1.
2.
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Far Eastern University – Nicanor Reyes Medical Foundation
GROSS HSB – B: POSTERIOR ABDOMINAL WALL II – August 3,
2020 Dr. James Bañez + Dr. Norman Valera PPT (but the
laboratory session was facilitated by Dr. Virginia Braga)
Objectives
Study retroperitoneal organs in the abdominal cavity proper
•
Kidney
•
Ureter
•
Adrenal gland
Study the respiratory diaphragm
RETROPERITONEAL SPACE & ASSOCIATED ORGANS
Lies on the posterior to the peritoneum wall behind the parietal
peritoneum
has peritoneum on their anterior side only
Note: Easy way to remember which abdominopelvic organs are
retroperitoneal is through the mnemonic, SAD F/PUCKR
PRIMARY (not GIT)
SECONDARY (GIT)
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Suprarenal Glands
• 2nd – 4th part of Duodenum
•
Aorta
• Pancreas
•
Fallopian Tube
• Colon (Ascending &
Descending)
•
Ureter, Urinary bladder,
Uterus
• Rectum (Middle)
•
Kidneys
Take note of the following:
•
Suprarenal glands
o
R – pyramidal shape
o
L – semilunar
FROM SNELL & VALERA PPT (MORE SUGGESTED TO USE THIS ONE)
RIGHT KIDNEY
LEFT KIDNEY
ANTERIOR
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Suprarenal gland
• Suprarenal gland
•
Liver
• Spleen
•
Second part of the
• Stomach
duodenum
• Pancreas
•
Right colic flexure
• Left colic flexure
• Coils of jejunum
POSTERIOR
•
Diaphragm
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Costodiaphragmatic recess of the pleura
•
12th rib (R & L kidney); 11th rib (L kidney)
•
Muscles: Psoas, Quadratus lumborum, and Transversus
abdominis
•
Nerves: Subcostal (T12), Iliohypogastric, and Ilioinguinal
nerves (L1) run downward and laterally
•
•
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KIDNEYS
Functions:
•
Eliminate water soluble waste products in
the metabolism thru URINE (primary
function)
o
Nitrogenous wastes
o
Toxins
o
Drugs
•
Maintains normal body fluid and
electrolyte
•
Acts as an endocrine = secrete hormones.
•
Hematopoeisis function
•
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LOCATION
In supine position, the kidneys extend from the 12th thoracic to the
3rd lumbar vertebra (T12-L3).
o
Upper poles: at level of T12
o
Renal hilum: at level of L1 (transpyloric plane)
o
Lower pole at level of L3
The upper pole of right kidney being slightly lower than the left due
to the right lobe of the liver.
o
Clinical variation of R & L kidney: 1 vertebra lower
The kidney is a primary retro-peritoneal organ lying in the diaphragm
and 3 posterior abdominal wall masses.
IMPORTANT RELATIONS (just pick kung ano mas prefer niyo)
FROM DOC’S PPT
RIGHT KIDNEY
LEFT KIDNEY
ANTERIOR
• Right Lobe of the Liver
• Stomach
• Gallbladder
• Spleen
• Hepatic Flexure/Right
• Tail of Pancreas
Colic Flexure of the Colon
• Distal part of
• Partly of the Jejunum
Transverse Colon
POSTERIOR
• Superior 1/3 of the kidney: (green)
o
Respiratory Diaphragm
o
Lower Ribs
• Inferior 2/3 of the kidney:
o
Psoas Major muscle - most medial (violet)
o
Quadratus Lumborum (yellow)
o
Aponeurosis of transversus abdominis – most
lateral surface (orange)
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•
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DESCRIPTION
The kidney is reddish-brown in color and is soft in consistency.
11 cm in length, 6 cm wide and 3 cm in thickness at the middle
o
10 cm, 5cm , 2.5 cm (Moore’s)
o
12 cm, 6cm, 3 cm (Netter’s)
Bean-shaped, with upper and lower poles, anterior and posterior
surfaces, concave medial and convex lateral borders.
