterus, and vagina. In males-and in emales who have had a hysterectomy (removal o the uterus)-the central peritoneum descends a short distance (as much as 2 cm) down the posterior surace (base) o the bladder and then refects superiorly onto the anterior surace o the inerior rectum, orming the (continued on p. Descends anterior abdominal wall (loose attachment allows insertion o the bladder as it flls) 2. Covers convex superior surace o the bladder and slopes down sides o roo to ascend lateral wall o pelvis, creating a paravesical ossa on each side 4. Laterally, orms old over ureters (ureteric old), ductus deerens, and superior ends o seminal glands (C) Right lateral view of female Female. Covers body and undus o the uterus and posterior ornix o the vagina; extends laterally rom uterus as double old or mesentery-broad ligament that enguls uterine tubes and round ligaments o uterus and suspends ovaries 6. Recto-uterine pouch extends laterally and posteriorly to orm a pararectal ossa on each side o the rectum 8. Ascends rectum; rom inerior to superior, rectum is subperitoneal and then retroperitoneal 9. Rectovesical pouch extends laterally and posteriorly to orm a pararectal ossa on each side o the rectum 8. Enguls sigmoid colon beginning at rectosigmoid junction a Numbers reer to table fgures. The emale recto-uterine pouch is normally deeper (extends arther caudally) than the male rectovesical pouch (7 in Table 6. In males, a gentle peritoneal old or ridge, the ureteric old, is ormed as the peritoneum passes up and over the ureter and ductus (vas) deerens (secretory duct o the testis) on each side o the posterior bladder, separating the paravesical and pararectal ossae. Posterior to the ureteric olds and lateral to the central rectovesical pouch, the peritoneum oten descends ar enough caudally to cover the superior ends or superior posterior suraces o the seminal glands (vesicles) and ampullae o the ductus deerens. Except or these sites (and the testis in its tunica vaginalis, which is derived rom peritoneum), the male reproductive organs are not in contact with the peritoneum. In both sexes, the inerior third o the rectum is below the inerior limits o the peritoneum. The posteriormost part o the band runs as the sacrogenital ligaments rom the sacrum around the side o the rectum to attach to the prostate in the male or the vagina in the emale. In emales, the lateral connection o the visceral ascia o the vagina with the tendinous arch o the pelvic ascia is the paracolpium. The paracolpia suspend the vagina between the tendinous arches, assisting the vagina in bearing the weight o the undus o the bladder. This "layer" is a continuation o the comparatively thin (except around kidneys) endoabdominal ascia that lies between the muscular abdominal walls and the peritoneum superiorly. Traditionally, the pelvic ascia has been described as having parietal and visceral components. The visceral pelvic ascia includes the membranous ascia that directly ensheathes the pelvic organs, orming the adventitial layer o each. The membranous parietal and visceral layers become continuous where the organs penetrate the pelvic foor. Here, the parietal ascia is thickened, orming the tendinous arch o pelvic ascia, a continuous bilateral band running rom the pubis to the sacrum along the pelvic foor adjacent to the viscera. The anteriormost part o this tendinous arch (puboprostatic ligament in males; pubovesical ligament in emales) connects the prostate to the pubis in the male or Oten, the abundant connective tissue remaining between the parietal and visceral membranous layers is considered to be part o the visceral ascia, but sometimes, it is labeled as parietal ascia. It is probably more realistic to consider this remaining ascia simply as extraperitoneal or subperitoneal endopelvic ascia. This ascia orms a connective tissue matrix or packing material or the pelvic viscera. Some o it is an extremely loose areolar (atty) tissue, relatively devoid o all but minor lymphatics and nutrient vessels. During dissection or surgery, the ngers can be pushed into this loose tissue with ease, creating actual spaces by blunt dissection, or example, between the pubis and bladder anteriorly and between the sacrum and rectum posteriorly. The presence o loose connective tissue here accommodates the expansion o the urinary bladder and rectal ampulla as they ll. Although types o endopelvic ascia do not dier much in their gross appearance, other parts o the endopelvic ascia have a much more brous consistency, containing an abundance o collagen and elastic bers and a scattering o smooth muscle bers. They encounter the so-called hypogastric sheath, a thick band o condensed pelvic ascia. This ascial condensation is not merely a barrier separating the two potential spaces. It gives passage to essentially all the vessels and nerves passing rom the lateral wall o the pelvis to the pelvic viscera, along with the ureters and, in the male, the ductus deerens. As it extends medially rom the lateral wall, the hypogastric sheath divides into three laminae (layers) that pass to or between the pelvic organs, conveying neurovascular structures and providing support. The anteriormost lamina, the lateral ligament o the bladder, passes to the bladder, conveying the superior vesical arteries and veins. Coronal and transverse sections o emale (A, B) and male (C, D) pelves demonstrating the parietal and visceral pelvic ascia and the endopelvic ascia between them, with its ligamentous and loose areolar components. The posteriormost lamina (lateral rectal ligament) passes to the rectum, conveying the middle rectal artery and vein. In the male, the middle lamina orms a relatively thin ascial partition, the rectovesical septum. In the emale, the middle lamina is markedly more substantial than the other two, passing medially to the uterine cervix and vagina as the cardinal ligament (transverse cervical ligament). In its superiormost portion, at the base o the peritoneal broad ligament, the uterine artery runs medially toward the cervix while the ureters pass immediately inerior to them. This relationship ("water passing under the bridge") is an especially important one or surgeons (see the Clinical Box "Iatrogenic Injury o Ureters"). The cardinal ligament, and the way in which the uterus normally "rests" on top o the bladder, provides the main passive support or the uterus.

