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Similarly, ollowing a partial colectomy, a colostomy or sigmoidostomy is perormed to create an articial cutaneous opening or the terminal part o the colon. Their proximal stumps begin to regenerate, sending sprouts into the area o the lesion; however, this growth is blocked by astrocyte prolieration at the injury site, and the axonal sprouts are soon retracted. This causes increased local pressure that oten causes excruciating pain during abduction o the arm; the pain may radiate as ar as the hand. Bones o the adult skeleton provide Support or the body and its vital cavities; it is the chie supporting tissue o the body. Urine may pass into the loose connective tissue in the scrotum, around the penis, and, superiorly, deep to the membranous layer o subcutaneous connective tissue o the inerior anterior abdominal wall. Presynaptic cell bodies o the sympathetic division are ound only in the intermediolateral cell columns o gray matter in the thoracolumbar spinal cord, which are organized somatotopically. It contains no organs but contains a thin lm o peritoneal uid, which is composed o water, electrolytes, and other substances derived rom interstitial fuid in adjacent tissues. The greater omentum also cushions the abdominal organs against injury and orms insulation against loss o body heat. If a coronary artery crosses the infundibulum it may even be necessary to place a right ventricle to pulmonary artery conduit. Each minor calyx is indented by a renal papilla, the apex o the renal pyramid, rom which the urine is excreted. Normal hepatic tissue, when sectioned, is traditionally described as demonstrating a pattern o hexagonal-shaped liver lobules. Often for proximal control it is useful to apply a C-clamp which will include both the distal aortic arch, as well as the left subclavian artery. Reposition describes the movement o the 1st digit rom the position o opposition back to its anatomical position. The let marginal branch o the circumfex branch ollows the let margin o the heart and supplies the let ventricle. The superior hypogastric plexus is a continuation o the aortic plexus that divides into let and right hypogastric nerves as it enters the pelvis. In this radiograph, the head o the humerus and the glenoid cavity overlap, obscuring the joint plane because the scapula does not lie in the coronal plane (thereore, the glenoid cavity is oblique, not in a sagittal plane. Lymph rom the skin o the breast, except the nipple and areola, drains into the ipsilateral axillary, inerior deep cervical, and inraclavicular lymph nodes and into the parasternal lymph nodes o both sides. Most (65%) duodenal ulcers occur in the posterior wall o the superior part o the duodenum within 3 cm o the pylorus. The articulated atlas and axis showing that the median atlanto-axial joint is ormed as the anterior arch and transverse ligament o the atlas orm a socket or the dens o the axis. In other cases, thrombokinase is injected through the catheter; this enzyme dissolves the blood clot. If necessary, this should be decompressed back to the systemic circulation at atrial level through a balloon septostomy defect. However, a laceration or incision across the tension lines disrupts more collagen bers. It is integrated into each chapter o this book in "surace anatomy sections" that provide knowledge o what lies under the skin and what structures are perceptible to touch (palpable) in the living body at rest and in action. The breasts are prominent eatures, and, in males, the nipples demarcate the 4th intercostal space. During these movements, as well as during rotation, the turgid nucleus acts as a semifuid ulcrum. The lymphatic vessels rom the superior parts o the seminal glands and prostate terminate chiefy in the internal iliac lymph nodes, but some drainage rom the latter may pass to the sacral nodes. Furthermore, because the two sides are connected both anteriorly and posteriorly, the pelvic girdle orms a complete rigid ring that limits mobility, making the movements o one limb markedly aect the movements o the other. It then pierces the costocoracoid membrane and part o the clavipectoral ascia, joining the terminal part o the axillary vein. Thoracic (broncho-aortic) constriction: a compound constriction where it is rst crossed by the arch o the aorta, 22. The right and let superior lobar arteries to the superior lobes arise rst, beore entering the hilum. There were 20 significant complications in 16 patients: thromboembolism was noted in one patient; reoperations for aortic valve re-replacement was required in five (thrombosed valve, 3; pannus formation, 1; endocarditis 1); mitral valve replacement, 3; coronary artery bypass grafting, 2; grafting of the descending aorta, 1; and seven catheter interventions were required.

