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Arch of aortaMitral valveLeft auricleABPulmonary arteriesPulmonary veinsValve of foramen ovaleLeft ventricleLeft atriumAscending aortaRight ventricleRight pulmonary veinLeft atriumEsophagusThoracic aortaLeft pulmonary vein Fig. 3.74 Internal view of the left ventricle. Arch of aortaCoronary sinusMitral valve posterior ...
Left vagus nerveRight vagus nerveVagal cardiac branchesVagal cardiac branchesCardiac nerves fromsympathetic trunkSuperior vena cavaArch of aortaSuperficial cardiac plexusPulmonary trunkLeft recurrent laryngeal nerveRight recurrent laryngeal nerveLeft vagus nerveRight vagus nerveCardiac nerves from sympathetic trunkDeep...
Left recurrent laryngeal nerveLeft vagus nerveRight mainbronchusTIV/VvertebrallevelLeft main bronchusLigamentum arteriosumLeft pulmonary arteryLeft subclavian arteryPulmonary trunkEsophagusEsophagusTracheaThoracic aortaArch of aorta Fig. 3.97 Esophagus. Right main bronchusLeft main bronchusLeft subclavian arteryLeft co...
Fig. 3.109 Anterior view of the chest wall of a man showing skeletal structures and the surface projection of the heart. Fig. 3.110 Anterior view of the chest wall of a man showing skeletal structures, heart, location of the heart valves, and auscultation points. Fig. 3.111 Views of the chest wall showing the surface p...
Table 3.1 Muscles of the pectoral region Table 3.2 Muscles of the thoracic wall Table 3.3 Branches of the thoracic aorta In the clinic Axillary tail of breast It is important for clinicians to remember when evaluating the breast for pathology that the upper lateral region of the breast can project around the lateral ma...
Clinically, “thoracic outlet syndrome” is used to describe symptoms resulting from abnormal compression of the brachial plexus of nerves as it passes over the first rib and through the axillary inlet into the upper limb. The anterior ramus of T1 passes superiorly out of the superior thoracic aperture to join and become...
Insertion of a chest tube is a commonly performed procedure and is indicated to relieve air or fluid trapped in the thorax between the lung and the chest wall (pleural cavity). This procedure is done for pneumothorax, hemothorax, hemopneumothorax, malignant pleural effusion empyema, hydrothorax, and chylothorax, and al...
A pleural effusion occurs when excess fluid accumulates within the pleural space. As the fluid accumulates within the pleural space the underlying lung is compromised and may collapse as the volume of fluid increases. Once a pleural effusion has been diagnosed, fluid often will be aspirated to determine the cause, whic...
If a small malignant nodule is found within the lung, it can sometimes be excised and the prognosis is excellent. Unfortunately, many patients present with a tumor mass that has invaded structures in the mediastinum or the pleurae or has metastasized. The tumor may then be inoperable and is treated with radiotherapy an...
Mitral valve disease is usually a mixed pattern of stenosis and incompetence, one of which usually predominates. Both stenosis and incompetence lead to a poorly functioning valve and subsequent heart changes, which include: left ventricular hypertrophy (this is appreciably less marked in patients with mitral stenosis);...
The most common abnormalities that occur during development are those produced by a defect in the atrial and ventricular septa. A defect in the interatrial septum allows blood to pass from one side of the heart to the other from the chamber with the higher pressure to the chamber with the lower pressure; this is clinic...
Auscultation of the heart reveals the normal audible cardiac cycle, which allows the clinician to assess heart rate, rhythm, and regularity. Furthermore, cardiac murmurs that have characteristic sounds within the phases of the cardiac cycle can be demonstrated (Fig. 3.81). In the clinic Classic symptoms of heart attack...
Coarctation of the aorta is a congenital abnormality in which the aortic lumen is constricted just distal to the origin of the left subclavian artery. At this point, the aorta becomes significantly narrowed and the blood supply to the lower limbs and abdomen is diminished. Over time, collateral vessels develop around t...
More superiorly, in the root of the neck, the right vagus nerve gives off the right recurrent laryngeal nerve, which “hooks” around the right subclavian artery as it passes over the cervical pleura. If a patient has a hoarse voice and a right vocal cord palsy is demonstrated at laryngoscopy, chest radiography with an a...
