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Anterior Abdominal Wall and Inguinal Canal Learning Objectives – 1/5/09 [LANE]

1. Define the boundaries of the abdominal cavity and the skeletal components related to the abdominal wall.

a. Boundaries:i. Superior: Diaphragm

ii. Anterior: Aponeurosesiii. Inferior: Superior pelvic aperture (imaginary)iv. Posterior: Anterior longitudinal ligament of vertebral bodies

b. Skeletal componentsi. Lumbar vertebrae

ii. Lower ribsiii. Pubic bones

1. Iliac crest2. Describe the major surface landmarks of the anterior abdominal wall.

a. Linea semilunaris: On the lateral side of each rectus abdominus muscleb. Umbilicus: Remnant of the umbilical cordc. Linea alba: “happy trail.” Medially between rectus abdominal mm.

3. Describe the lines and planes that are used to divide the abdomen into quadrants and regions.

a. Quadrantsi. Dividers

1. Transumbilical plane (TUP)a. IV disk L3/L4

2. Median plane (follows linea alba)ii. Regions (4)

1. Right upper quadrant (RUQ)2. Left upper quadrant (LUQ)3. Right lower quadrant (RLQ)4. Left lower quadrant (LLQ)

b. Regionsi. Dividers

1. Mid-clavicular lines (2): Middle of clavicle down2. Subcostal plane: Tangent to lowest ribs (L2)3. Transtubercular plane: Midway between the upper transverse

and the upper border of the symphysis pubis. Between iliac tubercles. (L5)

ii. Regions (9)1. Epigastric2. Right/Left hypochondriac3. Umbilical4. Right/Left lumbar5. Hypogastric6. Right/left inguial

c. Other planesi. Transpyloric: L1, just above subcostal at L2

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ii. Interspinous plane: Connects right/left ASIS, just above transtubercular

4. Describe the attachments, orientations, relative positions, actions, and fascia of the four major abdominal muscles.

a. External obliquei. Attachment

1. 5th-12th ribs, inferiorly2. (Linea alba)3. Pubic tubercle4. Anterior ½ of iliac crest. “jumps across” inguinal ligament

ii. Orientation1. Like a “V”, or “hands in pockets”

iii. Relative position1. Superior lateral, membranous tendon inferior medial

iv. Action1. Compress abdominal contents

v. Innervation1. Ventral rami T7-T12 (Thoracoabdominal nn.) +/- L1

vi. Fascia1. Superficial:

a. Camper’s: Fatty (superficial) layer of superficial fasciab. Scarpa’s: Membranous (deep) layer of superficial fasciac. Deep fascia

2. Deep:a. Deep fascia

b. Internal obliquei. Attachment

1. Thoracolumbar fascia2. Anterior 2/3 of iliac crest3. Inginal ligament (lateral ½)4. Lower ribs

ii. Orientation1. Upside-down “V”

iii. Relative position1. Inferior lateral, membranous tendon superior medial

iv. Action1. Unilateral: same side rotation/bending

v. Innervation1. Ventral rami T7-T12 (Thoracoabdominal nn.) +/- L1

vi. Fascia1. Superficial/Deep: Deep fascia

c. Transverse obliquei. Attachment

1. Ribs/costal muscle2. Thoracolumbar fascia3. Iliac crest4. Lateral 1/3 of inguinal ligament

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a. Important b/c it does NOT contribute a layer to the spermatic cord

ii. Orientation1. Horizontal

iii. Relative position1. Lateral, membranous medial

iv. Action1. Raise abdominal pressure

v. Innervation1. Ventral rami T7-T12 (Thoracoabdominal nn.) +/- L1

vi. Fascia1. Superficial: Deep2. Deep: Transversalis fascia

d. Rectus Abdominusi. Attachment

1. Costal cartilage of ribs 5-72. Xyphoid process3. Pubic crest

ii. Orientation1. Vertical

iii. Relative position1. Segmented, with 4 sets of membranous aponeurosess

iv. Action1. Flexes trunk, compresses abdomen

v. Innervation1. Ventral rami T7-T12 (Thoracoabdominal nn.) +/- L1

vi. Fascia1. Above arcuate line:

a. Superficial/Deep: Internal oblique aponeurosis2. At/below arcuate line:

a. Superficial: All abdominal aponeurosesb. Deep: Perietal peritoneum

5. Define the blood supply, nerve supply, fascial layers, muscle layers, extraperitoneal fat, and parietal peritoneum of the anterior abdominal wall. How do these relate to the various surgical approaches to the abdominal cavity?

a. Blood supplyi. Superior

1. Internal thoracic a.a. Musculophrenic a. branches laterally along subcostal

angleb. Superior epigastric a. branches medially along rectal

sheathii. Inferior

1. External Iliac a.a. Inferior epigastric a. branches superior medial. Supplies

more of rectus abdominus than superior epigastric because it is deep.

b. Deep circumflex iliac a. branches superior medial

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c. Femoral a. continuation inferior to inguinal ligamenti. Superficial epigastric a. branches superior

medialii. Superficial circumflex iliac a. branches superior

lateral along iliac crest superficiallyiii. Lateral

1. Intercostal aa. Even those of false ribs2. Subcostal a.

b. Nerve supplyi. Pathway:

1. Between internal oblique mm. and transverse abdominis mm., pierce the rectus sheath to supply rectus ab. Mm. + provide anterior cutaneous branches

ii. Thoracoabdominal nn. (T7-T11)1. Cutaneous innervation separately of medial/lateral portions

iii. Iliohypogastric n. (L1) supplies mons pubisiv. Ilioinguinal n. (L1) supplies scrotum/labia majorav. T10 supplies of umbilicus

vi. T5 supplies skin over xyphoid processc. Surgical approaches

i. General goals1. Try not to transect arteries/nerves2. Use “Gridiron technique” in appendix surgery with McBurney’s

pointii. Landmarks

1. Subcostal: outdated way for spleen surgery2. Median: linea alba3. Paramedian: just lateral to linea alba4. Super pubic: just above mons pubis, used in C-sections5. McBurney’s point

a. Line between ASIS and umbilicusb. 1/3 of the way from ASIS to umbilicusc. Used for appendix surgery

6. Describe the configuration of the anterior and posterior walls of the rectus sheath superior and inferior to the arcuate line.

a. Superior to the arcuate line, the internal oblique aponeurosis surrounds the abdominus rectus

b. Inferior to the arcuate line, the internal oblique aponeurosis is only superficial to the abdominus rectus since it pierces it

7. Define the inguinal canal, including the location of the deep and superficial inguinal rings.

a. Know the structures forming the walls of the inguinal canal.i. Superficial inguinal ring

1. Medial Crus2. Lateral Crus3. Intercrural fibers (not very pronounced in most cadavers)

ii. Borders:1. Anterior: External oblique

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2. Posterior: Internal oblique/conjoint tendon3. Superior: Internal oblique4. Inferior: Inguinal ligament

b. Define the function and mechanics of the inguinal canal.i. Route of passage for the testes from posterior abdominal wall to

scrotumii. Contains the spermatic cord in males and the round ligament in females

c. Describe the contents of the inguinal canal. How do these differ between the sexes?

i. Males: spermatic cord, (gubernaculums)ii. Females: round ligament

d. Describe the borders of the inguinal triangle (Hasselbach’s Triangle).i. rectus abdominis muscle (medially)

ii. inguinal ligament (inferiorly)iii. inferior epigastric vessels (superior and laterally).

8. Define the anatomy and relationships of the:a. Process vaginalis

i. Portion of peritoneal cavity that “follows” the testes as they descent. Normally is obliterated, but can be patent in adults.

b. Spermatic cordi. Fascia layers

1. External spermatic fascia2. Cremasteric fascia3. Internal spermatic fascia (continuous with transversalis fascia)

ii. Contents1. Ductus (Vas) deferens2. Testicular arvery, artery of Vas3. Pampiniform plexus of veins

a. Helps cool temperature in testicles4. Lymph vessels5. Nerves

c. Epididymusi. Narrow, tightly-coiled tube connecting the efferent ducts from the rear

of each testicle to its vas deferens.ii. Storage of sperm

d. Cremaster musclei. Originates from the internal oblique

ii. Surrounds the testesiii. Helps regulate testes temperature to optimal for spermatogenesis

e. Testesi. Site of spermatogenesis

ii. Consist of seminiferous tubulesf. Scrotum

i. Surrounds the testesii. Layers

1. Skin2. Tunica dartos Dartos fascia/muscle

a. Colles’ fascia and dartos m. (smooth m.)

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3. External spermatic fascia External oblique4. Cremaster muscle/fascia Internal oblique5. Internal spermatic fascia Transversalis fascia6. Tunica vaginalis (parietal/visceral) Peritoneum

9. Describe the coverings of the spermatic cord and their role in the descent of the testes during development. How do these layers relate to the coverings of the scrotum?

a. Many of the layers of the testes are continuous with analagous layers in the spermatic cord. However, the tunica vaginalis of the scrotum is a remnant of the peritoneum which is sealed off from the testes in normal adults

10. Chart the blood supply and lymphatic drainage of the testis. How do they differ from that of the scrotum?

a. Testesi. Blood: Testicular arteries

ii. Lymphatic: Inguinal Nodesb. Scrotum

i. Blood: Anterior/posterior scrotal arteriesii. Lymphatic: Deep lumbar nodes

11. What is an inguinal hernia? What features distinguish a direct from an indirect inguinal hernia?

a. Directi. Through the inguinal triangle

ii. Transversalis fascia forms hernia saciii. Occurs medially to epigastric arteryiv. Less common than indirect hernias

b. Indirecti. Through the deep/superficial inguinal rings

ii. Covered by all three layers of spermatic cordiii. Remains of the process vaginalis forms the hernia saciv. 20x more common in males than femalesv. More common in younger people

© 2009 Mark Tuttle

Peritoneum and Major Vessels -1/6/2009 [LANE]1. Define the peritoneum and peritoneal cavity.

a. Peritoneumi. Large, thin, transparent sheet of serous membrane which lines the walls

of the abdominopelvic cavity and is reflected onto the viscerab. Peritoneal cavity

i. Potential space between adjacent layers of peritoneum usually containing a small amount of fluid

2. Understand what distinguishes parietal from visceral peritoneum.a. Parietal peritoneum lines the abdominal and pelvic wallsb. Visceral peritoneum covers abdominal and pelvic organs

3. Describe the shape and extent of the peritoneal cavitya.

4. Know what the borders of the greater and lesser sac are.a. Lesser sac borders

i. Anterior1. Lesser omentum2. gastrocolic ligament

ii. Inferior1. Trasverse mesocolon

iii. Superior1. Caudate lobe of liver

iv. Posterior1. Pancreas2. Aorta3. Celiac trunk4. Splenic a. and v.5. Gastrosplenic fold6. Left suprarenal gland7. Left kidney

v. Right1. Liver2. Duodenal bulb

vi. Left1. Spleen2. Gastrosplenic ligament

b. Greater sac bordersi. Everything else within the peritoneum

5. Describe the components of the greater and lesser omentums.a. Greater Omentum

i. Attaches the stomach (along the greater curvature) to the posterior abdominal wall.

ii. Subdivided into 3 ligaments: (PCS)1. Gastrophrenic2. Gastrosplenic3. Gastrocolic

b. Lesser Omentumi. Attaches the stomach (along the lesser curvature) to the liver.

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ii. Subdivided into 2 ligaments:1. Hepatogastric2. Hepatoduodenal

6. Know what forms the borders of the epiploic foramen. What spaces does it connect?a. It connects the greater and lesser sacsb. Also known as the Foramen of Winslowc. Borders:

i. Anterior1. Hepatoduodenal ligament

ii. Posterior1. Peritoneum covering the inferior vena cava

iii. Superior1. Peritoneum covering the caudate lobe of the liver

iv. Inferior1. Peritoneum covering the duodenum/proper hepatic a.

7. Know what organs and structures within the abdomen are intraperitoneal (peritoneal) and which are primarily and secondarily retroperitoneal?

a. Primarily retroperitoneali. Esophagus

ii. Suprarenal glandsiii. Kidneysiv. Rectum

b. Secondarily retroperitoneali. Pancreas

ii. Duodenum (except for superior portion)iii. Ascending coloniv. Descending colon

c. Intraperitoneali. Everything else

8. Be able to describe and give examples of peritoneal pouches, folds, recesses and gutters.

a. Foldsi. Lateral umbilical fold (2) (inferior epigastric)

ii. Medial umbilical fold (2) (obliterated umbilical a.)iii. Median umbilical fold (1) (urachus)

b. Recessesi. Subphrenic recess

1. Between liver and diaphragmii. Superior recess of omental bursa

1. Posterior part of liver2. Part of the lesser sac3. Borders the greater sac via the coronary ligaments

iii. Inferior recess of omental bursa1. Between stomach and transverse colon

c. Pouches (pouch of peritoneum formed by peritoneal folds or ligaments)i. Rectovesical pouch

1. Everything eventually drains hereii. Hepatorenal pouch

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d. Guttersi. Right paracolic gutter

ii. Left paracolic guttere. Spaces

i. Supracolic compartmentii. Infracolic compartment

iii. Right infracolic space1. Leaks can stay localized here for a while2. Bordered by mesentery

iv. Left infracolic space9. Distinguish between mesentery, mesocolon, greater omentum, lesser omentum and

the various peritoneal ligaments.a. Mesocolon

i. Transverse + Sigmoid sections of colon that are intraperitonealb. Greater omentum

i. Hangs down from front of stomachii. Gastrophrenic + gastrosplenic + gastrocolic ligaments

c. Lesser omentumi. Between stomach and liver

ii. Hepatogastric + hepatoduodenal ligaments10. Describe the causes and relations of the peritoneal reflections located on the anterior

abdominal wall.a. Lateral umbilical folds (L + R)

i. Houses the inferior epigastric arteryb. Medial umbilical folds (L + R)

i. Houses the obliterated umbilical arteryc. Median umbilical fold

i. Houses remnant of urachus, an embryological canal connecting the urinary bladder of the fetus with the allantois

11. List the three unpaired branches of the abdominal aorta. Know the terminal branches of these main arteries.

a. Splenic a.i. Short gastric aa.

ii. Left gastro-omental a. (gastropiploic) (on the greater curvature)iii. Pancreatic a.iv. Posterior gastric a. (60-80% of people)

b. Proper hepatic a.i. Right gastric a.

ii. Left hepatic a.iii. Right hepatic a.iv. Cystic a.

c. Gastroduodenal a.i. Supraduodenal a.

ii. Superior pancreatocoduodenal a.iii. Right gastro-omental a. (gastroepiploic) (on the greature curvature)

12. Describe the venous drainage from the abdominal viscera. What is the hepatic portal system?

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a. Begins at the venous ends of capillaries in the organs of the GI tract and ends at the venous sinusoids in the liver

b. Formed bythe joining of the plenic vein with the superior mesenteric veinc. Inferior mesenteric vein usually joins the splenic veind. NO VALVES in portal vein

13. What is a portal-systemic anastomoses? Where do four major portal-systemic anastomosis occur in the body and what is the clinical significance of varicosities at these sites

a. Esophageal varicesi. Portal: Esophageal branch of left gastric v.

ii. Systemic: Esophageal branch to Azygous v.b. Anorectal varices

i. Portal: Superior rectal branch of inferior mesenteric v.ii. Systemic: Middle and inferior rectal to internal iliac v.

c. Caput medusai. Portal: Paraumbilical (in falciform ligament) branch of portal

ii. Systemic: Superior and inferior epigastric vv.d. Retroperitoneal varices (Veins of Retzius)

i. Portal: Colic, duodenal, and pancreatic vv.ii. Systemic: Lumbar and renal vv. to inferior vena cava

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GI Tract and Associated Organs - Lane1. Abdominal part of esophagus

a. Comes through the diaphragm at T82. Stomach:

a. Cardiac and pylorus orificesi. Cardiac orifice is at the top of the stomach at the gastroesophageal

junction in the cardia regionii. There are no chief cells in the cardiac region

iii. The pyloric orifice lies at the distal part of the stomach, part of the gastric sphincter

b. Relation with greater and lesser omentumi. The greater omentum takes its origin along the greater curvature of the

stomach1. Attaches the stomach to the posterior abdominal wall2. Composed of Gastrophrenic, gastrosplenic, and gastrocolic

ligamentsii. The lesser omentum takes origin along the lesser curvature of the

stomach and attaches to the liver1. Composed of hepatogastric and hepatoduodenal ligaments

c. Anterior and posterior surfacesi. On the posterior surface of the stomach runs the splenic artery off of

the celiac trunk and in 60-80% of peopled. Fundus and cardinal notch

i. Fundus is the most superior part of the stomach. It ascends above the gastricesophageal junction. Usually there is an air bubble here.

ii. The cardial notch is the region immediately superior to the gastroesophageal junction

e. Body and angular incisuresi. The body of the stomach is below the Cardia and the Fundus

ii. The angular incisures divides the body from the pyloric antrum, it is clearly evident in a deflated stomach

f. Pyloric antrumi. Distal to the gastric body is the pyloric antrum

g. Pylorus, pyloric sphincter, pyloric canali. The pyloric canal is a narrowing of the stomach approaching the pyloric

sphicterh. Mucous membrane appearance, gastric folds (rugae)

i. Rugae are oriented in the direction of flowi. Muscles of stomach wall

i. 3 layers whereas the rest of the GI is only 2ii. Oblique, circular, longitudinal

j. Describe relations of stomach with adjacent structures.i. Right side: spleen

ii. Above: diaphragm and liveriii. Left: liveriv. Behind: pancreasv. Below: transverse colon

k. Describe the blood supply of the stomach.