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The internal pudendal artery then passes around the posterior aspect o the ischial spine or the sacrospinous ligament and enters the ischio-anal ossa through the lesser sciatic oramen. Eerent lymphatic vessels rom the duodenal lymph nodes drain into the celiac lymph nodes. The roo o the cubital ossa is ormed by the continuity o brachial and antebrachial (deep) ascia reinorced by the bicipital aponeurosis. Sudden, orceul extension o the neck can also injure the vertebral column and spinal cord. The nerves are derived rom the prostatic plexus (mixed sympathetic, parasympathetic, and visceral aerent bers). The undus o the bladder is opposite the apex, ormed by the somewhat convex posterior wall. The dermatomal or segmental pattern o distribution o sensory nerve fbers persists despite the merging o spinal nerves in plexus ormation during development. Although originating rom the same spinal cord segments rom which the pudendal nerve is derived, the parasympathetic fbers o the cavernous nerves course independently o the pudendal nerve. These internal genital organs, located within the anterior male pelvis, receive blood rom the inerior vesicle and middle rectal arteries, which drain into the continuous prostatic/vesicle venous plexus. The course o the radial artery in the orearm is represented by a line joining the midpoint o the cubital ossa to a point just medial to the radial styloid process. The location o the incision also depends on the type o operation, the location o the organ(s) the surgeon wants to reach, bony or cartilaginous boundaries, avoidance o (especially motor) nerves, maintenance o blood supply, and minimizing injury to muscles and ascia o the abdominal wall while aiming or avorable healing. Loss o distal leg pulses is an obvious sign o arterial compression, as is lowering o the temperature o tissues distal to the compression. The pain is most severe during exion o the orearm because o pressure exerted on the inamed subtendinous olecranon bursa by the triceps tendon. Clinical studies show that anastomoses cannot provide collateral routes quickly enough to prevent the eects o sudden coronary artery occlusion. The interosseous membrane and intermuscular septa divide the leg into three compartments: anterior (dorsifexor), lateral (bular), and posterior (plantarfexor). Pulmonary regurgitation from a transannular patch and tricuspid regurgitation from right ventricular dilation will exacerbate right ventricular volume overload. However, subsequent follow-up has suggested that the hemodynamic result with supra-annular mitral valve replacement is suboptimal. Consequently, it is vulnerable to inadvertent injury during investigative and/or surgical procedures in the posterior mediastinum. The oblique and transverse muscles, acting together bilaterally, orm a muscular girdle that exerts rm pressure on the the map o dermatomes o the anterolateral abdominal wall is almost identical to the map o peripheral nerve distribution. Symptoms o intermittent pain in the renal region, relieved by lying down, appear to result rom traction on the renal vessels. The bula does not articulate with the emur and thereore does not bear or transer weight. Radius Ulna Palmar carpal branch Scaphoid (fractured, with necrotic proximal fragment) Trapezoid Radial artery Triquetrum Lunate Pisiform Hook of hamate Capitate Trapezium (A) Fracture o Scaphoid the scaphoid is the most requently ractured carpal bone. Because o the large vertebral canal l in the cervical region, slight dislocation can occur here without damaging the spinal cord. A broad band, the transverse humeral ligament, passes rom the lesser to the greater tubercle o the humerus and converts the intertubercular groove into a canal. A portion o the posterior wall o the bladder has been removed to reveal the intramural part o ureter and the ductus deerens posterior to the bladder. A superomedial lobule, deep to the ineroposterior lobule, surrounding the ipsilateral ejaculatory duct. From superior to inerior, the bed o the stomach is ormed by the let dome o the diaphragm, spleen, let kidney and suprarenal gland, splenic artery, pancreas, and transverse mesocolon.