Approx. 20% of the blood pumped by the heart passes to the kidney
COMPOSITION
Hilum – vertical slit on the medial border;
through it, the branches of the renal artery
enter the gland, and the veins and the
ureter leave.
o
Renal vein (most anterior) white
arrow
o
Renal artery – yellow arrow
o
Renal pelvis (most posterior) – green arrow
Sinus – space within the hilum of the kidney.
Yellow - Renal pelvis;
Blue – Tributaries of renal veins – most medial surface
Green – branches of renal artery
Other associated structure found in sinus: Renal calyces, lymph
vessels, nerves & fat.
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INVESTMENT OF KIDNEYS
Renal capsule a. k. a. Fibrous capsule / True capsule
Fits the kidney tightly but is not bound to it.
Basically, surrounds the kidney and is closely applied to its
outer surface (Snell, 9th edition); easily stripped off
Perirenal fat a.k.a Adipose capsule
Forms the fatty capsule of the kidney, running completely
around it, passing medially into the hilum and insinuates itself
between renal vessels
It covers the fibrous capsule (Snell, 9th edition)
Provides additional protection to the kidney
Helps keeps the kidney in its correct location
Renal fascia a. k. a. Gerota’s fascia – red
Condensation of connective tissue that lies outside the
perirenal fat (Snell, 9th edition)
Formed by transversalis fascia (endo-abdominal fascia) which
splits at the lateral border of the kidney enclosing the kidney
with its anterior and posterior layer.
It also encloses the suprarenal gland
Pararenal fat a. k. a. Retrorenal fat – blue
Lies external to the renal fascia and is often in large quantity.
(Snell, 9th edition)
Lies behind the kidney, located between aponeurosis of origin
of the transverses abdominis muscle and posterior layer of
renal fascia.
[Refer to the green area] L to R: sinuses, renal cortex, renal medulla
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[PICTURES ABOVE] RED – renal fascia fat ; BLUE – pararenal fat fat; GREEN
– perirenal fat
[PICTURE ON THE LEFT]
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RED – Renal cortex
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WHITE – Minor calyx
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YELLOW – renal papilla
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BLUE – Renal medulla
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BLACK – Major calyx
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GREEN – Columns of Bertini
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VIOLET – Renal pelvis
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LIGHT BLUE – Ureter
[NICE TO KNOW] Factors maintaining kidneys in position: renal fascia, renal
pedicle – consist of structure at the hilum: renal vessels, ureters, nerves
(Parbs MD2021 Trans)
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GROSS STRUCTURE
Convex anterior and relatively flat posterior surface
o
Again, medial concave margin called hilum leading to a cavity
the renal sinus
Renal parenchyma consist of:
o
Renal Cortex – pale staining
o
Renal Medulla
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RENAL CORTEX
contains mainly the renal corpuscle (nephrons) and the convoluted
portions of the light renal tubules
forms a continuous broad band of tissue on the periphery of kidney
beneath the capsule
rather pale, dense and homogenous macroscopically
projects between renal pyramids towards the renal sinus, the renal
columns (Bertini)