The left atrium has to work harder to fill the failing left ventricle. This extra work increases left atrial pressure, which is reflected in an increased pressure in the pulmonary veins, and this subsequently creates a higher pulmonary venular pressure. This rise in pressure will cause fluid to leak from the capillarie...
Coronary angiography—small arterial catheters are maneuvered from a femoral artery puncture site through the femoral artery and aorta and up to the origins of the coronary vessels. X-ray contrast medium is then injected to demonstrate the coronary vessels and their important branches. If there is any narrowing (stenosi...
A Doppler ultrasound scan revealed marked stenosis of the subclavian artery at the outer border of the rib with abnormal flow distal to the narrowing. Within this region of abnormal flow there was evidence of thrombus adherent to the vessel wall. This patient underwent surgical excision of the cervical rib and had no f...
This position is determined by palpating the sternal angle, which is the point of articulation of rib II. Counting inferiorly will determine the rib number and simple observation will determine the positions of the anterior axillary and midaxillary lines. Insertion of any tube or needle below the fifth interspace runs ...
The myocardial infarction Aortic dissection may extend retrogradely to involve the coronary sinus of the right coronary artery. Unfortunately, in this patient’s case the right coronary artery became occluded as the dissection passed into the origin. In normal individuals the right coronary artery supplies the anterior ...
After admission a bronchoscopy was carried out and sputum was aspirated from the left upper lobe bronchus. This was cultured in the laboratory and also viewed under the microscope and tuberculous bacilli (TB) were identified. A 68-year-old man came to his family physician complaining of discomfort when swallowing (dysp...
A 45-year-old woman, with a history of breast cancer in the left breast, returned to her physician. Unfortunately the disease had spread to the axillary lymph nodes and bones (bony metastatic disease). A surgeon duly resected the primary breast tumor with a wide local excision and then performed an axillary nodal clear...
Cystic fibrosis is an autosomal recessive disorder affecting the function of exocrine glands due to a gene mutation, leading to an abnormally low concentration of chloride in exocrine secretions, rendering them thick and sticky. Thick secretions cause blockage and subsequent damage to the airways, bowel, pancreas, live...
It relaxes during inspiration to accommodate expansion of the thoracic cavity and the inferior displacement of abdominal viscera during contraction of the diaphragm (Fig. 4.3). During expiration, it contracts to assist in elevating the domes of the diaphragm, thus reducing thoracic volume. Material can be expelled from...
Retroperitoneal structures include the kidneys and ureters, which develop in the region between the peritoneum and the abdominal wall and remain in this position in the adult. During development, some organs, such as parts of the small and large intestines, are suspended initially in the abdominal cavity by a mesentery...
The bladder expands superiorly from the pelvic cavity into the abdominal cavity and, during pregnancy, the uterus expands freely superiorly out of the pelvic cavity into the abdominal cavity. The abdomen communicates directly with the thigh through an aperture formed anteriorly between the inferior margin of the abdomi...
Part of the dorsal mesentery that initially forms part of the lesser sac greatly enlarges in an inferior direction, and the two opposing surfaces of the mesentery fuse to form an apron-like structure (the greater omentum). The greater omentum is suspended from the greater curvature of the stomach, lies over other visce...
In men, the testis, together with its neurovascular structures and its efferent duct (the ductus deferens) descends into the scrotum along a path, initially defined by the gubernaculum, between the processus vaginalis and the accompanying coverings derived from the abdominal wall. All that remains of the gubernaculum i...
One of the most significant is the left renal vein, which drains the kidney, suprarenal gland, and gonad on the same side. Another is the left common iliac vein, which crosses the midline at approximately vertebral level LV to join with its partner on the right to form the inferior vena cava. These veins drain the lowe...
The abdomen is the part of the trunk inferior to the thorax (Fig. 4.21). Its musculomembranous walls surround a large cavity (the abdominal cavity), which is bounded superiorly by the diaphragm and inferiorly by the pelvic inlet. The abdominal cavity may extend superiorly as high as the fourth intercostal space, and is...