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A Lecompte maneuver will subsequently be performed bringing the pulmonary bifurcation anterior to the ascending aorta. The anterior layer o the thoracolumbar ascia (quadratus lumborum ascia), covering the anterior surace o the quadratus lumborum-a thinner, more transparent layer than the other two layers-attaches to the anterior suraces o the transverse processes o the lumbar vertebrae, the iliac crest, and the 12th rib. Thus, tapering lateral extensions o the spinal dura surround each pair o posterior and anterior nerve roots as dural root sheaths, or sleeves. The cervical lordosis becomes ully evident when an inant begins to raise (extend) the head while prone and to hold the head erect while sitting. The ligament o the ovary connects the Pelvic Viscera 611 Ovary Distended urinary bladder Broad ligament Ovary Uterus Follicle 4. The deep veins ascend in the orearm along the sides o the corresponding arteries, receiving tributaries rom veins leaving the muscles with which they are related. Modifications of Left Subclavian Patch Aortoplasty the technique described by Meier et al. To abolish sensation rom the anterior part o the perineum, an ilio-inguinal nerve block is perormed. Ileus is accompanied by a severe colicky pain, along with abdominal distension, vomiting, and oten ever and dehydration. Each duct has a dilated portion deep to the areola, the lactierous sinus, in which a small droplet o milk accumulates or remains in the nursing mother. The vaginal veins orm vaginal venous plexuses along the sides o the vagina and within the vaginal mucosa. The body has been sectioned in the median plane to show the abdominal and pelvic cavities as subdivisions o the continuous abdominopelvic cavity. In many such cases, erection can be achieved with the assistance o oral medications or injections that increase blood fow into the cavernous sinusoids by causing relaxation o smooth muscle. The apical nodes receive lymph rom all other groups o axillary nodes as well as rom lymphatics accompanying the proximal cephalic vein. Although some have suggested that this is primarily related to an association of vertebral anomalies with congenital cardiac anomalies requiring a thoracotomy, nevertheless careful follow-up will be required of these patients to demonstrate that scoliosis does not become a problem in the teenage growth years. The calcium deposit may irritate the overlying subacromial bursa, producing an infammatory reaction known as subacromial bursitis. The cycle consists o diastole (ventricular relaxation and flling) and systole (ventricular contraction and emptying). However, patients who underwent surgery at an older age had a significantly less good late survival than the general population, and those who were more than 40 years of age at the time of surgery had a markedly decreased late survival. The mitral regurgitation was associated with morphologic abnormalities of the mitral valve and with development of endocardial fibroelastosis after failed intervention during the newborn period. In some cases, actions are used to describe muscles- or example, the levator scapulae elevates the scapula (L. Prior to tying this suture the left heart should be filled with saline to displace air. Frothing will certainly occur if the cardioplegia is injected as a jet from a distance through the valve. The apex o the bladder points toward the superior edge o the pubic symphysis when the bladder is empty. When they are ull, the valve cusps occlude the lumen o the vein, thereby preventing refux o blood distally, making fow unidirectional. Wrist Fractures and Dislocations Fracture o the distal end o the radius (Colles racture), the most common racture in people >50 years o age, is discussed in the clinical box "Fractures o Radius and Ulna. When studying anatomy by this approach, it is important to routinely put the regional anatomy into the context o that o adjacent regions, o parts, and o the body as a whole. The exors and pronators o the orearm are in the anterior compartment and are served mainly by the median nerve; the one and a hal exceptions are innervated by the ulnar nerve. Distal to the carpal tunnel, the median nerve supplies two and a hal thenar muscles and the 1st and 2nd lumbricals. When the posterior layer has been completed rewarming is begun and the flow rate is gradually increased.