o
Renal columns of Bertini – extensions of the cortex into the
medulla between adjacent pyramids
o
Medullary rays – striations of the cortex extending from the
base of the renal pyramids
o
Cortex cortices – subscapular zone of the cortex containing
cortical nephron
o
Cortical arches – portion of the cortex between the base of the
pyramids and the cortex which contains juxtoglomerular
nephron
RENAL MEDULLA
Made up of renal tubules and there are nipple like apices point into
the renal sinus called RENAL PAPILLAE (yellow)
o
At the summit of each papillae are openings, the papillary
ducts that drains urine into the MINOR CALYX (green).
o
Has a perforation called CrIbosa
Discontinuous line to the renal columns: the individual portion of the
medulla between them are the RENAL PYRAMIDS.
o
The renal pyramids are striated conical masses varying in
number from 8 - 18 and have their bases directed toward the
cortex or circumference of the kidney.
EXCRETORY DUCTS OF THE KIDNEY
RENAL PELVIS
Union of the major calyces
Occupying the renal sinus and represents the upper expanded end of
the ureter
Funnel-shaped structure, extending into the hilum
Lined by fibrous membrane continuous with the true capsule and
fibrous coats of the vessels and collecting system
MAJOR CALYX
2 or 3 of minor calyces unite
Super, middle, inferior
MINOR CALYX
From 4-14 in number
Cup-shaped tubes, each of which embraces one or 2 or more of the
renal papillae
2
Take note of the following:
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Infundibula – intermediate of minor calyx & major calyx; stalk
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URETERO-PELVIC JUNCTION
The junction between pelvis and ureter is located approximately
opposite the level of the lower pole of the kidney.
Purpose is physiological narrowing of the urinary tract.
RETROGERADE PYELOGRAM
Usually done by urologist by inserting a cystoscope to the urethra and
in the urinary bladder you will look for the ureteral orifice.
The urologist uses a water-soluble contrast material in order to
produce a picture of the renal pelvis and calyxes within the renal
sinus.
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NEUROVASCULAR & LYMPATHICS
Right renal artery is longer than the left; because the abdominal
aorta is closer to the left kidney
o
Right renal artery passes posterior to the inferior vena cava
(IVC)
Right renal vein is shorter than the left; because it is closer to the IVC
Left renal vein crosses the abdominal aorta anteriorly.
o
Receives veins both from the adrenal gland and gonadal vein.
Renal pelvis is generally infero-posterior to the vessels.
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(2) Lobar arteries arise from each segmental artery, 1 for each renal
pyramid
o
Gives off into 2 or 3 interlobar arteries before entering the
renal substance
(3) Interlobar arteries ascend between the pyramids and renal
columns (no branches to the renal parenchyma).
o
Give off the arcuate arteries at the junction of the cortex and
the medulla.
(4) Arcuate arteries located at the corticomedullary junction; arch
over the bases of the pyramid.
(5) Interlobular arteries lie between medullary rays; a. k. a cortical
radial arteries.
(6) afferent glomerular arterioles going to the renal glomeruli.
RENAL ARTERY
Branch of the Abdominal aorta
Branches into the anterior and posterior segmental arteries (1)
o
The anterior segmental artery further divides into 5 that enter
the hilum of the kidney:

Superior (apical)

Anterior superior (upper)

Anterior inferior (middle)

Inferior (lower)

Posterior
o
These 5 segmental branches are responsible for dividing the
kidney into segments.
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RENAL VEIN
Tributary of the Inferior Vena Cava.
Emerges from the hilum in front of the renal artery and drains into
the IVC.
LYMPH DRAINAGE
Towards the lateral aortic lymph nodes around the origin of the renal
artery
Left side: para-aortic lymph node
Right side: inter-aortocaval & paracaval lymph nodes
NERVE SUPPLY
From renal sympathetic plexus distributed along branches of renal
vessels.
Afferent fibers travel thru renal plexus and enter spinal cord in 10th –
12th thoracic spinal nerves.
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URETER
Completely retroperitoneal but adheres closely to the parietal
peritoneum
Expansile muscular tubes that extend from the kidneys to the
posterior surface of the urinary bladder; whitish in color
o
Propels urine by peristaltic contractions of the muscle coat,
assisted by the filtration pressure of the glomeruli
About 10 inches in length (Male)
Emerges from the hilum of the kidney and runs vertically downward
behind the parietal peritoneum (adherent to it) on the psoas muscle
o
Psoas muscle separates ureters from the tips of transverse
processes of the lumbar vertebrae
Passing over the pelvic brim at the crossing the bifurcation of the
common iliac artery in front of the sacroiliac joint
Runs down the lateral wall of the pelvis to the region of the ischial
spine and turns forward to enter the lateral angle of the bladder with
no valves or sphincters (IN SHORT, enters the bladder obliquely with
no valve at the point of entrance)
With abdominal, pelvic, and intramural parts
ABDOMINAL
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PELVIC
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RIGHT URETER
Right side of the IVC
Covered by the 2nd
part of duodenum
Vessels that crosses
in front are:
o
Right colic
artery (blue)
o
Gonadal
artery
(yellow)
o
Superior
mesenteric
artery (white)
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LEFT URETER
Lateral and beside
the inferior
mesenteric vein
Vessels that
crosses are:
o
Gonadal
vessels
(white)
o
Left colic
artery
(yellow)
o
Sigmoid
artery (blue)
Picture above: pelvic part of R & L ureter
Pelvic Ureter in females (white arrow)
It crosses the external iliac artery, passes along the internal iliac
artery and passes inferior to the fallopian tube, ovary and round
ligament.
The ureter crosses the external iliac artery that accompanies the
internal iliac artery beneath the broad ligament.
It is beside the cardinal ligament and the uterine artery and passes
beneath the ovary, fallopian tube and reaches the urinary bladder at
the base of that border.
Picture below shows the relation of the pelvic female ureter, the
internal genitalia that it passes under the ovary, fallopian tube
beneath the broad ligament.
Both R & L ureter crosses the external iliac artery
and accompanies the internal iliac artery
beneath the peritoneum
In MALES: Touches the base of the urinary
bladder passing beneath the vas deferents (Pink
arrow – refer to next page) in males.
Note for Left Ureter:
Its pelvis is more exposed than the right, and covered only by
peritoneum below the renal vessels
Left picture: abdominal part of R ureter
Right picture: abdominal part of L ureter
Two pictures above: female ureter
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RELATIONS
ANTERIORLY
POSTERIORLY
RIGHT URETER
Duodenum
Ileum (terminal part)
R colic and Ileocolic
vessels
R testicular/ovarian
vessels
Root of mesentery of
small intestine
R psoas muscle
Bifurcation of (R)
common iliac artery
LEFT URETER
Sigmoid colon
Sigmoid mesocolon
(L) colic vessels
(L) testicular/ovarian
vessels
(L) psoas muscle
Bifurcation of (L)
common iliac artery
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PHYSIOLOGIC CONSTRICTIONS
Physiologic narrowing of the ureter where stones (calculi) can be
arrested causing obstruction:
o
Uteropelvic junction – at the junction where renal pelvis joins
the ureter
o
At the brim of the pelvic whre the ureter crosses the common
iliac artery.
o
Uterovesical junction – where it pierces the bladder wall;
lowermost, at the junction of ureter with urinary bladder
Obstruction are more common to female.
These three constrictions are richly supplied by nerves = patient
commonly present with pain; has high pain sensation that makes
clinically & easily locate the stones.
Venous – correspond to the arteries
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LYMPH DRAINAGE
The lymph drains to the lateral aortic nodes and the iliac nodes.
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NERVE SUPPLY
Renal
Testicular/ovararian
Hypogastric plexus (in the pelvis)
Derived from the adjacent autonomic plexuses which contain pain fibers.
Afferent fibers travel with the sympathetic nerves and enter the spinal cord
in the 1st and 2nd lumbar segments.
SUPRARENAL GLAND (Adrenal Gland)
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NEUROVASCULATURE & LYMPHATICS
BLOOD SUPPLY
ABDOMINAL part
Renal artery – supplies upper end
Gonadal artery
Colic artery
PELVIC
Arterial
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Renal: supplies the upper end
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Testicular/ovarian – supplies the
middle portion
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Superior vesical artery – supplies
part in the pelvis
Inferior mesenteric vein
– at medial side
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Vesical artery
Middle vesical artery
LOCATION, DESCRIPTION, COMPOSITION & STRUCTURE
Yellowish retroperitoneal organs that lie on the upper poles of the
kidneys.
Surrounded by renal fascia but separated from kidneys by the
perirenal fat.
Composition:
o
Outer yellow CORTEX – secretes steroid hormones.

Mineralocorticoids (mainly aldosterone – salt steroid) –
from the zona glomerulosa
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Concerned with the control of fluid and
electrolyte balance.

Glycocorticoids (sugar steroids) – from the zona
fasciculata
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Concerned with the control of the metabolism of
CHO, fats, & CHON.

