What is the insertion of the external oblique?
insertion iliac crest,anterior superior iliac spine (pubic tubercle and crest by way of apon. of external oblique)
What is the origin of the internal oblique?
thoracolumbar fascia, iliac crest, lat 2/3 of inguinal ligament
What is the insertion of the internal oblique?
inferior border of last three ribs, linea alba, pubic crest
What is the origin of the transversus abdominis?
inner aspect of 6 inf. costal cart. iliac crest, lateral 1/3 inguinal lig.
What is the insertion of the pyramidalis?
linea alba anterior to rectus muscles, used to find midline
Where does the transversalis fascia arise?
inner aspect of costal margin, thoracolumbar fascia, iliac crest.
Where does the transversalis fascia insert?
linea alba, pubic crest. It has parietal and visceral component (endopelvic fascia) becomes inferior fascia of diaphragm
What are the boundaries of the inguinal triangle of Hesselbach?
inferior epigastric artery, linea semilunaris, inguinal ligament, it is site of direct hernia
A woman with a platypetelloid pelvis delivers a large baby. The next day she has severe back pain. Dx?
What is Cooper's ligament?
A condensation of fascia along pectinate line anteriorly used in Burch procedures
What are the contents of the greater sciatic foramen?
piriformis, superior gluteal nn, sciatic n, n. of quadratus femoris, inferior gluteal n, inferior gluteal vessels, post. cutaneous n. nn of obturator internus, internal pudendal n/a /v)
What are the boundaries of the pelvic inlet
sacral promontory, arcuate line, pectineal line, pubic crest, upper margin of symphysis
What muscles make up the lateral pelvic sidewall above the arcus tendineus?
piriformis, obtuator internus, iliopsoas
What is the orgin of the piriformis?
sacrum, (overlain by the sacral plexus coccygeus associate with the coccyx)
What is the origin of the obturator internus?
superior and inferior pubic rami exits lesser foramena
What is the insertion of the levator ani?
insertion central tendon, wall of anal canal (puborectalis), wall of vagina (pubovaginalis), anococcygeal lig, coccyx (pubococcygeus)
What are 2 muscles of the urogenital diaphragm?
deep transverse perineal and sphincter urethrae complex
What is the origin insertion, action and innervation of the deep transverse perineal muscle?
origin: med. aspect of ischiopubic rami insertion: lower vaginal wall
action: steadies central tendon innervation S2 to S4 perineal n
What is the origin insertion, action, and innervation of the sphincter urethrae?
origin: medial aspect of ischiopubic rami insertion: urethra and vagina
action: compresses urethra innervation S2 to S4
Name the 3 types of peritoneal fascia.
1. parietal covers muscles continuation of transversalis fascia includes arcus tendineus. 2. diaphragmatic : covers urogenital diaphragm Has two layers (internal and external) Internal or superior layer is strongest.
3.endopelvic fascia covers the three tubular structures
What is the hiatus of Schwalbe?
space between the levators and obturator fascia that may herniate to ischiorectal fossae/suprategmental space.
What is the boundary of the perineum?
symphysis, coccyx, inferior pubic ramus, ischial rami, ischial tuberosities, sacrotuberous ligaments. (External to the levators)
Name the 5 muscles that insert on the perineal body.
superficial transverse perineal x 2
deep transverse perineal x2,
Describe the path of the pudendal(Alcock's) canal.
runs from post ischirectal fossa at lesser sciatic foramen at edge of urogential diaphragm
Name the four arteries that supply the vagina.
Vaginal artery, vaginal branch from uterine a, middle rectal, internal pudendal
What are the azygos arteries of the vagina?
midline fusion of vaginal arteries, analogous to inferior ves aa in the male
What nodes would be positive soonest in a patient with vaginal cancer involving the upper 1/3 of the vagina?
What are the three layers to the vagina?
Mucosa, mucularis (inner circular & outer longitudinal), adventita
Describe the transformation zone.
The tissue of the cervix between the outer ring of the old squamocolumar junction the the current SCJ
Why does the abdominal wall have no deep fascia?