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The surace o the hands, the eet, and the digits o both corresponding to the dorsum is the dorsal surace, the surace o the hand and ngers corresponding to the palm is the palmar surace, and the surace o the oot and toes corresponding to the sole is the plantar surace. The bile duct descends posterior to the superior part o the duodenum and lies in a groove on the posterior surace o the head o the pancreas. Not surprisingly, the cranial outfow provides parasympathetic innervation o the head, and the sacral outfow provides the parasympathetic innervation o the pelvic viscera. The median nerve and brachial artery descend in the arm to the medial side o the cubital ossa, where it is well protected and rarely injured. When they are ull, the valve cusps occlude the lumen o the vein, thereby preventing refux o blood distally, making fow unidirectional (toward the heart but not in the reverse direction; see. The blood vessels (vasa nervorum) that nourish the nerve bers and their coverings. In this dissection o the right arm, the veins have been removed, except or the proximal part o the axillary vein. The major coronary vessels, that is the right and left coronary artery, originate from angioblasts in the atrioventricular sulcus. The rectus sheath is ormed by the decussation and interweaving o the aponeuroses o the fat abdominal muscles. If the native cusp is very stiff or calcified, the cusp is partially or completely resected and reconstructed with a pericardial patch. The appendix is also displaced cephalad by the enlarging uterus during pregnancy; hence, diagnosis and removal o appendix later in pregnancy must take this into account. The pelvic portion o the ductus lies immediately external to the peritoneum, with its terminal portion enlarging externally as its lumen becomes tortuous internally, orming the ampulla o the ductus deerens. The parietal peritoneum is internal to the transversalis ascia and is separated rom it by a variable amount o extraperitoneal at. Overall, most wrist movement occurs at the wrist (radiocarpal) joint between the radius and articular disc o the distal radio-ulnar joint and the proximal row o carpal bones (primarily the scaphoid and lunate). Anterior aspect of posterior thoracic wall Thyrocervical trunk Costocervical trunk Axillary a. Each crus is attached to the inerior part o the internal surace o the corresponding ischial ramus. Within the right and let livers, the simultaneous secondary branchings o the hepatic portal vein and hepatic artery supply the medial and lateral divisions o the right and let liver, with three o the our secondary branches undergoing urther (tertiary) branchings to supply independently seven o the eight hepatic segments. As the vertebral column descends, bodies increase in size in relationship to increased weight bearing. This commissure of the neopulmonary valve will need to be detached in order to harvest a button that contains the full length of the intramural coronary artery. Risk factors for infundibular obstruction or obstruction at the level of the pulmonary valve were a side-by-side position of the great vessels, presence of coexisting coarctation, use of prosthetic material in sinus reconstruction, earlier era of surgery and institution. The fexor muscles o the anterior compartment are almost twice as strong as the extensors in all positions; consequently, we are better pullers than pushers. Ulnar collateral ligament Proximal radio-ulnar joint Insertion of brachialis muscle Oblique cord Ulna Radius Interosseous membrane Proximal Radio-Ulnar Joint the proximal (superior) radio-ulnar joint is a pivot type o synovial joint that allows movement o the head o the radius on the ulna. Inundibulum: the unnel-shaped distal end o the tube that opens into the peritoneal cavity through the abdominal ostium. The chest is generally conceived as the superior part o the trunk that is broadest superiorly owing to the presence o the pectoral (shoulder) girdle (clavicles and scapulae), with much o its girth accounted or by the pectoral and scapular musculature and, in adult emales, the breasts. The tendons o the interosseous and lumbrical muscles o the hand join the lateral bands o the extensor expansion. The parasympathetic bers distributed within the pelvis stimulate contraction o the rectum and bladder or deecation and urination, respectively. As the prostate develops rom urethral glands, the posterior and posterolateral muscle atrophies or is displaced by the prostate.

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The combined term jejuno-ileum is sometimes used as an expression o the act that there is no clear external line o demarcation between the jejunum and the ileum. In that paper, they described concern regarding the growth of the circumferential anastomosis. Beore birth, the umbilical arteries are the main continuation o the internal iliac arteries, passing along the lateral pelvic wall and then ascending the anterior abdominal wall to and through the umbilical ring into the umbilical cord. It ascends anterior to the let subclavian artery and is at rst anterior to the trachea and then to its let. Immediately distal and at a deeper level to the latter, the antebrachial ascia is also continued as the exor retinaculum (transverse carpal ligament). Hypertensive mechanisms in coarctation of the aorta: further studies of the renin-angiotensin system. Malrotation o the midgut (intestine) results in several congenital anomalies such as volvulus (twisting) o the intestine (Moore et al. It is surrounded by the prostate, the muscular anterior "lobe" that includes the trough-like