Note: This is an outline of items to discuss -- NOT the "Answer"

1. Review the boundaries of Scarpa's fascia. (10 pts)
2. Review the anatomy of the 3rd (horizontal) segment of the duodenum (10 pts)
3. Review the anatomy of the testis. (12 pts)
4. Review the anatomy of the ovary.  (10 pts)
5. Review the anatomy of the lesser sac.  (10 pts)

1.  Discuss the boundaries of Scarpa's fascia and its derivatives with respect to the containment of urine.  Specify the fascial layers associated with the accumulation of urine.  Discuss whether urine will be in the ischiorectal fossa.  (10 pts)

• Anterior abdominal wall - between Scarpa's fascia and deep fascia of external oblique
• superior: Scarpa's fascia attaches to deep fascia in finger like projections at level of umbilicus
• inferior medial: open passage to scrotum
• inferior lateral: passage to thigh
• lateral: near mid-axillary line at the thoracolumbar fascia
• medial: along the linea alba, fundiform ligament
• anterior: Scarpa's fascia
• posterior: deep fascia of external oblique
• Thigh - between Scarpa's fascia and fascia lata
• Inferior: 2 cm below inguinal ligament
• superior: open
• lateral: iliotibial tract
• medial: pubic ramus
• anterior: Scarpa's fascia
• posterior: fascia lata
• Scrotum - between Darto's tunic (Scarpa's derivative) and external spermatic fascia (deep fascia)
• superficial: Darto's tunic
• deep: external spermatic fascia
• Penis - between Colle's fascia (Scarpa's derivative) and Bucks fascia (deep fascia)
• extends distally toward base of, but not including, the glans
• superficial: Colle's fascia
• deep: Buck's fascia
• Urogenital triangle - between superficial perineal fascia (derivative of Scarpa's fascia) and perineal membrane (deep fascia)
• superior: perineal membrane (inferior fascia of the urogenital diaphragm
• inferior: superficial perineal fascia
• anterior: open into scrotum
• posterior: posterior free edge of urogenital diaphragm
• lateral: conjoint rami
• medial: not restricted
• Extravasation into the ischiorectal fossa? - NO
• limited by superior fascia of UG diaphragm
• limited by superficial perineal fascia (attached to posterior free edge of UG diaphragm and conjoint rami)

2.  Discuss the anatomy of the 3rd (horizontal) segment of the duodenum and include the relationships (6 directions), boundaries, vertebral levels, structure, surfaces, vasculature, lymphatic drainage, and innervation. (10 pts)

• Relationships and boundaries - retroperitoneal
• Vertebral level L3
• Posterior - ureter of left kidney, IVC (to right), Aorta (to left), psoas major
• Anterior - crossed by root of mesentery, posterior surface of transverse mesocolon and colon
• Superior - head (including uncinate process) of pancreas, attachment of transverse mesocolon, liver
• Inferior - jejunum, inferior mesenteric artery
• Medial - pancreas and common bile duct
• Lateral = right colic flexure
• "Nutcracker"
• These superior mesenteric artery branches from the aorta near the L2 vertebral level. It courses inferiorly and anterior resulting in the formation of a "V" by the superior mesenteric artery and the aorta.
• Crossing the aorta just inferior to the branching of the superior artery is the left renal vein. The horizontal portion of the duodenum crosses the aorta immediately inferior to the left renal vein at the L3 level.
• A swelling of the superior mesenteric artery near its origin from the aorta or a swelling of the aorta just distal to the origin of the superior mesenteric artery could compress the left renal vein and the duodenum.
• Vomiting and left kidney problems could result.
• Innervation (bias toward superior mesenteric plexus with some celiac plexus contribution)
• Sympathetic
1. Preganglionic cell bodies - IMLCC of T10-11
• fibers travel within lesser splanchnic n.
2. Postganglionic cell bodies - Supererior mesenteric ganglion
• fibers travel with extensions of superior mesenteric plexus along inferior anterior/posterior pancreaticoduodenal aa.
• Parasympathetic
1. preganglionic cell bodies in dorsal motor nucleus of vagus nerve
• preganglionic fibers travel through super mesenteric ganglion without synapsing and contribute to superior mesenteric plexus
2. postganglionic cell bodies are within the gut wall in intrinsic ganglia
• General visceral afferent fibers
1. high threshold (visceral pain) follow sympathetic pathways to spinal levels T10-11
2. low threshold (homeostasis - visceral reflexes) follow vagal pathways to nucleus of the solitary tract.
• Vasculature and lymphatic supply (bias toward superior mesenteric artery with some supply by celiac trunk)
• inferior anterior/posterior pancreaticoduodenal aa and vv
• aa. from superior mesenteric a. from aorta
• vv. from superior mesenteric v. from portal v.
• anastomosis with superior anterior/inferior pancreaticoduodenal aa vv
• lymphatic drainage
• biased toward superior mesenteric nodes
• additional drainage to celiac and unpper lumbar nodes
• from paraaortic nodes to intestinal lymph trunks to cysterna chyli
• Support
• retroperitoneal - extraperitoneal connective tissue
• Clinical significance
• A swelling of the superior mesenteric artery near its origin from the aorta or a swelling of the aorta just distal to the origin of the superior mesenteric artery could compress the left renal vein and the duodenum.
• Vomiting and left kidney problems could result.