The deeper membranous layer of superficial fascia (Scarpa’s fascia) is thin and membranous, and contains little or no fat (Fig. 4.25). Inferiorly, it continues into the thigh, but just below the inguinal ligament, it fuses with the deep fascia of the thigh (the fascia lata; Fig. 4.26). In the midline, it is firmly atta...
Additional fibers extend from the lacunar ligament along the pecten pubis of the pelvic brim to form the pectineal (Cooper’s) ligament. Deep to the external oblique muscle is the internal oblique muscle, which is the second of the three flat muscles (Fig. 4.30, Table 4.1). This muscle is smaller and thinner than the ex...
The posterior wall of the rectus sheath consists of the other half of the aponeurosis of the internal oblique and the aponeurosis of the transversus abdominis. At a point midway between the umbilicus and the pubic symphysis, corresponding to the beginning of the lower one-quarter of the rectus abdominis muscle, all of ...
Along their course, nerves T7 to T12 and L1 supply branches to the anterolateral abdominal wall muscles and the underlying parietal peritoneum. All terminate by supplying skin: Nerves T7 to T9 supply the skin from the xiphoid process to just above the umbilicus. T10 supplies the skin around the umbilicus. T11, T12, and...
The final event in this development is the descent of the testes into the scrotum or of the ovaries into the pelvic cavity. This process depends on the development of the gubernaculum, which extends from the inferior border of the developing gonad to the labioscrotal swellings (Fig. 4.41). The processus vaginalis is im...
The anterior wall of the inguinal canal is formed along its entire length by the aponeurosis of the external oblique muscle (Fig. 4.44). It is also reinforced laterally by the lower fibers of the internal oblique that originate from the lateral two-thirds of the inguinal ligament (Fig. 4.45). This adds an additional co...
The internal spermatic fascia, which is the deepest layer, arises from the transversalis fascia and is attached to the margins of the deep inguinal ring. The cremasteric fascia with the associated cremasteric muscle, which is the middle fascial layer, arises from the internal oblique muscle. The external spermatic fasc...
A direct inguinal hernia does not traverse the entire length of the inguinal canal but may exit through the superficial inguinal ring. When this occurs, the peritoneal sac acquires a layer of external spermatic fascia and can extend, like an indirect hernia, into the scrotum. A thin membrane (the peritoneum) lines the ...
Usually a thin membrane, the greater omentum always contains an accumulation of fat, which may become substantial in some individuals. Additionally, there are two arteries and accompanying veins, the right and left gastro-omental vessels, between this double-layered peritoneal apron just inferior to the greater curvatu...
The abdominal esophagus represents the short distal part of the esophagus located in the abdominal cavity. Emerging through the right crus of the diaphragm, usually at the level of vertebra TX, it passes from the esophageal hiatus to the cardial orifice of the stomach just left of the midline (Fig. 4.62). Associated wi...
The first part of the small intestine is the duodenum. This C-shaped structure, adjacent to the head of the pancreas, is 20 to 25 cm long and is above the level of the umbilicus; its lumen is the widest of the small intestine (Fig. 4.66). It is retroperitoneal except for its beginning, which is connected to the liver b...
The ileum makes up the distal three-fifths of the small intestine and is mostly in the right lower quadrant. Compared to the jejunum, the ileum has thinner walls, fewer and less prominent mucosal folds (plicae circulares), shorter vasa recta, more mesenteric fat, and more arterial arcades (Fig. 4.69). The ileum opens i...
The appendix is a narrow, hollow, blind-ended tube connected to the cecum. It has large aggregations of lymphoid tissue in its walls and is suspended from the terminal ileum by the mesoappendix (Fig. 4.83), which contains the appendicular vessels. Its point of attachment to the cecum is consistent with the highly visib...
The arterial supply to the descending colon (Fig. 4.90) includes the left colic artery from the inferior mesenteric artery. The arterial supply to the sigmoid colon (Fig. 4.90) includes sigmoidal arteries from the inferior mesenteric artery. Anastomotic connections between arteries supplying the colon can result in a m...
Where the coronary ligaments come together laterally, they form the right and left triangular ligaments. The liver is divided into right and left lobes by the falciform ligament anterosuperiorly and the fissure for the ligamentum venosum and ligamentum teres on the visceral surface. (Fig. 4.104). The right lobe of the...