Sex hormones – from the zona reticularis
•
Play a role in prepubertal development of sex
organs.
o
Inner dark-brown MEDULLA – secretes catecholamines:
epinephrine & norepinephrine.
5
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Gross Structure:
RIGHT SUPRARENAL GLAND
PYRAMID SHAPED
Caps upper pole of the right
kidney
Lies behind the right lobe of
the liver
Extends medially behind the
IVC
Rest posteriorly on the
diaphragm
LEFT SUPRARENAL GLAND
CRESENTRIC / SEMILUNAR
SHAPE
Extends along the medial
border of the left kidney
from the upper pole to
the hilus
Lies behind the pancreas,
the lesser sac, and the
stomach
Rest posteriorly on the
diaphragm
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NEUROVASCULATURE & LYMPHATICS
MUSCLES
PSOAS MAJOR
QUADRATUS
LUMBORUM
ILIACUS
PSOAS MINOR
RIGHT ADRENAL GLAND
LEFT ADRENAL GLAND
RED – Superior adrenal artery Black – middle adrenal artery
GREEN – Inferior adrenal artery VIOLET – renal vein
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ARTERIES
Superior suprarenal artery
from the inferior phrenic
artery
Middle suprarenal artery
from the abdominal aorta
Inferior suprarenal artery
from the renal artery
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VEINS
Suprarenal vein merges
from the hilum of each
gland and drains into the
IVC (on the right) and
renal vein (on the left).
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ORIGIN
Transverse
processes of
the lumbar
vertebrae;
sides of
bodies of T1L5
Inferior
border of the
12th rib; tip of
lumbar
transverse
process
INSERTION
Lesser
trochanter
of femur
INNERVATION
L2-L4
ACTION
Flexes
the
vertebral
colum
Iliolumbar
ligament;
iliac crest
Ventral
branches of
T12 & L1-L4
Superior 2/3
of iliac fossa;
ala of sacrum;
sacroiliac
ligament
Bodies and
intervertebral
disc of T12-L1
Lesser
trochanter
of femur
Femoral nerve
(L2-L4)
Pectineal
line;
iliopectineal
eminence
L1
Extends
and
laterally
flexes
the
vertebral
column
Flexes
thigh
and
stabilizes
hip joint
Aids in
flexing
the trunk
RESPIRATORY DIAPHRAM
Primary muscle of respiration and being controlled by the
respiratory centers in the brain: medulla oblongata and the pons.
o
But as a skeletal muscle, we can also control it if we like.
The nerve that controls the diaphragm is the phrenic nerve, a branch
of the cervical plexus.
Dome-shaped musculofibrous septum which separates the thoracic
cavity from abdominal cavity
Peripheral part consists of muscular fibers which take origin from the
circumference of the thoracic outlet.
Central portion is the central tendon to which the muscular portion
ends.
ORIGINS
Lymphatic Drainage – lateral aortic nodes
Nerve Supply – preganglionic sympathetic nerve fibers derived from the
splanchnic nerve supply of the glands (mostly in the medulla).
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POSTERIOR ABDOMINAL WALL
Psoas Major & Minor
Quadratus lumborum
Iliacus
Transversus abdominis
Oblique muscles
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Sternal part (Xyphoid)
o
Arises by 2 fleshy slips from the back of the xiphoid process
o
It has short fibers, occasionally aponeurotic.
Costal part (Cartilages of lower 6 ribs)
o
Arises from the inner surface of the costal cartilages of lower
6 ribs on either side, interdigitating with the transverse
abdominis.
Lumbar part (Crura)
o
Arises from the aponeurotic arches, and from the lumbar
vertebrae by 2 pillars of crura.
o
Lumbo-costal arch:

Medial lumbo-costal arch a. k. a. Internal Arcuate
Ligament
•
A tendinous arch in the fascia covering the upper
part of the psoas major muscle
•
Medial attachment is body of the 1st or 2nd
lumbar vertebra, laterally it is attached and fixed
to the front of the transverse process of the 1st
or 2nd lumbar vertebra

Lateral lumbo-costal arch a. k. a. External Arcuate
Ligament
•
Arches across the upper part of the quadratus
lumborum muscle
•
Attached medially to the front of the transverse
process of the 1st lumbar vertebra
•
Attached laterally to the tip of the lower margin
of the 12th rib
6
o
Crura – tendinous at the origin, blending with the anterior
longitudinal ligament of the vertebral column

Right crus
•
Larger and longer than the left
•
Arises from the anterior surface of the bodies and
the intervertebral discs of the upper 3 lumbar
vertebra
•
The medial fibers ascend on the left side of the
esophageal hiatus