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i. The stomach is supplied by the right and left gastric arteries, (posterior gastric artery), and by the right and left gastro-omental arteries

3. Small Intestine:a. Identify and distinguish the 3 major divisions of the small intestine:

Duodenum, Jejunum, and Ilium. Note the major and minor doudenal papillaei. The duodemum is the most proximal part of the intestine, connecting to

the stomach. ii. The duodenum’s transition to jejunum occurs at the suspensetory

ligament of the duodenum (Ligament of Treitz)iii. There is no clearly defined border between the jejunum and the ileum,

but you can tell the difference between the two regions based on structure

iv. Jejunum1. Thicker wall2. Smaller number of arcardes, longer vasa recta, poorer

anastomoses3. Less fat4. Numerous plicae5. Few Peyer’s patches

v. Ileum1. Thinner wall2. Larger number of arcades, shorter vasa recta, better

anastomoses3. More fat4. Poorly defined plicae5. Many Peyer’s Patches

b. Describe their locations and relationships to other abdominal structures including mesenteries and peritoneum.

i. Superior mesenteric artery supplies the entire small intestine as well as the cecum (ileocolic), ascending colon (ileocolic), and transverse colon (middle colic)

ii. The inferior mesenteric artery supplies the descending colon (left colic), the sigmoid colon (sigmoid), and the rectum (superior rectal)

iii. The transverse colon, sigmoid colon, and cecum are intraperitoneal, but ascending, descending, are retroperitoneal (secondarily)

c. Describe the blood supply of the small intestine, note the distinct features of jejunal and ileal vessel arcades and vasa recta.

i. See above.ii. The jejunum has longer vasa recta but a smaller number of arcades than

the ileum4. Large Intestine:

a. Identify the various parts including the appendix, their location and relationships to other abdominal structures including mesenteries and peritoneum.

i. Ascending and descending colon are retroperitoneal (secondarily)ii. Cecum, transverse colon, and sigmoid colon are intraperitoneal

iii. The rectum is retroperitonealb. Describe the blood supply of the large intestine.

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i. See above, 3bc. Identify the appendix and its relationships.

i. Retrocecal (64%): posterior to the cecumii. Subcecal (<1%): just below the cecum

iii. Pelvic (32%): sticking into the pelvisiv. Preileal (<1%): Anterior to the distal-most part of the ileumv. Postileal (<1%): Posterior to the distal-most part of the ileum

d. Describe the teniae coli, omental appendices, haustra, semilunar folds.i. Teniae coli:

1. Smooth muscle bands2. 3 layers which correspond to muscularis externa in GI3. Mesocolic, free, and omental

ii. Omental appendices1. little processes or sacs of peritoneum filled with adipose tissue

and projecting from the serous coat of the large intestine, except the rectum; they are most evident on the transverse and sigmoid colon, being most numerous along the free tenia.

iii. Haustra1. Small pouches caused by sacculation, which give the colon its

segmented appearance. The taenia coli runs the length of the large intestine. Because the taenia coli is shorter than the intestine, the colon becomes sacculated between the taenia, forming the haustra. In between adjacent haustra are semi-lunar folds, known as the plicae semilunares.

2. Haustral contractions are slow segmenting movements that occur every 25 minutes. One haustrum distends as it fills, which stimulates muscles to contract, pushing the contents to the next haustrum.

iv. Semilunar folds1. See above

e. Understand the location and relations of the colic flexures.i. Right colic flexure (hepatic) (hepatocolic ligament?)

ii. Left colic flexure (phrenicocolic ligament)ACCESSORY ORGANS OF THE GASTROINTESTINAL TRACT

5. Liver:a. Define its major function.

i. Stores glycogen, secretes bileb. Describe the anatomical and functional lobes of the liver.

i. Anatomical1. Right + left lobes2. Caudate3. Quadrate

ii. Functional1. The central area where the common bile duct, hepatic portal

vein, and hepatic artery proper enter is the hilum or "porta hepatis". The duct, vein, and artery divide into left and right branches, and the portions of the liver supplied by these branches constitute the functional left and right lobes.

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c. Define the relations of the liver to other abdominal structures.i. The liver is on the right side and is adjacent to the stomach

ii. Just beneath the liver is the right kidneyd. Describe the porta hepatis and its contents.

i. On the posterior side of the liverii. Contains the transmits the hepatic portal vein, the hepatic artery

proper, the common hepatic duct, nerves and lymphaticse. Describe the peritoneal ligaments and the bile ducts associated with the liver.

i. L + R triangular ligamentsii. Anterior + Posterior coronary ligaments

iii. Falciclorm ligamentiv. Ligament of teres (remnant of ombilical v.)

f. Describe the blood supply of the liver.i. Portal vein (75%)

ii. Hepatic aa. (25%)6. Gall Bladder:

a. Describe its location, parts, relationships, functions, and the bile duct system.i. Neck, body, fundus

ii. NOT a gland, only a storage reservoiriii. Intimately invested in the liveriv. Spiral Valves of Heister: undulating folds or valves in the proximal

mucosa of the cystic ductv. Bile duct dumps bile into the Major Duodenal Papilla (Ampula of Vater)

7. Pancreas:a. Describe its location, relationships, functions and the pancreatic duct system.

i. Secondarily retroperitonealii. Has exocrine (pancreatic enzymes) and endocrine functions

(insulin/glucagon)b. Define its parts.

i. Headii. Uncinate process

1. Formed from the ventral pancreatic budiii. Neckiv. Body v. Tail

c. Describe its blood supply.i. Superior pancreatoduodenal a. branches off of the gastroduodenal

arteryii. Inferior pancreatoduodenal a. branching off of the superior mesenteric

a.iii. Splenic artery

8. Spleen:a. Describe its location, relationships, and functions.

i. Just lateral to the stomach, closely related to the diaphragmii. Centered at approximately the 9th rib on the left side

iii. Secured by the gastrosplenic and splenorenal ligamentsiv. Filters blood, removes old blood cells + foreign materialv. Protected by a delicate, thin capsule

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vi. Is the most frequently injured organ in the abdomenb. Describe its blood supply.

i. Highly vascularii. Supplied by the splenic artery branch of the Celiac Trunk

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Development of the GI System 1 - Lane1. List the three major regions of the embryonic gut and define the boundaries (limits) of

each in terms of embryonic structures and definitive structures.a. Foregutb. Midgutc. Hindgut

DIGESTIVE SYSTEM - FOREGUT2. List the structures derived from the foregut. What is the blood supply of the structures

derived from the caudal portion of the foregut?a. Structures

i. Esophagus and stomachii. Pharynx + lower respiratory system

iii. Duodenum (distal to opening of bile duct)iv. Liverv. Billiary apparatus

vi. Pancreasb. The GI structures are supplied by the Celiac Trunk

3. What are the germ layers of origin for the epithelial structures derived from the foregut; the smooth muscle and connective tissue; vascular supply; nerve supply?

a. Endoderm forms the lining of the GIb. Mesoderm forms the connective tissue and blood vessels for the GIc. (Neural crest ?) forms the nerves of the GI

4. Describe the development of the dorsal and ventral mesenteries and the formation of lesser sac.

a. Ventral mesentery (Degenerates almost entirely)i. Lesser omentum

ii. Falciform ligamentiii. Coronary/triangular ligaments

b. Dorsal mesenteryi. Greater omentum

ii. Splenorenal ligamentiii. gastrocolic ligaments

c. Formation of Lesser Saci. Isolated clefts develop in the mesenchyme forming the thick dorsal

mesogastrium. The clefts soon coalesce to form a single cavity, the omental bursa

ii. Rotation of the stomach pulls the dorsal mesogastrium to the left, thereby enlarging the bursa

iii. The bursa expands transversely and cranially and soon lies between the stomach and the posterior abdominal wall

iv. Dorsal mesogastrium continued inferior elongation forms the greater omentum

v. Facilitates movements of the stomach5. Describe the development of the esophagus, stomach and duodenum. What results

from the rotation of the stomach? What developmental anomalies are associated with each?

a. Esophagus

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i. Initially short but elongates quicklyii. Endoderm proliferates so much that the lumen is obliterated for a

while, then recanulatesiii. Striated muscle of the muscularis externa of the upper 1/3 is derived

from mesenchyme of the caudal pharyngeal archesiv. Smooth muscle of the lower 1/3 of the esophagus is derived from the

splanchnic mesenchymeb. Stomach

i. Starts as a dorsal enlargement of the caudal part of the foregut during the 4th week

ii. Differential growth leads to the formation of the greater/lesser curvatures

iii. Slowly rotates clockwise 90 degrees, causing the greater curvature to become positioned on the lft side of the stomach

c. Duodenumi. Begins to form during the 4th week at the caudal end of the foregut and

the cranial end of the midgutii. Develops a C-shape oriented anterior-posteriorly

iii. The C rotates clockwise with the stomachiv. The endoderm of the duodenum proliferates so much that the lumen is

oblitered for a while, then recanulates by week 8 (end of the embryonic period)

v. Marks the transition between foregut and midgut6. List the derivatives of the hepatic diverticulum.

a. Liverb. Gallbladderc. Billiary apparatus

7. Describe the formation of the liver within the substance of the septum transversum.a. Reflections of the ventral mesentery on to the diaphragm become the coronary

and triangular ligaments that surround the bare area of the liverb. Proliferating endodermal cells form cords of hepatic cells and the epithelia cells

of the billiary system within the liverc. Hepatic cords anastomose around the endothelium lined spaces that are

forming the hepatic sinusoidsd. The CT, endothelial cells, hemopoietic tissue and kupffer cells arise form the

splanchnic mesenchyme of the ventral mesenterye. Hematopoeisis begins in the liver around week 6. Bile formation begins around

week 12f. Liver represents 10% of the body wight by week 10g. Gall bladder and cy stic duct forms from the small caudal part of the hepatic

diverticulumh. Extrahepatic biliary apparatus is initially solid cords of epithelial cells but later

canalizedi. Initially the bile duct is attached to the ventral surface of the duodenal loop but

rotate nof the duodenum moves it to the posterior surfacej. Bile entering the duodenum after the 13th week gives the meconuum a dark

green color

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8. Describe the pancreatic buds and their positional changes involved in the formation of the adult pancreas, especially the formation of the definitive biliary and pancreatic duct system as well as related developmental anomolies .

a. Dorsal bud: neck, body, tail, most of headb. Ventral bud: part of head, uncinate processc. Endodermal cells form both the exocrine and endocrine pancreatic tissuesd. Splanchnic mesenchyme forms the CT elements of the pancreas

9. Define the terms: stenosis, atresia, hernias, polyhydramnios.a. Stenosis: hardening, narrowing of a lumenb. Atresia: hypoplastic, too small/shortc. Polyhydramnios: too much amniotic fluid because the fetus is not processing it

10. Describe the development of the spleen in the dorsal mesogastrium. a. No endoderm in spleenb. Arises from DORSAL mesogastriumc. Differentiate to form the capsule, connective tissue, and parenchyma of the

spleend. Begins to develop at week 5 and is initially lobulated

Development of the GI System 2 - LaneDIGESTIVE SYSTEM - MIDGUT1. List the adult structures derived from the midgut.

a. Midgut starts DISTAL to the major duodenal papillab. Distal duodenumc. Jejunud. Ileume. large intestine up to and including the proximal 2/3 of the transverse colonf. appendix

2. What is the blood supply and autonomic innervation pattern of the structures formed from the embryonic midgut?

a. All derivatives are supplied by the superior mesenteric artery3. Describe the positional changes that take place during the process of midgut rotation and

fixation.a. Rotation

i. Herniation1. By week 6, the midgut elongation nexceeds the capacity of the

peritoneal cavity (intraembryonic coelom). This produces a physiological umbilical herniation into the umbilical cord

2. While it is in the umbilical cord, the midgut loop rotates 90 degrees counterclockwise around the axis of the superior mesenteric artery.

3. This brings the cranial limb (small intestine) of the midgut loop to the right and the caudal limb (large intestine) to the left.

4. During rotation, the cranial limb elongates and forms intestinal loops (primordial of jejunum and ileum)

ii. Reversal of herniation1. During the 10th week the intestines return to the abdomen

(reduction of the midgut hernia)2. Small intestine returns first, passing posterior to the superior

mesenteric artery and occupies the central part of the abdomen

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3. As the large intestine returns, it undergoes a further 180 degree counterclockwise rotation

4. Later it comes to occupy the right side of the abdomen5. The ascending colon becomes recognizable as the posterior

abdominal wall elongates.b. Fixation

i. Results in ascending/descending colon & duodenum being retroperitonealii. The enlarged colon presses the duodenum and pancreas against the

posterior abdominal wallc. What developmental abnormalities are associated with these processes?

i. Malrotation of the midgut1. Nonrotation of gut (Left side colon)

a. 180 degree rotation ndoes not occurb. Colon entirely on the left, small intestine on the right (called

left-side colon)2. Mixed rotation

a. Cecum located near pyloris of stomachb. CT bands stretch over/compress duodenumc. Occurs w/volvulus of intestine

3. Reverse rotation (only really a problem if incomplete)a. Colon located posterior to duodenum + superior mesenteric

arteryb. Superior mesenteric artery is compressed as a result

4. Subhepatic cecum + appendixa. Only a problem if inflated appendix. Often misdiagnosed as

gallbladder problemb. Cecum fails to descend, fixes to liver

5. Internal Herniaa. Intestines push into mesentery + creates pocket

6. Mobile cecuma. Most common anomaly (10% of population)b. Problem because it can lead to volvulus (increased risk)

ii. Omphalocele1. Failure of a portion of the intestines to return to the abdominal

cavity2. Stays in umbilical cord3. Covered by epithelium of umbilical cord

iii. Gastroschisis1. Failure in formation of anterior abdominal wall2. Due to a defect of lateral folds in week 4 when lateral wall folds are

formed3. Nothing covers herniation

iv. Umbilical hernia1. Successful return to abdominal cavity but umbilicus didn’t seal off

properly2. Covered by skin

v. Internal hernia1. Only a problem if chyme flow is constricted

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2. Loop of small intestine pushes into mesentery of midgut loopvi. Ileal (Meckel) Diverticulum

1. Occurs in 2-4% of population2. 3-6cm long outpocket of the ileum3. May be attached to umbilicus4. Due to persistent yolk stalk that may be attached to umbilicus5. May contain ectopic gastric or pancreatic tissue Causes ulcers6. Can result in omphalocenteric fistula (milk squirts out of umbilicus

4. Correlate the organ positional relationships within the abdominal cavity with the developmental history of the region.

a. All of the foregut derivatives are supplied by the Celiac trunkb. All of the midgut derivates are supplied by the superior mesenteric arteryc. All of the hindgut derivatives are supplied by the inferior mesenteric artery

5. What is a Meckel’s form of ileal diverticulum? Umbilico-ileal fistula? What is the congenital basis of these conditions?

a. a remnant of the proximal part of the yolk stalk within the embryo that arises as a fingerlike diverticulum, 3–6 cm long, from the antimesenteric border of the ileum between 40 and 50 cm from the ileocecal junction; it may be attached to the umbilicus. If its mucosa includes gastric tissue, peptic ulceration and bleeding may result (see above)

6. Briefly describe the positional changes that occur in the arteries and veins associated with the caudal foregut and midgut.