The accessory pancreatic duct empties into the duodenum just above the major duodenal papilla at the minor duodenal papilla (Fig. 4.109). If the accessory duct is followed from the minor papilla into the head of the pancreas, a branch point is discovered: One branch continues to the left, through the head of the pancre...
The abdominal aorta begins at the aortic hiatus of the diaphragm, anterior to the lower border of vertebra TXII (Fig. 4.121). It descends through the abdomen, anterior to the vertebral bodies, and by the time it ends at the level of vertebra LIV it is slightly to the left of midline. The terminal branches of the abdomi...
Approaching the spleen, the splenic artery gives off short gastric arteries, which pass through the gastrosplenic ligament to supply the fundus of the stomach. It also gives off the left gastro-omental artery, which runs to the right along the greater curvature of the stomach, and anastomoses with the right gastro-omen...
The inferior pancreaticoduodenal artery is the first branch of the superior mesenteric artery. It divides immediately into anterior and posterior branches, which ascend on the corresponding sides of the head of the pancreas. Superiorly, these arteries anastomose with anterior and posterior superior pancreaticoduodenal ...
The inferior mesenteric artery is the anterior branch of the abdominal aorta that supplies the hindgut. It is the smallest of the three anterior branches of the abdominal aorta and arises anterior to the body of vertebra LIII. Initially, the inferior mesenteric artery descends anteriorly to the aorta and then passes to...
The splenic vein forms from numerous smaller vessels leaving the hilum of the spleen (Fig. 4.132). It passes to the right, passing through the splenorenal ligament with the splenic artery and the tail of the pancreas. Continuing to the right, the large, straight splenic vein is in contact with the body of the pancreas ...
The superior mesenteric artery (i.e., structures that are part of the abdominal midgut) drains to pre-aortic nodes near the origin of the superior mesenteric artery (Fig. 4.134)—these superior mesenteric nodes also receive lymph from the inferior mesenteric groups of pre-aortic nodes, and lymph from the superior mesent...
The splanchnic nerves are important components in the innervation of the abdominal viscera. They pass from the sympathetic trunk or sympathetic ganglia associated with the trunk, to the prevertebral plexus and ganglia anterior to the abdominal aorta. There are two different types of splanchnic nerves, depending on the ...
The aortic plexus consists of nerve fibers and associated ganglia on the anterior and lateral surfaces of the abdominal aorta extending from just below the origin of the superior mesenteric artery to the bifurcation of the aorta into the two common iliac arteries. The major ganglion in this plexus is the inferior mesen...
The pathway of sympathetic innervation of the stomach is as follows: A preganglionic sympathetic fiber originating at the T6 level of the spinal cord enters an anterior root to leave the spinal cord. At the level of the intervertebral foramen, the anterior root (which contains the preganglionic fiber) and a posterior r...
Superiorly, ribs XI and XII complete the bony framework of the posterior abdominal wall (Fig. 4.141). These ribs are unique in that they do not articulate with the sternum or other ribs, they have a single articular facet on their heads, and they do not have necks or tubercles. Rib XI is posterior to the superior part ...
Structurally, the diaphragm consists of a central tendinous part into which the circumferentially arranged muscle fibers attach (Fig. 4.143). The diaphragm is anchored to the lumbar vertebrae by musculotendinous crura, which blend with the anterior longitudinal ligament of the vertebral column: The right crus is the lo...
The domes are produced by: the liver on the right, with some contribution from the right kidney and the right suprarenal gland, and the fundus of the stomach and spleen on the left, with contributions from the left kidney and the left suprarenal gland. Although the height of these domes varies during breathing, a reaso...
On its lateral side, the lower half of the kidney is covered by the left colic flexure and the beginning of the descending colon, and, on its medial side, by the parts of the intraperitoneal jejunum. Posteriorly, the right and left kidneys are related to similar structures (Fig. 4.151). Superiorly is the diaphragm and ...
The minor calices receive urine from the papillary ducts and represent the proximal parts of the tube that will eventually form the ureter (Fig. 4.153). In the renal sinus, several minor calices unite to form a major calyx, and two or three major calices unite to form the renal pelvis, which is the funnel-shaped superi...
