 Good day, ladies and gentlemen. Welcome to our next series of dissection video. This time we are going to talk about theorta, the infirmena capa and the kidney ureter with some important surgical clinical coronations. My name is Dr. Sanjay Sanyal. I'm the professor and department chair in the western hemisphere and I'm happy to be here with you. So our pattern of descriptions will be as follows. After having removed all the anti-abdominal contents, we have kept the kidney, the ureter, theorta and the infirmena capa in situ, which we shall describe in sequence and after that we shall mention two interesting surgical historical facts just for your entertainment. But let that be a surprise. So this is the abdominal cavity as they were in situ after all the anti-abdominal contents were removed from the cadaver. Just to bring up to speed, this is the head end of the patient, the cadaver, this is the foot end, this is the right side, this is the left side. And what do we see here? This is where the diaphragm is located and we can see the abdominal aorta, we can see the infirmena capa, the two of them are dividing into the common area vessels here and we can see the two kidneys here. This is the pelvis, we can see part of the sigmoid which will continue down this rectum and this is the inguinal ligament below which the iliac vessels will pass and they will become the femoral vests. We can see part of the posterior abdominal wall. We can see the sova's major here which forms the posterior relation of the kidney as well as the posterior abdominal wall. And lateral to that will be the quadratus lumborum and we can see some of the fibres of the lumbar plexus here. So this is in a nutshell an overview of the abdominal cavity and what we are going to describe. Please take a look at the spara vertebral cutter which I am going to mention and it's got a clinical significance which I shall tell you a little later. So let's start off with the first structure namely the abdominal aorta. Let's take a look at the extent of the abdominal aorta. It starts from the aortic hiatus which is at the level of T12 in the diaphragm. The aortic hiatus is in the right crust of the diaphragm. It crosses, it continues down slightly to the left of the midline and at the level of the L4 lumbar vertebra it divides into the right and the left common iliac arteries. Let's take a quick look at the branches which are visible here are the contents of the branches. Straight away we can see that the three unpaired visceral branches namely the celiac trunk which is at the level of T12. The superior miscentric artery which is at the level of L1 and the inferior miscentric artery which is at the level of L3. These are the unpaired visceral which supply the forecut, midcut and the hindcut respectively. What else do we notice here? We notice just about the celiac trunk we have the contents of the inferior phrenic artery which are the paired parietal branches. We do not see the lumbar arteries because they have been removed in the specimen here. So this is the abdominal aorta. We also see the right renal artery dividing into the segmental artery which I shall describe later and you cannot see the left renal artery because it is behind the renal vein here. Let's take a quick look at this common iliac arteries. The common iliac arteries they run around the pelvic brim and they are crossed over by the ureter as you can see them here but I shall mention them again in more detail later on. The common iliac artery then divides into an internal iliac artery and continues down as the external iliac artery below the inguinal ligament. This has got a clinical significance which I shall mention in the next slide. This is essentially the same picture. The abdominal aorta here with slightly different perspectives. Some of the fascia has been removed to show you the crossing of the ureter on the right side and the crossing of the ureter on the left side. Let's mention a few important clinical correlations here. So as I told you this is the common iliac artery which runs along the pelvic brim and it is crossed over by the ureter. You can see the common iliac artery is giving off the internal iliac arteries in both the sides which divides into an anterior division and a posterior division. The anterior division is the one important one. It supplies most of the organs of the pelvis and the perineum. The posterior division supplies some structures in the gluteal region etc. And the remainder of the common iliac continues as the external iliac artery and below the inguinal ligament it continues as the femoral artery on either side. Media to that will be the external iliac vein which will continue down as the femoral vein. Let's mention a few important clinical correlations pertaining to the abdominal aorta, namely the three ones which I mentioned here. In a thin walled individual, a person whose abdominal wall is very lax and thin, we may be able to palpate the normal abdominal aorta with the heel of our hand pressing down on the lower abdomen against the lumbar vertebra, especially the L4 vertebra in this region. So feeding the abdominal aortic pulse stations in a normal person in a thin walled individual is not abnormal. But there's yet another situation which is a different ball game altogether and that is an abdominal aortic aneurysm which is a very serious condition which is usually seen in atherosclerosis but it can also be seen in other conditions like Marfan's syndrome. The abdominal aortic aneurysm when it occurs, it usually occurs below the origin of the real artery. As you can see the beginning of the right ring artery here which continues here and the left ring artery as I told you is not visible. So the abdominal aortic aneurysm the most common side is just below the real artery and it can go right up to the bifurcation of the abdominal aorta into the common iliacs. So therefore the inferior miscellaneous artery will rise from the top of the aneurysm. When we have an abdominal aortic aneurysm, how