7. Briefly describe the formation of enteric autonomic ganglia of the digestive system from neural crest cells

a. Sympathetici. Route

1. Neuronal axon exits the spinal cord via the ventral root and travels along a mixed spinal nerve.

2. Exits the spinal nerve via the white ramus and passes through a paravertebral ganglion w/out synapsing to any cell body

3. Travels via a splanchnic nerve to reach a pre-vertebral ganglion where it synapses with ganglion cell bodies

4. Axons from this ganglion travel through the mesentery to synapse with the target tissues in the gut

ii. Migrating neural crest cells are the origin of the sympathetic postganglionic cells that form the para-vertebral ganglia

b. Parasympathetici. Travels via the vagus nerve and innervates the neurons of Auerbach’s Plexus

and Meissner’s Plexusii. NCC give rise to the neurons of the Enteric Nervous System

8. Describe the developmental errors leading to: a. Ailiary atresiab. Anular pancreas

i. Messed up rotation of pancreatic buds results in part of the pancreas constricting the duodenum

c. Omphalocoel, Hiatal and umbilical herniasi. See above

d. Segmental duplication of the intestinal tract

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i. Abnormality that occurs when, during the solid stage of development, there is uneven canalization of the lumen resulting in a two lumens, one of which does not communicate with the rest of the GI tract.

ii. In the cystic type, it is a localized regioniii. In the tubular type, there are parallel tracts for part of the intestine with

one being closed off from the main tracte. Malrotations of the midgut resulting in: Subhepatic cecum, Mobile cecum,

Volvulusi. See above

DIGESTIVE SYSTEM - HINDGUT9. Define/describe:

a. Allantoisi. Endodermal evagination of the developing hindgut which becomes

surrounded by the mesodermal connecting stalk. The connecting stalk forms the umbilical vasculature.

ii. These endodermal and mesodermal tissues together form the human umbilical cord

iii. The allantois later becomes the urachus, which removes nitrogenous waste from the fetal bladde

b. Cloacai. The expended terminal part of the hindgut lined by endoderm

c. Cloacal membranei. In contact with surface ectoderm

d. Anal pit (Proctodeum)i. Region of the surface ectoderm overlying the cloacal membrane

e. Uroretal septumi. During development the cloaca is subdivided by the urorectal septum into a

ventral urogenital region nand a dorsal anal-rectal regionii. At week 7 the urorectal septum fuses with the cloacal membrane at the

future perineal body and subdivides it into a ventral urogenital membrane and a dorsal anal membrane

iii. The ventral part of the cloacal sphincter becomes all the muscles of the UG triangle

iv. The dorsal part of the cloacal sphincter becomes the external anal sphincterv. The anal membrane usually ruptures during week 8

f. How do these structures relate to those of the adult colon, rectum, anal canal and urogenital organs?

i. See above10. Describe the process by which the protodeum (anal pit) is formed.

a. Occurs during week 4-6b. Urorectal canal seperates into urinary and anal canalsc. Occurs before the 3rd monthd. Problems can occur either when it fails to separate or is deviated

11. Define/describe the location of the tissue that will form the urorectal septum.a. Dividedes the cloaca into dorsal and ventral parts by a wedge of mesenchyme, the

urorectal septum, that develops in the angle between the allantois and hindgut

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b. As the septum grows toward the cloacal membrane, it develops forklike extensions that produce infoldings of the lateral walls of the cloaca

c. These folds grow toward each other and fuse, forming a partitiond. Occurs by the 7th week (before 3rd month)

12. List the major structures (organs) that are definitively situated anterior to the tissue plane created by the urorectal septum; those situated posterior to the plane.

a. Urorectal septum divides the cloacal sphincter into anterior and posteriorb. Posterior part becomes the anal sphincterc. The anterior part develops into the superficial transverse perineal, bulbospongiosus,

and ischiocavernosus musclesd. This explains why one nerve, the pudendal nerve, supplies all of these muscles

13. Describe the vascular supply (blood and lymphatic) and innervation of the portion of the anal canal derived from the hindgut; the portion of the anal canal derived from the proctodeum.

a. The pectinate line divides the anal canal into hindgut endoderm and proctodeum ectoderm

b. Above pectinate linei. Autonomic nerves

ii. Superior rectal a.c. Below pectinate line

i. Somatic nervesii. Middle/inferior rectal a.

14. Explain: a. congenital megacolon (Hirschprung’s disease)

i. 1/5000ii. Absence of ganglion cells in a variable length of distal bowel

iii. Lack autonomic cells in the myenteric plexus distal to the dialated segment of colon

iv. Can be a result of failure of neural crest cells to migrate into the colon during the 5th-7th weeks

v. Dilation nresults form failure of relaxation nof the aganglionic segment, which prevents movement of the intestinal contents

vi. Usually only the rectum and sigmoid colon are involvedb. imperforate anus

i. 1/5000ii. More common in males

iii. Abnormal development of urorectal septum, resulting in incomplete separation of the cloaca into UG and anorectal portions

iv. There is normally a temporary communication between the rectum and anal canal dorsally from the bladder and urethra ventrally, but it should close when the urorectal septum fuses with the cloacal membrane

c. fistulae between the rectum and urethra in the malei. incomplete sparatio nby the urorectal septum

d. anoperineal fistulaei. Anal canal opens into the perineum

e. anal stenosisi. Anal canal is too narrow

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ii. Probably caused by a slight dorsal deviation of the urorectal septum as it grows caudally to fuse with the cloacal membrane

f. anorectal agenesis.i. Rectum ends superior to the puborectalis muscle when there is anorectal

agenesisii. Results in a fistula to the urethra in males or the vagina in females

DIGESTIVE TRACT - CHALLENGE15. Summarize the vascular supply of each portion of the gut,

a. Stomodeumi. ????

b. supradiaphragmatic foreguti. Celiac trunk

c. infradiaphragmatic foreguti. Celiac trunk

d. Midguti. Superior mesenteric artery

e. Hindguti. Inferior mesenteric artery

1. Superior rectal a.f. Proctodeum

i. Middle/inferior rectal a.16. Summarize the autonomic innervation of the portions of the gut mentioned above.

© 2009 Mark Tuttle

GI and Associated Glands – Chiaia1. List the functions of the liver.

a. Storage and filtration of bloodb. Vitamin storage and excretion (A, B12, C, D, E, K)c. Synthesis and secretion of biled. Metabolic

i. Protein synthesis (albumin, prothrombin, fibrinogen)ii. Lipoprotein and cholesterol synthesis

iii. Carbohydrate metabolism (glycogenesis, glycogenolysis, gluconeogenesis)

iv. Metabolism of lipid-soluble drugs and steroidsv. Urea formation (from ammonium ions)

2. Identify the components of the portal triad. Identify what the function is of each component.

a. Portal veinb. Hepatic a.c. Bile ductd. Nervese. Lymphatics

3. Describe the models of liver organization including the classic liver lobule, portal lobule and liver acinus.

c. Classic lobulei. Based on CT arrangement (indistinct in humans)

ii. Hexagonal-shaped parenchymal region bounded by portal tracts at each corner and central vein at each center

d. Portal lobulei. Secretory units whose outflow drains into a common interlobular duct

ii. So, defined in terms of bile flow (this is the exocrine function of liver)e. Acinus

i. Smallest functional unit of liverii. Diamond shaped mass of hepatocytes lying between two central veins

at the apices of its long axis and two portal tracts at the apices of its short axis

iii. The meridian of the diamond is tranversed by preterminal branches of a distributing arteriole which suypplies blood to the sinusoids

iv. Zones1. Zone 1

a. Well oxygenated blood and nutrients, minimally exposed to metabolic waste

2. Zone 2a. Receive only moderately oxygenated bloodb. Intermediate exposure to metabolic waste

3. Zone 3a. Receive poorly oxygenated bloodb. Constitutes the primary site of alcohol and drug detox

and its hepatocytes are much more vulnerable to toxic damage than those zone 1!

4. Describe the path of both blood flow and bile flow in the liver.

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a. 75% of blood supply is Portal v.b. 25% of blood supply is proper hepatic a.c. The liver is drained entirely by the hepatic v.d. Inlet arterioles and venules empty into endothelially-lined sinusoids where

separate the plates of hepatocytes in the parenchymae. The flow toward central veinf. Conducting vein, distributing vein, sinusoid, central veinule, sublobular vein,

collecting vein, hepatic vein, IVCg. Bile flows in the opposite direction, from inward out to the bile ducts

5. Describe the histological and functional organization of liver sinusoids including the contribution of Kupffer cells and endothelial cells.

f. Plates/cords are continuous arrangement of hepatocytes, endothelially linedg. Linked to hepatic sinusoid via Space of Disse, filled with plasma but no RBCsh. Numberous microvillii. Perisinusoidal cells of ito

i. Irregular cells with long cytoplasmic processesii. Concentrate vitamin A

iii. Function not well understooda. Endothelial cells are discontinuous without a continuous basal lamina

i. Riddled with clusters of holes – sieve platesb. Supported by reticular fibersc. Lumen of sinusoid contains large branched Kupffer cellsd. Phagocytose damaged RBCs and plasma debris

6. Describe the bile canaliculi and their function.a. Composed of the lateral domain of hepatocytes- that which borders another

hepatocyte (as opposed to that which borders the sinusoid)b. Membranes adjacent to this are surrounded by tight junctions which isolate the

canniliclus from extracellular spacec. Canaliculi empty into the bile ductules (Canals of Herring) which lead to the

portal bile ductsd. Lined by cuboidal epitheliume. Transported here via ATP-dependent transportersf. Composed of bile salts + bilirubin

7. Describe the general ultrastructure of the hepatocyte.a. Polygonal shapeb. Usually binucleated, centrally located nucleusc. Numerous mitochondriad. Abundant rER and free ribosomese. Prominent Golgif. Numerous peroxisomes, lysosomes, endosomesg. Lipid droplets (VLDLh. Abundant sER (drug detox)

i. Microsomal mixed function noxidase system responsible for the metabolism of barbiturates antibiotics and toxins

ii. Methylation, conjugation, and oxidation nare the most common methods of drug inactivation nand detoxification nperformed in the hepatocyte sER

© 2009 Mark Tuttle

iii. Cytorchrome p450 is the major enzyme in the liver involved in drug metabolism

iv. First pass metabolism: where a drug is removed before it even has the opportunity to work

8. Identify the endocrine and exocrine portions of the pancreas.a. Endocrine: insulin + glucagon (Islets of Langerhans)b. Exocrine: pancreatic enzymes (Acini)

i. Intralobular: simple cuboidal-columnarii. Interlobular duct: low columnar

iii. Centroacinar cells: Low cuboidaliv. All are pyramidal shapedv. Secretions

1. Tripsin proenzyme2. Trypsin inhibitor (protecting pancreas from auto-digestion by

trypsin until it reaches duodenum)3. Pancreatitis can result in lysis of the acinar cells and release of

active digestive enzymes into the abdominal cavity causing serious organ damage

9. Describe the histological organization of the islets of Langerhans. List the function of the various cell types.

a. Most numerous in the tail of the pancreasb. Ovoid groups of clear endocrine cells scattered throughout the exocrine

pancreas10. Describe the histological organization of the gall bladder and correlate the function to

the morphology of this organ.a. Simple columnar epithelium

i. Clear cellsii. Brush cells

b. Lamina propriac. Muscularis externa

i. Smooth muscle of mixed orientationii. Responsive to CCK

d. Perimuscular connective tissuee. Simple squamous epithelium (serosa)

© 2009 Mark Tuttle

Posterior Abdominal Wall – Lane1. Describe the skeletal, muscular, and fascial components of the posterior

abdominal wall.a. Skeletal

i. Lumbar vertebraeii. Sacral vertebrae (this is more pelvic than abdominal)

iii. Inferior thoracic vertebraeiv. Iliac Fossas

b. Musculari. Quadratus lumborum

ii. Psoas majoriii. Psoas minoriv. Iliacusv. Diaphragm

c. Fasciali. Thoracolumbar fascia

1. Fusion of erector spinae + quadrates tendons2. Components

a. Anterior: Just quadratusb. Middle: Quadratus + erector spinaec. Posterior: Just erector spinae

2. Describe the attachments and actions of the psoas major, iliacus and quadratus lumborum muscles.

a. Quadratus lumborumi. Attachment

1. Inferior portion of 12th rib2. TVPs of lumbar vertebrae3. Iliolumbar ligament

ii. Action1. Unilateral: Bend to same side

b. Iliacusi. Attachment

1. Ala of sacrum2. Superior 2/3 of iliac fossa3. Anterior Sacroiliac ligaments4. Lesser trochanter of femur

ii. Action1. Flex hip joint

c. Psoas majori. Attachment

1. TVPs2. IV discs3. Lesser trochanter of femur

ii. Action1. Flex hip joint

3. Understand the attachments, arches, apertures, components, innervations and blood supply of the diaphragm.

a. Attachments

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i. 12th ribii. Medial arcuate ligaments (2)

1. One for each place Psoas mm. pass through2. On lateral side of each crus

iii. Right crus1. Attaches to L1-L3/L4 vertebral body2. Wraps around esophageal hiatus

iv. Left crus1. Attaches to L1-L2/L3 vertebral body2. Ligament of Treitz

a. Supports duodenal/jejuna junctionb. Suspensory ligament of the duodenum

v. Median arcuate ligament (1)1. Fascia of the diaphragm2. Wraps around medial aspect of right and left cruses and

around the aortic hiatusb. Aperture

i. Hiatus for IVC (T8)ii. Esophageal hiatus (T10)

iii. Aortic hiatus (T12)1. Thoracic duct2. Azygous v.3. Hemiazygous v.

c. Blood supplyi. Pericardiacophrenic a. and v.

1. Branches laterally of of the internal thoracic a.ii. Musculophrenic a. and v.

1. Branches medially off of the internal thoracic a.iii. Superior phrenic a. and v.

1. Branches off of the aorta just superior/posterior to the aortic hiatus

2. “outside” the diaphragmiv. Inferior phrenic a. and v.

1. Branches off of the aorta just inferior to the aortic hiatus2. “Inside” the diaphragm3. Flows superior laterally

d. Innervationi. Efferent

1. Phrenic nn. (C3-C5)ii. Afferent

1. Phrenic nn. (C3-C5) in the center2. Intercostal nn. (T5-T11) at the periphery3. Subcostal nn. (T12) at the periphery

4. Be able to describe the relationships of the diaphragm to structures which pass through it.

a. See above: “apertures”5. Describe the course and "paired" branches of the abdominal aorta and inferior

vena cava as they travel through the posterior abdomen.

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a. Arteriesi. Lumbar arteries (4 on each side)

1. Analogous to intercostal aa.ii. Superior mesenteric a.

1. Branches off of abdominal aorta just inferior to celiac trunk (T12)

iii. Inferior mesenteric a.1. Branches off abdominal aorta inferior to SMA

iv. Left/Right renal aa.1. Branch off of abdominal aorta just inferior to celiac trunk

v. Left/Right Gonadal (testicular/ovarian) aa.1. Branch off of abdominal aorta just inferior to SMA

vi. Right/Left Common Iliac aa.1. Branch at the level of the aortic bifurcation (L4)2. External Iliac aa.

a. Deep circumflex aa.i. Branch and run along the inguinal canal and

iliac spine superior-laterallyb. Inferior epigastric aa.

i. Branch and run along the inguinal canal inferior-medially

3. Internal Iliac aa.b. Veins

i. Similar to arteriesii. Join with IVC on right

1. Azygous v.2. Right L1 v.3. Right gonadal v.4. Right renal v.

iii. Join with LEFT RENAL vein on left1. Hemiazygous v.2. Left L1 v.3. Left gonadal v.

6. Understand the system of lymphatic vessels and nodes located along the posterior abdominal wall. What is the pattern of lymphatic drainage within the abdomen?

a. Run concurrently with vasculatureb. Flow

i. Visceral nodes Parietal nodes Cysternae chyle Thoracic duct7. Describe the branches of the lumbar plexus, including their courses and

innervations.a. Iliohypogastric n. (L1)

i. Sensory to parietal peritoneumb. Ilioinguinal n. (L1)

i. Sensory to parietal peritoneumii. Bifurcation point off of L1 from iliohypogastric n is variable

c. Genitofemoral n. (L1-L2)i. Cremaster m. in male, sensory for labia in female

d. Lateral femoral cutaneous n. (L2-L3)

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i. Passes underneath inguinal ligament just medial to ASISii. Innervates skin on lateral surface of thigh

e. Femoral n. (L2-L4)i. Underneath Psoas Major m.

f. Obturator n. (L2-L4)i. Adductors of thigh

g. Lumbrosacral trunk (L4-L5)i. Runs over the ala of sacrum

ii. Contributes to sacral plexus (ex. sciatic n.)8. Describe the anatomy, relations, fascial coverings, internal structure, and vascular

supply of the kidneys.a. Kidney anatomy

i. Thin fibrous capsuleii. Cortex

1. Outer material2. Glomeruli present

iii. Renal columns1. Glomeruli present

iv. Medullav. Renal pyramid

1. Apex of pyramid is capped by minor calyxvi. Calyx

1. Duct for forming urine out of a section of the kidneyvii. Renal pelvis

1. 2-3 major calyxes form thisviii. Renal sinus

1. Has a lot of fat within it2. No urine here3. Vasculature present here

ix. Ureter1. Only a few millimeters in diameter2. Renal calculi (kidney stones) easily get lodged here

b. Renal coveringsi. Fibrous capsule

ii. Perirenal fat1. Underneath Pararenal2. Immediately surrounds kidney3. Within renal fascia4. Continuous with transversalis fascia/Psoas fascia

iii. Renal fasciaiv. Pararenal fat

1. Outside the renal fascia9. Know the course of the ureter as it passes along the posterior abdominal wall on

its way to the urinary bladder.a. Passes anterior to common iliac a. and v.