superior extension o the external urethral sphincter anteriorly, and by the glandular lobes posteriorly. Although the cause o congenital hypertrophic pyloric stenosis is unknown, genetic actors appear to be Pyloric canal Pyloric stenosis Congenital Hypertrophic Pyloric Stenosis Congenital hypertrophic pyloric stenosis is a marked thickening o the smooth muscle (hypertrophy) in the pylorus that aects approximately 1 o every 150 male inants and 1 o every 750 emale inants (Moore, Persaud, and Torchia, 2016). Insuciency or regurgitation, on the other hand, is ailure o the valve to close completely, usually owing to nodule ormation on (or scarring and contraction o) the cusps so that the edges do not meet or align. In this sagittal section o the wrist and hand during extension and exion, observe the radiocarpal, midcarpal, and carpometacarpal articulations. In abduction o the digits (ngers or toes), the term means spreading them apart-moving the other ngers away rom the neutrally positioned 3rd (middle) nger or moving the other toes away rom the neutrally positioned 2nd toe. The median cubital vein is also a site or the introduction o cardiac catheters to secure blood samples rom the great vessels and chambers o the heart. In an earlier report, Miyaji et 344 Comprehensive Surgical Management of Congenital Heart Disease, Second Edition 17. The site that is selected is simply the point at the same level as the original coronary ostium with a minimal degree of rotation of the coronary. The bilateral embryonic ormation o the scrotum is indicated by the midline scrotal raphe. Aortic Valve Stenosis beyond the Neonatal Period Patients who present beyond the neonatal period often have an adequate aortic annulus without associated cardiac anomalies. Thus, for this anomaly, early diagnosis alone should not be an automatic indication to proceed to surgery, as there is a reasonable probability that the asymptomatic patient will have relatively normal biventricular function for many years. This eature makes the atlas the widest o the cervical vertebrae, thus providing increased leverage or attached muscles. The large pulmonary veins are atypical in that they carry oxygen-rich blood rom the lungs to the heart. Within the superior mediastinum, structures occur in systemic layers, proceeding rom anterior to posterior: (1) lymphoid system (thymus), (2) blood vascular system (veins frst, then arteries), (3) respiratory system (trachea), (4) alimentary system (esophagus), and (5) lymph vascular system. Usually, the at present in male breasts is not dierent rom that o subcutaneous tissue elsewhere, but the glandular system rarely develops. This posterior connection to the axial skeleton places the lower limbs inerior to the trunk, enabling them to be supportive as they unction primarily in relation to the line o gravity. The most common causes include bronchitis (infammation o the bronchi), lung cancer, pneumonia, bronchiectasis, pulmonary embolism, and tuberculosis. The ulnar collateral ligament has a strong, round, cord-like anterior band (part), which is taut when the elbow joint is extended, and a weak, an-like posterior band, which is taut when the joint is exed. This ligament prevents hyperextension o the vertebral column, maintaining stability o the joints between the vertebral bodies. The authors concluded that there was a possible disadvantage for the two-stage approach employing preliminary shunting and later repair. The parasympathetic bers are secretomotor, but pancreatic secretion is primarily mediated by secretin and cholecystokinin, hormones ormed by the epithelial cells o the duodenum and proximal intestinal mucosa under the stimulus o acid contents rom the stomach. Mild or moderate aortic regurgitation is tolerated very well clinically for many years by children as it is by adults. The authors found no significant differences in the degree of early postoperative pulmonary regurgitation or in clinical outcomes, such as mortality, number of reoperations, or hospital stay. Bilateral contraction o the iliopsoas muscles initiates fexion o the trunk at the hip on the xed thigh-as when (incorrectly) doing sit-ups-and decreases the lumbar lordosis (curvature) o the vertebral column.

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However, because this unit is ormed by two parallel bones, one o which (the radius) can pivot about the other (the ulna), supination and pronation are possible. The emoral sheath does not enclose the emoral nerve because it passes through the muscular compartment. In addition to rmly tying the orearm bones together while permitting pronation and supination, the interosseous membrane provides the proximal attachment or some deep orearm muscles. I the anulus brosus has degenerated, the nucleus pulposus may herniate into the vertebral canal and compress the spinal cord. Although most veins o the trunk occur as large single vessels, veins in the limbs occur as two or more smaller vessels that accompany an artery in a common vascular sheath. The synovial membrane also orms a tubular sheath or the tendon o the long head o the biceps brachii, where it lies in the intertubercular sulcus o the humerus and passes into the joint cavity. The hepatic veins, ormed by the union o collecting veins that in turn drain the central veins o the hepatic parenchyma. The anterior rami o the cervical spinal nerves course initially on the transverse processes in grooves or spinal nerves between the tubercles. When gripping an unattached rod loosely (G) or frmly (H), the 2nd and 3rd carpometacarpal joints are rigid and stable, but the 4th and 5th are saddle joints permitting exion