Allows GI tract to expand. No deep fascia only Campers/Scarpas and muscles/aponeurosis
What structure is found in the median umbilical fold?
Urachus (all that is left from the ventral mesentery of the hind gut)
What is the contents of the medial umbilical ligament?
obliterated umbilical vessels from the hypogastric system
What is contained within the falciform ligament?
ligamemtum teres and obliterated left umbilical vein
How can you diagnose a direct hernia?
Occurs via internal ring , controlled by pressure 1/2 inch above femoral pulse that closes canal
How can you diagnose a direct hernia?
Through the post. wall of inguinal canal, medial to above point. Not controlled by occluding the inguinal canal.
What is the relationship of the deep inguinal ring and the epigastric artery?
The artery is the medial border of the ring
What is the blood supply to the bladder?
Blood from superior vesicular a, middle vesicular artery, inferior ves artery, middle hemorrhiodas artery, uterine, vaginal a..
On D&C a probe perforates the middle 1/3 of the vagina anteriorly. In what part of the bladder would it be found?
A woman with a bicornuate uterus presents to your clinic. This defect represents...
Failure of fusion of the mullerian system
Failure of central degeneration of the fused mullerian ducts results in what types of uterine anomalies?
arcuate, septum, didelphus, didelphus with vag septum
A patient presents with a cervix located on the anterior vaginal wall with the uterus angling posteriorly. This is called ...
Retroflexion. Flexion refers to the angle between the corpus and cervis (with in the uterus)
The name of the stitch placed throught the broad ligament to control post=partum hemorrhage is the ....
What are the boundaries to the foramen of Winslow?
Anterior: lesser omentum with hepatic art., hepatic portal v, CBD posterior: IVC, right crus of diaphragm superior: cuadate lobe of the liver inferior" duodenum
What are the boundaries of the lesser sac?
Anterior liver Superior diaphragm Posterior coronary Ligament Inferior gastrocolic ligament of greater omentum Left spleen Pouch of Morrison on right.
You are staging a patient for ovarian cancer. An accidental enterotomy is made somewhere in the small bowel. How can you tell duodenum from jejunum?
Duodenum has thicker walls, greater diameter, thinner mesentery and less fat, longer arcades with fewer branches.
What are the characteristics of a Meckel's diverticulum
Occurs in 2%, 2x males:females, 2 feet from ileocecal valve, 2 inches long. Remnant of vitello intestinal duct
Name two arteries that provide important collateral circulation to the large bowel.
Arch of Riolan, marginal artery of Drummond
You are resecting extensive peritoneal endometriosis. Your dissection extends down the sigmoid to the rectum. At what point does the rectum become retroperitoneal?
at level of pouch of Douglas
What is the pectinate line?
The transition from columnar epithelium to stratified squamous in the anus
A renal stone in the abdominal portion of the ureter refers pain to what dermatome?
abdominal L1 to L2 refer to inguinal & pubic region
Describe the sacral foramima.
4 posterior foramina (sacral n), 4 anterior foramina (sacral n. & lateral sacral vessels)
What is usually the first artery divided during abdominal hysterectomy?
Artery of Sampson (contained within the round ligament)
Describe the path of the round ligament.
Inserts in canal of Nuck deep inguinal ring, runs around inf epigastric vessels becomes extraperitoneal and crosses the obliterated hypogastric a. to insert in labia majora
What ligament primarily holds the cervix and vagina over the levator plate?
What nerves travel in the uterosacral ligaments?
parasympathetic and sympathetic fibers from the hypogastric plexus
You are doing a C section. You have divided the rectus muscles and entered the peritoneum. As you extend your incision toward the bladder, you divide thick connective tissue bands overlaying the peritoneum. What are they?
What is the difference between a pertoneal fold and a peritoneal ligament?
A ligament is a double layer of peritoneum covering a neurovascular structure. A fold appears over a single tubular structure (obliterated?) blood vessel or ureter
Name the major branches of the inferior mesenteric artery.
left colic (transv. to descending colon) sigmoid, superior rectal.