3.  Review the anatomy of the testis including relationships, structure, coverings, vasculature, lymphatics, and innervation. (12 pts)

• Structure and support
• "a firm ellipsoid organ, measuring approximately 4X3X2.5 cm"
• dense fibrous capsule - tunica albuginea
• seminiferous tubules feed the rete testis that, in turn, feed the efferent ductules of the epididymis (head of)
• cushioned by tunica vaginalis
• derived from peritoneal diverticulum
• parietal and visceral layers
• Relations (The testis is bounded in all directions by the tunics of the cord)
• anterior - tunica vaginalis
• posterior inferior - tail of epididymis, deferent vessels and nerves
• posterior superior - head of epididymis and testicular vessels and nerves
• lateral - tunica vaginalis
• medial - tunica vaginalis, scrotal septum
• superior - spermatic cord
• inferior - scrotal ligament
• Arterial supply (note: torsion of testis usually strangulates arterial supply)
• paired testicular arteries arise from the anterolateral surface of the aorta near the level of the third lumbar vertebra.
• testicular vessels pass through the inguinal canal within the internal spermatic fascia of the spermatic cord
• testicular artyery contributes to vascularization of the superior pole of the testis
• located anterior within internal spermatic fascia
• Additional blood supply is by the deferential artery from the internal iliac artery
• deferential artery contributes to vascularization of the inferior pole of the testis
• located posterior within internal spermatic fascia
• forms a weak anastomosis with the testicular artery
• Venous supply by pampiniform plexus (emerges from posterior aspect of testis)
• primary drainage is by the pampiniform plexus of veins  located anterior within the internal spermatic fascia
• surrounds the testicular artery (thought to lower arterial temperature to the testis)
• consists of 10 -15 veins - converge at deep ring to form singular testicular vein
• testicular veins arise from the IVC on the right and the left renal vein on the left
• Autonomic innervation
• preganlionic sympathetics from imlcc of spinal levels T10-12
• postganlionic sympathetics from superior mesenteric and aorticorenal ganglion
• follow renal and aortic plexuses to testicular arteries to form testicular plexus
• preganglionic parasympathetics are thought to be from the vagus
• parasympathetic fibers derived from pelvic spanchnics follow the deferential plexus
• autonomic fibers from the inferior hypogastric plexus form the deferential plexus
• Visceral afferent innervation
• high threshold (pain) fibers follow sympathetic pathways to T10-12 spinal levels
• Lymphatic drainage
• superior pole - upper lumbar nodes (testicular vessels)
• inferior pole - internal iliac nodes (deferential vessels)

4.  Review the anatomy of the ovary including relationships (6 directions), structure, surfaces, supports, vasculature, lymphatics, and innervation. (10 pts)