10. Describe the anatomy, relations, internal structure, and vascular supply of the suprarenal glands.

a. Anatomy

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i. Immediately superior to kidneysii. Retroperitoneal

iii. Near vertebra L 11iv. Surrounded by its own fibrous capsule distinct from kidney fibrous

capsulev. Surrounded by perirenal fat/renal fascia/pararenal fat

b. Internal structurei. Cortex

1. Produces and secretes corticosteroids and androgensii. Medulla

1. Chromaffin cells produce and secrete catecholamines (epinephrine + norephinepherine)

2. Chromaffin cells are innervated by preganglionic sympathetic fibers of the greater splanchnic n.

c. Arterial supplyi. Superior suprarenal a.

1. Branch off of the inferior phrenic a.2. Consistent

ii. Middle suprarenal a.1. Branch off of abdominal aorta2. Inconsistent

iii. Inferior suprarenal a.1. Branch off of renal a.2. Inconsistent

d. Venous drainagei. Left suprarenal v.

1. Drains into left renal veinii. Right suprarenal v.

1. Drains into IVCe. Innervation

i. Greater splanchnic nn.

© 2009 Mark Tuttle

Esophagus, Stomach, Intestines – Howard1. Describe the overall plan of the alimentary canal.

a. Mucosai. Epithelium

ii. Lamina propriaiii. Muscularis mucosae

b. Submucosai. Many glands here

c. Submucosal plexus of Meissnerd. Muscularis

i. (OBLIQUE LAYER IN STOMACH ONLY) (innermost)ii. Circular muscle

iii. Longitudinal musclee. Myenteric plexus of Auerbach

i. In between circular/longitudinal muscluarisf. Serosa

i. Connective tissueii. Epithelium

2. Describe the features of each layer of the alimentary canal.a. Mucosa

i. Epithelium1. Mostly simple columnar

a. Secretes enzymes and absorbs nutrientsb. Specialized cells

i. Goblet cells: secret mucous onto cell surfaceii. Enteroendocrine cells: secrete hormones

2. Stratified squamous (ESOPHAGUS & ANUS ONLY)3. Lamina propria

a. Thin layer of loose CT4. Muscularis mucosae

a. Thin layer of smooth muscleb. USUALLY 2 LAYERS EXCEPT IN ESOPHAGUS

b. Submucosai. Loose CT

ii. Contains BV, glands, lymphatic tissueiii. Meissner’s Plexus

c. Muscularis externai. Skeletal muscle in mouth, pharynx, upper esophagus, anus

ii. Smooth muscle everywhere else acts via peristalsis3. Describe the innervation of the alimentary canal.

a. All neurons & support cells derived from neural crestb. Myenteric Plexus of Auerbach

i. Mostly motorii. Regulates peristalsis

iii. Located between muscle layers in muscularis externac. Submucosal Plexus of Meissner

i. Mainly secretory-motorii. Release hormones and peptides

© 2009 Mark Tuttle

iii. Innervates mucosaiv. Located in the submucosav. Enterochromaffin cells (EC cells)

1. Bolus of food contacts and excites2. Release serotonin3. 5HC is released4. excites submocosal ganglion5. excites myenteric gangia6. peristaltic waves

d. Autonomic inputi. Parasympathetic – ACh increases motility

ii. Sympathethic – NE relaxes gut4. Describe the specializations of each region of the alimentary canal.

a. Esophagusi. Sero-mucous gland

ii. Serous glands1. Secrete pepsinogen and lysozyme

iii. **Muscularis layer is single and discontinuous here, everywhere else it is double layered and continuous

b. Stomachi. ** 3 layers of muscularis externa where there are usually 2. Extra one is

oblique layerii. Chemical

1. HCl2. Pepsin3. Rennin4. Gastric lipase

iii. Glands are in the lamina propria1. Parietal cells

a. HClb. Gastric intrinsic factor (B12 absorption)c. Receptors for

i. Gastrin (stretch on EC walls)ii. Histamine (stretch on EC walls)

iii. ACh (vagus n., psychological)2. Chief cells

a. Pepsinogenb. Gastric lipasec. Renind. **NO CHIEF CELLS IN CARDIA

3. Enteroendocrine cellsa. Glucagon (released when glucose low)b. Gastric inhibitory peptide (released when glucose high –

for absorption/insulin release)c. G cell

i. Release more gastric juiceii. Increase gastric motility

iii. Relax pyloric sphincter

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iv. Constrict esophageal sphincterc. Small intestine

i. 20 ft longii. Villi

1. Surface5. Describe/list the functions of the alimentary canal by region and cell type.

a. See above6. Describe the function of the specialized cells of the gut, e.g. digestive glands, gastric

pits, enterochromaffin cells, paneth cells, mucus neck cells etc.a. Gastric pits

i. Surface lining cell1. Glcocalyx + microvilli2. Mostly protective

ii. Regenerative cell1. Replaces anything2. ** Unusual position high up in pit for GI

iii. Mucous neck celliv. Parietal cellv. Chief cell

vi. Enteroendocrine cell7. Describe the structural and functional regions of the esophagus.

© 2009 Mark Tuttle

Urinary System – Crissman1. List the organs of the urinary system and give their functions.

a. Kidney: Produces urineb. Ureters: Carries urine from kidney to bladderc. Urinary bladder: Storage of urined. Urethra: Carries urine to exterior of body

2. List and describe the gross external structure of the kidney.a. Pararenal fatb. Renal fasciac. Parirenal fatd. Fibrous capsule

3. List and describe the gross internal structure and organization of the kidney.a. Cortex on the outside and medulla on the interiorb. Medulla forms numerous renal pyramids with the apex of the pyramid facing

toward the renal sinusc. Surrounding the pyramids are renal columns containing cortical material

4. Define, list and contrast the parts of the subdivisions of the kidney.a. See terms

5. Define, list and contrast the parts of the uriniferous tubule, nephron and collecting duct.

a.6. Describe and contrast the two major types of nephrons based upon their location in

the kidney.a. Cortical nephrons are entirely in the cortex and supplied with blood by the

peritubular capillaries (80% of nephrons)b. Juxtamedullary nephrons have Loops of Henle that descend into the medulla

and are supplied with blood by the vasa recta7. Describe and relate the morphology of the various parts of the nephron and collecting

ducts to their functions.a. See below

8. Describe the structure of the filtration barrier and relate it to its function.a. The filtration barrier consists of a fenestrated capillary endothelium

i. Simple squamous epitheliumii. This filters large molecules

iii. It is also negatively chargedb. Then interdigitated processes of pedicles of podocytes covered by a diaphragm

i. Highly modified simple squamous epitheliumii. Filters medium sized molecules

iii. Negatively charged9. Describe and integrate the blood supply to the kidney with its function.

a. Kidney is highly vascular and filters 1200ml of blood/min10. Describe and examine how the circulation to the cortex is different from that of the

medulla of the kidney. Relate this to the function of the kidney.11. Describe the morphology of the ureter and relate the structure to its function.12. Describe the morphology of the urinary bladder and relate the structure to its

micturition function.13. Describe and contrast the structure of the male and female urethra and relate its

structure to function.

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Renin Secreted by juxtaglomerular cells as instructed by macula densa cells. Increases blood pressure by increasing sodium and water reuptake. Also secreted by Chief cells in stomach.

fibrous capsule Outermost layer of kidney

cystitis inflammation of the urinary bladder. More common in women than men because of their shorter urethra.

major calyx Where 2-3 minor calices come together

minor calyx Apex of pyramid empties into this

renal pyramid Section of medulla between two renal columns of cortex

renal papilla Apical tip of medullary pyramid

area cribrosa That part of the renal crest or renal papilla at which the papillary ducts open into the minor calyx

renal columns Cortical tissue that descends down on the sides of medullary pyramids

renal lobe Pyramid plus overlying cortical material

renal lobule Part of a renal lobe. It consists of the nephrons grouped around a single medullary ray, and draining into a single collecting duct.

multi lobar Human kidneys contain multiple lobes (10-12) whereas some animals have unilobar

medullary rays Straight portions of proximal & distal tubules as well as collecting tubules

renal corpuscle Includes Bowman’s capsule, Bowman’s space, and glomerulus

Bowman's capsule The most proximal part of the nephron

proximal & distal convoluted tubule

These, along with the renal corpuscle form the cortical labyrinth

Loop of Henle Composed of the straight portions of the proximal and distal tubules. Also has thick and thin sections. Thick sections more prominent on the ascending side.

collecting ducts Convergence several collecting tubules. Not part of the nephron. Second half of the uriniferous tubules. Runs down the medullary ray. Empties into the Papillary ducts of Bellini.

papillary ducts The largest collecting duct. Empties into the minor calyx through area cribosa at the apex of the medullary pyramid

glomerulus Not part of nephron. Fenestrated capillaries without diaphragms within the Bowman’s corpuscle and the bowman’s capsule surrounded by Bowman’s space.

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visceral & parietal layer Parietal layer of the renal capsule is simple squamous epitheliumVisceral layer is modified simple squamous epithelium (podocytes)

vasa recta The efferent arterioles of the juxtamedullary nephrons. Run straight down into the medullar alongside the collecting ducts. Drain back into arcuate veins. Important because they pick up the reabsorbed water and essential ions from the connective tissue and return back to the body after the unwatned wastes are removed

glomerular filtrate Fluid in the Bowman’s space. Leaves capillary of glomerulus because of hydrostatic pressure. Must pass through fenestra of arteriole (large molecules caught) as well as the slit diaphragm of the podocytes (modified simple squamous visceral layer (medium molecules caught)

podocytes Modified simple squamous visceral layer. Lines the glomerulus

urinary pole Part of the Bowman’s corpuscle where filtrate exits.

vascular pole The part of the Bowman’s corpuscle where blood enters and forms the glomerulus

afferent & efferent arteriole

Pre and post-glomerulus artery. Note that it is still considered an artery post-glomerulus because it still contains oxygenated blood. This does not become a vein until it dumps oxygen into the peritubular capillary

Bowman's space Between Bowman’s Capsule and the glomerulus

macula densa Part of the JG apparatus where the distal tubule touches the afferent arteriole

pedicle Small foot processes that extend from the podocytes (visceral layer) and form the filtration slits

Slit pore Space between pedicles

juxtaglomerular cells Part of the afferent arteriole. Modified smooth muscle cells. In between the afferent arteriole endothelium and the macular densa of the distal convoluted tubule. Secrete rennin which increases blood pressure

J-G complex Junction of the Bowman’s capsule and the distal convoluted tubule. Specifically junction between the afferent arteriole and the distal convoluted tubule. Consists of the macular densa of the distal tubule, JG cells of the afferent arteriole & extraglomerular mesangial cells.

diaphragm

basal lamina Fused basal lamina between Fenestrated capillary and Podocyte. Negatively charged.

mesangial cell Located within JG apparatus. Difficult to identify and differentiate.

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Function as support cells

thick segment Simple cuboidal epithelium. Proximal portion of descending limb + greater proportion of distal ascending limb.

thin segment Simple squamous epithelium.

arcuate artery Supplies the glomerulus and then to the peritubular capillary in cortical nephrons or to the vasa recta of juxtaglomerular nephrons

interlobular artery Supply the peritubular capillary network of cortical nephrons

intralobular artery Run radially between the lobules in the cortexbranch off the arcuate arteries

Dome cell **Diagnostic of transitional epithelium

interlobar artery Supplies the arcuate arteries which in turn supply the afferent arterioles

intertubular capillary network

pyelonephritis Inflammation of renal pelvis. Type of UTI

urethritis Urethra infection. Type of UTI

Region Type of epithelium

Thick segment of descending limb Simple cuboidal w/microvilli

Thin segment of descending limb Simple squamous

Thin segment of ascending limb Simple squamous

Thick segment of ascending limb Low simple cuboidal

Endothelium of glomerulus Simple squamous

Podocytes Highly modified simple squamous

Straight portion of proximal tubule Simple cuboidal w/microvilli

Convoluted tubules Low simple cuboidal epithelium

Intercalated cells of cortical collecting ducts

Cuboidal

Medullary collecting ducts Cuboidal

Ureter Transitional

Mucosa of bladder Transitional

© 2009 Mark Tuttle

Perineum – Morse1. Define the boundaries of the anatomical region known as the perineum.

a. The perineum is everything below the pelvic diaphragm.b. Everything between pubic symphysis and the coccyxc. Composed of two triangles

i. Urogenital triangle1. Ischial tuberosities and the pubic symphysis

ii. Anal tangle1. Ischial tuberosities and the coccyx

2. Anal Trianglea. Define the boundaries of the ischioanal fossa.

i. The iscioanal fossa exists within the anal triangle and includes the space between levator ani, the ischial tuberosities and the anus

b. Describe the course of the pudendal nerve and internal pudendal vessels through the gluteal region and anal triangle.

i. Pudendal n.1. Leaves the sacral plexus and travels out of the Greater Sciatic

foramen and then back in through the lesser sciatic foramen through the pudendal canal (formed by fascia of obturator internus)

2. Gives off inferior rectal nn.3. Gives off the perineal n.

a. Superficial branch becomes the posterior scrotal n.b. The deep branch runs in the superficial pouch

4. The pudendal n. becomes the Dorsal n. of the Penisii. Internal pudendal a.

1. Gives off the inferior rectal a.2. Gives of transverse perineal a.3. Gives off the perineal a. (superficial to perineal membrane)4. Deep artery of penis/clitoris (deep to perineal mem – pierces

distally)5. Dorsal artery of penis/clitoris (deep to perineal mem. – pierces

distally)6. Urethral a.

c. Define the location and contents of the pudendal canal.i. The pudendal canal is formed from fascia of obturator internus m. and

contains the pudendal n. the internal pudendal a. and the internal pudendal v.

d. Describe the course and distribution of the inferior rectal nerve and vessels.i. These are the first branches of their respective parent neurovasicles

ii. The nerve supplies levator anie. Describe the location and divisions of the external anal sphincter muscle.

i. The external sphincter is at the external border of the anus and is skeletal muscle

f. Define the location and importance of the perineal body.i. The perineal body is the point of attachment of the transverse perineal

muscles and is important during childbirth because it may be cut in order to prevent vaginal tearing

g. Define the types of hemorrhoids and the vessels involved in each type.

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i. Internal hemorrhoids involve the internal venous plexus and aren’t painful while the external hemorrhoids involve the external veinous plexus and are very painful

h. Describe the lymphatic drainage of the anal trianglei. The pectinate line divides lymph drainage

1. The top part goes to pelvic lymph nodes2. The superficial part goes to inguinal lymph nodes

i. Understand the importance of the fat in the ischiorectal fossa.i. The fat here must be able to accommodate distension of the rectum during

defecation3. Urogenital Triangle

a. Describe the fascial reflections in the urogenital triangle and the relationships each layer has to the major subdivisions of the urogenital triangle (superficial and deep pouches).

i. Superficial to deep1. Subcutaneous fascia2. Superficial Perineal Fascia (Colle’s fascia)3. Superficial Perineal Pouch4. Deep Perineal fascia enveloping the corpus cavernosus/spongiosus5. Perineal membrane6. Deep pouch7. UG diaphragm and Levator ani (superficial fascia of UG)

b. Define the relationships of the fascia of the urogenital triangle to that on the anterior abdominal wall.

i. Dartos Tunic1. Dartos muscle none2. Colle’s Fascia Scarpa’s Fascia

ii. Coverings of Spermatic cord1. External spermatic Fascia External oblique2. Cremaster muscle Internal oblique3. Internal Spermatic Fascia Transversalis fascia

iii. Tunica vaginalis parietal/visceral Peritoneumc. Be able to trace the possible routes of spread for fluids escaping into the potential

space between the superficial and deep fascia (superficial pouch) of the urogenital triangle .

i. If the urethra is ruptured especially in a male, urine can track into the superficial perineal pouch and even up into the abdomen since it is contained within colle’s fascia

d. Describe the contents of the superficial and deep pouches of the urogenital triangle.

i. Superficial pouch1. Ischiocavernosus, Bulbocavernosus mm2. Superficial transverse perineal mm.

ii. Deep pouch1. Bulbourethral glands2. Membranous portion of the urethra in males3. Ischioanal fossa4. External sphincter

© 2009 Mark Tuttle

e. Describe the course of the pudendal nerve and internal pudendal vessels (and branches) through the superficial and deep pouches.

i. See abovef. Describe the role of the autonomic nervous system in the male and female sexual

response.i. Male

1. S2,3,4 Keep the penis off the floor2. Parasympathetic3. Sympathetic is involved in the refractory period

ii. Female1. Assume similar: Parasympathetic is responsible for clitoral erection

g. Describe the arrangement of the erectile bodies for the penis/clitoris.i. Females have two bolbospungiosi

h. Define the blood and nerve supply to the penis/clitoris.i. Same

ii. Deep aiii. Dorsal aiv. Deep dorsal vv. Supervicial dorsal v.

vi. Dorsal n. of penis/clitorisi. Define the position and importance of the muscles in the superficial and deep

pouches.i.

j. Define the perineal body and list the muscles that attach to it.i. External anal sphincter

ii. Bulbospongiosusiii. Superficial transverse perineal muscleiv. Anterior fibers of the levator aniv. Fibers from external urinary sphincter

vi. Deep transverse perineal musclek. Be able to define the following:

i. Vulva1. All the external female genetalia

a. Vagina (Vestibule)b. Labia majora/minorac. Clitorisd. Greater/lesser vestibular glandse. Mons pubis

ii. Vestibule1. Space inside the vagina before the cervix

iii. Prepuce1. Foreskin/Clitoral hood

iv. Hymen1. Temporary skin layer over the vaginal orifice

v. Episiotomy1. Cut through theperineal body during childbirth to prevent vaginal

tearingvi. Circumcision

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1. Removal of foreskin

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Pelvis Walls and Floor – Morse1. Define the relationship of the tendinous arch to the obturator internus and levator ani

muscles.a. Tendinous arch makes the lateral border of:

i. Lavator Ani1. Iliococcygeus m. (mostly)2. Pubococcygeus m.

ii. (Ischio)coccygeus m.b. Tendinous arch forms the medial border of:

i. Obturator internus m.2. Explain the difference in orientation of the pelvic and urogenital diaphragms.

a. ????????????????/3. Define the parts of the pelvic diaphragm/urogenital diaphragm.

a. Pelvic diaphragm (Concave)i. Levator Ani mm.