The intermesenteric plexus is part o the aortic plexus o nerves between the superior and the inerior mesenteric arteries stages of hiv infection according to who purchase nemasole 100mg with amex. The superior hypogastric plexus is continuous with the intermesenteric plexus and the inerior mesenteric plexus and lies anterior to the inerior part o the abdominal aorta and extends ineriorly across its biurcation (Table 5 hiv infection rate who 100mg nemasole order amex. Right and let hypogastric nerves join the superior hypogastric plexus to the inerior hypogastric plexus antiviral hiv nemasole 100mg order on-line. The inerior hypogastric plexuses are mixed sympathetic and parasympathetic plexuses ormed on each side as the hypogastric nerves rom the superior hypogastric plexus merge with the pelvic splanchnic nerves hiv infection rate atlanta order nemasole 100 mg without a prescription. The right and let plexuses are situated on the sides o the rectum hiv infection rates massachusetts buy genuine nemasole on-line, cervix o the uterus, and urinary bladder. The plexuses receive small branches rom the superior sacral sympathetic ganglia and the sacral parasympathetic outfow rom S2 through S4 sacral spinal nerves (pelvic [parasympathetic] splanchnic nerves). Extensions o the inerior hypogastric plexus send autonomic bers along the blood vessels, which orm visceral plexuses on the walls o the pelvic viscera. The celiac, superior mesenteric, and inerior mesenteric plexuses are interconnected. The celiac plexus, surrounding the root o the celiac (arterial) trunk, contains irregular right and let celiac ganglia (approximately 2 cm long) that unite superior and inerior to the celiac trunk. The parasympathetic root o the celiac plexus is a branch o the posterior vagal trunk, which contains bers rom the right and let vagus nerves. Vasomotion (control o blood fow) at this level infuences water and electrolyte movement. Corresponding plexuses with smaller, sparser ganglia extend to the pancreas, gallbladder, and cystic and major biliary ducts. Abdominal Viscera 531 the motor neurons o these plexuses are intrinsic or enteric ganglia that serve nominally as postsynaptic neurons or the parasympathetic system. In addition to unctioning as relay neurons, receiving and passing on eerent impulses sent by presynaptic parasympathetic neurons, they also receive input rom postsynaptic sympathetic bers (making them a third-order neuron in that system). They have vast interconnectivity with surrounding eerent neurons, both directly and via interneurons, as well as axons terminating on smooth muscle and glands. In addition, there are intrinsic aerent neurons with cell bodies in the plexuses that monitor mechanical and chemical conditions in the gut and communicate with the eerent neurons providing local (short) refex circuitry, as well as sending inormation centrally. Schematic illustration o the organization o the enteric nervous system within the intestinal wall. Flow chart demonstrating long (extrinsic) and short (intrisic) reexes involving the enteric nervous system. These intrinsic neurons and the complex enteric plexuses in which they are enmeshed integrate and control gastrointestinal unction with remarkable independence, sustaining visceral activities with local refex mechanisms. With regard to the smooth muscle sphincters, the roles o the sympathetic and parasympathetic systems reverse, with the sympathetic system maintaining tonus and the parasympathetic system inhibiting it. Relatively nonpermeable capillaries associated with the ganglia provide a diusion barrier resembling the blood­brain barrier o cerebral blood vessels. Approximate spinal cord segments and spinal sensory ganglia involved in sympathetic and visceral aerent (pain) innervation o abdominal viscera are shown. Visceral aerent bers conveying pain sensations accompany the sympathetic (visceral motor) bers. The pain impulses pass retrogradely to those o the motor bers along the splanchnic nerves to the sympathetic trunk, through white communicating branches to the anterior rami o the spinal nerves. Then they pass into the posterior root to the spinal sensory ganglia and spinal cord. The stomach (oregut) receives innervation rom the T6 to T9 levels, small intestine through transverse colon (midgut) rom the T8 to T12 levels, and descending colon (hindgut) rom the T12 to L2 levels. Starting rom the midpoint o the sigmoid colon, visceral pain bers run with parasympathetic bers, the sensory impulses being conducted to S2­S4 sensory ganglia and spinal cord levels. These are the same spinal cord segments involved in the sympathetic innervation o those portions o alimentary tract. Visceral aerent bers conveying refex sensations (that generally do not reach levels o consciousness) accompany the parasympathetic (visceral motor) bers. The fbers traverse the paravertebral ganglia o the trunks without synapsing, continuing as components o abdominopelvic splanchnic nerves. These nerves convey them to the abdominal aortic plexus, where they are joined by presynaptic parasympathetic fbers delivered by the vagus