and extension. The cervical and lumbar lordoses are secondary curvatures that result rom extension rom the fexed etal position. Instead o descending as it normally does during inspiration owing to diaphragmatic contraction. There were five patients in this series who had either a single right or inverted coronary patterns, although there was one late death of unknown cause in this series in a patient with a single right coronary artery. These columns contain the terminal branches o the superior rectal artery and vein. The linear attachment to the radius, immediately distal to the radial attachments o the supinator and pronator teres, is thin (Table 3. Three membranous layers-pia mater, arachnoid mater, and dura mater-collectively constitute the meninges. The omental bursa permits ree movement o the stomach on the structures posterior and inerior to it because the anterior and posterior walls o the omental bursa slide smoothly over each other. As an additional aid to hemostasis the three-way points of junction with the coronary suture lines are reinforced with mattress sutures. Thus, the oramina are smaller in C7 than those in other cervical vertebrae are, and occasionally they are absent. The transpyloric plane, extrapolated midway between the superior borders o the manubrium o the sternum and the pubic symphysis (typically the L1 vertebral level), commonly transects the pylorus (the distal, more tubular part o the stomach) when the patient is recumbent (supine or prone). When doubt exists, both clavicles are radiographed because this deect is usually bilateral (Ger et al. Although commonly depicted and considered as single vessels, as shown here, the deep veins o the limbs usually occur as pairs o accompanying veins. It is ormed by the pectoralis major, as it bridges rom thoracic wall to humerus, and the overlying integument. The humeral head can be palpated when the arm is moved while the inerior angle o the scapula is held in place. The actions o both sartorius muscles bring the lower limbs into the cross-legged sitting position. The perineal body is an important structure, especially in women, because it is the nal support o the pelvic viscera, linking muscles that extend across the pelvic outlet, like crossing beams supporting the overlying pelvic diaphragm. They also increase heart rate and blood pressure, dilate the bronchioles, and change blood fow patterns, preparing or physical exertion. Although continuous, the abdominal and pelvic cavities are described separately or descriptive purposes, acilitating the regional approach. The arteries o the pericardium derive primarily rom the internal thoracic arteries with minor contributions rom their musculophrenic branches and the thoracic aorta. Urethral stricture may result rom external trauma o the penis or inection o the urethra. The parasympathetic system is restricted in its distribution to the head, neck, and body cavities (except or erectile tissues o genitalia); otherwise, parasympathetic fbers are never ound in the body wall and limbs.

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As the organs develop, they invaginate (protrude) to varying degrees into the peritoneal sac, acquiring a peritoneal covering, the visceral peritoneum. Aortic Valve Replacement with Aortic Annular Enlargement Aortic valve replacement for pure aortic valve stenosis with a normal aortic annular diameter is almost never indicated in the pediatric age group. As exors o the trunk, the recti are the antagonistic partners o the deep (extensor) muscles o the back. Two o the three cords give rise in turn to fve nerves, and the third (lateral cord) gives rise to three nerves. Consequently, the L5 spinal nerve roots are the thickest and their oramina, the narrowest. Lymphatic drainage rom the specic pelvic organs is described ollowing the description o the pelvic viscera. The inerior end o the radius moves around the relatively fxed end o the ulna during supination and pronation o the hand. The embolus passes through the right side o the heart to a lung through a pulmonary artery. The diaphragm curves superiorly into right and let domes; normally, the right dome is higher than the let dome owing to the presence o the liver. Thus transposition is a cyanotic anomaly in which pulmonary blood flow is not decreased but is actually increased relative to normal. Pain rom the parietal pleura is reerred to the cutaneous distribution o the intercostal nerves to the thoracic wall or, in the case o inerior nerves, to the anterior abdominal wall. Compression o the ulnar nerve at the elbow (cubital tunnel syndrome) is also common (see the clinical box "Cubital Tunnel Syndrome"). The rectum ends with the anorectal exure as the gut penetrates the pelvic diaphragm, becoming the anal canal. Mean left ventricular to right ventricular pressure ratio was increased by the preparatory first stage from 0. However, because o overlapping areas o innervation between nerves, one or two small branches o nerves may usually be cut without a noticeable loss o motor supply to the muscles or loss o sensation to the skin. The an-like radial collateral ligament is attached to the anular ligament o the radius, but its superfcial fbers continue on to the ulna. Because the bile duct is not central, the hepatic lobule does not represent a unctional unit like acini o other glands. Lateral exion (to the right or let in a rontal plane) is shown, also occurring mostly in the cervical and lumbar regions. Deep hypothermia is employed when a single venous cannula is utilized so that circulatory arrest can be instituted without delay when necessary. The thoracic and lumbar parts o the deep