1. Puboccygeus m.2. Puborectalis m.3. Iliococcygeus m.

ii. (Ischio) Coccygeus m.b. Urogenital diaphragm

i. Fills the space within the pubic archii. covers the anterior part of the inferior pelvic aperture (pelvic outlet)

iii. Components1. superficial transversus perineal m.

a. a small bundle of muscle fibers that pass along the back border of the urogenital diaphragm and assists other muscles in supporting the pelvic tissues

2. bulbospongiosus m. (male only)a. are united and surround the base of the penis

3. ischiocavernosus m. (male only)a. a tendinous structure that extends down to the margin

of the pubic arch and assists the function of #2; and4. sphincter urethrae m.

a. muscles that arch around the urethra and unite with those on the other side.

4. Describe the relationship of the parts of levator ani to pelvic organs.a. Levator Ani has the bladder immediately superior to it (also prostate in males),

and the urethra pierces the Lavator Ani via the urethral hiatusb. The rectum pierces the Levator Anic. In females, the vagina also pierces the Levator ani.

5. Describe the nerve supply to levator ani.a. Book

i. Direct branches from sacral plexus (S4)ii. Inferior rectal n. from pudendal n.

b. Wikipediai. pubococcygeus and iliococcygeus mm:

1. levator ani nerve (S4)2. inferior rectal nerve from pudendal nerve (S3, S4)

© 2009 Mark Tuttle

3. coccygeal plexusii. puborectalis m:

1. S3, S4.2. levator ani nerve

6. Describe the branching pattern of the internal iliac artery.a. Right Internal Iliac Artery

i. R. Umbilical a.ii. R. Obturator a.

iii. R. Inferior vesical a.iv. R. Uterine a.v. R. Middle rectal a.

vi. R. Internal pudendal a.vii. R. Inferior gluteal a.

7. Describe the distribution of the branches of the sacral plexus.a.

8. Define the subplexuses that are derived from the inferior hypogastric plexus.

© 2009 Mark Tuttle

Development of the Urinary System – Crissman1. List the germ layer(s) from which the urinary system develops.

a. Intermediate mesoderm2. List/describe the structures that are contributed to by the pronephros, mesonephros

and the metanephros and their respective duct systems.a. Pronephros

i. Rudimentary, transitory, nonfunctionalii. Ducts run caudally to cloaca

b. Mesonephrosi. Mesonephric ducts develop lateral to the degerated mesonephric ducts

ii. Mesonephric tubues form (40) in craniocaudal successioniii. Enlarge to form ductiv. Differentiate into rudimentary adult nephronsv. Medial end of tubule forms Bowman’s Capsule

vi. Degenerates in females, but part of it is maintained n males to form part of ductus deferens

c. Metanephrosi. Ureteric bud forms the ureter, renal pelvis, calyces, collecting ducts

ii. Metanephric blastema forms nephron3. Describe the region of the embryonic body in which the mesonephros and

metanephros develop.a. Pronephros

i. cervicalb. Mesonephros

i. Upper thoracic to 3rd lumbarc. Metanephros

i. AKA sacral metanephric system4. Define/describe/explain the tissues or structures that combine to form the

metanephric kidney.a. Reciporical induction of ureteric bud and metanephric blastemab. WT-1 expressed by blastema, stimulates synthesis of GDNFc. C-ret, a receptor for GDNF on ureteric bud causes bifurcation (into lobes)d. Ureteric bud forms the ureter, renal pelvis, calyces, collecting ductse. Metanephric blastema forms nephron

5. Be able to list the parts of the uriniferous tubule (nephron & collecting ducts) that are derived from each tissue or structure.

a. See above6. Be able to relate the role of the following substances in the development of the

kidney, or in the formation of congenital defects: WT-1, c-ret, PDK-1 & -2,Mox-1, N-myc, LIM-1, Pax-2, BMP-7,Wnt-4, Wnt-11, Hoxc-9,NGF, IGF, cadherins, laminin, & integrin.

a. WT1i. Expressed in blastema, regulates GDNF

ii. Induces ureteric bud formationb. C-ret, receptor

i. For GDNF is responsible for branching and ureters & renal agenesisc. Pax 2, BF 2, and Wnt 2

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i. All needed to induce ureteric bud formation & transform mesenchymal cells into epithelial cells

d. Mox 1, N-myc, Hoxc-9i. Required for nephron differentiation & glomerulus formation

e. PDK-1i. Mal-expressio ncauses epithelial hyperplasia & autosomal dominant

polycystic kidney diseasef. NGF

i. Expression in the blastema is necessary for formation nof nephrogenic tubules

g. GDNFi. Needed for branching of ureteric bud

h. IGFi. Over-expression causes Wilm’s tumors

i. Cadherinsi. To make tight junctiosn in forming epithelial tubes

j. Laminin, integrini. Necessary for diapedesis to occur as cells migrate

7. Describe the development of the vascular supply to the definitive kidney. Explain the occurrence of "accessory renal arteries".

a. Kidney derives its blood supply form the nearest vesselsb. First blood supply comes from common iliac arteriesc. Vascular supply should change as kidney (relatively) ascendsd. Accessory renal arteries

i. Polar: inferior/superior renal artery (25%)ii. Obstruction of ureter can occur if inferior polar crosses anterior to

ureteriii. Causes hydrophrosis, dilation of pelvis and calyces due to backup of

urine8. Define/describe/explain fetal lobulation of kidney, renal agenesis, and renal

duplication, Potter's syndrome.a. Fetal lobulation

i. Bifurcation occurs as signaled by c-Retb. Renal agenesis

i. Lack of kidney 1/1000ii. Probably due to lack of ureteric bud

iii. Usually no symptoms due to compensatory hypertrophy of remaining kidney

c. Renal duplicationi. When two separate systems develop in the same kidney

ii. Two uretersd. Potter’s syndrome

i. 1/3000ii. Neither kidney forms

iii. Due to failure of ureteric bud or blastema forms9. Explain the formation of a "horseshoe" kidney and its positional relationships with

surrounding organs and vessels.a. 1/500

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b. Inferfior poles fused together to form one U shaped kidneyc. Kidney starts to ascend but gets held up by inferior mesenteric artery

10. Define/describe/relate polycystic kidney to it morphology and pathogenesis.a. Malexpression of PDK1 causes thisb. Numerous cysts throughout the kidneyc. Recurrent infectiosnd. Occurs because of nonfunctional ciliae. The cilium normally directs the flow of fluid through the tubulesf. In PCKD, the cilium is non-functional so the epithelial cells divide profusely and

form the cysts11. Explain the formation of the ureters, renal pelvises, and calices. Explain the bifid

ureter and common clinical findings associated with it.a. Ureters, renal pelvices, and calices are all progeny of the ureteric budb. Bifid ureter happens because complete division of the ureteric bud

12. List and describe the developmental history of the 3 portions of the urogenital sinus. What definitive structures are derived from each?

a. Vesicali. Superior continuous with allantois

ii. In males forms most of bladderiii. In females forms most of bladder

b. Pelvici. Middle portion

ii. In females forms complete urethrac. Phallic

i. Inferior portionii. In males forms proximale penile urethra

iii. Distal portion is formed by glandular urethral plateiv. In females, forms the vestibule of the vagina

13. Explain how exstrophy of the bladder occurs.a. Septation of the cloaca is occurring, mesonephric ducts with attached ureteric

buds are incorporated nto the posterior wall of the forming bladderb. The opened mesonephric ducts continue farther inferiorly to the opening of the

urethra14. Explain the development of the urethra.

a. See above15. Be able to relate the timing and chronology of above events to each other.

a. Pronephros early 4th weekb. Mesonephros late 4th weekc. Metanephros 5th week (functional in 9th week)d. Bifurcation Day 32 (5th week)e. Lobes formed 16th weekf. 4 bifurcatiosn 6th weekg. Bifurcation stops 32nd weekh. Kidneys in normal position: 9th week (T12-L3)

© 2009 Mark Tuttle

Pelvis (Visceras) – Morse1. Describe the surfaces of the urinary bladder and the viscera which contacts them.

a. The superior and lateral/medial parts of the bladder are covered by parietal peritoneum

2. Describe the pelvic course of the ureters.a. The ureters leave the kidney and travel inferiorly posterior to the gonadal

vessels and then anterior to the iliac vessels, anterior to the sacral plexus and then posterior to the deferens (in males)

b. The travel obliquely through the detrusor m3. Define the bladder trigone.

a. The two ureturs and the opening of the urethra4. Describe the pelvic course of the vas deferens.

a. The ductus deferens leaves the testes and enteres the superficial inguinal ring and the spermatic cord travel through the deep inguinal ring before leaving and then along the surface of the posterior portion of the bladder before meeting with (R and L separate) the seminal gland

5. Describe the position and gross anatomical structure of the seminal vesicles.a. Reside on the posterior side of the bladder on the superior portion of the vasb. They meet with each side’s respective vas just before forming the ejaculatory

duct6. Discuss the route of a sperm cell during emission and ejaculation.

a. passes through the ejaculatory ducts and is mixed with fluids from the seminal vesicles, the prostate, and the bulbourethral glands to form the semen, or ejaculate

b. Emission is a parasympathetic activity, but orgasm and ejaculation are predominantly under the control of the sympathetic nervous system. Also the detumescence/Resolution/refractory period are sympathetic

7. Describe the anatomy of the posterior wall of the prostatic urethra.a. The posterior wall of the prostatic urethra contains a crest called the urethral

crestb. On the urethral crest there is the prostatic utricle (vaginalis masculina). It is

flanked by the two ejaculatory ductsc. All along the urethra in this area are prostatic ducts

8. Define the lobes of the prostate and understand how enlargement effects urine flow and retention.

a. The prostate is divided into anterior and posterior lobes by a coronal plane through the urethra

b. In men, the posterior lobe is also subdivided into a middle lobe, sectioned off by the ejaculatory ducts

9. Describe the accessory reproductive glands of the male and define the contribution of each to semen.

a. Malei. Prostate

1. 30% of semen2. Alkaline, thin, milky, watery3. Citrate4. Phosphate5. Calcium

© 2009 Mark Tuttle

6. Profibrinolysina. After a few minutes, causes lysis of the mucoid clot of

semenii. Bulbourethral (Cowper’s)

1. Pre ejaculate (not really part of semen)2. Helps neutralize acid of urine in urethra and vagina3. Located in the deep pouch4. Analogous to greater vestibular glands in females (but females’

are located in the superficial pouch)5. Only component of semen which isn’t stored, just secreted at

the time of ejaculationiii. Seminal gland

1. 60% of semen2. Fructose3. Citric acid/other nutrients4. Prostaglandins

a. Reacts with cervical mucous to promote sperm movement

b. Reverse peristalsis to move sperm toward eggi. Sperm can reach distal tube in 5 min (couldn’t

possibly swim this fast)5. Fibrinogen

a. Helps clot to remain mucoid consistency to hold semen in upper vagina

iv. Testes1. Sperm are 10% of semen

b. Femalei. Greater vestibular gland (Bartholin’s)

1. Produce mucous to lubricate the vagina, but only a minute contribution

ii. Lesser vestibular gland (Skene’s)1. Organ of female ejaculation2. Develop from the Wolffian duct of the Mesonephric duct

a. In the males this develops in to the vas3. (Homologous to the prostate)

10. Describe the peritoneal reflections on the pelvic viscera in both sexes.a. Reflected over the bladder and rectum in both sexes and in addition the uterus

in the female11. Define the parts of the broad ligament.

a. Mesosalphinxi. Between the Fallopian tube and the ovary

b. Mesovariumi. Covers the ovary

ii. At a 90 degree angle to the other mesenteriesc. Mesometrium

i. Between ovary and uterus12. List the structures that lie between the lamellae of the broad ligament.

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a. The uterus, the uterine(fallopian) tubes, the ovary, the ligament of the ovary, the ovarian and uterine arteries, and the round ligament of the uterus

b. Uterine arteries, ovarian arteryc. opoopheron

13. Delineate the parts of the uterus and vagina.14. Define the normal position of the uterus and the terms anteversion/anteflexion and

retroversion/retroflexion.a. The normal position of the uterus is anteversion and antiflexed. Anteversion

refers to the angle at the external os being approximately 90 degrees, measured from the angle between the vagina and the cervical canal.

b. Anteflexion refers to the angle ate the internal os being approximately 170 degrees, measured from the angle between the uterine and cervical canal.

c. Retroversion is the widening of the angle between the vaginal and cervical axis greater than 90 degrees. If the angle of the external os increases and approaches 180 degrees, the uterus is in danger of fall into the vaginal canal.

d. Retroflexion is the widening of the angle between the cervical and uterine axis greater than 180 degrees.

e. The two angles are independent of each other, and the uterus can possibly be found in any combination of anteversion, retroversion, anteflexion, or retroflexion

15. Define the ligamentous supports for the uterus.a. Transverse Cervical (Cardinal) Ligament

i. This is really the major support of the uterusii. Contains the uterine a.

b. Round ligament of uterusi. Remnant of the gubernaculum

c. Broad Ligamenti. Contains mesosalphinx, mesovarium, and mesometrium

d. Ovarian ligamenti. Runs from the uterus to the ovary

e. Suspensatory ligament of the ovaryi. Ovarian (gonadal) a. runs through here

16. Explain the relationships and importance of the pelvic peritoneal pouches.a. Pelvic peritoneal pouches are of physiological importance because they may

accumulate blood, ascites, or other abdominal fluids as a result of pathology. For example, in a female, appendicitis may be detected by the presence of ascites in the rectouterine pouch.

b. The rectouterine pouch in particular is important because it represents the lowest point of the abdominal cavity when a woman is standing, and fluid in this area can be easily sampled by insertion of a needle through the posterior fornix of the vaginal canal and aspiration of fluid for analysis. Because the inner 4/5th of the vagina contains no somatic innervation, the woman will not feel pain when a needle pierces the posterior vaginal wall.

17. Distinguish between false and true pelvis and understand which organs are located in each.

a. The true pelvis is the region inferior to the pelvic brim, bounded inferiorly by the pelvic outlet. Organs found in the true pelvis include

i. empty bladder

© 2009 Mark Tuttle

ii. non-pregnant uterusiii. lower portion of the rectumiv. perineal structuresv. external reproductive organs of the male and female.

b. The false pelvis is the region superior to the pelvic brim, separated by a physiological line (continuous with the abdominal cavity) indicated by the inferior aspect of the 5th lumbar vertebral body and the anterior superior iliac spines (ASIS). Structures of the false pelvis include:

i. the upper part of the rectumii. the sigmoid colon

iii. the gravid uterus (pregnant)iv. the superior aspect of the full bladderv. the prostate in males.

18. Explain the relationships of the vaginal fornices to surrounding structuresa. The cervix creates recesses called fornices where it projects into the vagina.

Fornices are anterior, posterior, and lateral, being circumferential to the cervix. b. The posterior fornix is the deepest and most closely associated with the recto-

uterine pouch.c. The anterior fornix lies just posterior to the urinary bladder.