What are the 5 branches of the external iliac artery?
superficial epigastric, external pudendal, superficial circumflex iliac, inferior epigastric, deep circumflex iliac of sciatic foramen.
You are doing a Burch procedure and dissect out just a little to far. Your field fills with venous blood. What vessel was injured?
Plexus of Santorini
You are doing a Burch procedure and dissect just a little to far laterally. You encounter a brisk arterial bleeder. What vessel have you injured?
Aberrant obturator (in 35% the pubic branch of inferior epigastric is large and replaces obturator)
What 12 nerves make up the lumbosacral plexus?
Iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femaoral, obturator, superior gluteal, inferior gluteal, posterior femoral cutaneous, sciatic, pudendal
What nerve penetrates external oblique 1 to 2 cm superomedial to superficial ring?
Iliohypogastric L1 sensory
What nerve innervates the upper medial thigh and mons labia majora and pubis?
Ilioinguinal L1 (anterior labial nerve)
What nerve provides sensation to the anterior vulva and middle/upper anterior thigh?
Genitofemoral L1 to L2
How does the genitofemoral nerve exit the pelvis?
genital branch via inguinal ring femoral branch below ing lig.
What nerve provides sensory innervation to medial thigh
leg, hip, and knee? It also provides motor branches to the adductors of thigh.,Obturator L2 to L4
You are doing a lymph node dissection. You have moved the iliac vessels medially with a vein retractor and are dissecting with the Bovie. A nerve is triggered and the pts leg moves. What is the nerve?
Obturator L2 to L4
What 2 nerves supply only motor fibers to gluteal mmuscles?
superior gluteal n. (L4, L5, S1) and inferior gluteal n (L4, L5,S1,S2)
What nerve provides sensory innervation to leg and motor fibers to the posterior thigh leg and foot?
What nerve provides sensory innervation to the perianal skin vulva perineum, clitoris, urethra, and vestibule?
What nerve provides motor innervation to the external sphincter perineal mm and urogential diaphragm?
What nerve emerges within the inguinal canal and through the superficial inguinal ring to supply the mons & upper labia major?
anterior labial n. : branch of ilioinguinal
What is the path of the genital branch of the genitofemoral nerve?
enters the inguinal canal with the round ligament exits the superficial inguinal ring to anterior vulva.
What is the path of the perineal branches of the posterior femoral cutaneous nerve?
exit via GSF run anterior to ischial tuberosity to lateral perineum and labia majora
What nerves innervate the skin over the coccyx and sacrum?
Perforating cutaneous branches of the second and third sacral nn ; perforate the sacrotuberous ligament to supply the buttocks and perineum anococcygeal nn S4 to 5 perf. sacrotuberous lig. to supply skin of coccyx
What is Frankenhauser nerve plexus?
a condensation of uterovaginal nn on either side of cx that contains sympathetic (contraction) and parasympathetic (relaxation)nn to uterus, bladder, vagina. ympathetic nerves also reach the uterus in association with uterine arteries.
Where are the parasympathetic fibers (S1 to 4 via nervi eregentes) found?
Fibers run in anterior two thirds of u/s ligaments.
Where are the sympathetic trunks located?
lie on medial border of psoas muscle, pass behind common iliac v. on anterior sacrum.
What structures are innervated by the ovarian plexus?
ovaries, tube, broad ligament, this plexus is derived from aortic/renal plexus
What is the name for the continuation of the aortic plexus in the pelvis?
superior hypogastric plexus a.k.a. presacral nerves (a continuation of aortic plexus) retroperitoneal, in front of terminal aorta, L5, sacral promontory, medial to ureters, over middle sacral v.,
What types of nerves are found in the superior hypogastric nerves?
preganglionic fibers from lumbar n., postganglionic fibers from sympathetic nn., postganglionic fibers from sacral sympathetic trunks, viceral afferent fibers.
After passing the sarcal promonotory what is the fate of the superior hypogastric plexus?