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•
Left crus
•
Arises form anterior surfaces of the bodies and
the intervertebral discs of the upper 2 lumbar
vertebrae
•
Occasionally, a fasciculus crosses the aorta,
running obliquely across through the fibers of the
right crus toward the caval foramen.
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•
1.
ACTION OF DIAPHRAGM
draws the central tendon downward causing:
o
Increase in volume but decrease in intrathoracic pressure
o
Decrease in volume but increase in intraabdominal pressure
Phrenic nerve
NERVE SUPPLY
CLINICAL CORRELATIONS
Kidney or ureteric calculi
Stones usually composed of calcium oxalate or phosphate
and/or uric acid
Calcium containing stones are radio opaque while those
composed of uric acid are radio translucent.
Ureterolithiasis: Stone in the ureteropelvic junction resulting
dilatation of the renal pelvis and calyces
Refer to the picture below:
INSERTIONS
CENTRAL TENDON
Insertion of the muscular fibers.
Thin but strong aponeurosis situated near the center of the vault
formed by the muscular fibers
Consists of 3 leaflets, the right, middle, and the left, separated from
one another by slight indentations.
OPENING OF DIAPHRAGM
MNEMONICS: “I ATE(8) TEN(10) EGGS AT TWELVE(12) = I8 E10 A12”
[REFER TO THE PICTURE BELOW]
•
Aortic hiatus – black arrow
The lowest and most posterior
Lies at the level of T12 verterba
Aponeurotic opening between the diaphragm and the vertebral
column, so it lies behind the diaphragm
Situated slightly to the left of the aortic hiatus
Structures transmitted are:
o
Aorta
o
Azygous vein
o
Thoracic duct
•
Esophageal hiatus – green arrow
situated in the muscular part at the level of T10 vertebra
elliptical in shape
situated above and to the left of the aortic hiatus
Structures transmitted are:
o
Esophagus
o
Vagus nerve
o
Some small esophageal vessels
•
Vena cava foramen – blue arrow
Highest of the three
Situated above the level of T8 vertebra
Quadrilateral in form
Place in junction of the right & middle leaflets of the central
region
Structures transmitted are:
o
Inferior vena cava
o
Some branches of the right phrenic nerve
2.
Intravenous urography (pyelography)
Imaging procedure used to study the kidneys, ureters and
urinary bladder wherein a radio opaque contrast medium is
injected intravenously and exrcreted by the kidney, creating
the image of the calyces up to urinary bladder
Refer to the picture below:
3.
Retrograde Urogaphy (pyelography)
Procedure with the same purpose as number 2 wherein they
infuse a water soluble material/ contrast medium through a
catheter inserted by means of a cystoscope into uretral
orifice in the urinary bladder.
After identifying the ureteral stone a basket can be inserted
into the ureter and can extract the stone
Refer to the picture below:
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4.
Lithotripsy
Extracorporeal Shock Wave Lithotripsy (ESWL)
Procedure that uses sound waves to pulverize ureteric stones
painlessly making surgical intervention unnecessary
Refer to the picture below:
5.
Pheochromocytoma
Tumor derived from cells of adrenal medulla and
characterized by the secretion of catecholamines, resulting in
hypertension which may be paroxysmal.
Refer to the picture below:
6.
Cushing’s Syndrome
Adrenocortical tumor resulting from increased secretion of
cortisol characterized by centripetal obesity, moon facie,
hypertension, etc.
Refer to the picture below:
7.
Addison’s Disease
Chronic adrenocortical insufficiency
8.
Bochdalek’s Hernia
Dorsolateral hernia associated with a developmental defect
in the pleuroperitoneal membrane
9.
Hiatal Hernia
Part of the stomach through the esophageal hiatus of the
diaphragm
Refer to the picture below:
Sources:
1. Uploaded files in Moodle (Word + Slides)
2. Transes (JuanMD, Mermaid, & Parbs2021)
3. Dr. Banez’s Lecture, Dr. Braga’s laboratory discussion using Dr.
Valera’s PPT
4. Books: Snell & Moore’s
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