does it... the pulse stations may be visible from outside and when you try to palpate it you feel an expansile pulse station. This is a classical feature of abdominal aortic aneurysm and it is quite a serious condition. If it's more than 6 centimeters, it's got a high chance of rupture as seen by ultrasound or by imaging techniques. Another important clinical correlation which I want to mention at this juncture is the arterogram of the renal of the arteries of the branches of the abdominal aorta or the thoracic aorta. As I told you the abdominal aorta divides into the two common iliacs and the common iliac then continues as the external iliac and the femoral artery. That's the site which is used for cannulation by the so-called modified Sendinger technique. We palpate the femoral artery in the medic-vernal point just one inch below the medic-vernal point in the femoral triangle and we cannulate it. We pass the cannula under C-arm image intensifier and we pass the cannula going up. We negotiate the abdominal aorta and depending on which artery we want to visualize let's say the supramacentric artery or the celiac artery we cannulate it and we inject the dye and we take multiple extremes, multiple pictures. We can continue the procedure, we can go continue up through into the thoracic aorta and we can take images of the coronary arteries also by cannulating the right or the left coronary arteries in the coronary sinus in the aorta, the root of the aorta. So this is the root which is used for arterogram of the branches of the renal artery. So that's an important point. The next important point I want to mention to you was the renal artery. As you can see part of the right renal artery is visible here. The renal artery and here we can see it is dividing into two segmental arteries. The renal artery divides into five segmental arteries which supply the five segments of the kidney. The two anterior segments, the superior polar, inferior polar and one posterior segment and you can see two of the anterior segments here. So this is what is visible in this particular dissection. So this is about the what is... So I've already mentioned to you that these are the unpaired viscera and the kidneys and the renal arteries are the paired viscera. What is not visible here are the other paired, let me get the gonadal arteries. They have been removed in this particular specimen and they've also seen the inferior phrenic artery which I told you is a paired parietal branch. So that's so much about the normal aorta and its clinical correlations. Now let's come to the inferior vena cava. The inferior vena cava is located to the right and you can see the force that has been inserted to the cut-in of the inferior vena cava. Its aortic... its hiatus in the diaphragm is not visible here. It's somewhere in this region. It's through the central tendon of the diaphragm to the right of the midline and it's at the level of T8. Here I can give you a rule of thumb, T8, T10, T12. T8 is the cable hiatus. T10 is the esophageal hiatus and T12 is the aortic hiatus. Please note that the inferior vena cava, the abdominal segment is longer than the aorta. It starts from the T8 level and it divides into the two iliac veins at the level of L5 vertebra. Okay, so this is the inferior vena cava. What we can see here is the left renal vein. It's running anterior to the aorta. The left renal vein is longer than the right renal vein. The right renal vein is partially cut here. With the case of the real artery, the right renal artery is longer than the left renal artery for obvious reasons. The artery is always behind the vein for obvious reasons because the vein is likely to get compressed if it were the other way around. Okay, we can also see the right gonadal vessel, testicular or ovarian opening into the inferior vena cava. We cannot see the left one because the left one opens into the left renal vein. So this is the inferior vena cava. At this juncture, I would like to mention one important clinical correlation. Take a very good look. This, as I told you in the earlier slide, is the cut end of the superior miscentric artery. The superior miscentric artery goes in close relation to the left renal vein and it continues down. It travels in front of the third part of the teardrum and it supplies the parts of the midcut. As it descends down, it can compress the left renal vein and can produce what is known as the left renal vein entrapment syndrome. Not only that, we already know that the left renal vein also receives the left gonadal vein. Especially in maines, the left testicular vein. So therefore, compression of the left renal vein can produce varicoseal of the left testis because of the compression, concomitant compression of the left testicular vein and the paptoiform plexus. Unrelated to this particular situation, but by the same superior miscentric artery, as it descends down in front of the third part of the teardrum, it can also produce teardrum compression syndrome. But those are relatively uncommon. So that's an important clinical correlation I wanted to mention here. Before I get out of this slide, I would like you to notice that this is the ureter here on the right side and this is the ureter on the left side. And please note that both of them are crossing the pelvic brim anterior to the common iliac vessels because that is going to have a clinical correlation, which I'm going to mention later. Now let's take a look at the kidneys. So this is the little lobilator, right kidney and this is the left kidney here. This is the paravirtibular cutter. As I told you in the first slide, what do we mean by the paravirtibular cutter? This is the vertebral column here, which is elevated and therefore it is jutting forward anteriorly. And then the ribs and the other abdominal contents, the abdominal wall goes posteriorly. So therefore, a depression is produced on either side of the vertebra which is referred to the paravirtibular cutter. And because of this paravirtibular cutter, the orientation