continued on next page Diaphragm 533 the Bottom Line (continued) nerve. The sympathetic fbers pass to prevertebral ganglia, most o which are clustered around the major branches o the abdominal aorta. Ater synapsing within the ganglia, the postsynaptic sympathetic fbers join the presynaptic parasympathetic fbers, traveling via peri-arterial plexuses around the branches o the abdominal aorta to reach the viscera. A continuation o the abdominal aortic plexus inerior to the aortic biurcation (the superior and inerior hypogastric plexuses) conveys sympathetic innervation to most o the pelvic viscera. The sympathetic fbers mainly innervate the blood vessels o abdominal viscera and are inhibitory to the parasympathetic stimulation. The parasympathetic fbers synapse on or in the walls o the viscera with intrinsic postsynaptic parasympathetic neurons, which terminate on the smooth muscle or glands o the viscera. Parasympathetic innervation: the vagus nerves supply parasympathetic fbers to the digestive tract rom the esophagus through the transverse colon. Parasympathetic stimulation promotes peristalsis and secretion (although much o the latter is usually hormonally regulated). Sensory innervation: Visceral aerent fbers ollow the autonomic fbers retrograde to sensory ganglia. Aerent fbers conveying pain sensation rom abdominal viscera orad (proximal) to the middle o the sigmoid colon run with the sympathetic fbers to the thoracolumbar spinal sensory ganglia; all other visceral aerent fbers run with the parasympathetic fbers. Thus, visceral aerent fbers conveying reex inormation rom the gut orad to the middle o the sigmoid colon pass to vagal sensory ganglia; fbers conveying both pain and reex inormation rom the gut aborad (distal) to the middle o the sigmoid colon pass to spinal sensory ganglia S2­S4. Its mainly convex superior surace aces the thoracic cavity, and its concave inerior surace aces the abdominal cavity. The diaphragm is the chie muscle o inspiration (actually, o respiration altogether, because expiration is largely passive). It descends during inspiration; however, only its central part moves because its periphery, as the xed origin o the muscle, attaches to the inerior margin o the thoracic cage and the superior lumbar vertebrae. The pericardium, containing the heart, lies on the central part o the diaphragm, depressing it slightly. The diaphragm curves superiorly into right and let domes; normally, the right dome is higher than the let dome owing to the presence o the liver. During expiration, the right dome reaches as high as the 5th rib and the let dome ascends to the 5th intercostal space. The level o the domes o the diaphragm varies according to the phase o respiration (inspiration or expiration). The muscular part o the diaphragm is situated peripherally with bers that converge radially on the trioliate central aponeurotic part, the central tendon. The central tendon has no bony attachments and is incompletely divided into three leaves, resembling a wide cloverlea. Although it lies near the center o the diaphragm, the central tendon is closer to the anterior part o the thorax. The surrounding muscular part o the diaphragm orms a continuous sheet; however, or descriptive purposes, it is divided into three parts, based on the peripheral attachments: Sternal part: consisting o two muscular slips that attach to the posterior aspect o the xiphoid process; this part is not always present. Costal part: consisting o wide muscular slips that attach to the internal suraces o the inerior six costal cartilages and their adjoining ribs on each side; the costal parts orm the right and let domes. Lumbar part: arising rom two aponeurotic arches, the medial and lateral arcuate ligaments, and the three superior lumbar vertebrae; the lumbar part orms right and let muscular crura that ascend to the central tendon. The right crus, larger and longer than the let crus, arises rom the rst three or our lumbar vertebrae. The thoracic wall and cage have been removed to demonstrate the attachments and convexity o the right dome o the diaphragm. The eshy sternal, costal, and lumbar parts o the diaphragm (outlined with broken lines) attach centrally to the treoil-shaped central tendon, the aponeurotic insertion o the diaphragmatic muscle fbers. The right and let crura and the brous median arcuate ligament, which unites them as it arches over the anterior aspect o the aorta, orm the aortic hiatus. The diaphragm is also attached on each side to the medial and lateral arcuate ligaments. The medial arcuate ligament is a thickening o the ascia covering the psoas major, spanning between the lumbar vertebral bodies and the tip o the transverse process o L1. The lateral arcuate ligament covers the quadratus lumborum muscles, continuing rom the L12 transverse process to the tip o the 12th rib. The superior aspect o the central tendon o the diaphragm is used with the inerior surace o the brous pericardium, the strong, external part o the broserous pericardial sac that encloses the heart. Vessels and Nerves o Diaphragm the arteries o the diaphragm orm a branch-like