© 2009 Mark Tuttle

Female Reproductive System – Crissman1. Describe the process of oogenesis and indicate the embryologic origin of the

primordial germ cells.a. Oocytes are derived from Yolk Sac Endodermb. ~1 million ova present at birth, 200k-400k present at pubertyc. Primordial cells (oogonia) migrate from yolk sac endoderm to urogenital ridged. Follicular cells are derived from mesonephros sex cords (mesoderm)e. Primary oocytes are formed in prenatal life

i. Diploidii. Arrested at prophase by meiosis-inhibiting factor

2. Indicate in which stage of meiosis the oocyte exists prior to ovulation, at ovulation but prior to fertilization, and then following fertilization.

a. While dormant in the ovary, oocytes are arrested at prophaseb. At ovulation, becomes secondary oocyte

i. Completes 1st meiotic divisionii. Extrudes 1st polar body

iii. Arrested at metaphase of meiosis IIiv. Still considered diploid

c. At fertilization, completes meiosis II3. Describe the morphology of the ovary including the surface covering, the capsule, the

cortex, and medulla. Identify and contrast the components of each.a. Cortex

i. Covered by germinal epithelium (simple cuboidal)ii. Just deep to the epithelium is the tunica albuginea (white coat)

1. Dense irregular CTiii. CT layer w/fibroblasts which look like sm. Muscle

b. Medullai. Mostly stroma, ~dense irregular CT

ii. Very vasculariii. Contains helicine coiled arteries

4. Describe and integrate the development and morphology of ovarian follicles, beginning with primordial follicles and ending with Graafian follicles. Relate the follicular components to their origin, sites of hormonal production and describe their effects on the other components of the female reproductive tract.

a. Sequencei. Primordial follicles

1. Large cell2. Light staining3. Single layer of flattened follicular cells4. Don’t develop FSH receptors until puberty5. Under influence of activin secreted by the oocyte

ii. Primary follicle1. **cuboidal epithelial follicular cells diagnostic as opposed to

flattened cells in primordial2. Zona pellucid begins to form

a. Intimate with membrane around ovumb. Has glycoproteins secreted by oocytec. Contains microvilli for exchanging nutrients/wasts

© 2009 Mark Tuttle

d. Binds spermatozoa, and is required to initiate the acrosome reaction.

3. Theca begins to form outside folliclea. Not under control of FSH, unknown factors instead

iii. Secondary follicle1. Now under FSH control (post puberty)2. Form small spaces that coalesce to form a single space called

the antrum ** diagnostica. Filled with follicular liquorb. Like plasmac. Contains GAGs, steroid binding proteisd. Help regulate FSH & LH release

3. Ovum now displacd to side of follicle in heap of cells called cumulus oophorus

a. Ovab. Zona pelucidac. Corona radiate

4. Theca now well developeda. Externab. Interna

i. Highly vascularii. **Steroid producing cells that secrete

androgensiv. Graafian follicle (mature)

1. 1-2cm2. Bulges into cortex3. High estrogen levels in blood now from follicles

a. Inhibit FSH releaseb. Causes LH surgec. Causes meiosis inducing substance

4. Once ovulation occurs, becomes a corpus hemorrhagicus5. Describe the structure and functions of the theca cells.

a. Begins to form in primary follicleb. Matures in secondary follicle

i. Forms two layers: Internal and external layerii. Internal layer is highly vascular & secretes androgens

c. When follicle degenerates after ovulation, sometimes thecal cells persist, called interstitial bodies

6. Define and contrast an "atretic follicle" with other follicles.a. At start of cycle, more than one follicle responds to FSHb. 10-20 respond but only 1 is ovulatedc. The rest undergo atresia – autolysis, programmed cell deathd. Forms small scar

7. Describe the development and fate of the corpus luteum and how it changes when fertilization occurs. Include the theca lutein and granulosa lutein cells, their origin, their function, sites of hormonal production and describe how this affects other components of the female reproductive tract.

a. Forms from the corpus hemorrhagicus after ovulation

© 2009 Mark Tuttle

b. Under the influence of LHc. Temporary endocrine structured. Granulosal luteal cells develop from granulosal cells (former follicular cells)

i. Form 80% of cells in corpus luteumii. Pale staining

iii. ** secrete progesteroneiv. Continues to convert androgens secreted by theca luteal cells into

estrogene. Theca luteal cells develop from theca interna

i. Form remaining 20% of cellsii. Secrete mostly androgens, but also progesterone

iii. Found at peripheryf. Progesterone feedback reduces production of LH and stops corpus luteum

formationg. However, if pregnancy occur, corpus luteum continues to enlarge, promoted by

Human Chorionic Gonadotropin from placentah. If no pregnancy occurs, corpus luteum degenerates into Corpus Albicans

i. Invaded by fine CT forms scarii. Shrink with age, so largest ones are the youngest

8. Name the four parts of the uterine tube and distinguish their histological differences. Relate how the morphology integrates with its function.

a. Infindibulumi. Finger like processes, “fimbriae”

1. Help “grab the ovulation”b. Ampulla

i. Expanded regionii. Highly folded

iii. Fertilization usually occurs hereiv. Greatest number of cilia here

1. Sweep ovulated ovum into and down the ovarian tubec. Isthmus

i. Narrow portiond. Intermural

i. Portion traversing the uterine wallii. Few cilia

9. Describe the regions and the layers of the uterus and relate the morphology to its function.

a. Perimetriumi. Outermost (deepest)

ii. Thin layer of dense CTiii. ** Peritoneum on fundus

b. Myometriumi. Thickest layer of wall

ii. Smooth muscle cells1. Subdivided into 3-4 layers (longitudinal, middle=circular)2. Difficult to discern layers3. Increase in size during pregnancy4. Contracts during intercourse or menstruation

© 2009 Mark Tuttle

5. Under influence of prostaglandins and oxytocin6. At cervical region, the muscle is replaced by elastic fibers – to

allow more flexibility during childbirthc. Endometrium

i. Mucosal layer of uterusii. **simple columnar epithelium and lamina propria CT

iii. Lines tubular glands (uterine glands)iv. Place for implantation of zygotev. Two layers

1. Functionalis layera. Superficialb. Sloughed off during menstruationc. Composed of compacta (superficial) and spongiosa

(deeper, spongey)2. Basalis layer

a. Deep layerb. Not sloughed offc. Epithelium and glands regenerate functionalis from

here10. Identify and contrast the main phases of the menstrual cycle. Describe the

morphological changes in the endometrium during each phase of the menstrual cycle and integrate this with its functions. Indicate the principal hormones responsible for the morphology of each phase and from where they arise.

a. Menstrual phase i. Days 1-5

ii. Functionalis layer sloughs offiii. Endometrium at thinnestiv. **Diagnostic features

1. Luminal surface is ragged2. Stroma is full of blood3. Mostly basalis left

b. Proliferative phase(Follicular phase)i. Days 6-14

ii. Growth stageiii. Endometrium is responding to estrogen produced by growing folliclesiv. Increase in size of functionalis layer of endometriumv. Increased length of uterine glands

vi. Coiled arteries between glandsvii. Increased CT

viii. **Diagnostic features1. Narrow lumen2. Simple columnar epithelium3. Uterine glands go from straight to wavy

c. Secretory phase (Luteal or progravid phase)i. Days 15-27

ii. Uterine glands begin to actively secrete material to support zygoteiii. Under influence of progesteroneiv. **Diagnostic features

© 2009 Mark Tuttle

1. Glands become coiled2. Stroma CT between glands reduced3. Gland lumens dilated with secretions4. Coiled arteries not readily seen

v. Functionalis layer may slightly decrease but this is not readily seen11. Integrate the various hormones that impact and are produced by the female

reproductive system and what effects they have on their target organs. Also be able to relate the control mechanism for these hormones.

a. Progesteronei. Secreted by follicular layer (granular layer) of follicle and (to a minor

degree) Theca luteal cells of corpus luteumii. Acts on the corpus luteum to decrease leutenizing hormone (LH)

1. Stops corpus luteum formationiii. Maintains thick endometriumiv. Prepares uterus for implantationv. Peaks at day 25 of menstrual cycle

vi. Act on receptors of smooth muscle cells in functionalis coiled arteries1. Keep them open2. When progesterone drops (natural part of menstrual cycle),

coiled arteries close, endometrium functionalis becomes ischemic, sloughs off

b. Follicle Stimulating Hormone (FSH)i. secreted by cells in anterior pituitary gland stimulates follicle growth

ii. Follicular cells develop receptors for FSH beginning at pubertyiii. At beginning of cycle, more than one follicle responds to FSHiv. Follicular Antrum filled with follicular liquor helps regulate FSH releasev. Inhibited by high estrogen levels as when follicles are mature

vi. Granulosal cells of corpus hemorrhagicus secrete folliculostatin & inhibin

1. act as inhibitors of FSH releasec. Leutenizing Hormone (LH)

i. Secreted by pituitary glandii. Causes rupture of follicle, leading to ovulation

iii. Causes release of Meiosis Inducing Substanceiv. Acts on Corpus Hemorrhagicus to form Corpus Luteumv. Release is regulated by follicular liquor in the follicular antrum

vi. Inhibited by progesterone (acts on pituitary gland)1. When this starts to decrease, either menstrual cycle continues,

OR pregnancy has occurred and Human Chorionic Gonadotropin (HCG) takes over and helps maintain corpus leuteum that would otherwise have degenerated

d. Estrogeni. Inhibit FSH release

ii. Causes LH surgeiii. Produced by follicles/corpus luteum

1. Theca interna of secondary follicle produces androgens which are converted to estrogen by adjacent (deeper) granulosal cells

© 2009 Mark Tuttle

2. Theca luteal cells also produce androgens which are converted to estrogen by adjacent granulosal luteal cells in corpus luteum

12. Describe the specific type of epithelium and the shape of glands found in the uterine cervix, as well as the epithelial lining of the vagina. Be able to contrast the morphology and function of the vagina with that of the esophagus.

a. Cervixi. Lined by simple columnar epithelium (just like the uterus)

ii. BRANCHED cervical glands (unlike uterine simple glands)iii. Mucous secreting

b. Vaginai. Stratified squamous non-keritinizing epithelium transition here from

simple columnar of uterus/cervixii. NO layered muscularis externa (unlike esophagus circular/longitudinal)

iii. NO glands in lamina propria (unlike esophagus)13. Describe and integrate the blood supply and function of the ovary, endometrium and

fallopian tube.a. The ovary is supplied by helicine vessels of the ovarian (gonadal) artery arising

directly from the aorta and drained by the ovarian (gonadal) vein. It also supplies the fallopian tubes before anastomosing with the uterine artery

i. The ovarian artery runs through the suspensatory ligament of the ovary which is a fold of peritoneum

b. The endometrium is supplied by the coiled/straight arteries branching off of the radial arteries which branch off of the arcuate arteries running circumferentially around the uterus which branches off of the uterine artery which is a branch of the internal iliac artery

i. The uterine artery runs through the Cardinal Ligament (Transverse cervical ligament) and meets the cervix supravaginally running through endopelvic fascia

14. Identify the components of the breast. Explain how the morphology of the breast changes from the resting state to the active state (lactation).

a. Inactivei. Small amounts of glandular tissue/ducts

ii. Mostly adiposeiii. No milk being produced

b. Activei. Mostly glandular tissue producing milk

ii. Stimulated by estrogen and progesterone during pregnancy to form alveoli

iii. Stimulatd by prolactin secreted by the pituitary gland to produce milkiv. Sucking on nipple sends neural signal to hypothalamus, causes release

of oxytocinv. Oxytocin secreted from pituitary lgland causes myoepithelial glands to

contractvi. Glandular units form alveoli

1. Lined by simple cuboidal epithelium2. Wrapped in myoepithelial cells3. Alveoli produce IgM (clostrum) prior to birth

© 2009 Mark Tuttle

15. Be able to relate and integrate the types and modes of secretions from the various female reproductive organs with their functions.

a. Ovaryi. Cytocrine: whole cell secretion

b. Uterusi. Mucoid secretions to help the sperm reach the ovary

c. Vaginai. No secretions from glands but non-keritinized stratified squamous so

some water can get through16. Be able to relate where and when fertilization and implantation normally occur.

a. Implantation should occur in the endometrium b. Fertilization should occur in the oviduct (Fallopian tube)

granulosa cellszona pellucida

lactiferous ductantrum

cumulusoophorus

lactiferous sinustheca interna

theca externacolostrum

menarchemenopause milk

ejection reflexgerminal epithelium

tunica albugineaectopic pregnancy

follicular cellsprimary & secondary oocytegonorrhea

corpus hemorrhagicuscorpus albicans

endometriosiscoiled arteries

straight arteriescervical cancer

© 2009 Mark Tuttle

Autonomic Innervation of Abdominal and Pelvic Viscera – CBC1. Review the basic organization of the sympathetic and parasympathetic division of the

ANS.a.

2. What is the general organization of sympathetic innervation to abdominal viscera?a. Follows blood supplyb. Celiac

i. T5-T9 spinal cord levelii. Greater splanchnic n.

iii. Synapse at Celiac prevertebral gangliaiv. Postganglionic neuron goes to foregut structures

c. Superior Mesenterici. T10-T11 spinal cord level

ii. Lesser Splanchnic n.iii. Synapse at superior mesenteric prevertebral gangliaiv. Postganglionic neuron goes to midgut structures

d. Aorticorenali. T12 spinal cord level

ii. Least splanchnic n.iii. Synapse at aorticorenal prevertebral gangliaiv. Postganglionic neuron goes to kidney, gonads, suprarenals

e. Inferior Mesenteric3. Describe the following terms:

a. thoracic splanchnici. All the splanchnic nerves that originate from thoracic spinal cord levels

1. Greater splanchnic (T5-T9)2. Lesser Splanchnic (T10-T11)3. Least Splanchnic (T12)4. NOT lumbar splanchnic

b. lumber splanchnici. Not thoracic

ii. L1-L2 originiii. Inferior mesentericiv. Hindgut

c. prevertebral gangliai. sympathetic ganglia which lie between the sympathetic chain and the

organ of supplyd. paravertebral ganglia

i. Ganglia along the length of the sympathetic trunk4. Describe the details for sympathetic innervation for all viscera of the abdomen.

a. Follows the blood supplyb. Follows embryonic origin

5. What is the distribution of the vagus nerve in the abdomen? Describe the formation and distribution of pelvic splanchnic nerves.

a. Vagus n.i. Vagus nerve (CN 10) supplies organs supplied by Celiac Trunk and

Superior Mesenteric Artery (Foregut & Midgut)

© 2009 Mark Tuttle

ii. Appears to run with the postganglionic nerves of the celiac/superior mesenteric ganglia of the sympathetic division

iii. ALSO supplies the kidneys + gonadsb. Pelvic Splanchnic N.

i. Parasympatheticii. Originate at S2-S4 spinal cord levels

iii. Supply the organs of the inferior mesenteric arteryiv. Hindgutv. Synapse at terminal ganglia intimate with the effector and give off short

branches which make up the pelvic plexus6. What is the basic organization of sympathetic innervation to pelvic viscera?

a. Lumbar splanchnic n. (L1-L2) i. to the aortic plexus, then to the superior hypogastric plexus, then along

the Inferior Hypogastric nerve where it synapses at an unnamed ganglia and gives off postganglionic branches in the inferior hypogastric plexus and innervates pelvic structures (i.e. bladder)

ii. OR, just run directly to the inferior hypogastric plexus and synapseb. Sacral splanchnic (L1-L2)

i. Travels down the sympathetic trunk and synapses at a PARAvertebral ganglion at ~sacral region where it gives off the postganglionic SACRAL SPLANCHNIC n.

ii. Travels to the hypogastric plexus where it innervates the bladder.7. Describe the following terms: superior hypogastric plexus, hypogastric nerve, inferior

hypogastric plexus and sacral splanchnic.a. See above

8. What is the basic organization of parasympathetic innervation to pelvic viscera?a. Originates at S2-S4b. Travels in pelvic splanchnic n.

i. Note parasymp splanchnics are named by target region NOT originc. Travels to terminal ganglia in inferior hypogastric plexus

© 2009 Mark Tuttle

Gluteal Region and Posterior Thigh – Morse1. Describe the dermatome pattern for the lower limb.

a. Anteriorly, it is mostly L1-S1i. L1 is all of the UG triangle

ii. L4 is most of the thigh and kneeiii. L5 comes in across the shiniv. S1 is the lateral parts of the ankle and little toe

b. Posteriorlyi. S5 is the anus and extending out around the anus in concentric circles is

S4 and S3ii. L5 is the lateralmost parts of the thigh and part of the leg

iii. S1 is the middle of the thigh and leg2. Demonstrate the sacrotuberous and sacrospinous ligaments and describe how they

contribute to the formation of the sciatic foramina.a. Sacrotuberous

i. Sacrum to ischial tuberosityb. Sacrospinous

i. Sacrum to ischial spinec. Greater sciatic foramen

i. Greater sciatic notch + sacrospinous lig (+ maybe some sacrotuberous lig)

ii. Houses Pisiform m.d. Lesser sciatic foramen

i. Lesser sciatic notch + sacrotuberous + sacrospinous3. Review the anatomy of the bones of the pelvis and the femur.4. Demonstrate the surface anatomy of the sciatic nerve.

a. L4-S3b. Leaves the greater sciatic foramen just below Piriformis, but above Superior

Gamellusi. (superior gamellus does not travel through GSF, instead takes its origin

on the outside of the ischial spine)c. Runs down the posterior aspect of the thigh along with the posterior cutaneous

n of the thighi. superficial to superior gamellus, obturator internus, inferior gamellus,

obturator externus, quadrates femorisii. deep to Gluteus Maxiumus

d. The Posterior cutaneous n of the thigh dives deep, away from sciatic at about the ischial tuberosity (common origin of hamstrings)

e. Dives deep to the long head of biceps femorisf. Splits at the politeal fossa into common fibular and tibial nn.