Lymphatic drainage of the ureters follows a pattern similar to that of the arterial supply. Lymph from: the upper part of each ureter drains to the lateral aortic (lumbar) nodes, the middle part of each ureter drains to lymph nodes associated with the common iliac vessels, and the inferior part of each ureter drains to...
Anterior to the abdominal aorta, as it descends, are the pancreas and splenic vein, the left renal vein, and the inferior part of the duodenum. Several left lumbar veins cross it posteriorly as they pass to the inferior vena cava. On its right side are the cisterna chyli, thoracic duct, azygos vein, right crus of the d...
During its course, the anterior surface of the inferior vena cava is crossed by the right common iliac artery, the root of the mesentery, the right testicular or ovarian artery, the inferior part of the duodenum, the head of the pancreas, the superior part of the duodenum, the bile duct, the portal vein, and the liver,...
Finally, the lateral aortic or lumbar nodes form the right and left lumbar trunks, whereas the pre-aortic nodes form the intestinal trunk (Fig. 4.168). These trunks come together and form a confluence that, at times, appears as a saccular dilation (the cisterna chyli). This confluence of lymph trunks is posterior to th...
The lumbar plexus is formed by the anterior rami of nerves L1 to L3 and most of the anterior ramus of L4 (Fig. 4.173 and Table 4.6). It also receives a contribution from the T12 (subcostal) nerve. Branches of the lumbar plexus include the iliohypogastric, ilio-inguinal, and genitofemoral nerves, the lateral cutaneous n...
The femoral branch descends on the lateral side of the external iliac artery and passes posterior to the inguinal ligament, entering the femoral sheath lateral to the femoral artery. It pierces the anterior layer of the femoral sheath and the fascia lata to supply the skin of the upper anterior thigh (Fig. 4.175). Late...
A line between the anterior superior iliac spine and the pubic tubercle marks the position of the inguinal ligament, which separates the anterior abdominal wall above from the thigh of the lower limb below. The iliac crest separates the posterolateral abdominal wall from the gluteal region of the lower limb. The upper ...
The celiac trunk originates from the aorta at the upper border of the LI vertebra. The superior mesenteric artery originates at the lower border of the LI vertebra. The renal arteries originate at approximately the LII vertebra. The inferior mesenteric artery originates at the LIII vertebra. The aorta bifurcates into t...
Fig. 4.5 Abdominal wall. A. Skeletal elements. B. Muscles. Fig. 4.6 The gut tube is suspended by mesenteries. Branch of aortaGastrointestinal tractAortaDorsal mesenteryVentral mesenteryKidney—posterior toperitoneumVisceral peritoneumParietal peritoneum Fig. 4.7 A series showing the progression (A to C) from an intraper...
Superficial fasciaFatty layer(Camper's fascia)Membranous layer(Scarpa's fascia)SkinPubic symphysisPenisDartos fasciaScrotumInguinal ligamentAponeurosis of external obliqueFascia lata of thigh Fig. 4.26 Continuity of membranous layer of superficial fascia into other areas. Continuity with superficialpenile fasciaContinu...
Inguinal ligamentFemoral artery and veinInternal oblique muscleAponeurosis of internal oblique Spermatic cordConjoint tendonAnterior superior iliac spine Fig. 4.46 Transversus abdominis muscle and the inguinal canal. Fig. 4.47 A. Spermatic cord (men). B. Round ligament of uterus (women). Internal spermatic fasciaPariet...
RightvagusnerveTracheaArch of aortaAortaThoracicesophagusAbdominal esophagusRight crus ofdiaphragmLeft vagus nerve Fig. 4.63 Arterial supply to the abdominal esophagus and stomach. Fig. 4.64 Stomach. Fig. 4.65 Radiograph, using barium, showing the stomach and duodenum. A. Double-contrast radiograph of the stomach. B. D...
Fig. 4.86 Inflamed appendix. Ultrasound scan. Fig. 4.87 Axial CT shows inflamed appendix. Fig. 4.88 Colon. Fig. 4.89 Right and left colic flexures. Fig. 4.90 Arterial supply to the colon. Fig. 4.91 Rectum and anal canal. Fig. 4.92 Arterial supply to the rectum and anal canal. Posterior view. Fig. 4.93 Small bowel malro...