pattern on both its superior (thoracic) and inerior (abdominal) suraces. The arteries supplying the inerior surace o the diaphragm are the inerior phrenic arteries, which typically are the rst branches o the abdominal aorta; however, they may arise rom the celiac trunk. Some veins rom the posterior curvature o the diaphragm drain into the azygos and hemi-azygos veins (see Chapter 4, Thorax). The veins draining the inerior surace o the diaphragm are the inerior phrenic veins. The lymphatic plexuses on the superior and inerior suraces o the diaphragm communicate reely. The anterior and posterior diaphragmatic lymph nodes are on the superior surace o the diaphragm. Lymph rom these nodes drains into the parasternal, posterior mediastinal, and phrenic lymph nodes. Lymphatic vessels rom the inerior surace o the diaphragm drain into the anterior diaphragmatic, phrenic, and superior lumbar (caval/aortic) lymph nodes. Lymphatic capillaries are dense on the inerior surace o the diaphragm, constituting the primary means or absorption o peritoneal fuid and substances introduced by intraperitoneal (I. Sensory innervation (pain and proprioception) to the diaphragm is also mostly rom the phrenic nerves. Peripheral parts o the diaphragm receive their sensory nerve supply rom the intercostal nerves (lower six or seven) and the subcostal nerves. Also passing through the caval opening are terminal branches o the right phrenic nerve and a ew lymphatic vessels on their way rom the liver to the middle phrenic and mediastinal lymph nodes. Lymphatic vessels are ormed in two plexuses, one on the superior surace o the diaphragm and the other on its inerior surace; the plexuses communicate reely. The phrenic nerves supply all o the motor and most o the sensory innervation to the diaphragm. In most individuals (70%), both margins o the hiatus are ormed by muscular bundles o the right crus. In others (30%), a supercial muscular bundle rom the let crus contributes to the ormation o the right margin o the hiatus. The esophageal hiatus also transmits the anterior and posterior vagal trunks, esophageal branches o the let gastric vessels, and a ew lymphatic vessels. The bers o the right crus o the diaphragm decussate (cross one another) inerior to the hiatus, orming a muscular sphincter or the esophagus that constricts it when the diaphragm contracts. The esophageal hiatus is superior to and to the let o the aortic hiatus is the opening posterior in the diaphragm or the descending aorta. Because the aorta does not pierce the diaphragm, movements o the diaphragm do not aect blood fow through the aorta during respiration. The aorta passes between the crura o the diaphragm posterior to the median arcuate ligament, which is at the level o the inerior border o the T12 vertebra. This triangle transmits lymphatic vessels rom the diaphragmatic surace o the liver and the superior epigastric vessels. The sympathetic trunks pass deep to the medial arcuate ligament, accompanied by the least splanchnic nerves. There are two small apertures in each crus o the diaphragm; one transmits the greater splanchnic nerve and the other the lesser splanchnic nerve. Although this movement is oten described as the "descent o the diaphragm," only the domes o the diaphragm descend. This increases the volume o the thoracic cavity and decreases the intrathoracic pressure, resulting in air being taken into the lungs. In addition, the volume o the abdominal cavity decreases slightly and intra-abdominal pressure increases somewhat. Movements o the diaphragm are also important in circulation because the increased intra-abdominal pressure and decreased intrathoracic pressure help return venous blood to the heart. The diaphragm is at its most superior level when a person is supine (with the upper body lowered, the Trendelenburg position). In this position, the abdominal viscera push the diaphragm superiorly in the thoracic cavity. When a person lies on one side, the hemidiaphragm rises to a more superior level because o the greater push o the viscera on that side. Conversely, the diaphragm assumes an inerior level when a person is sitting or standing. For this reason, people with dyspnea (dicult breathing) preer to sit up, not lie down; nontidal (reserve) lung volume is increased, and the diaphragm is working with gravity rather than opposing it. Fascia o Posterior Abdominal Wall the posterior abdominal wall is covered with a continuous layer o endoabdominal ascia that lies between the parietal peritoneum and the muscles. The ascia lining the posterior abdominal wall is continuous with the transversalis ascia that lines the transversus abdominis muscle. The psoas ascia covering the psoas major muscle (psoas sheath) is attached medially to the lumbar vertebrae and pelvic brim. The psoas ascia (sheath) is thickened superiorly to orm the medial arcuate ligament. The psoas ascia uses laterally with the quadratus lumborum and thoracolumbar ascias. Inerior to the iliac crest, the psoas ascia is continuous with the part o the iliac ascia covering the iliacus.

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