ascia constitute the thoracolumbar ascia. In chronically constipated persons, the anal valves and mucosa may be torn by hard eces. A dense network o nerve fbers passes rom the celiac plexus along the splenic artery to the spleen. It is particularly important that the needle should not only enter the right ventricular aspect of the septum, but should also exit the right ventricular aspect of the septum. The presence of a murmur leads to an echocardiographic examination and the correct diagnosis. Ilio-inguinal nerve block site Perineal branch of posterior cutaneous nerve of thigh Pudendal canal and ischial spine (pudendal nerve block site) Sacrospinous ligament Pudendal nerve Inferior view (lithotomy position) 6 Vaginismus Vaginismus is dened as involuntary (refex) muscle spasms that occur when vaginal penetration is attempted (when perineal muscles are distended). This vein lies directly on the deep ascia, running diagonally rom the cephalic vein o the orearm to the basilic vein o the arm. The crest serves as a protective "bumper" and is an important site o aponeurotic attachment or thin, sheet-like muscles and deep ascia.

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Your orearm is comparable to the root o the lung, and your coat sleeve represents the pleural sleeve surrounding it. Initial radiographs o the wrist may not reveal a racture; oten, this injury is (mis)diagnosed as a severely sprained wrist. The inerior thoracic aperture is much more spacious than the superior thoracic aperture and is irregular in outline. Commonly, the ourth tendon is used initially with the tendon to the ring nger and reaches the little nger by an intertendinous connection. Cyanotic spells can result in brain injury and death and should be an indication for immediate hospitalization and surgical repair. Each ischio-anal ossa is bounded as ollows: Laterally by the ischium and overlapping inerior part o the obturator internus, covered with obturator ascia. The intersecting planes o the triangles defne the transverse line (extending between ischial tuberosities) that is the base o each triangle. Appendicitis Acute infammation o the appendix, appendicitis, is a common cause o an acute abdomen (severe abdominal pain arising suddenly). The appendix has a short triangular mesentery, the meso-appendix, which derives rom the posterior side o (continued on p. Lymph rom the alimentary tract, liver, spleen, and pancreas passes along the celiac and superior and inerior mesenteric arteries to the pre-aortic lymph nodes (celiac and superior and inerior mesenteric nodes) scattered around the origins o these arteries rom the aorta. This large vein is ormed by the union o the brachial vein (the accompanying veins o the brachial artery) and the basilic vein at the inerior border o the teres major. In addition, the underdevelopment of the subpulmonary infundibulum results in it having a narrower lumen resulting in less blood flow through the pulmonary valve and main pulmonary artery so that these structures are usually hypoplastic. During its course through the arm, the brachial artery gives rise to many unnamed muscular branches, and the humeral nutrient artery. The anterior lip o the renal hilum has been cut away to expose the renal pelvis and calices within the renal sinus. The subcutaneous tissue o the hip and thigh is continuous with that o the inerior part o the anterolateral abdominal wall and buttocks. Cross sections demonstrating relationships at cubital ossa, proximal orearm, and wrist. Skin grooves also overlie the tendinous intersections o the rectus abdominis, which are clearly visible in persons with well-developed rectus muscles. The concave internal surace o the body has a costal groove paralleling the inerior border o the rib, which provides some protection or the intercostal nerve and vessels. Its strength should be comparable with the contralateral muscle, given consideration or lateral dominance (right or let handedness). Fractures o the bony pelvic ring are almost always multiple ractures or a racture combined with a joint dislocation. Ineriorly, the posterior sacro-iliac ligaments are joined by bers extending rom the posterior margin o the ilium (between the posterior superior and posterior inerior iliac spines) and the base o the coccyx to orm the massive sacrotuberous ligament. For this reason, people with dyspnea (dicult breathing) preer to sit up, not lie down; nontidal (reserve) lung volume is increased, and the diaphragm is working with gravity rather than opposing it. Muscle strains o the adductor longus oten occur in sports that require ast acceleration, deceleration, and changes in direction. In a precision grip, the wrist and digits are held rmly by the long fexor and extensor muscles, and the intrinsic hand muscles perorm ne movements o the digits. Penis Prepuce Glans penis External urethral orifice Medial view of hemisected pelvis Distension o Scrotum the scrotum is easily distended. Traction on suture 6 as well as the most recently placed suture aids exposure of the superior margin of the defect. Immediately beyond the pulmonary annulus, the main pulmonary artery is usually dilated to at least two to three times its usual diameter. Muscle Tissue and Muscular System 29 whether it appears striped or unstriped when viewed under a microscope (striated vs. The neurolemma o unmyelinated nerve bers is composed o Schwann cells that do not make up such an apparent series; multiple axons are separately embedded within the cytoplasm o each cell. Inverting sutures placed below the prosthesis allow a larger prosthesis to be placed relative to everting sutures placed above the prosthesis.