5. Demonstrate the large gluteal muscles and understand their role in gait as well as their nerve and blood supply.

a. Gluteus mm are not heavily used in walking on a flat surfaceb. They do perform the tipping of the pelvis which is essential to a normal gait

while walkingc. Gluteal mm. are recruited and used heavily when running, climbing, and rising

from a seated position6. Describe the course structures take from the pelvic cavity to the gluteal region.

© 2009 Mark Tuttle

a. Out the greater sciatic forameni. Piriformis

ii. Sciatic niii. Posterior cutaneous n of thighiv. Superior gluteal a + n (superior to piriformis)v. Inferior gluteal a + n

vi. N. to obturator internusvii. N. to quadratus femoris

b. Out the lesser sciatic forameni. Tendon of Obturator internus .

c. Obturator canal (through the obturator fascia in the foramen)i. Obturator n. + a. + v.

7. Demonstrate the six lateral rotator muscles of the hip.a. Facts

i. All insert on the greater trochanterii. All innervated by small individual branches of the sacral plexus

b. Musclesi. Pisiform m.

ii. Superior Gamellus m.iii. Obturator internus m.iv. Inferior Gamellus m.v. Obturator externus m.

vi. Quadratus femoris m.8. Understand the course structures take from the gluteal region to the perineum.

a. Out of the pelvis through the greater sciatic foramen, back in to the perineum through the lesser sciatic foramen , then enters the pudendal canal, made up of Obturator Internus fascia before entering the perineum

b. Contentsi. Internal pudendal artery

ii. Internal pudendal veinsiii. Pudendal nerve

9. Define the hamstring muscle group and delineate their actions, nerve supply, and blood supply

a. Requirementsi. Originate on the Ischial Tuberosity

ii. Innervated by the Tibial N.

© 2009 Mark Tuttle

Thigh and Leg – Morse- Identify the bones of the thigh and leg and the major anatomical features of each.

a. Thighi. Femur

1. Head: articulates with the acetabulum of the pelvis2. Greater trochanter is on the posterolateral side3. Lesser trochanger is on the posteromedial side4. Pectineal line: distal attachment of pectinius – runs between lesser

trochanter and the linea aspera5. Gluteal tuberosity6. Linea aspera runs down the middle of the posterior side and splits

into medial/lateral supracondylar linesa. Exposes Popliteal surface

7. Medial/Lateral condyles8. Adductor tublercle on medial aspect of distal epiphysis

b. Leg (FLorida TradeMark)i. Tibia: larger, medial

1. Tibeal plateau articulates with condyles of the femura. (there are also condyles of tibia)

2. Intercondylar eminence comes up between plateaus3. Articulates with fibula on lateral condyle4. Shaft5. Medial malleolus: process which sticks downward

ii. Fibula: smaller, lateral1. Does NOT articulate with knee2. Shaft3. Lateral malleolus: process which sticks downward

- Define the boundaries and the contents of the femoral triangle.a. Boundaries

i. Inguinal ligament (superior)ii. Sartorius m. (lateral)

iii. Adductor longus m. (medial)iv. Iliopsoas m. + pectinius m. (posterior)

b. Contents (NAVL – lateral to medial)i. Femoral n.

ii. Femoral a.iii. Femoral v.iv. Femoral ln.

- Explain the anatomy of a femoral hernia and distinguish it from the inguinal hernias.a. Goes into the femoral triangle and a portion can go through the saphenous opening

and because - Demonstrate the course and the primary branching pattern for major vessels and nerves

of the thigh and leg.a. Nerves

i. Anterior1. Femoral n.

a. Muscular branches innervate i. Iliopsoas m.

© 2009 Mark Tuttle

ii. Pectineus m.iii. Sartorius m.iv. Quadriceps femoris mm.

b. Cutaneousi. Anterior cutaneous branch

ii. Saphenous n. (medial part of leg)2. Obturator n.

a. Runs through obturator foramen and superior/superfiscial to obturator externus

b. Superficial to adductor brevis, but deep to aductor longusc. Innervates

i. Obturator externusii. Adductor longus

iii. Adductor brevisiv. Adductor magnusv. Gracilis

vi. Pectineus3. Lateral cutaneous n. of thigh

a. Branches off of Genitofemoralb. Pierces through fascia lata laterally and supplies the skin

ii. Posterior1. Medial cutaneous innervation is provided by dorsal rami of L1,2,3

and S1,2,3a. Superior/middle/inferior cluneal nn.

2. Superior gluteal n. (L4-L5)a.

3. Sciatic n. and Posterior cutaneous n. of thigha. run parallel and then posterior cutaneous n of thigh dives

deep at about the level of the origin of biceps femoris long head (sciatic also deep to biceps, but not as deep)

b. Innervatesi. Semitendinosus

ii. Semimembranosusiii. Biceps femoris (long head)iv. Adductor magnus (medial part)

c. Branches above the popliteal fossa into:i. Tibial n.

1. Along tibiaii. Common Fibular n.

1. Along fibulab. Veins

i. Femoral v runs along with femoral a.1. Small saphenous v. on posterior part of leg runs up and dumps into

popliteal vein at the popliteal vossa.ii. Great Saphenous v. parts with femoral v. at saphenous hiatus and runs

down the medial aspect of the thigh and the leg1. runs with saphenous n. in the leg

© 2009 Mark Tuttle

2. posterior tibial and fibular vv. run along and meet with popliteal v. and short saphenous before rising superficially through the adductor hiatus becoming the femoral v.

c. Arteriesi. Femoral artery

1. Leaves pelvis deep to the inguinal ligament and enters the femoral triangle

2. Gives off the Profunda Femoris A. which supplies the entire posterior compartment of the thigh via perforating arteries

3. Enters the Subsartorial/Adductor/Hunter’s Canal- Identify arteries of the lower limb from which a pulse may be palpated.

a. Femoral triangleb. Popliteal fossac. Dorsum of foot between: (on foot between 1 + 2 toes)

i. Extensor halicus longus m.ii. Extensor digitorum longus m.

- Describe the course of the major superficial veins of the lower limb.a. See above

- List the contents of the subsartorial canal.a. Femoral A + Vb. Branches of Femoral N. – most notably the saphenous n.

- Demonstrate the muscles found in each anatomical “compartment” of the thigh and leg.a. See sheet

- Describe the nerve and blood supply for muscles of the thigh and leg.a. See above

- Define active and passive insufficiency as it relates to muscles.a. Active insufficiency

i. When a muscle is unable to exert maximal force on a joint because it cannot be shortened enough to cause full range of motion of both of the joints it crosses at the same time

b. Passive insufficiencyi. When a muscle is unable to exert maximal force on a joint because it cannot

be stretched enough to cause full range of motion of both of the joints it crosses at the same time

- Define the major actions of muscles acting on the hip, knee, ankle and digital joints.a. Hip

i. Flex1. Iliopsoas mm.

a. Psoas majorb. Psoas minor (accessory)c. Iliacus muscle

2. Anterior compartment of thigha. Rectus femoris. (Part of the Quadriceps.)b. Sartorius

3. Medial compartment of thigha. Pectineusb. Adductor longusc. Adductor brevis

© 2009 Mark Tuttle

d. Gracilis4. (Tensor fasciae latae)

ii. Extend1. Hamstrings

a. Semimembranosusb. Semitendonosusc. Biceps Femoris (long head)

2. Gluteus maximus recruited under certain circumstancesiii. ADduct

1. Adductor brevis2. Adductor longus3. Adductor magnus4. Pectineus5. Gracilis

iv. ABduct1. Gluteus Medius2. Gluteus Minimus3. Gluteus Maximus4. Piriformis5. Obturator externus

v. Medial Rotation1. Tensor fasciae latae2. Gluteus medius3. Gluteus minimus, anterior fibers

vi. Lateral Rotation1. Gemellus superior2. Gemellus inferior3. Obturator internus4. Obturator externus5. Quadratus femoris

b. Kneei. Extend

1. All anterior compartment of thigha. Quadriceps femors

i. Vastus medialisii. Vastus lateralis

iii. Vastus intermediusiv. Rectus femoris

b. Sartoriousii. Flex

1. All posterior compartment of thigha. Hamstring mm.

i. Semitendonosusii. Semimembranosus

iii. Biceps femoris (long head)b. Biceps femoris (short head)c. Sartorius

2. Gracilis

© 2009 Mark Tuttle

3. Popliteus4. Gasrocnemius

c. Anklei. Plantarflex

1. Posterior Superficial compartment of lega. Gastrocnemiusb. Soleusc. Plantaris (only weak participation)

2. Posterior Deep compartment of lega. Flexor hallucis longusb. Flexor digitorum longusc. Tibialis posterior

ii. Dorsiflex 1. Anterior compartment of leg

a. Tibialis Anteriorb. Extensor hallucis longusc. Extensor digitorum longus

2. Peroneus Tertiusiii. Evert

1. Fibularis longus2. Fibularis brevis

iv. Invert1. Tibialis anterior2. Tibialis posterior

- Define the boundaries of the popliteal fossa and describe its contents.a. Boundaries

i. Superior-lateral: Biceps femoris (both heads)ii. Superior-medial: Semimembranosus, semitendonosus

iii. Inferior-lateral: Gastrocnemiusiv. Inferior-medial: Gastrocnemius

b. Contentsi. Popliteal a. + v.

ii. Sciatic n. ends and splits here into:1. Tibial n.2. Common fibular n.

- Describe the relationship of muscles, vessels and nerves as they cross the ankle to enter the foot.

a. Posteriori. Tom Dick ANd Harry (from medial to lateral)

1. Tibialis Posterior m.2. Flexor Digitorum Longus m.3. Posterior Tibial A.4. Posterior Tibial N.5. Flexor Hallicus Longus m.

- Describe the vessels involved in collateral circulation for the hip, knee and ankle.a. Hip

i. Lateral circumflex femoral a. (branch of profunda femoris)ii. Medial circumflex femoral a. (branch of profunda femoris)

© 2009 Mark Tuttle

b. Kneei. Genicular aa.

1. Lateral inferior/superior2. Medial inferior/superior

c. Anklei. Anterior lateral malleolar a.

ii. Anterior medial malleolar a.

© 2009 Mark Tuttle

Development of the Reproductive System – Crissman1. Define/describe:

Urogenital sinus (three portions)

- Vesicle portiona. bladder

- Pelvic portiona. Membranous and prostatic urethra

- Phallic portiona. Penile urethra

Mesonephric duct (Wolffian duct)

- Males: Develops into everything between testis and prostate

- Females: degenerates into Epoopheron (homolog of epididymis)

Paramesonephric duct (Muellerian duct)

- Formed during 6th week- Females: develop into Fallopian tubes, uterus, and the

upper portion of the vagina- Males: degenerate into prostatic utricle

Uterovaginal primordium - Develops from fusion of Mullerian (Paramesonephric) ducts

- Bulge out at sinus tubercle- As duct migrates, drags tissue, vasculature with it,

forming broad ligament- Necessary signals:

a. Absence of testosteroneb. Absence of Mullerian-inhibiting factorc. Wnt-4d. Wnt-7ae. Hoxd 10-13

sinovaginal bulb - Where the fused Mullerian ducts meet the uterus and stimulate proliferation of endoderm

- Canalization moves from posterior to anterior

primary sex cords - Thickening of coelomic epithelium- In 6th week, primordial germ cells get embedded here

Cortical cords (secondary sex cords)

- Germ cells become embedded, remain in outer region- Oogonia undergo mitosis

seminiferous tubule - Formed from gonadal cord

ovarian follicle - Ovary at 2 weeks contains ovarian follicles

tunica albuginea - Forms around invading germinal cells in gonadal cord- In females, forms at the corticomedullary junction of the

fetal ovary

2. Describe the situation (location) of the embryonic gonad as it begins its development. What is the origin of the autonomic innervation and vascular supply of the developing gonad (both blood and lymphatic)?

© 2009 Mark Tuttle

a. Testis formation starts from indifferent gonad in gonadal ridge under the influence of TDF

b. This occurs during the 7th weekc. Initial descent

i. Due to testosteroneii. Cranial suspensory ligament regresses

iii. Mesonephric kidney degeneratesd. Transabdominal descent

i. Testes descend to level of deep inguinal ringii. Insl-3 + testosterone essential

e. Transinguinal descenti. Under influence of testosterone + gubernaculum

ii. Through to superficial ring by 26th weekf. Innervation

i. The nerves of the ovary descend along the ovarian vessels from the ovarian plexus.

ii. It is formed from the aortic, renal, and superior and inferior hypogastric plexuses.

iii. These nerves supply the ovaries, broad ligaments, and uterine tubes.iv. The parasympathetic fibres in the ovarian plexus are derived from the

vagus nerves.3. Describe the origin and migratory path of the primordial germ cells.

a. See #54. Explain the roles of the SRY locus, Testis Determining Factor, androgenic hormones,

Anti-Muellerian Factor (or Muellerian Inhibiting Substance), in development of the reproductive systems.

a. SRY locusi. Results in expression of TDF (testis-determining factor) which is

essential for male gonad developmentb. Anti-Mullerian factor

i. Secreted by fetal Sertoli cellsii. Causes involution of female ducts

5. Describe the migration of coelomic epithelial (mesothelial) cells into the mesenchyme of the gonad to produce the primary sex cords in the testes and the primary and secondary sex cords in the ovary. What ultimately develops from each generation of cords?

a. Germ cells migrate into urogenetal ridge during 5th weekb. Originate from endoderm of yolk sacc. Coelomic epithelium proliferates and forms Primary sex cordd. During 6th week, germ cells are embedded into gonadal cordse. Germ cells proliferate to up to millionsf. LIF, STEEL signal proliferationg. TDF signals testis formationh. All mature male structures develop from primary gonadal cordsi. If TDF is absent, females form cortical cords (Secondary gonadal cord)j. Germinal cells become embedded in outer region, undergo mitosisk. Female mature structures develop from secondary gondal cords

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6. What are the components and origin of each component of the seminiferous tubule, straight tubules, rete testes, efferent ductules, ductus epididymis, ductus deferens?

a. Seminiferous tubule Outer gonadal cordb. Straight tubule, Rete testes Inner portion of gonadal cordc. Epididymis Mesonephric ductd. Efferent ductules, vas deferens Mesonephric duct

7. Describe the formation of the seminal vesicle and the prostate.a. Testosterone is essentialb. Secreted by interstitial cells of Leydigc. Induces distal mesonephric duct to become highly convoluted to form

Epididymis as well as Ductus Deferens, Ejaculatory Ducts & Seminal Vesiclesd. Hox genes play role in transformation

8. What is the origin of the interstitial cells of the testis, theca interna of the ovarian follicle, interstitial gland of the ovary?

a. Leydigi. Mesenchyme differentiates into Interstitial Cells of Leydig that lodge

between the seminiferous tubulesii. Appear about 8th wk

b. Theca internai. Forms as follicle becomes tertiary

c. Interstitial gland of ovaryi. Forms from the theca interna of an atretic follicle. Secretes androgens

to become estrogen9. What is the primary determinant of genotypic (genetic) and phenotypic (morphologic)

sex in humans?a. Genetic: Y chromosomeb. Phenotypic: TDF (testis determining factor)

10. What substance (hormones) does the embryonic testis produce? What does each substance do in the body?

a. Testosterone secreted by fetal Leydig cells, stimulated by human chorionic gonadotropin

b. Mullerian inhibiting substance (MIS) secreted by sertoli cells causes involution of female ducts

c. Meiosis inhibiting factor (MIF) secreted by sertoli cells, slows spermatogenesisi. Essential for sertoli cells to receive Sox-9 for this to happen. Otherwise,

ovary forms11. Why does the testis use a duct system and the ovary does not?