Below the sacral promontory, the superior hypogastric plexus divides into hypogastric nn.. These move inferiorly and laterally to connect to inferior hypogastric plexus which overlie the internal iliac vessels.
What fibers are found in the inferior hypogastric plexus?
efferent sympathetic fibers, sensory fibers, parasymp. from S2 to S4
What structures does the inferior hypogastric plexus innervate?
This paired plexus divides into three portions to innervate the pelvic viscera as the Vesical plexus, Middle rectal plexus, and the Uterovaginal plexus.
What structures does the vesical plexus innervate?
Vesical plexus (branch of the hypogastric plexus) innervates the bladder and urethra which courses along vesical vessels.
What structures does the middle rectal plexus innervate?
Middle rectal plexus (branch of the inferior hypogastric plexus)innervates rectum and follows the middle rectal vessels.
What structres does the uterovaginal plexus innervate?
Uterovaginal plexus (Frankenhauser) innervates the uterus, vagina, clitoris, vestibular bulbs runs along uterine vessels (through the cardinal) and uterosacral ligaments, carries sympathetic and sensory fibers from T10 to L1, parasympathetic fibers from S2 to S4
What is the path of afferent innervation of the pelvis?
Follows blood vessels, first synapse in posterior spinal nerve gangila
The ventral mesentery of the primitive forgut persists as what structures?
The liver arises dividing mesentery into lesser omentum and falciform ligament.
Describe the development of the urinary system.
Begins with nephrogenic cord, then pronephros forms & fades. Then the mesonephros forms. The mesonephric duct lays groundwork of kidney and becomes the male duct .Uteric buds arise from mesonephric duct to form connection to metanephric blastema which induces formation of the kidney. Originally get blood from middle sacral artery. Inferiorly, the mesonephric duct connetion to outside dilates to form cloaca.
Describe the migration of the germ cells in early development.
Germ cells migrate from yolk sac via the mesentery of hindgut to T10
Describe the fusion of the Mullerian ducts.
Mullerian (paramesonephric) ducts form lateral to mesonephric ducts and grow caudally and fuse in the midline unless TDY and AMH are present.
What stage of the cell cycle are the germ cells in the pre pubescent female?
Germ cells enter 1st meiotic division & arrest until puberty.
Describe the fusion of the paramesonephric ducts.
Paramesonephric duct grows. Inferior fused portion recanalizes and becomes uterovaginal canal (epithelium/glands of uterus/vagina) surrounding mesenchyme forms endometrial stroma and myometrium.
What happens embryonically when renal agenisis occurs?
ureteric buds fail to induce metanephric blastema, associated with ipsilat. absence of Muellerian str.
How many layers in the detrusor muscle?
3 Layers are not distinct at the dome. At the base, they are outer longitudinal, intermediate oblique layer, inner plexiform ( trabecullations on cysto)
What is Heiss's loop?
A U shaped band of tissue in the vesical neck that may add sphinceteric function as it is paired with a second unnamed U shaped band, each straddles the urethra, but from opposite directions.
What are the three parts of the trigonal muscle?
Urinary trigone : anatomic landmark for finding the ureteral orifices, trigonal ring ( :adrenergic ring of tissue that is the most proximal cont. mechanism. Trigonal plate : a long fiber parallel to and on the vaginal side of the urethra that completes the circle of the U shaped striated sphincter
Describe the two portions of the urogenital sphincter?
Upper sphincteric portion (sphincter urethrae), lower arch like portion (urethrovaginal sphincter, compressor urethrae) Slow twitch muscle.
What are the layers of the urethra?
Outermost striated urogenital sphincter, circular smooth muscle, longitudinal smooth muscle, submucosa, mucosa
Describe the attachment of the urethra to the symphysis pubis.
Only the distal 1/3 is attached via the urigenital diaphragm and the urethrovaginal sphincter, compressor urethrae. The transition to the mobile portion is called the knee of the urethra
Describe the relationship between the urethra and the vagina
The are fused for the distal 2/3 due to common origin with the urogenital sinus.
What is Cullen's sign?
A faint blue coloration of the umbilicus associated with retroperitoneal bleeding