GallbladderPancreasPortal veinSplenic veinStomachLeft colonic flexureSpleenLeft kidneyAortaInferior vena cavaRight lobe of liverRight crusALeft crus Left lobe of liverBSplenic arterySuperior mesenteric arteryPancreasLeft renal veinAortaInferior vena cavaVertebra Fig. 4.109 Pancreatic duct system. Fig. 4.110 Arterial su...
LiverSpleenSplenic veinSuperior mesenteric veinSuperior rectal veinInferior rectal veinsInferior vena cavaInferior mesenteric veinLeft gastric veinPortal veinRectumStomachTributaries to azygos veinSuperficial veinson abdominal wallExternal iliac veinInternal iliac veinCommon iliac veinPara-umbilical veinsthat accompany...
Internal iliac arteryExternal iliac arteryCommon iliac arteryGonadal arteriesLeft kidneyLeft renal arteryRight renal arteryRight kidneyAbdominal aortaBladderUreterThird constriction—entrance to bladderSecond constriction—pelvic inletFirst constriction—ureteropelvic junctionUreter Fig. 4.156 Low-dose axial CT of urinary...
Subcostal nerveIliohypogastric nerveIlio-inguinal nerveLateral cutaneous nerve of thighFemoral nerveGenitofemoral nerveObturator nerveSubcostal nerve (T12)Iliohypogastric nerve (L1)Psoas major muscleIlio-inguinal nerve (L1)Lateral cutaneous nerve of thigh (L2,L3)Femoral nerve (L2 to L4)Genitofemoral nerve (L1,L2)Iliacu...
Fig. 4.181 Abdominal quadrants and the positions of major viscera. Anterior view of a man. Fig. 4.182 The nine regions of the abdomen. Anterior view of a woman. Fig. 4.183 Surface projection of the kidneys and ureters. Posterior view of the abdominal region of a woman. Fig. 4.184 Surface projection of the spleen. Poste...
Laparoscopic surgery has been further enhanced with the use of surgical robots. Using these systems the surgeon moves the surgical instruments indirectly by controlling robotic arms, which are inserted into the operating field through small incisions. Robot-assisted surgery is now routinely used worldwide and has helpe...
Hernias occur in a variety of regions. The commonest site is the groin of the lower anterior abdominal wall. In some patients, inguinal hernias are present from birth (congenital) and are caused by the persistence of the processus vaginalis and the passage of viscera through the inguinal canal. Acquired hernias occur i...
Incisional hernias occur through a defect in a scar of a previous abdominal operation. Usually, the necks of these hernias are wide and do not therefore strangulate the viscera they contain. A spigelian hernia passes upward through the arcuate line into the lateral border at the lower part of the posterior rectus sheat...
A perforated bowel (e.g., caused by a perforated duodenal ulcer) often leads to the release of gas into the peritoneal cavity. This peritoneal gas can be easily visualized on an erect chest radiograph—gas can be demonstrated in extremely small amounts beneath the diaphragm. A patient with severe abdominal pain and subd...
Posterior duodenal ulcers erode either directly onto the gastroduodenal artery or, more commonly, onto the posterior superior pancreaticoduodenal artery, which can produce torrential hemorrhage, which may be fatal in some patients. Treatment may involve extensive upper abdominal surgery with ligation of the vessels or ...
Cross sectional imaging using computed tomography or magnetic resonance is another way to assess the bowel lumen and wall. Magnetic resonance is particularly useful in assessment of the small bowel because it allows dynamic assessment of bowel distention and motility and provides good visualization of segmental or cont...
Acute appendicitis is an abdominal emergency. It usually occurs when the appendix is obstructed by either a fecalith or enlargement of the lymphoid nodules. Within the obstructed appendix, bacteria proliferate and invade the appendix wall, which becomes damaged by pressure necrosis. In some instances, this may resolve ...
Vomiting and absolute constipation, including the inability to pass flatus, will ensue. Early diagnosis is important because considerable fluid and electrolytes enter the bowel lumen and fail to be reabsorbed, which produces dehydration and electrolyte abnormalities. Furthermore, the bowel continues to distend, comprom...