• Structure and support
• The ovary is roughly cylindrical about 3 cm long and 1 cm in diameter.  The visceral peritoneum covering the ovary gives way to a specialized germinal epithelial cell layer.  The egg penetrates this layer to enter the peritoneal cavity.
• The ovary is suspended from the posterior lamina of the broad ligament by the mesovarium -- a peritoneal ligament.  Supporting the superior pole of the ovary to the pelvic brim is the suspensory ligament of the ovary.   Supporting the inferior pole of the ovary to the lateral uterus is the ovarian ligament.
• Relationships
• superior to the ovary is the pelvic brim and suspensory ligament
• inferior to the ovary is the uterine wall and the ovarian ligament
• anterior to the ovary is the broad ligament, uterine tube, and fimbria of uterine tube
• posterior to the ovary is the rectum and pelvic floor
• medial to the ovary is the pararectal fossa, rectouterine pouch, fundus of the uterus
• lateral to the ovary is the ovarian fossa (internal iliac a. and ureter), psoas major muscle, and obturator n.
• Vascular supply (mostly from the ovarian aa and vv.)
• paired ovarian arteries arise from the anterolateral surface of the aorta near the level of the third lumbar vertebra.
• ovarian veins arise from the IVC on the right and the left renal vein on the left.
• ovarian vessels pass through the suspensory ligament of the ovary to arrive at the superior pole
• Additional blood supply is by ascending branches of the uterine vessels (ovarian br.)  that anastomose with the ovarian av.  Anastomotic branches enter the mesovarium
• Lymph drainage (primarily along the embryological decent of the ovary).
• Follows ovarian vessels toward upper lumbar nodes in the vicinity of the renal arteries.
• Follows ovarian and round ligaments to the mons pubis and superficial inguinal nodes
• Follows the uterine artery toward internal iliac nodes.
• Innervation (motor and sensory)
• Parasympathetic preganglionic cell bodies are located in the central gray of the spinal cord (IMLCC) at levels S2-4.
• Preganglionic fibers enter the inferior hypogastric plexus by way of the pelvic splanchnic nerves.
• The inferior hypogastric plexus contributes a uterine plexus and then to the ovarian plexus.
• Postganglionic parasympathetic cell bodies are located in intrinsic ganglia of the ovary.
• The above pathway assumes that the uterovaginal plexus reaches the ovary.  This is not known for certain.
• Sympathetic preganglionic cell bodies are located in the interomedial lateral cell column at cord levels T10 (and perhaps T11-12).
• Preganglionic fibers follow the lesser and least splanchnic nerves to aortic ganglia near (and including) the superior mesenteric ganglion and the aorticorenal ganglion.
• Postganglionic fibers from these ganglia enter the aortic plexus and extend along the ovarian artery as the ovarian plexus.
• Parasympathetic pregangionic contributions from the vagus n. may also follow the ovarian plexus.
• Visceral afferent pathways follow the sympathetic pathways up to the T10 spinal level.  Additional visceral pathways follow parasympathetic pathways back to the S3-4 spinal levels.

5.  Review the anatomy of the lesser sac including relationships (6 directions), boundaries, structures, surfaces, vasculature, innervation, and lymphatics.  Explain why pain may originally be diffuse but suddenly becomes severe, and why depris from the the stomach may be found in the hepatorenal recess. (10 pts)

• Superior recess - posterior to liver, begins at epiploic foramen
• anterior - caudate lobe of liver and lesser omentum
• posterior - diaphragm
• superior - diaphragm
• inferior - lesser recess
• right - liver, ligamentum venosum
• left - splenic recess
• Inferior recess - inferior ot the right gastropancreatic fold (common hepatic a.)
• anterior - hepatoduodenal ligament, duodenum, gastrocolic ligament
• posterior - pancreas, tail of pancreas enters leinorenal ligament
• superior - superior recess
• inferior - transverse mesocolon
• right - liver
• left - gastroleino ligament
• Splenic recess - left of gastroepiploic fold (left gastric a.)
• anterior - stomach, gastrocolic ligament (greater omentum)
• posterior - aorta, left suprarenal gland, upper pole left kidney, splenic a., diaphragm
• superior - liver and diaphragm
• inferior - inferior recess
• right - caudate lobe, superior recess
• left - gastroleino and leinorenal ligaments
• Epiploic foramen - communication between lesser and greater sacs
• anterior - hepatoduodenal ligament
• posterior - inferior vena cava
• superior - caudate lobe liver
• inferior - duodenum
• right - opening into hepatorenal recess and right paracolic gutter
• left - lower recess of lesser sac
• Pathway of Materials?
• Person rolls to the right - contents of lesser sac enter the greater sac via the epiploic foramen
• Person returns to supine - contents enter the hepatorenal recess
• Person stands - contents follow the right paracolic gutter to the pelvic basin
• Vascular supply - vascular supply is by regional aa and vv
• posterior - splenic av
• anterior - common hepatic, right gastric, left gastric, aa
• inferior - right and left gastroepiploic aa vv, supra- and retroduodenal aa vv
• superior - inferior phrenic av
• left - short gastric aa vv
• right - right and left gastric aa vv
• Lymphatic drainage - follows vascular supply
• paraaortic nodes to lumbar trunks to cysterna chyli
• diaphragmatic border involves mediastinal and axillary nodes (anterior wall vasculature)
• Autonomic Innervation
• sympathetic preganglonics - mostly from greater and lesser splanchnic nerves (cell bodies in imlcc of T5-11)
• sympathetic postganglionics - mostly from celiac plexus (cell bodies in celiac ganglion)
• parasympathetic preganglionics - from vagus nerve (cell bodies in dorsal motor nucleus of vagus nerve)
• parasympathetic postganglionics - intrinsic ganglia
• Visceral afferent innervation
• "pain" follows sympathetic pathways to spinal levels T5-11
• Somatic afferent innervation
• parietal peritoneum of the posterior wall innervated by thoracoabdominal nerves
• Why sharp pain?
• Irritation of the parietal peritoneum of the posterior wall activates somatic afferent nerves.