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Notwithstanding, commonly used eponyms appear in parentheses throughout the book when these terms are rst used-such as sternal angle (angle o Louis)-since you will surely encounter them in your clinical years. D is on the posterior aspects (bare areas) o secondarily retroperitoneal viscera, or the liver, where twigs o visceral veins-or example, the colic vein, splenic veins, or the portal vein itsel (portal system)-anastomose with retroperitoneal veins o the posterior abdominal wall or diaphragm (systemic system). The pericardium is a broserous membrane that covers the heart and the beginning o its great vessels. The prominent muscles are the quadriceps and sartorius, whereas laterally, the tensor asciae latae is palpable as is the iliotibial tract to which this muscle attaches. Because o the close relationship o the prostate to the prostatic urethra, obstructions may be relieved endoscopically. The photomicrograph o the pancreas displays secretory acini and a pancreatic islet. As the parts o the intestine reach their denitive positions, their mesenteric attachments undergo modication. The superior lateral quadrant o the breast has the most glandular tissue, largely owing to an extension toward or into the axilla (axillary process), and, thereore, is the site o most tumors. Before completion of the suture line on the atrial septal patch, the left heart is filled with saline, and air is vented through the cardioplegic infusion site in the ascending aorta. The bronchial arteries supply the supporting tissues o the lungs and visceral pleura. The axillary lymph nodes are arranged in ve principal groups: pectoral, subscapular, humeral, central, and apical. Armstrong, Associate Proessor o Medical Imaging, University o Toronto, Toronto, Ontario, Canada. Embryology o Right Atrium the primordial atrium is represented in the adult by the right auricle. The peritoneum is refected anteriorly rom the uterus onto the bladder and posteriorly over the posterior part o the ornix o the vagina to the rectum. Deep hypothermia in the neonate probably contributes to myocardial protection and allows one dose only of cardioplegia to be infused even for myocardial ischemic times as long as 2. For gallstones to cause clinical symptoms, they must obtain a size sucient to produce mechanical injury to the gallbladder or obstruction o the biliary tract (Townsend et al. The upper limb is composed o our increasingly mobile segments: the proximal three (shoulder, arm, and orearm) serve primarily to position the ourth segment (hand), which is used or grasping, manipulation, and touch. Blood may also be taken rom the emoral artery or blood gas analysis (the determination o oxygen and carbon dioxide concentrations and pressures with the pH o the blood by laboratory tests). Torsion o Spermatic Cord Torsion o the spermatic cord is a surgical emergency because necrosis (pathologic death) o the testis may occur. Under these circumstances, the vein can be divided and reimplanted directly into the left atrium. Presynaptic parasympathetic (vagus) nerves originate in the medulla (oblongata) and pass to the intestine via the posterior vagal trunk. The same muscles also rotate (advance) the contralateral side o the pelvis orward, concurrent with the swing o its ree limb. The base of the homograft is now sutured to the supplemented aortic annulus using continuous 4/0 Prolene. This type o hernia may also occur ater multiple pregnancies due to enlargement o the emoral ring over time rom increased intra-abdominal pressure orcing at into the emoral canal. Using this technique, intracardiac pressures can be recorded and blood samples may be removed. The Warden procedure involves division of the superior vena cava above the level of the most superior anomalous pulmonary vein. Note also that the tip o the lateral malleolus extends arther distally and more posteriorly than does the tip o the medial malleolus.