of the kidney is not exactly anterior posterior but it is anterior medial and posterior lateral. That's the point I wanted you to notice. So this is the right kidney, this is the left kidney. We can see part of the renal sinus here. There's a space between the two anterior and posterior surfaces of the kidney through which the renal hyalum passes and all the structures of the renal hyalum enters. Namely, the renal vein behind that, the renal artery which you can see on this side and the pelvis. So the vein, artery and the renal pelvis are oriented in that order from front to back. Okay. As I've already described to you, the left renal vein is longer and the right renal artery is longer for obvious reasons. This is the pelvis and this is the pelvic reurutic junction and we can see the ureter. The ureter descends down in relation to the tips of the lumbar transverse processes, 5 centimeters from the midline on either side. And that is how we notice them on an intravenous filograms. As it descends down, it continues and it crosses the pelvic brim over the common alloy vessels and then it enters the pelvis and it moves in relation to the ischial spine and it enters the kidney, the bladder, sorry, the bladder from the posterior aspect and it travels in the intramural segment of the bladder and it opens into the bladder at the trigo which is the floor of the bladder. So this brings us to the next important point, namely the three sides of ureteric constrictions which are physiological but which can be the site of impaction of a ureteric calculus more than 0.5 centimeters. The first side of narrowing is the pelvic ureteric junction, the PUJ. The second side of constriction is where it crosses the pelvic brim anterior to the common alloy vessels. And the third side of constriction which you cannot see here because the bladder is not visible here is at the ureteric cycle junction. So these are the three common sides where we can have impaction or we can also have physiological or pathological narrowing of the ureter. Apart from that, there are two inconstant sides of narrowing, one in the male and one in the female. In the male it is the crossing of the ductus reference behind the bladder and the male-female it's the crossing of the root of the broad ligament in the pelvis. So these are some important sides of ureteric constriction. The next important clinical correlation which I want to mention apart from the renal entrapment syndrome which I've already described to you is the orientation of the kidney, the paravirtibular gutter. As I told you, the kidney is oriented anterior-medial and postural lateral because of this paravirtibular gutter. So therefore this produces a relative tendency for the urine to get dependent and collected here in this dependent portion of the pelvic galesian system. And therefore it can produce, especially when the patient is recumbent for a long duration of time, it can produce urinary stasis and can give rise to pelvic galesial calculus, namely the staghorn calculus. It is this orientation of the kidney which predisposes to this type of calculus formation in the pelvic galesian system. Another important clinical correlation which all of you are very familiar with is called the horseshoe kidney which is actually a congenital abnormality. Normally the kidney, the location of the kidney is T12 to L3 and it's got about one's vertebral length of mobility vertically depending on the posture and respiration. The right kidney is slightly lower than the left kidney because of the liver on the right side. A horseshoe kidney tends to be in this location because the lower poles of the two kidneys are fused. The horseshoe kidney tends to be the location of L3 to L5, why so? Because the inferior miscentric arteries I told you arises from here and therefore because the lower poles of the horseshoe kidney are fused together, the kidney cannot ascend up any further. So therefore this is the location of the horseshoe kidney. So remember it is the inferior miscentric artery which keeps the horseshoe kidney in its place in a lower location namely L3 to L5 as opposed to the normal lower orientation of kidney from T12 to L3. So these are some salient points about the kidney and the ureter and the real vessels and their clinical correlations. So this is a summary slide which shows you without any labels. It shows you just about everything and let this be a small exercise for you. Try to identify all the important structures which were already shown in the earlier and try to recollect some of the important clinical correlations. Before we conclude, let me show you an interesting historical slide from the 1600s in Holland. In those days getting cadaver for dissection was rather difficult. This was a particular person who had been convicted and sentenced to death by hanging and this is Dr. Nicholas Tulp who is performing a dissection on this cadaver caused to be by other surgeons and physicians and anatomists. And this picture was captured by Rembrandt in 1632 in Amsterdam. So this is a very interesting picture, a very interesting historical picture and a famous one. And this is another picture which some of you may find may be able to relate to especially those of you who are medical students now. This is a picture of a medical viva voce examination and you all of you I'm sure will understand what a gut-wrenching affair that used to be and that even now is. So you can see here one student holding him. A specimen here watched over by two professors and two examiners. There's another student here, he's being watched over by at least one examiner here and there's yet a third student here who's being watched over by two examiners and all of them have got models and specimens in front of them and I'm sure they are being grilled left, right and center. So on this happy note ladies and gentlemen thank you very much for watching. If you have any questions or comments put them in the comment section below. Dr. Sanjay Sanyal signing out. Have a nice day.