a. Far larger number of sperm are produced, and produced continuously12. Describe the site of formation and the method of formation of the paramesonephric

ducts.a. Formed during 6th weekb. Longitudinal invagination of coelomic mesothelium on surface of urogenital

ridge lateral to the mesonephric ductc. Grows caudally to reach urogenital sinus between entrance of mesonephric

ductsd. Initially doesn’t open into urogenital sinus

13. Describe the path or route of development of the paramesonephric ducts.a. See above

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14. Describe the formation and fate of the a. uterovaginal primordium

i. Two mullerian (paramesonephric) ducts fuse together ot form thisii. Gives rise to both uterus and vagina

b. sinus tuberclei. Bulge into the urogenital sinus from above structure

c. sinovaginal bulbsi. 2 of these form from the proliferation of endoderm at the urogenital

sinus at the point of the sinus tubercle (Mullerian ducts [paramesonephric]) met at this point

d. vaginal platei. Fused sinovaginal bulbs

ii. Canalization of this moves posterior to anterior, forms single vaginae. Hymen

i. Seperates urogenital sinus from the lumen of the vagina 15. Define/describe:

a. labioscrotal swellings (genital swellings)i. Flank the genital folds laterally

ii. Part of the indifferent external genetaliaiii. Indifferent period lasts until 7th week

b. urogenital folds (urethral folds)i. 2 of these surround the clocal membrane

ii. Covered by urogenital sinus endodermiii. Penile urethra formed by fusion of foldsiv. Surface ectoderm covers closure

c. genital tuberclei. develops from the genital eminence

ii. Forms the primordial Phallusd. phallic portion of urogenital sinus

i. Under influence of testosterone, forms penise. cloacal membrane

i. Remains intact until 8th weekf. urogenital membrane

i. Urorectal septum fuses with cloacal membrane at end of 6th weekii. Divides clocal membrane into anterior urogenital membrane, and

posterior anal membraneiii. Occurs during 6th weekiv. Both membranes degenerate the following week

16. Describe the complete formation of the male urethra.a. Urogenital folds enlarge under the influence of testosterone and

dihyrotestosterone to form lateral walls of urethral grooveb. Covered by urogenital sinus endodermc. Grooves fuse posterior to anteriord. Surface ectoderm covers closuree. Urethral seam formsf. Solid plate recanalizes and loses its connection to surface (forms hole)g. Corpus cavernosa/spongiosa develop from mesenchyme

17. Define:

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a. true hermaphroditei. Have barr bodies (sex chromatin positive)

ii. Have both ovarian and testicular tissue that is non-functionaliii. Extremely rareiv. Can be XX, XY, XX/XY mosaic

b. Pseudohermaphroditei. Can be male of female

ii. Female/male determined by sex chromatin barr bodies and genotypeiii. Female pseudo have enlarged clitorisiv. Male pseudo have low testosterone

1. Lack of MIS causes perseverance of female ductsc. What are several causes of pseudohermaphrodism?

i. Female pseudo1. Excessive androgens as in congenital adrenal hyperplasia (CAH)

ii. Male pseudo1. Low levels of testosterone and MIS

18. Define/describe the condition known as testicular feminization. Developmental error?a. Chromatin negativeb. XYc. Female external gentalia, uterus ends in blind pouchd. Have female secondary sex characteristics

i. Estrogen from conversion of androgens produced by adrenal cortex. Conversion occurs in adipose tissue

e. Defect in androgen receptors in genital tubercle, urogenital, labioscrotal folds

f. However, uterus, oviducts missing due to successful secretion of MIS by testis19. Define/describe the condition of hypospadias; epispadias. Developmental error for

each?a. Hypospadia

i. Most common anomaly of penis 1/300ii. Opening of external urethral orifice on ventral surface

iii. Inadequate production of androgensb. Epispadia

i. Same thing but when it occurs down the entire length of penis20. Describe the underlying developmental errors leading to complete or partial

duplication of the uterus and/or vagina.a. Incomplete fusion of Mullerian (paranephric) ducts leads to double uterusb. Incomplete recanalization of sinovaginal plate yields to double vagina

21. Describe the formation of the inguinal canal.a. Inguinal canal forms in both sexes at indifferent stage of development, 7th weekb. Created by gubernaculum

22. Describe the process and path of migration of the testis and ovarya. Testis

i. See #2b. Ovary

i. They descend along the posterior abdominal wall.ii. On reaching the pelvic brim, the ovarian arteries cross over the external

iliac vessels and enter the suspensory ligaments.

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Male Reproductive System – Crissman

1. List the organs and ducts of the male reproductive system.a. Organs

i. Penisii. Testes

b. Ductsi. Straight tubules

ii. Rete testisiii. Efferent ductsiv. Ductus epidydimusv. Ductus deferens

vi. Ejaculatory ductvii. Urethra

2. Describe and integrate the components and their morphology of the testis with the function of the testis.

a. Lined by germinal epithelium contains spermatogenic cellsb. Sertoli cells form the blood-testis barrierc. Straight tubules drain the seminiferous tubules and are lined by simple cuboidal

epitheliumd. Same in rete testise. Effecret ductules goes from rete testis to head of epididymis

i. Cogwheel lumenii. Contains ciliated cells to move immotile sperm

iii. Contains non-ciliated cells to resorb waterf. Epididymis contains Pseudostratified columnar epithelium (transitions to cuboidal

toward tail)i. Tall columnar cells with stereocilia

ii. Stem cells for principle cells (above)iii. Smooth muscle here moves sperm since stereocilia are immotile

g. Ductus deferensi. Stellate lumen

ii. Pseudostratified low columnar epitheliumiii. Thick lamina propriaiv. 3 layer muscularis (long, circular, long)

3. Describe the process of spermatogenesis and indicate how it differs from oogenesis. Distinguish "spermatogenesis" from "spermiogenesis".

a. Spermiogenesis is the transition from spermatids to spermatozoa (last step)b. Spermatogenesis is the whole processc. Spermatogenesis does not get arrested at a certain stage like oogenesis does

4. Describe and identify the adluminal and basal compartments of the seminiferous tubulesa. Adluminal

i. Everything adjacent to lumen of STb. Basal

i. Contains spermatogonia ONLY5. Describe, in detail, the morphology and function of the epithelium in the seminiferous

tubules including the different germ cells and the Sertoli cell. Identify the phases of spermatogenesis.

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a. Spermatogoniai. **Located on basement membrane of tubule (on basal side of blood-testis

barrier)ii. Darker is stem cell

b. Primary spermatocytesi. Most common cell

ii. **See clumped chromosomesiii. Diploid

c. Secondary spermatocytesi. Haploid

d. Spermatidi. **round, solid, dark chromatin pattern

e. Spermatozoai. **head & long tail

ii. Still embedded in cell but near lumen of STf. Sertoli cells

i. Provide physical/nutritional support for developing spermii. Joined by tight junctions

iii. Tall columnariv. Rest on basement membrane and reach lumen of STv. Produce large volumes of testicular fluid to wash immobile spermatozoa out

of tubulevi. Phagocytose excess cytoplasm from spermatids

6. Explain what is meant by the "cycle of seminiferous epithelium".a. Cross-section of a tubule showing the proliferation that is occurringb. Waves are looking down the length of the tubule

7. Describe and integrate the hormonal secretions that control the development and maintenance of the normal male reproductive system.

a. Anterior pituitaryi. FSH

1. Targets sertoli cells to produce Androgen Binding Protein (ABP) which targets testosterone to make it persist

2. Inhibin is produced by sertoli cells and feedsback on the anterior pituitary to reduce release of FSH

ii. LH1. Targets Leydig cells to produce more testosterone2. Testosterone feedsback and inhibits Leydigs

8. Describe the specific epithelial lining of the tubuli recti, rete testis, efferent ductules, epididymis, ductus deferens and ejaculatory duct. Identify examples of each and be able to integrate their morphology with their function.

a. See #29. Describe and integrate the morphology and function of the seminal vesicles, prostate and

bulbourethral glands. Be able to list characteristics necessary to distinguish one from the other. Explain the clinical significance of the mucosal glands, submucosal and main glands of the prostate.

a. Seminal vesiclei. **numerous cavities of varying sizes – honeycomb

ii. Low pseudostratified columnar (like proximal efferent ductules)

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iii. Testosterone-dependentiv. Makes up 70% of ejaculate

b. Prostatei. Mucosal glands

1. Drain directly into urethra2. Located directly proximal to urethra3. Undergo hypertrophy in BPH

ii. Submucosal glands1. Drain into prostatic sinus

iii. Main glands1. Most peripherally located2. Makes up most of gland3. Most prostatic cancer arises here

c. Bulbourethral glands (Cowper’s glands)i. Simple cuboidal epithelium that secretes viscous mucus

d. Glands of Littrei. Mucus-secreting glands along the penile urethra

10. Describe the morphology of the penis including the fascial layers, erectile tissue, blood vessels, as well as, the site and epithelial lining of the penile urethra. Be able to relate and integrate the morphological components of the penis in the flaccid and erect condition.

a. Unnecessary – know this well11. Be able to trace the normal pathway of sperm secretion. Be able to describe the

morphology of the pathway and how it relates to the specific function of each part.a. Seminiferous tubulesb. Straight tubulesc. Rete testisd. Efferent ductulese. Epididymis (head)f. Vas deferensg. Ejaculatory duct (meet with secretions of seminal vesicle)h. Prostatic urethra (meet with secretions of prostate)

12. Describe the process of ejaculation and integrate it with the function of the various male reproductive components.

a. Bulbourethrali. Part of pre-ejaculate to help neutralize acidity and clean out penile urethra

b. Prostatei. Lipids

ii. Proteolytic enzymesiii. Citric acidiv. Acid phosphatasev. pH near 7 (raises pH of vagina)

c. Seminal vesiclei. Fructose

tunica albuginea (testis & penis)

- Dense CT covering covers entire testis- Surrounds each erectile body in penis

tunica vaginalis - Covers tunica albuginea everywhere except when in contact with

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epididymis and where vessels enter

mediastium testis - CT which supports the rete testis

germinal epithelium - In males, the epithelium lining the STs with the range of sperm development and sertoli (support) cells

androgen-binding protein

- Sertoli cells secrete this in response to FSH from the anterior pituitary.

- Helps testosterone persist thereby raising the circulating level of testosterone, aiding in spermatogenesis

Spermatogonia - The first stage of sperm development- Diagnostic on the basement membrane, outside of the blood-

testes barrier

primary & secondary spermatocytes

- Primary spermatocytes are diploid and display clumped chromosomes

- Secondary spermatocytes are haploid and are hard to distinguish

Spermatids - Round, solid dark chromatin pattern- Don’t have flagella yet

Spermatozoa - Have flagella now

seminal colliculus - In the fore part of the urethral crest, containingo Ejaculatory ductso Prostatic ductso Prostatic utricle

Cowper’s glands - AKA bulbourethral glands- Component of pre-ejaculate that helps clean out the urethra

Utricle - AKA vagina masculine- Remnant of Mullarian duct (Paramesonephric duct)

pampiniform plexus - Plexus of veins which help cool the blood going to the testicle to maintain it at an optimal temperature. Work by cooling the adjacent arterial blood.

blood testis barrier - Formed by Sertoli cells

Leydig cells - AKA interstitial cells- Foamy appearance because of secreting steroid testosterone

Vasectomy - Cutting the vas

prostatic hypertrophy - Benign hypertrophy occurs in the middle lobe

prostatic concretions - Diagnostic for an older prostate- Composed of layered bodies, red staining

Impotence - Unable to achieve errection

Sterile - Less than 20 million sperm/ml- Normal is 66-100 million sperm/ml

Ejaculation 1. Bulbourethral, prostatic secretions2. Emission – seminal vesicle contracts3. Bulbospongiousus muscle contracts

© 2009 Mark Tuttle

Foot – Morse1. Demonstrate the relationship of extrinsic foot muscles to nerves and vessels of the

foot.a. Dorsum

i. Extensor Hallucis Longus tendon1. Deep fibular n. innervates the skin between toes 1 & 22. Anterior tibial a.

b. Plantari. Flexor digitorum longus tendon

1. Tibial n.2. Posterior tibial a. (entire plantar foot)

a. Lateral plantar a.b. Medial plantar a.

c. Notable absencesi. Fibular a. doesn’t do shit in the foot

2. Understand the function of intrinsic foot muscles.Adductor hallucis (oblique head)Adductor hallucis (transverse head)

Keep the toes from splaying

Abductor digiti minimi m. ABduct 5th toe

Abductor hallucis m. ABduct 1st toe

Flexor hallucis brevis m. Flex 1st toe

Quadratus plantae m. Redirect pull of Flexor hallucis longus to just flex toes, not invert

Lumbrical mm. Flex metatarsalsExtend intermetatarsal joints

Dorsal interosseous mm. ABduction

Plantar interosseous mm. ADduction

3. Define the arches of the foot and understand how each is maintained.a. Lateral longitudinal arch

i. Less prominent than medialii. Deltoid ligament (Medial collateral ligament)

1. Tibiocalcaneal lig.2. Anterior tibiotalar lig.3. Posterior tibiotalar lig.4. Tibionavicular lig.

b. Medial longitudinal archi. Components: calcaneus, the talus, the navicular, the three cuneiforms,

and the first, second, and third metatarsalsii. Lateral Collateral

1. Posterior talofibular lig.2. Calcaneofibular lig.3. Anterior talofibular lig.

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c. Transverse archi. Adductor halucis (transverse & oblique heads) prevents toes from

splayingd. Factors in arch strength

i. Intrinsic muscle strength Tie beam (spreads weight)ii. Extrinsic muscle strength Suspension cable

iii. Ligament strength Staplesiv. Talus strength Keystone

4. Define the role of the plantar aponeurosis.a. Helps maintain integrity of the arch of the footb. Acts as a tie beamc. Tear of this leads to plantar fasciitisd. Divides the sole of the foot into lateral, intermediate, and medial compartments

5. Understand the communication of dorsal and plantar arteries of the foot.a. The dorsal a. of the foot gives off a deep plantar a. which dives deep to the sole

between the 1st and 2nd toesb. Deep plantar a. supplies the dep plantar arch

6. Identify the retinacula of the ankle region.a. Superior Extensor retinaculum

i. Extensor digitorum longusii. Extensor hallucis longus

iii. Fibularus tertiusiv. Tibialis anterior v. Anterior tibial a. + v.

vi. Deep Fibular n.b. Inferior extensor retinaculumc. Flexor retinaculumd. Fibular retinaculum

i. Covers fibularis longus and brevis as they come into the footii. Brevis stops and attaches the the tuberosity of the 5th digit

7. Describe the sensory innervation for the foot.a. Dorsum

i. Superior fibular n.ii. Deep fibular n.

b. Plantai. Medial plantar n. (Tibial n.)

ii. Lateral plantar n. (Tibial n.)c. Lateral

i. Sural n. (Follows short saphenous v.)d. Medial

i. Saphenous n. (Follows long saphenous v.)

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Joints of the Lower Limb1. Identify the major extra and intracapsular ligaments for the hip, knee and ankle.

a. Hipi. Intracapsular

1. Ligament of head of femur (Fovea)a. A. of head of femur (Obturator a.) runs here

ii. Extracapsular1. Iliofemoral lig. (Y-ligament)2. Ischiofemoral lig.3. Pubofemoral lig.

b. Kneei. Intracapsular

1. Patellar lig.2. Tibial (medial) collateral lig. (MCL)3. Fibular (lateral) collateral lig.

a. Intrinsic only b/c it is intimate with the capsule at the superior portion. Popliteus tendon is deep to it at lower portion

4. Oblique politeal lig.5. Arcuate popliteal lig.6. Anterior cruciate ligament (ACL)7. Posterior cruciate ligament (PCL)8. Lateral meniscus9. Medial meniscus10. Transverse ligament of knee

ii. Extracapsularc. Ankle

i. Deltoid ligament (medial)1. Anterior tibiotalar lig.2. Posterior tibiotalar lig.3. Tibiocalcaneal lig.4. Tibionavicular lig.

ii. Lateral collateral ligament1. Anterior fibulotalar lig.2. Posterior fibulotalar lig.3. Fibulocalcaneal lig.

2. Explain the movements possible in each major joint of the lower limb.a. Hip

i. Flexionii. Extension

iii. ABductioniv. Adduction

b. Kneei. Flexion

ii. Extensionc. Ankle

i. Dorsiflexionii. Plantarflexion

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iii. Inversioniv. Eversion

3. Explain the position of each major joint of the lower limb when it is most vulnerable to injury.

a. Hipi. ?????????????????//

b. Kneei. Locked in full extension

c. Footi. Plantarflexed

4. Demonstrate the simple clinical tests to determine integrity of the support structures for the knee joint.

a. Drawer testi. Determine if PCL or ACL are injured by pushing leg anteriorly or

posteriorly. Should not move at all, if it does, there is a tear in the ligament