An ileostomy is performed when small bowel contents need to be diverted from the distal bowel. An ileostomy is often performed to protect a distal surgical anastomosis, such as in the colon to allow healing after surgery. There are a number of instances when a colostomy may be necessary. In many circumstances it is per...
The liver is divided by the principal plane, which divides the organ into halves of approximately equal size. This imaginary line is defined by a parasagittal line that passes through the gallbladder fossa to the inferior vena cava. It is in this plane that the middle hepatic vein is found. Importantly, the principal p...
Endoscopic retrograde cholangiopancreatography (ERCP) can be undertaken to remove obstructing gallstones within the biliary tree. This procedure combines endoluminal endoscopy with fluoroscopy to diagnose and treat problems in the biliary and pancreatic ducts. An endoscope with a side-viewing optical system is advanced...
The spleen is an organ of the reticuloendothelial system involved in hematopoiesis and immunological surveillance. Diseases that affect the reticuloendothelial system (e.g., leukemia or lymphoma) may produce generalized lymphadenopathy and enlargement of the spleen (splenomegaly) (Fig. 4.120). The spleen often enlarges...
The etiology of cirrhosis is complex and includes toxins (alcohol), viral inflammation, biliary obstruction, vascular outlet obstruction, nutritional (malnutrition) causes, and inherited anatomical and metabolic disorders. As the cirrhosis progresses, the intrahepatic vasculature is distorted, which in turn leads to in...
Surgery for obesity is also known as weight loss surgery and bariatric surgery. This type of surgery has become increasingly popular over the last few years for patients who are unable to achieve significant weight loss through appropriate diet modification and exercise programs. It is often regarded as a last resort. ...
Morgagni’s and Bochdalek’s hernias tend to appear at or around the time of birth or in early infancy. They allow abdominal bowel to enter the thoracic cavity, which may compress the lungs and reduce respiratory function. Most of these hernias require surgical closure of the diaphragmatic defect. However, large hernias ...
Renal cell tumors (Figs. 4.157 and 4.158) are unusual because not only do they grow outward from the kidney, invading the fat and fascia, but they also spread into the renal vein. This venous extension is rare for any other type of tumor, so, when seen, renal cell carcinoma should be suspected. In addition, the tumor m...
An ideal place to situate the transplant kidney is in the left or the right iliac fossa (Fig. 4.161). A curvilinear incision is made paralleling the iliac crest and pubic symphysis. The external oblique muscle, internal oblique muscle, transversus abdominis muscle, and transversalis fascia are divided. The surgeon iden...
With the aging population, the number of abdominal aortic aneurysms is increasing. Moreover, with the increasing use of imaging techniques, a number of abdominal aortic aneurysms are identified in asymptomatic patients. For many years the standard treatment for repair was an open operative technique, which involved a l...
From a clinical perspective, retroperitoneal lymph nodes are arranged in two groups. The pre-aortic lymph node group drains lymph from the embryological midline structures, such as the liver, bowel, and pancreas. The para-aortic lymph node group (the lateral aortic or lumbar nodes), on either side of the aorta, drain l...
A review of the patient’s old notes revealed that at the time of the injury the spleen was removed surgically, but it was not appreciated that there was a small rupture of the dome of the left hemidiaphragm. The patient gradually developed a hernia through which bowel could enter, producing the “hump” on the diaphragm ...
It is not uncommon for vomiting and weight loss (cachexia) to occur in patients with a malignant disease. The head of the pancreas lies within the curve of the duodenum, primarily adjacent to the descending part of the duodenum. Any tumor mass in the region of the head of the pancreas is likely to expand and may encase...
The liver function of patients with suspected liver disease is poor, as demonstrated by the patient’s jaundice—an inability to conjugate bilirubin. Importantly, because some liver products are blood-clotting factors involved in the clotting cascade, the blood-clotting ability of patients with severe liver disease is si...
Scrotal masses are common in young males, and determining the exact anatomical site of the scrotal mass is of utmost clinical importance. Any mass that arises from the testis should be investigated to exclude testicular cancer. Masses that arise from the epididymis and scrotal lesions, such as fluid (hydrocele) or hern...